Optimal Healing: A Guide to Traditional Chinese Medicine, 1st Edition

Chapter 15. TCM and Our Future


In America, we are facing a health-care crisis of colossal proportions. Many factors are at play. The political and economic interests that fuel this problem notwithstanding, my discussion will address it as if our interests were all aligned—to benefit the patient. In part, we are the victims of our progress. Increased life expectancy has added $20,000 to the cost of health care for each person per year. All would agree that we should maximize prevention, early detection, and intervention, and minimize risk and cost. How can Eastern medicine help us achieve these goals?

Training

Progress often comes at a price. The information age has given rise to identity theft; pesticides have led to pollution; the digital age has given rise to a new disease called repetitive strain injury. With tremendous advances in medical technology, we are also paying a price not only in the matter of high health-care costs but also in the gradual erosion of clinical skills among recently trained physicians. The trend is to rely heavily on technology. The mainstays of taking a history and doing a thorough physical examination have fallen by the wayside. In the 1990s, I performed a physical examination on a twenty-three-year-old woman. When I palpated for her heart on the left side of the chest, I could not feel the usual heartbeat. Further tests showed that she had situs inversus, a condition from birth in which the heart is on the right side of the chest rather than on the left. She marveled that despite having seen a number of pediatricians and gynecologists in her twenty-three years, no other physician had found her abnormality. Physical diagnosis is currently not given the emphasis it deserves in our training programs.

Recently, I have observed how modern technology has sometimes impeded rather than enhanced health care. One friend’s appendicitis ruptured because of a four-hour wait for a CT scan. Another friend’s intestinal obstruction was missed by an ER physician who discharged her because her abdominal ultrasound was normal. I made the diagnosis by listening to her history over the phone, confirmed it with a focused abdominal exam, and advised her to try another ER. At the second ER, diagnosis and treatment were delayed for three hours pending the result of a CT scan. I have witnessed physicians in mainstream hospitals miss diagnoses of appendicitis, hepatic carcinoma, and congestive heart failure. CT scans and MRIs are invaluable tools, but they should not replace clinical evaluation of the patient.

One glaring deficiency in Western medical training is in the physical diagnosis of musculoskeletal soft tissue maladies. Too often, the automatic response to such problems is to order MRIs without a thorough hands-on examination. Patients who consulted me for acupuncture liked to give me details of all the tests other doctors had ordered. Rarely were the test results helpful. What was most helpful was to listen to their stories: how the problem began, how it progressed, what made it improve, what made it worse, and how it limited function. Next in importance was a thorough examination, including not only palpating for muscle tension, tenderness, and range of motion, but also skin changes in the affected area.

Mark came to see me for acupuncture. While crossing the street, he had been hit by a car and thrown twenty feet. He was in his early forties and had been otherwise in excellent health. After the injury, he suffered from debilitating back pain. Because his MRIs were normal, the attorneys defending the driver who hit him deemed his injuries insignificant. His case went to court. The orthopedist who testified as an expert witness offered no objective findings to strengthen Mark’s case. The opposing attorney portrayed Mark as a malingerer. When I took the stand, I pointed out the one sign indicating that Mark’s pain was real. I had learned from a course on intramuscular stimulation that one sign of neuropathy was excessive localized sweating. Whenever I examined Mark’s back prior to acupuncture treatments, I observed profuse sweating over the specific location of his lumbar back pain. With that bit of evidence, the tables turned, and Mark won the case.

If we are to alter the costly path of modern medicine, we need to begin by redirecting how we train physicians. Before we had CT and MRI capabilities, physicians were trained to focus on the patient and use every noninvasive means to arrive at a diagnosis. TCM physicians went further because they lacked even labs and X-rays. TCM diagnosis is high in sensitivity but low in specificity. Using observation with pulse and tongue examination, Chinese practitioners can detect early imbalances in a region of the body at a very early stage of disease, but they are unable to pinpoint the exact location or specific nature of the problem. Western technology can pinpoint problems very specifically. Ideally, we should combine the sensitivity of the East with the specificity of the West. If we stretch our imaginations, perhaps we can even adapt our technology to detect early changes in the pulse that TCM practitioners have been trained to do after years of training and experience.

In California, physicians are now required to receive twelve hours of terminal care and pain-management training to maintain licensure. To meet these requirements, I attended two courses. In the first, palliative-care specialists taught how to use narcotic analgesics to manage pain in terminally ill patients. In the second course, I was appalled to find that pain-management experts in mainstream medicine recommended using narcotic analgesics for chronic musculoskeletal pain. Teaching physicians to use narcotics to manage pain in the terminally ill is appropriate, but teaching primary care doctors to use narcotics for chronic musculoskeletal pain is inappropriate and does society a great disservice. When we consider risk/benefit ratios, the risks of both NSAIDs and narcotics far outweigh their benefits when compared to acupuncture, yet acupuncture is not even mentioned in current pain-management curricula. One lecturer lamented that the public showed more interest in complementary therapies for neuropathic pain than the conventional allopathic drug approach he was teaching. The public should be commended for using common sense.

Research

In the area of research, the media has bedazzled Westerners regarding the potentials of Eastern medicine. This has misled us into doing research in inconsequential areas. Qi gong and acupuncture anesthesia for surgery sound beguiling, but do we need them? Only skilled masters can perform Qi gong properly. If used incorrectly, it can have harmful effects. How many can this ancient art benefit? As for acupuncture anesthesia, even in China, it is used in only 20 percent of cases, and patients are carefully selected. Only those with high pain thresholds are candidates. That criterion would eliminate most pampered Westerners. Often when I read in the newspapers about “new” discoveries in medicine, I am disappointed. Usually, the medical community has known about most of these so-called new developments for about a decade. We live in a global community. When NIH pronounced in 1995 that acupuncture might be effective for certain kinds of pain and for nausea, I could imagine our neighbors across the ocean asking, “Are they trying to reinvent the wheel?” Such information has been common knowledge not for years or decades but for millennia. The effectiveness of acupuncture for painful musculoskeletal conditions is common knowledge to acupuncturists and patients alike. In the pain management course I recently attended, the lecturer stated that because of their long established use, there was no need for controlled double blind studies to determine if narcotic drugs were effective for pain. That argument is even more applicable to acupuncture. As early as the nineteenth century in America, William Osler, considered the father of modern medicine, recommended acupuncture for treatment of back pain.

Research involves having a hypothesis, asking a question about whether the hypothesis is correct, and then proceeding to investigate for the answer. We in the west are squandering our resources by asking outdated questions. In the words of the famous American bank robber Willie Sutton, let us go “where the money is.”

Acupuncture

In 1971, when the New York Times reporter James Reston underwent emergency appendectomy while visiting Beijing and then was treated for postoperative pain with acupuncture, it made front-page news. We are ready for the next headline news: “Acupuncture cures appendicitis.” Existing Chinese studies show that the acupuncture point, Stomach 36, located in the vicinity of the lateral sural cutaneous nerve, the cutaneous branch of the saphenous nerve, and the deep peroneal nerve, can influence gastrointestinal motility and also improve immune function (O’Connor 1981, 529). We should be asking the question, “How is that possible?” Are there autonomic nerves accompanying the nerves at this acupuncture point that we have yet to map? Is the mechanism antidromic nerve conduction? How can needling a point on the leg influence the immune system? Does it cause release of hormones to stimulate the bone marrow or thymus gland or lymph nodes?

Chinese studies have shown that stimulating Stomach 36 and another point below it, called MLE 13 (Lanweixue), can regulate peristalsis in the appendix leading to passage of an impacted fecolith (O’Connor 1981). At present, if a patient sees a physician for right lower abdominal pain, appendicitis is the diagnosis to be considered. The treatment of choice is surgery. We examine the patient and order laboratory tests. If the pain is typical but our examination and tests do not show acute inflammation, we have the patient rest, restrict oral intake to fluids, and return for reexamination. Because the treatment is invasive and carries risk, we wait for signs that the appendix is actually inflamed before proceeding with surgery. During this period of watchful waiting, the Western approach lacks any measures to reverse the process. This is the gap that acupuncture can fill. Although acupuncture will not eliminate the need for surgery in all cases, we should investigate the possibility of its benefiting cases that are in the early stages.

Other Chinese studies show that stimulating GB 34 improves gallbladder function and facilitates flow through the biliary tract. Just as for early appendicitis, we can investigate how this information can benefit treatment of gallstones. Chinese studies also show that stimulating St 36, GB 34, and Li 3 can relieve morphine-induced spasms in the sphincter of Oddi (O’Connor 1981, 530). The sphincter of Oddi is the muscular ring controlling the ampulla of Vater, the common channel for bile and pancreatic juices to flow through on the way to the small intestines. Sometimes gallstones can obstruct the flow. The backed-up bile and digestive juices seep into the pancreas, setting up an intense inflammatory reaction called pancreatitis. Western treatment consists of pain medication, putting the digestive tract to rest by suctioning out stomach juices, intravenous fluids, and watchful waiting. When gallstones are suspected of obstructing the common bile duct or ampulla of Vater, gastroenterologists often use a procedure called ERCP to cut the smooth muscles of the sphincter of Oddi to widen the opening for the gallstones to pass. If acupuncture can relax the sphincter of Oddi, it may sometimes eliminate the need for cutting it.

There is evidence that stimulation of UB 67 located on the sural nerve in the foot can induce rotation of a breech presentation of the fetus in obstetrics. We should be asking, “How does this work? Can we save some costly C-sections using this method for breech presentations?”

The cost of infertility testing and treatment has reached stratospheric levels. As mentioned earlier, common experience tells us that TCM, by using both acupuncture and herbs, has a definite role in treating the problem of infertility. We could consider TCM as a first option for infertile couples before embarking on the expensive high tech route. There is room for the West to learn how China became the most populous country on the planet.

Western studies show that stimulation of Spleen 6 on the posterior tibial nerve can affect genitourinary function. These studies came about because urologists had tried to find ways to control bladder dysfunction by implanting various electrodes into the spinal cord and nerves that directly control detrusor muscle function (the muscle responsible for voiding). The problem was that patients could not tolerate the discomfort of these procedures. The urologists then thought of adopting the idea from acupuncture of stimulating the posterior tibial nerve that was easily accessible in the lower leg to achieve their end and found that it was as effective as their other more invasive techniques. Other Western researchers are similarly studying ways to control nervous dysfunction and chronic pain by implanting electrodes in the spinal cord. These procedures carry risk and are expensive. They could likewise borrow ideas from acupuncture to achieve these ends.

Herbal Therapy

Cardiovascular disease ranks high in research priorities of western countries. From firsthand clinical experience, I know that combinations of herbs in the quelling-Wind and mobilizing-Qi-and-Blood categories can influence peripheral vascular disease. Yet when I tried to apply for a grant with NIH to study the effect of herbs for peripheral vascular disease, I was told that the funding for complementary care research had been used up to study the effect of massage therapy on HIV-AIDS.

As I mentioned in chapter 3, we are made of a network of tubes or ducts. Mobilizing-Qi herbs function by relaxing the smooth muscles that make up the walls of ducts. In addition to using them to treat vascular disease, we can use them to treat conditions in which ducts are obstructed, such as in the case of kidney stones, gallstones, and salivary duct stones.

Obesity and type 2 diabetes mellitus are major concerns in developed and developing countries. We should ask some questions about the role of Spleen herbs in addressing these issues. Do they work by decreasing insulin resistance? Do they enhance incretin secretion? Are they useful for controlling obesity? Certain acupuncture points are also known to help lower blood glucose levels. We certainly have not exhausted the possibilities offered by TCM in these areas.

There is widespread misunderstanding in both Eastern and Western thinking regarding the role of TCM in cancer therapy. Many Chinese believe that the patient needs to avoid nourishing food and tonifying herbs to prevent the cancer cells from proliferating. The reality is that starving the cancer cells simultaneously starves the host and impairs his or her ability to fight the cancer. Chinese cancer patients often have the misconception that if Western chemotherapy offers only palliation and no hope of cure, they are better off turning to herbal therapy alone for cure. This either/or thinking is flawed. When even early stage cancer has been diagnosed, the cancer has already been growing for a long time—a matter of years. The presence of cancer cells represents a failure of the host’s own body to contain tumor growth. The TCM approach works best in early stage disease. To rely on herbs alone for a cure of a disease that can no longer be considered early is unrealistic. On the other side, many Western practitioners prohibit patients from taking herbal therapy, mainly because the effects are unknown to them. Yet there is little effort among Westerners to investigate the role of herbs.

Chinese herbal therapy can play two roles in cancer therapy. One is to ameliorate the devastating side effects of Western therapy. Many Yin tonifying herbs can restore moisture to dry mucous membranes. Tonifying Kidney and Spleen herbs can help with the debilitating fatigue of Western cancer therapy. After a course of chemotherapy or radiation, there is a watch-and-wait period when the patient doesn’t receive treatment but is monitored for recurrence. It is during this period that Chinese herbal therapy plays a second role. Some Chinese herbs have antitumor properties. Two common ones are Oldenlandie Diffusae img and Ganoderma Lucidum and Ganoderma Since img. More studies are needed. Such herbs in a prescription balanced with immune-boosting herbs could be considered for maintenance anticancer therapy. We are well aware of the toll Western cancer therapy takes on patients’ well-being. There is a need to study the potential benefits of adding Eastern treatments.

Currently Western medicine has shown intense interest in the immune system. In this area, Eastern methods trump Western ones. Certain acupuncture points and herbs that tonify Spleen and Kidney actually enhance the immune response. Western drugs usually only suppress the response. Let us consider autoimmune diseases, conditions in which the body inappropriately mounts an immune response to its own tissues. Our experience with the HIV-AIDS epidemic should have taught us a lesson about autoimmunity. Early in the epidemic, before there were antiretroviral drugs, we saw the natural progression of this deadly disease. It was common for HIV-AIDS patients, people with extremely weak immune systems, to develop autoimmune diseases. Logic would tell us that autoimmune diseases arise from a weakened, malfunctioning immune system. Knowing this, we should question our allopathic approach of using drugs such as steroids and antimetabolites that further suppress the immune response in autoimmune diseases. The immune system is extremely complex, consisting not only of cells that attack foreign invaders but also of other cells that direct what to attack. A portion of this system, called self-nonself recognition, specifically prevents attacks on one’s own tissues (Jiang and Chess 2006). When functioning normally, this component prevents autoimmune diseases. The Western approach of suppressing the entire immune system discounts the importance of the Yin-Yang balance in a functioning immune system. The Eastern approach strengthens the entire immune system and allows spontaneous rebalance of its various components.

Researchers have found that conditions in which there is prolonged inflammation are associated with cancer. Lung cancer can develop from benign-appearing scars that are the aftermath of pulmonary tuberculosis. In the case of latent tuberculosis, the immune system is constantly at work to contain the tuberculosis bacilli that years before gained entry into the body. In these cases, when immunity becomes compromised, such as with steroid treatment, tuberculosis can become reactivated. Colon cancer is more prevalent in patients who have the autoimmune disease ulcerative colitis, an inflammatory condition. Recent studies have focused on using anti-inflammatories to prevent colon cancer, but because of the serious deleterious effects of anti-inflammatories on the cardiovascular system, this approach has been abandoned (Bresalier, et al. 2005). If we think of the TCM concept of economics of energy, we should ask these two questions: Could it be that in these cases so much immune energy is directed at inflammation that the immune system becomes depleted and its function of surveillance against tumor cells become compromised? Could immune boosting with acupuncture and tonifying Spleen or Kidney herbs, in addition to antioxidants and diet control, have a role in prevention?

Up to now, Eastern and Western medicine have been entrenched in “us and them” camps. Even when Western practitioners pay lip service to complementary care as a viable option for their patients, they still view “them” as having strange, unintelligible ideas based on mysticism; as having treatments that, while sometimes effective, can’t be scientifically proven. Therefore comparing “them” on an equal footing with “us” in the allopathic camp is just untenable. Western practitioners of Chinese descent are particularly suspicious of TCM. Perhaps it is because they have seen the disastrous results when Chinese patients have triaged themselves, seeking TCM treatment inappropriately and getting Western help too late. Perhaps they have seen appendixes rupture or cancers progress to become inoperable. Eastern practitioners view Western ways as harmful. They view surgery as something to avoid at all costs and drugs as having toxic side effects and being incompatible with herbal therapy. It is my hope that this book will dispel some of these long-held notions and open dialogue between East and West in order to achieve optimal healing.