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A Discussion of Terrain, Stress, Root and Vulnerability within Chinese Medicine

by Leon Hammer

Introduction

It is my intention in this paper to frame the discussion of Chinese physiology and pathology in terms of the interplay of Terrain and Stress, and while acknowledging the importance of Stress [usually lifestyle], to return our clinical deliberation to the Terrain, the Root and the Individual (1) as the critical factors in the outcome of any physio-pathological event and therapeutic intervention.

Terrain

Central to this discussion but not its focus is the fact that Chinese medicine has a knowledge of the Terrain that has allowed it to achieve management and treatment modalities to influence it from `cradle to grave’.

From its inception, within recorded history, Chinese medicine has concerned itself with evaluating and managing the functional status of physiology; the qi, blood, essence, and body fluids, and deviations thereof from the `normal’ to which I refer to as Terrain. In Western medicine we have the rough equivalent, the Immune System, about which we continue to make amazing discoveries but about which we have little understanding how to influence. Instead, perhaps for this reason, the thrust and focus of biomedicine is on eliminating or ameliorating the stresses.

Fundamental to achieving a sophisticated and accurate evaluation of the Terrain, was, and still is the development of methods of measuring the `normal’ state and deviations thereof, using touch [the pulse, palpation of channels and abdomen] looking [tongue, eyes, colour], asking and listening. Having a baseline of `normality’ allows us to detect, with the modalities just mentioned, the slightest deviation and to access the development of disharmony that leads to disease at its earliest stage; thus my emphasis on sophisticated diagnosis as ineluctable to consistently successful clinical outcomes and prevention.

Within the Chinese medical community and society, stress has been the accepted consequence of fate, whereas in the Western civilizations, with rise of biological science, stress has taken a more prominent adversarial role in the pathogenesis of disease against which are committed to do battle.

In the event of an attack from what the Chinese would call an External Pathogenic Factor or biomedicine would call a virus or bacteria, the thrust in the West is to destroy the invader, while in the East the thrust has been to attenuate the invader and primarily to strengthen the defender, the qi, blood, essence and body fluids.

In the nineteenth century this difference reached its apogee in a monumental struggle between Louis Pasteur, who designated stress as the key issue, the bacteria, and another scientist [friend], known as `the father of experimental physiology’, Claude Bernard, who designated that key issue as `Le Milieu Interior’ [`Internal Environment’] or Terrain. The latter is the equivalent of the qi, blood, essence and body fluids long studied as the critical medical concern by the Chinese.

The ramifications of this struggle escalate to this day in which destroying the stressor is at the centre of biomedical research and practice with a strong financial incentive from the pharmaceutical companies. Little progress, relatively speaking, has been made in our ability to influence and strengthen the immune system.

This is true despite Pasteur’s last words as he died, “Bernard is right, `Le Meliu Interior (2)’ is everything, the bacteria nothing”.

Terrain is a determinant of another vital subject in medicine, Vulnerability and likewise with the issues of root and branch. Even more important the concept of Terrain is essential to our ultimate goal, to know and to help an Individual and to help them know and help themselves. Vulnerability has been a part of the literature of Chinese medicine since at least the Yellow Emperor Book of Internal Medicine through the system of correspondences in it’s various manifestations, as well as constitutional acupuncture from Korea and Japan.

The methodology of evaluating the terrain, Asking, Looking, Listening and Touching is the subject of a book currently in progress and not appropriate for an article limited in length. What we can do in this limited space is to examine the enlightening ramifications of the concepts of terrain and stress from a new perspective that places it in the centre of every practitioner’s mind each time they see a patient.

Root

A dilemma encountered endlessly in Chinese medicine is between those treating symptoms and those who treat conditions. It is my practice, described elsewhere, to exhaustively acquire all symptoms through an organized interview process that includes a comprehensive review of systems [ROS] once the initial complaints are detailed. I translate all symptoms into Chinese medical conditions, organize these conditions and collate them with signs such as the pulse, tongue, colour, eyes and sometimes the abdomen.

There are many ways of organizing the acquired information in Chinese medicine. There are the eight principles, the five phases, substances, solid or hollow organs, pathogenic factors [external and internal]. Let us assume that we have established a diagnosis, having gone through the diagnostic processes described above, and arrive at `heat in blood’ as the important Chinese medical condition. We have many well-known treatment options [Weng Qin Yin and moxa on Xuehai SP 10].

However, assuming that our treatment reduces the `heat in the blood’ and symptoms such as hypertension are ameliorated, what will keep the `heat in the blood’ from returning if we do not also eliminate the source of the `heat in the blood.’

There are many possibilities. External causes such as working in a very hot unventilated environment [restaurant kitchens], summer heat and meningitis, are easily identified. Internal causes such as excess heat in the Stomach-Intestines are diagnostically more difficult to recognize. However, why is there excess heat in the Stomach-Intestines. Is it because the food is indigestible and therefore like a car that overworks and overheats, the Stomach is overworking and overheating? Is this because the person cannot afford easily digestible food, or does not know enough about nutrition, or is emotionally driven to eat anything to assuage their hunger for other things like love? Or is the food good but the amounts, for similar reasons beyond the Stomach’s ability to digest it adequately? Or does the person eat too rapidly? Do they do this because of Heart qi Agitation, or because they work in an industry where little time is afforded for lunch, or where they are driven by their own ambition to set aside pleasure for gain? Or is the food too spicy? Or has the person been eating very cold foods that have created stagnation in the Stomach-Intestines and the body has brought metabolic heat to the area to overcome the stagnation.

An inefficient digestive process due to Spleen-Stomach qi deficiency can lead to the same overwork scenario described above due to the accumulation of incompletely digested food and the metabolic heat brought to move it. Since Liver Qi is responsible for moving the qi throughout the body, especially peristalsis, either Liver Qi stagnation [repressed emotion] or more often in our time, Liver Qi deficiency (3) [marijuana, LSD] will inhibit the downward movement of qi. Or could a hyper-vigilant `Nervous System Tense’ patient overwork the Liver and lead to the same result. Have the patient suffered from anorexia or bulimia, the first of which creates Spleen qi deficiency due to inadequate nutrition, and the latter that drains Spleen-Stomach qi by repeatedly going against the normal flow of that qi.

While most symptoms have multiple aetiologies, probably the most common contribution to heat in the blood are repressed emotions or Liver Qi stagnation. This sets off a process involving the Liver mobilizing metabolic heat to move the stagnation. If it does not succeed, the heat will become toxic, and the Liver must remove it. Since the Liver stores the blood it will usually move the toxic heat there as a retained pathogen and then become a pathogenic entity in itself, usually over time raising blood pressure. Some of the other causes of `heat in the blood’ could be medications, other heat creating drugs of abuse [cocaine, amphetamines].

Where does this lead us? To the personal questions regarding what emotions are being repressed, why does the person eat to assuage emotional pain, why is the person eating so rapidly in order to realize their ambitions? Now we are getting closer to the Root.

The Root usually lay in the deepest part of a person’s psyche or in the earliest experiences at conception, in utero, at birth or shortly thereafter, though emotional shock such as the loss of a parent or sexual abuse in childhood or other emotional insults can equally be the Root. Each of these complex issues are the subject of further in depth exploration too extensive for this discussion but each at the heart of our search for the Root of our patient’s `heat in the blood’.

What is the point of this exercise? To demonstrate that our conventional approaches to diagnosis and treatment, eight principles et al. described above are insufficient to heal the core human pain at the Root of our afflictions.

Stress, Trauma and Shock

A. Introduction
Stress, trauma and shock begin at least at conception depending on the life-style of the parents. Drugs and deleterious habits that affect sperm and ova, emotional strains, and especially age have a profound effect on the sperm-egg viability and on the terrain of the foetus. Stress continues throughout pregnancy again in terms of the parent’s life-style and what Shakespeare called “the slings and arrows of outrageous fortune”, the vicissitudes of life. And certainly vaginal birth is the prototype of stress in the struggle of a foetus to reach for their existence and individuality. In my experience, `insults’ during these early stages of development degrade Kidney Essence and the foetal Heart that experiences `shock’ and Circulation due to the effects of trauma on the placental circulation on which the foetus depends completely. All of these play a role in the ultimate shape of a person’s `terrain’.

There are methods of detecting and treating these early Kidney Essence deficiencies [qi gong] and Heart Shock, as well as other shocks to the Heart throughout life (4). We have found that all shock at any time affects the Heart and that chronic stress, the frustrations of everyday life affect the Liver, since it is the Liver that `contains’, as I explained in my article, `The Liver in Chinese Medicine’ (5). All this and much more is possible to detect with the pulse (6). Traumas during the early phases of development have lifetime consequences. Intractable headache, for example, is very often caused by direct trauma to the head, and healed only by direct treatment to areas of the scalp sensitive to touch, rather than from distant points.

B. Stress
Stress is usually associated with the chronic pressures and frustrations of everyday life and our adaptations and mal-adaptations to them. The function of the Liver to both move and contain responds to stress with an emphasis on containment that becomes the all too familiar Liver Qi stagnation. The Liver gradually becomes deficient due to the attempt of the organism to move the stagnant Qi, and throughout history in all parts of the world people have found ways to relieve stress and this stagnation with substances all of which have deleterious effects on the Liver and accelerate its decline into Liver Qi/Yang deficiency [marihuana, LSD, heroin] or severe Liver Yin deficiency [Alcohol, cocaine] (7).

It is obvious that stress is the inescapable motif of life. We are stress. Place a person in a room alone and they will begin to argue with themselves. A person wiser than myself once told me, “God is not interested in peace, only in clarity”. Human history of unending war speaks to this assertion.

Stress had something to do with expectations. If things do not go as planned and we are called upon to struggle we experience this as stress. As mentioned above, in societies such as in the orient [perhaps only in the past] the unfolding of events was experienced as fate, against which there was no point in struggling. There were certainly more than enough exigencies of life we call stress that because of this philosophy was less stressful.

So it is often the inner experience of life’s struggles that constitutes the stress associated with pathology. My teacher Dr. Shen was born into one the richest families in China. His grandfather was president of the first private bank in China in 1911 when the empire ceased and was raised in the utmost luxury. Throughout the war with Japan he escaped many times finally spending it in Chunking with the Nationalists. After Japan was defeated and he returned to Shanghai he was forced to flee to Taiwan when the victorious communists came because his family was rich and he sold rice to Chiang Ki Chek, their enemy. When I met him in the USA he lived in a very modest apartment in China Town where at first he earned his living through `face reading’. From that time throughout his increasingly successful and financially remunerative career he never changed, always trying to do better but always accepting his current state as fate.

Scientists such as Cannon [homeostasis-fight or flight] and Hans Selye [Pituitary-Adrenal- Axis (Cortisol)-General Adaptation Theory] traced to some extent the physiological pathways of stress that until our time has been illuminating but not ameliorating. More relevant to our discussion is how society responds to the effects of stress between the physical response and the mental response.

Speaking as a psychiatrist I can say categorically that society responds far more benignly to physically ill people than to those whose response is mental and emotional. If you are hospitalized for physical reasons there is no stigma and once you are released any follow up is purely voluntary. Once you are hospitalized for mental illness you are caught forever, without choice, in the mental health system. In 1972 the democratic vice- presidential candidate was forced to withdraw because he had been treated for depression.

The assessment of stress is the subject of separate articles involving a detailed discussion of the Asking, Looking, Listening and Touching diagnostic methodologies and their integration. Examples from Contemporary Chinese Pulse Diagnosis illustrates one aspect of this assessment process: Left Middle Position Empty: Cold substances [pot]; Rough Vibration on entire pulse: Shock; Spinning Bean: Shock; intractable pain; Cotton: Stuck in life; Muffled LDP: suppressed joy; Intensity Changing from Side to Side:

Interpersonal conflict; Inflated Left Diaphragm [3 or more]: anger replaces tender feeling w/separation; Right Diaphragm Inflated [3 or more]: lifting beyond `energy’

C. Trauma and Shock
Trauma on the other hand is an acute situation, such as a physical accident or the sudden loss of a loved one, or even of something that is very important to one such as money, or precious possessions. Trauma, even physical, is also almost always accompanied by a Shock to the Heart that drains Heart Yin, often simultaneously causes Phlegm Misting the Orifices and in my experience stagnates Qi especially in the Heart, Lungs [Muffled Quality and chest [Inflated Diaphragm] (8).

A seventy-year old man consulted me around the year 2000 for strong feelings of heat in his feet requiring him to put his feet in ice at bedtime in order to be able to sleep. He had excess heat in his blood and hypertension for which he was medicated. He returned three weeks later at which time I took his pulse again and found at his left distal position [Heart] a Muffled [5] quality [5 is the maximum].This is a sign of extreme stagnation of all substances, especially Qi [Heart Closed] (9) usually associated with extreme loss and emotional pain against which the Heart protects itself by a variety of defence mechanisms [i.e. denial, dissociation, etc.]. I asked what had happened to him since I saw him last since he had no Muffled quality before at the left distal position, suggesting some kind of catastrophe during the past three weeks. He reported that since his retirement he `day-traded’ on the stock market, and with the breaking of the dot Com bubble around 2000 he lost half of his savings, about six hundred thousand dollars since I had last seen him.

Vulnerability

A. Introduction
Which brings us to `vulnerability’, the balance between stress, shock, trauma, the outside forces, and Terrain, the inner environment. It is that interplay that determines the outcome of any encounter with life, outer or inner, mental or physical.

Vulnerability is a function of the viability of the terrain. In contradistinction to the `Law of Correspondences’, a stress will affect the most vulnerable organ or area rather than the one assigned by those laws. If the Lungs are more vulnerable than the Liver, anger will affect the Lungs before the Liver. [For a discussion of the areas controlled by each organ and their associated symptoms, see `Diagnostic Considerations-Primary Organ Functions below].

So, if you have a person with persistent Lung problems do not always look for grief as the cause. Don’t limit yourself to the `Law of Correspondences’, anger, or any of the emotions, could be just as important aetiologies if the Lung is vulnerable. If in the unlikely case that there are no particular vulnerabilities the `Law of Correspondence’ will probably hold. There is no information available to me whether a defective organ leads to the associated emotion according to the `Law of Correspondence’.

Harvard researchers recently published findings from a study that explored the link between anger and hostility and lung function. Even at the beginning of the study, men with the highest anger and hostility ratings had the poorest lung function, and their condition deteriorated over the period of the study. According to Dr Paul Lehrer, one of the authors of the study, "Stress-related factors are known to depress immune function and increase susceptibility to, or exacerbate a host of diseases and disorders," he said. "Indeed, it is hard to find a disease for which emotion or stress plays absolutely no part in symptom severity, frequency, or intensity of flare-ups”. "The scientists did not know how unresolved negative emotions contribute to the physical deterioration of the lungs but expect that this question will be the topic of another study. Another site that seem to be related was the Heart (10).

Furthermore, from the beginning we are not all created equal, and our competitive world causes people great internal pain by expecting everyone to succeed, to be the same, as if sheer will power can overcome inherent handicaps. Will power carries us beyond our capabilities at a great price to Terrain and an inevitable enhancement of vulnerability.

In interviewing a patient we must ask ourselves whether or not the clinical picture before us is the consequence more of the stressors in their life or the consequence more of their inability to cope with these stresses, with their Terrain. In my teaching experience it is the inclination of students to place their focus on the stress and overlook the vulnerability of the patient to the stress, their terrain.

While we are always dealing importantly with lifestyle changes that reduce stress, be it diet, work, sleep, abuse [drugs, etc.], work and even play, we are doing so in the context of the physiological landscape of that particular person, the Terrain. To the extent that the terrain physiology is compromised the person who owns it is vulnerable more or less to that stress, and the consequences are more a function of the Terrain than the stress unless the stress is so overwhelming that even the strongest terrain will accede and `break’.

B. Diagnostic Considerations
1. Primary Organ Function
Vulnerable areas will be the first to be affected by new insults, whether from the outside or the inside. If you have a problem in these areas look to these organs.

These lists are meant only as indicators and not for completeness.
a. Liver
Liver qi deficiency is evident in pain in the hypochondriac area, parietal headaches, and blood deficiency in problems with muscles, nerves, ligaments and tendons, with spasms, numbness and tingling and with easy eye fatigue, blurring and double- vision.

The Liver manages stress through its ability to contain emotion, which when it fails, spreads the contained qi to vulnerable areas such as the breast [fibrocystic tumours, Heart [palpitations at rest], Lungs-diaphragm [sudden shortness of breath], Spleen-Stomach [regurgitation, qi and food stagnation, pain], Intestines [explosive diarrhoea], the Bladder [interstitial urethritis] and migrating joint pains [retained repressed emotional pathogen through divergent or muscle Channels] made worse by stress, head [parietal area tight pain].

For example a middle-aged woman had been in a severe automobile accident involving extensive abdominal surgery including the removal of her Spleen. In subsequent years she would have severe abdominal pain and intestinal blockage. The gastro-enterologist postulated that the blockages occurred around the scar tissue but could not explain the timing of the occurrence. Over time it became clear that these attacks occurred in situations where she had profound emotions that she could not express or act upon and was a situation where stagnant Liver qi `attacked’ her most vulnerable area, the scars.

b. Gall Bladder
The Gall Bladder evidence of dysfunction involves the sinuses, post-nasal drip, headaches involving the eyes, eyebrows, behind the eyes, pain in the left hypchondriac area and right shoulder as well as intolerance to fats.

c. Kidney
If the Kidney qi, yang and essence are deficient, problems will occur in the lower burner including the perineum [inguinal hernia], lower back, knees, descending colon, reproductive organs, urinary difficulties, hearing difficulty especially early in life, allergies and asthma early in life and early neurological problems. Easily cold, coldness to the bone, are other symptoms of Kidney Yang deficiency some anaemia is a symptoms of Kidney Essence deficiency.

d. Lung
If Lung qi is deficient look to problems in the head and neck except the mouth and eyes. The ears, nose [sinus] and throat, as well of course, the Lungs, will be vulnerable to infection due to inadequate circulation of Wei Qi when the Lungs are insufficient.

e. Spleen-Stomach
Spleen-stomach qi deficiency manifests obviously with gastro-intestinal problems, especially chronic constipation and diarrhoea. Gum inflammation and lip sores are often associated with Stomach heat as well as forehead headaches. Generally not associated but clearly so in my experience is water retention in connective tissue. There is fundamental error in the textbooks regarding the Spleen’s control of areas of the body. Probably in mistranslation the Spleen as been assigned as controlling muscle whereas experience shows that the Liver controls muscles and that the Spleen controls connective tissue where it stores fluids that it cannot normally digest and disperse [retained pathogen].

f. Heart
When Heart qi is exiguous there will be shortness of breath, circulation throughout the entire body is compromised with cold extremities, migrating pains worse with fatigue and better with rest. Heart blood deficiency will manifest poor concentration and memory and blood stagnation as chest pain often migrating to the left shoulder and arm. Heart Qi agitation manifests as anxiety and internal chaos and phlegm misting the orifices I associate with neurosis and psychosis as well as some neurological problems including ADHD.

2. Vulnerability in Dr. Shen’s `Systems’ Model
a. `Nervous System’
We will consider the vulnerability first of the `Nervous System’. The integrity of the ‘nervous system’ as conceived by Dr. Shen (11) is the primary factor in the aetiology of all psychological disorders. No matter what the stress may be, if the ‘nervous system’ is vulnerable, there will inevitably be some kind of psychological disorder, and these disorders come relatively easily.

On the other hand, if this level of energy, which Dr. Shen calls the ‘nervous system,’ is strong, the stress is more likely to produce a physical illness than one which has psychological components, except, perhaps, as an eventual reaction to the physical illness should it last long enough or be serious enough.

Dr. Shen’s `Nervous System’ is essentially Kidney Yang Essence. Essence is our foundation. If the foundation is strong one can recover quickly from stress and stand again. If the foundation is weak one recovers more slowly if at all.

A paradox exists: the `nervous system weak’ person’s vulnerability may save their life because they are informed of a problem sooner than the stronger person and therefore they seek help earlier in the process. As a psychiatrist, when I received a call from an adolescent for help I knew that he was quite ill, usually schizophrenia, because unless they are totally desperate, adolescents do not ask for help. That early call has saved many lives that were otherwise lost to adolescent and young adult suicide in those who were able to function until then under the weight of the emotional chaos that earlier collapsed those with vulnerable `nervous systems’.

With sufficient stress, even an extraordinarily healthy ‘nervous system’ may develop severe psychological problems. This is quite clear during war, when people who are otherwise emotionally extremely stable break down due to impossible physical and emotional strain. In other words, everyone has their psychological breaking point, no matter how healthy their ‘nervous system’, their terrain, may be to begin with.

Western psychologists have always found it difficult to explain why, under similar circumstances, people who appear relatively equal respond so differently on the psychological level. Why, for example, do people raised in the same family, under very similar conditions, develop different psychological patterns? The concept of systems, according to Dr. Shen, brings some order to this area of confusion.

b). Dr. Shen’s Other Systems
Let us again take a situation of extreme stress, such as war. In my own experience during World War II, I observed responses to severe stress that more or less fit into this notion of the four systems. Of course these observations were made between the ages of eighteen and twenty-one and only recently have I noted the following connections. The advantage was the very large sample.

As discussed above and described below, some people had mental break-downs involving a vulnerable ‘nervous system.’ The rare few who fainted or had profuse sweating had difficulties with their ‘circulatory system.’ Most like myself had gastrointestinal reactions such as vomiting or diarrhoea and a vulnerable `digestive system’. Though I never observed it, I occasionally heard of people who seemed to simply die of suddenly, undoubtedly cardiac arrest, from what seemed like severe shock or fright, who undoubtedly had some kind of susceptibility (congenital anomaly in their ‘organ system’, e.g., aneurysm, formen ovale), since they were so young)

3. Vulnerable Areas due to other causes
These include previous trauma including surgery [see example above under Liver] previous illness in such as repeated strep throats as child [Rheumatic Fever] and subsequent Heart disease [especially valves]. Abused Areas such as the diaphragm with difficulty catching breath and chest pain in people who lift beyond their capacity or more often repress tenderness replaced by anger [acrimonious divorce].

Other disabilities, such as inguinal, abdominal and hiatal hernias, occur with people who lift beyond their `energy’ or lift improperly. The hernia is of course more likely if there is already a deficiency in the burner in which it occurs. The area to which the body sends retained pathogens [toxins, parasites etc] through divergent channels including joints, muscles, fascia become vulnerable. People born with congenital defects such as a depressed sternum become vulnerable to respiratory diseases due to lack of room to expand the lungs decreasing ventilation in the Lungs.

C. Balance Between Stress and Terrain and Finding the Root and the Individual

1. Patient With Minimum Stress and Minimum Terrain
a. Narrative
A 51 year old man presented with Chronic Fatigue, Fibromyalgia and ankylosing spondolithiasis of the spine and thoracic sternum, sensitivities to fragrances and loss of voice, all of which began since he had very severe flu with a low grade fever, shortness of breath and insomnia two and one half years prior. There has been an exacerbation of symptoms on the two anniversaries of the flu which lasts for months with relief only when he perspires heavily in hot weather.

Since childhood, to a lesser degree, he always felt easily fatigued, especially in the morning. Likewise, he has had poor digestion, oesophageal and stomach ulcers at age 30 and had many cavities. He was highly allergic as a child, and his left kidney was removed at age 19 due to congenital hydronephrosis.

There is a history of prolonged and extensive marihuana use. The pulse revealed a Nervous System Tense person with severe anxiety and a True Qi deficiency with considerable Separation of Yin and Yang. Energetic Heart Enlargement [at least] and Mitral Valve Prolapse and an absence of qualities in the LDP [Heart] suggest significant Heart Qi deficiency. [He is on a beta-blocker for palpitations several times a week].

Further inquiry revealed that his mother became psychotic during the pregnancy with him and remained so. He adored his father [“a functioning alcoholic”] who died when he was 16 at which time he left the home with relatives who had raised him.

b. Comment
The onset of this Chronic Fatigue Syndrome two and one-half years ago followed a severe flu. This is known route for the onset of this condition (12).

Deficient Wei Qi [right distal position absent] allowed the cold to penetrate deeply and his True Qi deficiency [five of six pulse positions qi deficient] and multiple Separations of Yin and Yang [three of six pulse positions and tired all of her life] has made it impossible for him to eliminate the cold since. The organism has attempted to eliminate exterior cold by bringing heat [Yang] to move it out which failed and the interior cold continues to cause Qi stagnation [and heat that develops as a consequence] over the years while [Floating Slippery pulse w/pounding] this futile attempt by the body to eliminate Internal heat added True and Wei Qi deficiency experienced as Chronic Fatigue Syndrome. The now interior cold gradually fatigues peripheral circulation that is attempting to bring the heat causing an artificial blood deficiency to nerve endings in the skin experienced as fibromyalgia.

The body’s intelligence routed some of the invading cold away from the vital organs as a Retained Pathogen in the spine resulting in ankylosiing spondelytis. The location is probably due to the insult to Kidney Essence in utero during his mother’s psychosis and perhaps the effect of alcohol on his father’s sperm from his alcoholism.

Life long easy fatigue, recurrent flu, inhalant restriction of his breath with certain odours, digestive disorders since early childhood and the congenitally deformed kidney, indicate a deficient terrain, most likely Kidney Essence deficiency, from birth [always feels cold]. His mother’s emotional state and poor nutrition during the pregnancy probably diminished placental circulation and his nutrition in-utero.
The fact that sweating relieves the symptoms is one guide to the beginning of the resolution, which is to remove the interior Cold stagnating the Qi and Blood, and now turning to internal Heat. The restoration of the Terrain including the True Qi and Blood deficiency and the Qi wild condition are ongoing measures, especially since he feels better after eating.

The most effective method of removing the cold is a ginger bath [3 slices of ginger the thickness of a coin for every cup of tea (bring to boil and simmer for 20 minutes), enough to partially a bathtub-adding the rest of the water to toleration. Because of his extremely deficient condition the time in the bath should be limited at first because the ginger bath can be draining.

A herbal formula, Duo huo ji sheng tang [Angelica Pubescens and Sangjisheng Decoction] was prescribed to remove the cold and Shen Ling Bai Shu Pian [Ginseng, Poria and Atractylodes] to begin to restore Qi, with longer range plans to support the Heart and Kidneys [Qi Gong], blood and yin were considered as well as the Nervous System Tense Formula for that condition found on the pulse and in his mind associated with anger at injustice about which he was very judgmental and a perfectionist [Metal in Worsley System].

We have identified the Terrain, his Qi Wild and True Qi [Wei qi] deficient condition. We have identified the Stress, invading cold [the flu] and we have described the pathogenesis, the interaction between the two. And as importantly, we have identified the Root, the initial source of his deficient Terrain, his mother’s psychosis during and after pregnancy and the ensuing Kidney Essence deficiency and shock to the Heart-Circulation where the Terrain issues began and where some of our treatment must be aimed [qi gong and herbs].

Beyond the root is the Individual person who has adapted to the destabilizing root conditions through obsessive-compulsive [mind organizing] thought processes and work habits. While it has until now permitted him to be functional and establish a way of staying in `contact’ in order to stay `intact’ through work-related associations, it has in fact kept him from forming a loving non-critical bond that might have nurtured his significant deficiencies.

2. Maximum stress Overcomes Maximum Terrain

Patient
Introduction
The following is a very attenuated account of a patient [Mrs. Y] beginning life with a relatively intact terrain who encountered stress throughout her life that eventually broke her mental and physical health. She is only one of a number of women with a similar history and outcome and in whom I first encountered the combination of Chronic Fatigue Syndrome and Fibromyalgia in the 1980s. I wish to point out that none of these women could have functioned so amazingly so long until their `break’ if their terrain had not been initially very strong.

Presentation
The patient is a 50 year old woman whose original biomedical diagnosis was Addison’s disease, Pernicious Anaemia, Chronic Fatigue, Fibromyalgia, Hypothyroidism, Kidney Stone, Hypotension, Malignant melanoma [removed without recurrence for several years], insomnia [sleep reversal] and loss of taste. Her original symptoms involved a total physical collapse, marked by the inability to focus or use her mind and inability to function for many years. She complained of spontaneous cold perspiration w/o exertion, tenderness on her entire body, sleep reversal, body & legs heavy & numb, irritable bowel, explosive b.m., palpitations at rest, hot flashes & night sweat that stop when awakes; cold-shiver, ventricular tachycardia, dependant oedema in hands, headaches, easily startled during sleep, constipation for 5-6 days, constipation diarrhoea in same movement and thirst large but often cannot drink. She was depressed, experienced panic and phobia, felt driven and unable to retreat, yet felt a lack of direction for that drive.

History
Apart from an emotionally abusive childhood Mrs. Y worked nights for 30 years as a nurse while raising children and then grandchildren, cooked, cleaned and cared for a difficult mother while undergoing two divorces from men who offered no support. As a nurse, she was exposed for years to chemicals without protection while preparing drugs for chemotherapy and had multiple falls from horses [her passion].

Signs
Briefly, the pulse showed signs of heart shock, a Change in Qualities in all of the Principal Positions representing the solid [zang] organs indicated a Qi Wild ubiquitous Separation of Yin and Yang, one of the most severe diagnosis possible, a propensity to neo-plasms and a toxic retained heat pathogen. Supporting the seriousness of her condition, her tongue showed a loss of colour in the heart and lung areas.

Initial Summary
Mrs. S. is a courageous 49 year old woman, with evidence of a True Qi deficiency and significant Kidney Qi-Yang-Jing deficiency, [adrenals, thyroid] leading to a Qi Wild condition of extreme physiologic chaos, especially of her Liver, Heart and Lungs. The Liver Separation of Yin & Yang, due largely to overwork, makes it difficult for her to retreat. There is strong evidence of trauma and shock to the Heart.

Driven by her fear of slipping into the grips of abusive, joyless childhood caretakers and dependant men and employing an extraordinary work-caretaking ethic to the point of exhaustion, she has depleted her endocrine system and produced the instability-deficiencies listed above, and at this point presents herself as broken person unable to function.

Conclusion

As the Chinese medical profession swings ever so strongly in the direction of the allopathic model I find it important to return the focus to the essential elements of the Chinese model, ones that we have herein discussed.

Simply we must restore the difficult part of Chinese medicine of evaluating the individual’s Terrain, their essential physiology and psychology to the centre of our medical attention. No medicine practiced in its most profound form can do this better than Chinese medicine, nor any medicine better to address the management and treatment of the individual Terrain from conception through to very old age.

While the Stresses of everyday life to which we are all exposed are necessary to delineate, their fate in any one person, except in the most extreme situations, is determined by the integrity of physiology, the individual coping mechanisms that I call Terrain.

Stresses themselves are, except in overwhelming cataclysmic circumstances, [earthquakes, hurricanes, tornados, floods, war] a function of lifestyle, of the individual and sometimes of a society. Destructive individual lifestyle ranges across human activity from sleep, food, sex, drugs, work and exercise that can be altered only by changing the offending lifestyle.

To achieve a true assessment of the Terrain and of the Stress we must search for the Root of each, often at the beginning of life in the former. Our diagnostic challenge is to decide as to what extent do we need to alter life style, rebuild terrain, address the Root of each, and the psyche whose mal-adaption made the rest inevitable (13).

In certain situations, as with toxicity, it is a matter of doing all in a particular cycle to enhance the patient’s ability to eliminate the toxin and at the same time assist when necessary, and of course with regard to the Root, eliminate the source of the toxin.

The critical issue is that once the symptom, the stress is cleared you must still deal with the vulnerability, the Terrain, the Root and the person (14), or the problem will recur endlessly. Place Terrain, Root and the Individual at the conceptual centre of your clinical mindset and realize the potential.

References

1. Hammer, Leon I. M.D.; Dragon Rises Red Bird Flies; Eastland Press, 2005, Chapter 7
2. Bernard, Claude: Le Meliu Interior; Rappot Sur La Progress et la Marche del Physiology Generale en France, 1865; University of Nebraska 1960Lincoln
3. Hammer, Leon I M.D..; The Liver in Chinese Medicine; Medical Acupuncture,
4. Hammer, Leon .I M.D..; Heart –Kidney Essence Formula
5. Hammer, Leon I. M.D..; Chinese Pulse Diagnosis: A Contemporary Approach; Eastland Press, 2005
6. Hammer, Leon I. M.D.; Chinese Pulse Diagnosis: A Contemporary Approach; Eastland Press, 2005, chapter 12
7. Hammer, Leon I., M.D. The Liver in Chinese Medicine; Medical Acupuncture, Vol 21, Number 3, 2009; Mary Ann Liebert, Inc. DOL: 10. 1089/acu.2009.0672
8. Hammer, Leon I.; Chinese Pulse Diagnosis: A Contemporary Approach; Eastland Press, 2005
9. Ibid P. 749
10. Dr. Paul Lehrer: http://www.hon.ch/News/HSN/ 534679.htmlhttp://www.news.harvard.edu/gazette/2006/09.21/01-anger.html
11. Hammer, Leon I. , M.D.; Dragon Rises Red Bird Flies; Eastland Press, 2005, Chapter 14
12. Giovanni Maciocia; The Practice of Chinese Medicine; Dr. John Shen-Personal Communication 1974-82
13. Hammer, Leon I. M.D.; The Patient-Practitioner Relationship in Chinese Medicine; Theime, 2008
14. Hammer, Leon I. M.D.; The Pulse and the Individual; The American Acupuncturist, Spring 2008, Vol 43

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