Hot and cold theory : the path towards personalized medicine 9783030809829, 9783030809836, 303080982X

Table of contents :
Foreword
Preface
Why did I Start This Project?
Who is the Target Audience? How did I Select the Contributors?
About the Book
Acknowledgements
Contents
Editor and Contributors
Abbreviations
1 Introduction: Hot and Cold Theory, the Path Towards Personalized Medicine
Abstract
References
Definitions and Beliefs
2 Principle of Hot and Cold and Its Clinical Application in Traditional Chinese Medicine
Abstract
2.1 Introduction
2.2 Methods
2.3 Case Presentation
2.4 The Concept of Qi
2.5 Yin and Yang Theory
2.6 Five Elements
2.7 The Concept of Heat and Cold in Chinese Medicine
2.7.1 Cold and Heat According to Yin–Yang Theory
2.7.2 Cold and Heat as Pathogenic Factors
2.7.3 Cold and Heat, According to the Nature of the Herbs
2.7.4 Cold and Heat in Acupuncture
2.8 Discussion
2.9 Conclusion
Acknowledgements
References
3 Principle of Hot and Cold and Its Clinical Application in Persian Medicine
Abstract
3.1 Introduction
3.2 Methods
3.3 Case Presentation
3.4 History
3.5 Definition
3.5.1 Elements
3.5.2 The Concept of Mizaj
3.6 Types of Mizaj
3.7 Identification of Mizaj
3.8 Factors Affecting Mizaj
3.8.1 Age
3.8.2 Gender
3.8.3 Seasons
3.8.4 Region
3.8.5 Foods
3.8.6 Drugs
3.9 Role of Mizaj in Disease Prevention and Treatment
3.9.1 Climate
3.9.2 Food and Drink
3.9.3 Sleep and Wakefulness
3.9.4 Body Movement and Repose
3.9.5 Mental and Emotional States
3.9.6 Retention of Healthy Matters and Excretion of Waste Matters
3.9.7 Role of Mizaj in Disease Diagnosis and Classification
3.9.8 Mizaj Diagnostic Tools
3.9.9 Case Discussion
3.10 Conclusion
Acknowledgements
References
4 Principle of Hot (Ushna) and Cold (Sheeta) and Its Clinical Application in Ayurvedic Medicine
Abstract
4.1 Ayurveda and Its Fundamentals: A Brief Introduction
4.2 Methods
4.3 Theory of Panchamahabhuta and Tridosha
4.4 The Emergence of Hot and Cold as a Cause of Disease and Treatment Modalities
4.5 Principle of Opposing Therapies
4.5.1 Therapeutic Applications of Heat and Cold in Ayurveda: The External Usage
4.5.2 Therapeutic Applications of Heat and Cold in Ayurveda: Internal Usage
4.6 Human Prakriti and Its Association with Sheeta and Ushna Properties
4.7 Acquainting with Hot and Cold Precepts: Examples from Ayurvedic Clinical Practice
4.8 Translational Value of Ushna and Sheeta in Disease Diagnosis and Management: A Few Case Examples
4.9 Conclusion
Acknowledgements
Textual References
References
5 Principle of Hot and Cold and Its Clinical Application in Latin American and Caribbean Medicines
Abstract
5.1 Introduction
5.2 Methods
5.3 Case Presentation
5.4 Hot and Cold Concepts in Latin American and Caribbean Medicines
5.5 Hot and Cold in Healthy Individuals
5.5.1 Body Humors, Heat and Cold
5.5.2 Pregnancy, Delivery, and Postpartum
5.5.3 Childhood and Adulthood
5.6 Hot and Cold Maladies
5.7 Hot and Cold Foods
5.8 Medicines from Hot to Cold
5.9 Discussion
5.10 Conclusions
Acknowledgements
References
Scientific Evidence
6 Hot and Cold Theory: Evidence in Nutrition
Abstract
6.1 Introduction
6.2 Methods
6.3 ‘Hot’ and ‘Cold’ Natured Properties of Food
6.3.1 Traditional Classifications of ‘Heating’ and ‘Cooling’ Properties of Food
6.3.2 Applications of Dietary Therapy for the Maintenance of Health and Disease Management
6.3.2.1 Applications of Dietary Therapy for Health Maintenance
6.3.2.2 Applications of Dietary Therapy for the Management of Disease
6.4 Scientific Evaluations of the ‘Heating’ and ‘Cooling’ Nature of Foods
6.4.1 Food Compositions and Their Associations with ‘Hot’ or ‘Cold’ Properties
6.4.1.1 Nutritional Content and Chemical Composition
6.4.1.2 Acidity and Alkalinity
6.4.2 In-vitro and In-vivo Studies Exploring Physiological Effects
6.4.2.1 Autonomic Nervous and Endocrine System Impacts
6.4.2.2 Pro- and Anti-inflammatory and Oxidative Effects
6.4.3 Summary
6.5 Conclusion
Acknowledgements
References
7 Hot and Cold Theory: Evidence in Pharmacology
Abstract
7.1 Introduction
7.2 Methods
7.3 Hot and Cold Medicinal Plants: Pharmacological Evidence
7.3.1 Hot-Tempered Plants
7.3.1.1 Cinnamon
7.3.1.2 Garlic
7.3.1.3 Ginger
7.3.1.4 Pepper
7.3.2 Cold-Tempered Plants
7.3.2.1 Cannabis
7.3.2.2 Lettuce
7.3.2.3 Purslane
7.3.2.4 Thorn Apple
7.4 Conclusions
Acknowledgements
References
8 Hot and Cold Theory: Evidence in Physiology
Abstract
8.1 Introduction
8.2 Methods
8.3 An Overview on the Research About Hot–Cold Theory Based on Body Systems
8.3.1 Cells and Organs
8.3.2 Membrane Physiology, Nerves, and Muscles
8.3.3 The Circulatory System
8.3.4 Body Fluids and Kidneys
8.3.5 Blood Cells and Immunity
8.3.6 The Respiratory System
8.3.7 The Nervous System
8.3.8 Gastrointestinal Physiology
8.3.9 Metabolism and Temperature Regulation
8.3.10 Endocrinology
8.3.11 Female Physiology
8.3.12 Sport’s Physiology
8.4 Conclusion
Acknowledgements
References
9 Hot and Cold Theory: Evidence in Systems Biology
Abstract
9.1 Introduction
9.2 Methods
9.3 Hot and Cold Theory in the Light of Systems Biology in TCM Studies
9.3.1 TCM Syndrome-Based Diagnosis and Therapy Classification
9.3.2 TCM Constitution-Based Studies
9.3.3 TCM Systems Pharmacology
9.4 Hot and Cold Theory in the Light of Systems Biology in Humoral Medicine Studies
9.5 Hot and Cold Theory in the Light of Systems Biology in Ayurvedic Studies
9.6 Latin American and Caribbean Medicines in the Light of Systems Biology Studies
9.7 Korean Medicine (Sasang Constitutional Medicine) in the Light of Systems Biology Studies
9.8 Conclusion
Acknowledgements
References
Perspective
10 Hot and Cold Theory: A Personalized Medicine Approach
Abstract
10.1 Introduction
10.2 Biological Basis of Hot and Cold Theory in Traditional Medicine
10.3 Drugs with Hot and Cold Nature in Traditional Medicine
10.4 Discussion and Future Perspective
Acknowledgements
References
11 Hot and Cold Theory: Future Perspective
Abstract
11.1 Hot and Cold Theory; Science and Pseudoscience Classification
11.2 Holistic Approach
11.3 Personalized Approach
11.4 Future Research
References

Citation preview

Advances in Experimental Medicine and Biology 1343

Maryam Yavari   Editor

Hot and Cold Theory: The Path Towards Personalized Medicine

Advances in Experimental Medicine and Biology Volume 1343

Series Editors Wim E. Crusio, Institut de Neurosciences Cognitives et Intégratives d’Aquitaine, CNRS and University of Bordeaux, Pessac Cedex, France Haidong Dong, Departments of Urology and Immunology, Mayo Clinic, Rochester, MN, USA Heinfried H. Radeke, Institute of Pharmacology & Toxicology, Clinic of the Goethe University Frankfurt Main, Frankfurt am Main, Hessen, Germany Nima Rezaei, Research Center for Immunodeficiencies, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran Ortrud Steinlein, Institute of Human Genetics, LMU University Hospital, Munich, Germany Junjie Xiao, Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Science, School of Life Science, Shanghai University, Shanghai, China

Advances in Experimental Medicine and Biology provides a platform for scientific contributions in the main disciplines of the biomedicine and the life sciences. This series publishes thematic volumes on contemporary research in the areas of microbiology, immunology, neurosciences, biochemistry, biomedical engineering, genetics, physiology, and cancer research. Covering emerging topics and techniques in basic and clinical science, it brings together clinicians and researchers from various fields. Advances in Experimental Medicine and Biology has been publishing exceptional works in the field for over 40 years, and is indexed in SCOPUS, Medline (PubMed), Journal Citation Reports/Science Edition, Science Citation Index Expanded (SciSearch, Web of Science), EMBASE, BIOSIS, Reaxys, EMBiology, the Chemical Abstracts Service (CAS), and Pathway Studio. 2020 Impact Factor: 2.622

More information about this series at https://link.springer.com/bookseries/5584

Maryam Yavari Editor

Hot and Cold Theory: The Path Towards Personalized Medicine

123

Editor Maryam Yavari School of Medicine Isfahan University of Medical Sciences Isfahan, Iran Canadian College of Naturopathic Medicine Toronto, ON, Canada

ISSN 0065-2598 ISSN 2214-8019 (electronic) Advances in Experimental Medicine and Biology ISBN 978-3-030-80982-9 ISBN 978-3-030-80983-6 (eBook) https://doi.org/10.1007/978-3-030-80983-6 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is dedicated to all those without whom the concept of this book would not have formed and this book would not be written; those who read and critically think about the idea and those who will develop it in future

Foreword

A few years ago, Maryam Yavari appeared at my Canadian College of Naturopathic Medicine office door and introduced herself. Your Dr. Saunders, you know about plants and you graduated from Duke University? I answered yes to all of the above and so this journey began. Our medical ancestors were keen observers of Mother Nature and human nature and, no doubt, quickly noticed that there were clinical ties between the two. Some were hot and some were cold, some were damp and some were dry, and so forth, and all had deep ties to the earth from which both food and medicines were obtained. The origins of hot and cold theory are lost in the mists of time, but I strongly suspect that early humans on all continents were in tune with nature in order to stay alive, treat the sick, and be healthy. It was not until the time of the Greeks, Persians, Chinese, Indian subcontinent, Japanese, and Koreans that this knowledge was recorded and codified. It was also part of the world’s first nations cultures, but word of mouth was their means of transmission since written language was minimal to nonexistent. The advent of more scientific means of inquiry and understanding caused a gradual and profound shift in medical practice. Diseases were named, often after the doctor who first published cases of the condition, the move away from hot–cold theory had begun, and with it the trend to categorize patients by the disease name and the treatment as well. Soon we had the medicine of the majority; you have hypothyroidism (regardless of type or cause) and you shall be treated with levothyroxine or T4, even if other medicines are appropriate. This style of medicine generally worked for the simple majority of patients, but it did not address the other half for whom diet, nutrients, herbs, spiritual practices, or other drugs were required to bring about balanced health. The two Flexner Reports for North America sealed the fate of both medical education and medical practice; those who viewed patients and clinical practice differently were shunned, lost their licenses, prosecuted, and persecuted. Some 50 years ago, the shift back to our ancient medical heritage slowly began as acupuncture and traditional Chinese medicine entered into the awareness of the Western mind and medical world. The West discovered that there were traditional medicines around the world, that Western or conventional medicine was actually new, expensive, and it was only for a minority of the world’s population. With that shift came the demand from patients for personalized medicine and the demand by these patients and some physicians that the cookie cutter approach was not working for often a majority of patients. In the West, there arose a strong interest and the need for training in vii

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what has loosely been called complementary and alternative medicine or integrative medicine, but to keep it under control there was often the need to treat it like Western medicine with double blind studies but limited funds have been allocated to support this research and its outcomes in clinical practice. The current SARS-CoV2 or Covid-19 pandemic is a classic example of where traditional medicines have been largely shut out as the West again seeks to find the correct drug combination that will successfully treat all patients regardless of their different temperaments. The role of diet, nutrients, herbs, acupuncture, microbiome, and mental/emotional status have been greatly downplayed or flatly ignored. Individualized or personalized medicine takes time to learn, one must listen to the patient, examine them individually, medicines must be individualized, and the patient needs personalized follow-up. Mentoring is key to learning, this style of medicine is a life-time endeavor, but the rewards on both sides are tremendous. Maryam Yavari, M.D., Ph.D., N.D., has undertaken the large task of connecting with experts in each of their respective fields, asked them to do a current literature review, and to put their review in the context of Western medical thought as well as the traditional medical philosophy they represent. The outcome is a detailed look at the terms, philosophy, and general treatments within traditional Chinese medicine, Persian medicine, Ayurvedic medicine, and Latin American and Caribbean medicine. In addition, you will find sections devoted to nutrition, pharmacology, physiology, and systems biology that reveal there are strong biological underpinnings to what ancient physicians knew thousands of years ago and what these physicians know today. The perspective section examines some of the future opportunities. The information is detailed and referenced, but likely uses unfamiliar terms and concepts. Read each chapter with an open mind, recognize that like all medical practice not every patient is cured, but these systems of medicine offer useful diagnostic techniques and treatments that have been successful, are successful today, and have a rightful place in both historical and modern clinical practice. Imagine where the medicine of today could be and how your patients could benefit if personalized medicine could become the standard of care. Paul Richard Saunders, Ph.D., N.D., R HOM, DHANP, CCH Professor of Materia Medica and Clinical Practice Canadian College of Naturopathic Medicine Toronto, Canada Professor of Materia Medica and Clinical Practice Canadian College of Homeopathic Medicine Toronto, Canada Professor of Materia Medica and Clinical Practice National University of Health Sciences Lombard, USA Dundas Naturopathic Centre Dundas, Canada March 2021

Foreword

Preface

My 4-year-old son was opening the window on a cold winter day while he was wearing a lightweight cloth. I asked him: “I am shivering, dear! why are you opening the window?!” Looking back at me, he replied: “Mommy! Don’t you know people are different?!!” ...and It was the start of this journey...

Why did I Start This Project? During my years of study and practice, I have realized that the concept of temperament (simply referred to as hot and cold) is a mutual fundamental base in all traditional medicine doctrines. While many of the concepts rooted in traditional medicines have been merged into conventional medical science, the concept of temperament has surprisingly not been touched by mainstream medical practice. This might be because this concept and its definitions are tied to philosophical old language, phrases, beliefs, and rationalizations that are barely digestible based on contemporary sciences. Besides, most of the traditional medicine (TM) textbooks and many research articles in this field are not available in English which makes them inaccessible for international researchers. The goal of this book is to propose that regardless of the philosophical explanations, the observed hot–cold patterns in TMs can help practitioners to consider the individual differences in prevention, diagnosis, and treatment. The semiology of temperament was developed based on the information that was achievable with ancient basic tools. It seems that the hot and cold theory, as the main core concept of TMs, needs to be delivered in scientific language by scholars with knowledge in both fields of TM and conventional medicine and to be investigated with modern scientific tools in terms of efficacy and physiopathology.

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Who is the Target Audience? How did I Select the Contributors? This book is written for the scientific community, especially medical scientists and healthcare professionals. We have tried to deliver the concept with a scientific, clinical approach to the readers. All authors and contributors have an academic background and are known scientists with high-ranked publications in their fields. It was hard to gather this unique, precious group of authors together and I see it as an invaluable pilot for future international collaborations in the field of integrated medicine. The authors have tried to follow the scientific methodology for gathering information and writing the chapters. The available evidence for TM concepts is limited in both number and quality, so the level of evidence is usually not high. This is due to the lack of funding in this field of research and the limited number of academic research centers. However, the authors have tried to critically appraise the articles and evidence they referred to in the chapters and to select the best available studies and information sources.

About the Book The first part of this book explains the basics of hot and cold theory, its definition and clinical application in various traditional medicine doctrines. The hot and cold theory is part of “Chinese medicine”, “Humoral medicine”, “Ayurvedic medicine”, and “Latin American and Caribbean medicine” which are widely practiced in many countries. Each chapter in part one is dedicated to one of these philosophies. The hot and cold theory is also present in “European traditional medicine”, “Japanese medicine”, “Iban medicine” and “Korean medicine”. I hope to add chapters on these philosophies and practices to the next versions of this book. In part one, information has been extracted from the primary main TM textbooks, in the original language, to let the readers access the original beliefs and foremost concepts without any alteration. To help the reader grasp the practical application of the hot–cold theory, some clinical cases are presented in each chapter. In reading the first part of this book, it is noteworthy that to understand the definition of the hot–cold theory in TMs, one must be exposed to some old, unfamiliar terms and philosophical rationales that sometimes hardly make sense in the context of today's knowledge and language. Although we have tried to keep the chapters in part one simple and understandable, some parts might still seem complicated for those readers that do not have a background in this field. As it was mentioned before, this “language barrier” has been the most important obstacle in the delivery of TM concepts to the modern science. Furthermore, the old rationales for the concept of hot and cold temperament might not seem scientific at first glance. We have intended to explain them “as is” in part one, and then analyze the concept based on the scientific approach in the second part. So please be patient with your many questions arising from the first part!

Preface

Preface

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The second part of the book is aimed to answer the questions: “Is this theory based on evidence, and is it clinically effective to be incorporated into today’s medicine?” This part, along with part three, looks into some scientific explanations for this theory and proposes how this theory may represent variations in the state of the complex body system to help better categorization of patients to achieve the best treatment outcomes. Some of the TMs such as Chinese medicine have been studied more rigorously as can be seen in part two; while, some like Latin American and Caribbean medicine are mostly practiced by local healers and have been transferred orally between generations so academic research is needed to provide evidence for this valuable knowledge. As the main concept of the hot and cold theory is very much the same across the doctrines with only minor differences, the research work done on one field can be generalized more or less to the others. This book is the result of the hard work of all the authors, who devoted their precious time to this project and I deeply appreciate their patience and dedication to the several rounds of challenging reviews and revisions. My special thanks to all the contributors and reviewers who helped us to improve the quality of this work. Maryam Yavari, M.D., Ph.D., N.D. Toronto, Canada Isfahan, Iran March 2021

Acknowledgements

With my deep gratitude to my family who supported me through this project. Thanks to Dr. Paul Richard Saunders, Ph.D., N.D., R HOM, DHANP, CCH, for his support in reviewing all the chapters and his precious suggestions on the project. Thanks to Dr. Mohammad Sadegh Adel Mehraban, M.D., Ph.D., for his great contribution in copyediting all the chapters and editing Chap. 10. Thanks to Dr. Amin Mahnam, Ph.D. for his smart thoughts and comments, extraordinary supports throughout the project and for reviewing several chapters. Thanks to Dr. Ayeh Naghizadeh, M.D., Ph.D., for editing Chap. 3. Thanks to Dr. Sanjeev Rastogi, M.D., Ph.D., for his valuable comments on Chap. 6. Thanks to Dr. Kieran Cooley, N.D., for his helpful suggestion on the scientific methodology of the book. Thanks to Dr. Mohieddin Jafari, Ph.D., for his priceless assistance throughout writing and reviewing Chap. 9. And my appreciation to the incredible authors’ team for their hard work, patience, and dedication during this challenging project.

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Contents

1

Introduction: Hot and Cold Theory, the Path Towards Personalized Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Maryam Yavari

Part I 2

3

4

5

Definitions and Beliefs

Principle of Hot and Cold and Its Clinical Application in Traditional Chinese Medicine . . . . . . . . . . . . . . . . . . . . . . . . Katayoon Keyhanian Principle of Hot and Cold and Its Clinical Application in Persian Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Mojgan Tansaz, Mahshid Chaichi-Raghimi, Shahpar Kaveh, Farooq A. Dar, and Morteza Mojahedi Principle of Hot (Ushna) and Cold (Sheeta) and Its Clinical Application in Ayurvedic Medicine . . . . . . . . . . . . . . . . . . . . . Sanjeev Rastogi and Ram Harsh Singh Principle of Hot and Cold and Its Clinical Application in Latin American and Caribbean Medicines . . . . . . . . . . . . . Carlos A. Vásquez-Londoño, Luisa F. Cubillos-Cuadrado, Andrea C. Forero-Ozer, Paola A. Escobar-Espinosa, David O. Cubillos-López, and Daniel F. Castaño-Betancur

Part II

1

7

21

39

57

Scientific Evidence 87

6

Hot and Cold Theory: Evidence in Nutrition . . . . . . . . . . . . . Simone Maree Ormsby

7

Hot and Cold Theory: Evidence in Pharmacology . . . . . . . . . 109 Roodabeh Bahramsoltani and Roja Rahimi

8

Hot and Cold Theory: Evidence in Physiology . . . . . . . . . . . . 119 Parva Namiranian, Ayeh Naghizadeh, Mohammad Sadegh Adel-Mehraban, and Mehrdad Karimi

9

Hot and Cold Theory: Evidence in Systems Biology . . . . . . . . 135 Farideh Bahari and Maryam Yavari xv

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Part III

Contents

Perspective

10 Hot and Cold Theory: A Personalized Medicine Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Yibai Xiong, Lan Yan, Xiaona Li, Naifan Duan, Lin Lin, Mozheng Wu, Cheng Lu, and Aiping Lyu 11 Hot and Cold Theory: Future Perspective . . . . . . . . . . . . . . . . 171 Maryam Yavari

Editor and Contributors

About the Editor Maryam Yavari, M.D., Ph.D., N.D. graduated as a medical doctor from Isfahan University of Medical Sciences and then worked as a research scholar at Duke University Clinical Research Institute. She received her Ph.D. degree in traditional humoral (Persian) medicine from Shahid Beheshti University of Medical Sciences and then joined Isfahan University of Medical Sciences as an assistant professor in the department of traditional medicine. Her passion for evidence-based complementary medicine, holistic personalized integrative practice, medical education and research contributed to instructing many courses and workshops and mentoring several research projects. She has authored over 50 peer-reviewed articles and 7 scientific books, and has received 17 awards and grants in her endeavors in science and clinical practice. She received her naturopathic medicine doctorate degree from the Canadian College of Naturopathic Medicine and is currently working there as a resident and clinic supervisor.

Contributors Farideh Bahari Pasteur Institute of Iran, Tehran, Iran Roodabeh Bahramsoltani Department of Traditional Pharmacy, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran; PhytoPharmacology Interest Group (PPIG), Universal Scientific Education and Research Network (USERN), Tehran, Iran Daniel F. Castaño-Betancur Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia Mahshid Chaichi-Raghimi Persian Medicine Office, Treatment, and Medical Education, Ministry of Health, Tehran, Iran Luisa F. Cubillos-Cuadrado Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia David O. Cubillos-López Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia xvii

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Farooq A. Dar Faculty of Unani Medicine, Department of Munafeul Aza, Aligarh Muslim University, Aligarh, India Naifan Duan Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China Paola A. Escobar-Espinosa Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia Andrea C. Forero-Ozer Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia Mehrdad Karimi Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran; Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran Shahpar Kaveh School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Katayoon Keyhanian Imohe (Institut de Medicina I Oncologia Holistica Eres), Barcelona, Spain Xiaona Li Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China Lin Lin Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China Cheng Lu Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China Aiping Lyu Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China; School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China Mohammad Sadegh Adel Mehraban Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran Morteza Mojahedi Traditional Medicine and History of Medical Sciences Research Center, School of Persian Medicine, Babol University of Medical Sciences, Babol, Iran Ayeh Naghizadeh Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran Parva Namiranian Department of Traditional Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran Simone Maree Ormsby NICM Health Research Institute, Western Sydney University, Penrith, NSW, Australia

Editor and Contributors

Editor and Contributors

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Roja Rahimi Department of Traditional Pharmacy, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran; PhytoPharmacology Interest Group (PPIG), Universal Scientific Education and Research Network (USERN), Tehran, Iran Sanjeev Rastogi Department of Kaya Chikitsa, State Ayurvedic College and Hospital, Lucknow University, Lucknow, India Ram Harsh Singh Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India Mojgan Tansaz School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Carlos A. Vásquez-Londoño Faculty of Medicine and Faculty of Science-Department of Pharmacy, Universidad Nacional de Colombia, Bogotá, Colombia Mozheng Wu Institute of Acupuncture and Moxibustion, China Academy of Chinese Medical Sciences, Beijing, China Yibai Xiong Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China Lan Yan Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China Maryam Yavari Canadian College of Naturopathic Medicine, Toronto, ON, Canada; School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

Abbreviations

5-HT ACTH AMQ AP aP2 AR B BMI BMR BPs BUN CAG CBP CCRAS Cd CD CDC CMAUP CNS Co CoA CORT CPT CPT-1 CREB CRH CSG CW CYP DEGs DMIM FA FABP4 FAO FBS

5-Hydroxytryptamine Adrenocorticotropic hormone Akhtari Mizaj Questionnaire Aerial parts Acid-binding protein Adrenergic receptor Bark Body mass index Basal metabolism rate Biological processes Blood urea nitrogen Chronic atrophic gastritis Binding protein Central Council for Research in Ayurvedic Sciences Cold Cold-dry Centre for Disease Control and Prevention Collective Molecular Activities of Useful Plants Central nervous system Cool Coenzyme A Cortisol Carnitine palmitoyltransferase Carnitine palmitoyltransferase 1 AMP-response element-binding protein Corticotropin-releasing hormone Chronic superficial gastritis Cold-wet Cytochrome P450 Cold differentially expressed genes Distance-based Mutual Information Model Fatty acid Fatty acid-binding protein 4 Fatty acid oxidation Fasting blood glucose xxi

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FFA Fl Fr FSH FT3 FT4 GFR GI GO H HCM HD HDL HDL-C HSL HW IFN-γ IL IPA IPCA IrGO ITM I-κB L LDL LH LPS MCHC ML MMQ MPAT NCOA NE NEI NF-κB NF-κB NMR OTUs PCA PCOS PGE2 PKA PM PMS POMC

Abbreviations

Free fatty acids Flowers Fruits Follicle stimulating hormone Free T3 Free T4 Glomerular infiltration rate Gastrointestinal Gene Ontology Hot Hypertrophic cardiomyopathy Hot-dry High-density lipoprotein High-density lipoprotein cholesterol Hormone-sensitive lipase Hot-wet Interferon-gamma Interleukin Ingenuity Pathway Analysis Incremental principal component analysis Iranian traditional medicine General Ontology Iranian Traditional Medicine Nuclear factor of kappa light polypeptide gene enhancer in B-cells inhibitor Leaves Low-density lipoprotein Luteinizing hormone Lipopolysaccharide Mean corpuscular hemoglobin concentration Machine learning Mojahedi Mizaj Questionnaire Modified Prakriti Analysis Tool Nuclear Receptor Coactivator Norepinephrine (Noradrenaline) Neuro-endocrine-immune Nuclear factor kappa-light-chain-enhancer of activated B cells Nuclear factor-κB Nuclear magnetic resonance Operational taxonomic units Principal component analysis Polycystic ovarian syndrome Prostaglandin E2 Protein kinase A Persian medicine Premenstrual syndrome Proopiomelanocortin

Abbreviations

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PP PPAR PPARγ PPAT PPIN PSQI PtdCho QLY R RA RRLC–ESI–QTOFMS

S S SCM SDH Se SE SMQ SRC SREBP-1c SVM SY T T3 T4 TCA TCM TE THC THRB TM TMs TNF TRH TSH TY UFA VLDL VMA W WHO WP

Plant Part Peroxisome proliferator-activated receptor Peroxisome proliferator-activated receptor gamma Prototype Prakriti Analysis Tool Protein-protein interaction network Pittsburgh Sleep Quality index Phosphatidylcholine Qing-Luo-Yin Roots Rheumatoid arthritis Rapid resolution liquid chromatography–electrospray ionization–quadrupole time of flight mass spectrometry Seeds Stem Sasang constitutional medicine Succinate dehydrogenase Selenium So-eum Salmannezhad Mizaj Questionnaire Steroid receptor coactivator Sterol regulatory element-binding protein-1c Support vector machine So-yang Temperate Triiodothyronine Thyroxin Tricarboxylic acid cycle Traditional Chinese medicine Tae-eum Δ9-tetrahydrocannabinol Thyroid hormone receptor beta Traditional medicines Traditional medicines Tumor necrosis factor Thyrotropin-releasing hormone Thyroid stimulating hormone Tae-yang Unsaturated fatty acid Very-low-density lipoprotein Vanillylmandelic acid Warm World Health Organization Whole plant

1

Introduction: Hot and Cold Theory, the Path Towards Personalized Medicine Maryam Yavari

Abstract

In traditional medicines, the concept of “hot and cold theory” or temperament evolved based on thousands of years of precise observation of individuals’ differences to provide efficacious personalized treatments. Based on the hot and cold theory, human body organs have extensive interactions forming a complex system in a dynamic equilibrium named temperament, Dosha, constitution, or Mizaj. This equilibrium is different between individuals and is affected by genetics, environment, and lifestyle. Deviation from this balance state on the coldness– hotness spectrum can predispose one to various diseases. The goal of prevention and treatment is to maintain or revive the body system’s status towards that person's original equilibrium. Keywords







Temperament Hot and cold Personalized medicine Precision medicine Holistic medicine Traditional medicine








M. Yavari (&) Canadian College of Naturopathic Medicine, Toronto, ON, Canada e-mail: [email protected] School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

Traditional medicine knowledge is the result of our ancestors’ thousands of years of observation and trial and errors. The definition of hot and cold theory is not exactly the same in different traditional medicine (TM) philosophies, but the core concept is mutual. Based on this theory, the body in the health state has a balance that is impaired in disease mode (Azam Khan 2009). The foods, medicines, environmental factors, emotions, sleep, physical activity, and all lifestyle behaviors have a defined effect on this balance state, which is different from person to person. The same concept also applies to imbalance which is considered as the disease state. Based on the TMs, there are indicators, obtainable by history and physical exam, to estimate the balance state for each person. Examples of these indicators include anatomical indices (meaning that this balance state is affected by the genetic background), physiological indices, psychological indices, and behavioral indices. The significant conclusion from this viewpoint is that, as the healthy state is not the same between individuals, the lifestyle recommendations for health promotion and disease prevention are different between individuals and need to be selected based on the person’s balance state. This traditional individualized approach to health and disease can be considered as a good companion to modern personalized-precision medicine, an approach that is capable of revolutionizing conventional clinical medicine in the near future (Chatterjee and Pancholi 2011;

© Springer Nature Switzerland AG 2021 M. Yavari (ed.), Hot and Cold Theory: The Path Towards Personalized Medicine, Advances in Experimental Medicine and Biology 1343, https://doi.org/10.1007/978-3-030-80983-6_1

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Matsui 2013). The goal of personalized medicine is to adjust treatments to the needs of an individual and not just the diagnosed disease (Mirnezami et al. 2012). The downside of modern personalized medicine is that the decisionmaking in this field is based on data obtained from expensive chemical and molecular measurement methods, so it is barely affordable for the public at this time. In comparison, in the hot– cold theory, the temperament of an individual is determined based on the coincidence of signs and symptoms that can be gathered just based on history and physical exam findings such as skin and hair characteristics, mental and cognitive status, behavior, sleep, and physical activity (Mojahedi et al. 2014). Therefore, if the hot–cold patterns predict the data obtained in modern personalized medicine, as was demonstrated in some studies explained in Chaps. 8, 9, and 10, the outcome would be having accessible personalized medicine for the public (Zhang et al. 2012; Rezadoost et al. 2016). The theory also has a holistic approach to health and disease as the criteria and determinant factors for diagnosis of temperament include symptoms/signs of different physical body organs, mental, emotional, social health, as well as the result of interactions of time, place, and life habits (Avicenna 1999). Therefore, having the individualized yet holistic approach at the same time is a unique characteristic of this viewpoint. The physiopathology of the hot–cold theory is not fully understood. However, many studies have been conducted on the foundation of this concept. Promisingly, recent research trend in academic centers is to test this hypothesis using scientific methodology with interdisciplinary collaborations. Some of these interesting researches are studies in the field of OMIC and systems biology, integrating the TM classifications and conventional medicine guidelines. Another example of ongoing research is the anatomical studies on the Primo Vascular System which has been proposed as a physical connecting architectonics between cardiovascular, nervous, immune, and hormonal systems involved in the development and the functions of living

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organisms from the embryonic period through life (Avijgan and Avijgan 2013; Stefanov et al. 2013). These studies may open a new horizon in understanding the physiopathology of traditional medicine concepts including hot and cold theory and may explain the reported connections between the body morphology, personality, and physiologic characters in temperament classifications in future. There are, however, some complications regarding the study of hot and cold theory. Firstly, our ancestors did not have today’s knowledge of anatomy, physiology, and pathology as well as paraclinical investigations, and standard research methodologies. Therefore, to make the connection between the observational findings and to explain the body system based on them, they used philosophy, spirituality, and the reasoning logic of their time. Such reasoning seems far from our modern interpretation of the human body, thus making the scientists reluctant to approach the traditional complementary medicine concepts, and this is one of the main reasons some of these concepts are untouched by today’s science. Clearly, not all the concepts presented in traditional medicine are valid, some are phased out, but others may include valuable valid observations covered with the old rationales. This makes the study of the TM concepts complicated as it needs open-mindedness and smart screening of the valid perceptions behind the old justifications. Secondly, the hot–cold theory cannot explain all medical conditions and not all treatments can be chosen based on the concept of temperament. Similarly, as discussed in Chap. 7, the herbal treatments and medications do have some effects that are not related to the concept of temperament. Thirdly, explaining the complexity of the body system with the hot and cold theory seems a simplification of reality. The fact is that the theory of hot and cold in practice is complex and multilayered. For example, in many clinical cases, the temperament is recognized for different organs separately which can be also different from the temperament diagnosed for the whole body. Accordingly, one medicinal herb may help

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Introduction: Hot and Cold Theory, the Path …

one organ to move to its balance but worsen the dystemperament of another organ. Furthermore, there are cases with imbalances in opposite directions simultaneously or advanced levels of dystemperament that are considered as non curable. Thus, the approach to diagnosis and management in clinical practice is complicated. After establishing the foundation of this theory using a scientific approach, our knowledge of physiology and pathophysiology will allow us to develop more layers on this theory for a more accurate representation of the complex body system. The concept of hot and cold is used in clinical practice all over the world and is accepted in some countries to the level that it is practiced in academic medical centers by medical doctors, and is being assessed in research centers. Despite this, there is no concise collection of evidence in this field that can unite different countries’ traditional medicine doctrines and propose it as a tool to access personalized medicine in a simple, accessible, evidence-based manner. Most health care practitioners are not familiar with this concept, and there is no trace of it in the medical textbooks. This book is the first of its kind to present this concept to the science community and suggest how it may bridge between our ancestors' experiences and the future of our medicine.

References Avicenna (1999) The canon of medicine = al-Q-an-un fi'l-tibb. Chicago, Great Books of the Islamic World Avijgan M, Avijgan M (2013) The infrastructure of the integrative human body; Qi/Dameh, Qi Movement/Rouh and Zheng/Mezadj; Scientific Base. Int J Integr Med 1(22):2013 Azam Khan HM (2009) The greatest Elixir (Exir Azam). Research Institute for Islamic and Complementary Medicine, Tehran

3 Chatterjee B, Pancholi J (2011) Prakriti-based medicine: a step towards personalized medicine. Ayu 32(2):141 Matsui S (2013) Genomic biomarkers for personalized medicine: development and validation in clinical studies. Comput Math Methods Med Mirnezami R, Nicholson J, Darzi A (2012) Preparing for precision medicine. N Engl J Med 366(6):489–491 Mojahedi M, Naseri M, Majdzadeh R, Keshavarz M, Ebadini M, Nazem E, Isfeedvajani MS (2014) Reliability and validity assessment of Mizaj questionnaire: a novel self-report scale in Iranian traditional medicine. Iran Red Crescent Med J 16(3) Rezadoost H, Karimi M, Jafari M (2016) Proteomics of hot-wet and cold-dry temperaments proposed in Iranian traditional medicine: a Network-based Study. Sci Rep 6:30133. https://doi.org/10.1038/srep30133 Stefanov M, Potroz M, Kim J, Lim J, Cha R, Nam MH (2013) The primo vascular system as a new anatomical system. J Acupunct Meridian Stud 6(6):331–338 Zhang A, Sun H, Wang P, Han Y, Wang X (2012) Future perspectives of personalized medicine in traditional Chinese medicine: a systems biology approach. Complement Ther Med 20(1–2):93–99. https://doi.org/10. 1016/j.ctim.2011.10.007

Maryam Yavari, graduated as a medical doctor from Isfahan University of Medical Sciences and then worked as a research scholar at Duke University Clinical Research Institute. She received her Ph.D. degree in traditional humoral (Persian) medicine from Shahid Beheshti University of Medical Sciences and then joined Isfahan University of Medical Sciences as an assistant professor in the department of traditional medicine. Her passion for evidence-based complementary medicine, holistic personalized integrative practice, medical education and research contributed to instructing many courses and workshops and mentoring several research projects. She has authored over 50 peer-reviewed articles and 7 scientific books, and has received 17 awards and grants in her endeavors in science and clinical practice. She received her naturopathic medicine doctorate degree from the Canadian College of Naturopathic Medicine and is currently working there as a resident and clinic supervisor.

Part I Definitions and Beliefs

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Principle of Hot and Cold and Its Clinical Application in Traditional Chinese Medicine Katayoon Keyhanian

Abstract

Keywords

With the advanced desire to look more into the traditional view and its possible health advantages, it is necessary to primarily understand the theoretical concepts of this perspective and then find ways to relate those concepts to conventional medicine through modern technologies. Traditional Chinese Medicine (TCM) is one of the main traditional medicines that has been spread worldwide and showed potentials to bring new insights into the conventional medical approach. One of the important concepts to be clarified in TCM is Heat and Cold. This article reviews the significance and importance of TCM-related heat/cold in relation to TCM philosophy and disease pathophysiology, diagnosis, and treatment. Likewise, the findings from published articles focused on the concept of heat/cold are reviewed in the hope of opening new doors into recognition of this work and fostering insights toward unifying the old and new.

Chinese medicine Heat and cold Pattern identification Syndrome identification Constitution

K. Keyhanian (&) Imohe (Institut de Medicina I Oncologia Holistica Eres), Barcelona, Spain




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Introduction

Traditional medicines can be game-changing skills for medical doctors who practice in this field and integrate with the western or conventional approaches. This type of medicine’s primary advantage is obtaining a holistic and more extended history and physical examination necessary for proper diagnosis in the traditional approach. This supplementary history evaluates the data in two different algorithms from the Western view and the traditional view. So, it is like looking at the condition of the patient with two different yet complementary lenses. The second advantage is the availability of more treatment options for treating health conditions. Even in some minor disorders, there are simple and effective remedies in the traditional view that have not been addressed in the western view. Like other traditional medicines, Traditional Chinese Medicine (TCM) has quite a long history. Its legendary existence goes back to before 2000 B.C when Shen Nung invented the rules of agriculture and became the father of herbology. He was dedicated to test numerous herbs and evaluate their properties, effects, and

© Springer Nature Switzerland AG 2021 M. Yavari (ed.), Hot and Cold Theory: The Path Towards Personalized Medicine, Advances in Experimental Medicine and Biology 1343, https://doi.org/10.1007/978-3-030-80983-6_2

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toxicities. His work on medicinal herbs was appreciated not only in China but also in neighboring countries. Even though the golden period of science in China was during the CHOU Dynasty (1122 B.C.–960 A.D.), medicinal contemplation flourished more in the time of the HAN Dynasty (202 BC.–220 AD). During this dynasty, important classics were written, and schools of different philosophies were developed. Even though many of these classics have not been preserved, there are enough resources to guide us through the ancient view. Hunag Di Nei Jing, “Yellow emperor’s classic of internal medicine,” is one of the most important medicinal classics from HAN dynasty that serves as the bible of TCM (Wong 1932; Wang 1999). It is composed of two drafts. The first part is called Su Wen (素問), also known as Basic Questions covering the theoretical foundation of Chinese Medicine and its diagnostic methods. The second part, Ling Shu (靈樞; Spiritual Pivot), discusses acupuncture in detail. Moreover, there are important classics from the same dynasty dedicated to epidemic and febrile diseases and, specifically, have the classification of the disease from their cold and heat origins. Markedly, Shang Han Za Bing Lun “Treatise on Cold Damage Disorders” by Zhang ZhongJing was compiled at the end of HAN dynasty with references to many classics like Su Wen, Nine Scrolls, 81 Difficulties, Yin Yang Grand Treatise, Tai Lu Medical records, and Healthy Pulse Differentiation. It is a significant work to evaluate diseases of cold nature and classifies the six stages disease organized into six chapters embracing herbal formula prescriptions of each condition. A significant number of formulas gathered in the book were referenced from the book named Decoction Canon, while there is no record of the book after the TANG dynasty (Seidman 2019). While the cold pathogen was the main theoretical focus in the north of China due to its cold weather, the major cause of diseases in central and southern China were warm pathogens, which later was explicated in the classic of Wen Bing Xue “Theory of warm disease” which

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introduced the basic information about warm disease accompanied by pattern identification and treatment (Koh 2010). Although there are more great classics, this article emphasizes the concept of heat and cold, which according to the classics introduced, had major implications for the development of TCM view. We start with the philosophical concept and terminology as the first step along with real clinical examples to facilitate the comprehension of their application.

2.2

Methods

To write this article, available online articles and books that could address the subject of heat and cold either as its relation to philosophy or its practical use in diagnosis and treatment were addressed. Unfortunately, most of the books and articles are in Chinese and without English abstracts. Search terms of cold/heat with yin/yang or qi to address the physiology, cold/heat with pattern differentiation, cold/heat with treatment, and cold/heat with acupuncture were used accompanied by terms such as the history of Chinese medicine, philosophy of Chinese medicine, the concept of qi, yin/yang, and five elements plus pathogenic factors in Chinese medicine. PubMed and Google Scholar were the primary preferred websites. We also included Google searches to find available online books that were in English or translated, which are available to read. Traditional books are mostly in Chinese; thus, books or articles that are quoting them in relation to our subject are being referenced here. The work of Maciocia Giovani was a great help in clarifying the philosophy.

2.3

Case Presentation

Robert is a 45-year-old male who was admitted to our clinic in March 2020. Recently, he started suffering from an accumulation of gas in the abdomen accompanied by abnormal bowel movements and mostly loose stool. Abdominal

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distention increased gradually and even started to form in the stomach causing frequent burping. It affected his lifestyle and interfered with his sleep with continuous burps awakening him during the night. He noticed the distension of his abdomen and an increasing weight of about 10 kg. He felt tired the whole day because of poor quality sleep. When he consulted his family physician, he was advised to take probiotics and do a diagnostic workup to determine the cause. He started the probiotics to see if they would relieve his symptoms, but unfortunately, there was no improvement after trying different types. Diagnostically, general blood analysis was normal so no finding from a western view. He also underwent endoscopy and colonoscopy, but they were normal as was the abdominal ultrasound. Thus, he was advised to try TCM and be evaluated according to the traditional view. In history taking according to TCM, he added the presence of cold hands and feet, slight edema around the ankles, a history of common cold in winter since childhood, and a disturbed focus during his work. He emphasized that his energy level is lower than before probably because of disturbed sleep. The physical examination showed a generally pale complexion, bulged belly with discomfort when pressed, mild edema of the ankle, which was positional and worse when standing too much, and constant gas, which made him uncomfortable even during the examination. His tongue was chubby and red with a thin mix of white and yellowish coating in the middle, plus teeth marks on the edges. The pulse rate was normal, and the quality was weak, deep, slippery, and wiry according to TCM. From a medical perspective, it is clear that his digestive system was not functioning properly. Because of the malfunctioning of the digestive system, excess gas, obesity, and low energy had been developed, and over time had become worse. While the probiotic seemed a good choice but was not enough to improve the patient’s condition. According to TCM and ignoring the tongue and pulse findings, symptoms were classified as a syndrome of spleen qi deficiency and a degree of kidney yang deficiency which resulted

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in the accumulation of dampness and phlegm. For this condition, the TCM approach would be tonifying the spleen qi and kidney yang, eliminating phlegm-dampness by acupuncture and/or herbs. This terminology will be explained after reviewing some of the philosophical basis of TCM. To understand the ancient framework, a brief explanation of the Chinese philosophy and terminology seems necessary. It has started with the history of an old country. According to careful observation of nature, China had its own philosophy of life with a series of laws. In ancient China, every aspect of life, from diet, exercise, behavior, and social relationships to medicine and country management, were designed based on this philosophy and respect of its laws. The Chinese language is composed of characters of life and nature, and it is common for each character to have different meanings and interpretations in different levels of profundity. This complexity makes it challenging to understand the ancient medical writings. Still, experts who have investigated the literature have tried to interpret their concepts and understandably translate them for new generations. Accordingly, in the past century, because of the demand for medical workers, governmental attention to the renovation of traditional medicine has renovated TCM development. A touch of the traditional view with a semi-modern structure is more understandable for physicians and more practical in today’s medical world. Although originally there were different philosophical approaches and schools of medicine throughout history, the main concepts that survived through time and built the TCM view are the three important principles of YinYang theory, Qi’s concept, and the laws of the five elements.

2.4

The Concept of Qi

Qi’s Chinese language characters are hard to translate because they are a philosophical concept rather than just a word. Qi’s meaning has been elucidated in many ways, but the most

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popular ones are “material energy,” “life force,” and “energy flow.” In the Chinese view, everything in the world is composed of a primordial substance called Qi. It is the driving force of all living organisms, and so it can transform between the different states of matter and energy. One of the pioneers of Chinese metaphysics philosophy named Zhang Zai from the SONG Dynasty believed that Qi was matter and that forces governed interactions between matter; that Qi was neither created nor destroyed. He emphasized that Qi goes through a continuous cycle of condensation and dispersion (Yin and Yang) and, even in its most dispersed and insubstantial state, still exists (Elstein 2021). Thus, Zang Zai saw the implication of indestructibility of the matter-energy phenomenon. According to this idea, Heaven and Earth were symbols of two extreme states of utmost rarefaction or utmost condensation of Qi. He affirmed that Qi’s extreme aggregation gave rise to a material substance called “Xing,” which established important Chinese medicine applications. Chinese philosophers considered the human’s Qi as part of the Qi of the universe and the result of the interaction of the Qi of Heaven and Earth; birth as the state of Qi’s condensation and death as of its dispersal. In another context, the human body was a mirror of the universe and was composed of the interrelation between all three qi levels in smaller scope: Jing (essence) the most condensed state, Shen (mind), with the most diluted Qi being in the middle. From a medical perspective, our body and mind are affected by various Qi types, classified into two major ways. In its form of refined energy, it is produced by the internal organs to move through the channels and nourish the body and mind. While in its second scheme, Qi is the functional aspect of the internal organs (Maciocia 2015). Moreover, the Qi production pathway via internal organs and the order of displacement of the qi among the internal organs and their relative channels have been explained clearly in TCM. However, it is not the focus of the chapter to discuss in detail. Consequently, during the history taking and physical examination, it is

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important to evaluate the internal organs’ qi level according to the symptoms and, more importantly, pulse measurements.

2.5

Yin and Yang Theory

Yin and Yang are two qualities of the qi opposite to each other yet complementary. They are two phases of a cyclical movement and two states of density. While they seem to be the two ends of the spectrum, they are interdependent and can transform into each other. Usually, their concept has been explained with the example of the shadow side (yin) and the lighted side (yang) of a hill, which are opposite to each other but relative to the time of the day and the place of the sun in the sky, they move and change size. Interestingly, when one reaches its utmost state (midday and midnight) when sun or shadow is covering the whole side of the hill, transformation to the other one begins, and that is why we say each one has the seed of the other one allowing them for transformation to one another (Maciocia 2015). The Yin–Yang philosophy suggests that there is neither absolute black nor white; yin and yang complement each other, pertain to each other, are living inside each other, give rise to each other and interplay with each other to form a dynamic and paradoxical unity (Fang 2014). It is important to have in mind that the sum of the yin and yang should equal one, and so, the pathological increase of either one leads to the pathological decrease of the other and can cause imbalance. In terms of their nature, Yin has a denser quality and belongs to the matter form of the Qi, and yang is less condensed and belongs to energy forms of the Qi. The application of the yin and yang concept in the body parallels to their point of view in nature. Yin is more related to the body’s original essence, body fluid, and blood, and thus more condensed and materialized. Yang is more related to motile function and the driving force for the body and is usually evaluated with the body’s level of metabolism and warmness. Figure 2.1 shows the symbol of yin–yang with some of their

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Principle of Hot and Cold and Its Clinical Application …

examples. From there, we could also conclude that yin is related to inertia, stability, and coldness while yang is about movement, activity, and heat. It should be noted that the concept of heat– cold has a close relationship with the level of qi and the balance of yin–yang, but to carry out a proper syndrome differentiation, one needs to become familiar with the five elements and their contribution to the internal organs.

2.6

Five Elements

The theory of five elements has broad implications for determining the pathologies of the internal organs and formulating the treatment plan. The elements are the basic materials that we all know from nature: water, wood, fire, earth, and metal. According to Chinese scholars’ observations, these elements have ordered position in a cycle with governing rules throughout their cycle.

Fig. 2.1 Yin and Yang symbol and examples of their concepts in nature

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Figure 2.2 shows a demonstration of the position of the elements, and the relationship among the elements in the cycle. From Fig. 2.2 we can see the element’s order of generation, which is how they transform into each other in nature. This order of generation is also called the mother–son or sheng cycle and shows the process of generation in nature between elements. There is another cycle in the middle of the generation cycle called the controlling or Ke cycle. This cycle controls the over-generation process and maintains a balance in the production of the elements. In an easy explanation, the grandmother is controlling the grandson. If any of the elements develop a deficiency in the generation cycle, the generation of the subsequent element (the son) is affected. At the same time, it loses control of the grandson. On the contrary, if there is pathologic excess energy with an element, it will weaken the mother in the sheng cycle trying to get energy from it like a hyperactive child and, on the other hand, over control of the grandson in the Ke cycle, making it deficient. In chronic conditions, the grandson can insult the grandmother, but it is unnecessary to discuss much. Each element has a corresponding medical organ in the body, and these organs also follow the same rules as the sheng and the Ke cycle. Accordingly, any organ’s excess or deficiency could affect other organs and disrupt their proper functioning. Except for fire, two organs pertain to each element called Zang–Fu organs (Fig. 2.2). Zang organs are yin, and Fu organs are yang. Again there is a balance of yin–yang in each element. It is important to note that the concept of the internal organs in Chinese medicine is not an exact match with the organs we learned in the western view, and even if they are similar in name, the TCM view is broader or in some cases like spleen, it seems to have the function of pancreas. The heart, pericardium, small intestine, and triple burner are the four organs pertaining to fire (two yin and two yang, respectively). Triple burner and pericardium are not again matched with western organs and their functions.

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Fig. 2.2 Five elements in TCM and their pertaining internal organs

The rest of the pertaining organs are shown in Fig. 2.2. It is worth noting that each person is usually born with the constitution of one of these elements, and nourishment and nurturing of that element and its level of harmonization with the other elements result in wellbeing or development of diseases (Maciocia 2015). A holistic, personalized diagnosis and treatment arises from this view. TCM professionals took a more global and dynamic view of the patterns considering the genetic and acquired qualities of the body types and classified them into nine types of TiZhi (Jiang et al. 2018). The first type is the balanced type, and the unbalanced types are Qideficiency, Yang-deficiency, Yin-deficiency, phlegm-dampness, damp-heat, blood-stasis, Qistagnation, and inherited-special constitution (Liang et al. 2020). This classification allows for more communication among practitioners and a practical view to bringing diagnoses and treatments into a more approachable pathway.

2.7

The Concept of Heat and Cold in Chinese Medicine

Now that we are familiar with Chinese medicine’s main structure, we can go over the position and significance of heat and cold in this medicine. The heat–cold concept is incorporated in multiple divisions of TCM, which will be covered individually for better understanding.

2.7.1 Cold and Heat According to Yin–Yang Theory As explained above, yin is material in nature and more stable. Thus, in TCM, anything with the same condition of stability and lack of movement pertains to yin, like earth, water, sleeping, blood, and so on. Coldness is a quality that has the specification to slow down the movement and bring more stability and pertains to yin. Yang is about movement and activity as a driving force; thus, heat with the capacity of facilitating the movement and vaporizing pertains to yang.

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Furthermore, hyper-activation of any of the organs is through an increase in that organ’s yang aspect or decreased level of yin. In some cases, hyper-activation is the result of the heat in the organ. For example, an increase in the heart rate due to exercise is a condition of an increase of the yang in the heart, which is physiologically normal. Otherwise, if the person experiences palpitation due to tachycardia or tachyarrhythmia while resting, it is considered a pathologic increase of the heart’s yang or qi, which could be due to emotional causes or consumption of herbs like caffeine that stimulate the rate. In some cases, there is a pathologic internal heat accompanying or accelerating the yang and not letting the heart return to its original state. It is not easy to distinguish between the two because heat pertains to yang as well unless we see more signs of heat from the status of the tongue and the quality of pulse. Generally, there are different syndrome differentiations to address palpitations like hyperactive yang in the heart or liver, liver depression, heat in the heart, or when yin is deficient, yang can manifest at a higher-level accompanied with deficient heat (Chen and Ba 2010). Accordingly, symptoms that could confirm the presence of heat are flushing, anxiety, thirst, dark urine, or constipation alongside pulse quality and tongue signatures of heat. A benign tachycardia in western medicine (without a pathologic finding) is usually left without treatment or considered a psychological problem or caused by stress, while, in TCM, various findings have the potential to be investigated for diverse treatment options. Contrary to the above example, lack of an organ’s function due to diminished qi normally is a sign of deficiency of the yang manifesting as a symptom of increased yin or coldness. For instance, some cases with edema of the limbs due to lower function of the kidney are classified as syndromes of kidney yang deficiency with the accumulation of dampness similar to what was seen in our case, Robert. Accompanying symptoms are often cold feelings in general, cold hands and feet, lack of thirst, and low energy, which are worse and less tolerated in winter (Jin and Zhang 2012)–emphasizing again

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that in primary phase or mild symptoms of kidney problems in TCM, usually, there are no positive finding of malfunctioning of the kidneys in routine laboratory analysis or just mild changes with no pathologic importance. With an accurate TCM diagnosis, we are touching the prevention of disease before being detected through routine checkups and treating them soon enough, not letting the disorder develop to a disease. If that is true, primarily, we need some proof that there is biological evidence beyond routine checkups to confirm the presence of biochemical changes in heat/cold syndromes. Secondly, showing that TCM treatments can fix such changes. To shed some light on the heat–cold concept in biology, Minzhi Wang and his colleagues looked into the gene expression profiles of patients with rheumatoid arthritis diagnosed with TCM deficiency patterns. They found that particular gene transcription and nucleotide metabolism-related apoptosis were responsible for the induction of inflammatory cytokine pathways linked to adaptive immune responses (Wang et al. 2013). With similar thinking, Zhongjian Zou and his colleagues investigated the differences of stomach heat and stomach cold patterns through microscopic histopathological examinations and NMR-based metabonomic studies in rats. In histopathological studies, both groups showed just some gastric mucosal injury compared to the control group but could not differentiate the findings between two cold and heat patterns. However, in the metabonomic studies, the opposite up-regulation or down-regulation of metabolites involved in energy metabolism were observed in both groups, accompanied by inhibition or stimulation of certain amino acid metabolism. Interestingly, energy metabolism in rats with cold and heat patterns moved in opposite directions except for ketogenesis (Zou et al. 2014). There are also more studies that either searched for distinct molecular signatures identified by microarray expression profiles in CD4-positive T cells (Lu et al. 2012) or genome-wide expression analysis that identify the functional gene networks for the sets of clinical symptoms classified into different

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patterns of cold and heat in rheumatoid arthritis (Jiang et al. 2011). Suppose a complex situation in the body existed, like having yin and yang deficiency simultaneously or coldness and qi deficiency of one organ and heat and excess in another. In that case, there is a need for a closer and more detailed analysis. The presence of such conditions in TCM view is common and more difficult to be diagnosed because the compensation of yin–yang develops a fake balance between them and sometimes minimizes the patient’s symptoms. For that reason, the symptoms are the first step toward syndrome differentiation. Still, the observation of the tongue and the pulse condition plays a major role in diagnosing the true underlying issues. Because pulse-taking is subjective and needs to be practiced for some time to develop proficiency, a more accurate way of diagnosis is by looking for the changes in the metabolites, gene expression profiles, cytokines, hormone levels, and neurotransmitters. For a wider application of this view and to establish a connection with conventional medicine, consider the work of Tao Ma and colleagues (Ma et al. 2010). Returning to our patient Robert, we already have some ideas about the meaning of his symptoms and diagnosis in TCM. Abdominal distention, accumulation of gas, and loose stool are the common signs of spleen yang qi deficiency, which usually presents with the coldness of hands and feet. Deficiency of spleen qi means that the spleen qi is not sufficient for transformation and transportation of food (which is the function of the spleen in TCM view to carry out the task of the digestive system in the western view). Thus, with his general feeling of cold, a deep pulse with mild edema around the ankle that is accompanied by low energy, a yang deficiency of the kidney is likely. After the fourth session of acupuncture, gas and abdominal distension symptoms were relieved enough to allow him to sleep normally and have more formed bowel movements. No herbal treatment was advised in order to assess the effect of acupuncture. Surprisingly, on the fifth session, he came with a new symptom of redness

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and heat of his legs, especially around the knees. The redness was neither painful nor itchy, and it was not on the sites of previous pinched acupuncture points. It was hot to the touch and inflamed, and by conventional medical colleagues was diagnosed as panniculitis. Consequently, at that moment, it was important to see what had changed recently to find the reason for his skin rash, which was considered a heat sign in TCM. During history taking about changes in the diet and medication, he explained that he was advised elsewhere to do enemas with thyme and coffee to enhance the bowel movement and improve transit time. He did these enemas for ten consecutive days, and although it helped with digestion and elimination of gas, the side effect was skin lesions on his legs. In TCM, thyme (Thymus Vulgare) is classified as a heat nature herb prescribed to treat cold syndromes. Even though according to the first part of his syndrome differentiation (spleen and kidney qi deficiency), thyme would be beneficial to relieve the digestive symptoms, and it was intended to be more of a local prescription, but adversely caused a side effect through its systemic absorption. Usually, side effect arises, if at the same time, there is another Zang-Fu organ suffering from some heat that has been concealed with severe yang deficiency of spleen and kidney as mentioned above.

2.7.2 Cold and Heat as Pathogenic Factors Another sector in Chinese medicine where the concept of heat/cold is prominent is when the six pathogenic factors invade the body. Even though in ancient times they were not aware of the existence of microbiomes, they did understand that there were infectious diseases which their source was from the outside, and according to the presentation of symptoms, they were classified as pathogenic factors such as wind, dampness, dryness, cold, heat, and summer heat. According to TCM, these pathogenic factors can invade the body from outside and affect the yin-yang and qi of the internal organs. They

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Principle of Hot and Cold and Its Clinical Application …

could affect the body solely or in combination with other pathogens. The wind is the strongest pathogenic factor, and because its nature is yang and forceful, it usually invades accompanied by other pathogenic factors like heat, cold, and dampness. Whereas dampness is the weakest pathogenic factor and because of its yin nature, needs another pathogenic factor to accompany for it to be invasive. When a pathogenic factor attacks the body, the balance of yin and yang and qi will be affected. Because of their exogenous origin, the nature of the effect is usually an excess condition, especially in the acute phase of the disease. In contrast, in the internal causes of disease, patterns of deficiency are more common. It means this pathogen’s energy would increase the level of the body’s yin or yang and disrupt the balance. If there is a proper treatment or a strong body, the extra qi can be controlled, and the pathogen eliminated. In contrast, if the pathogen is strong or the body is weak, or when the treatment is not enough, the condition could become chronic or more complicated to be treated. The treatment principle, as explained below, is similar for pathogenic factors as the other causes of diseases by bringing back the balance of yin/yang until the pathogenic factor is eliminated with the help of the immune system like the work of Hongri Xu et al. who used the Yiqi Qingwen Jiedu formula in flu-infected mice models. They observed that their formula could correct the imbalance of inflammatory cytokines and promote restoration (Xu et al. 2010).

2.7.3 Cold and Heat, According to the Nature of the Herbs Herbal treatment in TCM is based on the same above philosophy. Herbal remedies are classified according to their nature (property), taste, and meridian tropism (channels of destination) (Fu et al. 2017). The herb’s nature is either hot or warm, cool or cold, or neutral. The channels of destinations are the organs and channels that the herb has the potential to enter and function in.

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Herb’s function depends on the nature of the herb as well as the action of its molecular compound based on its ingredients. Thus, any prescribed formula should match the patient pattern and consideration of the possible effects on the destination channels. For example, mint (Mentha spicata) is a popular herb around the world. According to Chinese medicine, it is acrid and aromatic, cool in nature, and enters the lung and liver meridians. Its function is mainly to release the exterior, to disperse wind-heat. It has other benefits such as cooling the throat, head, and eyes, suppressing rashes, and relieving liver qi’s stagnation. Even though it has known to be a safe drink and included in many beverages and remedies, it is contraindicated in TCM for patients suffering from spontaneous sweating, liver yang rising, and deficiency of yin or blood with signs of deficient heat. In general, the therapeutic approach that TCM practitioners have used is to treat cold syndrome with herbs of a hot nature and to cure hot syndromes with herbs characterized by a cold nature (Zhou et al. 2019). To investigate the rationale behind herbs’ different nature, researchers investigated their composition, molecular weight, metabolomics, etc. Accordingly, in the chemical analysis performed by Fu et al. (2017), there were structural similarities for the same natured herbs. Compounds of a hot nature were significantly lighter in molecular weight than compounds within a cold or neutral nature. Similarly, the polar surface area was highest in the neutral nature compounds and higher in cold nature versus hot nature associated compounds (Fu et al. 2017). Interestingly, a strong connection was seen between an herb’s cold–heat property with lysophosphatidylcholine metabolism (Wang et al. 2016). Likewise, a recent study also showed that the chemical differences between cold and hot herbs were represented in the chemical composition and shared components’ contents. Biochemically, herbs with heat/cold properties up/down-regulate glucose aerobic oxidation enzymes expression. The cold/hot herbs were involved in inhibiting or promoting ATP storage,

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glucose uptake, lipolysis, glucose oxidation, fatty acid oxidation, mitochondrial respiration, and glycolysis. Hence, there was promotion and inhibition of synthesis of glycogen and fat in heat/ cold syndromes through inhibiting/promoting arginine–proline metabolism and tryptophan metabolism (Zhou et al. 2019) concluded that the principle of “treating cold syndrome with hot herbs and treating heat syndrome with cold herbs” could be substantiated from the perspective of material and energy metabolism. Our patient Robert, during the first session of physical examination, had a red tongue with white and yellow coating along with a wiry pulse, a representation of heat syndromes. Still, he did not have any sign of heat at that time since deficient yang qi was hiding the presence of accompanying heat. However, it was something to keep in mind and follow with the treatment plan because as the qi level increase, the heat would have a chance to appear and manifest itself. Unfortunately, with the help of thyme enema treatments that was hot in nature, an acute, unpleasant side effect developed, which confirmed the presence of underlying heat. By stopping the thyme enema and with the help of the acupuncture treatment, panniculitis was relieved rapidly. Consideration of the cold/heat properties is not only essential in TCM but also supported, by research, the effect of herbs in treatment approaches. Treatment in TCM is facilitated by formulas developed over time for many of the patterns differentiated. Classic formulas are usually a combination of herbs that treat the disease by their principal herbs and avoid side effects by adjuvant herbs that prevent harsh effects on other target organs; a holistic approach toward the whole body not just the target, itself. According to the patient’s conditions, formulas are usually prescribed either as they are or with a slight change of the herbs and dosage. In each formula’s development, the proper balance of heat/cold property of each herb related to its action and the final complex nature has been taken into serious consideration. For instance, when the condition of the patient is excess heat, the formula includes herbs

K. Keyhanian

that are cold in nature. Still, with the possible damage that cold herbs can do to the stomach, it also contains herbs to protect the stomach plus herbs for adjusting the effect of all of them together to prevent any toxic effect and vice versa in situations with apparent coldness.

2.7.4 Cold and Heat in Acupuncture In traditional Materia Medicas and herbal formulas, the concept of heat and cold is essential just as it is in acupuncture treatment. Point selections are usually based on conditions of excess or deficiency, the balance of yin-yang, the level of qi, and more importantly, the point’s function in relation to the pattern identified. Points that are at the distal parts of hands and feet such as the jing-well points and river points are usually better to clear heat, and stream points, Lu-connecting points, and Xi-cleft points are commonly used points for tonification purposes. Although this classification is used widely for the selection of the combination of points in acupuncture treatment, needling techniques, Moxibustion, cupping, and bloodletting also play an important role in this concept. It is very common to use reducing manipulation techniques to decrease the heat and reinforced needling to tonify the channel in use. Thus, the same acupoint could be used to release the excess and tonifying deficiency (Tian et al. 2019). Likewise, moxibustion is very useful for the removal of cold and releasing the stagnation of qi (Zheng et al. 2017). Bloodletting is applied for the syndromes of blood stasis, toxins, excess, and heat such as acne, herpes zoster, and stroke (Lv et al. 2020). Cupping is famous for expelling wind from the body, but all of these methods can be applied in all situations of heat, cold, excess, deficiency, and imbalance of yin/yang depending on the technique used (Liu and Gao 2019). Combining these methods is also practical when applied with a proper diagnosis of pattern differentiation, point selection, and consideration of the patient’s situation (Chen and Xu 2017).

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Principle of Hot and Cold and Its Clinical Application …

The most important aspect of the cold and heat concept in the treatment plan is paying attention to the nature of the condition, and evaluation of excess and deficiency in cold/heat syndromes as well as the balance of yin/yang.

2.8

Discussion

Finally, we can classify the heat–cold concept in TCM into different pathogenesis, diagnosis, and treatment segments. In pathogenesis, the heat/cold could either attack the body as an external pathogenic factor or develop internally within the imbalance of yin/yang or affected qi level. Internal development of heat/cold usually happens when an organ’s function is affected either physiologically or pathologically. A physiologic example is menopause with the signs of flushing, restlessness, and dryness, which arises from kidney yin deficiency resulting in deficient heat. A pathologic example could be simply the deficient heat caused by anemia categorized as heart yin/blood deficiency pattern. In diagnosis, TCM specific nomenclature called “syndrome (pattern) differentiation” is used, which is an explanation for an existing condition. Commonly, the existence of heat, cold, or other pathogenic factors are bolded in the diagnosis of the current disorder. However, one can still get some measure of the condition according to the level of qi, yin, and yang. For instance, wind–cold syndrome attacking the lung is about the invasion of wind and coldness. The patient is suffering from chills, the respiratory system is averse to cold, and symptoms develop because the lung is the internal organ that is affected by this pathogen. Likewise, when the syndrome is heart fire, there is heat in the fire element that is usually caused by emotional tension and manifest as severe anxiety, palpitation, restlessness, or even heart attack. Syndromes of liver yang rising and kidney yin deficiency indicate the current level of yin and yang, which according to the philosophy of yin deficiency or yang rising, there are some levels of heat to address. In clinical cases, there are times that the level of yin and yang are both

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deficient such as kidney yin and yang deficiency, which means that the chronic deficiency of one has affected the level of the other, and both should be tonified. In parallel, there are times that there is cold in one channel and heat in another one, and it is important to find them in the diagnosis and select the cold and heat properties of herbs accordingly. If an herbal formula is the chosen treatment, the selection of herbs in the formula is based on the presence of cold and heat, the level of yin– yang, and the measure of qi. Normally, cold and heat are treated with herbs in the formula that have opposite properties and the same approach to yin–yang. Having a rich collection of herbs in TCM is advantageous for the therapist to select from the options of similar function yet different properties. If tonification of the spleen is needed, there are various herbs with this function that tonify the spleen from a cold, hot, or neutral nature and can be selected according to the patient’s conditions. In practice, when conditions of heat and cold are present in different organs, the selection of herbs that help to neutralize can keep the balance. In acupuncturemoxibustion treatment, the point selection and needling techniques also need to be adapted to the cold/heat or yin/yang status.

2.9

Conclusion

Through TCM medical learning, one becomes aware of the challenges that will be faced and their necessary direction of treatment. The first challenge is the intermixed nature of this medical approach and the philosophical concepts that should be addressed to advance a medical diagnosis and a treatment plan. Many of these philosophical concepts have important clinical applications, but they have been overlooked in western medicine. The second challenge is the existence of an unusual and ancient vocabulary that is common in most ancient literature. They need to be interpreted and illustrated properly to be applicable in medical education and practice. The third and the most difficult challenge is to take this knowledge and examine

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its treatment capacity through research and clinical trials. The reason it can be difficult is the personalized view of the patient found in traditional medicine contrasts with the western or conventional research routine approach in study, design and treatment. A traditional treatment plan is optimized to the current condition and constitution of each patient and changes as the patient changes. This treatment may not be appropriate for another patient even with similar signs and symptoms or similar diagnoses. Each diagnosis in western medicine correlates with a much wider perspective on the syndrome compared to the more detailed differentiation in traditional medicine and, accordingly, the diversity of treatment approaches. Even though it seems like a greater effort to investigate traditional medicine’s effectiveness, there is the advantage of them having been used on human for quite a long time with significant effectiveness and safety. Finally, the fourth and last challenge is incorporating them into routine conventional medical approaches for diagnosis and treatment and not just as a side or alternative approach. Acknowledgements The author acknowledges Dr. Paul Richard Saunders, Ph.D., N.D., R HOM, DHANP, CCH for editing the manuscript.

References Chen C, Xu B (2017) Acupuncture-moxibustion syndrome differentiation based on differences between Jing-Jin diseases and Zangfu diseases. Zhongguo Zhen Jiu 37(10):1105–1107 Chen WG, Ba ZM (2010) Prof. ZHANG Yi’s experience in treating severe arrhythmia. J Tradit Chin Med 30 (1):47–50 Elstein D (2021) Zhang Zai (Chang Tsai, 1020–1077) Fang T (2014). Understanding Chinese culture and communication: the Yin Yang approach. Glob leadersh practices 12(5):171–187 Fu X, Mervin LH, Li X, Yu H, Li J, Mohamad Zobir SZ, Zoufir A, Zhou Y, Song Y, Wang Z, Bender A (2017) Toward understanding the cold, hot, and neutral nature of Chinese medicines using in silico mode-of-action analysis. J Chem Inf Model 57(3):468–483 Jiang M, Xiao C, Chen G, Lu C, Zha Q, Yan X, Kong W, Xu S, Ju D, Xu P, Zou Y, Lu A (2011) Correlation between cold and hot pattern in traditional Chinese

K. Keyhanian medicine and gene expression profiles in rheumatoid arthritis. Front Med 5(2):219–228 Jiang QY, Li J, Zheng L, Wang GH, Wang J (2018) Constitution of traditional Chinese medicine and related factors in women of childbearing age. J Chin Med Assoc 81(4):358–365 Jin R, Zhang B (2012) Investigation of the essence of chilliness and cold limbs of yang deficiency syndrome in Chinese medicine based on the adaptability of body to cold stimulation. Zhongguo Zhong Xi Yi Jie He Za Zhi 32(5):696–700 Koh A (2010) Wen Bing (Warm Diseases) and the 2009 H1N1 Influenza. Austral J Acupunct Chinese Med 5 (2):23–29 Liang X, Wang Q, Jiang Z, Li Z, Zhang M, Yang P, Wang X, Wang Y, Qin Y, Li T, Zhang T, Wang Y, Sun J, Li Y, Luo H, Li L (2020) Clinical research linking Traditional Chinese Medicine constitution types with diseases: a literature review of 1639 observational studies. J Tradit Chin Med 40(4):690– 702 Liu DM, Gao XY (2019) Clinical characteristics of ZHU Dan-xi’s acupuncture and moxibustion. Zhongguo Zhen Jiu 39(10):1127–1130 Lu C, Xiao C, Chen G, Jiang M, Zha Q, Yan X, Kong W, Lu A (2012) Cold and heat pattern of rheumatoid arthritis in traditional Chinese medicine: distinct molecular signatures indentified by microarray expression profiles in CD4-positive T cell. Rheumatol Int 32 (1):61–68 Lv ZX, Gong YN, Guo Y, Chen ZL, Song SM, Li WR, Meng X (2020) Indication of bloodletting therapy based on multi-dimensional evidence assessment. Zhongguo Zhen Jiu 40(4):450–454 Ma T, Tan C, Zhang H, Wang M, Ding W, Li S (2010) Bridging the gap between traditional Chinese medicine and systems biology: the connection of Cold Syndrome and NEI network. Mol Biosyst 6(4):613– 619 Maciocia G (2015) The foundations of Chinese medicine: a comprehensive text. Elsevier, Edinburgh Seidman Y (2019) Historical perspective of Shang Hun Lun Tian DZ, Li NQ, Zhai J (2019) Exploration on even reinforcing-reducing technique of acupuncture. Zhongguo Zhen Jiu 39(5):497–500 Wang M, Chen G, Lu C, Xiao C, Li L, Niu X, He X, Jiang M Lu A (2013) Rheumatoid arthritis with deficiency pattern in traditional chinese medicine shows correlation with cold and hot patterns in gene expression profiles. Evid Based Complement Alternat Med 2013:248650 Wang Y, Zhou S, Wang M, Liu S, Hu Y, He C, Li P, Wan JB (2016) UHPLC/Q-TOFMS-based metabolomics for the characterization of cold and hot properties of Chinese materia medica. J Ethnopharmacol 179:234–242 Wang Z, Chen P, Xie P (1999) History and development of traditional Chinese medicine

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Wong KCWL-t (1932) History of Chinese medicine. Being a chronicle of medical happenings in China from ancient times to the present period. Tientsin Press, Ltd Xu H, Wang C, Wang H, Jiang L, Liu Q, Zhang J (2010) Influence of separate components of Yiqi Qingwen Jiedu mixture to serum inflammatory cytokines of mice infected with influenza virus FM1. Zhongguo Zhong Yao Za Zhi 35(19):2599–2604 Zheng J, Zhang H, Liu J (2017) Different acupuncture and moxibustion methods at Heding (EX-LE 2) for knee osteoarthritis with yang-deficiency and coldstagnation syndrome. Zhongguo Zhen Jiu 37(6):594– 598 Zhou N, Yang, Y, Li K, Ke Y, Zheng X, Feng W, Bai Z, Liu T, Wang Y, Liu Z, Li X (2019) Integrating strategies of chemistry, biochemistry and metabolomics for characterization of the medication principle of “treating cold/heat syndrome with hot/cold herbs”. J Ethnopharmacol 239:111899

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Zou Z, Hanm B, Gong M, Wang S, Liang S (2014) NMRbased metabonomic studies on stomach heat and cold syndromes and intervention effects of the corresponding formulas. Evid Based Complement Alternat Med 2014:528396

Katayoon Keyhanian graduated from Isfahan University of Medical Sciences as a medical doctor (MD) and has studied molecular biology at Texas A&M University. She has practiced in the field of traditional Chinese medicine for several years and has earned a master of Chinese medicine from Beijing University of Chinese Medicine and Universitat de Barcelona. She has worked as a teaching assistant in the US for biology and anatomy courses and then using her background in science and medicine is mostly dedicated to work and research in Chinese medicine. Katayoon has several publications in peer-reviewed journals. She is currently working in the Institut de Medicina i Oncologia Holistica Eres which is a main referral oncologic center with a holistic integrative approach in Spain.

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Principle of Hot and Cold and Its Clinical Application in Persian Medicine Mojgan Tansaz, Mahshid Chaichi-Raghimi, Shahpar Kaveh, Farooq A. Dar, and Morteza Mojahedi

Abstract

Persian Medicine (PM) or Humoral Medicine is a traditional school of medicine with thousands of years of prolific history. The concept of Mizaj (temperament) and hot–cold theory is one of PM’s most important foundations. In the clinical setting, Mizaj represents individual differences in phenotypical, psychological, spiritual, and physiological functions. Mizaj has a crucial role in determining the treatment plan, to the point that a similar disease in patients with different Mizaj types may demand different treatments. In this chapter, the role of hot and cold theory in the

M. Tansaz School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran M. Chaichi-Raghimi Persian Medicine Office, Treatment, and Medical Education, Ministry of Health, Tehran, Iran S. Kaveh School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran F. A. Dar Faculty of Unani Medicine, Department of Munafeul Aza, Aligarh Muslim University, Aligarh, India M. Mojahedi (&) Traditional Medicine and History of Medical Sciences Research Center, School of Persian Medicine, Babol University of Medical Sciences, Babol, Iran

diagnosis and treatment of diseases to develop an integrative medical approach is discussed. Keywords




Mizaj Temperament Humoral medicine

3.1


Persian medicine


Introduction

Response to external or environmental stimuli is a characteristic feature of all living organisms, and humans are no exception. However, there are variations from individual to individual in their physiological responses to stimuli. These external stimuli include climate, food, and even the drugs and medicines that we consume. A specific environmental temperature may be comfortable for one person but be felt as cold and uncomfortable for another. This is one example of a wide range of individual variations that are considered in the treatment of diseases in the PM but not in the conventional medical approach. Why does disease severity differ in different people exposed to the same pathogen or risk factor in similar conditions? What causes diverse therapeutic effects and side effects of drugs in patients suffering from the same disease? Why is susceptibility to disease different among individuals? And finally, why are the treatment responses so diverse?

© Springer Nature Switzerland AG 2021 M. Yavari (ed.), Hot and Cold Theory: The Path Towards Personalized Medicine, Advances in Experimental Medicine and Biology 1343, https://doi.org/10.1007/978-3-030-80983-6_3

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These questions have led to establishing a new trend in medical sciences called personalized medicine. Nutrigenomics, pharmacogenomics, and metabolomics are examples of emerging scientific fields based on which prediction of susceptibility to diseases, reactions to food, and medicines are possible considering individuals’ genomic, metabolic, and biochemistry characteristics (Bates 2010; Jafari et al. 2014). However, access to people’s genetic background (genotype) is neither cheap nor available for the public. Centuries ago, physicians in Persia and Greece noticed these differences in the personal characteristics of people from the same race or tribe. They assessed and understood the potential links between these psychological traits, body functions and physiology, susceptibility to various diseases and responses to treatment. Based on experiences and analysis of observations, these physicians found a pattern named hot and cold classification that could represent the body system variations. They called the basis of this classification “Mizaj” (also called “temperament,” “constitution,” and “nature” (Naseri et al. 2010)). There is a particular emphasis on a holistic approach to health as the human is to be seen as an interrelated system in PM. The principles of health maintenance, prevention, and treatment in PM, are determined based on the Mizaj foundation which requires both a holistic and personalized view to the patient (Rafieian-kopaei et al. 2016; Zulkifle 2014). Mizaj identification in this school of medicine is so essential that without it, PM loses its basic concept and is degraded into merely a type of herbal medicine.

3.2

Methods

This study is a narrative review to determine the characteristics of the hot and cold theory of Mizaj based on PM literature. In the first step, all of the information related to keywords including “Mizaj identification,” “hot,” “cold,” “temperament,” “Mizaj,” “Persian Medicine,” “humoral

medicine,” and “Unani medicine” were extracted from the most trusted PM textbooks, including Al-Qanun fi al-Tibb (The Canon of Medicine), Kamil al-Sinaa al Tibbiyah, Liber Al-Mansuri, Hedayat al Mota'allemin fi al-Tibb, and Kholasat al-Hikmah. The search for these keywords was performed in Cochrane, Web of Science, Science Direct, Scopus, PubMed, Google scholar, and SID from 2000 to 2020. We reviewed the extracted data, kept relevant information related to hot–cold theory and its identification, and then summarized the information within our group to write this chapter.

3.3

Case Presentation

Sheila (a real case with fictitious name to protect patient privacy; informed consent was obtained) was a 36-year-old woman who presented with a complaint of secondary infertility to Shahid Beheshti University’s traditional medicine clinic. She had been trying to conceive for 6 years. During that time, she had two miscarriages at 8 weeks diagnosed as blighted ovum. The patient had dyspepsia and felt heavy after eating heavy meals, such as pasta and pizza. She was experiencing gas and bloating while eating cold-natured foods such as yogurt, buttermilk, and cucumber. She had constipation (firm stool and bowel movements every 2–3 days). She had menstrual issues including long cycles (40–50-day cycles) and reduced flow (oligohypomenorrhea). She was taking 500 mg Ibuprofen twice a day for dysmenorrhea. She also reported low libido. The patient complained of a feeling of coldness in the hypogastric and buttock regions. Moreover, she was suffering from poor sleep quality, occasional nightmares, and startling awake several times during night sleep. To compensate, she used to take a nap for 2–3 hours in the afternoon. Infertility caused a lot of stress and anxiety for her. Her hair color was brown but started to turn grey at the age of 35. She was an obese class I (BMI = 32 kg/m2) and her repeated attempts to lose weight had failed. She felt asthenia on low-calorie diets and salads (lettuce

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Principle of Hot and Cold and Its Clinical Application …

and cucumber), which made her discontinue the diet. The patient was on 25 µg Levothyroxine daily for borderline hypothyroidism. On physical examination, vital signs were within normal limits. She had light-colored skin, a small frame, and a large, pale, and wet tongue. Her pulse was considered slow and weak according to the PM pulsology. Her extremities were cold, and she stated that others were surprised by her hands’ coldness when shaking hands with her. On vaginal examination, a considerable amount of non-infectious white discharge was seen, although she was not in the ovulation stage. The vagina and cervix were pale. In para-clinical investigations, FSH and LH were 19.9 IU/L and 22 IU/L, respectively. TSH was 2.7 mIU/L. Other routine blood tests were normal. In hysterosalpingography, fallopian tubes were reported to be patent. Transvaginal ultrasound was normal. Her spouse had a normal spermogram. The diagnosis was “unexplained infertility” according to the fertility clinic report.

3.4

History

Persian Medicine is a traditional school of medicine with thousands of years of history. This school results from the many years of experience and efforts made by great scientists in a vast geographical region. Based on the available evidence, the origin of this school was ancient Persia and Greece (Tountas 2009; Zargaran 2014). This school is recognized as “Persian Medicine” in Iran, “Unani Medicine” in India, and “Humoral medicine” and “Mizaj Teb” in other parts of the world. There is some evidence of medical science and practice in ancient Persia (Iran) before Christ (Zargaran et al. 2013; Shoja and Tubbs 2007). The concept of Mizaj as the basis of individual differences was rooted in philosophers and physicians of Persia and ancient Greece. Hippocrates (370–460 BC) pioneered the idea of humors and individual differences, and Galen (129–216 AC) completed this theory with physiological commentaries (DeLisi and Vaughn 2014; Strelau 1998). Subsequently, during the

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Sassanid Dynasty in Iran (226–652 AC), this school thrived more in the University of Jondishapour with scientists from many parts of the world (Zargaran 2014). In the third stage, Muslim scientists such as Ali-Ibn Rabn Tabari (838– 870 AD), Rhazes (865–925 AD), Avicenna (980–1037 AD), Al-Akhawayni Bukhari (?–983 AD), and Ali-Ibn Abbas Majusi Ahvazi (949– 982 AD) further developed this school. The books written by these scientists, such as Canon in Medicine, were translated into Latin and other languages in the twelfth century and became the leading medical references in European universities (Cruse 1999; Modanlou 2011). Following the emergence of conventional medicine, attention to PM declined gradually. However, in some countries like Iran, India, and Pakistan, it still has followers, so, it is taught in academic centers and practiced in health care settings (Rezaeizadeh et al. 2009; Zargaran 2019). Since 1921, this school of medicine has continued to exist under Unani Medicine’s title as a university major in India, and Mahatma Gandhi founded the first Unani Medicine College in New Delhi. The main emphasis of India’s university centers in the recent decades has been educating practitioners to provide service for the Indian public. Recently, more attention has been paid to the research and development of scientific documentation in India’s academic centers (Lloyd 2009). Since 2007, the Iranian government has approved this school of medicine as a university Ph.D. program called Persian Medicine, with the main focus on research and development based on scientific evidence. Currently, there are 14 academic research centers and 22 departments of Persian medicine in Iran conducting research on the fundamental theories and clinical applications of this school of medical practice (Rezaeizadeh et al. 2009; Zargaran 2019).

3.5

Definition

“Mizaj” is sometimes translated as “temperament” in English, which is derived from the Latin word “temperamentum,” meaning “mixed”. Although originally this term was derived from

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the traditional concept of Mizaj in Persia and Greece, this word has a psychological connotation that deals with moral–mental characteristics, personality types, and individual differences in emotions and behaviors. Hence, the meaning interpreted from the word “temperament” in psychology cannot account for the vast concept of “Mizaj” in PM, which considers both physical–physiological and behavioral–mental characteristics (Cloninger 1994; Hoosen 2017). Therefore, we will use the word “Mizaj” in this chapter to convey the meaning more efficiently. In practice, the concept of Mizaj is a classification based on between-person variations in physical, physiological, and psychological characteristics. Each person’s unique phenotypic characteristic, the physical, physiological, and behavioral characteristics originates from gene– environment interaction. Therefore, in some cases, especially in clinical applications, the phenotype can be used as a representative of the genotype in making decisions about individualized treatment strategies (Naseri et al. 2010).

3.5.1 Elements Elements are part of the philosophical explanation of the Mizaj concept in PM, so, we will briefly explain it here. PM scholars believed that all living and non-living beings, including humans, consist of primary particles called elements (Arkan). Their definition of elements was that they could not be broken down into smaller particles. In other words, elements are the final stages of particle decomposition in the world of creation. According to the PM, these elementary particles are invisible and can be detected by the traces they leave behind or the phenomena they bring about (Avicenna 2005). Persian scientists chose some names for elements based on natural objects that were familiar for people and based on their features. They include fire, air, water, and earth. The fire element has features similar to natural fire, but it is distinct from the actual fire. It releases heat, is in

M. Tansaz et al.

motion, is a source of energy, increases the space between components of a whole, and expands. The fire also dries up humidity. Regarding earth, they believed that there should be an element to cause firmness and solidity of a creature’s form, and since natural earth has these features, this element has been called earth. Since natural earth is colder than the fire in temperature and heavier in weight, it is motionless, dry, and compact. Names specified for the other two elements, air and water, are on the same basis. Like steam, the air element contains more heat than water and, like gas, can easily take the form of its container. The water element is fluid like natural water; it is formable and has features of coldness and wetness (Shirbeigi et al. 2017). The body consists of four vital fluids called humors including black bile, yellow bile, blood, and phlegm. In each of these humors, one of the above elements is dominant. Air is the dominant element in blood, fire is the dominant element in yellow bile, water is the dominant element in phlegm, and earth is the dominant element in black bile (Aghili Shirazi 2006). According to the PM, each one of these elements has specific characteristics, by which their presence can be identified. Four primary qualities of hotness, coldness, dryness, and wetness were proposed regarding features of the elements. From which hotness–coldness are considered dominant qualities and wetness–dryness are nondominant qualities. The element of fire is light with hot and dry qualities; the element of air is relatively light with hot and wet qualities; the element of water is somewhat heavy with cold and wet qualities; and the element of earth is absolutely heavy with cold and dry qualities. In other words, the elements of fire and air are hot, and the elements of water and earth are cold (Shirbeigi et al. 2017). The hotness of elements implies far-spaced parts, expansion, lightness, and motion. In the human body, this quality is the primary energy source, power of living, and motion. In contrast, coldness in elements suggests dense parts, constancy, solidity, and tranquility. The role of this quality in the human

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Principle of Hot and Cold and Its Clinical Application …

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body is regulating extra heat, compressing components, creating appropriate density in body tissues, and preserving the body from excessive excretion (Majusi Ahwazi 2008).

mean that they have no warmness in their bodies but rather indicates that the person has less warmness than someone with a hot Mizaj (Razes 2008).

3.5.2 The Concept of Mizaj

3.6

The human body is composed of four elements and each element has its features of hotness, coldness, dryness, and wetness. Therefore, the combination of elements also has unique characteristics, according to the proportion of elements. The uniform quality resulting from the combination of elements in each being, including the human body, is called “Mizaj”. Usually, the elements are in relative balance; therefore, the Mizaj is temperate, but in some people, one or some elements are dominant, so, they present typical features of those elements (Mizaj types). For instance, a hot-tempered person (with the dominance of fire) is very hasty, moves quickly, becomes angry quickly, speaks fast, makes social contact easily, has a high metabolism, often feels hot, cannot stand the heat, does not wear heavy clothes even in cold seasons, and has more tendency to use cooling systems like fans and air conditioners in hot seasons than others. On the contrary, a cold-tempered individual with higher levels of earth or water element is patient, cool, slow-moving, rarely becomes angry, speaks slowly, is not very social, hardly speaks, has a low metabolism, feels less warm, cannot stand cold weather, and uses thick warm clothes, especially in cold seasons (Avicenna 2005). Likewise, the difference in the proportion of elements and the four qualities, in other beings, foods, and medicinal substances can be generalized. For example, foods and medicine with a higher proportion of fire than other elements, are warm-natured, inducing hotness in the body and increased metabolism. In contrast, food and medicine that contain cold elements like earth are cold-natured and lead to coldness, decreasing body metabolism. It is pertinent to mention that Mizaj is a relative concept. When, for instance, we say a person has a cold Mizaj, it does not

Each person’s body is composed of a unique proportion of elements. This means everyone has their individual Mizaj. Despite this broadness in types of Mizaj, to specify Mizaj more easily, PM scientists have divided Mizaj into nine groups and considered each group along a spectrum. For instance, cold Mizaj has a spectrum, ranging from extreme coldness to very mild coldness (Fig. 3.1). The signs and symptoms of each person’s Mizaj is on a spectrum of coldness–hotness and also wetness–dryness (Avicenna 2005). The horizontal axis displays Hot–Cold degrees, with the cold degree to the left. The vertical axis indicates Wet–Dry degrees with points lower than balanced being dry and higher points being wet. The PM nine main Mizaj types (healthy Mizaj types) include Temperate, Hot, Cold, Dry, Wet, Hot-Wet, Cold-Wet, HotDry, and Cold-Dry. Temperament changes eventually lead to dysfunction of the body, at this stage, it is named dystemperament. If one of the four humors becomes more than normal, it is called Humoral dominance. For example, Hot– Dry dystemperament is sometimes called Yellow Bile dominance.

3.7

Types of Mizaj

Identification of Mizaj

There are ten clinical characteristic criteria including physical, physiological, and psychological features which are used in practice to determine a person’s Mizaj type (Mojahedi et al. 2018) (Table 3.1). Touch: Shaking hands, everyone feels that another person’s hands are warmer or colder than theirs. The warmness of the skin to touch is a sign of hot Mizaj, while coldness is indicative of a cold Mizaj. Since ambient temperature alters

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Fig. 3.1 Mizaj (Temperaments) types

skin temperature, the person should remain at room temperature for enough time to properly assess this index (Yousefifard et al. 2018). Obesity and Thinness: Among individuals with the same diet and physical activity, and with normal clinical and laboratory evaluations, some are susceptible to obesity, and some are thin and have difficulty reaching their ideal weight. In individuals with a higher weight to height ratio, those with more muscle than fat gain a score for hot Mizaj, while those with higher fat mass than muscle mass have a cold Mizaj score. Thin people are of two types: a thin person with average muscle mass gains a score for hot and dry Mizaj. On the other hand, thinness with little muscle mass will gain score for cold and dry Mizaj (Ansari et al. 2010; Lari and Amin 2013; Parvizi et al. 2016). Hair Conditions: Hairiness, dark/black hair color, and rapid hair growth are signs of hotness. On the contrary, sparse bright hair and slow hair growth indicate coldness. Indeed, to specify individual differences based on Mizaj, variations in each factor must be considered among people of one race. The difference between races is not a topic of this research (Avicenna 2005). Skin Color Tone: Within each race, red, yellow, or dark tones are signs of hotness. And bright colors with white and faint hues are signs

of coldness. Areas that are not exposed to sunlight should be examined to assess skin color tone (Akhawayni 1992). Physique: This criterion includes height, frame, size of chest, joints, and extremities as well as pulse parameters. Assessment of pulses to determine the Mizaj needs special training and experience in PM pulsology. Individuals with hot Mizaj usually have a large frame, big chest, square shoulders, large and long limbs, prominent vessels, strong pulse, and large joints. On the contrary, in cold Mizaj, figures, chests, and limbs are small, the superficial veins are nonprominent, the pulse is weak, and joints are small and non-prominent (Harik-Khan et al. 2004). Impressibility from Hotness, Coldness, Dryness, and Wetness: People with hot Mizaj cannot tolerate heat and are more comfortable in cool weather. Moreover, they cannot tolerate consuming too many warm-natured foods such as some seasonings, pepper, and sweets. On the contrary, cold-mizaj people feel better in hot weather and with warm-natured foods (Majusi Ahwazi 2008). Sleep and Wakefulness: Oversleeping (more than 10 hours a day) is a sign of coldness, wetness, or both. Some people suffer from too much sleep when they travel to humid areas. A person with a cold-wet Mizaj needs more sleep in such

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Principle of Hot and Cold and Its Clinical Application …

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Table 3.1 The ten criteria of Mizaj identification Mizaj/Indices

Hot

Cold

Wet

Dry

Obesity and thinness

• More muscle than fat

• More fat than muscle

• Obesity • The looseness of soft tissues

• Thinness • Firmness of flesh

Skin color

• Red • Swarthy • Yellow

• White • Dark and faintcolored • Eggplant-colored • Plaster white, ivory

Hair condition

• • • • •

• Red inclined to yellow or white • Thin hair • Slow growth • Late baldness

• • • •

• • • •

Physique

• Wide chest • Large extremities • Laryngeal prominence • Prominent superficial veins

• Small chest and extremities • Non-prominent larynx • Narrow superficial veins • Short fingers

• Wide nose • Big, prominent eyes • Thick fingers

• Bony structure of body • Long nose and neck • Laryngeal prominence

Touch of skin

• Warm

• Cold with mild softness

• Soft

• Rough • Hard

Functions

• Quick growth • Strong digestion, appetite, and sexual desire • Projected voice • Fluent in speech • Quick movements • Strong pulse

• Slow growth • Weak digestion, appetite, sexual desire, and pulse • Short and shallow breath • A weak and low voice • Slow and discontinuous speech • Slow movements • Slow, short, and weak pulse

• Soft pulse

• Hard pulse (resistant to pressure)

Characteristics of waste matters

• • • • •

• Weak smell or odorless • Faint-colored • Too much excretion

• Too much excretion and secretion • Excess of sweating • Excess and softness of nose excretion

• Little excretion and secretion • Little sweating • Little and thick nose excretion

Sleep and wakefulness

• Less sleep • Light sleep

• Too much sleep • Deep sleep

• Too much sleep • Deep sleep • Need more sleep

• Less sleep • Light sleep • Need less sleep

Impressibility from hotness, coldness, dryness, and wetness

• Quick impressibility from hot weather

• Quick impressibility from cold weather

• Quick impressibility from humidity

• Quick impressibility from dry weather

Black Thick Dense Fast growth Early baldness

Strong smell Colorful Malodorous Dry Little

White Straight and hard Slow growth Late baldness

Fast growth Wavy Breakable Early baldness

(continued)

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Table 3.1 (continued) Mizaj/Indices

Psychic functions

Hot

Cold

Wet

Dry

and warm-natured foods

and cold-natured foods

and wet-natured foods

and dry-natured foods

• The strong power of comprehension, clever, keen • Bold, hasty, pioneer • Optimistic and hopeful • Joyful • Brave • Extreme rage • Impatience • Fearless and aggressive • Cruel • Manly behavior • Quick in expressing ideas • Determined in starting a task but not consistent in continuation • Little influence from environmental conditions

• Weak determination • Slow in learning, displeased, forgetful • Coward • Pessimistic and hopeless • Indolence • Less rage • Sensitive • Obstinate • Forgetful • Influence from environmental conditions

• The decadence of will, memory, and satisfaction • Quick decadence of actions • Indetermination • Forgetfulness

• Alert • Determined in will, memory, and satisfaction • Firm in emotions and meanings • Patient • Obstinate

places. Sleeping less (less than 6 hours per day) is usually a sign of hot or dry Mizaj or a combination of both (Azfar et al. 2020). Functions: All physical, physiological, and psychological functions of the body can signify a person’s Mizaj. Fast, powerful, and optimal physical activities are signs of hotness, whereas, slow, weak, and deficient physical activities are signs of coldness. Hot-tempered individuals have the following characteristics: fast growth of the body and hair, early teething, projected and loud voice, fast, loud, and fluent speech, more powerful, and brisk movements. The hotness of Mizaj sometimes leads to precipitance and hastiness and may result in a lack of resolution in decisions. Cold-tempered individuals, on the other hand, are quieter and slower in their movements (Shahabi and Hassan 2008). Quality of Waste Matter: Characteristics of secretions and excretory materials, including urine, feces, sweat, and other secretions, can

signify Mizaj. The strong color and odor of the secretions mentioned above signify hotness, whereas lighter colors and less odor indicate coldness (Razes 2008). Mental and Emotional States: Bravery, boldness, anger, risk-taking, hope, intelligence, and talent are signs of hotness, and their opposites are indicative of coldness. Hot-tempered individuals are happier, more talkative, and more quick-minded. They become angry more easily, are courageous, and take more risks. On the contrary, cold-tempered individuals are reserved and tend to keep quiet. They are shy and do not communicate with others easily. They have weaker memories, rarely become angry, are conservative, and seldom take risks (Salmannezhad et al. 2017). It is worthy to note that the basic “native” behavioral/personality characteristics of a person are used to determine Mizaj. It is not an easy assessment in many cases as most of the adults’

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Principle of Hot and Cold and Its Clinical Application …

behaviors are acquired and influenced by the training a person received (Aghili Shirazi 2006). The above-mentioned criteria are used to assess the general Mizaj of the body. However, there are detailed symptomology definitions to determine Mizaj of each organ of the body which is noticed in the clinical setting when a patient complains regarding a special organ rather than systematic symptoms. In PM, the heart, brain, and liver are called chief organs, so, the Mizaj of these organs contributes greatly in signifying the Mizaj of the body (Ansari et al. 2018). For example, sleep is a specific index of brain Mizaj. Skin color is a specific indicator of liver Mizaj and, the pulse is a specific index of heart Mizaj. Thus, it can be claimed that general Mizaj is the sum total of the Mizaj of all body organs, especially, those three mentioned above. Among these organs, the Mizaj of the heart and liver are relatively warmer, and the brain colder (Dar et al. 2011). Although Mizaj is the sum of the scores of the ten parameters mentioned, diagnosis is not always easy, and there might be some confusion, especially, when signs of hotness, coldness, and moderation all exist simultaneously. As mentioned previously, coldness and hotness are two ends of the spectrum; so, while identifying the two ends of the spectrum with consistent indices is easy, diagnosis of indices near the temperate or inconsistencies in hotness or coldness is complicated and need special training and experience.

3.8

Factors Affecting Mizaj

Genetically, everyone is born with a unique Mizaj, which can, to some extent, change with factors such as lifestyle, age, season, climate, place of residence, and habits. Mizaj in the beginning years of life is called the primary, main, or innate Mizaj. The Mizaj influenced by environmental factors is called secondary or acquired Mizaj. Therefore, to specify the main Mizaj, the characteristics in childhood and young adolescence should be considered. The influence of the environment on Mizaj is inevitable; thus,

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when the current conditions of a person are evaluated, the assessed Mizaj is always a secondary one (Aghili Shirazi 2006).

3.8.1 Age Variations of physical and mental factors in different ages are justified according to the Mizaj of age groups. Questions such as why children are more agile than adults; why children need to sleep more than adults; why children grow fast; and most physical and mental differences can be explained based on the difference in Mizaj of age groups. Based on PM, age groups are classified into four main categories. From birth until adolescence, especially in the first seven years, growth is faster. Mizaj is in the highest levels of hotness and wetness; as most of the growth occurs in this period. In the 30s and 40s, hotness and wetness are in balance, so, this stage of life is considered the most temperate, with body functions in their best state. Between 40 and 60 years of age, Mizaj gradually becomes colder and drier, and body strength decreases. After the age of 60, there is a gradual decrease in innate heat and innate fluid, resulting in reduced stamina (Avicenna 2005).

3.8.2 Gender Men’s Mizaj is hotter and drier than women's. Due to their colder Mizaj, women are more prone to cold diseases, like musculoskeletal and joint disorders (Aghili Shirazi 2006).

3.8.3 Seasons In PM, seasons are compared and classified according to their characteristics and are not necessarily coincident with the calendar. Considering that the season affects the body Mizaj, it is necessary to adopt lifestyle changes based on the seasons (Avicenna 2005). Spring: The Mizaj of this season is in most areas temperate, inclined to hotness and wetness.

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Warm diseases such as acne, urticaria, and allergies are common in this season. In spring, Persian practitioners (Hakims) suggest avoiding the use of hot seasonings and overuse of warmnatured and blood-producing foods such as meat and soft yolk. Balanced exercise is the best cleansing method, and preventive wet cupping (Hijama) and phlebotomy (Fasd) are recommended for individuals with hot-wet Mizaj (Aghili Shirazi 2006). Summer: With a hot and dry Mizaj, summer weather induces hotness in the human body, and as a result, signs of heat like the warmness of hands and legs, excessive thirst, and weak digestion appear. Warm diseases, especially in people with hot-dry Mizaj, are more prevalent in this season. Increasing rest-time, consuming cold-natured foods and beverages, using easy to digest foods and avoiding extreme physical activity are recommended in the summer (Avicenna 2005). Autumn: The Mizaj of autumn is cold and dry. In moderate areas, it is usually cold at night and warm during the day. Due to these climate changes, the body becomes weak, and digestion is impaired. Cold diseases like depression, obsession, and eczema are prevalent in this season. Therefore, it is recommended to consume blood-producing and warm-wet-natured foods such as lamb broth, soft yolk, carrots, figs, and raisins. Engaging in physical exercise to increase hotness and improve digestion is recommended (Aghili Shirazi 2006). Winter: The Mizaj of winter is cold and wet, especially when it snows. Cold and wet diseases like arthritis, pneumonia, and catarrh are more prevalent at this time. People with hot Mizaj are more refreshed in winter. In winter, internal body temperature increases, so internal organs like the digestion system are stronger during the winter compare to other seasons. Due to this, the consumption of heavy and rich foods, which need more energy for digestion, is permitted. Increased physical activities help to warm up the body. Individuals with cold-wet Mizaj, as well as older women, suffer more from musculoskeletal pains in winter. These individuals usually feel less pain by keeping the home warm and using

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hot nature drugs and foods such as garlic, black seed, and ginger (Avicenna 2005).

3.8.4 Region Land factors such as latitude, wind, vicinity to mountains and seas, soil type, and altitude influence the Mizaj of a region. For instance, mountainous areas increase the coldness of Mizaj, while hot deserts increase hotness (Shirbeigi et al. 2017).

3.8.5 Foods Foods have Mizaj and affect the body’s Mizaj as well. The Mizaj of food is usually referred to as their “nature”. The main criterion to identify the nature of foods is based on their effect on the body. Food Mizaj is categorized as hot, moderate, and cold (and based on the secondary qualities to dry, wet, and moderate) (Aghili Khorasani 2009). Interestingly, food’s nature has a grading system in PM. For example, almond is hot in the first degree/wet in the first degree, while pepper is hot in third degree/dry in the fourth degree. When the degree of a quality is higher than second, it is not considered “food” but rather a “drug”. For instance, pepper is not considered a food, but a drug, as it can change the body Mizaj to a great extent. In other words, based on PM, foods are defined as nutrients that do not change Mizaj dramatically. Substances that are considered drugs, should not be taken regularly without the physicians’ advice as it may lead to Mizaj disturbance (dystemperament) and disease (Aghili Shirazi 2006). Knowing the nature of foods helps recommend the best dietary advice to people based on their Mizaj. Makhzan al-Advieh is the main reference textbook of PM materia medica describing features of 3413 food and medicines including their Mizaj types and degrees. A database of natural medicinal substances has recently been created from this rich resource using both text mining methods and manual

3

Principle of Hot and Cold and Its Clinical Application …

editing (Naghizadeh et al. 2020). Named UnaProd, this database contains common names (in English and Persian), scientific names, and synonyms of medicinal substances in addition to the attributes described in Makhzan al-Advieh, and is also linked to Collective Molecular Activities of Useful Plants (CMAUP) and Iranian traditional medicine General Ontology (IrGO) databases (Naghizadeh Naghizadeh et al. 2019). Determination of food’s nature can be done based on experiments as well. The main criterion to identify the Mizaj of foods is their function in the body, and the qualities they induce in the body. Moreover, sensible criteria like color and, more importantly, taste can also help identify food’s nature. Based on dominant taste, each food belongs to one of the several Mizaj types (Table 3.2). Some examples of warm foods include lamb, grains like peas and beans, fruits like grapes and raisins, sweet foods, almonds, vegetables like celery, fenugreek, mustard, and dates. Fish, sour foods, cucumbers, sour cherries, tomatoes, lentils, and yogurt are examples of cold foods. Hot-tempered individuals feel better eating cold foods and fruits but feel uncomfortable taking too much warm foods. For instance, they may experience urticaria, rash, palpitations, or hot flashes upon consumption of honey, dates, and hot spices. In contrast, cold-tempered people feel better eating warm foods and spices. They may suffer from hyper-salivation, bloating, reflux, malaise, and sometimes sleepiness when consuming cold foods (Avicenna 2005).

Table 3.2 Identification of food nature based on tastes

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3.8.6 Drugs A cold or hot drug creates a cold or hot change in body Mizaj, respectively, upon entering the body and after undergoing metabolism. The purpose of determining the drug’s nature is to predict how they react in the human body (nature) and how strong is their effect (grade of nature). For example, the black seed is hot in grade 3 and dry in grade 3, so, it can produce more heat in the body than sesame seed which is hot in grade 2 and wet in grade 2. Nature and its grade vary between plants based on their type, growing region, and the consumed parts (seed, leaf, petal, or root). In general, there are four grades for the severity of hotness–coldness. First-grade drugs cause a slight change in Mizaj, even when consumed in large amounts or over a long time. Second-grade drugs induce an evident change in Mizaj following consumption, but not to the point of causing dysfunction. Third-grade drugs produce a huge change in the Mizaj and can lead to a disturbance in body functions. Finally, fourth-grade drugs cause such a huge change accompanied by a severe disturbance that may lead to intoxication (Naghizadeh et al. 2020). PM specialists consider the patient’s Mizaj deviation degree to decide which grade of drug nature and dosage is needed. For instance, a patient with a cold disease needs hot drugs for treatment, and the level of hotness is determined based on the severity of cold dystemperament. Obviously, if the drug produces more hotness than the person needs, it can cause side effects due to excessive heat (Aghili Shirazi 2006).

Taste

Nature

Example

Sour

Cold

Vinegar

Acrid

Cold

Unripe fruits

Bland

Temperate

Wheat

Fatty

Warm-inclined temperate

Butter and oil

Sweet

Warm-inclined temperate

Dates

Salty

Moderately warm

Salt

Bitter

Very warm

Aloe Vera

Pungent

Excessively warm

Pepper

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When prescribing combined drugs made by mixing different herbs with different Mizaj, traditional pharmaceutical specialists calculate the drug nature based on the amount, dosage, nature and grade of each constituent (Aghili Khorasani 2009). It should be noted that not all effects of herbal drugs are related to their nature and their effects on the body’s Mizaj. A part of herbal drug function depends on its bioactive compounds aside from their nature. Therefore, drugs can have therapeutic effects for all Mizaj types based on their bioactive compounds (Shirbeigi et al. 2017).

3.9

Role of Mizaj in Disease Prevention and Treatment

Lifestyle is a strong prevention and treatment tool to both maintain healthy Mizaj (temperament) and modify dystemperament. PM recommendations for health maintenance stand on two principles. The first includes instructions given to all people irrespective of their Mizaj. For instance, refraining from eating when the stomach is full and sleeping early at night. The second group includes recommendations that are tailored based on individualized Mizaj (Avicenna 2005). PM recommendations to maintain optimal health are based on six main principles which are always the first cornerstone in disease prevention and treatment. They are described as follows:

3.9.1 Climate In some diseases of dystemperament, changing the living place can modify the Mizaj. For instance, a person with muscle pain aggravated in cold weather or eating cold foods may improve considerably by moving to a hotter climate (Avicenna 2005).

3.9.2 Food and Drink Eating warm-natured foods like cinnamon, dates, or honey can sometimes improve some coldMizaj disorders. On the contrary, hot-Mizaj individuals feel better if they eat cold-natured foods, such as yogurt or watermelon, and feel irritated if they eat warm-natured foods such as pepper. Therefore, it is recommended that individuals avoid overeating foods that are not in harmony with their Mizaj (Razes 2008).

3.9.3 Sleep and Wakefulness Oversleeping can lead to coldness. This is why Persian physicians advise cold-tempered individuals to avoid too much sleep, particularly taking naps during the day. A short nap, of course, is useful for hot-tempered individuals, especially in summer. Sleep deprivation can reduce innate fluid (Rutubat Ghariziyya) and, subsequently, innate heat (Hararat Gharizyya), which in the long-term leads to cold dystemperament (Avicenna 2005).

3.9.4 Body Movement and Repose Moderate movement of average intensity and length creates hotness. Therefore, to maintain health, those with cold Mizaj need more exercise. In this regard, quick, strong sports in warm environments are beneficial for cold-tempered individuals. However, a long duration of heavy sport will eventually lead to cold dystemperament. Hot-tempered individuals, however, experience adverse effects from heavy exercise and are recommended less duration and lighter sports. Sports such as skiing or swimming which are done in cold and humid environments are suitable for this group. In conclusion, sports and bodily movements are to be individualized to fit one’s Mizaj (Avicenna 2005).

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Principle of Hot and Cold and Its Clinical Application …

3.9.5 Mental and Emotional States Depression induces coldness, whereas mild happiness and anger create hotness in the body. In recent studies, the relationship between some of the factors noted above with Mizaj has been investigated (Salmannezhad et al. 2017). This is the reason it is advised for elderly patients, who are prone to coldness, to avoid reading bitter, sad news. Social relationships, which have been proposed as a disease protective measure in recent studies, can prevent cold dystemperament in the elderly (Xu 2019).

3.9.6 Retention of Healthy Matters and Excretion of Waste Matters Optimal natural excretion of waste matters through urination, defecation, menstruation, sweat, and other ways such as mucus, sperm, hair, and nail are important to maintain health. The excretion ways can be reinforced through exercise, massage, wet cupping, bloodletting, and fasting. These measures can help excrete waste and disease-inducing matters and are prescribed based on an individual’s Mizaj, both as prevention and as treatment. On the other hand, retention is another principle of health, so, one should be careful not to lose healthy matters through natural or induced excretion ways such as excessive diarrhea, bleeding, bloodletting, menorrhagia, vomiting, heavy exercise, and sleep deprivation (Moradi et al. 2017).

3.9.7 Role of Mizaj in Disease Diagnosis and Classification According to the PM, a disease is an imbalanced state which leads to impaired organ function. A substantial portion of diseases is the result of dystemperaments, implying loss of healthy Mizaj in either the whole body or an organ that leads to dysfunction (Miraj et al. 2016). In such cases, treatment is achieved by rebalancing the Mizaj

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state (Aghili Shirazi 2006). Signs of the most prevalent general dystemperaments are listed in Table 3.3.

3.9.8 Mizaj Diagnostic Tools Developing standard diagnostic tools are the cornerstone to conduct clinical research and prepare valid guidelines. Therefore, several efforts have been made to design and validate Mizaj questionnaires (Mirzaeian et al. 2019). Among those, Mojahedi Mizaj Questionnaire (Mojahedi et al. 2014) for 20- to 40-year-old individuals, Salmannezhad Mizaj Questionnaire (Salmannezhad et al. 2018) for 40- to 60-yearolds, and Akhtari Mizaj Questionnaire for 60+ year-old individuals have passed all stages of standard-diagnostic scale development. Currently, preliminary studies are being carried out using these standardized scales to assess the correlation of Mizaj with clinical outcomes, genetic polymorphism, and biological factors (Rezadoost et al. 2016). Considerable psychometric studies to design and validate Mizajidentification questionnaires for organs including the brain, liver, stomach, uterus, and heart are being carried out in academic research centers in Iran. It is expected that the results of these studies will remarkably transform the scientific community’s understanding of the Mizaj concept.

3.9.9 Case Discussion According to the history and examinations, the cause of Sheila’s infertility was diagnosed as cold and wet dystemperament in general, and also in her uterus and stomach which presented with decreased metabolism and weight gain. As a general rule, an important principle in treating a disease is to restore the patient’s Mizaj to its normal state. To achieve this, the nature of the chosen drug must be opposite to Mizaj of the disease. So, treatment was established with lifestyle modifications according to the six principles of health in the first step, including increased physical activity, eliminating her cold-natured

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Table 3.3 Signs of dystemperaments of the whole body Type of disease

Hot and dry dystemperament (Dominance of Yellow Bile)

Hot and wet dystemperament (Dominance of Blood)

Cold and wet dystemperament (Dominance of phlegm)

Cold and dry dystemperament (Dominance of Black Bile)

Signs and symptoms

• Yellow discoloration of the face, eyes, and tongue • Bitter taste in the mouth • Dryness of the tongue • Nasal mucosa dryness • Excessive thirst • Rapid breathing and pulse • Nausea, yellowgreen-colored vomitus • Dark yellow urine • Scratching, burning, and needling sensation in the skin • Insomnia and light sleep • Anxiety and impatience • Excessive irritability, getting angry easily

• Redness of the face, eyes, and tongue • Heaviness feeling in body especially in the back of eyes, head, and temples • Warmness and softness of the skin • Daily naps and fatigue for no apparent reason • Yawning and the need to stretch the body • Sweet taste in the mouth • Thirst • Prominence of superficial veins • Nosebleeds, bleeding gums, hemorrhoids • Forgetfulness • Slow learning • Nightmares of blood and bleeding

• Whiteness and paleness of the skin and tongue • Loosenesof body’s soft tissues • Softness and coldness of the skin • Excess of saliva • Decreased feeling of thirst • Dyspepsia • Belching with a bitter smell and reflux • Excess sleep and sleepiness • Frailty • Slow learning • Colorless urine

• The dark color tone of body and tongue (regardless of the ethnicity) • Skin dryness • Thinness • Dark circles around eyes • Heartburn • Muscle spasm • False appetite (bulimia) • Hairiness • Sleeplessness • Too much thinking and obsession • Fear, hopelessness, and anxiety • Reticence and isolation • Nightmares of death and falling

diet, avoiding napping, depression prevention, and keeping the body away from cold. Those all are lifestyle recommendations that deviate the temperament toward hot. Warm-natured medicines such as fennel were recommended to warm the uterine area and regulate menstruation. Bodywork, including cupping on the hypogastric area, was performed to warm her uterus and ovaries by improving circulation, hence, enhancing the medications’ effect. Massaging the hypogastric region with chamomile oil was also recommended. Also, a diet was recommended to the patient using hot-natured foods. After 3 months of treatment, the patient was free of digestive symptoms and lost 8 kg of weight.

Menstruation became regular, and she became pregnant in the fourth month. At a follow-up 6 weeks later, the ultrasound showed that the fetal heart had formed.

3.10

Conclusion

The concept of Mizaj is one of the most important concepts in PM and is defined based on individual differences in phenotypical, psychological, spiritual, and physiological functions. According to this principle, individuals are categorized in terms of two pairs of qualities: hotness–coldness and wetness–dryness. The ten

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Principle of Hot and Cold and Its Clinical Application …

characteristic factors help to diagnose the general Mizaj of the body while there are other specific criteria to determine body organs’ Mizaj. Specific lifestyle recommendations based on Mizaj can promote health and prevent diseases. With deviation from healthy Mizaj, dystemperament happens which is often accompanied with the imbalance in four humors of black bile, yellow bile, phlegm, and blood. Major types of dystemperaments have their own clinical manifestations and are treated by lifestyle modification and medications that have a Mizaj opposite to the Mizaj of the disease. With the help of the newly developed Mizajidentification questionnaires, there have been reports of considerable clinical results, implementing the Mizaj concept into the clinical practice, although more comprehensive studies are needed to reach conclusive results (Akhtari et al. 2020). Integrating the Mizaj-based approach with conventional medical treatment has been shown in several studies to result in more effective disease management. Studies have shown that the PM theory of Mizaj in disease diagnosis and treatment is in accordance with personalized results from omic studies. Several challenges are faced in practicing the individualbased trend of personalized medicine. Using the group-based concept of Mizaj (phenotype identification), this science’s goals may become more practical, reachable, and economical (Jafarnejad et al. 2016; Baradaran-Akbarzadeh et al. 2018; Alibeigi et al. 2020). Acknowledgements The authors acknowledge Dr. Ayeh Naghizadeh, M.D., Ph.D. and Dr. Paul Richard Saunders, Ph.D., N.D., R HOM, DHANP, CCH for editing the manuscript.

References Aghili Khorasani M (2009) Makhzan-ol-Adviyah [Storehouse of Medicaments]. Tehran University of Medical Sciences, Tehran Aghili Shirazi M (2006) Kholase al hekmah (Persian). Esmailian, Quom Akhawayni A (1992) Hedayat al-mota’allemin fi al-tibb (An educational guide for medical students). Ferdowsi University of Mashhad Publication, Mashhad

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36 Jafarnejad F, Mohebi Dehnavi Z, Mojahedi M et al (2016) Effect of aerobic exercise program on premenstrual syndrome in women of hot and cold temperaments Lari Q, Amin M (2013) Distribution of body mass index (BMI) among individuals of Safravi and Balghami Temperatment. Hamdard Med Lloyd I (2009) Traditional and complementary systems of medicine. In: The energetics of health. Elsevier, pp 13–27 Majusi Ahwazi A (2008) Kamel al-Sanaah al-Tibbiyah (The Perfect Art of the Medicine), Lithograph. Astan-e Quds-e Razavi Miraj S, Alesaeidi S, Kiani S (2016) A systematic review of the relationship between dystemprament (sue Mizaj) and treatments and management of diseases (Ilaj and Eslah-e-Mizaj). Electron Phys 8:3378–3384. https://doi.org/10.19082/3378 Mirzaeian R, Sadoughi F, Tahmasebian S, Mojahedi M (2019) Progresses and challenges in the traditional medicine information system: a systematic review Mirzaeian et al. Progresses and challenges in the traditional medicine information system. J Pharm Pharmacogn Res 7:246–259 Modanlou HD (2011) Historical evidence for the origin of teaching hospital, medical school and the rise of academic medicine. J Perinatol 31:236–239. https:// doi.org/10.1038/jp.2010.162 Mojahedi M, Alipour A, Saghebi R, Mozaffarpur SA (2018) The Relationship between Mizaj and its indices in Persian medicine. Iran Red Crescent Med J 20. https://doi.org/10.5812/ircmj.57820 Mojahedi M, Naseri M, Majdzadeh R et al (2014) Reliability and validity assessment of Mizaj questionnaire: a novel self-report scale in Iranian traditional medicine. Iran Red Crescent Med J 16:e15924. https:// doi.org/10.5812/ircmj.15924 Moradi F, Alizadeh F, Naghizadeh A et al (2017) The concept of “Masam” (Pores) in Persian medicine. Tradit Integr Med 2:160–165 Naghizadeh A, Hamzeheian D, Akbari S et al (2020) UNaProd: a universal natural product database for materia medica of Iranian traditional medicine. Evidence Based Complement Altern Med 2020. https:// doi.org/10.1155/2020/3690781 Naghizadeh A, Hamzehyian D, Akbari S et al (2019) Revisiting temperaments with a fine-tuned categorization using Iranian traditional medicine general ontology. https://doi.org/10.20944/preprints201911.0024. v1 Naseri M, Rezaeizadeh H, Taheripanah T, Naseri V (2010) Temperament theory in the Iranian traditional medicine and variation in therapeutic responsiveness, based on pharmacogenetics. J Islam Iran Tradit Med 1:237–242

M. Tansaz et al. Parvizi MM, Salehi A, Nimroozi M et al (2016) The Relationship between body mass index and temperament, based on the knowledge of traditional Persian medicine. Iran J Med Sci 41:S14 Rafieian-kopaei M, Khajegir A, Kiani S (2016) The association between dystemperament and prevention of diseases: a systematic review. J Clin Diagn Res 10: YE01–YE06. https://doi.org/10.7860/JCDR/2016/ 19023.8511 Razi (Razes) M (2008) The Kitab al-Mansuri (Liber AlMansuri, a concise handbook of medical sciences). Tehran University of Medical Sciences, Tehran Rezadoost H, Karimi M, Jafari M (2016) Proteomics of hot-wet and cold-dry temperaments proposed in Iranian traditional medicine: a network-based study. Sci Rep 6. https://doi.org/10.1038/srep30133 Rezaeizadeh H, Alizadeh M, Naseri M, Ardakani MRS (2009) The traditional Iranian medicine point of view on health and disease. Iran J Public Health 38:169– 172 Salmannezhad H, Ebadi A, Mojahedi M et al (2017) An assessment of the correlation between happiness and Mizaj (temperament) of university students in Persian medicine. Iran Red Crescent Med J. https://doi.org/10. 5812/ircmj.55627 Salmannezhad H, Mojahedi M, Ebadi A et al (2018) Design and validation of Mizaj identification questionnaire in Persian medicine. Iran Red Crescent Med J in Press. https://doi.org/10.5812/ircmj.66709 Shahabi S, Hassan Z (2008) Hot and cold natures and some parameters of neuroendocrine and immune systems in traditional Iranian medicine: a preliminary study. J Altern Complement Med Shirbeigi L, Zarei A, Naghizadeh A, Vaghasloo MA (2017) The concept of temperaments in traditional Persian medicine. Tradit Integr Med 2:143–156 Shoja MM, Tubbs RS (2007) The history of anatomy in Persia. J Anat 210:359–378 Strelau J (1998) The history and understanding of the concept of temperament. In: Temperament: a psychological perspective. Springer Science & Business Media Tountas Y (2009) The historical origins of the basic concepts of health promotion and education: the role of ancient Greek philosophy and medicine. Health Promot Int 24:185–192. https://doi.org/10.1093/ heapro/dap006 Xu Y (2019) Role of social relationship in predicting health in China. Soc Indic Res 141:669–684. https:// doi.org/10.1007/s11205-017-1822-y Yousefifard M, Parviz M, Hosseini M et al (2018) Palm temperature and core temperature as important indices of temperament. J Med Physiol 3:3

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Zargaran A (2014) Ancient Persian medical views on the heart and blood in the Sassanid era (224–637 AD). Int J Cardiol 172:307–312. https://doi.org/10.1016/j. ijcard.2014.01.035 Zargaran A, Fazelzadeh A, Mohagheghzadeh A (2013) Surgeons and surgery from ancient Persia (5,000 years of surgical history). World J Surg 37:2002–2004. https://doi.org/10.1007/s00268-013-2055-0 Zargaran A (2019) Persian medicine 2018. Persian Medicine Office, Ministry of Health, Treatment and Medical Education. Tehran, Iran Zulkifle MI (2014) A temperamental approach in promotion of health. Altern Integr Med 03. https://doi.org/ 10.4172/2327-5162.1000165

Mojgan Tansaz is a medical doctor (M.D) and has a Ph.D. in Persian Medicine from Tehran University of medical sciences of Iran. She has 9 years of teaching and research experience and is working as an associate professor and head of the department of Iranian Traditional Medicine in the Faculty of Traditional Medicine, Shahid Beheshti University of Medical Sciences. She has delivered many invited talks and has presented her research works at more than 60 conferences. She has contributed six chapters to various books and has more than 26 research papers and articles published in refereed journals or popular magazines. From 2016 to 2020, she was a member of the standardization project of the liver, stomach, and uterus organ temperament questionnaires, which were conducted at Shahid Beheshti University of Medical Sciences. She is also the vice-chancellor of health promotion in the Persian Medicine office at Iran’s Ministry of Health, Treatment, and Medical Education.

Mahshid Chaichi-Raghimi has a Doctor of Medicine (M.D) degree from Tehran University of Medical Sciences and her Ph.D. degree is from the Department of Persian Medicine at Shahid Beheshti University of Medical Sciences. She works in the Persian Medicine Office, Ministry of Health, Treatment, and Medical Education. She served as the main author of the Persian Medicine Guideline of bloating and co-editor of three other gastrointestinal guidelines in Iran. She edited three PM books and wrote over 200 articles on health and medicine in popular Iranian magazines. She has more than five Research papers published in refereed journals. She has participated in the standardization project of the stomach, and liver temperament questionnaire, which was conducted at Shahid Beheshti University of Medical Sciences, from 2016 to 2020.

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Shahpar Kaveh has a Doctor of Medicine (M.D) and Ph.D. in Persian Medicine from Shahid Beheshti University of Medical Sciences, Tehran, Iran. She has a teaching and research experience of 2 years and is presently Assistant professor of Iranian Traditional Medicine at the Faculty of Traditional Medicine, Shahid Beheshti University of Medical Sciences. She has delivered many invited talks and has presented her research work at more than eight conferences. She has more than seven research papers and articles published in refereed journals or popular magazines.

Farooq Ahmad Dar has a Bachelor’s degree and a Doctor of Medicine (M.D.) in Unani Medicine from Aligarh Muslim University, India. He has a teaching and research experience of 13 years and is presently Associate professor and Chairperson Department of Munafeul Aza (physiology) at the Faculty of Unani Medicine, AMU. He has delivered many invited talks and has presented his research work at more than 30 conferences. He has contributed 11 chapters to various books and has more than 25 Research papers and articles published in refereed journals or popular magazines. From 2006 to 2018, he has served as co-editor and Associate editor of Unimed-Kulliyat, a journal of Unani Medicine, published by the Department of Kulliyat, AMU. He has worked as co-Investigator of an extramural research project on “Study of Nabd (Radial Pulse) Wave Form and its Physiological Variations in different Temperaments by a Self-Designed Pulse Wave Detection Module’ funded by the Ministry of AYUSH, Government of India. Between 2011 and 2015 he has also served as Assistant Editor of Unani Medicus, an International journal published by the Faculty of Unani Medicine, AMU.

Morteza Mojahedi is a Doctor of Medicine (M.D) and holds a Ph.D. in Persian Medicine from Shahed University, Tehran, Iran. He has taught topics related to Persian Medicine, especially the subject of temperament (Mizaj) since 2012 and has been an Associate professor in the Department of Persian Medicine at Babol University of Medical Sciences, Babol, Iran since 2014. The specific field of his research is the Mizaj diagnosis indices and so far, under his guidance, a significant number of standardization projects of Mizaj diagnosis questionnaires have been implemented or are being implemented in various Persian Medicine research centers. He has served as a consultant in several Mizaj standardization projects in Tehran, Babol and Shahid Beheshti Universities of Medical Sciences. He has written or edited five books and has had more than 50 published articles in international or local journals most of which are in the field of Mizaj. He is also the vice-chancellor in the Persian Medicine office at Iran’s Ministry of Health, Treatment, and Medical Education.

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Principle of Hot (Ushna) and Cold (Sheeta) and Its Clinical Application in Ayurvedic Medicine Sanjeev Rastogi and Ram Harsh Singh

Abstract

Hot (Ushna) and cold (sheet) are two fundamental precepts of Ayurvedic medicine reflected variously within the context of health and disease. These are fundamental for being essential attributes of three doshas, namely, Vata, Pitta, and Kapha, forming the very basis of Ayurvedic constructs of health and disease. Ushna is the inherent property of Pitta, symbolizing fire both inside and outside the body. There are pathologies of Pitta where this Ushna property participates in pathogenesis to present the features like burning, sour eructation, and fever. In such cases, the course of treatment eventually focuses on reducing Pitta or reducing the Ushna property of Pitta, in particular. A similar cold association is found with Vata and Kapha, where the pathogenesis is reflected as heaviness, cold and cough, and edema. The treatment of Vata and Kapha diseases eventually focuses upon their reduction or reducing cold-related pathogenesis, in particular. This is evident that these two form an essential and integral component of

S. Rastogi (&) Department of Kaya Chikitsa, State Ayurvedic College and Hospital, Lucknow University, Lucknow 226003, India R. H. Singh Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

Ayurvedic understanding of health and disease and are practically applied to make a diagnosis and define the treatment. In this chapter, we are expanding the details of Ushna and Sheeta constructs of Ayurvedic medicine and elaborating on their health and disease application. Keywords
















Ayurveda Dosha Pitta Kappa Vata Hot and cold

4.1

Ayurveda and Its Fundamentals: A Brief Introduction

Ayurveda is an ancient health science that predominated in the Indian subcontinent since the Vedic era (5000 BCE) (WHO 2010). A careful look at the currently available ancient texts of Ayurveda reveals it to be a highly organized and systematic branch of study, observing humans and their immediate environment as the key method of acquiring knowledge, with health and disease as the core focus of the observation. Ayurvedic science essentially has rules, ethics, and morality embedded so deeply in its methods and practices that it is easy to mistake it for being a scripture of ethical codes and related health benefits. The complexity and organization of

© Springer Nature Switzerland AG 2021 M. Yavari (ed.), Hot and Cold Theory: The Path Towards Personalized Medicine, Advances in Experimental Medicine and Biology 1343, https://doi.org/10.1007/978-3-030-80983-6_4

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knowledge available in Ayurvedic texts of the prehistoric era are not fully known so that current scientists are unable to find the actual sources of this knowledge (Jaiswal and Williams 2016). Although there are diverse opinions among historians about the source and history of Ayurveda, we may presume that Ayurveda originated in the form of natural and folklore knowledge about health and diseases and was enriched throughout its evolution through the process of unbroken observations of interactions between human and nature for their mutual benefit. The knowledge acquired through observations was further tested and analyzed across the time and population cohorts both vertically and horizontally, churned, assimilated, and brought down through generations with a focus on naturedriven preventive and curative health care (Rastogi et al. 2020) (Fig. 4.1). Tracing its roots from Atharvaveda, the first of all Vedic inscriptions, which are among the first documented literature available in human history, Ayurveda remained a major player in health keeping through a large part of human history (Mukherjee et al. 2017). Ayurveda has represented a global view of health care science as it spread across the world, predominantly

S. Rastogi and R. H. Singh

among the countries that traded with India. With the advent of Buddhism, Ayurveda reached the Far East countries and assimilated with native health care practices. Under Islamic influence, much of Ayurveda literature was brought to Middle East countries and translated into local languages during medieval times (Husain and Subhaktha 2000). During the Buddhist period, India had spectacular universities like Nalanda and Taksila, which were home to Ayurveda knowledge to scholars from across the world. Ayurveda texts were translated into local languages, and foreign medical disciples incorporated the Ayurveda knowledge from India. Thus, one finds conceptual and fundamental similarities between many traditional health care systems still prevailing today (Fan 1995). Among several fundamentals of Ayurveda regarding health and disease are Theory of Pancha Mahabhuta and Tridosha; the theory of biological distinctiveness of individuals (Prakriti); the Disharmonic theory of causes of diseases; Rebalancing theory of treatment; incremental and decremental theory of similarity and dissimilarity; and an all-inclusive theory that considers every substance as a potential therapeutic agent

Fig. 4.1 The genesis of Ayurveda through evolutionary phases

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Principle of Hot (Ushna) and Cold (Sheeta) …

(Rastogi 2010). Ayurvedic medicine system is not merely a compilation of folklore practices observed through centuries, but rather is a systematic and organized compendium of knowledge assimilated through continuous observations and experimentations over the millennia (Rastogi et al. 2020). This continuum of knowledge evolution eventually helped in the recognition of repetitive trends and patterns in health and disease which further helped the formulation of Ayurveda’s principles regarding health and disease.

4.2

Methods

To construct this topical review on ‘principle of hot (Ushna) and cold (Sheeta) and its clinical application in Ayurvedic medicine,’ three major classics of Ayurveda (Brihat Trayi), namely, Charaka Samhita, Sushrut Samhita, and Ashtanga Hridaya were searched. Three minor classics (laghutrayi), namely, Madhva Nidan, Bhava Prakash, and Sharangadhar Samhita, were also searched. The search was mainly done for the words ‘Ushna,’ ‘Sheeta,’ ‘Ushna Guna,’ ‘Sheeta Guna,’ ‘Ushna Virya,’ and ‘Sheeta Virya.’ This search was manually done by carefully looking into each chapter of the reference books for search items. Additionally, a search with similar words was also done electronically using the PubMed, Google Scholar, AYUSH research portal. For electronic search, words like ‘hot’ and ‘cold’ and ‘Ayurveda’ were also used. The search was done for the items available through 31 December 2020.

4.3

Theory of Panchamahabhuta and Tridosha

What comprises the universe, the living, and nonliving beings, and what are the cosmic relations between a human being and its microcosmic and macrocosmic surroundings? These are few intricate questions having their ontological and epistemological bearings borrowed from ancient Indian schools of philosophy. Ayurveda tried to

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amalgamate these philosophical connotations within its self-styled theory of Ayurvedic biology connecting the abstract philosophy with natural biological observations occurring within a living being (Valiathan 2016). One of the most significant dicta which originated from this was the theory of Lok-Purusha Samya (connectedness between the individual and their surroundings), which forms the basis of the Ayurvedic approach to look in a wider and inclusive perspective at the causes of diseases and interventions to bring back normality (Fig. 4.2). There is a new realization within the scientific community that the source of primary elements composing life C, H, N, and O are nothing but the universe. Such elements are sourced through various cosmic locations and events like big and small stars, cosmic rays, supernovae, and the big-bang (Lochner et al. 2003). The availability of these elements both inside a living being and macrocosm is a scientific revelation of the Ayurvedic conceptualization of ‘yat pinde tata brahmande’ dictum (what all is there inside, the same is there in the universe). This also became the basis of a common philosophical saying that ‘man is a miniature replica of the universe’ (Lyssenko 2004). A simple connotation of this realization of similarity among all creatures and an intricate reciprocal relationship between man and the universe became the ultimate basis for developing a balanced and harmonious ecosystem where care was eventually observed by every component of the ecosystem, not to make it distorted. Vasudhaiva kutumbkam (seeing the world as a united family) (Seelan 2015) and sarve bhavantu sukhina, sarve santu niramaya (let all live happy and all live free of diseases) are the epitomic sociological representations of this conceptualization of seeing oneness in everything. Ayurveda explored this philosophical concept for its deeper meaning, health care. Drawing heavily from this philosophy of oneness, Ayurveda proposed its dictums of sarvam drvyama hi paancha bhautikam (everything in the world is composed of five elements) and nanuashibhutam Jagat kinchit (nothing in this world is devoid of medicinal value). We see that this became the most important basis of Ayurvedic understanding of diseases and their treatment.

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Tridosha theory was added to the panchamahabhuta theory to understand the biological phenomena in a living body through analogies of hot (Ushna), cold (Sheeta), and movement (chala) as commonly perceptible attributes of the external world. Vata, Pitta, and Kapha subsequently were hypothesized as three functional phenomena in a living body responsible for the functions as are air, sun, and moon in the external world, akin to the attributes of movement, hotness, and coldness. For this analogy, these two sets of phenomena occurring in the external and internal worlds have been considered mutually prospering and promoting. Since panchamahabhuta was the original conceptualization of the elemental composition of the universe including living beings, Vata, Pitta, and Kapha subsequently were proposed to be derived of a different combination of akasha (space) and vayu (air); agni (fire); and jala (water) and prithvi (earth), respectively (Fig. 4.3). Their functions eventually were enumerated as reflective of their constituent mahabhuta (Parasuraman et al. 2014). The human body is considered a combination of five mahabhutas, three functional entities have been segregated based on their functions. The concept of mahabhuta was an abstract concept with the immeasurable entity and unproven existence of any mahabhuta, the whole concept was largely explained indirectly through their proposed functions. In this context, normal biological functions are considered symbolic of the balance of three doshas. Any deviation from the

Fig. 4.2 Microcosm and macrocosm depiction of Lok Purush Samya theory

S. Rastogi and R. H. Singh

normal, resembling a disease, is considered an over- or under-functioning of either or a variable combination of dosha (Hankey 2010).

4.4

The Emergence of Hot and Cold as a Cause of Disease and Treatment Modalities

Concepts of hot and cold play a central role in disease etiologies and treatments in many traditional healthcare systems. In these systems, ‘hot’ and ‘cold’ do not usually refer to the actual temperature states but include a wider meaning, including the abstract qualities a substance may have. Foods and bodily states are classified as being hot or cold, and diseases are thought to be caused by an excess of heat or cold in the body (Pool 1987). Hot and cold are the two most primitive conditions that are uniformly perceived by all living beings. The hot and cold perception had been linked with the natural occurrence of day and night and seasonal changes. With the day being hotter than nights, one easily is cognizant of the Sun and Moon and their role in hot and cold transformation, respectively. Air is omnipresent carrying both hot and cold in its closeness with the object. It is easy to perceive the features of hot and cold exposures in the form of excess or deficits in the normal biological functioning and subsequent diseases and the counter exposures as treatment. This became the basis of dwividha upkrama (twofold) therapy of Ayurveda composed of santarpana (invigoration) and apatarpana (emaciation) therapy mainly done through exposure to cold and hot therapy. More explanations about this are given in the latter part of this chapter. It may be presumed that the substances having cold and hot properties are primarily utilized for the contrary purposes of treatment. Among the three doshas, Vata and Kapha are considered to have cold property whereas Pitta is considered to have hot property. A disease caused by an excess of Vata and Kapha is treated by exposure to heat either externally or internally through the medicines having hot aftereffects (Concon 1980).

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Principle of Hot (Ushna) and Cold (Sheeta) …

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Fig. 4.3 Panchamahabhut, Tridosha, and three fundamental precepts of universe

More diseases are caused by cold and more deaths are reported to occur in cold weather than in hot. Implicating both internal and external cold as a bigger cause of morbidity than hot. An analysis by the Centers for Disease Control and Prevention (CDC) of the U.S. investigated temperature-related deaths between 2006 and 2010 and found that 63% of deaths were attributable to cold exposure, while only 31% were attributable to heat exposure (Berko et al. 2014). In Australia and the United Kingdom, coldrelated mortality between 1993 and 2006 exceeded heat-related mortality by an even greater margin (Vardoulakis et al. 2014). Researchers who evaluated 74 million U.K. and U.S. deaths reported in May 2015 found that low temperatures are associated with 7.3% of all deaths versus 0.4% for high temperatures, a ratio of more than 18 to 1.16. These observations indicate a wider and deeper implication of temperature on human physiology (Seltenrich 2015). From the Ayurveda’s perspective, increased morbidity caused by Sheeta has logic as two of the three doshas (Vata and Kapha) are dominated by Sheeta property, whereas Ushna remains limited to Pitta only. Cold and heat may impair the human physiological processes in multiple ways. It can create new health-related issues and can change the course of pre-existing morbidities. The primary concern with both exposures is the change in the body’s core temperature beyond a threshold range. Conventionally, high body temperature is associated with increased heart and respiratory rates as a compensatory feedback mechanism. It

may lead to the damage of vital functions at extreme levels due to the malfunctioning of various enzymes in temperatures exceeding their optimal function range (Arcus and Mulholland 2020). In cold exposure, the body loses heat faster than it can produce, leading to hypothermia, defined as a core temperature below 95 °F (35 ° C). Low temperatures again initiate the compensatory feedback mechanisms causing the blood vessels to constrict. This eventually increases the cardiac workload due to the increasing need for temperature maintenance by maintaining proper circulation. Like heat exposure, cold exposure may again cause body enzymes to function erratically, leading to disruption of many vital physiological functions (Daniel et al. 2008). Such changes in body physiology in response to external temperature variations can easily be explained through Ayurvedic fundamentals. As the external temperatures represent properties like hot and cold, they are causing corresponding changes in the body and making an appropriate change in the dosha. These doshic changes eventually lead to subsequent dysfunctions in the body (Hankey 2005). Hot and cold have also been linked to the temperament leading to the body’s corresponding pathophysiological changes. The hot and cold nature of temperament is inherently associated with Pitta and Kapha prikriti. Any factor that makes a change in the feeder dosha is also expected to make corresponding human temperament changes. Eventually, it also leads to the

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development of corresponding pathogenesis (Sharma et al. 2007). Pathology associated with heat and cold is also associated with the internal consumption of substances having excessively low or high temperature or food with heat or cold inducing aftereffects. From the aftereffects of food, this may be understood from the Ayurvedic perspective that it may be Sheeta or Ushna. Upper respiratory tract infections after consuming cold drinks or cold food are ready examples of how the temperature may affect the immune system. Although it is still unclear exactly how cold exposure affects the immune system, there is compelling evidence of reduced immunity and increased susceptibility to viral infections following a deliberate cold exposure (Polderman 2012). Importantly, Ayurveda considers a coconsumption of food having hot and cold properties, unhealthy and incompatible. Although many other traditional health care systems, including practice of mixing food of different nature for making a better balance, Ayurveda proposes it to be viruddhaahara (incompatible food), which may lead to several diseases. Heat– Cold duo is considered one among several unhealthy food combinations considered a potential reason for ama and subsequent diseases (Lurie 2014). The simple reason for this incompatibility of food combination having different Sheeta and Ushna properties is their unpredictable behavior in combination. Unless the behavior of such combinations is well studied, it is wise to stay away from any such experiments.

4.5

Principle of Opposing Therapies

Ayurveda has a predominant principle of opposing therapies where the diseases caused by one class of factors are treated by counterbalancing and opposing factors. Cold and hot conceptualizations have great clinical significance and application in this principle where diseases caused by cold-related factors are treated by hot applications and vice versa. However, there are exceptions to this general principle, and where treatments are not actually based upon the hot

and cold principle but rather are based upon more specific disease understanding. Although in most cases, the treatment is opposite to the nature of the diseases, in some cases, the treatment is of the same nature. For example, fever is caused by an excess of heat in the body. Still, instead of treating it with cold water (cold water is sometimes applied only to reduce the amount of heat transiently in case of high fever threatening to damage the vital functions), it is being treated with hot water. This contradiction of the general treatment logic of hot and cold had been explained in much detail in Ayurvedic classics like Charak Samhita (ज्वरितेभ्य: पानीयमुष्णम प्रयच्छन्ति भिषजो भूयिष्ठम न तथा शीतम; अस्ति च शीत साध्योअपि धातु ज्वर कर इति । च. वि. ३/ ३९). Therapeutic application of heat and cold in Ayurveda is practically done either as its external application in the form of direct transfer of heat or cold on the body through a heated or cold object, production of heat in the body by increasing energy expenditure and thereby raising the body temperature, and by consumption of food having heat or cold dissipating aftereffects. We will examine all these three therapeutic thermal applications as practiced in Ayurveda (Laderman 1987).

4.5.1 Therapeutic Applications of Heat and Cold in Ayurveda: The External Usage The application of heat for therapeutic purposes in its external form has rich references in Ayurveda literature. Swedana, which is the therapeutic application of various forms of heat externally on the body aiming to produce sweating (sweda = sweat), is described in detail in Ayurvedic classics. Charak Samhita has dedicated a full chapter describing various forms of heat and their application, indication, and standard operating procedures (Gaur 2014). Swedana, at the outset, is indicated as the first therapeutic principle to be used in diseases caused by Vata, Kapha, or their combination. The only difference in the application between these two pathologies is the form

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of heat, which is wet and dry, respectively, in Vata and Kapha conditions. Defining the variants of swedana, Ayurveda specifies them among those done either by direct contact with a heated object (saagni sweda) or the processes of generating heat by increasing energy expenditure by increasing the metabolic rate (niragni sweda). Table 4.1 summarizes various forms of direct and indirect swedana

procedures and specifications (Rastogi and Chiappelli 2013). The external use of heat through various forms of swedana has a clear demonstration of clinical knowledge about the amount and type of heat needed for the therapeutic purpose in each clinical condition and the body’s area needed to be provided the heat (Rastogi and Chiappelli 2013). The broader Ayurvedic distinction of dry

Table 4.1 Summary of various forms of therapeutic heat applied in Ayurveda Type of Swedana

Subtype of Swedana

Nearest English translation

Niragni sweda (sweating caused by internal heat generation)

Vyayam

Physical exercise

Ushma sadanam

Heated chamber

Guru pravaranam

Heavy clothing

Kshudha

Hunger (hunger initially promotes internal metabolism by mobilizing the stored substrates for energy production)

Bahupaanam

Excessive alcohol intake

Bhaya

Stress

Krodh

Anger

Upanaah

Poultice

Aahava

Friendly fight

Saagni sweda (sweating caused by direct exposure to heat)

Aatapa

Exposure to sun

Sankara sweda

Heat is given through a warm bag filled with hot material

Prastar sweda

Heat is given through stone bed

Nadi sweda

Heat is given through steam

Parishek sweda

Heat is given through a shower of hot water mixed with a decoction

Avagah sweda

Heat is given through immersion of body part in hot water

Jentak sweda

Sweating in a heated chamber

Ashmaghana sweda

A variant of heat given through stone bed

Karshu sweda

Heat is given through steam coming from the hot pit

Kuti sweda

Sweating in a hot chamber

Bhu sweda

Sweating done by lying on heated ground

Kumbhi sweda

Sweating through steam produced in a pitcher pot

Kupa sweda

Sweating through a variant of the hot pit with a larger crosssectional area

Holak sweda

Sweating through a variant of the hot pit with a moderate cross-sectional area

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heat (ruksha sweda) and wet heat (snigdha sweda) have distinct thermodynamic reasoning. Dry heat offered in the form of a bag filled with warm and dry material like sand (sankara sweda) has less specific heat capacity than water. For its lower heat capacity, sand gets heated quickly and loses it quickly. Since this sweda is to be applied directly to the respective body part, for example, joints, it quickly transfers its heat energy into the skin and underlying tissue. There ought to be the local effects of this heat transference. The first and immediate effect is vasodilatation and initiation of local cytokine response. These effects of sankar sweda are almost instant and remain stable for a period of 1–3 h. Another therapeutic action done by the sankar sweda is drying the local tissue by absorbing the skin’s moisture. From the Ayurvedic perspective, this is a Vata promotive and Kapha reductive action. For this reason, it is a perfect sweda for swollen joints where the pathology is caused by Kapha and ama (a product of incomplete digestion or metabolism) (Kumar et al. 2019). Compared to the dry heat, wet heat is given mostly by the steam from the decoction of medicinal herbs in conditions dominated by Vata. Water has a high specific heat capacity, and hence, it absorbs much of the energy before it reaches a boiling state and converts into steam. When steam is applied to a colder object, some part of the body leads towards a phase transition from the vapor state to a liquid state. During this process, steam releases all the energy it has acquired during the phase conversion of water to steam. For this reason, steam application on the affected part releases a high amount of energy having deeper and more sustained effects than the dry heat application. The addition of impurities like salt, plant extracts, and other water solutes increases its specific heat capacity and increases its boiling point. This means that a decoction made of herbs boils at a higher temperature compared to plain water. When this decoction steam is made to cool by pouring it upon a colder object, it releases a higher amount of energy compared to the simple water steam. This is one reason why Ayurveda puts high stress upon heating through steam made of herbal

S. Rastogi and R. H. Singh

decoctions rather than plain water. An additional benefit of herbal decoction is that in the process of its making, a greater amount of water-soluble active contents may be dissolved into the water which can add to the net benefits. If the decoction is made by the extracts of herbs that are hot in nature, the overall effect of the process increases. An example is steam inhalation in cases of upper respiratory tract disease, steam added with ginger, ocimum, black pepper, etc., are more effective compared to water steam alone. Care has always been recommended while applying any form of heat upon the body as it always has the potential to cause burn. Ayurveda, for this reason, explicitly details about the candidates who are eligible for any heat-related therapeutic procedure. Pitta prakriti people, and in diseases originating because of Pitta excess, swedana is contraindicated. In case if swedana is needed to be done in such conditions, special care should be given to places like eyes, heart, scrotum, etc. (Rastogi and Chiappelli 2013). Compared to external heat application for therapeutic purposes, Ayurveda has fewer instances of recommending cold for therapeutic reasons. In conditions where Pitta and Vata are simultaneously affected, there are recommendations of alternate heat and cold applications to balance the counteracting thermal properties of Pitta and Vata (Mooventhan and Nivethitha 2014). Agni Karma (thermal ablation) in Ayurveda: Agni karma is an Ayurvedic method of thermal ablation done on a local tissue. Sushruta Samhita, a compendium of surgical procedures in Ayurveda, deals elaborately with Agni Karma (Samson et al. 2020). There are various methods and purposes of doing agni karma; however, the primary mechanism involved in all such methods is focused tissue destruction with the help of direct application of intense heat on the target tissue for a minimal period. Thermal cauterization with freezing or objects with high temperature is a common practice in modern therapeutics. Ayurvedic agni karma, therefore, seems to be the most primitive form of such initiatives recognizing the therapeutic usage of intense heat. The distinction between various

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Principle of Hot (Ushna) and Cold (Sheeta) …

agni karma techniques is either of the material utilized for the purpose or of the method used to apply it on the skin. The material used for agni karma essentially makes a difference in its conductivity, heat stability, melting point, and specific heat capacity. Heat conductors like metals have a high melting point and offer an intense heat exchange between the probe and the skin contact point. There can be subtle differences in the amount of heat transferred owing to the different metals used (Bakhashi et al. 2010). Heat insulators have a limited heat retention scope, and hence, may offer only a limited amount of heat exchange. The contact location and contact time also make a big difference in net impact upon the tissue where agni karma is done. A transient point contact (bindu) may be transferring intense heat at a specific point only compared to the dispersed transfer of heat at a large surface area in case of a blunt object used for heat transfer, and a larger exposure (valaya, vilekha, pratisaran) is given to the tissue. The commonest indications of agnikarma recommended in Ayurveda are pain trigger points, warts, polyps, and growths. Agnikarma is praised enormously for its radical potential to facilitate the destruction of the pathological tissue (Brace 2011).

4.5.2 Therapeutic Applications of Heat and Cold in Ayurveda: Internal Usage Every medicinal or food substance is presumed to have its effects grossly identifiable as ‘Hot’ or ‘Cold’ based on their net actions on the body. Therefore, from Ayurveda’s perspective, hot and cold comes as the therapeutic outcome based upon the pharmacologically active components in a compound determining the direction and nature of its actions responsible for its properties and therapeutic benefits. Actions of a drug in Ayurveda are explained based on certain key attributes like rasa (taste of the drug), guna (qualities of the drug), virya (inbuilt effect in terms of hot, cold, or neither hot nor cold),

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vipaka (post-metabolic effects), and prabhava (special effects not explainable by any of the above-said properties). Experimental studies have tried to explore the thermodynamic reasoning behind Ayurveda’s connotations of Ushna and Sheeta based on the thermodynamic nature of metabolic reactions caused by the substance. An Ushna veerya substance is expected to give rise to an exothermic reaction (where energy is released inside the body when the drug acts upon the body tissue) compared to a sheet virya drug, which might give an endothermic reaction (where energy is consumed when the drug acts upon the body tissue) (Gupta and Prasad 2016). Despite its great importance in determining the type of personality (prakriti), disease, and remedies, including food, not much scientific exploration has been attempted in Ayurveda to establish the scientific rationale behind such classifications (Rastogi and Chiappelli 2017). A conventional layperson’s identification of some food as hot or cold has a large bearing on its aftereffects. A food that causes more sputum production and brings heaviness in the body is expected to be a Sheeta property compared to the one which causes warmth, hotness, dryness, and lightness in the body (Lambert 1992) (Table 4.2). Ayurveda places importance on the hotness or coldness of the food based on their place of origin. Such habitats are classified based on geoclimatic conditions and hydration. They are distinguished as anup (water-rich geo-climatic zone), jamgala (water-deficient geo-climatic zone), and sadharana (balanced geo-climatic zone). It is proposed that the property of food draws greatly from the geo-climatic zone where it is grown. A food item grown in anup has cold properties compared to the food which is grown in jamgala or sadharan desh. Identification of food for its hot or cold property has a direct application on diseases having a hot or cold inclination in the pathogenesis. Pitta’s disease caused by Pitta or which is hot by nature will benefit greatly from the food grown in anup geoclimatic condition. On the contrary, a disease caused by Vata–Kapha combination will benefit from a diet made of food grown in a jamgala or sadharana desh (Bhavana 2014).

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S. Rastogi and R. H. Singh

Table 4.2 Ayurveda hot and cold food classification

Hot foods

Cold foods

Foods with indistinct property

Sesame

Curd

Puffed rice

Papaya

Buttermilk

Roasted gram

Brinjal

Banana

Goat milk

Dried fish

Groundnut

Rock salt

Onion

Rice

Mung pulse

Garlic

Sugar

Aged rice

Chilli

Milk

Jaggery

Wheat

Alcohol

Most sweet fruits

Most pulses

Most vegetables

Date

Bakery products

Fenugreek

Most sweets

Egg

Watery fruits

Meat

Fish

Spices

Buffalo meat

Dry fruits Sour food

4.6

Human Prakriti and Its Association with Sheeta and Ushna Properties

Every human being is a unique entity in terms of its biological specifications. No two individuals in the world are similar in every aspect. There are biological reasons for these differences. Ayurveda classifies the human population based on their physical, physiological, and neuro-cognitive characteristics, and proposes that these characteristics primarily reflect the constitutional proportion of doshas in the body determined initially at the time of conception. Prakriti is an Ayurvedic biological phenomenon that recognizes the variability among individuals and attributes it to the dominance of individual doshas. Fundamentally, doshas are the functional representation of the various combinations of five mahabhuta with distinctive properties. Dosha, therefore are principally representing the characteristics possessed by their constituent mahabhuta. These dosha characters are available as alleles of contrasting characters expressed in individuals as the

dominant traits. This implies that a dosha’s dominance ensures the expression of certain peculiar characters in the individual otherwise not possessed by any other individual. Looking this way, the Ayurvedic percept of dosha and its influence upon prakriti seems to be an early account of human genetics (Patwardhan and Bodeker 2008). For the practical purposes of applying it in Ayurvedic clinics, human prakriti is identified through observation and interrogation about certain features known to represent certain dosha. An experienced physician may find it handy to assess the prakriti of the individual during clinical examination. For a novice, it may, however, require practice, and initially, a template may be needed to make the appropriate observations. Various app-based tools and questionnaires exist to examine prakriti in a healthy population and a clinical setting. Based on their formative doshas, the prakriti may be distinguished for their Ushna and Sheeta nature. Pitta prakriti is known for the characters representing the Ushna guna of Pitta. These characters are increased appetite, better tolerance to cold, heat intolerance,

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Principle of Hot (Ushna) and Cold (Sheeta) …

aggressiveness, increased perspiration, etc. Naturally, these features are more apparent in Pitta prakriti people. On the contrary, Vata and Kapha represent sheet guna, and thereby express the characters representing sheet among the people possessing the dominance of such dosha in their prakriti. As a result, Vata and Kapha are represented by increased cold intolerance and proneness to cold-induced diseases (Dey and Pahwa 2014). A very pertinent point about prakriti, their dosha dominance, and their connection with health and disease is that a person can remain healthy irrespective of its dosha dominance till it adheres to its basic dosha pattern. If this dosha pattern, which is native to an individual, is disturbed in terms of a changed pattern by altering the dosha, this will be called a disease. A treatment naturally helps to bring back this disturbing pattern to the pattern native to the individual.

4.7

Acquainting with Hot and Cold Precepts: Examples from Ayurvedic Clinical Practice

How does an Ayurvedic physician make use of concepts of hot and cold to reach a clinical diagnosis and subsequent derivations of the treatment? It would be interesting to explore this process by getting into an Ayurvedic clinical practice and finding how such concepts are truly brought into practice and are read as clinically important references having a translational value. Let us take the example from an Ayurveda arthritis specialty clinic at a secondary care teaching hospital in India. This clinic keeps an account of classical hot and cold connotations in determining the joint pathology and subsequent interventions (Rastogi 2020). Arthritis is an important clinical condition commonly seen among patients visiting Ayurveda clinics in India. Over 60% of all people with arthritis in India visit Ayurvedic clinics sometime during their illness (Rastogi 2020). Arthritis in Ayurveda is determined to be originating from three sources. These are either ama-induced (inflammatory pathologies), Vata-

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induced (degenerative pathologies), or Pittainduced (metabolic pathologies having episodic nature of presentation). There can also be conditions with a mix of such pathologies, i.e., where more than one reason for joint symptoms is expected to play. However, the treatment approach in joint disease in Ayurveda is largely determined by these major classes of pathogenesis. Ama-induced joint pathogenesis is supposed to be caused by an impairment in the digestive (pachakagni) and metabolic fire (dhatvagni), resulting in incomplete digestion and metabolism. The impaired digestion results in abnormal substrates with adhesive affinity to joints that can decrease the natural flow of substrates in joints and result in local inflammation. Due to ama’s homology with Kapha in their physical and chemical nature, ama has a natural affinity towards places dominated by Kapha. Joints are such places of Kapha domination in the body, and hence ama easily induces joint pathology (Gupta et al. 2015). Since this pathology of ama initiates through hypofunctioning of fire as a primary event, its features are largely related to reduced heat or increased cold. These features of hypo-functional fire are local as well as systemic. The local features related to the hypofunction of fire are coldness, swelling, and stiffness of the joint, which improves after movement and increases after periods of rest. Constitutional symptoms available in an ama-related pathology are loss of appetite, dullness, heaviness, generalized swelling, increased frequency of micturition, and constipation. This is obvious to note that such pathological distinctions of Ayurveda are identifiable only through clinical examination. No clear laboratory measures determine the level or presence of ama in the body (Amruthesh 2007). Once such distinction is made about the process of pathogenesis, the choice of interventions becomes clear. A disease caused due to hypofunction of the fire naturally requires a treatment that is expected to improve the fire. Therefore, ama pathology requires a deepan (fire initiator) and pachana (metabolic promoter) approach along with prevention of further ama generation and promotion of accumulated ama

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disintegration. There are systemic and local approaches to handle systemic and local ama. Systemically, it is done with the help of drugs having hot aftereffects, and locally, it is done with the application of dry heat over the joints. A diet that is hot in nature helps manage a disease caused by ama, whereas all the measures supposed to increase the Kapha, ama, and coldness in the body are contraindicated. Drinking hot water at regular intervals comes as a highly recommended measure in Ayurveda for amarelated pathologies since it helps in the disintegration of accumulated ama. Dietary items that are cold in nature (Table 4.2) are usually contraindicated in ama-related pathologies. Similar contraindications are also exercised with lifestyle measures that are expected to reduce the fire. Some related examples are water sports, sleeping during day hours, exposure to cold and humid air, and eating food before the earlier consumed food is digested (adhyasana). Rheumatoid arthritis is a classic example of ama-induced joint pathology in Ayurveda, and accordingly, it is referred to as amaVata in Ayurveda literature (Rastogi and Singh 2009). A joint disease induced by Vata usually refers to degenerative joint pathology marked with progressive features often predominantly seen in advanced ages. Although it is common among the elderly, it may also be seen among young adults if there is an imbalance between degenerative and regenerative biological activities in the body. If it exceeds the repair rate, degeneration is supposed to give related clinical features of Vata in joints and the whole body. The common features of Vata excess are pain, emaciation, deformity, loss of strength, anxiety, insomnia, tremors, and irritability. Like the pathologies of Kapha, Vata pathologies are also predominantly treated with hot therapy either as its local application or as an internal application. The only difference in local therapy is that here in Vatainduced disease, wet heat is preferred compared to dry heat preferred in Kapha pathologies. This distinction lies in the underlying fact that Vata has ruksha (dryness), khara (roughness), and parush (unevenness) as its inherent features, and hence its pathologies are marked with these

S. Rastogi and R. H. Singh

features presented clinically. Wet heat pacifies these features besides handling pain and deformity, which might be the main presenting features of Vata-induced joint pathologies. Dietary and lifestyle recommendations in Vata-induced joint pathology are like that of ama and Kapha pathologies except that here the oil and ghrita (clarified butter) are also permitted, which are otherwise not recommended in ama- and Kapharelated pathology. Osteoarthritis is a classic example of joint diseases caused by an excess of Vata. It is called sandhiVata in Ayurveda (Raut et al. 1991). Finally, there are joint diseases that cause an excess of Pitta. Pitta represents hotness and fire in the body. Such diseases are characterized by a feeling of local or generalized warmth, swelling, redness, occasional suppuration, tenderness on touch, etc. Such local features may also be accompanied by systemic features like increased thirst, irritability, and fever. Infective pathologies of joints and metabolic diseases affecting the joints due to crystal deposition in joint space like gout and calcium pyrophosphate deposition disease are classical examples of a Pitta disease affecting a joint. The management strategies in these cases are aiming at a reduction of Pitta or hotness locally as well as systemically. Local elimination of Pitta in an infected joint is always done by debridement of the joint and draining any accumulated suppurated material inside the joint space. Ayurveda proposes raktamokshana (bloodletting) as a very effective means of reducing hotness from the body for the simple reason that it considers blood as a derivative of Pitta and thus a representative of hotness (Rastogi and Chaudhari 2014). The approach of Ayurvedic diagnostic and examination methods to know precisely about pathogenesis in cases of joint diseases and subsequently, formulating their treatment strategies seems to be a highly successful approach, as it yields 60–70% improvement in the clinical status of most patients observed through the hospital records of a specialized Ayurveda Arthritis Clinic in India (Rastogi 2020). It is important to note here that in most cases, the diagnostic approach in Ayurveda remains an outpatient-

4

Principle of Hot (Ushna) and Cold (Sheeta) …

based clinical examination method supplemented through interrogations. An outpatient-based nadi (pulse) examination is an important method to help diagnose the current dosha status of the patient and its linkage with ongoing pathology. Vata nadi is presumed to be rapid, feeble, and slippery and is often referred to as having sarpa gati (snake like movement). Pitta nadi is fast, forceful, bouncing, and thrusting. It is referred to as manduka gati (frog-like movement). Kapha nadi is more synchronous and is referred to as hansa gati (swanlike movement) (Joshi et al. 2007). Although nadi examination has been in the practice of Ayurveda for a long time, and it presumably helps to screen the level of dosha and their impacts on physiology, its scientific rationale and objectivity are yet to be scientifically established. There had been much literature available on nadi examination and on physical forms of nadi available in various dosha dominance. Still, the value of this literature on scientific grounds is yet to be proven. In that case, if nadi examination adds any value to the clinical diagnosis in Ayurveda, it is largely individual expertise and not a generic phenomenon (Kurande et al. 2013). Other crucial components of clinical examination in joint diseases like prakriti (biological constitution), agni (metabolic state), ama (state of metabolic outcome), and koshtha (state of bowel movements) have also been attempted to be examined objectively by designing and validating tools for it. Prototype Prakriti Analysis Tool (PPAT), Modified Prakriti Analysis Tool (MPAT) developed by Rastogi et al., Ayusoft, and recent approaches of Central Council for Research in Ayurvedic Sciences (CCRAS), India are a few noteworthy steps in this direction (Rastogi 2012; Rastogi and Chiappelli 2017; Dornala and Dornala 2013; Singh et al. 2017; Patil et al. 2008). Nonetheless, it has been observed that Ayurvedic physicians still largely rely upon their examining skills to assess these crucial components of Ayurvedic clinical examination rather than employing any validated tools.

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One most practical example of applying the hot and cold concept in Ayurvedic rheumatology practice is the choice of bhallataka as a drug in a clinical setting. Bhallataka (Semicarpus anacardium L.f.) is one of the best medicines for Kapha- and ama-related disorders. It, therefore, qualifies as the most preferred drugs in amaVata. Despite its unique advantage of bhallataka in amaVata, it is associated with few side effects in Pitta dominant people. These side effects are related to the excess of Pitta features like burning, feeling of warmth, and bleeding. Due to the possibility of these side effects among Pitta dominated sub-population following bhallataka use, its use is cautioned and recommended only after a careful screening of the patient for any possibility of having a natural dominance of Pitta (Llanchezhian et al. 2012). There are many other examples of hot and cold applications in disease diagnosis and its treatment. Respiratory tract diseases marked with dry or wet cough are other clear examples where this strategy is employed successfully (Rastogi 2018). Various other published case reports show the importance of using Ayurvedic clinical approaches in disease diagnosis and management. These cases, which were related to metastatic liver disease, achalasia cardia, neurogenic bladder, traumatic brain injury, and nevus of Ota, have shown good clinical responses after Ayurvedic therapy (Rastogi and Chaudhari 2015; Rastogi and Chaudhari 2014; Rastogi and Rastogi 2012; Rastogi 2017, 2019).

4.8

Translational Value of Ushna and Sheeta in Disease Diagnosis and Management: A Few Case Examples

Case 1: Excess of Pitta in the body often reflects as heartburn, burning at various places in the body, excessive perspiration, constipation or loose motion, and erratic digestion. Amla Pitta is a clinical entity that encompasses all these features. The features of amla Pitta showing the presence of an excess of hotness in the body are often endorsed by the nadi (pulse) examination

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showing an excess of Pitta and seeing the personality determinants showing an excess of hotness in the body. In conventional medicine, such patients are diagnosed with gastroesophageal reflux disease and are treated with conventional antacids, proton pump inhibitors, and prokinetic drugs aiming to improve gastrointestinal (GI) motility. It is commonly observed that such patients remain stable on these medicines and do not stop the medication for fear of rebound hyperacidity. Such patients are treated in Ayurveda on a simple protocol of eliminating excess hotness (Pitta) by virechana (therapeutic purgation) followed by Pitta shamak drugs (heat reducing drugs). A young male (24-years-old) of average built presented with heartburn complaints following eating for several years, was taking antacids and proton pump inhibitors to relieve the symptoms. He was not able to bear even a day without drugs. This patient was initially treated with virechana to expel excess Pitta from the body. Following the complete protocol of virechana comprising of pre-procedure (a preparatory phase, preparing the body for Pitta eliminative process), procedure (the main process where some purgative is given to the patient in a monitored condition to eliminate excess Pitta), and post-procedure (dietary plan to restore agni after Pitta elimination) took 10 days. During this period, the patient did not require any antacid or proton pump inhibitor, and he did not feel any burning in the chest. Once the procedure was over, the patient was recommended for oral Pitta shamak (drugs having anti-hot properties) medicine. The patient was recovered during followups and was able to do well without any antacid therapy. This case is a clinical example of how the concept of Ushna and Sheeta helps in diagnosing pathogenesis and appropriate treatment. Case 2: A middle-aged male (40 years old), medical representative by profession, having had heartburn complaints for over 12 years and was prescribed proton pump inhibitors for the past 7 years. He had an erratic eating schedule due to his frequent traveling and work schedules. This added to his problems. He was unable to sleep well due to constant regurgitation and heartburn overnight. He skipped a meal to avoid the meal

S. Rastogi and R. H. Singh

associated with heartburn. For the past many years, he could not have a full meal at night because of its ill effects upon heartburn and sleep quality. He was diagnosed in an Ayurveda clinic to have a Pitta dominant disease with a Vata– Pitta dominant personality. Owing to Pitta dominance and its pathological placement in GI tract, virechana was considered as the first treatment approach in this case. He was prescribed virechana, and after this was recommended a few Pitta shamaka medicines. Virechana produced instant relief in his case, although the symptoms recurred in a milder intensity after some days. He was given repeated virechana three times in a 15day interval. Two years later, he is still fine. He is not on any regular medication from any system, including Ayurveda. Case 3: A middle-aged male had complaints of occasional hematuria and hematospermia for the past 2 months which was noticeable only after sexual intercourse. He did not have any associated features like pain, tenderness, or any other indicator of direct trauma. His ultrasound examination did not reveal any abnormality. His blood reports were also normal. This patient was diagnosed as having Pitta dominant shukra dushti (semen abnormality due to Pitta) and was treated with oral medication aiming to reduce the hotness of the body, particularly the urogenital tract. After about 2 months of treatment, he stopped showing any presence of haematuria or hematospemia. One year after the treatment, he is still fine and did not have any recurrence of symptoms. This case is a clear example showing that Ushna and Sheeta as the diagnostic and treatment strategies are not limited to GI-related disease but have equal applicability to many other body systems.

4.9

Conclusion

Hot and cold percept forms the very basis of traditional health care wisdom across the world. One can find their clinical usage almost in all traditional health care globally; Ayurveda is no exception to this. The hot and cold ideology is so pervasive in Ayurveda health care

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Principle of Hot (Ushna) and Cold (Sheeta) …

fundamentals that sometimes it becomes hard to distinguish it as an independent fundamental. It is part of the Ayurveda tridosha theory by assigning specific hot or cold properties to various dosha. It forms the basis of defining personalities, pathogenesis, diseases, and their treatment based on their association with hot or cold. The preventive aspect also classifies the edibles and lifestyle measures based on their hot or cold promoting properties. By looking carefully at the theory and presented cases, we can easily feel that such concepts are the integral components of Ayurvedic clinical practice and can give distinct therapeutic benefits, as are shown through the presented cases. Acknowledgements The authors acknowledge Dr. Paul Richard Saunders, Ph.D., N.D., R HOM, DHANP, CCH for editing the manuscript.

Textual References शीतोष्णम इति वीर्य तु क्रियते येन या क्रिया । नावीर्य कुरुते किंचित सर्वा वीर्य कृता क्रिया॥ च.सू.२६/६५ तच्च वीर्यम द्विविधम उष्णम शीतम च अग्निसोमीयत्त्वाज्जगत:। सु.सू अ.४०/५ शीतेनोष्णकृतान रोगांछमयन्ति भिषग्विद:। ये तु शीत कृता रोगास्तेषामुष्णम भिषग्जितम॥ च.वि. ३/४१ ज्वरितेभ्य: पानीयमुष्णम प्रयच्छन्ति भिषजो भूयिष्ठम न तथा शीतम; अस्ति च शीत साध्योअपि धातु ज्वर कर इति । च. वि. ३/ ३९

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54 Kurande V, Waagepetersen R, Toft E, Prasad R (2013) Intrarater and interrater reliability of pulse examination in traditional Indian Ayurvedic medicine. Integr Med Res 2(3):89–98. https://doi.org/10.1016/j.imr. 2013.07.001. Epub 2013 Jul 17. PMID: 28664059; PMCID: PMC5481710 Laderman C (1987) Destructive heat and cooling prayer: Malay humoralism in pregnancy, childbirth and the postpartum period. Soc Sci Med 25(4):357–365. https://doi.org/10.1016/0277-9536(87)90274-7 PMID: 3686085 Lambert H (1992) The cultural logic of Indian medicine: prognosis and etiology in Rajasthani popular therapeutics. Soc Sci Med 34(10):1069–1076. https://doi. org/10.1016/0277-9536(92)90280-4 Llanchezhian R, Joseph CR, Rabinarayan A (2012) Urushiol-induced contact dermatitis caused during Shodhana (purificatory measures) of Bhallataka (Semecarpus anacardium Linn.) fruit. Ayu 33 (2):270–273. https://doi.org/10.4103/0974-8520. 105250 Lochner CJ, Rohrbach G, Cochrane K (2003) What is your cosmic connection to the elements? https://www. nasa.gov/pdf/190387main_Cosmic_Elements.pdf Lurie DI (2014) A scientific examination of Western dietary practices as they relate to food practices in Ayurveda. In: Ayurvedic science of food and nutrition. Springer, New York, NY, pp 139–160 Lyssenko V (2004) The human body composition in static and dynamics: Ayurveda and the Philosophical Schools of Vaisesika and samkhya. J Indian Philos 32(1):31–56 Mooventhan A, Nivethitha L (2014) Scientific evidencebased effects of hydrotherapy on various systems of the body. N Am J Med Sci 6(5):199–209. https://doi. org/10.4103/1947-2714.132935 Mukherjee PK, Harwansh RK, Bahadur S et al (2017) Development of Ayurveda—tradition to trend. J Ethnopharmacol 197:10–24. https://doi.org/10. 1016/j.jep.2016.09.024 Parasuraman S, Thing GS, Dhanaraj SA (2014) Polyherbal formulation: concept of Ayurveda. Pharmacogn Rev 8(16):73–80. https://doi.org/10.4103/0973-7847. 134229. PMID: 25125878; PMCID: PMC4127824 Patil VC, Baghel MS, Thakar AB (2008) Assessment of Agni (digestive function) and Koshtha (bowel movement with special reference to Abhyantara snehana (internal oleation). Anc Sci Life 28(2):26–28 Patwardhan B, Bodeker G (2008) Ayurvedic genomics: establishing a genetic basis for mind-body typologies. J Altern Complement Med 14(5):571–576. https://doi. org/10.1089/acm.2007.0515. PMID: 18564959 Polderman KH (2012) Is therapeutic hypothermia immunosuppressive? Crit Care 16(Suppl 2):A8. https://doi.org/10.1186/cc11266 Pool R (1987) Hot and cold as an explanatory model: the example of Bharuch district in Gujarat, India. Soc Sci Med 25(4):389–399. https://doi.org/10.1016/02779536(87)90277-2

S. Rastogi and R. H. Singh Rastogi S (2010) Building bridges between Ayurveda and modern science. Int J Ayurveda Res 1(1):41–46. https://doi.org/10.4103/0974-7788.59943 Rastogi S (2012) Development and validation of a Prototype Prakriti Analysis Tool (PPAT): inferences from a pilot study. Ayu 33(2):209–218. https://doi. org/10.4103/0974-8520.105240 Rastogi S (2017) Low-pressure, low-flow voiding dysfunction in an elderly male treated through Ayurveda: a case report. J Evid Based Complementary Altern Med 22(4):846–850. https://doi.org/10.1177/ 2156587217712764 Rastogi S (2018) Management of chronic dry cough through Ayurveda: illustrating ayurvedic treatment principles through practice, Tang. J Humanita 8(1):1– 4. https://doi.org/10.5667/tang2018.0001 Rastogi S (2019) Coma with Glasgow coma scale score 3 at admission following acute head injury: experiencing the complete recovery supported through Ayurveda—a case report. Complement Med Res 26 (5):353–360. https://doi.org/10.1159/000498912 Rastogi S (2020) Emanating the specialty clinical practices in Ayurveda: preliminary observations from the Arthritis clinic and its implications (published online ahead of print, 2020 Apr 1). J Ayurveda Integr Med S0975-9476(19)30335-3. https://doi.org/10.1016/j. jaim.2019.09.009 Rastogi S (2020) Ayurvedic rheumatology: Quo vadimus? In: Rastogi S (ed) Contemporary Ayurveda, Chaukhambha Vishwabharati, Varanasi, pp 19–26 Rastogi S, Chaudhari P (2014) Pigment reduction in nevus of Ota following leech therapy. J Ayurveda Integr Med. 5(2):125–128. https://doi.org/10.4103/ 0975-9476.131736 Rastogi S, Chaudhari P (2015) Ayurvedic management of achalasia. J Ayurveda Integr Med. 6(1):41–44. https:// doi.org/10.4103/0975-9476.146556 Rastogi S, Chiappelli F (2013) Hemodynamic effects of Sarwanga Swedana (ayurvedic passive heat therapy): an observational study. Ayu 34(2):154–159 Rastogi S, Chiappelli F (2017) Ayurvedic Prakṛti analysis for healthy volunteers: validating a tool for clinical practice. Asian Med 12(1–2):119–136. https://doi.org/ 10.1163/15734218-12341389 Rastogi S, Rastogi R (2012) Ayurvedic intervention in metastatic liver disease. J Altern Complement Med 18 (7):719–722. https://doi.org/10.1089/acm.2011.0351 Rastogi S, Singh RH (2009) Development of diagnostic criteria for AmaVata: inferences from a clinical study. JRAS 30(3):1–10 Rastogi S, Bhattacharya A, Singh RH (2020) Evidence building in Ayurveda: generating the new and optimizing the old could be strategic. In: Kumar DS (ed) Ayurveda in new millennium. CRC Press. https:// doi.org/10.1201/9780429298936 Raut AA, Joshi AD, Antarkar DS, Joshi VR, Vaidya AB (1991) Anti-rheumatic formulations from Ayurveda. Anc Sci Life 11(1–2):66–69. PMID: 22556565; PMCID: PMC3336571

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Samson A, Patil DD, Patil PD (2020) Short-term efficacy of an integrated approach using spencer’s mobilization and agnikarma on movement and functional disability in a patient with shoulder impingement syndrome. J Dent Res Rev 7(Suppl S2):79–83 Seelan R (2015), Deconstructing global citizenship. In: Bashir H, Gray P (eds). Routledge, ISBN 9781498502580, p 143 Seltenrich N (2015) Between extremes: health effects of heat and cold. Environ Health Perspect 123(11): A275–A280. https://doi.org/10.1289/ehp.123-A275 Sharma H, Chandola HM, Singh G, Basisht G (2007) Utilization of Ayurveda in health care: an approach for prevention, health promotion, and treatment of disease. Part 1–Ayurveda, the science of life. J Altern Complement Med 13(9):1011–1019. https://doi.org/ 10.1089/acm.2007.7017-A. PMID: 18047449 Singh A, Singh G, Patwardhan K, Gehlot S (2017) Development, validation, and verification of a selfassessment tool to estimate Agnibala (digestive strength). J Evid Based Complementary Altern Med 22(1):134–140. https://doi.org/10.1177/ 2156587216656117 Valiathan MS (2016) Ayurvedic Biology: the first decade. Proc Indian Nat Sc Acad 82(1) Vardoulakis S, Dear K, Hajat S, Heaviside C, Eggen B, McMichael AJ (2014) Comparative assessment of the effects of climate change on heat- and cold-related mortality in the United Kingdom and Australia. Environ Health Perspect 122(12):1285–1292 WHO (2010) Benchmarks for training in traditional / complementary and alternative medicine: benchmarks for training in Ayurveda, p 1. http://digicollection.org/ hss/documents/s17552en/s17552en.pdf

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Prof. Sanjeev Rastogi obtained his MD (Ayurveda) from Banaras Hindu University, Varanasi and Ph.D. from Lucknow University, India. He worked as Director, Rashtriya Ayurveda Vidyapeeth (National Academy of Ayurveda), an autonomous organization under Ministry of Ayush, Govt of India. Currently he is working as professor and head, Department of Kaya Chikitsa at State Ayurvedic College and Hospital, Lucknow, India. Dr. Rastogi has over 120 research publications besides many chapter contributions and book publications. His recent book ‘Translational Ayurveda’ published by Springer Nature, Singapore is widely read across the world. Dr. Rastogi was awarded with IASTAM award for excellence in teaching in 2018 and TBRS best translational researcher award in 2020.

Prof. Ram Harsh Singh is distinguished professor in the Department of Kaya Chikitsa, Faculty of Ayurveda, Institute of Medical Sciences, Banaras Hindu University, Varanasi. He previously served as Dean, Faculty of Ayurveda, IMS, BHU, Varanasi and also served as founder vice-chancellor, Dr. Sarvepalli Radhakrishnan Rajasthan Ayurved University, Jodhpur, Rajasthan. He received numerous awards and recognitions for his contribution to Ayurveda. Govt of India felicitated him with Padma Shree in 2016 which is one among the highest civilian award conferred by the president of India. Having over 100 research papers, book chapters and books to his credit, Prof Singh is one of the most accomplished teachers, physicians and researchers in contemporary Ayurveda.

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Principle of Hot and Cold and Its Clinical Application in Latin American and Caribbean Medicines Carlos A. Vásquez-Londoño, Luisa F. Cubillos-Cuadrado, Andrea C. Forero-Ozer, Paola A. Escobar-Espinosa, David O. Cubillos-López, and Daniel F. Castaño-Betancur

Abstract

Historically hot and cold theories have been essential for the constitution and practice of Latin American and Caribbean traditional health systems. Nonetheless, the scarcity and dispersion of the available information impedes the recognition of the relevance and intercultural applicability of these medicines, both in the clinical, academic, and political settings. For these reasons, the aim of this narrative review is to describe hot and cold theories in the conformation and clinical

C. A. Vásquez-Londoño (&) Faculty of Medicine and Faculty of Science-Department of Pharmacy, Universidad Nacional de Colombia, Bogotá, Colombia e-mail: [email protected] L. F. Cubillos-Cuadrado
A. C. Forero-Ozer
P. A. Escobar-Espinosa
David O.Cubillos-López
D. F. Castaño-Betancur Faculty of Medicine, Universidad Nacional de Colombia, Bogotá, Colombia e-mail: [email protected] A. C. Forero-Ozer e-mail: [email protected] P. A. Escobar-Espinosa e-mail: [email protected] David O.Cubillos-López e-mail: [email protected] D. F. Castaño-Betancur e-mail: [email protected]

practice of Latin American and Caribbean medical systems. Hot and cold classifications apply to the traditional understanding of health, the body, its physiology, and disease, which therapeutic and preventive approaches are based on foods, habits, and medicinal plants of the opposite cold or hot category. There are recognizable similarities between hot and cold theories in Latin American and Caribbean medicines and in other medical cultures. The growing scientific research and evidence contributes to re-signify the clinical applicability of Latin American and Caribbean traditional medicines. Further research about hot and cold theories in Latin American and Caribbean medicines is strongly recommended, to optimize its integration with biomedicine in an equitable intercultural context. Keywords







Hot and cold Clinical practice Latin America Caribbean Traditional medicine




5.1




Introduction

The hot and cold theory is the foundational basis of most traditional medicines all over the world and is the central axis of a dichotomous ordination scheme of universal phenomena, from which

© Springer Nature Switzerland AG 2021 M. Yavari (ed.), Hot and Cold Theory: The Path Towards Personalized Medicine, Advances in Experimental Medicine and Biology 1343, https://doi.org/10.1007/978-3-030-80983-6_5

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diverse philosophical systems have emerged. The methodical and progressive coding through millennia of Chinese, Persian, Ayurvedic, Korean, Kampo, and Thai traditional medicines has evolved into structured complex health systems, which have overcome well-being challenges successfully and even reached a fair crosscultural integration with conventional medicine (Keji and Hao 2003; Terasawa 2004; Yin and Ko 2014; Shirbeigi et al. 2017; Jaiswal and Williams 2017; Lumlerdkij et al. 2018). Antique health concepts and practices have recently been studied scientifically, giving insight into effective and comprehensive approaches to complex human disease (Nayak 2012; Li and Zhang 2013; Moeini et al. 2017; Khoomrung et al. 2017; Arai 2021). The conceptualization of heat and cold in Latin American and Caribbean traditions has been reported since ancient times and is considered to be a shared mindscape connecting a vast multiplicity of medical cultures in the region. Hot and cold theories are still widely disseminated and serve a pivotal role in Latin American and Caribbean medicines. Its documentation has been scarce, and the scattered available information represents an impediment to delineate the structural roots of these traditional medical systems (Alarcón et al. 2003). The sparsity of evidence about these medical theories has stimulated their misinterpretation as a mere system of beliefs and superstitions, hindering their recognition as reliable medical systems in clinical, academic, and political settings (Nigenda et al. 2001; Aizenberg 2011). Until now, experiences of pluricultural health models have been developed only in few localities of Latin America and the Caribbean, with the majority of traditional medicines in the region continuing, far from being accepted as part of current health systems (Mignone et al. 2007; Vandebroek 2013). The increasing loss of biodiversity and the progressive extinction of indigenous cultures in the Americas, render autochthonous medicines and cosmogonies at great risk of being lost (Amorozo 2004; McChesney et al. 2007). For these reasons, the aim of this narrative review is to describe hot and cold theories in the

C. A. Vásquez-Londoño et al.

conformation and clinical practice of Latin American and Caribbean traditional medical systems.

5.2

Methods

Studies were searched using PubMed, Scopus, Biblioteca Virtual en Salud, Redalyc, and Scielo databases. Original research and reviews were not excluded based on their publication year or language. The following keywords were used in different languages: “hot and cold” AND “medicine” AND “Latin America”, “hot and cold” AND “medicine” AND “South America”, “hot and cold” AND “medicine” AND “Central America”, “hot and cold” AND “plant” AND “Latin America”, “hot and cold” AND “plant” AND “South America”, “hot and cold” AND “plant” AND “Central America”. Further papers were found through cross-referencing. All available books regarding Latin American and Caribbean traditional medicines were also consulted.

5.3

Case Presentation

A 27-year-old woman on her 15th day postpartum of her first pregnancy (delivered by cesarean section) presented with the main complaint of sharp and continuous supraorbital pain on the left side of her face, following the path of the trigeminal ophthalmic branch. Symptoms started suddenly and the pain was increasing in intensity as the days passed. At conventional medical services, she was diagnosed with trigeminal neuralgia but was unable to take the prescribed medications due to her past medical history of digestive issues and because she was breastfeeding. Relevant past medical history revealed chronic gastritis, gastro-esophageal reflux disease, and allergic rhinitis, which were stable without medication. There were no known allergies or previous history of surgeries at that time. An interview from the perspective of the local traditional medicine (Tolima and Magdalena Medio in Colombia) was conducted when she attended an intercultural setting. During the

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interview, she described opening the refrigerator as the trigger of the current pain. In addition, she was asked about her perception of her body’s temperature in terms of hot and cold qualities, and she expressed a life-long intolerance to cold weather and a sensation of coldness in her lower limbs that was accentuated at night. She also disclosed having a high intake of dairy products despite it used to trigger digestive discomforts such as colic pain and bowel sounds or borborygmi. It is worth noting that her symptoms started before completing the forty-day postpartum period which is considered the time when women must take special care; particularly of being exposed to extreme temperatures. The treatment plan consisted of increasing “hot” food intake aimed at generating internal heat, avoiding cold food intake, dairy products, and processed food. The outcome was a complete remission of symptoms which was still evident in a follow-up fifteen years later.

5.4

Hot and Cold Concepts in Latin American and Caribbean Medicines

Latin American and Caribbean medical traditions are highly diverse, historically developed from a myriad of indigenous cultural health systems, that since colonization syncretized to different extents with European and Afro-descendant medical concepts and practices (Pedersen and Baruffati 1985; Martínez and Luján 2011). Hot and cold theories are widely spread throughout many Latin American and Caribbean traditional medicines; these binary principles are considered the basis of classifications applied not only to illnesses, foods, and medicines but also to body areas, organs, fluids, or functions, to emotions, behaviors, life stages, heaven phases, as well as landscapes or natural phenomena (Tedlock 1987; Walter 2012). In Latin American and Caribbean medicines cold and hot categories are not used to literally denote temperatures but also to describe metaphorical discernments conceived to understand and resolve health concerns (Fock 1999; Froemming 2006). The spectrum of this

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dichotomous classification may fluctuate from very hot to hot, warm, temperate, cool, cold, or very cold scales not uniformly utilized in Latin American and Caribbean medicines (Boster and Weller 1990; García-Hernández et al. 2021). Cold always involves some heat, and heat includes cold to some extent (Faust 1988). In certain regions, the hot and cold grading is integrated with other opposing categories including dry and wet or rough and smooth (Trotter and Chavira 1980). Hot and cold theories in Latin American and Caribbean medicines are considered to have evolved both from Amerindian, European and African traditions, where interaction and permeation were facilitated through some coincident reasonings, predominantly related to hot and cold categorizing, and to a lesser extent, to other classifications like wet and dry (Barker et al. 2017; Scarpa 2020). There is historical and ethnographic evidence supporting the derivation of hot and cold concepts in current Latin American and Caribbean medicines from Native American traditions. Madsen (1955) and Messer (1987) reported Aztec theories regarding opposing supernatural forces of cold and heat, water and fire, female and male, earth and heaven, dark and light, and north and south, in which eternal engagement is constantly reorganizing the universe. Logan (1977) compiled examples of early ethnohistoric literature registering hot and cold concepts, like Badianus manuscript, Schagun’s studies on Nahuatl texts, and Landa´s interpretation of Maya glyphs. Ethnographic data also suggest Amerindian cultures were an important source for the development of hot and cold concepts in contemporary Latin American and Caribbean medicines. Colson and de Armellada (1983) highlight how hot and cold categories were evident in South American indigenous languages, environmental practices, as well as in spiritual and cosmological beliefs; these dichotomous concepts were also recorded in Kalinago peoples by 17th-century chronicles. In present-day Native American medicines, the utilization of cold and hot dichotomy is manifest in classifications related to transcendental aspects of their cosmogonies,

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binary concepts considered distant to colonizers’ traditions and therefore probably autochthonous to Amerindians. According to Andean indigenous traditions these binary gamuts comprise opposite categories like upper and lower layers of the universe, ancestral and unhealthy energies, the top of the mountains and wetlands, the sun and the moon, the right and the left, in correlation with hot and cold maladies, foods, and remedies (Osborn 1995; Portela 2002). Among some indigenous Latin American medicines, hot and cold qualities interconnect illness, plants, and territory. In this manner, the cold and down concept may refer to some wild territories linked to the underworld and occupied by supernatural forces able to lure people´s soul and heat, causing cold ailments treatable by shamans with hot and “spiritual” plants only growing in places considered sacred; conversely, the above and the hot corresponds to inhabited and cultivated areas, where an excess of energy derived mainly from certain foods, can cause hot diseases curable with home remedies prepared with cold medicines (Barajas 1995). There is also evidence regarding European contributions to the development of hot and cold theories in Latin American and Caribbean medicines. Foster (1987) and Walter (2012) pointed out similarities with Hippocratic medicine that predominated in Europe during the seventeenth century. Despite the humoral medicine belief in four elements (fire, air, earth, and water), four humors (blood, phlegm, black bile, and yellow bile), and four qualities (hot, cold, dry, and wet), Latin American and Caribbean medicine principles are predominantly based on the categories of hot, cold, dry, and wet, along with blood and bile, with the two elements of fire and wind. The African legacy in the conformation of hot and cold theories in Latin American and Caribbean medicines has been rarely documented and even neglected. Despite the use of hot and cold categories has been widely reported among afro-descendant groups in America, its origin has been attributed mainly to the influence of European colonial medicine (Aho and Minott 1977; Gutiérrez de Pineda and Vila de Pineda 1985). Cold and hot classifications have been

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described in African medical cultures from which present-time afro-descendant groups came (Vilakazi 1955; Conco 1972; Jegede 2002). In some Afro-Caribbean communities, hot and cold theories and cosmological beliefs are divergent from European colonial traditions, suggesting these binary concepts also have an African origin in Latin American and Caribbean medicines. In Palenque San Basilio, an afro-descendant group in Colombia that have preserved African linguistic roots, cold, and hot opposites are used to understand nature and disease, correlating these categories with wet and dry, water and fire, earth and wind, dark and light, fall and rise, body and spirit, urine and blood, female and male, as well as African deities hidden behind colonial saints, associated with the sea and thunder, birth and the death (Vásquez-Londoño 2012).

5.5

Hot and Cold in Healthy Individuals

According to Latin American and Caribbean medicines, health may be defined as the constantly changing equilibrium between cold and hot opposites (Messer 1987; Reyes-García 2010). A healthy body is characterized by an evenly and fluent distribution of warmth throughout (SmithOka 2012). To preserve the balance between hot and cold, it is recommended to avoid extreme thermal conditions or drastic temperature changes, both in daily feeding, physical activities, and climate conditions (Logan 1977; Chevalier and Sánchez-Bain 2003).

5.5.1 Body Humors, Heat and Cold Blood is the most important humor in numerous Latin American and Caribbean medicines and is the main regulator of constitutional heat and cold; it is conceived both as to warming and cooling, as it refreshes organs but when it is spilled takes the body's heat with it (Madsen 1955). Blood also commands the motion of other body humors and in conjunction with them, regulates body temperature; some traditional

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Principle of Hot and Cold and Its Clinical Application …

herbalists and midwives know how to assess humors, heat, and cold imbalances, through the observation of colors, sediments, and movements of urine collected in a glass jar (Antón and Pinzón 1998; Portela 2002). Sweat is considered cold, as it releases heat during exercise and cools hot disturbances; on the contrary, sperm is cataloged as hot because its loss generates coldness and worsens cold illnesses, fat tissues are also considered hot because of their warming effect (Madsen 1955). According to indigenous medical cultures, heat and cold, represented by energy and blood, flow throughout the body following paths perceived as “señas” or signs by shamans who palpate pulses while chewing coca leaves, especially at the “the house of the pulses” located on the wrists, where pulse motion is balanced (Portela 2002). From an anatomical view, heat predominates in the head, the heart, and in general all over the upper portion of the body, while cold prevails in the uterus, vagina, and other areas from the waist to the feet; cold becomes more pronounced with aging because blood weakens gradually, and also during menses and postpartum due to the loss of blood (Losonczy 1993).

5.5.2 Pregnancy, Delivery, and Postpartum Latin American and Caribbean medical traditions consider pregnancy a warm stage, which is explained by the heat resulting from the accumulation of blood that is no longer discarded monthly, and also from the heat generated by the child to be born, which is thought to be stronger if it is a girl (Vásquez-Londoño et al. 2012). A moderate warmth in pregnancy is thought to be necessary to sustain the baby in the womb, but heat can become excessive due to the consumption of too many hot foods or medicines, or by continuous exposure to the sun or fire (LópezHernández and Echeverría-García 2011). Excessive heat during the first months of pregnancy, which is called “irritation”, can trigger abortions or premature births, may cause anxiety, restlessness, insomnia, and anger to the mother, can

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give rise to skin problems in the newborn, or can be transmitted to others affecting their health (Arturo-Lucio 1970; Bayles 2008; CubillosCuadrado et al. 2019). To prevent these complications, women usually evade prolonged sun or fire exposures, avoid spicy, salty, bitter, or greasy foods or medicines classified as hot; and women also elude frozen liquids or foods, as well as places or climates that are too cold or wet, since the contrast between the inner heat and the external coldness produces pasmo (see Table 5.1). This can affect the baby's blood circulation and harm developing organs or can also delay deliveries (Velásquez 1957; Alarcón and Nahuelcheo 2008; Cantor 2016). To counteract excessive heat at the beginning of pregnancy and to prevent the above complications, midwives begin monitoring in the third month to regulate the intensity of heat in the pregnant woman, recommending cool or cold-natured foods and plants as needed, the latter frequently applied in sitz baths (Faust 1990). According to Latin American and Caribbean medicines, it is important to maintain pregnancy’s warmth until the birth, since cold is considered to cause difficult labor, retention of the placenta, and bleeding. For these reasons deliveries are traditionally attended in warm places protected from drafts, women preserve heat during childbirth by avoiding cold foods, medicines, environments, or bathing with cold water (Faust 1988; Hilgert and Gil 2007; Alarcón and Nahuelcheo 2008). To facilitate childbirth care midwives commonly use spicy or bitter plants classified as hot, administered both orally, or as sitz baths or plasters applied on the belly (Portela 2002). During postpartum the mother is more susceptible to the cold mainly because of blood loss. Exposure to cold wind, water, foods, or medicines at this stage, as well as sudden changes in temperature or also excessive heat from too much sun exposure or overwork, is thought to “loosen the womb” and prevent the normal descent of blood. They are also associated with a mother’s complaints of neuralgia and paralysis, fever, cold sweats, alterations of consciousness, headache, bone pain, as well as respiratory or breastfeeding disorders (Alarcón and

Causes

Excessive intake of hot foods or liquor harming the bile, liver, or spleen Climatic heat. In some regions, it is associated with malaria

The blood or Liver can be affected by excessive heat, commonly associated with contagious agents

Plethoric heat in the body due to excessive consumption of hot foods, high-fat diets

Hot ailments

Fevers

Heat in the blood

Heavy blood, thick blood, strong blood

Cold plants to “thin the blood” such as lemon are used

Induce sweating to release heat from the blood, calm the fever

High fever

Blood is more viscous and darker, not properly flowing through the vessels, it is related to high blood pressure, thrombosis, strokes, and heart attacks

Cold and fresh plants are applied externally; when malaria is detected bitter plants are used. Avoid hot foods and liquor

Treatment

A sensation of heat or fever, can be continuous or at intervals

Clinical manifestations

Table 5.1 Hot ailments in Latin American and Caribbean medicines

L

Sábila—Aloe vera

L

Amargo Andrés— Potalia amara

AP

S

Kanchalagua— Schkuhria pinnata

L

AP

Cashuro— Nostoc sphaericun

Flor escondida— Phyllanthus niruri

L

Martin galves— Senna alata

Tua tua—Jatropha sp.

AP

Cola de caballo— Equisetum bogotense

Fr

L

Limón—Citrus x limon

R

Gualanday— Jacaranda caucana

L

Guanábana—Annona muricata Zarza—Smilax spinosa

L L

Espíritu santo— Bryophyllum pinnatum

AP

Escubilla— Sida rhombifolia Malva—Malachra rudis

L L

Cacao—Theobroma cacao

L

Naranjo agrio—Citrus aurantium Naranjo—Citrus sinensis

L

PP

Matarratón— Gliricidia sepium

Medicinal plants

Cd

Co

Co

Cd

Co

Cd

Cd

Co

Co

T

Co

Co

Co

Co

Co

Co

Co

Co

Co

PT

(continued)

Fonnegra-Gómez et al. (2012), Vásquez-Londoño (2012)

Arturo-Lucio (1970), Blair and Madrigal (2005), Gonzales de la Cruz et al. (2014)

Zuluaga-Ramírez (2003), Blair and Madrigal (2005), Bruun and Elverdam (2006)

References

62 C. A. Vásquez-Londoño et al.

Causes

Excessive heat ascending the head can be caused after bathing or receiving rain, being overheated, or can also arise from an “infectious fever”

Not always associated with alterations of the heart as an organ, but also related to brain or mental dysfunctions Excessive heat from continuous or severe rage or worries Weakening of mental or heart functions can be due to excessive exposure to the sun, or by overwork

Hot ailments

Tabardillo

Heart Illnesses

Table 5.1 (continued)

Nervousness, insomnia, palpitations, headaches, dizziness, convulsions

Blood humor that gets dark, hot, and burning qualities, causing epistaxis, high fever, headaches, drowsiness, delirium

Clinical manifestations

Cooling and soothing plants, calm the mind. Avoid heat

Cold or cool plants are applied externally over the head

Treatment

L L R L Fl

Cidrón—Aloysia citriodora Perejil— Petroselinum crispum Valeriana—Valeriana spp. Curubo— Passiflora mollissima Manzanilla— Matricaria chamomilla

W

Co

Co

T

T

Co

L

Toronjil—Melissa officinalis

Co

Co

Co

AP

Cola de caballo— Equisetum bogotense L

B

Arizá- Brownea spp.

Cd

Co

Co

Co

Cd

PT

Quiche morado— Guzmania sanguinea

L L

L

Achiote—Bixa orellana Sábila—Aloe vera

L

Matarratón— Gliricidia sepium Malva—Malva parviflora

Fr

PP

Limón—Citrus x limon

Medicinal plants

(continued)

Amaya and Zuluaga (1989), Zuluaga (1995)

Arturo-Lucio (1970), Antón and Pinzón (1998), Pantoja (2008), Jernigan (2011), Fonnegra-Gómez et al. (2012), VásquezLondoño (2012)

References

5 Principle of Hot and Cold and Its Clinical Application … 63

Causes

The liver is particularly sensitive to hot foods, fat, liquor, and dehydration, easily “inflamed” producing excessive heat, dryness, or “raises the bile”

Eating abundant hot foods or too much sun exposure Heat can also be transferred through breast milk if the mother eats too much hot food or frequently feels emotions related to heat

Hot ailments

Liver diseases

Heat diarrhea

Table 5.1 (continued) Treatment Cold or cool bitter plants to purge and drain the liver

Cooling plants. Avoidance of hot food

Clinical manifestations Anger, restlessness, headaches, dizziness, indigestion, bitter taste in the mouth, halitosis, heartburn, stomach ache, constipation, eczemas, skin blemishes, exhaustion, peeling lips, palms and soles. If “bile raises” yellow vomiting and jaundice

Yellow or bloody stools with or without mucus, burning pain in the anus and foul-smelling feces, nausea, loss of appetite, night sweats, fever, and the stomach is warm to the touch

AP L S R L

Naranjo dulce—Citrus sinensis Maní de kamajurú— Sterculia apetala Bicho platanito—Senna spp. Santaclara asesó— Senna alata

L

Berro amarillo— Mimulus glabratus

Escobilla menuda— Scoparia dulcis

S

Kashakaña—Sonchus oleraceus

L

WP

Ratania— Krameria lappacea

Guayaba—Psidium guajava

L AP

WP

Apallanlla shakoq— Gentianella thyrsoidea Arzobispo—Justicia sericea

AP

Cola de caballo— Equisetum bogotense

Karamati—Jungia rugosa

WP

PP

Manayupa— Desmodium molliculum

Medicinal plants

Co

Co

Co

Co

Co

Co

Cd

Cd

Cd

Cd

Cd

Cd

Cd

Cd

PT

(continued)

Burleigh et al. (1990), Vásquez-Londoño (2012), García-Hernández et al. (2021)

Pantoja (2008), Gonzales de la Cruz et al. (2014)

References

64 C. A. Vásquez-Londoño et al.

Excessive heat and dehydration lead to inflammation or “irritation” due to the accumulation of “very hot air” Having cold baths after working in the sun

It is believed to be caused by people with a “strong eye” who admire or envy the affected person. The blood humor becomes hot and circulates strongly

Kidney sickness

Evil eye Prayers and plants are used externally

Cold or cool plants with a diuretic effect

Lumbar or “kidney” pain, difficult urination, scarce, concentrated and dark urine, fatigue, and sweating

More common in children who present with fever, stomach ache, headache, diarrhea, liver disorders, nervousness, pallor, chills, poor appetite

Treatment

Clinical manifestations

L

Yaku palma— Polypodium pycnocarpum

S

L

Malva—Malva parviflora

Matandrea—Alpinia sp.

AP

Cola de caballo— Russelia equisetiformis

L

L

Yaku palma— Polystichum cochleatum

Palillo—Piper sp.

AP

Cola de caballo— Equisetum bogotense

L

WP

Congona— Peperomia hartwegiana

Escobilla menuda— Scoparia dulcis

WP

Manayupa— Desmodium molliculum

WP

S

Huamanpinta— Chuquiraga spinosa

Escobilla blanca—Sida sp.

WP

PP

Hierba del perrito— Achyrocline ramosissima

Medicinal plants

Co

Co

Co

Co

Cd

Co

Co

Cd

Cd

Cd

Cd

Cd

Cd

PT

Burleigh et al. (1990), Zuluaga-Ramírez (2003)

Portela (2002), FonnegraGómez et al. (2012), Vásquez-Londoño (2012), Gonzales de la Cruz et al. (2014)

References

PP: Plant Part, PT: Plant Temperature, R: Roots, S: Stem, B: Bark, L: Leaves, AP: Aerial parts, Fl: flowers, Fr: Fruits, S: Seeds, WP: Whole plant, H: Hot, W: Warm, T: Temperate, Co: Cool, Cd: Cold

Causes

Hot ailments

Table 5.1 (continued)

5 Principle of Hot and Cold and Its Clinical Application … 65

66

Nahuelcheo 2008; Walter 2012). For these reasons it is customary for mothers after deliveries, to stay at rest in a warm place for several weeks, avoiding exposure to the cold or sudden changes in temperature, consuming warming foods and using hot plants both orally, in steam baths, or placed over the abdomen as plasters (Faust 1990; Portela 2002; ZuluagaRamírez 2003). It is traditional to keep the belly wrapped to avoid future prolapses (Faust 1990; Portela 2002; Zuluaga-Ramírez 2003). To prevent the newborn from developing empacho (see Table 5.2) during breastfeeding, mothers consume foods that provide strength and are balanced in hot and cold, and wet and dry properties (Monteban et al. 2018).

5.5.3 Childhood and Adulthood A newborn is considered to be cold and more susceptible to illnesses originating from cold, the body acquires heat progressively during childhood until adult levels of warmth are reached. Aging implies a gradual loss of heat until death arrives, a stage considered extremely cold. In women, the monthly loss and restoration of blood through the menstrual cycle is associated with monthly transitions from cold to hot, respectively. At menopause when menstrual blood losses stop, heat accumulates, ascends, and becomes perceptible mostly at night. Newborns are warmed to resemble mother's womb heat, they are protected from cold drafts, fontanels are covered to impede wind to penetrate, and the body is sheltered and “closed” applying hot plants over the navel or wearing unbreakable seeds in bracelets or collars, to prevent the entrance of cold ailments such as sereno, empacho, susto, descuaje (see Table 5.2) (Rodríguez 2008). As the navel can be an entrance for illnesses from cold, it is tied with a red wool cord so that it keeps warm (Iglesias-Alvis 2008). The first foods to be added to breast milk are recommended to be hot-natured because it is believed that consumption of cold foods at this time is linked to growth and teething delay, diarrhea, and fever which is classified as a kind

C. A. Vásquez-Londoño et al.

of pasmo (see Table 5.2) (Faust 1990; Alarcón and Nahuelcheo 2008). Andean children are usually sheltered with hot plants surrounded by a blanket called fajero, to prevent the entry of cold into the stomach and hernias. Hot plants are used in baths at night to expel coldness from the extremities and to facilitate walking after the first year of life (Vásquez-Londoño et al. 2012). As menstrual bleeding implies the loss of warm blood, it renders women more susceptible to cold and also to menstrual cramps and difficulties becoming pregnant, then hot foods and plants are used. There is also avoidance of cold water or winds, sour or cold meals and cold medicines (Faust 1990; Portela 2002; Bain and Chevalier 2003; Ticktin and Dalle 2005; Lans 2007; Flores and Quinlan 2014). Among indigenous medicines of the Orinoco region, fish are cataloged as cold because of their association with ainawi, a term used to denote water spirits and an ailment characterized by coldness, weight loss, constant hunger, and erotic dreams interpreted as the rapture of the soul to the underworld. Therefore fish intake is avoided mainly during menarche and postpartum, and its further consumption requires a ritual known as the “prayer of the fish”, where deals are made with ainawy spirits to allow people to eat aquatic animals (Queixalós and Jiménez 2010; Cubillos-Cuadrado et al. 2019). To maintain the balance between heat and cold during adulthood, it is customary to avoid prolonged or intense exposure to thermal extremes and sudden temperature changes. Aging makes the body colder; generally, the blood becomes weaker as cold restricts its proper circulation. Given that the elderly are particularly exposed to cold diseases, such as rheumatism, hot plants are frequently used (Fock 1999). As death emanates a coldness that can be passed on to the living, funerals, and cemeteries are avoided during life stages when cold is more pronounced. Attending burials makes it necessary to eat hot foods and use hot plants in baths to prevent the penetration of cold; places where death has recently happened are also washed with hot plants to expel the cold (Pérez 1980; Faust 1988, 2004).

Causes

Cold penetration into the body, especially during menstruation, pregnancy, or peripartum, sudden changes in temperature, more commonly from hot to cold climates, can cause slowed circulation of blood humor in the body, which is known as “pasmo”

Exposure to cold weather or foods, especially during flu

Cold ailments

Pasmo

Reuma or gripa

Watery nasal congestion, frontal headache

Coldness, painful menstruation, prolonged or painful labour, pain during postpartum, intense joint pain, headache, paleness, itching of ears and skin

Clinical manifestations

Table 5.2 Cold ailments in Latin American and Caribbean medicines

Decoction of hot or warm plants inhaled or used as baths or compresses on the forehead

Hot or warm plants are administered orally and externally

Treatment

L AP

Pino— Cupressus lusitanica Romero—Rosmarinus officinalis

AP

Ruda—Ruta graveolens

L

L

Ortiga— Urtica ballotifolia

Eucalipto—Eucalyptus globulus

AP

Hierba del pasmo— Baccharis glutinosa

Fr

H

L

Varasanta— Triplaris sp.

Esponjilla—Luffa cylindrica

H

AP

Romero—Rosmarinus officinalis

H

H

H

H

H

H

H

H

L

Santa maría de anís— Piper auritum

H

PT

L

PP

Altamisa— Ambrosia cumanensis

Medicinal plants

ZuluagaRamírez (2003), FonnegraGómez et al. (2012), Gonzales de la Cruz et al. (2014) (continued)

Velásquez (1957), Kay and Yoder (1987), Antón and Pinzón (1998), ZuluagaRamírez (2003), FonnegraGómez et al. (2012), VásquezLondoño (2012), GarcíaHernández et al. (2021)

References

5 Principle of Hot and Cold and Its Clinical Application … 67

Causes

Sudden cold wind especially after being overheated Abrupt temperature changes

Overeating cold food, exposure to cold climates or places, breastmilk can transfer cold if the mother eats too much food of a cold nature or is exposed to cold weather. The cold can worsen the symptoms of intestinal parasites

Eating cold or abundant meals at the wrong times, eating cold foods after hot ones, missing meals. Classified as cold but also as a hot ailment

Cold ailments

Colds

Cold diarrhea or white dysentery

Empacho

Table 5.2 (continued)

Stomach ache and bloating, poor appetite, vomiting, constipation and diarrhea, cold sweat, headache

Watery and whitish diarrhea, abdominal pain, stomach ache, poor appetite, nausea

Sore throat, headache, fever, nasal obstruction, cough

Clinical manifestations

Warming plants are taken orally and in ointments applied with massages over the abdomen. Avoid eating derangements

Decoction of hot and warm plants administered orally

Decoction of hot and warm plants administered orally, inhaled or applied externally

Treatment

AP Fl L L

Cempasúchil— Tagetes erecta Hierbabuena—Mentha sp. Yaku palma— Cheilanthes pruinata

S

Carqueja— Baccharis genistelloides

Pacunga— Bidens pilosa

L

Mastranzo—Mentha X rotundifolia

L

L

Ruda— Ruta chalepensis

Cilantro cimarrón— Eryngium foetidum

Fl

AP

Qaramati— Jungia paniculata

Cempasúchil— Tagetes erecta

L

Muña— Minthostachys mollis

L

L

Tzaq'pa— Oreocallis grandiflora

Hierbabuena—Mentha sp.

H

AP

Waman ripa— Senecio tephrosioides

Cd

H

H

H

H

H

H

H

H

H

H

H

H

H

PT

AP

PP

Ankush— Senecio canescens

Medicinal plants

(continued)

Weller et al. (1993), ZuluagaRamírez (2003), GarcíaHernández et al. (2021)

Madsen (1955), Logan (1977), GarcíaHernández et al. (2021)

Madsen (1955), Portela (2002), Walter (2012), Gonzales de la Cruz et al. (2014)

References

68 C. A. Vásquez-Londoño et al.

Causes

Affects infants during their first months of life exposed to cold wind or rain at night

Occurs in children who fall, causing the “cuajo” to fall. “Cuajo” represents organs or functions mainly of the digestive system that “fall” from their normal position and cause “descuaje”. Also associated with cold wind penetrating the body

Fractured bones or joints are more susceptible to cold since they are “breaking points”. The cold penetrates the body and can stay in the bones, which may lead to chronic pain and inflammation

Cold ailments

Sereno

Descuaje

Dislocations and fractures

Table 5.2 (continued)

Pain, movement restrictions, injured areas may be cold to touch

Glassy eyes, vomiting, stools of a liquid consistency, poor appetite. Diagnosis is made by listening to a sound similar to a water bag while palpating the abdomen, or by finding asymmetry in the length of both legs

Green or whitish diarrhea, white tongue, abdominal distention and coldness, stools are foamy

Clinical manifestations

Hot and warm plants are applied as ointments followed by massage to release coldness. Local therapists also use hot plants topically when they relocate bones and joints, to release the cold and prevent chronic pain

To relocate the “cuajo” above, the children are gently retained by the feet with the head down, then the abdomen is massaged towards the head, using hot plants and ointments, in order to remove the cold and to restore the normal position of the “cuajo”

Warming plants administered orally

Treatment

L L L AP

Tsamana— Dodonea viscosa Cheq'ya— Ophryosporus chilca Suelda— Dendrophthora clavata Ortiga hembra— Urtica urens

L

Hierbabuena—Mentha sp.

L

AP

Albahaca— Ocimum basilicum

Cardón— Dipsacus fullonum

Fl

Manzanilla— Matricaria chamomilla

H

H

H

H

H

H

H

W

H

B

Canela—Cinnamomum verum

H H

B

Canela—Cinnamomum verum

H

S

L

Hierbabuena—Mentha sp.

W

PT

Ajonjolí—Sesamum indicum

S

PP

Apio—Apium graveolens

Medicinal plants

Principle of Hot and Cold and Its Clinical Application … (continued)

Macias et al. (2007), Gonzales de la Cruz et al. (2014), MartínezSilva (2016)

SanínPineda (2015)

ZuluagaRamírez (2003)

References

5 69

Causes

Poison is considered cold in nature as snakes live on the ground and in shade and have wet temperament

It is believed that cold wind is emanated in certain wild and abandoned places (sacred), cemeteries or by corpses, it can also be sent by water spirits. Cold wind penetrates the body when overheated, driving out the body's warmth or vital energy

Cold ailments

Snake bites

Mal aire, mal viento, aire de cuevas or hielo

Table 5.2 (continued)

Coldness, chills, weakness, pain, headache, paleness, chronic diarrhea, poor appetite, vomiting, sweating, weight loss

Severe pain, swelling, bruising, bleeding, sweating, nausea, blurred vision

Clinical manifestations

Hot plants externally to expel the cold wind, prayers, rituals Avoiding cold wind, especially for infants or pregnant women

Hot and bitter-taste plants are administered orally and externally

Treatment

S L WP L

Ruda— Ruta chalapensis Valeriana— Stangea heinrici Pino— Cupressus lusitanica

L

Coca— Erythroxylum sp.

Jap’ru— Gynoxys oleifolia

R

Mamey— Mammea americana

L

B

Cruceto morado— Quassia amara

Tsuqirwa— Senecio rufescens

B

PP

Capitana— Aristolochia spp.

Medicinal plants

H

H

H

H

H

H

H

H

H

PT

(continued)

Cavender and Albán (2009), Walter (2012), Armijos et al. (2014), Gonzales de la Cruz et al. (2014)

Madsen (1955), Velásquez (1957), Coe and Anderson (2005)

References

70 C. A. Vásquez-Londoño et al.

In children is caused by a severe fright or fall, that leads to a sudden loss of body’s heat or soul by an acute production of bile humor. In adults, it can arise from irregular eating times. It is believed that it may be caused by encountering spirits

Susto or espanto Coldness, chills, shivering and startling at the slightest noise, crying, diarrhea, vomiting, headache, paleness, fatigue, sunken eyes, irregular pulses. In adults pain and heartburn

Clinical manifestations Hot plants are applied externally and in fumes

Treatment L AP WP L L

Palosanto de montaña —Turpinia occidentalis Cruz maq'e— Alternanthera porrigens Kouton nué— Gossypium barbadense Ti dité— Lippia micromera

PP

Tabaco—Nicotiana tabacum

Medicinal plants

W

W

W

H

H

PT Madsen (1955), Faust (1990), Portela (2002), Macias et al. (2007), Cavender and Albán (2009), Quinlan (2010), GarcíaHernández et al. (2015)

References

PP: Plant Part, PT: Plant Temperature, R: Roots, S: Stem, B: Bark, L: Leaves, AP: Aerial parts, Fl: flowers, Fr: Fruits, S: Seeds, WP: Whole plant, H: Hot, W: Warm, T: Temperate, Co: Cool, Cd: Cold

Causes

Cold ailments

Table 5.2 (continued)

5 Principle of Hot and Cold and Its Clinical Application … 71

72

5.6

C. A. Vásquez-Londoño et al.

Hot and Cold Maladies

In Latin American and Caribbean medicines, the disease is understood as the loss of balance between cold and hot opposites, causing ailments characterized by signs and symptoms of excessive heat or cold (Souto et al. 2011; Gonzales de la Cruz et al. 2014; Clement et al. 2015; Flores et al. 2018). Cold and hot ailments may not always be literally related to body temperature. Hot and cold categories are usually assigned to disorders depending on the recognized causes or the type of manifestations (Mathez-Stiefel et al. 2012; Scarpa 2020; García-Hernández et al. 2021). In some cases, the same ailment may have divergent temperature categories among different medical systems; there are also disorders that can have both cold and hot features, fluctuations associated with an increasing severity or long duration of disease (Burleigh et al. 1990; Bain and Chevalier 2003). Hot and cold maladies can be caused by imbalances of opposites such as cold or heat, dampness or dryness, as well as by the wind, the night, the moon, and water as carriers of cold; or by excesses in certain foods, emotions, physical activities or sun exposure as sources of heat. Intense and continuous external heat may generate internal fire, resulting in tabardillo (see Table 5.1) or even stoke; while sustained or extreme cold can penetrate to the blood, remaining in the bones, delaying the release of coldness by hot medicines (Moura and Marques 2008). Abrupt temperature changes can deteriorate blood circulation and cause dysfunction of different organs (Jernigan 2011). Furthermore, in the Latin American and Caribbean cultures, it is believed that hot and cold conditions can also be caused by non-material entities or influences, inhabiting nature, or intentionally sent through witchcraft. Based on these cultural beliefs, interactions with spirits in the wild can cause cold disorders through the subtraction of body heat or the soul, while the introduction of exogenous energies by others is associated with heat disturbances (Burleigh et al. 1990).

According to Latin American and Caribbean medicines, hot ailments more commonly affect the upper half of the body, with the exception of the teeth; while cold disturbances cause more frequent signs and symptoms from the waist down, being more common during menses, delivery, postpartum, in newborns, or with aging (Losonczy 1993). Ailments classified as hot or cold are usually treated with medicines or foods having the opposite thermal category to the disease (Smith-Oka 2012). Nevertheless, in some Andean indigenous groups, cooling or cleansing remedies can be used not only to cure heat excesses but also to restore the balance between hot and cold (Portela 2002; Clement et al. 2015). Hot ailments (see Table 5.1) are often described as diseases that may arise either as a result of external influences such as prolonged exposure to the sun or being too close to a cooking fire, as well as a consequence of an internal imbalance due to excessive ingestion of foods classified as hot. Excessive heat may cause fever, inflammation, nervousness, redness and dryness in skin, mucous membranes, eyes, and body excreta. It may also result in impaired function of the heart, liver, and kidney, as well as interfere with the healing of burns and wounds (Jernigan 2011). Among Latin American communities it is believed cold can be even more harmful than heat, as it disrupts the “intrinsic warmth” (García-Hernández et al. 2021). Many cold diseases (see Table 5.2) are directly related to impairments in blood circulation, as well as to alterations in digestive, respiratory, or other body functions, caused by the loss of heat or by the entrance and accumulation of cold mainly from environmental conditions or foods (Larme 1998).

5.7

Hot and Cold Foods

Among Latin American and Caribbean medicines, foods can be also classified as very hot, hot, temperate, cool, cold, and very cold; the

5

Principle of Hot and Cold and Its Clinical Application …

combination of hot and cold meals results in temperate dishes (Manderson 1987; Barker et al. 2017). These categories are assigned to edibles mainly based on their effects on the body's cold and heat, and it is also associated with flavors, colors, smells, digestive sensations, or environmental factors. In general, water is related to coldness and fire with heat (Fock 1999). Foods are classified as cold if their water content is abundant or when they inhabit watery ecosystems, as may be the case for fruits, vegetables, fish, and aquatic plants (Madsen 1955; Molony 1975; Bain and Chevalier 2003). Nocturnal animals are associated with coldness because they do not receive the warming effect of sun rays, amphibians are also classified as cold given their wet appearance (Logan 1977). According to this author, some foods are recognized for transmitting more heat, which can be correlated with their caloric content or with their dryness. Spicy foods are generally categorized as hot and their use can induce sweating (Fock 1999; Valadeau 2010). Eating excessive hot meals is considered to cause injury to internal organs including kidneys, liver, and stomach and thus they are avoided during convalescence (Valadeau 2010; Jernigan 2011). The thermal category of some foods may vary depending on how it is processed. Salt is cold but becomes hot when refined, while refining sugar transforms it from hot to cold (Fock 1999). Hot and cold foods are used medicinally and also avoided in order to maintain and restore the body's heat and cold balance (Lans 2006).

5.8

Medicines from Hot to Cold

Medicinal substances, mainly derived from plants but also from animals and minerals, are also classified in Latin American and Caribbean cultures as very hot, hot, warm, temperate, cool, cold, and very cold, and different plant parts can have different temperatures (Faust 1988; Soria et al. 2020). The principal reason to differentiate hot and cold categories is to guide treatments, by balancing temperature through remedies thermally opposed to the disease (Madsen 1955).

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The criteria for classifying medicines as hot or cold depends on their therapeutic effects, their habitat, flavor, color, textures, and other morphological or physiological features (Walter 2017). Hot plants warm organs and restore heat in cold illnesses or symptoms such as colds, menstrual cramps, prolonged labor, impotence, snake bites, or “wind” ailments like malaire, pasmo, and some types of paralysis or pain; while cold plants cool and drain the internal organs in heat ailments such as liver inflammation, kidney diseases, “irritation”, or evil eye (Pereachalá 2006). Magic plants which are plants used by local healers to diagnose or treat supernatural illnesses have been classified as temperate but often as hot, given their ability to restore vitality or heat in debilitating conditions. Andean shamans can recognize the heat or spirit of magic vegetation by the perception of señas or signs in their bodies when touching plants and chewing coca leaves (Faust 1988; Cavender and Albán 2009). Plants are cataloged as cold if they grow in moist or floodable soils close to bodies of water, or those more abundant in winter or evergreen during summer (Faust 1990; Vásquez-Londoño 2012). While most hot plants grow wild, inhabit well-drained soils, sylvan, or desolated areas, and some can resist extreme cold in the higher altitudes of the Andean mountains (Faust 1990; Vásquez-Londoño 2012). Bitter or spicy flavors in plants are associated with heat, while the lack of flavor, a sour taste, or thirst-quenching properties are related to cold. The bitter flavor of plants is compared with liver bitterness, and they are thought to improve blood circulation and therefore cold diseases like pasmo (Walter 2017; Geck et al. 2017). White in plants classifies them as cold and feminine, while red or purple are associated with heat and masculine (Losonczy 1993). Strong consistency, smell, and flavor are characteristic of hot plants, while fragile, soft, and odorless plants are related to coldness (Faust 1988). Aqueous or mucilaginous exudates, succulent, and fleshy tissues or coldness to the touch are classified as cold or cool features; while sticky, greasy, and viscous exudates or woolly and stinging textures

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are associated with heat (Walter 2012). Cold medicines are avoided during menstruation, delivery, postpartum, or in people diagnosed with cold conditions; while hot medicines are not recommended at the beginning of pregnancy or in those affected by heat. The cold and heat of medicines must be balanced in mixtures in order to prevent excessive effects; the simultaneous use of various very hot plants is usually forbidden because its continuous administration has been associated with toxic reactions (Faust 1988; Cadena-González et al. 2013). The water and fire during the preparation of remedies enhance the cold and heat properties of ingredients, respectively. The use of raw plants or soaking them in freshwater magnifies the cold effect of medicines, while prolonged decoctions or the use of direct fire augments the heat in the remedies (García-Hernández et al. 2021). Hot and cold medicines can influence the effects of manual therapies employed in Latin American and Caribbean health systems, hot remedies are used in ointments by midwives and bonesetters to ease manipulations and restore heat in cold conditions such as prolonged labor, descuaje, dislocations, and fractures (Alvarado et al. 1989; Sanín-Pineda 2015; AyalaArdila 2019).

5.9

Discussion

There are recognizable conceptual parallels regarding heat and cold, among Latin American and Caribbean medicines with other medical cultures. The symbolic duality regarding opposite qualities like heat and cold is central to diverse healing traditions all over the world. For instance, in Traditional Chinese Medicine the Yang and Yin concept is a central axis from which other opposite dimensions branch out, such as hot and cold, up and down, ascent and descent, outer and inner, fire and water, south and north, Qi and blood, Shen or spirit and Jing or essence, as well as Fu and Zang organs (Mahdihassan 1985). Hot and cold theories in Latin American and Caribbean traditional

medicines also exhibit traits of shamanism, as evidenced by the associations between the loss of body heat and the loss of vitality or soul, after encountering places or persons able to draw people's energy into the underworld; as well as in the relationship of the hot character of some plants, with their ability to diagnose and treat diseases of supernatural origin, commonly associated with coldness. Similarly, in cultures of Oceania and Asia, associations are reported between the “mystical or inner heat”, with the capacity of shamans and magic plants, to rescue the body’s heat or lost soul of the sick from the mythical abodes of the dead (Eliade 1964; Barrett and Lucas 1994). In Latin American and Caribbean medicines, any imbalance in the body's heat and cold is a manifestation of disease. These disturbances are assessed through the detection of symptoms and signs associated with heat or cold alterations affecting organ functions, humors, and behavior. Likewise, opposing categories such as hot and cold, as well as dry and wet, are also essential in Persian Medicine to define the individual’s qualities or Mizaj, which can be identified by evaluating the Ajnas-e-Ashara or ten criteria, including obesity and thinness, skin color, hair condition, texture of skin, physique functions, waste elimination, sleep and wakefulness, speed response to hotness and coldness, as well as psychic functions (Mozzafarpur et al. 2017). According to Latin American and Caribbean medical cultures, illnesses classified as hot frequently manifest with fever, inflammation, as well as generalized redness and dryness; while cold ailments are recognizable by coldness, chills, asthenia, poor appetite, diarrhea, and impaired circulation causing pain, difficult labor, erectiledysfunction, and delayed wound healing. In parallel, cold syndromes in Chinese Medicine exhibit symptoms such as hypothermia, cold limbs, nausea, vomiting, loss of appetite, and diarrhea, while hot syndromes are characterized by high fever, thirst, dry eyes, constipation, and dysphoria (Liu et al. 2021). It has been demonstrated that individuals in whom heat predominates, often had increased activity of the peripheral sympathetic nervous system, while in cold-natured

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persons the parasympathetic nervous system activities tend to be more active (Shahabi et al. 2008). In a similar way to other traditional medicines based on theories of heat and cold, in Latin American and Caribbean medicines the treatment for diseases caused by cold qualities is treated with hot property foods, habits, and medicinal plants; patients with diseases caused by heat are treated by cold potency substances (Madsen 1955; Liu et al. 2021). Among these traditional medical systems, foods and plants are classified as hot or cold depending on multiple factors such as plant flavors, smells, colors, temperature to touch, consistency, presence of exudates, environmental conditions, and according to the methods used to prepare the herbal remedies. In Ayurvedic medicine, opposing properties or gunas are core concepts assigned to substances or dravyas, including hot (Ushna) and cold (Sheeta), dry (Ruksha) and wet (Snigdha), light (Laghu) and heavy (Guru), sharp (teekshna) and dull (Manda), mobile (Sara) and static (Sthira), hard (Katrina) and soft (Mridu), rough (Khara) and smooth (Shlakshna), subtle (Sookshma) and gross (Sthoola), fluid (Sandra) and solid (Drava), and cloudy (Pichchila) and clear (Vishada) (Pole 2006). Phytochemical and pharmacological research reveals that various cold plants used in Chinese Medicine to clear heat have antipyretic properties, while medicines classified as hot have been shown to induce thermogenesis (Liu et al. 2021). Plants classified as cold in Latin American and Caribbean medicines and utilized to relieve hot ailments, such as Gliricidia sepium, Sida rhombifolia, Jungia rugosa, Sonchus oleraceus, Scoparia dulcis, Desmodium molliculum, Krameria lappacea, and Malva parviflora, have exhibited anti-inflammatory activity (Kumar and Mishra 1997; Ahmed et al. 2001; Vilela et al. 2010; Baumgartner et al. 2011; Bouriche et al. 2011; Acero-Carrión and Millones-Sánchez 2012; Kumar et al. 2014; Wilches et al. 2015). It has been demonstrated in rodents through metabolomic studies that the effects on the metabolism of cold herbs are opposite to the effects exerted by hot plants. Thus, while hot substances promote a catabolic state, cold medicines inhibit

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mitochondrial respiration, ATP generation, and storage, decrease glucose uptake, glycolysis and lipolysis, and promote glycogen and fat synthesis in the liver and adipocytes (Zhou et al. 2019). Some of the plants classified as cold in Latin American and Caribbean medicines, and utilized to treat hot illnesses, have been shown to exert hypoglycemic and lipid-lowering effects, including Annona muricata, Phyllanthus niruri, Bixa orellana, Psidium guajava, Passiflora mollissima, and Gentianella thyrsoidea (Tomas et al. 1999; Edwin et al. 2007; Russell et al. 2008; Shen et al. 2008; Florence et al. 2014; Najari Beidokhti et al. 2017). Experimental data and clinical trials have shown the anxiolytic effects of some of the cooling plants traditionally used for nervousness and insomnia, such as Aloysia citriodora, Melissa officinalis, Passiflora mollissima, Matricaria chamomilla, and Valeriana spp. (Murphy et al. 2010; Cases et al. 2010; Mao et al. 2016; Caldas Aburto 2018; Bahramsoltani et al. 2018). Pharmacological assays have also demonstrated that cold-natured plants employed to treat urinary or liver disorders, show diuretic, hypotensive, hepatoprotective effects, including Equisetum bogotense, Sonchus oleraceus, Malva parviflora, Russelia equisetiformis, and Achyrocline ramosissima (Rodriguez et al. 1994; Ochi et al. 2012; Mallhi et al. 2014; Arroyo-Acevedo et al. 2017; Chen et al. 2020). Among the plants classified as hot by Latin American and Caribbean medicines, some of the herbs used to improve blood circulation and treat pasmo have exhibited vasodilator effects, including Piper auritum, Rosmarinus officinalis, as well as species of the genus Ambrosia, Ruta, and Urtica (Feng et al. 1962; Chen et al. 1991; Testai et al. 2002; von Schoen-Angerer et al. 2018; Coimbra et al. 2020). Pharmacological assays have demonstrated anti-allergy and antimicrobial effects of some hot-natured plants used to treat colds and Reuma, such as Luffa cylindrica, Eucalyptus globulus, Minthostachys mollis, and Cupressus sp. (Tanaka et al. 1991; Cermelli et al. 2008; Sueng et al. 2015; Torrenegra-Alarcón et al. 2016). Plants such as Eryngium foetidum, Tagetes erecta, Bidens pilosa, Cinnamomum verum, Mentha spp.,

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and Ruta spp. are classified as hot and used to treat traditional ailments in which symptoms such as diarrhea, poor appetite, and nausea are present, have shown anthelmintic and antiprotozoal effects (N’dounga et al. 1983; Vidal et al. 2007; Forbes et al. 2014; Akkari et al. 2015; Piña-Vázquez et al. 2017; Batiha et al. 2020). There is also evidence about the hepatic and renal toxicity of some of the hot-natured plants, including Senecio spp. and Aristolochia spp., respectively, may be related to the traditional categorization of these plants as hot and thus as potentially toxic remedies (Nortier et al. 2000; Chen et al. 2015). Moreover, Zingiber officinalis, Rosmarinus officinalis, Ruta graveolens, Matricaria recutita, Quassia amara, Luffa cylindrica, and Aristolochia spp., plants classified as hot in Latin American and Caribbean medicines, have exhibited contraceptive effects, which can be related to the traditional contraindication of these plants at the beginning of pregnancy (Ng et al. 1992; de Freitas et al. 2005; van Andel et al. 2014). Further research into hot and cold theories in Latin American and Caribbean medicines is strongly recommended, to optimize its integration with biomedicine in an equitable intercultural context.

5.10

Conclusions

For several centuries to the present, hot and cold theories have played a critical role in the evolution and practice of Latin American and Caribbean traditional medicines, enabling the constitution of meaningful binary classifications for the understanding of health, the body, its physiology, disease, therapy, and prevention. The growing scientific research is advancing daily to provide evidence for understanding and integration, from current biomedical paradigms, the clinical applicability of Latin American and Caribbean traditional medicines, including hot and cold theories, as well as the medicinal use of foods and plants guided by this classification system. The increasing epistemological crossings between traditional

health concepts and current biomedical axioms represent potential integration points to strengthen the implementation of intercultural initiatives and policies in the academic, clinical, and public health spheres. Acknowledgements The authors acknowledge Dr. Paul Richard Saunders, Ph.D., N.D., R HOM, DHANP, CCH for editing the manuscript.

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C. A. Vásquez-Londoño et al. Zuluaga R (1995) El legado de las plantas medicinales en la Sabana de Bogotá: Investigación histórica y etnobotánica de la flora medicinal en el municipio de Cota. Prolabo Ltda

Carlos A. Vásquez-Londoño is a medical doctor, has a master’s degree in Alternative Medicine-Traditional Chinese Medicine and Acupuncture, and is a Ph.D. candidate in Pharmaceutical Sciences in the area of Phytochemistry and Pharmacognosy. Since 2013 he has been a lecturer in the areas of Phytotherapy, Nutrition in Alternative Medicine and Traditional Chinese Medicine at the Faculty of Medicine of the Universidad Nacional de Colombia. He has been a researcher for 15 years on Traditional Medicines and Phytotherapy, and also has authored or edited several books and articles in these fields.

Luisa Fernanda Cubillos-Cuadrado She is a physician from El Bosque University and has a master’s degree in Alternative Medicine from National University of Colombia. Her thesis was about conceptions and practices during the life cycle of Sikuani Women. She authored a research article about Fish consumption during menarche, menstruation, pregnancy and postpartum in Sikuani women from Meta, Colombia. In 2010 she started her studies on Ayurvedic Medicine in India. Currently, she teaches Ayurveda at the Alternative Medicine Master Program at the National University of Colombia and works as a physician in her clinic.

Andrea C. Forero-Ozer Obtained her medical degree at Universidad Militar Nueva Granada in Colombia and her masters’ degree in Alternative Medicine with an emphasis in Acupuncture at Universidad Nacional de Colombia, graduating with First-Class Honours. She has worked as a medical practitioner with an integrative approach to her patients in the private and public health systems in Colombia. Her research interests include the use of alternative medicine in chronic diseases as well as understanding Latin-American folk medicine and its relationship with other traditional medicines; publishing in topics such as sleep disorders and menopause within this field.

Paola Andrea Escobar-Espinosa She graduated from medicine in 2007 at the San Martin University Foundation. She is currently a second-semester teacher of Alternative Medicine with an emphasis on Traditional Chinese Medicine and Acupuncture at the Universidad Nacional de Colombia. She has worked in the field of intercultural health with the Indigenous Association of Cauca—AIC for more than 10 years.

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David Orlando Cubillos-López He is a physician who graduated from the Universidad de Caldas. He has 18 years of experience in private external and home consultation, neonatal intensive care, hospitalization, university teaching and integrative medicine. Currently, he is studying for a master’s degree in alternative medicine at the Universidad Nacional de Colombia.

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Daniel Felipe Castaño-Betancur He studied medicine at Universidad del Rosario in Bogotá, Colombia. He has been a medical practitioner since 2017 and has been working in prehospital attention since his grade. He’s coursing a master in Alternative Medicine (Chinese Traditional Medicine) at Universidad Nacional de Colombia since 2018. His degree project is about the uses of medicinal plants in the muinane community in Amazonas, Colombia. He has collaborated in genetics studies about rapid metabolizers of tramadol and adverse effects in Colombian population at Universidad del Rosario.

Part II Scientific Evidence

6

Hot and Cold Theory: Evidence in Nutrition Simone Maree Ormsby

Abstract

Ancient scholars across cultures have postulated that by being less potent versions of herbs, food plays a substantive role in the maintenance of health and treatment of disease. A commonality among these traditional medical systems is in relation to the ‘heating’ and ‘cooling’ properties of foods. In this chapter, ‘hot’ and ‘cold’ classifications of foods are explored, along with ways to optimize health and combat disease. Scientific evaluations of ‘hot’ and ‘cold’ properties are also reviewed in relation to chemical compositions and physiological impacts. A broad scoping Google Scholar search was conducted to identify relevant articles. Scientific evaluations were heterogeneous and of mixed quality. Nonetheless some evidence supported the traditional ‘hot’ and ‘cold’ classifications. Overall, ‘heating’ foods were associated with metabolism and sympathetic nervous system enhancement via increased proportions of caffeine, carbohydrate, protein, fat, and calories; as well as greater oxidation potential; vasodilatory and pro-inflammatory effects; and higher acidity and aromatic compound con-

S. M. Ormsby (&) NICM Health Research Institute, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia e-mail: [email protected]

tent. ‘Cooling’ foods were contrastly found to be higher in water, fiber, alkalinity, and aliphatic compounds; as well as associated with anti-inflammatory, and detoxification (elimination) processes. With the potential to specifically tailor diets to suit individual needs, further high-quality research to substantiate traditional food classifications is warranted. Keywords







Traditional medicine Dietary therapy Hot Cold

6.1




Introduction

The ‘binary opposition’ classification in traditional medicines (TM) (Redfield and Redfield 1940; Dulloo et al. 2000) of ‘hot’ or ‘cold’ foods has been documented across many cultures over the centuries, including in Asia, India, the Philippines, Mexico (Currier 1966), Latin America (Currier 1966; Logan 1977), Europe (Logan 1977), and the Middle East (Wandel et al. 1984; Logan 1977). Numerous scholars have referred to this classification as a simplified version of the Greek physician Hippocrates’s (460– 376 BC) ‘humoral pathology’ system (Currier 1966; Logan 1977; Jaiswal and Williams 2017), in which the humors (blood, phlegm, and black and yellow bile) are associated with the concepts

© Springer Nature Switzerland AG 2021 M. Yavari (ed.), Hot and Cold Theory: The Path Towards Personalized Medicine, Advances in Experimental Medicine and Biology 1343, https://doi.org/10.1007/978-3-030-80983-6_6

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of temperature (hot/cold), and moisture (dry/wet) (Logan 1977; Currier 1966). It is stated that the correct balance between these factors within the context of an individual’s constitution is what is required for optimal health (Anderson 1980). Logan in 1977 however highlighted that earlier Indian and Chinese teachings had as foundational concepts, opposition of temperatures in the respective Ayurvedic and Yin/Yang (relative cold to hot) theoretical systems, and therefore that these predate the Hippocratic period by many centuries. Logan thus asserted that it was these earlier medical traditions that greatly influenced the classical Greek physicians, and that from Greece, these ideas spread to Rome, Alexandria, and Bagdad, and later on, Europe, the Philippines, and the Americas. Anderson (1980) similarly concluded, at least in regard to early Daoist thought, that “it seems reasonable to assume that some coding of foods as more nourishing to yang or to yin was characteristic of Chinese thought before the specific details of humoral medicine entered [China]” [p. 243]. Indeed, Lo and Barrett (2005) reported that Yi Yin, the legendary chef and first minister to the Chinese King of the Shang (1600–1045 BCE), aimed to achieve the skill of ‘zhi wei,’ or the delicate blending of the “five sapors and feats of culinary alchemy,” in order to obtain the perfect mixing of yin and yang so that the “inner self is complete” [p. 396]. Later, in the famous treatise on Chinese medicine, ‘The Yellow Emperor’s Classic of Internal Medicine’ (approximately 300 BC), further details were provided regarding how dietary nourishment could assist in the avoidance of disease, not only with respect to commonsense ideas such as regulated eating and the avoidance of over or under consumption but also more complex considerations of yin/yang balance in relation to age (in which children were considered to have excess yang and insufficient yin); gender (whereby men were considered more yang than women); constitution (in which for example one may be relatively yang deficient and thus having the tendency to lack in both warmth and vitality); the season (whereby foods opposite in temperature were typically recommended); and work or homelife locality (in

S. M. Ormsby

which cold and wet conditions were, for instance, counteracted by warming and fluid resolving foods) (Wu and Liang 2018). Additional elaborations also provided included the system of the five elements (wood, fire, earth, metal, water), the five ‘sapors’ or flavors (pungent/acrid, sweet, salt, sour, bitter) (Lo and Barrett 2005), and the differing effects of heating, warming, neutral/balanced, cooling, or cold inducing foods in the body (Lo and Barrett 2005; Anderson 1980). According to Lo and Barrett (2005), from the seventh century onward, Chinese dietary authors systematically assigned a ‘sapor’ and a ‘thermostatic’ quality to all foods that was in turn associated with a therapeutic effect. Through the knowledge of the science of good taste, it was thought that “one could align physiological rhythms of the inner body with the seasons”’ [p. 404]. This work was then followed by Tao Hongjing (452–536 CE) in his ‘Collected Commentaries on Shennong’s Classic of Materia Medica’ and Sun Simiao’s ‘Food Therapy’ chapter in ‘Essential Prescriptions Worth a Thousand Gold Pieces for Emergencies,’ circa 652, in which further explanations of the importance of correct food combinations were provided, along with the suggestion that food could be used as medicine. Much later, another famous contributor, Li Shizhen (1518–1593), provided an updated and comprehensive materia medica of prescriptions, that also incorporated food as dietary therapy, that resulted in him being referred to by Joseph Needham, British biochemist, historian, and sinologist, as the “Prince of Pharmacists” [p. 399] (Lo and Barrett 2005). Over concurrent timeframes spanning three millennia to modern times, the health care system of ‘Ayu’ (life) and ‘Veda’ (knowledge) evolved in India from pre-Aryan Hindu teachings, and similarly incorporated holistic perspectives regarding food, as well as the important role it plays in both physiology and systems pathology (Payyappallimana and Venkatasubramanian 2016; Wandel et al. 1984; Jaiswal and Williams 2017). As with the other TM teachings, this system utilizes an individualized approach for both the prevention and treatment of disease (Dua and Dua 2011), as well as consideration of

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concepts such as the inherent temperature properties of foods (Wandel et al. 1984); dietary and environmental impacts; constitutional tendencies; metabolic processes; biological rhythms; seasonal variations; and pathological processes (Payyappallimana and Venkatasubramanian 2016; Jaiswal and Williams 2017). Indeed, the five elements are also incorporated, with the exception that ‘air’ and ‘space/ether’ (Payyappallimana and Venkatasubramanian 2016; Jaiswal and Williams 2017), are substituted for ‘wood’ and ‘metal’. However, where there are differences is in relation to how the elements are combined together to form the three ‘basic humours’ (Jaiswal and Williams 2017) or constitutional ‘doshas’ ‘Vata’ (space/air), ‘Pitta’ (fire) and ‘Kapha’ (water/earth) (Payyappallimana and Venkatasubramanian 2016; Rastogi 2010; Jaiswal and Williams 2017). Balance between the three ‘doshas,’ ‘agni’ (digestion and metabolism), ‘dhatus’ (tissues), ‘malas’ (excretions), and ‘prasanna’ (sensorial, mental, emotional, and spiritual aspects) are all required for good health and well-being (Jaiswal and Williams 2017; Dua and Dua 2011). With respect to digestive and temperature effects, ‘Vata’ moves, dries and cools; ‘Pitta’ like the Spleen function in traditional Chinese medicine (TCM), governs digestion, assimilation, metabolism and body temperature; and ‘Kapha’ provides vigor, lubrication and moisture to bodily structures and functions (Dua and Dua 2011). As is also the case in the other TM systems, tendencies toward a predominant constitutional weakness or ‘dosha’ require that diets be aimed at balancing the ‘dosha,’ in combination with lifestyle choices that are harmonious, and avoidant of aggravating factors (Guha 2006; Dua and Dua 2011). Dietary guidelines however extend beyond appropriate food choices, to additional considerations including food combinations and storage, cooking methods, environments for consumption, hygiene, and etiquette (Dua and Dua 2011). Overall, considerable emphasis in Ayurveda is given to ‘agni’ (metabolic fire), due to it being the major driving force behind digestive and metabolic activities essential to life.

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Additional medical systems fundamentally based upon humoral medical theories include Unani or Persian/Iranian medicine. While the origins of Unani medicine also reportedly predate Hippocrates (Ahmad and Akhtar 2007; Nimrouzi and Zare 2014), according to Ahmad and Akhtar (2007), it was Hippocrates who first presented the basic humoral theoretical frameworks. After that time, additional Greek scholars, including Galen (131–210 AD), provided contributions (Ahmad and Akhtar 2007; Zaman 2015), prior to the texts being transported to the medieval Near East in the eighth and ninth centuries, where they were then translated into Arabic. Following on from this, Islamic physicians continued to develop the medicine system until invasions forced scholars and physicians to flee to India, after which time, blending with Aruvedic medicine ensued (Ahmad and Akhtar 2007). For instance, foundational theories regarding the body being composed of elements [earth/soil, air, water, fire], and humors [blood, phlegm, and yellow and black bile], to form the four constitutional/temperament types Sanguine (blood dominant [hot/moist]), Phlegm (phlegm dominant [cold/moist]), Yellow Choler (yellow bile dominant [hot/dry]), and Melancholia (black bile dominant [cold/dry]) (Ahmad and Akhtar 2007; Zaman 2015; Nimrouzi and Zare 2014), are reportedly analogous to the three ‘doshas’ in Ayurveda (Rahman et al. 2008). However, many scholars of humoral medicine further divide temperament into nine categories including: temperate (balanced); simple (hot, cold, wet, dry); the compound temperaments (hot/dry, hot/wet, cold/dry, cold/wet); and ‘dystemperaments’, which are present in disease states, and defined as either an imbalance in these temperaments, or an excess in one of the four humors (Miraj et al. 2016). Additional concepts in common with other TM systems include: health being impacted upon by internal and external environments (Ahmad and Akhtar 2007; Zaman 2015); diet being used for the maintenance of health by eating according to one’s constitutional tendencies (Zaman 2015; Rahman et al. 2008); and, in the case of illness, modifications being

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made for therapeutic effect (Rahman et al. 2008; Ahmad and Akhtar 2007; Zaman 2015). Essentially however, the predominant teachings of humoral, Unani, or the Persian/Iranian medicine systems are the same; consequently, for the purpose of this chapter, further distinction between them has not been made, and rather, reference is made only to the humoral medicine system (HMS). According to Anderson (1980), even though differences between these TM systems existed, commonalities are remarkable regarding how temperature within environments, people, food, and herbs interact together to play a role in health and disease. While Western teaching of such concepts ceased in the early twentieth century, TM systems of East Asia, India, and the Middle East continue to incorporate these ideas into the present day (Anderson 1980). Currently, with advancements in scientific analytical techniques, there exists a unique opportunity to evaluate and potentially verify these long-held ancient beliefs. It is the aim of this chapter not only to further explore these traditional ‘hot’ and ‘cold’ food classifications, as well as the role they can play in the prevention and treatment of disease, but also, to evaluate for the purpose of possible future benefit, what biochemical/mechanistic investigations of the ‘hot’ and ‘cold’ food properties tell us so far. In the next sections, the methods by which the data sources and studies assessing intrinsic ‘warming’ and ‘cooling’ properties of foods were collected are provided, along with an evaluation of whether these ancient concepts do indeed appear to have any scientific basis.

6.2

Methods

As it was anticipated that the extent of literature exploring the scientific basis behind TM systems classifications of ‘heating’ and ‘cooling’ foods would be minimal, ‘Google Scholar’ was the search engine chosen for this evaluation. Using the advanced search option, no limits were applied with respect to date, so as to broaden the scope of literature captured. In the ‘with the exact

phrase’ field, the term “traditional or Persian, Unani, humoral, Ayurveda, and Chinese medicine” was inserted. In the ‘with at least one of the words’ field, the following search terms were included ‘hot, cold, heating, warming, cooling, food, nutrition, diet, dietary, therapy, mechanism, and scientific’. In the ‘where my words occur’ section, the option “anywhere in the article” was selected. The final search was performed on January 24th, 2021. The results yielded 4290 references, ordered by relevance. From these results, books, book chapters, theses, and articles were selected. Searching was ceased when no additional relevant sources were identified. Other sources were obtained from listed citations in selected publications, along with examination of the corresponding reference sections. In some cases, information was only provided in English in the abstract, hence discussion of these findings was avoided. Predominantly, articles were published in journals with lower impact factors; and study designs and rigor were heterogeneous and of lower to moderate quality. As the countries of publication and topics explored were variable, a pragmatic approach to both data collection and synthesis was taken, as pragmatism allows the drawing upon of different assumptions, world views, methods, and data collection and analysis techniques, on a ‘best fit’ basis (Creswell 2003).

6.3

‘Hot’ and ‘Cold’ Natured Properties of Food

6.3.1 Traditional Classifications of ‘Heating’ and ‘Cooling’ Properties of Food The nature of food is considered from the perspective of its intrinsic quality of being ‘hot’ or ‘cold’ (Wu and Liang 2018); the potency or ‘virya’ (feelings experienced in the body after ingestion/digestion) (Balasubramanian 2015); and the physiological ‘heating/cooling’ impacts (Liu et al. 2012; Han et al. 2020; Anderson 1980; Wandel et al. 1984). Within these temperature endpoints however, an expanded classification is also documented, in which ‘cool,’ ‘neutral’

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(balanced yin/yang), and ‘warm’ foods (Liu et al. 2012; Lee and Shen 2008; Logan 1977) provide a continuum from one extreme to the other (Anderson 1980), rather than black and white demarcations. As an overall broad classification, with the exception of spices, foods of plant origin are predominantly considered to be more ‘cooling’ (Zhou et al. 2012; Anderson 1980; Lee and Shen 2008; Huang and Wu 2002). In contrast, most meats, animal protein, oils and alcohol, are generally thought to be more ‘warming’ (Anderson 1980; Flaws 1998; Leggett 1995; Lee and Shen 2008; Manderson 1981) (see Table 6.1). A greater proportion of fruits and vegetables are also typically classified as ‘cool’ rather than ‘warm,’ which likely reflects the greater variety available in the warmer months. Several authors also suggest some other rules may apply. For instance, that more brightly colored fruits that are sweeter and not especially juicy such as litchi (lychee), longan, and durian may be more ‘heating’ (Xu 2019; Han et al. 2020; Zhou et al. 2012; Anderson 1980; Huang and Wu 2002); whereas those that are less brightly colored, and juicier (with higher fluid content equating to more ‘cooling’), are potentially ‘colder’ in nature (Anderson 1980; Wandel et al. 1984; Leggett 1995). Likewise, plants that are pale or darker in color (white, grey, green, blue, purple); quicker to grow; grown in winter, water, moist environments or closer to the ground (and thus more able to absorb water); as well as having less access to sunlight, maybe relatively ‘cooler’ than those that are more vibrantly colored (red, orange, yellow); slower to grow; having greater access to the sun; grown in summer, on land, and drier locations; and needing more warmth to ripen (such as red fruits) (Xu 2019; Lee and Shen 2008; Leggett 1995; Han et al. 2020; Anderson 1980; Zhou et al. 2012). According to TCM theory, spicy and sweet foods are considered to be more ‘heating/yang’ than the bitter and sour flavors (‘colder/yin’) (Xu 2019; Han et al. 2020). Interestingly, Leggett (1995) also suggests that foods artificially forced to grow quickly are more ‘cooling’ than those that are naturally grown, and in addition that some

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chemicals added to foods may cause ‘heating’ reactions. How food is prepared is additionally considered to alter intrinsic temperature properties (Currier 1966; Zhou et al. 2012; Anderson 1980; Payyappallimana and Venkatasubramanian 2016). Longer and slower cooking, for example, is believed to yield more ‘heating’ effects (McCracken 2012; Leggett 1995); as does the addition of certain ingredients during the cooking process, such as alcohol (McCracken 2012), ‘heating’ oils (Zhou et al. 2012; McCracken 2012), and many spices (Dua and Dua 2011; Guha 2006; McCracken 2012; Currier 1966; Aghili 2008). Other cooking methods also stated to be ‘warming’ include grilling, roasting, barbecuing, stewing, smoking, and long-simmering (McCracken 2012; Leggett 1995). With respect to more balanced cooking methods, steaming is thought to be predominantly neutral, and sundrying only marginally heating (Anderson 1980), whereas long slow-boiling is considered relatively more ‘cooling’, and cold-infusion, the coldest method. Further coding of food as ‘heating’ or ‘cooling’ is determined by observation of the resultant physiological effects after consumption (Anderson 1980; Wandel et al. 1984), or ‘virya’ in the Ayurvedic system (Balasubramanian 2015). Indeed, in humoral medicine, these impacts are the major determinants in food nature or body temperament classification (Aghili 2008; IbnSina 1998); however, in addition to ‘heating’ or ‘cooling’ properties, foods are also considered to a lesser extent, in regard to moistening and drying effects (Avicenna 2005). Overall therefore, foods may be classifiable as hot and dry; hot and moist; cold and dry; or cold and moist, with hot and dry considered to be the most heating (Ardekani et al. 2011). Anderson (1980), for example, classified ‘heating’ foods like chilies as irritants due to causing ‘hot’ symptoms, such as burning, and rubefacient (redness); as well as carminative (flatulence releasing) effects. Dried and scratchy foods like curry and coffee were also placed in this category, as a consequence of the mouth/throat dryness or soreness that may arise. Furthermore, hangovers and indigestion

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Table 6.1 ‘Heating’ and ‘cooling’ classifications of food System

Chinese (TCM)1,

2, 3, 4, 5, 6

Humoral7

Ayurveda8,

9, 10, 11, 12

Food

Heating (yang)

Cooling (yin)

Heating/Warming

Cooling/Cold

Heating/Warming

Beef/Venison (W/N) Mutton (W)/Lamb (W/H) Chicken/Turkey (W) Goat/Ham (W) Goose6

Rabbit (CL) Lamb Liver (CL)

Turkey Water fowl Chicken Rooster Quail Ostrich Mutton/Lamb Camel Deer Buffalo Liver

Goat Beef Peccary Rabbit

Beef Mutton Chicken

Shrimp/Prawn (W) Lobster/Crayfish (W) Anchovy/Eel (W) Mussel (W) Trout (H)

Frog (CL) Clam (CD) Crab (CD) Mullet (CD) Octopus (CD)

Shrimp

Fish Cockles

Salty Fish9

Cooling/Cold

Dark Flesh Fish10

Duck Eggs (CL)

Egg yolk

Egg White

Eggs

Butter/Ghee (W) Raw Cow Milk (W) Sheep/Goat Milk (W)

Yogurt (CD) Milk5

Milk Butter Ghee

Yogurt Cheeses Cream Whey

Sheep Milk Powdered Milk

Cow Milk Goat Milk Buttermilk Yogurt/Curd

Rice, sweet (W) Oats/Quinoa (W) Sorghum/Spelt (W) Black Bean (W) Tempeh (W)

Rice, Wild (CL) Barley/Buckwheat (CL) Millet/Wheat (CL) Wheat Bran (CL) Wheatgerm (CD) Soybean (yellow, CL) Lima/Mung Bean (CL) Tofu (CL/CD)/Agar (CD)

Wheat Chick Pea Kidney Bean Mung Bean Lentil

Rice Barley Maize

Wild Rice Quinoa

Rice Amaranth Barley Grass

Parsnip (W) Pumpkin (W) Squash (winter, W) Reishi/Oyster Mushroom (W) Brussels Sprout (W) Caper (W) Bell Pepper (W) Leek/Kale (W) Onion (W) Eggplant6

Alfalfa Sprouts (CL) Asparagus (CL) Lettuce/Chard (CL) Eggplant (CL) Bok Choy (CL) Broccoli (CL) Squash (summer, CL) Bamboo Shoot (CL) Spinach/Celery (CL) Cabbage (CL) Button Mushroom (CL) Radish (CL) Watercress (CL) Zucchini (CL) Cucumber (CD) Kelp/Seaweed (CD) Mung Bean Sprout (CD) Plantain (CD) Field mushroom (CD) Tomato (CD) Water Chestnut (CD) Lotus root (CD) Bitter Gourd5 Aloe Vera5 Green Beans6

Onion Mint Celery Leek Parsley Carrot Peppers Dill Beet Radish Mustard

Mushrooms Yam Gourd Lettuce Sprouts Zucchini Okra Coriander Spinach Squash Pumpkin Cucumber

Tomato Mushroom Radish Watercress Fennel Mustard Greens Leeks Spring Onions

Spinach Chlorella Bok Choy Celery Broccoli Lettuce Blue-green Algae Cucumber Zucchini Asparagus

Coconut (W) Lychee (W)

Apple/Pear (CL) Avocado (CL)

Fig Coconut

Pomegranate Rhubarb

Mango Papaya12

Bananas

(continued)

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Table 6.1 (continued) System

Chinese (TCM)1,

2, 3, 4, 5, 6

Humoral7

Ayurveda8,

9, 10, 11, 12

Kumquat (W) Longan (W) Blackberry (W) Raspberry (W) Peach/Cherry (W) Guava (W) Date (W) Durian4 Citrus6

Orange (CL) Mandarin (CL) Mango (CL) Loquat (CL) Strawberry (CL) Tangerine (CL) Banana (CD) Cranberry (CD) Gooseberry (CD) Grapefruit (CD) Lemon (CL/CD) Lime (CD) Persimmon (CD) Mulberry (CD) Rhubarb (CD) Melon/Watermelon (CD) Pineapple (N1/CL6)

Date Ripe Olive Sweet Apple Sweet Quince Pear Sweet Cherry Ripe Grape Melon Banana

Jackfruit Pineapple Starfruit Sour Apple Sore Quince Plum Sore Cherry Peach Orange Tangerine Lemon Watermelon

Kumquat Pineapple

Papaya (N/CL)10 Watermelon Melons Young coconut Citrus fruits Kiwi Mulberry Apple Cantaloupe Mango Avocado Citrus Jackfruit Plantain

Brown Sugar (W) Molasses (W) Rice syrup (W)

Sugar (N1/CL6)

Honey

Refined Sugar

Jaggery

Honey

Chestnuts (W) Walnuts (W) Pine Kernel (W) Coconut (W) Pumpkin Seed (W) Sunflower Seed (W) Dill/Fennel Seed (W)

-

Sesame Seed Almond Pistachio Apricot Kernel Walnut Pine Nut

Pumpkin Seed

Almonds

Vinegar (W) Soya Oil (W/H) Cottonseed Oil (H)

Sesame Oil (CL)

Oils (most)

Vinegar

Coffee (W) Carob (W) Chocolate3 Black Tea (N1/W5)

Dandelion Root (CL) Lemon Balm (CL) Green Tea (CL) Raspberry Leaf (CL)

Black Tea Coffee

Green Tea

Carob

Chive/Clove (W) Cumin/Turmeric (W) Chilli (H) Pepper (H) Cayenne (H) Garlic (H) Ginger (H) Cinnamon Bark (H) Galangal (H) Horseradish (H) Mustard (H) Jalapeno (H) Sweet Basil (H)

Barberry (CL) Purslane (CD) Salt (CD)

Lavender Bee balm Cinnamon Cumin Black seed Chamomile Oxtongue Hollyhock Nettle Garlic Salt Turmeric Sesame Saffron Ginger Pepper Thyme

Sumac Jujube Lemon powder Dry Coriander Barberry

Black Pepper Coriander Cinnamon Ginger Dill Chives Rosemary Ginseng Cloves Garlic Star Anise Cumin Basil

Wine (W) Spirits (H)

Beer (CL)

Alcohol incl. Beer Aromatic Drinks Young Coconut Water

Water Buttermilk Barley Water

Cilantro Peppermint

Key W-warm; H-hot; CL-cool; CL-cold; N-neutral. TCM 1Leggett (1995); 2Flaws (1998). Two comprehensive TCM sources were utilized for the purpose of standardization. When categorization disagreement occurred between these two authors, the other author’s coding was provided, e.g., CL/CD; CL/N. Additional data provided by: 3Anderson (1980); 4Zhou et al. (2012); 5Wu and Liang (2018); 6Han et al. (2020). Humoral 7Aghili (2008). Ayurveda/Indian 8Lee and Shen (2008); 9Patel (2010); 10Wandel et al. (1984); 11Guha (2006); 12Balasubramanian (2015). When coding discrepancies occurred between these authors, the alternative classification is provided, along with the source

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were suggested to be byproducts of the excessive consumption of ‘heating’ alcohol and fats. Directions of energy movement are also linked with temperature effects in TCM. For instance, ‘cooling’ foods are said to cool the upper and outer parts of the body first, direct energy inward and downward and slow the body down, whereas those that are ‘warming,’ warm from the inside to the outside, move energy upward and outward and speed the body up. Very hot foods such as chillies provide a mixed effect, by initially producing intense internal heat, followed by cooling via the induction of sweating (Leggett 1995). There are nonetheless regional variations and exceptions to these generalizations (Logan 1977; Currier 1966; Anderson 1980), as well as notable differences among TM systems. For example, Brussels sprouts being green in color would be assumed to be ‘cold’ however according to TCM, are ‘warming’ in nature (Leggett 1995). Similarly, bitter taste in TCM is associated with ‘cooling’ properties, yet in the HMS, it is considered ‘heating’ (Aghili 2008). Likewise, in TCM, both Leggett (1995) and Flaws (1998) code eggplant (aubergine) as ‘cooling’; however, Han et al. (2020) classified this vegetable as ‘warming/heating’; and in the HMS, it is also considered ‘heating’ (Aghili 2008). Wandel et al. (1984) also observed within Southern Sri Lankan communities that while the labeling of ‘heating,’ ‘cooling,’ and ‘neutral’ foods was relatively consistent, the degrees to which foods were ‘heating’ or ‘cooling’ was the subject of much disagreement. Nuances within coding may in part explain some of these discrepancies; for example, river fish in Ayurveda is regarded as ‘cooling’ (Patel 2010) due to being obtained from aqueous environments, however those that are salty (Patel 2010), stronger in flavor or stained with blood, are considered more ‘heating’ than those blander in taste (Wandel et al. 1984). Similarly, according to Lee and Shen (2008), other Indian classifications place fish in the ‘heating’ category on account of it being a meat. Furthermore, the raw versus prepared/cooked state may explain some differences, such as fresh cow’s milk being considered ‘cooling’ in

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Ayurveda, however ‘heating’ after drying (Wandel et al. 1984). It is possible that some intra- and inter-cultural variability may also be explained by genotype variants among plants (Logan 1977; Aghili 2008), as well as the seasons, climate, and environments in which the food is grown (Aghili 2008; Leggett 1995). For example, food grown in the wild may be more potent in effect than those that are domestically cultivated (Leggett 1995); and also, that soil compositions today may substantially differ from those in which coding first began. An additional possibility is attenuation to the impacts of commonly consumed foods over time, however when first introduced to a new culture, the effect is much stronger (Leggett 1995). Nonetheless, Anderson (1980) suggested that overall there was “striking similarity in coding cross-culturally” [p. 239], and in addition, that the opinions of the majority should be considered.

6.3.2 Applications of Dietary Therapy for the Maintenance of Health and Disease Management As medical symptomologies are also classified according to ‘hot’ or ‘cold’ predominance, diet and food preparation is able to be purposely modified for the maintenance of health, as well as rectification of disease. In this regard, two main principles are applied. Firstly, in the preventative approach, the avoidance of environmental as well as dietary extremes is recommended in order to maintain balance between the opposing forces of ‘hot’ and ‘cold.’ Secondly, for the management of illness, the principle of the ‘selective use of opposites’ is applied in an attempt to rectify imbalances (Logan 1977).

6.3.2.1 Applications of Dietary Therapy for Health Maintenance In the preventative approach, one should not excessively consume ‘cold’ foods, so as to not tip the balance within the body toward the predominance of ‘cold’ and ‘cold’ related disorders (such as cold intolerance, lethargy, and fluid

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retention). The converse also applies to the overconsumption of ‘hot’ natured foods (Logan 1977; Anderson 1980). Rather, one would aim to consume proportional quantities of ‘hot/warm’ and ‘cold/cooler’ foods (Logan 1977), as well as those regarded as neutral in nature. As raw food in both the humoral and classical Chinese medical systems is thought to be ‘colder’ in nature than cooked (Anderson 1980; Lee and Shen 2008; Leggett 1995), minimal consumption is also suggested (Guha 2006). Furthermore, all three medical systems suggest that ‘warmer’ natured/cooked foods are easier to digest than raw or ‘colder’ foods (Currier 1966; Flaws 1998; Guha 2006; Chashti 2004); due to warmth maintaining ‘agni’ or digestive ‘fire,’ as well as the cooking process providing pre-digestive effects (Guha 2006; Flaws 1998; Leggett 1995). Indeed, insufficient warmth for digestion is thought to result in ‘improperly processed’ foods (Flaws 1998; Guha 2006; Leggett 1995; Chashti 2004), as temperatures are lower than those at which digestion normally occurs (Leggett 1995), and enzyme functions are, therefore, suboptimal (Guha 2006). Consequently, consumption of refrigerated and/or frozen foods is not recommended (Leggett 1995; Flaws 1998). Additional dietary adaptation based upon knowledge of one’s constitution is also required for longer-term health management. For example, women and the elderly are generally ‘colder’ than men, hence even during the summer months, continued consumption of mostly ‘warmer/cooked’ food, along with minimal intake of fresh seasonal ‘cooling/raw’ produce is recommended. Furthermore, avoidance of foods aggravating to the individual’s ‘dosha’ or constitutional makeup is suggested that typically also includes factors in addition to temperature, such as, ‘dryness’ for the ‘Pitta’ (fire) constitution (Rastogi 2014a, b). More complex considerations of environments are additionally incorporated into dietary recommendations, as external conditions tend to aggravate those that predominate internally. For example, cold, damp weather may compound the incidence of mucous, catarrh, and colds in winter, hence cold, damp foods should be avoided at

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these times (Dua and Dua 2011). In addition, one could attentively consume foods opposite in nature, so as to minimize or counterbalance the impact (Lee and Shen 2008). Such a process naturally occurs to some extent when local seasonal produce is consumed, as ‘cooling’ foods are both more desirable and available in warmer months, and cooked or intrinsically ‘warming’/ spiced foods are preferable in winter. According to Wu and Liang (2018), balanced consumption in this way is thought to slow down the ageing process, possibly as a consequence of optimized digestion and nutrition assimilation.

6.3.2.2 Applications of Dietary Therapy for the Management of Disease In the secondary approach, nutrition may be utilized for the correction of illness, if, for example, consumption of one temperature was in excess, or constitutionally and environmentally considerate ‘cold,’ and ‘hot’ food choices were insufficient to prevent disease (Logan 1977; Currier 1966; Anderson 1980; Kastner 2004). In these cases, ‘food therapy’ or targeted consumption of foods opposite in nature to the presenting medical symptomologies are applied, while those of the same nature are avoided in order to not worsen the imbalance or condition (Ludman and Newman 1984; Lee and Shen 2008; Anderson 1980; Logan 1977; Zaman 2015). One such simple application from TCM is the postnatal consumption of ‘warming foods,’ such as a stew containing chicken, ginger, vinegar, and sugar, to counteract the temporary condition of ‘cold’ predominance resulting from childbirth (Anderson 1980). Another example provided by Logan (1977) from humoral medicine is the case of ‘very cold’ venom from a rattlesnake bite that can be remedied by the intake of ‘hot’ natured foods such as coffee and garlic. Likewise, the study by Mehraban et al. (2021) showed that ‘hot’ natured diseases such as gastrointestinal reflux can be treated by ‘cold’ natured plants such as damask rose. Neutral foods can in addition be included so as to buffer or harmonize the ‘heating’ or ‘cooling’ foods being consumed in remedy, as well as

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supplement blood and strengthen the body’s ability to fight external influences (Anderson 1980). Rather than just the simple use of opposites, in TCM additional complexity in treatment is also incorporated after consideration of the nature of the five flavors. For example, “sour food was said to be absorbed by the liver, spicy by the lungs, bitter by the heart, salty by the kidney, sweet by the spleen” [p. 3] (Wu and Liang 2018). Thus, in addition to overeating one food temperature, if consumption is “too sour, the liver-qi would increase, and the spleen-qi will decrease. If too salty, it could lead to bone damage, impotent muscle, and depressed heart-qi; if too sweet, the heart-qi would rise up, causing asthma, darkened skin, and imbalance of the kidney-qi; if too bitter, it could cause dryness of the spleen-qi, bloating of stomach; if too spicy, tendons and vessels would become flabby, and vigor would be undermined” [p. 3] (Wu and Liang 2018). Indeed, in TCM, temperature aspects are also associated with the different flavors, for example, salt is considered to have a moistening action that is beneficial for dryness; however, in excess, it can result in fluid retention, due to being relatively more ‘cooling’ than ‘warming.’ Bitter taste on the other hand ‘drains and dries,’ hence could be considered comparatively more ‘warming.’ Indulging in one particular flavor, therefore, can contribute to constitutional imbalance, as well as organ system disharmony via the route that flavor travels throughout the body (Leggett 1995). In Ayurveda, tastes are similarly described as in TCM, except for the addition of the ‘astringent’ category, along with the role they provide in digestive and immune system processes. However, it is additionally suggested that each taste is received on different parts of the tongue, and each of these anatomical locations in turn corresponds to different organs, such as, sweet to the thyroid glands and apices of the lungs (Guha 2006). Specific tastes are also reportedly derived from differing elemental compositions, and these, along with other qualities, are responsible for the differing physiological impacts (Guha 2006; Payyappallimana and Venkatasubramanian 2016). Indeed, food is classified according to the

S. M. Ormsby

active component or potency, as well as postdigestive and pharmacological effects (Guha 2006; Payyappallimana and Venkatasubramanian 2016). Similar teachings are also provided in the HMS, where it is thought that various temperature and moisture combinations in foods specifically target various organ systems, and hence the ability of food to be utilized for medicinal purposes (Nimrouzi and Zare 2014). Contrasts between the TM systems can nonetheless also be seen, with for example salt being regarded as moistening in TCM, whereas ‘heating’ and drying’ in the HMS (Aghili 2008). Additional considerations for the management of illness necessarily also incorporate knowledge of ‘susceptibilities’ (Anderson 1980) or constitutional differences in TCM, ‘doshas’ in Ayurveda, and temperament/Mizaj types in humoral medicine (Guha 2006; Ibn-Sina 1998). For example, men who generally have ‘hotter’ dispositions would predictably take longer to manifest a ‘cold’ condition from the overconsumption of ‘cooler’ foods or exposure to ‘cold’ environments, than most women, whose constitutional tendency is toward internal ‘cold’. Correspondingly, a ‘hot’ constitution type would also much more quickly manifest a ‘hot’ type illness when excessively consuming ‘heating’ foods or being overexposed to ‘hot’ environments. Another type of ’susceptibility’ relates to poor Stomach/Spleen function in TCM (Leggett 1995) or weak ‘digestive power’ in Ayurveda (Guha 2006; Payyappallimana and Venkatasubramanian 2016), in which one’s ability to process food is compromised. In such a case, TCM recommends a predominance of more easily digested cooked and non-sweetened foods, along with substances that specifically strengthen these functions, such as acrid warm spices like ginger, cardamom, and nutmeg (Flaws 1998). In Ayurveda convalescent food practices can also be designed to gradually restore ‘agni’ or ‘digestive fire’ (Rastogi 2014a, b), and likewise, in the HMS, minimally applied spices may be used to aid digestion by increasing food compatibilities, balancing adverse actions and providing nutritional content (Aghili 2008).

6

Hot and Cold Theory: Evidence in Nutrition

Overall, diets compatible with constitutions, ‘doshas’ and Mizaj types are considered foremost to good health and correct body functioning (Sarkar et al. 2015; Payyappallimana and Venkatasubramanian 2016); as well as the gradual restoration of health when systems are out of balance (Wandel et al. 1984). Factors in addition to the inherent biological properties of foods (Guha 2006) being incorporated into diets to combat disease include: the season, freshness, locations and environment in which the food grows (Payyappallimana and Venkatasubramanian 2016; Guha 2006; Wu and Liang 2018); where or how the food is consumed (Guha 2006; Leggett 1995); the working or living conditions (Logan 1977) of the individual; and their gender, age (Guha 2006; Sarkar et al. 2015; Wu and Liang 2018), current health (Sarkar et al. 2015; Logan 1977), illness severity (Logan 1977), and mental state (Sarkar et al. 2015). Knowledge of these variables provides a unique opportunity to individually tailor diets not only to correct illness but also maintain longer term balance. Nonetheless, some illnesses are very complex and include both ‘hot’ and ‘cold’ aspects (Currier 1966), such as mental health disturbances with ‘cold’ depression symptoms including lethargy, apathy, and lack of motivation, as well as ‘hot’ anxiety manifestations such as irritability, insomnia, and restlessness. Not surprisingly, these conditions can be much more difficult to treat. While the potency of food is weaker in magnitude than herbs in TCM (Wu and Liang 2018), longer-term impacts are considered possible due to more frequent consumption over extended periods of time. It was only when this type of rectifying food therapy was insufficient in effect that Tang Dynasty scholar Sun Simiao stated medicinal herbs should be prescribed for a more powerful effect (Wu and Liang 2018; Lo and Barrett 2005). In this way, it was considered that, “…medicine functions by means of food and food reinforces the effects of medicine” [p. 1] (Wu and Liang 2018). A similar concept was developed in humoral medicine, however expanded into a system of grading according to the impacts on the constitution or temperament

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of the individual, with the higher grades being considered the most medicinal and thus less frequently consumed (Zaman 2015). Indeed, Rhazes (865–925) famously stated that “If a physician can treat [a] patient by food, he has been fortunate”, and if this was insufficient “simple drugs” should be used, and in last line “compound drugs” [p. 1461] (Zargaran et al. 2014). Specifically, the lowest grade is defined as ‘absolute ailment’ and considered a source of energy, as well as able to be part of the body without changing its functions. The next level, ‘functional food’, provides a greater potential for conversion into energy, as well as the marginal ability to alter the function of the body. It is foods in these first two categories that are predominantly consumed. The third grade termed ‘pharmaconutrient’ includes those that have medicinal effects able to alter the body’s temperament that are considered superior to nutritional effects. Only a small proportion of these substances are utilizable for conversion to energy. Fourthly, ‘absolute medicament’ is defined as a drug that affects both structure and function, with little nutritional value. This last type can be poisonous as it has the potency to change the temperament to a maximum effect (Soleymani and Zargaran 2018; Aghili 2008). Most spices belong to the third category, with some also belonging to the forth (Aghili 2008).

6.4

Scientific Evaluations of the ‘Heating’ and ‘Cooling’ Nature of Foods

6.4.1 Food Compositions and Their Associations with ‘Hot’ or ‘Cold’ Properties 6.4.1.1 Nutritional Content and Chemical Composition Early research findings into humoral medicine and ‘hot’ and ‘cold’ food classifications identified some early preliminary categorizations with respect to nutritional content. Logan in his 1977 evaluation of previous research reported that

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niacin (vitamin B3) content was approximately doubled in foods considered to be ‘hot’ compared to ‘cold’, however no reference was provided regarding the source of this data. Logan also cited research from the McCullough’s [in Logan 1977] that stated that ‘hot’ foods had roughly eight times the protein and four times the calorific content of ‘cold’ foods (McCullough and McCullough 1974), however, this article was not published in English, hence the source of this information could not be identified. Additionally, Manderson likewise reported in 1981 and 1987 that ‘warmer’ foods had higher protein, fat, carbohydrate, and calorie contents, as well as lower water compositions (Manderson 1981, 1987). Anderson in 1980 additionally stated that ‘heating’ foods were high in iron and some vitamins, whereas ‘cooling’ foods were often rich in vitamins A and C. No citation was provided in this regard, however Anderson did support this statement with the example of ‘scurvy’ symptoms reflecting excess ‘heat’ (sores, bleeding gums, scaly skin), being remedied with vitamin C rich sour citrus fruits that are considered ‘cooling.’ In Ayurveda, foods resulting in skin eruptions such as tomatoes and mangos are reportedly also regarded as ‘heating’ (Wandel et al. 1984). Wandel et al. (1984) using Sri Lankan food composition tables (Perera et al. 1979) identified that foods considered to be more ‘heating’ were associated with higher energy, protein, fat, carbohydrate, B-complex vitamins, acid, and possibly also, poisonous contents (when mushrooms and cassava were included); whereas those regarded as more ‘cooling’ had higher compositions of water, iron, and carotene (Wandel et al. 1984). Additional analyses of ‘hot’ and ‘cold’ natures in relation to nutritional content has also been explored by TCM scholars. Xu (2019) and Liu et al. (2012) provided details of a Chinese study conducted by Zhang and Zhao (2008), in which 176 foods obtained from a Chinese food composition database were analyzed for nutritional content correlations with ‘hot’ and ‘cold’ labeling, to identify that ‘cold’ was associated with fiber, manganese, and copper, and ‘hot’ to protein, fat, carbohydrate, iron, selenium, and zinc

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(Zhang and Zhao 2008). Liu and colleagues (2012) likewise used a database of nutritional content for 284 foods, to identify significant differences in relation to content of water, energy, protein, fat, cholesterol, carotene, retinol, vitamin C, zinc, and selenium among the TCM classifications of ‘cold’, ‘neutral,’ and ‘hot’ groups (p < 0.05 or