The convergence of these three matrix factors, their overlapping, is what Antonovsky calls a “sense of coherence,” the knowledge of an internal connection accompanied by external support. The stronger the sense of coherence, the more stable one’s mental health, which has an immense influence on the body. From these ideas, Antonovsky developed a theory on the question of how health and well-being is actually created—salutogenesis. A salutogenic approach to medicine looks at which factors actually keep us healthy. A focus on salutogenesis is an alternative to conventional medicine’s focus on pathogenesis—the origination and development of a disease. Antonovsky’s goal was to uncover the factors that keep us healthy, rather than focus on what creates disease. Antonovsky suggested that enhancing and supporting the factors that maintain health and resilience might be as important as eradicating disease itself.
Salutogenesis: The Origins of Good Health
Health is generated by the interplay of comprehensibility, manageability, and meaningfulness. The intersection of these factors creates a sense of coherence (i.e., knowledge of internal connections accompanied by external support). The stronger the sense of coherence, the more stable the psychological health of a person, which in turn has a major influence on physical health.
How can we wake our “inner physician”? The relationship between doctor and patient is crucial. “Oh well, if we took as much time as the naturopaths,” conventional physicians often say, “our patients would be doing better, too.” But apart from the fact that we might ask ourselves why we as doctors don’t organize ourselves in a fundamentally different way but have created a system of practicing medicine that we no longer consider sufficient and humane, the real secret lies elsewhere: A good physician, I believe, should maintain a sense of equality. It’s important never to feel superior to patients, because of our profession and the institution we belong to. I don’t treat my patients with condescension. Some doctors think that the need to exude authority is part of the healing effect. But in the majority of cases, the opposite is true. During rounds or in my practice, I am faced with people who are the actual experts, because they know their bodies much better than I do. They know details that can’t be garnered from lab results or CT findings. The art of being a physician lies in detecting what has weakened a patient and made him ill, what could be the beginning of the knot, and what could make him healthy again once it is unraveled. Or at least significantly improve his symptoms.
PLACEBO: THE UNKNOWN POWER OF SELF-HEALING
Naturopathic doctors are often reviled by our conventional colleagues because we make time for our patients. Our treatment methods are often not taken seriously. When our methods work, they’re dismissed as “just” the placebo effect, a reaction to the extensive amount of care or a special “setting.” Anyone could do it.
The fact is this: What is usually belittled as “imagination” is part of the natural healing process and is connected to the patient’s faith that a procedure or a therapy is going to work. When we doctors are able to make a connection with our patients, we create hope and confidence and awake the patient’s “inner physician.” Neuroscientists like Fabrizio Benedetti have shown how hope activates certain areas of the brain—among other things, oxytocin, a peptide hormone that signals trust, is released.29 It has also been demonstrated that a painkiller placebo addresses those areas of the brain that are responsible for the moderation of pain just by the expectation of its effectiveness. By using high-resolution MRI scans, doctors at the University Clinic of Hamburg-Eppendorf were able to show that the body releases opioids that occur naturally—even if the placebo contains nothing but glucose.30
As it became clearer that the placebo effect could not be dismissed, a new argument rose in popularity: The idea that it would be unethical to make patients believe they were receiving actual medication. In order to disprove this argument, Harvard professor Ted Kaptchuk conducted the following experiment: In 2010, he openly offered a placebo to patients suffering from irritable bowel syndrome. He explained to patients that the drug contained no active pharmaceutical ingredients, but still worked for many people. And indeed, the group that had taken the placebo performed significantly better and twice as well compared to the control group that didn’t receive any treatment.31 This demonstrated that the success of a placebo does not necessarily depend on the belief that it is real—it works as long as we’re convinced that it works.
Kaptchuk also demonstrated the importance of care in another experiment with irritable bowel syndrome patients: A group of 262 subjects was placed on a waitlist and received no treatment for the time being. A second group received acupuncture without any special attention. A third group, however, was “surrounded by care,” according to Kaptchuk. The people placing the needles talked to the patients, showed empathy and understanding, and created physical contact with the patients. The results showed that the more care patients received, the more their symptoms disappeared.32
“The placebo effect,” says psychologist and behavioral immunobiologist Manfred Schedlowski, “is the activation of the body’s natural pharmacy.”33 That’s why he urges doctors to make more time for their patients.
In 2015, my research group and I invited Andreas Kopf, head of the Pain Center at the Charité Hospital, to lead a training course on placebos. Apart from his work as a pain therapist, anesthesiologist, and placebo expert, he has garnered a lot of knowledge and experience on shamanic rituals by cooperation with African medical institutions. To begin his talk, he listed the core elements of ritualized therapies conducted by shamans or medicine men in traditional and indigenous peoples: the administration of drugs with a sedative or hallucinogenic effect, the move to an unfamiliar location, the ritual washing, and the changing of the patient’s clothes. Then the medicine man enters, wearing a ritual outfit and carrying a unique set of tools.
Does this remind you of anything?
Next, Andreas Kopf introduced the rituals of a modern operation: the sedative drugs, the washing and disinfecting of the location of the operation, the putting of the hospital gown on the patient. Then the patient is moved to the OR, where the surgical team, wearing masks and scrubs, is waiting and preparing the tools.
The placebo effect is one of the most complex phenomena of medicine, and it is still not fully understood. Basically, placebo healing exists—with the exception of the most severe emergencies—in almost every medical field. The more chronic an illness is, the more it is characterized by the experience of pain, the higher the placebo effect is.
HOW TO DELIBERATELY INDUCE SELF-HEALING
So, what does this mean for naturopathy? Symbols, rituals, and even empathy send signals that can be used in a therapeutic manner. Physical contact alone—in acupuncture, wraps, and massages—has a positive effect in our work, as does the fact that we show great interest in the details of a patient’s history and condition, because we want to ensure her understanding and cooperation. This may be the biggest difference between naturopathy and conventionally oriented medicine: We not only look at the objectively measurable data, but also the many subjective details that can be instrumental in the healing process—because this makes the patient feel that she is taken seriously, among other things. This is not a strategic method—I know that a big part of my effect as a doctor depends on whether I can strengthen my patient’s faith in herself. A good doctor should also never discount a patient’s subjective convictions about her illness or her healing as absurd or unscientific, just because she is not able to explain it in the language of the doctor’s learned knowledge or because it doesn’t fit with the doctor’s own world view.
This does not mean that we don’t have to run targeted medical interference—yet, the focus of naturopathy, especially where chronic illnesses are concerned, is on inducing self-healing in a deliberate and controlled manner using sensible therapeutic and lifestyle methods.
CHAPTER TWO
Therapies of Antiquity Rediscovered<
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Leeches, Cupping, and Bloodletting
For most of us, leeches conjure up feelings of fear and revulsion. The idea of one of these strange creatures attaching itself to you in order to drink your blood is probably quite disturbing. This is a normal reaction. I used to feel the same way. That said, leeches are one of the oldest medicinal products in the world. These tiny but effective animals should not be underestimated.
My first encounter with leeches was in March of 1992. It left a deep impression on me. I had just transferred from the cardiology department at the Humboldt Hospital to the department for naturopathy at what was then the Moabit Hospital in Berlin. That’s where I was supposed to admit a new patient, a woman in her mid-sixties. She suffered from such severe osteoarthritis of the knees that she was barely able to climb stairs, and could get into a car only with great difficulty. The attending physician ordered leech therapy for the next day.
I was surprised. I had heard that leeches were used in some areas of naturopathy—usually by alternative practitioners—but at a renowned hospital? I hadn’t imagined that I would have to be confronted with disgusting leeches on the second day of my naturopathic training. When the appointed time for the leech therapy arrived, I met the nurse who was already on her way to the patient with a pot full of the little animals. Cheerfully, she asked whether I wanted to apply the leeches (for osteoarthritis of the knees, four to six leeches are placed around the joint). I couldn’t bring myself to touch the leeches. To be honest, I was nervous that they would bite me.
Over the next few days, I was astonished to see that the patient, who was much braver than I, was doing fantastically well. But how could that be? How could such a seemingly unscientific, medieval procedure make pain in the knees disappear?
LEECHES: EFFECTIVE ANCIENT HELPERS
There are indications that leeches were already being used during the Stone Age. They can be found in the cuneiform writings of the Babylonians. The Egyptians of the Pharaonic period recognized the healing effect of leeches. Sanskrit papers on Ayurveda mention them, too—leeches were even bred especially to be used in therapy. The Chinese and the Japanese dried leeches and ground them to a powder to be ingested.1
In Europe, leeches were initially only used locally in poisonous animal bites—they were meant to clean poison from the wound. Famous doctors of antiquity such as Pliny the Elder or Galen later used them to treat feverish illnesses, chronic headaches, or arthritis. Leech therapy had a resurgence in popularity in Europe in the sixteenth century, beginning in Renaissance Italy, where the gems of classical knowledge were in the process of being rediscovered.2
Treatment with leeches is classified as one of the drainage therapies, as is bloodletting, cupping, purging, and fasting. In antiquity, these therapies mainly served to “boost” that which we nowadays know as metabolism. Back then, the declared goal was the regulation of the humors—a theory that follows humoral pathology, the teachings of the four bodily fluids: yellow bile, black bile, phlegm, and blood. All major healing traditions have explanatory models like this, consisting of forces that should be in a certain balance—even if they carry different names and are described differently. These models are often culturally shaped. Our modern idea of effective medicine and what heals correctly is full of such models, too, including the belief—held too strongly for too many years—that antibiotics, i.e., the wish to eliminate all bacteria, are universally good.
Even though we have no more use for “yellow bile” or “black bile” today, humoral pathology was still a reflection of practical knowledge. The terminology of the four fluids was probably not taken literally: They were metaphors for daily observations made by physicians that served to better categorize the various properties and reactions of people. All traditional medical systems have such basic grids in common. In Ayurveda, it’s three constitutional types called doshas: vata, pitta, kapha. In Traditional Chinese Medicine it’s five elements: wood, fire, water, earth, metal.
In the first half of the nineteenth century, medicine began to disproportionately rely on the principles of humorism. Leeches were used excessively—up to a hundred leeches were used at a time. In addition, they were prescribed for all sorts of ailments—perhaps comparable to the misuse of antibiotics nowadays. In the course of this “bloody phase,” the yearly consumption of leeches rose from 33.6 million to 100 million in France between 1827 to 1850. Due to high demand the natural population of the animals rapidly diminished. Leeches were imported from Egypt, Syria, Turkey, Russia, and Central Asia. Breeding facilities were created. Leeches became an important medical commodity.3 Finally, in the mid-nineteenth century, the famed Charité pathologist Rudolf Virchow showed that illnesses have their origin in somatic cells and are caused by changes in the cells.4 Bloodletting and leeches were slowly abandoned. The modern world jumped at the new, scientifically founded models of explanation in medicine, at cytopathology and microbiology.
Around 1920, there was a sudden renaissance in the use of leeches. In France, thromboses and the resulting vein inflammations were successfully treated with leeches. At that time, no effective medications existed for those diseases. And there was an interest in leeches in wound surgery and military surgery, since it had been observed that wound healing and circulatory disorders after major surgeries improved after a few leeches were attached.5
WHAT HAPPENS WHEN A LEECH BITES
A leech has a pointed mouth with a small sucker and receptors for warmth, touch, and chemical analysis. When a leech encounters a host with a body temperature between 95 and 104 degrees that tastes of glucose or sweat, and if it then possibly feels the pulsing of a vein, it bites. Leeches have, as we know today, a jaw with 240 razor-sharp, tiny teeth that are attached to three jaw blades. Under the microscope, this forms a heart-shaped image. Once a leech has bitten, a wound in the shape of the star in the Mercedes logo remains due to the typical formation of the three jaws. This wound takes a few weeks to heal, because the teeth have essentially carved themselves into the top layer of skin. Yet this barely hurts, because leeches release numerous locally numbing and pain-relieving substances into the wound when they bite—after all, the leech doesn’t want to be found by its host animal or human too soon. The bite is often compared to that of a mosquito’s.
For most patients, the aversion to leeches subsides once they experience medical benefits of these small animals. Leeches are not moist and slimy, but warm and soft—and sometimes a little lazy. When they stop drinking, you have to caress them carefully, at which point they wake up and carry on. Leeches are also quite sensitive. They need quiet and dim light, otherwise they become stressed and don’t bite or suck. And since they need to be in clean water, many leech therapists swear by using specially chosen mineral water to get the best performance from the leeches. For hygienic reasons, leeches can only be attached to a human once—they can live off one meal for up to two years.
I’ve only had a leech attached to my arm once, just to give it a try. But if I did show certain symptoms, I wouldn’t hesitate to be treated with leeches. Simply by observing the effects of leech therapy, it becomes clear that these animals are symbionts—who don’t live at our cost but with us. Their saliva contains numerous compounds that prevent the host from suffering any harm. These substances, which facilitate blood coagulation, use similar signaling pathways to those that are activated for the prevention of inflammation. One of these substances is hirudin, a polypeptide (protein) that is very effective at stopping blood from coagulating—thus prolonging the time during which the leech can consume its food. Hirudin is such a strong anticoagulant that researchers initially hoped to use it to dissolve blood clots like those that occur in heart attacks or strokes. However, the substance derived from leech saliva blocked the entire coagulation system to such a great extent that it led to a dangerous amount of bleeding.6 This area of research was consequently abandoned by the pharmaceutical industry.
In an unrelated study, scientists at
the University of Lausanne were able to show that hirudin is not only the strongest known anticoagulant, but also that it notably reduces inflammation of the joints.7 There are also other bioactive substances contained in leech saliva, so much so that some call the creatures a “miniature pharmacy.” For example, their saliva contains hyaluronidase, an enzyme that helps different pharmacologically active substances permeate deeper into the tissue, such as the joint capsule of a knee joint externally treated with leeches.8 Swelling at the joints is likely reduced after a treatment with leeches because the lymph is activated from the small local venesection that takes place. Moreover, the bite and suction from the leeches themselves cause neural stimuli that change the perception of pain and “overwrite” it in the brain, so to say—a method of pain management that acupuncture also utilizes.
But we still don’t fully understand what exactly happens during leech therapy. Why, for example, do certain patients, depending on the thickness of the connective tissue surrounding the joint, respond to it better than others? And we also don’t know why the effect lasts for such a long time, usually up to a few months after the treatment. Surely leeches also evoke a strong placebo effect, called “unspecific” in scientific jargon, because most patients consider them exotic, unusual, and positive—all of which are factors that increase the effect they have. But the results of the research I’ve done with my group indicate that the purely therapeutic effect is significantly larger than what could usually be expected in a placebo effect.
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