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Table of Contents
RESEARCH ARTICLE
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 158-164

American patients' understanding of traditional Chinese medicine in the late 19th century: An interpretation of letters from The Science of Oriental Medicine


1 School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053, China
2 Zhejiang Chinese Medicine Museum, Zhejiang Chinese Medical University, Hangzhou 310053, China

Date of Submission26-May-2021
Date of Acceptance06-Jul-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Dr. Shan Liu
School of Basic Medical Sciences, Zhejiang Chinese Medical University, Hangzhou 310053
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CMAC.CMAC_28_21

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  Abstract 


This study explores American patients' understanding of traditional Chinese medicine (TCM) in the late 19th century by referring to letters from American patients recorded in The Science of Oriental Medicine, written by Tan Fuyuan (谭富园), a Chinese medicine doctor working in the United States in the late Qing dynasty. Identifying a focus on significant effects, pulse diagnosis, herbal teas, dietary control, and long-term treatment, the results also discussed the differences between TCM and Western medicine in simple terms to show that the “ideological” spread of TCM was based on its curative effect. However, the “theoretical” spread of TCM requires more of intercultural exchanges.

Keywords: American patients, Tan Fuyuan (谭富园), traditional Chinese medicine


How to cite this article:
Qi YQ, Zheng H, Liu S. American patients' understanding of traditional Chinese medicine in the late 19th century: An interpretation of letters from The Science of Oriental Medicine. Chin Med Cult 2021;4:158-64

How to cite this URL:
Qi YQ, Zheng H, Liu S. American patients' understanding of traditional Chinese medicine in the late 19th century: An interpretation of letters from The Science of Oriental Medicine. Chin Med Cult [serial online] 2021 [cited 2021 Oct 26];4:158-64. Available from: https://www.cmaconweb.org/text.asp?2021/4/3/158/327155




  Introduction Top


At the end of the 19th century, the Western public changed their impression of China from that of a civilized Eastern country to a backward and stagnant country. In Western media writings, the Chinese people were often mentioned in negative terms as being barbaric and ignorant. The media considered traditional Chinese medicine (TCM) to be a kind of witchcraft, and the study was even associated with stigmatization and demonization.[1],[2] One article stated that, “Most of the medicines used by Chinese physicians are herbs from the plant kingdom with little effect. In addition, many strange and abominable things are used, such as snake skin, fossil bones, rhinoceros or deer horn debris, silkworm or human secretions, asbestos, moths, oyster shells, etc.”[3] Some western missionaries contended that TCM practitioners had no basic knowledge of human organs, nerves, blood vessels, and other human structures, and that TCM could not be incorporated into modern medicine as it was based on superstition and mysticism.

Qin[4] explained that the motivation and enthusiasm of missionaries to spread TCM to the West were affected by the description and evaluation of TCM in the Western media, which tended to be slanderous rather than positive. The increasing number of TCM books introduced to the West by western missionaries improved the westerners' breadth and depth of knowledge about TCM. However, TCM knowledge became almost a “handmaiden” of Sinology; it was considered part of the intellectual heritage of a civilized Eastern country and was completely separated from clinical practice.

Comparatively, the situation was different in clinical medicine in the United States. By the middle of the 19th century, TCM had been introduced to American society by the increasing number of Chinese immigrants. Chinese physicians provided medical services for local Chinese and American people. They provided an alternative route for the transmission of TCM that did not depend on the effort by missionaries [Note 1]. At the end of the 19th century, Tan Fuyuan (谭富园) [Figure 1], a Chinese TCM practitioner in the United States, collected several letters from American patients in his book The Science of Oriental Medicine. Written in English, the book describes American patients' understanding of TCM at that time. The following part of this article discusses the contents of these letters as they are relevant to TCM.
Figure 1: The portrait of Tan Fuyuan (谭富园)

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  Tan Fuyuan and The Science of Oriental Medicine Top


Born in 1851 in Shunde (顺德), Guangdong (广东) Province in South China, Tan Fuyuan received his training of medicine in the medical hall of the Imperial Academy of Medicine (太医院). In 1890, he was invited by his uncle Li Putai (黎普泰) [Figure 2] to serve as an assistant in his TCM clinic in San Francisco, US. Upon the death of Li Putai, Tan Fuyuan began to practice TCM independently, and opened Foo and Wing Herb Company in Los Angeles in 1895 [Figure 3].[5]
Figure 2: The portrait of Li Putai (黎普泰)

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Figure 3: Office of the Foo and Wing Herb Company

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With his excellent medical skills, Tan Fuyuan cured many American patients of their illnesses, thus gaining a high social reputation and expanding the influence of TCM in American mainstream society. However, owing to a wave of anti-Chinese sentiment and the attempts to demonize TCM, Tan Fuyuan was also attacked by local doctors through the media. These physicians questioned his qualifications as a practitioner and his medical skills, accusing him of practicing medicine illegally and using impure substances such as toads and lizards in his practice. Tan Fuyuan turned to the media to counterattack. His patients also defended him, vouching for the authenticity of his qualifications and the reliability of the therapeutic effects of TCM, which is indicative that Tan Fuyuan had established good inter-personal relationships with his American patients.[6] Tan Fuyuan soon gained widespread prominence so that he attracted more American patients. In addition to his clinical activities, Tan Fuyuan wrote articles to better disseminate the TCM knowledge and some of these articles were later used in textbooks for American students in the Oriental Medical College.

Finally, Tan Fuyuan became a famous TCM doctor in Los Angeles. His achievements promoted the spread of TCM in the United States and eliminated much of the prejudice that many Americans held against TCM, which has turned out to be a substantial contribution to the development of TCM and its modern application in the United States. Moreover, the good relationships that Tan Fuyuan had with his white American patients played an important role in improving relationships between the Chinese Americans and white Americans and protecting the Chinese community.[6],[7]

In 1897, Tan Fuyuan published the book The Science of Oriental Medicine, which was actually a collection of his articles published on newspapers. The book consists of 20 chapters dealing with such topics as the history and theoretical knowledge of TCM, the diagnosis and treatment of common clinical diseases in various disciplines, the personal profile of Tan Fuyuan, Li Putai, and his son, and the plan for establishing the Oriental Medical College. It also contains a large number of letters that reflected Dr. Tan's communication with patients in his treatment. The following is a summary and analysis of the content of the letters.


  Statistics and Classification of Letters in The Science of Oriental Medicine Top


Ninety-five of the 99 letters in The Science of Oriental Medicine were written by Dr. Tan's patients, most of whom were Americans while a few of whom were Chinese. These 95 letters are all complete, and were either directly posted to Tan Fuyuan or published in newspapers at the time.

The letters were divided into approximately four categories by Tan Fuyuan: Four letters in Chapters II and VI of the book verifies the qualifications of the two TCM doctors from the Foo and Wing Herb Company, in response to media accusations of illegal practice. Nine letters in Chapter II provided evidence that Foo and Wing Herb Company used natural and pure herbs, in response to media reports of the use of impure substances as medicines. Four letters in Chapter IV provided evidence that Dr. Tan's plan to set up the Oriental Medicine College had received support from his patients. The remaining 78 letters, mostly in Chapters IX to XVIII, were letters of thanks from patients describing how Dr. Tan's treatment had improved or completely cured their diseases.

The letters also contain other descriptions of TCM. Further analysis by extracting keywords and examining their frequency [Table 1] showed that the patients emphasized the curative effect of TCM, and that pulse diagnosis, herbal medicine, and diet also received considerable attention. In addition, the letters briefly described medical expertise on the causes, location, treatment ideas, and drug effects on diseases. Articles related to TCM were mentioned by some American patients who were interested in the discipline and wanted to learn more about the TCM system.
Table 1: Frequency of traditional Chinese medicine keywords in the letters

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  American Patients' Understanding and Discussion of Traditional Chinese Medicine Top


Substantial effect of traditional Chinese medicine

The following statement in the book can serve as a good summary of Tan Fuyuan's treatment of disease: “In fact, so far as I could learn, all those cases were chronic, difficult and unyielding, where the ordinary means as employed by our American doctors had utterly failed to effect a cure.”[8] Most of Dr. Tan's American patients had been sick for many years and had not benefited appreciable or long-term results though they had received various types of treatment. In the extreme case, some patients were told that their disease was incurable. Then they turned to Tan Fuyuan for treatment as a last resort, after being told of his reputation or being persuaded by friends. After Dr. Tan's treatments, these patients reported that their conditions became substantially improved or completely healed.

Therefore, Dr. Tan's patients provided evidence that TCM treatment produced a favorable outcome. A letter signed by 45 patients [Figure 4] reads as follows:
Figure 4: Names of the patients who signed the letter

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“The results of our treatment by the Oriental system of medicine as practiced by you have been very satisfactory to us, and have proved to us that there is great benefit to be derived from the herbal remedies when their use is directed by the care and skill of which you are possessed... The favorable results in these cases have inspired confidence in the system and in your skill and ability. These remedies seem to be adapted to a great many different diseases and to be successful in an unusually large proportion of the cases which commence treatment.”[8]

The curative effect of TCM and Dr. Tan's excellent medical skills are evident in the patients' experiences and observations. These successful cases convinced Dr. Tan's patients that he could cure people of their diseases by using herbal treatment.

His patients also provided evidence that TCM had remarkable and persistently-effective effect in treating chronic diseases, as is evidenced in the following letter:

“In response to your inquiry I am pleased to say that my great improvement in health has continued until the present time. As advanced in age as I am I can now attend to my daily work, and feel well in every respect... I believe that if I had not obtained relief through your treatment and your herbal remedies, I should not have recovered. I still follow out in great measure the healthy diet which you taught me to observe, and I believe that it is of great assistance to me in keeping my health.”[8]

A patient wrote to Tan Fuyuan again 3 years after Tan cured his rheumatoid arthritis, stating that his disease had never recurred and he was healthy enough to do his daily work.

In addition to treating chronic diseases, Dr. Tan used TCM to deal with acute attack of chronic illnesses. His treatment was of timely rescue and effective enough. Mrs. A. Amayhew, one of the patients, suffered from a chronic cough. In the winter, when there was a high incidence of influenza, she was impressed with the quick relief of an acute attack of her chronic cough after consuming herbal teas.[8]

After being cured of by Tan Fuyuan, some patients built up full trust in TCM and would take TCM a primary choice for treatment when they were sick of subsequent diseases. A patient named Frank Ames said, “I get a bad cold occasionally, as most people do, and instead of taking quinine or some other poisonous drug, I go and take the doctor's herbs for a week or two and am cured.”[8]

Pulse diagnosis as the only diagnostic method

According to his patients, Tan Fuyuan used only pulse diagnosis rather than inquiry in clinical practice. By placing three fingers on the patient's wrist, he could recognize the disease judging from the beating of the pulse and describe it accurately to the patient, which is astonishing to the patient. The following letters recorded the patients' response:

“In the first place, there was a radical difference in diagnosis. Dr. Foo asked me no questions, except my age. He found out for himself, simply by feeling my pulse, all that he wanted to know, and told me more facts about my physical condition than I had ever known before. However, everything that he said was reasonable, and coincided with my experience. A peculiarity of this diagnosis was that it at once gave me confidence in Dr. Foo.”[8]

The method of pulse diagnosis was not available in Western medicine at that time. Most of the patients who turned to Dr. Tan for treatment had prior knowledge of their own diseases and physical conditions, so when Dr. Tan informed them of their conditions using only pulse diagnosis, they immediately grew into confidence in him and were willing to accept his treatment.

This diagnostic method was also highly appreciated by female patients. Mrs. Strong wrote in her letter thus:

“One beautiful thing about Dr. Foo's diagnosis is that the patient is not questioned. So many delicate, timid women suffer untold misery rather than go to a doctor and submit to a questioning process about all their aches and pains, their location, etc. Dr. Foo feels the pulse in both wrists, and then tells you what ails you, and whether or not he can cure you. I am satisfied with the results of this treatment, and I think it better than any that I ever tried before.”[8]

At that time, the medical environment in the United States was not conducive to medical treatment of women. For example, women's privacy could not be assured of safety during examinations using diagnostic equipment, so women were often unwilling to discuss their symptoms.[9] Female patients favored pulse diagnosis because it was very convenient and did not require a physical examination. The use of pulse diagnosis helped to protect women's privacy and demonstrated respect for women.

The principle of how the pulse diagnosis worked was not profoundly explored in the letters but one patient discussed Dr. Tan's innate ability, acquired it through long-term patient training and expressed a belief that this ability was not something that everyone could master.[8]

Herbal teas and dietary control

Herbal tea has been used as therapeutic medicine in TCM for centuries. A typical prescription would include 10–18 types of herbs into which two to six cups of water were poured, then the mixture was boiled down to one cup (which was one adult dose) and was drunk while it was hot.

The simplicity and purity of the botanical drugs and their effects surprised American patients. First, according to patients' observations, Dr. Tan used exclusively botanical drugs, including rhizomes, flowers, leaves, seeds, and peels, with no animal materials. Therefore, his patients believed that the accusation by American doctors that Dr. Tan was using impure drugs was exaggerated and baseless. Second, patients who had a deep understanding of the effects of herbal medicines realized that the use of natural plant medicines in TCM was safe and nontoxic compared with Western medicines, which usually carried side effects. One patient wrote in a letter thus:

“Due to the unfortunate selection of the remedies employed, the false assumption that the human body can assimilate and use mineral substances and other poisons that a thing which would hurt a well man can cure a sick man. The Chinese employ in their remedies only vegetable materials, which are readily assimilated, are largely in the nature of special foods, and to return to Dr. Holmes's [Note 2] statement of the case, supply exactly what is needed to meet the 'want of organization, nourishment or vital stimulation,' which is at the bottom of many cases of obscure and chronic disease.”[8]

In the late 19th century, the doctors in the United States would use quinine, aconitine, opiates, alcohol, amalgam, arsenic, and strychnine in their treatment and these substances had low efficacy and were even risky.[10] In contrast, herbal medicines were considered harmless and nutritious as most of them were foods that are easily absorbed. In other words, “drug homologous food.” Mr. E. M. Wade, a well-known Los Angeles businessman who had professional knowledge of chemistry and an ability for exact observation and close reasoning, was one of Dr. Tan's patients. Wade wrote a letter stating that, “Herbal tea was not only harmless, but also beneficial under your (Tan Fuyuan) guidance.”[8]

In addition to herbal treatment, Dr. Tan would strictly control his patients' diets during the treatment of their diseases. They would be provided with detailed menus to advise them the foods they were allowed to eat and those that were banned. However, Dr. Tan's patients had different views on dietary control, and it seemed that they did not realize the effect of diet on their health. Some patients did not understand the importance of dietary control and were worried that too light a diet during illness would affect their recovery. Nevertheless, they still followed the doctor's advice. As one patient said, “You gave me such a light diet that I feared you would starve me to death. After 12 days, you said you could cure me, provided I would follow your directions strictly, adding that the treatment would last about 7 months. You examined me, day after day, and I improved very much under your treatment.”[8]

Some patients found that the menu recommended by Dr. Tan, though simple, were very suitable for their body conditions and more effective than the supplementary foods prescribed by other doctors. “He (Tan Fuyuan) prescribed for me and placed me upon a diet which, although very plain and simple, accomplished more for me, together with the herb teas, than all the tonics, raw meats, eggs and other so-called strengthening foods ordered by my former physicians had been able to do.”[8]

In addition, some patients realized the important role of diet in the treatment of disease, as expressed in one letter:

“I believe that many mild cases of such diseases are made serious, and that many people are prevented from recovering by the use of stimulants and of strong foods in such attacks. I consider such treatment to be all wrong, and can see how a mistake in these matters is very likely to end in a fatal result.”[8]

What American doctors ignored was that daily diet had a great effect on the prognosis of diseases and the effects of drug. A beneficial diet improved the effects of drug on the body, whereas an inappropriate diet could aggravate the disease or interfere with drug effects.

Slow and continuous treatment process

In their letters, the patients also discussed the slow and stable characteristics of TCM treatment by recording those points during the treatment process when their diseases had substantially improved. It took about 3–6 weeks to obtain an obvious effect, and complete cure took longer, from 4 to 5 months to as many as 12 months, depending upon the individual cases.

“I feel encouraged by the results to the extent they had already reached in my case, and shall continue the herbal treatment for another year, the length of time which Dr. Wing says will be required for a complete cure.”[8] Dr. Wing's name is Li Wing. He was the son of Dr. Li Putai and the secretary of Foo Wing Herb Company.[8] As mentioned above, patients persisted in long-term treatment because they experienced gradual improvement in their symptoms and because Tan Fuyuan gave them the confidence to recover. There were also a few patients who realized that the treatment of chronic diseases required a slow and continuous process:

“I continued it for 3 months: Sometimes, I appeared to be a little better, sometimes worse. I saw so many of Dr. Foo's patients who were doing well, but a few of them not progressing very fast, that I decided to keep on. I noticed that, out of ten or twenty people, one or two would improve slowly, and I concluded that the difference was in the nature of the diseases and not in the character of the treatment. I reasoned that I could not expect to be cured at once of a difficulty of so long standing and of such a serious nature. Hence, I decided to keep on with the treatment in spite of discouragements.”[8]

This patient was still not cured after 3 months of treatment. However, she observed that out of 10–20 patients treated by Dr. Tan, only 1 or 2 improved very slowly. Through this observation, she realized that gradual treatment was needed to cure her of her disease, which she had suffered for a long time. Therefore, she opted to continue the treatment.

Advantages of the traditional Chinese medicine system

The patients had little professional knowledge of TCM, and they only briefly mentioned this in their letters. Some examples are “the origin of my troubles in the stomach and spleen, and not in the heart,” “congealed blood has settled about the seat of the injury and keeps up a constant irritation of the nerve centers,” “draw this blood away and to re-establish a normal circulation.”[8]

A few patients who were interested in TCM read some of the articles published by Tan Fuyuan in newspapers, in which the TCM system was systematically explained. These articles included Two Lessons on Physiology, The Cause and Origin of Diseases, Anatomy from the Chinese Standpoint, and The Herbal Remedies. Patients discovered that TCM was a completely new medical system that was different from Western medicine. They believed that its value and benefits should be explored and confirmed, and that it was worthwhile to be widely disseminated in the United States.

One patient named George stated that the Chinese ancient system of medicine was superior to Western medicine in many respects, both in theory and in practice, supplying two examples to illustrate that American physicians knew nothing about the functions of the spleen [Note 3]. One example was a prominent physician in Southern California, who accused Tan Fuyuan of false pretenses, claiming to know something about the function of the spleen. Another example was a patient who died after the attending physician had cut out his spleen.[8] TCM contains important information about the spleen, which Tan Fuyuan described in detail in his article. George also stated that TCM had advantages in the treatment of many diseases, whereas the methods of Western medicine were always effective to advance or improve the process of health care and the treatment of diseases.[8]

Another patient realized that the TCM concept of “preventive treatment” was very important for maintaining good health. He wrote as follows:

“But between the first of August and the first of October, it seemed to me that my system was not in as good trim as it had been, perhaps on account of the long continued hot weather. Then I saw at once what Dr. Foo had taught me was a necessary thing to know. I made up my mind that it is better to take medicine for health than for sickness. I made a big mistake once when I let my sickness go so long, and do not intend to make another of that kind. I propose to take a short course of medicine for 1 or 2 months and to check whatever difficulty there might be right at the start. I believe that in this way everybody could keep well and healthy, and could stop sickness at the start.”[8]

This patient gradually recovered after undergoing more than 4 months of treatment. He then asked Dr. Tan about the precautions he should take after stopping his medication. Dr. Tan told him about the concept of early prevention. As diseases occur through a process of gradual accumulation, timely treatment before the disease becomes serious can prevent the occurrence and deterioration of the disease. In particular, after being cured of a chronic disease, the patient's body could still be affected by factors such as weather, diet, emotions, and fatigue. This patient followed Dr. Tan's advice and promptly consulted a doctor when he felt uncomfortable. He believed that instead of allowing mild illness to progress into a serious situation, it was better to devote 1–2 months to treatment to maintain his health.


  Discussion Top


TCM is characterized by the dual attributes of natural science and humanism. Therefore, communication about TCM also has dual characteristics: That of scientific communication and cultural communication. In The Social Function of Science, Bernal states that, “This requires the most serious thinking out of the whole problem of scientific communications, not only between scientists but also to the public.”[11] Bernal defines scientific communication as the popularization of science, which includes communication between doctors and patients. At this level, the curative effect is the most important factor. However, because of the different cultural backgrounds between China and the United States, and the existence of intercultural communication problems, communication between Chinese physicians and American patients should depend upon the standpoint of TCM when it comes to explaining the treatment methods and the curative effects.

The letters in The Science of Oriental Medicine shed light on the research into the early spread of TCM and showed that American patients were appreciative of and complimentary about TCM. Compiled by Tan Fuyuan, these letters reflected the patients' attitudes that were completely different from the comments on TCM by the US media at that time.

Furthermore, the patients' letters demonstrated that they had only a temporary “ideological” understanding of TCM, rather than a “theoretical” understanding. In other words, because of the clinical effect achieved by Tan Fuyuan, American patients began to understand some of the TCM health concepts that differ from those of Western medicine, including pulse diagnosis, use of herbal teas, daily dietary control, and gradual treatment processes. However, most patients had not been aware of the more complex concepts of TCM, such as yin and yang, five elements, zang-fu organs, and meridians.

Tan Fuyuan's communication strategy based on cultural differences accounted for the patients' understanding of TCM. At that time, with the development of Western science and technology and the birth of modern Western medicine, TCM could not be incorporated into the Western medical system. Tan Fuyuan noticed that Western medicine could not address some aspects of diseases, so he used the curative effect as his starting point to introduce TCM. As the Chinese culture and medical concepts had met strong exclusion in the Western countries, to spread TCM under the pressure of the Western culture, Tan Fuyuan had to adapt TCM to the Western needs, using Western medical knowledge while highlighting those characteristics of TCM that differed from Western medicine.

Tan Fuyuan's practice embodied some of the characteristics of the early intercultural communication about TCM, such as the emphasis on practical effect supplemented by conceptual guidance, though his work did not reach the level of “intercultural education.” The concept of intercultural education was first proposed by the United Nations Educational, Scientific and Cultural Organization (UNESCO) in 1992 and it was further elaborated in 2006 in the “UNESCO Guidelines for Intercultural Education.”[12] Compared with intercultural communication, intercultural education requires a more comprehensive and continuous educational process, and places greater emphasis on initiative and interaction. In fact, it can be observed that Tan Fuyuan has possessed an awareness of intercultural education from his plan to set up a school, but the results of putting this awareness into practice were not observed. Judging from the practice of TCM over the last 100 years, the development of external exchange in TCM from intercultural communication to intercultural education requires the efforts of several generations. Tan Fuyuan's efforts in promoting the prevalence of TCM in the United States have turned out to be a reference for the dissemination of TCM in the new era.


  Notes Top


Note 1: Although acupuncture in TCM was introduced into the United States earlier than herbal medicines in TCM, its application was still limited to a small number of people and did not have much development. After 1972, acupuncture began to develop in the United States. For details, please refer to the papers A Brief History of Acupuncture Journey to the West by Gary Kaplan (The Journal of Alternative and Complementary Medicine, 1997), and Current and Future Development of Chinese Acupuncture and Moxibustion in the USA by Liu Xinyan (World Chinese Medicine, 2017).

Note 2: According to Tan Fuyuan's book The Science of Oriental Medicine, the late Dr. Holmes was a well-known anatomist and professor at Harvard University. He was the author of Border Lines of Knowledge.

Note 3: Tan Fuyuan gave a detailed explanation of the function of spleen in TCM in Chapter Ⅲ of his book. Spleen belongs to the earth element of the five elements, and has two functions: Governing transportation and transformation and controlling blood. In Western medicine, spleen is a lymphatic organ and does not have the function of digestion. Modern researches believe that the function of spleen in TCM is similar to that of pancreas in Western medicine. The difference in the understanding of the spleen between TCM and Western medicine is largely related to the translation dislocation between the Term Pi in TCM and Spleen in Western Medicine. For details, please refer to The Occurrence and Evolution of the Translation Dislocation between the Term Pi in Traditional Chinese Medicine and Spleen in Western Medicine by Zhou Donghao (Studies on the History of Natural Sciences, 2019).

Funding

This study was financially supported by the Key Programme of National Social Science Fund of China (NO.18ZDA175).

Authors' contributions

Yu-Qing Qi put forward the concept and wrote the original draft. Hong Zheng undertook the task of supervision. Shan Liu collected data, reviewed and edited the manuscript.

Ethical approval

The authors have no ethical conflicts to disclose.

Conflicts of interest

None.



 
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