Today an initial patient visit highlighted the integration of Contemporary Chinese Pulse Diagnosis, Contemporary Oriental Medicine, Classical Chinese medicine and Classical pulse diagnosis.
The patient, a 66 year old female artist (retired mostly due to jealousy of her now deceased husband and fear), complains of severe left hip pain and osteoarthritis. The pain began 5 years ago after her husband's death, a long drawn out illness of Alzheimer's and complications, in which the patient was the primary caregiver. She is a former yoga instructor (not in many years) and is troubled that she can no longer move her body freely. She is overly controlled by her aggressive daughter, as she was by her first husband (divorced, then re-married) and her sister in childhood. Her pain is on the left Gall Bladder channel around GB 29-30. Pain is localized, but is also felt around the knee cap and lateral shin, mostly Stomach channel. In addition, she has lost muscle tone in her left thigh. The hip pain is worsened upon walking and putting pressure on the leg during a full stride. Balance and posture have been affected.
Patient experiences anxiety and some panic, and fear since the death of her husband. When stressed, she experiences occipital tension and loss of smell and appetite with some nausea and occasional vomiting.
Childhood history: corrective procedure for being tongue-tied; polio age 13 (miracle cure by local healer); sled accident and back injury age 15.
A few relevant findings on the pulse:
1. CCPD:
HT qi deficiency (changing intensity (3-3+), Interrupted pulse, Changing Intensity (2) over Uniform Impressions)
HT blood deficiency (increase rate on exertion 28)
Yin-Jing-Essence deficiency (Ropy)
LR qi stagnation (Tense Robust Pounding (3+ to 4))
LR blood stagnation (Choppy, engorged distally (2+) and ulnar engorgement)
GB qi and blood stagnation (Choppy Inflated)
SP deficiency/connective tissue weakness (Squirmy entire right side, especially middle)(see comments for description of Squirmy)
ST qi stagnation with heat (Tense Robust Pounding (3+ to 4))
Blood Thick
2. CCM pulse:
HT not expressing its Shen
LU not diffusing wei qi to the surface
BL/KI sinew meridian activity
BL/KI divergent meridian activity
ST luo vessel heat/stagnation
LR blood stagnation
Analysis and Integration:
Seeing the connections between these two pulse systems and diagnoses and how they each relate and explain the patient's symptoms and findings are interesting.
Arthritis in COM has much to do with the HT and its ability to control the circulation and dissemination of blood to the distal regions of the body. It is very common to see HT qi deficiency on the pulse with arthritis. HT blood deficiency is another very common characteristic. I have written on this in the past in my journal article with Chinese Medicine Times. You can find that article
here.
Arthritis in CCM is often the result of bi obstruction syndrome resulting from an invasion of wind-cold-dampness. Often the initial location affects the tai yang system. There are different interpretations on progression, the Su Wen detailing a longer history towards the formation of the bi syndrome (penetration from the head, to the throat, chest, abdomen, sacrum, Kidneys, triple burner mechanism to the Bladder shu points). The Divergent meridians are another theory on progression wherein the bodymind is unable to resist a pathogenic external invasion allowing for the yuan qi to come to the assistance of wei qi and translocate the pathogen to the interior (typically at the level of the joints). Resources are diverted to allow for this latency and over time are depleted resulting in more chronic degenerative conditions. Initially, the resource that is used up is yin-jing fluids at the level of the BL/KI. When taxed, the jing converts to blood at the second confluence (GB/LR), then to thin fluids-jin (ST/SP), then to thick fluids-ye (SI/HT), etc. So, looking at the BL/KI divergent meridian problem with degeneration, we are seeing a yin-jing-essence condition. This is also reflected in the Ropy pulse (CCPD).
So we can see the connection with the HT deficiency, Ropy pulse and the BL/KI divergent meridian activity. They reflect lack of resources and degeneration of structure.
One can look at the muscle pain that the patient experiences from a sinew meridian perspective as well. Pain with movement, particularly extension, relates to the tai yang sinew meridian of the leg. (Pain elicited by rotation would suggest shao yang (if seated shaoyin), pain with weight bearing, yang ming, etc.) When flaccidity is present with weakness it implicates a more chronic picture in which the pathogen has affected the yin internal pair, here the Kidneys. So yang and yin sinew meridians are involved in this case.
So, putting it together we see the location of the pain as relating to the GB channel at the hip (qi and blood stagnation on the pulse) and knee cap (yang ming) and lateral leg (GB and ST channels) with the nature of that pain being related to the tai yang leg sinew meridian (BL: BL sinew meridian pulse) and leg shao yin (due to it's chronicity). The chronic nature is demonstrated by the lack of muscle tone and weakness, a yin deficiency according to CCM creating lack of fluid volume and resources to nourish the muscles/connective tissue, etc. This is further evidenced by the Squirmy pulse (CCPD) reflecting the connective tissue weakness and SP involvement. The ST heat shows up from a luo vessel perspective from internal factors (lifestyle, diet, emotions). The ST luo vessel psychological make-up from a CCM pespective is a retreat from stimulation, weak lower limbs (can’t move to the places to provide you with the experiences you want); feeling of emptiness, no enthusiasm or animation. The 2nd trajectory of the ST luo vessel goes to the KI channel and deals with fear even to the point where the legs can paralyze (ie loss of tone). This is emptiness of the ST luo. The patient does show some of the major themes, especially of the second trajectory. Fear has been a major issue for her since her second husband died 5 years ago. This is the exact time frame that her pain started as well. The heat from the ST also contributes to the yin deficiency and lack of nourishment of the earth element which controls the 4 limbs and the connective tissue. This exacerbates the sinew meridian lack of tone. After all, wei qi has its origin not just in Du mai/Kidney yang, but also via ST yin (the pure nourishes the sensory orifices and the turbid the sinews and skin).
Emotionally, the anxiety and panic can be explained in COM as an imbalance of the HT and KI. Being tongue-tied at birth suggests HT as well.
The symptoms of occipital tension and loss of smell with stress and accompanied nausea/vomting can be seen as BL sinew meridian symptoms (occiput and nasal area) involvement with the LR/GB internal organ imbalances of qi and blood stagnation with rebellious qi into the vulnerable earth organs.
The polio can be seen potentially as the first major challenge to yuan qi weakening the taiyang and shaoyin conformations.
And of course, the initial trauma to the patient's back setting the stage for where the chronic degeneration would manifest.
What is significant in tying these systems of diagnostics together is the richness of the information that they provide. The depth at which one can understand a patient's complaints and experience of suffering only enhances one's options therapeutically. Understanding all of this from multiple paradigms also allows for increased treatment options and modalities and more specific as well as varied interventions. Using CCM, one's options in treatment are extended to the use of not just the primary meridians, but also the sinews, divergents and luo vessels. Each of these secondary channels has a greater affinity towards a specific level of imbalance and allows for a more targeted approach. Of course, this is not an in depth discussion of either system of CM, either in general or as it pertains to this case...
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