Bulletin of Clinical Acupuncture

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1 Bulletin of Clinical Acupuncture A Compendium of Clinical Methods Editor in Chief: Dr. Holmes Keikobad MBBS DPH Dip Ac NCCAOM L Ac Vol VII Issue 106 Summer 2011 Copyright acu-free.com LLC Free Online Edition Published by acufree.com INC Fog curls around the peaks of Mt Lu (Lushan) Jiangxi province, China Image Courtesy: User:Pfctdayelise The most read world wide, Illustrated Acupuncture Bulletin

2 TERMS OF USE This Bulletin can be studied only as a download from its home on the web page http://www.acu-free.com It is OK to download a copy to your computer for your own personal use.

2 2 TERMS OF USE This Bulletin can be studied only as a download from its home on the web page It is OK to download a copy to your computer for your own personal use. Making hard copies for distribution in any way without written permission violates Federal Copyright Laws creating a liability which could result in steep fines or worse. If you want a colleague to be informed of the publication of Issues on a regular basis, request them to send an to that effect to ceus@acu-free.com or for sporadic reading, simply have them access the web page It is NOT PERMITTED to excerpt material, part or whole, to teach, or acu-free.com include in INC. a course. All rights reserved If you wish to do so, send in a request to the ceus@acu-free.com and we will gladly consider it. We really go to great lengths to research and write expert discussions and get the Bulletin to you, free of any cost or encumbrance. You can help us incredibly by making certain the Terms of Use are respected. In every sense of the word, Acupuncture is everyone s heritage. This Bulletin continues to guard and expand that great wisdom. With best wishes Dr. Holmes Keikobad Editor in Chief

3 3 Dermatology & Acupuncture In practice there are some conditions, which if you are familiar with the signs, you can easily diagnose. And if you are not, these can mystify, and cause you to undergo a long process of history taking, and tracking down signs and symptoms. In Dermatology one goes largely by the signs on the skin. Some rashes are level with it, some raised, some raised with liquid within, some with frank pus. The shape, size, contour, color, distortion, in most cases, all contribute to a pathognomonic, trade-mark, profile. In this Issue we present some conditions of this nature and explain parameters by which one can begin to identify the condition, finally confirming it with your usual process of diagnosis. Editor s Note The discussions on Phlegm covered in two dedicated Issues, had to be discontinued because it seemed even 3 more Issues would not suffice. Because of that and in order to offer space for other topics the series are at the moment at a halt. All the matter in this Issue is under copyright acu-free.com LLC and no part of it is allowed for reproduction in any manner.

4 Dermatology & Acupuncture Dr. Holmes Keikobad MBBS DPH DIP AC NCCAOM Bachelor of Medicine & Surgery, Diplomate in Public Health Diplomate in Acupuncture, National Board Certified in Acupuncture In this discussion we will present 3 common manifestations of skin lesions so that their principal characteristics are identified. But first, some basics: Dermatological Classification of Skin Lesions This is regulated by the degree to which the rash is raised from skin, and if it is, what it contains. The following is a standard classification of skin rashes into 4 categories, this suffices for most everyday usage: acu-free.com INC. All rights reserved 1. If the rash is at the same level as the skin, it is a macular rash. 2. If the rash is raised above the level of the skin, but is solid and contains no liquid, it is a papular rash. 3. If the rash is raised above the level of the skin, but contains some colorless liquid, it is a vesicular rash. 4. If the rash is raised above the level of the skin, but contains pus, it is a pustular rash. The critical factor is the degree of the rise above skin level, and if raised, what does the lesion contain. Whenever you see a skin rash, first categorize it into one of the 4 forms. Note some times there is a combination, such as maculo-papular, vesiculo-pustular. This shows a transition of one firm into another as the clinical condition progresses or regresses. On next page please see diagrams which explain:

5 Diagrams to explain skin rash classifications Skin Lesion 1. Rash at same level as skin, it is a macular rash. acu-free.com INC. All rights reserved 2. Rash raised above level of skin, solid and contains no liquid, it is a papular rash. 3. Rash raised above level of skin, contains some liquid, it is a vesicular rash. 4. Rash is raised above level of the skin, contains pus, it is a pustular rash

SECTION OF SKIN Go over this image to recapitulate organs and structures in the skin: In general: When you see heat in the skin it is because the arteries are involved When you see itching in the

6 SECTION OF SKIN Go over this image to recapitulate organs and structures in the skin: In general: When you see heat in the skin it is because the arteries are involved When you see itching in the skin it is because sabaceous glands are involved When you see dryness in the skin it is because the sweat glands are involved When you see hair problems it is because the hair follicles are involved. Note that hair on the body is under control of Metal whereas hair on scalp is ruled by Kidney.

LYME DISEASE Very likely to be seen particularly in areas where it is endemic and population is prone to be in contact with source. Content Providers(s): CDC/ James Gathany.

7 LYME DISEASE Very likely to be seen particularly in areas where it is endemic and population is prone to be in contact with source. Content Providers(s): CDC/ James Gathany. Picture: CDC/PHIL Classification of rash: papular. Trade-mark erythematous bull s-eye rash at site of a tick bite, called erythema migrans, seen in about 80% of Lyme disease patients. Cause: bacterium Borrelia burgdorferi. Transmitted to humans by the bite of infected blacklegged ticks. Comments: if you see this in your practice, narrow down history [recent], exposure [camping trip, stroll in forest, animals]. Rule out skin allergies [past history]. Clinical picture: fever, pain and discomfort; see trade mark bulls eye configuration. Hot to touch when acute. Call local health department to find out if more cases reported. Possibly a reportable

Make sure to keep a magnifying glass and a pen type flashlight handy in the clinic: Image Courtesy: Hannah Garrison.

8 More images Lyme Disease In this image also the typical bull s eye form of the lesion is seen. Note that on closer examination the rash will be papular. Make sure to keep a magnifying glass and a pen type flashlight handy in the clinic: Image Courtesy: Hannah Garrison. Original uploader was Jongarrison at en.wikipedia In this image also the rash in central portion is clearly see to be papular. Compare that to the outer circle of redness which seems to be macular. Close-up of Lyme rash taken 6 days post bite demonstrating the classic red, raised borders. Image Courtesy: Just Some Guy at Wikipedia

entertained: FREE RESOURCES The Vermont Dept of Health offers this booklet [left] and the poster [image below] free of cost.

9 GEOGRAPHIC DISTRIBUTION OF LYME DISEASE This image shows worldwide endemic distribution. If you practice in these areas the possibility of a case with a typical bull s eye type rash being Lyme Disease should always be entertained: FREE RESOURCES The Vermont Dept of Health offers this booklet [left] and the poster [image below] free of cost. If you are in an area where ticks are endemic and would like to increase awareness in people you can access both publications at this link:

and chills. Cause: Bacterial Staphylococcal Infections. Classification of rash: macular. This is an infection and will have heatedness, pain and discomfort. Will be acute with a history of infection.

10 INFECTIVE CELLULITIS An infection: staphylococcal orbital cellulitis. Note the periorbital swelling and erythema, redness. The symptoms associated with cellulitis, which by the way can happen anywhere on the body, can evolve and worsen due to systemic bacterial migration via the bloodstream, and include fever, malaise, and chills. Cause: Bacterial Staphylococcal Infections. Classification of rash: macular. This is an infection and will have heatedness, pain and discomfort. Will be acute with a history of infection. Check fever. If there is raised temperature it may be cellulitis. Next narrow down history etc. If you can have a lab test done there will be leucocytosis, raised level of white blood cells. Here is another case. Note rash is still papular. In cellulitis there is a tell tale redness, and skin may be hot to touch. Pictures & text from CDC/PHIL.

SCABIES Image Courtesy: http://phil.cdc.gov/phil/details.

11 SCABIES Image Courtesy: Classification of rash: papulo-macular Cause: It is caused by a tiny and usually not directly visible parasite, the mite Sarcoptes scabiei, which burrows under the host's skin, causing intense allergic itching. Rash as a trade-mark: the characteristic symptoms of a scabies infection include intense itching and superficial burrows. The burrow tracks are often linear, to the point that a neat "line" of four or more closely-placed and equally-developed mosquito-like "bites," is almost diagnostic of the disease. Clinical picture: severe itching especially at night, signs of allergic reaction, but no significant fever Call local health department to find out if more cases reported. Possibly a reportable condition, if you see one let Dept of Infectious Diseases know. Usually there is a case from which this was contracted, ideal to find that out.

12 DISCUSSION So you will see that just a little knowledge about a certain type of rash gives you a great advantage in knowing what is going on inside the patient. Conditions we have discussed are in Traditional parlance, in the category of External Pathogen Invading. The manifestations can be grouped as Heat and Damp in an Excess Mode. Excess Qi begins at 1:00:01 AM past midnight, at point LU 9. Then it travels through the 12 channels during the 24 hours and completes the circuit at the same point at 12:00:00 midnight. In every sense this is a closed circuit, Full and Vibrant, but with no Excess, which is to say, it flows within itself in entire harmony. A picture of Harmony 1 Midnight 7 PM 7 AM 1 Midday However when an External Pathogen Invading enters the system, as in Lyme Disease, Bacteria or the Scabies mite, this factor takes up space within, and causes a space occupying lesion, an an Excess results, with its signs of pain, heat, swelling and reddish discoloration of skin. A picture of Excess 1 Midnight 7 PM 7 AM 1 Midday External Pathogen Invading

13 STRATEGY As a rule even when the patient does not complain, ask if the patient has some skin problems. Often the rash is hidden away under clothing, or the patient has come for a problem unrelated to it and may not think to mention it. A skin lesion is actually an outward manifestation of an inward malady. Narrowing down the rash type can help reach a systemic diagnosis. Granted that lesions from Lyme Disease, Cellulitis and Scabies are episodic and due to an external pathogen [a tick, bacteria or a mite], Psoriasis is an illness which is born of a dysfunction which involves Deficiency in Spleen, Lung, Kidney and Triple Warmer. DERMATOLOGICAL KIT Keep a steady supply of gloves handy and there is a rash work with it with due protection. A pen type flashlight is a must. Rashes are best examined in indirect daylight. But there are times when that is not feasible and the flashlight comes in handy. A simple magnifying glass is a great asset especially when dealing with Scabies, poison ivy and rashes from bedbugs, mosquitos and ticks. Keep a small digital camera and as a rule, with the patient s permission, take pictures and post these into your case files. TRADITIONAL APPROACH Skin is ruled by Metal. As a rule Metal is Dry and when in dysfunction, there will be excessive dryness. However when you see Heat [redness] and Fire [bleeding], there may be an intrusion by Element Fire. A pustule or pus formation denotes a Spleen dysfunction. When there is pus and as well redness, HT, SP and LU are involved. For skin problems which result from external invasion, use points like LI 4 and LI 11 to disperse Heat. For skin problems from internal dysfunction like Psoriasis use points from SP LU K and TW.

14 ANCIENTS Who were these great doctors who worked out concepts of Qi and its coursing in the body, the individual points with specific functions, the horary nature of its flux and ebb. Today we use points taking for granted the effects written in text books. But how did these get there? What kind of research and application spanning centuries got the information refined so we read it in this day and age? The image of serene mountain retreats in fog bound quiet comes to mind, where the great souls sit and fathom the meanderings of the life force. When the integrated mind housed in a complete self decides to do it, it can access a greater resolve within, a deeper basis of introspection, where it communicates solely with its own self. Perhaps this was what the great doctors did. And the result was the arrival of the concept of Qi. One of its finest marvels is its timeliness where it flows for exactly 24 hours, no more nor less. This is because the day and night encompass that span of time. Fog curls around the peaks of Mt Lu (Lushan) Jiangxi province, China Image Courtesy: User:Pfctdayelise If you reflect on the distribution of the 2 hour spans devoted to each channel, you begin to see the almost unlimited relationships each has with others. For instance, LV flows between 1 AM and 3 AM. At the exact opposite time SI flows between the same time in 1-3 PM. By the Midday Midnight Law if there is a problem in LV one could use SI to influence that. And even further, to do that one can use juxtapositioned points, using the Fire point on LV, LV 2, and the Wood point on Fire, SI 3. What movement to the needles? None, just insert lightly and wait for the Qi to balance out, for if it is Deficient in one of the pair, it can be so only if it is Excess in the other.

15 MYSTERIES OF THE HORARY CLOCK SJ 9-11 PM GB 11 PM - 1 AM LV 1-3 AM LU 3-5 AM P 7-9 PM K 5-7 PM LI 5-7 AM ST 7-9 AM UB 3-5 PM SI 1-3 PM HT 11 AM - 1 PM SP 9-11 AM Notice some more relationships: LU & LV are in an controlling - potentially oppressive relationship where LU, when in Disharmony, can overcome LV ST & LI are in a strengthened relationship as the Yang Ming Pair; if the system has to be toned now is the time ST & LI are in a strengthened relationship as the Tai Yang Pair; if the back and spine has to be toned this is the time There are many more critical bonds which can help in clinical work no end. All this the Ancients worked out when there were no clocks other than a water clock or a sundial. The 5 Shu points are another grid for influencing Qi. Set these up on the clock above and we have a sophisticated system of healing unparalleled. In most cases these doctors worked silently and left their treasures open to those who would follow. Wherefore if we have to thank them we can say no more than: Thank you, Nameless Ones.

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Bulletin of Clinical Acupuncture

Bulletin of Clinical Acupuncture A Compendium of Clinical Methods Chief Editor: Dr. Holmes Keikobad MBBS DPH Dip Ac NCCAOM L Ac Editor: Carol Andrade PhD LAC. Editor: Vera Kaikobad LAc Vol VII Issue 119