Integral Approaches to Patient Care

Will Morris

(Matrix Regulation, Pulse Diagnosis, Lymph Function, Endocrine Function, and Chinese Medicine)

Integration of eastern and western medicine can occur at many cultural strata from the socio-political environment of the public policy makers to various forms of institutional collaboration to the collaborative efforts between practitioners.  Beyond sociological forms of integration, synthesis can occur between physiological and pathophysiological models.  This paper examines integration at the clinical level through a synthesis of western pathophysiological and Chinese medical thinking.  To accomplish the synthesis there will be an exploration of the relationship between immunology, fluid metabolism, lymph drainage, endocrine function and Chinese medicine with attention to pulse diagnosis.

Pulse Diagnosis and the Interstices

The pulse diagnostic methods of Chinese medicine can provide some insight into processes that are shared with both western and eastern scientific thinking.  Pulse qualities that suggest collection of fluid in the interstices such as the ‘cotton’ pulse of the Shen-Hammer system  suggest impeded flow of wei and ying qi which, in turn, suggests poor local perfusion resulting in the production of interstitial fluid accumulation and diminished lymph return. Table 1 correlates TCM and western concepts and common pulse diagnostic findings.

Table 1: Pulse diagnostic findings common to TCM and western medicine

Following is an explanation of each of the pulses and the ways in which they can contribute to interstitial fluid accumulation and correspondingly poor lymph return.  These phenomena are considered by the author to be synonymous with the Chinese medicine pathogen ‘damp.’.

Cotton Pulse

The cotton pulse is sometimes mistakenly considered as ‘ruo mai’ or soft pulse.  Hammer describes it as a sensation of a thread floating on water. It is usually considered to be in the deep family of pulses however. Further the cotton pulse is the sensation of the interstitiium surrounding the vessel.  The process involves dampness, or interstitial fluid accumulation.

Weak Pulse

The weak pulse lacks force and is very soft, deep and thin.  It can only be felt in the deep level.  This can be indicative of low cardiac output and a likely low circulating blood volume resulting in poor perfusion and interstitial fluid accumulation known as ‘damp.’

Deep Pulse

The deep pulse is found only at the organ depth.  It can be compounded by deficiency patterns suggesting poor perfusion and accumulation of interstitial fluid.

Floating Pulse

The floating pulse occurs when there is a depletion of qi or when there is an external pathogen.  When due to deficiencies, yin and yang lose intimate contact.  The warming and moving functions of qi allow for local metabolic functions to become impaired with a corresponding collection of damp.

Slow Pulse

The slow pulse may often be associated with poor circulation and local perfusion, resulting in the accumulation of interstitial fluids.  A chief exception is in the case of highly efficient cardiac ejection fraction as with an athlete.

Changing Qualities

When the pulse changes qualities, there are two primary reasons. First is that the physiology and structure of the vascular system cannot express all the processes that are occurring in complex patterns of disharmony at once, so they happen over time. The other is that the qi is deficient and cannot maintain the shape of the vessels over time so that they change. In the latter situation, the qi is deficient such that damp easily accumulates.

Changing Rate at Rest and Arrhythmias

When the pulse rate changes at rest, this can be due to sinus node inefficiencies and cardiac conductivity inefficiencies. It can also occur due to rapidly changing humoral influences with respect to the psycho-neuro-endocrinological loop – this usually occurs concomitantly with labile emotional tonus. Under these circumstances, the local perfusion is impacted and damp can accumulate. The same is true for the arrhythmias.

Lymph as a Portal to Integral Medicine

It has been argued that the lymph return system has features common to the flow of the defensive qi (wei qi).1 If a patient presents with a ‘cotton’ pulse,2 then there is an accumulation of interstitial fluid occurring that is consistent with poor lymph return. Hammer describes this as a ‘sad’ pulse wherein people live lives of quiet desperation, however, this may not be the only reason for such a pulse. Other causes may include spleen qi or yang depletion leading to damp accumulation; other causes include impaired cardiac function or kidney yang depletion. From a western perspective, this scenario can be induced through sedentary behaviors or reduced metabolism related to an impaired pancreatic function or hypothyroidism.3

Pre 1983 versions of Guyton's Physiology4 describe lymph function in substantial detail, yet later editions of the book have much of the lymph conversation deleted – this was to the author’s chagrin; he continues to consider lymph a critical piece of a normal physiological state. There are specialists who call themselves ‘lymphologists.’ This specialty refers to tissues states such as 'dry' or ‘wet.’ When the state of the cell and interstitial spaces is ‘dry,’ it tends to be richly oxygenated/nutrified and therefore healthier and pain-free, and long lived, while the 'wet' state tends to fatigue, malaise and patters related to spleen qi depletion.  This all applies directly to the tonality and function of the cell was as well.  The premise is to bring tissue and cellular integrity back to the 'dry' state for health and longevity to ensue, herbally, this is accomplished through the use of medicinals such as bai zhu (Rhizoma Atractylodes alba) or fu ling (Poria cocos).  Increasing the blood proteins such as albumin can also enhance the movement of fluids through tissues and across cell membranes. This will improve the osmolarity of the tissues due to the increase of protein mass within the circulating serum.  

The issues of poor lymph return are rooted in lifestyle, especially exercise. However, depression and worry can overwork the spleen and cause dampness to accumulate as the pure yang qi of the spleen is depressed. If this state of affairs continues, the yang of the kidney and heart shao yin axis can be affected as the disease progresses towards a chronic debilitative and poorly compensated state.5

The ability of cells to communicate with each other through electrical conductivity and energy movement within and between the cells is moderated through the 'sodium-potassium pump' which is the most important part of the mineral electrolyte conduction system since it is the only one that is ubiquitous.  The inner cellular mineral electrolyte mix becomes more potassium dominant closer to the nucleus, whereas it is sodium dominant near the cell membrane. The cell membrane is where the sodium-potassium pumping mechanism resides. If the inner-cellular fluid matrix becomes loaded with sodium, the highly structured fluid state within the cell breaks down and degenerative disease sets in, especially cancer. This is due to impaired nucleus communication with the other parts of the cell as the intracellular matrix is less conductive.6 

Perfusion through tissues with oxygen requires a functional sodium/potassium pump and this requires that the tissue spaces be in a 'dry' state, and for the 'dry' state to occur their must be adequate perfusion with nutrient supply and adequate waste removal. Under these circumstances,  lymph congestion can lead to inflammatory compound buildup3 this is another route to a toxic physiological environment wherein many chronic a diffuse functional disorders may occur. This set of problems is addressed by using medicinals that are ‘aromatic’ and ‘dry damp’ such as those medicinals that contain the term ‘xiang’ or fragrance in the name like mu xiang (Radix Sausurrea) or tan xiang (Lignum Santali albi),  These are combined with medicinals that clear heat toxins such as lian qiao (Fructus Forsythia) and jin yin hua (Flos Lonicera). Perfusion and effective regulation of the intracellular matrix also requires activities that improve circulation and move energy include qi gung, breathing exercises, moderate cardiovascular exercise7 and clean drinking water. Moderate stair-step type exercise induces deep breathing and the muscle movement helps propel lymph through the body and back to the thoracic duct and back through the subclavian vein into the blood system.8

Overeating impairs circulation through the mesenteric tract and subsequently te whole body. Any undigested or food that is too slowly digested builds up metabolic toxins that get into the blood stream, cause the capillaries to dilate and flood the interstitial spaces with excess fluids and blood proteins, which tends to congest the lymph system.  This process will cause an accumulation of peptides within the blood stream and can be felt as a widening of the vessel and blood stream as one lifts the fingers from the organ depth through the blood depth and a subsequent narrowing of the vessel as one lifts further to the qi depth. Hammer calls this pulse ‘blood unclear.’

Toxic influences due to improper diet, environmental factors, drugs and chemicals have the effect of dilating blood capillaries and flooding the tissues with excess fluids and blood proteins that cause histamine reactions as well as a series of inflammatory cascades involving kinins, that lead to chronic health problems and degenerative conditions. The pulse that indicates that this process gets even wider when lifting through the blood depth it is wider than the ‘blood unclear’ pulse and and is called ‘blood heat.’ This situation tends to respond well when mu dan pi (Cortex Mutan radicis) is added to the formula.

Emotional stability is an important part of the equation, so much so that the primary pulse of this condition – the ‘cotton’ pulse – is also called the ‘sad pulse’ by Hammer.  Emotional stresses can cause a spillage of blood proteins and excess fluids into the interstitial spaces.  Here, aromatic open orifice herbs are helpful with respect to opening the mind. It is important to cultivate non attachment and a moderate response to life events for those who tend to overreact. This is easier said than done and meditation is a key to cultivating a moderated response to difficult life situations.

The Thyroid Part of the Equation
When discussing the chronic and diffuse functional maladies of a mature western culture, it is necessary to discuss endocrinological influences. Here we will focus on thyroid and in particular the hypothyroid since it predisposes towards a local accumulation of damp due to impaired metabolic function. In terms of pulse diagnosis, if there is a cotton pulse, it is necessary to rule out impaired thyroid function.

Basic Physiology, there are three levels of feedback for the thyroid:9

The function of the thyroid gland is to take iodine and convert it into thyroid hormones: thyroxine (T4) and triiodothyronine (T3). Thyroid cells are the only cells in the body which can absorb iodine. These cells combine iodine and the amino acid tyrosine to make T3 and T4. T3 and T4 are then released into the blood stream and are transported throughout the body where they control metabolism (conversion of oxygen and calories to energy). Every cell in the body depends upon thyroid hormones for regulation of their metabolism. The normal thyroid gland produces about 80% T4 and about 20% T3, however, T3 possesses about four times the hormone strength as T4.

       1. Hypothalamus:

          thyrotropin releasing hormone

          (TRH, thyroliberin, protirelin) <----------------

               |                                           \

               |                                           |

               v                                           |

       2. Anterior Pituitary basophilic thyrotropes: <-----  NEGATIVE

       thyrotropin                                         \ FEEDBACK

       ('thyroid stimulating hormone', TSH)                |

               |                                           |

               |                                           |

               v                                           |

       3. Thyroid: T3 -------------------------------------/

       (and the "prohormone" T4)

The tripeptide TRH is secreted from the hypothalamus and passes via the portal system to the anterior pituitary, where TSH synthesis and release are stimulated. Thyroid hormones here diminish TSH production through a negative feedback mechanism. The glycoprotein TSH then stimulates receptors on the thyroid gland that promote both:

1. Release of thyroid hormones (which then feed back to the pituitary);
2. Thyroid gland proliferation.

Pathophysiology

Primary hypothyroidism is an abnormally low activity of the thyroid gland with low circulating thyroid hormone levels caused by thyroid disease. Secondary hypothyroidism results from hypothalamic-pituitary disease. Primary hypothyroidism is caused by microsomal autoantibodies precipitated in the glandular tissue. Lymphoid infiltration of the thyroid may eventually lead to atrophy with abnormally low production of T4. Another clinical form starts out as Hashimotos thyroiditis, often with hyperthyroidism and goitre. Following atrophy caused by microsomal autoantibodies, the condition ends as hypothyroidism, or the patient is euthyroid. Because long-term low thyroid function causes poor circulation and reduces delivery of oxygen to tissue and cells, it creates a terrain or an intracellular matrix that is associated with heart disease and cancer as well as general malaise.

Symptoms of Hypothyroidism:

Symptoms of hypothyroidism may include the following: Low body temperature, dry skin/hair, (red hair is at particular risk for low thyroid), inappropriate weight gain and/or an inability to lose weight, brittle nails, insomnia and/or narcolepsy, poor short-term memory and concentration, fatigue, headaches and migraines, premenstrual syndrome and related problems, menstrual irregularities, depression, hair loss (including outer third of eyebrows), low motivation and ambition, cold hands and feet, fluid retention, dizziness or lightheadedness, irritability, easy bruising, skin problems/infections/acne, infertility, dry eyes/blurred vision, heat and/or cold intolerance, low blood pressure, elevated cholesterol, digestive problems (irritable bowel syndrome, acid indigestion, constipation, etc.), poor coordination, diminished sex drive, reduced or excessive sweating, frequent colds/sore throats, asthma/allergies, slow healing, itchiness, food cravings, recurrent infections, food intolerances, increased susceptibility to substance abuse, anxiety/panic attacks, yellow-orange coloration on skin (particularly palms), yellow bumps on eyelids, slow speech, thickened tongue with scallop-like indentations and fluid in the ears.

Clinical Diagnosis of Hypothyroid Conditions

A clinical test for iodine deficiency given by Jonathon Wright, MD is to paint a quarter size dot of iodine (atomidine, a organic form of iodine develped by an Indian chemist and sold by the Heritage store) on the inner thigh at bedtime. If the patient is iodine deficient, the dot will mostly disappear overnight, and if not it will remain. If it disappears, continue to apply the iodine each night until it stops being absorbed, then stop. This test can be repeated in 3-4 weeks to determine iodine status.

The ‘cotton’ pulse is the most common pulse finding in hypothyroid conditions. The rate is often not slow because of complex factors that can create heat such as ‘hidden pathogens,’ liver depression qi stagnation, chemical exposures, tobacco consumption or damage by food and drink.  Jim Ramholz discusses a pulse position for exmining the thyroid which is at the second depth of five depths related to fire between the middle and distal positions.

The most common non-laboratory method for monitoring thyroid is basal body temperatures. Low body temperature seems to underlie many of the symptoms. Broda Barnes, MD, did the first studies correlating hypothyroidism to low body temperature. He found that having the patient take the axillary temperature for several mornings before getting out of bed could help document the trend correlating with the symptoms.10 An axillary temperature of <97.6 degrees F. indicated a hypothyroid state even when the blood tests did not show irregularities. Treating the patient with thyroid hormone seemed to relieve him/her of the often debilitating state. I would caution you on concluding that a low body temperature is only caused by hypothyroidism. See the Basal Body Temperature webpage for the proper technique and for other causes.

Thyroid function tests - an overview

The measurement of serum thyroid hormones, T4 by RIA (radioimmunoassay) is the most used commonly used thyroid lab test. It is frequently referred to as a T7 which means that a resin T3 uptake (RT3u) has been done to correct for certain medications such as birth control pills, other hormones, seizure medication, cardiac drugs, or even aspirin that may alter the routine T4 test. The T4 reflects the amount of thyroxine in the blood. If the patient does not take any type of thyroid medication, this test is usually a good measure of thyroid function.

Thyroxine (T4) represents 80% of the thyroid hormone produced by the normal gland and generally represents the overall function of the gland. The other 20% is triiodothyronine measured as T3 by RIA. Sometimes the diseased thyroid gland will start producing very high levels of T3 but still produce normal levels of T4. Therefore measurement of both hormones provides an even more accurate evaluation of thyroid function.

Most of the thyroid hormones in the blood are attached to a protein called thyroid binding globulin (TBG). If there is an excess or deficiency of this protein it alters the T4 or T3 measurement but does not affect the action of the hormone. If a patient appears to have normal thyroid function, but an unexplained high or low T4, or T3, it may be due to an increase or decrease of TBG. Direct measurement of TBG can be done and will explain the abnormal value. Excess TBG or low levels of TBG are found in some families as an hereditary trait. It causes no problem except falsely elevating or lowering the T4 level. These people are frequently misdiagnosed as being hyperthyroid or hypothyroid, but they have no thyroid problem and need no treatment.

Pituitary production of TSH is measured by a method referred to as IRMA (immunoradiometric assay). Normally, low levels (less than 5 units) of TSH are sufficient to keep the normal thyroid gland functioning properly. When the thyroid gland becomes inefficient such as in early hypothyroidism, the TSH becomes elevated even though the T4 and T3 may still be within the "normal" range. This rise in TSH represents the pituitary gland's response to a drop in circulating thyroid hormone; it is usually the first indication of thyroid gland failure. Since TSH is normally low when the thyroid gland is functioning properly, the failure of TSH to rise when circulating thyroid hormones are low is an indication of impaired pituitary function. The new "sensitive" TSH test will show very low levels of TSH when the thyroid is overactive (as a normal response of the pituitary to try to decrease thyroid stimulation). Interpretations of the TSH level depends upon the level of thyroid hormone; therefore, the TSH is usually used in combination with other thyroid tests such as the T4 RIA and T3 RIA.

In normal people TSH secretion from the pituitary can be increased by giving a shot containing TSH Releasing Hormone (TRH...the hormone released by the hypothalamus which tells the pituitary to produce TSH). A baseline TSH of 5 or less usually goes up to 10-20 after giving an injection of TRH. Patients with too much thyroid hormone (thyroxine or triiodothyronine) will not show a rise in TSH when given TRH. This "TRH test" is presently the most sensitive test in detecting early hyperthyroidism. Patients who show too much response to TRH (TSH rises greater than 40) may be hypothyroid. This test is also used in cancer patients who are taking thyroid replacement to see if they are on sufficient medication. It is sometimes used to measure if the pituitary gland is functioning. The new "sensitive" TSH test (above) has eliminated the necessity of performing a TRH test in most clinical situations.

Thyroid Therapeutics

Thyroid conditions may be managed along a continuum of progressively more intensive therapeutics. This is approached initially from a dietary perspective then progressively more intensive therapies including herbal medicinals then moving into glandular thyroid materials and then mineral supplements. The next level would be glandular pharmaceuticals such as Armour® and then moving toward synthetic materials such as Synthroid.®

Lifestyle  impact on thyroid function

The hypothyroid patient also needs to pay particular attention to diet. The thyroid can be weakened by eating large amounts of foods in the Brassicaceae Family such as broccoli, cabbage, cauliflower, kale,  rutabaga,  turnips and brussel sprouts, especially if consumed raw.  The reason is that they contain thiouracils which can block iodine uptake.11 Other foods to avoid, though not in the same family are millet, peanuts, pine nuts and soybeans. The thyroid gland becomes damaged by the excessive consumption of caffeine, sugar and refined carbohydrates, all of which stimulate pituitary activity, and impact the entire endocrinolgical system through the pancreas and corresponding neurological events related to blood sugar phenomena. Alcohol and stress can impair thyroid function (in part from ACTH). Most pesticides are similar to thyroid hormone (both have 2 benzene rings…) and therefore can block the effect of T3. Excess cadmium or lithium are also thyroid inhibitors. Fluoride which is in most drinking waters is a known thyroid inhibitor. 12, 13

Foods that benefit the thyroid gland  include cod roe,  dulse, hiziki, kelp, egg yolks,   lecithin, goat's milk,  mushrooms, Swiss chard, tahini and wheat germ. Juices should always be diluted 50%  with water and might include carrot, celery and clam. Molasses, egg yolks, parsley, apricots, dates, prunes, fish, chicken and raw milk and cheeses can supply nutrients necessary for proper thyroid function. If iodine is deficient, the thyroid gland tends to swell and blood vessels get hardened. The Japanese, known for their diet high in seafoods and sea vegetables, both rich sources of iodine rarely have goiter.  Most land bases foods only contain trace amounts of iodine. The sea vegetables, constantly bathed in the rich brine of the ocean have a softening, sinking effect that helps to clear both thyroid and liver stagnation.

Herbal formulas that are often used for hypothyroidism include bu zhong yi qi tang, li zhong tang, dang gui shao yao san, dang gui sini jia wuzhuyu shengjiang tang and zhen wu tang These are all prescriptions that boost either qi or yang of the middle burner, some nourish and regulate the blood. Professor Shigeru Ariji at the Institute of Oriental Medicine of Kinki University reported15 on a case of myxedema. Treatment consisted of zhen wu tang extracts (10 grams/day), and bu zhong yi qi tang extracts (10 grams/day), corresponding roughly to a decoction of the two formulas with a dosage of 90 grams/day. Within two weeks there was alleviation of subjective symptoms, and substantial improvement in objective symptoms within three months. She was able to resume normal lifestyle within six months.16

Pharmaceutical Interventions     

The common pharmaceutical approach is to use levothyroxine which is a synthetic preparation of T4 (Synthroid®/Levoxyl®/Levothroid®). Desiccated pork thyroid (Armour®, Westhroid®, Naturethroid®) is a natural mixture of mono and di-iodothryonine and T3 and T4 that provides the entire range of thyroid hormones. Thyrolar® is mixture of synthetic T4 and synthetic T3. Cytomel® is a synthetic T3 only product that is also available.

If the free T3 level is significantly lower than the free T4 level, then Synthroid/ Levoxyl/Levothroid (T4) may not be effective replacements. Cytomel®, a T3-only product, and can be used alone or in combination with a T4-only preparations. Because T3 has a short activity (or "half life"), it needs to be used twice a day. E. Denis Wilson, MD, in his book Wilson's Syndrome,14 found that many of patients respond best to T3-only (liothryonine). He believes there is a difference between thyroid gland dysfunction and thyroid system dysfunction. At the present time, no tests can test the cellular function. Therefore, he often diagnoses hypothyroidism by observing the patient's symptoms or one can use the BBT test. Often T3 (liothryonine) therapy will alleviate or eliminate many symptoms even those previously attributed to other causes. Dr. Wilson used T3-only because T3 is 4-9 times as active as T4. 14 Over-dosage symptoms, which are frequently only temporary during the adaptation stage. The symptoms may include: palpitations, nervousness, feeling hot and sweaty, rapid weight-loss, fine tremor, and clammy skin. One of the long-term results of excessive thyroid activity is osteoporosis and a tendency to stress the adrenal glands.

Summary and Closure

Diffuse complex clinical scenarios often involve several systems and the multifactorial events of life, the functional disorders that result from this set of circumstances often occur subclinically. However, Chinese medicine has a great deal to offer for this range of maladies. Impaired fluid metabolism, endocrinological concerns and poor lymph return often present with the ‘cotton’ pulse that demonstrates a stagnation of ‘wei qi’ or interstitial fluid and lymph. When this occurs, it is important to explore thyroid function. Here, we are considering the fluid metabolism lymph return and the impact of thyroid function on metabolic capacity to supply nutrients. When the lymph and metabolic function are slower than necessary, then the extra cellular and interstitial matrices are congested with fluid and toxins. This scenario predisposes a significant range of complex clinical scenarios that are both replete and delete, hot and cold, but in this case the cold is due to the metabolic insufficiency of thyroid deficiency or – yang depletion.

In closing, the malaise and fatigued state of the walking wounded are often bound with clinical scenarios involving hypothyroidism, depression, and a ‘wet’ cellular state. These conditions have clear diagnoses in Chinese medicine when they remain undiagnosed do to the subclinical nature of the disorders from a western medical perspective. There are tremendous advantages with respect to the TCM approach to these concerns. Lastly – the crossover in terms of the related pathophysiology for these conditions makes for fertile ground as a model of integration at the biological level.

References

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4. Guyton AC. Human physiology and mechanisms of disease. 3rd ed. Philadelphia: Saunders; 1982.

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9. Wiig H, Lund T. Relationship between interstitial fluid volume and pressure (compliance) in hypothyroid rats. Am J Physiol Heart Circ Physiol. September 1, 2001 2001;281(3):H1085-1092.

10. Barnes BO, Galton L. Hypothyroidism: the unsuspected illness. New York: Crowell; 1976.

11. Bächtold H. Die Beeinflussung des experimentellen Hochdrucks an der Ratte durch Methylthiouracil, Jod und Thyroxin. Basel; 1950.

12. Stoews G. Bioactive organosulfur phytochemicals in Brassica oleracea vegetables--a review. Food Chem Toxicol. Jun 1995;33(6):537-543.

13. Gaitan E CR, Legan J, Lindsay RH, Ingbar SH, Medeiros-Neto G. Antithyroid effects in vivo and in vitro of babassu and mandioca: a staple food in goiter areas of Brazil. Eur J Endocrinol. Aug 1994;131(2):138-144.

14.  Wilson ED, MD. Wilson’s Syndrome: The Miracle of Feeling Well. 1991.

15.  Hsu H-y. Applications of Chinese herb formulas and scientific research: Ginseng and Astragalus Combination. International Journal of Oriental Medicine. 1991;16(3).

16. Dharmananda S. Treatmenrs For Thyroid Disease With Chinese Herbal Medicine. 2004.