Springing Forward: Unique Applications of the Four Gates
Craig Williams, LAc, AHG
"When faced with something exasperating, one should calmly consider which is more important, anger or health. This comparison will enable one to gradually eliminate one's anger." — Cao Tong, Common Sayings of Gerontology (Qing Dynasty)
As a practitioner / teacher of qi gong and an acupuncturist, I tend to color my clinical perspective with the palette of the changing seasons. Each season has a unique personality and a unique effect upon the mind / body of the patient.
The spring season is associated with the liver organ / meridian, and during this season I discuss with patients the importance of examining areas of stagnation in their lives. Often as the winter season ends and the spring season unfolds, it is not uncommon for patients to experience health challenges rooted in issues related to liver qi stagnation (which I discussed in the context of herbal medicine in my April column).
As we move into the spring season and the corresponding connection to the liver, let's examine a specific modification of the classic acupuncture point combination "Four Gates" and its application in a case of chronic nose bleeding with concomitant hypertension.
The Clinical Case
The patient was a 53-year-old female who began experiencing unexplained nose bleeds coupled with hypertension occurring once a week for two months. Nose bleeds would occur during periods of extreme work stress and were associated with transient episodes of hypertension lasting 24 hours.
The patient visited the ER during one such episode, presenting with nosebleed with clots and blood pressure of 210/190, which phased to 135/79 after one hour. After examination, the ER offered no diagnosis and suggested the patient visit her primary care physician, who found no troubling signs. Upon examination, the patient's blood pressure was 118/75.
The patient consistently experienced similar nosebleeds with episodic hypertension lasting 12 to 24 hours during periods of high work stress. At this point, the patient sought acupuncture treatment. Upon examination, the patient presented with no particularly concerning signs; blood pressure was 118/75, tongue was a healthy red color with no cracks or toothmarks, and pulse was slow / slippery. The only symptoms the patient offered as complaints were occasional constipation and extreme frustration with her work environment.
The patient noted that issues with nosebleeds were always initiated by times of extreme anger and frustration that "seemed to clear after the bleeding stopped, almost like a pressure valve was released."
Modifying the Four Gates
This unique expression of emotional release post-nosebleed and occasional constipation suggested underlying liver depression; therefore, I chose the following modification of the classic Four Gates: LI 3 + LI 4 + Liv 2 + Liv 3. The actions of LI 4 and Liv 3 are well known among acupuncturists; however, adding LI 3 and Liv 2 is not as commonly known. LI 3 has the actions of expelling wind and heat, benefits the throat / head / teeth, and dispels fullness. I find the combination of LI 3 and LI4 to be more effective in resolving constipation than LI 4 alone.
Liv 2 has the actions of clearing liver fire, spreading liver qi, calming liver wind, clearing heat, stopping bleeding, and benefiting the lower jiao. The combination of Liv 2 and Liv 3 strongly helps to stop bleeding that may associated with underlying liver depression with concomitant depressive heat – more effectively than Liv 3 alone. Liv 2 was also uniquely chosen as it both stops bleeding and calms the emotions, which works nicely with the traditional Four Gates so often used for emotional issues.
Outcome / Clinical Pearls
After one treatment of the modified four gates point prescription, the patient's weekly nosebleed was completely resolved. After another follow-up session with no changes in tongue or pulse, the same point prescription was chosen again. After two sessions, the nosebleed remained resolved and the patient stated that bowel movements were more regular and that she was "able to see how her anger was not productive."
After three sessions of the modified acupuncture protocol, all initial presenting complaints were resolved. At this point, I taught the patient a qi gong protocol to help assure that any underlying issues of liver depression would clear during the spring season.
I found this simple case worthwhile for sharing as it shows how simple modifications of traditional point protocols can be highly effective; and how underlying root imbalances can cause a diverse array of sometimes-confusing symptoms.
When in doubt, listen to the clues the patient is revealing. The words of the patient are just as important as the tongue and pulse. In the words of William Osler: "Listen to your patient. He / She is telling you the diagnosis."
As modern medical standardization continues, the field of traditional Chinese medicine has the advantage of comprehensive personalization. For rare or complex cases, deeper consideration of constitution is invaluable. Proper constitutional assessment, especially with first-time clients, can guide desirable and predictable outcomes. This leads to a higher rate of return, and greater trust between you and your patient.
Though the creation of a financially sustainable, health-promoting model feels far away today, we are casting a vision for a full return on health, believing that this compels us to keep one foot firmly rooted in caring for the sick and the other foot firmly founded in maintaining health. Shifting from a fee-for-service model to value-based care using a phased approach is paramount.
Laser therapy has emerged as a powerful tool in the realm of traditional Chinese medicine (TCM). This new modality fits beautifully into the toolbox of the modern acupuncturist, as it can be used as a hybrid form of stimulation to acupuncture points, meridians, organs, nerves, and symptomatic areas in a new way that blends both moxa and energetic needle-like responses.
