Siloam Scenario (Part 2 of 3)

 Morgan Wills writes…

Welcome back!  If you’ve had a chance to ponder our recent case, you may have made the following assessment:  This woman has multiple, scattered round, flat lesions of varying size on her right upper arm.  The color is a little difficult to appreciate in the context of her moderately dark skin, but appears to be a reddish purple, both homogenous and uniform, implying that they began at the same point in time.

Depending upon the time of onset, the differential diagnosis could include such possibilities as:

–          Mongolian spots (type of birthmark)

–          Hemangiomas (overgrowths of small blood vessels)

–          Eczema

–          Ecchymoses (medical speak for “bruising”)

–          And other complicated sounding problems such as phytophotodermatitis, erythema multiforme, and idiopathic thrombocytopenic purpura

At this point, the history can help to clarify the possibilities.  As Jina recounts, this woman was complaining of gradually progressive pain and numbness in her right arm, especially over the past four days.  The pain was primarily in her right wrist and forearm, with some numbness in her hands, and an aching feeling all the way up into the right shoulder at times.  She is a married mother of two and works a cleaning job in a nail salon, but adds, “I don’t do nails.”

The physical exam revealed some diffuse tenderness throughout the arm and positive Phalen’s and Tinel’s signs (reproducible numbness and tingling caused by compression of the median nerve at the wrist).   Clinical types out there will pick up on the likely diagnosis of carpal tunnel syndrome—a compression neuropathy of the median nerve. 

But what about the skin lesions?  Carpal tunnel syndrome does not explain them, but two pieces of the history do: the woman is unconcerned about the skin findings, and . . . she is Vietnamese.  Why would that make a difference?  Well, you see these lesions are actually bruises, and they are self-inflicted.

This phenomenon, known as cupping, is a common folk remedy in Southeast Asia.  The marks are caused by a lighting a match inside a cup or similar device to create a vacuum until the puckered skin surface is bruised.   A similar practice, called “coining,” involves rubbing a coin in heated oil up and down the skin until streaky bruises are created. [see photo of a previous Siloam patient below].  Both practices are performed to treat “wind illnesses,” ailments that result from lack of internal balance or harmony in a person’s life.

Fortunately, in this case Jina did not show alarm at the signs of cupping but was able to acknowledge the patient’s understanding of her own illness and also explain the nature of carpal tunnel syndrome as she understood it biomedically.  By building this bridge, Jina and the patient were able to establish trust and mutual understanding of how to relieve the pain through a splint and behavior change.  If and when the patient develops a more serious illness, the patient’s experience of such a collaborative relationship will be all the more important.

In our next installment, we will briefly explore the implications of this finding for the clinicians and health care professional students.  In the meantime, an excellent website to learn more about such practices—and other aspects of crosscultural health—can be found at www.ethnomed.org.

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