Record
of Herbal Treatment Of Jonas from Hungary Improvement Of
MS
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Brief Summary:
On Nov. 20,2007, Janos, a MS
patient from Hungary, who suffered from diplopia repeatedly and
weakness of both lower limbs along with unsteady walking, was
hospitalized in our hospital. He has achieved great improvement
after about one-month TCM treatment.
Record of
Hospitalization
Name: Janos
Sex: Male
Age:
40 Profession:Chauffeur
Nationality:
Hungary Marital
status: Divorced
Onset Season:
Summer Date of
Admission: Nov. 20,2007
Complainer: The patient¡¯s
himself Reliability: Reliable
Major Complaint:
The
patient has suffered from diplopia repeatedly for 14 years, and
the condition has been aggravated by weakness of the double
lower limbs along with walking unsteadily for 5 years.
Present Illness:
In Nov. 1994, the patient suddenly suffered from diplopia, and
then he went to a local hospital for a diagnosis. After the MRI
examination, he was diagnosed with MS. He didn¡¯t take any
treatment. Later, his eyesight recovered. After his diplopia
disappeared, he was attacked by the same symptoms repeatedly,
sometimes serious sometimes light. In Nov. 2002, the patient
began to suffer from the weakness of the double lower limbs with
unsteady walking. He could only walk with the support of the
crutches, but he still took no treatment. In Mar. 2004, he began
to take the injection of Interferon
for once a month up to now. To seek for further
treatment, he arrived at our hospital on Dec. 20,
2007. Since he got the disease, his spirit and appetite were
both normal. His sleep was sound. His bowel movement and
urination were both normal.
Disease History:
he has been healthy all the time. No history of typhoid,
tuberculosis, hepatitis, malaria or other infectious diseases.
No allergic history of food or medicine. No history of blood
transfusion. No history of preventive vaccination. In July 1998,
his Right
elbow suffered from traumatic fracture, and cured after the
surgery of internal fixation. The next year, he took another
surgery for the extraction of internal fixation. In 2003, his left elbow suffered
from traumatic fracture and received the surgery of internal
fixation. Then in the next year, he was cured after taking
another surgery for the extraction of internal fixation.
Personal History:
He was born in Hungary, living in a dry environment. No contact
history of schistosomiasis. No addiction to smoking or alcohol.
He was mild-tempered and open-minded.
Marital History:
He got
married at the age of 23. Now, he has a daughter and a son. Both
of them are healthy.
Family History:
His aunt
suffered from MS. Now she is under the treatment. No other
family history of inherited disease.
Physical
Examination:
T 36.1¡æ£¬P
80 beats/minute, R 20 times/minute, BP 110/70mmHg.
He grew normally
with common nourishment. His mind was clear. His body was in a
positive posture and he was cooperative in examination. His skin
was moist. No jaundice in the sclera. No superficial lymph-node
enlargement. Bilateral pupils were round and equal in size and
sensitive to light. No deformity of
skull and the five sense organs.
No congestion
in throat.
No enlargement of his tonsils. With soft neck and
trachea placed in the middle. No enlargement
of the thyroid gland. No turgor in jugular vein.
No thoracic
deformity. Sound of breath was bilaterally normal on
auscultation. No respiratory rales or pleural friction rubs. No
apophysis of the precordial region. Heart border was normal.
Heart beat was 80 times/minute. Cardiac rhythm was regular. No
pathological murmurs on
auscultation. Abdomen touched flat and soft without tenderness
or rebounding tenderness. The liver and spleen were not
palpable. No percussion pains in renal region. Bowel sound was
normal. No spinal and pelvic deformity. No deformity or
inflexibility of his upper limbs. His lower limbs suffered from
weakness with unsteady walking. His walking was supported by the
crutches. . The muscle strength of lower limbs was Grade
¢ó
with normal muscle tension. His eyesight declined with diplopia
when looking at something. He didn¡¯t take the examinations of
the anus and pudendum. Other physiological reflex exists. Other
pathological symptoms have not been elicited. His tongue was
dark with thin and white tongue coating. His pulse was vacuous
and string-like.
Diagnostic
examination: Not provided.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification: Deficiency of the liver and kidneys, accompanied
with malnutrition of sinews and vessels.
Western medicine
diagnosis: Multiple sclerosis (MS)
First Medical
Record
Nov. 20,
2007
Janos, a
40-year-old male, has suffered from diplopia repeatedly for 14
years, and the condition has been aggravated by weakness of the
double lower limbs along with walking unsteadily for 5 years. He
was picked up by our staff at Zhijiang Airport and arrived in
Huaihua Red Cross Hospital for further treatment at 20:00 p.m.
on Nov. 20,2007.
Essentials for
Diagnosis:
1. The patient has
suffered from diplopia repeatedly for 14 years, and the
condition has been aggravated by weakness of the double lower
limbs along with walking unsteadily for 5 years.
2. In Nov. 1994,
the patient suddenly suffered from diplopia, and then he went to
a local hospital for a diagnosis. After the MRI examination, he
was diagnosed with MS. He didn¡¯t take any treatment. Later, his
eyesight recovered. After his diplopia dised, he was attacked by
the same symptoms repeatedly, sometimes serious sometimes light.
In Nov. 2002, the patient began to have the weakness of the
double lower limbs with unsteady walking. He could only walk
with the support of the crutches, but he still took no
treatment. In Mar. 2004, he began to take the injection of Interferon
for once a month up to now. To seek for further
treatment, he arrived at our hospital on Dec. 20,
2007. Since he got the disease, his spirit and appetite were
both normal. His sleep was sound. His bowel movement and
urination were both normal.
3. T 36.1¡æ£¬P
80 beats/minute, R 20 times/minute, BP 110/70mmHg.
4. He grew normally
with common nourishment. His mind was clear. His body was in a
positive posture and he was cooperative in examination.
5. No thoracic
deformity. Chest percussion noted resonance. Sound of breath is
bilaterally clear on auscultation. No sound of pleural friction.
6. Diagnostic
examination: In June 1999, after the examination of MRI, he was
diagnosed with MS in a capital hospital of his own country.
7. Diagnostic
examination: Not provided
Diagnostic Basis:
TCM: The patient
has suffered from diplopia repeatedly for 14 years, and the
condition has been aggravated by weakness of the double lower
limbs along with walking unsteadily for 5 years. It belongs to
vacuity of liver-kidneys, so the blood-essence could not nourish
the sinews and vessels. Since the lumber is the house of kidneys
and the kidneys are in charge of the bones, lack of the essence
results in limp aching lumbus and knees and weakness of the
lower limbs. While deficiency of the blood essence could not
nourish the eyes, so he could not see objects clearly with
diplopia. His tongue was dark with thin and white tongue
coating. His pulse was vacuous and string-like. All the symptoms
belong to the scope of wilting syndrome.
Western medicine:
The patient has suffered from diplopia repeatedly for 14 years,
and the condition has been aggravated by weakness of the double
lower limbs along with walking unsteadily for 5 years. His
eyesight declined with diplopia when looking at something.
His lower limbs suffered from weakness with unsteady walking. He was able
to walk with the support of the crutches. In 1994, he was
diagnosed with MS after the MRI examination in a local hospital.
Diagnostic
Differentiation:
TCM: The patient¡¯s
wilting syndrome should be differentiated from impediment
syndrome. Wilting syndrome is characterized by limp, weak, and
emaciated limbs with muscular atrophy. A patient suffered from
Wei-syndrome seriously may even become unable to hold an object
or to stand without any support. Besides, the patient¡¯s lower
limbs are more often affected, though he or she usually has no
joint pains. On the contrary, impediment syndrome is generally
characterized by aching pains, fixed heaviness and inflexibility
of sinews and bones, muscles and joints, with occasional
numbness or swelling, though, no paralytic manifestations. They
are not difficult to be distinguished in clinics.
Western medicine:
Wilting syndrome should be differentiated from CNS virus
infection.
CNS virus
infection is
always characterized as cephalitis or meningitis. However, it
seldom involves brainstem,
cerebellum, spinal cord and optic nerve. The patient got the
disease rapidly always with the symptoms of headache, fever,
coma, convulsions and meningeal irritation.
First Diagnosis:
TCM diagnosis:
Wilting syndrome
Symptom
identification: Deficiency of the liver and kidneys, accompanied
with malnutrition of views and vessels
Western medicine
diagnosis: MS
Plans for treatment
strategy and nursing:
1. Routine care of
traditional Chinese internal medicine
2. Grade II care.
3. Under the care
of a companion.
4. Regular diet.
5. Herbal tea (to
supplement and boost the liver and kidneys, sooth the sinews and
free the channels): one dosage a day and drink twice.
Main herbs in three
dosages of the herbal tea: gouqi (lycium), shudi (cooked
rehmannia root), zaopi (cornus fruit), etc.
6. Acupuncture and
massage: once a day.
7. Have more
medical examinations if necessary.
Date: Nov. 21,2007 Time: 9:30 a.m.
Today the patient
complained to Dr. Yang that he could not see objects clearly
with diplopia, accompanied with weakness of his lower limbs and
unsteady walking. The examination of the blood and urination
were both normal. The examination of the function of his liver
and kidneys were also normal.
Examination: T 36.1¡æ£¬P
80 beats/minute, R 20 times/minute, BP 110/70mmHg.
His heart and lungs
were normal, and his abdomen was soft and flat.
Doctor Yang¡¯s
analysis:
1. The patient has
suffered from diplopia repeatedly for 14 years, and the
condition has been aggravated by weakness of the double lower
limbs along with walking unsteadily for 5 years.
2. His eyesight
declined with diplopia when watching something.
His lower limbs suffered from weakness with unsteady walking, and he could
only walk with the support of the crutches.
3. In 1994, after
the examination of MRI, he was diagnosed with MS in a local
hospital.
According to the
above information, TCM considered it as Wei-syndrome (Flaccidity
syndrome). It is due to vacuity of liver-kidneys, so the
blood-essence could not nourish the sinews and vessels. Since
the lumber is the house of kidneys and the kidneys are in charge
of the bones, lack of the essence results in limp aching lumbus
and knees and weakness of the lower limbs. While deficiency of
the blood essence could not nourish the eyes, so he could not
see objects clearly with diplopia. His tongue was dark with thin
and white tongue coating. His pulse was vacuous and weak. Doc.
Yang analyzed that it belonged to deficiency of the liver and
kidneys, which resulted in malnutrition of sinews and vessels.
Principle of TCM
treatment:supplementing and boosting the liver and
kidneys, soothing the sinews and quickening the channels.
Herbal tea
prescribed for three days including gouqi (lycium), shudi
(cooked rehmannia root), zaopi (cornus fruit), etc. One dosage a
day and drink twice.
Doctor¡¯s
requirement is to take three dosages of the herbal tea of the
above prescription. Acupuncture and massage for once a day. The
patient will have more medical examinations if necessary.
Date: Nov. 22,2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still said that
he had diplopia when watching some objects, accompanied with
weakness of his lower limbs and unsteady walking. His heart and lungs
were normal, and his abdomen was soft and flat. He kept normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was dark
with thin and white tongue coating. His pulse was vacuous and
string-like. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: Nov. 23,2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still said that
he had diplopia when watching some objects, accompanied with
weakness of his lower limbs and unsteady walking. His heart and lungs
were normal, and his abdomen was soft and flat. He kept normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was dark
with thin and white tongue coating. His pulse was vacuous and
string-like. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: Nov. 28,2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort and still said that
he had diplopia when watching some objects, accompanied with
weakness of his lower limbs and unsteady walking. His heart and lungs
were normal, and his abdomen was soft and flat. He kept normal
spirit, appetite and sleep. His bowel movement and urination
were both normal. His tongue was dark
with thin and white tongue coating. His pulse was vacuous and
string-like. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: Dec. 3,2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort. He said that his
diplopia disappeared, and the weakness of his lower limbs
improved significantly and his unsteady walking also got better.
His heart and
lungs were normal, and his abdomen was soft and flat. His spirit
and appetite were both normal, and his sleep was sound. His
bowel movement and urination were both normal. His tongue was red
with thin and white tongue coating. His pulse was vacuous and
string-like. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: Dec. 8,2007 Time: 9:00 a.m.
The patient did not
complain about any other special discomfort. He said that his
diplopia disappeared, and the weakness of his lower limbs
improved significantly and his unsteady walking also achieved
obvious improvement. His heart and lungs
were normal, and his abdomen was soft and flat. His spirit and
appetite were both good, and his sleep was sound. His bowel
movement and urination were both normal. His tongue was red
with thin and white tongue coating. His pulse was vacuous and
string-like. Doctor¡¯s requirement is that the herbal tea should
follow the original formula.
Date: Dec. 13,2007 Time: 9:00 a.m.
The patient did not complain about any other special discomfort.
He said that his diplopia disappeared, and the weakness of his
lower limbs improved significantly and his unsteady walking also
achieved obvious improvement. His heart and lungs were normal,
and his abdomen was soft and flat. His spirit and appetite were
both good, and his sleep was sound. His bowel movement and
urination were both normal. His tongue was red with thin and
white tongue coating. His pulse was vacuous and string-like. The
patient demanded to leave the hospital today.
