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Record of Herbal Treatment Of Peter  from Holland Improvement Of ALS

 

 

 

 

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Brief Summary: Peter, from Holland, suffering from ALS, stayed in our hospital for five months. The abilities of his voice and swallowing have been improved a lot. The ability of the legs and arms is stabilized. He was quite satisfied with our treatment result.

 

 

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Record of Hospitalization

Name: Peter                                              Sex: Male

Age: 41                                                     Profession:  Office Clerk

Nationality: The Netherlands                    Marital Status: Married

Onset Season: Summer                            Date of Admission: Nov. 10, 2007  

Complainer: The patient himself                Reliability: Reliable

 

First Medical Record

Nov. 10, 2007  

Peter, a 41-year-old male, has suffered from weakness of the upper limbs, along with difficulty in flexibility of finger joints for two years, and the condition has been aggravated for one year. He was picked up by our staff in Zhijiang Airport and arrived in Huaihua Red Cross Hospital for further treatment at 20: 10 p.m. on Nov. 11, 2007.

Essentials for Diagnosis:

1. The patient has suffered from weakness of the upper limbs, along with difficulty in flexibility of finger joints for two years, and the condition has been aggravated for one year.

2. In the beginning of Nov. 2005, the patient began to feel weakness of the upper limbs without any obvious causes. At that time, the patient paid no attention to it, and did no examination or treatment about it. Therefore, the disease was developing progressively. Three months later, the patient had difficulty in the movement of fingers of both hands. The finger joints were not able to do any flexible movement. But he still took no examination or treatment. In Oct. 2006, the patient went to a local hospital for a diagnosis. After the MRI examination, he was diagnosed with amyotrophic lateral sclerosis (ALS). The hospital prescribed him rilutek capsule. After one-month medicine taking, he stopped taking it due to some discomfort. Then he did no other treatment. In Nov. 2006, the patient’s condition was aggravated, with symptoms of weakness of the lower limbs, the delay of his movement, and difficulty in speaking. To seek for a further comprehensive treatment, he arrived in our hospital at 19: 30 p.m. on July 18, 2007. Since he got the disease, his spirit and appetite were both normal. His sleep was slightly poor. His bowel movement and urination were both normal. 

3. T 36.3P 83 beats/minute, R 20 times/minute, BP 130/80 mmHg.

4. He grew normally with common nourishment. His mind was clear. He had an expression of chronic illness and languidness. His body was in a positive posture and he was cooperative in examination.

5. He has suffered from weakness of the upper limbs and slightly muscular atrophy of double arms. There were obvious atrophy on the muscles of thenar eminence and hypothenar of his double hands. His fingers of double hands had difficulty in flexible movement with poor fine movement. The experiment on his hands was (+). The muscular strength of his upper limbs was Grade with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty in walking. The muscular strength of his lower limbs was also Grade with muscle weak hypertonicity. The muscles all over his limbs beat uncontrollably and frequently. He had the symptoms of short of breath, weakness, as well as with difficulty in speaking. His tongue surface was uneven, and there were teeth marks at the edge of his tongue.

6. No thoracic deformity. Chest percussion noted resonance. Sound of breath is bilaterally clear on auscultation. No sound of pleural friction.

7. Diagnostic examination: Not provided

Diagnostic Basis:

TCM: The patient has suffered from weakness of the upper limbs, along with difficulty in flexibility of finger joints for two years, and the condition has been aggravated for one year. His limbs were atrophic and weak with languid spirit and pale face. He had difficulty in speaking. His tongue was red with thin and white tongue coating. His pulse was string-like. Because of the insufficiency of the liquids, abnormality of the qi and blood, and the lungs heat scoring the lobes, his limbs lose the nourishment. The deficiency of spleen and kidneys leads to deficiency of yin. Then it gradually resulted in flaccidity.

Western medicine: The patient has suffered from weakness of the upper limbs, along with difficulty in flexibility of finger joints for two years, and the condition has been aggravated for one year. His upper limbs were weak with slightly muscular atrophy of his arms. There were obvious atrophy on the muscles of thenar eminence and hypothenar of his double hands. His fingers of double hands had difficulty in flexible movement with poor fine movement. The experiment on his hands was (+). The muscular strength of his upper limbs was Grade with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty in walking. The muscular strength of his lower limbs was also Grade with muscle weak hypertonicity. The muscles all over his limbs beat uncontrollably and frequently. He had the symptoms of short of breath, weakness, as well as with difficulty in speaking. His tongue surface was uneven, and there were teeth marks at the edge of his tongue. In Oct. 2006, he went to a local hospital for a MRI examination, and was diagnosed with amyotrophic lateral sclerosis (ALS).

Diagnostic Differentiation:

TCM: The patient’s wilting syndrome should be differentiated from impediment syndrome. Wilting syndrome is characterized by the limp, weak, and emaciated limbs with muscular atrophy. A patient who has suffered from wilting syndrome 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, 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 grave myasthenia gravis, which is an acquired autoimmune disease with the transferring obstacles of nerve-muscles, and is caused by the autoimmune reaction resulting from the acetylcholine receptor (AchR) of the striated muscle. It can occur at any age and there are about 60 percent people stricken before 30 years old. Women are more often affected than men are. The most obvious characteristic of MG is rapid fatigability of the skeletal muscles affected, improved with rest or medicines that inhibits the activity of cholinesterase. It can involve cardiac muscle and smooth muscle. MG patients of different ages often have different clinical manifestations and courses, which are different from those of wilting syndrome patients.

First Diagnosis: 

TCM diagnosis: Wilting syndrome

Symptom identification: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind.

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

Plans for treatment strategy and nursing:

1. Routine care of traditional Chinese internal medicine.

2. Grade II care.

3. Under care of a companion.

4. high-protein diet.

5. Herbal tea (to nourish the lungs and supplement the kidneys, soften the liver and extinguish the wind): 5 dosages in total. One dosage a day and drink twice.

Main herbs used in the herbal tea: huangqi (astragalus root), taizishen (pseudostellaria root), danshen (salvia root), etc.

6. Acupuncture and massage: once a day.

7. Have more medical examinations if necessary.

 

Date: Nov. 13, 2007                               Time: 10:00 a.m.

After the examinations of ECG, B-ultrasonic and chest radiography, the patient was found no abnormality. The three regular examinations and the examinations of the functions of his liver and kidneys as well as the examination of E4A were all normal. According to the above information, the doctor advised him to continue to take herbal tea of the former prescription.

 

Date: Nov. 22, 2007                               Time: 10:00 a.m.

The patient’s diet has increased. The weakness of his lower limbs has got some improvement, and the incontrollable beating of the muscles all over his body was lessened. At night, there were some paroxysmal spasms on his limbs. His sleep was poor with dreaminess. His tongue body was thin, atrophic and tender. The surface of his tongue was uneven and trembling with teeth marks at the edge of the tongue. The patient would continue to take the same herbal tea.

 

Date: Dec. 5, 2007                               Time: 10:00 a.m.

The stiffness and weakness of his lower limbs, and difficulty in walking have been improved altogether. The incontrollable beating of the muscles all over his body and paroxysmal spasms on his limbs were lessened. Besides, the difficulties in speaking and breathing have become better. The doctor advised him that the herbal tea should be followed by the former prescription.

 

Summary Stage

Date: Dec. 9, 2007                              Time: 9:00 a.m.

Peter, a 41-year-old male, has suffered from weakness of the upper limbs, along with difficulty in flexibility of finger joints for two years, and the condition has been aggravated for one year. The patient was hospitalized in our Red Cross Hospital at 20:10 p.m. on Nov.11, 2007. He has been hospitalizing for 30 days.  

Condition of admission:

T 36.3P 83 beats/minute, R 20 times/minute, BP 130/80 mmHg.

His heart and lungs were normal, and his abdomen was soft and flat. He has suffered from weakness of the upper limbs and slightly muscular atrophy of double arms. There were obvious atrophy on the muscles of thenar eminence and hypothenar of his double hands. His fingers of double hands had difficulty in flexible movement with poor fine movement. The experiment on his hands was (+). The muscular strength of his upper limbs was Grade with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty in walking. The muscular strength of his lower limbs was also Grade with muscle weak hypertonicity. The muscles all over his limbs beat uncontrollably and frequently. He had the symptoms of short of breath, weakness, as well as with difficulty in speaking. His tongue was uneven, and there were teeth marks at the edge of his tongue. His spirit, appetite and sleep were all poor. Both of his bowel movement and urination were normal.

Diagnosis of Admission: 

TCM diagnosis: Wilting syndrome

Symptom diagnosis: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

The Course of Diagnosis:

Since the patient was hospitalized, he was prescribed herbal tea to nourish the lungs and supplement the kidneys, soften the liver and extinguish the wind. One dosage a day and drink twice. 100ml each time, accompanied with acupuncture and massage once a day for a comprehensive treatment. The patient’s condition got some improvement.

The Current Condition:

T 36.3P 83 beats/minute, R 20 times/minute, BP 130/80 mmHg.

.His heart and lungs were normal, and his abdomen was soft and flat. The difficulties in his speaking, breathing and walking have got some improvement, so have the weakness and stiffness of lower limbs and the incontrollable beating of the muscles all over his body. There is no obvious improvement in the weakness and tightness of his upper limbs. His spirit, appetite and sleep were all normal. Both of his bowel movement and urination were normal.

Diagnosis of Admission: 

TCM diagnosis: Wilting syndrome  

Symptom identification: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind.

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

Plans for treatment strategy: 

1. Continue to take the herbal tea. 

2. Acupuncture and massage for once a day.

3. Keep a pleasant mood and open-minded spirit.

 

Date: Dec. 15, 2007                               Time: 9:00 a.m.

 The incontrollable beating of the muscles all over his body and paroxysmal spasms on his limbs were lessened a lot. His sleep was normal, sometimes with a drumming in the ears. He continued to take the herbal tea of the same prescription.

 

Date: Dec. 20, 2007                               Time: 9:00 a.m.

The thin and tender tongue body became better, so did the uneven and trembling surface of his tongue. Besides, his tongue coating was white. His general strength has increased with pleasant spirit. What’s more, the difficulty in walking has been improved. He would continue to take the former formula.

 

Date: Dec. 30, 2007                               Time: 9:00 a.m.

Today the patient said that he had difficulty in speaking with unclear and influent speech. Besides, he felt difficulty in breathing with the symptoms of short of breath and weakness. His stiffness and weakness in the lower limbs, the difficulty in walking and the muscular beating all over the body all have got some improvement. There was no improvement in the tight and weak upper limbs. In the examination, his heart and lungs were normal, and his abdomen was flat and soft. His spirit, appetite and sleep were all normal. His bowel movement and urination were both normal too. His tongue was red with thin and white tongue coating. His pulse was thready and weak. The herbal tea would keep the same as before.

 

Summary Stage

Date: Jan. 9, 2007                             Time: 9:00 a.m.

Peter, a 41-year-old male, has suffered from weakness of the upper limbs, along with difficulty in flexibility of finger joints for two years, and the condition has been aggravated for one year. The patient was hospitalized in our Red Cross Hospital at 20:10 p.m. on Nov.11, 2007.  He has been hospitalizing for 60 days.  

Condition of Admission:

T 36.5P 80 beats/minute, R 20 times/minute, BP 130/80 mmHg.

His heart and lungs were normal, and his abdomen was soft and flat. He has suffered from weakness of the upper limbs and slightly muscular atrophy of double arms. There were obvious atrophy on the muscles of thenar eminence and hypothenar of his double hands. His fingers of double hands had difficulty in flexible movement with poor fine movement. The experiment on his hands was (+). The muscular strength of his upper limbs was Grade with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty in walking. The muscular strength of his lower limbs was also Grade with muscle weak hypertonicity. The muscles all over his limbs beat uncontrollably and frequently. He had the symptoms of short of breath, weakness, as well as with difficulty in speaking. His tongue was uneven, and there were teeth marks at the edge of his tongue. His spirit, appetite and sleep were all poor. Both of his bowel movement and urination were normal.

Diagnosis of Admission: 

TCM diagnosis: Wilting syndrome  

Symptom identification: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

The Course of Diagnosis:

Since the patient was hospitalized, he was prescribed herbal tea to nourish the lungs and supplement the kidneys, soften the liver and extinguish the wind. One dosage a day and drink twice. 100ml each time, accompanied with acupuncture and massage once a day for a comprehensive treatment. The patient’s condition got some improvement.

The Current Condition:

T 36.5P 80 beats/minute, R 20 times/minute, BP 130/80 mmHg.

.His heart and lungs were normal, and his abdomen was soft and flat. The strength of his lower limbs has increased, and the incontrollable beating of the muscles all over his body has been lessened. Besides, there was no obvious improvement in the weakness of his upper limbs. His speech was unclear and influent. While his spirit, appetite and sleep were all normal. Both of his bowel movement and urination were normal. His tongue was red with thin and white tongue coating. His pulse was string-like.

Diagnosis of Admission: 

TCM diagnosis: Wilting syndrome

Symptom identification: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind.

WM diagnosis: Amyotrophic Lateral Sclerosis (ALS)

Plans for treatment strategy: 

1. Continue to take the herbal tea. 

2. Acupuncture and massage for once a day.

3. Keep a pleasant mood and open-minded spirit.

 

Date: Jan. 10, 2008                               Time: 9:00 a.m.

The strength of his lower limbs has increased, and the muscular beating all over his body has been lessened. There was no obvious improvement in his upper limbs. Besides, his speech was still unclear. He kept a normal sleep. The patient said that his deafness began at his early age.

 

Date: Jan. 20, 2008                               Time: 9:00 a.m.

The thinness and tenderness of his tongue body, along with the uneven tongue surface has been improved markedly. What’s more, the trembling in the tongue body has been lessened significantly, and the strength of his lower limbs has also increased a lot. There was still no obvious improvement in his upper limbs. He would continue to take the former herbal tea.

 

Date: Jan. 31, 2008                               Time: 9:00 a.m.

The pains of his lower limbs’ joints have almost disappeared. The doctor would make some changes on the basis of his former herbal tea. 

 

Summary Stage

Date: Feb. 9, 2007                            Time: 9:00 a.m.

Peter, a 41-year-old male, has suffered from weakness of the upper limbs, along with difficulty in flexibility of finger joints for two years, and the condition has been aggravated for one year. The patient was hospitalized in our Red Cross Hospital at 20:10 p.m. on Nov.11, 2007. He has been hospitalizing for 90 days.  

Condition of Admission:

T 36.5P 80 beats/minute, R 20 times/minute, BP 130/80 mmHg.

His heart and lungs were normal, and his abdomen was soft and flat. He has suffered from weakness of the upper limbs and slightly muscular atrophy of double arms. There were obvious atrophy on the muscles of thenar eminence and hypothenar of his double hands. His fingers of double hands had difficulty in flexible movement with poor fine movement. The experiment on his hands was (+). The muscular strength of his upper limbs was Grade with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty in walking. The muscular strength of his lower limbs was also Grade with muscle weak hypertonicity. The muscles all over his limbs beat uncontrollably and frequently. He had the symptoms of short of breath, weakness, as well as with difficulty in speaking. His tongue was uneven, and there were teeth marks at the edge of his tongue. His spirit, appetite and sleep were all poor. Both of his bowel movement and urination were normal.

Diagnosis of Admission: 

TCM diagnosis: Wilting syndrome

Symptom identification: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind.

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

The Course of Diagnosis:

Since the patient was hospitalized, he was prescribed herbal tea to nourish the lungs and supplement the kidneys, soften the liver and extinguish the wind. One dosage a day and drink twice. 100ml each time, accompanied with acupuncture and massage once a day for a comprehensive treatment. The patient’s condition got some improvement.

The Current Condition:

T 36.5P 80 beats/minute, R 20 times/minute, BP 130/80 mmHg.

His heart and lungs were normal, and his abdomen was soft and flat. The strength of his lower limbs has increased, and the incontrollable beating of the muscles all over his body has been lessened. Besides, there was no obvious improvement in the weakness of his upper limbs. His speech was unclear and influent. While his spirit, appetite and sleep were all normal. Both of his bowel movement and urination were normal. His tongue was red with thin and white tongue coating. His pulse was string-like.

Diagnosis of Admission: 

TCM diagnosis: Wilting syndrome

Symptom identification: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind.

Western Medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

Plans for treatment strategy; 

1. Continue to take the herbal tea. 

2. Acupuncture and massage for once a day.

3. Keep a pleasant mood and open-minded spirit.

 

Date: Feb. 16, 2008                               Time: 9:00 a.m.

In recent days, the patient has had a slightly cold. Besides, the symptoms of the pharyngeal itching and expectoration have been aggravated. The doctor made some changes on the basis of his former herbal tea.

 

Date: Feb. 23, 2008                               Time: 9:00 a.m.

Recently, his repeated cold, cough has almost recovered. There still existed muscular beating in the upper limbs and paroxysmal spasms in his fingers. His diet and sleep were both normal. The herbal tea keeps the same as before.

 

Date: Mar. 5, 2008                               Time: 9:00 a.m.

The patient had too much saliva with poor sleep. His sometimes shoulder pains and muscular beating have been lessened. The herbal tea keeps the same as before.

 

Summary stage

Date: Mar. 9, 2007                           Time: 9:00 a.m.

Peter, a 41-year-old male, has suffered from weakness of the upper limbs, along with difficulty in flexibility of finger joints for two years, and the condition has been aggravated for one year. The patient was hospitalized in our Red Cross Hospital at 20:10 p.m. on Nov.11, 2007. He has been hospitalizing for 120 days.  

Condition of Admission:

T 36.5P 80 beats/minute, R 20 times/minute, BP 130/80 mmHg

His heart and lungs were normal, and his abdomen was soft and flat. He has suffered from weakness of the upper limbs and slightly muscular atrophy of double arms. There were obvious atrophy on the muscles of thenar eminence and hypothenar of his double hands. His fingers of double hands had difficulty in flexible movement with poor fine movement. The experiment on his hands was (+). The muscular strength of his upper limbs was Grade with muscle weak hypertonicity. His lower limbs were weak, stiff with difficulty in walking. The muscular strength of his lower limbs was also Grade with muscle weak hypertonicity. The muscles all over his limbs beat uncontrollably and frequently. He had the symptoms of short of breath, weakness, as well as with difficulty in speaking. His tongue was uneven, and there were teeth marks at the edge of his tongue. His spirit, appetite and sleep were all poor. Both of his bowel movement and urination were normal.

Diagnosis of admission: 

TCM diagnosis: Wilting syndrome  

Symptom identification: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind.

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

The Course of Diagnosis:

Since the patient was hospitalized, he was prescribed herbal tea to nourish the lungs and supplement the kidneys, soften the liver and extinguish the wind. One dosage a day and drink twice. 100 ml each time, accompanied with acupuncture and massage once a day for a comprehensive treatment. The patient’s condition got some improvement.

The Current Condition:

T 36.5P 80 beats/minute, R 20 times/minute, BP 130/80 mmHg.

His heart and lungs were normal, and his abdomen was soft and flat. The strength of his lower limbs has increased, and the incontrollable beating of the muscles all over his body has been lessened. Besides, there was no obvious improvement in the weakness of his upper limbs. His speech was unclear and influent. While his spirit, appetite and sleep were all normal. Both of his bowel movement and urination were normal. His tongue was red with thin and white tongue coating. His pulse was string-like.

Diagnosis of Admission: 

TCM diagnosis: Wilting syndrome  

Symptom identification: Liver-kidneys-lungs yin vacuity, accompanied with yin vacuity stirring wind.

Western medicine diagnosis: Amyotrophic Lateral Sclerosis (ALS)

Plans for treatment strategy: 

1. Continue to take the herbal tea. 

2. Acupuncture and massage for once a day.

 

Date: Mar. 20, 2008                               Time: 9:00 a.m.

The pains of his shoulder joints and hip joints have been lessened, so have the symptoms of the muscles all over his body and his fingers. He still felt weak in raising his arms. He has kept a sound sleep as well as pleasant spirit and normal diet. In the examination, his tongue body has broadened, and the uneven tongue surface with trembling and the teeth marks at the edge of his tongue have got some improvement. He would continue to take the herbal tea.

 

Date: Mar. 31, 2008                               Time: 9:00 a.m.

The thin and atrophic tongue body as well as the uneven tongue surface has been improved significantly, so has the slow and unclear speech. Besides, the stiffness and weakness of his lower limbs along with the difficulty in walking has also been improved significantly. His short of breath, poor spirit and sleep has turned out to be normal. While there were still no obvious changes in some of his symptoms, such as the muscular atrophy and weakness on his upper limbs, the difficulty in joints’ flexible movement, and the disability of laying his arms flat or raising his arms. All the symptoms have kept stable condition.

 

Date: Apr. 11, 2008                               Time: 9:00 a.m.

The stiffness and weakness of his lower limbs along with the difficulty in walking has been improved significantly. Besides, the thin and atrophic tongue body, as well as the uneven tongue surface and teeth marks at the edge of the tongue also has got much improvement, so has his slow and unclear speech. What’s more, the incontrollable beating of the muscles all over his body and paroxysmal spasms on his lower limbs were also lessened significantly. He has recovered with normal sleep and diet as well as pleasant spirit. He felt no tiredness with a good mood. He spoke highly of our TCM treatment, especially satisfied with his treatment results. Today he demanded to leave the hospital with two-month herbal tea for home taking.

 

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