Case Study for Internal Medicine
Attilio D' Alberto,
Doctor of Chinese Medicine (Beijing, China), BSc (Hons) TCM MATCM
Doctor of Chinese Medicine (Beijing, China), BSc (Hons) TCM MATCM
Introduction
Male, 63 years old. Single. Library assistant. Initial consultation 26th September 2002.
Chief Complaint
Excessive bowel movements with bleeding for 2 years.
History and Symptoms
During the last two years the patient had also suffered with distension, gas and tenesmus. He sometimes felt tired, with pain and had a temperature. His condition had improved recently and now he has just a bloating feeling with a little bleeding and had lost weight in the last two years. His sleep is disturbed as he has to pass urine every two hours. During these frequent visits to the toilet he had to wait until he passed urine. He has no night sweating and generally felt cold whilst his appetite was normal. Physical observations noted that his lips were slightly dry and red/pink. Further probing of his history found that he had a triple bypass heart operation in 1989. After being told of his cancerous condition he stopped smoking. Dietary information noted that he was a vegan and of Indian origin. His current medication included: carcinosin IM, acid nitric IM and iscador self medicated with no chemotherapy. Family history noted that his mother had cancer of the uterus.
Tongue inspection and pulses
The tongue was dark pink with lateral ecchymoses patches and a thin white coating. The pulse was thin and deep.
Orthodox Diagnosis
Carcinoma of the colon for two years.
TCM Diagnosis and syndrome differentiation
Kidney Yang and Spleen Qi deficiency with Blood stasis and damp toxic accumulation.
Principle of Treatment
Tonify Kidney Yang and Spleen Qi, clear the damp toxic accumulation and the blood stasis.
Base formula
Xue Fu Zhu Yu Wan
Jin Gui Shen Qi Wan
Bu Zhong Yi Qi Wan
Prescription
Xue Fu Zhu Yu Wan
Jin Gui Shen Qi Wan
Bu Zhong Yi Qi Wan
Eight pills from each formula to be taken three times a day after meals with water.
Other suggestions:
Qi Gong to help energy levels.
Course of Treatment
2nd consultation: 3rd October 2002. The lateral ecchymoses patches on the tongue have decreased, indicating that there is less Blood stasis. He woke up at 6.30am this morning and had 5 bowel movements before the appointment. The Qi Gong exercises have developed the increase feeling of Qi felt in his Dan Tian. The prescription administered is Xue Fu Zhu Yu Wan, Bu Zhong Yi Qi Wan, whilst Jian Pi Wan replaces Jin Gui Shen Qi Wan.
3rd consultation: 10th October 2002. The bleeding stopped for one day although the bowel movement is still sluggish. His energy levels are better and there is no longer any abdominal distension. The three lateral ecchymoses patches in the tongue are still present. The pulse is still thin and deep. The diarrhoea has reduced to four times a day. The prescription administered is the same as the previous week; Xue Fu Zhu Yu Wan, Bu Zhong Yi Qi Wan and Jian Pi Wan.
Discussion
In Traditional Chinese Medicine (TCM), excessive bowel movements is categorised as Xie Xie. However, this is a chronic syndrome of Xie Xie accompanied with Blood stasis that has resulted in the formation of damp toxic accumulation. The Bian Zheng Lun Zhi is further categorised into excess and deficiency. The excess aspect of this syndrome is shown in the branch symptoms of damp heat accumulation and Blood stasis. The damp heat accumulation caused by the deficiency of Qi may well be causing the majority of the bleeding and is indicated by the patient's tenesmus and discharge of purulent and bloody stools. The Blood stasis is caused by a deficiency of Qi and may have lead to the accumulation of damp heat which further aggravated the damp toxic accumulation. The deficient aspect is the deficiency of Kidney Yang noted with the diarrhoea before dawn seen on 3rd October, abdominal pain and the feeling of coldness. The other deficient organ is the Spleen as seen with the lose of weight, tiredness and bleeding (Bo 2000). The treatment strategy employed is to treat the same disease with different methods (Bo 2000). Firstly, warm and tonify the Kidney Yang to strengthen the source Yang, warm the body and the middle Jiao. Also invigorate the Spleen, the source of Qi and Blood to stop diarrhoea, the feeling of tiredness and strengthen the Zheng Qi in its ability to fight the evil Qi. Lastly, spread the Liver Qi to remove the toxic accumulation and dispel Blood stasis.
The development of cancer in TCM is due to an obstruction of turbid dampness, a stagnation of toxic heat or a stagnation of Qi and Blood all of which can be seen in this case and are all determined by the strength of Zheng Qi (Lan 1998). Most of these syndromes can be caused by a deficiency of Spleen Qi and its symptoms are commonly seen in cancer patients (Lan 1998). The basic pathogenesis of carcinoma of the colon however, is rooted by a deficiency syndrome characterised by an insufficient amount of vital essence (Jing) held in the Kidney (Zhufan and Jiazhen 1993). The relationship between the Kidney and Spleen lies in pre-heaven and post-heaven Qi. Kidney essence (pre-heaven Qi) will be greatly depleted if there is a deficient Spleen as the demands of the Zangfu cannot be meet by the Spleen's production of Qi and Blood (post-heaven Qi) The fact that the patient is 63 years ago also indicates a deficiency of Kidney Yang which is commonly seen in the elderly.
Jin Gui Shen Qi Wan is used to warm and tonify the Kidney Qi or source Yang. A deficiency of Kidney Qi will cause the failure of the regulation of water in the lower Jiao, thereby affecting the Bladder's ability to restrain the water which will manifest as incontinence as seen in this patient.
Bu Zhong Yi Qi Wan is used to tonify the middle Jiao, the Spleen, and raise the sunken Yang Qi (Bensky and Barolet 1990). By tonifying the Spleen, it can then regulate water metabolism and reduce the quantity of loose stool movements whilst also commanding the Blood to stop the bleeding. The bleeding however can be a combination of damp toxin accumulation causing the Blood to boil out of the vessels along with the failure of Spleen Qi to command Blood (Pi Tong Xue). As the strength of the Spleen improves, the production of Qi and Blood will increase and the Zheng Qi will have the power to fight the evil Qi. This struggle between the Zheng Qi and the evil Qi upsets the dynamic equilibrium of Yin and Yang, damages the normal physiological functions of the Zangfu and other tissues, affects the normal ascending and descending Qi and causes a derangement of Qi and Blood and may explain the mechanisms of the five bowels movements seen in the morning of 3rd October.
Huang Qi is an important herb used in the fight against cancer. It raises the Yang and strengthens the Qi. Huang Qi in combination with Sheng Ma and Chai Hu, all of which are used to make up the formula Bu Zhong Yi Qi Wan, will give good results. Huang Qi tonifies Qi and contains the leakage of Blood; it strengthens the Wei Qi and so consolidates the exterior. Modern research shows that the use of Huang Qi regulates the readings of cAMP and cGMP of the liver and blood plasma, and so strengthens the phagocytosis of the reticuloendothelial system. It can also inhibit the growth of tumours and sometimes reduce cancer cells (Lan 1998).
Xue Fu Zhu Yu Wan is used to invigorate the Blood, spread the Liver Qi to dispel Blood stasis, remove damp toxic accumulation and unblock the channels as the bleeding may be caused by the blockage of dead Blood in the meridians. The damp toxic accumulation can also block the Qi movement thereby causing the Blood stasis as the evil stagnates in the intestines and may well be aggravated by the patient's spicy Indian diet. This may also explain the excessive five bowel movements seen on the morning of the 3rd October as the herbs to remove the Blood stasis are Qi regulating and therefore an increase in the movement of Qi will lead to an increase in bowel movements.
Jian Pi Wan is used to strengthen the Spleen whilst reducing food stagnation and stop diarrhoea. This replaced Jin Gui Shen Qi Wan in the second consultation as the patient's five bowel movements of 3rd October needed to be resolved quickly to stop the lose of fluid and blood, both of which are Yin and their depletion will aggravate the damp toxic accumulation.
However, Bo (2000) states that a deficiency of Kidney Yang accompanied with a deficiency of Spleen Yang could be much better treated using Si Shen Wan, Li Zhong Wan and Tao Hua Tang. I disagree. In this case the addition of damp toxic accumulation along with the benefit of the western medical diagnosis of cancer, allows the physician to modify their treatment strategy accordingly to one which treats the syndrome differentiation but allows attacks the cancer. Therefore, warming the source Yang, uplifting the middle Jiao Yang Qi to greatly strengthen Zheng Qi are the best ways to promote strength to fight the cancer whilst regulating Qi is the best way of dispelling damp toxic accumulation and Blood stasis without injuring Yin and Zheng of which are too important in this critical case.
Conclusion
The long history of this condition accompanied with the lost of Blood, fluid and weight over the two years along with the age of the patient in relation to the depletion of Kidney essence make for a poor prognosis. The emphasis is to reduce the branch (Biao) symptoms as the root (Ben) cause of a deficiency of Kidney essence is means a poor prognosis.
References
Bensky, D. & Barolet, R. (1990). Formulas & Strategies. Seattle: Eastland Press, Inc.
Bo, P. (2000). Traditional Chinese Internal Medicine. Beijing: People's Medical Publishing House.
Lan, J. ‘The Use of Huang-Qi in the Treatment of Cancer', The Journal of Chinese Medicine, 28, 9, p1.
Zhufan, X. & Jiazhen, L. (1993). Traditional Chinese Internal Medicine. Beijing: Foreign Languages Press.
Male, 63 years old. Single. Library assistant. Initial consultation 26th September 2002.
Chief Complaint
Excessive bowel movements with bleeding for 2 years.
History and Symptoms
During the last two years the patient had also suffered with distension, gas and tenesmus. He sometimes felt tired, with pain and had a temperature. His condition had improved recently and now he has just a bloating feeling with a little bleeding and had lost weight in the last two years. His sleep is disturbed as he has to pass urine every two hours. During these frequent visits to the toilet he had to wait until he passed urine. He has no night sweating and generally felt cold whilst his appetite was normal. Physical observations noted that his lips were slightly dry and red/pink. Further probing of his history found that he had a triple bypass heart operation in 1989. After being told of his cancerous condition he stopped smoking. Dietary information noted that he was a vegan and of Indian origin. His current medication included: carcinosin IM, acid nitric IM and iscador self medicated with no chemotherapy. Family history noted that his mother had cancer of the uterus.
Tongue inspection and pulses
The tongue was dark pink with lateral ecchymoses patches and a thin white coating. The pulse was thin and deep.
Orthodox Diagnosis
Carcinoma of the colon for two years.
TCM Diagnosis and syndrome differentiation
Kidney Yang and Spleen Qi deficiency with Blood stasis and damp toxic accumulation.
Principle of Treatment
Tonify Kidney Yang and Spleen Qi, clear the damp toxic accumulation and the blood stasis.
Base formula
Xue Fu Zhu Yu Wan
Jin Gui Shen Qi Wan
Bu Zhong Yi Qi Wan
Prescription
Xue Fu Zhu Yu Wan
Jin Gui Shen Qi Wan
Bu Zhong Yi Qi Wan
Eight pills from each formula to be taken three times a day after meals with water.
Other suggestions:
Qi Gong to help energy levels.
Course of Treatment
2nd consultation: 3rd October 2002. The lateral ecchymoses patches on the tongue have decreased, indicating that there is less Blood stasis. He woke up at 6.30am this morning and had 5 bowel movements before the appointment. The Qi Gong exercises have developed the increase feeling of Qi felt in his Dan Tian. The prescription administered is Xue Fu Zhu Yu Wan, Bu Zhong Yi Qi Wan, whilst Jian Pi Wan replaces Jin Gui Shen Qi Wan.
3rd consultation: 10th October 2002. The bleeding stopped for one day although the bowel movement is still sluggish. His energy levels are better and there is no longer any abdominal distension. The three lateral ecchymoses patches in the tongue are still present. The pulse is still thin and deep. The diarrhoea has reduced to four times a day. The prescription administered is the same as the previous week; Xue Fu Zhu Yu Wan, Bu Zhong Yi Qi Wan and Jian Pi Wan.
Discussion
In Traditional Chinese Medicine (TCM), excessive bowel movements is categorised as Xie Xie. However, this is a chronic syndrome of Xie Xie accompanied with Blood stasis that has resulted in the formation of damp toxic accumulation. The Bian Zheng Lun Zhi is further categorised into excess and deficiency. The excess aspect of this syndrome is shown in the branch symptoms of damp heat accumulation and Blood stasis. The damp heat accumulation caused by the deficiency of Qi may well be causing the majority of the bleeding and is indicated by the patient's tenesmus and discharge of purulent and bloody stools. The Blood stasis is caused by a deficiency of Qi and may have lead to the accumulation of damp heat which further aggravated the damp toxic accumulation. The deficient aspect is the deficiency of Kidney Yang noted with the diarrhoea before dawn seen on 3rd October, abdominal pain and the feeling of coldness. The other deficient organ is the Spleen as seen with the lose of weight, tiredness and bleeding (Bo 2000). The treatment strategy employed is to treat the same disease with different methods (Bo 2000). Firstly, warm and tonify the Kidney Yang to strengthen the source Yang, warm the body and the middle Jiao. Also invigorate the Spleen, the source of Qi and Blood to stop diarrhoea, the feeling of tiredness and strengthen the Zheng Qi in its ability to fight the evil Qi. Lastly, spread the Liver Qi to remove the toxic accumulation and dispel Blood stasis.
The development of cancer in TCM is due to an obstruction of turbid dampness, a stagnation of toxic heat or a stagnation of Qi and Blood all of which can be seen in this case and are all determined by the strength of Zheng Qi (Lan 1998). Most of these syndromes can be caused by a deficiency of Spleen Qi and its symptoms are commonly seen in cancer patients (Lan 1998). The basic pathogenesis of carcinoma of the colon however, is rooted by a deficiency syndrome characterised by an insufficient amount of vital essence (Jing) held in the Kidney (Zhufan and Jiazhen 1993). The relationship between the Kidney and Spleen lies in pre-heaven and post-heaven Qi. Kidney essence (pre-heaven Qi) will be greatly depleted if there is a deficient Spleen as the demands of the Zangfu cannot be meet by the Spleen's production of Qi and Blood (post-heaven Qi) The fact that the patient is 63 years ago also indicates a deficiency of Kidney Yang which is commonly seen in the elderly.
Jin Gui Shen Qi Wan is used to warm and tonify the Kidney Qi or source Yang. A deficiency of Kidney Qi will cause the failure of the regulation of water in the lower Jiao, thereby affecting the Bladder's ability to restrain the water which will manifest as incontinence as seen in this patient.
Bu Zhong Yi Qi Wan is used to tonify the middle Jiao, the Spleen, and raise the sunken Yang Qi (Bensky and Barolet 1990). By tonifying the Spleen, it can then regulate water metabolism and reduce the quantity of loose stool movements whilst also commanding the Blood to stop the bleeding. The bleeding however can be a combination of damp toxin accumulation causing the Blood to boil out of the vessels along with the failure of Spleen Qi to command Blood (Pi Tong Xue). As the strength of the Spleen improves, the production of Qi and Blood will increase and the Zheng Qi will have the power to fight the evil Qi. This struggle between the Zheng Qi and the evil Qi upsets the dynamic equilibrium of Yin and Yang, damages the normal physiological functions of the Zangfu and other tissues, affects the normal ascending and descending Qi and causes a derangement of Qi and Blood and may explain the mechanisms of the five bowels movements seen in the morning of 3rd October.
Huang Qi is an important herb used in the fight against cancer. It raises the Yang and strengthens the Qi. Huang Qi in combination with Sheng Ma and Chai Hu, all of which are used to make up the formula Bu Zhong Yi Qi Wan, will give good results. Huang Qi tonifies Qi and contains the leakage of Blood; it strengthens the Wei Qi and so consolidates the exterior. Modern research shows that the use of Huang Qi regulates the readings of cAMP and cGMP of the liver and blood plasma, and so strengthens the phagocytosis of the reticuloendothelial system. It can also inhibit the growth of tumours and sometimes reduce cancer cells (Lan 1998).
Xue Fu Zhu Yu Wan is used to invigorate the Blood, spread the Liver Qi to dispel Blood stasis, remove damp toxic accumulation and unblock the channels as the bleeding may be caused by the blockage of dead Blood in the meridians. The damp toxic accumulation can also block the Qi movement thereby causing the Blood stasis as the evil stagnates in the intestines and may well be aggravated by the patient's spicy Indian diet. This may also explain the excessive five bowel movements seen on the morning of the 3rd October as the herbs to remove the Blood stasis are Qi regulating and therefore an increase in the movement of Qi will lead to an increase in bowel movements.
Jian Pi Wan is used to strengthen the Spleen whilst reducing food stagnation and stop diarrhoea. This replaced Jin Gui Shen Qi Wan in the second consultation as the patient's five bowel movements of 3rd October needed to be resolved quickly to stop the lose of fluid and blood, both of which are Yin and their depletion will aggravate the damp toxic accumulation.
However, Bo (2000) states that a deficiency of Kidney Yang accompanied with a deficiency of Spleen Yang could be much better treated using Si Shen Wan, Li Zhong Wan and Tao Hua Tang. I disagree. In this case the addition of damp toxic accumulation along with the benefit of the western medical diagnosis of cancer, allows the physician to modify their treatment strategy accordingly to one which treats the syndrome differentiation but allows attacks the cancer. Therefore, warming the source Yang, uplifting the middle Jiao Yang Qi to greatly strengthen Zheng Qi are the best ways to promote strength to fight the cancer whilst regulating Qi is the best way of dispelling damp toxic accumulation and Blood stasis without injuring Yin and Zheng of which are too important in this critical case.
Conclusion
The long history of this condition accompanied with the lost of Blood, fluid and weight over the two years along with the age of the patient in relation to the depletion of Kidney essence make for a poor prognosis. The emphasis is to reduce the branch (Biao) symptoms as the root (Ben) cause of a deficiency of Kidney essence is means a poor prognosis.
References
Bensky, D. & Barolet, R. (1990). Formulas & Strategies. Seattle: Eastland Press, Inc.
Bo, P. (2000). Traditional Chinese Internal Medicine. Beijing: People's Medical Publishing House.
Lan, J. ‘The Use of Huang-Qi in the Treatment of Cancer', The Journal of Chinese Medicine, 28, 9, p1.
Zhufan, X. & Jiazhen, L. (1993). Traditional Chinese Internal Medicine. Beijing: Foreign Languages Press.
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