By Mark Wright

In this case, a female patient aged 62 years old presented with advanced sarcoidosis and sarcoid lymphomas of the nose and ear.

[boxibt style=”gray”] Preamble

Identified pathologies in biomedicine and Chinese medicine usually do not afford a one-to-one correspondence. For example, a common cold can be caused either by a wind heat attack or by a wind cold attack on the lung. To Chinese medicine, these are critically different. The cool herbs used in treating a wind heat attack would aggravate a wind cold attack and vice versa. It is not the name of a condition that is important in Chinese medicine, but the description. These days, there are many books available making a bridge between biomedical disease names and Chinese medical syndromes. Thus, should a patient ask whether or not ulcerative colitis could be treated by Chinese medicine, a textbook could be consulted to reveal that this condition may manifest as a result of: a) heat and dampness in the intestines, b) liver attacking spleen, c) deficiency of spleen and stomach, or d) deficiency of kidney yang. This is useful, because for a patient with ulcerative colitis being found, through traditional diagnosis, to have any one of these Chinese medical syndromes, greater confidence in prognosis may be offered to the patient. These points appear throughout the following case history.
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[boxibt style=”gray”]Herb Nomenclature

In recent times, the convention used for the identification of herbs has been to use a Latin pharmacological name, for example, Chai Hu (Radix Bupleuri). In fact, this indicates only that Chai Hu is the root of an unstated species of Bupleurum. Chai Hu actually is the root of Bupleurum chinense, it is not the root of B. longiradiatum or B. smithii, both of which have been used as local substitutes and both of which have resulted in toxic reactions. There are many examples of how the current convention can be misleading and dangerous. Therefore, in this piece, in the interests of precision, botanical names are given to species level.
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[boxibt style=”gray”]The Case History

Name Anne
Age at first consultation 62 Reporting complaint sarcoidosis and sarcoid lymphomas of nose and ear lobe First diagnosed 1990 Date of first consultation 24th July 1996
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[boxibt style=”gray”]Outline of biomedical points

Anne had never smoked. She had an asthmatic wheeze, but was prone to thrush and athlete’s foot, so could not use the recommended inhalers as these provoked thrush attacks in her throat. As a result of the impaired lung function, between September 1995 and July 1996, Anne had had three bouts of pneumonia, two of pleurisy and one of bronchitis. She had a chronic cough. Cold weather and air caused breathing distress. She had been given frequent doses of steroids and antibiotics to treat the frequent upper respiratory tract infections. The steroids had caused her to gain weight from 10½ to 13 stones in the period from September 1995 to the time of the July 1996 consultation.

The sarcoid had damaged her nasal lining giving a crusty, bloody discharge in place of normal nasal fluids.

She had a large sarcoid lymphoma on her nose and a smaller one on her left ear lobe. She had decided not to have surgery for these.
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Outline of The Chinese Medical Diagnosis:

The fast pulse, a red tongue body, a preference for cold drinks and an above-average thirst (these despite a tendency to feel cold) reflected the presence of full heat in the lung, spleen and bladder, and the empty heat arising from kidney yin deficiency.

[boxibt style=”gray”]Interpretation

In this case, no reference to sarcoidosis was found in Chinese medical books, so it was not possible to construe this a priori in terms of a Chinese medical syndrome. A reference was found to lymphoma, which was given as rou liu (lit. flesh tumour) and ascribed to spleen deficiency states. It seemed reasonable, nonetheless, to work from the basis of the following aetiology.

The spleen deficiency predisposed the body to invasion by dampness. With regard to endogenous phlegm, the spleen is the source and the lung the receptacle. Dampness generated in the intestines can move up to the lungs as phlegm. The concurrent kidney yin deficiency gave rise to empty heat ascending to the throat and lung (as demonstrated by the chronic non-red sore throat), where it hardened the phlegm. The conclusion was that the sarcoid deposits in the lung must be construed as ‘intractable old phlegm’. The prolonged poor digestion would account for progressive deficiency of liver blood. It was not clear whether a chronic kidney yang deficiency had failed to support the spleen leading to its deficiency of qi and yang, or whether a protracted spleen deficiency had led to a weakening of the kidney yang as it constantly overworked in its effort to warm the spleen. In practice, it was not critical to resolve this point; simply the kidney yang and spleen qi and yang needed warming.
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[boxibt style=”gray”]Strategy

It was determined to promote digestion, so as to prevent the generation of phlegm dampness and heat in the spleen; to tonify the spleen so that the root of the weak digestion could be broken; to clear heat from all places where it manifest, so as to prevent it congealing phlegm dampness into hard phlegm; to tonify the kidney yin so as to remove the root of the empty heat; and to use phlegm transforming herbs to erode intractable old phlegm that had already formed.

The case has stretched over four years and over 40 sheets of A4 paper, so only key points of the course are set out below. Throughout the treatment, only powdered concentrated herbs were used. These are a 5:1 concentration over their raw herb counterparts, so a prescription totalling 45g, and taken at a full dose level, would be taken as 9g of powder per day, perhaps as 3g t.i.d. In this case history, prescription total weights were frequently very high, and usually in the region of 130g, however, prescribed dose regimes were mostly of the order of 4.5g t.i.d. or 6g t.i.d.
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Initial Prescription:

This could be interpreted as being a coalescence of the classical formulas Zhi Bai Di Huang Wan (for treatment of deficiency of kidney yin with damp heat in the bladder and empty heat flaring upwards) and Ban Xia Xie Xin Tang (damp heat of the spleen with diarrhoea), further amended by a number of other herbs.

Within five days of starting treatment, the cystitis was much better and the ‘nasty burning’ had gone; the stool was firmer; the lung felt improved, there was no tight knot in the centre of the chest and Anne was no longer coughing; the nose was less dry and crusty; the external nose lymphoma was less red and the wheeze a little better.

Within two weeks, the nocturia was down to 1/night; the stool was soft-formed with no undigested food and no diarrhoea, but still some urgency.

By the end of two months, these improvements had maintained, and the skin and eyes were becoming less dry, but the urinary incontinence was ‘horrendous’.

By the end of three months, the sarcoid lymphoma on the ear had reduced in size, and that on the nose felt ‘softer and less rooted’. However, the urinary incontinence was awful. It was decided to switch the prescription from primarily treating the yin deficiency and associated heat, with secondary support for the spleen, to the opposite polarity, so as to target the bladder prolapse. The herbs were coupled with acupuncture support. Within one week, the bladder had improved some. By the end of one month, Anne reported her bladder as being 80% better.

By the end of December 1996, Anne had been consistently free of cystitis and thrush, her skin was feeling better, her bladder was maintaining, and her stool was soft but stable.

In January 1997, she caught the flu. She stopped the herbs (yin tonics are a problematic for people with influenza) for two weeks. She recovered from the flu without the previous complications of pneumonia/pleurisy/bronchitis and did not suffer particularly with regard to other aspects of her health during the absence of herbs. She noted that the purpura in her hands and feet stopped when on herbs and returned without them (the spleen’s action of holding the blood in the pathways explains this observation).

By the middle of February 1997, Anne no longer preferred cold drinks, her thirst had decreased and her pulse speed was down to 90, these signs reflecting a reduction in heat. She was bruising less easily and only had one floater in her field of vision – reflecting some recovery of the spleen qi and liver blood respectively. The prescription prioritising the bladder prolapse/urinary leakage was continued with minor variations until late April 1997, when Anne decided she would like to prioritise the sarcoid lymphomas again, so the original prescriptive theme was re-instated. Unfortunately, this was only for one month, by which time it was clear that the bladder was still ‘seeping’ following even minor exertions (exertions draw upon the spleen qi). Anne noted a correspondence between flare-ups of thrush and athlete’s foot and worsening of the bladder leakage. These three symptoms were all rooted in the deficiency of the spleen. Further attempts were made to restore the bladder by use of doses of as much as 9g t.i.d. of that prescriptive theme. The bladder continued to be tolerable around the house, but a real problem following such routine exertions as going for a short walk or a shopping trip. This had never been Anne’s primary concern, the herbs and acupuncture had been given a fair trial with only limited success and the sarcoidosis was endlessly taking a back-seat in the treatment. Therefore, she decided to have an operation under spinal block to stitch up the bladder. The operation, 8th September 1997, was successful and Anne’s recovery was good.

By November 1997, Anne’s prescription was as follows:

This prescription was taken at 4½ g t.i.d.. It shows a significant shift from the original one. The first nine herbs above comprise a standard formula for the treatment of deficient spleen qi with impaired digestion and a presence of phlegm or dampness. Although some yin tonics and heat clearing herbs still featured, they were less in number and dosage. The herbs for warming the kidney were replaced by milder ones, less active with regard to liquid stool with undigested food, as those symptoms had been consistently absent for many months.

Where a condition is multi-factorial, the different facets usually improve at different rates. In this case, the kidney yin and yang were recovering faster than the spleen. The heat signs had largely cleared, but the source of phlegm and damp prevailed. As time passes, more aspects fall away, until one is left with a relatively simple picture of, for example, spleen qi deficiency alone, perhaps manifesting as a sensitive digestion only.

There had, earlier in the case, just after the bladder operation, been heart irregularities – pounding and pain radiating into the arms. This had quickly settled down. No action was taken. However, this re-appeared in December 1997, at the same time, Anne was troubled by early waking and having something of a restless sleep. Although some of the herbs in the prescription (Gui Zhi, Mai Men Dong and Sha Ren) are useful in settling the heart, nevertheless, these problems did still manifest. The Dang Gui 3g was replaced by Suan Zao Ren (seed of Ziziphus spinosa) 9g. This immediately stopped and the early waking and the heart settled down to normal.

Unfortunately, in February 1998, Anne caught a bad chest flu, was hospitalised and administered antibiotics and steroidal inhalers. Having recovered from this, she found herself with a bad attack of thrush again (antibiotics are very cold and weaken the spleen predisposing it to an attack of dampness such as might manifest with thrush). Her skin was red and sore after stopping the steroids (steroids destroy the yin and so provoke red, dry type symptoms). Anne re-started her herbs and the narrow path was re-gained.

In Early May 1998, Anne suffered a thrombosis into her eye. Following the flu, her prescription had been somewhat modified and the Chuan Xiong had been removed. In view of the thrombosis, Chuan Xiong 3g and Hong Hua (flower of Carthamus tinctorius) 3g were added. They are ‘blood moving and stasis resolving’ herbs employed when there has been bruising or haemorrhage so as to accelerate the re absorption of blood into the system. Within three weeks, the thrombosis had much reduced leaving only some ‘gnats’ in the field of vision. By the middle of August 1998, there were no further ‘gnats’ and the eye was back to normal. The consultant expressed surprise at the rapidity of the recovery.

In August 1998, mindful of her hospitalisation earlier that year, Anne was offered a flu vaccination. From the point of view of Chinese medicine, such vaccinations often appear to be associated with the inception of ME. There is a clear explanation for this, but this is not the place for that. In view of all considerations, Anne decided not to have the vaccination, but instead to have added to her prescription the herb Zi Su Zi (seed of Perilla frutescens) 15g. This herb is considered prophylactic against flu epidemics.

At 5th November 1998, Anne’s position was:
Nose still dry and prone to bleeding. Skin sensitive, but not dry. Digestion wheat sensitive and prone to bloating. Bowels no problem. Thirst average, with a preference for hot drinks. Tongue colour normal. Nocturia occasional. Heart normal. Thrush, none for months; athlete’s foot intermittent and slight. Cough occasional and provoked by cold winds. Variations of the last listed prescription (above) were continued.

27th December 1998, Anne caught a very bad cold, but had recovered by 5th January 1999, without recourse to steroids or antibiotics.

The dry, crusty, bloody nose continued to be a nuisance. Attempts were made to settle this down using yin tonic and haemostatic herbs. Unfortunately, although the nose settled rapidly, the herbs upset the bowels too much (cool yin tonics do provoke diarrhoea). Sometimes, however much a patient may want to prioritise one side of a problem, there is no option but to hold to a more or less middle route through the constellation of imbalances, with all aspects being addressed moderately. It is rather like the circus act of keeping many plates spinning at the same time; too much attention to one plate allows others to come crashing to the ground. By the summer of 1999, the crusty nose problem had settled to being only a ‘slight problem’.

Following some dental work in March 1999, Anne developed cardiac arrhythmias and pleurisy developing into an unproductive cough with green phlegm, increased thirst and night sweats. Apparently, there had been aspiration of some infected dental debris. She was given atenolol for the arrhythmias and a nine day course of herbs aimed solely at her cough.

At the end of this short course, the cough, night sweats and increased thirst were gone.

In May 1999, the heart problem was taken into the prescription. She was diagnosed as having angina and given a sublingual spray, for use as necessary, in addition to the atenolol. In Chinese medicine, angina can be due to a) deficient heart qi, b) phlegm obstructing the qi flow in the chest, or c) blood stasis in the chest. It was clear that Anne’s problem was largely the second of these (this would correspond to fatty artery disease in biomedical terms). Given that the principal root of her problem was phlegm and dampness, this is not surprising. To a minor variation of the last listed prescription (above) were added Gua Lou Ren (seed of Trichosanthis kirilowii) 6g, and Xie Bai (bulb of Allium macrostemon) 6g. Gua Lou Ren is also good for treating pulmonary phlegm conditions. She was to take the prescription with one capful of clear spirits per dose. Viewing these with the Ban Xia already in the prescription reveals the formulas Gua Lou Xie Bai Ban Xia Tang and Gou Lou Xie Bai Jiu Tang, both of which are classically used for phlegm obstruction of the chest. Dan Shen (root of Salvia miltiorrhizae) was also included. This is considered particularly good for promoting the growth of new tissues. It tonifies the heart and creates new blood.

Very often, a patient manifesting what to biomedicine would be seen as several completely different conditions, in Chinese medicine, will be seen to have little more than variations on a theme. In this case, the diversion in prescription needed to encompass the heart problem was minor, because the two conditions were both due to phlegm arising from a weak spleen. In the case of the sarcoidosis, the phlegm was in the lung, whilst in the case of the angina, it was in the chest. The chest problem could be seen as a different branch on the same tree.

By October 1999, Anne reported that she had not needed to use her sublingual spray for months. Her thirst was below average (showing the continued reduction of heat and yin deficiency). She had only one floater in one eye and her eyes were no longer tired. Cold winds were no longer provoking a cough. She was sleeping well with no night sweats and only occasional nocturia. The same basic prescriptive strategy was retained – tonify the spleen, promote digestion, dry dampness, dispel phlegm from the chest and lungs, promote circulation of the qi of the chest.

In November 1999, Anne had another bad cold, which cleared without complication. A small piece of ‘cartilage-like’ material was spontaneously ejected from the ear, after which time, it had been completely normal. (This is reminiscent of a case of a lipoma on a lady’s back. After some months of treatment with a prescription to tonify the spleen and dispel phlegm, the lipoma spontaneously burst, discharged and disappeared.) A chest X-ray showed the sarcoid deposits to be much fainter.

Anne had been using HRT patches for a long time to help with yin deficient symptoms, notably the dry skin. With those symptoms being so much better, she discontinued use of the patches, this coincided with the skin becoming drier again. In January 2000, the yin and blood tonic herbs Bai Shao Yao 6g, Gou Qi Zi (fruit of Lycium chinense) 6g and He Shou Wu (root of Polygonum multiflorum) 6g were added at low levels to help this problem. By March 2000, the skin was a little improved, by May, moreso, though still abnormally dry.

It seemed clear that although the lymphoma on the nose had changed from purple to a normal colour, reduced in size a little and become less ‘rooted’, it was not going to go away. A more direct attempt at abating this had been made earlier by adding the herb Niu Bang Zi (fruit of Arctium lappa) to the prescription. This had caused an immediate reduction, followed by no progress so the attempt was abandoned. In view of this, Anne started a course of steroid injections which reduced it very powerfully. The line of thinking was that with the underlying factors in the pathology ( i.e. heat and phlegm) being substantially clear, a reduction of the lymphoma by local means might be permanent – no more building blocks to regenerate it. This treatment continues.

During the summer of 2000, Anne moved house. Despite the heavy work of lifting furniture around, and the stress of moving, Anne did not have to resort to her sublingual spray once. She is still taking the atenolol. Her new GP agrees that it would be a good idea to try stopping using it now, and agreement of the consultant in the near future is sought before following this line. Her blood cholesterol has dropped from 7.0 mmol/l to 4.0 mmol/l (normal range 2.8 – 7.8 mmol/l). This represents a fall from the upper to lower quartile of the normal range. Her doctor has expressed that many people would consider her current level ‘enviable’. The plan is to stop the atenolol while continuing with the relevant herbs, and if all goes well, to phase out those herbs in stages.

She went through a phase of coughing up very thick ‘old’ phlegm. This was promoted by spending more time in the warmer climate of Surrey, as opposed to her north of Scotland home, and helped by taking steam inhalations. Having moved house, Anne re-registered at a new hospital who decided to make a clean appraisal of her case. The new X-rays showed no sign of sarcoid material in the lungs and showed lung function tests to be 98% normal (a recovery from 60% at commencement of treatment). The doctors were so surprised that they could not quite accept her claim of having had a bad case of sarcoidosis. They therefore sent for her original records. Indeed, she had had sarcoidosis and now her X-ray plates are completely clear. Her consultant has expressed that the only way this could possibly be accounted for is as a result of taking the Chinese herbs.

Currently, the case is on the edge of what will hopefully be its final phase. If the steroid injections can reduce the lymphoma at the nose, and the heart has normalised, as all parties now expect, Anne should be able to proceed on a prescription targeting the weak spleen qi and sensitive digestion, with auxiliary herbs to continue to restore the yin so as to moisten the skin.

[boxibt style=”gray”]Conclusion

This case has shown the value of approaching problems from a descriptive/prescriptive base – it was not the name of the disorder that enabled it to be treated, but its description (deficiency of spleen, with dampness and phlegm, deficiency of kidney yin and yang with empty heat, phlegm obstructing the chest). It has shown how biomedicine can complement Chinese medicine (the bladder operation, the lymphoma at the nose) and how Chinese medicine can complement biomedicine (the sarcoidosis, thrush, thrombosis, angina). It has shown how much can be achieved when the two medical approaches, each working within their own terms and models, come together.
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Addendum – June 2001

Sarcoid Deposits Around The Eye

At a re-appraisal, Anne mentioned a continued problem caused by the sarcoid material around her left eye and temple. This caused headache pain around the back of her eye and made reading a trial rather than a pleasure. The problem had not been mentioned much previously because in earlier times, it was a relatively small part of the whole picture. During her re-appraisal visit, she received acupuncture at one point (B2) near to her eye, and had a cow basil (Vaccaria segetalis) seed taped to the ear acupuncture point for the forehead/temple area. The ear seed was to remain in place for one week. The herbal prescription was amended to give especial attention to the eye problem.

The prescription retained the spleen tonic and phlegm resolving herbs, the heart and chest circulation herbs and some yin tonics, as detailed above. To these were added:

The idea was that the acupuncture and ear stimulation would give a ‘kick start’ to circulating the energy locally and thereby facilitate the action of the herbs. There was concern that the action of the herbs alone would not be enough to break up the sarcoid deposit, and that she would need a course of acupuncture and ear seed treatment to resolve the problem. In fact, following an immediate clearing of her headache during the first treatment, the eye has continued to be very much better with the herbs alone. Anne has written, ‘Thank you, I can enjoy reading again.’ She is using steam inhalations to potentiate the treatment and reports that catarrh is coming away in hard lumps. Whereas she had been free of a cough for some time, she now has one again as a result of the sinus/nasal drainage of this old catarrh (alias ‘sarcoid’). However, the cough remains at the level of being a ticklish nuisance in her upper chest. This is likely to continue as long as the peri-ocular sarcoid is dis-aggregating. At the same time, the sarcoma on her nose is becoming pinker and less swollen. The nose-bleeds and crusty fragile nasal lining are also improving. With regard to the ‘sarcoidosis’ of her lung, she has essentially been given the all-clear and put on annual review by the hospital.

[boxibt style=”success”]About The Author

Mark Wright trained in Taiwan where he graduated with a Diploma of Oriental Medicine in 1986. He is a Fellow of The Register of Chinese Herbal Medcine (FRCHM) and a Member of the British Acupuncture Council (MBAcC).[/boxibt]