Chinese medicine is and has always been a part of natural science that is essential for the treatment and prevention of diseases and the prosperity of human beings. From ancient times to the present, there is no famous doctor who is not proficient in mastering the treatise on typhoid fever, and no one who does not use scripture prescriptions.
What is Jingfang: Jingfang is defined in the dictionary as follows: Jingfang: a term of Chinese medicine, a generic term for ancient prescription books. In the Han Dynasty, Zhang Zhongjing’s “Treatise on Typhoid Fever” and “The Essentials of the Golden Horoscope” were called Jing Fang, as opposed to the current prescriptions after the Song and Yuan Dynasties. The characteristics of classic prescriptions are “concise in taste, precise in quantity, flexible in addition and reduction, and outstanding in efficacy”. The treatise on typhoid contains 397 articles and 113 prescriptions. How can we guide ourselves in clinical practice to broaden our thinking and apply its ideas to clinical diagnosis? The following is a combination of clinical experience in the treatment of kidney disease to discuss their own views.
I. Familiarize with the classics, identify the symptoms and select the prescriptions
According to the symptoms, we should select the appropriate article that can reflect the whole picture of most of the symptoms, and then select the formula according to the article.
Case 1 A woman, 45 years old, is afraid of cold and wind, sweats a lot, regardless of day and night, has pain in the joints of the limbs, and has frequent episodes of urinary tract infections, has undergone cystoscopy at the Sino-Japanese Hospital, and there are no changes of chronic pyelonephritis. The Treatise on Typhoid Fever? Article 19 of the “Treatise on Sun Diseases”: “If a person has a sun disease and sweats, and then leaks more than once, and he has bad wind, difficulty in urinating, slight urgency in the extremities, and difficulty in flexing and stretching, Gui Zhi plus Radix et Rhizoma Polygonatum is the mainstay”. After three doses, no more sweating at night, and slowly less sweating during the day, all symptoms improved significantly after one month. So I understand that Zhang Zhongjing’s earliest idea of applying sutra prescriptions was probably the earliest to make prescriptions based on symptoms. In the book “Interpreting Zhang Zhongjing’s Medicine”, Mr. Feng Shilun interpreted this article as, due to mistaken sweating, “so that the Sun surface deficiency evidence is not yet resolved and falls into the Yin evidence of Shaoyin disease”. It is also clearly stated that “Gui Zhi Tang treats the Sun disease, i.e. the superficial Yang evidence, and Gui Zhi plus Radix et Rhizoma Polygonati treats the Shao Yin disease, i.e. the superficial Yin evidence.” This formula corresponds to Ephedra with Radix et Rhizoma Glycyrrhizae Tang, one treating Shao-Yin disease with sweating and the other treating Shao-Yin disease without sweating. The difference lies in the fact that one side is paired with Gui Zhi to detoxify the muscle, and the other side is paired with Ephedra to generate sweating. The difference is that one side is paired with Gui Zhi to detoxify the muscle, and the other side is paired with Ma Huang to generate sweat. This formula is often used with addition or subtraction, regardless of whether the patient sweats during the day or at night.
Case 2 [2011 in Inner Mongolia, rural area] Male, 45 years old, with chicken chest for many years and a history of heart failure, this time his symptoms were mainly dizziness, headache, pinnacle pain, nausea, and obvious cold. On that day I checked the room, his tongue was white and greasy, and his pulse was stringent. I gave him 5 doses of Ling Gui Zhu Gan Tang combined with Wu Zhu Yu Tang. Article 67 of the “Treatise on Typhoid Fever”: “In typhoid fever, if vomiting is followed by downward movement, the heart is rebelliously full, Qi rushes up to the chest, the head is dizzy when rising, the pulse is sunken and tight, sweating moves the menstruum, and the body is vibrating and shaking, Ling Gui Zhu Gan Tang is the mainstay.” Article 377 of the Treatise on Typhoid Fever, “For dry vomiting and salivation, headache, Wu Ju Ju Tang is indicated.” After taking 2 doses, the head was no longer dizzy, no longer nauseous, and the chest was no longer stuffy, and the last time the original prescription was prescribed for 10 doses, the symptoms improved significantly.
Of course, the complex symptoms do not mean that you have to treat one prescription, but you can also choose to use two or more prescriptions together. The first hurdle in learning typhoid is to memorize the articles, the articles are clearly remembered, the symptoms are grasped, the prescription will come out, rather than to focus on his urinary routine and various laboratory indicators. For those who are new to typhoid, this is still a very effective application.
Second, the integration, know the machine cubes
The article is familiar with, clinical application is also handy, this time we often see patients, sometimes the article is not fully respond to the symptoms you want, then you already have a certain thinking or application has your own grasp of the etiology of typhoid. When all the symptoms are described at the same time, the table, yin and yang, cold, heat, deficiency and prescriptions will be drawn up, which may be another stage of learning sutra.
Case 3 A male, 62 years old, found to have urine protein for 1 year, with a history of pulmonary alveoli and tuberculosis for 15 years, weighing 150 pounds at the time of initial onset, weighing only 92 pounds at the time of consultation, wasting heavily, having frequent episodes of pneumothorax, and having to sit down and rest when walking less than 10 meters. The symptoms are: coldness, weakness, poor appetite, four rebellions, abdominal distention and fullness, coughing, dry mouth, palpitations, dry stools, 5-6 times a day, floating pulse. 3 days ago in a Chinese medicine clinic to take tonics, laxative-based, 5-6 times a day stools. The Golden Horoscope: “Phlegm and Cough Disease”: Wai Tai Fu Ling Drink, treats phlegm and persistent water between the heart and chest, after vomiting out the water, the heart and chest is deficient, full of gas and unable to eat, eliminating phlegm and water, so that you can eat. Typhoid: Article 71 “Sun disease, after sweating, sweating out, stomach dry, irritable can not sleep, want to get to drink water, less and less with the drink, so that the stomach and gas will be cured. If the pulse is floating, the urine is unfavorable, and the slight heat is thirsty, Wu Ling San is the mainstay”. Identify: Taiyin deficiency cold combined with Sun Yang Ming syndromes. After one month, the weight increased to 102 pounds, and the stool was once a day, and the patient is still being followed up. This patient was diagnosed as having a deficiency of the Sun’s surface and heat entering the interior, with a stoppage of drinking under the heart and unfavorable urination. Through detailed consultation, analysis of the symptoms, identification of the pathogenesis, and identification of yin and yang, cold and heat, deficiency and actuality in the surface and interior, the patient was prescribed and given medicine, which was very effective.
Case 4 A female, 18 years old, a high school student, was first diagnosed on 2012-6-5. She complained of increased nocturia for 2 years, rising more than 10 times each night, and urinary routine check of half plus to one plus many times. The symptoms are: coldness in the lumbar region, cold hands and feet, frequent urination, obvious at night, slightly dry mouth, dislike of drinking, poor sleep, normal bowel movements, thin pulse. What is the key to Jin Kui? The five organs of wind and cold accumulation disease pulse evidence and treatment chapter “kidney with the disease, his body weight, waist in the cold, as sitting in water, the shape of water, but not thirsty, urination, diet as before, the disease belongs to the lower jiao, body labor sweating, cold wet clothes, cold pain below the waist, the abdomen is heavy as with 5,000 money, Gan Jiang Ling Art Tang is the main. In the second week of treatment, the number of nocturnal episodes was reduced to 2, and after 3 weeks of continuous treatment, no more nocturnal episodes were observed. When he came to the clinic, he was happy and smiling. Combined with the symptoms, cold hands and feet, bad cold, night spirit, poor sleep and dreaminess, and dry mouth, it belongs to Sun Yang Ming syndromes; cold waist and frequent nocturnal urination, it belongs to Tai Yin deficiency cold, cold waist and heavy urination, the formula and evidence combined to receive immediate effect.
Case 5 Patient, male, 20 years old. He was admitted to the hospital on July 13, 2010 mainly because of “intermittent bilateral lower limb swelling for 10 days, aggravated by fever for 4 days”. After admission, the patient was found to have urine protein (3+), plasma albumin 13.9 g/L, urea nitrogen 8.6 mmol/L, creatinine 88.3 mmol/L, uric acid 414.3 μmol/L, glutamate transaminase 175 U/L, aspartate aminotransferase 84 U/L. The diagnosis was “nephrotic syndrome, anxiety and depression, abnormal liver function cause To be investigated”. The patient had been febrile for 4 days before admission, and was treated with cefuroxime for 4 days in an outside hospital (the exact dosage of the drug is unknown), but the fever did not subside. After admission, her body temperature was 38.5℃, and an urgent chest X-ray showed a pleural effusion. The following symptoms were observed: fever and chills, no sweating, dry mouth, irritability, poor appetite, nausea, poor sleep, constipation, stool had not been passed for three days, edema of both lower limbs. The tongue is red, the tongue coating is white and greasy, and the pulse is floating and slippery. Prescription: 10g of roasted ephedra, 12g of bitter almonds, 6g of cinnamon stick, 9g of roasted licorice, 60g of raw gypsum, 5g of wine rhubarb. 1 dose of decoction was taken warm. After taking 1 decoction, the patient had sweating in the axillae, back and groin area, body temperature returned to normal (36.5℃), stool 5 times, dilute stool, and edema of both lower limbs reduced. Although the patient had 5 bowel movements, her mental symptoms improved significantly. The patient was instructed not to take the remaining second decoction of Chinese medicine and to eat a light diet, and was discharged on July 18, 2010, after the urine protein 2+ and edema disappeared on July 15, 2010. Article 38 of the Treatise on Typhoid Fever: “If a person has a sun stroke with a floating and tight pulse, fever, malignant cold, body pain, and irritability without sweating, Da Qing Long Tang is the mainstay”; Article 39: “If a person has a typhoid fever with a floating and slow pulse, no body pain, but heavy, with lightness at first, and no Shao Yin evidence, Da Qing Long Tang is the mainstay “. In the “Fax on Typhoid Fever”, Mr. Feng believes that “Da Qing Long Tang is a combination of Ephedra Tang and Yue Maid Tang. The evidence of this case is superficial but not allowed to sweat, internal heat can not be crossed externally, thus annoyed and agitated also, so the main body of this formula which is a combination of Ephedra Tang and Yueh Yu Tang is used”. In this case, the patient had fever, chills, heavy body, swelling, white and thick moss for the Sun’s superficial evidence of unresolved dampness, and chest tightness and irritability, with a floating and slippery pulse for Yangming internal heat. The treatment was based on dispersing wind-cold and clearing internal heat, and Da Qing Long Tang was given with extra flavor. At the same time, Yue Mudan Tang is also a good formula used by Feng Lao for treating edema in clinical practice.
Third, the clear identification of the disease, the dark identification of the formula evidence
The above mentioned mostly refers to the early stage of the disease or the early stage of chronic kidney disease, where there is only slight hematuria or proteinuria, and even there are not many identifiable symptoms, we often apply the mode of thinking. Chronic kidney disease is a chronic progressive disease, the clinical use of a variety of treatment options sometimes not significant, then we often first identify the disease, the disease here refers to both the name of the disease in Western medicine, but also refers to the definition of Chinese medicine, such as edema disease, vomiting disease, headache disease, back pain disease, thirsty kidney disease, etc., and secondly, on the basis of knowledge of the mechanism to identify the prescription evidence.
Edema disease is the most common evidence of kidney disease, which can be seen in both early and late stage patients. Firstly, we have to identify the edema of what disease, primary glomerulopathy or secondary glomerulopathy, followed by the selection of prescriptions, warming Yang and promoting water with Zhen Wu Tang, Ren Ren Ren Tang, Ling Gui Zhu Gan Tang; invigorating Blood and promoting water with Angelica Paeoniae San, Angelica Bella Bitter Ginseng Pill, Pu Ash San; promoting lung and promoting water with Ma Huang and Phyllanthus Tang, Da Qing Long Tang, Yue Spleen Tang; benefiting Qi and promoting water with Fang Ji Huang Qi Tang, Fang Ji Fu Ling Tang; nourishing Yin and promoting water with Pig Ling Tang and so on, and finally. Finally, add or subtract the formula with the disease mechanism, whether to attack more than tonic or tonic more than attack.
Case 6 Li, 63 years old, was first seen on August 12, 2010. Complaint: recurrent episodes of edema for more than 4 years. The patient was diagnosed with “type 2 diabetes mellitus and coronary heart disease” in 1999, and was admitted to the hospital in 2005 with the diagnosis of “diabetic nephropathy” after finding increased foam in the urine. He was treated with insulin to lower glucose and Irbesartan to lower blood pressure. He had swelling of the eyelids and lower limbs, aggravated by activity, weakness and shortness of breath, cold pain below the waist; dizziness, palpitations and chest tightness; dry stools, one line in 2 or 3 days; nocturia 2-4 times/night. The tongue is light red, with a slightly white and greasy coating, stagnation at the base of the tongue, and a weak pulse. 24h urine protein quantification: 3.21 g/24h. Renal function: Cr: 165 mmol/L, BUN: 12.4 mmol/L, UA: 462 mmol/L. Diagnosis: chronic renal failure. Diagnosis: internal accumulation of turbidity and toxicity, blood and water are unfavorable. Treatment: Promote blood circulation and water circulation by removing turbidity from the internal organs. In the article “Jin Kui Yao * abdominal fullness and cold hernia with persistent food disease”, the pain under the hypochondrium is partial, feverish, and the pulse is tight and stringent, this is also cold, so it is appropriate to use warm medicine to subdue it. Prescription: Rhubarb and Radix Pseudoginseng Soup with Radix Angelicae Sinensis, Ren Ren Tang and Fangji Huangqi Tang with addition and subtraction. Prescription: 12g of Rheum palmatum, 15g of Radix Aconiti (decoction first), 60g of Astragalus, 15g of Radix Ginger, 15g of Radix Angelicae Sinensis, 15g of Radix Paeoniae, 9g of Rhizoma Ligustici Chuanxiong, 30g of Poria, 15g of Rhizoma Zedoaria, 30g of Rhizoma Atractylodis Macrocephalae, 6g of Radix Glycyrrhiza Uralensis. 26 October 2010, follow-up examination: 2 months after taking the above, edema of the lower limbs disappeared, fear of cold improved, urine normal, stool twice a day, dilute. 24 hours urine protein quantification: 2.09%. 24-hour urine protein quantification: 2.09g/24h, Cr: 135mmol/L BUN: 15.52mmol/L, UA: 387mmol/L. At present, the patient has been taking the medication for two years, the quality of life has been improved, no obvious complaints of discomfort. 24-hour urine protein quantification: 1.32g/24h. renal function: Cr: 143mmol/L, BUN: 11.8 mmol/L.
IV. Integrating Western medicine with Chinese medicine, connecting ancient and modern
Some people think that we should cultivate pure Chinese medicine, that is, Western medicine should not be too good. I think the real combination of Chinese and Western medicine is to cultivate talents with the level of combination of Chinese and Western medicine. The foundation of Western medicine is great, and the thinking of Chinese medicine is strong; know the shortcomings of Western medicine and the strengths of Chinese medicine; face patients, know when to choose Chinese medicine treatment, when to choose Western medicine treatment, this is the highest level.
So what is the highest level for nephrologists? To combine macroscopic disease identification with microscopic pathology. The identification of disease has been mentioned above, so how to combine micro pathology? For example, there are five common pathological types of primary nephrotic syndrome: microscopic lesions, focal segmental glomerulosclerosis, thylakoid glomerulonephritis, membranous nephropathy, membranoproliferative glomerulonephritis, in addition, there are also secondary renal diseases and so on. Modern medicine has different medication regimens for different pathological types, and it is still not advisable to refuse any hormone or immunosuppressant treatment, regardless of whether you choose Western medical treatment or purely Chinese medical treatment. What’s more, some pathological types must be modern medical intervention, such as crescentic nephritis, the slightest hesitation, the patient will be plunged into the abyss of chronic renal failure.
Case 7 Yan, male, 58 years old. Complaint: found abnormal urine color for 3 months, blood creatinine elevated for 1 week. History: 3 months ago after exertion, urine urine color is thick tea, no urine volume decreased, accompanied by weakness. 2 days ago to check kidney function: blood creatinine: 426umol / L, urea nitrogen: 27mmol / L, potassium: 5.8mmol / L. Urine routine: occult blood: 3 +, protein: 2 +, to “hematuria, proteinuria to be investigated”. He was admitted to the hospital. On 2010-10-28, he was admitted to the hospital with the following symptoms: weakness, dry mouth with oral ulcers, chest tightness and shortness of breath, dizziness with headache, nausea, coldness in the limbs, increased foam in the urine, red urine, bowel movements, and mild swelling of both lower limbs. 2010-10-28: urine routine: protein 1+, occult blood 3+; urine sediment: red blood cells: full field, deformation rate 50%, no white blood cells; blood routine: hemoglobin: 99g/L, platelets. 76*10~9/L; blood biochemistry: BuN 29.8mmol/L, Scr 465umol/L, 24-hour urine protein quantification: 1.14g/2800ml immune series: ANA: 1:3200; ds-DNA negative; SSA: positive; RNP antibody: positive; ultrasound of both kidneys: left kidney 11.5*5.4cm, right kidney 11.2* 5.6cm; electrocardiogram: atrial fibrillation. Ventricular rate 67-72 beats/min; admission diagnosis: systemic lupus erythematosus, lupus nephritis; acute renal failure. Western medical analysis: acute renal failure? Monistic consideration: type IV lupus nephritis is likely, but there has been no decrease in urine output; binary consideration: glomerular disease combined with drugs secondary to interstitial tubulopathy. TCM diagnosis: Taiyin-Shaoyin combination disease, deficiency of kidney yang and stagnation of veins. Treatment: Methylprednisolone 48mg orally once daily. Chinese herbal medicine was given to warm yang and benefit qi, resolve blood stasis and relieve water retention. Zhen Wu Tang, Fang Ji Fu Ling Tang and Angelica Paeoniae San were given orally. On November 24: renal function: blood creatinine 226umol/l, BUN 27.1mmol/l, blood routine: white blood cell: 7.23*10~9/L, hemoglobin: 104g/L, platelet: 107*10~9/L. Follow-up at outpatient clinic for improvement. December 2010 The patient was readmitted to the hospital on December 31, 2010: the patient had fever after catching cold 20 days ago, coughing and sputum, wheezing, Tmax 39.0℃, morning fever, chest X-ray on December 14 in our outpatient clinic: symmetrical thorax, thickened lung texture, lamellar high-density shadow in the right lung; blood routine: WBC 4.2×109/L, RBC 2.23×1012/L, Hb 82g/L, PLT 38× 109/L, urine routine: BLD 3+, PRO 2+, so on the same day in Beijing Sanjia West Hospital, the diagnosis of lung infection, pulmonary fungal infection, given static Maspine 1g, 3 times a day; Dafukang 0.2g, 1 time a day; anti-infection treatment for 11 days, stop Dafukang, maintain oral cefuroxime 0.5g, 3 times a day anti-infection. The lamellar shadow was similar to the previous one, with interstitial lesions in both lungs, bilateral pleural effusion, pericardial effusion, ascites, and still coughing and sputum. The body temperature is 37-38.5℃, mild edema of both lower limbs, coughing yellowish white sputum, shortness of breath, wheezing when moving, no chest pain, dry throat, sore tongue, chapped mouth, appetite, little food, dry stool, 1 line per day, urine volume of about 1000ml per day, sleep is possible. Evidence: deficiency of spleen and dampness, deficiency of lung yin. Treatment: Strengthening the spleen and resolving dampness, nourishing Yin and clearing the lung, resolving phlegm and relieving cough. Recipe: Mulberry Bark 15g, Ground Bone Bark 15g, Raw Gypsum 15g, Almond 10g, Qian Hu 10g, Radix Platycodon 10g, Hou Pu 10g, Gua Pou 15g, Angelica Sinensis 10g, Mai Dong 10g, Radix Rehmanniae 20g, Peach kernel 10g, Shen Qu 10g, Radix Glycyrrhiza Uralensis 10g, Malva 10g. 2011-12-10 Urine routine: protein +/-, occult blood 1+, red blood cells 3-6/-. HP; routine blood: white blood cell: 6.31*10*9/L, hemoglobin: 125g/L, platelet: 104*10*9/L. Blood biochemistry: urea nitrogen 7.2mmol/L, creatinine 124umol/L, uric acid 495umol/L. Immune series: ANA: 1:1000; IgA, IgG, IgM, complement C3 normal. Still under outpatient follow-up.
Regardless of sutra and prescriptions, as long as they can cure the disease, they are good prescriptions, and there is also this image of discriminatory relationship between doctors and diseases. As a doctor, no matter working in a tertiary hospital or a primary hospital, treating the disease and keeping the patient is the basic guideline that every doctor should abide by. In the face of a disease, neither Chinese nor Western should be biased, and which method should be chosen if it has immediate effect, especially for the diagnosis of modern medicine, CT and MRI are also essential for us TCM doctors. My mentor, Prof. Chen Yipu, often says: “I am not afraid of not being able to cure any disease, but I am afraid of not being able to see through it; Mr. Feng Shilun also does not oppose the application of hormones in the clinical treatment of kidney disease.
Let us continue our belief in fighting against diseases through continuous exploration and discussion, and be a realistic modern doctor!