Case 1

Case 1

Wang ××, male, 18 years old, a young man who had been sent to work in the countryside, was first seen in early October 1976. Two years earlier, after a cold, the patient developed facial edema, fatigue, joint pain throughout the body. He was admitted to the Second Affiliated Hospital of Lanzhou Medical College with a diagnosis of acute nephritis. After more than 20 days of Western medical treatment, the edema subsided, and the proteinuria decreased from (+++) to trace amounts. After discharge, the edema recurred due to recurrent colds and tonsillitis, leading to a return of edema, with proteinuria reaching (++++) again. Subsequently, the edema progressively worsened, and the patient requested to be discharged from the hospital for traditional Chinese medicine treatment.

Physical examination: body temperature was 36.6°C, pulse rate was 72 beats per minute, blood pressure was 16.0/12.0 kPa (120/90 mmHg), development was normal, nutrition was poor, the face appeared pale, and generalized edema was present, most notably in the feet and ankles. Heart and lungs were unremarkable, liver and spleen were not palpated, the abdomen was distended, with ascites present. Pulse was slow and weak, tongue coating was pale, with tooth marks and a thin white coating.

Laboratory tests: urinalysis showed proteinuria (+++), red blood cells 2–5 per low-power field, white blood cells 1–2 per low-power field, and a small number of transparent tubular casts. Blood routine: hemoglobin was 10 g/L, white blood cell count was 11,200/mm³, with neutrophils accounting for 66%, lymphocytes 34%. Blood cholesterol was 490 mg/mL, NPN was 40 mg/mL, total serum protein was 4.5 g/L, albumin was 2.1 g/L, globulin was 2.4 g/L. Western medical diagnosis: chronic nephritis (nephrotic type).

Traditional Chinese medicine diagnosis: the patient presented with pale complexion, fatigue, dizziness, tinnitus, lower back pain, leg discomfort, fear of cold with spontaneous sweating, generalized edema, and poor appetite. The pulse was slow and weak, especially in the two fingers of the wrist. The tongue was swollen, pale, with tooth marks and a thin white coating. The diagnosis was characterized by spleen and kidney yang deficiency, with water-dampness overflowing; the treatment should focus on warming the kidneys, strengthening the spleen, and eliminating water and reducing edema. The formula used was Jisheng Shenqi Tang with additions:

Sheng Di 10 g, Shan Yu Rou 6 g, Shan Yao 10 g, Dan Pi 6 g, Fu Ling 12 g, Ze Xie 10 g, Rou Gui 10 g, Fu Pian 10 g, Che Qian Zi 10 g, Niu Xi 10 g, Dang Shen 10 g, Sheng Shi Gao 20 g, Gan Cao 6 g, Yimu Cao 30 g, Su Jing 10 g, Chan Yi 10 g. The herbs were decocted in water and taken once daily. After more than a month of medication, the edema had largely disappeared, proteinuria remained (+++), red blood cells were 0–1 per low-power field, and white blood cells were 0–1 per low-power field. The patient’s mental state and appetite improved compared to before, and his fear of cold and spontaneous sweating also improved. The pulse remained slow and weak, and the tongue was swollen, pale, with tooth marks and a thin white coating. The formula was adjusted to remove Ma Huang and Sheng Shi Gao, and instead added San Ling, E Jue, Hai Cao, and Kun Bu each 6 g. After taking this formula for over 150 doses, the patient felt energetic and physically strong. A follow-up examination in September 1977 showed normal urinalysis, with blood cholesterol at 200 mg%. Subsequently, from 1979 to 1980, the patient underwent several follow-up examinations, and his overall condition remained good. Except for occasional white blood cells 0–1 per low-power field, urinalysis was otherwise normal.