|Year : 2016 | Volume
| Issue : 1 | Page : 3-7
A Restricted Understanding of Dr. Xu Songnian's Academic Thoughts
Wenshu Ge, Yueyi Deng
Department of Nephrology, Long Hua Hospital, Shanghai University of Traditional Chinese Medicine, Xuhui District, Shanghai 200032, China
|Date of Web Publication||1-Feb-2016|
725 Wan Ping South Road, Xuhui District, Shanghai 200032
Source of Support: None, Conflict of Interest: None
This paper introduces academic thoughts and clinical experience of Xu Songnian, a famous modern clinical Traditional Chinese Medicine (TCM) doctor in Shanghai. He studied medical knowledge under Ding Jiwan's guidance. Dr. Ding Jiwan was the descendant of the Zhang Family Internal Medicine. After accumulating clinical experience for a decade, Xu Songnian had concluded unique insights in the treatment of miscellaneous diseases. Dr. Xu put his concentration on the development of renal disease treatment in middle age and gradually formed a set of theoretical system in clinical experience, which made great contribution to the later TCM renal disease development. This paper will give restricted understanding of Dr. Xu's academic thoughts and make a brief introduction of it.
Keywords: Academic thoughts, experience of renowned doctor, Xu Songnian
|How to cite this article:|
Ge W, Deng Y. A Restricted Understanding of Dr. Xu Songnian's Academic Thoughts. J Integr Nephrol Androl 2016;3:3-7
| Introduction|| |
Ding School was one of the four Meng River Schools, with Ding Ganren as its representative. Having learned enough medical knowledge, Ding Ganren practiced medicine in Meng River Town of Wujin District in Changzhou, and later moved to Wuxi and Suzhou successively. Then he came to Shanghai and soon after, he honored reputation there by his excellent medical skills. His achievement was broadcast around, so many patients came to Shanghai to seek treatment from him. Besides serving as a doctor, Ding Ganren had also recruited hundreds of disciples nationwide, gradually, Ding School coming into being. Ding Menggan, Ding Ganren's son, passed away in his early age, so the eldest grandson Ding Jiwan inherited the family's medical property. Xu Songnian acquired medical knowledge under the guidance of Ding Jiwan.
Xu Songnian, born in January 1990, was a member of China Democratic League. He once served as the headman in nephrology group, Shanghai Association of Chinese Medicine, Committee Member of Internal Medicine Society, and Chinese Medical Association. He graduated from Shanghai Traditional Chinese Medicine (TCM) Specialized Training College in 1936. Xu Songnian had learned so much medical knowledge from Ding Jiwan, which helped him make a solid foundation in the field of Chinese medicine. With reference to Ding's experience with internal injury, Xu Songnian gradually formed a system of his own.
| Etiology and Pathogenesis of Chronic Kidney Disease|| |
Basic pathogenes of hematuria
Hematuria is termed Niao Xue or Sou Xue in the Inner Canon of Yellow Emperor (the Earliest Medical Classics in China). The bleeding is mainly caused by the blood which fails to circulate along channel and flows out of its path. In general, predecessors held that hematuria was often caused by retention of dampness-heat in the bladder or by the weakness of the spleen and kidney. However, Dr. Xu proposed that bleeding be differentiated into deficiency and excess patterns. As for the excess pattern, exuberant heat and frenetic blood moving were the main factors. As for the deficiency pattern, hematuria might appear when the blood loses its attachment in the presence of qi deficiency. Hematuria may also be caused when deficiency fire scorches channels due to Yin deficiency with excessive internal heat.
Basic pathogenesis of edema
Nephrotic syndrome in modern medicine, corresponds to the category of "water swelling" whereas protein corresponds to the "Jing (essence)" category. Protein is the essence of the human body and basic substance of Kidney Yin source. The viscera accumulate all the essence in the kidney, so there is a famous saying "essence is stored in the kidney" in Plain Questions · On True Words of the Golden Chamber (Su Wen · Jingui Zhenyan Lun one chapter in the Inner Canon of Yellow Emperor).  In Dr. Xu's opinion, excessive protein loss from urine, is attributed to kidney qi insecurity and genuine Yin depletion. For this reason, priority should be given to the kidney treatment. In clinical practice, Dr. Xu advocated that with view to the qi activity of triple energizer, the treatment of edema should start with the lung, spleen and kidney. The key to treat nephrotic syndrome was to tonify spleen, warm the kidney, clear away heat, and disinhibit water. Among them, clearing away heat and disinhibiting water was also an innovative method put forward by Dr. Xu.
Basic pathogenesis of kidney-wind edema, anuria and vomiting, and deficiency-consumption
There was no clear record about chronic renal failure (CRF) in ancient literature. In Dr. Xu's opinion, the clinical manifestations such as nausea, vomiting, oliguria, fatigue, chest tightness, and palpitations in CRF, bear a resemblance to some extent to "deficiency-consumption", "anuria and vomiting" and "kidney-wind edema" in medical literature. For these terms, two ancient medical books had mentioned. In Supplement to and Compilation of Diagnosis and Treatment,  a book in the Qing Dynasty, it mentioned "Patients with anuria and vomiting … (they would definitely) suffer from the urinary stoppage and unreasonable vomiting between morning and evening. This is due to accumulation of turbid pathogen in the triple energizer (sanjiao), which prevents healthy qi from descending. As a result, urine obstruction in the lower part of the body and vomiting in the upper part ensue. Consequently, Yin and Yang would be blocked and exhausted. This is very dangerous because the patient will die in one-day." Another book, Plain Questions·Treatise on Strange Diseases  (Su Wen· Qi Bing Lun) recorded, "there are patients whose bodies suffer from swelling and their pulses are large and tight. They do not seem to be thin if their bodies are not aching. However, they are unable to eat or eat less … This is called kidney-wind edema because something is wrong with their kidneys." Dr. Xu deemed that in the later stage of CRF, deficiency of both the spleen and kidney serves as the major cause whereas dampness-heat serves as the minor cause. Dampness-toxin and obstruction appear at the same time. Consequently, the clear, refined substance could not flow out, and the foul substance could not be excreted regularly. Clinically, this would lead to such symptoms as vomitting, nausea, oliguria, pruritus, loss of appetite, etc. If no further treatment is received, it would be transformed both cardiac and nephretic failures, giving rise to coma, convulsions, etc.
| Treatment and Diagnosis of Chronic Kidney Disease|| |
Management of edema
According to Jingyue Complete Works·Swelling  (Zhongjing Quanshu · Zhongzhang a medical literature in the Ming Dynasty), Dr. Xu emphasized the principle of regulating fluid passages, gasification of dampness toxin and obstruction and simultaneous treatment of the lung, spleen, and kidney. The original statement in Jingyue Complete Library Swelling was "some symptoms, like edema, are related to the lung, spleen, and kidney. The appearance of edema is determined by the kidney. However, it can be evaporated into gaseous substance by the organ of the lung. Moreover, it is the common sense that water can be filled by earth. In the medical perspective, the spleen serves as the role to produce "earth". Accordingly, when something is wrong with the lung, the gaseous substance cannot be transformed into essence, but into water. The "soil" from the spleen cannot fill water. Thus, the water cannot be released by some organs but deposited in the spleen. In this condition, edema appears…"
Treatment of lung
The lung, located in the upper energizer, is a tender organ, and is the organ to regulate watery substances in the human body. If the lung fails to spread and descend, the opening and closing of the striae and interstices will be affected, resulting in edema. As to the method of treatment, Dr. Xu advocated "opening the channel to empty the turbid" - sweating and diuresis. He also created a medical formula with the effects of diffusing the lung and clearing away heat so as to promote diuresis. The above mentioned formula consists of diffusa, Cicada, Paris polyphylla, dandelion, Radix Isatidis, raw rice kernel, stigmata maydis, TianZi herb, huoyu herb, licorice, rhizoma imperatae, etc. Some ingredients in this formula, like diffusa, Cicada, Paris polyphylla, dandelion, Radix Isatidis, Tianzi herb, huoyu herb, and rhizoma imperatae, have the effects of clearing away heat and toxin whereas raw rice kernel could fortify the spleen and percolate dampness, and stigmata maydis has an excellent effect on edema. If severe qi deficiency is present, Dr. Xu would add Cimicifuga and Codonopsis pilosula to raise yang, lift the sunken, tonify Qi and Yin. This is particularly effective in clinical treatment.
Treatment of spleen
The main functions of the spleen is to transform and transmit nutrient substances. If the spleen does not work, the fluids, and foods in the body cannot be transformed into nutrient substances. The abnormal circulation will make water deposited, resulting in edema. When it comes to spleen treatment, Dr. Xu emphasized three methods, i.e., fortifying the spleen to move water, drying dampness to move water and warming and transforming dampness. Dr. Xu was good at prescribing formulas such as Astragalus Center-tonifying Decoction (Huáng Qí Bù Zhāong Tāang), Stephania Root and Poria Decoction (Fáng Jŭl Fú Líng Tāang), Spleen-Strengthening Decoction (Shí Pí Tāang) and Stomach-Calming Poria Decoction (Wèi Líng Tāang). Moreover, Dr. Xu was also an expert of dietetic invigoration. He suggested using black carp soup to warm the stomach and make the water in the body circulate regularly. Together with the soup of Phaseolus calcaratus and fistular onion, Atractylodes and mulberry bark were also helpful to clear and regulate the lung and spleen and to promote urination and alleviate edema.
Treatment of kidney
The kidney is the congenital origin of life and is a water organ which controls bowel movements and urination, restricts bladder's function and regulates water metabolism, and excretion of the whole body. The deficiency of the Qi (vital essence) in the kidney may cause edema and urination disturbance. Based on Yin-Yang pattern identification, Dr. Xu would respectively choose two methods, kidney nourishing for diuresis, and kidney warming for diuresis. In clinical treatment, True Warrior Decoction (Zhāen Wŭu Tāang), Polyporus Decoction (Zhŭ Líng Tāang) and Life-Saving Kidney Qi Pill (JÌ Shāeng Shèn QÌ Wán ) were often prescribed to treat edema.
Treatment of hematuria
Dr. Xu advocated clearing heat and purging fire and nourishing Yin and cooling the blood as the basic principles to treat hematuria. In his opinion, the hematuria caused by chronic pyelonephritis, chronic glomerulonephritis, nephrophthisis, and nephroptosis is an enduring condition accompanied by kidney qi deficiency. If kidney Yin deficiency with vigorous fire is present, the warming method was advocated. Clinically, Major Yin-Supplementing Pill (Dΰ Bŭu Yŭln Wán) is prescribed in combination with gardenia, goldthread and scutellaria baicalensis to clear heat-fire, and donkey-hide gelatin and radices peonie alba to enrich Yin and nourish the blood. For patients with kidney Yang deficiency, Chinese yam Pill with Cimicifuga, Codonopsis pilosula, and Astragalus mongholicus is prescribed. Besides, for people with urinary infections complicated with hematuria, Dr. Xu liked to use Semen sojae preparatum, Schizonepeta, and gardenia to clear heat-fire and control hematuria, with remarkable effects. In hematuria treatment, although Dr. Xu continued to take ancient classics as a principle, he was never constrained by them for he was good at using other methods to improve his own treatment methods. For example, in treating hematuria, the use of semen sojae preparatum was first proposed by Xu Donggao (a famous doctor). "For hematuria patients, drugs that are cold in nature cannot cure them completely. Acrid drugs should be added. If this still doesn't work, the warm drugs should be used by adding wine to enhance the efficacy." Dr. Xu skillfully and creatively used previous experience of others. Now that hematuria includes both hematochezia and hematuria Dr. Xu associated semen sojae preparatum with hematuria.
Treatment of chronic renal failure (deficiency-consumption, anuria and vomitting, and kidney-wind edema)
Dr. Xu held that CRF was caused by both the spleen and kidney deficiency and the deposited dampness toxin. Therefore, attention should be given to both the healthy qi and pathogenic factors. Moreover, he divided CRF into three stages, based on pattern identification:
Early stage (retention of dampness toxin in the center, weakness of the spleen and stomach)
In this stage, patients often present the symptoms of oliguria, lumbersome body, anorexia, nausea and vomiting, a deep thready pulse, loose stools, and a swollen tongue, etc. At this time, the methods of warming the kidney and fortifying the spleen, harmonizing the middle, and detoxification are needed. The commonly-used formulas are Spleen-Warming Decoction (Wāen Pí Tāang) and Coptis gallbladder-warming Decoction (Huáng Lián Wāen Dŭan Tāang).
Middle stage (lung, spleen, and kidney obstruction)
Patients in this stage are often found the symptoms such as edema, a pale complexion, nausea and vomiting, urinary smell in the mouth, weakness, anxiety, dry stools, a turbid slimy tongue, and a deep wiry pulse. The methods of warming the kidney and detoxification, and regulating the triple energizer are needed. Kidney-Warming and Toxin-Resolving Decoction (Wēn Shèèn Jiŭe Dú Tāang) and is the best choice.
End stage (deficiency of the kidney with stirring wind)
In this stage, patients often suffer from an abnormal state of mind, coma and delirium, hands grouping in the air, convulsions, dry stools, anuria, a red and dry tongue and string pulse, etc. Accordingly, the methods of cooling blood and detoxification are needed. Rhinoceros Horn and Rehmannia Decoction (XĬ Jiăo DÌ Huáng Tāang), Coptis Toxin-Resolving Decoction (Huáng Lián Jiŭe Dú Tāang), and Bovine Bezoar Qi-Guiding Decoction (Niú Huáng Chéng QÌ Tāang), etc., are often prescribed.
It is worth mentioning that when treating CRF, Dr. Xu often made simple and convenient prescriptions according to the restricted social environment and living conditions at that time, to let patients get medicinal materials nearly and conveniently. For example, Chinese patent drugs Two Matured Substances Decoction (Ér Chén Tāang) added with 3 slices of ginger, 4.5 g coptis could be used to treat early stage renal failure; or 6 g raw, dry ginseng boiled in water was used for patients to take Peaceful Palace Bovine Bezoar Pill (Ān Gōng Niú Huáng Wán).
Treatment of albuminuria
As to the treatment of nephropathy, physicians of all generations took warming yang to move water as a regular method. In albuminuria treatment, Dr. Xu followed the principles of Yin and Yang mutually aiding each other and tonifying the kidney and used kidney-warming and Yin-enriching medicinals simutaneously. In Dr. Xu's mind, kidney is a water-fire organ which contains both Yin and Yang, and they are insaparable. Accordingly, he created the "kidney-strengthening formula" to treat albuminuria through nourishing kidney essence and urine protein. In clinical practice, Center-Supplementing and Qi-Boosting Decoction (Bŭu Zhāong Yì Qì Tāang) created by Donghuan LI (a renowned physician) in combination with Kidney-Strengthening Formula (including ingredients of Yam, Rehmannia, Asarum, Circium japonicum, Pyrrosia lingua, motherwort, Eucommia, psoralen, raspberry, and walnut kernel) created by Dr. Xu were often used as the principal formula for the treatment of albuminuria.
In this prescription, Rehmannia could nourish Yin essence, and psoralen, whereas Eucommia, walnut meat, and raspberry were useful to tonify kidney. Especially, Asarum in the prescription could clear away obstructions in the body, make the blood and sweat flow circularly and restrain pains in the body. In the Chinese ancient medical literature, Herbal Classic (Ben Cao Jing Shu), there were quotations recorded like this, "(Asarum can) promote sweating and blood circulation, nourish the liver and gallbladder and connect vital essence due to its nature of pungency." Therefore, Asarum, when used in combination with Rehmannia, could nourish the organ and clear away obstruction; when with psoralen, Eucommia, and raspberry could enhance the effects of warming the kidney and strengthening essence, to eliminate lumbago, foot and knee flaccid, etc.
If proteinuria patients take hormone and then the phenomenon of relapse appears, Yang-boosting drugs, such as herbs Epimedium, Curculigo Orchioides gaertn, cornu cervi degelatinatum, and cinnamon, should be added to replace the function of hormone. People who have a prolonged administration of hormones are often susceptible to colds, pharyngitis and others, which would make the condition unstable. Dr. Xu held this was caused by excessive protein loss, making Yin essence in people's body deficient and by the imbalance of water-fire. So, the useful prescription at this time often contains Rehmannia, turtleback, Rhizoma Anemarrhenae, cypress, figwort, rhizome, selfheal, diffusa, Circium japonicum, Pyrrosia lingua, rice kernel, Rhizoma Dioscoreae hypoglauce, and Chinese magnoliavine, etc. If patients met with spleen deficiency, insecurity of the wei-exterior, deposited dampness and heat, repeated skin eczema and itching, and urine protein difficult to decrease, the best choice was Jade Wind-Barrier Powder (Yù Píng Fēeng Săan) added with some heat clearing and dampness eliminating drugs, such as Astragalus mongholicus, Saposhnikovia divaricata or Notopterygium root, Atractylodes, rice kernel root, stigmata maydis, fructus kochiae, dictamni cortex, Rhizoma dioscoreae hypoglaucae, matrine, and ebony and red date.
Treatment of chronic kidney disease
Use of insect drugs to activate blood circulation and dissipate blood stasis
In accordance with the principle of "opening the channel to empty the turbid" and blood-water circulation theory, Dr. Xu put forward that blood circulation and stasis drugs should be taken to treat refractory nephrotic syndrome, namely, edema patients. In the book Synopsis of Golden Chamber· Co-treatment of Gas Pulse and Symptoms (Jingui Yaolüe· Shuiqibing Mai Zheng Bingzhi),  there was a statement "blood noncirculation makes edema." This narration provides a theoretical foundation for activating blood circulation and dissipating blood stasis in edema treatment. For example, in renal disease treatment, Dr. Xu was likely to add Ligusticum wallichii, red flower, angelica, teasel root, and Achyranthes in the prescription. Besides, he liked to use insects and turtleback drugs when treating chronic kidney disease (CKD). Dr. Xu often told patients to take earthworm tablet to dissipate blood stasis. Moreover, Daididang pill was also a good choice, which stemmed from the book Zhunsheng. In this book, it said Zhang Zhongjing (a famous doctor in the East Han Dynasty) was afraid that leech and other toxic drugs would have a strong effect, so descendants used Daididang pill to replace it. In blood circulation, Dr. Xu thought the animal medicinals were different from herbal drug. So it was suitable to treat intractable proteinuria. The above methods had a deep influence on the proteinuria decrease of intractable kidney disease, creatinine stability, and extended the time coming to virus disease. Up to now, in clinical treatment, many doctors still use the above experience to treat CKD.
Use of local medicinal herbs according to local conditions
Professor Xu was a traditional Chinese doctor in Shanghai and was enlightened and inspired by the Ding family, so he had widely absorbed lots of skills and experience when studying in Shanghai. Located in the South of Yangtze River, the climate in Shanghai is warm and humid, which is different from the North, dry and cold, so the floras here also have its own characteristic. After years of accumulation and the studies of western medical pharmacology, Dr. Xu had developed herbal medicine with local characteristics to treat renal diseases according to local conditions. In the book Materia Medica of the Kaibao Era,  the effects of many herbs were recorded. For instance, Chinese peashrub root could clear away the lung-heat and nourish the spleen, and is indicated for dizziness, cough, asthma, infirmities, and bleeding; Chinese violet is bitter in taste, slightly pungent and cold in nature; patients who suffer from blood deficiency could take angelica and Astragalus mongholicus; patients with deposited heat and damp ache could add Poria cocos, Plantago seed, Honeysuckle and Achyranthes to clear away heat and promote diuresis. The method of clearing away heat and promoting diuresis was creatively put forward by Dr. Xu. Through this method, lung obstruction could be cleared, so the edema would naturally disappear. Herba violae with Achyranthes could remove heat and dampness in the kidney and bladder, and Poria cocos, rice kernel, and rice kernel root could make the spleen circulate regularly and eliminate edema. With reference to modern pharmacological research, Dr. Xu noticed that nightshade, humid euphorbia, and dandelion could inhibit Staphylococcus aureus, hemolytic Streptococcus, Pneumococcus, meningococcus, F's dysentery Bacillus, Bacillus typhi and Pseudomonas aeruginosa, Dr. Xu held that these Chinese medicines had excellent effects in treating hematuria and increasing white blood cells in urine. In Bie record (Bie Lu), it recorded, "Ranunculus sceleratus can calm the vital essence in the kidney and spleen, and nourish Yin-essence and skin. In addition, in the book Materia Medica of the Mindong Region,  it said, "huoyu herb can nourish the lung, vital essence, liver and kidney, which is indicated for nyctalopia, night sweats and lumbago. This flexible application of medicine had gotten the effect in spleen deficiency and increased proteinuria. The above prescriptions belonged to Dr. Xu's special drug usage characteristics in accordance with different conditions and time.
| Conclusions|| |
Although Dr. Xu took ancient classics as the principle, he was not constrained by the classics. He was good at using other methods to improve his own treatment methods. He also had strong sympathy for patients, sighed with the social conditions at that time, and created many dietary therapies to help people in need. The dietary therapies often made use of local drugs. It was easy to operate and had basic effect in treating renal diseases. This paper briefly narrates Dr. Xu's clinical experience with CKD, but cannot cover all the valuable experience of Dr. Xu, so it is only an insight into Dr. Xu's clinical experience. Dr. Xu's TCM kidney disease treatment system makes great contribution to TCM kidney development, and he deserves respect by younger generations.
Financial support and sponsorship
This work was supported by the development of traditional Chinese medicine, a comprehensive action plan for three years in Shanghai (No. ZY3-cccx-1-1001).
Conflicts of interest
There are no conflicts of interest.
| References|| |
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