Appreciation of a Case of Prof. Yin Huihe Treating Rheumatic Fever

A certain Guan, female, aged 10. After a cold she developed a high fever reaching above 41°C. A variety of antibacterial and anti-inflammatory drugs, including penicillin and streptomycin, were used, but the condition not only failed to resolve but tended to worsen. Blood testing showed an erythrocyte sedimentation rate of 100 mm/h, and the hospital diagnosed rheumatic fever, treating it with aspirin. Yet the temperature still would not come down, sweating increased daily, and she was extraordinarily listless.

Yin Huihe was invited in consultation. He saw a thin child, sweating profusely with a grimy face. Her chief complaint, from the onset, had been alternating chills and fever, fullness and oppression in the chest and hypochondrium, body pain, and a heavy, distended head. Her abdomen was distended, and she had not had a bowel movement for over ten days. The tongue was red with a dry, yellow coating; the pulse was rapid. Around the navel he felt lumps as hard as piled stones. Judging from the obstruction of the fu-organs, he determined that the persistent fever was due precisely to constipation, with interior heat having no way to discharge downward.

Alternating chills and fever are the indication for Xiao Chaihu Tang (Minor Bupleurum Decoction), so Prof. Yin Huihe decided to treat her with a modified Xiao Chaihu Tang.

First-visit prescription: Chaihu (Bupleurum) 9 g; Huangqin (Scutellaria) 9 g; Banxia (Pinellia) 9 g; raw Shigao (gypsum) 24 g (decocted first); Yuxingcao (Houttuynia) 24 g; Shandangen (Sophora tonkinensis root) 10 g; raw Dahuang (rhubarb) 6 g (added later).

After one dose, bowels moved and sweating stopped; the temperature fell to 38.2°C. She took another dose of the same formula and the temperature returned to normal. He then used Qingluo Yin (Collateral-Clearing Drink) to clear the remaining pathogen and consolidate the result; the child soon recovered her health. Repeated ESR tests stayed normal, and the diagnosis of rheumatic fever no longer seemed to hold.

In this case, Prof. Yin cured rheumatic fever with only two doses—an effect so rapid it is admirable. The key to success lay in adhering to the principle of treatment based on syndrome differentiation, rather than prescribing at will. Here the child showed the classic signs of Xiao Chaihu—alternating chills and fever, fullness and oppression in the chest and hypochondrium—so treating with Xiao Chaihu Tang as the principal formula was naturally well matched.

The Yuxingcao and Shandangen in this formula are, in TCM terms, heat-clearing, toxin-resolving herbs; modern pharmacology shows that such herbs often have antibacterial and anti-inflammatory effects. Yin added them chiefly because the patient had a red tongue with a dry, yellow coating. She also had constipation, so Dahuang was added to drain heat and move the bowels.

Rheumatic fever is a secondary disease caused by group A beta-hemolytic streptococcal infection and is an immune-mediated condition. In modern medical terms, after the body is infected with beta-hemolytic streptococci, the immune system produces large numbers of antibodies that mistakenly attack itself, while also activating T cells that specifically attack the body's own tissues; this ultimately damages organs such as the heart and triggers rheumatic fever. If treatment is not thorough, it can leave refractory sequelae such as chronic rheumatic arthritis and chronic rheumatic heart disease, affecting the patient for life.

Western medicine treats streptococcal infection mainly with antibiotics such as penicillin and streptomycin, adding aspirin once rheumatic fever appears. This is the classic textbook approach and is usually effective. But once it fails, Western medicine has few options—Western medicine has developed for only a short time, and the available drugs are limited.

Through several thousand years of development, TCM has built a vast library of formulas for syndrome differentiation and treatment; this is its most precious resource. I have always maintained that those studying TCM should focus on learning the classic TCM formulas and Chinese herbs of the dynasties. These are the most precious clinical experiences our ancient physicians worked out in practice, and medical fundamentals closely tied to clinical work. Master them, and when treating disease you can at least be purposeful rather than at a loss.

If a physician can master the indications of 500–3,000 formulas, clinical results will be good. If he can master more formulas and know the indications of most commonly used herbs, results will of course be better. Specialists should, besides memorizing formulas related to their specialty, also master a certain number of formulas for common diseases.

The classic cases in textbooks are actually rare in real life; real cases are far more complex than those in textbooks (whether TCM or Western). The cases introduced in medical-school courses usually involve a single disease, but patients seen in clinic are almost always disease composites, with multiple conditions and complex symptoms intertwined. Without a knowledge of symptomatic herbs and formulas for common diseases, it is hard to achieve results that satisfy patients.

Take the child in this case: hers was a typical case of rheumatic fever with a complex cause. Beyond rheumatic fever, she very likely had other conditions. The two intertwined, so that conventional treatments such as penicillin, streptomycin, and aspirin alone did not work. But while treating her rheumatic fever, Prof. Yin Huihe also used herbs to resolve her other problems, and the child's illness rapidly cleared.

This child was fortunate to meet a great clinician like Yin Huihe in the acute phase and have her problem solved. More often in reality we meet patients who have been repeatedly misdiagnosed, whose condition dragged on, and who finally suffer for decades from lingering illness. They may go on to develop more severe rheumatic heart disease, while also suffering from other intractable or chronic comorbidities—such as hypertension, diabetes, systemic lupus erythematosus, or Sjögren's syndrome.

For such patients, one can search every medical textbook and still find no perfect comprehensive plan, and treatment becomes all the more thorny. Any physician with some clinical experience knows that the complex cases I describe are the most common in the real world; the simple textbook classics are hardly ever encountered. So when we study medical knowledge, we must not confine ourselves to a narrow specialty.