Appreciation of Two Cases of Aplastic Anemia Treated by Professor Liang Yijun
Professor Liang Yijun was born in 1927 into a TCM family in Beijing. She served as director of the TCM Internal Medicine Department at China-Japan Friendship Hospital and was a national-level expert. In 1990 she was named by the two ministries and one bureau as one of the first cohort of nationally renowned veteran TCM physicians, a state-designated mentor for inheriting academic experience, and a recipient of the State Council special allowance. She specialized in treating blood diseases, difficult internal-medicine conditions, and gynecological diseases with Chinese medicine. This article excerpts two of her cases of aplastic anemia, from which we may learn her approach.
Case 1
Chen, male, 36. First seen by Professor Liang on February 1, 1982. He had had recurrent palpitations and dizziness for over two months. In 1981, after an external contraction with high fever treated with terramycin and painkillers, he developed a pale complexion and palpitations; blood tests showed hemoglobin 50 g/L and bone marrow aspiration showed "severe aplastic anemia." On February 1, 1982 he was admitted to China-Japan Friendship Hospital; admission labs showed abnormal complete blood count and platelets. He had palpitations and dizziness, vertigo on slight exertion, lightheadedness on urination, profuse sweating, and weakness of the limbs; diet and bowel/bladder function were normal. His complexion was pale, with scattered petechies on the anterior chest and left groin. The tongue was pale white with a thin brownish coating; the pulse was wiry, slippery, fine, and rapid.
Professor Liang diagnosed TCM "blood exhaustion" (xue lao), differentiated as extreme yin-blood deficiency, yin failing to constrain yang, leading to yin deficiency with yang rising, marrow exhaustion and blood dryness, and the kidney failing to engender blood. The treatment principle was to nourish yin and boost qi, nourish blood and constrain yang.
First-visit prescription: Shengdi (Rehmanniae Radix, raw) 30 g, Shudi (Rehmanniae Radix Praeparata) 30 g, Huaishanyao (Dioscoreae Rhizoma) 30 g, Heshouwu (Polygoni Multiflori Radix) 25 g, Wuweizi (Schisandrae Chinensis Fructus) 15 g, Sangshen (Mori Fructus, mulberry fruit) 25 g, Tusizi (Cuscutae Semen) 20 g, Gouqizi (Lycii Fructus) 15 g, Danggui (Angelicae Sinensis Radix) 15 g, Ejiao (Asini Corii Colla, ass-hide glue) 15 g (dissolved separately), Niuxi (Achyranthis Bidentatae Radix) 20 g, Mohanlian (Ecliptae Herba) 25 g, Sheng Muli (raw oyster shell) 25 g (decoct first), Huangqi (Astragali Radix) 30 g. One dose daily, taken morning and evening. Because the patient was seriously ill, he also received stanozolol (Kang Lilong) 20 mg each time three times daily, plus antibiotics, blood transfusions, and other supportive care.
On the second visit the patient reported frequent epistaxis, bloody stools, and low fever; the above formula was modified by adding Cebaiye (Platycladi Cacumen) 20 g, Diyu (Sanguisorbae Radix) 40 g, Nüzhenzi (Ligustri Lucidi Fructus) 30 g, Sanqi tablets 15 g, Zhimu (Anemarrhenae Rhizoma) 15 g, and Digupi (Lycii Cortex) 25 g. He was told that once bleeding and low fever were controlled, the added herbs should be removed; thereafter take Renshen (Ginseng) 5 g daily, together with Lutai Gao (deer fetus paste) 2 g/day.
With combined treatment through the end of March, his condition stabilized; his spirits improved, palpitations and dizziness at rest and on exertion resolved, appetite increased, and he could basically care for himself; heart rate was 80-90 bpm. But epistaxis, subcutaneous bleeding, and fecal occult blood recurred, with low fever, and he still needed 300 ml of blood every 5-7 days. In early May the decoction was shifted to clear heat, nourish yin, nourish blood, and subdue yang, using a modified Cangyu Qianlong Tang (Azure Jade Dragon-Subduing Decoction).
Prescription: Baishao (Paeoniae Radix Alba) 40 g, Shengdi 30 g, Mudanpi (Moutan Cortex) 15 g, Guijia (Testudinis Carapax, tortoise shell) 20 g, Longmu (dragon bone and oyster shell) 30 g each, Shashen (Glehniae/Adenophorae Radix) 20 g, Sheng Shigao (Gypsum Fibrosum, raw) 25 g, Shihu (Dendrobii Caulis) 20 g, Zhimu 15 g, Maogen (Imperatae Rhizoma) 40 g, Oujie (Nelumbinis Nodus Rhizomatis, lotus node) 40 g, Diyu 40 g, Cebai (Platycladi Cacumen) 20 g. In addition, Yunnan Baiyao was taken every 6 hours, a quarter of a vial each time, and Renshen 15 g was decocted separately daily.
Treating with this plan through early July, the bleeding tendency lessened markedly; infections became fewer and milder, and transfusion intervals lengthened from 5 to 7-8 days, with hemoglobin maintained at 30-35 g/L. At one point warming-kidney-yang herbs (Tusizi, Bajitian, Rougui) were increased, but because recurrent infection, fever, and bleeding became hard to control, treatment returned to modified Cangyu Qianlong Tang, which stabilized the condition.
In mid-September (fourth visit), the patient reported less bleeding and normal temperature; hemoglobin, red cells, white cells, and platelets remained low, so qi-, blood-, and kidney-supplementing, blood-engendering herbs were gradually added.
Prescription: Baishao 30 g, Shengdi 40 g, Mudanpi 15 g, Shashen 20 g, Maogen 50 g, Oujie 50 g, Shouwu 25 g, Hanliancao (Ecliptae Herba) 20 g, Xianhecao (Agrimoniae Herba) 20 g, Nüzhenzi 25 g, Huangqi 20 g, Danggui 10 g, Tusizi 20 g. Thereafter the dosage of qi- and kidney-warming yang herbs was gradually increased while prednisone was tapered.
By the end of October (fifth visit), bleeding was no longer obvious, temperature was normal and stable, spirits and strength had improved, transfusion intervals could stretch to 11 days, and hemoglobin had risen. Kidney-yang-warming and qi-boosting herbs were then increased to promote blood engenderment.
Prescription: Above formula plus Sheng Huangqi (raw astragalus) 35 g, Tusizi 30 g, Ejiao 15 g, Shudi 40 g, Bajitian (Morindae Officinalis Radix) 15 g, Rougui (Cinnamomi Cortex, cinnamon bark) 3 g, Dangshen (Codonopsis Radix) 20 g.
By the end of December, hemoglobin and red cells had continued to rise; since results were showing, the basic approach was unchanged.
Prescription: Dangshen 20 g, Baizhu (Atractylodis Macrocephalae Rhizoma) 20 g, Huangqi 30 g, Danggui 10 g, Baishao 15 g, Ejiao 15 g, Shudi 25 g, Shouwu 25 g, Nüzhenzi 25 g, Tusizi 10 g, Bajitian 15 g, Jixueteng (Spatholobi Caulis) 25 g, Chenpi (Citri Reticulatae Pericarpium) 15 g, Shanzha (Crataegi Fructus) 25 g, Rougui 3 g.
Treating through mid-March 1983, as the blood picture gradually rose, the patient's complexion grew ruddy, spirits and strength improved, temperature was normal, bleeding ceased, stool was occult-blood negative, and dizziness and palpitations were gone. Professor Liang then added Lujiaojiao (deer-horn glue) 20 g and had him take Lutai Gao or Lurong Jing (deer antler essence) orally. Treatment continued until January 20, 1984; through outpatient decoctions the blood picture normalized completely and he returned to work—719 days of treatment in all.
Case Two
Li, male, 23. First seen by Professor Liang on November 17, 1999. He had had dizziness and extreme fatigue for over half a year. Since April 1999 he had developed dizziness and fatigue for no reason; at a hospital in Shanxi he was diagnosed with aplastic anemia. Treated with prednisone and testosterone propionate plus intermittent transfusions, with poor effect. In September a repeat bone marrow aspiration showed markedly hypoplastic marrow consistent with aplastic anemia; he was given stanozolol, batilol, carbazochrome, vitamin K, and 200-400 ml of whole blood weekly, with little change.
Professor Liang differentiated this patient as dual deficiency of kidney yin and kidney yang, with essence and blood unable to be generated and transformed. The treatment principle was to warm and supplement both kidney yin and kidney yang, boost qi and engender blood.
First-visit prescription: Huangqi 40 g, Danggui 10 g, Baishao 20 g, Shudi 30 g, Shouwu 30 g, Nüzhenzi 20 g, Hanliancao 20 g, Tusizi 25 g, Gouqizi 20 g, Xianlingpi (Epimedii Folium) 10 g, Bajitian 10 g. Prednisone was gradually tapered.
On March 24, 2000 (second visit), the patient reported that after more than four months on the above formula he had not needed transfusion; hemoglobin was still low, but his general condition had markedly improved, strength had increased, he had had no external contraction, and no oral ulcers or epistaxis. His condition was stable, and the formula was continued with modifications.
Second-visit prescription: Huangqi 50 g, Danggui 10 g, Baishao 20 g, Shudi 35 g, Shouwu 40 g, Nüzhenzi 20 g, Hanliancao 20 g, Tusizi 30 g, Gouqizi 30 g, Xianlingpi 20 g, Bajitian 25 g. Added: Rougui powder 3 g, taken infused, to strengthen kidney-yang warming and engender blood.
On recheck on April 6, the blood picture had improved greatly and prednisone was stopped. Rougui was increased to 5 g and Sheng Huangqi to 60 g.
On May 10, labs continued to improve. On the prior formula, Rougui was increased to 7 g, Sheng Huangqi to 65 g, Shudi to 40 g, Gouqizi to 30 g, and Jixueteng 20 g was added. By June 2, his spirits and strength were those of a normal person, with no obvious discomfort, only a few small petechies on the inner arms; the blood picture had normalized. He was told to continue the above formula for a period to consolidate.
Aplastic anemia is a severe condition; from the TCM standpoint it is a deficiency syndrome, so treatment centers on supporting upright and securing the root. Professor Liang treated many such cases with good results. Per her own summary, yang-deficiency cases are easier to treat: warming kidney-yang herbs raise hemoglobin markedly. Yin-deficiency cases are much harder, requiring simultaneous nourishing of yin and supporting yang.
Both of Professor Liang's cases emphasize supporting upright. Case 1 focused on boosting qi and nourishing yin, using modified Cangyu Qianlong Tang. Case 2 focused on tonifying kidney yang and kidney yin, combining the Huangqi-Danggui Blood-Augmenting Decoction with the kidney-yin Six-Ingredient formula. Both patients received relatively large doses of herbs, following the principle that severe, stubborn illnesses require heavy doses; she prescribed without rigid convention, and both cases ended well. During treatment, Professor Liang also emphasized integrated Chinese-Western care: transfuse when transfusion was needed, use hormones when hormones were needed; only after the condition gradually stabilized did she taper them off, making treatment safer and more reliable.