Experience with Maxing Yigan Tang for Cancer Fever and Pain
Mahuang Xingren Yiyi Gancao Tang (Ephedra, Apricot Kernel, Coix and Licorice Decoction) comes from the Jingui Yaolüe (Synopsis of Prescriptions of the Golden Chamber). In the chapter "On Spasm, Dampness and Sunstroke: Pulse, Manifestations and Treatment, Part 2," there is a passage: "The patient has generalized pain and fever, which worsens in the late afternoon; this is called wind-warmth. This disease is caused by being exposed to wind while sweating, or by prolonged injury from taking cold; one may give Mahuang Xingren Yiyi Gancao Tang." The formula's composition is: "half a qian of Mahuang (Mahuang, nodes removed), one liang of Gancao (honey-fried), half a qian of Yiyiren (Coix seed), ten Xingren (apricot kernels)." It is decocted in one and a half zhan of water down to eight fen, strained, and taken warm; continue until a slight sweat appears, and avoid wind.
Mahuang Xingren Yiyi Gancao Tang mainly treats the pattern of both fever and generalized body pain. The late afternoon (ri bu) is the Shen period, i.e., 3 to 5 p.m. Most people's body temperature is highest at this time; patients with chronic-disease fever also have the highest temperature then, and "worsening in the late afternoon" refers to the patient's temperature peaking around 3 to 5 p.m.
This is rather different from the fever of acute patients; the temperature in acute infectious diseases does not follow this pattern, and fever caused by acute infection can keep rising at any time of day. But certain chronic diseases—such as cancer, pulmonary tuberculosis, rheumatism, and immune diseases—do exhibit this pattern. Patients will also tell the doctor that they begin to have a fever each afternoon, sometimes lasting into the evening, sometimes only gradually improving at night.
Later physicians regard Mahuang Xingren Yiyi Gancao Tang as the representative formula for the exterior-excess pattern of wind-dampness with a tendency to transform into heat; clinically it is characterized by body pain with difficulty in bending and stretching, and late-afternoon fever. This formula replaces Guizhi (Cinnamon Twig) in Mahuang Tang with Yiyiren; it is less acrid-warm than Mahuang Tang, but adds the function of dispelling dampness. So it both has the effect of sweating, releasing the exterior and reducing fever, and the effect of dispelling dampness to stop pain; it suits patients who have both wind-cold and dampness.
Recently, a cancer patient I treated developed an immune-storm phenomenon after receiving ipilimumab: fever and generalized aching that could be relieved somewhat by blowing hot air from a hair dryer on the painful areas; other Chinese and Western analgesics and antipyretics had little effect on the pain. I had tried prescriptions from various angles, none of which solved the pain. Seeing her symptoms, I decided to set aside the old precept against using Mahuang in summer and try Mahuang Xingren Yiyi Gancao Tang. Prescription: Mahuang 6g, Xingren 6g, Zhigancao (honey-fried licorice) 3g, Yiyiren 12g.
After taking the above formula, the patient sweated a good deal all over, and the pain was much relieved. Seeing that she sweated profusely, I had the family reduce the Mahuang in the original formula by half; as a result, the antipyretic and analgesic effect disappeared. But the patient reported dry mouth after taking the formula, so I had them add Maidong (Ophiopogon) 15g and Tiandong (Asparagus) 10g to improve the dry mouth. I also told the family to prepare baby powder; if the patient sweated a lot after taking the medicine, they should dust her with baby powder to avoid electrolyte disturbance. After adding these two herbs, the patient no longer had dry mouth.
This was a case of refractory pain. Western medicine holds that this patient's pain was so severe because her tumor was next to blood vessels rich in nerves, making it prone to pain, and routine analgesics were ineffective. I had also tried Chai Ge Jieji Tang and Huoxiang Zhengqi Tang on her, and the family had themselves used Sanren Tang; none had good analgesic effect. But after using Mahuang Xingren Yiyi Gancao Tang, the analgesic effect was much better.
I have seen several cases of pain similar to this patient's. Some advanced cancer patients, when in pain, get relief from moxibustion, hot compresses, hot-air blowing, or soaking in a bath; from the TCM perspective, such patients' pain all belongs to wind-cold-induced pain. TCM says "treat cold with heat"; for wind-cold-induced pain, one must use acrid-warm formulas, and Mahuang Xingren Yiyi Gancao Tang is precisely the representative formula for acrid-warm analgesia, so it is no surprise that it works.
But Mahuang Xingren Yiyi Gancao Tang does indeed have the problem of easily inducing excessive sweating, so when using it one must pay attention to promptly stopping sweat and replenishing fluids. Dusting with baby powder can stop sweating, and adding some rehydration salts to drinking water can replenish fluids. Such measures prevent the patient from sweating too much and thereby disturbing the body's electrolytes.