Five Cases by Qin Bowei on Fever in Leukemia
Qin Bowei (1901-1970) was a great contemporary TCM physician. He served as TCM advisor to the Central Ministry of Health, member of the board of Beijing College of Traditional Chinese Medicine, and vice president of the Chinese Medical Association. Diligent and learned throughout his life, he published more than 60 works totaling over ten million characters. He was rich in both teaching and clinical experience; many of today's famous TCM physicians were his students. He had many distinctive insights on treating difficult and complicated diseases. Below I reprint five of his cases of fever in leukemia for readers interested in the disease.
Case 1: Female patient
Chief complaint and history: acute lymphoblastic leukemia with high fever above 40°C. The patient reported irregular fever over the past three months, coming on whenever she became fatigued, accompanied by chills, cough, dizziness, palpitations, a feeling of nausea and dry lips.
Examination: pulse thin and rapid; profuse sweating.
Pattern differentiation: internal heat from yin deficiency complicated by a new external contraction.
Treatment: Sheng Di Huang (Rehmanniae Radix), Bie Jia (Trionycis Carapax), Huang Qi (Astragali Radix), Sheng Ma (Cimicifugae Rhizoma), Qing Hao (Artemisiae annuae Herba), Sang Ye (Mori Folium), Mu Dan Pi (Moutan Cortex), Qian Hu (Peucedani Radix). After 3 doses the fever gradually subsided.
Commentary: This is a modified Bie Jia Qing Hao Tang. Bie Jia Qing Hao Tang, composed mainly of Sheng Di Huang, Bie Jia, Qing Hao, Mu Dan Pi and Zhi Mu (Anemarrhenae Rhizoma), is a classic formula for bone-steaming tidal fever that nourishes yin and blood and clears deficiency heat. Adding Sheng Ma and Huang Qi imitates Bu Zhong Yi Qi Tang's use of sweet-warm herbs to dispel great heat; adding Sang Ye and Qian Hu strengthens the heat-clearing effect.
Case 2: Male patient
Chief complaint and history: chronic myeloid leukemia. Fever began every evening reaching 40°C, with spontaneous sweating and cooling in the latter half of the night; the fever swung widely for half a year. Usually the palms were slightly warm, the feet were cold, there was especially heavy soreness below the waist, and bowel movements occurred every few days.
Examination: tongue coating thick and greasy; pulse deep, fine and forceless.
Pattern: deficiency of both yin and yang in the lower jiao with failure of middle qi to rise.
Treatment: Huang Qi, Sheng Di Huang and Shu Di Huang (raw and processed Rehmannia), Dang Gui Shen (Angelica body), Rou Cong Rong (Cistanches Herba), Sheng Ma, Bai Zhu (Atractylodis Macrocephalae Rhizoma) and Ze Xie (Alismatis Rhizoma), using sweet-warm herbs to dispel heat. The following evening the fever was calm.
Commentary: Chronic myeloid leukemia is a wasting disease; after prolonged illness the patient is necessarily deficient, with depletion of qi and blood and often anemia. Fever arises at night as immunity falls. Qin Bowei's formula derives from Liu Wei Di Huang Wan combined with Bu Zhong Yi Qi Tang, supplementing deficiency so that deficiency heat of itself recedes.
Case 3: Male patient
Chief complaint and history: acute exacerbation of chronic myeloid leukemia. Cough on and off for a month, fever every night for a week. Before the fever there were red eyes, chest oppression and chills; body temperature reached 41°C and resolved with spontaneous sweating. Accompanied by dry mouth and scant urine.
Examination: tongue coating yellow, thick and sticky; pulse thin, slippery and forceful.
Pattern: deficiency body invaded by pathogen, with phlegm-dampness congealed and unable to be expelled.
Treatment: Chai Hu (Bupleuri Radix), Huang Qin (Scutellariae Radix), Ban Xia (Pinelliae Rhizoma), Huang Lian (Coptidis Rhizoma), Hou Po (Magnoliae Cortex), Zhi Mu, Bei Mu (Fritillariae Bulbus) and Ju Hong (Citri erythrocarpae exocarpium), harmonizing and clearing. Taken in the afternoon, chills and fever settled by evening; one more episode occurred the next morning, reaching only 38.5°C.
Commentary: The patient's symptoms showed alternating chills and fever, a classic indication for Xiao Chai Hu Tang. Because fever was accompanied by cough, dark urine, chest oppression and dry mouth, Qin Bowei merged the phlegm-resolving and cough-suppressing logic of Er Chen Tang into Xiao Chai Hu Tang, modifying the two formulas for a more comprehensive effect.
Case 4: Male patient.
Chief complaint and history: acute lymphoblastic leukemia with persistent fever, sticky productive cough, stabbing pain in the right hypochondrium, and sore throat with white slough.
Examination: tongue coating rough and greasy; pulse thin, slippery and rapid.
Pattern: lingering heat in the lung with injury to both qi and yin.
Treatment: Xuan Shen (Scrophulariae Radix), Mai Dong (Ophiopogonis Radix), Shi Gao (Gypsum), Zhi Mu, Bei Mu, Sang Bai Pi (Mori Cortex), Lu Gen (Phragmitis Rhizoma) and Mao Gen (Imperatae Rhizoma). Fever and cough gradually settled.
Commentary: Sticky cough and white slough on the throat are heat patterns; treatment should clear heat, detoxify, resolve phlegm and stop cough. This formula derives from Bai Hu Tang: Shi Gao, Zhi Mu, Lu Gen, Mao Gen and Sang Bai Pi clear heat; Mai Dong and Bei Mu moisten the lung and stop cough. The logic is clear and the herbs appropriate, hence effective.
Case 5: Male patient
Chief complaint and history: acute myeloid leukemia. Fever with hot palms, distending pain at both temples and forehead, glomus and fullness in the chest and abdomen, oral erosions and bad breath, constipation and dark urine.
Examination: greasy coating; pulse large, slippery and rapid.
Pattern: dual deficiency of lung yin with damp-heat accumulation in the intestines and stomach.
Treatment: Xi Yang Shen (American ginseng), Sha Shen (Glehniae/Adenophorae Radix), Zhi Mu, Pei Lan (Eupatorii Herba) and Shan Zhi Zi (Gardeniae Fructus), plus Lu Hui Fen (aloe powder) taken separately to clear heat and drain accumulation. After the medicine, bowel movements eased, the chest and abdomen gradually relaxed, and the fever subsided.
Commentary: Chest-abdominal glomus, oral erosions, bad breath, constipation and dark urine constitute TCM "damp-heat syndrome." TCM holds that when dampness and heat combine, they are like oil mixed into flour—hard to separate. In treating such febrile diseases, Qin Bowei combined purgation of the fu-organs to drain heat with yin-nourishing heat-clearing: aloe powder (a purgative TCM herb) drains heat through the stool; Zhi Zi drains lower-jiao heat through the urine; Xi Yang Shen, Sha Shen and Zhi Mu nourish yin and support the root; Pei Lan regulates qi movement so that the viscera recover their normal discharging function. This combination is the standard method for resolving damp-heat.
Although all the above patients had leukemia, Qin Bowei's treatments differed completely according to their different clinical symptoms; this embodies TCM pattern differentiation and the principle of treating the same disease differently. Strictly speaking, these methods only relieved the patients' transient fever symptoms and did not cure the leukemia itself. But even relieving clinical symptoms is highly meaningful.