A Case: Wan Wenmo Treating Malignant Transformation of Cirrhosis with Uncontrolled Gingival Bleeding
Professor Wan Wenmo (1923-2008) served as director of the TCM department at Wuhan Ninth Hospital. Over more than 50 years of clinical practice he attained deep TCM scholarship and rich experience; in his later years he specialized in difficult and complicated diseases, excelling in disorders of the liver, stomach, and kidneys, and was especially expert in liver disease.
On November 27, 1980, Dr. Wan saw a patient with cirrhosis and incessant gingival bleeding. The patient, surnamed Yao, was 50 years old, with a past history of chronic hepatitis, erysipelas, and hypertension. At the visit his eyes were faintly yellow, his cheeks showed red macules and threadlike veins, the coating was yellow and greasy, the tongue was red-purple, and his breath had a bloody odor. The liver and spleen were enlarged, liver function was abnormal, and platelets were low. Western medicine diagnosed malignant transformation of cirrhosis; for the gingival bleeding they applied a hemostatic paste, but with little effect.
Dr. Wan differentiated the pattern as prolonged retention of damp-heat toxin, phlegm congealing and blood stasis, spleen failing to transport, yin deficiency with fire effulgence, and blood recklessly moving outside its vessels. Treatment should address both branch and root by clearing heat and resolving toxin, nourishing yin and stopping bleeding, resolving stasis and dissipating nodules, and regulating the spleen and stomach.
The initial prescription was: Hanliancao (Ecliptae Herba) 30 g, Nüzhenzi (Ligustri Lucidi Fructus) 30 g, Baimaogen (Imperatae Rhizoma) 30 g, Xiaoji (Cirsii Herba) 30 g, Sheng Muli (raw Ostrae Concha) 30 g, Huzhang (Polygoni Cuspidati Rhizoma) 15 g, Yinchen (Artemisiae Scoposae Herba) 15 g, Xiakucao (Prunellae Spica) 15 g, Shengdihuang (Rehmanniae Radix) 15 g, Biejia (Amydae Carapax) 15 g, Ejiao (Asini Corii Colla) 10 g, Mudanpi (Moutan Cortex) 10 g, Chenpi (Citri Reticulatae Pericarpium) 10 g, Fuling (Poria) 10 g, Sanqi powder (Notoginseng Radix) 6 g (infused), six doses, decocted in water, one dose daily.
The initial formula was Erzhi Wan (composed of Hanliancao and Nüzhenzi) plus hemostatic herbs such as Baimaogen, Xiaoji, and Sanqi powder. Biejia, Mudanpi, Shengdihuang, and Ejiao nourish yin and cool the blood; Chenpi moves qi and strengthens the spleen; Fuling transforms dampness and strengthens the spleen; Huzhang and Yinchen promote urination and reduce jaundice; Sheng Muli, Xiakucao, and Biejia soften and dissipate hard masses. Dr. Wan's formula thus comprehensively addressed both branch and root.
By December 4, the gingival bleeding had stopped, the dental paste had been removed, the dry bitter taste and foul odor in the mouth were gone, the bowels moved regularly, and the patient felt better. Dr. Wan told him to remove Shengdihuang from the initial formula and continue for another six doses.
At the second visit, constipation had resolved. Shengdihuang contains rhubarb anthraquinones that have a purgative effect; long-term use tends to cause loose stools or diarrhea, so it was removed from the previous formula and the patient continued, to consolidate the effect.
The patient followed the advice. At the third visit on December 24, he told Dr. Wan that a recent Western B-ultrasound had found abnormal shape of the right hepatic lobe with multiple hypoechoic areas of varying size, the largest 7.8x5.6 cm, suggesting a space-occupying liver lesion. Alpha-fetoprotein was positive, erythrocyte sedimentation rate was 94 mm/1 h, and platelets had recovered somewhat. Western medicine diagnosed malignant transformation of cirrhosis. Symptoms included faint distending pain in the liver area, formed stools, still-yellow urine, a slightly bitter and dry mouth, and tongue and pulse as before. Dr. Wan planned treatment by resolving toxin and masses and regulating the spleen and stomach.
The third-visit prescription was: Huzhang 30 g, Yinchen 30 g, Baihuasheshecao 30 g, Banzhilian 30 g, Longkui (Solanum Nigri Herba) 30 g, Nüzhenzi 30 g, Taizishen (Pseudostellariae Radix) 30 g, Sheng Biejia (raw Amydae Carapax) 30 g, Tengligen (Actinidiae Radix) 15 g, Tianhuafen (Trichosanthis Radix) 15 g, Danshen 15 g, Ejiao 10 g, Baizhu 10 g, Chenpi 10 g, Ganchan (dried toad) 6 g, Sanqi 6 g, 45 doses, decocted in water. In addition, he was told to swallow 3 g of Xihuang Wan twice daily. He also cooked dishes with toad oil (one live toad, gutted and washed, decocted in 500 g sesame oil until charred, strained, and reserved) as a dietary accompaniment.
Dr. Wan's third-visit prescription strengthened the heat-clearing, toxin-resolving force: Baihuasheshecao, Banzhilian, Longkui, Tengligen, and Tianhuafen all clear heat and resolve toxin. Xihuang Wan resolves toxin, fights cancer, softens and reduces swelling; both dried toad and toad oil contain cinobufagin, which has some effect on hepatitis, cirrhosis, and liver cancer. Biejia is a standard herb for cirrhosis and liver cancer, so it was continued and the dose increased. Most modern patients cannot tolerate dried toad or toad oil because the foul smell is nauseating; such patients can use cinobufagin preparations instead.
The patient kept taking the medicine until March 2, 1984. Jaundice had faded, stools were formed, urine was sometimes clear and sometimes yellow, spirits and appetite had improved, sleep was poor, the coating was thin yellow, and the pulse was slippery. ESR and platelets returned to normal and AFP became negative. Dr. Wan considered the prior formula effective and advised continuing along its basic line with slight adjustments.
The fourth-visit prescription was: Sheng Huangqi (raw Astragali Radix) 30 g, Taizishen 30 g, Baihuasheshecao 30 g, Banzhilian 30 g, Baiying (Solanum Lyratum) 30 g, Longkui 30 g, Nüzhenzi 30 g, Mohanlian (Ecliptae Herba) 30 g, Guiban (Testudinis Plastrum) 30 g, Biejia 30 g, Sheng Muli 30 g, Chenpi 10 g, Gancao 10 g, Fuling 10 g, Ejiao 10 g. 26 doses, decocted in water.
By the fourth visit symptoms had improved and relevant markers were normal. Xihuang Wan was expensive and harmed the stomach over time, and toad oil and dried toad were foul, damaging the appetite; so Dr. Wan removed these. He retained the heat-clearing, toxin-resolving, blood-cooling, and swelling-reducing herbs, while adding Sheng Huangqi and Taizishen to support the righteous and secure the root, guarding against depletion of healthy qi after prolonged illness and prolonged medication. Such measured advance and retreat, steady and reliable, bespeaks a master physician.
In early June 1984 the patient returned to work. Afterward he took the formula with minor additions and subtractions for about another year. On August 26, 1986, follow-up showed the space-occupying lesion had disappeared, and liver function, platelets, ESR, and AFP were all normal. The liver and spleen remained mildly enlarged and firm, so Dr. Wan advised him to regularly decoct 30 g each of Longkui, Baihuasheshecao, Danshen, Huangqi, Fuling, and Nüzhenzi as a tea substitute. Into the 1990s the patient generally felt well and could work full days; follow-up B-ultrasound and liver function on March 5, 1991 showed no obvious abnormalities.
That a liver space-occupying lesion could be treated with pure Chinese medicine until it disappeared is truly remarkable. TCM holds that once a drug has hit the disease one should stop, and medication should not be excessive. But malignant transformation of cirrhosis is not a minor ailment; a period of consolidation is needed to prevent relapse. Dr. Wan again reduced the medication, using only a light tea decoction for consolidation. This consolidation formula included Longkui and Baihuasheshecao to clear heat and resolve toxin, Danshen to activate blood and resolve stasis, and Huangqi, Fuling, and Nüzhenzi to support the righteous and secure the root—balancing support of righteous and expulsion of evil. This is a "gradual withdrawal" approach that stabilizes effect and reduces recurrence risk.
The patient achieved a good result under Dr. Wan's orderly treatment. The course was very long; without deep trust in Dr. Wan, the patient could hardly have persisted. Their mutual doctor-patient trust was itself a guarantee of efficacy.