1. case summary Wang X, male, 54 years old, from Xuanwu District, Beijing, was admitted to the hospital on August 12, 2008 for initial consultation. He was admitted to the hospital on August 12, 2008 with the main reason of “primary hepatocellular carcinoma”: pain in the liver area for more than 4 months, aggravated by fever for more than 2 weeks. He had a history of type 2 diabetes mellitus for 2 years and was on subcutaneous insulin (10iu in the morning and 8iu in the evening) for blood glucose control. He had a history of smoking for more than 30 years, 20 cigarettes/day, and a history of alcohol abuse for more than 10 years, with the heaviest amount of alcohol consumption exceeding 1 kg/day. He denied the history of coronary heart disease and hypertension, no history of surgery or trauma, no history of blood transfusion, denied the history of infectious diseases such as hepatitis and tuberculosis and their contact, and denied the history of drug and food allergy. The patient developed pain and discomfort in the liver area, nausea, weakness and progressive wasting after heavy drinking on April 10, 2008, which was not actively treated. On July 17, 2008, the abdominal ultrasound at Beijing Friendship Hospital showed that the right lobe of the liver was out of proportion, the left lobe was enlarged, the oblique diameter of the right liver was 16.0 cm, and a hypoechoic occupancy of 9.6×8.7 cm was seen in the right liver near the diaphragm, with poorly defined borders and abundant blood flow through it. On July 22, 2008, CT abdomen of Cancer Hospital of Chinese Academy of Medical Sciences showed: large liver, diffuse hypoechoic nodules in the right and left lobes of the liver. The nodules had unclear borders and were partially fused into clusters. The right branch of the portal vein and its distal branches and the distal left external branch were seen as long segmental hypointense filling defects, and the bile ducts in the left external lobe of the liver were slightly dilated. Multiple enlarged lymph nodes were seen in the abdominal cavity and retroperitoneum, the larger one was about 2.3×1.5 cm. The left adrenal gland was enlarged, the spleen was large, and no abnormal density was seen, and multiple thick calcified foci were seen in the pancreas. No clear abnormal density was seen in both kidneys. No ascites was seen. The scan field showed patches and cords in both lower lungs. Diagnosis: 1 Diffuse lesions in the right and left lobes of the liver, considering hepatocellular hepatocellular carcinoma, not excluding combined bile duct cell carcinoma. 2 Multiple lymph node enlargement in the abdominal cavity and retroperitoneum, considering metastasis. 3 Thickening of the left adrenal gland, please note the follow-up. 4 Multiple calcifications in the pancreas 5 Patches and cords in both lower lungs. The hospital considered the lesions too extensive and survival too short for transhepatic arterial catheter interventional chemotherapy (TACE) and recommended immunotherapy. He was treated with subcutaneous injection of recombinant human interleukin-2 (2 million IU, every other day) and oral Chinese medicine for 3 weeks, but his symptoms continued to worsen. In the past 2 weeks, he developed a persistent afternoon fever with temperature fluctuating from 36.8 to 37.9℃. He was admitted to our department with worsening pain in the liver area. Pain and discomfort in the liver region. Mild swelling of both lower limbs. He had persistent afternoon fever with temperature fluctuating from 36.8 to 37.9℃. Feeling cold and fearful of cold in both lower limbs, emaciation, stomach distension, nausea, poor appetite and weakness. Mood is dry and irritable, mouth is bitter and dry and does not want to drink. The five hearts are hot and bothered, and sleep is poor. Small amount of urine with yellow color, loose stools at times. The tongue is pale and dark with little fluid, the coating is white and greasy, and the pulse is smooth and slightly counted. Physical examination: body temperature 36.5○C, pulse rate 80 times/min, respiration 20 times/min, blood pressure 105/70mmHg. card score 70. Poor mental health, wasted body shape, mild yellowish sclera of the skin, no palpable enlargement of superficial lymph nodes throughout the body. The pharynx was not congested and the tonsils were not enlarged. The breath sounds of both lungs were clear, and no dry and wet rales were heard. The heart rate was 80 beats/minute, rhythmical, and no obvious pathological murmur was heard in the auscultation area of each valve. The abdominal wall was tense, the right upper abdomen was bulging, the abdominal wall veins were varicose, and no spider nevus was seen all over the body. There was pressure pain in the hepatic region (++) and rebound pain (-). The liver was 2 fingers below the ribs and about 2 fingers below the saber, with irregularity of the lower hepatic border and moderate quality. The spleen is not palpable under the ribs. Ascites sign (+). No percussion pain in both kidney areas. Mild depressed edema in both lower extremities. Admission cardiac ultrasound suggested: hyposystolic left ventricular function and a small amount of pericardial effusion. Abdominal ultrasound showed multiple solid intrahepatic occupations, tumor thrombus formation in the right and left sagittal branches of portal vein, gallbladder wall thickening, multiple calcified foci in the pancreas, splenomegaly, ascites, and multiple enlarged lymph nodes in the abdominal cavity. Ultrasound of deep veins of both lower extremities: no thrombosis was seen. Electrocardiogram: sinus tachycardia. Biochemistry: GLU:14.76 mmol/L, ALB:28g/L, ALP:538U/L, γ-GT: 217U/L. D-dimer: 334ug/L. Tumor markers: AFP:2.14 IU/ml, CA199:41.92 U/ml, CA125:47.82 U/ml. Immunological examination: T-cell subpopulation, NK cell function and hepatitis virus series were within normal range. This disease belongs to the category of “liver accumulation” and “yinhuang” in Chinese medicine, which is caused by long-term heavy drinking, combined with depression and anger, diet and fatigue, and inappropriate rest, resulting in dysfunction of the internal organs, leading to qi stagnation and blood stasis, toxic stagnation and phlegm coagulation, and stagnation of liver ligaments, which becomes accumulation over time. Our experience is that in the process of normal liver cancer, liver stagnation and spleen deficiency are the basic pathological mechanisms throughout the whole process of liver cancer, and the pathological factors involve qi stagnation, dampness, heat (fire), stasis and toxicity. In the early stage, dampness and qi stagnation are the main factors on the basis of liver depression and spleen deficiency. In the middle stage, Qi stagnation, blood stasis, dampness and heat, stasis and toxicity are intertwined. In the later stage, poisonous evil is detained for a long time, dampness, toxicity and stasis are intertwined, positive deficiency and evil is real, liver, spleen and kidney are deficient, and the prognosis is poor. Therefore, draining the liver and strengthening the spleen, resolving dampness and detoxifying toxins is the fundamental treatment for this disease. The patient has persistent low-grade fever, damp-heat and toxic evil consume qi and yin. On closer examination, the patient sees generalized coldness and fear of cold in the stomach and epigastric region, distention and fullness in the upper abdomen, but prefers warmth and pressure; bitter mouth, dry mouth but does not want to drink cold, and loose stools. The tongue is pale and dark with little fluid, the moss is white and greasy, and the pulse is stringent and slippery. The evidence is that the spleen and stomach are deficient in cold, so called “hiding adultery in a solitary place”. The cause of this is that the spleen and yang are damaged by the cold diet, or the yin and yang are damaged by dampness and toxicity. It is due to the lack of yang in the body, it is difficult to transform the dampness and toxicity, the accumulation of a long time difficult to eliminate. According to the Nei Jing, “the kidney is the gateway to the stomach, and when the door is closed, water is collected from its class”, and the core link to promote water metabolism lies in the transpiration and vaporization of Yang Qi in the kidney, and if the spleen Yang is insufficient, blood stasis and water stagnation will make ascites stubborn and difficult to subside. Therefore, while strengthening the spleen and regulating the liver, detoxifying and relieving dampness, due attention should be paid to protecting the spleen and kidney yang qi, which is a breakthrough to improve the efficacy of the disease. This disease is characterized by deficiency of both yin and yang, mixed cold and heat, and positive deficiency of evil, which poses higher requirements for the identification and use of medicine. For the treatment of ascites in liver cancer, Chinese and Western medicine should follow the ancient teaching of “Nei Jing” that “a large accumulation of fluid can be committed, but it should be stopped by decaying most of it”, and remember to take discriminative treatment as the guideline. The patient has a large tumor load, extensive tumor thrombosis in the portal vein, persistent afternoon low-grade fever, rapid weight loss and progressive wasting within one month, all suggesting rapid deterioration, short survival and poor prognosis. It is suggested that Chinese drug treatment or with targeted therapy may be beneficial to improve the quality of life. It is suggested that Chinese medicine should be based on turtle nail decoction pill and Yin Chen Jie Fu Tang with addition and subtraction. Since most patients with hepatocellular carcinoma have increased portal pressure and abnormal coagulation mechanism, attention should be paid to the dosage and timing of application of blood-breaking drugs and monitoring of DIC series if necessary to reduce the potential risk of triggering gastrointestinal bleeding. 3. Postscript After patient ideological enlightenment, the patient agreed to take Chinese medicine. The TCM treatment was based on warming Yang, relieving dampness, draining the liver and strengthening the spleen, and softening firmness. The formula is based on the following formula: 30g of prunus ginseng, 60g of gypsum (first decoction), 30g of vinegar of Caihu, 15g of ground bark, 15g of dandan bark, 45g of inoceramus, 30g of turtle nail, 10g of wuling fat, 30g of neijin, 15g of hawthorn and hammer, 30g of sage, 10g of dogwood, 30g of red poria, 15g of sage (first decoction), 15g of Atractylodes macrocephala, 15g of beehive, 10g of roasted licorice, 6g of sandy nuts. Glycyrrhiza glabra 10g, Sharen 6 (later down), roasted licorice 6. 7 doses with water decoction, 1 dose/day, 2 times/day. Combined with sedative drip of 200ml of Conrad Injection, 1 time/day. After 5 days of treatment, the patient’s mental and physical strength improved, distension in the liver area and epigastric distension were significantly reduced, food intake increased, and urine volume increased. 2 weeks later, body temperature returned to normal. After 2 weeks, his body temperature returned to normal. He felt that his mental and physical strength had recovered significantly, and the coldness and fear of cold in both lower limbs had been reduced significantly. The amount of food was larger, about 1 nearly/day. The stool was dry and then diluted, and the urine was yellow in volume. Still has bitter and dry mouth, drinks more water, basically disappeared the five heartburn, sleep improved. The tongue is light and dark with little fluid, the coating is white and thick, and the pulse is smooth and slightly counted. Adjustment of prescription: Prince’s ginseng 30g, gypsum 30g (first decoction), vinegar chestnut 30g, ground bones 15g, dandan bark 15g, inchi 30g, turtle nail 30g, wuling fat 6g, neijin 30g, hawthorn and hammer 15g each, rat’s wife 15g, dogwood 10g, red poria 30g, big belly bark 30g, sliced sapodilla 15g (first decoction), raw atractylodes 15g, beehive 15g, roasted licorice 10g, sandy nut 15g (later down), trigonella 15g, curcuma 15, roasted licorice 6. 14 doses with water decoction, 1 dose/day, 2 times/day. On September 3, 2008, the hospital rechecked the abdominal CT (scan+enhancement), which showed that “the liver was enlarged, with the oblique diameter of the right liver 16.1 cm. the echogenicity of the liver was obviously uneven, with diffuse distribution of multiple hypoechoicities in the left and right lobes, with unclear borders and uneven internal echogenicity. The echogenicity of the liver is not clear and the internal echogenicity is uneven. Enlarged lymph nodes were seen around the first hepatic hilar, peripancreatic, and epigastric abdominal aorta. No free fluid was seen in the abdominal cavity: Consider: multiple solid intrahepatic occupations, no significant tumor thrombus in the portal vein. The gallbladder wall was thickened, multiple calcified foci in the pancreas, splenomegaly, and enlarged lymph nodes in the abdominal cavity”. He was discharged from the hospital on September 10, 2008 with significant improvement in his symptoms and continued to take oral herbal medicine on an outpatient basis, and was re-tested on September 23, 2008 with a weight gain of 18 kg. The portal vein has abundant collateral circulation. Impressions: 1. cirrhosis with portal vein collateral circulation formation; 2. lymph node shadow around the abdominal aorta. Liver puncture was not performed because no lesion was found. The patient complained of mental and physical strength as usual, no obvious discomfort, and insisted on outpatient oral Chinese medicine treatment, followed by appropriate reduction of the previous prescription. 2009 September reexamination of all indicators are within the normal range, no obvious signs of relapse, clinical cure, the current still based on the above prescription, adhere to the consolidation of Chinese medicine treatment. The patient has resumed normal work.