The liver is the largest organ in the human body.  Its function is important and complicated and if injured, the influence is wide and it can cause a series of physiologic or pathologic changes.  Liver is a detoxification organ; impairment of liver function can cause abnormality of metabolism and excretory disturbances.  If the liver cannot detoxify metabolites, then, the respective metabolites would retain in the blood and further more the body cannot normally obtain substances required for nutrition.  In severe cases, the laboratory examination results would show significant abnormalities which indicate that the liver disease has produced metabolic disturbances and accumulation of abnormal substances in the blood (called by TCM as wetness-heat).  If the attack is acute and severe, the result may be hepatic coma and death.

         Metabolic substances may retain in the body, if hepatic detoxification function is impaired.  Clinically, hypercholesterolemia may induce cardiovascular disease, high blood uric acid may induce gout, hypoproteinemia and hepatic edema may lead to imbalance of auricular fluid and the production of vertigo.  These conditions may be cured without special treatment if systemic TCM therapy is administered.

According to our observation, many symptoms caused by the response of immune system are usually mild.  These symptoms are often recognized by physicians as local symptoms and diagnosed as:

•           Nasal hypersensitivity (nasal obstruction, nasal discharge, repeated sneezing, especially occurring in the morning);
  
•           Tracheal hypersensitivity (itching and soreness of throat, cough, abundant expectoration, shortness of breath, asthma, sensation of foreign body in the trachea and chest, inability to expectorate or swallow, named by TCM as globus hystericus);
  
•           Gastrointestinal hypersensitivity (loss of appetite, nausea, belching, distension of abdomen, stomache ache, constipation or diarrhea, indigestion of food containing heterologous protein, high lipids and certain food made from protein or inability of taking certain common protein containing food such as fresh milk, eggs etc.);
  
•           Dermal hypersensitivity (dryness of skin, hyperkeratosis, ichthyosiform desquamation, pruritus, repeated attacks of German measles, eczema and acne).  So, attention is usually paid on treatment of the superficial and not the fundamental, and the chronic hepatitis condition would become worse and the patient could not be treated in time.

The above mentioned symptoms caused by hypersensitive conditions are in fact described in the respective systems.  Its pathogenesis is closely related to hepatic metabolism, but in clinical practice, they are often considered as disease entities and not given treatment according to liver disease; their treatment are superficial and not fundamental.  Therefore, when the child has the above symptoms, further examination by physician is advisable so as to avoid neglect of diagnosis and treatment of chronic hepatitis.

  Introduction of cases – Hypersensitive constitution form

Case 5-1:   male, age 4-1/2 yrs, repeated nasal hypersensitivity and asthma for over 2 yrs.

Case 5-2:   Wong sisters, elder sister age 5 yrs, history of nasal hypersensitivity and asthma.    Younger sister age 16 months suffering from common cold, roseola and varicella, parents being sufferers of chronic hepatitis.

Case 5-3:   male, age 1 yr, pediatric eczema, malnutrition, poor development, grandfather and grandmother being sufferers of chronic hepatitis.

Case 5-4:   male, age 8 yrs, repeated rubella since infancy, susceptible to common cold, sorethroat, hyperhidrosis, fatigue and paleness of skin.

Case 5-1

Chan – (Computer No. 358) male, age 4-1/2 yrs.  The mother said that her child had repeated nasal hypersensitivity and asthma for 2 years.  He frequently suffered from loss of appetite, distension and pain of abdomen, vomiting diarrhea, dryness and pruritus of skin.  Physical examination revealed a thin stature with pale skin, scanty subcutaneous fat, poor nourishment and development, soft and distended abdomen and hepatomegaly of 1.5 cm.  After taking 13 parcels of TCM drugs, the liver was normal and the bowl movements smooth.  Medication stopped after 3 weeks of systemic TCM treatment.  He was re-examined half a year later and no hepatomegaly was found.

Wong sisters, parents were sufferers of chronic hepatitis.  Her mother had history of acute icteric hepatitis during infancy (about 8-10 years of age) and was not systematically treated.

Her father had history of hepatitis preventive injection two years ago.  On visiting, he complained of severe loin pain for two weeks and he was susceptible to fatigue and also had symptoms of chronic hepatitis such as repeated abdominal pain, diarrhea, exopathy and cough.  Physical examination revealed a hepatomegaly of 4.5 cm, bradycardia (48/min).  He was clinically cured by systemic TCM therapy.

Elder sister Wong – (Computer No. 507), female, age 5 yrs.  She had history of nasal hypersensitivity and asthma which occurred repeatedly.  In the recent 2 days, she was attacked by fever, cough and varicella.  Her first visit was on 30 October 1997.  Physical examination: scantly varicella eruptions over skin of whole body, part of them formed scabs; hepatomegaly of 1.5 cm.  After taking 9 parcels of TCM drugs, the liver was normal and varicella eruptions also healed.  Medication continued for 4 weeks.

Younger sister Wong – (Computer No. 508), female, age 16 months.  Her first visit was on 30 October 1997.  Her mother said that the child had otitis media two months ago and was hospitalized because of pneumonia and high fever for 5 days.  She was discharged after 12 days of hospitalization after which she again suffered from common cold, bronchitis roseola and varicella, associated with diarrhea and nocturnal crying.  She asked for TCM treatment.  Physically examination: skin of chest and back scanty varicella marks, hepatomegaly of 1.5 cm.  After taking 9 parcels of TCM drugs, the varicella healed, cough stopped and the liver returned to normal.  A total of 27 parcels of TCM drugs were administered and the child achieved clinical cure.  A return visit was made 3 months later because of common cold and fever but the liver was still normal.

Yuan – (Computer No. 314), male, age 1 yr.  His grandmother and his parents all had chronic hepatitis and were treated in this clinic.  First visit: 23 March 1997.  The mother said that the child had dermal lesions 10 more days after birth and it was diagnosed as pediatric eczema, but although it was repeatedly treated by specialists, the effect was still not significant.

Physical examination revealed that the infant was poorly nourished and developed; on the face, axilla, wrist and ankles there were erosions, erythema and multiple small eruptions; the abdomen was soft and distended; the liver enlarged to 1.5 cm.  TCM therapy was not given for the time being because the parents could not bear the pain of the child in taking the medicine.  TCM treatment was accepted on 16 July 1997 because the child was attacked by generalized eruptions dermal, erythema, dryness and fissures; he also had a hot temper, poor sleeping, nocturnal crying and frequent bowl movement, 4-6 times a day.  He could only take soybean milk, his abdomen still soft and distended and hepatomegaly still 1.5 cm.

After taking 8 parcels of TCM drugs, the child’s liver was normal, the skin erosions and pruritus decrease, the skin over the face and limbs slightly reddish, dry and desquamated.  TCM treatment stopped 4 weeks later, at which time his urine was till yellowish, appetite poor and the skin at the flexor surface of the articulations of the extremities still slightly reddish and desquamated.

Eight months later (April 1998) the child was hospitalized because of tonsilitis and fever.  After subsidence of fever, the pediatric eczema relapsed and he made a return visit to the clinic.  He was found to have flush of face, maculopapular eruptions of the left facio-buccal skin.  He was thin looking, his abdomen soft and distended.  After 4 days of TCM treatment and it was found that the facio-buccal flush subsided, the eruptions disappeared and the liver retracted to 1.5 cm.  He took another 4 days of medicine and his mother said that no more skin eruptions were found, the liver was normal but nocturnal dermal pruritus was still present.  Medication stopped after 4 weeks of systemic therapy.

On 12 January 1999, his father had a return visit to the clinic and said that the child’s skin was smooth but his appetite was not so good.

Dong (Computer No. 2136), male, age 8 yrs.  First visit: 25 May 2000.

The mother said that the child had repeated attacks of German measles since infancy and when severe, he had to be sent to the emergency department.  He was susceptible to common cold, sorethroat, hyperhidrosis, fatigue, loss of appetite, ozostomia, constipation, bowl movements often once in a week.  He frequently suffered from insomnia, difficulty in falling asleep and could be easily awakened.  Physical examination: skin palish yellow, tongue normal, abdominal wall showing prominent subcutaneous veins, percussion tenderness of liver hepatomegaly of 3 cm.

After taking 3 parcels of TCM drugs, the liver was normal.  He continued the TCM therapy and constipation gradually improved.  There was some oral ulceration and occasional scanty rubella eruptions.  Sleeping was good one week later.  After 2 weeks of TCM therapy, he could feel hungry, his appetite improved and bowl movement became once a day.  After 3 weeks, there were still occasional rubella eruptions, hyperhidrosis and loss of hair.  The chest and abdominal wall and lower limbs still showed prominent veins.  When TCM drugs were taken for one month, sometimes he was still not able to have bowl movement daily.  A total of 64 parcels of TCM drugs were taken to complete the systemic course of therapy.  He was followed up.

Half a year later, he suffered from common cold, constipation, loss of appetite, fatigue and hyperhidrosis and returned for medication.  Physical examination revealed a hepatomegaly of 3 cm (being the first relapse).  After taking 3 parcels TCM drugs, the liver was normal.  During systemic TCM therapy, the patient had fever, sorethroat, cough and redness of tongue.  Then he stopped the TCM drugs by himself and turned to WM treatment for two weeks.  When he returned for TCM treatment, the liver was found to be enlarged 1.5 cm (being the second relapse of hepatomegaly).  After taking 3 parcels of TCM drugs, the liver returned to normal and TCM therapy was continued.  But 10 days later, he suffered from abdominal pain, diarrhea and cough because of eating raw fish.  He took WM drugs and felt sleepy after the treatment.  WM drugs were taking for 7 times and the liver was enlarged 3 cm (being the third relapse of hepatomegaly).  He was given 3 parcels of TCM drugs and the liver was again normal.

A return visit was made in February 2001.  The mother said that the child was given WM drugs because of severe coughing and expectoration.  The patient’s liver enlarged 1.5 cm (being the fourth relapse of hepatomegaly).  After taking 3 parcels of TCM drugs, the liver returned to normal.  TCM therapy was continued until a 4 week systemic course was completed.  He was clinically cured in April, then medication was topped and he was followed up.  In the following 2 years, there were nine episodes of relapse.  He had nasal hypersensitivity, rubella, constipation and hemorrhoids which required TCM therapy; in the time following, several times of physical examination did not reveal any abnormality.

translated by Professor ZHENG Hua En in April 2006

       Most of the hormones in the human body are metabolized in the liver.  In the liver disease, metabolism of these hormones is affected and imbalance is formed among these hormones.  Hormonal imbalance can lead to nutritional metabolic disturbance and together with gastrointestinal absorptive dysfunction caused by chronic hepatitis, they can induce pediatric nutritional deficiency.  Due to decrease of growth hormone, the diseased child has calcium deficiency which causes osteal malnutrition and further, retardation of growth and development.  During the course of body development, the patient may suffer from acute or chronic hepatitis which may induce endocrine disorder and even, the formation of fatty liver and secondary obesity.  The stature of the diseased child, may therefore develop into one of the two extremities, that is “ricketic dwarfism” and “secondary obesity”.

(I)  Ricketic dwarfism

Children suffering from chronic hepatophilic virus disease are usually infected through mother-infant communication and close contact.  So, these infants have poor nutrition and in some of them, development may be affected.  The hepatic metabolic function in children is lower than adults, their protein synthetic ability is weaker.  When the liver is injured, the synthesis of albumin, fibrmogen and coagulative factors is insufficient and therefore these patients often present hypo-proteinemia, defective calcium absorption and bleeding tendency.  A small number of cases may develop into “hepatic dwarfism”.  The patient’s face loses brightness, the stature short and lean showing slow growth and retarded development; there is defect calcification of bones which leads to rickets.  In severe cases there are rachitic beads, chicken breast and anomaly of foot.   The diseased child usually presents a soft and distended abdomen, the abdominal wall showing telangiectasis or varicosities of collateral circulation.  The liver is usually enlarged and in elder children, percussion tenderness over the hepatic region may be detected or the patient may complain of pain of the right hypochrondrium.

If the child has bleeding tendency, there may be repeated epistaxis, hematochezia, bleeding of gingivae or occurrence of subcutaneous ecchymoses upon slight contusion.  When hepatitis attacks the patient during infancy or childhood, physical examination later in the school age or adolescent and middle age would reveal asymmetry of right and left hypochondria, the left side slightly depressed and the right side somewhat full or even buldging.

Ricketic dwarfism – Introduction of cases

Case 4-1

        Han (computer No. 1991) female, age 7 yrs.  First visit: 20 November 1999.  The mother said that the child had repeated nasal hypersensitivity and dermal eczema since infancy, exacerbating in the summer season every year.  Now, over the extensor side of the joints of limbs, one could still see local eczema, dryness scratch marks and desquamation.  The lower jaw and pelvic bone showed asymmetric anomaly.  The skin was palish yellow and dry, and generalized sweat stains could be seen.  The child was thin, tired looking and listless.  Physical examination revealed a soft abdomen, percussion tenderness over hepatic region and a hepatomegaly of 3 cm.  The diagnosis was chronic hepatophilic virus disease complicated with nasal hypersensitivity, sweat stains, pediatric eczema and osteal malnutrition.

        After taking 5 parcels of TCM drugs, the liver returned to normal.  Administration of TCM drugs was continued and the symptoms gradually alleviated and the skin lesions subsided slowly.  After 3 weeks, there was no nasal hypersensitivity, the eczema healed and the skin appearance was completely normal.  The patient was clinically cured after 4 weeks of TCM treatment and was followed up.

Case 4-2

        Jin (computer No. 3883) male, age 17 yrs.  First visit: 2 April 2004.  He had anomaly of the chest since infancy.  There was a depression below the xyphoid process at the anterior aspect of the chest.  He was lean, had long time multiple acne, the face showing multiple sebaceous glaud protrusions.  He often experienced abdominal pain, voiding of yellowish urine and passing of loose stools several times a day.  The lower edge of the upper lip presented a pearl like appearance; the tongue was enlarged with teeth prints and thin white coating.  The chest showed typical funnel shape; there was a hepatomegaly of 1.5 cm.  The diagnosis was chronic hepatophilic virus disease complicated with hepatic osteal malnutrition (rickets), endocrine disorder, viral gastrointestinal disease.

        After taking the first parcel of TCM drugs, he had diarrhea 3 times, the stools watery and after 3 parcels, he still had multiple acne and desquamation of lips, the tongue enlarged with teeth prints and thin white coating.  The liver returned to normal.  After taking another 6 parcels of TCM drugs, he did not feel any discomfort but he still suffered from diarrhea, twice a day.  He had occasional abdominal pain; sleeping was good and acne decreased.  Another 6 parcels of TCM drugs were taken and the acne subsided.  The stools were watery, 3 times a day, and the tongue coating was thick and yellow.  He took another 6 parcels of TCM drugs and the tongue coating became thin and white; he had no discomfort, the bowl movements were normal, the feces were in shape, being 1-2 times a day.  He slept well and the liver was normal.  He was cured clinically and followed up.

Case 4 -3 : The Lam brothers, twins

        Elder brother (computer No. 3564), male, age 12 yrs.  First visit: 20 September 2003.  He was fat since infancy, susceptible to diarrhea and wetness-heat abdominal pain and had to defecate right after meal.  He had tenesmus and passed loose stools 1-2 times a day.  He had acne for a year.  Weight 150 lbs (68 kg), Height 1.74 m, BMI = 22.51 (for 12 years, ideal BMI range: 16-22) hepatomegaly 1.5 cm.

        After taking 3 parcels of TCM drugs, he slept well without discomfort and his liver returned to normal.  He continued the TCM therapy and he still had diarrhea, stools 3 times a day, loose and large in amount.  During the second week of medication, he still used to defecate after meal and the stools were watery, 2-3 times a day.  Multiple acne were still present; the tongue was clean and sleeping was good.  In the 3rd week of medication, the skin was normal, sleeping was good. The tongue became thinner and without teeth prints.  Bowl movements were still 3-4 times a day; the liver was normal.  Medication stopped after attainment of clinical cure.

        Younger brother (computer No. 3563), male, age 12 yrs.  First visit: 20 September 2003.  His appetite was poor since infancy; he was lean and suffered from repeated acne for a year.  Height: 1.76 m, Weight 50 kg, BMI = 16.13. (for 12 years, the ideal BMI range:16 – 22.2)  Anomaly of hypochondria, hepatomegaly of 1.5 cm.

        After taking 3 parcels of TCM drugs, he had no discomfort, bowl movements normal, sleeping good and the liver was normal.  He continued the TCM therapy and his appetite improved markedly and he could sleep well.  He had no acne but on the forehead and face there were still many sebaceous protrusions.  He took another week of TCM drugs and the liver remained normal.  Acne and sebaceous protrusions decreased markedly.  The skin was smooth, bowl movements normal and the urine was not yellowish.  TCM drugs were taken for a total of 3 weeks and the treatment was stopped.  The patient was followed up.

Physician’s comment:

      The father of the twins had positive type B hepatitis antibodies and frequently suffered from nasal hypersensitivity, fatigue, sleepiness, insomnia and edema of lower limbs.  He received local injections for hemorrhoids.  His liver was found to be enlarged 3 cm in the first visit and was diagnosed as chronic hepatitis and treated with TCM drugs in our clinic.  The brothers, although under the same living condition, had very different body constitution, but they both had endocrine disorder.  The elder brother’s symptoms were of the chronic hepatitis wetness-heat vaporization form with gastrointestinal wetness-heat as the chief manifestation.  Prolonged gastrointestinal wetness-heat together with endocrine disorder formed secondary obesity, so that his BMI = 22.51.  The younger brother had loss of appetite, thinness, anomaly of hypochondria.  Due to malnutrition and poor development, his BMI was only 16.13.

        The body weight and development of the twins turned respectively to opposite extremities.  It might be the result of liver function damaged by hepatophilic virus infection.  The severity of damage was not the same in the two children and so the result was different.  Early administration of systemic TCM therapy and stoppage of damage of liver function to avoid malnutrition and underdevelopment are imperative.  As to the effectiveness of TCM therapy, a short course is enough to bring the liver back to normal and attain clinical cure, including the disappearance of the chief clinical symptoms.

Case 4 -4 : Lao (computer No. 3477) male, age 15 yrs.  First visit: 12 July 2003

        The child, after birth, was found to have microencephalic anomaly and tremor of eyes and funnel shape chest.  He had hematuric twice and was treated by WM drugs.  He had frequently sorethroat, common cold, asthma and also amblyopia and alternating strabismus.  He was weak, had occasional insomnia, bowl movements twice a day, lip mucosa edematous, tongue enlarged with fissure.  His intellectual ability was normal and had polylogia and a hepatomegaly of 3 cm.

        After taking 3 parcels of TCM drugs, the stools were watery, being 3 – 4 times a day.  The liver was normal.  TCM therapy continued for 1 week and urination was smooth, sleeping good and bowl movements normal.  There was occasional nasal hypersensitivitiy in the morning.  TCM drug administration continued for 6 weeks, at which time, there were nasal hypersensitivity, nasal obstruction with abundant discharge, occasional loose stools, 1 – 2 times a day and the urine was yellow and turbid.  After the 4th week of treatment, no apparent nasal hypersensitivity was experienced and the tongue showed medial vertical fissures.  No hepatomegaly was administered for a total of 6 weeks at the end of which the patient obtained clinical cure.

(II)   Secondary obesity

        In children, whose acute icteric hepatitis had been cured or who were suffering from chronic liver disease, especially cirrhosis of liver, complications of endocrine hormone abnormality were frequently encountered.  The hormonal metabolic disturbances are complicated and varied in liver disease; they may lead to high somatotropinemia, decreased 生長介素, disturbance of inactivation of rennin and sub-aldosterone, hypofunction of thyroid, rise of insulin blood level and decrease of glucose tolerance.  In liver disease, there is also inhibition of sex hormone stimulating hormone, significant increase of blood estrogens and prolactin and decrease of male hormone.  The above abnormal changes of the endocrine system can master the growth and developing tendency of the child, especially the child infected by type B and C hepatitis virus directly through mother-infant communication and such a child would manifest persisting infection and chronicity early in the infantile stage.  But the diagnosis of chronic hepatitis in infants and children is generally neglected by physicians and parents, so that often times the chance of treatment is lost and some people even refuse TCM therapy.  (Although TCM therapy can not provide radical cure but systemic TCM therapy can usually give clinical cure).  Therefore, if the disease is prolonged and persistent, the endocrine and metabolic disorders may increase gradually leading to decrease of glucose tolerance or hypoglycemia.  Some of the children have increase of appetite during the convalescent stage and if self-control ability is poor, it is easy to develop secondary obesity and fatty liver.

Post-hepatitis fatty liver has the following characteristics:

(1)    Most have history of becoming fat after hepatitis, usually over standard body weight (usually increase 6-50 lbs, average 20 lbs).

(2)    General condition good, usually no apparent symptoms.

(3)    Appetite good, no aversion to oily food.

(4)    Blood transaminase usually mild or moderate increase.

(5)    70% – 80% patients have significant increase of blood neutral fat.

Secondary obesity – Introduction of cases

Case 4-5: male, age 13 yrs, abnormally fat since infancy, liver function normal, ultrasound examination: hepatomegaly of 2 cm, diagnosed as chronic persisting hepatitis.

Case 4-6: brothers, age 9 yrs and 11 yrs, plump, grandfather died of liver diseasse complicated with abdominal distension in 1958, mother blood examination two months ago showing no abnormality.

Case 4-7: male, age 10 yrs, secondary obesity, grandfather died of carcinoma of liver in 1990.

Chan (computer No. 458) male, age 13 yrs.  First visit: Middle of July, 1996.  Grandfather had history of acute icteric hepatitis; his parents were sufferers of chronic hepatitis.

When the child was a fetus in his mother’s uterus, the mother suffered from chronic hepatitis complicated by threatened abortion and required hospitalization.  She took TCM drugs to treat the hepatitis and to stabilize the pregnancy and there after she achieved a normal delivery.  The child was abnormally fat since infancy.  He received type B hepatitis preventive injection 7 years ago, but one year after that, he suffered from acute icteric hepatitis and was hospitalized for treatment.  After discharge, he had repeated examinations and recently he was found to have positive type B hepatitis antibodies.  His liver function was normal and had hepatomegaly of 2 cm, examined by ultrasonography.  He was diagnosed as chronic persisting hepatitis.  He felt tired and could not sleep well.  Physical examination revealed secondary obesity, pulse rate 120/min, the breasts showed significant development, the external genitals were infantile and the hepatomegaly was 1.5 cm.

After taking 10 parcels of TCM drugs, the margin of liver dullness was normal.  After systemic TCM therapy, testosterone was given for 6 weeks and the development of the external genital organ showed significant improvement, the glans protruded and could be seen externally, giving a normal appearance.  BMI lowered from 23 to 22.86 (for 13 yrs male, the ideal BMI range : 16.6 – 22.8).

He had his vacation in Hong Kong in August, 2002.  A doubtful relapse happened with manifestations of acne over the forehead, temporal region and chest for one month accompanied by constipation abdominal pain and generalized sweat stains.  He made a return visit and was found to be in a good nutritional and developmental condition (weight 75 kg, height 1.77 m, BMI = 23.93).  The lips were lined clearly, the tongue enlarged with teeth prints, the hypochondria showing anomaly and the liver enlarged 1.5 cm.  After taking 4 parcels of TCM drugs, the liver was normal; he farted frequently and bowl movements were 1-2 times a day, the amount large and associated with tenesmus.  He slept well and the acne gradually subsided.  Systemic TCM therapy was given for 4 weeks, after which clinical cure was obtained and the boy returned to school in Singapore.

Case 4-6

Cheung brothers, maternal grandfather died of liver disease with tympanites in 1958, mother blood examination with no abnormality two months ago, but diagnosed in this clinic as chronic hepatitis, deficiency of yin and yang complicated with gout.

Elder brother Cheung – (computer no. 83) male, age 11 yrs.  He complained that he had long time insomnia, fatigue, vertigo, headache, a hot temper, urine yellowish and stinking and wetness-heat stools.  Physical examination: good nourishment and development, puffy, height 1.44 m, weight 45 kg, BMI = 21.7 (11 years, ideal BMI range :15.5 – 21.9), chest showing hypochondriac anomaly, left side depression, right side bulging, hepatomegaly of 3 cm, with percussion tenderness, external genital organ normal.

After taking 4 parcels of TCM drugs, the liver was normal, but percussion tenderness was still present.  There was also nasal discharge, occasional coughing and yellowish urine.  Through the continuation of TCM therapy, the symptoms disappeared 1 week later.  Treatment stopped after completion of a systemic 4-week course.  The patient was followed up and no abnormal condition was discovered up to the present.

Younger brother Cheung – (Computer No. 85) male, age 9 yrs.  For a long time, he suffered from fatigue, poor sleeping, difficulty in falling asleep after awakening, repeated nasal hypersensitivity and epistaxis, bleeding occasionally large in amount.  For 3 years, he had repeated abdominal distension and pain, diarrhea, bowl movements at the most reaching 12 times a day, belching and frequent farting, significant abnormal obesity and retardation of memory.  Physical examination: the child showed marked puffiness, skin color dark and yellowish, height 1.34 m, weight 47 kg, BMI = 26.18 (10 years ideal BMI range : 15.2 – 21.2), tongue enlarged with teeth prints, abdomen full and distended, right hypochondrium abvionsly bulging with percussion tenderness, hepatomegaly of 1.5cm, edmea (+) of lower extremities, external genitalia comparatively infantile in development.

After taking 4 parcels of TCM drugs, epistaxis stopped; he was not so weak but still had generalized soreness of the body, nasal hypersensitivity, abdominal distension, frequent farting and hepatomegaly of 1.5 cm.  He took another 4 parcels of TCM drugs and in his return visit, he showed no discomfort besides generalized soreness of the body.  The tongue coating was thick and whitish, the liver was normal but still showing percussion tenderness.  In the following days, he had no discomfort only for occasional nasal hypersensitivity and epistaxis.  He received totally 7 weeks of systemic TCM therapy and was then followed up.  Up to the present, he had 3 return visits and no relapse of hepatomegaly occurred.  These were occasional common cold symptoms and epistaxis.

Case 4-7

Lee – (computer No. 281) male, age 10 yrs.  His maternal grandfather died of carcinoma of liver in 1990 and several family members of the maternal side were carriers of type B hepatitis virus. 

His first visit was on 18 April 1997 at which time the child had secondary obesity with a height of 1.36 m, weight 44 kg and BMI = 23.78 (10 yrs child ideal BMI range : 15.2 – 21.2).  He had long term constipation (once in 5-7 days), repeated common cold attacks, abundant nasal discharge, coughing, sleepiness, distension of abdomen and hepatomegaly of 1.5 cm.  He did not receive treatment and was observed for three months, but the hepatomegaly was as before and his tongue coating was yellowish white and scanty.  He was given 2 parcels of TCM drugs and amount of stools was large, being three times a day.  His tongue coating detached and the liver was normal.  He received 6 weeks of systemic TCM therapy and then stopped the medication.

In the following year, on 26 March 1998, he had a return visit, complaining of exopathic fever and repeated coughing for 2 weeks.  He was treated with anti-inflammatory drugs for 9 days with no avail.  His tongue coating was thin and white, and had a hepatomegaly of 1.5 cm, which was the first relapse.  After taking 7 parcels of TCM drugs, the liver returned to normal and the cough stopped completely within 2 weeks.  He received systemic therapy and then stopped the medication.

In February, March, May and October 1999, he had repeated relapses of hepatomegaly but was not treated systemically.  Recently, he was hospitalized because of high fever, associated with sorethroat, vesicles at the mouth angles, shortness of breath, severe cough and icterus of skin and conjunctivae.  The Margaret Hospital ascertained the diagnosis of EBV (EB virus infection).

During hospitalization, he was not treated with WM drugs, but he received TCM drugs from our clinic and after 2 parcels of administration, the fever subsided and the transaminase dropped from 700u to 200u.  Six days later, he was discharged and continued the TCM treatment in our clinic. Physical examination showed a hepatomegaly of 1.5 cm.  After another 4 parcels of TCM drugs, the liver returned to normal.  He completed the 6-week systemic TCM therapy and his condition remained good.

Proper treatment of liver disease often stops the progression of secondary obesity

Recently, an investigation of the nutritional state of children in Hong Kong reveals: 13.7% of boys and 9.8% of girls are obese, and obesity increases with the increase of age, the climax of obesity in boys and girls being at the age of 11 years.  One third of the young people with obesity have the tendency of developing diabetes.  Another statistical data has shown that 5% – 8 % of chronic active hepatitis patients have hepatic diabetes.  These statistics demonstrate that obesity in children is a problem deserving attention.  But, is simple “over nutrition” and “bad eating habits” the only cause of such results?  This deserves our deeper consideration.  If a part of these fat children are sufferers of hepatitis, proper treatment of liver disease often times can stop the progression of secondary obesity, particularly those associated with decrease of male hormone and increase of serum estrogeus (male pediatric secondary obesity).  One may also encounter male patients with breast development and atrophy of testicles and external genitalia.  If these fat boys are treated with systemic TCM drugs and supplemented with adequate dose of male hormone, they would certainly obtain normal development.

In some types of hepatitis, there exists a virus infection phenomenon of “family coacervation”.  This may also explain the phenomenon that a number of fat people can be seen together in a family, a clan or in a district or village.  These fat people (especially secondary obesity) may not be due to heredity, and the possibility of the result of hepatitis virus infection should be considered.

Liver disease can also cause damage to the nervous system

Liver disease can also cause damage to the nervous system. Acute of chronic virus hepatitis can cause simultaneous or subsequent damage of the nervous system leading to psychotic and neurotic symptoms as well as diseases like acute or chronic hepatic encephalopathy, meningitis and epilepsy.  In fact, in the hypothalamus, there are two nuclei which regulate food eating activity, one is the ventromedial nucleus (satiation centre) the other ventral lateral nucleus (hunger centre).  Animal experiments show that if its ventral medical nucleus is destroyed, the animal increases its food intake and becomes fat.  In clinical practice, the sequelae of some encephalitis or meningitis patients are chiefly characterized by polyphagia and obesity.  In children having been attacked by acute hepatitis and also those with chronic hepatitis, the appearance of secondary obesity is related or not to the damage of hypothalamus, is a problem still to be investigated.  But children recovered from acute hepatitis and those having chronic active hepatitis, are often complicated by secondary obesity, and this is a fact with no controversy.

According to statistics, 70% – 80% virus hepatitis patients have symptoms of cranial nerve injury.  In chronic active hepatitis patients, 10% have hepatitis neural disease like radiculoneuritis and neurasthenia.  These conditions indicate that doubtlessly hepatitis virus causes damage to the nervous system.  But in children infected by hepatitis virus, whether their secondary obesity is the result of nerve tissue damage or due to endocrine disorder should be further investigated.

Besides an external obese stature, chronic hepatitis pediatric patients with secondary obesity may have the association of listlessness, laziness, failing memory, migraine, sleepiness, intolerance to labor, fatigue, shortness of breath, distension of abdomen, dark colored urine and in older children, vague pain over the right upper abdomen.  In addition, the diseased child may also have some obstinate and nearly incurable symptoms of chronic hepatitis (such as the symptoms mentioned above).  Physical examination would reveal hepatomegaly in the absolute majority of cases and in blood examination, one can find the respective positive results, so that, in general, the diagnosis is not difficult.

By WONG Kwok Hung

translated by Professor ZHENG Hua En in April 2006

        The liver is the axis of body metabolism, its function is very complicated and some of its functions are closely related to the blood system and metabolism of glucose, protein, fat, water, electrolytes, vitamins and microelements.  Liver is an hemopoietic organ when the fetus is 2-5 months and although bone marrow is the chief hemopoietic organ after birth, the liver still has close relation with hemopoiesis.  Many hemopoietic factors like Vitamin B12, folic acid and iron are stored in liver to fulfill the need of bone marrow hemopoiesis. In pediatric hepatitis, viruses attack directly the bone marrow stem cells and the liver and bone marrow may be simultaneously injured by autoimmune response, leading to impairment of hemopoietic function.

        The diseased child may suffer from prolonged loss of appetite due to chronic hepatitis and may also develop mal-absorption of the gastrointestinal tract and decrease storage of hepatic hemopoietic factors and the child may have chronic blood loss due to a bleeding tendency caused by hemolysis and liver disease.  (In infants, it may be repeated epistaxis and in older girls it may be menorrhagia, menstrual disorders and in a few cases, intestinal polyps or hemorrhoids).  Therefore, in chronic hepatitis, the incidence of anemia may reach 75% and it is often called hepatic anemia.  Anemic conditions are often of mild to moderate degree.  Besides the clinical characteristics of liver disease, the child may have contemporary manifestations of anemia such as paleness of skin and mucosa, vertigo, palpitation and insomnia.  A small number of patients with virus hepatitis or in the post-hepatitis period (especially type B and type C hepatitis) may suffer from aplastic anemia. Clinically, it is called post-hepatitis aplastic anemia or hepatitis aplastic anemia syndrome.  Aplastic anemia often occurs at the stage of recovery of acute icteric hepatitis; the incidence in young people is higher and about 90% occurs within one year after the attack of hepatitis.

        In addition, when there is organic pathologic changes in the liver following virus hepatitis, various metabolic disturbances may be evoked and those commonly seen are as follows:

•          Hepatogenic diabetes – in pediatric diabetes, enuresis may often be the first symptom; the onset may be acute and the symptom may be serious, associated with apparent emaciation, polydipsia, polyuria, polyphagia, getting hungry easily, fatigue and inactivity, susceptibility to infection; children suffering from prolonged illness may show dryness of skin, ichthyotic desquamation, pruritus and hairiness.

•          Hepatogenic hypoglycemia – hypoglycemic encephalopathy manifestations such as susceptibility to hunger, palpitation, perspiration, tremor of hands, paleness of face, restlessness, and in severe cases, dizziness, headache, blurring of vision, slowness of response and even psychosis.

•          Hypokalemia – may present weakness of muscle, bitterness of taste, loss of appetite, decrease of food intake, abdominal distension, hypotension, and in severe cases, restlessness, emotional instability and sleepiness.

•          Hyponotremia – frequently encountered symptoms are listlessness, weakness, indifference, loss of appetite, thirst, anxiety, vertigo, distension of head, headache, anorexia, nausea, vomiting, paleness and coldness of limbs, and in severe cases, painful muscular spasm, blurring of vision, hypotension and postural fainting.

•                       Liver disease causes decrease of amount of liver cells as well as liver function, insufficient food intake and decrease of anabolism; these may lead to hypoproteinemia, nutritional disturbance and finally to malnutrition and underdevelopment.

        Besides symptoms caused by metabolic disturbance, patients of this form often present thinness, a listless looking, fatigue, paleness of skin, conjunction and lips, whitish color of tongue mucosa, dryness or hyperkeratosis of skin, or even dermal desquamation or skin diseases showing fissures, eczema, rubella or sweat stains. The diseased child is susceptible to many kinds of infection due to decrease of immunologic function.  Some of these patients may be irritable and cannot sleep well or become taciturn, indifferent to the surroundings or have regression of memory or childish behavior. The child shows also apparent malnutrition, soft and distended abdomen, shallow flat umbilicus (or even protruded), scarcity of subcutaneous fat, and the skin can be picked up easily by fingers.  If there is significant hypoproteinemia, the patient may have edema of the ankles and pitting edema over the pretibial region (obvious pitting after pressing with the finger).

Introduction of cases – Nutritional disturbance or anemia form

Father, Ho (computer No. 355) male, age 48 yrs.  He was diagnosed as chronic hepatitis complicated by weakness of liver and kidney.  The man was extremely thin, malnourished and poorly developed.  He had anomalies of both hypochondria (depression of left hypochondrium and buldging of the right), hepatomegaly of 3 cm with apparent percussion tenderness.  He had plenty of white hair and multiple senile plaques on the upper arms.  He often experienced insomnia and pain in the liver.  After the first visit, which was on 14 August 14 1996, he took 19 parcels of TCM drugs and the liver returned to normal.  Three months later, the senile plaques on the upper arms faded in color markedly and its size also decreased.  Four months later, his white hairs decreased in number and he no more needed hair staining.

Mother, Chan (computer No. 67), female, age 39 yrs.  She was diagnosed as chronic hepatitis complicated with hepatic heart disease.  She often had vertigo, palpitation, hypochondriac pain, epistaxis, repeated common cold, sorethroat and repeated pain of the knee joints since delivery.  On 28 December 1995, the day of first visit, her liver was found to be enlarged 3 cm and heart murmur was heard associated with a heart rate of 104/min.  After taking 19 parcels of TCM drugs, the liver returned to normal and palpitation disappeared.  Systemic therapy continued for 6 weeks. Abnormality was not found during a return visit in 1998.

Elder sister, Ho (computer No. 354) female, age 14 yrs.  She first visited the clinic on 28 December 1995 with the chief complaint of repeated vertigo, abdominal distension and pain and diarrhea.  She had menstruation for 2 years and had also menstrual disorders, dysmenorrhea and repeated bleeding.  Physical examination: anemic and thin, hepatomegaly of 3 cm.  After taking 12 parcels of TCM drugs, the liver returned to normal, but hepatomegaly reappeared for five times following postmenstrual blood loss.  The liver returned to normal each time after administration of TCM therapy and nutritional support.  After July 1996, hepatomegaly was not found following menstruation period and an observation of six months did not reveal any abnormality.  She was followed up for another one more year and the last return visit was 9 January 1998, at which time no relapse was observed.

Younger sister, Ho (computer No. 353), female, age 10 yrs.  Her first visit was on 26 December 1995.  She was accompanied by her mother who said that the girl had repeated upper abdominal pain, constipation and diarrhea.  She was diagnosed as stomache ache and given gastric drugs.  Recently she frequently suffered from common cold, cough, expectoration, loss of appetite and yellowish urine.  Physical examination: poor nourishment and development, tongue red without coating, hepatomegaly of 3 cm, tenderness below xyphoid process in upper abdomen.  After taking 15 parcels of TCM drugs, the liver returned to normal.  Systemic therapy lasted for 8 weeks and ceased on 21 March 21 1996.  The patient was followed up.

This patient had hepatomegaly of 1.5 cm relapsed for 4 times, namely, 3 June 1996, 22 June 1996, 16 September 1997, 31 October 1998.  The clinical manifestation was common cold with fever in two times and wetness–heat abdominal pain in the other two, but in all episodes the symptoms disappeared after TCM treatment.  Every time, the hepatomegaly recovered after 3 to 6 days of TCM drug administration.  Observation continued for 2 more years after treatment; the patient’s constitution improved significantly and anemia was corrected.  Her body weight increased from 52 lbs to 76 lbs.  The last return visit was on 2 January 1998; the girl’s appetite was good, she had no discomfort and her liver was normal.

Case 3-2

Yuan (computer No. 1052) male, age 6 yrs.  His father had type A icteric hepatitis five years ago and now he still suffered from fatigue, edema, palpitation, abdominal pain and distension.  His mother had a history of carrier of type B hepatitis virus and she had also menstrual disorders.  On 24 July 1999, when the three of them made their first visit to the clinic, all were found to have hepatomegaly.  His mother had physical examination several months ago and was detected to have increased liver ferment.

The child had history of repeated constipation, rhino-sinusitis and otitis media and he frequently had enuresis.  Physical examination: poor nourishment and development, skin pale and yellowish, abdomen distended, prominent veins over abdominal wall, hepatomegaly of 3 cm.  After taking 7 parcels of TCM drugs, the liver was normal.  Enuresis and other clinical symptoms disappeared after 6 weeks of systemic treatment.

A return visit was made on 20 November 1999.  His mother said that her son took some refreshments in school together with 10 classmates and then they vomited.  The vomiting was associated with diarrhea, coughing with abundant expectoration and abdominal distension.  WM drugs were taken according to common cold but of no avail.  Enuresis was cured after the previous treatment.  Re-examination of the patient showed hepatomegaly of 3 cm which was the first relapse.  He took half parcel of TCM drugs a day and the liver was normal after 6 days of administration and the clinical symptoms also completely disappeared.  Systemic therapy persisted for 4 weeks, at the end of which clinical cure was obtained.

Case 3-3

Au (computer No. 3508) female, age 10 yrs. Day of first visit: 4 August 2003.  Her mother had suffered from chronic hepatitis.

The patient after had nasal hypersensitivity, loss of appetite, fatigue, sleepiness, fissures, edema and desquamation of lip mucosa and geographic tongue.  Physical examination revealed thinness, paleness of skin, prominent eye-bags and dark colored skin around the eyes, poor nourishment and development, anemic looking

and hepatomegaly of 3 cm.

After taking 3 parcels of TCM drugs, the liver returned to normal, but nasal hypersensitivity was still present.  She had frequent farting and fissuring of lip mucosa; however, the severity of geographic tongue decreased.  When TCM drugs had been administered for 2 weeks, there was occasional coughing with much expectoration, but the tongue became normal and lip desquamation ceased.  After 3 weeks of medication, the child’s cough stopped and dryness of lips decreased; urination in one episode was of the wetness-heat kind and she sometimes suffered from frequent urination. Systemic therapy lasted for 4 weeks, by the end of which clinical cure was obtained and she was followed up.

Lai (computer No. 3483), female, age 12 years. First visit: 19 July 2003.  Height: 1.65m, weight: 42 kg; BMI = 15.5 (normal 16 – 21).  She felt tired, suffered from nasal discomfort and frequent epistaxis.  She was tall, lean with long limbs (typical female hormone deficiency stature).  Interval between menstruations changed to 45 days; the menstrual blood was dark red, large in amount but without clots and dysmenorrhea.  Leucorrheal discharge was abundant in amount and she had a hepatomegaly of 1.5 cm.

After taking 7 parcels of TCM drugs, she had no discomfort and liver was normal.  TCM treatment was continued.  She had premenstrual insomnia but leueorrhea and frequency of urination decreased.  After the medication, her menstrual blood turned red, was more in amount and the liver was normal.  At the third week of therapy, she travelled to Philippine and medication was interrupted.  When she returned to Hong Kong, she had abdominal pain, wetness-heat stools and diarrhea, but the liver was not enlarged. TCM drugs were administered for another 3 weeks to complete the systemic therapy.  She was clinically cured and followed up.

Chan (computer No. 3582), male, age 13 yrs.  First visit: 2 October 2003.  He was found to have diabetes two years ago and now he had to receive insulin injection treatment.  He felt thirsty and had ozostomia; his tongue was purplish red with thin white coating in the centre.  He had frequent nocturia, constipation and blood tinged toilet paper after defecation.  Physical examination: the child had an ester odor in his breathing and a hepatomegaly of 1.5 cm.  After taking 3 parcels of TCM drugs, the liver returned to normal and during therapy, he experienced mild vertigo.

After one week of TCM treatment, nocturia disappeared, ester odor in breathing and the purplish red color in tongue and lips alleviated.  Bowl movements were smooth, no blood was seen in toilet paper after defecation and the liver was normal.  Another 6 parcels of TCM drugs were given.  On his return visit, examination revealed subsidence of edema of lip mucosa, but the fissures were still deep.  In the recent two days, there was epistaxis but the amount of blood was small.  There was still some blood on toilet paper after defecation; the liver was normal.  He continued to take another 7 parcels of TCM drugs, and epistaxis stopped.  Blood tinged toilet paper was occasionally seen after defecation.  There was cough sometimes but no expectoration.  Sleeping was well and the liver was normal.  Therefore, another week of TCM drugs was given and after a course of 5 weeks of TCM therapy, the patient was cured clinically.  He was followed up after cessation of treatment.

By WONG Kwok Hung

translated by Professor Zheng Wah En in 2006

In virus hepatitis, the virus can attack any part of the gastrointestinal tract.  In the past, people thought that the gastrointestinal symptoms were merely manifestations of the liver disease, but now, it is confirmed that the symptoms of digestive system in chronic hepatitis are caused by direct viral infiltration of gastric or intestinal mucosa or by damage of gastrointestinal mucosa following disorder of immune system evoked by virus.  Gastrointestinal mucosal biopsies of these patients show significant inflammatory changes.

The gastrointestinal symptoms and clinical manifestations of virus hepatitis usually include poor appetite, anorexia, nausea, vomiting, distension of upper abdomen, belching, borborygmus, or recurrent paroxysmal abdominal pain, diarrhea, constipation, oral ulcerations, edema, dryness, desquamation and fissures of lip mucosa, obstinate tongue coating, ozostomia and indigestion.  A small number of hepatitis patients, when associated with hepatogenic peptic ulcer may be easily complicated by hemorrhage of digestive tract or venous varicosities of colon leading to repeated hematochezia (polyps, hemorrhoids or anal fissure).  Therefore, pediatric hepatitis patients are prone to have repeated alternating constipation and diarrhea and also tenesmus, defecation right after meal, abdominal distension, anorexia, frequent farting and susceptibility to wetness-heat abdominal pain.  For infants, the common symptoms are poor appetite, indegestion, recurrent diarrhea, abdominal distension, milk regurgitation, restless sleeping, nocturnal crying and susceptibility to aphthae.  One should think of the existence of hepatic disease if these manifestations are present.  The more severe cases may be associated with thinness, malnutrition and hypoalbuminemia (such as presence of edema of the ankles).

The infants and children with the above symptoms should be examined for hepatomegaly and be ascertained whether or not suffering from hepatitis.  It should be mentioned that hepatogenic diarrhea is one of the common clinical symptoms of liver disease (including acute or chronic hepatitis, cirrhosis or carcinoma of liver).  In liver disease, sometimes hepatogenic diarrhea may be the first symptom to appear as well as the chief symptom causing the patient to seek for medical help.  According to statistics, 4% – 30% of chronic active hepatitis patients have diarrhea, so this condition should not be neglected.

Introduction of cases –

2nd Form : Gastrointestinal, dermal of lower-jiao wetness-heat form

Case 2-1: The siblings were diagnosed as hepatomegaly for investigation.  Their parents had hepatomegaly and were treated simultaneously with TCM drugs in our clinic (the mother had history of positive type B hepatitis antibodies).

The elder sister: Yang – (computer no. 1981) female, age 7 yrs.

First visit: 8^th November 1999.  The patient was thin, poorly nourished and underdeveloped for a long time; she also had poor appetite and sleepiness.  In the recent days, she experienced abdominal pain, belching, nausea and vomiting, the vomitus being food remnants.  Doctors diagnosed the disease as exopathy attacking the stomache.  WM drugs were taken but of no avail.  Physical examination revealed an enlarged tongue with thin white coating, percussion tenderness of hepatic region, hepatomegaly of 1.5 cm.  After taking TCM drugs, the abdominal pain and vomiting ceased.  Another 3 parcels of TCM drugs were taken and the appetite improved and other symptoms disappeared only for the presence of thick white tongue coating.  The liver was normal.  TCM drugs were continued for 3 weeks, the appetite was good and the tongue coating detached completely.  At the fourth week of medication, her body weight increased 1.5 kg (from 22 kg to 23.5 kg).  A total 6 weeks of TCM drugs were taken, at the end of which, she was clinically cured and was then followed up.

In the following 3 months when medication was stopped, she received monthly examination and the liver was found to be normal.  But after the Spring festival, she took unclean food and felt tired, sleepy and listless.  By the middle of March 2000, she had sorethroat and western medical examination discovered tonsilitis but the administration of anti-inflammatory drugs was not effective.  She returned to our clinic on 19^th March and looked thin, listness and tired.  Her tongue coating was thin, yellowish; the margin of hepatic dullness increased 1.5 cm and percussion tenderness was present.  After taking 3 parcels of TCM drugs, her sorethroat disappeared, appetite improved, coating of tongue disappeared and the color of tongue deep red.  The liver was normal but her expectoration was still abundant.  Systemic TCM therapy was administered for 4 weeks and clinical cure was obtained.  The patient was followed up.

The brother: Yang – (computer no. 1983) male, age 3 yrs.

No apparent discomfort was complained.  He was examined because of hepatomegaly found in his parents and elder sister.  Physical examination revealed a hepatomegaly of 3 cm.  He took the same TCM drugs as his sister and during treatment he had vomiting and diarrhea.  After 3 parcels of drugs, the liver was normal.  His systemic therapy was similar to that of his sister.  After that, hepatomegaly did not relapse.  His sister had a relapse several months later but the patient’s liver was shown to be normal by physical examination.

Case 2-2:

Zhang – (computer no. 1580) female, age 11 yrs.

First visit: 10^th August 1999.  Her mother said that the child had a poor constitution and a habit of taking food irregularly and experienced abdominal pain and distension, diarrhea, listlessness and occasional constipation.  In the recent days, she had nausea, vomiting, vertigo, poor appetite, abdominal distension, vomiting right after food intake, loose, watery stools, being two or three times a day.  WM drugs were not effective.  Physical examination: poorly nourished, underdeveloped, skin pale yellow, lean, tongue enlarged without coating, percussion tenderness over hepatic region, hepatomegaly of 3 cm.  After taking 2 parcels of TCM drugs, nausea and vomiting ceased.  She had apparent feeling of hunger, and her appetite recovered.  Bowel movements were 1-2 times a day with loose stools, percussion tenderness was still present but the liver was normal.  Systemic therapy continued for 4 weeks and she obtained clinical cure.  She was followed up.

Case 2-3:

Lee – (computer no. 3262) male, age 14 yrs.

First visit: 18^th March 2003.  The patient suffered from nasal hypersensitivity for a long time and was susceptible to aphthae.  He was restless, had grinding of teeth at night and history of abdominal pain.  He was diagnosed as stomache disease but the taking of “gastric drugs” did not show effectiveness.  He also had frequent attacks of common cold, fever, occasional coughing, edema fissure and desquamation of lip mucosa, and enlarged tongue with apparent thin white coating.  Physical examination revealed hepatomegaly of 3 cm.

After taking 3 parcels of TCM drugs, the liver was normal.  He was sleep well and restlessness decreased.  The tongue coating was thinner and partly detached.  He had manifestations of a mild degree of common cold.  Administration of TCM drugs was continued during which time there were repeated aphthae, epistoxis and occasional nasal hypersensitivity.  In the third week, nasal hypersensitivity was not seen and at the fourth week these was no oral ulceration.  Clinical cure was obtained at the end of the sixth week of TCM therapy.  The patient was followed up.

One year later (7^th March 2004), the first relapse occurred.  On visiting, he complained of fatigue, sleepiness, facial acne and edema of lip mucosa.  His bowl movements were normal.  Physical examination revealed hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, the liver was normal.  After another week of medication, the acne disappeared and edema of lip mucosa gradually subsided.  No other discomfort was found.  Another week of TCM therapy was administered and then he stopped the medication.

Case 2-4:

Huang – (computer no. 3840) female, age 5 yrs.

First visit: 7^th March 2004.  Her grandmother died of cirrhosis of liver.  When she was 4 years old, she suffered from repeated abdominal pain and was diagnosed as appendicitis and so operation was performed.  Postoperatively, her appetite was poor and she had frequent abdominal distension and pain, wetness-heat stools, repeated vomiting and poor sleeping.  Physical examination revealed edema and desquamation of lip mucosa, distension of abdomen, a slant incision mark on skin of right lower abdomen and a hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, the mother came saying that the patient had nasal obstruction, poor sleeping and loose stools.  She took 4 parcels of drugs.  After the medication, the patient’s abdominal distension alleviated and her bowl movements were more smooth, being once a day.  She slept well but dreamful and her liver returned to normal.  A total 4 weeks of TCM drugs were taken and clinical cure was achieved.  During the course of treatment, she farted frequently with stinking smell; the stools were loose, dark in color, 1-3 times a day, but gradually it became normal in shape and once a day.  She had no abdominal distension and pain and she slept well.

Physician’s comment:

The patient had the typical gastrointestinal wetness-heat symptoms of “chronic hepatitis” and it is not difficult to find from the history that her gastrointestinal wetness-heat symptoms were rather obstinate.  The diagnosis of appendicitis and its operative treatment is not under evaluation in our article, but at least, it can be ascertained that the operation was not able to cure the disease from the fundamental.  Furthermore, it did not relieve the clinical symptoms such as repeated vomiting, abdominal distension and pain and abnormal stools.  Clinical cure and disappearance of symptoms were accomplished only after thorough TCM therapy.

Chan – (computer no. 3474) female, age 9 yrs

First visit: 12^th July 2003.  Her father was a carrier of type B hepatitis virus.  The child’s complaint was substituted by the mother who said that the patient had repeated intestinal pain, poor appetite, dysuria, hard stools and often bleeding from anal fissure following defecation since infancy.  The patient also experienced repeated aphthae which caused difficult swallowing; she slept badly and dreamfully.  She had enuresis, nocturia and difficulty in enduring a distended bladder so that her panties got wet easily.  Physical examination: lean, pale looking, tongue, thin white coating at posterior part, hepatomegaly of 1.5 cm.  After taking 3 parcels of TCM drugs, the aphthae healed up; tongue coating clean, urination smooth and liver normal.  TCM treatment continued; she had no more abdominal pain and her bowl movements were smooth, the stools in shape.  After 2 weeks medication, the tongue coating detached completely, the tip of tongue was red, the stools not hard and in rod shape.  Her urination was smooth, but her panties were wet occasionally and nocturia reduced to 0-1 time a night.  During treatment, she had incontinence of urination occasionally, but nocturnal enuresis ceased.  Aphthae occurred occasionally and the stools were loose.  TCM drugs were taken for 4 weeks totally and clinical cure was obtained.

Physician’s comment:

This patient had typical symptoms of the gastrointestinal wetness-heat form of “chronic hepatitis” associated with lower–jiao wetness-heat.  In the latter condition, the mucosal tissues of the genitourinary system show viral inflammation in which can induce respective urinary symptoms or vulvitis.  TCM therapy given in time may accomplish clinical cure.

Case 2-6:

Wong – (computer no. 3580) female, age 12 yrs.

First visit: 2^nd October 2003.  The girl took soy beam milk 15 days ago, after that she had vomiting and diarrhea.  She was given anti-diarrhea drugs but she still had vomiting repeatedly and also gastric distension and poor sleeping.  One week after the onset of illness, she was admitted to a local hospital.  She had fluid infusion for 2 days and was then discharged.  She vomited after in take of food recently.  Her menstruation was frequently delayed, the color of blood deep red, with many clots.  The last menstrual period was half a month ago and she had occasional dysmenorrhea.

Physical examination: poor nourishment and under developed, lean, long limbs, hary lower extremities, edema of lip mucosa, tongue enlarged with teeth prints and thin white coating, hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, gastric distension and vomiting disappeared.  She had short time diarrhea and she passed loose stools twice a day.  Sleeping was well and the liver became normal.  TCM drugs were taken for another week by which time the edema of lip mucosa subsided; she did not vomit but her appetite was still not so good.  Her bowl movements were normal, being once daily.  TCM therapy continued for 6 weeks, after which she was cured clinically and was followed up.

Physician’s comment:

The patient had gastrointestinal wetness-heat symptoms induced by virus gastroenteritis.  Despite WM treatment and fluid infusion in hospital, she was not cured.  According to her history, symptoms and physical signs, one should consider wetness-heat of chronic hepatitis.  The patient in this case was poorly nourished and underdeveloped, thin, had long limbs and hairy lower extremities (due to decrease of female sex hormones) and the association of lip mucosal edema, enlarged tongue with teeth prints and thin white coating and hepatomegaly of 3 cm.  The impression of hepatophilic virus disease is reasonable.  On the administration of TCM drugs, the symptoms disappeared and clinical cure was obtained.  Systemic treatment was of advantage to the improvement of liver function and therefore, helped to correct her sexual hormone disorder and to regulate her menstruation.

Case 2-7:

Gao – (computer no. 2422) male, age 7 yrs.

First visit: 21^st March 2001.  His parents suffered from chronic active hepatitis.  His complaint was substituted by his father, saying that the child had repeated common cold for a long time and had been operated for congenital urethral stricture, but after the operation, he still suffered from unsmooth urination and yellowish urine with occasional tea like color.  The tongue coating was white and thick in the centre and the hepatomegaly was of 3 cm.  After taking 3 parcels of TCM drugs, the liver was normal.  He did not feel any discomfort and the stools were loose, being twice a day.  There was still thin whitish coating at the centre of tongue.  Another 4 parcels were taken but there was still wetness-heat stools, being 1-3 times a day.  The tongue coating had detached and the liver normal.  Two weeks later, he stopped the medication for 2 days because of common cold.  His expectoration was abundant.  Another week of TCM drugs was given and the child’s bowl movements were 3-4 times a day, his urination was smooth, color of urine clear and the amount was large.  He had no more cough, his appetite good and sleeping was well.  He continued to take another week of TCM drugs, making a total of 4 weeks of systemic therapy.  The patient was followed up.  Two weeks later, a return visit was made.  The patient was found to have slightly thin white tongue coating, good appetite, smooth urination, normal stools and the liver was also normal.

Physician’s comment:

The patient had liver stagnation and lung dryness and wetness-heat of lower-jiao since infancy.  His repeated exopathic symptoms were in fact manifestations of liver stagnation and lung dryness.  The postoperative urination should be smooth and the reason that it was not was due to wetness-heat of lower-jiaofrom chronic hepatitis.  Therefore, he suffered from prolonged unsmooth urination, voiding of yellowish or even tea-like urine with frequent interruption.  Systemic TCM therapy was administered and after 3 parcels of TCM drugs, the liver was normal, the wetness-heat of stomache, intestines and lower-jiao was gradually expelled and clinical cure was achieved after 4 weeks of therapy.

Case 2-8:

Lau – (computer no. 3691) female, age 14 yrs.

First visit: 25^th December 2003.  Her father was a carrier of type B hepatitis virus and had abnormal liver function.  Her mother had a history of type A hepatitis. She had repeated gastrointestinal discomfort and abdominal distension since infancy.  She had also frequent constipation (once in 2-3 days), the stools hard and in the shape of lumps.  She frequently suffered from common cold and cough.  Menarche came at the age of 10 and thereafter, she had irregular menstruation and in one episode the menstrual blood persisted for nearly a month.  Her left ear lost hearing ability since infancy but examination by specialist did not reveal abnormality.  Physical examination: nutritional state and development satisfactory, forehead showing red macules and multiple acne, abdomen distended, hepatomegaly of 1.5 cm.

After taking 3 parcels of TCM drugs, her bowl movements were smooth and of large amount; the liver was normal.  After another 3 parcels, she still had abdominal distension and pain, poor appetite and large amounts of loose stools; she also had chilliness, sleepiness and fatigue.  She was given another five parcels, at which time she experienced gastric discomfort, nausea poor appetite, scanty amount of stools, nasal discharge, scanty expectoration, insomnia and pain of upper thigh.  The liver was still normal.  At the 10^th day of drug administration, menstruation appeared, it was normal, without pain and blood clots and persisted for 7 days associated with poor appetite and gastric discomfort.

TCM drugs were continued for 4 weeks, during which time, she had occasional abdominal distension and pain, scanty stools, tenesmus, nasal discharge, abundant expectoration, shortness of breath which required deep breathing, coldness of limbs, poor appetite, small amount of food intake, fatigue, paroxysmal abdominal pain but acne disappeared and sleeping was well.  TCM drugs were taken for 6 weeks altogether, and clinical cure was obtained.  The patient was followed up.

Since infancy, the patient had liver stagnation, lung dryness and heat of large intestines (common cold, cough, constipation, hard stools) and repeated gastrointestinal wetness-heat of “chronic hepatitis” (gastrointestinal discomfort, abdominal distension, suppressive sensation on stomache, nausea, poor appetite, paroxysmal abdominal pain) and dermal wetness-heat (dermal erythema of face, acne) symptoms.

Female pediatric patients at the post-adolescent period are prone to develop menstrual disorders, leading to symptoms of deficiency of qi and blood.  (In this case, there were menstrual disorder, menorrhagia, prolonged menstrual bleeding, dysmenorrhea, fatigue, insomnia, coldness of limbs, vertigo).  Therefore, in female pediatric patients with chronic hepatitis, it is important to pay attention to early diagnosis and to give timely TCM treatment.  If early diagnosis and treatment is neglected, the patient is prone to develop liver disease complications like sexual hormone disorder and anemia at the post-adolescent period and these conditions would affect development and body constitution seriously.  In this case, after treatment of the liver disease, the patient still suffered from prolonged menstruation which was examined to be caused by progesterone deficiency and drugs were given to control the bleeding.

Case 2-9:

Zhang – (computer no. 4240) male, age 9 yrs.

First visit: 16^th October 2004.  His mother had history of carrier of type A and B hepatitis virus.  The patient was fat and short in height since infancy; his height was 1.29 m, weight 38.5 kg, BMI = 23.2 (normal 15).  The mother said that her child suffered from prolonged nasal hypersensitivity, fatigue, sleepiness and occasional cough.  Recently he had belching, repeated desquamation of lips, post-auricular dermal itching and erosion.  There were eczema on the back and oral ulcers.  The patient stature was fat and short; his lips showed fissures and erosion; the lower limbs showed slight pitting edema; the abdomen was highly distended; development of genital organs satisfactory, the penis circumcised and hepatomegaly was of 3 cm.

After taking 3 parcels of TCM drugs, the regurgitation ceased but belching, occasional cough and lip desquamation was present.  Edema of lower extremities subsided, splenic dullness was present and the liver was normal.  Another 3 parcels were taken, the belching and coughing ceased; sleeping was well, there was no sputum, but headache was present.  Bowl movements were once a day, the stools hard.  Splenic dullness was not detected and the liver was still normal.  TCM drugs were continued, fissuring of lip mucosa decreased and the post-auricular dermal eczema or eruptions completely disappeared.  The stools were passed smoothly at times, being loose and of the wetness-heat character.  A total of 6 weeks TCM therapy was administered and clinical cure was achieved.  The patient was followed up.

This pediatric patient possessed typical symptoms of liver stagnation and lung dryness and wetness-heat vaporization forms of “chronic hepatitis” including gastrointestinal wetness-heat, viral lip mucosal pathologic changes and dermal wetness-heat leading to chronic generalized eczema and secondary obesity.  It was fortunate that the patient responded well to the TCM therapy and the liver was normal after 3 parcels of TCM drugs.  All of the symptoms disappeared rapidly and the eczema was well in two weeks.

        Upper respiratory tract infection is the most frequently encountered disease in children; many viruses and bacteria can cause upper respiratory tract infection, virus infection being the most common.  Upper respiratory tract infection includes acute rhinopharyngitis (commonly called common cold), acute pharyngitis, acute tonsilitis and acute and chronic inflammation in various sites of the respiratory tract.  But the symptoms of upper respiratory tract infection are also prodromal symptoms of many virus diseases like measles, chickenpox, mumps and virus hepatitis.  Similarly, in the preicteric phase of acute hepatitis and active stage of chronic hepatitis, there may be repeated attacks of fatigue, listlessness, nasal obstruction and discharge, sneezing, sorethroat, chilliness, fever, cough, expectoration, generalized tiredness, marked regression of appetite, nausea and instability in sleeping.  Older children may feel tired and complain of symptoms like headache, vertigo, inability to concentrate, regression of memory, soreness of muscles and articulations and mental depression.  The severe cases (most are older children) may present serious clinical symptoms, uncontrollable cough (chiefly choking) and occasional shortness of breath; such patients generally have a long course.  X-ray examination usually shows no abnormality or the chest film only reveals increase of lung linings, network like shadows of lower lungs or small patchy infiltration characteristic of interstitial pneumonitis.  Clinically, it is often misdiagnosed as bronchopneumonia, asthma, or even pulmonary tuberculosis.  The effect of anti-inflammatory drugs is not satisfactory, but if there is association of increase of margin of liver dullness, the application of TCM drugs can yield very good results.  (A test of TCM treatment is therefore advisable).

       It is not difficult to differentiate pediatric upper respiratory tract infection with hepatitis.  If the patients’ symptoms occur repeatedly, it can not be explained by simple common cold.  If they have history of close contact with hepatitis or with family members suffering from hepatitis or hepatic carcinoma, or if they have positive antigen or antibodies, abnormal liver function or association of signs of hepatomegaly and percussion tenderness of hepatic region, then it can be ascertained that these symptoms are of the liver stagnation and lung dryness form induced by hepatitis.

      (It is worthwhile to say something about hepatomegaly in pediatric examination.  In the past, it was considered that a hepatomegaly of 3 cm in children was within normal range.  But clinical practice repeatedly demonstrated that in pediatric hepatomegaly, under TCM treatment, the lower margin of liver can recover to 1.5 cm above costal margin which proves that the hepatomegaly is actually produced by pathological changes. )

      Moreover, the result of blood examination in pediatric hepatitis can only serve as a reference; a positive result helps to confirm the diagnosis, but a negative result does not rule out hepatitis.  It is because:

First, the present examination methods can not entirely detect the seven types of hepatitis as well as other hepatophilic virus infections.  Laboratory examination reports of negative antigen and antibody of type A and type B hepatitis can not rule out the existence of other types of hepatitis.

Second, children with the so called “negative HBsAg” may be actually HBsAg positive in a very small number of cases.  The latter cannot be ruled out is due to the insensitivity of the method of examination.  The examination deviation or other factors can cause a negative result.  Some reports pointed out that patients with negative HBsAg when examined repeatedly for type B hepatitis virus DNA, had a 64% positive result.

       Therefore, clinicians must base on history, symptoms and signs and various related conditions to make a comprehensive estimation and should not give up diagnosis and treatment of pediatric hepatitis lightly.

Case 1-1

Lee – (computer no. 257) male, age 7 yrs.  His father, mother and Philippine housemaid all had hepatomegaly and were sufferers of chronic active hepatitis.

His first visit was on 28^th March 1998.  His mother said that the child had nasal hypersensitivity for a long time, especially during the change of weather and there was also occasional abdominal pain, yellowish urine, poor appetite, repeated oral ulceration affecting the intake of food.  Physical examination revealed a poorly nourished and underdeveloped thin child; a distended abdomen and varicosities over abdominal wall, protrusion of right hypochondrium and depression of left hypochondrium, percussion tenderness over hepatic region and hepatomegaly of 4.5 cm. Clinical symptoms improved after taking 3 parcels of TCM drugs, hepatomegaly reduced to 1.5 cm and the patient did not continue the TCM treatment.

One month later, that is on 1^st May 1998, a return visit was made with the complaint of fever and cough for 2 weeks and treatment by western medical drugs for 3 days was of no avail.  The patient turned to request for TCM treatment.  Physical examination: hepatomegaly of 3 cm.  He was treated according to the liver stagnation and lung dryness form of chronic hepatitis and 3 parcels of TCM drugs were prescribed.  After the medication, the patient went to stools five times a day, feces were paste-like, large in amount and black in color.  The anus was painful; cough was relieved and expectoration became less in amount.  In the morning, ocular discharge was found abundant.  Physical examination found the liver normal.  Cough stopped after taking 10 parcels of TCM drugs.  The child received 7 weeks of systemic TCM treatment and was then followed up.

In the return visit on 8^th September 1998, the child was well besides occasional wetness-heat abdominal pain and hepatomegaly was not found.

On 15^th December 1998, the patient took some modern medical drugs because of head injury and nausea and vomiting.  Examination did not reveal any abnormality of brain, but the liver was found to be enlarged 1.5 cm which returned to normal after taking 3 parcels of TCM drugs.  The child took another 10 parcels and went to Singapore travelling for 5 days.  When he came back to Hong Kong, he had repeated epistaxis and severe coughing.  Western medical drugs were taken with no avail and he had to seek for TCM drugs.  Physical examination revealed hepatomegaly of 3 cm and percussion tenderness over hepatic region.  Three parcels of TCM drugs stopped the epistaxis, coughing was relieved and the liver returned to normal.  A following course of 4 weeks TCM therapy was instituted and clinical cure was attained.

Physician’s comment :

In this case, the response of the patient after TCM therapy was apparent, showing the necessity of systemic therapy for chronic hepatitis.  The clinical symptoms and signs in the first visit were obvious and although the symptoms improved and the liver margin retracted after TCM therapy, yet the stoppage of treatment was too early.  It caused the reactivation of the virus infection and hence, the exacerbation of liver stagnation and lung dryness symptoms.  He turned to TCM therapy because of the ineffectiveness of western medicine.  Therefore, the liver returned to normal in 3 days and the symptoms disappeared in a week.  Treatment ceased after 7 weeks of systemic TCM therapy.  In the following three months the liver was still normal.  Two times of relapse of hepatomegaly occurred following head injury and traveling three months later.  However, all were satisfactorily cured with TCM therapy.

Case 1-2

Kwan–  (computer no. 731), male, age 2-1/2 yrs.

His father had type B hepatitis 10 more years ago.  (He was still a sufferer of chronic active hepatitis with hepatomegaly of 3 cm; he received TCM therapy and obtained clinical cure).  The patient experienced repeated coughing, abundant expectoration, poor appetite, wakeful sleeping, repeated episodes of German measles, all of which were of no avail with WM treatment.  He finally turned to TCM therapy on 6^th December 1996 at which time the child was found to be thin, and the tongue geographic appearance, breathing coarse, pulmonary rales not heard and a 3 cm hepatomegaly was discovered.  After taking 12 parcels of TCM drugs, the margin of liver dullness reduced 1.5 cm and his coughing decreased.  Another 9 parcels brought the liver to normal.  Five parcels of TCM drugs were taken afterwards but he could not finish the systemic course and stopped the medication.

A month more later, the patient was hospitalized because of vomiting caused by gastroenteritis.  He made a return visit after hospitalization.  Physical examination showed that the child had a yellowish thick tongue coating and a hepatomegaly of 1.5 cm.  After taking TCM drugs, the latter was normal and in the following 3 months interrupted TCM treatment was given for 7 weeks.  In this interval, hepatomegaly of 1.5 cm relapsed for two times, associated with transient cough, tongue coating, poor appetite, occasional German measles and wakeful sleeping.  After TCM treatment, the liver returned to normal. The patient carried through the 6 weeks systemic TCM therapy to the end.  He was followed up for half a year and no relapse was found.

Physician’s comment:

This patient’s father had suffered from type B hepatitis and the child had apparent symptoms of liver stagnation and lung dryness and wetness-heat vaporization form associated with hepatomegaly of 3 cm.  Due to interrupted administration of TCM drugs, clinical symptoms and hepatomegaly reappeared.  In the later period, the family members at last took the advice of physician and completed the systemic course of treatment.  The liver was normal in the following six months of observation.

Case 1-3:

Kong brother and sister.   Their father died of carcinoma of liver 3 years ago and at that time their mother was found to have positive type B hepatitis antibodies by blood examination but examination results of the siblings were negative.  Therefore, they received type A and type B hepatitis preventive injections.

Brother, Kong – (computer no. 74) male, age 9 yrs.  His first visit was on 8^th May 1993 with chief complaint of repeated nasal obstruction, copious expectoration, cough, fever, abdominal pain and distension, poor appetite and yellowish urine.  After 3 weeks of TCM therapy, the liver returned to normal.  In the following half a year, repeated administration of TCM drugs amounted to more than 30 parcels for the treatment of liver stagnation and lung dryness, oral ulcerations and for symptoms of exopathy.  The liver was not enlarged.  In 1994 and 1995, the patient was still under observation.  He made 9 return visits because of discomfort but abnormality of margin of liver dullness was not found.

Five years later (patient being 15 years old) a return visit was made on 9^th August 1998, when he complained of frequent abdominal pain, discomfort of stomache and intestines, loose stools being 1-2 times a day, associated with insomnia, fatigue, difficulty in falling asleep, nasal hypersensitivity, repeated nasal obstruction, abundance of nasal discharge, sneezing and multiple acne of face.  Physical examination: adequate nourishment and development, multiple acne of the face, tongue reddish and enlarged but without coating, apparent percussion tenderness over hepatic region, hepatomegaly of 3 cm.  After taking 9 parcels of TCM drugs, the liver returned to normal and clinical symptoms disappeared.  During treatment, the patient produced a large amount of nasal discharge in the morning associated with nasal obstruction and oral ulceration.  He was treated with TCM drugs for 4 weeks and was then followed up.  No complaints were made during observation.

In the following year, on 25^th November 1999, he came to the clinic complaining of a significant increase of 37.5 lbs of body weight in the recent six months.  His body weight was 67 kg, height 1.69 m, BMI = 23.45 which was within normal range.  He had repeated abdominal pain, wetness-heat stools, frequent nasal obstruction, abundant nasal discharge, sneezing, occasional cough, frantic ingestion of food when hungry, abdominal distension and shortness of breath.  Physical examination revealed an enlarged tongue with teeth prints, distended abdomen and hepatomegaly of 1.5 cm with percussion tenderness.  After taking 3 parcels of TCM drugs, the liver was normal.  He received a course of systemic therapy and achieved clinical cure.  He was then followed up.

Sister Kong (computer no. 73), female, age 8 yrs.

Her first visit was on 16^th May 1993.  Her mother substituted for the complaint which was repeated exopathy with fever, copious expectoration, fatigue, vertigo, thinness, poor appetite, ozostomia, hypochondriac pain, yellowish urine and constipation.  Physical examination revealed poor nourishment and development, light yellowish skin, pale mucosa, tongue coating thick and whitish, hepatomegaly of 3 cm with percussion tenderness.  She took TCM drugs in succession for 8 months.  The liver recovered to a completely normal state.  (In the early stage, the physician did not request the patient to take TCM drugs daily and decision had not yet been made as how long the course of systemic treatment should take).  Medication stopped in March 1994.

A return visit was made 4 and a half years later.  She had no symptoms, no hepatomegaly and had satisfactory nourishment and development and normal tongue appearance.

The father of the siblings died at the age of 30 from carcinoma of liver and although these two children had no positive blood examination results, it was still reasonable to make the diagnosis of liver disease and to give them preventive injections.  In their first visits, there were typical symptoms and signs of liver stagnation and lung dryness and wetness–heat vaporization forms of chronic hepatitis.  The sister was poorly nourished and underdeveloped with symptoms of deficiency of qi and weakness of blood.  Ideal results were obtained after systemic TCM therapy and the liver was normal during the several years of observation.  The brother had two episodes of relapse and yet clinical cure was obtained with repeated TCM therapy.  If the conventional standard of diagnosis of hepatitis was used to rule out chronic hepatitis, the chance of systemic TCM treatment would be lost and the prognosis would certainly be bad.  The best policy is that for children with a family history of liver disease, great attention must be paid to assure timely TCM treatment and a normal margin of liver dullness.

Case 1-4

Chan, (computer no. 181), male, age 4-1/2 yrs.

The mother visited the clinic for the first time in 1991 with the complaint of fatigue, repeated headache from exopathy, severe dysmenorrhea, loin pain (usually at ovulatory phase), abdominal distension, constipation, thick tongue coating and edema of lower extremities.  She was married over a year and still not pregnant.  The diagnosis was chronic hepatitis.  After four visits, her dysmenorrhea improved, the tongue coating disappeared and the enlarged liver of 1.5 cm became normal.  She was pregnant 7 months after treatment and delivered a child on 14^th April 1993.  Her parents also had chronic hepatitis and made frequent visits to the clinic.

In August 1997, when the boy was 4 years old, he made his first visit.  The mother said that the child had nasal hypersensitivity, poor appetite, thin body build, nasal obstruction and uninterrupted sneezing.  Nasal obstruction after affected sleeping at night and he had to seek for the help of nasal drug drops to relieve hypertrophy of nasal mucosa.  Physical examination revealed a lean child with hepatomegaly of 1 5 cm.  After taking 6 parcels of TCM drugs, the margin of liver dullness was normal.  Clinical cure was obtained after treatment with systemic TCM drugs.

In November 1998, he had a relapse which showed repeated nasal hypersensitivity complicated by many episodes of epistaxis, the blood rather large in amount.  His appetite was still poor, the body still thin and sleeping was not so good.  Physical examination: skin pale and yellowish, hepatomegaly of 3 cm.  After taking 7 parcels of TCM drugs, the liver was normal.  He stopped the medication after another 7 parcels of TCM drugs.

The child was seen 3 months later, complaining of tiredness, nasal obstruction, poor appetite, constipation and enuresis.  Physical examination found the liver enlarged again to 3 cm and vertical veins of the abdominal wall and hypochondria were apparent.  After taking 3 parcels of TCM drugs, the amount of stools became larger, being once a day.  Nasal obstruction alleviated and nasal spray was not necessary.  The liver was normal but enuresis was still present.  In the following 2 months systemic treatment was not administered.  The patient only took TCM drugs occasionally and hepatomegaly of 1.5 cm relapsed for two times when treatment was not persisted and there were also nasal hypersensitivity hoarseness of voice, cough, expectoration and epistaxis.  Finally, the patient took the advice of the physician and received a 4 weeks uninterrupted course of TCM treatment until clinical cure was attained.

Case 1-5

Lee (computer no. 2290), male, age 4-1/2 yrs.

His first visit was on 3^rd December 2000.  His grandmother had a history of cirrhosis of liver and cholecystitis.  His father was a carrier of type B hepatitis virus and his mother had a hepatomegaly of 3 cm.  The child frequently suffered from nasal obstruction, nasal hypersensitivity, epistaxis, sneezing, coughing, shortness of breath, insomnia, poor appetite, vomiting and over activity.  Physical examination revealed poor nourishment and underdevelopment, dark yellowish skin, edema of mucosa of lips and hepatomegaly of 3 cm.

After taking 3 parcels of TCM drugs, the liver was normal, but he still had much sneezing and occasional coughing.  His sleeping and appetite was satisfactory.  He had another 5 parcels of TCM drugs and his nasal obstruction was limited to night time, his lip mucosa was dry, desquamating and with fissures.  Another 6 parcels of TCM drugs brought the cessation of nasal hypersensitivity.  The feces were abundant, defecation being once a day.  During the course of treatment, sleeping was well but sometimes the appetite was not so good.  No other discomfort was experienced.  A total of 42 parcels of TCM drugs were taken, at the end of which clinical cure was obtained.  The patient was followed up.

Chui (computer no. 3261) female, age 6 yrs.

His first visit was on 18^th March 2003.  Her mother said that her daughter had long term coughing, shortness of breath and constipation.  She was treated with WM and TCM drugs and she used nasal spray to control nasal hypersensitivity and to improve shortness of breath but all were ineffective.  Physical examination revealed a hepatomegaly of 3 cm.  After taking 3 parcels of TCM drugs, the symptoms disappeared and she stopped the medication.

Three months later, the child began to cough again and in several days, expectoration was copious.  The mother brought the girl back for treatment and she was discovered to have a hepatomegaly of 1.5 cm (the first relapse of hepatomegaly).  After taking 4 parcels of TCM drugs, the liver was normal, but there was still occasional coughing.  Therefore, another 8 parcels of TCM drugs were given to her after which all symptoms disappeared and she stopped the medication herself.

But three weeks later, there was relapse of symptoms and she experienced fatigue and coughing.  The liver was found to be enlarged by 1.5 cm (the second relapse of hepatomegaly).  After taking 3 parcels of TCM drugs, the liver was again normal.  TCM therapy persisted for 3 weeks, during which time she had cough but with no sputum and had constipation after taking chicken wings.  Some time later, she had normal bowl movements and coughing occurred occasionally.  She had been treated with WM drugs for 4 days because of common cold.  She then made a return visit and hepatomegaly of 1.5 cm was found (the third relapse of hepatomegaly).  After taking 3 parcels of TCM drugs, the hepatomegaly disappeared.  Her mother accepted the physician’s advice and arranged the child a 3 weeks course of systemic TCM therapy.  The patient’s cough alleviated markedly and at the fourth week, it completely stopped.  Bowl movement was normal.  She was clinically cured and followed up.

This is a typical case of liver stagnation and lung dryness form of chronic hepatitis.  It is not difficult to find that in the TCM treatment of pediatric chronic hepatitis, it is important to do “without a break”.  In this case, the child had 3 relapses of hepatomegaly.  The first is due to stoppage of treatment just after 3 parcels of TCM drugs.  The second is because of discontinuation of the 8 parcels of TCM drugs by herself immediately after recovery of the liver and hence, causing relapse of clinical symptoms and hepatomegaly in a short time.  The third is due to the administration of WM drugs for 4 days to match the common cold while still in the course of TCM therapy.  Is it due to reinfection of “hepatophilic virus” or due to damage of liver by the WM drugs, it is hard to define.  The intake of dryness–heat food like chicken wings can arouse lung dryness cough and constipation.  This fact deserves attention.  Finally, her mother’s insistence on the administration of an uninterrupted course of systemic TCM therapy, enabled the child to obtain clinical cure.