Hepatic psychoneurosis (Part 2)

Strenuous urban life causes neurasthenia of the Hong Kong people; they are also susceptible to nervousness, mental fatigue, depression and insomnia.  TCM principle bases on the balance of yin and yangand considers that the physiologic role of liver is chiefly smoothing and regulating and storage of blood.  It is on this basis that TCM analyses hepatogenic psychoneurosis.

The symptoms of hepatogenic psychoneurosis are widely encountered.  Liver disease patients with impairment of liver function have a 65% incidence of central nervous system damage; the cause is chronic hepatitis after infection by hepatophitic virus and this is also the fundamental cause of peripheral nervous disease and psychosis which are frequently seen in clinical practice.  Early in the beginning of 19^th century, scholars reported that nervous system complication occurred in virus hepatitis and cirrhosis of liver.  Although the pathogenesis of hepatic psychoneurosis is not clear, yet modern medical research has confirmed that “injury of autoimmune function, lack of vitamin B complex or impairment of liver function can cause inability of detoxication and elimination of toxic material”; these conditions can cause damage to brain and nervous tissues.

The course of hepatogenic encephalopathy may be acute or chronic, its clinical manifestation may be mild or severe.  Severe cases of hepatic encephalopathy often present manifestations of acute liver disease which includes symptoms of mental confusion (confusion of consciousness, taciturnity, depression or joyfulness, polylogia, hyperactivity, excitability and mania, or passing into disturbance of consciousness or even hepatic coma) and dyskinesia (flutter-fibrillation).  The severe cases that have to be treated immediately in hospital are not mentioned here, but it should be emphasized that the danger of becoming chronic hepatitis by hepatophilic virus infection must be made clear to everyone and it must be treated at the stage of “chronic hepatitis’ with effective systemic TCM therapy in order to prevent damage to the brain and nervous tissues.

As to the cases belonging to “subclinical hepatic encephalopathy”, the patients may show no psychoneurotic symptoms after the hepatitis attack, their routine psychotic and nervous system examinations are also normal, but with intellectual or psycho logic monitoring, abnormality demonstrating encephalic atrophy may be found following long term liver disease.  According to statistics, the incidence of subliminal hepatic encephalopathy is 60% in cirrhosis of liver.  Due to lowering of intelligence and ability of decision, the individual is extremely susceptible to traffic accident if he is a driver; therefore, if the disease is discovered early and treated in time, accidents may be avoided.

In addition, chronic hepato-encephalic degeneration is often seen in male patients with cirrhosis of liver, presenting, in the early stage, psychoneurotic symptoms such as tremor of fingers, dysphonia, slowness and monotony of speech, unclear enunciation, tremulous and involuntary movements.  It may also show intellectual disturbance and paroxysmal disturbance of consciousness (mild cases showing haziness, severe cases coma persisting several hours to several days and attacks occurring once in two weeks or several times in one week) associated with flutter-fibrillation and stiffness of muscles.  If consciousness recovers, the symptoms may be relieved (folks regard this condition as the body occupied by ghost).  If treatment does not aim at the primary liver disease and at protection of the liver, the patient would gradually show infantile disposition, apparent thinness, contracture of limbs, and degeneration of mental function.  It was said that from mental degeneration to death, the time may be 1-2 years (the course may be 8 months in sub-acute cases and more than 6 years in chronic cases).

In late cases of hepatogenic psychoneurosis, no doubt, treatment is difficult, but one should not forget that early diagnosis and treatment of liver disease can prevent the progression of disease into hepato-encephalic degeneration.  Hepatophilic virus infection is extremely common.  “China has 50 million people suffering from various kinds of brain diseases”. “Cerebral palsy has an incidence of 18.4% in the population, week-minded children occupying 22.2%, senile encephalopathy having an incidence of 10% in the elderly population” (seen in 19^th November, 2002 Ta Kung Pao – Special Topics).  According to the above figures, we cannot estimate yet how many of them are the result of “hepatophilic virus” infection.  However, clinical practice has demonstrated that in the early stage of chronic hepatitis, treatment of psychoneurotic symptoms with TCM drugs gives immediate effectiveness.  TCM drugs can effectively eliminate antigen-antibody complex, relieve edema, improve microcirculation of encephalic nervous tissues, recover hepatic function and can further abolish disturbances of metabolism, excrete retained noxious metabolic materials, and increase activity of nerve cells.

In the course of life time, the individual might have been repeatedly infected by hepatophilic virus within the maternal body or during infancy.  When the individual is ascertained to have “chronic hepatitis”, various symptoms of different forms of chronic hepatitis may display during different periods of life and different clinical symptoms of psychoneurosis may manifest.  It is only during different periods, according to commonly seen symptoms, that people consider it as a kind of disease.  It is unfortunate that some physicians as well as patients do not understand that its origin is related to hepatophilic virus infection and its consequence, chronic hepatitis. Because of such misunderstanding, one would let the chance of fundamental treatment slip by.  The following common diseases are in fact hepatogenic psychoneurosis related to chronic hepatitis.

As early as 1944, scholars suggested that patients who had been attacked by acute hepatitis but whose liver function or even liver biopsy was normal still presented subjective symptoms, this condition should be called “post-hepatitis syndrome”.  In the recent thirty years, because of the understanding of the complexity of chronic form of type B, type C hepatitis and the difficulty of differentiating “post hepatitis syndrome” from chronic persistent hepatitis, this term is rarely used now.

Clinically some patients although devoid of history of acute hepatitis, may have no abnormality of liver function.  But, still, there are quite a number of patients presenting the five main symptoms of “post-hepatitis syndrome”: abnormal margin of percussion dullness of hepatic region, edema of lips, tongue and hypochondria of various degrees, prominence of veins, and percussion tenderness of hepatic region.

The five main symptoms are:

• Fatigue (especially significant during active stage, vacant expression, sleepiness);
• Hepatic pain (paroxysmal pain of right hypochondrium or distensive pain of right upper abdomen which may be the only hepatic manifestation, some patients may have palpable margin of a soft, enlarged liver with mild tenderness or percussion tenderness);
• Psychoneurotic symptoms (emotional instability, flush, hyperhidrosis, heaviness in chest, palpitation, insomnia, dreamfulness, vertigo, headache, anxiety, depression, disturbance of thought, regression of memory, dermal pruritus, generalized soreness, decrease of working efficiency, aggravation of symptoms after overloading labor or getting angry);
• Indigestion (poor appetite, sick of oil, nausea, discomfort of upper abdomen, abdominal distension, defecation right after meal, small fecal volume, tenesmus, diarrhea alternated with constipation);
• Malnutrition or secondary obesity (abnormal obesity). 

In fact, people previously considered that “post-hepatitis syndrome” was usually seen among intellectuals and medical workers due to their mental overload and worriness about liver disease.  But now, according to clinical observation, “ post-hepatitis syndrome” patients are actually chronic “hepatophilic virus disease” patients whom are disseminated widely and usually found to have signs and symptoms of chronic hepatitis and most of them are suffering from a disease during activation.  Though several decades of investigation, the diagnosis of chronic hepatitis was standardized according to the results of laboratory examination, type B ultrasound and computer scan.  But the dependence on the latter items was over emphasized and this caused the loss of opportunity of early diagnosis in many patients.  The existence of these “post-hepatitis syndrome” patients is an objective matter, therefore, the term “liver disease syndrome” is more appropriate.  Clinical practice has demonstrated that TCM drugs yield ideal results in these patients.

Climacteric syndrome refers to disorder of autonomic nervous system caused by fluctuation or lowering of estrogenic hormones before or after menopause or loss of ovarian function after surgical excision or radio therapy.  From the TCM viewpoint, it is caused by regression of kidney qi or imbalance of yin and yang of the body.  Quite a number of female patients had been infected by hepatophilic virus originally and had different degrees of endocrine disorder in early years, so that when they passed into the climacteric stage, the symptoms of excessive yang became apparent.  When ovarian function decreases and disturbance of autonomic nervous system appears, somewhat prominent climacteric symptoms may appear as the individual passes into the pre-climacteric or climacteric years.  Therefore, the existence of “abnormal margin of liver dullness” often becomes one of the criteria of diagnosing simple climacteric syndrome.

So, when patients with abnormal margin of hepatic dullness have climacteric symptoms, such as hypertension, repeated migraine, menorrhagia, varicosities of lower limbs, glomerulate telangiectasis and hepatic edema, simple hormonal treatment should be avoided and effective systemic TCM therapy should be applied.  In such a way, climacteric symptoms would subside by using less effort and result in greater effectiveness.

Case 1: Wong (code number 097), female, age 30 years.

Her mother had carcinoma of liver and died in 1997.  One year later, she had blood examination and was found to be a carrier of type B hepatitis virus.  At the first visit in September 1998, she complained of fatigue and sleepiness, palpitation, insomnia, pain of shoulders and neck and repeated right hypochondriac pain.  She often experienced loss of appetite, aphthae belching, abdominal distension, tenesmus, abdominal pain, diarrhea and she had history of hemorrhoids.  She had menorrhagia with numerous blood clots and dysmenorrheal.  Body weight: 46 kg.  Height :1.62 m. BMI: 17.69.

Physical examination: BP 80/60 mmhg, tongue red with numerous teeth prints, tenderness over both hypochondria, hepatomegaly of 3 cm.  The diagnosis was “liver disease syndrome”.

After taking 3 parcels of TCM drugs, the liver reduced 1.5 cm and after another 3 parcels, it was normal.  The symptoms subsided and insomnia disappeared.  But she stopped the TCM drugs by herself after taking only 15 parcels.  She made return visits later, one at the end of 1998 and another at the beginning of 1999, with a hepatomegaly of 1.5 cm and 3 cm respectively, but systemic TCM therapy was not administered.  Afterwards, a return visit was made in March, 2000, when she complained of fatigue, constipation, hematochezia, repeated exopathic headache, cough, insomnia, deep yellowish urine and a hepatomegaly of 3 cm.  After 3 parcels of TCM drugs, the liver returned to normal.  The systemic TCM therapy continued for 4 weeks and was stopped after achievement of clinical cure.

Her first visit was in December 1994.  She had cholecystectomy in 1980 due to bladder stones and complained of suffering frequently from insomnia, flush, anxiety, depression, dermal pruritus, fatigue, vertigo, headache, loin and abdominal pain, alternation of diarrhea and constipation and defecation right after meal.

Physical examination: percussion tenderness over hepatic region, hepatomegaly of 3 cm, (+) pitting edema of lower extremities.  She was diagnosed as neurosis and climacteric syndrome.  Repeated TCM and WM treatment did not show effectiveness.  She came to our centre and was diagnosed as chronic hepatophilic virus disease with wetness-heat vaporization, deficiency of blood and weakness of qi forms; hepatogenic malnutrition.  After taking 18 parcels of TCM drugs, the liver was normal and the symptoms disappeared.  Following 4 weeks of systemic TCM therapy, clinical cure was achieved and the climacteric symptoms disappeared.  She was followed up after cessation of TCM drugs.

Four years later, she had a return visit because of insomnia for 2 weeks associated with fatigue, vertigo, headache, loin pain, she was afraid of relapse of the liver disease.  Physical examination revealed a hepatomegaly of 3 cm, percussion tenderness over hepatic region and (+) edema of lower extremities.  TCM therapy was administered and after 3 parcels, the liver returned to normal and the symptoms subsided.  Continuation of TCM therapy for 2 weeks ended in disappearance of symptoms and afterwards she stopped the medication.

Published on 28^th November 2002

Translated by Professor Zheng in April 2004