Hepatic psychoneurosis (Part 3)

Preface

Nervous system damage and psychotic disturbance following liver disease may occur simultaneously or one after another, their clinical manifestations complicated and varied.  From the viewpoint of TCM, consciousness and mental condition are closely related to liver.  There was an old saying: “Seven emotions and six desires” can hurt the liver.  Clinical cases indicate that this is true.  The author encountered two sisters with chronic hepatitis who had obtained clinical cure but both had relapse of disease because of their mother’s critical illness and also another case with clinically cured cirrhosis of liver who had relapse of disease following the run away of his wife and daughter.  They were all cured through administration of TCM drugs.  Review of TCM theory concerning origin of disease give us a clear understanding that “liver disease” is an important origin of “psychoneurotic disease” symptoms.

In liver disease, the underlying pathogenesis is related to the attack of “pestilential toxic evil” which causes the flaring up of heart fire, liver fire and kidney fire as well as the heat of large intestines, forming symptoms of different systems in different periods of life.  Prolonged consumption of   would certainly produce deficiency of liver and kidney.  In this aspect, ancient medical literature had many penetrating views, e.g.:

• When fire in the liver is excessive, thinking is complicated and varied, leading to weakness of heart qi, deficiency of brain and spinal cord and resulting in instability of spirits and transformation of illusions into the “dream syndrome”; or
• Internal invasion of pestilential toxic evil, over load of thinking, stagnation of liver inducing weakness of qi in the zang organ or stagnation of blood and qi, or wetness-heat or sputum to form the “stagnant syndrome” – the symptoms of which are stagnation ofqi, extremely sentimental and easily get angry or sensation of cold alternated with hotness, fullness or heaviness in chest, or distension of lower abdomen or full of dissatisfaction and grievance.
• It may also be induced by internal “heat evil” which causes deficiency of liver, spleen and kidney channels, so that nourishment of blood is insufficient, yang is strong and yinweak, kidney fluid is deficient below while fire in the heart flares up above; heat retains in the heart and body fluid is consumed; dryness of five zang organs; fond of darkness and hate brightness; heaviness of body; restlessness and annoyance; irritable and hot tempered (irritability means those with such involvement are in anguish but not manifested externally; hot temperament means that the individual show restless movements of the limbs displaying an uneasy sensation internally and externally; irritability belongs to yang heat, is milder and hot temperament involves the yin channel and is more severe).  These are called “restlessness of deficiency type”.
• Progression of disease causes over production of liver yang, deficiency of yin and strain of body, inability of qi to return to its origin, so that heart loses nourishment from qi and blood and it promotes the formation of restlessness; consumption of heart blood forms the condition called “severe palpitation”, the symptoms of which include floating feeling of chest, vibrative sensation lateral to umbilicus, and susceptibility to agitation and awakening.  Deficiency of kidney fluid and too much consideration would lead to retention of fluid below the heart causing palpitation; this is in fact due to attack on heart by water evil.  When there is weakness of qi and deficiency of blood, the latter would lead to breakdown of the normal physiological coordination between heart and kidney (心腎不交), so that the brain is not nourished and the result is an untranquil mental state and difficulty in sleeping.  These are called “insomnia of blood deficiency type”.
  
• When liver disease causes gastric disturbances and unsmooth sleeping, or if the individual has a history of disease of seven emotions, there may be distraction, poor sleeping, psychasthenia, frightfulness or inability to lie down because of fullness of abdomen or restlessness affecting sleep or ranting rigmarole or restlessness from frightening; these conditions are called “inability to sleep”.
• In addition, a woman whose erotic desire not satisfied and being in a state of sentimental depression, may suffer from insidious drying of liver wood where the internal fire increases day by day; the fire disturbs the mind and flares up finally to form “erotomania”.  The individual may talk nonsense, becomes shameless or even naked in the public and doing licentious movements.
• The individual may feel depressed or angry because of unfair and if prolonged, the thinking goes to extremes, qi and blood deviates and if sputum obstructs the airway, the heart qi is entrapped, heat evil retains in the interior and finally the condition becomes “madness”.  At the beginning, the individual is unhappy without reason and feels severe headache, the eyes become red and looking askance and gradually the individual becomes absent-minded, confused in speech, sometimes crying and sometimes laughing or acting like a drunkard or stamping and cursing with fury.

Liver disease develops during infancy and childhood; if clinical cure is not achieved through effective systemic TCM treatment, the disease would be carried along the entire life time of an individual.  At different stages of life, the disease progresses “from superficial to deep, from exterior to interior” and its clinical symptoms are manifested as those described in the forms classified by TCM for chronic hepatitis.  Therefore, in certain periods of life, the psychoneurotic symptoms may differ in accordance with the degree of liver function damage and express itself as certain forms of psychoneurotic disease.  These conditions include not only those mentioned above: neurasthenia and climacteric syndrome, but also depression, postpartum depression, schizophrenia, disturbance of autonomic nervous system, migraine, internal ear vertigo(imbalance of auricular fluid), hepatic neural disease, etc; all these are psychoneurotic complications seen after liver disease.  Since the disease comes from damage of hepatic function, administration of effective systemic TCM therapy may produce complete cure.

Chronic liver disease patients usually have simultaneous damage of autonomic nervous system and this is more commonly seen in cirrhosis of liver.  According to reports, the incidence of hepatopathic autonomic nervous system disturbance is 49%-64%.  Previously, autonomic nervous system disturbance was thought to be common in alcoholic liver disease, but recent researches have demonstrated that it is also very common in virus hepatitis.  Because autonomic nervous system disturbance causes disorder of hemodynamics, the patient’s heart rate and cardiac output increases, but the blood pressure is low, indicating lowering of peripheral vascular resistance, and so low blood pressure is the symptom frequently encountered.  Other symptoms include a rather rapid heart rate, vertigo, abnormal perspiration, difficulty in swallowing, dryness of mouth and eyes, impotence, retention of urine, constipation or diarrhea, and in severe cases, fecal incontinence.

Chan (code number 352), male, age 48 years.  First visit in January 1987.  He had a history of positive type B hepatitis virus carrier and frequently suffered from common cold, aerophobia and chilliness, sore throat and fever, itching of throat and cough, fatigue and headache, heat and restlessness in five hearts, dryness of mouth and throat, aphthae, constipation, hematochezia, acne, insomnia, pain in hypochondrium, dryness and desquamation of lips, and repeated pain of right knee joint.

Physical examination: edema of lower extremities, low blood pressure (82-96/50-60 mm Hg.), show pulse rate (42-60/min), hepatomegaly of 1.5 cm.  The diagnosis was chronic hepatitis with TCM classification ofliver stagnation and lung dryness complicated by disturbance of autonomic nervous system.

The patient received treatment and observation for ten more years in our clinic, during which time his hepatomegaly relapsed for five times (all 1.5 cm) and every relapse was cured by systemic TCM therapy.  Blood examination on 27^th February 2001 showed a negative result for type B hepatitis virus.

Wang – (code number 528) female, age 19 years.  Date of first visit :16^th May 1994.  She complained that she had a cardiac murmur since childhood and often experienced vertigo, palpitation, low blood pressure and insomnia for 3 to 4 years, and occasionally could fall asleep only at 2-3 AM at night, being dreamful and also wakeful.  She also had dryness of throat, thirst, nocturnal drinking, distension of abdomen, poor appetite, constipation alternated with diarrhea, yellowish urine and frequent nocturnal urination.  Physical examination: lean, pale looking, pulse 100 per minute, percussion tenderness over hepatic region – hepatomegaly of 3 cm.  The diagnosis was hepatomegaly for investigation with TCM classification of deficiency of blood and weakness of qi, complicated by disturbance of autonomic nervous system.

After taking two weeks of TCM drugs, her sleeping improved, could sleep 5-6 hours in a night; her mental status was good; the pulse 82/min and the medication was stopped.

On 1^st September 1994, she made a return visit and her menstruation was in the fourth day with a larger amount and bright red color.  She also had palpitation and insomnia.  Physical examination revealed a hepatomegaly of 3 cm and pulse 100/min.  After 17 parcels of TCM drugs, the liver returned to normal, insomnia disappeared and the mental status remained good.  She completed the four week TCM treatment, achieved clinical cure and was fallowed up after cessation of therapy.

According to reports, about 10% chronic active hepatitis patients would develop hepatic neurosis, such as acute multiple radiculoneuritis, multiple peripheral neuritis and cranial nerve palsy.  In the 3048 cases with abnormal margin of liver dullness treated in our centre, 129 cases (amounting to 4.23%) have symptoms of hepatic peripheral nerve disease, in which, female 96:1954 = 4.91%, male 33:1094 = 3%.  These cases include trigeminal neuralgia, sciatica, intercostals neuralgia, multiple neuritis, facial neuritis.

Lee (code number 2115), female, age 70 years.  First visit: April 2000.  She complained of long time insomnia, palpitation, fatigue and weakness of lower limbs, feverish sensation in the chest, palms and soles, restlessness and frequent nocturia as many as 5-6 times a night.  Last years, left trigeminalgia persisted for several months leading to marked emaciation.  Relapse of neuralgia now induced insomnia, distension of abdomen, left loin pain and frequent urination.  She had been operated on uterine myoma and appendicitis.

Physical examination: lean, anomaly of hypochondria, percussion tenderness over hepatic region, hepatomegaly of 3 cm, (+) edema of lower extremities.  The diagnosis was hepatomegaly for investigation, hepatic neurasthenia, hepatic neural disease (fifth cranial nerve).

During TCM therapy, she had abdominal pain, diarrhea, large amount of stools, but after the second parcel of TCM drugs, neuralgia subsided and she could sleep well; her emotions calmed down.  She had no palpitation and nocturia ceased; the margin of hepatic dullness was normal.  Another 3 parcels resulted in good sleeping, abdominal distension and loin pain disappeared and bowl movements occurred every other day.  She did not feel any discomfort; the blood pressure was 160/86 mm Hg.  She completed the four week course of TCM therapy, at which time clinical cure was obtained and treatment was stopped.

Previously, the etiology of this disease was considered not clear.  But recently, it is acknowledged that the course may be functional disturbance of autonomic nervous system leading to edema of labyrinth of internal ear.  The typical symptoms are paroxysmal vertigo associated with tinnitus and disturbance of hearing.  The attack is sudden; the sensation is spinning of surrounding things usually associated with nausea, vomiting paleness of face, perspiration and lying on bed with eyes shut, daring not to move a little bit.  In our 3048 cases of abnormal margin of liver dullness, 116 cases have symptoms of auditory vertigo (3.81%) in which female 93: 1954 = 4.75%, male 23:1094 = 2.1%.

Cheung(code number 237) male, age 48 years.  His first visit was on 21 January 1997.  He had an appendectomy in 1976, and was examined to have type A hepatitis antibodies; he was given type B hepatitis preventive injection.  Four months ago, blood examination showed abnormal liver function and high ferment, and there was no special treatment in western medicine.  In the recent 3 months, he had repeated vertigo, vomiting and was hospitalized on one occasion for severe vomiting and vertigo.  He was treated with WM drugs and physiotherapy but of no avail; now the attacks repeatedly occurred but the time was transient.  In the past, he often felt tired and had generalized pain of bones, yellowish urine, poor appetite, palpitation, insomnia, pain over hypochondrium and frequent nocturia.

Physical examination: pulse 104/min, dryness, desquamation and scaly appearance of skin of abdomen and lower extremities, tongue enlarged with teeth prints, abdomen distended, percussion tenderness over hepatic region, hepatomegaly of 1.5 cm, (+) edema of lower extremities.

After taking 13 parcels of TCM drugs, the liver was normal.  During systemic treatment, vertigo disappeared.  The patient was treated and followed up for many years in our centre and for five more years no relapse of vertigo was seen.

Migraine was previously considered as a disease of unknown etiology.  It is more common in females and it usually begins in adolescence and manifests cyclic attacks.  Migraine is in fact a kind of functional disturbance of vascular contraction and relaxation which leads to paroxysmal headache.  The attack is usually associated with symptoms such as nausea, vomiting, intestinal gurgling, perspiration, constipation, diarrhea, photophobia and numbness of limbs.  After attack, the patient often feels tired and sleepy.  In female patients the attack of migraine is often related closely to menstrual blood loss.

In the 3048 cases of abnormal margin of percussion dullness of liver in our centre, 160 cases (5.25%) have migraine symptoms, in which female 126:1954=6.4%, male 33:1094=3%.  In female chronic hepatitis patients, migraine attacks usually occur before or after menstruation.  In some of these cases, attacks are likely to occur when these patients had repeated postmenstrual blood loss (blood deficiency headache: deficiency of blood causes deprivation of nourishment of brain, a condition susceptible to invasion of wind evil and turbid air leading to headache).

Chan (code number 293) male, age 55 years.  His first visit was on 10^th October 1993 with the chief complaint of repeated hypertension, migraine, neurodermatitis and hemorrhoids for several decades and treatment was of no avail.  He had received hemorrhoidectomy, appendectomy and sebacious cyst excision of the back.

Physical examination: hepatomegaly of 4.5 cm.  The diagnosis was hepatomegaly for investigation with TCM classification of blockage of channels and stasis of blood and excess of liver yang associated with migraine.  After treatment with systemic TCM drugs, the symptoms were under control to a marked degree and the anti-hypertension drugs taken for a long time were stopped; dermal pruritus and migraine disappeared.  Hemorrhridal sufferings had markedly decreased.  He was followed up for nearly ten years and took TCM drug occasionally.

Shu (code number 024) female, age 27 years.  First visit: September 1992.  She gave birth to a female infant one year ago and thereafter, she often felt tired and had also vertigo, sleepiness, abundance of sputum and distension of abdomen which was more marked after meal.  The skin was susceptible to ecchymosis and brushing of teeth often induced bleeding of gums.  Her menstruation was usually overtime.

Physical examination revealed an anemic looking, a soft abdomen with tympanites, shrinkage of liver margin, the lower limit 4.5 cm above costal margin and (+) edema of lower extremities.  After TCM treatment for 11 days, the liver returned to normal and clinical cure was obtained after systemic TCM therapy.  The patient was followed up after cessation of treatment.

In May, 1994, she had a return visit, complaining of paroxysmal migraine and when severe, radiating to the neck with simultaneous association of lacrimation and excessive nasal discharge.  If the attack is at night, the patient might be awakened by the pain.  Western medical drugs did not show effectiveness.

Physical examination: hepatomegaly of 3 cm with percussion tenderness.  After taking 10 parcels of systemic TCM drugs, the liver was normal and migraine disappeared.  The treatment persisted for another 4 weeks and was stopped.  Five weeks of follow-up did not show any abnormality.

Tong (code number 2546) female, age 45 years.  First visit: June 2001.  She complained of right side migraine for 20 more years.  She had history of gastric illness and rather severe hemorrhoids with hematochezia.  She also had (±) edema of lower limbs, hepatomegaly of 3 cm and percussion dullness over splenic region.  The diagnosis was hepatomegaly for investigation with TCM classification of  wetness-heat vaporization, blockage of channels and stasis of blood complicated with migraine.

After taking 3 parcels of TCM drugs, the liver was normal, the splenic dullness was present and the right side migraine decreased in severity.  There was flatulence, dermal pruritus and red eruptions.  After another 3 parcels, the persisting time of migraine attack was markedly shortened, but there was still vertigo.  The headache gradually subsided during the continuation of TCM treatment.  Her sleeping was poor and some pain was present in the tongue.  The splenic dullness disappeared.  Four weeks later, the dermal pruritius disappeared, her appetite and sleeping was good, no migraine occurred but there was occasional vertigo.  She completed her 6 week systemic TCM course of treatment and was followed up.

By WONG Kwok Hung

Published on 30th January 2003

Translated by Professor Zheng in June 2005