The formation of “Deficiency of blood and weakness of Qi” in chronic hepatitis The third form of chronic hepatophilic virus disease is the “deficiency of blood and weakness of Qi” form, which is extremely common in clinical practice. We should also know that in broad sense, “deficiency of blood and weakness of Qi” is the inevitable result of chronic “liver disease”, because when the hepatitis virus, acting as a pestilential evil, invades the human body, and, if the latter has low resistance and does not have the power to drive out evil, the “evil” would hide within the blood and attack the five gang-organs and six fu-organs. The evil not only hurts body energy and lowers body resistance, but can also disturb qi and blood and if there is hemophysis, emitamisis, hematochezia, menorrhagia or postpartum bleeding, the patient would present deficiency of qi and blood, if treatment is not given in time or if there is collapse of qi and menorrhagia, mental stress, over work, exhaustion of heart and kidney, abundant loss of blood and liale blood regeneration, the pathological changes of disorders of qi and blood would gradually appear. In the past years, this clinic received 2785 cases of “chronic hepatophilic virus disease” patients with abnormal margin of hepatic dulness, in which male patients were 995, female patients 1790. There were 568 patients with chronic liver disease symptoms of the TCM third form, “deficiency of blood and weakness ofqi”. These cases accounted for 20.39% of the total. In this part, male patients with “deficiency of blood and weakness of qi” form symptoms amounted to 79 cases, occupying 7.93% of male patients. Female patients amounted to 489 cases, occupying 27.3% of the total female patients. From this, we can see that patients with chronic liver disease may have various degrees of symptoms of the deficiency of blood and weakness of qiform, and this condition is extremely common. In our group of cases, they were diagnosed only when marked anemia was clinically present, so the incidence was somewhat low. But it is enough to show that the physiological feature of female chronic liver disease patients may render 1/4 of them clinically to take the consequence of “deficiency of blood and weakness of qi”.
Clinical symptoms of “deficiency of blood and weakness of qi” form The chief clinical symptoms of deficiency of blood and weakness of qi are rather complicated. From the TCM viewpoint, they should include deficiency of blood associated with heat, deficiency of blood and stagnation of qi, deficiency of blood with headache, vertigo and dim eyesight, severe palpitation and insomnia, dreaminess or sleepiness, pallor and listlessness, low voice and indolence in speaking, fatigue, coldness of limbs, tinnitus and deafness, unclear hearing, tympanites and abdominal pain, stomache-heat and constipation, palpitation and costal pain, deficiency of blood and weakness of tendons (atrophy and weakness of limbs, pale yellowish color of face, and staggering), in severe cases, convulsion of limbs. In female, there is often headache due to deficiency of blood during the premenstrual or postmenstrual periods (usually appearing as poroxysmal migraine) and weakness of skin leading to exopathy in the postmenstrual interval. If the patient has, for a long time, deficiency of yang, enclosed wetness and hepatic edema, secondary obesity may occur. Deficiency of blood may lead to weakness of skin and if, at the same time, there is enclosed wetness, the patient may develop generalized soreness of body, shortness of breath, mental as well as body fatigue, lack of nimbleness of joints, tiredness, indolence in speaking, spontaneous perspiration, hyperhidrosis, night sweat, or even shortness of breath during activity. Physical examination may reveal a lean, ill-nourished and underdeveloped individual with a haggard looking. The face may present a pale or yellowish color with pigmented patches over the cheeks; the lips show clear linings with edematous mucous membrane, broad lip protrusion, scarce deep lip furrows or even fissures and repeated desquamation. There may be the commonly seen hypochondrial anomaly showing costal asymmetry.If the patient has hepatic edema, there will be an enlarged tongue with marginal teeth prints and a pale color like being merged in water. If there is association of wetness-heat, the tongue may show the respective color and coating. The abdomen shows navicular depression, or is soft, distended, tympanitic and occasionally revealing veins of the abdominal wall. The hepatic region often presents percussion tenderness and abnormality of margin of percussion dulness.
In patients with hepatic edema, there is often edema of lower extremities and marked pitting edema over the pretibial region. If the patient has hypertension of the inferior vena cava, one may see prominent veins in the lower extremities, varicosities or conglomerate talangiectasis. Laboratory examination may show decrease of plasma, albumin and also various degrees of low red cells, hemoglobin, white cells and platelet counts. It is destined that “deficiency of blood and weakness of qi" will occur insidiously in cases of liver disease, because the liver is the metabolic axis of the human body, an organ indispensible in the maintenance of life and having close relationship with the blood system. Many important substances in the human body are metabolized in the liver, such as glucose, protein, fat, water, electrolytes, some related vitamins and hormones. Therefore, in liver disease, if there are metabolic changes in certain systems, clinical symptoms usually appear and they can affect the recovery of the disease. Clinically, there is great need of paying attention to the fundamental of liver disease, and to cure the patient with thorough TCM treatment, so that, at the end, it is possible to stop the chronic progressive damage of hepatic function.
From the statistical data, we have found that there are some regular patterns in patients with “deficiency of blood and weakness of Qi”. (1) Patients with chronic hepatitis are prone to develop “deficiency of blood and weakness of qi in the early stage It is observed clinically that “deficiency of blood and weakness of qi” is often the result of prolonged invasion of pestilential virus evil or due to damage to the five zang-organs and six fu-organs for a comperatively long time (especially infection during infantile stage or childhood). Therefore, when the patients manifestation is only the 1st form “liver stagnation and lung dryness”, or the 2nd form “wetness-heat vaporization” one should consider that the degree of the patient’s illness is comparatively “mild” or “superficial”. But according to the concept of TCM, “wetness” is the yin evil which may easily hurt the yang qi; and when the body is infected by “wetness evil” the spleen yang is the first to be injured. If “wetness evil” is entrapped inside spleen and stomache, the spleen loses “transportation power” first and then the stomache loses its descending & regulation function. If the enclosure in spleen is prolonged, dysfunction of spleen and stomache can result and consequently symptoms of “spleen deficiency” may occur. Following the appearance of “spleen deficiency”, digestion and absorption of food are greatly impaired, causing malnutrition, anemia or endocrine disorder. If the condition continues, many organs of the body may gradually present functional regression, insufficient genesis of “qi” and “blood” and subsequently give rise to “deficiency of blood and weakness of qi”. Metabolism of substances in the body is affected and there is “loss of regulation of yin and yang”; so, it is certain that the disease has already passed into the “severe” and “deep” stage. Another important finding is that hypochondriac anomaly nearly appears in every chronic hepatitis patient; that is, asymmetry of the hypochondriac regions. Taking the midline running from the sternum to the umbilicus, one can see on the left costal region, narrowness, internal depression or even angular protrusion and on the right costal region fullness or flatness or outward extension. It is often seen that the right hypochondriac diameter is significantly greater than the left and its formation is estimated to be due to early hepatomegaly resulted from virus infection during infantile or childhood, in addition, due to the association of hepatogenic malnutrition. In the statistics data, we add “hypochondriac anomaly” to the physical examination items, and deal it as an evidence of a comparatively long course of virus infection, because marked hepatomegaly before puberty is easier to cause hypochondriac anomaly than that after puberty. According to statistical data, in the 568 cases of “deficiency of blood and weakness of qi”, 110 cases have hypochondriac anomaly, accounting for 19.37% and, in fact, among the 2785 cases, 298 cases have hypochondriac anomaly, occupying only 10.70%. In the male 995 cases, 66 cases present hypochondriac anomaly, occupying 7.93%, and in the female 1790 cases, 232 have hypochondriac anomaly, occupying 12.93%. This indicates that the TCM “deficiency of blood and weakness of qi” form is prone to occur in female patients with prolonged course of disease.
(2) "Deficiency of blood and weakness of qi” can also occur after tangible blood loss “Deficiency of blood and weakness of qi “often occurs after tangible blood loss, because where pestilential evil invades the body, wetness-heat gathers first in the middle-jiao like spleen and stomache, then vaporizes to reach the liver and gallbladder and accumulates in the gastrointestinal tract. Following, the heat toxin run downward in the course of deficiency to the lower-jiao and affects the urinary bladder, large intestines and uterus. The liver collects blood and so, liver hotness means also blood hotness. When heat evil hides in the blood, the liver yin is consumed and yin fluid in blood is also consumed. If in the kidney, both water and fire are abundant, and the blood is very hot, the Conception Vessel and Thoroughfare Vessel may present deficiency of qi and can not hold the blood, so that, in female, the menstruation is irregular, predating, profuse in amount and twice within a month or even continuous without stopping. Besides the occurrence of prolonged and abundant menstruation and repeated hemorrhages in female, other hemorrhagic conditions may also occur, such as repeated epistaxis in children, gastric hemorrhage in youths or repeated hemorrhoidal hemorrhage due to congestion of hepatic blood which flows in the adverse direction to the anus, These are the “chronic” bleedings with an amount by no means small and such bleedings are usually the result of “chronic hepatitis” which affects blood clotting or even inhibits bone marrow function. It is a pity that these results are usually not noticed by the patients (due to diagnosis of liver disease not confirmed ). If treatment is not given in time or if it is not proper, especially when drugs harmful to the liver are given, the result is exacerbation of the clinical symptoms of “deficiency of blood and weakness ofqi” and, with the pass of time, aggravation of disease occurs. It is worthwhile to notice that the patients with “deficiency of blood and weakness of qi” form, all have abnormal liver margin and clinical symptoms or signs of TCM chronic hepatitis “deficiency of blood and weakness of qi” form. But the computer data showed that in 568 cases, only 122 were diagnosed as chronic hepatitis, occupying 21.47%. In these patients, 400 cases of hepatophilic virus disease could only be diagnosed as “hepatomegaly for investigation”. This indicates that adequacy of the present criteria for diagnosis of chronic hepatitis should receive further consideration. (Because general clinical laboratory examination can only detect part of the type A, B, C positive patients and those with abnormal hepatic function, so that, there are virtually many chronic hepatitis cases not diagnosed ).
(3)Female chronic hepatitis patients are prone to develop “deficiency of blood and weakness of qi " Among 1790 female chronic hepatitis patients with abnormal margin of hepatic dulness, those having deficiency of blood and weakness of qi symptoms amounted to 489 cases, being 27.3%. So, we can see that the “physiologic character” of female chronic hepatitis patients is the chief cause in the formation of deficiency of, blood and weakness of qi; this coincides with the TCM viewpoint that for female patients, one should “treat the disease and at same treat blood”. In our statistics, there are 489 cases of female “deficiency of blood and weakness of qi” form, in which menstrual disorders 257 cases, occupying 52.55% ; cases associated with dysmenorrheal 131, occupying 26.73%. This shows that chronic hepatitis leading to menstrual disorders, hypermenorrhagia and dysmenorrheal is extremely common. The data also show that in 2787 cases, those having both “deficiency of blood and weakness of qi” form and “blockage of channel and stasis of blood” form are 365 cases, occupying 13.10%; but in this group, male patients are only 19 cases, its amount, among patients with both forms of symptoms, is 5.20% (19/365), and females amount to 346 cases, reaching 94.79%. This indicates that in chronic hepatitis, liver Qi stagnation and blockage of channels and stasis of blood are the chief causes of menstrual disease in females. Modern medicine demonstrates similarly that in chronic hepatitis, the patients coagulation mechanism is abnormal, and there are menstrual disorders, hypermenorrhagia or, it is complicated with myoma of uterus, the menstrual blood is profuse and it causes anemia which is also a fundamental cause of “deficiency of blood and weakness of qi” in female patients with liver disease.
Extra hepatic diseases usually seen in the “deficiency of blood and weakness of qi” form Clinically, the symptoms of “deficiency of blood and weakness of qi” form in TCM chronic hepatitis classification are rather complicated. Because the etiology is not the same, and the severity is of various degrees, therefore, the clinical manifestations of extrahepatic diseases are not similar. The disease is already serious when it passes into the middle and late stage, so it is not mentioned here (because the patients usually go to special clinic or hospitalized). The symptoms of deficiency of blood and weakness of qi form of chronic hepatitis usually include hepatogenic malnutrition, hepatogenic anemia, hepatitis aplastic syndrome, hepatogenic neurosis, hepatognic endocrine disorder, hepatogenic obesity (hepatic edema), hepato-cardiac syndrome, hepatogenic hypogly cemia and hepatogenic protein metabolic dysfunction. We hope for the opportunity of recommending them respectively to make clear that “hepatophilic virus disease” is the origin of many diseases. By WONG Kwok Hung Published on 28th March 2002 Translated by Professor Zheng in October 2004