2 Traditional Chinese Medicine’s Understanding of the Pathogenesis of Viral Hepatitis

“Those who experience yellowing and redness of the skin while lying down are considered to have jaundice; those with yellowed eyes are also classified as having jaundice.” (Suwen, Chapter on “The State of Health and Meteorological Patterns”) “After seven or eight days of cold disease, the body turns yellow—this is called ‘Yangming Jaundice.’” (Shanghan Lun, Yangming Chapter) “When damp heat combine, people suffer from itching.” (Suwen, Chapter on “Six Yuan’s Correct Guidelines”) “Jaundice caused by dampness.” (Jin Gui Yao Lü, Chapter on Jaundice) “When epidemics spread across the land, causing jaundice, it is commonly known as ‘Plague Jaundice,’ which can claim the lives of many in an instant.” (Shen Shi Zun Sheng Fang, Chapter on Jaundice) “When there is heat in the spleen and stomach, and the heat toxins accumulate, jaundice suddenly appears, accompanied by fullness in the heart and shortness of breath—life can be lost in an instant. This is why it is referred to as ‘Rapid Jaundice.’” (Zhu Bing Yuan Hou, Chapter on Rapid Jaundice) “Jaundice arises from weakness of the spleen and stomach qi, when damp heat is encountered and stagnates in the skin’s pores, infiltrating the skin and accumulating as jaundice.” (Zheng Zhi Zhuan, Chapter on “Correct Diagnosis and Treatment”) “In damp-heat diseases, if the middle qi is strong, the illness resides in Yangming; if the middle qi is weak, the illness resides in Taiyin.” (Wet Heat Disease Chapter) “Yin jaundice is caused by cold dampness in the spleen.” (Liang Zheng, Chapter on “Disease Diagnosis and Treatment”) “In Yangming diseases, stagnant heat resides within the body, causing jaundice—this is treated with Yin Chen Hao Tang.” (Shanghan Lun, Yangming Disease Chapter) “When yin dampness causes jaundice, use Yin Chen Fu Ling Tang or Yin Chen Si Yi Tang.” (Yizong Bi Du, Chapter on “Essential Medical Knowledge”) “When jaundice arises from damp-heat, if the middle qi is strong, the illness lies in Yangming; if the middle qi is weak, the illness lies in Taiyin.” “If there is blood stasis causing jaundice, the stool will inevitably be black, and there may be masses or distension in the abdomen and flanks; if the pulse is deep or wiry, use Tao He Cheng Qi Tang, and once all the black matter is expelled, the condition will improve.” (Zhang Shi Yi Tong, Chapter on “Miscellaneous Cases”) “For liver diseases, pain often occurs in the two flanks.” (Suwen, Chapter on “The Timing and Function of Internal Organs”) “Liver wood has a nature of rising and dispersing; it does not tolerate stagnation. When stagnation occurs, the qi becomes reversed—causing belching, bloating, vomiting, sudden anger, flank pain, and chest fullness with loss of appetite.” (Liang Zheng, Chapter on “Liver Qi”) “When evil enters the liver, a surge of qi rises in the two flanks, and dark blood accumulates internally.” (Ling Shu, Chapter on “Five Evils”) “There is a distinction between flank pain caused by internal injury and external exposure.” (Jing Yue Quan Shu, Chapter on “Flank Pain”) “In chronic illnesses, qi and blood become blocked in the channels. Blood accumulation forms solid masses, while qi flows freely without trace.” (Lin Zheng Gong An, Chapter on “Flank Pain”) “When damp-heat accumulates and fire is activated, wind invades externally, causing flank pain. If flank pain persists for a long time without improvement, it indicates phlegm accumulation forming masses—liver accumulations are known as ‘Fat Qi,’ which may occur occasionally, especially when liver wood is overactive.” (Zheng Zhi Hui Bu) “Masses are visible when they are solid; clusters are invisible when they are fluid. Most diseases caused by masses reside in the blood, while those caused by clusters often affect the qi.” (Jing Yue Quan Shu, Chapter on “Accumulation”) “When accumulation forms, it is due to insufficient righteous qi, allowing evil qi to take hold. When righteous qi is still strong and evil qi is still shallow, one can easily withstand attack; when evil qi is deeper and righteous qi is weaker, one must both endure attack and replenish.” (Zhang Shi Yi Tong, Chapter on “Accumulation”) “Abdominal distension, pale yellow in color, with prominent abdominal muscles.” (Ling Shu, Chapter on “Water Distension”) “Any tumor, mass, or lump is the root cause of distension; over time, accumulation builds up, leading to a belly as large as a winnowing basket or as big as a jar—this is simply distension.” (Yi Men Fa Lü, Chapter on “Disease Diagnosis and Treatment”) “When water toxicity accumulates internally, the abdomen gradually enlarges, with sounds of movement.” (Zhu Bing Yuan Hou, Chapter on “Causes of Disease”) “Qi, water, and blood are closely interconnected: when qi lags behind blood, blood accumulates, and when blood accumulates, water follows and pools.” (Yi Que, Chapter on “Swelling”)

(2) Traditional Chinese Medicine’s Understanding of the Pathogenesis of Viral Hepatitis Traditional Chinese Medicine views this disease as resulting from exposure to damp-heat or epidemic viruses, where righteous qi and evil qi clash, either remaining latent or manifesting as jaundice or even without jaundice. When damp-heat and epidemic toxins remain unresolved, they deeply penetrate the blood vessels, and over time, lead to imbalances and deficiencies in the internal organs, yin and yang, and qi and blood. This pathological process aligns well with the concept of acute hepatitis evolving into chronic hepatitis or cirrhosis. Whether the virus is carried, whether the infection is acute, chronic, mild, or severe, the key factor lies in the virulence of the virus and the varying degrees of the body’s defensive capabilities. Damp-heat and epidemic toxins affect the spleen and stomach, disrupting the functions of the middle burner—transmission, transformation, and regulation—and the toxic energy spreads inward, affecting the liver. This leads to stagnation of liver qi, which then reverses and disrupts the function of the spleen and stomach, resulting in symptoms like fatigue, reduced appetite, abdominal distension, flank and rib pain, mild hepatosplenomegaly, elevated ALT levels, and positive hepatitis virus markers. If liver stagnation remains unresolved, qi becomes blocked, meridians become obstructed, and qi stagnates while blood stagnates, leading to fixed, hard masses in the flank area. Over time, these masses become dense and painful, accompanied by dark complexion, bruised moles, purple tongue, and a wiry, fine pulse. At this stage, chronic hepatitis may progress to cirrhosis, with progressive enlargement of the liver and spleen, repeated or persistent dysfunction of liver function, and microcirculatory disorders throughout the liver and body. If the spleen fails to ascend and the stomach fails to descend, and liver qi cannot be released, bile does not flow along its normal pathway into the bloodstream but instead spills onto the skin, causing jaundice. In cases of severe damp-heat, the jaundice may be bright yellow like orange, accompanied by fatigue, reduced appetite, nausea, flank pain, a yellowish, greasy tongue coating, and a wiry, slippery pulse—this is known as “yang jaundice.” In some cases, the heat toxins are intense, and the evil energy penetrates the blood, entering the pericardium, causing delirium and bleeding, with the entire body turning yellow—this is known as “rapid jaundice” or “plague jaundice.” A small number of patients with yang jaundice fail to receive proper treatment, and the condition persists for a long time, with cold dampness becoming a contributing factor, resulting in dull yellowing, fatigue, fear of cold, abdominal distension, loose stools, a pale tongue with a greasy coating, and a deep, thin pulse—these patients are diagnosed as “yin jaundice.” The severity of jaundice generally correlates with the degree of hepatocellular necrosis and intrahepatic bile stasis; in cases of severe necrosis, jaundice tends to be more pronounced, with a poorer prognosis. However, when inflammation of the capillary bile ducts predominates, and bile stasis develops within the liver, the disease course may be relatively prolonged, sometimes lasting for years, and in some cases progressing to biliary cirrhosis. Therefore, traditional Chinese medicine also considers rapid jaundice to be dangerous, and that yin jaundice—or those with phlegm-dampness adhering to the blood—tend to be difficult to treat. As we can see, this disease originates from external exposure to damp-heat and epidemic toxins, primarily affecting the liver; however, the liver stores blood, possesses a nature akin to wind and wood, governs tendons, and shares a common origin with the kidneys. It relies on kidney yin to nourish the liver, and the liver and gallbladder are related through the exterior–interior pathways. When liver qi is affected by spleen qi, and liver disease persists for a long time, it naturally leads to depletion of other organs, yin and yang, and qi and blood throughout the body. When severe toxins enter the blood, hepatic encephalopathy and DIC may develop. In cases of chronic illness, or when liver and kidney yin are deficient, or when spleen and kidney yin are deficient, or when qi stagnates and blood stagnates, the condition may persist for years, accumulating into masses and distension—eventually leading to cirrhosis, ascites, or even cancer. Ultimately, this can result in liver and kidney failure, as well as systemic failure. Of course, these cases are rare; most patients recover fully, with a favorable prognosis.

(3) TCM Syndrome Differentiation and Treatment Methods Chronic type B hepatitis is the most prevalent infectious disease among viral hepatitis. Currently, antiviral Western medicines such as interferon and nucleoside analogs are the first-line treatments for hepatitis B, achieving significant efficacy in suppressing HBV replication—but they cannot eliminate the ccDNA within liver cells, and HBV infections can recur after stopping medication, failing to completely eradicate HBV infection. In 2006, at the Shanghai-Hong Kong International Liver Disease Conference, the application of traditional Chinese medicine in liver disease research and treatment was highlighted as a major topic for discussion. TCM syndrome differentiation and treatment methods played an important role in the treatment of hepatitis B. The “TCM Syndrome Differentiation Standards for Viral Hepatitis” (Pilot Version), revised in 2004, established the “TCM Syndrome Differentiation Standards for Viral Hepatitis” (Revised Draft) as follows:

1. Acute Hepatitis (1) Clinical Manifestations of Acute Jaundice-Type Hepatitis Due to Damp-Heat Accumulation: Yellowing of both the skin and eyes, with a vivid yellow hue; loss of appetite, nausea, aversion to oily foods; dry mouth and bitter taste; heavy and sluggish head and body; fullness in the chest and abdomen; fatigue; constipation; yellowish-red urine; yellowish, greasy tongue coating; a wiry, slippery, rapid pulse. Main symptoms: ① Yellowing of both the skin and eyes, with a vivid yellow hue and yellowish-red urine; ② Loss of appetite and nausea, aversion to oily foods; ③ Yellowish, greasy tongue coating. Secondary symptoms: ① Dry mouth and bitter taste; ② Constipation; ③ Heavy and sluggish head and body; ④ Fullness in the chest and abdomen. Diagnostic requirements: First, if a patient exhibits either symptom ① or ②, or any one of symptoms ③, they are considered to have this syndrome; second, if a patient exhibits symptoms ① and secondary symptoms ① or ②, they are classified as having a condition where heat outweighs dampness; third, if a patient exhibits symptoms ① and secondary symptoms ③ or ④, they are classified as having a condition where dampness outweighs heat; fourth, if a patient exhibits symptoms ① and secondary symptoms ① or ②, as well as one of symptoms ③ or ④, they are considered to have a condition where both heat and dampness are present. For a condition where heat outweighs dampness, the treatment focuses on clearing heat, promoting diuresis, detoxifying, and resolving masses. Prescription: Yin Chen Hao Tang with additions. Use 30–60g of Yin Chen, 10–30g of Dahuang, 15–30g of Huo Zhang, 30g of Che Qian Cao, 20g of Fuling, 15g of Zhu Ling, and 10g each of Ze Xie, Zhizi, and Huang Bo. For constipation, use Da Cheng Qi Tang; for severe liver and gallbladder heat, use Long Dan Xie Gan Tang; for nausea, add Huang Lian and Zhu Ru. For a condition where dampness outweighs heat, the treatment focuses on promoting diuresis, eliminating turbidity, clearing heat, and reducing jaundice. Prescription: Yin Chen Si Ling San with additions. Use 30–60g of Yin Chen, 20g each of Feng Ye Ka, Fuling, Zhu Ling, Ze Xie, Bai Zhu, and Sha Ren. For nausea, add Ban Xia and Chen Pi; for severe abdominal distension, add Da Fu Pi and Mu Xiang. For a condition where both dampness and heat are present, the treatment focuses on clearing heat, resolving dampness, and releasing the exterior. Prescription: Ma Huang Lian Qiao Chi Xiao Dou Tang combined with Gan Lu Xiao Du Dan with adjustments—add 10g each of Lian Qiao, Huo Xiang, Bai Kou Ren, Bo He, Huang Qin, Hua Shi, and Ju Pu, along with 10g of Yin Chen, 15g of Chi Xiao Dou, 6g each of Ma Huang, Mu Tong, and Gan Cao, 3 slices of Fresh Ginger, and 6 Jujubes. For a condition where cold dampness burdens the spleen, clinical manifestations include yellowing of the skin and eyes, with a duller yellow hue; loss of appetite and abdominal distension, or fatigue and weakness; fear of cold and a preference for warmth; loose stools; a plump tongue, pale tongue body, white, slippery tongue coating, and a deep, slow, weak pulse. Main symptoms: ① Yellowing of the skin and eyes, with a duller yellow hue; ② Loss of appetite and abdominal distension; ③ Deep, slow, weak pulse. Secondary symptoms: ① Fatigue and weakness, fear of cold and a preference for warmth; ② Loose stools; ③ Plump tongue, pale tongue body. Diagnostic requirements: First, if a patient exhibits all of the main symptoms, they are considered to have this syndrome; second, if a patient exhibits any one of the two main symptoms and any two of the secondary symptoms, they are also considered to have this syndrome. Treatment principles: Strengthen the spleen and stomach, warm the center and resolve dampness. Prescription: Yin Chen Shu Fu Tang with adjustments: 30–60g of Yin Chen, 60g each of Fuzi, Gan Jiang, and Gan Cao, 20g of Fuling, 10g each of Bai Zhu and Ze Xie. For severe abdominal distension and thick tongue coating, add Cang Zhu, Hou Po, and Da Fu Pi. (2) Acute Non-Jaundice-Type Hepatitis: Damp-Clotting Blockage Syndrome: Clinical manifestations include discomfort in the abdomen, lack of appetite, heavy and sluggish limbs, lethargy and a desire to lie down, sticky oral sensations, loose stools, a greasy tongue coating, and a slow, moist pulse. Main symptoms: ① Discomfort in the abdomen, lack of appetite; ② Greasy tongue coating. Secondary symptoms: ① Heavy and sluggish limbs; ② Sticky oral sensations; ③ Loose stools. Diagnostic requirements: First, if a patient exhibits all of the main symptoms, they are considered to have this syndrome; second, if a patient exhibits any one of the two main symptoms and any two of the secondary symptoms, they are also considered to have this syndrome. Treatment principles: Promote diuresis and restore the spleen. Prescription: Yin Chen 30g, Qian Cao 15g, Bai Zhu 15g, Huo Xiang 10g, Ban Xia 10g, Chen Pi 10g, Zhi Ke 10g, Ze Xie 10g, Jiao San Xian each 10g. Additions: For gastric fullness and a thick, greasy tongue coating, add Bai Dou Kou 10g, Shi Chang Pu 15g, Hua Shi 20g; for obvious fatigue, add Sheng Huang Qi 10g, Taizi Shen 10g. For liver qi stagnation syndrome: Clinical manifestations include flank pain and abdominal discomfort, chest tightness and discomfort, frequent sighing, depressive mood, loss of appetite, or a bitter taste with a desire to vomit, dizziness and blurred vision, a white tongue coating, and a wiry pulse; women may experience breast swelling and pain, menstrual irregularities, or dysmenorrhea. Main symptoms: ① Flank pain and abdominal discomfort; ② Wiry pulse. Secondary symptoms: ① Loss of appetite; ② Dizziness and blurred vision; ③ Depressive mood; ④ Breast swelling and pain in women, menstrual irregularities, or dysmenorrhea. Diagnostic requirements: First, if a patient exhibits all of the main symptoms, they are considered to have this syndrome; second, if a patient exhibits any one of the two main symptoms and any two of the secondary symptoms, they are also considered to have this syndrome; third, if a patient exhibits any one of the two main symptoms and any three of the secondary symptoms, they are also considered to have this syndrome. Treatment principles: Unblock the liver and regulate qi. Prescription: Chai Hu 10g, Sheng Zhi Shi 10g, Yu Jin 15g, Quan Gua Ling 30g, Red and White Peony each 15g, Dang Gui 15g, Dan Shen 15g, Chen Pi 10g, Jiao San Xian each 10g. Additions: For obvious jaundice, add Yin Chen 20g, Huo Zhang 15g; for flank pain that persists, add Jin Ling Zi 10g, Yan Hu Suo 10g, Hong Hua 10g.