Exploring Hepatitis From the Perspective of Iranian Traditional Medicine

Abstract

Hepatitis is a global health problem, with significant adverse impacts on patients’ quality of life. In this study, we aimed to review major resources of Iranian traditional medicine and determine whether the etiology and semiology of hepatitis, in particular chronic hepatitis, in traditional and conventional medicine might be aligned. Through such studies, we might be able to develop new approaches for clinical research to improve our current knowledge on the etiology and treatment of this condition. In this qualitative study, recently published studies, scientific databases, and reliable Iranian traditional medicine resources, including the Canon of Medicine, were searched. The integrative use of conventional and traditional medicine for diagnostic and therapeutic purposes could be evaluated to develop new modalities for dealing with this condition. An integrated approach is recommended in clinical research in order to find more efficient and safer treatment.

Hepatitis is one of the most frequent causes of chronic liver disease and a leading cause of liver transplant in the world.^1,2 There are many causes for hepatitis, including toxins, infections, and metabolic and autoimmune disease. Hepatitis C virus has affected 160 to 200 million people worldwide, and its prevalence rate has been estimated at 2% to 3%.^3,4 With regard to hepatitis B virus infection, between 350 and 400 million people are estimated to suffer from this infection. Moreover, the overall prevalence of hepatitis C has been estimated to be 1% in Iran.^5–8

Treatment of hepatitis imposes significant costs on patients.⁹ The increased prevalence of this condition in all age groups, the financial burden on health care systems, the adverse impacts on quality of life, and dissatisfaction of current treatment strategies because of the high complication rate, contraindicated in children and many other diseases, and partial response to treatment explain the tendency of patients and clinicians to move toward the use of complementary and alternative medicine.^10,11

Complementary and alternative medicine has been explained as a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine. Complementary and alternative medicine includes procedure such as herbal medicine, homeopathy, acupuncture, chiropractic, spiritual healing, and traditional medicine such as Chinese traditional medicine, Iranian traditional medicine, and systems used in other countries.¹²

Iranian traditional medicine is a collection of scientific principles and practice of medicine written in known texts such as the following: Al-Qanun fit-tib (Avicenna, 980-1037 ad), Al-Hawi (Zakariya al-Razi, 864-930 ad), Zakhireh Khaarazmshahi (Seyed Esmail Jorjani, 1042-1137 ad), among others.¹³

So far, hepatitis has not been discussed from the perspective of Iranian traditional medicine. In Iranian traditional medicine resources, liver is considered as 1 of 3 main organs in health maintenance and disease treatment. Avicenna (980-1037 ad), one of the most renowned physicians in the world, is famous for his book titled Al-Qanun fi al-Tibb (Canon of Medicine).¹⁴ The book has been translated into various languages.¹⁵ In this book, Avicenna provides a summary of all medical conditions known until then.¹⁶ In fact, liver diseases have been discussed and examined in this book.¹⁷

The aim of this study was to review Avicenna’s and other Iranian traditional medicine sources’ viewpoints about hepatitis, in particular chronic hepatitis, and compare the issues presented in them with the current medical knowledge including the following items: (a) definition of hepatitis and related terms, (b) etiology, (c) physiopathology, and (d) symptoms and signs because we need new knowledge of this disease, especially for treatment.^18,19 In this article, Iranian traditional medicine concepts in the ancient books was updated, which facilitated the research for new and innovative solutions for the diagnosis and treatment of hepatitis.

Methods

Methodology

In this qualitative study, the symptoms and diagnosis of chronic hepatitis was extracted from conventional medicine. Iranian databases including SID, Civilica, MagIran, and Irandoc and international databases including PubMed, Google Scholar, and Scopus were searched, using the following keywords. Then details of liver diseases were extracted from the Canon of Medicine. Based on the aforementioned list, other selected books of traditional medicine were searched. The information including symptoms and their equivalent words in traditional medicine sources were organized in notes. The notes were put together in order to analyze the information as content analysis. Each note theme was then extracted. All the themes pertaining to the notes of a group were put together to form a new note. After that, these themes were summarized in a text format with applied tables in order to achieve the goal of study, including the causes of all symptoms and common etiology associated with liver diseases. The findings were discussed by the research group in terms of rigor, correctness, and matching level in different sessions. After the final confirmation, they were included in the process of analysis and explanation. No time limitations were applied. Data were based on the preliminary search, which provided 356 articles and 16 books, but of these articles, 259 were excluded based on exclusion criteria. Thus, 41 articles and 8 books remained for evaluation (Figure 1).

Figure 1.

Flow chart showing the selection process and exclusion criteria.

Inclusion and Exclusion Criteria

Inclusion criteria included text books and articles in Persian, English, and Arabic language and literature reviews, systematic reviews, and meta-analyses. The titles and abstracts of the articles were evaluated. Exclusion criteria included articles with invalid references and those lacking accurate methodology.

According to Iranian traditional medicine textbooks, these books have complete explanations about liver disease, and they are available with the authors.

Quality Assessment

For quality control of articles and resources, methods like peer checking and finding results from various credible sources of traditional medicine were combined to increase rigor and credibility. The findings were checked in terms of the correctness of interpretations and coding process by the research team to increase conformability. The texts of notes and codes were proofread and reviewed by the research team to achieve consensus. The cases lacking consensus were discussed in order to find a final solution. Qualitative research methodology was used.

Results

Hepatitis in Conventional Medicine

Hepatitis Etiology

Hepatitis is an inflammation of the liver. It may be caused by drugs, alcohol use, toxins, infections, metabolic disease, and autoimmune disease. But in most cases, it is caused by a virus. This is known as viral hepatitis, and the most common forms are hepatitis A, B, and C. Hepatitis can affect the hepatic tissue either acutely or chronically.^1,23

Clinical Signs and Symptoms of Hepatitis

Acute hepatitis is normally asymptomatic. In symptomatic cases, after a period of incubation, general symptoms such as loss of appetite, nausea, vomiting, fatigue, neurosis, joint and muscle pain, headache, photophobia, pharyngitis, cough, and symptoms of coryza may appear.^5,24 Most cases of chronic hepatitis are reported in asymptomatic patients with no background of hepatitis, and are diagnosed via routine laboratory test or blood test. Most of the chronic hepatitis cases remain asymptomatic, and the most common symptom is fatigue.¹

Pathology of Hepatitis

The pathology of acute hepatitis infection includes the infiltration of mononuclear cells, various degrees of cholestasis, cell damage in the liver, and activity of Kupffer immune cells. Hepatic cell damage is characterized by the destruction and necrosis of cells, cell separation, ballooning degeneration, distortions in the normal lobular architecture of the hepatic parenchyma (loss of normal architecture or structure of the liver), and regenerative changes (proliferation of liver cells).^1,25 Necrosis and loss of liver cells and replacement by abnormal collagens in the scaffold of reticular hepatic tissues lead to liver stiffness and fibrosis in chronic hepatitis.^1,2

Complications of Hepatitis

In general, most cases of acute hepatitis leads to chronic hepatitis, which eventually leads to cirrhosis and liver cancer within 20 to 30 years.²⁶

Viewpoints of Avicenna and Other Iranian Traditional Medicine Physicians About Hepatitis

Basic Content of Iranian Traditional Medicine

Iranian traditional medicine consists of theoretical and practical content and might be applied for the diagnosis, prevention, and elimination of various diseases.^27,28 Although the terminology and doctrine of Iranian traditional medicine is not yet perfectly explained, several studies have attempted to determine the connection between Iranian traditional medicine and conventional medicine through biochemical, immunological, or endocrine mechanisms.²⁹ However, various comparative studies have been performed to line up the concepts of Iranian traditional medicine and conventional medicine. Recent publications have highlighted Avicenna’s views on numerous diseases, such as hypercholesterolemia,³⁰ hypertension,³¹ epilepsy,³² cardiology,³³ nausea and vomiting,³⁴ cataracts,³⁵ hepatoprotective herbs,³⁶ stroke,³⁷ respiratory diseases,³⁸ and fatty liver, and so forth.

In Iranian traditional medicine literature, a general temperament (mizaj) has been described for the whole body. Moreover, for each body organ, a certain temperament has been considered based on the individual’s age, place of residence, occupational status, gender, and presence or absence of different diseases.³⁹ Temperament or body nature is highly individualistic. According to Avicenna, temperament is defined as the new state of a matter, having a different quality from that present in the elements or compounds before coming into intermixture.^40,41

Hippocrates (460-377 bc) conceptualized the theory of humors and introduced 4 humors circulating in the body: phlegmatic, choleric, sanguine, and melancholic. He assumed that imbalance in these humors causes diseases. Traditionally, humors (akhlat) are believed to originate from the liver and the digestion process in the stomach and liver. In the normal state, 4 types of humor can be described including bile (safra), which is warm and dry; blood (dam), which is warm and wet; phlegm (balgham), which is cold and wet; and black bile (sauda), which is cold and dry in nature. Abnormalities in each of these humors are discussed in the pathogenesis of diseases in Iranian traditional medicine.^20–22,39

Each body organ in its natural temperament has normal functions. If an organ is changed from its natural temperament for any reason, dystemperament (sou-e mizaj) occurs, which is based on its type and the organ involved, manifesting different clinical symptoms. Temperament consists of a combination of 4 elements, traditionally known as air, water, soil, and fire. Temperament can be divided into 2 groups: simple (hot, cold; dry, wet) and mixed (cold and wet, cold and dry, hot and wet, and hot and dry).⁴²

Temperament of liver in Iranian traditional medicine is warm and wet. This organ is the place of natural spirit and forces. The major physiological functions of the liver are responsibility for digestion and absorption, location of the last phase of humors’ (akhlat) production and distribution, and protecting the part from instinctive heat.⁴³

Liver Diseases in Iranian Traditional Medicine

Avicenna classified liver diseases into 17 types and explained mechanisms for each one of them. In liver dystemperament with an abnormal hot and dry temperament (either with an internal or external origin), the following clinical signs can be observed: loss of appetite, excessive thirst, bitter mouth, constipation, tachycardia, yellow-colored urine, fever, warmness in the liver, dry tongue, vomiting, occasional heaviness in the right side of the chest, yellowish color of the eyes, and dry cough. Continuation of liver dystemperament can cause liver damage and inflammation or waram, as mentioned in Iranian traditional medicine.^20,41

Hepatitis Definition in Iranian Traditional Medicine

In Iranian traditional medicine literature, hepatitis is referred to as O’ram or Waram-e kabed (liver inflammation).

Hepatitis Etiology in Iranian Traditional Medicine

Chronic hepatitis is considered to be caused by hotness and dryness of materials in the liver.^21,41

Pathology of O’ram

This condition has been characterized with the following phases: (a) dystemperament (physiological dysfunction of the liver); (b) Tafarroqol-ittisal, which refers to the loss of continuity in an organ or separation of the connection cells; (c) Soddah, which denotes any blockage of small vessels or ducts caused by thick humor; and (d) Soo’ol-tarkib, meaning the loss of normal structure (size, shape, number, and form) in an organ or disturbance in the lobular order.^20,41

Clinical Signs and Symptoms O’ram

O’ram kabed or waram-e kabed can be divided into 2 general categories of hot or cold and soft or hard waram.

Waram kabed harr (harr or essence carrying heat as quality)

Hot waram has a severe and advancing process with more obvious symptoms such as fever, thirst, and feeling warm during examination and it could transform into an abscess.⁴¹

Waram kabed barid (barid or essence carrying coldness as quality)

Cold waram has a gradual start and it could be a residue from a hot waram; the symptoms are not very obvious and mostly are associated with surface hardness of the area and pain with a feeling of heaviness, especially in the advanced stages of the disease.⁴¹ The comparative signs and symptoms are shown in Table 1.

Table 1.

Iranian Traditional Medicine Classification of Liver Inflammation or Waram-e Kabed.

Liver Inflammation	Etiology	Signs and Symptoms	Proposed Equivalent in Conventional Medicine
Hot liver inflammation (harr waram)	Hot dystemperament of the liver	Jaundice, fever, loss of appetite, excessive thirst, dark stool or pale urine, small rashes on the tongue, and heaviness of liver	Acute hepatitis
Cold liver inflammation (barid waram)	Cold dystemperament of the liver	Black color of the face and tongue, no fever, decreased appetite, thirst, weight loss, dry eyes, no pain, and feeling of tightness in the ribs	Chronic hepatitis
Hard liver inflammation (sulb waram)	Hot or cold dystemperament of the liver	No fever, no pain, fatigue, and asymptomatic characteristics	Chronic hepatitis; liver cancer

Complications of O’ram Harr

O’ram harr depletes and recovers in the natural course or becomes chronically infected. Therefore, infectious foci are formed in the liver, and parts of liver tissues become rigid by a chronic swelling. In Iranian traditional medicine, this is also known as waram solb. In some patients the progression of the disease could weaken liver function and lead to conditions such as liver weakness, ascites, and cancer. Tables 2 and 3 outline the described clinical presentations of hepatitis, when compared to modern medicine.^21,41

Table 2.

Signs and Symptoms of Chronic Hepatitis and Waram Sulb (Hard).

Signs and Symptoms	Waram Sulb (Hard)	Chronic Hepatitis
No pain	✓	✓
No fever	✓	✓
Fatigue	✓	✓
Heaviness of liver	✓
Weight loss	✓	✓
Redness of skin	✓
Hardness and stiffness of the liver	✓	✓
Nonsymptom characteristics	✓	✓

Table 3.

Signs and Symptoms of Acute Hepatitis and Waram Kabde Harr.

Signs and Symptoms	Waram Kabde Harr	Acute Hepatitis
Decreased appetite	✓	✓
Low fever	✓	✓
Jaundice	✓	✓
Nausea and vomiting	✓	✓
Fatigue	✓	✓
Dark stool	✓	✓
Pale urine	✓	✓
Thirst	✓
Liver pain	✓	✓
Heavy gravity liver	✓
Dry cough	✓	✓

Discussion

Based on Iranian traditional medicine literature, the etiology of hepatitis can be considered in line with hot and dry characteristics of humor describing high injury potential, heat intensity, high breakdown speed, softness, and tendency to remain in the liver.⁴¹

Hot dystemperament of the liver advances differently, according to the basic temperament of the liver in each individual. The natural temperament of the liver is hot and wet, and the amount of damage to this organ varies, based on the extent of warmness and wetness. Therefore, similar to conventional medicine, the occurrence of clinical symptoms and extent of damages are variable among different cases in Iranian traditional medicine literature.⁴¹

Hot dystemperament of the liver can become chronic, which is followed by the occurrence of clinical symptoms and tissue changes in the liver; in fact, the Waram-e kabed in Iranian traditional medicine is analogous to chronic hepatitis, and waram or inflammation in Iranian traditional medicine refers to the pathology and clinical manifestations of hepatitis, based on clinical evidence and differs from simple swelling in conventional medicine.⁴¹

A normal or abnormal increase in the content (matter) of liver cells increases the volume of waram (inflammation), changes the appearance of cells and liver structure, and causes cell disruption and rupture of the cell wall (tissue lysis), which eventually leads to the substantial loss of moisture in the liver and its components (soft tissue, liver reticular). This increases the stiffness of the liver and its components, thus reducing the moisture of the scaffolding liver tissue (probably matched with fibrosis). This pathological description based on clinical evidence in Iranian traditional medicine is consistent with physiopathological findings of chronic hepatitis in conventional medicine.^41,44,45

These changes in the temperature of the liver cause combustion (a biochemical or biological process) in the disease-causing matters. Based on the extent of combustion, more warmth, dryness, and damage may be observed in the produced matter (dry and hot), causing chronic inflammation (waram), as seen in the final stages of chronic hepatitis and cirrhosis. Moreover, in case the combustion of matter continues, and its chemical or biological changes in the structure (equivalent to genetic changes of the virus) occur, the temperament of the liver changes from hot to cold and dry with a more destructive power. Additionally, the development of a dry solid tumor (fibrosis) and cancer is facilitated.^46,47 The clinical course of hepatitis in Iranian traditional medicine is demonstrated in Table 1.

In this article, Iranian traditional medicine concepts in ancient books was updated, facilitating the research for new and innovative solutions for the diagnosis and treatment of hepatitis. For example, chronic hepatitis can be matched in traditional medicine texts, such as liver weakness, liver soddah, O’ram liver. In Iranian traditional medicine, for the treatment of these forms of the diseases, several treatment methods and drugs are recommended, such as camel milk.^48,49 So maybe the use of camel milk is recommendable as part of the treatment of chronic hepatitis.

The strengths of this study include investigating various sources of traditional medicine and conducting consulting sessions with experienced experts and professors of the research group with different specialties. However, the weaknesses of this study may include the lack of specific texts on hepatitis and too many repeated texts in traditional sources.

Conclusions

Acute hepatitis in Iranian traditional medicine is the equivalent to O’ram harr, and chronic hepatitis in Iranian traditional medicine is the equivalent to O’ram solb. In fact, the clinical course of hepatitis in Iranian traditional medicine and conventional medicine are similar. The orientation of the World Health Organization toward the use of traditional medicine has promoted the medical capacity to investigate and explore new fields. Integration of traditional and conventional approaches for the analysis, diagnosis, and treatment of diseases could provide a new integrated model for dealing with patients. By applying Iranian traditional medicine approaches, different treatment strategies might be proposed, which could be evaluated in future studies. Also, the viewpoints of Avicenna and traditional physicians about liver can be an interesting subject for further studies and articles.