Jaundice is a common medical condition characterized by yellowing of the skin, the eyes and the urine. It results when turbid Dampness causes dysfunction of the liver, the gallbladder, the spleen and the stomach, so that the gallbladder is unable to discharge bile normally. As a result bile extravasates from its normal channel.
Etiology and Pathology
In general, jaundice may result from exogenous as well endogenous causes, often both. The most common exogenous pathogenic evil is turbid Dampness, which may be accompanied by Cold (Cold-Dampness) or Heat (Heat-Dampness). Among endogenous causes, the most common is disease of the spleen and the stomach extending to involve the liver and the gallbladder. The basic pathological mechanism is blockage by turbid Dampness, so that bile cannot follow its normal pathway but extravasates instead.
The main types of jaundice are Yang jaundice and Yin jaundice, depending on whether Heat or Cold is involved. Occasionally, the causative agent may be especially potent and invade the Nutritive and the Blood Levels. In that case, the jaundice is known as acute jaundice Of these types, Yang jaundice is the most common.
Exogenous Pathogenic Evil. Exogenous Heat-Dampness and Dampness in conjunction with Summer Heat or pestilential evil can each lodge in the middle-jiao and cause disturbance in the transportation and transformation functions of the spleen and the stomach. Dampness and Heat together steam the liver and the gallbladder, impairing their functions and forcing bile to overflow and extravasate. The overflowing bile stains the skin, the eyes and the urine, giving them the characteristic yellow or yellow-orange color. In the case of exogenous Cold-Dampness, they also lodge in and obstruct the middle-jiao, blocking the movement of liver and gallbladder Qi and inducing bile to overflow and extravasate.
Improper Diet. Unclean foods, irregular cycles of satiation and starvation, overindulgence in fatty or sweet foods, or overindulgence in alcohol can injure the spleen and the stomach. Failure of these organs fosters the formation of endogenous
Dampness, which if allowed to accumulate and gel may transform into Heat. Endogenous Dampness and Heat steam the liver and the gallbladder, leading to jaundice as before.
Deficiency-Cold in the Spleen and the Stomach. In chronic weakness of the spleen and the stomach, excessive fatigue with exhaustion or following injury by another illness, endogenous Cold can form readily and further transform into Dampness. Cold and Dampness can readily obstruct the middle-jiao and block the normal flow of bile.
Food Retention. Protracted food retention can lead to blood stasis, which in turn can cause blockage of the bile tract and force bile to extravasate and flow abnormally.
Mechanical Obstruction. Mechanical obstruction of the bile tract by gallstones or ascarid worms can force bile to extravasate and flow abnormally. Gallstones often form from protracted action of Dampness and Heat.
Clinical Manifestation
In the early stages of the illness, yellowing of the sclera may not be apparent. Instead, the illness may manifest such symptoms as chills and fever, anorexia, nausea or vomiting, abdominal distention, borborygmus or weakness in the limbs. Yellowing of the sclera then appears after 3-5 days, followed by yellowing of the skin and the urine.
In Yang jaundice, the yellow color is bright and fresh. There are also fever, thirst, a yellow and greasy tongue coating and a taut and rapid pulse. In Yin jaundice, the yellow color is gray or smoky. There are also lassitude, coldness with cold-aversion, a white and greasy tongue coating and a soft and even pulse.
In acute jaundice, the yellow color appears rapidly and may deepen into an orange or a gold-like color. There may be accompanying high fever, severe thirst, and mental confusion or delirium.
Key Points of Analysis
Jaundice Type. Yang jaundice tends to develop abruptly and has a short course. The color is usually a bright and fresh yellow, but may be orange. The illness is usually in acute condition and is mostly due to Dampness-Heat. Yang jaundice is a condition of Heat and of disease evil strength.
Yin Jaundice. tends to develop gradually and has a long course. The color is usually a gray or smoky yellow. The illness is usually chronic or even severe and is mostly due to gelling of Cold-Dampness in the spleen and the stomach, leading to Qi deficiency. Yin jaundice is a condition of Cold and of deficiency.
Acute Jaundice. develops explosively, with rapid onset and deepening of color. The illness is mostly due to Dampness-Heat with accompanying noxious toxins. There may be accompanying symptoms of the Nutritive and Blood Levels. Acute jaundice is a serious condition and requires great care in diagnosis and management.
Illness Course. Gradual intensification of jaundice, especially when associated with lassitude and increasing anorexia, indicates exacerbation of the illness. Gradual lightening of jaundice, especially when associated with increasing appetite, indicates improvement and a favorable prognosis. A dull and lusterless color accompanied by restlessness or coma, hematemesis and epistaxis indicates deterioration and poor prognosis.
If improperly or inadequately treated, Yang jaundice may progress to Yin jaundice. Conversely, Yin jaundice may show symptoms of Yang jaundice if the patient is invaded simultaneously by exogenous Dampness or Heat, resulting in a condition of mixed deficiency and strength.
Herbal Treatment
Yang Jaundice
Dampness-Heat with Exterior Symptoms
Main Symptoms. Mild or vague yellowing of the sclera initially; epigastric fullness, anorexia; yellow urine; chills and fever; and heaviness and pain in the head and body. The tongue coating is thin and greasy, and the pulse either floating and taut or taut and rapid.
Therapeutic Principle. Cool heat, eliminate Dampness, and release the exterior.
Treatment. Mahuang Lianqiao Chixiaodou Tang (Ephedra-Forsythia-Phaseolus Decoction) combined with Gan Lu Xiao Du Dan (Sweet Dew Detoxification Pill). The combined prescription has the following composition: mahuang (Ephedra) 6 g, bohe (Mentha) 9 g, huoxiang (Agastache) 10 g, baidoukou (Amomum cardamomum) 9g, shichangpu (Acorus) 10 g, huangqin (Scutellaria) 10 g, lianqiao (Forsythia) 6g, huashi (talcum) 10 g, mutong (Akebia quinata) 6 g, chixiaodou (Phaseolus calcara-tus) 12 g, yinchenhao (Artemisia) 10 g, shengjiang (Zingiber) 6g, dazao (Ziziphus)10 g, and raw gancao (Glycyrrhiza) 6 g.
If the symptoms of the exterior are minor, the amounts of mahuang and bohe should be small.
If the color of jaundice is strong, use larger amounts of yinchenhao.
More Heat Than Dampness
Main Symptoms. Fresh lustrous jaundice of the skin and sclera; fever, thirst; dysphoria; nausea, vomiting; dark urine; constipation; and subcostal pain with guarding. The tongue is red, with yellow and greasy coating. The pulse is rapid or slippery and rapid.
Therapeutic Principle. Cool Heat, eliminate Dampness and purge the bowels.
Treatment. Yinchenhao Tang (Artemisia Decoction). It has the following composition: yinchenhao (Artemisia) 20 g, zhizi (Gardenia) 10 g, and dahuang (Rheum palmatum) 6g.
Depending on the clinical requirements, add huzhang (Polygonum), daqingye (Isatis tinctoria) and lianqiao (Forsythia) to cool Heat and detoxify poisons, cheqianzi (Plantago), zhuling (Polyporus) and zexie (Alisma) to enhance the elimination of Dampness-Heat.
If subcostal distention and pain are severe, add chuanlianzi (Melia) and yujin (Curcuma) to unblock the liver and regulate Qi.
Note: pay attention to the degree of fever to determine the amount of bitter-cold herbs to use. If too much of bitter-cold herbs is used, the illness may turn into one in which there is more Dampness than Heat or one of Yin jaundice.
More Dampness than Heat
Main Symptoms. Jaundice of the body and sclera, but the color is not so fresh and bright as when there is more Heat than Dampness. Heaviness of body and head; low grade fever; chest and epigastric tightness; anorexia, nausea; stickiness in the mouth without thirst; difficulty with urination and with defecation. The tongue coating is thick and greasiness, with slight yellow color. The pulse is soft and even or taut and slippery.
Therapeutic Principle. Eliminate turbid Dampness and induce catharsis.
Treatment. Yinchen Si Ling Tang (Poria-Four-Substances Decoction with Arter-misia). Its basic composition is as follows: yinchenhao (Artemisia) 20 g, zhuling (Polyporus) 10 g, fuling (Poria) 10 g, zexie (Alisma) 10 g, and baizhu (Atractylodes) 10 g.
If Dampness impedes Qi movement, causing severe chest and epigastric distention, nausea and anorexia, add cangzhu (Atractylodes), houpo (Magnolia) and chenpi (Citrus tangerina) to strengthen the spleen, dry Dampness, mobilize Qi and settle the stomach.
If anorexia is prominent, add fried maiya (Hordeum) and jineijin (Gallus gallus domesticus) to activate the spleen and promote digestion.
Acute Jaundice
Main Symptoms. Rapid onset jaundice with rapid darkening; high fever, severe thirst; frequent vomiting; subcostal abdominal distention and pain, with guarding; oliguria, constipation; mental confusion, delirium, or coma; epistaxis or hema-tochezia; and cutaneous purpura. The tongue is red or crimson, with dry yellow coating. The pulse is taut and rapid or surging and large.
Therapeutic Principle. Cool Heat, detoxify poisons, cool blood and open the orifices.
Treatment. Shuiniujiao San (Water Buffalo Horn Powder). It has the following composition: shuiniujiao (Bubalus bubalis) 6g, huanglian (Coptis) 6g, zhizi (Gardenia) 10 g, shengma (Cimicifuga) 10 g, yinchenhao (Artemisia) 20 g.
If the patient is still conscious, add large amounts of herbs that purge Heat and detoxify poisons, such as jinyinhua (Lonicera), lianqiao (Forsythia), pugongy-ing (Taraxacum), daqingye (Isatis tinctoria) and dahuang (Rheum palmatum). Alternatively, use Wu Wei Xiao Du Yin (Five-Ingredient Detoxification Drink) in combination with large amounts of dahuang (Rheum palmatum). Wu Wei Xiao Du Yin has the following composition: pugongying (Taraxacum) 20 g, jinyinhua (Lonicera) 15 g, yejuhua (Chrysanthemum indicum) 12 g, zihuadiding (Viola) 12 g, and tiankuizi (Semiaquilegia adoxoides) 10 g.
If the patient is comatose, add An Gong Niuhuang Wan to resuscitate and open the orifices.
If there is significant bleeding, add charred cebaiye (Biota orientalis) and charred diyu (Sanguisorba).
Yin Jaundice
Main Symptoms. Jaundice of the skin and sclera, with the color of dull or smoky yellow; diminished appetite, epigastric fullness; lassitude; cold-aversion; and loose feces. The tongue is pale, with white and greasy coating. The pulse is soft and even or deep and slow.
Therapeutic Principle. Strengthen the spleen, settle the stomach and use warm herbs to dispel Cold and remove Dampness.
Treatment. Yinchen Zhu Fu Tang (Artemisia-Atractylodes-Aconitum Decoction). It has the following composition: yinchenhao (Artemisia) 30 g, processed fuzi (Aconitum) 6 g, baizhu (Atractylodes) 10 g, ganjiang (Zingiber) 10 g, gancao (Glycyrrhiza) 6 g, and rougui (Cinnamomum) 6 g.
For abdominal distention with a thick tongue coating, remove baizhu and ganjiang but add cangzhu (Atractylodes lancea) and houpo (Magnolia) to dry Dampness and reduce distention.
If gallstones obstruct the bile tract, with jaundice of the skin and sclera, there may be right-sided subcostal pain radiating to the shoulder or upper back, or cold-intolerance, fever and clay-colored feces. Use Da Chaihu Tang augmented with yinchenhao, jinqiancao (Glechoma), haijinsha (Lygodium) and yujin (Curcuma) to eliminate gallstones, normalize gallbladder function, cool Heat and remove jaundice.
If ascarid worms obstruct the bile tract, there may be abrupt appearance of jaundice and intermittent subcostal pain as though being drilled. Use Wumei Wan augmented with yinchenhao, zhizi (Gardenia), chuanlianzi (Melia) and binglang (Areca) to relieve pain, normalize the function of the gallbladder, remove jaundice and expel the ascarid worms.
Acupuncture Treatment
Yang Jaundice. Select the acupoints Danshu (BL-19), Taichong (LR-3) and Neit-ing (ST-44). Use filiform needles and apply the reducing method.
Yin Jaundice. Select the acupoints Danshu (BL-19), Pishu (BL-20), Yinlingquan (SP-9) and Sanyinjiao (SP-6). Use filiform needles and apply the even method.
Case Study
The patient was a 17-year old male student who had abrupt onset of jaundice 5 days earlier. Its color was orange. He had dizziness, a bitter taste, reddish-yellow urine, dry feces, epigastric distention, nausea, anorexia, afternoon temperature of 37.2-37.6°C (99-99.7°F) in the afternoon, lassitude and somnolence.
On examination, his general condition was fair. He had jaundice of the skin and sclera. The lung was clear on auscultation. The cardiac border was normal on percussion. The heart rate was 90/min, with regular rhythm. The liver was palpable at 2 cm below the rib margins and was tender to pressure. There was no edema. Neurological examination showed no abnormality. The tongue was plump, with thick white and greasy coating. The pulse was slippery and rapid.
Liver function tests were abnormal, showing the following: ALT 2615 U/l, AST 932 U/l, bilirubin 8.1 mg%, direct bilirubin 4.6 mg% and anti-HA IgM positive. He was diagnosed to have “acute infectious hepatitis with jaundice”.
Diagnosis. Jaundice of the Yang type due to accumulated Dampness-Heat steaming the liver and the gallbladder, causing blockage and forcing bile to overflow and extravasate.
Therapeutic Principle. Remove blockage, mobilize liver and gallbladder Qi, cool Heat, eliminate Dampness and detoxify poisons.
Treatment and Course. The prescription had the following composition: yinchen-hao (Artemisia) 30 g, chaihu (Bupleurum) 15 g, huangqin (Scutellaria) 10 g, zhizi (Gardenia) 10 g, cangzhu (Atractylodes) 10 g, houpo (Magnolia) 15 g, chenpi (Citrus tangerina) 10 g, banxia (Pinellia) 12 g, zhuru (Phyllostachys nigra) 15 g, fengweicao (Pteris multifida) 15 g, and shuihonghuazi (Polygonum orientale) 10 g. Note: yinchenhao was decocted first.
After seven daily doses, the jaundice lightened. Epigastric fullness, nausea and anorexia also improved. The low-grade fever subsided. Defecation came on alternate days. Urine remained reddish-yellow. Lassitude and weakness persisted. He was averse to pungent or fishy odors. His tongue coating was white and greasy, and his pulse taut and slippery.
Diagnosis. Persistent Dampness-Heat difficult to eradicate.
The prescription was changed. The new prescription had the following composition: yinchenhao (Artemisia) 30 g, jinqiancao (Glechoma) 30 g, chuipencao (Sedum sarmentosum) 15 g, chaihu (Bupleurum) 15 g, huangqin (Scutellaria) 10 g, tuful-ing (Smilax glabra) 15 g, baihuasheshecao (Oldenlandia diffusa) 15 g, fengweicao (Pteris multifida) 15 g, fried gancao (Glycyrrhiza) 4 g, zelan (Lycopus lucidus) 10 g, tubiechong (Eupolyphaga sinensis) 10 g, andQiancao (Rubia) 10 g.
After seven daily doses of the new prescription, jaundice disappeared and the patient’s appetite improved markedly. Liver function tests now showed ALT 141 U/l, AST 42 U/l and direct bilirubin 2.1 mg%. The prescription was continued for 14 days. At follow-up half a year later, there was no relapse.
