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Jaundice

Treatment based on differentiation of symptoms and signs

Ⅰ. Main points of differentiation of syndrome and signs

(Ⅰ) Firstly, confirm whether it is jaundice. Yellow conjunctivas are an important basis for diagnosis of jaundice, so clinically should observe colour of the conjunctiva, skin and urine. 

(Ⅱ)Differentiation of jaundice property:

1.      differentiation from time of attack and duration of disease: Yang jaundice   attackes suddenly, with short duraton of disease; Yin jaundice attackes slowly with long duration; Acute jaundice attackes suddenly and changes quickly.

2.      Differentiation from colour of jaundice: Yang jaundice is of fresh yellow colour, belonging to heat syndrome and excess syndrome; Yin jaundice is of dull or dim, belonging to deficiency syndrome and cold syndrome; Aute jaundice is of yellow body like gold colour, belonging excessive heat pathogen, and deficiency syndrome complicated by excess syndrome may appear due to exhausion of Qi Ying at late stage.

（Ⅲ ）Differentiation of state of illness: Mainly observe colour of jaundice.

That colour of jaundice darkens gradually suggestes exacerbation of the disease; That Jaundice becomes gradually light indicates improvement of state of illness; Fresh colour jaundice and consciousness indicate favorable case, mild state of disease; Dull colour and restlessness indicate a deteriorating case, sevious state of disease.

Main points of differentiation of Yang jaundice and Yin jaundice

 Ⅱ.Differentiative diagnosis

Jaundice should be differentiated with Wei-jaundice

 (Ⅰ) Causes of disease and pathogenesis: Causes of disease of jaundice are affection by exopathogens, impairment due to improper diet, deficiency and cold in the spleen and stomach, and turning of mass in abdomen, and its pathogenesis is stagnation of dampness pathogen in the middle-Jiao, failure of the liver and gallbladder in excretion, or obstruction of biliary  tract by blood stasis, roundworm and gallstones, etc. Leading to failure of bile to circulate in normal tract, flowing into the muscle and skin to produce yellow; or due to deficiency of the spleen and lochioschesis, and unability to flourih due to retention of lochioschesisin the body lead to appearance of yellow. Wei-jaundice is caused by retention of worm and food, inducing deficiency of the spleen, failure of food to transform into neutrients and to produce Qi and blood, or bleeding, dificiency of Qi and blood after illness, insufficiency of Qi and blood, yellow appears in the muscle and skin.

(Ⅱ) Main syndrome: Yellow eyes, body and urine are main syndromes for jaundice, and with different pathogenesis of damp-heat, cold-dampness and stagnation of blood stasis in the interior, the yellow may show the differences of fresh yellow and dark yellow.

Main symptoms of Wei-jaundice are: the muscle and skin show light yellow ,dry and no gloss, but without yellow in eyes and urine, often accompanied by dizziness, tinnitus, palpitation, insomina and other symptoms.

Ⅲ. Main points of therapeutic principle

Because jaundice is caused by dampness pathogen, eliminating dampness and diuresis are basical principle for treatment of jaundice. The method of eliminating dampness includes mainly inducing diuresis with bland drugs, clearing away heat and promoting diuresis, warming Yang for diuresis. In treatment of jaundice, eliminating dampness, resolving dampness and dispelling dampness are often used for removing dampness and resolving yellow. Resolving dampness, i.e. warming Yang for diuresis, clearing away heat and eliminating dampness, eliminating dampness with aromatics, removes dampness pathogen from the middle-Jiao; dispelling dampness,i.e. relaxing the bowels to eliminating dampness, removing stagnation to dispel dampness, eliminate dampness pathogen from stool. Clinically, different methods of eliminating dampness are respectively used for jaundice of different properties. For Yang jaundice, clearing away heat and eliminating dampness method is mainly used, and if it is necessary, relaxing the bowels is combined; Yin jaundice adopts mainly warming Yang for removing dampness, and its combination with nourishing Qi and blood, or soothing the liver and promoting flow of blood; acute jaundice belongs Yang jaundice, and it is caused by excessive heat pathogen, pathogen invading Ying-blood, so clearing away heat and toxic material, and removing heat from Ying and inducing resuscitation methods should adopted.

Ⅳ. Treatment based on classifications of jaundice

(Ⅰ)Yang jaundice

Yang jaundice has mainly three types, always with damp-heat.

1.    Heat and Dampness with external symtoms  

Jaundice at initial stage, white eye area change to yellow is not serious, urine yellow, chest is not comfortable, don’t want to eat, feeling cold, headache and body feels heavy tire.

Tongue and pulse: thin white fur tongue, taut and rapid pulse.

Analysis: At summer time, Body suffer heat, dampness and exterior wind symtoms.

Therapeutic principle: clearing away heat, dampness and exterion wind symtoms.

2.    Heat over dampness

Main symptoms: Yellow body and eyes, orange-like fresh yellow, with brightness, and scanty dark urine.

Accompanying symptoms: often fever and thirst, restlessness, fullness of abdomen, nausea and desire to vomit, dry mouth and bitter taste, constipation.

Tongue and pulse: yellowish and greasy fur on the tongue, taut and rapid pulse.

Analysis: Accumulation of damp-heat, bile flowing into the muscle and skin, heat is yang pathogen, so fresh yellow appears. Excess of damp-heat in the interior, over heat pathogen, heat consumes of body fluid, so fever and thirst occur. Damp-heat interfering the gallbladder, hypofunction of  Qi-transmission induces scaty dark urine. Excessive heat in Yangming causes constipation, and failure of the flow of Forgan-Qi results in distention and fullness of abdomen; accumulation of damp-heat, turbit of the stomach and bile adversely flow up,causing restlessness, nausea and desire to vomit, dry mouth and bitter taste. Yellowish  and greasy fur, and taut and rapid pulse are signs of excessive damp-heat of the liver, gallbladder, spleen and stomach in the interior.

Therapeutic principle: Clearing away heat and eliminating dampness.

3.    dampness over heat

Main symptoms: Yellow body and eyes, with no so bright yellow as that in more heat syndrome.

Accompanying symptoms: No high fever, heaviness of head, tastelessness with no thirst, fullness in the chest and the stomach, anoresia, distention in abdomen, aversion to greasy food, nausea and desire to vomit, loose stool.

Tongue and pulse: Thick, greasy and yellow fur on  the tongue, taut and slippery, or weak and slow pulse.

Analysis: Retention of dampness and heat, failure of bile to circulate in normal tract, flowing into muscle and skin and inducing yellow body and conjunctivas. Because of dampness over heat, and dampness is Yin pathogen, so the yellow is not so bright as that in more heat. No high fever occurs due to excessive dampness. Retention of damp-heat in interior, clear Yang can not be dispeled, so haviness of the head appears. Tastelessness with no thirst, fullness in the chest and stomach, anoresia, nausea and desire to vomit, distention in abdomen all are caused by retention of dampness in the spleen, and dysfunction of the spleen and stomach. Thick, greasy and yellow fur, and taut and slipery or weak and slow pulse are signs of more dampness syndrome with less heat syndrome.

Therapeutic principle: Eliminating dampness and turbit-transmission, clearing away heat as adjunctment method.

4.    Heat at gallbladder

Main symptoms: Bright yellowish color at body and eyes, painful at hypochondium and painful will like electricity to the back shoulder, feeling cold and hot, come and forth, bitter and thirsty, nausea and desire to vomit, yellow urine, no stool.

Tongue and pulse: Dry yellow fur on the tongue, taut and rapid pulse.

Therapentic principle: clearing the hot and dampness at the gallbladde and let the bile flowing smooth and at right way.

5.    Excessive noxius heat type(acute jaundice)

Main symptoms:Sudden and acute attack,jaundice rapidly becomes darkness,gold-like colour.

Accompanying symptoms:High fever and excessive thirst, hypochondrial pain and abdominal fullness, coma and delirium,or epistaxis, hemafecia,or ecchymosis on the skin, bright red tongue.

Tongue and pulse:Bright red tongue with yellowish and dry fur, taut, slippery and rapid or fine and rapid pulse.

Analysis: Damp-heat with noxious pathogen, excessive noxious heat, induce rapid attack; high fever and thirst, noxious heat inducing bile flowing into the muscle and skin, so jaundice rapidly becomes dark with yellow body and conjunctias, like gold colour. Excessive noxious heat in interior, disorder of activity of Qi induces hypochondrial pain and abdominal fullness; noxious heat causes failure of blood to circulate in blood vessels, so epistaxis and hemafecia appear ,or ecchymosis occurs on the skin. Bright red tongue, yellowish and dry fur,and taut slippery, rapid or fine, rapid pulse are signs of excessive noxious heat in the liver and gallbladder.

Therapeutic principle: Clearing away heat and toxic material, removing heat from blood and inducing resuscitation.    

(Ⅱ) Yin jaundice

1.    Retention of cold-damp pathogen

Main symptoms: Dark yellow, like smoking.

Accompanying symptoms: Mental tiredness and aversion to cold, anorexia and indigestion, fullness in the stomach, loose stool, tastelessness and no thirst.

Tongue and pulse: Pale tongue with and greasy fur, weak and slow or deep and rapid pulse.

Analysis: retention of cold-damp pathogen in the spleen and stomach, hypofunction of Yang-Q i, bile overflowing, and cold –dampness is Yin pathogen, so dark yellow skin appears like smoking; retention of dampness in the spleen, hypofunction of the spleen-Yang, disorder of transporting and transforming nutrients, lead to anorexia, fullness in the stomach, loose stool, tastelessness, no thirst and other symptoms. Insufficiency of Yang, deficiency of Qi and blood induce aversion to cold and mental tiredness. Pale tongue with greasy fur, weak and slow or deep and slow pulse are often signs of Yang-deficiency and unability to remove dampness, and retention of cold-dampness in Yin system.

Therapeutic principle: Strengthening the spleen and regulating the stomach, warming and removing cold-dampness.

2.    Retention of blood stasis

Main symptoms: Dark yellow body and eyes.

Accompanying symptoms: vascular spider in the skin, darkish complexion, mass in hypochondrium with fixed pain, black stool.

Tongue and pulse: green and purple tongue or with ecchymosis, taut and uneven or fine and uneven pulse.

Analysis: Retention of blood stasis, ckecking of the flow of bile result in yellow body and eyes; retention of blood stasis in interior, new blood can supply to the face, so dimmish and blackish complexion appears; retention of blood stasis in the hypochondium, ckecking of circulation of Qi and blood bring about mass in the hypochondium with pain. And vascular spider in the skin,dark stool and changes of tongue and pulse are signs of blood stasis.

Therapeutic principle: Activating circulation of blood, removing blood stasis and eliminating jaundice.

3.    Deficiency of the spleen and blood(Jandice of deficiency type)

Main symptoms: yellow eyes and skin, pale and dim complexion, dark urine, or obvious in night.

Accompanying symptoms: mental tiredness and weakness, lassitude in limbs, palpitation and shortness of breath, anorexia and loose stool, restlessness in night.

Tongue and pulse: Pale tongue with and fur, fine and weak pulse.

Analysis: Deficiency of the spleen and stomach, dysfunction of transporting and transforming nutrients, insufficiency of resource of Qi and blood, poor blood supplying to the face and the body, so appearence of yellow face and skin, pale and dim complexion, dark urine ,or being obvious in night. Insufficiency of the spleen-Qi induces mental tirdness and weakness, lassitude in limbs, shortness of breath and dislike to speak. Deficiency of blood is inable to nurish the heat, irritability induces palipitation and restlessness in night. Hypofunction of transport due to deficiency of the spleen, leading to anorexia and loose stool. Pale tongue with thin and white fur, and fine and weak pulse are signs of deficiency of the spleen and blood.

Therapeutic principle: strengthening the spleen and warming the middle-Jiao, supplementing and nourishing Qi and blood.

Appendix: Obstructive jaundice

Obstructive jaundice has some differences with jaundice, its main symptoms are no yellow in both eyes, light yellow in muscle and skin in whole body, dry skin with no gross, free urination with no yellow, tiredness and weakness, dizziness and tinnitus, palpitation and insomnia, loose stool, pale tongue with thin fur, weak and fine pulse.

In the disease, retention of worm and food induce deficiency of the spleen and stomach, failure of food in transforming nutrients to produce Qi and blood, and deficiency of Qi and blood can not nourish the skin and muscle, and viscera, leading to yellow muscle and skin with no gross. In addition, loss of blood, or after servere disease, exhaustion of Qi and blood induces insufficiency of Qi and blood, leading to attack of this disease, which is commonly-seen clinically.

For treatment of the disease, regulating the spleen and stomach, nourishing Qi and supplementing blood should mainly adopted, with Huang Qi Jian Zhong Decoction or Ren Shen Yin Yany Decoction selected. For the disease caused by hookworm, antiscolic therapy should be adopted.

Measures of Prevention and Nursing Care

1.      Pay attention to take rest, bed rest is a main when jaundice has not been eliminated.

2.      Proper diet, avoid fat, oil, greasy, sea food and purgent food, sea and fornbid drinking.

3.      For the patients with infectivity, should take isolation for prevention from transport to noxious pathogens.

4.      Keep optimistic and stable emotion, actively coorperate for treatment.

Jaundice is marked by yellow conjunctivas, body and urine. Yellow conjunctivas is a key for diagnosis of the disease. Its attack is always related with affection by exopathogens, improper diet, deficiency and cold of the spleen and stomach, blood stasis, obstruction of gallstones and worm in bibiary tract, and injury of internal organs, but it is mainly caused by dampness pathogen, most invading the liver, gallblader, spleen and stomach.

Clinically, should differentiate Yang jaundice and Yin jaundice, jaundice due to deficiency and obstructive jaundice. Both Yang jaundice and Yin jaundice are caused by dampness pathogen, and Yang jaundice belongs to excess syndrome heat syndrome, and Yin jaundice belongs to deficiency syndrome, cold syndom or deficiency syndrome accompanied by excess syndrome. The differences of Yang jaundice and Yin jaundice are not obsolute, they can transform each other. Both Jaundice due to deficiency and obstructive jaundice belong to deficiency syndrome, jaundice due to deficiency is marked by yellow conjunctiva, body and urine as main symptoms, and obstructive jaundice does not have yellow conjunctiva and urine, which can be used for their differentiation.

 Removing dampness from urine is an important therapeutic principle for treatment of jaundice. The drugs of clearing or warming, and expelling dampness from stool, and strengthening the spleen and nourishing blood, activating circulation of blood, etc. can be combined according to property of jaundice. The patient who at initial stage receives in time proper treatment, has favourable prognosis. In the patient with protracted disease, repeated attack, stagnation of Qi and blood stasis, mass in the hypocondrium, body resistance weakened while pathogenic factors prevailing, is difficult to be cured. Acute jaundice is a crisis of jaundice, it should actively receive emergince treatmeat. After elimination of jaundice, midication can not be suddenly stopped and should properly administer drugs of regulating the spleen and stomach according to differences of syndromes.

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