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Jaundice and Homoeopathy

What is jaundice?

Jaundice, also known as icterus (attributive adjective: "icteric"), is yellowish discoloration of the skin, sclerae(whites of the eyes) and mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood). This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluids. Typically, the concentration of bilirubin in the plasma must exceed 1.5mg/dL, three times the usual value of approximately 0.5mg/dL, for the coloration to be easily visible. Jaundice comes from the French word jaune, meaning yellow.

Jaundice is not a disease but rather a sign that can occur in many different diseases. Jaundice is the yellowish staining of the skin and sclerae (the whites of the eyes) that is caused by high levels in blood of the chemical bilirubin. The color of the skin and sclerae vary depending on the level of bilirubin. When the bilirubin level is mildly elevated, they are yellowish. When the bilirubin level is high, they tend to be brown.

Jaundice is a yellowy tinge to the skin and the whites of the eyes. It is caused by a build-up of the chemical bilirubin in the blood. Bilirubin is made when red-blood cells are broken down. The body is usually able to get rid of it easily unless there is something wrong with your liver or biliary system (this releases bile to help with digestion).

Neonatal jaundice often affects newborn babies during the first few weeks of life. This is because their livers take a while to get working properly. Jaundice in adults and older children is not related to neonatal jaundice; it is usually the sign of a health problem.

There are three types of jaundice in adults and older children: haemolytic jaundice, hepatocellular jaundice and obstructive jaundice. Hepatocellular jaundice is the most common. It is usually caused by a problem with the  liver.

What causes jaundice?

Bilirubin comes from red blood cells. When red blood cells get old, they are destroyed. Hemoglobin, the iron-containing chemical in red blood cells that carries oxygen, is released from the destroyed red blood cells after the iron it contains is removed. The chemical that remains in the blood after the iron is removed becomes bilirubin.

The liver has many functions. One of the liver's functions is to produce and secrete bile into the intestines to help digest dietary fat. Another is to remove toxic chemicals or waste products from the blood, and bilirubin is a waste product. The liver removes bilirubin from the blood. After the bilirubin has entered the liver cells, the cells conjugate (attaching other chemicals, primarily glucuronic acid) to the bilirubin, and then secrete the bilirubin/glucuronic acid complex into bile. The complex that is secreted in bile is called conjugated bilirubin. The conjugated bilirubin is eliminated in the feces. (Bilirubin is what gives feces its brown color.) Conjugated bilirubin is distinguished from the bilirubin that is released from the red blood cells and not yet removed from the blood which is termed unconjugated bilirubin.

Jaundice occurs when there is 1) too much bilirubin being produced for the liver to remove from the blood. (For example, patients with hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that releases large amounts of bilirubin into the blood), 2) a defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin/glucuronic acid (conjugated) or secreted in bile, or 3) blockage of the bile ducts that decreases the flow of bile and bilirubin from the liver into the intestines. (For example, the bile ducts can be blocked by cancers, gallstones, or inflammation of the bile ducts). The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice.

Causes

When a pathological process interferes with the normal functioning of the metabolism and excretion of bilirubin just described, jaundice may be the result. Jaundice is classified into three categories, depending on which part of the physiological mechanism the pathology affects. The three categories are:

Pre-hepatic: The pathology is occurring prior the liver

Hepatic: The pathology is located within the liver

Post-Hepatic: The pathology is located after the conjugation of bilirubin in the liver

Pre-hepatic

Pre-hepatic jaundice is caused by anything which causes an increased rate of hemolysis (breakdown of red blood cells). In tropical countries, malaria can cause jaundice in this manner. Certain genetic diseases, such as sickle cell anemia, spherocytosis and glucose 6-phosphate dehydrogenase deficiency can lead to increased red cell lysis and therefore hemolytic jaundice. Commonly, diseases of the kidney, such as hemolytic uremic syndrome, can also lead to coloration. Defects in bilirubin metabolism also present as jaundice. Jaundice usually comes with high fevers.

Laboratory findings include:

Urine: no bilirubin present, urobilirubin > 2 units (except in infants where gut flora has not developed).

Serum: increased unconjugated bilirubin.

Hepatic

Hepatic jaundice causes include acute  hepatitis, hepatotoxicity and alcoholic liver disease, whereby cell necrosis reduces the liver's ability to metabolise and excrete bilirubin leading to a buildup in the blood. Less common causes include primary biliary cirrhosis, Gilbert's syndrome (a genetic disorder of bilirubin metabolism which can result in mild jaundice, which is found in about 5% of the population), Crigler-Najjar syndrome and metastatic carcinoma. Jaundice seen in the newborn, known as neonatal jaundice, is common, occurring in almost every newborn as hepatic machinery for the conjugation and excretion of bilirubin does not fully mature until approximately two weeks of age.

Laboratory Findings include:

Urine: Conjugated bilirubin present, Urobilirubin > 2 units but variable (Except in children)

Post-hepatic

Post-hepatic jaundice, also called obstructive jaundice, is caused by an interruption to the drainage of bile in the biliary system. The most common causes are gallstones in the common bile duct, and pancreatic cancer in the head of the pancreas. Also, a group of parasites known as "liver flukes" live in the common bile duct, causing obstructive jaundice. Other causes include strictures of the common bile duct, biliary atresia, ductal carcinoma, pancreatitis and pancreatic pseudocysts. A rare cause of obstructive jaundice is Mirizzi's syndrome.

The presence of pale stools and dark urine suggests an obstructive or post-hepatic cause as normal feces get their color from bile pigments.

Patients also can present with elevated serum cholesterol, and often complain of severe itching or "pruritus".

Laboratory Results

Laboratory Tests

 

Pre-hepatic Jaundice

Hepatic Jaundice

Post-hepatic Jaundice

Total bilirubin

Normal / Increased

Increased

Increased

Conjugated bilirubin

Normal

Normal / Decreased

Increased

Unconjugated bilirubin

Increased

Normal / Increased

Normal

Urobilinogen

Increased

Normal / Increased

Decreased / Negative

Urine Colour

Normal

Dark

Dark

Stool colour

Normal

Normal

Pale

Symptoms

Jaundice makes your skin and the whites of your eyes turn a yellowy colour. This may look a bit like a suntan. In people with dark skin, jaundice can be noticed in the whites of the eyes.

Depending on what is causing your jaundice, you may have other symptoms such as tiredness, abdominal pain, weight loss, vomiting and fever.

If you have obstructive jaundice, you may be very itchy. Your urine will probably be darker than usual and your stools might be paler.

What problems does jaundice cause?

Jaundice or cholestasis, by themselves, causes few problems (except in the newborn, and jaundice in the newborn is different than most other types of jaundice, as discussed later.) Jaundice can turn the skin and sclerae yellow. In addition, stool can become light in color, even clay-colored because of the absence of bilirubin that normally gives stool its brown color. The urine may turn dark or brownish in color. This occurs when the bilirubin that is building up in the blood begins to be excreted from the body in the urine. Just as in feces, the bilirubin turns the urine brown.

Besides the cosmetic issues of looking yellow and having dark urine and light stools, the symptom that is associated most frequently associated with jaundice or cholestasis is itching, medically known as pruritus. The itching associated with jaundice and cholestasis can sometimes be so severe that it causes patients to scratch their skin “raw,” have trouble sleeping, and, rarely, even to commit suicide.

It is the disease causing the jaundice that causes most problems associated with jaundice. Specifically, if the jaundice is due to liver disease, the patient may have symptoms or signs of liver disease or cirrhosis. (Cirrhosis represents advanced liver disease.) The symptoms and signs of liver disease and cirrhosis include fatigue, swelling of the ankles, muscle wasting, ascites (fluid accumulation in the abdominal cavity), mental confusion or coma, and bleeding into the intestines.

If the jaundice is caused by blockage of the bile ducts, no bile enters the intestine. Bile is necessary for digesting fat in the intestine and releasing vitamins from within it so that the vitamins can be absorbed into the body. Therefore, blockage of the flow of bile can lead to deficiencies of certain vitamins. For example, there may be a deficiency of vitamin K that prevents proteins that are needed for normal clotting of blood to be made by the liver, and, as a result, uncontrolled bleeding may occur.

What diseases cause jaundice?

Increased production of bilirubin

There are several uncommon conditions that give rise to over-production of bilirubin. The bilirubin in the blood in these conditions usually is only mildly elevated, and the resultant jaundice usually is mild and difficult to detect. These conditions include: 1) rapid destruction of red blood cells (referred to as hemolysis), 2) a defect in the formation of red blood cells that leads to the over-production of hemoglobin in the bone marrow (called ineffective erythropoiesis), or 3) absorption of large amounts of hemoglobin when there has been much bleeding into tissues (e.g., from hematomas, collections of blood in the tissues).

Acute inflammation of the liver 

Any condition in which the liver becomes inflamed can reduce the ability of the liver to conjugate (attach glucuronic acid to) and secrete bilirubin. Common examples include acute viral hepatitis, alcoholic hepatitis, and Tylenol-induced liver toxicity.

Chronic liver diseases 

Chronic inflammation of the liver can lead to scarring and cirrhosis, and can ultimately result in jaundice. Common examples include chronic hepatitis B and C, alcoholic liver disease with cirrhosis, and autoimmune hepatitis.

Infiltrative diseases of the liver 

Infiltrative diseases of the liver refer to diseases in which the liver is filled with cells or substances that don't belong there. The most common example would be metastatic cancer to the liver, usually from cancers within the abdomen. Uncommon causes include a few diseases in which substances accumulate within the liver cells, for example, iron ( hemochromatosis), alpha-one antitrypsin (alpha-one antitrypsin deficiency), and copper (Wilson's disease).

Inflammation of the bile ducts

Diseases causing inflammation of the bile ducts, for example, primary biliary cirrhosis or sclerosing cholangitis and some drugs, can stop the flow of bile and elimination of bilirubin and lead to jaundice.

Blockage of the bile ducts

The most common causes of blockage of the bile ducts are gallstones and pancreatic cancer. Less common causes include cancers of the liver and bile ducts.

Drugs

Many drugs can cause jaundice and/or cholestasis. Some drugs can cause liver inflammation (hepatitis) similar to viral hepatitis. Other drugs can cause inflammation of the bile ducts, resulting in cholestasis and/or jaundice. Drugs also may interfere directly with the chemical processes within the cells of the liver and bile ducts that are responsible for the formation and secretion of bile to the intestine. As a result, the constituents of bile, including bilirubin, are retained in the body. The best example of a drug that causes this latter type of cholestasis and jaundice is estrogen. The primary treatment for jaundice caused by drugs is discontinuation of the drug. Almost always the bilirubin levels will return to normal within a few weeks, though in a few cases it may take several months.

Genetic disorders

There are several rare genetic disorders present from birth that give rise to jaundice. Crigler-Najjar syndrome is caused by a defect in the conjugation of bilirubin in the liver due to a reduction or absence of the enzyme responsible for conjugating the glucuronic acid to bilirubin. Dubin-Johnson and Rotor's syndromes are caused by abnormal secretion of bilirubin into bile.

The only common genetic disorder that may cause jaundice is Gilbert's syndrome which affects approximately 7% of the population. Gilbert's syndrome is caused by a mild reduction in the activity of the enzyme responsible for conjugating the glucuronic acid to bilirubin. The increase in bilirubin in the blood usually is mild and infrequently reaches levels that cause jaundice. Gilbert's syndrome is a benign condition that does not cause health problems.

Developmental abnormalities of bile ducts

There are rare instances in which the bile ducts do not develop normally and the flow of bile is interrupted. Jaundice frequently occurs. These diseases usually are present from birth though some of them may first be recognized in childhood or even adulthood. Cysts of the bile duct (choledochal cysts) are an example of such a developmental abnormality. Another example is Caroli's disease.

Jaundice of pregnancy

Most of the diseases discussed previously can affect women during pregnancy, but there are some additional causes of jaundice that are unique to pregnancy.

Cholestasis of pregnancy. Cholestasis of pregnancy is an uncommon condition that occurs in pregnant women during the third trimester. The cholestasis is often accompanied by itching but infrequently causes jaundice. The itching can be severe, but there is treatment (ursodeoxycholic acid or ursodiol). Pregnant women with cholestasis usually do well although they may be at greater risk for developing gallstones. More importantly, there appears to be an increased risk to the fetus for developmental abnormalities. Cholestasis of pregnancy is more common in certain groups, particularly in Scandinavia and Chile, and tends to occur with each additional pregnancy. There also is an association between cholestasis of pregnancy and cholestasis caused by oral estrogens, and it has been hypothesized that it is the increased estrogens during pregnancy that are responsible for the cholestasis of pregnancy.

Pre-eclampsia. Pre-eclampsia, previously called toxemia of pregnancy, is a disease that occurs during the second half of pregnancy and involves several systems within the body, including the liver. It may result in high blood pressure, fluid retention, and damage to the kidneys as well as anemia and reduced numbers of platelets due to destruction of red blood cells and platelets. It often causes problems for the fetus. Although the bilirubin level in the blood is elevated in pre-eclampsia, it usually is mildly elevated, and jaundice is uncommon. Treatment of pre-eclampsia usually involves delivery of the fetus as soon as possible if the fetus is mature.

Acute fatty liver of pregnancy. Acute fatty liver of pregnancy (AFLP) is a very serious complication of pregnancy of unclear cause that often is associated with pre-eclampsia. It occurs late in pregnancy and results in failure of the liver. It can almost always be reversed by immediate delivery of the fetus. There is an increased risk of infant death. Jaundice is common, but not always present in AFLP. Treatment usually involves delivery of the fetus as soon as possible.

Summary of Causes

The liver is a very important organ. One of its functions is to remove a yellowy chemical, called bilirubin from the body.

Bilirubin is found in bile and is made from the breakdown of red blood cells, which carry oxygen around the body. The body usually removes bilirubin from the bloodstream by passing it though the liver and to the kidneys for disposal. If there is too much bilirubin in the blood or the liver cannot get rid of it for some reason, this can lead to jaundice.

There are three types of jaundice:

Haemolytic jaundice - too much bilirubin is produced. This is usually caused by excessive breakdown of red blood cells. This can be due to a number of conditions such as anaemia or a problem with the metabolism (the way the body makes energy).

Hepatocellular jaundice - bilirubin cannot leave the liver cells and get into the bile to be removed by from the body by the kidneys. This type of jaundice is usually caused by liver failure, liver disease (cirrhosis), hepatitis (inflammation of the liver) or taking certain drugs. It may also be caused by a tumour in the liver, or a tumour elsewhere that has spread to the liver. People who have been drinking excess amounts of alcohol over a length of time can do serious damage to their iver.

Obstructive jaundice - there is an obstruction (blockage) in the bile duct and the bilirubin cannot leave the liver. This type of jaundice is usually caused by a gallstone, or a tumour or cyst in the bile duct or pancreas.

People with inherited conditions such as Gilbert's syndrome, Rotor's syndrome, Dubin-Johnson syndrome, or Crigler-Najjar syndrome are more likely to get jaundice.

What is neonatal jaundice (jaundice in newborn infants)?

Neonatal jaundice is jaundice that begins within the first few days after birth. (Jaundice that is present at the time of birth suggests a more serious cause of the jaundice.) In fact, bilirubin levels in the blood become elevated in almost all infants during the first few days following birth, and jaundice occurs in more than half. For all but a few infants, the elevation and jaundice represents a normal physiological phenomenon and does not cause problems. 

The cause of normal, physiological jaundice is well understood. During life in the uterus, the red blood cells of the fetus contain a type of hemoglobin that is different than the hemoglobin that is present after birth. When an infant is born, the infant's body begins to rapidly destroy the red blood cells containing the fetal-type hemoglobin and replaces them with red blood cells containing the adult-type hemoglobin. This floods the liver with bilirubin derived from the fetal hemoglobin from the destroyed red blood cells. The liver in a newborn infant is not mature, and its ability to process and eliminate bilirubin is limited. As a result of both the influx of large amounts of bilirubin and the immaturity of the liver, bilirubin accumulates in the blood. Within two or three weeks, the destruction of red blood cells ends, the liver matures, and the bilirubin levels return to normal. 

There is another uncommon syndrome associated with neonatal jaundice, referred to as breast-milk or breast feeding jaundice. In this syndrome, jaundice appears to be caused by or at least accentuated by breast feeding. Although the cause of this type of jaundice is unknown, it has been hypothesized that there is something in breast milk that reduces the ability of the liver to process and eliminate bilirubin. With breast-milk jaundice, the bilirubin levels rise and reach peak levels in approximately two weeks, remain elevated for a week or so, and then decline to normal over several weeks or months. This timing of the elevation in bilirubin and jaundice is different than normal physiological jaundice described previously and allows the two causes of jaundice to be differentiated. The real importance of the more prolonged jaundice associate with breast-milk jaundice is that it raises the possibility that there is a more serious cause for the jaundice that needs to be sought, for example, biliary atresia (destruction of the bile ducts). Breast-milk jaundice alone usually does not cause problems for the infant. 

Physiologic jaundice and breast-milk jaundice usually do not cause problems for the infant; however, there is a concern that high or prolonged elevations in levels of unconjugated bilirubin (the type of bilirubin that is not attached to glucuronic acid and the main type of bilirubin that is present in physiologic and breast-milk jaundice) will cause neurologic damage to the infant. Therefore, when unconjugated bilirubin levels are high or prolonged, treatment usually is started to lower the levels of bilirubin. Treatment may be started earlier in infants who are born prematurely since their livers take longer to mature, and the risk of higher and more prolonged elevations of bilirubin is greater. Treatment involves phototherapy with artificial or natural sunlight and, if phototherapy is not successful, exchange transfusion in which the infant's blood is exchanged for normal blood from blood donors. 

The benign nature of physiologic and breast-milk allergy need to be distinguished from hemolytic disease of the newborn, a much more serious, even life-threatening cause of jaundice in newborns that is due to blood group incompatibilities between mother and fetus, for example Rh incompatibility. The incompatibility results in an attack by the mother's antibodies on the babies red blood cells leading to hemolysis. Fortunately, because of modern management of pregnancy, this cause of jaundice is rare.

How is the cause of jaundice diagnosed?

Many tests are available for determining the cause of jaundice, but the history and physical examination are important as well.

History

The history can suggest possible reasons for the jaundice. For example, heavy use of alcohol suggests alcoholic liver disease, whereas use of illegal, injectable drugs suggests viral hepatitis. Recent initiation of a new drug suggests drug-induced jaundice. Episodes of abdominal pain associated with jaundice suggests blockage of the bile ducts usually by gallstones.

Physical examination

The most important part of the physical examination in a patient who is jaundiced is examination of the abdomen. Masses (tumors) in the abdomen suggest cancer infiltrating the liver (metastatic cancer) as the cause of the jaundice. An enlarged, firm liver suggests cirrhosis. A rock-hard, nodular liver suggests cancer within the liver.

Blood tests

Measurement of bilirubin can be helpful in determining the causes of jaundice. Markedly greater elevations of unconjugated bilirubin relative to elevations of conjugated bilirubin in the blood suggest hemolysis (destruction of red blood cells). Marked elevations of liver tests (aspartate amino transferase or AST and alanine amino transferase or ALT) suggest inflammation of the liver (such as viral hepatitis). Elevations of other liver tests, e.g., alkaline phosphatase, suggest diseases or obstruction of the bile ducts.

Ultrasonography

Ultrasonography is a simple, safe, and readily-available test that uses sound waves to examine the organs within the abdomen. Ultrasound examination of the abdomen may disclose gallstones, tumors in the liver or the pancreas, and dilated bile ducts due to obstruction (by gallstones or tumor).

Computerized tomography (CT or CAT scans)

Computerized tomography or CT scans are scans that use x-rays to examine the soft tissues of the abdomen. They are particularly good for identifying tumors in the liver and the pancreas and dilated bile ducts, though they are not as good as ultrasonography for identifying gallstones.

Magnetic resonance imaging (MRI)

Magnetic Resonance Imaging scans are scans that utilize magnetization of the body to examine the soft tissues of the abdomen. Like CT scans, they are good for identifying tumors and studying bile ducts. MRI scans can be modified to visualize the bile ducts better than CT scans (a procedure referred to as MR cholangiography), and, therefore, are better than CT for identifying the cause and location of bile duct obstruction.

Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound 

Endoscopic retrograde cholangiopancreatography (ERCP) provides the best means for examining the bile duct. For ERCP an endoscope is swallowed by the patient after he or she has been sedated. The endoscope is a flexible, fiberoptic tube approximately four feet in length with a light and camera on its tip. The tip of the endoscope is passed down the esophagus, through the stomach, and into the duodenum where the main bile duct enters the intestine. A thin tube then is passed through the endoscope and into the bile duct, and the duct is filled with x-ray contrast solution. An x-ray is taken that clearly demonstrates the contrast-filled bile ducts. ERCP is particularly good at demonstrating the cause and location of obstruction within the bile ducts. A major advantage of ERCP is that diagnostic and therapeutic procedures can be done at the same time as the x-rays. For example, if gallstones are found in the bile ducts, they can be removed. Stents can be placed in the bile ducts to relieve the obstruction caused by scarring or tumors. Biopsies of tumors can be obtained. 

Ultrasonography can be combined with ERCP by using a specialized endoscope capable of doing ultrasound scanning. Endoscopic ultrasound is excellent for diagnosing small gallstones in the gallbladder and bile ducts that can be missed by other diagnostic methods such as ultrasound, CT, and MRI. It also is the best means of examining the pancreas for tumors and can facilitate biopsy through the endoscope of tumors within the pancreas.

Liver biopsy

Biopsy of the liver provides a small piece of tissue from the liver for examination under the microscope. The biopsy most commonly is done with a long needle after local injection of the skin of the abdomen overlying the liver with anesthetic. The needle passes through the skin and into the liver, cutting off a small piece of liver tissue. When the needle is withdrawn, the piece of liver comes with it. Liver biopsy is particularly good for diagnosing inflammation of the liver and bile ducts, cirrhosis, cancer, and fatty liver.

Diagnosis

If your GP thinks you may have jaundice they will send you for some tests to confirm it, and see what's causing it.

A blood test will be done to see if your liver is working properly, if you have enough red blood cells, and if you have any infections.

If an obstruction is suspected, you may have a scan to look at the liver. You may also have a biopsy, which means a small sample of tissue from your liver is taken away to be examined. You will be given a local anaesthetic and the doctor will use a special needle to get the sample. You may have to stay in hospital overnight after your liver biopsy.

You might need to have a scan such as an ultrasound, MRI (magnetic resonance imaging) or CT (computerised tomography) to look at your liver or bile ducts

How is jaundice treated?

With the exception of the treatments for specific causes of jaundice mentioned previously, the treatment of jaundice usually requires a diagnosis of the specific cause of the jaundice and treatment directed at the specific cause, e.g., removal of a gallstone blocking the bile duct.

Treatment

Treatment of jaundice in adults and older children depends on what is causing it. Your doctor will carry out a number of tests (see diagnosis) to find out what is causing your jaundice. You will then be able to have the appropriate treatment. 

· If it is caused by anaemia you might have to start taking iron tablets.

· If it is caused by hepatitis you might need to start taking tablets, but not all types of hepatitis can be treated.

· If it is caused by taking particular drugs, your doctor might prescribe an alternative.

· If it is caused by an obstruction such as a gallstone or a tumour, you may need to have surgery. 

· If the liver is severely damaged, the damage cannot be reversed. If you stop drinking alcohol this will increase your chances of survival. You may be considered for a liver transplant if the damage is very severe.

Treatment

Management : Constipation should be avoided. If needed, enema should be given.
Patient should be kept on simple diet. Fish, meat, egg, ghee should be avoided.
Fruit juice including canejuice should be preferred.

Homeopathic Medicines :

According to symptoms, following medicines are indicated:

Bryonia alb 200 - If there is inflammation of liver and excessive thirst with dryness of mouth.

Cardus Mar 3x - If there is bitter taste in mouth, constipation, nausea and vomiting and the liver is tender.

Chelidonium 3x - If pain is felt in the liver along with the pain in the right shoulder.

China off 30 - If both liver and spleen are enlarged, there is gas in the stomach, erructation, and no desire to take meal.

Hydrastis 3x - If there is pain in the lever and the liver functionis week.

Bryonia. [Bry]

When there are stitching pains in the right hypochondriac region, Bryonia is the first remedy to be thought of, though for these pains we have other remedies, such as Chelidonium and Kali carbonicum. Under Bryonia the liver is swollen, congested and inflamed; the pains in the hypochondriac region are worse from any motion, and better from lying on the right side, which lessens the motion of the parts when breathing . It is one of the chief remedies for jaundice brought on by a fit of anger. Chamomilla has this symptom, but the Chamomilla patient gets hot and sweats, while the Bryonia patient is apt to be chilly, though he appears hot. There is a bitter in the mouth and the stools are hard and dry, or , if loose, papescent and profuse and associated with a colic. Berberis has stitching pains from the liver to the umbilicus. Chelidonium is distinguished by the character of the stools. Bryonia is pre-eminently a gastro-hepatic remedy, and has pain in right shoulder,giddiness, skin and eyes slightly yellow. Hughes says it hardly reaches true hepatitis.

Mercurius. [Merc]

This remedy has much sensitiveness and dull pain in the region of the liver; the patient cannot lie on the right side. The liver is enlarged. The skin and conjunctiva are jaundiced. The stools are either clay-colored from absence of bile, or yellowish-green bilious stools passed with a great deal of tenesmus. There is a yellowish white coated tongue which takes the imprint of the teeth and there is a foetid breath, loss of appetite and depression of spirits. Leptandra has aching and soreness in the region of the liver and is especially indicated in the lazy livers of city men; but is distinguished from Mercurius in the stools, which are pitchlike and black, accompanied with no tenesmus, but rather a griping and the pains of Leptandra are dull, aching and burning in the posterior part of the liver. The character of the diarrhoea will also distinguish Mercurius from Magnesia muriatica, which is useful in the enlarged livers of puny and rachitic children. Mercurius is the remedy for jaundice arising from abuse of quinine when fever is present. It is a splendid remedy for "torpid liver." It suits well simple jaundice in children. Cowperthwaite believes that, as a rule, Mercurius dulcis 2X is the most effective preparation of mercury in catarrhal jaundice.

Podophyllum. [Podo]

The principal use of Podophyllum is in liver affections. Primarily, it induces a large flow of bile, and, secondarily, great torpidity, followed by jaundice. It is indicated in torpid or chronically congested liver, when diarrhoea is present. The liver is swollen and sensitive, the face and eyes are yellow and there is a bad taste in the mouth. The tongue is coated white or yellow and the bile may form gall stones. There is a loose watery diarrhoea, or if constipation be present the stools are clay-called. It somewhat resembles Mercurius; it is sometimes called "vegetable mercury." There are a number of drugs having the symptom that the tongue takes the imprint of the teeth, namely; Mercurius, Podophyllum, Yucca, Stramonium, Rhus and Arsenic. Another symptom of Podophyllum is that the patient constantly rubs the region of the liver with the hand. Functional torpor of the portal system and the organs connected there with indicates Podophyllum. There is constipation, clay-colored stool, jaundice and langour.

Chelidonium. [Chel]

The liver symptoms of Chelidonium are very prominent. There is soreness and stitching pains in the region of the liver, but the keynote for this drug in hepatic diseases is a pain under the angle of the right shoulder blade, which may extend to the chest, stomach, or hypochondrium; there is swelling of the liver, chilliness, fever, jaundice, yellow coated tongue, bitter taste and a craving for acids and sour things, such as pickles and vinegar. The stools are profuse, bright yellow and diarrhoea; they may be clayey in color. It is remedy to be used in simple biliousness and jaundice, and in hepatic congestion or inflammation the character of the stools will distinguish Bryonia. Taken altogether, Chelidonium is perhaps our greatest liver remedy; it causes the liver to secrete thinner and more profuse bile than any remedy; it is a useful remedy to promote the expulsion of gall stones, and to prevent their formation. It was Rademacher's great remedy for gall stones, and Cowperthwaite finds it his best remedy. In simple catarrhal jaundice it is often all sufficient. It affects the left lobe of the liver much less than does Carduus marianus.

Digitalis. [Dig]

When jaundice arises from cardiac diseases, Digitalis may be the remedy. There is no retention of bile, nor obstruction of the ducts, but the jaundice is due to the fact that the liver does not take from the blood the elements which go to form bile. There is present drowsiness, bitter taste, soreness , enlargement and bruised feeling in the region of the liver. Sepia has the yellow sallow face with the yellow saddle across the nose, with stools of bright yellow or ashy color. Digitalis is useful in the worst forms of jaundice if the pulse be irregular and intermittent, and if there be rapid prostration of the strength.

Myrica cerifera. [Myric]

Myrica is an important liver remedy. There is first despondency and also jaundice due to imperfect formation of bile in the liver, and not to any obstruction, comparing here with Digitalis. There is dull headache, worse in the morning, the eyes have a dingy, dirty, yellowish hue, the tongue is coated yellow. The headache is worse in the morning. The patient is weak and complains of muscular soreness and aching in the limbs; there is slow pulse and dark urine. It is more superficial in action than Digitalis. The jaundice calling for its use is catarrhal and this is the form produced by the drug. The throat and nasal organs are filled with an offensive, tenacious mucus. Dull pain in right side below the ribs no appetite, and desire for acids; unrefreshing sleep.

Nux vomica. [Nux-v] 

In liver affections occurring in those who have indulged to excess in alcoholic liquors, highly seasoned food, quinine, or in those who have abused themselves with purgatives, Nux is the first remedy to be thought of. The liver is swollen hard and sensitive to the touch and pressure of clothing is uncomfortable. The first remedy in cirrhosis of the liver. Colic may be present. Jaundice induced by anger also calls for Nux, also jaundice from abuse of quinine, in the former cases reminding of Chamomilla , which is an excellent remedy for biliousness of nervous, irritable women. In the enlarged liver of drunkards, Sulphur, Lachesis, Fluoric acid, Arsenic and Ammonium muriaticum must also be borne in mind, together with Nux. Juglans cinerea causes a jaundice like Nux vomica, with stitching pains about the liver and under the right scapula, bilious stools and occipital headache. Nux must be compared with China, Pulsatilla in liver affections from over-eating. Iris seems to have a solvent action upon the bile, it is especially useful in torpid liver and when gastric disorders result from perversion of hepatic and intestinal functions. Jaundice and constipation. Aloes has biliousness from torpor of the portal system, distension of the liver, bitter taste and jaundice.

Lycopodium. [Lyc]

Lycopodium acts powerfully on the liver. The region of the liver is sensitive to the touch, and there is a feeling of tension in it, a feeling as if a cord were tied about the waist. Cirrhosis. The pains are dull and aching instead of sharp and lancinating, as under Chelidonium. Fulness in the stomach after eating a small quantity. There are no real icteric symptoms, but there is a peculiar sallow complexion. Natrum sulphuricum is useful when the patient has a bad, slimy taste in the mouth and "thinks he is bilious." There is apt to be weight and aching in the liver; he can lie on that side, but on turning to the left side the liver seems to pull and draw. Natrum sulphuricum is the greatest Schuessler specific for liver affections, and clinically it has often worked well. Dr. Alfred Pope claims that Lycopodium is more useful than any other remedy in old hepatic congestions. Pain in back and right side from congestion will often yield to the remedy.

Carduus marianus. [Card-m]

This remedy is indicated in jaundice with dull headache, bitter taste, white tongue with red edges, nausea and vomiting of a greenish fluid. There is an uncomfortable fullness in the region of the liver, the stools are bilious and the urine golden yellow; there is sensitiveness in the epigastrium and right hypochondrium. Burnett regards a dark brownish patch over the lower part of the sternum as a useful hint for Carduus, and in such cases he observes that both the liver and heart are at fault. The presence of "liver spots seems to be a special indication for the remedy. Biliousness following la grippe has been cured with Carduus. Hydrastis has a bitter taste and chronic torpor of the bowels, lack of appetite, coated tongue and yellow urine. Carduus resembles Aloes. Hale says that it stands between Aloes and Hamamelis in its action on the veins. It has been used in gall stone colic successfully in the tincture, and it deserves a trial before resorting to opiates.

Sulphur. [Sulph]

Sulphur is suitable to chronic affections of the liver; it increases the flow of bile and there is much pain and soreness in the liver. Sulphur often completes the cure commenced by Nux. Liver complaints from abuse of mercury will oftentimes call for Sulphur. If the stools are colorless and if much jaundice or ascites be present Sulphur is contra-indicated. Lachesis, however, has jaundice, as do all snake poisons, and is useful in the enlarged livers of drunkards, with tenderness on pressure and throbbing in the right side. Jaundice from sexual excesses call for Cinchona. Dr. Thayer, of Boston, recommended Cinchona in biliary calculi,and Dr. Williams,of Augusta, Me., has had success with Ipecac in this connection. Burnett claims that Hydrastis is the best remedy in gall-stone colic. Berberis vulgaris is also an important remedy in gall-stone affections.

Phosphorus. [Phos]

Phosphorus is homoeopathic to fatty degeneration of the liver, with well marked soreness and jaundice. The stools are grayish white. Cirrhosis and atrophy may also call for Phosphorus. The jaundice is indicative of organic diseases, and the remedy is a useful one in malignant diseases of the liver. Digitalis has also been recommended in acute yellow atrophy. Jaundice accompanying pneumonia may also call for Phosphorus.

Taraxacum [Tarax]

This is a decided liver remedy, and the indications are a mapped tongue and a bitter taste in the mouth, chilliness after eating, pain and soreness in the region of the liver and bilious diarrhoea. Kali bichromicum also has a mapped tongue. Yucca filamentosa has a pain going from the upper region of the liver to the back and a bad taste in the mouth. The stools are loose and bilious, accompanied with much flatus. The face is yellow and sallow and the tongue takes the imprint of the teeth. Another remedy used in bilious troubles is Euonymus; it has intense heavy, wearing, occipital headache, the stools are deficient in bile, and it is useful in cardiac disturbance from inaction of the liver. Euonymus 2X is an admirable remedy in hepatic congestion. Dr. Wm. E. Leonard says: " In the case of torpid livers with tendency to attacks of biliary colic, it anticipates and prevents the colic." Chionanthus has biliousness, sick headache, coated tongue, nausea and complete anorexia. It is remedy highly recommended for biliary calculi. Jaundice and hepatic pain are its indications. It overcomes catarrh, liquifies the bile, prevents the formation of calculi and promotes the discharge of those already formed. Sluggish circulation in the liver with the long train of symptoms resulting therefrom are indications. Ptelea has sharp pains in right hypochondria, distress in liver and constipation.

Commonly used homeopathic medicines for jaundice : Carduus marianus, Natrum sulph, Chelidonium, Bryonia, Chionathus, Cinchona, Lycopodium, Merc sol, Phosphorus.