黄胆之证，中说谓脾受湿热，西说谓胆汁滥行，究之二说原可沟通也。黄胆之载于方书者，原有内伤、
外感两种，试先以内伤者言之。内伤黄胆，身无热而发黄，其来以渐，先小便黄，继则眼黄，继则周身皆黄，
饮食减少，大便色白，恒多闭塞，乃脾土伤湿（不必有热）而累及胆与小肠也。盖人身之气化由中焦而升降，
脾土受湿，升降不能自如以敷布其气化，而肝胆之气化遂因之湮瘀（黄坤载谓肝胆之升降由于脾胃确有至理），
胆囊所藏之汁亦因之湮瘀而蓄极妄行，不注于小肠以化食，转溢于血中而周身发黄。是以仲景治内伤黄胆
之方，均是胆脾兼顾。试观《金匮》黄胆门，其小柴胡汤显为治少阳胆经之方无论矣。他如治谷疸之茵陈
蒿汤，治酒疸之栀子黄柏汤，一主以茵陈，一主以栀子，非注重清肝胆之热，俾肝胆消其炎肿而胆汁得由正
路以入于小肠乎？至于硝石矾石方，为治女劳疸之的方，实可为治内伤黄胆之总方。其方硝石（俗名火硝
亦名焰硝）矾石等分为散，大麦粥汁和服方寸匕（约重一钱），日三服，病随大小便去。小便正黄色，大便正
黑色是也。特是方中矾石，释者皆以白矾当之，不无遗议。考《神农本草经》矾石一名羽涅，《尔雅》又名涅
石。徐氏说文释涅字，谓黑土在水中，当系染黑之色。矾石既名为涅石，亦当为染黑色所需之物，岂非今之
皂矾乎？是知皂矾、白矾，古人皆名为矾石。而愚临症体验以来，知以治黄胆，白矾之功效，诚不如皂矾。
盖黄胆之证，中法谓由脾中蕴蓄湿热，西法谓由胆汁溢于血中。皂矾退热燥湿之力，不让白矾，故能去脾中
湿热。而其色绿且青（亦名绿矾又名青矾），能兼入胆经，借其酸收之味，以敛胆汁之妄行。且此物化学家
原可用硫酸水化铁而成。是知矿中所产之皂矾，亦必多含铁质。尤可借金铁之余气，以镇肝胆之本也。硝石性
寒，能解脏腑之实热，味咸入血分，又善解血分之热。且其性善消，遇火即燃，又多含养气。人身之血，得
养气则赤。又借硝石之消力，以消融血中之渣滓，则血之因胆汁而色变者，不难复于正矣。矧此证大便难者
甚多，得硝石以软坚开结，湿热可从大便而解。而其咸寒之性，善清水腑之热，即兼能使湿热自小便解也。至
用大麦粥送服者，取其补助脾胃之土以胜湿，而其甘平之性，兼能缓硝矾之猛峻，犹白虎汤中之用粳米也。
按∶原方矾石下注有烧字，盖以矾石酸味太烈，制为枯矾则
稍和缓。而愚实验以来，知径用生者，其效更速。临证者，相其身体强弱，斟酌适宜可也。
或曰∶硝石、朴硝性原相近，仲景他方皆用朴硝，何此方独用硝石？答曰∶朴硝味咸，硝石则咸而兼辛，
辛者金之味也。就此一方观之，矾石既含有铁质，硝石又具有金味，既善理脾中之湿热，又善制胆汁之妄行，
中、西医学之理，皆包括于一方之中，所以为医中之圣也。且朴硝降下之力多，硝石消融之力多（理详砂淋丸
下）。胆汁之溢于血中者，布满周身难尽降下，实深赖硝石之善消融也。又朴硝为水之精华结聚，其咸寒之
性，似与脾湿者不宜。硝石遇火则燃，兼得水中真阳之气。其味之咸不若朴硝，且兼有辛味。
似能散湿气之郁结，而不致助脾湿也。
特是《金匮》治内伤黄胆，虽各有主方，而愚临证经验以来，知治女劳疸之硝石矾石散不但治女劳疸
甚效，即用以治各种内伤黄胆，亦皆可随手奏效。惟用其方时，宜随证制宜而善为变通耳。
按∶硝石矾石散原方，用硝石、矾石等分为散，每服方寸匕（约重一钱），大麦粥送下。其用大
麦粥者，所以调和二石之性，使之与胃相宜也。至愚用此方时，为散药难服，恒用炒熟大麦面，或
小麦面亦可，与二石之末等分，和水为丸，如五味子大，每服二钱，随证择药之相宜者，数味煎汤送下（
因药中已有麦面为丸，不必再送以大麦粥）。其有实热者，可用茵陈、栀子煎汤送服。有食积者，可用生鸡
内金、山楂煎汤送服。大便结者，可用大黄、麻仁煎汤送服。小便闭者，可用滑石、生杭芍煎汤送服。恶
心呕吐者，可用赭石、青黛煎汤送服。左脉沉而无力者，可用生黄 、生姜煎汤送服。右脉沉而无力者，可用
白术、陈皮煎汤送服。其左右之脉沉迟而弦，且心中觉凉，色黄黯者，附子、干姜皆可加入汤药之中。脉浮有
外感者，可先用甘草煎汤送服西药阿斯匹林一瓦，出汗后再用甘草汤送服丸药。又凡服此丸药而
嫌其味劣者，皆可于所服汤药中加甘草数钱以调之。
又黄胆之证，西人谓恒有胆石阻塞胆囊之口，若尿道之有淋石也。硝石、矾石并用，则胆石可消。又西
人谓小肠中有钩虫亦可令人成黄胆。硝石、矾石并用，则钩虫可除。此所以用此统治
内伤黄胆，但变通其送服之汤药，皆可随手奏效也。
至外感黄胆，约皆身有大热。乃寒温之热，传入阳明之府，其热旁铄，累及胆脾，或脾中素有积湿，热
入于脾与湿合，其湿热蕴而生黄，外透肌肤而成疸；或胆中所寄之相火素炽，热入于胆与火并，其胆管因热
肿闭，胆汁旁溢混于血中，亦外现成疸。是以仲景治外感黄胆有三方，皆载于《伤寒论》阳明篇，一为茵陈
蒿汤，二为栀子柏皮汤，三为麻黄连翘赤小豆汤，皆胆脾并治也。且统观仲景治内伤、外感黄胆之方，皆
以茵陈蒿为首方。诚以茵陈蒿性凉色青，能入肝胆，既善泻肝胆之热，又善达肝胆之
郁，为理肝胆最要之品，即为治黄胆最要之品。
至愚生平治外感黄胆，亦即遵用《伤寒论》三方。而于其热甚者，恒于方中加龙胆草数钱。又用麻黄连
翘赤小豆汤时，恒加滑石数钱。恐连翘利水之力不足，故加滑石以助之。若其证为白虎汤或白虎加人参汤
证及三承气汤证，而身黄者，又恒于白虎承气中，加茵陈蒿数钱。其间有但用外感诸方不效者，亦可用外感
诸方煎汤，送服硝石矾石散。
黄胆之证又有先受外感未即病，迨酿成内伤而后发现者。岁在乙丑，客居沧州，自仲秋至孟冬一方多有
黄胆证。其人身无大热，心中满闷，时或觉热，见饮食则恶心，强食之恒作呕吐，或食后不能下行，剧者
至成结证，又间有腹中觉凉，食后饮食不能消化者。愚共治六十余人，皆随手奏效。其脉左似有热，右多郁
象，盖其肝胆热而脾胃凉也。原因为本年季夏阴雨连旬，空气之中所含水分过度，人处其中，脏腑为
湿所伤。肝胆属木，禀少阳之性，湿郁久则生热，脾胃属土，禀太阴之性，湿郁久则生寒，此
自然之理也。为木因湿郁而生热，则胆囊之口肿胀，不能输其汁于小肠以化食，转溢于血分，色透肌表而
发黄。为土因湿郁而生寒，故脾胃火衰，不能熟腐水谷，运转下行，是以恒作胀满，或成结证。为疏方用
茵陈、栀子、连翘各三钱，泻肝胆之热，即以消胆囊之肿胀；浓朴、陈皮、生麦芽各二钱，生姜五钱开脾胃之
郁，即以祛脾胃之寒；茯苓片、生薏米、赤小豆、甘草各三钱，泻脏腑之湿，更能培土以胜湿，且重用甘草
即以矫茵陈蒿之劣味也（此证闻茵陈之味多恶心呕吐故用甘草调之）。服一剂后，心中不觉热者，去栀子，
加生杭芍三钱，再服一剂。若仍不能食者，用干姜二钱以代生姜。若心中不觉热转觉凉者，初服即不用栀子，
以干姜代生姜。凉甚者，干姜可用至五六钱。呕吐者，加赭石六钱或至一两。服后吐仍不止者，可先用开水
送服赭石细末四五钱，再服汤药。胃脘肠中结而不通者，用汤药送服牵牛（炒熟）为末三钱，通利后即减
去。如此服至能进饮食，即可停药。黄色未退，自能徐消。此等
黄胆，乃先有外感内伏，酿成内伤，当于《伤寒论》、《金匮》所载之黄胆以外另为一种矣。
或问∶医学具有科学性质，原贵证实，即议论之间，亦贵确有实据。仲景治黄胆虽云胆脾并治，不过
即其所用之药揣摩而得。然尝考之《伤寒论》，谓“伤寒脉浮而缓，手足自温，是为系在太阴，太阴者，身
当发黄。”是但言发黄证由于脾也。又尝考之《金匮》，谓“寸口脉浮而缓，浮则为风，缓则为痹，痹非
中风，四肢苦烦，脾色必黄，瘀热以行”，是《金匮》论黄胆亦责重脾也。夫古人立言原多浑括，后世注
疏宜为详解。当西医未来之先，吾中华方书之祖述仲景者，亦有显然谓黄胆病由于胆汁溢于血中者乎？答曰∶有
之。明季喻嘉言着《寓意草》，其论钱小鲁嗜酒成病，谓胆之热汁满而溢于外，以渐渗于经络，则身目俱
黄，为酒疸之病云云。岂非显然与西说相同乎？夫西人对于此证
必剖验而后知，喻氏则未经剖验而已知。非喻氏之智远出西人之上，诚以喻氏最深于《金匮》、《伤寒论》，
因熟读仲景之书，观其方中所用之药而有所会心也。由斯观之，愚谓仲景治黄胆原胆脾并治者，固非无稽之谈也。
附录∶
徐××云∶《金匮》硝石矾石散方，原治内伤黄胆，张锡纯氏之发明功效卓然大着。至矾石即皂矾，
张石顽亦曾于《本经达源》论及，而先生则引《神农本草经》兼名涅石、《尔雅》又名羽涅，即一涅字，知
其当为皂矾，又即其服药后大便正黑色，愈知其当为皂矾，可谓具有特识。又于临证之时，见其左脉细弱者，
知系肝阳不能条畅，则用黄 、当归、桂枝尖诸药煎汤送服；若见其右脉濡弱者，知系脾胃不能健运，则用白
术、陈皮、薏米诸药煎汤送服，不拘拘送以大麦粥，此诚善用古方，更能通变化裁者也。友人史××，治一
妇人病黄病五六年，肌肤面目俱黄，癸亥秋感受客邪，寒热往来，周身浮肿。史××与柴胡桂枝汤和
解之，二剂肿消，寒热不作。遂配硝石矾石散一剂，俾用大麦粥和服。数日后复来云∶此药入腹似难容受，
得无有他虑否？史××令放胆服之∶“倘有差错，吾愿领咎。”又服两剂其黄尽失。史××欣然述之于予。
予曰∶“仲圣之方固属神矣，苟非张先生之审定而阐发之，则亦沉潜汨没，黯淡无光耳。”噫！古人创方固
难，而今人用方亦岂易易哉！
黄疸这一病证，中医经典认为由脾受湿热所致，西医理论认为是胆汁异常运行。究其本质，这两种说法原本是可以相互贯通的。黄疸在医方书籍中记载，原有内伤、外感两种类型，现在先以内伤型黄疸来论述。内伤黄疸，身体没有发热且出现发黄，病情发展缓慢，起初小便变黄，接着眼睛发黄，随后全身都发黄，饮食减少，大便颜色发白，常常多现闭塞不通，这是脾土被湿邪所伤（不一定伴有热邪）进而累及胆和小肠的缘故。大概人体的气化功能由中焦升降出入，脾土受湿邪困扰，升降功能不能自如地布散气化，导致肝胆的气化随之郁滞（黄坤载认为肝胆的升降取决于脾胃，确有至理），胆囊所贮藏的胆汁也因此郁滞蓄积至极而妄行，不注入小肠以消化食物，反而溢出到血液中导致全身发黄。因此张仲景治疗内伤黄疸的方剂，都是胆脾兼顾的。试看《金匮要略》黄疸篇，小柴胡汤显然是治疗少阳胆经的方剂，这就不用说了。其他如治疗谷疸的茵陈蒿汤，治疗酒疸的栀子柏皮汤，一个主药是茵陈，一个主药是栀子，这不是注重清泻肝胆的热邪，使肝胆消除炎症肿胀，从而使胆汁能由正道进入小肠吗？至于硝石矾石方，是治疗女劳疸的确切方剂，实际上可以作为治疗内伤黄疸的总方。这个方子将硝石（俗称火硝，也叫焰硝）和矾石等分研成散剂，用大麦粥汁调和服用一方寸匕（约重一钱），每天服三次，病邪随大小便排出。小便变成正黄色，大便变成正黑色，就是排病之象。只是方中的矾石，注释者都用白矾来对应，不免有遗漏和争议。考证《神农本草经》，矾石一名羽涅，《尔雅》又名涅石。徐氏在《说文解字》中解释“涅”字，说是黑土在水中，应当是染黑色的物质。矾石既然名叫涅石，也应当是染黑色所需之物，难道不是现在的皂矾吗？由此可知皂矾、白矾，古人都称为矾石。而我临症体验以来，知道治疗黄疸，白矾的功效确实不如皂矾。大概黄疸的病证，中医方法认为由脾中蕴蓄湿热引起，西医方法认为由胆汁溢于血中引起。皂矾退热燥湿的力量，不亚于白矾，所以能去除脾中的湿热。而且它的颜色绿且青（也叫绿矾，也叫青矾），能兼入胆经，借助它酸收的味道，来收敛胆汁的妄行。况且此物化学家原本可以用硫酸水化铁制成。由此可知矿中所产的皂矾，也必然多含铁质。尤其可以借用铁气的余气，来镇摄肝胆的本元。硝石性寒，能解除脏腑的实热，味咸入血分，又善于解除血分的热邪。而且它的性质善于消散，遇火即燃烧，又多含氧气。人身体的血液，得到氧气则呈红色。又借助硝石的消解力量，来消融血液中的渣滓，那么因胆汁而变色的血液，不难恢复常态了。何况这种病证大便困难的很多，得到硝石来软坚散结，湿热可以从大便而解。而且它咸寒的性质，善于清除六腑的热邪，同时也能使湿热从小便解出。至于用大麦粥送服，是取它补助脾胃的土气以胜湿，而且它甘平的性质，又能缓和硝石、矾石的猛烈峻烈，就像白虎汤中使用粳米一样。
按语：原方矾石下注有“烧”字，大概是因为矾石酸味太烈，制成枯矾则稍微和缓。而我实验以来，知道直接用生矾石，疗效更快。临证时，根据患者身体的强弱，斟酌适宜即可。
有人问：硝石、朴硝性质原本相近，张仲景其他方剂都用朴硝，为什么这个方子独用硝石？回答说：朴硝味咸，硝石则咸而兼辛，辛是金的味道。就这一个方子来看，矾石既含有铁质，硝石又具有金味，既善于调理脾中的湿热，又善于制约胆汁的妄行，中医、西医的理论，都包含在一个方子之中，所以被称为医中之圣。而且朴硝降下的力量多，硝石消融的力量多（道理详见砂淋丸下方）。胆汁溢于血中的情况，布满周身难以全部降下，实在深深依赖硝石善于消融的特性。另外朴硝是水的精华结聚而成，它的咸寒性质，似乎不适合脾湿的患者。硝石遇火则燃烧，兼得水中真阳之气。它的味道咸不如朴硝，而且兼有辛味。似乎能疏散湿气的郁结，而不会助长脾湿。
只是《金匮要略》治疗内伤黄疸，虽然各有主方，但我临症经验以来，知道治疗女劳疸的硝石矾石散不但治疗女劳疸很有效，即使用来治疗各种内伤黄疸，也都可以随手奏效。只是在用这个方子时，应该随证制宜并善于变通罢了。
按语：硝石矾石散原方，用硝石、矾石等分研成散剂，每次服用一方寸匕（约重一钱），用大麦粥送下。使用大麦粥的原因，是为了调和两石药性，使之与胃相适宜。至于我使用此方时，因为散药难服，常用炒熟的大麦面，或者小麦面也可以，与两石药末等分，加水做成丸药，如五味子大小，每次服用二钱，根据证候选择适宜的药材，几味煎汤送服（因为药丸中已有麦面，不必再送大麦粥）。其中有实热的，可用茵陈、栀子煎汤送服。有食积的，可用生鸡内金、山楂煎汤送服。大便结滞的，可用大黄、麻仁煎汤送服。小便闭阻的，可用滑石、生杭芍煎汤送服。恶心呕吐的，可用赭石、青黛煎汤送服。左脉沉而无力的，可用生黄芪、生姜煎汤送服。右脉沉而无力的，可用白术、陈皮煎汤送服。左右脉沉迟而弦，且心中觉得凉，面色黄暗的，附子、干姜都可以加入汤药中。脉浮有外感的，可先用甘草煎汤送服西药阿斯匹林一瓦，出汗后再用甘草汤送服丸药。另外凡是服用此丸药嫌味道不好的，都可以在所服的汤药中加入甘草数钱来调和。
还有黄疸的病证，西方人认为常有胆石阻塞胆囊之口，就像尿道有结石一样。硝石、矾石并用，则胆石可消。又西方人认为小肠中有钩虫也可令人患黄疸。硝石、矾石并用，则钩虫可除。这就是用此方统治内伤黄疸，只要变通其送服的汤药，都可以随手奏效的原因。
至于外感黄疸，大约都有身体大热。这是寒温之热邪，传入阳明之腑，热邪旁侧灼烁，累及胆脾，或者脾中素有积湿，热邪入脾与湿结合，湿热蕴结而生黄，外透肌肤而成疸；或者胆中所寄的相火素来炽盛，热邪入胆与火合并，胆管因热肿胀闭塞，胆汁旁溢混于血中，也外现成疸。因此张仲景治疗外感黄疸有三方，都记载于《伤寒论》阳明篇，一是茵陈蒿汤，二是栀子柏皮汤，三是麻黄连翘赤小豆汤，都是胆脾并治。而且纵观张仲景治疗内伤、外感黄疸的方剂，都以茵陈蒿为首选方剂。确实因为茵陈蒿性凉色青，能入肝胆，既善于泻肝胆之热，又善于通达肝胆之郁，是调理肝胆最重要的药物，也就是治疗黄疸最重要的药物。
至于我生平治疗外感黄疸，也是遵照使用《伤寒论》三方。而对于热势严重的，常在方中加入龙胆草数钱。另外使用麻黄连翘赤小豆汤时，常加滑石数钱。恐怕连翘利水的力量不足，所以加滑石来辅助它。如果证候属于白虎汤或白虎加人参汤证及三承气汤证，而出现身黄的，又常在白虎汤、承气汤中加入茵陈蒿数钱。其间有用外感诸方不生效的，也可以用外感诸方煎汤，送服硝石矾石散。
黄疸的病证又有先受外感未立即发病，等到酿成内伤而后发作的。乙丑年，客居沧州，从仲秋到孟冬，一方多有黄疸证。这些人身体没有大热，心中满闷，有时觉得热，见到饮食就恶心，勉强吃往往作呕吐，或者食后不能下行，严重甚至结成痞块，间或有腹中觉得凉，食后饮食不能消化的。我共治疗六十多人，都随手奏效。他们的脉象左似有热，右多郁象，大概是肝胆热而脾胃凉。原因是本年季夏阴雨连绵旬日，空气中所含水分过度，人处于其中，脏腑为湿所伤。肝胆属木，禀赋少阳之性，湿郁久则生热；脾胃属土，禀赋太阴之性，湿郁久则生寒，这是自然之理。因为木因湿郁而生热，则胆囊之口肿胀，不能输泄胆汁于小肠以消化食物，反而溢于血分，色泽透肌表而发黄。因为土因湿郁而生寒，故脾胃火衰，不能熟腐水谷，运转下行，所以常常胀满，或者结成痞块。为此开方用茵陈、栀子、连翘各三钱，泻肝胆之热，即以消除胆囊之肿胀；浓朴、陈皮、生麦芽各二钱，生姜五钱开通脾胃之郁，即以祛除脾胃之寒；茯苓片、生薏米、赤小豆、甘草各三钱，泻脏腑之湿，更能培土以胜湿，且重用甘草即以矫正茵陈蒿的劣味（此证闻到茵陈的气味多恶心呕吐，故用甘草调和）。服用一剂后，心中不觉热的，去掉栀子，加生杭芍三钱，再服一剂。如果仍不能进食的，用干姜二钱代替生姜。如果心中不觉热转觉凉的，初服即不用栀子，以干姜代生姜。凉得很厉害的，干姜可用至五六钱。呕吐的，加赭石六钱或至一两。服后吐仍不止的，可先用开水送服赭石细末四五钱，再服汤药。胃脘肠中结而不通的，用汤药送服牵牛（炒熟）为末三钱，通利后即减去。如此服用直到能进饮食，即可停药。黄色未退，自然会慢慢消退。这类黄疸，乃是先有外感内伏，酿成内伤，应当在《伤寒论》、《金匮要略》所载的黄疸之外另列为一种了。
有人问：医学具有科学性质，原本贵在证实，即使在议论之间，也贵在确有实据。张仲景治疗黄疸虽说胆脾并治，不过是根据他所用的药物揣摩得出的。然而我曾考证《伤寒论》，说“伤寒脉浮而缓，手足自温，是为系在太阴，太阴者，身当发黄。”这是只说发黄证由于脾。又曾考证《金匮要略》，说“寸口脉浮而缓，浮则为风，缓则为痹，痹非中风，四肢苦烦，脾色必黄，瘀热以行”，这是《金匮要略》论黄疸也重视脾。古人立言原本多浑括，后世注疏应当详解。当西医尚未到来之前，我们中华方书之祖述张仲景的，也有明显说黄疸病由于胆汁溢于血中的吗？回答说：有的。明代末年喻嘉言著《寓意草》，他论述钱小鲁嗜酒成病，说胆的热汁满而溢于外，逐渐渗入经络，则身目俱黄，为酒疸的病等等。这难道不是显然与西医说法相同吗？西方人对于此证必须剖验后才知晓，喻氏则未经剖验而已知晓。并非喻氏的智慧远出西方人之上，实在是因为喻氏深通《金匮要略》、《伤寒论》，因熟读张仲景之书，观察其方中所用的药物而有所领悟。由此看来，我认为张仲景治疗黄疸原为胆脾并治，固然不是无稽之谈。
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徐××说：《金匮要略》硝石矾石散方，原治内伤黄疸，张锡纯先生的发明功效卓著。至于矾石即皂矾，张石顽也曾于《本经达源》论及，而先生则引《神农本草经》兼名涅石、《尔雅》又名羽涅，即一个“涅”字，知道它应当是皂矾，又根据服药后大便正黑色，更加知道它应当是皂矾，可谓具有特识。又在临证之时，见其左脉细弱的，知道是肝阳不能条畅，则用黄芪、当归、桂枝尖诸药煎汤送服；若见其右脉濡弱的，知道是脾胃不能健运，则用白术、陈皮、薏米诸药煎汤送服，不拘泥于送以大麦粥，这确实是善用古方，更能通变化裁的人。友人史××，治疗一位妇人患黄疸病五六年，肌肤面目俱黄，癸亥秋感受客邪，寒热往来，周身浮肿。史××给予柴胡桂枝汤和解，二剂肿消，寒热不作。于是配制硝石矾石散一剂，让用大麦粥和服。数日后复来说：此药入腹似难容受，莫非有其他顾虑吗？史××令放胆服用：“倘有差错，我愿领咎。”又服两剂其黄尽失。史××欣然讲述给我听。我说：“仲景之方固属神妙，如果不是张先生审定而阐发它，则也会沉潜埋没，黯淡无光啊。”唉！古人创方固然难，而今人用方又岂是容易的呢！
The syndrome of jaundice, according to traditional Chinese medicine classics, is caused by damp-heat affecting the spleen; Western medicine attributes it to the abnormal circulation of bile. Ultimately, these two theories can be mutually integrated. Jaundice recorded in medical formularies originally falls into two categories: internal injury and external contraction. Let us first discuss the internal injury type. In internal injury jaundice, the body has no fever but presents with yellowing. The onset is gradual: initially the urine turns yellow, followed by yellowing of the eyes, and subsequently the entire body becomes yellow. There is a decrease in appetite, the stool color becomes white, and constipation is common. This occurs because the spleen earth is injured by dampness (not necessarily accompanied by heat), which then affects the gallbladder and small intestine. Generally, the qi transformation of the human body ascends and descends through the middle jiao. When spleen earth is affected by dampness, its ascending and descending functions cannot freely distribute qi transformation, causing the qi transformation of the liver and gallbladder to become stagnant (Huang Kunzai correctly stated that the ascent and descent of liver and gallbladder depend on the spleen and stomach). The bile stored in the gallbladder thus stagnates and accumulates excessively, leading to erratic movement. Instead of entering the small intestine to aid digestion, it overflows into the blood, causing whole-body yellowing. Therefore, Zhang Zhongjing's formulas for treating internal injury jaundice always address both the gallbladder and the spleen. Observing the Jaundice chapter in *Jin Gui Yao Lue*, Xiao Chai Hu Tang is clearly a formula for treating the Shaoyang gallbladder meridian, which needs no further explanation. Other examples include Yin Chen Hao Tang for grain jaundice and Zhi Zi Bai Pi Tang for wine jaundice. One uses Yin Chen as the chief herb, the other Zhi Zi. Is this not emphasizing the clearing of liver and gallbladder heat, so that inflammation subsides and bile can enter the small intestine via the correct pathway? As for Xiao Shi Fan Shi Fang, it is the specific formula for female labor jaundice and can essentially serve as a general formula for all internal injury jaundices. This formula mixes Xiao Shi (commonly known as fire saltpeter or flame saltpeter) and Fan Shi in equal parts into a powder. Take one fang cun bi (approximately 3 grams) mixed with barley porridge juice, three times daily. The pathogen exits via stool and urine. Normal yellow urine and black stool indicate the expulsion of disease. However, commentators usually identify Fan Shi as Bai Fan (white alum), which may be an oversight. Consulting *Shennong Ben Cao Jing*, Fan Shi is also called Yu Nie. *Erya* calls it Nie Shi. Xu Shen's *Shuo Wen Jie Zi* explains "Nie" as black soil in water, implying a substance used for dyeing black. Since Fan Shi is named Nie Shi, it should be a material for black dyeing—is it not today's Zao Fan (green vitriol)? Thus, ancients referred to both Zao Fan and Bai Fan as Fan Shi. My clinical experience confirms that for treating jaundice, Bai Fan is indeed less effective than Zao Fan. TCM theory posits jaundice arises from damp-heat accumulating in the spleen; Western medicine attributes it to bile overflowing into the blood. Zao Fan's ability to clear heat and dry dampness rivals Bai Fan, allowing it to remove spleen damp-heat. Moreover, its green-blue color (also called Lv Fan or Qing Fan) allows it to enter the gallbladder meridian. Its sour and astringent flavor helps restrain the erratic flow of bile. Chemically, Zao Fan can be produced using sulfuric acid and iron, suggesting mineral-derived Zao Fan contains significant iron. This iron qi can help anchor the root of the liver and gallbladder. Xiao Shi is cold in nature, clearing excess heat in organs, salty entering the blood level, and effectively clearing blood heat. It also has dissolving properties, igniting upon contact with fire, and contains oxygen. Blood requires oxygen to remain red. Using Xiao Shi's dissolving power helps eliminate debris in the blood, restoring normal blood color affected by bile. Furthermore, since many such patients suffer from difficult defecation, Xiao Shi softens hardness and resolves accumulation, allowing damp-heat to exit via stool. Its salty-cold nature clears heat in the six fu organs and facilitates damp-heat elimination via urine. Barley porridge is used for administration to tonify spleen-earth to overcome dampness. Its sweet and neutral nature moderates the harshness of Xiao Shi and Fan Shi, similar to the use of Jing Mi (rice grain) in Bai Hu Tang.
Note: The original formula notes "calcined" for Fan Shi, likely because raw Fan Shi is too acidic/astringent, and calcining it makes it milder. However, my experiments show raw Fan Shi acts faster. Clinicians should adjust based on patient strength.
Question: Xiao Shi and Pu Xiao have similar properties. Why does Zhang Zhongjing use Pu Xiao in other formulas but Xiao Shi here? Answer: Pu Xiao is salty; Xiao Shi is salty and pungent. Pungency corresponds to Metal. In this formula, Fan Shi contains iron (Metal), and Xiao Shi has a pungent taste (Metal). Together, they regulate spleen damp-heat and restrain erratic bile flow, integrating TCM and Western theories, hence being considered a sage formula. Pu Xiao primarily directs downward; Xiao Shi primarily dissolves. Bile overflowing into the blood spreads throughout the body and is hard to direct downward alone; it relies heavily on Xiao Shi's dissolving power. Pu Xiao is condensed water essence; its salty-cold nature may not suit spleen-dampness. Xiao Shi ignites in fire, absorbing true yang from water. Its saltiness is less than Pu Xiao, and it has a pungent quality, helping disperse dampness stagnation without aggravating spleen dampness.
Although *Jin Gui Yao Lue* has specific formulas for internal injury jaundice, my experience shows Xiao Shi Fan Shi San is highly effective not only for female labor jaundice but for various internal injury jaundices if modified appropriately.
Note: The original Xiao Shi Fan Shi San uses equal parts Xiao Shi and Fan Shi as powder, one fang cun bi per dose with barley porridge. I find powders hard to take, so I often use roasted barley flour or wheat flour mixed with the powders to make pills the size of Wu Wei Zi seeds (approx. 6g per dose). These are taken with decoctions tailored to symptoms: Yin Chen and Zhi Zi for excess heat; Sheng Ji Nei Jin and Shan Zha for food stagnation; Da Huang and Ma Ren for constipation; Hua Shi and Sheng Bai Shao for urinary retention; Zhe Shi and Qing Dai for nausea/vomiting; Sheng Huang Qi and Sheng Jiang for weak left pulse; Bai Zhu and Chen Pi for weak right pulse; Fu Zi and Gan Jiang for deep-slow-wiry pulses with cold sensation and dark yellow complexion. For floating pulse indicating external contraction, administer Aspirin (1 grain) with Gan Jiang decoction first, induce sweating, then take pills with Gan Jiang decoction. If the taste is unpleasant, add Gan Jiang to the decoction.
Western medicine notes gallstones blocking the gallbladder duct can cause jaundice; Xiao Shi and Fan Shi together can dissolve stones. They also note hookworms in the small intestine can cause jaundice; this combination eliminates hookworms. Thus, modifying the accompanying decoction allows this formula to treat various internal injury jaundices effectively.
External contraction jaundice typically presents with high fever. Heat from cold-warm diseases enters the Yangming fu organ, spreading laterally to affect the gallbladder and spleen. Or, pre-existing spleen dampness combines with invading heat, creating damp-heat that manifests externally as jaundice. Or, excessive ministerial fire in the gallbladder combines with invading heat, causing duct swelling and bile overflow into blood. Zhang Zhongjing treats external contraction jaundice with three formulas in the Yangming chapter of *Shang Han Lun*: Yin Chen Hao Tang, Zhi Zi Bai Pi Tang, and Ma Huang Lian Qiao Chi Xiao Dou Tang, all addressing both gallbladder and spleen. Across all his jaundice formulas, Yin Chen Hao is consistently the chief herb. Its cool nature and green color enter the liver/gallbladder, clearing heat and resolving stagnation, making it essential for jaundice treatment.
In my practice, I follow these three formulas. For severe heat, I add Long Dan Cao. For Ma Huang Lian Qiao Chi Xiao Dou Tang, I add Hua Shi to enhance diuresis. If the case fits Bai Hu Tang or Cheng Qi Tang patterns with jaundice, I add Yin Chen Hao. If external formulas fail, I use them as decoctions to wash Xiao Shi Fan Shi San pills.
There is also a type where external contraction lies dormant, brewing into internal injury before manifesting. In Yichou year, residing in Cangzhou, many cases occurred from mid-autumn to early winter. Patients had no high fever, chest fullness, occasional heat sensation, nausea upon seeing food, vomiting if forced to eat, or inability to digest food. Some felt abdominal coldness. I treated over 60 patients successfully. Pulses were hot-like on the left and stagnant on the right, indicating liver/gallbladder heat and spleen/stomach cold. The cause was prolonged summer rains increasing atmospheric moisture, injuring organs with dampness. Liver/gallbladder (Wood, Shaoyang nature) generates heat from damp stagnation; Spleen/stomach (Earth, Taiyin nature) generates cold from damp stagnation. Wood heat causes gallbladder swelling, preventing bile secretion into the small intestine, leading to blood overflow and yellowing. Earth cold causes spleen-fire decline, failing to digest food, leading to distension or obstruction. I prescribed: Yin Chen, Zhi Zi, Lian Qiao (3 qian each) to clear liver/gallbladder heat and reduce swelling; Hou Po, Chen Pi, Sheng Mai Ya (2 qian each), Sheng Jiang (5 qian) to open spleen/stomach stagnation and dispel cold; Fu Ling, Sheng Yi Mi, Chi Xiao Dou, Gan Cao (3 qian each) to drain dampness and support earth. Gan Cao also masks the bitter taste of Yin Chen. After one dose, if chest heat subsides, remove Zhi Zi, add Sheng Bai Shao (3 qian). If still unable to eat, replace Sheng Jiang with Gan Jiang (2 qian). If chest feels cold initially, omit Zhi Zi and use Gan Jiang instead. For severe cold, increase Gan Jiang to 5-6 qian. For vomiting, add Zhe Shi (6 qian to 1 liang). If vomiting persists, take Zhe Shi powder (4-5 qian) with warm water first. For intestinal obstruction, take Chao Qian Niu powder (3 qian) with decoction until relieved. Stop medication once eating resumes; jaundice will fade gradually. This type, originating from latent external contraction becoming internal injury, should be classified separately from those in *Shang Han Lun* and *Jin Gui Yao Lue*.
Question: Medicine is scientific and values evidence. Zhang Zhongjing's dual treatment of gallbladder and spleen seems inferred from herbs. Yet *Shang Han Lun* says "Taiyin... body should yellow," focusing on spleen. *Jin Gui Yao Lue* says "Spleen color must yellow... stagnant heat moves," also focusing on spleen. Ancient texts are vague; modern commentaries should clarify. Did any pre-Western Chinese text explicitly state jaundice results from bile overflowing into blood? Answer: Yes. Yu Jiayan in *Yu Yi Cao* discussed a wine-drinker, stating "hot bile from gallbladder overflows externally, seeping into collaterals, causing yellow eyes and body." This aligns perfectly with Western theory. Westerners require autopsy to know this; Yu knew it without autopsy. Not because Yu was smarter, but because he deeply understood *Jin Gui* and *Shang Han*, inferring mechanisms from herbal actions. Thus, Zhang Zhongjing's dual approach is not baseless.
Appendix:
Xu XX states: *Jin Gui*'s Xiao Shi Fan Shi San treats internal injury jaundice. Zhang Xichun's elucidation is brilliant. Identifying Fan Shi as Zao Fan via textual analysis (*Ben Cao Jing*, *Erya*) and clinical observation (black stool post-treatment) shows unique insight. Modifying the delivery method based on pulse (Huang Qi/Dang Gui/Gui Zhi for weak left pulse; Bai Zhu/Chen Pi/Yi Mi for weak right pulse) rather than rigidly using barley porridge demonstrates flexible application of ancient formulas. Friend Shi XX treated a woman with chronic jaundice (5-6 years) who contracted external pathogens in autumn, presenting with alternating chills/fever and edema. Chai Hu Gui Zhi Tang resolved edema and fever in two doses. Shi then prescribed Xiao Shi Fan Shi San with barley porridge. The patient feared intolerance. Shi encouraged her, taking responsibility. Two doses cleared the jaundice. Shi praised Zhang Xichun's work, noting that without Zhang's clarification, Zhang Zhongjing's formulas might have remained obscure. Indeed, creating formulas is hard; applying them wisely is equally challenging.