（法十五条 律三条）
《经》言∶溺黄赤安卧者，瘅病。溺黄赤者，热之征也。安静嗜卧者，湿之征也。所以有开鬼门洁净府之法。开鬼
门者，从汗而泄其热于肌表也。洁净府者，从下而泄其湿于小便也。此特辨名定治之大端，而精微要渺，惟《金匮》有
独昭焉。要知外感发黄一证，伤寒阳明篇中已悉。《金匮》虽举外感内伤诸黄，一一发其底蕴，其所重尤在内伤，兹特
详加表彰，为后学法程焉。
《金匮》论外感热郁于内，而发黄之证云∶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。其义取伤寒风湿相搏之变证为言，见风性虽善行，才与湿相合，其风即痹而不行，但郁为瘀热而已。及郁之
之极，风性乃发，风发遂挟其瘀热以行于四肢，而四肢为之苦烦，显其风淫末疾之象。挟其瘀热以行于肌肤，而肌肤为
之色黄，显其湿淫外渍之象。其脉以因风生热故浮。因湿成痹故缓。此而行《内经》开鬼门洁净府之法，俾风挟之热从
肌表出，湿蒸之黄从小便出，而表里分消，为有据也。
《金匮》重出伤寒阳明病不解，后成谷瘅一证云∶阳明病脉迟者，食难用饱，饱则发烦，头眩，小便必难，此欲作
谷瘅；虽下之，腹满如故，所以然者，脉迟故也。此因外感阳明，胃中之余热未除，故食难用饱。饱则食复生热，两热
相合，而发烦头眩，小便难，腹满，势所必至。在阳明证本当下，阳明而至腹满，尤当急下，独此一证，下之腹满必如
故，非但无益，反增困耳。以其脉迟，而胃气空虚，津液不充，其满不过虚热内壅，非结热当下之比。《金匮》重出此条，
原有深意。见脉迟胃虚，下之既无益，而开鬼门洁净府之法，用之无益，不待言矣。尝忆余友问∶仲景云下之腹满如故，
何不立一治法？余曰∶仲景必用和法，先和其中，后乃下之。友曰∶何以知之？余曰∶仲景云脉迟尚未可攻，味一尚字，
其当攻之旨跃然。《金匮》又云∶诸黄腹痛而呕者，用小柴胡汤。观此仍是治伤寒，邪高痛下，故使呕也。小柴胡汤主之
之法，是以知之耳。陈无择治谷瘅，用谷芽枳实小柴胡汤，差识此意，但半消半和半下，三法并用，漫无先后。较诸仲
景之丝丝必贯，相去远矣。
《金匮》又云∶趺阳脉紧而数，数则为热，热即消谷，紧则为寒，食即为满。尺脉浮为伤肾，趺阳脉紧为伤脾。风
寒相搏，食谷则眩，谷气不消，胃中苦浊，浊气下流，小便不通，阴被其寒，热流膀胱，身体尽黄，名曰谷瘅。此论内
伤发黄，直是开天辟地未有之奇，东垣脾胃论仿佛什一。后世乐宗《金匮》奥义，置之不讲，殊可慨也！请细陈之。人
身脾胃居于中土，脾之土，体阴而用则阳。胃之土，体阳而用则阴。两者和同，则不刚不柔。胃纳谷食，脾行谷气，
通调水道，灌注百脉，相得益彰，其用大矣。惟七情饥饱房劳，过于内伤，致令脾胃之阴阳，不相协和。胃偏于阳，无
脾阴以和之，如造化之有夏无冬，独聚其热而消谷。脾偏于阴，无胃阳以和之，如造化之有冬无夏，独聚其寒而腹满，
其人趺阳之脉紧寒数热，必有明征，诊其或紧或数，而知脾胃分主其病。诊其紧而且数，而知脾胃合受其病，法云精矣。
然更有精焉，诊其两尺脉浮，又知并伤其肾。夫肾脉本沉也，胡以反浮？盖肾藏精者也，而精生于谷，脾不运胃中谷气
入肾，则精无裨而肾伤，故沉脉反浮也。知尺脉浮为伤肾，则知趺阳脉紧，即为伤脾。然紧乃肝脉，正仲景所谓紧乃弦，
状若弓弦之义。脾脉舒缓，受肝木之克贼，则变紧。肝之风气，乘脾聚之寒气，两相搏激，食谷即眩。是谷入不能长气
于胃阳，而反动风于脾阴，即胃之聚其热而消谷者，亦不过蒸为腐败之浊气，而非精华之清气矣。浊气繇胃热而下流入
膀胱，则膀胱受其热，气化不行，小便不通，一身尽黄。浊气繇脾寒而下流入肾，则肾被其寒，而克贼之余，其腹必满
矣。究竟谷瘅由胃热伤其膀胱者多，由脾寒伤其肾者，十中二三耳。若饮食伤脾，加以房劳伤肾，其证必腹满而
难治矣。仲景于女劳瘅下，重申其义曰∶腹如水状不治，岂不深切着明乎？
女劳瘅额上黑，谓身黄加以额黑也。黑为北方阴晦之色，乃加于南方离明之位，此必先有胃热脾寒之浊气，下流入
肾，益以女劳无度，而后成之，其繇来自非一日。《肘后》谓因交接入水所致，或有所验。然火炎薪烬，额色转黑，虽
不
入水，其能免乎？故脾中之浊气，下趋入肾，水土互显之色，但于黄中见黑滞耳。若相火从水中上炎，而合于心之君火，
其势燎原，烟焰之色，先透于额，乃至微汗亦随火而出于额，心之液且外亡矣。手足心热，内伤皆然。日暮阳明用事，
阳明主阖，收敛一身之湿热，疾趋而下。膀胱因而告急，其小便自利，大便黑，时溏，又是膀胱蓄血之验，腹如水状，
实非水也，正指蓄血而言也，故不治。
酒瘅心中懊 ，而热不能食，时欲吐。酒为湿热之最，气归于心肺，味归于脾胃，久积之热，不下行而上触，则生
懊。痞塞中焦，则不能食。其湿热之气，不下行而上触，则为呕。呕则势转横逆，遍渍周身也。《伤寒论》谓阳明病
无汗，小便不利，心中懊 者，身必发黄。是知热甚于内者，皆足致此，非独酒矣。
《金匮》治酒瘅，用或吐或下之法云∶酒黄瘅，必小便不利，其候心中热，足下热，是其证也。又云∶或无热，清
言了了，腹满欲吐，鼻煤，其脉浮者，先吐之。沉弦者，先下之。又云∶心中热，欲呕者吐之愈。又云∶心中懊 ，或
热痛，栀子大黄汤主之。又云∶下之久久为黑瘅，言虽错出，义实一贯。盖酒之积热入膀胱，则气化不行，必小便不利，
积于上焦则心中热。积于下焦则足下热。其无心中足下热者，则清言了了，而神不昏，但见腹满，欲吐，鼻煤三证。可
知其膈上与腹中，阴阳交病，须分先后治之。当辨脉之浮沉，以定吐下之先后。脉浮病在膈上，阳分居多，先吐上焦，
而后治其中满。脉沉弦病在腹中，阴分居多，先下其中满，而后治其上焦，若但心中热欲呕，则病全在上焦，吐之即愈，
何取下为哉？其酒热内结，心神昏乱，而作懊 ，及痛楚者，则不可不下。但下法乃劫病之法，不可久用。久久下之，
必脾肺之阳气尽伤，不能总领其阴血，其血有日趋于败而变黑耳，曾谓下法可渎用乎？仲景于一酒瘅，胪列先后次第，
以尽其治，其精而且详若此。
酒瘅之黑，与女劳瘅之黑，殊不相同。女劳瘅之黑，为肾气所发。酒瘅之黑，乃荣血腐败之色。荣者水谷之精气，
为湿热所瘀而不行，其光华之色，转为晦黯，心胸嘈杂，如啖蒜齑状，其芳甘之味，变为酸辣。乃至肌肤抓之不仁，大
便正黑，脉见浮弱，皆肺金治节之气不行而血瘀也。必复肺中清肃之气，乃可驱荣中瘀浊之血，较女劳瘅之难治，特一
间耳。方书但用白术汤，理脾气解酒热以言治，抑何庸陋之甚耶？
黄瘅繇于火土之热湿，若合于手阳明之燥金，则热湿燥三气，相搏成黄。其人必渴而饮水，有此则去湿热药中，必
加润燥，乃得三焦气化行，津液通，渴解而黄退。渴不解者，燥有未除耳，然非死候也，何又云瘅而渴者难治，则更虑
其下泉之竭，不独云在中之津液矣。
合论《金匮》桂枝黄 汤、小柴胡汤、麻黄醇酒汤三方 仲景治伤寒方，首用麻黄汤为表法，今观《金匮》治
黄瘅之用表，主之以桂枝黄 汤、小柴胡汤、附之以《千金》麻黄醇酒汤，明示不欲发表之意。故其方首云∶诸病黄家，
但利小便，假令脉浮，当以汗解之，宜桂枝加黄 汤。可见大法当利小便，必脉浮始可言表。然瘅证之脉，多有荣卫气
虚，湿热乘之而浮，故用桂枝黄 汤，和其荣卫。用小柴胡汤，和其表里，但取和法为表法，乃仲景之微旨也。而表实
发黄，当汗之证，岂曰无之！再取千金麻黄醇酒汤一方附入，必不自出麻黄峻表之方，皆立法之本意，又仲景之苦心也。
读此而治病之机，宛然心目矣。
桂枝黄 汤 表虚者必自汗，汗虽出而邪不出，故用桂枝黄 以实表，然后可得驱邪之正汗，此义不可不知。
小柴胡汤 邪正相击，在下则痛，在上则呕，即《伤寒论》邪高痛下之旨也。故取用和表里之法，和其上下。
《千金》麻黄醇酒汤 表有水寒，入于荣血，闭而不散，热结为黄。故赖麻黄颛力开结散邪，加醇酒以行之也。
合论《金匮》大黄硝石汤栀子大黄汤茵陈蒿汤三方 湿热郁蒸而发黄，其当从下夺，亦须仿治伤寒之法，里热
者始可用之。重则用大黄硝石汤，荡涤其湿热，如大承气汤之例；稍轻则用栀子大黄汤，清解而兼下夺，如三黄汤之例；
更轻则用茵陈蒿汤，清解为君，微加大黄为使，如栀豉汤中加大黄如博棋子大之例。是则汗法固不敢轻用，下法亦在所
慎施，以瘅证多夹内伤，不得不回护之耳。
大黄硝石汤 热邪内结而成腹满，与伤寒当急攻下之证无异，故以大黄、硝石二物，荡邪开结。然小便赤，则膀胱
之气化亦热，又借柏皮、栀子寒下之力，以清解其热也。
栀子大黄汤 此治酒热内结，昏惑懊 之剂。然伤寒证中有云∶阳明病无汗，小便不利，心中懊 者，身必发黄。
是则诸凡热甚于内者，皆足致此，非独酒也。
茵陈蒿汤 此治谷瘅寒热不能食之方。然此繇脾胃内郁之热，外达肌肤，与外感之寒热少异，热壅于胃，故不能食。
方中但治里热，不解表邪，从可识矣。
论瓜蒂汤方 瓜蒂汤，吐药也。邪在膈上，浅而易及，用此汤以吐去其黄水，正《内经》因其高而越之之旨也。
然此亦仲景治伤寒之正方，曷为治瘅证，但附于后，是亦不欲轻用之意矣。
合论《金匮》小建中汤小半夏汤二方 黄瘅病为湿热之所酿矣，然有湿多热少者，有湿少热多者，有湿热全无
者，不可不察也。仲景虑瘅病多夹内伤，故尔慎用汗吐下之法。其用小建中汤，则因男子发黄，而小便自利，是其里无
湿热，惟以入房数扰其阳，致虚阳上泛为黄耳。故不治其黄，但和荣卫以收拾其阳，听其黄之自去。即取伤寒邪少虚多，
心悸而烦，合用建中之法以治之，此其一端也。又有小便本赤黄，治之其色微减，即当识其蕴热原少，或大便欲自
利，腹满上气喘急，即当识其脾湿原盛，或兼寒药过当，宜亟用小半夏汤，温胃燥湿，傥更除其热，则无热可除，胃寒
起而呃逆矣。此又一端也，凡治湿热而罔顾其人之虚寒者，睹此二义，能无悚惕耶？
小建中汤 即桂枝汤倍芍药加胶饴也。男子数扰其阳，致虚阳上泛为黄，用此汤固护其卫，则阳不能外越。而芍药
之酸，收其上泛之阳，以下归于阴；甘草胶饴培其中土，土浓则所收之阳，不能复出，此天然绝妙之方也。然必小便自
利，证非湿热者乃可用之。不然，宁不犯酒家用桂枝、呕家用建中之大禁乎？
小半夏汤 小便色小变而欲自利，湿虽积而热则微，若其脾湿不行而满，脾湿动肺而喘，此但当除湿，不可除热，
热除则胃寒气逆而哕矣。凡遇湿多热少之证，俟其热少除，即用此以温胃燥湿，其治热多湿少，当反此而推之。
合论《金匮》猪膏发煎茵陈五苓散二方 此治湿热中重加燥证之方也。燥者秋令也，夏月火炎土燥，无俟入秋，
湿土转燥之证已多，不可不察。况乎郁蒸之湿热，必先伤乎肺金，肺金一燥，则周身之皱揭禁固，有不可胜言者。所以
仲景于瘅证中，出此二方。后人罔解其意，按剑相盼，不敢取用，讵不深可惜乎？然燥有气血之分，猪膏煎借血余之力，
引入血分，而润其血之燥，并借其力开膀胱瘀血，利其小水，小水一利，将湿与热且俱除矣。其五苓散，原有燥湿滋干
二用，今人颇能用之，本草言茵陈能除热结黄瘅，小便不利，用之合五苓以润气分之燥，亦并其湿与热而俱除矣。制方
之妙，夫岂思议之可几哉？
猪膏发煎 《肘后方》云∶女劳瘅身目尽黄发热，恶疮，少腹满，小便难，以大热大劳，交接入水所致者，用此方。
又云∶五瘅，身体四肢微肿，胸满，不得汗，汗出如黄柏汁，由大汗出入水所致者，猪脂一味服。其意以身内黄水，因
受外水遏抑而生，与仲景治血燥之意相远。唯《伤寒类要》云∶男子女人黄瘅，食饮不消，胃胀热生黄，病在胃中，有
干燥使然。猪脂煎服下乃愈，是则明指血燥言矣。盖女劳瘅，血瘀膀胱，非直入血分之药，必不能开。仲景取用虻虫、
水蛭、矾石，无非此义。然虻、蛭过峻，不可以治女劳；矾石过燥，又不可以治女劳之燥，故更立此方以济之。世之入
多宝山而空手归者。可胜道哉！
茵陈五苓散 湿热郁蒸于内，必先燥其肺气，以故小水不行。五苓散开腠理，致津液，通血气，且有润燥之功，而
合茵陈之辛凉，清理肺燥，肺金一润，其气清肃下行，膀胱之壅热立通，小便利而黄去矣。
论《金匮》硝石矾石散方 此治女劳瘅之要方也。原文云∶黄家，日晡所发热，而反恶寒，此为女劳。得之，
（治疗法则十五条，禁忌三条）
《黄帝内经》中说：小便黄赤且嗜睡安卧的，是瘅病。小便黄赤，是热邪的表现；安静嗜卧，是湿邪的表现。因此有“开鬼门”和“洁净府”的治疗方法。“开鬼门”，是通过发汗使热邪从肌表宣泄出去。“洁净府”，是通过利小便使湿邪从下焦排泄出去。这仅仅是辨别名称、确定治疗大法的纲领，而其中精微深奥的道理，只有《金匮要略》阐述得最为清晰明了。要知道，外感引起的发黄一证，在《伤寒论·阳明病篇》中已经详尽论述了。《金匮要略》虽然列举了外感和内伤等各种黄疸，一一揭示其内在机理，但其侧重点更在于内伤，这里特意详细表彰这些内容，作为后学者的学习典范。
《金匮要略》论述外感热邪郁结于内从而发黄的证候说：“寸口脉浮而缓，浮脉主风，缓脉主痹，这里的痹并非中风；四肢感到烦扰不适，脾的颜色必然发黄，瘀滞的热邪随之运行。”这句话的意思是取伤寒风湿相搏产生的变证来论述，说明风性虽然善于行走，但一旦与湿邪结合，风即变得痹阻而不行，只是郁结成为瘀热罢了。等到郁结到极点，风的特性才会发作，风发动便挟带瘀热运行于四肢，导致四肢苦于烦扰，显现出风邪淫溢于肢体末端的病症象。挟带瘀热运行于肌肤，导致肌肤颜色发黄，显现出湿邪淫溢浸渍体表的象。其脉象因为因风生热所以浮，因为因湿成痹所以缓。据此施行《内经》“开鬼门、洁净府”的方法，让风挟带的热从肌表排出，湿蒸腾的黄从小便排出，从而使表里之邪分消，这是有据可依的。
《金匮要略》再次论述伤寒阳明病不解，后来形成谷疸一证说：“阳明病脉迟的，进食难以吃饱，饱食后就会发生烦闷、头晕目眩，小便必定困难，这是将要形成谷疸的迹象；即使使用下法，腹部胀满依然如故，之所以这样，是因为脉迟的缘故。”这是因为外感阳明病，胃中的余热未除，所以进食难以吃饱。饱食后食物复生热，两热相合，导致烦闷、头晕、小便难、腹满，这是势所必然的。在阳明病证本应当用下法，到了阳明病出现腹满，尤其应当急下，唯独这一种证候，使用后腹满必定依旧，不仅无益，反而增加困顿。因为其脉迟，胃气空虚，津液不充盈，这种胀满不过是虚热内壅，不是实热结聚应当急下的情况。《金匮要略》重复列出这一条，原本有深意。意思是看到脉迟胃虚，使用下法既无益处，那么“开鬼门、洁净府”的方法，使用也无益，是不言而喻的。曾经回忆我的朋友问：“张仲景说使用后腹满如故，为什么不设立一个治疗方法？”我说：“张仲景必定是用和法，先调和其中焦，然后再考虑下法。”朋友问：“怎么知道的呢？”我说：“张仲景说脉迟尚不可攻，‘尚’字一词，其应当攻下的旨意跃然纸上。《金匮要略》又说：各种黄疸腹痛而呕吐的，用小柴胡汤。看这个，仍然是治疗伤寒，邪气在高处疼痛在下处，所以引起呕吐。用小柴胡汤主治的方法，就是由此知道的。陈无择治疗谷疸，使用谷芽、枳实、小柴胡汤，稍微懂得这个意思，但是半消导、半和解、半攻下，三种方法并用，漫无先后顺序。与张仲景丝丝入扣、环环相扣相比，相差太远了。
《金匮要略》又说：“趺阳脉紧而数，数脉主热，热则消谷善饥；紧脉主寒，食入则腹胀。尺脉浮为伤肾，趺阳脉紧为伤脾。风寒相搏，进食则眩晕，谷气不能消化，胃中苦于浊气，浊气下流，小便不通，阴分受寒，热流注膀胱，身体尽黄，名叫谷疸。”这段论述内伤发黄，简直是开天辟地以来未曾有的奇迹，李东垣的《脾胃论》大概只学到了十分之一。后世喜欢推崇《金匮要略》的奥妙义理，却放置不讲，实在令人感慨！请让我细细陈述。人身体的脾胃居于中土，脾属土，体阴而用阳；胃属土，体阳而用阴。两者和谐同调，则不刚不柔。胃受纳谷物食物，脾运化谷气，通调水道，灌注百脉，相得益彰，作用很大。只有七情失调、饥饱失常、房劳过度，过于内伤，导致脾胃的阴阳不相协和。胃偏于阳，没有脾阴来调和它，就像自然界只有夏天没有冬天，独自聚集热邪而消谷；脾偏于阴，没有胃阳来调和它，就像自然界只有冬天没有夏天，独自聚集寒邪而腹满。这个人趺阳脉紧寒数热，一定有明显的征象，诊察脉象或紧或数，就知道脾胃分别主管各自的病变。诊察脉象既紧又数，就知道脾胃共同承受病变，医书说法很精妙了。然而还有更精妙的，诊察两尺脉浮，又知道同时伤了肾。肾脉本来应该是沉的，为什么反而浮？因为肾藏精，而精生于谷，脾不运化胃中的谷气进入肾，则精没有补益而肾受伤，所以沉脉反而浮。知道尺脉浮是伤肾，就知道趺阳脉紧就是伤脾。然而紧是肝脉，正是张仲景所说的“紧即是弦，形状像弓弦”的意思。脾脉舒缓，受到肝木的克制贼害，则变为紧脉。肝的风气，乘袭脾聚集的寒气，两者相互搏击，进食就眩晕。这是谷气进入后不能在胃阳中长养正气，反而在脾阴中动风，即使是胃聚集热邪消谷，也不过蒸腾为腐败的浊气，而不是精华的清气了。浊气由胃热而下流入膀胱，则膀胱受其热，气化不行，小便不通，一身尽黄。浊气由脾寒而下流入肾，则肾被其寒，而在克制之余，腹部必定胀满。终究谷疸由胃热损伤膀胱的多，由脾寒损伤肾的，十人中二三而已。如果饮食伤脾，加上房劳伤肾，其证候必定腹满而难治。张仲景在女劳疸下面，重申这个意义说：“腹部像水状的不治”，难道不是深切著明吗？
女劳疸额头黑，是说身体黄加上额头黑。黑色是北方阴晦的颜色，却加在南方离明（心火/面部）的位置，这一定是先有胃热脾寒的浊气，下流入肾，再加上房事无度，而后形成的，其由来非一日之功。《肘后备急方》说是因为性交后入水所致，或许有验证。然而火燃烧尽，额头颜色转黑，即使不入水，能避免吗？所以脾中的浊气，下趋进入肾，水土互显的颜色，只是在黄色中看到黑色的滞涩罢了。如果相火从水中上炎，而合于心之君火，其势燎原，烟焰的颜色，先透出于额头，以至于微汗也随着火而出于额头，心的津液就要外亡了。手足心发热，内伤病都是这样。傍晚时阳明经当令，阳明主阖，收敛一身之湿热，疾速下行。膀胱因而告急，其小便自利，大便黑，时而溏泄，这又是膀胱蓄血的验证，腹部像水状，实际上不是水，正是指蓄血而言，所以不治。
酒疸心中懊憹（ào náo，烦闷不安），发热不能进食，时常想吐。酒是湿热之最，气归于心肺，味归于脾胃，久积的热邪，不下行而上冲，则产生懊憹。痞塞中焦，则不能进食。其湿热之气，不下行而上冲，则引起呕吐。呕吐则病势转为横逆，遍渍周身。《伤寒论》说阳明病无汗，小便不利，心中懊憹的，身体必定发黄。由此可知热甚于内的，都足以导致此证，不仅仅是酒造成的。
《金匮要略》治疗酒疸，或用吐法或用下法说：“酒黄疸，必定小便不利，其征象是心中热，足下热，这就是它的证候。”又说：“或者无热，言语清楚明白，腹满想吐，鼻头色黑，其脉浮的，先用吐法。脉沉弦的，先用下法。”又说：“心中热，想吐的，用吐法就好了。”又说：“心中懊憹，或者热痛，用栀子大黄汤主治。”又说：“下法久久使用会变成黑疸”，话虽然交错说出，义理其实一贯。大概酒的积热进入膀胱，则气化不行，必定小便不利，积于上焦则心中热，积于下焦则足下热。那些没有心中足下热的，则言语清楚，神志不昏乱，只见腹满、想吐、鼻头黑三个证候。可以知道膈上与腹中，阴阳交杂生病，必须分先后治疗。应当辨脉的浮沉，来决定吐下的先后。脉浮病在膈上，阳分居多，先吐上焦，然后治疗其中的胀满。脉沉弦病在腹中，阴分居多，先下其中的胀满，然后治疗其上焦。如果只是心中热想吐，则病全在上焦，吐之即愈，何必用下法呢？如果是酒热内结，心神昏乱，而产生懊憹，以及疼痛痛苦的，则不可不下。但是下法是劫夺病邪的方法，不可久用。久久使用下法，必定脾肺的阳气全部受伤，不能统领阴血，其血一天天趋向败坏而变黑，岂能说下法可以轻率滥用吗？张仲景对于一个酒疸，罗列先后次第，以穷尽其治疗，其精详竟然如此。
酒疸的黑，与女劳疸的黑，完全不同。女劳疸的黑，是肾气所发。酒疸的黑，是营血腐败的颜色。营是水谷的精气，被湿热瘀阻而不行，其光华之色，转为晦暗，心胸嘈杂，像吃蒜泥的样子，其芳甘的味道，变为酸辣。乃至肌肤抓之不仁，大便正黑，脉见浮弱，都是肺金治节之气不行而血瘀。必须恢复肺中清肃之气，才能驱除营中瘀浊的血，比女劳疸的难治，只是一线之隔罢了。医书只用白术汤，调理脾气解除酒热来说明治疗，是多么平庸浅陋啊！
黄疸源于火土的热湿，如果合于手阳明的燥金，则热、湿、燥三气，相搏结成黄疸。其人必定口渴而饮水，有此症状则在祛湿热药中，必须加润燥药，才能使三焦气化运行，津液通畅，渴解而黄退。渴不解的，是燥邪未除罢了，然而不是死证，为什么说疸而渴的难治，则是更担忧其下焦真阴枯竭，不只是说中焦的津液了。
综合讨论《金匮要略》桂枝加黄芪汤、小柴胡汤、麻黄醇酒汤三方：张仲景治疗伤寒方，首先用麻黄汤作为表法，现在看《金匮要略》治疗黄疸之用表法，以桂枝加黄芪汤、小柴胡汤为主，辅以《千金方》的麻黄醇酒汤，明示不欲大发汗解表的意思。所以其方首句说：“各种患黄疸的人，只要利小便，假如脉浮，应当用汗法解表，适宜用桂枝加黄芪汤。”可见大法应当利小便，必须脉浮才可以谈表证。然而疸证的脉，多有营卫气虚，湿热乘虚而浮，所以用桂枝加黄芪汤，调和其营卫。用小柴胡汤，调和其表里，只是取和法作为表法，这是张仲景的微旨。而表实发黄，应当汗出的证候，难道说没有吗！再取《千金方》麻黄醇酒汤一方附入，必定不是出自麻黄峻猛发汗的方子，这都是立法的本意，也是张仲景的苦心。读到这里，治病的关键，宛然在目了。
桂枝加黄芪汤：表虚者必定自汗，汗虽出而邪不出，所以用桂枝加黄芪汤来充实肌表，然后才能得到驱邪的正汗，这个道理不可不知。
小柴胡汤：邪正相击，在下则痛，在上则呕，即《伤寒论》邪高痛下的旨意。所以取用调和表里的方法，调和其上下。
《千金方》麻黄醇酒汤：表有水寒，进入营血，闭阻而不散，热结而成黄。所以依赖麻黄全力开结散邪，加醇酒来推动药力。
综合讨论《金匮要略》大黄硝石汤、栀子大黄汤、茵陈蒿汤三方：湿热郁蒸而发黄，其应当从下夺，也必须仿照治疗伤寒的方法，里热者才可以使用。重则用大黄硝石汤，荡涤其湿热，如同大承气汤的例子；稍轻则用栀子大黄汤，清解兼下夺，如同三黄汤的例子；更轻则用茵陈蒿汤，以清解为主，微加大黄为使，如同栀豉汤中大黄如博棋子大的例子。这样看来，汗法固然不敢轻用，下法也在所慎重施用，因为疸证多夹杂内伤，不得不回护正气罢了。
大黄硝石汤：热邪内结而成腹满，与伤寒应当急攻下的证候无异，所以用大黄、硝石二物，荡涤邪气开结。然而小便赤，则膀胱的气化也热，又借黄柏、栀子寒下的力量，来清解其热。
栀子大黄汤：这是治疗酒热内结，昏惑懊憹的方剂。然而伤寒证中有说：“阳明病无汗，小便不利，心中懊憹的，身体必定发黄。”那么凡是热甚于内的，都足以导致此证，不仅仅是酒造成的。
茵陈蒿汤：这是治疗谷疸寒热不能食的方子。然而这是由于脾胃内郁之热，外达肌肤，与外感的寒热略有不同，热壅于胃，所以不能食。方中只治里热，不解表邪，从这里就可以认识了。
论瓜蒂汤方：瓜蒂汤，是吐药。邪在膈上，浅而易及，用此汤以吐去其黄水，正是《内经》因其高而越之的旨意。然而这也是张仲景治疗伤寒的正方，为什么治疗疸证，只附在后面，这也是不欲轻用的意思。
综合讨论《金匮要略》小建中汤、小半夏汤二方：黄疸病是湿热所酿成的，然而有湿多热少的，有湿少热多的，有湿热全无的，不可不考察。张仲景担心疸病多夹杂内伤，所以谨慎使用汗、吐、下法。他使用小建中汤，是因为男子发黄，而小便自利，是其里没有湿热，只是因为入房多次扰动其阳，导致虚阳上泛而为黄。所以不治其黄，只调和营卫以收敛其阳，听任其黄自行消退。即取伤寒邪少虚多，心悸而烦，合用小建中法来治疗，这是一个方面。又有小便本来赤黄，治疗后颜色微减，就应当识别其蕴热原少，或者大便想要自利，腹满上气喘急，就应当识别其脾湿原盛，或者兼用寒药过当，宜紧急用小半夏汤，温胃燥湿，倘若再除去其热，则无热可除，胃寒起而呃逆了。这是另一个方面。凡是治疗湿热而不顾及其人的虚寒的，看到这两个道理，能不警惕吗？
小建中汤：就是桂枝汤加倍芍药加饴糖。男子多次扰动其阳，导致虚阳上泛而为黄，用此汤固护其卫气，则阳不能外越。而芍药的酸味，收摄其上泛之阳，以下归于阴；甘草、饴糖培补其中土，土厚则所收之阳，不能复出，这是天然绝妙的方子。然而必须小便自利，证非湿热者才可用。不然，岂不是犯了酒家用桂枝、呕家用建中的大忌吗？
小半夏汤：小便颜色小变而想要自利，湿虽积但热则微，如果其脾湿不行而胀满，脾湿动肺而喘，这只能除湿，不可除热，热除则胃寒气逆而哕了。凡是遇到湿多热少的证候，等其热少除，就用此以温胃燥湿，其治热多湿少，应当反过来推演。
综合讨论《金匮要略》猪膏发煎、茵陈五苓散二方：这是治疗湿热中重加燥证的方子。燥是秋令，夏月火炎土燥，不必等到入秋，湿土转燥的证候已多，不可不考察。况且郁蒸的湿热，必先伤乎肺金，肺金一燥，则全身的皱揭禁固，有不可胜言的。所以张仲景在疸证中，提出这两方。后人不懂其意，按剑相看，不敢取用，岂不是很可惜吗？然而燥有气血之分，猪膏发煎借血余（头发）的力量，引入血分，而润其血之燥，并借其力开膀胱瘀血，利其小便，小便一利，将湿与热都将一起除去了。茵陈五苓散，原有燥湿滋干两种用途，今人颇能用之，本草说茵陈能除热结黄疸，小便不利，用它合五苓散以润气分之燥，也将湿与热一起除去了。制方的妙处，哪里是思议可以企及的呢？
猪膏发煎：《肘后方》说：“女劳疸身目尽黄发热，恶疮，少腹满，小便难，因大热大劳，交接入水所致的，用此方。”又说：“五疸，身体四肢微肿，胸满，不得汗，汗出如黄柏汁，由大汗出入水所致的，单服猪脂。其意是以身内黄水，因受外水遏抑而生，与张仲景治血燥的意思相差很远。只有《伤寒类要》说：“男子女人黄疸，食饮不消，胃胀热生黄，病在胃中，有干燥使然。猪脂煎服下乃愈”，这是明确指血燥而言了。大概女劳疸，血瘀膀胱，不是直入血分的药，必定不能开通。张仲景取用虻虫、水蛭、矾石，无非是这个意思。然而虻、蛭过于峻猛，不可以治女劳；矾石过于燥烈，又不可以治女劳之燥，所以另立此方来济助它。世上的人大多进宝山而空手而归，能说尽吗！
茵陈五苓散：湿热郁蒸于内，必先燥其肺气，所以小便不行。五苓散开腠理，致津液，通血气，且有润燥之功，而合茵陈的辛凉，清理肺燥，肺金一润，其气清肃下行，膀胱的壅热立即通利，小便利而黄退了。
(Fifteen Treatment Principles, Three Prohibitions)
The *Huangdi Neijing* (Yellow Emperor's Inner Canon) states: "Urine that is yellow and red, accompanied by a desire to lie still and sleep, indicates Dan disease (febrile jaundice). Yellow urine indicates the sign of heat; quietness and lethargy indicate the sign of dampness. Therefore, there are methods of 'opening the ghost gate' (inducing sweating) and 'cleansing the fu organs' (promoting urination). 'Opening the ghost gate' means venting heat from the muscle surface through sweating. 'Cleansing the fu organs' means draining dampness from the lower jiao through urination. These are merely the general principles for distinguishing names and determining treatment strategies. The subtle and profound details are elucidated uniquely in the *Jingui Yaolue* (Essential Prescriptions of the Golden Cabinet). It must be known that the syndrome of jaundice caused by external contraction is already fully discussed in the Yangming chapter of the *Shanghan Lun* (Treatise on Cold Damage). Although the *Jingui Yaolue* lists various types of jaundice caused by both external and internal factors, revealing their underlying mechanisms, its emphasis lies particularly on internal injury. Here, these points are specifically detailed and highlighted as models for future learners.
The *Jingui Yaolue* discusses the syndrome of jaundice caused by external heat constrained internally, stating: "The pulse at the cunkou position is floating and slow. Floating indicates wind; slow indicates bi-syndrome (obstruction), but this bi-syndrome is not wind-stroke. The limbs suffer from vexation. The color of the spleen must turn yellow, and the stagnant heat circulates." The meaning here takes the variant syndrome of cold damage with wind-dampness binding together as the subject. It shows that although wind nature is agile and moving, once combined with dampness, the wind becomes obstructed and immobile, merely stagnating into stagnant heat. When stagnation reaches its extreme, the nature of wind manifests. The wind movement then carries the stagnant heat to circulate in the four limbs, causing them to suffer from vexation, manifesting the image of wind pathogen invading the extremities. Carrying the stagnant heat to circulate in the skin and muscles, it causes the skin and muscles to turn yellow, manifesting the image of damp pathogen invading and soaking the exterior. The pulse floats because heat is generated by wind; it is slow because obstruction is formed by dampness. Based on this, one should apply the *Neijing* methods of 'opening the ghost gate' and 'cleansing the fu organs', allowing the heat carried by wind to exit from the muscle surface, and the yellow color steamed by dampness to exit via urination, thereby dispersing pathogens from both interior and exterior. This is well-founded.
The *Jingui Yaolue* reiterates: "In Yangming disease due to cold damage, if unresolved, it later develops into Grain Jaundice (Gu Dan): If the pulse in Yangming disease is slow, the patient finds it difficult to eat until full. After eating until full, they develop vexation, dizziness, and difficulty in urination. This indicates impending Grain Jaundice. Even if purgatives are used, abdominal fullness remains unchanged. The reason for this is the slow pulse." This occurs because residual heat in the stomach has not been eliminated due to external Yangming contraction, making it difficult to eat until full. Eating until full generates more heat; the combination of two heats leads to vexation, dizziness, difficulty in urination, and abdominal fullness, which is inevitable. In Yangming syndromes, purgation is usually indicated. When Yangming disease presents with abdominal fullness, urgent purgation is especially warranted. However, in this specific case, purgation will leave abdominal fullness unchanged; it is not only ineffective but also increases debility. Because the pulse is slow, indicating empty stomach qi and insufficient body fluids, the fullness is merely internal congestion of deficient heat, not comparable to excess heat accumulation requiring urgent purgation. The repetition of this clause in the *Jingui Yaolue* holds deep significance. It implies that seeing a slow pulse and deficiency of the stomach, purgation is useless; consequently, the methods of 'opening the ghost gate' and 'cleansing the fu organs' are also useless, which goes without saying. I recall a friend asking: "Zhang Zhongjing says purgation leaves abdominal fullness unchanged; why does he not establish a treatment method?" I said: "Zhang Zhongjing must intend to use the Harmonizing Method (He Fa), first harmonizing the middle jiao, and only then considering purgation." The friend asked: "How do you know?" I said: "Zhang Zhongjing states that when the pulse is slow, attack is not yet appropriate. The word 'yet' (shang) clearly reveals the intent to eventually attack. The *Jingui Yaolue* also states: 'For all jaundices with abdominal pain and vomiting, use Xiao Chai Hu Tang (Minor Bupleurum Decoction).' Observing this, it is still treating cold damage, where the pathogen is high and pain is low, causing vomiting. Knowing the method of using Xiao Chai Hu Tang allows us to understand this. Chen Wuzhe treated Grain Jaundice using Gu Ya (Sprouted Grain), Zhi Shi (Immature Bitter Orange), and Xiao Chai Hu Tang. He somewhat understood this idea, but combined half expelling, half harmonizing, and half purging methods simultaneously, without clear sequence. Compared to Zhang Zhongjing’s meticulous coherence, the difference is vast.
The *Jingui Yaolue* further states: "The pulse at the foot yang position is tight and rapid. Rapid indicates heat; heat consumes grain. Tight indicates cold; food intake leads to fullness. Floating pulse at the chi position indicates kidney injury; tight pulse at the foot yang position indicates spleen injury. Wind and cold bind together; eating causes dizziness. Grain qi does not digest. The stomach suffers from turbid qi. Turbid qi flows downward, causing urinary obstruction. The yin aspect is affected by cold, while heat flows into the bladder. The whole body turns yellow, named Grain Jaundice." This discussion on jaundice caused by internal injury is truly unprecedented since the beginning of heaven and earth. Li Dongyuan’s *Pi Wei Lun* (Treatise on the Spleen and Stomach) resembles only a fraction of it. Later generations delight in the profound mysteries of the *Jingui Yaolue* yet neglect discussing them, which is truly lamentable! Let me elaborate carefully. The spleen and stomach reside in the central earth of the human body. The spleen’s earth is Yin in substance but Yang in function. The stomach’s earth is Yang in substance but Yin in function. When they harmonize, neither is too rigid nor too soft. The stomach receives grain and food; the spleen transports grain qi, regulates water passages, and irrigates the hundred vessels. They complement each other greatly, and their functions are significant. Only when seven emotions, hunger/fullness irregularities, or sexual fatigue cause excessive internal injury do the yin and yang of the spleen and stomach fail to harmonize. If the stomach leans toward Yang without spleen Yin to harmonize it, it is like having summer without winter, accumulating only heat to consume grain. If the spleen leans toward Yin without stomach Yang to harmonize it, it is like having winter without summer, accumulating only cold to cause abdominal fullness. In such a person, the foot yang pulse being tight (cold) and rapid (heat) provides clear evidence. Diagnosing either tight or rapid pulses reveals whether the spleen or stomach independently governs the disease. Diagnosing both tight and rapid pulses reveals that both spleen and stomach jointly suffer the disease. The medical maxim is precise. However, there is even greater precision: diagnosing floating pulses at both chi positions additionally reveals kidney injury. The kidney pulse should originally be sunken; why does it float? Because the kidney stores essence, and essence is generated from grain. If the spleen fails to transport stomach grain qi into the kidney, essence lacks nourishment and the kidney is injured, so the sunken pulse reverses to float. Knowing that floating chi pulse indicates kidney injury, we know that tight foot yang pulse indicates spleen injury. However, tightness is a liver pulse, exactly as Zhang Zhongjing meant by "tight is string-like, resembling a bowstring." The spleen pulse is relaxed and slow; when subjected to liver wood’s suppression and attack, it changes to tight. The liver’s wind qi takes advantage of the cold qi gathered in the spleen. The two struggle against each other; eating causes dizziness. Thus, grain entering cannot generate qi in stomach Yang but instead stirs wind in spleen Yin. Even the stomach’s heat that consumes grain merely steams into corrupt turbid qi, rather than essential clear qi. Turbid qi from stomach heat flows downward into the bladder, heating the bladder, stopping qi transformation, causing urinary obstruction, and turning the whole body yellow. Turbid qi from spleen cold flows downward into the kidney, chilling the kidney; after the attack subsides, abdominal fullness ensues. Ultimately, most Grain Jaundice cases involve stomach heat injuring the bladder, while fewer (two or three out of ten) involve spleen cold injuring the kidney. If dietary injury damages the spleen, compounded by sexual fatigue damaging the kidney, the syndrome will definitely present with abdominal fullness and be difficult to treat. Zhang Zhongjing reiterates this meaning below Female Labor Jaundice: "Abdominal fullness resembling water indicates incurability," which is profoundly clear.
Female Labor Jaundice presents with blackening of the forehead, meaning the body is yellow plus a black forehead. Black is the color of northern yin obscurity, yet it appears on the southern bright position (face/heart fire). This must result from turbid qi of stomach heat and spleen cold flowing downward into the kidney, compounded by excessive sexual activity, forming over a long period. *Zhou Hou Bei Ji Fang* (Emergency Prescriptions Kept Up One’s Sleeve) attributes it to intercourse followed by entering water, which may have some validity. However, if fire burns out the firewood, the forehead turns black; even without entering water, can it be avoided? Thus, turbid qi from the spleen descends into the kidney. The mixed colors of earth and water appear only as blackish stagnation within the yellow. If ministerial fire flares up from water and combines with the sovereign fire of the heart, the momentum spreads like a prairie fire. The color of smoke and flame first penetrates the forehead. Even slight sweat follows the fire out from the forehead, and the fluid of the heart is lost externally. Heat in the palms and soles is common in internal injuries. At dusk, the Yangming meridian takes command. Yangming governs closing, gathering the body’s damp-heat and rushing it downward. The bladder thus faces urgency. Urine flows freely, stool is black, sometimes loose. This is another verification of blood stasis in the bladder. Abdominal fullness resembling water is actually not water, but refers to blood stasis; hence, it is incurable.
Wine Jaundice presents with ao nao (restlessness and bitterness in the chest), fever, inability to eat, and occasional vomiting. Wine is the utmost of damp-heat. Its qi returns to the heart and lungs; its flavor returns to the spleen and stomach. Long-accumulated heat, failing to descend, rises upward, generating ao nao. Obstruction in the middle jiao prevents eating. The damp-heat qi, failing to descend, rises upward, causing vomiting. Vomiting causes the pathogenic force to turn horizontal and inundate the entire body. The *Shanghan Lun* states: "In Yangming disease, if there is no sweat, urination is unsmooth, and the patient experiences ao nao in the chest, the body will surely turn yellow." Thus, knowing that intense heat inside is sufficient to cause this, not just wine.
The *Jingui Yaolue* treats Wine Jaundice using either emetic or purgative methods, stating: "Wine yellow jaundice must have unsmooth urination. Its signs are heat in the chest and heat under the feet; this is the syndrome." It also states: "Or there is no heat, speech is clear and lucid, abdominal fullness with desire to vomit, black nose tip. If the pulse is floating, use emesis first. If sinking and wiry, use purgation first." It further states: "Heat in the chest with desire to vomit resolves with emesis." And: "Ao nao in the chest, or heat and pain, is primarily treated with Zhi Zi Da Huang Tang (Gardenia and Rhubarb Decoction)." Although stated separately, the principle is consistent. Generally, accumulated heat from wine enters the bladder, stopping qi transformation and causing unsmooth urination. Accumulating in the upper jiao causes chest heat; accumulating in the lower jiao causes foot heat. Those without chest or foot heat have clear speech and unconfused spirit, showing only abdominal fullness, desire to vomit, and black nose tip. This indicates yin-yang pathology in both the diaphragm above and the abdomen below, requiring sequential treatment. One must distinguish floating vs. sinking pulses to determine the sequence of emesis vs. purgation. Floating pulse indicates disease in the diaphragm above, mostly in the yang division; first emesis of the upper jiao, then treat central fullness. Sinking-wiry pulse indicates disease in the abdomen, mostly in the yin division; first purgation of central fullness, then treat the upper jiao. If merely chest heat and desire to vomit, the disease is entirely in the upper jiao; emesis suffices, why use purgation? If wine heat knots internally, confusing the mind spirit and causing ao nao and pain, purgation is necessary. However, purgation is a drastic method and must not be used long-term. Long-term purgation injures spleen and lung yang qi completely, preventing them from leading yin blood. Blood gradually deteriorates and turns black. How can purgation be used frivolously? Zhang Zhongjing lists the sequence for Wine Jaundice comprehensively, demonstrating such precision and detail.
The blackness of Wine Jaundice differs significantly from that of Female Labor Jaundice. Female Labor Jaundice blackness originates from kidney qi. Wine Jaundice blackness is the color of corrupted Ying (Nutritive) blood. Ying is the refined essence of grain and water, blocked by damp-heat stagnation. Its lustrous color turns dull. The chest feels restless, like eating minced garlic. Sweet flavors turn sour and pungent. Skin itching leads to numbness. Stool is jet black. Pulse is floating and weak. All indicate failure of Lung Metal’s regulating qi and blood stasis. One must restore the Lung’s clear and descending qi to drive out the turbid blood in the Ying level. This is only slightly less difficult to treat than Female Labor Jaundice. Medical texts only use Bai Zhu Tang (Atractylodes Macrocephala Decoction) to regulate spleen qi and resolve wine heat, which is extremely mediocre and shallow!
Jaundice arises from fire-earth damp-heat. If combined with Hand-Yangming Dryness Metal, the three pathogens—heat, dampness, and dryness—bind to form jaundice. The patient will be thirsty and drink water. In this case, moistening agents must be added to damp-heat resolving formulas to allow San Jiao qi transformation to proceed, fluids to flow, thirst to cease, and jaundice to recede. If thirst persists, dryness remains, but it is not a death prognostic. Why then say "jaundice with thirst is difficult to treat"? This worries about the exhaustion of the lower spring (kidney yin/fluids), not just middle jiao fluids.
Synthesizing the three formulas from *Jingui Yaolue*: Gui Zhi Jia Huang Qi Tang (Cinnamon Twig plus Astragalus Decoction), Xiao Chai Hu Tang (Minor Bupleurum Decoction), and Ma Huang Chun Jiu Tang (Ephedra and Mellow Wine Decoction): Zhang Zhongjing’s treatment of cold damage begins with Ma Huang Tang as the exterior-releasing method. Now, observing his use of exterior methods for jaundice in the *Jingui Yaolue*, he prioritizes Gui Zhi Jia Huang Qi Tang and Xiao Chai Hu Tang, supplemented by Ma Huang Chun Jiu Tang from *Qian Jin Fang*. This explicitly shows an intention not to forcefully release the exterior. Hence, the formula preface states: "For all jaundice patients, promote urination. If the pulse is floating, release via sweating using Gui Zhi Jia Huang Qi Tang." This shows the major principle is promoting urination; only when the pulse is floating can exterior release be considered. However, jaundice pulses often show deficient Ying and Wei qi, with damp-heat taking advantage to float. Thus, Gui Zhi Jia Huang Qi Tang harmonizes Ying and Wei. Xiao Chai Hu Tang harmonizes interior and exterior. Taking the Harmonizing Method as the exterior method is Zhang Zhongjing’s subtle intent. Yet, exterior-excess jaundice requiring sweating certainly exists! Adding Ma Huang Chun Jiu Tang from *Qian Jin Fang* confirms that strong exterior-releasing formulas like those with Ephedra were not his primary choice. This reflects his legislative intent and painstaking care. Reading this, the mechanism of treating diseases becomes clear.
Gui Zhi Jia Huang Qi Tang: Exterior deficiency causes spontaneous sweating. Sweat exits, but pathogens remain. Thus, Gui Zhi Jia Huang Qi Tang is used to consolidate the exterior, enabling proper sweating to驱邪 (expel pathogens). This principle must be known.
Xiao Chai Hu Tang: Pathogen and righteous qi clash. Below causes pain; above causes vomiting. This aligns with the *Shanghan Lun* principle of "pathogen high, pain low." Thus, the method of harmonizing interior and exterior is taken to harmonize upper and lower.
Ma Huang Chun Jiu Tang (*Qian Jin Fang*): Exterior water-cold enters Ying blood, closing and not dispersing, heat knots to form jaundice. Thus, relying on Ephedra’s strength to open knots and scatter pathogens, aided by mellow wine to promote circulation.
Synthesizing the three formulas from *Jingui Yaolue*: Da Huang Xi Shi Tang (Rhubarb and Niter Decoction), Zhi Zi Da Huang Tang (Gardenia and Rhubarb Decoction), and Yin Chen Hao Tang (Artemisia Capillaris Decoction): Damp-heat constraint steaming leads to jaundice, requiring downward purgation. This must also follow cold damage treatment principles, usable only when interior heat exists. Severe cases use Da Huang Xi Shi Tang to scour damp-heat, analogous to Da Cheng Qi Tang. Mild cases use Zhi Zi Da Huang Tang to clear and purge, analogous to San Huang Tang. Lighter cases use Yin Chen Hao Tang, clearing as the sovereign herb, with minor rhubarb as assistant, analogous to adding rhubarb to Zhi Chi Tang. Thus, sweating methods are cautiously avoided, and purgation is applied sparingly, because jaundice often involves internal injury, necessitating protection of healthy qi.
Da Huang Xi Shi Tang: Heat knotting internally causes abdominal fullness, similar to cold damage requiring urgent purgation. Thus, Rhubarb and Niter scour pathogens and open knots. However, red urine indicates bladder qi transformation is heated. Therefore, Huang Bo (Phellodendron) and Zhi Zi (Gardenia) provide cold-purging power to clear heat.
Zhi Zi Da Huang Tang: This treats internal knotting of wine heat causing confusion and ao nao. However, the *Shanghan Lun* states: "Yangming disease, no sweat, unsmooth urination, ao nao in chest, body will turn yellow." Thus, any intense internal heat can cause this, not just wine.
Yin Chen Hao Tang: This treats Grain Jaundice with chills, fever, and inability to eat. However, this stems from internal constraint of spleen-stomach heat reaching the skin, differing slightly from external chills/fever. Heat congests the stomach, causing inability to eat. The formula treats interior heat only, not exterior pathogens, which is evident.
Discussion on Gua Di Tang (Melon Spicule Decoction): Gua Di Tang is an emetic. Pathogens in the diaphragm above are superficial and accessible. Using this decoction to vomit out yellow water aligns with the *Neijing* principle: "Due to its height, elevate it." However, this is also a standard formula for cold damage in Zhang Zhongjing’s work. Why is it attached at the end for jaundice treatment? This again shows reluctance to use it lightly.
Synthesizing the two formulas from *Jingui Yaolue*: Xiao Jian Zhong Tang (Minor Construct the Middle Decoction) and Xiao Ban Xia Tang (Minor Pinellia Decoction): Jaundice is brewed by damp-heat. However, there are cases of more damp than heat, more heat than damp, or no damp-heat at all. These must be distinguished. Zhang Zhongjing fears jaundice often involves internal injury, so he uses sweating, emesis, and purgation cautiously. He uses Xiao Jian Zhong Tang because male jaundice with free urination indicates no damp-heat in the interior. Instead, frequent sexual activity disturbed yang, causing deficient yang to float upward, resulting in yellow complexion. Thus, he does not treat the yellow directly but harmonizes Ying and Wei to gather the yang, letting the yellow resolve spontaneously. This parallels treating cold damage with little pathogen and much deficiency, palpitations, and vexation, using the Jian Zhong method. This is one aspect. Another case: Urine was originally dark yellow, treatment reduces color slightly, indicating little latent heat. Or, if stool tends toward looseness, abdominal fullness, and shortness of breath, it indicates abundant spleen dampness. Or, if cold herbs were overused, urgently use Xiao Ban Xia Tang to warm the stomach and dry dampness. If heat is removed further, there is no heat left to remove, stomach cold arises, and hiccups occur. This is another aspect. Anyone treating damp-heat while ignoring the patient’s deficiency and cold should tremble upon understanding these two principles.
Xiao Jian Zhong Tang: This is Gui Zhi Tang doubled in Shao Yao (Peony) plus Yi Tang (Maltose). Frequent sexual activity disturbs yang, causing deficient yang to float upward as yellow. This formula protects Wei qi, preventing yang from escaping outward. The sourness of Shao Yao gathers the floating yang and directs it down to yin. Gan Cao (Licorice) and Yi Tang cultivate the central earth. Thickened earth prevents the gathered yang from re-emerging. This is a naturally exquisite formula. However, it is only usable if urination is free and the syndrome is not damp-heat. Otherwise, one commits the great taboo of using Gui Zhi in wine-induced vomiting or Jian Zhong in vomiting syndromes.
Xiao Ban Xia Tang: Urine color changes slightly and tends toward looseness. Dampness accumulates, but heat is mild. If spleen dampness fails to move causing fullness, or moves the lung causing wheezing, one should only dry dampness, not remove heat. Removing heat causes stomach cold, qi rebellion, and hiccups. For syndromes with more damp than heat, wait until heat is mildly reduced, then use this to warm the stomach and dry dampness. For more heat than damp, reverse this logic.
Synthesizing the two formulas from *Jingui Yaolue*: Zhu Gao Fa Jian (Pig Fat and Hair Decoction) and Yin Chen Wu Ling San (Artemisia and Five-Ingredient Poria Powder): These treat damp-heat complicated by severe dryness. Dryness belongs to autumn. In summer, fire blazes and earth dries; damp-earth turning dry is common before autumn arrives, requiring attention. Moreover, constrained damp-heat first injures Lung Metal. Once Lung Metal is dry, the body’s pores and constraints become problematic beyond words. Thus, Zhang Zhongjing presents these two formulas for jaundice. Later generations misunderstand their intent, hesitate, and dare not use them, which is deeply regrettable. However, dryness has blood and qi distinctions. Zhu Gao Fa Jian uses Xue Yu Tou (Hair Ash) to enter the blood level, moistening blood dryness, and opens bladder blood stasis to promote urination. Once urination flows, damp and heat are removed together. Wu Ling San originally has functions of drying dampness and nourishing dryness. Modern practitioners use it well. Materia Medica states Yin Chen removes heat-knot jaundice and promotes urination. Combining it with Wu Ling San moistens qi-level dryness, removing damp and heat together. The subtlety of formula preparation is beyond mere speculation!
Zhu Gao Fa Jian: *Zhou Hou Bei Ji Fang* states: "For Female Labor Jaundice with whole-body and eye yellowing, fever, foul sores, lower abdominal fullness, and difficult urination, caused by extreme heat/labor and intercourse followed by water entry, use this formula." It also states: "For the five jaundices with slight swelling of body and limbs, chest fullness, inability to sweat, or sweat like yellow bark juice, caused by heavy sweating followed by water entry, take pig fat alone." Its intent is that internal yellow water is generated because it is suppressed by external water, far from Zhang Zhongjing’s intent to treat blood dryness. Only *Shanghan Lei Yao* states: "Male or female jaundice, undigested food, stomach distension, heat generating yellow, disease in the stomach, caused by dryness. Pig fat decoction cures it." This clearly refers to blood dryness. Generally, Female Labor Jaundice involves blood stasis in the bladder. Without drugs entering the blood level, blockage cannot be opened. Zhang Zhongjing uses Meng Chong (Blue Bottle Fly) and Shui Zhi (Leech) for this purpose. However, these are too harsh for Female Labor Jaundice. Fan Shi (Alum) is too drying for the dryness of Female Labor Jaundice. Thus, he established this formula to assist. Many people enter the treasure mountain and return empty-handed; how can this be described adequately!
Yin Chen Wu Ling San: Damp-heat constrained internally first dries lung qi, causing unsmooth urination. Wu Ling San opens interstices, generates fluids, and unites blood qi, possessing moistening dryness functions. Combined with Yin Chen’s acrid-cool nature, it clears lung dryness. Once Lung Metal is moist, its qi descends clearly and purely. Bladder congestion-heat is immediately cleared. Urination flows, and jaundice disappears.
Discussion on Xiao Shi Fan Shi San (Niter and Alum Powder) from *Jingui Yaolue*: This is the key formula for treating Female Labor Jaundice. The original text states: "Jaundice patients who feel feverish around sunset but paradoxically fear cold, this is Female Labor Jaundice. Acquiring it,"