热病误治，热灼津伤，邪从燥化，因热燥而病黄疸者有之。如《伤寒论》114条，“太阳病中风，以火劫发汗，邪风被火热，血气流溢，失其常度，两阳相熏灼，其身发黄。阳盛则欲衄，阴虚小便难，阴阳俱虚竭，身体则枯燥，但头汗出，剂颈而还、腹满、微喘、口乾、咽烂，或不大便，……。”即是叙述了这一证型。因风为阳邪，火为阳热，两阳相熏灼，伤津劫液，病从燥化，故身黄之外，小便难，身枯燥，口咽干或不大便等燥的症状颇为突出。又205条：“阳明病，被火，额上微汗出，而小便不利者，必发黄。”笔者认为：这一条误用火攻，火热相合，两阳熏灼，消烁津液的情况，与上条完全相同，故亦作热燥黄疸看为妥，若概认为黄疸病小便难，或小便不利均为湿乏去路之表现，从而将上述条文俱作湿热解释，实谬。
热燥黄疸之症状表现，主要是热与燥二个方面。但上二条文只着重论述了病因病理及燥的表现，关于热的症状描述不很具体，但《金匮·黄疸篇》“师曰，病黄疸，发热，烦喘，胸满，口燥者，以病发时火劫其汗，两热所得。然黄家所得，从湿得之。一身尽发热而黄，肚热，热在里，当下之。”这一条也是论述热燥黄疸之文，且于热的症状描述较详，可以合参。其中“黄家所得，从湿得之"两句，是插笔。燥湿对举以为衡，是仲景作论常用之法。在论热燥黄疸之时而提及湿，目的在于既强调了黄疸毕竟以湿热为常，又告诫黄疸辨证，须就燥化湿化的不同病机，注意作鉴别诊断，有叫人对勘意。至于用下法治疗，是因热燥二面，处在因热而燥，尚以热为主的情况下，热邪入里，邪从燥化，必致里结，故治用釜底抽薪、急下以存阴。
刘完素深明仲景治疽以燥湿分论之旨，故《河间六书》云：“大抵凡诸黄者有二，一则湿热气郁而黄，万物皆然，义如麦秀而黔雨，湿热过极则黄疸也，及水涝而天气湿热，则草木将死而湿变黄者也；或病血液衰，则虚，燥热太甚，而身面痿黄者，犹亢旱而草木痿黄也，夫病燥热而黄者，当退热润燥而已。”黄宫绣之说，即基刘氏说而来。张石顽亦云“黄疸有干有湿”，惜片言只语，论述不详，为与临床相印证，现举前人治验一则，以备参究：
“朱天一年二十余，喜食糖及燥炙诸饼，忽病黄，面目如金，脉之两关数实有力尽滑，大便六七日不行，小便黄涩，此敦阜太过，加以素嗜炙火，其色必黄，非湿证也，与小承气汤加当归、白芍，一剂便行而瘥。"(《续名医类案，黄疸》)
按：此案明云非湿，诊者确有见识，其治方与仲景论热燥黄疸之文互参，实有互为补充，互为说明之妙，使人很受启迪。可见陈修园“黄疸皆由湿热成”(《医学实在易》)之说，乃为初学者说法，若医者止足于此而不入仲景之堂奥，以流于浅薄为自足，是固不足与语高深者。
燥淤黄疸
经云：“孙络水溢，则经有留血。”故津伤与血淤常可同时发生。若因发热而致伤津劫液，或热病后期，热邪虽退，阴津不足，因燥致淤，淤结发黄者亦有之。《金匮》：“腹满，舌痿黄，躁不得睡，属黄家”条，即是言此种证型。此条之舌痿是身痿，痿黄是形容黄色枯燥不润泽，与湿病篇的“熏黄”是形容黄晕如油正相反，亦宜对勘。腹满是胃肠燥结，肠中干粪不去之征。躁不得睡，则是热去阴伤之表现。黄疸篇“诸黄，猪膏发煎主之”条，即是为燥淤黄疸出治法。据前人治验，此方治燥淤黄疸效果很好。黄疸因多属湿热，油腻生湿助热，最为大忌，此其常也。惟燥淤黄疸，不但不忌，且可用猪油治疗。《肘后方·治卒发黄疸诸黄病第三十一》中曰：“伤寒频要疗男子妇人黄疸病医不愈，耳目悉黄，饮食不消，胃中胀热，生黄衣，在胃；中有干屎使病耳，用煎猪脂一小升，温热顿服之，日三，燥屎下乃愈。”《沈氏尊生》亦云：“有服对证药不效，耳目皆黄，食不消者，是胃中有干粪也。宜饮熬猪油，量人令禀，或一杯，或半杯，日二次，以燥粪下为度，即愈。”这是单用猪油治黄疸的记载，然唯燥甚淤微者为适宜，如淤甚，古人也有单用血余来治疗的，血余祛淤而兼能利水，对淤甚而兼湿者为适宜，若是燥淤黄疸，则总以猪膏发煎为妥贴。
燥淤黄疸用猪膏发煎取得显效之治验，可与下“《伤寒论》200条释疑"一文中之例案相互参。
淤血黄疸
淤是黄疸常见之病理产物，故仲景治疸，常淤热并提，或淤湿同治。但淤血化水或阻滞肝胆等也可以是引起黄疸之因，而且，在一定条件下，淤血有时还可能成为疸病久治不愈之症结所在。《伤寒论》129条：“太阳病，身黄，脉沉结，少腹粳，小便不利者，为无血也；小便自利，其人如狂者，血证谛也，抵当汤主之。”此后半条是血蓄下焦，淤血发黄，病不在气分，与湿无涉，故小便自利。《金匮》，“酒疸下之，久久为黑疽，目青面黑，心中如啖蒜薤状，大便正黑，皮肤爪之不仁，其脉浮弱，虽黑微黄，故知之，”以及“黄家日晡所发热而反恶寒，此为女劳得之，膀胱急，少腹满，身尽黄，额上黑，足下热，囚作黑疸，其腹胀如水状，大便必黑，时溏，此女劳之病，非水也。腹满者难治，硝石矾石散主之。”这二个条文，也是淤血为主，故有非水也之明示。惟前者病在太阳而属实，故用抵当汤峻攻，后者病在少阴而属虚，故用硝石矾石散缓消。浙江诸暨已故名中医杨则民谓：“仲景用猪膏发煎治女劳疽。”说明女劳疸既有以淤为主，以虚为主之分，亦有病从燥化，病从湿化之别。硝石矾石散所治之女劳疸是以淤为主，虚而兼湿，故以泻为补，行淤兼以化湿，猪膏发煎所治之女劳疽是以虚为主，淤而兼燥，故以补为泻，润燥兼以行淤。
淤血黄疸之脉证，除上述条文描述者外，也可与“病者如热状，烦满，口干燥而渴，其脉反无热，此为阴伏，是淤血也，当下之”等论述淤血的有关条文互参。
现举淤血黄疸例案二则以资参阅
一、“中翰汪先于病疸，服茵陈五苓不应。八月间，邀石顽诊之，脉弦大而芤，肾伤夹淤，结积刁二散所致，急乘元气尚可攻击时，用金匮硝石矾石散，兼桂苓丸之剂，以洗涤之，迟则难为力矣。汪氏有业医者，以为药力太峻，不便轻用，旋值公郎乡荐继以公车，未免萦心，不及调治，迨至新正二日，复邀石顽相商，脉转弦而革，真元竭尽无余，半月以来，日眼人参数钱，如石投水……”(《张氏医通》)。
按：虚实之理，原有对待。人谓女劳疸属虚，多不敢用泻药，而后世亦咸以肾气丸为主治，至硝石矾石散一方，遂束之高阁，不独敢用者罕，敢服者亦罕，此案即是一例，良由仲景大法不明于世故也。
二，“应天王治中遍身发黄，妄言如狂，苦于胸痛，手不可近，此中焦蓄血为患，用桃仁承气汤，一剂，下淤血而愈。又太守朱阳山弟下部淤血发狂，用抵当汤而愈”(《续名医类案》)。
按；黄疸病机，多属湿热淤，但重湿者则曰无湿不成疸，重热者则曰疸以胃家实热为本，重淤者则曰黄疸必伤血，治疽要活血。实则湿重主以茵陈五苓散，热重主以茵陈蒿汤，淤重主以抵当汤，原是仲景之常法。后人偏执其一端，实失仲景之活法。上案是淤血黄疸之属实者，故用桃仁承气汤、抵当汤下蓄血而愈。若湿盛热重或正虚者，各宜辨证定方，又当别论，而偏执一端，划地为牢以自囿，诚为黄疸治疗之大忌。
虚寒黄疸房事不节，精血内伤，或脾阳不振，中土失健，虽无湿热，但因气血之败，不能华色，亦可产生疽黄。如太阴黄疸有寒湿与虚寒二个证型，《伤寒论》所论者属寒湿，故有“小便白利者，不能发黄。”“伤寒发汗已，身目为黄，所以然者，以寒湿在里不解故也”等论述。《金匮》中所论者属虚寒，故曰；“男子黄，小便自利，当予虚劳小建中汤。”“黄疸病，小便色不变，欲自利……”等论述。此外，《金匮》“额上黑，微汗出，手足中热，薄暮即发，膀胱急，小便自利，名曰女劳疽。”以及“尺脉浮为伤肾”，“女劳之病，非水也，”等条文所述，虽不属太阴黄疸而属少阴黄疸，但也属虚寒而不是因于湿，故后人每用畜鱼置介法治疗。诚因虚寒黄疸非因于湿，故小便自利，且色亦可不变。而寒湿黄疸，则与湿热黄疸一样，同样与湿邪排泄不畅有关，故均有小便不利并色变黄之征。当然，寒湿者可以兼虚，虚寒者可以兼湿，淤热者可以挟湿，湿热者亦多兼淤，但这是另一个问题，宜当别论。
现举虚寒黄疸治案一则如下
“柴屿青治觉罗马德夫人病疸，医投茵陈五苓散未效，又合末药服之，肌肤白，眼皆如金色，转致不思饮食，右关缓弱特甚。柴曰：胃为水谷之海，脾为仓禀之官，腑脏失职，湿热滋甚，今唯有调其土，使能健运，湿热自去，不必治疸，而疸自愈矣，六君子汤加厚朴、炮姜以温中，神曲、麦芽以助戊巳之化，不数剂而全愈。”(《续名医类案》)
按：泛用苦寒清利以治疽之时弊，前人早巳论及，儿科于此，尤须注意，陈复正云：“小儿黄病，昧者一概呼为湿热。无非除湿利水，清热退黄，除此之外，无别法矣，岂知湿热发黄者少，脾虚发黄者多。盖脾土强者，足以悍御湿邪，必不生黄，惟其脾虚不运，所以湿来乘之。”湿热发黄少，脾虚发黄多，在儿科者或如是，成人则究亦以湿热黄疸为居多，但虚寒黄疸亦不可忽视，上案虚作实治，泛用清利，反致增疾之覆辙，今人亦有重蹈者，此所以余尝有治疸须重脾之论也。
疫毒瘟黄
瘟黄仲景书中未见记载，其名出自《明医杂著》，实即急黄，急黄最早见载于《渚病源候论》，认为是：“因为热毒所加”而致。《杂病源流犀烛》认为是感受“天行疫疠”之气，故亦可称为疫毒急黄。此种黄疸的临床表现具有发病急，病势重的特点，常一患病即出现卒然身黄，迅速加深，黄色如金，心满气喘，高热口渴，尿如柏汁；腹胀胁痛，神昏詀语，烦躁，脉弦数或细数，舌红绛，苔黄燥，吐衄便血，身见斑疹，或出现腹水昏迷等证。这种急剧症状的出现，与病因属特殊的热毒疫气，不同于一般的湿热有关。从其病理变化来看，此种；热毒之邪很易内陷心包，入侵营血，故化燥伤阴较速。其治疗以清热解毒、凉血滋阴、清心开窍为大法，一般用犀角散为主方，配合生地、丹皮、玄参类的凉血滋阴药以及金花汤，牛黄丸一类的清热解毒、清心开窍剂加减。此证有时虽亦可挟湿，但由于病因主要是热毒，且每从燥化，故也是一种非湿黄疸。若与热燥黄疸比较，彼之病因非疫毒，此则是疫毒为患，故证有轻重之殊。囿于“黄疸无湿不成”之认识者，由于论疸不离一个“湿”字，谓此证亦是“湿热挟毒”，实属不妥。此证无论就病因论，从病机看，或结合治疗分析，均不得谓是湿作祟。
结语：论黄疸若只强调湿热，或只强调淤热，而全然不知有燥化非湿之诸证型，这种认识是片面的，须知仲景治疸之法，有麻黄连翘赤小豆汤的汗法；抵当汤的下法；栀子豉汤的吐法；栀子柏皮汤的清法星小柴胡汤的和法，小建中汤的补法，硝石矾石散的消法；于寒湿中求之的温法；茵陈五苓散的利法，猪膏发煎的润法等等。其层次之明，法度之严，方药之细，均可师可法。如单就阳黄论，则在太阳分经府气血，入阳明别吐清下润，在少阳立疏和通泄，治亦不同，凡此均足以说明，仲景并不专执一法一方以泛治。若此而不知，竟以“湿，热、淤”三字作茧自缚，唯知以清热利湿行淤之品杂凑成方为用，是划地为牢，自陷于狭隘。一字真传空费解三生幻相尽随缘2005/11/3020:09三七生管理员积分20145发帖18080注册2005/7/8#4《伤寒论》第200条释疑①
《伤寒论》第200条的原文是：“阳明病，脉迟，食难用饱，饱则微烦头眩，必小便难，此欲作谷疸。虽下之，腹满如故。所以然者，脉迟故也。"此条亦见于《金匮·黄疸篇》，仅“微烦”作“发烦”。历代医家对此条的解释很不一致。笔者不揣谫陋，略谈己见，以供参考。
一、历代医家的几种解释
历代医家对此条的解释，约有五种：
1·认为是阳明(胃)中寒证。考历代之注《伤寒论》，持此种观点者甚众，如柯琴、方有执、程云来、舒弛远、程应旄等。成都中医学院主编的《伤寒论讲义》也持此说：“阳明病脉应沉大或沉实，今脉迟，是胃阳虚弱，阳明中寒证。"②
2·认为是阳明(经脉)虚寒证。张隐庵说此条是“言阳明经脉虚寒而成谷疽也。……病在经脉，虽下之而腹满如故，所以然者，以脉迟而经脉虚寒故也。”③一般说，阳明病有传有中，传是从经脉传，中是直中于里，所传为热，所中属寒。此外，尚有认为是经脉虚寒证者，则第236条；“阳明病，脉迟，汗出多，微恶寒者，可发汗，宜桂枝汤。”即指此言。
3·认为是阳明经热证。成无己说：“阳明病脉迟，则邪方入里，热未为实也。食入于阴，长气于阳。胃中有热，食难甩饱，……脉迟为热气未实，虽下之，腹满亦不减也”④成氏所说的意思是虽有热，但尚未形成阳明腑实证，仍是阳明经热证。
热病误治，导致热邪灼伤津液，病邪从燥化，因热燥而引发黄疸的情况是存在的。例如《伤寒论》第114条：“太阳病中风，用火法强行发汗，风邪被火热所迫，气血运行溢出常态，两阳（风与火）相互熏灼，身体发黄。阳气盛则想流鼻血，阴气虚则小便困难，阴阳俱虚竭，身体干枯，仅头部出汗，至颈部而止，腹部胀满，轻微气喘，口干，咽喉溃烂，或者大便秘结……。”这就是在叙述这一证型。因为风为阳邪，火为阳热，两阳相互熏灼，损伤津液，疾病从燥化，所以在身体发黄之外，小便困难、身体干枯、口咽干燥或大便秘结等燥的症状非常突出。另外第205条：“阳明病，被火攻，额头微微出汗，而小便不利的，一定会发黄。”笔者认为：这一条误用火攻，火热相合，两阳熏灼，消烁津液的情况，与上一条完全相同，所以也将其视为热燥黄疸比较妥当，如果一概认为黄疸病的小便难或小便利都是湿邪没有出路的表现，从而将上述条文都解释为湿热，实际上是错误的。
热燥黄疸的症状表现，主要是热和燥两个方面。但上述两条条文只着重论述了病因病理及燥的表现，关于热的症状描述不是很具体，但《金匮要略·黄疸篇》中“老师说，患黄疸病，发热，心烦气喘，胸满，口干的，是因为发病时用火法劫汗，两热相合所致。然而黄家所得之病，是从湿得来的。全身发热而发黄，肚腹热，热在里，应当用下法。”这一条也是论述热燥黄疸的文章，且对于热的症状描述较详细，可以合参。其中“黄家所得，从湿得之”两句，是插笔。燥湿对举以作权衡，是张仲景作论的常用方法。在论热燥黄疸之时提及湿，目的在于既强调了黄疸毕竟以湿热为常，又告诫黄疸辨证，须就燥化湿化的不同病机，注意作鉴别诊断，有叫人对照勘验的意思。至于用下法治疗，是因热燥两面，处在因热而燥，尚以热为主的情况下，热邪入里，病邪从燥化，必致里结，所以治疗用釜底抽薪、急下以存阴的方法。
刘完素深明张仲景治黄疸以燥湿分论的宗旨，所以《河间六书》说：“大抵凡诸黄者有二，一则湿热气郁而黄，万物皆然，义如麦子秀穗而遇黔雨，湿热过极则黄疸也，及水涝而天气湿热，则草木将死而湿变黄者也；或病血液衰，则虚，燥热太甚，而身面痿黄者，犹亢旱而草木痿黄也，夫病燥热而黄者，当退热润燥而已。”黄宫绣的说法，即基于刘氏之说而来。张石顽也说“黄疸有干有湿”，可惜片言只语，论述不详，为了与临床相印证，现举前人治验一则，以备参考研究：
“朱天一二十多岁，喜欢吃糖及燥烤的各种饼，忽然患病发黄，面目如金色，诊脉两手关部数实有力尽滑，大便六七天不通，小便黄涩，这是土气太过，加上平素嗜好炙火之物，其色必黄，不是湿证，给予小承气汤加当归、白芍，一剂大便通下而痊愈。”（《续名医类案，黄疸》）
按：此案明确说非湿，诊者确有见识，其治方与张仲景论热燥黄疸的条文互参，实在有互为补充、互为说明的妙处，使人很受启迪。可见陈修园“黄疸皆由湿热成”（《医学实在易》）的说法，乃是给初学者说的，如果医者止步于此而不进入张仲景的堂奥，以流于浅薄为满足，这固然不足以与谈论高深的人说话。
燥瘀黄疸
经云：“孙络水溢，则经有留血。”所以津伤与血瘀常可同时发生。若因发热而导致伤津劫液，或热病后期，热邪虽退，阴津不足，因燥致瘀，瘀结发黄的情况也是有的。《金匮要略》：“腹满，舌痿黄，躁不得睡，属黄家”条，即是言此种证型。此条之舌痿是身痿，痿黄是形容黄色枯燥不润泽，与湿病篇的“熏黄”是形容黄晕如油正相反，也宜对照勘验。腹满是胃肠燥结，肠中干粪不去的迹象。躁不得睡，则是热去阴伤的表现。黄疸篇“诸黄，猪膏发煎主之”条，即为燥瘀黄疸提出治法。据前人治验，此方治燥瘀黄疸效果很好。黄疸多属湿热，油腻生湿助热，最为大忌，这是常理。惟独燥瘀黄疸，不但不忌，且可用猪油治疗。《肘后备急方·治卒发黄疸诸黄病第三十一》中说：“伤寒频要疗男子妇人黄疸病医不愈，耳目悉黄，饮食不消，胃中胀热，生黄衣，在胃；中有干屎使病耳，用煎猪脂一小升，温热顿服之，日三，燥屎下乃愈。”《沈氏尊生》也说：“有服对证药不效，耳目皆黄，食不消者，是胃中有干粪也。宜饮熬猪油，量人令禀，或一杯，或半杯，日二次，以燥粪下为度，即愈。”这是单用猪油治黄疸的记载，然而唯燥甚瘀微者为适宜，如瘀甚，古人也有单用血余来治疗的，血余祛瘀而兼能利水，对瘀甚而兼湿者为适宜，若是燥瘀黄疸，则总以猪膏发煎为妥贴。
燥瘀黄疸用猪膏发煎取得显效之治验，可与下“《伤寒论》200条释疑”一文中之例案相互参。
瘀血黄疸
瘀是黄疸常见的病理产物，所以张仲景治疸，常瘀热并提，或瘀湿同治。但瘀血化水或阻滞肝胆等也可以是引起黄疸之因，而且，在一定条件下，瘀血有时还可能成为疸病久治不愈的症结所在。《伤寒论》129条：“太阳病，身黄，脉沉结，少腹硬，小便不利者，为无血也；小便自利，其人如狂者，血证谛也，抵当汤主之。”此后半条是血蓄下焦，瘀血发黄，病不在气分，与湿无涉，故小便自利。《金匮要略》，“酒疸下之，久久为黑疸，目青面黑，心中如啖蒜薤状，大便正黑，皮肤爪之不仁，其脉浮弱，虽黑微黄，故知之，”以及“黄家日晡所发热而反恶寒，此为女劳得之，膀胱急，少腹满，身尽黄，额上黑，足下热，因作黑疸，其腹胀如水状，大便必黑，时溏，此女劳之病，非水也。腹满者难治，硝石矾石散主之。”这两个条文，也是瘀血为主，故有非水也之明示。惟前者病在太阳而属实，故用抵当汤峻攻，后者病在少阴而属虚，故用硝石矾石散缓消。浙江诸暨已故名中医杨则民谓：“张仲景用猪膏发煎治女劳疸。”说明女劳疸既有以瘀为主，以虚为主之分，亦有病从燥化，病从湿化之别。硝石矾石散所治之女劳疸是以瘀为主，虚而兼湿，故以泻为补，行瘀兼以化湿，猪膏发煎所治之女劳疸是以虚为主，瘀而兼燥，故以补为泻，润燥兼以行瘀。
瘀血黄疸的脉证，除上述条文描述者外，也可与“病者如热状，烦满，口干燥而渴，其脉反无热，此为阴伏，是瘀血也，当下之”等论述瘀血的有关条文互参。
现举瘀血黄疸例案二则以资参阅
一、“中翰汪先于病疸，服茵陈五苓不应。八月间，邀石顽诊之，脉弦大而芤，肾伤夹瘀，结积刁二散所致，急乘元气尚可攻击时，用金匮硝石矾石散，兼桂苓丸之剂，以洗涤之，迟则难为力矣。汪氏有业医者，以为药力太峻，不便轻用，旋值公郎乡荐继以公车，未免萦心，不及调治，迨至新正二日，复邀石顽相商，脉转弦而革，真元竭尽无余，半月以来，日眼人参数钱，如石投水……”（《张氏医通》）。
按：虚实之理，原有对待。人谓女劳疸属虚，多不敢用泻药，而后世亦咸以肾气丸为主治，至硝石矾石散一方，遂束之高阁，不独敢用者罕，敢服者亦罕，此案即是一例，良由张仲景大法不明于世故也。
二、“应天王治中遍身发黄，妄言如狂，苦于胸痛，手不可近，此中焦蓄血为患，用桃仁承气汤，一剂，下瘀血而愈。又太守朱阳山弟下部瘀血发狂，用抵当汤而愈”（《续名医类案》）。
按：黄疸病机，多属湿热瘀，但重湿者则曰无湿不成疸，重热者则曰疸以胃家实热为本，重瘀者则曰黄疸必伤血，治疸要活血。实则湿重主以茵陈五苓散，热重主以茵陈蒿汤，瘀重主以抵当汤，原是张仲景之常法。后人偏执其一端，实失张仲景之活法。上案是瘀血黄疸之属实者，故用桃仁承气汤、抵当汤下蓄血而愈。若湿盛热重或正虚者，各宜辨证定方，又当别论，而偏执一端，划地为牢以自囿，诚为黄疸治疗之大忌。
虚寒黄疸房事不节，精血内伤，或脾阳不振，中土失健，虽无湿热，但因气血之败，不能华色，亦可产生疽黄。如太阴黄疸有寒湿与虚寒二个证型，《伤寒论》所论者属寒湿，故有“小便白利者，不能发黄。”“伤寒发汗已，身目为黄，所以然者，以寒湿在里不解故也”等论述。《金匮要略》中所论者属虚寒，故曰；“男子黄，小便自利，当予虚劳小建中汤。”“黄疸病，小便色不变，欲自利……”等论述。此外，《金匮要略》“额上黑，微汗出，手足中热，薄暮即发，膀胱急，小便自利，名曰女劳疸。”以及“尺脉浮为伤肾”，“女劳之病，非水也，”等条文所述，虽不属太阴黄疸而属少阴黄疸，但也属虚寒而不是因于湿，故后人每用畜鱼置介法治疗。诚因虚寒黄疸非因于湿，故小便自利，且色亦可不变。而寒湿黄疸，则与湿热黄疸一样，同样与湿邪排泄不畅有关，故均有小便不利并色变黄之征。当然，寒湿者可以兼虚，虚寒者可以兼湿，瘀热者可以挟湿，湿热者亦多兼瘀，但这是另一个问题，宜当别论。
现举虚寒黄疸治案一则如下
“柴屿青治觉罗马德夫人病疸，医投茵陈五苓散未效，又合末药服之，肌肤白，眼皆如金色，转致不思饮食，右关缓弱特甚。柴曰：胃为水谷之海，脾为仓禀之官，腑脏失职，湿热滋甚，今唯有调其土，使能健运，湿热自去，不必治疸，而疸自愈矣，六君子汤加厚朴、炮姜以温中，神曲、麦芽以助戊巳之化，不数剂而全愈。”（《续名医类案》）
按：泛用苦寒清利以治疸之时弊，前人早巳论及，儿科于此，尤须注意，陈复正云：“小儿黄病，昧者一概呼为湿热。无非除湿利水，清热退黄，除此之外，无别法矣，岂知湿热发黄者少，脾虚发黄者多。盖脾土强者，足以悍御湿邪，必不生黄，惟其脾虚不运，所以湿来乘之。”湿热发黄少，脾虚发黄多，在儿科者或如是，成人则究亦以湿热黄疸为居多，但虚寒黄疸亦不可忽视，上案虚作实治，泛用清利，反致增疾之覆辙，今人亦有重蹈者，此所以余尝有治疸须重脾之论也。
疫毒瘟黄
瘟黄张仲景书中未见记载，其名出自《明医杂著》，实即急黄，急黄最早见载于《诸病源候论》，认为是：“因为热毒所加”而致。《杂病源流犀烛》认为是感受“天行疫疠”之气，故亦可称为疫毒急黄。此种黄疸的临床表现具有发病急，病势重的特点，常一患病即出现卒然身黄，迅速加深，黄色如金，心满气喘，高热口渴，尿如柏汁；腹胀胁痛，神昏谵语，烦躁，脉弦数或细数，舌红绛，苔黄燥，吐衄便血，身见斑疹，或出现腹水昏迷等证。这种急剧症状的出现，与病因属特殊的热毒疫气，不同于一般的湿热有关。从其病理变化来看，此种热毒之邪很易内陷心包，入侵营血，故化燥伤阴较速。其治疗以清热解毒、凉血滋阴、清心开窍为大法，一般用犀角散为主方，配合生地、丹皮、玄参类的凉血滋阴药以及金花汤，牛黄丸一类的清热解毒、清心开窍剂加减。此证有时虽亦可挟湿，但由于病因主要是热毒，且每从燥化，故也是一种非湿黄疸。若与热燥黄疸比较，彼之病因非疫毒，此则是疫毒为患，故证有轻重之殊。囿于“黄疸无湿不成”之认识者，由于论疸不离一个“湿”字，谓此证亦是“湿热挟毒”，实属不妥。此证无论就病因论，从病机看，或结合治疗分析，均不得谓是湿作祟。
结语：论黄疸若只强调湿热，或只强调瘀热，而全然不知有燥化非湿之诸证型，这种认识是片面的，须知张仲景治疸之法，有麻黄连翘赤小豆汤的汗法；抵当汤的下法；栀子豉汤的吐法；栀子柏皮汤的清法星小柴胡汤的和法，小建中汤的补法，硝石矾石散的消法；于寒湿中求之的温法；茵陈五苓散的利法，猪膏发煎的润法等等。其层次之明，法度之严，方药之细，均可师可法。如单就阳黄论，则在太阳分经府气血，入阳明别吐清下润，在少阳立疏和通泄，治亦不同，凡此均足以说明，张仲景并不专执一法一方以泛治。若此而不知，竟以“湿，热、瘀”三字作茧自缚，唯知以清热利湿行瘀之品杂凑成方为用，是划地为牢，自陷于狭隘。一字真传空费解三生幻相尽随缘2005/11/3020:09三七生管理员积分20145发帖18080注册2005/7/8#4《伤寒论》第200条释疑①
《伤寒论》第200条的原文是：“阳明病，脉迟，食难用饱，饱则微烦头眩，必小便难，此欲作谷疸。虽下之，腹满如故。所以然者，脉迟故也。"此条亦见于《金匮要略·黄疸篇》，仅“微烦”作“发烦”。历代医家对此条的解释很不一致。笔者不揣谫陋，略谈己见，以供参考。
一、历代医家的几种解释
历代医家对此条的解释，约有五种：
1·认为是阳明(胃)中寒证。考历代之注《伤寒论》，持此种观点者甚众，如柯琴、方有执、程云来、舒弛远、程应旄等。成都中医学院主编的《伤寒论讲义》也持此说：“阳明病脉应沉大或沉实，今脉迟，是胃阳虚弱，阳明中寒证。"②
2·认为是阳明(经脉)虚寒证。张隐庵说此条是“言阳明经脉虚寒而成谷疽也。……病在经脉，虽下之而腹满如故，所以然者，以脉迟而经脉虚寒故也。”③一般说，阳明病有传有中，传是从经脉传，中是直中于里，所传为热，所中属寒。此外，尚有认为是经脉虚寒证者，则第236条；“阳明病，脉迟，汗出多，微恶寒者，可发汗，宜桂枝汤。”即指此言。
3·认为是阳明经热证。成无己说：“阳明病脉迟，则邪方入里，热未为实也。食入于阴，长气于阳。胃中有热，食难甩饱，……脉迟为热气未实，虽下之，腹满亦不减也”④成氏所说的意思是虽有热，但尚未形成阳明腑实证，仍是阳明经热证。
If heat disease is treated incorrectly, the heat scorches and damages body fluids, pathogens transform into dryness due to heat, and jaundice occurs due to heat-dryness. For example, Article 114 of *Shanghan Lun* states: "In Taiyang disease with wind-stroke, if forced sweating is induced by fire therapy, the pathogenic wind is subjected to intense heat, causing blood and qi to overflow and lose their normal rhythm. The mutual scorching of two Yangs (wind and fire) leads to yellowing of the body. Excess Yang may cause epistaxis, while Yin deficiency leads to difficult urination. When both Yin and Yang are depleted, the body becomes dry and withered. Sweat appears only on the head, stopping at the neck; abdominal fullness, slight wheezing, dry mouth, and throat ulceration may occur, or constipation..." This describes this specific syndrome pattern. Since wind is a Yang pathogen and fire is Yang-heat, their mutual scorching damages fluids, leading the disease to transform into dryness. Thus, besides yellowing of the body, symptoms of dryness such as difficult urination, bodily dryness, dry mouth and throat, or constipation are prominent. Additionally, Article 205 states: "In Yangming disease, after being subjected to fire therapy, if there is slight sweating on the forehead but difficulty in urination, jaundice will certainly develop." The author believes that this case of incorrect fire therapy, where heat and fire combine and scorch each other, consuming body fluids, is identical to the previous article. Therefore, it is appropriate to view it as heat-dryness jaundice. If one generally assumes that difficult or obstructed urination in jaundice is merely a manifestation of dampness lacking an exit route, and interprets all these articles as damp-heat, it is actually erroneous.
The symptom manifestations of heat-dryness jaundice mainly involve heat and dryness. However, the aforementioned two articles focus primarily on etiology, pathology, and dryness manifestations, with less specific description of heat symptoms. In contrast, the section in *Jinkui Yaolue · Jaundice Chapter* says: "The Master said, regarding jaundice patients who experience fever, irritability, wheezing, chest fullness, and dry mouth, this is because fire therapy was used to induce sweating during the onset of the disease, combining two heats. However, jaundice arises from dampness. When the whole body is hot and yellow, with heat in the abdomen indicating interior heat, purgative methods should be used." This article also discusses heat-dryness jaundice, providing more detailed descriptions of heat symptoms, and can be consulted together. The phrases "jaundice arises from dampness" are inserted remarks. Contrasting dryness and dampness for balance is a common method used by Zhang Zhongjing in his treatises. Mentioning dampness when discussing heat-dryness jaundice serves to emphasize that jaundice is commonly associated with damp-heat, while also warning that differentiation must consider the different pathological mechanisms of dryness transformation versus dampness transformation, serving as a reminder for comparative diagnosis. The use of purgative methods is justified because, in the context of heat transforming into dryness where heat is still predominant, pathogenic heat entering the interior and transforming into dryness inevitably leads to interior accumulation. Therefore, treatment employs the method of removing fuel from under the cauldron (clearing heat from the source) and urgent purgation to preserve Yin.
Liu Wansu deeply understood Zhang Zhongjing's principle of differentiating jaundice based on dryness and dampness. Thus, *Hejian Liushu* states: "Generally, there are two types of jaundice. One is caused by damp-heat stagnation, similar to how wheat turns yellow after excessive rain due to extreme damp-heat, or how grass and trees turn yellow and die during floods with humid weather; the other is due to blood deficiency leading to emptiness, where extreme dry-heat causes the body and face to become withered and yellow, like plants turning yellow and withering during severe drought. For jaundice caused by dry-heat, one should clear heat and moisten dryness." Huang Gongxiu's theory is based on Liu's views. Zhang Shiweng also stated, "Jaundice can be dry or damp," but his comments were brief and lacked detailed explanation. To verify with clinical practice, here is a past medical case for reference:
"Zhu Tianyi, in his early twenties, had a habit of eating sugar and various baked cakes. He suddenly developed jaundice, with his face and eyes appearing golden. His pulse at both Guan positions was rapid, excess, forceful, and slippery. He had not had a bowel movement for six or seven days, and his urine was yellow and astringent. This indicates excessive Earth element, compounded by his preference for roasted foods, leading to yellowing. It is not a dampness syndrome. He was given Xiao Chengqi Tang added with Danggui (Angelicae Radix) and Baishao (Paeoniae Radix Alba). After one dose, his bowels moved, and he recovered." (*Xu Mingyi Leian, Jaundice*)
Note: This case explicitly states it is not dampness, showing the physician's insight. Comparing this treatment with Zhang Zhongjing's discussion on heat-dryness jaundice reveals mutual supplementation and clarification, offering great inspiration. Thus, Chen Xiuyuan's statement in *Yixue Shizai Yi* that "all jaundice is formed by damp-heat" is intended for beginners. If physicians stop here without delving into the depths of Zhang Zhongjing's theories, content with superficial understanding, they cannot discuss profound matters.
Dryness-Stasis Jaundice
The Classics state: "When fluid overflows from Sunluo collaterals, stagnant blood remains in the main vessels." Therefore, fluid injury and blood stasis often occur simultaneously. If fever causes fluid damage, or in the late stage of heat disease, although the heat has subsided, Yin fluids are insufficient, leading to stasis due to dryness and yellowing due to stasis accumulation, this condition does exist. *Jinkui Yaolue* states: "Abdominal fullness, tongue withered and yellow, restlessness preventing sleep, belongs to the Jaundice family." This refers to this syndrome type. Here, 'tongue withered' refers to bodily withering, and 'withered yellow' describes a dry, non-lustrous yellow color, which is opposite to the 'smoked yellow' described in the Dampness Disease chapter (describing a greasy, oily yellow hue), and should be compared. Abdominal fullness indicates intestinal dryness and accumulation, a sign of dry feces remaining in the intestines. Restlessness preventing sleep indicates heat subsiding and Yin injury. The article "All jaundices are treated with Pig Fat and Hair Decoction" in the Jaundice chapter provides the treatment method for dryness-stasis jaundice. According to past cases, this formula is very effective for dryness-stasis jaundice. Generally, jaundice is attributed to damp-heat, and greasy foods generate dampness and aid heat, which is strictly contraindicated. However, for dryness-stasis jaundice, this is not only not contraindicated but pig fat can be used. *Zhouhou Beiji Fang · Treating Sudden Onset Jaundice and Various Yellows, Chapter 31* states: "For men and women with jaundice unresponsive to medical treatment, with yellow eyes and ears, indigestion, stomach bloating and heat, and dry stool in the stomach causing illness, use one sheng of boiled pig fat, take warm in one dose, three times a day. Recovery occurs when dry stool passes." *Shenshi Zunsheng* also states: "For those whose symptoms do not improve with correct medication, with yellow eyes and ears and indigestion, there is dry stool in the stomach. It is suitable to drink boiled pig oil, according to the person's capacity, either one cup or half a cup, twice a day, until dry stool passes, then recovery." This records the use of pure pig oil for jaundice, suitable only when dryness is severe and stasis is mild. If stasis is severe, ancients sometimes used solely Xuerou (Human Hair Charcoal) for treatment, which removes stasis and promotes diuresis, suitable for severe stasis with dampness. For dryness-stasis jaundice, Pig Fat and Hair Decoction is always the most appropriate choice.
Effective cases of treating dryness-stasis jaundice with Pig Fat and Hair Decoction can be cross-referenced with the case study in the article "Clarification of Article 200 of Shanghan Lun" below.
Blood Stasis Jaundice
Stasis is a common pathological product of jaundice, so Zhang Zhongjing often mentions stasis and heat together, or stasis and dampness together, when treating jaundice. However, stasis transforming into water or blocking the Liver and Gallbladder can also cause jaundice. Under certain conditions, blood stasis may even be the crux of chronic, untreatable jaundice. *Shanghan Lun* Article 129 states: "In Taiyang disease, if the body is yellow, pulse is deep and knotted, lower abdomen is hard, and urination is difficult, it is no blood stasis; if urination is free, and the patient acts like a madman, it is definitely a blood syndrome, treated with Didang Tang." The latter half of this article describes blood accumulation in the Lower Jiao, with yellowing due to blood stasis. The disease is not in the Qi level and is unrelated to dampness, hence urination is free. *Jinkui Yaolue* states: "If Jiudu (wine jaundice) is treated with purgatives, it eventually becomes Hei Du (Black Jaundice), with blue eyes and black face, a sensation in the heart like eating garlic shoots, black stool, skin numbness, floating and weak pulse, though black slightly yellow, thus known." And: "Jaundice patients who feel feverish at dusk but instead have aversion to cold, this is obtained from female labor. Bladder urgency, lower abdominal fullness, whole body yellow, black forehead, hot feet, leading to Black Jaundice. Abdominal distension like water accumulation, stool must be black, occasionally loose. This is a disease of female labor, not water retention. Abdominal fullness is difficult to treat, treated with Xiaoshi Fanshi San." These two articles also emphasize blood stasis as primary, hence the explicit statement "not water retention." The former is Taiyang disease and excess, treated with aggressive Didang Tang; the latter is Shaoyin disease and deficiency, treated with gentle Xiaoshi Fanshi San. The late famous TCM practitioner Yang Zemin from Zhuji, Zhejiang, stated: "Zhang Zhongjing uses Pig Fat and Hair Decoction to treat Female Labor Jaundice." This indicates that Female Labor Jaundice can be primarily stasis or primarily deficiency, and can transform via dryness or dampness. Xiaoshi Fanshi San treats Female Labor Jaundice primarily due to stasis, deficiency with dampness, using purgation as tonification, moving stasis while resolving dampness. Pig Fat and Hair Decoction treats Female Labor Jaundice primarily due to deficiency, stasis with dryness, using tonification as purgation, moistening dryness while moving stasis.
Regarding the pulse and symptoms of blood stasis jaundice, besides the descriptions above, they can be cross-referenced with relevant articles on blood stasis such as: "The patient feels like having heat, irritability and fullness, dry mouth and thirst, but the pulse shows no heat. This is hidden Yin [stasis], it is blood stasis, should be purged."
Here are two cases of blood stasis jaundice for reference:
One: "Wang Xianyu, a Hanlin Academician, suffered from jaundice and did not respond to Yinchen Wuling San. In August, I invited Shiwan to diagnose him. The pulse was wiry, large, and hollow. Kidney injury with stasis, caused by accumulation, treated urgently with Jin Gui Xiaoshi Fanshi San combined with Guiling Wan to cleanse it before it becomes difficult to manage. Wang had a physician in his family who thought the medicine was too harsh and hesitant to use it lightly. Soon after, his son passed the provincial exams and entered the capital examinations, causing mental distress and lack of proper treatment. By the second day of the New Year, he invited Shiwan again. The pulse turned wiry and革 (leather-like), true Yuan essence completely exhausted. For half a month, taking several qian of Ren Shen daily was like throwing a stone into water..." (*Zhangshi Yitong*).
Note: The principles of deficiency and excess are relative. People say Female Labor Jaundice is deficiency, so few dare to use purgatives, and later generations mostly use Shenqi Wan as the main treatment, leaving Xiaoshi Fanshi San neglected. Not only are few daring to use it, but few dare to take it. This case is an example, largely because Zhang Zhongjing's major principles were not clear to the world.
Two: "Yingtian Wang Zhizhong had generalized yellowing, spoke wildly like a madman, suffered from chest pain intolerable to touch. This was blood accumulation in the Middle Jiao. Used Taoren Chengqi Tang. After one dose, stasis blood was passed and he recovered. Also, the younger brother of Prefect Zhu Yangshan had lower body blood stasis causing madness, cured with Didang Tang." (*Xu Mingyi Leian*).
Note: The pathogenesis of jaundice is mostly damp-heat-stasis. Those emphasizing dampness say "no dampness, no jaundice"; those emphasizing heat say "jaundice is based on stomach excess heat"; those emphasizing stasis say "jaundice must injure blood, treating jaundice requires moving blood." Actually, heavy dampness is primarily treated with Yinchen Wuling San, heavy heat with Yinchen Hao Tang, and heavy stasis with Didang Tang. This is Zhang Zhongjing's standard method. Later generations adhering to one aspect lost Zhang Zhongjing's flexible approach. The above case is an excess type of blood stasis jaundice, so Taoren Chengqi Tang and Didang Tang were used to purge accumulated blood and achieve recovery. If dampness is abundant, heat is heavy, or Zheng Qi is deficient, formulas should be determined by differentiation, which is a separate discussion. Adhering rigidly to one aspect and limiting oneself is indeed a major taboo in jaundice treatment.
Deficiency-Cold Jaundice
Excessive sexual activity injuring essence and blood, or Spleen Yang failing to rise causing Middle Earth dysfunction, can produce jaundice even without damp-heat, due to the failure of Qi and Blood to nourish the complexion. For example, Taiyin Jaundice has Cold-Damp and Deficiency-Cold patterns. The *Shanghan Lun* discusses Cold-Damp, stating: "If urine is white and clear, jaundice cannot develop." "After sweating in cold damage, if the body and eyes turn yellow, it is because cold-damp lingers in the interior." The *Jinkui Yaolue* discusses Deficiency-Cold, stating: "For men with yellow complexion and free urination, give Xu Lao Xiao Jianzhong Tang." "In jaundice disease, if urine color does not change and there is desire for spontaneous diarrhea..." Additionally, *Jinkui Yaolue* states: "Black forehead, slight sweating, heat in hands and feet, occurring at dusk, bladder urgency, free urination, named Female Labor Jaundice." And "Floating pulse at Chi position indicates Kidney injury," "Female labor disease is not water retention." Although these do not belong to Taiyin Jaundice but to Shaoyin Jaundice, they are also deficiency-cold and not due to dampness. Hence, later generations often used the method of keeping fish in water/mollusks (metaphor for retaining moisture/nourishing). Indeed, because deficiency-cold jaundice is not due to dampness, urination is free and color may not change. In contrast, Cold-Damp Jaundice, like Damp-Heat Jaundice, is related to poor discharge of dampness, hence both present with difficult urination and yellowing. Of course, Cold-Damp can coexist with deficiency, Deficiency-Cold with dampness, Stasis-Heat with dampness, and Damp-Heat often with stasis, but these are separate issues requiring distinct discussion.
Here is a case of deficiency-cold jaundice treatment:
"Chai Yuqing treated Lady Luode's jaundice. Physicians administered Yinchen Wuling San without effect, and she also took powdered medicines. Her skin became pale, eyes golden, leading to loss of appetite. The Right Guan pulse was particularly slow and weak. Chai said: The Stomach is the sea of water and grain, the Spleen is the official of granaries. When organs fail in their duties, damp-heat proliferates. Now we must regulate the Earth element to enable healthy transportation, so damp-heat will naturally disappear. There is no need to treat jaundice directly, and jaundice will heal itself. Use Liujunzi Tang added with Houpo and Paojiang to warm the middle, Shenqu and Maiya to assist the transformation of Wu and Si (Earth elements). After a few doses, she fully recovered." (*Xu Mingyi Leian*)
Note: The弊端 (drawbacks) of indiscriminately using bitter-cold and draining herbs to treat jaundice were discussed by ancients long ago, especially in pediatrics. Chen Fuzheng stated: "For children's jaundice, ignorant people call it all damp-heat. They only use methods to remove dampness, promote diuresis, clear heat, and reduce jaundice, claiming no other methods exist. How can they know that few cases are damp-heat jaundice, while many are Spleen deficiency jaundice? Strong Spleen Earth can resist dampness and prevent jaundice; only when Spleen is deficient and fails to transport does dampness invade." While damp-heat jaundice may be rare and Spleen deficiency common in pediatrics, adults mostly suffer from damp-heat jaundice, but deficiency-cold jaundice should not be ignored. The above case treated deficiency as excess, using indiscriminate clearing and draining, worsening the disease. Modern practitioners repeat this error, which is why I once argued that treating jaundice must prioritize the Spleen.
Epidemic Toxic Plague Jaundice
Plague Jaundice is not recorded in Zhang Zhongjing's books; its name comes from *Mingyi Zazhu*, essentially equivalent to Ji Huang (Acute Jaundice). Ji Huang first appeared in *Zhubing Yuanhou Lun*, attributed to "addition of heat toxins." *Zabing Yuanliuxizhu* attributes it to contracting "epidemic pestilence Qi," so it can also be called Epidemic Toxic Acute Jaundice. The clinical manifestations of this jaundice feature sudden onset and severe progression. Patients often present with sudden yellowing, rapidly deepening to golden yellow, chest fullness and wheezing, high fever and thirst, urine like dark soy sauce, abdominal distension and hypochondriac pain, coma and delirium, irritability, wiry-rapid or fine-rapid pulse, red/crimson tongue with dry yellow coating, hematemesis, epistaxis, melena, petechiae/ecchymosis, or complications like ascites and coma. The appearance of these acute symptoms is related to the etiology being special heat-toxic epidemic Qi, differing from general damp-heat. Pathologically, this heat-toxic pathogen easily penetrates into the Pericardium and invades Ying and Blood levels, causing rapid transformation into dryness and Yin injury. Treatment primarily involves clearing heat, detoxifying, cooling blood, nourishing Yin, clearing the Heart, and opening the orifices. Generally, Xijiao San is used as the main formula, combined with cooling-blood and nourishing-Yin herbs like Shengdi, Danpi, and Xuanshen, and heat-clearing, detoxifying, and orifice-opening agents like Jinhua Tang and Niuhuang Wan. Although this syndrome can sometimes involve dampness, since the etiology is mainly heat-toxin and it often transforms into dryness, it is also a non-damp jaundice. Compared to heat-dryness jaundice, the former's etiology is not epidemic toxin, while this one is caused by epidemic toxin, hence differences in severity. Those constrained by the belief that "no dampness, no jaundice," focusing solely on "dampness" in jaundice discussions, and claiming this syndrome is "damp-heat with toxin," is inappropriate. Whether analyzing etiology, pathogenesis, or treatment, this syndrome cannot be attributed to dampness.
Conclusion: Discussing jaundice by only emphasizing damp-heat or stasis-heat, while completely ignoring non-damp syndromes involving dryness transformation, is one-sided. One must know that Zhang Zhongjing's methods for treating jaundice include the sweating method of Mahlian Liaoqiao Chixiaodou Tang; the purgative method of Didang Tang; the vomiting method of Zhizi Chi Tang; the clearing method of Zhizi Bopi Tang; the harmonizing method of Xiao Chaihu Tang; the tonifying method of Xiao Jianzhong Tang; the reducing method of Xiaoshi Fanshi San; the warming method sought within cold-damp; the draining method of Yinchen Wuling San; and the moistening method of Zhigao Faxian. Its clarity of levels, strictness of methods, and detail of prescriptions are worthy of emulation. Even discussing only Yang Jaundice, treatments differ by Taiyin (distinguishing meridians, fu-organs, Qi, and Blood), Yangming (distinguishing vomiting, clearing, purging, moistening), and Shaoyang (establishing dispersing, harmonizing, unblocking, draining). All this illustrates that Zhang Zhongjing did not adhere rigidly to a single method or formula for general treatment. Ignoring this and binding oneself with the three characters "damp, heat, stasis," merely compounding heat-clearing, damp-draining, and stasis-moving herbs into formulas, is self-limiting and narrow-minded. A true transmission of one character is empty understanding; three lives of illusions follow fate. 2005/11/30 20:09 Sanqisheng Administrator Points 20145 Posts 18080 Registered 2005/7/8 #4 Clarification of Article 200 of Shanghan Lun ①
The original text of Article 200 of *Shanghan Lun* is: "Yangming disease, pulse is slow, food intake is difficult to tolerate fullness, after eating slight irritability and dizziness occur, urination must be difficult, this is about to become Grain Jaundice. Even if purged, abdominal fullness remains as before. The reason is the slow pulse." This article also appears in *Jinkui Yaolue · Jaundice Chapter*, with "slight irritability" written as "onset of irritability." Interpretations by physicians through the ages have been inconsistent. Without presuming my limited knowledge, I briefly share my views for reference.
I. Several Interpretations by Physicians Through the Ages
There are approximately five interpretations of this article by physicians through the ages:
1. Considered as Cold Syndrome in Yangming (Stomach). Many annotators of *Shanghan Lun* hold this view, such as Ke Qin, Fang Youzhi, Cheng Yunlai, Shu Chiyuan, Cheng Yingmao, etc. The *Shanghan Lun Lecture Notes* edited by Chengdu University of TCM also holds this view: "In Yangming disease, the pulse should be deep-large or deep-excess. Now the pulse is slow, indicating Stomach Yang deficiency, Yangming Middle Cold Syndrome." ②
2. Considered as Deficiency-Cold Syndrome of Yangming (Meridians). Zhang Yinan stated this article is "discussing Yangming meridian deficiency-cold forming Grain Jaundice... The disease is in the meridians; even if purged, abdominal fullness remains. The reason is the slow pulse indicating meridian deficiency-cold." ③ Generally, Yangming disease involves transmission and direct invasion. Transmission is from meridians, carrying heat; direct invasion is into the interior, carrying cold. Additionally, some consider the meridian deficiency-cold syndrome to refer to Article 236: "Yangming disease, pulse slow, much sweating, slight aversion to cold, can be sweated, suitable for Guizhi Tang."
3. Considered as Heat Syndrome of Yangming Meridian. Cheng Wuji stated: "In Yangming disease, if the pulse is slow, the pathogen is just entering the interior, heat is not yet solid. Food enters Yin and generates Qi in Yang. Heat in the Stomach makes it difficult to eat full... Slow pulse indicates heat Qi is not yet solid; even if purged, abdominal fullness does not decrease." ④ Mr. Cheng's meaning is that although there is heat, it has not yet formed Yangming Fu-organ excess syndrome, remaining as Yangming Meridian Heat Syndrome.