湿热俱甚。则发黄。阳明热胜。如橘黄而明。太阴湿胜。如熏黄而晦。
邵评∶发黄有因热因湿之不同。热属阳明而色明亮者。阳黄也。湿属太阴而色晦暗者。
阴黄也。故治发黄。当辨其湿热阴阳之不同。
太阳蓄血亦发黄。但以小便不利。为湿热发黄。小便自利。为蓄血发黄也。
邵评∶蓄血有身黄一症。非蓄血必发黄也。此以发黄之小便不利。借证蓄血之小便自利。非以蓄血发黄
二症对勘也。其实以湿热之小便不利。借证蓄血之小便自利耳。
又评∶蓄血有身黄者。非发黄因于蓄血也。不可以湿热发黄与蓄血发黄对列。
盖发黄因外则汗不得泄。内则小便不利。以致湿邪瘀热。郁而成黄。故湿热发黄。小便不利。蓄血不
在气分。且小便自利。则内之湿邪瘀热已得外泄。何能发黄。要知蓄血与发黄。无并见之理。热于膀胱。
则为发黄。血结膀胱。则为蓄血。病之在气在血。有形无形。截然相反。若果太阳发黄。用治蓄血
之峻剂抵当汤。服之。则前阴下血如泉而立毙。蓄血而亦言发黄。其误非小。故特辨之。
蓄血发黄。脉沉细而结。湿热发黄。脉浮滑而数。
邵评∶此辨蓄血湿热发黄脉象之不同。
蓄血发黄。则便利而清。湿热发黄。则便黄而浊。
邵评∶此以便之黄浊清利。辨发黄蓄血。
太阳失表。瘀热在里。表实无汗。小便不利。身体发黄者。麻黄连翘赤小豆汤主之。使黄从汗解也。
邵评∶太阳失于发表。外无汗出。而内则小便不利。热入于里而不外越。谓之瘀热。热蒸
发黄。此热瘀而未实之症也。因其有表里症。故用麻黄、杏仁、生姜之发
汗散表。赤豆、梓白皮、连翘根之苦寒清热而利水也。盖发黄热瘀而未实。故以
发汗清利。双解表里为治。
阳明病。遍身无汗。但头汗出。小便不利。渴欲饮水者。是热不得越。瘀于里而发黄
也。茵陈蒿汤主之。使黄从下解。
邵评∶此阳明湿热发黄之症。但头汗而身无汗。郁热上熏而邪不外达也。小便不利。其热又不得下泄。
而又渴欲饮水。则热之蓄于内者方炽。而湿之引于外者无已。湿与热合。瘀郁不解。未能表达里通。
势必蒸发为黄矣。用茵陈蒿汤苦寒通泄。使内瘀之湿热下趋。则黄从便出而下解也。此条伤寒论原文有
腹满一症。因邪不得外泄下通。郁热为黄。邪深入里而腹满。为阳明热实之症。故方
中用大黄清湿而下里实也。
太阴病小便不利。湿土为热所蒸而发黄者。茵陈五苓散主之。使黄从小便而解。
邵评∶太阴湿伏。不从小便而下泄。遏于内而蒸热为黄。此太阴湿热症也。用五苓散宣化膀胱之气而利
小便。加茵陈以清渗湿热也。盖太阴湿郁蒸热为黄。热而未实。当宣其气化。使邪从小便而解。
瘟疫论云。疫邪传里。遗热下焦。小便不利。邪无输泄。经气郁滞。其传为疸。身目如
金。宜茵陈蒿汤。若用茵陈五苓散。不但不能退黄。即小便亦难利。此乃胃家移热。是以大黄有专功也。
邵评∶瘟疫湿浊之邪传入阳明。热在中下二焦。结而成实。气不宣通。郁而为黄。
此阳黄实热。用茵陈蒿汤。下其热实也。盖疫邪热入于里。阳明胃家热而成实。故用茵陈蒿汤下其热实。
与上条湿热发黄。热而未实者不同也。
伤寒身热发黄。无表里症者。栀子柏皮汤主之。
邵评∶此阳明之经症。表无邪郁。里未成实。故曰无表里症。乃身热发黄热瘀阳明经也。故但治以清热。
凡发黄。热多脉必数。一身不痛。解毒为主。湿多脉必缓。一身尽痛。渗湿为主。
邵评∶热盛阳明。蒸郁为黄。脉数而身不痛者。阳黄也。清热解毒治之。太阴湿胜。
滞气为黄。脉缓身痛。湿入经络。而为阴黄。渗湿行气主之。惟热黄脉数属阳明。湿黄脉缓属太阴。
阳明发黄。热多。二便俱秘。茵陈蒿汤。
邵评∶此阳明热实发黄之正法。
太阴发黄。湿多。小便不利。茵陈五苓散。
邵评∶此太阴湿郁发黄之正法。
身热发黄。无表里症。栀子柏皮汤。
邵评∶此阳明经瘀热发黄之治法。方中宜再加泽兰、红曲以消瘀。以上论阳黄症。
发黄汗出身冷。脉沉迟。小便不利。口不渴者。阴黄症也。五苓散加干姜、茵陈。二便俱利者。
理中汤加茵陈。
伤寒遇辰戌丑未年。太阳太阴司天。医用寒凉太过。往往有阴黄之症。脉沉迟。肢体冷。而发
黄者。宜理中汤加茵陈主之。小水不利。理中加二苓官桂。呕者理中合二陈生姜。若天久霪雨。湿令
大行。又当理中合平胃为当。甚者加附子。
邵评∶寒水湿土当令之年。如其人阳气本虚。偶受湿邪。医者过用寒凉。伤其中阳。而成阴黄
之症。所见脉症。俱是阴寒之象。与阳黄之热实者大相迳庭。用理中汤加茵陈。温运中阳而化湿也。
阴寒甚者。当加附子以扶阳泄浊为治。若中
阳虚弱。寒湿内伏。阳气不得宣化。而小水不利。加苓、桂以通阳利水。呕者。胃虚有寒痰也。合二陈
生姜。以和其胃气而化痰饮。惟久雨湿盛。阴浊之气太甚。脾胃中土受戕。故用理中温运中宫。合平
胃除湿化邪。此脾阳虚弱。寒湿内伏而成阴黄。治以温中化湿为主。
脾绝似黄症。一身尽黄。寸口无脉。鼻中冷气。摇头直视。环口黧黑。形如烟煤。此脾
家真气绝。非发黄也。第一书云。胆气绝。则面黄。脾气绝。则身黄。此皆黄如土色。干枯无神气者也。
邵评∶脾为阴土。黄者。土之本色也。脾阳衰乏。阳气不运。故寸口无脉。阳微欲绝。
则气冷不温。所见各症。纯是一派阴浊用事。微阳将欲埋没。脾之真气告绝。土之本色。发露无余而外现。
故一身尽见黄色。此脏绝之症。与发黄之有外邪者各殊也。
金鉴云。环口黧黑冷汗者。阴黄死证也。身体枯燥如烟熏者。阳黄死证也。
邵评∶阴黄阳绝则死。阳黄阴竭亦死。
When damp-heat pathogens are both severe, jaundice (yellowing of the skin and eyes) occurs. If heat is predominant in the Yangming channel, the yellow color is bright and lustrous like an orange peel; if dampness is predominant in the Taiyin channel, the yellow color is dull and dark like something smoked.
Shao's Commentary: Jaundice differs depending on whether it is caused by heat or dampness. Heat belongs to the Yangming channel, and a bright color indicates Yang Jaundice. Dampness belongs to the Taiyin channel, and a dark color indicates Yin Jaundice. Therefore, when treating jaundice, one must distinguish between the differences in damp-heat and yin-yang.
Blood stasis accumulation in the Taiyang channel can also cause jaundice, but it is distinguished by urination: urinary difficulty indicates damp-heat jaundice, while spontaneous free urination indicates blood stasis jaundice.
Shao's Commentary: Blood stasis syndrome has the symptom of body yellowing, but blood stasis does not necessarily cause jaundice. Here, the urinary difficulty of damp-heat jaundice is used to contrast with the spontaneous free urination of blood stasis, rather than comparing the two symptoms of "blood stasis jaundice" directly. In essence, it uses the urinary difficulty caused by damp-heat to corroborate the spontaneous free urination of blood stasis.
Further Commentary: The body yellowing seen in blood stasis is not jaundice caused by blood stasis. One should not list damp-heat jaundice and blood stasis jaundice side by side. Generally, jaundice arises because external pathogens prevent sweat excretion, and internally, urinary difficulty leads to the stagnation of dampness and stagnant heat, which condense to form yellow. Thus, in damp-heat jaundice, there is urinary difficulty. Blood stasis resides in the blood level, not the qi level, and features spontaneous free urination, meaning internal dampness and stagnant heat have been externally discharged; how could jaundice form? It must be understood that blood stasis and jaundice do not coexist. Heat in the Bladder causes jaundice; blood coagulation in the Bladder causes blood stasis. Pathology in the qi level versus the blood level, and有形 (solid/form) versus 无形 (formless), are截然 opposite (completely distinct). If Taiyang jaundice were mistakenly treated with the harsh formula Didang Tang (Cassia Twig and Fermented Soybean Decoction) for blood stasis, bleeding from the anterior orifice would gush like a spring, leading to immediate death. Discussing jaundice in the context of blood stasis is a significant error, hence this clarification.
The pulse in blood stasis jaundice is deep, fine, and knotted. The pulse in damp-heat jaundice is floating, slippery, and rapid.
Shao's Commentary: This distinguishes the pulse presentations of blood stasis jaundice versus damp-heat jaundice.
In blood stasis jaundice, bowel movements are smooth and clear. In damp-heat jaundice, stool is yellow and turbid.
Shao's Commentary: This differentiates jaundice from blood stasis based on whether the stool is yellow/turbid or clear/smooth.
If Taiyang disease fails to resolve the exterior, causing stagnant heat to remain inside, with exterior excess, no sweating, urinary difficulty, and body yellowing, Mahuang Lianqiao Xiaodou Tang (Ephedra, Forsythia, and Red Bean Decoction) is the primary treatment, allowing the jaundice to resolve through sweating.
Shao's Commentary: Failure to release the exterior in Taiyang disease results in no external sweat and internal urinary difficulty. Heat enters the interior without dispersing outward, termed stagnant heat. Heat steaming causes jaundice; this is a condition where heat is stagnant but not yet solidified. Since there are both exterior and interior signs, Mahuang, Xingren, and Shengjiang are used to induce sweating and disperse the exterior, while Chidou, Zibai Pi, and Lianqiao Gen are used for their bitter-cold properties to clear heat and promote diuresis. Because jaundice here involves heat stagnation without solidification, the treatment employs sweating and clearing/diuresis to simultaneously resolve the exterior and interior.
In Yangming disease, with generalized lack of sweat, only head sweating, urinary difficulty, and thirst desire for water, this indicates heat cannot vent, stagnates in the interior, and causes jaundice. Yinchen Hao Tang (Artemisiae Scopariae and Sorghum Decoction) is the primary treatment, allowing the jaundice to resolve through bowel movement.
Shao's Commentary: This describes Yangming damp-heat jaundice. Head sweating without body sweating indicates stagnant heat steaming upward while pathogens fail to reach the exterior. Urinary difficulty prevents heat from draining downward. Thirst indicates intense internal heat accumulation, while dampness persists externally. Dampness and heat combine, stagnating unresolved, unable to vent via the exterior or unblock the interior, inevitably evaporating into jaundice. Yinchen Hao Tang uses bitter-cold purgation to direct internal stagnant damp-heat downward, so jaundice exits via stool. The original Shanghan Lun text includes "abdominal fullness," indicating pathogens failed to vent downward, stagnant heat formed jaundice, and pathogens penetrated deeply causing abdominal fullness—a Yangming heat-excess syndrome. Thus, Dahuang is used in the formula to clear damp-heat and purge interior excess.
In Taiyin disease, with urinary difficulty, where damp-earth is steamed by heat causing jaundice, Yinchen Wuling San (Artemisiae Scopariae and Five-Ingredient Poria Powder) is the primary treatment, allowing jaundice to resolve through urination.
Shao's Commentary: Taiyin dampness lies dormant, failing to drain via urine, obstructing internally and steaming heat to cause jaundice; this is a Taiyin damp-heat syndrome. Wuling San promotes bladder qi transformation to aid urination, added with Yinchen to clear and leach damp-heat. Since Taiyin damp-stagnation steams heat to cause jaundice without solidification, promoting qi transformation allows pathogens to exit via urine.
Wenbing Tiao Bian states: When epidemic pathogens transmit to the interior, leaving heat in the Lower Jiao, urinary difficulty occurs, pathogens lack drainage, meridian qi stagnates, transforming into jaundice with body and eyes golden-yellow. Yinchens Hao Tang is appropriate. If Yinchen Wuling San is used, it will not only fail to reduce jaundice but also hinder urination. This is due to heat transferring to the Stomach home, where Dahuang has specific efficacy.
Shao's Commentary: Epidemic damp-turbid pathogens transmit to Yangming, with heat in the Middle and Lower Jiao, consolidating into excess, blocking qi flow, and stagnating into jaundice. This is Yang Jaundice excess-heat, treated with Yinchen Hao Tang to purge heat-excess. Epidemic heat entering the interior causes Yangming Stomach heat to become solid; thus, Yinchen Hao Tang purges heat-excess. This differs from the previous case of damp-heat jaundice where heat was not yet solid.
In Shanghan, if there is fever and jaundice without exterior or interior excess syndromes, Zhizi Bopi Tang (Gardeniae Cortex Phellodendri Decoction) is the primary treatment.
Shao's Commentary: This is a Yangming meridian syndrome. There is no exterior pathogen stagnation, nor interior excess formation, hence "no exterior-interior syndrome." Body heat and jaundice result from heat stagnating in the Yangming meridian. Treatment focuses solely on clearing heat.
Generally, in jaundice, if heat is predominant, the pulse is rapid, the body does not ache, and treatment prioritizes detoxification. If dampness is predominant, the pulse is slow, the whole body aches, and treatment prioritizes leaching dampness.
Shao's Commentary: Heat excess in Yangming steams and stagnates to cause jaundice; rapid pulse without body pain indicates Yang Jaundice, treated with heat-clearing and detoxification. Taiyin dampness excess blocks qi to cause jaundice; slow pulse with body pain indicates dampness entering meridians, forming Yin Jaundice, treated with damp-leaching and qi-moving methods. Only heat jaundice with rapid pulse belongs to Yangming; damp jaundice with slow pulse belongs to Taiyin.
Yangming jaundice with excessive heat and constipation of both bowels and bladder is treated with Yinchen Hao Tang.
Shao's Commentary: This is the standard method for Yangming heat-excess jaundice.
Taiyin jaundice with excessive dampness and urinary difficulty is treated with Yinchen Wuling San.
Shao's Commentary: This is the standard method for Taiyin damp-stagnation jaundice.
Body heat with jaundice, without exterior-interior syndromes, is treated with Zhizi Bipi Tang.
Shao's Commentary: This is the treatment for Yangming meridian stagnant-heat jaundice. Zelán and Hongqu should be added to the formula to resolve blood stasis. The above discusses Yang Jaundice syndromes.
Jaundice with sweating but cold body, deep-slow pulse, urinary difficulty, and no thirst is Yin Jaundice. With urinary difficulty, use Wuling San plus Ganjiang and Yinchen. With free urination and defecation, use Lizhong Tang plus Yinchen.
In Shanghan, during years governed by Chen, Xu, Chou, Wei, with Taiyang and Taiyin ruling the Heaven, physicians using excessive cold-cooling herbs often encounter Yin Jaundice. Pulse is deep-slow, limbs are cold, and jaundice appears; Lizhong Tang plus Yinchen is indicated. For urinary difficulty, add Lingzhi (Poria) and Guigui (Cinnamon Bark) to Lizhong Tang. For vomiting, combine Lizhong Tang with Erchen Tang and Shengjiang. If prolonged rain causes excessive dampness, combine Lizhong Tang with Pingwei San. Severe cases require adding Fuzi.
Shao's Commentary: In years of Cold-Water and Damp-Earth dominance, if the person has deficient Yang and contracts dampness, excessive use of cold herbs damages Middle Yang, forming Yin Jaundice. All observed pulses and symptoms are Yin-cold signs, vastly different from Yang Jaundice heat-excess. Lizhong Tang plus Yinchen warms and moves Middle Yang to transform dampness. For severe Yin-cold, add Fuzi to support Yang and drain turbidity. If Middle Yang is weak with internal cold-damp stagnation preventing Qi transformation and causing urinary difficulty, add Fuling and Guizhi to unblock Yang and promote diuresis. Vomiting indicates Stomach deficiency with cold-phlegm; combining Erchen Tang and Shengjiang harmonizes Stomach Qi and transforms phlegm-fluids. Prolonged rain causes excessive Yin-turbidity, damaging Spleen-Stomach Earth; thus, Lizhong Tang warms the Middle Palace, combined with Pingwei San to drain dampness. This is Yin Jaundice caused by Spleen Yang deficiency and internal cold-damp stagnation, treated primarily by warming the Middle and transforming dampness.
Spleen exhaustion mimicking jaundice presents as total body yellowing, absence of pulse at Cun Kou, cold air from nose, head shaking, fixed gaze, blackening around the mouth, and body resembling burnt coal smoke. This is the exhaustion of Spleen True Qi, not jaundice. The First Book states: Gallbladder Qi exhaustion causes facial yellowing; Spleen Qi exhaustion causes body yellowing. These present as yellow like earth, dry, and devoid of spirit.
Shao's Commentary: Spleen is Yin Earth; yellow is the true color of Earth. Spleen Yang deficiency fails to move Yang, resulting in absent Cun Kou pulse. Weak Yang nearing exhaustion causes cold air and lack of warmth. All symptoms reflect pure Yin-turbidity acting, with faint Yang about to be buried. Spleen True Qi is exhausted, and the Earth's true color reveals itself externally, causing total body yellowing. This is a Zang exhaustion syndrome, distinct from jaundice caused by external pathogens.
Yizong Jinjian states: Blackening around the mouth with cold sweat is a fatal Yin Jaundice sign. Dry, withered body resembling smoke is a fatal Yang Jaundice sign.
Shao's Commentary: Yin Jaundice with Yang exhaustion leads to death; Yang Jaundice with Yin depletion also leads to death.