Library

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.