Library

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.