喻嘉言曰∶《金匮》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，热结膀胱，
身体尽黄，名曰谷瘅。此论内伤发黄，直是开辟。
盖人身脾胃，居于中土。脾之土，体阴而用阳；胃之土，体阳而用阴。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。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。
更有精焉，诊其两尺脉浮，又知兼伤其肾。夫肾脉本沉也，何以反浮？盖肾藏精者也，而精生于谷，
脾不运胃之谷气入肾，则精无俾而肾伤，故沉浮反浮也。知尺脉浮为伤肾，即知趺阳脉紧为伤脾。然紧乃肝
脉，正仲景谓紧乃弦，状若弓弦之义。脾脉舒缓，受肝克贼则变紧。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，亦特蒸为腐败之气，而非精华
之清气矣。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，而克贼之余，其腹必满矣。
究竟谷瘅由胃热伤膀胱者多，由脾寒而伤肾者，十中二三耳。若饮食伤脾，加以房劳伤肾，其症必腹
满而难治矣。
黄瘅由于火土之湿热，若合于手阳明之燥金，则湿、热、燥三气，相搏成黄，其人必渴而饮水。有此
则去湿热药中，必加润药，乃得三焦气化行、津液通，渴解而黄退。渴不解者，燥未除耳。然非死候。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。
仲景云诸病黄家，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。然瘅症之脉，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。
湿热郁蒸而黄发，其当从下夺，亦须仿治伤寒之法，里热者始可用之。重则大黄硝石汤，荡涤其湿热，
如大承气之例；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，如栀子豉汤中
加大黄如博棋子大之例。是则汗法固不可轻用，下法亦在所慎施。以瘅症多夹内伤，不得不回护之耳。
然瘅症有湿多热少者，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。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。
又有小便本黄赤，治之其色稍减，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。倘更除其热，则无热可除，胃寒起而呃逆矣。此又一端也。
黄家日晡所发热，而反恶寒，此为女劳得之。膀胱急，小腹满，身尽黄，额上黑，足下热，因作黑瘅，
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。夫男子血化为精，精动则一身之血俱动
，以女劳而倾其精，血必继之。故因女劳而尿血者，其血尚行，犹易治也；因女劳而成瘅者，血淤不行
，为难治矣。甚者血瘀之久，而成血蛊，尤为极重。非亟去其膀胱少腹之淤血，万无生路。然女劳瘅蓄
积之血，必非朝夕，峻攻无益。《金匮》以硝石矾石散方，取药石之悍，得以疾趋而下达病所。硝石寒咸走
血，可逐淤，为君；矾石，本草谓能除锢热在骨髓，用以清肾及膀胱脏腑之热，并建消淤除浊之功，此方之
极妙也。
朱丹溪曰∶瘅病不必分五，同是湿热，热多加芩连，余但以利小便为先，小便利黄自退矣。
赵羽黄曰∶黄瘅之病，经云∶中央色黄，入通于脾。盖脾属土，色黄，外至肌肉，上应湿化。今太阴邪
气炽盛，湿
滞热蒸，郁而不发，如 曲相似，遂成黄色，所谓病痛是也。治法有汗、下之分，补、泻之异焉。今人治此，
但用平胃、五苓、茵陈汤之类，清热渗利之外，并无他说，虽然，其湿热之甚于肠胃者，或可攻之，若郁
于肌肤之间而不得发越，过用疏利，则湿热反内陷而不出矣。
仲景治身热发黄者，有麻黄连翘赤小豆汤一法，无非急解其表，令热邪自外而散耳。方论止知可降，
而不知可升者，非理也。
至于素患脾虚，寒凉过甚，或小水清白，而大便微溏，力倦神疲，而脉细少食，皆太阴脾气虚极，而
真色外现之候也。惟用补中益气汤，略加车前、茯苓一二味。热胜者，连理汤尤宜。
今此每遇此症，不辨其孰实孰虚，在表在里，概用寒凉通利。讵知脾胃虚者不宜寒，寒之则中气愈败矣；
脾胃弱者不宜降，降之则下多亡阴矣。或攻或补，或升或降，惟随时变通可耳。
喻嘉言说：《金匮要略》中提到：趺阳脉（足背动脉，候脾胃之气）紧而数，数脉主热，热则消谷善饥；紧脉主寒，寒则食后腹胀。尺脉（手腕内侧近腕横纹处，候肾气）浮为伤肾，趺阳脉紧为伤脾。风寒邪气相互搏结，进食后头晕目眩，谷气不能正常消化，胃中苦于浊气内停，浊气下流，导致小便不通，阴分受寒邪侵袭，热邪结聚于膀胱，全身发黄，称为谷瘅（因饮食内伤导致的黄疸）。这种论述对于内伤发黄的病机分析，真是开创性的见解。
大概人体的脾胃，居于中焦土位。脾之土，体性属阴而功能属阳；胃之土，体性属阳而功能属阴。两者调和，则不刚不柔，胃能纳受谷食，脾能运化谷气，通调水道，灌注滋养全身经脉。只有当七情过极、饥饱失调、房劳过度等内伤因素太过，导致脾胃的阴阳不能协和。胃偏于阳，没有脾阴来调和它，就像自然界有夏无冬，独自聚集热邪而消谷善饥；脾偏于阴，没有胃阳来调和它，就像自然界有冬无夏，独自聚集寒邪而腹部胀满。此时人的趺阳脉出现紧（寒）和数（热）的脉象，必有明显的征象。诊察脉象如果只见紧或只见数，就能知道是脾胃分别主治其病；如果诊察到紧而且数并见，就知道是脾胃共同受病。医理说得非常精妙。
更有精微之处在于，诊察两尺脉浮，又知道兼伤了肾。肾脉本应沉，为什么反而浮？因为肾藏精，而精由水谷化生，脾不能将胃中的谷气输送入肾，则精气无所资助而肾受伤，所以脉象由沉反浮。知道尺脉浮是伤肾，也就知道趺阳脉紧是伤脾。然而紧脉本是肝脉的特征，正如张仲景所说紧即弦，形状像弓弦一样。脾脉本舒缓，受到肝木克制贼害则变为紧脉。肝的风气，乘袭脾所聚的寒气，两者相互搏激，进食后即感眩晕。这是谷气入胃不能助长胃阳，反而扰动脾阴，即胃中聚集的热邪用来消谷的，也仅仅蒸腾为腐败之气，而非精华的清气了。浊气由胃热而下流入膀胱，则膀胱受热，气化功能不行，小便不通，一身尽黄。浊气由脾寒而下流入肾，则肾被寒邪所伤，加上被肝木克制的余势，腹部必然胀满。
究竟谷瘅多由胃热损伤膀胱引起，由脾寒损伤肾脏引起的，十人中仅有二三。如果是饮食损伤脾，再加上房劳损伤肾，症状必定是腹部胀满且难以治疗。
黄瘅由于火（心/热）与土（脾/湿）的湿热所致，如果合并于手阳明大肠经的燥金之气，则湿、热、燥三气相互搏结而成黄，病人必定口渴想喝水。有此症状，则在去除湿热药中，必须加入润燥药，才能使三焦气化运行、津液通畅，口渴解除而黄疸消退。如果口渴不解，说明燥邪未除。但这并非死证。又说瘅病伴口渴者难治，则是更担心下焦肾水枯竭，不仅仅指中焦津液不足罢了。
张仲景说各种黄疸病患者，只要通利小便即可。假如脉浮，应当用发汗法解表，适宜用桂枝加黄芪汤。可见大法当以通利小便为主，必须脉浮才可以谈解表。然而瘅病的脉象，多有营卫气虚，湿热乘虚而致脉浮，所以用桂枝加黄芪汤调和营卫，用小柴胡汤调和表里，只是取和解之法作为解表之法，这正是张仲景的微旨所在。
湿热郁蒸而发黄疸，应当从下面攻逐，也必须仿照治疗伤寒的方法，只有里热实证才可用之。病情重的用大黄硝石汤，荡涤湿热，如同大承气汤的例子；稍轻的用栀子大黄汤，清解兼攻下，如同三黄汤的例子；更轻的用茵陈蒿汤，以清解为主，微微加入大黄为使药，如同在栀子豉汤中加入如博棋子大小的黄药的例子。这样看来，发汗法固然不可轻用，攻下法也在慎重施用之列。因为瘅病多夹杂内伤，不得不加以回护保护。
然而瘅病有湿多热少的，有湿少热多的，有湿热全无的，不可不仔细辨别。张仲景考虑到瘅病多夹内伤，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，这说明里没有湿热，只是因为多次行房扰动阳气，导致虚阳上泛而发黄。所以不直接治黄，而是调和营卫，收敛浮越之阳，听任黄疸自行消退，这就像治疗伤寒邪少虚多、心悸而烦，合用小建中汤的方法来治疗。
又有小便本来黄赤，治疗后颜色稍减，就应当识别其蕴藏的火热原本就不多；或者大便想要自利，腹部胀满，上气喘急，就应当识别其脾湿原本就旺盛；或者因为兼用寒凉药太过，应当紧急使用小半夏汤温胃燥湿。倘若再清除其热，则无热可除，会导致胃寒兴起而出现呃逆。这是另一种情况。
黄疸病患者常在日晡时（下午3-5点）发热，反而恶寒，这是女劳瘅（因房事过度导致的黄疸）所致。膀胱拘急，小腹满，全身发黄，额头色黑，脚底发热，因此形成黑瘅。如果腹胀如水状，大便必黑，时而溏泄，这是女劳的病，不是水气病。腹部胀满的难治。男子的血化为精，精动则一身之血随之而动，因女劳而耗竭其精，血必随之亏损。所以因女劳而尿血的，其血尚能运行，还容易治疗；因女劳而成黄疸的，血瘀不行，就难治了。严重的血瘀日久，形成血蛊，尤为极重。如果不紧急去除膀胱和小腹的淤血，万无生路。然而女劳瘅蓄积的淤血，必定非朝夕之间形成，峻猛攻伐无益。《金匮要略》用硝石矾石散方，取药物石类的悍烈之性，得以迅速直达病所。硝石寒咸走血，可逐淤，为君药；矾石，本草认为能除去骨髓中的锢热，用以清肾及膀胱脏腑之热，并建立消淤除浊的功效，此方的精妙之处就在这里。
朱丹溪说：瘅病不必分为五类，都是湿热，热多加黄芩、黄连，其余只需以利小便为先，小便利则黄自退。
赵羽黄说：黄瘅的病，《内经》说：中央色黄，入通于脾。大概脾属土，色黄，外至肌肉，上应湿化。如今太阴邪气炽盛，湿滞热蒸，郁结而不发，像酒曲发酵相似，遂成黄色，这就是所谓的病痛。治疗方法有汗、下的区别，补、泻的不同。现在的人治疗此病，只用平胃散、五苓散、茵陈汤之类，除了清热渗利之外，没有其他说法，虽然如此，那些湿热甚于肠胃的，或许可以攻下，若郁结在肌肤之间而不能发散，过度使用疏利药物，则湿热反而内陷而不能出。
张仲景治疗身热发黄的，有麻黄连翘赤小豆汤一法，无非是急于解表，令热邪自然从外而散。对方论只知道可以降，而不知道也可以升，是不符合医理的。
至于素患脾虚，寒凉药用得过多，或者小便清白，大便微溏，乏力神疲，脉细少食，这都是太阴脾气极度虚弱，真色外露的征候。只需用补中益气汤，略微加入车前子、茯苓一两味。热胜者，连理汤尤其适宜。
如今遇到这种情况，不辨别虚实，不分表里，一概使用寒凉通利药物。哪里知道脾胃虚者不宜用寒药，用寒药则中气更加败坏；脾胃弱者不宜用降药，用降药则下利多亡阴。或者攻或者补，或者升或者降，只有随时变通才行。
Yu Jiayan stated: The *Jingui Yaolue* (Essential Prescriptions from the Golden Cabinet) mentions: If the Duyang pulse (foot dorsalis pedis artery, reflecting Spleen and Stomach Qi) is tight and rapid, rapid indicates heat, and heat consumes grain (causing hunger); tight indicates cold, and cold causes abdominal fullness after eating. A floating Chi pulse (wrist radial pulse position reflecting Kidney Qi) indicates Kidney injury, and a tight Duyang pulse indicates Spleen injury. Wind and cold pathogens contend with each other; after eating, dizziness occurs, grain qi fails to digest, the Stomach suffers from turbid qi stagnation, turbid qi flows downward, causing urinary obstruction. The Yin aspect is invaded by cold, while heat knots in the Bladder, resulting in whole-body yellowing, termed Grain Jaundice (jaundice caused by dietary internal injury). This discussion on the pathogenesis of jaundice due to internal injury is truly pioneering.
Generally, the human Spleen and Stomach reside in the central Earth element. The Spleen's Earth has a Yin substance but Yang function; the Stomach's Earth has a Yang substance but Yin function. When harmonized, they are neither rigid nor soft; the Stomach receives grain food, the Spleen transports grain qi, regulates water passages, and irrigates all vessels. Only when excessive internal injuries—such as emotional excess, irregular diet, or sexual exhaustion—occur 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, like nature having summer without winter, it gathers heat alone and consumes grain; if the Spleen leans toward Yin without Stomach Yang to harmonize it, like nature having winter without summer, it gathers cold alone and causes abdominal fullness. In such cases, the patient's Duyang pulse will show tightness (cold) and rapidity (heat), providing clear evidence. Palpating only tight or only rapid pulses reveals whether the disease is governed separately by the Spleen or Stomach; palpating both tight and rapid together reveals joint involvement. The medical principle is exquisite.
More subtly, palpating a floating Chi pulse indicates concurrent Kidney injury. Since the Kidney pulse should normally be deep, why does it float? Because the Kidneys store Essence, which is generated from grain. If the Spleen fails to transport Stomach grain qi into the Kidneys, Essence lacks support and the Kidneys are injured, causing the pulse to change from deep to floating. Knowing that a floating Chi pulse indicates Kidney injury allows one to know that a tight Duyang pulse indicates Spleen injury. However, a tight pulse is characteristic of the Liver pulse, just as Zhang Zhongjing stated that tight equals wiry, resembling a bowstring. The Spleen pulse is naturally relaxed; when subjected to Liver Wood overacting, it becomes tight. Liver wind qi attacks the cold gathered in the Spleen, contending with each other, causing dizziness upon eating. This means grain entering the Stomach fails to nourish Stomach Yang but instead disturbs Spleen Yin. The heat gathered in the Stomach for digestion merely steams into foul qi rather than essence-clear qi. Turbid qi from Stomach heat flows down into the Bladder, heating it, stopping Qi transformation, causing urinary obstruction, and turning the body yellow. Turbid qi from Spleen cold flows down into the Kidneys, injuring them with cold, and combined with the residual effect of Liver overacting, causes abdominal fullness.
Ultimately, Grain Jaundice is mostly caused by Stomach heat injuring the Bladder; cases caused by Spleen cold injuring the Kidneys account for only two or three out of ten. If dietary injury affects the Spleen compounded by sexual exhaustion injuring the Kidneys, symptoms will inevitably include abdominal fullness and be difficult to treat.
Jaundice arises from damp-heat of Fire (Heart/Heat) and Earth (Spleen/Dampness). If combined with the dryness of the Hand-Yangming Large Intestine meridian, dampness, heat, and dryness contend to produce jaundice, and the patient will likely feel thirsty and desire water. With this symptom, moistening herbs must be added to the damp-heat clearing formula so that Sanjiao Qi transformation can proceed, fluids can circulate, thirst resolves, and jaundice recedes. If thirst persists, dryness remains. However, this is not a death omen. It is also said that jaundice with thirst is difficult to treat, implying fear of depletion of the lower source (Kidney water), not just middle Jiao fluid deficiency.
Zhang Zhongjing stated that for most jaundice cases, promoting urination is sufficient. If the pulse is floating, sweating should be used to release the exterior, suitable for Guizhi Jia Huangqi Tang (Cinnamon Twig Decoction plus Astragalus). Thus, the general rule is to promote urination; only when the pulse is floating can exterior release be considered. However, jaundice pulses often show Ying and Wei Qi deficiency with damp-heat taking advantage to cause floating. Therefore, Guizhi Jia Huangqi Tang is used to harmonize Ying and Wei, and Xiaochaihu Tang (Minor Bupleurum Decoction) to harmonize interior and exterior. Taking harmonization as the method for exterior release is Zhang Zhongjing's subtle intent.
When damp-heat stagnation and steaming cause jaundice, purgation from below may be indicated, following Shaoyang/Shanghan methods, applicable only for interior heat excess. For severe cases, Dahuang Xishi Tang (Rhubarb and Niter Decoction) sweeps away damp-heat, similar to Dachengqi Tang; for milder cases, Zhizi Dahuang Tang (Gardenia and Rhubarb Decoction) clears and purges slightly, similar to Sanhuang Tang; for the mildest, Yinchenshao Tang (Artemisiae Scopariae Decoction) uses clearing as the primary action with slight rhubarb as an assistant, similar to adding rhubarb pieces to Zhizi Chitang. Thus, sweating is certainly not to be used lightly, nor is purgation to be applied carelessly, because jaundice often involves internal injury requiring protection.
However, jaundice varies: some have more dampness than heat, some more heat than dampness, some no damp-heat at all. These must be distinguished. Zhang Zhongjing feared internal injury in jaundice, hence cautioning against sweating, vomiting, and purging. He used Xiao Jianzhong Tang (Minor Construct the Middle Decoction) for men with jaundice and spontaneous urination, indicating no interior damp-heat, but rather damage to Yang from frequent intercourse causing deficient Yang to float upward. Thus, he did not treat the jaundice directly but harmonized Ying and Wei to gather Yang, allowing jaundice to resolve spontaneously, akin to treating Shanghan with little pathogen and much deficiency causing palpitations and irritability using Jianzhong methods.
If urine is originally yellow-red and lightens after treatment, recognize that latent heat was minimal. If stool tends toward diarrhea with abdominal fullness and upper body wheezing, recognize that Spleen dampness was originally abundant. If cold herbs were overused, urgently use Xiaobanxia Tang (Minor Pinellia Decoction) to warm the Stomach and dry dampness. Further clearing heat would remove non-existent heat, causing Stomach cold and hiccups. This is another scenario.
Jaundice patients often experience fever during the Ding hour (3-5 PM) with aversion to cold, indicating Female Labor Jaundice (jaundice from sexual exhaustion). Bladder urgency, abdominal fullness, whole-body yellowing, black forehead, and hot soles constitute Black Jaundice. If abdominal distension resembles water accumulation, stools are black and loose, this is Female Labor disease, not water retention. Abdominal fullness is difficult to treat. Men transform blood into essence; essence movement moves all blood. Sexual exhaustion depletes essence, leading to blood loss. Hematuria from sexual labor is easier to treat as blood still flows; jaundice from sexual labor involves stagnant blood, making it difficult. Severe long-term blood stasis forms Blood Distortion (Xue Gu), extremely critical. Urgent removal of bladder and lower abdominal blood stasis is essential for survival. However, accumulated blood from Female Labor Jaundice is not formed overnight; harsh attack is useless. *Jingui Yaolue* uses Xiaoshi Fanshi San (Niter and Alum Powder), utilizing the fierce nature of minerals to reach the disease site quickly. Niter is cold, salty, enters blood, and drives out stasis (Chief herb); Alum clears entrenched heat in marrow, cleanses Kidney and Bladder organs, and eliminates stasis and turbidity. This is the brilliance of this formula.
Zhu Danxi stated: Jaundice need not be divided into five types; all are damp-heat. Add Huangqin and Huanglian for more heat; otherwise, prioritize promoting urination. Once urination flows, jaundice recedes.
Zhao Yuhuang stated: Regarding jaundice, the Classics say: Central color is yellow, connecting to the Spleen. Spleen belongs to Earth, color yellow, extending to muscles, corresponding to damp transformation. Now, if Taiyin pathogenic qi is rampant, damp stagnation and heat steaming,郁结 not releasing, like yeast fermenting, results in yellow color, which is the pathology. Treatment differs between sweating/purging and tonifying/draining. Modern practitioners use Pingwei San, Wuling San, or Yinchenshao Tang, focusing only on clearing heat and draining dampness. While effective for damp-heat in intestines/stomach, if damp-heat is trapped in skin/muscles unable to vent, overuse of draining herbs causes damp-heat to sink inward.
Zhang Zhongjing treated body heat with jaundice using Ma Huang Lian Qiao Chi Xiao Dou Tang (Ephedra, Forsythia, and Adzuki Bean Decoction), aiming to urgently release the exterior so heat dissipates outward. Critics who only see descending properties in formulas but miss ascending ones misunderstand the theory.
For those with chronic Spleen deficiency, excessive cold herbs, clear urine, loose stools, fatigue, weak spirit, fine pulse, and poor appetite, these are signs of extreme Taiyin Spleen Qi deficiency with true color appearing externally. Use Buzhong Yiqi Tang (Tonify the Middle and Augment Qi Decoction) with minor additions of Cheqianzi and Fuling. For heat excess, Lianli Tang (Scutellaria and Ginger Decoction) is suitable.
Currently, practitioners often fail to distinguish deficiency/excess or interior/exterior, indiscriminately using cold and draining herbs. They do not realize that deficient Spleen/Stomach cannot tolerate cold, which further damages Middle Qi; weak Spleen/Stomach cannot tolerate descending, which loses Yin through excessive downward flow. Whether attacking or tonifying, ascending or descending, flexibility according to circumstances is key.