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。
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。
“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。
《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。
4·认为是阳明虚热证。尤在泾在《金匮心典》中说：“脉迟胃弱，则谷化不速，谷化不速，则谷气郁而生热，而非胃有实热，故虽下之而腹满不去。”他在《伤寒贯珠集》中，也有类似的注文。喻昌也说：“因外感阳明，胃中之余热未除，故食难用饱，饱则食复生热，二热相合，而发烦头眩。……不过虚热内壅，非结热当下之比。”⑤
5·认为是太阴(脾)虚寒证。吴谦说：“谷疸属胃热，脉当数。今脉迟，脾脏寒也。……其证原属太阳寒湿郁黩而生……属脾阴寒化而不可下者也。”④今人宗此说者较多，如南京中医学院编的《金匮要略译释》说：“这显是太阴虚寒证”；成都中医学院编的《金匮要略选读》说：“本条论述谷疸从寒化的病机。……是太阴脾虚寒证。”
由于对病机认识不一致，各家的治方也就不同。柯琴说：“当用五苓散调胃利水，”；⑦张璐说：“不但下之无益，即发汗利小便之法，亦不可用，惟当用和法，如甘草于姜汤，先温其中，然后少与凋胃微和胃气可也。”⑧喻昌虽亦主和，但他认为应该用小柴胡汤⑨；近代多宗温法，如《金匮要略译释》和《金匮要略选读》说：“当用温法，如理中、四逆等方。”同一条文，在临床应用中出入如此之大，实有辨析清楚之必要。
二、证属燥淤之我见
查本条脉证有三：(1)脉迟，(2)食难用饱，饱则发烦头眩，(3)必小便难。根据“虽下之，腹满如故”一句，可知原有腹满，因此，实际共有四证。据其脉证进行分析，笔者不同意上述五种解释。
第一、阳明中寒证属虚寒，但“发烦”明是热证，不得谓“烦”为寒证。阳明中寒证，因胃中虚冷，饮水则哕，是胃气逆行，不能纳食，故称“不能食”，本条称“食难用饱”，且与“饱则发烦，，连为一句，与“不能食”用词有异，蕴义有别，不应等同。
第二、如果说是阳明经脉虚寒证，参考《伤寒论》笫236条，则应有微恶寒而不应有发烦及腹满。
第三、如果说是阳明经热证，则不应有“脉迟”“腹满”这二大腑病脉证。
第四、太阴病属虚寒，故与热证“发烦”相悖。脉迟，腹满虽可见于太阴病，但也可见于阳明腑证。称太阴病为阳明病，考诸《伤寒论》，仲景并无此种提法。太阴病既有脾虚不运，也有胃气上逆而吐，故称“食不下”，此亦不应与“食难用饱”等同，大阴病以吐利、腹满为主证，但小便不难，若谓太阴黄疸小便必难，此亦不然，因太阴黄疸有寒湿与虚寒两个证型，“若小便自利者，不能发黄”，这是针对寒湿型言，若虚寒型，小便可以自利，《金匮》有“男子黄，小便自利”、“黄疸病，小便色不变”等条文为证，如果本条是虚寒型黄痘，仲景必不谓“必小便难”，而脉迟、腹满、溲难这三证，非为太阴证及阳明中寒证所独具。故为此而置“烦”字于不论或曲解“烦”字，均为不妥。
根据以上分析，笔者认为“阳明虚热证”之说还稍近理。但尤在泾注解失之简略，奥旨未能昌明，近世多不采用；而喻昌之出方，尤悖经义，故须商榷。
我认为此条病机应届本虚标实。胃家实是阳明病之提纲，而最易损津耗液则是阳明病之特点。阳明病之脉，经病洪，腑病迟，既然是“阳明病，脉迟”，就宜作阳明腑病看。阳明病多从燥化，后期热邪虽退，而津液受伤，胃肠干燥，大便多硬，此时虽不象中寒证及太阴病那样，因有哕、呕而“不能食”或“食不下”，但“食难用饱”，这是因为胃中余热未除，若饱食则食复生热(此即说明“食难用饱”，是形容多食不适，与“不能食”“食不下”不同)，二热相合而发烦头眩。胃肠中糟粕，因津亡液燥而结实，常引起排便困难，大便坚燥准下，故腹满。至于小便难，则说明津液内竭，这与114条“阴虚小便难”情况类似，都是津液耗伤的表现，不是指湿邪内蓄，排尿不畅。这时虽“有燥屎在胃中”，但因为是津液内竭所致，故“虽硬不可攻之”。因此，本条应届本虚标实之证。其病机是津伤肠燥，因燥致结，田结实而致淤，因淤结而发黄，在这种情况下发生的黄疸，与谷物化成之糟粕壅实不去、加之多食饱食、造成食复的关系甚大，故曰；“此欲作谷疸。”吴谦说：“谷疸属胃热”，有一定道理，但谷疸之脉不一定“数”。
因此，瘀血是黄疸常见的病理产物，所以张仲景治疗黄疸时，常将瘀与热并提，或将瘀与湿同治。但是，瘀血化为水饮或阻滞肝胆等，也可以是引起黄疸的原因，而且，在一定条件下，瘀血有时还可能成为黄疸久治不愈的关键所在。《伤寒论》第129条说：“太阳病，身体发黄，脉象沉而结，少腹部硬满，小便不利的，是无瘀血；如果小便自利，其人神志如狂的，则是瘀血的实证确凿无疑，用抵当汤主治。”这条的后半段讲的是瘀血蓄积在下焦，因瘀血而发黄，病位不在气分，与湿邪无关，所以小便通利。《金匮要略》中说：“酒疸如果用攻下法治疗，日久会变成黑疸，出现眼睛青、面色黑，心中像吃了蒜和葱一样的辛辣感，大便颜色正黑，皮肤麻木按之不痛，脉象浮弱，虽然面色黑但微带黄色，据此可以诊断。”以及“黄疸病患者在申时（下午3-5点）发热反而恶寒，这是女劳疸所致，膀胱拘急，少腹胀满，全身发黄，额头发黑，脚心发热，日久变成黑疸，腹部胀大像有水状，大便必定发黑，时而稀溏，这是女劳疸的病，不是水气病。如果腹部胀满则难治，用硝石矾石散主治。”这两条条文，也是以瘀血为主，所以有“不是水气病”的明确说明。前者病在太阳经且属实证，所以用抵当汤峻猛攻逐；后者病在少阴经且属虚证，所以用硝石矾石散缓慢消散。浙江诸暨已故著名中医杨则民说：“张仲景用猪膏发煎治疗女劳疸。”这说明女劳疸既有以瘀血为主的，也有以虚损为主的区分，还有病从燥化、病从湿化的不同。硝石矾石散所治的女劳疸是以瘀血为主，虚而兼夹湿邪，所以以泻为补，行瘀兼以化湿；猪膏发煎所治的女劳疸是以虚损为主，瘀而兼夹燥邪，所以以补为泻，润燥兼以行瘀。
瘀血黄疸的脉象和症状，除了上述条文描述的外，也可以与“病人好像有热象，心烦胸满，口干燥而渴，但脉象并不见热象，这是阴分伏热，属于瘀血，应当用攻下法”等论述瘀血的有关条文互相参照。
现举瘀血黄疸医案两则以供参考：
一、“中翰汪先生患黄疸，服用茵陈五苓散无效。八月间，邀请石顽诊察，脉象弦大而芤，是肾伤夹瘀，由结积丸散所致，趁元气尚可攻击之时，用《金匮》硝石矾石散，配合桂苓丸的剂型，以洗涤瘀滞，迟了则难以奏效了。汪氏家有行医者，认为药力太峻猛，不便轻用，恰逢其子乡试中举继而又参加会试，未免挂念操心，来不及调治，等到新年正月初二，又邀请石顽商量，脉象转为弦而革，真元竭尽无余，半月以来，每天用人参数钱，如同石头投入水中……”（《张氏医通》）。
按语：虚实之理，原本是对立的。人们说女劳疸属虚证，大多不敢用泻药，而后世也都以肾气丸为主治方，至于硝石矾石散这一方，于是被束之高阁，不仅敢用的医生很少，敢服用的患者也很少，此案就是一个例子，确实是因为张仲景的大法不被世人明了的缘故。
二、“应天王治疗遍身发黄，胡言乱语如发狂，苦于胸痛，手不能触碰，这是中焦蓄血为患，用桃仁承气汤，一剂后，排出瘀血而痊愈。又有太守朱阳山的弟弟下部瘀血发狂，用抵当汤而痊愈”（《续名医类案》）。
按语：黄疸的病机，多属湿热瘀，但重视湿者则说“无湿不成疸”，重视热者则说“疸以胃家实热为本”，重视瘀者则说“黄疸必伤血，治疸要活血”。实际上，湿重主用茵陈五苓散，热重主用茵陈蒿汤，瘀重主用抵当汤，这原是张仲景的常规法则。后人偏执其一端，实在失去了张仲景的灵活变法。上案是瘀血黄疸属于实证的，所以用桃仁承气汤、抵当汤攻下蓄血而痊愈。如果是湿盛热重或正气虚弱者，各自应当辨证定方，又是另一种说法，而偏执一端，划地为牢自我局限，确实是黄疸治疗的大忌。
虚寒黄疸由于房事不节，精血内伤，或者脾阳不振，中土功能失健，虽然没有湿热，但因为气血败坏，不能荣华于色，也可以产生黄疸。比如太阴黄疸有寒湿与虚寒两个证型，《伤寒论》所论述的属于寒湿，所以有“小便清白者，不能发黄”、“伤寒发汗后，身体面目发黄，之所以这样，是因为寒湿在里不解”等论述。《金匮要略》中所论述的属于虚寒，所以说：“男子发黄，小便自利，应当给予虚劳小建中汤”、“黄疸病，小便颜色不变，想自行腹泻……”等论述。此外，《金匮要略》中“额头发黑，微汗出，手足心热，傍晚即发作，膀胱拘急，小便自利，名叫女劳疸。”以及“尺脉浮为伤肾”，“女劳的病，不是水气病”等条文所述，虽然不属于太阴黄疸而属于少阴黄疸，但也属于虚寒而不是因为湿邪，所以后人常用畜鱼置介法治疗。确实因为虚寒黄疸不是因于湿邪，所以小便自利，且颜色也可以不变。而寒湿黄疸，则与湿热黄疸一样，同样与湿邪排泄不畅有关，所以均有小便不利并颜色变黄的表现。当然，寒湿者可以兼夹虚证，虚寒者可以兼夹湿邪，瘀热者可以挟带湿邪，湿热者也多兼夹瘀血，但这是另一个问题，应当另外讨论。
“柴屿青治疗觉罗马德夫人患黄疸，医生投用茵陈五苓散未见效，又合末药服用，肌肤苍白，眼珠皆如金色，转而导致不思饮食，右关脉缓弱特别严重。柴医生说：胃是水谷之海，脾是仓廪之官，脏腑失职，湿热滋盛，现在唯有调理脾胃，使其能健运，湿热自然去除，不必专门治疸，而疸自愈矣，用六君子汤加厚朴、炮姜以温中，神曲、麦芽以助脾胃之化，不到几剂就全愈。”（《续名医类案》）
按语：泛用苦寒清利药物来治疗黄疸的时弊，前人早已论及，儿科对此尤须注意，陈复正说：“小儿黄病，无知的人一概呼为湿热。无非除湿利水，清热退黄，除此之外，没有别法了，哪里知道湿热发黄的少，脾虚发黄的多。大概脾土强盛的，足以抵御湿邪，必定不生黄，只有脾虚不运化，所以湿邪来乘虚而入。”湿热发黄少，脾虚发黄多，在儿科或许是这样，成人则究竟还是以湿热黄疸为居多，但虚寒黄疸也不可不忽视，上案将虚证作实证治，泛用清利，反而导致增加疾病的覆辙，今人也有重蹈此辙的，这就是我常说治疸须重视脾脏理论的原因。
疫毒瘟黄
瘟黄在张仲景书中未见记载，其名出自《明医杂著》，实际上就是急黄，急黄最早见于《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。这种黄疸的临床表现具有发病急、病势重的特点，常常一患病就出现突然身体发黄，迅速加深，黄色如金，心胸闷满气喘，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，身上出现斑疹，或出现腹水昏迷等证候。这种急剧症状的出现，与病因属于特殊的热毒疫气有关，不同于一般的湿热。从其病理变化来看，这种热毒之邪很容易内陷心包，入侵营血，所以化燥伤阴较快。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。此证有时虽然也可挟带湿邪，但由于病因主要是热毒，且每从燥化，所以也是一种非湿性黄疸。若与热燥黄疸比较，彼之病因非疫毒，此则是疫毒为患，所以证候有轻重之别。局限于“黄疸无湿不成”的认识者，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，均不得说是湿邪作祟。
结语：论述黄疸如果只强调湿热，或只强调瘀热，而全然不知道有燥化非湿的各种证型，这种认识是片面的，须知张仲景治疗黄疸的方法，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；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。其层次之分明，法度之严谨，方药之细致，均可师法。如单就阳黄论，则在太阳分经腑气血，入阳明别吐清下润，在少阳立疏和通泄，治法也不同，凡此均足以说明，张仲景并不专执一法一方来泛治。如果这样却不知道，竟以“湿、热、瘀”三字作茧自缚，只知道以清热利湿行瘀之品杂凑成方使用，是划地为牢，自我陷入狭隘。
《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。笔者不揣浅陋，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。考察历代注解《伤寒论》的著作，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疸也。……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，食难用饱，……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。
4. 认为是阳明虚热证。尤在泾在《金匮心典》中说：“脉迟胃弱，则谷化不速，谷化不速，则谷气郁而生热，而非胃有实热，故虽下之而腹满不去。”他在《伤寒贯珠集》中，也有类似的注文。喻昌也说：“因外感阳明，胃中之余热未除，故食难用饱，饱则食复生热，二热相合，而发烦头眩。……不过虚热内壅，非结热当下之比。”⑤
5. 认为是太阴（脾）虚寒证。吴谦说：“谷疸属胃热，脉当数。今脉迟，脾脏寒也。……其证原属太阳寒湿郁遏而生……属脾阴寒化而不可下者也。”⑥今人宗此说者较多，如南京中医学院编的《金匮要略译释》说：“这显是太阴虚寒证”；成都中医学院编的《金匮要略选读》说：“本条论述谷疸从寒化的病机。……是太阴脾虚寒证。”
由于对病机认识不一致，各家的治方也就不同。柯琴说：“当用五苓散调胃利水，”；⑦张璐说：“不但下之无益，即发汗利小便之法，亦不可用，惟当用和法，如甘草干姜汤，先温其中，然后少与调胃微和胃气可也。”⑧喻昌虽亦主和，但他认为应该用小柴胡汤⑨；近代多宗温法，如《金匮要略译释》和《金匮要略选读》说：“当用温法，如理中、四逆等方。”同一条文，在临床应用中出入如此之大，实有辨析清楚之必要。
二、证属燥瘀之我见
查本条脉证有三：(1)脉迟，(2)食难用饱，饱则发烦头眩，(3)必小便难。根据“虽下之，腹满如故”一句，可知原有腹满，因此，实际共有四证。据其脉证进行分析，笔者不同意上述五种解释。
第一、阳明中寒证属虚寒，但“发烦”明显是热证，不得谓“烦”为寒证。阳明中寒证，因胃中虚冷，饮水则哕，是胃气逆行，不能纳食，故称“不能食”，本条称“食难用饱”，且与“饱则发烦”连为一句，与“不能食”用词有异，蕴义有别，不应等同。
第二、如果说是阳明经脉虚寒证，参考《伤寒论》第236条，则应有微恶寒而不应有发烦及腹满。
第三、如果说是阳明经热证，则不应有“脉迟”“腹满”这两个腑病脉证。
第四、太阴病属虚寒，故与热证“发烦”相悖。脉迟，腹满虽可见于太阴病，但也可见于阳明腑证。称太阴病为阳明病，考诸《伤寒论》，仲景并无此种提法。太阴病既有脾虚不运，也有胃气上逆而吐，故称“食不下”，此亦不应与“食难用饱”等同，太阴病以吐利、腹满为主证，但小便不难，若谓太阴黄疸小便必难，此亦不然，因太阴黄疸有寒湿与虚寒两个证型，“若小便自利者，不能发黄”，这是针对寒湿型言，若虚寒型，小便可以自利，《金匮》有“男子黄，小便自利”、“黄疸病，小便色不变”等条文为证，如果本条是虚寒型黄疸，仲景必不谓“必小便难”，而脉迟、腹满、溲难这三证，非为太阴证及阳明中寒证所独具。故为此而置“烦”字于不论或曲解“烦”字，均为不妥。
根据以上分析，笔者认为“阳明虚热证”之说还稍近理。但尤在泾注解失之简略，奥旨未能昌明，近世多不采用；而喻昌之出方，尤悖经义，故须商榷。
我认为此条病机应属本虚标实。胃家实是阳明病之提纲，而最易损津耗液则是阳明病之特点。阳明病之脉，经病洪，腑病迟，既然是“阳明病，脉迟”，就宜作阳明腑病看。阳明病多从燥化，后期热邪虽退，而津液受伤，胃肠干燥，大便多硬，此时虽不像中寒证及太阴病那样，因有哕、呕而“不能食”或“食不下”，但“食难用饱”，这是因为胃中余热未除，若饱食则食复生热（此即说明“食难用饱”，是形容多食不适，与“不能食”“食不下”不同），二热相合而发烦头眩。胃肠中糟粕，因津亡液燥而结实，常引起排便困难，大便坚燥难下，故腹满。至于小便难，则说明津液内竭，这与114条“阴虚小便难”情况类似，都是津液耗伤的表现，不是指湿邪内蓄，排尿不畅。这时虽“有燥屎在胃中”，但因为是津液内竭所致，故“虽硬不可攻之”。因此，本条应属本虚标实之证。其病机是津伤肠燥，因燥致结，因结实而致瘀，因瘀结而发黄，在这种情况下发生的黄疸，与谷物化成之糟粕壅实不去、加之多食饱食、造成食复的关系甚大，故曰：“此欲作谷疸。”吴谦说：“谷疸属胃热”，有一定道理，但谷疸之脉不一定“数”。
Therefore, blood stasis (blood stasis) is a common pathological product of jaundice (jaundice). Thus, Zhang Zhongjing often mentioned blood stasis and heat together when treating jaundice, or treated blood stasis and dampness simultaneously. However, blood stasis transforming into fluid retention or obstructing the liver and gallbladder can also be causes of jaundice. Moreover, under certain conditions, blood stasis may sometimes become the key factor in refractory jaundice. Article 129 of *Shanghan Lun* states: "In Taiyang disease, if the body is yellow, the pulse is deep and knotted, and the lower abdomen is hard and full, with difficult urination, there is no blood stasis; if urination is free, and the person is delirious as if mad, this is undoubtedly a confirmed case of blood stasis, to be treated with Shidang Tang." The latter half of this article discusses blood accumulation in the lower jiao, where jaundice arises from blood stasis. The pathology is not in the qi level and is unrelated to dampness, hence urination is free. *Jingui Yaolue* states: "If Jiudan (wine-induced jaundice) is treated with purgatives, it may eventually transform into Heijiu (black jaundice), presenting with blue eyes, black complexion, a sensation in the heart like eating garlic and scallions, black stool, insensate skin that does not hurt when scratched, a floating and weak pulse, and although the complexion is black, it retains a slight yellow hue, which allows for diagnosis." It also states: "Jaundice patients who feel feverish but paradoxically experience aversion to cold at the Shen hour (3-5 PM) are suffering from Nülaodu (female labor jaundice). They present with bladder urgency, lower abdominal fullness, generalized yellowing, black forehead, hot soles, and over time develop black jaundice. The abdomen swells as if filled with water, stools are invariably black yet occasionally loose. This is Nülaodu disease, not water qi disease. If abdominal fullness occurs, it is difficult to treat; treat with Xiaoshi Fanshi San." These two articles primarily involve blood stasis, hence the explicit statement "not water qi disease." The former involves Taiyang disease and is an excess pattern, thus treated with the vigorous purgative Shidang Tang. The latter involves Shaoyin disease and is a deficiency pattern, thus treated with the gradual resolving Xiaoshi Fanshi San. Yang Zemin, a renowned late TCM practitioner from Zhuji, Zhejiang, stated: "Zhang Zhongjing used Pig Fat and Hair Decoction to treat Nülaodu." This indicates that Nülaodu varies by being primarily blood stasis or primarily deficiency, and differs by transforming towards dryness or dampness. Xiaoshi Fanshi San treats Nülaodu primarily due to blood stasis, with deficiency and dampness; thus, it uses purging as tonification, moving blood stasis while resolving dampness. Pig Fat and Hair Decoction treats Nülaodu primarily due to deficiency, with blood stasis and dryness; thus, it uses tonification as purging, moistening dryness while moving blood stasis.
The pulse and symptoms of jaundice due to blood stasis, besides those described in the above articles, can also be cross-referenced with discussions on blood stasis such as: "The patient appears to have heat signs, irritability, chest fullness, dry mouth and thirst, yet the pulse shows no heat; this is hidden yin heat, indicating blood stasis, which should be treated with purgation."
Here are two cases of jaundice due to blood stasis for reference:
One: "Wang Xian, a Hanlin Academy scholar, suffered from jaundice and did not respond to Yinchen Wuling San. In August, Shiwan was invited to diagnose him. The pulse was wiry, large, and hollow, indicating kidney injury with blood stasis caused by accumulated pills/powders. While the primordial qi could still withstand attack, Jingui's Xiaoshi Fanshi San was used, combined with Guiling Wan, to wash away the stagnation; delaying would make it difficult to act. Wang had a physician in his family who thought the medication was too harsh and hesitant to use it lightly. Soon after, his son passed the provincial examination and prepared for the metropolitan exam, causing mental distress and lack of time for treatment. By the second day of the New Year, Shiwan was consulted again. The pulse had turned wiry and革 (leather-like), indicating complete exhaustion of true yuan. For half a month, several qian of Ren Shen (Ginseng Radix) were taken daily, like stones thrown into water..." (*Zhangshi Yitong*).
Commentary: The principles of deficiency and excess are inherently opposing. People say Nülaodu is a deficiency pattern and dare not use purgatives, while later generations predominantly used Shenqi Wan. Consequently, Xiaoshi Fanshi San was shelved; few dared to prescribe it, and even fewer dared to take it. This case is an example, truly because Zhang Zhongjing's major methods were not well understood.
Two: "Yingtianwang presented with generalized yellowing, delirious speech resembling madness, severe chest pain intolerable to touch. This was blood accumulation in the middle jiao. Taoren Chengqi Tang was administered; one dose expelled blood stasis and cured him. Also, the younger brother of Prefect Zhu Yangshan suffered from lower body blood stasis causing madness, cured by Shidang Tang" (*Xu Mingyi Leian*).
Commentary: The pathogenesis of jaundice mostly belongs to damp-heat and blood stasis. Those emphasizing dampness say "no dampness, no jaundice"; those emphasizing heat say "jaundice is based on stomach excess heat"; those emphasizing blood stasis say "jaundice inevitably injures blood, treating jaundice requires activating blood." In reality, heavy dampness is primarily treated with Yinchen Wuling San, heavy heat with Yinchen Hao Tang, and heavy blood stasis with Shidang Tang. These are originally Zhang Zhongjing's standard methods. Later generations adhered rigidly to one aspect, losing Zhang Zhongjing's flexible application. The above case is an excess pattern of jaundice due to blood stasis, thus cured by purging accumulated blood with Taoren Chengqi Tang and Shidang Tang. If dampness is abundant with heavy heat or if righteous qi is deficient, formulas must be determined by syndrome differentiation, which is another discussion. Rigidly adhering to one aspect and limiting oneself is indeed a major taboo in treating jaundice.
Deficiency-cold Jaundice
Due to sexual indiscretion injuring essence and blood internally, or spleen yang failing to rise leading to dysfunction of the central earth, even without damp-heat, the deterioration of qi and blood preventing them from flourishing the complexion can also produce jaundice. For instance, Taiyin jaundice has two patterns: cold-damp and deficiency-cold. The *Shanghan Lun* discusses the cold-damp type, stating "if urine is clear/white, jaundice cannot occur" and "after Hansen Lun sweating, body and eyes turn yellow; this is because cold-damp remains unresolved in the interior." The *Jingui Yaolue* discusses the deficiency-cold type, stating "Men with yellow complexion and free urination should be given Xulao Xiao Jianzhong Tang" and "Jaundice disease, urine color unchanged, desire for spontaneous diarrhea..." Additionally, *Jingui Yaolue* mentions "black forehead, slight sweating, hot palms and soles, onset at dusk, bladder urgency, free urination, named Nülaodu," and "floating chi pulse indicates kidney injury," "Nülaodu disease is not water qi disease." Although these do not belong to Taiyin jaundice but to Shaoyin jaundice, they are also deficiency-cold and not due to dampness. Hence, later practitioners often used the method of keeping fish and shells. Indeed, since deficiency-cold jaundice is not due to dampness, urination is free and color may remain unchanged. Cold-damp jaundice, like damp-heat jaundice, is related to poor discharge of dampness, thus presenting with difficult urination and yellowing. Of course, cold-damp can combine with deficiency, deficiency-cold can combine with dampness, blood-stasis-heat can carry dampness, and damp-heat often combines with blood stasis, but these are separate issues for separate discussion.
Here is one case of deficiency-cold jaundice treatment:
"Chai Yuqing treated Lady Jialuomade for jaundice. Physicians prescribed Yinchen Wuling San without effect, then mixed powders. Skin became pale white, eyes golden-yellow, 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 restore healthy transportation; damp-heat will naturally dissipate. No need to specifically treat jaundice, and jaundice will heal itself. Liu Junzi Tang plus Houpo (Magnolia Bark) and Pao Jiang (Prepared Ginger) to warm the center; Shenqu (Medicated Leaven) and Maiya (Sprouted Hordeum) to assist the transformation of Wu and Si [Stomach and Spleen]. Within a few doses, full recovery occurred." (*Xu Mingyi Leian*)
Commentary: The malpractice of indiscriminately using bitter-cold clearing and draining drugs for jaundice was discussed by predecessors long ago, especially in pediatrics. Chen Fuzheng said: "For pediatric jaundice, ignorant people call it all damp-heat. Their only methods are removing dampness, promoting diuresis, clearing heat, and retreating jaundice. Who knows that damp-heat jaundice is rare, while spleen-deficiency jaundice is common. Strong spleen earth resists dampness and prevents jaundice; only spleen deficiency fails to transport, allowing dampness to invade." While damp-heat jaundice is less common and spleen-deficiency jaundice more common in pediatrics, adults predominantly suffer from damp-heat jaundice, but deficiency-cold jaundice cannot be ignored. The above case treated deficiency as excess, using clearing/draining indiscriminately, worsening the condition. Modern practitioners repeat this error, reinforcing my argument that treating jaundice must prioritize the Spleen.
Epidemic Toxic Plague Jaundice
Plague Jaundice (Wenhuang) is not recorded in Zhang Zhongjing's books; the name comes from *Mingyi Zazhu*. It is essentially Ji Huang (Rapid Jaundice), first appearing in *Zhubing Yuanhou Lun*, attributed to "addition of heat toxin." *Zabing Yuanliuxizhu* attributes it to contracting "epidemic pestilence qi," thus also called Epidemic Toxic Rapid Jaundice. Clinical manifestations include sudden onset, severe progression, rapid deepening of yellowing (golden yellow), chest fullness and asthma, high fever and thirst, urine like dark soy sauce, abdominal distension and hypochondriac pain, coma and delirium, restlessness, wiry-rapid or fine-rapid pulse, red/crimson tongue with yellow/dry coating, vomiting blood/nosebleeds/melena, petechiae/ecchymoses, ascites, and coma. These acute symptoms arise from special heat-toxin epidemic qi, differing from general damp-heat. Pathologically, this heat-toxin easily penetrates the Pericardium and invades Ying and Blood levels, causing rapid drying and yin injury. Treatment principles are clearing heat, detoxifying, cooling blood, nourishing yin, clearing the heart, and opening orifices. Generally, Xijiao San is the main formula, combined with cooling/nourishing herbs like Shengdi (Rehmannia Root), Danpi (Moutan Cortex), Xuanshen (Scrophularia Root), and heat-clearing/orifice-opening agents like Jinhua Tang or Niuhuang Wan. Although this pattern can sometimes carry dampness, the primary cause is heat-toxin, often transforming towards dryness, making it a non-damp jaundice. Compared to Heat-Dry Jaundice, whose cause is not epidemic toxin, this is caused by epidemic toxin, resulting in severity differences. Those confined to the notion "no dampness, no jaundice," insisting on "dampness" in all jaundice discussions, claiming this is "damp-heat carrying toxin," is inappropriate. Whether analyzing etiology, pathogenesis, or treatment, this pattern cannot be blamed on dampness.
Conclusion: Discussing jaundice by emphasizing only damp-heat or only blood-stasis-heat, while ignoring dryness-transforming non-damp patterns, is one-sided. One must know Zhang Zhongjing's methods for jaundice include: Sweating method via Mahlian Liaoqiao Chixiaodou Tang; Purging method via Shidang Tang; Vomiting method via Zhizi Chi Tang; Clearing method via Zhizi Baipi Tang; Harmonizing method via Xiao Chaihu Tang; Tonifying method via Xiao Jianzhong Tang; Resolving method via Xiaoshi Fanshi San; Warming method sought within cold-damp; Draining method via Yinchen Wuling San; Moistening method via Zhigao Faxian Tang. Its clarity of layers, rigor of methods, and detail of prescriptions are worthy of emulation. Even focusing solely on Yang Jaundice, treatments differ by Taiyang channel/fu/qi/blood, Yangming vomiting/clearing/purging/moistening, and Shaoyin dispersing/harmonizing/unblocking/excreting. This proves Zhang Zhongjing did not rely on a single method or formula. Ignoring this and binding oneself with "damp, heat, stasis," merely mixing heat-clearing, damp-draining, and stasis-moving herbs, is self-imprisonment and narrow-mindedness.
Clarification of Article 200 of *Shanghan Lun* ①
The original text of Article 200 of *Shanghan Lun* is: "Yangming disease, pulse is slow, difficulty in eating to fullness; if full, slight irritability and dizziness, necessarily difficult urination. This is about to form Gu Dan (Grain Jaundice). Even if purged, abdominal fullness remains. The reason is the slow pulse." This article also appears in *Jingui · Huangdan Pian*, with "slight irritability" written as "develops irritability." Interpretations by历代医家 (past physicians) vary greatly. I offer my humble views for reference.
I. Several Interpretations by Past Physicians
There are approximately five interpretations:
1. Considered as Yangming (Stomach) Middle-Cold Pattern. Many commentators hold this view, e.g., Ke Qin, Fang Youzhi, Cheng Yunlai, Shu Chiyuan, Cheng Yingmao. The *Shanghan Lun Lecture Notes* edited by Chengdu University of TCM also holds this: "Yangming pulse should be deep-large or deep-solid; now it is slow, indicating weak stomach yang, Yangming Middle-Cold Pattern." ②
2. Considered as Yangming (Meridian) Deficiency-Cold Pattern. Zhang Yinan says this article describes "Yangming meridian deficiency-cold forming Grain Jaundice... Disease is in the meridian; even if purged, abdominal fullness remains because the slow pulse indicates meridian deficiency-cold." ③ Generally, Yangming disease has transmission (from meridian) and direct invasion (into interior). Transmission brings heat; direct invasion brings cold. Some consider Meridian Deficiency-Cold, citing Article 236: "Yangming disease, slow pulse, much sweating, slight aversion to cold, can sweat, suitable for Guizhi Tang."
3. Considered as Yangming Channel Heat Pattern. Cheng Wuji says: "Yangming disease, slow pulse, means pathogen is entering the interior, heat is not yet solid. Food enters yin, generates qi in yang. Heat in stomach makes eating to fullness difficult... Slow pulse indicates heat qi not yet solid; even if purged, abdominal fullness does not decrease." ④ Cheng means there is heat, but not yet Yangming Fu-excess pattern; it remains Yangming Channel Heat.
4. Considered as Yangming Deficiency-Heat Pattern. You Zaijing in *Jingui Xin Dian* says: "Slow pulse, weak stomach, grain digestion is slow; slow digestion leads to grain qi stagnation generating heat, not stomach excess heat; thus even if purged, abdominal fullness persists." Similar notes appear in *Shanghan Guanzhu Ji*. Yu Chang also says: "Due to external contraction of Yangming, residual heat in stomach remains; thus eating to fullness is difficult; if full, food generates heat again. Two heats combine, causing irritability and dizziness... Only deficiency-heat internal obstruction, not comparable to结热 (knotted heat) requiring purging." ⑤
5. Considered as Taiyin (Spleen) Deficiency-Cold Pattern. Wu Qian says: "Grain Jaundice belongs to stomach heat, pulse should be rapid. Now pulse is slow, spleen organ is cold... The syndrome originally arises from Taiyin cold-damp stagnation... Belongs to spleen yin cold transformation and cannot be purged." ⑥ Many modern scholars follow this, e.g., *Jingui Yaolue Translation and Explanation* by Nanjing University of TCM says: "This is clearly Taiyin Deficiency-Cold Pattern"; *Selected Readings of Jingui Yaolue* by Chengdu University of TCM says: "This article discusses the pathogenesis of Grain Jaundice transforming from cold... It is Taiyin Spleen Deficiency-Cold Pattern."
Due to inconsistent understanding of pathogenesis, treatments varied. Ke Qin said: "Should use Wuling San to regulate stomach and promote water metabolism"; ⑦ Zhang Lu said: "Not only purging is useless, sweating and diuretics are also contraindicated; only harmonizing method should be used, such as Gancao Ganjiang Tang, first warming the center, then slightly regulating stomach qi." ⑧ Yu Chang also favored harmonizing but suggested Xiao Chaihu Tang ⑨; modern times favor warming methods, e.g., *Jingui Yaolue Translation and Explanation* and *Selected Readings* say: "Should use warming method, such as Lizhong or Sini Fang." Such divergence in clinical application necessitates clarification.
II. My View on Dryness-Blood Stasis Pattern
Checking the pulse and symptoms of this article: (1) Slow pulse, (2) Difficulty eating to fullness, if full then develops irritability and dizziness, (3) Necessarily difficult urination. Based on "even if purged, abdominal fullness remains," it is known there was pre-existing abdominal fullness. Thus, there are actually four symptoms. Analyzing these, I disagree with the above five explanations.
First, Yangming Middle-Cold is deficiency-cold, but "develops irritability" is clearly a heat sign; one cannot call "irritability" a cold sign. Yangming Middle-Cold, due to stomach deficiency-cold, causes hiccups upon drinking water, stomach qi rebelling, inability to accept food, hence called "cannot eat." This article says "difficulty eating to fullness," linked with "if full then develops irritability," differing in wording and meaning from "cannot eat," and should not be equated.
Second, if considered Yangming Meridian Deficiency-Cold, referencing Article 236, there should be slight aversion to cold, not irritability and abdominal fullness.
Third, if considered Yangming Channel Heat, there should not be "slow pulse" and "abdominal fullness," two fu-organ pulse/symptoms.
Fourth, Taiyin disease is deficiency-cold, contradicting the heat sign "irritability." While slow pulse and abdominal fullness can appear in Taiyin, they also appear in Yangming Fu-patterns. Calling Taiyin disease "Yangming disease" is not found in *Shanghan Lun*. Taiyin involves spleen failure to transport and stomach qi rebellion with vomiting, hence "food not accepted." This should not be equated with "difficulty eating to fullness." Taiyin's main symptoms are vomiting, diarrhea, and abdominal fullness, but urination is not difficult. If Taiyin jaundice necessarily had difficult urination, that would be incorrect. Taiyin jaundice has cold-damp and deficiency-cold patterns. "If urination is free, jaundice cannot occur" refers to cold-damp. In deficiency-cold, urination can be free, evidenced by *Jingui* articles "Men with yellow complexion, free urination" and "Jaundice disease, urine color unchanged." If this article were deficiency-cold jaundice, Zhang Zhongjing would not say "necessarily difficult urination." The three symptoms of slow pulse, abdominal fullness, and difficult urination are not exclusive to Taiyin or Yangming Middle-Cold. Therefore, ignoring or misinterpreting "irritability" is inappropriate.
Based on the above analysis, I believe the "Yangming Deficiency-Heat Pattern" theory is closer to logic. However, You Zaijing's annotation is too brief, failing to clarify the profound meaning, and is rarely adopted recently; Yu Chang's prescription contradicts classic principles, so it requires discussion.
I believe the pathogenesis of this article belongs to root deficiency and branch excess. "Stomach home excess" is the outline of Yangming disease, and damaging fluids/yin is its characteristic. Yangming channel pulse is surging; fu-pulse is slow. Since it is "Yangming disease, slow pulse," it should be viewed as Yangming Fu-disease. Yangming disease often transforms towards dryness. In late stages, although heat subsides, fluids are damaged, intestines/stomach dry, stools are often hard. At this time, unlike Middle-Cold or Taiyin where hiccups/vomiting cause "inability to eat," here "difficulty eating to fullness" exists because residual heat remains in the stomach; if overeating, food generates heat again (explaining "difficulty eating to fullness" means discomfort with overeating, distinct from "inability to eat"). Two heats combine, causing irritability and dizziness. Waste matter in intestines/stomach becomes solid due to fluid depletion and dryness, causing defecation difficulty, hard/dry stools, hence abdominal fullness. As for difficult urination, it indicates internal exhaustion of fluids, similar to Article 114 "yin deficiency difficult urination," both showing fluid consumption, not dampness accumulation or poor urination flow. Although "dry feces exist in the stomach," because it is caused by fluid exhaustion, "although hard, it cannot be aggressively purged." Therefore, this article belongs to root deficiency and branch excess. The pathogenesis is fluid damage and intestinal dryness, leading to knotting due to dryness, leading to blood stasis due to knotting, leading to jaundice due to blood stasis. Jaundice occurring in this situation is closely related to grain waste accumulating and not going, plus overeating causing food-relapse heat, hence "this is about to form Grain Jaundice." Wu Qian said: "Grain Jaundice belongs to stomach heat," which has some merit, but the pulse for Grain Jaundice is not necessarily "rapid."