阳明病,发热汗出,此为热越,不能发黄也;但头汗出,身无汗,剂颈而还,腹满,小便不利,渴饮水浆,
此为瘀热在里,身必发黄,茵陈蒿汤主之。
阳明多汗,此为里实表虚,反无汗,是表里俱实矣。表实则发黄,
里实则腹满。但头汗出,小便不利,与麻黄连翘证同。然彼属太阳,因误下而表邪未散,热虽里而未深,故口不
渴、腹不满,仍当汗解。此属阳明,未经汗下,而津液已亡,故腹满、小便不利、渴欲饮水,此瘀热在里,非汗
吐所宜矣。身无汗,小便不利,不得用白虎;瘀热发黄,内无津液,不得用五苓。故制茵陈汤以佐栀子、承气
之所不及也。但头汗,则身黄而面目不黄;若中风不得汗,则一身及面目悉黄。以见发黄是津液所生病。
伤寒七八日,身黄如橘子色,小便不利,腹微满者,茵陈蒿汤主之。
伤寒七八日不解,阳气重也。黄色鲜明者,汗在肌肉而不达也。小便不利,内无津液也。腹微满,胃家实也。
调和二便,此茵陈之职。
茵陈蒿汤∶
茵陈蒿(六两) 栀子(十四枚) 大黄(二两)
以水一斗,先煮茵陈,减六升,内二味,煮取三升,去滓,分温三服。小盒饭利,尿如皂角汁状,色正赤,
一宿腹减,黄从小便去。
茵陈禀北方之色,经冬不凋,受霜承雪,故能除热邪留结。栀子以通水源,大黄以调胃实,令一身内外之瘀
热悉从小便出,腹满自减而津液无伤。此茵陈汤为阳明利水之妙剂也。
伤寒发汗已,身目为黄。所以然者,以寒湿在里、不解故也。不可下,于寒湿中求之。
发黄有因瘀热者,亦有因寒邪者,有因于燥令者,亦有因于湿化者。则寒湿在里,与瘀热在里不同,是非汗、
下、清三法所可治矣。伤寒固宜发汗,发之而身目反黄者,非热不得越,是发汗不如法,热解而寒湿不解也。太
阴之上,湿气主之,则身自黄而面不黄,以此知系在太阴,而非阳明病矣。当温中散寒而除湿,于真武、五苓辈求之。
阳明病,出现发热且汗出,这是热邪向外发散的表现,因此不会发生黄疸;如果仅头部出汗,身体无汗,汗水只到颈部即止,伴有腹部胀满、小便不通畅、口渴想喝汤水,这是瘀滞的热邪结聚在体内,身体必然会出现黄疸,应当用茵陈蒿汤主治。
阳明病通常多汗,这属于里实表虚,现在反而无汗,说明表里都呈现实证。表实会导致发黄,里实会导致腹满。仅头部出汗、小便不利,与麻黄连翘赤小豆汤证的情况相同。然而那个证候属于太阳病,是因为误用下法导致表邪未散,热邪虽然入里但程度不深,所以口不渴、腹部不胀满,仍然应当通过发汗来解表。此证属于阳明病,未经过发汗或攻下治疗,而津液已经耗伤,所以出现腹满、小便不利、口渴想喝水,这是瘀热结聚在里,不适合使用发汗或催吐的方法。身体无汗、小便不利,不能使用白虎汤;瘀热发黄、体内缺乏津液,不能使用五苓散。因此制定茵陈蒿汤,以辅助栀子及承气汤类方剂所不及之处。仅头部出汗,则身体发黄而面目不一定黄;如果是中风病而无汗,则全身及面目都会发黄。由此可见,发黄是津液代谢失常所产生的疾病。
伤寒病程经过七八天,身体黄色像橘子色一样鲜明,小便不通畅,腹部轻微胀满的,用茵陈蒿汤主治。
伤寒七八天仍未解除,说明阳气郁闭较重。黄色鲜明,说明热邪在肌肉层而不能透达体表。小便不利,说明体内津液不足。腹部轻微胀满,说明胃家(胃肠)有实邪。调和大小便,这是茵陈的主要功效。
茵陈蒿汤方:
茵陈蒿(六两) 栀子(十四枚) 大黄(二两)
用水一斗,先煮茵陈,水量减少六升后,加入另外两味药,煮取三升药液,去除药渣,分三次温服。服药后小便会通利,尿液颜色像皂角汁一样红赤,过一夜腹部胀满减轻,黄色从小便排出。
茵陈禀受北方的黑色(水色),经历冬天也不凋谢,承受霜雪,所以能清除热邪的留结。栀子用来疏通水源(利尿),大黄用来调理胃肠实邪,使全身内外的瘀热全部从小便排出,腹满自然减轻且津液不受损伤。这是茵陈蒿汤作为阳明病利水的妙方。
伤寒发汗之后,身体和眼睛发黄。之所以这样,是因为寒湿在体内,未能解除的缘故。此时不可使用攻下法,应当在温化寒湿中寻求治疗方法。
发黄有的因瘀热引起,有的因寒邪引起,有的因燥令引起,有的因湿化引起。那么寒湿在里,与瘀热在里不同,这不是发汗、攻下、清热三种方法所能治疗的。伤寒本来适宜发汗,发汗后身体和眼睛反而发黄的,不是热邪不能发散,而是发汗方法不当,热邪虽解但寒湿未解。太阴经之上,由湿气主司,所以身体发黄而面部不发黄,由此可知病系在太阴,而不是阳明病。应当采用温中散寒并除湿的方法,从真武汤、五苓散这类方剂中寻找治法。
Yangming disease, characterized by fever and sweating, indicates that the heat is venting outward; therefore, jaundice will not occur. If there is only sweating on the head, no sweating on the body, with sweat stopping at the neck, accompanied by abdominal fullness, difficulty in urination, and thirst for drinking fluids, this signifies stasis-heat lodged in the interior. Jaundice will inevitably manifest, and Yinchen Hao Tang (Cinnamon Twig and Rhubarb Decoction) should be administered as the primary treatment.
Yangming disease typically presents with excessive sweating, indicating interior excess and exterior deficiency. The absence of sweating here implies both interior and exterior are in a state of excess. Exterior excess leads to jaundice, while interior excess leads to abdominal fullness. Head-only sweating and urinary difficulty are similar to the presentation in Mahlian Lianqiao Xiaodou Tang (Mahuang, Forsythia, and Soybean Decoction). However, that condition belongs to Taiyang disease, resulting from improper purgation that failed to disperse exterior pathogens; although heat has entered the interior, it is not deep-seated, hence there is no thirst or abdominal fullness, and resolution via sweating is still appropriate. This condition belongs to Yangming disease, where neither sweating nor purgation has been applied, yet body fluids have already been depleted. Consequently, abdominal fullness, urinary difficulty, and thirst arise due to stasis-heat lodged in the interior, making sweating or emesis inappropriate. With no sweating and urinary difficulty, Baihu Tang (White Tiger Decoction) cannot be used; with stasis-heat causing jaundice and internal fluid depletion, Wuling San (Five-Ingredient Powder with Poria) cannot be used. Therefore, Yinchen Tang was formulated to supplement the effects of Zhizi (Gardeniae Fructus) and Chengqi Tang formulas. Head-only sweating results in body jaundice but not necessarily facial jaundice; whereas wind-strike without sweating causes jaundice throughout the entire body and face. This demonstrates that jaundice is a disease arising from disorders of body fluids.
In cold damage lasting seven to eight days, if the body exhibits a yellow color like an orange peel, accompanied by urinary difficulty and slight abdominal fullness, Yinchen Hao Tang should be administered.
Cold damage persisting for seven to eight days without resolution indicates heavy accumulation of yang qi. A bright yellow hue suggests heat residing in the muscle layer but failing to reach the surface. Urinary difficulty indicates a lack of internal fluids. Slight abdominal fullness indicates excess in the stomach and intestines. Harmonizing the two bowels is the function of Yinchen (Artemisiae Scopariae Herba).
Yinchen Hao Tang:
Yinchen Hao (Herba Artemisiae Scopariae, six liang), Zhizi (Fructus Gardeniae, fourteen pieces), Dahuang (Radix et Rhizoma Rhei, two liang).
Boil one dou of water, first decoct Yinchen until the volume reduces by six sheng, then add the other two herbs, boil to obtain three sheng of liquid, remove dregs, and divide into three warm doses. After administration, urine will become profuse, resembling the dark red juice of soapberries; after one night, abdominal fullness will decrease, and the jaundice will exit via the urine.
Yinchen absorbs the color of the North (water), remains evergreen through winter, and endures frost and snow; thus, it can eliminate lingering heat and stagnation. Zhizi unblocks the water source, and Dahuang regulates gastric excess, allowing all stasis-heat inside and outside the body to exit via urine, thereby reducing abdominal fullness without damaging body fluids. This makes Yinchen Tang an excellent formula for promoting diuresis in Yangming disease.
After sweating therapy for cold damage, if the body and eyes turn yellow, it is because cold-dampness resides in the interior and fails to resolve. Purging is contraindicated; treatment should seek methods to resolve cold-dampness.
Jaundice may result from stasis-heat, cold pathogen, dry climate, or damp transformation. Cold-dampness in the interior differs from stasis-heat in the interior and cannot be treated by sweating, purging, or clearing heat alone. Although cold damage is suitable for sweating, if jaundice appears after sweating, it is not because heat cannot vent, but due to improper sweating technique; the heat resolves, but cold-dampness remains. The Taiyin channel is governed by dampness; thus, the body turns yellow while the face does not, indicating the disease is related to Taiyin rather than Yangming. Treatment should involve warming the middle, dispelling cold, and resolving dampness, utilizing formulas such as Zhenwu Tang (Aconite Decoction) or Wuling San.