2g. 六经辩证-合病或并病

2g. Six Jing diagnosis –co-exist stages

 

现在我们已经介绍了伤寒病的六经辩证。临床上，病邪可以在当下的阶段尚未结束就又传到下一个阶段，如从太阳阶段未尽而病邪也传到了阳明或少阳阶段。或者是病邪同时直中太阳和阳明，太阳和少阳，或太阳阳明和少阳，而形成多个阶段的合病或并病现象。另外，病人在得本次伤寒病之前就已经处于或阳明，或少阳，或太阴，或太阴，或厥阴病阶段，这样，临床上的病情表现就会非常复杂。

Now we learn how to diagnose the six stages of the Shanghan disease, the Taiyang, Yangming, Shaoyang, Taiyin, Shaoyin and Jueyin stages. In clinic, the disease can develop into the next stage without completely leaving the previous stage. Also, the Xieqi can invade into the body into two or more stages at the same time. Further more, a patient can also have been in a Yangming, Shaoyang, Taiyin, or Shaoyin, or Jueyin stage before they get the new Cold- or Wind-attack to come into the Taiyang stage. Therefore, there could be two or more stages exist the same time in the body.

以下是伤寒论书中介绍过的几种合病并病现象：

Here are some examples:

太阳与阳明合病者，必自下利，葛根汤主之。太阳与阳明合病，不下利，但呕者，葛根加半夏汤主之。

If the Taiyang and Yangming stage co-exist, and the patient has diarrhea, use Gegen Tang. If the patient has no diarrhea but only nausea, use Gegen plus Banxia Tang for the treatment.

太阳与阳明合病，喘而胸满者，不可下，宜麻黄汤。

In the Taiyang and Yangming co-exist condition, the patient has asthma, bloating feeling in the chest, use Mahuang Tang, not to use colon-cleansing therapy.

太阳与少阳合病，自下利者，与黄芩汤，若呕者，黄芩加半夏生姜汤主之。

In the Taiyang and Shaoyang co-exist condition, the patient has diarrhea, use Huangqin Tang. If the patient has nausea, use Huangqin plus Banxia and Shengjiang Tang mostly.

太阳与少阳并病，头项强痛，或眩冒，时如结胸，心下痞僐者，当刺大椎、第一间 (商阳穴),  肺俞、肝俞。慎不可发汗，发汗则谵语。脉弦，五、六日，谵语不止，当刺期门。

In the Taiyang-Shaoyang co-exist condition, the patient feels strong headache, or dizziness, or feels hard and pain in the upper stomach, use acupuncture on the Dazhui point, Shangyang, Feishu, and Ganshu. Do not use sweat therapy, otherwise the patient will have delirium. If the pulse feels string, and the delirium continues for five to six days without stop, acupuncture on the Qimen point. 

阳明病，脉迟，汗出多, 发热, 微恶寒者，表未解也，可发汗，宜桂枝汤。

In the Yangming stage, if the patient has delayed pulse, heavy sweat, fever, slight chilly, it means the Taiyang stage still exists. Sweat therapy can still be used. Use Guizhi Tang.

阳明病，脉浮，无汗而喘者，发汗则愈，宜麻黄汤。

In the Yangming stage, if the patient has no sweat but asthma, and if the pulse feels floating, use sweat therapy. Use Mahuang Tang.

阳明中风，口苦咽干，腹满微喘，发热恶寒，脉浮而紧，若下之，则腹满小便难也。本证中, 发热恶寒，脉浮而紧为太阳表证; 口苦咽干为少阳证; 腹满微喘为阳明证. 三阳合病, 不可单用下法, 否则表邪更陷, 加重阳明证. 若表证重, 用桂枝加大黄汤. 若少阳阳明证重, 用大柴胡汤治之.

In the Wind-attack Yangming stage, patient may feel bitter in mouth, dry in throat, bloating in stomach, slight short of breath, fever with chilly, and the pulse is floating and tight. In such condition, the fever and chilly, and floating-tight plus suggest Taiyang stage. Bitter taste in mouth and dry throat suggests Shaoyang stage. Bloating stomach and slight short of breath suggests Yangming stage. In such co-exist three Yang stages, Colon-cleansing therapy can not be used, otherwise, the patient will have more bloating and difficulty in urination. In such case, if the Taiyang stage is more, use Guizhi plus Dahuang; if the Shaoyang and Yangming stage is more, use Da Chaihu Tang.  

阳明病，脉浮而紧，咽燥口苦，腹满而喘，发热汗出，不恶寒反恶热，身重。本证为太阳少阳阳明之三阳合病. 脉浮而紧为太阳病. 咽燥口苦为少阳病. 腹满而喘，发热汗出，不恶寒反恶热，身重为阳明病. 此证不得用汗法, 温灸法, 或下法. 若发汗则躁，心愦愦反。若加温 ，必怵惕烦躁不得眠。若下之，则胃中空虚，客气动膈.

In the Yangming stage, patient may has floating-tight pulse, feel dry mouth and throat, bitter taste in mouth, bloating belly and short of breath, fever with sweat, not dislike cold but dislike hot, and feel heavy in the body. This is co-exist of Taiyang, Yangming and Shaoyang, the three Yang stages in the body. Floating-tight pulse is Taiyang stage; dry mouth and bitter taste is Shaoyang stage, bloating stomach and asthma, fever with sweat, and heavy body, suggest Yangming stage. For such a complex condition, it should not be used the moxibustion, the colon-cleansing therapy, or sweat therapy. IF the patient feels more irritated with thick tongue cover, use Zhizi Chi Tang. If the patient feels very thirsty, dry in mouth the throat, use Baihu plus Rensheng Tang. If the patient feels fever, thirsty with desire to drink water, has difficulty in urination, and floating pulse, use Zhuling Tang (The Zhuling Tang should not be used if the sweat is heavy).

脉浮而大，心下反硬，有热. 此为太阳阳明证. 脉浮为太阳病, 脉大为阳明病. 心下硬却未到腹满地步, 故此时该汗,该下, 颇为难定. 论中提示: 若临床表现主要为阳明腑证 (即大便难), 不可发汗; 若临床表现主要为阳明经证 (即发热汗出, 不恶寒, 反恶热), 不可用利小便法. 利小便法 (如用猪苓汤) 会致病陷阳明腑证.  

If the pulse is floating and big, and the stomach feels hard and the patient has fever, it is co-exist of Taiyang and Yangming stages. Floating pulse is Taiyang stage; big pulse and hard in stomach area are Yangming stage. If the patient shows more Yangming stage, do not use sweat therapy. If it is more the meridian phase of the Yangming stage, do not use urination therapy.

阳明、少阳合病，必下利，其脉不负者为顺也。负者失也，互相克贼，名为负也。脉滑而数者，有宿食也，当下之，宜大承气汤。

When the Yangming and Shaoyang co-exist, there will be diarrhea. If the pulse is slippery and frequent, it suggests that there is old-food in the colon. Use Da Chengqi Tang for the treatment.

三阳合病，腹满身重，难以转侧，口不仁，面垢，谵语，遗尿，发汗则谵语，下之则额上生汗，手足逆冷，若自汗出者 ，白虎汤主之。

When the three Yang stages co-exist, the patient feels bloating in stomach, heavy in the body, hard to turn the body, discomfort feeling in mouth, dirty tint on face, delirium, leak of urine. If there is sweat in such condition, use Baihu Tang for the treatment (fever-cleansing therapy). Sweat therapy will cause delirium, and colon-cleansing therapy will cause cold hand and feet with sweat on the front head. 

伤寒四、五日，身热恶风，颈项强，胁下满，手足温而渴者，小柴胡汤主之。

Upon the fourth or fifth days of the Shanghan disease, the patient feels fever, dislikes wind, feels strong tight on the neck, fullness feeling in the upper side of the belly, has warm hands and feet, and feels thirsty, use Xiao Chaihu Tang for the treatment. In this case, the dislike wind and tight neck suggest Taiyang stage. Bloating in the upper side of the belly is Shaoyang stage. Fever and thirsty suggest Yangming stage.

阳明病，发潮热，大便溏，小便自可，胸胁满不去者，与小柴胡汤.

In Yangming stage, the patient has wave-fever, loosed bowel movement, easy urination, but consist bloating feeling in the chest and in the upper side of the belly, us Xiao Chaihu Tang for the treatment. Here, wave-fever and loose stool belong to Yangming, while bloating feeling the chest and in the upper side of the belly suggest Shaoyang stage.

伤寒六、七日，发热微恶寒，支节烦疼，微呕，心下支结，外证未去者，柴胡桂枝汤主之.

Upon the sixth or seventh day of the Shanghan disease, the patient feels fever and slight chilly, annoying pain in the joints, slight nausea, bloating feeling in the upper stomach. Use Chaihu Guizhi Tang for the treatment. Here, the fever, chilly, joint pain, slight nausea suggest the Wind-attack Taiyang stage. The bloating feeling in the upper stomach suggests the Shaoyang stage.

伤寒五、六日，已发汗而复下之，胸胁满微结，小便不利，渴而不呕，但头汗出，往来寒热，心烦者，此为未解也，柴胡桂枝干姜汤主之。

Upon the fifth or sixth day of the Shanghan disease, a sweat therapy has been used but a colon-cleansing therapy was used again. The patient feels bloating and slight hard in the chest and upper side of the belly, has difficulty in urination, thirsty but no nausea. The sweat is only on the head. He/she has hot-cold shift feeling and irritated. Use Chaihu Guizhi Ganjiang Tang for the treatment. In this case, the hot-cold shift, irritated, bloating and hard in the chest and upper side of the belly is Shaoyang stage. Head sweat is Wind-attacked Taiyang stage. Thirsty and difficult urination is disorder of water distribution.  

伤寒五、六日，头汗出，微恶寒，手足冷，心下满，口不欲食，大便硬，脉沉细, 为阳微结. 阳气结于表. 小柴胡汤治之. (可与小柴胡汤，不如柴胡桂枝干姜汤 – 胡希恕). Upon the fifth or sixth day of the Shanghan disease, the patient has sweat only on the head, slight chilly, cold in hands and feet, fullness in the upper stomach, no desire to eat, hard in stool, and deep-thin pulse. Use Xiao Chaihu Tang for the treatment.

注意事项和说明：

Notice and explanation:

1. 临床上真正常见的是这些合病和并病现象。如何判断是二阳合病，三阳合病，拟或为阳证和阴证共存，如阳明太阴，太阳厥阴合病等，考验着医生的水平。

1. It is very common for such co-exist conditions in clinic. It is a real challenge for a TCM doctor to identify the co-exist condition.

2. 至此，读者也许注意到合病并病的治疗原则当是缓则先解表，急则先救里。合病并病中有少阳证者先解少阳 （小柴胡汤或柴胡类方）；有少阴证者先解少阴（四逆汤为主），之后随证再治。

2. The principle in the treatment of the co-exist condition is to release the body surface syndrome first if overall disease condition is not so dangerous; otherwise to treat the inside stages first. If there is Shaoyang stage (condition) in the co-exist conditions, solve the Shaoyang condition first by use of Xiao Chaihu Tang , or Chaihu-containing formulae. If there is Shaoyin stage (condition) in the co-exist conditions, treat the Shaoyin condition first (by use of Si Ni Tang). After that, treat the remaining disease accordingly.