伤寒论 六经辨证:少阳病

  Six Jing diagnosis –Shaoyang stage
 

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 2c. 六经辨证:少阳病

2c. Six Jing diagnosis –Shaoyang stage

 

如果病邪入侵更深,但是没有到达阳明层次,即里层,而是逗留在半表半里的层面,我们就说邪在少阳。这时候的病症就被称为少阳病。

If the Xieqi (the disease-causing energy entity) invades deeper than the Taiyang layer, but not to the Yangming layer, e.g. it stays in between the Taiyang and the Yangming stage, the disease belongs to the Shaoyang stage.

(1). 就伤寒论书中提示,诊断少阳病的要点是口苦咽干目眩。我们可以先將这个综合症说成是少阳I 型综合症,这是为了以后讨论其它少阳类型的方便。

(1). As indicated in the Shanghan Lun, the key point to diagnose Shaoyang stage is the bitter taste in mouth, dryness in throat and eye dizziness. We can first name this syndrome as Shaoyang type I syndrome. It is for easier discussion later with other types of Shaoyang stage.

如果病人口中有苦味,咽喉干燥,头有些晕晕乎乎,我们就说他得了少阳病,或者说他的病是伤寒病中的少阳阶段。

If a patient has bitter taste in mouth, dryness in throat, dizziness, we will say that the patient gets into the Shaoyang stage of the Shanghan disease.

口苦:口中可以是典型的苦味,但是也可以是其它味道,比如说甜味,辣味,辛味,等等。如果仅仅拘泥于苦味而诊断少阳病,对伤寒论的理解就有些狭隘了。后世医生将甜味归为脾脏之疾;苦味为心之疾;辛味为肺之疾,和咸味为肾之疾,是受黄帝内经的影响。这里要提出的是,伤寒论对于疾病的病理生理的理解似乎并不完全遵循黄帝内经-我们同意这种观点。临床上,口中有异味,包括口中粘粘腻腻的不清爽的感觉,就当考虑少阳病,而不要过度强调是什么味。

Bitter taste in mouth: the taste can be really a bitter, but can also be some other kinds of taste, such as sweet, puckery, astringency, salty, or spicy. Doctors in College style may only remember from their text book that it should be bitter taste only, because they learned from text book that the sweet taste belongs to Spleen; the Spicy taste belongs to Lung; the Salty state belongs to Kidney; and the sour taste belongs to Liver. However, according to the text book (the theory comes from Huang Di Nei Jing actually), the bitter taste should belong to the Heart. Here in Shanghan Lun, the bitter taste belongs to Shaoyang stage, e.g. the Liver-gall bladder system. It appears that, the Shanghan Lun does not follow the Huang Di Nei Jing system. In clinic, whenever there is strange state in mouth, we should consider the possibility of Shaoyang stage, regardless what kind of taste in mouth.   

咽喉干燥:伤寒病在太阳阶段,没有口干或口渴。病在阳明,当为口渴。而病在少阳,为咽喉干。

Dryness in throat: in the Taiyang stage, the patient has no dryness or thirsty feeling in mouth or throat. In Yangming stage, the patient feels thirsty. Here, the patient feels only dryness. Apparently, whether the patient feels dry or thirsty is very important in the diagnosis.

目眩:目眩当指睁开眼睛或闭眼后有头旋,或头重脚轻的感觉,也可以是眼睛怕光的感觉,但不指由于体位变动而出现的这种平衡失常的感觉。如果是后者,或者由于颈椎病,或者属于血虚等,需要不同的治疗方法。阳明病也有眩晕,如阳明中风经证者,头眩;阳明伤寒经证者,进食后也会有头眩。这些都是头眩,其头眩和体位及睁眼闭眼关系都不太大。

Eye dizziness: it should mean that the dizziness happens when the eye is open. It disappears or stops after close of the eye. It can also be that the dizziness occurs after close of eye, but be better after open the eyes. The eye dizziness can be dizziness but can also be a dislike or fear of light.  If the dizziness is related to the head position and body position, it suggests that the disease might be due to something else, such blood deficiency or cervical spondylosis.

In the Yangming stage, patient can also have dizziness, but it is not affected by the position of the head or body, or by the open of close of the eyes. In the Yangming Wind-attack syndrome, the dizziness is there no matter the patient eats or not. In the Yangming Cold-attack syndrome, the patient feels dizziness mostly after eating.

对于少阳 I 型的治疗主方是著名的小柴胡汤。

For the treatment of the Shaoyang type I syndrome, Xiao Chaihu Tang is used. Xiao here means small; Chaihu is the name of a herb.

(2). 少阳 II 型综合征:少阳中风, 寒热往来,胸胁苦满,默默不欲饮食,心烦喜呕,或胸中烦而不呕,或渴,或腹中痛,或胁下痞硬,或心下悸,小便不利,或不渴,身有微热,或咳者,小柴胡汤主之。服柴胡汤已,渴者,属阳明,以法治之。

(2). Shaoyang type II syndrome

The patient feels shift of chilly and hotness, similar to that of menopause syndrome; feels strong bloating in chest, no appetite at all, feels irritated, and tends to have nausea. We call these conditions as “Shaoyang type II syndrome”.

Patient with this syndrome could have much more other symptoms, such as irritated feeling in chest without nausea, or feels thirsty, or feels pain in belly, or has sticky bloating and hard feeling in the upper side of the belly, or feels palpitation in the upper stomach, and has difficulty in urination, or not thirsty feeling but has slight hot feeling in the body, or have cough. After drink of the Chaihu-containing herbal tea and if the patient feels thirsty, the condition belongs to Yangming stage. Treat the Yangming stage (refer to the Yangming chapter for solution).

在伤寒中风病程中, 一旦出现上述任何一项, 如寒热往来, 或默默不欲饮食, 或心烦喜呕, 即可认为病已涉及少阳. 当考虑加用柴胡类药物治疗.

To diagnose this syndrome, either one of the symptoms is enough to set up the diagnosis:  shift of chilly and hotness; strong bloating in chest, no appetite, irritated and tends to have nausea. Once the diagnosis is set up, we can consider the use of the Chaihu-containing herbal formulae for the treatment. Of course if all the three symptoms exist, the diagnosis of Shaoyang stage is more correct.

这里的心烦喜呕指的是病人主动作出呕吐的动作来缓解不舒服。这和阳明病时病人进食就呕不一样。阳明病呕吐时病人不舒服,所以病人都不敢吃东西。

That the patient “tends to have nausea” means the patient wants to have nausea so as to release the discomfort. This is different from the nausea in the Cold-attacked Yangming stage, in which the nausea comes after eat and the nausea makes the patient feel not good.

少阳病时病人没有食欲,也能吃,但吃了也没有什么特别的不舒服。而阳明病时病人一吃东西就不舒服(特别是阳明中寒证时是如此)。

In the Shaoyang stage, the patient has no desire to eat. In the Yangming stage, the patient has desire to eat, but dares not to eat, because after eat, the patient will feel pain in stomach and has nausea.

(3). 少阳 III 型综合症:如果病人听力下降,眼睛发红,胸满闷,心烦,也属于少阳,也以小柴胡汤为治疗主方。(原文是:少阳中风. 两耳无所闻,目赤,胸满而烦. 用小柴胡汤)

(3). The deafness – red eyes – bloating in Chest and irritated feeling syndrome of the Shaoyang stage

If the patient feels reduced hearing ability, has red color in the eyes, feels bloating in chest and feels irritated, we will say that the patient also comes into the Shaoyang stage.

听力下降:可以是真正的听力下降,也可以是耳内有堵塞感或痒感。

The deafness: the hearing ability is reduced, or even completely lost. The patient may feel block feeling in the ears.

眼睛发红:眼睛发红可伴有或痒,或干,或胀,或少许流泪的感觉。

Red eyes: one eye or both eyes turns into red color. The eye may also feel pain or itch, or tearing from the eyes.

For the treatment of this syndrome, Xiao Chaihu Tang is also the choice.

(4). 少阳 IV 综合征:少阳中风, 腹中急痛, 脉浮涩, 或沉弦, 先与小建中汤,不差者,与小柴胡汤主之。

(4). Shaoyang type IV syndrome: Acute stomach pain syndrome of Shaoyang stage.

If a patient has any of the symptoms above, which is sufficient to diagnose Shaoyang stage, and also has acute stomach pain (the pulse can be either floating-harsh or deep-and-string), use Xiao Jiang Zhong Tang for the treatment first. If it does not work, change to use Xiao Chaihu Tang.

 

少阳病特殊类型为

1. 热入血室:

Special type of Shaoyang stage in female:

(1). 妇人中风,发热恶寒,经水适来,得之七、八日,热除而脉迟身凉,胸胁下满,如结胸状,谵语者,此为热入血室也,当刺期门,随其实而泻之。

(1).  If a female got the Shanghan disease and feels chilly and hot, and the same time she has menstruation comes, her fever is over, but she feels cold in the body, has slow pulse, bloating feeling in the upper-side of the belly, and has delirium, this is the condition that we call it Hotness invasion into uterus. For the treatment, use acupuncture on Qimen point, to deplete the Xieqi through the acupuncture treatment.

(2). 妇人伤寒,发热,经水适来,昼日明了,暮则谵语,如见鬼状者,此为热入血室,无犯胃气及上二焦,必自愈。

(2). When the female has Shanghan disease when her menstruation comes, she had delirium at night seeming she see a ghost, but normal during day time. This is also a kind of hotness invasion in uterus. This condition will cure by itself, if the Xieqi does not affect the stomach and the chest.

(3). 妇人中风,七、八日续得寒热,发作有时,经水适断者,此为热入血室,其血必结,故使如疟状,发作有时,小柴胡汤主之。

(3). When the Hotness invades into the uterus, seven to eight days after the Shanghan disease, the Xie Hotness will entangle in the uterus, which stops the menstruation and makes the female feel chilly and hot shift, which happens on fixed time. In this case, use Xiao Chaihu Tang for the treatment.

 

2. 少阳结胸证

2. Jie Xiong condition:

结胸证是由于邪气纠结与胸部所致。这是由于应用汗法后出汗过多邪陷胸部所致。(注意:汗出不畅会导致邪陷阳明经证)

Jie means to entangle; Xiong means chest. It means the Xieqi is entangled in the chest cavity. This condition is caused by over sweat due to sweat therapy (Insufficient sweat therapy makes the disease falls into the meridian phase of Yangming stage).

结胸者有气短,心烦,焦躁,上腹部硬而痛。需要用大陷胸汤治疗。

The patient with the Jie Xiong condition feels shot of breath, irritated, anxiety, and feels hard and pain in the upper stomach area. This condition needs Da Xian Xiong Tang for the treatment. Da here means big. Xian means to shrink in, or to fall down. Xiong means chest.

结胸证者也会有从上腹部到下腹部的胀满痛 类似于阳明腑证。但结胸证者腹痛而拒按。也会数日不大便,口干舌燥而渴, 午后稍发热。本证也需要用大陷胸汤治疗。

The patient with the Jie Xiong condition can also feel hard, fullness, bloating and pain from the upper stomach to the lower stomach (the whole belly – similar to the organ phase of the Yangming stage), which is so pain that the patient do not want the stomach be touched. The patient has no bowel movement for several days, feels dry and thirsty in the mouth and tongue, and has fever in the afternoon. The Da Xian Xiong Tang is also used for the treatment of this type of Jie Xiong condition.

如果病人心下痛, 按之痛, 脉浮滑, 为小结胸证, 为邪陷少阳型. 用小陷胸汤治疗.

If the patient feels pain in the upper stomach, which is painful when touch, with floating-slippery pulse, it is called Small Jie Xiong condition. This condition needs Xiao Xian Xiong Tang for the treatment. Xiao here means small.

伤寒病结胸证, 项强如柔痉状, 用大陷胸丸下之.

If the patient feels hard and pain in the upper stomach, and feels very tight and stiffness on the neck, we use Da Xian Xiong pill for the treatment. 

 

3. 栀子豉汤证

3. Zhizi Chi Tang

伤寒论中有栀子豉汤证,该症候散在于太阳病篇,阳明病篇和厥阴病篇中,但几乎都是作为误治后病情的诊断和治疗来介绍的。这种栀子豉汤证或出现在发汗吐下,或加烧针后。其基本特点是虚烦,心中烦闷苦恼。其病变位置在胸(其实在于胸膜腔)而不是肺脏,所以病人没有咳嗽咯痰等呼吸系统症状,反而是情感障碍性反应。而情感障碍反应是少阳病特点之一,因为太阳病,阳明病,太阴病,少阴病和厥阴病都没有这种无名之烦恼症状。在其它这些疾病中,如果病人烦,是由于有具体的病变导致疼痛等而烦。

There is a condition or syndrome called Zhizi Chi Tang in Shanghan Lun. It is introduced and scattered in different chapters for different stages (in the Taiyang, Yangming and Jueyin stages), but it is almost always introduced as a outcome of a improper treatment of that disease by use of sweat therapy, vomiting therapy, a colon cleansing therapy, or a hot-needle acupuncture therapy. It is characterized as irritated without clear reason (no clear physical reason, such as pain, or emotional reason, such as angry to someone). The location of the disease is in the chest (actually it is located in the pleural cavity), not in the lung, therefore the patient has no cough or phlegm, such respiratory symptoms, but has emotional symptoms, such as irritated (not means stress or anxiety). There is no such irritated symptom in other Shanghan disease stages. Here we should mention that, the irritated feeling is not the restless feeling. They are different. For the restless symptom, the patient has restless arm and/or legs. The arm and/or leg jumps from time to time. It is a typical symptoms indicating Shaoyin stage. 

 

伤寒论中介绍栀子豉汤的篇幅如下:

Followings are the paragraph introducing the Zhizi Chi Tang:

<<伤寒论; 太阳病中篇>>: “发汗吐下后, 虚烦不得眠, 若剧者, 必反复颠倒, 心中懊侬 (烦闷而苦), 栀子豉汤主之.”

Shanghan Lun – Taiyang disease-middle part: “After sweat therapy, vomiting therapy or colon-cleansing therapy, if the patient feels no-reason irritated feeling and hard to fall into sleep, in severe case, the patient may turn over and over on the bed and feels terrible irritated. In this case, use Zhizi Chi Tang for the treatment.”

发汗, 若下之而烦热, 胸中窒者, 栀子豉汤主之.”

“After sweat therapy or colon cleansing therapy, if the patient feels annoying hot, and feel chock and press in chest, use Zhizi Chi Tang for the treatment.”

<<伤寒论; 阳明篇>>: “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. 若发汗则躁, 心愦愦 (心思不平静之貌), 反谵语; 若加烧针, 必怵惕 (惶恐), 不得眠; 若下之, 则胃中空虚, 客气动膈, 心中懊侬, 舌上胎者, 栀子豉汤主之.”

Shanghan Lun – Yangming disease: “In the Yangming disease, if the pulse feels floating and tight, the patient feels dry mouth and bitter taste in mouth, the stomach feels full and the patient has asthma, fever and sweat, no chilly feeling, but dislikes hot, and if the body feels heavy, in such case, the use of sweat therapy would cause restless and the patient feels frustrated or fluttered feeling in heart and has delirium. If hot acupuncture needle is used, the patient will have scare feeling, palpitation and hard to fall into sleep. If colon-cleansing therapy is used, the stomach becomes hollow and empty, with a feeling as gas rushes up the diaphragm, a feeling of irritated, and the tongue is with heavy tongue covering. In this case, use Zhizi Chi Tang for the treatment. 

阳明病下之, 其外有热, 手中温, 不结胸, 心中懊侬, 饥而不能食, 但头汗出者, 栀子豉汤主之.”

After use of colon-cleansing therapy in Yangming stage, if the patient feels hot, warm in hands, no Jiexiong syndrome, feels irritated, feels hungry but cannot eat, and has sweat on head, use Zhizi Chi Tang for the treatment.”

<<伤寒论; 厥阴篇>> : “下利后更烦, 按之心下濡 () , 为虚烦也, 宜栀子豉汤.”

Shanghan Lun – Jueyin disease: “If, after colon-cleansing therapy, the patient feels more irritated, but the stomach area is soft when press, it is no-mass irritated (Xu irritated), use Zhizi Chi Tang for the treatment.”

 

注意事项和解释:

Notice and explanations:

(1). 少阳病也分为少阳中风和少阳伤寒两类。但是少阳中风类型远远多于少阳伤寒类型。似乎是中风者易患少阳病,而中寒者易得太阴病(见后)。

(1). The Shaoyang stage can also be separated into the Cold-attack Shaoyang stage and the Wind-attacked Shaoyang stage, but the most of the Shaoyang condition belongs to the Wind-attacked Shaoyang stage. Most of the Taiyin stage comes from Cold-attack. See later chapter

(2). 中医教科书中每当提到应用小柴胡汤时,脉象必为弦脉。如果我们查仲景原文,前三个少阳证型中都没有特意点明诊断少阳病之脉象必须为弦脉。所以,如果我们按照中医教科书的理论,拘泥于诊断少阳病以及决定是否使用柴胡类方时必得弦脉才行,那么使用小柴胡汤的可能性就大大降低了。

(2). It should be pointed out that in the TCM text book, to diagnosis the Xiao Chaihu Tang syndrome (condition), the pulse should be string. This is not indicated in the Shanghan Lun. In the Jing Fang style of TCM, the pulse in the shaoyang stage might be largely variable, though certainly it should not be deep (deep pulse indicates Shaoyin stage, see bellow). In the first three types of Shaoyang stage, there is no indication that the string pulse is necessary for the diagnosis. If we stick to the idea from the TCM textbook that to diagnose Shaoyang stage, and to decide whether to use Chaihu-containing herbal formulae, need the string pulse, we will miss a lot of chance to use the Chaihu Tang series.

(3). 现在一般中医医生一看到病人一阵热一阵冷,所谓的寒热往来,就想到是小柴胡汤症,就会用小柴胡汤治疗。实际上在伤寒论中,还有其它证型也有类似的“寒热往来”。都需要和小柴胡汤鉴别。主要的有太阳病中的宜桂枝二麻黄一汤,桂枝麻黄各半汤,桂枝二越婢一汤等。另外还有更年期综合征时的寒热往来,也不是小柴胡汤的适应症。

(3). Nowadays, once seeing a patient with the hot and chilly shift feeling, the ordinary doctor will soon consider about the half-surface-half-inner symptom and consider the use of Xiao Chaihu Tang for the treatment. In fact, the Xiao Chaihu Tang condition needs to be distinguished with other conditions in the book Shanghan Lun, such as Guizhi Two Mahuang One Tang, and Guizhi two Yuebi One Tang. In addition, in menopause syndrome, the patient can also feel hot, then followed by sweat and chilly. Such hot-cold shift symptom needs different herbal therapy.

桂枝二麻黄一汤者发热恶寒脉洪大;桂枝麻黄各半汤者,发热恶寒,热多寒少,面有热色,身痒;桂枝二越婢一汤者发热恶寒,热多寒少,脉微弱者。而小柴胡汤寒热往来,但还有胸胁苦满,默默不欲饮食,心烦喜呕。

For the Guizhi Two Mahuang One Tang condition, the patient feels fever, dislikes cold, and the pulse feels big-wave like.

For the Guizhi Half and Mahuang Half Tang, the patient feels fever and chilly, more fever than chilly, red color on face and itch in body. For the Guizhi Two Yuebi One Tang, the patient also has fever and chilly, more fever than chilly, but the pulse feels weak. For the Xiao Chaihu Tang condition, the patient has annoying floating feeling in the chest, silent without desire to eat, annoying and nausea, beside the hot-chilly shift.

(4). 现在我们看,太阳病,病位主要在体表背部 (后头部,项后部,背部,下肢后方,踝关节外侧等(膀胱部位特殊);阳明病,病位主要在腹部之胃至大肠和直肠部位);而少阳病,病位主要在眼,耳,口咽喉,膈肌和情感方面(子宫部位特殊)。似乎是太阳病病在体表,阳明病病在与外界相联通的“里”。比如说从胃,小肠,大肠,到结肠,都和外界通过口和肛门“相通”。而少阳病牵连的是这些入口处,如眼,耳,口,咽喉,以及与外界不通的腔体,如胸膜腔(诸陷胸证和栀子豉汤证)和腹膜腔(大柴胡汤证 以后讨论)。

(4). Now we can see that, for Taiyang stage, the disease is located mostly on the back of the body surface: the back of head, the back of neck, the back of body, the back of the legs and the outside of the ankles (Urine bladder is special).

For Yangming stage, the disease is located mostly in the stomach (including the large intestine and colon mostly). The disease location still connects to the out side of the body (through the mouth and anus).

However, for the Shaoyang stage, the disease mostly affects the opening of the body, such as the eyes, the ears, the mouth and the throat (uterus is special), as well as the sealed space of the chest (e.g. the pleural cavity) and the stomach (peritoneal cavity).

特殊的是鼻子和肺脏。外感导致和激发的过敏性鼻炎需要用小青龙汤或桂枝附子,或桂枝加附子汤治疗,属于太阳病范畴;而慢性鼻窦炎,肥厚型鼻炎之类需要葛根汤类方治疗,又属于阳明病范畴。但就伤寒论而言,怎么都和少阳无关。伤寒论中有关肺部疾病的诊断和治疗都在伤寒杂病论中讨论了,并没有特定提示其属于六经中的任何一经。

It is a question for which stage the nose and the lung should belong to. An allergic sinusitis needs treatment by use of Xiao Qinglong Tang, or Guizh Fuzi Tang, or Guizhi plus Fuzi Tang. For chronic sinusitis or hypertrophic rhinitis, it is needed to use Gegeng Tang or similar formula, which of the formulae belong to Yangming stage. All in all, they do no belong to Shaoyang stage disease. The diagnosis and treatment of the respiratory diseases has been discussed in a sister book of the Shanghan Lun: the Shanghan Za Bing Lun. No clear indication for which stage the diseases of nose and lung mostly belong to.

我们倒不是说眼睛,耳朵,咽喉有病就先考虑少阳病,但如果这些部位的病变病程短,而且是先有感冒症状,后有这些部位的病变,那么先考虑少阳病,而且先用柴胡类方是没有大错的。

We do not mean that the Shaoyang stage should be considered first if the disease involves the eyes, the ears or the throat. But if the course of the diseases in these locations is short, and if the disease follows a common cold, we consider the Shaoyang disease and to use the Chaihu-containing herbal formulae is reasonable.

(5). 伤寒论中,相对于太阳病和阳明病,少阳病的篇幅很短。但这绝不是说少阳病的证型很少,而是因为少阳病处于半表半里,病邪强则病深入而表现为更多阳明病证,机体抵抗力恢复或治疗得当,则病返回太阳病范围多一些。另外,特别是在太阳病阶段,治疗失误则病极易进一步到达少阳,病人出现烦,闷,恹恹,恶心,胀,寒热往来等表现。由此,我们將太阳病误治后的病症,除了明显归于阳明病的表现,都按照邪陷少阳病看待。

(5). In the Shanghan Lun, compared with the chapters for Taiyang disease and Yangming disease, the chapter for Shaoyang disease is very short. This does not mean that there are less kinds of syndromes or conditions in the Shaoyang stage, or there is no more need to discuss for the Shaoyang disease. This is because the disease location of the Shaoyang is between the body surface layer (Taiyang stage) and the inner layer (Yangming stage). If the disease energy is stronger, the disease develops deeper into the Yangming stage, and if the body defense system becomes stronger or the treatment is proper, the disease could turn back to the Taiyang stage. Also, when the disease is in the Taiyang stage, an improper treatment in the Taiyang is easy to push the disease deeper into the Shaoyang stage, making the patient feel irritated, stroke feeling, depression, nausea, bloating, hot-cold shifting feeling, etc. For this reason, we regard most of the syndromes that happen after improper treatment of Taiyang stage, into the Shaoyang stage, unless it has been clearly indicated in the book that the symptoms belong to Yangming stage.

 

 

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 Millwoods Acupuncture Center is located in Edmonton, Alberta, Canada and serves Edmonton and its surrounding area, including: St. Albert, Big Lake, Spruce Grove, Stony Plain, Devon, Beaumont, Sherwood Park, Calgary, Red Deer and Whitecourt, Barrhead, Westlock, Wetaskiwin, Camrose, Fort Saskatchewan, Grande Prairie. Our clients also come from Vancouver and Saskatoon.

 

 

 

 

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