2b. 六经辨证- 阳明病

2b. Six Jing diagnosis –Yangming stage

如果邪气强，或机体抵抗力弱，或邪气在太阳经时治疗不当等，邪气可进一步入侵阳明层次，形成阳明病。

If the Xieqi (the disease-causing energy entity) is too strong, or if the body is too weak, or if the treatment is improper in the early Taiyang stage, the Shanghan disease would develop into the deeper stage: the Yangming stage.

阳明病的初期为阳明经证。因入侵邪气的性质而分为阳明中寒和阳明中风两个亚型。阳明病的高潮期为阳明腑证。阳明腑证也有阳明中寒和阳明中风之分。

The early phase of the Yangming stage is Yangming meridian phase. It can further more be separated into Cold-attack meridian phase and Wind-attack meridian phase.

The deeper phase of the Yangming stage is called organ phase. It can also be separated into Cold-attack organ phase and Wind-attack organ phase.

阳明中寒和阳明中风者，都有发热汗出，不恶寒，反恶热，口渴，脉洪大。整个人体都像一团火。病人已经没有丝毫的恶寒感。这种情况多见于急性感染性疾病，如急性大叶性肺炎，病毒性脑膜炎，急性阑尾炎，等等。如果病人有以上这些临床表现，我们就可以诊断他得了阳明病。

In both the Cold-attack and the Wind-attack meridian phase, the patient feels hot, has fever, thirsty, sweat, and not dislikes cold but hot. The pulse feels big as wave. The patient has no chilly at all. The whole body appears as in a fire condition. This condition can be seen in the acute pneumonia, acute appetites, or other acute diseases. If a patient has such manifestations, we will diagnose the condition as the meridian phase of the Yangming stage.  

阳明中寒和阳明中风的区别是：阳明中寒者食欲下降，而阳明中风者食欲不受影响。

The difference between the Cold-attack and the Wind-attack meridian phase are: in the former, the patient has reduced appetite and in the later, the appetite remains no change.

阳明中寒者也会有多汗，然而，如果病人不出汗，就会有尿频，并且有皮下虫行感。这种病人会有咳嗽，恶心，手脚冰凉，以及强烈头痛。如果病人没有咳嗽，恶心，手脚冰冷，就不会有头痛。

If patient in the Cold-attack meridian phase has no sweat (but still have fever), the patient would have frequent urination, or have itching feeling under the skin that feels as insect moving. These patients may have cough, nausea, cold hands and feet, and strong headache. If the patients have no cough, nausea, or cold hands and feet, they would have no headache.

阳明中寒由太阳伤寒发展而来，由于发汗不彻底所致。

The Cold-attack meridian phase can be developed from Cold-attack Taiyang stage, when the sweat therapy used for the Taiyang stage was not thorough.    

阳明中风者没有食欲改变，但会有头眩。如果有咳嗽，就必然会有咽痛。如果没有咳嗽，就不会有咽痛。

Patient in the Wind-attack meridian phase have no reduced appetite, but have dizziness. If they have cough, they must have sour throat (if they have no cough, they would have no sour throat).

阳明中寒腑证者不能食。一吃东西就觉得腹胀，头眩，微烦，手足出汗，小便不利及腹泻。

Patient in the Cold-attack organ phase have difficulty to eat. When eat, they feel bloating, dizziness, slight annoyed, and sweat in hands. They have difficulty in urination, and loose bowel movement. The stool might even contain non-digested food.

阳明中风腑证者全腹胀满，大便困难或多日无大便。这种情况可见于急性肠梗阻，多种急性疾病高热期等。

In the Wind-attack organ phase, the patient feels bloating and pain in the whole belly and is hard to have a bowel movement. This condition can be seen in acute intestinal obstruction. Patient in the Wind-attack organ phase has no problem to eat. Their urination is not affected, but they have constipation or even no bowel movement.

对于治疗，阳明中寒经证者如果汗出者主要用桂枝附子类方；无汗而有尿频，用小青龙汤或小青龙汤加石膏；食后恶心者用吴茱萸汤。阳明中寒腑证者，用四逆汤。

For the treatment of Cold-attack meridian phase, if the patient has sweat, use Guizhi-Fuzi series formulae. If there is no sweat but frequent urination, use Xiao Qinglong Tang. If there is nausea after eat, use Wuzhuyu Tang. For the treatment of the Cold-attack organ phase, use Sini Tang for the treatment.

阳明中风经证者，用葛根汤或白虎汤；如果口极渴而饮水多者用白虎加人参汤。如果高热，大汗，用大承气汤。如果病人心烦，用调味承气汤。

For the treatment of Wind-attack meridian phase, herbal formula Gegen Tang or Baihu Tang is used. If the patient has strong desire to drink water, use formula Baihu plus Rensheng Tang. If the patient has fever and has too strong sweat, use Da Chengqi Tang. If the patient has annoyed feeling, use Tiao Wei Chengqi Tang.

阳明中风腑证者用承气汤。承气汤有大承气汤，小承气汤和调味承气汤之分，这里暂不作介绍。

For the treatment of Wind-attack organ phase, herbal formula Cheng Qi Tang is used.

小青龙汤中含有麻黄，四逆汤中有附子，白虎汤中有石膏，而承气汤中有大黄。这几种草药对于经方派来说是常用的，而对于学院派医生来说是很少用，也不怎么敢用的。

The Xiao Qinglong Tang contains herb Mahuang; Sini Tang contains herb Fuzi; Bai Hu Tang contains herb Shigao and Chengqi Tang contains herb Dahuang. These herbs are rarely used, and dared not to be used, by TCM doctor of College style, but frequently and commonly used by Jing Fang style TCM doctors.

阳明病的几种特殊类型：

There are several special conditions in the Yangming stage.

(1). 阳明蓄血证

(1). Blood stagnation type:

阳明蓄血证，喜忘者，大便黑而硬，大便反易，宜抵当汤下之。

The patient has poor memory. The stool is hard and black in color but the bowel movement is easy. In such case, use Didang Tang for the treatment.

(2). 阳明黄疸证

(2). Jaundice condition:

病人皮肤眼睛发黄。阳明黄疸分为寒湿型和湿热型。寒湿型黄疸需要用大黄附子汤治疗，而湿热型黄疸需要选用麻黄连翘赤小豆汤，茵陈蒿汤，或栀子柏皮汤治疗, 取决于湿和热，孰轻孰重。

The patient has jaundice in the skin and eyes. The jaundice can be a Cold-wetness type and a Hot-wetness type. For the treatment of the Hot-wetness type of the jaundice, the herbal formulae used are Mahuang Liangqiao Chixiaodou Tang, Yinchengao Tang or Zhizi Bopi Tang, depending on the amount of the Hot and the wetness in the body.

注意事项及说明：

Notice and explanation:

(1). 病至阳明，病人已经没有恶寒，却有发热汗出，胸胀满及/或胸痛，腹胀及/或腹痛，但都有大便难。食欲降低，或食后症状加重者多为阳明中寒证，而食欲没有改变，或进食不加重症状者多为阳明中风。中寒者用热药，如麻黄，附子，吴茱萸类热性药物驱寒。中风者用石膏清热或大黄泻热。

In the Yangming stage, there is no more cold-dislike feeling, but hot-dislike feeling. The patient has fever, sweat, bloating and/or pain in the chest or in the whole stomach. All patients should have difficulty in bowel movement or no bowel movement.

If the patient has reduced appetite, or if the sufferings become worse after eat, the condition belongs more to the Yangming Cold-attack syndrome. If the appetite is not affected, or if the syndrome does not become worse after eating, it would be most possibly due to Yangming Wind-attack.

For Yangming Cold-attack syndrome, we use warm herbs for the treatment, such as Mahuang, Fuzi, Wuzhuyu, so as to expel the cold. For Yangming Wind-attack syndrome, we use Shigao or Dahuang to expel Fire through colon.

(2). 对于阳明中寒的诊断，伤寒论中散在介绍。对于其治疗方案没有明示。这里介绍的主治方剂来自于其它中医大师的经验，仅供参考。一直以来，对于阳明病的诊断和治疗都局限在阳明中风经证和腑证。但临床上阳明中寒表现的病人很多，有必要在此强调一下。

(2). For the diagnosis of Yangming Cold-attack syndrome, it is introduced in scattered manner in the Yangming chapter. No systematic introduction for its treatment. The herbal formulae introduced here come from experience and idea of other TCM experts. It is listed here for reference. For a long time, the diagnosis and treatment of Yangming stage are limited to the Yangming Wind-attack syndrome. However, in clinic, there are also many cases of Yangming Cold-attack syndrome. This has to be emphasized and reminded. 

(3). 西方人中身热，恶热，喜冷饮冰饮的人很多。临床上我们常用白虎汤，白虎加人参汤，或竹叶石膏汤治疗。如果病人身热恶热但喜欢热饮且易疲乏者，我们也用补中益气汤治疗。如果辩证得当，治疗效果很好。这些治疗能改善体质。

There are many western people who feel hot, dislike hot, and like to drink cold or even ice drink. Such condition can also be regarded as Yangming Wind-attack meridian syndrome. For such cases, we use Baihu Tang, Baihu plus Rensheng Tang, or Zhuye Shigao Tang for the treatment. If the person feels hot, dislikes hot, but like to drink warm water, and feels tired, we would use Bu Zhong Yi Qi Tang for the treatment (This formula does not belong to Shanghan Lun). If the diagnosis is correct and the herbal formula is used in a proper way, the healing effect is excellent. It works to change the body constitution.   

(4). 阳明病诊断要点之一是大便难。这里强调的是大便困难而不是数日不大便。如果数日不大便，但是大便时大便仍然通畅，就不算大便难，也不作为便秘对待。但是如果每天大便一次，大便难下，也当作为便秘对待。这个概念和西医是不同的。

(4). One of the main points to diagnose Yangming stage is the difficulty in bowel movement. Here we emphasize the difficulty, not once for how many days for the bowel movement. If the person has bowel movement once several days, but the person does not feel stomach pain or bloating, and if the stool passes pretty easy, it should not be regarded as constipation. On the other side, it should be regarded as constipation, even if the person has bowel movement every day, but the stool passes very difficult. This is different from the western medicine in the concept of constipation.

(5). 伤寒论书关于阳明病有太阳阳明，正阳阳明和少阳阳明之分。正阳阳明即为上面所介绍的阳明中风腑证。争议较多的是太阳阳明和少阳阳明。特别是太阳阳明。书中说太阳阳明者为脾约证。当用麻子仁丸治疗。脾约者，小便数，大便硬。但是这种证的本质为何？众说纷纭。有认为脾约为脾虚脾弱脾阴不足而脾弱不能为胃行其津液，故大便硬。问题是，脾弱当为大便溏泻而非大便硬。

(5). There are Taiyang-Yangming, Zhengyang-Yangming and Shaoyang-Yangming concepts in the book Shanghan Lun. The Zhengyang-Yangming syndrome should be the same as the Yangming Wind-attack syndrome above. There are large difference in the understanding of the Taiyang-Yangming and the Shaoyang-Yangming syndrome. Especially for the Taiyang-Yangming syndrome, most doctor or scholars believe that it is a condition, in which the Spleen is weak, is in insufficient status, or in a Yin deficiency condition, so that the weak Spleen fails to move waster material (stool) down to colon to pass (so causes constipation). The question is: if the Spleen is weak, it should be diarrhea or a loose bowel movement, rather than constipation.

我们认为太阳阳明为病邪从太阳传至阳明导致的阳明病，少阳阳明为阳明证从少阳病发展而来。太阳阳明的脾约之本质当为湿热郁脾，浊阴不降而大便硬，多余湿气偏走膀胱而小便频。这从麻子仁丸的组成可以看出：麻子仁润肠滋燥通利大便，大黄清热化湿、通腑降浊，芍药和营益阴、缓和里急；杏仁宣通肺气、润肠降浊，枳朴泄热去实、调畅气机；使以蜂蜜为丸，缓图其功。总之具有清湿热、畅气机、调二便之功。

麻子仁丸以治实祛邪为主，并非治疗虚证之方。这也许是临床上用麻子仁丸常失败的原因：麻子仁丸被用于虚证便秘，如肾阴虚便秘，或气虚便秘了。

We believe and agree with the idea that the Taiyang-Yangming develops from the Taiyang stage and the Shaoyang-Yangming from Shaoyang stage (as most doctors believe so), but the nature of the Taiyang-Yangming is the block or the stagnation of Spleen by Wetness-Hotness. Normally, the Spleen likes dryness environment but hates humidity. Now it is suppressed by Wetness. It fails to move water material down to colon to move out, so the stool is hard.

This idea is supported by the herb constitution of the Maziren Wan, which is suggested in the book Shanghan Lun to treat the Taiyang-Yangming syndrome. The Maziren works to wet the intestine and colon to make the stool move smoothly and easier. Herb Dahuang works to clear fire and to remove wetness, so to conduct the stool movement in intestine and colon. Herb Shaoyao works to nourish the Yin part of the body, to relax muscle to stop pain. Xingren works to conduct Lung Qi down, so to improve bowel movement and to remove stool. The herb Zhishi and Houpu both work to clear fire and make Qi move smoothly and easier in the intestine. The herbs are made into pill form with honey to fold them. The pill form of herbs works slowly but constantly. All the herbs work together to clear the wetness and fire, to conduct the Qi, and to improve the stool movement. Therefore, the Maziren Wang works to clear the overwhelming condition, not to nourish the weak condition. This might be one of the reasons that the use of Maziren Wan fails to solve constipation: it has been used in constipation condition that is caused by weakness condition (deficiency condition), such as Kidney Yin deficiency or Qi deficiency, not the wetness-fire condition.

而少阳阳明者，为发汗利小便之后，胃中燥烦实，而大便难。仲景先生未给出药方。我们觉得当用大柴胡汤。

The Shaoyang-Yangming syndrome forms after sweat therapy, or urination therapy. In this case, the stomach is dry and annoying overwhelming, so that the stool is hard to pass. Master Zhongjing did not tell us which herbal formula to use. We feel that Da Chaihu Tang might be a proper one.

这里，太阳阳明之脾约证和少阳阳明之大便难都可以看作是阳明腑病的亚型。

Here, the Taiyang-Yangming and Shaoyang-Yangming syndrome can be regarded as a sub-type of the Yangming Wind-attack organ stage (the Zhengyang-Yangming syndrome). In the Taiyang-Yangming, the stomach feels less bloating. In the Zhengyang-Yangming, the stomach feels very full and bloating (if the stomach also feels very painful, it is the Da Jiexiong syndrome or Xiao Jiexiong syndrome). In the Shaoyang-Yangming syndrome, the stomach feels bloating mostly in the upper and upper-sided stomach area. 

(6). 伤寒论原文对于阳明病描述得相当复杂。我们这里仅作初步归纳和介绍。进一步的学习和理解需要在此之后再读原文或参照伤寒大家的解释才能慢慢理解。在这里读者仅需要记住阳明阶段有中寒和中风之别，和阳明经证和腑证的区别就可以了。

(6). The description of Yangming stage in Shanghan Lun is very complex. Here we can only make a preliminary summary about its main idea. Readers need to check the original content of the book, as well as refer to the explanation of other TCM experts in the Shanghan Lun. Here readers need only to remember that in the Yangming stage, there are Wind-attack and Cold-attack, and there are Yangming meridian phase and Yangming organ phase.   

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