太阳病项背强KT KT 。反汗出恶风者。桂枝加葛根汤主之。（KT 同）
太阳病。项背强KT KT 。无汗恶风。葛根汤主之。
二条以有汗无汗。定伤风伤寒。仲景以所显证全似太阳。其间略兼项背强KT KT 为阳明之候。未至两经各半。
故不用合病二字。然虽不名合病其实乃合病之初证也。KT KT 颈不舒也。项属太阳而颈属阳明。二经合病。则颈项皆
不和矣。太阳风伤卫证中。才见阳明一证。即于桂枝汤中加葛根一药太阳寒伤营证中。才见阳明一证。即于麻黄汤中加
葛根一药。此大匠天然不易之彀率也。然第二条不用麻黄汤加葛根。反用桂枝全方加麻黄葛根者。以颈项背俱是阳位。
易于得汗之处。设以麻黄本汤加葛根。大发其汗。将毋项背强KT KT 者。变为经脉振摇动惕乎。此仲景之所以精义
入神也。
太阳与阳明合病不下利但呕者葛根加半夏汤主之。
太阳与阳明合病者。必自下利葛根汤主之。
二条又以下利不下利。辨别合病主风主寒之不同也。风者阳也。阳性上行。故合阳明胃中之水饮而上逆。寒者阴也。
阴性下行。故合阳明胃中之水谷而下奔。然上逆则必加半夏入葛根汤。以涤饮止呕。若自下利则但用葛根汤以解两经之
邪。下利里证也。而仲景以此汤主之。盖以邪气。并于阳。则阳实而阴虚。阴虚故下利也。与此汤以散经中之邪。则阳
不实而阴气平。不治利而利自止耳。
太阳与阳明合病。喘而胸满者。不可下。宜麻黄汤主之。
两经合病。当合用两经之药何独偏用麻黄耶。此见仲景析义之精。盖太阳邪在胸。阳明邪在胃。两邪相合。必上攻
其肺。所以喘而胸满麻黄杏仁治肺气喘逆之专药也。用之恰当。正所谓内举不避亲也。何偏之有。○按太阳与阳明合病。
所重全在于表故主以葛根麻黄二汤。若太阳与少阳合病。则邪渐迫里。合用小柴胡柴胡桂枝二汤。若混病之太阳少阳合
病。当用黄芩汤黄芩加半夏生姜汤。其下阳明少阳合病。以邪入腑脉来滑数即用大承气下之。与二阳并病太阳证罢不殊
也。设经证未罢脉不滑数。又当从大柴胡。两解表里无疑其太阳与少阳合病。本条。见温热病篇中宜参看。
阳明少阳合病必下利。其脉不负者。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。
木土之邪交动则水谷不停而急奔。故下可必也。阳明脉大。少阳脉弦。两无相负。乃为顺候。然两经合病。阳明之
气衰则弦独见。少阳胜而阳明负矣。下之固是通因通用之法而上受克贼之邪。势必藉大力之药急从下夺。乃为解围之善
着。然亦必其脉洪而数。有宿食者始为当下无疑。设脉不滑数而迟覆方虑上败垂亡。尚敢下乎。
以上合病例。
二阳并病太阳初得病时发其汗。汗先出不彻。因转属阳明。续自微汗出。不恶寒若太阳病证不罢者。不可下。下之
为逆。如此可小发汗设面色缘缘正赤者。阳气怫郁在表当解之薰之若发汗不彻。不足言阳气怫郁不得越。当汗不汗。其
人躁烦不知痛处。乍在腹中。乍在四肢按之不可得。其人短气但坐以汗出不彻故也。更发其汗则愈。何以知汗出不彻以
脉涩故知也。
二阳并病。太阳证罢。但发潮热。手足 汗出。大便难而谵语者。下之则愈。宜大承气汤。
二阳并病二条皆是太阳与阳明并病。上条证初入阳明。而太阳仍未罢。则宜小汗。此条证已入阳明而太阳亦随罢。
故宜大下也。按上条太阳初症寒伤营之病因汗出不彻。故传阳明。续自微汗出。不恶寒阳明热炽。似平当用下法。以太
阳之邪未彻。故下之为逆。谓其必成结胸等证也。如此者可小发汗。然后下之。设面色缘缘正赤者。寒邪深重。阳气怫
郁在表。必始先未用麻黄汤。或已用麻黄汤而未得汗。所以重当解之熏之又非小汗所能胜矣。若是发汗不彻不当言阳气
怫郁不得越也。毕竟当汗不汗。其人躁烦不知痛处。乍寒乍热。病在四肢按之不可得。方是阳气不得越耳。阳不越因汗
不彻而邪气未尽气受伤也。脉涩者。以其邪留于肌腠。而营气不能条达。血受病也。汗后短气脉涩。但当断之以汗出不
彻者。用桂枝二越脾一汤小发其汗则愈。
太阳病桂枝证医反下之利遂不止。脉促者。表未解也。喘而汗出者。葛根黄芩黄连汤主之。
太阳病原无下法。但当用桂枝解外若当用不用。而反下之利遂不止。则热邪之在太阳者。未传阳明之经。已入阳明
之里。所以其脉促急其汗外越其气上奔则喘下奔则泄。故舍桂枝而用葛根专主阳明之表。加芩连以清里热。则不治喘而
喘自亡。不治利而利自止。又太阳阳明两解表里之变法。与治痞之意不殊也。
太阳与少阳并病头项强痛或眩冒寒。如结胸心下痞硬者。当刺大椎第一间肺俞肝俞。断不可发汗。发汗则谵语。脉
弦五六日谵语不止。当刺期门。
刺大椎者。泻三阳督脉也。刺肺俞者。使肺气下行而膀胱气化也。刺肝俞者。所以泻胆也。刺期门者。泻肝胆之实
也。
太阳少阳并病心下硬。颈项强而眩者。当利大椎。肺俞肝俞慎勿下之。
重申不可下之禁。与上条不可汗互发。
伤寒腹满谵语。寸口脉浮而紧。此肝乘脾也。名曰纵刺期门。
肝木直乘脾土为纵。此本太阳少阳并病以其人平素肝盛脾衰。故其证腹满谵语尽显。肝邪乘脾之候。盖少阳虽主风
水仍赖卫气荣养。所以仲景云。此属胃。胃不和。所以腹满谵语也。其脉寸口浮紧为太阳寒伤营之脉。寸口即气口。乃
脾胃之所主。肝木挟邪过盛。所以脾胃之土益受其制也。刺期门。以泄肝邪。则中此攸宁矣。
伤寒发热啬啬恶寒大渴欲饮水。其腹必满。自汗出小便利。其病欲解。此肝乘肺也。名曰横刺期门。
肝木反乘肺金为横。此亦太阳少阳并病。以其人素常肝盛肺虚。故其证虽发热恶寒。为太阳表证未除而大渴饮水。
则少阳里热已着。盖木盛则火易燔。金虚则水不生。所以求水为润木得水助其势益横。水势泛溢。其腹必满。亦当刺期
门以泄肝邪。则肺自安矣。然但腹满而不谵语。其邪稍轻。以肺金较。肝木虽虚。原无他病。能暗为运布。或自汗而水
得外渗。或小便利而水得下行。是以病欲自解。不必刺也。读者毋以刺期门在欲解下。而以辞害义也。○按纵横之证不
同。而皆刺期门者。以贼土侮金。总由木盛。腹满谵语。证涉危疑。故急以泻木为主也。○十四条俱用刺法。今伤寒家
不谙此理。若论用药无过柴胡桂枝汤加减。观下条发汗多亡阳谵语治法可类推矣。
发汗多亡阳谵语者。不可下。与柴胡桂枝汤和其营卫。以通津液后自愈。
太阳与少阳并病。不可发汗。发汗则谵语。误汗亡阳谵语者复不可下宜桂枝柴胡以和二经营卫也。
伤寒六七日。发热微恶寒。肢节烦疼微呕。心下支结外证未去者。柴胡桂枝汤主之。
支结者。支饮聚结于心下之偏旁。非中正也。伤寒至六七日宜传经已遍。乃发热微恶寒。肢节烦疼微呕。其邪尚在
少阳之界未入于里虽心下支结。而外证未除。终非结胸可拟。故但用柴胡桂枝。使太阳之邪。仍从太阳而解。邪去而支
饮自开矣。
伤寒五六日。已发汗而复下之。胸胁满微结不便不利。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。初服微烦。复服汗出便愈。
五六日已发汗。邪虽未解而势已微因误下之微邪凝聚于上焦。则肺气壅遏。所以渴而不呕。头汗出。往来寒热心烦。
知邪气。已入少阳之界。故为不解因与柴胡桂枝解太阳少阳之邪。黄芩甘草以内外之热。干姜主胃中寒饮。栝蒌根治膈
上热渴。牡蛎以开胁下之微结也。服汤后反加微烦者。近世谓之药烦以汗后津液受伤。胃气虚。热不能胜药力也。必须
复服药胜病邪。方得汗出而解。○三二条皆太阳少阳并病。因本文中有支结微结。所以后世遂认结胸。致节庵又以小柴
胡加桔梗治痞结。亦不过治。表邪初犯中焦者。方克有效。若真结胸则邪已因误下引入内结。非大小陷胸汤丸峻攻。必
不能解散也。
阳明病发潮热。大便泻小便自可。胸胁满不去者。小柴胡汤主之。
此阳明少阳并病也。潮热者。阳明胃热之候若大便泻小便自可。则胃全不实更加胸胁满不去。则证已兼见少阳矣。
才兼少曰即有汗下二禁。惟小柴胡一汤。合表里而总和之。乃少阳一经之正治。故阳明少阳。亦取用之。无别法也。
阳明病胁痛硬满不大便而呕。舌上白苔者。可与小柴胡汤。上焦得通津液得下。胃气因和。身 然汗出。而解也。
此亦阳明少阳并病。不但大便泻为胃未实即使不大便而见胁下硬满呕与舌苔之证则少阳为多。亦当从小柴胡汤分解
阴阳则上下通和。 然汗出。而舌苔呕逆胁满之外证。不时俱解矣既云津液得下。则大便自行。亦可知矣。此一时表里
俱彻。所以为当也。○上焦得通津液得下。八字关系病机最切。风寒之邪。胁津液而上聚膈中。为喘为呕。为水逆为结
胸常十居。六七是风寒不解。则津液必不得下倘误行发散。不惟津液不下。且转增上。逆之势愈无退息之期矣。
以上并病例。
太阳病，出现项背部僵硬不适。如果反而有汗出、怕风的症状，用桂枝加葛根汤主治。（“KT KT”同“几几”，形容颈项强直不舒的样子）
这两条条文通过有汗和无汗的区别，来判定是伤风还是伤寒。张仲景认为这些证候看起来完全像太阳病，但其中略微兼有项背部僵硬不适这一症状，这是阳明经的征候，但尚未达到两经各占一半的程度。因此不使用“合病”二字。然而虽然不称为合病，其实乃是合病的初期证候。“KT KT”即颈部不舒展。项部属于太阳经，颈部属于阳明经。两经合病，则颈项都不和顺。在太阳中风伤卫的证候中，刚见到阳明的一证，就在桂枝汤中加入葛根一味药；在太阳伤寒伤营的证候中，刚见到阳明的一证，就在麻黄汤中加入葛根一味药。这是高明医生天然不可改变的法度。然而第二条不用麻黄汤加葛根，反而用桂枝全方加上麻黄、葛根，是因为颈、项、背都属于阳位，是容易出汗的地方。假如用麻黄本方加葛根，大发其汗，恐怕会使项背部僵硬不适者，变为经脉颤动惊惕之症。这就是张仲景精妙义理入神之处。
这两条条文又以下利和下利与否，来辨别合病主风或主寒的不同。风属阳，阳性上行，所以合病阳明时，胃中的水饮会上逆；寒属阴，阴性下行，所以合病阳明时，胃中的水谷会下奔。然而上逆则必须在葛根汤中加入半夏，以涤除痰饮、止呕。如果是自下利，则只用葛根汤以解除两经的邪气。下利属于里证，而张仲景用此汤主治，大概是因为邪气并归于阳，则阳实而阴虚，阴虚故导致下利。给予此汤以疏散经络中的邪气，则阳不实而阴气平和，不治利而利自然停止。
太阳与阳明合病，气喘且胸部胀满的，不可用下法，宜用麻黄汤主治。
两经合病，应当合用两经的药物，为何唯独偏用麻黄呢？这体现了张仲景分析义理的精细。太阳的邪气在胸，阳明的邪气在胃，两邪相合，必定向上攻冲肺部，所以出现气喘和胸部胀满。麻黄、杏仁是治疗肺气喘逆的专用药物。使用它们恰到好处，正所谓“内举不避亲”，有什么偏颇呢？○按：太阳与阳明合病，重点全在于表，所以主治用葛根汤、麻黄汤二方。若是太阳与少阳合病，则邪气逐渐逼近里，合用小柴胡汤、柴胡桂枝汤二方。若是混病之太阳少阳合病，当用黄芩汤、黄芩加半夏生姜汤。若是阳明少阳合病，因邪气入腑，脉象滑数，即用大承气汤下之，这与二阳并病、太阳证罢的情况没有不同。假如经证未罢，脉不滑数，又应当从大柴胡汤两解表里，毫无疑问。关于太阳与少阳合病的本条，见温热病篇中，宜参看。
阳明与少阳合病，必然下利。其脉象不负（即脉象与病情相符，如阳明脉大、少阳脉弦，两者并存而不相克）的，为顺证。负（即脉象与病情相悖，互相克制贼害），名为负。脉象滑而数的，是有宿食，当下之，宜用大承气汤。
木（肝/少阳）土（脾/阳明）之邪交动，则水谷不停而急奔，所以下利可必。阳明脉大，少阳脉弦，两者互不克制，乃为顺候。然而两经合病，若阳明之气衰，则仅见弦脉，此为少阳胜而阳明负。下法是通因通用的方法，但上受克制贼害之邪，势必借助大力药物急从下夺，才是解围的良策。然而也必须是脉洪大而数，且有宿食者，始为当下无疑。假如脉不滑数而迟涩，方才忧虑上焦败亡，岂敢用下法呢。
以上为合病例。
二阳并病，太阳初得病时，发其汗，汗先出不透彻，因而转属阳明，续发自微汗出，不怕冷。如果太阳病证未罢，不可下，下之为逆。如此情况可小发其汗。假如面色缘缘正赤，是阳气怫郁在表，当解之薰之。如果发汗不透彻，不足以言阳气怫郁不得越，应当发汗而未发汗，其人躁烦，不知痛处，乍在腹中，乍在四肢，按之不可得。其人短气，只因汗出不透彻的缘故。再发其汗则愈。何以知道汗出不透彻？以脉涩故知也。
二阳并病，太阳证罢，但发潮热，手足濈然汗出，大便难而谵语的，下之则愈，宜用大承气汤。
二阳并病两条皆是太阳与阳明并病。上条证初入阳明，而太阳仍未罢，则宜小汗。此条证已入阳明而太阳亦随罢，故宜大下。按：上条太阳初症，寒伤营之病因汗出不彻，故传阳明，续自微汗出，不恶寒，阳明热炽，似乎当用下法，但因太阳之邪未彻，故下之为逆，谓其必成结胸等证。如此者可小发其汗，然后下之。设面色缘缘正赤者，寒邪深重，阳气怫郁在表，必始先未用麻黄汤，或已用麻黄汤而未得汗，所以重当解之熏之，又非小汗所能胜任了。若是发汗不彻，不当言阳气怫郁不得越也。毕竟当汗不汗，其人躁烦，不知痛处，乍寒乍热，病在四肢，按之不可得，方是阳气不得越耳。阳不越因汗不彻而邪气未尽，气受伤也。脉涩者，以其邪留于肌腠，而营气不能条达，血受病也。汗后短气脉涩，但当断之以汗出不彻者，用桂枝二越婢一汤小发其汗则愈。
太阳病，桂枝证，医反下之，利遂不止。脉促者，表未解也。喘而汗出者，葛根黄芩黄连汤主治。
太阳病原无下法，但当用桂枝解外。若当用不用，而反下之，利遂不止，则热邪之在太阳者，未传阳明之经，已入阳明之里。所以其脉促急，其汗外越，其气上奔则喘，下奔则泄。故舍桂枝而用葛根专主阳明之表，加芩连以清里热，则不治喘而喘自亡，不治利而利自止。又是太阳阳明两解表里的变法，与治痞之意不殊也。
太阳与少阳并病，头项强痛，或眩冒，寒（此处疑为“如”字之误，指如结胸状），心下痞硬的，当刺大椎第一间、肺俞、肝俞。断不可发汗，发汗则谵语。脉弦，五六日谵语不止，当刺期门。
刺大椎者，泻三阳督脉也。刺肺俞者，使肺气下行而膀胱气化也。刺肝俞者，所以泻胆也。刺期门者，泻肝胆之实也。
太阳少阳并病，心下硬，颈项强而眩者，当刺大椎、肺俞、肝俞。慎勿下之。
重申不可下之禁。与上条不可汗互发。
肝木直乘脾土为纵。此本太阳少阳并病，以其人平素肝盛脾衰，故其证腹满谵语尽显，为肝邪乘脾之候。盖少阳虽主风水，仍赖卫气荣养。所以仲景云：“此属胃。”胃不和，所以腹满谵语也。其脉寸口浮紧为太阳寒伤营之脉。寸口即气口，乃脾胃之所主。肝木挟邪过盛，所以脾胃之土益受其制也。刺期门，以泄肝邪，则中州攸宁矣。
伤寒发热，啬啬恶寒，大渴欲饮水，其腹必满。自汗出，小便利，其病欲解。此肝乘肺也。名曰横，刺期门。
肝木反乘肺金为横。此亦太阳少阳并病，以其人素常肝盛肺虚，故其证虽发热恶寒，为太阳表证未除，而大渴饮水，则少阳里热已着。盖木盛则火易燔，金虚则水不生，所以求水为润木，得水助其势益横，水势泛溢，其腹必满。亦当刺期门以泄肝邪，则肺自安矣。然但腹满而不谵语，其邪稍轻，以肺金较肝木虽虚，原无他病，能暗为运布，或自汗而水得外渗，或小便利而水得下行，是以病欲自解，不必刺也。读者毋以刺期门在欲解下，而以辞害义也。○按：纵横之证不同，而皆刺期门者，以贼土侮金，总由木盛。腹满谵语，证涉危疑，故急以泻木为主也。○十四条俱用刺法，今伤寒家不谙此理。若论用药，无过柴胡桂枝汤加减，观下条发汗多亡阳谵语治法可类推矣。
发汗多亡阳谵语者，不可下。与柴胡桂枝汤和其营卫，以通津液，后自愈。
太阳与少阳并病，不可发汗，发汗则谵语。误汗亡阳谵语者，复不可下，宜桂枝柴胡以和二经营卫也。
伤寒六七日，发热微恶寒，肢节烦疼，微呕，心下支结，外证未去者，柴胡桂枝汤主治。
支结者，支饮聚结于心下之偏旁，非中正也。伤寒至六七日，宜传经已遍，乃发热微恶寒，肢节烦疼，微呕，其邪尚在少阳之界，未入于里，虽心下支结，而外证未除，终非结胸可拟。故但用柴胡桂枝，使太阳之邪，仍从太阳而解，邪去而支饮自开矣。
伤寒五六日，已发汗而复下之，胸胁满微结，不便不利，渴而不呕，但头汗出，往来寒热心烦者，此为未解也。柴胡桂枝干姜汤主治。初服微烦，复服汗出便愈。
五六日已发汗，邪虽未解而势已微，因误下之，微邪凝聚于上焦，则肺气壅遏，所以渴而不呕，头汗出，往来寒热，心烦。知邪气已入少阳之界，故为不解。因与柴胡桂枝解太阳少阳之邪，黄芩甘草以内外之热，干姜主胃中寒饮，栝蒌根治膈上热渴，牡蛎以开胁下之微结也。服汤后反加微烦者，近世谓之药烦，以汗后津液受伤，胃气虚，热不能胜药力也。必须复服药胜病邪，方得汗出而解。○三二条皆太阳少阳并病，因本文中有支结、微结，所以后世遂认结胸，致节庵又以小柴胡加桔梗治痞结，亦不过治表邪初犯中焦者，方克有效。若真结胸则邪已因误下引入内结，非大小陷胸汤丸峻攻，必不能解散也。
阳明病发潮热，大便溏，小便自可，胸胁满不去者，小柴胡汤主治。
此阳明少阳并病也。潮热者，阳明胃热之候。若大便溏，小便自可，则胃全不实，更加胸胁满不去，则证已兼见少阳矣。才兼少阳，即有汗下二禁，惟小柴胡一汤，合表里而总和之，乃少阳一经之正治，故阳明少阳，亦取用之，无别法也。
阳明病，胁痛硬满，不大便而呕，舌上白苔者，可与小柴胡汤。上焦得通，津液得下，胃气因和，身濈然汗出，而解也。
此亦阳明少阳并病。不但大便溏为胃未实，即使不大便而见胁下硬满、呕与舌苔之证，则少阳为多，亦当从小柴胡汤分解阴阳，则上下通和。濈然汗出，而舌苔、呕逆、胁满之外证，不时俱解矣。既云津液得下，则大便自行，亦可知矣。此一时表里俱彻，所以为当也。○上焦得通，津液得下，八字关系病机最切。风寒之邪，挟津液而上聚膈中，为喘、为呕、为水逆、为结胸，常十居六七。是风寒不解，则津液必不得下，倘误行发散，不惟津液不下，且转增上逆之势，愈无退息之期矣。
以上为并病例。
Taiyang disease (Disease of the Taiyang channel) presenting with stiffness and discomfort in the nape, neck, and back. If there is sweating and aversion to wind instead, Guizhi Jia Gegen Tang (Cinnamon Twig Decoction plus Puerariae Radix) is the primary treatment. ("Ji Ji" describes the sensation of stiffness and inability to extend the neck.)
Taiyang disease (Disease of the Taiyang channel) presenting with stiffness and discomfort in the nape, neck, and back, without sweating and with aversion to wind, is primarily treated with Gegen Tang (Puerariae Radix Decoction).
These two clauses distinguish between Wind Strike (Shang Feng) and Cold Strike (Shang Han) based on the presence or absence of sweating. Zhang Zhongjing considers these manifestations to appear entirely as Taiyang disease (Disease of the Taiyang channel), but the slight concomitance of stiffness and discomfort in the nape, neck, and back indicates a sign of the Yangming channel (Yangming Jing). Since it has not yet reached the state where both channels are equally affected, the term "He Bing" (Combined Disease) is not used. However, although not named Combined Disease, it is essentially the initial stage of Combined Disease. "Ji Ji" refers to the lack of flexibility in the neck. The nape belongs to the Taiyang channel, while the neck belongs to the Yangming channel. In Combined Disease of these two channels, both the neck and nape become disharmonious. In Taiyang Wind Strike damaging the Wei (Defensive) level, upon the first appearance of a Yangming sign, one adds Gegen (Puerariae Radix) to Guizhi Tang (Cinnamon Twig Decoction); in Taiyang Cold Strike damaging the Ying (Nutritive) level, upon the first appearance of a Yangming sign, one adds Gegen (Puerariae Radix) to Mahuang Tang (Ephedra Decoction). This is the unchangeable standard of master physicians. However, the second clause does not use Mahuang Tang (Ephedra Decoction) plus Gegen (Puerariae Radix), but rather uses the full Guizhi Tang (Cinnamon Twig Decoction) plus Mahuang (Ephedra) and Gegen (Puerariae Radix). This is because the neck, nape, and back are all Yang positions, areas prone to sweating. If one were to use Mahuang Tang (Ephedra Decoction) plus Gegen (Puerariae Radix) to induce heavy sweating, it might cause the stiffness in the nape, neck, and back to transform into trembling and palpitations of the meridians. This demonstrates the profound and divine precision of Zhang Zhongjing's principles.
When Taiyang (Disease of the Taiyang channel) and Yangming (Disease of the Yangming channel) present as Combined Disease, if there is no diarrhea but only vomiting, Gegen Jia Banxia Tang (Puerariae Radix Decoction plus Pinelliae Rhizoma) is the primary treatment.
When Taiyang (Disease of the Taiyang channel) and Yangming (Disease of the Yangming channel) present as Combined Disease, if there is spontaneous diarrhea, Gegen Tang (Puerariae Radix Decoction) is the primary treatment.
These two clauses further distinguish between Wind-dominant and Cold-dominant Combined Disease by the presence or absence of diarrhea. Wind is Yang; its nature is ascending. Thus, when combining with Yangming, the fluids and phlegm in the Stomach tend to rebel upward. Cold is Yin; its nature is descending. Thus, when combining with Yangming, the food and fluids in the Stomach tend to rush downward. For upward rebellion, Banxia (Pinelliae Rhizoma) must be added to Gegen Tang (Puerariae Radix Decoction) to dissipate fluid retention and stop vomiting. For spontaneous diarrhea, only Gegen Tang (Puerariae Radix Decoction) is used to resolve the pathogenic factors of both channels. Diarrhea is a interior syndrome, yet Zhang Zhongjing treats it with this decoction. This is likely because when pathogenic factors congregate in the Yang, Yang becomes excess and Yin becomes deficient; this deficiency leads to diarrhea. By administering this decoction to scatter the pathogenic factors in the meridians, Yang excess is resolved and Yin Qi is balanced. The diarrhea stops spontaneously without direct treatment for it.
In Combined Disease of Taiyang (Disease of the Taiyang channel) and Yangming (Disease of the Yangming channel), if there is wheezing and chest fullness, purgation (Xia Fa) is contraindicated; Mahuang Tang (Ephedra Decoction) is appropriate.
In Combined Disease of two channels, why use only Mahuang (Ephedra) exclusively? This reflects the precision of Zhang Zhongjing’s analysis. The pathogen of Taiyang is in the chest, and the pathogen of Yangming is in the Stomach. When combined, they attack the Lung upwards, causing wheezing and chest fullness. Mahuang (Ephedra) and Xingren (Armeniacae Semen Amarum) are specific herbs for treating Lung wheezing and rebellious Qi. Using them appropriately is like recommending a relative for office—there is no bias. ○ Note: In Combined Disease of Taiyang and Yangming, the focus is entirely on the exterior, hence the primary treatments are Gegen Tang (Puerariae Radix Decoction) and Mahuang Tang (Ephedra Decoction). If Taiyang and Shaoyang (Disease of the Shaoyang channel) present as Combined Disease, the pathogen is gradually pressing inward, so Xiao Chaihu Tang (Minor Bupleurum Decoction) and Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) are combined. If Taiyang and Shaoyang Mixed Disease occurs, Huangqin Tang (Scutellaria Decoction) or Huangqin Jia Banxia Shengjiang Tang (Scutellaria Decoction plus Pinelliae Rhizoma and Fresh Ginger) should be used. If Yangming and Shaoyang Combined Disease occurs, and the pathogen enters the Fu organs with a slippery and rapid pulse, Da Chengqi Tang (Major Order the Golden Gate Decoction) is used for purgation, similar to the case where Two-Yang Combined Disease resolves with the cessation of Taiyang signs. If the Meridian syndrome persists and the pulse is not slippery and rapid, Da Chaihu Tang (Major Bupleurum Decoction) should be used to simultaneously resolve the exterior and interior, without doubt. The original clause regarding Taiyang and Shaoyang Combined Disease can be found in the Warm Heat Disease chapter for reference.
In Combined Disease of Yangming (Disease of the Yangming channel) and Shaoyang (Disease of the Shaoyang channel), diarrhea is inevitable. If the pulse does not show "Fu" (defeat/clashing), it is a favorable condition. "Fu" means defeat or loss, indicating mutual clashing and harming. A slippery and rapid pulse indicates retained food; purgation is indicated, using Da Chengqi Tang (Major Order the Golden Gate Decoction).
When Wood (Liver/Gallbladder) and Earth (Spleen/Stomach) pathogens interact, water and grain move rapidly, making diarrhea certain. Yangming pulse is large, Shaoyang pulse is wiry. If neither defeats the other, it is a favorable sign. However, in Combined Disease, if Yangming Qi declines, only the wiry pulse appears, meaning Shaoyang prevails and Yangming is defeated. Purgation is a method of "treating obstruction with draining agents," but since the upper part suffers from clashing pathogens, powerful drugs are needed to urgently drain from below to relieve the siege. However, this is only indicated if the pulse is surging and rapid, and there is retained food. If the pulse is not slippery and rapid but slow and deep, one must worry about the collapse of the upper Jiao; how could purgation be dared?
The above cases involve Combined Disease.
In Two-Yang Combined Disease, at the initial onset of Taiyang disease, sweating was induced, but the sweat was incomplete. Consequently, the condition transferred to Yangming, with subsequent slight sweating and no aversion to cold. If the Taiyang syndrome has not ceased, purgation is contraindicated; doing so is erroneous. In such cases, mild sweating may be induced. If the face is persistently red, it indicates Yang Qi stagnation in the exterior; it should be resolved through fumigation or bathing. If sweating was incomplete, it is insufficient to say Yang Qi is stagnant and unable to vent. If sweating should have been induced but was not, the patient becomes restless and irritable, with pain that shifts between the abdomen and limbs, which cannot be pinpointed upon pressure. The patient experiences shortness of breath solely due to incomplete sweating. Inducing sweating again will lead to recovery. How do we know sweating was incomplete? Because the pulse is choppy.
In Two-Yang Combined Disease, if the Taiyang signs have ceased, but tidal fever occurs, hands and feet sweat continuously, defecation is difficult, and delirium is present, purgation will cure it; Da Chengqi Tang (Major Order the Golden Gate Decoction) is indicated.
Both clauses of Two-Yang Combined Disease refer to Combined Disease of Taiyang and Yangming. In the first clause, the pathogen has just entered Yangming, but Taiyang has not yet ceased, so mild sweating is appropriate. In this clause, the pathogen has entered Yangming, and Taiyang has also ceased, so strong purgation is appropriate. Note: In the first clause, the initial Taiyang Cold Strike damages the Ying level; due to incomplete sweating, it transmits to Yangming. Subsequent slight sweating and no aversion to cold indicate intense Yangming heat, which seems to warrant purgation. However, because the Taiyang pathogen is not fully resolved, purgation is erroneous, potentially leading to Tie Xiong (Glomus) syndromes. In such cases, mild sweating should be induced first, then purgation. If the face is persistently red, it indicates severe cold pathogen and Yang Qi stagnation in the exterior. This implies either Mahuang Tang (Ephedra Decoction) was not used initially, or it was used but failed to induce sweat. Therefore, strong resolution via fumigation/bathing is required, beyond the capacity of mild sweating. If sweating was incomplete, one should not speak of Yang Qi stagnation. Rather, failing to sweat when necessary causes restlessness, shifting pain, alternating chills and fever, and limb pain that cannot be pressed, indicating Yang Qi failure to vent. Yang fails to vent because incomplete sweating leaves residual pathogen and injures Qi. A choppy pulse indicates pathogen remaining in the muscle interstices, preventing smooth flow of Ying Qi and injuring Blood. After sweating, shortness of breath and a choppy pulse indicate incomplete sweating; Guizhi Er Yuebi Yi Tang (Cinnamon Twig Decoction twice minus Yubi Decoction once) should be used to mildly induce sweating for recovery.
In Taiyang disease with Guizhi syndrome, if the physician erroneously applies purgation, diarrhea persists. If the pulse is hurried, the exterior is unresolved. If there is wheezing and sweating, Gegen Huangqin Huanglian Tang (Puerariae Radix, Scutellariae Radix, and Coptidis Rhizoma Decoction) is the primary treatment.
Taiyang disease originally has no indication for purgation; Guizhi Tang (Cinnamon Twig Decoction) should be used to release the exterior. If this is neglected and purgation is applied erroneously, resulting in persistent diarrhea, the heat pathogen in Taiyang has not transmitted to the Yangming Meridian but has entered the Yangming Interior. Hence, the pulse is hurried, sweat escapes outward, Qi rebels upward causing wheezing, and flows downward causing diarrhea. Therefore, Guizhi is abandoned, and Gegen (Puerariae Radix) is used specifically for the Yangming exterior, while Huangqin (Scutellariae Radix) and Huanglian (Coptidis Rhizoma) clear interior heat. Wheezing stops without direct treatment, and diarrhea ceases without direct intervention. This is a variant method for simultaneously resolving the exterior and interior of Taiyang and Yangming, similar to the principle of treating Pi (Glomus).
In Combined Disease of Taiyang (Disease of the Taiyang channel) and Shaoyang (Disease of the Shaoyang channel), with stiff and painful nape and neck, dizziness, vertigo, or a sensation like Tie Xiong (Glomus) with hardness beneath the heart, acupuncture at Dazhui (GV14), Feishu (BL13), and Ganshu (BL18) is indicated. Sweating is absolutely contraindicated; inducing sweating leads to delirium. If the pulse is wiry and delirium persists for five to six days, Qimen (LR14) should be acupunctured.
Acupuncture at Dazhui (GV14) drains the Du Mai (Governing Vessel) and the three Yang channels. Acupuncture at Feishu (BL13) directs Lung Qi downward and promotes Bladder Qi transformation. Acupuncture at Ganshu (BL18) drains the Gallbladder. Acupuncture at Qimen (LR14) drains excess in the Liver and Gallbladder.
In Combined Disease of Taiyang and Shaoyang, with hardness beneath the heart, stiff and painful nape and neck, and dizziness, acupuncture at Dazhui (GV14), Feishu (BL13), and Ganshu (BL18) is indicated. Purging (Xia Fa) is strictly forbidden.
This reiterates the prohibition against purging, complementing the previous clause's prohibition against sweating.
In Shanghan (Cold Damage), abdominal fullness and delirium with a floating and tight pulse at the Cun Kou (Radial Pulse) indicate Liver overacting on Spleen. This is named Zong (Vertical); acupuncture at Qimen (LR14) is indicated.
Liver Wood directly overcoming Spleen Earth is called Zong. This originates from Combined Disease of Taiyang and Shaoyang. Due to the patient's inherent Liver excess and Spleen deficiency, symptoms of abdominal fullness and delirium manifest fully, representing Liver pathogen overacting on Spleen. Although Shaoyang governs Wind-Water, it still relies on Wei (Defensive) and Ying (Nutritive) Qi for nourishment. Thus, Zhang Zhongjing states: "This belongs to the Stomach." Disharmony of the Stomach causes abdominal fullness and delirium. The floating and tight pulse at Cun Kou (Radial Pulse) is the pulse of Taiyang Cold Strike damaging Ying. Cun Kou (Radial Pulse) is governed by the Spleen and Stomach. Excessive Liver Wood carrying pathogen further constrains Spleen-Stomach Earth. Acupuncture at Qimen (LR14) drains Liver pathogen, stabilizing the Middle Jiao.
In Shanghan (Cold Damage), fever, aversion to cold, intense thirst with desire to drink, and inevitable abdominal fullness. If spontaneous sweating occurs and urination is free, the disease is about to resolve. This is Liver overacting on Lung. This is named Heng (Horizontal); acupuncture at Qimen (LR14) is indicated.
Liver Wood counter-acting Lung Metal is called Heng. This is also Combined Disease of Taiyang and Shaoyang. Due to inherent Liver excess and Lung deficiency, although fever and aversion to cold indicate unresolved Taiyang exterior, intense thirst indicates established Shaoyang interior heat. Wood excess easily generates Fire; Metal deficiency fails to generate Water. Seeking water moistens Wood, and water support increases its horizontal aggression, causing water overflow and abdominal fullness. Acupuncture at Qimen (LR14) drains Liver pathogen, calming the Lung. However, if there is only abdominal fullness without delirium, the pathogen is lighter. Although Lung Metal is weaker than Liver Wood, there is no other disease; hidden transport functions operate. Spontaneous sweating allows water to seep out externally, or free urination allows water to flow downward, so the disease resolves spontaneously without need for acupuncture. Readers should not let the placement of "acupuncture at Qimen" under "about to resolve" mislead the meaning. ○ Note: Although Vertical and Horizontal conditions differ, both use acupuncture at Qimen because Wood overacting on Earth and insulting Metal stems from Wood excess. Abdominal fullness and delirium are critical and suspicious, so urgent drainage of Wood is prioritized. ○ All fourteen clauses use acupuncture. Modern Shanghan practitioners do not understand this principle. Regarding medication, nothing exceeds modified Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction). One can infer this from the treatment of delirium due to Yang collapse from excessive sweating in the next clause.
Delirium due to Yang collapse from excessive sweating is not suitable for purgation. Administer Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) to harmonize Ying and Wei, facilitating the flow of Body Fluids, after which recovery will occur naturally.
In Combined Disease of Taiyang and Shaoyang, sweating is contraindicated; inducing sweating leads to delirium. Delirium due to Yang collapse from erroneous sweating is also not suitable for purgation; Guizhi and Chaihu should be used to harmonize the Ying and Wei of both channels.
In Shanghan (Cold Damage) for six to seven days, with fever, slight aversion to cold, vexing pain in joints, slight vomiting, and subcostal binding (Zhi Jie), with exterior signs unresolved, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) is the primary treatment.
Zhi Jie refers to fluid retention binding obliquely beneath the heart, not in the center. By six to seven days in Shanghan, transmission should be complete. Yet with fever, slight aversion to cold, joint pain, and slight vomiting, the pathogen remains in the Shaoyang boundary, not entering the interior. Although there is subcostal binding, the exterior signs persist, so it cannot be compared to Tie Xiong (Glomus). Therefore, only Chaihu Guizhi Tang is used, allowing the Taiyang pathogen to resolve from the Taiyang channel. Once the pathogen is gone, the fluid retention opens.
In Shanghan (Cold Damage) for five to six days, after sweating and erroneous purging, with fullness and slight binding in the chest and hypochondrium, difficulty in bowel movement and urination, thirst without vomiting, only head sweating, alternating chills and fever, and irritability, this is unresolved. Chaihu Guizhi Ganjiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction) is the primary treatment. Mild irritability upon the first dose; upon repeated dosing, sweating occurs and recovery follows.
After five to six days of sweating, the pathogen is unresolved but weak. Erroneous purging causes minor pathogens to condense in the Upper Jiao, obstructing Lung Qi, causing thirst without vomiting and head sweating. Alternating chills, fever, and irritability indicate the pathogen has entered the Shaoyang boundary, hence unresolved. Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) resolves Taiyang and Shaoyang pathogens; Huangqin (Scutellariae Radix) and Gancao (Glycyrrhizae Radix) clear internal and external heat; Ganjiang (Zingiberis Rhizoma Recens) addresses Cold-Fluid in the Stomach; Gualougen (Trichosanthis Radix) treats upper diaphragm heat and thirst; Muli (Concha Ostreae) opens slight binding in the hypochondrium. Mild irritability after the first dose is called "medication irritability" in modern times, due to injured Body Fluids and deficient Stomach Qi after sweating, unable to overcome the medicinal force. Repeated dosing overcomes the pathogen, leading to sweating and resolution. ○ Clauses 32 and others involve Taiyang-Shaoyang Combined Disease. Due to terms like "subcostal binding" and "slight binding" in the text, later generations mistook them for Tie Xiong (Glomus). Zhe'an used Xiao Chaihu Tang (Minor Bupleurum Decoction) plus Jiegeng (Platycodonis Radix) to treat Pi (Glomus), which is effective only for initial exterior pathogen invading the Middle Jiao. True Tie Xiong involves pathogen drawn inward by erroneous purging; only major purgatives like Da/Xiao Xianxiong Tang/Wan (Major/Minor Chest Glomus Decoctions/Pills) can resolve it.
In Yangming disease with tidal fever, loose stools, normal urination, and persistent hypochondriac fullness, Xiao Chaihu Tang (Minor Bupleurum Decoction) is the primary treatment.
This is Combined Disease of Yangming and Shaoyang. Tidal fever is a sign of Yangming Stomach heat. Loose stools and normal urination indicate the Stomach is not full/excess. Persistent hypochondriac fullness indicates concomitant Shaoyang involvement. Once Shaoyang is involved, both sweating and purging are contraindicated. Only Xiao Chaihu Tang (Minor Bupleurum Decoction) harmonizes the interior and exterior, being the correct treatment for Shaoyang alone. Thus, it is also used for Yangming-Shaoyang Combined Disease, with no other method.
In Yangming disease, with hypochondriac pain and hardness, constipation, vomiting, and a white coating on the tongue, Xiao Chaihu Tang (Minor Bupleurum Decoction) may be administered. Once the Upper Jiao is unblocked, Body Fluids descend, Stomach Qi harmonizes, and the body sweats continuously, resolving the disease.
This is also Combined Disease of Yangming and Shaoyang. Loose stools indicate the Stomach is not full. Even with constipation, if hypochondriac hardness, vomiting, and tongue coating are present, Shaoyang predominates. Xiao Chaihu Tang (Minor Bupleurum Decoction) should be used to separate Yin and Yang, harmonizing upper and lower. Continuous sweating resolves the exterior signs of tongue coating, vomiting, and hypochondriac fullness. Since Body Fluids descend, bowel movements occur naturally. This simultaneous resolution of interior and exterior is appropriate. ○ "Upper Jiao unblocked, Body Fluids descend" highlights the critical pathogenesis. Wind-Cold pathogens carry Body Fluids upward to accumulate in the diaphragm, causing wheezing, vomiting, Water Rebellion, or Tie Xiong (Glomus), accounting for six or seven out of ten cases. If Wind-Cold is unresolved, Body Fluids cannot descend. Erroneous dispersal not only prevents fluid descent but increases upward rebellion, with no end in sight.
The above cases involve Combined Disease.