【纲】仲景曰。两感病俱作。治有先后。伤寒下之后。复下利清谷不止。身疼痛者。急当救里。
宜四逆汤。后身体疼痛。清
便自调者。急当救表。宜桂枝汤。
【目】王叔和伤寒论例曰。若两感于寒者。一日太阳受之。即与少阴俱病。则头痛口干烦满而
渴。二日阳明受之。即与太阴同病。则腹满身热。不饮食。谵语。三日少阳受之。即与厥阴同病。
则耳聋囊缩而厥。水浆不入。不知人者。六日死。若三阴三阳。五脏六腑皆受病。则营卫不行。脏
腑不通而死矣。
朱肱曰。庞安常云。脉沉大者。太阳少阴。沉长者。阳明太阴。沉弦者。少阳厥阴。诸方书不
载两感脉。安常特设以示后人。素问。热病论云。两感于寒而病者。必不免于死。法不过六日。
黄帝曰。有三日而死者。何也。岐伯曰。阳明者。十二经脉之长也。若三日而气绝则死矣。仲景亦
无治法。
杨士瀛曰。活人书五卷序云。伤寒惟两感不治。仲景但一说云。两感病俱作。治有先后。张翼
说与仲景同。谓如下利清谷。身体疼痛。急当救里。四逆汤。身体疼痛。清便自调。急当救表。桂
枝汤。症治论并活人书。解仲景治有先后之说。皆云宜先救里。内才温。则可医矣。然救表亦不可
缓也。以上所论。并先救里。然后救表。愚意当消息之。如下利不止。身体疼痛。则先救里。如不
下利。身体疼痛。则先救表。此亦谓之治有先后也。然则两感亦有可治之理。而不可必其成效耳。
赵嗣真曰。仲景论两感为必死之症。而复以发表攻里之说继之者。盖不忍坐视。而欲觊其万一
之可治也。乃活人云救里以四逆。救表以桂枝。殊不知仲景云。太阳与少阳俱病。则头痛。为太阳
邪盛于表。口干而渴。为少阴邪盛于里也。阳明与太阴同病。则身热谵语。为阳明邪盛于表。不食
腹满。为太阴邪盛于里也。少阳与厥阴同病。则耳聋。为少阳邪盛于表。囊缩。为厥阴邪盛于里也。
三阳之头痛身热耳聋。救表。已自不可。三阴之腹满口干囊缩而厥。不可下乎。活人引下利身疼
虚寒救里之例。而欲施于烦渴腹满谵语囊缩热实之症。然乎否乎。盖仲景所谓发表者。葛
根、麻黄是也。仲景所谓攻里者。调胃承气是也。活人救里则四逆。救表则桂枝。若用四逆。则以
火济火。而腹满谵语囊缩等症。何由而除。脏腑何由而通。营卫何由而行。而六日死者。可立待也。
吁。两感虽为不治症。然用药之法。助正除邪。虚实实虚。补不足。损有余之理。学人不可不素有
一定之理于胸中也。
李杲曰。问。两感从何道而入。答曰。经云。两感者死不治。一日。太阳少阴俱病。太阳者腑也。
自背俞而入。人所共知之。少阴者脏也。自鼻息而入。人所不知也。鼻息通于天。故寒邪无形之气。
从鼻而入。肾为水也。水流湿。故肾受之。经曰。伤于湿者。下先受之。同气相求耳。又云天之
邪气。感则害人五脏。以是知内外两感。脏腑俱病。欲表之则有里。欲下之则有表。表里既不能一
治。故云。两感者死不治。然所禀有虚实。所感有浅深。虚而感之深者必死。实而感之浅者犹或可
治。治之而不救者有矣。未有不治而获生者也。予尝用此。间有生者。故立大羌活汤。以待好生君
子。
吴绶曰。两感必死者。乃一日传二经。阴阳俱病也。欲治阳而有阴。欲治阴而有阳。表里不可
并攻。故不治也。活人有先后之法。救里四逆。救表桂枝。此表里皆寒急救之法。非日传二经之法
也。（清划）
保命集曰。内伤于寒。外伤于风。或内伤于食。外伤于风。或先伤于湿。后伤于风。
或先伤于风。后伤于湿。或先伤于寒。后伤于风之类。此亦内外俱病。表里俱伤。（此非两感）
乃为可治。故宜大羌活汤间有生者。易老丹溪。岂真贤于仲景哉。
李 曰。两感者。半入于阳。半入于阴。阴阳两感。脏腑俱病。故为必死之症。但禀浓而感邪
浅者。或挟异气风温湿温之类。犹可救疗。所以仲景有治有先后。发表攻里之说。法当审其表里缓
急虚实何如。如表里俱急者。大羌活汤主之。如阳症阳经先受病。身体痛而不下利者。为表急。先
以葛根、麻黄发表。后以调胃承气攻里。如阴症阴经先受病。身体痛而下利不止者。为里急。先用
四逆救里。后以桂枝救表。如阴阳未分者。陶氏冲和汤探之。古法。一日太阳少阴。五苓散。头痛
加羌、防。口渴加知、柏。二日阳明太阴。大柴胡汤。三日少阳厥阴。危甚。大承气汤加芎、柴救
之。活人书
不分阴阳。专用四逆桂枝。先辈皆以为谬。大抵两感。脉从阳可治。从阴难治。
张介宾曰。病两感于寒者。固为死症。细察之。亦有缓急可辨。若三阳之头痛身热耳聋胁痛恶寒
而呕。此在表者。不得不解于外。其三阴之腹满口渴囊缩谵语。此在里者。不得不和其中。若其邪
自外入。而外甚于里者。必当以外为主。而兼调其内。若其邪因虚袭。而元气不支者。速宜单顾根
本。不可攻邪。但使元阳不败。则强敌亦将自解。其庶乎有望也。钱祯曰。两感者。本表里之同病。似若皆以外感为言。
而实有未尽然者。正以外内俱传。便是
两感。今见有少阴先溃于内。而太阳断之于外者。即纵情肆欲之两感也。太阴受伤于里。而阳明重
感于表者。即劳倦竭力饮食不调之两感也。厥阴气逆于脏。少阳复病于腑者。即七情不慎疲筋败血
之两感也。人知两感为伤寒。而不知伤寒之两感。内外俱困。病斯剧矣。但伤有重轻。医有知有不
知。则生死系之。或谓两感症不多见者。盖亦见之不广。而义有未达耳。其于治法。亦在乎知其由
而救其本也。此言最切此病。诚发人之未发。
陈士铎曰。伤寒两感。隔经相传。每每杀人。如一日宜在太阳。二日阳明。三日少阳。四日太
阴。五日少阴。六日厥阴。此顺传经也。今一日太阳即传阳明。二日阳明即传少阳。三日少阳即传
太阴。四日太阴即传少阴。五日少阴即传厥阴。此过经传也。更有一日太阳即传少阳。二日阳明即
传太阴。三日少阳即传少阴。四日太阴即传厥阴。此隔经传也。若一日太阳即传少阴。二日阳明即
传太阴。三日少阳即传厥阴。此两感传也。顺传者。原有生机。至七日自愈。过传者。有生有死。隔
传者。死多于生。两感传者。三日水浆不入。不知人即死。今传二方。一救过经传。一救隔经传。过
经传方。名救过起死汤。柴胡、麻黄、浓朴、知母、半夏、黄芩各一钱。石膏、青蒿、茯苓各五钱。
山栀五分。当归三钱。水煎服。一剂即生。盖过经之传。必然变症纷纭。断非初起之一二日也。
所以方中不用桂枝散太阳之邪。止用麻黄散表。伤寒至三四日。内热必甚。故以石膏、知母为君。
以泄阳明邪火。又用青蒿、山栀。柴胡以凉散肝火。使木不自焚。而各经之
邪。亦不攻自散。况又重用茯苓以健脾行湿。引火下行。尽从膀胱而出之乎。且黄芩清肺。浓朴逐
秽。半夏清痰。五脏无非生气矣。隔经传方。名救阴起死汤。青蒿一两。人参、石膏各五钱。白芍、
山栀各三钱。柴胡二钱。知母、半夏、甘草各一钱。水煎服。隔经之传。必至三日。而症乃明。
虽已过阳明。而余火未散。故少阴之火助其焰。少阳之火失其权。若不仍用石膏、知母。则阳明之
火势不退。而少阴之火势不息也。然太阴脾土。不为急救。则火气凌亢。何以能生。故用人参以助生
气。又恐厥阴太燥以克脾。故用柴、芍、栀、蒿。以凉散木中之邪。况半夏清痰。甘草和中。
起死回生。实非虚语。故一见有隔经之传。即以此方救之。必能转败为功也。至青蒿不独息肝火。
尤能泻阳明之焰。且性静而不动。更能补阴也。三日少阳与厥阴两感相传方。名救脏汤。麦冬三两。
元参、白芍各二两。人参、当归各一两。花粉三钱。荆芥二钱。水煎服。多用当归者。助肝胆以
生血也。多用麦冬者。救肺气之绝。以制肝胆之木。使火不旺而血易生。斯胃气有养。脏腑可救其
坏也。
【纲】张仲景说：两感病同时发作，治疗有先后顺序。伤寒经过泻下治疗后，如果仍然腹泻不止、排出未消化的食物残渣，且身体疼痛，应当紧急救治里证。适宜使用四逆汤。之后如果身体依然疼痛，但大小便正常，应当紧急救治表证。适宜使用桂枝汤。
【目】王叔和在《伤寒论例》中说：如果是两感于寒邪，第一天太阳经受邪，就与少阴经同时发病，会出现头痛、口干、心烦胀满和口渴的症状。第二天阳明经受邪，就与太阴经同时发病，会出现腹部胀满、身体发热、不想饮食、胡言乱语的症状。第三天少阳经受邪，就与厥阴经同时发病，会出现耳聋、睾丸收缩和四肢厥冷的症状。如果水浆不能入口，神志昏迷不知人，六天后就会死亡。如果三阴三阳、五脏六腑都受到病邪侵害，那么营卫之气运行停滞，脏腑气机不通，就会导致死亡。
朱肱说：庞安常认为，脉象沉大的，是太阳与少阴同病；脉象沉长的，是阳明与太阴同病；脉象沉弦的，是少阳与厥阴同病。各种医书没有记载两感的脉象，庞安常特意设立这些脉象以教导后人。《素问·热病论》说：两感于寒而患病的人，必定难免一死，病程不超过六天。黄帝问：有三天就死亡的，是什么原因？岐伯回答：阳明经是十二经脉之长。如果到了第三天阳气断绝就会死亡。张仲景也没有针对这种情况的治疗法则。
杨士瀛说：《活人书》第五卷序言中提到：伤寒中只有两感是不治之症。张仲景只有一种说法：两感病同时发作，治疗有先后顺序，如下利清谷、身体疼痛时，应紧急救治里证，用四逆汤；身体疼痛、二便自调时，应紧急救治表证，用桂枝汤。《症治论》和《活人书》在解释张仲景“治有先后”的说法时，都认为应该先救里，待体内温暖后，才可以进行治疗。然而救表也不可迟缓。以上论述都是主张先救里，然后救表。我个人的意见是需要斟酌情况。如下利不止、身体疼痛，就先救里；如果不腹泻、身体疼痛，就先救表。这也称为治疗有先后顺序。既然如此，两感也有可治的道理，只是不能保证一定有效罢了。
赵嗣真说：张仲景论述两感为必死的病症，却又接着发表攻里的说法，大概是不忍心坐视不管，而希望有一线生机可以治愈。然而《活人书》说救里用四逆汤，救表用桂枝汤，却不知道张仲景说的是：太阳与少阳同病，则头痛，这是太阳邪气盛于表；口干而渴，这是少阴邪气盛于里。阳明与太阴同病，则身热谵语，这是阳明邪气盛于表；不食腹满，这是太阴邪气盛于里。少阳与厥阴同病，则耳聋，这是少阳邪气盛于表；囊缩，这是厥阴邪气盛于里。三阳病的头痛、身热、耳聋，如果要救表，本来就已经很难处理了；三阴病的腹满、口干、囊缩和厥冷，难道可以用泻下法吗？《活人书》引用下利身疼属于虚寒需救里的例子，却想应用于烦渴、腹满、谵语、囊缩等热实证候，这合适吗？所谓张仲景所说的发表，是指葛根、麻黄；张仲景所说的攻里，是指调胃承气汤。《活人书》救里用四逆汤，救表用桂枝汤。如果使用四逆汤，那就是以火助火，腹满、谵语、囊缩等症状如何能消除？脏腑如何能通畅？营卫如何能运行？六日死亡的结果，就可以立刻等待到了。唉！两感虽然是不治之症，然而用药的原则，是扶助正气、祛除邪气，遵循“虚者补之，实者泻之”（注：原文“虚实实虚”疑为笔误或特定语境下的对举，此处依中医常规理法意译为扶正祛邪及调整虚实），补不足、损有余的道理。学习者心中不可没有一定的准则。
李杲说：有人问：两感从什么途径进入人体？回答说：经典说：两感者死，不治。第一天，太阳与少阴同病。太阳是腑，从背部的俞穴进入，这是人们所共知的。少阴是脏，从鼻息进入，这是人们所不知道的。鼻息通于天气，所以无形寒气从鼻子进入。肾属水，水流向湿处，所以肾受邪。经典说：伤于湿者，下部先受之，这是同气相求的缘故。又说：天之邪气，感则伤害人五脏。由此可知内外两感，脏腑都生病。想要解表就有里证阻碍，想要攻里就有表证存在。表里既不能同时治疗，所以说：两感者死，不治。然而人的禀赋有虚实之分，感受邪气有深浅之别。禀赋虚弱而感受邪气深的必定死亡，禀赋充实而感受邪气浅的或许还可以治疗。治疗了却没有救活的案例是有的，但没有不治疗而获生的案例。我曾经使用这个方法，偶尔有救活的，所以制定了大羌活汤，以待喜好救人的君子使用。
吴绶说：两感必死的情况，是因为一天之内传入两条经络，阴阳同时发病。想要治疗阳经的病却有阴经的病，想要治疗阴经的病却有阳经的病，表里不可同时攻伐，所以说不治。《活人书》提出的先后之法，救里用四逆汤，救表用桂枝汤，这是表里皆寒时的急救方法，而不是一日传二经的治疗方法。（清代学者批注）
《保命集》说：内伤于寒，外伤于风；或者内伤于饮食，外伤于风；或者先伤于湿，后伤于风；或者先伤于风，后伤于湿；或者先伤于寒，后伤于风之类。这也是内外俱病，表里俱伤。（但这并非两感）而是可以治疗的，所以适宜用大羌活汤，偶尔有救活的。易老（李东垣）、丹溪（朱震亨），难道真的比张仲景贤能吗？
李氏（指李杲或其他李姓医家，此处原文简写为李）说：两感者，一半入于阳经，一半入于阴经，阴阳两感，脏腑俱病，所以是必死的病症。但禀赋浓厚而感受邪气浅的，或者夹杂风温、湿温等其他邪气的，还可以救治。所以张仲景有治疗有先后顺序，发表攻里的说法。方法应当审察其表里缓急虚实的情况。如果表里都急迫，以大羌活汤主治。如果是阳证阳经先受病，身体痛但不腹泻的，为表急，先用葛根、麻黄发表，后用调胃承气汤攻里。如果是阴证阴经先受病，身体痛且腹泻不止的，为里急，先用四逆汤救里，后用桂枝汤救表。如果阴阳界限不明确，用陶华氏的冲和汤试探。古法规定：第一天太阳少阴同病，用五苓散，头痛加羌活、防风，口渴加知母、黄柏。第二天阳明太阴同病，用大柴胡汤。第三天少阳厥阴同病，病情危重，用大承气汤加川芎、柴胡来抢救。《活人书》不分阴阳，专用四逆汤和桂枝汤，前辈们都认为这是错误的。大抵两感病，脉象从阳者可治，从阴者难治。
张介宾说：病两感于寒，固然是死症，仔细考察，也有缓急可以辨别。如果是三阳病的头痛、身热、耳聋、胁痛、恶寒而呕吐，这是在表，不得不从外部解除。如果是三阴病的腹满、口渴、囊缩、谵语，这是在里，不得不调和其中焦。如果邪气从外侵入，且外表症状重于里证，必须以外证为主，兼调内部。如果邪气因正气虚弱而侵袭，且元气不支，应当迅速单独顾护根本，不可攻伐邪气。只要元阳不败，那么强敌也将自行解散，这样或许还有希望。
钱祯说：两感者，本来是表里同病，似乎都是以外部感染来说的，但实际上并不完全如此。正是因为内外互相传变，才叫作两感。现在见到有少阴先溃败于内，而太阳阻断于外的，这就是纵情肆欲导致的两感。太阴受伤于里，而阳明再次感受于表的，这就是劳倦竭力、饮食不调导致的两感。厥阴气逆于脏，少阳再次病于腑的，这就是七情不慎、疲筋败血导致的两感。人们知道两感是伤寒，却不知道伤寒的两感，内外都困顿，病势就会加剧。但是损伤有轻重，医生有有无知识之分，生死就系于此。有人说两感症不多见，大概也是见得少，且义理未通达罢了。对于治疗方法，也在于知道病因而救治根本。这些话最切合此病，确实揭示了前人未曾阐发的道理。
陈士铎说：伤寒两感，隔经相传，常常杀人。比如第一天应在太阳，第二天阳明，第三天少阳，第四天太阴，第五天少阴，第六天厥阴，这是顺传经。现在第一天太阳即传阳明，第二天阳明即传少阳，第三天少阳即传太阴，第四天太阴即传少阴，第五天少阴即传厥阴，这是过经传。更有一种情况：第一天太阳即传少阳，第二天阳明即传太阴，第三天少阳即传少阴，第四天太阴即传厥阴，这是隔经传。如果第一天太阳即传少阴，第二天阳明即传太阴，第三天少阳即传厥阴，这是两感传。顺传者，原有生机，到七天自愈。过传者，有生有死。隔传者，死多于生。两感传者，三天水浆不入、不知人就会死亡。现在传授两个方子，一个救过经传，一个救隔经传。过经传方，名叫救过起死汤，由柴胡、麻黄、厚朴、知母、半夏、黄芩各一钱，石膏、青蒿、茯苓各五钱，山栀五分，当归三钱组成，水煎服。一剂即可生还。因为过经的传变，必然变症纷纭，绝不是初起的一两天。所以方中不用桂枝发散太阳之邪，只用麻黄发散表邪。伤寒至三四天，内热必然很甚，所以以石膏、知母为君药，以泄阳明邪火。又用青蒿、山栀、柴胡来凉散肝火，使木气不自焚，而各经的邪气，也会不攻自散。况且重用茯苓来健脾行湿，引火下行，尽从膀胱而出。而且黄芩清肺，厚朴逐秽，半夏清痰，五脏无非生气矣。隔经传方，名叫救阴起死汤，由青蒿一两，人参、石膏各五钱，白芍、山栀各三钱，柴胡二钱，知母、半夏、甘草各一钱组成，水煎服。隔经的传变，必至三天，症状才明显。虽然已过阳明，但余火未散，所以少阴之火助长其焰，少阳之火失去其权。如果不仍用石膏、知母，那么阳明的火势不退，而少阴的火势也不息。然而太阴脾土，如果不急救，则火气凌亢，怎么能生化？所以用人参以助生气。又恐怕厥阴太燥以克脾，所以用柴胡、白芍、山栀、青蒿，来凉散木中之邪。况且半夏清痰，甘草和中，起死回生，实在不是虚语。所以一见有隔经的传变，就用这个方子抢救，一定能转败为功。至于青蒿不仅平息肝火，尤其能泻阳明之焰，且性质静而不妄动，更能补阴。第三天少阳与厥阴两感相传方，名叫救脏汤，由麦冬三两，元参、白芍各二两，人参、当归各一两，花粉三钱，荆芥二钱组成，水煎服。多用当归，是为了助肝胆以生血。多用麦冬，是为了救肺气之绝，以制约肝胆之木，使火不旺而血易生，这样胃气有养，脏腑可救其坏也。
[General Principle] Zhang Zhongjing stated: When Lianggan disease (simultaneous infection of exterior and interior meridians) occurs, treatment must follow a specific sequence. In cases of Taiyang disease (disease of the Taiyang meridian) where purgation has been performed, if diarrhea with undigested food persists and body pain remains, urgent rescue of the Interior syndrome is required. Si Ni Tang (Four Reversal Decoction) is appropriate. Subsequently, if body pain persists but bowel and bladder functions are normal, urgent rescue of the Exterior syndrome is required. Gui Zhi Tang (Cinnamon Twig Decoction) is appropriate.
[Commentary] Wang Shuhe, in the "Examples of Shanghan Lun," stated: If one contracts cold from both exterior and interior, on the first day, the Taiyang meridian is affected and simultaneously involves the Shaoyin meridian, resulting in headache, dry mouth, mental restlessness, fullness, and thirst. On the second day, the Yangming meridian is affected and simultaneously involves the Taiyin meridian, resulting in abdominal fullness, fever, anorexia, and delirium. On the third day, the Shaoyang meridian is affected and simultaneously involves the Jueyin meridian, resulting in deafness, retraction of the genitals, and cold limbs. If the patient cannot ingest fluids or water and loses consciousness, death will occur within six days. If all three Yin and three Yang meridians, as well as the five zang organs and six fu organs, are diseased, the Ying and Wei qi will cease to circulate, and the zang and fu organs will become obstructed, leading to death.
Zhu Gong stated: Pang Anchang believed that a deep and large pulse indicates simultaneous involvement of Taiyang and Shaoyin; a deep and long pulse indicates simultaneous involvement of Yangming and Taiyin; and a deep and wiry pulse indicates simultaneous involvement of Shaoyang and Jueyin. Medical texts do not record the pulses for Lianggan disease; Pang Anchang specifically established these to instruct future generations. The *Suwen* (Plain Questions), chapter "Reheat Disease," states: Those who contract Lianggan from cold will inevitably die, with the course not exceeding six days. The Yellow Emperor asked: Why do some die in three days? Qibo answered: The Yangming meridian is the leader of the twelve meridians. If qi fails by the third day, death ensues. Zhang Zhongjing also provided no treatment method for this condition.
Yang Shiying stated: The preface to Volume 5 of the *Huo Ren Shu* (Book of Saving Lives) mentions: Among shanghan diseases, only Lianggan is considered untreatable. Zhang Zhongjing offered only one principle: when Lianggan disease occurs simultaneously, treatment follows a sequence. For instance, if there is diarrhea with undigested food and body pain, urgent rescue of the Interior is needed using Si Ni Tang (Four Reversal Decoction); if there is body pain but bowel and bladder functions are normal, urgent rescue of the Exterior is needed using Gui Zhi Tang (Cinnamon Twig Decoction). Both the *Zheng Zhi Lun* and the *Huo Ren Shu*, in interpreting Zhang Zhongjing’s principle of sequential treatment, advocate rescuing the Interior first. Once the interior is warm, treatment can proceed. However, rescuing the Exterior should not be delayed. All the above discussions advocate rescuing the Interior first, then the Exterior. My personal view requires deliberation. If there is persistent diarrhea and body pain, rescue the Interior first. If there is no diarrhea but body pain exists, rescue the Exterior first. This is also referred to as sequential treatment. Thus, Lianggan does have treatable aspects, although success is not guaranteed.
Zhao Sizhen stated: Zhang Zhongjing described Lianggan as invariably fatal, yet followed this with methods for releasing the Exterior and purging the Interior. This was likely out of reluctance to stand by idly, hoping for a sliver of chance for recovery. However, the *Huo Ren Shu* suggests using Si Ni Tang (Four Reversal Decoction) to rescue the Interior and Gui Zhi Tang (Cinnamon Twig Decoction) to rescue the Exterior. It fails to recognize that Zhang Zhongjing stated: Simultaneous involvement of Taiyang and Shaoyang causes headache, indicating excess pathogenic factors of Taiyang at the Exterior; dry mouth and thirst indicate excess pathogenic factors of Shaoyin at the Interior. Simultaneous involvement of Yangming and Taiyin causes fever and delirium, indicating excess pathogenic factors of Yangming at the Exterior; anorexia and abdominal fullness indicate excess pathogenic factors of Taiyin at the Interior. Simultaneous involvement of Shaoyang and Jueyin causes deafness, indicating excess pathogenic factors of Shaoyang at the Exterior; genital retraction indicates excess pathogenic factors of Jueyin at the Interior. Treating the Exterior for the headache, fever, and deafness of the Three Yang meridians is already difficult; how can purgation be applied to the abdominal fullness, dry mouth, genital retraction, and cold limbs of the Three Yin meridians? The *Huo Ren Shu* cites the example of diarrhea and body pain (deficiency-cold requiring Interior rescue) and attempts to apply it to symptoms of vexation, thirst, abdominal fullness, delirium, and genital retraction (excess-heat). Is this appropriate? Zhang Zhongjing’s methods for releasing the Exterior involve Ge Gen (Kudzu Root) and Ma Huang (Ephedra); his methods for purging the Interior involve Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction). The *Huo Ren Shu* uses Si Ni Tang (Four Reversal Decoction) for the Interior and Gui Zhi Tang (Cinnamon Twig Decoction) for the Exterior. Using Si Ni Tang (Four Reversal Decoction) in such heat-excess conditions would be adding fire to fire; how could abdominal fullness, delirium, and genital retraction be resolved? How could the zang and fu organs unblock? How could Ying and Wei qi circulate? Death within six days would be imminent. Alas! Although Lianggan is considered untreatable, the principles of medication—supporting healthy qi and eliminating pathogenic factors, tonifying deficiency and reducing excess—are fundamental. Practitioners must have a firm understanding of these principles.
Li Gao stated: Question: Through what pathway does Lianggan enter? Answer: The classics state: Lianggan is fatal and untreatable. On the first day, Taiyang and Shaoyin are involved. Taiyang is a Fu organ, entering through the Back-Shu points on the back, which is common knowledge. Shaoyin is a Zang organ, entering through the nose and breath, which is less known. The nose connects to heavenly qi, so formless cold pathogens enter via the nose. The Kidney belongs to Water; water flows to damp places, so the Kidney receives the pathogen. The classics state: Those injured by dampness suffer first in the lower part, due to the attraction of similar energies. It is also said: Heavenly pathogenic qi harms the five Zang organs upon contact. Thus, we know that in internal and external Lianggan, both Zang and Fu organs are diseased. Attempting to release the Exterior encounters Interior obstruction; attempting to purge the Interior encounters Exterior presence. Since Exterior and Interior cannot be treated simultaneously, it is said: Lianggan is fatal and untreatable. However, constitution varies in deficiency and excess, and pathogenic depth varies. Those with deficient constitutions and deep infection will surely die; those with robust constitutions and shallow infection may still be treatable. There are cases where treatment failed, but none where survival occurred without treatment. I have occasionally achieved cures using this approach, hence I formulated Da Qiang Huo Tang (Great Notopterygium Decoction) for benevolent physicians to use.
Wu Shou stated: Lianggan is invariably fatal because it involves transmission to two meridians in one day, affecting both Yin and Yang. One wishes to treat the Yang meridians but faces Yin pathology; one wishes to treat the Yin meridians but faces Yang pathology. Exterior and Interior cannot be attacked simultaneously, hence it is deemed untreatable. The *Huo Ren Shu* proposes a sequential method: rescuing the Interior with Si Ni Tang (Four Reversal Decoction) and the Exterior with Gui Zhi Tang (Cinnamon Twig Decoction). This is an emergency method for simultaneous Cold in both Exterior and Interior, not a method for daily transmission to two meridians. [Qing dynasty annotation]
The *Bao Ming Ji* (Collection for Preserving Life) states: Internal injury from Cold, external injury from Wind; or internal injury from food stagnation, external injury from Wind; or prior injury from Dampness, subsequent injury from Wind; or prior injury from Wind, subsequent injury from Dampness; or prior injury from Cold, subsequent injury from Wind, etc. These are also cases of simultaneous internal and external injury, and simultaneous Exterior and Interior damage. (However, this is not Lianggan) and are treatable, hence Da Qiang Huo Tang (Great Notopterygium Decoction) is appropriate, with occasional cures. Did Yilao (Li Dongyuan) and Danxi (Zhu Zhenheng) truly surpass Zhang Zhongjing in wisdom?
Li stated: Lianggan involves half entering the Yang meridians and half entering the Yin meridians. Simultaneous involvement of Yin and Yang, and disease of both Zang and Fu organs, makes it invariably fatal. However, those with strong constitutions and shallow infection, or those complicated by other pathogens like Wind-Warmth or Damp-Warmth, may still be salvageable. Therefore, Zhang Zhongjing advocated sequential treatment, releasing the Exterior and purging the Interior. The method requires assessing the urgency and deficiency/excess status of the Exterior and Interior. If both are urgent, Da Qiang Huo Tang (Great Notopterygium Decoction) is the primary formula. If Yang syndromes/Yang meridians are affected first, with body pain but no diarrhea, the Exterior is urgent; first release the Exterior with Ge Gen (Kudzu Root) and Ma Huang (Ephedra), then purge the Interior with Tiao Wei Cheng Qi Tang (Regulate the Stomach and Order the Qi Decoction). If Yin syndromes/Yin meridians are affected first, with body pain and persistent diarrhea, the Interior is urgent; first rescue the Interior with Si Ni Tang (Four Reversal Decoction), then rescue the Exterior with Gui Zhi Tang (Cinnamon Twig Decoction). If Yin and Yang are indistinguishable, use Tao Hua’s Chong He Tang (Harmonizing Decoction) to probe. Ancient protocols specify: Day 1, Taiyang-Shaoyin involvement, use Wu Ling San (Five-Ling Powder); add Qiang Huo (Notopterygium Rhizome) and Fang Feng (Saposhnikovia Root) for headache; add Zhi Mu (Anemarrhena Rhizome) and Huang Bo (Phellodendron Bark) for thirst. Day 2, Yangming-Taiyin involvement, use Da Chai Hu Tang (Major Bupleurum Decoction). Day 3, Shaoyang-Jueyin involvement, critical condition, use Da Cheng Qi Tang (Major Order the Qi Decoction) plus Chuan Xiong (Ligusticum Rhizome) and Chai Hu (Bupleurum Root) to rescue. The *Huo Ren Shu* ignores Yin-Yang differentiation and exclusively uses Si Ni Tang (Four Reversal Decoction) and Gui Zhi Tang (Cinnamon Twig Decoction), which predecessors considered erroneous. Generally, in Lianggan, a pulse indicating Yang suggests treatability; a pulse indicating Yin suggests difficulty.
Zhang Jiebin stated: Disease involving Lianggan from cold is indeed a fatal syndrome, but careful observation reveals differences in urgency. If the symptoms are headache, fever, deafness, hypochondriac pain, aversion to cold, and vomiting (Three Yang symptoms), these are at the Exterior and must be resolved externally. If the symptoms are abdominal fullness, thirst, genital retraction, and delirium (Three Yin symptoms), these are at the Interior and require harmonization internally. If the pathogen enters from the exterior and the Exterior symptoms are more severe than the Interior, priority must be given to the Exterior while concurrently regulating the Interior. If the pathogen invades due to deficiency and vital qi is unsupported, immediate focus must be on supporting the root (vital qi); attacking the pathogen is contraindicated. As long as the Yuan Yang (Primordial Yang) remains intact, even strong enemies will dissolve spontaneously. This offers hope.
Qian Zhen stated: Lianggan is fundamentally simultaneous disease of the Exterior and Interior. Although often attributed solely to external contraction, this is incomplete. True Lianggan arises from mutual transmission between interior and exterior. For example, Shaoyin collapsing internally while Taiyang is blocked externally results from licentious behavior. Taiyin injured internally while Yangming is re-infected externally results from overexertion and dietary irregularity. Jueyin qi rebellion in the Zang organs while Shaoyang disease recurs in the Fu organs results from emotional neglect and exhaustion of sinews and blood. People know Lianggan as shanghan, but fail to realize that in shanghan Lianggan, both interior and exterior are besieged, making the disease severe. Mortality depends on the severity of the injury and the physician’s knowledge. Some claim Lianggan is rare, likely due to limited exposure and lack of theoretical understanding. Treatment lies in identifying the cause and addressing the root. These words precisely address this disease, revealing insights previously unexpressed.
Chen Shiduo stated: Shanghan Lianggan, transmitted across meridians, often proves fatal. Normally, Day 1 affects Taiyang, Day 2 Yangming, Day 3 Shaoyang, Day 4 Taiyin, Day 5 Shaoyin, Day 6 Jueyin; this is順传 (sequential transmission) and has vitality, resolving spontaneously by Day 7. Current patterns show Day 1 Taiyang transmitting to Yangming, Day 2 Yangming to Shaoyang, Day 3 Shaoyang to Taiyin, Day 4 Taiyin to Shaoyin, Day 5 Shaoyin to Jueyin; this is Guo Jing Chuan (transmission beyond the proper meridian). Another pattern: Day 1 Taiyang to Shaoyang, Day 2 Yangming to Taiyin, Day 3 Shaoyang to Shaoyin, Day 4 Taiyin to Jueyin; this is Ge Jing Chuan (skipping meridian transmission). If Day 1 Taiyang transmits to Shaoyin, Day 2 Yangming to Taiyin, Day 3 Shaoyang to Jueyin, this is Lianggan Chuan (Lianggan transmission). Sequential transmission has vitality. Transmission beyond the meridian has variable outcomes. Skipping meridian transmission has more deaths than survivals. Lianggan transmission leads to death if the patient cannot ingest fluids and loses consciousness by Day 3. I now present two formulas: one for transmission beyond the meridian, one for skipping meridian transmission. The formula for transmission beyond the meridian is named Jiu Guo Qi Si Tang (Decoction to Rescue Beyond-Meridian Transmission and Revive the Dead), containing Chai Hu (Bupleurum Root), Ma Huang (Ephedra), Hou Po (Magnolia Bark), Zhi Mu (Anemarrhena Rhizome), Ban Xia (Pinellia Tuber), Huang Qin (Scutellaria Root) each 1 qian; Shi Gao (Gypsum), Qing Hao (Artemisia Annua), Fu Ling (Poria) each 5 qian; Shan Zhi (Gardenia Fruit) 0.5 fen; Dang Gui (Angelica Sinensis) 3 qian. Decoct in water and take orally. One dose brings life. Transmission beyond the meridian inevitably presents complex changes, occurring well after onset. Hence, Gui Zhi (Cinnamon Twig) is omitted to disperse Taiyang pathogens; only Ma Huang (Ephedra) is used to release the Exterior. By Days 3-4, internal heat is intense; thus, Shi Gao (Gypsum) and Zhi Mu (Anemarrhena Rhizome) serve as sovereign herbs to clear Yangming pathogenic fire. Qing Hao (Artemisia Annua), Shan Zhi (Gardenia Fruit), and Chai Hu (Bupleurum Root) cool and dissipate Liver fire, preventing Wood from self-immolating, allowing pathogens in other meridians to dissipate naturally. Fu Ling (Poria) strengthens the Spleen and moves Dampness, guiding fire downward to exit via the Bladder. Huang Qin (Scutellaria Root) clears the Lungs; Hou Po (Magnolia Bark) expels turbidity; Ban Xia (Pinellia Tuber) clears phlegm, restoring vital energy to the five Zang organs. The formula for skipping meridian transmission is named Jiu Yin Qi Si Tang (Decoction to Rescue Yin Transmission and Revive the Dead), containing Qing Hao (Artemisia Annua) 1 liang; Ren Shen (Ginseng Root), Shi Gao (Gypsum) each 5 qian; Bai Shao (White Peony Root), Shan Zhi (Gardenia Fruit) each 3 qian; Chai Hu (Bupleurum Root) 2 qian; Zhi Mu (Anemarrhena Rhizome), Ban Xia (Pinellia Tuber), Gan Cao (Licorice Root) each 1 qian. Decoct in water and take orally. Skipping meridian transmission becomes evident by Day 3. Although Yangming has passed, residual fire remains; thus, Shaoyin fire fuels the flame, and Shaoyang fire loses its control. Without Shi Gao (Gypsum) and Zhi Mu (Anemarrhena Rhizome), Yangming fire will not subside, nor will Shaoyin fire cease. However, if the Taiyin Spleen Earth is not urgently supported, the flaming fire will overwhelm it, preventing transformation. Thus, Ren Shen (Ginseng Root) supports vital energy. To prevent excessive dryness of Jueyin Wood from overcoming the Spleen, Chai Hu (Bupleurum Root), Bai Shao (White Peony Root), Shan Zhi (Gardenia Fruit), and Qing Hao (Artemisia Annua) cool and dissipate pathogens in Wood. Ban Xia (Pinellia Tuber) clears phlegm; Gan Cao (Licorice Root) harmonizes the middle. Reviving the dead is no empty talk. Upon detecting skipping meridian transmission, use this formula immediately to turn defeat into victory. Qing Hao not only calms Liver fire but especially drains Yangming flames; its quiet nature prevents agitation and further nourishes Yin. The formula for Day 3 Shaoyang-Jueyin Lianggan transmission is named Jiu Zang Tang (Decoction to Rescue the Zang Organs), containing Mai Dong (Ophiopogon Tuber) 3 liang; Yuan Shen (Trichosanthes Root), Bai Shao (White Peony Root) each 2 liang; Ren Shen (Ginseng Root), Dang Gui (Angelica Sinensis) each 1 liang; Hua Fen (Trichosanthes Root powder) 3 qian; Jing Jie (Schizonepeta Spike) 2 qian. Decoct in water and take orally. High dosage of Dang Gui (Angelica Sinensis) assists the Liver and Gallbladder in generating blood. High dosage of Mai Dong (Ophiopogon Tuber) saves the Lung qi from collapse, restraining Liver-Gallbladder Wood, preventing excessive fire and facilitating blood generation, thereby nourishing Stomach qi and saving the failing zang and fu organs.