[Discussion] If cold pathogen simultaneously attacks both the exterior and interior meridians (known as "Liang Gan" or Double Contraction), on the first day, the Taiyang meridian is affected, and concurrently the Shaoyin meridian becomes diseased; this results in headache, dry mouth, mental restlessness, fullness, and thirst. On the second day, the Yangming meridian is affected, and concurrently the Taiyin meridian becomes diseased; this results in abdominal fullness, body heat, loss of appetite, and delirious speech (Zhenyu). On the third day, the Shaoyang meridian is affected, and concurrently the Jueyin meridian becomes diseased; this results in deafness, retraction of the testicles, cold limbs, inability to take fluids, and unconsciousness. If the condition persists into the sixth day, death ensues. If all three Yin and three Yang meridians, along with the five Zang organs and six Fu organs, are affected, causing the stagnation of Ying and Wei Qi and the blockage of Zang-Fu organ functions, death will occur.

[Pang Anchang's View] Pang Anchang stated: A pulse that is deep and large indicates Liang Gan of Taiyang and Shaoyin; a pulse that is deep and long indicates Liang Gan of Yangming and Taiyin; a pulse that is deep and wiry indicates Liang Gan of Shaoyang and Jueyin. Many medical texts do not record the pulses for Liang Gan; Pang Anchang specifically established these to instruct future generations. The *Suwen* (Plain Questions) states: Patients suffering from Liang Gan inevitably die, usually within 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 its Qi is exhausted by the third day, death occurs. Zhang Zhongjing also did not provide specific treatments for Liang Gan. The preface to Volume 5 of the *Huo Ren Shu* (Book That Saves Lives) states: Among cold damage diseases, only Liang Gan is considered incurable. Zhang Zhongjing offered only one principle regarding treatment sequence. The *Zheng Zhi Zhun Sheng* cites Zhang Yi’s view, which aligns with Zhang Zhongjing, stating that when there is diarrhea with undigested food and body pain, one should urgently treat the Interior syndrome (using Sini Tang / Four Reversal Decoction); if there is body pain but normal bowel movements, one should urgently treat the Exterior syndrome (using Guizhi Tang / Cinnamon Twig Decoction). Both the *Zheng Zhi Zhun Sheng* and the *Huo Ren Shu* interpret Zhang Zhongjing’s “treatment has priority” as treating the Interior first; once the Interior is warmed, treatment can proceed. However, treating the Exterior cannot be delayed. The above discussions advocate treating the Interior before the Exterior. My opinion suggests exercising discretion: if diarrhea persists with body pain, treat the Interior first; if there is no diarrhea but body pain exists, treat the Exterior first. This is also referred to as treatment having priority. Thus, Liang Gan syndromes may have curative potential, but success is not guaranteed.

[Zhaosijin's View] Zhang Zhongjing described Liang Gan as a fatal syndrome, yet followed this with statements about treatment priorities, releasing the Exterior, and purging the Interior. This was likely out of reluctance to watch patients die without intervention, hoping for a slim chance of survival. The *Huo Ren Shu* suggests using Sini Tang to rescue the Interior, followed by Guizhi Tang to rescue the Exterior. However, it overlooks that Zhang Zhongjing stated: In concurrent Taiyang and Shaoyin disease, headache arises because Taiyang pathogenic factors are abundant at the Exterior, while dry mouth and thirst arise because Shaoyin pathogenic factors are abundant at the Interior. In concurrent Yangming and Taiyin disease, body heat and delirium arise because Yangming pathogenic factors are abundant at the Exterior, while anorexia and abdominal fullness arise because Taiyin pathogenic factors are abundant at the Interior. In concurrent Shaoyang and Jueyin disease, deafness arises because Shaoyang pathogenic factors are abundant at the Exterior, while testicular retraction and cold limbs arise because Jueyin pathogenic factors are abundant at the Interior. For the Three Yang syndromes (headache, body heat, deafness), rescuing the Exterior cannot be delayed; for the Three Yin syndromes (abdominal fullness, dry mouth/thirst, testicular retraction, cold limbs), failing to rescue the Interior is unacceptable. The *Huo Ren Shu* cites examples of deficiency-cold (diarrhea, body pain) requiring rescue, yet attempts to apply this to excess-heat syndromes (restlessness/thirst, abdominal fullness, delirium, testicular retraction). Is this appropriate? Zhang Zhongjing’s methods for releasing the Exterior involve herbs like Gegen (Kudzu Root) and Mahuang (Ephedra); his methods for purging the Interior involve Tiaowei Chengqi Tang (Stomach-Regulating Major Order the Qi Decoction). The *Huo Ren Shu*’s method for rescuing the Interior uses Sini Tang, and for rescuing the Exterior, Guizhi Tang. To equate “rescuing” with “attacking/purging” contradicts the original intent. Using Sini Tang in such cases would be adding fire to fire; how could symptoms like abdominal fullness, delirium, and testicular retraction be resolved? How could Zang-Fu functions clear? How could Ying and Wei Qi circulate? The outcome of death by the sixth day would be imminent. Alas, although Liang Gan is generally considered incurable, the principles of medication—supporting healthy Qi, eliminating pathogenic factors, addressing deficiency and excess, tonifying insufficiency, and reducing surplus—are essential. Practitioners must have a firm theoretical framework in mind.

[Li Gao’s Q&A] Question: Through what pathway does Liang Gan enter? Answer: The classic texts state that Liang Gan is fatal and untreatable. On the first day, concurrent Taiyang and Shaoyin disease presents with headache, fever, aversion to cold, dry mouth, restlessness, and thirst. Taiyang belongs to the Fu organs and enters via the Back-Shu points on the back, which is commonly known. Shaoyin belongs to the Zang organs and enters via the nose and breath, which is less known. Nasal qi connects with heavenly Qi, so formless cold pathogen enters through the nose. Kidney corresponds to Water; water flows toward dampness, so the Kidney receives the pathogen. The classics state: “When injured by dampness, the lower part is affected first,” due to the attraction of similar energies. It also states: “Heavenly pathogenic factors, when contracted, harm the Five Zang organs.” From this, we know that in internal-external double contraction, both Zang and Fu organs are diseased. Attempting to release the Exterior is hindered by Interior symptoms, and attempting to purge the Interior is hindered by Exterior symptoms; since Exterior and Interior cannot be treated simultaneously, death results. Hence, Liang Gan is deemed untreatable. However, individual constitution varies in deficiency or excess, and pathogenic depth varies. Those with deficient constitutions contracting deep pathogens will certainly die; those with robust constitutions contracting shallow pathogens may still be treatable. There are cases where treatment fails, but none where recovery occurs without treatment. I have used this formula, and among those treated here, two or three out of ten survive. Therefore, I established this formula for benevolent physicians to use.

Da Qianghuo Tang (Great Notopterygium Decoction):
Fangfeng (Saposhnikoviae Radix), Qianghuo (Notopterygii Rhizoma et Radix), Duhuo (Angelicae Pubescentis Radix), Fangji (Stephaniae Tetrandrae Radix), Huangqin (Scutellariae Radix), Huanglian (Coptidis Rhizoma), Cangzhu (Atractylodis Rhizoma), Baizhu (Atractylodis Macrocephalae Rhizoma), Gancao (Glycyrrhizae Radix et Rhizoma, roasted), Xixin (Asari Radix et Rhizoma) — each 3 qian; Zhimu (Anemarrhenae Rhizoma), Chuanxiong (Ligusticum Chuanxiong Rhizoma), Shengdihuang (Rehmanniae Radix) — each 1 liang.
Process the herbs by chopping. Take 0.5 liang per dose, add 2 cups of water, decoct until 1.5 cups remain, strain, and obtain 1 large cup of clear liquid. Drink hot. If the condition does not resolve, administer another 3–4 cups. Stop when resolved. If residual symptoms persist, follow Zhang Zhongjing’s method of treating according to the affected meridian.

[Wu Kun’s View] Liang Gan is considered fatal and untreatable because within one day, two meridians are transmitted, affecting both Yin and Yang simultaneously. Urgently treating the Yang aspect is complicated by the urgency of the Yin aspect, and vice versa. Exterior and Interior cannot be attacked simultaneously, and Yin and Yang cannot be treated with a single method; hence, it is deemed untreatable. The *Huo Ren Shu* proposes a sequential method: urgently rescue the Interior with Sini Tang, then rescue the Exterior with Guizhi Tang. This applies to cases where both Exterior and Interior are Cold, representing an emergency rescue protocol, not the protocol for transmission to two meridians in one day. The *Baoming Ji* (Collection for Preserving Life) states: Internal injury from Cold, external injury from Wind; or internal injury from Food, external injury from Wind; or prior injury from Dampness followed by Wind; or prior injury from Wind followed by Dampness; or prior injury from Cold followed by Wind. These constitute simultaneous internal-external and Exterior-Interior injuries, which are treatable, thus making Da Qianghuo Tang appropriate. Occasionally, survival is possible. Do Yilao (Li Dongyuan) and Danxi (Zhu Zhenheng) truly surpass Zhang Zhongjing in wisdom?