伤寒有六经之证，有六经之脉，证脉井然不杂，则可直指为某经之病。若两经、三经，阴阳混淆，不可以
一经名者；或一经未罢又传一经，二经、三经同病，不归并一经者，则名曰合病。或二经、三经同病，其后
归并一经自病者，则名曰并病。论中所着合病、并病，虽单举阳经，未及阴经，然阳经既有合病、并病，则阴
经亦必有之可知矣。如太阳病脉反沉，少阴病反发热，是少阴、太阳合病也；阳明病脉迟，太阴病大实痛，是
太阳、阳明合病也；少阳病脉细而厥，厥阴病呕而发热，是厥阴、少阳合病也；少阳病脉细而厥，厥阴病呕而
发热，是厥阴、少阳合病也。是虽无合病之名，而确有合病之实。且三阳皆有发热证，三阴皆有下利证，如发
热而下利，是阴阳合病也。阴阳合病，若阳盛者属阳经，则下利为实热，即论中所谓太阳阳明、阳明少阳、太
阳少阳合病者是也。阴盛者属阴经，则下利为虚寒，即论中所谓少阴下利反发热不死，少阴下利清谷，里寒外
热，不恶寒而面赤者是也。盖阳与阳合，不合于阴，为三阳合病，则不下利而自汗出，乃白虎汤证也；阴与阴
合，不合于阳，为三阴合病，则不发热而吐利厥逆，乃四逆汤证也。诚以人之脏腑互根，阴阳相合，三阳既有
合并之病，则三阴亦有合并之病，不待言矣。
太阳与阳明合病者，必自下利，葛根汤主之。太阳与阳明合病，不下利，但呕者，葛根加半夏汤主之。
【注】一经未罢，又传一经，二经、三经同病，而不归并一经者，谓之合病。太阳与阳明合病者，谓太
阳之发热，恶寒无汗与阳明之烦热不得眠等证，同时均病，表里之气，升降失常，故不下利，则上呕也。治法
只须先解太阳之表，表解而阳明之里自和矣。若利，则宜葛根汤表而升之，利自可止；呕则加半夏，表而降之，
呕自可除也。
【集注】成无己曰∶邪气外盛，阳不主里，则里气不和。里气下而不上者，但利而不呕；里气上逆而不下
者，但呕而不利，故以葛根汤以散表邪，加半夏以下逆气也。
葛根汤方
葛根（四两） 麻黄（去节，三两） 桂枝（二两） 芍药（二两） 甘草（炙，二两） 生姜（切，三两） 大枣
（擘，十二枚）
上七味， 咀，以水一斗，先煮麻黄、葛根，减二升，去沫，纳诸药，煮取三升，温服一升，覆取微似汗，
不须啜粥，余如桂枝法将息及禁忌。
葛根加半夏汤方
于葛根汤内，加半夏半升，余根据葛根汤法。
【方解】是方即桂枝汤加麻黄、葛根也。麻黄佐桂枝，发太阳荣卫之汗；葛根君桂枝，解阳明肌表之邪。
不曰桂枝汤加麻黄葛根，而以葛根命名者，其意重在阳明，以呕利多属阳明也。二阳表急，非温服覆而取汗，
其表未易解也。或呕，或利，里已失和，虽啜粥而胃亦不能输精于皮毛，故不须啜粥也。
【集解】柯琴曰∶李杲定为阳明经药，洁古云∶未入阳明者，不可便服。岂二子未读仲景书耶？要之葛根、
桂枝，俱是解肌和里
之剂，故有汗、无汗，下利、不下利，俱可用，与麻黄之专于发表者不同也。
汪琥曰∶《外台方议》问曰∶经云下利不可发汗，发汗则胀满。今此下利又发汗者何也？答曰∶少阴病下
利清谷者，为里虚，若更发汗，则脾虚而胀。今太阳病未罢，或有头痛、恶风寒等证，尚在于表，其脉尚带浮，
便传入阳明而有口渴、身热等证，又自下利，必须此方发散太阳之表，以中有葛根能除阳明之邪也。故诸证但
发热，兼有里而脉浮者，此方最善。
太阳与阳明合病，喘而胸满者，不可下，宜麻黄汤。
【注】太阳阳明合病，不利不呕者，是里气实不受邪也。若喘而胸满，是表邪盛，气壅于胸肺间也。邪在
高分之表，非结胸也，故不可下，以麻黄汤发表通肺，喘满自愈矣。
【集注】喻昌曰∶两经合病，当用两经之药，何得专用麻黄汤耶？盖太阳、阳明两邪相合，邪攻其胃，不
呕则利，故用葛根汤。今邪攻其肺所以喘而胸满，麻黄杏仁者，肺气喘逆之专药也。
魏荔彤曰∶二经合病，独见证于胸肺之间，喘而作满，此正二经之表邪为患，不可误认胸膈属里，妄施攻
下，如大、小陷胸之类也。
太阳与少阳合病，自下利者，与黄芩汤；若呕者，黄芩加半夏生姜汤主之。
【注】太阳与少阳合病，谓太阳发热、恶寒，与少阳寒热往来等证并见也，若表邪盛，肢节烦疼，则宜与
柴胡桂枝汤，两解其表矣。今里热盛而自下利，则当与黄芩汤清之，以和其里也。若呕者，更加半夏、生姜，
是清和之中兼降法也。
【集注】程知曰∶言太阳、少阳合病下利，宜用和法也。曰太阳则尚有表证也。然已见下利，则入里之热
已明，故不解外而清内。成无己云∶太阳阳明合病，下利为在表，当与葛根汤；阳明少阳合病，下利为在里，
可与承气汤。此太阳、少阳合病，下利为在半表半里，非汗下所宜，故与黄芩、芍药以和解之。呕者，邪上逆
也。故加半夏、生姜以散逆气。
汪琥曰∶太少合病而至下利，而在表之寒邪，悉入而为里热矣。里热不实，故与黄芩汤以清里热，使里
热清而在表之邪自和矣。所以此条病，不但太阳桂枝在所当禁，并少阳柴胡亦不须用也。
黄芩汤方
黄芩（三两） 甘草（炙，二两） 芍药（二两） 大枣（擘，十二枚）
上四味，以水一斗，煮取三升，去滓，温服一升，日再服，夜一服。
黄芩加半夏生姜汤方
于黄芩汤方内，加半夏半升，生姜三两，余根据黄芩汤法。
【方解】里热不和，故自下利，用黄芩清热，甘草和中，得芍药、大枣其功倍焉，热清里和，而利可止。
【集解】柯琴云∶因热不在半表，故不用柴胡；热已入半里，故入黄芩加芍药也。非微弱胃虚，不须人
参。若兼呕者，仍加半夏、生姜可也。
阳明、少阳合病，必下利。其脉不负者为顺也；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。
【注】阳明属土，少阳属土，二经偏里，故合病必下利也。阳明脉大，少阳脉弦，脉得大弦，是为本脉，
宜黄芩汤清热和土，兼泻木邪，利自止矣，若脉单大不弦，则为土不受邪，其病易愈，名为顺也；单弦不大，
则为木来克土，其病难治，名为负也。今脉不大，弦而滑数，则知非木土为害，乃宿食为病之热利也，故不用
黄芩汤，而以大承气汤
下之也。太阳、阳明合病下利，表证居多，故以葛根汤发之；阳明、少阳合病下利，里证居多，故以大承气汤
攻之；太阳、少阳合病下利，半表半里居多，故以黄芩汤和之。若非合病，则桂枝汤、麻黄汤分主太阳之表，
五苓散、抵当汤分主太阳之里；葛根汤主阳明之表，三承气汤主阳明之里；小柴胡汤主少阳之表，大柴胡汤主
少阳之里。是各有专司也。
【集注】张兼善曰∶凡合病皆下利，各从外证以别焉。夫太阳病，头项痛，腰脊强；阳明病，目痛鼻干，
不得卧；少阳病，胸胁痛，耳聋。凡遇两经病证齐见而下利者，曰合病也。然两经但各见一二证便是，不必悉具。
林澜曰∶此节是三证在内，大承气只治得脉滑而数有宿食之证，非并治上两证也。其脉不负者，虽下利而
脉未至纯弦也，不言治法。陶华谓尝以小柴胡加葛根白芍治之，取效如拾芥是也。负者，脉纯弦也，土败但见
鬼贼之脉，不必治矣。盖虽同是阳明之合病，而有入经在腑之殊，安可以在经之际，概归之承气乎？
三阳合病，脉浮大上关上，但俗眠睡，目合则汗。
【按】浮大上之“上”字，当是“弦”字，始合论中三阳合病之脉。若是“上”字，则经论中从无两寸脉，
主三阳病之理。
【注】脉浮大弦，三阳合病之脉也。浮大弦皆见于关上，知三阳之热邪，皆聚于阳明也。热聚阳明，则当
烦不得眠，今但欲眠睡，是热盛神昏之昏睡也，昏睡自然目合，热蒸则汗自出也。若施治得宜，使邪还于表而
解，否则未可卜也，宜以柴胡、桂枝、白虎三汤，酌其所当，合而用之可也。
【集注】方有执曰∶太阳脉浮，阳明脉大，关上乃少阳之部位，故曰∶三阳合病。
魏荔彤曰∶诊其脉浮为太阳，大为阳明，其长上于关上，则弦可知矣。弦又为少阳，是三阳之经同受邪，
所以三阳之脉同见病。如此再谛之于证，但欲眠睡非少阴也，乃阳盛神昏之睡也，及目合则汗出，是阳胜争于
阴中之汗出也。
三阳合病，腹满身重，难以转侧，口不仁，面垢，谵语，遗尿。发汗则谵语；下之则额上生汗，手足逆冷。
若自汗出者，白虎汤主之。
【注】此承上条复详其证，以明其治也。三阳合病者，太阳、阳明、少阳合而为病也。必太阳之头痛、发
热，阳明之恶热、不眠，少阳之耳聋、寒热等证皆具也。太阳主背，阳明主腹，少阳主侧，今一身尽为三阳热
邪所困，故身重难以转侧也，胃之窍出于口，热邪上攻，故口不仁也。阳明主面，热邪蒸越，故面垢也。热结
于里则腹满；热盛于胃，故谵语也。热迫膀胱则遗尿；热蒸肌腠，故自汗出。证虽属于三阳，而热皆聚胃中，
故当从阳明热证主治也。若从太阳之表发汗，则津液愈竭，而胃热愈深，必更增谵语；若从阳明之里下之，则
阴益伤而阳无根据则散，故额汗肢冷也。要当审其未经汗下，而身热自汗出者，始为阳明的证，宜主以白虎汤，
大清胃热，急救津液，以存其阴可也。
【集注】汪琥曰∶或问白虎汤何以能解三阳之热？答云∶病至自汗出，则太少之邪总归阳明矣，安得不从
阳明而专治之耶？
郑重光曰∶三阳合病，表里俱伤也。发汗偏攻太阳，则邪并于阳明而谵语益甚。攻下偏治阳明，则额上生
汗，汗出不流，手足厥冷，必成亡阳之证。然则既不宜于汗下，惟有白虎一汤，两解阳明表里之热。若无自汗，
表犹未解，尚不可用此条，当与 证参治也。
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、熏之。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，更发汗则愈，何以知汗出不彻？以脉涩故知也。
【按】当解之下“熏之”二字，当是“以汗”二字，始与上下文义相属。
【注】一经未罢，又传一经，同病而后归并一经自病者，名曰并病。二阳者，太阳、阳明也。太阳初得病
时发汗，汗出不彻，未尽之邪，因而转属阳明，若续自微微汗出，不恶寒反恶热，始为阳明可下之证。若不微
微汗出，而恶寒者，则是太阳之表犹未罢，不可下也，下之为逆矣。如已经发汗，尚有未尽之表，宜仍与麻桂
各半汤，或桂枝二越婢一汤，小小发汗，以和其表，自可解也。缘缘，接连不已也。正赤，不杂他色也，谓满
面接连赤色不已也。此由于汗出不彻，故阳气怫郁不得宣越，所以其人烦躁短气，脉涩，不知痛处，乍在腹中，
乍在四肢，求之而不可得也。是皆邪气壅甚于经，漫无出路，但坐经汗出不彻之故耳。当更用大青龙汤或葛
根汤，发其汗则愈矣。
【按】面赤一证，劳损颧红，发于午后者，骨蒸阴虚也。格阳浮赤，兼厥利脉微者，阳虚也。赤色深重，
潮热便硬，里实也。赤色浅淡，恶寒无汗，表实也。短气脉涩，内因多气血虚，若外因短气，必气粗，是汗出
不彻，邪气壅促胸中，不能布息之短气，非过汗伤气，气乏不足续息之短气也。外因脉涩必有力，是汗出不彻，
邪气壅滞，荣卫不能流通之脉涩，非过汗伤液，液少不滋脉道之脉涩也。
【集注】王肯堂曰∶因病太阳，故当汗；因病阳明，故当小汗。先字最有次第，乃仲景之枢机也。下之以
大、小承气，汗之以麻黄等汤。
程应旄曰∶太阳既转属阳明，宜从阳明治矣。然恐转递之处，表邪去尚未尽，里邪乘其未深，两邪相持，
而前后互见，是曰并病。纵使表少里多，终是带表之阳明也。太阳不应有腹痛，以邪无出路，意欲内攻，故乍
在仍不知其处。
林澜曰∶汗不彻者，脉必涩，非再汗邪奚自去乎？是知未汗则为并病，已汗即为转属阳明。未汗则为阳气
怫郁在表，已汗则为汗出不彻。汗不彻者，必更汗之；转属者，必下除之；未汗者，可小发汗；怫郁者，可解
之以汗。邪由不同，为病自不同，故施治亦不同耳。
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。
【注】二阳并病，太阳、阳明同病也。太阳证罢，尽归并于阳明，所以但发潮热，手足 汗出，大便难
而谵语也，是皆阳明胃实之证，故下之则愈，宜大承气汤。
【集注】喻昌曰∶并病二条，皆是太阳、阳明。上条初入阳明，太阳之邪未彻，故仍宜汗之；此条已入阳
明，太阳证罢，而尽归并阳明，故宜下之。
伤寒病有六经的证候，也有六经的脉象。如果证候与脉象条理清晰、互不混杂，就可以直接指明为某一经的病证。如果是两经或三经同时发病，阴阳症状混淆，不能仅用一经来命名的；或者一经的病证尚未痊愈，又传变到另一经，导致二经、三经同时患病，且不归并于单一经的，这种病证称为“合病”。如果是二经、三经同时患病，随后病邪归并到一经而单独发病的，这种病证称为“并病”。《伤寒论》中论述的合病、并病，虽然只列举了阳经，未涉及阴经，但既然阳经存在合病、并病，那么阴经也必然存在合病、并病，这是可以推知的。例如：太阳病（太阳经受邪所致的病证）脉象反而沉，少阴病（少阴经受邪所致的病证）反而发热，这是少阴与太阳合病；阳明病（阳明经受邪所致的病证）脉象迟，太阴病（太阴经受邪所致的病证）出现大实痛，这是太阳与阳明合病；少阳病（少阳经受邪所致的病证）脉细且四肢厥冷，厥阴病（厥阴经受邪所致的病证）呕吐且发热，这是厥阴与少阳合病；少阳病脉细且四肢厥冷，厥阴病呕吐且发热，这是厥阴与少阳合病。这些情况虽然没有合病的名称，但确实具有合病的实质。况且三阳经都有发热的证候，三阴经都有下利的证候，如既发热又下利，这就是阴阳合病。阴阳合病，如果阳气偏盛属于阳经，则下利属于实热，即《伤寒论》中所说的太阳阳明合病、阳明少阳合病、太阳少阳合病等就是这种情况。如果阴气偏盛属于阴经，则下利属于虚寒，即《伤寒论》中所说的少阴下利反而发热不死、少阴下利排出未消化的食物、里有寒气外有假热、不恶寒而面部发红等就是这种情况。大概阳与阳相合，不与阴相合，成为三阳合病，则不下利而自汗出，这是白虎汤证；阴与阴相合，不与阳相合，成为三阴合病，则不发热而呕吐下利、四肢厥逆，这是四逆汤证。诚然，人的脏腑互为根本，阴阳相互结合，三阳既有合并的病证，那么三阴也有合并的病证，是不言而喻的。
太阳经与阳明经合病者，必定自发性下利，主治方剂为葛根汤（Pueraria Decoction）。太阳经与阳明经合病，若不下利，只是呕吐的，主治方剂为葛根加半夏汤（Pueraria and Pinellia Decoction）。
【注】一经的病证尚未痊愈，又传变到另一经，二经、三经同时患病，且不归并于单一经的，称为合病。太阳经与阳明经合病，是指太阳经的发热、恶寒、无汗与阳明经的烦热、不得安眠等证候，同时均出现。表里之气升降失常，所以若不下利，就会上逆而呕吐。治疗方法只需先解除太阳经的表邪，表邪解除后，阳明经的里气自然调和。如果有下利，适宜用葛根汤发表并升提清气，下利自然可止；如果有呕吐，则加入半夏，在解表的同时降逆气，呕吐自然可消除。
【集注】成无己说：邪气在外强盛，阳气不能主司里气，导致里气不和。里气下行而不向上逆的，只有下利而没有呕吐；里气上逆而下行的，只有呕吐而没有下利，所以用葛根汤来疏散表邪，加入半夏来降逆气。
葛根汤方
葛根（四两） 麻黄（去节，三两） 桂枝（二两） 芍药（二两） 甘草（炙，二两） 生姜（切，三两） 大枣（擘开，十二枚）
以上七味药，切碎，用水一斗，先煮麻黄、葛根，减少二升水，撇去浮沫，加入其余药物，煮取三升药液，温服一升，服药后覆盖衣被使身体微微出汗，不需要喝热粥，其余调养方法及禁忌同桂枝汤法。
葛根加半夏汤方
在葛根汤的基础上，加入半夏半升，其余按照葛根汤的方法煎服。
【方解】这个方子就是桂枝汤（Cinnamon Twig Decoction）加上麻黄、葛根。麻黄辅助桂枝，发散太阳经营卫之汗；葛根作为君药配合桂枝，解除阳明经肌表的邪气。之所以不叫桂枝汤加麻黄葛根，而以葛根命名，是因为其用意重在阳明经，因为呕吐和下利多属于阳明经病变。二阳经表证紧急，如果不温服并覆盖衣被以取汗，表邪不易解除。或者呕吐，或者下利，里气已经失和，即使喝热粥，胃也不能输布精气于皮毛，所以不需要喝热粥。
【集解】柯琴说：李杲将其定为阳明经药，洁古说：邪气未入阳明者，不可立即服用。难道这两位先生没有读过仲景的书吗？总之，葛根、桂枝，都是解肌和里的药剂，所以无论有汗、无汗，下利、不下利，都可以使用，这与麻黄专于发表不同。
汪琥说：《外台方议》问道：经文说下利不可发汗，发汗则会导致胀满。现在此条下利又要发汗，为什么呢？回答说：少阴病下利排出未消化食物的，属于里虚，如果再发汗，则脾虚而胀满。现在太阳病尚未痊愈，或者有头痛、恶风寒等证候，尚在于体表，脉象还带浮象，便传入阳明而有口渴、身热等证候，又自发性下利，必须用此方发散太阳之表，因为方中含有葛根能祛除阳明之邪。所以各种证候只要发热，兼有里证而脉浮的，此方最为适宜。
太阳经与阳明经合病，出现气喘且胸部胀满的，不可用攻下法，适宜用麻黄汤（Ephedra Decoction）。
【注】太阳与阳明合病，不下利也不呕吐的，说明里气充实不受邪气侵犯。如果出现气喘且胸部胀满，是表邪强盛，气机壅塞于胸肺之间。邪气在高位的体表，不是结胸证，所以不可攻下，应用麻黄汤发表通肺，气喘胀满自然痊愈。
【集注】喻昌说：两经合病，应当用两经的药物，怎么能专用麻黄汤呢？盖因太阳、阳明两邪相合，邪气攻击胃部，不呕吐就下利，所以用葛根汤。现在邪气攻击肺部，所以气喘且胸部胀满，麻黄、杏仁是治疗肺气喘逆的专用药物。
魏荔彤说：二经合病，唯独见证于胸肺之间，气喘且感到胀满，这正是二经的表邪为患，不可误认胸膈属里，妄施攻下法，如大陷胸汤、小陷胸汤之类。
太阳经与少阳经合病，自发性下利的，给予黄芩汤（Scutellaria Decoction）；如果呕吐的，主治方剂为黄芩加半夏生姜汤（Scutellaria, Pinellia and Ginger Decoction）。
【注】太阳与少阳合病，是指太阳经的发热、恶寒，与少阳经的寒热往来等证候并见。如果表邪强盛，肢体关节烦疼，则适宜用柴胡桂枝汤（Bupleurum and Cinnamon Twig Decoction），两解其表邪。现在里热盛而自发性下利，则应当用黄芩汤清解里热，以调和里气。如果呕吐，再加半夏、生姜，这是在清和之中兼用降逆之法。
【集注】程知说：这里说的是太阳、少阳合病下利，适宜用和解法。提到太阳，说明还有表证。但既然已见下利，说明入里的热邪已经明确，所以不解表而清里。成无己说：太阳阳明合病，下利属于在表，当用葛根汤；阳明少阳合病，下利属于在里，可用承气汤。此条太阳、少阳合病，下利属于在半表半里，不适合汗法和下法，所以用黄芩、芍药来和解。呕吐，是邪气上逆。所以加半夏、生姜来散逆气。
汪琥说：太阳、少阳合病而至下利，而在表的寒邪，全部入里化为热邪了。里热不实，所以用黄芩汤清里热，使里热清除而在表的邪气自然调和。所以此条病证，不但太阳经的桂枝汤在所禁忌，连少阳经的柴胡汤也不需要用了。
黄芩汤方
黄芩（三两） 甘草（炙，二两） 芍药（二两） 大枣（擘开，十二枚）
以上四味药，用水一斗，煮取三升，去渣，温服一升，每日两次，夜间一次。
黄芩加半夏生姜汤方
在黄芩汤方内，加入半夏半升，生姜三两，其余按照黄芩汤的方法煎服。
【方解】里热不和，所以自发性下利，用黄芩清热，甘草和中，得到芍药、大枣的配合，功效加倍，热清里和，下利即可停止。
【集解】柯琴说：因为热不在半表，所以不用柴胡；热已入半里，所以加入黄芩、芍药。如果不是胃气微弱虚弱，就不需要人参。如果兼有呕吐，仍然可以加半夏、生姜。
阳明经与少阳经合病，必定下利。脉象不负者为顺证；负者为逆证。互相克贼，称为负。脉滑而数的，是有宿食，应当攻下，适宜用大承气汤（Major Emodi Decoction）。
【注】阳明属土，少阳属木（注：原文此处有误，少阳属胆木，阳明属胃土，原文写“少阳属土”应为笔误或特定语境下的五行生克论述偏差，通常少阳为甲木/胆，阳明为戊土/胃，木克土。但根据下文“木来克土”，此处应理解为少阳木邪克阳明土），二经偏里，所以合病必定下利。阳明脉大，少阳脉弦，脉得大弦，是本脉，适宜用黄芩汤清热和土，兼泻木邪，下利自然停止。如果脉单大不弦，则为土不受邪，病易愈，称为顺证；如果脉单弦不大，则为木来克土，病难治，称为负证。现在脉不大，弦而滑数，则知道不是木土相害，而是宿食引起的热利，所以不用黄芩汤，而用大承气汤攻下。太阳、阳明合病下利，表证居多，所以用葛根汤发散；阳明、少阳合病下利，里证居多，所以用大承气汤攻下；太阳、少阳合病下利，半表半里证居多，所以用黄芩汤和解。如果不是合病，则桂枝汤、麻黄汤分别主治太阳经的表证，五苓散、抵当汤分别主治太阳经的里证；葛根汤主治阳明经的表证，三承气汤主治阳明经的里证；小柴胡汤主治少阳经的表证，大柴胡汤主治少阳经的里证。这是各有专门的主治范围。
【集注】张兼善说：凡是合病都会下利，各自从外部证候来辨别。太阳病，头项痛，腰脊强直；阳明病，目痛鼻干，不得安卧；少阳病，胸胁痛，耳聋。凡是遇到两经病证同时出现而下利的，称为合病。然而两经只要各见一二个证候即可，不必全部具备。
林澜说：这一节包含三个证候在内，大承气汤只治疗脉滑而数有宿食的证候，并非一并治疗上面两个证候。脉不负者，虽然下利但脉象未到纯弦的程度，文中未言治法。陶华说曾用小柴胡汤加葛根、白芍治疗，取得效果如拾芥般容易。负者，脉象纯弦，土败只见鬼贼之脉，不必治疗了。虽然同为阳明之合病，但有入经在腑的区别，怎么可以在入经的时候，一概归之于承气汤呢？
【按】浮大上之“上”字，应当是“弦”字，才符合《伤寒论》中三阳合病的脉象。如果是“上”字，则经论中从无两寸脉主三阳病的道理。
【注】脉浮大弦，是三阳合病的脉象。浮大弦都见于关上，知道三阳的热邪，都聚集在阳明经。热聚阳明，则应当烦躁不得安眠，现在只想睡觉，是热盛神昏的昏睡，昏睡自然闭眼，热蒸腾则汗自出。如果施治得当，使邪气还于表而解，否则结果不可预测，适宜用柴胡汤、桂枝汤、白虎汤三汤，斟酌其所应当，合而用之即可。
【集注】方有执说：太阳脉浮，阳明脉大，关上是少阳的部位，所以说：三阳合病。
魏荔彤说：诊其脉浮为太阳，大为阳明，其长上于关上，则弦可知矣。弦又为少阳，是三阳之经同受邪，所以三阳之脉同见病。如此再审视于证候，只想睡觉不是少阴病，乃是阳盛神昏的睡，及闭眼则汗出，是阳胜争于阴中之汗出。
三阳合病，腹部胀满，身体沉重，难以翻身转侧，口不知味，面色垢浊，说胡话，遗尿。发汗则说胡话更甚；攻下则额头出汗，手足逆冷。如果自汗出的，主治方剂为白虎汤（Tiger Bone Decoction / White Tiger Decoction）。
【注】这是承接上一条详细阐述其证候，以明确其治法。三阳合病，是太阳、阳明、少阳合而为病。必定具备太阳的头痛、发热，阳明的恶热、不眠，少阳的耳聋、寒热等证候。太阳主背，阳明主腹，少阳主侧，现在全身尽为三阳热邪所困，所以身体沉重难以翻身转侧，胃的窍出于口，热邪上攻，所以口不知味。阳明主面，热邪蒸越，所以面色垢浊。热结于里则腹部胀满；热盛于胃，所以说胡话。热迫膀胱则遗尿；热蒸肌腠，所以自汗出。证候虽属于三阳，而热皆聚于胃中，所以应当从阳明热证主治。如果从太阳之表发汗，则津液更加枯竭，而胃热更深，必定更增加说胡话；如果从阳明之里攻下，则阴液更加受伤而阳无所依则散失，所以额头出汗、肢冷。要审察其未经过汗法和下法，而身热自汗出的，才是阳明的证候，适宜主以白虎汤，大清胃热，急救津液，以保存阴液即可。
【集注】汪琥说：有人问白虎汤何以能解三阳之热？回答说：病至自汗出，则太阳、少阳的邪气总归阳明了，怎能不从阳明而专治它呢？
郑重光说：三阳合病，表里俱伤。发汗偏攻太阳，则邪气并入阳明而说胡话更严重。攻下偏治阳明，则额头出汗，汗出不流，手足厥冷，必成亡阳之证。既然如此，既不宜于汗法和下法，惟有白虎汤一汤，两解阳明表里之热。如果没有自汗，表邪仍未解，尚不可用此条，应当与其他证候参合治疗。
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，继续自微汗出、不恶寒。如果太阳证候未罢的，不可攻下，攻下为逆，像这样可以用小发汗法。假设面色缘缘正赤的，阳气怫郁在表，应当解表、熏蒸。如果发汗不透彻，不足以言，阳气怫郁不得宣越，当汗不汗，其人躁烦，不知道疼痛的具体部位，一会儿在腹中，一会儿在四肢，按压找不到痛点，其人短气，只能坐着，是因为汗出不透彻的缘故，再次发汗则痊愈，怎么知道汗出不透彻？因为脉涩所以知道。
【按】当解之下“熏之”二字，应当是“以汗”二字，才与上下文义相属。
【注】一经的病证尚未痊愈，又传变到另一经，同病而后归并一经单独发病的，称为并病。二阳者，太阳、阳明也。太阳初得病时发汗，汗出不透彻，未尽之邪气，因而转属阳明，如果继续自微微汗出，不恶寒反恶热，始为阳明可攻下的证候。如果不微微汗出，而恶寒的，则是太阳之表犹未罢，不可攻下，攻下为逆了。如已经发汗，尚有未尽之表邪，适宜仍用麻黄桂枝各半汤，或桂枝二越婢一汤，小小发汗，以调和其表，自然可解。缘缘，接连不已也。正赤，不杂他色也，谓满面接连赤色不已也。这是由于汗出不透彻，故阳气怫郁不得宣越，所以其人烦躁短气，脉涩，不知道疼痛部位，一会儿在腹中，一会儿在四肢，求之而不可得也。这些都是邪气壅盛于经脉，漫无出路，只是由于汗出不透彻的缘故罢了。应当再用大青龙汤或葛根汤，发其汗则痊愈了。
【按】面赤一证，劳损颧红，发于午后的，是骨蒸阴虚。格阳浮赤，兼厥利脉微的，是阳虚。赤色深重，潮热便硬的，是里实。赤色浅淡，恶寒无汗的，是表实。短气脉涩，内因多气血虚，若外因短气，必气粗，是汗出不彻，邪气壅促胸中，不能布息之短气，非过汗伤气，气乏不足续息之短气也。外因脉涩必有力，是汗出不彻，邪气壅滞，营卫不能流通之脉涩，非过汗伤液，液少不滋脉道之脉涩也。
【集注】王肯堂说：因病太阳，故当汗；因病阳明，故当小汗。先字最有次第，乃仲景之枢机也。下之以大、小承气，汗之以麻黄等汤。
程应旄说：太阳既转属阳明，宜从阳明治矣。然恐转递之处，表邪去尚未尽，里邪乘其未深，两邪相持，而前后互见，是曰并病。纵使表少里多，终是带表之阳明也。太阳不应有腹痛，以邪无出路，意欲内攻，故乍在仍不知其处。
林澜说：汗不彻者，脉必涩，非再汗邪奚自去乎？是知未汗则为并病，已汗即为转属阳明。未汗则为阳气怫郁在表，已汗则为汗出不彻。汗不彻者，必更汗之；转属者，必下除之；未汗者，可小发汗；怫郁者，可解之以汗。邪由不同，为病自不同，故施治亦不同耳。
二阳并病，太阳证候罢，只发潮热，手足濈然汗出，大便难而说胡话的，攻下则痊愈，适宜用大承气汤。
【注】二阳并病，太阳、阳明同病也。太阳证候罢，尽归并于阳明，所以只发潮热，手足濈然汗出，大便难而说胡话也，这都是阳明胃实的证候，所以攻下则痊愈，适宜用大承气汤。
【集注】喻昌说：并病二条，皆是太阳、阳明。上条初入阳明，太阳之邪未彻，故仍宜汗之；此条已入阳明，太阳证罢，而尽归并阳明，故宜下之。
Typhoid fever presents with the syndromes of the Six Channels (Liu Jing), as well as the pulses of the Six Channels. If the syndromes and pulses are distinct and non-mixed, one can directly identify it as a disease of a specific channel. However, if two or three channels are involved simultaneously, with Yin and Yang symptoms confused such that it cannot be named after a single channel; or if a disease in one channel has not yet resolved before transmitting to another channel, resulting in simultaneous involvement of two or three channels without merging into a single channel, this is termed "He Bing" (Combined Disease). If two or three channels are involved simultaneously, but subsequently the pathogen merges into one channel to manifest independently, this is termed "Bing Bing" (Consecutive Disease). Although the Treatise only mentions He Bing and Bing Bing for the Yang channels and does not explicitly address the Yin channels, given that He Bing and Bing Bing exist for the Yang channels, it can be inferred that they also exist for the Yin channels. For example: Taiyang disease (Disease of the Taiyang Channel) presenting with a pulse that is unexpectedly deep, and Shaoyin disease (Disease of the Shaoyin Channel) presenting with unexpected fever, constitutes a combined disease of Shaoyin and Taiyang; Yangming disease (Disease of the Yangming Channel) presenting with a slow pulse, and Taiyin disease (Disease of the Taiyin Channel) presenting with severe abdominal pain due to excess, constitutes a combined disease of Taiyang and Yangming; Shaoyang disease (Disease of the Shaoyang Channel) presenting with a fine pulse and cold extremities, and Jueyin disease (Disease of the Jueyin Channel) presenting with vomiting and fever, constitutes a combined disease of Jueyin and Shaoyang. Although these cases lack the name "combined disease," they indeed possess the reality of combined disease. Furthermore, all Three Yang channels have fever syndromes, and all Three Yin channels have diarrhea syndromes. For instance, simultaneous fever and diarrhea constitute a combined disease of Yin and Yang. In a combined disease of Yin and Yang, if Yang is predominant and belongs to the Yang channels, the diarrhea is due to excess-heat; this corresponds to what the Treatise calls combined diseases of Taiyang-Yangming, Yangming-Shaoyang, and Taiyang-Shaoyang. If Yin is predominant and belongs to the Yin channels, the diarrhea is due to deficiency-cold; this corresponds to what the Treatise describes as Shaoyin diarrhea with unexpected fever (indicating survival), Shaoyin diarrhea with undigested food, interior cold with exterior false heat, aversion to cold absent but facial redness present. Generally, when Yang combines with Yang without involving Yin, forming a combined disease of the Three Yang channels, there is no diarrhea but spontaneous sweating, which is a syndrome for Baihu Tang (White Tiger Decoction). When Yin combines with Yin without involving Yang, forming a combined disease of the Three Yin channels, there is no fever but vomiting, diarrhea, and cold extremities, which is a syndrome for Sini Tang (Frigid Extremities Decoction). Indeed, human Zang-Fu organs are mutually rooted, and Yin and Yang interact. Since there are combined diseases of the Three Yang channels, it goes without saying that there are also combined diseases of the Three Yin channels.
In a combined disease of Taiyang and Yangming channels, spontaneous diarrhea will inevitably occur; Gegen Tang (Pueraria Decoction) is the primary formula. In a combined disease of Taiyang and Yangming channels, if there is no diarrhea but only vomiting, Gegen Jia Banxia Tang (Pueraria and Pinellia Decoction) is the primary formula.
[Annotation] When a disease in one channel has not yet resolved before transmitting to another, resulting in simultaneous involvement of two or three channels without merging into a single channel, it is called He Bing (Combined Disease). A combined disease of Taiyang and Yangming refers to the simultaneous occurrence of Taiyang symptoms such as fever, aversion to cold, and anhidrosis, with Yangming symptoms such as irritability, heat, and insomnia. The ascending and descending of Wei Qi (Defensive Qi) and Ying Qi (Nutritive Qi) between the exterior and interior become disordered. Therefore, if there is no diarrhea, there will be upward reversal leading to vomiting. The treatment method requires first resolving the exterior of the Taiyang channel; once the exterior is resolved, the interior of the Yangming channel will naturally harmonize. If diarrhea occurs, Gegen Tang should be used to release the exterior and lift clear Yang, and the diarrhea will stop; if vomiting occurs, Banxia (Pinelliae Rhizoma) should be added to descend rebellious Qi while releasing the exterior, and the vomiting will cease.
[Collected Annotations] Cheng Wuji stated: When pathogenic factors are strong on the exterior, Yang fails to govern the interior, causing interior disharmony. If interior Qi descends without reversing upward, there is only diarrhea without vomiting; if interior Qi reverses upward without descending, there is only vomiting without diarrhea. Therefore, Gegen Tang is used to scatter exterior pathogens, and Banxia is added to direct rebellious Qi downward.
Gegen Tang Formula
Gegen (Puerariae Radix, 4 liang), Mahuang (Ephedrae Herba, processed, 3 liang), Guizhi (Cinnamomi Ramulus, 2 liang), Shaoyao (Paeoniae Radix Alba, 2 liang), Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried, 2 liang), Shengjiang (Zingiberis Rhizoma Recens, sliced, 3 liang), Dazao (Ziziphi Jujubae Fructus, broken open, 12 pieces).
The above seven ingredients are coarsely crushed. Boil in 10 dou of water. First decoct Mahuang and Gegen, reduce by 2 dou, skim off the foam, then add the remaining herbs. Decoct to obtain 3 sheng of liquid. Take 1 sheng warm. Cover with blankets to induce slight sweating. There is no need to drink hot porridge. Other nursing care methods and contraindications follow those of Guizhi Tang.
Gegen Jia Banxia Tang Formula
To the Gegen Tang formula, add Banxia (Pinelliae Rhizoma, half sheng). All other procedures follow the Gegen Tang method.
[Formula Analysis] This formula is essentially Guizhi Tang (Cinnamon Twig Decoction) plus Mahuang and Gegen. Mahuang assists Guizhi to induce sweating from the Ying and Wei levels of the Taiyang channel. Gegen acts as the sovereign herb alongside Guizhi to resolve pathogens in the muscle layer of the Yangming channel. It is named Gegen Tang rather than Guizhi Tang plus Mahuang and Gegen because the emphasis is on the Yangming channel, as vomiting and diarrhea often belong to Yangming pathology. When both Yang channels have urgent exterior conditions, warm administration and covering to induce sweat are necessary, otherwise the exterior will not easily resolve. Whether vomiting or diarrhea occurs, the interior is already disharmonious. Even if hot porridge is consumed, the Stomach cannot transport essence to the skin and hair. Therefore, drinking hot porridge is unnecessary.
[Collected Exegesis] Ke Qin stated: Li Gao designated it as a medicine for the Yangming channel, and Jiegu said: Do not administer it immediately if the pathogen has not entered the Yangming channel. Did these two scholars not read Zhang Zhongjing's works? In essence, both Gegen and Guizhi are agents that resolve the muscle layer and harmonize the interior. Thus, they can be used whether there is sweating or not, and whether there is diarrhea or not, differing from Mahuang which is specialized for releasing the exterior.
Wang Hu stated: The *Waitai Fangyi* asks: The classic states that diarrhea should not be treated with sweating, as sweating leads to abdominal distension. Why is sweating indicated here for diarrhea? The answer is: In Shaoyin disease, diarrhea with undigested food indicates interior deficiency; further sweating would cause Spleen deficiency and distension. Here, the Taiyang disease has not yet resolved; there may still be headache, aversion to wind and cold, etc., indicating the pathogen is still at the exterior, and the pulse is still floating. It has transmitted to the Yangming channel, presenting with thirst, body heat, etc., accompanied by spontaneous diarrhea. One must use this formula to release the Taiyang exterior, because it contains Gegen which can eliminate Yangming pathogens. Therefore, for any condition featuring fever combined with interior signs and a floating pulse, this formula is most suitable.
In a combined disease of Taiyang and Yangming channels, characterized by wheezing and chest fullness, purgation is contraindicated; Mahuang Tang (Ephedra Decoction) is appropriate.
[Annotation] In a combined disease of Taiyang and Yangming, if there is no diarrhea or vomiting, it indicates that the interior Qi is solid and resistant to pathogens. If wheezing and chest fullness occur, it signifies that exterior pathogens are strong and Qi is congested in the chest and lungs. The pathogen is located in the high-level exterior, not constituting a Chest Bind (Jie Xiong); therefore, purgation is contraindicated. Use Mahuang Tang to release the exterior and unblock the Lungs; the wheezing and fullness will resolve spontaneously.
[Collected Annotations] Yu Chang stated: In a combined disease of two channels, medicines for both channels should be used. How can one use only Mahuang Tang? When pathogens from Taiyang and Yangming combine and attack the Stomach, if there is no vomiting, there is diarrhea; thus, Gegen Tang is used. Now, since the pathogen attacks the Lungs, causing wheezing and chest fullness, Mahuang and Xingren (Armeniacae Semen Amarum) are the specific drugs for treating Lung Qi rebellion and wheezing.
Wei Litong stated: In a combined disease of two channels, if symptoms manifest solely in the chest and lungs with wheezing and fullness, this is precisely the harm caused by exterior pathogens of the two channels. Do not mistakenly consider the chest and diaphragm as interior and recklessly apply purgative methods like Da Xianxiong Tang (Major Chest Bind Decoction) or Xiao Xianxiong Tang (Minor Chest Bind Decoction).
In a combined disease of Taiyang and Shaoyang channels, if there is spontaneous diarrhea, administer Huangqin Tang (Scutellaria Decoction); if there is vomiting, Huangqin Jia Banxia Shengjiang Tang (Scutellaria, Pinellia and Ginger Decoction) is the primary formula.
[Annotation] A combined disease of Taiyang and Shaoyang refers to the simultaneous appearance of Taiyang symptoms (fever, aversion to cold) and Shaoyang symptoms (alternating chills and fever). If exterior pathogens are strong, causing vexation and pain in the limbs and joints, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) should be used to resolve the exterior of both channels. Now, with strong interior heat causing spontaneous diarrhea, Huangqin Tang should be used to clear the heat and harmonize the interior. If vomiting occurs, add Banxia and Shengjiang, employing a descending method within the clearing and harmonizing approach.
[Collected Annotations] Cheng Zhi stated: This discusses diarrhea in a combined disease of Taiyang and Shaoyang, indicating the use of the Harmonizing Method. Mentioning Taiyang implies that exterior signs remain. However, since diarrhea is present, it is clear that heat has entered the interior. Therefore, instead of releasing the exterior, the interior is cleared. Cheng Wuji said: In a combined disease of Taiyang and Yangming, diarrhea indicates the pathogen is in the exterior, so Gegen Tang is used; in a combined disease of Yangming and Shaoyang, diarrhea indicates the pathogen is in the interior, so Chengqi Tang can be used. In this case of combined Taiyang and Shaoyang, diarrhea indicates the pathogen is in the half-exterior/half-interior region, making sweating and purgation inappropriate. Therefore, Huangqin and Shaoyao are used to harmonize. Vomiting indicates pathogenic Qi rebelling upward. Thus, Banxia and Shengjiang are added to disperse rebellious Qi.
Wang Hu stated: When a combined disease of Taiyang and Shaoyang leads to diarrhea, the exterior cold pathogens have all transformed into interior heat. Since the interior heat is not excessive accumulation, Huangqin Tang is used to clear the interior heat. Once the interior heat is cleared, the exterior pathogens will naturally harmonize. Therefore, for this condition, not only is Guizhi Tang for Taiyang contraindicated, but Chaihu Tang for Shaoyang is also unnecessary.
Huangqin Tang Formula
Huangqin (Scutellariae Radix, 3 liang), Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried, 2 liang), Shaoyao (Paeoniae Radix Alba, 2 liang), Dazao (Ziziphi Jujubae Fructus, broken open, 12 pieces).
The above four ingredients are boiled in 10 dou of water to obtain 3 sheng of liquid. Strain. Take 1 sheng warm, twice daily and once at night.
Huangqin Jia Banxia Shengjiang Tang Formula
To the Huangqin Tang formula, add Banxia (Pinelliae Rhizoma, half sheng) and Shengjiang (Zingiberis Rhizoma Recens, 3 liang). All other procedures follow the Huangqin Tang method.
[Formula Analysis] Interior heat disharmony causes spontaneous diarrhea. Huangqin clears heat, Gancao harmonizes the middle, and with the assistance of Shaoyao and Dazao, the efficacy is doubled. Once heat is cleared and the interior is harmonized, diarrhea stops.
[Collected Exegesis] Ke Qin stated: Because the heat is not in the half-exterior, Chaihu is not used; because the heat has entered the half-interior, Huangqin and Shaoyao are added. If the Stomach Qi is not weak and deficient, Renshen (Ginseng Radix) is not needed. If vomiting is concurrent, adding Banxia and Shengjiang is appropriate.
In a combined disease of Yangming and Shaoyang channels, diarrhea will inevitably occur. If the pulse is "not negative" (Fu), it is a favorable sign; if "negative," it is unfavorable. Mutual overcoming and robbing is termed "Negative." A slippery and rapid pulse indicates retained food; purgation is indicated, and Da Chengqi Tang (Major Emodi Decoction) is appropriate.
[Annotation] Yangming belongs to Earth, and Shaoyang belongs to Wood (Note: The original text says "Shaoyang belongs to Earth," which is likely a textual error or specific theoretical context, as Shaoyang is typically Wood/Gallbladder and Yangming is Earth/Stomach, with Wood overacting on Earth. The subsequent text clarifies "Wood coming to overcome Earth"). Both channels are偏向 interior, so combined disease inevitably leads to diarrhea. Yangming pulse is large, and Shaoyang pulse is wiry. A pulse that is both large and wiry represents the proper pulse for this combination. Huangqin Tang should be used to clear heat and harmonize Earth, while draining Wood pathogenic factors, stopping the diarrhea. If the pulse is large but not wiry, it means Earth is not affected by Wood, the disease is easy to cure, and it is termed "Favorable" (Shun). If the pulse is wiry but not large, it means Wood is overcoming Earth, the disease is difficult to treat, and it is termed "Negative" (Fu). Now, if the pulse is not large, but wiry, slippery, and rapid, it indicates that the pathology is not due to Wood overcoming Earth, but rather heat-diarrhea caused by retained food. Therefore, Huangqin Tang is not used, but Da Chengqi Tang is used for purgation. In combined Taiyang-Yangming diarrhea, exterior signs predominate, so Gegen Tang is used to release the exterior. In combined Yangming-Shaoyang diarrhea, interior signs predominate, so Da Chengqi Tang is used to purge the interior. In combined Taiyang-Shaoyang diarrhea, half-exterior/half-interior signs predominate, so Huangqin Tang is used to harmonize. If it is not a combined disease, Guizhi Tang and Mahuang Tang respectively manage Taiyang exterior, Wuling San and Didang Tang respectively manage Taiyang interior; Gegen Tang manages Yangming exterior, the three Chengqi formulas manage Yangming interior; Xiao Chaihu Tang manages Shaoyang exterior, and Da Chaihu Tang manages Shaoyang interior. Each has its specific domain.
[Collected Annotations] Zhang Jianshan stated: All combined diseases involve diarrhea, distinguished by external signs. Taiyang disease presents with headache, stiff neck, and back stiffness; Yangming disease presents with eye pain, dry nose, and insomnia; Shaoyang disease presents with hypochondriac pain and deafness. Whenever two-channel syndromes appear simultaneously with diarrhea, it is called combined disease. However, it suffices if each channel shows one or two symptoms; complete manifestation is not required.
Lin Lan stated: This section involves three syndromes internally. Da Chengqi Tang only treats the syndrome of slippery and rapid pulse with retained food, not the previous two syndromes simultaneously. "Not negative" means that although there is diarrhea, the pulse has not become purely wiry. The treatment method is not stated. Tao Hua claimed to have treated it with Xiao Chaihu Tang plus Gegen and Baishao, achieving results effortlessly. "Negative" means the pulse is purely wiry, indicating Spleen failure and only seeing the "ghost thief" pulse (overacting pulse). No treatment is needed. Although both are combined diseases involving Yangming, there is a distinction between pathogen entering the channel versus the Fu organ. How can one generalize to Chengqi Tang during the channel stage?
In a combined disease of the Three Yang channels, the pulse is floating, large, and extends to the Guan position. The patient desires sleep, and sweats when closing the eyes.
[Commentary] The character "Shang" (Up) in "floating, large, Shang Guan" should be "Xian" (Wiry) to conform to the pulse of combined disease of the Three Yang channels in the Treatise. If it were "Shang," there is no precedent in the classics for both Cun pulses governing Three Yang diseases.
[Annotation] A floating, large, and wiry pulse is the pulse for combined disease of the Three Yang channels. Floating, large, and wiry appearing at the Guan position indicates that heat pathogens of the Three Yang channels gather in the Yangming channel. Heat gathering in Yangming should cause vexation and insomnia. Now, the patient only desires sleep, which is drowsiness due to heat overwhelming the Spirit. Drowsiness naturally involves closing the eyes. Heat steaming causes spontaneous sweating. If treatment is appropriate, allowing the pathogen to return to the exterior and resolve, the outcome is good; otherwise, it is unpredictable. It is appropriate to use Chaihu Tang, Guizhi Tang, and Baihu Tang, selecting and combining them according to the specific indications.
[Collected Annotations] Fang Youzhi stated: Taiyang pulse is floating, Yangming pulse is large. The Guan position is the location of Shaoyang. Hence, it is called combined disease of the Three Yang channels.
Wei Litong stated: Diagnosing a floating pulse indicates Taiyang, a large pulse indicates Yangming. If the pulse extends long to the Guan position, it can be known to be wiry. Wiry also indicates Shaoyang. Thus, the meridians of the Three Yang channels are simultaneously affected by pathogens, so the pulses of the Three Yang channels show disease simultaneously. Examining the symptoms again, desiring sleep is not Shaoyin disease, but sleep due to Yang excess overwhelming the Spirit. Sweating upon closing the eyes indicates Yang winning and struggling with Yin, causing sweating.
In a combined disease of the Three Yang channels, the abdomen is full, the body is heavy, turning the side is difficult, the mouth lacks sensation (taste), the face is grimy, there is delirium, and urinary incontinence. Sweating induces delirium; purgation causes sweating on the forehead and cold extremities. If there is spontaneous sweating, Baihu Tang (White Tiger Decoction) is the primary formula.
[Annotation] This continues the previous clause to detail the symptoms and clarify the treatment. Combined disease of the Three Yang channels refers to the combination of Taiyang, Yangming, and Shaoyang diseases. It must include Taiyang symptoms (headache, fever), Yangming symptoms (aversion to heat, insomnia), and Shaoyang symptoms (deafness, alternating chills and fever). Taiyang governs the back, Yangming governs the abdomen, and Shaoyang governs the sides. Now, the entire body is trapped by heat pathogens of the Three Yang channels, hence the heaviness and difficulty in turning. The orifice of the Stomach opens to the mouth; heat pathogens attacking upward cause loss of taste (mouth lacking sensation). Yangming governs the face; heat pathogens steaming outward cause a grimy complexion. Heat binding in the interior causes abdominal fullness; heat flourishing in the Stomach causes delirium. Heat forcing the Bladder causes urinary incontinence; heat steaming the muscle layer causes spontaneous sweating. Although the syndrome belongs to the Three Yang channels, the heat gathers in the Stomach. Therefore, it should be treated primarily as a Yangming heat syndrome. If one releases the exterior via sweating (from Taiyang), fluids are exhausted further, and Stomach heat deepens, worsening delirium. If one purges the interior (from Yangming), Yin is further injured, and Yang has no foundation and dissipates, causing forehead sweating and cold extremities. One must examine whether the patient has not yet undergone sweating or purging, and presents with body heat and spontaneous sweating. Only then is it a Yangming syndrome, and Baihu Tang should be used to clearly clear Stomach heat, urgently rescue fluids, and preserve Yin.
[Collected Annotations] Wang Hu stated: Someone asked how Baihu Tang can resolve heat of the Three Yang channels? The answer is: When the disease reaches spontaneous sweating, the pathogens of Taiyang and Shaoyang have all returned to Yangming. How can one not treat it specifically from Yangming?
Zheng Zhongguang stated: Combined disease of the Three Yang channels involves injury to both exterior and interior. Sweating biased towards attacking Taiyang causes pathogens to merge into Yangming, worsening delirium. Purgation biased towards treating Yangming causes forehead sweating (non-flowing), cold hands and feet, inevitably leading to collapse of Yang. Thus, neither sweating nor purgation is suitable. Only Baihu Tang can resolve the heat of both exterior and interior of Yangming. If there is no spontaneous sweating, the exterior is not yet resolved, and this clause should not be applied alone; it should be treated in conjunction with other syndromes.
In a consecutive disease of Two Yang channels, when Taiyang disease was initially acquired, sweating was induced. The sweat did not come out thoroughly, so the pathogen subsequently transferred to Yangming, presenting with continuous slight sweating and absence of aversion to cold. If Taiyang signs have not ceased, purgation is contraindicated; purgation is adverse. In such cases, mild sweating may be induced. If the face is persistently and purely red, Yang Qi is constrained and depressed in the exterior; it should be resolved and fumigated. If sweating was not thorough, insufficient to describe, Yang Qi is constrained and depressed, unable to diffuse. Because sweating was indicated but not achieved, the person becomes restless and irritable, unaware of the exact location of pain, sometimes in the abdomen, sometimes in the limbs, unable to be pinpointed by pressure. The person experiences shortness of breath and can only sit. This is due to incomplete sweating. Inducing sweating again will lead to recovery. How do we know sweating was incomplete? By the choppy pulse.
[Commentary] The characters "Xun Zhi" (fumigate) under "Dang Jie Zhi" (should resolve) should be "Yi Han" (with sweat) to align with the context.
[Annotation] When a disease in one channel has not yet resolved before transmitting to another, and the simultaneous disease subsequently merges into one channel to manifest independently, it is called Bing Bing (Consecutive Disease). "Two Yang" refers to Taiyang and Yangming. When Taiyang disease was initially acquired, sweating was induced, but the sweat was not thorough. The remaining pathogen transferred to Yangming. If there is continuous slight sweating and aversion to cold transforms into aversion to heat, this marks the Yangming syndrome suitable for purgation. If there is no slight sweating, but aversion to cold persists, the Taiyang exterior has not yet resolved, and purgation is contraindicated (adverse). If sweating has already been induced, but some exterior pathogen remains, Mahuang Guizhi Ge Ban Tang (Mahuang and Guizhi Half-Decoction) or Guizhi Er Yuebi Yi Tang (Guizhi Double and Yuebi Single Decoction) should be used to mildly release the exterior and harmonize it, leading to resolution. "Yuanyuan" means continuously without cessation. "Zheng Chi" means purely red without other colors, referring to the entire face being continuously red. This is due to incomplete sweating, causing Yang Qi to be constrained and unable to diffuse. Hence, the person is restless, short of breath, has a choppy pulse, does not know the pain location, feels pain intermittently in the abdomen and limbs, and cannot find it by pressing. These are all due to pathogenic factors congesting the meridians with no outlet, solely because of incomplete sweating. One should use Da Qinglong Tang (Major Green Dragon Decoction) or Gegen Tang to induce sweating for recovery.
[Commentary] Facial redness: Red malar flush occurring in the afternoon due to exhaustion indicates Yin deficiency with bone-steaming heat. Floating redness due to repelled Yang, accompanied by cold extremities, diarrhea, and faint pulse, indicates Yang deficiency. Deep red color with tidal fever and hard stool indicates interior excess. Pale red color with aversion to cold and anhidrosis indicates exterior excess. Shortness of breath with choppy pulse: Internal causes are mostly Qi and Blood deficiency. If external cause, breath must be coarse. This is shortness of breath due to pathogenic congestion in the chest from incomplete sweating, preventing normal respiration, not shortness of breath from Qi deficiency due to excessive sweating. External cause choppy pulse must be forceful, indicating pathogenic stagnation from incomplete sweating preventing Ying and Wei circulation, not choppy pulse from fluid deficiency due to excessive sweating failing to nourish the vessels.
[Collected Annotations] Wang Kentang stated: Because the disease is Taiyang, sweating is indicated; because it is Yangming, mild sweating is indicated. The word "first" (Xian) has the most sequence, representing the pivot of Zhang Zhongjing's methodology. Purgation uses Da and Xiao Chengqi Tang; sweating uses Mahuang and other formulas.
Cheng Yingmao stated: Once Taiyang transfers to Yangming, it should be treated from Yangming. However, fearing that at the point of transfer, exterior pathogens are not yet fully gone, and interior pathogens take advantage of their shallow depth, the two pathogens contend, and signs appear alternately. This is called consecutive disease. Even if exterior signs are few and interior signs many, it is ultimately Yangming with exterior signs. Taiyang should not have abdominal pain; because the pathogen has no exit and intends to attack inward, the pain location is uncertain.
Lin Lan stated: Incomplete sweating necessarily results in a choppy pulse. Without re-sweating, how will the pathogen leave? Thus, unsweated disease is consecutive disease; sweated disease is transfer to Yangming. Unsweated means Yang Qi is constrained in the exterior; sweated means sweating was incomplete. Incomplete sweating requires re-sweating; transfer requires purgation; unsweated allows mild sweating; constrained allows resolution via sweating. Different pathogenic origins lead to different diseases, hence different treatments.
In a consecutive disease of Two Yang channels, when Taiyang signs cease, only tidal fever occurs, hands and feet sweat continuously, defecation is difficult, and delirium appears. Purgation leads to recovery; Da Chengqi Tang (Major Emodi Decoction) is appropriate.
[Annotation] Consecutive disease of Two Yang channels involves simultaneous Taiyang and Yangming disease. When Taiyang signs cease, everything merges into Yangming. Hence, only tidal fever, continuous sweating of hands and feet, difficult defecation, and delirium occur. These are all signs of Yangming Stomach excess. Therefore, purgation leads to recovery, and Da Chengqi Tang is appropriate.
[Collected Annotations] Yu Chang stated: The two clauses on consecutive disease both involve Taiyang and Yangming. The first clause involves initial entry into Yangming, where Taiyang pathogens are not yet thorough, so sweating is still appropriate. This clause involves entry into Yangming, where Taiyang signs have ceased and everything merges into Yangming, so purgation is appropriate.