【闡釋】太陽與陽明合病下利，鄭氏以“風寒主證之不同，風為陽而上逆，寒為陰而下行”之論。則上逆而嘔，下注而為利，自是正確的，方與證合拍。
五、太陽與陽明合病，喘而胸滿者，不可下，〔宜〕麻黃湯（主之）。原文36
鄭論：按喘而胸滿，胸中之陽為寒所束，上攻於肺，呼吸錯亂，而喘證作，此條舉太陽陽明而言。若火刑於肺而喘者，下之不宜。若少陰腎氣上沖於肺而喘，不（謂）〔僅〕麻黃不可用，用之是速其亡也。原文之言不可下，是謂寒束於肺，下之恐引邪深入，必生別病，故曰不可下，下之為患不小。首用麻黃湯大開腠理，表氣一通，裏氣則暢，邪自表分出，而內境安守也。
【闡釋】陽明可下，合病則表證未解，故不可不。喘而胸滿者，因汗不得出，熱毒壅迫於肺臟故也，與麻黃湯發汗，則喘滿自除。表裏證同時出現，先解表，後攻裏，為治療原則之一，本條就是在說明這個道理。故鄭氏說：“用麻黃湯大開腠裏，表氣一通，裏氣則暢，邪自表分出”，則病解也。
六、太陽與少陽合病，自下利者，與黃芩湯，若嘔者，黃芩加半夏生薑湯主之。原文172
鄭論：按太少合病，總要兩法病情相孚，照兩經法治之，此但舉太少合病，而曰自下利者，與黃芩湯，嘔者加半夏生薑湯，其中不能無疑，疑者何？夫自下利而嘔，是屬太陰證乎？是屬太陽協熱下利乎？少陽本氣喜嘔乎？若果屬太陽協熱下利，黃芩湯乃為正治法。若嘔果係少陽本氣者，黃芩加半（下）〔夏〕生薑湯，本為對證法。如屬太陰，又當以理中湯加柴、桂，庶為合法。
【闡釋】本條雖提太陽與少陽合病，並無發熱惡寒，頭痛項強之太陽表證，亦無胸脅苦滿之少陽半表半裏證。原文僅提太少合病而至下利，故鄭氏對此條提出質疑“是屬太陽協熱下利乎？少陽本氣喜嘔乎？是屬太陰證乎”？實則太少合病，其在表之寒邪悉入而為裏熱，裏熱不實，故與黃芩湯以清裏熱，使裏熱清而在表之邪自和矣。若嘔者，乃是胃氣上逆所致，則應再加半夏生薑，以降逆止嘔。如此解釋，則明白了然，可以釋疑矣。
黃芩湯方（校補）
黃芩三兩芍藥二兩甘草二兩（炙）大棗十二枚（擘）上四味，以水一鬥，煮取三升，去渣，溫服一升，日再，夜一服。
黃芩加半夏生薑湯方（校補）
即上方加半夏半升（洗）生薑一兩半，一方三兩（切）
【方解及其應用範圍】黃芩、芍藥之苦以撤熱和陰，甘草、大棗之甘以調中，而緩其津液之下奔也，有苦甘合化清熱存陰之義。嘔為氣逆，加半夏辛降，生薑辛散，則氣逆得降，嘔亦自止。後世推廣用之以治熱痢。治痢之方劑，大都由此方化裁而來。
七、陽明少陽合病，必下利，其脈不負者，〔為〕順也。負者，失也①，互相克賊，名為負也。脈滑而數者，有宿食也，當下之，宜大承氣湯。原文256
①其脈……失也：這是根據五行生克的學說，從脈象上來解釋疾病的順逆。陽明屬土，少陽屬木，二經合病而下利，如純見少陽弦脈，則木必克土，病情較逆，是即所謂“負也”，“失也”；如果脈見滑數，則木不克土，是即所謂“順也”。證狀與脈象不符為“負”。脈象與證狀相合為“順”。
鄭論：按陽明少陽合病，察係兩經表邪，當從兩經解表法治之。但下利，裏未實也，何得下之？此以脈滑而斷為宿食者當下之。然亦當辨其果有宿食，與未有宿食，有食可下，無食斷乎不可。
【闡釋】傷寒合病章4條太陽與陽明合病自下利，是病偏重於太陽之表者，故用葛根湯；6條太陽與少陽合病自下利，是邪偏重于少陽之半表半裏者，故用黃芩湯。此節為陽明少陽合病，從脈象上來判斷順逆。脈證相符的為順，容易獲愈；脈證不符的為逆，不易治療。必下利者，脾虛裏有寒也，當用理中湯溫其裏。鄭氏曰：“有食可下，無食斷乎不可”。縱有宿食，亦宜溫下之，用附子理中湯加砂仁、雞內金、大黃，中病即止，豈有下利而反用大承氣湯下之之理？
八、三陽合病①，脈浮大，〔上〕關上②，但欲眠睡，目合則汗。原文268
①三陽合病：即太陽、少陽、陽明三經同時發病。
②上關上：脈搏長大，從關部上至寸口的意思。
鄭論：按三陽同病，陽邪盛已。關上浮大，胃邪熾也，欲眠睡者，熱甚神昏也；閉目汗出，內熱之驗也。雖然，不可不詳辨之，其中實實虛虛，千變萬化，實難窺測。有名為三陽，卻非三陽，此則專為三陽說法，若係由內出外之熱，有似此三陽者，餘亦詳而驗之，但其人舌無苔而潤，口不渴者，餘即不按三陽法治之，專主回陽，屢試屢效。
【闡釋】三陽病均屬熱證，三陽合病則邪熱尤盛，因高熱而神昏欲眠睡，不惡寒而惡熱也，與寒中少陰，但欲寐者，其人惡寒，脈必沉而微細者顯然不同；目合則汗，是由於陽熱太甚，則陰不內守。鄭氏說：“若係由內出外之熱，有似此三陽者，餘亦詳而驗之，但其人舌無苔而潤，口不渴者，餘即不按三陽法治之，專主回陽”。此鄭氏示人辨證宜細心求之，雖未列出治療方劑，總不出四逆、白通之類大劑回陽。
九、三陽合病，腹滿身重，難以轉側，口不仁③，面垢④，譫語遺尿。發汗則譫語，下之則（頞）〔額〕上生汗，手足逆冷，若自汗〔出〕者，白虎湯主之。原文219
③口不仁：言語不利，不知食味。
④面垢：面部油垢污濁。
鄭論：按三陽合病，必有三陽實據可憑，此則所現，純陰居十八，僅有腹滿譫語似陽明，餘故細辨之者，何也？陽主身輕，陰主沉重，陽主開而陰主闔；口之不仁，陰也；身重難以轉側，陰也；面垢、遺尿，腎氣不納，陰也。果係三陽表邪，汗之則解，何至腹滿譫語；果係三陽裏實，下之則解，何至（頞）〔額〕汗出，而手足逆冷？學者務于未汗下時，詳其舌之潤與不潤，舌之燥與不燥，口氣之粗與不粗，口之渴與不渴，飲之喜冷喜熱，二便之利與不利，而三陽合病之真假自得矣。原文所論之病象，大有可疑，故詳辨之。
【闡釋】鄭氏之詳辨陰證、陽證，可為後學準繩，筆者從之，無贅言也。
傷寒並病
計四法（據舒本校補）
一、二陽並病①，太陽初得病時，發其汗，汗先出不徹，因轉屬陽明，續自微汗出，不惡寒。若太陽病證不罷者，不可下，下之為逆，如此可小發汗。設面色緣緣正赤者②，陽氣（拂）〔怫〕鬱在表③，當解之熏之。若〔發〕汗（出）不徹，不足言陽氣（拂）〔怫〕鬱不得越④，當汗不汗，其人（煩燥）〔躁煩〕，不知痛外，乍在腹中，乍在四肢，按之不可得，其人短氣但坐，以汗出（而）不徹（之）故也，更發汗則愈。何以知汗出不徹，以脈澀故知也。原文48
①並病：一經之證未罷，又見到另一經證狀的，叫做並病。
②緣緣：不斷之意。
③怫鬱：此處是遏鬱之意。
④越：發、散之意。
鄭論：按太陽初病，漸至不惡寒獨有熱象，方為轉屬陽明，若已得汗而解，無發熱，不得為轉屬陽明。即轉屬陽明，而太陽證未罷，胃未實，即不得妄下，下之則逆，可以小發汗者，是指太陽證未罷，裏邪未即時也。若面色赤者，是內熱怫鬱之征，亦在可表可熏之例。若汗出不徹，雖面赤即不得謂之怫鬱不得越。至於當汗不汗，煩（燥）〔躁〕者，熱攻於內，而內不安也，乍腹乍四肢，總以汗未出透，裏氣不暢也。然則何以知其汗出不徹乎？以脈澀知之。余常謂澀為血少，以此澀脈而定為汗出不徹，未免牽強，夫汗之徹與不徹，實係乎正氣之旺與不旺，正氣旺則邪必盡出無遺，何致有不徹之患哉？
【闡釋】發汗不徹，為太陽與陽明並病的主要原因。雖為並病，但表證仍然存在的時候，仍當用發汗的方法，而不能使用下法。原文所舉諸種證狀，皆汗出不徹之故。何以知其汗出不徹，原文雲：以脈澀知之。鄭氏謂：“澀為血少，此以澀脈而定為汗出不徹，未免牽強。夫汗之徹與不徹，實係乎正氣之旺與不旺，正氣旺則邪必盡出無遺”。澀脈，《內經》謂參伍不調為澀，指下觸覺脈搏的波動澀滯不流利，為血行障礙的脈象，汗閉或汗出不徹，雖可能見到這種脈象，究不常見，更不可能根據脈搏的澀滯，而預知其汗不徹的情況。鄭氏之論，亦有足取。
二、二陽並病，太陽證罷，但發潮熱，手足漐漐汗出，大便艱而譫語者，下之則愈，宜大承氣湯。原文220
鄭論：按此條指太陽傳至陽明，而寒邪已化為熱，所見潮熱、譫語、大便艱、汗出，全是陽明，故稱太陽證罷，下之可愈，便是用藥的法竅處也。
【闡釋】本太陽病並于陽明，名曰並病。前條太陽證未罷，故不可下，今則表邪已解，所現全為裏實證，可用大承氣湯下之以清裏熱，此鄭氏謂“下之可愈”也。
三、太陽與少陽並病，頭頂強痛或眩冒，時如結胸，心下痞鞕者，當刺大椎第一間①、肺俞②、肝俞③，慎不可發汗，發汗則譫語，脈弦，五日譫語不止，當刺期門（穴）④。原文142
①大椎第一間：在第七頸椎和第一胸椎棘突之間（督脈經）。
②肺俞：當第三第四胸椎橫突起間，在脊外方一寸五分（膀朧經）。
③肝俞：當第九第十胸椎橫突起間，在脊椎外方一寸五分（膀朧經）。
④期門：乳直下二脅間（肝經）。
鄭論：按太少合病，如何只有太陽經證，而無少陽經證，似不可以言並病。若謂眩冒本屬少陽，加結胸，心下鞕，仍屬太陽，何也？太陽之氣，由下而上至胸腹，今結胸心下痞，多係寒水上逆而成，理應按法施治，又何必以針刺，而傷無病之經哉？
【闡釋】太陽與少陽並病，就是太陽之邪傳並少陽，而太陽之邪未罷，既有頭痛項強的太陽證，又見到頭眩昏冒胸脅痞滿的少陽證，由於邪已漸入，所以又有時如結胸的現象。汗、下治法皆非所宜，原文採取針法治之。鄭氏曰：“理應按法施治，又何必以針刺，而傷無病之經哉？”然則如何按法施治？邪入少陽而太陽證未罷，可用柴胡桂枝湯治之。桂枝湯以解太陽之邪，柴胡湯以和解少陽，則眩冒可除。若誤汗則熱邪入於肝經而譫語，當如太陽下篇16、17條例，刺期門以泄肝邪，肝之邪熱去，譫語自止。
四、太陽少陽並病，而反下之，成結胸，心下鞕，下利不止，水漿不下，其人心煩。原文150
鄭論：按此條大約當解表而不解表，誤下之，則邪正相搏，結下心下而成痞鞕，以致上之水漿不入，下之利不止，其人心煩，實危亡之首，可不（謹）〔慎〕軟？
【闡釋】此為太陽少陽並病，本不當下而反下之，三焦氣阻，水道不行，與水相結而成結胸，因而心下鞕。正虛於下則下利不止，邪逆于上則水漿不下，氣結於中則心煩，此乃誤下而成結胸之危候。鄭氏曰：“實危亡之道”。然則坐以待斃耶？筆者認為應大劑回陽收納，待正氣充實，繼用陷胸湯攻之，俟邪去而以溫補調之，斯為得矣。
傷寒壞病
計二法（據舒本校補）
一、太陽病三日，已發汗，若吐、若下、若溫針①，仍不解者，此為壞病②。桂枝不中與〔之〕也③。（現）〔觀〕其脈證，知犯何逆，隨證治之。原文16前段
①溫針：針炙的一種方法，用針針於一定穴位，以艾裹針體而蒸燒之，以冀發汗。
②壞病：因治療錯誤致病情發生惡化，證候變亂，而不能稱其名者。
③不中與：就是不中用的意思。
鄭論：按太陽證，既經汗、吐、下、溫針，治皆不愈，總其未得病之源委而誤用之也，仍究察其何逆，而隨機治之，然亦不得為之真壞證也。
【闡釋】太陽證，既經汗、吐、下、溫針的治療，病仍未解，原因是治法不當，使病情變化，成了壞病。鄭氏曰：“仍究察何逆，而隨機治之”。假如發汗、溫針亡陽，則有脈微身寒之變，宜桂枝加附子湯。吐傷中氣，氣逆脈促者，宜生薑半夏湯。下之而寒水下陷，利遂不止，脈濡滑者，宜四逆理中輩。此即原文隨證治之之義矣。
二、〔本〕太陽病不解，轉入少陽者，脅下鞕滿，幹嘔不能食，往來寒熱，尚未吐、下，脈沉緊者，與小柴胡湯。若已吐、下、發汗、溫針，譫語，柴胡證罷，此為壞病，知犯何逆，以法治之。原文266、267
鄭論：按太陽之邪不解，應當傳入陽明，何得越位而轉入少陽也？然太陽寒水之氣，亦許結於脅下鞕滿，如此而言。亦可謂轉屬少陽也。迨至幹嘔不欲食，往來寒熱，少陽之本證具也，未經吐、下，可與小柴胡湯以和解之，若已經汗、吐、下，溫針而見譫語，未見柴胡證，似從譫語法治之，亦不得盡目之為壞病也。學者又當于臨證時，細細求之可也。
【闡釋】本條前段提出太陽病不解，轉入少陽，既具少陽主證，脈雖沉緊與證不符，當舍脈從證，可與小柴胡湯治療。後段則述及少陽病誤治的變證及救誤的原則，鄭氏曰：“亦不得盡目之為壞病也，當于臨證時，細細求之可也”。
總之誤用汗、吐、下、溫針，非病胃燥，即為血熱。胃燥之證，輕則小承氣，重則調胃承氣，最重則為大承氣。血熱之證。輕則刺期門，重則桃核承氣，尤重者抵當湯，隨證施治可也。
傷寒痰病
計三法（據舒本校補）
[Explanation] When Taiyang (Taiyang disease) and Yangming (Yangming disease) diseases occur simultaneously (He Bing, combined disease) with diarrhea, Zheng Qin'an argued: "The main symptoms caused by wind pathogen and cold pathogen are different; wind is a yang pathogen and tends to move upward and reverse, while cold is a yin pathogen and tends to move downward." Therefore, wind pathogen moving upward causes vomiting, and cold pathogen moving downward causes diarrhea. This view is correct and aligns with clinical manifestations.
Five. When Taiyang and Yangming diseases occur simultaneously, presenting with wheezing and chest fullness, purgation (Xia Fa) should not be used; Mahuang Tang (Cinnamon Twig Decoction) should be administered as the primary treatment. Original Text 36
Zheng Qin'an's Commentary: In this case, wheezing and chest fullness occur because the yang qi in the chest is constrained by cold pathogen, which attacks the lungs upward, disrupting respiration and causing wheezing. This section mentions the simultaneous involvement of Taiyang and Yangming meridians. If wheezing is caused by fire pathogen damaging the lungs, purgation is inappropriate. If wheezing is caused by Kidney qi from Shaoyin (Shaoyin disease) rushing up to the lungs, not only is Mahuang Tang contraindicated, but its use would accelerate death. The original text states "do not purge" because cold constrains the lungs; purging might draw the pathogen deeper into the interior, inevitably causing other complications. Thus, it says "do not purge," as the harm from incorrect purgation is significant. First, using Mahuang Tang vigorously opens the Cou Li (pores and interstitial spaces), allowing exterior qi to flow freely. Once exterior qi is unblocked, interior qi also becomes smooth, and the pathogen naturally exits from the exterior, stabilizing the internal environment.
[Explanation] Yangming disease typically allows for purgation, but since this is a combined disease where the exterior syndrome has not resolved, purgation is contraindicated. Wheezing and chest fullness arise because sweat cannot be excreted, and heat toxin stagnates and pressures the lungs. Administering Mahuang Tang to induce sweating will resolve the wheezing and fullness. When exterior and interior syndromes appear simultaneously, resolving the exterior first and then attacking the interior is one of the treatment principles. This section illustrates this principle. Hence, Zheng Qin'an stated: "Using Mahuang Tang to vigorously open the Cou Li, once exterior qi flows, interior qi becomes smooth, and the pathogen separates from the exterior," leading to recovery.
Six. When Taiyang and Shaoyang (Shaoyang disease) diseases occur simultaneously, presenting with spontaneous diarrhea, administer Huangqin Tang (Scutellaria Decoction); if accompanied by vomiting, Huangqin Jia Banxia Shengjiang Tang (Scutellaria Decoction plus Pinellia and Fresh Ginger Decoction) should be used. Original Text 172
Zheng Qin'an's Commentary: Regarding the combined disease of Taiyang and Shaoyang, one must generally assess the condition according to both meridians and treat them accordingly. Here, only the combined disease of Taiyang and Shaoyang is mentioned, stating that for spontaneous diarrhea, Huangqin Tang is given, and for vomiting, Banxia and Shengjiang are added. There are doubts here. What are the doubts? If there is spontaneous diarrhea with vomiting, does it belong to Taiyin (Taiyin disease) syndrome? Or is it Taiyang协同 heat diarrhea (Taiyang協熱下利)? Or is it vomiting due to the fundamental nature of Shaoyang? If it truly belongs to Taiyang协同 heat diarrhea, Huangqin Tang is the correct treatment. If the vomiting is indeed due to the fundamental nature of Shaoyang, Huangqin Jia Banxia Shengjiang Tang is the appropriate formula. If it belongs to Taiyin, Lizhong Tang (Regulate the Middle Decoction) added with Chaihu (Bupleurum) and Guizhi (Cinnamon Twig) would be more appropriate.
[Explanation] Although this section mentions the combined disease of Taiyang and Shaoyang, there are no Taiyang exterior signs such as fever, aversion to cold, headache, or stiff neck, nor are there Shaoyang half-exterior/half-interior signs like chest and hypochondriac distress. The original text only mentions diarrhea resulting from the combined disease of Taiyang and Shaoyang. Therefore, Zheng Qin'an questioned: "Is this Taiyang协同 heat diarrhea? Is it vomiting due to the fundamental nature of Shaoyang? Or is it a Taiyin syndrome?" In reality, in the combined disease of Taiyang and Shaoyang, the cold pathogen on the exterior fully enters the interior and transforms into interior heat. However, this interior heat is not solid/excess. Therefore, Huangqin Tang is given to clear the interior heat. Once the interior heat is cleared, the pathogen on the exterior harmonizes itself. If there is vomiting, it is caused by rebellious Stomach qi. In this case, Banxia (Pinellia Rhizome) and Shengjiang (Fresh Ginger) should be added to direct rebellious qi downward and stop vomiting. Such an explanation clarifies the matter and resolves doubts.
Huangqin Tang Formula (Corrected and Supplemented)
Huangqin (Scutellariae Radix) 3 liang, Shaoyao (Paeoniae Radix Alba) 2 liang, Gancao (Glycyrrhizae Radix et Rhizoma Preparata) 2 liang (roasted), Dazao (Ziziphi Jujubae Fructus) 12 pieces (split). These four ingredients are boiled in 1 dou (approx. 2 liters) of water to obtain 3 sheng (approx. 600 ml). Remove the dregs. Take 1 sheng warm, twice daily and once at night.
Huangqin Jia Banxia Shengjiang Tang Formula (Corrected and Supplemented)
Take the above formula and add Banxia (Pinelliae Rhizoma Preparata) half sheng (washed) and Shengjiang (Zingiberis Rhizoma Recens) 1.5 liang (another version uses 3 liang, sliced).
[Formula Analysis and Scope of Application] The bitterness of Huangqin and Shaoyao clears heat and harmonizes yin. The sweetness of Gancao and Dazao regulates the middle jiao and prevents the excessive loss of body fluids. This embodies the principle of bitter-sweet combination to clear heat and preserve yin. Vomiting is due to rebellious qi. Adding Banxia (pinellia) provides acridity to descend qi, and Shengjiang (fresh ginger) provides acridity to disperse, thereby directing rebellious qi downward and stopping vomiting. Later generations expanded its use to treat heat-type dysentery. Most formulas for treating dysentery are derived from modifications of this formula.
Seven. When Yangming and Shaoyang diseases occur simultaneously, diarrhea is inevitable. If the pulse does not show a controlling relationship (Fu, negative/defeat), it is considered a favorable condition (Shun, smooth). "Fu" means failure/loss①. Mutual overacting and damaging are called "Fu." A slippery and rapid pulse indicates retained food (Su Shi, accumulated food), requiring purgation; Dachengqi Tang (Major Order the Qi Decoction) is suitable. Original Text 256
① Its pulse... means failure: This interpretation is based on the theory of Five Elements generation and control, explaining disease prognosis through pulse diagnosis. Yangming belongs to Earth, and Shaoyang belongs to Wood. In their combined disease with diarrhea, if only the wiry pulse of Shaoyang is seen, Wood controls Earth, indicating a unfavorable/rebellious condition (Ni), which is the so-called "Fu" or "Loss"; if the pulse is slippery and rapid, Wood does not control Earth, which is the so-called "Shun" or favorable condition. Mismatch between symptoms and pulse is "Fu." Match between symptoms and pulse is "Shun."
Zheng Qin'an's Commentary: Regarding the combined disease of Yangming and Shaoyang, if it involves exterior pathogens of both meridians, treatment should follow the methods for releasing the exterior of both meridians. However, diarrhea indicates that the interior is not solid/excess. How can purgation be used? Here, purgation is suggested only because the slippery pulse suggests retained food. Nevertheless, one must distinguish whether there is actually retained food or not. Purgation is indicated only if food retention exists; it is absolutely contraindicated if there is no food retention.
[Explanation] In the Combined Disease chapter of Shanghan Lun, Article 4 describes Taiyang and Yangming combined disease with spontaneous diarrhea, where the pathology favors the Taiyang exterior, so Gegen Tang (Kudzu Decoction) is used. Article 6 describes Taiyang and Shaoyang combined disease with spontaneous diarrhea, where the pathogen favors the Shaoyang half-exterior/half-interior, so Huangqin Tang is used. This section discusses Yangming and Shaoyang combined disease, judging favorability/unfavorability via pulse. Pulse-symptom match is favorable and easier to cure; mismatch is unfavorable and harder to treat. "Inevitable diarrhea" implies Spleen deficiency and interior cold, warranting Lizhong Tang to warm the interior. Zheng said: "If there is food, purgation is possible; if no food, it is absolutely impossible." Even with retained food, a warming purgation method should be used, such as Fuzi Lizhong Tang added with Sharen (Amomi Fructus), Jinneijin (Galli Gigerii Endothelium Corneum), and Dahuang (Rhei Radix et Rhizoma), stopping as soon as the illness responds. How could one use the harsh purgative Dachengqi Tang for diarrhea?
Eight. San Yang (Three Yang) combined disease① presents with a floating and large pulse, [extending] to the Guan position②, somnolence (desire to sleep), and sweating upon closing the eyes. Original Text 268
① San Yang combined disease: Simultaneous onset of Taiyang, Shaoyang, and Yangming meridians.
② Extending to Guan: The pulse is long and large, extending from the Guan position to the Cun position.
Zheng Qin'an's Commentary: In simultaneous disease of the Three Yang, yang pathogens are abundant. A floating and large pulse at the Guan position indicates blazing stomach pathogen heat. Somnolence results from severe heat causing mental confusion. Sweating upon closing the eyes is a sign of interior heat. However, detailed differentiation is essential, as虚实 (deficiency and excess) changes are complex and hard to predict. Some cases named "Three Yang" are not true Three Yang diseases. This discussion applies specifically to true Three Yang diseases. If the heat originates internally and moves outward, resembling Three Yang symptoms, I have verified this carefully. But if the patient has a tongue without coating and moist, and no thirst, I do not treat it according to Three Yang methods but focus solely on restoring yang (Hui Yang). This approach has proven effective repeatedly.
[Explanation] Diseases of the Three Yang are all heat syndromes. In San Yang combined disease, pathogenic heat is particularly intense. High fever causes mental confusion and desire to sleep, with aversion to heat rather than cold. This is clearly distinct from Shaoyin cold injury, where patients desire sleep, feel cold, and have a deep, fine, and weak pulse. Sweating upon closing the eyes occurs because extreme yang heat fails to allow yin to remain within. Zheng stated: "If heat originates internally and moves outward, resembling Three Yang symptoms... but the tongue is coating-less and moist, and there is no thirst, I do not treat it according to Three Yang methods but focus solely on restoring yang." Zheng teaches careful differentiation. Although no specific formula is listed, the treatment generally involves large doses of Hui Yang formulas like Sini Tang (Frigid Extremities Decoction) or Baitong Tang (White Pass Decoction).
Nine. San Yang combined disease presents with abdominal fullness, heavy body, difficulty turning over, insensitivity of the mouth③, greasy facial appearance④, delirium (Chan Yu), and urinary incontinence. If sweating is induced, delirium worsens; if purgation is used, sweat appears on the forehead, and extremities become cold. If there is spontaneous sweating, Baihu Tang (White Tiger Decoction) should be administered. Original Text 219
③ Insensitivity of the mouth: Difficulty speaking, loss of taste sensation.
④ Greasy facial appearance: Oily and dirty complexion.
Zheng Qin'an's Commentary: True San Yang combined disease must have substantial evidence of the Three Yang. The symptoms described here are predominantly yin (eighteen parts yin). Only abdominal fullness and delirium resemble Yangming. Why differentiate carefully? Yang governs lightness of body; Yin governs heaviness. Yang governs opening; Yin governs closing. Insensitivity of the mouth is yin. Heavy body and difficulty turning are yin. Greasy face and urinary incontinence indicate Kidney qi failing to grasp, which is yin. If it were truly Taiyang exterior pathogen, sweating would resolve it, leading to abdominal fullness and delirium? If it were truly Yangming interior excess, purgation would resolve it, leading to forehead sweat and cold extremities? Scholars must carefully examine tongue moisture/dryness, breath roughness, thirst preference (cold/hot drinks), and bowel/bladder function before inducing sweat or purging. Then the truth/falsehood of San Yang combined disease will become clear. The pathological phenomena described in the original text are highly questionable, hence the detailed differentiation.
[Explanation] Zheng’s detailed differentiation of yin and yang syndromes serves as a standard for students. I follow his lead without adding redundant comments.
Shanghan Bingbing (Consecutive Disease)
Four Methods (Based on Shu Ben edition supplements)
One. Er Yang (Two Yang) consecutive disease①: When Taiyang disease is first contracted, sweating is induced. If the sweat is initially incomplete, the condition may transform to Yangming, continuing with slight sweating and no aversion to cold. If Taiyang symptoms persist, purgation is contraindicated; doing so is incorrect. In such cases, mild sweating may be induced. If the face is persistently red②, it indicates yang qi [stagnant/depressed] in the exterior③, requiring resolution via sweating or fumigation. If [induced] sweat is incomplete, it is insufficient to claim yang qi [stagnant/depressed] cannot escape④. When sweating should occur but does not, the patient becomes [restless/agitated], unaware of pain location, with pain shifting between abdomen and limbs, unpressable. The patient suffers from shortness of breath and can only sit, due to incomplete sweating [cause]. Re-inducing sweating leads to recovery. How to know sweat was incomplete? Through a choppy (Se) pulse. Original Text 48
① Bingbing (Consecutive Disease): When symptoms of one meridian persist while symptoms of another meridian appear.
② Yuan Yuan: Continuous/uninterrupted.
③ Fu Yu: Depressed/stagnant here.
④ Yue: Emerge/disperse.
Zheng Qin'an's Commentary: Initially, Taiyang disease gradually loses aversion to cold and shows only heat signs when transforming to Yangming. If sweat resolves the disease without fever, it is not transformation to Yangming. Even if transformed to Yangming, if Taiyang symptoms persist and the Stomach is not solid, blind purgation is forbidden; purging is incorrect. "Mild sweating" refers to cases where Taiyang symptoms persist and interior pathogens have not yet solidified. Facial redness indicates internal heat stagnation, falling under the category of exterior-releasing or fumigation treatments. If sweat is incomplete, facial redness alone does not constitute "stagnant yang qi unable to escape." When sweating is indicated but withheld, agitation results from heat attacking the interior. Pain shifting locations is due to incomplete sweating and unsmooth interior qi. How to know sweat is incomplete? Via choppy pulse. I often say choppy pulse indicates blood deficiency. Using choppy pulse to define incomplete sweating is somewhat forced. Whether sweat is complete depends on the strength of righteous qi (Zheng Qi). Strong righteous qi expels pathogens completely, preventing incomplete sweating.
[Explanation] Incomplete sweating is the main cause of Taiyang-Yangming consecutive disease. Even in consecutive disease, if exterior symptoms persist, sweating methods should be used, not purgation. All symptoms cited in the original text result from incomplete sweating. How to know? Choppy pulse. Zheng argues: "Choppy pulse indicates blood deficiency; defining incomplete sweating solely by choppy pulse is forced. Completeness of sweating depends on righteous qi strength." Choppy pulse, defined in Neijing as irregular and non-smooth, reflects impaired blood circulation. While seen in sweat retention or incomplete sweating, it is uncommon. Predicting incomplete sweating solely from pulse sluggishness is unreliable. Zheng’s critique has merit.
Two. Er Yang consecutive disease: When Taiyang symptoms cease, presenting only with tidal fever, continuous slight sweating on hands and feet, difficult defecation, and delirium, purgation leads to recovery; Dachengqi Tang is suitable. Original Text 220
Zheng Qin'an's Commentary: This section describes transmission from Taiyang to Yangming, where cold pathogen has transformed into heat. Tidal fever, delirium, hard stool, and sweating are all Yangming symptoms. Thus, Taiyang symptoms have ceased. Purging can cure this, revealing the key to medication application.
[Explanation] This is Taiyang disease consecutively involving Yangming, called Bingbing. In the previous article, Taiyang symptoms persisted, so purgation was contraindicated. Now, exterior pathogens have resolved, presenting purely as interior excess. Dachengqi Tang can be used to purge and clear interior heat. Zheng states "purging cures this."
Three. Taiyang and Shaoyang consecutive disease: Occipital stiffness/pain or dizziness/vertigo, sometimes resembling Jie Xiong (Chest Binding), epigastric stuffiness and hardness. Acupoints Dazhui (First Intervertebral Space)①, Feishu②, and Ganshu③ should be needled. Sweating is strictly contraindicated. Sweating causes delirium and wiry pulse. If delirium persists for five days, Qimen (Acupoint)④ should be needled. Original Text 142
① Dazhui First Intervertebral Space: Between spinous processes of C7 and T1 (Du Meridian).
② Feishu: Between transverse processes of T3 and T4, 1.5 cun lateral to spine (Bladder Meridian).
③ Ganshu: Between transverse processes of T9 and T10, 1.5 cun lateral to spine (Bladder Meridian).
④ Qimen: Below nipple, between costal margins (Liver Meridian).
Zheng Qin'an's Commentary: In Taiyang-Shaoyang combined disease, why are there only Taiyang symptoms and no Shaoyang symptoms? It seems inappropriate to call this consecutive disease. If dizziness belongs to Shaoyang, and Chest Binding/epigastric hardness belongs to Taiyang, why needle? Taiyang qi moves upward from lower to upper chest/abdomen. Chest Binding and epigastric stuffiness are often caused by cold-water rebellion. Standard treatment should apply; why needle and injure healthy meridians?
[Explanation] Taiyang-Shaoyang consecutive disease means Taiyang pathogen transmits to Shaoyang while Taiyang symptoms persist. There are Taiyang signs (headache, stiff neck) and Shaoyang signs (dizziness, hypochondriac fullness). As pathogen enters deeper, symptoms may resemble Jie Xiong. Neither sweating nor purging is appropriate; the original text uses acupuncture. Zheng asks: "Why needle?" How to treat properly? With Shaoyang pathogen invasion and persistent Taiyang symptoms, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) can be used. Guizhi Tang releases Taiyang pathogen; Chaihu Tang harmonizes Shaoyang, resolving dizziness. Incorrect sweating drives heat into Liver meridian, causing delirium. Following Articles 16-17 of Taiyang chapter, needling Qimen drains Liver pathogen. Removing Liver heat stops delirium.
Four. Taiyang-Shaoyang consecutive disease, incorrectly treated with purgation, resulting in Jie Xiong, epigastric hardness, incessant diarrhea, inability to take food/fluids, and mental restlessness. Original Text 150
Zheng Qin'an's Commentary: This case likely failed to release the exterior, leading to incorrect purgation. Pathogen and righteous qi struggle, binding in the epigastrium causing stuffiness/hardness. Upper obstruction prevents intake; lower weakness causes incessant diarrhea. Mental restlessness ensues. This is a critical danger. Must one not be [cautious]?
[Explanation] This is Taiyang-Shaoyang consecutive disease, incorrectly purged. Sanjiao qi obstruction blocks water passages, binding with water to form Jie Xiong, causing epigastric hardness. Righteous deficiency below causes diarrhea; pathogen rebellion above prevents fluid intake; qi binding in middle causes restlessness. This is a critical state of Jie Xiong from incorrect purgation. Zheng says: "This is the path to danger and death." Should one wait passively? I believe large-dose Hui Yang (restore yang) and grasping qi methods should be used first. Once righteous qi is sufficient, Xianxiong Tang (Depress the Chest Decoction) can attack the pathogen. After pathogen removal, tonify and regulate with warmth. This is the proper approach.
Shanghan Huaibing (Ruined Disease)
Two Methods (Based on Shu Ben edition supplements)
One. After three days of Taiyang disease, if sweating, emesis, purgation, or warm needle① therapy still fails to resolve the condition, this is Huaibing (Ruined Disease)②. Guizhi Tang is ineffective [for it]③. Observe the pulse and symptoms, determine what error occurred, and treat according to the syndrome. Original Text 16 (first part)
① Warm Needle: An acupuncture method where needles are inserted into specific points and heated with moxa to induce sweating.
② Huaibing: Disease deterioration and symptom chaos due to incorrect treatment, making standard naming impossible.
③ Not useful: Means ineffective/useless.
Zheng Qin'an's Commentary: For Taiyang syndrome, if sweating, emesis, purgation, and warm needle fail, it is due to misunderstanding the disease origin and misapplying treatments. One must investigate the specific deviation and treat flexibly. However, this is not necessarily a true "ruined" state.
[Explanation] Taiyang syndrome remains unresolved after sweating, emesis, purgation, or warm needle therapy due to improper treatment methods, leading to changed conditions known as Huaibing. Zheng said: "Investigate the deviation and treat flexibly." If sweating/warm needle caused yang collapse, presenting with faint pulse and cold body, Guizhi Jia Fuzi Tang (Cinnamon Twig Decoction plus Aconite) is suitable. Emesis damaging middle qi with rebellious qi and surging pulse warrants Shengjiang Banxia Tang (Fresh Ginger and Pinellia Decoction). Purgation causing cold water sinking and incessant diarrhea with soggy/slippery pulse requires Sini and Lizhong categories. This embodies the meaning of "treat according to syndrome."
Two. [Originally] Taiyang disease unresolved, transmitting to Shaoyang: Hardness/fullness in hypochondrium, dry retching, inability to eat, alternating chills and fever. If not yet vomited or purged, and pulse is deep and tight, administer Xiao Chaihu Tang (Minor Bupleurum Decoction). If already vomited, purged, sweated, or warmed with needle, presenting with delirium, and Chaihu symptoms have ceased, this is Huaibing. Determine the error and treat accordingly. Original Text 266, 267
Zheng Qin'an's Commentary: Unresolved Taiyang pathogen should transmit to Yangming. How can it skip to Shaoyang? However, Taiyang cold-water qi may bind in hypochondriac hardness. In this sense, it can be called transmission to Shaoyang. When dry retching, anorexia, and alternating chills/fever appear, Shaoyang fundamental symptoms are complete. Without prior emesis/purgation, Xiao Chaihu Tang can harmonize. If already subjected to sweating, emesis, purgation, or warm needle, presenting with delirium without Chaihu symptoms, one might treat delirium. However, it should not be entirely labeled as Huaibing. Scholars must seek details carefully during clinical practice.
[Explanation] The first part states Taiyang unresolved transmitting to Shaoyang, possessing Shaoyang main symptoms. Although pulse is deep/tight (mismatching symptoms), prioritize symptoms over pulse. Xiao Chaihu Tang is suitable. The second part describes Shaoyang disease complications from incorrect treatment and rescue principles. Zheng said: "Do not label entirely as Huaibing; seek details carefully in clinical practice."
In summary, incorrect use of sweating, emesis, purgation, or warm needle either causes Stomach dryness or Blood heat. Stomach dryness: mild cases use Xiaochengqi Tang, moderate Tiaoweichengqi Tang, severe Dachengqi Tang. Blood heat: mild cases needle Qimen, moderate Taohé Chengqi Tang, severe Didang Tang. Treat according to syndrome.
Shanghan Tanbing (Phlegm Disease)
Three Methods (Based on Shu Ben edition supplements)