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Taiyang disease (Disease of the Taiyang channel) presenting with stiffness and discomfort in the nape, neck, and back. If there is sweating and aversion to wind instead, Guizhi Jia Gegen Tang (Cinnamon Twig Decoction plus Puerariae Radix) is the primary treatment. ("Ji Ji" describes the sensation of stiffness and inability to extend the neck.)

Taiyang disease (Disease of the Taiyang channel) presenting with stiffness and discomfort in the nape, neck, and back, without sweating and with aversion to wind, is primarily treated with Gegen Tang (Puerariae Radix Decoction).

These two clauses distinguish between Wind Strike (Shang Feng) and Cold Strike (Shang Han) based on the presence or absence of sweating. Zhang Zhongjing considers these manifestations to appear entirely as Taiyang disease (Disease of the Taiyang channel), but the slight concomitance of stiffness and discomfort in the nape, neck, and back indicates a sign of the Yangming channel (Yangming Jing). Since it has not yet reached the state where both channels are equally affected, the term "He Bing" (Combined Disease) is not used. However, although not named Combined Disease, it is essentially the initial stage of Combined Disease. "Ji Ji" refers to the lack of flexibility in the neck. The nape belongs to the Taiyang channel, while the neck belongs to the Yangming channel. In Combined Disease of these two channels, both the neck and nape become disharmonious. In Taiyang Wind Strike damaging the Wei (Defensive) level, upon the first appearance of a Yangming sign, one adds Gegen (Puerariae Radix) to Guizhi Tang (Cinnamon Twig Decoction); in Taiyang Cold Strike damaging the Ying (Nutritive) level, upon the first appearance of a Yangming sign, one adds Gegen (Puerariae Radix) to Mahuang Tang (Ephedra Decoction). This is the unchangeable standard of master physicians. However, the second clause does not use Mahuang Tang (Ephedra Decoction) plus Gegen (Puerariae Radix), but rather uses the full Guizhi Tang (Cinnamon Twig Decoction) plus Mahuang (Ephedra) and Gegen (Puerariae Radix). This is because the neck, nape, and back are all Yang positions, areas prone to sweating. If one were to use Mahuang Tang (Ephedra Decoction) plus Gegen (Puerariae Radix) to induce heavy sweating, it might cause the stiffness in the nape, neck, and back to transform into trembling and palpitations of the meridians. This demonstrates the profound and divine precision of Zhang Zhongjing's principles.

When Taiyang (Disease of the Taiyang channel) and Yangming (Disease of the Yangming channel) present as Combined Disease, if there is no diarrhea but only vomiting, Gegen Jia Banxia Tang (Puerariae Radix Decoction plus Pinelliae Rhizoma) is the primary treatment.

When Taiyang (Disease of the Taiyang channel) and Yangming (Disease of the Yangming channel) present as Combined Disease, if there is spontaneous diarrhea, Gegen Tang (Puerariae Radix Decoction) is the primary treatment.

These two clauses further distinguish between Wind-dominant and Cold-dominant Combined Disease by the presence or absence of diarrhea. Wind is Yang; its nature is ascending. Thus, when combining with Yangming, the fluids and phlegm in the Stomach tend to rebel upward. Cold is Yin; its nature is descending. Thus, when combining with Yangming, the food and fluids in the Stomach tend to rush downward. For upward rebellion, Banxia (Pinelliae Rhizoma) must be added to Gegen Tang (Puerariae Radix Decoction) to dissipate fluid retention and stop vomiting. For spontaneous diarrhea, only Gegen Tang (Puerariae Radix Decoction) is used to resolve the pathogenic factors of both channels. Diarrhea is a interior syndrome, yet Zhang Zhongjing treats it with this decoction. This is likely because when pathogenic factors congregate in the Yang, Yang becomes excess and Yin becomes deficient; this deficiency leads to diarrhea. By administering this decoction to scatter the pathogenic factors in the meridians, Yang excess is resolved and Yin Qi is balanced. The diarrhea stops spontaneously without direct treatment for it.

In Combined Disease of Taiyang (Disease of the Taiyang channel) and Yangming (Disease of the Yangming channel), if there is wheezing and chest fullness, purgation (Xia Fa) is contraindicated; Mahuang Tang (Ephedra Decoction) is appropriate.

In Combined Disease of two channels, why use only Mahuang (Ephedra) exclusively? This reflects the precision of Zhang Zhongjing’s analysis. The pathogen of Taiyang is in the chest, and the pathogen of Yangming is in the Stomach. When combined, they attack the Lung upwards, causing wheezing and chest fullness. Mahuang (Ephedra) and Xingren (Armeniacae Semen Amarum) are specific herbs for treating Lung wheezing and rebellious Qi. Using them appropriately is like recommending a relative for office—there is no bias. ○ Note: In Combined Disease of Taiyang and Yangming, the focus is entirely on the exterior, hence the primary treatments are Gegen Tang (Puerariae Radix Decoction) and Mahuang Tang (Ephedra Decoction). If Taiyang and Shaoyang (Disease of the Shaoyang channel) present as Combined Disease, the pathogen is gradually pressing inward, so Xiao Chaihu Tang (Minor Bupleurum Decoction) and Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) are combined. If Taiyang and Shaoyang Mixed Disease occurs, Huangqin Tang (Scutellaria Decoction) or Huangqin Jia Banxia Shengjiang Tang (Scutellaria Decoction plus Pinelliae Rhizoma and Fresh Ginger) should be used. If Yangming and Shaoyang Combined Disease occurs, and the pathogen enters the Fu organs with a slippery and rapid pulse, Da Chengqi Tang (Major Order the Golden Gate Decoction) is used for purgation, similar to the case where Two-Yang Combined Disease resolves with the cessation of Taiyang signs. If the Meridian syndrome persists and the pulse is not slippery and rapid, Da Chaihu Tang (Major Bupleurum Decoction) should be used to simultaneously resolve the exterior and interior, without doubt. The original clause regarding Taiyang and Shaoyang Combined Disease can be found in the Warm Heat Disease chapter for reference.

In Combined Disease of Yangming (Disease of the Yangming channel) and Shaoyang (Disease of the Shaoyang channel), diarrhea is inevitable. If the pulse does not show "Fu" (defeat/clashing), it is a favorable condition. "Fu" means defeat or loss, indicating mutual clashing and harming. A slippery and rapid pulse indicates retained food; purgation is indicated, using Da Chengqi Tang (Major Order the Golden Gate Decoction).

When Wood (Liver/Gallbladder) and Earth (Spleen/Stomach) pathogens interact, water and grain move rapidly, making diarrhea certain. Yangming pulse is large, Shaoyang pulse is wiry. If neither defeats the other, it is a favorable sign. However, in Combined Disease, if Yangming Qi declines, only the wiry pulse appears, meaning Shaoyang prevails and Yangming is defeated. Purgation is a method of "treating obstruction with draining agents," but since the upper part suffers from clashing pathogens, powerful drugs are needed to urgently drain from below to relieve the siege. However, this is only indicated if the pulse is surging and rapid, and there is retained food. If the pulse is not slippery and rapid but slow and deep, one must worry about the collapse of the upper Jiao; how could purgation be dared?

The above cases involve Combined Disease.

In Two-Yang Combined Disease, at the initial onset of Taiyang disease, sweating was induced, but the sweat was incomplete. Consequently, the condition transferred to Yangming, with subsequent slight sweating and no aversion to cold. If the Taiyang syndrome has not ceased, purgation is contraindicated; doing so is erroneous. In such cases, mild sweating may be induced. If the face is persistently red, it indicates Yang Qi stagnation in the exterior; it should be resolved through fumigation or bathing. If sweating was incomplete, it is insufficient to say Yang Qi is stagnant and unable to vent. If sweating should have been induced but was not, the patient becomes restless and irritable, with pain that shifts between the abdomen and limbs, which cannot be pinpointed upon pressure. The patient experiences shortness of breath solely due to incomplete sweating. Inducing sweating again will lead to recovery. How do we know sweating was incomplete? Because the pulse is choppy.

In Two-Yang Combined Disease, if the Taiyang signs have ceased, but tidal fever occurs, hands and feet sweat continuously, defecation is difficult, and delirium is present, purgation will cure it; Da Chengqi Tang (Major Order the Golden Gate Decoction) is indicated.

Both clauses of Two-Yang Combined Disease refer to Combined Disease of Taiyang and Yangming. In the first clause, the pathogen has just entered Yangming, but Taiyang has not yet ceased, so mild sweating is appropriate. In this clause, the pathogen has entered Yangming, and Taiyang has also ceased, so strong purgation is appropriate. Note: In the first clause, the initial Taiyang Cold Strike damages the Ying level; due to incomplete sweating, it transmits to Yangming. Subsequent slight sweating and no aversion to cold indicate intense Yangming heat, which seems to warrant purgation. However, because the Taiyang pathogen is not fully resolved, purgation is erroneous, potentially leading to Tie Xiong (Glomus) syndromes. In such cases, mild sweating should be induced first, then purgation. If the face is persistently red, it indicates severe cold pathogen and Yang Qi stagnation in the exterior. This implies either Mahuang Tang (Ephedra Decoction) was not used initially, or it was used but failed to induce sweat. Therefore, strong resolution via fumigation/bathing is required, beyond the capacity of mild sweating. If sweating was incomplete, one should not speak of Yang Qi stagnation. Rather, failing to sweat when necessary causes restlessness, shifting pain, alternating chills and fever, and limb pain that cannot be pressed, indicating Yang Qi failure to vent. Yang fails to vent because incomplete sweating leaves residual pathogen and injures Qi. A choppy pulse indicates pathogen remaining in the muscle interstices, preventing smooth flow of Ying Qi and injuring Blood. After sweating, shortness of breath and a choppy pulse indicate incomplete sweating; Guizhi Er Yuebi Yi Tang (Cinnamon Twig Decoction twice minus Yubi Decoction once) should be used to mildly induce sweating for recovery.

In Taiyang disease with Guizhi syndrome, if the physician erroneously applies purgation, diarrhea persists. If the pulse is hurried, the exterior is unresolved. If there is wheezing and sweating, Gegen Huangqin Huanglian Tang (Puerariae Radix, Scutellariae Radix, and Coptidis Rhizoma Decoction) is the primary treatment.

Taiyang disease originally has no indication for purgation; Guizhi Tang (Cinnamon Twig Decoction) should be used to release the exterior. If this is neglected and purgation is applied erroneously, resulting in persistent diarrhea, the heat pathogen in Taiyang has not transmitted to the Yangming Meridian but has entered the Yangming Interior. Hence, the pulse is hurried, sweat escapes outward, Qi rebels upward causing wheezing, and flows downward causing diarrhea. Therefore, Guizhi is abandoned, and Gegen (Puerariae Radix) is used specifically for the Yangming exterior, while Huangqin (Scutellariae Radix) and Huanglian (Coptidis Rhizoma) clear interior heat. Wheezing stops without direct treatment, and diarrhea ceases without direct intervention. This is a variant method for simultaneously resolving the exterior and interior of Taiyang and Yangming, similar to the principle of treating Pi (Glomus).

In Combined Disease of Taiyang (Disease of the Taiyang channel) and Shaoyang (Disease of the Shaoyang channel), with stiff and painful nape and neck, dizziness, vertigo, or a sensation like Tie Xiong (Glomus) with hardness beneath the heart, acupuncture at Dazhui (GV14), Feishu (BL13), and Ganshu (BL18) is indicated. Sweating is absolutely contraindicated; inducing sweating leads to delirium. If the pulse is wiry and delirium persists for five to six days, Qimen (LR14) should be acupunctured.

Acupuncture at Dazhui (GV14) drains the Du Mai (Governing Vessel) and the three Yang channels. Acupuncture at Feishu (BL13) directs Lung Qi downward and promotes Bladder Qi transformation. Acupuncture at Ganshu (BL18) drains the Gallbladder. Acupuncture at Qimen (LR14) drains excess in the Liver and Gallbladder.

In Combined Disease of Taiyang and Shaoyang, with hardness beneath the heart, stiff and painful nape and neck, and dizziness, acupuncture at Dazhui (GV14), Feishu (BL13), and Ganshu (BL18) is indicated. Purging (Xia Fa) is strictly forbidden.

This reiterates the prohibition against purging, complementing the previous clause's prohibition against sweating.

In Shanghan (Cold Damage), abdominal fullness and delirium with a floating and tight pulse at the Cun Kou (Radial Pulse) indicate Liver overacting on Spleen. This is named Zong (Vertical); acupuncture at Qimen (LR14) is indicated.

Liver Wood directly overcoming Spleen Earth is called Zong. This originates from Combined Disease of Taiyang and Shaoyang. Due to the patient's inherent Liver excess and Spleen deficiency, symptoms of abdominal fullness and delirium manifest fully, representing Liver pathogen overacting on Spleen. Although Shaoyang governs Wind-Water, it still relies on Wei (Defensive) and Ying (Nutritive) Qi for nourishment. Thus, Zhang Zhongjing states: "This belongs to the Stomach." Disharmony of the Stomach causes abdominal fullness and delirium. The floating and tight pulse at Cun Kou (Radial Pulse) is the pulse of Taiyang Cold Strike damaging Ying. Cun Kou (Radial Pulse) is governed by the Spleen and Stomach. Excessive Liver Wood carrying pathogen further constrains Spleen-Stomach Earth. Acupuncture at Qimen (LR14) drains Liver pathogen, stabilizing the Middle Jiao.

In Shanghan (Cold Damage), fever, aversion to cold, intense thirst with desire to drink, and inevitable abdominal fullness. If spontaneous sweating occurs and urination is free, the disease is about to resolve. This is Liver overacting on Lung. This is named Heng (Horizontal); acupuncture at Qimen (LR14) is indicated.

Liver Wood counter-acting Lung Metal is called Heng. This is also Combined Disease of Taiyang and Shaoyang. Due to inherent Liver excess and Lung deficiency, although fever and aversion to cold indicate unresolved Taiyang exterior, intense thirst indicates established Shaoyang interior heat. Wood excess easily generates Fire; Metal deficiency fails to generate Water. Seeking water moistens Wood, and water support increases its horizontal aggression, causing water overflow and abdominal fullness. Acupuncture at Qimen (LR14) drains Liver pathogen, calming the Lung. However, if there is only abdominal fullness without delirium, the pathogen is lighter. Although Lung Metal is weaker than Liver Wood, there is no other disease; hidden transport functions operate. Spontaneous sweating allows water to seep out externally, or free urination allows water to flow downward, so the disease resolves spontaneously without need for acupuncture. Readers should not let the placement of "acupuncture at Qimen" under "about to resolve" mislead the meaning. ○ Note: Although Vertical and Horizontal conditions differ, both use acupuncture at Qimen because Wood overacting on Earth and insulting Metal stems from Wood excess. Abdominal fullness and delirium are critical and suspicious, so urgent drainage of Wood is prioritized. ○ All fourteen clauses use acupuncture. Modern Shanghan practitioners do not understand this principle. Regarding medication, nothing exceeds modified Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction). One can infer this from the treatment of delirium due to Yang collapse from excessive sweating in the next clause.

Delirium due to Yang collapse from excessive sweating is not suitable for purgation. Administer Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) to harmonize Ying and Wei, facilitating the flow of Body Fluids, after which recovery will occur naturally.

In Combined Disease of Taiyang and Shaoyang, sweating is contraindicated; inducing sweating leads to delirium. Delirium due to Yang collapse from erroneous sweating is also not suitable for purgation; Guizhi and Chaihu should be used to harmonize the Ying and Wei of both channels.

In Shanghan (Cold Damage) for six to seven days, with fever, slight aversion to cold, vexing pain in joints, slight vomiting, and subcostal binding (Zhi Jie), with exterior signs unresolved, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) is the primary treatment.

Zhi Jie refers to fluid retention binding obliquely beneath the heart, not in the center. By six to seven days in Shanghan, transmission should be complete. Yet with fever, slight aversion to cold, joint pain, and slight vomiting, the pathogen remains in the Shaoyang boundary, not entering the interior. Although there is subcostal binding, the exterior signs persist, so it cannot be compared to Tie Xiong (Glomus). Therefore, only Chaihu Guizhi Tang is used, allowing the Taiyang pathogen to resolve from the Taiyang channel. Once the pathogen is gone, the fluid retention opens.

In Shanghan (Cold Damage) for five to six days, after sweating and erroneous purging, with fullness and slight binding in the chest and hypochondrium, difficulty in bowel movement and urination, thirst without vomiting, only head sweating, alternating chills and fever, and irritability, this is unresolved. Chaihu Guizhi Ganjiang Tang (Bupleurum, Cinnamon Twig, and Dried Ginger Decoction) is the primary treatment. Mild irritability upon the first dose; upon repeated dosing, sweating occurs and recovery follows.

After five to six days of sweating, the pathogen is unresolved but weak. Erroneous purging causes minor pathogens to condense in the Upper Jiao, obstructing Lung Qi, causing thirst without vomiting and head sweating. Alternating chills, fever, and irritability indicate the pathogen has entered the Shaoyang boundary, hence unresolved. Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) resolves Taiyang and Shaoyang pathogens; Huangqin (Scutellariae Radix) and Gancao (Glycyrrhizae Radix) clear internal and external heat; Ganjiang (Zingiberis Rhizoma Recens) addresses Cold-Fluid in the Stomach; Gualougen (Trichosanthis Radix) treats upper diaphragm heat and thirst; Muli (Concha Ostreae) opens slight binding in the hypochondrium. Mild irritability after the first dose is called "medication irritability" in modern times, due to injured Body Fluids and deficient Stomach Qi after sweating, unable to overcome the medicinal force. Repeated dosing overcomes the pathogen, leading to sweating and resolution. ○ Clauses 32 and others involve Taiyang-Shaoyang Combined Disease. Due to terms like "subcostal binding" and "slight binding" in the text, later generations mistook them for Tie Xiong (Glomus). Zhe'an used Xiao Chaihu Tang (Minor Bupleurum Decoction) plus Jiegeng (Platycodonis Radix) to treat Pi (Glomus), which is effective only for initial exterior pathogen invading the Middle Jiao. True Tie Xiong involves pathogen drawn inward by erroneous purging; only major purgatives like Da/Xiao Xianxiong Tang/Wan (Major/Minor Chest Glomus Decoctions/Pills) can resolve it.

In Yangming disease with tidal fever, loose stools, normal urination, and persistent hypochondriac fullness, Xiao Chaihu Tang (Minor Bupleurum Decoction) is the primary treatment.

This is Combined Disease of Yangming and Shaoyang. Tidal fever is a sign of Yangming Stomach heat. Loose stools and normal urination indicate the Stomach is not full/excess. Persistent hypochondriac fullness indicates concomitant Shaoyang involvement. Once Shaoyang is involved, both sweating and purging are contraindicated. Only Xiao Chaihu Tang (Minor Bupleurum Decoction) harmonizes the interior and exterior, being the correct treatment for Shaoyang alone. Thus, it is also used for Yangming-Shaoyang Combined Disease, with no other method.

In Yangming disease, with hypochondriac pain and hardness, constipation, vomiting, and a white coating on the tongue, Xiao Chaihu Tang (Minor Bupleurum Decoction) may be administered. Once the Upper Jiao is unblocked, Body Fluids descend, Stomach Qi harmonizes, and the body sweats continuously, resolving the disease.

This is also Combined Disease of Yangming and Shaoyang. Loose stools indicate the Stomach is not full. Even with constipation, if hypochondriac hardness, vomiting, and tongue coating are present, Shaoyang predominates. Xiao Chaihu Tang (Minor Bupleurum Decoction) should be used to separate Yin and Yang, harmonizing upper and lower. Continuous sweating resolves the exterior signs of tongue coating, vomiting, and hypochondriac fullness. Since Body Fluids descend, bowel movements occur naturally. This simultaneous resolution of interior and exterior is appropriate. ○ "Upper Jiao unblocked, Body Fluids descend" highlights the critical pathogenesis. Wind-Cold pathogens carry Body Fluids upward to accumulate in the diaphragm, causing wheezing, vomiting, Water Rebellion, or Tie Xiong (Glomus), accounting for six or seven out of ten cases. If Wind-Cold is unresolved, Body Fluids cannot descend. Erroneous dispersal not only prevents fluid descent but increases upward rebellion, with no end in sight.

The above cases involve Combined Disease.