【纲】仲景曰。三阳合病。腹满身重。难以辗侧。口不仁而面垢。遗尿。发汗。则谵语。下之。
则额上出汗。手足冷。若自汗出者。
白虎汤主之。三阳合病。脉浮大在关上。但欲睡眠。合目则汗。太阳与阳明合病。喘而胸满者。不可下。麻
黄汤主之。太阳与阳明合病。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。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。阳明少阳合病。必
自下利。其脉不负者。顺也。负者。失也。互相克贼。名为负。少阳负趺阳者。为顺也。
【目】李 曰。或一阳先病。一阳随病。或二阳同病。或三阳同病。不传者谓之合病。自利者。下利溏泄。三阳合
病。寒邪盛而里气不和也。气行下则利。气逆上则呕。太阳合阳明。
自利恶寒。升麻葛根汤。恶热者。白虎汤。太阳合少阳自利者。黄芩汤。并加半夏生姜。阳明少
阳。自利最重。小柴胡合升麻葛根汤。有宜下者。本太阳病。因汗下渗亡津液。胃腑燥实。转属阳
明。谓之太阳阳明。脾约丸润之。本少阳病。因汗渗。热入胃腑。大便燥者。大柴胡微下之。本阳
明经病。热盛。传入胃腑。谓之正阳阳明。乃本经自病也。宜调胃承气汤从中治之。盖太阳少气。
少阳少血。惟阳明居二阳之中。气血俱多。所以从中治阳明而不敢犯太阳少阳也。又三阳合病面垢
等一条。白虎加人参汤主之。不可汗下。亦从中治也。有宜汗者。表症头疼恶寒未除。为太阳尚未
过经。尤宜发汗。如太阳阳明喘而胸满者。麻黄汤。太阳少阳麻黄合小柴胡汤。通用九味羌活汤加
石膏、知母、枳壳。盖在经则汗。过经则下也。
柯琴曰。首条。本阳明病而略兼太少也。虽三阳合病。而阳明症居多。则当独取阳明矣。无表
症。则不宜汗。胃不实。则不宜下。此阳明半表里症。
首条。论病状及治方。
二条。详病脉。探病情。究病机。必两条合参。而合病之大要始得。
三条。三阳俱受气于胸中。而部位则属阳明。若喘属太阳。呕属少阳。故胸满而喘者。尚未离
乎太阳。虽有阳明可下之症而不可下。如呕多。虽有阳明可攻之症而不可攻。亦以未离乎少阳也。
四条。不言两经相合何等症。但举下利而言。是病偏于阳明矣。
五条。太阳阳明合病。太阳少阳合病。阳明少阳合病。必自下利。则下利似乎合病当
然之症。今不下利而呕。又似乎与少阳合病矣。于葛根汤加半夏。兼解少阳半里之邪。便不得为三
阳合病。
六条。两阳合病。阳盛阴虚。阳气下陷入阴中。故自下利。太阳与阳明合病。是邪初入阳明之
里。太阳与少阳合病。是邪初入少阳之里。
七条。两阳合病。必见两阳之脉。阳明脉大。少阳脉弦。此为顺脉。若大而不弦。负在少阳。
弦而不大。负在阳明。是互相克贼。皆不顺之候。
鳌按。合病并病。本兼阳明少阳。今但列太阳经者。从其先也。既列太阳。自不必复入阳明少
阳款中矣。特志于此。
[General Principle] Zhang Zhongjing stated: In San Yang He Bing (Combined Disease of the Three Yang Channels), symptoms include abdominal fullness, heaviness of the body, difficulty in turning over, numbness of the mouth and loss of taste (Kou Bu Ren) with a dirty appearance of the face, and urinary incontinence. If sweating therapy is mistakenly applied, it will lead to delirium (Chan Yu). If purgation is mistakenly applied, it will result in sweat on the forehead and cold hands and feet. If there is spontaneous sweating (Zi Han Chu), Bai Hu Tang (White Tiger Decoction) should be administered as the primary treatment. In San Yang He Bing, if the pulse is floating and large at the Guan position, and the patient desires sleep, sweating occurs when closing the eyes. In Tai Yang and Yang Ming He Bing, if there is wheezing and chest fullness, purgation is contraindicated; Ma Huang Tang (Ephedra Decoction) should be administered. In Tai Yang and Yang Ming He Bing, if there is spontaneous diarrhea (Zi Xia Li), Ge Gen Tang (Pueraria Decoction) should be administered. In Tai Yang and Yang Ming He Bing, if there is no diarrhea but only vomiting, Ge Gen Jia Ban Xia Tang (Pueraria Decoction with Added Pinellia) should be administered. In Tai Yang and Shao Yang He Bing, if there is spontaneous diarrhea, Huang Qin Tang (Scutellaria Decoction) should be given; if there is vomiting, Huang Qin Jia Ban Xia Sheng Jiang Tang (Scutellaria Decoction with Added Pinellia and Fresh Ginger) should be administered. In Yang Ming and Shao Yang He Bing, there must be spontaneous diarrhea. A pulse that does not show "Fu" (Defeat/Overcoming) indicates a favorable condition (Shun); a pulse showing "Fu" indicates an unfavorable condition (Shi). Mutual overcoming is called "Fu". If the Shao Yang pulse (Wiry) is weaker than the Fu Yang pulse (Stomach pulse), it is considered favorable.
[Detailed Commentary] Mr. Li stated: Sometimes one Yang channel becomes diseased first, followed by another; sometimes two channels become diseased simultaneously; or all three channels become diseased simultaneously. This simultaneous onset without transmission is called He Bing. "Zi Li" refers to loose stools or diarrhea. San Yang He Bing is caused by severe cold pathogen and disharmony of interior Qi. If Qi moves downward, it causes diarrhea; if Qi rebels upward, it causes vomiting. In Tai Yang combined with Yang Ming, if there is spontaneous diarrhea and aversion to cold, Sheng Ma Ge Gen Tang (Bupleurum and Pueraria Decoction) should be used; if there is aversion to heat, Bai Hu Tang (White Tiger Decoction) should be used. In Tai Yang combined with Shao Yang with spontaneous diarrhea, Huang Qin Tang (Scutellaria Decoction) should be used, possibly adding Ban Xia (Pinellia Rhizome) and Sheng Jiang (Fresh Ginger). In Yang Ming combined with Shao Yang, spontaneous diarrhea is most severe; Xiao Chai Hu Tang (Minor Bupleurum Decoction) combined with Sheng Ma Ge Gen Tang (Bupleurum and Pueraria Decoction) can be used. There are cases suitable for purgation: Originally a Tai Yang disease, due to excessive sweating or purgation leading to fluid depletion, the stomach fu becomes dry and solid, transforming into Yang Ming disease, called Tai Yang Yang Ming. Pi Yue Wan (Splei Restriction Pill) should be used to moisten. Originally a Shao Yang disease, due to sweating or diuresis, heat enters the stomach fu, causing dry stool; Da Chai Hu Tang (Major Bupleurum Decoction) should be used for mild purgation. Originally a Yang Ming Jing disease, with intense heat transmitting to the stomach fu, called Zheng Yang Yang Ming (True Yang Ming), which is a disease originating from the channel itself. Tiao Wei Cheng Qi Tang (Regulate the Stomach and Direct Downward Decoction) should be used to treat from the middle jiao. This is because Tai Yang has little Qi, Shao Yang has little Blood, while Yang Ming resides between the two Yangs and has abundant Qi and Blood. Therefore, treating Yang Ming from the middle is preferred to avoid offending Tai Yang and Shao Yang. Regarding the case of San Yang He Bing with facial dirtiness, Bai Hu Jia Ren Shen Tang (White Tiger Decoction with Added Ginseng) should be used; sweating and purgation are contraindicated, also treating from the middle. There are cases suitable for sweating: If exterior symptoms like headache and aversion to cold persist, indicating Tai Yang has not passed the stage, sweating is particularly appropriate. For example, in Tai Yang Yang Ming He Bing with wheezing and chest fullness, Ma Huang Tang (Ephedra Decoction) is used; in Tai Yang Shao Yang He Bing, Ma Huang Tang combined with Xiao Chai Hu Tang (Minor Bupleurum Decoction) is used, or generally Jiu Wei Qiang Huo Tang (Nine-Ingredient Notopterygium Decoction) added with Shi Gao (Gypsum), Zhi Mu (Anemarrhena Rhizome), and Zhi Ke (Aurantii Fructus). Generally, if the pathogen is in the exterior, use sweating; if it has entered the interior, use purgation.
Ke Qin stated: The first clause describes a Yang Ming disease slightly complicated by Tai Yang and Shao Yang. Although it is San Yang He Bing, Yang Ming symptoms predominate, so treatment should focus solely on Yang Ming. Without exterior symptoms, sweating is inappropriate; if the stomach is not solid, purgation is inappropriate. This is a half-exterior, half-interior syndrome of Yang Ming.
The first clause discusses disease manifestations and treatment formulas.
The second clause details the disease pulse, explores the condition, and investigates the pathogenesis. Both clauses must be consulted together to grasp the essentials of He Bing.
The third clause states that the Qi of the Three Yangs is received in the chest, but the location belongs to Yang Ming. Wheezing belongs to Tai Yang, vomiting belongs to Shao Yang. Therefore, chest fullness with wheezing indicates the pathogen has not yet left Tai Yang; although there are symptoms suitable for purgation in Yang Ming, purgation is contraindicated. If vomiting is frequent, although there are symptoms suitable for attacking in Yang Ming, attacking is contraindicated because the pathogen has not yet left Shao Yang.
The fourth clause does not specify the symptoms of the combination of two channels but mentions diarrhea, indicating the disease leans towards Yang Ming.
The fifth clause: Tai Yang Yang Ming He Bing, Tai Yang Shao Yang He Bing, and Yang Ming Shao Yang He Bing all necessarily involve spontaneous diarrhea, making diarrhea seem like a natural symptom of He Bing. Now, if there is no diarrhea but vomiting, it seems to combine with Shao Yang. Adding Ban Xia (Pinellia Rhizome) to Ge Gen Tang (Pueraria Decoction) helps resolve the semi-interior pathogen of Shao Yang, thus it cannot be considered San Yang He Bing.
The sixth clause: In the combination of two Yangs, Yang is excess and Yin is deficient. Yang Qi sinks into Yin, causing spontaneous diarrhea. Tai Yang and Yang Ming He Bing means the pathogen has just entered the interior of Yang Ming. Tai Yang and Shao Yang He Bing means the pathogen has just entered the interior of Shao Yang.
The seventh clause: In the combination of two Yangs, pulses of both Yangs must appear. Yang Ming pulse is large, Shao Yang pulse is wiry. This is a favorable pulse. If large but not wiry, the defeat lies with Shao Yang; if wiry but not large, the defeat lies with Yang Ming. This indicates mutual overcoming, which is an unfavorable sign.
Shen Jin'ao commented: He Bing and Bing Bing (Combined and Concurrent Diseases) originally involve Yang Ming and Shao Yang. Here, only Tai Yang channel cases are listed, following the principle of prioritizing the initial channel. Since Tai Yang is listed, it is unnecessary to repeat entries under Yang Ming and Shao Yang. This is recorded here for reference.