三：猪苓汤：治心烦不得眠，咳而呕渴下利，下焦水热相并者，（雪按：黄连阿胶汤育阴清热，猪苓汤育阴利水，治心烦不得眠同，而兼证相异得也。又少阴本但欲寐为主证，此即心烦不得眠为要点，是正相对举，可资研究者也。此二条皆缓证，与虚寒实热急证重证，远相异民。至四逆散是厥阴少阴相错之治，谓少阴病极不合，其冒首三字，必误不疑。又若桃花汤，虽唯忠发明是真武汤证服后不效，继见便脓血之治方，以日数见证等为言，似甚有理，然终觉牵合，不似仲师原法之率真简白，余谓桃花汤之治虚寒下利便脓血，与白头翁之治热利下重口渴，赤石脂禹余粮之治下焦滑脱下利，原不必限定厥阴少阴证也，一是肠寒，一是肠热，一是肠滑不收，同为下利对证治疗之妙法，所云伤寒转杂病坏证者是也。必斤斤于厥阴少阴云云，反失活泼用方之妙矣。其它咽痛咽疮诸方，不过少阴治标之药耳，浅田言是，正珍谓是叔和掺入，原非属少阴原文，尤爽绝也。瓜蒂散，以证相似对示之条，原非本门所有，更不论焉。少阴厥阴门中，因类证变异这故，所收非本门应有条甚多，后人每作本门病解之，大误也。至本门应有之文，又多散见太阳三篇之内，须意会收辑之，以便归纳而分析焉。
获野原凯曰：天明间，温疫流行，其证似胃实，而微见阴状，殆与岭南瘴疟类，医用大黄则死，用附子则生，尔后年年所行，疫证颇同，多用附子以免危，其以大黄治者，十不过二三也。
梯谦曰：天宝间，凡疫汛滥，阖门伏枕，大率上盈下虚及少阴证，当时遵用古方者，专为汗下，或主吴氏疫论，荐投驶药，而不顾正气之亏，故服大黄死者，十居其九，服附子死者，百中一二耳。
辨厥阴病：
盖厥阴者，三阴之极，无有所传，然物极则必反，于是有阴变阳，寒化热之证，（物极必变，阴变阳，寒化热之语，厥阴主旨）。
雪按：由少阴而厥阴，其极而不变化者，则诚如山田正珍所云，厥阴为至深至极之候，其文虽缺，以意推之：四肢厥逆，烦躁吐利，脉微欲绝等等，固不竢言，当较少阴证为更急焉，然如篇中所载吴茱萸汤条，四逆汤条，通脉四逆汤条，均为少阴篇所固有之证，浅田所谓“治法与少阴极地者无异”是也，然则何必于少阴之外另立厥阴一门哉？知其所重不独在此，而另注目于阴变阳，寒化热之证，此证则厥阴所独。如《素问·热论》，六日厥阴之后渐有来复之机者，则物极必变之理，而厥阴篇中热厥互见诸条所渊源者也。又按：先热者后必厥，先厥者后必热，热五日，厥亦五日，若厥日少，热日多，为欲愈。则热不退纯从热化，或咽痛，或便脓血，必居其一，此余热蕴留之所致也。若热日少，厥日多，则于病为进，为阳气衰少而有偏，或少阴虚寒厥逆之证之倾向矣，故吾谓厥阴之厥，倘不热而从寒化，则是少阴，倘热盛而从热化，则有向愈之机，转向少阳之机会，原文所谓“厥而发热，下利必自止”，正是阳回胜阴之表示也。山田但知至深至极一面，而不知另一面实有阴尽阳生之机，故谓厥阴之要文已止，浅田宗伯则知之而未能畅其旨，所论如干姜黄连黄芩人参汤之于吐下，是化热未离虚寒者也，白头翁汤之于下利渴欲饮水，则已专于热者也，二条尚是厥阴正证，至如小柴胡汤条，是呕吐之比较证，栀子豉汤条是烦躁之比较证，小承气汤是下利之比较证，白虎之热厥条，瓜蒂之寒实厥条，茯苓甘草之心下有水悸厥条，均是因厥一条引为较比者，种种均与厥阴无关，不过以其证相近，列于一处，以资辨别耳。此或后人所排者，非一定原次也，乃浅田均以为寒化热之治法及旁证，岂非大误耶？吾固谓其虽知而未能畅其旨也。
又按：厥阴消渴，气上撞心一条，直宽士粟以为上热下寒，极合。正珍谓叔和所撰者非也。乌梅丸主之，厥阴正经也，烦躁有时，得食呕吐，吐蛔而厥之蛔厥，亦厥阴正证，乌梅丸所言同也。若脏寒脏厥，脉微肤冷，躁无暂安时者，浅田谓治与少阴无异，则当用四逆白通辈矣，吾谓从躁无暂安时着想，从厥阴脏寒论治，则干呕吐涎沫之吴茱萸汤，大可借用，且少阴病之吐利烦躁欲死者，亦借用此方，则本门之躁无暂安者，不更合耶？当以兼证旁参之。
三阴皆元气不足，肠胃虚乏，邪气直入，攻夺真元者，故见自利，厥逆，脉沉细，呕哕振寒等证，治宜理中，四逆，吴茱萸，白通等，譬飞骑突入重围，使既散真阳复合，以胜阴复阳者也。
雪按：此但就三阴虚寒一面泛而论之，大概虽尔，非精细辨认也，中川故曰：凡每岁自春至秋初，少阴状者多，此为常。然厥阴状者亦间杂其中，治深以浅祸不旋踵。又曰：余幼时太阴状者流行，名护屋玄医之徒能治之，大有声誉。其后少阴之状者大行，当时余既过冠，故亲疗之，（雪按：此日殆亦少阴之状者大行其道之时也，否则，何以人人桂附，乃不为害耶？附记一笑。）然此二者，世未有载之书者，故当今虽多有厥阴状者，漫然疗这，无得其治法者也。
雪按：此说颇新奇，殆即陆九芝所云大司天运气所系之故欤。医家每云见证治证最妙，于此运会推移之说，十九不然，然观今日沪医家之大用桂附，亦殊有效，则此说不为无理，故录以备考，且此以六经治法分属之，似更明白了当，易于仿学者焉。
辨合病：
合者同也，会也，二病三病相混也，谓之合病。盖其初感邪表里同时受病，故设此目，以为治法之标准也。张介宾曰：今时之病，皆合病并病耳，合并二者，治法之紧关，不可不明核，若内外并治，则不止难愈，百坏变出，古人云，发表未除，不可攻里，上盛未除，不可攻下，亦合病之谓也。
雪按：此说非一定，如经方桂枝人参汤，桂枝大黄汤均表里并治之方也，须审证所要而施，不可一言限定耳。又按：三阳合病，多是伏邪蕴发热证，如太阳阳明合病，葛根黄芩黄连汤（而浅田所云：热盛于表，势迫及里，下奔为利，上逆为呕者是也，原文葛根汤是或误，浅田因之，未详审矣。至不下利但呕之葛根加半夏证，乃太阳阳明合病轻证，所以示别于必自下利，伏邪蕴发之合病重证也。以二条相连，人多信为一方不疑，不知其大有不同者也）。少阳明明合病，黄芩汤（原文是太阳少阳，余早疑是少阳阳明，已见开美本伤寒批上），又阳明少阳合病，大承气汤，均必自下利，均治以苦寒清下之剂，而三阳合病之口不仁，面垢，谵语，遗尿，腹满，身重难转侧，若自汗出者，白虎汤主之。更可见是伏温蕴发，三阳混合之证无疑矣。
安时云：三阳皆有合病，三阴无合病，刘茝庭曰：三阴病机虽各异，其位相同，此所以无合病。中西深斋曰：三阴不设合病之名，直举其脉证，以具之治法耳。
雪按：三阴未尝无合病，第温里之药，大概相同，故不举其名，但具之脉证治法中耳。如少阴之吐利，烦躁欲死，则厥少二阴同病也，少阴见厥，十九皆同厥阴，又有阴阳合病者，如下利清谷，里寒外热，身体疼痛，先温其里，乃攻其表，温里四逆，攻表桂枝等条，即是阴阳合病之证也。庞言既非，刘言亦未妥，须辨之。
雪又按：合病是伏邪各自蕴发，同时而见，其症重剧，并病是一邪转移变化，其证轻减，此合病与并病大异之点，山田诸公但知合病为重，而不解其所以然也。浅田亦然，兹特举之。
辨并病：
张璐玉曰：并病者，一阳经病未罢，又加一经证见，二经连贯为病也。
雪按：并病是一邪转移传变，与合病之由蕴伏自发者，大不相同，浅田乃谓合病与并病虽有缓急之别，于其治法，则无有异焉，大谬甚矣。盖由未细审仲师所用合病诸方之故，粗疏之过难辞。大法，太阳阳明并病，太阳表病未罢者，当先表后里，太阳证罢，但有阳明证者，始可攻里也。太阳少阳并病，柴胡桂枝汤太少并治（原文太少并病之条，一，头项强痛或眩冒，或如结胸，心下痞硬者，慎不可发汗，汗则谵语。二，心下硬，颈项强而眩也，慎勿下之。）
雪按：不可下，固也，不可汗，汗则谵语，转或胃中燥实，殆指麻黄葛根等大发汗剂而言，若桂枝当不在此例，则太少并病，亦当先治太阳，则当用桂枝无疑，今以桂柴各半为治，则最妥当之法矣。太阳证罢，但有少阳证者，小柴胡汤和之。少阳阳明并病，先治少阳，（雪按：如阳明病胁下硬满及阳明病胸胁满不去者，均以小柴胡治之是也，畑惟和曰：论中合并之病，阳明多，少阳少，则言阳明病，实则冒首无关系也）或阳明证多者，则两顾之，而仍以少阳为重，如柴胡加芒硝汤是也。
雪按：此余节其所言这大概而分析之，得先后之例如上，可见三阳并病，先表后里为必然之理，此就三阳浅深表里见证，而分别论治，固有大用，以现在所见之症，一经单纯者少，唯合病之旨，深微难解，而症又重剧，较此并病相去宵壤，昔人多以合并并言岂知其中固远有别耶？余于合病一层，颇多创获，另文详之，此特示意耳。辨表热里寒（雪按：浅田此篇无甚发明，且举例亦未清晰妥当，今依其所言，而再为分析之如下）
一：表有邪而里寒者，治分二法，其证如外有寒热表证，而里下利清谷者。先里后表，例如先服四逆汤治里寒下利清谷，后以桂枝汤治身体疼痛之表，此先里后表之治也。
表里并治：例如桂枝人参汤一方，中含理中以治下利，桂枝一味，以解表邪，此并治也。大概里重于表者，先里后表，如第一例下利是少阴证，故先治里也。第二例下利是太阴证，不若少阴之甚，故可表里并治焉。
一：表热全是假象，里寒却为真寒，因真寒而见假热，如少阴厥阴下利清谷，里寒外热诸条皆是。但里无表，例如四逆汤之治内寒外热，下利清谷，通脉四逆汤之治里寒外热亦然，所谓真寒假热，一于救里是也。
雪按：表热里寒，不出上列二大法，及三种方治，至如桂枝加附子汤，桂枝去芍加附子汤等，是表未解而阳已虚，不在此例之中，浅田之言固然，唯桂枝人参汤证，则正在此例中者，乃也谓在例外，误矣。附子泻心汤与表热里寒不和，是寒热错杂之治，不当征引及之也。又首引太阴病脉浮桂枝汤，少阴病反发热麻黄附子细辛汤，甘草汤二条，谓是从表治，及表里相参之治之例，亦微有不和，二证是阴经本经受邪治法，非表里并病也，唯麻黄附子细辛之治，亦可如桂枝人参汤之例，列在表里并治中乎？则余尚以为不可，盖里寒以自利为主，此无自利也。况原文明谓无里证，不过因阴经受寒，故用温经以散寒耳。当与桂枝加附等汤证，，事属例外，乃引为正例，其不当甚矣。此浅田见识所未及，辨认所示真也欤。
表热里寒：则先表而后里，先实里者，恐脱证悠至，邪也从陷也，里既实，从事于表，亦不为迟。
雪按：温里之药，且也兼能散表寒也。
表热里实：则先表而后里，先攻表者，恐表邪并入，里热壅重也，表已解，从事于里，亦不为迟，设先攻里，则胃空邪乘，为坏病矣。
雪按：此刘茝庭说也。仲景明律，确如此分别，甚隹。畑唯和曰：里寒格阳，虽身有大热，内证口虽干渴，必不喜冷，饮不多，舌虽有黑，苔必滑润，或小水清频，气短懒言，色暗神倦，或错语郑声，或斑如蚊迹，浅红细碎，与紫赤极热者不同，此假斑也。假热之脉，必沉细迟弱，或虽浮大紧数，而无力无神，此热在皮肤，寒在脏腑，但使元阳渐复，热必退藏，外台秘要曰：阴躁欲坐井中，宜热药，须冷服，热因寒用之法也。
假热象：大热大渴，舌短舌肿，唇焦齿逢出血，谵语发狂，手足躁扰，捻衣摸床，肌热如蒸如火辽，面目俱赤，烦躁有汗，欲坐卧于水中。
真寒据：脉七八至，按之则散，或洪而数，弦而大，按之则真虚或全无，舌白苔而滑，或质黑而光润。
此阳浮于外，阴伏于内，内真寒而外假热，无根之火也，宜用大剂回阳，肾气，参附，四逆之属，冷饮之，虚火归源，诸证自止。
此节录李明之说也。
雪按：仲师之言，真寒假热也，必以下利清谷为主候，此真寒之确据也，确据既得，假象可明矣。再以脉之细微欲绝，合之身之大热而手足厥冷，尚何可疑耶？其言简而明，人人可知可举者也，后贤则论过玄奥，甚至谓大便闭结，小便赤涩者，亦有假热象（如畑唯和所云，未录入）即如明之所辨，虽似详备，然均不言下利清谷一主候也，于许多热证证据中，仅凭脉之空虚一点，而投死生系焉之药，戛戛乎难矣哉，与仲师之法平易近人，证据充足者，大相悬疑矣。吾意后贤所言，虽高而空，若过信之，一有不当，贻祸非浅，不若仲师之脚踏实地，不衿奇而真确可靠也，吾从仲师矣。
辨外寒里热：
一：假寒真热：
一名热厥，是阳气郁内，不能四布于外也，以祛里热为主。
大承气：胃家燥实，热实而厥者也。
3. Zhu Ling Tang (Polyporus Decoction): Treats irritability and inability to sleep, cough accompanied by vomiting, thirst, and diarrhea, which is a condition where water-dampness and heat pathogen intertwine in the Lower Jiao (Lower Burner). (Cheng Menxue's commentary: Huanglian Ejiao Tang (Coptis and Donkey-Hide Gelatin Decoction) nourishes Yin and clears heat, while Zhu Ling Tang nourishes Yin and promotes urination to remove dampness; both treat irritability and insomnia, but their accompanying symptoms differ. Furthermore, the main symptom of Shaoyin disease (Lesser Yang disease affecting the Heart and Kidney channels) is "danyu mei" (desire to sleep); here, "irritability and inability to sleep" is the key point, offering a direct contrast for researchers. These two clauses belong to mild conditions, far removed from the urgent and severe conditions of deficiency-cold or excess-heat. As for Sini San (Frigid Extremities Powder), it treats the intermingling of Jueyin (Terminal Yin) and Shaoyin pathogenesis. To say that Shaoyin disease is extremely inconsistent with this is certain; the first three characters of the title must be erroneous. Regarding Taohua Tang (Peach Blossom Decoction), although only Zhong clarified that it is the formula used when Zhenwu Tang (True Warrior Decoction) fails and dysentery with pus and blood subsequently appears, basing its indication on days and symptoms seems reasonable, yet I still feel it is forced and not as straightforward and simple as Zhang Zhongjing's original methods. I believe Taohua Tang treats deficiency-cold diarrhea with pus and blood, Baitouweng Tang (Patrinia Decoction) treats heat-type diarrhea with tenesmus and thirst, and Chishizhi Yuyuliang Tang (Red Halloysite and Hematite Decoction) treats Lower Jiao sliding and unconsolidated diarrhea. Originally, these need not be limited to Jueyin or Shaoyin syndromes; they correspond respectively to intestinal cold, intestinal heat, and intestinal looseness without retention, all being excellent methods for treating diarrhea based on specific indications, referring to the transformation of Shanghan (Cold Damage) into miscellaneous diseases or complicated conditions. If one sticks rigidly to classifying them as Jueyin or Shaoyin syndromes, one loses the subtlety of flexible formula application. Other formulas for sore throat and throat ulcers are merely symptomatic treatments for Shaoyin disease; Sayama Sohaku (Asada Souhaku) was correct, and Zhengzhen believed they were interpolated by Wang Shuhe and did not originally belong to the Shaoyin text, which is particularly conclusive. Gouti San (Melon Seed Powder) is listed due to similar symptoms for comparison and does not originally belong to this category, so there is no need to discuss it further. In the Shaoyin and Jueyin chapters, due to the variation in classified syndromes, many clauses included do not originally belong to these categories. Later scholars often interpret them as diseases of these categories, which is a major error. The texts that should belong to these chapters are mostly scattered within the three chapters of Taiyang (Greater Yang), requiring careful collection and organization for induction and analysis.
Kano Haruka stated: During the Tenmei era, warm epidemics prevailed. The symptoms resembled Yangming Fu syndrome (Excess Heat in the Stomach and Intestines) but slightly showed Yin signs, likely similar to malarial fevers in the Lingnan region. Physicians who used Dahuang (Rhubarb Root) caused death, while those who used Fuzi (Aconite Lateral Root) brought life. Thereafter, annual epidemics were quite similar; using Fuzi avoided danger, while using Dahuang succeeded in only two or three out of ten cases.
Ti Qian stated: During the Tianbao era, whenever plagues flooded, entire families lay sick in bed. Generally, these were cases of upper fullness and lower deficiency, or Shaoyin syndromes. Physicians adhering to ancient formulas focused solely on sweating or purging, or advocated Wu Youxing's theories on plagues, recommending harsh medicines without regard for the depletion of healthy Qi. Consequently, nine out of ten died from taking Dahuang, while only one or two out of a hundred died from taking Fuzi.
Differentiating Jueyin Disease:
Jueyin represents the extreme of the Three Yin stages, with no further transmission. However, when things reach an extreme, they must reverse, leading to conditions where Yin transforms into Yang and Cold transforms into Heat. (The principle that extremes reverse, Yin transforms into Yang, and Cold transforms into Heat, is the main theme of Jueyin.)
Cheng Menxue's commentary: Transmission from Shaoyin to Jueyin, if reaching the extreme without change, aligns with Yamada Masazumi's statement that Jueyin is a state of utmost depth and extremity. Although the text is lacking, inferring by meaning: limb coldness and reversal, irritability, vomiting and diarrhea, and a faint pulse nearly imperceptible are certainly beyond saying; these should be more urgent than Shaoyin syndromes. However, the Wuzhuyu Tang (Evodia Decoction) clause, Sini Tang (Frigid Extremities Decoction) clause, and Tongmai Sini Tang (Pulse-Recovering Frigid Extremities Decoction) clause recorded in the chapter are inherent to the Shaoyin chapter. This is what Asada Sohaku meant by "the treatment method is no different from that of Shaoyin at its extreme." Then why establish a separate Jueyin category outside of Shaoyin? It is known that the emphasis is not solely here, but also on the conditions where Yin transforms into Yang and Cold transforms into Heat, which are unique to Jueyin. As stated in *Suwen·Re Lun* (Plain Questions: Treatise on Febrile Diseases), after the sixth day of Jueyin, there is a gradual opportunity for recovery, reflecting the principle of reversal at the extreme, which is the origin of the alternating heat and cold-jue clauses in the Jueyin chapter. Furthermore: Those who heat first will later experience cold-jue; those who have cold-jue first will later heat up. If fever lasts five days and cold-jue lasts five days, but cold-jue days are fewer and fever days are more, it indicates impending recovery. If fever persists and transforms entirely into heat, either sore throat or dysentery with pus and blood will occur, as this is caused by lingering residual heat. If fever days are few and cold-jue days are many, the disease progresses, indicating a decline in Yang Qi or a tendency toward Shaoyin deficiency-cold cold-jue. Therefore, I say that Jueyin cold-jue, if it does not heat up but transforms into cold, belongs to Shaoyin; if heat is excessive and transforms into heat, there is a chance of recovery and turning toward Shaoyang. The original text states, "Cold-jue accompanied by fever, diarrhea will stop spontaneously," which is precisely a sign of Yang returning and overcoming Yin. Yamada Masazumi knew only the aspect of utmost depth and extremity but ignored the other aspect of Yin exhaustion and Yang birth. Thus, he claimed the essential text of Jueyin had ended. Asada Sohaku knew this but failed to expound its essence fully. His discussion on Ganjiang Qinlian Huangqin Renshen Tang (Galanga, Coptis, Scutellaria, and Ginseng Decoction) for vomiting and diarrhea represents heat transformation not yet脱离ting deficiency-cold; Baitouweng Tang for diarrhea with thirst and desire to drink water focuses entirely on heat. These two clauses are still proper Jueyin syndromes. The Xiaochaihu Tang (Minor Chest Guardian Decoction) clause is a comparative case for vomiting; the Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) clause is a comparative case for irritability; the Xiaochengqi Tang (Minor Order the Qi Decoction) is a comparative case for diarrhea; the Baihu Tang (White Tiger Decoction) heat-jue clause, Gouti San cold-excess jue clause, and Fuling Gancao Tang (Poria and Licorice Decoction) heart-fullness with water palpitation jue clause are all cited for comparison due to the "jue" symptom. None of these are related to Jueyin; they are merely grouped together because their symptoms are similar, for differentiation purposes. This may be the arrangement of later scholars, not necessarily the original order. Yet Asada Sohaku considered all of them as treatment methods for cold transforming into heat and collateral evidence, which is a great error. I maintain that he knew but could not fully expound the essence.
Furthermore: The Jueyin clause on xiaoke (wasting-thirst) and qi rushing up to strike the heart, Naohiro Shiosu correctly identified as upper heat and lower cold. Zhengzhen claimed it was written by Wang Shuhe, which is incorrect. Wumei Wan (Mume Pill) is the primary treatment, representing the proper Jueyin channel. Irritability occurring at times, vomiting after eating, and vomiting roundworms accompanied by cold-jue constitute huijue (roundworm cold-jue), which is also a proper Jueyin syndrome, consistent with what Wumei Wan addresses. If it is zang han (visceral cold) or zang jue (visceral cold-jue), with a faint pulse, cold skin, and restlessness with no moment of peace, Asada said the treatment is no different from Shaoyin, implying the use of Sini Tang or Baitong Tang. I argue that considering "restlessness with no moment of peace" and treating from the perspective of Jueyin visceral cold, Wuzhuyu Tang for dry vomiting and spitting saliva can be borrowed. Moreover, for Shaoyin disease with vomiting, diarrhea, and irritability desiring death, this formula can also be borrowed; thus, for the restlessness in this category, is it not even more suitable? One should consider accompanying symptoms for reference.
Diseases of the Three Yin involve insufficient Yuan Qi (Original Qi), deficiency and weakness of the intestines and stomach, allowing pathogens to enter directly and attack the True Yuan. Hence, symptoms such as spontaneous diarrhea, cold-jue, deep and fine pulse, vomiting, hiccupping, and chills appear. Treatment should employ Lizhong Tang (Regulate the Middle Decoction), Sini Tang, Wuzhuyu Tang, Baitong Tang, etc., akin to a mounted rider breaking through heavy encirclement, causing the scattered True Yang to recombine and overcome Yin to restore Yang.
Cheng Menxue's commentary: This discusses only the deficiency-cold aspect of the Three Yin generally. Although broadly true, it lacks precise differentiation. Nakagawa stated: From spring to early autumn each year, Shaoyin-pattern illnesses are common, which is normal. However, Jueyin-pattern illnesses also occur intermittently; treating a deep illness lightly leads to immediate disaster. He also said: In my youth, Taiyin-pattern illnesses prevailed, and a physician named Miya Gen'i could treat them, gaining great fame. Later, Shaoyin-pattern illnesses became prevalent. By then, I was past adulthood, so I treated them personally. (Cheng Menxue notes: This period was likely when Shaoyin-pattern illnesses were rampant; otherwise, why would everyone using Guizhi (Cinnamon Twig) and Fuzi cause no harm? Recorded for a smile.) However, neither of these situations was recorded in books, so today, although many Jueyin-pattern illnesses exist, random treatment yields no correct method.
Cheng Menxue's commentary: This view is quite novel, likely relating to Lu Jiuzhi's theory of Da Sitian (Great Heavenly Master) climate and Qi dynamics. Physicians often claim that treating symptoms as they appear is best, but regarding this theory of shifting climate cycles, most disagree. However, observing that contemporary Shanghai physicians effectively use large amounts of Guizhi and Fuzi, this theory is not without merit. Thus, it is recorded for reference. Classifying Six Meridian treatment methods this way seems clearer and easier for students to emulate.
Differentiating Combined Diseases (He Bing):
"He" means same or meeting. When two or three diseases mix, it is called Combined Disease. Generally, this occurs because the initial pathogenic invasion affects both exterior and interior simultaneously. This category is established as a standard for treatment methods. Zhang Jiebin stated: Modern diseases are all combined and concurrent diseases. Merging the two is a critical link in treatment and must be clearly understood. Treating both interior and exterior simultaneously makes cure difficult and invites various complications. The ancients said, "If the exterior has not been released, the interior cannot be attacked"; "If upper fullness has not been resolved, downward purging cannot be performed." This refers to combined diseases.
Cheng Menxue's commentary: This statement is not absolute. For example, Jingfang (Classical Formulas) like Guizhi Renshen Tang (Cinnamon Twig and Ginseng Decoction) and Guizhi Dahuang Tang (Cinnamon Twig and Rhubarb Decoction) are formulas that treat both exterior and interior simultaneously. Treatment must be tailored to the specific needs of the syndrome and cannot be limited by a single statement. Furthermore: Three-Yang combined diseases are mostly latent pathogens accumulating and generating heat. For instance, Taiyang-Yangming combined disease uses Gegen Qinlian Tang (Kudzu, Scutellaria, Coptis, and Licorice Decoction). (Asada noted: Heat is excessive on the exterior, pressing inward, causing downward flow as diarrhea and upward rebellion as vomiting. This is correct. The original text mentions Gegen Tang, which may be an error; Asada followed this without detailed examination. The clause for Gegen plus Banxia Decoction, where there is no diarrhea but only vomiting, is a mild case of Taiyang-Yangming combined disease, shown to distinguish it from the severe case of latent pathogen accumulation with inevitable diarrhea. Because these two clauses are linked, people mistakenly believe they are the same formula, unaware of their significant differences.) Shaoyang-Yangming combined disease uses Huangqin Tang (Scutellaria Decoction) (The original text says Taiyang-Shaoyang, but I long suspected it was Shaoyang-Yangming, as seen in Kaimei's annotations on Shanghan). Yangming-Shaoyang combined disease uses Dachengqi Tang (Major Order the Qi Decoction). Both inevitably present with diarrhea and are treated with bitter-cold clearing and purging agents. In contrast, Three-Yang combined disease presenting with loss of taste/speech (kou bu ren), greasy face, delirium, urinary incontinence, abdominal fullness, heaviness making turning difficult, and spontaneous sweating is treated with Baihu Tang (White Tiger Decoction). This confirms beyond doubt that these are conditions of latent warm pathogens accumulating and manifesting across all Three Yangs.
An Shi stated: All Three Yangs have combined diseases, but the Three Yin do not. Liu Chaiting stated: Although the pathogenesis of the Three Yin differs, their locations are the same, which is why there are no combined diseases. Zhongxi Shen-zhai stated: The Three Yin do not name combined diseases; they simply list the pulse and symptoms to provide corresponding treatments.
Cheng Menxue's commentary: The Three Yin do have combined diseases, but since warming interior herbs are largely the same, the name is not emphasized, appearing only in the pulse, symptoms, and treatment descriptions. For example, Shaoyin vomiting, diarrhea, and irritability desiring death indicate simultaneous disease of Jueyin and Shaoyin. Shaoyin presenting with jue coincides with Jueyin in ninety percent of cases. There are also Yin-Yang combined diseases, such as diarrhea with undigested food, interior cold with exterior heat, and body pain. First warm the interior, then attack the exterior; warming the interior uses Sini Tang, attacking the exterior uses Guizhi Tang, etc. These are examples of Yin-Yang combined diseases. Pang's statement is incorrect, and Liu's statement is imprecise; they require discrimination.
Cheng Menxue further notes: Combined disease involves latent pathogens accumulating and manifesting simultaneously, resulting in severe symptoms. Concurrent disease (Bing Bing) involves the shift and transformation of a single pathogen, with milder symptoms. This is the major difference between combined and concurrent diseases. Scholars like Yamada knew combined disease was severe but did not understand why. Asada was the same; I highlight this specifically.
Differentiating Concurrent Diseases (Bing Bing):
Zhang Lu Yu stated: Concurrent disease occurs when a disease in one Yang meridian has not resolved, and symptoms of another meridian appear, with two meridians connected in disease.
Cheng Menxue's commentary: Concurrent disease involves the transfer and progression of a single pathogen, greatly differing from combined disease where pathogens accumulate and manifest spontaneously. Asada claimed that although combined and concurrent diseases differ in urgency, their treatment methods are identical. This is a gross error, likely due to failing to carefully examine the combined disease formulas used by Zhang Zhongjing, an oversight of carelessness. The general principle: In Taiyang-Yangming concurrent disease, if the Taiyang exterior pathogen has not resolved, release the exterior first, then treat the interior. Only when Taiyang symptoms resolve and only Yangming symptoms remain can the interior be attacked. In Taiyang-Shaoyang concurrent disease, use Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) to treat both Taiyang and Shaoyang. (Original text clauses for Taiyang-Shaoyang concurrent disease: 1. Stiffness and pain in the head and neck, or dizziness, or feeling like chest binding, with epigastric hardness. Do not sweat; sweating causes delirium. 2. Epigastric hardness, stiffness in the neck, and dizziness. Do not purge.)
Cheng Menxue's commentary: Purging is indeed contraindicated. Sweating is contraindicated because sweating causes delirium and may lead to dryness and excess in the stomach, likely referring to strong diaphoretics like Mahuang (Ephedra) and Gegen. If Guizhi is used, it is not in this category. Thus, for Taiyang-Shaoyang concurrent disease, treating Taiyang first with Guizhi Tang is undoubtedly correct. Using a half-half combination of Guizhi and Chaihu is the most appropriate method. When Taiyang symptoms resolve and only Shaoyang symptoms remain, use Xiaochaihu Tang to harmonize. In Shaoyang-Yangming concurrent disease, treat Shaoyang first. (Cheng Menxue notes: For Yangming disease with hardness under the hypochondrium or persistent fullness in the chest and hypochondrium, Xiaochaihu Tang is used, which is correct. Hata Yowa stated: In the Treatise, concurrent diseases mention Yangming more often than Shaoyang, so mentioning Yangming disease is just a heading unrelated to the core issue.) Or, if Yangming symptoms predominate, address both, prioritizing Shaoyang, such as using Chaihu Jia Mangxiao Tang (Bupleurum with Natron Decoction).
Cheng Menxue's commentary: This is my analysis of the general principles, deriving examples of sequence as above. It shows that for Three-Yang concurrent diseases, treating the exterior before the interior is an inevitable principle. This distinguishes treatment based on the depth and exterior-interior nature of Three-Yang manifestations, which is highly useful. Given current clinical presentations, pure single-meridian diseases are rare. The essence of combined disease is profound and difficult to understand, with severe symptoms, vastly different from concurrent disease. Ancients often conflated combined and concurrent diseases, not realizing the significant distinction. I have made many innovations regarding combined disease, detailed in another paper; here I merely illustrate the concept. Differentiating Exterior Heat and Interior Cold (Cheng Menxue notes: Asada's chapter lacks significant insight and unclear examples. I analyze his statements below.)
1. Exterior pathogen with Interior Cold: Treatment divides into two methods. Symptoms include exterior cold-heat signs with interior diarrhea of undigested food. Treat interior first, then exterior. For example, first administer Sini Tang to treat interior cold and diarrhea of undigested food, then use Guizhi Tang to treat body pain (exterior). This is treating interior first, then exterior.
Exterior and Interior Simultaneous Treatment: For example, Guizhi Renshen Tang contains Lizhong Tang to treat diarrhea and a dose of Guizhi to release the exterior pathogen. This is simultaneous treatment. Generally, when interior is heavier than exterior, treat interior first, then exterior. In Example 1, diarrhea is a Shaoyin syndrome, so treat interior first. In Example 2, diarrhea is a Taiyin syndrome, less severe than Shaoyin, so simultaneous treatment is possible.
1. Exterior heat is entirely false, while interior cold is true cold. False heat appears due to true cold, as seen in Shaoyin and Jueyin clauses on diarrhea of undigested food, interior cold with exterior heat. But there is no exterior pathogen. For example, Sini Tang treats internal cold with external heat and diarrhea of undigested food; Tongmai Sini Tang similarly treats interior cold with exterior heat. This is true cold with false heat, focusing solely on rescuing the interior.
Cheng Menxue's commentary: Exterior heat and interior cold do not exceed the two major methods and three formula treatments listed above. Guizhi Jia Fuzi Tang (Guizhi Decoction plus Aconite) and Guizhi Qu Shaoyao Jia Fuzi Tang (Guizhi Decoction minus Peony plus Aconite) represent unresolved exterior with deficient Yang, falling outside this category. Asada's statement is correct, except that Guizhi Renshen Tang falls exactly within this category, yet he excludes it, which is an error. Fuzi Xiexin Tang (Aconite and Pinellia Decoction) addresses mixed cold and heat, not exterior heat and interior cold, and should not be cited. Also, citing Taiyin disease with floating pulse treated with Guizhi Tang, and Shaoyin disease with fever treated with Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction) and Gancao Tang (Licorice Decoction) as examples of treating from the exterior or combining interior and exterior is slightly inaccurate. These two cases are treatments for pathogens invading the primary meridians of the Yin channels, not concurrent exterior-interior diseases. Can Mahuang Fuzi Xixin Tang be listed under simultaneous exterior-interior treatment like Guizhi Renshen Tang? I still think not, as interior cold primarily presents with spontaneous diarrhea, which is absent here. Moreover, the original text explicitly states "no interior symptoms"; it merely uses warming meridians to dispel cold due to Yin channel cold invasion. This belongs to exceptions like Guizhi Jia Fuzi Tang, yet it is cited as a standard example, which is highly inappropriate. This reflects Asada's limited insight and failure to discern truth.
Exterior Heat with Interior Cold: Treat exterior first, then interior. Solidifying the interior first prevents collapse and sinking of pathogens. Once the interior is solid, treating the exterior is not too late.
Cheng Menxue's commentary: Warming interior herbs can also disperse exterior cold.
Exterior Heat with Interior Excess: Treat exterior first, then interior. Attacking the exterior first prevents exterior pathogens from merging inward and worsening interior heat. Once the exterior is resolved, treating the interior is not too late. If the interior is attacked first, the stomach becomes empty, pathogens exploit the void, leading to complicated diseases.
Cheng Menxue's commentary: This is Liu Chaiting's view. Zhang Zhongjing's clear rules indeed differentiate this so well, which is excellent. Hata Yowa stated: In interior cold repelling Yang, although the body has high heat, internally, despite dry mouth and thirst, there is no preference for cold drinks, and intake is small. The tongue may be black, but the coating is slippery. Urine may be clear and frequent. There may be shortness of breath, reluctance to speak, dark complexion, spiritual fatigue, confused speech, or repetitive murmurs. Spots may resemble mosquito bites, light red and fine, differing from the deep purple-red of extreme heat; this is false spotting. The pulse of false heat must be deep, fine, slow, and weak, or if floating, large, tight, and rapid, it lacks force and spirit. Heat is in the skin, cold in the viscera. If Yuan Yang gradually recovers, heat will retreat and hide. *Waitai Miyao* states: Yin restlessness desires sitting in a well; hot medicine should be taken cold, a method of using heat due to cold.
False Heat Signs: Great heat and thirst, short and swollen tongue, cracked lips, bleeding gums, delirium and madness, restless limbs, picking at clothes and beds, skin heat like steaming or fire, red face and eyes, irritability with sweat, desire to sit or lie in water.
True Cold Evidence: Pulse rapid (7-8 beats per breath) but scattering upon pressure, or surging and rapid, string-taut and large, but truly deficient or imperceptible upon pressure. Tongue white with slippery coating, or black body but glossy.
This is Yang floating on the exterior and Yin hiding inside, true interior cold with false exterior heat, rootless fire. Use large doses of Yang-restoring formulas such as Shenqi Tang, Shenfu Tang, or Sini Tang, taken cold. When deficient fire returns to its source, symptoms cease.
This excerpt records Li Ming's views.
Cheng Menxue's commentary: Zhang Zhongjing's description of true cold with false heat must take diarrhea of undigested food as the primary symptom, which is the definitive evidence of true cold. Once this evidence is obtained, false signs become clear. Combining the faint, nearly imperceptible pulse with high body heat and cold extremities, what remains to doubt? His words are concise and clear, understandable to all. Later scholars' discussions are overly abstruse, even claiming that constipation and dark, scanty urine can also present false heat signs (as Hata Yowa stated, not included here). Even with Li Ming's detailed differentiation, none mention the primary symptom of diarrhea of undigested food. Among many heat evidence points, relying solely on the emptiness of the pulse to administer life-or-death drugs is extremely difficult. This contrasts greatly with Zhang Zhongjing's approach, which is accessible, well-evidenced, and reliable. I believe later scholars' theories, though high-sounding, are empty. Over-reliance on them risks grave consequences if misapplied. It is better to follow Zhang Zhongjing's down-to-earth, non-mystical, and accurate methods. I follow Zhang Zhongjing.
Differentiating Exterior Cold and Interior Heat:
1. False Cold with True Heat:
Also known as Re Jue (Heat Cold-Jue), where Yang Qi is constrained internally and cannot circulate to the exterior. Treatment focuses on clearing interior heat.
Sini San (Frigid Extremities Powder): Pathogen obstructing the semi-exterior semi-interior causing cold-jue.
Baihu Tang (White Tiger Decoction): Heat結 (accumulated) in the interior, diffuse without excess, with great irritability and thirst, slippery pulse and cold-jue.
Dachengqi Tang (Major Order the Qi Decoction): Dry excess in the Stomach house, heat excess causing cold-jue.
Wumei Wan (Mume Pill): Mixed cold and heat causing roundworm cold-jue, slightly different from exterior cold and interior heat.
Cheng Menxue's commentary: These are methods for cold-jue that is heat-related rather than cold-related. Zhu Ling Tang, Baitouweng Tang, and Ganjiang Qinlian Huangqin Renshen Tang do not present cold-jue symptoms; this is an error by Asada.