黄芩三两 甘草（炙）二两 芍药二两 大枣（擘）十二枚
右四味，以水一斗，煮取三升，去滓，温服一升，日再服，夜一服。
于黄芩汤方内，加半夏半升，生姜三两，余根据黄芩汤法
【方解】
里热不和，故自下利，用黄芩清热，甘草和中，得芍药、大枣其功倍焉，热清里和，
而利可止。
【集解】
柯琴云：因热不在半表，故不用柴胡，热已入半里，故主黄芩加芍药也。非微弱胃虚
，不须人参，若兼呕者，仍加半夏、生姜可也。
@@@
阳明、少阳合病，必下利，其脉不负者为顺也。负者失也，互相□贼，名为负也。脉
滑而数者，有宿食也，当下之，宜大承气汤。
【注】
阳明属土，少阳属木，二经偏里，故合病必下利也。阳明脉大，少阳脉弦，脉得大弦
，是为本脉，宜黄芩汤清热和土，兼泻木邪，利自止矣。若脉单大不弦，则为土不受
邪，其病易愈，名为顺也；单弦不大，则为木来克土，其病难治，名为负也。今脉不
大，弦而滑数，则知非木土为害，乃宿食为病之热利也，故不用黄芩汤，而以大承气
汤下之也。太阳、阳明合病下利，表证居多，故以葛根汤发之；阳明、少阳合病下利
，里证居多，故以大承气汤攻之；太阳、少阳合病下利，半表半里居多，故以黄芩汤
和之。若非合病，则桂枝汤、麻黄汤，分主太阳之表，五芩散、抵当汤分主太阳之里
；葛根汤主阳明之表，三承气汤主阳明之里；小柴胡汤主少阳之表，大柴胡汤主少阳
之里，是各有专司也。
【集注】
张兼善曰：凡合病皆下利，各从外证以别焉。夫太阳病，头项痛，腰脊强；阳明病，
目痛鼻干，不得卧；少阳病，胸□痛，耳聋，凡遇两经病证，齐见而下利者，曰合病
也。然两经但各见一、二证便是，不必悉具。
林澜曰：此节是三证在内，大承气只治得脉滑而数有宿食之证，非并治上两证也。其
脉不负者，虽下利而脉未至纯弦也，不言治法。陶华谓：尝以小柴胡，加葛根白芍治
之，取效如拾芥是也。负者，脉纯弦也。土败但见鬼贼之脉，不必治矣。盖虽同是阳
明之合病，而有入经在府之殊，安可以在经之际，概归之承气乎？
@@@
三阳合病，脉浮大上，关上，但欲眠睡，目合则汗。
【按】
浮大上之「上」字，当是「弦」字，始合论中三阳合病之脉。若是「上」字，则经论
中从无两寸脉，主三阳病之理。
【注】
脉浮大弦，三阳合病之脉也。浮大弦皆见于关上，知三阳之热邪，皆聚于阳明也。热
聚阳明，则当烦不得眠，今但欲眠睡，是热盛神昏之昏睡也，昏睡自然目合，热蒸则
汗自出也。若施治得宜，使邪还于表而解，否则未可卜也，宜以柴胡、桂枝、白虎三
汤，酌其所当，合而用之可也。
【集注】
方有执曰：太阳脉浮，阳明脉大，关上乃少阳之部位，故曰：三阳合病。
魏荔彤曰：诊其脉浮为太阳，大为阳明，其长上于关上，则弦可知矣。弦又为少阳，
是三阳之经同受邪，所以三阳之脉同见病。如此再谛之于证，但欲眠睡非少阴也，乃
阳盛神昏之睡也。及目合则汗出，是阳胜争于阴中之汗出也。
@@@
三阳合病，腹满身重，难以转侧，口不仁，面垢，□语，遗尿，发汗则□语，下之则
额上生汗，手足逆冷，若自汗出者 ，白虎汤主之。
【注】
此承上条复详其证，以明其治也。三阳合病者，太阳、阳明、少阳合而为病也。必太
阳之头痛、发热，阳明之恶热、不眠，少阳之耳聋、寒热等证皆具也。太阳主背，阳
明主腹，少阳主侧，今一身尽为三阳热邪所困，故身重难以转侧也。胃之窍出于口，
热邪上攻，故口不仁也。阳明主面，热邪蒸越，故面垢也。热结于里则腹满；热盛于
胃，故□语也。热迫膀胱则遗尿；热蒸肌腠，故自汗也。证虽属于三阳，而热皆聚胃
中，故当从阳明热证主治也。若从太阳之表发汗，则津液愈竭，而胃热愈深，必更增
□语；若从阳明之里下之，则阴益伤而阳无根据则散，故额汗肢冷也。要当审其未经汗
下，而身热自汗出者，始为阳明的证，宜主以白虎汤，大清胃热，急救津液，以存其
阴可也。
【集注】
江琥曰：或问白虎汤何以能解三阳之热？答云：病至自汗出，则太、少之邪总归阳明
矣，安得不从阳明而专治之耶？
郑重光曰：三阳合病，表里俱伤也。发汗偏攻太阳，则邪并于阳明而□语益甚。攻下
偏治阳明，则额上生汗，汗出不流，手足厥冷，必成亡阳之证。然则既不宜于汗下，
惟有白虎一汤，两解阳明表里之热。若无自汗，表犹未解，尚不可用此条，当与暍证
参治也。
@@@
二阳并病，太阳初得病时，发其汗，汗先出不彻，因转属阳明，续自微汗出、不恶寒
。若太阳证不罢者，不可下，下之为逆，如此可小发汗。设面色缘缘正赤者，阳气怫
郁在表，当解之、熏之。若发汗不彻，不足言，阳气怫郁不得越，当汗不汗，其人躁
烦，不知痛处，乍在腹中，乍在四肢，按之不可得，其人短气，但坐，以汗出不彻故
也，更发汗则愈。何以知汗出不彻，以脉涩故知也。
【按】
当解之下「熏之」二字，当是「以汗」二字，始与上下文义相属。
【注】
一经未罢，又传一经，同病而后归并一经自病者，名曰并病。二阳者，太阳、阳明也
。太阳初得病时发汗，汗出不彻，未尽之邪，因而转属阳明，若续自微微汗出，不恶
寒反恶热，始为阳明可下之证。若不微微汗出，而恶寒者，则是太阳之表犹未罢，不
可下也，下之为逆矣。如已经发汗，尚有未尽之表，宜仍与麻桂各半汤，或桂枝二越
婢一汤，小小发汗，以和其表，自可解也。缘缘，接连不已也，正赤，不杂他色也，
谓满面接连赤色不已也。此由于汗出不彻，故阳气怫郁不得宣越，所以其人烦躁短气
，脉涩，不知痛处，乍在腹中，乍在四肢，求之而不可得也。是皆邪气壅甚于经，漫
无出路，但坐以汗出不彻之故耳。当更用大青龙汤或葛根汤，发其汗则愈矣。
【按】
面赤一证，劳损颧红，发于午后者，骨蒸阴虚也。格阳浮赤，兼厥利脉微者，阳虚也
。赤色深重，潮热便□，里实也。赤色浅淡，恶寒无汗，表实也。短气脉涩，内因多
气血虚，若外因短气，必气麤，是汗出不彻，邪气壅促胸中，不能布息之短气，非过
汗伤气，气乏不足续息之短气也。外因脉涩必有力，是汗出不彻，邪气壅滞，荣卫不
能流通之脉涩，非过汗伤液，液少不滋脉道之脉涩也。
【集注】
王肯堂曰：因病太阳，故当汗；因病阳明，故当小汗。先字最有次第，乃仲景之枢机
也。下之以大、小承气，汗之以麻黄等汤 。
程应旄曰：太阳既转属阳明，宜从阳明治矣。然恐转递之处，表邪去尚未尽，里邪乘
其未深，两邪相持，而前后互见，是曰并病。纵使表少里多，终是带表之阳明也。太
阳不应有腹痛，以邪无出路，意欲内攻，故乍在仍不知其处。
林澜曰：汗不彻者，脉必涩，非再汗邪奚自去乎？是知未汗则为并病，已汗即为转属
阳明。未汗则为阳气怫郁在表，已汗则为汗出不彻。汗不彻者，必更汗之；转属者，
必下除之；未汗者，可小发汗；怫郁者，可解之以汗。邪由不同，为病自不同，故施
治亦不同耳。
@@@
二阳并病，太阳证罢，但发潮热，手足□□汗出，大便难而□语者，下之则愈，宜大
承气汤。
【注】
二阳并病，太阳、阳明同病也。太阳证罢，尽归并于阳明，所以但发潮热，手足□□
汗出，大便难而□语也，是皆阳明胃实之证，故下之则愈，宜大承气汤。
【集注】
喻昌曰：并病二条，皆是太阳、阳明。上条初入阳明，太阳之邪未彻，故仍宜汗之；
此条已入阳明，太阳证罢，而尽归并阳明，故宜下之。
程知曰：并病者，一经证多，一经证少，有归并之势也。太阳证罢，而归并阳明，但
手足□□汗出，是大便已□也，与大承气汤以下胃热可也。
@@@
太阳与少阳并病，头项强痛，或眩冒，时如结胸，心下痞□者，当刺大椎、第一间、
肺俞、肝俞。慎不可发汗，发汗则□语。脉弦，五、六日，□语不止，当刺期门。
【注】
太阳与少阳并病，故见头项强痛，或眩冒，时如结胸，心下痞□之证。而曰、或曰时
如者，谓两阳归并未定之病状也。病状未定，不可以药，当刺肺俞，以泻太阳，以太
阳与肺通也；当刺肝俞，以泻少阳，以肝与胆合也。故刺而俟之，以待其机也。苟不
知此，而以头项强痛为太阳之邪，目眩胸满为少阳之邪，发其汗，两阳之邪乘燥入胃
，则发□语。设脉长大，则犹为顺，可以下之，今脉不大而弦，五、六日□语不止，
是土病而见木脉也，名曰负。负者，□贼也。慎不可下，当刺期门，以直泻其肝可也
。
【集注】
方有执曰：并，犹合也。彼此相兼合，而有轻重多寡之不同，谓之并。盖少阳间隔阳
明，去太阳远，故但兼并也。
喻昌曰：少阳之脉，络□肋间，并入太阳之邪，则与结胸证似是而实非也。肝与胆合
，刺肝俞所以泻胆也。膀胱不与肺合，然肺主气，刺肺俞以通其气，斯膀胱之气化行
，而邪自不能留矣。发汗则□语，与合病木盛克土之意同。脉弦亦即合病内少阳胜而
阳明负之互词，刺期门以泻木邪之盛也。
林澜曰：大椎即百劳穴，一椎上陷中，主泻胸中诸热气。第一间疑即商阳，在手食指
内侧，主胸中气满，热病汗不出。肝俞在九椎下，肺俞在三椎下，各去脊中二寸，二
穴并主泻五藏之热。期门在乳根二肋端，主伤寒，胸中烦热，过经汗不出。
@@@
太阳少阳并病，心下□，颈项强而眩者，当刺大椎、肺俞、肝俞，慎勿下之 。
【注】
此承上条，戒不可下之义也。太阳、少阳并病，心下□而眩者，少阳也；颈项强者，
太阳也。当刺肺俞、肝俞，以泻太阳、少阳之邪，慎不可下也。若以心下□，而误下
之，必变逆候矣。
【集注】
成无己曰：慎勿下之。攻少阳之邪，太阳之邪乘虚入里，必作结胸。经曰：太阳、少
阳并病，而反下之，成结胸。
程知曰：上言不可汗，此言不可下也。不可汗，恐其□语；不可下，恐其结胸也。
程应旄曰：此并病心下□居首，颈项强而眩次之，似尚可下，不知少阳三法有禁，只
可刺而慎勿下也。
汪琥曰：大椎一穴，实合太、少而齐泻。诸家注皆不明用针之理，竟置大椎而不论，
大误之极。
@@@
太阳少阳并病，而反下之，成结胸，心下□，下利不止，水浆不下，其人心烦。
【注】
此承上条，而言误下之变也。太阳、少阳并病，不刺肺俞、肝俞，而反下之，两阳之
邪，乘虚陷里，则时如结胸，竟成结胸矣。心下□，变为下利不止，水浆不入矣。上
不入而下常出，则中空无物，其人心烦忙乱，而变成坏证，虽有前条刺法，亦无所用
矣。
【集注】
程知曰：此二阳并病，误下之变也。太阳表邪乘虚入里，则为结胸，心下□；少阳半
里之邪，乘虚入里，则为下利不止。上下俱病，而阳明之居中者，遂至水浆不入，而
心烦也。
喻昌曰：并病即不误用汗、下，已如结胸，心下痞□矣，况又误下乎？故比太阳一经
，误下之变、殆有甚焉。其人心烦似不了之语，然经谓结胸证具，躁烦者死，意此亦
谓其人心烦者，死乎？
汪琥曰：太阳病在经者，不可下，少阳病，下亦在所当禁，故以下之为反也。
[Formula Analysis]
Internal heat disharmony leads to spontaneous diarrhea. Huangqin (Scutellariae Radix) is used to clear heat, Gancao (Glycyrrhizae Radix et Rhizoma) harmonizes the middle jiao, and combined with Shaoyao (Paeoniae Radix) and Dazao (Ziziphi Jujubae Fructus), the therapeutic effect is doubled. Once heat is cleared and the interior is harmonized, the diarrhea can stop.
[Ji Jie Commentary]
Ke Qin stated: Because the heat is not at the half-exterior level, Chaihu (Bupleuri Radix) is not used; because the heat has entered the half-interior level, the primary treatment involves Huangqin Tang (Scutellaria Decoction) plus Shaoyao (Paeoniae Radix). If there is no weak stomach deficiency, Renshen (Ginseng Radix) is not needed. If accompanied by vomiting, Banxia (Pinelliae Rhizoma) and Shengjiang (Zingiberis Rhizoma Recens) can still be added.
@@@
When Yangming and Shaoyang meridians are involved simultaneously (He Bing), diarrhea must occur. A pulse that does not show mutual overcoming (Fu) indicates a favorable prognosis. "Fu" implies failure or loss of balance due to mutual overcoming between organs/pulses. A slippery and rapid pulse indicates retained food stagnation, requiring purgation; Dachengqi Tang (Major Order the Qi Decoction) is appropriate.
[Zhu Annotation]
Yangming belongs to Earth, and Shaoyang belongs to Wood. Both meridians are偏 (biased towards) the interior, so simultaneous involvement necessarily results in diarrhea. The Yangming pulse is large, and the Shaoyang pulse is wiry. A pulse presenting as both large and wiry represents the intrinsic pulse of these meridians; Huangling Tang (Scutellaria Decoction) should be used to clear heat and harmonize Earth while draining Wood pathogenic factors, stopping the diarrhea naturally. If the pulse is merely large without being wiry, it indicates Earth is not affected by Wood, and the disease is easy to cure, termed "Shun" (favorable). If the pulse is merely wiry without being large, it indicates Wood overcoming Earth, making the disease difficult to treat, termed "Fu" (unfavorable/defeat). Currently, the pulse is not large but wiry, slippery, and rapid, indicating that the pathology is not caused by Wood-Earth conflict but by heat-type diarrhea due to retained food stagnation. Therefore, Huangling Tang is not used; instead, Dachengqi Tang (Major Order the Qi Decoction) is used for purgation. In Taiyang-Yangming He Bing with diarrhea, exterior symptoms predominate, so Gegen Tang (Kudzu Decoction) is used to induce sweating. In Yangming-Shaoyang He Bing with diarrhea, interior symptoms predominate, so Dachengqi Tang (Major Order the Qi Decoction) is used for purgation. In Taiyang-Shaoyang He Bing with diarrhea, half-exterior/half-interior symptoms predominate, so Huangling Tang (Scutellaria Decoction) is used for harmonization. If not He Bing, then Guizhi Tang (Cinnamon Twig Decoction) and Mahuang Tang (Ephedra Decoction) respectively manage Taiyang exterior patterns, Wuling San (Five Ling Powder) and Didang Tang (Definitive Blood-Removing Decoction) manage Taiyang interior patterns; Gegen Tang (Kudzu Decoction) manages Yangming exterior patterns, the three Chengqi Decoctions manage Yangming interior patterns; Xiaochaihu Tang (Minor Bupleurum Decoction) manages Shaoyang exterior patterns, and Daichaihu Tang (Major Bupleurum Decoction) manages Shaoyang interior patterns. Each has its specific domain.
[Ji Zhu Commentary]
Zhang Jianshan said: All He Bing cases involve diarrhea, distinguished by external symptoms. Taiyang disease presents with headache and stiff neck, lower back and spine stiffness; Yangming disease presents with eye pain, dry nose, and inability to sleep; Shaoyang disease presents with chest and hypochondriac pain, and deafness. When symptoms from two meridians appear simultaneously along with diarrhea, it is called He Bing. However, it is sufficient if only one or two symptoms from each meridian are present; all do not need to be complete.
Lin Lan said: This section contains three types of syndromes. Dachengqi Tang (Major Order the Qi Decoction) only treats the syndrome characterized by a slippery and rapid pulse with retained food, not the previous two syndromes simultaneously. "Pulse not Fu" means although there is diarrhea, the pulse has not become purely wiry. No treatment method is specified here. Tao Hua stated: He successfully treated this using Xiaochaihu Tang (Minor Bupleurum Decoction) added with Gegen (Puerariae Radix) and Baishao (White Peony Root), achieving results easily like picking up a mustard seed. "Fu" refers to a purely wiry pulse. When Earth qi fails and only shows a "ghost thief" pulse, no treatment is needed. Although both are Yangming He Bing, there is a distinction between pathogen in the channels versus the fu organs. How can one attribute channel-level pathogens generally to Chengqi formulas?
@@@
San Yang He Bing (Simultaneous involvement of the Three Yang meridians): The pulse is floating, large, and extends to the Guan position. The patient desires sleep, and sweats when closing the eyes.
[An Note]
The character "Shang" (Up) in "Floating, Large, Shang" should likely be "Xian" (Wiry) to align with the pulse description of San Yang He Bing in the Treatise. If it were "Shang," there would be no theoretical basis in classic texts for bilateral Cun pulses governing San Yang diseases.
[Zhu Annotation]
A floating, large, and wiry pulse is characteristic of San Yang He Bing. Since these qualities appear at the Guan position, it indicates that heat pathogens from the Three Yang have gathered in Yangming. Heat gathering in Yangming typically causes irritability and insomnia. The current desire to sleep indicates stupor due to severe heat confusing the spirit. Natural closure of eyes accompanies stupor, and heat steaming causes spontaneous sweating. If treatment is appropriate, allowing the pathogen to return to the exterior for resolution, the outcome may be good; otherwise, it is unpredictable. It is advisable to use a combination of Chaihu Tang (Bupleurum Decoction), Guizhi Tang (Cinnamon Twig Decoction), and Baihu Tang (White Tiger Decoction),酌情 (judging) which components apply.
[Ji Zhu Commentary]
Fang Youzhi said: Taiyang pulse is floating, Yangming pulse is large. The Guan position corresponds to Shaoyang. Hence, it is called San Yang He Bing.
Wei Litong said: A floating pulse indicates Taiyang, a large pulse indicates Yangming. If the pulse extends long to the Guan position, it implies a wiry quality, representing Shaoyang. Thus, the Three Yang channels are simultaneously affected, resulting in concurrent pulse manifestations. Examining the symptoms: desire to sleep is not Shaoyin disease but sleepiness due to Yang excess confusing the spirit. Sweating upon closing eyes indicates Yang striving against Yin.
@@@
San Yang He Bing: Abdominal fullness, heaviness of the body, difficulty turning over, insensitivity of the mouth (loss of taste/speech difficulty), greasy facial appearance, delirium, and urinary incontinence. If sweating is induced, delirium worsens; if purgation is used, sweat appears on the forehead, and cold limbs result. If there is spontaneous sweating, Baihu Tang (White Tiger Decoction) is the primary treatment.
[Zhu Annotation]
This elaborates on the previous clause to clarify symptoms and treatment. San Yang He Bing involves simultaneous pathology of Taiyang, Yangming, and Shaoyang. Symptoms include Taiyang headache and fever, Yangming aversion to heat and insomnia, and Shaoyang deafness and alternating chills and fever. Taiyang governs the back, Yangming governs the abdomen, and Shaoyang governs the sides. Now, the whole body is constrained by heat pathogens of the Three Yang, causing heaviness and difficulty moving. The stomach opens to the mouth; heat attacking upwards causes oral insensitivity. Yangming governs the face; heat steaming outward causes a greasy facial appearance. Heat knotting internally causes abdominal fullness; heat flourishing in the stomach causes delirium. Heat forcing the Bladder causes urinary incontinence; heat steaming muscle pores causes spontaneous sweating. Although the syndrome belongs to the Three Yang, the heat gathers in the Stomach; thus, it should be treated primarily as a Yangming heat syndrome. Inducing sweat (Taiyang approach) depletes fluids further and deepens stomach heat, worsening delirium. Purgation (Yangming interior approach) injures Yin, leaving Yang unanchored and dissipating, leading to forehead sweating and cold limbs. One must verify that the patient has not yet undergone sweating or purgation, and exhibits fever and spontaneous sweating, confirming a Yangming syndrome. Baihu Tang (White Tiger Decoction) should be used to vigorously clear stomach heat, urgently rescue fluids, and preserve Yin.
[Ji Zhu Commentary]
Jiang Hu asked: Why can Baihu Tang (White Tiger Decoction) resolve heat from the Three Yang? Answer: Once spontaneous sweating occurs, the pathogens of Taiyang and Shaoyang have converged into Yangming. How else can one treat it except specifically targeting Yangming?
Zheng Zhongguang said: San Yang He Bing injures both exterior and interior. Sweating biased towards Taiyang drives pathogens into Yangming, worsening delirium. Purgation biased towards Yangming causes forehead sweating (non-flowing), cold limbs, and potentially Yang collapse. Since neither sweating nor purgation is suitable, only Baihu Tang (White Tiger Decoction) can resolve heat in both the exterior and interior of Yangming. Without spontaneous sweating, the exterior is not resolved, and this clause's method should not be applied; it should be considered alongside heat-stroke (Ye Zheng) treatments.
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Er Yang Bing Bing (Consecutive involvement of Two Yang meridians): At the onset of Taiyang disease, sweating was induced, but the sweat was incomplete. Consequently, the condition transferred to Yangming, characterized by continued slight sweating and absence of aversion to cold. If Taiyang symptoms persist, purgation is contraindicated; doing so is adverse. In such cases, mild sweating may be induced. If the face is persistently red, it indicates Yang qi stagnation at the exterior, requiring release and fumigation. If sweating was insufficient, Yang qi stagnates and cannot vent. The patient becomes restless and irritable, unable to locate pain, which shifts between the abdomen and limbs, and cannot be pinpointed. The patient experiences shortness of breath and can only sit. This is due to incomplete sweating. Re-inducing sweating will lead to recovery. How do we know sweating was incomplete? By a choppy pulse.
[An Note]
The characters "Xun Zhi" (fumigate) after "Dang Jie Zhi" (should be released) should likely be "Yi Han" (with sweat) to fit the context.
[Zhu Annotation]
When one meridian's pathology has not resolved and transmits to another, merging into a single meridian's independent pathology, it is called Bing Bing. Er Yang refers to Taiyang and Yangming. If initial sweating for Taiyang was incomplete, residual pathogens transfer to Yangming. Continued slight sweating and aversion to heat indicate Yangming patterns suitable for purgation. However, if there is no slight sweating and aversion to cold persists, the Taiyang exterior is not resolved, and purgation is contraindicated (adverse). If sweating has already been attempted but residual exterior signs remain, Mahuang Guizhi Gemi Tang (Ephedra and Cinnamon Twig Half-Half Decoction) or Guizhi Er Yuebi Yi Tang (Cinnamon Twig Twice-Bupleurum Once Decoction) should be used for mild sweating to harmonize the exterior. "Yuanyuan" means continuous/uninterrupted; "Zheng Chi" means pure red without other colors, describing persistent facial redness. This results from incomplete sweating causing Yang qi stagnation and inability to vent, leading to restlessness, shortness of breath, choppy pulse, and migratory, unlocatable pain. These are due to pathogenic congestion in the channels with no exit, solely caused by incomplete sweating. Dachengqing Long Tang (Major Azure Dragon Decoction) or Gegen Tang (Kudzu Decoction) should be used to induce sweating for recovery.
[An Note]
Facial redness due to consumption and malar flush appearing in the afternoon indicates bone-steaming Yin deficiency. Floating redness with cold limbs, diarrhea, and faint pulse indicates Yang deficiency. Deep red color with tidal fever and hard stool indicates interior excess. Pale red color with aversion to cold and no sweat indicates exterior excess. Shortness of breath with choppy pulse usually indicates internal Qi/Blood deficiency. However, external cause shortness of breath involves coarse breathing, caused by pathogenic congestion in the chest preventing normal respiration due to incomplete sweating, distinct from Qi deficiency caused by excessive sweating. External cause choppy pulse is forceful, indicating pathogenic stagnation blocking Ying and Wei circulation due to incomplete sweating, distinct from fluid-deficiency choppy pulse caused by excessive sweating damaging fluids.
[Ji Zhu Commentary]
Wang Kentang said: Pathology in Taiyang requires sweating; pathology in Yangming requires mild sweating. The sequence is crucial, representing Zhang Zhongjing's key mechanism. Purgation uses Dachengqi/Xiaochengqi Tang; sweating uses Mahuang etc. Decoctions.
Cheng Yingmao said: Once Taiyang transfers to Yangming, treatment should follow Yangming. However, during transition, if exterior pathogens are not fully gone and interior pathogens have not deeply settled, the two pathogens contend, presenting mixed symptoms, called Bing Bing. Even if interior symptoms dominate, it remains Yangming with exterior involvement. Taiyang should not have abdominal pain; if present, it suggests pathogens seeking an internal route due to lack of exit.
Lin Lan said: Incomplete sweating results in a choppy pulse. Without re-sweating, how will the pathogen leave? Thus, un-sweated is Bing Bing; sweated is transfer to Yangming. Un-sweated means Yang stagnation at exterior; sweated means incomplete sweating. Incomplete sweating requires re-sweating; transferred cases require purgation; un-sweated cases allow mild sweating; stagnant cases allow release via sweating. Different pathogens cause different diseases, hence different treatments.
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Er Yang Bing Bing: Taiyang symptoms have ceased, manifesting only as tidal fever, continuous sweating on hands and feet, difficult defecation, and delirium. Purgation leads to recovery; Dachengqi Tang (Major Order the Qi Decoction) is indicated.
[Zhu Annotation]
Er Yang Bing Bing involves Taiyang and Yangming. With Taiyang symptoms ceased, pathology merges entirely into Yangming. Manifestations include tidal fever, continuous hand/foot sweating, difficult defecation, and delirium. These are all signs of Yangming Stomach excess. Purgation leads to recovery; Dachengqi Tang (Major Order the Qi Decoction) is indicated.
[Ji Zhu Commentary]
Yu Chang said: Both Bing Bing clauses involve Taiyang and Yangming. The first clause involves early entry into Yangming with unresolved Taiyang pathogens, requiring sweating. This clause involves entry into Yangming with ceased Taiyang symptoms, merging entirely into Yangming, requiring purgation.
Cheng Zhi said: Bing Bing implies one meridian has more symptoms than the other, showing a trend of merging. With Taiyang symptoms ceased and merging into Yangming, continuous hand/foot sweating indicates hardened stool. Dachengqi Tang (Major Order the Qi Decoction) can purge Stomach heat.
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Taiyang and Shaoyang Bing Bing: Head and neck stiffness and pain, dizziness or vertigo, intermittent sensation resembling Jie Xiong (Chest Binding), and epigastric fullness/stuffiness. Acupuncture at Dazhui (GV14), Diyi Jian (LI1/Shangyang?), Feishu (BL13), and Ganshu (BL18) is indicated. Sweating is strictly contraindicated; inducing sweating causes delirium. If the pulse is wiry and, after five to six days, delirium persists, acupuncture at Qimen (LR14) is indicated.
[Zhu Annotation]
Taiyang-Shaoyang Bing Bing presents with head/neck stiffness, dizziness, intermittent chest-binding sensations, and epigastric fullness. Terms like "or" and "intermittent" indicate unstable convergence of the two Yang paths. Due to instability, herbal medicine is avoided; acupuncture at Feishu (BL13) drains Taiyang (connected to Lung); acupuncture at Ganshu (BL18) drains Shaoyang (Liver/Gallbladder connection). Wait for the condition to stabilize. Misidentifying head/neck stiffness as Taiyang and dizziness/chest fullness as Shaoyang, and inducing sweating, allows pathogens to enter the Stomach with dryness, causing delirium. If the pulse is large and long, purgation might be considered favorable. However, a wiry pulse without largeness, with persistent delirium after 5-6 days, indicates Liver (Wood) affecting Spleen/Stomach (Earth), termed "Fu" (defeat/thief). Purgation is strictly contraindicated; acupuncture at Qimen (LR14) directly drains the Liver.
[Ji Zhu Commentary]
Fang Youzhi said: "Bing" implies conjunction with differences in severity and quantity. Shaoyang is separated from Taiyang by Yangming, hence only "Bing" (conjunction) rather than full "He" (combination).
Yu Chang said: Shaoyang meridians connect to the costal region. Conjoining with Taiyang pathogens mimics Jie Xiong but is distinct. Liver and Gallbladder are paired; acupuncturing Ganshu (BL18) drains the Gallbladder. Bladder does not pair with Lung, but Lung governs Qi; acupuncturing Feishu (BL13) promotes Qi flow, enabling Bladder Qi transformation and expelling pathogens. Sweating causing delirium parallels the Wood-overcoming-Earth mechanism in He Bing. The wiry pulse reflects Shaoyang dominance over Yangming; acupuncturing Qimen (LR14) drains excessive Wood pathogen.
Lin Lan said: Dazhui (GV14) is also known as Bailao, located in the depression above the first thoracic vertebra, clearing chest heat. Diyijian is suspected to be Shangyang (LI1), on the radial side of the index finger, treating chest fullness and heat-induced anhidrosis. Ganshu (BL18) is below the ninth thoracic vertebra, Feishu (BL13) below the third, both 2 cun lateral to the spine, clearing Five Zang heat. Qimen (LR14) is at the end of the sixth intercostal space near the nipple, treating cold damage, chest heat, and post-stage anhidrosis.
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Taiyang-Shaoyang Bing Bing: Epigastric fullness/stuffiness, neck stiffness, and dizziness. Acupuncture at Dazhui (GV14), Feishu (BL13), and Ganshu (BL18) is indicated. Purgation is strictly contraindicated.
[Zhu Annotation]
This continues the previous warning against purgation. Epigastric fullness/dizziness indicates Shaoyang; neck stiffness indicates Taiyang. Acupuncture at Feishu (BL13) and Ganshu (BL18) drains both. Purgation is forbidden. Mistaking epigastric fullness for an interior excess pattern and purging will lead to adverse outcomes.
[Ji Zhu Commentary]
Cheng Wuji said: Strictly avoid purgation. Attacking Shaoyang pathogens allows Taiyang pathogens to enter the interior through deficiency, forming Jie Xiong. The Classic states: Taiyang-Shaoyang Bing Bing with erroneous purgation results in Jie Xiong.
Cheng Zhi said: The previous clause forbade sweating; this forbids purgation. Sweating risks delirium; purgation risks Jie Xiong.
Cheng Yingmao said: Epigastric fullness is primary, followed by neck stiffness/dizziness. It might seem suitable for purgation, but Shaoyang has prohibitions against the three methods (sweating, vomiting, purging). Only acupuncture is allowed; purgation is forbidden.
Wang Hu said: Dazhui (GV14) simultaneously drains both Taiyang and Shaoyang. Commentators ignoring the rationale for acupuncture and omitting Dazhui are extremely mistaken.
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Taiyang-Shaoyang Bing Bing with erroneous purgation results in Jie Xiong (Chest Binding), epigastric fullness/stuffiness, incessant diarrhea, inability to swallow liquids, and mental restlessness.
[Zhu Annotation]
This describes the complications of erroneous purgation in the previous clause. Without acupuncturing Feishu (BL13) and Ganshu (BL18), purgation allows pathogens to sink into the interior. Intermittent chest-binding sensations become established Jie Xiong. Epigastric fullness transforms into incessant diarrhea and inability to ingest liquids. Inability to take in and constant outflow creates an empty interior, causing mental agitation and transforming into a complex/damaged syndrome. Previous acupuncture methods are now useless.
[Ji Zhu Commentary]
Cheng Zhi said: This is the complication of erroneous purgation in Er Yang Bing Bing. Taiyang exterior pathogens enter the interior through deficiency, causing Jie Xiong and epigastric fullness. Shaoyang half-interior pathogens enter the interior through deficiency, causing incessant diarrhea. With upper and lower pathology, the central Yangming Stomach cannot accept liquids, leading to restlessness.
Yu Chang said: Even without erroneous sweating/purgation, Bing Bing resembles Jie Xiong and epigastric fullness. How much worse is it with erroneous purgation? The complications are more severe than single-Taiyang errors. The phrase "mental restlessness" seems incomplete, but the Classic states that Jie Xiong with restlessness/death implies this case also signifies death.
Wang Hu said: Taiyang channel pathology cannot be purged; Shaoyang pathology prohibits purgation. Hence, purgation is considered erroneous ("Fan").