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If cold pathogen simultaneously attacks the exterior and interior meridians (known as "Liang Gan" or Double Contraction), on the first day, the Taiyang meridian is affected, and concurrently the Shaoyin meridian becomes diseased; symptoms include headache, dry mouth, mental restlessness, and thirst. On the second day, the Yangming meridian is affected, and concurrently the Taiyin meridian becomes diseased; symptoms include abdominal fullness, body fever, anorexia, and delirium. On the third day, the Shaoyang meridian is affected, and concurrently the Jueyin meridian becomes diseased; symptoms include deafness, retraction of the testicles (scrotal contraction), and cold extremities. If the patient cannot ingest water or food and loses consciousness, death occurs on the sixth day. If all three Yin and three Yang meridians, as well as the five Zang and six Fu organs, are afflicted, causing the stagnation of Ying and Wei Qi and the obstruction of organ function, death ensues.

Pang Anchang stated: A pulse that is deep and large indicates Liang Gan of Taiyang and Shaoyin; a pulse that is deep and long indicates Liang Gan of Yangming and Taiyin; a pulse that is deep and wiry indicates Liang Gan of Shaoyang and Jueyin. Various medical texts do not record the pulses for Liang Gan; Pang Anchang specifically established these to instruct future generations. The *Suwen: Re Lun* states: Patients suffering from Liang Gan will inevitably die. The treatment method involves a period of six days. Huangdi asked: Why do some die in three days? Qibo answered: The Yangming meridian is the leader of the twelve meridians; if its Qi is exhausted by the third day, death occurs. Zhang Zhongjing also did not provide specific treatments for Liang Gan. The preface to Volume 5 of *Huoren Shu* states: Among cold damage diseases, only Liang Gan is incurable. Zhang Zhongjing offered only one principle: when Liang Gan occurs simultaneously, treatment must follow a sequence. *Zhengzhi Lun* cites Zhang Yi’s view, aligning with Zhang Zhongjing, stating that if there is diarrhea with undigested food and body pain, one should urgently treat the interior syndrome (using Sini Tang); if there is body pain but normal bowel movements, one should urgently treat the exterior syndrome (using Guizhi Tang). Both *Zhengzhi Lun* and *Huoren Shu* interpret Zhang Zhongjing’s “treatment with sequence” as prioritizing the rescue of the interior; once the internal Yang is warmed, treatment can proceed. However, treating the exterior should not be delayed. The above discussions all advocate treating the interior first, then the exterior. My personal opinion suggests adapting to circumstances: if diarrhea persists with body pain, treat the interior first; if there is no diarrhea but body pain exists, treat the exterior first. This is also referred to as treatment with a sequence. Thus, Liang Gan cases may have treatable aspects, but a cure is not guaranteed.

Zhao’s Commentary on Zhang Zhongjing’s Discussion of Liang Gan:
Zhang Zhongjing classified Liang Gan as a fatal condition, yet followed this with methods for releasing the exterior and purging the interior in a specific sequence. This was likely out of reluctance to watch patients die without intervention, hoping for a slim chance of survival. *Huoren Shu* suggests using Sini Tang to rescue the interior first, followed by Guizhi Tang to rescue the exterior. However, it ignores that Zhang Zhongjing stated: When Taiyang and Shaoyin are diseased together, headache arises because Taiyang pathogenic factors are abundant at the exterior, while dry mouth and thirst arise because Shaoyin pathogenic factors are abundant at the interior. When Yangming and Taiyin are diseased together, body fever and delirium arise because Yangming pathogenic factors are abundant at the exterior, while anorexia and abdominal fullness arise because Taiyin pathogenic factors are abundant at the interior. When Shaoyang and Jueyin are diseased together, deafness arises because Shaoyang pathogenic factors are abundant at the exterior, while scrotal contraction and cold extremities arise because Jueyin pathogenic factors are abundant at the interior. For the Three Yang disorders located at the exterior (headache, fever, deafness), rescuing the exterior cannot be delayed; for the Three Yin disorders located at the interior (abdominal fullness, dry mouth/thirst, scrotal contraction, cold extremities), leaving them untreated is unacceptable? *Huoren Shu* applies the example of treating deficiency-cold (diarrhea, body pain) to heat-excess syndromes (restlessness/thirst, abdominal fullness, delirium, scrotal contraction). Is this correct? Zhang Zhongjing’s “releasing the exterior” refers to Gegen and Mahuang; his “purging the interior” refers to Tiaowei Chengqi Tang. *Huoren Shu*’s “rescuing the interior” uses Sini Tang, and “rescuing the exterior” uses Guizhi Tang. To equate “rescue” with “attack” here is contradictory. Using Sini Tang would be adding fire to fire; how would symptoms like abdominal fullness, delirium, and scrotal contraction be resolved? How would organ function be restored? How would Ying and Wei Qi circulate? Consequently, the prognosis of death on the sixth day would be immediate. Alas! Although Liang Gan is considered incurable, the principles of medication—supporting healthy Qi, eliminating pathogenic factors, tonifying deficiency, and reducing excess—must be firmly established in the mind of the practitioner.

Yuan’s Q&A:
Q: Through what pathway does Liang Gan enter?
A: The classic states: Liang Gan is a fatal, incurable condition. On the first day, Taiyang and Shaoyin are diseased together, presenting with headache, fever, aversion to cold, dry mouth, restlessness, and thirst. The Taiyang meridian belongs to the Fu organs and enters via the Back-Shu points on the back; this is commonly known. The Shaoyin meridian belongs to the Zang organs and enters via the nose and breath; this is less known. Nasal Qi connects with Heaven’s Qi, so formless cold pathogenic Qi enters through the nose. The Kidney corresponds to Water; water flows toward dampness, so the Kidney receives the pathogen. The classic states: Those injured by Dampness suffer injury in the lower part first, due to the attraction of similar energies. It also states: Pathogenic Qi from Heaven, upon infection, harms the Five Zang organs. From this, we know that external and internal simultaneous contraction leads to disease in both Zang and Fu. Attempting to release the exterior is hindered by interior syndromes; attempting to purge the interior is hindered by exterior syndromes. Since exterior and interior cannot be treated simultaneously, death results. Hence, Liang Gan is deemed incurable. However, individual constitution varies in deficiency or excess, and pathogenic invasion varies in depth. Those with deficient constitutions and deep invasion will certainly die; those with robust constitutions and shallow invasion may still be treatable. There are cases where treatment fails to save the patient, but none where survival occurs without treatment. I have used this formula to save some patients, achieving two or three successes out of ten. Therefore, I formulated this prescription for benevolent physicians to use.

Da Qianghuo Tang Formula:
Fangfeng, Qianghuo, Duhuo, Fangji, Huangqin, Huanglian, Cangzhu, Baizhu, Gancao (roasted), Xixin (each 3 qian); Zhimu, Chuanxiong, Shengdihuang (each 1 liang).
The herbs are coarsely crushed. Take 0.5 liang per dose, add two zhan of water, decoct until one and a half zhan remain. Strain to obtain a clear liquid of one large zhan. Drink hot. If symptoms persist, take another three to four zhan. Discontinue when symptoms resolve. If residual symptoms remain, treat according to Zhang Zhongjing’s method of following the meridian.

Wu’s Commentary:
Liang Gan is considered fatal and incurable because within one day, two meridians are transmitted, affecting both Yin and Yang. Urgently treating the Yang aspect is constrained by the urgency of the Yin aspect; urgently treating the Yin aspect is constrained by the urgency of the Yang aspect. Exterior and Interior cannot be attacked simultaneously, and Yin and Yang cannot be treated with a single method; hence, it is deemed incurable. *Huoren Shu* proposes a sequential method: urgently rescue the interior with Sini Tang, then rescue the exterior with Guizhi Tang. This is a rescue method for simultaneous Exterior-Interior Cold, not a method for transmission to two meridians within one day. *Baoming Ji* states: Internal injury from Cold, external injury from Wind; or internal injury from Food, external injury from Wind; or prior injury from Dampness followed by Wind; or prior injury from Wind followed by Dampness; or prior injury from Cold followed by Wind. These scenarios involve simultaneous internal/external and exterior/interior injury, which are treatable, thus Da Qianghuo Tang is appropriate. Occasionally, survival is possible. Are Yilao (Li Dongyuan) and Danxi truly superior to Zhang Zhongjing?