桂枝一两 芍药四两 甘草二两 人参三两 生姜(切)四两 大枣(擘)十二枚
右六味,以水一斗二升,微火煮取三升,去滓,分温服,如桂枝法 。
【方解】
是方即桂枝汤倍芍药、生姜、加人参也。汗后身疼痛,是荣卫虚而不和也,故以桂枝
汤调和其荣卫。倍生姜者,以脉沉迟荣中寒也;倍芍药者,以荣不足血少故也;加人
参者,补诸虚也。桂枝得人参,大气周流,气血足而百骸理;人参得桂枝,通内联外
,补荣阴而益卫阳,表虚身疼未有不愈者也。
病发热头痛,脉反沉,若不差,身体疼痛,当温其里,宜四逆汤。
【按】
身体疼痛之下,当有「下利清谷」四字,方合当温其里之文。观太阴篇云:伤寒医下
之,续得下利清谷不止,身痛者,急当救里,宜四逆汤。此虽未下,但脉反沉,可知
里寒,必是脱简。
【注】
病发热头疼,太阳表证也。脉当浮,今反沉,是太阳表证而得少阴里脉也。凡太阳、
少阴表里皆寒无汗之病,均宜以麻黄附子细辛汤发之。若不差不下利者,更以麻黄附
子甘草汤和之;若下利清谷,即有身体疼痛之表未解,不可更汗,当温其里,宜四逆
汤。防其阳从阴化,变厥惕亡阳之逆,断不可谓病在太阳,无可温之理也。
见少阴篇
伤寒,若吐若下后,七、八日不解,热结在里,表里俱热,时时恶风,大渴,舌上干
燥而烦,欲饮水数升者,白虎加人参汤主之。
【按】
伤寒二字之下,当有「若汗」二字,盖发汗较吐下更伤津为多也。时时恶风,当是时
汗恶风,若非汗字,则时时恶风,是表不解,白虎汤在所禁也。论中谓发热无汗,表
不解者,不可与白虎汤,渴欲饮水,无表证者,白虎加人参汤主之。读者细玩经文自
知。
【注】
伤寒,若汗、若吐、若下后,七、八日不解,以致热结在里,时汗恶风者,结热在表
未解也;大渴舌上干燥而烦,欲饮水数升者,结热在里已彰也。故曰表里俱热,宜白
虎加人汤主之。以白虎能外解肌热,内清里热也。加人参者,因汗吐下后,津亡气弱
,借此以益气生津也。
【按】
大青龙汤治太阳表里俱热,表多里少,故不渴也。白虎汤治阳明表里俱热,里多表少
,故大渴也。今大渴燥烦,时汗恶风,是热在阳明又兼太阳也。而用白虎汤者,以阳
明里热证多,太阳表热证少也。若无汗微渴,则为太阳表证多,即表里大热,又当用
大青龙汤矣。
【集注】
喻昌曰:玩此条本文,热结在里,表里俱热,己自酌量,惟热结在里,所以表热不除
,况加大渴饮水,安得不以清热为急耶!
程知曰:表热者,身热也;里热者,内热也。以汗、吐、下后不解,故邪气乘虚结为
里热;惟结热在里,所以表热不除,有恶风证也。大渴引饮,里热炽盛,安得不以白
虎急解之。石膏辛寒,能清里热,兼散表热也;惟其在汗、吐、下后,故必加人参以
顾其正气也。
汪琥曰:与白虎汤加人参扶正气,以分解内外之邪热。要之,此汤惟正气虚而邪气微
者宜之;若邪气甚者,不敢轻加人参也。
Cinnamon Twig (Guizhi) 1 liang, White Peony Root (Shaoyao) 4 liang, Licorice Root (Gancao) 2 liang, Ginseng Root (Renshen) 3 liang, Fresh Ginger (Shengjiang) sliced 4 liang, Jujube (Dazao) pitted 12 pieces.
The above six ingredients are boiled with 12 sheng of water over a gentle fire until reduced to 3 sheng of liquid. The dregs are removed, and the decoction is taken in three divided warm doses, following the administration method of Guizhi Tang (Cinnamon Twig Decoction).
[Formula Analysis]
This formula is essentially Guizhi Tang (Cinnamon Twig Decoction) with increased dosages of Shaoyao (White Peony Root) and Shengjiang (Fresh Ginger), plus the addition of Renshen (Ginseng Root). Body pain after sweating indicates deficiency and disharmony of Ying (Nutritive Qi) and Wei (Defensive Qi); therefore, Guizhi Tang (Cinnamon Twig Decoction) is used to harmonize Ying (Nutritive Qi) and Wei (Defensive Qi). The dosage of Shengjiang (Fresh Ginger) is doubled because the pulse is deep and slow, indicating cold in the Ying (Nutritive Qi) level; the dosage of Shaoyao (White Peony Root) is doubled because of insufficient Ying (Nutritive Qi) and blood deficiency; Renshen (Ginseng Root) is added to tonify various deficiencies. When Guizhi (Cinnamon Twig) combines with Renshen (Ginseng Root), the Zong Qi (Pectoral Qi) circulates throughout the body, and sufficient Qi and Blood regulate the bones and muscles; when Renshen (Ginseng Root) combines with Guizhi (Cinnamon Twig), it connects the interior and exterior, tonifies Ying Yin (Nutritive Yin) and benefits Wei Yang (Defensive Yang). There is no case of body pain due to Exterior Deficiency that cannot be cured.
If the patient presents with fever, headache, and a pulse that is unexpectedly deep, and if the condition does not improve accompanied by body pain, the Interior should be warmed, and Sini Tang (Frigid Extremities Decoction) is indicated.
[Commentary]
Under the phrase "body pain," the four characters "diarrhea with undigested food" (xiali qinggu) should likely appear to align with the text "the Interior should be warmed." As stated in the Taiyin Chapter: In cold damage, if a physician incorrectly uses purgatives, resulting in persistent diarrhea with undigested food and body pain, one must urgently rescue the Interior using Sini Tang (Frigid Extremities Decoction). Although here there was no purgative treatment, the unexpectedly deep pulse indicates Interior Cold, suggesting a textual omission.
[Annotation]
Fever and headache are signs of a Taiyang Exterior syndrome. The pulse should be floating; its unexpected depth indicates a Taiyang Exterior syndrome presenting with a Shaoyin Interior pulse. For diseases involving both Taiyang and Shaoyin where both Exterior and Interior are cold and there is no sweat, Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction) is suitable for inducing sweating. If the condition persists without diarrhea, Mahuang Fuzi Gancao Tang (Ephedra, Aconite, and Licorice Decoction) is used to harmonize; if diarrhea with undigested food occurs, even if Exterior symptoms like body pain remain, sweating should not be induced again. Instead, the Interior should be warmed using Sini Tang (Frigid Extremities Decoction) to prevent Yang from transforming into Yin, which could lead to reversal conditions such as cold extremities, palpitations, and collapse of Yang. One must never argue that because the disease is in Taiyang, warming is inappropriate.
See Shaoyin Chapter.
In cold damage, if vomiting or purging has been performed and the disease remains unresolved after seven or eight days, with heat accumulating in the Interior, causing fever in both Exterior and Interior, occasional aversion to wind, extreme thirst, dryness and irritability on the tongue, and a desire to drink several sheng of water, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) should be administered.
[Commentary]
After the term "cold damage," the words "if sweating" (ruohan) should likely be present, as sweating injures Jin Ye (Body Fluids) more severely than vomiting or purging. "Occasional aversion to wind" should read "occasional sweating with aversion to wind." Without the character "sweating," "occasional aversion to wind" would indicate an unresolved Exterior syndrome, making Baihu Tang (White Tiger Decoction) contraindicated. The text states: For fever without sweat and unresolved Exterior syndrome, Baihu Tang is forbidden; for thirst with desire to drink water and no Exterior syndrome, Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is indicated. Readers will understand upon careful study of the original text.
[Annotation]
After cold damage is treated with sweating, vomiting, or purging, if the disease remains unresolved after seven or eight days, leading to heat accumulation in the Interior, occasional sweating with aversion to wind indicates that the accumulated heat in the Exterior has not yet resolved; extreme thirst, dryness and irritability on the tongue, and desire to drink several sheng of water indicate that the accumulated heat in the Interior is manifest. Thus, it is said that both Exterior and Interior are hot, and Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction) is indicated. Baihu Tang (White Tiger Decoction) can release muscle-heat from the Exterior and clear Interior heat. Renshen (Ginseng Root) is added because sweating, vomiting, and purging deplete Jin Ye (Body Fluids) and weaken Qi; this ingredient is used to tonify Qi and generate fluids.
[Commentary]
Da Qinglong Tang (Major Green Dragon Decoction) treats Taiyang syndrome with heat in both Exterior and Interior, where Exterior heat predominates over Interior heat, hence there is no thirst. Baihu Tang (White Tiger Decoction) treats Yangming syndrome with heat in both Exterior and Interior, where Interior heat predominates over Exterior heat, hence extreme thirst. Now, with extreme thirst, dryness, irritability, occasional sweating, and aversion to wind, the heat is in Yangming combined with Taiyang. Baihu Tang (White Tiger Decoction) is used because Yangming Interior heat patterns are more prevalent than Taiyang Exterior heat patterns. If there is no sweat and slight thirst, Taiyang Exterior patterns predominate; even with severe heat in both Exterior and Interior, Da Qinglong Tang (Major Green Dragon Decoction) should be used.
[Collected Annotations]
Yu Chang stated: Examining this clause, "heat accumulating in the Interior, heat in both Exterior and Interior" allows for self-judgment. Precisely because heat accumulates in the Interior, Exterior heat cannot dissipate. Moreover, with extreme thirst and desire to drink water, clearing heat must be urgent!
Cheng Zhi stated: Exterior heat refers to body heat; Interior heat refers to internal heat. Because the disease remained unresolved after sweating, vomiting, and purging, pathogenic factors took advantage of deficiency to accumulate as Interior heat. Precisely because heat accumulates in the Interior, Exterior heat does not dissipate, accompanied by aversion to wind. Extreme thirst indicates blazing Interior heat; how can one not use Baihu Tang (White Tiger Decoction) to urgently resolve it? Shi Gao (Gypsum) is pungent and cold, capable of clearing Interior heat and dispersing Exterior heat. Precisely because this follows sweating, vomiting, and purging, Renshen (Ginseng Root) must be added to protect Zheng Qi (Upright Qi).
Wang Hu stated: Administering Baihu Tang (White Tiger Decoction) with Renshen (Ginseng Root) supports Zheng Qi (Upright Qi) to resolve pathogenic heat inside and outside. Essentially, this formula is suitable only for cases where Zheng Qi (Upright Qi) is weak and pathogenic factors are mild; if pathogenic factors are severe, adding Renshen (Ginseng Root) lightly is inadvisable.