伤寒脉浮滑。此表有热。里有寒。白虎汤主之。
方注。浮者风也。言不独伤于寒也。滑为里热。以滑且浮。知热不独在里也。故指
言此表有热。盖表里俱热之谓也。里有寒者。里字非对表而称。以热之里言。盖
伤寒之热。本寒因也。故谓里有寒。指热之所以然者言也。夫表里皆热。欲两偕
而解之。诚哉极其难也。譬如夏秋两届之间。燥热酷甚。非金风之荐凉。则毒暑不解也。
又注。世本作表有热。里有寒。必系传写之误。夫白虎本为治热病暑病之药。其
性大寒。安得里有寒者可服之理。详本文脉浮滑。不但无紧。且复多滑。乃阳气
盛而郁蒸。此里有热也。里热甚。必格寒于外。多厥逆身凉。而为亢害之证。此表有寒也。厥阴篇中脉
滑而厥者。里有热也。白虎汤主之。则知此表里二字。为错误可知。当为上下更易。
周注。热病皆伤寒伏邪也。至发则但热矣。乃仲景仍以伤寒揭之者。所谓乐乐
其所自生。礼不忘其本也。
白虎汤
知母（六两） 石膏（一斤碎） 甘草（二两） 粳米（六合）
上四味。以水一斗。煮米熟汤成。去滓。温服一升。日三服。
方注。白虎者。西方之金神。司秋之阴兽。虎啸谷风冷。凉生酷暑消。神于解热。莫
如白虎。知母、石膏。辛甘而寒。辛者金之味。寒者金之性。辛甘且寒。得白虎之体
焉。甘草、粳米。甘平而温。甘取其缓。温取其和。缓而且和。得伏虎之用焉。饮四物
之成汤。来白虎之嗥啸。阳气者。以天地之疾风名也。风行而虎啸者。同气相求
也。虎啸而风生者。同声相应也。风生而热解者。物理必至也。抑尝以此合大小
青龙真武而论之。四物者。四方之通神也。而以命名。盖谓化裁四时。神妙万世。
名义两符。实自然而然者也。方而若此。可谓至矣。然不明言其神。而神卒莫之
掩者。君子盛德。此其道之所以大也。
三阳合病。腹满身重。难以转侧。口不仁而面垢。谵语遗溺。发汗则谵语。下之则额
上生汗。手足逆冷。若自汗出者。白虎汤主之。
周注。此因中 而引动伏邪齐出。三阳为病极重。腹满者。热本病也。身重难以
转侧者。湿本病也。若口不仁而面垢。谵语遗溺。则是 本病矣。惟热 相兼。其
热势尤剧。此时倘复汗之。则津液外亡。而谵语转甚。若下之。则阴气下竭。而阳
气上脱。故额上汗而手足逆冷矣。故必仍自汗者。主以白虎。设误汗下而证如上者。加人参为无疑也。
伤寒脉滑而厥者。里有热也。白虎汤主之。
周注。滑为邪实。何反至厥。即热深厥深之义。故特申之曰。里有热也。里热安得不用白虎汤乎。
伤寒脉浮。发热无汗。其表不解者。不可与白虎汤。渴欲饮水。无表证者。白虎加人参汤主之。
周注。发热汗出。热本病也。今脉浮无汗。必因邪风袭表矣。岂可竟与白虎汤乎。
故必以辛凉先撤其邪。然后治热。始为无碍。假使表邪解而烦渴转甚者。明系
因邪以更耗津液。白虎汤固非解表之剂。又岂有助正之功。加人参者。益其元也。元稍益而热易清矣。
伤寒无大热。口燥渴。心烦。背微恶寒者。白虎加人参汤主之。
周注。燥渴且烦。为热证本病。而曰无大热者。以独背微恶寒也。背为太阳经位。
正气大虚。故微恶寒。安得不用补正之药。于本汤中乎。
阳明病脉浮而紧。咽燥口苦。腹满而喘。发热汗出。不恶寒反恶热。身重。若发汗则
躁。心愦愦。反谵语。若加烧针。必怵惕烦躁。不得眠。若下之。则胃中空虚。客气动膈。
心中懊 。舌上苔滑者。栀子豉汤主之。（方见前）若渴欲饮水。口干舌燥者。白虎加人
参汤主之。若脉浮发热。渴欲饮水。小便不利者。猪苓汤主之。
周注。浮紧伤寒脉也。何以为热病。以其发于夏。反恶热不恶寒也。又何以独言
阳明。以夏时湿热上蒸。邪从胃发。且腹满而喘。种种皆阳明证也。然咽燥非少
阴证耶。不知阳明为从出之途。少阴其伏脏之地也。夫既阳明热病。曷又为脉
反浮紧。正以夏时肌腠本开。人本多汗。邪风袭入。致腠理反闭而无汗。故夏之
风脉。每反显冬之寒脉也。今云汗出而脉亦浮紧者。正因浮甚有力。热邪盛而
致也。若不知者。以辛热汗之。耗其津液。必至躁妄昏昧。火劫温针。燥其阴血。必
至惊扰无寐。下之必亡其阴。必至胃虚邪陷。心中懊 。此皆误治。将何以救之
乎。观舌上苔滑者。则外邪尚在。以栀子解热。香豉去邪。是为合法。若渴饮水浆。
口干舌燥。知其外邪亦入。总以白虎汤为治。加人参者。以误治而津液大伤也。
设使紧脉去而浮在。发热饮水。小便不利。则其浮为虚。而热已入膀胱矣。入膀
胱者。曷不饮以四苓。而主以猪苓耶。伤寒之小便不利。结于气分。热病之小便
不利。由于血分者也。因邪郁既深。耗液日久。故必以阿胶补虚。滑石祛热。而无取于白术也。
白虎加人参汤
知母（六两） 石膏（一斤碎） 甘草（二两） 粳米（六合） 人参（三两）
上五味。以水一斗。煮米熟汤成。去滓。温服一升。日三服。
周注。口至干。舌至燥。无津液极矣。能生津液而神速者。莫若人参。故加之。
猪苓汤
猪苓（一两去皮） 茯苓（一两） 阿胶（一两） 滑石（一两碎） 泽泻（一两）
上五味。以水四升。先煮四味。取二升去滓。内下阿胶。烊消尽。温服七合。日三服。
周注。热甚膀胱。非水能解。何者。水有止渴之功。而无祛热之力也。故用猪苓之
淡渗。与泽泻之咸寒。与五苓不异。而此易白术以阿胶者。彼属气此益血也。易
桂以滑石者。彼有表而此为消热也。然则所蓄之水去。则热消矣。润液之味投。则渴除矣。
阳明病。汗出多而渴者。不可与猪苓汤。以汗多胃中燥。猪苓汤复利其小便故也。
周注。渴而小便不利。本当用猪苓汤。然汗多在所禁也。此与伤寒入腑。不令溲
数同意。盖邪出阳明。已劫其津。汗出复多。更耗其液。津液曾几。尚可下夺耶。当
以白虎加人参去其热。则小便之不利者。津回而自利矣。
伤寒病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。
周注。吐下后至七八日不解。知误治而热邪不为吐下少衰。反因吐下转甚。时恶风者。阳外
虚也。舌燥而烦渴。饮水至数升者。阴内亡也。舍人参白虎。将何以解其表里。补其津液耶。
服桂枝汤。大汗出后。大烦渴不解。脉洪大者。白虎加人参汤主之。
周注。桂枝辛热药也。热病本汗。或疑为风。饮以此汤。不更益其热。而大汗淋漓
乎。如是则津液益伤。烦渴益甚。洪大转增。当与本汤加人参也审矣。
Shanghan disease presenting with a floating and slippery pulse. This indicates heat on the exterior and cold on the interior (referring to the etiology originating from cold pathogen). Baihu Tang (White Tiger Decoction) is the primary treatment.
Formula Annotation: A floating pulse indicates wind pathogen invasion, suggesting that it is not merely an injury by cold. A slippery pulse indicates heat within. Because the pulse is both slippery and floating, it is known that heat is not confined solely to the interior. Hence, it is pointed out that this represents heat in both the exterior and interior. The phrase "cold in the interior" does not use "interior" as a counterpart to "exterior," but rather refers to the perspective of heat penetrating into the body. Generally, the heat syndrome of Shanghan originates from cold; thus, saying "cold in the interior" refers to the root cause of the heat. Since there is heat in both the exterior and interior, resolving them simultaneously is indeed extremely difficult. It is like the period between summer and autumn, where dryness and heat are severe; unless cool winds arrive, the toxic summer heat cannot be resolved.
Another annotation states: The version circulating in the world reads "heat on the exterior, cold in the interior," which must be a copying error. Baihu Tang is originally a medicine for treating heat diseases and summerheat diseases; its nature is greatly cold. How could it be administered to someone with cold in the interior? Detailed analysis of the original text's floating and slippery pulse shows no tightness and instead features slipperiness, indicating vigorous yang qi stagnating and steaming, which proves heat in the interior. If interior heat is extreme, it will repel cold to the exterior, causing cold limbs and cool body—symptoms of excessive harm—which constitutes the so-called "cold on the exterior." In the Jueyin Chapter of Shanghan Lun, it says: "Pulse slippery with cold limbs indicates heat in the interior; Baihu Tang is the main treatment." From this, it is evident that the characters "exterior" and "interior" here are erroneous and should likely be swapped with "upper" and "lower."
Zhou Yangjun's Note: Heat diseases are all latent pathogens from Shanghan that manifest later. When they erupt, only heat is present. However, Zhang Zhongjing still uses "Shanghan" to summarize them, akin to how one remembers the source of joy or honors origins in rituals.
Baihu Tang (White Tiger Decoction)
Zhimu (Anemarrhenae Rhizoma, 6 liang) Shigao (Gypsum Fibrosum, 1 jin, crushed) Gancao (Glycyrrhizae Radix et Rhizoma, 2 liang) Jingmi (Oryza Sativa, 6 he)
The above four ingredients are boiled in 10 dou of water until the rice is cooked and the decoction is ready. Strain the dregs. Take 1 sheng warm, three times daily.
Formula Annotation: Baihu (White Tiger) is the Metal Spirit of the West, the Yin Beast governing autumn. When the tiger roars, cold wind arises in the valley, and coolness dissipates the intense heat. In resolving heat, none surpasses Baihu. Zhimu and Shigao are acrid, sweet, and cold. Acridity is the flavor of Metal; coldness is the nature of Metal. Being acrid, sweet, and cold, they embody the essence of Baihu. Gancao and Jingmi are sweet, neutral, and warm. Sweetness provides moderation; warmth provides harmony. Moderation and harmony fulfill the function of taming the fierce tiger. Drinking this four-ingredient decoction summons the roar of Baihu. Human yang qi can be likened to the swift wind of heaven and earth. Wind moves and the tiger roars due to resonance of similar energies; the tiger roars and wind arises due to corresponding sounds; wind arises and heat resolves according to natural laws. I have compared this formula with Da Qinglong Tang (Major Green Dragon Decoction), Xiao Qinglong Tang (Minor Green Dragon Decoction), and Zhenwu Tang (True Warrior Decoction). These four ingredients symbolize the spiritual entities of the four directions. Naming it thus implies adapting to the four seasons with divine efficacy, matching name and reality naturally. Such formulation design reaches perfection. Yet, not explicitly stating its divinity allows its spirit to remain unmasked, reflecting the great virtue of the gentleman and the greatness of his Dao.
San Yang He Bing (Combined Disease of the Three Yang Meridians): Abdominal fullness, heaviness of the body, difficulty turning over, numbness of the mouth and tongue with facial dirtiness, delirium, and urinary incontinence. If sweating is induced, delirium worsens; if purgatives are used, sweat appears on the forehead and limbs become cold. If spontaneous sweating occurs, Baihu Tang is the main treatment.
Zhou Yangjun's Note: This occurs when the middle jiao is affected, triggering latent pathogens to emerge together. Combined disease of the Three Yang is extremely severe. Abdominal fullness is the manifestation of heat as the root pathology. Body heaviness and difficulty turning are manifestations of dampness as the root pathology. Numbness of the mouth/tongue, facial dirtiness, delirium, and incontinence are manifestations of heat disturbing the heart spirit and internal organs. Only when heat and dampness combine does the heat intensity become particularly severe. At this time, inducing sweating would cause fluid loss, worsening delirium; using purgatives would exhaust yin qi below and scatter yang qi above, leading to forehead sweating and cold limbs. Therefore, only those with spontaneous sweating should receive Baihu Tang. If symptoms arise after mistaken sweating or purging, adding Renshen (Ginseng Radix et Rhizoma) is undoubtedly correct.
Shanghan disease with a slippery pulse and cold limbs indicates heat in the interior; Baihu Tang is the main treatment.
Zhou Yangjun's Note: A slippery pulse indicates excess pathogen. Why do cold limbs occur? This illustrates the principle of "deeper heat leads to deeper cold limbs." Thus, it is specifically stated: "Heat in the interior." How can interior heat not be treated with Baihu Tang?
In Shanghan disease, if the pulse is floating, there is fever, no sweating, and the exterior pattern is unresolved, Baihu Tang must not be given. If there is thirst desire to drink water and no exterior pattern, Baihu Jia Renshen Tang (White Tiger Decoction plus Ginseng) is the main treatment.
Zhou Yangjun's Note: Fever with sweating is the standard presentation of heat disease. Now, with a floating pulse but no sweating, it must be due to wind pathogen attacking the exterior. How can Baihu Tang be given directly? One must first use acrid-cool herbs to release the exterior pathogen, then treat the heat, to avoid harm. If the exterior pathogen resolves but irritability and thirst worsen, it clearly indicates further fluid consumption by the pathogen. Baihu Tang is not an exterior-releasing agent nor does it benefit righteous qi. Adding Renshen tonifies the primal qi. Slightly replenishing primal qi makes clearing heat easier.
In Shanghan disease, if there is no significant high fever, dry mouth and throat, irritability, and slight aversion to cold on the back, Baihu Jia Renshen Tang is the main treatment.
Zhou Yangjun's Note: Dryness, thirst, and irritability are standard heat signs. Saying "no significant high fever" refers specifically to slight aversion to cold on the back. The back is the location of the Taiyang meridian. Extreme deficiency of righteous qi causes slight aversion to cold. How can one not use herbs to tonify righteous qi? Thus, add Renshen to the base decoction.
Yangming disease with a floating and tight pulse, dry throat, bitter taste, abdominal fullness with panting, fever with sweating, aversion to cold replaced by aversion to heat, and body heaviness. If sweating is induced, restlessness, mental confusion, and delirium occur. If burning needles are applied, fright, irritability, and insomnia result. If purged, the stomach becomes empty, rebellious qi disturbs the diaphragm, causing inner vexation and regretfulness; if the tongue coating is slippery, Zhizi Chi Tang (Gardenia and Fermented Soybean Decoction) is the main treatment. (Formula seen previously.) If thirsty for drinking water with dry mouth and tongue, Baihu Jia Renshen Tang is the main treatment. If the pulse is floating with fever, thirst desire to drink water, and dysuria, Zhuling Tang (Polyporus Decoction) is the main treatment.
Zhou Yangjun's Note: Floating-tight is the pulse of Shanghan. Why is it a heat disease? Because it occurs in summer, with aversion to heat rather than cold. Why mention only Yangming? Because in summer, damp-heat steams upward, and pathogens originate from the Stomach. Symptoms like abdominal fullness and panting are all Yangming patterns. Is dry throat not a Shaoyin pattern? Know that Yangming is the pathway for pathogen exit, while Shaoyin is the hiding place for latent pathogens. Since it is a Yangming heat disease, why is the pulse floating and tight? Because in summer, skin pores are open, and people sweat much. Wind pathogen invasion causes pores to close abnormally without sweating. Thus, summer wind pulses often resemble winter cold pulses. Now, sweating with a floating-tight pulse occurs because the floating is forceful, caused by abundant heat pathogen. Those who do not understand this may use acrid-hot herbs to induce sweating, consuming fluids, leading to mania and coma. Fire therapy with warm needles dries yin blood, causing panic and insomnia. Purging destroys yin, leading to stomach deficiency and pathogen sinking, causing inner vexation. All these are mis treatments. How to save them? Observing a slippery tongue coating indicates external pathogen remains. Use Zhizi (Gardeniae Fructus) to clear heat and Chichi (Sojae Preparata Semen) to remove pathogen, which is correct. If thirsty for liquids with dry mouth and tongue, knowing external pathogen has entered internally, generally treat with Baihu Tang. Add Renshen because mis treatment severely damaged fluids.
If the tight pulse disappears and only floating remains, with fever, thirst, and dysuria, the floating indicates deficiency, and heat has entered the Bladder. Why not use Wuling San (Five-Ingredient Powder with Poria) for heat entering the Bladder, but use Zhuling Tang? Dysuria in Shanghan stems from Qi level obstruction; dysuria in heat diseases stems from Blood level damage. Due to deep pathogen stagnation and long-term fluid consumption, use Ejiao (Asini Corii Colla) to tonify deficiency and Huashi (Talcum) to clear heat, without needing Baizhu (Atractylodis Macrocephalae Rhizoma).
Baihu Jia Renshen Tang (White Tiger Decoction plus Ginseng)
Zhimu (Anemarrhenae Rhizoma, 6 liang) Shigao (Gypsum Fibrosum, 1 jin, crushed) Gancao (Glycyrrhizae Radix et Rhizoma, 2 liang) Jingmi (Oryza Sativa, 6 he) Renshen (Ginseng Radix et Rhizoma, 3 liang)
The above five ingredients are boiled in 10 dou of water until the rice is cooked and the decoction is ready. Strain the dregs. Take 1 sheng warm, three times daily.
Zhou Yangjun's Note: Extreme dryness of the mouth and tongue indicates exhaustion of fluids. Nothing generates fluids quickly like Renshen. Hence, it is added.
Zhuling Tang (Polyporus Decoction)
Zhuling (Polypori Sclerotium, 1 liang, peeled) Fuling (Poria, 1 liang) Ejiao (Asini Corii Colla, 1 liang) Huashi (Talcum, 1 liang, crushed) Zexie (Alismatis Rhizoma, 1 liang)
The above five ingredients are boiled in 4 sheng of water. First boil the first four ingredients, obtain 2 sheng, strain dregs. Add Ejiao, melt completely. Take 7 ge warm, three times daily.
Zhou Yangjun's Note: Intense heat in the Bladder cannot be resolved by water alone. Water stops thirst but lacks heat-clearing power. Therefore, use Zhuling's bland leaching action combined with Zexie's salty-cold nature. This differs from Wuling San: here, Baizhu is replaced by Ejiao (benefiting blood vs. qi); Guizhi (Cinnamon Twig) is replaced by Huashi (clearing heat vs. releasing exterior). Once accumulated water is removed, heat dissipates; once moistening flavors are administered, thirst ceases.
In Yangming disease, if there is profuse sweating and thirst, Zhuling Tang must not be given. Because profuse sweating causes dryness in the Stomach, and Zhuling Tang promotes urination, further damaging fluids.
Zhou Yangjun's Note: Thirst with dysuria warrants Zhuling Tang, but it is contraindicated if sweating is profuse. This aligns with the principle in Shanghan that when pathogens enter the Fu organs, frequent urination should be avoided. Pathogens exiting via Yangming have already depleted fluids. Profuse sweating further consumes fluids. How much fluid remains to be drained downward? One should use Baihu Jia Renshen Tang to clear heat; as fluids recover, dysuria will resolve spontaneously.
In Shanghan disease, if after vomiting or purging, the disease persists for seven to eight days without resolution, with heat binding in the interior, heat in both exterior and interior, occasional aversion to wind, extreme thirst, dry tongue, irritability, and desire to drink several liters of water, Baihu Jia Renshen Tang is the main treatment.
Zhou Yangjun's Note: Persistence after seven to eight days post-vomit/purge indicates mis treatment; heat did not decrease but worsened due to depletion. Occasional aversion to wind indicates exterior yang deficiency. Dry tongue, irritability, and drinking several liters indicate interior yin exhaustion. Besides Renshen and Baihu Tang, what else can resolve exterior-interior heat and replenish fluids?
After taking Guizhi Tang (Cinnamon Twig Decoction), if profuse sweating occurs followed by extreme unresolved irritability and thirst, with a flooding-large pulse, Baihu Jia Renshen Tang is the main treatment.
Zhou Yangjun's Note: Guizhi is an acrid-warm herb. Heat diseases naturally involve sweating. Suspecting wind, administering this decoction might increase heat, causing profuse sweating. This would further injure fluids, worsen irritability and thirst, and intensify the flooding-large pulse. Administering the base decoction with Renshen is certainly appropriate.