武清县孙××，年三十三岁，于孟秋时得温病。
病因 未病之前，心中常觉发热，继因饭后有汗，未暇休息，陡有急事冒风出门，致得温病。
证候 表里俱觉壮热，嗜饮凉水、食凉物，舌苔白浓，中心已黄，大便干燥，小便短赤，脉象
洪长有力，左右皆然，一分钟七十八至。
诊断 此因未病之先已有伏气化热，或有暑气之热内伏，略为外感所激，即表里陡发壮热，一
两日间阳明府热已实，其脉之洪长有力是明征也。拟投以大剂白虎汤，再少佐以宣散之品。
处方 生石膏（四两捣细） 知母（一两） 鲜茅根（六钱） 青连翘（三钱）
甘草（三钱） 粳米（三钱）
共煎汤三盅，分三次温服下。
复诊 将药分三次服完，表里之热分毫未减，脉象之洪长有力亦仍旧，大便亦未通下。此非
药不对证，乃药轻病重药不胜病也。夫石膏之性《神农本草经》原谓其微寒，若遇阳明大热之
证，当放胆用之。拟即原方去连翘加天花粉，再将石膏加重。
处方 生石膏（六两） 知母（一两） 天花粉（一两） 鲜茅根（六钱）
甘草（四钱） 粳米（四钱）
共煎汤三大盅，分三次温服下。
复诊 将药分三次服完，下燥粪数枚，其表里之热仍然不退，脉象亦仍有力。愚谓孙××曰∶余
生平治寒温实热证，若屡次治以大剂白虎汤而其热不退者，恒将方中石膏研极细，将余药
煎汤送服即可奏效。今此证正宜用此方，孙××亦以为然。
处方 生石膏（二两研极细） 生怀山药（二两） 甘草（六钱）
将山药、甘草煎汤一大碗，分多次温服。每次送服石膏末二钱许，热退勿须尽剂，即其热未尽退，
若其大便再通下一次者，亦宜将药停服。
效果 分六次将汤药饮完，将石膏送服强半，热犹未退，大便亦未通下，又煎渣取汤两盅，分数
次送服石膏末，甫完，陡觉表里热势大增。时当夜深，不便延医。孙××自持其脉弦硬异常，因常
阅《衷中参西录》，知脉虽有力而无洪滑之象者，用白虎汤时皆宜加人参，遂急买高丽参五钱，煮汤顿饮下，
其脉渐渐和缓，热亦渐退，至黎明其病霍然全愈矣。
帮助 按伤寒定例，凡用白虎汤若在汗吐下后及渴者，皆宜加人参。细询此证之经过始知曾发大
汗一次，此次所服之药虽非白虎汤原方，实以山药代粳米，又以石膏如此服法，其力之大，可以不用知母
是其方亦白虎汤也。若早加党参数钱，与山药、甘草同煎汤以送服石膏，当即安然病愈。乃因一时疏
忽，并未见及，犹幸病者自知医理以挽回于末路。此虽白虎汤与人参前后分用之，仍不啻同时并用之也。
此证加人参于白虎汤中其益有三∶发汗之后人之正气多虚，人参大能补助正气，俾正气壮旺自能运化药
力以胜邪，其为益一也；又发汗易伤津液，津液伤则人之阴分恒因之亏损。人参与石膏并用，能于邪热炽
盛之时滋津液以复真阴，液滋阴复则邪热易退，其为益二也；又用药之法，恒热因凉用凉因热用，《内经》所
谓伏其所因也。此证用山药、甘草煎汤送服石膏之后，病则纯热，药则纯凉，势若冰炭不兼容，
是以其热益激发而暴动。加人参之性温者以为之作引，此即凉因热用之义，为凉药中有热药引之以消热，
而后热不格拒转与化合，热与凉药化合则热即消矣，此其为益三也。统此三益观之，可晓然于此病之所以愈，
益叹仲圣制方之妙。即约略用之，亦可挽回至险之证也。
武清县的孙某某，三十三岁，在初秋时节患上了温病。
病因 在发病之前，心中常常感觉发热，随后因为饭后出汗，来不及休息，突然有急事顶着风出门，因此导致了温病。
证候 身体表里都感到剧烈发热，喜欢喝凉水、吃凉的食物，舌苔白厚，中间部分已经变黄，大便干燥，小便短少且颜色深红，脉象洪大、长而有力，左右手脉象都一样，一分钟跳动七十八次。
诊断 这是因为在发病之前体内已有伏气化热，或者暑气之热内伏，稍微受到外感刺激，就导致表里突然爆发壮热，一两天内阳明腑热已经结实，其脉象洪大、长而有力就是明显的证据。打算投以大剂量的白虎汤，再少量加入宣散的药物。
处方 生石膏（四两，捣碎） 知母（一两） 鲜茅根（六钱） 青连翘（三钱） 甘草（三钱） 粳米（三钱）
共同煎煮成三碗药汤，分三次温服。
复诊 将药物分三次服用完毕，表里的热度丝毫未减，脉象的洪大、长而有力也依然如故，大便也没有通下。这不是药不对症，而是药轻病重，药力不胜病邪。《神农本草经》原本记载石膏的性质是微寒，如果遇到阳明大热的病症，应当大胆使用。打算就在原方中去掉连翘，加入天花粉，并将石膏的用量加重。
处方 生石膏（六两） 知母（一两） 天花粉（一两） 鲜茅根（六钱） 甘草（四钱） 粳米（四钱）
共同煎煮成三大碗药汤，分三次温服。
复诊 将药物分三次服用完毕，排出几枚燥屎，但表里的热度仍然不退，脉象也仍然有力。我对孙某某说：“我生平治疗寒温实热证，如果多次用大剂量白虎汤治疗后热度仍不退的，通常将方中的石膏研成极细粉末，用其他药物的煎汤送服即可见效。现在这个病症正适合用这种方法。”孙某某也认为是对的。
处方 生石膏（二两，研成极细粉末） 生怀山药（二两） 甘草（六钱）
将山药、甘草煎煮成一大碗汤，分多次温服。每次送服石膏末约二钱，热度退去后就不必服完所有药剂；即使热度未尽退，如果大便再次通畅一次，也应该停止服药。
效果 分六次将汤药喝完，送服了大半份石膏，热度仍未退，大便也没有通下。又煎煮药渣取汤两碗，分多次送服石膏末，刚服完，突然觉得表里的热势大增。当时夜深，不便延请医生。孙某某自己切脉发现脉象弦硬异常，因为他常阅读《衷中参西录》，知道脉象虽然有力但没有洪滑之象时，使用白虎汤时都应该加人参，于是急忙买了五钱高丽参，煮成汤一次性饮下，脉象渐渐变得和缓，热度也逐渐消退，到了黎明时分，病霍然全愈。
按语 按照伤寒的定例，凡是使用白虎汤如果在汗、吐、下法之后以及口渴的情况下，都应该加人参。仔细询问此病的经过才知道曾出过一次大汗，这次所服用的药虽然不是白虎汤的原方，但实际上是用山药代替了粳米，又以如此服用石膏的方法，其药力之大，可以不用知母，所以这个方子也是白虎汤。如果早点加入党参几钱，与山药、甘草同煎汤来送服石膏，当时就应该安然病愈。只是因为一时的疏忽，并没有考虑到这一点，幸好病人自己懂医理，在最后关头挽回局面。这虽然是白虎汤与人参前后分开使用，但仍然不啻于同时并用。在这个病症中，在白虎汤中加入人参有三点益处：发汗之后人的正气大多虚弱，人参非常能够补助正气，使得正气壮旺自然能运化药力以战胜邪气，这是第一点益处；另外发汗容易损伤津液，津液损伤则人的阴分往往会因此亏损。人参与石膏并用，能在邪热炽盛的时候滋润津液以恢复真阴，津液滋润、阴分恢复则邪热容易消退，这是第二点益处；还有用药的方法，通常是热因凉用、凉因热用，《内经》所说的“伏其所因”。此病用山药、甘草煎汤送服石膏之后，病则是纯热，药则是纯凉，形势如同冰炭互不相容，因此热势更加激发而暴动。加入性温的人参作为引导，这就是“凉因热用”的意义，即在凉药中有热药作为引子来消除热邪，然后热邪不再格拒反而与药化合，热与凉药化合则热就消除了，这是第三点益处。综合这三点益处来看，就可以清楚地明白此病痊愈的原因，更加感叹张仲景制定方剂的精妙。即使粗略地运用它，也可以挽回极其危险的病症。
Sun XX from Wuqing County, aged thirty-three, contracted warm disease (Wen Bing) in early autumn.
Etiology Before the onset of illness, he often felt heat in his heart. Subsequently, after a meal, he sweated and did not have time to rest. Suddenly having urgent business, he went out exposing himself to wind, which led to the contraction of warm disease.
Symptoms He felt intense fever both on the exterior and interior. He craved cold water and cool foods. His tongue coating was thick and white, with the center already turning yellow. His stool was dry, and his urine was scanty and dark red. His pulse was surging (Hong), long, and forceful, identical on both left and right sides, beating seventy-eight times per minute.
Diagnosis This condition arose because latent heat had already transformed within the body prior to the onset, or summer-heat pathogen was internally latent. Slightly stimulated by an external contraction, it caused sudden intense fever throughout the interior and exterior. Within one or two days, Yangming Fu-organ heat became solidified; the surging, long, and forceful pulse is clear evidence of this. I proposed administering a large dose of Baihu Tang (White Tiger Decoction), supplemented with a small amount of dispersing herbs.
Prescription Sheng Shigao (Raw Gypsum Fibrosum, 4 liang, crushed) Zhi Mu (Anemarrhenae Rhizoma, 1 lian) Xian Maogen (Fresh Imperatae Rhizoma, 6 qian) Qing Lianqiao (Forsythiae Fructum, 3 qian) Gancao (Glycyrrhizae Radix et Rhizoma, 3 qian) Jingmi (Oryza Sativa, 3 qian)
Decoct together to make three bowls of soup, taken warm in three divided doses.
Second Visit After completing the three doses, the fever on the exterior and interior remained unchanged, and the surging, long, and forceful pulse persisted. The stool had not yet passed. This was not due to incorrect prescription, but rather that the medication was too mild for the severity of the disease; the medicinal power could not overcome the pathogen. The *Shennong Bencao Jing* originally states that the nature of Shigao (Gypsum Fibrosum) is slightly cold. However, when encountering severe Yangming heat syndromes, one should use it boldly. I planned to remove Lianqiao (Forsythiae Fructum) from the original formula, add Huatifen (Trichosanthis Radix), and increase the dosage of Shigao (Gypsum Fibrosum).
Prescription Sheng Shigao (Raw Gypsum Fibrosum, 6 liang) Zhi Mu (Anemarrhenae Rhizoma, 1 liang) Huatifen (Trichosanthis Radix, 1 liang) Xian Maogen (Fresh Imperatae Rhizoma, 6 qian) Gancao (Glycyrrhizae Radix et Rhizoma, 4 qian) Jingmi (Oryza Sativa, 4 qian)
Decoct together to make three large bowls of soup, taken warm in three divided doses.
Third Visit After completing the three doses, several pieces of dry feces were passed, but the fever on the exterior and interior still did not recede, and the pulse remained forceful. I said to Sun XX: "In my lifetime treating excess heat syndromes of cold and warm diseases, if the fever does not recede after multiple treatments with large doses of Baihu Tang (White Tiger Decoction), I usually grind the Shigao (Gypsum Fibrosum) in the formula into an extremely fine powder and administer it using the decoction of the other herbs. This can achieve efficacy. This case is precisely suitable for this method." Sun XX agreed.
Prescription Sheng Shigao (Raw Gypsum Fibrosum, 2 liang, ground to an extremely fine powder) Sheng Huaishanyao (Dioscoreae Rhizoma, 2 liang) Gancao (Glycyrrhizae Radix et Rhizoma, 6 qian)
Decoct the Huaishanyao (Dioscoreae Rhizoma) and Gancao (Glycyrrhizae Radix et Rhizoma) to make one large bowl of soup, taken warm in multiple divided doses. Each time, take about 2 qian of Shigao powder with the soup. If the fever subsides, there is no need to finish the entire dose. Even if the fever has not completely subsided, if the stool passes again once, the medication should be stopped.
Outcome After drinking the herbal soup in six divided doses and taking nearly half of the prescribed Shigao powder, the fever still did not recede, and the stool had not passed. I then decocted the dregs to obtain two bowls of liquid, which were taken in divided doses along with Shigao powder. Immediately after finishing, the intensity of the fever on the exterior and interior suddenly increased significantly. It was late at night, making it inconvenient to invite a doctor. Sun XX palpated his own pulse and found it wiry (Xuan) and hard (Ying) abnormally. Having frequently read *Yixue Zhongzhong Canxi Lu*, he knew that when the pulse is forceful but lacks a surging and slippery quality, Ren Shen (Ginseng Radix) should be added when using Baihu Tang (White Tiger Decoction). He hurriedly bought 5 qian of Gaolishen (Korean Ginseng), decocted it into a soup, and drank it in one go. His pulse gradually became harmonious and slow, and the fever gradually receded. By dawn, the illness was completely cured.
Commentary According to the standard rules for Shanghan (Cold Damage), whenever Baihu Tang (White Tiger Decoction) is used after sweating, vomiting, or purging, or when thirst is present, Ren Shen (Ginseng Radix) should be added. Upon detailed inquiry into the course of this illness, it was learned that he had sweated profusely once. Although the medicine taken this time was not the original Baihu Tang (White Tiger Decoction) formula, it essentially functioned as such by substituting Jingmi (Oryza Sativa) with Huaishanyao (Dioscoreae Rhizoma) and employing a specific method of administering Shigao (Gypsum Fibrosum) where its potency was sufficient to render Zhi Mu (Anemarrhenae Rhizoma) unnecessary. If Dangshen (Codonopsis Radix) had been added earlier, along with Huaishanyao (Dioscoreae Rhizoma) and Gancao (Glycyrrhizae Radix et Rhizoma) decocted to send the Shigao powder, the patient would likely have recovered peacefully. Due to a momentary oversight, this was not considered. Fortunately, the patient's own knowledge of medical principles salvaged the situation at the last moment. Although Baihu Tang (White Tiger Decoction) and Ren Shen (Ginseng Radix) were administered sequentially here, it is equivalent to simultaneous administration. Adding Ren Shen (Ginseng Radix) to Baihu Tang (White Tiger Decoction) in this case offers three benefits: First, after sweating, the body's Zheng Qi (Upright Qi) is often deficient. Ren Shen (Ginseng Radix) greatly tonifies Zheng Qi (Upright Qi); when Zheng Qi (Upright Qi) becomes robust, it can naturally transform and utilize the medicinal power to overcome the pathogen. Second, sweating easily damages Jin Ye (Body Fluids). When Jin Ye (Body Fluids) are damaged, the Yin aspect of the body is often depleted. The combination of Ren Shen (Ginseng Radix) and Shigao (Gypsum Fibrosum) can nourish Jin Ye (Body Fluids) and restore True Yin during periods of blazing pathogenic heat. When Jin Ye (Body Fluids) are nourished and Yin is restored, pathogenic heat retreats easily. Third, regarding the method of medication, heat is often treated with cold, and cold with heat, as described in the *Neijing* ("subduing the root cause"). In this case, after administering Shigao (Gypsum Fibrosum) with a decoction of Huaishanyao (Dioscoreae Rhizoma) and Gancao (Glycyrrhizae Radix et Rhizoma), the disease presented as pure heat, while the medicine was pure cold. This creates a dynamic similar to ice and charcoal being incompatible, thereby further exciting and agitating the heat. Adding Ren Shen (Ginseng Radix), which has a warm nature, serves as a guide. This embodies the principle of "using heat to facilitate cold treatment." The warm herb acts as a guide within the cold formula to dissipate heat, preventing rejection and allowing chemical integration between the heat and the cold medicine. Once integrated, the heat is eliminated. Considering these three benefits, it becomes clear why this illness healed, further marveling at the ingenuity of Zhang Zhongjing's formula creation. Even approximate application of this principle can salvage critical conditions.