人参（甘温） 甘草（炙甘平） 白术（甘温） 干姜（辛热以上各三两）
上四味。捣筛为末。蜜和。丸如鸡黄大。以沸汤数合。和一丸。研碎温服之。日三
服。夜
二服。腹中未热。益至三四丸。然不及汤。汤法以四物根据两数切用。水八升。煮取三升。
去滓。温服一升。日三服。加减法。
内经曰。脾欲缓。急食甘以缓之。用甘补之。人参白术甘草之甘。以缓脾气调中。
寒淫所胜。平以辛热。干姜之辛。以温胃散寒。
后加减法。
若脐上筑者。肾气动也。去术。加桂四两。
脾虚肾气动者。脐上筑动。内经曰。甘者令人中满。术甘壅补。桂泄奔豚。是相易
也。
吐多者去术。加生姜三两。
呕家不喜甘。故去术。呕家多服生姜。以辛散之。
下多者。还用术。悸者。加茯苓二两。
下多者。用术以去湿。悸加茯苓以导气。
渴欲得水者。加术。足前成四两半。
津液不足则渴。术甘以缓之。
腹中痛者。加人参。足前成四两半。
里虚则痛。加人参以补之。
寒者。加干姜。足前成四两半。
寒淫所胜。平以辛热。
腹满者。去术。加附子一枚。服汤后。如食顷。饮热粥一升许。微自温。勿发揭衣
被。
胃虚则气壅腹满。甘令人中满。是去术也。附子之辛。以补阳散壅。
活人云。或四肢拘急。或转筋者。亦去术加附子。
吐利止而身痛不休者。当消息和解其外。宜桂枝汤小和之。
吐利止。里和也。身痛不休。表未解也。与桂枝汤小和之。外台云。里和表病。汗
之则愈。
吐利汗出。发热恶寒。四肢拘急手足厥冷者。四逆汤主之。
上吐下利。里虚汗出。发热恶寒表未解也。四肢拘急。手足厥冷。阳虚阴胜也。与
四逆汤助阳退阴。
既吐且利。小便复利而大汗出。下利清谷。内寒外热。脉微欲绝者。四逆汤主之。
吐利亡津液。则小盒饭少。小便复利而大汗出。津液不禁。阳气大虚也。脉微为亡
阳。若无外热。但内寒。下利清谷。为纯阴。此以外热为阳未绝。犹可与四逆汤救之。
吐已下断。汗出而厥。四肢拘急不解。脉微欲绝者。通脉四逆加猪胆汁汤主之。
吐已下断。津液内竭。则不当汗出。汗出者不当厥。今汗出而厥。四肢拘急不解。
脉微欲绝者。阳气大虚。阴气独胜也。若纯与阳药。恐阴为格拒。或呕或躁。不得复入
也。与通脉四逆汤。加猪胆汁。胆苦入心而通脉。胆寒补肝而和阴。引置汤药。不被格
拒。内经曰。微者汗之。甚者从之。此之谓也。
Ren Shen (Ginseng Radix, sweet and warm) Zhi Gan Cao (Prepared Licorice Root, sweet and neutral after processing) Bai Zhu (Atractylodis Macrocephalae Rhizoma, sweet and warm) Gan Jiang (Dried Ginger, pungent and hot; each of the above three liang).
Crush and sieve the above four herbs into powder. Mix with honey to form pills the size of a chicken egg yolk. Take several he of boiling water, place one pill in it, crush it, and take it warm. Take three times a day and two times at night. If warmth is not felt in the abdomen, increase the dosage to three or four pills per administration. However, the efficacy is inferior to that of the decoction. For the decoction method, cut the four herbs according to the specified dosages. Add eight sheng of water, boil until three sheng remain. Strain the dregs. Take one sheng warm. Take three times a day. Modifications are as follows:
The *Neijing* states: "The Spleen desires relaxation; urgently use sweet substances to relax it. Use sweet substances to tonify it." The sweetness of Ren Shen, Bai Zhu, and Gan Cao can relax the Spleen Qi and regulate the Middle Jiao.
When Cold pathogen prevails excessively, use pungent-hot substances to level it. The pungency of Gan Jiang can warm the Stomach and scatter Cold.
Subsequent modifications:
If there is a throbbing sensation above the umbilicus, this indicates Kidney Qi moving. Remove Bai Zhu and add Gui Zhi (Cinnamon Twig) four liang.
When Spleen deficiency causes Kidney Qi to move recklessly, resulting in throbbing above the umbilicus: The *Neijing* states: "Sweet substances cause fullness in the Middle Jiao." Bai Zhu is sweet and cloying/tonifying; Gui Zhi drains Ben Tun (fleeing tumor). Thus, they are exchanged for each other.
If vomiting is excessive, remove Bai Zhu and add Sheng Jiang (Fresh Ginger) three liang.
Those prone to vomiting do not favor sweet substances, hence remove Bai Zhu. Those prone to vomiting often consume Sheng Jiang to disperse using its pungent property.
If diarrhea is excessive, continue using Bai Zhu. If palpitations occur, add Fu Ling (Poria) two liang.
For excessive diarrhea, use Bai Zhu to eliminate dampness. For palpitations, add Fu Ling to guide Qi.
If thirsty and desiring water, increase Bai Zhu so that the total amount becomes four and a half liang.
Insufficiency of Jin Ye (Body Fluids) leads to thirst. Bai Zhu's sweetness can alleviate this.
If there is abdominal pain, increase Ren Shen so that the total amount becomes four and a half liang.
Interior deficiency causes pain. Add Ren Shen to tonify.
If cold dominates, increase Gan Jiang so that the total amount becomes four and a half liang.
When Cold pathogen prevails excessively, use pungent-hot substances to level it.
If abdominal fullness occurs, remove Bai Zhu and add one Fu Zi (Aconite Lateralis Radix Praeparata). After taking the decoction, wait approximately the time it takes to eat a meal, then drink about one sheng of hot porridge to induce slight warmth. Do not uncover clothes or blankets.
Stomach deficiency leads to Qi stagnation and abdominal fullness. Sweet substances cause fullness in the Middle Jiao, hence remove Bai Zhu. The pungency of Fu Zi tonifies Yang and dissipates stagnation.
The *Huoren Shu* states: If there are spasms and tightness of the four limbs or muscle cramps, also remove Bai Zhu and add Fu Zi.
If vomiting and diarrhea cease but body pain persists, one should assess the situation to harmonize the exterior. It is appropriate to use Gui Zhi Tang (Cinnamon Twig Decoction) in a small dose to harmonize.
Vomiting and diarrhea ceasing indicates interior harmony. Persistent body pain indicates the exterior pattern is unresolved. Administer Gui Zhi Tang in a small dose to harmonize. The *Waitai Mi Yao* states: When the interior is harmonious but the exterior is diseased, sweating will lead to recovery.
If vomiting and diarrhea are accompanied by sweating, fever, aversion to cold, spasms and tightness of the four limbs, and cold extremities, Si Ni Tang (Frigid Extremities Decoction) is the primary treatment.
Upper vomiting and lower diarrhea indicate interior deficiency and sweating. Fever and aversion to cold indicate the exterior pattern is unresolved. Spasms and tightness of the four limbs and cold extremities indicate Yang deficiency and Yin excess. Administer Si Ni Tang to assist Yang and retreat Yin.
If both vomiting and diarrhea occur, urination is frequent, profuse sweating ensues, diarrhea contains undigested food, there is interior cold with exterior heat, and the pulse is faint and nearly imperceptible, Si Ni Tang (Frigid Extremities Decoction) is the primary treatment.
Vomiting and diarrhea deplete Jin Ye (Body Fluids), so urination should be scant. Frequent urination and profuse sweating indicate loss of fluid control due to severe Yang deficiency. A faint pulse indicates loss of Yang. If there is no exterior heat, only interior cold, and diarrhea contains undigested food, it is a Pure Yin condition. Here, because there is exterior heat, Yang has not yet perished, and Si Ni Tang can still be used to rescue it.
If vomiting and diarrhea have ceased, but sweating and cold extremities persist, spasms and tightness of the four limbs remain unresolved, and the pulse is faint and nearly imperceptible, Tong Mai Si Ni Tang Jia Zhu Dan Ye (Decoction to Restore the Pulse with Si Ni Tang plus Porcine Bile) is the primary treatment.
With cessation of vomiting and diarrhea, Jin Ye (Body Fluids) are exhausted internally, so sweating should not occur. With sweating, cold extremities should not occur. Now, sweating with cold extremities, unresolved spasms and tightness of the four limbs, and a faint, nearly imperceptible pulse indicate severe Yang deficiency and dominance of Yin. If purely administering Yang-tonifying drugs, there is fear that Yin will reject them, causing vomiting or restlessness, preventing the medicine from entering. Administer Tong Mai Si Ni Tang with added Zhu Dan Ye (Porcine Bile). Bile is bitter and enters the Heart to unblock vessels; bile is cold and enters the Liver to harmonize Yin. Used as an guiding agent in the decoction, it prevents rejection. The *Neijing* states: "For mild conditions, use sweating; for severe conditions, follow their nature." This refers to this situation.