治脾肾双虚, 子后作泻, 不思食, 不化食. 肉果二两
补骨脂 ( 炒 ) 四两 五味子二两 吴茱萸 ( 炮 ) 二两, 右为末,
红枣四十九枚, 生姜四两, 切, 水煮, 枣熟去姜, 取枣肉捣, 和药丸
,桐子大. 空心盐汤下.
去茱萸, 五味
五味子散 去肉果, 补骨脂.
【集注】柯琴曰: 泻利为腹疾, 而腹为三阴之都会, 一脏不调, 便能
泻利. 故三阴下利, 仲景各为立方以主之: 太阴有理中, 四逆; 厥阴
有乌梅, 白头翁, 少阴有桃花, 真武, 猪苓, 猪肤, 四逆汤散, 白通
,通脉等剂, 可谓曲尽病情, 诸法备矣. 然祗为一脏立法, 若三脏相
关, 久留不痊, 如子后作泻一证, 犹未之及也. 夫鸡鸣至平旦, 天
之阴 , 阴中之阳也. 因阳气当至而不至, 虚邪得以留而不去, 故作
泻于黎明. 其由有四: 一为脾虚不能制水, 一为肾虚不能行水, 故二
神丸君补骨脂之辛燥, 补肾以行水, 佐肉果之辛温, 补脾以制水, 丸
以姜, 枣, 又辛甘发生诸阳也; 一为命门火衰不能生土, 一为少阳气
虚无以发陈, 故五味子散, 君五味子之酸温, 以收坎宫耗散之火, 使
少火生气以培土也, 佐吴茱萸之辛温, 以顺肝木欲散之势, 为水气开
滋生之路, 以奉春生也. 此四者, 病因虽异, 而见证则同, 皆水亢为
害.二神丸是承制之剂, 五味子散是化生之剂也. 二方理不同而用则
同,故可互用以助效, 亦可合用以建功. 合为四神丸是制生之剂也,
制则生化, 久泄自瘳矣. 称曰四神, 比理中, 八味二丸较速欤!
【按】命门无火, 不能为中宫腐熟水谷之用; 肾气不固, 谁复司其闭
藏之职. 故木气才萌, 不疏泄而亦疏泄矣. 虽是木邪干土, 亦实肾之
侮脾也. 此际当脾肾双补, 固涩平肝. 故以补骨脂温肾, 肉果补脾
.五味子收涩, 吴茱萸泻肝. 肾暖而气蒸, 肝平而脾旺, 关门闭而水
谷腐矣.
主治脾肾两虚，黎明前腹泻，食欲不振，食物不消化。肉豆蔻二两，补骨脂（炒）四两，五味子二两，吴茱萸（炮制）二两，以上四味研为细末，红枣四十九枚，生姜四两，切片，用水煮至枣熟后去掉生姜，取枣肉捣烂，与药粉混合制成丸药，大小如梧桐子大。空腹时用盐开水送服。
若去掉吴茱萸和五味子，即为二神丸；若去掉肉豆蔻和补骨脂，即为五味子散。
【集注】柯琴说：泄泻痢疾属于腹部疾病，而腹部是三阴经（太阴、少阴、厥阴）汇聚之处，任何一个脏腑功能失调，都能导致泄泻痢疾。因此对于三阴经引起的下利，张仲景分别制定了不同的方剂来主治：太阴病有理中汤、四逆汤；厥阴病有乌梅丸、白头翁汤；少阴病有桃花汤、真武汤、猪苓汤、猪肤汤、四逆散、白通汤、通脉四逆汤等方剂，可以说详尽地分析了病情，各种治法都具备了。然而这些方剂只是针对单一脏腑立法，如果三个脏腑相互关联，久病不愈，像黎明前腹泻这一证候，之前的方剂就没有涉及到了。从鸡鸣时到平旦（天亮），是自然界阴气盛的时候，也是阴中之阳初生的时候。因为阳气应当到来却没有到来，虚邪得以停留而不能去除，所以在黎明时分发生腹泻。其病因主要有四种情况：一是脾虚不能制约水湿，二是肾虚不能运化水液，所以二神丸以补骨脂的辛燥之性为君药，补肾以行水，佐以肉豆蔻的辛温之性，补脾以制水，再用姜、枣制成丸剂，利用其辛甘之性生发诸阳之气；三是命门火衰不能温煦脾土，四是少阳之气虚弱无法生发万物，所以五味子散以五味子的酸温之性为君药，收敛坎宫（肾）耗散的阳气，使少火生气以培补脾土，佐以吴茱萸的辛温之性，顺应肝木欲疏泄的趋势，为水气的滋生开辟道路，以顺应春生之气。这四种情况，病因虽然不同，但表现出的症状相同，都是水湿亢盛为害。二神丸是制约水湿的方剂，五味子散是化生阳气的方剂。这两个方子道理不同但作用相似，所以可以互换使用以增加疗效，也可以合用建功立业。合在一起成为四神丸，就是既制约又化生的方剂，通过制约达到生化，久泻自然痊愈。称之为“四神”，比理中汤、八味丸等方剂见效更快吧！
【按语】命门没有火力，就不能发挥腐熟水谷的作用；肾气不固，谁又来掌管闭藏的职责呢？所以只要木气刚刚萌动，即使不想疏泄也会发生疏泄。这虽然是木邪侵犯脾土，实际上也是肾气亏虚反侮脾土的表现。此时应当脾肾双补，固涩止泻并平抑肝气。所以用补骨脂温补肾阳，肉豆蔻补益脾气，五味子收敛固涩，吴茱萸疏泄肝气。肾暖则气化正常，肝平则脾气旺盛，关门关闭而水谷得以正常腐熟消化。
Indicated for deficiency of both the Spleen and Kidney, diarrhea occurring before dawn (cock-crow diarrhea), loss of appetite, and indigestion. *Myristicae Semen* (Nutmeg) 2 liang, *Psoraleae Fructus* (Buguzhi, 补骨脂) [stir-fried] 4 liang, *Schisandrae Fructus* (Wuweizi, 五味子) 2 liang, *Evodiae Fructus* (Wuzhuyu, 吴茱萸) [processed] 2 liang. The above four herbs are ground into fine powder. Red dates (Jujubae Fructus) 49 pieces, fresh ginger (Zingiberis Rhizoma Recens) 4 liang, sliced. Boil in water until the dates are cooked, remove the ginger, take the date pulp, mash it, mix with the herbal powder, and make pills the size of paulownia seeds. Take on an empty stomach with salted warm water.
If Evodiae Fructus and Schisandrae Fructus are removed, it becomes Ershen Wan (Two-Spirit Pill). If Myristicae Semen and Psoraleae Fructus are removed, it becomes Wuweizi San (Schisandra Powder).
[Collected Notes] Ke Qin stated: Diarrhea and dysentery are abdominal diseases, and the abdomen is the convergence point of the Three Yin meridians (Taiyin, Shaoyin, Jueyin). Dysfunction of any single zang organ can lead to diarrhea or dysentery. Therefore, for lower purging caused by the Three Yin meridians, Zhang Zhongjing formulated different prescriptions to treat them respectively: Taiyin has Lizhong Tang (Regulate the Middle Decoction) and Sixine Tang (Four-Reverse Decoction); Jueyin has Wumei Wan (Mume Pill) and Baitouweng Tang (Pulsatilla Decoction); Shaoyin has Taohua Tang (Peach Kernel Decoction), Zhenwu Tang (True Warrior Decoction), Zhuling Tang (Polyporus Decoction), Zhufu Tang (Pig Skin Decoction), Sixin San (Four-Reverse Powder), Baotong Tang (White Connective Decoction), Tongmai Sixinjia Huanglian Ejiao Tang (Pulse-Unblocking Four-Reverse plus Coptis and Donkey-Hide Gelatin Decoction), etc. These can be said to have thoroughly analyzed the disease conditions and provided comprehensive treatment methods. However, these formulas are legislated for a single zang organ. If three organs are interrelated and the illness persists without cure, such as the syndrome of diarrhea before dawn, previous formulas did not address this. From cock-crow to dawn, heaven's yin is dominant, which is yang within yin. Because yang qi should arrive but does not, pathogenic vacuity evil remains and cannot be expelled, thus causing diarrhea at dawn. There are four causes: First, Spleen deficiency fails to control water; second, Kidney deficiency fails to transport water. Therefore, Ershen Wan uses Psoraleae Fructus as the sovereign herb for its acrid-warm nature to tonify the Kidney and move water, assisted by Myristicae Semen for its acrid-warm nature to tonify the Spleen and control water, made into pills with ginger and dates to generate yang qi through acrid-sweet properties; Third, Mingmen (Gate of Life) fire decline fails to generate Earth (Spleen); Fourth, Shaoyang qi deficiency lacks the ability to give birth to new things. Therefore, Wuweizi San uses Schisandrae Fructus as the sovereign herb for its sour-warm nature to gather the scattered fire of Kan Palace (Kidney), allowing Shao Huo (Ministerial Fire) to generate Qi to cultivate Earth, assisted by Evodiae Fructus for its acrid-warm nature to smooth the Liver wood's tendency to disperse, opening a path for water qi generation to serve spring growth. These four cases, although differing in etiology, present similar symptoms, all involving excessive water causing harm. Ershen Wan is a formula for restraining and controlling, while Wuweizi San is a formula for transformation and generation. Although the principles of these two formulas differ, their applications are similar; thus, they can be used interchangeably to enhance efficacy, or combined to achieve greater results. Combined, they form Sishen Wan (Four-Spirit Pill), which is a formula for both restraint and generation. Through restraint comes generation, and chronic diarrhea will naturally heal. It is called "Four Spirits," implying it acts faster than Lizhong Tang or Bawei Wan (Eight-Treasure Pill)!
[Commentary] When Mingmen lacks fire, it cannot perform the function of rotting and ripening food and drink in the Central Palace (Spleen/Stomach). When Kidney Qi is insecure, who manages the duty of closure and storage? Thus, when Wood Qi begins to sprout, even if there is no desire for dispersion, dispersion occurs. Although this appears to be Wood evil invading Earth, it is essentially Kidney deficiency insulting the Spleen. At this time, one should tonify both the Spleen and Kidney, secure and astringe, and calm the Liver. Therefore, Psoraleae Fructus is used to warm the Kidney, Myristicae Semen to tonify the Spleen, Schisandrae Fructus to secure and astringe, and Evodiae Fructus to drain the Liver. When the Kidney is warm, Qi steams normally; when the Liver is calm, the Spleen prospers; when the gate closes, food and drink are properly rotted and digested.