大意
人受水谷之气以生。所谓清气营气元气卫气春升之气。皆胃气之别名也。若劳役过度。胃气本弱。则元
气不能自生。诸病生焉。（东垣）
内因
劳力过度。起居不时。皆损其气。气衰则火旺。火旺则乘其脾土。脾既病。胃不能独行其津液。故亦从而病焉。脾
胃俱病。纳化皆难。（东垣）形气衰少。谷气不盛。上焦不行。下脘不通。而胃气热。热气熏胸中。故内热。（内经）
外候
中气不足。下流肝肾。阴火独旺。上乘土位。故发热头疼。营卫失守。故恶风恶寒。气短而烦。气高而喘。口不
知味。怠惰嗜卧。四肢不收。自汗不敛。无气以动。无气以言。（东垣）
症似阳明
有体虚怯弱之人。饥困劳役之后。肌肤壮热。燥渴引饮。目赤面红。谵语闷乱。或日晡转甚。或昼夜不息。症
虽有余。脉实不足。洪大空虚。重按全无。经曰。脉虚则血虚。血虚则发热。证似白虎。而脉不长实为异。（准绳）
症似伤风
有劳役辛苦。肾中阴火沸腾。或脱衣。或沐浴。歇息凉处。其阴火不行。还归皮肤。腠理极虚。无阳以护。被风
与阴凉所遏。以此表虚。不任风寒。与外感恶风相似。但气息短促。懒于言语。困倦无力有别。（准绳）
始受热中
火与元气。势不两立。一胜则一负。脾胃气衰。元气不足而心火独盛。心火者。阴火也。起于下焦。其系系于
心。心不主令。相火代之。上乘阳分。为头痛。为口渴。为烦躁。为肌热。脉洪大无力。名曰热中。（准绳）
末传寒中
人之元气。根据胃为养。脾胃久虚。阳气衰少。心腹两胁隔噎不通。腰脊皆痛。足不任地。骨乏无力。两丸清冷。
或涎唾。或清涕。或多溺。或多汗。不渴不泻。脉盛大以涩。名曰寒中。（准绳）
脉法
平人脉大为劳。脉虚极亦为劳。劳之为病。其脉弦大。手足烦热。（金匮）右寸气口脉急大而数。时一代而涩。（此
饮食失节劳役太过太虚之脉也）右关脉大而数。数中显缓。时一代也。（此饮食失节劳役病之轻脉也）右关胃脉损弱。则
隐而不见。但内显脾脉之大数微缓。时一代。（此饮食失节寒热失所之脉也）内伤劳役。豁大不禁。若损胃气。隐而难寻）
治法
治以辛甘温剂。补中升阳。甘寒泻火。则愈。大忌苦寒。损伤脾胃。所谓劳者温之。损者益之是也。（东垣）
治忌克伐
苟内伤不足之病。误认外感而反泻之。是虚其虚也。盖内伤脾胃。乃伤其气。外感风寒。乃伤其形。伤其形
者有余。有余可泻。伤其气者不足。不足当补。故汗之吐之下之克之之类。皆泻也。温之和之养之调之之
类。皆补也。当补而泻。祸如反掌。（医贯）
内外伤辨
夫劳倦内伤而认作外感者。因有恶风恶寒发热头疼之症也。殊不知外感寒热。齐作无间。内伤寒热。间
作不齐。外感头疼。如破如裂。内伤头痛。时作时止。外感恶寒。虽近烈火不除。内伤恶寒。得就温暖即解。外
感恶风。不耐一切风寒。内伤恶风。偏恶些少贼风。外感发热。无有休歇。直待汗下方退。内伤发热。昼夜不
常。或自袒裸便凉。外感筋骨疼痛。不自支持。便着床褥。内伤四肢不收。无力倦怠而已。间有气衰火旺。变
为骨消筋缓者。然非初病即显是症也。内伤神思昏怠。言语懒倦。先重而后轻。外感神思猛壮。语言强健。
先轻而后重。内伤手心热而手背不热。外感手背热而手心不热。内伤症显在口。故口不知味。外感症显
在鼻。故鼻息不利。内伤从内而出。故右脉洪大。外感从外而入。故左脉浮盛。
用药
主以补中益气汤。挟外邪。随六经见症治之。挟痰。加半夏、茯苓、姜汁。头痛。加蔓荆。头眩。加天麻。巅痛。
加本、细辛。心下痞。加黄连。腹痛。加芍药。脐下痛。加熟地。便滞。加归梢。腹胀。加枳实、浓朴。胸中滞气。
加青皮。至于似阳明症者。当归补血汤。夏月劳役内伤。兼冒暑气。汗泄脉虚者。清暑益气汤。
劳倦选方
补中益气汤（方见中风）
加白芍药、五味子。名调中益气汤。加半夏、神曲、黄柏、草豆蔻。名升阳顺气汤。
小建中汤 治脾胃劳伤。肝木太过。及阳气不足诸病。
桂枝 甘草 生姜（各三两） 芍药（六两） 大枣（二枚） 饴糖（一斤）
加黄 。名黄 建中汤。
理中汤 治脾胃虚寒。大理中焦。兼益元阳。所谓大虚必挟寒也。（方见中寒）
补中宁嗽汤 治内伤中气。胃弱恶食。或食不生肉。不长气力。常常微热。怯冷神疲。或带痰嗽。
白术（炒一钱半） 茯苓（一钱） 半夏（八分） 干葛（七分） 陈皮（八分） 山楂（一钱） 人参（一钱） 砂
仁（五分） 炙甘草（三分）
加姜枣煎。
人参养卫汤 治劳役辛苦。用力过多。以致内伤发热。
人参 白术（炒） 麦门冬（各二钱去心） 黄 （蜜炒） 陈皮（各一钱半） 五味子（十粒研） 炙甘草（七
分）
加姜枣煎。食前服。如劳倦甚者。加熟附子五分。
白雪糕 养元气。健脾胃。生肌肉。润皮肤。益血秘精。安神定智。壮筋力。养精神。进饮食。功同参苓白术散。
白茯苓 怀山药 芡实仁 莲肉（去心皮各四两共为末） 陈仓米（半升） 白砂糖（斤半）
先将药米二末。用麻布袋盛放甑内。蒸极熟。取出。入白砂糖。同搅匀。印饼晒干。男妇小儿。任意取食。
大意
人依靠摄入水谷的精微之气而生存。所谓的清气、营气、元气、卫气、春升之气，都是胃气的不同名称。如果劳役过度，导致胃气本来虚弱，那么元气就不能自行化生，各种疾病就会由此产生。（李东垣）
内因
用力过度劳作，起居没有规律，都会损伤人体的正气。正气衰弱则虚火亢盛，虚火亢盛会克制脾土。脾一旦生病，胃就不能独自输送津液，因此也会随之发病。脾胃都患病，受纳和运化功能都会困难。（李东垣）形体和正气衰少，水谷精气不充足，上焦不能宣发，下脘不能通降，导致胃中热气熏蒸胸中，所以产生内热。（《黄帝内经》）
外候
中气不足，向下流注于肝肾，导致阴火单独亢盛，向上侵犯土位（脾胃），所以出现发热、头痛。营卫之气失守，所以恶风、恶寒。气短且心烦，气逆而上喘，口不知味，怠惰嗜睡，四肢无力收持，自汗不止，没有力气活动，没有力气说话。（李东垣）
症似阳明
有体质虚弱怯弱的人，在饥饿、困倦、劳役之后，肌肤壮热，燥渴想喝水，眼睛红赤，面色发红，胡言乱语，烦闷混乱，或者在下午申时（日晡）加重，或者昼夜不停。症状虽然看起来像有余实证，但脉象实际不足，洪大却空虚，重按完全无根。经书说：脉虚则血虚，血虚则发热。证候看似白虎汤证，但脉象不长实，这是其不同之处。（《医学准绳六要》）
症似伤风
有因劳役辛苦，导致肾中阴火沸腾的人。或者脱衣，或者沐浴后，在凉处休息，使得阴火不能正常运行，反而回归皮肤。此时腠理极度虚弱，没有阳气来护卫，被风和阴凉所遏制。因此表虚，不能耐受风寒，这与外感恶风相似。但是气息短促，懒于言语，困倦无力，这是区别所在。（《医学准绳六要》）
始受热中
火与元气，势力不相两立，一方胜则另一方负。脾胃气衰，元气不足而心火独盛。心火，就是阴火。起于下焦，其脉络系于心。心不主令，由相火代替。相火上冲阳分，表现为头痛、口渴、烦躁、肌热，脉象洪大无力，这叫做热中。（《医学准绳六要》）
末传寒中
人的元气，依靠胃气来滋养。脾胃久虚，阳气衰少，心腹及两胁之间隔噎不通，腰脊都痛，脚不能支撑身体，骨骼乏力，睾丸清冷，或者多涎唾，或者流清涕，或者小便多，或者出汗多，口不渴，不腹泻，脉象盛大而涩，这叫做寒中。（《医学准绳六要》）
脉法
平人脉大为劳损之脉，脉极虚也是劳损之脉。劳损病的脉象弦大，伴有手足烦热。（《金匮要略》）右寸气口脉急大而数，偶尔一代而涩。（这是饮食失节、劳役太过、太虚的脉象）右关脉大而数，数中显缓，偶尔一代。（这是饮食失节、劳役病较轻的脉象）右关胃脉损弱，则隐而不见，只在内显现脾脉的大数微缓，偶尔一代。（这是饮食失节、寒热失调的脉象）内伤劳役，脉豁大不禁；如果损伤了胃气，脉象隐伏难寻。（李东垣）
治法
治疗用辛甘温的药剂，补中益气，升举阳气，用甘寒药泻火，就能痊愈。特别忌讳苦寒药物，以免损伤脾胃。这就是所说的“劳者温之，损者益之”。（李东垣）
治忌克伐
如果是内伤不足的病，误认为是外感而反而使用泻法，这是使虚者更虚。因为内伤脾胃，是伤了气；外感风寒，是伤了形。伤形的属于有余，有余可以泻；伤气的属于不足，不足应当补。所以汗法、吐法、下法、克伐之类，都属于泻法；温法、和法、养法、调法之类，都属于补法。应当补而反用泻法，灾祸如反掌之间发生。（《医贯》）
内外伤辨
把劳倦内伤认作外感的，是因为有恶风、恶寒、发热、头痛等症状。殊不知外感的寒热，同时发作，没有间歇；内伤的寒热，交替发作，没有规律。外感的头痛，像破像裂；内伤的头痛，时作时止。外感的恶寒，即使靠近烈火也不能消除；内伤的恶寒，得到温暖就缓解。外感的恶风，不耐受一切风寒；内伤的恶风，特别厌恶少许贼风。外感的发热，没有休止，直到出汗后才退；内伤的发热，昼夜无常，有时袒露身体便觉凉爽。外感的筋骨疼痛，不能自我支持，必须卧床；内伤的四肢无力收持，只是疲倦无力而已。间或有气衰火旺，变为骨消筋缓的，但这并非初病即显现的症状。内伤神思昏沉怠惰，言语懒倦，先重后轻；外感神思猛壮，语言强健，先轻后重。内伤手心热而手背不热；外感手背热而手心不热。内伤症状表现在口，所以口不知味；外感症状表现在鼻，所以鼻息不利。内伤从内而出，所以右脉洪大；外感从外而入，所以左脉浮盛。
用药
主要使用补中益气汤。挟带外邪，根据六经见症治疗。挟痰，加半夏、茯苓、姜汁。头痛，加蔓荆子。头眩，加天麻。巅顶痛，加藁本、细辛。心下痞，加黄连。腹痛，加芍药。脐下痛，加熟地黄。大便滞涩，加当归梢。腹胀，加枳实、厚朴。胸中滞气，加青皮。至于类似阳明症的，用当归补血汤。夏季劳役内伤，兼冒暑气，汗泄脉虚的，用清暑益气汤。
劳倦选方
补中益气汤（方剂见中风章节）
加白芍药、五味子，名为调中益气汤。加半夏、神曲、黄柏、草豆蔻，名为升阳顺气汤。
小建中汤 治疗脾胃劳伤，肝木太过，以及阳气不足的各种疾病。
桂枝 甘草 生姜（各三两） 芍药（六两） 大枣（二枚） 饴糖（一斤）
加黄芪，名为黄芪建中汤。
理中汤 治疗脾胃虚寒，大力调理中焦，兼益元阳。所谓大虚必挟寒也。（方剂见中寒章节）
补中宁嗽汤 治疗内伤中气，胃弱恶食，或者吃了不长肉，不长气力，常常微热，怯冷神疲，或者带有痰嗽。
白术（炒一钱半） 茯苓（一钱） 半夏（八分） 干葛（七分） 陈皮（八分） 山楂（一钱） 人参（一钱） 砂仁（五分） 炙甘草（三分）
加生姜、大枣煎服。
人参养卫汤 治疗劳役辛苦，用力过多，以致内伤发热。
人参 白术（炒） 麦门冬（各二钱去心） 黄芪（蜜炒） 陈皮（各一钱半） 五味子（十粒研） 炙甘草（七分）
加生姜、大枣煎服。饭前服用。如果劳倦严重的，加熟附子五分。
白雪糕 滋养元气，健脾胃，生肌肉，润皮肤，益血秘精，安神定智，壮筋力，养精神，进饮食，功效同参苓白术散。
白茯苓 怀山药 芡实仁 莲肉（去心皮各四两共为末） 陈仓米（半升） 白砂糖（斤半）
先将药米二种磨成末，用麻布袋盛放甑内，蒸极熟，取出，加入白砂糖，同搅匀，印成饼晒干。男女小儿，任意取食。
General Principle
Human beings derive their life from the qi of water and grain. The so-called clear qi, Ying (nutritive) qi, Yuan (original) qi, Wei (defensive) qi, and spring-rising qi are all alternative names for Stomach Qi. If labor is excessive and Stomach Qi is originally weak, then Yuan Qi cannot generate itself, and various diseases will arise. (Li Dongyuan)
Internal Causes
Excessive physical labor and irregular daily routines both damage the body's Zheng (upright) Qi. When Zheng Qi declines, ministerial fire flares up; when ministerial fire flares up, it overacts on Spleen Earth. Once the Spleen is diseased, the Stomach cannot independently transport fluids, thus also becoming diseased. When both Spleen and Stomach are diseased, ingestion and transformation become difficult. (Li Dongyuan) When form and Qi are depleted and grain Qi is insufficient, the Upper Jiao fails to circulate, and the Lower Wan (stomach outlet) fails to unblock, causing stomach heat to steam the chest, resulting in internal heat. (Huangdi Neijing)
External Manifestations
When Middle Qi is insufficient, it flows downward into the Liver and Kidneys, causing Yin Fire to flare independently and ascend to invade the Earth position (Spleen/Stomach), leading to fever and headache. Because Ying and Wei Qi lose their guard, there is aversion to wind and cold. There is shortness of breath with irritability, upward rushing Qi with asthma, loss of taste, lethargy and desire to lie down, inability to control the four limbs, spontaneous sweating that does not收敛 (consolidate), lack of Qi to move, and lack of Qi to speak. (Li Dongyuan)
Symptoms Resembling Yangming Disease
In individuals with weak and timid constitutions, after hunger, fatigue, or labor, the skin and muscles may have high fever, dry thirst with desire to drink, red eyes and face, delirium, and restlessness. Symptoms may worsen at Shen hour (3-5 PM) or persist day and night. Although the symptoms appear as excess, the pulse is actually deficient: large and empty, with no root upon deep pressure. The Classics state: "A deficient pulse indicates Blood deficiency; Blood deficiency leads to fever." The presentation resembles Baihu Tang syndrome, but the difference lies in the pulse not being long and solid. (Yixue Zhunsheng)
Symptoms Resempling Wind Injury
In cases of hard labor where Yin Fire in the Kidneys boils, if one undresses, takes a bath, or rests in a cool place, the Yin Fire may fail to circulate properly and return to the skin. At this time, the Cou Li (pores) are extremely deficient, lacking Yang Qi to protect them. Being constrained by wind and coolness, the exterior becomes deficient and unable to withstand wind-cold, resembling external wind injury. However, there is shortness of breath, reluctance to speak, and exhaustion/weakness, which distinguishes it. (Yixue Zhunsheng)
Initial Heat Zhong (Heat in the Middle)
Fire and Yuan Qi are mutually exclusive; when one wins, the other loses. With Spleen-Stomach Qi decline and insufficient Yuan Qi, Heart Fire flares independently. Heart Fire is also called Yin Fire. It originates in the Lower Jiao and its channels connect to the Heart. Since the Heart does not issue commands, Xiang (ministerial) Fire acts on its behalf. Ascending to the Yang regions, it manifests as headache, thirst, irritability, and muscle heat, with a large and forceless pulse. This is called Re Zhong (Heat Zhong). (Yixue Zhunsheng)
Late Transmission Han Zhong (Cold in the Middle)
Human Yuan Qi relies on Stomach Qi for nourishment. Chronic Spleen-Stomach deficiency leads to declining Yang Qi. Obstruction occurs between the heart, abdomen, and hypochondrium; the lower back and spine ache; the feet cannot support the body; bones lack strength; the testicles feel cold; there may be excessive saliva or clear nasal discharge; urination or sweating may be frequent. There is no thirst or diarrhea. The pulse is large and rough. This is called Han Zhong (Cold Zhong). (Yixue Zhunsheng)
Pulse Diagnosis
In healthy people, a large pulse indicates Lao (exhaustion); an extremely deficient pulse also indicates Lao. In Lao diseases, the pulse is wiry and large, accompanied by vexatious heat in the hands and feet. (Jingui Yaolue) The Right Cun Qi Kou pulse is urgent, large, rapid, occasionally intermittent and choppy. (This is the pulse for dietary irregularity, excessive labor, and extreme deficiency.) The Right Guan pulse is large and rapid, appearing slow within the rapidness, occasionally intermittent. (This is the lighter pulse for dietary irregularity and labor disease.) The Right Guan Stomach pulse is damaged and weak, hidden and invisible, revealing only the Spleen pulse which is large, rapid, slightly slow, and occasionally intermittent. (This is the pulse for dietary irregularity and disharmony of cold and heat.) Internal injury from labor shows a wide, unrestrained pulse; if Stomach Qi is damaged, it becomes hidden and hard to find. (Li Dongyuan)
Treatment Principles
Treat with acrid-sweet-warm formulas to tonify the Middle and raise Yang, and use sweet-cold herbs to drain fire, and the condition will resolve. Bitter-cold herbs must be strictly avoided to prevent damaging the Spleen and Stomach. This follows the principle: "For exhaustion, warm it; for deficiency, benefit it." (Li Dongyuan)
Contraindication: Attack and Depletion
If an internal injury of deficiency is mistaken for an external pathogen and treated with purgatives, it further depletes the deficient. Internal injury to the Spleen and Stomach damages Qi; external invasion of wind-cold damages Form. Damaging Form results in Excess, which can be purged; damaging Qi results in Deficiency, which must be tonified. Therefore, methods such as sweating, vomiting, purging, and attacking are all draining methods; warming, harmonizing, nourishing, and regulating are all tonifying methods. Tonifying when one should tonify but instead draining leads to disaster instantly. (Yiguan)
Differentiation of Internal and External Injuries
Mistaking internal injury from fatigue for external infection is due to symptoms like aversion to wind/cold, fever, and headache. However, external cold-heat appears simultaneously without interruption, while internal cold-heat appears intermittently. External headache feels like breaking or splitting; internal headache comes and goes. External aversion to cold persists even near intense fire; internal aversion to cold resolves with warmth. External aversion to wind cannot tolerate any wind-cold; internal aversion to wind specifically dislikes slight drafts. External fever has no respite until sweat reduces it; internal fever varies day and night, sometimes feeling cool when exposing the body. External injury causes bone/muscle pain requiring bed rest; internal injury causes limb weakness and fatigue. Occasionally, Qi decline and fire flare lead to bone wasting and tendon laxity, but this is not an initial symptom. Internal injury causes mental dullness and lethargic speech, starting severe and becoming mild; external infection causes vigorous spirit and strong speech, starting mild and becoming severe. Internal injury causes hot palms but cool backs of hands; external infection causes hot backs of hands but cool palms. Internal injury symptoms manifest in the mouth (loss of taste); external infection symptoms manifest in the nose (nasal obstruction). Internal injury arises from within, showing a large Right pulse; external infection enters from outside, showing a floating and full Left pulse.
Medication
The primary formula is Buzhong Yiqi Tang. If complicated by external pathogens, treat according to Six Channels manifestations. If complicated by phlegm, add Banxia, Fuling, and Jiangzhi. For headache, add Manjingzi. For dizziness, add Tianma. For vertex headache, add Gaoben and Xixin. For epigastric fullness, add Huanglian. For abdominal pain, add Shaoyao. For periumbilical pain, add Shudihuang. For constipation, add Dangguishao. For abdominal distension, add Zhishi and Houpo. For stagnation in the chest, add Qingpi. For symptoms resembling Yangming disease, use Danggui Buxue Tang. For summer labor injury complicated by summerheat, with sweating and deficient pulse, use Qingshu Yiqi Tang.
Selected Formulas for Fatigue
Buzhong Yiqi Tang (See Stroke chapter)
Add Baishaoyao and Wuweizi, named Tiaozhong Yiqi Tang. Add Banxia, Shenqu, Huangbai, and Caodoukou, named Shengyang Shunqi Tang.
Xiao Jianzhong Tang Treats Spleen-Stomach injury from labor, excessive Liver Wood, and various conditions of insufficient Yang Qi.
Guizhi, Gancao, Shengjiang (each 3 liang), Shaoyao (6 liang), Dazao (2 pieces), Yitang (1 jin).
Add Huangqi, named Huangqi Jianzhong Tang.
Lizhong Tang Treats Spleen-Stomach deficiency-cold, greatly regulating the Middle Jiao and benefiting Yuan Yang. As stated, great deficiency must involve cold. (See Cold Damage chapter)
Buzhong Ningsou Tang Treats internal injury to Middle Qi, weak Stomach with food aversion, failure to gain flesh or strength, chronic low-grade fever, fear of cold with mental fatigue, or cough with phlegm.
Baizhu (stir-fried 1.5 qian), Fuling (1 qian), Banxia (0.8 fen), Gange (0.7 fen), Chenpi (0.8 fen), Shanzha (1 qian), Renshen (1 qian), Sharen (0.5 fen), Zhi Gancao (0.3 fen).
Decoct with Shengjiang and Dazao.
Renshen Yangwei Tang Treats hard labor and excessive effort leading to internal injury fever.
Renshen, Baizhu (stir-fried), Maimendong (each 2 qian, remove heart), Huangqi (honey-fried), Chenpi (each 1.5 qian), Wuweizi (10 grains, crushed), Zhi Gancao (0.7 fen).
Decoct with Shengjiang and Dazao. Take before meals. For severe fatigue, add Shufuzi 0.5 fen.
Baixue Gao Nourishes Yuan Qi, strengthens Spleen and Stomach, generates muscle, moistens skin, benefits blood and secures essence, calms the spirit and stabilizes intelligence, strengthens tendons and bones, nourishes spirit, promotes appetite. Its efficacy is similar to Shenling Baizhu San.
Baifuling, Huaishanyao, Qianshiren, Lianrou (remove heart and skin, each 4 liang, ground together), Chencangmi (0.5 sheng), Baishatang (1.5 jin).
First, grind medicine and rice into powder, place in a linen bag inside a steamer, steam thoroughly until very cooked. Remove, add white sugar, mix well, mold into cakes, and sun-dry. Men, women, and children may eat as desired.