人参 白术 甘草（炙） 干姜（炮，恐热，以干生姜代之）
上等分，炼蜜丸，每两作五丸。白汤化下，水煎服之亦得。缓后失治，急也。
尤急者，若无汗，宜附子干姜甘草汤。若自汗者，宜附子白术甘草汤。量脉证，可宜四
逆汤、
真武汤、通脉四逆汤等，宜选用治之。至于用附子，不得已也。若身与四肢俱热，不至于凉
，或厥逆，不宜用附子，故理中有四顺。理中汤、丸之名。四顺者，手足自温不厥逆是也。
急则失治，尤急也。
阴证阳从内消，服温热药烦躁极甚，发渴欲饮，是将汗也，人不识此，反以为热，误矣
！热
上冲胸，服温热药烦躁少宁，反不欲饮，中得和也。人若识此，续汤不已愈矣！一则始病不
躁，药而躁，脉当浮之实大，阳气充也。手足温和则生；若浮之损小，阳气走也，手足厥逆
则死。一则始病躁，药而不躁，脉沉之实大，阳气回也。手足温和则生；沉之损小，阳气消
也，手足厥逆则死。二证服温热药，阳气不能充与不能回者，经云∶责其无火也。
问∶下之，而其脉反大者，何也？
答云∶下之而脉小者，理所当然。小犹可生，生之则易。仲景云∶下之而脉反大者，虚
也，
阳将走而变。医若不识而复下之，则气消而成大阴矣！亦有阴躁发热不止，大渴欲饮冷，热
上冲胸，火独炎上，亦将尽也。以阴遍身皆寒，惟存胸中火，阴独持权，不相管辖，迫而至
此，与下之而脉大同意。下之脉大，别不见热处，阴躁发热，但脉小耳！一则见脉不见证，
一则见证不见脉。又经云∶下利脉大者，虚也，以其强下之故也。设脉浮革，固卤肠鸣者，
属当归四逆汤。革为寒，寒虚相搏则肠鸣。
发汗病不解，反恶寒者，虚故也，芍药甘草附子汤主之。发汗若下之，病仍不解，反烦
躁，
茯苓四逆汤主之。汗下后，白日烦躁不得眠，夜而安静，不呕不渴，无表证，脉沉微，身无
大热者，干姜附子汤主之。
人参、白术、甘草（炙）、干姜（炮制，若担心其过于温热，可用干生姜替代）。
以上药物等分，用炼蜜制成丸剂，每两药粉做成五丸。用温水送服化开，或者水煎服用也可以。如果病情拖延后未能及时治疗，情况就紧急了。
更为紧急的情况是，如果没有汗出，适宜使用附子干姜甘草汤。如果有自汗现象，适宜使用附子白术甘草汤。根据脉象和证候，可以选择四逆汤、真武汤、通脉四逆汤等方剂进行治疗。至于使用附子，是在不得已的情况下才采用的。如果身体和四肢都发热，没有发凉，或者出现手足厥逆，就不宜使用附子，所以理中汤/丸中有“四顺”的说法。“理中汤、丸”的名称由来，“四顺”指的是手足自然温暖而不发生厥逆。如果病情急迫而失治，那就更加危急了。
阴证中阳气从内部消亡，服用温热药物后烦躁非常严重，口渴想喝水，这是将要出汗的征兆，人们如果不理解这一点，反而认为是热证，这就错了！如果热邪上冲胸部，服用温热药物后烦躁稍微缓解，反而不想喝水，说明中焦已经调和。如果医生能识别这种情况，继续服药不停止，病就会痊愈！第一种情况是起初患病时不烦躁，服药后出现烦躁，脉象应当浮取实大，这是阳气充盛的表现。如果手足温和则预后良好；如果浮取脉象损小，说明阳气外散，手足厥逆则预后不良死亡。第二种情况是起初患病时就烦躁，服药后不再烦躁，脉象沉取实大，这是阳气回复的表现。如果手足温和则预后良好；如果沉取脉象损小，说明阳气消亡，手足厥逆则预后不良死亡。这两种证候在服用温热药物后，如果是阳气不能充盛或不能回复的，经书说：这是因为体内无火（肾阳虚衰）的缘故。
问：经过攻下治疗后，脉象反而变大的，是什么原因？
答：经过攻下治疗后脉象变小，是符合常理的。脉象小还可以生存，治疗起来也容易见效。张仲景说：攻下后脉象反而变大，是因为正气虚弱，阳气即将耗散而发生变化。医生如果不认识这一点，再次进行攻下治疗，那么正气就会消亡而变成严重的阴寒证！也有因阴躁导致发热不止，极度口渴想喝冷水，热感上冲胸部，这是火势独炎于上的表现，也是阳气将尽的征象。因为阴寒遍布全身，只有胸中残存一点火气，阴气独自掌权，不受管辖，逼迫至此，这与攻下后脉大的道理相同。攻下后脉大，并没有看到其他热证表现；阴躁发热，只是脉象细小罢了！一种是只见脉象不见症状，一种是只见症状不见脉象。另外经书说：腹泻且脉大的，是虚证，是因为强行攻下的缘故。如果脉象呈现浮革之象，伴有肠鸣音，属于当归四逆汤证。革脉主寒，寒与虚相互搏结则导致肠鸣。
发汗后病未解除，反而恶寒的，是因为虚损，由芍药甘草附子汤主治。发汗或者攻下后，病仍未解除，反而烦躁的，由茯苓四逆汤主治。汗法和下法之后，白天烦躁不能入睡，夜间安静，没有呕吐，没有口渴，没有表证，脉象沉微，身体没有大热的，由干姜附子汤主治。
Ren Shen (Ginseng Radix), Bai Zhu (Atractylodis Rhizoma), Gan Cao (Licorice Radix et Rhizoma, prepared with honey), Gan Jiang (Zingiberis Rhizoma).
The above ingredients are divided into equal parts, processed with refined honey to make pills, where each liang of powder forms five pills. They can be taken by dissolving in warm water or decocted in water for oral administration. If treatment is delayed after the onset, the condition becomes urgent.
In more critical cases where there is no sweating, Fuzi Ganjiang Gancao Tang (Aconite, Dried Ginger, and Licorice Decoction) is suitable. If spontaneous sweating occurs, Fuzi Baizhu Gancao Tang (Aconite, Atractylodes, and Licorice Decoction) is suitable. Based on the pulse and syndrome, one may select Si Ni Tang (Frigid Extremities Decoction), Zhen Wu Tang (True Warrior Decoction), Tong Mai Si Ni Tang (Pulse-Resuscitating Frigid Extremities Decoction), etc., for treatment. The use of Fu Zi (Aconiti Lateralis Radix Praeparata) is a last resort. If the body and four limbs are hot and not cold, or if Jue Ni (cold reversal/extremity coldness) occurs, Fu Zi should not be used. Therefore, Li Zhong Tang/Wan (Regulate the Middle Decoction/Pill) includes the concept of "Si Shun" (Four Smoothnesses). "Li Zhong" refers to regulating the middle jiao. "Si Shun" means the hands and feet remain naturally warm without Jue Ni. If the acute condition is neglected, it becomes even more critical.
In Yin syndromes, when Yang Qi dissipates from within, taking warming and hot herbs may cause extreme restlessness (Fan Zao) and thirst with a desire to drink, which indicates that sweating is about to occur. If people do not understand this, they mistakenly consider it a Heat syndrome! If heat rushes upward to the chest, and after taking warming and hot herbs, the restlessness slightly subsides and there is no desire to drink, it indicates that the Middle Jiao has harmonized. If physicians recognize this, continuing the medication will lead to recovery. In the first scenario, if there was no restlessness at the beginning but restlessness appears after medication, the pulse should be floating, excess, and large, indicating abundant Yang Qi. If the hands and feet are warm, survival is likely; if the floating pulse is deficient and small, it indicates Yang Qi scattering, and Jue Ni leads to death. In the second scenario, if there was restlessness at the beginning but it ceases after medication, the deep pulse should be excess and large, indicating the return of Yang Qi. If the hands and feet are warm, survival is likely; if the deep pulse is deficient and small, it indicates the extinction of Yang Qi, and Jue Ni leads to death. For these two syndromes, if taking warming and hot herbs fails to replenish or restore Yang Qi, the Classics state: this is due to the lack of Fire (Kidney Yang deficiency).
Question: Why does the pulse become large after purgation?
Answer: It is logical for the pulse to become small after purgation. A small pulse still allows for survival, and recovery is easier. Zhang Zhongjing stated: If the pulse becomes large after purgation, it indicates deficiency, and Yang Qi is about to scatter and change. If physicians fail to recognize this and purge again, Qi will diminish, resulting in a severe Yin Cold syndrome! There are also cases of Yin restlessness with continuous fever, extreme thirst desiring cold drinks, heat rushing to the chest, and fire blazing upward alone, which signifies the exhaustion of Yang Qi. Because Yin cold pervades the whole body, only a remnant of fire remains in the chest, allowing Yin to dominate unchecked, forcing this situation. This is consistent with the logic of a large pulse after purgation. A large pulse after purgation shows no other heat signs; Yin restlessness with fever presents only with a small pulse! One case reveals the pulse but not the symptoms; the other reveals the symptoms but not the pulse. Furthermore, the Classics state: Diarrhea with a large pulse indicates deficiency, caused by forced purgation. If the pulse is floating and革 (Ge/Pounding Bamboo), accompanied by borborygmus (intestinal rumbling), it belongs to Dang Gui Si Ni Tang (Angelica Sinensis Resuscitating the Extremities Decoction). Ge pulse indicates cold; the combination of cold and deficiency causes borborygmus.
If sweating fails to resolve the disease and chills worsen, it is due to deficiency, treated by Shao Yao Gan Cao Fu Zi Tang (Peony, Licorice, and Aconite Decoction). If sweating or purgation fails to resolve the disease and restlessness ensues, it is treated by Fu Ling Si Ni Tang (Poria Resuscitating the Extremities Decoction). After sweating and purgation, if there is daytime restlessness preventing sleep but quietness at night, without vomiting, thirst, or exterior syndrome, with a deep and faint pulse and no significant body heat, it is treated by Gan Jiang Fu Zi Tang (Dried Ginger and Aconite Decoction).