大法。秋宜下。
秋时阳气下行。则邪亦在下。故宜下。
凡服下药。用汤胜丸。中病即止。不必尽剂也。
汤之为言荡也。涤荡肠胃。溉灌脏腑。推陈燥结。却热下寒。破散邪疫。理导润泽
枯槁。悦人皮肤。益人血气。水能净万物。故胜丸散。中病即止者。如承气汤证云。若
一服利而止后服。又曰。若一般谵语止。更莫复服。是不必尽剂。
下利。三部脉皆平。按之心下硬者。急下之。宜大承气汤。
下利者。脉当微厥。今反和者。此为内实也。下利三部脉平者。已为实而又按之。
心下硬者。则邪甚也。故宜大承气汤下之。
下利。脉迟而滑者。内实也。利未欲止。当下之。宜大承气汤。
经曰。脉迟者。食干物得之。金匮要略曰。滑则谷气实。下利脉迟而滑者。胃有宿
食也。脾胃伤食。不消水谷。是致下利者。为内实。若但以温中浓肠之药。利必不止。可
与大承气汤。下去宿食利自止矣。
王宇泰云。脉迟而有力。方可用此法。若无力而外证无所据者。恐虚寒。不宜妄投
大承气也。
问曰。人病有宿食。何以别之。师曰。寸口脉浮而大。按之反涩。尺中亦微而涩。故知
有宿食。当下之。宜大承气汤。
寸以候外。尺以候内。浮以候表。沉以候里。寸口脉浮大者。气实血虚也。按之反
涩。尺中亦微而涩者。胃有宿食。里气不和也。与大承气汤以下宿食。
王三阳云。尺涩。亦有血虚者。须审外证恶食气痞。及胸膈饱闷痞。方是。
下利不欲食者。以有宿食故也。当下之。与大承气汤。
伤食则恶食。故不欲食。如伤风恶风。伤寒恶寒之类也。
王三阳云。亦有热在胃口。不能食者。不宜下。
下利瘥后。至其年月日复发者。以病不尽故也。当下之。宜大承气汤。
乘春。则肝先受之。乘夏。则心先受之。乘至阴。则脾先受之。乘秋。则肺先受之。假
令春时受病。气必伤肝。治之难愈。邪有不尽者。至春时元受月日。内外相感。邪必复
动而痛也。下利为肠胃疾。宿积不尽。故当下去之。
下利。脉反滑。当有所去。下之乃愈。宜大承气汤。
脉经曰。脉滑者。为病食也。下利脉滑。则内有宿食。故云当有所去。与大承气汤
以下宿食。
病腹中满痛者。此为实也。当下之。宜大承气汤。
金匮要略曰。病者腹满。按之不痛为虚。痛为实。可下之。腹中满痛者。里气壅实
也。故可下之。
伤寒后。脉沉。沉者内实也。下解之。宜大柴胡汤。
伤寒后为表已解。脉沉为里未和。与大柴胡汤。以下内实。经曰。伤寒瘥以后。更
发热。脉沉实者。以下解之。
脉双弦而迟者。必心下硬。脉大而紧者。阳中有阴也。可以下之。宜大承气汤。
金匮要略曰。脉双弦者。寒也。经曰。迟为在脏。脉双弦而迟者。阴中伏阳也。必
心下硬大则为阳。紧则为寒。脉大而紧者。阳中伏阴也。与大承气汤。以分阴阳。
活人云。伤寒里证。须看热气浅深。故仲景有直下之者。如大小承气、十枣大柴胡
汤是也。有微和其胃气者。如调胃承气汤、脾约丸。少与小承气微和之之类是也。
李东垣云。下药用大承气汤最紧。小承气次之。调胃承气又次之。大柴胡汤又次之。
王宇泰云。屠氏四时治要。谓仲景活人书。下证俱备。当行大承气。必先以小承气
试之。合用大柴胡。必先以小柴胡试之。按汤剂丸散。生灵之司命也。死生寿夭。伤寒
之瞬息也。岂以试为言哉。昔鸡峰张锐。宋之神医也。疗一伤寒。诊脉察色皆为热极。煮
承气汤欲饮。复疑。至于再三。如有掣其肘者。姑持药以待。病者忽发战悸。覆绵衾四
五重。稍定。有汗如洗。明日脱然。使其药入口。则人已毙矣。
由是观之。则屠氏之探试。虽非仲景本旨。得非粗工之龟鉴欤。
General principles. In autumn, purgation is appropriate.
During autumn, Yang Qi descends, and pathogens also reside in the lower part; therefore, purgation is suitable.
When administering purgative medicines, decoctions are superior to pills. Stop medication once the disease is cured; there is no need to finish the entire dose.
"Decoction" (Tang) implies sweeping away; it cleanses the intestines and stomach, irrigates the viscera, pushes out old dry accumulations, eliminates heat and expels cold, breaks up and disperses epidemic pathogens, regulates and guides moisture to nourish withered tissues, pleases the skin, and benefits blood and Qi. Water can cleanse all things; thus, decoctions surpass pills and powders. "Stop when the disease is cured" means, as stated in the Chengqi Tang syndrome: "If bowel movement occurs after one dose, stop subsequent doses." It also says: "If delirium occurs only once, do not continue taking it." This means there is no need to finish the full dosage.
Diarrhea with flat pulses in all three positions (Cun, Guan, Chi), but hardness upon pressing the epigastrium requires urgent purgation; Da Chengqi Tang (Great Order the Qi Decoction) is indicated.
In diarrhea, the pulse should be faint or extremities cold. Now that the pulse is harmonious/flat, this indicates internal excess. Diarrhea with flat pulses already suggests excess; combined with hardness at the epigastrium upon palpation, the pathogen is severe. Therefore, Da Chengqi Tang (Great Order the Qi Decoction) is suitable for purgation.
Diarrhea with a slow and slippery pulse indicates internal excess. The diarrhea will not cease on its own; purgation is required, and Da Chengqi Tang (Great Order the Qi Decoction) is indicated.
The Classics state: A slow pulse results from consuming dry food. *Jin Gui Yao Lue* states: A slippery pulse indicates abundant grain Qi. Diarrhea with a slow and slippery pulse indicates retained food in the stomach. Spleen and Stomach injury from food retention leads to inability to digest water and grain, causing diarrhea, which constitutes internal excess. If only warming and astringent herbs are used, the diarrhea will likely persist. Da Chengqi Tang (Great Order the Qi Decoction) can be given to purge the retained food, after which the diarrhea will naturally stop.
Wang Yutai said: Only if the slow pulse is forceful can this method be used. If the pulse is weak and there are no supporting external symptoms, it may be deficiency-cold, and Da Chengqi Tang (Great Order the Qi Decoction) should not be administered recklessly.
Question: How to distinguish retained food in a patient? The Master said: The Cun Kou (Radial) pulse is floating and large; upon pressure, it feels choppy; the Chi position is also faint and choppy. Thus, we know there is retained food, and purgation is required. Da Chengqi Tang (Great Order the Qi Decoction) is indicated.
The Cun position inspects the exterior; the Chi position inspects the interior. Floating pulses inspect the exterior; sinking pulses inspect the interior. A floating and large Cun Kou pulse indicates Qi excess and Blood deficiency. Choppy upon pressure and faint/choppy at the Chi position indicates retained food in the Stomach and disharmony of interior Qi. Da Chengqi Tang (Great Order the Qi Decoction) is given to purge the retained food.
Wang Sanyang said: A choppy Chi pulse can also indicate Blood deficiency. One must examine external symptoms such as aversion to food, Qi stagnation, and chest/diaphragm fullness and oppression before applying this method.
Diarrhea accompanied by anorexia is due to retained food; purgation is required. Da Chengqi Tang (Great Order the Qi Decoction) is given.
Food injury causes aversion to food, hence anorexia, similar to wind-injury causing aversion to wind or cold-injury causing aversion to cold.
Wang Sanyang said: There are cases where heat in the Stomach opening prevents eating; these are not suitable for purgation.
After diarrhea has resolved, if it recurs on the same month, day, or year, it is because the pathogen was not fully eliminated. Purgation is required; Da Chengqi Tang (Great Order the Qi Decoction) is indicated.
If it recurs in spring, the Liver is affected first; in summer, the Heart; in late summer (Zhi Yin), the Spleen; in autumn, the Lung. For example, if illness contracted in spring damages Liver Qi, it is difficult to cure. If pathogens remain, upon reaching the original time of contraction, internal and external factors resonate, and the pathogen will reactivate causing pain. Diarrhea is a gastrointestinal disorder; if old accumulations remain, they must be purged.
Diarrhea with a reversely slippery pulse indicates something needs to be removed; purgation leads to recovery. Da Chengqi Tang (Great Order the Qi Decoction) is indicated.
*Mai Jing* states: A slippery pulse indicates food pathology. Diarrhea with a slippery pulse indicates internal retained food; thus, it is said that something must be removed. Da Chengqi Tang (Great Order the Qi Decoction) is given to purge the retained food.
Abdominal fullness and pain indicate excess; purgation is required. Da Chengqi Tang (Great Order the Qi Decoction) is indicated.
*Jin Gui Yao Lue* states: Abdominal fullness without pain upon pressure is deficiency; with pain is excess, and purgation may be used. Abdominal fullness and pain indicate interior Qi congestion and excess; thus, purgation is applicable.
After Shang Han (Cold Damage), a sinking pulse indicates internal excess. Purge to resolve; Da Chaihu Tang (Major Bupleurum Decoction) is indicated.
After Shang Han, the exterior is resolved; a sinking pulse indicates the interior is not harmonized. Da Chaihu Tang (Major Bupleurum Decoction) is given to purge internal excess. The Classics state: After Shang Han resolves, if fever returns with a deep and solid pulse, purge to resolve it.
A double-string-tight and slow pulse indicates epigastric hardness. A large and tight pulse indicates Yin within Yang; purgation can be used. Da Chengqi Tang (Great Order the Qi Decoction) is indicated.
*Jin Gui Yao Lue* states: Double-string-tight pulse indicates Cold. The Classics state: Slow pulse indicates disease in the Zang organs. A double-string-tight and slow pulse indicates Yang hidden within Yin, leading to epigastric hardness. Large indicates Yang; tight indicates Cold. A large and tight pulse indicates Yin hidden within Yang. Da Chengqi Tang (Great Order the Qi Decoction) is given to differentiate Yin and Yang.
*Liu Ren Shu* states: For interior syndromes in Shang Han, one must assess the depth of heat. Zhang Zhongjing had direct purgation methods, such as Xiao Chengqi Tang, Da Chengqi Tang, Shi Zao Tang, and Da Chaihu Tang. There were mild methods to harmonize Stomach Qi, such as Tiao Wei Chengqi Tang, Pi Yue Wan, and small doses of Xiao Chengqi Tang for mild harmonization.
Li Dongyuan said: Regarding purgatives, Da Chengqi Tang (Great Order the Qi Decoction) is the most urgent/potent, followed by Xiao Chengqi Tang (Minor Order the Qi Decoction), then Tiao Wei Chengqi Tang (Regulate the Stomach Order the Qi Decoction), and finally Da Chaihu Tang (Major Bupleurum Decoction).
Wang Yutai said: Tu Shi's *Si Shi Zhi Yao* claims that in Zhang Zhongjing's *Shang Han Lun* and *Liu Ren Shu*, when purgative indications are complete, Da Chengqi Tang (Great Order the Qi Decoction) should be used, but one must first test with Xiao Chengqi Tang (Minor Order the Qi Decoction). When Da Chaihu Tang (Major Bupleurum Decoction) is indicated, one must first test with Xiao Chaihu Tang (Minor Bupleurum Decoction). Decoctions and pills are masters of life and death; life, death, longevity, and premature death in Shang Han change in an instant. How can one speak of "testing"? In the past, Zhang Rui of Jifeng Mountain, a divine physician of the Song Dynasty, treated a Shang Han patient. Pulse diagnosis and color inspection both indicated extreme heat. He boiled Chengqi Tang intending to administer it, but doubted himself, hesitating repeatedly, as if someone were holding back his arm. He held the medicine waiting. Suddenly, the patient experienced chills and palpitations, covered with four or five layers of cotton quilts. After calming down, he sweated profusely. The next day, he recovered completely. Had the medicine entered his mouth, he would have died.
From this, we see that Tu Shi's testing method, although not Zhang Zhongjing's original intent, serves as a warning against crude practitioners.