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。
治疗的大法。秋季适宜使用下法。
秋季时阳气下行，邪气也随之位于下部，所以适宜使用下法。
凡是服用泻下药，用汤剂优于丸剂，一旦病愈就停止服药，不必服完全部剂量。
“汤”的意思是荡涤，能够洗涤肠胃，灌溉脏腑，推除陈旧的燥结，清除热邪并驱散寒邪，破除消散疫邪，调理疏导使枯槁之处得到润泽，使人皮肤愉悦，补益人的血气。水能洗净万物，所以汤剂胜过丸散。所谓“中病即止”，如承气汤证中说：“如果服一次药后大便通畅就停止后续服药。”又说：“如果只出现一次谵语就停止，不要再继续服用。”这就是不必服完全部剂量的意思。
下利（腹泻），三部脉象都平和，但按压心下部位感觉坚硬者，应当紧急使用下法，适宜用大承气汤。
下利的患者，脉象应当微弱或四肢厥冷，现在反而平和，这是体内有实邪。下利而三部脉象平和，已经说明是实证，再加上按压心下部位坚硬，则邪气很盛，所以适宜用大承气汤攻下。
下利，脉象迟而滑的，属于体内有实邪。下利不会自行停止，应当使用下法，适宜用大承气汤。
经典说：脉迟，是因为吃了干硬食物导致的。《金匮要略》说：脉滑表示谷气充实。下利而脉迟且滑，说明胃中有宿食。脾胃因伤食而不能消化水谷，导致下利，这属于内实。如果只用温中涩肠的药物，下利必定不能停止。可以给予大承气汤，下去宿食，下利自然就会停止。
王宇泰说：脉迟而有力，才可以采用这种方法。如果脉无力且没有外在证候依据的，恐怕是虚寒，不宜随意投用大承气汤。
问：人患有宿食，如何辨别？老师说：寸口脉浮而大，按之反而涩，尺部脉也微而涩，所以知道有宿食，应当使用下法，适宜用大承气汤。
寸部用来候察外部，尺部用来候察内部；浮脉用来候察表证，沉脉用来候察里证。寸口脉浮大，表示气实血虚。按之反而涩，尺部脉也微而涩，说明胃中有宿食，里气不和。给予大承气汤以攻下宿食。
王三阳说：尺脉涩，也有血虚的情况，必须审察是否有恶食、气痞以及胸膈饱闷痞满等外证，才适用此法。
下利而不想吃东西的，是因为有宿食的缘故，应当使用下法，给予大承气汤。
伤食就会厌恶食物，所以不想吃，就像伤风厌恶风、伤寒厌恶寒冷一样。
王三阳说：也有热邪在胃口导致不能进食的，不适宜使用下法。
下利痊愈后，到了原来的年月日又复发的，是因为病邪未尽的缘故，应当使用下法，适宜用大承气汤。
如果在春季复发，肝先受邪；在夏季复发，心先受邪；在长夏（至阴）复发，脾先受邪；在秋季复发，肺先受邪。假如在春季患病，气必然损伤肝脏，治疗难以痊愈。邪气未尽，到了春季原本患病的年月日，内外相感，邪气必定再次发动而引起疼痛。下利是肠胃的疾病，宿积未尽，所以应当攻下去除它。
下利，脉象反而滑的，应当有所去除，使用下法才能痊愈，适宜用大承气汤。
《脉经》说：脉滑，表示有病在食滞。下利而脉滑，说明内有宿食，所以说应当有所去除，给予大承气汤以攻下宿食。
腹部胀满疼痛的，这是实证，应当使用下法，适宜用大承气汤。
《金匮要略》说：病人腹满，按之不痛为虚证，痛为实证，可以使用下法。腹部胀满疼痛，说明里气壅塞实证，所以可以使用下法。
伤寒之后，脉象沉，沉脉表示体内有实邪，应当使用下法解除，适宜用大柴胡汤。
伤寒之后表证已解，脉沉表示里气未和，给予大柴胡汤，以攻下内实。经典说：伤寒痊愈后，再次发热，脉象沉实的，应当使用下法解除。
脉象双弦且迟的，一定心下坚硬；脉象大而紧的，是阳中有阴，可以使用下法，适宜用大承气汤。
《金匮要略》说：脉双弦，表示寒邪。经典说：迟脉表示病在脏。脉双弦且迟，是阴中伏阳，一定心下坚硬。大脉表示阳，紧脉表示寒。脉大而紧，是阳中伏阴。给予大承气汤，以分清阴阳。
《活人书》说：伤寒的里证，必须看热气深浅。所以张仲景有直接攻下的方法，如大小承气汤、十枣汤、大柴胡汤等。有轻微调和胃气的方法，如调胃承气汤、脾约丸，少量给予小承气汤轻微调和等。
李东垣说：使用下法，大承气汤最急迫，小承气汤次之，调胃承气汤又次之，大柴胡汤又次之。
王宇泰说：屠氏《四时治要》认为，张仲景《伤寒论》和《活人书》中，具备下证时，应当行大承气汤，但必须先以小承气汤试探。合用大柴胡汤时，必须先以小柴胡汤试探。按汤剂丸散，是众生命运的主宰，死生寿夭，在伤寒病中瞬息万变，怎么能用“试探”来说呢？过去鸡峰山的张锐，是宋代的神医，治疗一个伤寒病人，诊脉察色都显示热极，煮好承气汤准备给病人喝，又产生怀疑，犹豫再三，好像有人拉着他的手臂阻止他。姑且拿着药等待，病人突然发生战栗惊悸，盖上四五层绵被，稍后平静，出汗如洗，第二天完全康复。如果让药入口，那人就已经死了。
由此看来，屠氏的试探方法，虽然不是张仲景的本意，难道不是粗劣医生的借鉴吗？
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.