具见六经中。
大法秋宜下。
【注】
天至秋则气降，物至秋则成实，实则宜下。凡邪在下者，俱宜取法乎此义也。
凡可下者，用汤胜丸散，中病便止，不必尽剂也。
【注】
汤者荡也，丸者缓也。下药贵速，故凡服下药用汤，所以胜丸也。中病即止，不必尽
剂者，恐尽剂反伤其正气也。
【集注】
程应旄曰：用汤胜丸，贵活法也。中病即止，示节制也。
下利，三部脉皆平，按之心下□者，急下之，宜大承气汤。
【注】
下利心下□者，诸泻心汤证也。若寸、关、尺三部脉平实有力，虽下利仍宜攻其□也
。
【集注】
方有执曰：三部脉皆平，血气和可知矣。心下□实也，所以急下之也。
张锡驹曰：本经云：若自下利者，脉当微厥。今反和者，此为内实也，宜下之。
@@@
下利，脉迟而滑者，内实也，利未欲止，当下之，宜大承气汤。
【注】
脉迟不能兼滑，惟浮取之迟，沉取之滑，则有之矣。今下利脉迟而滑，谓浮迟而沉滑
也，浮迟则外和，沉滑则内实。欲止内实之下利，仍当下之，使积去则利自止，宜大
承气汤。
【集注】
程应旄曰：迟而滑，滑在下而迟在上，知为物阻之迟，非寒阴之迟，故但下其所阻，
则内实去而利自止矣！
@@@
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。
【按】
尺中「微」字，当是「大」字，若是「微」字，断无当下之理。
【注】
寸口脉浮而大，按之反涩，谓按之且大、且涩、且有力也，关上尺中亦然。大涩有力
，为实而不利之诊，故知有宿食也，当下之，宜大承气汤。
【集注】
程知曰：滑为有食，结滞经宿，则脉涩矣。尺以候内，沉以候里，故宿食之脉，按之
反涩，尺中亦大而涩也。
@@@
下利不欲食者，以有宿食故也，当下之，宜大承气汤。
【注】
初下利不欲食者，是伤食恶食，故不欲食也。若久下利不欲食者，是伤脾，食后饱胀
不欲食也。今初下利即不欲食，故知有宿食也，当下之，宜大承气汤无疑也。
【集注】
程应旄曰：伤食恶食，故不欲食，与不能食者自别。下利有此，更无别样虚证，知非
三阴之下利，而为宿食之下利也，故当下之。
@@@
下利差，至其年月日时复发者，以病不尽故也，当下之，宜大承气汤。
【注】
下利差后，至其年月日时而复发其利者，此宿食积病攻之不尽故也。若其人形气不衰
，饮食尚强，当攻其未尽，自不复发矣，宜大承气汤。
【集注】
方有执曰：其期也，谓周其一年之月日期也。
程应旄曰：下利差后，而余邪之栖于肠胃回折处者未尽，是为伏邪。凡得其候而伏者
，仍应其候而伸下，则搜而尽之矣。
@@@
下利脉反滑，当有所去，下乃愈，宜大承气汤。
【注】
此承上条互发其义，以详其脉也。下利脉反滑，是证虚脉实不相宜也。若其人形气如
常，饮食如故，乃有当去之积未去也，下之乃愈，宜大承气汤
【集注】
程应旄曰：滑为实，故可行通因通用之法。
@@@
病腹中满痛者，此为实也，当下之，宜大承气汤。
【注】
腹中不满而痛者，病或属虚，若满而痛，则为实矣，当下之，宜大承气汤。
【集注】
张璐曰：腹中既满且痛，为实结无疑，急须下之。
程应旄曰：病腹中满痛，虽在阴经，亦可下，不必其为阳明矣。
@@@
伤寒后脉沉，沉者内实也，下之解，宜大柴胡汤。
【注】
伤寒后不解脉沉，沉而有力者，内实也，宜以下解。然其人必午后小有潮热，故取大
柴胡两解之也。
@@@
脉双弦而迟者，必心下□，脉大而紧者，阳中有阴也，可下之，宜大承气汤。
【注】
双弦，谓左关、右关，皆见弦脉也。左关脉弦，肝本脉也；右关脉弦，本刑土也。弦
者，饮也；迟者，寒也。心下□者，是肝邪挟寒饮而伤胃，故不可下，乃生姜泻心汤
证也。若脉大按之紧，是阳有余而阴亦实也，乃有余之□，非胃伤者比，故可下之，
宜大承气汤也。
（上述内容）在六经辨证中均有记载。
治疗大法上，秋季适宜使用下法。
【注】
天气到了秋天则气机下降，万物到了秋天则果实成熟，果实成熟则适宜用下法。凡是病邪位于体内的，都应当取法这一原则。
凡是适用下法的病症，使用汤剂的效果优于丸剂和散剂，一旦病情好转就应停药，不必服完全部药量。
【注】
汤剂的作用是涤荡清除，丸剂的作用是缓慢作用。下药贵在迅速起效，所以服用下药时选用汤剂，因此优于丸剂。所谓“中病即止，不必尽剂”，是担心如果服完全部药量反而会损伤人体的正气。
【集注】
程应旄说：使用汤剂优于丸剂，贵在灵活变通。中病即止，是为了显示用药有节制。
出现下利症状，寸、关、尺三部脉象都平和，但按压心下部位感觉痞硬者，应当紧急使用下法，宜用大承气汤。
【注】
下利伴有心下痞硬的症状，属于诸泻心汤证的范畴。但如果寸、关、尺三部脉象平实有力，虽然伴有下利，仍然应当攻逐心下的痞实证。
【集注】
方有执说：寸、关、尺三部脉象都平和，说明血气调和可知。心下痞硬属实证，所以要紧急使用下法。
张锡驹说：本经原文说：如果是自发性下利，脉象应当微弱或厥冷。现在脉象反而调和，这是体内有实邪，应当使用下法。
出现下利症状，脉象迟而滑的，是体内有实邪，下利不会停止，应当使用下法，宜用大承气汤。
【注】
脉象迟通常不能兼见滑象，只有浮取时见迟脉，沉取时见滑脉，这种情况才存在。现在所说的下利脉迟而滑，是指浮取迟、沉取滑。浮取迟表示外邪已和，沉取滑表示内有实邪。想要止住因内实引起的下利，仍然应当使用下法，使积滞去除后下利自然停止，宜用大承气汤。
【集注】
程应旄说：脉迟而滑，滑象在下部而迟象在上部，知道这是被物阻滞导致的迟脉，而不是寒阴之迟，所以只要攻下其所阻滞之物，内实去除了下利自然就会停止！
问：人患病有宿食，如何辨别？老师说：寸口脉浮而大，重按反而涩，尺中脉也微而涩，所以知道有宿食，应当使用下法，宜用大承气汤。
【按语】
尺中脉的“微”字，应当是“大”字，如果是“微”字，绝对没有可以使用下法的道理。
【注】
寸口脉浮而大，重按反而涩，意思是重按时脉象既大、又涩、又有力量，关上和尺中脉也是如此。脉大、涩且有力量，是实证且不通利的脉象，所以知道有宿食，应当使用下法，宜用大承气汤。
【集注】
程知说：滑脉主有食，结滞经过一夜，脉象就会变得涩。尺脉以候内部，沉取以候里部，所以宿食的脉象，重按反而涩，尺中脉也是大而涩。
出现下利且不想吃东西的症状，是因为有宿食的缘故，应当使用下法，宜用大承气汤。
【注】
刚开始下利就不想吃东西，是伤食厌恶食物，所以不想吃。如果是长期下利不想吃东西，是伤了脾气，饭后饱胀不想吃。现在是刚开始下利就不想吃，所以知道有宿食，应当使用下法，毫无疑问宜用大承气汤。
【集注】
程应旄说：伤食导致厌恶食物，所以不想吃，这与不能吃东西的情况自然不同。下利出现这种情况，如果没有其他虚证，就知道不是三阴经的下利，而是宿食引起的下利，所以应当使用下法。
下利痊愈后，到了原来的年、月、日、时再次复发，是因为病根未除的缘故，应当使用下法，宜用大承气汤。
【注】
下利痊愈后，到了原来的时间再次复发下利，这是因为宿食积滞的病邪攻伐不彻底所致。如果这个人形体和气力没有衰退，饮食依然旺盛，应当攻逐未尽的病邪，自然就不会复发了，宜用大承气汤。
【集注】
方有执说：所谓“其期”，是指满一年的年月日时周期。
程应旄说：下利痊愈后，残存的邪气潜伏在肠胃回折处未被清除干净，这叫做伏邪。凡是遇到这种征候而潜伏的邪气，仍应根据相应的征候而施用下法，从而将其搜刮干净。
下利脉象反而滑，说明体内有当去的积滞，使用下法后才能痊愈，宜用大承气汤。
【注】
这是承接上一条互相阐发其义，详细论述脉象。下利脉象反而滑，是证候虚而脉象实，不相适宜。如果这个人形体气色如常，饮食如故，那是因为有应当去除的积滞尚未去除，使用下法后才能痊愈，宜用大承气汤。
【集注】
程应旄说：滑脉主实证，所以可以运用“通因通用”的治疗方法。
病人腹部胀满疼痛的，这是实证，应当使用下法，宜用大承气汤。
【注】
腹部不满但疼痛的，病可能属虚证；如果既满又痛，就是实证了，应当使用下法，宜用大承气汤。
【集注】
张璐说：腹部既满又痛，无疑是实邪结聚，急需使用下法。
程应旄说：病在腹部胀满疼痛，即使在阴经，也可以使用下法，不一定非要是阳明病。
伤寒后脉象沉，沉脉代表体内有实邪，使用下法可以解除，宜用大柴胡汤。
【注】
伤寒后病不解，脉象沉，沉而有力的，是体内有实邪，应当通过下法来解除。然而这个人必定在午后有轻微的潮热，所以选取大柴胡汤来表里双解。
脉象左右两手都弦而且迟的，一定有心下痞硬；脉象大而紧的，是阳中有阴，可以使用下法，宜用大承气汤。
【注】
双弦，是指左关、右关两部脉都见到弦脉。左关脉弦，是肝的本脉；右关脉弦，是木克土的表现。弦脉主饮邪；迟脉主寒。心下痞硬的，是肝邪挟带寒饮伤害胃腑，所以不可使用下法，这是生姜泻心汤的证候。如果脉大且重按感到紧，是阳气有余而阴气也实，这是有余的痞硬，不同于胃气受伤的情况，所以可以使用下法，宜用大承气汤。
(The above content) is recorded in the Six Channels differentiation.
In general treatment principles, purgation (Xia Fa) is suitable in autumn.
[Annotation]
When heaven reaches autumn, the Qi descends; when things reach autumn, they bear fruit. When fruit is ripe, purgation is suitable. For any pathogenic factors located internally, one should follow this principle.
For conditions suitable for purgation, decoctions (Tang) are superior to pills and powders. Stop medication once the disease is addressed; there is no need to consume the entire dose.
[Annotation]
Decoctions act by sweeping away pathogens, while pills act slowly. Purgatives aim for rapid effect, hence decoctions are preferred over pills. "Stop when the disease is addressed" implies avoiding the consumption of the full dose to prevent damage to healthy Qi (Zheng Qi).
[Collected Annotations]
Cheng Yingmao stated: Using decoctions over pills values flexibility. Stopping when the disease is addressed demonstrates restraint.
If diarrhea occurs, and the pulse at the cun, guan, and chi positions on both hands is level/normal, but palpation of the epigastrium reveals hardness/fullness, urgent purgation is required. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Annotation]
Diarrhea accompanied by epigastric fullness/hardness typically belongs to the patterns treated by various Xi Xin Tang (Heart-Draining Decoctions). However, if the pulses at the cun, guan, and chi positions are level, solid, and forceful, despite the diarrhea, one should still attack the epigastric excess/fullness.
[Collected Annotations]
Fang Youzhi stated: The pulses at the three positions being level indicates that blood and Qi are harmonious. The epigastric fullness/hardness is an excess condition, hence urgent purgation is required.
Zhang Xiju stated: The classic text says: If there is spontaneous diarrhea, the pulse should be faint or cold. Now that the pulse is harmonious, this indicates internal excess, so purgation is indicated.
If diarrhea occurs, and the pulse is slow and slippery, it indicates internal excess. The diarrhea will not cease until purgation is performed. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Annotation]
A slow pulse usually does not coexist with a slippery quality. However, superficial palpation may reveal a slow pulse while deep palpation reveals a slippery pulse. Here, "slow and slippery" refers to superficial slowness and deep slipperiness. Superficial slowness suggests external harmony, while deep slipperiness indicates internal excess. To stop diarrhea caused by internal excess, purgation is still required. Once the accumulation is removed, the diarrhea will cease spontaneously. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Collected Annotations]
Cheng Yingmao stated: Slow and slippery, with slipperiness below and slowness above, indicates slowness due to obstruction, not cold-yin slowness. Therefore, only the obstruction needs to be purged. Once the internal excess is removed, the diarrhea will cease!
Q: How can one distinguish food retention (Su Shi) in a patient?
A: The pulse at the cun kou position is floating and large, but becomes choppy upon pressure. The chi position is also faint and choppy. Thus, food retention is known to exist, and purgation is required. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Commentary]
The character "faint" (wei) in the chi position should likely be "large" (da). If it were "faint," purgation would absolutely be contraindicated.
[Annotation]
The pulse at the cun kou is floating and large, becoming choppy upon pressure, meaning it is large, choppy, and forceful upon pressing. This applies to the guan and chi positions as well. A large, choppy, and forceful pulse is a diagnostic sign of excess and lack of free flow, indicating food retention. Purgation is required. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Collected Annotations]
Cheng Zhi stated: Slippery pulse indicates food presence. If stagnation persists overnight, the pulse becomes choppy. The chi position reflects the interior, and deep palpation reflects the interior. Thus, the pulse for food retention is choppy upon pressure, and the chi position is large and choppy.
If diarrhea occurs accompanied by loss of appetite, it is due to food retention. Purgation is required. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Annotation]
Initial diarrhea with loss of appetite is due to food injury causing aversion to food. Long-term diarrhea with loss of appetite is due to spleen injury, causing postprandial fullness and loss of appetite. Since this case involves initial diarrhea with immediate loss of appetite, food retention is confirmed. Purgation is undoubtedly indicated. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Collected Annotations]
Cheng Yingmao stated: Food injury causes aversion to food, distinguishing it from inability to eat. Diarrhea with this symptom, without other deficiency signs, indicates it is not diarrhea of the Three Yin channels, but diarrhea due to food retention. Hence, purgation is required.
If diarrhea resolves but recurs at the same time of year, month, day, or hour, it is because the pathogen was not fully eliminated. Purgation is required. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Annotation]
Recurrence of diarrhea at the specific time after resolution indicates that the food retention and accumulated pathogen were not fully cleared. If the patient's constitution and strength remain robust and appetite is strong, the remaining pathogen should be attacked to prevent recurrence. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Collected Annotations]
Fang Youzhi stated: "Its period" refers to the cycle of one year's months, days, and hours.
Cheng Yingmao stated: After diarrhea resolves, residual pathogens lingering in the folds of the intestines and stomach are not fully cleared; this is called latent pathogen (Fu Xie). Whenever such symptoms appear, the latent pathogen extends accordingly, and purgation should be applied to search out and eliminate it completely.
If diarrhea occurs with a surprisingly slippery pulse, there is something to be expelled. Purging will lead to recovery. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Annotation]
This elaborates on the previous clause regarding the pulse. A surprisingly slippery pulse during diarrhea indicates a mismatch between deficiency symptoms and excess pulse. If the patient's appearance and qi are normal, and diet is unchanged, it means there is accumulation that needs to be removed. Purging will lead to recovery. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Collected Annotations]
Cheng Yingmao stated: Slippery pulse indicates excess, so the method of "treating obstruction with unblocking agents" (Tong Yin Yong Tong) can be applied.
If abdominal fullness and pain occur, this is an excess condition. Purgation is required. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Annotation]
Abdominal pain without fullness may belong to deficiency. However, fullness combined with pain indicates excess. Purgation is required. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Collected Annotations]
Zhang Lu stated: Abdominal fullness and pain undoubtedly indicate excess knotting; urgent purgation is necessary.
Cheng Yingmao stated: Even if abdominal fullness and pain occur in the Yin channels, purgation can be used; it does not have to be Yangming disease.
After Shang Han (Cold Damage), if the pulse is sunken, sunken indicates internal excess. Purging will resolve it. Da Chai Hu Tang (Major Bupleurum Decoction) is indicated.
[Annotation]
If Shang Han remains unresolved with a sunken pulse, and the pulse is sunken and forceful, it indicates internal excess, which should be resolved via purging. However, the patient must have slight tidal fever in the afternoon, hence Da Chai Hu Tang (Major Bupleurum Decoction) is chosen to resolve both exterior and interior simultaneously.
If the pulse is double-string-taut (shuang xian) and slow, there must be epigastric fullness/hardness. If the pulse is large and tight, it indicates yang containing yin. Purgation is possible. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.
[Annotation]
"Double-string-taut" refers to the string-taut (xian) pulse appearing at both the left guan and right guan positions. Left guan string-taut is the liver's native pulse; right guan string-taut indicates wood insulting earth. String-taut indicates fluid retention; slow indicates cold. Epigastric fullness/hardness here is caused by liver pathogen combining with cold-fluid retention to injure the stomach, so purgation is contraindicated; this is a pattern for Sheng Jiang Xi Xin Tang (Fresh Ginger Heart-Draining Decoction). If the pulse is large and tight upon pressure, it indicates excess yang and excess yin. This is excess-type fullness/hardness, distinct from stomach injury, so purgation is permitted. Da Cheng Qi Tang (Major Order the Golden Decoction) is indicated.