〔补注〕夫曰疝气。则寒者特气凝而不化。非诚有积滞于其间也。虽然气既凝。则
血必滞。热则流通。寒必结聚。理之常也。假如因寒而有聚者。于法不得不去。又
于何知之。故圣人反复以言脉也。脉者血气之会也。有虚有实。殆必见焉。故数
紧乃弦状。至按而不移。其为寒也。不得谓之虚矣。夫数者阳也。弦者阴也。紧且
迟阴也。大则阳也。大既阳也。紧又阴也。疝为阴脉合矣。而又兼见阳。是必有滞。
故曰可下。然所下者何。曰下其寒。曰阳中有阴。已出手眼矣。其即以温药下之之义乎。
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。大承气汤主之。
〔补注〕寸口。即气口也。宿食停滞。关与寸浮大有力。是不待言。若按之反涩。知中
有所伤。阻抑中气。不得宣越。遂令尺中亦微涩。所滞之物。原已深重。设不大下。
所伤不亦多乎。然余观伤寒下例。用大承气。非试不敢漫投。甚以不可轻攻为
戒。何至宿食更无顾忌耶。盖既无外感。则不致有结胸痞痛之变证可知也。且
有恶食不大便。或实满之里证可知也。又何惮而不为此。
脉数而滑者实也。此有宿食。下之愈。宜大承气汤。
〔补注〕数为在腑。食积于胃而为热。故显数。遂使各部显有余之象。乃兼滑。苟不
急下。其为热耗津液何限乎。
下利。不欲食者。有宿食也。当下之。宜大承气汤。
〔补注〕不欲食。言伤食恶食也。脾土受伤不能健运。岂能去故而新是谋乎。盖言
受病未几。而利数旁流。虽下利而积聚未消也。苟久利之后。中州败坏。致不能
食者。即欲温补。尚恐难救。岂可反用承气。读者当于下利不欲食句着眼。始知
下利为宿食。不欲食亦止因宿食也。
宿食在上脘。当吐之。宜瓜蒂散。
瓜蒂散方
瓜蒂（一分熬黄） 赤小豆（一分煮）
上二味。各别捣筛为散已。合治之。取一钱匕。以香豉一合。用熟汤七合。煮作稀
糜。去滓。取汁和温服。顿服之。不吐者。少少加。得快吐乃止。诸亡血虚家。不可与之。
〔补注〕食既云宿。决非上脘。既非上脘。何以用吐。今言上脘。又言宿食。则必有痰
载物。不使得下。则为喘为满。不能具见。故一吐而痰与食俱出矣。
脉紧如转索无常者。有宿食也。
〔补注〕紧至于转索无常。此胃气垂绝之象。亦已危矣。又或停滞冷物。遂令胃气不复发越耳。
脉紧头痛。风寒。腹中有宿食不化也。
〔补注〕伤食者不头痛。今头痛。故知或风或寒。乃浮紧又寒脉也。若但紧不浮。则
知腹有所滞。虽兼外邪。因不见浮。治之者须知内伤外感。用药自有分寸。而不急于下也明矣。
【补注】所谓疝气，是指寒气凝滞而不能化散，并非体内确实有积滞存在。虽然气机已经凝滞，那么血液必然也会瘀滞不通。热邪能使气血流通，寒邪则导致气血结聚，这是常理。假如是因为受寒而形成的积聚，按照治法不得不将其去除。又怎么知道是这种情况呢？所以圣人反复通过脉象来阐述。脉象是气血汇聚之处，有虚证也有实证，必定会在脉象上表现出来。所以脉数、脉紧呈现出弦脉的形态，重按而不移动，这说明是寒邪所致，不能称之为虚证。数脉属于阳，弦脉属于阴，紧脉且迟涩属于阴，脉大属于阳。既然脉大属阳，紧脉又属阴，疝气的脉象符合阴脉的特征，而又兼见阳脉，这必定是有瘀滞存在。所以说可以使用下法。然而所下的内容是什么？说是攻下寒邪。这就是“阳中有阴”的高明见解吧。这大概就是以温药攻下的意思吗？
问：人患病有宿食（食物停滞不化），如何辨别它？
师曰：寸口脉浮而大，重按反而涩滞，尺部脉也微而涩。因此知道有宿食。主治方剂是大承气汤。
【补注】寸口，就是气口。宿食停滞，关部和寸部的脉象浮大有力，这是不言而喻的。如果重按反而感到涩滞，说明中焦有所损伤，阻碍了中气的宣发和输布，从而导致尺部脉也出现微涩之象。所停滞的食物原本已经很严重，如果不使用峻下之法，受到的伤害不是更多吗？然而我观察伤寒论中的下法案例，使用大承气汤时，如果不是经过仔细试探，不敢轻易投用，甚至以不可轻率攻下为戒。为什么对于宿食反而没有顾忌呢？大概是因为既然没有外感病邪，就不会产生结胸、痞痛等变证，这是可以知道的。而且有厌恶饮食、不大便，或者腹部实满等里证，也是可以知道的。又有什么可畏惧而不采用这种方法呢？
脉象数而且滑，这是实证。这说明有宿食，使用下法可以痊愈，适宜用大承气汤。
【补注】数脉表示病在腑，食物积滞在胃中化为热，所以显现出数脉。这使得各部脉象都显示出有余的象，如果再兼见滑脉，如果不紧急攻下，热邪耗伤津液的程度该有多大呢？
出现下利（腹泻），不想吃东西的，是有宿食。应当使用下法，适宜用大承气汤。
【补注】“不欲食”，说的是因伤食而厌恶进食。脾土受伤，不能正常运化，怎么能去旧生新呢？这里的意思是说，患病时间不长，而下利呈多次旁流之势，虽然在下利，但体内的积聚并没有消除。如果是久利之后，中焦脾胃败坏，导致不能进食的情况，即使想要用温补之法，恐怕也难以救治，哪里还能反过来使用承气汤呢？读者应当在“下利不欲食”这一句上下功夫体会，才能知道下利是因为宿食，不欲食也是因为宿食。
瓜蒂散方
瓜蒂（一分，炒至微黄） 赤小豆（一分，煮过）
以上两味药，分别捣碎并筛成细粉，混合均匀。取一钱匕的药末，用香豉一合，加入七合沸水，煮成稀粥状，滤去渣滓，取汁液与药末调和，温服。一次性服用。如果不呕吐，就少量增加剂量，直到引起快速呕吐为止。凡是失血患者及体质虚弱的人，禁止服用。
【补注】既然说是宿食，决不可能仅仅停留在上脘。既然不在上脘，为什么用吐法？现在既说在上脘，又说宿食，那一定是因为有痰浊承载食物，使得食物不能下行，从而表现为气喘、胀满等症状，这些症状不一定全部显现出来。所以通过一次吐法，痰和食都能排出体外。
脉象紧，像转动绳索一样无常变化的，是有宿食。
【补注】脉紧到了像转动绳索那样无常变化的程度，这是胃气即将衰竭的迹象，也已经很危险了。或者是停滞了冷物，导致胃气不能重新宣发透达罢了。
【补注】伤食的病人通常不会头痛。现在出现头痛，所以知道可能是风邪或寒邪所致，浮紧脉也是寒脉。如果仅仅是紧脉而不浮，就知道腹部有停滞之物。虽然兼有外邪，但因为脉不浮，治疗者必须清楚内伤和外感的区别，用药自然要有分寸，并且明白不应该急于使用下法。
[Supplementary Annotation] The term "Shan Qi" (Hernia Qi) refers to cold pathogen condensing and failing to transform, rather than there being actual accumulation or stagnation within. Although the Qi has condensed, Blood must inevitably become stagnant. Heat promotes circulation, while Cold causes aggregation; this is a general principle. Suppose an aggregation occurs due to Cold; according to treatment principles, it must be eliminated. How do we know this? Therefore, the Sages repeatedly expound upon pulse diagnosis. The pulse is the convergence of Qi and Blood, manifesting as either deficiency or excess, which must be observed. Thus, a rapid (Shu) and tight (Jin) pulse presents with the characteristics of a wiry (Xian) pulse; pressing down reveals no movement, indicating Cold, and thus cannot be classified as deficiency. A rapid pulse belongs to Yang, a wiry pulse to Yin, a tight and slow pulse to Yin, and a large pulse to Yang. Since a large pulse indicates Yang, and a tight pulse indicates Yin, the pulse pattern of Shan Qi aligns with Yin pulses, yet simultaneously exhibits Yang signs. This necessarily implies stagnation. Hence, it is said that purgation is indicated. However, what is being purged? It is said to purge Cold. This demonstrates the insight of "Yang containing Yin," likely implying the use of warming herbs to facilitate purgation.
Question: When a patient suffers from retained food (Su Shi), how can it be distinguished?
Master says: The Cun Kou (Inch Port) pulse is floating and large; upon pressure, it feels choppy (Se). The Chi Port (Cubit Port) is also faint and choppy. Therefore, one knows there is retained food. Da Cheng Qi Tang (Major Order the Qi Decoction) should be administered.
[Supplementary Annotation] Cun Kou is also known as Qi Kou. With retained food stagnating, the Guan (Carpal) and Cun positions showing floating, large, and forceful pulses goes without saying. If pressure reveals a choppy quality, it indicates injury in the Middle Jiao, obstructing the diffusion and ascent of Middle Qi, causing the Chi position to appear faint and choppy. The retained material is originally severe; if not aggressively purged, the damage would be even greater. However, observing the purgative protocols in Shang Han Lun (Treatise on Cold Damage), Da Cheng Qi Tang is used only after careful trial and is never thrown in lightly; caution against light attack is emphasized. Why would there be no hesitation regarding retained food? Presumably, since there is no exterior contraction, complications such as Jie Xiong (Chest Binding) or Pi Tong (Fullness and Pain) are unlikely. Furthermore, symptoms such as aversion to food, constipation, or abdominal fullness indicate interior excess. What reason is there to fear employing this method?
A pulse that is rapid and slippery indicates Excess. This signifies retained food; purgation will lead to recovery. Da Cheng Qi Tang is appropriate.
[Supplementary Annotation] A rapid pulse indicates pathology in the Fu organs. Food retention in the Stomach generates heat, hence the rapid pulse. This creates an impression of surplus in all pulse positions. If accompanied by a slippery pulse, failure to urgently purge will result in significant consumption of Body Fluids by the heat.
Diarrhea accompanied by anorexia indicates retained food. Purgation is indicated; Da Cheng Qi Tang is appropriate.
[Supplementary Annotation] "Anorexia" here refers to aversion to food due to dietary injury. The Spleen Earth is damaged and fails to transport and transform; how can it eliminate the old and generate the new? This means that shortly after illness onset, frequent loose stools occur. Although diarrhea is present, the accumulation remains. If, after prolonged diarrhea, the Middle Jiao collapses leading to inability to eat, even warming tonification might fail to save the patient, let alone using Cheng Qi formulas. Readers should focus on the phrase "diarrhea with anorexia" to understand that the diarrhea is caused by retained food, and the anorexia is also solely due to retained food.
When retained food resides in the Upper Wan (Upper Epigastrium), emesis is indicated. Gua Di San (Melon Tip Powder) is appropriate.
Formula for Gua Di San
Gua Di (Melon Tip): 1 fen, stir-fried until slightly yellow
Chi Xiao Dou (Red Adzuki Bean): 1 fen, boiled
The above two ingredients are separately pounded and sifted into powder, then mixed. Take one Qian Bi (a measuring spoon) of the powder. Use Xiang Chi (Prepared Soybean) 1 He, added with 7 He of boiling water, boiled into a thin porridge. Strain the dregs, take the juice, mix with the powder, and administer warm. Take in one dose. If vomiting does not occur, increase the dose slightly. Stop when rapid vomiting is achieved. Contraindicated in patients with blood loss or deficiency constitutions.
[Supplementary Annotation] If it is called retained food, it certainly does not reside solely in the Upper Wan. If not in the Upper Wan, why use emesis? Now, stating it is in the Upper Wan and calling it retained food implies that phlegm carries the food matter, preventing it from descending, resulting in wheezing and fullness, though these symptoms may not all be visible. Thus, a single emetic action expels both phlegm and food.
A pulse that is tight and changes unpredictably like a turning rope indicates retained food.
[Supplementary Annotation] A tight pulse changing unpredictably like a turning rope is a sign of impending exhaustion of Stomach Qi, which is critical. Alternatively, it may be due to the stagnation of cold substances, preventing Stomach Qi from re-emerging and diffusing.
Tight pulse with headache indicates Wind-Cold; retained food in the abdomen is undigested.
[Supplementary Annotation] Patients with dietary injury typically do not have headaches. The presence of a headache suggests Wind or Cold pathogens; a floating-tight pulse is characteristic of Cold. If the pulse is merely tight without floating, it indicates abdominal stagnation. Although exterior pathogens may coexist, the absence of a floating pulse requires the practitioner to distinguish between internal injury and external contraction, applying medication with precision, and clearly understanding that urgent purgation is not warranted.