沈自南云、中恶之证。俗谓绞肠乌痧。即臭秽恶毒之气。直从口鼻入于心胸。肠胃
脏腑壅塞。正气不行。故心痛腹胀。大便不通。是为实证。似非六淫侵入。而有表里虚
实清浊之分。故用巴豆极热大毒峻猛之剂。急攻其邪。佐杏仁以利肺与大肠之气。使邪
从便出。一扫尽除。则病得愈。若缓须臾。正气不通。营卫阴阳机息则死。是取通则不
痛之义也。
问曰。人病（则食自少。若以食少而误认为宿食。往往以楂曲枳朴消导之药。虚其
中气。以致外邪乘虚入里者。不可胜计。然而果）有宿食。何以别之。师曰。（宿食脉
似当于关部见其沉滑。而患之颇久。则不然。其谷气积而壅盛。则）寸口脉浮而大。（
饮食不节。则阴受之。阴受之则血先伤。故）按之（不滑而）反涩。（且中气阻滞，而水
谷之精。不能下逮。其）尺中亦微而涩。故（于微涩中）知（其所以受伤者。由于）有宿食。
（以）大承气汤主之。 脉数而滑者。（有余之象。为谷气之）实也。此（脉断其）
有宿食。（所可疑者。上言微涩为宿食。兹何以又言数滑为宿食乎。而不知因宿食而受伤。
则为微涩。若宿食之本脉。则为数滑。新旧虽殊。病源则一。）下之（则）愈。（
宜大承气汤。久利而不欲食者。是脾伤不能食也。若）下利（之初。即）不欲食者。
此有宿食。（所谓伤食则恶食是也。）当下之。宜大承气汤。
此三节。言宿食可下之证。
参各家说。脾胃者。所以化水谷而行津气。不可或止者也。谷止则化绝。气止则机
息。化绝机息。人事不其顿乎。故必大承气速去其停谷。谷去则气行。气行则化续而生
以全矣。若徒用平胃散及谷芽麦芽山楂神曲之类。消导克化。则宿食未得出路。而生气
积日消磨。岂徒无益。而又害之。医者当知所返矣。
大承气汤方（见痉病）
（胃有三脘。宿食在上脘者。膈间痛而吐。此可吐而不可下也。在中脘者 心中
痛而吐。或痛而不吐。此可吐而亦可下也。在下脘者。脐上痛而不吐。此不可吐而可下
也。今）宿食在上脘。当吐之。宜瓜蒂散。
此言宿食可吐之证也。
瓜蒂散方
瓜蒂（一分熬黄） 赤小豆（三分煮）
上二味。杵为散。以香豉七合煮取汁。和散一钱匕。温服之。不吐者。少加之。以
快吐为度而止。
（总之。治病以脉为凭。上言浮大反涩微滑数滑。皆于活泼泼中。以意会之。不可
以言传之也。而于紧脉中定其宿食。此旨则微而尤微。）脉紧如转索无常者。宿食也。
按脉紧为外感之定脉。而所异者。在无常二字。言忽而紧。忽而不紧也。
脉紧头痛（如）风寒。腹中有宿食不化也。
按脉紧头痛风寒。言脉紧头痛。与风寒证无异。但风寒证有恶风恶寒强项脉浮等证
兼见。而此则但觉头痛也。 此以紧脉论宿食。是诊脉之最元妙而难言也。尤注得旨。
尤在泾云、脉紧如转索无常者。紧中兼有滑象。不似风寒外感之紧。为紧而带弦也。
故寒气所束者。紧而不移。食气所发者。乍紧乍滑。如以指转索之状。故曰无常。脉
紧头痛风寒者。非既有宿食。而又感风寒也。谓宿食不化。郁滞之气。上为头痛。有如
风寒之状。而实为食积类伤寒也。仲景恐人误以为外感而发其汗。故举以示人曰。腹中
有宿食不化。意亦远矣。
沈自南说：中恶这种病证，民间称为绞肠乌痧。这是由臭秽恶毒之气，直接从口鼻进入心胸所致。导致肠胃脏腑气机壅塞，正气运行受阻，因此出现心痛、腹胀、大便不通等症状。这属于实证，似乎并非由六淫（风、寒、暑、湿、燥、火六种外感病邪）侵入引起，也没有表里、虚实、清浊的明显区分。所以使用巴豆这种极热、大毒、峻猛的药物，急攻以祛除邪气；佐以杏仁来疏通肺与大肠的气机，使邪气从大便排出，一扫而尽，疾病就能痊愈。如果拖延片刻，正气不通，营卫阴阳机能停止，就会死亡。这就是取“通则不痛”的道理。
问：人患病时饮食自然减少。如果因为吃得少就误认为是宿食（食物停滞不化），往往使用山楂、神曲、枳实、厚朴等消导药物，这会损伤其中的中气（脾胃之气），导致外邪乘虚入里，这种情况不可胜数。然而，如果确实有宿食，如何辨别呢？老师说：“宿食的脉象应当在关部见到沉滑之象，但如果患病时间较长，情况就不一样了。谷气积聚而壅盛，寸口脉会浮而大。饮食不节制，阴分受邪，阴分受邪则血先受伤，所以按之脉象不滑反而涩滞。且因中气阻滞，水谷的精微物质不能下达，尺部脉也微而涩。所以在微涩的脉象中，知道其受伤的原因是由于有宿食，用大承气汤主治。”
脉象数而滑的，是有余的现象，为谷气充实的表现。这说明有宿食。（令人疑惑的是，上文说微涩脉是宿食，这里为什么说数滑脉也是宿食呢？却不知道因宿食而受伤后表现为微涩，若论宿食本来的脉象，则是数滑。虽然新旧病情不同，但病源是一样的。）用下法治疗就能痊愈。（适宜用大承气汤。）长期腹泻而不想吃东西的，是脾脏受伤不能进食。如果在腹泻初期就不想吃东西，这是有宿食。（所谓伤食就会厌恶食物。）当下之，适宜用大承气汤。
这三节内容，论述了宿食可以使用下法的证候。
参考各家说法：脾胃是消化水谷并运行津液和气的器官，不可有一刻停止。谷物停滞则化源断绝，气机停滞则生机息止。化源断绝、生机息止，人的事情难道不是顿时终结吗？所以必须用大承气汤迅速去除停积的谷物，谷物去除则气机运行，气机运行则生化继续，生命得以保全。如果仅仅使用平胃散以及谷芽、麦芽、山楂、神曲等消导克化的药物，宿食没有出路，而生气却日复一日地消磨，这不仅无益，反而有害。医生应当知道返回正道。
（胃分为上脘、中脘、下脘。宿食在上脘的，膈间疼痛并呕吐，这可以用吐法而不可以用下法。在中脘的，心中疼痛并呕吐，或者疼痛但不呕吐，这既可以用吐法也可以用下法。在下脘的，脐上疼痛且不呕吐，这不可以用吐法而可以用下法。现在）宿食在上脘，应当用吐法，适宜用瓜蒂散。
这节论述了宿食可以使用吐法的证候。
瓜蒂散方
以上两味药，研成散剂。用香豉七合煮取汁液，调和散剂一钱匕，温服。如果不吐，稍微增加剂量。以痛快吐出为度而停止。
总之，治病以脉象为依据。上文提到的浮大反涩、微滑、数滑，都要在活泼生动的脉象中，用心意去领会，不能用言语完全传达。而在紧脉中确定宿食，这一旨意更为微妙深奥。脉象紧如转索且无常变化的，是宿食。
按：脉紧通常是外感病的定脉，所不同的是“无常”二字。意思是忽而紧，忽而不紧。
按：脉紧伴头痛看似风寒，是说脉紧头痛与风寒证无异，但风寒证伴有恶风、恶寒、强项、脉浮等证候同时出现，而此证仅感觉头痛。这是以紧脉来论述宿食，是诊脉中最精妙难以言说的地方。尤在泾注解说得很有旨趣。
尤在泾说：脉紧如转索且无常变化，是指紧脉中兼有滑象，不像风寒外感的紧脉那样紧而带弦。所以寒气束缚导致的紧脉是固定不移的，食气引发的紧脉则是乍紧乍滑，像手指转动绳索的样子，所以说“无常”。脉紧头痛看似风寒，并不是既有宿食又感受风寒。而是说宿食不化，郁滞之气上冲导致头痛，症状类似风寒，但实际上是食积类似伤寒。张仲景恐怕人们误以为是外感而发汗，所以举出此例示人曰：腹中有宿食不化。用意深远。
Shen Zinan stated: The condition of "Zhong E" (Sudden Severe Poisoning), commonly known in folklore as "Jiao Chang Wu Sha" (Intestinal Twisting Black Miasma), is caused by foul and toxic miasmal qi entering directly from the mouth and nose into the heart and chest. This leads to obstruction and stagnation in the intestines, stomach, and zang-fu organs, hindering the movement of Zheng Qi (Upright Qi). Consequently, symptoms such as heart pain, abdominal distension, and constipation occur. This belongs to Excess patterns (Shi Zheng), seemingly not invaded by the Six Exogenous Pathogens (Liu Yin - Wind, Cold, Summerheat, Dampness, Dryness, Fire), nor does it present clear distinctions between Exterior/Interior, Deficiency/Excess, or Clear/Turbid. Therefore, Radix Crotonis Fructus (Badou, *Crotonis Fructus*)—a drug that is extremely hot, highly toxic, and drastic—is used to urgently attack and expel the pathogen. Semen Armeniacae Amarum (Xingren, *Armeniacae Semen Amarae*) is added to facilitate the Qi mechanism of the Lung and Large Intestine, allowing the pathogen to exit via stool, clearing everything away so that the disease may be cured. If delayed even for a moment, Zheng Qi will fail to circulate, and the mechanisms of Ying-Wei (Nutritive-Defensive) and Yin-Yang will cease, leading to death. This illustrates the principle that "patency relieves pain."
Question: When a person is ill, food intake naturally decreases. If this reduced intake is mistaken for Food Stagnation (Su Shi - undigested food retained in the stomach/intestines), doctors often mistakenly use digestive agents such as Fructus Crataegi (Shanzha, *Crataegi Fructus*), Shen Qu (Medicated Leaven), Rhizoma Atractylodis Macrocephalae combined with Pericarpium Citri Reticulatae (Zhiqi & Zhimu, though text implies Zhi Shi & Hou Po), which damage the Middle Qi (Spleen-Stomach Qi). This allows external pathogens to enter the interior through the deficiency, a phenomenon too numerous to count. However, if there truly is Food Stagnation, how can it be distinguished? The Master said: "The pulse of Food Stagnation should typically appear as Deep and Slippery at the Guan position. However, if the illness has persisted for a long time, this is not the case. When Grain Qi accumulates and becomes obstructed and abundant, the Cun Kou (Radial Artery at the wrist) pulse appears Floating and Large. Irregular diet injures the Yin; when Yin is injured, Blood is damaged first. Therefore, upon palpation, the pulse is not Slippery but instead Choppy (Se). Furthermore, due to obstruction of Middle Qi, the essence of water and grain cannot descend, causing the Chi position pulse to also be Faint and Choppy. Thus, within the Faint and Choppy qualities, one knows that the injury is due to Food Stagnation, and Da Cheng Qi Tang (Great Order the Yang Decoction) should be administered."
A pulse that is Rapid and Slippery indicates an Excess state and abundant Grain Qi, confirming the presence of Food Stagnation. (One might wonder: why was the Faint-Choppy pulse associated with Food Stagnation earlier, while now the Rapid-Slippery pulse is also associated with it? One must understand that when Food Stagnation causes injury, the pulse manifests as Faint-Choppy; however, the intrinsic pulse of Food Stagnation itself is Rapid-Slippery. Although the new and old presentations differ, the source of the disease is identical.) Treatment with purgation will lead to recovery. (Da Cheng Qi Tang is appropriate.) In cases of chronic diarrhea where there is no desire to eat, it is due to Spleen injury preventing digestion. However, if there is no desire to eat at the onset of diarrhea, this indicates Food Stagnation ("Injury from food leads to aversion to food"). It should be treated with purgation, using Da Cheng Qi Tang.
These three sections discuss syndromes of Food Stagnation suitable for purgative therapy.
Referencing various scholars' opinions: The Spleen and Stomach are responsible for transforming water and grain and circulating Jin-Ye (Body Fluids) and Qi; they cannot function without continuity. If grain stagnates, transformation ceases; if Qi stagnates, vital mechanisms halt. If transformation ceases and mechanisms halt, human life ends abruptly. Therefore, Da Cheng Qi Tang must be used to rapidly eliminate stagnant grain. Once the grain is removed, Qi moves; once Qi moves, transformation continues, preserving life. If one merely uses Ping Wei San (Calm the Stomach Powder) or digestive aids like Germinatus Hordei (Maiya, *Hordei Fructus Germinatus*), Germinatus Oryzae Sativae (Guyaya, *Oryzae Germens*), Fructus Crataegi (Shanzha), and Shen Qu, the Food Stagnation has no outlet, while the Sheng Qi (Vital Qi) is consumed day by day. This is not only ineffective but harmful. Physicians must know how to return to the correct path.
Da Cheng Qi Tang Formula (See Chapter on Spasm Diseases)
(If Food Stagnation is in the Upper Wan (Upper Stomach), there is pain in the diaphragm region accompanied by vomiting; this is suitable for emesis but not purgation. If in the Middle Wan (Middle Stomach), there is epigastric pain with or without vomiting; both emesis and purgation may be used. If in the Lower Wan (Lower Stomach), there is periumbilical pain without vomiting; this is unsuitable for emesis but suitable for purgation. Now,) if Food Stagnation is in the Upper Wan, emesis should be induced using Gua Di San (Melon Sepal Powder).
This section discusses syndromes of Food Stagnation suitable for emetic therapy.
Gua Di San Formula
Gua Di (Melon Sepal, *Momordicae Fructus*): 1 fen, roasted until yellow.
Chi Xiao Dou (Red Adzuki Bean, *Vigna angularis*): 3 fen, boiled.
Grind these two ingredients into a powder. Boil Xiang Chi (Fermented Soybean, *Sojae Semen Praeparatum*) 7 he in water to extract the juice. Mix one qian bi (approx. 2-3 grams) of the powder with the decoction and administer warm. If vomiting does not occur, slightly increase the dose. Stop when vigorous vomiting is achieved.
In summary, treatment relies on pulse diagnosis. The Floating-Large-Reversed-Choppy, Faint-Slippery, and Rapid-Slippery pulses mentioned above must be understood intuitively within their dynamic nature, as they cannot be fully conveyed by words. Determining Food Stagnation from a Tight pulse is particularly subtle and profound. A pulse that is Tight like a turning rope and variable/unpredictable indicates Food Stagnation.
Note: A Tight pulse is typically fixed for exterior contraction diseases. The difference lies in the term "variable/unpredictable" (Wu Chang), meaning it fluctuates between tight and not-tight.
A Tight pulse with headache resembles Wind-Cold, but actually indicates undigested Food Stagnation in the abdomen.
Note: A Tight pulse with headache resembling Wind-Cold means the pulse and symptom mimic Wind-Cold. However, Wind-Cold presents with aversion to wind/cold, stiff neck, and Floating pulse concurrently. Here, only headache is felt. Using the Tight pulse to diagnose Food Stagnation is the most subtle and difficult aspect of pulse diagnosis. You Zaijing's commentary captures the essence well.
You Zaijing stated: A pulse Tight like a turning rope and variable indicates that Tightness is combined with Slipperiness, unlike the Tightness of Wind-Cold exterior contraction, which is Tight and wiry (Xian). Cold constriction causes a Fixed Tightness; Food Qi generation causes alternating Tightness and Slipperiness, resembling fingers turning a rope, hence "variable." "Tight pulse, headache, resembling Wind-Cold" does not mean having both Food Stagnation and Wind-Cold simultaneously. It means that undigested Food Stagnation causes stagnant Qi to rise, resulting in headache that mimics Wind-Cold, but is essentially Food Accumulation resembling Taiyang disease (Shang Han). Zhang Zhongjing feared people would mistake this for an exterior pathogen and induce sweating, so he presented this example, stating: "There is undigested Food Stagnation in the abdomen," implying a profound intent.