不贯。如人君之不能以仁远被。而天地父母之阳春慈爱。于此独薄者然。故曰不仁。是则不特痹重板滞。不
可以名此。即麻木之似是者。亦不得取以相代。以痹重板滞及麻木等。皆一枝一体之自为病。故就病者一
边言之。此则手足皮肤。本自无病。盖就心阳不贯一边而言也。古人状病之细密类如此。
二十条 其脉数而紧。乃弦。状如弓弦。按之不移。脉数弦者。当下其寒。脉紧大而迟者。必心下坚。
脉大而紧者。阳中有阴。可下之。
若病疝之人。诊其阳明之脉。举之见数。沉之则如两头绷急而紧。此乃弦脉。名虽同紧。而非如转索之谓也。
弦脉状如弓弦。往下按之而不下移。如两头绷急之象。故亦名为紧。其实是数而弦也。下文两紧字同义。盖
形如夺索之紧。为真正阴寒。微明将熄之应。大温大灸。九死一生。况敢下乎。凡言弦紧紧弦。俱紧急之紧。弦
脉之劲疾者是也。其谓数弦之脉。皆因阴寒之疝。上冲阳位。经久不消。以致微阳失下运之用。而大便不去。
一则积成假热。再则胃液亦枯。故数也。又弦为肝脉。弦而如弓弦之不可下按。则又木得寒而枝劲之象。夫
热而液枯者当下。阴木之邪上乘而至劲急者。又非合温药以下其寒不可也。下文两脉。又从数弦而推展
之。凡阳明之脉。实弦而似紧。又大而迟者。弦紧为肝气上乘之诊。大则中空而液短。迟则鼓谩而阳虚。心下
为胃之脘。胃中阴阳俱虚。而肝木以寒疝乘之。谓非心下坚硬而何。又大为阳明之本脉。按之而见实弦似
紧之紧。则阳腑中有阴脏之客气显然矣。曰可下者。犹言皆可以温药下其寒之谓。
二十一条 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。
此下三条。承前十三条之腹满不减。设为问答。而申言内实宜下之脉症也。胃为水谷之海。其所化之津液。
上之从脾以滋肺。下之从肺以灌肝肾者也。寸口为心肺之应。若其脉举之见浮大。按之见涩。夫浮为气机
上郁之诊。大为阳明本脉。涩则津液不滋之象。且浮又底虚。大又中芤。以浮大之反面。与无阴之涩脉正合。
则是阳明之气不下通。而上郁心肺之夹空。并无胃液上滋之应矣。尺中为肝肾之诊。浮之见微。而沉之亦
涩。则是胃中无悍气下充。故微无精汁下润。故涩。即经所谓二阳发病。有不得隐曲。女子不月之理也。夫寸
口。则逆热浮而土液不蒸。尺中。则悍气衰而精汁不灌。谓非宿食内结胃腑。阳液不暇自救。焉得有此干浮
虚燥之脉乎。此从胃之上下两头。而知宜主大承之脉者。一也。
二十二条 脉数而滑者。实也。此有宿食。可下之。宜大承气汤。
不言部位而但曰脉。盖亦指阳明而言。末后两言脉紧同义。数为在腑。又数为热。滑者。谷气自结。而不灌注
四旁之象。夫在腑有热。而谷气自结。非胃实而何。此从胃之本位。而知宜主大承之脉者。又一也。既曰实
而又曰有宿食者、非复也。盖以实言症。而以宿食句。还答问语耳。
二十三条 下利。不欲食者。有宿食也。当下之。宜大承气汤。
此紧承上文脉数而滑句。盖脉不数滑。则下利不欲食。便不得断以宿食故也。言阳明之脉。数而且滑。倘然
下利。则数为胃火自盛。而滑为谷气自还之应。盒饭能食。今不欲食。则系宿食占其胃分。而其所以下利者。
为气滞旁流之故。犹云但不欲食。虽已经下利。亦不得为数滑者。宽其下也。此从消息饮食而知宜主大承
之症者。又一也。
二十四条 宿食在上脘。当吐之。宜瓜蒂散。
瓜蒂散方 瓜蒂（一分熬） 赤小豆（一分煮）
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。亡血
及诸虚者。不可与之。
脘。即胃之管。自喉嗓下至胃。作三分。故有上中下脘之别。任脉之经穴以当之而外得名者。李氏援以注此。
未是。若宿食在胃之上脘。而未入胃腑者。大承下之。则宿食高。而攻下之药。低不能及。且徒伤其胃气。不如
越而吐之之便矣。瓜蒂蔓生。气味苦寒。且其性属上提。而不容下坠者。蔓生则走胃络。味苦则能使胃系急
而自拳。凡气寒者。俱为胃之所恶。其性上提而不容下坠。故能令胃气上涌而致吐也。但吐则伤阴。而火气
自浮。此吐家必生烦热懊 之症。香豉滋阴降气。故煮汁和服者。盖为预防之计。以济其偏者也。
二十五条 脉紧如转索无常者。有宿食也。
紧为寒。紧如转索。盖索具坚收。转呈短缩之象。夫阳明胃腑中。因寒敛而见坚收短缩者。非宿食而何哉。
二十六条 脉紧。头痛。恶风寒。腹中有宿食不化也。
脉紧紧承上文转索而言。头痛。胃中结气上冲之应。恶风寒者。无精悍以行其卫气故也。故知有宿食不化。
此与上条。俱当着眼在脉紧二字。尤当着眼在阳明部中之脉紧。盖紧如转索。即是胃阳虚冷。不能运化。
以致宿食停滞。与二十一等三条之下症大异。故前条但曰有宿食。此条亦曰宿食不化。而俱不出方。则其
为宜温胃阳。而资其自化。与不欲攻下之意。已在言外。即或不得已而用下。其亦宜大黄、附子之温药耶。又
本文脉症。全是伤寒。而独断为宿食不化。以脉紧为阳明部中之脉紧。而头痛恶风寒等之外症。又为阳明
风寒症中之所绝无者。从两经经腑。其脉症之交错处看出。故知表非太阳伤寒之症。而里为阳明宿食之
脉矣。以此二者。故曰当着眼在脉紧。尤当着眼在阳明部中之脉紧也。
不能贯通。就像君主不能用仁德广施恩泽，而天地父母般的阳春慈爱，唯独在这里显得淡薄，所以称为“不仁”。这样看来，不仅痹证的沉重板滞，不能用来命名这种病；即使是看似麻木的情况，也不能拿来代替。因为痹证的沉重板滞以及麻木等，都是肢体局部的自发病变。所以从患病部位这一方面来说，这里的手足皮肤本身并没有病变。这是就心阳不能贯通这一方面而言的。古人描述病情的细致入微，就像这样。
第二十条：脉象数而且紧，这就是弦脉，形状像弓弦一样，按压时位置固定不移。脉象数而弦的，应当用攻下法祛除寒邪。脉象紧大而迟的，必然心下（胃脘部）坚硬。脉象大而且紧的，是阳中有阴，可以用攻下法。
如果是患疝气的人，诊察其阳明经的脉象，轻取（举之）见到数脉，重按（沉之）则感觉两头绷急而紧，这就是弦脉。虽然名称与紧脉相同，但并不是像绳索转动那样的紧脉。弦脉的形状像弓弦，往下按压而不移动，呈现出两头绷急的样子，所以也称之为紧。其实质是数脉兼弦脉。下文中的两个“紧”字含义相同。那种形状像争夺绳索一样的紧脉，属于真正的阴寒，是微弱的阳气即将熄灭的反应，需要大温大灸，九死一生，何况敢用攻下法呢？凡是说弦紧、紧紧弦，都是指紧急的紧，即弦脉劲疾的特点。所谓数弦的脉象，都是因为阴寒的疝气上冲阳位，经久不消，导致微弱的阳气失去在下运化的作用，从而大便不通。一方面积结成假热，另一方面胃液也枯竭了，所以脉数。另外，弦脉属肝脉，弦得像弓弦一样不可下按，这是木气受寒后枝条劲硬的征象。对于热盛而津液枯竭的，应当攻下；对于阴寒之邪上乘而至劲急的，又非配合温药来攻下寒邪不可。下文的两条脉象，又是从数弦推展出来的。凡是阳明经的脉象，实弦而似紧，又大而迟的，弦紧是肝气上乘的诊候，大表示中空而津液短少，迟表示鼓动缓慢而阳气虚弱。心下是胃的脘部，胃中阴阳都虚弱，而肝木以寒疝乘虚侵袭，能说不是心下坚硬吗？另外，大是阳明经的本脉，按下去见到实弦似紧的紧象，那么阳腑中有阴脏的客气显然可见。说“可下”，意思是都可以用温药来攻下寒邪。
第二十一条：问：人患有宿食，如何辨别？老师说：寸口脉浮而大，按下去反而涩，尺中脉也微而涩，所以知道有宿食。以大承气汤为主治方剂。
这三条承接前文第十三条腹满不减的内容，设为问答，进一步阐述内实适宜攻下的脉症。胃是水谷之海，它所化生的津液，向上通过脾滋养肺，向下通过肺灌溉肝肾。寸口对应心肺，如果脉象轻取见浮大，重按见涩。浮是气机郁结于上的诊候，大是阳明经的本脉，涩则是津液不能滋润的征象。而且浮脉底部空虚，大脉中间芤空，以浮大的反面，与无阴的涩脉正好相合。这就是阳明之气不能下行通畅，反而郁结在心肺之间的夹空之处，没有胃液向上滋润的反应了。尺中对应肝肾，轻取见微，重按也涩，这就是胃中没有悍气向下充养，所以微；没有精汁向下润泽，所以涩。这就是《内经》所说的二阳发病，出现不得隐曲（情志抑郁或排泄困难），女子月经闭止的道理。寸口脉象，逆热浮越而土中津液不蒸腾；尺中脉象，悍气衰弱而精汁不灌注。能说这不是宿食内结在胃腑，阳气津液无暇自救，怎么会得到这种干浮虚燥的脉象呢？这是从胃的上下一端来推断适宜主用大承气汤的脉象，这是一点。
第二十二条：脉象数而滑的，是实证。这是有宿食，可以用攻下法，适宜用大承气汤。
不说具体部位只说脉，大概也是指阳明经。末尾两个“紧”字同义。数脉表示病在腑，又数代表热。滑脉，是谷气自行结聚，而不能灌注到四周的征象。既然在腑有热，而谷气自行结聚，难道不是胃实吗？这是从胃的本位来推断适宜主用大承气汤的脉象，这是又一点。既然说是实证又说有宿食，并不是重复。是用“实”来描述症状，用“有宿食”一句来回答前面的提问罢了。
第二十三条：下利，不想吃东西的，是有宿食，应当攻下，适宜用大承气汤。
这紧密承接上文脉数而滑的句子。如果脉不数滑，那么下利不想吃东西，就不能断定是宿食造成的。说的是阳明经的脉，数而且滑，倘若出现下利，那么数是胃火自盛，滑是谷气自还的反应，本应该能吃东西。现在不想吃，则是宿食占据了胃的分野，而下利的原因是气滞旁流。也就是说，只要是不想吃东西，即使已经下利，也不能认为数滑脉是宽缓的下利脉。这是从观察饮食情况来推断适宜主用大承气汤的症状，这是又一点。
瓜蒂散方：瓜蒂（一分炒），赤小豆（一分煮）。
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。不呕吐的，稍微增加剂量。以痛快呕吐为度而停止。亡血及各种虚证患者，不可服用。
脘，就是胃的管道，自喉咙下到胃，分为三部分，所以有上、中、下脘的区别。任脉的经穴以此得名，李氏引用这个来注释此条，是不恰当的。如果宿食在胃的上脘，而没有进入胃腑，用大承气汤攻下，则宿食位置高，而攻下的药力低，不能达到，而且徒然损伤胃气，不如用涌吐法方便。瓜蒂蔓生，气味苦寒，而且它的性质属于向上提升，不容许向下坠落。蔓生则走窜胃络，味苦则能使胃系紧缩而自然卷曲。凡是气寒的，都是胃所厌恶的。它的性质向上提升不容许向下坠落，所以能使胃气上涌而导致呕吐。但是吐法会伤阴，而火气自然上浮，这是使用吐法的人必然产生烦热懊恼的症状。香豉滋阴降气，所以煮汁调和服用，大概是作为预防的措施，来补救其偏颇。
第二十五条：脉象紧得像转动的绳索且变化无常的，是有宿食。
紧脉主寒，紧得像转动的绳索，大概是因为绳索具有坚收的特性，转动呈现短缩的样子。在阳明胃腑中，因为寒邪收敛而出现坚收短缩的，难道不是宿食吗？
脉紧紧承上文转索而言。头痛，是胃中结气上冲的反应；恶风寒，是因为没有精悍之气来运行卫气。所以知道有宿食不消化。这一条与上一条，都应当着重看“脉紧”二字，尤其应当着重看阳明部位的脉紧。因为紧如转索，就是胃阳虚冷，不能运化，导致宿食停滞，这与前面三条的下症大不相同。所以前条只说有宿食，此条也说宿食不化，而且都不出方剂，那么适宜温补胃阳，资助其自行消化的意思，已经在言外了。即使不得已而用攻下法，也应该选用大黄、附子这样的温药吧？另外，本文的脉症，完全是伤寒的表现，却单独断定为宿食不化，是因为脉紧是阳明部位的脉紧，而头痛、恶风寒等外症，又是阳明风寒症中所绝对没有的。从两经的经腑交错处看出，所以知道表证不是太阳伤寒的症状，而里证是阳明宿食的脉象。基于这两点，所以说应当着眼在脉紧，尤其应当着眼在阳明部位的脉紧。
Cannot penetrate. It is like a ruler who cannot extend benevolence far and wide, and the spring-like compassion of Heaven and Earth, which acts as parents, appears particularly thin here; therefore it is called "Ren Bu" (Inhumanity/Lack of Penetration). Thus, not only can the heaviness and stagnation of Bi syndrome (Obstruction Syndrome) not be used to name this condition, but even cases that seem similar to numbness cannot replace it. This is because the heaviness and stagnation of Bi syndrome, as well as numbness, are diseases originating from the limbs themselves. Therefore, speaking from the perspective of the diseased part, the skin of the hands and feet itself has no pathology. This discussion focuses on the aspect of Heart Yang failing to penetrate. The ancients described the subtleties of disease in such detail.
Article 20: If the pulse is rapid and tight, it is a Xian pulse (Wiry Pulse), resembling the string of a bow, and does not shift when pressed. For a rapid and wiry pulse, cold should be purged using a draining method. For a tight, large, and slow pulse, there must be hardness in the Xin Xia (epigastric region/sub-xiphoid area). For a large and tight pulse, there is Yin within Yang, and a draining method may be used.
If a patient suffers from Shan (Hernia/Colic), and upon examining the Mai Yang (Stomach Meridian) pulse, lifting reveals a rapid pulse, while pressing reveals tension at both ends and tightness, this is a Xian pulse. Although named similarly to Jin (Tight), it is not like a twisting rope. The Xian pulse resembles a bowstring; pressing down does not cause it to move, presenting an image of tension at both ends, hence also referred to as Jin. In reality, it is Rapid and Wiry. The two instances of "Jin" in the following text share the same meaning. The Jin pulse resembling a twisting rope represents true Yin-Cold, a sign of fading Yang about to extinguish, requiring strong warming and moxibustion, with only one chance of survival out of nine; how could one dare to use purging? Whenever "Xian Jin" or "Jin Xian" is mentioned, it refers to urgent tightness, specifically the vigorous and swift nature of the Xian pulse. The so-called Rapid-Wiry pulse arises because Yin-Cold Shan rises to attack Yang positions, persisting for a long time, causing weak Yang to lose its function of descending and transforming, leading to constipation. On one hand, false heat accumulates; on the other, Stomach fluids dry up, resulting in a rapid pulse. Furthermore, Xian belongs to the Liver meridian. A Xian pulse like a bowstring that resists pressure indicates Wood becoming rigid due to Cold. For conditions with Heat and fluid depletion, purging is indicated. However, for pathogenic Yin-Cold rising to become rigid and urgent, it is necessary to combine warm herbs to purge the cold. The subsequent pulses expand upon the Rapid-Wiry theme. Generally, if the Mai Yang pulse is solidly Wiry and seemingly Tight, yet Large and Slow, Wiry-Tight indicates Liver Qi attacking upward; Large indicates emptiness in the center and shortness of fluids; Slow indicates sluggish beating and Yang deficiency. Xin Xia is the Wan (pylorus/upper stomach); if both Yin and Yang in the Stomach are deficient, and Liver Wood attacks via Cold-Shan, how can it not result in hardness in the epigastrium? Additionally, Large is the fundamental pulse of the Yang-Fu (Stomach). Pressing and finding Solid-Wiry-Simulating-Tight indicates obvious pathogenic Qi from a Yin-Zang (Liver) invading a Yang-Fu. Saying "Ke Xia" (can be purged) means all these cases can be treated by using warm herbs to purge the cold.
Article 21: Question: How can one distinguish Su Shi (Retained Food)? The Master said: If the Cun Kou (Radial artery at the wrist) pulse is Floating and Large, but feels Slippery (Se) upon pressing, and the Chi position is also faint and Slippery, then one knows there is retained food. Da Cheng Qi Tang (Major Order the Qi Decoction) is the primary formula.
These three articles follow Article 13 regarding abdominal fullness that does not decrease, setting up a Q&A to elaborate further on the pulse and symptoms indicating internal excess suitable for purging. The Stomach is the Sea of Water and Grain; its transformed fluids ascend via the Spleen to nourish the Lungs and descend via the Lungs to irrigate the Liver and Kidneys. Cun Kou corresponds to the Heart and Lungs. If the pulse is Floating and Large upon lifting, and Slippery upon pressing: Floating indicates Qi mechanism depression upward; Large is the fundamental pulse of Yang Ming; Slippery indicates lack of fluid nourishment. Moreover, Floating implies voidness at the base, and Large implies hollowing in the center. The opposite of Floating-Large coincides with the fluid-deficient Slippery pulse. This means Yang Ming Qi fails to descend smoothly and instead depresses in the empty spaces between the Heart and Lungs, without the response of Stomach fluids ascending to nourish. Chi corresponds to the Liver and Kidneys. Faint upon lifting and Slippery upon pressing indicates that Wei Zhong (Stomach) lacks Hao Qi (Pivotal Qi/Hao-Gas) to fill downward, hence Faint; it lacks Jing Zhi (Essential Fluids) to moisten downward, hence Slippery. This aligns with the Classic's statement: "When Er Yang (Yang Ming/Stomach and Intestines) disease occurs, there is inability to express hidden concerns [emotional/excretory blockage], and women experience amenorrhea." At Cun Kou, rebellious Heat floats while Earth fluids do not steam; at Chi, Hao Qi declines and Essential Fluids do not irrigate. Could this dry, floating, void, and dry pulse be anything other than Su Shi internally knotted in the Stomach Fu, leaving Yang fluids too busy saving themselves? This infers the indication for Da Cheng Qi Tang from the upper and lower extremes of the Stomach—this is point one.
Article 22: A Rapid and Slippery pulse indicates Excess. This signifies retained food; purging is appropriate, preferably with Da Cheng Qi Tang.
Not specifying the location but simply saying "pulse," it generally refers to Yang Ming. The final two mentions of "Jin" have the same meaning. Rapid indicates disease in the Fu organs, and Rapid also indicates Heat. Slippery indicates grain Qi self-aggregating and failing to irrigate the surroundings. Since there is Heat in the Fu and grain Qi self-aggregates, is this not Wei Shi (Stomach Excess)? This infers the indication for Da Cheng Qi Tang from the fundamental position of the Stomach—this is another point. Saying "Excess" and then "retained food" is not redundant. "Excess" describes the symptom, while "retained food" answers the question.
Article 23: Diarrhea accompanied by loss of appetite indicates retained food; purging is required, preferably with Da Cheng Qi Tang.
This closely follows the previous sentence regarding the Rapid and Slippery pulse. If the pulse were not Rapid and Slippery, diarrhea with loss of appetite could not be diagnosed as caused by retained food. It refers to the Yang Ming pulse being Rapid and Slippery. If diarrhea occurs despite this, Rapid indicates excessive Stomach Fire, and Slippery indicates the return of grain Qi; one should normally be able to eat. Now, since there is no desire to eat, it is because retained food occupies the Stomach sector. The reason for diarrhea is Qi stagnation causing peripheral flow. That is, as long as there is no desire to eat, even if diarrhea has occurred, one cannot interpret the Rapid-Slippery pulse as a loose/purging pulse. This infers the indication for Da Cheng Qi Tang from observing dietary intake—this is another point.
Article 24: Retained food in the Shang Wan (Upper Stomach) should be expelled via vomiting; Gua Di San (Melon Tip Powder) is appropriate.
Gua Di San Formula: Gua Di (Melon Tip, 1 fen, roasted), Chi Xiao Dou (Red Adzuki Bean, 1 fen, boiled).
Grind the above two ingredients into powder. Boil Xiang Chi (Black Soybean Paste, 7 he) to extract juice. Mix with one qian bi of the powder and take warm. If vomiting does not occur, increase the dose slightly. Stop when vomiting is thorough. Contraindicated in patients with blood loss and various deficiency patterns.
Wan refers to the tube of the Stomach, extending from the throat to the Stomach, divided into three parts, hence Upper, Middle, and Lower Wan. Li Shi referenced Ren Mai acupoints to annotate this, which is incorrect. If retained food is in the Shang Wan of the Stomach and has not entered the Stomach Fu, using Da Cheng Qi Tang to purge would mean the food is high while the purgative medicine is low and cannot reach it, merely injuring Stomach Qi unnecessarily. It is more convenient to induce vomiting. Gua Di grows on vines, has a bitter and cold taste, and its nature tends upward, resisting downward descent. Vining growth allows it to traverse Stomach collaterals; bitterness causes the Stomach ligaments to contract and curl. All cold-natured substances are disliked by the Stomach. Its upward tendency prevents downward descent, thus forcing Stomach Qi upward to induce vomiting. However, vomiting damages Yin, causing Fire Qi to float upward, inevitably leading to irritability and restlessness (Ao Nao) in those who vomit. Xiang Chi nourishes Yin and descends Qi; boiling it to mix with the powder serves as a preventive measure to counterbalance this bias.
Article 25: A pulse that is Tight like a twisting rope and variable indicates retained food.
Jin (Tight) indicates Cold. Tight like a twisting rope suggests the rope's firm contraction and shortening during rotation. In the Yang Ming Stomach Fu, if firm contraction and shortening appear due to Cold constriction, is this not retained food?
Article 26: Tight pulse, headache, aversion to wind and cold, indicate retained food in the abdomen that is not digesting.
The Tight pulse continues from the previous description of twisting. Headache is the response to knotted Qi in the Stomach rushing upward. Aversion to wind and cold occurs because there is no Hao Qi (vigorous Qi) to circulate as Wei Qi (Defensive Qi). Thus, one knows there is undigested retained food. Both this article and the previous one require focusing on the word "Tight" in the pulse, especially the Tight pulse in the Yang Ming region. Tight like a twisting rope indicates Yang deficiency and Cold in the Stomach, failing to transform and transport, leading to stagnant retained food. This differs greatly from the purging indications in Articles 21-23. Therefore, the previous articles merely stated "retained food," and this one states "undigested retained food," providing no formulas. The implication is that warming Stomach Yang to aid self-digestion is preferred over attacking with purges. Even if purging is不得已 (unavoidable), warm herbs like Da Huang (Rhubarb) and Fu Zi (Aconite) should be used. Furthermore, the pulse and symptoms here resemble Tai Yang Shang Han (Cold Damage), yet they are distinctly diagnosed as undigested retained food because the Tight pulse is specific to the Yang Ming region, and external symptoms like headache and aversion to wind/cold are absent in typical Yang Ming Wind-Cold patterns. Observing the intersection of meridians and Fu organs reveals that the exterior is not Tai Yang Cold Damage, but the interior is Yang Ming retained food pulse. Hence, emphasis is placed on the Tight pulse, particularly in the Yang Ming region.