成无己曰∶约者结约之约，胃强脾弱，约束津液，不得四布，但输膀胱，故小便数而大便硬，故曰脾约。与此丸以
下脾之结燥，肠润结化，津流入胃，大便利，小便少而愈矣。愚切有疑焉。何者？既曰约，脾弱不能运也；脾弱则土亏
矣，必脾气之散，脾血之耗也。原其所由，久病大下大汗之后，阴血枯槁，内火燔灼，热伤元气，又伤于脾，而成此证。
伤元气者，肺金受火，气无所摄；伤脾者，肺为脾之子，肺耗则液竭，必窃母气以自救，金耗则木寡于畏，土欲不伤，
不可得也。脾失转输之令，肺失传送之官，宜大便秘而难下，小便数而无藏蓄也。理宜滋养阴血，使孤阳之火不炽，而
金行清化，木邪有制，脾土清健而营运，精液乃能入胃，则肠润而通矣。今以大黄为君，枳实、浓朴为臣，虽有芍药之
养血，麻仁、杏仁之温润，为之佐使，用之热甚而气实者，无有不安。愚恐西北二方，地气高浓，人禀壮实者可用。若
用于东南之人，与热虽盛而血气不实者，虽得暂通，将见脾愈弱而肠愈燥矣。后之欲用此方者，须知在西北以开结为主，
在东南以润燥为主，慎勿胶柱而调瑟。
心肺，阳也，居上；肝肾，阴也，居下；脾居中，亦阴也，属土。经曰∶饮食入胃，游溢精气，上输于脾，脾气散
精，上归于肺，通调水道，下输膀胱，水精四布，五经并行。是脾具坤静之德，而有干健之运。故能使心肺之阳降，肾
肝之阴升，而成天地交之泰，是为无病之人。今也七情内伤，六淫外侵，饮食不节，房劳致虚，脾土之阴受伤，转输之
官失职，胃虽受谷不能运化，故阳自升阴自降，而成天地不交之否，于斯时也。清浊相混，隧道壅塞，气化浊血瘀郁而
为热。热留而久，气化成湿，湿热相生，遂生胀满。经曰鼓胀是也。以其补虽坚满，中空无物，有似于鼓。其病胶固，
难以治疗，又名曰蛊。若虫侵蚀，有蛊之义。验之治法，理宜补脾，又须养肺金以制木，使脾无贼邪之虑；滋肾水以制
火，使肺得清化之令。却盐味以防助邪，断妄想以保母气，无有不安。医不察病起于虚，急于作效，炫能希赏。病者苦
于胀急，喜行利药，以求一时之快，不知宽得一日半日。其肿愈甚。病邪甚矣，真气伤矣，去死不远。古方惟禹余粮丸，
又名石中黄丸，又名紫金丸，制肝补脾殊为切当，亦须随证，亦须顺时加减用之。
余友俞仁叔，儒而医，连得家难，年五十得此疾，自制禹余粮丸服之。予诊其脉，弦涩而数。曰∶此丸新制，锻炼
之火邪尚存，温热之药太多，宜自加减，不可执方。俞笑曰∶今人不及古人，此方不可加减。服之一月，口鼻见血，色
骨立而死。
又杨兄，年近五十，性嗜好酒，病疟半年，患胀病，自察必死，来求治。诊其脉弦而涩，重则大，疟未愈，手足瘦
而腹大，如蜘蛛状。予教以参、术为君，当归、川芎、芍药为臣，黄连、陈皮、茯苓、浓朴为佐，生甘草些少作浓汤饮
之。一日定三次，彼亦严守戒忌。一月后疟因汗而愈。又半年，小便长而胀愈。中间稍有加减，大意只是补气行湿。
又陈氏年四十余，性嗜酒，大便时见血，于春间患胀，色黑而腹大，其形如鬼。诊其脉数而涩，重似弱。予以四物
汤加黄连、黄芩、木通、白术、陈皮、浓朴、生甘草，作汤与之，近一年而安。
一补气，一补血，余药大率相出入，皆获安以保天寿。或曰∶气无补法，何子补气而获安，果有说以通之乎？予曰∶
气无补法，世俗之言也。以气之为病，痞闷壅塞似难于补，恐增病势。不思正气虚者不能营运，邪滞所着而不出，所以
为病。经曰∶壮者气行则愈，怯者着而成病。苟或气怯不用补法，气何由行？或曰∶子之药，审则审矣，何效之迟也？
病者久在床枕，必将厌子之迂而求速者矣。予曰∶此病之起，或三五年，或十余年，根深矣，势笃矣，欲求速效，自求
祸耳！知王道者能治此病也。或曰∶胀病将终不可与利药耶？予曰∶灼知其不因于虚，受病亦浅，脾胃尚壮，积滞不痼，
而又有可下之证，亦宜略与疏导。若授张子和浚川散、禹功丸为例行速攻之策，实所不敢。
成无己说：“约”是约束、结聚的意思。胃气强盛而脾气虚弱，导致津液受到约束，不能向全身四布，只能输送到膀胱，所以小便频数而大便干硬，因此称为“脾约”。用这丸药来攻下脾的结燥，肠道滋润后结滞化解，津液流入胃中，大便通畅，小便减少，病就好了。但我对此存有疑问。为什么呢？既然叫“约”，说明脾气虚弱不能运化；脾气虚弱则土气亏损，必然导致脾气散失、脾血耗损。推究其起因，多是在久病、大泻或大汗之后，阴血枯槁，内火炽盛灼烧，热邪损伤元气，又伤及脾脏，从而形成此证。损伤元气的，是因为肺金受火邪克制，气无所摄纳；损伤脾脏的，是因为肺为脾之子脏，肺气耗损则津液枯竭，必然窃取母脏（脾）之气以自救，金气耗损则木气缺乏制约，土气想要不受伤，是不可能的。脾失去转输的功能，肺失去传送的职责，应当是大便秘结难下，小便频数且无蓄积。按理应当滋养阴血，使孤阳之火不致炽盛，从而使金行清肃化源，木邪得到制约，脾土清健而正常营运，精液才能入胃，这样肠道滋润而通畅了。现在以大黄为君药，枳实、厚朴为臣药，虽然有芍药养血，麻仁、杏仁温润作为佐使药，用于热势很盛且正气充实的人，没有不安稳的。我担心西北两地，地势高峻气候浓烈，人体禀赋壮实者可以使用。如果用于东南地区的人，以及虽然热势盛但气血不实的人，虽然能暂时通便，将会看到脾更虚弱而肠更干燥。后来想使用此方的人，必须知道在西北地区以开结为主，在东南地区以润燥为主，千万不要拘泥固执不知变通。
心与肺属阳，位居上焦；肝与肾属阴，位居下焦；脾位居中，也属阴，五行属土。《内经》说：“饮食进入胃，游溢精气，向上输送给脾，脾气散布精微，向上归于肺，通调水道，向下输送到膀胱，水谷精微向四周布散，运行于五脏经脉。”这说明脾具备坤卦静止的德行，却拥有乾卦刚健的运化功能。所以能使心肺的阳气下降，肝肾的阴气上升，形成天地交泰的局面，这就是健康无病的人。如今七情内伤，六淫外侵，饮食不节制，房劳过度导致虚损，脾土的阴气受伤，转输之官失职，胃虽然受纳谷物但不能运化，所以阳气自升、阴气自降，形成天地不交的否塞局面。在这个时候，清气与浊气相混，经络隧道壅塞，气化不利，浊血瘀郁而生热。热邪停留日久，气化转为湿邪，湿热相生，于是产生胀满。《内经》所说的鼓胀就是这种病。因为它的腹部虽然坚硬胀满，中间却是空的，像鼓一样。这种病胶固难治，难以治愈，又名叫蛊。如同虫子侵蚀物体，有蛊的含义。验证其治法，理应补脾，又须养肺金以制约肝木，使脾没有贼邪的忧虑；滋补肾水以制约心火，使肺得到清肃化源的命令。忌食盐味以防助长邪气，断绝妄想以保护母气（脾），没有不安稳的。医生不考察疾病起于虚损，急于求效，炫耀技能希求赏赐。病人苦于胀急，喜欢用泻利药，以求一时的痛快，不知道只宽限一天半天，随后肿胀会更严重。病邪已经很盛，真气已经受伤，离死不远了。古方中只有禹余粮丸，又名石中黄丸，又名紫金丸，制肝补脾非常恰当，但也必须随证候变化，顺应时令加减使用。
我的朋友俞仁叔，既是儒生又是医生，接连遭遇家庭变故，五十岁时得了这个病，自己制作禹余粮丸服用。我诊察他的脉象，弦涩而数。我说：“这丸药是新制的，煅炼的火邪尚存，温热的药物太多，应该自行加减，不可拘执原方。”俞仁叔笑着说：“今人不如古人，此方不可加减。”服用一个月后，口鼻出血，形销骨立而死。
又有杨兄，年近五十，嗜好饮酒，患疟疾半年，出现胀病，自己察觉必死无疑，前来求治。诊察他的脉象弦而涩，重按则大，疟疾未愈，手足消瘦而腹部巨大，像蜘蛛的形状。我教他以人参、白术为君药，当归、川芎、芍药为臣药，黄连、陈皮、茯苓、厚朴为佐药，少量生甘草煎成浓汤饮用。每天分三次服用，他也严格遵守禁忌。一个月后疟疾因出汗而痊愈。又过了半年，小便增多而胀病痊愈。中间稍有加减，大意只是补气行湿。
还有陈氏，四十多岁，嗜好饮酒，大便时常带血，春季患胀病，面色黑而腹部巨大，形状像鬼。诊察他的脉象数而涩，重按似弱。我用四物汤加黄连、黄芩、木通、白术、陈皮、厚朴、生甘草，煎汤给他喝，将近一年才安稳。
一个是补气，一个是补血，其余药物大体相似出入，都获得了安宁并保全了天年。有人说：“气没有补法，为什么您补气而获得安宁，果然有说法可以通晓吗？”我说：“气无补法，是世俗的说法。认为气之为病，痞闷壅塞似乎难于补益，恐怕增加病势。但不思考正气虚弱者不能营运，邪滞附着而不能排出，所以才生病。《内经》说：‘壮者气行则愈，怯者着而成病。’如果气怯不使用补法，气如何能运行？”有人说：“您的用药，审慎倒是审慎了，为什么见效这么慢呢？病人长期卧床，必将厌烦您的迂阔而追求速效。”我说：“这个病的起因，有的三五年，有的十几年，病根已深，病势已笃，想求速效，是自找祸害啊！懂得王道治国道理的人才能治好这个病。”有人说：“胀病到最后难道绝对不能给泻利药吗？”我说：“确切知道它不是由于虚损，受病也很浅，脾胃还强壮，积滞不顽固，并且又有可下的证候，也应当略微给予疏导。如果把张子和的浚川散、禹功丸作为例行快速攻下的策略，实在不敢苟同。”
Cheng Wuji stated: "Yue" refers to constraint and aggregation. When Stomach Qi is strong but Spleen Qi is weak, Body Fluids (Jin Ye) are constrained and cannot distribute to the four directions, but only transport to the Bladder. Consequently, there is frequent urination and hard stools; thus it is called Pi Yue (Spleen Constraint). Administering this pill to purge the dryness and aggregation of the Spleen allows the intestines to become moist and the aggregation to resolve. Body Fluids then flow into the Stomach, bowel movements become smooth, urine volume decreases, and the disease resolves. However, I harbor doubts about this. Why? Since it is termed "Yue" (constraint), it implies that Spleen Qi is too weak to transform and transport. If Spleen Qi is weak, Earth Qi is deficient, inevitably leading to the dispersion of Spleen Qi and consumption of Spleen Blood. Tracing the origin, this condition often arises after prolonged illness, severe purging, or profuse sweating, where Yin Blood is withered, internal fire blazes and scorches, heat damages Yuan Qi (Original Qi), and further injures the Spleen. The damage to Yuan Qi occurs because Lung Metal is controlled by Fire, causing Qi to lose its grasping function. The injury to the Spleen occurs because the Lung is the child organ of the Spleen; when Lung Qi is depleted, fluids are exhausted, necessitating the borrowing of Mother Qi (from the Spleen) for self-rescue. When Metal is depleted, Wood lacks restraint; under such circumstances, it is impossible for Earth to remain uninjured. With the Spleen losing its transforming and transporting command, and the Lung losing its transmitting and descending function, one should expect constipation and difficult defecation, along with frequent urination without retention. Theoretically, one should nourish Yin and Blood to prevent the solitary Yang fire from blazing, thereby allowing Metal to perform clear transformation, restraining Wood pathogenic factors, and enabling Spleen Earth to be clear, healthy, and operational. Only then can essence and fluids enter the Stomach, moistening the intestines and ensuring patency. Currently, Rhubarb (Da Huang) is used as the Sovereign herb, Immature Bitter Orange (Zhi Shi) and Magnolia Bark (Hou Po) as Ministers. Although Peony (Shao Yao) nourishes blood, and Hemp Seed (Ma Ren) and Apricot Kernel (Xing Ren) provide warmth and moisture as Assistants and Envoys, this formula is suitable only for those with intense heat and substantial Zheng Qi (Upright Qi), bringing peace to them. I fear that in the Northwest regions, where the terrain is high and climate dense, and people have robust constitutions, it may be used. However, if applied to people in the Southeast, or those whose heat is intense but Qi and Blood are not substantial, although temporary relief of bowels may occur, the Spleen will become weaker and the intestines drier. Those who wish to use this prescription in the future must know that in the Northwest, the focus should be on resolving aggregation, while in the Southeast, the focus should be on moistening dryness. One must not be rigid and inflexible like tuning a zither without adjusting the pegs.
The Heart and Lungs are Yang, residing in the Upper Jiao; the Liver and Kidneys are Yin, residing in the Lower Jiao; the Spleen resides in the Middle and is also Yin, belonging to Earth. The Classics state: "When food enters the Stomach, its essence overflows and is transported upward to the Spleen. The Spleen scatters the essence, sending it upward to return to the Lung. The Lung regulates water passages, transporting downward to the Bladder. Water essences distribute to all four directions, and the five meridians run together." This indicates that the Spleen possesses the stillness of Kun (Earth) yet has the strength of Qian (Heaven). Thus, it enables the Yang of the Heart and Lung to descend and the Yin of the Liver and Kidney to ascend, achieving the harmony of Heaven and Earth interaction, which characterizes a healthy individual. Now, due to internal injury from the Seven Emotions, external invasion by the Six Excesses, irregular diet, or sexual exhaustion causing deficiency, the Yin of Spleen Earth is injured, and the official of transformation and transport fails. Although the Stomach receives grain, it cannot transform and transport it. Consequently, Yang rises spontaneously and Yin descends spontaneously, creating a state of non-interaction between Heaven and Earth (Pi Syndrome). At this time, clear and turbid qi mix, meridians and collaterals become obstructed, Qi transformation turns turbid, blood stasis stagnates and generates heat. Prolonged retention of heat leads to Qi transformation turning into dampness; dampness and heat generate each other, resulting in distension. This is what the Classics call Gu Zhang (Drum Distension). It is named so because although the abdomen is firm and full, the center is empty, resembling a drum. The disease is stubborn and difficult to treat, hence also called Gu (Poison/Parasite), implying something like insect erosion. Regarding treatment principles, one should tonify the Spleen, nourish Lung Metal to control Liver Wood, preventing the Spleen from suffering from hostile pathogens; nourish Kidney Water to control Heart Fire, allowing the Lung to receive commands for clear transformation. Avoid salty flavors to prevent aiding pathogens, and cut off delusions to protect Mother Qi (Spleen). There will be no unrest. Physicians who fail to recognize that the disease originates from deficiency, eager for quick effects, and showing off skills to seek rewards, are misguided. Patients suffer from distension and urgency, preferring purgatives for immediate relief, unaware that any comfort lasts only half a day, after which swelling worsens. Pathogens become excessive, True Qi is damaged, and death is near. Among ancient formulas, only Yu Yu Liang Wan (Hematit Pill), also known as Shi Zhong Huang Wan or Zi Jin Wan, appropriately controls the Liver and tonifies the Spleen. However, it must still be modified according to symptoms and seasons.
My friend Yu Renshu, a scholar and physician, suffered consecutive family tragedies. At fifty, he contracted this disease and prepared Yu Yu Liang Wan himself to take. Upon examining his pulse, I found it wiry, choppy, and rapid. I said, "This pill is newly prepared; the fire toxicity from calcination remains, and there are too many warm-hot herbs. You should modify it yourself; do not stick rigidly to the formula." Yu smiled and said, "Modern people are inferior to ancients; this formula cannot be modified." After taking it for one month, he bled from the mouth and nose and died emaciated.
Another patient, Brother Yang, nearly fifty years old, addicted to alcohol, had suffered malaria for half a year and developed distension. Believing he would surely die, he sought treatment. His pulse was wiry and choppy, large upon heavy pressure. The malaria had not resolved; his limbs were emaciated while his abdomen was massive, resembling a spider. I instructed him to use Ginseng (Ren Shen) and Atractylodes Macrocephala (Bai Zhu) as Sovereign herbs, Angelica Sinensis (Dang Gui), Ligusticum Chuanxiong (Chuan Xiong), and Peony (Shao Yao) as Ministers, Coptis (Huang Lian), Tangerine Peel (Chen Pi), Poria (Fu Ling), and Magnolia Bark (Hou Po) as Assistants, with a small amount of Licorice Root (Gan Cao) decocted into a thick tea. He took it three times daily and strictly observed dietary restrictions. After one month, the malaria resolved through sweating. Half a year later, urine output increased, and the distension healed. There were slight modifications during the process, but the main principle was tonifying Qi and promoting dampness removal.
Another case involved Mr. Chen, in his forties, addicted to alcohol, with occasional blood in stool. He developed distension in spring, with a dark complexion and a massive abdomen, looking ghost-like. His pulse was rapid and choppy, weak upon heavy pressure. I prescribed Si Wu Tang (Four Substances Decoction) added with Coptis (Huang Lian), Scutellaria (Huang Qin), Akebia Stem (Mu Tong), Atractylodes Macrocephala (Bai Zhu), Tangerine Peel (Chen Pi), Magnolia Bark (Hou Po), and Licorice Root (Gan Cao), decocted as a soup. He remained stable for nearly a year.
One case focused on tonifying Qi, the other on nourishing Blood; the remaining herbs varied slightly, yet both achieved stability and longevity. Someone asked: "It is said that Qi does not require tonification. Why did your Qi tonification succeed? Is there a theory to explain this?" I replied: "'Qi does not require tonification' is a secular saying. They argue that Qi disorders manifest as fullness, oppression, and blockage, seemingly difficult to tonify for fear of exacerbating the condition. But they fail to consider that when Zheng Qi (Upright Qi) is deficient, it cannot circulate; pathogenic stagnation adheres and cannot exit, causing disease. The Classics state: 'Those who are vigorous recover as Qi moves; those who are timid develop disease as pathogens adhere.' If timid Qi is not tonified, how can it move?" Another asked: "Your medication is indeed prudent, but why is the effect slow? Patients bedridden for long periods will likely find your approach tedious and seek speed." I replied: "The onset of this disease may span three to five years, or even ten-plus years. The root is deep, and the condition is severe. Seeking quick results invites disaster! Only those who understand the 'Kingly Way' (gradual, holistic healing) can cure this disease." Someone asked: "Is it absolutely forbidden to give purgatives for distension at the terminal stage?" I replied: "If it is certain that the disease is not due to deficiency, the pathology is shallow, the Spleen and Stomach are still strong, the accumulation is not entrenched, and there are signs indicating purgation is indicated, then mild guidance and drainage may be appropriate. However, adopting Zhang Hezi's Xun Chuan San or Yu Gong Wan as standard protocols for rapid aggressive purging is something I dare not endorse."