脉 两关脉实数。右寸涩数。两尺弦涩。盖数者火盛也。涩者血枯也。由火盛而血衰。服药
而脉变缓滑者。易治。反结促者。难治。集成云∶脾脉沉数。下连于尺。为热结。两尺脉虚
。或沉细而迟者。为阴结。右尺浮。为风结也。
症 内经云∶肾主大便。大便难取足少阴。东垣曰∶肾主五液。津液润。则大便如常。若饥
饱劳逸。损伤胃气。及食辛热味浓之物。而助火邪伏于血中。耗散真阴。津液亏少。故大便
结燥。窃详燥之为病不一。有热燥有风燥。有阳结。有阴结。吐泻后。肠胃虚。服热药多
者。为热结。宜承气汤下之。肺受风邪入肠中。为风结。宜麻仁丸。年老气弱。津液不足。
或产后内亡津液。而结为气血虚也。六味地黄丸主之。大便闭。小便数则为脾约。脾约者。
脾血耗散。肺金受火。无所摄脾。津液故竭。宜养血润燥。若能食。小便赤。为实闭。麻仁
七宣等药主之。不能饮食。小便清。为虚闭。为气闭也。浓朴汤主之。小肠移热于大肠。为
宓瘕。是便涩闭也。医者不究其源。一概用巴豆牵牛等药下之。损其津液。燥结愈甚复下复
结。极则以致引导于下。而不能通者。遂成不救之症。可不谨哉。
治 内经云∶肾恶燥。急食辛以润之。结者散之。治法云∶如少阴不得大便。以辛润之。太
阴不得大便。以苦泻之。阳结者散之。阴结者温之。有物结者下之。久病腹中有实热。大肠
闭者。以润肠丸治之。慎勿峻利。脾约者。谓胃脾弱。约束津液。不得四布。但轮膀胱。故
小便数而大便难。名曰脾约。与脾约丸以下脾之结燥。使肠润结化。津液入胃而愈。然既曰
脾约。必阴枯槁。内火燔约。热伤元气。故肺金受火烁而津竭。必窃母气以自救。金耗则土
受木伤。脾失转输。肺失传送。宜大便难。小便数。而无藏蓄也。理宜滋养阴血。使阳火不
炽。肺金行清化。而脾土清健。津液入胃。肠润而通矣。今此丸用之于热甚而气实。与西北
人禀壮实者。服无不安。若用之于东南方人。与热虽盛而气血不实者。虽得暂安。将见脾愈
弱而肠愈燥矣。惟知西北以开结为主。东南以润燥为主。斯无误矣。
方 滋血润肠汤治大便秘结。或血虚秘。气滞秘。风秘。热秘。并治之。
当归（身尾一钱五分） 桃仁（一钱五分） 麻仁（去壳一钱五分） 大黄（一钱五分） 羌活 防
风（各一钱） 生地黄 枳壳 槟榔（各八分） 甘草（生五分） 皂仁（七分） 红花（二分） 木
香（一分）
上作一服。姜一片。枣一枚。煎。食前服。
又方 脾约丸治大便难。而小便数。名脾约。以此丸治之。
枳实（去穣麸炒） 浓朴（姜汁制） 芍药（各二两酒炒） 大黄（酒蒸四两） 麻仁（去壳净一两
三） 杏仁（去皮尖一两二钱）
上为末。炼蜜丸梧子大。每服三五十丸。白汤下。量虚实用之。
【脉象】
左右关脉实而数。右寸脉涩而数。两尺脉弦而涩。一般来说，数脉代表火邪亢盛。涩脉代表血液枯竭。这是由于火邪亢盛导致血液衰少。如果服药后脉象变为缓滑，则容易治疗；如果反而出现结代或促脉，则难以治疗。《医宗集成》中说：脾脉沉数，且下连于尺部，属于热结。两尺脉虚弱，或者沉细而迟缓的，属于阴结。右尺脉浮，属于风结。
【症状】
《黄帝内经》说：肾主管大便。大便困难应取足少阴肾经的穴位。李东垣说：肾主管五液。津液滋润，则大便正常。如果因饥饱失常、劳逸过度损伤了胃气，以及食用辛辣、热气重、味道浓烈的食物，从而助长火邪潜伏在血中，耗散真阴，导致津液亏少，所以大便秘结干燥。我仔细考察，燥证这类疾病有多种情况：有热燥、有风燥、有阳结、有阴结。呕吐腹泻之后，肠胃虚弱，服用热药较多的人，属于热结，适宜用承气汤攻下。肺受风邪侵入肠道，属于风结，适宜用麻仁丸。年老体弱、气虚，津液不足，或者产后体内津液亡失，而结滞为气血虚弱所致，适宜用六味地黄丸主治。大便闭结，小便频数，这叫做脾约。所谓脾约，是脾血耗散，肺金受到火邪克制，无法制约脾土，导致津液枯竭，适宜养血润燥。如果能进食，小便颜色赤红，属于实闭，适宜用麻仁七宣等药物治疗。不能进食，小便清长，属于虚闭，也属于气闭，适宜用浓朴汤主治。小肠的热邪移注到大肠，形成积聚（此处指腹部包块或病理产物），导致大便涩滞闭结。医生如果不探究其根源，一概使用巴豆、牵牛子等峻下药攻下，会损伤津液，使燥结更加严重。反复攻下又反复结滞，极端情况下会导致元气下陷而不能通畅，最终成为无法救治的病症。怎能不谨慎呢？
【治法】
《黄帝内经》说：肾厌恶燥，应当急食辛味药物以滋润之。结滞者应当消散它。治法云：如果是少阴病导致的大便不通，用辛味药物滋润它；太阴病导致的大便不通，用苦味药物泻下它。阳结者应当消散它，阴结者应当温补它。有形实邪结滞者应当攻下它。久病腹中有实热，大肠闭结的，用润肠丸治疗。千万不要使用峻猛的泻药。所谓脾约，是指胃和脾虚弱，约束津液，使其不能四布全身，只能偏渗到膀胱，所以小便频数而大便困难，名叫脾约。给予脾约丸以解除脾的结燥，使肠道滋润，结滞化解，津液进入胃中而痊愈。然而既然称为脾约，必然是阴液干枯槁焦，内火炽盛约束，热邪损伤元气，所以肺金受到火邪灼烧而津液枯竭，必然盗取母脏（肾）之气以自救。金气耗损则土气受木气伤害，脾失去转输功能，肺失去传送功能，适宜表现为大便难、小便数，而没有脏腑内的蓄积。按理应当滋养阴血，使阳火不炽盛，肺金行使清化功能，而脾土清纯健运，津液进入胃中，肠道滋润而通畅。现在这个方剂（指脾约丸/麻子仁丸类）用于热势很盛且正气充实的人，以及西北方人体质壮实的人，服用没有不安稳的。如果用于东南方的人，以及虽然热势盛但气血不充实的人，虽然能得到暂时的安宁，将会看到脾更虚弱而肠道更干燥。只有知道西北地区以开结为主，东南地区以润燥为主，才不会出错。
【方剂】
滋血润肠汤治疗大便秘结。无论是血虚秘、气滞秘、风秘、热秘，都一并治疗。
当归（身尾一钱五分） 桃仁（一钱五分） 麻仁（去壳一钱五分） 大黄（一钱五分） 羌活 防风（各一钱） 生地黄 枳壳 槟榔（各八分） 甘草（生用五分） 皂角仁（七分） 红花（二分） 木香（一分）
以上为一服量，加生姜一片，大枣一枚，煎煮。饭前服用。
又一方：脾约丸治疗大便困难，而小便频数，名叫脾约，用此丸治疗。
枳实（去瓤麸炒） 厚朴（姜汁制） 芍药（各二两酒炒） 大黄（酒蒸四两） 麻仁（去壳净一两三钱） 杏仁（去皮尖一两二钱）
以上研为末，炼蜜制成梧桐子大小的丸药。每次服用三五十丸，白开水送下。根据虚实情况调整用量。
<Pulse>
The pulses at both Guan positions are full and rapid. The pulse at the right Cun position is choppy and rapid. The pulses at both Chi positions are wiry and choppy. Generally, a rapid pulse indicates an excess of Fire. A choppy pulse indicates blood depletion. This arises because excessive Fire leads to blood deficiency. If the pulse becomes slow and slippery after taking medicine, it is easy to treat. If it instead becomes knotted (intermittent) or hurried, it is difficult to treat. *Yi Zong Ji Cheng* states: If the Spleen pulse is deep and rapid, extending down to the Chi position, it indicates Heat binding. If both Chi pulses are deficient, or deep, fine, and slow, it indicates Yin binding. If the right Chi pulse is floating, it indicates Wind binding.
<Symptoms>
*Huang Di Nei Jing* states: The Kidney governs defecation. For difficulty in defecation, points from the Foot-Shaoyin Kidney meridian should be selected. Li Dongyuan stated: The Kidney governs the five fluids. When body fluids are moistening, defecation is normal. If stomach Qi is damaged by irregular eating and drinking, overwork, or rest, and if one consumes pungent, hot, and rich-tasting foods, this aids Fire pathogenic factors to lurk within the blood, consuming True Yin. Consequently, body fluids become deficient, leading to dry and bound stools. Upon careful examination, diseases of dryness vary: there is Heat dryness, Wind dryness, Yang binding, and Yin binding. After vomiting and diarrhea, when the intestines and stomach are weak, and many hot medicines have been taken, it constitutes Heat binding, which should be purged with Chengqi Tang. When Lung Wind pathogens enter the intestines, it constitutes Wind binding, which should be treated with Maren Wan. In the elderly with weak Qi and insufficient body fluids, or postpartum patients who have lost body fluids internally, resulting in binding due to Qi and Blood deficiency, Liuwei Dihuang Wan is indicated. Constipation accompanied by frequent urination is called Pi Yue (Spleen Constraint). Pi Yue refers to the consumption of Spleen Blood, where Metal of the Lung is controlled by Fire and cannot regulate the Spleen, leading to the exhaustion of body fluids. Nourishing Blood and moistening dryness is appropriate. If the patient can eat and urine is red, it is Excess constipation, treated with drugs such as Maren Qixuan. If the patient cannot eat and urine is clear, it is Deficiency constipation, also known as Qi closure, treated with Houpo Tang. When Heat from the Small Intestine transfers to the Large Intestine, it forms masses (accumulations), causing涩 (astringent/stagnant) and bound stools. If physicians do not investigate the root cause and indiscriminately use drastic purgatives like Radix Crotonis (Badou) and Semen Persicae (Qianniu), they damage body fluids, making the dryness and binding worse. Repeated purging and binding eventually lead to sinking of Yuan Qi without unblocking, resulting in an incurable condition. How can one not be cautious?
<Treatment>
*Huang Di Nei Jing* states: The Kidney dislikes dryness; urgently consume Pungent substances to moisten it. Binding conditions should be dispersed. Treatment principles state: For Shaoyin cases with no stool, use Pungent substances to moisten. For Taiyin cases with no stool, use Bitter substances to purge. Yang binding should be dispersed; Yin binding should be warmed. Cases with tangible accumulations should be purged. For chronic illness with excess Heat in the abdomen and Large Intestine closure, Run Chang Wan is used. Do not use drastic purgatives. Pi Yue refers to weakness of the Stomach and Spleen, which constrain body fluids, preventing them from distributing throughout the body, causing them to flow only to the Bladder. Thus, there is frequent urination and difficult defecation, named Pi Yue. Administer Pi Yue Wan to resolve the Spleen's binding dryness, moisten the intestines, dissolve the binding, allow body fluids to enter the Stomach, and achieve recovery. However, since it is called Pi Yue, it implies Yin fluid is dry and withered, internal Fire is blazing and constraining, and Heat damages Yuan Qi. Therefore, Lung Metal is scorched by Fire, depleting fluids, and must steal Qi from its mother organ (Kidney) to save itself. When Metal is depleted, Earth suffers Wood injury; the Spleen loses its transport function, and the Lung loses its descending function. It is appropriate for symptoms of difficult defecation and frequent urination without internal accumulation. Ideally, nourish Yin and Blood to prevent Yang Fire from becoming excessive, allow Lung Metal to perform clearing and transforming functions, keep Spleen Earth pure and healthy, let body fluids enter the Stomach, and moisten the intestines for unblocking. Currently, this pill is suitable for those with severe Heat and solid Qi, and for people in the Northwest with robust constitutions, bringing safety. If used for people in the Southeast, or those with strong Heat but deficient Qi and Blood, although temporary relief may occur, the Spleen will become weaker and the intestines drier. One must know that the Northwest focuses on resolving binding, while the Southeast focuses on moistening dryness, to avoid errors.
<Formula>
Zixue Runchang Tang treats large bowel constipation. It treats all types including Blood deficiency constipation, Qi stagnation constipation, Wind constipation, and Heat constipation.
Dang Gui (Radix Angelicae Sinensis, body and tail 1 qian 5 fen)
Taoren (Semen Persicae 1 qian 5 fen)
Maren (Semen Cannabis, shelled 1 qian 5 fen)
Dahuang (Radix et Rhizoma Rhei 1 qian 5 fen)
Qianghuo (Rhizoma Notopterygii)
Fangfeng (Radix Saposhnikoviae, each 1 qian)
Sheng Dihuang (Radix Rehmanniae Preparata 8 fen)
Zhike (Fructus Aurantii 8 fen)
Binglang (Areca Seed 8 fen)
Gancao (Radix Glycyrrhizae, raw 5 fen)
Zaoren (Semen Gleditsiae Sinensis 7 fen)
Honghua (Flos Carthami 2 fen)
Muxiang (Radix Aucklandiae 1 fen)
Take as one dose. Add one slice of fresh ginger and one jujube. Decoct. Take before meals.
Another Formula: Pi Yue Wan treats difficult defecation with frequent urination, named Pi Yue. Treat with this pill.
Zhishi (Fructus Aurantii Immaturus, pith removed, bran-fried)
Houpo (Cortex Magnoliae Officinalis, processed with ginger juice)
Shaoyao (Radix Paeoniae Alba, each 2 liang, wine-fried)
Dahuang (Radix et Rhizoma Rhei, steamed with wine 4 liang)
Maren (Semen Cannabis, shelled and cleaned 1 liang 3 qian)
Xingren (Semen Pruni Armeniacae, skin and tip removed 1 liang 2 qian)
Grind into powder. Make pills using refined honey, size of wu zi (wukeng seeds). Take 30-50 pills per dose, washed down with warm water. Adjust dosage according to deficiency or excess.