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The Yellow Emperor asked: How does the pulse at the cunkou (inch position) manifest to indicate distension? Bole replied: A pulse that is large, firm, and choppy indicates distension. When pathogenic factors are abundant, the pulse becomes large; when pathogens are solid, the pulse becomes firm. A choppy pulse signifies deficiency of qi and blood and lack of smooth flow. A surging and large pulse indicates a decline in yin qi, while a firm and strong pulse indicates damage to stomach qi. Therefore, a large, firm, and choppy pulse suggests that the disease should present as distension. Thus, the spleen possesses the virtue of Kun (earth), which is quiet and yielding, yet has the function of Qian (heaven), which is vigorous and active. It enables the yang qi of the heart and lungs to descend and the yin qi of the liver and kidneys to ascend, thereby achieving the harmonious state of Taiji (Heaven and Earth interacting), which characterizes a healthy person (Ping Ren). Currently, internal injury from the seven emotions, external contraction of the six climatic factors, irregular diet, and excessive sexual activity leading to deficiency, all injure the yin of the spleen earth. The official responsible for transportation and transformation loses its duty. Although the stomach receives food, it cannot transform and transport it. Consequently, the yang qi of the heart and lungs cannot descend, and the yin qi of the liver and kidneys cannot ascend, resulting in the state of Pi (Heaven and Earth not interacting). Clear and turbid qi mix together, meridians and collaterals become obstructed, stagnation generates heat, and lingering heat transforms into dampness. Dampness and heat generate each other, eventually forming distension and fullness. This is originally a disease of formless qi, making it difficult to treat as if it were a tangible symptom. Some say that treatment in autumn, summer, and winter is relatively easy, but spring is the most difficult, because wood qi is prosperous in spring, overcoming spleen earth, preventing it from controlling water. However, mild cases are all easy to treat, and severe cases are all difficult, not just in spring. Named "Drum" (Gu), it is so called because it is hollow inside and floating outside, taking its image as its name. Renamed "Gu" (Worm/Insect), it is named for its erosive harm, taking its meaning as its name. Treatment should tonify the spleen, and also nourish lung metal to control liver wood, ensuring the spleen suffers no invasion from hostile pathogens. Nourish kidney yin to control ministerial fire, allowing the lungs to receive the command of clear transformation. When the qi of the spleen, lungs, and kidneys communicates smoothly, food and drink will naturally be digested. Avoid alkaline flavors, cut off delusions, and there will be no unrest. Physicians eager for quick results, and patients suffering from distension and fullness, often prefer using purgative or diuretic drugs to seek relief. They do not realize that after one or two days, the pathogenic factor of distension becomes more severe, and the primordial qi is further damaged. There are also cases where the branch manifestation is excess but the root is deficiency. Purging is contraindicated, and tonification is ineffective, making the condition extremely dangerous. Success depends entirely on preventing subtle changes before they occur, handling both root and branch appropriately, allowing the primordial yang of the spleen and kidneys to arise, so that the stagnation of yin pathogens is naturally resolved.

Edema and Drum Distension are both caused by spleen deficiency. However, edema is mild, while Drum Distension is severe. Why? In edema, appetite remains normal; in Drum Distension, appetite is less than normal. If swelling starts in the head and feet and later the abdomen enlarges, it is water disease/edema. If the abdomen enlarges first and later the limbs swell, it is qi disease/distension. To treat edema, one need only tonify the spleen and guide out water. To treat Drum Distension, one must tonify the spleen, guide out water, and simultaneously promote digestion of grains, which may succeed. Although Drum Distension differs in terms of qi, blood, cold, and heat, it mostly arises from anger injuring the liver, where wood pathogen overcomes earth, causing spleen disease and inability to transform and transport water and grain. One must again nourish lung metal to control liver wood, so the spleen has no hostile pathogens, allowing transformation to proceed and water/grain to digest. From this perspective, the method for treating Drum Distension must focus on tonifying the spleen, controlling the liver, guiding out water, and promoting digestion. Depending on accompanying factors, add appropriate herbs: if accompanied by qi stagnation, disperse qi; if by blood stasis, break blood; if by cold, warm against cold; if by heat, clear heat. There will surely be no case that does not heal. Those that cannot be treated are due to extreme spleen deficiency, constituting a Zang-Fu organ collapse disease (Zhen Zang Bing). Zhen Zang Bing occurs because true fire cannot generate spleen earth; it is not merely a spleen issue.

When a person engages in sexual intercourse with excessive effort, sweat comes from the kidneys. The Classic states that sweat comes from the kidneys. If exposed to wind, it cannot enter internally to the zang-fu organs nor exit externally to the skin, but lodges in the xuanku (pores). Moving through the skin, it transmits to swelling, originating in the kidney, named Feng Shui (Wind Water). Treatment should nourish the kidney and scatter wind, such as Si Wu Tang added with Jing Jie, Fang Feng, Qiang Huo, Chai Hu, and Fang Ji. Do not treat it as spleen deficiency with dampness-induced swelling using Ren Shen and Bai Zhu, nor use diuretics, as this would cause the wind pathogen to sink deeper internally.

Fire nature flares upward; water nature moistens downward. Xiao Ke (Wasting-Thirst) syndrome occurs because water and fire do not interact, and fire is predominant. Shui Qi (Water Qi) syndrome occurs because water and fire do not interact, and water is predominant. The treatment method lies in restraining the excess to allow mutual assistance. Small fire cannot transform large water; one must first drain the water, then tonify the fire. "Kai Gui Men" (Open the Ghost Gate) refers to inducing sweating to drain water located in the exterior and upper body. "Jie Jing Fu" (Cleanse the Pure Mansion) refers to promoting urination to drain water located in the interior and lower body. Once the water momentum is reduced, then use warm medicines to tonify primordial qi. This is the sequence for treating excess and heat syndromes. If one does not understand deficiency/excess and cold/heat, and solely adheres to the method "purging resolves distension," although temporary relief may be gained, the true qi will further decline, and swelling will recur shortly thereafter, leading to untreatable conditions. Therefore, for cases involving deficiency, warm and tonify the spleen and kidneys, such as with Shen Qi Wan. Tonify slightly while draining to allow gradual recovery. However, the King's Way (Wang Dao) yields no immediate results; efficacy must be sought gradually. Did ancient and modern wise physicians not know that attacking/draining works quickly? Yet they persisted in slow methods because the middle qi was already depleted, fearing the disaster of "deficiency inducing deficiency." Zhong Man (Middle Fullness) symptoms are identical to Drum Distension and Edema. Why is it attributed to qi deficiency? Qi deficiency here refers to deficiency of fire qi in the kidney. Zhong Man means hollow inside like a drum, a false fullness rather than true fullness. The Classic says: All dampness, swelling, and fullness belong to the spleen. It also says: The root is in the kidney, the branch is in the lungs; all are accumulations of water. Although all meridians can have swelling, none do not originate from the spleen, lungs, and kidneys. Spleen earth manages transportation; Lung metal manages qi transformation; Kidney water manages the five fluids. All fluids transformed by the five qi belong to the kidney. All qi moving the five fluids belongs to the lungs. The transmission between these two zang organs, controlling water to generate metal, belongs to the spleen. If the spleen cannot scatter stomach water essence to the lungs, disease arises in the middle; if the lungs cannot regulate stomach water pathways to the bladder, disease arises in the upper; if the kidneys cannot manage the stomach's gate to time its excretion, disease arises in the lower. Thus, stomach earth cannot control kidney water; water rebels and moves upward, transmitting to the lungs. Although water is controlled by the spleen, it is actually governed by the kidney, for the kidney is fundamentally a water organ, yet it is the source from which yang qi emerges. If kidney yang is deficient, Mingmen fire declines. It cannot control yin-cold internally, nor warm and nourish spleen earth. Yin and yang lose their proper balance and transform into pathogens. Treaters who only know how to drain water without knowing how to benefit the stomach, or who benefit the stomach without warming the kidney, often use purgatives to force water out, ignoring the natural cycle of heaven and earth. This causes stomach qi to become more deficient and kidney yang more damaged, leading to outbreaks that cannot be controlled. It is better to act according to natural processes, which is the best strategy. Why immediately apply methods from the Neijing such as removing accumulation, opening the ghost gate, and cleansing the pure mansion, using formulas like Zhou Che Wan or Yu Gong San? If one truly knows that water-dampness qi has invaded the middle jiao and skin, appearing bright like crystal and rebounding immediately upon pressure, one dose of the aforementioned gentle medicine will resolve it. However, for chronic illness, post-major illness, post-typhoid/malaria/dysentery, postpartum women, post-smallpox children, or those with constitutionally weak primordial qi, applying these aggressive methods generally will cause spleen qi to leak and become more deficient, becoming irrecoverable. Therefore, when treating swelling, prioritize spleen earth. Tonify the middle and boost qi, or use Liu Jun Zi Tang to warm and tonify. Then use Jin Gui Shen Qi Wan to tonify earth to support the mother (kidney), so that spleen strength and earth prosperity allow scattering essence to the lungs, regulating water pathways, and transporting down to the bladder. Water essence distributes everywhere, and the five meridians circulate together. Some doubt that adding purely tonifying agents to wheezing, distension, and water-fullness might increase fullness, suggesting adding qi-moving and diuretic herbs to tonics. This view seems to fit the condition but is not the profound truth of gathering qi and returning to the source. Since lung qi is deficient, it cannot be further moved; since kidney water is depleted, it cannot be further drained. Purely tonifying agents may initially feel uncomfortable, but once the medicinal power acts, qi returns to its place and flows naturally. Like soil in rain turning to mud, when warmed by gentle winds and sun, moisture leaves and yang harmony is restored, allowing all things to grow.

Li Dongyuan said: For treating Zhong Man, one should open the ghost gate, cleanse the pure mansion, and purge from within. This means when spleen and stomach are diseased, allow dampness to dissipate from above and below. The lower jiao is like a ditch, and qi and blood naturally differentiate. Or, in cases of great excess and fullness with difficulty in urination and defecation, temporarily use cold and hot purgatives. This discusses treating excess syndromes. As for tonifying the kidney to treat swelling, his explanation is hard to clarify. It is akin to Yu the Great controlling water by doing nothing (following nature). If one tries to dredge every detail, one errs. Those today who treat water using Niu Bang Zi (Pipiza) and Da Ji (Euphorbia) display the petty wisdom of crude practitioners, which Yu the Great detested. Occasionally, Wu Ling San or Wu Pi Yin are used as moderate approaches, but they lead to more draining and more deficiency, further depleting kidney qi and reducing its ability to push forward. Thus, one must use kidney tonification. The Classic says: The kidney opens into the two orifices. When kidney qi transforms, the two orifices open; when closed, the stomach becomes full and distended. The kidney is the gate of the stomach. If the gate is not functional, water gathers according to its kind. The Classic also says: The kidney governs the lower jiao. The San Jiao is the official of drainage, from which water passages emerge. The Bladder is the palace of the capital, storing fluids. Only after the fire transformation of the San Jiao can they be discharged. The San Jiao meridian, in the upper, spreads in the Danzhong, dispersing around the Pericardium. In the lower, it emerges at Weiyang, connecting upwards to the Bladder. It assists the heavenly dao in transformation and the earthly dao in generation. It forms an exterior-interior relationship with the Hand Jueyin, acting as the messenger responding to all meridians. Thus, kidney deficiency is deficiency of fire in the lower jiao. Although clear and long urination depends on lung metal transformation, bladder qi must be vigorous to absorb chest qi and draw it downward. Since kidney and bladder are exterior-interior, bladder failure in transformation must stem from kidney qi decline. Initially, small fire cannot transform water; later, even large fire cannot transform the accumulated water. The Classic says: In San Jiao disease, there is qi fullness, hardness in the lower abdomen, and inability to urinate. Overflow leads to water retention and distension. Zhang Zhongjing's Jin Gui Shen Qi Wan tonifies without stagnation and unblocks without leaking; it is indeed a divine formula for treating swelling.

In some cases, only the face and feet swell. Morning brings severe facial swelling; evening brings severe foot swelling. The Classic says: Facial swelling is due to wind; foot swelling is due to water. This is caused by wind-heat. However, in people whose primordial qi has not recovered after illness, this is often seen. It is due to the instability of true qi and root. During the day, sitting or walking causes qi to sink to the lower part, leading to evening foot swelling. At night, sleeping causes qi to float upward, leading to morning facial swelling. If treated generally as wind-dampness, it further damages deficiency. Thus, using methods for deficiency to treat excess is acceptable, but using methods for excess to treat deficiency is not.

Any masses, nodules, or痞块 (pi blocks) are the root of distension diseases. Day by day, month by month, the abdomen enlarges like a basket or a jar, known as Dan Chu Zhang (Single Abdominal Distension). This differs from water qi scattered on the skin, face, eyes, and limbs. Because the central region (middle jiao) has been blocked for a long time, the axis of the four movements fails: clear qi does not ascend, turbid qi does not descend. They knot together, firmly unbreakable. This is truly due to the decline of spleen earth and the failure of the zang-fu officials. The human body relies on the center to move the four peripheries. Now that the center is exhausted, how can essence reach everywhere? Thus, emaciation and withering occur, with the middle abdomen like a drum. Ignorant practitioners fiercely use plundering drugs. Temporary reduction is followed by worse swelling. They wonder what evil qi is so powerful. They do not realize that the fierce drugs attack the body's own primordial qi, turning it against itself, like driving good citizens to become bandits. Understanding this, there is a method of cultivation: tonifying primordial qi. There is a method of recruitment: for spleen deficiency with sinking, raise yang qi; for kidney deficiency with floating, gather qi and return to the source. There is a method of dispersion: open the ghost gate and cleanse the pure mansion. These three methods do not explicitly mention purging, yet purging is included within them.

When qi and blood stagnate and stop, over time blood bi (obstruction) prevents flow, damp-heat generates worms, the abdomen becomes large and filled, with solid matter inside. This is named Gu (Worm/Insect). It is not like Drum Distension where the abdominal skin is tight and it belongs to qi, being hollow inside. Careful differentiation is required. Women have differences between Water Component and Blood Component. If the chest and heart are hard and large, disease originates above, starting with water distension and then amenorrhea, it is called Water Component. If blood knots in the uterus gate, disease originates below, starting with amenorrhea and then water distension, it is called Blood Component. Edema all arises from excessive sexual fatigue. Swelling starts in the shins and later the abdomen enlarges; pressing it rebounds immediately—it is water. Single abdominal distension is extreme spleen deficiency. It requires large doses of Ren Shen, Bai Zhu, Gui Zhi, and Fu Zi. For lower yuan deficiency-cold, use Jin Gui Shen Qi Wan ingredients in large doses as a decoction. Initial intake may cause unbearable distension and stuffiness, but over time, righteous qi becomes prosperous, transportation improves, and distension subsides. This is the Neijing method of "treating blockage with blockage" (Sei Yin Sei Yong). Small doses cause stagnation above; large doses provide harsh tonification below. Since the middle region is deficient and stagnant, it relies on major tonification to circulate qi.

The Classic says: Ying Qi follows the vessels; Wei Qi reversing causes Mai Zhang (Vessel Distension). Once Wei Qi reverses, it follows between the muscle intervals, causing Fu Zhang (Skin Distension). Thus, the human body is primarily governed by qi. Loss of harmony makes it pathogenic qi; gaining balance makes it righteous qi. Righteous qi is True Qi and Yuan Qi. If breath does not move for a moment, the mechanism ends; if continuity breaks for an instant, heaven and earth are separated. Qi is mainly governed by the lungs; the lungs are the director of all qi. Qi is born in the stomach; the stomach is the source of transformation. Qi originates in the kidney; the kidney is the place of foundation. Therefore, qi deficiency... Tonifying deficiency is a fixed method. Saying "qi has no tonification method" is a vulgar theory. Although bloating and obstruction seem difficult to tonify, one does not know that if righteous deficiency is not tonified, how can pathogens move? However, some find tonification ineffective because they do not know the method of tonification. Regarding all upward-rising qi, people only seek treatment in the spleen and lungs, not in the kidney. The moving qi in the kidney cavity is the root of the five zang and six fu organs, the root of the twelve meridians, the door of respiration, and the origin of the San Jiao. People who are immoderate in sexual activity or overthink all injure the kidney. Thus it is said: Harm from thinking is greater than harm from desire. Once the kidney is injured, qi has no restraint and becomes stagnant. The lungs exhale qi; the kidneys inhale qi. If kidney deficiency cannot inhale qi, qi rises and does not descend. This is lung disease but actually kidney disease. Child disease affecting the mother: Treaters should not merely attend to the lungs but should make tonifying the kidney the foundation. The key to tonifying the kidney especially lies in inhaling qi. The method of inhaling qi is guiding fire back to its source, for fire is the root of qi.

The Classic says: Turbid qi in the upper generates Chang Zhang (Distension). Thus, although Drum Distension is a spleen-stomach disease, its principle of qi originates in the kidney. Spleen is the most yin among yin, occupying a fixed position. Heaven is yang, fire. Earth is yin, water. In humans, this corresponds to the spleen, transforming like yin water. If middle qi is sufficient, primordial yang operates vigorously. Otherwise, yang qi cannot transform fine essences, which accumulate and change not, causing distension and fullness. Warm and tonifying agents should be entered to nurture the generating qi of the stomach, ascending through the clear pathways, so turbid yin naturally descends, and distension/fullness heals themselves. If one focuses on separating and eliminating to seek temporary relief, spleen qi becomes more deficient due to separation, and transformation becomes harder due to deficiency. This is the argument for treating spleen and stomach, but it does not reach the kidney. Although the kidney is a water organ, the ministerial fire of Mingmen resides there. If Mingmen fire declines, true yang becomes weak and spleen earth becomes weak, generating distension and fullness. The Classic says: Cold in the zang generates fullness diseases. Therefore, to tonify earth, nothing is better than tonifying the true fire in the kidney. Fire prosperous means earth strong, and distension heals itself. As for opening the ghost gate and cleansing the pure mansion, these treat external contraction tangible excess syndromes, not internal injury formless qi diseases.

Edema is a spleen disease. It emerges from the lungs and originates in the kidneys. Cold qi of the three meridians causes disease, but essentially it stems from the non-transformation of San Jiao qi. Closed and not moving, it stays and overflows as swelling. The spleen controls water. If earth is attacked by pathogens, water rebels against it. The lungs generate water. If metal qi is diseased, water cannot be transported. However, the root lies even more in the kidney. Although the kidney is a water organ, it is actually the source from which primordial yang qi emerges. If kidney yang is deficient, Mingmen fire declines. How can it warm and nourish spleen and stomach? Thus yin-cold attacks upward, supreme yin becomes further distressed, and cannot perform vigorous transformation. Know that qi is fire, yang. Essence is water, yin. When yang is prosperous, it transforms essence into qi. When yang declines, it cannot transform, and water becomes pathogen. When fire declines, it cannot transform water. When water is abundant, fire cannot transform yin. Not following yang, both essence and qi can transform into water. Thus, the water in edema is essentially no water. It originates from the transformation of qi. When true qi is prosperous, water becomes qi; when true qi declines, qi transforms into water. This is caused by the prior depletion of true yuan qi of the spleen, lungs, and kidneys. The kidney resides in the lower jiao, belongs to water, controls yin fluids, and is the root of water. The spleen resides in the middle jiao, belongs to earth, combines with muscles as the dam of water, governs transforming grains and generating fluids to irrigate the meridians. The lungs reside in the upper jiao, belong to metal, are the source of water transformation, circulate Ying and Wei, govern regulation, and regulate water pathways. If people injure their zang organs through fatigue or sexual excess, the kidney cannot control and disseminate, leading to stagnation. The spleen cannot act as a dam and irrigate, leading to flooding. The lungs cannot generate, transform, and regulate, leading to blockage. San Jiao qi closes, the official of drainage is suppressed, water passages do not flow, body fluids close, blood vessels do not flow, all transforming into water. Water is closed by qi; qi is congested by water. Swelling worsens daily. Observing this, we know it derives from the spleen, lungs, and kidneys, and fundamentally from qi and fire. Thus the Classic says: Contraction of the three yin is called water. Contraction of the three yin means cold contraction of the spleen and lung pulses. Spleen and lung cold contraction causes qi to transform into water. Therefore, Jin Gui Shen Qi Wan uses Gui Zhi and Fu Zi internally to move the pivot, so water goes down naturally, unlike Wu Ling San which specializes in moving water.

In all treatments of swelling and distension, yin/excess and deficiency must not fail to be distinguished. Generally, yang syndromes must be hot; heat usually indicates excess. Yin syndromes must be cold; cold usually indicates deficiency. Distension inside first, then swelling outside, is excess. Swelling outside first, then distension inside, is deficiency. Yellow-red urine and constipation indicate excess. Clear-white urine and loose stools indicate deficiency. Slippery, rapid, and forceful pulse indicates excess. Wiry, floating, faint, and fine pulse indicates deficiency. Red color and coarse breath indicate excess. Sallow complexion and short voice indicate deficiency. All excess syndromes, whether from six excess pathogens externally or dietary injury internally, involve rapid yang pathogens arriving violently, often forming within days. If deficiency syndromes, whether from emotional labor or excessive alcohol/sex, accumulate day by day and month by month, arriving gradually, they often form after months. Treating excess is quite easy; managing deficiency is always difficult. Qi distension in deficient people is due to spleen deficiency failing to move qi. Edema in deficient people is due to earth deficiency failing to control water. Although water is controlled by the spleen, it is actually governed by the kidney. The kidney is fundamentally a water organ, housing primordial yang. Mingmen fire decline means it cannot control yin-cold internally, nor warm spleen earth. Yin does not follow yang, and essence transforms into water. Thus, when the true yang of the kidney is prosperous, water attaches internally and stores with kidney qi. Edema syndromes mostly belong to fire decline. Dan Xi believed it was damp-heat. He suggested nourishing lung metal to control water, so the spleen has no hostile threat; nourishing kidney water to control fire, so the lungs gain the power of clear transformation. Controlling fire certainly protects metal, but does one not worry about harming earth? This is suitable only for heat syndromes. For yang deficiency, would it not worsen the disease?

Furthermore, women may have internal accumulations that resemble water distension but are not. The Classic says: Shi Xia (Stone Mass) arises in the uterus. Cold qi lodges in the Zi Men (cervical opening). Zi Men closes, qi cannot pass, evil blood should discharge but does not, blood stays and stops, growing larger day by day, resembling pregnancy, with menstruation not occurring on time. It can be guided and discharged. If cold qi lodges outside the intestines, contending with Wei Qi, qi cannot nourish, binding internally, forming癖 (Pi) and attaching inside, polyps...