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When the pulse in distension and fullness is wiry (Xian, wiry), it indicates that Earth (Spleen/Stomach) is controlled by Wood (Liver/Gallbladder). A rapid and surging (Hong, surging) pulse indicates damp-heat; a slow and weak pulse indicates Yin-cold.

A floating (Fu, floating) pulse signifies empty/fullness (Xu-man); a tight (Jin, tight) pulse signifies interior excess. A floating and large pulse is treatable; a deficient and small pulse indicates extreme danger.

"Distension" (Zhang) refers to swelling on the exterior; "fullness" (Man) refers to stuffiness and fullness within the middle. The pathogenic factor displaces the Zang-Fu organs and expands the chest and hypochondrium, tightening the skin and exposing the collaterals, with the umbilicus protruding and the waist appearing round. Percussion of the abdomen produces a drum-like sound. This is a disease of the chest and abdomen. Occasionally, distension extends to the head, face, and limbs. It is largely similar but slightly different from edema (Shui-zhong, water swelling), except that there is no accumulation of fluid in this condition. Generally, irregular diet, improper daily routine, excessive sexual activity, and endless worry and thought can, over time, consume the Yin that guards the body and weaken the Yang's transformative function. This leads to Qi stagnation and retention in the middle Jiao, gradually giving rise to distension and fullness diseases. Therefore, excess patterns are few, while deficiency patterns are many; heat patterns are few, while cold patterns are many; cases originating from other Zang-Fu organs are few, while those originating from the Spleen and Stomach are many. Because deficiency causes Qi to float emptily, it easily becomes distended and enlarged. Cold causes Qi to coagulate and stagnate, making it easily obstructed and hard. The Spleen and Stomach reside in the center, regarding the chest and abdomen as their palace city. They belong to Earth and transform dampness; their nature is slow and their Qi tends to accumulate, so they are prone to distension and fullness. This merely describes the common pattern. Regarding distension caused by the decline or excess of the Five Zang and Six Fu organs, or by the winning and losing of the Five Movements and Six Qi, there are excess patterns, heat patterns, and those arising from other organs, which cannot be fully covered by these few points. It is up to the flexible and astute physician to examine and distinguish them carefully. It is also advisable to refer to Zhang Jingyue's discussion on Water Distension (Shui-zhang), and one will grasp the essence.

In *Ling Shu* (Spiritual Pivot), various discussions on distension include: In the chapter *Ben Shen* (Root of Spirit): "When Kidney Qi is in excess, distension occurs." (The Kidney governs storage. If the storage is already full and further subjected to excess, the resulting distension is self-evident.) In the chapter *Jing Mai* (Meridians): "Stomach disease results in large abdominal edema." (The Stomach belongs to Earth and governs the Middle Jiao. When Earth disease fails to control Water, Water floods and causes abdominal enlargement.) It also states: "Cold in the Stomach results in distension and fullness," because cold causes Qi stagnation and obstruction. It also states: "Deficiency of Foot-Taiyin [Spleen] meridian results in drum-like distension." (Foot-Taiyin Spleen governs transportation and transformation. Deficiency leads to failure of transportation, causing distension. Deficiency implies emptiness, hence resembling a drum.) In the chapter *Xieqi Zangfu Bingxing* (Pathogenic Factors, Zang-Fu Diseases, and Manifestations): "Disease of the Sanjiao [Triple Burner] presents with abdominal Qi fullness, especially hardness in the lower abdomen, inability to urinate, and distress/urgency. Overflowing fluid remains, forming distension. The sign is observed in the large collateral outside Foot-Taiyang [Bladder]." (Sanjiao governs Qi transformation and is the region of Qi circulation. Disease causes Qi transformation stagnation and blocked circulation, hence these symptoms. The manifestation at Taiyang is due to the connection between Sanjiao and Bladder.) In the chapter *Re Bing* (Heat Diseases): "Men resemble Gu [poisonous worm] disease, women resemble pregnancy." (Gu refers to Gu poison; abdominal urgency resembles Gu accumulation. 'Zu' means obstruction, resembling pregnancy due to blockage. Both describe massive abdominal enlargement.)

In *Su Wen* (Basic Questions), various discussions on distension include: In the chapter *Mai Jie* (Pulse Explanation): "What Taiyin calls disease of distension is related to Taiyin Zi [November]. In the eleventh month, the Qi of all things is stored within, hence called disease of distension." (Qi is stored and the interior is full, hence such disease.) In the chapter *Da Qi Lun* (Great Strange Discourse): "Fullness/excess in Liver, Lung, and Kidney, all being excess, results in swelling. Lung congestion causes panting and fullness in both flanks. Liver congestion causes fullness in both flanks, waking with fright during sleep, and inability to urinate. Kidney congestion causes fullness from the flanks down to the lower abdomen, calves varying in size, thighs becoming large with limping, and predisposition to hemiplegia." (Lung governs Qi and respiration. Both flanks are associated with Liver, which governs fright and free flow, and its meridians pass through the flanks. Kidney meridians pass through calves and thighs, and the lower abdomen is its domain. Thus, Lung excess causes panting and flank fullness; Liver excess causes flank fullness, sleep fright, and difficult urination; Kidney excess causes lower abdominal fullness, abnormal calf/thigh size, limping, and hemiplegia.) In the chapter *Tiao Jing Lun* (Regulating Meridians Discourse): "Excess in Zhi [Will/Kidney Essence] results in abdominal distension." (Zhi is stored by the Kidney. Excess implies reality/excess, leading to distension, same meaning as Kidney Qi excess causing distension.) In the chapter *Mai Yao Jing Wei Lun* (Essential Discourse on Pulse Necessities): "Excess in Stomach Qi results in distension." (Stomach meridian passes below the diaphragm, belongs to Stomach, and connects to Spleen. Its branch starts below the stomach gate, runs along the abdominal interior. Excess causes the meridian to surge, hence distension.) In the chapter *Yin Yang Ying Xiang Da Lun* (Great Discourse on Yin-Yang Correspondences): "For central fullness, purge from within." (Central fullness-excess should be purged internally, e.g., using purgatives. If it is empty-fullness or empty-distension, purging causes harm; caution is required.) It also states: "If turbid Qi stays above, distension arises." (Clear Yang ascends, turbid Yin descends. If turbid Qi does not descend and Yin stagnates above, distension arises.) In the chapter *Sheng Qi Tong Tian Lun* (Discourse on Vital Qi Connecting to Heaven): "Swelling due to Qi disorder, when the four extremities alternate in disease, Yang Qi is exhausted." (Qi refers to Ying-Wei and Zang-Fu Qi. If flowing normally, how could there be swelling? If disordered and unsmooth, stagnation occurs and swelling appears externally. The four extremities are the root of all Yang Qi. If they alternate in disease, does not Yang Qi exhaust here? This aligns with the text's meaning: loss of balance causes external muscle congestion and dispersal of Wei Qi.) In the chapter *Tai Yin Yang Ming Lun* (Taoyin and Yangming Discourse): "Those who do not regulate diet and do not follow proper routines suffer Yin invasion. Yin invasion enters the Five Zang. Entering the Zang results in痞满 (Pi-man, stuffiness and fullness) and obstruction." (Diet and routine are internal injuries; internal injury invades Yin and enters the Zang. Hence, internal Pi-man and obstruction occur.) In the chapter *Ping Ren Qi Xiang Lun* (Discourse on Normal People's Qi and Manifestations): "Surging and tight [pulse] is called distension." (This refers to the pulse of distension disease. Surging indicates Qi excess, tight indicates strong Qi. Both imply excess pathogens in the center, hence distension.) In the chapter *Yi Fa Fang Yi Lun* (Discourse on Different Methods and Regions): "Cold in the Zang generates fullness disease." (This explains distension arising from regional climate. Northern lands are cold; people eat milk and cheese. External cold constricts while internal dampness/lubricants stagnate, generating fullness disease.) In the chapter *Wu Chang Zheng Da Lun* (Great Discourse on Five Constant Policies): "Adapting to cold and cool causes distension." ('Shi' means going to. Going to cold and cool places causes external closure and internal depression, hence distension.) In the chapter *Ci Re Pian* (Acupuncture for Heat Chapter): "Below the Yache [dental arch] point corresponds to abdominal fullness." (This indicates external facial color reflects internal abdominal status to know distension. Yache is where the jaw moves. Below Yache corresponds to the abdomen. In abdominal distension, blue-white color should appear below Yache. Blue-white indicates cold; cold causes stagnation, hence distension.)

In *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet), discussing various distensions and fullnesses: "Fuyang pulse [pulse at dorsum pedis] is slightly wiry; according to method, abdominal fullness should occur. If there is no fullness, there must be difficulty in defecation and pain in both flanks. This is deficiency-cold rising from below. Treat with warm medicines." (Slightly wiry pulse indicates Yang cannot transform; abdominal fullness naturally follows. Even if no fullness, difficulty in defecation and flank pain indicate failure of transformation and blockage. Since it appears at the Stomach/Fuyang pulse, we know deficiency-cold rises from below. Warm medicines promote flow and transformation, leading to cure, e.g., Zhishi Lizhong Tang.) It also states: "Patients with distension and fullness: pressing without pain indicates deficiency; pressing with pain indicates excess. Purgatives may be used. If the tongue coating is yellow and purgatives have not been used, purging will remove the yellow coating." (Internal deficiency: pressing fills the deficiency, hence no pain. Internal excess: pressing fills the excess, hence pain.) It also states: "Abdominal fullness that decreases occasionally and returns to normal. This is cold; give warm medicines." (Warmth reduces it, e.g., Lizhong Tang plus Dingxiang and Rougui.) It also states: "Patient with abdominal fullness, fever for ten days, floating and rapid pulse, normal appetite. Main treatment: Nongpu Qiwu Tang." It also states: "Pressing the epigastrium reveals fullness and pain. This is excess; it should be purged." (Purging is applicable, but determine the nature of the fullness/pain.) Use Dachaihu Tang. It also states: "Abdominal fullness that does not decrease, or decreases insignificantly. Must be purged. Use Dachengqi Tang."

All the aforementioned distensions and fullnesses, though diverse, are invariably related to the Spleen and Stomach. Spleen and Stomach belong to Earth, reside in the center, and irrigate the four Zang organs. The chest and abdomen are their citadel. Chest and abdominal distension is like the collapse of a citadel. There is no scenario where a citadel collapses yet Earth remains intact. What exists internally manifests externally; this is an inevitable principle. If the pulse is wiry, it indicates Wood insulting Earth, which is even more ominous. If the pulse is rapid and surging, it indicates damp-heat stagnation. If the pulse is slow and weak, it indicates Yin-cold coagulation. Floating pulse indicates Qi dispersion; although the exterior is full, the interior must be deficient. Tight pulse indicates Qi contraction; although the exterior is firm, the interior is more excess. Floating and large pulse indicates vigorous Yuan Qi [Original Qi], compatible with the disease form, hence "treatable." Deficient and small pulse indicates declining Yuan Qi, contrary to the disease form, hence "extremely critical."

Additionally, there are two conditions: Changtan (Intestinal Polyp/Tumor) and Shijia (Stone Mass), which are diseases in women. *Baojian* discusses them in detail. Since they resemble distension and fullness, they are appended here. Changtan: Cold pathogen lodges outside the intestines, battling with Wei Qi [Defensive Qi]. Qi fails to nourish, binding into a mass internally. Evil Qi arises, and flesh polyps grow. Initially, it is egg-sized, gradually enlarging until it resembles pregnancy. After a year or more, it is hard to pressure but movable. Menstruation comes on time. This is its sign. (Chang refers to Large Intestine; Tan means extension. Large Intestine governs transmission, is the Fu organ of Lung. Lung governs Wei, Wei is Qi. Heat dissipates it, cold coagulates it. Now cold lodges in Large Intestine, so Wei Qi fails to nourish, binding and attaching masses internally. Extending long, it is named Changtan. Qi scatters to clear, gathers to turbid. Forming masses, evil Qi arises, polyps grow. Gradually enlarging, belly swells like pregnancy. This is Qi disease, not Blood disease, hence menstruation continues normally. Not pregnancy; distinguish by this. Treat with Bailu Wan and Muxiang Tongqi San.) Shijia: Born in the Baozhong [uterus]. Cold pathogen lodges in Zimen [cervix]. Zimen closes, Qi cannot flow, evil blood should discharge but does not. Blood stasis remains and stops, enlarging daily, resembling pregnancy. Menstruation does not come on time. All occur in women; treat with guiding and purging methods. (Bladder is the storehouse of fluids; Qi transformation allows excretion. Now cold lodges in Zimen, Qi blocks and does not flow, Blood stagnates and does not move, stasis remains and stops, hardening like stone, named Shijia. This disease begins with Qi disorder then Blood disorder, hence menstruation stops; guide and purge to expel. *Nan Jing* says: Ren Mai disease feels like internal knotting. In men, Seven Hernias; in women, Jia Ju [masses]. This is what is meant. Only potent acrid-hot agents can cure. Take Jianlu Wan and Hexue Tongjing Tang.)

Various distension and fullness diseases: Abdominal distension with body heat. Or massive abdominal distension, cold extremities, emaciation, severe diarrhea. Or abdominal distension with bloody stool, large pulse, intermittently absent. Or vomiting and coughing, abdominal distension with undigested food diarrhea, absent pulse. Or black complexion, elongated and dirty teeth, abdominal distension and closure, upper and lower blockage. Or abdominal distension preventing breathing, frequent belching and vomiting. Vomiting causes reversal of Qi; reversal causes red face. No reversal means upper-lower blockage; blockage causes black face and scorched skin/hair. Or disappearance of palm creases, or protruding umbilicus with shortness of breath, etc. These signs all indicate certain death.