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Hejian stated: "Pi" (fullness and obstruction) is synonymous with "Pi" (blockage), meaning a state of non-communication and lack of smooth flow. When there is stuffiness in the heart and diaphragm without pain, it is called Pi Man (fullness and obstruction); when both internal and external areas are swollen and tense, it is called Zhong Zhang (swelling). Although these two conditions appear similar, they are fundamentally different.

There are cases where weak Middle Qi fails to transport and transform essential nutrients, leading to Pi; there are cases where food retention and phlegm accumulation fail to be transformed, leading to Pi; there are cases where damp-heat is excessive and rises to affect the epigastrium, leading to Pi; and there are cases where improper use of purgatives leads to internal deficiency and pathogenic invasion, resulting in Pi. All these are diseases caused by the evil of Earth (Spleen/Stomach).

Dongyuan stated: In Shanghan (Cold Damage) and miscellaneous diseases, excessive purgation leads to Pi Man, which belongs to blood/Yin injury. Purgation destroys Yin, and here "Yin" refers to the Yin of the Spleen and Stomach. Consequently, Qi in the chest sinks into the region of the Heart due to Yin deficiency, causing fullness and obstruction in the epigastrium. Treatment should regulate the Spleen and Stomach while incorporating Yin-nourishing herbs. If only Qi-regulating herbs are used, the fullness will worsen. This elucidates insights previously unexplored.

However, Pi differs in excess and deficiency: Excess Pi presents with ability to eat but constipation; bitter herbs like Huanglian (Coptis Rhizome), Zhishi (Immature Bitter Orange), and Houpo (Magnolia Bark) are used to drain. Deficiency Pi presents with inability to eat but free stool; sour herbs like Baishao (White Peony Root) and Chenpi (Aged Tangerine Peel) are used to astringe. With Dampness, limbs feel heavy and urine is scant; herbs like Cangzhu (Atractylodes Rhizome), Fuling (Poria), Banxia (Pinellia Tuber), Huashi (Talcum), and Zexie (Alisma Rhizome) are used to leach out dampness. With stagnation and indigestion, herbs like Fuxiong (Ligusticum Chuanxiong Rhizome), Houpo, Xiangfu (Cyperus Rhizome), Cangzhu, and Zhishi are used to open stagnation. For Pi due to Spleen/Stomach deficiency and poor transformation, Ganwen (sweet-warm) herbs like Renshen (Ginseng Root), Gancao (Licorice Root), Fuling, and Baizhu (Atractylodes Macrocephala Rhizome) are used to warm and tonify. For Cold Pi due to dietary overindulgence, Qingpi (Green Tangerine Peel), Zhishi, Houpo, Shanzha (Hawthorn Fruit), and Shenqu (Medicated Leaven) are used to digest and guide out food. For Phlegm-Blood forming nodules, Taoren (Peach Kernel), Honghua (Safflower), Xiangfu, and Dahuang (Rhubarb Root) are used. If the Right Guan pulse is wiry and slow, indicating hardness and fullness in the epigastrium due to Liver Wood overacting on Spleen Earth and stagnant Qi, Muxiang Shunqi Wan (Costus Root Qi-Circulating Pill) is indicated. For Pi following severe illness with unrecovered Yuan Qi (Original Qi), Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) with added Chenpi is used.

Li Shicai stated: The *Neijing* discusses swelling involving all five Zang and six Fu organs. Detailed examination reveals: *Mai Yao Jing Wei Lun* states, "Stomach pulse excess leads to distension." *Bing Xing Pian* states, "Stomach disease manifests as abdominal distension." *Ben Shen Pian* states, "Spleen excess leads to abdominal distension and difficult urination/defecation." *Ying Xiang Lun* states, "Turbid Qi remaining above generates distension." These four points describe Excess Distension. *Tai Yang Yang Ming Lun* states, "Irregular diet and lifestyle, entering the five Zang, causes fullness and blockage." *Shi Chuan Pian* states, "Deficiency in the collateral Sunqiong of Foot Taiyin leads to Drum Distension." These two points describe Deficiency Distension. *Jing Mai Pian* states, "Cold in the Stomach leads to fullness and distension." *Fang Yi Lun* states, "Organ cold generates fullness diseases." *Feng Lun* states, "Stomach wind with diaphragmatic cold and obstruction leads to distension upon exposure to cold." These three points describe Cold Distension. *Liu Yuan Zheng Ji Da Lun* and *Zhi Zhen Yao Da Lun* state that arrival of Taiyin causes edema, and during Earth Depression or Taiyin's initial Qi/victory-reversal, it is swelling due to Dampness excess. Some attribute it to Water Transport excess; some to Cold excess causing floating; some to Taiyang ruling heaven/victory-reversal or Shaoyang ruling heaven/victory-reversal; some to Heat excess causing swelling. These are Heat Distension due to Fire excess. Some attribute it to Jueyin ruling heaven/in泉 or Yangming reversal, representing Water Evil insulting Earth or Metal Qi counter-excess, causing swelling. Thus, the Five Movements and Six Qi also each have their own types of swelling.

However, the classics provide a general principle: "All dampness-induced swelling and fullness belong to the Spleen"; also, "The root is in the Kidney, the branch is in the Lung," referring to water accumulation. Also, "The Kidney is the gate of the Stomach; if the gate is not functional, water accumulates and follows its kind." Thus, although all meridians can present with swelling, none do not originate from the Spleen, Lung, and Kidney. The Spleen Earth manages transport and transformation; the Lung Metal manages Qi transformation; the Kidney Water manages the five fluids. All fluids transformed by the five Qi belong to the Kidney; all Qi transported by the five fluids belongs to the Lung; the transmission between these two organs, controlling Water generating Metal, belongs to the Spleen. Therefore, swelling does not exceed these three meridians.

However, Yin/Yang and Excess/Deficiency must be distinguished. Generally, Yang syndromes involve heat, and heat often indicates excess; Yin syndromes involve cold, and cold often indicates deficiency. Swelling starting internally then externally indicates excess; swelling starting externally then internally indicates deficiency. Yellow/red urine and constipation indicate excess; clear/white urine and diarrhea indicate deficiency. Slippery, rapid, and forceful pulses indicate excess; wiry, rapid, faint, and fine pulses indicate deficiency. Red complexion and coarse breathing indicate excess; sallow complexion and short voice indicate deficiency. All excess syndromes, whether from Six Evils invading externally or dietary injury internally, involve rapid Yang pathogens, often manifesting violently within days. Deficiency syndromes, whether from emotional labor, excessive alcohol/sex, accumulate gradually over months.

Treating excess is relatively easy; treating deficiency is consistently difficult. Deficiency Qi distension is due to Spleen deficiency failing to move Qi. Deficiency Water swelling is due to Earth deficiency failing to control Water. Although Water is controlled by the Spleen, it is ultimately governed by the Kidney. The Kidney is a Water organ but houses Original Yang. Decline of Mingmen Fire (Gate of Life Fire) means it cannot control internal Cold nor warm the Spleen Earth, so Yin does not follow Yang, and essence transforms into water. Thus, edema often belongs to Fire decline.

Danxi believed it was Damp-Heat, advocating nourishing Metal to control Water (protecting Spleen from thief evils) and nourishing Water to control Fire (allowing Lung Metal to clear and transform). While controlling Fire protects Metal, does one not worry about harming Earth? This is only suitable for Heat syndromes. For Yang deficiency, would this not worsen the condition?

Some, unaware of excess/deficiency, strictly adhere to "purgation cures distension." Though providing temporary relief, Yuan Qi further declines, and swelling returns shortly after, leading to untreatable conditions, which is lamentable.

For my approach: For excess, directly clear Yangming for quick results. For deficiency, warm and tonify Spleen/Stomach for gradual recovery. For mixed mild excess/deficiency, start with clearing/drainage, then tonify middle and regulate.

For superficial excess with root deficiency, purging is contraindicated, tonifying is ineffective, making it highly dangerous. Regarding nomenclature: Gu Zhang (Drum Distension) has an empty center, tight skin, mostly Qi-related; Gu Zhang (Insect Distension) has solid contents, enlarged abdomen, either parasites or Blood stasis. In Gynecology: Qi aspect involves upper body firmness, starting with water swelling then amenorrhea; Blood aspect involves blood binding at the uterus, starting with amenorrhea then water swelling. Regarding treatment: Regulate Lung vs. Regulate Spleen. Wheezing first then distension treats the Lung; distension first then wheezing treats the Spleen. This is the general overview.

Abdominal distension with body heat: death. Abdominal distension with chills/fever resembling malaria: death. Large abdominal distension, cold extremities, emaciation, severe diarrhea: adverse prognosis. Abdominal distension with bloody stool, large pulse intermittently absent: death. Black/swollen lips: Liver injury. Flat clavicular fossa: Heart injury. Protruding umbilicus: Spleen injury. Flat soles: Kidney injury. Flat back: Lung injury. These five injuries lead to death. Loose stools with unresolved edema: death. Abdominal distension with visible veins after diarrhea: death. Scrotal/penile swelling: death. Edema starting in abdomen then spreading to limbs: treatable. Edema starting in limbs then returning to abdomen: death.

Zhao Yangkui stated: Zhong Man (Middle Fullness) is similar to Drum Distension and edema, but differs as Zhong Man is hollow like a drum, being false fullness rather than true fullness. It is generally caused by Spleen/Kidney dual deficiency. Physicians only know to drain water but not benefit the Stomach, so it recurs uncontrollably.

If truly knowing it is Water-Damp Qi lodging in the Middle Jiao, invading skin, shining like crystal, rebounding instantly upon pressure, the *Neijing* methods of removing accumulation, opening pores (sweating), and cleansing the bladder (diuresis), using formulas like Zhouche Wan or Yugong San, can resolve it in one dose. What error is there?

However, for chronic/severe illness post-phase, post-Shanghan/malaria/dysentery, post-partum women, post-smallpox children, or those with inherent weak Yuan Qi, applying these methods exhausts Spleen Qi irreparably. Thus, treating swelling prioritizes tonifying Spleen Earth.

If accompanied by wheezing/fullness, adding pure tonification may worsen distension; adding Qi-moving and diuretic herbs is better. But if Lung Qi is already deficient, moving Qi is contraindicated; if Kidney Water is already depleted, draining Water is contraindicated. Pure tonics may initially feel uncomfortable, but as药效 takes effect, order is restored.

Zhang Zhongjing's Jin Gui Shen Qi Wan (Kidney Qi Pill from the Golden Cabinet) tonifies without stagnation and unblocks without leakage, a divine formula for swelling. Zhong Man originates from deficient Fire Qi in the Kidney failing to move Water. This formula uses eight ingredients to tonify Kidney Fire, empowering the Triple Burner to move Water. Fire generates Earth; solid Earth controls Water. Achyrhantes Root (Niuxi) and Plantago Seed (Cheqianzi) are particularly apt. Cheqianzi promotes urination without depleting Qi, functioning like Fuling, strengthening Yin and benefiting essence; Niuxi treats elderly incontinence, supplements the middle, reconnects severances, strengthens Yang and benefits essence. This formula is highly effective, hence detailed here.

The previous discussion addressed Spleen/Kidney dual deficiency. For pure Spleen deficiency, using Renshen and Sijunzi Tang (Four Gentlemen Decoction) as main, one must also use Shenqi Wan to tonify Mingmen Fire, as Spleen Earth cannot generate without Mingmen, following the principle of tonifying the mother in deficiency.

Yu Jiayan stated: Generalized swelling of face/body is easier to treat; isolated abdominal distension/swelling is difficult. Generalized swelling shows symptoms in various organs, so draining Liver/Lung/Bladder/Intestines may occasionally work. Isolated abdominal distension blocks the central pivot, preventing clear rising and turbid descending, causing stubborn aggregation due to Spleen Qi decline. Dare one casually use Spleen-draining herbs? Some say swelling is great fullness/excess requiring purging; should post-illness or post-partum swelling be purged?

People overly trust Liu Wansu and Zhang Congzheng, using sweating/vomiting/purging to eradicate diseases, ignoring frail Yuan Qi. Purging drugs may reduce swelling initially, but later become ineffective, then resistant as iron. Laypeople wonder at the severity of the pathogen; experts see it as damage by harsh drugs, turning the body's own Qi against itself, like driving good people to banditry. Only regulating the Spleen works. Thus, cultivation (tonifying Yuan Qi) is key. The three methods imply purging within tonification, leaving no room for improvement.

Xu Donggao stated: Classics say organ cold generates fullness, stomach cold causes distension, Taiyin arrival causes middle fullness. Generally, Spleen Dampness excess without Yang cannot transform, like soil becoming mud after rain. Only warm sun and breeze remove dampness and generate Yang for growth. Treatment requires acrid-hot herbs. For Damp-Heat with dietary excess and solid Spleen/Stomach, purging is possible. For Shanghan entering interior with hard abdomen and constipation, Chengqi Decoctions purge. For Spleen deficiency as main cause, add slight acrid-hot herbs to move stagnant Qi, strengthening Spleen Earth for transport, fulfilling the classic "treating obstruction with obstruction" principle.

Zhang Jingyue stated: Swelling is fully described by "Qi" and "Water"; distinguishing excess/deficiency covers all aspects. Qi-biased disease treats Qi primarily; Water-biased disease treats Water primarily. Since Qi and Water are related, treating Water requires managing Qi (tonifying Qi transforms Water); treating Qi requires managing Water (moving Water moves Qi).

Qi-biased disease arises from Qi stagnation, Qi/Blood rebellion, dietary rebellion, Cold/Heat/Damp/Wind rebellion, or Qi deficiency failing to transform. Any failure in regulation causes Qi-biased distension. Excess/Deficiency treatments are opposite as ice and charcoal; careful distinction is needed for adaptive therapy.

Water-biased disease involves Yin exceeding Yang, causing generalized, shiny, slow-rising swelling from below with distinct boundaries. To distinguish Water/Qi, differentiate Yin/Yang. Qi-biased includes both Yang/Yin syndromes; Water-biased is exclusively Yin syndrome. Strong Yang transforms Qi, turning water into essence; weak Yang fails to transform Qi, turning essence into water. Water is blood/Qi in the body; whether pathogenic or normal depends on transformation. Failure to transform water due to Qi deficiency implies Yin lacking Yang.

Water is governed by Kidney, Qi by Lung. Clear water below, exhausted Qi above leads to lower swelling/fullness and upper wheezing, affecting root and branch, critically urgent. One must quickly save the root. Treating as excess wheezing and draining the Lung will inevitably fail.