灵枢胀论云。其脉大坚以涩者。胀也。水胀云。肤胀者。寒气客于皮肤之间。 然不坚。
腹大。身尽肿。皮浓。按其腹。 而不起。腹色不变。此其候也。腹胀身皆大。大与肤胀等。色
苍黄。腹筋起。此其候也。夫胀者。皆在于脏腑之外。排脏腑而郭胸胁。胀皮肤。故命曰胀。
五脏六腑。各有畔界。其病各有形状。营气循脉。卫气逆为脉胀。卫气并脉循分为肤胀。三里而
泻。近者一下。远者三下。无问虚实。工在疾泻。夫心胀者。烦心短气。卧不安。肺胀者。虚满
而喘咳。肝胀者。胁下满而痛引小腹。脾胀者。善哕。四肢烦 。体重不能胜衣。卧不安。肾胀
者。腹满引背。央央然腰髀痛。胃胀者。腹满胃脘痛。鼻闻焦臭。妨于食。大便难。大肠胀者。
肠鸣而痛濯濯。冬日重感于寒则飧泄不化。小肠胀者。少腹 胀。引腰而痛。膀胱胀者。小腹满
而气癃。三焦胀者。气满于皮肤中。轻轻然而不坚。胆胀者。胁下痛胀。口中苦。善太息。凡此
诸胀。其道在一。明知逆顺。针数不失。补虚泻实。神归其室。久塞其空。谓之良工。
按诸胀统言无问虚实。工在疾泻。次云补虚泻实。神归其室。二说相左。其义何居。原夫诸
胀之因。良由卫气僭逆。故宜疾泻以下其气。气下则胀消矣。卫为水谷之悍气。常行脉外。不能
入于脉。今以僭逆过甚。乃并居营分而入于脉。则为脉胀。卫气并脉。循分肉间。则为肤胀。故
昭揭于脏腑诸胀之前。且言凡此诸胀。其道在一。故其治。总不
越针三里以疾泻之也。明知逆顺者。知胃逆之甚与不甚也。针数不失者。随近远之一下三下也。
素问云。有病心腹满。旦食则不能暮食。名为鼓胀。治之以鸡矢醴。一剂知。二剂已。其有
时复发者。何也。此饮食不节。故时有病气聚于腹也。胃脉实则胀。脾气实则腹胀。泾溲不利。
浊气在上。则生 胀。中满者。泻之于内。下之则胀已。（论实证。）饮食起居失节。入五脏则腹
满闭塞。（论虚证。）腹满 胀。支鬲 胁。下厥上冒。过在足太阴阳明。
太阴之厥。则腹满 胀。后不利。不饮食。食则呕。不得卧。胃中寒则胀满。脏寒生满病。
胃风鬲塞不通。腹善满。失衣则 胀。（论寒证。）热胜则肿。诸胀腹大。皆属于热。诸病有声。
鼓之如鼓。皆属于热。（论热证。）
丹溪曰。单腹胀。乃脾虚之甚。必用大剂参、术。佐陈皮、茯苓、苍术、浓朴之类。或曰。
腹已胀矣。反用参、术何耶。曰。乃内经塞因塞用之法。正气虚而不能营运。浊气滞塞于中。今
扶助正气。使之自然健运。邪无所留。而胀消矣。
盛启东云。凡下气虚乏。中焦气壅。欲散满则恐虚其下。欲补下则满甚于中。况少服则资壅。
多服则宣通。当以启峻汤峻补其下。疏启其中。故气既得峻补。则上行而启其中。中焦营运之令。
使之疏通。则中满自消。下虚自实。乃塞因塞用也。补脾药必佐姜制浓朴。以其温能益气。辛能
宽胀也。
张介宾曰。按五脏六腑。虽皆有胀。然无不本于脾肺肾三脏。脾属土主运化。肺属金主五气。
肾属水主五液。故五气所化之液。咸本于肾。五液所行之气。咸本于肺。转输于金水二家。以制
水而生金者。咸本于脾。是以肿胀之病。无不由此三者。但阴阳虚实。治法各殊耳。大抵阳证必
热。热者多实。阴证必寒。寒者多虚。先胀于内后胀于外者多实。先胀于外后胀于内者多虚。小
便黄赤大便秘结者多实。小水清白大便稀溏者多虚。脉滑数有力者多实。脉细微无
力者多虚。形色红黄气息粗大者多实。容颜枯槁音声喘促者多虚。胀起于经年累月。由食少多泻
而致者。虚也。当补中为主。胀起于旬日之间。忽因七情六气而成者。实也。当疏利为主。朝宽
暮急。血虚。暮宽朝急。气虚。朝暮皆急。气血俱虚。余于胀满。察其实者。直清阳明。反掌收
功。若涉虚者。温补脾肾。渐次康复。其有不大实亦不大虚者。先以清利见功。继以补中调摄。
又有标实而本虚。泻之不可。补之无功。极为危险。在病名有鼓胀与蛊胀之殊。鼓胀者。中空无
物。腹皮绷急。多属于气也。蛊胀者。中实有物。腹形充大。非蛊即血也。在治法有理脾理肺之
殊。先喘而后胀者治在肺。先胀而后喘者治在脾。然胀则必喘。喘则必胀。二者相因也。脾不运
而浊火上炎。肺不得清则喘。肺气被郁。喘而不得下降则胀。治分新久虚实。初起脉实大。二陈、
苏子、葶苈泄之。二便通畅。喘胀俱减。其功易易也。
喻嘉言曰。从来肿胀。遍身头面俱肿。尚易治。若只单单腹胀。则难治。遍身俱肿胀者。
五脏六腑各有见证。故泻肝泻脾。泻膀胱大小肠。间有取效之时。单单腹胀久窒。而清者不升。
浊者不降。互相结聚。牢不可破。实因脾胃之衰微所致。而泻脾之药。安敢漫用乎。且肿胀之可
泻者。但可施之于壮盛。及田野之流。岂膏粱老弱所能受。设为肿病。为大满大实。必从乎泻。
则久病后肿与产后肿。将亦泻之耶。后人不察。概从攻泻。其始非不遽消。其后攻之不消矣。其
后再攻之如铁石矣。不知者见之。方谓何物邪气。若此之盛。自明者观之。不过为猛药所攻。即
此身之元气。转与身为难。有如驱良民为盗贼之比。明乎此。则有培养一法。补益元气是也。则
有招纳一法。宣布五阳是也。则有解散一法。开鬼门洁净府是也。三法是不言泻。而泻在其中矣。
夫胀皆脾胃之气虚弱。不能运化精微。致水谷聚而不散。故成胀满。饮食不节。不能调养。
则消气下降。浊气填满。胸
腹湿热相蒸。遂成此证。小便短涩。其病胶固。难以治疗。用半补半泻之法。健脾顺水宽中为主。
不可过用猛烈。反伤脾胃。病再复胀。不可治也。宜分消汤、分消丸。随寒热虚实加减治之。胀
满得之未久。或胀或消。腹皮稍软。不泄不喘。随治随愈。若脐心凸起。利后胀复急。久病羸乏。
喘急不得安者。名曰脾肾俱败。无有愈期。至咳嗽失音。青筋横绊腹上。及爪甲青。卒肿。头面
苍黑。呕吐头重。上喘下泄者。皆不治。蓄血成胀。腹上青紫筋见。或手足有红缕赤痕。小水利。
大便黑。金匮下瘀血汤。不应。抵当丸去水蛭。加樗鸡作丸。空腹日进梧子大三丸。血下止后服。
轻则散血消胀汤。肥白人腹胀。多是湿痰。二陈、六君、平胃、五苓参酌。瘦人腹满是热。用炒
川连、浓朴、白芍、香附。妇人血肿。烦躁漱水不欲咽。神昏善忘。小便多。大便黑。散血消胀
汤。虚人血蛊。琥珀人参丸。或因产崩血虚。或瘀血不散。亦成肿胀。其人必脉涩面黑。不可作
水湿治之。腹胀便血。其脉大。时绝者死。腹大胀。四末清。形脱泄甚。上气喘息者死。腹胀误
用攻药暂宽。复胀者皆不治。先胀于内后胀于外。小便赤涩大便秘结。气色红亮声音高爽者。实
也。木香、沉香、砂仁、枳实、浓朴、苍术、大腹皮。以治脾也。桑皮、葶苈、蔻壳、苏子、桔
梗枳、橘。以治肺也。木通、防己、茯苓、车前、泽泻、猪苓。以利小便也。麻黄、防风、羌活、
葛根。以发汗也。如气壮能食。年少新病者。大黄、芒硝皆可应用。先胀于外后甚于内。小便淡
黄大便不实。气色枯白语言低怯者。虚也。参、苓、白术、陈皮、甘草。以补脾也。人参、黄 、
桔梗、苡仁。以补肺也。沉香、枳壳、木香。以理气也。桂、苓、泽泻、猪苓、白术以利小便。
升麻、柴胡以开鬼门。如虚甚多寒。桂、附、姜、萸。俱宜取用。金匮肾气丸。益火消阴。脉沉
者。诚为切要之药。然必小腹胀极。而后旁及于上者为宜。试观冰盘冷气。必从下渗。冰坛胀满。
则从上而裂矣。小建中汤。于土中泻木。必脉浮而弦强者。乃为合剂。亦须胁下胀急而后旁及于中者。方
可投之。盖风木之邪起于东方。土败木贼。然后中央受困耳。胀而本虚证实。攻补两难者。丹方。
用陈香橼去穣。入溺白 过。水肿用通草汤。气肿用砂仁汤。血肿浓煎土牛膝汤。虚极用人参
汤。每日空腹服二钱。此方能散积滞而不大伤元气也。胀而虚实莫辨。宜用火酒热饮。觉辣喉者。
属实热。当进苦寒燥湿攻坚之剂。若饮热火酒如啜冷水者。属虚寒。参、术、姜、桂须大剂频投。
方可救援。金蟾散。治一切实胀。用大虾蟆一只。以砂仁堆满腹中。盐泥固济。 令红透。烟尽
去泥研末、陈酒下三钱。并治小儿疳积腹胀。米汤下一钱。肿胀服药。最忌盐、酱、糟物。愈久
欲食。须用开盐酱法。用大鳢鱼一个破开。入五苓散。放瓦上对合。上下俱用火炙黄焦存性。为
末。加麝香少许。空心姜、枣汤服之。水肿亦然。惟火胀不忌盐、酱。如面色枯槁。肢体消瘦。
单腹胀急而块垒不平者。皆属火胀。此非水肿。无虑助肾水之邪也。若脉弦细涩。虽能饮食。终
亦必亡。火肿误服金匮肾气等药。急投连、柏、金铃、白芍之类。仍用桂、附少许。为热因热用
之向导。庶可挽回。若喘泻肢枯。脉无胃气者不救。
〔诊〕脉弦为肝克脾胃。脉实则胀。此属实。关上脉虚即胀满。此属虚。洪数为热胀。迟弱为
阴寒。浮为虚满。紧为中实。虚数者不可治。实大浮洪者易治。沉微细小者难痊。盛而紧大。坚
以涩。迟而滑。皆胀满多热。脉浮大。腹胀为逆。发热不休。或寒热如疟。皆不可治。腹大胀。
四肢冷。泄泻。不及一时而死。腹胀便血。脉大时绝为逆。胀而上则喘咳。下则泄泻。脉浮大沉
细。皆不治。
项彦章治一女。腹胀如鼓。四体骨立。众医或以为妊为蛊为瘵。诊其脉。告曰。此气薄血室。
其父曰。服芎、归辈积岁月。非血药乎。曰。失于顺气也。夫气道也。血水也。气一息不运。则
血一息不行。经曰。气血同出而异名。故治血必先
顺气。俾经隧得通。而后血可行。乃以苏合香丸投之。三日而腰作痛。曰。血欲行矣。急以芒硝、
大黄峻逐之。下污血累累如瓜者数十枚而愈。缘其六脉弦滑而数。弦为气结。滑为血聚。实邪也。
故行气而血大下。又一女病同而诊异。项曰。此不治。法当数月死。向者脉滑为实邪。今脉虚。
元气夺矣。又一女病亦同。而六脉俱弦。项曰。真藏脉见。法当逾月死。后皆如之。
喻嘉言治一血蛊。服药百日后。大腹全消。左胁始露病根一条。如小枕状。以法激之。呕出
黑污血斗许。余从大便泄去始消。每思蛊胀不论气血水痰。总必自开一宇。如寇贼蟠据。必根据山
傍险。方可久聚。内经论五岁之积。皆有定所。何独于六腑之积久为患。如鼓胀等类者。遂谓漫
无根柢区界乎。
石顽治文学顾若雨。鼓胀喘满。昼夜不得寝食者二十余日。吾吴名医。用大黄三下不除。技
穷辞去。更一医先与发散。次用消克破气二十余剂。少腹至心下。遂坚满如石。腰胁与 中。皆
疼痛如折。亦无措指而退。彼戚王墨公邀余往诊。脉得弦大而革。按之渐小。举指复大。询其二
便。则大便八九日不通。小便虽少而清白如常。此因克削太过。中气受伤。浊阴乘虚。僭据清阳
之位而然。以其浊气上逆。不便行益气之剂。先与生料六味丸加肉桂三钱。
沉香三分。下黑锡丹二钱。导其浊阴。是夜即胀减六七。胸中觉饥。侵晨便进糜粥。但腰胯疼软。
如失两肾之状。再剂胸腹全宽。少腹反觉微硬。不时攻动。此大便欲行。津液耗竭。不能即去故
也。诊其脉。仅存一丝。改用独参汤加当归、枳壳。大便略去结块。腰痛稍可。少腹遂和。又与
六味地黄。仍加肉桂、沉香。调理而安。
The *Ling Shu: Treatise on Distension* states: When the pulse is large, firm, and choppy, it indicates distension. The *Ling Shu: Water Distension* states: In skin distension (*Fu Zhang*), cold qi lodges between the skin and flesh. Percussion of the abdomen produces a hollow sound but feels not firm; the abdomen is enlarged, the whole body is swollen, the skin is thickened, and pressing the abdomen leaves an indentation that does not rise immediately. The abdominal color remains unchanged. This is its clinical manifestation. In abdominal distension with generalized swelling, the degree of swelling is equal to that of skin distension; the complexion is dark yellow, and the abdominal collateral vessels are exposed. This is its clinical manifestation. Generally, distension occurs outside the zang-fu organs, pushing against them, expanding the chest and hypochondrium, and distending the skin; hence it is named "distension."
The five zang and six fu organs each have their boundaries, and their diseases present with distinct shapes. Ying (nutritive) qi circulates within the vessels; when Wei (defensive) qi rebels, it causes vessel distension (*Mai Zhang*). When Wei qi merges with the vessels and circulates along the muscle intervals, it causes skin distension (*Fu Zhang*). Treatment involves reducing the ST36 (Zusanli) acupoint. For lesions near the surface, reduce once; for those distant, reduce three times. Regardless of deficiency or excess, the key lies in rapid reduction.
Symptoms of Heart Distension include mental restlessness, shortness of breath, and restless sleep. Symptoms of Lung Distension include a sensation of empty fullness in the chest, wheezing, and coughing. Symptoms of Liver Distension include fullness and pain under the hypochondrium radiating to the lower abdomen. Symptoms of Spleen Distension include frequent hiccups, heaviness and irritability in the four limbs, a body so heavy that one cannot bear the weight of clothes, and restless sleep. Symptoms of Kidney Distension include abdominal fullness radiating to the back, and aching pain in the waist and thighs. Symptoms of Stomach Distension include abdominal fullness, epigastric pain, olfactory hallucinations of a burnt smell, difficulty eating, and constipation. Symptoms of Large Intestine Distension include borborygmus and gurgling pain; if re-exposed to cold in winter, it leads to undigested diarrhea. Symptoms of Small Intestine Distension include lower abdominal distension radiating to the waist with pain. Symptoms of Bladder Distension include lower abdominal fullness and urinary retention. Symptoms of Sanjiao Distension include qi filling the subcutaneous tissue, feeling light upon pressure but not firm. Symptoms of Gallbladder Distension include pain and distension under the hypochondrium, bitter taste in the mouth, and frequent sighing.
For all these types of distension, the principle lies in one aspect. By clearly understanding the direction of qi flow (rebellious vs. smooth), applying acupuncture correctly without error, tonifying deficiency and reducing excess, allowing the Shen (spirit) to return to its residence, and retaining the needle to fill emptiness, one is called a skilled physician.
The text previously stated that for all distensions, regardless of deficiency or excess, the key is rapid reduction; subsequently, it mentioned tonifying deficiency and reducing excess, allowing the Shen to return. These two statements seem contradictory. What is the rationale? Investigating the causes of various distensions, they largely stem from the rebellion and overstepping of Wei qi. Therefore, rapid reduction is suitable to calm the qi; once the qi descends, the distension subsides. Wei qi is the fierce qi derived from food and water, usually circulating outside the vessels and unable to enter them. Now, due to excessive rebellion, it merges with Ying qi and enters the vessels, causing vessel distension; when Wei qi merges with the vessels and circulates along the muscle intervals, it causes skin distension. Thus, before discussing the distensions of individual zang-fu organs, this point is emphasized, stating that the principle for all these distensions is one. Therefore, treatment generally involves puncturing ST36 (Zusanli) for rapid reduction. "Clearly understanding the direction" means knowing the severity of Stomach qi rebellion. "Not missing the number of needles" means determining whether to reduce once or three times based on the distance of the lesion.
The *Su Wen* states: There is a disease characterized by abdominal and epigastric fullness, where the patient can eat in the morning but not in the evening, named Drum Distension (*Gu Zhang*). It is treated with Ji Shi Li (Chicken Excrement Fermented Liquid); one dose brings improvement, two doses bring cure. If it recurs occasionally, why? This is due to irregular diet, causing pathogenic qi to gather in the abdomen. Excess in the Stomach meridian causes distension; excess in the Spleen qi causes abdominal distension; obstruction of urination and defecation, with turbid qi rising to the upper jiao, generates distension. For middle-jiao fullness, purging from within resolves the distension after evacuation. (This discusses excess patterns.) Irregular diet and lifestyle allow pathogens to enter the five zang organs, causing abdominal fullness and obstruction. (This discusses deficiency patterns.) Abdominal fullness and distension supporting the diaphragm and hypochondrium, with cold in the lower extremities and confusion in the upper body, indicates pathology in the Foot Taiyin (Spleen) and Foot Yangming (Stomach) meridians. Taiyin meridian reversal causes abdominal fullness and distension, difficult defecation, anorexia, vomiting after eating, and inability to lie down. Cold in the Stomach causes distension; cold in the zang organs generates fullness diseases. Wind invading the Stomach causes diaphragmatic obstruction and easy abdominal fullness, worsening upon exposure to cold. (This discusses cold patterns.) Excessive heat causes swelling; all distensions with a large abdomen belong to heat. All diseases with sounds, where percussion of the abdomen sounds like a drum, belong to heat. (This discusses heat patterns.)
Zhu Danxi stated: Single abdominal distension is extreme Spleen deficiency, requiring large doses of Ren Shen (Ginseng) and Bai Zhu (Atractylodes Macrocephala), assisted by Chen Pi (Tangerine Peel), Fu Ling (Poria), Cang Zhu (Atractylodes Lancea), and Hou Po (Magnolia Bark). Someone asked: Since the abdomen is already distended, why use Ren Shen and Bai Zhu? He replied: This is the method of "treating blockage with blockage" (*Se Yin Se Yong*) from the *Nei Jing*. When Zheng qi (healthy qi) is deficient and cannot circulate, Zhuo qi (turbid qi) stagnates in the middle. By supporting Zheng qi, natural transportation is restored, leaving no room for pathogens, and the distension subsides.
Sheng Qidong stated: In cases of deficiency in the lower jiao qi and stagnation in the middle jiao, dispersing fullness may further deplete the lower, while tonifying the lower may worsen the middle. Small doses nourish stagnation, while large doses promote circulation. One should use Qi Jun Tang to strongly tonify the lower and unblock the middle. Once the lower is strongly tonified, qi ascends to open the middle, restoring middle-jiao transportation and resolving fullness, thereby solidifying the lower deficiency. This is also "treating blockage with blockage." Spleen-tonifying herbs must be assisted by Ginger-processed Hou Po, as Ginger's warmth benefits qi and Hou Po's pungency widens the middle.
Zhang Jiebin stated: Although all zang-fu organs can have distension, they all originate from the Spleen, Lung, and Kidney. The Spleen (Earth) governs transportation and transformation; the Lung (Metal) governs the five qi; the Kidney (Water) governs the five fluids. Thus, fluids transformed from the five qi root in the Kidney; qi circulated by the five fluids roots in the Lung. Transportation relies on Metal and Water, while controlling Water to generate Metal roots in the Spleen. Therefore, swelling and distension diseases all stem from these three. However, treatments differ based on yin/yang and deficiency/excess. Generally, Yang patterns involve heat and are often excess; Yin patterns involve cold and are often deficiency. Distension starting internally then externally is often excess; starting externally then internally is often deficiency. Yellow/red urine and constipation indicate excess; clear/white urine and loose stools indicate deficiency. Slippery, rapid, forceful pulses indicate excess; fine, minute, weak pulses indicate deficiency. Red/yellow complexion and coarse breathing indicate excess; withered complexion and panting voice indicate deficiency. Distension developing over years due to poor appetite and diarrhea is deficiency, requiring central tonification. Distension developing suddenly over days due to emotional or climatic factors is excess, requiring dispersion and drainage. Ease in the morning and urgency in the evening indicates Blood deficiency; ease in the evening and urgency in the morning indicates Qi deficiency; urgency day and night indicates combined Qi and Blood deficiency. In my experience with distension, for excess patterns, directly clearing the Yangming meridian yields quick results. For deficiency patterns, warming and tonifying the Spleen and Kidney leads to gradual recovery. Cases with superficial excess and root deficiency are dangerous, as neither purging nor tonifying works well.
Regarding nomenclature, there is a distinction between Drum Distension (*Gu Zhang*) and Gu Distension (*Gu Zhang* - worm/blood). Drum Distension is hollow with tight skin, mostly related to Qi. Gu Distension has internal masses and a large abdomen, related to worms or Blood. Regarding treatment, there is a distinction between regulating Spleen and Lung. Wheezing preceding distension indicates Lung pathology; distension preceding wheezing indicates Spleen pathology. However, distension always accompanies wheezing, and wheezing always accompanies distension; they are interdependent. Spleen failure leads to turbid fire flaming upward; Lung failure to clear leads to wheezing; Lung Qi depression prevents descent, leading to distension. Treatment distinguishes new/old and deficiency/excess. Early stage with strong, large pulses: use Er Chen Tang, Su Zi, Ting Li Zi to drain; once bowels and urine are free, wheezing and distension decrease easily.
Yu Jiayan stated: Previously, swelling involving the whole body and face was easier to treat. Single abdominal distension is difficult. Generalized swelling allows targeting specific zang-fu (Liver, Spleen, Bladder, Intestines) for occasional success. Long-standing single abdominal distension involves stuck clear qi failing to ascend and turbid qi failing to descend, forming unbreakable knots, truly due to Spleen-Stomach decline. How dare one casually use Spleen-purging drugs? Purging for swelling is only suitable for robust individuals or laborers, not for the pampered elderly and weak. If one assumes all large-fullness-excess cases require purging, would post-illness or postpartum edema also be purged? Later generations, unaware, universally used attacking purgatives. Initially, swelling might vanish quickly, but later becomes resistant to purging, eventually becoming hard as iron. Laypeople see this and think the pathogen is incredibly strong. Experts see it as damage to Yuan qi by harsh drugs, akin to driving good citizens into banditry. Understanding this, there is the method of cultivation (tonifying Yuan qi), the method of recruitment (distributing Yang qi), and the method of dispersion (opening the pores/sweating, cleansing the bladder/diuresis). These three methods imply purging without explicitly stating it.
Distension arises from Spleen-Stomach Qi weakness, failing to transform essence, causing food and water to accumulate. Irregular diet fails to nourish, causing clear qi to sink and turbid qi to fill, steaming damp-heat in the chest and abdomen. Short, scanty urine makes the condition stubborn and hard to treat. Use half-tonifying, half-draining methods, focusing on strengthening the Spleen, smoothing water, and widening the middle. Do not overuse harsh drugs to avoid damaging the Spleen-Stomach and causing recurrent distension, which becomes incurable. Use Fen Xiao Tang or Fen Xiao Wan, modified for cold/heat and deficiency/excess. Recent distension with soft abdomen, no diarrhea/wheezing, heals quickly. Umbilical protrusion, recurrence after purging, chronic emaciation, and severe wheezing indicate Spleen-Kidney failure, with no hope of cure. Cough, aphonia, abdominal varices, blue nails, sudden swelling, black face, vomiting, head heaviness, upper wheezing/lower diarrhea are all untreatable. Blood stasis causing distension shows purple veins on the abdomen or red streaks on limbs, normal urination, black stool. Use Xia Yu Xue Tang from *Jin Gui Yao Lue*; if ineffective, use Di Dang Wan removing Shui Zhi (Leech), adding Chu Ji (Stick Insect) as pills, three pill-sized doses daily on an empty stomach until blood passes, then stop. Mild cases use San Xiao Xiao Zhang Tang. Fat people with abdominal distension often have damp-phlegm; consider Er Chen Tang, Liu Jun Zi Tang, Ping Wei San, Wu Ling San. Thin people with abdominal fullness often have heat; use Fried Chuan Lian Zi (Coptis), Hou Po, Bai Shao, Xiang Fu. Women with blood swelling, irritability, desire to rinse mouth but not swallow, confusion, amnesia, polyuria, black stool: use San Xiao Xiao Zhang Tang. Deficient persons with blood gu: use Hu Po Ren Shen Wan. Postpartum hemorrhage deficiency or unresolved stasis can also cause swelling, presenting with choppy pulse and black face; do not treat as water-dampness. Abdominal distension with bloody stool, large pulse with intermittent cessation: death. Large abdomen, cold extremities, wasting, severe diarrhea, upper qi wheezing: death. Abdominal distension temporarily relieved by mistaken purging then recurring: untreatable.
Distension starting internally then externally, with red/dark urine, constipation, bright red complexion, and loud voice: Excess. Use Mu Xiang, Chen Xiang, Sha Ren, Zhi Shi, Hou Po, Cang Zhu, Da Fu Pi to regulate Spleen; Sang Bai Pi, Ting Li Zi, Dou Kou Ke, Su Zi, Jie Geng, Zhi Ke, Ju Pi to regulate Lung; Mu Tong, Fang Ji, Fu Ling, Che Qian Zi, Ze Xie, Zhu Ling to promote urination; Ma Huang, Fang Feng, Qiang Huo, Ge Gen to induce sweating. For robust, young, new-onset cases, Da Huang and Mang Xiao are applicable. Distension starting externally then worsening internally, with pale yellow urine, loose stools, withered white complexion, and quiet voice: Deficiency. Use Ren Shen, Fu Ling, Bai Zhu, Chen Pi, Gan Cao to tonify Spleen; Ren Shen, Huang Qi, Jie Geng, Yi Yi Ren to tonify Lung; Chen Xiang, Zhi Ke, Mu Xiang to regulate Qi; Gui Zhi, Fu Ling, Ze Xie, Zhu Ling, Bai Zhu to promote urination; Sheng Ma, Chai Hu to open the pores. For severe deficiency with cold, Gui Zhi, Fu Zi, Gan Jiang, Shan Zhu Yu are suitable. Jin Gui Shen Qi Wan, benefiting fire to eliminate yin, is crucial for deep pulses, especially when lower abdominal distension spreads upward. Like cold penetrating ice from below, or an ice jar bursting from above. Xiao Jian Zhong Tang, draining Wood from Earth, suits floating, wiry-strong pulses, especially when hypochondriac distension spreads centrally. Wind-Wood evil originates East; Earth failure allows Wood to invade, confining the Center.
For distension with root deficiency and superficial excess, where attack and tonification are both difficult: Use a folk formula. Take aged Xiang Yuan (Citron), remove pulp, insert Niao Bai (Urine Sediment), calcine until red and smokeless, grind to powder, take 3 qian with aged wine. For edema: Tong Cao Tang; for Qi distension: Sha Ren Tang; for Blood distension: concentrated Tu Niu Xi Tang; for extreme deficiency: Ren Shen Tang. Take 2 qian daily on an empty stomach. This formula dissipates accumulation without severely damaging Yuan qi.
When deficiency and excess are indistinguishable: Drink hot liquor. If it burns the throat, it is excess-heat; use bitter-cold drying/hard-resolving agents. If it tastes like cold water, it is deficiency-cold; use large doses of Ren Shen, Bai Zhu, Gan Jiang, Gui Zhi frequently for rescue. Jin Chan San treats all real distensions. Take one large toad, stuff with Sha Ren, seal with salt mud, roast until red and smoke-free, remove mud, grind to powder, take 3 qian with aged wine. Also treats pediatric malnutrition distension: 1 qian with rice soup.
During medication for swelling/distension, salt, soy sauce, and fermented foods are strictly forbidden. For long-term cravings, use a method to open tolerance: Take one snakehead fish, split it, add Wu Ling San, place on tile, cover with another tile, roast until charred but preserved, grind to powder, add a little She Xiang (Musk), take on an empty stomach with Ginger-Jujube decoction. Applies to edema too. Only Fire Distension does not forbid salt/soy sauce. Withered complexion, emaciation, single abdominal distension with lumps: Fire Distension. Not edema, so worry not about aiding Kidney Water evil. If pulse is wiry/fine/choppy, even with good appetite, death is inevitable. If Fire Distension is mistakenly treated with Jin Gui Shen Qi Wan, urgently use Huang Lian, Huang Bo, Jin Ling Zi, Bai Shao, with a small amount of Gui Zhi/Fu Zi as guides for "treating heat with heat," to potentially reverse the condition. If wheezing, diarrhea, withered limbs, and pulse lack Stomach Qi: incurable.
[Diagnosis] Wiry pulse indicates Liver overcoming Spleen-Stomach; excess pulse with distension indicates excess. Deficient pulse at Guan position with distension indicates deficiency. Surging-rapid pulse indicates Heat Distension; slow-weak pulse indicates Yin-Cold. Floating pulse indicates empty fullness; tight pulse indicates interior excess. Weak-rapid pulse is untreatable; strong-large-floating-surge pulse is easy to treat. Deep-micro-small pulse is difficult to cure. Strong-tight-large, firm-choppy, slow-slippery pulses all indicate distension with much heat. Floating-large pulse with abdominal distension is adverse. Unceasing fever, or chills/fever like malaria: untreatable. Large abdomen, cold limbs, diarrhea: death within an hour. Abdominal distension with bloody stool, large pulse with intermittent cessation: adverse. Distension with upper wheezing/cough and lower diarrhea, floating-large/deep-small pulse: untreatable.
Xiang Yanzhang treated a woman with drum-like abdominal distension and emaciated limbs. Physicians suspected pregnancy, gu-distension, or consumption. His pulse diagnosis revealed Qi thinning the Blood Chamber. Her father objected, noting years of Chuan Xiong and Dang Gui (Blood herbs). Xiang replied: Failure to smooth Qi. Qi is the pathway; Blood/Water are the content. If Qi stops for a breath, Blood stops for a breath. *Nei Jing* says: Qi and Blood emerge from the same source but have different names. Thus, treating Blood requires first smoothing Qi to open collaterals. He administered Su He Xiang Wan. After three days, lumbar pain occurred, indicating Blood was moving. He urgently used Mang Xiao and Da Huang to purge violently, expelling dozens of melon-like clots of dirty blood, curing her. Her six pulses were wiry-slippery-rapid: Wiry indicates Qi knotting, Slippery indicates Blood gathering, Excess pathogen. Hence, moving Qi caused massive Blood discharge. Another woman had similar symptoms but different pulse. Xiang said: Untreatable, will die in months. Previous slippery pulse indicated excess; current deficient pulse indicates depleted Yuan Qi. Another woman had similar symptoms but wiry-six pulses. Xiang said: True Zang pulse visible, will die in over a month. All predictions came true.
Yu Jiayan treated a case of Blood Gu. After 100 days of medication, the large abdomen resolved, revealing a pillow-like mass in the left hypochondrium. Stimulating it caused vomiting of a bucket of black muddy blood, with the remainder expelled via stool, finally resolving. He reflected that Gu Distension, whether Qi, Blood, Water, or Phlegm, always establishes a stronghold like bandits occupying mountains. *Nei Jing* states five accumulations have fixed locations. Why assume chronic Six-Fu accumulations like Drum Distension have no root or boundary?
Shi Wan treated scholar Gu Ruoyu with Drum Distension, wheezing, and fullness, unable to sleep or eat for 20+ days. Local famous doctors used Da Huang three times without success and left. Another doctor used dispersants followed by 20+ doses of Qi-breaking/purging herbs, resulting in stone-hard lower abdomen to epigastrium, and breaking pain in waist/hypochondrium/navel. Invited by relative Wang Mogong, Shi examined the pulse: Wiry-large-leather, diminishing on pressure, enlarging on lift. Bowels blocked for 8-9 days; urine scant but clear. Cause: Over-purging damaged Middle Qi, allowing Turbid Yin to occupy Clear Yang positions due to rebellion. Due to rebellious turbid Qi, Tonifying Qi was contraindicated initially. First, Sheng Liu Wei Wan + Rou Gui (3 qian), Chen Xiang (0.3 qian), and Hei Xi Dan (2 qian) to guide Turbid Yin Down. That night, distension reduced by 60-70%, hunger felt in chest, ate porridge next morning. Lumbar/hip soreness remained like lost Kidneys. Second dose: Chest/abdomen wide, lower abdomen slightly hard with occasional movement, indicating stool desire but exhausted fluids preventing passage. Pulse barely thread-like. Switched to Du Shen Tang + Dang Gui, Zhi Ke. Stool passed slightly hardened, lumbar pain eased, lower abdomen harmonized. Then Liu Wei Di Huang Wan + Rou Gui, Chen Xiang for regulation and recovery.