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Generally, edema that starts in the abdomen and then spreads to the four limbs is treatable; edema that starts in the four limbs and then returns to the abdomen is difficult to treat. Swelling of the palms with disappearance of skin creases indicates death. Sliding diarrhea with persistent edema indicates death. Black lips, swollen lips, and scorched teeth indicate death. Protruding umbilicus indicates death. A flat supraclavicular fossa (Quepen) indicates death. Simultaneous swelling of the scrotum and penis indicates death. Absent pulse, open mouth, and swollen feet indicate death. Severe foot swelling with knees enlarged like a斗 (dou, a unit of measure) indicates death. Visible green veins on the abdomen with abdominal swelling persisting after purgation indicates death. In men, swelling progressing from the lower body upward, and in women, swelling progressing from the upper body downward, are both difficult to treat.

For distension and fullness arising from Qi disorders, one must distinguish between deficiency and excess of Qi. If distension is located internally rather than externally, the pathology is mostly excess. As stated in the classics: "Fullness in the center should be drained from within," which refers to this situation. If it is indeed caused by alcohol and rich foods, leading to Qi stagnation and a slippery pulse, resulting in severe fullness and excess, Kuoqing Yin (Clearing Decoction) should be used as the principal formula. If accompanied by pain and unresponsive to other medicines, Shenxiang San (Divine Fragrance Powder) should be used. If the Zang-Fu organs exhibit fullness, hardness, and severe pain, Chengqi Tang (Coptis Decoction) or Baishun Wan (Hundred Compliance Pill) may be used for purgation. However,峻猛攻下 (drastic purgation) is only permissible if the patient is young and strong, has no history of injury or weakness, and presents with sudden onset of distension; otherwise, slow treatment is appropriate. If Qi is excessive internally while both interior and exterior are distended, garlic cloves boiled in boiling water until slightly cooked (to retain properties), dipped sparingly in salt and vinegar, and consumed frequently as an accompaniment can greatly break Qi stagnation and resolve accumulation, which is also an excellent method. For Qi distension accompanied by difficult urination, Siling San (Four-Ingredient Powder) combined with pills made from mashed semi-cooked garlic is extremely effective.

First, for distension and fullness in the stomach and middle Jiao caused by food stagnation, use Xiaodazhonghe Yin (Minor Great Harmonizing Decoction) or Dazhonghe Yin (Great Harmonizing Decoction) as appropriate. If accompanied by pain, Paiqi Yin (Expel Qi Decoction) is indicated.

Second, for anger causing rebellion in the middle Jiao, resulting in alternating distension and pain, Paiqi Yin (Expel Qi Decoction) or Jiegan Jian (Soothe Liver Decoction) should be used. If accompanied by wheezing and distension, Simo Yin (Four-Mortar Decoction) or Shenxiang San (Divine Fragrance Powder) is indicated.

Third, for adults and children who normally lack signs of Spleen deficiency and loose stools but suddenly develop generalized edema or difficult urination, the cause is often irregular diet or damp-heat. Kuoqing Yin (Clearing Decoction) with modifications is indicated, or Siling San (Four-Ingredient Powder) and Weiling Tang (Stomach-Ling Decoction). If dampness predominates, Pingwei San (Regulate the Stomach Powder) is indicated.

Fourth, for Spleen and Stomach deficiency-cold, weak Middle Qi, and distension of the Three Jiao, this is termed Qi-deficiency central fullness. Symptoms necessarily include acid regurgitation, belching of rotten food, aversion to food and cold, or frequent loose stools, without heat signs or heat pulses. This belongs to Cold of the Zang organs, known as "Cold of the Zang generates fullness diseases," and requires warming and tonification. For Cold in the Middle Jiao, Wenwei Yin (Warm the Stomach Decoction) or Lizhong Tang (Regulate the Center Decoction) is indicated. For Cold in the Lower Jiao, Liyin Jian (Nourish Yin Decoction) or Bawei Dihuang Tang (Eight-Ingredient Rehmannia Decoction) is indicated.

Fifth, isolated abdominal distension is named Guzhang (Drum Distension) because although the exterior is hard and full, the interior is hollow, resembling a drum. It is also called Guzhang (Gu Distension) due to blood and Qi aggregation that cannot be dispersed, with toxicity akin to Gu poison. Since the limbs are unaffected and only the abdomen is distended, it is also called Danzhang (Single Abdominal Distension). This is essentially a disease of the Spleen and Stomach. The Spleen and Stomach are the Earth organs, the officials of the granary. They receive grain and water, possessing the receptive virtue of Kun (Earth), and transform blood and Qi, possessing the vigorous function of Qian (Heaven). If the Spleen and Stomach are strong, food is transformed immediately, so how could there be distension? This arises from poor self-care. Excessive emotional stress, fatigue, improper diet, or sexual indulgence can damage Zang Qi, causing Spleen Earth to decline, transport functions to fail, Zheng Qi (Upright Qi) to stagnate, and clear and turbid Qi to mix, forming this condition. When treating this, if the disease originates in the Middle Jiao, focus on the Spleen and Stomach, using herbs such as Renshen (Ginseng), [Text missing], Baizhu (Atractylodes Macrocephala), Ganjiang (Dried Ginger), and Gancao (Licorice). If the disease originates in the Lower Jiao, focus on the Mingmen (Gate of Life) ancestral Qi, using Renshen (Ginseng), Shudi (Prepared Rehmannia), Danggui (Angelica Sinensis), Shanyao (Dioscorea), Fuzi (Aconite), and Rougui (Cinnamon Bark). If there is Qi blockage making pure tonification difficult, add small amounts of acrid-aromatic herbs like Chenpi (Tangerine Peel), Houpo (Magnolia Bark), Sharen (Amomum Fruit), Xiangfu (Cyperus Rhizome), Dingxiang (Clove), and Baijiezi (White Mustard Seed). If water pathways are obstructed and dampness does not move, assist the Spleen in moving dampness and add diuretic herbs like Zhuling (Polyporus), Zexie (Alisma), and Fuling (Poria). If all medicines fail, moxibustion should be employed as described later. These methods are general guidelines. However, once Single Drum Distension forms, it is ultimately an ill omen, resulting from gradual depletion. Unless worldly affairs are completely abandoned and careful regulation is undertaken, survival is unlikely.

Sixth, treating distension requires distinguishing deficiency and excess. If caused by food stagnation, specifically eliminate the food retention; if caused by Qi, specifically regulate the Qi; if caused by rebellious Blood obstruction, specifically clear the Blood. For heat, use cold herbs; for aggregation, use dispersing herbs; for mixed clear and turbid Qi, use separating and draining methods; or regulate Qi ascent and descent, or digest and guide out pathogens. These are methods for treating excess. However, most cases of swelling involve deficiency. In patients past middle age, or those with chronic labor injuries, loose stools, wiry-deficient pulses, haggard voice and complexion, post-illness states, or over-treatment with purgatives leading to distension, these are evident signs of deficiency. Such cases require rapid tonification of Yuan Qi (Primordial Qi) and rescue of the root; otherwise, mild cases will worsen, and severe cases will become critical. For deficiency in Spleen and Lung, Sizijunzi Tang (Four Gentlemen Decoction) or Guipi Tang (Restore the Spleen Decoction) is indicated. For Spleen deficiency with Cold, Lizhong Tang (Regulate the Center Decoction), Wenwei Yin (Warm the Stomach Decoction), or Wujunzi Jian (Five Gentlemen Decoction) is indicated. For Spleen deficiency with Phlegm, Liu Junzi Jian (Six Gentlemen Decoction) is indicated. For Kidney deficiency with Phlegm, Jinshui Liujun Jian (Metal-Water Six Gentlemen Decoction) is indicated. For deficiency in Liver and Kidney, Liuwei Dihuang Tang (Six-Ingredient Rehmannia Decoction) is indicated. For Kidney deficiency with Cold, Liyin Jian (Nourish Yin Decoction) or Bawei Dihuang Wan (Eight-Ingredient Rehmannia Pill) is indicated; for severe cases, modified Shenqi Tang (Kidney Qi Decoction) from *Jin Gui Yao Lue* is indicated. Using draining and reducing methods recklessly on deficiency cases results in nearly 100% mortality. Only in cases of true excess due to youth/stagnation, strong Liver Qi rebellion, or epidemic pathogenic factors can direct attack be used, but differentiation must be detailed and not neglected.

Seventh, external toxic wind pathogens remaining in the skin and interstices can also cause sudden edema, as Dongyuan described regarding eight beneficial pathogens entering from outside. However, the onset is rapid, and symptoms must include tight pulse, headache, and bone pain to confirm an external contraction. Initially, disperse the pathogen using Zheng Chaihu Yin (Correct Bupleurum Decoction), Xiao Chaihu Tang (Minor Bupleurum Decoction), Baidu San (Defend Against Toxins Powder), Shensu Yin (Ginseng-Sophora Decoction), or Gegen Congbai Tang (Kudzu-Green Onion Decoction) as appropriate. If Wind combines with Fire causing interior-exterior heat, Shaoyao Qinggan San (Peony Clearing Liver Powder) or Longdan Xiegan Tang (Gentian Draining Liver Decoction) is indicated. If the pathogen enters the interior, involving Taiyang and Yangming concurrent diseases, with severe Stomach excess-heat, afternoon tidal fever, and intense thirst requiring drinking, Baihu Tang (White Tiger Decoction) is indicated. For severe excess-fullness with unresolved heat binding, Dachengqi Tang (Major Coptis Decoction) or Baishun Wan (Hundred Compliance Pill) is used for purgation. For Shaoyang-Yangming concurrent diseases with alternating chills and fever, fullness, and excess, Dachaihu Tang (Major Bupleurum Decoction) is used for purgation. The *Wuchangzheng Dalun* states: "Purgation resolves distension," referring to such cases.