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(The "Treatise on Distension" from *Ling Shu* - Complete Text [Appendix: Treatment Methods for Swelling and Distension]

Yellow Emperor asked: How does the pulse at Cun Kou reflect distension? Qi Bo replied: A pulse that is large, firm, and choppy indicates distension. (A large pulse indicates an abundance of pathogenic factors. A firm pulse indicates excess of pathogenic factors. Choppi-ness is due to deficiency of Qi and Blood failing to flow smoothly. Generally, a surging and large pulse implies a decline of Yin Qi; a firm and strong pulse implies damage to Stomach Qi. Therefore, a pulse that is large, firm, and choppy suggests the disease manifests as distension.) Yellow Emperor asked: How can one know which Zang or Fu organ is affected by distension? Qi Bo replied: Yin corresponds to Zang organs, and Yang corresponds to Fu organs. (A choppy and firm pulse belongs to Yin, with distension in the Zang organs. A large and firm pulse belongs to Yang, with distension in the Fu organs. Another interpretation states: if the pulse pathology is in Yin, distension is in the Zang; if in Yang, distension is in the Fu. This is also valid.) Yellow Emperor asked: Does the Qi causing distension reside within the blood vessels, or inside the Zang and Fu organs? Qi Bo replied: It exists in all three places, but these are not the dwelling place of distension. ("She" refers to the place where it stays and rests.) Yellow Emperor said: I wish to hear about the dwelling place of distension. Qi Bo replied: Distension resides outside the Zang and Fu organs, pushing against them and expanding into the chest and hypochondrium, filling the skin. Hence it is named distension. (It pushes outward from outside the Zang and Fu, using the chest and hypochondrium as its outer boundary, residing within the skin; this is the location of distension.) Yellow Emperor said: The Zang and Fu organs are located within the chest, hypochondrium, and abdomen, like forbidden artifacts stored in boxes and cabinets. Each has its fixed abode, different names but adjacent locations, all within one region, yet their Qi differs. I wish to understand why. (There should originally be another paragraph of Qi Bo's answer here, which must have been lost.) Yellow Emperor said: I do not fully understand your meaning; let me ask again. Qi Bo replied: The chest and abdomen are the outer walls of the Zang and Fu. (The chest and abdomen protect the internal organs, thus serving as the outer walls of the Zang and Fu.) Dan Zhong is the palace city of the Heart Master. (Dan Zhong is the center of the chest. The Lung covers above, and the diaphragm blocks below, forming a clear, empty, and dense palace, the residence of the Heart Master, hence called the palace city. "Dan" is pronounced Tang Tan Qie.) The Stomach is the Grand Granary. (The Stomach is the sea of water and grain, hence called the Grand Granary.) The pharynx and small intestine are responsible for transmission. (The pharynx transmits, allowing grain Qi to enter from above. The small intestine transmits, allowing clear and turbid substances to exit from below.) The five openings of the Stomach are the gates of the neighborhood. ("Lu" means alley gate. "Li" means neighborhood. The *Rites of Zhou* records: five families form a Bi, five Bis form a Lu. Approximately twenty-five families make up a Lu. *Feng Su Tong* says: five families form a Gui, ten Guis form a Li. Approximately fifty families make up a Li. Saying the five openings of the Stomach are the gates of the neighborhood does not mean the Stomach has five openings literally, but rather that from the upper stomach opening down to the small and large intestines, all belong to the Stomach, hence called the gates of the neighborhood. Such as the pharyngeal gate, cardiac orifice, pyloric gate, ileocecal valve, and anal gate, are all channels through which Stomach Qi flows, so they collectively belong to the five openings of the Stomach. "Gui" is pronounced Gui.) Lian Quan and Yu Ying are the pathways for fluids. (Both acupoints belong to the Ren Mai. Yu Ying is the same as Yu Tang.) Therefore, the Zang and Fu organs each have their boundaries, and their diseases present with distinct shapes. (Boundaries have specific affiliations, so the manifestations of disease can be palpated. "Pan" is pronounced Pan.) Ying Qi circulates within the vessels; when Wei Qi rebels, it causes vessel distension. (Clear substances form Ying Qi, which resides within the vessels. Its Qi is refined and concentrated, not immediately causing distension. Turbid substances form Wei Qi, which travels outside the vessels. Its Qi is swift, slippery, and moves between the muscle intervals. Thus, only when Wei Qi rebels does the pathology affect Ying Qi, resulting in vessel distension. Therefore, all cases of distension originate from Wei Qi.) When Wei Qi merges with the vessels and circulates along the muscle intervals, it causes skin distension. (Wei Qi rebels and merges with the vessels, then circulates along the muscle intervals, causing skin distension.) Needle San Li (Zusanli) to drain. For nearby conditions, needle once; for distant conditions, needle three times. Regardless of deficiency or excess, the key lies in rapid draining. (San Li is an acupoint of the Foot-Yangming Meridian. The Yangming Meridian is the sea of Qi and Blood for the Zang and Fu organs and governs the muscles. Therefore, distension in the skin and muscles should be treated by needling to drain. "Once and three times" refers to one, two, and three sessions. Because pathogens vary in distance, the difficulty of draining varies.)

Yellow Emperor said: I wish to hear about the forms of distension. (This section discusses the signs and symptoms of distension diseases.) Qi Bo replied: Heart distension presents with mental restlessness, shortness of breath, and restless sleep. Lung distension presents with empty fullness in the chest, wheezing, and coughing. Liver distension presents with fullness and pain under the hypochondrium radiating to the lower abdomen. Spleen distension presents with frequent hiccups, heaviness and discomfort in the four limbs, body weight so great that one cannot bear the weight of clothes, and restless sleep. Kidney distension presents with abdominal fullness and pain radiating to the center of the back, and pain in the waist and thighs. (These are the distensions of the five Zang organs. "Fan" refers to mental oppression. "Yang Yang Ran" describes a state of distress. "Mei Ben Qie".) Six Fu Distensions: Stomach distension presents with abdominal fullness, epigastric pain, smelling burnt odors from the nose, difficulty eating, and constipation. Large Intestine distension presents with borborygmus and gurgling pain. If exposed to cold again in winter, it leads to undigested diarrhea. Small Intestine distension presents with lower abdominal fullness and pain radiating to the waist. Bladder distension presents with lower abdominal fullness and urinary retention. San Jiao distension presents with Qi filling the skin, feeling light and soft but not hard. Gallbladder distension presents with pain and fullness under the hypochondrium, bitter taste in the mouth, and frequent sighing. (These are the distensions of the six Fu organs. "Zhuo Zhuo" refers to the sound of water in the intestines. "Sun Xie Bu Hua" refers to diarrhea with undigested food. "Qi Long" refers to closure of Qi in the bladder and inability to urinate. "Sun" is pronounced Sun. "Chen" is pronounced Chen. "Long" is pronounced Liang Zhong.)

In general, the principle behind all these distensions is singular: knowing the reversal and smoothness of Qi, and the number of needle insertions without error, draining deficiency and tonifying excess. If the Shen (Spirit) leaves its chamber, it leads to the invasion of pathogens and loss of righteousness, making the True Qi unstable. This failure by incompetent physicians is called premature death. Conversely, tonifying deficiency and draining excess allows the Shen to return to its chamber and fills the emptiness over time; this is called a skilled practitioner. (This section discusses the gains and losses in treating distension. Distension has deficiency and excess types, requiring either tonification or drainage. The principle is unique, with no divergence. Those who can discern this are called skilled practitioners; those who are crude and misuse treatment harm people's lives.) Yellow Emperor asked: How is distension generated? What is the cause? Qi Bo replied: Normally, Wei Qi in the body runs alongside the vessels and along the muscle intervals. Its movement has reversal and smoothness, with Yin and Yang following each other, achieving harmony with Heaven. The five Zang organs renew their functions, the four seasons follow their order, and grains are digested. (This is the normal regulation of Wei Qi.) Then, rebellious Qi arises from below, Ying and Wei Qi stagnate, Cold Qi rebels upward, and True Qi and Pathogenic Qi attack each other. The two Qi interlock and combine to form distension. (The previous section discussed the smooth flow of Wei Qi; this section clarifies the rebellion of Wei Qi. Rebellious Qi rises from below, disrupting Ying and Wei, causing True and Pathogenic Qi to clash and form distension.) Yellow Emperor said: Excellent. How can confusion be resolved? Qi Bo replied: By aligning with the True Qi, combining three aspects to obtain the truth. Yellow Emperor said: Excellent. (Without grasping the True Qi, confusion arises. Although distension stems from Wei Qi, it combines with the blood vessels in the meridians, with Zang organs in the Yin aspect, and with Fu organs in the Yang aspect. Once these three combinations are clear, the truth is obtained.)

Yellow Emperor asked Qi Bo: The "Treatise on Distension" states that regardless of deficiency or excess, the key is rapid drainage: once for nearby conditions, three times for distant ones. Now, some patients do not improve after three treatments. Where is the fault? ("Not descending" means the distension does not subside.) Qi Bo answered: This refers to needles sinking into the muscular fat (Huang) but missing the Qi acupoints. (When it says "once or three times," it implies the needle must sink into the Huang and hit the Qi acupoint to be effective. The meaning of "Huang" is seen in Article 67 of this category.) Missing the Qi acupoint causes internal Qi blockage; failing to sink into the Huang prevents Qi movement. If the needle goes too high into the muscle, Wei Qi becomes chaotic, and Yin and Yang pathogens chase each other. (Missing the acupoint and not sinking into the Huang means striking randomly between muscle intervals. Thus, Wei Qi becomes chaotic, and Yin/Yang pathogens attack the body.) For distension, if drainage is indicated but not performed, Qi fails to descend. (Failure to locate the correct acupoint and Huang area.) If three insertions do not work, the method must be changed. Stop only when Qi descends; if it doesn't, restart. This ensures safety; where is the danger? (If three insertions fail, the location was likely incorrect, so changing the acupoint and needling again is necessary.) For distension, one must examine the lips' KT (likely a typo for Pulse), drain if indicated, tonify if indicated. Like a drum responding to a strike, how could distension not subside? (Sores on the lips are called KT. The severity of distension manifests on the lips, so examining here helps assess deficiency/excess. However, "KT" is inappropriate and likely a typo for "Mai" (Pulse). "KT" is synonymous with "Zhen" (rash). "Fu" is pronounced Fu. My commentary: Regarding swelling and distension, this chapter implies all Zang and Fu organs can be affected. Other texts confirm this: *Su Wen: Essential Essentials of Pulse Diagnosis* states: Excess Stomach pulse and surplus Qi cause distension. *Su Wen: Pathogenic Factors and Organ Diseases* states: Stomach disease involves abdominal distension and epigastric pain. *Su Wen: Original Spirit* states: Excess Spleen Qi causes abdominal distension and difficult urination/defecation. *Su Wen: Yin-Yang Ying Xiang Da Lun* states: Turbid Qi staying above causes distension. These are all excess distensions. *Su Wen: Tai Yin Yang Ming Lun* states: Irregular diet and lifestyle entering the five Zang causes obstruction and fullness. *Su Wen: Meridians* states: Deficiency in the Luo-connecting vessel of Foot-Taiyin (Gongsun) causes drum-like distension. These are deficiency distensions. *Su Wen: Teacher's Transmission* states: Cold in the Stomach causes abdominal distension. *Su Wen: Different Methods and Suitable Areas* states: Cold in the Zang generates fullness diseases. *Su Wen: Wind Treatise* states: Stomach wind causes blockage and frequent abdominal fullness, worsening with cold exposure. These are cold distensions. *Su Wen: Yin-Yang Differentiation* states: Disease involving Two Yin and One Yang causes distension and heart fullness. *Su Wen: Diagnostics and Meridian Termination* states: Termination of Hand-Shaoyin and Foot-Taiyin meridians involves abdominal distension and closure. These are distensions due to Heart and Spleen injury. Furthermore, *Su Wen: Six Yuan Zheng Ji* and *Zhi Yao Da Lun* mention: Tai Yin arrival causes heavy swelling; Earth depression onset, Tai Yin initial Qi, Tai Yin victory/reversal all involve dampness-induced swelling. Water transport excess, Cold victory causing floating, Tai Yin ruling heaven/victory-reversal all involve cold-induced swelling. Shao Yin/Shao Yang ruling heaven/victory-reversal and Heat victory causing swelling involve fire-induced swelling. Jue Yin ruling heaven/in泉, Jue Yin reversal, Yang Ming reversal involve Wood insulting Earth and Metal counter-winning swelling. Thus, not only Zang/Fu, but also Five Movements and Six Qi can cause this disease. However, *Zhi Yao Da Lun* states: All dampness, swelling, and fullness belong to the Spleen. *Shui Re Xue Lun* states: The root is in the Kidney, the branch in the Lung, both gathering water. It also says: The Kidney is the gate of the Stomach; if the gate is dysfunctional, water gathers and multiplies. Thus, although all meridians can have distension, none do not affect the Spleen, Lung, and Kidney. The Spleen belongs to Earth, governing transformation and transportation; the Lung belongs to Metal, governing Qi; the Kidney belongs to Water, governing the five fluids. Fluids transformed by the five Qi belong to the Kidney; Qi moving the five fluids belongs to the Lung; transfer between these two organs to control Water generating Metal belongs to the Spleen. Therefore, swelling and distension arise from these three. However, syndromes differ in Yin/Yang and deficiency/excess, as described in various treatises, which must be distinguished. Generally, Yang syndromes are often hot and excess; Yin syndromes are often cold and deficient. Distension starting internally and spreading externally is often excess; swelling starting externally and worsening internally is often deficient. Yellow/red urine and constipation indicate excess; clear/white urine and loose stools indicate deficiency. Slippery, rapid, forceful pulses indicate excess; wiry, floating, faint, fine pulses indicate deficiency. Red/yellow complexion and coarse breathing indicate excess; haggard appearance and short voice indicate deficiency. All excess syndromes result from external injury by the Six Excess Pathogens or internal injury by diet and anger, leading to blocked Qi flow and San Jiao congestion. This affects the Qi level, reaching everywhere, often causing generalized edema without specific localization. Or, Qi excess in the middle causes isolated abdominal distension. Yang pathogens are swift and violent, appearing suddenly within days or weeks, common in young adults. Breaking Qi stagnation and unblocking congestion cures this; this is the method for treating excess. Deficiency syndromes result from emotional labor or excessive alcohol/sex damaging the Spleen and Kidney over time. These develop gradually, often affecting middle-aged people. Signs show obvious deficiency-cold patterns, unlike the sudden onset of excess syndromes with heat congestion or liver Qi rebellion. Treating excess is easy; treating deficiency is hardest. Deficiency can be in Qi or Water. Qi deficiency involves Spleen deficiency-cold failing to transform, known as Qi-deficiency central fullness. Water deficiency involves Spleen failing to control Water, allowing Cold Water to insult Earth, flooding as pathogen. It starts in the Yin aspect, rising gradually, leaving pitting edema with defined borders, known as Ascites/Water Distension. Although Water is controlled by the Spleen, it is governed by the Kidney. The Kidney is the Water organ, source of Primordial Yang Qi. If Kidney Yang is deficient, Mingmen Fire declines, failing to control Cold or warm the Spleen. Yin and Yang lose balance, becoming pathogenic. Qi is Fire; Essence is Water. They are similar but differ in transformation. Strong Yang transforms, turning Essence into Qi; weak Yang fails to transform, turning Water into pathogen. Fire excess/Water deficiency causes dryness; Water excess/Fire deficiency causes dampness. If Fire cannot transform, Yin does not follow Yang, and Essence/Qi become Water. Thus, edema mostly belongs to Yang deficiency, explaining why cold distension is more common than hot distension. However, Zhu Danxi treated swelling by saying mixed clear/turbid substances and blocked pathways cause heat; heat retains dampness, generating distension. He advocated tonifying Spleen, nourishing Lung Metal to control Wood, and nourishing Kidney Water to control Fire. His focus was on damp-heat and controlling Fire. Controlling Fire protects Metal, but does it not hinder Earth generation? This method works for Yang-excess/heat, but for Yang-deficiency/non-transformation, it aids Yin pathogens and worsens the condition. Therefore, I always check for true excess before clearing Yangming easily. For deficiency exhaustion, warming and tonifying Spleen/Kidney restores health. If deficiency/excess is unclear, I prefer tonifying deficiency first to probe excess. If symptoms worsen without medication, tonification is contraindicated, and methods can be changed safely. If symptoms worsen despite medication, severity and真假 (true/false) must be carefully observed. Misusing excess-treatment on deficiency, especially after harsh purging, damages True Qi beyond repair even with divine medicine. Clearing/draining may temporarily relieve symptoms, but without strongly tonifying Spleen/Kidney to secure the root, relapse and death are inevitable. This is the method for treating deficiency. Swelling/distension often presents with superficial excess and root deficiency, a critical condition. Unclear differentiation causes severe harm.)