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The distension caused by the obstruction of pathogenic factors is a deficiency syndrome. For excess syndromes, dispel them; for deficiency syndromes, tonify them; for cold syndromes, treat with heat; for heat syndromes, treat with cold; for stagnations, scatter them; for retention, move them.

When pathogenic factors enter from the exterior into the interior and become abundant in the middle jiao, first treat the exterior, then regulate the interior. When Yin qi rises from below and becomes abundant in the middle jiao, first suppress it and regulate the middle jiao. When Yang qi descends from above and becomes abundant in the middle jiao, first lift it and regulate the middle jiao, so that Yin and Yang each return to their respective sectors. Thus, the treatment principles in *Neijing* state: "Balance and weigh, remove accumulated decay, open the ghost gates (sweat pores), cleanse the clean mansion (bladder), and distribute the five Yang energies, so that the great Qi may be balanced." This is what is meant. It is often seen that unskilled physicians do not understand this principle, exclusively adhering to the single method that "purging relieves distension." Although they may gain one or two days of slight relief, the True Qi inevitably escapes downward due to purging, and since the pathogenic factor does not descend, it will inevitably gather again to form distension, ultimately leading to untreatable conditions. This is truly lamentable! Therefore, I record a few cases to verify this.

A son of the Shen family in Jiading, aged eighteen, suffered from distension in the chest, abdomen, body, and face. Medical treatment for half a month was ineffective. His pulse at all six positions was imperceptible. Therefore, decoctions of Zisu (Perilla Leaf) and Jiegeng (Platycodon Root) were administered. After one cup, there was slight sweating in the chest; after another dose, the whole body sweated, and his previously imperceptible peaceful pulses emerged. Within one or two days, all symptoms resolved.

Another man, over thirty years old, had a distended chest and abdomen, irritability, thirst, facial redness, inability to lie down, and cold feet. Knowing he drank alcohol regularly, I surmised that intercourse after drinking depleted his Essence, causing Essence to overflow downward, allowing pathogenic factors to ascend with it. The ascending Yin Qi resulted in distension. The Yang Qi of the Upper Jiao, pressured by the ascending pathogenic factors from below, became obstructed in the upper part, causing irritability. This is a case where pathogenic factors ascend from below and become abundant in the upper jiao. I used Wuzhuyu (Evodia Fruit), Fuzi (Prepared Aconite Root), Renshen (Ginseng Root), etc., to retreat the Yin rebellion, administering them with ice-cold water to resolve the floating heat in the Upper Jiao. Upon swallowing, he felt immediate relief in the chest. Shortly after, loud flatulence occurred like bull roaring, passing five or seven times. By the next day, he was cured.

Distension due to Wind-Cold, Summer-Heat, and Dampness: Huoxiang Zhengqi San (Agastache Powder to Rectify the Qi). Distension due to Seven Emotions: Wuge Kuanzhong San (Five Diaphragms Powder to Broaden the Middle), Muxiang Liqi Yin (Costus Decoction to Move Qi), Chenxiang Jiangqi Tang (Aquilaria Decoction to Descend Qi). If injured by diet, with Spleen-Stomach weakness leading to accumulation and non-digestion of food and water, this is distension due to Cold-Damp oppression: Xiangsha Tiaozhong Tang (Amomum and Aucklandia Decoction to Regulate the Middle). Distension due to Great Anger: Fenxin Qi Yin (Heart-Splitting Qi Decoction). Distension due to Excessive Worry and Thought: Zisuzi Tang (Perilla Seed Decoction). Internal Heat-Dampness abundance, causing heart and abdominal fullness, difficult urination, loose stools, and edema: Da Jupi Tang (Large Citrus Peel Decoction). Injury from irregular hunger and satiety, epigastric stuffiness, acid retention, eating well in the morning but unable to eat in the evening, named Grain Distension (Gu Zhang): Dayi Xiang San (Greatly Differentiated Fragrant Powder). Jishi Li (Chicken Dropping Wine) treats heart and abdominal distension, where one can eat in the morning but not in the evening. Due to Spleen Yuan weakness failing to control Water, Water Qi ascends and infiltrates Earth (Spleen); Earth-Dampness fails to transform food and water, Qi fails to circulate freely, causing upper and lower blockage, resulting in central fullness. In the morning, Yang Qi is growing, grain Qi digests easily, so one can eat. In the evening, Yin Qi is advancing, grain cannot digest, so one cannot eat. The pulse is deep, solid, and slippery; the disease is named Grain Distension. Use Ban Sheng (half a sheng) of Jishi Bai (White Chicken Droppings), soaked in one dou of good wine for seven days. Take one cup after meals, warmed before bed. Spleen Earth affected by Dampness fails to control Water; Water infiltrates intestines and stomach, overflows into skin, making gurgling sounds, palpitations, and panting; this is named Water Distension (Shui Zhang): Banxia Tang (Pinellia Decoction). Irritability, mouth rinsing without swallowing, confusion, forgetfulness,惊狂 (fright and madness), pain, stuffiness, panting, aversion, spontaneous sweat, syncope, frequent urination, bloody stools; this is named Blood Distension (Xue Zhang): Ren Shen Xiong Gui Tang (Ginseng, Ligusticum, and Angelica Decoction). Cases where masses attack each other, causing pain or distension: initially use Qiqi Xiaojusan (Seven Qi Powder to Dissipate Masses). If long-standing, with Yuan Qi deficiency and weak Spleen-Stomach causing distension: Shenzhu Jianpi Tang (Ginseng and Atractylodes Powder to Strengthen the Spleen), with a small addition of digestion-promoting herbs. Distension due to stasis and dead blood, with blue-purple veins visible on the abdominal skin, normal urination, and knotted/rough pulse; common in women: initially use Taoren Chengqi Tang (Peach Kernel and Rhubarb Decoction). For severe cases, use Didang Tang (Wait-and-See Decoction). For deficient patients who cannot tolerate purgation, temporarily use Danggui Huoxue San (Angelica Blood-Moving Powder) for regulation. Distension due to fatigue injuring Spleen-Stomach transport: Buzhong Yiqi Tang (Middle-Boosting Qi-Invigorating Decoction) modified; see Fatigue Section. Distension arising from dietary imbalance after serious illness, injuring Spleen-Stomach and hindering transport: initially use Huazhi Tiaozhong Tang (Stasis-Transforming Middle-Regulating Decoction), followed by Shenling Baizhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder). Distension due to excessive use of purgatives after diarrhea/dysentery, causing extreme Spleen weakness: focus primarily on tonifying the Spleen. If diarrhea/dysentery persists, occasionally use Weifeng Tang (Stomach-Wind Decoction). Panting and fullness preventing lying down: for deficiency, use Renshen Shengmai San (Ginseng Pulse-Generating Powder) type formulas; for excess, use Tingli Tang (Descurainia Decoction) type formulas. Chest and diaphragm fullness, generalized edema of face and body, nasal congestion, cough, clear rhinorrhea: use Xiao Qinglong Tang (Minor Green Dragon Decoction) two or three doses to separate and drain the meridians, then administer distension-resolving medicines. Chronic diarrhea, day and night without cessation, indicates Qi collapse: use Yizhiren (Bitter Apricot Seed) decocted in thick soup, which cures immediately.

Regarding abdominal and hypogastric distension, there are Kidney Heat, Sanjiao Deficiency-Cold, Stone Water (Shishui), Intestinal Abscess (Changyong), and Female Labor Jaundice (Nulao Dan). *Jingui Yaolue* states: "Cunkou pulse is slow and choppy; slow indicates Cold, choppy indicates Blood deficiency. Duyang pulse is faint and slow; faint indicates Qi deficiency, slow indicates Cold. Cold Qi combined with insufficiency causes cold extremities. Cold extremities lead to poor Ying-Wei circulation. Poor Ying-Wei circulation causes abdominal distension and borborygmus, Qi shifting to the Bladder, exhausting both Ying and Wei. Obstruction of Yang Qi causes cold body; obstruction of Yin Qi causes cold bones. Anterior flow of Yang Qi causes aversion to cold; anterior flow of Yin Qi causes numbness. When Yin and Yang harmonize, Qi flows; when the Great Qi turns, pathological Qi scatters. Excess manifests as flatus; deficiency manifests as enuresis. This is named Qi Fen (Qi Division)." "Cunkou pulse is deep and slow; deep indicates Water, slow indicates Cold. Cold and Water contend. Duyang pulse is hidden; food and water are not transformed. Spleen Qi decline causes palpitations and loose stools; Stomach Qi decline causes bodily swelling. Shaoyang pulse is low; Shaoyin pulse is fine. Men suffer difficult urination; women suffer amenorrhea. Menses are Blood; if Blood is stagnant, it becomes Water. This is named Xue Fen (Blood Division)." The Master said: "Cunkou pulse is deep and rapid; rapid indicates outward movement (Yang), deep indicates inward entry (Yin). Outward movement indicates Yang Excess; inward entry indicates Yin Knotting. Duyang pulse is faint and wiry; faint indicates lack of Stomach Qi, wiry indicates difficulty breathing. Shaoyin pulse is deep and slippery; deep indicates interior, slippery indicates excess. Deep and slippery contending means Blood knots at the Bao Gate (uterus). The mass does not discharge, meridians are blocked. This is named Blood Division." Asked: "What distinguishes Blood Division and Water Division?" The Master said: "If menses stop first, then Water disease appears, it is named Blood Division; this is difficult to treat. If Water disease appears first, then menses stop, it is named Water Division; this is easy to treat. Why? Removing Water allows menses to resume naturally. Qi Division refers to distension due to Qi obstruction; Blood Division refers to distension due to Blood obstruction. These are not separate diseases outside of distension, but distinct categories within it. Generally, if Qi and Blood are obstructed, Water also fails to circulate, leading to oliguria; oliguria causes gradual water accumulation in the abdomen forming distension. However, Qi Division presents with hardness and fullness in the epigastrium and originates above; Blood Division involves Blood knotting at the Bao Gate and originates below. Qi Division: Water distension precedes amenorrhea. Blood Division: Amenorrhea precedes water distension." Liu Lizhi stated: "For Qi Division, priority should be given to descending Qi and reducing distension, such as Zhike San (Citrus Aurantium Powder), Muxiang Liqi Yin, and Sanhe San (Three Harmonies Powder). *Jingui Yaolue* formula for Qi Division presenting with epigastric hardness large as a plate, edges like an inverted cup, caused by fluid retention: Guizhi Qu Shaoyao Jia Mahuang Xixin Fuzi Tang (Cinnamon Twig Decoction minus Peony plus Ephedra, Cinnamon Twig, and Prepared Aconite). Liangfang Jiawei Zhizhu Tang (Modified Atractylodes and Aurantium Decoction) treats Qi Division distension. For women's Blood Division, Dueming Dan (Life-Taking Pill) and Heishen San (Black Divine Powder) are essential medicines. Blood Division is common after miscarriage or postpartum. Only pre-partum foot edema differs; postpartum cases are all due to lochia stasis and must be treated via the Blood aspect."

[Intestinal Polyp / Changtan] Changtan arises when Cold pathogens lodge outside the intestines, contending with Chong Mai (Penetrating Vessel) Qi. Qi fails to nourish, becoming bound, forming癖 (masses) that adhere internally. Evil Qi arises, and polyps grow. Initially, it is egg-sized, gradually enlarging until it resembles pregnancy. Long-standing cases exceed a year. Pressing makes it hard; pushing moves it. Menstruation occurs on time. This is its presentation. 'Chang' refers to Large Intestine; 'Tan' means extending. The Large Intestine governs conduction and is the Fu organ of the Lung. The Lung governs Wei Qi (Defensive Qi). Wei Qi is Qi; it dissipates with heat and coagulates with cold. Now Cold lodges in the Large Intestine, so Wei Qi fails to nourish. Binding and stopping cause internal masses adhering. Prolonged extension is named Changtan. Scattered Qi is clear; gathered Qi is turbid. Knotting forms masses, causing Evil Qi to arise and polyps to grow, gradually enlarging until the abdomen bulges like pregnancy. This is a Qi disease without Blood involvement, hence menstruation continues normally. It is not pregnancy; distinguish by this. Treat with Lu Wan (Dew Pill) and Muxiang Tongqi San (Costus Qi-Unblocking Powder).

[Stone Mass / Shi Xia] Shi Xia arises in the Bao Palace (Uterus). Cold pathogens lodge at Zi Men (Os Uteri). Zi Men closes, Qi fails to pass. Evil Blood should discharge but remains, enlarging daily, resembling pregnancy. Menstruation does not occur on time. This affects women only and can be treated by guiding downward. The Bladder is the Fu organ of Fluids; Qi transformation allows excretion. Now Cold lodges at Zi Men, blocking Qi flow. Blood stagnates and fails to circulate, remaining and hardening like stone, named Shi Xia. This disease begins with Qi pathology affecting Blood later, hence amenorrhea. It can be guided and discharged. *Nanjing* states: "Disease of Ren Mai causes internal knotting; men develop Seven Hernias, women develop Masses. This is it." Only major acrid-hot agents can cure it. Take Jianlu Wan (see Dew Pill) and Hexue Tongjing Tang (Blood-Harmonizing Meridian-Unblocking Decoction).

[Diagnosis] Pulses that are vigorous and tight, large and firm with choppy quality, or slow and slippery all indicate distension. Deficiency at Guan position indicates internal distension. For distension pulses, floating, large, surging, and solid are easy to treat; deep, fine, weak, and thready are difficult. Upward deviation of the lip indicates Spleen deviation; Spleen deviation leads to frequent fullness and distension. Abdominal distension with fever and large pulse is adverse; death occurs within 15 days. (Distension accompanied by fever or malaria-like symptoms is untreatable, verified repeatedly.) Massive abdominal distension with cold extremities, emaciation, and severe diarrhea is adverse; death occurs within one shichen (2 hours). Abdominal distension with bloody stool and intermittent large pulse is adverse. Vomiting, coughing, abdominal distension, and immediate postprandial diarrhea with absent pulse is adverse. Termination of Shaoyin channel: black face, elongated dirty teeth, abdominal distension and closure, upper and lower blockage leads to death. Termination of Taiyin channel: abdominal distension and closure, inability to breathe, frequent belching and vomiting. Vomiting leads to reversal; reversal causes red face. Without reversal, upper and lower blockage leads to black face, scorched skin/hair, and death.