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[Ping An]: This chapter, from the beginning to "how can there be those who do not descend," is found in *Ling Shu* (Spiritual Pivot), Volume 6, Chapter 35, "Treatise on Distension" (Zhang Lun), and also in *Jia Yi Jing* (Classified Classic of Acupuncture and Moxibustion), Volume 8, Chapter 3. From "Huangdi asked Qibo: Water and skin distension" to "also puncture to remove their blood vessels Huangdi said good," it is found in *Ling Shu*, Volume 9, Chapter 57, "Water Distension" (Shui Zhang), and also in *Jia Yi Jing*, Volume 8, Chapter 4. From "Huangdi asked Qibo: There is a disease with fullness in the heart and abdomen" to the end, it is found in *Su Wen* (Basic Questions), Volume 11, Chapter 40, "Treatise on Abdominal Center" (Fu Zhong Lun), and *Jia Yi Jing* is cited above.

Huangdi said: How does the pulse manifestation at the Cun Kou (inch position) indicate distension? Qibo said: When the pulse is large, firm, and choppy (Se), it indicates distension. (A large pulse often indicates abundant blood but deficient Qi. A choppy pulse also indicates abundant blood but deficient Qi, accompanied by slight cold. A full and tight pulse at the Cun Kou indicates injury from diet. Based on the pulse manifestations of abundant blood, deficient Qi, and slight cold, this is distension caused by dietary injury. Ping An: In *Ling Shu*, "its arrival" is written as "its pulse." In *Jia Yi Jing*, the character "zhi" (straight/direct) appears after "jian" (firm).)

Huangdi said: How can one know the distension of the Zang and Fu organs? Qibo said: Yin pulses govern the Zang organs, and Yang pulses govern the Fu organs. (When a distending pattern is diagnosed with Yin pulses, it is considered Zang distension; when diagnosed with Yang pulses, it is considered Fu distension.)

Huangdi said: Does the Qi that causes distension reside within the blood vessels or inside the Zang and Fu organs? (Blood vessels refer to the twenty-eight meridians. This asks about the location of the distension.) Qibo said: Both exist, yet neither is the abode of distension. (Wei Qi (Defensive Qi) travels alongside the vessels, circulating between the muscle intervals to cause distension. Blood vessels and the five Zang and six Fu organs each experience distension, hence it is said both exist. However, they are not the place where distension resides. Ping An: In *Ling Shu*, "two" is written as "three," with a note saying: one version writes "two.")

Huangdi said: I wish to hear about the abode of distension. Qibo said: Distension always occurs outside the Zang and Fu organs, pushing against them, expanding the chest and hypochondrium, and swelling the skin; therefore, it is named distension. (The following describes the abode of distension. The treatment points are located between the Zang and Fu organs externally, in the chest, hypochondrium, and skin. Qi resides here, expanding and pushing, thus named distension.)

Huangdi said: The Zang and Fu organs are located within the chest, hypochondrium, and abdominal covering, like forbidden artifacts stored in boxes and cabinets. Each has its fixed residence, different names but occupying the same space, like various winds within a single city. I wish to understand the reason. (The following discusses the residences of the Zang and Fu organs. Forbidden artifacts metaphorically represent the Zang and Fu organs. The chest, hypochondrium, and abdominal covering metaphorically represent boxes and cabinets. Residences refer to the specific locations of the five Zang and six Fu organs. Although the names of the Zang and Fu organs differ, they share the same enclosure, yet they are distinct. Please explain the reasons for their similarities and differences. Ping An: *Jia Yi Jing* omits the five characters "chest, hypochondrium, and abdominal covering." "City" is written as "domain." *Ling Shu* is the same. After "the reason," there are nine characters: "Huangdi said: I have not understood the meaning, I ask again.")

Qibo said: The chest and abdomen are the city walls of the Zang and Fu organs. (City walls refer to the location of the Zang and Fu organs. Ping An: *Ling Shu* omits the character "city".) Dan Zhong (Chest Center) is the official of the monarch. (Dan Zhong contains the Qi of the Heart and Lungs, thus serving as the chief official of the Zang and Fu organs. Ping An: In *Ling Shu*, "official of the monarch" is written as "palace city of the heart master." In *Jia Yi Jing*, it is written as "central palace of the heart master".) The Stomach is the great granary. (The Stomach stores water and grain to nourish the body, thus serving as the great granary of the Zang and Fu organs.) The pharynx and small intestine are the officials of transmission. (The pharynx transmits water and grain inward, the small intestine transmits waste outward, and the larynx transmits the entry and exit of Qi; thus, they are called officials of transmission. Ping An: In *Ling Shu*, "dao" (way/path) is written as "song" (send).) The five apertures of the Stomach are the gates and doors of the neighborhoods. (The apertures of the pharynx, stomach, large intestine, small intestine, and bladder all belong to the Stomach, thus serving as the neighborhood gates and doors of the Zang and Fu organs.) Lian Quan (Throat Center) and Yu Ying (Jade Flower) are the pathways of fluids and juices. Therefore, the five Zang and six Fu organs each have boundaries, and their diseases manifest in different shapes. (Lian Quan is the pathway for saliva, and Yu Ying is the pathway for urine and feces, hence named the pathway of fluids and juices. These are the boundaries of the Zang and Fu organs, so their pathological forms vary. Ping An: In *Jia Yi Jing*, the character "lu" (road) follows "dao".) Ying Qi (Nutritive Qi) circulating within the vessels causes vessel distension (Mai Zhang). Wei Qi (Defensive Qi) traveling alongside the vessels through the muscle intervals causes skin distension (Fu Zhang). Puncture Zusanli (ST 36) using the reducing method. For recent onset, one puncture suffices; for distant onset, three punctures are needed. Regardless of deficiency or excess, the key lies in rapid reduction. (The following discusses distension caused by Ying and Wei Qi. Ying Qi circulating around the abdominal cavity causes vessel distension, named Mai Zhang. Wei Qi exists outside the vessels, traveling alongside them through the muscle intervals, accumulating Qi and causing swelling in the muscles, named Fu Zhang. Zusanli is an important acupoint for treating distension, so regardless of deficiency or excess, the reducing method is required. If the illness is recent, one puncture reduces the pathogen; if distant, three punctures reduce it. "Xia" means the distension subsides. Ultimately, rapid reduction must be performed without hesitation. Ping An: In *Ling Shu*, three characters "Wei Qi Ni" follow "Ying Qi Xun Mai". *Jia Yi Jing* writes "Wei Qi Bing Xue Mai Xun Fen Rou". *Jia Yi Jing* writes "Qu Zusanli Xie Zhi" for "Sanli Er Xie". For "Yi Xia", *Jia Yi Jing* notes: another version writes "fen" (divide/interval), same below.)

Huangdi said: I wish to hear about the forms of distension. (I wish to hear the forms of distension for the five Zang and six Fu organs.) Qibo said: Those with Heart Distension experience mental restlessness, shortness of breath, and restless sleep. (Ping An: In *Jia Yi Jing*, the character "de" (obtain) precedes "an" (peace/restful).) Those with Lung Distension experience empty fullness, wheezing, and coughing. Those with Liver Distension experience fullness and pain under the hypochondrium radiating to the lower abdomen. Those with Spleen Distension frequently belch, have stiff limbs, heavy body weight, and difficulty wearing clothes. Those with Kidney Distension experience abdominal fullness pulling on the back with a feeling of discomfort, and pain in the waist and thighs. (Qi is outside the Zang and Fu organs, pushing against them, expanding the chest and hypochondrium, and swelling the skin. Frequent mental restlessness, shortness of breath, and restless sleep indicate Heart Distension. Understanding this, the distension of all five Zang and six Fu organs can be inferred similarly, differing only according to their respective organ characteristics. Kuang means uncomfortable or obstructed. Ping An: In *Ling Shu*, "shao fu" (lower abdomen) is written as "xiao fu". "Xi yue" (likes to belch) is written as "shan yue" (often belches) in *Ling Shu* and "ku yue" (suffers from belching) in *Jia Yi Jing*. "Si zhi ji" (limbs stiff) is written as "si zhi fan yu" (limbs vexed/stifled) in *Ling Shu* and "si zhi men" (limbs stuffy) in *Jia Yi Jing*. In *Ling Shu*, the character "sheng" (bear/endure) precedes "yi" (clothes). Kuang ran in *Ling Shu* is written as "yang yang ran".)

Distension of the six Fu organs: Stomach Distension involves abdominal fullness, gastric pain, smelling burnt odors in the nose, obstruction to eating, and difficult defecation. Large Intestine Distension involves borborygmus and gurgling pain (sound of water in the intestines); if exposed to cold again in winter, diarrhea occurs with undigested food. Small Intestine Distension involves lower abdominal distension pulling on the waist and causing pain. Bladder Distension involves lower abdominal fullness and urinary retention. San Jiao (Triple Burner) Distension involves Qi filling the skin, feeling light but not firm. Gallbladder Distension involves pain and distension under the hypochondrium, bitter taste in the mouth, and frequent sighing. (Fragrance is the odor of the Spleen, burnt is the odor of the Heart. Now, in Spleen and Stomach diseases, smelling burnt odors occurs because the child organ is diseased and seeks the mother's Qi. Ke is pronounced with a reverse cut of the mouth corner. [Character missing], describes a certain appearance. The current character implies seeming solid but not firm. Ping An: "Xie Shi" in *Ling Shu* is written as "sun xie" (diarrhea with undigested food), in *Jia Yi Jing* as "xie sun". "Shao fu man" in *Ling Shu* and *Jia Yi Jing* is written as "xiao fu man". In *Ling Shu*, it is written as "qing qing" (lightly/lightly). "Hao tai xi" is written as "shan tai xi" (frequently sighs).)

For all these types of distension, the principle lies in one aspect: clearly understanding reversal and smoothness, and not failing in the number of needle insertions. (One aspect refers solely to knowing tonification and reduction. Properly tonifying deficiency and reducing excess ensures no failure.) Reducing deficiency and tonifying excess causes the Shen (Spirit) to leave its chamber, inviting evil and losing righteousness, making the true essence unstable; this destruction by incompetent physicians is called premature death. (The Shen chamber is the Heart. Tonifying excess and reducing deficiency harms the Shen, causing it to leave the Heart chamber. Leaving the Heart chamber, it invites evil Qi and loses the righteous Qi of the four seasons, making truth and falsehood indistinguishable.) Tonifying deficiency and reducing excess allows the Shen to return to its chamber, sealing the emptiness for a long time; this is called a skilled physician. (The Shen is at peace in the organs, hence returning to the chamber. With the Shen returning to the organs, it departs from evil, and the cou li (pores/skin texture) remain closed, preventing evil entry; this is called a superior physician.)

Huangdi said: How is distension generated, and why is it named so? (Ping An: *Ling Shu* lacks the words "name and form".) Qibo said: Wei Qi (Defensive Qi) in the body constantly travels alongside the vessels through the muscle intervals. Its movement has reversal and smoothness, with Yin and Yang following each other, thereby attaining heavenly harmony. (Wei Qi travels alongside the vessels through the muscle intervals, having both reversal and smoothness. Moving downward from the eyes along the Foot Yang Ming meridians is smooth; moving downward from the eyes along the Hand Yang Ming meridians is reversal. Because Wei Qi movement has reversal and smoothness, the Yin and Yang Qi become harmonious and smooth. Ping An: In *Ling Shu*, the character "ran" (so/thus) follows "chang" (constant). In *Jia Yi Jing*, the character "rou" (flesh/muscle) follows "fen" (interval), same as *Ling Shu*.) The five Zang organs take turns governing, the four seasons follow order, and grains are digested. Then, Jue Qi (Rebellious Qi) arises below, Ying and Wei Qi stagnate, Cold Qi rebels upward, True Qi and Evil Qi attack each other, the two Qi clash, and together they form distension. (The five Zang organs belong to the Five Elements, so they take turns ruling. The four seasons' cold and heat follow order, allowing grains entering the abdomen to transform. Cold-Jue Qi remains between Ying and Wei Qi. Ying and Wei Qi do not circulate, Cold Qi rebels upward, clashing with Righteous Qi, engaging in fierce struggle, which is called distension. Ping An: "Geng Zhi" in *Ling Shu* is written as "Geng Shi" (restart), in *Jia Yi Jing* as "Jie Zhi" (all govern). "You Xu" in *Ling Shu* is written as "Xun Xu" (follow order), in *Jia Yi Jing* as "Jie Xu" (all order). "Bo" in *Ling Shu* is written as "Bo" (clash). In *Jia Yi Jing*, "nai he wei zhang" is written as "nai she wei zhang" (then reside as distension).)

Huangdi said: Good. How can confusion be resolved? Qibo said: Align with the True Qi, achieve harmony through three combinations. Huangdi said: Good. (When applying tonification and reduction, taking one point near aligns with True Qi, leading to recovery; taking three points far away aligns with True Qi, termed resolving confusion.)

Huangdi asked Qibo: The "Treatise on Distension" states: Do not ask about deficiency or excess; the skill lies in rapid reduction, one insertion for recent cases, three for distant ones. Now, even after three insertions, the distension does not subside. Where is the fault? (Previously, it was stated that reducing deficiency and tonifying excess causes the Shen to leave its chamber; now it says do not ask about deficiency or excess, focusing on rapid reduction. What is the reason? It is said that early in the disease, it is not yet severe deficiency, so re-taking Zusanli focuses on rapid reduction. If deficiency has already formed, taking other points is unsuitable for deficiency. Now, reaching three insertions without resolution, please explain the cause of the fault.) Qibo said: This refers to needles sinking into the muscular fat and hitting the Qi acupoints. (Muscular fat is the membrane above the muscle beneath the skin, similar in nature to the skin and flesh. Qi acupoints are the points where the distending meridian Qi emerges.) If the Qi acupoint is not hit, Qi becomes internally blocked; (Puncturing other areas without hitting the Qi acupoint of the distension prevents the distension from dissipating. Ping An: The note mistakenly prints "ji" (plan/count) instead of "zhen" (needle) in Yuan edition.) If the needle does not sink into the fatty membrane, Qi cannot circulate; (Not sinking into the fatty membrane prevents Qi from circulating between the muscle intervals.) If it does not penetrate the muscle, Wei Qi becomes chaotic, and Yin and Yang chase each other. Regarding distension, if reduction is indicated but not applied, Qi will not descend. If three insertions fail to make Qi descend, one must change the method. Only when Qi descends should one stop; if not, restart. This ensures complete safety, how could there be danger? (If the needle enters the skin but is lifted without penetrating the muscle, Wei Qi circulation becomes disordered, and Yin and Yang Qi merge chaotically. Sui means merging/chasing. Because reduction was indicated but not applied, Qi did not descend after three insertions. One must change to other points to apply tonification and reduction, aiming for the subsidence of distension as success, thus achieving complete safety and avoiding life-threatening disasters. Ping An: "Bu Yue" in *Ling Shu* and *Jia Yi Jing* is written as "Shang Yue" (ascend/penetrate). "Xiang Sui" in *Ling Shu* is written as "Xiang Zhu" (chase), in *Jia Yi Jing* as "Xiang Ni" (oppose/reverse).) Regarding distension, one must carefully examine the diagnosis. Reduce when indicated, tonify when indicated. Like a drum responding to a beat, how could distension not subside? (Saying the diagnosis is careful means it responds like a drum to a beat, leaving no room for error. Ping An: "Zhen" in *Ling Shu* is written as "HT ", noted as pronounced "zhen".)

Huangdi asked Qibo: How to differentiate Water Distension, Skin Distension, Drum Distension, Intestinal Polyp (Chang Tan), Stone Mass (Shi Xia), and Stone Water (Shi Shui)? (These six diseases are difficult to distinguish, hence the request for differentiation. Ping An: *Jia Yi Jing* lacks "Shi Shui". *Ling Shu* and *Jia Yi Jing* add "zhi" (particle) after "bie" (differentiate).) Qibo said: At the onset of Water Disease, the eyelids swell slightly, resembling the appearance after just waking up. The neck pulse throbs, there is occasional coughing, coldness in the inner thigh, swelling of the feet, and then the abdomen enlarges. At this point, the water pathology is established. Pressing the abdomen with the hand causes it to rise immediately, like a bag containing water; this is its sign. (The signs of Water Disease include six distinctions: First, slight swelling of the eyelids. Second, the Renying pulse of the Foot Yang Ming meridian shows throbbing without needing pressure. Third, distending Qi rushes upward along the Foot Shao Yin meridian to the lungs, causing occasional coughing. Fourth, coldness in the genital area and inner thighs. Fifth, swelling of the calves. Sixth, the abdomen resembles a bag holding water, soft upon pressure, rising immediately upon release. These six constitute the signs of Water Disease. Ping An: In *Ling Shu* and *Jia Yi Jing*, "mu guo" is written as "mu ke" (eye nest/socket), "wei " as "wei zhong" (slight swelling). "Zu " in *Ling Shu* is written as "zu jing " (calf swelling), in *Jia Yi Jing* as "zu jing zhong" (foot/calf swelling). The note renders as "yan" (eye).)

Huangdi said: How to diagnose Skin Distension? Qibo said: Skin Distension occurs when Cold Qi lodges between the skin and flesh. It feels light but is not firm. The abdomen is large, the whole body is swollen, the skin is thick. Pressing the abdomen leaves an indentation that does not rise immediately, and the abdominal color remains unchanged. This is its sign. (Next, explaining Skin Distension, there are five distinctions: First, Cold Qi follows Wei Qi and lodges between the skin and flesh. Second, it causes swelling but is not firm. Third, the abdomen is large and the body is swollen. Fourth, the skin is thick, and pressing leaves a deep indentation ( , pronounced "yan" with reverse cut, meaning deep). Fifth, the abdominal color does not change. The cause and signs of Skin Distension have these five distinctions. Ping An: "Ran" in *Ling Shu* is written as " ". " " in *Jia Yi Jing* is written as "fu xian" (abdominal depression).)

What about Drum Distension? Qibo said: Both the abdomen and body are enlarged, equal in size to Skin Distension. The complexion is greenish-yellow, and abdominal veins are prominent. This is its sign. (Next, explaining Drum Distension, there are six distinctions. The cause and signs share four similarities with Skin Distension. Fifth, the abdominal color is greenish-yellow. Sixth, abdominal veins are visible. These six constitute the signs of Drum Distension. Ping An: "Fu shen jie da" in *Ling Shu* is written as "Fu Zhang Shen Jie Da" (abdominal distension and body all large), in *Jia Yi Jing* as "Fu Shen Jie Zhong" (abdomen and body all swollen). In *Ling Shu* and *Jia Yi Jing*, "cang" is written as "cang" (green/blue), "mai qi" as "jin qi" (veins emerge). *Jia Yi Jing* notes: another version writes "mai" (vessel).)

What about Intestinal Polyp (Chang Tan)? Qibo said: Cold Qi lodges outside the intestines, clashing with Wei Qi. Qi fails to circulate properly. Due to its attachment, a mass forms and adheres internally. Evil Qi arises, and polyps grow. Initially, it is as large as a chicken egg, gradually increasing. Upon completion, it resembles pregnancy. Long-standing cases may last over a year. Pressing makes it hard; pushing moves it. Menstruation occurs on time. This is its sign. (Next, explaining Chang Tan, it is water accumulation. Chang Tan has six distinctions: First, the cause: Cold lodges outside the intestines, combining with Wei Qi, forming a mass internally. Second, the size of the formed shape. Third, the duration of the disease (Li means passing/experiencing); long cases may span years. Fourth, hardness upon pressing. Fifth, movability upon pushing. Sixth, timely menstruation. The cause and signs of Chang Tan have these six distinctions. Ping An: In *Ling Shu* and *Jia Yi Jing*, "xiang bo" is written as "xiang bo" (clash). "Qi bu de ying" in *Jia Yi Jing* is written as "Zheng Qi bu de ying" (Righteous Qi fails to circulate). In *Ling Shu*, "ying" is written as "rong" (nutritive), "xia" as "pi" (mass), "xi rou" as " rou". In *Jia Yi Jing*, "li sui" is written as "li sui yue" (passing months/years).)

What about Stone Mass (Shi Xia)? Qibo said: Shi Xia originates in the uterus. Cold Qi lodges in the Zi Men (uterine opening). The Zi Men closes, Qi does not flow, and evil blood should be discharged but is retained, accumulating daily and enlarging. It resembles pregnancy, but menstruation does not occur on time. (Next, explaining Shi Xia, there are four distinctions: First, the location of the mass. Second, the cause: Cold lodges in the Zi Men, causing evil blood to coagulate and not discharge. Third, the size and shape of Shi Xia. Fourth, irregular menstruation. The cause and signs of Shi Xia have these four distinctions. Shi Shui is omitted without explanation. Ping An: "Qi bu tong" in *Ling Shu* is written as "Qi bu de tong" (Qi fails to flow).) All occur in women and can be treated by guiding or purging downwards.

Huangdi said: Can Skin Distension and Drum Distension be treated with acupuncture? Qibo said: First puncture the blood collaterals in the abdomen, then regulate the meridians, and also puncture to remove blood from the vessels. Huangdi said: Good. (Chang Tan and Shi Xia are diseases of women. Water disease is treated by puncturing to remove it. Chang Tan and Shi Xia can be guided down via acupuncture. It is unknown whether Skin Distension and Drum Distension can be punctured. First, drain the blood collaterals to remove evil blood, then regulate the meridians, also removing blood from collaterals. Ping An: In *Ling Shu*, "fu zhi xue luo" is written as "zhang zhi xue luo" (distension's blood collaterals), "qu qi xue mai" as "qu qi xue luo" (remove their blood collaterals).)

Huangdi asked Qibo: There is a disease with fullness in the heart and abdomen. One cannot eat dinner if one eats breakfast. What disease is this? Qibo said: It is named Drum Distension. Huangdi said: How to treat it? Qibo said: Treat with Ji Li (Chicken Fermented Wine). One dose brings improvement, two doses bring cure. Huangdi said: Why does it sometimes recur? Qibo said: This is due to unregulated diet, causing occasional pain. Although the disease seems resolved, pain occurs at times because Qi gathers in the abdomen. (Qi fills the heart and abdomen, so one cannot eat dinner after eating breakfast; this is named Drum Distension. One can use chicken dung made into pills, burn until smoke is heavy, pour half a dou of clear wine over it, collect the juice, named Ji Li. Drinking induces sweating. If one dose is ineffective, proceed to two doses. This not only treats Drum Distension but also cures Skin Distension. Recurrence is due to failure to regulate diet carefully. Ping An: For "Gu Zhang", *Su Wen* New Correction states: "*Tai Su* writes 'Gu' as 'Gu' (grain)." This version still uses "Gu" (drum), note same. In *Su Wen* and *Jia Yi Jing*, "Ji Li" is written as "Ji Shi Li" (Chicken Dropping Fermented Wine), "Qi" as "Ji" (dose), "gu shi tong" as "gu shi you bing ye" (thus having disease at times). "Shi dang tong" in *Su Wen* is written as "shi gu dang bing", in *Jia Yi Jing* as "yin dang feng" (due to wind). Note: Yuan edition writes "qu han" (extract sweat) as "qu zhi" (extract juice).)