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Huangdi said: How do the pulse manifestations at the Cun Kou (inch position) reflect distension? Qibo replied: A pulse that is large, firm, and choppy indicates distension. Huangdi asked: How can one determine which Zang or Fu organ is affected by distension?

Qibo replied: Yin meridians correspond to Zang organs, and Yang meridians correspond to Fu organs.

This passage continues from the previous text, discussing the circulation of Wei Qi (Defensive Qi) inside and outside the body and organs, which can be either smooth or reversed. If the flow is not smooth, it manifests externally as Mai Distension (distension of the vessels) or Fu Distension (distension of the skin); internally, it manifests as distension of the Zang or Fu organs. At the Cun Kou, a firm and large pulse is a Yang pulse, while a choppy pulse is a Yin pulse. By observing the Yin-Yang nature of the pulse, one can determine whether the distension involves a Zang or a Fu organ.

Huangdi asked: Does the pathogenic Qi causing distension reside in the blood vessels, or within the Zang and Fu organs? Qibo replied: Pathogenic factors exist in all three locations (vessels, organs, and skin/subcutaneous tissue), but these are not the primary seat (She) of distension.

Huangdi said: I wish to hear where the primary seat of distension lies. Qibo replied: Distension occurs outside the Zang and Fu organs, compressing them, expanding the chest and hypochondrium, and filling the skin. Therefore, it is named "Distension."

Yao Shiyin stated: This disease originates in Qi and subsequently affects the tangible aspects of Zang/Fu organs and blood vessels; thus, factors exist in all three areas. However, the primary seat of distension, when internal, lies in the empty spaces outside the Zang and Fu organs; when external, it lies between the skin and interstices. Hence, it is called "Distension," indicating that distension resides in the formless Qi aspect.

Huangdi said: The Zang and Fu organs are located within the chest, hypochondrium, and abdomen, like precious artifacts stored in boxes and cabinets. Each has its specific location, different names, yet they share the same region while having distinct Qi dynamics. I wish to understand the reason behind this.

Wang Fanghou noted: Huangdi asks how to distinguish which Zang or Fu organ is distended when the distending Qi is located outside the organs, given that each organ has boundaries and distinct Qi. There appears to be missing text in Qibo's subsequent response.

Huangdi said: I still do not understand. Please explain further. Qibo replied: The chest and abdomen are the outer walls (Guo) of the Zang and Fu organs. Dan Zhong (Chest Center) is the palace city of the Heart Master (Pericardium). The Stomach is the Great Granary (Tai Cang). The pharynx and small intestine are responsible for transmission. The five orifices of the stomach are like the gates of neighborhoods. Lian Quan and Yu Ying are the pathways for Body Fluids. Thus, the Zang and Fu organs have distinct boundaries, and their diseases present with specific shapes/symptoms.

Ying Qi (Nutritive Qi) circulates within the vessels. When Wei Qi rebels, it causes Mai Distension. When Wei Qi moves along with the vessels and permeates the muscle intervals, it causes Fu Distension. One should needle San Li (ST36) using the reducing method. For conditions close to the surface, one needling suffices; for distant conditions, three needleings are required. Regardless of deficiency or excess, the key for the skilled practitioner is rapid reduction.

This section explains that Wei Qi is generated from the essence of water and grain in the Stomach. It travels through the Yang during the day and the Yin at night. Rebellion in the Yang leads to Mai Distension and Fu Distension; rebellion in the Yin leads to distension of the empty spaces and the Zang/Fu organs. The chest and abdomen are the outer walls of the organs; Dan Zhong is the palace of the Heart Master. Distension occurs outside the organs, compressing them and expanding the chest/hypochondrium. This represents Wei Qi rebelling in the Yin, leading to organ distension. The Stomach receives and stores water and grain, acting as the Great Granary in the Middle Jiao. Superiorly, it connects to the pharynx, transmitting Qi and food; inferiorly, it connects to the small intestine, transmitting waste and fluids. The five orifices of the stomach are like neighborhood gates. Since food enters the stomach and has five flavors, Body Fluids follow different paths: sourness enters the Liver first, bitterness the Heart, sweetness the Spleen, pungency the Lung, and saltiness the Kidney. The Zang organs store the essence of water and grain. The fluids overflowing into the Lower Jiao exit via the Ren Mai through Lian Quan and Yu Ying to moisten the upper orifices. Thus, the Zang and Fu organs have boundaries, and their diseases manifest differently. For instance, if Ying Qi circulates in the vessels and Wei Qi rebels within them, Mai Distension occurs. If Wei Qi accompanies the vessels and spreads into the muscle intervals, Fu Distension occurs. Although Wei Qi usually travels with the vessels through the muscles, its movement can be smooth or rebellious. If it travels smoothly with the vessels but invades the vessel interior, it causes Mai Distension; if it travels in the flesh, it causes Fu Distension. These are all reversals of Wei Qi. Therefore, one should reduce ST36 on the Foot Yangming Meridian. For superficial/distal conditions near the skin/vessels, one reduction suffices; for deeper/distant conditions in the "walls" (organs), three reductions are needed. Regardless of deficiency or excess, the skilled practitioner acts quickly to reduce. Retention of Qi leads to organ distension. Since Wei Qi originates from the Great Granary (Stomach), reducing ST36 is indicated.

Yao stated: "Ying Qi circulates in the vessels; Wei Qi rebellion causes Mai Distension" shares the same meaning as the previous chapter's "Ying Qi follows the vessels smoothly; Wei Qi moves in reverse." Wu stated: When Wei Qi rebels in the empty spaces, it causes Drum Distension (Gu Zhang); when it adheres to the Mu Yuan (Omenta/Mesentery) and blocks fluid transmission, it causes Intestinal/Stomach Distension; when the gates and boundaries are unclear, it causes Zang Distension. These are all pathways of the Stomach Fu, hence reducing foot ST36 is indicated. If the disease has become chronic and deficient, reducing again would damage Stomach Qi; thus, "the skilled practitioner acts quickly to reduce" refers to treating the initial stage. Yang Yuanru stated: Reversal gradually diminishes the mechanism of growth, so long-standing cases inevitably become deficient. One must examine blockages in transmission and reduce them; unblock blocked gates and fluid pathways; regulate unclear boundaries; tonify insufficient Zheng Qi. Combining tonification, reduction, and regulation is the excellent method for treating distension. For new-onset distension without severe deficiency, aggressive attack is urgent, potentially resolving it in one strike. Zhu Yongnian stated: Physicians only know to reduce to eliminate distension, ignoring the gates and pathways. Understanding these allows one to dissect according to natural structures. Thus, this classic is about addressing the root and clearing the source. Ni Chongzhi stated: Lian Quan and Yu Ying are fluid pathways. Blockage here closes the orifices and causes Qi reversal. Therefore, treating distension requires first unblocking fluids, hence "If you wish to drain downwards, you must first lift upwards." Zhuweigong stated: Fluids nourish essence and moisten orifices. Branch Qi exits the ears for hearing; Zong Qi (Gathering Qi) exits the nose for smell; Turbid Qi exits the stomach for taste via lips/tongue; Essence-Qi ascends to the eyes for vision. If fluid pathways are blocked, all Qi becomes rebellious.

Huangdi said: I wish to hear the forms of distension. Qibo replied: In Heart Distension, there is mental restlessness, shortness of breath, and disturbed sleep. In Lung Distension, there is false fullness, wheezing, and coughing. In Liver Distension, there is fullness and pain under the hypochondrium radiating to the lower abdomen. In Spleen Distension, there is frequent hiccups, irritability and heaviness in the four limbs, body weight such that even clothes feel burdensome, and disturbed sleep. In Kidney Distension, there is abdominal fullness radiating to the back, a feeling of oppression (Ai Ai Ran), and pain in the waist and thighs. Regarding Fu Distension: In Stomach Distension, there is abdominal fullness, epigastric pain, smelling burnt odors from the nose, difficulty eating, and difficult defecation. In Large Intestine Distension, there is borborygmus and pain (Zhuo Zhuo sound); if exposed to cold in winter, it leads to undigested diarrhea. In Small Intestine Distension, there is lower abdominal distension radiating to the waist and pain. In Bladder Distension, there is lower abdominal fullness and urinary retention (Qi Long). In San Jiao Distension, Qi fills the skin, feeling light but not hard. In Gallbladder Distension, there is painful distension under the hypochondrium, bitter taste in the mouth, and frequent sighing.

Wu stated: This describes Wei Qi rebelling within the "city walls" (chest/abdomen), causing organ distension. "Wishing to hear the forms" asks about the manifestations of Zang/Fu distension, showing the progression from formless Qi to tangible pathology.

For all these distensions, the principle lies in one point: clearly understanding reversal and smoothness, and applying acupuncture counts accurately. Tonify deficiency and reduce excess. If Shen (Spirit) leaves its chamber, it招致邪气 (attracts pathogens) and loses righteousness, making the true Qi unstable. A crude physician’s failure is called premature death. Conversely, tonifying deficiency and reducing excess allows Shen to return to its chamber and fills the emptiness; this is called a skilled artisan.

Yao stated: "The principle lies in one" means the harmony of Heaven, Earth, and Humanity. "Reversal and smoothness" refers to Ying Qi moving in the vessels and Wei Qi moving outside, interacting in reverse and smooth patterns. "Filling the emptiness" means preventing external疏空 (looseness/emptiness) of vessels and skin, and ensuring internal abundance of Zang/Fu Shen Qi, thereby avoiding reversal disorders. This is the skilled artisan’s prevention of disease. Mo Zhongchao noted: The previous section said "regardless of deficiency/excess, act quickly to reduce"; this section says "reduce deficiency, tonify excess, Shen leaves its chamber." This implies one must assess pathogen vs. righteous Qi before tonifying/reducing. The Sage’s foresight is profound; students must deeply comprehend this. Wang Fanghou stated: Shen is formed by the interaction of congenital essence and food essence.

Huangdi asked: How does distension arise? What is the cause? Qibo replied: Wei Qi in the body usually travels with the vessels and through the muscle intervals, with movement being either smooth or reversed. When Yin and Yang follow each other, Harmony with Heaven is achieved. The Five Zang organs function in rotation, the Four Seasons follow order, and grains are digested. However, if Jue Qi (Rebellious Qi) arises below, Ying and Wei Qi stagnate, Cold Qi rebels upward, True Qi and Pathogenic Qi attack each other, and the two Qi types clash, resulting in distension.

This section explains that Wei Qi reversal is caused by Cold Qi in the Lower Jiao. Wei Qi usually travels with vessels through muscles, with smooth or reversed movement. "Yin and Yang following each other" means Ying and Wei outside the vessels move together; Yin/Yang and Clear/Turbid have smooth or reversed flows, achieving Heavenly Harmony, mirroring the sky’s rotation and rivers’ flow. "Five Zang organs rotating" means Ying Qi circulates through organ meridians, entering/exiting, cycling endlessly. "Four Seasons orderly" means Wei Qi travels Yang by day and Yin by night, responding to seasonal changes. When Yin/Yang are peaceful, grains digest, and Ying/Wei are generated. This first discusses Yin/Yang harmony, then the cause of reversal: Jue Qi below, stagnation of Ying/Wei, upward rebellion of Cold, clash of True/Pathogenic Qi, leading to distension.

Huangdi said: Excellent. How can confusion be resolved? Qibo replied: By combining [Ying, Wei, and Zhen] Qi, the triad yields the answer. Emperor said: Excellent.

Zhen Qi (True Qi) is received from Heaven and combined with Grain Qi to nourish the body. The congenital Zhen Yuan of the Lower Jiao combines with Yangming (Stomach/Large Intestine) to transform grain essence into Ying and Wei Qi. Yuan Zhen Qi communicates through the Cou Li (interstices), merges with Ying/Wei, and circulates throughout the body. Thus, Ying and Wei Qi combine with Zhen Yuan, and the triad reveals the cause of reversal. If Tian Zhen Qi rebels downward, Ying/Wei Qi stagnates upward. If Lower Jiao Cold Water Qi rebels upward, True and Pathogenic Qi clash, and Ying/Wei Qi combats, resulting in distension. Wu stated: Yuan Zhen Qi is the primordial essence of Heaven. Combined with Cold Water Qi, when True and Pathogenic Qi clash, True Qi rebels downward and Cold Qi rebels upward. True Qi cannot combine with Ying/Wei, causing stagnation.

Huangdi asked Qibo: The Treatise on Distension states "regardless of deficiency/excess, act quickly to reduce," needing one needling for close conditions and three for distant ones. Now, if three needleings fail to resolve distension, where is the error? Qibo replied: This occurs when the needle sinks into the Muscular Huang (Blind Tissue) but misses the Qi Acupoint. If the Qi Acupoint is missed, Qi closes internally. If the needle does not sink into the Huang layer, Qi cannot ascend and disperse. If only muscle is pierced, Wei Qi becomes chaotic, and Yin/Yang chase each other. For distension, if reduction is indicated but not applied, Qi will not descend. If three needleings fail, one must change the approach. Once Qi descends, stop. If it doesn't descend, restart correctly. This ensures safety; danger is unlikely. For distension, one must examine the condition (Zhen). Reduce if indicated, tonify if indicated. Like a drum responding to a beat, how could distension remain unresolved? (Note: Huang sounds like 'huang'; KT is pronounced 'ren', same as 'Zhen').

This section discusses distension caused by Wei Qi reversing internally, distinguishing between City Walls and Mu Yuan (Omenta). Mu Yuan is the Huang/Gao of the organs. Distension due to internal Wei Qi reversal lies in the empty spaces of the palace/city walls, so ST36 is used, requiring three needleings. If three needleings fail, it is because the needle sank into muscular Huang without hitting the Qi Acupoint, or hit muscle instead of acupoint. If the acupoint is missed, Qi closes internally. If the Huang layer is not reached, Qi cannot ascend. Thus, if three needleings fail, change the method to target Qi Acupoints. There are 365 Qi Acupoints corresponding to the year, such as Wei Wan (Upper Ji) and Guan Yuan (Lower Ji), which are not merely gatherings of grain. Piercing only muscle causes Wei Qi chaos and Yin/Yang conflict. Wei Qi travels in skin/flesh textures; now targeting Qi Acupoints, one should not just pierce muscle. Yao stated: According to *Jin Gui Yu Han*, Cou (pores) are where San Jiao communicates Yuan Zhen; Li (textures) are skin/flesh patterns. Organ textures are the fleshy layers of Mu Yuan, containing vessel systems. Since Wei Qi sinks into Huang membranes and enters vessels, Qi Acupoints must be targeted. Wang Fanghou stated: *Su Wen* has chapters on Qi Fountains and Qi Acupoints, covering all Six Yin/Yang meridians. Distinguishing Fu and Acupoints: Fu stores and suppresses Blood/Qi internally; Acupoints are cavities where Qi enters and exits.