灵枢经·胀论 Discourse on Distension

Huangdi said: 'How does distension manifest in the pulse at the inch opening?' Qibo said: 'When the pulse is large, firm, and rough, this indicates distension.' Huangdi said: 'How does one know whether the distension is of the viscera or of the bowels?' Qibo said: 'Yin corresponds to the viscera, and yang corresponds to the bowels.'

Huangdi said: 'When qi causes a person to become distended, does this occur within the blood vessels, or within the viscera and bowels?' Qibo said: 'All three are involved, yet none of these is the true dwelling place of distension.' Huangdi said: 'I wish to hear of the dwelling place of distension.' Qibo said: 'Distension always occurs outside the viscera and bowels; it pushes the viscera and bowels aside, encases the chest and rib-sides, and distends the skin — hence it is called distension.'

Huangdi said: 'The viscera and bowels lie within the chest, rib-sides, and abdomen, stored away like precious vessels within a case or chest; each has its own place and dwelling, and though they bear different names they occupy the same region, and within this one region their qi each differ — I wish to hear the reason for this.' Huangdi said: 'I have not yet grasped the meaning of this; let me ask again.' Qibo said: 'The chest and abdomen form the outer wall of the viscera and bowels. The chest center is the palace-city of the pericardium, the heart's ruling minister; the stomach is the great granary; the throat and the small intestine serve as the conduits of transmission; the five orifices of the stomach are the gates of the villages and wards; and Lianquan and Yuying are the pathways of fluid and humor. Thus the five viscera and six bowels each have their own borders and boundaries, and their diseases each take their own distinct forms. When the nutritive qi follows the vessels properly, but the defensive qi moves in reverse, this produces distension of the vessels; when the defensive qi merges with the vessels and moves along the interstices, this produces distension of the skin. Draining at Zusanli: for cases nearby, one draining suffices; for cases more distant, three drainings are needed. Without inquiring whether the condition is deficient or excess, the skilled physician's task lies in swift drainage.'

Huangdi said: 'I wish to hear the manifestations of distension.' Qibo said: 'In heart distension, there is vexation of the heart, shortness of breath, and restless sleep. In lung distension, there is an empty fullness together with wheezing and coughing. In liver distension, there is fullness beneath the rib-sides with pain drawing into the lower abdomen. In spleen distension, there is a tendency toward foul eructation, the four limbs feel vexed and heavy, the body feels so heavy that one cannot bear the weight of one's own clothing, and sleep is restless. In kidney distension, there is fullness of the abdomen drawing into the back, a feeling of oppressive discomfort, and pain in the lower back and hips. Among the distensions of the six bowels: in stomach distension, there is fullness of the abdomen, pain in the epigastrium, a scorched odor perceived at the nose, interference with eating, and difficulty in defecation. In large intestine distension, there is rumbling and gurgling pain in the intestines, and if additionally struck by cold in winter, this brings diarrhea with undigested food. In small intestine distension, there is a cautious, guarded distension of the lower abdomen, with pain drawing into the lower back. In bladder distension, there is fullness of the lower abdomen together with painful urinary blockage. In triple burner distension, the qi fills the skin, giving a sensation of lightness and puffiness without firmness. In gallbladder distension, there is pain and distension beneath the rib-sides, bitterness in the mouth, and a tendency to frequent sighing.'

In all these various forms of distension, the underlying principle is one and the same: one must clearly understand accord and opposition, and not err in the number of needlings. To drain what is deficient and supplement what is already replete drives the spirit from its dwelling, brings about evil and the loss of what is proper, and leaves the true qi unable to settle — this is the failure of the unskilled practitioner, and when it occurs, it is attributed to fate. To supplement what is deficient and drain what is replete allows the spirit to return to its dwelling, and by long sealing up the void, this is called the mark of the skilled physician.

Huangdi said: 'How does distension arise? From what cause does it come about?' Qibo said: 'The defensive qi, in its ordinary course through the body, runs alongside the vessels and travels through the interstitial flesh, its movement having its proper accord and opposition; when yin and yang follow each other properly, harmony with Heaven is attained, the five viscera renew themselves in turn, the four seasons proceed in their proper sequence, and the five grains are thereby transformed. But when reversal qi settles below, the nutritive and defensive qi become lodged and stagnant, cold qi rebels upward, the true qi and the evil qi assail one another, and these two qi contend together — this is what combines to form distension.' Huangdi said: 'Good. But how may one resolve remaining doubt in this matter?' Qibo said: 'By verifying it against the true condition — when the three aspects converge, the diagnosis is confirmed.' Huangdi said: 'Good.'

Huangdi asked Qibo: 'The Discourse on Distension states that, without inquiring whether the condition is deficient or excess, the physician's task lies in swift drainage — for cases nearby, one draining suffices, and for cases more distant, three drainings are needed. But now there are cases in which three drainings fail to relieve the distension — where lies the fault?' Qibo replied: 'This refers to needling that has sunk into the fatty membrane yet has struck the qi-point precisely. If the needle does not strike the qi-point precisely, the qi becomes internally sealed off; if the needle does not sink into the membrane, the qi does not move; and if it passes above and strikes only the flesh, the defensive qi becomes thrown into disorder, and yin and yang chase after one another erratically. In the case of distension, when drainage is called for but is not properly carried out, the qi therefore fails to descend; if three drainings fail to relieve it, one must certainly change the approach — once the qi descends, the treatment should stop, and if it has not yet descended, one begins again. In this way complete success can be assured — how then could there be failure? In treating distension, one must carefully examine its full extent, draining when drainage is called for and supplementing when supplementation is called for, responding as a drum responds to the drumstick — how then could there be a case that fails to yield?'