Loading...
Chapter 35 of 81
黄帝内经·灵枢
Overall Paraphrase
The Yellow Emperor asked: From the manifestation of the Cunkou pulse (the radial artery pulsation at the wrist, the primary site for pulse-taking in Chinese medicine), how does one determine distension disease? Qi Bo replied: If the pulse is large, firm, and rough/sluggish, it indicates distension.
The Yellow Emperor further asked: How does one know whether it is distension of the zang (solid organs) or the fu (hollow organs)? Qi Bo said: The yin pulse corresponds to the zang organs, and the yang pulse corresponds to the fu organs. The Yellow Emperor further inquired: When qi causes distension in a person, does it reside within the blood vessels or within the zang-fu organs? Qi Bo replied: Qi exists in both the blood vessels and the zang-fu organs, but the place where distension settles is elsewhere.
The Yellow Emperor said: I wish to hear where distension settles. Qi Bo explained: What is called distension all resides outside the zang-fu organs. It displaces the zang-fu organs, expands outward to the chest and rib-side, causing the skin to bulge—hence it is called "distension." The Yellow Emperor asked again: The zang-fu organs lie within the chest, rib-side, and abdominal cavity, like precious objects stored in a box or cabinet, each having its own order and position. Though their names differ, they share the same region, and the qi within each is not the same. I wish to hear the reasoning behind this.
Qi Bo explained: The chest and abdomen are the outer enclosure of the zang-fu organs; Danzhong (the periphery of the pericardium, the meeting point of qi) is the palace-city of the heart ruler; the stomach is the Grand Granary (the storehouse for water and grain); the throat and small intestine are the passageways for transmitting water and grain; the five orifices of the stomach are like alleyways and gates; Lianquan and Yuying are the pathways through which fluids travel. Therefore, the five zang and six fu each have their boundaries, and their diseases each have their own manifestations.
Nutritive qi (qi that moves within the vessels and has nourishing functions) circulates within the channels; Defensive qi (qi that moves outside the vessels with warming and protective functions) moving in rebellion and disorder can form vessel distension; when defensive qi merges into the channels and moves among the intermuscular spaces, it can form skin distension. In ancient times, it was proposed to needle Zusanli (ST 36) with reducing method—once for recent cases, three times for prolonged cases—with the saying "regardless of deficiency or excess, the physician should hurry to drain pathogenic qi." However, this was an early-stage experience; the later text provides further syndrome differentiation.
The Yellow Emperor said: I wish to hear the specific manifestations of the various distensions. Qi Bo said:
Distension of the six fu:
These distension diseases share the same principle; the key lies in understanding the against/with movement of qi mechanism, and in not erring in the supplementing and reducing methods of needling. If one mistakenly applies reducing to deficiency and supplementing to excess, the spirit-qi will leave its place of residence, inviting pathogenic qi and harming the righteous qi; the true qi cannot be stabilized. This is the erroneous treatment of a crude practitioner, which may be called harming life. Correct supplementing deficiency and reducing excess causes the spirit-qi to return to its place, and long-term nourishment fills the empty spaces—this is what is called a good physician.
The Yellow Emperor asked: How does distension arise? What causes it? Qi Bo said: Defensive qi in the body, under normal conditions, moves in parallel with the channels, circulating through the intermuscular spaces. Its movement has against and with patterns, yin and yang coordinate with each other, enabling harmony with nature. The five zang alternate in governing the seasons, the four seasons follow their order, and the five grains are transformed into qi and blood. If there is reversed qi in the lower jiao, nutritive and defensive qi arrest and stop, cold evil moves upward against the flow, and righteous qi and pathogenic qi attack each other—the two qi contend and combine to form distension.
The Yellow Emperor asked: How does one resolve this doubt? Qi Bo said: One must integrate the three factors—righteous qi, pathogenic qi, and disease location—and examine them comprehensively before arriving at a correct understanding.
The Yellow Emperor pressed further: Earlier it was said, "regardless of deficiency or excess, the physician should hurry to drain, one needling for recent cases, three for prolonged cases." But now after three needlings the distension has not resolved—where does the fault lie? Qi Bo replied: This means that needling must penetrate deeply into the rouhuang (fascial spaces between muscles) and accurately strike the qi acupoints (holes where channel qi is infused). If the qi acupoint is not struck, qi will become internally blocked; if the needle does not penetrate the rouhuang, qi cannot move; if needling is too shallow, reaching only the muscles, it instead causes defensive qi to become chaotic and yin and yang to pursue and harass each other. For distension disease, when draining is indicated but not performed, qi will not descend; if it does not descend after three attempts, one must change the needling pathway; only when qi descends can one stop; if it still does not descend, one may adjust again to seek complete success—how could there be danger? In treating distension, one must carefully examine the disease manifestations: drain when draining is indicated, supplement when supplementing is indicated—like a drumstick striking the drum with immediate response. How could it fail to resolve?
The core of this chapter is to clearly define distension as a disease pattern primarily involving "qi accumulating outside the zang-fu organs." It is not simply the solid accumulation of a single organ but rather a state of fullness formed in the chest, rib-side, skin, and intermuscular spaces due to abnormal qi movement.
In terms of pathogenesis, the chapter emphasizes "nutritive and defensive qi arrest and stop, cold evil moves upward, righteous and pathogenic qi contend, two qi combat each other." This demonstrates that distension is not caused by a single factor but is the result of blocked righteous qi movement, participation of external evil or internal cold, and the contention of qi movement. This understanding carries clear thinking about ascending, descending, exiting, and entering of qi movement.
In terms of syndrome differentiation, the chapter details the five zang distensions and six fu distensions, showing that ancient physicians already observed how different zang-fu pathologies produce distinct locations and accompanying symptoms of distension. For example: liver distension below the ribs, gallbladder distension with bitter taste and frequent sighing, bladder distension with lower abdominal fullness and urinary difficulty. This reflects the viscera-manifestation diagnostic approach that "what is within must manifest externally."
In terms of treatment principles, the chapter contains a valuable evolution of understanding: first stating "regardless of deficiency or excess, the physician should hurry to drain," then through the Yellow Emperor's questions proposing that not all distensions can be resolved by draining alone—one must strike the qi acupoints, penetrate the rouhuang, and "drain when draining is indicated, supplement when supplementing is indicated." This shows that early experience may have emphasized draining pathogenic qi, while the latter text emphasizes pattern-based supplementing and reducing and accurate needling—reflecting the self-correction and enrichment of TCM theory.
From the symptom perspective, the abdominal distension, rib-side pain, wheezing and cough, bitter taste, and urinary difficulty described in the chapter share certain similarities with manifestations in modern medicine such as gastrointestinal gas accumulation, functional bloating, chronic obstructive pulmonary disease, hepatobiliary disorders, and urinary retention. However, TCM "distension" is a symptom group explained through the core concept of "qi stagnation," and cannot be simplistically equated to any single modern disease.
Ancient physicians used "qi" to explain distension—this is a theoretical model. From a modern perspective, some phenomena can be understood through gastrointestinal motility abnormalities, smooth muscle tension changes, increased interstitial fluid, and autonomic nerve dysregulation, but concepts like "defensive qi rebellion" and "cold evil moving upward" belong to traditional understanding and cannot be fully mapped to modern indicators.
The discussion on needling "qi acupoints" and penetrating "rouhuang" has certain resonance with modern acupuncture's emphasis on acupoint localization, needling depth, and fascial layers. However, the terms "qi acupoints" and "rouhuang" still belong to traditional channel theory and cannot be completely explained by anatomical structures.
It should be objectively noted that "regardless of deficiency or excess, the physician should hurry to drain" in this chapter is an early-stage experience that later generations already revised into pattern-based supplementing and reducing. Descriptions such as "smelling a burnt odor from the nose" and "frequent sighing" can be treated as documentary records of ancient clinical observation but should not be over-interpreted out of context.
BuGua Note: This content is based on classical Chinese medicine texts and is provided solely for traditional cultural study and research. It does not constitute any medical diagnosis, medication prescription, or treatment advice. If you feel unwell, please seek medical attention promptly.