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[Scriptural Meaning]
The Yellow Emperor asked: There are cases where the disease does not originate from the hair follicles, but rather the Yang Qi of the Five Zang organs has already been exhausted. Body fluids fill the chest and abdomen, Yin essence resides alone within, while Jing (essence) is depleted inside and Qi dissipates outside. The body becomes so emaciated that it cannot even be covered by clothes. This presents with stiffness in the four extremities accompanied by internal symptoms. This indicates that Qi is blocked internally, while the physical form deteriorates externally. How should this be treated? Qibo replied: One should balance the Yin and Yang through weighing and measuring, remove the accumulated stale matter within, gently move the four extremities, keep warm, apply Miao acupuncture at the affected sites to restore the physical form. Open the "Ghost Gates" (sweat pores) to induce sweating, and purify the "Clean House" (bladder) to promote urination, allowing Jing to be distributed in due course. When the Yang Qi of the Five Zang organs is distributed, and the five organs are dredged and cleansed, Jing will naturally generate, the physical form will naturally prosper, bones and flesh will protect each other, and the Great Qi will become peaceful. ○ The Kidney belongs to Supreme Yin; Supreme Yin tends to accumulate water. The Lung belongs to Taiyin, and the Shaoyin meridian is the pulse of winter. The root of edema lies in the Kidney, while its manifestation lies in the Lung; both are caused by water accumulation. ○ Why can the Kidney accumulate water and cause disease? Because the Kidney is the gate of the Stomach. If the gate is not functioning properly, water accumulates and spreads according to the principle of similarity. ○ Water disease manifests below as edema and abdominal distension, and above as wheezing, calling out, and inability to lie flat. This is a condition where both the root and the branch are diseased. ○ Inability to lie flat, with wheezing upon lying down, is caused by the invasion of water Qi. ○ Pulsation in the neck vessels, accompanied by severe wheezing and coughing, is called water disease. Slight swelling in the inner canthus of the eye, resembling a silkworm resting, is called water disease. ○ When Yin and Yang Qi knot and slant, with excessive Yin and deficient Yang, it is called Stone Water. ○ Knotting of the Three Yin meridians is called water disease. ○ Swelling caused by Qi stagnation, with alternating dysfunction of the four seasons, leads to the exhaustion of Yang Qi. ○ Excessive Heat causes swelling. ○ All dampness-induced swelling and fullness belong to the Spleen. ○ All distension and abdominal enlargement belong to Heat. ○ Turbid Qi remaining in the upper jiao produces bloating. ○ A disease characterized by abdominal fullness, where one can eat in the morning but not in the evening, is named Drum Distension (Gu Zhang). It is treated with Ji Shi Li (Chicken Dropping Fermented Liquid); one dose brings improvement, two doses bring cure. (From *Su Wen*)

Skin distension (Fu Zhang) occurs when Cold pathogen lodges between the skin. The abdomen is distended but not hard. The whole body is swollen, the skin is thickened, pressing the abdomen leaves an indentation that does not rise immediately, and the abdominal color remains unchanged. This is its clinical presentation. ○ Drum Distension (Gu Zhang) presents with generalized enlargement equal to that of Skin Distension, with a sallow-yellow complexion and visible subcutaneous veins on the abdomen. This is its clinical presentation. ○ Deficiency of the Foot-Taiyin Spleen meridian leads to Drum Distension. ○ Excess of Spleen Qi leads to abdominal distension. ○ Heart Distension presents with vexation, shortness of breath, and restless sleep. Lung Distension presents with empty fullness, wheezing, and coughing. Liver Distension presents with fullness and pain under the hypochondrium radiating to the lower abdomen. Spleen Distension presents with frequent hiccups, irritability and heaviness in the four limbs, and a body weight so great that one cannot bear clothing. Kidney Distension presents with abdominal fullness radiating to the back, and aching pain in the waist and thighs. Stomach Distension presents with abdominal fullness, epigastric pain, olfactory hallucinations of burnt odor, difficulty eating, and constipation. Large Intestine Distension presents with borborygmus and gurgling pain; if exposed to cold again in winter, it leads to undigested stool diarrhea. Small Intestine Distension presents with lower abdominal distension radiating to the waist and causing pain. Bladder Distension presents with lower abdominal fullness and urinary retention. Sanjiao Distension presents with Qi filling the skin, feeling light but not hard. Gallbladder Distension presents with pain and distension under the hypochondrium, bitter taste in the mouth, and frequent sighing. (From *Ling Shu*)

[Philosophical Discourse]
Regarding Distension (Zhang) and Swelling (Zhong), the internal causes differ, but the external appearances are often similar. They can be distinguished as follows: If the abdomen enlarges first, followed by swelling of the four limbs, it is a Distension disease. If the head and feet swell first, followed by abdominal enlargement, it is Water disease. However, if the abdomen is large but the four limbs do not swell at all, it is a Distension disease. If the umbilicus, abdomen, and four limbs are all swollen, it is Water disease. (Shen Jin'ao)

All excess syndromes, whether caused by the Six Exogenous Pathogens or dietary injury, involve Yang pathogens which are rapid in nature. Their arrival is sudden, often forming within a few days. If it is a deficiency syndrome, whether due to emotional labor or excess in wine and sexual activity, it accumulates day by day and month by month. Its onset is gradual, often forming after several months. (Li Shicai)

Someone asked: Is there a distinction between swelling and distension? I replied: Swelling is swelling, and distension is distension. When Qi and Blood flow freely, the Zang-Fu organs are harmonious, and the collaterals are unobstructed, how can swelling occur externally? How can distension occur internally? This happens because the person's Kidney Qi is deficient, losing the power of opening and closing; Lung Qi is deficient, losing the function of clearing and descending; Spleen Qi is deficient, losing the normal state of transformation and transportation; Exterior Qi is deficient, allowing external pathogens to easily enter. Thus, swelling arises in the muscles, and distension arises in the Zang-Fu organs. Manifesting externally, one knows it is swelling, and others know it is swelling. Occurring internally, one knows it is distension, but others do not know it is distension. However, swelling and distension have many variations, and deficiency/excess patterns differ. Wind, Cold, Dampness, Heat, Water, Parasites, Blood, and Food stagnation—all these various causes must be discussed in detail to know which approach to follow. Swelling caused by external invasion of Wind-Cold is an excess syndrome, such as swelling of the face/head, parotitis (Fayi), or gums. Swelling caused by external invasion of Damp-Heat is mostly excess, but can also be deficiency, such as swelling from sores/ulcers, isolated abdominal swelling (Dan Fu), or swelling from painful obstruction (Tong Bi). As for swelling caused by Qi, Water, Parasites, or Blood, there are both excess and deficiency syndromes, such as swelling under the eyes, generalized swelling, swelling of hands/feet, shiny abdominal skin swelling, scrotal/penile swelling, and swelling with blue veins on the abdomen. Treatment methods must be determined by combining syndrome differentiation with pulse diagnosis. However, Distension and Swelling are fundamentally different. Decline of Kidney Fire and deficiency-cold of the Middle Earth (Spleen/Stomach) lead to distension due to failure of Spleen Yuan to transform. Water failing to nourish the Liver, leading to Wood stagnation and disharmony of the hypochondrium, leads to distension. Yin Fire burning Metal, causing Lung Qi stagnation, wheezing, coughing, and congestion, leads to distension. Not only that, there is also distension due to Damp-Heat in the Spleen/Stomach, fluid retention in the Middle Jiao, blood stasis in the Middle Jiao, parasite accumulation in the intestines/stomach, Qi stagnation and food obstruction in the Yangming, and blockage of urination/defecation in the lower abdomen causing distension. External Wind does not cause distension diseases, but distension diseases are not uniform. Generally speaking, Swelling has form, while Distension is formless; Distension is the beginning of Swelling, mostly caused by internal injury; Swelling is the severity of Distension, rarely associated with external contraction. Internal injuries present with both distension and swelling; external contractions present with swelling but no distension. If physicians can clearly distinguish external swelling from internal distension, confirming them accurately, then swelling will be recognized as swelling, and distension as distension, bringing clarity to the mind! (*Huixin Lu*)

Swelling and distension involving the Qi level are due to Qi stagnation. Such as reversal of Qi and Blood, dietary reversal, interference of Cold/Heat/Wind/Dampness, and reversal due to Qi deficiency failing to transform. As long as the regulatory function fails, all stem from the Qi level and can cause distension. For diseases of the Qi level, the complexion is sallow, the interior is firm, distension may extend to the chest and hypochondrium, pain may affect the Zang-Fu, or sudden edema may occur; this is Yang nature, rapid in movement. Or developing from top to bottom, because Yang originates from above. Or generalized swelling throughout the body, because Qi reaches everywhere. Some rebound immediately upon pressure, like pressing an air bag. Although all these belong to the Qi level, Qi diseases vary: There is distension due to Qi Heat, i.e., "All distension and abdominal enlargement belong to Heat." There is distension due to Qi Cold, i.e., "Cold in the Stomach causes distension," "Cold in the Zang generates fullness diseases." There is distension due to Qi Dampness, i.e., "All dampness-induced swelling and fullness belong to the Spleen." There is distension due to Qi Deficiency, which is Yuan Qi deficiency, i.e., "Deficiency of Foot-Taiyin leads to Drum Distension." There is distension due to Qi Excess, which is Pathogenic Excess, i.e., "Excess of Kidney Qi causes distension," "Excess of Spleen Qi causes abdominal distension," "Excess of Stomach Qi causes distension." Although all these are distension diseases, the key to treatment lies entirely in distinguishing deficiency and excess. Generally, Yang syndromes are mostly Heat, and Heat syndromes are mostly Excess; Yin syndromes are mostly Cold, and Cold syndromes are mostly Deficiency. Distension starting internally and then affecting the exterior is mostly Excess; swelling starting externally and gradually affecting the interior, or external swelling without internal distension, is mostly Deficiency. Red urine and constipation indicate Excess; clear urine and loose stools indicate Deficiency. Slippery and forceful pulses indicate Excess; wiry, floating, faint, and fine pulses indicate Deficiency. Red-yellow complexion and coarse breathing indicate Excess; emaciated appearance and short voice indicate Deficiency. Youth and vigor with obstructed Qi pathways indicate Excess; middle-age decline with chronic fatigue, mental fatigue, and timid Qi indicate Deficiency. The treatments for deficiency and excess are as opposite as ice and charcoal; misuse will surely cause harm. ○ Diseases in the Water level are due to Yin surpassing Yang. The skin and muscles are all swollen. This is fundamentally different from Qi syndromes. For Water diseases, the complexion is bright and moist, the skin is thin and glossy, the swelling develops slowly, usually rising from below, pressing the flesh feels like mud, and the swelling has distinct boundaries. Because Yin originates from below, and infiltration is gradual, these are all signs of Water disease. Observing the *Water Distension Chapter*, it says that distension from Cold Qi shows indentation upon pressing that does not rise; whereas Edema shows immediate rebound upon pressing, like a bag wrapping water. However, based on my observations and clinical verification, this contradicts that theory. In fact, for all Water syndromes, pressing causes indentation that does not rise immediately. This is because the water is in the flesh, like dregs or mud; pressing disperses it, and it cannot gather quickly, unlike a water bag. Cases that rebound immediately upon pressing are due to void Qi, which moves fast. Therefore, differentiation must be done thus. To distinguish differences in Water Qi, one must differentiate Yin and Yang. If the disease is in the Qi level, both Yang and Yin syndromes exist; if in the Water level, it is mostly Yin syndromes. Why? Although Water and Qi are of the same category, when Yang is vigorous, Qi transforms, and Water becomes Essence; when Yang declines, Qi fails to transform, and Essence becomes Water. Therefore, all Water diseases originate from the body's own Qi and Blood, but whether they become pathogenic or healthy depends on transformation. Failure of Water transformation is due to Qi deficiency; is this not Yin lacking Yang? This is why Edema diseases mostly belong to Yang Deficiency. However, Water is governed by the Kidney, and Qi by the Lung. Water soaking below while Qi exhausts above results in lower swelling/fullness and upper wheezing/urgency, affecting both root and branch, which is extremely critical. One must urgently rescue the origin to preserve life. If one mistakes deficiency wheezing for excess pathogen and still uses Lung-draining methods, failure is inevitable. (Zhang Jingyue)

Swelling stems from Water, and Distension stems from Qi. Swelling is divided into Yang Water and Yin Water. External origin implies surplus, hence Yang Water; internal origin implies insufficiency, hence Yin Water. The causes of Distension are more numerous, and the locations of distension vary. It can be caused by Dampness, Stagnation, Cold, Heat, Qi, Blood, Phlegm, Accumulation, or Parasites, all capable of causing distension. Whether in Zang-Fu, collaterals, skin, or anywhere in the body's upper/lower or interior/exterior, distension can occur. Furthermore, it may start as Cold and become Heat due to long-term stagnation, or start as Heat in the interior and transmit to Cold in the interior. Distension need not accompany swelling, but swelling must accompany distension. There are also cases where swelling and distension occur simultaneously, with变幻 (changing) manifestations. For Dampness below, use separation and drainage; for Dampness in Upper/Middle/Lower Jiao, use separation and elimination; for Dampness adhering to the interior, use Wu Ling San to unblock the Bladder; for Damp-Stagnation with Heat, use Ban Xia Xie Xin Tang for bitter-pungent descending; for Damp-Heat Qi-Blood stagnation accumulating, use Ji Jin San for simultaneous digestion and diuresis; for Qi-Blood stagnation with lingering Damp-Heat, use Xiao Wen Zhong Wan to clear Minister Fire and strengthen the Middle Jiao; for intermingled Damp-Heat and Cold-Water Qi with wheezing and oliguria and generalized swelling, use Yu Yu Liang Wan to fortify Earth to control Water, warm the Lower Jiao, and drain turbidity; for Cold-Damp in the Qi level, use Ginger and Aconite; for Cold-Damp entering the Blood level, use Cinnamon and Aconite; for Dampness rising excessively causing Heat, use Ephedra, Apricot Kernel, Gypsum, and Coix Seed to clear and肃ify the Upper Jiao; for Dampness sinking causing Bi syndrome, use Modified Huo Luo Dan to vent the Lower Jiao stagnation. Use Scallion White and Trichosanthes Fruit to lubricate Qi obstruction in the abdomen/hypochondrium; use Processed Polygonum Multiflorum and Angelica Sinensis Tail to search out and expel coagulated blood in the meridians; use Yu Hu Wan, Kong Xian Dan, Shen You Wan, and Shen Xiong Wan to drive out Phlegm-Fluid-Accumulation according to severity. These are conditions where Zang Qi is not yet damaged, located only in the Fu organs' upper/lower or membranes' exterior/interior. If Stomach Yang is deficient, Ginseng and Poria must be advanced; if Spleen Yang declines, Atractylodes and Aconite must be administered; if the Kidney is injured, Jia Jian Ba Wei Wan or Jisheng Wan are needed. ○ In summer, Damp-Heat steams and郁蒸s, Spleen-Stomach Qi weakens, Grain-Water Qi fails to transform, Dampness accumulates internally turning to Heat, gradually leading to edema and abdominal distension with difficult urination. Improper treatment allows Water-Dampness to soak for long, reverse attack the Lung, causing cough and wheezing, potentially progressing to orthopnea and inability to bend/extend, indicating imminent danger. Generally, wheezing generates distension, and distension generates wheezing. Formulas state that wheezing preceding distension treats the Lung, while distension preceding wheezing treats the Spleen. *Jin Gui Yao Lue* distinguishes Wind Water, Skin Water, Stone Water, Correct Water, and Yellow Sweat to differentiate exterior/interior treatments. Hejian Liu Wan Su proposed Triple Burner separation; Zihe Zhang proposed grinding accumulation and draining water; both have profound meanings. Secular discussions on Water-Dampness Wheezing-Distension claim opening Ghost Gates (sweating) is exterior treatment, and separating/draining urine (purifying Clean House) is interior treatment. Also claiming "All dampness swelling/fullness belongs to Spleen," using Spleen-fortifying and Damp-drying as a stable treatment, often yields no effect, leaving physicians helpless. They do not know that all diseases stem from Yin-Yang. Unblocking exterior and promoting urination vents Meridian Qi and Fu Qi, which is the treatment for Yang diseases. Warming the Water Organ, warming Spleen/Kidney, tonifying Yang to drive Water, is the treatment for Yin diseases. Treating the Lung requires light/clear agents to open the upper; treating the Spleen must assist with warming/unblocking. If Yin-Yang and Interior-Exterior are discordant, and Zhen Qi daily depletes, Yin-Yang fails to transport, leading to distension. Treatment with Yang-unblocking can achieve results, such as Yu Yu Liang Wan from *Ju Fang*. Even with Triple Burner obstruction, separation is necessary; with intestinal blockage, purgation is necessary. But do not equate this with Excess-Heat in Cold Damage; arbitrarily administering Nitre, Rhubarb, Immature Bitter Orange, and Magnolia Bark disturbs Yin Blood. If it is Taiyin Spleen organ with Fluid-Damp obstructing Qi, and warming/tonifying fails, attempting purgation, small doses of Kansui pills may be used. (*Lin Zheng Zhi Nan*)

Edema and Drum Distension are both caused by Spleen Deficiency. But why is Edema mild while Drum Distension is severe? Because Edema patients eat normally, whereas Drum Distension patients eat less than usual. Treating Edema requires only Spleen-tonifying and Water-guiding. Treating Drum Distension requires Spleen-tonifying, Water-guiding, plus Grain-digesting, to be effective. (Feng Chuzhan)

In treating Distension-Fullness, clinicians often use attacking drugs that damage Spleen and Kidney, leading to irreversible diarrhea and wheezing. Often, using *Jin Gui* Shen Qi Wan turns danger to safety. The妙 (wonder) lies in Cinnamon Twig and Aconite tonifying the Mother of the Spleen (Fire generates Earth). Zhang Sanxi added Ginseng and Atractylodes, saving many lives. (Xue Lizhai)

Middle Fullness originates from deficiency of Fire-Qi in the Kidney, failing to move Water. Use Ba Wei Wan to tonify Kidney Fire, so the Sanjiao receives endowment, Kidney Qi becomes sufficient, and Water moves. If it is purely Spleen Deficiency, although using Shen Ling Si Jun Tang as the main formula, one must also use Ba Wei Wan to tonify Mingmen Fire together. Because Spleen Earth cannot be generated without Mingmen Fire, this is the meaning of "Tonifying the Mother when Deficient." Another type is pure Yin Deficiency, where Fire of the Sanjiao and Chong Mai rebels upward, Water overflows from Fire, accumulates in the Lung causing cough, or severe wheezing/orthopnea, scatters in Yin Collaterals causing swelling, and enters/pools according to Zang deficiency causing distension. All are diseases caused by Minister Fire overflowing Water. Use Liu Wei Tang plus Ophiopogon and Schisandra, which is effective. (Zhao Yangkui)

Swelling-Fullness due to Cold Water insulting Earth starts with swelling of the head, face, and four limbs, then affects the abdomen. This syndrome can be treated with Bu Zhong Yi Qi Tang, swallowing *Jin Gui* Jia Jian Shen Qi Wan. However, treat it early; otherwise, Water forces breach, Earth collapses, and it is useless. (*Ji Ren Bian*)

[Edema]
The Master said: Diseases include Wind Water, Skin Water, Correct Water, Stone Water, and Yellow Sweat. ○ Wind Water: Pulse is floating; exterior signs include bone/joint pain and aversion to wind. ○ Skin Water: Pulse is also floating; exterior signs include edema, pitting upon pressure, no aversion to wind, drum-like abdomen, no thirst; should induce sweating. ○ Correct Water: Pulse is deep and slow; exterior sign is spontaneous wheezing. ○ Stone Water: Pulse is self-deep; exterior sign is abdominal fullness, no wheezing. ○ Yellow Sweat: Pulse is deep and slow, body fever, chest fullness, swelling of four limbs/head/face; if prolonged, leads to abscess/pus. ○ Heart Water: Body heavy, shortness of breath, inability to lie flat, vexation/restlessness, genital swelling. ○ Liver Water: Abdominal enlargement, inability to turn over independently, hypogastric pain, occasional slight saliva production, intermittent urination. ○ Lung Water: Body swelling, difficult urination, frequent loose stools. ○ Spleen Water: Abdominal enlargement, heavy limbs, lack of saliva generation, shortness of breath, difficult urination. ○ Kidney Water: Abdominal enlargement, umbilical swelling, lower back pain, inability to urinate, genital moisture like sweat on a cow's nose, cold feet, yet emaciation. ○ For all Water diseases: Swelling below the waist requires promoting urination; swelling above the waist requires inducing sweating, then recovery. ○ Question: What are Blood Level and Water Level diseases? Master said: Menstruation stops first, then Water disease occurs, named Blood Level; this is difficult to treat. Water disease occurs first, then menstruation stops, named Water Level; this is easy to treat. Why? Remove the Water, and menstruation returns naturally. ○ Wind Water, pulse floating, body heavy, sweating, aversion to wind: Fang Ji Huang Qi Tang governs. ○ Wind Water, aversion to wind, whole body swelling, pulse floating, no thirst, continuous spontaneous sweating, no high fever: Yue Bi Tang governs. ○ Skin Water disease, four limbs swelling, Water Qi in skin, four limbs twitching: Fang Ji Fu Ling Tang governs. ○ Interior Water: Yue Bi Jia Zhu Tang governs; Gan Cao Ma Huang Tang also governs. ○ Question: Yellow Sweat disease, body swelling, fever, sweating with thirst, resembling Wind Water, sweat stains clothes yellow like juice, pulse self-deep. How is it acquired? Master said: Bathing in water while sweating, Water enters through sweat pores. Yi Shao Yao Gui Zhi Jiu Tang governs. (*Jin Gui Yao Lue*)

Commentary: The phrase "person's genital swelling" should be in the Kidney Water section; this is a misplaced slip, should be moved. ○ Below "face appears emaciated," the phrase "person's genital swelling" from the previous section should be added. ○ The character "Interior" in Interior Water should be "Skin." How could Interior Water use Ephedra? Should be corrected. (*Yi Zong Jin Jian*)

Wind Swelling: Rough skin, numbness/anesthesia, migrating pain. Qi Swelling: Thick skin, emaciated limbs, distended abdomen/hypochondrium. Blood Swelling: Red streaks/blood threads in the skin. Pregnant women may have Qi blocking Water channels causing swelling, with normal diet, resolving after delivery; this is called Zi Zhong (Fetal Swelling). (Zhu Danxi)

Thick skin, sallow color, emaciated limbs, chest/abdominal stuffiness, developing from top to bottom: Mostly Qi. Thin/tender skin, distinct swelling boundaries, developing from bottom to top: Mostly Water. Also, non-pitting and immediate rebound: Qi; pitting and slow rebound: Dampness. (*Yi Xue Ru Men*)

Commentary: Edema can be formed by Phlegm obstruction, Food accumulation, Blood stasis, causing Clear not ascending, Turbid not descending—these are Excess syndromes. Can be formed by Cold/Cooling drugs injuring diet, Middle Qi deficiency—these are Deficiency syndromes. Can be formed post-major illness with exhausted Zheng Qi—Deficiency. Can be formed by difficult urination, chaotic Water fluids, Spleen unable to control—Deficiency. Should be treated separately. (*Yi Fang Ji Jie*)

When Kidney Qi is strong, Water returns to the Kidney; when Kidney Qi is weak, Water scatters into the skin. (Hua Yuanhua)

*Classic* says: "Heat excess causes swelling." The four limbs are the root of all Yang. Yang knots externally, cannot enter Yin, so Evil Heat stagnates in the four limbs, causing swelling. Moreover, if Evil is in the Six Fu organs, Yang meridians are disharmonious; Yang meridian disharmony causes Qi stagnation; due to Qi stagnation, swelling occurs. (*Sheng Ji Zong Lu*)

Regarding the two sentences from *Nei Jing*: "Four dimensions alternate, Yang Qi is exhausted." Wang Bing (Wu Taipu)注释: Four dimensions refer to Flesh, Blood, Sinew, Bone. Wu Hegao注释: Four dimensions refer to Blood Vessels, Sinew, Bone. Taking this as...