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(Full text of "Water Swelling" chapter from *Ling Shu*)

Huangdi asked Qibo: How can we distinguish between edema (Shui), skin distension (Fu Zhang), drum distension (Gu Zhang), intestinal polyps (Chang Qin), stone masses (Shi Jia), and stone water (Shi Shui)? (These six conditions have different etiologies but similar appearances, so there must be ways to differentiate them. Qin is pronounced like "Tan". Jia is pronounced as "Jia" or "Jia".)

Qibo replied: When edema first begins, the area below the eyes swells slightly, resembling the appearance after just waking up (The area below the eye is called Mu Ke. Slight swelling resembling the post-sleep state looks like a silkworm lying down. Ke is pronounced like "Ke"). The pulse at the neck throbs, and there is occasional coughing (The neck pulse refers to the Renying point of the Foot-Yangming Stomach Meridian. The Yangming meridian descends from Renying along the interior of the abdomen; when water pathogen invades this area, it causes the neck pulse to throb. The manifestation of water pathology is in the Lung, hence the occasional cough). There is coldness in the inner thighs, swelling in the calves, and the abdomen enlarges; at this point, the water disease is established (Yin pathogen starts in the Yin aspects. Ting, same as "Zhong" [swelling]). Pressing the abdomen with the hand results in immediate rebound, resembling a bag filled with water; this is the sign of edema (When pressing a water-filled sac, it always rebounds immediately; thus, patients with water disease behave similarly. The above points describe signs of edema).

Huangdi asked: How is skin distension diagnosed? Qibo said: Skin distension occurs when cold qi lodges between the skin and muscles. Percussion yields a hollow sound, and the abdomen is not hard. The abdomen is large, and the entire body is swollen, with thickened skin ( Kong represents the sound of a drum. When cold qi lodges between the skin, Yang qi fails to circulate, and the pathology is in the Qi aspect, producing a sound like a drum. Qi has no form, hence it feels soft. Qi pervades everywhere, causing abdominal distension and full-body swelling. If caused by water, only areas with water swell, while others do not, allowing for differentiation. However, if there is water, the skin is lustrous and thin; if dry, the skin is thick. Kong is pronounced like "Kong"). Pressing the abdomen leaves an indentation that does not immediately recover, and the abdominal color remains unchanged; this is the sign of skin distension (Cold qi in the skin and interstices disperses upon pressure but cannot quickly re-aggregate, hence the indentation persists. Unchanged abdominal color is due to thickened skin. My commentary: The previous two paragraphs stated that immediate rebound indicates water, while persistent indentation indicates Qi. This is generally true. However, pressing an air-filled sac also rebounds; furthermore, if water lies within the muscles, pressing disperses it, preventing quick re-aggregation, similar to pressing a bag of dregs, which also shows persistent indentation. Therefore, rebound alone is not the definitive criterion for distinguishing water from Qi. One should observe whether the skin is thick and pale, whether the swelling is generalized or descending, which often indicates Qi disorders; whereas thin, lustrous skin, localized swelling, or ascending swelling often indicates Water disorders. For further details on Wind-Water and Skin Distension, see Pulse and Color Class, Chapter 18. Yan means deep.)

What about drum distension? Qibo said: The abdomen is distended and the body is enlarged, comparable in size to skin distension. The complexion is greenish-yellow, and abdominal veins are prominent; this is the sign of drum distension (Abdominal distension and bodily enlargement are consistent with the symptoms of skin distension mentioned earlier. Greenish-yellow complexion implies thickened skin and unchanged abdominal color, differing mainly by the prominence of abdominal veins. Generally, this is also a pathology in the Qi aspect, hence named Drum Distension. See Chapter 55 for further meaning of Drum Distension.)

What about intestinal polyps (Chang Qin)? Qibo said: Cold qi lodges outside the intestines and contends with Wei Qi (Defensive Qi). Qi fails to nourish properly, becomes bound, and forms fixed accumulations. Evil Qi arises, and flesh growths develop (Qin means extending deeply. Contention between cold qi and Wei Qi leads to stagnation and accumulation outside the intestines, binding and lodging, causing fixed accumulations and flesh growths, with the disease progressing daily. Zhuo Rou refers to abnormal flesh. The retention of Wei Qi in the abdomen is discussed in the *Wei Qi Buxiang* chapter; see Needling Class, Chapter 26. Pi is pronounced like "Pi". Xi is pronounced like "Xi"). Initially, it is the size of a chicken egg, gradually increasing until it resembles pregnancy. After more than a year, it feels firm upon pressure but moves upon pushing. Menstruation occurs on time; this is the sign of intestinal polyps (Li Sui means exceeding a year. Cold pathogen lodges outside the intestines, not in the uterus, so menstruation is unaffected, indicating it is not a blood disorder. It likely arises from the aggregation of fluids and juices; this is the sign of intestinal polyps.)

What about stone masses (Shi Jia)? Qibo said: Stone masses arise in the uterus (Bao refers to the uterus, present in both men and women; in men, it is called the Essence Chamber; in women, the Sea of Blood. Zi Men is the gate of the uterus. See *San Jiao Bao Luo Ming Men Bian* in *Fu Yi*, Vol. 3). The gate of the uterus closes, Qi fails to circulate, and evil blood should be discharged but is retained. The mass grows day by day, resembling pregnancy, and menstruation is delayed. These occur only in women and can be treated with draining methods ( Xi refers to coagulated and degenerated blood. Closure of Zi Men causes blood stasis, becoming hard as stone, hence "Stone Jia". Delayed menstruation is unique to women, so blood-draining agents can be used to purge it. Note: Huangdi asked about Shi Shui at the beginning, but there is no answer here, implying a textual loss. Checking the *Yin Yang Bie Lun*: "Yin-Yang knotting with evil, where Yin is excessive and Yang deficient, is called Shi Shui, with lower abdominal swelling." The meaning aligns here; see Class 6. Xi is pronounced "Pu Bei".)

Huangdi asked: Can skin distension and drum distension be treated with acupuncture? Qibo said: First, drain the collateral vessels associated with the distension, then regulate the meridians, removing the collateral vessels (Draining the collaterals of distension means that regardless of deficiency or excess, any visible external collaterals must first be drained, followed by regulating the meridians based on deficiency or excess. Removing collateral vessels reiterates the principle of initial drainage. Note: From the section on Water, six conditions are discussed. Why ask specifically about needling for these two? Because the 57 Water Acupoints were detailed in the *Shui Re Xue Lun*, so no further question was needed. Mentioning Skin Distension and Drum Distension here likely encompasses all five conditions collectively; though concise, the intent is included.)