灵枢：水胀第五十七 - 黄帝内经·灵枢

Modo de lectura

Lingshu: Water Swelling, Fifty-Seventh

Overall Paraphrase

The Yellow Emperor asked Qi Bo: How should one distinguish water swelling (swelling caused by the accumulation of fluids in the body), subcutaneous swelling (swelling caused by stagnant qi between the skin layers), tympanitic distension (abdominal swelling like a drum), intestinal polyp (a mass outside the intestines), stone mass (a mass inside the uterus), and stone water (a type of fluid accumulation condition)?

Qi Bo answered one by one:

The onset of water swelling proceeds as follows: first, the eyelids become slightly puffy, like when one has just woken from sleep; the pulsation at the Renying acupoint on the neck becomes clearly visible; there is occasional coughing; the inner thighs feel cold; the calves also swell; and when the abdomen becomes distended, the accumulation of fluid has already formed. If one presses the abdomen with the hand, the skin rebounds immediately upon release, like pressing on a water-filled bag—these are the characteristics of water swelling.

The manifestations of subcutaneous swelling are: cold qi invades between the skin layers; the abdomen is bloated but does not feel hard upon palpation; the entire body is swollen and the skin becomes thickened. When pressing the abdomen with the hand, the depression does not rebound immediately, and the color of the abdominal skin shows no change—these are the characteristics of subcutaneous swelling.

The manifestations of tympanitic distension are: the abdomen is distended and the whole body also swells, with severity similar to subcutaneous swelling. The distinction lies in the skin color being greenish-yellow and dull, with the veins (visible venules) on the abdominal wall protruding and exposed—these are the characteristics of tympanitic distension.

The formation of intestinal polyp is: cold qi lodges outside the intestines and contends with the defensive qi (the qi that circulates on the body surface, responsible for protection and warmth circulation). The defensive qi becomes unable to circulate and distribute normally; the cold qi, blood and qi become entangled and attach outside the intestines, and from this pathological qi, a growth (a polypoid mass) gradually develops. Initially it is only the size of a chicken egg, then slowly increases in size. When it reaches a certain size, the abdomen becomes distended like in pregnancy. In long-standing cases, it can persist for several years. Upon palpation, the mass feels hard, but it can be moved with pushing. The menstrual cycle still arrives on time—these are the characteristics of intestinal polyp.

The formation of stone mass is: the mass grows within the uterus. Cold qi invades the cervix (the uterine opening), causing it to close and block. Qi and blood cannot flow smoothly, and the blood that should be discharged as lochia cannot be expelled. As a result, stagnant blood accumulates within the uterus, gradually increasing in size, and the abdomen becomes distended as in pregnancy, while the menstruation cannot arrive on time. This disease occurs while staying within women and, having built to a certain stage, resolves or must be dispelled — or treated so that the accumulated blood can be expelled in a downward direction as stated: the method permits directing the conductions, so that expulsion of congestion is initiated.

The Yellow Emperor then asked: Can subcutaneous swelling and tympanitic distension be treated with acupuncture? Qi Bo replied: First, puncture the blood collaterals in the distended area to release blood, then regulate the corresponding meridians, and remove the stagnant blood collaterals.

🧠 In-Depth Understanding

Core Principles 💡

The core value of this chapter lies in differential diagnosis—using a comprehensive approach of inspection, palpation, and inquiry to distinguish five types of abdominal distension conditions:

Condition	Location	Key Features	Palpation Characteristics	Menstruation
Water swelling	Whole body, mainly abdominal	Eyelids swell first, neck vessel pulsation, cough	Springs back immediately upon release	—
Subcutaneous swelling	Between the skin layers	Thickened skin, whole-body swelling	Depression does not rebound on palpation	—
Tympanitic distension	Abdomen	Sallow complexion, protruding abdominal veins	Abdominal distension	—
Intestinal polyp	Outside the intestines	Mass gradually enlarges like pregnancy	Hard on palpation, movable when pushed	Menstruation on time
Stone mass	Inside the uterus	Stagnant blood mass like pregnancy	Abdominal distension	Menstruation not on time

This diagnostic framework embodies the Huangdi Neijing principle that "what is within necessarily manifests without"—inferring the location and nature of internal pathology through external signs. Particularly, the distinguishing palpation techniques (immediate rebound vs. persistent depression; hard and movable vs. fixed position) constitute an important methodological foundation for early Chinese medicine's abdominal palpation. The key distinction between intestinal polyp and stone mass lies in whether menstruation remains normal, indicating that ancient physicians had already recognized the connection between the location of the mass (outside the intestine vs. inside the uterus) and gynecological function.

Modern Perspective 🌟

The description of water swelling—eyelid puffiness, lower limb edema, abdominal distension, pitting on palpation—closely matches the clinical presentation of generalized edema in modern medicine (such as cardiac, renal, or hepatic edema). Although the ancients did not understand microcirculation or colloid osmotic pressure mechanisms, their observations of the sequence and signs of edema are remarkably accurate.
The description of tympanitic distension with "sallow-greenish complexion and protruding abdominal veins" is nearly identical to the clinical picture of ascites due to portal hypertension in liver cirrhosis, abdominal wall venous varicosities, and jaundice. This represents an outstanding achievement of clinical observation in antiquity.
The non-rebounding depression on palpation in subcutaneous swelling is physically similar to myxedema or lymphedema; however, the ancients attributed it to "cold qi lodging between the skin layers," an explanatory framework at the level of qi transformation that cannot be directly equated with modern pathological mechanisms.
The description of intestinal polyp (an extraintestinal mass that gradually enlarges, is hard but movable upon palpation, with normal menstruation) may represent an early record of ovarian cysts, mesenteric tumors, or retroperitoneal benign masses. The use of "normal menstruation" as a marker to exclude gynecological pathology reflects a simple yet effective diagnostic logic.
The stone mass ("menstruation not on time," "stagnant blood that should be expelled is not expelled") has a discussable correspondence to conditions such as uterine fibroids, adenomyosis, or uterine cavity hematocele that cause amenorrhea and abdominal distension, though the disease names should not be directly equated.
Limitations: The ancients attributed most swelling conditions to a single external cause—cold qi—without knowledge of infection, metabolic, genetic, or immune factors; although the treatment principle of "directing downward to expel" contains the embryonic form of blood-activating and stasis-resolving therapy, it lacked anatomical and pathological support at the time and should not be directly applied in modern clinical settings.

Health Insights ⚡

Protect against cold in daily life: This chapter repeatedly emphasizes "cold qi" as the core cause of swelling. In daily life, keep the abdomen, lower back, and lower limbs warm; avoid prolonged sitting in cold and damp environments; and especially refrain from excessive cold exposure during seasonal transitions.
Moderate diet: Edema and tympanitic distension are closely related to the spleen and stomach's function of transporting and transforming dampness. Daily diet should be light and regular; avoid prolonged consumption of raw, cold, greasy, and sweet foods, allowing the spleen and stomach adequate capacity for transformation and transport.
Observe bodily signals: The ancients taught us to identify internal imbalances through external changes in the eyelids, lower legs, abdominal circumference, and skin complexion. Modern people can also cultivate the habit of paying attention to subtle bodily changes—such as morning eyelid puffiness, delayed rebound after pressing the lower limbs, or unusual abdominal distension—and seek professional evaluation promptly.
Maintain emotional flow: Qi and blood stagnation are important pathological mechanisms in mass-type conditions. Keeping emotions expansive and avoiding prolonged suppression and frustration helps maintain the normal circulation of qi and blood.

📚 Related Knowledge

Related Concepts

Defensive qi: Qi that circulates outside the vessels and within the skin and flesh, responsible for warmth, defense, and opening and closing of the pores. In this chapter, the pathogenesis of intestinal polyp is "cold qi contending with defensive qi," where dysfunctional defensive qi becomes a link in the formation of masses.
Blood collaterals: Small, visibly congested vessels on the body surface. This chapter's proposal to "first drain the blood collaterals of the distended area, then regulate the meridians" is an early record of bloodletting therapy, embodying the principle of "removing what has long been stagnant."
Cervix (Zi Men): The uterine opening (cervix); the Lingshu era already had early anatomical understanding of female reproductive organs.
Stone water: Although mentioned in the opening question, this term is not elaborated in the main text. The Suwen·Yinyang Bielun states, "When yin and yang bind obliquely, with excess yin and deficient yang, it is called stone water, with lower abdominal swelling," which can serve as a reference.

Further Reading

Lingshu·Treatise on Distension, Chapter 35: Dedicated to the classification of distension conditions and acupuncture principles; can be referenced alongside this chapter
Suwen·Plain Questions on Normal Qi of Man: Discusses pulse manifestations in edema
Suwen·On Decoctions and Fermented Beverages: Discusses the great treatment principles for edema—"opening the ghost gates [sweating] and cleansing the fu organs [promoting urination and defecation]"
Jingui Yaolue·Symptom and Treatment of Water Qi Diseases: Zhang Zhongjing's systematic classification of edema (wind water, skin water, true water, stone water, yellow sweat) and their treatments

This content is based on classical Chinese medicine texts and is provided solely for the study and appreciation of traditional culture. It does not constitute any medical diagnosis, medication prescription, or treatment advice. Please consult a qualified healthcare professional if you experience any discomfort.