Discussion on Phlegm, Damp and Water Retentions

Hui Jun Shen

Phlegm ( , Tan ), damp ( , Shi) and water ( , Shui) retentions are three syndrome patterns of body fluids retention in TCM. The occurrence of these body fluids retentions is due to the abnormality of body fluid metabolism and distribution, mainly involves the dysfunction of three Zang Organs in the human body: Lung, Spleen and Kidney (Maciocia G, 2005). These retentions syndromes can be caused by various deficient or excessive pathogenic factors. However, once they are formed, phlegm, damp and water themselves belong to excess patterns. 1. Ancient Literature Review on Body Fluid Metabolism: Huang Di Nei Jing, or Yellow E Medicine, records the very first discussions about body fluid drinks are taken into Stomach, and then their essence will be transported into Spleen. Spleen transforms and scatters the (food) essence, and ascends the essence to Lung. Lung disperses and descends water through its pathways and surplus body fluid is 1, the predominant role of Kidney in body fluid metabolism is emphasised: Kidney dominates water (metabolism). (Huang Di, 200BC?) Therefore, the cooperative functions of three Zang organs, Lung Spleen and Kidney, are the key mechanism for body fluid metabolism and distribution. The dysfunction of any of these three organs could give rise to body fluid retention- phlegm, damp or water. Jin Gui Yao Lue (Golden Chamber of Synopsis) by Zhang Zhong Jing in East Han Dynasty (approx 200-219 DC) is the first book to discuss the clinical manifestations, differentiation and treatment of these three retentions. The discussions are scattered in three separate chapters, named Shui Qi (water Qi, or edema), Shi (damp) and Tan Yin (phlegm-fluids). Dr Zhang did not give much detail discussion on Shui Qi, and he only discussed damp from exogenous source invading meridians. However, he did discuss Tan Yin in great depth and divided Tan Yin into four types (Zhang Zhong Jing, 200-219DC?). In the long history of TCM, the later generations further developed Dr n these three retentions and established new concept of body fluid retention which is still used in nowadays clinical practice. 2. Body Fluid Retention: Aetiology and Pathogenesis Phlegm Phlegm is an endogenous pathogenic product, formed interiorly due to dysfunction of zang-fu organs or meridians, although such dysfunction can be triggered by exogenous wind invasion. Once phlegm is formed, it can in turn cause further pathological damage and give rise to various symptoms and/or illnesses (Liu Y, 1998). In this sense, phlegm is mutually pathological consequence as well as etiological cause.

Ancient TCM literature classify phlegm syndrome into substantial phlegm and non-substantial phlegm (Liu Y, 1998). Most cases of phlegm syndrome are of substantial phlegm in respiratory patients with lung dysfunction in dispersing and descending (D&D) body fluids as a key etiological and pathogenic role, and the location of phlegm retention is mainly in Upper Jiao. However, phlegm retention can be located in other body parts such as in heart, head, meridians, joint and under the skin, giving rise to some very different illnesses. In such cases there is no actual phlegm liquid (sputum) that can be classification does cysts and subcutaneous nodules. Therefore a better classification Respiratory phlegm is the phlegm as excretion of the lungs and bronchial tubes, ie sputum. This phlegm is the same concept as the phlegm or sputum in western medicine. Non-respiratory phlegm is the phlegm located in elsewhere of the body rather than respiratory system. This is a unique form of phlegm only recognised in TCM. See details in Table 1. In terms of the formation phlegm, there is a TCM saying as

the importance of Spleen in the formation of phlegm, it has also misled TCM professionals for many centuries to the ignorance on the important role of Lung in the phlegm formation, especially for the respiratory phlegm. Lung has dispersing and descending (D&D) function to work not only on the distribution of Qi, but also on the distribution of body fluids (Maciocia G, 2005). Any reasons causing Lung dysfunction in D&D can affect the normal distribution of body fluids to the body surface and descend of body fluids to Kidney/Bladder. With the dysfunction of Lung in D&D on Qi distribution and breathing, the body fluids will inevitably accumulate in Lung itself and cause further respiratory symptoms. Therefore, Lung dysfunction in D&D is as important as Spleen dysfunction in T&T (transformation and transportation) in the formation of phlegm, and even more important in case of respiratory phlegm. For other factors that cause phlegm, see Table 1. Damp Damp is also an abnormal retention of body fluids, which affects the physical functions of organs (most commonly spleen) and metabolism that can further cause other symptoms or illnesses (Liu Y, 1998). Therefore, similar with phlegm, damp also has a dual role in TCM etiology and pathogenesis. Damp can accumulates in our body via both exogenous and endogenous pathways. Exogenous damp can invade the body due to damp climate/weather and living in a damp environment etc. Endogenous damp is often caused by dietary or emotional and other factors impairing the transformation and transportation (T&T) functions of Spleen. The concept of exogenous damp and

Table 1: Outline of Phlegm Syndrome

Outline of Phlegm Syndrome Phlegm: its dual roles in TCM etiology and pathology Formation of phlegm 1. 2. 3. 4. 5. 1. 2.

Both a pathological condition and an aetiological factor. Dysfunctions of body fluids metabolism/ distribution create phlegm as a pathological product, And then phlegm goes on as a pathogenic factor to create other illnesses. Spleen deficiency: failing in T&T of body fluids, damp retention transforming into phlegm; Lung dysfunction: failing in D&D of body fluids, body fluids retention in lung itself. (Shen, 2009) Obstruction of meridians: body fluids failing to circulate but accumulating in certain location Heat: boiling body fluids to form phlegm Cold: condensing body fluids into phlegm Substantial phlegm phlegm in Lung (sputum): cough with profuse sputum. Non-substantial phlegm phlegm w joints, etc. in Middle Jiao- abdominal distension, nausea misting heart- coma, loss of consciousness, delirium, mania under skin- cysts, lumps of non-blood stasis type in channels/joints- numbness in limbs, swelling and deformation of joints misting orifice of brain- epilepsy, wind-stroke.

Classification of phlegm

A better classification: Respiratory Phlegm Non-Respiratory Phlegm Clinic syndrome patterns 1. 2. 3. 4. 5. (Damp) Phlegm: respiratory or non-respiratory Cold Phlegm: respiratory or non-respiratory Heat Phlegm: respiratory or non-respiratory Dry Phlegm: respiratory phlegm only Wind Phlegm: non-respiratory phlegm only in channels- tremor misting orifice of brain- epilepsy, wind-stroke

endogenous damp is commonly used in understanding of damp etiology. When coming to treatment, same or similar herbal medicines or acupuncture points are used to drain damp from the body, no matter exogenous or endogenous. Spleen dysfunction (mostly Spleen deficiency) in T&T for body fluids gives rise to damp retention. Once damp is accumulated in

the body interior for any reasons, Spleen is the most susceptible organ to be impaired by damp. The location of damp retention is mainly in Middle Jiao, but can be in joints/meridians, etc (Maciocia G, 2005).

Exogenous Damp: fluids? Damp environment, damp weather, etc. Damp accumulating in Middle Jiao Endogenous damp: Cold food/ unhealthy diet
The clinical classification, or further differentiation, of damp retention syndrome is largely based on damp being associated with other pathogenic factors and the location of damp retention. By looking at other pathogenic factors accompanying with damp, there are damp (alone), wind damp, cold damp, damp heat and damp phlegm syndromes. By location, wind damp often invades or accumulates in exterior or meridians causing headache

Spleen Dysfunction

/migraine or Bi syndrome of wind damp pattern; cold damp can invade or accumulate in both meridians or internal Zang-Fu organs; damp heat tends to invade or accumulate in Zang-Fu organs much more often; Damp phlegm can be in Upper Jiao (respiratory phlegm), Middle Jiao or in meirdians. Dam heat Table 2: Classification of damp retention Associating with other pathogenic factors In exterior Wind damp Wind damp Exogenous In meridians Cold damp Damp phlegm Endogenous In internal zangfu organs* Damp phlegm Cold damp Damp heat

syndrome can be further classified by the location as damp heat in Middle Jiao (Spleen & Stomach), damp heat in intestines, damp heat in Liver/Gallbladder, damp heat in bladder, and damp heat in Lower Jiao. See details in Table 2.

Etiology

Location

Clinical patterns Wind damp exterior syndrome Headache/migraine, Bi syndrome Bi syndrome Local retention causing swelling, heaviness, etc In upper Jiao (respiratory phlegm), in middle Jiao Cold damp in middle Jiao, in intestines, in lower Jiao In middle Jiao, in Liver/gallbladder, in interstines, in bladder, in lower Jiao, in blood (systemic damp heat)

*: internal damp can be caused through either exogenous or endogenous route. Water Water retention causes edema. This is also due to the abnormality of body fluids metabolism and distribution in our body, which is primarily dominated by Kidney. Water retention is purely due to endogenous pathogenic reasons, although in some cases, such interior pathogenic changes can be triggered out by exogenous wind invasion. As a pathogenic consequence, water retention is the outcome of zang-fu dysfunctions and predominantly due to Kidney deficiency, although dysfunction of Spleen in T&T and Lung in D&D also can cause water retention. Once formed, it does not cause any further impairment to the zang-fu organs and meridians, etc. So in this sense edema or water retention is not an etiological factor. The principal location for water retention is Lower Jiao. 3. Biomedical Understanding on Three Retentions: Body fluid retention also exists in western medicine. Although western medicine and TCM are so different in term of understanding the physiological functions and pathological changes of the body, the subject they look into is actually the same: abnormality of body fluid metabolism. While most of the time it is almost impossible to use biomedical knowledge to explain the theory of TCM, a very unique and exclusive similarity between the two medical systems can be disclosed in the understanding of body fluid retention. Water retention (oedema): this is basically the same concept in the two medical systems. The body fluid accumulates in the space outside of body cells or between body cells; therefore we can give it a name as inter-cellular retention. In western medicine it is called extra-cellular edema. The functions of body cells are not directly affected; therefore edema usually does not cause other symptoms or other disorders. Damp retention: not recognised in western medicine. However, this is immensely likely as intre-cellular retention, the fuild retention inside the body cells. As the result, the interior environment and functions of body cells are affected, causing dysfunction in cellular metabolism, especially the energy metabolism of cells, giving rise to various symptoms, mostly as Qi deficiency like symptoms. Many studies show that in damp syndrome patients, certain cellular metabolic enzymes become abnormal in quantity or activity ( , et al. 2001). This also gives evidence that damp syndrome is more related to cellular metabolism. Further researches should be performed to further explore this hypothesis. Phlegm retention: Both medical systems share the same concept on respiratory phlegm, or sputum, which is a sticky mucus fluid produced in the respiratory truct. However, phlegm has a wider meaning in TCM, which include various localised fluid rention in other parts of the body, or non-respiratory phlegm as discussed above. In terms of western medicine, both respiratory and non-respiratory phlegms are localised fluid term which means all body cavities, including pathological cysts. ms to the definition of third space retention. Non-respiratory phlegm syndrome is also the phlegm retention in the third space. Hydrothorax (fluid retention in pleural cavity) and ascites (fluid retention in peritoneal cavity) were classified into phlegm syndrome as early as in Golden Chamber of Synopsis (Zhang Zhong Jing, 200-219DC?). Other two good examples of nonthe accumulation of lymphatic fluid in the inner ear tube causing pressure to the vestibulocochlear nerve and disturbing its function of maintaining body balance. PCOS is pathological fluid accumulation and formation of multiple cysts in the ovary which as an occupant disorder affects the normal structure and therefore the function of the ovary itself. These two conditions are totally irrelevant in western medicine. However, they have a same nature as fluid retention in a third space. In TCM, we believe they are both phlegm (non-respiratory phlegm) retention and we treat these conditions by using phlegm resolving herbs.

4. Summery of three retentions (Table 3) Phlegm Damp Water Retention Retention Retention Retention of body fluids Due to abnormality of body fluids metabolism/distribution Mainly involve dysfunction of Lung, Spleen and Kidney Excess syndrome. Endogenous Endogenous Endogenous Exogenous Lung Upper Jiao Both pathological product & aetiological factor Spleen Middle Jiao Both pathological product & aetiological factor Intre-cellular retention Kidney Lower Jiao Purely pathological product

What in common

Aetiology Main involved organ

Main location Pathological role

Biomedical understanding References: Huang Di?, etc ( Medicine

Inter-cellular retention

Liu. Y (1998) Fundamental Theories of Traditional Chinese Medicine, Beijing: Academy Press Maciocia G (2005) The Foundations of Chinese Medicine(Second Edition). Edinburgh: Churchill Livingstone.
Shen, H (2009) Syndrome Differentiation: No More Confusions. ATCM Seminar Note 1st November 2009 Zhang Zhong Jing (200-219DC?) Golden Chamber of Synopsis na+-k+-atpase 2001 33(10) 30. . dbhase j .