Discussion on Phlegm, Damp and Water Retentions

Hui Jun ShenSenior Lecturer of Acupuncture Programme

University of Lincoln, UK

Phlegm ( , Tan ), damp ( , Shi) and water ( , Shui)retentions are three syndrome patterns of body fluids retention inTCM. The occurrence of these body fluids retentions is due tothe abnormality of body fluid metabolism and distribution,mainly involves the dysfunction of three Zang Organs in thehuman body: Lung, Spleen and Kidney (Maciocia G, 2005).These retentions syndromes can be caused by various deficientor 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 EMedicine, records the very first discussions about body fluid

drinks are taken into Stomach, and then their essence will betransported into Spleen. Spleen transforms and scatters the (food)essence, and ascends the essence to Lung. Lung disperses anddescends water through its pathways and surplus body fluid is

1, thepredominant role of Kidney in body fluid metabolism isemphasised: Kidney dominates water (metabolism). (Huang Di,200BC?)

Therefore, the cooperative functions of three Zang organs, LungSpleen and Kidney, are the key mechanism for body fluidmetabolism and distribution. The dysfunction of any of thesethree organs could give rise to body fluid retention- phlegm,damp or water.

Jin Gui Yao Lue (Golden Chamber of Synopsis) by ZhangZhong Jing in East Han Dynasty (approx 200-219 DC) is thefirst book to discuss the clinical manifestations, differentiationand treatment of these three retentions. The discussions arescattered in three separate chapters, named Shui Qi (water Qi, oredema), Shi (damp) and Tan Yin (phlegm-fluids). Dr Zhang didnot give much detail discussion on Shui Qi, and he onlydiscussed damp from exogenous source invading meridians.However, he did discuss Tan Yin in great depth and divided TanYin into four types (Zhang Zhong Jing, 200-219DC?). In thelong history of TCM, the later generations further developed Dr

n these three retentions and established newconcept of body fluid retention which is still used in nowadaysclinical practice.

2. Body Fluid Retention: Aetiology and Pathogenesis

Phlegm

Phlegm is an endogenous pathogenic product, formed interiorlydue to dysfunction of zang-fu organs or meridians, althoughsuch dysfunction can be triggered by exogenous wind invasion.Once phlegm is formed, it can in turn cause further pathologicaldamage and give rise to various symptoms and/or illnesses (LiuY, 1998). In this sense, phlegm is mutually pathologicalconsequence as well as etiological cause.

Ancient TCM literature classify phlegm syndrome intosubstantial phlegm and non-substantial phlegm (Liu Y, 1998).Most cases of phlegm syndrome are of substantial phlegm inrespiratory patients with lung dysfunction in dispersing anddescending (D&D) body fluids as a key etiological andpathogenic role, and the location of phlegm retention is mainlyin Upper Jiao. However, phlegm retention can be located inother body parts such as in heart, head, meridians, joint andunder the skin, giving rise to some very different illnesses. Insuch 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 andbronchial tubes, ie sputum. This phlegm is the same concept asthe phlegm or sputum in western medicine. Non-respiratoryphlegm is the phlegm located in elsewhere of the body ratherthan respiratory system. This is a unique form of phlegm onlyrecognised 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 alsomisled TCM professionals for many centuries to the ignoranceon the important role of Lung in the phlegm formation,especially for the respiratory phlegm. Lung has dispersing anddescending (D&D) function to work not only on the distributionof Qi, but also on the distribution of body fluids (Maciocia G,2005). Any reasons causing Lung dysfunction in D&D canaffect the normal distribution of body fluids to the body surfaceand descend of body fluids to Kidney/Bladder. With thedysfunction of Lung in D&D on Qi distribution and breathing,the body fluids will inevitably accumulate in Lung itself andcause further respiratory symptoms. Therefore, Lungdysfunction in D&D is as important as Spleen dysfunction inT&T (transformation and transportation) in the formation ofphlegm, 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 affectsthe 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 adual role in TCM etiology and pathogenesis.

Damp can accumulates in our body via both exogenous andendogenous pathways. Exogenous damp can invade the bodydue to damp climate/weather and living in a damp environmentetc. Endogenous damp is often caused by dietary or emotionaland 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 dualroles in TCMetiology andpathology

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.

Formation ofphlegm

1. Spleen deficiency: failing in T&T of body fluids, damp retention transforming into phlegm;

2. Lung dysfunction: failing in D&D of body fluids, body fluids retention in lung itself. (Shen, 2009)

3. Obstruction of meridians: body fluids failing to circulate but accumulating in certain location

4. Heat: boiling body fluids to form phlegm

5. Cold: condensing body fluids into phlegm

Classification ofphlegm

1. Substantial phlegm phlegm in Lung (sputum): cough with profuse

sputum.

2. 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.

A better classification:

Respiratory Phlegm

Non-Respiratory Phlegm

Clinic syndromepatterns

1. (Damp) Phlegm: respiratory or non-respiratory

2. Cold Phlegm: respiratory or non-respiratory

3. Heat Phlegm: respiratory or non-respiratory

4. Dry Phlegm: respiratory phlegm only

5. Wind Phlegm: non-respiratory phlegm only

in channels- tremor

misting orifice of brain- epilepsy, wind-stroke

endogenous damp is commonly used in understanding of dampetiology. When coming to treatment, same or similar herbalmedicines or acupuncture points are used to drain damp from thebody, no matter exogenous or endogenous.

Spleen dysfunction (mostly Spleen deficiency) in T&T for bodyfluids gives rise to damp retention. Once damp is accumulated in

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

fluids?

The clinical classification, or further differentiation, of dampretention syndrome is largely based on damp being associatedwith 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 anddamp phlegm syndromes. By location, wind damp often invadesor accumulates in exterior or meridians causing headache

Dampaccumulating in

Middle Jiao

SpleenDysfunction

Exogenous Damp:Damp environment,damp weather, etc.

Endogenous damp:Cold food/ unhealthy

diet

/migraine or Bi syndrome of wind damp pattern; cold damp caninvade or accumulate in both meridians or internal Zang-Fuorgans; damp heat tends to invade or accumulate in Zang-Fuorgans much more often; Damp phlegm can be in Upper Jiao(respiratory phlegm), Middle Jiao or in meirdians. Dam heat

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

Table 2: Classification of damp retention

Etiology LocationAssociating with

other pathogenic factorsClinical patterns

Exogenous

In exterior Wind damp Wind damp exterior syndrome

In meridians

Wind damp

Cold damp

Damp phlegm

Headache/migraine, Bi syndrome

Bi syndrome

Local retention causing swelling, heaviness, etc

Endogenous In internal zang-

fu organs*

Damp phlegm

Cold damp

Damp heat

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.

WaterWater retention causes edema. This is also due to theabnormality of body fluids metabolism and distribution in ourbody, which is primarily dominated by Kidney. Water retentionis purely due to endogenous pathogenic reasons, although insome cases, such interior pathogenic changes can be triggeredout by exogenous wind invasion. As a pathogenic consequence,water retention is the outcome of zang-fu dysfunctions andpredominantly due to Kidney deficiency, although dysfunctionof Spleen in T&T and Lung in D&D also can cause waterretention. Once formed, it does not cause any further impairmentto the zang-fu organs and meridians, etc. So in this sense edemaor water retention is not an etiological factor. The principallocation for water retention is Lower Jiao.

3. Biomedical Understanding on Three Retentions:

Body fluid retention also exists in western medicine. Althoughwestern medicine and TCM are so different in term ofunderstanding the physiological functions and pathologicalchanges of the body, the subject they look into is actually thesame: abnormality of body fluid metabolism.

While most of the time it is almost impossible to use biomedicalknowledge to explain the theory of TCM, a very unique andexclusive similarity between the two medical systems can bedisclosed in the understanding of body fluid retention.

Water retention (oedema): this is basically the same concept inthe two medical systems. The body fluid accumulates in thespace outside of body cells or between body cells; therefore wecan give it a name as inter-cellular retention. In westernmedicine it is called extra-cellular edema. The functions of bodycells are not directly affected; therefore edema usually does notcause other symptoms or other disorders.

Damp retention: not recognised in western medicine. However,this is immensely likely as intre-cellular retention, the fuildretention inside the body cells. As the result, the interiorenvironment and functions of body cells are affected, causing

dysfunction in cellular metabolism, especially the energymetabolism of cells, giving rise to various symptoms, mostly asQi deficiency like symptoms. Many studies show that in dampsyndrome patients, certain cellular metabolic enzymes become

abnormal in quantity or activity ( , et al. 2001). This alsogives evidence that damp syndrome is more related to cellularmetabolism. Further researches should be performed to furtherexplore this hypothesis.

Phlegm retention: Both medical systems share the sameconcept on respiratory phlegm, or sputum, which is a stickymucus fluid produced in the respiratory truct. However, phlegmhas a wider meaning in TCM, which include various localisedfluid rention in other parts of the body, or non-respiratoryphlegm as discussed above. In terms of western medicine, bothrespiratory and non-respiratory phlegms are localised fluid

term which means all body cavities, including pathological cysts.

ms to the definition ofthird space retention.

Non-respiratory phlegm syndrome is also the phlegm retentionin the third space. Hydrothorax (fluid retention in pleural cavity)and ascites (fluid retention in peritoneal cavity) were classifiedinto phlegm syndrome as early as in Golden Chamber ofSynopsis (Zhang Zhong Jing, 200-219DC?). Other two goodexamples of non-

the accumulation of lymphatic fluid in the inner ear tube causingpressure to the vestibulocochlear nerve and disturbing itsfunction of maintaining body balance. PCOS is pathologicalfluid accumulation and formation of multiple cysts in the ovarywhich as an occupant disorder affects the normal structure andtherefore the function of the ovary itself. These two conditionsare totally irrelevant in western medicine. However, they have asame nature as fluid retention in a third space. In TCM, webelieve they are both phlegm (non-respiratory phlegm) retentionand we treat these conditions by using phlegm resolving herbs.

4. Summery of three retentions (Table 3)

PhlegmRetention

DampRetention

WaterRetention

What in common Retention of body fluidsDue to abnormality of body fluids metabolism/distributionMainly involve dysfunction of Lung, Spleen and KidneyExcess syndrome.

Aetiology Endogenous EndogenousExogenous

Endogenous

Main organinvolved

Lung Spleen Kidney

Main location Upper Jiao Middle Jiao Lower Jiao

Pathological role Both pathologicalproduct & aetiologicalfactor

Both pathologicalproduct &aetiological factor

Purely pathological product

Biomedicalunderstanding

Intre-cellular retention Inter-cellular retention

References:

Huang Di?, etc (

Medicine

Liu. Y (1998) Fundamental Theories of TraditionalChinese Medicine, Beijing: Academy Press

Maciocia G (2005) The Foundations of ChineseMedicine(Second Edition). Edinburgh: ChurchillLivingstone.

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 dbhase j .

2001 33(10) 30.