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[size=24]对中医痰证、湿证和水证的新认识[/size]

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沈惠军
(英国林肯大学针灸专业,英国中医药学会会长,全欧洲中医药学会联合会副主席,世界中医药学会联合会副主席)
摘要 中医的体液潴留证词包括 痰证, 湿证和 水证. 本文探讨了三种体液潴留证的相似性和区别, 基于
古代文献的简短回顾, 作者重点分析和比较了三种体液潴留证的病因和病理机制, 分类和临床症型, 并首
次提出三种体液潴留证的新认识, 尤其是对痰证的一些新观点. 例如肺不仅是贮痰之器,更是生痰之重要一
源; 痰证分为 “有形之痰”, “无形之痰”不够妥当,应该分为 “呼吸之痰” 和 “非呼吸之痰”; 本文还探讨了生
物医学对体液潴留症的认识, 发现两个医学体系在此有很强的类似性, 因而首次提出了中医的三种体液潴
留证类似与生物医学的细胞间,细胞内和 “第三间隙”的水液潴留这一假说.
关键词 体液代谢;体液潴留;痰证;湿证;水证
Discussion on Phlegm, Damp and Water Retention Syndromes
Shen Hui Jun
(Senior Lecturer of Acupuncture Programme, University of Lincoln, UK;President, the Association of
Traditional Chinese Medicine and Acupuncture UK;Vice Chairman, Pan European Federation of TCM
Societies;Vice Chairman, World Federation of Chinese Medicine Societies)
Abstract Body fluid retentions syndromes include phlegm retention, damp retention and water retention. This
article discusses the similarity and difference between these three types of body fluid retentions. Ancient literature
is briefly reviewed, followed by the analysis and comparison of three retentions on aetiology and pathogenesis,
classification and clinical patterns. Some new ideas are explored for the first time on three retention syndromes,
especially on phlegm syndrome, such as Lung as one source for phlegm formation rather than just deemed as a
storage, respiratory phlegm and non-respiratory phlegm. Biomedical understanding is also attempted and the
hypothesis on the similarity between two medical systems is explored for three retentions as inter-cellular,
intra-cellular and “third space” retentions of body fluid.
Key Words Body fluid metabolism, body fluid retention, phlegm syndrome, damp syndrome, water retention.
Phlegm (痰, Tan ), damp (湿, Shi) and water (水, 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 [1]. 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 Emperor’s Classic of Internal Medicine, records the very first discussions about
body fluid metabolism and distribution. It states in Chapter 21: “Food and 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 descended to
urinary bladder for excretion.” In Chapter 1, the predominant role of Kidney in body fluid metabolism is
emphasised: Kidney dominates water (metabolism) [2].
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 [3]. In the long history of TCM, the later generations further developed Dr Zhang’s theory on 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
第九届世界中医药大会
The 9th World Congress of Chinese Medicine
•537•
临 证 体 会
Clinical experience
2.1 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 [4]. 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 [4]. 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 seen so this is called “non-substantial phlegm”. This classification does not
make good sense as some “non-substantial phlegm” actually does have a visible form such as cysts and
subcutaneous nodules. Therefore a better classification should be “respiratory phlegm” and “non-respiratory
phlegm”. 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 “Spleen is the source of phlegm, whilst Lung is the
storage of phlegm” [4]. While this saying is right to emphasise the importance of Spleen in the formation of
phlegm, it has also misled TCM professionals for centuries to the ignorance on the important role of Lung in
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 [1]. Any reasons causing Lung
dysfunction in D&D can affect the normal distribution of body fluids to the body su***ce and descending of body
fluids to Kidney/Bladder. With the dysfunction of Lung in D&D on Qi distribution and breathing, the body fluids
will very often 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.
Table 1: Outline of Phlegm Syndrome
Outline of Phlegm Syndrome
Phlegm: its dual
roles in TCM
etiology and
pathology
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 of
phlegm
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
Classification
of phlegm
Substantial phlegm – phlegm having a “form”: phlegm in Lung (sputum): cough with profuse
sputum.
Non-substantial phlegm – phlegm without a “form”: phlegm in channels, under skin, in heart, in
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
syndrome
patterns
(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
第九届世界中医药大会
The 9th World Congress of Chinese Medicine
•53 8•
临 证 体 会
Clinical experience
2.2 Damp Damp is also an abnormal retention of body fluids, which affects the physical functions of organs
(most commonly spleen) and tissues (muscles etc), leading to dysfunction of body’s metabolism that can further
cause other symptoms or illnesses [4]. 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 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 [1].
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
/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 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.
fluids?
Table 2: Classification of damp retention
Etiology Location Associating with
other pathogenic factors Clinical patterns
In exterior Wind damp Wind damp exterior syndrome
Exogenous 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 intestines,
in bladder, in lower Jiao, in blood (systemic damp
heat)
*: internal damp can be caused through either exogenous or endogenous route.
2.3 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
Damp
accumulating in
Middle Jiao
Spleen
Dysfunction
Endogenous damp:
Cold food/ unhealthy
diet
Exogenous Damp:
Damp
environment,
damp weather, etc.
第九届世界中医药大会
The 9th World Congress of Chinese Medicine
•539•
临 证 体 会
Clinical experience
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 intra-cellular retention,
the fluid 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 patients with damp
syndrome, certain cellular metabolic enzymes become abnormal in quantity or activity [5]. 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 retention in other parts of the body, or non-respiratory phlegm as discussed above.
In terms of western medicine, both respiratory phlegm and non-respiratory phlegm are localised fluid retention in
so called “third space”. Third space is a biomedical term which means all body cavities, including pathological
cysts. Bronchial tubes and pulmonary alveoli are classified into “third space”, so the respiratory phlegm conforms
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 [3]. Other two good examples of non-respiratory phlegm are Meniere’s disease
and polycystic ovary syndrome (PCOS). Meniere’s disease is due to the 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 Summary of three retentions (Table 3)
Phlegm
Retention
Damp
Retention
Water
Retention
What in common
Retention of body fluids
Due to abnormality of body fluids metabolism/distribution
Mainly involve dysfunction of Lung, Spleen and Kidney
Excess syndrome.
Aetiology Endogenous Endogenous
Exogenous Endogenous
Main organ involved Lung Spleen Kidney
Main location Upper Jiao Middle Jiao Lower Jiao
Pathological role Both pathological product
& aetiological factor
Both pathological
product &
aetiological factor
Purely pathological product
Biomedical
understanding “Third Space” Retention Intra-cellular retention Inter-cellular retention
第九届世界中医药大会
The 9th World Congress of Chinese Medicine
•54 0•
临 证 体 会
Clinical experience
References:
[1] Maciocia G (2005) The Foundations of Chinese Medicine(Second Edition). Edinburgh: Churchill Livingstone.
[2] Huang Di?, etc (200BC?) Yellow Empirer’s Classic of Internal Medicine
[3] Zhang Zhong Jing (200-219DC?) Golden Chamber of Synopsis
[4] Liu. Y (1998) Fundamental Theories of Traditional Chinese Medicine, Beijing: Academy Press
[5] 祈建生,杨春波,汪碧萍等.慢性胃炎脾胃湿热证红细胞膜na+-k+-atpase 与血清dbhase 关系探讨[J].新中医,2001,33(10):30.

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