Phlegm Retention and Coagulated Blood
Discussion of Difficult Points

6. Phlegm Retention and Coagulated Blood

Both Phlegm Retention and Coagulated Blood are the pathologic products of the process of diseases due to the action of pathogenic factots. When they are formed, however, they may affect directly or indirectly the functional activities of Zangfu Organs, leading to various kinds of diseases; therefore, they are also pathogenic factors.

1. Phlegm Retention

This is the combined name of Phlegm and Phlegm Fluids, are both pathologic products of disturbed water metabolism. Generally speaking, Phlegm is the thicker product that will flow throughout the whole body following the ascent and descent of Qi, while phlegm Fluids is the thinner one that tends to stay in a local areas. In TCM, Phlegm is divided into two types: the visible and the invisible. The visible Phlegm usually refers to the sputum that often occurs with coughs, while the invisible Phlegm refers to the thicker retained water existing in Zangfu Organs, Channels, or skin and muscles. They can be seen only by the manifestations of Phlegm, such as greasy and thick tongue coating, obesity, full sensations in the affected parts, or sputum-like pus. According to the manifestations, a diagnosis of Phlegm can be made and the treatment should be aimed at eliminating Phlegm.

1-1. Formation of Phlegm Retention

Water metabolism is a process concerning a number of ZangFu Organs, especially the dispersing and descending actions of the Lung, the transforming and transporting actions of the Spleen and the controlling effect of the Kidney. Therefore, disturbance of any of these organs, if involving water metabolism, will lead to disturbance of the distribution and discharge of water and ensuing Phlegm Fluids. For example, when External pathogens attack the Lung, Body Fluids in the Lung will not be able to be distributed through the dispersing and descending actions of Lung Qi, from which Phlegm results. Thus, Lung disorders are usually marked by expectoration of sputum. After formation, Phlegm will flow to Zangfu Organs internally and the skin and muscles externaily, giving rise to various diseases with various manifestations. As the Phlegm may exist in multiple parts of the human body, there are the sayings that "hundreds of diseases are caused by Phlegm" and that "Phlegm contributes to unusual diseases". Phlegm Fluids often stays in certain areas of the body such as the pleurae, the gastrointestinal tract, the subcutaneous regions and the diaphragm.

1-2. Pathologic characteristics of Phlegm Retention

The manifestations of Phlegm Retention vary with the areas they affects after their formation. But they are most likely to obstruct the flow of Qi and disturb the ascent and descent of Qi of Zangfu Organs.

The commonly seen symptoms caused by Phlegm include: cough with sputum and asthma due to uneven ascent and descent of Lung Qi arising from Phlegm obstructing the respiratory tract and blocking the way for Lung Qi to flow; chest fullness and palpitations due to blockage of the Heart vessel by Phlegm; coma or dementia due to Phlegm confusing the Mind; mania due to Phlegm disturbing the Heart in combination with Fire; nausea, vomiting and epigastric distention due to Phlegm disturbing the descent of Stomach Qi; scrofula and numbness of the limbs or hemiplegia due to obstruction of Phlegm in the channels, bones and tendons; dizziness with blurring of vision due to an attack of Phlegm in tbe head; and globus hystericus, marked by the feeling of a foreign body obstructing the throat that cannot be swallowed or vomited, due to Phlegm interlocking with Qi in the throat, etc.

Generally speaking, Phlegm, as a substantial pathogen, has four characteristics when causing diseases. First, it tends to obstruct circulation of Qi and Blood, leading to distention and Blood Stasis. Secondly, it prevents Qi from ascending, descending, en- tering or exiting, leading to disturbance of Zangfu Organs. Thirdly, it affects water metabolism, leading to new retention of water in the body; and fourthly, it tends to disturb mental activities, as stagnation of Phlegm in the Heart often brings about disorders of mentality.

2. Coagulated Blood

This refers to either impeded Blood in the vessels or extravasated Blood incZangfu Organs or Channels, which is not dissipated promptly. Coagulated Blood is itself a pathofogic product, but after its formation, it may cause new pathologic changes, therefore, it is also a pathogenic factor.

Bloodmust flow smoothly in the vessels so that it can reach the required areas, as the free flow of Blood in the vessels is imperative for it to perform its nourishing effect. In the case of extravasation or impeded flow of Blood, it will lose its nourishing function, so Coagulated Blood is also known as Dead Blood, or Dry Blood in TCM.

2-1. Formation of Coagulated Blood

Circulation of Blood is concerned with the propelling and controlling actions of Qi, the temperature of Blood, and maintaining vessel integrity. Generally speaking, Coagulated Blood in the vessel is caused by Deficiency of Qi which hasn't enough power to propel the circulation of Qi, Blood Cold, leading to the contraction of vessels and coagulation of Blood, and Blood Heat which consumes Body Fluids in the Blood, leading to the sluggish flow of Blood. Extravasated Blood is mostly caused by direct injury to the vessels, Deficiency of Qi which fails to keep the Blood flowing in the vessels, or Blood Heat which forces Blood to flow too swiftly. When the extravasated Blood cannot be dissipated promptly, it will coogulate.

2-2. Pathologic characteristics of Coagulated Blood

After formation, Coagulated Blood will not only lose its normal nourishing function, but will also obstruct the free flow of Blood in the whole body or in a local area, causing pain, bleeding or accumulation of Coagulated Blood in the internal organs or in the skin and muscles. The manifestations of Coagulated Blood are rather different, depending on its positions and causes. Coagulated Blood in the Heart is marked by palpitations, chest fullness and precordial pain, bluish purplish lips and nails, or even coma, and accompanied by sweating and cold limbs; that in the Lung is manifested as chest pain, hemoptysis, or coughing with purulent and bloody sputum that in the gastrointestinal tract often presents with epigastric and abdominal pain, hematemesis, and tarry stools that in the Liver may lead to hypochndriac pain with abdominal masses; that which attacks the Heart often causes mania; that in the Uterus may give rise to pain in the lower abdomen, irregular menstruation, dysmenorrhea, amenorrhea, dark menses with blood clots, or metrostaxis and metrorrhagia; and that in a local area of the skin and muscles will cause pain and swelling with a purple skin color in the affected area. Diseases due to Coagulated Blood have some common features, which are as follow:

There is usually stabbing pain, which is localized, aggravated by pressure, and more severe at night. This is becaued Coagulated Blood is a substantial pathogen, tending to cause severe obstruction. Besides, Blood is of Yin nature; at night, Yin in nature prevails, thus the coagulation of Blood is more severe.

Coagulated Blood of the skin and muscles often leads to purple swelling or lumps. If it is in the internal organs, there will be hard abdominal masses which are fixed.

Bleeding, which is usually dark with blood clots, is caused by the obstruction of Blood flow by Coagulated Blood.

Fever is mostly seen at night, accompanied by a dry mouth with a desire to gargle water but not to swallow it, because the fever affects the Blood instead of Qi.

Dark reddish-purple tongue, lips, nails and skin
On observation, there is a dark and dim complexion, dry and thickened skin with desquamation, purplish lips and nails, varicose sublingual veins, and the tongue may be dark purple or dotted with ecchymosis.

The pulse is usually thready, hesitant, deep and wiry, or intermittent and knotted, as a result of Coagulated Blood blocking the outgoing of Qi and Blood.

7. Discussion of Difficult Points

1. What is a toxic pathogen?

In TCM, we often read such phrases as toxic Damp, toxic Fire, toxic Heat or toxic pathogen. What does the "toxic" mean here? Is toxic Damp another kind of pathogen that is different from Damp?

The word "toxic" means all the things that may do severe harm to the body, including the toxic substances produced by a snake, or those originating from further developed common pathogens. Toxic Damp, for example, is not an isolated pathogen from the pathogenic Damp mentioned above. It only refers to the Damp or retained water seen in severe diseases, like the edema in patients with nephrotic Syndrome. Take toxic Heat or Fire for another example. In most cases. the causative factors of a localized diseases marked by swelling, pain, hotness and redness are called so, the manifestations of Heat or Fire in the diseased part are more obvious or severe than those we usually mention in other common diseases caused by Heat or Fire, such as Excess of Stomach Heat which is marked by dry stools, thirst and red tongue.

2. Why is the theory of epidemic factors not well developed in TCM?

Epidemic factors, which were suggested by a famous doctor during the Ming Dynasty of China, are a group of pathogenic factors different from the Six External Pathogens which have their own characteristics. To a great extent, they are similar to the specific pathogens mentioned in Western medicine, because they are believed to be specific to different infectious diseases. The question is, however, why the theory of the epidemic factors was not well developed in later times, which seems to be very strange.

It is true that infectious diseases are different from the diseases caused by the Six External Pathogens, because their clinical manifestations are very different, and infectious diseases seem to be more severe than the diseases caused by the Six External Pathogens. However, as infectious diseases present mostly Heat symptoms in accordance with TCM theory, they should be caused by the pathogens Hot in nature. And, since pathogenicHeat or one of the Six External Pathogens, it is impossible fot epidemic factors to be isolated from them, although their differences are stressed in TCM. These differences lie mainly in the degree of the pathogens instead of their nature. So epidemic factors are in fact a group of Heat pathogens with a strong capacity for causing diseases.

Another reasonis that the way of thinking stiggested by the theory of epidemic factors is opposite to that adopted in TCM. If the epidemic factors were analyzed and understood in the same way as Western medicine, it could not be used to guide the treatment of infectious diseases with Chinese traditional methods. This is because the differentiation of Syndromes and the resultant corresponding treatments in TCM are carried out on the basis of the patients' systemic manifestations rather than on the local structural changes or pathologic changes which are the basis for the understanding of the epidemic factors from the viewpoint of Western medicine. For these reasons, the theory of epidemic factors compared with that of the Six External pathogens, is not well clarified, but it is, in fact, included in the External pathogens theory in TCM.

3. What is the dlffereuce between Damp, Phlegm Fluids and Water?

All three of these concepts refer to the products of the disturbance of water metabolism in the human body, which after being produced will cause furtber pathologic changes, and thus are regarded as pathogenic factors in TCM. They are often used interchangeably, but they really have some differences and should, therefore, be used differently.

Damp is both a physiological and a pathologic concept in TCM. As a physiological concept it refers to the water received by the Stomach and digested and absorbed by the Spleen, so it is also called Water Damp. As a pathologic concept, it refers to the re- tained water caused by disturbance of the Spleen, so it is mainly used in the case of water retention due to Spleen diseases. Phlegm retention, on the one hand, is a general term for all disturbed water in the human body. On the other band, it mainly indicates retained water not directly related to the Spleen. For example, we may ascribe the cause of diarrhea to the downward flow of excess Water Damp from the Middle Jiao, or the cause of edema to the outward flow of Water Damp as a result of the hypofunctioning of the Spleen. But we usually say the causative factor of goiter is accumulation of Phlegm Fluids, because this is a disease mainly secondary to stagnation of Liver Qi, which futher disturbs water metabolism, instead of being secondary to Spleen disorders. As for Water, it is mainly used to describe the water that accumulates in a cavity of the body, such as pleural effusion, ascites or edema.

Other related topics:

1. The Six External Pathogens
2. Epidemic Pathogens.
3. Internal Impairment by the Seven Emotions
4. Improper Diet and Imbalance Between Work and Rest
5. Traumatic Injuries

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