an observation concerning phlegm vs. pathogenic fluids

[Guest guest]

Just wanted to add a perspective regarding the " pathogenic inflammatory fluid "

concept. In Western med language, lymphatic fluid collects locally in response

to irritated or inflamed tissue. This is a local manifestation and not the

source of a problem, though it may add a level of complication to the condition.

I know we use different language than Western medicine but I'm using it to

illustrate the distinction between a local response and a systemic imbalance.

 

I am not familiar with all of the details of the case, but didn't see many other

indications of the presence of dampness or phlegm to support a diagnosis of

phlegm in this post. From what I did see, it sounds as if you are on a better

direction with tx.

 

Kim Waldeck, L.Ac., L.MsT

 

 

 

 

 

 

 

 

_______________

Be the filmmaker you always wanted to be—learn how to burn a DVD with Windows®.

http://clk.atdmt.com/MRT/go/108588797/direct/01/

 

 

[Guest guest]

How did she respond to the formulas that Z'ev suggested?

Geoff

 

 

, yehuda frischman

< wrote:

>

> Some months ago, we met with our esteemed colleague ,

who suggested that her case seemed to reflect internal wind from

pathogenic heat scorching and injuring Kidney Yin and liver blood.

Essentially, he contended, the Liver is doing the work of the Kidneys,

with water unable to restrain wood. He suggested considering formulas

such as E Jiao Ji Zi huang Tang or Di Huang Yin Zi.

[Guest guest]

Thanks for the reply. I guess the operative word here is " response " .

What I'm getting is that he applies an intelligence to the body, it

responds, whereas in TCM we generally might have a condition which

transforms into another. I'm convinced that this isn't just a semantic

difference although the transformation might be the same, as to the

damp and heat example.

We've discussed if (and the answer is no) if damp is created in

response to Yin Xu. So does this make my question any clearer?

 

So I don't know if this comes up in his talks. The workshops I've

taken with him were a number of years ago, I never picked up on this

nor had the quickness to ask. I bring it up here again because of

Yehuda's post.

Anyone?

Doug

 

 

 

, david appleton

<acuapple wrote:

>

> Doug,

>

> I have studied with Jeffrey for a while- damp heat can be either

damp responding to heat or heat responding to damp; it depends on what

other presenting symptoms are there.

>

> His perspective is different depending on which school or method he

is teaching- which is why it is important to be coherent within the

school or tradition you are using when attempting to treat in this

manner. Do you have specific examples of where you dont see the

transformations?

>

> sincerely,

>

> David Appleton L.Ac.

>

> --- On Mon, 8/25/08, wrote:

>

>

> Re: an observation concerning phlegm vs. pathogenic

fluids

>

> Monday, August 25, 2008, 2:03 AM

, yehuda

> I hope you can get to the bottom of your wife's complex case.

> Not to deflect energy away discussing her case I want to separately

> pick up on something, not explicitly in relation to you wife, but a

> sentence you wrote.

> " It is my firm conviction that it is not phlegm at all, rather

> pathogenic, inflammatory fluid which the body has created in response

> to extreme dryness and inflammation. "

>

> I give this to the group, this is a rather common thread in Jeffery

> Yuen's work as well as others. Do others think this that the body

> creates other conditions? I see conditions turning to a different

> pathology but somehow I don't get these responses. In the case above

> we could say that a damp heat condition is somehow created out of the

> above but I think this is different than a response. (I am getting

> deja vu. I think I have brought this up before.)

>

> Doug

>

>

>

>

>

>

>

>

>

>

>

>

 

[Guest guest]

Yehuda, all,

A couple of comments here.

 

1) I am not sure what is meant by 'pathogenic fluid' as opposed to

phlegm here. I think any discussion of 'pathogenic fluid' is entirely

speculative unless we know what technical term is being used by

referring to a pinyin or Chinese source term in a CM dictionary.

 

2) I don't think it is 'standard TCM' to just attack phlegm so

strongly. Obviously, in Chana's case, the root is long-term vacuity,

and kidney yin vacuity is one cause of stubborn phlegm to develop.

Whoever suggested the attacking method, in my opinion, missed the

boat and just went for the branch, without dealing with the root.

This just exacerbates, as Yehuda pointed out, the dryness and vacuity

of yin, blood and qi.

 

3) Most likely the aloe vera juice caused irritation from mild

toxicity, not from heat.

 

 

 

On Aug 24, 2008, at 10:44 PM, yehuda frischman wrote:

 

> Dear Henry,

>

> Thank you for your wise comments. This was originally a very complex

> case with both vacuitous and replete heat. The case has evolved

> now, and though there still is some vacuitous kidney heat, it is

> more of an emptiness now, of liver blood, Kidney and heart Yin, and

> Lung Qi, The repletion that remains is the pathogenic fluid that I

> describe and the liver wind. So as you can see, we are primarily

> dealing with deficiency. And even the two manifestations of

> repletion both result from the Yin vacuity, and so indeed the

> approach is to supplement and nourish.

>

> Again, as you mention that the TCM approach would be to throw every

> herb in the arsenal to resolve the phlegm, I can assure you that

> that approach was tried and was completely unsuccessful. That is

> why I now think differently, that this really is not phlegm but

> rather pathogenic inflammatory dampness (as in swelling).

>

> I will give it a try, adding K3 (Kid Yuan) on the left and Lu9

> (Mother point of mother channel) on the right.

>

> I'll let you know, IY " H how it goes.

>

>

>

>

>

> --- On Sun, 8/24/08, Henry Ahlefelder <hahlefelder wrote:

>

> Henry Ahlefelder <hahlefelder

> Re: an observation concerning phlegm vs. pathogenic

> fluids

>

> Sunday, August 24, 2008, 7:10 PM

>

> Thank you for sharing this very interesting case. In the interest of

> learning, and hopefully contributing, I would like to share my

> thoughts. While I use TCM as the basis for my herbal formulas, I

> practice a Japanese style of acupuncture, from which I learned one

> very important and practical rule: always look for and treat the

> deficiency first. In TCM, phlegm is usually considered excess, and

> the strategy is to immediately try to resolve or dry, which is a

> good idea, to a degree. At the same time, it is probably more

> important to figure what deficiency is causing the excess. You

> mentioned a Lung Qi deficiency which makes sense, and in Japanese

> style, the Liver can also be deficient, and I immediately saw a

> large Liver component as well. The TCM approach would normally be to

> throw every phlegm herb/formula to try to resolve the phlegm. It

> sounds to me like by tonifying and nourishing, your currrent formula

> is actually resolving it better. The only

> suggestion I might offer, would be to use th epulse to determine

> which Yin organ is the most deficient, and needle the Yuan Source

> point on one side, as well as the mother point on the mother

> meridien on the same side, normally right on a woman.

>

> Please keep us informed as to how this goes. I'm interested to hear.

>

> Henry

>

>

> >

> TCM <traditional_ chinese_medicine @.

> com>; Traditional Chinese Herbal Medicine

> Sunday, August 24, 2008 5:07:32 PM

> an observation concerning phlegm vs. pathogenic fluids

>

> Dear Colleagues,

>

> I want to revisit a discussion that we had about a year ago. We have

> discussed many aspects of phlegm before, and over the years I have

> presented to you observations concerning the progress of my wife,

> who has suffered from an ideopathic seizure and movement disorder

> for many years. What is particularly interesting is that the

> seizures were originally accompanied by a clear, viscous fluid in

> her throat, and now this fluid is there a good part of the time.

> This is particularly interesting as we are taught that the classics

> teach that seizures result from phlegm misting the heart channel.

>

> As would be expected, therefore, the treatment formula my wife would

> always receive from the time that I began as a student in 2000 would

> include herbs such as Ban Xia, and Dan Nan Xing, and Shi Chang Pu.

> Yet, the " phlegm " would never seem to be completely resolved, and

> the seizures would continue to occur (almost like a menstrual cycle)

> every 28 or so days. As I observed the pattern each month, it

> started to dawn on me that my " supervisors " just didn't get it, she

> would seem to not do better with those herbs, maybe even worse, and

> whereas previously her tongue would have a dry " baked " black

> coating, with a red tip and cracks, recently, it has had a pale

> coatless body, sometimes dry and sometimes moist, with a appearance

> of piece of raw meat, but pale, not red. Meanwhile the " phlegm " is

> nearly constant, at times drooling from her mouth and interfering

> with her ability to talk clearly as if she is waterlogged and is

> constantly in her

> throat, and her thinking has become increasingly muddled recent

> past. About a year ago, I purchased an aspirator, which would at

> least allow her to be understood, but she hates it and it makes her

> feel very uncomfortable.

>

> A couple of months ago, when she had a dental appointment, the

> dentist gave her aloe vera juice to rince out her mouth with.

> Interestingly, it seemed to temporarily resolve the phlegm, and so I

> purchased a gallon of aloe vera juice, and have been using it

> instead of the aspirator. What is interesting, is that even though

> energetically, we know that Aloe is cold, she remarks that it feels

> like it burns her throat! I should mention at this point, four

> important other observations: 1. She has always considered it unlady-

> like to spit out phlegm and saliva, and so since childhood, she has

> swallowed it. 2. Since her first acupuncture treatment in 2000, when

> the supervisor needled Du 26, her jaw has been shaking, at times

> violently, most of the time. 3. Her pharynx is extremely sensitive

> to the touch. 4. The constant shaking of the jaw has clearly

> depleted her Lung Qi, and her voice is very soft.

>

> Some months ago, we met with our esteemed colleague ,

> who suggested that her case seemed to reflect internal wind from

> pathogenic heat scorching and injuring Kidney Yin and liver blood.

> Essentially, he contended, the Liver is doing the work of the

> Kidneys, with water unable to restrain wood. He suggested

> considering formulas such as E Jiao Ji Zi huang Tang or Di Huang Yin

> Zi.

>

>

> Sincerely,

>

>

> www.traditionaljewi shmedicine. net

>

>

[Guest guest]

Not really much change, although if I remember correctly, initially, the

seizures came a week later than before.

 

 

 

 

 

 

--- On Mon, 8/25/08, G Hudson <ozark.canuck wrote:

 

G Hudson <ozark.canuck

Re: an observation concerning phlegm vs. pathogenic fluids

 

Monday, August 25, 2008, 3:52 PM

 

 

 

 

 

 

How did she respond to the formulas that Z'ev suggested?

Geoff

 

, yehuda frischman

<@.. .> wrote:

>

> Some months ago, we met with our esteemed colleague ,

who suggested that her case seemed to reflect internal wind from

pathogenic heat scorching and injuring Kidney Yin and liver blood.

Essentially, he contended, the Liver is doing the work of the Kidneys,

with water unable to restrain wood. He suggested considering formulas

such as E Jiao Ji Zi huang Tang or Di Huang Yin Zi.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[Guest guest]

Do you remember how long you used the formulas for? I am slowly

learning not to change formulas for chronic conditions too quickly

(maybe only change after 3 weeks to a month) - but I'm a very slow

learner and very impatient... ;-)

 

I don't know if it pertains to your wife's case or not - but I seem to

remember an axim about the Lung that 'when the Lung is damaged, Phlegm

will be formed'. I can't think of any other organ, except the Spleen,

where Phlegm (or Damp) is formed when damaged.

 

It sounds like you are on the right track - but these Phlegm

situations are stubborn cases! I have a patient right now that's

really working my brain. She originally came in for difficulty

speaking. The voice was weak, but there was also constriction in the

throat - with drooling and phlegm. When it started, which was acute

onset, there was also facial paralysis on the left side. Looked like

stroke sequelae, right? Well, after many doctors visits and a couple

of trips to the Mayo clinic - they all said no stroke, no diagnosis.

A year later, they are now calling it ALS. Because of the diagnosis,

I'm not changing my treatment much (just adding Du Channel points

according to Wang Le-Ting's theories in Bob's book), just changing

prognosis. Very long story short - it's been a very stubborn and

variable course of treatment over the last year, but some weeks she's

doing pretty well and some weeks aren't great. Very testing patients

for impatient practitioners! All that to say - think about sticking

with a course of treatment long enough to see some changes.

 

Geoff

 

 

 

 

, yehuda frischman

< wrote:

>

> Not really much change, although if I remember correctly, initially,

the seizures came a week later than before.

>

>

[Guest guest]

Hi Z'ev,

 

Allow me to clarify--

 

I use the term pathogenic fluid to describe what empirically as well as

rationally seems to me to be a completely different kettle of fish than anything

and everything I have read and learned about phlegm: a.  Phlegm results from a

thickening of damp repletion which originates from stagnation in the spleen. 

The pathogenesis of this fluid seems to be related to liver wind fanning and

drying out healthy body fluids.  b.  In the upper Jiao, phlegm manifests as

viscous white or yellow discharge.  This is clear.  c.  Even in cases of drool

in the literature which are attributed to spleen vacuity, this phenomenon is

attributed to underdeveloped or retarded children with constant drooling whereas

Chana's drooling is only during certain times of the month.  d. The formula Ding

Xian Wan which treats phlegm blocking the channels with loud raspy mucus sounds

in the throat (very much like Chana " sounds " and which also treats seizures,

though seemingly

applicable is a red herring for the following reasons:  it presents in cases of

repletion, with a thick tongue coating, seizures that occur during waking,

vertigo, and a wiry slippery pulse.  e.  Herbs and formulas that treat phlegm or

saliva drooling have only exascerbated her symptoms, rather than helped them. 

Chana presents with vacuity, and a thready, slightly slippery and slightly

choppy pulse.  So for all these reasons, I feel that this viscous fluid should

not be considered, nor treated as phlegm. 

 

On Z'ev's second point, I agree with him that 18 years of seizures has

transformed her situation from one of repletion to one of vacuity.  But I don't

think that the phlegm heat which may have originally contributed to the seizures

(in presentation, but not necessarily in pathogenesis) has become a hidden

pathogen.  Rather, I would agree, that now she presents with severe depletion

and vacuity.  The important question, though, is of what and how to treat it.  I

think I have addressed what I view, IMVHO, as the approach I have taken.  A

point that I want to clarify though is whether  this fluid is not a

manifestation of the root.  As I have mentioned, in addition to Blood and Yin

vacuity, there also appears to be severe fluid depletion at the root.  That is

why I have also included herbs such as Tian Hua Fen, and that if, as my theory

goes, the pathogenic fluid is the body's reaction to depletion of body fluid, by

using herbs to rehydrate,

healthy moisture will replace this pathogenic fluid.  As I am writing this I

can think of a biochemical parallel:  We find that often, patients who are

calcium deficient have plenty of free Calcium in the blood or calcium deposits

in the fascia.  It appears that the body is trying to take from its own reserves

to replenish what it is unable to receive from nutritional intake or diet, thus

paradoxically appearing to be in excess, when in reality it has severe

deficiency.

 

Finally, concerning the Aloe Vera juice.  It is interesting that when Chana has

less of this pathogenic fluid or is starting to show moisture or a  coat on her

tongue, the Aloe doesn't burn her.

 

 

All the best,  

 

 

 

 

 

 

--- On Mon, 8/25/08, <zrosenbe wrote:

 

<zrosenbe

Re: an observation concerning phlegm vs. pathogenic fluids

 

Monday, August 25, 2008, 10:56 PM

 

 

 

 

 

 

Yehuda, all,

A couple of comments here.

 

1) I am not sure what is meant by 'pathogenic fluid' as opposed to

phlegm here. I think any discussion of 'pathogenic fluid' is entirely

speculative unless we know what technical term is being used by

referring to a pinyin or Chinese source term in a CM dictionary.

 

2) I don't think it is 'standard TCM' to just attack phlegm so

strongly. Obviously, in Chana's case, the root is long-term vacuity,

and kidney yin vacuity is one cause of stubborn phlegm to develop.

Whoever suggested the attacking method, in my opinion, missed the

boat and just went for the branch, without dealing with the root.

This just exacerbates, as Yehuda pointed out, the dryness and vacuity

of yin, blood and qi.

 

3) Most likely the aloe vera juice caused irritation from mild

toxicity, not from heat.

 

 

 

On Aug 24, 2008, at 10:44 PM, yehuda frischman wrote:

 

> Dear Henry,

>

> Thank you for your wise comments. This was originally a very complex

> case with both vacuitous and replete heat. The case has evolved

> now, and though there still is some vacuitous kidney heat, it is

> more of an emptiness now, of liver blood, Kidney and heart Yin, and

> Lung Qi, The repletion that remains is the pathogenic fluid that I

> describe and the liver wind. So as you can see, we are primarily

> dealing with deficiency. And even the two manifestations of

> repletion both result from the Yin vacuity, and so indeed the

> approach is to supplement and nourish.

>

> Again, as you mention that the TCM approach would be to throw every

> herb in the arsenal to resolve the phlegm, I can assure you that

> that approach was tried and was completely unsuccessful. That is

> why I now think differently, that this really is not phlegm but

> rather pathogenic inflammatory dampness (as in swelling).

>

> I will give it a try, adding K3 (Kid Yuan) on the left and Lu9

> (Mother point of mother channel) on the right.

>

> I'll let you know, IY " H how it goes.

>

>

> www.traditionaljewi shmedicine. net

>

>

> --- On Sun, 8/24/08, Henry Ahlefelder <hahlefelder@ > wrote:

>

> Henry Ahlefelder <hahlefelder@ >

> Re: an observation concerning phlegm vs. pathogenic

> fluids

>

> Sunday, August 24, 2008, 7:10 PM

>

> Thank you for sharing this very interesting case. In the interest of

> learning, and hopefully contributing, I would like to share my

> thoughts. While I use TCM as the basis for my herbal formulas, I

> practice a Japanese style of acupuncture, from which I learned one

> very important and practical rule: always look for and treat the

> deficiency first. In TCM, phlegm is usually considered excess, and

> the strategy is to immediately try to resolve or dry, which is a

> good idea, to a degree. At the same time, it is probably more

> important to figure what deficiency is causing the excess. You

> mentioned a Lung Qi deficiency which makes sense, and in Japanese

> style, the Liver can also be deficient, and I immediately saw a

> large Liver component as well. The TCM approach would normally be to

> throw every phlegm herb/formula to try to resolve the phlegm. It

> sounds to me like by tonifying and nourishing, your currrent formula

> is actually resolving it better. The only

> suggestion I might offer, would be to use th epulse to determine

> which Yin organ is the most deficient, and needle the Yuan Source

> point on one side, as well as the mother point on the mother

> meridien on the same side, normally right on a woman.

>

> Please keep us informed as to how this goes. I'm interested to hear.

>

> Henry

>

>

> >

> TCM <traditional_ chinese_medicine @.

> com>; Traditional Chinese Herbal Medicine

> Sunday, August 24, 2008 5:07:32 PM

> an observation concerning phlegm vs. pathogenic fluids

>

> Dear Colleagues,

>

> I want to revisit a discussion that we had about a year ago. We have

> discussed many aspects of phlegm before, and over the years I have

> presented to you observations concerning the progress of my wife,

> who has suffered from an ideopathic seizure and movement disorder

> for many years. What is particularly interesting is that the

> seizures were originally accompanied by a clear, viscous fluid in

> her throat, and now this fluid is there a good part of the time.

> This is particularly interesting as we are taught that the classics

> teach that seizures result from phlegm misting the heart channel.

>

> As would be expected, therefore, the treatment formula my wife would

> always receive from the time that I began as a student in 2000 would

> include herbs such as Ban Xia, and Dan Nan Xing, and Shi Chang Pu.

> Yet, the " phlegm " would never seem to be completely resolved, and

> the seizures would continue to occur (almost like a menstrual cycle)

> every 28 or so days. As I observed the pattern each month, it

> started to dawn on me that my " supervisors " just didn't get it, she

> would seem to not do better with those herbs, maybe even worse, and

> whereas previously her tongue would have a dry " baked " black

> coating, with a red tip and cracks, recently, it has had a pale

> coatless body, sometimes dry and sometimes moist, with a appearance

> of piece of raw meat, but pale, not red. Meanwhile the " phlegm " is

> nearly constant, at times drooling from her mouth and interfering

> with her ability to talk clearly as if she is waterlogged and is

> constantly in her

> throat, and her thinking has become increasingly muddled recent

> past. About a year ago, I purchased an aspirator, which would at

> least allow her to be understood, but she hates it and it makes her

> feel very uncomfortable.

>

> A couple of months ago, when she had a dental appointment, the

> dentist gave her aloe vera juice to rince out her mouth with.

> Interestingly, it seemed to temporarily resolve the phlegm, and so I

> purchased a gallon of aloe vera juice, and have been using it

> instead of the aspirator. What is interesting, is that even though

> energetically, we know that Aloe is cold, she remarks that it feels

> like it burns her throat! I should mention at this point, four

> important other observations: 1. She has always considered it unlady-

> like to spit out phlegm and saliva, and so since childhood, she has

> swallowed it. 2. Since her first acupuncture treatment in 2000, when

> the supervisor needled Du 26, her jaw has been shaking, at times

> violently, most of the time. 3. Her pharynx is extremely sensitive

> to the touch. 4. The constant shaking of the jaw has clearly

> depleted her Lung Qi, and her voice is very soft.

>

> Some months ago, we met with our esteemed colleague ,

> who suggested that her case seemed to reflect internal wind from

> pathogenic heat scorching and injuring Kidney Yin and liver blood.

> Essentially, he contended, the Liver is doing the work of the

> Kidneys, with water unable to restrain wood. He suggested

> considering formulas such as E Jiao Ji Zi huang Tang or Di Huang Yin

> Zi.

>

>

> Sincerely,

>

>

> www.traditionaljewi shmedicine. net

>

>

[Guest guest]

See below:

 

 

 

_____

 

 

On Behalf Of yehuda frischman

Tuesday, August 26, 2008 2:14 PM

 

Re: an observation concerning phlegm vs. pathogenic fluids

 

 

 

Hi Z'ev,

 

Allow me to clarify--

 

I use the term pathogenic fluid to describe what empirically as well as

rationally seems to me to be a completely different kettle of fish than

anything and everything I have read and learned about phlegm: a. Phlegm

results from a thickening of damp repletion which originates from stagnation

in the spleen.

 

(Jason) Phlegm does not have to originate in this manner.

 

The pathogenesis of this fluid seems to be related to liver wind fanning and

drying out healthy body fluids.

 

(Not necessarily)

 

c. Even in cases of drool in the literature which are attributed to spleen

vacuity, this phenomenon is attributed to underdeveloped or retarded

children with constant drooling whereas Chana's drooling is only during

certain times of the month.

 

(Jason) Although oral mucus (ÏÑ, xi¨¢n) (drool) is said to be the thick

fluid of the spleen. It can come about from a qi disorder, such as from

Fright (¾ª, jing1). Also spitting up of foamy oral mucus can also be from

protective level deficiency. It may also come about from a wind pathogen

entering the zang.

 

d. The formula Ding Xian Wan which treats phlegm blocking the channels with

loud raspy mucus sounds in the throat (very much like Chana " sounds " and

which also treats seizures, though seemingly

applicable is a red herring for the following reasons: it presents in cases

of repletion, with a thick tongue coating, seizures that occur during

waking, vertigo, and a wiry slippery pulse.

 

I agree with Z¡¯ev¡¯s previous post. One cannot just attack in this case,

this is just bad medicine, and probably why you find it does not work. These

previous doctors just miss treated / diagnosed.

 

 

 

e. Herbs and formulas that treat phlegm or saliva drooling have only

exascerbated her symptoms, rather than helped them. Chana presents with

vacuity, and a thready, slightly slippery and slightly choppy pulse. So for

all these reasons, I feel that this viscous fluid should not be considered,

nor treated as phlegm.

 

It is common to have phlegm with underlying deficiency. I would not just

rule out phlegm for the reasons you mention. There are many many ways to

deal with it!

 

On Z'ev's second point, I agree with him that 18 years of seizures has

transformed her situation from one of repletion to one of vacuity. But I

don't think that the phlegm heat which may have originally contributed to

the seizures (in presentation, but not necessarily in pathogenesis) has

become a hidden pathogen. Rather, I would agree, that now she presents with

severe depletion and vacuity. The important question, though, is of what

and how to treat it. I think I have addressed what I view, IMVHO, as the

approach I have taken. A point that I want to clarify though is whether

this fluid is not a manifestation of the root. As I have mentioned, in

addition to Blood and Yin vacuity, there also appears to be severe fluid

depletion at the root. That is why I have also included herbs such as Tian

Hua Fen, and that if, as my theory goes, the pathogenic fluid is the body's

reaction to depletion of body fluid, by using herbs to rehydrate,

 

(I am unclear what this pathogenic fluid is??)

 

My 2cents¡­

 

-Jason

 

 

 

 

 

 

[Guest guest]

Geoff,

 

I agree with you, and view our role as equivalent to sculptors.  Though I do

often make changes, they are subtle, with finesse and often just dosage

adjustments.

 

All the best,

 

 

 

 

 

 

--- On Tue, 8/26/08, G Hudson <ozark.canuck wrote:

 

G Hudson <ozark.canuck

Re: an observation concerning phlegm vs. pathogenic fluids

 

Tuesday, August 26, 2008, 10:50 AM

 

 

 

 

 

 

Do you remember how long you used the formulas for? I am slowly

learning not to change formulas for chronic conditions too quickly

(maybe only change after 3 weeks to a month) - but I'm a very slow

learner and very impatient... ;-)

 

I don't know if it pertains to your wife's case or not - but I seem to

remember an axim about the Lung that 'when the Lung is damaged, Phlegm

will be formed'. I can't think of any other organ, except the Spleen,

where Phlegm (or Damp) is formed when damaged.

 

It sounds like you are on the right track - but these Phlegm

situations are stubborn cases! I have a patient right now that's

really working my brain. She originally came in for difficulty

speaking. The voice was weak, but there was also constriction in the

throat - with drooling and phlegm. When it started, which was acute

onset, there was also facial paralysis on the left side. Looked like

stroke sequelae, right? Well, after many doctors visits and a couple

of trips to the Mayo clinic - they all said no stroke, no diagnosis.

A year later, they are now calling it ALS. Because of the diagnosis,

I'm not changing my treatment much (just adding Du Channel points

according to Wang Le-Ting's theories in Bob's book), just changing

prognosis. Very long story short - it's been a very stubborn and

variable course of treatment over the last year, but some weeks she's

doing pretty well and some weeks aren't great. Very testing patients

for impatient practitioners! All that to say - think about sticking

with a course of treatment long enough to see some changes.

 

Geoff

 

, yehuda frischman

<@.. .> wrote:

>

> Not really much change, although if I remember correctly, initially,

the seizures came a week later than before.

>

>

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[Guest guest]

Dear Jason,

 

Sorry for the delay.  Your responses to my comments:

 

" I use the term pathogenic fluid to describe what empirically as well as

rationally seems to me to be a completely different kettle of fish than

anything and everything I have read and learned about phlegm: a. Phlegm

results from a thickening of damp repletion which originates from stagnation

in the spleen. "

(Jason) Phlegm does not have to originate in this manner.

" The pathogenesis of this fluid seems to be related to liver wind fanning and

drying out healthy body fluids. "

(Not necessarily)

This exchange sent me to look at Clavey's wonderful book, "  Fluid Physiology

& Pathology in TCM " ISBN: 9780443071942

 

lack of Kidney yang. Therefore he feels that xu phlegm must never be

‘attacked’ as a method of treatment; since this phlegm is a product of

the mis-transformation of foods and fluids, it can be produced as fast as

it is expelled. Furthermore, attacking treatments can damage the con-

stitutional (yuan) qi, and the use of preparations such as Gun Tan Wan

(‘Vaporize Phlegm Pill’, Formulas and Strategies, p. ) is

‘looking only

at the present with no thought for what follows.’

Zhang Jing-Yue taught that the best principle of treatment in

phlegm disease is to ‘cause it not to be produced’, which is to say, in cer-

tain long-term cases of stubborn phlegm, one needs to warm and toni-

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

knot of phlegm. In the same context he goes on to say: ‘Phlegm may be

produced in any disorder of the five zang-organs... therefore the

transformation of phlegm must occur from the Spleen but the Root of

Phlegm is none other than the Kidneys’. Obviously the key point in the

development of xu (deficient) phlegm is a weakness of Kidney yang,

especially in so far as this is related to ‘fire not supporting Earth’ and

an

overflow of pathogenic water building up into phlegm.



Similar theoretical descriptions from the Ming and Qing dynasties

are numerous, from such authors as Lin Pei-Qin and Chen Xiu-Yuan

who also spoke of the Kidneys as the source of phlegm, the Spleen as its

transport and the Lungs as the storehouse; all showing clearly that the

development of phlegm is closely related to Kidney yang or Kidney yin

deficiency, or a disruption of the yin-yang balance in the Kidneys

Zhang Jing-Yue taught that the best principle of treatment in

phlegm disease is to ‘cause it not to be produced’, which is to say, in cer-

tain long-term cases of stubborn phlegm, one needs to warm and toni-

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

knot of phlegm. In the same context he goes on to say: ‘Phlegm may be

produced in any disorder of the five zang-organs... therefore the

transformation of phlegm must occur from the Spleen but the Root of

Phlegm is none other than the Kidneys’. Obviously the key point in the

development of xu (deficient) phlegm is a weakness of Kidney yang,

especially in so far as this is related to ‘fire not supporting Earth’ and

an

overflow of pathogenic water building up into phlegm

On page 275 he says, "  Zhang Jing-Yue taught that the best principle of

treatment in

phlegm disease is to ‘cause it not to be produced’, which is to say, in cer-

tain long-term cases of stubborn phlegm, one needs to warm and toni-

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

phlegm disease is to ‘cause it not to be produced’, which is to say, in cer-

tain long-term cases of stubborn phlegm, one needs to warm and toni-

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

knot of phlegm. In the same context he goes on to say: ‘Phlegm may be

produced in any disorder of the five zang-organs... therefore the

transformation of phlegm must occur from the Spleen but the Root of

Phlegm is none other than the Kidneys’. Obviously the key point in the

development of xu (deficient) phlegm is a weakness of Kidney yang,

especially in so far as this is related to ‘fire not supporting Earth’ and

an

overflow of pathogenic water building up into phlegm.



Similar theoretical descriptions from the Ming and Qing dynasties

are numerous, from such authors as Lin Pei-Qin and Chen Xiu-Yuan

who also spoke of the Kidneys as the source of phlegm, the Spleen as its

transport and the Lungs as the storehouse; all showing clearly that the

development of phlegm is closely related to Kidney yang or Kidney yin

deficiency, or a disruption of the yin-yang balance in the Ki

phlegm disease is to ‘cause it not to be produced’, which is to say, in cer-

phlegm disease is to ‘cause it not to be produced’, which is to say, in cer-

tain long-term cases of stubborn phlegm, one needs to warm and toni-

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

phlegm disease is to ‘cause it not to be produced’, which is to say, in cer-

tain long-term cases of stubborn phlegm, one needs to warm and toni-

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

knot of phlegm. In the same context he goes on to say: ‘Phlegm may be

produced in any disorder of the five zang-organs... therefore the

transformation of phlegm must occur from the Spleen but the Root of

Phlegm is none other than the Kidneys’. Obviously the key point in the

development of xu (deficient) phlegm is a weakness of Kidney yang,

especially in so far as this is related to ‘fire not supporting Earth’ and

an

overflow of pathogenic water building up into phlegm.



Similar theoretical descriptions from the Ming and Qing dynasties

are numerous, from such authors as Lin Pei-Qin and Chen Xiu-Yuan

who also spoke of the Kidneys as the source of phlegm, the Spleen as its

transport and the Lungs as the storehouse; all showing clearly that the

development of phlegm is closely related to Kidney yang or Kidney yin

deficiency, or a disruption of the yin-yang balance in the Kidneys.

Case history: Kidney deficiency creating phlegm and causing nausea and

vomiting, treated by Zhu Ceng-Bo

Yang, a boy aged 14 years, had first experienced symptoms one day four months

ago: occasional nausea and vomiting of sticky yellowish phlegmy fluid. Several

days later it happened again, but more severely, and this time there was also

reduced appetite, tiredness, dizziness and pale lusterless complexion. The

strange

thing was that the nausea and vomiting began when the boy was quiet, and

improved with movement. As soon as he slowed down he would become nau-

seous, dizzy and would vomit; he was unable to continue his studies. (We may be

tempted to consider ‘desire to avoid school’ as a contributory factor here,

but this

Chinese boy would almost certainly have found missing school a great stress.) As

treatment in his local area had been ineffective, he and his family travelled a

great

distance to see me.

In addition to the symptoms mentioned above, the tongue was pale and the

root area was thickly covered with a white greasy coat that never disappeared.

The

pulse was deficient and weak (xu ruo), and urination was scanty. Western

medicine

examinations were all negative.

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Comment

Generally speaking, nausea and vomiting are usually caused by loss of harmonious

descent of Stomach qi, or by an imbalance in the ascent and descent of Spleen

and

Stomach qi, or again by Liver qi accosting the Spleen and Stomach. These are the

most common causes.

This case, though, is completely different: here, the root of the disorder is in

the

Kidneys. The young patient’s Kidney qi is insufficient, added to which his

intense

studying had led to exhaustion that further injured Kidneys. The deficient

Kidneys

were unable to transform qi and facilitate water movement, causing pathogenic

water qi to accumulate and generate phlegm. Phlegm and thin mucus then over-

came the Spleen, Stomach, Liver and Gall Bladder. The constitutional heat of the

latter two organs gradually led to nausea and ceaseless vomiting of yellowish

sticky

phlegm and fluids.

How do we know this is so? The pale tongue, deficient pulse and pale lusterless

complexion are all external signs of Kidney deficiency. The persistent thick

greasy

tongue coat at the root of the tongue indicates Kidneys not transforming qi so

that

phlegm and thin mucus halt and accumulate internally. As to the reason that the

condition worsens with stillness and improves with movement, this is due to

‘still-

ness abetting and generating yin’; Kidney yang is shrouded, and the

yin-natured

pathogenic phlegm increases its influence until nausea and vomiting result.

Movement lessens the condition because the yang qi by this [rather inefficient]

means is able to break up the phlegm concentration, and thus reduce the

influence

of phlegm. Thus, while moving, the nausea and vomiting temporarily stop. This is

the ‘equilibrium of stillness and movement’ explained by the yin-yang theory

of

traditional Chinese medicine, and a cogent example of the contribution that this

ancient scientific theory can bring to clinical medicine.

All the previous treatments had been based on stopping nausea and bringing

down rebellious qi: all were ‘quieting’ without any ‘moving’ and thus

were ineffec-

tive in dealing with this pattern of disorder. The proper method must be to

benefit

Kidneys, transform phlegm, and restore normal yang activity while curbing patho-

logical movement (i.e. vomiting).

Prescription

Gou Qi Zi

15g

Lycii Chinensis, Fructus

He Shou Wu

15g

Polygoni Multiflori, Radix

Fu Zi

6g

Aconiti Carmichaeli Praeparata, Radix

Fu Ling

30g

Poriae Cocos, Sclerotium)

Zhu Ru

20g

Bambusae in Taeniis, Caulis, prepared with vinegar

Ze Xie

15g

Alismatis Plantago-aquaticae, Rhizoma

Wu Zhu Yu

6g

Evodiae Rutacarpae, Fructus, soaked then dry-fried

Ban Xia

10g

Pinelliae Ternatae, Rhizoma

Huo Xiang

10g

Agastachis seu Pogostemi, Herba

Chai Hu

6g

Bupleuri, Radix

Gan Cao

3g

Glycyrrhizae Uralensis, Radix

Five bags, decocted, small amounts sipped as desired.

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Page 13

Explanation

The Gou Qi Zi (Lycii Chinensis, Fructus), He Shou Wu (Polygoni Multiflori,

Radix) and

Fu Zi (Aconiti Carmichaeli Praeparata, Radix) are the main herbs in the

prescription,

as they warm and nourish Kidney qi.

Fu Ling (Poriae Cocos, Sclerotium) and Ze Xie (Alismatis Plantago-aquaticae,

Rhizoma) leach thin mucus and prevent phlegm from forming, draining these

pathological fluids outward via the urine. Thus they do not treat phlegm

directly,

but remove the underlying conditions for phlegm. Fu Ling is neutral, sweet and

bland, and calms while it leaches, so it is used in a fairly large dose.

Ban Xia (Pinelliae Ternatae, Rhizoma) and Huo Xiang (Agastachis seu Pogostemi,

Herba) harmonize the Stomach and awaken the Spleen, direct rebellious qi down-

ward, transform phlegm and stop nausea.

Ginger-prepared Zhu Ru (Bambusae in Taeniis, Caulis) and Wu Zhu Yu (Evodiae

Rutacarpae, Fructus) that has been soaked in water then dry-fried to reduce its

intense pungent quality—also known as dry-fried Wu Zhu Yu (Evodiae)—is a

com-

bination of cool bitter Zhu Ru and hot pungent Wu Zhu Yu used to treat phlegm

heat in the Liver and Gall Bladder.

Chai Hu (Bupleuri, Radix) is added to help dredge and drain Liver and Gall

Bladder, and thus treat the branch.

Gan Cao (Glycyrrhizae Uralensis, Radix) harmonizes the other herbs, but—as

always with nausea—should be used in small doses.

This prescription combines the traditional formulas Zhen Wu Tang (True Warrior

Decoction, Formulas and Strategies, p. 197), Wen Dan Tang (Warm the Gallbladder

Decoction, Formulas and Strategies, p. 435) and Xiao Chai Hu Tang (Minor

Bupleurum Decoction, Formulas and Strategies, p. 136), designed to transform

phlegm and thin mucus. It warms the Kidneys to settle thin mucus, both tonifies

and reduces by directing downward, harmonizes the Stomach, transforms phlegm

and stops vomiting and nausea, thus dividing and conquering by separately

addressing the various components of the single disorder. The results were

gratify-

ingly rapid.

At a somewhat deeper level, the formula contains warm or pungent yang herbs

that govern movement—Wu Zhu Yu (Evodia), Huo Xiang (Agastaches) and Chai Hu

(Bupleurum)—in order to restore yang activity and counter the ‘stillness

that abets

and generates yin’. It also contains yin herbs that nourish or leach damp, and

there-

by curb pathological movement. These are Gou Qi Zi (Lycium), He Shou Wu

(Polygoni Multiflorum), Fu Ling (Poriae Cocos) and Ze Xie (Alismatis

Plantago-aquat-

icae). Thus the formula also addresses a key mechanism in the disorder: the

junc-

ture of normal and pathological movement.

Results

In patterns of nausea and vomiting, herbs should be sipped slowly in small

doses,

which is ‘a large prescription used lightly’ (zhong yao qing yong); the

patient is

directed to take the herbs when the stomach feels the most comfortable. After

the

first bag, the symptoms reduced; by the third bag they were 80–90% gone; by

the

fifth bag the patient was cured; and after several days of resting he was able

to

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Page 14

return to his home and his studies. Over the next six months, I received two

letters

expressing his thanks, and reporting that everything remained normal, and his

health improved daily.

Physiology of San Jiao

The yuan qi of the Kidneys is the source of warming energy for the San

Jiao. This heat enables the San Jiao to control qi transformation, the

products of which, according to Chapter  of the Ling Shu, go to warm

and nourish the muscles and flesh, and to firm the skin. The first chap-

ter of the Jin Gui Yao Lue (‘Essentials from the Golden Cabinet’, c.

AD

) states: ‘The crevices in the surface tissues on the exterior of the

body and the organs are the place where the San Jiao moves and gath-

ers the Original True [qi], the area suffused with qi and blood.’ Thus the

transformation and then transportation of qi, blood and fluids by the

Five Zang and Six Fu require the qi transformation and movement of

the San Jiao. This is its first function.

The San Jiao and the Urinary Bladder are connected, and the action

of the San Jiao is to maintain clear fluid passage, transporting fluids

throughout the body and supplying the Urinary Bladder with cast-off

fluids. Because of this, the Nei Jing names the Urinary Bladder ‘the

Ditch Official’, which ensures that no backlog of water or disruption of

flow occurs. The San Jiao must act closely with the Lungs and the

Kidneys, however, if this function is to be performed properly.The Lungs

are responsible for transporting the essential part of the fluids (received

from the Spleen) to the rest of the body, and separately sending the

remainder to the Urinary Bladder. This function is mirrored in the

Kidneys, which ‘distil’ the still useful portion of the fluids sent for dis-

posal, and that portion is returned upward for redistribution. The path-

way for all this movement is the San Jiao. This is its second function.

San Jiao and phlegm.

Again it was the Zhu Bing Yuan Hou Lun that

first suggested the mechanisms of the relationship between the San

Jiao and phlegm, saying such things as ‘phlegm and thin mucus dis-

ease is a result of weak yang qi failing to maintain open pathways for

qi, so that the body fluids are unable to transit smoothly’, and ‘the qi of

yin and yang cannot circulate smoothly [so that] the upper Jiao block-

age produces heat [and thereafter phlegm]’. Because of this book’s

influence on traditional Chinese medicine, later works such as Sheng Ji

Zong Lu (‘Comprehensive Recording of the Sages’ Benefits’, c.

AD

)

and Ji Sheng Fang (‘Formulas to Aid the Living’, ) all contain

pas-

sages like this: ‘If the San Jiao qi is blocked, channel flow will be

obstructed causing water and fluids to stop and gather without proper

circulation, collecting to form phlegm and leading to diseases innu-

merable.’ In the Zheng Zhi Zhun Sheng (‘Standards of Patterns and

Treatments’, ) Wang Ken-Tang observes: ‘A long-term accumula-

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tion of phlegm resembles a ditch which has been backed-up for a long

time, the water running contrary to its normal direction of flow so that

everywhere is clogged with stagnating filth. If one seeks to avoid open-

ing the ditch, and tries to purify the standing water, this simply shows

lack of sense.’



When Wang says ‘open the ditch’, he is referring to the normaliza-

tion of the San Jiao qi transformation process, clearing the water pas-

sages and so dispelling phlegm.

There are two related conditions that should be clarified here.

Although San Jiao functioning depends on the heat of Kidney yang, a

breakdown of San Jiao qi transformation is different from weak Kidney

yang unable to ‘vaporize’ the qi of water. The latter is a Kidney deficien-

cy leading to a state known as ‘excess water producing phlegm’, the

primal yang (yuan yang) is exhausted, and symptoms will be serious. A

blockage of the qi transformation function of the San Jiao means inter-

ruption in the flow of fluids, which then gather and congeal to form

phlegm. In this case the symptoms will be less severe and deep rooted.

Zhang Jing-Yue observes, ‘Qi can transform water and distribute flu-

ids’, and also says, ‘Qi is the Mother of Water, and those who know that

the Way of regulating water lies in the principle “The transformation

of qi leads to the excretion of water [from the Urinary Bladder]â€, they

are the ones who have grasped a large part of the process.’



This again

refers to the qi transformation process of the San Jiao, functioning to

clear and harmonize the passage of fluids, water and damp. Thus when

phlegm-damp or stagnation of water is found in a clinical situation,

warming San Jiao and promoting its qi transformation process is an

essential part of treatment.

Physiology of Liver

Both physiologically and pathologically, the Liver is the most complex

of the five organs. Actively yang while structurally yin, the Liver not

only exercises functions of dispersion but also of storage, at once hard

and at the same time yielding. It has earned the title ‘the Bandit of the

 Illnesses’ because of the many different types of disease to

which it gives rise: emotional problems, respiratory, digestive, circula-

tory and reproductive disorders among them. The section on Liver qi in

the Lei Zheng Zhi Cai (‘Tailored Treatments Arranged According to

Pattern’) by Lin Pei-Qin, (d. ), lists  different symptoms

attrib-

uted to Liver qi disharmony, including cough, distension, nausea,

fainting, subcostal pain, and so on. Beyond all these, Liver also has a

hand in the development of certain types of phlegm.

Liver and phlegm.

The ‘shu-xie’ function of the Liver—which is the

rising and spreading of Liver qi—not only maintains the yin, yang, qi

and blood equilibrium of the Liver organ itself, ensuring against the

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Page 16

tendencies of Liver qi to stagnate or rebel upward, but also exercises a

tremendous influence on the Spleen and Stomach. If the Liver qi move-

ment is obstructed, the digestion and distribution abilities of the Spleen

and Stomach are directly affected, causing a reduction in transporta-

tion and the gradual production of phlegm. This is a pathological

mechanism with which the ancient physicians were well familiar, often

discussing in the same breath the theories ‘Spleen is the source of

phlegm’ and ‘Phlegm is produced from stagnation of qi’. Li Shi-Zhen

states: ‘Excessive Wind and Wood come to oppress Spleen Earth, so that

the transportation of qi is interrupted, obstruction occurs and phlegm

is formed’.



Note that despite the involvement of the Spleen, the root

cause of the phlegm here is the problem in the Liver.

But it is not only by affecting the functioning of the Spleen that

obstruction of the Liver qi can lead to phlegm. Because qi must carry

the fluids around the body, any slow-down in this movement can allow

fluids to coalesce and become phlegm. It was Zhu Dan-Xi who said:

‘Those who treat phlegm effectively do not treat the phlegm, but first

treat the qi. When the circulation of the qi is smooth and ordered, this

will lead the body fluids in a smooth and ordered circulation as well.’

He explains: ‘the substance of phlegm follows the qi in its rise or fall, so

that every place in the body may be reached.’

The Song dynasty physician Chen Wu-Ze in the San Yin Ji Yi Bing

Zheng Fang Lun (‘Discussion of Illnesses, Patterns and Formulas Related

to the Unification of the Three Etiologies’, ) says:

The reasons that people have phlegm and thin mucus disease are: lack of clear-

ness in the nutritive and protective qi (ying wei bu qing) so that qi and blood

fail (bai) and become turbid, then form knots and produce [phlegm]. Internally,

the seven emotions cause havoc, the zang-organ qi cannot move, it stops and

produces thickened fluid, which in its turn produces thin mucus.

15

Zhao Xian-Ke says: ‘The seven emotions cause internal damage,

occlusion, and finally, phlegm’; Yan Yong-He also discusses the rela-

tionship between emotional disturbance leading to a blockage of qi and

the consequent development of phlegm disease, and finally Li Yong-Cui

records: ‘Shock, fury, sadness, and worry: phlegm stems therefrom’. In

many ancient medical works, again, mention is made of qi-tan (qi-

phlegm), feng-tan (wind-phlegm), jing-tan (shock-phlegm), tan-jue

(phlegm-coma) and so on, all of which can be linked with Liver qi

disharmony.

Besides directly slowing the flow of fluids by failing to move qi, there

are several other mechanisms by which Liver dysfunction can indirect-

ly cause the production of phlegm. One is through heat or fire resulting

from Liver qi obstruction or even Liver yin deficiency. This can dry the

fluids into phlegm. Another is through the Liver channel influence on

the San Jiao, which like Gall Bladder is Shao Yang, and thus linked to

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the state of the qi flow in the Jue Yin Liver channel. Yet another, even

more indirect, is qi blockage leading to blood stagnation, so that the

fluids within the stagnated blood also coagulate into phlegm.

Thus the state of the Liver is an extremely crucial factor in the

healthy transport of fluids, because any abnormality of Liver can so

easily result in the production of phlegm.

Physiology of the Heart

Although every functional activity in the body influences the whole,

this does not mean that each activity is influentially equal. In the pro-

duction of phlegm, for example, the Lungs, Spleen and Kidneys are pri-

marily significant, the San Jiao and Liver secondarily so, and the Heart

and the six fu organs of the least consequence. This is not, of course, to

say irrelevant. The Heart controls consciousness (shen ming) and rules

emotion. In the Lei Jing (‘Systematic Categorization of the Nei Jing’,

), it says:

In terms of the injury from emotions, although each of the Five Zang has its

own attribution, if one is looking for the source, it is nowhere but the

Heart...The Ling Shu, Chapter 28, says: ‘Sorrow, sadness and worry all move

the Heart; when the Heart is moved, then the Five Zang and Six Fu are agitat-

ed’. Thus it can be seen that the Heart is the Supreme Master (da zhu) of the

Five Zang and Six Fu, and presides over the hun (ethereal soul) and the po (cor-

poreal soul), while encompassing thought (yi) and will (zhi) as well. Therefore

when sadness moves in the Heart, the Lungs respond; when thought moves in

the Heart, the Spleen responds; when anger moves in the Heart, the Liver

responds; [and] when fear moves in the Heart, the Kidneys respond. This is why

only the Heart controls the Five Emotions. If one can cultivate this Heart well,

living in a safe and quiet place, without fear, without rapture, agreeably going

along with things without strife, and accepting without Self the changes of

Time, then the will and the thought harmonize, the spirit (jing shen) settles,

regret and anger do not arise, the hun and po do not scatter, and the Five Zang

and Six Fu are totally peaceful. What, then, can a pathogen do to one?

16

The Heart also controls blood, a major component of which is fluid,

and which requires the warming action of Heart yang for continuous

circulation. (The relationship of the blood and the fluids, and also with

the sweat, was discussed in an earlier chapter.)

Heart and phlegm.

It is interesting to note that, while the Heart is the

zang organ least involved in phlegm production, it suffers some of the

most grievous consequences, such as coma and epilepsy from ‘phlegm

misting the Heart’, palpitations, insomnia and other disturbed Heart

shen disorders, and even pain in the cardiac region resulting from the

combination of stagnant blood and phlegm. In contradistinction to

this suffering by the Heart, the Kidneys—which are deeply involved in

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Page 18

phlegm development—are subject to little direct harm from phlegm, so

that it is even said ‘phlegm is never found in the Kidneys’.



The mechanisms by which the Heart does contribute to phlegm pro-

duction are primarily through the activities of Heart fire and the defi-

ciencies of Heart yin or yang.

Heart fire, like any fire, can dry the fluids, in this case particularly

the fluids of the blood, leading to the condition known as ‘phlegm-fire

disturbing the Heart’. This will require bitter-cold herbs to drain the

excess fire, with salty-cold herbs to cut hot phlegm, and some pungent

cooling blood-movers to ensure Heart blood circulation.

Deficiency of Heart yin can also produce fire but of a different

nature, and requiring a different approach in treatment, even though

it too can be called ‘phlegm-fire disturbing the Heart’. Here the treat-

ment method must be to moisten yin fluids to settle deficient-fire, while

lightly using cooling bitter and pungent herbs to break up the phlegm

that has already formed. Unless the Spleen is also deficient, one need

not worry overmuch that the use of yin-moistening herbs will increase

the phlegm: this phlegm is the consequence of xu-fire drying already

weakened fluids, not the result of weak Spleen transformation.

Moistening the yin fluids will in fact help to ‘float’ the pathogenic

phlegm and allow it to be eliminated even more easily.

Heart yang deficiency is well documented as a contributor to phlegm

production. Six of the ten formulas introduced to treat thoracic-bi syn-

drome and heart pain in the Jin Gui Yao Lue (‘Essentials from the Golden

Cabinet’) contain herbs to transform phlegm and open the flow of yang

qi. In the Qing dynasty, Li Yong-Cui in the section discussing palpita-

tions in the Zheng Zhi Hui Bu (‘A Supplement to Diagnosis and

Treatment’), says: ‘The master of the body is the Heart, the nourish-

ment of the Heart is the blood. If the Heart blood is deficient, the shen

departs and its residence is left empty. The empty residence [without

the direction of shen] becomes stuffy and phlegm builds up. Phlegm

collecting in the position of the Heart: this is the origin of fright (jing)

and palpitations.’



This describes the actions of both the Heart yin (blood) and the

Heart yang (shen), saying that if the Heart yang activity is not support-

ed by the yin blood, it will fail to move, and fluids will collect into

phlegm. It also implies that as this phlegm is the result of deficiency, its

treatment will require tonification rather than attack.

Summary

The role of each of the five zang organs in the production of phlegm is

closely determined by the part each plays in normal fluid metabolism,

and byits susceptibility to the influence of other pathogenic factors. Each

of these aspects will have a bearing upon the manifestations of phlegm

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in the individual patient. Awareness of the possible range of involvement

each zang may have with phlegm production, and the mechanisms by

which such involvement occurs, will allow accurate interpretation of

those symptoms with which a patient may present. Some further con-

siderations in symptom interpretation are presented below.

CONSTITUTIONAL INDICATIONS OF PHLEGM

. Extended illness without weakening; repeated attacks and remis-

sions; typically middle age and above.

. Eye movements are lackadaisical; eye sockets are dark; there may

be exudate in the corners of the eyes. Complexion is dull and wan;

the face appears puffy.

. Obviously greasy skin; moist, often odorous, secretions from the

armpits, genitals, palms and soles. Shiny face as if oiled.

. Heavy-set, with thick fingers and hands, especially if the flesh is

not muscular but soft and flabby.

. Aching distended feeling in the hands and feet.

. Tongue coat usually white and greasy.

. Tongue body is more slack and flabby than normal.

. Pulse usually deep and rolling; but could also be wiry; soft, floating

and rolling; or just deep.

. Dislike for oily greasy food and dairy products, prefers bland foods

and drinks. Odors such as petrol or perfume can cause headaches,

dizziness and nausea.

. Lack of concentration and poor memory, or, when severe, even

depression, paranoia or hyperactivity.

. Excessive salivation, or even uncontrolled dribbling. Constant

expectoration of phlegm or saliva.

. Lethargy or excessive sleep.

. Sluggish incomplete bowel movements, but not dry stool. Stool

may contain mucus.

. Symptoms may worsen with weather or seasonal changes.

Explanation of the constitutional indications of phlegm

Extended illness without weakening; repeated attacks and

remissions; typically middle age and above

‘Without weakening’ means that the patient’s strength, appetite, mus-

culature and even voice show no signs of illness.

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In patients who do become somewhat emaciated, their energy and

voice seem normal. At the time when phlegm accumulates and

obstructs there may be temporary lethargy—and this is when it is eas-

iest to misdiagnose as deficiency—but as soon as the phlegm breaks up

slightly, the patient’s energy returns. This is because, although the

zheng qi is obstructed by the phlegm, it is not deficient. In fact, some

patients look stronger than before the illness, owing to a gain in

weight.

‘Repeated remissions and attacks’ occur because of the tendency of

phlegm to disperse, so that symptoms disappear, and then accumulate

again, so that symptoms reappear.

Case history: Alternating dispersal and collection of phlegm and damp

My patient was an Australian male, 30 years of age, who had been noticing over

the

past few years an unusual cycle of symptoms: for several weeks he would be happy

and energetic, with good urine flow and a clear tongue coat, but after a period

of

time he would start to feel heavy and tired, the urine would become frequent but

scanty, the bowels irregular—either loose or constipated—and he would notice

a

‘line of tenderness’ which traced exactly the right side Gall Bladder

channel, from

Feng Chi (GB-20) to the foot. The most telling sign was perhaps the tongue coat,

which would change from relatively clear to thick greasy yellow at the root.

It was plain that the condition stemmed from the alternating dispersal and col-

lection of phlegm and damp, combined with obstruction of the qi in the Liver and

Gall Bladder channels, with each blockage able to provoke the other. Liver qi

stasis

failing to move fluids and failing to support the Spleen could begin the process

of

phlegm and damp gathering, which itself could further obstruct qi flow,

initiating a

vicious cycle that would culminate in the above constellation of symptoms.

Alternatively, over-eating or eating the wrong types of food could begin the

process with Spleen damp and phlegm assembling and then hampering Liver and

Gall Bladder qi flow, with the same result.

The scantiness of the urine was the result of damp and phlegm preventing

normal Urinary Bladder function, while the irregular bowel functions

demonstrated

the twin processes of the condition: when the qi flow was obstructed, the

peristaltic action of the bowels was arrhythmic and led to constipation; the

build-

up of heavy sinking damp and phlegm, on the other hand, finally resulted in

loose

stool.

Treatment combined removal of phlegm and damp with support for both the

Spleen and the Liver function, using a combination of Xiang Sha Liu Jun Zi Tang

(‘Six Gentlemen Decoction with Aucklandia and Amomum’, Formulas and

Strategies, p. 238) and Xiao Yao San (‘Rambling Powder’, Formulas and

Strategies,

p. 147).

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Phlegm diseases are most likely to begin in middle age: as the yang qi

starts to decline, years of stress and tension continually slowing the

flow of qi allow fluids gradually to thicken and accumulate into

phlegm, and over-rich foods have wrought their wrack on the Spleen’s

digestive and distributive functions.

If, of course, the phlegm is itself the result of deficiency (e.g. Spleen

and Kidney yang deficiency eventually allowing untransformed food

and fluids to accumulate and become phlegm) then, of course, the

patient will show the deficiency and not have ‘extended illness without

weakening’.

Eye movements are lackadaisical; eye sockets are dark; there

may be exudate in the corners of the eyes. Complexion is dull

and unfresh; the face appears puffy

In TCM theory, the essential jing-qi of the Five Zang and Six Fu pours

upwards into the eyes, allowing them to move freely, in a lively manner,

and providing sharp vision.

But as damp and phlegm can follow the qi anywhere, the eyes too

can be affected. Patients occasionally report an unusual sticky yet

stretchy substance secreted from the corners of the eyes, which is often

a sign of Liver phlegm-fire. If the jing-qi is prevented from rising to the

eyes, the eye movement slows and becomes lethargic.

In China, dark or black areas around, and especially under, the eyes

are (in certain levels of society) called ‘leukorrhea circles’ in women, as

leukorrhea is itself due to an accumulation of damp and phlegm. Puffy

face and dark complexion result from the superficial accumulation of

phlegm and damp obstructing the normal circulation of nutritive and

protective qi in the face.

Obviously greasy skin; moist, often odorous, secretions from

the armpits, genitals, palms and soles. Shiny face as if oiled

This is a reflection of phlegm-heat. Heat is a yang pathogen and so by

nature is active and spreads outward. When heat and phlegm combine,

phlegm is pushed outward toward the surface. A shiny oily face, there-

fore, is an important diagnostic sign of phlegm-heat, while a dull black

complexion signals phlegm-damp or turbid phlegm obstructing physi-

ological yang qi.

Both are phlegm signs but they need to be differentiated for proper

treatment.

Heavy-set, with thick fingers and hands, especially if the flesh

is not muscular but soft and flabby

Phlegm is heavy and murky, and by nature tends to obstruct Spleen,

which hates damp. Digestion and distribution suffer, leaving residue

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which adds to the already excessive phlegm, and the person ‘gains

weight’. Traditional axioms such as ‘fat people usually have excessive

phlegm’ and ‘skinny people usually have excessive fire’ are quite

dependable as clinical reminders, although not sufficient for a diagno-

sis on their own. An initial impression of ‘overweight’ or ‘underweight’

signals the experienced Chinese doctor to look specifically for phlegm

and damp, say, in the former case, and fire symptoms in the latter.

There must be other confirming symptoms for a reliable diagnosis.

Aching distended feeling in the hands and feet

Fullness or distended feeling in the hands, feet, neck and upper back

can often be traced to phlegm obstructing the flow of qi and preventing

the required nourishment from reaching the tissues, thus causing

aching; distension will be the result of accumulation of both qi and

phlegm. The limbs are ruled by the Spleen, because of the identity of

both with Earth; phlegm, being of the same nature as damp, is also

related to Earth—like calls to like.

Tongue coat usually white and greasy

The tongue coat will usually be white and greasy, and may stay this

way for years, or may disappear and reappear repeatedly. It may appear

only on the sides, or may just be permanently greasy at the root.

The coat will vary depending upon the nature of the phlegm:

whether it is mixed with hot or cold, or the result of a deficiency or

another shi-pathogen, or has caused qi blockage or blood stagnation,

and so on. The location of the phlegm accumulation or the stage of the

illness will also affect the tongue coat, making it thick in the middle,

say, for middle Jiao phlegm damp, or pooled just behind the tip for

phlegm gathered in the Lungs, and so on.

One important fact to recognize is that a peeled coat (or a coat peeled

only in the center) can point to phlegm as well as to yin deficiency. The

differentiating factor is whether or not the patient has a yin-deficient

body type, or any yin deficiency symptoms. If not, it is probably

phlegm.

However, it is also said ‘stubborn phlegm [brings out] strange symp-

toms’, and sometimes the tongue may, surprisingly, have little coat at

all. In these cases one must balance the rest of the symptoms against

the solitary contradiction of the tongue, and make a reasoned judge-

ment. In some cases this will be a signal that the phlegm is simply not

involved with the digestive system, and so is less likely to manifest on

the tongue coat. In other situations, such as the case history described

above, the phlegm is lodged deep within the body, and appears only

when stirred up by a precipitating factor.

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Tongue body is more slack and flabby than normal

A slack tongue is a cardinal sign of qi deficiency with phlegm reten-

tion. But the slack tongue of phlegm disease is not as severe as that of a

stroke victim, where the tongue body is often lolling, drooling and diffi-

cult to retract. Slack tongue in phlegm disease is very slight and

extremely easy to miss unless watched for carefully. When the illness is

at a peak, it may be more obvious.

Qi-deficient patients with retained phlegm usually have a pale white

tongue. Phlegm and blood stagnation occurring together show up as a

dull purplish tongue.

Pulse usually deep and rolling; but could also be wiry; soft,

floating and rolling; or just deep

The pulse typically manifests as deep and slippery, or soft floating and

slippery (ru ), but it could be wiry, or just deep.

Dislike for oily greasy food and dairy products, preference for

bland foods and drinks. Odors such as petrol or perfume can

cause headaches, dizziness and nausea

If the person is not addicted to junk food and is somewhat in touch

with what makes them feel physically better, they will prefer simple

bland food, and report that greasy foods, even the icing on cakes, will

make them nauseous. Greasy foods have what the Chinese call a

‘heavy’ flavor and odor, like phlegm itself, and so tend to increase damp

and phlegm.

Bland, as a flavor, is classed as yang and encourages diuresis, thus

reducing damp. Heat, too, is yang, while phlegm is yin, and so heated

foods and drinks can temporarily reduce excessive internal yin. Certain

fragrant foods such as coriander or basil can disperse and dry damp,

and also provide some relief to the patient.

However, piercingly strong fragrant odors such as petrol or perfume

will break up phlegm because of the yang-expanding nature of fra-

grance. This is used even in herbal treatment as a principle of damp

treatment: fragrance to disperse damp and phlegm. Here, though, the

effect is from the environment and therefore uncontrolled. Once the

phlegm is broken up by these odors, the yang nature of the fragrance

starts it on its rise upward, and then the phlegm is lifted with the nor-

mal flow of clear yang to the head, obstructing the orifice of the mind,

and bringing on dizziness and headaches. Nausea is caused because of

the rising phlegm’s interference with the normal descent of Stomach

qi.



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Lack of concentration and poor memory; or when severe, even

depression, paranoia or hyperactivity

Lack of concentration and poor memory are extremely common symp-

toms of phlegm and damp obstructing the flow of clear yang to the

head. As such it will usually be most noticeable in the early morning,

before the excessive yin that has settled over the night-time has had a

chance to be dispersed by the activity of yang. It will also be poor after

eating, when Spleen yang is fully engaged in digestion and unable to

break through the already formed phlegm-damp to lift clear yang to

the head. The depression, paranoia and hyperactivity are symptoms of

phlegm disturbing the Heart shen and may be obvious and severe, as in

mental illness or stroke.



Excessive salivation, or even uncontrolled dribbling. Constant

expectoration of phlegm or saliva

Stool examination to eliminate intestinal parasites as a possible

causative factor is necessary with this symptom. While frequently a

result of Spleen or Kidney deficiency, excess phlegm obstructing the

normal descent of Stomach qi is another possible origin. If Stomach qi

cannot descend it will rebel upward, carrying the accumulated

untransformed fluids with it, producing excessive saliva. A characteris-

tic sign of phlegm, though, is that this symptom is worse when the

patient is depressed, or has nothing to distract them. This is because

the excess saliva is often related to an impairment of Liver assistance in

the proper ascent and descent of Spleen and Stomach qi. ‘Spleen and

Stomach are the pathway for ascent and descent, while Liver is the

pivot’, observed the Qing dynasty physician Zhou Xue-Hai.

For proper treatment when this symptom is the main presenting

complaint—as it may well be, due to the distress it can cause to the

patient and their family—it is important to distinguish deficiency and

excess, as suggested above. Excess conditions result from functional

disharmony of the Liver, Spleen, Stomach and Lungs, whereas the defi-

ciency conditions (which involve primarily the Spleen and Kidneys)

result from yang qi not transforming fluids.



Lethargy or excessive sleep

This can be the outcome of either excessive phlegm-damp (i.e. an

excess condition), or deficient Spleen producing phlegm (which is a

mixed xu-shi state). In both cases Spleen yang is fatigued and the urge

to sleep increased.

However, there is a difference: in the case of excessive phlegm, the

urge to sleep and then the sleep itself is heavy, while the lethargy is less

marked.

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On the other hand, when qi is deficient, blood too is affected and fails

to nourish the Heart. The patient is constantly sitting, lying or leaning

against something to rest, but when it comes to actually sleeping, this

is difficult. Often they cannot get to sleep due to recurring thoughts. If

they do manage to sleep, they awaken easily.The whole clinical picture

is strikingly different to the log-like sleep of excess-type phlegm sup-

pressing the yang qi, and was in fact noted centuries ago. The Zhu Bing

Yuan Hou Lun (‘General Treatise on the Etiology and Symptomatology

of Disease’,

AD

) by Chao Yuan-Fang recorded: ‘Shortness of breath

and desire to sleep is a sign of phlegm.’



This hypersomnolence can itself be a presenting symptom, or of

course can be admixed with other symptoms. If it is the presenting

symptom, usually it will be found to be excess-type phlegm suppressing

yang qi. If admixed, all the other factors must be considered before

determining treatment.

Sluggish incomplete bowel movements, but not dry stool. The

stool may contain mucus

If the sluggishness is minor, it may be accompanied only by abdominal

distension, or by epigastric fullness and discomfort. If the constipation

is more serious, there may be symptoms such as restless feelings of agi-

tation in the chest, fullness and distension in the head, and disorienta-

tion, disturbing normal thinking, eating and sleeping. Symptoms such

as these are not life threatening but are very annoying. A tell-tale indi-

cation of the root cause of the whole syndrome is that, on those occa-

sions when the bowels move well, the patient suddenly feels light and

clear, ‘on top of the world’.



The underlying mechanism in this type of constipation is deep inter-

nal phlegm obstructing the descent of fu-organ qi. A common associ-

ated factor is Liver qi stasis, which by overcoming the Spleen can cause

damp and eventually phlegm. It can also directly influence the descent

of qi through the Stomach and Intestines.

It should be noted that this is not parched phlegm (zao tan

) or

phlegm-fire causing the constipation by drying out the stool, but

rather turbid phlegm: the stool is not dry and may even contain mucus.

‘Phlegm-constipation’, however, is a diagnosis often overlooked by

even experienced Chinese doctors amongst the myriad of other causes:

fire, heat, parching dryness, cold, qi obstruction, qi deficiency, yin defi-

ciency, and so on. However, it has to be considered, if only to under-

stand why certain treatments fail.



Symptoms may worsen with weather or seasonal changes

Many illnesses are affected by the weather but phlegm diseases are the

most obvious. This is due to the nature of phlegm, which follows the

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flow of qi anywhere in the body and therefore reacts as much to

meteorological conditions as does the qi itself.

For example, if cold phlegm has accumulated internally and the

weather changes to an overcast or damp state, this increase in yin

influence can cause worsening of the heaviness in the head, stuffy

chest, nausea, excess salivation, insomnia and heavy limbs, to the

extent that the patient may have to stop whatever they are doing and

rest.

However, in summer, or a very dry autumn, these symptoms will

lessen or even disappear altogether.

On the other hand, hot phlegm that has accumulated inside the

body will react to weather that is hot or warm and muggy, or to a work

environment that is at a high temperature, or to a noisy disturbing or

dirty environment. Symptoms such as distension in the head, palpita-

tions, anxiety, distension of the hands, feet and neck, greasy skin, and

bitter taste or sticky feeling in the mouth will all worsen. When the

temperature is cool, the symptoms can lessen or be relieved, or even in

some cases disappear.

TYPICAL PHLEGM SYMPTOMS

. Vertigo, headache and heavy head.

. Nausea, vomiting, borborygmus; sticky greasy feeling in the

mouth; or dry mouth with no desire to drink.

. Intermittent plum-stone throat.

. Difficulty swallowing; vomiting of thin phlegm.

. Chronic chest tightness and stuffiness (this may be described as

‘shortness of breath’ by the patient); possible sudden heart pain

like pressure, heaviness or compression.

. Palpitations, anxiety, easily startled; insomnia; even fainting and

convulsions, or mental disturbance. However, neurological signs

and symptoms are normal; also no signs of yin xu with yang

rising.

. Heavy body, low-grade fever; or subjective fever only.

. Local heat sensations (e.g. in the limbs or trunk); or local chills

(e.g. a hand-sized cold feeling on the back); or numbness without

pain or itching; or a local swelling on the limbs that feels different

from the surrounding areas. Western diagnosis is inconclusive.

. Sores and ulcers, or tissue necrosis with weeping or exudation of a

sticky phlegm-like material. Long-term failure of such sores to

heal over. Also local thickening of the skin with flaking but no

weeping.

. Stuffy chest, distended or cool feeling in the back, which improves

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with massage or beating; and frequent sighing. These symptoms

become more obvious on muggy, overcast or rainy days, or in rapid

weather changes.

. Masses or nodes (e.g. subcutaneous nodules or abdominal mass-

es), with little change to the overlying skin except perhaps a slight

feeling of coolness or darkening of the skin.

. Raw pain in the mouth.

. Subcostal swelling and fullness, possibly with slight pain.

. Variable pulse manifestations.

Explanation of the special characteristics of typical phlegm symptoms

Vertigo, headache and heavy head

In Chinese medicine, the head is considered ‘the mansion of clear

expanse’ (qing xu zhi fu

), the residence of original shen

(yuan shen

)



which requires the nourishment of qi, blood,

essence and marrow, and which cannot endure interference from

unclean murky pathogens.

For example, if phlegm or damp rise up and disturb the ‘clear

expanse’, then the result may be vertigo, headache and a stuffy full

feeling in the head. The pathogens phlegm and damp are heavy, turbid

and substantial, and as the TCM dictum states: ‘It is the nature of

phlegm, when causing disease, to follow qi in its ascent and descent,

reaching every place without exception.’ Thus phlegm-damp can rise,

impede clear yang, and also enter and choke the circulation both inside

and outside the blood vessels. In biomedical terms, the resulting condi-

tion is similar to that of hypertension with loss of vascular elasticity

and eventually sclerosis. It is noteworthy, too, that hypertensive

patients with symptoms of phlegm rising and clouding the clear yang

usually respond well to treatment based upon transforming and clear-

ing phlegm-damp.

There is a fundamental difference between the mechanisms involved

in phlegm-induced vertigo, headache and heavy head, and the similar

condition resulting from deficiency of qi and blood. They both may be

constant and chronic, or intermittent, but in the case of phlegm the

use of qi lifting and tonifying will worsen the condition.

Nausea, vomiting, borborygmus; sticky greasy feeling in the

mouth; or dry mouth with no desire to drink

Phlegm and damp hindering the normal descent of Stomach and

Intestinal qi will lead to nausea, vomiting and the sound of fluids slosh-

ing about the abdomen.

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Phlegm and mucus being carried upward will lead to a sticky feeling

in the mouth and a greasy taste.

Phlegm and mucus are originally derived from physiological fluids

(jin-ye): when normal fluid transformation fails, the jin-ye condense

and the end result is a pathological production of phlegm. As this

pathogen begins to build up, however, its very accumulation further

retards the normal fluid transformation and transportation. The

inability of the Spleen to transport fluids upward, because of phlegm-

damp oppression, leads to dryness of the mouth. Moreover, the ever-

growing impediment to Spleen transport means that less and less

normal fluids are being produced, which further exacerbates the

situation. The most effective treatment approach is to warm and assist

Spleen transformation of phlegm and damp, with a formula such as

Ping Wei San (Calm the Stomach Powder, Formulas and Strategies,

p. ), or moxa on Zhong Wan (CV-) with reduction of Feng Long

(ST-). In some cases it may be necessary to open the Liver qi flow to

assist Spleen transport.

The differentiating point in this symptom is the lack of desire to

drink. If questioned closely, the patient will often report that, even

though they have a dry mouth, drinking water does not help, and that

they even feel epigastric discomfort or nausea. This is because adding

water to an excess of damp will additionally hamper Spleen and

Stomach function.

Intermittent plum-stone throat

Usually this is a consequence of Liver qi knotting up due to emotional

imbalance. As it gets worse, Spleen is affected, normal transport and

digestion is diminished, and body fluids coalesce into phlegm. This

phlegm follows the qi up to the throat and jams there, bringing on a

feeling of something physically stuck in the throat, which cannot be

swallowed or brought up.

One of the characteristics of phlegm, as noted previously, is its cycli-

cal accumulation and dispersal. In this case the cycle depends on the

emotional state and the effect of that emotional state on the qi. When

the qi flows openly without restraint, the throat is clear; but with stress

or pressure, the feeling in the throat returns. If this process continues

for an extended period of time, deficiency of yin may occur, because

Spleen production of normal yin fluids is reduced, while pathological

fluids such as phlegm and damp increase. As yin decreases, xu-fire

builds up which further damages the yin. This results in a combined

yin-deficiency and phlegm-excess condition. At this stage, simply

attempting to remove phlegm would be disastrous. Normal fluids

would be severely injured and the dry obstructed throat symptoms

would become worse. Yin-moistening herbs must be added to support

fluids, and dispersal becomes secondary.

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Difficulty swallowing; vomiting of thin phlegm

Here, again, emotions precipitate the symptoms. The qi flow is

impaired, jin-ye dries, phlegm forms, and it may even reach the stage

where blood stagnates and fuses with the phlegm.

This is the difference between the former symptom of plum-stone

throat and the present dysphagia: in the previous condition, despite a

feeling of obstruction, there was no actual difficulty swallowing. In the

present state, the barrier is substantial.

If, however, the mass is not located in the throat but in or around the

stomach, the result can be an inhibition of downward movement from

the Stomach, with a consequent vomiting upward of thin phlegm.

Chronic chest tightness and stuffiness (this may be described

as ‘shortness of breath’ by the patient); possible sudden heart

pain like pressure, heaviness or compression

In this case phlegm is impeding the Heart yang, yang qi is failing to cir-

culate properly, and the patient will feel, first, a tightness in the chest

and then, as the yang qi becomes more obstructed, pain.

Alternatively, it may initially be the Heart yang itself that is deficient,

so that a yin ‘mist’ arises and clouds the Heart yang, finally ending in

phlegm oppressing the chest.

These symptoms are similar to the biomedical disorder of coronary

heart disease, but for patients whose TCM etiology involves phlegm, the

use of blood stagnation removers



of any description will not be

enough. They must be accompanied by herbs that warm yang and

transform phlegm in order to achieve effect.

Palpitations, anxiety, easily startled; insomnia; even fainting

and convulsions, or mental disturbance. But neurological

signs and symptoms are normal; also no signs of yin xu with

yang rising

Zhu Dan-Xi says in regard to severe palpitations: ‘This is generally

blood deficiency. If it is worse with worry or anxiety, it is from deficien-

cy, and usually lack of blood. If it comes and goes, this is phlegm being

moved by fire. In thin people, lack of blood will usually be the cause; in

fat people it is almost always from phlegm.’



The other symptoms, too,

can result from phlegm misting the Heart, and occluding the shen.

Heavy body, low-grade fever; or subjective fever only

Phlegm is a yin pathogen, with a sticky nature that easily lies latent

deep inside the body. This latent deep-lying phlegm can hinder the

yang qi from expanding properly, so that yang increases internally and

heat builds up.

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This is different from exogenous fever and also from yin, blood or qi-

deficient fever. The special differentiating point is the heavy body and

low fever.

Clinically, idiopathic low-grade fever is quite common. As a rule, if it

is not in the category of yin deficiency or qi deficiency, it is probably

phlegm. Careless use of yin or qi tonifying herbs in this case will add to

the phlegm and turn the condition into a long drawn-out affair. To

avoid this, symptoms such as pulse and tongue should be painstakingly

checked to determine the real underlying cause.

Local heat sensations (e.g. in limbs or trunk); or local chills

(e.g. palm-sized cold feeling on the back); or numbness

without pain or itching; or a local swelling on the limbs that

feels different from the surrounding areas. Western diagnosis

is inconclusive

These symptoms result from local phlegm build-up obstructing the

flow of protective and nutritive qi through the surface tissues.

Numbness from pathogenic wind tends to be fleeting and not fixed in

position, whereas numbness from phlegm will not move as quickly.

Over a period of time, if not dispersed, the phlegm can collect and form

nodes and lumps. As the saying has it: ‘[Phlegm’s] accompanying

symptoms may all be different, and there may be hundreds of possible

pathological permutations.’

Sores and ulcers, or tissue necrosis with weeping or exudation

of a sticky phlegm-like material. Long-term failure of sores to

heal over. Also local thickening of the skin with flaking but no

weeping

Phlegm and damp, or hot phlegm accumulation, affect the local flow of

qi and blood, and can cause exudation of the substantial phlegm.

When this becomes severe, it can lead to ulceration.

Long-term cases will have weak zheng qi, plus an open wound

allowing exogenous invasion of wind, cold or heat. Under these condi-

tions, normal nutritive and protective qi cannot reach the area to heal

it in the usual way.

This can start as turbid phlegm accumulation but end as qi and yin

deficiency plus stubborn-phlegm (wan tan

). Once at this stage,

the skin often thickens and scales, the lack of exudate showing that

normal fluids are exhausted.

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Stuffy chest, distended or cool feeling in the back, that

improves with massage or beating; and frequent sighing.

These symptoms become more obvious on muggy, overcast,

or rainy days, or in rapid weather changes

Phlegm frustrates yang qi flow, including the spread and dispersal of

Lung qi. Massage, beating and even sighing helps qi to move, thus pro-

viding relief, although only temporarily.

If phlegm stalls in the back, the hindering of yang qi flow generates

a feeling of distension or cold.

As noted previously, the symptoms’ responsiveness to weather

changes is an indication of phlegm (or damp) involvement.

Masses or nodes (e.g. subcutaneous nodules or abdominal

masses), with little change to the overlying skin except

perhaps a slight feeling of coolness or darkening of the skin

Yang qi deficiency or emotions leading to qi obstruction can weaken

Spleen’s ability to transport, so that damp and finally phlegm gather

and begin to interfere with the flow of qi. Once turbid phlegm collects,

the flow of qi becomes even more clogged and the phlegm can coalesce

into knots or swellings. The patient often worries about this, and a

vicious cycle of increasing qi stasis and phlegm build-up occurs, with

the nodes becoming ever more firm and difficult to break up.

If the skin or complexion is obviously darkened, this means the

accumulation is formed from stubborn phlegm and ‘dead’ blood (si xue

). This can be treated only by both transforming stubborn phlegm

and breaking up dead blood. If the condition is chronic, attacking and

tonifying will have to be used in combination by adding yang warming

and yin nourishing herbs, plus fragrant piercing substances such as

musk or insect drugs to enter the lump and disperse. This will help to

prevent a further development of the mass.

Raw pain in the mouth

This is intermittent raw pain in the mouth, with a tender red tongue

that is sensitive to pungent, spicy, salty, hot, sour or astringent foods; or

even acid foods such as oranges. The symptom can be very debilitating,

influencing eating, work and finally overall health.

Usually mouth pain is considered a fire or heat symptom. While this

is not exactly wrong, most often the symptom is a result of combined

yin deficiency and phlegm, occurring most frequently in women

patients with damaged blood and fluids.

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There are three facets to treatment: nourishing yin, moistening dry-

ness and transforming hot phlegm. If the phlegm transformation is

ignored, the results will not be satisfactory. Raw pain in the mouth

should always alert one to look for yin deficiency with parched phlegm.

(See the case history ‘Chronic phlegm-heat’ later in this chapter.)

Subcostal swelling and fullness, possibly with slight pain

Subcostal swelling, stuffiness and pain is related, usually, to the stresses

of work and living, through the chronic inhibition of Liver qi. Such a

chronic condition rarely leaves the Spleen unscathed, and phlegm is

the almost inevitable result. This is especially so because impairment of

the flow of qi will slow fluid circulation in general around the body, so

that even a tiny local obstruction of fluids can, under these conditions,

grow into phlegm. Thus subcostal fullness should be a reminder to look

for symptoms of phlegm.

Variable pulse manifestations

The most usual types of pulse in phlegm cases are slippery, wiry, deep

and slow.

Strong hot phlegm internally is shown by a slippery and wiry

pulse.

Knotted stubborn phlegm internally produces deep or slow pulses.

Li Shi-Zhen, in his Bin Hu Mai Xue (‘The Pulse Studies of Bin Hu’,

), says:

. Rapid means heat, slow is cold, slippery is phlegm.



. Deep cun (distal) position means phlegm obstruction or stagnant

pathological water in the chest.



. Slow shows a zang illness or abundant phlegm.



. Cun (distal) slippery means phlegm around the diaphragm causing

nausea and vomiting.



Clinically, however, it is difficult to predict exactly what type of pulse

a patient with phlegm may present, owing to the numerous variables

involved in phlegm pathology. Therefore a diagnosis of phlegm—or no

phlegm—should not be based solely on the pulse but should include all

symptoms, equally weighed.

Summary

The symptoms described in the two sections above are typical clinical

manifestations of phlegm, with regard to both symptoms and body

types.

But it must be remembered that not every patient will have every

manifestation. Factors such as climate (hot or cold, wet or dry), work

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(mental or physical), age, sex, standard of living, life-style habits, and

so on, will all make a big difference in the presenting symptoms of indi-

vidual patients. For example, a sedentary office worker who fancies

himself a gourmet will tend to grow fat, become dizzy and have palpita-

tions—all highly likely symptoms. Or, a late-middle-aged woman with

Liver qi stasis failing to assist Spleen transport will probably have

phlegm obstructing the chest, back, flanks or epigastric area, or

obstructing the throat. Because of the feelings of obstruction, she will

probably often sigh a lot to disperse the phlegm, and feel temporary

relief after massage. Thus the special characteristics of phlegm symp-

toms and the constitutional indications of phlegm must be considered

in the light of the patient’s actual living situation to appreciate their

diagnostic significance.

COMBINATION OF PHLEGM AND OTHER PATHOGENS

Phlegm has a tendency to combine with other pathogens, often those

that led to the phlegm formation in the first place. These are, therefore,

often described in the TCM literature, both classical and modern, in

terms of a combined nomenclature. For example, accumulation of

damp into phlegm, with some pathogenic damp still remaining in con-

junction with the phlegm, is usually termed ‘phlegm-damp’ (tan shi

) or ‘damp-phlegm’ (shi tan

). Wind and phlegm existing

together is called ‘wind-phlegm’ (feng tan

), although the prob-

lem then remains as to whether the wind referred to is exogenous or

endogenous; this is solved by calling it ‘wai feng feng tan’ (‘exogenous-

wind wind-phlegm’

) or ‘nei feng feng tan’ (‘endogenous-

wind wind-phlegm

); phlegm resulting from the invasion of

a zao-drying pathogen that desiccates the fluids is called ‘dry-phlegm’

(or ‘parched-phlegm’—zao tan

); phlegm building up as the con-

sequence of stagnating food in the middle Jiao is called ‘food-phlegm’

(shi tan

); phlegm resulting from deficiency of either yin or yang

is called ‘deficient-phlegm’ (xu tan

); while all other types of

phlegm are known as ‘excess-phlegm’ (shi tan

); and so on. The

seeming complexity of the terminology reflects the extent to which

Chinese medicine has investigated phlegm pathology, but there is little

actual difficulty when the terms are found in context.

Figures .‒. are examples of how and where these pathogenic

combinations interact and the symptoms engendered by this interac-

tion.



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FLUID PHYSIOLOGY AND PATHOLOGY IN TRADITIONAL CHINESE MEDICINE

298

Emotional

imbalance

Liver qi stasis

turns to fire

Endogenous fire, or

exogenous pathogen

turning hot

Constitutional

yin deficiency

Dried fluids

become phlegm

Phlegm-heat

(or phlegm-fire)

Internal xu-fire

Fig. 7.3 Production of hot-phlegm or phlegm-fire (re tan, tan huo)

Lung qi

obstruction

Accumulation

into phlegm

Wind pathogen

invading Lungs

Pathogenic wind and

phlegm combine to

form (exogenous)

wind-phlegm

Failure of fluids

to be distributed

Fig. 7.1 Production of exogenous wind-phlegm (wai feng feng tan)

Fluids fail to be

distributed properly

Fluids congeal

into phlegm

Liver channel

qi stasis

Liver qi

movement reduced

Stress

Phlegm and

obstructed qi

combine to form

qi-phlegm

Fig. 7.2 Production of qi-phlegm (qi tan)

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PHLEGM: ETIOLOGY AND SYMPTOMATOLOGY

299

Constitutional yin

deficiency with

yang rising

Constitutional yin

deficiency leading

to xu-fire

Yang rising

Liver qi stasis

turns to fire

Qi stasis congeals

fluids into phlegm

Xu-fire dries fluids

into phlegm

Phlegm

Internal wind

Internal wind and

phlegm combine

Stress or emotional

imbalance leading

to Liver qi stasis

Fig. 7.4 Production of endogenous wind-phlegm (nei feng feng tan)

Intemperate eating

or over-consumption

of cold or raw foods

Damage to Spleen

and Stomach

functioning

Stress or emotional

imbalance leading

to Liver qi stasis

Liver qi fails to

assist transport

Poor digestion

and distribution

create damp

Damp thickens

to create

damp-phlegm

Fig. 7.5 Production of damp-phlegm (shi tan)

Phlegm and blood

stagnation combine

to form

stagnation-phlegm

Fire dries fluids

into phlegm

Liver qi stasis

turns to fire

Qi stasis congeals

fluids into phlegm

Qi blockage leads

to blood stagnation

Stress or emotional

imbalance leading

to Liver qi stasis

Fig. 7.6 Production of stagnation-phlegm (tan yu)

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NOTES TO THE FIGURES

See also Appendix 3

. Wind-phlegm will be located in the Lungs and have a white, thin, frothy

appearance. It may be accompanied by surface symptoms such as chills,

fever and recently developed cough; and the tongue coat will be thin

white.

. Qi-phlegm will be located either in the channels and collaterals, the Liver

or the Heart. The telling symptoms may be soft painless nodes in the

neck, breast or inguinal region that do not have any changes in skin

color; ‘plum-stone throat’; sensation of fullness in the chest; mood

swings; apathy; or the loss of concentration and mental ‘presence’. The

tongue coat will usually be thin and greasy.

. Hot-phlegm will be located in the Lungs and have sticky thick yellow

phlegm, possibly with pus or even blood in it. The face may be red; there

may be thirst and possibly fever. The tongue body will be red, the tongue

coat yellow and greasy.

FLUID PHYSIOLOGY AND PATHOLOGY IN TRADITIONAL CHINESE MEDICINE

300

Exogenous

zao-parching

pathogen

Lung yin

deficiency

Weakness of

jin fluids

tain long-term cases of stubborn phlegm, one needs to warm and toni-

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

knot of phlegm. In the same context he goes on to say: ‘Phlegm may be

produced in any disorder of the five zang-organs... therefore the

transformation

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

knot of phlegm. In the same context he goes on to say: ‘Phlegm may be

produced in any disorder of the five zang-organs... therefore the

transformation of phlegm must occur from the Spleen but the Root of

Phlegm is none other than the Kidneys’. Obviously the key point in the

development of xu (deficient) phlegm is a weakness of Kidney yang,

especially in so far as this is related to ‘fire not supporting Earth’ and

an

overflow of pathogenic water building up into phlegm.

Similar theoretical descriptions from the Ming and Qing dynasties

are numerous, from such authors as Lin Pei-Qin and Chen Xiu-Yuan

lack of Kidney yang. Therefore he feels that xu phlegm must never be

‘attacked’ as a method of treatment; since this phlegm is a product of

the mis-transformation of foods and fluids, it can be produced as fast as

it is expelled. Furthermore, attacking treatments can damage the con-

stitutional (yuan) qi, and the use of preparations such as Gun Tan Wan

(‘Vaporize Phlegm Pill’, Formulas and Strategies, p. ) is

‘looking only

at the present with no thought for what follows.’

Zhang Jing-Yue taught that the best principle of treatment in

phlegm disease is to ‘cause it not to be produced’, which is to say, in cer-

tain long-term cases of stubborn phlegm, one needs to warm and toni-

fy Kidney yang, ‘tonifying fire to support Earth’ in order to disperse the

knot of phlegm. In the same context he goes on to say: ‘Phlegm may be

produced in any disorder of the five zang-organs... therefore the

transformation of phlegm must occur from the Spleen but the Root of

Phlegm is none other than the Kidneys’. Obviously the key point in the

development of xu (deficient) phlegm is a weakness of Kidney yang,

especially in so far as this is related to ‘fire not supporting Earth’ and

an

overflow of pathogenic water building up into phlegm.



Similar theoretical descriptions from the Ming and Qing dynasties

are numerous, from such authors as Lin Pei-Qin and Chen Xiu-Yuan

who also spoke of the Kidneys as the source of phlegm, the Spleen as its

transport and the Lungs as the storehouse; all showing clearly that the

development of phlegm is closely related to Kidney yang or Kidney yin

deficiency, or a disruption of the yin-yang balance in the Kidneys

who also spoke of the Kidneys as the source of phlegm, the Spleen as its

transport and the Lungs as the storehouse; all showing clearly that the

development of phlegm is closely related to Kidney yang or Kidney yin

deficiency, or a disruption of the yin-yang balance in the Kidneys. "

 

He brings down much more, but the point I learn from this is completely

different from everything I have ever been taught about phlegm being always

excess.  The obvious conclusion is that since phlegm, in this case is NOT

repletion, but rather vacuity, using formulas such as Gun Tan Wan which attack

the phlegm, is precisely the WRONG approach to take! And that using such a

formula will damage the Yuan Qi and further weaken and exascerbate the vacuous

patient. 

 

Thanks Z'ev and Jason for the guidance.  This brings clarity to me on the

concept that what Chana suffers from, actually is phlegm, but deficient

(vacuous) rather than excess (replete) phlegm.

 

Respectfully,