Chapter Nine. Syndrome of phlegm and formula composition
CHAPTER OUTLINE
This chapter introduces the principles, methods and strategies for the composition of formulas that transform, dry and eliminate phlegm. They are used to treat phlegm syndrome.
Syndrome of phlegm
Phlegm is both a pathological product and a secondary pathogenic factor that will lead to further pathological changes in the body.
In the concept of traditional Chinese medicine, phlegm and dampness are considered to be substances with the same nature and to come from the same origin. They are the pathological products of failure of water metabolism, which is caused directly by dysfunctions of the Lung, Spleen, Kidney and San Jiao. If water spreads without visible form, it is referred to as dampness; if water becomes thick and turbid, accumulates in one place and has form, it is referred to as phlegm.
Dysfunctions of the Lung, Spleen, Kidney and San Jiao are the principal causes of phlegm: the Lung disperses and descends the water; the Spleen transports the water and transforms it into body fluids; the Kidney receives body fluids and separates the clean from the turbid by steaming them, as well as warming the Spleen-Yang to accelerate the function of the Spleen; the San Jiao is the passage of Qi and water. Dysfunction of these organs can lead to water accumulation.
Other factors may also influence the formation of phlegm. Cold can condense water, make water move slowly in the body and cause accumulation; exterior dampness can directly invade the body via skin, nose and mouth, as well as from food and drink; heat can consume body fluids, which become turbid and thick and form phlegm with other pathogenic factors; Qi stagnation can cause water accumulation directly. Constitution and dietary habit are also important in producing phlegm. A Yang constitution and a diet with spicy, hot and fatty food may easily generate phlegm-heat. A Yin constitution and a diet with cold and raw food or low-calorie food may generate cold, further injure the Yang of the Spleen and form damp-phlegm or phlegm-cold.
As soon as the phlegm is formed, it interferes and blocks the normal Qi movement. In addition, it is also pushed by Qi to move throughout the body. A type of visible phlegm often accumulates in the Lung, nose, sinuses, stomach and intestines and can be expectorated or discharged; a type of invisible phlegm exists in other parts of the body and cannot be discharged. These types of phlegm can result in different symptoms. In general, phlegm syndrome is divided into damp-phlegm/cold-phlegm syndrome and phlegm-heat syndrome.
Manifestations
Main symptoms
Damp-phlegm/cold-phlegm syndrome: large amount of white, sticky, thick or thin phlegm without smell that is easy to expectorate.
Phlegm-heat syndrome: large amount of green or yellowish sticky phlegm with a foul smell that can be expectorated.
Symptoms according to the affected regions and organs
Phlegm in the Lung and sinus: cough, wheeze, phlegm that can be expectorated, nose obstruction or runny nose.
Phlegm obstruction of the throat: sticky phlegm that is difficult to expectorate, or having a sensation that a plum-pit blocks the throat which cannot be swallowed or expectorated.
Phlegm obstruction of the Stomach: nausea, vomiting, loss of appetite, fullness in the upper abdomen.
Phlegm accumulates in the intestines: discharge of mucus and pus.
Phlegm obstruction of the sensory orifices: dizziness, vertigo, tinnitus, deafness, heavy sensation in the head, loss of consciousness, wind-stroke and epilepsy.
Phlegm obstruction of the Heart: palpitations, chest pain, restlessness, insomnia, depression, mental confusion, delirium and mania.
Phlegm obstruction of the meridians and collaterals: in blocked areas, having the sensation of numbness, heaviness, tingling, cramp, twitch and pain.
Phlegm obstruction with other pathogenic factors for a long period of time: lymphadenitis, scrofula and tumors.
Secondary symptoms
Fullness, distending sensation or pain in the related areas.
Tongue
Damp-phlegm/cold-phlegm syndrome: pale or dull pale with a white sticky coating.
Phlegm-heat syndrome: red with a yellow sticky coating.
Pulse
Damp-phlegm/cold-phlegm syndrome: slippery, wiry or deep.
Phlegm-heat syndrome: slippery and rapid.
Associated disorders in western medicine
Sinusitis, laryngopharyngitis, acute and chronic bronchitis, pulmonary emphysema, upper respiratory infection, pneumonia, lung abscess, influenza, gastritis, morning sickness of early pregnancy, dysentery, colitis, migraine and Ménière’s disease, schizophrenia, depression, facial paralysis, facial spasm, epilepsy, hemiplegia, neuralgia, lymphadenitis, nodules, goiter, scrofula, hepatosplenomegaly, cirrhosis of liver and tumors.
Analysis of the syndrome
Phlegm is a pathological product caused by failure of water metabolism. As soon as phlegm is formed, it interferes and blocks the normal flow of Qi. At the same time, it is pushed by Qi to travel throughout the body and cause different symptoms.
Visible phlegm
Phlegm can be easily observed when it accumulates in the Lung as it can be expectorated:
• When there is no heat, the phlegm is white, sticky, thick or thin, present in large amounts and easy to expectorate.
• When there is heat, the phlegm has a yellow or green coloration. Because heat consumes dampness, the phlegm becomes sticky and is difficult to expectorate.
• When the Lung-Qi is unable to disperse and descend, coughing, wheezing and fullness in the chest often exist, sometimes accompanied by pain and a stifling sensation.
• When the sinuses are filled with phlegm, symptoms often present as a blocked sensation and pain in the cheeks or over the forehead with a copious nasal discharge.
• If phlegm blocks the throat, sticky, difficult-to-expectorate phlegm may occur, or plum-pit syndrome presents.
• If phlegm accumulates in the stomach, there may be nausea and vomiting of fluid, phlegm and food, patients lose their appetite and feel fullness in the upper abdomen.
• If the phlegm accumulates in the intestines, it presents as mucus or pus in the feces.
Invisible phlegm
Invisible phlegm can result in different symptoms:
• If the phlegm is pushed by the rebellious Qi, moves upwards and disturbs the sensory orifices of the head, patients will have dizziness, vertigo, tinnitus, deafness, a heavy sensation in the head, possible loss of consciousness, wind-stroke or epilepsy.
• If phlegm obstructs the Heart, blocks the blood circulation and disturbs the mind, it causes palpitations, chest pain, restlessness, insomnia, depression, mental confusion, delirium and mania.
• If phlegm obstructs the meridians and collaterals, blocks the blood circulation and Qi movement, some corresponding symptoms may occur in the local area: on the face, there may be deviation of the mouth and the eyes; in the limbs or the trunk, there will be a sensation of numbness, heaviness, tingling, cramp or twitch.
• If phlegm accumulates over a long period of time, if combined with other pathogenic factors it can form masses and can present as different types of tumor.
• When phlegm accumulates, a sticky tongue coating and a slippery and wiry pulse are the typical signs. In a cold-phlegm syndrome, a deep, wiry pulse can be felt as cold obstructs the Qi and blood; in a phlegm-heat syndrome, a rapid and forceful pulse can be felt as the Qi forcefully pushes the phlegm.
Treatment principle: Expel, transform, dry and eliminate phlegm; regulate the function of the internal organs
Herb selection principles and formula composition strategies
• First, herbs that can dissipate phlegm-heat or damp-phlegm should be selected. These herbs should be pungent and bitter, either cold or warm, enter the Spleen, Stomach and Lung meridians, and have dispersing, ascending, reducing and descending properties. In addition, herbs that enter the related meridians and organs, and treat a specific phlegm syndrome should be selected.
• Second, for treating damp-phlegm syndrome, bitter and warm herbs that can dry dampness, or sweet and bland herbs that can leach out dampness, are selected; for treating phlegm-heat syndrome, cold and moistening herbs that can dilute phlegm are selected.
• Third, herbs that promote food digestion, purge the accumulation and regulate the Qi should be selected to assist the herbs that dissolve, dry and eliminate phlegm.
• Herbs that clear heat or warm the interior can be used in the formula to treat phlegm-heat or damp-phlegm respectively.
• Herbs that strengthen the Spleen are often used in chronic conditions to prevent the generation of phlegm.
CAUTIONS
1. Pay attention to the Spleen:
Dysfunction of the Spleen is considered the main source of phlegm generation. There is a saying in traditional Chinese medicine: Spleen is the generator of phlegm and the Lung is a container of the phlegm.
2. Refer to other chapters and selections of herbs:
In this chapter, the study emphasis is mainly on the accumulation of phlegm in the Spleen and the Lung. When phlegm exists in other regions and causes related symptoms and syndromes, the herbs in the other chapters should be consulted – for example, herbs that dissolve dampness, remove food stagnation, purge accumulation, transform dampness aromatically, treat Spleen deficiency, extinguish Liver-wind, calm the mind or open the orifices, as well as herbs that regulate the Qi.
3. Avoid sweet and sour herbs when treating phlegm:
As phlegm is an excess pathogenic factor, herbs that are sweet or sour in taste may retain dampness and phlegm, and should be avoided in a formula.
4. Advance warning about uneasy sensations:
Formulas that actively and intensively remove phlegm, especially invisible phlegm, may cause unpleasant feelings and sensations at the start of treatment because the phlegm is moving in the body. Practitioners should therefore inform patients in advance.
5. Follow an appropriate diet:
An appropriate diet to strengthen the Spleen-Qi as well as to reduce phlegm generation should be advised.
Structure of the formula and selection of the herbs
Chief: Dry dampness, clear heat and eliminate phlegm
Ban Xia ( Pinelliae rhizoma), Ju Hong ( Citri erythrocarpae pars rubra epicarpii) and Chen Pi ( Citri reticulatae pericarpium)
Ban Xia, Ju Hong and Chen Pi are the most commonly used herbs to treat damp-phlegm no matter where it is located.
Ban Xia is warm, pungent and poisonous, and enters the Spleen and Stomach meridians. This herb is able to dry dampness and transform phlegm in the Middle-Jiao. When dampness is removed, the transportation function of the Spleen is recovered and phlegm is no longer generated. In the formulas that treat phlegm, Ban Xia is often selected as chief to dry and eliminate phlegm, as it particularly treats cough with a large amount of white sputum and tightness in the chest. Ban Xia can also effectively soothe the Stomach-Qi and transform damp-phlegm in the Stomach. It can relieve nausea, vomiting and fullness in the epigastria, and improve appetite. Since raw Ban Xia is poisonous, this herb is often used after processing.
Ju Hong is fresh tangerine peel that has been dried and stored for up to 1 year. It is warm and pungent, and enters the Lung and Stomach meridians. Like Ban Xia, it can dry dampness and remove damp-phlegm. It is particularly used when there is a large amount of phlegm that can be easily expectorated. Since Ban Xia and Ju Hong work via the same approach, they are often used together to enhance each other’s ability.
Chen Pi is tangerine peel that has been dried and stored for more than a year. Its pungent and warm nature decreases with time, but it is excellent to move the Qi. It enters the Stomach and Spleen meridians. In the formula for removing phlegm, it is often selected to enhance the ability of Ban Xia to dry and eliminate phlegm. Its aromatic smell can soothe the Stomach-Qi and stimulate the Spleen to transform dampness.
Chuan Bei Mu ( Fritillariae cirrhosae bulbus), Zhe Bei Mu ( Fritillariae thunbergii bulbus), Gua Lou ( Trichosanthis fructus), Gua Lou Ren ( Trichosanthis semen), Dan Nan Xing ( Pulvis arisaemae cum felle bovis) and Zhu Ru ( Bambusae caulis in taeniam)
These herbs are the most commonly used herbs to treat phlegm-heat. They are selected as chief in formulas to treat phlegm-heat syndrome.
Bei Mu is divided into Chuan Bei Mu and Zhe Bei Mu. Both are bitter and cold, and enter the Lung and Heart meridians. They can transform phlegm-heat, dissipate nodules and treat cough with thick green sputum that is difficult to expectorate, as well as dryness in the mouth and nasal cavities.
Chuan Bei Mu is also sweet but less cold than Zhe Bei Mu; thus it can moisten the Lung, transform phlegm and relieve cough. It is effective for treating phlegm-heat syndrome with signs of Lung-Yin or fluid deficiency. The symptoms are of a small amount of very sticky and thick sputum that is difficult to expectorate. It is often used with herbs that nourish the body fluid to dilute the phlegm. Furthermore, this herb can dissipate thick phlegm and disperse the constrained Qi in the chest. If combined with herbs that spread the Liver-Qi, it can treat depression, plum-pit syndrome and nodules, which are caused by the obstruction of Qi and phlegm.
Zhe Bei Mu is more bitter and colder than Chuan Bei Mu. It has no function in moistening the Lung, but is stronger in clearing heat and reducing fire, and is more suitable for treating severe phlegm-heat in the Lung. This herb is also stronger in breaking up congealed phlegm and dissipating nodules than Chuan Bei Mu. It can be selected to treat red, swollen and painful scrofula or abscesses. If combined with other herbs, it is used to treat tumors.
Gua Lou and Gua Lou Ren are also frequently selected to treat phlegm-heat. They are sweet, bitter and cold, and enter the Lung, Stomach and Large Intestine meridians. Both can clear heat from the Lung, transform phlegm-heat and unbind the Qi in the chest. They are selected as chief to treat cough with a large amount of green sputum, distension, constriction and pain in the chest, and irritability. They can also be used for treating abscesses. The strong point of these herbs is that they can promote bowel movement and treat constipation, as well as accelerate the descending of Lung-Qi and remove phlegm-heat in the Lung. Comparing the functions of the two herbs, Gua Lou is stronger in clearing heat and transforming phlegm; Gua Lou Ren is stronger in moistening the intestines and promoting bowel movement. If combined with herbs that clear heat, Gua Lou Ren is effective for removing phlegm-heat from the intestines and for treating colitis and dysentery.
When the powder of Tian Nan Xing ( Arisaematis rhizoma) is processed with bovine bile, it is called Dan Nan Xing. Dan Nan Xing is bitter and cold. It is characterized by its ability to clear heat, eliminate phlegm, extinguish wind and calm spasm. It can effectively treat cough without phlegm or with scanty green sputum that is difficult to expectorate. Moreover, since it is particularly able to eliminate the invisible phlegm that covers the Heart and blocks the orifices, it can treat epilepsy and wind-stroke.
Zhu Ru is slightly cold and enters the Lung, Stomach and Gall Bladder meridians. As well as clearing heat and transforming phlegm from the Lung, it can effectively disperse the constrained Qi, eliminate irritability and calm the mind. It is often selected in formulas that treat depression, anxiety and other mental disorders due to phlegm-heat disturbing the Heart, Gall Bladder and Stomach. It is also effective for soothing the Stomach-Qi, clearing heat and treating nausea and vomiting, such as morning sickness of early pregnancy, heatstroke, migraine and Ménière’s disease.
Deputy: Eliminate phlegm from different organs and regions
Shi Chang Pu ( Acori graminei rhizoma) and Yuan Zhi ( Polygalae radix)
These herbs are able to remove damp-phlegm and phlegm-heat from the Heart meridian.
Damp-phlegm may disturb or cover the Heart and cause mental disorders, which manifest as poor concentration, forgetfulness and difficulty with making decisions, a white and sticky tongue coating and a slippery pulse.
Shi Chang Pu is pungent, bitter and warm, and enters the Heart and Stomach meridians. As its aromatic smell and pungent property can transform phlegm and open up the Heart orifice, it treats all these symptoms.
Yuan Zhi is pungent, bitter and warm, and enters the Heart, Spleen and Lung meridians. It can stimulate the Heart-Yang and Qi, connect the Heart-Qi with the Kidney-Qi and remove the phlegm from these meridians, thus improving concentration and memory. Shi Chang Pu and Yuan Zhi are often used together to enhance the ability to remove phlegm and open up the orifices.
Tian Zhu Huang ( Bambusae concretio silicea) and Zhu Li ( Bambusae succus)
These herbs are able to remove phlegm-heat from the Heart meridian. They are sweet and cold, and enter the Heart meridian. They have the functions of clearing heat and transforming phlegm. They are selected either as deputy or chief in formulas that remove phlegm-heat from the Heart.
Zhu Li is colder than Tian Zhu Huang. It enters the Heart, Lung and Stomach meridians. It has a lubricating nature and its function is characterized by strongly eliminating phlegm-heat from the Heart and reviving the Heart-shen. It treats a syndrome where patients lose consciousness and have gurgling sounds in the throat, such as in epilepsy, cerebrovascular accident and myocardial infarction. Zhu Li is also often used to treat conditions such as schizophrenia and anxiety when phlegm-heat disturbs the mind.
Tian Zhu Huang enters the Heart and Liver meridians. It is effective in dislodging phlegm, clearing heat, cooling the Heart and controlling convulsions. It is often used to reduce high fever, irritability and convulsions caused by disturbance of the Heart and Liver by phlegm-heat.
In order to increase the strength of their action, they are often used in formulas with other herbs that transform phlegm or regulate the Qi, such as Tian Ma ( Gastrodiae rhizoma)**, Yu Jin ( Curcumae radix), Zhu Ru ( Bambusae caulis in taeniam), Zhi Ke ( Aurantii fructus), Zhi Shi ( Aurantii fructus immaturus) and Meng Shi ( Lapis micae seu chloriti)*. They are also used with herbs that promote blood circulation and calm the mind, such as Dan Shen ( Salviae miltiorrhizae radix), Hong Hua ( Carthami flos), Hu Po ( Succinum), Ci Shi ( Magnetitum) and Zhen Zhu Mu ( Concha margaritifera usta).
Xuan Fu Hua ( Inulae flos), Zi Su Zi ( Perillae fructus), Zi Su Ye ( Perillae folium), Zhu Ru ( Bambusae caulis in taeniam), Pi Pa Ye ( Eriobotryae folium) and Huang Qin ( Scutellariae radix)
These herbs can be selected as deputy to remove phlegm from the Stomach. As they soothe the Stomach-Qi, they can relieve nausea, vomiting, fullness in the epigastria, reduced appetite and distension in the abdomen. In most cases, patients have a sticky tongue coating and a rapid, wiry or slippery pulse.
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