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Zhe Yan (Philosophical Remarks)

There are ten types of phlegm diseases: wind-phlegm, dampness-phlegm, heat-phlegm, cold-phlegm, constraint-phlegm, qi-phlegm, food-phlegm, wine-phlegm, fright-phlegm, and deficiency-phlegm; their origins are not uniform. (Zhu Danxi)

Phlegm is originally transformed from body fluids (Jinye); when flowing, it is called fluid, and when accumulating, it becomes phlegm; when circulating, it is Jin (thin fluid), and when stagnant, it becomes Xian (thick saliva). (*Shengmo*)

Thick and turbid substance is Phlegm, formed by the condensation of body fluids; clear and thin substance is Yin (fluid retention), formed by the accumulation of water and fluids. Sticky and entangled substance is Xian, formed by the combination of wind-heat and body fluids; clear and foamy substance is Mo, caused by Qi deficiency leading to poor circulation of fluids. (*Yijie Bianzheng*)

Heat-phlegm resembles the foam floating on top of a boiling pot; cold-phlegm resembles water in a ditch. (*Yican*)

From birth until death, every person has phlegm. It originates in the Spleen and gathers in the Stomach, because the human body requires phlegm (referring to normal fluids) for nourishment. However, this substance flows unpredictably, so its harmful effects reach from the vertex of the head to the Yongquan acupoint at the sole of the foot, rising and descending with Qi, reaching all parts inside and outside the body, existing in the Five Zang and Six Fu organs. Just like clouds and mist in the sky and earth, it has no root and no destination, coming and going without warning, gathering and scattering without stability. When Fire moves, phlegm arises; when Qi stagnates, phlegm worsens; when Wind drums, phlegm surges, creating hundreds of bizarre changes. Therefore, phlegm is the source of various diseases, and strange diseases are mostly caused by phlegm. Yet, just as clouds and mist dissipate without a trace when the sun shines, if the Primordial Yang (Yuanyang) of the human body is strong, Yin-dampness will not coagulate, and phlegm will disappear without a trace; the principle is indeed the same.

Heat-phlegm is caused by excessive Fire. Phlegm is tangible Fire, and Fire is intangible Phlegm; Phlegm rises and falls with Fire, and Fire guides Phlegm to move horizontally, generating various syndromes that are countless; Fire relies on Qi from the Five Zang organs, and Phlegm relies on fluids from the Five Flavors. Excess Qi becomes Fire, and excess fluids become Phlegm. (Wang Ang)

Phlegm is simply human body fluids, nothing but the transformation of grain and food. This phlegm is also a product of transformation, not something untransformed. If transformation occurs correctly, the physique becomes strong, Ying (Nutritive) and Wei (Defensive) Qi become abundant, and the original phlegm and saliva are essentially part of Blood and Qi. If transformation goes awry, the Zang-Fu organs become diseased, body fluids deteriorate, and Blood and Qi turn into phlegm and saliva. This is like bandits in chaotic times; who among them was not a good citizen in peaceful times? Generally, the transformation of phlegm and saliva originates from grain and food. If the Spleen is strong and the Stomach healthy, food is transformed immediately upon ingestion, becoming Blood and Qi, how could it remain as phlegm? Only because it cannot be fully transformed, leaving one or two parts out of ten, these become phlegm; leaving three or four parts, they become phlegm; even leaving seven or eight parts, one only sees Blood and Qi daily diminishing while phlegm and saliva daily increase. The reason for this is precisely that Yuan Qi (Primordial Qi) cannot transport and transform, and the more deficient it is, the more abundant the phlegm becomes. (Zhang Jingyue)

The airways of humans must be smooth and regulated for body fluids to circulate freely; otherwise, where would phlegm come from? If externally invaded by Wind, Summerheat, Dryness, and Dampness, or internally disturbed by Fright, Fear, Worry, and Thought, combined with dietary irregularities, overwork, and unrestrained sexual activity, leading to disharmony of Ying and Wei Qi and deterioration of Blood and Qi, which steam and vaporize body fluids, phlegm is generated. ○ Those who were formerly fat but are now thin have phlegm; those with eye bags and under-eye areas darkened like smoke stains have phlegm; those with blurred vision, difficulty moving, and whole-body pain have phlegm entering the bones; those with sallow complexion, flaccid paralysis of limbs, and inability to flex or extend have Rheumatism complicated by phlegm. (*Zhengzhi Huibu*)

Cold-phlegm is clear, dampness-phlegm is white, fire-phlegm is black, heat-phlegm is yellow, and old-phlegm is sticky. ○ At the onset of phlegm syndromes, it stays in the Middle Jiao, causing headache, aversion to cold, and fever, resembling exterior syndromes; later, it stops in the Spleen and Lungs, causing morning cough and evening worsening, resembling interior injury syndromes; flowing into joints causing pain, resembling Wind-Bi syndrome. However, phlegm diseases are distinguished by chest fullness, reduced appetite, normal muscle color, and slippery yet irregular pulse. (*Yixue Rumen*)

Heat-phlegm often forms irritability and heat; wind-phlegm often forms paralysis; cold-phlegm often forms bone Bi; dampness-phlegm often forms fatigue and weakness; fright-phlegm often forms heart pain and epilepsy; drink-phlegm often forms hypochondriac and arm pain; food-stagnation phlegm often forms epigastric masses and fullness. (*Chishui Xuanzhu*)

Inability to expectorate phlegm indicates lack of strength. Black phlegm comes from the Kidney, indicating deficiency-cold of Middle Qi and flooding upward of Kidney Water. (Zhou Shenzhai)

If the human body had no phlegm, what is called phlegm is merely gathered body fluids. When five grains enter the Stomach, their dregs, body fluids, and Zong Qi (Gathering Qi) are divided into three pathways. Thus, Zong Qi accumulates in the chest, emerges from the throat, penetrates the Heart and Lungs, and governs respiration. Ying Qi secretes its fluids, injects them into the vessels, transforms them into Blood, nourishes the four extremities, and internally irrigates the Five Zang and Six Fu organs, corresponding to the passage of time. Wei Qi emits its fierce and rapid energy, proceeding first through the four extremities, interstices of muscles, and skin without rest. It travels through Yang during the day and Yin at night, often passing through the branches of Foot-Shaoyin, circulating through the Five Zang and Six Fu organs. When full, it moves; when deficient, it gathers. Gathering becomes phlegm; dispersing returns to body fluids, Blood, and Qi. Initially, there is no other pathogenic evil or filth within the meridians and Zang-Fu organs called "phlegm" to harm the body, which must be removed before cessation. In my youth, I liked to spit phlegm; the more I spat, the more there was. Later, I stopped. Whenever I felt unbearable obstruction in the throat, I would sip a few mouthfuls of plain hot water, spit it out, grind it with my tongue, rinse my mouth over a hundred times until filled with saliva, then inhale through the nose and swallow, directing the intention to the Dantian. After a moment of silence, the throat became clear and peaceful. If not clear, rinse and swallow again until completely dissolved. When first expectorated, it tastes very salty; after rinsing, it becomes sweet. People say it is turbid matter with no possibility of clarification, how absurd! I once crossed a river and saw boatmen scoop muddy water into jars, sprinkle alum powder, and it clarified instantly. This can enlighten us to the method of treating phlegm. Therefore, if Zong Qi in the Upper Jiao is insufficient, phlegm gathers in the chest and diaphragm, causing throat obstruction and panting breath; if Ying Qi in the Middle Jiao is insufficient, blood turns into phlegm, blocking vessel pathways and changing unpredictably; if Wei Qi in the Lower Jiao is insufficient, its vigor declines, fluids stagnate, causing numbness and swelling in the extremities and muscle interstices. To treat the root, tonification should come first; to treat the branch, there are methods for resolution. (*Zhengzhi Zhunsheng*)

Fluids nourish the sinews. If Blood is stagnant and does not flow, phlegm gathers above the diaphragm, causing weak hands and feet. (Mei Yingzuo)

Phlegm, as a substance, rises and falls with Qi, reaching everywhere. It manifests as wheezing, coughing, vomiting, diarrhea, dizziness, palpitations, anxiety, chills, fever, swelling, pain, epigastric fullness, and obstruction. Sometimes the chest and hypochondrium gurgle like thunder; sometimes the whole body feels like insects crawling; sometimes nodules appear in the body, neither red nor swollen; sometimes lumps form on the neck, resembling scrofula but not quite; sometimes obstructing the throat, feeling like a plum pit; sometimes expectorated, shaped like peach gum; sometimes two energies seem to knot in the chest; sometimes a spot on the back feels constantly cold; sometimes skin becomes red and swollen like fire; sometimes epigastric area feels cold and painful like ice; sometimes one limb becomes swollen, hard, and numb; sometimes hypochondriac masses form; sometimes bone joints suffer stabbing pain intermittently; sometimes lower back and legs feel sore, stabbing, and weak; sometimes cold saliva, green water, or black juice is vomited; sometimes dreaming of fire, smoke, swords, and halberds growing densely; sometimes pus in urine or stool; sometimes Guan-Ge (obstruction) preventing passage; sometimes rapid throat bi; sometimes toothache and tinnitus; extending to consumptive tuberculosis and epilepsy; loss of voice and paralysis; amenorrhea and leukorrhea in women; convulsions and tremors in children; even seeing ghosts without cause, resembling possession but not quite—all belong to phlegm syndromes. (Wang Yinjun)

Diseases of the human body number 404. Externally, they do not exceed the six Qi (Wind, Cold, Summerheat, Dampness, Dryness, Fire) invading; internally, they do not exceed the Seven Emotions (Joy, Anger, Worry, Thought, Fright, Fear, Sorrow) injuring. Changes manifest in the Zang-Fu, meridians, and skin/hair as disease. How can there be so-called "strange" diseases? Quack doctors do not understand the disease mechanism. Upon encountering unfamiliar syndromes, they immediately claim that strange diseases mostly belong to phlegm. Moreover, phlegm is not inherently present in the body. Once body fluids become diseased and turn into phlegm, they manifest according to the meridians involved. How can one use this phrase as an excuse? ○ According to the theory, Zang-Fu body fluids becoming diseased and turning into phlegm, rising and falling with Qi, is a normal principle. But in the spaces between skin and fascia, and in the bends of limbs and joints, how can phlegm from the Zang-Fu organs flow there? This is simply the local body fluids, encountering cold or heat, coagulating into phlegm and causing disease. It is absolutely not body fluids from other parts becoming diseased, turning into phlegm, abandoning their original location, and moving to another part. Furthermore, Qi is inherently formless, thus penetrating everywhere, and fluids follow Qi's movement, circulating via Qi. However, once body fluids become diseased and turn into phlegm, they become tangible and stagnant. How can they circulate with Qi to the most minute and dense places? (*Fengshi Jinnang*)

"The Spleen is the source of phlegm production, the Lung is the vessel of phlegm storage" is baseless talk. The Spleen transports fluids for the Stomach to irrigate the surroundings, and water essence ascends to the Lung. How can it coagulate into phlegm? Only the Kidney is the gate of the Stomach. If the gate is not functional, water gathers and floods, becoming phlegm. Thus, we should say the Kidney is the source of phlegm production. The *Classic* says: What receives grain becomes turbid, what receives Qi becomes clear. Clear Yang goes to the Five Zang, turbid Yin returns to the Six Fu. The Lung is Hand-Taiyin, receiving only the clarity of Qi, not the tangibility of turbidity. How can it store phlegm? Only the Stomach is the sea of water and grain, the destination of all things. If it slightly loses its transport function, damp-heat coagulates into phlegm, adhering to the Stomach and failing to descend. Thus, we should say the Stomach is the vessel of phlegm storage. (Ke Yunbo)

Supplementary Compilation

Treating phlegm requires seeking the root; then phlegm will never fail to clear. If one only knows how to treat phlegm, the error is great. For phlegm caused by Fire, treating Fire should be prioritized; for phlegm caused by Cold, warming the Middle should be primary. Wind-phlegm should be dispersed, requiring acrid-warm herbs; dampness-phlegm should be dried, requiring leaching and draining herbs. Constraint-phlegm has deficiency and excess patterns. Constraint accompanied by anger requires suppressing Liver Evil; constraint accompanied by sorrow requires cultivating Liver and Lung. Phlegm from diet varies: some due to Cold, some due to Heat, some due to excessive rich/sweet foods, some due to alcohol-damp injuring the Spleen. All these can generate phlegm, each having deficiency/excess distinctions. For example, Spleen deficiency failing to control dampness, and Kidney deficiency failing to grasp water, both generate phlegm, belonging to cold-phlegm; or Spleen Yin drying up causing fluid to become glue, or Metal-Water deficiency making phlegm originate from Blood, these belong to heat-phlegm. These two categories account for 80-90% of phlegm syndromes and are deficiency-phlegm that must not be purged. (Zhang Jingyue)

Phlegm syndromes vary unpredictably. Ancients did not investigate root and branch, often prescribing phlegm-resolving formulas. Descendants followed these methods, found them ineffective, and thus called phlegm a "strange disease." They did not know phlegm is the branch of disease, not the root. A skilled practitioner treats the source of phlegm generation; then, without resolving phlegm directly, it disappears naturally. I have studied carefully: Phlegm arises from external invasion of the Six Qi, causing dysfunction of Spleen, Lung, and Stomach transportation and transformation, leading to inadequate digestion of food; or from excessive consumption of rich foods, tea, and wine; or from Spleen-Stomach Yang deficiency causing stagnation of damp-turbidity; or from constraint causing Qi-Fire discomfort and steaming transformation; or from Kidney deficiency causing water flooding; or from Yin deficiency consumptive syndromes where Dragon-Minister Fire flares up, scorches the Lung, causing phlegm-cough. Other phlegms all arise from dampness. Although named wind, fire, or dryness phlegm, they are all transformed by Qi; wind, fire, or dryness do not generate phlegm independently. Treatment methods: Only when phlegm-Qi temporarily blocks the throat is it necessary to temporarily use phlegm-expelling and Qi-descending agents to open it. Otherwise, one must treat the root. The saying "See phlegm, do not treat phlegm" is indeed a timeless maxim. Phlegm is transformed from food-damp and turbidity. Can one forbid eating? If one specifically tries to eliminate it, for cases due to external pathogens, eliminating the pathogen may clear the phlegm, such as warming cold-phlegm, clearing heat-phlegm, drying damp-phlegm, moistening dry-phlegm, and dispersing wind-phlegm. For cases involving the root, phlegm will be eliminated and regenerated simultaneously, potentially persisting until death. (*Linzheng Zhinan*)

Wang Jiezhai said: Heat-phlegm is cleared, dampness-phlegm is dried, wind-phlegm is dispersed, constraint-phlegm is opened, stubborn-phlegm is softened, food-phlegm is digested, phlegm in the chest/diaphragm is induced to vomit, phlegm in the intestines/stomach is purged. This establishes laws for excess patients. For Lung deficiency with phlegm, preserve the Lung to nourish fluids; for Spleen deficiency with phlegm, cultivate the Spleen to transform phlegm-saliva; for Kidney deficiency with phlegm, tonify the Kidney to guide storage. ○ The Spleen and Lung often suffer together because the Spleen is the source of phlegm and the Lung is the vessel of storage, and their organ energies are constantly connected. Thus, exterior symptoms show Lung disease (cough with thick phlegm, dry throat/nose) and Spleen disease (epigastric fullness, poor appetite, frequent diarrhea). At this time, using drying herbs to tonify the Spleen hinders the Lung, and using moistening herbs to benefit the Lung hinders the Spleen. One must balance both, avoiding bitter-cold and aromatic-drying herbs, focusing on harmonization, without exclusively using Lung-clearing and phlegm-resolving drugs. Because the Spleen generates the Lung, but the Lung does not support the Spleen. Use Yigong San, adding Coix Seed, Ophiopogon, Dendrobium, Platycodon, Yam, Hyacinth Bean, Lotus Seed, etc. ○ Phlegm in the body is like sap in wood or saliva in fish, reaching everywhere. For deficiency-phlegm overflowing upward, tonify Qi to move phlegm. Overusing emetics fails to nourish meridians, leading to Kidney exhaustion and bone萎 (atrophy/weakness). (*Zhengzhi Huibu*)

In my lifelong medical practice, I take tonifying Middle Qi as the foundation, hence achieving efficacy. Often treating patients with excessive phlegm, direct phlegm treatment fails. Specifically tonifying Middle Qi, over time, the phlegm disappears naturally. (Wuang Huangchi)

Spleen Earth corresponds to Heaven, originating in Dampness transformation. If grain-food fluids do not circulate, they stagnate and become phlegm. Eight or nine out of ten people suffering from phlegm diseases: the elderly should not rapidly reduce Fire, and deficient persons should not completely eliminate phlegm. Attacking too urgently worsens the disease and leads to danger. One must secure Yuan Qi as the root. (Kongtongzi)

Chest and hypochondriac distending pain, nausea, vomiting, occurring intermittently, all belong to phlegm. Because old phlegm stagnates in the chest/diaphragm, forming a nest, gradually filling up, causing distension and vomiting. After vomiting phlegm-saliva, the chest feels comfortable the next day. Wait half a month, and the illness recurs, lingering for years without cure. How to treat this? We often hear that governing unruly people requires virtue first, assisted by punishment. Treating disease is the same. The aforementioned symptoms require first tonifying Spleen and Kidney, combined with regulating Qi and moving phlegm, allowing Blood and Qi to circulate, preventing phlegm stagnation. Only after prolonged medication can success be achieved. If Spleen-Stomach is strong but phlegm remains non-fluid, it is called stubborn-phlegm. Having accumulated for a long time, it cannot be suddenly removed. One must use the Dao Cang Fa (Stomach Emptying Method), emptying the nest. After vomiting, use tonics combined with phlegm-resolving herbs to prevent recurrence. This is the sequence of treatment. Indulgence and leniency will never cure it. However, not tonifying Spleen-Stomach and solely attacking/vomiting inevitably leads to death. ○ When using phlegm medicines, add Qi-moving herbs like Aucklandia, Cyperus, or Amomum. Stomach Qi moves with fragrant flavors, and phlegm-saliva does not stagnate with Qi movement. Without Qi-moving herbs, efficacy is rare. For cold-phlegm, Qi herbs are natural. For heat-phlegm, although using Scutellaria and Coptis, Qi herbs must assist, known as the "following treatment" method. Otherwise, if phlegm is already sticky and cold herbs are used, circulation will fail. Commonly, people fail to treat heat-phlegm with cold herbs because they lack Qi herbs as guides. The human body takes Qi as the root. Qi stagnation causes phlegm stagnation; Qi movement causes phlegm movement. Ancients said treating phlegm begins with regulating Qi; this grasps the essence. (Yu Fushan)

There is no upward-flowing phlegm in the human body, just as there is no backward-flowing water in the world. Therefore, skilled practitioners do not treat phlegm but treat Qi. When Qi is smooth, body fluids throughout the body follow Qi and become smooth. (Pang Anchang)

Wang Jiezhai said: The root of phlegm is Water, originating in the Kidney; the movement of phlegm is governed by the Spleen. Ancients used Er Chen Tang as a general phlegm remedy. While effective for dampness-phlegm and cold-phlegm, if Yin-Fire flares upward, steaming the Upper Jiao, depressing Lung Qi, causing fluids to ascend with Qi, coagulating into foul, thick, turbid phlegm, even bloody, this is not comparable to Middle Jiao cold/damp phlegm, nor can Banxia (Pinellia) or Nanxing (Arisaema) treat it. Only Qingqi Huatan Tang clears it effectively. Alas! Jiezhai discusses phlegm, revealing its origin in the Kidney, uncovering what predecessors missed. Unfortunately, he started but did not finish the argument; his formulas were all branch-treating. Cold-cooling herbs damage Spleen-Stomach. Only Zhang Zhongjing said: For Qi deficiency with phlegm, use Shenqi Wan to tonify and expel. Wu Jiaoshan said: Bawei Wan treats the root of phlegm. These two gentlemen truly opened paths for later learners, saving countless lives. Phlegm is a disease name, not inherent to humans. It is either water flooding as phlegm or water boiling as phlegm. One must distinguish Fire presence. Kidney deficiency failing to control Water means Water does not return to its source, flowing backward like reverse water, flooding as phlegm—this is No-Fire, so use Bawei Wan to tonify Kidney Fire. Yin deficiency with Fire movement causes water boiling. Movement in Kidney is like Dragon Fire emerging from the sea; Dragon rises, water follows. Movement in Liver is like Thunder Fire emerging from earth; storm and rain, water surges as phlegm—this is With-Fire, so use Liuwei Wan to balance Fire. This treats the root, not the branch. How to distinguish Fire/No-Fire? No-Fire is pure clear water; With-Fire contains heavy turbid white foam. For Kidney deficiency, first use Liuwei/Bawei to strengthen Water/Fire, then Sijunzi/Liu Junzi to tonify Earth controlling Water. For Spleen deficiency, use Buzhong Yiqi Lizhong, then Liuwei/Bawei to control Water and benefit Mother. The way to treat phlegm is nearly complete. Pang Anchang said: Yin Water deficiency, Yin Fire ascending, Lung受 (affected) by Fire, unable to descend clearly, causing fluid turbidity, generating phlegm instead of Blood. Treat with moistening agents like Ophiopogon, Rehmannia, Cornus to nourish Yin, returning ascending Fire to its home, clearing phlegm naturally. Using Er Chen Tang brings immediate peril. More cases: Kidney deficiency failing to grasp Qi, Qi exits but cannot be grasped, accumulating, stagnating, generating phlegm. Use Bawei Wan primarily. (*Yiguan*)

Lizhai treated phlegm, often stating Kidney deficiency water flooding causes phlegm, requiring Kidney tonification. In autumn of Ren-Shen year, I suffered cough with much phlegm, knowing it was due to excessive desire and Kidney deficiency. I strictly took Liuwei Wan, cured in a month. Contemporary doctors treating phlegm most avoid Shudi (Prepared Rehmannia), thinking it cloying. Who knows the subtlety? (*Zegong Manlu*)

Kidney deficiency water flooding causing phlegm, using Shenqi Wan yielded no effect repeatedly. Thinking phlegm is Yin-type, using Shudi to assist Yin is inappropriate. Remove Shudi and Shan Zhu Yu from the formula, add Shichangpu (Acorus) and Chenxiang (Aquilaria) to open Qi, naturally effective. (*Zhangshi Yitong*)

Methods of treating phlegm: Expel, Guide, Wash, Transform, Emetic, Regulate Spleen, Descend Fire, Move Qi. Predecessors' methods were detailed. As for phlegm in nests/cysts, like bees in honeycombs or lotus seeds in pods, easy to grow, hard to remove, narrow outside, wide inside. Regardless of expelling, guiding, washing, or emetic drugs, they only injure other organs, as the cavity rejects entry. Not only in nests is phlegm hard to remove, but outside lung lobes, between membrane origins, stubborn phlegm stuck for years, like trees...