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Phlegm belongs to the category of damp-heat, transformed from body fluids. Due to invasion by wind-cold-damp-heat pathogens, or injury from seven emotions and diet, leading to rebellious qi and turbid fluids, it transforms into phlegm-fluids. It may be vomited or coughed up, stagnate in the stomach and diaphragm, accumulate in the intestines and stomach, lodge in the meridians and limbs, and rise and fall with qi, reaching every part of the body without exception. The diseases it causes include: asthma, cough, nausea and vomiting, fullness and obstruction, Guan-Ge (obstruction syndrome) and other abnormal conditions, diarrhea, dizziness, gastric discomfort, palpitations, fright and anxiety, manic-depressive psychosis, alternating chills and fever, pain and swelling; or rumbling sounds in the chest, a cold sensation at a specific point on the back, or numbness and insensitivity in the limbs. All these are caused by phlegm. In many of the hundred diseases, there are cases complicated by phlegm, which people often do not realize.

There is a difference between new and old phlegm, and between mild and severe cases. New and mild phlegm is clear in color and form, and faint in odor; old and severe phlegm is yellow, turbid, thick and sticky, difficult to cough out, gradually developing foul tastes such as sour, spicy, fishy, musky, salty, and bitter, and even containing blood.

Treatment methods: Phlegm originates in the spleen and stomach, so one should strengthen the spleen and dry dampness. Since phlegm rises with qi, regulating qi should come first, followed by separating and guiding. Qi rising is often related to fire, so regulating qi lies in descending fire. For heat-phlegm, clear it; for damp-phlegm, dry it; for wind-phlegm, disperse it; for stagnant-phlegm, open it; for stubborn-phlegm, soften it; for food stagnation-phlegm, resolve it. For phlegm located above, use emesis; for phlegm in the middle, use purgation. Additionally, for deficiency of middle qi, secure the middle qi to transform phlegm; if attack is too heavy, stomach qi becomes deficient and phlegm increases.

Main Formula: Er Chen Tang (Orange Peel and Pinellia Decoction)
Ju Hong (Exocarpium Citri Reticulatae), Ban Xia (Rhizoma Pinelliae Praeparatum, soaked in decoction), Bai Fu Ling (Poria), Zhi Gan Cao (Radix Glycyrrhizae Preparata), Sheng Jiang (Rhizoma Zingiberis Recens).
The above formula treats phlegm throughout the body. To guide medicine downward, add descending agents; to guide medicine upward, add ascending agents.
For excessive damp-phlegm with softness, such as physical fatigue, add Cang Zhu (Rhizoma Atractylodis Macrocephalae) and Bai Zhu (Rhizoma Atractylodis Macrocephalae); for cold-phlegm obstructing the chest, double the dose of Ban Xia, and in severe cases add Ma Huang (Herba Ephedrae), Xi Xin (Radix et Rhizoma Asari), and Wu Tou (Radix Aconiti Lateralis Preparata).

My commentary: Phlegm is the body fluid of the spleen and stomach. It arises from dietary injury or disturbance by seven emotions and six excesses, causing qi stagnation and phlegm accumulation. The proverb says "fat people have much phlegm," but thin people also have phlegm. Why? The spleen governs blood and moves qi. If qi and blood are abundant, where would phlegm come from? This is due to excessive thinking and dietary injury damaging the meridians. When spleen blood is deficient, stomach qi stands alone. Spleen is Ji Earth, Stomach is Wu Earth; Wu and Gui transform into fire. Thus, dampness transforms via qi into phlegm, hence the abundance of phlegm. Phlegm travels throughout the body. When phlegm-qiang is strong, the pathogen defeats the host. If it deprives the great collateral of the spleen of qi, sudden collapse occurs, known as Phlegm Jue (syncope). Rising to the lung, it causes asthma and cough; confusing the heart, it causes palpitations and confusion; moving to the liver, it causes dizziness, numbness, and hypochondriac distending pain; affecting the kidney, it causes excessive saliva without yawning; staying in the stomach, it causes vomiting, diarrhea, and chills/fever; pouring into the chest, it causes throat obstruction and supraorbital pain; entering the intestines, it causes gurgling sounds; scattered it makes noise, aggregated it causes obstruction. I believe that if spleen qi is weak and cannot transform dampness, use Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) plus Fu Ling and Ban Xia; if caused by spleen deficiency with damp-heat, use Dong Yuan Qing Zao Tang (Dong Yuan's Clear Dryness Decoction); if due to stomach qi deficiency with cold-phlegm stagnation, use Ren Shen Li Zhong Tang (Ginseng Regulate the Middle Decoction); if due to spleen-stomach deficiency-cold with phlegm stagnation, use Li Zhong Hua Tan Wan (Regulate the Middle Transform Phlegm Pill); if due to spleen deficiency with phlegm stagnation and rebellious qi, use Liu Jun Zi Tang (Six Gentlemen Decoction) plus Mu Xiang; if due to spleen-stomach weakness with liver wood overacting, use Liu Jun Zi Tang plus Chai Hu; for headache, use Ban Xia Bai Zhu Tian Ma Tang (Pinellia, Atractylodes, and Gastrodia Decoction); if due to spleen-kidney weakness with cold pathogen causing headache, use Fu Zi Xi Xin Tang (Aconite and Asarum Decoction).

For wind-phlegm, add Nan Xing (Rhizoma Arisaematis Cum Bile), Zhi Qiao (Fructus Aurantii), Bai Fu Zi (Rhizoma Typhonii), Tian Ma (Rhizoma Gastrodiae), Jiang Can (Bombyx Batryticatus), and Zhu Ya Zao Jiao (Semen Gleditsiae Sinensis). For qi deficiency, add Zhu Li (Nodus Bambusae in Taedia); for qi excess, add Jing Li (Nodus Bambusae in Taedia), both taken with Jiang Zhi (Zingiberis汁).

My commentary: Mai Jue states: "Heat generates wind," thus saying "wind comes from fire." If wind pathogen causes qi stagnation and phlegm accumulates in the chest, this method is suitable; if phlegm is generated by wind-heat in the lung meridian, use Jin Fei Cao San (Boiling Grass Powder); if phlegm is generated by intense wind-heat in the liver meridian due to wind-fire conflict, use Niu Huang Bao Long Wan (Calculus Bovis Encasing Dragon Pill) or Niu Huang Qing Xin Wan (Calculus Bovis Clear Heart Pill); if phlegm is generated by liver blood dryness, use Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia); if phlegm is generated because heat controls metal and fails to subdue wood, use Chai Hu Zhi Zi San (Bupleurum and Gardenia Powder); if phlegm is generated because middle qi is weak and cannot transform, use Liu Jun Zi Tang, Chai Hu, and Gou Teng.

For heat-phlegm, add Huang Qin (Radix Scutellariae) and Huang Lian (Rhizoma Coptidis). If phlegm rebels upward due to excessive fire, descending fire is priority; add Bai Zhu, Huang Qin, Ruan Shi Gao (Gypsum Fibrosum), and Huang Lian. For dizziness and gastric discomfort, which are fire stirring phlegm, also add Shan Zhi (Fructus Gardeniae), Huang Qin, and Huang Lian.

My commentary: The previous formulas are suitable for excess fire in the lungs and stomach; for wind-cold with constrained heat, use Shen Su Yin (Ginseng and Perilla Decoction) plus Shan Zhi and Pian Qin; for middle qi deficiency with heat, use Bu Zhong Yi Qi Tang plus Ban Xia and Jie Geng; for kidney deficiency with yin fire flaming upward, use Liu Wei Di Huang Wan; for kidney qi deficiency with cold-phlegm surging upward, use Ba Wei Di Huang Wan (Eight-Ingredient Pill with Rehmannia).

For blood deficiency with phlegm, add Tian Men Dong (Radix Asparagi), Zhi Mu (Rhizoma Anemarrhenae), Gua Lou Ren (Semen Benincasae), Xiang Fu Mi (Rhizoma Cyperi), Zhu Li, and Jiang Zhi; if bleeding is present, add Huang Qin, Bai Shao Yao (Radix Paeoniae Alba), and Sang Bai Pi (Cortex Mori Radicis); if blood stagnation prevents flow and there is fluid retention in the middle jiao, take Zhu Li mixed with fresh juice of Sheng Jiang and Jiu Cai, drinking three to five cups; gastric irritability will occur, then self-healing follows.

My commentary: The previous formulas consist of bitter-cold, sweet-cold, and pungent-warm herbs to descend fire, transform phlegm, move qi, and break blood stasis. One must examine whether the disease matches the medicine before taking it. Stop when the disease is 60-70% resolved; overdosing damages middle qi and worsens the condition. Generally, internal causes belong to spleen-stomach weakness; investigate the cause and nourish. Heavy dosages again damage stomach qi, causing multiple deficiency syndromes.

For qi deficiency with phlegm, add Ren Shen (Radix Ginseng) and Bai Zhu; for spleen deficiency, strengthen middle qi to transform and descend phlegm, adding Bai Zhu, Bai Shao Yao, Shen Qu (Massa Medicata Fermentata), Mai Ya (Fructus Hordei Germinatus), and concurrently use Sheng Ma (Rhizoma Cimicifugae) to lift. For internal injury with phlegm, add Ren Shen, Huang Qi (Radix Astragali), and Bai Zhu, transmitted with Jiang Zhi, or adding Zhu Li is more effective.

My commentary: For previous symptoms due to spleen-lung qi deficiency failing to transform phlegm, use Liu Jun Zi Tang plus Mu Xiang; for lung qi deficiency failing to clear and transform, use Liu Jun Zi Tang plus Jie Geng; for phlegm with blood due to spleen meridian qi stagnation, use Jia Wei Gui Pi Tang (Modified Restore the Spleen Decoction); for phlegm with blood due to liver meridian blood heat, use Jia Wei Xiao Yao San (Modified Free and Easy Wanderer Powder); for phlegm with blood due to liver-kidney yin deficiency, use Liu Wei Di Huang Wan; for spitting phlegm with blood due to excessive intake of cold-cooling agents, use Si Jun Zi Tang (Four Gentlemen Decoction) as the main treatment.

For food stagnation-phlegm, add Shen Qu, Mai Ya, Shan Zha (Fructus Crataegi), Chao Huang Lian (Rhizoma Coptidis stir-fried), and Zhi Shi (Fructus Aurantii Immaturus) to resolve it. In severe cases, purgation is necessary, using pills. If combined with blood deficiency, use tonics to deliver the medicine; if phlegm is in the middle jiao, it is also food stagnation, and stomach qi relies on nourishment; if attacked completely, deficiency results.

My commentary: For previous symptoms where original qi was originally solid, accidentally caused by overeating, use the main formula to digest retained stagnation. Food-phlegm is mostly due to spleen deficiency making food hard to digest and turning into phlegm; blood deficiency is mostly due to spleen qi weakness failing to generate blood. All should regulate and tonify spleen-stomach qi, eliminating food stagnation and generating blood naturally. Thus, Li Dong Yuan said: If spleen-stomach qi is excess, use Huang Lian and Zhi Shi to purge; if deficient, use Bai Zhu and Chen Pi to tonify. The formulas use Shen Qu and Mai Ya, discussed in the upper volume.

Shen Wenji's mother, a student at the provincial academy, ate wet noodles, experienced acid regurgitation, vomiting, and anorexia. After taking Huang Qin and Huang Lian preparations, she developed chills and fever, dry mouth, and salivation. Eating a small piece of winter melon made vomiting worse. I said this is spleen qi deficiency and cold. Urgently apply salt, Ai Ye (Folium Artemisiae Argyi), and Fu Zi (Radix Aconiti Lateralis Preparata) heated, moxa-fuming the umbilicus and abdomen. Also, use her son's breath to connect with her spirit, slightly reviving her. Make powder of Ren Shen, Bai Zhu, Fu Zi, and Chen Pi, pill size of millet grains, swallow 5-7 grains with saliva, increasing to over ten the next day, gradually taking 1-2 spoons of decoction, then desiring porridge. With 50+ doses of Ren Shen and Bai Zhu, she recovered. (See *Nei Ke Yao Yao*).

If there is an object in the throat, impossible to spit out or swallow, this is phlegm knot. Use medicine to dissolve it, adding salty herbs to soften hardness, such as Gua Lou Ren, Xing Ren (Semen Armeniacae Amarum), Hai Shi (Lapis Calcitae), Jie Geng, Lian Qiao (Fructus Forsythiae), and Xiang Fu, with a little Po Xiao (Natrii Sulfas) and Jiang Zhi, refined honey and pill, held in the mouth. If pulse is choppy, opening is difficult and requires long regulation. For excess qi and heat-phlegm knot, difficult to spit out, or forming clumps, qi stagnation is hard to treat.

My commentary: This formula treats fullness of form and symptoms. Previous symptoms include those injuring yin blood due to spleen meridian depression; those with yin fire flaming upward due to kidney water deficiency; those with phlegm generated by spleen-lung fire depression. Treatment: For seven emotions depression with phlegm-saliva stuck in the throat, first use Ju Fang Si Qi Tang (Four Seven Decoction from the Bureau) to harmonize stagnant qi, then use Gui Pi Tang to tonify spleen blood. For spleen fire injuring blood, use Jia Wei Gui Pi Tang; for kidney water deficiency, use Liu Wei Di Huang Wan; for lung meridian depressed fire, use Zhi Mu Fu Ling Tang. For women with this condition plus leukorrhea, all due to depression injuring liver-spleen, assist with Si Qi Tang delivered with Qing Zhou Bai Wan Zi (Qingzhou White Pills). These syndromes have spleen-stomach qi deficiency as root and qi stagnation-phlegm knot as branch. Ancient formulas like Shi Zao Tang (Ten Date Decoction), Kong Xian Dan (Control Fluid Pellet), Shen You Wan (Divine Protection Pill), Gun Tan Wan (Rolling Phlegm Pill), Yi Xiang Zhi Shi (Rare Fragrant Aurantium), Li Ge Di Tan (Clear Diaphragm Eliminate Phlegm), Tou Luo Po Yin (Penetrate Net Break Fluid), Jiang Qi Hua Tan (Descend Qi Transform Phlegm) decoctions, and Su He Xiang Wan (Styrax Pill) are medicines for fullness of form and disease. People in the northwest use them with good results. Those who are deficient develop abdominal distension and die.

Li Beiquan, Grand Secretary, frequently spat phlegm-saliva, had internal heat and thirst, limb fatigue, and hot feet after exertion. I said: This is kidney water flooding transforming into phlegm, method should tonify kidney. He did not believe, used another phlegm-resolving decoction and Gun Tan Wan, resulting in vomiting, diarrhea, anorexia, dizziness, and closed eyes. I used Liu Jun Zi Tang for several doses, stomach qi gradually recovered; used Liu Wei Di Huang Wan, various symptoms gradually healed.

A scholar, with severe cough and phlegm, chest-abdominal discomfort, poor appetite, limb fatigue, floating-large pulse, weak upon pressure. Taking Er Chen Tang and Zhi Qiao worsened it. I said: This is spleen-lung-kidney deficiency. Used Bu Zhong Yi Qi Tang and Liu Wei Di Huang Wan, and he recovered.

If phlegm is in the intestines and stomach, it can be cured by purgation, using Zhi Shi, Gan Sui (Radix Kansui), Ba Dou (Semen Crotonis), Da Huang (Radix et Rhizoma Rhei), and Mang Xiao (Natrii Sulfas). If phlegm is outside the spleen membrane, only Jiang Zhi and Zhu Li can reach it; in the limbs, only Zhu Li can open it; in the meridians, also use Zhu Li, assisted by Jiang and Jiu Cai juice. If phlegm is in the diaphragm, or manic-depression, or amnesia, or wind-phlegm, all use Zhu Li, same effect as Jing Li. For qi deficiency with little eating, use Zhu Li; for qi excess with good eating, use Jing Li. If phlegm is in the hypochondrium, only Bai Jie Zi (Semen Sinapis Albae) can reach it.

My commentary: Previous symptoms are mostly due to improper diet, lifestyle, and seven emotions, consuming original qi, moving internal fire and causing disease. Seek the origin and treat the root. The previous methods are harsh agents; only use if form and qi are clearly full. First examine disease form, pulse, and symptoms to know the pathogen, treating according to exterior-interior, upper-lower, deficiency-excess. Cold and deficiency complications must be considered.

A scholar, with spleen qi deficiency, vomiting phlegm-saliva, abdominal distension after anger, poor appetite. Left Guan pulse string-long, weak upon pressure; Right Guan pulse string-long, weak upon pressure. This is wood overcoming earth. Treated with Liu Jun Zi Tang plus Chai Hu, Shan Zhi, and Mu Xiang, and recovered.

A woman, with spleen-stomach weakness, usually little food intake, suddenly phlegm congestion and asthma, head shaking, eye rolling, hand waving, foot kicking, difficult to feel pulse. Face color yellow mixed with green. This is liver wood overacting on spleen-stomach. Treated with Liu Jun Zi Tang plus Chai Hu and Sheng Ma, revived; further regulated with Bu Zhong Yi Qi Tang plus Ban Xia, and recovered.

For old phlegm, use Hai Shi, Ban Xia, Gua Lou Ren, Xiang Fu Mi, and Lian Qiao. Wu Bei Zi (Galla Chinensis) assists other herbs, greatly treating stubborn phlegm, suitable as pills.

My commentary: For previous symptoms where spleen qi is congested and phlegm lodges in the middle jiao, first use this formula to treat phlegm, then use Liu Jun Zi Tang to tonify spleen qi, phlegm will disappear. If initially failing to treat phlegm thoroughly, spleen qi becomes more deficient, fluids do not move, and phlegm increases.

A man, spitting phlegm, chest-diaphragm discomfort, poor appetite, taking Hai Shi and Gua Lou, ineffective. I said: This is spleen qi deficiency, unable to digest and transform into phlegm, should focus on strengthening spleen. He did not believe, took expelling agents, phlegm surged, limbs swollen, lower abdomen swollen, urine difficult. I said: This is re-injuring spleen-kidney. First treated with Jin Gui Jian Shen Qi Wan (Golden Cabinet Kidney Qi Modified Pill) and Bu Zhong Yi Qi Tang, symptoms gradually decreased; then used Ba Wei Wan combined with previous decoction, and recovered.

A man, usually spitting phlegm, phlegm worsens after anger, chest-diaphragm fullness. This is liver controlling spleen earth. Treated with Liu Jun Zi Tang plus Mu Xiang, and recovered.

A woman, usually depressed, stomach-diaphragm not wide, spitting phlegm like glue. Treated with Jia Wei Gui Pi Tang, and healed.

A woman, spitting phlegm, dizziness, yellow-green leukorrhea. Treated with Si Qi Tang delivering Bai Wan Zi, and Xiao Chai Hu Tang plus Bai Zhu and Fu Ling, and stabilized.

Lumps in the upper, middle, or lower body are phlegm. Ask what foods they usually like? After emesis and purgation, then use medicine.

If nodules appear in head, face, neck, cheeks, or body, non-painful, non-red, non-suppurating, all are phlegm deposits, use medicine locally to resolve them.

My commentary: For previous symptoms where spleen-lung qi rebels and phlegm stays in muscles, scattered or unchanged skin color, non-painful, non-hard upon pressure, these are phlegm nodules. Investigate the cause and treat the root, phlegm will disappear. If due to depression and anger, injuring liver-spleen, or violent anger stirring liver-gallbladder fire, causing blood disease nodules, or tendon spasms at neck sides and ear fronts, or chest-hypochondriac swelling and pain, or chills and fever, these are Luoli (scrofula). Use Chai Hu Qing Gan San (Bupleurum Clear Liver Powder) plus Gou Teng and Shan Zhi to nourish blood-qi and clear liver fire. If skin color unchanged, afternoon fever and internal heat, belonging to liver blood deficiency and fire hyperactivity, use Xiao Yao San plus Long Dan Cao (Radix Gentianae) to nourish liver blood and clear liver fire. Or nodules at joints, bead-like, unchanged color, also liver fire and blood dryness causing tendon spasms, use Chai Shao Shen Ling San (Bupleurum, Peony, Ginseng, and Poria Powder) plus Gou Teng to nourish blood-qi, assisted by Liu Wei Di Huang Wan to generate kidney water.

Scholar Yang Zezhi, irritable and lustful, had a nodule in the collarbone depression. This is liver fire, blood dryness, and tendon spasm. Method should nourish kidney water and generate liver blood. He did not believe, internally took fire-descending and phlegm-transforming medicine, externally applied Nan Xing and Shang Lu (Radix Phytolaccae), turning large as a bowl. I used Bu Zhong Yi Qi Tang and Liu Wei Di Huang Wan, interspersed with Lu Hui Wan (Aloe Pill), over a year original qi gradually recovered and swelling subsided.

A woman, irregular menstruation, nodules in liver-gallbladder meridians, like hazelnuts and beans, countless, unchanged skin color, painful only upon deep pressure. Or giving phlegm-resolving and detoxifying medicine, spontaneous pain without pressure, fever and thirst, worsening at dusk. I said this is liver fire syndrome. Used blood-nourishing, depression-resolving, and liver-clearing medicine, over 100 doses symptoms retreated, only neck nodules remained; further took Dang Gui Long Hui Wan (Angelica and Gardenia Pill) several times, and Si Wu Tang, Chai Hu, and Shan Zhi, and recovered.

A woman, nodules around ears, slight ear swelling, chills and fever, bitter taste, treated with Xiao Chai Hu Tang, Shan Zhi, Jie Geng, and Chuan Xiong (Radix Ligustici Chuanxiong), four doses and recovered. Later due to anger, pain around ears and two corners of head, fever and aversion to cold, treated with Xiao Chai Hu Tang, Shan Zhi, Chuan Xiong, Jie Geng, and Qiang Huo (Radix Notopterygii), two doses and recovered. (See *Wai Ke Shu Yao*).

Gun Tan Wan attacks and purges intestinal and gastric phlegm accumulation, pediatric food-stagnation-phlegm, and severe acute convulsive phlegm, is the most important medicine, always prepare, but must measure person's deficiency-excess before use.

My commentary: Gun Tan Wan is a life-saving agent of seizing flags and breaking gates. Only usable for phlegm stagnating in chest-diaphragm, constipation and difficulty, where form, qi, and disease qi are all excess. Or spleen qi cannot control saliva and it floods upward, or kidney qi cannot control water and it overflows. Mistakenly using it for excess phlegm brings disaster instantly; Jiangnan people especially caution against it.

A woman, originally weak original qi, phlegm-qiang occasionally acting, throat discomfort, chest fullness, etc. I thought depression injured spleen, treated with Jia Wei Gui Pi Tang, and recovered. Later met anger, previous symptoms returned, confused by public opinion, thought it was phlegm-fluid, wrongly used phlegm-resolving agents, vomited and diarrhea several times, changed to various strange symptoms, jaw locked and unconscious. I thought spleen-stomach re-injured. Daily used one dose of Liu Jun Zi Tang, thick decoction with rice drink, spoonfuls frequently taken. By fourth day, gradually advanced to porridge food, then took previous medicine, interspersed with Gui Pi Tang. Glad of her good nourishment, over two months all symptoms healed.