Phlegm-rheum

Phlegm and rheum are two kinds of pathological products of the body. Phlegm is a thick, viscous fluid that gathers principally in the lung but can also reach other parts. Rheum is a thinner fluid that gathers in various parts of the abdominothoracic cavity. The two are referred to generically as phlegm-rheum¹ (痰饮 tán yǐn). It is important to note, however, that phlegm-rheum also refers to a specific form of rheum (phlegm-rheum²), which is discussed below.

Phlegm

Phlegm (痰 tán) arises in the following ways:

1. Water-damp collecting and thickening as a result of impaired splenic movement and transformation is the main factor in the production of phlegm. The importance of the spleen in the production of phlegm is highlighted by the fact that it is often called the source of phlegm formation. The maxim that obese people tend to have copious phlegm (肥人多痰 féi rén duō tán) reflects the fact that spleen disturbances that give rise to obesity also lead to the formation of phlegm.
2. Disturbance of the lung’s diffusion and depurative downbearing action preventing fluids from being released as sweat or carried down to the kidney and bladder to be released as urine.
3. Heat boiling and concentrating the fluids of the body into phlegm.
4. Depressed liver qì affecting the distribution of fluids. Depressed liver qì hampers splenic movement and transformation, fostering the process described in point 1 above. It also easily transforms into fire and hence fosters the process described in point 3.

Tangible and intangible forms: A distinction is made between two forms of phlegm:

• Tangible phlegm (有形之痰 yǒu xíng zhī tán) is phlegm that collects in the lungs and can be expectorated.
• Intangible phlegm (无形之痰 wú xíng zhī tán) is phlegm that can move around the body and settle in different places, causing dizziness, clouded spirit, numbness and tingling, phlegm nodes, scrofula, and other kinds of sores.

Both forms are characterized by a slimy tongue fur and by slippery or stringlike pulses.

Because of its phlegm’s ability to assume an intangible form, it is traditionally said to be the cause of unusual diseases. The Zá Bìng Yuán Liú Xī Zhú (杂病源流犀烛 Incisive Light on the Source of Miscellaneous Diseases) states, Phlegm is the source of various diseases; strange diseases all arise because of phlegm (痰为诸病之源, 怪病皆因痰成 tán wéi zhū bìng zhī yuán; guài bìng jiē yīn tán chéng).

Many conditions involve a combination of wind and phlegm, where the phlegm is moved by wind to affect the upper body and spirit. Zhū Zhèn-Hēng of the Yuán Dynasty stated, Wind-phlegm usually manifests in strange signs (风痰多见奇证 fēng tán duō jiàn qí zhèng).

Location: Tangible phlegm gathers in the lung (the lung is the receptacle of phlegm). Intangible phlegm is more mobile. As well as being able to be carried upward by wind, it can follow qì upward and downward, reaching all inner and outer parts of the body (随气升降, 周内外皆到 suí qì shēng jiàng, zhōu shēn nèi wài jiē dào), and thus gather in almost any part of the body.

• Collecting in the lung, phlegm causes cough and panting with phlegm.
• Obstructing the chest, it causes chest impediment (xiōng bì).
• Collecting in the stomach duct and abdomen, it causes glomus and fullness.
• Clouding the clear orifices, it can cause dizziness, epilepsy, and mania and withdrawal.
• When carried by liver wind, it can give rise to wind stroke and fright wind.
• Obstructing the channels and network vessels, it can cause numbness and tingling of the limbs, hemiplegia, deviated eyes and mouth, scrofula, goiter, phlegm nodes, and yīn flat-abscesses (yīn jū).

Combinations of phlegm with other evils: Phlegm is regularly associated with dampness because it most commonly arises when dampness gathers and concentrates. It is often seen with fire (heat), since it can also arise when heat scorches and concentrates the fluids of the body. In addition, it can combine with cold and wind.

Phlegm-damp (痰湿 tán shī) is phlegm forming as dampness gathers and thickens. It can give rise to headache and dizziness. It manifests in a white slimy tongue fur and a slippery pulse. Phlegm-damp is a major cause of infertility.

Phlegm-fire (痰火 tán huǒ): Also called phlegm-heat (痰热 tán rè). The two may arise separately and then bind together. Alternatively, phlegm arises when fire-heat scorches and concentrates the fluids. Phlegm-fire harassing the spirit is a major pathomechanism in heart disease.

Phlegm-fire in externally contracted disease patterns results in high fever, copious phlegm, and clouded spirit. In miscellaneous disease, it can cause manic derangement of spirit-mind, traditionally described in terms of beating people and smashing objects, greater-than-normal physical strength, talking nonsense, and abnormal crying and laughing.

Phlegm-fire can also give rise to dizziness, fearful throbbing, headache, deafness, or tinnitus. It is usually characterized red tongue with a slimy tongue fur and a pulse that is slippery and rapid. See phlegm-fire harassing the spirit and phlegm-heat congesting the lung.

Cold-phlegm (寒痰 hán tán) is phlegm resulting when cold (external or arising internally) combines with phlegm. It manifests in cold and phlegm signs. Cold-phlegm is seen notably in certain impediment (bì) patterns. The tongue is pale with a slimy white or glossy white fur. The pulse is stringlike and slippery. See cold phlegm obstructing the lung for an example.

Wind-phlegm (风痰 fēng tán) , a combination of phlegm and wind, occurs in epilepsy and wind stroke (apoplexy). Epilepsy, for example, manifests in clouding collapse (sudden loss of consciousness that causes a standing patient to fall down), convulsions, and copious phlegm and drool (in epilepsy, with foaming at the mouth). The loss of consciousness is caused by the phlegm, and the sudden onset and convulsions are explained by wind. The tongue fur is usually slimy and the pulse is stringlike. See phlegm clouding the heart spirit and liver yáng transforming into wind.

Phlegm-stasis (痰瘀 tán yū) is a combination of phlegm and static blood. When the two are present together, they can exacerbate each other in a process called phlegm and stasis binding together, which occurs in heart vessel obstruction. The tongue is purple or dull purple with stasis speckles and a thick slimy tongue fur. The pulse is stringlike and slippery or sunken and rough. See phlegm and stasis binding together and heart vessel obstruction.

Categorization of patterns featuring expectoration of phlegm: The term phlegm is also used specifically to denote patterns of substantial phlegm characterized primarily by expectoration of phlegm. Damp phlegm, cold phlegm, heat phlegm, and dryness phlegm patterns exist.

• Damp phlegm (湿痰 shī tán) is a pattern in which easily expectorated thin white phlegm is associated with other signs of dampness, such as heavy body, cumbersome limbs, fatigue, a tendency to lie down, abdominal distension, possibly abdominal pain, diarrhea, and a slippery moderate pulse.
• Cold phlegm (寒痰 hán tán) is marked by cough with clear white phlegm, a white glossy tongue fur, and a pulse that is slightly stringlike. It also includes cold signs, such as physical cold and cold limbs. This is often seen in chronic bronchitis and asthma. Note that the Chinese for cold phlegm is the same as for cold-phlegm.
• Heat phlegm (热痰 rè tán) is characterized by cough with thick yellow or sticky phlegm and rapid breathing, together with heat effusion, dry mouth, pain in the chest, and a red tongue with yellow fur. The pulse has the slipperiness associated with phlegm and the rapidity associated with heat.
• Dryness phlegm (燥痰 zào tán) arises as a result of external contraction of dryness or dryness arising internally as a result of yīn vacuity. It manifests in scant white phlegm that is difficult to expectorate, by dry skin, mouth, tongue, throat, and nose, as well as cough with hasty panting.

Rheum

Rheum (饮 yǐn) is often referred to as water-rheum (水饮 shuǐ yǐn), a term that highlights the fact that this pathological product is thinner in consistency than phlegm. It arises by the same pathomechanisms as phlegm. It can be associated with cold but not with heat. Four rheum patterns are distinguished according to the location of the rheum evil. These are called the four rheums, first described in the Jīn Guì Yào Lüè (Essential Prescriptions of the Golden Cabinet).

Phlegm-rheum² (痰饮 tán yǐn), here used in a narrow sense, is rheum evil in the stomach and intestines. It is also called flowing rheum (流饮 liú yǐn). It is marked by vomiting of clear thin phlegm-drool, by gurgling intestines (the sound of water in the stomach), and by diarrhea. Note that phlegm-drool is thin mucus collecting in the stomach, drool referring to the slight viscosity that resembles drool as the fluid of the mouth. It is treated by warming yáng and transforming rheum with formulas such as líng guì zhú gān tāng (Poria, Cinnamon Twig, White Atractylodes, and Licorice Decoction) or jīn guì shèn qì wán (Golden Cabinet Kidney Qì Pill).

Suspended rheum (悬饮 xuán yǐn) is rheum evil beneath the rib-side. It manifests in fullness, distension, and pain in the chest and rib-side. When palpated, there is a rippling sensation. It is accompanied by cough, shortness of breath, and rapid breathing. The pain in the chest and rib-side is exacerbated by cough and by turning sides when lying in bed. It is treated by expelling rheum with shí zǎo tāng (Ten Jujubes Decoction).

Propping rheum (支饮 zhī yǐn) is rheum evil affecting the chest and lung. It is characterized by coughing of foamy white phlegm, rapid panting and qì counterflow (sensation of qì rising), and inability to lie flat. In some cases, it manifests in puffy swelling of the face. Propping rheum is so called because the patient feels as if their chest and abdomen are propped up. It is treated by warming the lung, transforming rheum, and calming panting with formulas such as xiǎo qīng lóng tāng (Minor Black Dragon Decoction).

Spillage rheum (溢饮 yì yǐn) arises when water qì (pervasive surplus fluid) spills out into the limbs. It is marked by heavy painful or even swollen limbs and is sometimes accompanied by panting and cough. It is treated by warming the lung and transforming rheum, promoting sweating and dispelling evil with formulas such as dà qīng lóng tāng (Major Black Dragon Decoction) and xiǎo qīng lóng tāng (Minor Black Dragon Decoction).

In addition to the four classical patterns, there is also lodged rheum (留饮 liǔ yǐn), which is persistent rheum that fails to transform. This is treated differently depending on where it occurs, with emphasis not only on expelling rheum but also on supporting right, as by fortifying the spleen, warming the kidney, and securing the root.

Phlegm-Rheum Patterns

There are many different phlegm-rheum patterns.

• Phlegm clouding the heart spirit
• Phlegm-fire harassing the spirit
• Phlegm-heat congesting the lung
• Cold phlegm obstructing the lung
• Rheum collecting in the chest and rib-side
• Cold rheum collecting in the stomach

In addition, expectoration of phlegm occurs in many lung patterns whose names do not include the word phlegm or rheum because phlegm is a by-product rather than the cause. Furthermore, liver wind stirring internally often involves wind stirring phlegm.