Saturday, July 7, 2012


As discussed for Damp-Heat, in Phlegm-Heat, the primary aspect is the Phlegm rather than the Heat.  It is Phlegm that is hot rather than the Heat having Phlegm.  In a similar way as we said for Damp-Heat, a better name would be “Hot Phlegm” rather than “Phlegm-Heat”.  This has important implications in treatment as this should be aimed at resolving Phlegm primarily and clearing Heat secondarily.
Interestingly, the Chinese character for Phlegm ( 痰 ) is based on the radical for “disease” and that for “Fire” (twice). This would seem to imply that Phlegm derives from Heat: indeed, in many cases it does but we should remember that Phlegm is also frequently combined with Cold.

Emotional stress
Emotional stress in the beginning stages leads to Qi deficiency or Qi stagnation and sometimes both.  Phlegm is a pathological accumulation of fluids which itself derives either from Qi deficiency or Qi stagnation or both as it is Qi that transforms, transports and excretes fluids. Therefore both Qi deficiency or Qi stagnation in time may lead to the accumulation of fluids and to Phlegm.
However, please note that there is no emotion that would be lead to Phlegm directly, e.g. we could not say “anger leads to Phlegm”.  Each emotion would cause a derangement of Qi first.   Li Ding says: “Phlegm is due to the accumulation of Qi deriving from the seven emotions.”
However, there are quotations from Chinese doctors who say that emotional stress leads to Phlegm.  For example, Chen Wu says: “The seven emotions cause chaos and lead to Phlegm.”  Li Yong Cui says: “Shock, fear, worry and pensiveness lead to Phlegm.
Most emotions initially cause Qi stagnation and it is important to stress that many organs, not just the Liver, may suffer from Qi stagnation.  Indeed, in the mental-emotional field, the Heart and Lungs frequently suffer from Qi stagnation from worry, sadness and grief.
A modern Chinese book says: “When emotions cause stagnation of Liver-Qi this impairs the Spleen transformation which leads to Phlegm; or emotional stress may lead to Qi stagnation which may turn into Fire: this condenses the body fluids and leads to Phlegm”.

Figure 1 illustrates the derangement of Qi from emotional stress.

Figure 1.  Derangement of Qi from emotional stress.

Diet is of course an important aetiological factor leading to Phlegm.  The excessive consumption of greasy foods, sugar, sweets and dairy foods leads to Phlegm. Overeating itself is also a cause of Phlegm.
In the particular case of Phlegm-Heat, this is often due to the excessive consumption of greasy foods together with that of alcohol.

Excessive physical work
Excessive physical work weakens the Spleen and this leads to Phlegm.

Long-term retention of Dampness easily leads to Phlegm.

Phlegm is always due to a pathology of the transformation, movement and excretion of fluids. This involves a dysfunction of many organs, e.g. Lungs, Spleen, Stomach, Kidneys, Liver, Bladder, Intestines and Triple Burner.

Figure 2 illustrates the dysfunction of the fluids metabolism leading to Phlegm.

Figure. 2. Dysfunction of the fluids metabolism leading to Phlegm.

There are many types of Phlegm as this can combine with Cold, Dampness, Heat or Wind.  When diagnosing Phlegm-Heat, I make a basic distinction between Phlegm-Heat on a physical or mental-emotional level. Of course, this may seem a complete contradiction of the fundamental characteristic of Chinese medicine, i.e. the unity of body and mind.  However, with this distinction, I mean cases of actual phlegm (sputum) in the Lungs following invasions of Wind as opposed to those of non-actual phlegm but of Phlegm obstructing the Shen: the two are very different situations with different aetiology, pathology and treatment.
On a physical level, Phlegm-Heat affects primarily the Lungs but also the Stomach and Liver. On a mental-emotional level, Phlegm-Heat affects the Heart and Liver.  Phlegm-Heat on a physical level always presents with profuse expectoration of sputum and often cough.  Phlegm-Heat on a mental-emotional level does not necessarily present with the expectoration of actual sputum.  The main symptoms of Phlegm in the latter case would be a feeling of oppression of the chest, a Swollen tongue and a Slippery pulse.  However, in cases of mental-emotional Phlegm-Heat, there may also be the occasional expectoration of scanty sputum.  This may also be just the expectoration of some sputum just once in the morning.
Of course, such a distinction between physical and mental-emotional conditions should not be taken too rigidly as Phlegm-Heat on a physical level may of course affect the Shen.  However, this distinction is important for the choice of herbal treatment.

Phlegm-Heat on a physical level may be acute or chronic.

Acute Phlegm-Heat
In acute cases, Phlegm-Heat is the consequence of an invasion of external Wind that has penetrated into the Interior and changed into Heat. The dysfunction of the Stomach and Spleen caused by the pathogenic factors contributes to the formation of Phlegm; this combines with Heat to form Phlegm-Heat which settles in the Lungs. This is the most common consequence of an invasion of external Wind.
This causes the cough with expectoration of yellow sputum that comes after the beginning stages of a cold or influenza.  This is a very common consequence of invasions of Wind and, in the context of the 4 Levels, it  corresponds to the Qi Level.
The formula for the acute form of Phlegm-Heat in the Lungs is Qing Qi Hua Tan Tang Clearing Qi and Resolving Phlegm Decoction.
The points I use for Phlegm-Heat in the Lungs are LU-7 Lieque, LU-5 Chize, Ren-22 Tiantu, LU-1 Zhongfu, BL-13 Feishu, ST-40 Fenglong.

Chronic Phlegm-Heat
Chronic Phlegm-Heat in the Lungs is usually the consequence of a residual Phlegm-Heat in the Lungs following an invasion (or repeated invasions) of external Wind. This happens when the external pathogenic factor penetrates into the Interior to form Phlegm-Heat, the patient appears to get better but there is a residual Phlegm-Heat in the Lungs.  This is more likely to occur if the patient takes antibiotics.
Often there are no symptoms of the Phlegm-Heat except on the tongue: the front third of the tongue (Lung area) will be swollen and slightly red. This area may also have red points (which indicates that the Heat is pronounced).

Swollen and red front third  

Red front third with red points

The formula I use for chronic Phlegm-Heat in the Lungs is Wen Dan Tang Warming the Gall-Bladder Decoction with the addition of Gua Lou Fructus Trichosanthis and Sang Bai Pi Cortex Mori.
With acupuncture, I use LU-5 Chize, LU-7 Lieque, Ren-17 Shanzhong, BL-13 Feishu, P-6 Neiguan, ST-40 Fenglong.

Phlegm-Heat has a deep effect on the Shen because Heat agitates it and Phlegm obstructs it. Agitation of the Shen causes anxiety and insomnia while obstruction of the Shen causes mental confusion, some obsessive behaviour and occasionally a slight manic behaviour. When to an extreme degree, Phlegm-Heat in the Heart may cause severe mental illness (e.g. bipolar disease or schizophrenia).
On a physical level, this Shen disturbance is felt in the chest with a feeling of oppression of the chest.  Other symptoms include sighing and perhaps the occasional expectoration of scanty sputum.
For this pattern, I use the same formula as above i.e. Wen Dan Tang Warming the Gall-Bladder Decoction with the addition of Yuan Zhi Radix Polygalae, Shi Chang Pu Rhizoma Acori tatarinowii  and Gua Lou Fructus Trichosanthis.
With acupuncture, I use LU-7 Lieque, P-6 Neiguan, HE-7 Shenmen, Ren-17 Shanzhong, Ren-15 Jiuwei, Du-24 Shenting, ST-40 Fenglong.

I shall now list the patterns of Phlegm-Heat in the Lungs, Heart, Liver and Stomach.

Clinical manifestations
Barking cough with profuse sticky-yellow or green sputum, shortness of breath, wheezing, a feeling of oppression of the chest, a feeling of heat, thirst, insomnia, agitation.
Tongue: Red, Swollen with a sticky-yellow coating.
Pulse: Slippery-Rapid.
LU-5 Chize, LU-7 Lieque, LU-10 Yuji, L.I.-11 Quchi, LU-1 Zhongfu, BL-13 Feishu, Ren-12 Zhongwan, ST-40 Fenglong.
Qing Qi Hua Tan Tang Clearing Qi and Resolving Phlegm Decoction.  For acute case.
Wen Dan Tang Warming the Gall-Bladder Decoction. For chronic case.

This is Phlegm-Heat in the Lungs on a physical level. This is either an acute case following an invasion of external Wind, or a chronic case due to repeated invasions that have not been expelled properly and have led to the formation of a residual pathogenic factor (i.e. Phlegm-Heat).

The following picture is an example of chronic Phlegm-Heat in the Lungs (swollen and red in the front third).

Clinical manifestations
Palpitations, mental restlessness, thirst, red face, a feeling of oppression of the chest, dark urine, occasional expectoration of phlegm, bitter taste, insomnia, dream-disturbed sleep, agitation, mental confusion, slight manic behaviour.
Tongue: Red with redder and swollen tip and a sticky-yellow coating.  In severe cases there will be a deep Heart crack with a sticky-dry yellow coating inside it.
Pulse: Slippery-Rapid or Slippery-Overflowing-Rapid.
P-5 Jianshi, HE-7 Shenmen, HE-8 Shaofu, P-7 Daling, Ren-15 Jiuwei, BL-15 Xinshu, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, BL-20 Pishu, G.B.-13 Benshen, G.B.-17 Zhengying, Du-24 Shenting.
Wen Dan Tang Warming the Gall-Bladder Decoction.

This is Phlegm-Heat on a mental-emotional level. Heat agitates the Shen and causes anxiety and insomnia; Phlegm obstructs the Shen and causes mental confusion and possibly a slight manic behaviour.
This pattern is caused my a combination of emotional stress (especially worry, fear, shame or guilt) and the excessive consumption of Phlegm-inducing foods together with alcohol.

The following picture is a good example of Phlegm-Heat in the Heart.  It is red (indicating Heat), swollen (indicating Phlegm) and has a deep Heart crack with sticky-yellow coating inside it (indicating Phlegm-Heat in the Heart).

Clinical manifestations
Irritability, propensity to outbursts of anger, tinnitus and/or deafness (with sudden onset), temporal headache, dizziness, red face and eyes, thirst, bitter taste, dream-disturbed sleep, dark-yellow urine, a feeling of oppression of the chest and hypochondrium, a feeling of muzziness (fuzziness) of the head, occasional expectoration of sputum.
Tongue: Red with redder sides, Swollen and with sticky-yellow coating.
Pulse: Wiry-Slippery-Rapid.
LIV-2 Xingjian, LIV-3 Taichong, G.B.-20 Fengchi, G.B.-13 Benshen, L.I.-11 Quchi, Du-24 Shenting, Ren-12 Zhongwan, Ren-9 Shuifen, ST-40 Fenglong, SP-9 Yinlingquan.
Wen Dan Tang Warming the Gall-Bladder Decoction.
Ling Jiao Gou Teng Tang Cornu Antelopis-Uncaria Decoction.
Long Dan Xie Gan Tang Gentiana Draining the Liver Decoction.

The first two formulae would have to be modified with the addition of herbs that clear Liver-Heat such as Mu Dan Pi Cortex Moutan and Shan Zhi Zi Fructus Gardeniae and herbs that calm the Shen such as Suan Zao Ren Semen Ziziphi and Zhen Zhu Mu Concha Margaritiferae. The third formula would have to be modified with the addition of the two herbs mentioned above to calm the Shen.

The two pictures below illustrate Phlegm-Heat in the Liver.  The one on the top is a case of Liver-Heat while the one below of Liver-Fire (because it has a thicker and drier coating). They are both red, with redder sides and with a sticky-yellow coating.

Clinical manifestations
Burning epigastric pain, thirst without desire to drink, mental restlessness, bleeding gums, dry stools, dry mouth, mouth ulcers, sour regurgitation, nausea, vomiting soon after eating, excessive hunger, foul breath, a feeling of heat, a feeling of oppression of the chest and epigastrium,  insomnia, excessive dreaming, expectoration of phlegm.
Tongue: Red in the centre with  a sticky-yellow or dark-yellow (or even black) coating, Stomach crack with a rough, sticky-yellow coating inside it.
Pulse: Slippery-Rapid and slightly Overflowing on the Right-Middle position.
ST-44 Neiting, ST-34 Liangqiu, ST-21 Liangmen, Ren-12 Zhongwan, Ren-13 Shangwan, L.I.-11 Quchi, L.I.-4 Hegu, Ren-11 Jianli, ST-40 Fenglong, SP-9 Yinlingquan, Ren-9 Shuifen.
Wen Dan Tang Warming the Gall-Bladder Decoction.

The picture below is an example of Phlegm-Heat in the Stomach.  It is red, swollen (indicating Phlegm), it has a wide Stomach crack with sticky-dry-yellow coating inside it.