Due to the decline in the spleen’s ability to transform and transport water and dampness, or obstacles in the circulation and excretion of fluids within the body, water cannot properly nourish the body and instead forms an abnormal accumulation, becoming a pathological substance. This abnormal accumulation of water is referred to in Traditional Chinese Medicine (TCM) as “Phlegm-Dampness (tan yin)”.
The turbid, viscous, and thick part is called “Phlegm (tan)”, while the clear, thin, and transparent part is referred to as “Dampness (yin)”.
Therefore, in TCM, “Phlegm” does not merely refer to the mucus produced in the lungs that can be expelled through coughing and is visible to us. TCM’s concept of “Phlegm” also includes pathological products that arise from metabolic disorders of fluids, characterized by turbid, viscous, and thick properties.
For example, obesity is referred to as “Phlegm” in TCM. Since this type of “Phlegm” is not as easily recognized as the phlegm from the lungs, it is termed “Invisible Phlegm (wu xing zhi tan)”, while the phlegm produced in the lungs that can be expelled through coughing and is visible is called “Visible Phlegm (you xing zhi tan)”. Together, these two concepts form the TCM understanding of “Phlegm”.
“Visible Phlegm” primarily exists in the lungs and may arise from either internal metabolic disorders of fluids or external pathogenic factors invading the lungs. Once produced, this phlegm can be expelled through coughing and is observable, making it easier to understand.
We are quite familiar with “Visible Phlegm”, as we often encounter it during colds and coughs. However, have we noticed a detail: even though the phlegm coughed up from the lungs is the same, there are various differences in its characteristics?
For instance, some phlegm is white and sticky, some is white and thin, some is white and foamy, some is yellow and thick, some is gray-black, and some is yellow-green… Why does the same phlegm exhibit so many variations?
Upon careful analysis, the various characteristics of phlegm can be summarized into two aspects: one is the texture, which can be thick, thin, or foamy; the other is the color, which can be white, gray-black, yellow, or yellow-green.
1. Different Textures and Colors of Phlegm
Let’s consider a common phenomenon: dissolving sugar in water. We obtain a colorless and transparent liquid. If we heat this colorless and transparent sugar water, what will happen? We can see that the sugar water gradually becomes thick, and its color changes from transparent to light yellow and then to deep yellow.
This phenomenon can be extrapolated to the phlegm in the body; the thickness and color of phlegm are closely related to the “heat” within the body. If there is heat in the body, the phlegm will be yellow and thick; if there is no heat, the phlegm will be thin and white. The higher the degree of yellow thickness, the higher the degree of heat in the body.
According to this principle, TCM categorizes phlegm that is white and thin, or foamy, or jelly-like as “Cold Phlegm (han tan)”, while phlegm that is yellow and thick, or even yellow-green, is categorized as “Heat Phlegm (re tan)”.
Since Cold Phlegm and Heat Phlegm reflect completely opposite natures, their treatments are also entirely different.
Treating Cold Phlegm requires warming and transforming it, with commonly used herbs including Gan Jiang (Dried Ginger), Xi Xin (Asarum), Ban Xia (Pinellia), Chen Pi (Aged Tangerine Peel), Bai Jie Zi (White Mustard Seed), and Lai Fu Zi (Radish Seed); while treating Heat Phlegm requires clearing heat and transforming phlegm, with commonly used herbs including Zhe Bei Mu (Zhejiang Fritillaria), Chuan Bei Mu (Sichuan Fritillaria), Tian Zhu Huang (Bamboo Sugar), Dan Nan Xing (Arisaema), Gua Lou (Trichosanthes), and Tian Hua Fen (Trichosanthes Root).
However, whether it is Cold Phlegm or Heat Phlegm, TCM emphasizes a focus on the concept of “transformation” in treatment. What does “transformation” mean?
In the past, before the advent of running water, if the water quality was murky, we often added a small amount of alum to the water tank, and after a while, the water would become clear. The alum acted to decompose and settle the turbid substances in the murky water, which is the essence of “transformation”.
The phlegm-transforming herbs used in TCM for various phlegm conditions serve a similar role to that of alum, enabling the phlegm turbidity to decompose and settle, thus removing diseases caused by phlegm turbidity.
Western medicine also recognizes phlegm in two categories: one is infectious phlegm, such as that caused by bacterial, fungal, mycoplasma, or chlamydia infections; the other is exudative phlegm, often formed due to excessive secretion of mucus by respiratory mucosal cells.
In this case, antibiotics can be effective against phlegm caused by bacterial infections, but there are limited options in Western medicine for phlegm caused by fungal, mycoplasma, or chlamydia infections, as well as for exudative phlegm. How does TCM view and treat these “phlegm” diseases?
TCM believes that microorganisms such as fungi, mycoplasma, and chlamydia naturally exist in the air and do not harm the body under normal circumstances. Only when there is excessive accumulation of water and dampness in the body, creating an overly humid internal environment, do these microorganisms proliferate and reproduce, thereby harming health and causing various diseases.
Therefore, for these types of diseases, the internal environment’s “humidity” is the true root cause.
Just like in the rainy season, the humid environment allows fungi to proliferate, making things prone to mold. If you can recognize that a humid environment is the main cause of fungal proliferation in natural phenomena, why would the human body be any different?
So, how should we treat phlegm caused by internal humidity? In daily life, humidity is often associated with overcast and rainy weather. If the sky is clear and the sun is shining, a humid environment will not form.
There is a saying: “When the sun is blazing, the haze dissipates,” which illustrates this point. The blazing sun can drive away humidity, primarily relying on its heat. Therefore, when treating this type of phlegm, we should use warming herbs to create a “blazing sun” effect within the body, thus dispersing the humid “haze”.
This eliminates the root cause of water and dampness accumulation in the body, preventing the environment for the survival and reproduction of fungi and other microorganisms, thereby providing quick efficacy against phlegm caused by infections from fungi, mycoplasma, and chlamydia, as well as exudative phlegm.
The Han Dynasty medical sage Zhang Zhongjing already proposed in the “Jin Gui Yao Lue” that the principle for treating this disease is “For those with phlegm-dampness, one should use warming herbs to harmonize it.” This still seems remarkably insightful today, and we cannot help but admire the ancient methods and thoughts in exploring the mysteries of life and disease.
2. Invisible Phlegm
Having discussed Visible Phlegm, what is “Invisible Phlegm”, and how can we determine its existence? TCM has four criteria for judging the presence of “Invisible Phlegm” in the body.
1. Obesity
In TCM, it is said that “obese individuals have much phlegm-dampness,” referring to the presence of “Invisible Phlegm” in obese individuals, as fat possesses the turbid, viscous, and thick characteristics of phlegm. It is formed from the turbid portion of water and dampness accumulated in the body.
2. Thick and Greasy Tongue Coating
A thick and greasy tongue coating is the most direct manifestation of excessive water and dampness in the body.
3. Masses
Any mass that is not red, protrudes from the skin surface, is nodular, and feels soft or resilient upon palpation, is referred to in TCM as a “Phlegm Nodule (tan kuai)” if it contains water, mucus, or jelly-like substances.
4. Slippery Pulse
In TCM, pulse diagnosis categorizes pulses into over twenty types based on different sensations felt under the fingers. The slippery pulse is one of them, described as “flowing smoothly like beads rolling on a plate,” indicating the presence of phlegm turbidity in the body and serving as a primary basis for diagnosing “Phlegm” in TCM.
Based on TCM’s understanding of phlegm, combined with Western medicine’s microscopic examinations, the concept of “Invisible Phlegm” can be made more concrete and intuitive.
For instance, conditions such as hyperlipidemia, cysts, lymph node tuberculosis, and bone tuberculosis all exhibit characteristics of turbidity, viscosity, and thickness, and can thus be considered phlegm-related diseases. In this way, Western medical examinations extend the TCM diagnostic methods of observation, listening, inquiry, and pulse diagnosis.
Through TCM’s understanding of the mechanisms of phlegm formation, we can relate the occurrence of these diseases to the overall balance state of the body, finding fundamental treatment methods for the diseases.
For example, hyperlipidemia, cysts, and lymph node tuberculosis all conform to the characteristics of TCM phlegm, and their fundamental causes are related to the spleen’s dysfunction in transforming and transporting water and dampness, leading to excessive accumulation of phlegm turbidity in the body. Therefore, treatment can be approached through strengthening the spleen’s ability to transform and transport, and transforming phlegm and softening hardness. Moreover, by eliminating the generation of phlegm from the root, the treatment effect is long-lasting.
Here, I can provide two examples. One patient with hyperlipidemia took medications such as Shujian Zhi and Liping Zhi without significant effect, feeling dizzy and fatigued, with poor appetite, daytime drowsiness, frequent dreams at night, palpitations, and unformed stools, with a pale complexion and a thin, weak pulse.
I diagnosed him with spleen deficiency leading to an inability to transform and transport water and dampness, resulting in the accumulation of phlegm turbidity in the body, which affected the circulation of qi and blood, causing illness. I prescribed a TCM formula to strengthen the spleen and transform phlegm: Chao Bai Zhu (Stir-fried Atractylodes) 30g, Dang Shen (Codonopsis) 15g, Chen Pi (Aged Tangerine Peel) 10g, Ban Xia (Pinellia) 10g, Gan Cao (Licorice) 6g, Fu Ling (Poria) 15g, Ju Luo (Tangerine Peel) 6g, Dan Nan Xing (Arisaema) 10g, Jiao Shan Zha (Hawthorn) 15g, and 5 slices of Sheng Jiang (Fresh Ginger).
After taking the 7 doses of medicine, the patient felt a significant improvement in energy and appetite, with dizziness reduced by more than half, and stools became mostly formed. I then advised the patient to continue with the same formula for another 7 doses. Upon returning for a follow-up, the patient reported that various symptoms had become minimal, and a recheck of blood lipids showed they had returned to normal levels.
Another patient with a popliteal cyst came for consultation due to fear of surgery.
In TCM, the formation of cysts is the result of phlegm turbidity accumulating in a specific area, and the production of phlegm turbidity is directly related to the spleen’s ability to transform and transport water and dampness. Therefore, by improving and enhancing the spleen’s ability to transform and transport, we can eliminate the accumulation of phlegm turbidity in the body, thus resolving the cyst.
Based on this approach, I prescribed a formula to strengthen the spleen, transform phlegm, and promote diuresis to reduce swelling: Chao Bai Zhu (Stir-fried Atractylodes) 45g, Ze Xie (Alisma) 15g, Hua Shi (Talc) 15g, Zhu Ling (Polyporus) 10g, Fu Ling (Poria) 15g, Gui Zhi (Cinnamon Twig) 10g, Ban Xia (Pinellia) 20g, Zhi Nan Xing (Processed Arisaema) 10g, Yi Yi Ren (Job’s Tears) 30g, and Qing Pi (Green Tangerine Peel) 10g.
The patient took this formula continuously for about a month, and the popliteal cyst completely disappeared. During this time, the formula was slightly adjusted based on symptom changes, but the main herbs remained as listed. These two examples clearly demonstrate that the theory of phlegm in TCM withstands practical testing.
The spleen’s insufficient ability to transform and transport water and dampness leads to the accumulation of water and dampness in the body, and the turbid substances within the water and dampness can condense into phlegm nodules in specific areas of the body.
As mentioned earlier, conditions such as cysts, lymph node tuberculosis, and bone tuberculosis can also enter the meridians and blood vessels, traveling throughout the body with the circulation of qi and blood, as seen with hyperlipidemia.
These turbid substances possess viscous properties, often leading to obstruction of qi and blood flow in the meridians and blood vessels, causing pathological changes due to ischemia and hypoxia in the organs and tissues, resulting in various diseases.
For example, if phlegm accumulates in the head, it can affect blood supply to the brain, leading to symptoms such as dizziness, forgetfulness, drowsiness, and even coma, hemiplegia, or speech difficulties, which Western medicine refers to as cerebral infarction. Many cases in TCM are considered phlegm-related.
If phlegm accumulates in the limbs, it can lead to blood supply disorders in the limbs, resulting in symptoms such as numbness in the limbs and cold extremities.
If phlegm accumulates in the blood vessels, it can lead to insufficient blood supply to the heart, causing symptoms such as palpitations, anxiety, arrhythmia, and chest tightness, which in many cases are closely related to phlegm, as described in Western medicine as coronary heart disease.
Additionally, phlegm can also affect a person’s mental state. If the turbid qi of phlegm-dampness obstructs normal mental activities, it can lead to symptoms such as incessant talking, depression, and unexplained sadness, which are classified as depressive mental disorders in TCM.
Since TCM believes that the “Heart (xin)” is the ruler of the mind, mental disorders caused by excessive “phlegm turbidity” are referred to as “Phlegm Obstructing the Heart Orifices (tan mi xin qiao)” in TCM.
3. The Mobility of Phlegm
Regarding the mobility of phlegm, the great physician Zhu Danxi from the Yuan Dynasty stated: “Phlegm, as a substance, rises and falls with qi, reaching everywhere.”
It is precisely because of the characteristic that phlegm “reaches everywhere” that TCM attributes many strange illnesses or diseases that do not respond well to various treatments to “phlegm”.
Thus, there is a saying in TCM: “Strange diseases often arise from phlegm.” Zhu Danxi also proposed the theory that “many diseases are accompanied by phlegm,” which adds a new perspective to disease diagnosis and treatment. Some diseases may have correct differentiation and appropriate medication, but the clinical effects are not ideal. In such cases, we can consider adding phlegm-transforming methods, which often yield unexpectedly good results.
I once treated a patient with vertigo who had experienced it for over a year. If he stood up suddenly after squatting or sitting for a long time, he would experience blackouts and even fainting.
He felt lethargic throughout the day, spoke softly, had a pale complexion, average appetite, and normal bowel and bladder function. His tongue was pale red with a thin white coating, and his pulse was weak and thin. In the past month, his vertigo seemed to worsen. Western medicine diagnosed him with insufficient cerebral blood supply.
At that time, I thought this was a typical case of qi sinking. Qi deficiency leads to the inability of qi and blood to rise and nourish the head, which should be easy to treat. So, I prescribed 5 doses of Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction), and I confidently told the patient that he would definitely see significant improvement after finishing the 5 doses.
However, five days later, the patient returned for a follow-up and poured cold water on my head, telling me that there was no improvement in his vertigo! He also reassured me that it might take time to improve since he had this problem for a long time.
Upon further inquiry into the patient’s condition, I concluded that it was indeed qi deficiency. Since there was no diagnostic error, why was there no effect?
At that moment, I recalled Zhu Danxi’s saying that “many diseases are accompanied by phlegm,” and I suddenly understood. Since there was qi deficiency, it must lead to abnormal fluid metabolism, resulting in internal phlegm turbidity, which obstructed the brain and caused vertigo.
The previous treatment was ineffective because I only considered qi deficiency and did not take into account the phlegm turbidity present in the meridians and blood vessels. Therefore, I prescribed a new formula to tonify qi and transform phlegm: Huang Qi (Astragalus) 15g, Dang Shen (Codonopsis) 15g, Chao Bai Zhu (Stir-fried Atractylodes) 12g, Jiang Ban Xia (Ginger Pinellia) 10g, Fu Ling (Poria) 10g, Chen Pi (Aged Tangerine Peel) 6g, Chuan Xiong (Szechuan Lovage) 10g, Sheng Ma (Cimicifuga) 3g, Chai Hu (Bupleurum) 3g, Jie Geng (Platycodon) 6g, Ju Luo (Tangerine Peel) 6g, and Zhi Nan Xing (Processed Arisaema) 6g. I still prescribed 5 doses.
Five days later, the patient joyfully reported that this medicine was indeed effective; after just five days, his dizziness had significantly reduced. I then advised him to take Xiang Sha Liu Jun Wan (Fragrant Sand Six Gentlemen Pill) for consolidation, and after about a month of use, I followed up with the patient a year later, and he had not experienced any recurrence of vertigo.
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