Zhang Siter: The Phlegm-Dampness Caused by Yin Deficiency Should Not Be Ignored!

TCM Case Studies / Medical Discussions / Reference Articles for Clinical Study of Traditional Chinese MedicineIntroduction: The principles and treatments regarding phlegm-dampness caused by Yin deficiency have been discussed by physicians throughout history (especially during the Ming and Qing dynasties), but there has been little introduction to its pathogenesis and treatment over the years. The author shares his understanding and clinical experience regarding this issue.Discussing Phlegm-Dampness Caused by Yin DeficiencyAuthor: Zhang Siter, Zhang SijieYin refers to the totality of body fluids, nutrient blood, and Yin essence. The principles and treatments regarding phlegm-dampness caused by Yin deficiency have been discussed by physicians throughout history (especially during the Ming and Qing dynasties), but there has been little introduction to its pathogenesis and treatment over the years. Based on my understanding and clinical experience regarding this condition, I will share my superficial insights on this issue as follows.1. The Mechanism of Phlegm-Dampness Caused by Yin DeficiencyThe influence of Yin on the functional activities of the human body mainly lies in its role in “Yin forming substance,” such as the fullness and nourishment of the body, as well as the moistening of the skin and hair, all of which rely on “Yin forming substance” to be accomplished. The Suwen states: “Therefore, the vessel is the universe of transformation; when the vessel disperses, it divides, and the transformation ceases.” This clearly points out that the existence of the “vessel” (the body) is a prerequisite for survival, and the “vessel” must be continuously nourished and moistened to maintain its normal functional activities. Therefore, Yin fluid deficiency can lead to various pathological changes.Body fluids are distributed throughout the body, primarily serving to nourish and moisten all tissues and organs. When body fluids are deficient, the organs and tissues will lose their moisture, leading to weakened or obstructed functional activities. “When fluids are lost, the pores open, and sweating is excessive,” “When fluids are lost, the bones are unable to flex and extend, the complexion is pale, the brain marrow is consumed, the shins are sore, and the ears ring frequently.” Among these, the opening of the pores, difficulty in flexion and extension, and frequent ringing in the ears are manifestations of weakened or obstructed functional activities of the corresponding organs and tissues. Body fluids are governed by the lungs and stomach; the lungs require body fluids to descend and disperse, while the stomach requires body fluids to receive and digest. Clinical examples of weakened or obstructed lung and stomach functions due to body fluid deficiency are numerous.Nutrient blood circulates within the body, nourishing the five organs, six bowels, limbs, and all body tissues to ensure they perform their normal physiological functions and maintain coordination among their functional activities.Ancient sages said: “Lonely Yin does not give birth, and solitary Yang does not grow; without Yang, Yin cannot give birth, and without Yin, Yang cannot transform,” emphasizing that only the mutual action of Yin and Yang can produce life activities of birth, growth, and transformation; solitary Yang or lonely Yin can only present a lifeless state of non-birth, non-growth, and non-transformation.From this, it can be inferred:The rise and fall of Yin or Yang can enhance or weaken the functional activities of the human body through their respective pathways..The essence of Yin is Yin essence. The Suwen states, “Essence transforms into Qi,” and later generations extended this to say that Yin essence is the mother of Qi; when essence is deficient, Qi is weak, and when essence is abundant, Qi is strong. The so-called weak Qi and strong Qi refer to the weakening and strengthening of the functional activities of the human body.In summary,Yin deficiency can lead to weakened or obstructed functions of the corresponding organs, meridians, and tissues, and if these pathological changes affect the body’s water metabolism, phlegm-dampness will inevitably arise.Since Yin is a tangible substance that occupies a certain space in the body, the term “fullness” implies this meaning.Yin fills the meridians, blood vessels, bone marrow, brain and spine, organs, and muscles; when Yin is deficient, corresponding gaps will be left, and tangible evils will take advantage of these gaps, with phlegm-dampness being a common manifestation of these tangible evils.2. Historical Discussions on Phlegm-Dampness Caused by Yin DeficiencyRegarding the principles and treatments of phlegm-dampness caused by Yin deficiency, physicians from the Ming and Qing dynasties have made some discussions. Although lacking systematic theory, they provide great inspiration.For example, Shi Shoutang in “Yiyuan: Outline of All Diseases” analyzes the two Qi of dryness and dampness, which is extremely insightful. He said: “Moreover, Yin and Yang are mutually rooted, and Qi and blood share the same source. When Yang is severely deficient, Yin must also be deficient; without fuel, how can the pot steam and transform the essence? When Qi is severely deficient, blood must also be deficient; without wheels, how can the cart draw water for irrigation? Often, it begins with dampness, and then dampness transforms into dryness; when Yin is severely deficient, Yang must also be deficient; when the lamp is dim and the oil is exhausted, how can it shine brightly? When blood is deficient, Qi must also be deficient; when the water is shallow, the boat cannot move, how can it rush forward? Often, it begins with dryness, and then dryness is accompanied by dampness. The transformation of dampness is still from the outside (although internal dampness is generated, it is ultimately transformed from water and drink, which is still insufficient for the excess disease), while the transformation of dryness is from internal depletion.”Therefore, those who transform dampness from dryness should still treat dryness as the root and dampness as the branch; those who transform dryness from dampness should treat dampness as the root and dryness as the branch; this is the major principle of treating root and branch.Here, Shi has theoretically discussed the mechanism of phlegm-dampness caused by Yin deficiency and proposed the principle of “treating dryness as the root and dampness as the branch” in treatment, also mentioning in diagnosis thatdryness precedes dampness, which means dryness generates dampness, or Yin deficiency generates dampness.Summarizing the various specific discussions of predecessors on phlegm-dampness caused by Yin deficiency, they can be divided into the following three aspects:(1) Yin Deficiency and Excessive Fire Leading to Phlegm-DampnessYin deficiency leads to excessive fire, and excessive fire generates phlegm-dampness, thus Yin deficiency is the root cause of fire generating phlegm-dampness.In the Ming dynasty, Gong Juzhong’s book “Red Stove Pointing Snow” discusses the treatment of consumption and tuberculosis, arguing that water deficiency and fire excess harm the metal, emphasizing that “all phlegm-fire conditions begin with Yin deficiency, and the treatment should be to tonify Yin.” He believes that “phlegm-fire conditions originate from blood loss and essence depletion, and both essence and blood are true water and true Yin, tangible and substantial, difficult to form and easy to deplete; thus, the so-called phlegm-fire refers to forgetting the root and focusing on the branches.”In the Qing dynasty, You Zaijing’s case of cough and asthma states: “The pulse is weak and rapid, the cheeks are red, the voice is low, the cough is severe, and food is vomited. In the afternoon, heat rises, and there is much restlessness. This is due to liver and kidney Yin deficiency, with Yang floating above, and essence transforming into phlegm foam. The illness has lasted three years; it is an internal injury, and it cannot be cured by simply eliminating phlegm and treating cough. It is necessary to stabilize the lower jiao and completely abstain from desires, maintaining the same diet for years to expect recovery. The formula is Duqi Wan with Nu Zhen Zi, Gou Qi Zi, and Tian Dong added.”(2) Yin Deficiency and Qi Deficiency Leading to Phlegm-DampnessQi deficiency refers to weakened functional activities; when Yin deficiency and Qi deficiency occur, it often leads to an inability to control water, resulting in phlegm-dampness.In the Qing dynasty, Wang Mengying treated Zhang Yuzhi’s mother, who had long suffered from phlegm cough. Due to a fine pulse and abundant phlegm, he diagnosed it as “Yin deficiency with water overflowing” and used a large dose of Shu Di to achieve results. He treated Wang, who was over sixty years old and had long suffered from phlegm cough. His pulse was thin and weak on the left, and both right pulses were rapid. He diagnosed it as Yin deficiency with Qi unable to descend and absorb, prescribing Shu Di, Cong Rong, Gui Ban, Hu Tao, Bai He, Zi Shi Ying, Fu Ling, and Dong Chong Xia Cao, which cured him in ten days.This type of phlegm cough is easily misdiagnosed as Qi deficiency with phlegm-dampness, so Wang advised that if mixed with Ren Shen, Huang Qi, or Bai Zhu to assist Qi, it would easily worsen the illness.Wang’s specific discussions on phlegm-dampness caused by Yin deficiency are numerous and valuable, worthy of further exploration today. In the Qing dynasty, Zhang Yuqing also clearly pointed out in his case of cough and asthma: “It is particularly the Yin deficiency of the kidney and the Yang deficiency of the kidney that cause Qi to not be stored,” emphasizing that for phlegm-dampness rising due to Yin deficiency and Qi not being stored, “only nourishing water and nourishing the liver, and storing kidney Yin, can prevent water from rising; then phlegm will be transformed into body fluids and liquid, which should not be overlooked.”From this, it can be seen that Zhang Jingyue’s statement, “If there is Qi deficiency due to essence deficiency, one should supplement essence to transform Qi; if essence is deficient due to Qi deficiency, one should supplement Qi to generate essence,” has significant clinical guidance value. Although both are deficiencies of essence and Qi, the causal relationship is different, and the treatment methods are also different. Mixing treatments will inevitably lead to poor results, especially in the treatment of phlegm-dampness caused by Yin deficiency and Qi deficiency, which should be given special attention.(3) Yin Deficiency Leaving Gaps for Phlegm-Dampness to InvadeAfter Yin deficiency, the gaps left are often occupied by phlegm-dampness. At this time, eliminating phlegm-dampness is only treating the symptoms; the root treatment is to tonify Yin to fill the gaps and expel dampness, which is also a specific manifestation of the righteous Qi being weak and the evil Qi invading.In the Qing dynasty, Wang Tailin’s case of stroke states: “The kidney stores essence and governs the bones, the liver stores blood and governs the tendons. When the essence and blood of the kidney and liver are weak, the tendons and bones will have many gaps, and damp-heat phlegm will invade the meridians, leading to weakness in the right hand and foot, a stiff tongue root, and a root-like condition. Nourishing essence and blood, promoting meridian circulation, and transforming phlegm and dampness, while maintaining rest, may help prolong life.”In the Qing dynasty, You Zaijing treated atrophy and paralysis, stating: “The pulse is weak and rapid, both knees are soft and swollen, unable to flex and extend. This is due to damp-heat invading due to Yin Qi deficiency, which, if prolonged, will lead to ‘crane knee wind.’ The formula includes Sheng Di, Niu Xi, Fu Ling, Mu Guo, Dan Pi, Yi Ren, Huai Shan Yao, Shan Yao, Ze Xie, and Bi Xie.”From the above selected literature, it is evident that predecessors have long recognized the theoretical possibility and clinical existence of phlegm-dampness caused by Yin deficiency. For this fragmented information, if one pays attention to accumulation, it is not difficult to obtain a wealth of experience for our reference.3. Treatment Examples of Phlegm-Dampness Caused by Yin DeficiencyPhlegm-dampness caused by Yin deficiency has many symptoms, mainly seen in internal injuries and miscellaneous diseases, as well as in the later stages of exogenous heat diseases. Due to space limitations, only two or three clinical symptoms will be cited as examples.EdemaEdema caused by Yin deficiency is characterized by abdominal distension, protruding navel, visible veins, swelling of the limbs, short and scanty urination, flushed face, thirst, dry stools, red tongue, and thin rapid pulse. This is due to kidney Yin deficiency, with excessive fire causing water to overflow, resulting in edema from Yin deficiency and water overflow. Zhang Jingyue pointed out: “All pungent, aromatic, dry, and hot agents must be avoided; it is advisable to use Liu Wei Di Huang Tang with Niu Xi, Che Qian Zi, and Mai Dong.” Zhao Yangkui also believes that edema “is purely due to Yin deficiency, with symptoms of abdominal distension, protruding navel, waist pain, swelling of the lower limbs, short and scanty red urination, and thirst… with dry stools,” using Liu Wei Di Huang Tang with Mai Dong and Wu Wei Zi, which has been “proven effective in practice.”In the “Ding Gan Ren Medical Case,” there is a case of edema that is particularly memorable, which I will transcribe as follows:XU Youchan, two months after giving birth, had generalized edema, a pulse that moved during coughing, difficulty lying flat, dry mouth and thirst, abdominal distension, short and red urination, a bright red tongue without coating, and a thin, wiry, rapid pulse. This was due to a significant loss of Yin, with the liver failing to nourish, wood overcoming earth, the spleen not functioning properly, and Yang water and damp heat accumulating over time, rising to the lungs, preventing the lungs from regulating the water pathways, and the water dampness having no way to exit, leading to overflow everywhere. The pulse and symptoms combined indicate that harsh agents are particularly contraindicated. The urgent prescription is to nourish lung Yin to soften liver wood, promote middle earth to benefit water dampness, hoping for a response to avoid danger.Prescription: Nan Bei Sha Shen each 9g, Lian Pi Fu Ling 15g, Sheng Bai Zhu 6g, Zhi Gan Cao 2g, Huai Shan Yao 9g, Chuan Shi Hu 9g, Chen Guang Pi 3g, Sang Bai Pi 6g, Chuan Bei Mu 9g, Da Fu Pi 6g, Han Fang Ji 9g, Dong Gua Zi and Pi each 9g, Sheng Yi Ren 15g, and use Dong Gua juice warm as tea.Second Diagnosis: After taking three doses of medicine, urination gradually increased, and the water dampness showed a downward trend, with slight reduction in generalized edema. However, coughing and shortness of breath persisted, making it difficult to lie flat, with internal heat and dry mouth, and after eating, abdominal distension increased. The tongue was bright red, and the pulse was thin, wiry, and rapid. All of this was due to blood deficiency and Yin depletion, with wood fire rising, causing water Qi to reverse into the lungs, preventing the lungs from descending, and the middle earth being bullied by wood, leading to the spleen’s loss of normal function. It is still advisable to nourish metal to control wood, exalt earth to benefit water, allowing lung metal to have the power to regulate, and the spleen earth to gain strength, thus enabling the regulation of water pathways and preventing water Qi from rising.Prescription: Nan Bei Sha Shen each 9g, Lian Pi Fu Ling 15g, Sheng Bai Zhu 6g, Zhi Gan Cao 2g, Chuan Shi Hu 9g, Fei Zhi Mu 4.5g, Chuan Bei Mu 6g, Sang Bai Pi 6g, Da Fu Pi 6g, Han Fang Ji 6g, Zhi Bai Su Zi 4.5g, Tian Gua Zi and Pi each 9g, and Jin Nei Jin Tan 6g.Phlegm CoughPhlegm cough due to Yin deficiency has many patterns, such as in warm diseases with severe heat, where lung and stomach Yin fluids are damaged, leading to cough with sticky white phlegm that is difficult to expel (as per “Warm Disease Differentiation”);lung and stomach Yin injury, with Qi fire rising, leading to cough with sputum and foam, dry throat and thirst, red tongue without coating, and thin rapid pulse (as per “Jin Gui Yao Lue”);lung and kidney Yin deficiency, with virtual fire rising, leading to dry and painful throat, cough with blood-streaked phlegm, hot hands and feet, red tongue with little coating, and thin rapid pulse (as per “Bai He Guo Jin Tang”);dampness injuring the lungs, with insufficient lung Yin, virtual fire scorching metal, leading to the transformation of fluids into phlegm, characterized by choking cough, shortness of breath, difficult phlegm expectoration, thick and sticky phlegm, and even forming strips or blocks, with dry throat and painful swallowing, and frequent hoarse cough (as per “Yao Yi Xin Wu”);lung and kidney Yin deficiency, with internal phlegm-dampness, leading to cough, nausea, and shortness of breath with abundant phlegm (as per “Jing Yue Quan Shu”).In “Fu Qingzhu’s Male Diseases,” the treatment for this condition includes Shu Di, Huai Shan Yao, Shan Yao, Mai Dong, Wu Wei Zi, Fu Ling, Yi Zhi Ren, Yi Ren, Qian Shi, and Che Qian Ren, or Liu Wei Di Huang Tang with Mai Dong and Wu Wei Zi, emphasizing that “it is essential not to treat phlegm as arising from spleen dampness.”This record from “Continuing Famous Physician Cases: Phlegm” is quite incisive. “Huang Lixu said: In treating phlegm, it is often said that kidney deficiency and fire overflow lead to phlegm, and the treatment should be to tonify the kidney. I, in the autumn of the Ren Shen year, had a cough with much phlegm, knowing it was due to color, followed the teacher’s method, strictly taking Liu Wei Wan, and did not treat it, and after several months, the phlegm cough was completely cured.At that time, the teacher treated phlegm, most avoided Shu Di, believing it to be greasy and obstructive; how could he know the subtle principles within?” This book has several cases of treating phlegm cough with Liu Wei Wan, which can further inspire thought.AtrophyYin deficiency leads to emptiness in the muscles and bones, resulting in phlegm-dampness retention, which is not uncommon in clinical practice.Ye Tianshi has a case stating: “Atrophy in the lower body is often due to liver and kidney diseases. However, there must be damp-heat in the constitution, with heat stagnating and dampness obstructing, leading to Qi and blood not circulating. Muscles shrink, and the body becomes heavy and difficult to move, which is merely the deep-seated damp evil. If discussing Yang deficiency, it should not lead to extensive sores. However, chronic illness is not a quick fix; do not expect immediate results, and only then can the disease be cured. The formula includes Sheng Di, Xian Cong Rong, Dang Gui Xu, Niu Xi, Huang Bai, Sheng Ci Li, Chuan Shi Hu, and Bi Xie.”Above are the experiences of predecessors in treating phlegm-dampness caused by Yin deficiency. I will now introduce two of my recent cases:Case 1:Wang XX, male, 68 years old.In recent years, he has experienced edema in both lower limbs up to the knees, fluctuating in severity, with routine urinalysis and electrocardiogram showing no abnormalities. Blood pressure fluctuates between 190-160/110-96 mmHg, with occasional dizziness, palpitations, and phlegm in the throat.The tongue is bright red, the coating is slippery and greasy, the pulse is thin and rapid, with thirst. Taking warming Yang and diuretic agents worsens the condition, with urination becoming red and painful.This is due to kidney Yin deficiency causing edema, treated with Liu Wei Di Huang Tang plus Shi Hu, Mai Dong, and Che Qian Zi, leading to gradual reduction of lower limb edema.Case 2:Liu XX, male, 4 years old.After several days of fever, he developed atrophy in the right leg, diagnosed as “poliomyelitis” at XX hospital, treated with acupuncture, physiotherapy, and oral vitamins, as well as injections of Galantamine for over two months with poor results, and then transferred to TCM treatment.Symptoms included a red tongue with thin yellow greasy coating, little thirst, short and painful urination, and poor appetite. Initially, using methods to clear damp-heat was ineffective, and the greasy coating slightly increased.Changed to the effective formula for atrophy: Sheng Di, Shu Di each 20g, Dang Shen, Sha Shen, Xuan Shen, Mai Dong, Ju Hua, Di Gu Pi each 15g, Che Qian Zi 12g, Qin Jiao 10g. After ten doses, he recovered. During this period, the tongue coating gradually decreased, and appetite gradually improved.This shows that phlegm-dampness caused by Yin deficiency will not benefit from simply tonifying Yin.It has been a year and a half since recovery, and follow-up shows everything is good, with no sequelae.In summary,phlegm-dampness caused by Yin deficiency is also commonly seen in clinical practice, and predecessors have summarized and developed specific treatments that should not be ignored or avoided.Both tonifying Yin and eliminating phlegm-dampness, as well as tonifying Yang and eliminating phlegm-dampness, are fundamental principles in TCM treatment of phlegm-dampness. Both are effective treatment principles formulated for different pathogenesis and should not be neglected. When combined, they provide a more comprehensive approach, making clinical treatment of phlegm-dampness more refined.This article is excerpted from “New Chinese Medicine,” 1984, Issue 12, Author/Zhang Siter, Zhang Sijie. Edited by Yan Qifeng, Proofread by Tan Quanyong, Bi Lihui. Transferred from the TCM Book Friends Association.You May Also Like, click to read the original text:No appetite? 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