The Four Types of 痰飲 Phlegm-Rheum

“Tanyin” is an umbrella term meaning phlegm-rheum, but it’s also the name of one of four phlegm-rheum sub-types. The four types of of phlegm-rheum are:

i. 痰飲 Tanyin (“dilute-rheum”): watery rheum collecting in the stomach and intestines; caused by impaired Spleen transformation & transportation; identified by borborygmus; emaciation; abdominal fullness; dry mouth & tongue; dizziness; and drool.

Tanyin Formulas: LGZGT, Ji Jiao Li Huang Wan, WLS. (We can also consider various Banxia formulas for dilute-rheum, including BXXXT, GCXXT, SJXXT; however, in JGYL 12, Banxia mainly treats Zhiyin “poking-rheum.”)

ii. 懸飲 Xuanyin (“hanging-rheum”): water-rheum collecting in and clinging to the rib-side; caused by Sanjiao accumulation of phlegm-rheum and disharmony of the LR/GB channel networks; identified by cough with rib-side pain; spitting; fullness and distention in the chest and rib-side; dry retching; SOB; a deep & wiry pulse.

Xuanyin Formulas: SZT; possibly GSBXT (see “lodged-rheum” below for this formula). (We can also consider formulas like Da Xianxiong Tang, Da Xianxiong Wan, and Dahuang Fuzi Tang, for hanging-rheum.)

iii. 溢飲 Yiyin (“overflow-rheum”): water-rheum flowing out into the flesh of the four limbs; caused by either (a) impairment of sweating, (b) impairment of the Lung’s descending & dispersing, or (c) impairment of the Spleen’s transformation & transportation; identified by pain of the four limbs and a subjective feeling of heaviness (including in the head); aversion to cold; absence of sweating; joint-pain; coughing, panting, and vomiting of phlegm-drool; a pulse that’s floating & tight, or wiry & tight. Yiyin is similar to Water-qi (edema).

Yiyin Formulas: DQLT, XQLT, and various formulas in JGYL 2 & 14.

iv. 支飲 Zhiyin (“poking-rheum”): water-rheum collecting in the chest and diaphragm; caused by insufficiency of chest yang, which allows rheum to collect in the chest & diaphragm, affecting the Heart & Lung; identified by SOB preventing the px from lying down; cough-counterflow; panting & fullness; hard glomus below the Heart; veiling-dizziness; chest-pain; vomiting & retching; absence of thirst; soot-black facial complexion; a swollen appearance in the upper body; and a wiry pulse.

Zhiyin Formulas: MFJT (and MFJqSGjFLMXT), ZXT, TLDZXFT, XBXT, XBXjFLT, SZT (for chronic, severe Zhiyin), Fuling Yin

Two Additional Types of Tanyin: Lodged-Rheum and Lurking-Rheum

JGYL lines 12.8-12.10 describe 留飲 Liuyin (“lodged-rheum”):
• Lodged-rheum xinxia manifests with cold in the back (over HT back-shu).
• Lodged-rheum can manifest in pain under the rib-side stretching into the supraclavicular fossa that is exacerbated by coughing.
• Lodged-rheum in the chest manifests in SOB and thirst, joint-running pain of the four limbs, and a deep pulse.
• Lodged-rheum seems to simply be a general term for rheum that collects somewhere (it could overlap with any of the four sub-types, or even dampness).
• Formulas for Liuyin: GSBXT.

JGYL 12.11 discusses 伏飲 Fuyin (“lurking-rheum”):
• Phlegm above the diaphragm can lead to fullness, panting, cough, vomiting, cold or heat, back and lumbar pain, spontaneous tearing, and severe trembling.
• Wiseman: This is rheum that is stuck deep in the inner body that erupts in episodes and is difficult to eliminate. An external evil can stir the lurking-rheum, creating the above symptoms. Some scholars think this rheum refers to asthma; others say Zhiyin.

Categorizing Phlegm-Rheum According to the Zang-Organs

JGYL 12.3-7 describe the manifestations of water lodging in the five zang:
• Water in the HT results in hardness and pounding below the Heart, SOB, and aversion to water with no desire to drink.
• Water in the LU results in ejection of drool and foam, with desire to drink water. (Note that in JGYL 12.13, we are told that in LU-rheum, the pulse is not wiry, and the px only suffers from panting & SOB.)
• Water in the SP results in SOB and generalized heaviness.
• Water in the LR results in poking fullness under the rib-side and pain on sneezing.
• Water in the KD results in palp’s below the HT.

Pulse

The Tanyin pulse tends to be wiry; however:
• JGYL 12.12 says it can be wiry on just one side.
• JGYL 12.13 says Lung-rheum does not have a wiry pulse.
• JGYL 12.14 says Zhiyin can have a normal pulse.
• JGYL 12.19: “A floating, fine, slippery pulse means damage by rheum.”
• JGYL 12.20: “A wiry, rapid pulse with cold-rheum is hard to treat.”
• JGYL 12.21: “A pulse that is deep and wiry means Xuanyin is causing pain in the inner body.”
• JGYL 12.34: “If a patient with cough that has endured for several years has a weak pulse, it can be treated; if it is excess, large, and rapid, [the patient] will die. If the pulse is empty, [the patient] will suffer from veiling. This is because such patients originally have Zhiyin in the chest. Treat them like rheum patients.”

Medicinals: How to Treat Phlegm-Rheum

• JGYL 12.15: “In Tanyin disease, one should use warm medicinals to harmonize.”

• Core single herbs in this chapter include FL, GZ, Zhu, GC, TLZ, GS, ZX, MH, XX, GJ, SJ, BX, WWZ, XR, DZ, and FJ.

• Representative formulas include LGZGT and XQLT. Also consider formulas from JGYL 2, JGYL 7, JGYL 9 (such as GLXBBXT and FLXRGCT), JGYL 11 (such as Ling Jiang Zhu Gancao Tang), JGYL 14, JGYL 17 (such as FLZXT and ZLS), and the chapters on women’s diseases (BXHPT). Lastly, we can also look to the SHL (such as Jiexiong formulas; Jiegeng Tang; and Banxia Xiexin Tang & its variants).

• Shuqi (in formulas like GZqSYjSQLGMLT and MLT) also seems to have been a phlegm-focused herb (in the context of mental-emotions patterns); it might be useful to consider phlegm-focused substitute herbs.

Let’s explore the formulas within each of the four types of Tanyin:

i. Tanyin (dilute-rheum) formulas

Ling Gui Zhu Gan Tang
• FL 4 GZ 3 Zhu 3 GC 2
• JGYL 12.16, 12.17
• “Tanyin below the HT with poking fullness in the chest and rib-side, and dizzy vision.”
• “For SOB with mild rheum: eliminate it via the urine. (SQW also governs.)”
• Wiseman: With mild rheum, the outward signs might be limited to SOB. The root lies in SP & KD yang; when it’s the SP, use LGZGT; when it’s the KD, use SQW.
• Zhu & FL both treat dizziness. At root, this formula features FL + GZGC: a water metabolism issue plus weak heart yang (as in FLGCT, LGCZT, LGWWGCT, FLZXT); so, we can also look for anxiety due to water accumulation, and heart palp’s due to overwork.

Ji Jiao Li Huang Wan
• FJ 1 Jiaomu 1 TLZ 1 DaH 1 (instructions say you can add MX for thirst)
• JGYL 12.29
• “There is abdominal fullness, and both the mouth and tongue are dry: this [means] there is water-qi within the intestines; Ji Jiao Li Huang Wan governs.”
• Water-rheum is stagnating in the intestines, causing heat signs (dryness above).
• Though it’s not categorized in the line, this must be Tanyin.

Wuling San
• ZX ZL FL Zhu GZ • JGYL 12.31
• “If an emaciated patient has pulsation below the navel, spitting-up of frothy sputum, and dizziness: this is water [disease]; Wuling San governs.”
• Though it’s not categorized in the line, this must be Tanyin.

ii. Xuanyin (hanging-rheum) formulas

Shizao Tang
• Gansui; Yuanhua (genkwa flower); Daji (euphorbia/knoxia root); DZ [1st 3 are powdered]
• JGYL 12.22, 12.32, 12.33
• “The patient has Xuanyin: Shizao Tang governs.”
• “In a patient with cough, the pulse is wiry: [this] indicates there is water; Shizao Tang governs.”
• GS purges water accumulation; DZ treats pulling tightness and moderates the others.
• Yakucho single herb patterns for Yuanhua & Daji: “Yuanhua governs expelling water. It simultaneously treats cough with pulling pain.” “Daji governs smoothening water. It simultaneously treats pulling pain, cough, and vexation.”
• (This formula is also for chronic Zhiyin with cough, vexation & pain. Zhiyin is not normally associated with chest pain or HT vex’n; however these signs might appear if the condition persists for a long time.)

*Note that we might also consider Gansui Banxia Tang a Xuanyin formula (although perhaps it’s best understood as a Zhiyin formula, given the location of disease and the presence of Banxia); Da Xianxiong Tang, Da Xianxiong Wan, and Dahuang Fuzi Tang are also candidates for Xuanyin formulas.

iii. Yiyin (overflow-rheum) formulas

Da Qinglong Tang & Xiao Qinglong Tang
• DQLT: MH 6 GZ 2 GC 2 XR 40 pcs SJ 3 DZ 20 pcs SG 1 lump
• XQLT: MH 3 GZ 3 SY 3 GC 3 WWZ ½ sheng GJ 3 XX 3 BX ½ sheng
• JGYL 12.23
• “The patient has Yiyin: one should promote a sweat; Da Qinglong Tang governs; Xiao Qinglong Tang also governs.”
• Body heaviness and pain, with no sweating. Wiseman contends that Yiyin is caused by blockage of the LU, which is supposed to regulate the waterways; fluid, which is supposed to descend to the BL, spills out to the four extremities. The pores are closed (again reflecting LU dysfxn), so there’s no sweating. We use DQLT & XQLT to effuse sweat. DQLT should have heat/vex’n. XQLT should have cold rheum below the HT.

Also consider the following formulas from JGYL chapters 2, 5 & 14 for Yiyin:

Relevant Mahuang formulas:
• MHjZhuT (JGYL 2.20); Ma Xing Yi Gan Tang (JGYL 2.21); GZSYZMT (JGYL 5.8); Yuebi Tang (JGYL 14.23); Yuebi jia Zhu Tang (JGYL 14.5); GCMHT (JGYL 14.25); MHFZT (JGYL 14.26); GZqSYjMHXXFZT (JGYL 14.31)

Relevant non-Mahuang formulas:
• FJHQiT (JGYL 2.22); FJFLT (JGYL 14.24); Wutou Tang (JGYL 5.10); GZFZT/GZFZqGjZhuT/GCFZT (JGYL 2.23-24); Puhui San (JGYL 14.27); Huangqi Shaoyao Guizhi Baijiu Tang (JGYL 14.28); GZjHQiT (JGYL 14.29); Zhi Zhu Tang (JGYL 14.32)

iv. Zhiyin (poking-rheum) formulas

Xiao Qinglong Tang
• MH 3 GZ 3 SY 3 GC 3 WWZ ½ sheng GJ 3 XX 3 BX ½ sheng
• JGYL 12.35, (see 12.36-12.40 for transmuted patterns)
• “For cough-counterflow with belabored breathing and insomnia: Xiao Qinglong Tang governs.”
• Cough, asthma, water-qi below the heart, headache, mucus.

Tingli Dazao Xiefei Tang
• TLZ pills DZ 12 pcs
• JGYL 12.27
• “Zhiyin with inability to breathe: Tingli Dazao Xiefei Tang governs.”
• Also for Feiyong (Lung Abscess) with inability to lie down; fullness & distention in chest; facial swelling; nasal congestion with inability to smell; and cough.

Xiao Banxia Tang
• BX 1 sheng SJ half-jin (using a long boiling process)
• JGYL 12.28 (also in JGYL 15 & JGYL 17 for n/v)
• “Patients with nausea and vomiting: they are generally thirsty; thirst means there is about to be resolution. [If] now, however, there is no thirst: [it means] there is Zhiyin below the heart; Xiao Banxia Tang governs.”
• Zhiyin with chronic nausea/vomiting with no thirst (suggesting water-rheum is continually collecting below the HT).

Xiao Banxia jia Fuling Tang
• BX 1 sheng SJ half-jin FL 3
• JGYL 12.30, 12.41
• “There is sudden nausea and vomiting, with a glomus below the heart, water within the diaphragm, dizziness, and palpitation: Xiao Banxia jia Fuling Tang governs.”
• “Thirst first and then nausea: this means water is collecting below the heart. This [symptom] belongs to rheum-patients; Xiao Banxia Fuling Tang governs.”
• Though it’s not categorized in the line, this must be Zhiyin (water in the chest and diaphragm). There was just n/v with no thirst in XBXT; now there’s also glomus, dizziness & palp’s.

Mufangji Tang (& Mufangji qu Shigao jia Fuling Mangxiao Tang)
• FJ 3 SG 12 pcs GZ 2 RS 4 (FJ 2 GZ 2 RS 4 FL 4 MX 3 ge)
• JGYL 12.24
• “Zhiyin in the diaphragm, with panting and fullness, a hard glomus below the heart, a dark facial complexion, and a pulse that is deep and tight…”
• There is severe Zhiyin in the diaphragm, with rheum & heat binding (with depressed heat steaming the face).

Zexie Tang
• ZX 5 Zhu 2
• JGYL 12.25
• “Below the heart, there is Zhiyin, and the patient suffers from veiling-dizziness: Zexie Tang governs.”

Houpo Dahuang Tang
• HP 1 chi DaH 6 ZS 4 pcs
• JGYL 12.26
• “Zhiyin with chest-fullness: Houpo Dahuang Tang governs.”
• This might be describing a process of Zhiyin with chest-fullness leading to intestinal excess (with fullness & constipation).

Fuling Yin
• JGYL 12.31 (appended, from the Waitai Miyao)
• FL 3 RS 3 Zhu 3 ZS 2 Jupi 2.5 SJ 4
• “treats stagnant phlegm and lodged water in the heart and chest, [occurring] following spontaneous vomiting of water, [and leading to] deficiency within the heart and chest, qi-fullness, and inability to eat. [The formula] disperses phlegm-qi, and causes [the patient] to be able to eat.”
• Though it’s not categorized in the line, this must be Zhiyin.

v. Liuyin (lodged-rheum) formula

Gansui Banxia Tang
• GS 3 large pcs BX 12 pcs SY 5 pcs GC 1 pc Honey
• JGYL 12.18
• “There is a hidden pulse; the patient is on the verge of spontaneous diarrhea, and with diarrhea comes unexpected satisfaction; but despite the diarrhea, hardness and fullness below the heart remain: this means there is lodged rheum that is about to go away; Gansui Banxia Tang governs.”
• Wiseman: Collecting water-rheum stops the flow of yang qi, causing a hidden pulse. Sudden diarrhea with relief afterwards means the lodged evil is beginning to disappear. If it doesn’t disappear, and is just re-accumulating daily, use this formula to attack and dispel phlegm and quiet the center.

Formulas for Transmuted Zhiyin Patterns

• Lines JGYL 12.36-12.40 discuss transmutations of Zhiyin patterns; in particular, they tell us what to do when a xu patient has taken XQLT. When Mahuang (in the context of XQLT) is given to a xu patient, it forces out the yang that is trying to conserve itself; this can lead to such transmuted Zhiyin patterns as surging qi, impediment of the extremities, veiling, cough with chest fullness, nausea, swelling, and facial heat. The following formulas are recommended for such transmuted Zhiyin patterns. (Note that they can be used even in the absence of prior mistreatment with MH, as long as the pattern matches.)

Fuling Guizhi Wuwei Gancao Tang
• FL 4 GZ 4 WWZ ½ sheng GC 3
• JGYL 12.36
• After taking XQLT, “the patient has copious spittle and a dry mouth, a deep cun-pulse and faint chi-pulse, reversal-counterflow of the hands and feet, qi surging upward from the lower abdomen to the chest and throat, impediment of the hands and feet, gentle warmth of the face (as in inebriation), and, as a result of flow returning to the yin parts [inguinal region], difficult urination and periodic recurrent veiling: give Fuling Guizhi Wuwei Gancao Tang to treat the surging of qi.”

Ling Gan Wuwei Jiang Xin Tang
• FL 4 GC 3 WWZ ½ sheng GJ 3 XX 3
• JGYL 12.37
• “The surging qi has been lowered but now there is cough and chest fullness.”
• We must replace GZ with GJ and XX.

Ling Gan Wuwei Jiang Xin Xia Tang
• FL 4 GC 2 WWZ ½ sheng GJ 2 XX 2 BX ½ sheng
• JGYL 12.38
• There should be thirst after taking GJ & XX; if there is no thirst, it means Zhiyin is still present. “As for Zhiyin: according to rule, one should experience veiling. As for veiling: there will be nausea. As for nausea: take [the decoction] again, now with the insertion of Banxia, in order to eliminate the water.”

Ling Gan Wuwei Jiang Xin Xia Ren Tang
• FL 4 GC 3 WWZ ½ sheng GJ 3 XX 3 BX ½ sheng XR ½ sheng
• JGYL 12.39
• “When water is eliminated and nausea ceases, the patient has bodily swelling: adding Xingren governs.”
• This line says to not use Mahuang for cases of swelling with [qi & blood] deficiency. In such cases, MH can cause impediment (numbness) of the extremities.

Ling Gan Wuwei Jiang Xin Xia Ren Huang Tang
• FL 4 GC 3 WWZ ½ sheng GJ 3 XX 3 BX ½ sheng XR ½ sheng DaH 3
• JGYL 12.40
• “If there is facial heat as in inebriation: this means stomach-heat is surging upward to smoke the face; add Dahuang to smoothen.”