The pattern of combined phlegm and qi, also known as depressive phlegm pattern, is a collective term for a series of symptoms caused by the combination of phlegm and qi depression in various parts of the body. The pattern of combined phlegm and qi is often caused by damage from the seven emotions, leading to qi stagnation and phlegm obstruction.

The main clinical manifestations of this syndrome are: emotional distress, irritability, fullness and discomfort in the chest and hypochondrium, frequent sighing, or a sensation of a plum pit stuck in the throat, or difficulty swallowing, or mental dullness, or the development of scrofula, thin and greasy tongue coating, and a wiry, thin, and slippery pulse.

The pattern of combined phlegm and qi is mainly seen in diseases such as "chest impediment," "globus hystericus," "dysphagia," "epilepsy," "goiter," and "scrofula."

In clinical practice, this syndrome should be differentiated from the "pattern of liver and spleen disharmony" and the "liver-stomach disharmony pattern."

bubble_chart Differentiation and Treatment

The pattern of combined phlegm and qi is complex in clinical manifestations due to the different locations of obstruction and varying symptoms. Common manifestations include emotional depression, irritability, fullness and discomfort in the chest and hypochondrium, and frequent sighing. In different diseases, the characteristics vary.

1. If phlegm and qi fullness accumulate in the chest, leading to impeded qi movement and resulting in chest impediment, symptoms include chest stuffiness and fullness, shortness of breath, pain radiating to the heart and back, and discomfort during bending or stretching. Treatment should focus on promoting qi circulation, resolving phlegm, and lowering adverse qi. The modified Jupi Zhijiang Decoction (Jingui Yaolue) is recommended.
2. If phlegm and qi bind in the throat, it forms globus hystericus, characterized by a sensation of a plum pit or cotton obstructing the throat, difficulty swallowing, chest stuffiness, and qi depression. Treatment should aim to regulate qi and disperse phlegm, using the modified Four Seven Decoction (Taiping Huimen Heji Jufang).
3. If phlegm obstructs the esophagus due to the meeting of yin qi and yang qi, it causes dysphagia, with symptoms such as difficulty swallowing, vomiting of phlegm and saliva, chest stuffiness, and dry mouth. Early relief may occur when the condition is alleviated. Treatment should focus on relieving stagnation, resolving phlegm, and moistening dryness, using the modified Qige Powder (Yixue Xinwu).
4. If phlegm and qi depression bind and cloud mental activity, it may lead to depressive psychosis, manifesting as emotional depression, apathy, silence, dementia, slow movement, and incoherent speech. Treatment should aim to regulate qi, relieve depression, resolve phlegm, and promote resuscitation, using the modified Phlegm-Guiding Decoction (Jisheng Fang).
5. If phlegm and qi bind in the meridians, it may form goiter, often presenting as a neck mass, diffuse swelling or lumps, unchanged skin color, and soft texture upon palpation. Treatment should focus on regulating qi, relieving depression, resolving phlegm, and softening hardness, using the modified Sargassum Jade Flask Decoction (Waike Zhengzong). It may also form scrofula in the neck, armpit, or groin, presenting as bean-like lumps, painless and without heat, gradually increasing in size and number, sometimes with mild pain. Treatment should aim to soothe the liver, relieve depression, soften hardness, and resolve phlegm, using the modified Scrofula-Eliminating Pill (Yixue Zhongzhong Canxilu).

The pattern of combined phlegm and qi is often seen in individuals with emotional depression and constrained liver qi, especially in women. Emotional distress, constrained liver qi, and phlegm-qi depression lead to this syndrome. In spring, when liver qi is prone to stagnation, this syndrome often occurs or worsens. The condition frequently fluctuates with emotional changes, so it is important to address the patient's mental state and encourage optimism to aid recovery.

During the progression of the pattern of combined phlegm and qi, it is often complicated by the pattern of liver qi depression, spleen deficiency with dampness encumbrance, and ascending counterflow of stomach qi. The pattern of combined phlegm and qi often develops from liver qi depression, and the binding of phlegm and qi further exacerbates liver qi depression. Thus, it is commonly associated with liver qi depression, which manifests as emotional depression, chest and hypochondrium distension, irritability, and a wiry pulse. Spleen deficiency with dampness encumbrance not only contributes to phlegm formation but also leads to liver qi hyperactivity, further aggravating spleen deficiency. Therefore, the pattern of combined phlegm and qi is often complicated by spleen deficiency with dampness encumbrance, which presents as abdominal distension, poor appetite, nausea, heavy limbs, greasy tongue coating, and a soggy pulse. Additionally, the pattern of combined phlegm and qi may lead to ascending counterflow of stomach qi due to phlegm rising, resulting in symptoms such as poor appetite, epigastric distending pain, belching, hiccups, and vomiting.

bubble_chart Differentiation of Similar Patterns

1. pattern of liver and spleen disharmony and pattern of combined phlegm and qi: The pattern of combined phlegm and qi is caused by liver qi depression, impaired qi movement, and the binding of phlegm and qi. The pattern of liver and spleen disharmony, also known as the pattern of liver depression and spleen deficiency, is caused by stagnant anger damaging the liver, leading to impaired liver dispersion and transverse invasion of the spleen, resulting in dysfunction of the spleen in transportation. Both syndromes can manifest with common symptoms such as emotional depression, irritability, chest and hypochondriac fullness, and frequent sighing. However, the pattern of combined phlegm and qi may also present with symptoms such as chest impediment, globus hystericus, dysphagia, epilepsy, goiter, and scrofula due to different sites of obstruction. In contrast, the pattern of liver and spleen disharmony may present with symptoms of spleen qi deficiency such as poor appetite, abdominal distension and fullness, loose stools, fatigue, and lack of strength. In terms of tongue and pulse, the pattern of combined phlegm and qi is characterized by a greasy tongue coating and a wiry, thin, and slippery pulse, while the pattern of liver and spleen disharmony often presents with a thin tongue coating and a wiry pulse.
2. liver-stomach disharmony pattern and pattern of combined phlegm and qi: The liver-stomach disharmony pattern is caused by liver depression and qi stagnation, impaired dispersion, liver qi invading the stomach, and stomach failing to harmonize and descend. Both the pattern of combined phlegm and qi and the liver-stomach disharmony pattern can present with common symptoms such as emotional depression, chest and hypochondriac distension, and irritability. However, the pattern of combined phlegm and qi may also present with symptoms such as a sensation of throat obstruction, difficulty swallowing, mental dullness, goiter, and scrofula, while the liver-stomach disharmony pattern may present with symptoms such as epigastric distending pain, hiccups, belching, acid regurgitation, and epigastric upset. In terms of tongue and pulse, the pattern of combined phlegm and qi is characterized by a thin and greasy tongue coating and a wiry, thin, and slippery pulse, while the liver-stomach disharmony pattern presents with a thin and yellow tongue coating and a wiry pulse.

bubble_chart Documentation

1. Zhengyin Maizhi‧Phlegm Syndrome: "The syndrome of stagnant phlegm manifests as chest fullness and distension, obstruction of the nine orifices, restlessness, subcutaneous nodules in the throat, restless sleep, gastrointestinal discomfort, hindered eating and drinking, or adverse qi flow, leaning and panting with shoulder movement—these are the symptoms of stagnant phlegm. What causes stagnant phlegm? It is due to injuries from the seven emotions, which easily lead to stagnation, stagnation of lung qi, failure of spleen's original qi to move, pensiveness causing qi stagnation, and depression forming phlegm—these are the causes of stagnant phlegm. The pulse of stagnant phlegm is often deep and slow; deep and slow indicates cold stagnation, deep and rapid indicates heat, deep and solid indicates stubborn phlegm, deep and firm indicates internal knotting. The treatment for stagnant phlegm: for cold stagnation, use pungent dispersing agents like Xiangxiong Two Old Ingredients Decoction; for heat stagnation, use clearing and resolving agents like Zhilian Two Old Ingredients Decoction. For lung channel stagnant phlegm, use Jiezhai Resolving Phlegm Pill with kelp and Danxing."
2. Danxi Xinfa‧Six Stagnations: "Phlegm stagnation causes panting upon movement, and the wrist pulse is deep and slippery."
3. Leizheng Zhicai‧Stuffiness and Fullness: "Dysphagia and stuffiness are due to phlegm and qi wrestling, unable to disperse and flow freely. Phlegm is agitated by qi to rise, and qi is hindered by phlegm to stagnate, hence stuffiness and dysphagia form. Use Coptis Regulating Decoction and Fresh Ginger Heart-Draining Decoction."