Expectoration refers to the expulsion of phlegm through coughing, that is, the phlegm from the lungs and the respiratory tract (trachea), which is expelled through the throat and mouth via coughing. The ancient character for phlegm (痰) was the same as that for "thin" (澹), meaning "the appearance of water shaking" (Shuowen). Therefore, all conditions of water retention in the body (such as in the intestines, chest, flanks, or limbs) were referred to as phlegm or phlegm-fluid retention, which also means water or fluid retention. The phlegm produced by the lungs and respiratory tract was anciently called "saliva" (涎), "foam" (沫), "spittle" (唾), or "turbidity" (濁) (Jingui Yaolue).

Generally, the clearer and thinner ones could be called saliva or foam, while the stickier and thicker ones could be called spittle or turbidity. These saliva, foam, spittle, and turbidity are also formed due to the failure of water-dampness to transform, leading to the accumulation of phlegm in the lungs. Later generations referred to saliva, foam, spittle, and turbidity as phlegm or phlegm-fluid retention, with the clearer and thinner ones called "fluid" (飲) and the stickier and thicker ones called "phlegm" (Yizong Jinjian). Therefore, phlegm can be understood in a broad or narrow sense. In the broad sense, phlegm refers to water, and phlegm-fluid retention refers to fluid retention. In the narrow sense, phlegm is the product of the lungs and respiratory tract, with the thicker ones called phlegm and the thinner ones called fluid. This section only discusses the narrow sense of phlegm, or phlegm-fluid retention, expelled through coughing.

bubble_chart Pattern Analysis

1. Lung Heat︰The sputum is yellow, sticky, and lumpy, or mixed with blood. Symptoms include fever, cough, chest pain, panting, or flaring nostrils, red face, red eyes, red and swollen sore throat, thirst, dry lips, scanty dark urine, dry stool accumulation, a red tongue with yellow coating, and a slippery-rapid or rapid-strong pulse. It is mostly caused by external contraction of pathogenic heat. The clinical characteristics are: if caused by dampness-heat, large amounts of purulent sputum or purulent-bloody sputum are expelled; if caused by pathogenic heat, yellow sputum or sticky lumpy sputum is expelled. Common symptoms include high fever, red face, red eyes, yellow urine, and dry stool. The tongue is red or deep red with a dry yellow coating. The treatment and medication are the same as before.
2. Lung Cold︰The expectorated phlegm is white and thin, the patient has chills and cold limbs, severe aversion to cold with mild fever, cough and chest pain, panting, a pale or bluish complexion, or even a darkish face, coughing and dyspnea in a semi-reclining position, shortness of breath preventing lying down, a pale or purplish-dark tongue with white slippery coating, and a deep wiry or tight pulse. It is often caused by exposure to cold and consumption of cold drinks, leading to internal retention of cold fluid, or constitutional yang deficiency with exuberant yin, where cold pathogens lurk in the lungs and are triggered by wind-cold. In lung cold, the coughed-up phlegm is white and thin. It is mainly accompanied by cold symptoms, such as chills and cold limbs, pale face and clear eyes, a pale tongue, and a deep wiry pulse. Treatment should involve Apricot Kernel and Perilla Powder or Canopy Powder with modifications.
3. Wind Pathogen Invading the Lung︰The sputum is thin and foamy, accompanied by fever and chills, cough, nasal congestion, runny nose, dry and itchy throat, headache, and body pain. The tongue tip and edges are red with a thin white coating, and the pulse is floating-tight or floating-rapid. This is mostly due to external contraction of wind pathogens, which may be wind-heat or wind-cold attacking the lungs. The lungs, being a delicate zang-organ, once invaded by wind pathogens (wind-cold or wind-heat), result in the failure of lung qi to disperse, leading to fluid retention and the formation of phlegm-turbidity, causing coughing with phlegm. Wind pathogens invading the lungs belong to an exterior pattern, manifesting as cough, nasal congestion, runny nose, itchy throat, along with headache, fever, and chills. If wind-cold attacks the lungs, there is severe aversion to cold, mild fever, and absence of sweating. If wind-heat attacks the lungs, there is severe fever, mild aversion to cold, redness, swelling, and pain in the throat, aversion to wind, sweating, a thin white or thin yellow tongue coating, and a floating-tight or floating-rapid pulse. For wind-heat invading the lungs, the main treatment is Mulberry Leaf and Chrysanthemum Decoction. For wind-cold invading the lungs, Inula Herb Powder with modifications can be used.
4. Lung Dryness Due to Yin Deficiency︰The sputum is scanty, sticky, and difficult to expectorate, or the cough is accompanied by bloody sputum or hemoptysis. If caused by dryness pathogens, it may be accompanied by fever or aversion to wind and cold, chest pain, parched lips, dry nose, dry throat, and thirst. If caused by yin deficiency, symptoms may include a feverish feeling in the palms and soles, restlessness and insomnia, tidal fever and night sweats, flushed cheeks, a bright red tongue with little coating or a yellow and dry coating, and a floating-rapid or deep-thin-rapid pulse. The disease etiology may be due to external contraction or internal damage. External contraction of warm-heat pathogens damages the lungs and scorches fluids, leading to yin deficiency and lung dryness, or chronic cough disease depletes lung yin, resulting in lung qi failing in its purifying function and lung qi ascending counterflow, hence producing dry sputum (thick and difficult to expectorate, or bloody). Cough with phlegm due to dampness invading the lungs is mostly caused by spleen deficiency, as "the spleen is the source of phlegm, and the lung is the container of phlegm." Spleen deficiency impairs transportation, leading to the accumulation of dampness into phlegm, which then ascends to the lungs and causes cough with phlegm. The clinical manifestations of the two conditions differ: the former presents with scanty, sticky sputum that is difficult to expectorate, sometimes hemoptysis or bloody sputum, often accompanied by yin deficiency symptoms (flushed cheeks, dry throat, dark urine, dry stools, tidal fever and night sweats, a red tongue with little coating, and a thin-rapid pulse, etc.). Treatment may involve modifications of Dryness-Clearing Lung-Rescuing Decoction, Enriching Yin and Clearing the Lung Decoction, or Lily Bulb Metal-Securing Decoction.
5. Dampness Invading the Lung︰The sputum is copious, white, slippery, and easy to expectorate. There is fatigue and weakness in the limbs, vertigo, drowsiness, facial puffiness, epigastric stuffiness, anorexia, loose stool, and a sweet, sticky taste in the mouth. This condition is commonly seen in prolonged cough or elderly patients. The tongue is swollen with tooth marks, dull in color, and has a white, greasy coating; the pulse is slippery and slow. The sputum is copious, white, slippery, and easy to expectorate, with rare instances of hemoptysis. It may present as spleen deficiency (anorexia, loose stool, weakness) and excessive dampness (limb fatigue, epigastric stuffiness, swollen tongue with white, greasy coating, etc.). Treatment can be modified with Two Old Ingredients Decoction combined with Three-Seed Filial Devotion Decoction.
6. Dampness-heat Accumulating in the Lung︰Coughing up purulent and bloody sputum or foul-smelling sputum, high fever or tidal fever, chest tightness and pain, difficulty turning over, or even inability to lie down due to wheezing, sweating, dry mouth and throat without thirst, dysphoria, red tongue with yellow greasy coating, slippery and rapid pulse or rapid and forceful pulse. It may be caused by external contraction of dampness-heat pathogens or preexisting phlegm-heathexcess, or excessive consumption of alcohol and dairy products, or indulgence in spicy foods, leading to dampness-heat accumulation and upward steaming to the lungs. There may also be signs of dampness-heat, such as epigastric and abdominal distension and fullness, anorexia, greasy tongue coating, etc. The main characteristics are a red tongue with yellow greasy coating. Treatment can include Lonicera and Forsythia Powder supplemented with Skullcap Root, Coptis Rhizome, etc.

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bubble_chart Documentation

1. Suwen-Ping Rebing Lun: "Emperor said: How is the disease of common cold due to overstrain? Qibo said: The method for common cold due to overstrain lies below the lungs, and the disease it causes makes people forcefully look upwards with dim vision, spit out as if it were mucus, have an aversion to wind and shiver with cold. This is the disease of common cold due to overstrain. Emperor said: How to treat it? Qibo said: To save from bending and lifting. For those with strong yang essence, it takes three days, for middle-aged people five days, and for those without essence seven days. They will cough out green-yellow mucus, which looks like pus and is as big as a pellet, coming out from the mouth or nose. If it does not come out, it will injure the lungs, and injuring the lungs leads to death."
2. Zhengyin Maizhi．external contraction phlegm pattern: "The cause of wind phlegm is external wind pathogens attacking the body's surface, binding the internal depressed fire, preventing it from venting. When external pathogens transmit internally, and internal and external steaming occurs, then the symptoms of wind phlegm arise. The pulse of wind phlegm is mostly floating and slippery; floating and rapid indicates wind-heat, floating and tight indicates wind-cold. If deep and slippery is seen, it indicates internal binding of wind pathogens; large and full is easy to treat, deep and thin is difficult to cure." "The cause of damp phlegm is either sitting or lying in low and damp places, or rushing through wind and rain, then dampness attacks the body, internally congealing with the body's fluids to form abdominal mass. Lingshu says, wind and rain attack the deficiency of yin, the disease arises from above and forms accumulations; clear dampness attacks the deficiency of yin, the disease arises from below and forms gatherings. This is the cause of damp phlegm. The pulse of damp phlegm is mostly floating and large; floating and moderate indicates wind, floating and rough indicates dampness, floating and slippery indicates damp phlegm, deep and slippery indicates stubborn binding." "The cause of dry phlegm is either excessive yang activity, encountering the fire season, dryness-heat qi dries the lung system, causing panting and coughing, injuring the intestines and stomach, causing phlegm and cough, thus external contraction dry phlegm arises. The pulse of dry phlegm is necessarily large and rapid; floating and rapid injures the exterior, deep and rapid injures the interior, left pulse large and rapid indicates dryness injuring the liver and gallbladder, right pulse large and rapid indicates dryness injuring the lungs and stomach."
3. Zhengyin Maizhi．internal damage phlegm syndrome: "The cause of dry phlegm is the fire of five emotions, sometimes moving within, or excessive sexual desire, true water drying up, or rich food accumulating heat, intestines and stomach being scorched, steaming the lungs, refining into phlegm, then the symptoms of dry phlegm arise. The pulse of dry phlegm is rapid and large in the right inch, indicating heat in the lung system; deep and rapid in the right guan indicates heat in the intestines and stomach; rapid in the left guan indicates wood-fire pathogens; deep and rapid in both chi indicates dryness exhausting kidney water." "The cause of damp phlegm is insufficient middle qi, stomach yang unable to digest, spleen yang unable to distribute, then water and grain stagnate, forming phlegm and fluid, and the symptoms of damp phlegm are formed. The pulse of damp phlegm is mostly deep and slippery; slippery and solid indicates stubborn phlegm, slippery and soft indicates deficiency stagnation, slippery but not rapid indicates spleen dampness forming phlegm, slippery and rapid indicates dampness-heat."