Phlegm is a concept that carries different connotations depending on which healing system and perspective you are viewing it from. There is one outstanding consistent characteristic of phlegm, and that is its growing predominance as an imbalance in modern society, both in superficial and deep-rooted manifestations.
Poor nutrition can often be found at the root of phlegm regardless of how it is examined. There are many contributing factors to this including individual financial strain, changes in agricultural practices, hurried and stressful lifestyles, competing priorities, poor habituated food choices and preferences, and lack of awareness and knowledge. Poor nutrition results in dysfunction of cellular metabolism, which is reflected in all current herbal healing knowledge bases as a major root of disease. In Ayurveda phlegm is commonly linked to poor agni (digestive fire or the ability to metabolize nutrients) and the accumulation of ama (toxic waste) in the system. In Western Herbalism, phlegm is often linked to poor immunity. In TCM, we see Phlegm as a manifestation of both visible and invisible types. In the below comparisons of what phlegm means and how it develops we will explore its common related ailments, and how to treat them with herbs and nutrition.
Western Perspective of Phlegm
From the Western herbal perspective, phlegm evolves from and is a pathological transformation of mucus. Mucus is a normal liquid substance in the body that acts to lubricate and provide a protective barrier to tissue surfaces such as mucous membranes, internal organs, ligaments and joints/bones.
Mucus lines the entire digestive tract from mouth to anus, the respiratory tract from nasal passages to bronchioles and alveoli, and the joints where bones meet, to name a few locations in the body. In its normal state, mucus protects the stomach and digestive organs from harsh acids, the bronchioles and lungs from invading pathogens (that get trapped and expelled) and dry air, and the joints, bones, and cartilage from abrasive wear and tear.
In the Western medical paradigm phlegm usually refers to the pathological (dysfunctional) transformation of mucus in the respiratory tract from a thin, clear and slightly sticky protective fluid barrier, to a thicker, stickier, often colored substance that contains dead cells, pathogens, and sometimes blood. This phlegm is often difficult to expectorate and can, therefore, cause obstruction of the airways and associated signs and symptoms like shortness of breath, cough (productive and non-productive), headache, heaviness in the chest and head, fever, and sneezing amongst others. In Western allopathic medicine, typically phlegm is assessed for color and thickness to determine possible pathogenic origins, and culture and sensitivity tests can be done to confirm this.
Western Herbs for Phlegm:
Western herbal treatment strategies generally involve expectorants, antitussives, lymphatics, antimicrobials, demulcents, and emetics. These herbs move and expel phlegm from where it is seated, eradicate infection and sedate spasmodic cough. Some of these Western herbs include yerba santa, grindelia, licorice, hyssop, lobelia, mullein, wild cherry bark, elecampane, slippery elm, sweet violet, comfrey, horehound, marshmallow, lungwort, pleurisy root, coltsfoot, and elderberry.
TCM Perspective of Phlegm
The TCM perspective on Phlegm includes a broader concept than the Western and generally can apply to locations and manifestations in the entire body and its parts and constituents, including the more subtle aspects such as channels and meridians. Here I will mention briefly that the Chinese medicine concept of organs differs from the Western concept in that each “organ” is not just a literal reference to the biological structure, but includes a broad range of functions that are often interwoven with other cellular and organ functions in the body. The organs and their respective patterns/imbalances in TCM are capitalized to allow the distinction that we are referring to the broader concept.
Briefly, there are Yin and Yang organs that are paired and share complementary functions as a “husband and wife” team. Heart, Liver, Spleen, Kidneys, and Lungs are Yin organs, and Small Intestines, Gallbladder, Stomach, Bladder, and Large Intestines are the respective corresponding Yang organs. There is also a “theoretical” organ called the Triple Warmer or Triple Burner, which is thought to regulate fluid distribution throughout the body.
Other important concepts in TCM include Qi (the fundamental life force and vital energy of all things), Blood (warms, moistens and nourishes the body), Fluids (moisten, nourish, lubricate and protect the body), Essence (basis of reproduction, growth and decline, and intimately linked to the Kidneys) and Shen (essence of Mind and Spirit, housed in the Heart). These are called the five fundamental substances, and balanced biophysical functioning is dependent on the free flow and appropriate distribution of each.
There is one outstanding consistent characteristic of phlegm, and that is its growing predominance as an imbalance in modern society, both in superficial and deep-rooted manifestations.
In TCM, Phlegm evolves out of Dampness when it congeals and stagnates becoming a chronic condition due to impaired water metabolism. Dampness is an excess of Fluids in the body resulting from dysfunction of transformation, movement, and excretion of Fluids. The aetiology of Dampness (and hence Phlegm) usually involves Kidney or Spleen Yang deficiency causing an inability of the Spleen to transform and transport Fluids and foods (its major role in the body), and impairing the Kidneys’ ability to control and regulate Fluids and convert them to Qi, as well as hold the Qi down. Qi Deficiency or Stagnation is a key factor in the development of Phlegm, and either can perpetuate the other.
The Liver is also involved in accumulating Dampness, as the Liver metabolizes body Fluids and regulates the smooth flow and direction of Qi throughout the body (its major role). Liver Qi Stagnation may impair Spleen and Kidney function as Qi and Blood fail to be circulated properly, affect the emotional state causing anger, frustration, and depression, and fail to remove Stagnant Qi from the Triple Warmer which regulates Fluid distribution, as well as clear water passages. The Triple Warmer may fail to transport and distribute Fluids due to blockages.
Finally, the Lungs regulate Fluid and water and their dispersal and descent in the body, as well as assist in the formation and circulation of Qi. Impairment of function of any of these organ processes can lead to water and Fluid retention and Dampness, eventually transforming to Phlegm which further aggravates organ function and perpetuates a feedback loop. As an example, Phlegm can alter the flow of Qi, causing the innate and natural direction of Qi in different areas to reverse, counterflow or stagnate, as in Lung and Stomach Qi ascending instead of descending, with symptoms like shortness of breath, wheezing and vomiting.
Related to the above causes is the key underlying factor of malabsorption, with nutritional factors being a large influence. Also influences such as stress and unreleased emotional excess, sedentary lifestyle, humid environment, endogenous and exogenous Heat and Cold, and Wind can play a role in Phlegm development. Cold will slow Qi circulation and organ processes and cause Stagnation of Fluid transformation. Heat will congeal Dampness into Phlegm, and this sometimes happens following an invasion of External Wind (exogenous pathogens) causing dysfunction of the Stomach and Spleen. When residual Phlegm remains in the Lungs it can become chronic.
As previously mentioned, Phlegm occurs anywhere in the body in the TCM paradigm. Some manifestations include the circulatory system (arterial plaques and cholesterol), brain (amyloid plaques and dementia), adipose tissue (cellulite), respiratory system (chest pains, shortness of breath, wheezing), GI tract (nausea, vomiting, loss of appetite), lymphatic system (swollen glands, goitre). In TCM, associated Western diagnoses might include CVA/stroke, heart attack/MI, Alzheimer’s disease, pneumonia, TB, asthma, gastritis, cancer, fibrocystic disease, fibroids, and lymphoma.
Herbal and nutritional treatment of Phlegm in TCM depends on the presenting pattern and location of Phlegm. Herbs to resolve and transform Phlegm, drain Dampness, course/move the Qi, open the orifices, dissipate nodules, tonify Deficiencies, and dispel Wind/Cold/Heat Damp are general categories. Generally, digestion and absorption must be improved and the digestive fire restored via carminative herbs, and diet instituted appropriate to the type of Phlegm (Hot or Cold) and underlying patterns. Avoidance of Phlegm producing foods like dairy, white sugar, greasy food, excessive alcohol, cold foods, and wheat and flour products is recommended. Staying active and exercising daily is also important to break Stagnation and maintain circulation and movement of food, Fluids, Blood, and Qi. However, overwork should be avoided as it can lead to Spleen weakness.
TCM Patterns That Cause Phlegm:
As mentioned above Phlegm is caused primarily by Dampness that is unchecked and congeals into Phlegm. Dampness can be related to External Pernicious Influence (External Dampness) or can be Internal Dampness. Dampness can combine with Heat, Cold, and Wind and stagnate and congeal to create various patterns of Phlegm (Wind, Cold, and Heat Phlegm). There are numerous organ imbalances and patterns that can influence the formation of Dampness and Phlegm that were already discussed in the previous section, but they all are caused by or lead to Damp:
- External Damp (Wind-Heat-Damp or Wind-Cold-Damp): Damp Pernicious Influences include invading pathogens that cause dysfunction in regulation of organ Qi, Yin, and Yang, causing Dampness and Phlegm (specific organ patterns mentioned previously). Also, an improper diet of cold, oily and refined foods can be a factor in External Damp accumulation. Stomach symptoms can develop such as nausea, vomiting, anorexia, and loose stool. Spleen Yang may be unable to transform and transport Fluids and food, resulting in symptoms of Dampness such as diarrhea and edema. Wind-Heat can invade the Lungs causing sputum, congestion, and cough initially and later congealed Dampness and retained chronic Phlegm. Humid environments of either the Cold or Hot type can aggravate and perpetuate Dampness. External Dampness tends to be acuter but can linger and eventually develop into more chronic Internal Dampness. Other symptoms of External Damp include fever not relieved by sweating, heavy vaginal discharge, cloudy urine, chest/abdomen tightness or constriction, oozing skin eruptions, heavy diarrhea, aversion to cold, discharges that are cloudy, turbid or sticky, achy sore limbs and body, and no thirst. The tongue coating is slippery and the pulse is slippery and floating. Herbal treatment for External Cold Damp includes warm, spicy, carminative herbs such as pepper, ginger and cinnamon, and those that drain Cold Damp like yerba mansa, angelica, and sassafras. Treatment for External Hot Damp includes cool and spicy herbs such as mint, basil, coriander, chrysanthemum, and wintergreen. Formulas like Magnolia and Hoelen combination to dispel Spleen Damp and restore agni are used to treat External Damp.
- Internal Dampness (Damp-Heat or Damp-Cold): Internal Dampness occurs when the organs (especially the Spleen) become unable to regulate Fluid metabolism adequately due factors like chronic accumulation of External Dampness and poor diet of cold, oily and refined foods. This is especially predominant in modern Western culture. The Qi and Yang function of organs like Spleen, Kidney, Liver, and Lungs responsible for Fluid metabolism become obstructed and further compromised, and Water and Fluids (lymph) stagnate and congeal, and diseases of Damp and Phlegm occur in various parts of the body. Internal Damp also combines with Heat or Cold similarly to External Damp. Internal Damp symptoms can include those of External Damp, plus edema, nausea, poor appetite, indigestion, vomiting, and possibly nodules and cysts. The pulse is soft, thready and slippery, and the tongue has a creamy coating. Herbal formulas like Citrus and Pinellia Combination dispel Dampness, regulate Spleen and Stomach, and resolve Phlegm.
In TCM, there are 2 general classifications of Phlegm:
Substantial Phlegm is described as condensed Phlegm. It commonly occurs in the Stomach, digestive organs, and respiratory system, but can appear in various organs and tissues. It is visible, palpable, and audible. In other words, it is directly perceptible to the senses. It is Phlegm manifesting on the physical level. Substantial Phlegm causes swellings and conglomeration such as cysts, nodules, lumps, tumors, fibrous tissue swellings, and swollen lymph nodes/scrofula. It is also sputum and borborygmus. Substantial Phlegm is considered accumulating Phlegm.
Insubstantial Phlegm is not visible, palpable or audible. It is not directly perceptible to the senses and is hidden. However, there are pathological manifestations of Insubstantial Phlegm. It combines with other influences to create patterns of Wind-Phlegm, Cold-Phlegm, Hot-Phlegm, and Turbid-Phlegm. Insubstantial Phlegm is often related to symptoms of brain, nerve and consciousness dysfunction due to “Phlegm-mist”, and also affects the Heart. Often it is seen disturbing the Shen as a mental-emotional manifestation of Phlegm. The symptoms are dizziness, coma, stroke, mania, convulsions, psychosis, lockjaw, stiffness, sudden sensory loss, and dementia. “Phlegm misting the Heart orifices” and “Phlegm misting the Mind” are the associated imbalances. Insubstantial Phlegm can hide in various areas of the body and is difficult to treat. It is considered dispersing Phlegm.
How Phlegm Relates to the Metal Element in TCM:
In the TCM 5 phases or 5 elements theory, the Lungs and Large Intestines belong to the Metal element. The Lungs and Large Intestines are known as the “containers” for Phlegm. Earth (Spleen and Stomach) is the mother of Metal. Therefore, we say that Earth nourishes Metal. When Dampness overflows the Earth element due to Spleen Deficiency, it is contained in the Metal element and causes symptoms like diarrhea, mucusy stools, respiratory phlegm, and runny nose.
The emotions related to Metal element are grief and sadness, both contributors to stress, as well as the ability or inability to “let go”. In TCM excessive or pent-up grief and sadness (as well as other emotions) can injure the Lungs resulting in conditions like bronchitis and pneumonia, which involve Phlegm.
The Metal season is Autumn, during which time it is common to see complaints of Dampness or mucus in the Lungs and Large Intestines.
Metaphorically speaking, the energy of Metal is considered alchemical and transformative. A physical analogy for this is the breath, which has the power of transformation via sustaining focus and concentration and moving Qi to awaken awareness. Through this, we can receive vitalization of Life Force Energy and spiritual upliftment. The Lungs are the seat of “Po”, the Corporeal Soul, the manifestation of the breath of life and Qi, which bridges or connects our physical and spiritual being. If our breath and hence connection to the Life Force is out of sync, we see Phlegm induced pathologies like asthma, allergies, and pneumonia, which are also related to the actual physical phenomena of being out of breath.
Deficient Metal constitutional types often are unable to resist external pathogens and climatic influences, like cold air, allergens or microbes. Imbalances such as asthma, emphysema, and allergies are frequently seen. The Wei Qi (defensive immunity) is weak. There may also be a lack of peristalsis and energy to affect bowel movements.
Excess Metal constitutional types more often manifest Hot or Cold Phlegm in the form of congestion, stagnation, and allergies. There is a need to release the overflow of excess Earth to eliminate the Phlegm and symptoms. We see a similar theme in the underlying associated emotional aspect of Metal, in which grief and sadness can represent “letting go”.
TCM Herbs for Phlegm:
In TCM herbs used to treat Phlegm and the underlying causes and co-existing patterns include diuretics that drain Dampness, anti-rheumatics that dispel Wind-Damp, expectorants, antitussives, anti-asthmatics, herbs that regulate Stagnation if Qi, Blood and Fluids, herbs that calm Shen, and other categories. Many of the above mentioned Western herbs are used, as well others such as bamboo sap and sugar, fritillary, honey locust fruit pod, pinellia, magnolia, platycodon, loquat leaf, angelica root, sigesbeckia, Chinese skullcap, calamus root, reishi mushroom, and Chinese licorice. Well known TCM formulas to treat Phlegm include those such as du huo and loranthes combination.
Phlegm in Ayurveda
Phlegm is closely related to the concept of ama in Ayurveda. Ama is the accumulated toxic waste in the body caused by improperly digested or metabolized particles that block channels or srotas. The srotas govern the processes of metabolism in the body, and imbalance occurs as when similarly in TCM, there is impaired flow of nutrients, waste, and energy through them. This can include excess, deficiency, wrong direction of flow, wrong place of flow, and blockages. Ama accumulates where there is weakness in the body – similar to the Deficiency/Phlegm relationship in TCM. Low digestive agni (fire), low tissue agni, and resulting inability to metabolize and excrete waste products and toxins all produce ama.
Phlegm is a manifestation of Kapha energy (earth and water), and is more easily provoked in the Kapha constitution, although anyone can experience Kapha and phlegm accumulation. In Ayurveda, a general approach is to reduce and balance Kapha by increasing Pitta (fire) and restore agni. Since Kapha is heavy, cold and wet, light, dry, warming, and stimulating energies are required to counteract its effects. There is a focus on the pungent/spicy and bitter flavors (and occasionally astringent) in foods and herbs to accomplish this, as well as some specific herbs like guggul which break up ama and move Qi.
Ayurveda includes some symptoms and conditions of ama that are similar to those of TCM Phlegm: tongue coating, stickiness of body fluids, bloating, gas, pains, fatigue, any kind of stagnation in the channels, and specific symptoms of tissues and organs such as arteriosclerosis and plaques and high cholesterol, tumors, arthritis, endometriosis and nervous disorders.
Ayurvedic Herbs for Phlegm:
Diuresis, diaphoresis, and draining Damp are major strategies of the Ayurvedic approach to treating phlegm, as is improving digestion and metabolism. In Panchakarma therapy, emesis is considered the strongest way to eliminate Kapha, as its natural seat in the body is the stomach. Ayurvedic herbs used to treat phlegm include asafoetida, ajwan, turmeric, saffron, coriander, camphor, vasa, anthrapachaka, gokshura, bamboo, jatamansi, punarnava, angelica, pippali, cardamom, cinnamon, cloves, ginger, garlic, calamus, nutmeg, and guggul. Well-known formulas for phlegm include trikatu, sitopaladi, and the various guggulu formulas like yogaraj guggulu and punarnava guggulu.
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