Cough

Cough

When water essence is evenly distributed throughout the body, the water channels are unobstructed, liver qi flows smoothly, and kidney qi remains stable, there will be no cough. Blood is the yin essence transformed from fire, while water essence is the yang essence transformed from qi; the two naturally complement and nourish each other. If water fails to nourish fire, blood will be damaged; if blood fails to nourish qi, water will be depleted. When water is depleted, water essence cannot moisten the lungs, and when lung blood is damaged, fire will overpower metal. With metal overcome by fire, it loses its ability to regulate and control, allowing qi below to flow upward. Once qi flows upward, water essence cannot follow and distribute downward, leading to condensation into phlegm. The excess water below, carried upward by qi, turns into fluid retention, both of which contribute to coughing. I have already discussed hemoptysis in detail in the section on coughing, and here I reiterate the examples listed below for easy reference.

First, when lung essence is deficient and fire qi takes advantage of this weakness, dry cough develops, accompanied by choking and sticky phlegm or traces of blood. Over time, this can lead to lung wasting, which can be treated with Qingzao Jiufei Tang.

Second, when phlegm and fire condense, causing coughing, choking, and phlegm buildup in the throat due to stagnation of water essence blocking the airway, treatment should focus on clearing phlegm and nourishing water essence, with Ziyuan San being the preferred remedy.

Third, when fluid retention surges into the lungs, causing severe coughing and difficulty breathing, this is often due to excessive wind-fire in the liver of someone who has lost blood, which stirs up water and forces it upward into the lungs. When lying down, the lung lobes expand, further pushing the fluid upward, making it impossible to breathe comfortably. In such cases, Tingli Dazao Xiefei Tang is the appropriate treatment. I usually combine Erchen Tang with suzi, bupleurum, white mustard seed, scutellaria, gypsum, apricot kernel, schizonepeta, peppermint, and loquat leaf to effectively treat fluid retention in the lungs. This differs from coughs caused by cold-induced fluid retention in other diseases. For cold-induced fluid retention, treatments like Xiaoqinglong Tang and Zhenwu Tang are more suitable. Coughs associated with blood disorders are often caused by internal wind-fire stirring up water, which is precisely what Xiaoqinglong and Zhenwu avoid; physicians must distinguish between these conditions.

In fact, coughs caused by deficiency and exhaustion stem from fire overpowering metal and water invading the lungs, but if we delve deeper into the root cause, we find that the problem lies in the stomach. The stomach is the sea of food and grain, where water and blood are produced; if blood is insufficient, fire becomes overly strong, and if water essence is not generated, the lungs become dry. If water metabolism is impaired, fluid retention accumulates and rises upward, interfering with lung function. To treat stomach fire, Baihu Tang combined with shengdi, baihe, and wuweizi is recommended, or Yunu Jian can also be used. For stomach phlegm, Guntan Wan and Zhimi Fuling Wan are effective, with Huotan Wan being suitable for mild cases. For stomach fluid retention, Erchen Tang combined with suzi, tai jie zi, fang ji, zhi ke, apricot kernel, and ginger is recommended; if the fluid retention is accompanied by fire, add bupleurum, scutellaria, angelica, and white peony.

According to the "Inner Canon," all five viscera and six bowels can produce coughs (1). However, all these coughs ultimately converge on the stomach and lungs, as discussed in the previous section on treating the stomach and lungs. There is one formula that can effectively treat both the stomach and lungs: Xiao Chaihu Tang. For excessive lung fire, add mai dong; for excessive heart fire, add huang lian and angelica; for excessive liver fire, add angelica and huang lian; for evening coughs caused by fire floating in the lungs, add wubeizi and wuweizi to contain it; for early morning coughs caused by food stagnation that flows into the lung meridian by the hour of the tiger, add laibuzi; for those with phlegm condensation and qi stagnation, add gualou shuang, xuanfuhua, apricot kernel, jiegeng, shegan, and chuanbeimu; for those with fluid retention rising upward, add tinglizi, sangbaipi, xixin, and wuweizi; for those with cold, add ganjiang and yunfuling; and if there is also an external pathogenic factor, such as fever, chills, nasal congestion, headache, and cough, Xiao Chaihu Tang combined with jingjie, zisu, apricot kernel, and peppermint is recommended. Xiao Chaihu Tang can harmonize water essence, disperse stagnant fire, elevate the pure and descend the turbid, adapting flexibly to different situations, and its adjustments are perfectly balanced, fully demonstrating its excellence.

There are also cases of coughing due to phlegm and blood, where the patient experiences severe coughing and difficulty breathing, similar to the situation of fluid retention in the lungs. This is because the human airway should not be blocked. If there is blood stasis, it obstructs the airway, preventing normal airflow, thus leading to coughing. Airway obstruction means water obstruction, and since air is water, water obstruction leads to phlegm formation. Phlegm is blocked by blood stasis, which further exacerbates the impact on the lung meridian, causing the lung to expand again when standing, while blood stasis descends, leaving the airway relatively unobstructed, so the cough is not too severe. However, when lying down, the blood stasis reverses, further obstructing the airway, and the lung lobes expand, making it even harder to control the cough, hence the inability to breathe comfortably. If we continue to treat fluid retention in the lungs with Tingli Dazao Tang, we are only addressing the fluid retention, not the blood stasis. It is important to understand that the blockage caused by phlegm and water is due to blood stasis, but once the blood stasis is resolved, the phlegm and water will naturally dissipate. Therefore, we should replace Tingli Dazao Tang with Di Dang Wan combined with yunfuling and fahansha, or use Xuefu Zhuyu Tang combined with tinglizi and suzi for mild cases. There are also cases where the patient coughs more severely when lying on one side, and turning over makes the cough even worse. Many texts claim that lying on one side is a sign of untreated blood-related cough, but they fail to recognize that the root cause is still blood stasis. Since blood stasis tends to concentrate on one side, one side of the airway remains open while the other is blocked. The open side can lie on its side, while the blocked side becomes even more congested when lying on its side, thus worsening the cough when turning over. In such cases, Xuefu Zhuyu Tang combined with apricot kernel and wuweizi is recommended. For those who lie on the left side, since there is blood stasis on the left, they should not lie on the right side, as the blood stasis on the right will reverse and further obstruct the airway. Therefore, it is advisable to use qingpi, biejia, and ezhushi to remove the blood stasis on the left side. For those who lie on the right side, since there is blood stasis on the right, they should not lie on the left side, and it is recommended to use yujin, sangpi, and jianghuang to remove the blood stasis on the right side. All these cases of blood-stasis-related cough are rarely mentioned in textbooks, though Zhu Danxi briefly touched upon them, without providing a clear explanation. Through my clinical experience, I have come to realize the importance of speaking out loudly, aiming to revive the dead and restore flesh to bones—how could I possibly keep such vital information secret?

There are also cases of coughing caused by surging qi, where the surging pulse originates from the blood sea and travels upward along the Yangming meridian. When the blood sea is injured, the surging pulse becomes erratic, merging with the Yangming meridian and causing fiery, dry coughs. Mai Men Dong Tang and Yu Nu Jian are both effective in suppressing the surging pulse and preventing it from becoming erratic, thereby alleviating the cough.

Additionally, there are cases where the surging pulse intersects with the liver meridian's fire, ascending to the lung meridian. Patients experience dizziness, bitter taste in the mouth, and incessant coughing dozens of times, with abdominal pain accompanying the cough, and cheeks turning red. In such cases, Si Wu Tang combined with Zuo Jin Wan, along with human urine, pig bile, oysters, and wuweizi, is recommended. Since the liver is responsible for the blood room, and the surging pulse originates from the blood room, the fire in the liver meridian can ascend via the surging pulse. Xiao Chaihu Tang combined with wuweizi, qingpi, longgu, oysters, danpi, and digupi can also be used to treat such cases, with heavier cases requiring huang lian.

Although the surging pulse originally belongs to the liver meridian, its manifestation is in the Yangming meridian, while its root lies in the kidneys. The surging pulse originates in the cell, and kidney qi resides in the cell. Kidney qi rises to the lungs for respiration, and also uses the surging pulse pathway to enter the lungs, which is why the acupoint near the navel associated with the surging pulse is called "qi surge." The "Inner Canon" explicitly states that the surging pulse is a qi surge. The intersection of the surging pulse and the kidney meridian is thus established. Therefore, whenever the surging pulse encounters virtual fire in the kidneys, it ascends and causes coughing, shortness of breath, dry throat, red cheeks, and even pig ling tang combined with wuweizi, ophiopogon, niuxi, phellodendron, shengdi, and guiban, or maiwei dihuang tang to calm it down, or sancai tang combined with tie luo to stabilize it, or da bu yin wan combined with ci zhu wan and wuweizi to absorb the surging pulse and return it to the kidneys, thus preventing the cough. There are also cases where water inside the cell moves, and the surging pulse encounters water moving upward, causing coughing. In such cases, the upper part is hot while the lower part is cold, with dragon thunder fire rising, red face and swelling, dizziness, sore throat, fever, palpitations, loose stools, lower back pain, and urinary incontinence. Gui ling gan cao wuweizi tang is recommended for treatment, as is kidney qi wan. See the section on hemoptysis for more details.

The root cause of coughing lies in the lungs, while the fundamental issue resides in the kidneys. Coughs related to blood disorders are particularly common among patients with kidney deficiency. The kidneys are the root of qi; when the kidney meridian is deficient in yin, yang has nowhere to attach, qi cannot return to its roots, resulting in floating, wheezing, and coughing. In such cases, sancai tang combined with wuweizi and sandalwood is recommended. Chen Xiuyuan used er jia longgu oysters tang combined with ejiao, mai dong, and wuweizi, with only a small amount of fuzi used as a guide. I personally use zhibai dihuang tang, adding a small amount of wuweizi and cinnamon as a reward, and regularly taking du qi wan is also beneficial. For those with kidney yang deficiency, unable to metabolize water, experiencing lower back pain and short bowel movements, and suffering from wheezing and coughing, kidney qi wan combined with wuweizi is recommended. Additionally, when kidney water overflows and spleen soil cannot control it, resulting in fluid retention-related cough, this falls under the category of five types of fluid retention, not something that should occur in blood-loss patients. There are relevant books available for reference, so I will not elaborate further.

[Notes]

(1) The original text of "Suwen·Cough Chapter" reads: "All five viscera and six bowels can cause coughing, not just the lungs."

[Commentary] Coughs related to blood disorders are mostly due to deficiency and exhaustion. This article discusses the pathogenesis and diagnostic characteristics of this condition. Those who experience severe coughing and difficulty breathing are often caused by heat-induced fluid retention, where fluid rushes into the lungs, and it is recommended to use Erchen Tang combined with suzi, bupleurum, etc. If mistakenly treated as cold-induced fluid retention and given Xiaoqinglong Tang, it may result in futile efforts. Furthermore, surging pulse intersecting with liver fire, kidney fire, or water movement within the cell can all lead to coughing. For those intersecting with liver fire, use Si Wu Tang; for those intersecting with kidney fire, use Pig Ling Tang; for those intersecting with water movement within the cell, use Ling Gui Wei Gan Tang. Although many blood-related coughs are caused by fire overpowering metal and water invading the lungs, the root cause ultimately lies in the stomach. Since the stomach is the sea of food and grain, the source of water and blood production, it is crucial to focus on treating the stomach. For those with excessive stomach fire, use Baihu Tang combined with shengdi, baihe, and wuweizi; for those with phlegm and fire accumulating in the stomach, use Guntan Wan; for those with fluid retention in the stomach, use Erchen Tang combined with flavorings.

There are also cases of coughing due to phlegm and blood, which are similar to fluid retention in the lungs, arising from phlegm and water accumulation. The author believes that "phlegm and water accumulation are caused by blood stasis," so the solution is to treat the blood stasis, "but once the blood stasis is resolved, the phlegm and water will naturally dissipate," recommending replacing Tingli Dazao Tang with Di Dang Wan combined with fahansha, or using Xuefu Zhuyu Tang combined with tinglizi and suzi for mild cases. If only Tingli Dazao Tang is used to treat fluid retention, the cough will never truly heal. The article also emphasizes that "the root cause of coughing lies in the lungs, while the fundamental issue resides in the kidneys," and that blood-related coughs are particularly common among patients with kidney deficiency, so treatment must focus on the kidneys. For those leaning toward yin deficiency, use sancai tang combined with wuweizi and sandalwood; for those leaning toward yang deficiency, use kidney qi wan combined with wuweizi.

In summary, this article demonstrates through clinical practice the validity of the "Inner Canon's" assertion that "all five viscera and six bowels can cause coughing, not just the lungs," and proposes the pathological mechanisms and treatment principles for coughs caused by blood stasis and surging pulse.

---

Fever

Patients with hemoptysis generally have a quiet pulse and cool body temperature, and can recover without medication, because although yin is deficient, yang is not overly strong, and yin and yang are still in harmony, making recovery relatively easy. Alternatively, if there is a slight fever and sweat appears on the skin, this indicates yang seeking yin and water seeking blood, and can also resolve on its own. The term "fever" is different from having a slight fever.

For patients who have lost blood, yang qi is trapped within the blood, causing internal heat to build up (1), but with sweat appearing on the head. The reason for this is that the heat is confined inside and cannot escape outward. However, when sweat appears on the head, it indicates that the fire is rising upward, and since the exterior is constrained, the fire cannot spread freely, thus intensifying the heat upward while sweat appears on the head. The treatment should focus on relieving the stagnation, allowing a slight sweat to appear on the body, so that qi can reach the exterior, and yang does not overpower yin, thereby stopping the heat and treating the blood as well. This is similar to how intense summer heat can be relieved by sweating, and Xiao Chaihu Tang is the recommended treatment.

There are also cases of fever caused by blood stasis, where the blood is trapped in the muscles, causing a constant feeling of warmth, with symptoms resembling Baihu Tang—thirst, irritability, and sharp pain in the limbs. In such cases, Danggui Buxue Tang combined with Jiaji Huatu Tang, adding peach kernel, safflower, bupleurum, fangfeng, ophiopogon, and gypsum, is recommended, as is Xuefu Zhuyu Tang. When blood stasis is in the muscle fascia, there is alternating cold and heat, as the muscle fascia serves as a semi-inner, semi-outer layer, with yin inside and yang outside, mutually overcoming each other. In such cases, Xiao Chaihu Tang combined with dangu, baishao, danpi, taoren, jingjie, and safflower is recommended, and Taonu San combined with scutellaria and bupleurum is also effective. When blood stasis is in the internal organs, the blood room is in charge, with symptoms such as tidal fever in the afternoon, clarity during the day, and delirium in the evening. Since the blood room is considered the sea of blood, and its pulse is closely linked to the Yangming meridian, there are symptoms of yin-yang dry heat, which can be treated with Taoren Chengqi Tang, or Xiao Chaihu Tang combined with taoren, danpi, and baishao. When blood stasis is in the viscera, the liver is in charge, as the liver governs blood, with symptoms such as bone-steaming fever, burning palms and soles, dark eyes, and brittle hair, often regarded as difficult to treat, but in reality, it is caused by excessive blood in the liver, so Bupleurum Qinggu San combined with taoren, amber, dried lacquer, and danpi is recommended.

All of the above discussions pertain to actual cases of fever in blood-related patients. There are also cases of febrile syndromes due to deficiency, divided into two categories: blood deficiency and water deficiency, which will be discussed separately below.

For those with blood deficiency, fever and sweating occur because blood does not match qi, resulting in excess qi that leaks outward. Alternatively, fever may occur at night, as night is dominated by the blood element, or during the hours of Yin and Mao (3), when fever occurs because Yin and Mao belong to the Shaoyang phase, and when liver blood is deficient, the Shaoyang fire is most active during these hours, causing fever. Di Gu Pi San combined with bupleurum, artemisia, huang lian, yunfuling, and licorice is recommended for such cases. Additionally, if the fire in the cells is caused by insufficient blood, combining with Yangming dry qi, resulting in tidal fever in the afternoon, Xijiao Dihuang Tang is recommended.

For those with water deficiency (4), since water is transformed from qi, if water essence is insufficient, qi becomes hot, the skin becomes dry, the mouth and throat develop ulcers, spermatorrhea and urinary incontinence occur, and fever appears in the afternoon. Da Bu Yin Wan is recommended to replenish water and quench fire, or Qingzao Jiufei Tang can be used to generate water essence from the stomach and lungs, ensuring sufficient water to nourish blood, thus preventing yang from becoming overly strong and eliminating dry heat. Five Steaming Soup also controls this situation.

Furthermore, when yin is deficient internally while yang floats externally, and fever occurs, it is necessary to greatly tonify yin while also restoring yang. Therefore, postpartum fever can be treated with Si Wu Tang combined with black ginger, and blood-loss fever can also be treated similarly. For those with excessive fire, add more scutellaria and huang lian. If kidney yin is deficient and true yang floats externally, causing fever and shortness of breath, it indicates that yin does not cling to yang and yang does not enter yin, so it is necessary to draw yang from yin, using Er Jia Longgu Tang combined with wuweizi, mai dong, and ejiao, or San Cai Tang combined with a little salt-fried cinnamon, mulberry leaves, yunfuling, baishao, winter worm summer grass, cornelian cherry, niuxi, wuweizi, ophiopogon, and sandalwood. In addition, there are cases of fever caused by food stagnation, with heat in the hands, feet, and abdomen, chest fullness, hiccups, and irregular bowel movements, especially in the afternoon and at night, when people feel restless. In such cases, zhike, houpu, and dahuang can be used to eliminate the blockage, preventing the heat from building up. Do not assume that those with deficiency have no real symptoms.

[Notes]

(1) Yu Mao: refers to feelings of depression, dizziness, and temporary fainting. According to "Jin Kui Yao Lue": "New mothers... lose blood and sweat, with excessive cold, leading to depression and fainting."

(2) Bian: same as bian.

(3) Yin and Mao hours: 3–5 a.m. is Yin hour, 5–7 a.m. is Mao hour.

(4) Water deficiency: same as yin deficiency.

[Commentary] This article divides fever in blood-related patients into two categories: deficiency and excess.

For excess cases, there are two scenarios: fever caused by qi stagnation in the blood and fever caused by blood stasis. For the former, Xiao Chaihu Tang is used to relieve stagnation and promote the outward flow of yang qi. For the latter, depending on whether the blood stasis is in the muscles, muscle fascia, viscera, or internal organs, different treatments are applied: Danggui Buxue Tang combined with Jiaji Huatu Tang, Xiao Chaihu Tang combined with dangu, baishao, danpi, Taoren Chengqi Tang, and Bupleurum Qinggu San combined with taoren, amber, dried lacquer, and danpi. In addition, there are cases of fever caused by food stagnation, with symptoms such as hiccups in the afternoon, irregular bowel movements, and restlessness, which can be treated with nitro-gold laxatives.

For deficiency cases, there are two categories: blood deficiency and water deficiency. For blood deficiency-related fever, Di Gu Pi San combined with bupleurum, artemisia, huang lian, etc., is used to tonify yin and blood and dispel虚热. If the fire in the cells rises to the Yangming meridian along with the surging pulse and causes fever, Xijiao Dihuang Tang is recommended. For water deficiency-related fever, Da Bu Yin Wan is used to replenish water and reduce fire, or Qingzao Jiufei Tang is used to generate water essence and moisturize the blood. For those with yin deficiency internally and yang floating externally, it is recommended to adopt a strategy of tonifying yin and subduing yang, using Si Wu Tang combined with black ginger, or Er Jia Longgu Tang combined with wuweizi, mai dong, and ejiao.

This article provides a fairly detailed discussion of fever caused by blood stasis, which has significant clinical guidance value.

---

Cold Extremity

In general diseases, cold extremities are caused by yang deficiency in the spleen and kidneys, preventing qi from reaching the four extremities, and Si Ni Tang is the recommended treatment. However, for patients who have lost blood, occasional episodes of cold extremities may also occur, often due to internal heat invasion, hidden deep within the body, presenting as apparent coldness on the surface, with a body as cold as water, dim vision, absent pulse, or sudden cold followed by fever, or prolonged cold spells alternating with fever. In cases where cold extremities are accompanied by excessive heat, it indicates that yang is extremely strong and resembles yin, meaning the heat has reached its peak; whereas in cases where cold extremities are accompanied by minimal heat, it suggests that the hidden heat is still being released, indicating that the heat is relatively shallow. This aligns with the principle stated in "Shanghan Lun·Jue Yin Chapter": "The deeper the heat, the deeper the cold; the shallower the heat, the shallower the cold." Since the jue yin liver meridian harbors gallbladder fire, when the disease occurs, the fire hides in the yin and causes cold extremities; when the fire emerges in the yang, it results in fever. Fever is indeed a sign of excessive fire, but when cold extremities occur, it means the fire is hidden within the body and even more intense. Therefore, the first step is to treat the hidden fire, allowing the fire to emerge and turning cold extremities into fever, followed by further cooling the heat, only then can the condition be cured. If one mistakenly assumes that cold extremities in general diseases are caused by external cold and uses warming medicines, it will only hasten the patient's demise. The distinguishing feature is that cold extremities in general diseases are accompanied by continuous vomiting and diarrhea, weak pulse, and lack of heat, while cold extremities caused by hidden fire show signs of heat after the cold subsides, with an unpleasant taste in the mouth, loose stools, unclear urination, heartache and heat, restlessness, aversion to light and preference for darkness, thirst for drinks, and bleeding from vomiting and nosebleeds—all indicative of true heat disguised as cold. First, use Qinghua Tang combined with Shengjiang San to attack the hidden fire, or use Danggui Aloe Vera Wan to combat it, followed by Five Steaming Soup to further cleanse the remaining heat. If the cold extremities persist despite treatment, use Da Bu Yin Wan or Dihuang Tang to tonify yin. For cases of cold extremities caused by external cold that prevents the fire from emerging, use Zhongjing Si Ni San combined with jingjie, huang lian, and kuqin. For those whose yang is trapped inside and cannot escape, use Bai Tou Weng Tang to clear the way, and Shengyang San Huo Tang to warm and release the fire; both methods should be used appropriately based on the specific situation.

In blood-related patients, fever is often true heat disguised as cold, but there are also cases of true cold. Excessive blood loss causes qi to leak along with the blood, resulting in weakened middle qi and insufficient original qi, leading to cold extremities, loss of appetite, and loose stools—this is a manifestation of deficiency giving rise to cold. The appropriate treatment is warming and tonifying, with Shi Quan Da Bu Tang, Shen Fu Tang, and Yang Rong Tang used as needed.

[Commentary] Cold extremities in blood-loss patients are often true heat disguised as cold, fundamentally different from cold extremities caused by yang deficiency in general diseases. The former is often accompanied by intermittent cold and heat, restlessness, and thirst—symptoms of internal heat—while the latter is characterized by cold without heat, continuous vomiting and diarrhea, and weak pulse—symptoms of yang deficiency. For blood-related patients with cold extremities, it is recommended to first use Qinghua Tang combined with Shengjiang San or Danggui Aloe Vera Wan to treat the hidden fire, followed by Five Steaming Soup to cleanse the remaining heat. If one mistakenly uses Si Ni Tang-like remedies, it may only exacerbate the situation. In cases of excessive blood loss, true cold extremities may also occur, with profuse sweating and yang deficiency, in which case emergency measures such as large doses of Shen Fu Tang should be taken to quickly restore yang, followed by continued use of Shi Quan Da Bu Tang-type remedies.