Exterior cold and interior thin-fluids are common allies, therefore resolving the exterior and dispelling thin-fluids must be carried out simultaneously

A patient who had once come to see Dr. Hú with a chronic cough was given xiǎo qīng lóng tāng (Minor Bluegreen Dragon Decoction) with the addition of fú líng (Poria). A senior physician asked the doctor whether he felt this gentleman’s cough was due to external contraction or to internal damage? Dr. Hú simply answered “this patient’s cough is the result of external contraction combined with interior thin-fluids, and fits a xiǎo qīng lóng tāng (Minor Bluegreen Dragon Decoction) with fú líng (Poria) presentation”. This is a complete formula, which is able to address the root cause, and treat the cough’s pattern of external contraction and interior thin-fluids. Zhāng Jǐng-Yuè pointed out that coughs can be divided into two main patterns, one being external contraction, the other being internal damage. This is how we classify them according to theory, however in clinical reality, these two patterns frequently simultaneously coexist. Internal damage can easily provoke external contraction, and external contraction can also easily bring about internal damage. Therefore, in clinical practice, one does not necessarily need to determine whether the cause is external contraction or internal damage, as long as there are definite symptoms of each, and treatment is based on pattern identification, that would be sufficient. Classifying coughs into either external contraction or internal damage is of course easy to remember for new practitioners or ones with little clinical experience, however, once faced with these presentations in clinic, one would run in to difficulties finding the right formulas. For example, if a patient presents with cough, and we were to use this aforementioned strategy, determining whether or not one should diffuse and resolve (the exterior), or supplement, and boost would prove difficult and would completely neglect treatment of one or the other pattern, prolonging and failing to treat the disease. The following case clearly elucidates this problem.

Case Study 

On January 7th, 1966, a 32-year-old female patient presented at the clinic complaining of a cough that starts every winter for the last three years. The current cough has already been going on for the last two months. A previous physician had prescribed sān ǎo tāng (Three-Unbinding Decoction), and a modified version of xìng sū sǎn (Apricot Kernel and Perilla Leaf Powder), which offered her no relief. Afterwards, she was given over twenty packages of modified zhǐ sòu sǎn (Stop Cough Formula), which had very little effect, and finally, she was prescribed a formula containing èr chén täng (Two-Aged [Herb] Decoction) combined with sān zǐ yǎng xīn tāng (three seed decoction to nourish ones’ parents), which again offered very little effect. 

Current signs and symptoms: cough, spitting up of copious amounts of white colored phlegm, an aversion to cold felt over her back, cold extremities, dry mouth with little desire to drink, chest fullness, epigastric fullness and focal distention, poor appetite, loose stools, a white-slippery tongue coat, dark tongue body, and a deep-wiry-thin pulse. 

Dr. Hú’s formula: 

má huáng (Ephedrae Herba) 3 qián

guì zhī (Cinnamomi Ramulus) 3 qián

bái sháo (Paeoniae Radix alba) 3 qián

xì xǐn (Asari Herba) 3 qián

gān jiāng (Zingiberis Rhizoma) 3 qián

zhì gān cǎo (Glycyrrhizae Radix preparata) 3 qián

wǔ wèi zǐ (Schisandrae Fructus) 4 qián

bàn xià (Pinelliae Rhizoma preparatum) 5 qián

fú líng (Poria) 4 qián 

Results: After taking three packages, her chest fullness, and spitting up of phlegm had decreased substantially. After another six packages, the cough had obviously improved. The formula was continued for another two weeks, after which the cough had completely disappeared, and her overall condition was eliminated. 

At the end of treatment, Dr. Hú once again emphasized the treatment principles for external cold with interior thin-fluids; “This treatment principle has repeatedly been stressed in the explanations of specific formula presentations such as, guì zhī qù guì jiā fú líng bái zhú tāng (Cinnamon Twig Decoction Minus Cinnamon with Added Poria and Atractylodes), and xiǎo qīng lóng tāng (Minor Bluegreen Dragon Decoction) where the root is as such”: “There are cold pathogens in the exterior, and thin-fluids in the interior. These fluids create stoppage in the interior, whereas the interior is somewhat obstructed. At the same time nothing is able to penetrate the exterior and if water is unable to be disinhibited, the exterior would be unable to resolve. If a strong sweat is promoted, or if the exterior is diffused strongly, the interior thin-fluids will be agitated and numerous signs will appear. If we simply disinhibit water, pathogens will invariably enter the interior”. In this particular case, an exterior resolving formula with medicinals to disinhibit water, and drive out thin-fluids was used, thereby, affecting both the exterior and interior. The formula used contains má huáng (Ephedrae Herba), guì zhī (Cinnamomi Ramulus), bái sháo (Paeoniae Radix alba), and gān cǎo (Glycyrrhizae Radix) to promote sweating, in order to expel exterior pathogens. bàn xià (Pinelliae Rhizoma preparatum), gān jiāng (Zingiberis Rhizoma), wǔ wèi zǐ (Schisandrae Fructus), and fú líng (Poria) drive out cold in order to eliminate interior thin-fluids. Therefore, once the exterior is resolved and interior thin-fluids removed, the cough will spontaneously cease. 

A dry cough does not necessarily mean an absence of phlegm. A formula to transform phlegm and lower qì can arrest these coughs

Patients with dry coughs are commonly seen in clinical practice, and Dr. Hú would commonly treat these patients with phlegm transforming, counterflow descending medicinals such as, Bàn Xià Hòu Pò Tāng (Pinellia and Magnolia Bark Decoction), or Líng Gān Wǔ Wèi Jiāng Xīn Xià Tāng (Poria, Licorice, Schisandra, Ginger, Asarum, and Pinellia Decoction), which can quickly arrest coughing. Because this can seem quite puzzling many of us have asked, “Since many cases of dry coughs are due to yīn deficiency or hyperactive fire, and treatment should involve enriching yīn or clearing heat and descending fire, wouldn’t this be considered an adverse treatment?” Dr. Hú would just say, “This is actually the correct treatment and not an adverse treatment”. Furthermore, he shared with us his vast experience and clinical applications of their treatment. He would say that there are many patients with dry coughs who continuously take formulas, and the coughs fail to resolve even after several months. One would view the case and identify the pattern as lung fire, or liver fire, or yīn deficiency, and treat with medicinals such as huáng qín (Scutellariae Radix), zhī zǐ (Gardeniae Fructus), shēng dì huáng (Rehmanniae Radix), zhī mǔ (Anemarrhenae Rhizoma), bèi mǔ (Fritillariae Bulbus), etc, and even after extended periods of time, there is minimal effect. What is the reason? Actually this principle is quite simple; the Chinese medicine concept of treatment based on pattern identification is used for the whole body, and not just according to one individual symptom. Phlegm and thin-fluids harassment is one of the main causes of coughing and wheezing, and the coughing up of phlegm is one basis for pattern identification, but is not the only symptom. The Chinese medical concept of phlegm and thin-fluids is quite extensive, and there are numerous cases where in an absence of phlegm, there is an absence of cough, just as there are numerous cases of cough in the absence of phlegm. We must do an overall differentiation of patterns. The following case helps illustrate this point. 

Case Study 

A 38-year-old female was first seen on Feb 12 1966. This patient had suffered with a dry cough and itchy throat for over a month. She had taken a modified version of zhǐ sòu sǎn (Stop Cough Formula), and modified versions of sāng xìng tāng (Mulberry Leaf and Apricot Kernel Decoction) and mài mén dōng tāng (Ophiopogonis Decoction). The cough not only failed to improve, but was actually getting worse. Currently she presents with a dry cough, itchy throat, dry mouth with no desire to drink, belching, chest oppression, loose bowel movements occurring once or twice daily, a thick slimy tongue coating and a slippery thin pulse. 

She was prescribed a modified version of Líng Gān Wǔ Wèi Jiāng Xīn Xià Tāng (Poria, Licorice, Schisandra, Ginger, Asarum, and Pinellia Decoction)

fú líng (Poria) 4 qián

xì xǐn (Asari Herba) 2 qián

wǔ wèi zǐ (Schisandrae Fructus) 4 qián

bàn xià (Pinelliae Rhizoma preparatum) 5 qián

zhì gān cǎo (Glycyrrhizae Radix preparata) 2 qián

chén pí (Citri reticulatae Pericarpium) 5 qián

shēng jiāng (Zingiberis Rhizoma recens) 3 qián

xìng rén (Armeniacae Semen amarum) 3 qián

jié gěng (Platycodi Radix) 3 qián

zhì pí pá yè (Eriobotryae Folium preparata) 3 qian

Results: After taking one package of the above formula, the cough had decreased. After three packages the cough stopped. 

The above patient suffered from a dry cough, itchy throat and dry mouth commonly seen in lung heat, liver fire or yīn deficiency patterns. In addition this patient also had no desire to drink, belching, chest oppression, sloppy stools, a thick slimy tongue coating and a slippery pulse. All these signify a phlegm-thin-fluids pattern. The dry cough is from phlegm-thin-fluids invading the lung and impaired diffusion and downbearing of the lung. The dry cough and itchy throat are a result of stagnation and obstruction to fluids, which are unable to bear upwards. Therefore when treating this type of dry cough, using bitter cold, heat clearing medicinals or sweet cold yīn enriching herbs will only worsen the stagnation and obstruction of fluids and cause phlegm and thin-fluids to harass the upper (burner) and delay recovery. Because phlegm was treated by restraint and the formula was chosen on the basis of the pattern, only three packages were needed for recovery. 

When diffusing the lungs and transforming phlegm is ineffective, harmonizing and resolving shào yáng can achieve surprisingly remarkable results

A common cause for coughs is the upward harassment of phlegm and thin-fluids, with the lungs losing their ability to diffuse and downbear. Therefore, a major method of treatment is to diffuse the lungs, and transform phlegm. However when treating according to this law, and our effectiveness is less than satisfactory, this is mainly because of failure to analyze the cause, poor pattern identification, or failing to use medicinals and formulas according to the pattern. There are some cases of coughs where pathogenic factors are neither in the exterior, nor the interior, but are half-exterior, half-interior. If we use methods such as diffusing the lungs, transforming phlegm, resolving the exterior and transforming thin-fluids when treating these kinds of coughs, then of course we won’t see positive results. Here, we must use the method of harmonizing and resolving the shào yáng, in order to obtain quick resolution of the condition. There is a very clear-cut account of this in the Shāng hán lùn (傷寒論 Discussion of Cold Damage) where it states in line 96: 

“When in cold damage or wind strike that has lasted for six or seven days, there is alternating chills and fever, chest and subcostal fullness, dejection with no desire to eat or drink, irritability, and frequent vomiting, or possibly irritability in the chest with no vomiting; or thirst, or abdominal pain, or sub-costal hard focal distention, or palpitations below the heart with difficult urination, or absence of thirst with mild generalized heat, or cough; xiǎo chái hú tāng (Minor Bupleurum Decoction) masters it”. 

Where it says ‘or cough’, it is mentioning it alongside the numerous signs of a xiǎo chái hú tāng (Minor Bupleurum Decoction) presentation. When we see cases of coughing, in combination with some of the other representative signs and symptoms of a xiǎo chái hú tāng (Minor Bupleurum Decoction) presentation, this formula may be used. Therefore, Dr. Hú commonly used this formula in the treatment of coughs. 

Case Study 

On March 12, 1965, a thirty-four-year old female patient presented at the clinic, complaining of a cough that has lasted for well over two years. It had previously started after contracting a common cold, and presents all year: worse in the winter, and mild in the summer. She explained that the cough would typically manifest in the late morning (10:00am), late afternoon (between 3:00pm and 4:00pm), and again in the early evening (8:00pm). She was seen at another hospital where she was given over thirty packages of a formula (containing various lung diffusing, phlegm transforming medicinals such as xìng rén (Armeniacae Semen amarum), jié gěng (Platycodi Radix), bàn xià (Pinelliae Rhizoma preparatum), guā lóu (Trichosanthis Fructus), pí pá yè (Eriobotryae Folium), qián hú (Peucedani Radix), etc.) all to no avail.  

Current symptoms: spitting up of white-frothy sputum, nausea, dry throat, absence of sweating, bilateral subcostal distension and fullness, a red tongue body, a thin white tongue coat, and a wiry-slippery pulse. In addition, she was diagnosed with tuberculosis in 1962. 

Dr. Hú prescribed a modified version of xiǎo chái hú tāng (Minor Bupleurum Decoction) 

chái hú (Bupleuri Radix) 3 qián

dǎng shēn (Codonopsis Radix) 3 qián

bàn xià (Pinelliae Rhizoma preparatum) 3 qián

huáng qín (Scutellariae Radix) 3 qián

dà zǎo (Jujubae Fructus) 4 pieces

zhì gān cǎo (Glycyrrhizae Radix preparata) 2 qián

shēng jiāng (Zingiberis Rhizoma recens) 3 qián

jié gěng (Platycodi Radix) 2 qián

bái sháo (Paeoniae Radix alba) 2 qián 

Results: After taking six packages of the formula, her cough had decreased. bái sháo (Paeoniae Radix alba) was removed from the formula, and 2 qián of zhǐ shí (Aurantii Fructus immaturus), and 4 qián each of shēng lóng gǔ (Fossilia Ossis Mastodi), and mǔ lì (Ostreae Concha) were added. After six more packages, the subcostal distension and fullness was gone. Afterwards, she was given over ten packages of a modified version of Bàn Xià Hòu Pò Tāng (Pinellia and Magnolia Bark Decoction), and her cough had completely resolved. 

The characteristics signs of this case were the cough, which occurred at specific times, the subcostal distension and fullness, nausea, and dry throat, which are all typical of a Shào Yáng presentation. We can say that with this case, the pathogenic factors were neither in the exterior, nor the interior, but lay in the half-exterior, and half-interior aspects of the body. It can also be said that in cases of enduring coughs, both the stomach qì and the defensive qì are deficient, which explains why lung diffusing, phlegm transforming medicinals would be ineffective, and unable to expel the pathogenic factors. Here we must use medicinals such as dǎng shēn (Codonopsis Radix), bàn xià (Pinelliae Rhizoma preparatum), shēng jiāng (Zingiberis Rhizoma recens), dà zǎo (Jujubae Fructus), and gān cǎo (Glycyrrhizae Radix) in order to supplement the center and strengthen the defense. Only then can the pathogens be expelled into the exterior, and once they are eliminated, the cough can resolve on its own. 

Commentary: The five cases above (see part 1 here) introduced us to five different formula presentations, and Dr. Hú’s main strategies and experience in treating coughs. Dr. Hú always utilized the method of differentiation according to formula presentations, and in the treatment of coughs, there are numerous such as, guì zhī jiā hòu pò xìng zǐ tāng (Cinnamon Twig Decoction Plus Magnolia Bark and Apricot Kernel), má xìng shí gān tāng (Ephedra, Apricot Kernel, Gypsum and Licorice Decoction), sāng jú yǐn (Mulberry Leaf and Chrysanthemum Decoction), má xìng yǐ gān tāng (Ephedra, Apricot Kernel, Coicis and Licorice Decoction), xiè xīn tāng (Drain the Epigastrium Decoction), mài mén dōng tāng (Ophiopogonis Decoction), líng gān wǔ wèi jiāng xīn xià xìng dá huáng tāng (Poria, Licorice, Schisandra, Ginger, Asarum, Pinellia, Apricot Kernel, and Rhubarb Decoction), etc. With that being said, once we encounter a specific formula presentation, we are able to employ specific formulas and medicinals to treat the condition, and must not be limited by the idea of one formula – one method.