bubble_chart Concept

Cough, also known as 咳, Suwen．The Cough Treatise specifically discusses cough and proposes the idea that "the five zang-organs and six fu-organs can all lead to cough, not just the lung." Sometimes referred to as cough, it is often mentioned alongside abnormal rising of qi, as in Suwen．The chapter on the generation of the five zang-organs states "cough abnormal rising of qi," and in the book Jingui Yaolue, sometimes "cough abnormal rising of qi" is mentioned together, and other times "phlegm-fluid retention cough" is mentioned together. Jingui Yaolue and "Han Dynasty Wuwei Medical Bamboo Slips" also refer to "cough" and "cough abnormal rising of qi." It can be seen that before the Han Dynasty, 咳, cough, and cough were synonymous, and cough was particularly closely related to abnormal rising of qi (喘) and phlegm-fluid retention, hence they were often mentioned together.

Zhubing Yuanhou Lun clearly distinguishes between cough, abnormal rising of qi, and phlegm-fluid retention, discussing each in separate sections. Among them, "Cough Disease Princes．Fifteen Discussions" points out that "cough is caused by the lung being affected by cold, and a mild case results in cough." If caused by warm and hot pathogens, it is discussed separately under "seasonal epidemic cough" and "warm disease cough." If caused by internal damage, it is discussed under "deficiency fatigue cough." Suwen Bingji Qiyi Baomingji states: "咳 refers to having sound without phlegm, caused by lung qi being injured and not clear. 嗽 refers to having phlegm without sound, caused by spleen dampness moving to produce phlegm. Cough refers to having both phlegm and sound, caused by injury to lung qi and movement of spleen dampness, resulting in cough and 嗽."

Clinically, there is no need to distinguish between 咳, 嗽, and cough, and they can be collectively referred to as cough. Cough is a clinical manifestation of lung phlegm disease. If it is phlegm-fluid retention cough, it is mostly a disease of the lung and spleen. If it is cough abnormal rising of qi, it is mostly a disease of the lung and kidney (for abnormal rising of qi and phlegm-fluid retention, see the discussions under panting and 咳痰 sections).

bubble_chart Pattern Analysis

1. External Contractionwind-cold︰The symptoms include cough, nasal congestion, clear nasal discharge, throat itching with a heavy voice, thin and white sputum, headache, fever, aversion to cold or aversion to wind, joint aching pain, thin white tongue coating, and floating-tight or floating-moderate pulse. Due to the invasion of wind-cold pathogens binding the exterior and attacking the lung, lung qi fails to disperse, leading to cough; dysfunction of lung qi and impaired distribution of body fluids result in thin white sputum and clear nasal discharge; wind-cold binding the exterior and obstructing the striae and interstice manifest as headache, fever, aversion to wind, and cold. The treatment involves dispersing wind and dissipating cold, ventilating the lung, and relieving cough. The formula of choice is Apricot Kernel and Perilla Powder with modifications. If the exterior pathogen remains unresolved while interior heat intensifies, forming a cold enveloping fire syndrome with cough, panting, dry and bitter mouth, and yellow sputum—or even cough-induced chest pain, dark red sputum, and panting more severe than coughing—it is appropriate to use Ephedra, Bitter Apricot Seed, Gypsum and Licorice Decoction with additions to clear heat with pungent-cool medicinals. If the exterior pathogen penetrates inward and transforms into heat, turning into lung heat cough, clinical differentiation is necessary. Zhengyin Maizhi·Cough distinguishes whether cold-damage disease cough has transformed into heat based on the pulse: "For cold-damage disease cough, if the pulse is floating and tight, there is no internal heat stagnation. If the pulse is floating and surging, lung heat has already stagnated. Tight with rapidness indicates cold enveloping heat."
2. Wind-heat Invading the Lung︰The symptoms include cough with difficulty expectoration, yellow or yellow-white sticky sputum. Dry mouth, sore throat, headache, nasal congestion, fever with aversion to wind and sweating, or slight aversion to wind and cold, thin yellow tongue coating, and floating rapid pulse. This is due to wind-heat pathogen invading the lung, leading to failure of lung qi in purification, heat scorching body fluids, hence the cough with difficulty expectoration, sticky yellow sputum, thirst, and sore throat. Wind-heat disturbing the clear orifices causes reversed flow of qi and blood in the head, resulting in headache. The struggle between healthy qi and pathogenic qi leads to hyperfunction, hence elevated body temperature and fever. Pathogenic qi attacking the exterior causes dysfunction of defensive qi, leading to aversion to wind. The wind-heat pathogen, characterized by ascending and dispersing, opens the striae and interstices, resulting in sweating. Treatment involves dispersing wind, clearing heat, ventilating the lung, and relieving cough. The formula Mulberry Leaf and Chrysanthemum Decoction is selected with modifications. Wind-heat invading the lung causing cough may also present with unresolved exterior syndrome or intense lung heat.
3. Dryness Evil Injures the Lung︰The symptoms include cough with scanty, sticky, and difficult-to-expectorate sputum, or sputum streaked with blood, or dry cough without sputum. Severe coughing may lead to chest pain, dry nose and throat, or itchy and sore throat, accompanied by chills and fever. The tongue tip is red with a yellow coating, and the pulse is floating and rapid or thin and rapid. Dryness pathogens (here referring to warm dryness. Cool dryness refers to the autumn cool qi, which, after causing disease, is treated as wind-cold fettering exterior cough) commonly occur in the dry autumn climate or are caused by excessive consumption of pungent and dry foods. The dryness-heat pathogen consumes and damages body fluids, leading to the lung losing its clear and moistening function, resulting in disturbance of qi movement. This manifests as dry cough without sputum, or scanty yellow and sticky sputum, and even chest pain. When the dryness-heat pathogen injures the lung collaterals, it causes sputum streaked with blood. Dryness-heat damage to fluids may present as dry nose, dry or sore throat, and a dry tongue with scant fluid. The dryness-heat pathogen Xieke affects the body surface, causing the defense qi to become unstable, resulting in chills, fever, and other exterior patterns. Treatment involves ventilating the lung, moistening dryness, and relieving cough. The recommended formula is Mulberry Leaf and Apricot Kernel Decoction with modifications.
4. Summer-dampness︰The symptoms include cough with copious and thick sputum, chest tightness, feverish body, profuse sweating without relief, distension in the head, thirst with little desire to drink, irritability, flushed face, scanty and dark urine, thin yellow tongue coating with a red tongue body, and a soggy, rapid pulse. If summerheat predominates over dampness, the cough will sound clear and high-pitched, accompanied by feverish body, flushed face, and irritability. The tongue will be red, and the pulse will be rapid. The condition must occur during the long summer season when summerheat is prevalent. Summerheat-dampness invades the lungs, obstructing lung qi and causing cough; dampness damages the spleen, leading to dysfunction of spleen transportation and resulting in phlegm production, hence the copious sputum. As summerheat is a yang pathogen with a scorching nature, excessive heat leads to yellow, sticky sputum. Summerheat-dampness injures the exterior, manifesting as heaviness in the body, profuse sweating with unresolved fever, head distension, sore throat, and other exterior symptoms. Heat damages body fluids, causing thirst, but dampness accumulation internally may result in thirst with little desire to drink. Treatment involves clearing summer-heat to diffuse the lung, resolving dampness, and harmonizing the spleen. The recommended formula is Three-Ingredient Mosla Decoction combined with Minor Pinellia plus Poria Decoction. If the cough sounds clear and high-pitched with little or no sputum, indicating predominant summerheat pathogen and milder dampness, the treatment focuses on clearing summerheat, using Collateral-Clearing Decoction with modifications.
5. Lung Heat︰The symptoms include coughing with panting, yellow and thick phlegm, or even blood-streaked phlegm, hot breath from the mouth and nose, bitter taste in the mouth, dry throat, or a sensation of sore throat, or chest pain and tightness, yellow tongue coating, and wiry-rapid pulse. The lungs are oppressed by pathogenic heat, leading to counterflow ascent of lung qi, where coughing is often accompanied by panting, chest tightness or pain, along with manifestations of lung heat. Treatment involves clearing the lung and resolving phlegm, with the prescription selected being White-Draining Powder with modifications.
6. Dryness of the Lung︰The symptoms include dry cough without phlegm, cough-induced chest pain, hoarse voice, dry nose and throat, red tongue texture with thin and dry coating, and a fine and slightly rapid pulse. Dryness pathogen damages the lungs, depletes body fluids, leading to deficiency of body fluids and failure of the lungs to be nourished, resulting in dryness of the airways. This manifests as dry cough without phlegm, dry nose and throat, hoarse voice, cough-induced chest pain, etc. Treatment involves clearing heat and moistening dryness, promoting fluid production to relieve cough. The recommended formula is Dryness-Clearing Lung-Rescuing Decoction with modifications.
7. Damp Phlegm︰The symptoms include cough with copious white sputum, cessation of coughing upon expectoration, accompanied by chest and epigastric distension and oppression, reduced appetite; or nausea and vomiting, or facial edema. The tongue coating is white and greasy, and the pulse is soggy and slippery. This is due to exuberant phlegm-dampness, where the cough is caused by phlegm, hence the characteristic of cessation upon expectoration. It is a combined manifestation of exuberant phlegm-dampness and dysfunction of the spleen in transportation (reduced appetite, chest and epigastric distension and oppression, or nausea and vomiting). Treatment involves invigorating the spleen and drying dampness, resolving phlegm and relieving cough. The formula of choice is Two Old Ingredients Decoction combined with Stomach-Calming Powder with modifications. If phlegm-dampness accumulates and transforms into heat, presenting as yellow, thick sputum, yellow, greasy tongue coating, and slippery, rapid pulse, this indicates phlegm-heat cough. Treatment involves clearing heat and resolving phlegm, with the formula of choice being Phragmites Stem Decoction combined with Minor Chest Bind Decoction with modifications. If there is preexisting phlegm-fluid retention or internal retention of water qi, combined with contraction of cold pathogens, leading to internal retention of cold-fluid, or cough with lingering external pathogens, manifesting as expectoration of white, thin, clear sputum, chest and diaphragmatic fullness and oppression, or even vomiting and aversion to cold, treatment involves warming the lung and resolving fluid retention. The formula of choice is Minor Green-Blue Dragon Decoction with modifications.
8. Spleen Qi Deficiency︰The symptoms include cough, profuse white sputum that is easy to expectorate, facial puffiness, shortness of qi, fatigue, aversion to cold, epigastric distension, poor appetite, and bland taste in the mouth. The tongue coating is thin and white, and the pulse is thin. The main cause is spleen qi deficiency, leading to impaired transportation and transformation, accumulation of dampness and phlegm, and obstruction of the lungs by phlegm-dampness, resulting in cough with profuse white sputum that is easy to expectorate. This condition is also accompanied by manifestations of spleen qi deficiency (shortage of qi, facial puffiness, poor appetite, loose stool, etc.). The treatment principle is to tonify the spleen and replenish qi, dry dampness and resolve phlegm. The recommended formula is Six Gentlemen Decoction with modifications.
9. Lung Qi Deficiency︰The symptoms include cough, shortness of breath, and thin, clear sputum. The complexion is pale and lustrous, with sweating upon exertion and susceptibility to external pathogens. The tongue texture is pale and tender with a thin white coating, and the pulse is weak and feeble. This is often due to congenital yang qi deficiency, weak lung qi, or cold-fluid retention, which injures lung qi, leading to impaired lung purification and descent functions, resulting in cough. There must be manifestations of weakened lung function, such as a low and weak voice, shortness of breath, and a pale complexion. Since the lung is related to the skin and body hair, impaired dispersion weakens the defensive qi, leading to spontaneous sweating, aversion to wind, and susceptibility to common cold. Treatment involves tonifying the lung and replenishing qi, using Lung-Nourishing Decoction combined with Jade Screen Powder.
10. Lung Yin Deficiency︰The symptoms include persistent chronic cough disease with scanty and sticky sputum, or blood-streaked sputum, emaciation, dry mouth and throat, or hoarse cough. In cases of yin deficiency with effulgent fire, manifestations such as tidal fever, night sweat, shortage of qi, and chest dull pain may be observed. The tongue texture is red with scant coating, and the pulse is thin and rapid. This condition often arises from constitutional yin deficiency with effulgent fire, internal obstruction of phlegm-heat, or lung yin depletion and failure of qi to clear and descend after Rebing, leading to cough. Due to the lung losing its nourishment, lung qi ascends counterflow, resulting in dry cough with scanty sputum, hoarse cough, dry mouth, and throat. Yin deficiency with effulgent fire may also present with afternoon tidal fever, night sweat, vexing heat in the chest, palms, and soles, and is prone to stirring yin-blood, damaging the lung collaterals and causing blood-streaked sputum. Treatment involves nourishing yin to stop cough, with Adenophora and Ophiopogon Decoction as the recommended formula. For cases of yin deficiency with effulgent fire with blood-streaked sputum, the approach should focus on nourishing yin and clearing heat, moistening the lung and relieving cough, using Lily Bulb Metal-Securing Decoction.
11. Kidney Yang Deficiency︰The symptoms include cough with clear, thin, frothy sputum, incontinence of urine when coughing severely, shortness of breath, and worsening upon exertion. The face appears dark and swollen, or there may be edema in the limbs. The tongue coating is white, and the tongue body is pale, with a deep and thin pulse. This condition is often caused by constitutional yang deficiency or prolonged coughing in the elderly or weak, affecting the kidneys. The kidneys govern bones, store essence, and regulate qi. Kidney yang deficiency leads to an inability to regulate qi, resulting in frequent cough accompanied by wheezing, or wheezing that triggers coughing, difficulty breathing, and even a sensation of qi surging upward from below the navel, with symptoms worsening after exertion. The kidneys govern water metabolism, and kidney yang deficiency causes water-dampness to rise and form phlegm, which may have a salty taste. The kidneys control urination and defecation, and insecurity of kidney qi leads to incontinence of urine when coughing severely. Treatment involves warming and tonifying kidney yang, using the formula Kidney Qi Pill with additions such as Schisandra Fruit and Psoralea. For severe cough and wheezing with copious salty phlegm, the treatment focuses on tonifying the kidneys and resolving phlegm, using the formula Jian Six Gentlemen Metal and Water Decoction.
12. Liver Fire Invading Lung︰The symptoms include cough with qi counterflow, difficulty in expectorating phlegm, which may resemble a plum-pit or resemble rotten cotton and is hard to cough up. Coughing is accompanied by a flushed face and may lead to hypochondriac pain. There is dryness in the throat, dysphoria, and irritability. The tongue is red at the edges and tip, with thin, yellow, and dry coating, and the pulse is wiry and rapid. This syndrome is often caused by depression and anger damaging the liver, leading to impaired liver dispersion, liver excess insulting the lung, and lung qi ascending counterflow. The characteristic symptoms include manifestations of liver qi depression (chest and hypochondriac oppression or surging, emotional depression, dysphoria, irritability, etc.) and symptoms of lung qi ascending counterflow (cough with qi counterflow or cough with wheezing and urgency), as well as signs of qi depression and phlegm binding (difficulty in expectorating phlegm, or phlegm resembling a plum-pit or rotten cotton). Treatment involves soothing the liver to resolve depression, regulating qi and resolving phlegm, with modifications of Peripatetic Powder combined with Pinellia and Magnolia Bark Decoction. If depression transforms into fire, presenting with a bitter taste in the mouth, yellow phlegm, a red tongue, and a wiry, rapid pulse, the approach should focus on clearing the liver and draining fire, moistening dryness and resolving phlegm, using the Clearing the Lung and Resolving Phlegm Decoction combined with Indigo and Clam Shell Powder.

Wind-cold fettering exterior and wind-heat invading the lung are both caused by external pathogens, hence both exhibit exterior pattern. The key points for differentiation between these two patterns lie in the characteristics of the cough, the nature of the phlegm, and the accompanying exterior pattern.

Dryness pathogen damaging the lung and summerheat dampness are also caused by external pathogens, hence they also exhibit exterior pattern. However, their onset is seasonal. Due to the different nature of the pathogens, the clinical manifestations also differ, which can be used to differentiate them from wind-cold fettering exterior and wind-heat invading the lung.

Lung heat and lung dryness, heat being the gradual form of fire, and fire always being dry, hence the disease cause of cough in these two patterns, although one is pathogenic heat and the other is dryness pathogen, their symptoms have similarities (such as cough causing chest and rib pain), and should be differentiated based on their accompanying symptoms.

Phlegm-fluid retention and spleen deficiency both have phlegm-dampness as the pathogen, but their disease cause and mechanism of disease are different.

For the symptom of cough, the first step is to differentiate whether it is cough due to external contraction or cough due to internal damage. Generally speaking, cough due to external contraction often has a clear pathogenic cause, a rapid onset, and a short course, characterized by the presence of exterior pattern, mostly belonging to excess pattern. Cough due to internal damage often has no obvious trigger, a slow onset, and a long course, especially lung yin deficiency and kidney yang deficiency cough, often lasting for a long time without healing, or recurring, mostly belonging to deficiency pattern.

In the differentiation of cough, it is important to grasp the characteristics of the cough and the phlegm. For example, cough that is worse during the day is often due to heat or dryness, while cough that is worse at night is mostly due to kidney deficiency, spleen deficiency, or phlegm-dampness. In terms of differentiating phlegm, clear and thin phlegm belongs to dampness, while sticky and thick phlegm belongs to heat or dryness; white phlegm belongs to wind, cold, or dampness, while yellow phlegm belongs to heat; a large amount of phlegm belongs to phlegm-dampness or spleen and kidney deficiency, while a small amount of phlegm is mostly due to wind-cold fettering exterior or yin deficiency. Dry cough with little phlegm that is difficult to expectorate, or even no phlegm at all.

bubble_chart Documentation

1. Danxi Xinfa．cough: "In the morning, frequent coughing indicates stomach fire, use Fritillaria Bulb、Gypsum to reduce stomach fire; frequent coughing in the afternoon indicates yin deficiency, must use Four Ingredients Decoction plus fried Phellodendron、Anemarrhena to reduce fire; coughing at dusk is due to fire qi floating in the lungs, should not use cooling herbs, but Schisandra Fruit、Chinese Gall to astringe and descend it; frequent coughing at dawn indicates food accumulation in the stomach, at this time, fire qi flows into the lungs, use Anemarrhena、Chinese Wolfberry Root-bark to reduce lung fire."
2. Jingyue Quanshu．cough: "Cough, if it occurs every autumn and winter, it is cold wrapping heat. Just resolve the cold, the heat will dissipate on its own, suitable are Liu'an Decoction、Two Old Ingredients Decoction、Jian Six Gentiemen Metal and Water Decoction three formulas, observe the deficiency and excess, use appropriately according to age and condition, if internal heat is severe, may assist with Skullcap Root、Anemarrhena and the like."
3. Zabing Yuanliu Xizhu．cough asthma origin: "Sound without phlegm is called cough, not without phlegm, but phlegm is not easily expelled, the disease is in the lungs, the lungs govern sound, so sound comes first and phlegm follows. Phlegm without sound is called expectoration, not without sound, but phlegm comes out with expectoration, the sound is not very loud, the disease is in the spleen, the spleen stores phlegm, so phlegm comes out and expectoration stops."