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Fire pathogen scorches Lung Metal, causing dryness and itching that is unbearable, leading to cough. Cough arises from itching, itching arises from fire and dryness; thus, cough must involve fire. However, there are deficiency and excess patterns, so cold-cooling herbs should not be used indiscriminately.

Sputum production (Su) originates from phlegm, which is fundamentally caused by Spleen dampness. If the Spleen is hot, dampness steams into hot phlegm; if the Spleen is cold, dampness overflows into cold phlegm. Hot phlegm carries fire to cause itching, so both coughing and sputum production occur together. Cold phlegm lacks fire and does not cause itching, manifesting only as the expulsion of phlegm. Therefore, ancients distinguished "sound without sputum" as Ke (Cough) (not necessarily devoid of sputum, but because Ke stems from itching rather than sputum, sputum is not mentioned); "sputum without sound" as Su (Phlegmy Cough) (not necessarily silent, but because Su aims to expel sputum rather than producing sound from rebellious fire, sound is not mentioned); and "sound with sputum" as Ke-Sou (Cough).

Both external contraction and internal injury patterns center on the Lung. External pathogens enter via the skin and hair, which are the exterior extensions of the Lung. When the skin and hair are affected by cold, sweat pores are congealed and closed by cold, causing Lung Qi to stagnate internally and generate heat. Alternatively, heat affecting the skin and hair transmits to the Lung, causing Lung heat. This is indeed centered on the Lung. In cases of internal injury with flaming fire, since fire nature flares upward, regardless of which Zang-Fu organ's fire it is, it will harass the Lung upwards; thus, this is also centered on the Lung.

External contraction coughs are relatively mild because although Lung Qi is stagnant, it can still circulate. Thus, symptoms include clear nasal discharge, nasal itching with sneezing, and throat itching with coughing. If stagnation is severe, heat congestion prevents upward communication, resulting in a dry and stuffy nose, without sneezing or coughing. This is because when stagnation is not severe, the healthy Qi still attempts to disperse outward and communicate upward; when severe, it does not disperse outward but attacks inward, nor does it communicate upward but stagnates downward. Internal injury coughs are relatively severe. For instance, fire from the Liver and Kidneys initially affects the Lower Jiao and does not immediately harass the Lung. After a long time, as the fire becomes blazing, it reaches the Lung, making the condition serious. (If Lung fire itself is excessive, this discussion does not apply.)

For wind-strike cough, use Xiao Feng Ning Sou Tang (Wind-Dispersing and Cough-Calming Decoction). Individuals with inherent Lung fire are prone to wind-strike because Lung fire causes frequent sweating and open interstices, allowing pathogens to enter easily. Additionally, with abundant internal fire, slight constraint leads to heat generation. Treatment should resolve the exterior while clearing the fire. *Jingui Yaolue* states: Cough with rebellious Qi and a voice in the throat like a water frog (sound produced by phlegm-fluid colliding with Qi), use Shegan Mahuang Tang (Belamcanda and Ephedra Decoction). Rebellious Qi, Lung distension, wheezing, eyes protruding as if falling out (describing severe wheezing and coughing where eyes bulge), with a floating and large pulse, use Yuespi Banxia Tang (Mahuang, Poria, Licorice, Ginger, Jujube, and Pinellia Decoction). Rebellious Qi, rapid and dry wheezing belonging to Lung distension, intending to develop into Fengshui edema (see Edema chapter), resolves with sweating; use Xiao Qinglong Tang (Minor Green Dragon Decoction) (see Phlegm-Fluid chapter) plus Shigao (Gypsum Fibrosum). Cough with a floating pulse uses Nongpu Mahuang Tang (Magnolia Bark and Ephedra Decoction) (to disperse external pathogens); a sinking pulse uses Zeqi Tang (Phallus Decoction) (to drive out internal fluids).

Epidemic cough with fever, aversion to cold, nasal congestion, and rapid breathing, starting with bedridden state and improving after one to two days, commonly known as "Toad Plague," uses Shen Su Yin (Ginseng and Perilla Infusion) (see Fever chapter) plus 5 fen of Xixin (Asarum). External cold-wind contraction neglected with exterior-resolving treatment, persisting for a long time leading to hemoptysis. Physicians mistakenly treated it as consumptive disease, frequently administering cold-cooling herbs to clear Lung metal and descend fire. The external cold was not resolved, and internal cold arose, lingering for years, leading to physical collapse, turning false consumption into true consumption (the common saying that unresolved wind-strike turns into consumption refers to this). This requires careful observation. *Yi Guan* states: When the Lung channel is affected by cold, blood coagulates and fails to circulate. Cough brings up blood with sputum. The patient must have aversion to cold, a tight pulse, and the blood expelled may be purple or black in small spots (this may also involve fire signs, do not adhere rigidly). Use Mahuang Guizhi Tang (Ephedra and Cinnamon Twig Decoction); several people recovered with mild sweating. Sweat and blood share the same origin; those who lose blood have no sweat, and those who lose sweat have no blood. Treating this as Yin deficiency with fire agitation would be disastrous. Wind sensation causes nasal congestion and heavy voice; cold sensation causes shivering and fear of cold; heat involvement causes irritability; dampness involvement causes heaviness and stagnation; blood stasis causes stifling and fishy sensation in the chest; fluid retention causes palpitations in the epigastrium. In summer, when fire is abundant, nourish Water to clear Metal; Huanglian (Coptidis Rhizoma) is essential. Dampness sensation causes body heaviness and pain, difficult urination, possibly with sweat; use Baizhu Jiu (Atractylodes Macrocephala Wine) (see Middle Jiao Dampness chapter). Autumn dryness requires moistening; use Xingren (Armeniacae Semen Amarum) and Gualou (Trichosanthis Fructus). Mixed cold and heat, due to improper clothing adjustment, contracting both cold and heat, causes cough upon sudden cold, sudden heat, drinking hot liquids, or drinking cold liquids (also applies to those with inherent Lung fire); use Jin Fei Cao San (Boiling Herb Powder) and Xiao Feng San (Wind-Dispersing Powder) (see Headache chapter) decocted together. Or use Kuantonghua San (Adenophora Flower Powder), replacing Mahuang with Bohe Ye (Menthae Haplocalycis Folium). Sudden hoarseness indicates cold wrapping fire; use acrid-cool dispersants. Phlegm congestion in the Lung causes "Metal solid does not ring"; must clear Lung pathogenic stagnation; use Qingyan Ningfei Tang (Throat-Clearing and Lung-Calming Decoction). Cough with hoarse voice uses Xingren Jian (Almond Decoction), Runfei Wan (Lung-Moistening Pill), and Qingyin Wan (Voice-Clearing Pill). Heat cough causing loss of voice and sore throat, worsened by cold medicines, uses Shengjiang Zhi (Fresh Ginger Juice) to mix Xiao Feng San (see Headache chapter), administered in small amounts. However, aphonia occurs in non-excess patterns too; examine carefully, assist with Ganlan Wan (Olive Pill) for sucking, and concurrently decoct Pipaye San (Loquat Leaf Powder) (see Summerheat chapter) to take warm. All external cold-wind contractions should be treated with acrid dispersion, as "Lung desires acrid." If dispersion is excessive, or if constitution and pathogenic Qi are both deficient, tonification is indicated. For internal injuries with Yin deficiency and fire hyperactivity, treatment should be sweet and moistening; acrid-aromatics are strictly forbidden, as "Qi diseases should not consume much acrid." However, if deficiency contains excess, moving stagnation is appropriate. Fire depression in Lung Qi level, with wheezing, cough, facial swelling, and body heat without phlegm, uses Xiebai San (Drain White Powder) (see Fever chapter). If face is red, coughing blood, fire depresses in Blood level; add Huangqin (Scutellariae Radix) and Shengdi (Rehmanniae Radix). Severe internal heat adds Huanglian (Coptidis Rhizoma). Urgent cough, vomiting, reverse Qi, and hypochondriac pain indicate Liver fire; add Qingpi (Citri Reticulatae Pericarpium Viride) and Qingdai (Indigo Naturalis). Wheezing with facial edema and inability to lie flat indicates phlegm-fluid-water Qi; add Ku Tingli (Koelreuteriae Fructus) to drain. Lung dryness requires moistening; use Donghua (Donggu and Mugu), Beimu (Fritillariae Bulbus), Ejiao (Colla Corii Asini), and Jiziqing (Egg White). Phlegm difficult to expectorate due to dryness adds Gualou Ren (Trichosanthis Semen); wheezing adds Xingren (Armeniacae Semen Amarum). Wheezing and fullness upon movement indicate Lung distension (severe cases show elevated chest and prominent bones). Left or right side, unable to sleep, indicates phlegm mixed with blood stasis obstructing Qi; use Siwu Tang (Four Substances Decoction) (see Blood chapter) plus Taoren (Persicae Semen), Hezi (Terminalia Chebulae Fructus), Qingpi (Citri Reticulatae Pericarpium Viride), Zhuli (Bambusa Textilis Caulis Succus), Jiangzhi (Zingiberis Recensis Succus), and Jiuzhi (Allii Tuberosi Succus). Obstruction preventing sleep is difficult to treat. Chronic cough with Lung distension requires astringency; Hezi (Terminalia Chebulae Fructus) is primary, assisted by Haishi (Lapis Marmoratus), Xiangfu (Cyperi Rhizoma) (soaked in Child's Urine for three days), Gualou Ren (Trichosanthis Semen), Qingdai (Indigo Naturalis), Banxiaqu (Pinelliae Fermentatum), Xingren (Armeniacae Semen Amarum), Jiangzhi (Zingiberis Recensis Succus), mixed with honey for sucking. (Initial external contraction Lung distension, see previous *Jingui* two entries, avoid astringents. All astringents like Hezi, Wuweizi, Wubeizi, Wumei, and Yingsuke are late-stage products; never use in initial illness.) Phlegm-cough stops when phlegm is expelled. Severe phlegm presents externally as alternating chills and fever. Abundant clear phlegm indicates cold excess; abundant sticky phlegm indicates heat excess; both obstruct healthy Qi. Cold excess uses Touluo Dan; heat excess uses Xiefei Wan (Lung-Draining Pill). Phlegm accumulation cannot be removed without Qingdai (Indigo Naturalis) and Gualou (Trichosanthis Fructus). Cough with red face, constant heat in chest/abdomen/hypochondrium, cool feet occasionally, and flooding pulse indicates hot phlegm in chest-diaphragm; use Xiaoxianxiong Tang (Minor Stagnant Chest Decoction) (see Chest Pain chapter) or Mengshi Gun Tan Wan (Lead Ore Rolling Phlegm Pill) (see Phlegm chapter). Zhang Hezi's purgative/vomiting methods are even more effective. Pale face, sadness, sneezing, or hypochondriac urgency/pain/swelling, with sinking, wiry, slow, fine pulse indicates cold phlegm in chest/abdomen; use Banxia Wenfei Tang (Pinellia Warming Lung Decoction). Food stagnation generating phlegm causing cough and fever uses Banxia (Pinelliae Rhizoma) and Nanxing (Arisaematis Rhizoma) as sovereign, Gualou (Trichosanthis Fructus) and Laifuzi (Raphani Semen) as minister, Qingdai (Indigo Naturalis) and Shijue (Haliotidis Concha) as envoy. Food stagnation patients have varying green-white-yellow faces, with crab-claw-like lines on the face, alternating yellow and white. Treat wine-induced cough with Qingdai (Indigo Naturalis) and Gualou (Trichosanthis Fructus) honey pills for sucking to save the Lung. Drinking cold/hot wine or cold water injuring Lung causing cough uses Ziwan Yin (Sinosenecionis Root Infusion). Alcohol injuring Lung with abundant phlegm uses Gualou (Trichosanthis Fructus), Xingren (Armeniacae Semen Amarum), Qingdai (Indigo Naturalis), Huanglian (Coptidis Rhizoma) pills, swallowed with Zhuli (Bambusa Textilis Caulis Succus) decoction and Jiuzhi (Allii Tuberosi Succus). If concerned about excessive cold suppressing fire, first use acrid dispersants, then sour astringents; severe cases use vomiting, followed by Wuling San (Five Ling Powder) (see Dampness Injury chapter) or Ganlu San (Sweet Dew Powder) (see Cholera Disorder chapter) to overcome dampness and remove phlegm. *Yi Guan* states: Lung is a delicate organ, fearing heat and cold. Fire scorching Metal causes cough (Kidney Water deficiency with flaming fire uses Liuwei Wan/Six Ingredient Pill with Rehmannia); Cold water freezing Metal causes cough (Kidney Fire deficiency, Lower Jiao cold forcing fire upward to harass Lung, causing Lung heat cough. Though not strictly "Metal cold," it is deficient heat, treated similarly with cold methods, using Bawei Wan/Eight Ingredient Pill). Also, Spleen/Stomach deficiency failing to control water, causing water overflow into phlegm harassing Lung; or initial Heart fire scorching Metal, but damaged Spleen by cold herbs causing Lung deficiency cough. These require Liujunzi Tang (Six Gentlemen Decoction) (see Qi chapter) plus Paojiang (Prepared Ginger) to tonify Spleen/Lung, and Bawei Wan (Eight Ingredient Pill) (see Deficiency Consumption chapter) to tonify Earth mother. Furthermore, Wang Jiezhai stated that those damaging True Yin through excessive alcohol and sex should not take Renshen (Ginseng Radix et Rhizoma). This view greatly misleads people. I encounter such cases, first using Liuwei Wan (Six Ingredient Pill with Rehmannia) (see Deficiency Consumption chapter) to strengthen Water and descend fire, then using Renshen (Ginseng Radix et Rhizoma) to save the Lung, allowing Metal and Water to generate each other for recovery. Using cold-cooling herbs is wrong; knowing to use Renshen (Ginseng Radix et Rhizoma) but not knowing to first strengthen Water is also wrong, leading to flourishing Yang fire and further Yin damage, showing ignorance of priority steps. Cough moving all limbs, feeling Qi rushing upward from below the navel, indicates Kidney deficiency with Qi failing to return to its source; use Anshen Wan (Kidney-Anchoring Pill) etc. Labor cough includes those becoming consumptive from chronic cough, or coughing due to consumptive disease. Symptoms include alternating chills and fever, or isolated fever, tidal fever, night sweats, dry painful throat, mental fatigue, phlegm thick or pale, possibly bloody, inability to speak. Baohe Tang (Preserve Harmony Decoction), Ziyin Qinghua Wan (Nourish Yin Clear Transform Pill), and Wuzhi Gao (Five Juices Paste) are applicable. Dry cough without phlegm is fire depression pattern (common in frustrated people); use Jiegeng (Platycodonis Radix) to open (Xiaoyao San is better), followed by tonics like Siwu Tang (Four Substances Decoction) (see Blood chapter) plus Chao Bai (Stir-fried Phellodendri Cortex) and Zhuli (Bambusa Textilis Caulis Succus). Unresolved, it becomes consumption. Chronic medication failure without other symptoms differs from labor cough; preserve Lung using Yibai Bu Gao (Single Stemona Paste), Sangzhi Jian (Mulberry Twig Decoction), Bixiao San (Certain Efficacy Powder), and Qinhua Wan (Sucking Pill).

Cough predominant in the first half of the day is Yang fire (Yang fire flourishes during Yang hours); phlegm is thick and yellow; use Erchen Tang (Two Aged Ingredients Decoction) (see Phlegm chapter) plus Beimu (Fritillariae Bulbus), Shigao (Gypsum Fibrosum), and Zhuru (Bambusa Textilis Caulis Succus). Predominant in the second half is Yin fire, originating from Lower Jiao; phlegm is blue-black and sticky; use Siwu Tang (Four Substances Decoction) (see Blood chapter) plus Chao Bai (Stir-fried Phellodendri Cortex) and Zhimu (Anemarrhenae Rhizoma), or Zhibai Bawei Wan (Anemarrhena, Phellodendron, and Eight Ingredient Pill). Cough predominant at dusk indicates fire floating in Lung (Lung Qi should descend at this time but fails, causing fire to float); cold medicines are inappropriate; use Wuweizi (Schisandrae Chinensis Fructus) and Wubeizi (Galla Chinensis) to astringe and descend. Waking suddenly from sleep at dusk coughing up phlegm indicates food stagnation phlegm (Spleen静止 during sleep fails to transport, causing phlegm retention and cough. Previous case was fire cough, this is phlegm cough); use Erchen Tang (Two Aged Ingredients Decoction) (see Phlegm chapter), Shanzha (Crataegi Fructus), and Maiya (Hordei Fructus Germinatus) for digestion and resolution. Cough at dawn (Wugeng) is also due to phlegm retention (principles detailed in Phlegm chapter). Cough also belongs to fire; fire erupts when empty (At Yin hour daily, Qi and Blood flow into Lung; the Lung is empty, unobstructed, so fire follows Qi floating upward); use Erchen Tang (Two Aged Ingredients Decoction) plus Huangqin (Scutellariae Radix), Jiegeng (Platycodonis Radix), and Sangbai Pi (Mori Cortex). Lighter by day, heavier by night indicates Yin deficiency; use Erchen Tang (Two Aged Ingredients Decoction) plus Danggui (Angelicae Sinensis Radix).