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Teacher: When encountering patients with cough in clinical practice, one must first distinguish whether it is an internal injury cough (internal injury cough) or an external contraction cough (external contraction cough). This patient has no history of chronic cough or phlegm-fluid retention, nor any deficiency signs of lung Qi or lung Yin. The illness began only about a month ago after accidental exposure to external pathogens. Although the cough has persisted, there are no symptoms such as shortness of breath and fatigue, excessive phlegm with rebellious Qi, tidal fever, or malar flush; thus, it is clearly not an internal injury cough. Moreover, the initial onset was accompanied by systemic discomfort, aversion to cold, absence of sweating, and nasal congestion, confirming that this is undoubtedly an external contraction cough. Knowing it is an external contraction cough, we must further differentiate which pathogen caused it. From the perspective of the season of onset, the illness began around mid-November, at the transition between Frost's Descent and Start of Winter. During this period, temperatures gradually drop while dryness Qi prevails, making dry-cold Qi particularly strong. Dry-cold Qi injures the human body in two ways: first, cold pathogen enters from the exterior, binding the skin and hair, and the pathogen moves inward to lodge in the Lung; second, dry-cold pathogen enters through the mouth and nose, directly injuring the Lung. Combining this with clinical manifestations, the patient presents with cold signs but no heat signs, along with dry mouth and throat with itching, and dry cough without phlegm. These symptoms perfectly match those caused by dry-cold pathogen. Furthermore, considering the medications previously taken—mostly heat-clearing and phlegm-resolving drugs (such as Chuanbei Jing Pian) and acrid-cool exterior-releasing agents (such as Yinqiao Pian and Sangju Ganmao Pian)—which proved ineffective, it indicates that this cough is neither due to phlegm-heat stagnating in the Lung nor wind-heat attacking the Lung. This provides necessary corroboration for our syndrome differentiation. Since the cough is caused by dry-cold, we adopted the method of "acrid-opening and warm-moistening." We used acrid-warm herbs to open the Lung and disperse cold, and warm-moistening herbs to warm the Lung and moisten dryness, achieving good results.

Doctor Yi: Please discuss cold-dry cough and its syndrome differentiation and treatment.

Teacher: Cold-dry cough refers to cases where the cold aspect of cool-dry cough (cool-dry cough) is predominant. It generally occurs in late autumn and early winter. From the perspective of seasonal timing and dominant Qi, between Autumn Equinox and Light Snow, dryness Qi is in command. The weather is mostly sunny with little rain, and dryness Qi is strong. Within this period, due to variations in temperature (cool vs. warm), dryness syndromes differ into warm-dry and cool-dry. Between Autumn Equinox and Frost's Descent (approximately late September to mid-October), temperatures remain relatively high (especially obvious in North China and Northwest China), and dry-heat Qi is strong. Diseases caused by contracting dry-heat pathogen are called warm-dry. After Frost's Descent, temperatures drop sharply, and the climate turns cold. At this time, dry-cool Qi prevails, and contracting it leads to cool-dry disease. In Northeast China, temperatures are already quite cold; referring to it merely as "cool" is insufficient to describe the reality, so it is termed "cold." Diseases caused by "dry-cool" pathogen are called "cool-dry," so we term coughs caused by "dry-cold" pathogen as "cold-dry cough." This type of cough is quite common in late autumn and early winter. Some patients suffer from it for a long time without cure, extending through the entire winter. Mild cases may resolve spontaneously over time. The persistence of this syndrome is not due to difficulty in treatment but rather incorrect treatment. The Lung is a delicate organ, susceptible to heat, cold, and especially dryness. When the weather turns suddenly cold and dry in late autumn and early winter, people often struggle to adapt. Especially under conditions of fluctuating temperatures and drastic changes between cold and heat, one is highly susceptible to dry-cold pathogen. The syndrome involves both exterior signs of cold binding the skin and hair and interior signs of dryness injuring Lung fluids. Thus, exterior signs such as systemic discomfort or pain, headache, aversion to cold, absence of sweating, and nasal congestion often appear, alongside cough as the main symptom. The cough is characterized by continuous bouts, heavy and turbid sound, and dry cough without phlegm. Even if phlegm exists, it is scanty and clumped (if the person has a constitution prone to phlegm-dampness, copious clear phlegm may occur). Cough worsens upon exposure to cold; therefore, when going outdoors, during the coldest hours of the night, or when undressing before sleep and dressing in the morning, the invasion of cold air into the skin and lodging in the Lung triggers continuous coughing. Upon exposure to heat, the cough alleviates or stops completely. Due to dryness injuring the Lung and insufficient fluids, symptoms include dry cough without phlegm, or scanty sticky clumped phlegm, along with dry and itchy throat and dry lips. However, these manifestations are often overlooked; unless prompted, patients rarely volunteer this information.

From the above analysis, the key to this syndrome lies in "cold" and "dryness," with cold being primary and dryness secondary. Therefore, treatment focuses on warming and moistening, prioritizing warming and assisting with moistening. The "acrid-opening and warm-moistening" method uses acrid-warm herbs to warm the Lung and disperse cold pathogen, and warm-moistening herbs to nourish Yin and moisten Lung dryness. Crucially, cold-dispersing herbs must not be too hot, lest they damage fluids and generate dryness; dryness-moistening herbs must not be too cold, lest they increase Lung cold. Thus, herbs commonly used for warm-dry, such as Glehniae Radix (Shashen), Ophiopogonis Radix (Maidong), Dendrobii Caulis (Shihu), Asparagi Radix (Tian Dong), Paeoniae Radix Alba (Huafen - *Note: usually refers to Trichosanthis Radix here*), Rehmanniae Radix (Sheng Di), Scrophulariae Radix (Xuanshen), and Polygonati Odorati Rhizoma (Yuzhu), are highly unsuitable for this syndrome. This prescription heavily employs warm-moistening herbs like Stemona Radix (Baibu), Asteris Radix (Zi Wan), Farfioris Flos (Kua Dong Hua), and Armeniacae Semen Amarum (Xing Ren), which can both warm the Lung to disperse cold and moisten the Lung to nourish dryness. It also uses light and ascending acrid-warm herbs like Schizonepetae Herba (Jing Jie), Perillae Folium (Su Ye), and Zingiberis Rhizoma Recens (Sheng Jiang) to reach the Lung from above and the skin from outside, allowing cold pathogen entering via the skin to dissipate outward. Additionally, Citri Reticulatae Pericarpium (Chen Pi), Platycodonis Radix (Jie Geng), and Glycyrrhizae Radix et Rhizoma (Gan Cao) regulate Lung Qi and resolve phlegm. The herbs used align with the aforementioned treatment principles. Historically, Xing Su San (Apricot and Perilla Powder) was the primary formula for cold-dry cough, composed of Er Chen Tang plus Armeniacae Semen Amarum, Perillae Folium, Aurantii Fructus Immaturus (Zhi Ke), Peucedani Radix (Qian Hu), Platycodonis Radix, Glycyrrhizae Radix et Rhizoma, Zingiberis Rhizoma Recens, and Jujubae Fructus. While it has effects of regulating Qi, resolving phlegm, and dispersing cold, its herbs are predominantly drying with few moistening ones, making it less suitable than this prescription for Lung cold with dryness. In recent years, this prescription has proven effective for cold-dry coughs in autumn and winter that do not respond to other medicines.

Doctor Bing: What might be the reasons for diagnostic and treatment errors in this syndrome?

Teacher: Although the incidence of cold-dry cough varies annually, it remains common in late autumn and winter. Most cases are mild and may resolve spontaneously without medication. Severe cases, if misdiagnosed or improperly treated, often become chronic. Reasons for diagnostic (mainly syndrome differentiation) and treatment errors include: First, theoretical understanding. As analyzed, the pathogenesis involves "cold" and "dryness." However, throughout TCM history, "dryness" was often neglected. For instance, among the Nineteen Pathogenesis Statements in *Su Wen: Zhi Zhen Yao Da Lun*, there are Wind, Cold, Fire, Heat, and Dampness, but no Dryness. Similarly, *Su Wen: Yin Yang Ying Xiang Da Lun* states, "Winter injury by cold leads to warmth diseases in spring; spring injury by wind leads to undigested food diarrhea in summer; summer injury by summer-heat leads to malaria in autumn; autumn injury by dampness leads to cough in winter." *Su Wen: Sheng Qi Tong Tian Lun* says, "Autumn injury by dampness causes rebellious Qi leading to cough and flaccidity/numbness." Autumn (especially after Autumn Equinox) should be dominated by dryness Qi, yet the text mentions dampness causing cough and flaccidity, which are actually results of dryness injuring the Lung and drying up fluids. Due to these influences, later generations held the view that "dryness does not cause disease." Consequently, pre-Jin-Yuan medical texts discussed dryness diseases sparingly. It was not until Liu Hejian in the Jin-Yuan period who, in *Su Wen Xuan Ji Yuan Bing Shi*, proposed "All astringency, withering, drying, stiffness, and cracking belong to dryness," supplementing the *Nei Jing*. Later, Yu Jiayan in Qing Dynasty's *Yi Men Fa Lv: Qiu Zao Lun* changed "autumn injury by dampness" to "autumn injury by dryness" and created Qing Zao Jiu Fei Tang. However, his arguments and prescriptions still focused mainly on dry-heat. Subsequently, Fei Boxiong proposed viewing dryness as the whole, with heat and coolness as its applications. Only then did the understanding of dryness syndromes become comprehensive. Historical reasons inevitably led to omissions in recognizing dryness syndromes. Second, from a differentiation perspective, certain factors contribute. As mentioned, if doctors do not prompt or ask detailed questions regarding dryness symptoms, patients often overlook them and do not volunteer this information, making it difficult to consider a "dryness" syndrome. Besides dryness signs being easily ignored, cold clinical manifestations are also prone to omission. Looking at the history of TCM exogenous febrile diseases, two major therapeutic errors occurred. Before the formation of the Warm Disease School in the Qing Dynasty, acrid-warm formulas were often used for the initial stage of warm diseases (pathogen in the Wei level), inevitably aiding heat with warmth, damaging fluids, and generating dryness. Today, the situation is reversed: acrid-cool (or cold-cool) agents are frequently used to treat wind-cold exterior syndromes. Currently, diseases caused by cold pathogen are ubiquitous, yet the recognition of "cold" is fading. People often see only the heat symptoms resulting from cold, ignoring the cold etiology. This phenomenon exists not only in exogenous syndromes but across all specialties, potentially turning mild diseases severe or chronic. Third, the market availability of Chinese patent medicines plays a significant role. Recently, most cough-patent medicines are acrid-cool exterior-releasers, lung-heat-clearers, or phlegm-resolvers, such as Yinqiao Jiedu Wan/Pian, Sangju Ganmao Pian, Chuanbei Jing Pian, Shedan Chenpi Mo, Niuhuang Qingfei San, and Zhuhuang San. Acrid-warm lung-opening or lung-warming herbs are scarce; even previously common Shen Su Li Fei Wan and Juhong Wan are becoming rare. This contributes significantly to the tendency to treat cold with cold.

Bi Syndrome prolonged, deficiency emerging after medication

Professor Xiao Yonglin and Chen Fengzhi, Changchun University of Traditional Chinese Medicine

Liu XX, male, 53 years old, visited in April 1986. Ten years prior, joint pain began after sleeping in a damp, cold place. Pain started in the knees, then spread to ankles and hips, eventually affecting all joints. Rheumatoid medications temporarily relieved pain, leading to discontinuation. However, pain recurred during cold weather and rainy days, particularly during seasonal transitions in spring and autumn. Initially, only pain was felt; later, joint mobility decreased, legs felt cold (especially feet), waist movement was stiff, and lower back and knees felt sore and weak. Treatments included Xiao Huoluo Dan, Fengshi Han Tong Pian, Shenjin Huoluo Wan, Fengluo Tong, and Tiger Bone Wine. Self-medication involved soaking roots of Heracleum hemsleyanum (Zoumaqin/Du Huo), Old Stork's Bill (Laoguancao/Guanjin), Cissus sicyoides (Zuandifeng), and Panax japonicus (Qiannianjian) in wine for long-term consumption. Initially, these provided relief and improved mobility. However, prolonged use led to poor efficacy, resulting in physical weakness, fatigue, a sensation of looseness and weakness in all joints, sore and weak lower back and knees (worse with standing/walking), scorched lips, thirst for cold drinks, dry and burning throat, reduced appetite, palpitations and sweating upon exertion, while lower limbs remained cold. Tongue was pale red and dry; pulse was deep, rapid, and forceless.

Based on symptoms, the priority was to nourish Yin and Blood, clear dry-heat, and tonify deficiency. Prescription: Sheng Di Huang 25g, Bai Shao 15g, Xuan Shen 25g, Mai Dong 15g, Du Zhong (Du Zhong) 20g, Xu Duan 20g, Niu Xi 15g, Sang Zhi 15g, Gan Cao 10g. Decocted in water three times, taken morning and evening. After 5 doses, lip dryness, thirst, and throat burning improved significantly, though other symptoms remained unchanged. Based on this, Ren Shen 10g, Du Zhong 15g, and Gou Qi Zi 15g were added. After another 5 doses, lip/throat dryness and thirst were basically eliminated, appetite increased, strength returned, and sweating/palpitations improved, but lower back/knee soreness and leg coldness persisted. With fluid returning to the tongue, a new prescription was given: Sheng Di Huang 25g, Bai Shao 20g, Dang Gui 15g, Huang Qi 15g, Ren Shen 10g, Xu Duan 20g, Du Zhong Tan 20g, Du Zhong 20g, Gou Ji 15g, Gou Qi Zi 25g, Ba Ji Tian 10g, Lu Hui Ye 10g, Gui Zhi 10g, Niu Xi 15g, Gan Cao 10g. After 5 doses, fatigue and lower back/knee soreness improved, and palpitations/sweating during activity were lighter. Considering the chronic nature of the disease, immediate cure was unlikely. Since this case was not purely external pathogen but involved significant Qi/Blood deficiency and Yin/Yang weakness, decoction was switched to pills for gradual effect, aiming to restore Zheng Qi so Xie Qi would naturally depart. New prescription: Dang Gui 25g, Sheng Di Huang 25g, Shan Yao 25g, Huang Qi 20g, Ren Shen 15g, Bai Zhu 20g, Fu Ling 20g, Xu Duan 20g, Du Zhong Tan 20g, Du Zhong 20g, Gou Qi Zi 25g, Ba Ji Tian 10g, Lu Hui Ye 10g, Gui Zhi 10g, Niu Xi 15g, Ji Xue Teng 20g, Jiang Huang 15g, Gan Cao 15g, Bai Shao 20g. Five doses were dried, ground into fine powder, and formed into honey pills, each 15g, taken 2-3 times daily. In mid-November, the patient reported making over 210 honey pills. After about 3 months of use, physical strength gradually increased, and lower body coldness, pain, and soreness alleviated. Additionally, previous symptoms of cold/damp genitals, weak erection, reduced libido, and frequent nocturia (previously unreported as unrelated) improved significantly. The patient refilled the prescription for 5 doses. Upon finishing, pain and soreness disappeared, strength noticeably increased, and no recurrence occurred despite the cold autumn weather.

Doctor A asked why the first prescription contained few typical Bi-syndrome herbs besides Du Zhong, Xu Duan, and Sang Zhi.

Teacher: Correct! This prescription primarily aims to nourish Yin/Blood and clear dry-heat, rather than using standard Bi-syndrome herbs. This approach was dictated by the patient's specific condition. Having suffered from Bi syndrome for a long time and taken wind-dispelling, cold-resolving, damp-draining, and channel-unblocking herbs for an extended period, the patient developed signs of Yin/Blood deficiency and internal dry-heat. Ignoring these symptoms and continuing with the same herbs would be adding fuel to the fire, worsening dry-heat. Moreover, concurrent loss of appetite indicated severe stomach dry-heat and Yin depletion. Other symptoms like weakness, sore back/knees, palpitations, and sweating indicated that deficiency of Zheng Qi, rather than pathogen obstruction, was dominant. Thus, the treatment abandoned dispelling pathogens and unblocking channels for pain relief, avoiding harsh, drying, and penetrating herbs. Instead, tonifying deficiency and supporting Zheng Qi became the main principle, specifically starting with nourishing Yin/Blood and clearing dry-heat using soft, moist, cold-cool herbs like Sheng Di Huang, Xuan Shen, Mai Dong, and Bai Shao. The intent was to clear dry-heat and restore Stomach Yin to improve appetite. The treatment outcome confirmed expectations: dry-heat gradually cleared, Stomach Yin restored, diet improved, essence transformed, Qi/Blood filled, and Yin/Yang strengthened, laying a solid foundation for subsequent treatment.

Doctor B: Bi syndrome is caused by invasion of Wind, Cold, and Dampness, presenting as excess. Yet your prescriptions seem primarily tonifying. Is this patient's disease a deficiency syndrome?