肺主气。咳者气病也。故咳血属之于肺。肺之气。外合于皮毛。而开窍于鼻。外证鼻塞。皮毛固闭。则其气反
而内壅。呛出喉间。发为咳嗽。此外因之咳也。肺之气下输膀胱。转运大肠。通调津液。而主制节。制节下行。
则气顺而息安。若制节不行。则气逆而咳。此内因之咳也。夫外因之咳。不过其窍闭塞。肺气不得达于肤
表。于是内奔喉间而为咳。其于肺之本体。固未常受伤也。至于内因之咳。则由于制节不行之故。盖肺为
金体。其质轻清。肺中常有阴液。冲养其体。故肺叶下垂。如天道下际。其气泽之下降。亦如雨露之下滋。因
之膀胱通。大便调。五脏六腑之气。皆得润利而不壅遏。肺气通调之益也。设肺中阴液不足。被火克刑。则
为肺痿。肺叶焦举不能下垂。由是阴液不能垂之下注。肺中之气。乃上逆而为咳。此内因之咳。难治之证
也。以上二者。乃肺之本病。自致咳嗽者也。又有为他脏所干。而亦咳嗽者。则以肺为华盖。诸脏皆居其下。
故他脏痰饮火气。皆能上熏冲射。使肺逆咳。故内经咳嗽论。详别脏腑。而总言之曰。聚于胃关于肺。病虽
由于他脏。而皆关于肺。此肺之所以主咳嗽也。人必先知咳嗽之原。而后可治咳血之病。盖咳嗽固不皆
失血。而失血则未有不咳嗽者。或外感失血。病由皮毛。内合于肺。自应咳嗽。或由胃中积热。火盛乘金。气
上而咳。或由肝之怒火上逆而咳。此失血之实证。必致咳嗽者也。或由阴虚火旺。肺失清肃之令。痿燥作
咳。或挟脾经忧郁。心经虚火。以致咳嗽。或肾经阴虚。阳气不附。上越而咳。此失血之虚证。不免咳嗽者也。
又有痰咳。界在半虚半实之间。又有气咳。属在虚多实少之证。或先咳而后失血。或先失血而后咳。或暂
咳即愈。或久咳不止。种种不一。必细推究之。而于失血虚劳。庶得调治之法。
一实咳。外感风寒。先见头痛。恶寒发热等证。仲景云。咳而喘息有音。甚则吐血者。用麻黄汤。李东垣师其
意。用麻黄人参芍药汤。可见咳嗽吐红之证。多有因外感者。古法用麻黄。乃劫病之剂。且是气分之药。于
血分尚少调治。须知咳固气病。然使不犯血分。又何缘而失血也哉。故必以兼顾血分为宜。医宗金鉴用
苏子降气汤。予则用小柴胡汤。加紫苏荆芥当归白芍丹皮杏仁。于气分血分两兼治之。最得和表清里
之法火重秘结者。加酒军。恶寒无汗者。加麻黄。胸胁腰背刺痛胀满者。为有瘀血。再加桃仁红花。盖小柴
胡。为通利三焦。治肺调肝。和荣卫之良方。加减得宜。左宜右有。凡血家兼有表证者。以此方为主。极为妥
当。普明子止嗽散亦可用。但药力薄。不堪治重病。如咳嗽轻带血少者。又须用此轻剂以调之。斯为中病。
而不致太过。止血者。再加蒲黄藕节。清火者。再加枯芩寸冬。降痰加尖贝茯苓。降气加杏仁枳壳。补血加
当归生地。凡上两方。及加减之法。皆为新病咳血而设。其有外感既久。陈寒入肺。久咳喘满。因而失血者。
乃咳嗽气逆。牵动诸经之火。以克肺金。肺气亦能牵动胸背脉络之血。随咳而出。是病虽生于寒。而实因
寒动火。治法但温其寒。益动其火。宜清火疏寒。面面俱到。斯不差爽。用千金麦门冬汤。并小柴胡加苏子
冬花。盖寒中包火者。宜小柴胡加减。以清郁火。火中伏寒者。宜千金麦门冬汤。以搜陈寒。或用细辛代麻
黄。再加黑姜五味。尤去肺寒要药。但血证多忌刚燥。更合枯芩寸冬玉竹瓜霜以柔之。用去火中伏寒。庶
几调剂得法。然而寒在肺中。久亦变从火化。既化为火。盒饭专治其火。兼温其寒。是犹抱薪救火矣。以上
所论。外感风寒。变为咳血。此证最多。医者误治。往往酿成痨瘵。慎之慎之。此外又有内受温暑湿热者。亦
能攻发而为咳血。其证身热口渴。小便不利。胸腹烦满。与外感风寒相似。治宜专清其里。忌发其表。盖此
病皆袭人口鼻。侵人脉络。伏留肠胃膜原之间。不似伤寒。从肤表入者。故但用清里之药。不可发表。以张
病势。里清则表自和。咳血自止。人参泻肺汤治之。若其人素嗜浓味。胃火炎上作咳者。用犀角地黄汤。加
麦冬五味杏仁枳壳藕节。又或肝经怒火逆上。侮肺作咳。则用柴胡梅连散。加青皮牡蛎蒲黄丹皮生地。
又有热邪激动水气。水上冲肺。咳逆不得卧。或其人面目浮肿者。仲景谓之风水。用越婢汤。血家风火相
动。激水气上升者。毋庸以麻桂发表。平肝风。宜柴胡白芍桑寄生僵蚕青蒿荆芥薄荷之属。清肺火。宜枯
芩知母石膏天麦冬。清肝火。宜胆草黄柏。清心火。宜黄连炒栀。治激动冲上肺中之水。宜葶苈苡仁防己
桔梗杏仁云苓。合此数品药。以求方治。其于风火激动水气冲肺。肺胀咳嗽之证。乃为合宜。盖仲景越婢
汤。是治外感肺胀之法。吾所论者。乃血证内伤肺胀之法。吾曾治数人。有用泻白散。合葶苈泻肺汤而效
者。有用二陈汤。和知母石膏荆芥薄荷防己木通而效者。有用小柴胡。加荆芥紫苏杏仁防己木通寸冬
兜铃而效者。又丹溪云。此证多系痰挟瘀血。碍气为病。若无瘀血。何致气道如此阻塞。以致咳逆倚息。而
不得卧哉。用四物汤。加桃仁诃子青皮竹沥姜汁治之。丹溪此论。洵中病情。盖失血之家。所以有痰。皆血
分之火。所结而成。然使无瘀血。则痰气有消容之地。尚不致喘息咳逆。而不得卧也。血家病此。如徒以肺
胀法治之。岂不南辕北辙。丹溪此论。可谓发 振聩。第其用四物汤加减。于痰瘀两字。未尽合宜。予谓可
用通窍活血汤。加云苓桔梗杏仁桑皮丹皮尖贝。小柴胡。加当芍桃仁丹皮云苓尤妥。此皆血家咳嗽属
实证者。再兼参咳嗽条更详。
一虚咳。肺为娇脏。无论外感内伤。但一伤其津液。则阴虚火动。肺中被刑。金失清肃下降之令。其气上逆。
嗽痰咳血。变为肺痿重病。吐白沫如米粥。咽痛声哑。皮毛洒淅。恶寒憎热。皆金损之证。不易治也。此病无
论寒久变火。火郁似寒。总以十药神书保和汤治之。盖肺金火甚。则煎熬水液而为痰。水液伤。则肺叶不
能腴润下垂。其在下之肝肾。气又熏之。肺叶焦举。不能制节。故气逆为咳。气愈逆。所以久咳不止也。此方
润肺涤痰。止血和气。无论寒久变火。火郁似寒。痰血痿燥等证。皆统治之。凡由外伤。变作虚咳劳证者。以
此方为第一。又有肺中阴虚。本脏气燥。生痰带血。发为痿咳。以及失血之后。肺燥成痿。痰凝气郁。久咳不
止。此乃内伤所致。不必治其余病。但补其肺。诸病自愈。用清燥救肺汤。甘凉滋润。以补胃阴。而生肺金。肺
金清润。则火自降。痰自祛。气自调。咳自止。血枯加生地。火甚加犀角。痰多加贝母。带血加蒲黄。以上二方。
于肺经虚火治法綦详。失血之人。多是阴虚火旺。照上治法者。十居八九。亦有一二属肺经虚寒者。内经
云。形寒饮冷则伤肺。肺恶寒。多漩唾上气。仲景用甘草干姜汤治之。然金匮自言遗溺小便数。所以然者。
以上虚不能制下故也。则明见有虚冷遗溺之实据。乃用甘草干姜以温之。且其脉必沉弦迟微。痰必清
稀泛溢。不似清燥保和二汤所治。故主温药。吾谓可用六君子为主。再加当归白芍炮姜五味。则于止咳
止血皆宜。脾经虚寒。痰动咳嗽者。此方亦宜。若脾经虚火。生痰带血。则宜逍遥散。加寸冬藕节蒲黄。若肝
经虚火生痰带血。亦宜逍遥散。加丹皮山栀五味。又有肾经虚火。生痰带血者。另详唾血咯血门。肝肾虚
证。均详吐血门。降冲气条。并详见六卷咳嗽门。
一痰咳。肺中痰饮实热。气逆而咳血者。扬汤止沸。不如釜底抽薪。泻肺丸主之。夫咳血之证。未有不与痰
为缘者。人身之气以运血。人身之血。即以载气。血少。则气多不能载之。壅于内而为热。热则水津被灼。煎
熬成痰。是以火旺则痰盛。痰盛。则滞气之往来。气阻则壅积。而益生其热。故痰甚而火益旺。此时补虚。则
助邪。此时逐邪。则重虚。是惟攻补兼用。庶几两得其治。先用十药神书消化丸。临卧。用饴糖拌吞。以攻其
实。即噙化太平丸以补之。攻补兼施。为除暴安良之妙法。时医但事滋补。岂不误了多人。若病家兢业。不
敢用消化丸者。可用二陈汤以初解之。二陈降气利水。为祛痰通剂。若欲兼利肺气。加杏仁苏子桑皮。咳
逆倚息不得卧者。为水饮冲肺。肺叶不得下降。加葶苈大枣。若火甚者。加栝蒌霜黄芩老连。火轻者加寸
冬知母。兼理风寒。加柴胡荆芥防风。兼理血分。加当归白芍丹皮桃仁。上方皆是去实痰之治法。又有虚
痰。乃肺经阴虚。燥气生痰。粘着喉间。滞涩声音。喘咳发热。脉细数者。不宜渗利。再伤水津。但宜滋润以生
津。津生则痰豁。宜保和汤。清燥救肺汤。紫菀散。如喉中有痰核气核。哽塞不得吞吐者。为梅核证。乃心火
凝痰。宜豁痰丸加牛蒡子。香苏饮加桔梗枳壳尖贝云苓旋复甘草。亦治之。又有胃中疼气动膈。证见胸
胁逆满。咳喘哕呃者。失血家往往有之。宜用礞石滚痰丸治之。若胃中气虚挟痰饮者。宜旋复代赭石汤。
兼治血分。则加当归白芍苏木。兼治火热。则加寸冬枯芩。哕呃详六卷。兹论痰咳。未及备载。痰咳之证。又
在肝气上逆。干犯肺经。挟痰滞气。以致咳嗽。其证口苦头痛。颊赤多怒。两胁作痛。宜温胆汤。加青皮白芥
柴胡山栀。若肝火横决怒逆者。加姜黄大黄。若肝经虚火郁而生痰。宜用丹栀逍遥散。加龙骨牡蛎阿胶
贝母。夫痰饮之病。其标在肺。其本在肾。肾水上泛。是为痰饮。痰饮冲肺。乃生咳嗽。故治痰饮以肾为主。肾
经阳虚。不能镇水。水气泛上。振寒喘咳者。用真武汤。加细辛干姜五味。若肾水因寒而动。上凌心火。心悸
喘咳。虚阳上浮。咽痛面热。宜用苓桂术甘汤。加细辛五味。温寒利水。然此乃单为痰饮立法。血家阴虚阳
亢。多忌刚燥。往往以此等药剂为忌。即系肾阳不能化水。以致便短。喘咳。痰饮上干。亦只宜肾气丸。从阴
化阳。温而不烈。此方自宋元来。莫不珍为至宝。谓失血虚痨。上热下寒。阳浮于外。阴孤于内。唯此方引阳
入阴。用药神妙。顾肾阳虚浮者。此方诚为至宝。若肾阴虚浮者。此方又非所宜。夫失血之人。浮热昏烦。痰
喘咳嗽。多是真阴内虚。阳无所守。究阳之所以不守。实由阴虚使然。非阳虚也。径投此方。阴未生而阳愈
亢。名为以阳生阴。实则以阳促阴也。如果上热下寒。外阳内阴之证。则尺脉必微弱。大小便必溏泄。手足
必清冷。即渴欲饮。亦是饮一溲二。乃用此方最为神效。设纯是阴虚。则此方又不宜用。即欲以阳生阴。亦
只可少用桂附。以反佐之。如滋肾用知柏各五钱。而桂只五分。借以从阳引阴耳。岂可多用桂附。而助阳
以敌阴哉。若是肾中阴虚。火上水升。凝滞为痰。则宜猪苓汤主之。地黄汤。加麦冬五味旋复阿胶杏仁蛤
蚧牛膝。亦仲景猪苓汤意。而滋补之功尤多。参看咯血门更详。
一气咳。无痰无血。但是气呛作咳。乃失血家真阴虚损。以致肺气不敛。肾气不纳。其病至重。最为难治。审
其由肺气不敛者。其人不能仰卧。卧则气逆而咳。咳则心下煽动。或肺叶偏枯。则侧卧一边。翻身则咳不
休。俱宜用清燥救肺汤。加百合五味琥珀钟乳石。以镇补肺金。金得保养。则能覆下收敛。而气自不咳。审
其由肾气不纳者。其人短气喘息。阴火上冲。两颧发赤。咽喉不利。仲景谓失血脉数。发热而咳者。不治。即
谓此阳不附阴。气不归元之重证。六味丸。加沉香五味麦冬磁石。以滋补镇纳之。使气既吸引归肾。而肾
水滋生。又有以封镇其气。则气自不咳逆矣。或用肾气丸。加麦冬五味牛膝。借桂附以引气归元。陈修园
谓肺肾不交。水天俱虚。用二加龙骨汤。加阿胶麦冬五味。予按肾气丸。二加龙骨汤。皆是肾阳虚。肺阴虚。
上热下寒之治法也。若肺肾之阳俱虚。元气不支。喘息困惫者。则宜用保元汤。加五味。上二方。又不恰切。
若肺肾之阴俱虚者。上三方俱不中肯。失血家气喘咳逆者。多是阴虚。气生于肾而主于肺。肺阴足。则气
道润而不滞。肾阴足。则气根蓄而内涵。惟肺阴不足。是以气燥而咳。肾阴不足。是以气浮而咳。此乃肺肾
阴虚不交之证。治宜参麦地黄汤。及三才汤。以滋二脏之阴。纳肺气。则加百合五味钟乳石。纳肾气。则加
磁石沉香五味。此外又有冲气上逆之治法。说详吐血。及六卷咳嗽门。
一骨蒸咳。失血证久咳不止。发热盗汗。世谓之骨蒸劳咳。乃肝之血分。夹有瘀滞 结。则肝气郁而不和。
肝寄相火。肝气即相火也。相火内行三焦。外行腠理。血分无瘀滞。则腠理无阻。是以相火往来。温养肌肉。
而不遏抑。故肌肉不寒冷。相火温之也。而亦不发热。相火不遏郁之故也。观妇人经不调。每遇行经必发
寒热。为血分瘀滞所致。则失血骨蒸。为血分瘀滞。郁遏相火而使然也。小柴胡汤清理之。若延日既久。发
The Lung governs Qi. Coughing is a disorder of Qi; therefore, hemoptysis (coughing up blood) is attributed to the Lung. The Qi of the Lung externally harmonizes with the skin and hair, and opens into the nose. In external patterns, nasal congestion occurs; when the skin and hair are closed and solid, the Lung Qi becomes internally obstructed, rushes out from the throat, and manifests as coughing. This is cough caused by external factors. The Qi of the Lung descends to the Bladder, transports through the Large Intestine, regulates body fluids, and exercises control and regulation (regulating the movement of Qi and fluids among organs). When this regulatory function descends properly, Qi flows smoothly and breathing is calm. If regulation fails, Qi rebels upward causing cough. This is cough caused by internal factors.
Regarding cough due to external factors, it merely involves the obstruction of orifices, preventing Lung Qi from reaching the surface. Consequently, Qi rushes inward to the throat causing cough. The本体 (substance) of the Lung itself remains unharmed. However, cough due to internal factors arises from the failure of regulation. The Lung is of the Metal element, light and clear in nature, and normally contains Yin fluids that nourish its structure. Thus, the lung lobes hang downward, akin to Heaven’s influence descending; its moistening Qi descends like rain and dew. Consequently, the Bladder functions freely, bowel movements are regular, and the Qi of the Zang-Fu organs remains moistened and unobstructed. This is the benefit of the Lung’s free flow. If Yin fluids in the Lung are insufficient and attacked by Fire, it leads to Lung萎 (Lung atrophy/flaccidity), where lung lobes become scorched and cannot hang down. As a result, Yin fluids cannot descend, Lung Qi rebels upward causing cough. This type of internal cough is difficult to treat. These two types represent the primary diseases of the Lung causing cough. Additionally, interference from other Zang-Fu organs can also cause cough. Since the Lung acts as the "Canopy" (covering all lower organs), pathological factors such as Phlegm-Fluids, Fire, or Heat from other organs can ascend and harass the Lung, causing rebellious Qi and cough. Thus, the *Neijing* states regarding cough: "Accumulated in the Stomach, related to the Lung." Although the disease originates in other organs, it always involves the Lung. This explains why the Lung governs cough. One must first understand the origin of cough before treating hemoptysis. While not all coughs involve bleeding, all cases of bleeding involve cough. For instance, external pathogenic invasion affecting the skin and hair may internally combine with the Lung, naturally causing cough. Or, accumulated heat in the Stomach, with excessive Fire overcoming Metal (Fire overacting on Metal), causes Qi to rebel upward. Or, Liver Fire rebelling upward causes cough. These are excess patterns of hemoptysis that inevitably lead to cough. Alternatively, Yin deficiency with hyperactive Fire, leading to loss of the Lung’s clearing and descending function, causes cough due to flaccidity and dryness. Or, accompanied by Spleen depression or Heart deficient Fire, leading to cough. Or, Kidney Yin deficiency with Yang failing to anchor, floating upward causing cough. These are deficiency patterns of hemoptysis that inevitably involve cough. There is also Phlegm-cough, situated between half-deficiency and half-excess. And Qi-cough, characterized by more deficiency than excess. Cough may precede bleeding, or bleeding may precede cough. Cough may cease temporarily or persist for a long time. Various presentations require careful investigation to find appropriate treatment for hemoptysis and consumptive disease.
1. Excess Cough: External contraction of Wind-Cold initially presents with headache, aversion to cold, fever, etc. Zhang Zhongjing stated: "For cough with wheezing and sound, progressing to vomiting blood," use Mahuang Tang (Ephedra Decoction). Li Dongyuan adopted this principle, using Mahuang Renshen Shaoyao Tang (Ephedra, Ginseng, and Peony Decoction). This shows that many cases of coughing blood stem from external pathogens. Ancient methods used Mahuang (Ephedra), which is a harsh agent for expelling pathogens and primarily affects the Qi level, with little adjustment for the Blood level. It must be noted that although cough is a Qi disorder, if the Blood level were not involved, how would bleeding occur? Therefore, treatment should address both levels. *Yizong Jinjian* uses Suzi Jiangqi Tang (Perilla Seed Decoction to Direct Qi Downward); I use Xiaochaihu Tang (Minor Bupleurum Decoction) modified with Zisu (Perilla Leaf), Jingjie (Schizonepeta), Danggui (Angelica Sinensis), Baishao (White Peony Root), Danpi (Moutan Bark), and Xingren (Apricot Kernel). This treats both Qi and Blood levels, best achieving the method of harmonizing the exterior and clearing the interior. For severe Fire with constipation, add Jiujun (Wine-processed Rhubarb); for aversion to cold and no sweat, add Mahuang; for stabbing pain and distension in the chest, hypochondrium, waist, and back indicating Blood stasis, add Taoren (Peach Kernel) and Honghua (Safflower). Xiaochaihu Tang is an excellent formula for unblocking the Sanjiao (Triple Burner), regulating the Lung and Liver, and harmonizing Ying and Wei (Nutritive and Defensive levels). With appropriate modifications, it is highly suitable for patients with blood disorders presenting with exterior signs. Pumingzi’s Zhisou San (Stop Cough Powder) can also be used, but its efficacy is weak and unsuitable for severe cases. For mild cough with slight bleeding, this gentle formula is appropriate to avoid excessive treatment. To stop bleeding, add Huyang (Polygonatum Rhizome) and Ou Jie (Lotus Node); to clear Fire, add Kuqin (Scutellaria Root) and Cundong (Ophiopogon Tuber); to direct Phlegm downward, add Jianbei (Fritillaria Bulb) and Fuling (Poria); to direct Qi downward, add Xingren and Zhike (Aurantii Fructus); to tonify Blood, add Danggui and Shengdi (Rehmannia Root). Both aforementioned formulas and their modifications are designed for acute hemoptysis. For prolonged external contraction where old Cold enters the Lung, causing chronic cough, wheezing, fullness, and subsequent bleeding, the rebellious Qi stirs Fire from various meridians to attack Lung Metal. Lung Qi also disturbs blood in the chest and back collaterals, which exits with cough. Although the disease originates from Cold, it is actually driven by Cold stirring Fire. Treatment should not merely warm the Cold, as this would further stir Fire. Instead, one should clear Fire and disperse Cold comprehensively. Use Qianjin Maidong Tang (Thousand Gold Ophiopogon Decoction) combined with Xiaochaihu Tang modified with Suzi and Donghua (Cynanchum Flower). For Cold enclosing Fire, modify Xiaochaihu Tang to clear stagnant Fire; for Fire hiding Cold, use Qianjin Maidong Tang to search out old Cold. Alternatively, replace Mahuang with Xixin (Asarum), adding Heijiang (Black Ginger) and Wuwei Zi (Schisandra Berry), which are key herbs for dispelling Lung Cold. However, blood disorders generally contraindicate acrid-dry herbs; thus, combine with Kuqin, Cundong, Yuzhu (Polygonatum Odoratum Rhizome), and Guashuang (Trichosanthes Peel) to soften and moisten, eliminating hidden Fire while resolving Cold. If Cold in the Lung transforms into Fire over time, treating only Fire while warming Cold is like adding firewood to a blaze. The above discusses external Wind-Cold transforming into hemoptysis, a common pattern. Mismanagement often leads to tuberculosis (Laozai). Be cautious. Additionally, internal contraction of Warmth, Summerheat, or Damp-Heat can also trigger hemoptysis. Symptoms include fever, thirst, difficulty urinating, and chest/abdominal irritability, resembling external Wind-Cold. Treatment should focus solely on clearing the interior, avoiding releasing the exterior. These pathogens enter via mouth and nose, invade collaterals, and lodge between the intestines/stomach and membrane source, unlike Cold Damage entering from the surface. Thus, use interior-clearing herbs, not exterior-releasing ones, to avoid exacerbating the condition. Clearing the interior harmonizes the exterior, stopping hemoptysis. Ren Shen Xiefei Tang (Ginseng Decoction to Drain the Lung) treats this. For those accustomed to rich foods, with Stomach Fire flaming upward causing cough, use Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) modified with Maidong, Wuwei Zi, Xingren, Zhike, and Ou Jie. If Liver Fire rebels upward, insulting the Lung, use Chaihu Meilian San (Bupleurum, Plum, and Coptis Powder) modified with Qingpi (Green Tangerina Peel), Muli (Oyster Shell), Huyang, Danpi, and Shengdi.
When Heat pathogens agitate Water Qi, causing it to rush upward to the Lung, resulting in rebellious cough and inability to lie flat, or facial/ocular edema, Zhang Zhongjing calls this Fengshui (Wind-Water), treated with Yuespi Tang (Ma Huang Decoction). In blood disorders, Wind and Fire interact, agitating Water Qi upward. Do not use Mahuang and Guizhi (Cinnamon Twig) to release the exterior. To pacify Liver Wind, use Chaihu, Baishao, Sangjisheng (Taxillus Stem), Jiangcan (Silkworm), Qinghao (Artemisia Annua), Jingjie, Bohe (Mint). To clear Lung Fire, use Kuqin, Zhimu (Anemarrhena Rhizome), Shigao (Gypsum), Tianmaidong and Maidong. To clear Liver Fire, use Danshen (actually Longdancao/Gentian Root) and Huangbai (Phellodendron Bark). To clear Heart Fire, use Huanglian (Coptis Rhizome) and Chaozhi (Fried Gardenia). To treat Water Qi agitated and rushing to the Lung, use Tingli (Descurainia Seed), Yiren (Coix Seed), Fangji (Stephania Root), Jiegeng (Platycodon Root), Xingren, and Yunling (Poria). Combining these herbs addresses cough and lung distension caused by Wind-Fire agitating Water Qi. Zhang Zhongjing’s Yuespi Tang treats external Lung distension; my discussion addresses internal injury Lung distension in blood disorders. I have treated several cases effectively using Xiebai San (Drain White Powder) combined with Tingli Xiefei Tang (Descurainia Decoction to Drain the Lung); or Erchen Tang (Two-Cured Decoction) combined with Zhimu, Shigao, Jingjie, Bohe, Fangji, and Mutong (Akebia Stem); or Xiaochaihu Tang modified with Jingjie, Zisu, Xingren, Fangji, Mutong, Cundong, and Doulou (Belamcanda Rhizome). Danxi stated: "This pattern is mostly due to Phlegm combined with Blood Stasis obstructing Qi. Without stasis, how could the airway be so blocked, causing rebellious cough and inability to lie flat?" He treated it with Siwu Tang (Four Substance Decoction) modified with Taoren, Hezi (Chebula Fruit), Qingpi, Zhu Li (Bamboo Juice), and Jiang Zhi (Ginger Juice). Danxi’s analysis is accurate. In blood disorders, Phlegm forms from Fire in the Blood level. However, without stasis, there is room for Phlegm and Qi to dissipate, preventing severe wheezing and cough. Treating blood patients with Lung distension methods alone is misguided. Danxi’s insight is enlightening. However, his use of Siwu Tang does not fully address Phlegm and Stasis. I suggest Tongqiao Huoxue Tang (Unblock Orifices and Invigorate Blood Decoction) modified with Fuling, Jiegeng, Xingren, Sangpi (Mulberry Bark), Danpi, and Jianbei; or Xiaochaihu Tang modified with Danggui, Baishao, Taoren, Danpi, and Fuling, which is even better. These are excess patterns of cough in blood disorders. Refer to the Cough section for more details.
2. Deficiency Cough: The Lung is a delicate organ. Whether from external or internal injury, once Body Fluids are damaged, Yin deficiency leads to Fire hyperactivity, punishing the Lung. Metal loses its clearing and descending function, Qi rebels upward, causing phlegm cough and hemoptysis, transforming into severe Lung Atrophy. Symptoms include spitting white foam like rice porridge, sore throat, hoarseness, chills, and alternating fever—all signs of Metal damage, difficult to treat. Regardless of whether old Cold transforms into Fire or Fire stagnation mimics Cold, always treat with Baohe Tang (Harmonize and Preserve Decoction) from *Shiyao Shenshu*. When Lung Metal Fire is excessive, it boils fluids into Phlegm. Damaged fluids prevent lung lobes from hanging moistly. Qi from the lower Liver and Kidneys steams upward, causing scorched, elevated lung lobes that cannot regulate, leading to rebellious Qi and cough. The more rebellious the Qi, the longer the cough persists. This formula moistens the Lung, eliminates Phlegm, stops bleeding, and harmonizes Qi. It treats all patterns including Cold-to-Fire transformation, Fire stagnation, Phlegm-Blood, Atrophy, and Dryness. For external injuries transforming into deficiency cough and consumption, this is the primary formula. For Lung Yin deficiency with internal dryness generating Phlegm and blood, leading to atrophy cough, or post-hemorrhage Lung dryness causing atrophy, Phlegm condensation, Qi stagnation, and chronic cough, this is an internal injury. Treat the Lung directly, and other symptoms will resolve. Use Qingzao Jiufei Tang (Clear Dryness Rescue the Lung Decoction), sweet-cool and moistening, to tonify Stomach Yin and generate Lung Metal. Once Lung Metal is clear and moist, Fire descends, Phlegm clears, Qi regulates, and cough stops. Add Shengdi for blood depletion, Xijiao (Rhinoceros Horn - substitute with Niuhuang or others clinically) for severe Fire, Beimu (Fritillaria) for abundant Phlegm, and Huyang for bleeding. These two formulas detail treatments for Lung Meridian deficient Fire. Most blood patients have Yin deficiency with hyperactive Fire; 80-90% respond to these methods. A few have Lung Meridian deficiency-Cold. The *Neijing* states: "Cold form and cold drinks injure the Lung." The Lung dislikes Cold, manifesting as frothy saliva and upward Qi. Zhang Zhongjing uses Gancao Ganjiang Tang (Licorice and Ginger Decoction). The *Jingui Yaolue* notes enuresis and frequent urination because upper deficiency fails to control the lower. Clear evidence of deficiency-cold enuresis justifies warming with Gancao Ganjiang Tang. Pulse must be deep, wiry, slow, and faint; Phlegm clear and profuse, unlike patterns treated by Qingzao or Baohe Tangs. Thus, warming herbs are indicated. I suggest Liu Junzi Tang (Six Gentlemen Decoction) as the base, adding Danggui, Baishao, Paojiang (Prepared Ginger), and Wuwei Zi, suitable for stopping cough and bleeding. This formula also suits Spleen deficiency-Cold with Phlegm-induced cough. For Spleen deficiency-Fire generating Phlegm and blood, use Xiaoyao San (Free and Easy Wanderer Powder) modified with Cundong, Ou Jie, and Huyang. For Liver deficiency-Fire generating Phlegm and blood, use Xiaoyao San modified with Danpi, Shanzhi (Gardenia), and Wuwei Zi. For Kidney deficiency-Fire generating Phlegm and blood, see Saliva/Blood Spitting sections. Liver/Kidney deficiency patterns see Vomiting Blood section. Descending衝 Qi (Chong Qi) see Vol 6 Cough section.
3. Phlegm Cough: When Phlegm-Fluids and Excess-Heat in the Lung cause Qi rebellion and hemoptysis, "stirring soup to stop boiling" is inferior to "removing firewood from under the pot." Xiefei Wan (Drain Lung Pill) is primary. Hemoptysis is always associated with Phlegm. Qi moves Blood; Blood carries Qi. When Blood is scant, Qi cannot be carried, accumulating internally as Heat. Heat burns fluids into Phlegm. Thus, high Fire means abundant Phlegm; abundant Phlegm obstructs Qi flow, causing accumulation and increasing Heat. So, severe Phlegm increases Fire. Tonifying deficiency here aids Evil; expelling Evil here worsens deficiency. Only combined attack and tonification achieve balance. First, use Xiaohua Wan (Digestion Pill) from *Shiyao Shenshu*, swallowed with maltose before bed, to attack excess. Then, dissolve Taiping Wan (Peace Pill) to tonify. Combined attack and tonification is a妙法 (wonderful method) to remove violence and protect goodness. Contemporary physicians only use tonification, harming many. If patients fear Xiaohua Wan, start with Erchen Tang (Two-Cured Decoction). Erchen directs Qi downward and promotes diuresis, a Phlegm-resolving agent. To benefit Lung Qi, add Xingren, Suzi, and Sangpi. For rebellious cough and inability to lie flat due to Water-Fluid attacking the Lung, add Tingli (Descurainia) and Dazao (Jujube). For severe Fire, add Gualou Shuang (Trichosanthes Peel), Huangqin (Scutellaria), and Lalian (Coptis); for mild Fire, add Cundong and Zhimu. For Wind-Cold, add Chaihu, Jingjie, and Fangfeng. For Blood level involvement, add Danggui, Baishao, Danpi, and Taoren. These treat excess Phlegm. Deficient Phlegm arises from Lung Yin deficiency and dryness, sticking to the throat, obstructing voice, causing wheezing, cough, fever, and fine-rapid pulse. Avoid diuretics to prevent further fluid damage. Moisten to generate fluids; once fluids return, Phlegm resolves. Use Baohe Tang, Qingzao Jiufei Tang, or Ziwan San (Aster Powder). If Phlegm nodules block the throat (Plum-pit Qi) due to Heart Fire condensing Phlegm, use Huotan Wan (Resolve Phlegm Pill) modified with Niubangzi (Arctium Fruit); or Xiangsu Yin (Fragrant Perilla Decoction) modified with Jiegeng, Zhike, Jianbei, Fuling, Xuanfu (Inula Flower), Gancao, treating this pattern. For Stomach pain disturbing the Diaphragm with chest/hypochondriac fullness, cough, wheezing, and hiccups, common in blood patients, use Mengshi Guntan Wan (Calamine Rolling Phlegm Pill). For Stomach Qi deficiency with Phlegm-Fluids, use Xuanfu Daizhe Shi Tang (Inula and Hematite Decoction). To treat Blood level, add Danggui, Baishao, and Sumu (Sappan Wood); to treat Heat, add Cundong and Kuqin. Hiccups see Vol 6. This discussion on Phlegm cough is not exhaustive. Phlegm cough also results from Liver Qi rebelling, harassing the Lung, carrying Phlegm and obstructing Qi, causing cough with bitter taste, headache, red cheeks, anger, and hypochondriac pain. Use Wendan Tang (Warm Gallbladder Decoction) modified with Qingpi, Baijiezi (White Mustard Seed), Chaihu, and Shanzhi. For rampant Liver Fire, add Jianghuang (Turmeric) and Dahuang (Rhubarb). For Liver deficiency-Fire stagnation generating Phlegm, use Danzhi Xiaoyao San (Moutan and Gardenia Free and Easy Wanderer Powder) modified with Longgu (Dragon Bone), Muli, Ejiao (Donkey-hide Gelatin), and Beimu. Phlegm-Fluid disease has its manifestation in the Lung but its root in the Kidney. Kidney Water flooding upward is Phlegm-Fluid. Phlegm-Fluid attacking the Lung causes cough. Thus, treat Phlegm-Fluid focusing on the Kidney. For Kidney Yang deficiency failing to control Water, causing chills and wheezing, use Zhenwu Tang (True Warrior Decoction) modified with Xixin, Ganjiang, and Wuwei Zi. If Kidney Water moves due to Cold, attacking Heart Fire, causing palpitations, wheezing, floating deficient Yang, sore throat, and facial heat, use Linggui Zhugan Tang (Poria, Cinnamon, Atractylodes, and Licorice Decoction) modified with Xixin and Wuwei Zi to warm Cold and promote water metabolism. This legislation is for Phlegm-Fluid alone. Blood patients with Yin deficiency and Yang hyperactivity generally contraindicate acrid-dry herbs. Even if Kidney Yang fails to transform Water causing short urine, wheezing, and Phlegm-Fluid, only Shenqi Wan (Kidney Qi Pill) should be used to transform Yang from Yin, warming gently. Since Song/Yuan dynasties, this formula has been treasured for blood deficiency-consumption with upper Heat/lower Cold, floating Yang, and isolated Yin, guiding Yang into Yin. For Kidney Yang deficiency-floating, it is a treasure. For Kidney Yin deficiency-floating, it is unsuitable. Blood patients with floating Heat, confusion, Phlegm-wheezing, and cough usually have true Yin deficiency with unanchored Yang. The reason Yang is unanchored is Yin deficiency, not Yang deficiency. Using this formula directly generates Yang before Yin, worsening Yang hyperactivity—called "generating Yin via Yang" but actually accelerating Yin destruction. If truly upper Heat/lower Cold with external Yang/internal Yin, pulse at Chi position must be weak, stool/urine loose, extremities cold, and drinking one part producing two parts urine. Then this formula is miraculous. If purely Yin deficiency, do not use it. If attempting to generate Yin via Yang, use minimal Guizhi and Fuzi (Aconite) as counter-agents. E.g., use Zhi Mu and Huang Bai (5 qian each) for nourishing Yin, but only 5 fen of Guizhi to guide Yang from Yin. Do not use much Guizhi/Fuzi to fight Yin with Yang. For Kidney Yin deficiency with Fire rising and Water ascending, condensing into Phlegm, use Zhuling Tang (Polyporus Decoction). Dihuang Tang (Rehmannia Decoction) modified with Maidong, Wuwei Zi, Xuanfu, Ejiao, Xingren, Gejie (Gecko), and Niu Xi (Achyranthes Root) follows Zhang Zhongjing’s Zhuling Tang intent with greater tonifying power. See Hemoptysis section for details.
4. Qi Cough: No Phlegm or Blood, merely Qi irritation causing cough. This is true Yin deficiency in blood patients, leading to unconsolidated Lung Qi and ungrasping Kidney Qi. It is severe and difficult to treat. If due to unconsolidated Lung Qi, the patient cannot lie supine; lying down causes Qi rebellion and cough, with palpitations below the heart. If lung lobes are partially atrophic, they lie on one side, coughing upon turning. Treat all with Qingzao Jiufei Tang modified with Baihe (Lily Bulb), Wuwei Zi, Hupo (Amber), and Zhongru Shi (Stalactite) to settle and tonify Lung Metal. Protected Metal can cover and consolidate, stopping cough. If due to ungrasping Kidney Qi, the patient has shortness of breath, wheezing, Yin Fire rushing up, red malar eminences, and throat discomfort. Zhang Zhongjing said: "Hemoptysis with rapid pulse, fever, and cough is untreatable," referring to this severe pattern of Yang failing to attach to Yin and Qi failing to return to the Source. Use Liuwei Wan (Six-Ingredient Pill) modified with Chenxiang (Agarwood), Wuwei Zi, Maidong, and Cishi (Magnetite) to tonify and grasp. This attracts Qi to the Kidney, generates Kidney Water, and seals Qi, stopping rebellious cough. Alternatively, use Shenqi Wan modified with Maidong, Wuwei Zi, and Niu Xi, borrowing Guizhi and Fuzi to guide Qi to the Source. Chen Xiuyuan stated: "Lung-Kidney non-interaction, Water and Heaven both deficient," use Erjia Longgu Tang (Double Added Dragon Bone Decoction) modified with Ejiao, Maidong, and Wuwei Zi. I note that Shenqi Wan and Erjia Longgu Tang treat Kidney Yang deficiency, Lung Yin deficiency, upper Heat/lower Cold. If Lung-Kidney Yang are both deficient, Yuan Qi fails, causing exhaustion and wheezing, use Baoyuan Tang (Preserve Origin Decoction) modified with Wuwei Zi. The above two are inappropriate. If Lung-Kidney Yin are both deficient, the above three miss the mark. Wheezing and cough in blood patients are mostly Yin deficiency. Qi is born in the Kidney and governed by the Lung. Sufficient Lung Yin keeps airways moist and unobstructed; sufficient Kidney Yin stores Qi roots internally. Insufficient Lung Yin causes dry Qi cough; insufficient Kidney Yin causes floating Qi cough. This is Lung-Kidney Yin deficiency non-interaction. Treat with Shenmai Dihuang Tang (Ginseng, Ophiopogon, and Rehmannia Decoction) and Santang (Three Immortals Decoction) to nourish both Zang Yin. To grasp Lung Qi, add Baihe, Wuwei Zi, Zhongru Shi; to grasp Kidney Qi, add Cishi, Chenxiang, Wuwei Zi. For Chong Qi rebellion, see Vomiting Blood and Vol 6 Cough sections.
5. Bone-Vapor Cough: Chronic cough in blood disorders with fever and night sweats is called Bone-Vapor Consumptive Cough. It involves Liver Blood level stasis, causing Liver Qi stagnation. The Liver houses Ministerial Fire; Liver Qi is Ministerial Fire. Ministerial Fire circulates internally in Sanjiao and externally in interstices. Without Blood stasis, interstices are open, allowing Ministerial Fire to circulate, warming muscles without oppression, preventing coldness or fever. Women with irregular menstruation often have chills/fever during periods due to Blood stasis. Similarly, bone-vapor in blood disorders is due to Blood stasis suppressing Ministerial Fire. Xiaochaihu Tang clears and resolves this. If prolonged...