Dr Hu Xi-shu's (胡希恕) Clinical Experience in the Treatment of Cough
胡希恕中国百年百名中医临床家丛书
作者 :冯世纶主编
Traduction : Thomas van Gelder
19 octobre 2012
The main cause of cough is tanyin (phlegm-fluids). To treat it, one must warm, transform, and direct counterflow downward.
Prescriptions for treating cough are extremely numerous — one could even say innumerable. However, the formula that Dr Hu uses most often is Ban Xia Hou Po Tang. The main reason for this is that cough, in the Jin Gui Yao Lüe, is discussed in a chapter specifically devoted to tan yin. It is stated there that tan yin and cough have a close relationship: in many cases, cough is caused by tan yin attacking upward, whereupon qi ni (counterflow qi) prevents descent. Regarding the treatment of tan yin, the Jin Gui Yao Lüe — chapter Tan Yin Ke Sou Bing — states: "For diseases of tan yin, one must harmonize with warm medicinals" (病痰饮者，当以温药和之). This is a fundamental principle in the treatment of tan yin, as well as in the treatment of cough. Under this guiding principle, if one further selects the appropriate formula, results will prove highly effective.
Clinical case No. 1
Mrs Huang, female, 38 years old, patient No. 67951.
First consultation, 12 February 1966. For one week the patient has had a cough with white sputum, itchy throat, chest oppression, dry mouth without desire to drink, and distension of the hypochondriac region. Several doses of a decoction have already been administered without effect. The tongue coating is thick, white and greasy; the pulse is hua (slippery) and xi (thin). This pattern belongs to the category of tan yin attacking upward. The Lung has lost its function of diffusion and descent. The treatment consists of warming, promoting transformation, and directing counterflow downward, using a modified Ban Xia Hou Po Tang.
Prescription:
Ban Xia 12g, Hou Po 9g, Fu Ling 12g, Zi Su Zi 9g, Ju Pi (Chen Pi) 15g, Xing Ren 9g, Jie Geng 9g, Sheng Jiang 9g.
Results: After two doses, the cough had stopped.
Originally, in the Jin Gui Yao Lüe — Fu Ren Za Bing chapter, Ban Xia Hou Po Tang treats the symptom of "a sensation as if a piece of roasted meat were lodged in the throat, in women" (the classical description of mei he qi 梅核气, "plum-pit qi"). Dr Hu considers that this formula derives from Xiao Ban Xia Jia Fu Ling Tang with the addition of Hou Po and Zi Su Ye. It is used for chest fullness, throat obstruction and cough caused by tanyin knotting the qi; it warms and transforms tanyin, directs counterflow downward, and rectifies the qi. This patient's cough is caused by tanyin; the prescription therefore matches the pattern and is highly effective. The original formula contains Zi Su Ye, but Dr Hu often uses Zi Su Zi instead. If there is a clear exterior (biao) pattern, one may add Zi Su Ye as well, or — depending on the pattern — combine with Gui Zhi Tang or Ma Huang Tang. If there are pronounced manifestations of heat, one may add Sheng Shi Gao. If there is an old-standing cough with cold phlegm-fluids but no clear exterior pattern, one may use Ling Gan Wu Wei Jiang Xin Xia Tang.
Long-standing stagnation of tan yin often transforms into heat. One must distinguish false heat from true cold.
In clinical practice, one sees many patients with cough who take a great deal of medication without any improvement — and sometimes with worsening symptoms. One of the main causes is failure to clearly distinguish cold from heat. By examining the treatment of case No. 2, this issue becomes clear.
Clinical case No. 2
Mr Li, male, 63 years old, patient No. 156679.
First consultation, 4 January 1966. Cough with expectoration of yellow-white sputum for four months. Since October the patient has had a cough with sputum and sore throat, and has been under treatment since that time. The cough has not diminished; on the contrary, dyspnea has appeared. The patient is very meticulous and brought with him all the medications he had been taking. The main prescription was a modified Sang Xing Tang. He himself reports having taken more than one jin (500 g) of Chuan Bei Mu.
Current symptoms: cough, abundant yellow-white sputum, heart vexation (xin fan 心烦) and chest fullness, aversion to cold in the back, dry mouth with desire to drink but stomach discomfort after drinking; yellow greasy coating, red tongue tip, pulse xian (wiry), hua (slippery) and xi (thin).
Dr Hu prescribed Xiao Qing Long Jia Shi Gao Tang:
Ma Huang 9g, Gui Zhi 9g, Xi Xin 6g, Gan Jiang 6g, Bai Shao 9g, Zhi Gan Cao 9g, Wu Wei Zi 9g, Ban Xia 15g, Sheng Shi Gao 45g.
At the end of the consultation, Dr Hu was asked whether it was appropriate to prescribe warm medicinals when the patient presented obvious manifestations of heat. He replied: "The patient has taken many medicinals that clear heat, and his symptoms have grown steadily worse. This shows that those medicinals do not address the pattern. Observing his current symptoms again — aversion to cold in the back, epigastric discomfort after drinking water — one perceives that there is retention of phlegm-fluids internally. This retention of cold phlegm-fluids has been treated with bitter and cold medicinals to clear heat and transform phlegm; not only did the phlegm fail to leave, but on the contrary, owing to injury of the body's yang, the tanyin has increased. As tanyin worsens and stagnates over time, it transforms into heat and attacks the Heart and chest — hence the heart vexation and chest fullness. If one does not treat the tanyin, the heat will not go away, and the cough will not settle. The cause of this type of pattern, where heat rises, is the simultaneous presence of external cold and internal phlegm-fluids. With Xiao Qing Long Jia Shi Gao Tang, one addresses the pattern. The use of Xiao Qing Long Tang releases the surface and dispels the phlegm-fluids — treating the root. The use of Sheng Shi Gao clears the ascending heat — treating the branch. Whether or not this proves effective, we shall see from the results."
Results: After 3 doses, heart vexation and chest fullness had diminished, expectoration of yellow sputum had slightly decreased, and dryness of the mouth had lessened. The tongue coating was white and slightly greasy. Xi Xin and Gan Jiang were increased to 9g, Sheng Shi Gao was reduced to 30g, and treatment continued for 6 more doses. After this, aversion to cold in the back had resolved, sputum had further diminished and was no longer yellow; Sheng Shi Gao was removed. Treatment continued for 12 further doses until the illness was fully resolved.
External cold and internal phlegm-fluids often attack together. One must simultaneously release the surface and expel the phlegm-fluids.
For a patient with chronic cough, Dr Hu begins with Xiao Qing Long Tang Jia Fu Ling. A physician in training once asked him: "What type of cough does this patient have — external attack or internal damage?" Dr Hu simply replied: "This patient has a cough that is externally of cold type and internally of phlegm-fluid type; with Xiao Qing Long Tang Jia Fu Ling, we address the pattern." The following case builds on this foundation and demonstrates the treatment of external cold combined with internal phlegm-fluids.
It should be emphasized that Zhang Jing-yue divided cough into two categories — external attack and internal damage. This is a theoretical division. In actual clinical practice, these two categories often coexist. Internal damage predisposes to external attack, and external attack leads to internal damage. Therefore, in clinical practice, it is not necessary to determine exhaustively whether the cough is due to external attack or internal damage. It is sufficient to examine the specific symptoms, perform pattern differentiation, and select the treatment accordingly. Subdividing cough into these two broad categories is, for beginners and for those without clinical experience, an easy classification to remember, but its clinical application often raises problems. As soon as a coughing patient is seen, external attack and internal damage can be neatly separated, and treatment can likewise be divided into diffusion-and-release versus tonification-and-support; but one often forgets that these patterns must be treated simultaneously. This is why the illness fails to improve over long periods. Clinical case No. 3 illustrates precisely this problem.
Clinical case No. 3
Mrs Xia, female, 32 years old, patient No. 106421.
First consultation, 7 January 1966. For 3 years, every winter and spring, the patient has had a cough. This time, the cough has already lasted 2 months. Previously, physicians had prescribed modified San Ao Tang and Xing Su San, without effect. Then they prescribed more than 20 doses of modified Zhi Sou San, still without effect. They then used modified Er Chen Tang and San Zi Yang Qin Tang, with no clear improvement.
Current symptoms: cough with abundant thin white sputum, aversion to cold in the back, cold extremities, dry mouth without desire to drink, chest oppression, epigastric distension and fullness, poor appetite, loose stools; tongue coating white and slippery, tongue body dusky; pulse chen (deep), xian (wiry) and xi (thin).
Dr Hu prescribed:
Ma Huang 9g, Gui Zhi 9g, Bai Shao 9g, Xi Xin 9g, Gan Jiang 9g, Zhi Gan Cao 9g, Wu Wei Zi 12g, Ban Xia 15g, Fu Ling 12g.
Results: After 3 doses, chest oppression and expectoration of white sputum diminished. After 6 further doses, the cough had clearly abated. Two weeks later, the cough had stopped and the other symptoms had also resolved.
At the end of treatment, Dr Hu emphasized once again that this was the principle for treating external cold with internal phlegm-fluids. This principle, which he had highlighted many times, accounts for the use of Gui Zhi Qu Shao Yao Jia Fu Ling Bai Zhu Tang, Xiao Qing Long Tang, and similar formulas to treat this pattern. In other words, this case likewise involves cold pathogen at the surface with shuiyin (water-fluids) internally. The shuiyin have ceased to circulate internally, causing internal blockage. The surface, in turn, cannot be relieved because it cannot draw upon the internal fluids and thus cannot be released. If one forcibly induces sweating to strongly diffuse the surface, this will stir the internal phlegm-fluids and transform the pattern in multiple ways. If one only promotes water drainage, one drives the pathogen deeper. This is equivalent to welcoming the invader and shutting the gate behind him — leading the wolf into the room. In this situation, one needs a formula that releases the surface while simultaneously using medicinals that drain water and expel phlegm-fluids. Only thus can one achieve the desired effect of treating both li and biao. In the prescription, Ma Huang, Gui Zhi, Bai Shao and Zhi Gan Cao induce sweating and expel the pathogen; Ban Xia, Gan Jiang, Wu Wei Zi and Fu Ling dispel cold and expel internal phlegm-fluids. Thus the biao is released and the li phlegm-fluids are eliminated, and the cough resolves on its own.
Dry cough is not necessarily without sputum. Transforming phlegm and directing qi downward is the method to arrest cough.
In clinical practice, one often sees a number of patients with dry cough. Yet Dr Hu prescribes medicinals to transform phlegm and direct counterflow downward — for example, Ban Xia Hou Po Tang, Ling Gan Wu Wei Jiang Xin Xia Xing Tang, and so forth. The cough can thereby be stopped very rapidly. One may be surprised and ask: "In many cases dry cough is due to yin deficiency or exuberant fire; the treatment should consist of nourishing yin, or of clearing heat and directing fire downward. Why treat it in this opposite way instead?" Dr Hu explains: "These are direct treatments (正治 zheng zhi), not paradoxical treatments (反治 fan zhi)."
His clinical observations back this up: many patients present with dry cough, take medications, and remain unhealed after several months. The case is briefly observed, pattern differentiation is performed, and the diagnosis given is Lung fire, Liver fire, or yin deficiency. Treatment with Huang Qin, Shan Zhi Zi, Sheng Di, Zhi Mu, Bei Mu is prolonged and ineffective. Why? In fact the reason is very simple. Pattern differentiation and treatment in Chinese medicine is based on the whole body — not on an isolated symptom. Tanyin attacking upward and provoking cough is one of the main causes of cough and dyspnea, and therefore expectorated sputum is one of the bases for pattern differentiation. But it is not the only symptom. Chinese medicine describes tan yin as a very broad concept. Cases without sputum and without cough are very numerous; cases of cough without sputum are also very numerous. The essential thing is to observe the whole and to differentiate the pattern. In the following case, this can be seen clearly.
Clinical case No. 4
Mrs Huang, female, 38 years old, patient No. 67951.
First consultation, 12 February 1966. Dry cough and itchy throat for more than a month. The patient first took modified Zhi Sou San, then modified Sang Xing Tang, modified Mai Men Dong Tang, and so on. Not only did the cough fail to improve, it became increasingly severe. At present: dry cough, itchy throat, dry mouth without desire to drink, belching, chest oppression, pasty-loose stools 1 to 2 times a day; tongue coating thick, white and greasy; pulse hua (slippery) and xi (thin).
Modified Ling Gan Wu Wei Jiang Xin Xia Tang was prescribed:
Fu Ling 12g, Xi Xin 6g, Wu Wei Zi 12g, Ban Xia 15g, Zhi Gan Cao 6g, Chen Pi 15g, Sheng Jiang 9g, Xing Ren 9g, Ku Jie Geng 9g, Zhi Pi Pa Ye 9g.
Results: After one dose, the cough diminished. After 3 doses, the cough had stopped.
This patient had dry cough, throat itching, and dry mouth — symptoms often seen in Lung heat, Liver fire, or yin deficiency. But she had no desire to drink, and she presented with belching, chest oppression, sparse pasty-loose stools, a thick white greasy coating, a slippery pulse, and so on: all of these indicate a tan yin pattern. The main reason for the dry cough is tan yin attacking the Lung; the Lung then loses its function of diffusion and descent. As for the dry mouth and throat itching, they arise because tan yin obstructs the jin ye (fluids), which can no longer support the upper body. To treat this type of dry cough by using bitter cold medicinals to clear heat, or sweet cold medicinals to nourish yin, would only make the tan yin obstruction more severe — and as the tanyin worsened, it would attack upward all the more. Treatment would become progressively heavier, delaying recovery. Whereas by treating the tan yin and matching the prescription to the pattern, health is restored after 3 doses.
When diffusing the Lung and transforming phlegm are both ineffective, harmonizing and releasing the shaoyang can achieve remarkable results.
Many cases of cough are principally caused by tan yin attacking upward, with the Lung losing its function of diffusion and descent. Diffusing the Lung and transforming phlegm is therefore the main method. However, sometimes this method proves unsatisfactory. One must analyse the causes, which are chiefly inaccurate differential diagnosis and a prescription that does not match the pattern. In some coughing patients, the pathogen lies neither in the exterior nor in the interior, but rather in the half-exterior half-interior. In such coughs, diffusing the Lung and transforming phlegm, releasing the biao and transforming the phlegm-fluids will of course produce no effect. But the method of harmonizing and releasing the shaoyang can bring about rapid recovery. This is clearly stated in the Shang Han Lun, as in article 96:
"In Shang Han or Zhong Feng lasting five or six days, with alternating aversion to cold and effusion of heat, the patient suffering from fullness of the chest and hypochondria, taciturn behaviour with no desire to drink or eat, heart vexation (xin fan 心烦) and frequent nausea; or agitation in the chest without nausea; or thirst; or abdominal pain; or a lump and hardness below the hypochondria; or palpitations below the heart with inhibited urination; or absence of thirst with mild fever; or cough — then Xiao Chai Hu Tang governs."
(伤寒中风，五六日，往来寒热，胸胁苦满，嘿嘿不欲饮食，心烦喜呕，或胸中烦而不呕，或渴，或腹中痛，或胁下痞硬，或心下悸、小便不利，或不渴、身有微热，或咳者，小柴胡汤主之。)
"Or cough" frequently appears in the Xiao Chai Hu Tang pattern, and here it certainly does not refer to a disease of cough per se, but to the combination of a typical Xiao Chai Hu Tang pattern with cough disease. It is then appropriate to use Xiao Chai Hu Tang to treat this type of cough. In such cases, Dr Hu often uses this formula as the base for treating cough.
Clinical case No. 5
Mrs He, female, 34 years old, patient No. 493816.
First consultation, 12 March 1965. Intermittent cough for 2 years. Two years ago, the patient caught a cold and then developed a cough. The cough is present throughout all four seasons; it worsens in winter and abates in summer. It manifests in a paroxysmal manner: in the morning at 10 am, in the afternoon at 3–4 pm, and in the evening at 8 pm. Over the past month, the patient attended a hospital of Chinese medicine, where more than 30 doses of herbal prescriptions were given (containing many medicinals that diffuse the Lung and transform phlegm, such as Xing Ren, Jie Geng, Qing Ban Xia, Gua Lou, Pi Pa Ye, Qian Hu, and so on), all without effect. Currently: cough with expectoration of foamy sputum, nausea, dry throat, no sweating, distension and fullness of the hypochondria; red tongue with thin white coating; pulse xian (wiry) and hua (slippery). Medical history: contracted tuberculosis in 1962.
Dr Hu prescribed modified Xiao Chai Hu Tang:
Chai Hu 9g, Dang Shen 9g, Ban Xia 9g, Huang Qin 9g, Da Zao 4 pieces, Zhi Gan Cao 6g, Sheng Jiang 9g, Jie Geng 6g, Bai Shao 6g.
Results: After 6 doses, the cough had diminished. Following this, Bai Shao was removed, and Zhi Shi 6g and raw Long Mu (Long Gu and Mu Li) 12g each were added. After 6 further doses, the hypochondriac distension and fullness had ceased. Then modified Ban Xia Hou Po Tang was prescribed; after 10 doses, the cough had stopped.
Special features of this case: the cough presented at regular hours. There was hypochondriac distension and fullness, nausea, and dry throat — a shaoyang pattern, which explains that the pathogen of the cough was neither in the exterior nor in the interior, but in the half-exterior half-interior. This also accounts for the fact that it was an old-standing cough: Stomach qi and wei qi (defensive qi) were vacuous. Using only medicinals to diffuse the Lung and transform phlegm cannot expel the external pathogen. One must use Dang Shen, Ban Xia, Sheng Jiang, Da Zao and Gan Cao to tonify the centre and reinforce the defensive qi; only then can the pathogen be expelled outward, and once the pathogen has gone, the cough resolves on its own.
In summary, the 5 clinical cases and 5 prescriptions above illustrate Dr Hu's principal experience in the treatment of cough. The prescriptions selected through pattern differentiation, and the methods used by Dr Hu in treating cough, are very numerous. Examples include Gui Zhi Jia Hou Po Xing Zi Tang, Ma Xing Shi Gan Tang, Sang Ju Yin, Ma Xing Yi Gan Tang, Xie Xin Tang, Mai Men Dong Tang, Ling Gan Wu Wei Jiang Xin Xia Xing Da Huang Tang, and so on. Whatever pattern is encountered, one must use the prescription that treats that pattern, and not limit oneself to "one formula, one method".