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Pediatrics class one

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Pediatrics class one

    Pediatrics class one

    Introduction:

    Pediatrics of TCM studies the growing of children and prevention and treatment of infants and children‟s diseases.

    The treatment of children has undergone evolutionary changes in Chinese medicine. Chinese pediatric dates back several thousand years. Pediatric treatment was mentioned in the Nei Jing. In the twelfth century Song dynasty, the famous child specialist, Qian Yi, wrote the first pediatric textbook that recognized children as unique beings with distinctive physiology and pathophysiology of diseases that merit different diagnoses and treatment from adults. During the Ming dynasty and the last dynasty_ Qing dynasty in the fourteenth to the beginning of twentieth century , pediatric flourished with formulation of specific herbal and TuiNa or acupuncture protocols for children, and introduction of preventive measures.

    Infants and children have unique physiological functions and pathophysiology of illnesses. The first class discusses general pediatric physiology and pathophysiology, followed by the characteristic in diagnosis and treatment of pediatric diseases.

Age stages ( Stages from birth to 12 years old)

    1. From birth to 28 days old (Newborn stage)

    In this age, mainly there are low temperature, or delivery injure such as head haematoma, tetanus neonatorium, etc . Newborn may has respiratory tract infection, even seizure.

    2. From 28 day to 1 year old (infant stage)

    In this stage, is a fast physical growth stage. After 6 months old, infants are easy to catch cold, and some infection diseases. Also with improper feed, easy to have digestion problem, such as diarrhea, vomiting, dyspepsia, infantile malnutrition. Eczema.

    3. 1 year old to 3 years old (Toddler stage)

    Except infection diseases of respiratory system and digestion system, delayed growing disease as five kinds of retardation in standing, walking, hair-growing, tooth eruption and the faculty of speech.

    4. 3 year old to 7 years old (preschooler stage)

    Important stage for psychological growth, except diseases of respiratory and digestion, epilepsy, wet-bed occur.

    5. From 7 years old to 12 years old(Pupil stage)

    From immature to mature in physical and psychological development, diseases are

    similar as adult, edema, asthma, autism, attention deficit disorder or attention deficit hyperactivity.

     Characteristic of physiology and pathophysiology

    The general physiology and pathology of children and childhood illnesses can be classified ad follows:

    ; General physiology of children

    „PURE YANG‟- maximum Yang.

    „YOUNG YANG AND YOUNG YIN‟

    „CLEAR VISCERAL QI‟

    ; General pathophysiology of childhood illnesses

    Easy onset- fragile and immature organs, pathogenic evils enter easily

    Rapid transformation disease progression and changes occur quickly

    Rapid recovery

    Physiology

    Pure yang

    The doctrines of pure yang metaphor fast growth of children, looking like the rising Sun, vigorous. The first characteristic of physiology is

    1. vigorous body with fast growth. The term „pure yang‟ does not imply that the child

    is devoid of yin. The child has special Yang Qi, which is not include in adults- the

    process of growth and development. Pure yang refers to the fact that the child has

    pure or maximum potential for growth. Just as a seed or a young tree has the full

    potential of becoming a full grown tree, the zygote has the fullest potential of

    becoming a human being.

    Young yang and young yin

    The doctrines of young yin and young yang metaphors the child‟ s skin is tender and Wei Qi is weak. The internal organs are delicate and immature and Qi within them is insufficient. So the second characteristic is

    2. Organs delicate and immature and insufficiency of Qi and blood and essence.

    The physiological functions both Yin and Yang of the internal organs are not well

    developed.

    Young yin and young yang also means pure /clear visceral Qi which is uncontaminated.

Pathology

    1. Easy onset: Child is easy to sick by the attack of pathogen. The child „s skin is

    tender and delicate, and Wei Qi is low and internal organs are delicate and

    immature (young yin and young yang), so pathogens can easily enter the child and

    cause diseases and illnesses.

    Young yin and young yang in lung- Lung is delicate and lung qi is insufficient.

    Children are predisposed to catch cold, cough, fever, sore throat, asthma, etc. Young yin and young yang in spleen-Spleen Qi is insufficient. The spleen in children

    is „immature‟ and constitutionally weak. Unhealthy diet in modern day further contributes to spleen deficiency. The stressful lifestyle of children and excess school pressure can cause more deterioration of spleen function. There is impairment of all spleen function_ transformation and transformation of food essence, production of qi and blood, holding blood in the blood vessel, mentally responsible to concentration and clear thinking, especially spleen dysfunction may cause insufficient Ying Qi and blood, along with a tendency toward accumulation of phlegm. So children are predisposed to have digestive problem, manifest as colic in infancy, indigestion, abdominal pain, diarrhea, vomiting, anemia.

    Young yang and young yin in kidney- Kidney insufficiency. Growing of bone, marrow,

    hair, ears, and teeth, all is related with kidney function. During growing, kidneys are in

    insufficiency condition and gradually enrich. Some diseases related with delayed development in children are caused by kidney insufficiency.

    Liver yin is insufficient, and liver yang tend to hyperactivity. Child‟s is easy to have

    fever and seizure(convulsion), epilepsy, attention deficit hyperactivity disorder. Heart blood deficiency, spirit unsettle. Child „s problems is to develop into coma, and

    night crying and anemia are common child‟s diseases.

    2. Rapid Transformation: Child’s diseases are easy to have syndrome change.

    Once the pathogen enters, because of the delicate Qi and fluid balance, “young

    yang and young yin”, disease processes undergo easy and rapid transformation

    form cold syndrome to heat syndrome, excess syndrome to deficiency syndrome,

    deficiency to excess, or even the simultaneous exhaustion of both yin and yang.

    3. Rapid recovery: With pure yang (vigorous Qi) and clear visceral Qi, child‟s

    illnesses are more responded to the proper treatment. Children tend to recover

    rapidly from illnesses.

Diagnosis

    Inspection is more important diagnosis method in pediatric.

    Inspect face and five senses. Pay attention on color and vitality, facial inspection in children stress on special facial area.

    ; Shan Gen, root of mountain :between eyebrows. Shan Gen, “root of mountain”, is

    the area at the root of the bridge of the nose between two eyes. This area is the

    below the Yintang point. Greenish veins visible on the face indicate week spleen

    in infants and small children. The more prominent the vein, the weaker is the

    spleen. Veins with bluish tinge indicate kidney involvement, possibility kidney

    weakness in constitution.

    ; Yintang: is related with lung. Red and dry skin in children indicates heart and

    lung internal heat. Dark and blackish is a sign for pre-coma.

    ; Right cheek indicates lung, left cheek indicates liver. Forehead indicates heart.

    Nose indicates spleen and chins indicates kidney.

    Inspect tongue, food accumulation show thick tongue, geographic tongue indicate kidney deficiency, or stomach yin deficiency.

    Pediatric tongue-play symptom

    Inspect Two Yin

    Inspect skin rash and eruption: mostly indicates heat/fire in blood or damp-heat in spleen and liver. From the distribution and color of the skin rash and eruption, we can evaluate the severity of the illnesses and differentiate diseases.

    ; Erythematous, maculopapular rash usually is viral exanthema, measles, rubella,

    or scarlet fever in acute condition which is blood heat. In chronic condition, is

    purpura caused by blood heat or Qi deficiency.

    ; Vesicular rash is varicella, i.e., chickenpox, in Chinese medicine, it is damp heat

    febrile diseases.

    ; Hives are due to blood heat.

Special inspection: Vessel of Three Bars at the Tiger’s Mouth

    Chinese pediatricians have inspected the vein at the base of the side of the palmar surface of the index finger(Hu kou San Guan) in children under age 3, to determine severity of illness. It is located between the thumb and index finger when both are fully extended. The three bars are the three joints of the index finger. Look for any visible vein.

    ; Wind bar is at the metacarpophalageal (MCP) joint.

    ; Qi bar is at the proximal interphalangeal (PIP) joint.

    ; Life bar is at the distal interphalangeal (DIP) joint.

    Look at the depth, color, size, and location, for indications of heat, cold, deficiency, excess, progression, and seriousness.

     Listening and Smelling

    Listening voice and crying, cough.

    Smelling breath, vomit, stool and urine.

Inquiring

    Generally, pediatrician need to know from inquiring about chief complaint, history of present history, detailed dietary history, sleep, activities, prenatal and perinatal history, past medical history, review of systems, family history, and social history.

Palpation

    Pulse: pulse diagnosis can be done in children over 3 years of age (the vein on the finger is examined prior to age 3). In young children, the three position of the pulse may be too close to be palpated by individual fingers, so that the examiner can use the thumb to get an overall impression of all three positions. |In older children, it is often possible for the examiner to place fingers close together for three-finger palpation.

    Generally, a much more simplified pulse-taking is used in children than adult: pulses are classified as strong or weak, fast or slow, superficial or deep, regular or irregular. Strong pulses are seen in excess conditions ; weak pulses in deficient conditions; fast pulses in heat, slow in cold conditions; superficial pulse in exterior conditions whereas a deep pulse signifies penetration into the interior.

    The pulse rate in children is faster than adults and varies with age as follows:

    ; Newborn: 120-140 beats/minute(7-8 per breath)

    ; 1 year : 110-120(6-7 per breath)

    ; 4-6 year :110(6 per breath)

    ; 8 year: 90 (5 per breath)

    ; 14 year: same as adult.

     Body palpation: is done at the superficial and the deep level, mainly on skin, head, abdomen, palms and soles.

    Superficial palpation can feel the skin of child for subtle temperature differences. Deep and firm palpation can find inside abnormal appearance.

    Skin temperature: Warmer indicates excess heat or yin deficiency(especially on palms and soles), lower temperature(especially palms, sole, abdomen, back) indicates deficiency.

    Fontanelles: babies‟s fontanelles should feel soft. The posterior fontanelle usually closes at 2-3 months of age, and the anterior fontanelle closes between 12 and 18 months of age. Delayed closure may reflect kidney essence deficiency, a bulging fontanelle may indicate increased intracranial pressure as in meningitis, which is damp heat of the brain. A sunken fontanelle may be associated with dehydration, which correlates to yin (fluid) deficiency or yang excess.

    Neck and armpit check for glands (lymph nodes): children usually have palpable glands in the cervical, postauricular areas because of frequent URI, sore throat, and ear infection (exterior wind-heat syndrome).

    Nontender and smooth feeling is normal condition. But nontender nodes are also considered to be sites of phlegm accumulation where qi flow is sluggish, and are often found in chronic illnesses. Red, swollen, tender glands indicates presence of heat or toxin.

Treatment

    1. Prescription should be done in time, correctly.

    Because the characteristic of changing and transforming rapidly in disease process, treatment for children should be provided in time. Incorrectly treatment injure children‟s

    health more serious than adult because the young yin and young yang body constitution. Pediatrician should be very careful to do diagnosis and treatment.

    2. Don’t over-dosage.

    With the constitution of delicating, vigorous, children‟s illnesses are more responded to

    the treatment. So when treating children‟s problem, be cautious to the herb which are extreme bitter, cold, pungent, hot tastes. Don‟t use toxin herb. Each visit, prescript herb formula for shorter period (less than 4 days) over-dosage may injure Zheng Qi. 3. Convert dosage between adult and child.

    Newborn is 1/6 of adult. Infant and toddler is 1/3 to ?. Child under 6 years old can be 2/3 of adult. Child above 6 years old can be used adult dosage.

    4. cooking and taking method.

    Under 1 year old: 60-100 ml daily

    1-6 years: 150-200 ml a day

    7-12 year old: 200-250 ml.

Other treatment

    1) TuiNa: In pediatric, Tui Na is more effective than adult to treat internal disease.

    Common diseases can be treated by Tui Na have: cold and fever,asthma, dyspepsia

    and indigestion, infantile malnutrition, diarrhea, convulsion, abdomen pain,

    constipation, Wei syndrome, wet bed, etc.

    Special Tui Na method for children

    Opening Tianmen:

    1. location: the part above the line between the eyebrows up to the anterior hair line. 2. Manipulstion: Pushing straightly with radial surface or face of thumbs alternatively

    from below to above. Do 30 to 50 times.

    3. Function: dispelling wind, relieving exterior syndrome. For fever, headache, cold due

    to wind cold, etc.

    Parting_pushing Fu Yin-yang and rubbing the abdomen

    1. location: on the abdomen

    2. Manipulation: Parting-pushing obliquely down with the face of the thumbs or ribbed

    surface of the index, middle, ring and little fingers simultaneously from Zhongwan

    point to both sides is called “parting-pushing Fu Yin-yang. Rubbing the abdomen

    with the palm or the four fingers is called “rubbing the abdomen” Palm-rubbing

    clockwise mean reduce, otherwise, means reinforcing.

    3. Function: regulating qi, promoting digestion, for abdomeinal pain, abdominal

    distention, ingestion, nausea, vomiting, food retention in stomach, rubbing the

    abdomen by reduce method can treat constipation.

    Qijiegu

    1. Location: the line from the fourth lumbar vertebra to caudal vertebra. 2. Manipulation: (1) push-up Qijiegu: Push straightly from coccyx up to the fourth

    lumbar vertebra with the radial surface of the thumb or ribbed surface of index and

    middle fingers. Have function of warming yang and relieving diarrhea. (2). Push-

    down Qijiegu: push from the fourth lumbar vertebra to the end of coccyx with the

    radial surface of the thumb or the faces of index and middle fingers. Have the

    function of expelling pathogenic heat to treat constipation.

    Hand Massage: Old saying : “ All the channels and collaterals of children converge in

    the hands.”

    Points of spleen, liver, heart, lung, and kidney, large intestine, small intestine. Nipping-kneading Sihengwen for infantile malnutrition.

    Nipping-kneading Xiaohengwen for reduce fever, relieving distention. Kneading Zhangxiaohengwen.

    Clearing Weijing.

    Arc-pushing Banmen.

    Pushing from Banmen to Hengwen.

    Pushing from Hengwen to Banmen

    Kneading Neilaogong.

    Shuidilaomingyue(fishing for the Moon in the water).

    Arc_pushing Neibagua.

    Nipping-kneading Xiaotiaoxin.

    Kneading Zongjin.

    Parting-pushing Dahengwen.

    Nipping Shixuan.

    Nipping-kneading Ershanmen

    Nipping-kneading Erma.

    Kneading Wailaogong

    Kneading Yiwofeng.

    Pushing Sanguan.

    Pushing Liufu.

    Clearing Tianheshui.

Ni Ji therapy (Spinal Pinch pull)

    Technique: begin at the sacrum with one hand on each side of the spine. Grip the skin with both of therapist thumbs and index fingers. Gently lift up and begin moving along the spine. Continuously rolling the skin up and lifting it away from the spine. Continue

    along the length of the spine to the base of the neck. 3-5 times for one treatment. Once day, 6 treatments for one course.

     Action: regulate yin, yang, qi, and blood; harmonize organs, promote smooth meridian function, tonify deficiency.

Prick Sifeng

    Technique: prick to squeeze out a small amount of yellowish viscous fluid at the location of palm of hand, midpoint of lines at the second segment of all four fingers. Action: poor appetite, malnutrition and indigestion syndrome in children.

    Pediatric class two

    Cold

    Cold is caused by attack of six evils, especially wind cold or wind heat. Manifest fever and chilly, running nose, cough, etc. Occur in four seasons, more in spring and winter. During the disease process, it may have complicated cases such as convulsion, dyspepsia, phlegm syndrome, etc.

    Children who catch cold need treatment to fast recovery. Some children suffer from frequently catching cold. To them, the purpose of treatment is that strengthening the body resistance and prevents the cold recurrence.

    Pathogenic factors and pathogenesis

    Main pathogenic factors: wind cold, wind heat, or summer heat with dampness. Through mouth and nose, affect lung organ. Obstruction of the lung-qi will cause the symptoms of running nose and stuff nose and cough. Incoordination of Ying Qi(nutrient Qi) and Wei Qi(protective Qi) cause fever and chilly.

    Because of pure yang and young yang and young yin constitution, with insufficiency of liver, during cold with high fever, convulsion(seizure) may occur. With insufficiency of spleen, some children may combine with food accumulation and have symptoms of distension of abdomen and vomiting and diarrhea. Pathogenic factor enter deeper, affecting more lungs‟ function, manifested cough with lots of phlegm.

    With deficiency of Wei qi and lung qi and spleen qi, failure of superficial-qi to protect the body against disease, some children repeatedly catch cold.

    Diagnosis

    1. Main symptoms: fever, chilly, stuff nose and running nose, sneeze, itching of throat

    or sore throat. Or accompany with cough. If having complicating symptoms may

    companies with vomiting, diarrhea, distension of abdomen, or high fever with

    convulsion.

    2. Occurring in four seasons, always occurring when suddenly change of weather,

    abnormal cold weather or hot weather.

    3. If symptom is more severe, and with epidemic spread, it is flu. Flu treatment is

    similar as cold.

    4. If patient often catch cold more than twice a month, it is deficiency cold. For

    deficiency cold, not only treat the child when he catches cold, should also treat the

    child before he catch the cold.

    5. Should differentiate cold from dyspnea and cough due to pneumonia, measles, and

    chickenpox.

    Differentiation and Treatment

    1. Cold due to wind cold

    Manifestation: fever with chilly, no sweating, headache, stuff nose and running nose,

    sneeze, cough, absence of thirsty, thin white tongue coating, superficial and tense pulse Treatment principle: relieving the exterior syndrome with pungent and warm nature of herbs.

    Formula: Modified Jing Fang Bai Du san

    Ingredient: qiang Huo, chai hu, qian hu, zhi ke, fu ling, jing jie, fang feng, jie geng, chuan xiong, gan cao.

    Headache: add ge gen, bai zhi.

    Vomiting: add Ban Xia, zi su.

    Flu with high fever, add Da Qing yie, Ban Lan Gen, Pu Gong Ying. Or using Chai Ge

    Jie Ji Tang( Cai hu, ge gen, gan cao, huang qin, qiang huo, bai zhi, shao yao, jie geng). Other treatment:

    Cupping: on back, along foot tai yang meridian.

    Simple formula: Cong Chi Tang for mild case of cold due to wind cold. (Chinese green onion stalk and fermented soybean.

    2. Cold due to wind heat

    Manifestation: more severe fever, aversion to wind, sweating, but fever not relief after sweating. Headache, stuff nose, or yellowish nose discharge, cough, thick sputum or thick yellow sputum, sore throat, thirsty, red tongue, thin white or thin yellow and dry coating, superficial and rapid pulse.

    Treatment: Relieving the exterior syndrome with pungent and cool nature herbs

    Formula: Yin Qiao San

    Ingredient: Yin hua, Lian Qiao, Jie geng, bo he, Zhu yie, Gan cao, Jing jie, Dan Dou Chi, Nu bang zi,

    More cough, add Sang Yie, xing ren.

    Sore throat, add xuan shen, ban lan gen.

    Other treatment: Gua Sha threapy.

    Another syndrome called as fire wrapped by cold. This is the accumulated heat in the interior complicated by the exposure to exogenous cold. Manifest aversion to cold, absence of sweating, fever, running nose, sore throat, and cough with yellow thick sputum. Treatment should expel the pathogenic factors from both interior and exterior of the body. Herb as jing jie, fang feng, or ma huang, Dan dou zhi pungent warm nature, combined with lian qiao, Po he, and Shi gao, Huang qin cold nature herb to clear interior heat.

    3. Cold due to summer heat

    Manifestation: High fever, no sweating, headache, heavy sensation of the body, fullness of chest and nausea, poor appetite, or accompanied with vomiting, diarrhea, cough, thin white coating or greasy coating, rapid pulse.

    Treatment: Eliminating summer heat from superficies of the body by diaphoresis Formula: Xin Jia Xiang Lu Yin.

    Ingredient: Xiang ru, Yin hua, Bian dou hua, hou po, lian qiao,

    With dampness factor, has nausea and yellow greasy tongue coating, add Pei Lan, Huo Xiang.

    Diarrhea symptom, add Ge gen, Huang Qin, and Huang Lian.

    Other treatment

     Pediatric Massage

    Opening Tianmen, Parting-pushing Kangong, Kneading Taiyang(Extra2), Kneading Erhougaogu and conducting Huangfeng Rudong

    Modification: Cold due to wind cold: Kneading Ershanmen and pushing Sanguan. Cold due to wind heat: clearing Feijing and Tianheshui and pushing Tianshugu. With sputum: Kneading Rupang and Rugen and rubbing Xielei.

    With stagnated food: Reinforcing Pijing, kneading Banmen, Arc-pushing Bagua and rubbing the abdomen.

    With fear: Clearing Ganjing and pinching-kneading Banmen, arc-pushing Bagua and rubbing the abdomen.

    With cough: Pushing-kneading Tanzhong and kneading Feishu.

    4. deficiency cold

    Manifestation: fever but not very high, recurrence, spontaneous sweating, pale complexion, aversion to wind and cold, blocking of nose and running nose, tiredness, poor appetite, or cough, light red tongue color and delicated tongue, thin white coating, thready and weak pulse.

    Treatment: Regulating Ying and Wei to treat disharmony between ying and wei. Formula: Huang Qi Gui Zhi Wu Wu Tang

    Ingredient: Huang qi, Gui zhi, Bai shao, Sheng Jiang, Gan cao, Da Zao. Modification: aversion to cold and stuff nose, add Jing jie, Fang feng. Cough, add Xing ren, Zhe Bei Mu, Qian Hu.

    With deficiency of qi and yin, irregular fever, night sweating, cough, dry mouth, red tongue and less coating, add Yu Zhu, Dan pi, Sha shen, Bai bu.

    Complication symptoms

    1. with fear: Symptoms as cold symptom accompanied with night cry due to fright,

    restlessness in sleep, even convulsion with hyperphoria. Yin Qiao San, add Ju Hua,

    Gou Teng, Shi Jue Ming, Can Dui.

    2. With stagnated food. Symptoms as cold symptoms accompanied with distention of

    abdomen, belching with food smell. Even vomiting, loose bowel, thick and greasy

    tongue coating, rapid pulse. Add Shen qu, Mai Ya, Shan Zha, Zhi ke, Lai Fu Zi.

    3. With sputum: more phlegm, even short breath with phlegm sound in the throat and

    trachea. cold phlegm, add Er chen Tang plus Su Zi; heat phlegm, add Hai Ge Qiao,

    Sang Bai Pi, Ting Li Zi.

    Cough

    Cough can be a symptom in upper respiratory tract infection, but it is a mainly symptom. Mostly cough is caused by exopathogen factors, which affect lung. Some cough is caused by endogenous factors.

    In western medicine, it is mostly related with trachitis and bronchitis.

Pathogenic factors and pathogenesis

    Main pathogenic factors: exopathogenic factors as wind, cold, summer heat, wetness, dryness and fire.

    Affecting organ is lung, second is spleen.

    Pathogenesis; exopathogenic factor, mainly wind, often combined with cold or heat, affect lung, lung qi is unable to dispersing, so cough occur.

    Wind -cold syndrome can have symptoms of stuff nose and running nose with thin clear discharge.

    Wind-heat syndrome can have symptoms of dryness of nose or with thick nose discharge. Wind- dryness syndrome may manifest dry cough, dry throat and lips. In endogenous factors, Phlegm is produced in the spleen, stored in the lung and lung qi is unable to disperse and descend, so cough occurs.

    Liver fire steam fluid to form phlegm and stay in lung also cause cough. Heat-fire in heart channel steam fluid to form phlegm cause cough. Long term cough can exhaust lung qi and lung yin, Both qi and yin deficiency make cough worst and difficult to cure.

    Diagnosis:

    1. Main symptom is cough, with or without exopathogenic symptoms, with or without

    phlegm. Mostly at beginning, catch cold, after cold symptoms subsidence, cough

    become patients‟s main suffering.

    2. Should differentiate cough from pertussis(whooping cough), asthma due to

    pneumonia.

    Differentiation and treatment

    Should differentiate cough due to exopathogenic factors or cough due to internal injure. Also should differentiate excess type or deficiency type, cold type or heat type. Treatment principle: for exopathogenic cough, dispel exopathogenic factors and promoting the dispersing and descending function of lung qi. For cough due to internal injure, focus on which organs have been involved, according to the differentiation to decide the treatment plan.

    Cough due to exopathogenic factors

    1. Cough due to wind cold

    Manifestation: cough with or without phlegm, thin white phlegm, itching of throat, accompanied with aversion to cold, stuff nose and running nose, no sweating, or fever, headache, light red tongue with thin white coating, supperficial and tense pulse. Treatment: dispel wind and cold, dispersing lung qi

    Formula: Xing Su San

    Ingredients: Su yie, Ban xia, Gan cao, Qian hu, Jie geng, Zhi ke, Ju pi, Xing ren, Fu ling, Sheng jiang, Da zao.

    For exterior cold symptoms, or with asthma, add Ma huang.

    dissolving phlegm, add Jin Fo cao, Su zi.

    With fullness of chest, or up-rising of qi, add Hou po.

    For heat wrapped by cold( exterior cold with interior heat), symptoms as hoarse voice, thirsty, sore throat, , add Ban lan Gen, Huang qin, Pi Ba yie.

    2. Cough due to wind heat

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