问曰。病有霍乱者何。答曰。呕吐而利。名曰霍乱。
此言无表证之霍乱也。有声无物为干呕。声物兼有为呕。有物无声为吐。呕则邪气在表。吐则邪气在里。
邪独在上。则呕而不利。邪独在下。则利而不呕。若为暴寒所中。寒邪直入中焦。太阴脾脏受寒。故胃中骤冷而
上吐下利。转筋腹痛。手足厥逆者。名曰霍乱。此皆六气胜复之变也。太阳寒水。及太阴湿土司天在泉之胜复。
或厥阴阳明之胜复皆有之。即少阳少阴二火司天在泉。或为诸寒湿之间气客气所胜者亦然。且尤于阴晴风雨。酷暑暴寒
之中。每每
有之。一家之中。一里之内。或阖境皆然。乃时行寒湿也。但霍字未详其义。大约是倏忽间吐泻扰乱之意耳。
成氏以挥霍撩乱解之。恐未必然。方有执云。灵枢五乱篇曰。清气在阴。浊气在阳。清浊相干。乱于肠胃。则
为霍乱也。
问曰。病发热头痛。身疼恶寒吐利者。此属何病。答曰。此名霍乱。自吐下。又利止。复更发热也。
此言有表证之霍乱也。发热头痛。身疼恶寒者。寒邪在表也。吐利者。寒邪在里也。言伤寒之邪。在太阳而
发热头痛。身疼恶寒。则无吐利。若伤寒之邪。在阴经而有吐利恶寒。则无发热头痛。此虽较前又多表证。
酷似伤寒。然吐利仍在。故此亦名霍乱。然始而吐下。继而利止。则霍乱之里邪已矣。复更发热者。表邪未解。
霍乱将仍转而为伤寒矣。成氏云。利止里和。复更发热。还是伤寒。必汗出而解。窃恐霍乱暂止。里未必和。
吐泻之后。汗不轻发。当谅其虚实。故不言发汗也。
伤寒其脉微涩者。本是霍乱。今是伤寒。却四五日。至阴经上转入阴。必利。本呕下利者。不可治也。似欲
大便而反矢气。仍不利者。属阳明也。便必硬。十三日愈。所以然者经尽故也。
此承上文言。以发热头痛。身疼恶寒吐利之霍乱。利既止而复发热。是霍乱仍归于伤寒矣。但伤寒之脉阴阳俱紧。
以寒邪在表。或见浮紧。已发热者。或见浮数而已。其脉微涩者。阳气大衰则微。阴血凝泣则涩。微涩之脉。阴
阳两受伤残矣。因前本是表里俱寒之霍乱。其寒邪在表则伤阳。在里则伤阴故也。今复更发热。是霍乱不已。仍变而
为伤寒。却延至四五日。揆其日数。其候至阴经受邪位次之上。即素问热论所谓四日太阴受之。五日少阴受之是也。
至阴经上而竟转入阴。则阴脏受邪。寒邪入里。故必利也。此因前霍乱时。本已先呕下利。至于脉微涩则已在阴阳两
伤之后。又因在表之寒邪不去。复更发热。又传入阴经下利。是阴阳已伤再伤。阳气已败复败。故为不可治也。
若利止发热之后。至四五日而病患似欲大便。颇虞其复利。而反但转矢气。仍不下利者。此为邪气不转入阴
而转属阳明也。何也。凡下利者。必溏泄而无矢气。即或有之。亦必稀粪随矢气而出矣。岂能但转矢气哉。今但
转矢气。是以知其大便必硬。已还阳明矣。所谓阳明中土。为万物所归。无所复传之地。至十三日而愈矣。
但言便硬而不言下法者。以阴寒吐利之后。胃阳复还而硬。非若阳明证之便硬为实热盛也。经尽者。前太阳总
证云。头痛至七日以上自愈者。以行其经尽故也。盖言太阳之邪。七日以上。经尽而衰去也。十三日者。即所
谓再作经也。七日太阳之经已尽。复传阳明。至十三日而其经亦尽故也。
下利后。当便硬。硬则能食者愈。今反不能食。到后经中颇能食。复过一经能食。过之一日当愈。不愈者。
不属阳明也。
此又承上文言霍乱利止后。复更发热者。是霍乱复为伤寒矣。四五日不转入阴而入阳明之里。则当便硬。硬则胃
阳已复。寒邪已去。故当能食而愈也。今反不能食。到后经中颇能食者。言今便已硬。犹不能食者。胃中阳气未
回也。后经。谓七日之后。再作一经也。言到七日以后。再作阳明一经。胃气方醒而颇能食。是复过一经而能食也。
如此。则于过经之一日。当即愈。方为转入阳明。如其不愈者。是未入阳明。故曰不属阳明也。可见入阴即为不治。
入阳则为即愈。阴阳之迥别如此。
恶寒脉微而复利。利止。亡血也。四逆加人参汤主之。
此又承上文脉微转入阴经必利而言也。言如前证而不发热。但恶寒。脉微而复下利。则阴寒在里。
阳气微弱甚矣。而忽得利止。此非阳回利止。乃亡血也。亡血二字。以仲景词义推之。皆无阳之意。不知是何深义。
殊不能解。如太阳中篇云。假令尺中迟者。不可发汗。盖尺中迟。则为下焦虚冷。真阳衰少。恐更亡其阳。
故云不可发汗。不意下文即曰何以知之。然以营气不足。血少故也。以阳虚而云血少。因有营气不足四字。此段犹
为易解。既云营气不足。则知夺血者无汗。夺汗者无血。天地以阳蒸阴而为雨。人身以阳蒸阴而为汗。故曰阳之汗。
以天地之雨名之。若发其汗。则阳气随汗而泄。汗泄则营血去而阳随之以亡矣。故以尺中虚为血少耳。又如厥阴
篇中云。伤寒五六日。不结胸。腹软脉虚。复厥者不可下。此为无血。下之死。既曰腹软脉虚。复至四肢厥冷。
是以阳虚阴盛而不可下也。亦谓之无血。岂非以无阳为无血乎。此所谓殊不可解者也。此条以恶寒脉微之下利。
宁非虚寒所致。而以利止为亡血。而又以四逆加人参汤主之。岂非亦以无阳为亡血乎。此又一殊不能解者也。
不得已而强解之。除是阴无阳不生。阳气虚衰。则阴血亦亡。故以四逆汤挽救真阳。而加人参汤以扶补其气血
之虚也。未知然否。姑妄议之。以俟后之君子。
四逆加人参汤。于四逆汤内加人参一两。余根据前法。
霍乱头痛发热。身疼痛。热多欲饮水者。五苓散主之。寒多不用水者。理中丸主之。
此又承上文言有表证之霍乱。头痛发热身疼而不恶寒者。既不转入阴经。而反热多欲饮水者。非阳明胃
热渴欲饮水之证也。盖因本系表里均受寒邪而致霍乱。所以上吐下利。今其头痛发热身疼之太阳表证尚在。
因寒邪内犯太阳之腑。故膀胱为津液之所藏。寒在下焦。气液不能上腾而为涕唾。所以虚阳在上。热多而欲饮水。
即如太阳
中篇所谓脉浮数而烦渴者。五苓散主之之义也。故以桂肉之辛热。助下焦肾中蒸腾之阳气。而以四苓沛肺家下
行之水。如此则肾中之地气上升而渴自止。肺藏之天气下降而便自利矣。苟非长沙之圣。孰有不认为胃无津液。
而用寒凉以济之者耶。然后贤犹未达五苓之义而不敢用。每改桂为桂枝。良可慨也。至于寒多而不用水者。则中
焦已寒。脾胃虚冷。故用理中丸温补之也。
理中丸方
人参 白术 甘草 干姜（以上各三两）
上四味。捣筛为末。蜜和丸如鸡黄大。以沸汤数合和一丸。研碎温服之。日三服。夜二服。腹中未热。益至
三四丸。然不及汤。汤法以四物根据两数切。用水八升。煮取三升。去滓。温服一升。日三服。
参术甘草。补中气而益脾。干姜温热。守中而散寒。为足太阴之专药。故能治理中焦而驱除阴慝。为脾胃虚寒
之主剂也。
后加减方
文理背谬。量非仲景之法。姑存而辨之。以资考校之用。
若脐上筑者。肾气动也。去术加桂四两。
太阳上编云。气从少腹上冲心者。必作奔豚。此乃肾气动也。此云脐上筑。则非从下上冲之肾气矣。肾肝
在下。岂反于脐上筑筑然而动乎。此所谓筑者。非心下悸。即脐间之动气耳。未可云肾气动也。成氏既注为脾虚
肾气动。则脾
虚之证。不应去术。又云甘者令人中满。术味甘而壅补。又何去术而独留甘草邪。即此观之。出自仲景者。果如是乎。
吐多者去术。加生姜三两。
霍乱吐多。乃胃气虚寒。最宜理中全用。若胃有宿食。恐助其痞满。固当去之。成氏谓呕家不喜甘。故去术。盖
呕与吐。大相悬绝之证也。邪气在表则呕。如中风有鼻鸣干呕。伤寒有体痛呕逆。阳明有伤寒呕多。虽有阳
明证。不可攻之。亦是太阳表证未罢也。少阳有呕而发热。心烦喜呕。此皆有表证而呕也。至若吐证。则为寒邪在里。
如太阴有腹满而吐。少阳有欲吐不吐。有咽痛而复吐利。有饮食入口即吐。心下温温欲吐。厥阴则有吐蛔而下利者矣。
呕吐之分如此。而成氏不辨。以呕为吐。误矣。呕家以生姜为圣药者。取其辛温发散也。吐家以干姜为主治者。取其
温中去寒也。方中既有干姜。加与不加皆可。
下多者还用术。悸者加茯苓二两。
霍乱而下多。则寒邪在里。理中自宜全用。已不必言。前小柴胡汤加减云。悸者加茯苓四两。盖以水停心下。
小便不利。故心下筑筑然而悸也。此亦加茯苓。焉知上文脐上筑者。非心下悸而又去术加桂邪。总非仲景之笔。
遂多此等不伦之语。
渴欲得水者。加术足前成四两半。
太阳邪入膀胱。五苓散之渴也。阳明热邪入胃。津液枯燥。白虎汤之渴也。此因渴欲得水而加术。术性本
燥湿。岂宜于渴者。五苓散中用之。全赖肉桂之蒸腾。故气液得升耳。不然。术岂渴证所宜。且理中丸已自有术。又加
至
四两半。
不知又属何意。成氏谓津液不足则渴。术甘以缓之。愚谓津液不足而反用燥湿之术。已不可解。况渴证而
用缓法。何也。
腹中痛者加人参。足前成四两半。
成氏谓里虚则痛。加人参以补之。愚窃谓虚则因何而痛。痛则何故补之。此真所谓随文顺释。洵不虚也。
寒者加干姜。足前成四两半。
原方中四味等分。已有干姜三两。不为少矣。又加一两半。殊未切当。若果至寒甚。何不即加附子。直待腹满。
然后加入邪。
腹满者去术。加附子一枚。服汤后如食顷。饮热粥一升许。微自温。勿发揭衣被。
霍乱腹满。本属阴寒。附子或可。至于去术之说。亦当略分虚实。若吐下未已。浊气留中。固当去术。若吐利已过。
中气虚寒。则术附恰当同用。即中气不寒者。亦如补中益气汤。治气虚中满可也。若果能饮热粥升许。则术亦可不去矣。
饮热粥而微温。勿揭衣被者。即服桂枝汤。取 微似汗之法也。寒邪在里而腹胀。阳气衰微而加附子。似不宜于
汗。然已有附子回阳。微汗亦不妨矣。
吐利止而身痛不休者。当消息和解其外。宜桂枝汤小和之。
消息二字最妙。方为活法。身痛不休。未易拟议。如伤寒第二条之身疼腰痛。骨节疼痛。乃寒邪在表而痛。
此麻黄汤证也。如发汗后身疼痛。脉沉迟者。此乃汗后亡阳。阳虚里寒。无阳气以嘘培和暖其筋骨。营血凝涩而痛。此
桂枝加
芍药生姜人参新加汤证也。如太阳下编之首条。发热恶寒身疼痛。不汗出而烦者。此风寒并感。温热之表
邪所致。大青龙汤证也。又如太阳下编伤寒医下之。续得下利清谷不止。身疼痛者。急当救里。宜用四逆汤者。
后身疼痛。清便自调。急当救表。宜用桂枝汤者。又如厥阴篇之下利腹胀满。身体疼痛者。先温其里。乃攻
其表。温里宜四逆汤。攻表宜桂枝汤者。历观论中之身疼痛者。表里不同。虚实各异。而更有虚实表里互相
参错者。临证酌治。能不为之消息详辨乎。若使毫厘之差。必致千里之谬。死生存亡系焉。司命者其可有所失欤。
所以吐利止后之身痛不休。或阳气虚损。营血不行。乃阴寒所致。可用四逆者。或病后新虚。气血未和。
而可用如人参新加汤之类者。或果有表邪未解。虽属寒邪。病后不宜更汗。舍麻黄而用桂枝汤和表者。各当以
脉证审辨可耳。但其辨甚微。非浅事也。故曰消息二字最妙。果能如此。方为活法也。
吐利汗出。发热恶寒。四肢拘急。手足厥冷者。四逆汤主之。
汗出发热恶寒。似桂枝证。然霍乱则与中风迥异。盖中风之初。有表证而尚无里证。但治其表可也。霍乱则
方有表证。而寒邪已先入里。故上吐下利也。且吐且利。而又四肢拘急。则诸寒收引也。手足厥冷。则阳气衰
微而不充于四肢也。其证之急。里甚于表。故急宜救里。当以四逆汤主之。寒中霍乱。本无汗下及寒凉之治者。
皆以寒邪在里。阳气虚衰故也。所以但用温经散寒。而其表证亦无不解也。
既吐且利。小便复利而大汗出。下利清谷。内寒外热。脉微欲绝者。四逆汤主之。
吐利则寒邪在里。小便复利。无热可知。而大汗出者。真阳虚衰而卫气不密。阳虚汗出也。下利清水完谷。胃寒不
能
杀谷也。内寒外热。非表邪发热。乃寒盛于里。格阳于外也。阴寒太甚。阳气 微。故脉微欲绝也。急当挽救
真阳。故以四逆汤主之。
吐已下断。汗出而厥。四肢拘急不解。脉微欲绝者。通脉四逆加猪胆汁汤主之。
此合上文两条之脉证而言。吐利之时。所以有此脉证。今吐既已而下利又断。当邪解而愈矣。仍汗出而厥
四肢拘急而不解。脉仍微而欲绝者。此寒邪固结而不解。阳气虚尽而欲竭。所以吐亦无气以出而自已。利亦津
液不行而自断。此非欲愈之吐下得止。乃无阳气以流行。肠胃不通。脏气不行之征也。当急救真阳。无奈寒邪
太盛。又恐拒格而不受。非前方可治。故以热因寒用之通脉四逆加猪胆汁汤主之。
Question: What is Huoluan disease?
Answer: Vomiting accompanied by diarrhea is called Huoluan (Vomiting and Diarrhea Syndrome).
This refers to Huoluan without exterior syndrome. Dry retching (Dry Omission) is when there is sound but no material vomited; vomiting (Omission) is when there is both sound and material; spitting up (Spitting) is when there is material but no sound. Vomiting indicates the pathogenic factor is at the exterior, while spitting/diarrhea indicates the pathogenic factor is at the interior.
If the pathogenic factor gathers exclusively in the Upper Jiao, there will be vomiting without diarrhea; if it gathers exclusively in the Lower Jiao, there will be diarrhea without vomiting. If struck by sudden cold, with Cold Pathogen entering directly into the Middle Jiao, causing the Taiyin Spleen to suffer from cold, leading to sudden coldness in the Stomach, resulting in upper vomiting and lower diarrhea, along with muscle cramps, abdominal pain, and cold reversal of the hands and feet, this is called Huoluan. These are all changes resulting from the victory and recovery of the Six Qi. The victory and recovery of Taiyang Cold Water Qi, as well as Taiyin Damp Earth Qi when ruling the Heaven or Earth phases, or the victory and recovery of Jueyin and Yangming, can all produce such conditions. Even when Shaoyang and Shaoyin Fire Qi rule the Heaven or Earth phases, if overcome by various Cold-Damp inter-qi or guest-qi, similar situations occur. Especially during cloudy/rainy or sunny weather, violent wind and rain, intense heat, or sudden cold, these often happen. Within one family, within one village, or even the entire region may be affected; this is due to epidemic Cold-Damp pathogens. The meaning of the character "Huo" remains unclear, but it roughly describes the meaning of sudden vomiting and diarrhea chaos. Cheng Wuji interpreted it as "hasty and chaotic," which may not necessarily be correct. Fang Youzhi stated that in *Ling Shu: Wu Luan Pian* (Five Disorders Chapter), it is recorded: "Clear Qi is in the Yin, Turbid Qi is in the Yang. When Clear and Turbid Qi interfere with each other and disturb the intestines and stomach, it is called Huoluan."
Question: A patient suffers from fever, headache, body ache, aversion to cold, accompanied by vomiting and diarrhea. What disease is this?
Answer: This is called Huoluan. Initially vomiting and diarrhea, followed by the cessation of diarrhea, yet recurring fever.
This refers to Huoluan with exterior syndrome. Fever, headache, body ache, and aversion to cold indicate Cold Pathogen at the exterior. Vomiting and diarrhea indicate Cold Pathogen at the interior. If the Cold Pathogen of Shanghan (Cold Damage) is in the Taiyang channel, it causes fever, headache, body ache, and aversion to cold, but without vomiting and diarrhea. If the Shanghan pathogen is in the Yin channels, causing vomiting, diarrhea, and aversion to cold, there would be no fever or headache. Although this case has more exterior symptoms than the previous one and closely resembles Shanghan, because vomiting and diarrhea persist, it is also named Huoluan. However, initially there was vomiting and purging, followed by the cessation of diarrhea, meaning the interior pathogen of Huoluan has been eliminated. The recurrence of fever indicates that the exterior pathogen has not resolved, and Huoluan is about to transform back into Shanghan. Cheng Wuji said, "Cessation of diarrhea indicates harmony in the interior; recurring fever means it is still Shanghan, which must be resolved through sweating." I fear that although Huoluan has temporarily stopped, the interior may not be harmonious. After vomiting and diarrhea, one should not lightly induce sweating; instead, one must assess deficiency and excess. Therefore, inducing sweating is not mentioned.
In Shanghan, if the pulse is faint and choppy, it was originally Huoluan, now it is Shanghan. After four or five days, when the pathogen enters the Yin channels, diarrhea will inevitably occur. Those who originally had vomiting and diarrhea are difficult to treat. If the patient feels the urge to defecate but only passes gas, without actual diarrhea, it belongs to Yangming. The stool will likely be hard, and healing will occur after thirteen days. This is because the meridian cycle has completed.
This follows the previous discussion regarding Huoluan characterized by fever, headache, body ache, aversion to cold, vomiting, and diarrhea. After diarrhea stops and fever recurs, Huoluan returns to being Shanghan. However, in Shanghan, the pulse is tight in both Yin and Yang positions due to Cold Pathogen at the exterior; it may appear floating-tight, or if fever has already started, floating-rapid. A faint and choppy pulse indicates severe decline of Yang Qi (faint) and stagnation of Yin Blood (choppy). Such a pulse signifies damage to both Yin and Yang. This is because the previous Huoluan involved Cold in both exterior and interior; Cold at the exterior damages Yang, while Cold at the interior damages Yin. Now, with recurring fever, Huoluan has not ceased and has transformed into Shanghan. After four or five days, estimating the timeline, the condition reaches the stage where Yin channels are affected, corresponding to what *Su Wen: Re Lun* states: "On the fourth day, Taiyin is affected; on the fifth day, Shaoyin is affected." When the pathogen enters the Yin channels and transfers inward, the Yin Zang organs are affected, Cold Pathogen enters the interior, and thus diarrhea inevitably occurs. Since the patient had already vomited and suffered diarrhea during the Huoluan phase, and the pulse became faint and choppy indicating prior Yin-Yang damage, combined with the persistence of exterior Cold, recurring fever, and transmission to Yin channels causing further diarrhea, this represents double injury to Yin and Yang, and repeated failure of Yang Qi. Thus, it is considered untreatable.
If, after diarrhea stops and fever occurs, on the fourth or fifth day, the patient feels the urge to defecate, raising concern for recurrent diarrhea, but instead only passes gas without actual diarrhea, this indicates the pathogen is not transferring to the Yin channels but shifting to Yangming. Why? In cases of diarrhea, stools are invariably loose without passing gas. Even if gas is passed, loose stool accompanies it. How could it be merely passing gas? Since only gas is passed, we know the stool must be hard, indicating a return to Yangming. As stated, Yangming, belonging to Central Earth, is the destination of all things and a place where transmission ceases. Healing occurs by the thirteenth day.
The text mentions hard stool but does not prescribe purgation because, following Yin-Cold vomiting and diarrhea, the hard stool results from the restoration of Stomach Yang, unlike the hard stool in Yangming syndromes caused by excessive Excess-Heat. "Meridian completion" refers to the earlier statement in the Taiyang general section: "Headache resolving spontaneously after seven days is due to the completion of the meridian cycle." This implies that Taiyang pathogenic factors, after seven days, cease as the meridian cycle completes. Thirteen days refers to "re-entering the meridian cycle." After the seven-day Taiyang cycle completes, transmission moves to Yangming, and by thirteen days, its cycle also completes.
After diarrhea stops, stool should become hard. If the patient can eat despite hardness, they will heal. If they cannot eat, but later (in the next meridian period) can eat slightly, and then fully after another period, they should heal one day after completing the period. If they do not heal, it does not belong to Yangming.
This continues the discussion on Huoluan where, after diarrhea stops and fever recurs, Huoluan transforms back into Shanghan. If after four or five days the pathogen does not enter Yin but goes to the interior of Yangming, stool becomes hard. Hardness indicates Stomach Yang has recovered and Cold has departed, so eating should resume and healing follow. If the patient cannot eat, but eats slightly in the next meridian period (after seven days), it means although stool is hard, Stomach Yang has not yet returned. The "next meridian period" refers to after seven days, re-entering a meridian cycle. By the time Yangming's cycle begins, Stomach Qi awakens, allowing slight eating. This represents passing another period before eating. In such cases, healing should occur one day after passing the period, indicating entry into Yangming. If healing does not occur, the pathogen has not entered Yangming, hence "does not belong to Yangming." Thus, entry into Yin implies incurability, while entry into Yang implies imminent healing. The distinction between Yin and Yang is profound.
Aversion to cold, faint pulse, and recurring diarrhea, with subsequent cessation of diarrhea, indicate loss of Blood. Treat with Si Ni Jia Ren Shen Tang (Four Reversals Plus Ginseng Decoction).
This follows the previous discussion on faint pulses entering Yin channels causing diarrhea. It states that if symptoms include aversion to cold (but no fever), faint pulse, and recurring diarrhea, it indicates Cold at the interior and extreme weakness of Yang Qi. The sudden cessation of diarrhea is not due to Yang recovery but to blood loss. Regarding the term "loss of blood," inferring from Zhang Zhongjing's terminology, it generally implies absence of Yang. The deep meaning is unclear. For example, in the Taiyang middle section: "If the Chi position pulse is slow, sweating is contraindicated." A slow Chi pulse indicates lower Jiao deficiency-cold and declining True Yang, fearing further loss of Yang. Later, it asks, "How do we know?" Answer: "Due to insufficient Ying Qi and little Blood." Linking Yang deficiency to little blood relies on "insufficient Ying Qi." This part is easier to understand. Knowing Ying Qi is insufficient implies that those who lose blood have no sweat, and those who lose sweat have no blood. Heaven and earth form rain via Yang steaming Yin; the human body forms sweat via Yang steaming Yin. Thus, human sweat is likened to heavenly rain. Inducing sweating causes Yang to leak with sweat; once sweat leaks, Ying Blood departs, and Yang perishes with it. Hence, a deficient Chi pulse indicates little blood. Similarly, in the Jueyin section: "Shanghan for five or six days, no chest binding, soft abdomen, void pulse, and cold limbs indicate inability to purge. This is lack of blood; purging leads to death." With soft abdomen, void pulse, and cold limbs, Yang deficiency and Yin excess preclude purging. This is also called "lack of blood." Does this equate lack of Yang with lack of blood? This is particularly puzzling. This case involves diarrhea with aversion to cold and faint pulse, presumably due to Deficiency-Cold, yet cessation of diarrhea is termed "blood loss," treated with Si Ni Jia Ren Shen Tang. Is this also equating lack of Yang with blood loss? Another puzzle. Forced interpretation: Perhaps Yin cannot grow without Yang; severe Yang deficiency leads to blood loss. Thus, Si Ni Tang saves True Yang, and adding Ren Shen supports Qi and Blood deficiency. Whether correct is unknown; offered for future scholars' consideration.
Si Ni Jia Ren Shen Tang: Add one liang of Ren Shen (Ginseng Root) to Si Ni Tang. Prepare and administer according to previous methods.
Huoluan with headache, fever, body ache, excessive heat, and desire to drink water is treated with Wu Ling San (Five Ingredient Powder with Poria). If there is excessive cold and no desire to drink water, treat with Li Zhong Wan (Regulate the Middle Pill).
This continues discussing Huoluan with exterior syndrome: headache, fever, body ache, without aversion to cold. Not transferring to Yin, but showing excessive heat and thirst, this is not the thirst of Yangming Stomach Heat. It arises because Huoluan resulted from Cold affecting both exterior and interior. Headache, fever, and body ache indicate persistent Taiyang exterior syndrome. Cold invading Taiyang Fu organs affects the Bladder, the reservoir of Body Fluids. Cold in the Lower Jiao prevents Qi and Fluids from ascending to form saliva/thirst, causing deficient Yang to float upward, creating sensation of heat and thirst. This aligns with the Taiyang middle section: "Floating-rapid pulse with irritability and thirst, treat with Wu Ling San." Thus, Rou Gui (Cinnamon Bark) uses its acrid-hot nature to assist Kidney steaming Yang in the Lower Jiao, while Si Ling (the four draining herbs) promotes downward flow of Lung Water. This allows Kidney Earth Qi to ascend (stopping thirst) and Lung Heaven Qi to descend (promoting urination). Only Zhang Zhongjing, the Sage of Changsha, would recognize this mechanism rather than assuming Stomach fluid deficiency and using Cold-Cooling herbs. Yet later scholars, failing to fully grasp Wu Ling San's principle, often substitute Rou Gui with Gui Zhi (Cinnamon Twig), which is lamentable. For excessive cold without thirst, the Middle Jiao is cold, and Spleen-Stomach are deficient-cold; thus, Li Zhong Wan warms and tonifies.
Li Zhong Wan Formula:
Ren Shen (Ginseng Root), Bai Zhu (Atractylodes Rhizome), Gan Cao (Licorice Root), Gan Jiang (Dried Ginger) (each 3 liang).
Pulverize the four ingredients. Mix with honey to form pills the size of a chicken egg. Dissolve one pill in warm boiled water and take. Three times daily, twice at night. If warmth is not felt in the abdomen, increase to three or four pills. Decoction is superior. Decoction method: Cut four ingredients according to dosage. Boil in 8 sheng of water until 3 sheng remain. Strain. Take 1 sheng warm, three times daily.
Ren Shen, Bai Zhu, and Gan Cao tonify Middle Qi and benefit the Spleen. Gan Jiang is warm-hot, stabilizing the Middle and dispersing Cold. It is a specific herb for Foot Taiyin, governing the Middle Jiao and expelling Yin Evil, serving as the primary formula for Spleen-Stomach Deficiency-Cold.
Later Modifications:
These modifications seem logically inconsistent and likely not Zhang Zhongjing's original method. Preserved here for critical study.
If there is throbbing above the navel, it indicates Kidney Qi moving. Remove Bai Zhu, add Gui Zhi (Cinnamon Twig) 4 liang.
*Taiyang Upper Section* states: "Qi rushing from lower abdomen to heart causes Ben Tun (Running Piglet)." This is Kidney Qi movement. Here, throbbing above the navel differs from upward rushing Kidney Qi. Liver and Kidney are located inferiorly; how can they throb above the navel? This "throbbing" likely refers to palpitations below the heart or qi movement at the navel, not necessarily Kidney Qi. Cheng Wuji annotated this as Spleen deficiency with Kidney Qi movement. If Spleen deficiency exists, removing Bai Zhu (which tonifies Spleen) is contradictory. Also, sweet flavors cause fullness; Bai Zhu is sweet and cloying. Why remove it and keep Gan Cao? This suggests these modifications may not be authentic.
For excessive vomiting, remove Bai Zhu, add Sheng Jiang (Fresh Ginger) 3 liang.
Excessive vomiting in Huoluan indicates Stomach Qi deficiency-cold, best treated with complete Li Zhong Wan. If food stagnation exists, removing Bai Zhu prevents exacerbating fullness. Cheng Wuji claimed vomiters dislike sweet flavors, hence removing Bai Zhu. However, dry heaving (Ou) and vomiting/spitting (Tu) are distinct. Ou (dry heaving/retching) relates to exterior pathogens (e.g., Wind Strike with nasal congestion/dry heaving, Shanghan with body pain/retching, Yangming with frequent retching). Tu (vomiting/spitting) relates to interior Cold (e.g., Taiyin with abdominal fullness/vomiting, Shaoyang with desire to vomit, throat pain/vomiting-diarrhea, immediate vomiting upon eating, Jueyin with vomiting roundworms/diarrhea). Cheng Wuji confused Ou with Tu. For Ou, Sheng Jiang is preferred for its acrid-warm dispersing action. For Tu, Gan Jiang is preferred for warming the Middle and dispelling Cold. Since Gan Jiang is already present, adding Sheng Jiang is optional.
For excessive diarrhea, retain Bai Zhu. For palpitations, add Fu Ling (Poria) 2 liang.
Excessive diarrhea in Huoluan indicates interior Cold; Li Zhong Wan should be used fully. Previous Xiao Chai Hu Tang modifications state: "Palpitations, add Fu Ling 4 liang" due to Water retention in the Heart causing palpitations. Adding Fu Ling here addresses palpitations. It is unlikely that "throbbing above the navel" referred to palpitations requiring removal of Bai Zhu and addition of Gui Zhi. These additions seem unauthentic.
For thirst and desire to drink water, increase Bai Zhu to 4.5 liang.
Thirst in Taiyang involves Bladder pathology (Wu Ling San); thirst in Yangming involves Stomach Heat and fluid dryness (Bai Hu Tang). Adding Bai Zhu (a drying herb) for thirst seems inappropriate. In Wu Ling San, Rou Gui aids fluid ascent. Without it, Bai Zhu is unsuitable for thirst. Furthermore, Li Zhong Wan already contains Bai Zhu; increasing it to 4.5 liang lacks clear rationale. Cheng Wuji claimed Bai Zhu moistens via sweetness. I argue using drying herbs for fluid deficiency is inexplicable, let alone using sweet-slowing methods for thirst.
For abdominal pain, add Ren Shen, bringing total to 4.5 liang.
Cheng Wuji stated deficiency causes pain, so add Ren Shen to tonify. I question why deficiency causes pain and why tonification is the remedy. This appears to be superficial textual interpretation.
For cold sensations, add Gan Jiang, bringing total to 4.5 liang.
The original formula contains 3 liang of Gan Jiang. Adding another 1.5 liang is questionable. If Cold is severe, why not add Fu Zi immediately? Waiting for abdominal fullness to add it seems delayed.
For abdominal fullness, remove Bai Zhu, add one Fu Zi (Aconite Root). After taking the decoction, wait about the time of a meal, then drink one sheng of hot porridge to maintain mild warmth. Do not uncover clothes or blankets.
Abdominal fullness in Huoluan is due to Yin-Cold; Fu Zi is appropriate. Removing Bai Zhu requires distinguishing deficiency/excess. If vomiting/diarrhea persist and turbid Qi remains, removing Bai Zhu is correct. If vomiting/diarrhea have ceased but Middle Qi is deficient-cold, Bai Zhu and Fu Zi should be used together. Even without Cold, similar to Bu Zhong Yi Qi Tang for Qi-deficiency fullness. If the patient can drink hot porridge, retaining Bai Zhu is acceptable. Drinking hot porridge and keeping warm mimics the method of Gui Zhi Tang to induce mild sweating. Although Cold in the interior with abdominal fullness and Yang deficiency treated with Fu Zi might seem incompatible with sweating, Fu Zi restores Yang, making mild sweating permissible.
If vomiting and diarrhea stop but body pain persists, assess the condition to harmonize the exterior. Use Gui Zhi Tang (Cinnamon Twig Decoction) gently.
The term "Xiao Xi" (assess/consider) is excellent, representing flexible treatment. Persistent body pain requires careful differentiation. Body pain with low back ache and joint pain in Shanghan Line 2 indicates exterior Cold, treated with Ma Huang Tang. Body pain with deep-slow pulse after sweating indicates post-sweat Yang loss, interior Cold, and nutritive Blood stagnation, treated with Gui Zhi Jia Shao Yao Sheng Jiang Ren Shen Xin Jia Tang. Fever, aversion to cold, body pain, no sweat, and irritability indicate concurrent Wind-Cold and Warmth pathogens, treated with Da Qing Long Tang. Post-purging Shanghan with continuous clear grain diarrhea and body pain requires urgent interior rescue with Si Ni Tang; later, if stool normalizes and body pain persists, urgent exterior rescue with Gui Zhi Tang. Jueyin diarrhea with abdominal fullness and body pain requires warming the interior first (Si Ni Tang), then attacking the exterior (Gui Zhi Tang). Observing body pain in the text reveals different interior/exterior and deficiency/excess patterns, sometimes mixed. Clinical judgment must carefully assess these nuances. A slight error leads to major consequences, affecting life and death. Physicians must not err.
Thus, post-Huoluan body pain may result from Yang deficiency, nutritive Blood stasis, or Yin-Cold (treat with Si Ni Tang); or post-illness new deficiency, unharmonized Qi/Blood (treat with Ren Shen Xin Jia Tang variants); or unresolved exterior pathogen (treat with Gui Zhi Tang instead of Ma Huang Tang due to post-illness fragility). Differentiation based on pulse and symptoms is crucial. This differentiation is subtle and complex. Hence, "Xiao Xi" is key to flexible treatment.
Huoluan with vomiting, diarrhea, sweating, fever, aversion to cold, limb tetany, and cold reversal of hands/feet is treated with Si Ni Tang (Four Reversals Decoction).
Sweating, fever, and aversion to cold resemble Gui Zhi Tang syndrome. However, Huoluan differs significantly from Wind Strike. Wind Strike begins with exterior symptoms and no interior symptoms, treatable by addressing the exterior. Huoluan presents with exterior symptoms but Cold Pathogen has already entered the interior, causing vomiting and diarrhea. Limb tetany indicates Cold contraction; cold hands/feet indicate Yang deficiency failing to nourish limbs. Interior urgency exceeds exterior urgency; thus, urgent interior rescue with Si Ni Tang is required. Cold-type Huoluan never uses sweating, purging, or Cold-Cooling therapies because Cold is interior and Yang is deficient. Warming meridians and dispersing Cold resolves both interior and exterior.
Simultaneous vomiting and diarrhea, with free urination, profuse sweating, diarrhea of undigested food, interior Cold with exterior Heat, and faint pulse nearly imperceptible is treated with Si Ni Tang.
Vomiting/diarrhea indicate interior Cold. Free urination indicates absence of Heat. Profuse sweating indicates True Yang deficiency and insecure Wei Qi (Yang deficiency sweating). Diarrhea of undigested food indicates Stomach Cold failing to digest. Interior Cold with exterior Heat is not exterior pathogen fever but Cold excess in the interior repelling Yang to the exterior. Severe Yin-Cold and weak Yang cause faint, nearly imperceptible pulse. Urgent rescue of True Yang is needed; hence, Si Ni Tang.
Vomiting has ceased, diarrhea has stopped, but sweating and cold reversal persist, limb tetany is unresolved, and pulse is faint and nearly imperceptible is treated with Tong Mai Si Ni Jia Zhu Dan Tang (Pulse-Restoring Four Reversals Plus Pig Bile Decoction).
Combining the previous two sections' pulse/symptoms: During vomiting/diarrhea, these signs appeared. Now that vomiting and diarrhea have ceased, one expects pathogen resolution and healing. However, sweating, cold reversal, limb tetany, and faint pulse persist. This indicates Cold Pathogen is firmly bound and unresolved, and Yang Qi is exhausted. Vomiting stopped due to lack of Qi to expel; diarrhea stopped due to lack of fluids to flow. This is not healing cessation of vomiting/diarrhea but a sign of absent Yang circulation, intestinal obstruction, and Zang organ dysfunction. Urgent rescue of True Yang is needed. However, Cold Pathogen is too strong, risking rejection of the medicine. The previous formula is insufficient. Thus, use Tong Mai Si Ni Jia Zhu Dan Tang, employing "heat for cold" strategy.