问曰。病有霍乱者。何。答曰。呕吐而利。此名霍乱。（此名。成本。玉函。作名曰。千金翼。何下。有
也字。名。作为。）
〔成〕三焦者。水谷之道路。邪在上焦。则吐而不利。邪在下焦。则利而不吐。邪在中焦。则既吐且利。
以饮食不节。寒热不调。清浊相干。阴阳乖隔。遂成霍乱。轻者止曰吐利。重者挥霍撩乱。名曰霍乱。〔锡〕
霍者。忽也。谓邪气忽然而至。防备不及。正气为之仓忙错乱也。胃居中土。为万物之所归。故必伤胃。邪气
与水谷之气。交乱于中。故上呕吐而下利也。吐利齐作。正邪纷争。是名霍乱。
病源候论曰。霍乱者。人温凉不调。阴阳清浊二气。有相干乱之时。其乱在于肠胃之间者。因遇饮食而变。
发则心腹绞痛。其有先心痛者。先吐。先腹痛者。则先痢。心腹并痛者。则吐痢俱发。霍乱。言其病挥霍之间。
便致撩乱也。
千金方曰。原夫霍乱之为病也。皆因食饮。非关鬼神。饱食肫脍。复餐乳酪。海陆百品。无所不啖。眠卧
冷席。多饮寒浆。胃中诸食。结而不消。阴阳二气。拥而反戾。阳气欲降。阴气欲升。阴阳乖隔。变成吐利。
头痛如破。百节如解。遍体诸筋。皆为回转。论证虽小。卒病之中。最为可畏。
外台秘要。必效方云。上吐下利者。名为湿霍乱。
案文选蜀都赋。翕响挥霍。刘曰。奄忽之间也。济曰。沸乱貌。文赋。纷纭挥霍。善曰。挥霍。疾貌。
唐惠琳藏经音义云。转霍。呼郭反。按霍倏。急疾之貌也。霍然。忽霍。皆是也。又霍然。倏忽速疾之貌也。
由是考之。成氏云。挥
霍撩乱。锡驹云。忽也。钱云。大约是倏忽间。吐泻扰乱之意耳。其义并同。方氏云。霍。吐也。乱。杂乱也。
其说不通。
问曰。病发热头痛。身疼恶寒。吐利者。此属何病。答曰。此名霍乱。霍乱自吐下。又利止。复更发热也。
（成本。无下霍乱二字。玉函。寒下。有不复二字。此名。作当为。无自字。又字。千金翼。寒下。有而复二字。）
〔鉴〕此承上条。以详出其证也。头痛身疼。发热恶寒。在表之风寒暑热为病也。呕吐泻利。在里之饮食
生冷为病也。具此证者。名曰霍乱。若自呕吐已。又泻利止。仍有头痛身疼恶寒。更复发热。是里解而表不解
也。沈明宗曰。吐利已止。复更发热。乃里气和。而表邪未解。当从解表之法。或无表证。但有腹痛吐利。此
为里邪未解。当以和里为主。〔方〕发热头痛。身疼恶寒。外感也。吐利。内伤也。上以病名求病证。此以病
证实病名。反复详明之意。〔锡〕夫但曰利止。而不曰吐止者。省文也。
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。
欲似大便。而反失气。仍不利者。此属阳明也。便必硬。十三日愈。所以然者。经尽故也。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。（成本。
玉函。方氏诸本。并以下利后当便硬以下。别为一条。玉函。本上。有素字。欲似。玉函。及钱本。作似欲。
成本。属上无此字。）
〔鉴〕此承上条。辨发热头痛。身疼恶寒。吐利等证。为类伤寒之义也。若有前证。而脉浮紧。是伤寒也。
今脉微涩。本是霍乱也。然霍乱初病。即有吐利。伤寒吐利。却在四五日后。邪传入阴经之时。始吐利也。此
本是霍乱之即呕吐。即下利。故不可作伤寒治之。俟之自止也。若止后。似欲大
便。而去空气。仍不大便。此属阳明也。然属阳明者。大便必硬。虽大便硬。乃伤津液之硬。未可下也。当俟
至十三日经尽。胃和津回。便利自可愈矣。若过十三日。大便不利。为之过经不解。下之可也。下利后。肠胃
空虚。津液匮乏。当大便硬。硬则能食者。是为胃气复。至十三日。津回便利。自当愈也。今反不能食。是为
未复。俟到十三日后。过经之日。若颇食。亦当愈也。如其不愈。是为当愈不愈也。当愈不愈者。则可知不属
十三日过经便硬之阳明。当属吐利后。胃中虚寒。不食之阳明。或属吐利后。胃中虚燥之阳明也。此则非药不
可。俟之终不能自愈也。理中脾约。择而用之可矣。
恶寒。脉微（【原注】一作□）而复利。利止亡血也。四逆加人参汤主之。
〔成〕恶寒脉微。而利者。阳虚阴胜也。利止则津液内竭。故云亡血。金匮玉函曰。水竭则无血。与四
逆汤。温经助阳。加人参。生津液益血。
案金鉴曰。利止亡血。如何用大热补药。利止。当是利不止。亡血。当是亡阳。钱氏亦疑亡血之为亡阳。
然徐大椿曰。案亡阴。即为亡血。不必真脱血也。此说似是。
四逆加人参汤方
甘草（二两炙） 附子（一枚生去皮破八片） 干姜（一两半） 人参（一两）
上四味。以水三升。煮取一升二合。去滓。分温再服。（千金。外台。用人参三两。利甚者。加龙骨二
两。短剧。名四顺汤。）
〔魏〕于温中之中。佐以补虚生津之品。凡病后亡血津枯者。皆可用也。不止霍乱也。不止伤寒吐下后也。
〔徐〕今利虽止。而恶寒脉微如故。则知其非阳回。而利止。乃津液内竭。而利止也。故曰亡血。又当加人参。
以生津益血矣。
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。（用字。方氏。作
欲饮二字。丸。成本。作员。玉函。作汤。千金翼同。）
〔魏〕伤寒者。外感病。霍乱者。内伤病也。伤寒之发热头痛。身疼恶寒。风寒在营卫。霍乱之头痛身疼
恶寒。必兼吐下。风寒在胃腑也。风寒外邪。何以遽入于胃腑。则平日中气虚歉。暴感风寒。透表入里。为病
于内。因其为风寒客邪。故发热头痛。身疼恶寒。与伤寒同。因其暴感胃腑。故兼行吐利。与伤寒异。此二病
分关之源头也。其所以吐利时不热。利止复热者。则亦因中气虚弱。当吐利行时。邪虽在胃。而气散热不能发。
利止气收方发耳。亦异于伤寒之热发在表。无作息时也。既明霍乱致病之由。为病与伤寒之异。而治法方可就
其人之寒热施之。热多者。胃虽虚自热。多虚热者。吐利行必大饮水。五苓散主之。导湿清热滋干。所必用也。
寒多者。胃素虚且寒。多虚寒者。吐利行。必不用水。理中丸主之。温中燥湿补虚。所必用也。
伤寒类方曰。案霍乱之症。皆由寒热之气不和。阴阳拒格。上下不通。水火不济之所致。五苓。所以分其
清浊。理中。所以壮其阳气。皆中焦之治法也。
医史。戴良撰吕沧洲翁传云。内子王病伤寒。乃阴隔阳。面赤足蜷。而下利躁扰不得眠。论者有主寒主温
之不一。余不能决。翁以紫雪匮理中丸进。徐以水渍甘草干姜汤饮之愈。且告之曰。下利足蜷。四逆证也。苟
用常法。则上焦之热弥甚。今以紫雪折之。徐引辛甘以温里。此热因寒用也。闻者皆叹服。
理中丸方（【原注】下有作汤加减。○玉函。丸。作圆。）
人参 干姜 甘草（炙） 白术（各三两）
上四味。捣筛。蜜和为丸。如鸡子黄许大。以沸汤数合。和一丸。研碎温服之。日三四。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。若脐
上筑者。肾气动也。去术。加桂四两。吐多者。去术。加生姜三两。下多者还用术。悸者。加茯苓二两。渴欲
得水者。加术。足前成四两半。腹中痛者。加人参。足前成四两半。寒者。加干姜。足前成四两半。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。（成本。玉函。筛下。有为末二
字。无子许二字。若脐上上。有加减法三字。日三四。瘥后病篇。玉函。成本。作日三服。）
〔方〕理。治也。料理之谓。中。里也。里阴之谓。参术之甘。温里也。甘草甘平。和中也。干姜辛热。
散寒也。〔程〕阳之动始于温。温气得而谷精运。谷气升而中气赡。故名曰理中。实以燮理之功。予中焦之阳
也。盖谓阳虚。即中气失守。膻中无发宣之用。六腑无洒陈之功。犹如釜薪失焰。故下至清谷。上失滋味。五
脏凌夺。诸证所由来也。参术炙甘。所以守中州。干姜辛以温中。必假之以燃釜薪。而腾阳气。是以谷入于阴。
长气于阳。上输华盖。下摄州都。五脏六腑。皆受气矣。此理中之旨也。〔钱〕后加减方。文理背谬。量非仲
景之法。
伤寒类方曰。桂枝汤之饮热粥。欲其助药力以外散。此饮热粥。欲其助药力以内温。
金匮要略。胸痹。心中痞。气结在胸。胸满胁下逆抢心。人参汤主之。程林注。此即理中汤也。中气强。
则痞气能散。胸满能消。胁气能下。人参白术。所以益脾。甘草干姜。所以温胃。脾胃得其和。则上焦之气开
发。而胸痹亦愈。
千金方。治中汤。治霍乱吐下。胀满。食不消化。心腹
痛。即本方。四味 咀。以水八升。煮取三升。分三服。不瘥频服三剂。远行防霍乱。根据前作丸。如梧子大。
服三十丸。如作散服方寸匕。酒服亦得。若转筋者。加石膏三两。又四理顺中丸。已产讫可服此方。新生脏虚。
此所以养脏气也。（即本方）
外台秘要。崔氏理中丸。疗三焦不通。呕吐不食。并霍乱吐逆下痢。及不得痢。（即本方）
及延年理中丸。疗霍乱吐利。宿食不消。
于本方。加大麦 。
又广济。疗冷热不调。霍乱吐利。宿食不消。理中丸。
于本方。加良姜桂心。
又范汪茯苓理中汤。疗霍乱脐上筑而悸。
于本方。加茯苓木瓜。
又范汪理中加二味汤。疗霍乱胸满。腹痛吐下。
于本方。加当归芍药。
又延年增损理中丸。主霍乱。下气能食。止泄痢。
于本方。加浓朴茯苓。○直指。水煎。亦名理中汤。
又短剧扶老理中散。疗羸老冷气。恶心食饮不化。腹虚满。拘急短气。及霍乱呕逆。四肢厥冷。心烦气闷流汗。
于本方。加麦门冬附子茯苓。
活人书。或四肢拘急。腹满下利。或转筋者。去白术。加附子一枚生用。
三因方。病者因饮食过度伤胃。或胃虚不能消化。致翻呕吐逆。物与气上冲蹙胃口。决裂所伤吐出。其
色鲜红。心腹绞痛。白汗自流。名曰伤胃吐血。理中汤。能止伤胃吐血者。以其功最理中脘。分利阴阳。安定
血脉。方证广如局方。但不出吐血证。学人当自知之。或只煮干姜甘草汤饮之。亦
妙。见养生必用。
又加味理中丸。治饮酒过多。及啖炙爆热食动血。发为鼻衄。
于本方中。加干葛川芎各等分。（济生方。不用川芎。直指方。于本方加木香。治饮食伤胃失血诸证。）
又附子理中汤。治五脏中寒。口噤。四肢强直。不语。
于本方。加大附子。各等分。
施氏续易简方。有中寒气虚。阴阳不相守。血乃妄行者。经所谓阳虚阴必走。是也。咯血吐血。衄血便
血。皆有此证。理中汤。加官桂治之。人皆知此药能理中脘。不知其有分利阴阳。安定血脉之功也。
又理中汤。治伤寒时气。里寒外热。加五味子阿胶末等分。名顺味丸。治寒邪作嗽甚妙。老人吐泻不止。
去甘草。加白茯苓一两。名温中汤。
直指方。理中丸。补肺止寒嗽。
于本方。加炒阿胶五味子。
又加味理中汤。治肺胃俱寒咳嗽。
于本方。加半夏。茯苓。橘红。细辛。五味子。姜枣煎。
又妇人妊娠胎动。腹胁腰痛。下血水者。以真料理中汤。加缩砂佐之。
体仁汇编。三建汤。此必审真房劳。及冬月真伤寒。方可用。本方。加川乌鹿茸。
医汇。腹痛全然不思饮食。其人本体素弱。而腹冷痛。以手按之则不痛。此亦虚也。本方。如良姜吴茱萸。
阴证略例。寒证不能食。理中建中各半汤。为二中汤。
医经会解。本方。倍白术人参。加猪苓泽泻茯苓肉桂。名理苓汤。吃忒。加丁香柿蒂。
张氏医通。衄血。六脉弦细而涩。按之空虚。色白不泽者。脱血也。此大寒证。理中汤加黄 。
吐利止。而身痛不休者。当消息和解其外。宜桂枝汤小和之。
〔成〕吐利止。里和也。身痛不休。表未解也。与桂枝汤小和之。外台云。里和表病。汗之则愈。〔方〕消
息。犹斟酌也。小和。言少少与服。不令过度之意也。
伤寒直格。消息。谓损益多少也。
吐利汗出。发热恶寒。四肢拘急。手足厥冷者。四逆汤主之。
〔志〕吐利汗出。乃中焦津液外泄。发热恶寒。表气虚也。四肢拘急。津液竭也。手足厥冷者。生阳之气。
不达于四肢。故主四逆汤。启下焦之生阳。温中焦之土气。
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。（内。玉函。作里。）
〔钱〕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。故脉几欲
绝也。急当挽救真阳。故以四逆汤主之。
Question: Some diseases are called Huoluan (Huo Luan, Cholera-like disease with sudden vomiting and diarrhea). Why? Answer: Vomiting accompanied by diarrhea is called Huoluan. ("This name" in the text, Cheng's edition and Yuhan edition read "ming yue" (named as); Qianjin Yi edition has the character "ye" after "he". The character "ming" is written as "wei".)
Cheng Wuji's Commentary: The Sanjiao (Triple Burner) is the pathway for water and grain. If pathogenic factors are in the Upper Jiao, there is vomiting without diarrhea; if in the Lower Jiao, there is diarrhea without vomiting; if in the Middle Jiao, there is both vomiting and diarrhea. This occurs due to irregular diet and disharmony of cold and heat, causing clear and turbid qi to interfere with each other, and yin and yang qi to deviate and block each other, thus forming Huoluan. Mild cases are merely called vomiting and diarrhea; severe cases involve sudden turmoil and chaos, hence named Huoluan.
Xi Ju's Commentary: "Huo" means sudden. It refers to pathogenic factors arriving suddenly, catching one off guard, causing the healthy qi to become panicked and disordered. The Stomach resides in the Central Earth and is the gathering place for all things, so it must be injured. Pathogenic factors and food qi interact chaotically in the middle, causing vomiting above and diarrhea below. Simultaneous onset of vomiting and diarrhea indicates fierce struggle between healthy qi and pathogenic factors, which is named Huoluan.
Bing Yuan Hou Lun states: Huoluan arises from improper adjustment of body temperature to external conditions, leading to interference and chaos between yin/yang and clear/turbid qi. When this chaos occurs between the intestines and stomach, it is triggered by diet. Onset involves colic pain in the heart and abdomen. If heart pain precedes, vomiting occurs first; if abdominal pain precedes, diarrhea occurs first; if both heart and abdomen hurt, vomiting and diarrhea occur simultaneously. Huoluan implies that within a fleeting moment, chaos ensues.
Qianjin Fang states: Investigating Huoluan, these illnesses are caused by diet, not spirits or ghosts. Overeating meat sauces and consuming dairy products, eating various seafood and land foods indiscriminately, sleeping on cold mats, and drinking excessive cold fluids cause food in the stomach to congeal and fail to digest. Yin and yang qi become obstructed and rebellious. Yang qi desires to descend, yin qi desires to ascend, but they deviate and block each other, resulting in vomiting and diarrhea. Headache feels like splitting, joints feel like dislocating, tendons throughout the body twist. Although the symptoms may seem minor, among acute emergencies, it is most terrifying.
Waitai Miyao citing Bixiao Fang states: Upper vomiting and lower diarrhea are called Shi Huoluan (Wet Huoluan).
Textual Research: In Wenxuan's Shudu Fu, "xi xiang huo huo", Liu Liang notes: "In an instant." Li Shan notes: "Boiling and chaotic appearance." Wen Fu: "Fen yun huo huo", Li Shan notes: "Huo huo, rapid appearance." Tang Hui Lin's Zang Jing Yin Yi explains: "Zhuan Huo", pronounced hu guo fan. According to Huo Shu, it is the appearance of urgency and speed. Huo ran, hu huo, all share this meaning. Furthermore, Huo ran is the appearance of sudden speed. From this research, Cheng's commentary says "huo huo liao luan" (sudden turmoil), Xi Ju says "hu ye" (sudden), Qian Tianlai says: roughly the meaning of sudden vomiting and diarrhea chaos. Their meanings are identical. Fang's commentary says: Huo means vomiting, Luan means disorder. This explanation is untenable.
Question: A patient presents with fever, headache, body ache, aversion to cold, vomiting, and diarrhea. What disease is this? Answer: This is named Huoluan. Huoluan naturally involves vomiting and diarrhea; additionally, even after diarrhea stops, fever may recur. (Cheng's edition lacks the characters "Huoluan"; Yuhan edition adds "bu fu" after "han". "Ci ming" is written as "dang wei"; lacks "zi". Qianjin Yi edition adds "er fu" after "han".)
Jian's Commentary: This follows the previous clause to detail the syndrome. Headache, body ache, fever, aversion to cold indicate Wind-Cold-Heat affecting the exterior. Vomiting and diarrhea indicate Cold-Dampness/Dietary injury affecting the interior. Possessing these syndromes is named Huoluan. If vomiting stops and diarrhea ceases, yet headache, body ache, aversion to cold persist, and fever recurs, this indicates the interior is resolved but the exterior remains unresolved. Shen Mingzong states: After vomiting and diarrhea stop, recurrent fever indicates interior harmony but unresolved exterior pathogen; treat with exterior-resolving methods. If no exterior signs exist, only abdominal pain, vomiting, and diarrhea are present, this indicates unresolved interior pathogen; treat primarily with interior-harmonizing methods. Fang's commentary states: Fever, headache, body ache, aversion to cold are external contraction; vomiting and diarrhea are internal injury. The former seeks syndrome from disease name; the latter verifies disease name through syndrome, providing detailed clarification. Xi Ju notes: Only mentioning cessation of diarrhea but not vomiting is elliptical writing.
Shanghan disease with faint and choppy pulse was originally Huoluan, now is Shanghan. After four or five days, when pathogen enters the Yin meridians, turning to Yin必然 leads to diarrhea. Originally having vomiting and diarrhea should not be treated as Shanghan. If one feels the urge to defecate but only passes gas and does not defecate, this belongs to Yangming. Stool will likely be hard. Recovery occurs after thirteen days because the meridian cycle completes. After diarrhea, stool should be hard; if hard but able to eat, recovery is indicated. Now unable to eat; upon reaching the next meridian period, slight ability to eat; after passing one more meridian period, able to eat; recovery expected one day later. If not recovered, it does not belong to Yangming. (Cheng's, Yuhan, and Fang editions separate the section starting from "after diarrhea stool should be hard" into a new clause. Yuhan adds "su" before "ben". "Yu si" in Yuhan and Qian editions reads "si yu". Cheng edition lacks "ci" before "shu".)
Jian's Commentary: This follows the previous clause to differentiate Huoluan syndromes (fever, headache, body ache, aversion to cold, vomiting/diarrhea) from similar Shanghan presentations. If preceding symptoms exist with floating-tight pulse, it is Shanghan. Now with faint-choppy pulse, it is originally Huoluan. Huoluan presents with immediate vomiting and diarrhea upon onset; Shanghan vomiting/diarrhea appears only after 4-5 days when pathogen transmits to Yin meridians. Since this is Huoluan with simultaneous vomiting and diarrhea, do not treat as Shanghan; wait for spontaneous resolution. If after cessation, urge to defecate occurs with flatus but no stool, this belongs to Yangming. Belonging to Yangming implies hard stool. However, this hardness results from fluid damage, not excess heat requiring purgation. Wait until day thirteen when meridian cycle ends, Stomach Qi harmonizes, fluids return, and bowel movement resolves naturally. If past day thirteen, stool remains difficult, this is "passing the meridian without resolution," purgation may be used. Post-diarrhea, intestines/stomach are empty, fluids depleted, stool should be hard. Hardness with ability to eat indicates Stomach Qi recovery. By day thirteen, fluid return and normal bowel movement indicate natural recovery. Now inability to eat indicates non-recovery. Wait until post-thirteen days, during meridian transition; if slight appetite returns, recovery expected. If still unrecovered, it is "expected recovery but failed." This failure indicates it does not belong to the Yangming pattern of hard stool post-meridian cycle, but rather Yangming pattern of deficiency-cold preventing eating post-vomiting/diarrhea, or Yangming pattern of deficiency-dryness post-vomiting/diarrhea. Medication is necessary; waiting will not yield self-healing. Choose between Lizhong Wan or Piyue Wan.
Aversion to cold, faint pulse, recurring diarrhea, cessation of diarrhea due to blood loss (fluid depletion). Treat with Sini Jia Renshen Tang (Four Reversal Decoction plus Ginseng).
Cheng Wuji's Commentary: Aversion to cold and faint pulse with diarrhea indicate Yang deficiency and Yin excess. Cessation of diarrhea implies internal exhaustion of fluids, hence termed "blood loss" (metaphorically referring to fluid/blood depletion). Jingui Yuhan states: Water exhaustion leads to blood exhaustion. Administer Sini Tang to warm meridians and assist Yang; add Renshen to generate fluids and benefit blood.
Case Note: Yizong Jinjian questions how large-hot tonics apply to "cessation of diarrhea due to blood loss." They suggest "cessation of diarrhea" should be "non-ceasing diarrhea" and "blood loss" should be "Yang collapse." Qian Tianlai also doubts "blood loss" vs "Yang collapse." However, Xu Dachun states: Case analysis: Loss of Yin is equivalent to loss of blood; it need not imply actual hemorrhage. This view seems reasonable.
Sini Jia Renshen Tang Formula
Gancao (Licorice Root, 2 liang, roasted) Fuzi (Aconite Root, 1 piece, raw, peeled, broken into 8 slices) Ganjiang (Dried Ginger, 1.5 liang) Renshen (Ginseng Root, 1 liang)
These four ingredients, boil in 3 sheng of water to obtain 1.2 sheng. Remove dregs. Divide into two warm doses. (Qianjin Fang and Waitai Miyao use 3 liang Renshen. For severe diarrhea, add Longgu 2 liang. Duanju Fang names this Sishun Tang.)
Wei Nianting's Commentary: Among warming-middle herbs, supplement with those tonifying deficiency and generating fluids. Applicable to post-illness blood/fluid depletion. Not limited to Huoluan, nor only to post-Shanghan vomiting/purging.
Xu Lingtai's Commentary: Although diarrhea has stopped, aversion to cold and faint pulse remain unchanged, indicating this is not Yang recovery but cessation of diarrhea due to internal fluid exhaustion. Hence termed "blood loss." Add Renshen to generate fluids and benefit blood.
Huoluan with headache, fever, body ache, abundant heat, and desire to drink water. Treat with Wuling San (Five-Ingredient Powder with Poria). Abundant cold, no desire to drink water. Treat with Lizhong Wan (Regulate the Middle Pill). ("Yong" character in Fang edition reads "yu yin" [desires to drink]. "Wan" in Cheng edition reads "yuan"; Yuhan edition reads "tang"; Qianjin Yi edition same.)
Wei Nianting's Commentary: Shanghan is an external contraction disease; Huoluan is an internal injury disease. Shanghan's fever, headache, body ache, aversion to cold involve Wind-Cold in Ying/Wei levels. Huoluan's headache, body ache, aversion to cold necessarily accompany vomiting/diarrhea, involving Wind-Cold in the Stomach Fu. How can external Wind-Cold suddenly enter the Stomach? Because daily Zhong Qi (Middle Qi) is deficient, sudden exposure to Wind-Cold penetrates the exterior into the interior, causing internal disease. Being Wind-Cold pathogens, symptoms like fever, headache, body ache, aversion to cold mirror Shanghan. Due to sudden invasion of the Stomach, vomiting/diarrhea occur, differing from Shanghan. This distinguishes the origins of these two diseases. The reason for no heat during vomiting/diarrhea, but recurrence after cessation, is also due to weak Zhong Qi. During vomiting/diarrhea, although pathogen is in Stomach, Qi scatters and heat cannot manifest; after diarrhea stops, Qi gathers, then heat manifests. This differs from Shanghan heat occurring at the exterior without rhythmic pauses. Having clarified Huoluan etiology and differences from Shanghan, treatment can be applied based on patient's cold/heat presentation. Heat-dominant cases: Stomach is deficient but internally hot, mostly deficiency-heat; heavy drinking desired post-vomiting/diarrhea. Use Wuling San to guide dampness, clear heat, and moisten dryness. Cold-dominant cases: Stomach is inherently deficient and cold, mostly deficiency-cold; no desire to drink post-vomiting/diarrhea. Use Lizhong Wan to warm middle, dry dampness, and tonify deficiency.
Shanghan Leifang states: Huoluan symptoms result from disharmony of cold/heat qi, rejection between Yin/Yang, obstruction of upper/lower communication, and lack of interaction between Water/Fire. Wuling San separates clear/turbid; Lizhong Wan strengthens Yang Qi. Both are Middle Jiao treatments.
Yishi biography of Lv Cangzhou by Dai Liang states: My wife Wang suffered from Shanghan, presenting as Yin blocking Yang (Yin Excess repelling Yang), red face, curled legs, diarrhea, restlessness, insomnia. Debaters differed on cold vs. warm treatments. I could not decide. Master Lv administered Zixue Dan (Purple Snow Pellet) combined with Lizhong Wan, slowly giving Ganshang Ganjiang Tang (Licorice and Dried Ginger Decoction) soaked in warm water. She recovered. He advised: Diarrhea and curled legs constitute Sini Syndrome. Using standard methods would exacerbate upper Jiao heat. Using Zixue to subdue heat, then gradually guiding acrid-sweet herbs to warm the interior exemplifies "treating heat with cold" method. Listeners were amazed.
Lizhong Wan Formula (Note below: "make decoction with modifications." ○ Yuhan edition, "wan" reads "yuan".)
Renshen (Ginseng Root) Ganjiang (Dried Ginger) Gancao (Licorice Root, roasted) Baizhu (Atractylodes Rhizome) (each 3 liang)
Grind these four ingredients into powder, mix with honey to form pills the size of chicken egg yolks. Dissolve one pill in several he of boiling water, crush, and take warm. Take 3-4 times daily, 2 times at night. If abdomen does not feel warm, increase to 3-4 pills. However, decoction is superior. Decoction method: Cut four ingredients according to weight, boil in 8 sheng water to obtain 3 sheng. Remove dregs. Take 1 sheng warm, 3 times daily. If pulsation above navel (Kidney Qi moving), remove Baizhu, add Guizhi 4 liang. If frequent vomiting, remove Baizhu, add Shengjiang 3 liang. If frequent diarrhea, retain Baizhu. If palpitations, add Fuling 2 liang. If thirsty wanting water, add Baizhu, increasing total to 4.5 liang. If abdominal pain, add Renshen, increasing total to 4.5 liang. If cold, add Ganjiang, increasing total to 4.5 liang. If abdominal fullness, remove Baizhu, add Fuzi 1 piece. After taking decoction, approx. meal time, drink ~1 sheng hot porridge to maintain mild warmth. Do not expose body to cold. (Cheng/Yuhan editions add "wei mo" [powder] after "shi"; lack "xu". "Ruo qishang shang" includes "jianjian fa" [modification methods]. "Ri san si" in Chaihou Bing Pian, Yuhan/Cheng editions read "ri san fu".)
Fang Youzhi's Commentary: Li means governance/regulation. Zhong means interior, specifically Interior Yin. Renshen/Baizhu sweetness warms interior. Gancao sweet-neutral harmonizes middle. Ganjiang acrid-hot disperses cold.
Cheng Zhi's Commentary: Yang movement begins with warmth. When warm Qi spreads, grain essence circulates; grain Qi rises, Middle Qi suffices. Hence named Lizhong (Regulate Middle). It actually uses regulating power to bestow Yang upon the Middle Jiao. Yang deficiency means Middle Qi loses its hold; Danzhong lacks dispersing function; Six Fu lack spreading functions. Like a stove losing flame, leading to undigested food below and loss of taste above, with Five Zang organs attacking each other, causing various syndromes. Renshen, Baizhu, roasted Gancao secure the Central State; Ganjiang acrid-warms middle. Must borrow it to ignite the stove fire, raising Yang Qi. Thus grain enters Yin, nourishes Yang, transports up to Huagai (Lungs), controls Zhou Du (Bladder/Kidneys). Five Zang and Six Fu receive Qi. This is the essence of Lizhong.
Qian Tianlai states: Subsequent modification formulas contradict textual logic, likely not Zhang Zhongjing's method.
Shanghan Leifang states: Gui Zhi Tang drinking hot porridge aims to assist medicine to scatter outward; here drinking hot porridge aims to assist medicine to warm inward.
Jingui Yaolue: Chest Bi (Obstruction), central chest oppression, Qi knotting in chest, chest fullness, Qi reversing seizing heart. Ren Shen Tang treats this. Cheng Lin notes: This is Lizhong Tang. Strong Middle Qi disperses oppression, eliminates chest fullness, directs Qi downward. Renshen/Baizhu benefit Spleen; Gancao/Ganjiang warm Stomach. Harmonized Spleen/Stomach opens Upper Jiao Qi, curing Chest Bi.
Qianjin Fang: Zhizhong Tang treats Huoluan vomiting/diarrhea, fullness, indigestion, heart/abdominal pain. It is this formula. Four ingredients chopped, boiled in 8 sheng water to 3 sheng. Divide into three doses. If not cured, take frequently for three doses. Prevent Huoluan when traveling: make pills like wutong seeds, take 30 pills. If powder, take fangcun bi, wine administration acceptable. If tendon cramping (zhuan jin), add Shigao 3 liang. Also Sishun Lizhong Wan, suitable postpartum. Newborn organs are deficient; this nourishes organ Qi. (Same formula.)
Waitai Miyao: Cui Shi Lizhong Wan treats Three Jiao obstruction, vomiting, anorexia, Huoluan vomiting/reverse flow/diarrhea, and inability to defecate. (Same formula.)
Also Yannian Lizhong Wan treats Huoluan vomiting/diarrhea, retained food stagnation.
Add Damai (Barley) to this formula.
Also Guangji Fang: Treats cold-heat imbalance, Huoluan vomiting/diarrhea, retained food stagnation, Lizhong Wan.
Add Liangjiang (Galangal) and Guixin (Cinnamon Bark) to this formula.
Also Fan Wang Fuling Lizhong Tang treats Huoluan pulsation above navel with palpitations.
Add Fuling (Poria) and Mugua (Chaenomelos) to this formula.
Also Fan Wang Lizhong Erwei Tang treats Huoluan chest fullness, abdominal pain, vomiting/diarrhea.
Add Danggui (Angelica Sinensis) and Shaoyao (Peony Root) to this formula.
Also Yannian Zengsun Lizhong Wan main indication: Huoluan, descending Qi, appetite return, stopping dysentery.
Add Houpo (Magnolia Bark) and Fuling to this formula. ○ Zhizhi Fang, decocted, also named Lizhong Tang.
Also Duanju Fulaol Lizhong San treats frail elderly cold Qi, nausea, indigestion, abdominal vacuous fullness, spasm, shortness of breath, Huoluan vomiting/reverse flow, cold limbs, vexation, air闷 sweating.
Add Maidong (Ophiopogon), Fuzi (Aconite), Fuling to this formula.
Heren Shu: If limb spasms, abdominal fullness, diarrhea, or tendon cramping, remove Baizhu, add raw Fuzi 1 piece.
Sanyin Fang: Patient overeating injures Stomach, or Stomach deficiency fails digestion, causing retching/vomiting, matter/Qi rushing against cardia, tearing injury, vomiting bright red blood, heart/abdominal colic, spontaneous white sweat, named "Stomach Injury Hematemesis." Lizhong Tang stops Stomach Injury Hematemesis because its merit regulates Middle Jiao, separates Yin/Yang, stabilizes blood vessels. Formulas/syndromes extensive like Ju Fang, though hematemesis syndrome not explicitly listed; students should know. Alternatively, boil only Ganjiang/Gancao decoction, also excellent. See Yangsheng Biyong.
Also Jiawei Lizhong Wan treats excessive alcohol intake and spicy/fried hot foods causing blood movement, inducing epistaxis.
Add Gegen (Kudzu Root) and Chuanxiong (Ligusticum) equal parts to this formula. (Jisheng Fang omits Chuanxiong; Zhizhi Fang adds Muxiang to treat dietary Stomach injury bleeding syndromes.)
Also Fuzi Lizhong Tang treats Five Zang Cold Invasion, locked jaw, limb rigidity, muteness.
Add large Fuzi equal parts to this formula.
Shi Shi Xuyijian Fang: Middle Cold Qi deficiency, Yin/Yang failing to guard each other, blood wanders recklessly. Classic states: Yang deficiency, Yin must flee. This applies to hemoptysis, hematemesis, epistaxis, hematochezia. Lizhong Tang + Guirou (Cinnamon Twig) treats this. People know this herb regulates Middle Jiao, unaware of its Yin/Yang separation and blood stabilization merits.
Also Lizhong Tang treats Shanghan seasonal Qi, interior cold exterior heat, add Wuweizi (Schisandra) and Ejiao (Donkey-hide Gelatin) powder equal parts, named Shunwei Wan. Excellent for cold-induced cough. Elderly persistent vomiting/diarrhea: remove Gancao, add Baifuling (White Poria) 1 liang, named Wenzhong Tang.
Zhizhi Fang: Lizhong Wan tonifies Lung, stops cold cough.
Add fried Ejiao and Wuweizi to this formula.
Also Jiawei Lizhong Tang treats Lung/Stomach dual cold cough.
Add Banxia (Pinellia), Fuling, Juhong (Citrus Peel), Xixin (Asarum), Wuweizi, Jiang (Ginger), Zao (Jujube) decocted.
Also pregnant women fetal movement, abdominal/flank/lower back pain, bloody discharge: use authentic Lizhong Tang + Suazhen (Amomum).
Tiren Huibian: Sanjian Tang. Must verify true Kidney Essence exhaustion and Winter True Shanghan before use. This formula adds Chuanwu (Chuanwu Aconite) and Lurong (Deer Antler).
Yihui: Abdominal pain, complete anorexia, constitutionally weak, cold abdominal pain, pressure relieves pain. This is deficiency. This formula adds Liangjiang, Wuzhuyu.
Yinzheng Lueli: Cold syndrome anorexia, Lizhong/Jianzhong half-half decoction, forms Erzhong Tang.
Yijing Huijie: This formula doubles Baizhu/Renshen, adds Zhuling (Polyporus), Zexie (Alisma), Fuling, Rougui (Cinnamon Bark), named Lizheng Tang. Hiccups, add Dingxiang (Clove), Shidi (Persimmon Calyx).
Zhangshi Yitong: Epistaxis, six pulses string-thin-choppy, empty on pressure, pale lusterless complexion, indicates blood loss. This is major cold syndrome. Lizhong Tang + Huangqi (Astragalus).
Vomiting/diarrhea cease, but body pain persists. Adjust to harmonize exterior, preferably Gui Zhi Tang (Cinnamon Twig Decoction) in small amounts.
Cheng Wuji's Commentary: Vomiting/diarrhea cease, interior harmonized. Body pain persists, exterior unresolved. Give Gui Zhi Tang to gently harmonize. Waitai Miyao states: Interior harmonized, exterior diseased, sweating cures it.
Fang Youzhi's Commentary: "Xiaoxi" means deliberation/moderation. "Xiaohe" means administering small amounts, avoiding excess.
Shanghan Zhige: Xiaoxi means adjusting dosage up or down.
Vomiting/diarrhea with sweating, fever, aversion to cold, limb spasms, cold extremities. Treat with Sini Tang (Four Reversal Decoction).
Zhang Zhicong's Commentary: Vomiting/diarrhea sweating indicates Middle Jiao fluids leaking externally. Fever/aversion to cold indicates Exterior Qi deficiency. Limb spasms indicate fluid exhaustion. Cold extremities indicate Life-Giving Yang Qi failing to reach limbs. Hence Sini Tang initiates Lower Jiao Life-Giving Yang, warms Middle Jiao Earth Qi.
Both vomiting and diarrhea, urination becomes frequent/profuse, profuse sweating, diarrhea with undigested food, interior cold exterior heat, pulse faint almost imperceptible. Treat with Sini Tang. ("Nei" in Yuhan edition reads "Li".)
Qian Tianlai's Commentary: Vomiting/diarrhea indicate Cold pathogen in interior. Frequent urination indicates absence of heat. Profuse sweating indicates True Yang deficiency and insecure Wei Qi (Defensive Qi), leading to Yang-deficiency sweating. Diarrhea with undigested food indicates Stomach Cold failing to cook food. Interior cold/exterior heat is not exterior pathogen fever, but Cold excess in interior repelling Yang to exterior. Yin Cold too severe, Yang Qi extremely weak, hence pulse nearly vanishing. Urgently rescue True Yang; hence Sini Tang.