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*Suwen: Liuyuan Zhengji Dalun* states: "When the Qi of Taiyin prevails, it leads to fullness in the middle jiao and cholera with vomiting and diarrhea."

The damp-earth Qi of Taiyin corresponds internally to the Spleen. Fullness in the middle jiao, cholera, vomiting, and diarrhea are mostly caused by pathogenic dampness in the middle jiao. Therefore, when the Qi of Taiyin prevails, one should not rigidly adhere to the concepts of Si Tian (ruling heavenly Qi) ascending or the scorching heat of summer sun descending. Humans exist within the intersection of heaven and earth Qi, subject to steaming and humidifying influences. Pathogens enter through the mouth, nose, skin, and hair; if they remain and do not disperse, they form various diseases such as warm-heat, summer-heat, and epidemic diseases. Cholera is merely one type among them. If a person's original Yang Qi is deficient, and Earth Qi cannot overcome Dampness, or if they excessively consume cold drinks and seek coolness, the Dampness may transform into Cold, resulting in cholera. However, transformation into Heat is the natural course of celestial movements; transformation into Cold is due to individual constitutional factors. Understanding both the normal and the variable allows for appropriate treatment without error.

*Ling Shu: Jing Mai Pian* states: "When the Jue Qi of the Foot-Taiyin channel rebels upward, it results in cholera."

The Foot-Taiyin Spleen is an Earth Zang organ. Its corresponding climate is Dampness, its nature prefers dryness, and it governs the central pivot, responsible for ascending the clear and descending the turbid. Only when Dampness is excessive and obstructs the mechanism of ascent and descent does the turbid rebel upward, while the clear is suppressed downward, leading to cholera. Although cholera can be divided into heat-transformation and cold-transformation types, treatment should focus on venting the turbidity. Once the turbidity is cleared, the rebellion calms, the chaos settles, and the clear Qi ascends naturally.

*Shanghan Lun* asks: "What about diseases called cholera?" The answer is: "Vomiting accompanied by diarrhea is named cholera."

This question-and-answer format clarifies the disease of cholera. It means that pathogens located in the upper jiao tend to cause vomiting; those in the lower jiao tend to cause diarrhea. When pathogens are in the middle jiao, rebelling upward causes vomiting, and flowing downward causes diarrhea; this combination is called cholera. "Cholera" refers to a sudden onset causing extreme confusion and distress within moments, characterized by rapid and unstable changes. If a chronic condition involves the inability to retain food above and inability to control excretion below, it is simply named vomiting and diarrhea, not cholera.

It further states: "Regarding a disease with fever, headache, body pain, aversion to cold, vomiting, and diarrhea, what kind of disease is this?" The answer is: "This is named cholera. After spontaneous vomiting and diarrhea, when the diarrhea stops, fever recurs."

Xu Huixi stated: "Here, cholera is a transformed syndrome of Shanghan (Cold Damage)." Guo Baiyun said: "The discussion of cholera here resembles symptoms of Shanghan. In cases where Shanghan leads to cholera, Yin and Yang Qi become chaotic in the chest. In cases where cholera occurs spontaneously without prior illness, it is often due to irregular diet causing chaotic reversal in the chest. The classic says: Clear Qi resides in the Yin, Turbid Qi in the Yang. When Turbid Qi disrupts the chest, vomiting occurs; when it disrupts the intestines, diarrhea occurs. The 'Five Disruptions' mentioned in the classics include cholera as one of them." Zhang Luyu said: "Vomiting and diarrhea from Shanghan are caused by pathogenic Cold, constituting cold-type cholera."

Wang Shihong's commentary: Cholera may arise from dietary injury, internal accumulation of dampness, or stagnant Qi. Since there are exterior syndromes such as fever, headache, body pain, and aversion to cold, the treatment must address the exterior simultaneously. This is the rationale behind Zhang Zhongjing's primary use of Wuling San (Five-Ingredient Poria Pill). However, exterior syndromes can be addressed concurrently not only with Cold pathogens but also with Warm-Heat or Wind-Heat pathogens. By analogy, flexible application depends on the practitioner. For cases where Warm-Heat or Summer-Heat directly invades the Spleen and Stomach, cooperating with internal pathogens, once the interior harmonizes and vomiting/diarrhea cease, the pathogen may return to the exterior causing fever; Ji Qing Tang (Driving Light Decoction) is indicated. For cold-type cholera where the exterior syndrome remains unresolved, Zhang Zhongjing's Guizhi method (Cinnamon Twig Method) is applicable.

*Yi Che* states: "The manifestation of cholera comes suddenly and violently, with abdominal pain and restlessness. There are cases of simultaneous vomiting and diarrhea, cases of vomiting without diarrhea, cases of diarrhea without vomiting, and cases of neither vomiting nor diarrhea. This indicates that pathogens vary in location (upper/lower) and depth. Generally, recovery is achieved when the pathogen can be vomited out. Where pathogens enter, they must exit. Salt water can be used to induce vomiting to expel pathogens. Cases caused by dietary imbalance and contact with foul pathogens are particularly common. Once Stomach Qi is damaged, clear and turbid Qi interfere with each other. If pathogens are not expelled, healthy Qi cannot be at peace; thus, expelling pathogens is more critical than tonifying healthy Qi. Even in severe stages with cold limbs, hidden pulse, muscle cramps, and hoarseness, rebellious pathogens must be driven out completely. Because eliminating pathogens ensures the peace of healthy Qi, unlike other conditions where tonifying healthy Qi naturally eliminates pathogens. Therefore, during an outbreak, rice drink should not be consumed. Ancient sages earnestly warned against this; surely there is reason! Observing Gan Huoluan (Dry Cholera), where one cannot vomit nor defecate, the severity arises because pathogens cannot exit. Practitioners should ponder this deeply."

This outlines the general principles for treating cholera. Emphasizing vomiting as a pathway for pathogen expulsion refers specifically to the previously mentioned Dry Cholera where neither vomiting nor defecation is possible. "If pathogens are not expelled, healthy Qi cannot be at peace" is a profound saying applicable to all diseases. However, although cholera generally lacks the principle that "tonifying healthy Qi eliminates pathogens," there are occasional cases of deficiency predominating with minimal pathogens. In such instances, combining exterior-resolving and interior-stabilizing methods is indeed a valid approach.

*Bing Yuan* states: "In cholera, a large pulse indicates treatability; a minute and fine pulse indicates untreatability. In cholera with vomiting and diarrhea, a minute and slow pulse, weak breathing, and reluctance to speak indicate untreatability."

*Zhifa Hui* states: "In vomiting and diarrhea, the appearance of a Dai pulse (intermittent pulse) is actually a favorable sign. A Xian-Hua (wiry-slippery) pulse at the Cun-Kou position indicates retained food in the diaphragm. Even if vomiting has occurred, salt water combined with a goose feather should still be used to induce vomiting. After complete expulsion, administer harmonizing medications. In any case of vomiting and diarrhea, whether the pulse is Jie-Cu-Dai (knotted-rapid-intermittent), hidden, or洪大 (surging-large), one should not hastily declare it a death sentence. Only when the pulse is minute, fine, and nearly absent, accompanied by shortness of breath, silence, tongue retraction, and testicular retraction, is it considered untreatable."

*YiTong* states: "A hidden or minute-choppy pulse indicates cholera. A long pulse indicates a primary disease of the Yangming channel. A surging-large pulse in cholera is auspicious. A pulse that is deficient, minute, slow, and fine, accompanied by panting, is ominous. Tongue retraction and testicular retraction in cholera are signs of death."

*Jin Gui Zhuanjin Zhengzhi* states: "In severe cases of this syndrome, the pulse becomes hidden immediately due to pathogen closure blocking the Qi channels. Do not readily believe quacks who claim the pulse is absent and incurable."

Commentary: In cases of Ying (Nutritive) deficiency and Qi exhaustion with a minute, fine, and nearly absent pulse, Fumai Tang (Restore the Pulse Decoction) is indicated. In cases of Qi dispersion and Yang floating with a minute, fine, and nearly absent pulse, Sini Tang (Frigid Extremities Decoction) is indicated. If external pathogens penetrate deeply leading to Yang collapse and death; or if closure syndromes are mistakenly treated with tonification leading to pathogen entrapment and death.

Another commentary: Ye Tianshi stated: "The classic says: Acute illnesses and sudden deaths all belong to Fire. Fire constrained internally cannot reach the exterior, so it mimics cold syndromes. Orifices are blocked, meridians are unobstructed, and pulse pathways fail to circulate, often presenting with deep, sluggish pulses lacking fire signs. I believe this applies to all syndromes; knowing one example allows inferring others. However, this insight is not known to those without profound clinical experience."