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Chapter 21 of 29
伤寒杂病论
Overall Paraphrase
This chapter, "Distinguishing the Pulses and Syndromes of Sudden Turmoil-Plus-Vomiting-and-Diarrhea, and Its Treatment," focuses on a category of acute spleen-stomach disorders characterized by sudden simultaneous vomiting and diarrhea. It must be stated at the outset that the "sudden turmoil" (approximately huòluàn) referred to here is a disease name in traditional Chinese medicine, broadly denoting conditions in which the qi mechanism of the middle burner is thrown into disorder and the clear and turbid rise and fall counter to each other, resulting in simultaneous vomiting above and diarrhea below. It is by no means equivalent to the modern medical concept of cholera caused by Vibrio cholerae.
I. What is "Sudden Turmoil" (Huòluàn)?
The opening dialogue of the original text states: when there is both vomiting and diarrhea, this is called "sudden turmoil."
Zhang Zhongjing further explains: the location of sudden turmoil disease is the Greater Yin (Taiyin), that is, the spleen-stomach system. Sudden turmoil always presents with both vomiting and diarrhea. However, not all cases of vomiting and diarrhea are necessarily sudden turmoil. The basic pathogenesis of sudden turmoil is that cold and heat pathogenic qi become chaotically intermingled in the middle burner — hot qi rebels upward, causing vomiting; cold qi pours downward, causing diarrhea. Additionally, if eating and drinking are not moderate and food stagnation becomes congested in the middle and upper burners, this may produce vomiting upward and diarrhea downward; this is called "vomiting and diarrhea," not "sudden turmoil."
Someone asks: When there is fever, headache, body aches, and aversion to cold, together with simultaneous vomiting and diarrhea — what disease is this? The reply: This is not sudden turmoil. Sudden turmoil is mainly spontaneous vomiting and diarrhea. Since this person additionally has aversion to cold, body aches, and fever, it is known that this is not sudden turmoil, but rather a concurrent external contraction.
II. Common Syndrome Patterns and Treatments for Sudden Turmoil
Based on the pulse, cold and heat presentation, and characteristics of vomiting and diarrhea, this chapter enumerates a variety of syndrome types with corresponding formulas. All of the following are theories recorded in classical texts, provided for study purposes only, and are not to be taken as medication guidance.
Middle burner deficiency-cold type: sudden turmoil with vomiting, diarrhea, absence of significant fever or aversion to cold, pulse soft and weak — use Li Zhong Tang (Regulate the Middle Decoction). The formula consists of ginseng, Atractylodes macrocephala (bái zhú), licorice, and dried ginger, embodying the approach of warming the middle, dissipating cold, strengthening the spleen, and stopping diarrhea.
Food stagnation obstructing the middle type: vomiting diarrheayya occurs after initial vomiting, with abdominal distension and pain. No chills or fever. Pulse is soft-weak and rough. This is due to retained food stagnation, treated with Bái Zhú Fú Líng Bàn Xià Zhǐ Shí Tāng (Atractylodes, Poria, Pinellia, and Immature Bitter Orange Decoction). The formula consists of bái zhú, fú líng, bàn xià, and zhǐ shí, aiming to strengthen the spleen, transform rheum, dissolve food stagnation, and guide it downward.
Food stagnation in the upper burner type: Feeling of fullness and oppression in the chest, desire to vomit but inability to do so. Diarrhea is intermittent. There is cramping abdominal pain. The cùn-kǒu (inch-mouth) pulse is weak and bound (jié). This is due to food stagnation lodged in the upper stomach. Treatment uses Guā Dì Sǎn (Melon Pedicle Powder) to induce vomiting. The formula consists of guā dì (melon stalk) and chì xiǎo dòu (red adzuki beans), taken with a decoction of prepared fermented soybean (xiāng chǐ), dosing until vomiting occurs. This method is relatively harsh and is rarely used in modern times.
Yang deficiency with exuberant cold type: sudden turmoil with vomiting, diarrhea of undigested food, cold limbs (jué lěng in hands and feet), and a deep, slow pulse — use Sì Nì Tāng (Frigid Extremities Decoction). The formula consists of honey-fried licorice, dried ginger, raw processed aconite (shēng fù zǐ — likely prepared, though often translated this way), and ginseng, with the major focus on returning yang and rescuing from rebellion/collapse.
Cold-heat complex type: Vomiting and diarrheaa with fever, a soft-weak but large pulse. Treatment is Bái Zhú Shí Gāo Bàn Xià Gān Jiāng Tāng (Atractylodes, Gypsum, Pinellia, and Dried Ginger Decoction). In this formula, bái zhú and gān jiāng are warming, shí gāo is cooling, and bàn xià harmonizes the stomach — reflecting concurrent use of cold and warm agents. If there is thirst, add rén shēn and huáng lián.
Verminous reversal (jué) type with cold-heat complex: pronounced vomiting (even of roundworms), diarrhea that is frequent then sparse, slight fever, cold extremities, bluish facial complexion, deep wiry and tight pulse — use Sì Nì Jiā Wú Zhū Yú Huáng Lián Tāng (Frigid Extremities Decoction plus Evodia and Coptis). Formula: shēng fù zǐ, gān jiāng, honey-fried licorice, rén shēn, wú zhū yú, and huáng lián. It both warms yang and rescues inversion, and clears heat with bitter cold while directing rebellious qi downward and settling worms.
Qi and yin deficiency type: sudden turmoil with vomitingdiarrhea, thirst, sweating, shortness of breath, weak and soft pulse — use Lǐ Zhōng Jiā Rén Shēn Guā Lóu Gēn Tāng (Regulate the Middle Decoction plus Ginseng and Trichosanthes Root). This adds rén shēn and guā lóu gēn to the Lǐ Zhōng formula, warming the middle while promoting fluid generation.
Spleen-kidney yang deficiency type: Vomiting occurs immediately upon drinking water, eating grains leads to diarrhea, pulse is slow and weak. Use Lǐ Zhōng Jiā Fù Zǐ Tāng (Regulate the Middle Decoction plus Aconite) — the Lǐ Zhōng Tāng plus fù zǐ, adding reinforcement of warming yang and dissipating cold.
Middle burner qi stagnation type: distension and pain in the abdomen, vomiting when the pain presses upward, diarrhea when the pain presses downward, a soft but rough pulse — use Lǐ Zhōng Tāng (a principle, though also given a formula option in original - noted as such or partially specified - context suggests Lǐ Zhōng here).
Differentiation-based treatment for deficiency and excess: Huòluàn yǒu xū-shí zhī fēn. De viññāṇa bodily constitution has its antecedent deficiency or excess, thus clinical manifestations also transform. The deficient are treated with Lǐ Zhōng Tāng; the excess (rapid, hasty pulse) with Gě Gēn Huáng Qín Huáng Lián Gān Cǎo Tāng (Kudzu, Scutellaria, Coptis, and Licorice Decoction). The latter consists of gé gēn, huáng qín, huáng lián, and honey-fried licorice — clearing heat and dampness, lifting the clear and stopping diarrhea.
Abdominal cramping of the tendons type: Huòluàn lying with “zhuǎn jīn” (muscle/limb spasms) because of pre-existing latent cold in the sinews, impairing the yíng (nutritive) qi, aggravatedduring illness. Where the pulse ought to be soft-weak but is instead wiry-urgent on palpationaccompanied with inversion cold in the four limbs, treat with Lǐ Zhōng Jiā Fù Zǐ Tāng.
Post-Huòluàn residuary pathogenic influence: Youxié residual: Whenhuòluàn vomiting and diarrhea are stopped yet headache, fever and bodily pain remain — if heat predominates, with thirstand a desire to drink — use Wǔ Líng Sǎn (Five-Ingredient Powder with Poria — standardized context implies specifically wuling) (composed of zhū líng, bái zhú, fú líng, guì zhī, zé xiè) which activates qi transit and disinhibits water appropriately. Meanwhile when cold predominates accompanying absence of thirst and no desire to drink — giveLǐ Zhōng Wán warming and fortifying the spleen.
III. Differentiation of Huòluàn vs. Cold-Damage (Shanghan) and its Prognosis
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Overall Paraphrase
This chapter, "Distinguishing the Pulses and Syndromes of Sudden Turmoil-Plus-Vomiting-and-Diarrhea, and Its Treatment," focuses on a category of acute spleen-stomach disorders characterized by sudden simultaneous vomiting and diarrhea. It must be stated at the outset that the "sudden turmoil" (approximately huòluàn) referred to here is a disease name in traditional Chinese medicine, broadly denoting conditions in which the qi mechanism of the middle burner is thrown into disorder and the "clear and turbid" rise and fall counter to each other, resulting in simultaneous vomiting above and diarrhea below. It is by no means equivalent to the modern medical concept of cholera caused by Vibrio cholerae.
I. What is "Sudden Turmoil"?
The opening dialogue of the original text states: when there is both vomiting and diarrhea, this is called "sudden turmoil."
Zhang Zhongjing further explains: the location of sudden turmoil disease is the Greater Yin (Taiyin), that is, the spleen-stomach system. Sudden turmoil always presents with both vomiting and diarrhea. However, not all cases of vomiting and diarrhea are necessarily sudden turmoil. The basic pathogenesis of sudden turmoil is**cold and heat pathogenic qi becoming chaotically intermingled in the middle burner* — hot qi rebels upward, causing vomiting; cold qi pours downward, causing diarrhea. Additionally, if eating and drinking are not moderate and food stagnation becomes congested in the middle and upper burners, this may produce vomiting upward and diarrhea downward; this is called "vomiting and diarrhea," not "sudden turmoil."
Someone asks: When there is fever, headache, body aches, and aversion to cold, together with simultaneous vomiting and diarrhea — what disease is this? The reply: This is not sudden turmoil. Sudden turmoil is mainly spontaneous vomiting and diarrhea. Since this person additionally has aversion to cold, body aches, and fever, it is known that this is not sudden turmoil, but rather a concurrent external contraction.
II. Common Syndrome Patterns and Treatments for Sudden Turmoil
Based on the pulse, cold and heat presentation, and characteristics of vomiting and diarrhea, this chapter enumerates a variety of syndrome types with corresponding formulas. All of the following are theories recorded in classical texts, provided for study purposes only, and are not to be taken as medication guidance.
Middle burner deficiency-cold type: sudden turmoil with vomiting, diarrhea, absence of significant fever or aversion to cold, pulse soft and weak — use Lǐ Zhōng Tāng (Regulate the Middle Decoction).
Food stagnation obstructing the middle type: Emesis and loose stools after an initial phase ofretching, with abdominal distension and subjective pain, but without chills or fever.DimThe pulse is soft-weak and rough. This is due to retained food stagnation, treated with. Bái Zhú Fú Líng Bàn Xià Zhǐ Shí Tāng: This contains bái zhú. Re object overall (note)–full*, that havepatientized continue into astext later both…
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Overall Paraphrase
This chapter focuses on a category of acute spleen–stomach disorders characterized by the sudden onset of both vomiting and diarrhea. It must be clarified at the outset that “sudden turmoil” (huòluàn) here is a traditional Chinese medicine disease name, broadly referring to conditions in which the qi mechanism of the middle burner is thrown into disorder and the clear and turbid rise and fall counter to each other, manifesting as simultaneous vomiting and diarrhea. It is not equivalent to the modern medical concept of cholera caused by Vibrio cholerae.
I. What Is “Sudden Turmoil”?
The opening dialogue of the original text states: when there is both vomiting and diarrhea, this is called “sudden turmoil.”
Zhang Zhongjing further explains: sudden turmoil disease is located in the Greater Yin (Taiyin), namely the spleen–stomach system. Sudden turmoil always involves both vomiting and diarrhea. However, the presence of vomiting and diarrhea does not always mean sudden turmoil. The basic pathogenesis of sudden turmoil is that cold and heat pathogenic qi are chaotically intermingled in the middle burner — hot qi rebels upward, causing vomiting; cold qi pours downward, causing diarrhea. In addition, if one eats and drinks without moderation, so that food stagnation becomes congested in the middle and upper burners, this may cause both vomiting and diarrhea; that is called “vomiting and diarrhea,” not “sudden turmoil.”
Someone asks: When there is fever, headache, body aches, and aversion to cold, together with simultaneous vomiting and diarrhea — what disease is this? The reply: This is not sudden turmoil. Sudden turmoil occurs mainly as spontaneous vomiting and diarrhea. Because this person additionally has aversion to cold, body aches, and fever, it is known that this is not sudden turmoil but rather indicates the presence of a separate external contraction.
II. Common Syndrome Patterns and Treatments for Sudden Turmoil
This chapter, drawing on the pulse, cold/heat manifestations, and characteristics of vomiting and diarrhea, sets forth various syndrome differentiations with corresponding formulas. All of the following are theories contained in the classical text, provided for scholarly study only, and are not intended as medication guidance.
Middle burner deficiency–cold type: Sudden turmoil with vomiting and diarrhea, no significant fever or aversion to cold, pulse soft and weak — treat with Lǐ Zhōng Tāng (Regulate the Middle Decoction). The formula is composed of ginseng, Atractylodes macrocephala (bái zhú), licorice, and dried ginger, embodying the approach of warming the middle, dispersing cold, strengthening the spleen, and stopping diarrhea.
Food stagnation obstructing the middle type: Vomiting followed by diarrhea, abdominal distension and pain, no chills or fever, pulse soft-weak and rough (sè) — this is retained food stagnation. Treat with Bái Zhú Fú Líng Bàn Xià Zhǐ Shí Tāng (Atractylodes, Poria, Pinellia, and Immature Bitter Orange Decoction), composed of bái zhú, fú líng, bàn xià, and zhǐ shí. The intention is to strengthen the spleen, transform rheum, dissolve food stagnation, and direct it downward.
Food stagnation in the upper burner type: Fullness and oppression in the chest, desire to vomit but inability to do so, diarrhea that is sometimes frequent and sometimes sparse, cramping abdominal pain. The cùn-kǒu (inch-mouth) pulse is weak and bound (jié). This is food stagnation lodged in the upper stomach. An emetic method with Guā Dì Sǎn (Melon Pedicle Powder) is appropriate. The formula consists of guā dì (melon stalk) and chì xiǎo dòu (red adzuki beans), taken with a decoction of prepared fermented soybean (xiāng chǐ); dosing continues until vomiting occurs. This method is relatively vigorous and is almost never used in modern times.
Yang deficiency with exuberant cold type: Sudden turmoil with vomiting, diarrhea of undigested food, reversal cold of the limbs, and a deep, slow pulse — treat with Sì Nì Tāng (Frigid Extremities Decoction). The formula consists of honey-fried licorice, dried ginger, raw processed aconite (shēng fù zǐ), and ginseng, with the major purpose of returning yang and rescuing from collapse.
Cold–heat complex type: Vomiting and diarrhea accompanied by fever; pulse is soft-weak but large. Treat with Bái Zhú Shí Gāo Bàn Xià Gān Jiāng Tāng (Atractylodes, Gypsum, Pinellia, and Dried Ginger Decoction). Here bái zhú and gān jiāng are warm in nature, shí gāo is cold, and bàn xià harmonizes the stomach — illustrating the concurrent use of cold and warm agents. If there is thirst, add rén shēn and huáng lián.
Verminous reversal (jué) type with cold–heat complex: Severe vomiting to the point of expelling roundworms, diarrhea that is frequent then sparse, slight fever, reversal cold of the four limbs, a bluish facial complexion, and a deep, wiry, and tight pulse — treat with Sì Nì Jiā Wú Zhū Yú Huáng Lián Tāng (Frigid Extremities Decoction plus Evodia and Coptis). The formula is made of shēng fù zǐ, gān jiāng, honey-fried licorice, rén shēn, wú zhū yú, and huáng lián. It both warms yang and rescues from collapse, while also clearing heat with bitter cold, directing rebellious flow downward, and settling worms.
Qi and yin deficiency type: Sudden turmoil with vomiting and diarrhea, thirst, sweating, shortness of breath, and a pulse that is weak and soft — treat with Lǐ Zhōng Jiā Rén Shēn Guā Lóu Gēn Tāng (Regulate the Middle Decoction plus Ginseng and Trichosanthes Root). To the base Lǐ Zhōng Tāng are added rén shēn and guā lóu gēn, warming the middle while also promoting generation of fluids.
Spleen–kidney yang deficiency type: Vomiting immediately upon drinking water, diarrhea upon eating grains, pulse slow and weak — treat with Lǐ Zhōng Jiā Fù Zǐ Tāng, i.e., Lǐ Zhōng Tāng plus fù zǐ to strengthen the power of warming yang and dissipating cold.
Middle burner qi stagnation type: Distension and pain in the abdomen. When the pain surges upward, vomiting follows; when the pain presses downward, diarrhea follows. The pulse is soft but rough (sè) — treat with Lǐ Zhōng Tāng.
Differentiation between deficiency and excess: Sudden turmoil has deficiency and excess presentations. If the patient’s constitution is originally deficient, the disease pattern tends toward deficiency, marked pulse soft and weak — suitable treatment is Lǐ Zhōng Tāng. When latent constitution is more replete, the presentation tends toward excess with an urgent and hasty pulse — suitable treatment is Gě Gēn Huáng Qín Huáng Lián Gān Cǎo Tāng (Kudzu, Scutellaria, Coptis, and Licorice Decoction). The latter formula consists of gé gēn, huáng qín, huáng lián, and honey-fried licorice, clearing heat and dampness, lifting the clear and stopping diarrhea.
Muscle cramping (zhuǎn jīn) type: Sudden turmoil accompanied by cramping of the sinews, pre-existing cold retained amidst the sinews damaging the yíng (constructive/nutritive) qi, manifesting during the illness. If the pulse should be soft and weak but instead is wiry and urgent, accompanied by reversal cold of the four limbs, treat with Lǐ Zhōng Jiā Fù Zǐ Tāng.
Residual pathogenic effects after sudden turmoil: Sudden turmoil vomiting and diarrhea have stopped, but headache, fever, and body aches persist. If heat predominates, with thirst and a desire to drink water, use Wǔ Líng Sǎn (Five-Ingredient Powder with Poria) to transform qi and disinhibit water; if cold predominates, without thirst and without desire to drink, use Lǐ Zhōng Wán to warm the middle and fortify the spleen. Wǔ Líng Sǎn is composed of zhū líng, bái zhú, fú líng, guì zhī, and zé xiè; Lǐ Zhōng Wán consists of rén shēn, gān jiāng, gān cǎo, and bái zhú.
III. Differentiation and Prognosis of Sudden Turmoil and Cold Damage (Shanghán)
If the patient’s pulse is fine and rough (wēi sè) and the condition was originally sudden turmoil, now presenting with cold damage manifestations, and after four or five days being transmitted into the yin channels: if it shifts into yin, diarrhea will certainly occur; if, although desiring to defecate, only gas is passed and the stool is not delivered, this indicates that the disease belongs to yang brightness (yáng míng) and the stool will become hard. In such a case, after about thirteen days recovery is expected — indicating completion of the traditional six-channel transmission cycle.
After diarrhea has ended, the stool may become hard. When stool is hard and the patient is able to eat, the prognosis tends to be recoverable. If the patient is initially unable to eat but subsequently the appetite gradually returns, further observation is necessary. If illness does not resolve at the expected time, then it does not belong to yang brightness disease.
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