Cargando...
Capítulo 21 de 29
伤寒杂病论
Overall Meaning (General Translation)
This chapter, Discernment and Treatment of Sudden Turmoil with Vomiting and Diarrhea: Pulse Patterns and Syndromes, focuses on a category of acute spleen and stomach disorders characterized by the simultaneous occurrence of sudden vomiting and diarrhea. It is important to clarify upfront that “Huòluàn” (Sudden Turmoil) here is a term from Traditional Chinese Medicine (TCM). It broadly refers to conditions where the qi mechanism of the Middle Jiao is in chaos, and the clear and turbid substances become disordered, leading to symptoms of vomiting above and diarrhea below. This is not the same as the modern medical condition caused by Vibrio cholerae infection.
I. What is Huòluàn?
The opening Q&A of the original text states: If there is both vomiting and diarrhea, this is called “Huòluàn”.
Zhang Zhongjing further explains: Huòluàn is located in Taiyin (Greater Yin), i.e., the spleen and stomach system. Huòluàn inevitably involves both vomiting and diarrhea, but not all cases of simultaneous vomiting and diarrhea are necessarily Huòluàn. The basic pathogenesis of Huòluàn involves mixed chaotic cold and heat pathogens in the Middle Jiao — heat qi rises, causing vomiting; cold qi pours downward, causing diarrhea. Additionally, if one's diet is irregular and food stagnation obstructs the Middle and Upper Jiao, it may cause vomiting upward and diarrhea downward, but this is termed “vomiting and diarrhea” (Tùlì), not “Huòluàn”.
Someone asks: If there is fever, headache, body aches, and aversion to cold, accompanied by vomiting and diarrhea, what disease is this? The answer says: This is not Huòluàn. Huòluàn primarily involves spontaneous vomiting and diarrhea. Since this person also has aversion to cold, body aches, and fever, it is known to be not Huòluàn but rather a condition with external contraction factors.
II. Common Syndromes and Treatments for Huòluàn
Based on pulse, cold/heat patterns, and characteristics of vomiting/diarrhea, this chapter lists various syndrome types and corresponding formulas. The following are all principles and methods recorded in ancient texts, provided for study purposes only, and are not intended as medication guidance.
Middle Jiao Deficiency-Cold Type: Huòluàn with vomiting, diarrhea, no obvious fever or aversion to cold, pulse weak and soft (rú ruò). Use Lǐzhōng Tāng (Regulating the Center Decoction). The formula consists of Renshen (Ginseng), Baizhu (White Atractylodes), Gancao (Licorice), and Ganjiang (Dried Ginger), embodying the approach of warming the Middle, dissipating cold, and strengthening the spleen to stop diarrhea.
Food Stagnation Obstructing the Middle Type: Vomiting first, then diarrhea, with abdominal fullness, pain, no chills or fever, pulse weak-soft and choppy (sè). This is due to stagnated food. Use Baizhu Fuling Banxia Zhishi Tāng (White Atractylodes, Poria, Pinellia, and Immature Bitter Orange Decoction). The formula consists of Baizhu, Fuling (Poria), Banxia (Pinellia), and Zhishi (Immature Bitter Orange), aiming to strengthen the spleen, resolve fluids, dissipate food, and guide stagnation out.
Food Stagnation in the Upper Type: Feeling of fullness and stuffiness in the chest, wanting to vomit but unable to, diarrhea that is sometimes frequent and sometimes sparse, cramping abdominal pain, and a weak and knotted (jié) pulse at the Cunkou position. This is food stagnation in the upper stomach. It is appropriate to use Guādi Sǎn (Melon Stalk Powder) to induce vomiting. The formula consists of Guādi (Melon Stalk) and Chixiaodou (Red Adzuki Beans), taken with a decoction ofxiangchi (Prepared Soybean). The goal is to achieve vomiting. This method is relatively potent and drastic, and is very rarely used in modern times.
Yang Deficiency with Severe Cold Type: Huòluàn with vomiting, diarrhea containing undigested food (clear food), cold extremities (shǒu zú jué lěng), and a deep, slow pulse. Use Sì Nì Tāng (Frigid Extremities Decoction). The formula consists of Zhigancao (Honey-Fried Licorice), Ganjiang (Dried Ginger), raw Fuzi (Aconite), and Renshen (Ginseng), focusing on returning Yang and rescuing from collapse.
Mixed Cold and Heat Type: Vomiting, diarrhea, fever, pulse weak-soft but large. Use Baizhu Shigao Banxia Ganjiang Tāng (White Atractylodes, Gypsum, Pinellia, and Dried Ginger Decoction). In the formula, Baizhu and Ganjiang tend to be warming; Shigao (Gypsum) is cold; Banxia harmonizes the stomach, manifesting the use of both cold and warm herbs. If there is thirst, add Renshen (Ginseng) and Huanglian (Coptis).
Jue-type Reversal with Mixed Cold, Heat, and Roundworms Type: Severe vomiting, possibly even expelling roundworms (ascaris ascariasis), diarrhea that is sometimes dense and sometimes sparse, slight fever in the body, cold extremities, bluish complexion, and a deep, wiry (xián), and tight (jǐn) pulse. Use Sì Nì JR Wu zhū yú Huáng lián Tāng (Frigid Extremities Decoction with Evodia and Coptis). The formula consists of raw Fuzi, Ganjiang, Zhigancao, Renshen, Wuzhuyu (Evodia), and Huanglian (Coptis), serving to warm Yang, rescue from collapse, clear heat with bitter cold, and descend adverse qi to control roundworms.
Qi and Yin Damage Type: Huòluàn with vomiting, diarrhea, thirst, sweating, shortness of breath (qì duǎn), and a weak, soft pulse. Use Lǐzhōng Jiā Renshen Guālóu Gēn Tāng (Regulating the Center Decoction plus Ginseng and Trichosanthes Root). This formula adds Renshen and Guālóu Gēn to the Lǐzhōng Tāng base, warming the Middle while also generating fluids.
Spleen and Kidney Yang Deficiency Type: Vomiting immediately after drinking water, diarrhea upon eating food, with a slow and weak pulse. Use Lǐzhōng Jiā Fùzǐ Tāng (Regulating the Center Decoction plus Aconite). This involves adding Fuzi to Lǐzhōng Tāng to strengthen the power of warming Yang and dissipating cold.
Middle Jiao Qi Stagnation Type: Abdominal fullness and pain; when the painful qi rushes upward, it causes vomiting; when it presses downward, it causes diarrhea; pulse soft and choppy (sè). Use Lǐzhōng Tāng.
Differentiation and Treatment of Deficiency and Excess: Huòluàn can be differentiated into deficiency and excess types. The patient's constitution may be deficient or excessive, and the disease manifestation changes accordingly. In deficiency, the pulse is weak-soft; use Lǐzhōng Tāng. In excess, the pulse is rapid and urgent; use Gě Gēn Huáng Lián Huáng Qín Gān Cǎo Tāng (Pueraria, Coptis, Scutellaria, and Licorice Decoction). The latter formula consists of Gegen (Pueraria), Huanglian (Coptis), Huangqin (Scutellaria), and Zhigancao, clearing damp-heat and lifting clear qi to stop diarrhea.
Transluminal Spasm (Zhuǎnjīn) Type: Huòluàn accompanied by cramps in the sinews (calves/abdomen). This indicates there was already latent cold in the sinews, damaging the Rong Qi (Nutritive Qi), which flares up during the illness. If the pulse should be weak-soft but instead is wiry and tight, with cold extremities, use Lǐzhōng Jiā Fùzǐ Tāng.
Residual Pathogens After Huòluàn: After the vomiting and diarrhea of Huòluàn have stopped, if headache, fever, and body aches remain, with more heat and thirst, resulting in a desire to drink water, use Wǔlíng Sǎn to transform qi and promote diuresis. If there is more cold and no thirst, with no desire to drink water, use Lǐzhōng Wán to warm the Middle and strengthen the spleen. Wǔlíng Sǎn consists of Zhuling (Polyporus), Baizhu, Fuling, Guizhi (Cinnamon Twig), and Zexie (Alisma). Lǐzhōng Wán consists of Renshen, Ganjiang, Gancao, and Baizhu.
III. Differentiation Between Huòluàn and Cold Damage (Shānghán), and Prognosis
If the patient's pulse is faint and choppy (sè), and they originally had Huòluàn but now exhibit symptoms resembling Cold Damage (Shānghán), and after four to five days the condition reaches the Yin channels: If it turns into the Yin channels, there will be diarrhea. If the patient has the urge to defecate but only passes gas, without actual stools, it indicates the condition belongs to the Yangming (Stomach/Intestines). The stool will become hard, and recovery might occur around the thirteenth day, as the cycle of channel transmission is complete.
After diarrhea, the stool should normally become harder. If the stool is hard and the patient can eat, the prognosis is relatively good. If the patient cannot eat, but gradually regains appetite later, one must continue to observe. If recovery doesn't happen by the expected time, it indicates the condition does not belong to the Yangming pattern.
In Cold Damage, if the pulse is faint and there is diarrhea, and then the diarrhea stops spontaneously, this is due to Wang Xue (depletion of blood), i.e., deficiency of fluids and blood. Use Sì Nì Jiā Rénshēn Tāng (Frigid Extremities Decoction plus Ginseng). The formula consists of Zhigancao, raw Fuzi, Ganjiang, and Renshen, returning Yang, rescuing from collapse, boosting qi, and generating fluids.
After vomiting and diarrhea have stopped, if body aches continue without cease, one should gently harmonize the Nutritive and Defensive (Ying/Wei) and release the external pathogen. Guìzhī Tāng (Cinnamon Twig Decoction) is suitable. The formula consists of Guìzhī, Shaoyao (Peony), Zhigancao, Shengjiang (Fresh Ginger), and Dazao (Jujube Dates).
For those with vomiting, diarrhea, sweating, fever, aversion to cold, spasms/hypertonicity of the limbs (sì zhī jū jí), and cold hands and feet, use Sì Nì Tāng.
For those who both vomit and have diarrhea, yet urine is profuse, sweat pours out, and diarrhea contains undigested food (qīng gǔ), belonging to internal cold with external heat and a faint pulse on the verge of cessation, also use Sì Nì Tāng.
If vomiting has stopped and diarrhea has ceased, but there is sweating, cold extremities, unremitting spasms/hypertonicity of the limbs, and a very faint pulse on the verge of stopping, use Tōng Mài Sì Nì Jiā Zhū Dǎn Zhī Tāng (Unblocking the Pulse and Frigid Extremities Decoction plus Pig Bile). The formula consists of Zhigancao, Ganjiang, raw Fuzi, Pig Bile, and Renshen, returning Yang, rescuing from collapse, nourishing Yin, and harmonizing Yang.
After vomiting and diarrhea, sweating occurs, and the pulse is already calm, but there is slight restlessness in the heart/mind. This is due to the body being newly weakened after illness and unable to tolerate excessive Gu Qi (food qi/nutrients); that is, the digestive capacity has not yet recovered.
The core of this chapter is chaos in the qi mechanism of the Middle Jiao. Although Huòluàn manifests as vomiting above and diarrhea below, its essence lies in the failure of the spleen and stomach's ascending and descending functions, leading to turbid substances overcoming the clear.
Specifically, Zhang Zhongjing emphasizes several key diagnostic points:
The “Huòluàn” in this chapter cannot be equated with modern cholera. Modern cholera is an acute intestinal infectious disease caused by Vibrio cholerae, characterized by severe watery diarrhea, vomiting, and dehydration. Severe cases can lead to shock due to massive loss of water and electrolytes, requiring immediate fluid replacement and antibiotic treatment.
The Huòluàn described by ancient Chinese medicine is closer in modern terms to conditions such as acute gastroenteritis, food poisoning, or gastrointestinal type cold, which involve vomiting and diarrhea as the main complaints. Although ancient physicians did not know about bacteria or viruses, they observed that vomiting and diarrhea rapidly deplete fluids and Yang Qi. Their proposed treatments to warm Yang, stabilize collapse, and generate fluids indicate a practical clinical perception related to dehydration and circulatory failure.
From a modern perspective, formulas like Lǐzhōng Tāng and Sì Nì Tāng, which warm the Middle and restore Yang, might have conditional value in cases of deficiency-cold type gastrointestinal dysfunction or chronic diarrhea. However, they lack high-quality modern clinical evidence, and they absolutely cannot replace modern emergency medical care. Methods like Guādi Sǎn for inducing vomiting are extremely rare and carry certain risks in contemporary practice. Complex formulas like Tōng Mài Sì Nì Jiā Zhū Dǎn Zhī Tāng should also be viewed rationally within their historical context.
Associated Concepts:
Taiyin Disease (太阴病), Yangming Disease (阳明病), Food Stagnation (宿食), Transluminal Spasm (转筋), Rong Qi (荣气/Nutritive Qi), Wang Xue (亡血/Depletion of Blood), Gu Qi (谷气/Food Qi), Lǐzhōng Tāng/Wán (Regulating the Center Decoction/Pill), Sì Nì Tāng-type Formulas (Frigid Extremities Decoctions), Wǔlíng Sǎn (Five-Ingredient Powder with Poria), Guìzhī Tāng (Cinnamon Twig Decoction)
Further Reading:
Bu Guā Tip: This content is based on classic Chinese medicine texts and is intended solely for the study and appreciation of traditional culture. It does not constitute medical diagnosis, medication, or treatment advice. If you feel unwell, please consult a doctor promptly.