霍乱者，因风寒暑热，饮食生冷之邪，杂揉交病于中，正不能堪，一任邪之挥霍撩乱
，故令三焦混淆，清浊相干，乱于肠胃也。表甚，则有头痛身痛，发热恶寒之证；里
甚，则有呕吐泻利，腹中大痛之证；寒甚，则转筋厥逆冷汗；暑甚，则大渴引饮不已
。病既不同，治亦各异，惟在详审其因，分而疗之，庶卒然之顷，不致有误矣。
@@@
问曰：病有霍乱者何？答曰：呕吐而利，此名霍乱。
【注】
问曰：病有霍乱者，其状何似？答曰：卒然呕吐、泻利者，是名霍乱也。
【集注】
成无己曰：三焦者，水谷之道路。邪在上焦，则吐而不利；在下焦，则利而不吐；在
中焦，必既吐且利。以饮食不节，寒热不调，清浊相干，阴阳乖隔，而成霍乱。轻者
只曰吐泻，重者挥霍撩乱，故曰霍乱。
@@@
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。
【注】
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，宜用藿香正气汤或香薷饮，散而
和之可也。若不头痛身疼，恶寒吐泻，汗出发热，渴而引饮，是表解而里未解也，宜
辰砂六一散或白虎加人参汤，补而清之可也。
【集注】
方有执曰：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。
程应旄曰：霍乱之证，仅见呕吐而利，谁不知责重中焦者！若病有发热头痛，身疼恶
寒，夹此吐利而来，表里之间，仓卒难辨，故从属定名，破去伤寒之称，名曰霍乱，
不欲人以表惑里也。
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。
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□，十三日愈
，所以然者，经尽故也。
【注】
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□，虽大便□，乃伤津液之□，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。
【集注】
魏荔彤曰：此申解霍乱病，似乎伤寒，应为辨明孰为伤寒之吐利，孰为霍乱之吐利，
以定治法无误也。伤寒中之吐利，有六经形证；而霍乱中之吐利，有表里阴阳，俱应
一一辨明，方有确见，而不摇惑也。
@@@
下利后，当便□，□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。
【注】
此申上条下利后便必□之义也。凡下利后，肠胃空虚，津液匮乏，当大便□，□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，是为胃气未复，俟
到十三日后，过经之日，若颇能食，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□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。
【集注】
张璐曰：若利止而不能食，邪热去而胃气空虚也，俟过一经，胃气渐复，自能食矣。
@@@
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
。
【注】
霍乱者，水饮内发，故吐泻交作也。风寒外袭，故头痛发热，身疼痛也。热多欲饮水
者，是饮热也，主五苓散以两解其饮热。若不欲饮水者，是中寒也，主理中丸以独温
其中。理中丸，即理中汤和剂作丸也。
【集注】
方有执曰：霍乱，热多欲饮水者，阳邪盛也。寒多不用水者，阴邪盛也。五苓散者，
水行则热泻，是亦两解之谓也。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。
沈明宗曰：此言霍乱须分寒热而治也。头痛、发热、身疼痛者，风寒伤于表也，外风
而挟内热，饮食以致吐利，必欲饮水，当以五苓散两解表里，使邪从汗出，里邪即从
小便而去。不欲饮水者，寒多无热，胃阳气虚，当以理中丸温中散寒为主，此以表里
寒热辨证治病也。
@@@
吐利止，而身痛不休者，当消息和解其外，宜桂枝汤小和之。
【注】
霍乱吐利已止，而身痛不休者，此里和而表未和，当消息轻重以治之，故宜桂枝汤，
小汗以和其外也。
【集注】
方有执曰：吐利止，里和也。身痛，表退而新虚也。消息，犹言斟酌也。桂枝汤固卫
以和表也。小和，言少少与服，不令过度之意也。
程应旄曰：吐利俱止，毫无霍乱证矣，仅是身痛不休，方可从桂枝例。一和解其外，
以其中有芍药之寒，故犹当消息，犹曰小和。况吐利未止，敢恣意于寒凉也哉！
张锡驹曰：本经凡言小和、微和者，谓微邪而毌庸大攻也。
@@@
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。
【注】
霍乱之为病，即吐且利，津液内亡，小盒饭少，而无汗。今小便复利，而大汗出，下
利清谷，脉微欲绝者，是外之阳虚，不能固护；内之阴寒，独盛于中，内真寒而外假
热也。故不用理中，而以四逆主之也。
【集注】
成无已曰：吐利亡津液，则小盒饭少，小便复利而大汗出，津液不禁，阳气大虚也。
脉微为亡阳，若无外热，但内寒下利清谷，为纯阴证。此以外热为阳未绝，犹可与四
逆汤救之。
吴人驹曰：既吐且利，而大汗出，则泄路尽开，而小便又复利，云复利者，反不欲其
利，而为收藏之地也。下利清谷，内寒外热，且脉微欲绝，一线之微阳，挽回诚为不
易，四逆之施，讵可缓乎？
@@@
吐利汗出，发热恶寒，四肢拘急，手足厥冷者，四逆汤主之。
【注】
霍乱，吐利汗出，发热恶寒，四肢拘急，手足厥冷者，乃中外皆寒之证也，宜四逆汤
助阳以胜阴也。
【集注】
方有执曰：吐利，四肢拘急，手足厥冷，里阴盛也；汗出，发热，恶寒，表阳虚也，
宜四逆汤中外合救之剂也。
程知曰：吐利而复汗出，阳气几于走失矣。发热、恶寒、为阳未尽亡，四肢拘急，手
足厥冷，不得不用四逆以助阳退阴也。又按少阴证云；恶寒身蜷而利，手足厥冷者不
治。又云：下利恶寒而蜷卧，手足温者可治。此之吐、利、汗出，四肢拘急，手足厥
冷，而用四逆治之者，以有发热一证也。发热为阳未尽亡，犹是病人生机。故经又曰
：吐利手足不逆冷，反发热者不死。
@@@
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。
【注】
霍乱吐、下已止，汗出而厥，四肢拘急，脉微欲绝者，乃中寒盛极，阻格阳气不达于
四肢也，宜通脉四逆汤加猪胆汁，从阴以通阳也。
【集注】
成无己曰：吐已下断，津液内竭，则不当汗出而厥。今汗出而厥，四肢拘急不解，脉
微欲绝者，阳气大虚，阴气独盛也。若纯与阳药，恐阴为格拒，或呕或躁，不得复入
也。与通脉四逆汤加猪胆汁，胆苦入心而通脉，胆寒补肝而和阴，引阳药使不被格拒
。『内经』曰：微者逆之，甚者从之。此之谓也。
方有执曰：已，止也。下，即利也。断，绝也。言吐、利两皆止绝，而又以其余证之
不解者，更出其治也。
@@@
恶寒脉微而腹利。利止，亡血也，四逆加人参汤主之。
【按】
利止亡血，如何用大热补药？利止，当是「利不止」。亡血，当是「亡阳」。
【注】
霍乱吐、下已止，若恶寒、脉微而复利，利不止者，是阳气虚也，宜四逆加人参，益
其阳补其气也。
【集注】
林澜曰：霍乱要在审察寒热而治。若果夏月中暑霍乱，脉虚小便赤少，不可用附子、
干姜，须仔细辨之，利止脉微而恶寒，乃可用耳。又曰：中暑霍乱，只宜五苓散，加
香薷、萹豆、葛根、姜汁、炒黄连之类治之。
霍乱病，是由于风寒暑热等外邪，以及饮食生冷等内伤因素，混杂侵袭人体中焦，正气无法承受，任由邪气在体内肆意扰乱，导致三焦功能混乱，清气与浊气相互干扰，在肠胃中发生紊乱。如果表证严重，就会出现头痛、身体疼痛、发热、怕冷的症状；如果里证严重，就会出现呕吐、腹泻、腹部剧烈疼痛的症状；如果寒邪严重，就会出现筋脉拘挛抽搐、四肢厥冷、出冷汗的症状；如果暑邪严重，就会出现极度口渴、大量饮水不止的症状。既然病情各不相同，治疗方法也各异，关键在于详细审察病因，分别进行治疗，这样在疾病突然发作时，才不会出现误治。
【注解】
问：霍乱病的症状是什么样子的？答：突然发生呕吐、腹泻的，就叫做霍乱。
【集注】
成无己说：三焦是水谷运行的通道。邪气在上焦，就会只呕吐不腹泻；在下焦，就会只腹泻不呕吐；在中焦，就会既呕吐又腹泻。因为饮食不节制，寒热不调和，导致清浊之气相干，阴阳之气阻隔，从而形成霍乱。轻的只叫吐泻，重的挥霍撩乱，所以叫霍乱。
@@@
问：患发热、头痛、身体疼痛、怕冷，同时又有呕吐腹泻的，这是什么病？答：这叫做霍乱，如果是自己呕吐腹泻后，腹泻停止，却又再次发热的。
【注解】
这是承接上一条，详细说明其症状。头痛、身体疼痛、发热、怕冷，是风、寒、暑、热等邪气在体表引起的病变；呕吐、腹泻，是饮食、生冷等邪气在体内引起的病变，具备这些症状的，名叫霍乱。如果呕吐已止，腹泻也停，但仍然有头痛、身体疼痛、怕冷，并且再次发热，这是里证已解而表证未解，适宜用藿香正气汤或香薷饮，发散邪气并调和机体即可。如果不头痛、身体疼痛，不怕冷，但有呕吐腹泻，出汗发热，口渴想喝水，这是表证已解而里证未解，适宜用辰砂六一散或白虎加人参汤，补益正气并清除里热即可。
【集注】
方有执说：发热、头痛、身体疼痛、怕冷，是外感邪气。呕吐腹泻，是内伤饮食。上文是用病名来推求病证，这里是用病证来确定病名，反复详明的意思。
程应旄说：霍乱的病症，仅仅见到呕吐和腹泻，谁不知道责任在于中焦！如果有发热头痛、身体疼痛怕冷，夹杂在呕吐腹泻之前而来，在表里之间，仓促间难以辨别，所以从属于伤寒的分类而定名，破除伤寒的名称，叫做霍乱，是不希望人们被表证迷惑而忽视里证。
沈明宗说：呕吐腹泻停止后，再次发热，是里气调和而表邪未解，应当采用解表的方法。或者没有表证，只有腹痛呕吐腹泻，这是里邪未解，应当以调和里气为主。
伤寒病，如果脉象微涩的，本来是霍乱，现在说是伤寒，却过了四五天传入阴经，转入阴经必然腹泻，原本就有呕吐腹泻的，不可按伤寒治疗。想要大便却反而排气，仍不排便的，这属于阳明病，大便必定干结，十三天后会痊愈，之所以这样，是因为经气运行完毕的缘故。
【注解】
这是承接上一条，辨析发热、头痛、身体疼痛、怕冷、呕吐腹泻等症状，是为了区分类似伤寒的情况。如果有上述症状且脉象浮紧，是伤寒。现在脉象微涩，本来是霍乱。然而霍乱初起就有呕吐腹泻，伤寒的呕吐腹泻，却在四五日后邪气传入阴经时才出现。这本来是霍乱，即呕吐即腹泻，所以不能当作伤寒治疗，等待它自然停止即可。如果停止后似乎想大便，而去放屁，仍然不大便，这属于阳明病。既然属于阳明病，大便必定干结，虽然大便干结，但这是损伤津液导致的干结，不可使用攻下法，应当等待到十三天经气运行完毕，胃气和顺、津液恢复，大便利通自然就会痊愈。如果过了十三天大便仍不通利，这叫过经不解，可以使用攻下法。
【集注】
魏荔彤说：这是进一步解释霍乱病，看似伤寒，应当辨明哪是伤寒的呕吐腹泻，哪是霍乱的呕吐腹泻，以确定正确的治疗方法而不致错误。伤寒中的呕吐腹泻，有六经的形证；而霍乱中的呕吐腹泻，有表里阴阳的区别，都应当一一辨明，才有确切的见解，而不被迷惑。
@@@
腹泻停止后，大便应当干结，大便干结如果能吃东西就是痊愈。现在反而不能吃，等到下一个经气周期时，稍微能吃一点，再过一个经气周期能吃东西，过了一天应当痊愈，如果不愈，就不属于阳明病。
【注解】
这是申述上一条腹泻后大便必干结的道理。凡是腹泻后，肠胃空虚，津液匮乏，大便应当干结，大便干结如果能吃东西，这是胃气恢复，十三天后津液恢复，大便利通自然就会痊愈。现在反而不能吃，这是胃气未恢复，等到十三天后，经过经气周期的日子，如果稍微能吃一点，也应当痊愈。如果还是不愈，这就是当愈不愈的情况。当愈不愈，就知道不属于十三天过经后大便干结的阳明病，而是属于吐泻后胃中虚寒不想吃的阳明病，或者属于吐泻后胃中虚燥的阳明病。这种情况非用药不可，等待终究不能自愈，理中丸或脾约丸，选择使用即可。
【集注】
张璐说：如果腹泻停止但不能进食，是邪热去除而胃气空虚，等到经过一个经气周期，胃气逐渐恢复，自然就能进食了。
@@@
霍乱病，头痛发热，身体疼痛，热多想要喝水的，用五苓散主治；寒多不想喝水的，用理中丸主治。
【注解】
霍乱病，是水饮在内发动，所以呕吐腹泻交替发作。风寒从外部侵袭，所以头痛发热，身体疼痛。热多想要喝水的，是饮热互结，主用五苓散来同时解除饮邪和热邪。如果不想喝水的，是中焦寒盛，主用理中丸来单独温补中焦。理中丸，就是把理中汤的药剂制成丸剂。
【集注】
方有执说：霍乱病，热多想要喝水的，是阳邪盛。寒多不想喝水的，是阴邪盛。五苓散的作用，是水行则热泄，这也是两解的意思。理，治理的意思。中，里的意思，指里阴。人参、白术的甘温性质是补里的，甘草的甘平性质是调和中的，干姜的辛热性质是散寒的。
沈明宗说：这是说霍乱必须分寒热来治疗。头痛、发热、身体疼痛，是风寒伤于体表，外风挟带内热，因饮食导致吐泻，一定想喝水，应当用五苓散两解表里，使邪气从汗出，里邪就从小便而去。不想喝水的，寒多无热，胃阳气虚，应当用理中丸温中散寒为主，这是通过表里寒热辨证来治病。
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呕吐腹泻停止，但身体疼痛不止的，应当斟酌情况和解其表，适宜用桂枝汤小剂量调和。
【注解】
霍乱呕吐腹泻已经停止，但身体疼痛不止的，这是里气已和而表气未和，应当斟酌轻重来治疗，所以适宜用桂枝汤，微微发汗来调和体表。
【集注】
方有执说：呕吐腹泻停止，是里气已和。身体疼痛，是表邪退去而新近虚弱。消息，就是斟酌的意思。桂枝汤固护卫气以调和表气。小和，意思是少量服用，不让药力过度的意思。
程应旄说：呕吐腹泻都停止，完全没有霍乱的症状了，仅仅是身体疼痛不止，才可以遵循桂枝汤的法则。一是和解其表，因为其中有芍药的寒性，所以还应当斟酌，还说小和。何况呕吐腹泻未止，怎么敢肆意使用寒凉药物呢！
张锡驹说：本经凡是说小和、微和的，是说邪气轻微而不用大力攻伐。
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既呕吐又腹泻，小便反而通畅，并且大汗出，腹泻排出未消化的食物，内寒外热，脉象微弱几乎摸不到，用四逆汤主治。
【注解】
霍乱这种病，既呕吐又腹泻，津液在内耗亡，小便应当减少，而无汗。现在小便反而通畅，并且大汗出，腹泻排出未消化的食物，脉象微弱几乎摸不到，这是体外的阳气虚，不能固护；体内的阴寒独盛于中焦，是真寒假热的表现。所以不用理中丸，而用四逆汤主治。
【集注】
成无己说：呕吐腹泻耗亡津液，小便应当减少，现在小便反而通畅且大汗出，津液不禁，阳气大虚。脉微是亡阳，如果没有外热，只有内寒腹泻排出未消化食物，是纯阴证。这里因为有外热说明阳气未绝，还可以用四逆汤救治。
吴人驹说：既呕吐又腹泻，且大汗出，那么泄路全开，而小便又反而通畅，说“复利”，是反意，不希望其利，而将其作为收藏之地。腹泻排出未消化食物，内寒外热，且脉象微弱几乎摸不到，一线微弱的阳气，挽回确实不容易，四逆汤的使用，岂可迟缓呢？
@@@
呕吐腹泻伴出汗，发热怕冷，四肢拘挛紧急，手脚冰冷，用四逆汤主治。
【注解】
霍乱，呕吐腹泻伴出汗，发热怕冷，四肢拘挛紧急，手脚冰冷，这是内外皆寒的证候，适宜用四逆汤助阳以战胜阴寒。
【集注】
方有执说：呕吐腹泻，四肢拘挛紧急，手脚冰冷，是里阴盛；出汗，发热，怕冷，是表阳虚，适宜用四逆汤作为内外合救的药剂。
程知说：呕吐腹泻而又出汗，阳气几乎要走失。发热、怕冷，说明阳气未尽亡，四肢拘挛紧急，手脚冰冷，不得不用四逆汤来助阳退阴。另外按少阴证说：恶寒身蜷而腹泻，手脚冰冷的不治。又说：腹泻恶寒而蜷卧，手脚温暖的可以治。这里的呕吐、腹泻、出汗，四肢拘挛紧急，手脚冰冷，而用四逆汤治疗的，是因为有发热这一症状。发热说明阳气未尽亡，还是病人的生机。所以经书又说：呕吐腹泻手脚不冰冷，反而发热的不死。
@@@
呕吐停止腹泻断绝，但出汗且手脚冰冷，四肢拘挛紧急不缓解，脉象微弱几乎摸不到，用通脉四逆加猪胆汁汤主治。
【注解】
霍乱呕吐、腹泻已经停止，但出汗且手脚冰冷，四肢拘挛紧急，脉象微弱几乎摸不到，这是中寒极盛，阻格阳气不能通达于四肢，适宜用通脉四逆汤加猪胆汁，从阴引阳以通阳。
【集注】
成无己说：呕吐停止腹泻断绝，津液在内枯竭，本不应出汗且手脚冰冷。现在出汗且手脚冰冷，四肢拘挛紧急不缓解，脉象微弱几乎摸不到，是阳气大虚，阴气独盛。如果单纯给予阳药，恐怕阴气格拒，或者呕吐或者烦躁，药不得入。给予通脉四逆汤加猪胆汁，胆苦入心而通脉，胆寒补肝而和阴，引导阳药使其不被格拒。《内经》说：轻微的逆治，严重的从治。说的就是这个道理。
方有执说：已，停止。下，即腹泻。断，绝。说呕吐、腹泻两者都停止断绝，而又以其余症状未缓解，进一步提出治疗方法。
@@@
怕冷，脉微且腹部腹泻。腹泻停止，是亡血，用四逆加人参汤主治。
【按语】
腹泻停止亡血，如何能用大热补药？腹泻停止，应当是“腹泻不止”。亡血，应当是“亡阳”。
【注解】
霍乱呕吐、腹泻已经停止，如果怕冷、脉微且再次腹泻，腹泻不止的，是阳气虚，适宜用四逆加人参汤，益阳补气。
【集注】
林澜说：霍乱要在审察寒热后治疗。如果确实是夏天中暑引起的霍乱，脉虚小便赤少，不可用附子、干姜，须仔细辨别，只有腹泻停止、脉微且怕冷，才可用。又说：中暑霍乱，只宜用五苓散，加香薷、扁豆、葛根、姜汁、炒黄连之类治疗。
Huo Luan (Acute Vomiting and Diarrhea Disease) is caused by the mixed invasion of external pathogens such as Wind-Cold, Summerheat, and Heat, along with internal injuries from cold and raw food. The healthy Qi cannot withstand this, allowing the pathogens to cause chaotic disturbance within the body. This leads to confusion in the San Jiao (Triple Burner), interference between Clear and Turbid Qi, and disorder in the intestines and stomach. If the exterior syndrome is severe, symptoms include headache, body pain, fever, and aversion to cold. If the interior syndrome is severe, symptoms include vomiting, diarrhea, and severe abdominal pain. If Cold is severe, symptoms include tendon spasms, cold limbs, and cold sweating. If Summerheat is severe, symptoms include extreme thirst and incessant drinking. Since the conditions differ, treatments vary; the key lies in carefully examining the etiology and treating accordingly, so as to avoid errors during sudden onset.
Question: What is Huo Luan? Answer: It is named Huo Luan when characterized by vomiting and diarrhea.
[Annotation]
Question: What are the manifestations of Huo Luan? Answer: Sudden onset of vomiting and diarrhea is called Huo Luan.
[Collected Notes]
Cheng Wuji stated: The San Jiao (Triple Burner) is the pathway for water and grain. Pathogens in the Upper Jiao cause vomiting without diarrhea; in the Lower Jiao, diarrhea without vomiting; in the Middle Jiao, both vomiting and diarrhea occur. Due to irregular diet and imbalance of Cold and Heat, Clear and Turbid Qi interfere, and Yin and Yang become separated, resulting in Huo Luan. Mild cases are merely called vomiting and diarrhea; severe cases involve chaotic disturbance, hence the name Huo Luan.
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Question: A patient presents with fever, headache, body pain, aversion to cold, vomiting, and diarrhea. What disease is this? Answer: This is named Huo Luan. If vomiting and diarrhea cease spontaneously, but fever recurs subsequently.
[Annotation]
This follows the previous clause to detail the symptoms. Headache, body pain, fever, and aversion to cold indicate pathogenic factors of Wind, Cold, Summerheat, or Heat affecting the exterior. Vomiting and diarrhea indicate pathogenic factors of diet and cold/raw food affecting the interior. Having these symptoms constitutes Huo Luan. If vomiting stops and diarrhea ceases, yet headache, body pain, and aversion to cold persist, accompanied by recurrent fever, it indicates that the interior is resolved but the exterior remains unresolved. In this case, Huoxiang Zhengqi Tang (Patchouli and Magnolia Bark Decoction) or Xiangru Yin (Elsholtzia Drink) should be used to disperse and harmonize. If there is no headache, body pain, or aversion to cold, but rather vomiting, diarrhea, sweating, fever, and thirst with desire to drink, it indicates that the exterior is resolved but the interior remains unresolved. In this case, Chensha Liuyi San (Cinnabar Six-One Powder) or Baihu Jia Renshen Tang (White Tiger Decoction plus Ginseng) should be used to tonify and clear heat.
[Collected Notes]
Fang Youzhi stated: Fever, headache, body pain, and aversion to cold are external contractions. Vomiting and diarrhea are internal injuries. The previous text deduced symptoms from the disease name; here, symptoms are used to confirm the disease name, emphasizing detailed clarification.
Cheng Yingmao stated: For Huo Luan, seeing only vomiting and diarrhea makes one realize the focus is on the Middle Jiao. However, if fever, headache, body pain, and aversion to cold accompany vomiting and diarrhea, distinguishing between exterior and interior becomes difficult in haste. Therefore, it is classified under a specific name, breaking away from the term "Shang Han" (Cold Damage), and called Huo Luan, to prevent being misled by exterior signs while ignoring interior pathology.
Shen Mingzong stated: Recurrent fever after vomiting and diarrhea stop indicates that the interior Qi is harmonized but exterior pathogens remain; treatment should focus on releasing the exterior. If there are no exterior signs, only abdominal pain, vomiting, and diarrhea, it indicates unresolved interior pathogens; treatment should focus on harmonizing the interior.
In Shang Han (Cold Damage), if the pulse is faint and choppy, it was originally Huo Luan. Now, if it is considered Shang Han, and after four or five days the pathogen enters the Yin meridians, diarrhea will ensue. If the patient originally had vomiting and diarrhea, it should not be treated as Shang Han. Wait for it to stop spontaneously. If the patient feels the urge to defecate but passes gas instead, without actual defecation, this belongs to the Yangming stage. Stool will likely be dry. Recovery is expected around the thirteenth day because the meridian cycle completes.
[Annotation]
This continues the differentiation of fever, headache, body pain, aversion to cold, vomiting, and diarrhea to distinguish them from similar Shang Han presentations. If these symptoms are present with a floating-tight pulse, it is Shang Han. With a faint-choppy pulse, it is originally Huo Luan. Huo Luan involves immediate vomiting and diarrhea upon onset, whereas Shang Han typically develops vomiting and diarrhea after four or five days when the pathogen transmits to the Yin meridians. Since this is Huo Luan with immediate symptoms, it should not be treated as Shang Han; wait for spontaneous cessation. If after cessation, the patient feels an urge to defecate but passes gas without stool, this belongs to Yangming. Although stool may be dry, it is due to fluid injury, not excess heat requiring purgation. Wait until the thirteenth day for the meridian cycle to complete, stomach Qi to recover, and fluids to return, leading to natural recovery. If constipation persists beyond thirteen days, it is termed "passing the meridian without resolution," and purgation may be used.
[Collected Notes]
Wei Litong stated: This further explains Huo Luan resembling Shang Han, clarifying the distinction between Shang Han's vomiting/diarrhea and Huo Luan's vomiting/diarrhea to ensure correct treatment. Shang Han vomiting/diarrhea has Six Meridian manifestations; Huo Luan vomiting/diarrhea involves Exterior/Interior and Yin/Yang distinctions, all of which must be clearly differentiated.
@@@
After diarrhea stops, the stool should be dry. If the patient can eat, they will recover. If they cannot eat now, but can eat slightly during the next meridian cycle, and more so after another cycle, they should recover the following day. If not, it does not belong to Yangming.
[Annotation]
This elaborates on the principle that stool becomes dry after diarrhea. After diarrhea, the intestines and stomach are empty, and fluids are depleted, so stool becomes dry. If the patient can eat when stool is dry, it indicates the restoration of Stomach Qi. Around the thirteenth day, with fluid recovery, normal bowel movements and recovery occur. If the patient cannot eat, Stomach Qi has not recovered. Waiting until the thirteenth day, if appetite returns slightly, recovery is expected. If not, it indicates failure to recover as expected. This suggests it does not belong to the Yangming pattern of dry stool after the meridian cycle, but rather to Yangming patterns of deficiency-cold or deficiency-dryness in the Stomach following vomiting/diarrhea. Medication is necessary; waiting will not lead to self-healing. Choose between Lizhong Wan (Regulate the Middle Pill) or Piyue Wan (Splee Restriction Pill).
[Collected Notes]
Zhang Lu stated: If diarrhea stops but eating is impossible, it indicates pathogenic heat has cleared but Stomach Qi is empty. After passing one meridian cycle, as Stomach Qi gradually recovers, eating ability will return naturally.
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For Huo Luan with headache, fever, and body pain: if there is more heat and desire to drink water, Wuling San (Five-Ingredient Powder with Poria) is the primary formula. If there is more cold and no desire to drink water, Lizhong Wan (Regulate the Middle Pill) is the primary formula.
[Annotation]
Huo Luan arises from internal water-fluid retention causing alternating vomiting and diarrhea. External invasion of Wind-Cold causes headache, fever, and body pain. Excessive heat with desire to drink indicates combined water-fluid and heat; Wuling San is used to resolve both. No desire to drink indicates middle Jiao Cold; Lizhong Wan is used to warm the middle exclusively. Lizhong Wan is simply Lizhong Tang (Decoction) prepared as pills.
[Collected Notes]
Fang Youzhi stated: Desire to drink in Huo Luan indicates excess Yang pathogen. No desire to drink indicates excess Yin pathogen. Wuling San promotes water flow to dissipate heat, achieving dual resolution. "Li" means regulation; "Zhong" means interior/Yin. Ginseng and Atractylodes are sweet-warm to tonify the interior; Licorice is sweet-neutral to harmonize the center; Dried Ginger is pungent-hot to dispel cold.
Shen Mingzong stated: Huo Luan must be treated by distinguishing Cold and Heat. Headache, fever, and body pain indicate Wind-Cold at the exterior. External Wind with internal Heat from dietary issues causes vomiting/diarrhea and thirst; Wuling San resolves both exterior and interior, expelling pathogens via sweat and urine. No desire to drink indicates Cold predominance without heat, and deficiency of Stomach Yang; Lizhong Wan warms the middle and dispels cold. This is treatment based on Exterior/Interior and Cold/Heat differentiation.
@@@
If vomiting and diarrhea stop but body pain persists, cautiously harmonize the exterior using Guizhi Tang (Cinnamon Twig Decoction) in small doses.
[Annotation]
When vomiting and diarrhea cease but body pain continues, the interior is harmonized but the exterior is not. Treatment should be adjusted according to severity. Guizhi Tang is appropriate to induce slight sweating and harmonize the exterior.
[Collected Notes]
Fang Youzhi stated: Cessation of vomiting/diarrhea indicates interior harmony. Body pain indicates residual exterior weakness. "Xiao Xi" means discretion. Guizhi Tang protects Wei Qi and harmonizes the exterior. "Xiao He" (small harmony) implies administering small amounts to avoid excessive potency.
Cheng Yingmao stated: When vomiting and diarrhea completely stop and Huo Luan symptoms vanish, leaving only persistent body pain, one may follow the Guizhi Tang protocol. Because it contains Shao Yao (Peony) which is cool, discretion ("Xiao He") is still required. How could one recklessly use cooling herbs if vomiting/diarrhea were ongoing?
Zhang Xiju stated: Terms like "small harmony" or "micro-harmony" in the classic imply mild pathogens do not require strong attack.
@@@
If there is simultaneous vomiting and diarrhea, frequent urination, profuse sweating, diarrhea with undigested food, interior cold with exterior heat, and a pulse that is faint and nearly imperceptible, Sini Tang (Frigid Extremities Decoction) is the primary formula.
[Annotation]
In Huo Luan, simultaneous vomiting and diarrhea deplete internal fluids, usually reducing urine output and causing anhidrosis. Frequent urination, profuse sweating, diarrhea with undigested food, and a faint-nearly imperceptible pulse indicate exterior Yang deficiency failing to secure, and interior Yin-Cold dominating the middle. This is true interior cold with false exterior heat. Therefore, Lizhong Wan is not used; Sini Tang is indicated.
[Collected Notes]
Cheng Wuji stated: Vomiting/diarrhea deplete fluids, normally reducing urine. Frequent urination and profuse sweating indicate uncontrolled fluids and severe Yang deficiency. Faint pulse indicates loss of Yang. Without exterior heat, pure interior cold with undigested food diarrhea is a Pure Yin syndrome. Here, exterior heat indicates Yang is not yet extinct, so Sini Tang can still rescue.
Wu Renju stated: With vomiting, diarrhea, and profuse sweating, exit pathways are open. Frequent urination is contrary to expectation, as it should be retained. Undigested food diarrhea, interior cold/exterior heat, and faint pulse indicate a thread of微弱 Yang is hard to restore. Delaying Sini Tang is inadvisable.
@@@
With vomiting, diarrhea, sweating, fever, aversion to cold, tetanic cramps of the limbs, and cold hands and feet, Sini Tang (Frigid Extremities Decoction) is the primary formula.
[Annotation]
Huo Luan with vomiting, diarrhea, sweating, fever, aversion to cold, limb cramps, and cold extremities indicates Cold in both interior and exterior. Sini Tang is used to assist Yang and overcome Yin.
[Collected Notes]
Fang Youzhi stated: Vomiting/diarrhea, limb cramps, and cold extremities indicate interior Yin excess. Sweating, fever, and aversion to cold indicate exterior Yang deficiency. Sini Tang serves as a combined interior-exterior rescue formula.
Cheng Zhi stated: Vomiting/diarrhea with sweating nearly loses Yang. Fever and aversion to cold show Yang is not fully lost. Limb cramps and cold extremities necessitate Sini Tang to assist Yang and retreat Yin. Note: Shaoyin syndrome with aversion to cold, curling up, diarrhea, and cold extremities is untreatable. However, if extremities are warm, it is treatable. Here, despite severe symptoms, Sini Tang is used because fever indicates remaining Yang vitality. The classic states: Vomiting/diarrhea without cold extremities, but with fever, is not fatal.
@@@
If vomiting stops and diarrhea ceases, but sweating and cold extremities persist, limb cramps do not resolve, and the pulse is faint and nearly imperceptible, Tongmai Sini Tang plus Pig Gallbladder Bile (Unblocking Pulse Frigid Extremities Decoction with Porcine Gallbladder Bile) is the primary formula.
[Annotation]
After Huo Luan vomiting and diarrhea stop, persistent sweating, cold extremities, limb cramps, and faint-nearly imperceptible pulse indicate extreme interior Cold blocking Yang from reaching the limbs. Tongmai Sini Tang plus Pig Gallbladder Bile is used to guide Yang through Yin.
[Collected Notes]
Cheng Wuji stated: Cessation of vomiting/diarrhea depletes fluids; sweating and cold extremities should not occur. Their presence indicates severe Yang deficiency and dominant Yin. Pure Yang tonics might be rejected by Yin, causing vomiting or restlessness. Adding Pig Gallbladder Bile to Tongmai Sini Tang uses its bitterness to enter the Heart and unblock pulses, and its cold nature to nourish the Liver and harmonize Yin, guiding Yang tonics without rejection. As the Neijing says: Treat mild cases oppositely, severe cases similarly (following the pathogen). This applies here.
Fang Youzhi stated: "Yi" means stop. "Xia" means diarrhea. "Duan" means cut off. This describes the cessation of vomiting/diarrhea and addresses the unresolved remaining symptoms.
@@@
Aversion to cold, faint pulse, and abdominal diarrhea. If diarrhea stops, it is Blood exhaustion; Sini Tang plus Ginseng (Frigid Extremities Decoction plus Ginseng) is the primary formula.
[Commentary]
How can large hot tonics be used for "Blood exhaustion" after diarrhea stops? "Diarrhea stops" should be "Diarrhea does not stop." "Blood exhaustion" should be "Yang exhaustion."
[Annotation]
After Huo Luan vomiting and diarrhea stop, if aversion to cold, faint pulse, and recurrent diarrhea (non-stop) occur, it indicates Yang deficiency. Sini Tang plus Ginseng is used to benefit Yang and tonify Qi.
[Collected Notes]
Lin Lan stated: Huo Luan treatment requires distinguishing Cold and Heat. If it is Summerheat Huo Luan in summer, with deficient pulse and scanty red urine, Aconite and Dried Ginger must not be used. Careful differentiation is needed; only when diarrhea stops, pulse is faint, and aversion to cold exists, can they be used. Also, Summerheat Huo Luan should be treated with Wuling San plus Elsholtzia, Polygonum, Kudzu Root, Ginger Juice, and Stir-fried Coptis.