《素问·气交变大论》曰∶岁土不及，民病飧泄霍乱。
岁土不及，则脾胃素虚之人，因天运而更见其虚，中阳既虚，寒湿自盛，以致朝食暮泻而为
飧泄，甚加呕吐而为霍乱。观其与飧泄并称，则知利者，必是清谷而非臭秽，吐者亦必澄
澈而非酸浊。小便之利，口之不渴，又从而可必矣。如此，才是寒湿霍乱，可以理中、五苓之
类治之。故读书须以意逆其理，自然触处洞然，无往而不贯矣。且寒霍乱，多见于安逸之人。
以其深居静处，阳气不伸，坐卧风凉，起居任意。冰瓜水果，恣食为常，虽在盛夏之时，所患
多非暑病，王安道论之详矣。轻则藿香正气散，或平胃加木香、藿香、生姜、半夏之类。湿盛而四肢重
着，骨节烦
。头痛
臭
足厥冷，或烦热发躁，揭去衣被，但察其泻出不臭者，乃内虚阴盛格阳，宜理中汤，甚则四
逆汤，加食盐少许。更有暴泻如水，冷汗四逆，脉弱不能言者，急进浆水散救之，并宜冷服
。
然此辈实由避暑而反为寒伤致病，若拘泥时令，误投清暑之剂而更助其阴，则顷刻亡阳莫挽
矣。前人有治此证而愈者，尚未确知其为寒病也。遂谓夏月暑病，通宜热药。妄立阴暑名目
，贻误后人，此因偶中而错认面目也。余于《温热经纬》，辨之详矣。
《至真要大论》曰∶诸病水液，澄澈清冷，皆属于寒。
或曰∶医者，精脉理，谙药性，胸罗经史，口熟方书，斯可以济世矣。余曰∶不可，必也能
辨证乎。苟不辨证，而但凭脉以用方药，虽引古证今，有典有则，恐不免为二竖所笑也。惟圣人早
料及此，以辨证之法，大书特书，垂示后世，可谓既详且尽，岂但为霍乱分寒热哉！
《伤寒论》曰∶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。
此霍乱之因伤寒而致者，故兼有头痛发热身痛诸表证也。虽欲饮水，而表证未罢，故以五苓
散为两解之法。二方皆为风寒而设，热多，谓表热未衰；寒多，谓里寒较盛。于一病中，
察其内外之轻重，而辨邪气之聚散，以施治法。圣人辨证，详尽如是。而后人颟
，或至误会。凡夏秋热霍乱之口渴者，辄用五苓，多致偾事。须
知桂术为渴家所忌，惟风寒之邪，郁阻气机，至水液不行而渴者，始可用以行气化水也。
（分析甚明，发前人所未发。盖热多并非表里大热，欲饮水亦与大渴引饮不同也。
又曰∶吐利止而身痛不休者，当消息和解其外，宜桂枝汤小和之。
吐利止，里已和也。身痛不休者，表未解也。故须桂枝和解其外，所谓表病里和，
汗之则愈也。但此为寒霍乱后之兼有风寒表邪者而言，若温热暑疫霍乱后之表未解者，不得率尔
引用也。余拟驾轻汤一方，最为合治，然其意亦不敢出圣人之范围也。详其一曰消息，再
曰小和之者，盖以吐利之余，里气已伤，故必消息其可汗而汗之，亦不可大汗而小和之也。况热
霍乱后，津液尤虚者，其可妄施汗法乎。故余但以轻清为制也。
又曰∶吐利发汗，脉平小烦者，以新虚不胜谷气故也。
吐利可发汗者，伤寒霍乱也。脉平为邪已解，而小烦者，以吐下后胃气新虚，不能消谷，故
霍乱病。 时内不可便与饮食，必待胃渐下行为顺，而
仓廪始开也。暑热霍乱，尤夺胃津，溉以甘凉，自能思谷。
先曾祖秉衡公曰∶伤寒，外感之
总名；《伤寒论》，统论外感之书也。先大父永嘉公曰∶《难经》云∶伤寒有五。则五种外感
，古人皆谓之伤寒矣。《伤寒论》有治风、治温、治 、治湿诸法，则非专论一伤寒矣。杨素园大尹曰∶注伤
寒者，无虑数十家，皆以为专论伤寒之书，故恒觉支离附会，不适于用。雄尝谓伤寒有五，疟亦有五，不
过重轻之别耳。伤寒，惟感寒即病者，为正伤寒，乃寒邪由表而受，治宜温散。其邪在半表
半里，或所感邪气较轻，不为伤寒而为正疟者，脉象必弦，并宜和解。设冬伤于寒而不即病
，则为春温夏热之病。其较轻者，则为温疟、瘅疟。若感受风温、湿温、暑热之气者，重则
为时感， 轻则为时疟。今世温热多而伤寒少，故疟亦时疟多而正疟少。惟叶天士先生，精于温热、暑湿
诸感，故其治疟也，一以贯之。余师其意，凡治时疟，必辨其为风温、为湿温、为暑热、为伏
邪者，仍以时感法清其源。故四十年来，治疟无难愈之证。推而广之，仍不止疟疾尔也，如
风寒暑湿，皆可以为霍乱。则冬寒内伏，至春夏不为温热病，亦可以为霍乱也，特不多见，
故从来无人道及。今年春、夏之交，余在濮院，即有是证，未交芒种，薄游海上，则沿门阖
户，已成大疫，盖去冬积雪久冻，伤于寒者较深，而流离失所，斗米千余，精神之不藏者既多
，中气之不馁者亦罕。且今春过冷，入夏甚凉，殆肃杀之气未消，发生之机不畅，故伏邪不
能因升发之令，外泄以为温，久伏深藏，如奸匪潜匿，毫无觉察，或其人起居饮食之失调
，或外感稍侵而引动，遂得乘机卒发，直犯中枢而为霍乱，故多无腹痛之兼证。而愈后辄有
余波，与向来夏秋所行因于暑湿为患者，证候则一，病情迥殊也，治法亦稍有不同。然伏邪
化热，自里达外，与伏暑内发，理无二致，故其人必口渴，而刺血则紫黑。不知者以为暑令
未行，有何热证，放胆姜附，涂炭生民，岂亦劫运使然耶，可哀也已。镇海周君采山，极为
折服，遂以此说刊印，传播远近。元和金君 斋，同邑周君二郊，秀水吕君慎庵，鸟程汪谢
城孝廉，桐乡陆定圃进士，皆见而韪之，爰赘于伤寒霍乱后，以谂来者。
又曰∶吐利汗出，发热恶寒，四肢拘急，手足厥逆者，四逆汤主之。
此阳虚之体，寒邪得以直入而为霍乱也。发热恶寒者，身虽热而恶寒，身热为格阳之假象
，恶寒为虚冷之真谛也。四肢拘急，手足厥逆者，阳气衰少，不柔于筋，不温于四末也。首重
汗出者，为阳有外亡之象，故径用四逆汤，祛其既入之寒，而挽其将去之阳。若止见厥逆恶
寒，四肢拘急，脉来沉细沉紧，面如尘土，泻出不臭，虽属阴寒，而无汗出之候者，但宜冷
香饮子治之。寒主收引，故四肢拘急，乃筋强不能屈伸之谓，与热证之转筋迥殊。监证极宜
分别，苟或颠倒误施，祸不旋踵。
又曰∶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
。
此亦虚冷霍乱之候。四肢拘急，手足厥逆，虚冷之着于外也。下利清谷，脉微欲绝，虚冷
之着于内也。虚冷甚于内，则反逼其阳于外矣，故其外候，每多假热之象。或烦躁去衣而欲坐地
，或面赤喜冷而不欲咽，或脉大虚弦而不任按，是皆元气耗散，虚阳失守，甚加喘哕，最为危
险。惟四逆汤可以驱内胜之阴，而复外散之阳。但既吐且利之下，紧接曰小便复利，重申曰
下利清谷，何其丁宁而郑重耶？故读者最宜着眼。洄溪所谓一证不具，即当细审也。倘热霍
乱因暑邪深入而滞其经隧，显脉细肢寒之假象者，必有溺赤便臭，口渴苔黄之真谛，临诊慎
毋忽焉。
又曰∶吐下已断，汗出而厥，四肢拘急，脉微欲绝者，通脉四逆加猪胆汤主之。
尤拙吾曰∶吐下已止，阳气当复，阴邪当解。乃汗出而厥，四肢拘急，而又脉微欲绝，则阴
无退散之期，阳有散亡之象，于法为较危矣。故于四逆加干姜一倍，以救欲绝之阳。而又虑
温热之过，反为阴气格拒而不入，故加猪胆汁之苦寒，以为向导之用，即《内经》盛者从之
之意也。
又曰∶少阴病吐利，手足厥冷，烦躁欲死者，吴茱萸汤主之。少阴病吐利，烦躁四逆者，
死。
寒中少阴，吐利交作，阴邪盛极，而阳气不胜也。然先厥冷而后烦躁者，犹有阳欲复而来争
之兆，故以吴茱萸温里散寒，人参、大枣益虚安中为治也。若先烦躁而后四逆者，阳不胜而
将绝也，故死。此二条本少阴中寒，非霍乱也，然有类乎霍乱。既明霍乱之治，复列其类证以
广其例，俾临证不致眩惑也。
又曰∶少阴病，自利清水，色纯青，心下必痛，口干燥者，急下之，宜大承气汤。
寒邪化热，传入少阴，逼迫津水，注为自利。质清而无滓秽相杂，色青而无黄赤相间。可
见阳邪炎威之极，反与阴邪无异。但阳邪传自上焦，其人心下必痛，口必干燥。设系阴邪，则
心下满而不
以
之少阴证，而口干燥，心下痛，自利清水，尚宜急下。其病非伤寒，脉不微细，精情瞀乱而
口渴，心下拒按之霍乱证，顾可以燥热药治之哉？《内经》以水液澄澈清冷为寒。此证虽自
利清水，必热而不冷，或小便赤短，审问之，自有分别。而仲圣于下利证，专以口渴与否，判清
温之治，尤为简当。临证者，当奉为南针也。
（此证最宜细辨，余尝见一霍乱轻证，医投凉膈散，次日下血而殒，谢城。）
《千金要方》曰∶霍乱四逆，吐少呕多者，附子粳米汤主之。治中汤，治霍乱吐
下，胀满，食不消
胃之间
，则吐利俱发。挟风而实者，身发热、头痛、体痛，而复吐利。虚者，但吐利，心腹刺痛而已。亦有
饮酒
脾胃，脾胃得冷则不磨，不磨则水谷不消化，亦令清浊二气相干。脾胃虚弱，便作吐利，水
谷不消，则心腹胀满，皆成霍乱。
热霍乱，流行似疫，世之所同也；寒霍乱，偶有所伤，人之所独也。巢氏所论虽详，乃寻常
寒霍乱耳。执此以治时行霍乱，犹腐儒将兵，其不覆败者鲜矣。
又曰∶霍乱而转筋者，由冷气入于筋故也。冷入于足之三阴三阳，则脚转筋。入于手之三阴
三阳，则手转筋。随冷所入之筋，筋即转，转者皆由邪冷之气，击动其筋而移转也。
转筋有因热因寒之异，须合兼证脉候而辩析之。
（无病之人，亦有时患转筋者，不过足受微凉，不足为病。乃时医专以转筋为邪入
三阴，讵知三阳亦能转筋，巢氏之论甚明乎。谢城。）
又曰∶干霍乱者，是冷气搏于肠胃，致饮食不消，但腹满烦乱， 痛短气，
其肠胃先挟实，故不吐利，名为干霍乱也。
干霍乱，属寒湿者固有之，挟食者亦或有之，亦有因寒湿而夹秽臭恶毒之气者。故治法审
非暑火为患，不可误用清凉。但宜芳香辛散以宣通之。其姜、附、椒、巴等剂，勿轻信而妄试
也。
医道通治道，治国者必察民情，听讼者必察狱情。用药如用兵，为将者必察敌情，为医者
必察病情。民情得而政教行，狱情得而曲直分，敌情得则胜权独操，可以寡克众，可以逸待
劳。病情得则生机在握，可以御 疠，可以挽造化。呜呼！不辨虚实
寒热而治霍乱者，犹之弃其土地，民众而讲战守也，故列病情第一。
《素问·气交变大论》说：如果岁运土气不足，百姓就会患完谷不化的泄泻和霍乱。
岁运土气不足，那么脾胃原本虚弱的人，会因天体运行（气候异常）而显得更加虚弱，中焦阳气既然虚弱，寒湿自然强盛，导致早上吃晚上拉，形成完谷不化的泄泻；如果加重呕吐，就变成霍乱。观察它与完谷不化泄泻并列提及，就知道这种腹泻，一定是排泄物中有未消化的食物而不是气味臭秽的；呕吐物也一定是清澈透明而不是酸浊的。小便通利，口不渴，由此也可以推断出来。像这样，才是寒湿型霍乱，可以用理中汤、五苓散之类的方剂治疗。所以读书必须用心意去推究其中的道理，自然能处处通达，无所不通。而且寒性霍乱，多见于生活安逸的人。因为他们深居静室，阳气不能舒展，坐卧于风凉之处，起居随心所欲。冰镇瓜果，随意食用成为常态，即使在盛夏时节，所患的多不是暑病，王安道对此论述得很详细了。轻症用藿香正气散，或者平胃散加木香、藿香、生姜、半夏之类。如果湿气重且四肢沉重，骨节烦痛，头痛，身体有异味，足部厥冷，或者烦躁发热发狂，掀开衣被，但只要观察其泻下物没有臭味，这是内里虚寒、阴盛格阳（阴寒内盛，逼迫阳气浮越于外），适宜用理中汤，严重的用四逆汤，加少许食盐。更有暴发性腹泻如水样，冷汗淋漓，四肢厥冷，脉象微弱不能说话的情况，急需进服浆水散来急救，并且适宜冷服。
然而这些人实际上是因为避暑反而受寒致病，如果拘泥于时令季节，错误地投用清解暑热的药剂从而更助长阴寒之气，那么顷刻间阳气亡脱就无法挽救了。前人有治愈此证的人，尚且不确定那是寒病。于是认为夏季暑病，普遍适宜用热药。妄立“阴暑”这一名目，贻误后人，这是因为偶然治中而错认了病症面目。我在《温热经纬》中已经详细辨析过了。
《素问·至真要大论》说：各种病的水液分泌物，清澈寒冷，都归属于寒证。
有人说：医生，精通脉理，熟悉药性，胸藏经史，熟读方书，这样就可以济世救人了吧。我说：不行，必须能够辨证啊。如果不辨证，只凭脉象来使用方药，虽然引用古代案例验证现在，有经典依据和法则，恐怕不免被病魔（二竖）嘲笑。只有圣人早就料到这种情况，将辨证的方法，大大书写特别强调，留给后世示范，可以说是既详细又完备，难道仅仅是为了区分霍乱的寒热吗！
《伤寒论》说：霍乱，出现头痛、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。
这种霍乱是因为伤寒引起的，所以兼有头痛、发热、身痛等表证。虽然想喝水，但表证未解除，所以用五苓散作为表里双解的方法。这两个方子都是为风寒之邪设立的，“热多”，是指表热未衰；“寒多”，是指里寒较盛。在同一种病中，观察其内外的轻重，辨别邪气的聚散，从而施以治疗方法。圣人辨证，详尽到如此程度。而后人糊涂，甚至产生误解。凡是夏秋季节热霍乱口渴的，就用五苓散，大多导致事情败坏。须知桂枝、白术是口渴患者所忌讳的，只有风寒之邪，郁阻气机，导致水液不行而口渴的，才可以用来行气化水。
（分析非常明白，阐发了前人未曾发现的问题。大概“热多”并不是表里大热，“想喝水”也与大渴引饮不同。）
又说：呕吐腹泻停止但身体疼痛不止的，应当斟酌情况调和其表证，适宜用小剂量的桂枝汤和解。
呕吐腹泻停止，说明里气已调和。身体疼痛不止，说明表证未解。所以需要桂枝汤来和解表邪，所谓表病里和，发汗就能痊愈。但这只是针对寒性霍乱后兼有风寒表邪的情况而言，如果是温热暑疫霍乱后表证未解的，不得轻易引用这个方子。我拟定了一个驾轻汤一方，最为合宜，但其用意也不敢超出圣人的范围。详细说明“消息”（斟酌）、“小和之”（轻微调和）的原因，大概是因为呕吐腹泻之后，里气已经受伤，所以必须斟酌是否可以发汗再发汗，也不可大汗，而是轻微调和。何况热霍乱后，津液尤其虚弱的，怎么可以妄用发汗法呢？所以我仅以轻清的药物来制方。
又说：呕吐腹泻后发汗，脉象平和但略有心烦的，是因为新近虚弱不胜受谷物之气的影响。
呕吐腹泻后可以发汗的，是伤寒霍乱。脉象平和说明邪气已解，略有心烦，是因为吐下之后胃气新近虚弱，不能消化谷物，所以在霍乱病期间不可立即给予饮食，必须等待胃气逐渐下行顺畅，而肠胃功能才开始恢复。暑热霍乱，尤其耗夺胃津，灌溉甘凉滋润之物，自然能思食。
先曾祖秉衡公说：伤寒，是外感病的总称；《伤寒论》，是统论外感病的书籍。先祖父永嘉公说：《难经》讲：伤寒有五。那么五种外感病，古人都称为伤寒。《伤寒论》中有治风、治温、治湿等各种方法，那么就不是专门论述一种伤寒的书了。杨素园大尹说：注释《伤寒论》的，无虑数十家，都认为它是专门论述伤寒的书，所以常常觉得支离破碎、牵强附会，不适于实用。我曾说伤寒有五，疟疾也有五，不过是轻重之别罢了。伤寒，只有感受寒邪即发病的，才是正伤寒，乃寒邪由体表侵入，治疗适宜温散。邪气在半表半里，或者所感邪气较轻，不为伤寒而为正疟的，脉象必定弦，并适宜和解。假设冬天感受寒邪而不立即发病，就成为春温夏热之病。其中较轻的，就是温疟、瘅疟。如果感受风温、湿温、暑热之气的，重的为时行感冒，轻的为时行疟疾。当今世界温热病多而伤寒少，所以疟疾也是时行疟疾多而正疟少。只有叶天士先生，精通温热、暑湿等各种外感，所以他治疗疟疾，一以贯之。我师从他的意旨，凡是治疗时行疟疾，必定辨别其为风温、湿温、暑热、伏邪的，仍然用治疗时行感冒的方法清除病源。所以四十年来，治疗疟疾没有难以痊愈的病例。推广开来，还不止于疟疾而已，如风寒暑湿，都可以导致霍乱。那么冬季寒邪内伏，到了春夏季不表现为温热病，也可以表现为霍乱，只是不多见，所以从来没有人提到过。今年春夏之交，我在濮院，就有这样的病例，未到芒种节气，短暂游历海上，则沿街满户，已成大瘟疫，大概因为去年冬天积雪久冻，受寒较深，而流离失所之人众多，精神不能内守的也多，中气不虚弱的也很少。况且今春过冷，入夏甚凉，大概是肃杀之气未消，生发之机不畅，所以伏邪不能因升发的命令，向外宣泄成为温病，长久潜伏深藏，如同奸匪潜匿，毫无觉察，或者其人起居饮食失调，或外感稍侵而引动，便得以乘机突然发作，直犯中枢而导致霍乱，所以多没有腹痛的兼证。而痊愈后往往有余波，与向来夏秋季节因暑湿为患者相比，证候相同，病情却截然不同，治疗方法也稍有不同。然而伏邪化热，自里达外，与伏暑内发，道理没有两样，所以其人必定口渴，而刺血则呈紫黑色。不知情的人认为暑令未行，有什么热证，大胆使用姜、附等热药，使百姓陷入苦难，难道是劫数使然吗，可悲啊。镇海的周采山君，极为信服，于是将此说刊印，传播远近。元和的金斋君，同邑的周二郊君，秀水的吕慎庵君，乌程的汪谢城孝廉，桐乡的陆定圃进士，都见到并赞同它，于是附加在伤寒霍乱篇后，以此告知后来者。
又说：呕吐腹泻出汗，发热恶寒，四肢拘挛紧急，手足厥冷的，用四逆汤主治。
这是阳虚体质，寒邪得以直接侵入而导致的霍乱。发热恶寒，身体虽热但怕冷，身热是格阳的假象，恶寒是虚冷的真谛。四肢拘挛紧急，手足厥冷，是阳气衰少，不能柔养筋脉，不能温暖四肢末端。首先重视出汗，是阳气外亡的迹象，所以直接用四逆汤，祛除已经进入体内的寒邪，挽回即将离去阳气。如果只见厥冷恶寒，四肢拘急，脉象沉细或沉紧，面色如尘土，泻下物无臭味，虽然属于阴寒，但没有出汗征候的，只适宜用冷香饮子治疗。寒主收引，所以四肢拘急，是筋脉僵硬不能屈伸的意思，与热证的转筋截然不同。监证极需分别，如果颠倒误施，灾祸立刻降临。
又说：既呕吐又腹泻，小便反而通利，大汗出，下利完谷不化，内寒外热，脉微欲绝的，用四逆汤主治。
这也是虚冷型霍乱的征候。四肢拘急，手足厥冷，是虚冷表现于外。下利完谷不化，脉微欲绝，是虚冷表现于内。虚冷甚于内，则反逼阳气于外，所以其外在征候，多有假热的现象。或者烦躁脱衣想坐在地上，或者面赤喜冷但不愿咽下，或者脉大虚弦而不能按压，这些都是元气耗散，虚阳失守，加上气喘呃逆，最为危险。只有四逆汤可以驱除体内胜盛的阴寒，而复归体外散失的阳气。但既呕吐又腹泻之下，紧接着说小便通利，重申说下利完谷不化，何其叮咛郑重啊！所以读者最应着眼注意。洄溪所说一个证候不具备，就应当仔细审察。倘若热霍乱因暑邪深入而阻滞经络，显现脉细肢寒的假象的，必定有小便黄赤、大便臭秽、口渴苔黄的真相，临诊千万不要忽视。
又说：呕吐腹泻已停止，出汗而厥冷，四肢拘急，脉微欲绝的，用通脉四逆加猪胆汤主治。
尤拙吾说：呕吐腹泻已止，阳气应当恢复，阴邪应当解散。竟然出汗而厥冷，四肢拘急，而又脉微欲绝，那么阴邪没有退散的时候，阳气有散亡的迹象，按法算是比较危重的了。所以在四逆汤基础上加干姜一倍，以救欲绝的阳气。而又担心温热太过，反被阴气格拒而不入，所以加猪胆汁的苦寒，作为向导之用，即《内经》“盛者从之”的意思。
又说：少阴病呕吐腹泻，手足厥冷，烦躁欲死的，用吴茱萸汤主治。少阴病呕吐腹泻，烦躁四肢厥冷的，死。
寒邪中伤少阴，呕吐腹泻交替发作，阴邪盛极，而阳气不胜任。然而先厥冷而后烦躁的，还有阳气欲复而来抗争的征兆，所以用吴茱萸温里散寒，人参、大枣补益虚损安定中焦来治疗。如果先烦躁而后四肢厥冷的，阳气不胜任而将要断绝，所以死。这两条本属少阴中寒，不是霍乱，但有类似霍乱的地方。既然明确了霍乱的治疗，又列出其类证以扩大其例，使临证不至于迷惑。
又说：少阴病，自利清水，颜色纯青，心下必定痛，口干燥的，急下之，适宜用大承气汤。
寒邪化热，传入少阴，逼迫津液，注为自利。质地清而无渣滓混杂，颜色青而无黄赤相间。可见阳邪炎威之极，反而与阴邪无异。但阳邪传自上焦，其人心中必定痛，口必定干燥。如果是阴邪，则心中满而不痛。以少阴证来看，口干燥，心下痛，自利清水，尚且适宜急下。那病非伤寒，脉不微细，神情昏乱而口渴，心下拒按的霍乱证，难道可以用燥热药治疗吗？《内经》以水液清澈寒冷为寒。此证虽然自利清水，必定热而不冷，或者小便赤短，仔细询问，自然有分别。而仲景对于下利证，专以口渴与否，判断清热温里的治法，尤为简便得当。临证者，应当奉为指南针。
（此证最宜仔细辨别，我曾见过一例霍乱轻证，医生投用凉膈散，次日下血而死，谢城记载。）
《千金要方》说：霍乱四肢厥冷，吐少呕多的，用附子粳米汤主治。治中汤，治疗霍乱呕吐腹泻，胀满，食物不消化。
胃之间，则吐利俱发。挟风而实证的，身体发热、头痛、身体痛，而又呕吐腹泻。虚证的，只是呕吐腹泻，心腹刺痛而已。也有饮酒损伤脾胃，脾胃得冷则不能磨化，不能磨化则水谷不消化，也令清浊二气相干扰。脾胃虚弱，便作呕吐腹泻，水谷不消，则心腹胀满，都成为霍乱。
热霍乱，流行似瘟疫，是世人共同的；寒霍乱，偶尔有所伤害，是个人的独特遭遇。巢元方所论述的虽然详细，乃是寻常的寒霍乱罢了。执此来治疗时行霍乱，犹如腐儒带兵，不覆灭失败的很少了。
又说：霍乱而出现转筋的，是由于冷气进入筋脉的缘故。冷气进入足部的三阴三阳经，则脚部转筋。进入手部的三阴三阳经，则手部转筋。随着冷气进入的筋脉，筋即发生转筋，转筋都是由邪冷之气，击动其筋而移转造成的。
转筋有因热因寒的不同，须结合兼证脉候来辨析。
（无病之人，也有有时患转筋的，不过是足部受微凉，不足以成为疾病。然而当时医生专以转筋为邪入三阴，岂知三阳也能转筋，巢氏的论述很明白了。谢城记载。）
又说：干霍乱，是冷气搏结于肠胃，导致饮食不消，只是腹部胀满烦乱，心痛短气，因为其肠胃先前挟实，所以不吐利，名为干霍乱。
干霍乱，属寒湿者固有之，挟食者亦或有之，也有因寒湿而夹杂秽臭恶毒之气的。所以治疗方法审慎如果不是暑火为患，不可误用清凉。只适宜芳香辛散以宣通之。那些姜、附、椒、巴豆等药剂，不要轻信而妄试。
医道通治道，治国者必须考察民情，听讼者必须考察狱情。用药如用兵，为将者必须考察敌情，为医者必须考察病情。民情得到了解则政教可行，狱情得到了解则曲直分明，敌情得到了解则制胜权独操，可以寡克众，可以逸待劳。病情得到了解则生机在握，可以抵御疠气，可以挽回造化。唉！不辨虚实寒热而治疗霍乱的，犹如放弃土地、民众而去讲战守，所以列病情第一。
The *Suwen: Qiaobi Bian Dalun* (Treatise on the Great Changes of Qi Intercourse in the Basic Questions) states: If the annual Earth Qi is insufficient, the people will suffer from undigested stool diarrhea and Huoluan (cholera-like syndrome).
When the annual Earth Qi is insufficient, individuals with originally weak Spleen and Stomach will appear even more deficient due to celestial movements (abnormal climate). Once the Middle Jiao Yang Qi is deficient, Cold-Dampness naturally becomes prevalent, leading to morning intake and evening evacuation, resulting in undigested stool diarrhea; if vomiting is added, it becomes Huoluan. Observing its mention alongside undigested stool diarrhea, we know that such diarrhea must contain undigested food rather than foul-smelling excrement; vomitus must also be clear and transparent rather than sour and turbid. The presence of free urination and absence of thirst can also be inferred thus. Only in this manner is it Cold-Damp Huoluan, which can be treated with formulas such as Lizhong Tang (Regulate the Middle Decoction) or Wuling San (Five-Ingredient Poria Pill). Therefore, when studying texts, one must use one's mind to deduce the underlying principles, thereby achieving clarity everywhere and universal understanding. Moreover, Cold-type Huoluan is often seen in people living a comfortable life. Because they dwell in quiet places, their Yang Qi cannot extend; they sit and lie in cool breezes, and live arbitrarily. They consume iced melons and fruits at will as a routine. Even in midsummer, what they suffer from is mostly not Summerheat disease. Wang Andao discussed this in detail. For mild cases, Huoxiang Zhengqi San (Patchouli Powder to Rectify the Qi) or Pingwei San (Calm the Stomach Powder) plus Muxiang (Aucklandiae Radix), Huoxiang (Patchouli Herba), Shengjiang (Zingiberis Rhizoma Recens), Banxia (Pinelliae Tuber), etc., are used. If Dampness is heavy and limbs feel heavy, bones and joints are painful, headache occurs, body odor is present, feet are cold, or there is irritability, fever, and restlessness causing the patient to remove clothes and bedding, but observing that the stool is not foul-smelling, this indicates Interior Deficiency with Yin Excess forcing Yang outward (Yin Excess Repelling Yang). Lizhong Tang is appropriate; for severe cases, Sini Tang (Frigid Extremities Decoction) with a little salt is indicated. In cases of sudden watery diarrhea, cold sweat all over, cold extremities, weak pulse, and inability to speak, Jiangshui San (Fermented Rice Water Powder) should be administered urgently for rescue, and it is suitable to take it cold.
However, these patients actually contracted illness by trying to avoid summer heat but instead being injured by Cold. If one adheres rigidly to the season and mistakenly administers Summerheat-clearing agents, further aiding Yin-Cold, Yang collapse will occur instantly and become irretrievable. Some predecessors cured this condition but were unsure it was a Cold disease. Thus, they claimed that Summerheat diseases in summer generally require hot medicines. They recklessly established the category of "Yin Summerheat," misleading later generations. This was a misidentification due to accidental success. I have detailed this refutation in my book *Wenre Jingwei* (Comprehensive Analysis of Warm Diseases).
The *Suwen: Zhen Yao Da Lun* (Great Treatise on the Most Essential and Necessary Questions) states: All bodily fluids that are clear, cold, and chilly belong to Cold.
Someone said: A physician who masters pulse diagnosis, understands drug properties, possesses knowledge of classics and history, and is familiar with prescriptions can save the world. I say: No, one must be able to differentiate syndromes (Bianzheng). If one does not differentiate syndromes but relies solely on pulses to prescribe, even citing ancient precedents with classical basis, one risks being mocked by the disease spirits. Only the Sages anticipated this, explicitly writing down methods of syndrome differentiation for posterity, detailing them thoroughly. Was it merely to distinguish Cold and Heat in Huoluan?
The *Shanghan Lun* (Treatise on Cold Damage) states: In Huoluan, if accompanied by headache, fever, and body pain, with more Heat and desire for water, Wuling San governs it; if more Cold and no desire for water, Lizhong Wan governs it.
This type of Huoluan arises from Cold Damage, hence accompanied by exterior symptoms like headache, fever, and body pain. Although there is a desire for water, the exterior syndrome remains unresolved, so Wuling San is used as a method to resolve both interior and exterior. Both formulas are designed for Wind-Cold. "More Heat" refers to unresolving exterior Heat; "More Cold" refers to prevailing interior Cold. Within one disease, one observes the severity of interior and exterior, differentiates the aggregation and dispersion of pathogenic factors, and applies treatment accordingly. The Sage’s differentiation is so exhaustive. Later generations, however, are confused and misunderstand. Whenever patients with Hot Huoluan in summer and autumn have thirst, Wuling San is used, often leading to failure. One must know that Guizhi (Cinnamon Twig) and Baizhu (Atractylodis Macrocephalae Rhizoma) are contraindicated for those with thirst. They are only applicable when Wind-Cold pathogens obstruct Qi mechanism, causing fluid metabolism failure and thirst, to promote Qi movement and fluid transformation.
(Analysis is very clear, revealing insights previously undiscovered. "More Heat" does not mean intense interior-exterior Heat, and "desire for water" differs greatly from extreme thirst craving large amounts.)
It also states: If vomiting and diarrhea cease but body pain persists, one should carefully assess and harmonize the exterior; Guizhi Tang (Cinnamon Twig Decoction) in small doses is appropriate.
Cease of vomiting and diarrhea indicates Interior harmony. Persistent body pain indicates the exterior is unresolved. Thus, Guizhi Tang is needed to harmonize the exterior, known as "Exterior disease, Interior harmony," where sweating leads to recovery. However, this applies only to Cold Huoluan complicated by Wind-Cold exterior pathogen. For Hot Huoluan caused by Warmth, Summerheat, or Epidemic Toxins with unresolved exterior, this formula should not be casually applied. I devised Jiaying Tang (Driving Light Decoction), which is most suitable, yet its intent stays within the Sage’s scope. The terms "carefully assess" and "harmonize slightly" imply that after vomiting and diarrhea, Interior Qi is damaged; thus, one must judge if sweating is possible before inducing it, avoiding excessive sweating. Especially after Hot Huoluan, where Fluids are particularly depleted, how can sweating be rashly applied? Hence, I formulate with light and clear herbs.
It also states: After vomiting and diarrhea, if sweating occurs, pulse is peaceful but slight irritability exists, it is because new deficiency cannot withstand grain Qi.
Sweating after vomiting/diarrhea applies to Cold Damage Huoluan. Peaceful pulse means pathogens are resolved. Slight irritability results from new Stomach Qi deficiency post-evacuation, unable to digest grains. During Huoluan, diet should not be introduced immediately; one must wait for Stomach Qi to descend smoothly and digestive function to recover. In Summerheat-Hot Huoluan, Stomach Fluids are severely depleted; sweet-cool nourishment naturally restores appetite.
My late great-grandfather Bingheng Gong said: Cold Damage is the general term for external contraction; *Shanghan Lun* discusses external contractions comprehensively. My late grandfather Yongjia Gong said: *Nanjing* states "Cold Damage has five types." Thus, the ancients called all five external contractions Cold Damage. *Shanghan Lun* contains methods for treating Wind, Warmth, Dampness, etc., so it is not exclusively about one type of Cold Damage. Yang Suyuan Dayin noted: Dozens of commentators view it as exclusive to Cold Damage, finding it fragmented and impractical. I once said Cold Damage has five types, just as Malaria has five types; it is merely a difference in severity. True Cold Damage occurs when Cold invades the exterior immediately; treatment requires warming and dispersing. If pathogen is in half-exterior/half-interior or is mild, manifesting as true Malaria, the pulse is wiry, requiring harmonization. If Winter Cold is retained without immediate onset, it becomes Spring-Warmth or Summer-Heat diseases. Milder forms are Warm Malaria or Dan Malaria. Contracting Wind-Warmth, Damp-Warmth, or Summerheat leads to seasonal infections (heavy) or seasonal malaria (light). Today, Warm diseases are common, Cold rare; thus, seasonal malaria is common, true malaria rare. Only Mr. Ye Tianshi mastered Warmth and Damp-Heat, applying consistent logic to malaria treatment. I follow his intent: for seasonal malaria, I differentiate Wind-Warmth, Damp-Warmth, Summerheat, or latent pathogens, clearing the source via seasonal infection protocols. For forty years, no malaria case was incurable. Extending this principle, Wind, Cold, Summerheat, and Dampness can all cause Huoluan. Winter Cold latent inside may manifest as Huoluan in Spring/Summer rather than Warmth disease, though rarely seen, never mentioned before. This spring/summer, in Puyuan, I encountered such cases. Before Mangzhong solar term, traveling near the sea, households were filled with epidemic Huoluan. Last winter’s deep freeze caused severe Cold injury; displaced persons had depleted Spirit and weak Middle Qi. This spring was too cold, summer too cool; killing Qi persisted, generating Qi was sluggish. Latent pathogens could not vent as Warmth, hiding deeply like criminals. Triggered by lifestyle imbalance or minor external invasion, they suddenly attacked the center, causing Huoluan, often without abdominal pain. Post-recovery waves differed from typical Summer/Damp Huoluan, though symptoms resembled, pathology diverged, requiring distinct treatment. Latent Heat emerging from interior matches latent Summerheat logic; patients are thirsty, bloodletting yields dark purple blood. Ignorant practitioners, thinking Summerheat hasn't arrived, boldly use Ginger and Aconite, harming people. Is this fate? Pitiable. Zhou Caishan of Zhenhai accepted this theory, printed it, spreading it widely. Jin Zhai, Zhou Erjiao, Lu Shen’an, Wang Xiecheng, Lu Dingpu all approved it. I append this to Huoluan chapters to inform future readers.
It also states: With vomiting, diarrhea, sweating, fever, aversion to cold, limb stiffness, and cold extremities, Sini Tang governs it.
This is Yang-deficient constitution allowing Cold to enter directly, causing Huoluan. Fever with aversion to cold: body heat is false (Yang repelled outward); aversion to cold is true (Interior deficiency-cold). Limb stiffness and cold extremities indicate Yang deficiency failing to nourish tendons and warm extremities. Prominent sweating signals Yang escaping externally; thus, Sini Tang is used to expel invading Cold and salvage departing Yang. If only cold extremities, aversion to cold, limb stiffness, deep-thin/tight pulse, dusty complexion, non-foul stool exist without sweating, Lengxiang Yinzi (Cold Fragrant Drink) is appropriate. Cold causes contraction; limb stiffness here means tendon rigidity preventing flexion/extension, distinct from Heat-induced muscle cramps. Differentiation is crucial; error brings swift disaster.
It also states: Vomiting and diarrhea, frequent urination, profuse sweating, undigested stool evacuation, interior Cold with exterior Heat, faint pulse nearly imperceptible: Sini Tang governs it.
This is also deficiency-cold Huoluan. Limb stiffness/cold extremities show Cold outside; undigested stool/faint pulse show Cold inside. Severe interior Cold forces Yang outward, creating false Heat signs: irritability removing clothes, red face preferring cold but not swallowing, large-empty-wiry pulse unpressable. These indicate Yuan Qi depletion and floating Yang loss, worsened by wheezing/belching—critical danger. Only Sini Tang drives out excess Yin and restores scattered Yang. The emphasis on frequent urination and undigested stool highlights the gravity. Readers must pay attention. As Huoxi said, if one symptom is missing, scrutinize carefully. If Hot Huoluan mimics Cold via Summerheat blocking collaterals (fine pulse, cold limbs), true signs include dark urine, foul stool, thirst, yellow coating. Do not ignore these.
It also states: Vomiting/diarrhea stopped, sweating with cold extremities, limb stiffness, faint pulse: Tongmai Sini Tang plus Pig Gallbladder Bile governs it.
You Zhuowu said: Cessation of vomiting/diarrhea suggests Yang recovery and Yin resolution. Yet sweating, cold extremities, stiffness, and faint pulse indicate Yin persistence and Yang collapse—critical. Doubling Ganjiang (Dried Ginger) in Sini Tang saves dying Yang. Pig bile (bitter-cold) is added as a guide to prevent rejection by Yin, following *Neijing*'s "follow the excess" principle.
It also states: Shaoyin disease with vomiting/diarrhea, cold extremities, severe irritability: Wuzhuyu Tang governs. Shaoyin disease with vomiting/diarrhea, irritability, cold extremities: death.
Cold invading Shaoyin causes alternating vomiting/diarrhea; Yin excess overwhelms Yang. Preceding cold then irritability suggests Yang returning to fight; Wuzhuyu Tang warms interior, Renshen/Jujube tonifies deficiency. Preceding irritability then cold indicates Yang defeat/death—fatal. These are Shaoyin Cold patterns, not Huoluan, but similar. Listing them clarifies differential diagnosis.
It also states: Shaoyin disease, spontaneous clear watery stool, pure green color, epigastric pain, dry mouth: urgent purgation with Dachengqi Tang.
Cold transforming to Heat enters Shaoyin, forcing fluids into spontaneous diarrhea. Clear quality, green color without turbidity/yellow-red mix shows extreme Yang Fire resembling Yin. Pathogen from Upper Jiao causes epigastric pain and dry mouth. Yin pathogen would cause fullness without pain. Given Shaoyin signs (dry mouth, pain, clear stool), urgent purgation is needed. For non-Cold Damage Huoluan with confusion, thirst, epigastric tenderness, can燥热 (hot-dry) drugs be used? *Neijing* says clear/cold fluids are Cold. This clear stool is likely hot, not cold, possibly with dark scant urine. Careful inquiry distinguishes them. Zhongjing uses thirst to distinguish Warm vs. Cold treatments for diarrhea—simple and effective. Clinicians should follow this compass.
(This case requires careful differentiation. I saw a mild Huoluan case treated with Liangge San; patient died of bloody stool next day. Recorded by Xiecheng.)
*Qianjin Yaofang* states: Huoluan with cold extremities, less vomiting more retching: Fuzi Jingmi Tang governs. Zhizhong Tang treats Huoluan vomiting/diarrhea, distension, indigestion.
Between Stomach and Intestines, vomiting/diarrhea occur together. Wind-complicated excess presents with fever, headache, body ache, vomiting/diarrhea. Deficiency presents only with vomiting/diarrhea and stabbing heart/abdominal pain. Alcohol damaging Spleen/Stomach, combined with Cold impairing digestion, causes turbid/clear Qi conflict. Weak Spleen/Stomach leads to vomiting/diarrhea, indigestion, distension—all becoming Huoluan.
Hot Huoluan, epidemic-like, is common to all; Cold Huoluan, occasional injury, is individual. Chao Yuanfang’s detailed discussion covers ordinary Cold Huoluan only. Applying this to epidemic Huoluan is like an inept scholar commanding troops—failure is likely.
It also states: Huoluan with muscle cramps results from Cold Qi entering tendons. Cold entering foot meridians causes leg cramps; hand meridians cause arm cramps. Cramping follows Cold entry, driven by pathogenic Cold striking tendons.
Cramps differ by Heat/Cold etiology; differentiate via accompanying symptoms and pulses.
(People without disease sometimes get cramps from minor foot chill, not pathological. Modern doctors assume cramps always involve Three Yin meridians, ignoring Three Yang involvement. Chao’s theory is clear. Recorded by Xiecheng.)
It also states: Gan Huoluan (Dry Huoluan) is Cold Qi clashing in intestines/stomach, causing food stagnation, abdominal distension, irritability, chest pain, shortness of breath. Prior intestinal excess prevents vomiting/diarrhea, hence "Dry."
Gan Huoluan can be Cold-Damp, Food-stagnation, or Cold-Damp mixed with foul/toxic qi. Treatment must confirm it is not Summerheat-Fire before avoiding cooling agents. Use aromatic-acrid dispersants to open pathways. Do not blindly trial strong agents like Ginger, Aconite, Pepper, or Croton seed.
Medical之道 parallels governance: rulers examine public sentiment; judges examine legal facts; generals examine enemy intelligence; physicians examine disease conditions. Understanding public sentiment enables good governance; legal facts ensure justice; enemy intelligence ensures victory (few against many, rested against weary). Disease condition mastery secures life, wards off plagues, reverses fate. Alas! Treating Huoluan without distinguishing Deficiency/Excess or Cold/Heat is like abandoning land/people to discuss defense. Hence, examining disease conditions comes first.