问曰、病有霍乱者何。答曰、呕吐而利。名曰霍乱。
此设为问答。以明霍乱之病。谓邪在上者。多吐。邪在下者。多利。邪邪中焦。上逆为呕吐。复下
注而利者。
则为霍乱。霍乱、挥霍撩乱。成于顷刻。变动不安。而其发热恶寒。亦与阳明相类也。
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。
此即上条之意而详言之。盖霍乱之病。本自外来。以其人中气不足。邪得乘虚入里。伤于
脾胃而作吐利。所以有发热头痛。身疼恶寒之证。或邪气直侵脾胃。先自吐下。迨利止里和。则邪
气复还之表。而为发热。今人吐利之后。往往发热烦渴者是也。
伤寒。脉微而涩者。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。属阳明也。便必硬。十三日愈。所以然者。经尽故也。
脉微为少气。涩为无血。伤寒脉不应微涩。而反微涩者。以其为霍乱吐下之后也。本是霍乱。今是
伤寒者。吐下止而复更发热。如上条所云也。热则邪还于表。当从阳而解矣。乃四五日。至阴经上
转入阴必利者。邪气不从阳而解。而复入阴为利也。夫霍乱之时。既呕且利。里气已伤。今邪转入
里而复作利。则里气再伤。故不可治。若欲大便而反失气仍不利者。胃、气复而成实。邪气衰而欲
退也。故可期之十三日愈。所以然者。十二日经气再周。大邪自解。更过一日。病必愈耳。
下利
后。当便硬。硬则能食者。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。
下利后。便硬者。病后太阴而转属阳明也。阳明病。能食者为胃和。不能食者为胃未和。是以下
利后。便硬而能食者。愈。或始先不能食。继复转而能食者。过于前一日亦愈。其不愈者。则病不
属阳明。虽能食。不得为胃和。故病不愈也。
恶寒脉微而利。利止。亡血也。四逆加人参汤主之。
恶寒脉紧者。寒邪在外也。恶寒脉微者。阳虚而阴胜也。则其利为阴寒而非阳热。其止亦非邪
尽而为亡血矣。故当与四逆以温里。加人参以补虚益血也。按此条本非霍乱证。仲景以为霍乱之后
。多有里虚不足而当温养者。故特隶于此欤。
四逆加人参汤方
于四逆汤方内加人参一两。余根据四逆汤法服。
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。
霍乱该吐下而言。头痛发热。身疼痛。则霍乱之表证也。而有热多寒多之分。以中焦为阴阳之
交。故或从阳而多热。或从阴而多寒也。热多则渴欲饮水。故与五苓散去水而泄热。寒多则不能胜
水而不欲饮。故与理中丸燠土以胜水。
理中丸方
人参（三两） 甘草（三两） 白术（三两） 干姜（三两）
上四味。捣筛为末。蜜和丸。如鸡黄大。以沸汤数合。和一丸。碎研温服之。日三。夜二
服。腹中未热。益至三四丸。然不及汤。汤法。以四物根据两数切。用水八升。煮取三升。去滓。温
服一升。日三服。
加减法
若脐上筑者。肾气动也。去术。加桂四两。
脐上筑者。脐上筑筑然跳动。肾气上而之脾也。脾方受气。术之甘能壅脾气。故去之。桂之辛
能下肾气。故加之。
吐多者。去术。加生姜三两。
吐多者。气方上壅。甘能壅气。故去术，辛能散气。故加生姜。
下多者。还用术。悸者。加伏苓二两。
下多者。脾气不守。故须术以固之。悸者。肾水上逆。故加茯苓以导之。
渴欲得水者。加术。足前成四两半。
渴欲得水者。津液不足。白术之甘。足以生之。
腹中痛者。加人参。足前成四两半。
腹中痛者。里虚不足。人参之甘。足以补之。
寒者。加干姜。足前成四两半。
寒者。腹中气寒也。干姜之辛。足以温之。
腹满者。去术。加附子一枚。服汤后。如食顷。饮热粥一升许。微自温。勿发揭衣被。
腹满者。气滞不行也。气得甘则壅。得辛则行。故去术加附子。
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。曰消息。曰小和之者。以吐利之余。里气已伤。故必消息其可汗而后汗之。亦不可大汗。而可
小和之也。
吐利汗出。发热恶寒。四肢拘急。手足厥逆者。四逆汤主之。
此阳虚霍乱之候。发热恶寒者。身虽然而恶寒。身热为阳格之假象。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。故宜四逆汤助阳气而驱阴气。
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。虚冷之着于外者也。下利清谷。脉微欲绝。虚冷之
着于里者也。而其为霍乱则一。故吐利汗出。内寒外热。与上条同。而其用四逆驱内胜之阴。复外
散之阳。亦无不同也。
吐已下断。汗出而厥。四肢拘急。脉微欲绝者。通脉四逆加猪胆汁汤主之。
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。反为阴气所
拒而不入。故加猪胆汁之苦寒。以为向导之用。内经盛者从之之意也。
四逆加猪胆汁汤方
于四逆汤方内加入猪胆汁半合。余根据前法服。如无猪胆。以羊胆代之。
吐利发汗。脉平。小烦者。以新虚不胜谷气故也。
吐利之后。发汗已。而脉平者。为邪已解也。邪解则不当烦而小烦者。此非邪气所致。以吐下后
胃气新虚。不能消谷。谷盛气衰。故令小烦。是当和养胃气。而不可更攻邪气者也。
Question: What is Huoluan disease? Answer: Vomiting accompanied by diarrhea is called Huoluan.
This sets up a question-and-answer format to clarify the concept of Huoluan disease. It means that when pathogenic factors are in the Upper Jiao (Upper Burner), vomiting predominates; when they are in the Lower Jiao (Lower Burner), diarrhea predominates; when they are in the Middle Jiao (Middle Burner), upward rebellion causes vomiting, and downward pouring causes diarrhea, thus forming Huoluan. Huoluan implies sudden onset and chaotic symptoms, developing in an instant with restless changes. Its symptoms of fever and aversion to cold are also similar to Yangming disease.
Question: If a patient presents with fever, headache, body pain, aversion to cold, along with vomiting and diarrhea, what disease does this belong to? Answer: This is named Huoluan. The patient initially vomits and has diarrhea, then the diarrhea stops, but fever recurs.
This elaborates on the meaning of the previous clause. Huoluan disease originates from external pathogens. Because the person's Middle Qi (Central Energy) is deficient, pathogens take advantage of the deficiency to enter the interior, damaging the Spleen and Stomach, thereby causing vomiting and diarrhea. Hence, symptoms such as fever, headache, body pain, and aversion to cold appear. Alternatively, pathogens directly invade the Spleen and Stomach, causing initial vomiting and diarrhea. When the diarrhea stops and the interior harmonizes, the pathogens return to the exterior, causing fever. Currently, after vomiting and diarrhea, patients often experience fever, restlessness, and thirst, which illustrates this principle.
In Shaoyang Cold Damage (Shanghan), if the pulse is faint and choppy, it was originally Huoluan. Now it is Shanghan. After four or five days, when the pathogen enters the Yin meridians and transitions into the Yin level, diarrhea must occur. If there was originally vomiting and diarrhea, it is difficult to treat. If one feels the urge to defecate but instead passes flatus and still does not have diarrhea, it belongs to Yangming. The stool will likely be hard. Recovery is expected on the thirteenth day. The reason for this is that the meridian cycle has completed its course.
A faint pulse indicates a lack of Qi, and a choppy pulse indicates a lack of Blood. In Shanghan, the pulse should not be faint and choppy; rather, it appears so because of the aftermath of Huoluan vomiting and diarrhea. Originally Huoluan, now Shanghan (referring to the recurrence of fever after vomiting and diarrhea cease), as mentioned in the previous clause. Heat implies pathogens returning to the exterior, where they should resolve via the Yang level. However, after four or five days, if the pathogen enters the Yin meridians and transitions into the Yin level, diarrhea occurs because the pathogen did not resolve via the Yang level but instead entered the Yin level causing diarrhea. During Huoluan, both vomiting and diarrhea occur, injuring the Interior Qi. Now, if the pathogen transitions inward and causes diarrhea again, the Interior Qi is injured a second time, making it difficult to treat. If one feels the urge to defecate but only passes flatus without diarrhea, it indicates that Stomach Qi has recovered and formed excess, while pathogens are declining and retreating. Thus, recovery can be expected on the thirteenth day. This is because after twelve days, the meridian Qi circulates twice, resolving major pathogens; after one more day, the illness must heal.
After diarrhea ceases, the stool should become hard. If the stool is hard and the patient can eat, it indicates healing. If currently unable to eat, but able to eat slightly during the next meridian cycle, and able to eat after another cycle, recovery is expected one day later. If not healed, it does not belong to Yangming.
After diarrhea ceases, if the stool becomes hard, it indicates the disease transitioning from Taiyin to Yangming. In Yangming disease, the ability to eat indicates harmonious Stomach Qi, while inability to eat indicates unharmonious Stomach Qi. Therefore, after diarrhea ceases, if the stool is hard and the patient can eat, it indicates healing. If initially unable to eat but later able to eat, recovery occurs after surpassing the previous day. Those who do not heal do not belong to Yangming; even if they can eat, it does not signify harmonious Stomach Qi, so the illness does not heal.
Aversion to cold, faint pulse, and diarrhea, where diarrhea stops due to loss of Blood, should be treated with Sini Decoction plus Ginseng (Sini Jia Renshen Tang).
Aversion to cold with a tight pulse indicates cold pathogens on the exterior. Aversion to cold with a faint pulse indicates Yang deficiency and Yin excess. Thus, the diarrhea is due to Yin-cold rather than Yang-heat, and its cessation is not due to the exhaustion of pathogens but due to loss of Blood. Therefore, Sini Decoction (Four Counterflow Decoction) should be used to warm the interior, and Ginseng added to tonify deficiency and benefit blood. Note: This clause originally does not describe a Huoluan syndrome. Zhang Zhongjing considered that after Huoluan, there are often cases of interior deficiency requiring warming and nourishment, hence it is specifically classified here.
Formula for Sini Decoction plus Ginseng (Sini Jia Renshen Tang):
Add one qian of Ginseng (Renshen) to the formula for Sini Decoction. Prepare and administer according to the method for Sini Decoction.
For Huoluan presenting with headache, fever, and body pain, if heat predominates and there is desire to drink water, Wuling San (Five-Ling Powder) should be used. If cold predominates and there is no desire to drink water, Lizhong Wan (Regulate the Middle Pill) should be used.
Huoluan encompasses vomiting and diarrhea. Headache, fever, and body pain are the exterior syndromes of Huoluan. There is a distinction between predominant heat and predominant cold because the Middle Jiao is the intersection of Yin and Yang. Thus, some transform from Yang with predominant heat, and some transform from Yin with predominant cold. Predominant heat leads to thirst and desire to drink, so Wuling San is given to drain water and clear heat. Predominant cold leads to inability to manage water and no desire to drink, so Lizhong Wan is given to warm Earth (Spleen/Stomach) to overcome water.
Formula for Lizhong Wan (Regulate the Middle Pill):
Ren Shen (Ginseng Root) (3 liang), Gan Cao (Licorice Root) (3 liang), Bai Zhu (Atractylodes Rhizome) (3 liang), Gan Jiang (Dried Ginger) (3 liang).
Grind the above four ingredients into powder. Mix with honey to form pills the size of a chicken egg yolk. Dissolve one pill in a small amount of boiling water, crush and take warm. Take three times daily and twice at night. If warmth is not felt in the abdomen, increase to three or four pills. However, decoctions are superior to pills. Method for decoction: Cut the four ingredients according to the weights listed. Boil in eight sheng of water until three sheng remain. Strain. Take one sheng warm, three times daily.
Modifications:
If there is throbbing above the navel, indicating Kidney Qi moving, remove Bai Zhu and add Gui Zhi (Cinnamon Twig) four liang.
"Throbbing above the navel" refers to pulsation above the navel, where Kidney Qi rises to the Spleen. Since the Spleen is receiving Qi, the sweetness of Bai Zhu may obstruct Spleen Qi, so it is removed. The pungency of Gui Zhi can descend Kidney Qi, so it is added.
If vomiting is excessive, remove Bai Zhu and add Sheng Jiang (Fresh Ginger) three liang.
Excessive vomiting indicates Qi stagnating upward. Sweetness obstructs Qi, so remove Bai Zhu; pungency disperses Qi, so add Sheng Jiang.
If diarrhea is excessive, continue using Bai Zhu. If palpitations occur, add Fu Ling (Poria) two liang.
Excessive diarrhea indicates Spleen Qi failing to hold; thus, Bai Zhu is needed to secure it. Palpitations indicate Water of the Kidney rebelling upward; thus, Fu Ling is added to guide it downward.
If there is thirst and desire to drink water, increase Bai Zhu to four and a half liang total.
Thirst and desire to drink water indicate insufficient Body Fluids. The sweetness of Bai Zhu is sufficient to generate fluids.
If there is abdominal pain, increase Ren Shen to four and a half liang total.
Abdominal pain indicates interior deficiency. The sweetness of Ren Shen is sufficient to tonify it.
If there is cold sensation, increase Gan Jiang to four and a half liang total.
Cold sensation indicates cold Qi in the abdomen. The pungency of Gan Jiang is sufficient to warm it.
If there is abdominal fullness, remove Bai Zhu and add one Fu Zi (Aconite Lateral Root). After taking the decoction, wait about the time it takes to eat a meal, then drink about one sheng of hot porridge to maintain slight warmth. Do not uncover clothes or blankets.
Abdominal fullness indicates stagnant Qi. Qi becomes obstructed by sweetness and moves with pungency; therefore, remove Bai Zhu and add Fu Zi.
If vomiting and diarrhea cease but body pain persists, carefully assess the situation and harmonize the exterior. Guizhi Tang (Cinnamon Twig Decoction) in a small dose should be used to harmonize.
When vomiting and diarrhea cease, the interior is harmonized. Persistent body pain indicates the exterior is unresolved. Therefore, Guizhi Tang is needed to harmonize the exterior. This is referred to as "exterior pathology with interior harmony," where sweating resolves the condition. The terms "carefully assess" and "small harmonization" are used because after vomiting and diarrhea, the interior Qi is injured. One must carefully assess whether sweating is appropriate before inducing sweat. Sweating should not be heavy; gentle harmonization is sufficient.
If vomiting and diarrhea are accompanied by sweating, fever, aversion to cold, spasm and stiffness of the limbs, and cold extremities, Sini Decoction (Four Counterflow Decoction) should be used.
This is a syndrome of Yang-deficient Huoluan. Fever and aversion to cold: although the body feels hot, there is aversion to cold. The body heat is a false appearance caused by Yang repulsion; aversion to cold is the true nature of deficiency-cold. Spasm/stiffness of limbs and cold extremities indicate deficient Yang Qi, unable to soften the sinews and warm the four extremities. Therefore, Sini Decoction should be used to assist Yang Qi and drive away Yin Qi.
If there is simultaneous vomiting and diarrhea, frequent urination, profuse sweating, diarrhea with undigested food (Qinggu), interior cold with exterior heat, and a faint pulse nearly imperceptible, Sini Decoction (Four Counterflow Decoction) should be used.
This is also a syndrome of deficiency-cold Huoluan. Spasm/stiffness of limbs and cold extremities represent deficiency-cold manifesting externally. Diarrhea with undigested food and faint pulse nearly imperceptible represent deficiency-cold manifesting internally. Although it is Huoluan, the presentation of vomiting/diarrhea/sweating, interior cold/exterior heat is identical to the previous clause. The use of Sini Decoction to drive out prevailing Yin and restore scattered Yang is also the same.
If vomiting and diarrhea have ceased, but there is sweating and cold extremities, spasm/stiffness of the limbs, and a faint pulse nearly imperceptible, Tongmai Sini Decoction plus Pig Bile (Tongmai Sini Jia Zhuzhi Dan Tang) should be used.
With vomiting and diarrhea stopped, Yang Qi should recover and Yin pathogens should dissipate. However, now there is sweating and cold extremities, limb stiffness, and a faint pulse nearly imperceptible. This indicates Yin has no time to dissipate, and Yang shows signs of scattering and loss. This is relatively critical in treatment. Therefore, double the amount of Gan Jiang in Sini Decoction to rescue the nearly extinct Yang. Furthermore, fearing that excessive heat might be rejected by Yin, bitter-cold Pig Bile is added as a guide. This aligns with the principle in the Neijing: "Follow the excess."
Formula for Sini Decoction plus Pig Bile (Tongmai Sini Jia Zhuzhi Dan Tang):
Add half he of Pig Bile to the formula for Sini Decoction. Prepare and administer according to the previous method. If Pig Gallbladder is unavailable, Sheep Gallbladder may be substituted.
After vomiting and diarrhea, if sweating occurs, the pulse becomes normal, and there is mild irritability, it is because the newly deficient Stomach Qi cannot withstand the grain Qi.
After vomiting and diarrhea, following sweating, if the pulse is normal, it indicates pathogens have resolved. With pathogens resolved, irritability should not occur. Mild irritability arises not from pathogens, but because after vomiting and diarrhea, the Stomach Qi is newly deficient and cannot digest grain. Excess grain Qi with deficient Stomach Qi causes mild irritability. At this point, one should harmonize and nourish Stomach Qi, and must not attack pathogens further.