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
表不解表也，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。
欲似大便而反矢气，仍不利者，此属阳明也，便必硬，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，大便必硬，虽大便硬，乃伤津液之硬，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。
【注】此申上条下利后便必硬之义也。凡下利后，肠胃空虚，津液匮乏，当大便硬，硬则能食者，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硬之阳明，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，谓微邪而毋庸大攻也。
即吐且利，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，既吐且利，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】成无己曰∶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，犹是病患生
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、脉微而复利，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、扁豆、葛根、姜汁炒黄连之
类治之。
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。
吐利发汗，脉平、小烦者，以新虚不胜谷气故也。
【注】霍乱，吐已利断，汗出已止，脉平和者，内外俱解也。法当食，食之小烦者，以吐下后新虚，不
胜谷气故也。节其饮食，自可愈矣。
【集注】郑重光曰∶吐、利、发汗、脉平，阴退阳回，乃有此象，犹以新虚不胜谷气，而致小烦。盖霍
乱吐利， 时不可便与饮食，以胃气逆反，仓廪未固，不可便置米谷耳！
张锡驹曰∶霍乱一病，夏秋最多，是风寒暑湿之邪，中人皆能病霍乱，非止一寒邪也。若吐利过甚，损
伤中焦之气，以致阴阳间隔，手足厥冷，脉微欲绝，不多饮水者，无分寒暑，皆宜四逆理中治之。盖邪盛而正
实者，当泻其邪；邪盛而正衰者，宜扶其正。况夏月之时，阳气浮于外，阴气伏于内，复以冷风寒其形，冷水
寒其胃，内外皆寒，风暑之邪，未有不乘虚入于阴经者。所以夏月只有阴证，而无伤寒，今人患暑证死，而手
足指甲皆青者，阴证也。古人以大顺散治暑，良有以也。
霍乱，是由于风寒暑热以及饮食生冷等邪气，混杂交攻于人体中焦，正气不能承受，任由邪气挥霍撩乱，从而导致三焦功能混乱，清浊之气相互干扰，在肠胃中发生紊乱。如果表证严重，就会出现头痛、身痛、发热、恶寒的症状；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，就会出现转筋（肌肉痉挛）、四肢厥冷、冷汗淋漓；如果暑邪严重，就会出现极度口渴、饮水不止。既然病情不同，治疗方法也各异，关键在于详细审察病因，分别进行治疗，这样在突然发病时，才不会导致误治。
【注】问：霍乱病的症状是什么样子的？答：突然发生呕吐、腹泻的，就称为霍乱。
【集注】成无己说：三焦是水谷运行的通道。邪气在上焦，则只呕吐而不腹泻；在下焦，则只腹泻而不呕吐；在中焦，则既呕吐又腹泻。因为饮食不节制，寒热不调和，导致清浊之气相互干扰，阴阳之气乖违阻隔，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、身疼、恶寒、呕吐腹泻的病，这属于什么病？答：这叫霍乱，如果是自己先出现呕吐腹泻，后来腹泻停止，又重新发热，这也属于霍乱的范畴。
【注】这是承接上一条，详细阐述其症状。头痛、身疼、发热、恶寒，是风、寒、暑、热邪气在体表致病；呕吐、腹泻，是饮食生冷邪气在体内致病。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、身疼、恶寒，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，发散邪气并调和营卫即可。如果不头痛、身疼，也没有恶寒、呕吐、腹泻，而是出汗、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、身疼、恶寒，是外感邪气。呕吐腹泻，是内伤饮食。前一条是用病名来推导病证，这一条是用病证来确定病名，反复详细说明的意思。
程应旄说：霍乱的病症，仅仅见到呕吐和腹泻，谁不知道责任主要在中焦！如果有发热头痛、身疼恶寒，夹杂着呕吐腹泻一起来，表里之间，仓促间难以辨别，所以从属定名，破除伤寒的名称，命名为霍乱，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，又重新发热，这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。
患伤寒，脉象微涩的，本来是霍乱，现在说是伤寒，却过了四五天传到阴经，转入阴经必然腹泻，原本就是呕吐腹泻的，不可当作伤寒治疗。
想要大便却反而放屁，仍然不排便的，这属于阳明病，大便必定干硬，十三天会痊愈，之所以这样，是因为经气运行完毕的缘故。
【注】这是承接上一条辨析发热、头痛、身疼、恶寒、呕吐腹泻等症状，是为了区分类似伤寒的情况。如果有前面的症状但脉象浮紧，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，却在四五天后邪气传入阴经时才出现。这本来是霍乱，即呕吐即腹泻，所以不可当作伤寒治疗，等待它自然停止即可。如果停止后似乎想大便，排出气体，仍然不大便，这属于阳明病。既然属于阳明病，大便必定干硬，虽然大便干硬，却是损伤津液导致的干硬，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，大便通畅自然就会痊愈。如果过了十三天大便仍不通利，这是过了经气周期仍未解除，可以使用攻下法。
【集注】魏荔彤说：这里进一步解释霍乱病，看似伤寒，应该辨明哪是伤寒的呕吐腹泻，哪是霍乱的呕吐腹泻，以确定治疗方法无误。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。都应该一一辨明，才有确切的见解，而不被迷惑。
腹泻停止后，大便应当变硬，变硬后能吃东西的就会痊愈。现在反而不能吃，等到下一个经气周期，稍微能吃一点，再过一个经气周期能吃，过了一天应当痊愈。如果不愈，说明不属于阳明病。
【注】这是申述上一条腹泻后大便必硬的道理。凡是腹泻后，肠胃空虚，津液匮乏，大便应当变硬，变硬后能吃东西的，是胃气恢复，十三天津液恢复，大便通畅自然就会痊愈。现在反而不能吃，是胃气未恢复，等到十三天后，经过经气周期的日子，如果能稍微吃点东西，也应当痊愈。如果还是不愈，是该愈却不愈。该愈却不愈的，就知道不属于十三天经气周期后大便硬的阳明病，可能属于腹泻后胃中虚寒不能食的阳明病，或者属于腹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、脾约丸，选择使用即可。
【集注】张璐说：如果腹泻停止而不能进食，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，头痛发热，身体疼痛，热多想喝水的，用五苓散主治；寒多不想喝水的，用理中丸主治。
【注】霍乱，是水饮在体内发作，所以呕吐腹泻交替出现。风寒侵袭体表，所以头痛发热，身体疼痛。热多想喝水的，是饮热互结，主用五苓散来同时解决水饮和热邪。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，就是把理中汤做成丸剂。
【集注】方有执说：霍乱，热多想喝水的，是阳邪盛；寒多不想喝水的，是阴邪盛。五苓散，水行则热泄，这也是两解的意思。理，治理；中，里，指里阴。人参、白术的甘温可以补里，甘草的甘平可以和中，干姜的辛热可以散寒。
沈明宗说：这里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。外受风邪夹杂内热，因饮食导致呕吐腹泻，必定想喝水，应当用五苓散两解表里，使邪气从汗出，里邪从小便而去。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。
呕吐腹泻停止，但身体疼痛不止的，应当斟酌轻重和解表邪，适宜用桂枝汤轻微调和。
【注】霍乱呕吐腹泻已停止，但身体疼痛不止的，这是里气调和而表气未调和，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，里气调和。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邪。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。一是和解表邪，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，是说邪气轻微而不需要大力攻伐。
立即呕吐且腹泻，小便反而通利，并且大汗出，下利完谷不化，内寒外热，脉微欲绝的，用四逆汤主治。
【注】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。现在小便反而通利，并且大汗出，下利完谷不化，脉微欲绝，这是外在阳气虚，不能固护，内在阴寒独盛于中，内真寒而外假热。所以不用理中汤，而以四逆汤主治。
【集注】成无己说：呕吐腹泻亡失津液，则小便应当少，现在小便反而通利且大汗出，津液不禁，阳气大虚。脉微是亡阳，如果没有外热，只是内寒下利完谷不化，为纯阴证。这里因为有外热认为阳未绝，还可以用四逆汤救治。
吴人驹说：既呕吐又腹泻，且大汗出，则泄路全开。而小便又复利，说“复利”，是反意，不欲其利，因为小便为收藏之地。下利完谷不化，内寒外热，且脉微欲绝，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？
呕吐腹泻出汗，发热恶寒，四肢拘急，手足冰冷的，用四逆汤主治。
【注】霍乱，呕吐腹泻出汗，发热恶寒，四肢拘急，手足冰冷，这是内外皆寒的证候，适宜用四逆汤助阳以胜阴。
【集注】方有执说：呕吐腹泻，四肢拘急，手足冰冷，是里阴盛；出汗，发热，恶寒，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、恶寒，说明阳未尽亡，四肢拘急，手足冰冷，不得不使用四逆汤来助阳退阴。又按少阴证说：恶寒身蜷而利，手足冰冷者不治。又说：下利恶寒而蜷卧，手足温者可治。这里的呕吐、腹泻、出汗，四肢拘急，手足冰冷，而用四逆汤治疗的，是因为有发热这一症状。发热说明阳未尽亡，还是病人的生机。所以经书又说：呕吐腹泻手足不冰冷，反而发热者不死。
呕吐停止腹泻断绝，出汗而四肢厥冷，四肢拘急不解，脉微欲绝的，用通脉四逆加猪胆汁汤主治。
【注】霍乱呕吐、腹泻已停止，出汗而四肢厥冷，四肢拘急，脉微欲绝，这是中寒盛极，阻格阳气不达于四肢，适宜用通脉四逆汤加猪胆汁，从阴以通阳。
【集注】成无己说：呕吐停止腹泻断绝，津液在内枯竭，则不应当出汗而厥冷。现在出汗而厥冷，四肢拘急不解，脉微欲绝，是阳气大虚，阴气独盛。如果纯用阳药，恐怕阴气格拒，或者呕吐或者烦躁，药不得入。用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：病轻的逆治，病重的从治。说的就是这个道理。
方有执说：已，停止。下，即腹泻。断，绝。说呕吐、腹泻两者都停止绝迹，而又将其余症状未解的情况，另行提出治疗方法。
【按】腹泻停止亡血，如何能用大热补药？此处“利止”当是“利不止”。亡血，当是“亡阳”。
【注】霍乱呕吐、腹泻已停止，如果恶寒、脉微而又腹泻，腹泻不止的，是阳气虚，适宜用四逆加人参，益其阳补其气。
【集注】林澜说：霍乱要在审察寒热来治疗。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；腹泻停止脉微而恶寒，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。
四逆加人参汤方
在四逆汤方内，加人参一两，其余按照四逆汤的方法。
呕吐腹泻发汗，脉象平和，轻微心烦的，是因为新近虚弱不胜受纳谷气的缘故。
【注】霍乱，呕吐已停止腹泻断绝，出汗已止，脉象平和，是内外都解除了。法度上应当进食，吃了之后轻微心烦的，是因为吐下后新近虚弱，不胜受纳谷气的缘故。节制饮食，自然可以痊愈。
【集注】郑重光说：呕吐、腹泻、发汗、脉平，阴退阳回，才有此象，仍然因为新近虚弱不胜受纳谷气，而导致轻微心烦。大概霍乱呕吐腹泻，当时不可立刻给予饮食，因为胃气逆反，仓廪未固，不可立刻放置米谷！
张锡驹说：霍乱这一病，夏秋最多，是风寒暑湿之邪，中人皆能病霍乱，不仅仅是一个寒邪。如果呕吐腹泻过甚，损伤中焦之气，以致阴阳间隔，手足冰冷，脉微欲绝，不多喝水的，不分寒暑，都适宜用四逆汤、理中汤治疗。大概邪盛而正实者，应当泻其邪；邪盛而正衰者，适宜扶其正。况且夏季之时，阳气浮于外，阴气伏于内，又以冷风寒其形体，冷水寒其胃，内外皆寒，风暑之邪，无不乘虚进入阴经的。所以夏季只有阴证，而没有伤寒，今人患暑证死，而手脚指甲都青的，是阴证。古人用大顺散治疗暑证，是有道理的。
Huo Luan (Vomiting and Diarrhea Syndrome) is caused by the mixed attack of pathogenic factors such as Wind-Cold, Summer-Heat, and Cold-Dampness from diet on the Middle Jiao. When the Righteous Qi cannot withstand them, it yields to the chaotic movement of pathogens, leading 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 ache, 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 muscle spasms (Jing Jin), cold limbs (Jue Ni), and cold sweating. If Summer-Heat is severe, symptoms include extreme thirst and incessant drinking. Since the diseases differ, treatments vary; one must carefully examine the cause and treat separately to avoid errors during sudden onset.
Question: What is Huo Luan? Answer: Vomiting accompanied by diarrhea is named Huo Luan.
[Note] Question: What are the manifestations of Huo Luan? Answer: Sudden onset of vomiting and diarrhea is named Huo Luan.
[Collected Notes] Cheng Wuji said: The San Jiao 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 with each other, and Yin and Yang become separated, resulting in Huo Luan. Mild cases are called only vomiting and diarrhea; severe cases involve chaotic turmoil, hence named Huo Luan.
Question: A patient has fever, headache, body ache, aversion to cold, vomiting, and diarrhea. What disease is this? Answer: This is named Huo Luan. If vomiting and diarrhea stop spontaneously, followed by recurrent fever, it still belongs to Huo Luan.
[Note] This follows the previous clause to detail the symptoms. Headache, body ache, fever, and aversion to cold indicate Wind, Cold, Summer-Heat, or Heat pathogens affecting the Exterior. Vomiting and diarrhea indicate Cold-Dampness or raw/cold food affecting the Interior. Having these symptoms constitutes Huo Luan. If vomiting stops and diarrhea ceases, but headache, body ache, and aversion to cold persist with recurrent fever, the Interior is resolved but the Exterior remains unresolved. Huoxiang Zhengqi Tang (Agastache Powder to Rectify the Qi) or Xiangru Yin (Elsholtzia Decoction) should be used to disperse and harmonize. If there is no headache, body ache, or aversion to cold/vomiting/diarrhea, but rather sweating, fever, and thirst for water, the Exterior is resolved but the Interior remains unresolved. 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 said: Fever, headache, body ache, and aversion to cold are external infections. Vomiting and diarrhea are internal injuries. The previous clause deduced symptoms from the disease name; this clause determines the disease name from symptoms, providing detailed clarification.
Cheng Yingmao said: For Huo Luan, seeing only vomiting and diarrhea makes anyone realize the focus is on the Middle Jiao. If fever, headache, body ache, and aversion to cold accompany vomiting and diarrhea, distinguishing between Exterior and Interior is difficult in haste. Thus, it is named Huo Luan to distinguish it from Shang Han (Cold Damage), preventing confusion between Exterior and Interior.
Shen Mingzong said: Recurrent fever after vomiting and diarrhea stop indicates Interior harmony but unresolved Exterior pathogen; treat by releasing the Exterior. If there are no Exterior signs, only abdominal pain, vomiting, and diarrhea, the Interior pathogen is unresolved; treat by harmonizing the Interior.
In Shang Han, if the pulse is faint and choppy, it was originally Huo Luan. Now if it is Shang Han, after four or five days, the pathogen enters the Yin meridians, inevitably causing diarrhea. If it was originally vomiting and diarrhea, it cannot be treated as Shang Han. Wait for it to stop naturally. If the patient feels the urge to defecate but passes gas instead, and does not defecate, this belongs to the Yangming stage. Stool will likely be hard. It will heal in thirteen days because the meridian cycle completes.
[Note] This clarifies the differentiation between Huo Luan and Shang Han-like symptoms. If the aforementioned symptoms present with a floating-tight pulse, it is Shang Han. With a faint-choppy pulse, it is Huo Luan. Huo Luan presents with immediate vomiting and diarrhea upon onset, whereas Shang Han develops these symptoms after four or five days when pathogens enter Yin meridians. Since Huo Luan involves simultaneous vomiting and diarrhea, do not treat it as Shang Han; wait for spontaneous cessation. If after cessation, the patient feels the urge to defecate, passes gas, but does not defecate, it belongs to Yangming. Yangming hardness is due to fluid damage, not excess heat requiring purgation. Wait until day thirteen for fluids to return and stool to normalize. If constipation persists beyond thirteen days, it is an unresolved condition past the meridian cycle, and purgation may be used.
[Collected Notes] Wei Litong said: This explains that Huo Luan resembles Shang Han. One must distinguish Shang Han's vomiting/diarrhea (Six Meridians patterns) from Huo Luan's vomiting/diarrhea (Exterior/Interior/Yin-Yang patterns) to ensure correct treatment.
After diarrhea stops, stool should become hard. If the patient can eat, they will heal. If they cannot eat now, but can eat slightly in the next meridian cycle, and fully eat after another cycle, healing occurs within a day. If not healed, it does not belong to Yangming.
[Note] This elaborates on post-diarrhea stool hardening. After diarrhea, intestines are empty and fluids depleted, leading to hard stool. Ability to eat indicates recovery of Stomach Qi; healing occurs around day thirteen. Inability to eat means Stomach Qi has not recovered. If eating capacity returns after the meridian cycle, healing occurs. If not, it is not the Yangming pattern of post-cycle hardening, but rather Yangming deficiency-cold or deficiency-dryness post-vomiting/diarrhea. Medication is required; waiting will not work. Use Lizhong Wan (Regulate the Middle Pill) or Jizhong Wan (Abdominal Restriction Pill) as appropriate.
[Collected Notes] Zhang Lu said: If diarrhea stops but appetite is absent, pathogenic heat has cleared but Stomach Qi is empty. After one meridian cycle, Stomach Qi recovers, and appetite returns.
For Huo Luan with headache, fever, body ache, and excessive heat with desire for water, Wuling San (Five-Ingredient Powder with Poria) is indicated. For excessive cold with no desire for water, Lizhong Wan (Regulate the Middle Pill) is indicated.
[Note] Huo Luan arises from internal fluid retention causing alternating vomiting and diarrhea. External Wind-Cold causes headache, fever, and body ache. Excessive heat with thirst indicates fluid-heat accumulation; Wuling San resolves both fluid and heat. No desire for water indicates Middle Jiao Cold; Lizhong Wan warms the Middle. Lizhong Wan is simply Lizhong Tang made into pills.
[Collected Notes] Fang Youzhi said: Desire for water indicates excess Yang pathogen; no desire for water indicates excess Yin pathogen. Wuling San promotes water metabolism to drain heat, achieving dual resolution. "Li" means manage; "Zhong" means Interior/Yin. Ginseng and Atractylodes tonify the Interior; Licorice harmonizes; Dried Ginger disperses Cold.
Shen Mingzong said: Huo Luan must be treated by differentiating Cold and Heat. Headache, fever, and body ache indicate Wind-Cold on the Exterior. Exterior Wind with Internal Heat from diet causes vomiting/diarrhea and thirst; use Wuling San to resolve Exterior and Interior, expelling pathogens via sweat and urine. No desire for water indicates Cold excess, no heat, and deficient Stomach Yang; use Lizhong Wan to warm the Middle and dispel Cold. This treats based on Exterior/Interior and Cold/Heat differentiation.
If vomiting and diarrhea stop but body pain persists, assess severity and harmonize the Exterior with Guizhi Tang (Cinnamon Twig Decoction) gently.
[Note] Post-Huo Luan, if vomiting/diarrhea cease but body pain continues, the Interior is harmonized but the Exterior is not. Assess severity and use Guizhi Tang to induce slight sweating and harmonize the Exterior.
[Collected Notes] Fang Youzhi said: Cessation of vomiting/diarrhea indicates Interior harmony. Body pain indicates residual Exterior weakness. "Xiao Xi" means to deliberate. Guizhi Tang protects Wei Qi and harmonizes the Exterior. "Xiao He" means administer small doses to avoid excess.
Cheng Yingmao said: Only when vomiting/diarrhea completely cease and only body pain remains should one follow the Guizhi Tang protocol. Due to the cooling nature of Peony, caution ("deliberation") is needed. If vomiting/diarrhea persist, using cooling herbs recklessly is forbidden.
Zhang Xiqiu said: "Xiao He" or "Wei He" in the Classic refers to mild pathogens not requiring strong attack.
If vomiting and diarrhea occur simultaneously, urination becomes frequent, profuse sweating occurs, diarrhea contains undigested food, there is internal Cold with external Heat, and the pulse is faint and nearly imperceptible, Sini Tang (Frigid Extremities Decoction) is indicated.
[Note] In Huo Luan, simultaneous vomiting/diarrhea depletes fluids, usually reducing urination and stopping sweat. Frequent urination, profuse sweating, undigested food diarrhea, and faint pulse indicate severe Exterior Yang deficiency failing to secure, and severe Interior Yin Cold dominating. This is True Cold inside with False Heat outside. Therefore, Lizhong Tang is unsuitable; Sini Tang is used.
[Collected Notes] Cheng Wuji said: Vomiting/diarrhea deplete fluids, normally reducing urination. Frequent urination and profuse sweating indicate loss of fluids and severe Yang deficiency. Faint pulse indicates Yang exhaustion. Without external heat, pure internal Cold with undigested food diarrhea is a Pure Yin syndrome. The presence of external heat suggests Yang is not entirely extinct, allowing rescue with Sini Tang.
Wu Renju said: Simultaneous vomiting/diarrhea and profuse sweating open all exit pathways. Frequent urination ("Fu Li") is undesirable as urine storage is compromised. Undigested food diarrhea, internal Cold, external Heat, and faint pulse indicate a sliver of Yang difficult to restore. Sini Tang application cannot be delayed.
With vomiting, diarrhea, sweating, fever, aversion to cold, limb stiffness, and cold hands/feet, Sini Tang is indicated.
[Note] Huo Luan with these symptoms indicates Cold throughout Interior and Exterior. Sini Tang assists Yang to overcome Yin.
[Collected Notes] Fang Youzhi said: Vomiting/diarrhea, limb stiffness, cold extremities indicate Interior Yin excess. Sweating, fever, aversion to cold indicate Exterior Yang deficiency. Sini Tang serves as a combined Interior-Exterior rescue formula.
Cheng Zhi said: Vomiting/diarrhea with sweating nearly loses Yang. Fever/aversion to cold show Yang is not extinct. Limb stiffness/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 vomiting/diarrhea/sweating/stiffness/cold extremities, Sini Tang is used because of fever. Fever indicates remaining Yang vitality. The Classic states: Vomiting/diarrhea with non-cold extremities and recurrent fever is not fatal.
If vomiting stops, diarrhea ceases, but sweating and cold limbs persist, limb stiffness remains unresolved, and the pulse is faint and nearly imperceptible, Tongmai Sini Tang plus Pig Gallbladder Bile is indicated.
[Note] Post-Huo Luan, cessation of vomiting/diarrhea with sweating, cold limbs, stiffness, and faint pulse indicates extreme Interior Cold blocking Yang from reaching extremities. Tongmai Sini Tang plus Pig Gallbladder Bile guides Yang through Yin.
[Collected Notes] Cheng Wuji said: Cessation of vomiting/diarrhea depletes fluids; sweating/cold limbs should not occur. Their presence indicates severe Yang deficiency and Yin excess. Pure Yang herbs may be rejected by Yin, causing vomiting or restlessness. Adding Pig Gallbladder Bile to Tongmai Sini Tang uses bitter taste to enter Heart and unblock vessels, and cold nature to nourish Liver and harmonize Yin, guiding Yang herbs without rejection. As the Neijing states: Treat mild conditions oppositely, severe conditions similarly (following the pathogen).
Fang Youzhi said: "Yi" means stop. "Xia" means diarrhea. "Duan" means cut off. This addresses cases where vomiting/diarrhea cease but other symptoms persist.
With aversion to cold, faint pulse, and recurrent diarrhea, if diarrhea stops, it indicates blood depletion; Sini Tang plus Ginseng is indicated.
[Commentary] How can large hot tonics be used for "blood depletion" after diarrhea stops? "Diarrhea stops" should be "diarrhea persists." "Blood depletion" should be "Yang depletion."
[Note] If after Huo Luan cessation, aversion to cold, faint pulse, and persistent diarrhea occur, it indicates Yang deficiency. Sini Tang plus Ginseng tonifies Yang and Qi.
[Collected Notes] Lin Lan said: Huo Luan requires differentiating Cold and Heat. Summer Heat Huo Luan with weak pulse and scanty red urine contraindicates Aconite and Dried Ginger. Careful differentiation is needed; Sini Tang plus Ginseng is suitable only for stopped diarrhea, faint pulse, and aversion to cold. Summer Heat Huo Luan should use Wuling San plus Elsholtzia, Lablab, Kudzu Root, and Stir-fried Coptis with Ginger Juice.
Sini Tang plus Ginseng Formula
Add one liang of Renshen (Ginseng Radix et Rhizoma) to the Sini Tang formula. Follow Sini Tang preparation methods otherwise.
After vomiting, diarrhea, and sweating, if the pulse is normal and there is slight irritability, it is due to new deficiency unable to handle food energy.
[Note] Post-Huo Luan, with ceased vomiting/diarrhea/sweating and normal pulse, Interior and Exterior are resolved. Diet should resume. Slight irritability after eating is due to new deficiency unable to process grain qi. Regulating diet leads to natural healing.
[Collected Notes] Zheng Zhongguang said: Vomiting, diarrhea, sweating, and normal pulse indicate Yin retreating and Yang returning. Slight irritability is due to new deficiency handling grain poorly. During Huo Luan, do not feed immediately as Stomach Qi is rebellious and the "granary" is unstable.
Zhang Xiqiu said: Huo Luan is most common in summer/autumn, caused by Wind, Cold, Summer-Heat, and Dampness, not just Cold. Severe vomiting/diarrhea damages Middle Jiao Qi, separating Yin/Yang, causing cold limbs and faint pulse. Regardless of season, if water intake is low, Sini Tang or Lizhong Tang is appropriate. When pathogen is strong and Righteous Qi solid, purge pathogen; when pathogen is strong and Righteous Qi weak, support Righteous Qi. In summer, Yang floats externally and Yin hides internally. Cold wind and cold water create internal/external Cold. Summer-Heat/Wind pathogens invade Yin meridians via deficiency. Thus, summer features Yin syndromes, not typical Shang Han. Death from "Summer Heat" with blue fingernails/toes is actually a Yin syndrome. Ancient use of Dashun San for Summer Heat is justified.