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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.

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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.

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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.

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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.

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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.

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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.

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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.