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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.