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"Si Nuè" (Malaria-like syndrome) refers to the regular and accurate timing of chills and fever. Generally, both "Si Nuè" and "Chao Re" (Tidal Fever) adhere to their respective timing patterns. However, only fever without chills is termed "Chao Re"; chills followed by fever is termed "Si Nuè". Therefore, it is called "Si Nuè" and belongs to Exterior Syndromes (Biao Zheng). If it occurs during the day (Yin-Mao hours), the pathogen is in the Yang aspect and Qi level, indicating a lighter condition; if it occurs at night (Wei-Shen hours, etc.), the pathogen is in the Yin aspect and Blood level, indicating a heavier condition.

If the onset occurs during the Yin and Mao hours, it is a Shaoyang Disease (Shaoyang Bing), primarily treated with Chaihu Tang (Bupleurum Decoction). If chills are predominant, add Qiang Huo (Notopterygii Rhizoma et Radix) and Fang Feng (Saposhnikoviae Radix); if fever is predominant, add Huang Qin (Scutellariae Radix) and Shan Zhi (Gardeniae Fructus). If the onset occurs during the Chen, Si, and Wu hours, or once daily, it is a Taiyang Disease (Taiyang Bing), primarily treated with Jiajian Qiang Huo Tang (Modified Notopterygium Decoction). If chills are severe, double the dosage of Qiang Huo and Fang Feng; if fever is severe, add Huang Qin and Shan Zhi. If the onset occurs during the Wei and Shen hours, or every other day, it is a Yangming Disease (Yangming Bing), primarily treated with Shengma Gange Tang (Cimicifugae and Puerariae Decoction). If irritability and heat appear first during the Yin-Mao hours, and fever intensifies during the Wei-Shen hours, this is Yangming disease combined with Shaoyang disease; increase the dosage of Chai Hu (Bupleuri Radix) and Huang Qin. If chills are predominant during onset, add Qiang Huo and Fang Feng; if fever is predominant, add Zhi Mu (Anemarrhenae Rhizoma) and Shi Gao (Gypsum Fibrosum). This method distinguishes the primary treatment for each meridian based on the time of onset.

Furthermore, if it occurs once daily with chills, headache, and a floating and rapid pulse, it is a Taiyang Meridian disease; use the aforementioned Qiang Huo Tang. If it occurs every other day with more fever than chills, a long and large pulse, irritability, and thirst with water drinking, it is a Yangming Meridian disease; use the aforementioned Gange Tang with modifications. If there are alternating chills and fever, bitter taste in the mouth, and a string-tight and rapid pulse, it is a Shaoyang Meridian disease; use the aforementioned Xiao Chai Hu Tang (Minor Bupleurum Decoction) with modifications. This is another method of distinguishing primary treatments for each meridian based on symptoms and pulses.

Chills and fever occurring before noon belong to Exterior Syndromes and are suitable for exterior-releasing methods. Chills and fever occurring after noon indicate the pathogen is in the Half-Exterior Half-Interior stage; half is dispersed from the exterior, and half is cleared from the interior. If there is only fever without chills, occurring after noon, this is Dan Yang Syndrome (Heat Exhaustion Syndrome), requiring urgent clearing of interior heat. Generally, for "Si Nuè" syndromes where the发作 (onset) does not deviate from its cycle, it is not deficiency-heat; regardless of the number of days, it should be treated as an excess pathogenic factor. If there is exterior pathogen causing chills, failing to release the exterior pathogen allows it to lodge internally and transform into other syndromes. If there is interior pathogen, mistreatment ensures the interior pathogen will not resolve. If hands and feet are cold during onset, even to the point of numbness, this is because accumulated heat arises from within but is constrained externally by wind-cold, preventing the interior heat from venting; thus, hands and feet become cold. It is appropriate to first release the exterior pathogen and then clear the accumulated heat. The accumulated heat was contracted first and lay dormant internally before manifesting; the wind-cold was contracted later and constrained the exterior, causing the disease to manifest. The subsequently contracted wind-cold is external and proximate, hence chills occur first; the previously contracted accumulated heat is internal and distant, hence fever occurs later. Accumulated heat is the root disease, while exterior cold is the branch manifestation; treating the proximate (branch) first means that for such diseases, one must first release the exterior and then clear the interior.

If upon onset there is chest fullness, vomiting, fever, epigastric discomfort, pain, or nausea, this indicates phlegm-fluid retention lodged internally causing vomiting; Erchen Daotan Tang (Two-Aged Phlegm-Resolving Decoction) is appropriate. If occurring in the hot season with fire signs, add Shan Zhi and Chuan Lian (Coptidis Rhizoma), mixed with Zhu Li (Bamboo Sap) and taken warm. If there is chest fullness, vomiting, and inability to eat, this is food stagnation in the Stomach; Pingwei Baohe San (Peaceful Stomach and Harmony Powder), Qingpi Binglang San (Green Peel and Areca Seed Powder), or Caoguo Yin (Tsaoko Decoction) with Bai Doukou (Amomi Fructus Rotundus) and Chuan Lian are appropriate. If there is interior accumulated heat, avoid acrid-drying herbs; Luobo Zhi (Radish Juice) can be mixed in. Since "Si Nuè" syndromes invariably involve phlegm and food, it is said that patients with malaria often have yellow fluid accumulation in the Zhongwan area, with phlegm-fluid and food stagnation in the intestines and stomach. At the time of onset, these rise upward; it is appropriate to first induce vomiting, then use Daotan Tang, Caoguo Yin, and Baohe San to eliminate phlegm and stagnation, heavily using Bing Lang (Arecae Semen) and Zha Rou (Crataegi Fructus) to prevent complications like Mamo (splenomegaly).

Generally, for "Si Nuè" caused by phlegm, food, and stagnation, if occurring in the hot season, although acrid-warm-drying flavors are contraindicated, cold and raw foods that suppress yang are also contraindicated, as this syndrome easily becomes severe. Malaria typically occurs every other day; after onset, the patient feels refreshed and can walk and eat. If it occurs once daily, and although the body cools after onset, the patient cannot rise or eat, this is the chills-and-fever disease of the Taiyang Meridian (chills first, then fever), not true malaria. Initially presenting with chills then fever, resembling malaria, if wind-cold and diet are not avoided, once fever starts, it does not subside. In this syndrome, if fever is accompanied by profuse sweating and the exterior pathogen is not resolved, the chronic illness will not heal. One must wait until sweating decreases to see the sign of heat reduction and recovery. If there has been no sweat from the beginning, or very little, and exterior signs like chills persist, one must wait until profuse sweating occurs, which is the sign of the exterior pathogen dispersing. Thus, it is said: no sweat and chills indicate an Exterior Syndrome; to induce sweat, releasing the exterior is paramount. Sweat and tidal fever indicate an Interior Syndrome; to stop sweat, clearing the interior is urgent. If initially there is chest fullness, chills, fever, and loss of appetite, this indicates stagnation in the Stomach. One must wait until the chest feels comfortable and eating resumes to anticipate recovery. If the Stomach is strong and the patient eats well but fever persists, this indicates Heat in the Yangming; reducing food intake prevents grain qi from assisting the pathogenic heat, so the heat naturally subsides. Hence it is said: slight irritability at dusk resolves with reduced food intake.

In Taiyang Disease, after eight or nine days, presenting like malaria with fever and chills, more heat than cold, no vomiting, and normal bowel/bladder function, if it occurs two or three times a day and the pulse is slightly slow and moderate, it indicates impending recovery. If the pulse is slightly weak with chills, this indicates deficiency of both Yin and Yang; do not use diaphoresis, purgation, or emesis. If the face appears flushed with heat color, the pathogen has not resolved; due to the inability to produce slight sweating, the body will likely itch; Guizhi Mahuang Ge Ban Tang (Half-Dose Combination of Cinnamon Twig and Ephedra Decoction) is appropriate.

In Taiyang Disease, after eight or nine days, occurring once daily with chills first then fever, resembling malaria, if the patient does not vomit and bowel/bladder functions are normal, there is no interior pathogen, and it should resolve spontaneously. If it occurs two or three times a day, the pathogen is dispersing, becoming lighter and irregular; if the pulse is slightly slow and moderate, it indicates spontaneous recovery. If chills and exterior signs persist with a weak pulse, know that Yin and Yang are deficient; do not use diaphoresis, purgation, or emesis. If facial heat and redness appear, the exterior pathogen has not resolved, slight sweating has not occurred, and the body will itch; diaphoresis is still required. In winter in the North, use Mahuang Ge Ban Tang; in summer in the South, use Qiang Huo and Fang Feng Tang.

After taking Guizhi Tang (Cinnamon Twig Decoction), if profuse sweating occurs and the pulse becomes flooding and large, continue giving Guizhi Tang as previously directed. If the condition resembles malaria, occurring twice a day, resolution will follow sweating; Guizhi Er Mahuang Yi Tang (Two Parts Cinnamon Twig, One Part Ephedra Decoction) is appropriate.

After taking Guizhi Tang, if profuse sweating occurs but the disease does not resolve, and the pulse reverses to flooding and large, give Guizhi Tang again. If the condition resembles malaria, occurring twice a day, this is a sign that the exterior pathogen is resolving. Because Guizhi Tang treats wind pathogen but cannot disperse cold pathogen, adding half the dose of Mahuang (Ephedrae Herba) disperses the cold pathogen, ensuring resolution through sweating. Thus, it is evident that Taiyang "Si Nuè" is primarily treated by releasing the exterior, unlike Yangming "Si Nuè" which has both purgative and diaphoretic approaches.

If the patient experiences irritability and heat, resolving with sweat, yet resembles malaria with fever in the late afternoon (Wu hour), it belongs to Yangming. If the pulse is solid, purgation is appropriate; if the pulse is deficient and floating, diaphoresis is appropriate. For purgation, use Da Chengqi Tang (Major Order the Qi Decoction). For diaphoresis, use Guizhi Tang.

Taiyang malaria-like syndromes are all exterior pathogens. Late afternoon fever indicates a Yangming malaria-like syndrome. Thus, if the pulse is deep and solid, use Da Chengqi Tang for purgation. If the pulse is not solid but floating, it remains a Taiyang malaria-like syndrome, treated with Guizhi Tang for diaphoresis.

The Shaoyang Chapter states: In women with Wind-Stroke, after seven or eight days, continuous chills and fever occurring at specific times, coinciding with the abrupt cessation of menstruation, this is Heat Entering the Blood Chamber (Re Ru Xue Shi). The blood must be congealed, causing symptoms resembling malaria with regular onset; Xiao Chai Hu Tang is the primary treatment.

This section specifically discusses the "Si Nuè" syndrome of Heat Entering the Blood Chamber in gynecology. Xiao Chai Hu Tang treats both Shaoyang and Jueyin; add herbs that enter the Blood level.

Xiao Chai Hu Tang - See sections on Chills/Fever and Dizziness.

Note: For "Si Nuè" occurring during Yin-Mao hours with a string-tight and rapid pulse, this formula is primary. If chills and body ache exist, add Qiang Huo; if no sweat, add Fang Feng; if chest fullness, add Zhi Ke (Aurantii Fructus), Hou Po (Magnoliae Officinalis Cortex), Cao Guo (Tsaoko Fructus), and Bai Doukou; if thirsty, add Zhi Mu, Shi Gao, and Gan Ge (Puerariae Radix); if vomiting/nausea, add Zhu Ru (Bambusae Caulis in Taenia) and double Ban Xia (Pinelliae Rhizoma).

Jiajian Qiang Huo Tang - See Chills.

"Si Nuè" occurring before noon with chills, body ache, yawning, and stiffness indicates a Taiyang syndrome; thus, this formula is used to release the exterior.

Shengma Gange Tang
Sheng Ma (Cimicifugae Rhizoma), Gan Ge (Puerariae Radix), Bai Shao Yao (Paeoniae Radix Alba), Gan Cao (Glycyrrhizae Radix et Rhizoma).
This treats Yangming Meridian malaria with sweat and chills. If no sweat, remove Bai Shao Yao, add Fang Feng; for chills/body ache, add Qiang Huo; for vomiting/nausea, add Ban Xia and Hou Po; for thirst/water drinking, add Gan Ge and Shi Gao; for chest fullness, add Cao Guo and Bai Doukou.

Bai Hu Jia Guizhi Tang (White Tiger Plus Cinnamon Twig Decoction)
For "Si Nuè", if there is exterior cold pathogen, Bai Hu Tang is contraindicated; if there is interior accumulated heat, Guizhi is contraindicated. Here, the cooling nature of Shi Gao combined with Guizhi can still release the exterior. The acrid-warm nature of Guizhi combined with Shi Gao transforms into cooling. Guizhi treats the initial chills; Shi Gao treats the subsequent fever.

Erchen Daotan Tang
Ban Xia, Nan Xing (Arisaematis Cum Bile), Zhi Shi (Aurantii Fructus Immaturus), Chi Fu Ling (Poria cum Risu Rubrum), Ju Hong (Citri Reticulatae Pericarpium), Gan Cao, Shi Chang Pu (Acori Tatarinowii Rhizoma).
Chest fullness with chills and fever resembling malaria is caused by phlegm inducing malaria; thus, this formula is established. For exterior wind-cold, add Qiang Huo, Chai Hu, Gan Ge. For interior accumulated heat, add Shan Zhi, Huang Lian (Coptidis Rhizoma), Bai Doukou, and Hou Po.

Pingwei San - See Delirium.
Damp-heat in the intestines and stomach frequently causes "Si Nuè". If chest fullness occurs at onset, treat as food stagnation. If complicated by cold pathogen, add Qiang Huo, Chai Hu, Ge Gen (Puerariae Radix), Fang Feng; if complicated by interior accumulated heat, add Shan Zhi, Huang Lian, Zhi Ke. For severe food stagnation, add 1 liang of Zha Rou (Crataegi Fructus) and 3 qian of Qing Pi (Aurantii Fructus Viridis); for vomiting, add Zhu Ru, Ban Xia, Bai Doukou.

Caoguo Yin
Cao Guo Ren (Tsaoko Fructus), Qing Pi, Bai Zhi (Angelicae Dahuricae Radix), Gan Cao, Zi Su (Perillae Folium), Bai Doukou, Shan Zha (Crataegi Fructus), Lai Fu Zi (Radish Seed).
When contracting external pathogens, only chills and fever occur, not forming malaria. If there is pre-existing food stagnation and phlegm-fluid in the intestines/stomach, followed by external wind-cold, "Si Nuè" develops; thus, this family secret formula eliminates phlegm-stagnation. If chills and body ache occur at onset, the recently contracted exterior pathogen is urgent; add Qiang Huo, Chai Hu, Sheng Ma. If thirst and dry lips occur, the previously contracted accumulated heat is heavy; add Zhi and Lian (Shan Zhi and Huang Lian).

Loss of appetite with unresolved "Si Nuè": eliminating food prevents heat pathogen assistance, and heat removes itself. Ability to eat with unresolved "Si Nuè": restricting food prevents evil heat assistance, and heat reduces itself. "Si Nuè" syndromes are all due to internal phlegm-fluid and accumulated heat.

Family Secret Jié Nuè Yin (Malaria-Cutting Decoction)
Qiang Huo, Chai Hu, Sheng Ma, Ban Xia, Hou Po, Bing Lang, Qing Pi, Zhi Ke, Mu Tong (Akebiae Caulis), Zha Rou.