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Malaria is caused by wind and summerheat pathogens. It may occur once daily, once every two days, or once every three days; some cases involve consecutive attacks on alternate days, some occur both day and night, some present with sweating, others without; some attack in the first half of the day, some in the second half, and some at night. Treatment principles: Since the pathogen enters from the exterior, dispersing methods should be used, but supporting Stomach Qi (Stomach Energy) must be the foundation. Medication must also be differentiated according to Yang divisions and Yin divisions. For excess-type malaria and newly onset cases, dispersing or intercepting methods are applicable; for deficiency-type malaria and chronic cases, tonifying Qi and Blood is appropriate. Overuse of intercepting medicines may damage the Spleen and Stomach, leading to a lingering and intractable course.

Main Formula: Chai Hu (Bupleuri Radix), Bai Zhu (Atractylodis Rhizoma) (each 1.5 qian), Cang Zhu (Atractylodis Rhizoma) (soaked in rice water, 1 qian; these three herbs are essential for treating malaria), Gan Ge (Puerariae Radix) (1.2 qian), Chen Pi (Citri Reticulatae Pericarpium) (0.7 qian), Gan Cao (Glycyrrhizae Radix et Rhizoma) (roasted, 0.5 qian).

My Commentary: The aforementioned symptoms arise primarily from initial injury by summerheat, followed by contraction of wind. The pathogen lodges between Ying (Nutritive) and Wei (Defensive) levels. When Cou Li (pores/skin texture) are not dense, exposure to wind-cold causes closure, trapping the pathogen outside the intestines and stomach. It travels alongside Ying and Wei, moving through Yang during the day and Yin at night. When the pathogen merges with Ying/Wei, disease manifests; when it separates, symptoms cease. Merging with Yang generates heat; merging with Yin generates cold. Shallow involvement leads to daily attacks; deep involvement leads to alternate-day attacks. Involvement of Qi results in earlier onset; involvement of Blood results in later onset. According to the *Ben Jing* (Divine Farmer's Materia Medica): The pulse in malaria is naturally wiry (Xian). A wiry and rapid pulse indicates much heat; a wiry and slow pulse indicates much cold; a wiry and short pulse suggests food retention; a wiry and slippery pulse indicates much phlegm. A wiry and tight pulse warrants purgation; a floating and large pulse warrants emesis; a wiry and slow pulse warrants warming. These are the general principles for treating malaria. If heat predominates over cold, with irritability and poor sleep, the pathology belongs to the Heart, named Wen Malaria (Warm Malaria), treated with Chai Qin Tang (Scutellaria and Bupleurum Decoction). If cold predominates over heat, with lower back pain and cold feet, the pathology belongs to the Kidney, named Han Malaria (Cold Malaria), treated with Gui Fu Er Chen Tang (Cinnamon Twig, Aconite, and Two-Chen Decoction). If chills precede high fever accompanied by cough, the pathology belongs to the Lung, named Dan Malaria (Fever Malaria), treated with Shen Su Yin (Ginseng and Perilla Drink). If heat lasts longer than cold, with tendon contraction, the pathology belongs to the Liver, named Feng Malaria (Wind Malaria), treated with Xiao Chai Hu Tang (Minor Bupleurum Decoction) plus Wu Yao (Linderae Radix) and Xiang Fu (Cyperi Rhizoma). If chills and heat are equal, with vomiting of phlegm-saliva, the pathology belongs to the Spleen, named Shi Malaria (Food Malaria), treated with Qing Pi Yin (Clearing Spleen Drink). After malaria subsides, if both Yin and Yang are deficient, manifesting as nocturnal emission and cough, failure to maintain health properly may lead to Lao Zhai (Consumption Disease). If one can clear the Heart, nourish the body, regulate diet, and avoid wind, such regulation ensures recovery.

If attacks occur once daily or before noon, the pathogen is in the Yang division. Add Ku Huang Qin (Scutellariae Radix), Fu Ling (Poria), and Ban Xia (Pinelliae Rhizoma) (each 1 qian). If heat is severe with headache, add Chuan Xiong (Ligustici Chuanxiong Rhizoma) and Ruan Shi Gao (Gypsum Fibrosum) (each 1 qian). If dry mouth occurs, add Shi Gao (Gypsum Fibrosum), Zhi Mu (Anemarrhenae Rhizoma), and Mai Men Dong (Ophiopogonis Radix) (each 1 qian).

My Commentary: Mr. Liu Zongnong stated: Attacks from Mao hour to Wu hour indicate pathogen in the Large Intestine and Small Intestine, suitable for Da Chai Hu Tang (Major Bupleurum Decoction) for purgation. Attacks from Wu hour to You hour indicate pathogen in the Heart and Kidney, suitable for Da Cheng Qi Tang (Major Order the Qi Decoction) for purgation. These represent interior pathogen invasion. Attacks from You hour to Zi hour indicate pathogen in the Heart and Gallbladder; attacks extending to Yin hour indicate pathogen in Qi and Blood, suitable for Tao Ren Cheng Qi Tang (Peach Kernel Order the Qi Decoction) for mild purgation, followed by Xiao Chai Hu Tang to eliminate residual pathogen. If body heat, eye pain, heat predominating over cold, and a wiry, long, and solid pulse are present, use Da Chai Hu Tang first for purgation; if residual heat remains, use Bai Zhi Tang (Angelica Dahurica Decoction). If severe cold with slight heat, or only cold without heat, named Pin Malaria (Yin Malaria), use Chai Hu Gui Zhi Tang (Bupleurum and Cinnamon Twig Decoction) to release the exterior.

If attacks occur on alternate days or every three days, or in the afternoon or at night, the pathogen has entered the Yin division. Add Chuan Xiong, Dang Gui (Angelicae Sinensis Radix), Shao Yao (Paeoniae Radix Alba) (wine-fried), Shu Di Huang (Rehmanniae Radix Preparata), and Zhi Mu (each 1 qian); Hong Hua (Carthami Flos) (wine-washed), Huang Bo (Phellodendri Cortex) (wine-fried), and Sheng Ma (Cimicifugae Rhizoma) (each 0.4 qian) to raise Yang Qi, allowing interception of the malaria.

My Commentary: Zhang Zhongjing stated: Malaria with no other symptoms, presenting as alternate-day attacks with chills preceding heat, where chills predominate over heat, is treated with Gui Zhi Shi Gao Tang (Cinnamon Twig and Gypsum Decoction); nighttime attacks are treated with Ma Huang Huang Qin Tang (Ephedra and Scutellaria Decoction). I believe that if the above symptoms result from Middle Jiao Qi deficiency with alternate-day attacks, use Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction). If Qi and Blood are both deficient with attacks every three days, use Shi Quan Da Bu Tang (Ten Great Tonics Decoction). Generally, pathogen in the Yang division is shallow and easy to treat; pathogen in the Yin division is deep and difficult to treat.

If attacks occur on alternate days with consecutive two-day attacks, or daily and nightly attacks, both Qi and Blood are affected. Add Ren Shen (Ginseng Radix et Rhizoma), Huang Qi (Astragali Radix), and Bai Fu Ling (Poria) (each 1 qian) to tonify Qi; Chuan Xiong, Dang Gui, Shao Yao, and Shu Di Huang (each 1 qian) to tonify Blood.

My Commentary: This treatment principle should be cross-referenced with previous discussions for medication adjustment.

For Yang malaria with excessive sweating, use Huang Qi, Ren Shen, and Bai Zhu to consolidate. For absence of sweating, use Chai Hu, Cang Zhu, Bai Zhu, Huang Qin, and Gan Ge to disperse.

My Commentary: Zhang Zhongjing said: Malaria occurring before the End of Heat solar term, with head and neck pain, floating pulse, aversion to wind, and sweating, is treated with Gui Zhi Qiang Huo Tang (Cinnamon Twig and Notopterygium Decoction). If aversion to wind exists without sweating, use Ma Huang Qiang Huo Tang (Ephedra and Notopterygium Decoction). If prolonged sweating leads to open Cou Li and inability of Yang to secure, supplementation and consolidation are required. If there is no sweating, Cou Li are dense, preventing pathogen resolution, requiring dispersal. If caused by dietary injury, Six Gentlemen Decoction (Liu Jun Zi Tang) is primary. If caused by labor injuring Yuan Qi, Bu Zhong Yi Qi Tang is primary.

For Yin malaria with excessive sweating, use Dang Gui, Bai Shao Yao (White Peony Root), Shu Di, Huang Lian (Coptidis Rhizoma), Huang Bo, and Huang Qi to consolidate. For absence of sweating, use Chai Hu, Cang Zhu, Chuan Xiong, Hong Hua, and Sheng Ma to disperse. Thus, for those with sweating, the goal is to stop sweating, prioritizing support of Zheng Qi (Upright Qi); for those without sweating, the goal is to induce sweating, prioritizing dispersion of Xie Qi (Pathogenic Qi).

My Commentary: If chills and heat are severe regardless of sequence, this is a combined syndrome of Tai Yang (Greater Yang) and Yang Ming (Yang Brightness). Severe chills and heat cause shivering. The Classics state: Excess heat causes movement; fever leads to sweating. Also: Sweating without cure indicates internal heat. In syndromes of Yang excess and Yin deficiency, there is internal excess and external deficiency. Without treatment, it may transmit to Yin meridians over time; Gui Zhi Shao Yao Tang (Cinnamon Twig and Peony Decoction) is indicated. For chronic illness, major tonification of Spleen and Stomach is primary, as nourishing Zheng Qi eliminates Xie Qi.

If the patient has weak Stomach Qi, poor appetite, or reduced intake due to damaging the Spleen and Stomach with intercepting medicines, add Ren Shen (1.5 qian), Shao Yao (wine-fried, 1 qian), and Da Mai Ya (Hordei Fructus Germinatus, 1 qian).

My Commentary: Using cold and cooling medicines to stop malaria damages the Spleen and Stomach, leading to a lingering course. Recovery is impossible without cultivating Yuan Qi. However, Shao Yao and Mai Ya may damage Spleen and Kidney, so they should not be overused.

The mother of Ma Zhiqing from Dongting suffered from emaciation after malaria, with fever, aversion to cold, spontaneous and night sweats, chest and diaphragm fullness, drinking only about a cup of rice water daily. Taking Ren Shen and Bai Zhu increased bloating, leaving her bedridden for half a year. I diagnosed Yang Qi deficiency and cold, prescribing a large dose of Bu Zhong Yi Qi Tang plus 1 qian of Fu Zi (Aconiti Lateralis Radix Preparata). After two doses, symptoms gradually receded and appetite improved; after two more doses, she fully recovered.

For food stagnation causing fullness or existing food accumulation, add Shen Qu (Massa Medicata Fermentata), Mai Ya, and Zhi Shi (Immature Bitter Orange) (roasted, each 1 qian), and Huang Lian (roasted, 0.5 qian).

My Commentary: If Spleen and Stomach are intact but symptoms arise from overeating combined with sudden anger causing chest fullness, this formula aids digestion of retained stagnation. If food has digested but fullness persists, Liu Jun Zi Tang regulates and tonifies Spleen and Stomach. If labor injures Yuan Qi with retained food, Bu Zhong Yi Qi Tang plus Ban Xia and Fu Ling raises and tonifies Spleen and Stomach. If anger combines with food stagnation, Er Chen Tang plus Ren Shen, Bai Zhu, Mu Xiang (Aucklandiae Radix), Xiang Fu, and Shan Zhi (Gardeniae Fructus) tonifies Spleen and soothes Liver.

Zhu Shengan, an official in the Ministry of Works, contracted malaria from retained food and cold. Self-medicating with Qing Pi and jie nue (intercept malaria) drugs led to postprandial abdominal distension and pain. Taking Er Chen Tang, Huang Lian, and Zhi Shi resulted in heavy sensation in the lower abdomen and edema of legs and feet. Adding Bai Zhu and Shan Zha (Crataegi Fructus) failed to stop vomiting of undigested food. I stated: Postprandial distension and pain indicate Spleen deficiency failing to transform; heavy lower abdomen indicates Yang Qi failing to ascend; leg edema indicates Stomach Qi failing to circulate; vomiting undigested food indicates Spleen-Stomach deficiency cold. Treatment with Bu Zhong Yi Qi Tang plus Wu Zhu Yu (Evodiae Fructus), Sheng Jiang (Zingiberis Rhizoma Freshum), Rou Gui (Cinnamomi Cortex), and Mu Xiang cured him in few doses.

A woman developed malaria after eating, with vomiting, indicating internal retained food and external wind-cold. She recovered using Huo Xiang Zheng Qi San (Patchouli Powder to Rectify the Qi). Later, due to anger, she vomited copious phlegm, spoke deliriously, had intense heat, chest/diaphragm distending pain relieved by pressure, and a surging pulse that was minute upon deep palpation. I diagnosed Liver and Spleen meridian blood deficiency with fire hyperactivity, prescribing Jia Wei Xiao Yao San (Modified Free Wanderer Powder) plus Shu Di and Chuan Xiong. Symptoms retreated after two doses; stability was achieved with Shi Quan Da Bu Tang.

For excessive phlegm, add Ban Xia (prepared with ginger juice), Nan Xing (Arisaematis Rhizoma), and Zhi Shi (each 1 qian); Huang Qin (roasted) and Huang Lian (each 0.6 fen).

My Commentary: The previous formulas are unsuitable for phlegm generated by rich food and accumulated heat/excess fire. For phlegm due to Middle Qi deficiency, use Bu Zhong Yi Qi Tang plus Fu Ling and Ban Xia. If ineffective, fresh Ginger Juice alone is beneficial.

To intercept malaria, add Bing Lang (Arecae Semen), Huang Qin, Qing Pi (Citri Reticulatae Pericarpium Viride), and Chang Shan (Dichroae Radix) (each 1 qian), plus three Wumei Rou (Mume Fructus flesh).

My Commentary: For Qi and Blood deficiency, taking 1 liang each of Ren Shen and Sheng Jiang decocted stops attacks immediately, effective for both new and chronic cases. If sour taste in throat/mouth occurs, and diet is regulated, even with intense thirst during paroxysms, hot Ginger Water is effective for interception. Consuming raw/cold foods often reduces symptoms temporarily but damages Spleen/Stomach, making treatment difficult. If the pathogen is vigorous, do not hastily intercept within the first one or two attacks, lest the pathogen remain while Zheng Qi is injured. This method is beneficial and harmless.

A scholar experienced diarrhea from food retention, or malaria, dysentery, or cholera every summer/autumn. Labor induced phlegm expectoration, dizziness, fatigue, fever, and aversion to cold. He indiscriminately used Si Wu Tang (Four Substances Decoction), Er Chen Tang, Huang Qin, and Huang Lian. Taking anti-intercept medicines for malaria worsened prior symptoms, sometimes causing whole-body prickling sensations. I diagnosed Middle Qi deficiency with heat, prescribing Bu Zhong Yi Qi Tang plus Fu Ling and Ban Xia, with Ren Shen and Huang Qi at 3 qian each, Dang Gui and Bai Zhu at 2 qian each. After forty-plus doses, he fully recovered.

For chronic deficiency malaria with mild chills/heat, or slight heat without chills, where pathogen is absent, use Si Jun Zi Tang (Four Gentlemen Decoction) combined with Si Wu Tang plus Chai Hu, Huang Qin, and Chen Pi to tonify Qi and Blood.

My Commentary: For Stomach Qi deficiency, use Si Jun Zi Tang plus Sheng Ma and Dang Gui. For Spleen Blood deficiency, use Si Jun Zi Tang plus Chuan Xiong and Dang Gui. For sinking of Middle Qi, use Bu Zhong Yi Qi Tang plus Fu Ling and Ban Xia. Chronic malaria generally involves Yuan Qi deficiency and cold. Qi deficiency causes cold; Blood deficiency causes heat; Stomach deficiency causes aversion to cold; Spleen deficiency causes fever. Downward flow of Yin Fire causes alternating chills and heat; spitting saliva, anorexia, shivering, diarrhea, and cold extremities all stem from Spleen-Stomach weakness. Tonifying the Middle with Qi resolves all symptoms.

A woman with chronic malaria had fever, dry mouth, and extreme fatigue. This was Spleen-Stomach deficiency heat. She drank large doses of Qi Wei Bai Zhu San (Seven-Ingredient White Atractylodes Powder) plus Mai Men Dong and Wu Wei Zi (Schisandrae Fructus). Upon recurrence, symptoms were milder; she then took Bu Zhong Yi Qi Tang plus Fu Ling and Ban Xia, recovering after ten-plus doses.

Another woman with chronic malaria chills/heat took Qing Pi Yin, resulting in chest/diaphragm fullness and reduced appetite. She recovered using Bu Zhong Yi Qi Tang plus Fu Ling, Ban Xia, and Pao Jiang (Prepared Ginger) (each 1 qian).