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Sha syndrome presents with alternating chills and fever, resembling malaria. Some cases exhibit coma and heaviness, or delirium; some suffer from incessant phlegm-wheezing, chest and heart vexation and stuffiness, and unremitting shouting; some experience vomiting, hiccups, expectoration of phlegm, and restless sleep; some have constipation of both stool and urine, and a black tongue with prickles. When the condition is this severe, the pulse must be abnormal and different from that of malaria, requiring careful differentiation.

Clinical Case 1:
Shen Riyang, in July, experienced alternating chills and fever at dusk, accompanied by coma, distension, and stuffiness, along with constipation and a scorched tongue with thick coating. He sought my treatment for malaria. His left pulse was floating, large, and deficient, while his right pulse was deep, fine, and choppy. I reasoned that such ominous pulses (deficient and choppy) are inappropriate for malaria. Upon inspection, bluish veins were visible under his breasts. I punctured them to release two needles' worth of purple-black toxic blood and instructed him to perform Sha scraping (Gua Sha), but he did not recover. I prescribed a formula to dissipate Sha, detoxify, and invigorate blood, adding three qian of Da Huang (Rhei Radix et Rhizoma). Taken slightly cold, it promoted bowel movement and alleviated most symptoms, except for the persistent chills and fever. I then treated him with Xiaochaihu Tang (Minor Bupleurum Decoction), followed by Sijunzi Tang (Four Gentlemen Decoction) for regulation, leading to recovery.

Patients bedridden with malaria often contract Sha due to invasion by summerheat and dampness causing mental confusion and stuffiness, or due to epidemic qi interacting with Sha. Malaria transforming into Sha is inevitable. One must not casually dismiss it as mere malaria. While malaria can persist for a long time, Sha causes direct harm to the person. Even mild Sha, if untreated, lingers and cannot heal quickly; even if it miraculously heals, relapse makes full recovery difficult. Unless Sha is treated first, complete recovery is unlikely. The dangers of concurrent Sha are manifold.

Clinical Case 2:
The wife of Qian Gongchen suffered from malaria with persistent fever, phlegm-cough, vexation, thirst, and anorexia. My diagnosis revealed a deficient Qi Kou pulse, and the three positions on the left hand were faint, choppy, and rapid, indicating concurrent Sha. I ordered Sha bleeding (Fang Sha). A formula to dissipate Sha, regulate Qi, invigorate blood, and detoxify was administered without success. On the second day, Sha bleeding was performed again; the pulse became wiry and rapid. Taking the previous formula relieved her vexation. Subsequently, Chaihu Shuangjie Yin (Bupleurum Dual-Resolution Drink) for three doses cured the malaria. Finally, phlegm-resolving and Qi-regulating herbs combined with Tongbian (Child's Urine) for five doses cured the phlegm and cough.

Clinical Case 3:
Yu San's fifth son, in May, suffered from violent malaria. His left pulse was deep and faint, and his right pulse was hidden. Examination revealed bluish veins in the popliteal fossa and arms. Puncture released purple-black toxic blood, providing slight relief in the chest. Baohua San (Precious Flower Powder) and Chenxiang Wan (Agarwood Pill) were taken slightly cold, followed by Dahuang Wan (Rhubarb Pill), allowing him to sit up. The next day, food stagnation triggered another episode of concurrent Sha, worsening the violence. Further Sha bleeding reduced the severity. Five doses of herbs to dissipate Sha, digest food, regulate Qi, and detoxify brought slight stability. Later, food stagnation caused fever again. Shan Zha (Crataegi Fructus), Bo Zi (Brassicae Semens), Qing Pi (Aurantii Fructus Pericarpium Viride), Chen Pi (Citri Reticulatae Pericarpium), Zi Pu (Magnoliae Officinalis Cortex), and Bai Jie Zi (Sinapis Semen) were given for four doses. Constipation ensued, so Zhi Shi (Aurantii Fructus Immaturus) and Da Huang (Rhei Radix et Rhizoma) were added, resolving constipation and reducing fever. Due to prolonged illness and extreme deficiency, he experienced dizziness and palpitations, with restless sleep. Zaoren (Ziziphi Spinosae Semen), Fushen (Poria cum Radix Pini), Renshen (Ginseng Radix), Huangqi (Astragali Radix), and Shudi (Rehmanniae Radix Praeparata) were decocted with one or two slices of Shu Fuzi (Aconiti Lateralis Radix Praeparata). This stabilized his sleep. After four months of tonic regulation, he recovered.

Clinical Case 4:
The wife of Shen Hengsheng contracted malaria in June. After eight days of evening chills and fever, she suddenly developed high fever, coma, and unresponsiveness. My examination showed an uneven wiry-rapid left pulse and a deficient, deep-choppy right pulse. I stated, "An uneven left pulse and deficient-choppy right pulse are not typical of malaria. This must be a variant of malaria, specifically Sha." I punctured a bluish vein on the left arm, releasing flower-like purple-black toxic blood, but there was no improvement. She was given Jingjie Tang (Schizonepeta Decoction) with Huoxiang (Pogostemonis Herba), Bo Zi (Brassicae Semens), Zi Pu (Magnoliae Officinalis Cortex), and Binglang (Arecae Semen), plus Huduan Dan (Detoxification Pill), served slightly chilled. She regained slight consciousness. The next day, three needles punctured the fingertips to release purple-black blood. Jingjie Tang with Zhi Shi (Aurantii Fructus Immaturus) and Da Huang (Rhei Radix et Rhizoma) was served slightly chilled. After the fever subsided, Sanxiang San (Three Fragrances Powder) was used to move Qi. After one month of regulation, she recovered.