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Zhang (miasma malaria) and Nue (ague/malaria) appear similar but are fundamentally different. Therefore, mild cases of Zhang closely resemble Nue. If physicians are unaware of the treatment principles for Zhang and indiscriminately employ Changshan (Dichroa Root), Bai Pi (White Arsenic), and Caoguo (Black Cardamom) to induce vomiting and expel phlegm, it will cause those with sufficient Yuan Qi (primordial qi) to suffer from lingering discomfort, while those with deficient Yuan Qi will immediately develop edema, often leading to death. This is deeply lamentable. The reason is that Zhang disease arises from the failure of Yang Qi to descend; inducing vomiting further causes this non-descending Yang Qi to rise excessively and weakens the Middle Qi (Spleen/Stomach qi). Cases that do not become critical are extremely rare. Thus, Bai Pi and Caoguo must absolutely not be used. However, Changshan still has its utility; its potency can remove miasma qi from the skin and pores, as well as pathogenic factors causing chills and fever, which typically reside in the Ying-Wei (Nutritive-Defensive) system and between the muscles. To eradicate the root cause, Changshan is indispensable. Yet, Changshan frequently induces vomiting; it must be processed to prevent emesis before use. It can be taken cold with Qibao Yin (Seven Treasures Decoction) or Jiemie Wan (Malaria-Cutting Pill), administered six to seven times daily with wine, which also prevents vomiting. These are proven effective remedies. One must understand that such drugs serve as a last resort ("the rear guard"). When Zhang first manifests, one must first harmonize the Zheng Qi (righteous qi), warm the Middle and anchor the Lower, and secure the patient's Yuan Qi. This corresponds to the military strategy of "avoiding the enemy's sharpness when they first arrive." During the intermittent phase of fever, when it is clear that the pattern follows a rhythm—occurring once daily for five to six hours before subsiding, or every other day—and upon confirming that the Spleen and Stomach have harmonized, damp-cold in the Lower Jiao (Triple Burner) has dissipated, and Yuan Qi is gradually recovering while pathogenic heat diminishes, then Qibao Yin or Jiemie Wan should be administered, resulting in a swift cure. This aligns with the strategy of "striking the enemy when they are weary and retreating." If this principle is not understood, using Changshan during the peak of intense heat will not only be ineffective but will further damage the Zheng Qi.

The onset of Zhang disease is generally due to summer-heat, causing loose Cou Li (skin pores and interstices) and spontaneous sweating. Physicians, observing this spontaneous sweating, treat it according to Nue protocols, using tonifying formulas containing Renshen (Ginseng), Danggui (Angelica Sinensis), Baizhu (Atractylodes Macrocephala), etc. After ingestion, patients feel increasingly restless and uncomfortable, becoming delirious and unconscious. Just as sultry weather requires rain to bring relief, the steaming heat of Zhang disease requires sweating to dissipate. Baizhu stops sweating, Huangqi (Astragalus) stops sweating, and they tighten the Cou Li, preventing sweat from exiting. Consequently, the steaming heat has no outlet to resolve, exacerbating restlessness and coma. Therefore, Baizhu and Huangqi should not be hastily employed. Some ask: Since Baizhu and Huangqi have astringent properties to stop sweating, they are unusable; yet Rougui (Cinnamon Bark) is also not a diaphoretic herb, why is it used? I reply: Although Rougui can stop sweating, Materia Medica states it warms the Middle and, being rooted in the earth, tends downward. It is used to tonify the Kidney; thus, its nature can guide Yang Qi from the Upper Jiao down to the Kidney Meridian, making it usable. Others ask: You stated that sultry weather resolves with rain, and Zhang heat resolves with sweat. Since the patient is sweating spontaneously, shouldn't the Zhang disease be resolving? Why does it persist? I answer: This spontaneous sweating only provides momentary relief from heat and oppression. For true resolution, one must warm the Middle and consolidate the Lower, harmonize the Zheng Qi, ensure Yin rises and Yang descends, and harmonize Ying and Wei so that pathogens have no place to lodge. Naturally, profuse sweating like rain will occur, covering the head to toe. After this profuse sweating, the body becomes ice-cold, with only the breath from the mouth remaining slightly warm. If these signs do not appear, the Zhang heat will not recur. At this stage, careful nursing is essential; after one hundred days, the Yuan Qi can return to normal.