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The Master said: The pulse of malaria naturally presents as a string-like (Xian) pulse. A string-like and rapid pulse indicates mostly heat; a string-like and slow pulse indicates mostly cold. If the pulse is string-like, small, and tight, purgation may be used for recovery; if it is string-like and slow, warming methods may be applied; if it is string-like and tight, diaphoresis or acupuncture may be used; if it is string-like, floating, and large, emesis may be employed; if it is string-like and rapid, it constitutes wind-heat onset, which can be controlled through dietary regulation.

[Commentary] The character "small" in "string-like, small, and tight" should likely be "deep", which would justify the use of purgation. "String-like and tight" should likely be "string-like, floating, and tight", justifying diaphoresis. "String-like, floating, and large" should likely be "string-like, slippery, and large", justifying emesis. This interpretation does not violate the original meaning that "the malaria pulse is naturally string-like."

[Annotation] Malaria is characterized by alternating chills and fever. It can occur in all three Yin and three Yang meridians. Because the pathogen lies latent between the exterior and interior, it belongs to Shaoyang (Lesser Yang), and the pulse is naturally string-like. A string-like and rapid pulse indicates mostly heat, referring to Yang excess during attacks; a string-like and slow pulse indicates mostly cold, referring to Yin excess. In Taiyang-Shaoyang disease (Cold Damage affecting the Shaoyang channel), there are prohibitions against diaphoresis, emesis, and purgation. Since malaria also pertains to Shaoyang, why are these three methods applicable? This is because malaria is classified as a miscellaneous disease, a fact one must understand. In early-stage malaria, if the pulse is string-like with deep-tightness, the pathology is internal, and purgation is indicated; if accompanied by a slow pulse, the pathology is cold, and warming is indicated; if accompanied by a floating-tight pulse, the pathology is external, and diaphoresis is indicated; if accompanied by a slippery-large pulse, the pathology involves fluid retention, and emesis is indicated; if accompanied by a rapid pulse, it is wind-heat onset, meaning wind-heat, and clearing methods are indicated. If the condition persists for a long time, these methods should not be used. Instead, one should regulate diet and nurture the body to stop the attacks, as acute illness prioritizes expelling pathogens, while chronic illness prioritizes nourishing healthy Qi. Other types include Dan-malaria (malaria with only heat and no chills), which corresponds to the Dan-malaria described in the *Neijing* (Classic of Internal Medicine); Wen-malaria (warm malaria, caused first by wind then by cold, with more heat than chills), corresponding to the Wen-malaria in the *Neijing*; Pin-malaria (cold malaria, caused first by cold then by wind, with more chills than heat), corresponding to the cold malaria in the *Neijing*. Only the syndrome of Malaria Mass (Nuomu) is not detailed in the classics. However, no text discusses various malarias more comprehensively than the *Neijing*. Although the wording differs slightly, it is likely due to lost bamboo slips. Nevertheless, no therapeutic methods surpass those of Zhang Zhongjing.

[Collected Annotations] Xu Bin stated: The word "naturally" implies that after contracting wind-cold, the pulse merely exhibits a string-like quality. Thus, given this fixed pulse image, acceleration indicates heat, and slowness indicates cold; this is the general principle.

You Yi stated: The seat of malaria is indeed between the exterior and interior, but human organs vary in their predominance or deficiency. Therefore, some cases have more heat, some more cold, some more internal involvement requiring purgation, and some more external involvement requiring diaphoresis or emesis. Treatment should follow the pulse accordingly.

Zhou Yangjun stated: Malaria syndromes in humans result from external pathogens entering and lodging between the exterior and interior. When the pathogen enters and contends with Yin, chills occur; when it exits and contends with Yang, fever occurs, hence the alternating chills and fever. Treating Shaoyang means that while concurrent symptoms of other meridians may exist, it is impossible for the condition to completely exclude Shaoyang. Zhang Zhongjing said, "The malaria pulse is naturally string-like," precisely because the rapidity, slowness, smallness, tightness, floating nature, and largeness of the pulse are indeterminate, but they must all accompany a string-like pulse, which is the Shaoyang pulse. When the pathogen invades Shaoyang and resides with Wei-Qi (Defensive Qi), and since Wei-Qi travels through Yang during the day and Yin at night, the pathogen moves outward upon encountering Yang and presses inward upon encountering Yin. The struggle between interior and exterior causes daily attacks. If the pathogen's residence is deep, pressing inward on Yin, causing Yang to flare alone while Yin remains internally stuck, and Yin and Yang contend without release, attacks occur every other day. Thus, Yin predominance leads to more cold, and Yang predominance leads to more heat. Whether Dan-malaria, Wen-malaria, or Pin-malaria, all originate from Shaoyang and reach their extremes. To correct imbalance, treatment must start from the Shaoyang boundary, allowing the pathogen to depart so that Yin and Yang harmonize, leading to recovery.

Regarding malaria occurring monthly: If it starts on the first day, it should resolve within fifteen days. If it does not resolve, it should clear by the end of the month. If it still does not resolve, what should be done? The Master said: This forms a mass (Jia), named Malaria Mass (Nuomu). It requires urgent treatment, preferably using Biejia Jian Wan (Turtle Shell Decoction Pill).

[Annotation] For malaria counted by months: if it starts on day one, it should heal in fifteen days because fifteen days mark the change of a solar term (Qi). Humans receive Qi from Heaven; when Heavenly Qi changes, human Qi also changes. When the new Qi is prosperous, the body resists malaria pathogens, thus healing. If it does not heal, it should resolve by month's end, marking another cycle of prosperous Qi. If two cycles pass without improvement, the malaria pathogen has not declined. It combines with the patient's Blood, Qi, Phlegm, and Fluids to form a mass called Malaria Mass. Urgent treatment is required, preferably using Biejia Jian Wan to attack the mass.

[Collected Annotations] Cheng Lin stated: Five days constitute one Hou (decad), three Hou make one Qi (solar term), totaling fifteen days. Humans receive Qi from Heaven; as solar terms shift, Ying-Qi (Nutritive Qi) and Wei-Qi change accordingly.

Biejia Jian Wan Formula
Bie Jia (Turtle Shell, processed by roasting, 12 fen) Wu Shan (Iris Tectorii Rhizome, roasted, 3 fen) Huang Qin (Scutellaria Root, 3 fen) Chai Hu (Bupleurum Root, 6 fen) Shu Fu (Ground Beetle, processed by frying, 3 fen)
Gan Jiang (Dried Ginger, 3 fen) Da Huang (Rhubarb Root and Rhizome, 3 fen)
Shao Yao (Peony Root, 5 fen) Gui Zhi (Cinnamon Twig, 3 fen) Ting Li (Lepidium Seed, processed by frying, 1 fen) Shi Wei (Pyrrosia Leaf, de-haired, 3 fen) Hou Po (Magnolia Bark, 3 fen) Mu Dan Pi (Moutan Cortex, heart removed, 5 fen) Qu Mai (Polygonum Aviculare Herb, 2 fen) Zi Wei (Nyctanthes Arbor-tristis Flower, 3 fen) Ban Xia (Pinellia Tuber, 1 fen) Ren Shen (Ginseng Root, 1 fen) E Chong (Ground Beetle/Earthworm variant, processed by frying, 5 fen) E Jiao (Donkey-hide Gelatin, 3 fen) Feng Ke (Honeycomb, processed by roasting, 4 fen) Chi Xiao (Red Niter, 12 fen) Qiang Lang (Dung Beetle, processed by frying, 6 fen) Tao Ren (Peach Seed, 2 fen)

Grind the above twenty-three ingredients into powder. Take one dou (unit of volume) of ash from under the stove and one hu (unit of volume) of clear wine. Soak the ash in the wine. When half the wine has evaporated, add the Bie Jia and boil until it dissolves into a glue-like consistency. Strain the juice, add the powdered herbs, and decoct into pills the size of wutong seeds. Take seven pills on an empty stomach, three times daily.

[Collected Exegesis] Xu Bin stated: The reason for using Bie Jia Jian is that Bie Jia enters the Liver, expels pathogens, and nourishes Zheng-Qi (Upright Qi). Combined with the wine soaked in stove ash, it eliminates masses, serving as the Sovereign drug. Xiao Chai Hu Tang (Minor Bupleurum Decoction), Gui Zhi Tang (Cinnamon Twig Decoction), and Da Cheng Qi Tang (Major Order the Qi Decoction) are primary medicines for the Three Yang channels, serving as Ministers. However, Gan Cao (Licorice Root) is too soft and slow, reducing efficacy; Zhi Shi (Immature Bitter Orange) is too disruptive to Qi and acts directly downward, so they are omitted. Gan Jiang (Dried Ginger) and E Jiao (Donkey-hide Gelatin) are added to assist Ren Shen (Ginseng) and Bai Zhu (Atractylodes Macrocephala Rhizome) in warming and nourishing, serving as Assistants. Masses rely on Blood stasis and Phlegm accumulation, so Si Chong (Four Insects) and Tao Ren (Peach Seed) combined with Ban Xia (Pinellia) eliminate blood stasis and transform phlegm. Accumulations arise from Qi stagnation; when Qi flows freely, accumulations dissipate. Thus, Wu Shan (Iris) and Ting Li (Lepidium Seed) benefit Lung Qi, combined with Shi Wei (Pyrrosia Leaf) and Qu Mai (Polygonum Aviculare) to clear pathogenic heat, transform Qi, and dissipate blood clots. Since pathogen aggregation generates heat, Mu Dan Pi (Moutan Cortex) and Zi Wei (Nyctanthes Flower) remove latent fire in the blood and solid heat in the diaphragm, serving as Guides. The *Qianjin Fang* removes Shu Fu and Chi Xiao, adding Hai Zao (Sargassum) and Da Ji (Euphorbia Lathyris) to soften hardness and transform water, which is even more effective.

The Master said: When Yin Qi is isolated and exhausted, and Yang Qi flares alone, symptoms include fever, shortness of breath, oppression and irritability, hot hands and feet, and nausea. This is named Dan-malaria. If there is only heat without chills, the pathogen hides internally in the Heart and externally lodges in the interstices of muscles and flesh, causing muscle wasting.

[Commentary] This refers to Dan-malaria. The text has missing sections; the *Neijing* details it sufficiently, so no further explanation is provided.

Wen-malaria presents with a pulse similar to normal, absence of chills, presence of only heat, painful and vexed joints, and occasional vomiting. It is treated with Baihu Jia Guizhi Tang (White Tiger plus Cinnamon Twig Decoction).

[Commentary] This refers to Wen-malaria. The text has missing sections; the *Neijing* details it sufficiently, so no further explanation is provided.

Baihu Jia Guizhi Tang Formula
Zhi Mu (Anemarrhena Rhizome, 6 liang) Gan Cao (Licorice Root, processed by roasting, 2 liang) Shi Gao (Gypsum Fibrosum, 1 jin) Jing Mi (Glutinous Rice, 2 he) Gui Zhi (Cinnamon Twig, 3 liang)

Cut the herbs. For each dose of five qian, add one and a half lamps of water. Decoct until eight parts remain. Remove dregs and take warm. Recovery occurs with sweating.

When malaria presents with predominant chills, it is named Pin-malaria. It is treated with Shuqi San (Shuqi Powder).

[Commentary] This refers to Pin-malaria. The text has missing sections; the *Neijing* details it sufficiently, so no further explanation is provided.

Shuqi San Formula
Shu Qi (Prepared Perilla Leaf, washed to remove fishy odor) Yun Mu (Muscovite/Mica, roasted for two days and nights) Long Gu (Fossilized Bones, equal parts)

Grind the above three ingredients into a powder. Before the attack begins, take half a qian bi (measure) with Jiang Shui (fermented grain water). For Wen-malaria, add half a qian bi of Shu Qi. Take one qian bi at the time of onset.

[Collected Exegesis] Li Gao stated: Pin-malaria syndromes are predominantly Yin-cold, so treatment should focus on assisting Yang and dispersing cold with warmth. Yun Mu (Muscovite) originates from Yang Qishi (Actinolite), lies below Muscovite, and is often covered by clouds; its nature is warm and ascending, making it a substance that raises Yang Qi. Long Gu (Fossilized Bones) is Yang in nature, capable of driving out Yin pathogens and raising Yang Qi. Shu Qi is the sprout of Chang Shan (Dichroa Root). Its function treats malaria. Using the sprout rather than the root takes advantage of its ascending nature, which can penetrate and raise Yang Qi upwards. Adding Shu Qi to Wen-malaria also utilizes its ascending and dispersing properties.