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All present pain. The tongue coating is white, thin, and slippery. If caused by summerheat-dampness, the body aches and limbs are flaccid, with more heat, vexation, and thirst; the tongue coating is intermixed yellow and white. If complicated by phlegm and food retention, there is coughing with sputum, belching with a putrid odor, acid regurgitation, and the tongue coating is white, greasy, and thick, or yellow, thick, and greasy. For infants in swaddling clothes, cold causes shivering, while heat causes weak breathing and coma, resembling convulsions and epilepsy. One must differentiate syndromes according to the season, and must not mistakenly diagnose it as convulsions or epilepsy, nor recklessly apply the picking method (a folk therapy).

[Pulse] A wiry-tight or wiry-slow pulse indicates malaria transformed from wind-cold. A wiry-hong (surging) or wiry-stagnant pulse indicates malaria transformed from summerheat-dampness. A wiry-slippery and forceful pulse indicates phlegm coagulation. A wiry-solid and forceful pulse indicates food accumulation.

[Treatment] For young adults suffering from malaria for the first time, treat based on the etiology; methods have been detailed above. For children, whose constitutions are more fragile and prone to both deficiency and excess, herb selection and formula preparation require particular flexibility. First, distinguish the degree of cold and heat: In cases where cold predominates over heat, first administer Congchi Hemijian (Scallion and Fermented Soybean Decoction with Lotus Leaf and Rice), adding Shengjiang (Zingiberis Rhizoma Recens, 1 fen) and Xi Yacha (Fine Bud Tea, 2 fen), to induce slight sweating and harmonize the condition. Subsequently, use Pingwei San (Calm the Stomach Powder: Zhi Cangzhu 2 fen, Chuan Pu 3 fen, Guang Pi 4 fen, Zhi Gancao 2 fen), added with Caoguo Ren (Tsaoko Fructus, 2 fen) and Chao Changshan (Processed Radix Dichroae, 2 fen), to arrest the malaria. Finally, use Bingtang Wumei Tang (Rock Sugar and Dark Plum Decoction: Bingtang 1 qian, Wumei Rou 1 fen, water one tea cup, decocted strongly to half a cup); the sweet and sour nature nourishes the stomach to conclude treatment. In cases where heat predominates over cold, first use Baihu Tang (White Tiger Decoction: Zhimu 1 qian, Sheng Shigao 1.5 qian, Sheng Gancao 3 fen, Sheng Jingmi 30 grains, wrapped in He Ye), added with Caoguo Ren (2 fen) and Chao Changshan (3 fen), using acrid-cool properties to resolve phlegm and arrest the malaria. Subsequently, use Wuzhi Yizhi Jian (Five Juices and One Branch Decoction), removing Zisu Pangzhi (Perilla Stem) and Shengjiang Zhi (Ginger Juice), adding Bingtang (1 qian), and serving warm after double-boiling; the light, clear, sweet, and moistening nature tonifies the condition. When cold and heat are balanced, use Banbei Jiangcha Yin (Pinellia and Fritillaria Ginger Tea Drink: Jiang Banxia, Chuan Bei, Shengjiang, Xi Yacha each 3 fen, two tea cups of Yin-Yang Water, decocted to one cup); warming and clearing are used together to harmonize. Next, distinguish between new and chronic: For new malaria, arrest first then tonify; for chronic malaria, tonify first then arrest; this is the general principle. However, one must distinguish between Yang and Yin aspects: For daytime onset with Qi deficiency in the Yang aspect, presenting with cold extremities and profuse sweating, use Lujian Yin (Dew-Exposed Ginger Drink: Biezhi Renshen 3 fen, Shengjiang 2 fen, two tea cups of Yin-Yang Water, decocted to one cup, exposed overnight before taking); warming and tonifying Yang Qi to arrest the malaria. For pathology in the Yin aspect with Blood deficiency, presenting with night fever and mental restlessness, use Shouwu Biejia Tang (Polygoni Multiflori and Turtle Shell Decoction: Sheng Shouwu, Zhi Biejia each 1 qian, Wumei Rou 2 fen, Bingtang 8 fen, snow water and boiling water two cups, decocted to one cup, strain and take warm); clearing and nourishing Yin Blood to arrest the malaria.

[Rongzhai's Note] The disease name "Tai Malaria" (Fetal Malaria) did not exist in ancient texts; this concept originated from Wan's Pediatrics. Wan Mizhai of the Ming Dynasty stated: "For young children and adults suffering from malaria for the first time, all are termed Tai Malaria and should be treated based on etiology. Those caused by wind-cold are treated as wind-cold; those by summerheat-dampness as summerheat-dampness; those by phlegm-food as phlegm-food. The main idea is to first distinguish the degree of cold and heat; for cold > heat, first use Xiangsu Congchi Tang to release the exterior, then Pingwei San with Caoguo and Changshan to remove the malaria. For heat > cold, first use Chaihu Baihu Tang to resolve heat, then Baihu Tang with Changshan and Caoguo to calm the malaria." This is Wan's method for treating Tai Malaria. Yu Ge applied and mastered this, making it a powerful weapon.

9. Epidemic Malaria

[Etiology] There are approximately four types. One is caused by the toxic vapor of mountain miasma (Lanzhang). Two is caused by toxin accumulated in Yin waters. Three is caused by corpse transmission and sudden fright (Shizhu and Kewu). Four is caused by pathogenic factors due to abnormal climate. All can transform into malaria.

[Symptoms] At the onset of miasma toxin, the body feels heavy and confused, the mouth is mute, and speech is impaired, followed by delirious speech and狂言 (mad talk), or mild cold with severe heat, or severe cold with mild heat, chest oppression and abdominal fullness, with the tongue coating gray and greasy covering the whole surface, or white, thick, and greasy. At the onset of water toxin, cold is heavy and heat is light, with fullness and pain in the chest and diaphragm, producing gurgling sounds upon palpation, dry retching, shortness of breath, or vomiting clear fluid; severely, abdominal pain and diarrhea, cold extremities and swollen feet, heavy waist and scanty urination occur, with a white, moist tongue coating, or yellow at the tip and edges with a white segment in the middle. At the onset of sudden fright, chills and fever occur daily, occasionally with delirium, frequent nightmares at night, occasional restlessness, palpitations, timidity, and excessive fear; the tongue coating is pale white, occasionally mixed with pale gray. At the onset of seasonal toxins, wind-toxin presents with headache and aversion to wind; initially chills and fever occur daily, later heat predominates over cold, with sore throat and swollen throat, or swollen cheeks, or red rashes, or red macules. The tongue coating is white and thin, with red and dry edges and tip. Filth-toxin presents with heavy head and abdominal pain, chest and epigastric oppression, nausea and desire to vomit, abdominal pain and confusion, alternating chills and heat indistinctly; the tongue coating is intermixed yellow and white, or mixed with gray and greasy.

[Pulse] A hidden pulse at Right Cun and wiry-slipper pulses at both Guan indicate sudden contraction of Lanzhang toxin due to hot weather and moldy mountain air. Bilateral wiry and slow, or even wiry-slow pulses indicate internal injury from Yin-coagulating toxin due to water qi stagnation trapping Yang qi. Pulses that fluctuate between large and small, rapid and sparse indicate inherent Yin constitution and unsteady Gallbladder qi, suddenly struck by Kewu, commonly known as Ghost Malaria occurring at night. Floating-wiry-rapid pulses in both hands indicate simultaneous contraction of Wind-Toxin by Hand-Taiyin and Foot-Shaoyang meridians. Wiry-thin-slow pulses in both hands indicate simultaneous contraction of Filth-Toxin by Hand-Taiyin and Foot-Taiyin meridians.

[Treatment] For Miasma Toxin, first use Miaoxiang Wan from Ju Fang (Regulated Formulas) to open orifices and guide out phlegm to awaken the spirit. Subsequently use Huoxiang Zhengqi Tang (Agastache Decoction to Rectify the Qi) adjusted with Zhongchun Zijian (Purple Gold Tablets: Wen Ge 4 qian, Mao Cigu 2.5 qian, Chen Sha and Yao Huang each 2 qian, Hongya Daji and Qianjin Shuang each 1.8 qian, Suhexiang 1 qian, Bingpian 5 fen, Dangmenzi 3 fen, all ground fine, mixed evenly, formed into small tablets with rice paste, dried, stored in porcelain bottles; dose 3-5 fen, up to 1 qian for severe cases) to avoid miasma and resolve toxin to eliminate malaria. Finally use Chaiping Tang combined with Chumie Shengjin Wan to transform dampness and drain heat to eradicate the root. For Water Toxin, first use Lingzhu Erchen Jian to transform qi and promote urination to resolve Yin toxin. Subsequently use Chaiping Tang with Chao Changshan (2 qian) and Caoguo Ren (8 fen) to warm the middle and wash away saliva to arrest malaria. Finally use Xiangsha Erchen Tang to use aromatic and bland warmth to harmonize Stomach qi. For Sudden Fright, first use Suhexiang Wan (Suhexiang, Anshixiang, Guang Muxiang each 2 liang, Xijiao, Shexiang, Meibing, Xiangfu, Ruxiang, Chenxiang, Dingxiang, Dongzhu each 1 liang, ground fine, honey pills, 200 pills total, coated with 1 liang Chen Sha, sealed with wax, revised by Wang Jin-san) to use acrid-aromatic properties to develop and expel evil. Subsequently use Wendan Tang modified (Dan Zhuru 3 qian, Jiang Banxia 2 qian, Chao Guangpi 1.5 qian, Chen Fushen, Qinglongchi, Zuomuli each 4 qian, Chuan Guizhi, Qingzhigancao each 5 fen, Zijian 3 fen, melted and poured in) to use acrid-unblocking and calming-affecting properties to strengthen the Gallbladder. If seasonal toxin is due to fierce wind, use Jingfang Baidu San modified (Jingjie, Fangfeng, Bohe, Lianqiao, Niubang each 3 qian, Chaihu, Qianhu each 1.5 qian, Qianghuo, Duhuo each 1 qian, Juhong, Zhike, Jiegeng each 2 qian, Zijian, Sheng Gancao each 1 qian, ground coarse, dose 7 qian, steep in boiling water for clear soup, gargle and swallow, twice day, twice night) to disperse wind-toxin and release the exterior. If rash has not fully emerged, urgently use Tousha Jiedu Tang (Lianqiao, Bohe, Chao Niubang each 2 qian, Chan Yi 1 qian, Danshichu 2 qian, Xian Congbai 2 pieces cut, Daqingye, Xian Sangye, Naotou each 4 qian, first decoct Yegugen 2 liang and Xian Xi Heliu 3 qian in water as substitute) to penetrate channels and collaterals to lift the rash. Once rash is fully emerged and fluids/Qi are injured, use Renshen Baihu Tang with Xian Shengdi (1 liang), Xian Shihu (4 qian), Xian Maogen (8 qian) to greatly generate fluids and conclude treatment. Due to foul odors, first use Huoxiang Zhengqi Tang plus Zijian to use aromatic properties to avoid filth and resolve toxin. After toxin resolves and filth is removed, use Xiangsha Erchen Tang with Chao Guma Ya to mildly warm and harmonize Stomach qi.

[Xiu's Note] Master Yu differentiates etiology and syndrome, treats symptoms accordingly; he speaks without reservation. His approach to treating malaria seems comprehensive. Regarding arresting malaria, Caoguo and Changshan are most effective; Banbei Wan (Sheng Banxia, Sheng Chuanbei each 3 qian, ground fine, mixed with Ginger Juice into pills, dose 3-5 li, taken with raw/cooked water soup) is also verified. For old malaria of the Three Yin, Chumie Gen Wan is miraculous. After arresting, medication must still be taken for regulation to prevent recurrence and worsening.

[Rongzhai's Note] Regarding epidemic malaria, the original works by Yu and He lost focus; since no epidemic malaria occurred in Shaoxing during that era, and the two masters would not fabricate clinical cases, their theoretical discussion is somewhat fragmented. I now excerpt the Task Report of the Traditional Chinese Medicine Association Touring Diagnosis Team in Rugao County, Jiangsu Province, 1934, to enrich the treatment examples. Because a pandemic epidemic malaria occurred in Rugao County and its vicinity in the autumn of that year. According to the report: "According to Baojia investigation, infected people in various districts reached 50,000-60,000; in one Jia (neighborhood unit), at least half of households suffered from this epidemic malaria; about 30 deaths per Bao, totaling over 5,000." The reporter was Mr. Huang Xinglou, who participated in the touring diagnosis. He stated: Cause of Epidemic: Summer climate was too cool, continuous rain during Major Heat, Fahrenheit thermometer never exceeded 90 degrees; even in midsummer, layers were worn morning and evening; after Start of Autumn, weather suddenly warmed, thermometer often reached 100 degrees, dropping to around 80 degrees at night; irregular cold and warmth allowed pathogenic roots to lie latent; coupled with recent month-long drought and abnormally dry/arid climate, latent pathogens erupted opportunistically, hence the severity of this syndrome. Symptoms of Epidemic Disease: Initially aversion to cold and shivering, then high fever without sweat, or slight sweat after fever, alternating severity every other day, unclear resolution of heat, headache and brain distension, soreness and numbness of limbs and joints, chest/diaphragm oppression, reduced appetite, sallow and dull complexion, white greasy tongue coating, occasional vomiting/diarrhea; if prolonged and untreated, macules/rashes appear, white papules erupt, or coma/fever/head sweat, or delirium/madness, or black tongue/hard stool, or bloody stool/vomiting roundworms, severely red face/cold feet, night fever/confusion, asthma/belching, irritability, and convulsions. Verification of Disease Name: Ancient experts discussing epidemics, such as Yu Jiayan, Zhang Shiwang, Wu Youke, and Lei Shaoyi, are most detailed. Selected excerpts follow: Yu stated that abnormal Qi of four seasons causes disease, initially not called epidemic; only when death occurs does disease Qi and corpse Qi mix with abnormal Qi, becoming epidemic! Also, Warm/Summer/Heat/Damp Qi intertwine and steam; humans within cannot avoid it. Zhang stated epidemic pathogens arise from Damp-Heat stagnation, entering via mouth/nose to Membrane Source, reaching Yangming Meridian; Yangming is interior to Taiyang, exterior to Shaoyang, the middle path of Three Yang; pathogen attacking Membrane Source requires harmonizing and purging filth. Wu stated after 2-3 or 7-8 attacks of malaria, sudden day/night fever, vexation/thirst without aversion to cold, prickly tongue coating, heart/abdominal oppression, inability to eat, is Epidemic Malaria. Lei stated Epidemic Malaria arises from abnormal seasonal cold/heat, pathogen invading Membrane Source via deficiency, wanting to exit exterior but unable to penetrate, wanting to sink interior but lacking space, causing alternating chills/heat, 2-3 times daily or once, irregular; mild cold/heavy heat, thirst with sweat, Right pulse stronger than Left, affecting entire neighborhood, young and old similar, is Epidemic Malaria. Verifying these theories against current symptoms confirms the name Epidemic Malaria. Prescription Summary: Early stage epidemic pathogen, use Huoxiang Zhengqi San; with Damp-Heat, use Ganlu Xiaodu Dan; with coma/confusion, use Qingfen Biyi Tang; with heavy damp/depression, use Kaiyu Tongluo Yin; with Damp-Warmth, use Sanren Tang; initial cold then heat, use Xiao Chaihu Tang; cold/heat with constipation, use Da Chaihu Tang; heat > cold, use Baihu Jia Guizhi Tang; plague/miasma malaria, use Jiedu Wanbing Dan; with phlegm, use Changshan Yin; with food, use Qingpi Yin. These formulas are merely examples. Others with Warm-Thermal elements still require Warm-Thermal category treatments.

[Liankan's Commentary] Ancients stated malaria is inseparable from Shaoyang. Thus, treating malaria follows Zhongjing's methods, mostly modifying Xiao Chaihu Tang. Adhering to rigid methods for dynamic diseases is a flaw even learned scholars like Zhang Jingyue, Xu Lingtai, and Wei Yuheng committed. Did they not know Master Ye Tianshi clarified early on? He stated malaria is mostly caused by Summerheat complicated by Phlegm-Food. Initial stage must have chest/diaphragm tightness, vomiting, anorexia; is this not food stagnation transforming into phlegm? Even chronic malaria forming Malaria Mother is mostly due to stubborn phlegm and blood stasis interacting. Large-scale malaria syndromes must be differentiated by Twelve Meridians, equal to cough syndromes. Children suffering from malaria mostly have Spleen/Stomach pathology. Pediatricians often use Xiao Chaihu Tang removing Renshen, or adding Xiangru, Gegen. This violates Zhang Fengkui's *Zhi Shu Quan Shu*: "Chaihu depletes Liver Yin; Gegen exhausts Stomach fluids," leading to frequent complications. Later learned scholars like Zhang Qianli also stated Jiang-Zhe people's diseases often carry Dampness; lightly using Chai/Gegen lifting agents guarantees adverse reactions (Mingxuan), yet efficacy remains distant. Ye's prohibition on use is truly experiential advice; Xu's criticism is rigid dogma. This explains Liu Hejian's passionate argument that ancient methods cannot be blindly followed. Medical scholars as profound as Wang Mengying also stated malaria is essentially a contracted syndrome, merely lighter than Shanghan. In recent times, Southern regions have few true Shanghan, mostly Warm-Thermal/Summerheat-Dampness diseases. True malaria is rare; seasonal malaria is common. Since Warm-Thermal/Summerheat-Dampness cannot be treated with Mahuang/Guizhi Shanghan methods, how can seasonal malaria be treated with Xiao Chaihu True Malaria methods? One must differentiate whether it is Wind-Warmth, Damp-Warmth, Summerheat-Heat, or Latent Pathogen, and still use Seasonal Contraction methods to clear the source. Based on these three views, the弊端 (drawbacks) of using Chaihu for malaria are indeed evidenced. Therefore, my treatment of malaria mostly follows Ye's methods. Between Summer and Autumn, first distinguish Summerheat and Dampness. Summerheat malaria is mostly dry; treatment focuses on Lung, using Guizhi Baihu Tang as main formula. Damp malaria is mostly cold; treatment focuses on Spleen, using Huoxiang Zhengqi San modified. Equal Summerheat and Dampness; treatment focuses on Spleen/Stomach, using Guiling Ganlu Yin modified. If accompanied by much phlegm, add Banxia, Chuanbei. If food stagnation, add Zhishi, Qingpi. Repeated administration yields verification. Occasionally ineffective cases use Chumie Shengjin Wan to arrest, or Cinchona Bark Pills to forcefully stop; often achieving sensitive effects. For chronic malaria, clearly differentiate Qi/Blood/Yin/Yang. For Yang deficiency/Qi collapse, Si Shou Yin is main. For Yin deficiency/Blood heat, Qinghao Biejia Tang plus Sangye, Shouwu, Wumei. For Malaria Mother, use Huoxue Tongluo Tang delivering Biejia Jian Wan, externally applying Bixian Gao. Trusting persistence yields results. Other malaria types and Shanghan transforming into malaria all follow Chengfa, achieving rapid success.

[Rongzhai's Note] Regarding the standard for using Chaihu in malaria, based on Mr. He Lianchen's view, agreeing with Ye Tianshi, Zhang Fengkui, Zhang Qianli, Wang Mengying, etc., believing: "True Malaria can use it, Summerheat-Dampness Malaria cannot use it." Mo Meishi in *Yanjing Yan Shuo* stated: "Shanghan pathogen enters from exterior, interior has no root; lifting with Chaihu brings it out. Summer/Autumn diseases have new cool outside and accumulated summerheat inside, interior has root; if lifted with Chaihu, although exterior pathogen resolves, interior heat rises, often resulting in deafness/red eyes, delirium/coma, leaking sweat/emaciation, progressing to untreatable conditions." He affirmed the usability and non-usability of Chaihu from practical issues, which is relatively well-founded. However, Japanese physician Katsusuke Yimoto offered another view: "Zhongjing's books use Chaihu only for Chest/Hypochondriac Fullness syndrome. Now applying it to those with Chest/Hypochondriac Fullness and alternating chills/heat, the response is immediate; not just malaria, other diseases too. Without Chest/Hypochondriac Fullness syndrome, using it is ineffective." Thus, Chaihu's ability to treat malaria lies in Chest/Hypochondriac Fullness, not alternating chills/heat. Mr. Yuanlei Lu provided detailed analysis in *Epidemic Disease Essentials*: "The syndrome for using Chaihu in ancient medical books is 'Chest/Hypochondriac Ku Man' (Bitter Fullness). This 'Man' character must be read as 'Men' (Oppression/Stuffiness), meaning subjective chest stuffiness. However, typical chest stuffiness due to Stomach disease centers at the epigastrium; this is not Chaihu's domain, suitable for Huanglian/Huangqin etc.; the 'Ku Man' oppression of Chest/Hypochondriac centers inside the lateral ribs, feeling like bloating/pain, or blockage; severely, pressing along the rib circle upward with fingertips reveals hardness and pain; such cases are the specific indication for Chaihu."

Note: Mr. Lianchen's commentary here summarizes the nine malaria types in this section, not solely referring to Epidemic Malaria.