震按高鼓峰治新安程结先子病疟。皆从此案描出。但每日辰时大寒。午时大热。热即厥
两目直视。不能出声。颏脱。涎水从口角涌出不止。日流数升。至丑时始汗解。饮食不进
昏冒欲绝。其为虚甚。尤易识耳。惟以大剂参、 、桂、附而兼熟地。是宗景岳法。与喻
又治中尊陆六息久疟。一日轻。一日重。食减肌瘦。困倦嗳气。嘉言云。是由饥饱劳佚
所感。受伤在阳明一经。故饮食减。而大便转觉艰涩者。胃病而运化之机迟也。饥肉消瘦者
胃主肌肉也。形体困倦者。胃病而约束之机关不利也。口中时时嗳气者。胃中不和而显晦
塞之象也。一日轻一日重者。因时日干支之衰旺。与人身相关。故甲丙戊庚壬为阳。乙丁己
辛癸为阴。疟久食减。胃中之正已虚。而邪去未尽。是以值阳日助正。而邪不能胜则轻。值
阴日助邪。而正不能胜则重也。当以理中汤。助胃家中脘。俾得运用。则下脘之浊气。自能
传入肠中。而大便不艰。不复升至胸中。而膈间宽快矣。
震按此条议论通畅。而干支衰旺之说前人从未道及。可比昌黎之张皇幽渺矣。
张路玉治张怡泉。年七十五。居恒常服参、附、鹿角胶等阳药。秋间病疟。误用常山止
截药一剂。遂致人事不省。六脉止歇。按之则二至一止。举指则三五至一止。惟在寒热之际
诊之则不止歇。热退则止歇如前。此真气衰微。不能贯通于脉。所以止歇不前。在寒热之时
邪气冲激经脉。所以反得开通。此虚中伏邪之象。乃用常山一钱酒拌。同人参五钱焙干。
去常山。但用人参以助胸中大气而祛逐之。当知因常山伤犯中气而变剧。故仍用常山为向导
耳。连进二服。遂得安寝。但寒热不止。脉如前。乃日进人参一两。分二次进。并与稀糜助
其胃气。数日寒热渐减。脉微续而安。
震按此条论歇止脉最有见。其用常山法。与杨介以冰煎药。皆为巧作。然寒热不止。脉
止如前。巧且无益。惟日进人参一两。不兼他药。真大巧若拙也。
又治顾大来。年逾八旬。初秋患瘅疟。昏热谵语。喘乏遗尿。或者以为伤寒谵语。或者
以为中风遗尿。危疑莫定。路玉曰。无虑。此三阳合病。谵语遗尿。口不仁而面垢。仲景暑
证中。原有是例。遂以白虎加人参。三啜而安。
震按内经论瘅疟。纯是实热证。故推其未病。则曰中气实而不外泄。溯其受病。则曰用
力出汗。风寒舍于皮肤分肉。究其病发。则曰阳气盛而不衰。经文虽不言脉。谅脉之洪实有
力可知也。此条系瘅疟。故谵语遗尿不死。然八旬之外有此证。死者甚多。勿轻以此案作榜
中翰金淳还乃郎。八月间患疟。发于辰戌丑未。而子午卯酉每增小寒热。直至初夏。石
顽诊其六脉如丝。面青唇白。乃与六君子加桂、附。四服不应。每服加人参至一两。桂、附
各三钱。又四服而辰戌丑未之寒热顿止。子午卯酉之寒热更甚。此中土有权而邪并至阴也。
仍与前药四服。而色荣。食进寒热悉除。后与独参汤送八味丸。调理而安。
震按此案与虞花溪案同阅。始知轻重各有妙处。
飞畴治沈子嘉平。向来每至夏间。脐一着扇风则腹痛。且不时作泻。六脉但微数。无他
异。此肾脏本寒。闭藏不密。易于招风也。下寒则虚火上僭。故脉数耳。曾与六味去泽泻。
加肉桂、肉果、五味、白蒺。作丸服。因是脐不畏风。脾胃亦实。明秋患疟。医用白虎、竹
叶、石膏等。疟寒甚而不甚热。面青足冷。脉亦弦细而数。用八味地黄。三倍桂附作汤。更
以四君合保丸。早暮间进。二日疟止。调理而愈。
震按腹之部位。当脐属肾。脐着扇风即痛泻。自宜温肾。但不以六脉带数而畏投温药。
可取也。蒺藜一味。加得更好。至如治疟。不以脉之细数而不倍加桂、附。更可取也。
马元仪治工部那公太夫人。年七十外。恶寒发热如疟。迁延月余。神昏食少。舌胎兼刺
小腹肿痛。上连胸胁。诸医莫效。马诊两手脉弦涩而结。尺中倍弱。知为内伤重而外感轻
得之劳倦且郁。病在肝脾两经也。劳则伤脾。郁能伤肝。肝脾气血两伤。邪气独从内结。
治之者责其实而忘其虚。以致加重。今须大顾元气。微兼治邪。始克有济。用人参三钱。扶
其元气。桂枝七分。散其虚邪。黄连、肉桂。使上下交通。炮姜、半夏。以开痞散结。一剂
而脉渐透。再剂而神气颇清。右关转见滑实。元仪方以脉有转机为庆。前医疑热药太过。欲
投白虎汤。马曰。此津液元气两亏之证。服药后两脉透起。神气清爽。业已养正而透邪。但
今津液尚枯。虚热内甚。当进以滋燥清热之品。其与阳明实热证可峻行肃杀者。奚啻天壤也
仍用人参为主。加生首乌以养津润燥。佐黄连、枳实、杏仁、半曲。以除热散结而化痰。
三日。大便已行。后加芦根汁、蔗浆。甘寒养阴之品。六七日。右关脉和。舌刺亦平。微见
利下。前医又疑寒药所致。欲用理中。马曰。数日以来。纯用甘寒清燥之剂。三四日而始大
便通。六七日而始舌刺平。今津液方回。虽见利下。继必自止。何得喜功生事。且今胸腹间
尚有结气未释。正宜疏畅肝脾。以通和气道。且气道通和。虽不治利。利亦自止。所谓一举
而两得也。仍用人参、半、曲、广皮、茯苓、郁金、佛手等剂。六七日后。气和而利止。周
身浮肿。下体不能转移。此久病后元气大亏。脾虚不运。如盗去而舍空之比。复与大剂参、
术、苓、草、附、桂。至二十剂而肿平。乃得全愈。
震按印机草中所载寒热痞闷中州结痛者。每用人参、桂枝、肉桂、黄连、炮姜、半夏。
或合枳、朴。或合枳、桔。继见燥象。即以人参、生首乌、栝蒌实、蔗浆、梨汁、芦根汁等
或合黄连、知母。或合橘、半。若见虚寒象。多用理中加桂汤。或白通加人尿猪胆汁汤。
其用人参有一二两至五六两作一剂者。亦可谓大手笔。但雷同之案太多。故此集所选独少。
又见其治身热胸满喘嗽多痰者。必重用栝蒌实、紫菀。佐以半曲、贝母、杏仁、苏子、枳、
结。或合柴胡、秦艽。或合前胡、干葛。大约相同。惟治汪生咳嗽梦泄。面白畏风。两寸浮
大而虚。关尺虚小。用玉屏风散。多加人参。为不同。及治朱千秩喘嗽。寒热自汗。食减身
重。自夏至秋。脉象浮涩。亦用玉屏风加贝、杏、苏子、桔梗。云一剂而脉症和。此不敢信
也。继以六味加参。颇妥当。至如栝蒌实合炮姜及桂枝、生首乌者。不一而足。虽其运用纯
熟。未免数见不鲜。因并舍之。
〔附〕嘉善一张姓少年。春间患寒热如疟。始用发散。继用养阴。已愈矣。越数日。疟
又作。且兼白浊不止。用小柴加首乌、生地、丹皮、萆 等。不应。又数日。寒热渐重。不
能起坐。口渴烦躁。舌赤唇焦。一老医用白虎汤。而热益甚。发晕。昏沉几死。热气冲开
二三尺。两目赤肿。目眵胶闭。舌红且干。唇焦面赤。两足如烙。惟大便泄泻。脉虚而软。
余友沈尧封兄用人参二钱。熟附子三钱。茯苓五钱。白芍一钱五分。一剂而热少定。遂连服
十余日。惟以牡蛎、牛膝、枸杞、生地出入加减。粥进热退。诸证去其六七矣。忽然腹痛大
作。连泻二三十次。烦渴又作。懊 迷闷不安。举家骇泣。沈曰。无恐。此久积之寒饮。因
脾得参附之力以运动之。欲乃大下也。复用附子五钱。干姜二钱。苓、芍、炙草。数剂而安
又用参术平补全愈。
震选疟疾诸案虽不多。然皆精深高妙。可以启发后学。若浅近之法未载。略为补之。古
云。日作者轻。间日者重。此不可拘。若日作而寒热之时短。势又不甚。则诚轻。倘势甚。
而时又长。反不如间日者尚有休息之一日也。何可云轻。惟疟发渐早为易痊。渐晏为未止。
乃一定之局。间有不一定者。如发渐早而热退之时如旧。则其寒热加长矣。愈长则正气愈虚
而加剧。不得引内经其气上行九日出于缺盆之中为证也。又有发渐晏而热退之时如旧。则其
寒热渐短矣。愈短则邪气愈衰而自止。不得引昔贤自阳之阴者难愈为证也。隔二日曰三阴疟
较诸疟为最重。有二三年未愈者。亦有二三月即愈者。只看其寒热之轻重短长。以辨其病
之浅深。然三阴疟无骤死之理。反不比日作与间日者。有骤死之人也。此皆就予生平所验而
言之。大抵疟疾因风寒者。多初起无汗。必该发散。羌、苏、防、葛之类。若有汗。则用桂
枝、白芍。兼见热象。则桂枝柴胡各半汤。深秋初冬。寒重无汗。口不渴。脉不数者。麻黄
汤小剂用之。兼见热象。则加石膏。即越婢法也。表证而挟里证。有痰食者。加入朴、半、
麦芽之类。向有无痰不成疟。无食不成疟二说。未可全废。疟疾因于暑者。必热多寒少。有
汗口渴。桂枝白虎汤、竹叶石膏汤酌用。暑兼湿。则苍术白虎汤、桂苓甘露饮酌用。以上皆
疟疾之表证药。而疟发每多呕逆痞闷。又须以草果、知母、藿香、枳、朴、白蔻、姜汁、干
姜、竹茹、芦根等。审其寒热加入。亦统属疟疾之实证药也。若素虚人。或病后疮后产后。
不可一例论。古云。无汗要有汗。散邪为主。有汗要无汗。扶正为先。汗之一端。尚且严为
分别。岂以虚证虚脉而可虚其虚乎。补中益气汤、人参养营汤、参茸归桂饮、理中、八味、
真武等方。择其脉证相合者用之。盖温补温通补脾补肾。方义微别耳。惟是大虚必挟寒。昔
肾谓治久疟用补者。少加附子。其效如神。故虚疟之用桂、附。与三阴疟之用丁香。俱有奇
功可据也。然或虚疟不见寒证。却有热象。脉弦数或洪数者。势难投以温药。则甘寒生津如
蔗浆、秋露水、梨藕汁。壮水制火如二地、二冬、阿胶。以及生脉散、何人饮。又堪供我驱
策矣。复有虚实参半之热证。则小柴胡原方、人参白虎汤、半夏泻心汤、黄连汤。可以奏功
若虚实参半而寒者。较易治。毋庸再赘。但寒热二字。全在凭之以脉。纵使热多。甚至但
热无寒而脉细软者。当以虚治。不得轻用白虎。寒多。甚至但寒无热而脉洪实者。当以热治
不得便用姜、桂。此妙诀也。夜疟皆云邪入血分。当用血药以提其邪。说固可通。景岳归
柴饮、鼓峰香红饮二方俱佳。然初起在夜。嗣后不早不晏。始终发于夜者是也。设趱前渐定
日昃。缩后已至日出。皆不得谓之夜疟矣。禁法与截法不同。禁是外为镇厌。其法甚多。效
者亦多。即祝由之一类。然轻者效。重者不效。三疟全不效。比之打仗。掠其残兵耳。设用
药中綮。何藉此乎。截是服药以截止。常山截三疟有奇效。截止后须谨慎调摄。否则复发增
重。用砒者亦然。然砒必大吐。恐至伤人。其间日与日作者。原不须截。欲截则露姜饮最佳
虚加人参尤妙。缪仲淳谓疟由于暑。暑得露而解也。予考古法。要冷冻饮料以存露性。今怕冷
饮。隔汤炖温犹可。若着火则露性全失矣。临证指南以秋露煎药。非也。外有胆汁二姜丸、
蒜烧 、草果蒸参、常山炒参诸方。以及景岳云。小柴胡汤加常山二钱。截疟如神。皆在乎
人之善用耳。疟母必用鳖甲煎丸。丸中除去人参为大谬。或以参汤送之。汤力已过。丸力才
行。譬如悍卒无良将统驭。步伐岂能整齐。又按此丸偏于寒削。若阳虚者不宜。惟仲淳疟母
丸重用参、桂为宜。三疟虽属三阴。亦只要辨明寒热虚实。而应以温凉补泻。若谓阳经
之方。治之无益。必以仲景治三阴之法为根蒂。似属高谈。实门外汉也。总之。医者多读书
多阅历。病者能调摄。能谨慎。斯四难并。二美合矣。
俞震按：高鼓峰治疗新安程结先的父亲患疟疾。这一案例的描述都源自此案。患者每天辰时（早晨7-9点）感到极度寒冷，午时（中午11-13点）感到极度发热。发热时出现四肢厥冷、两眼直视、不能发声、下巴脱臼感、口水从口角涌出不止，每天流出数升。直到丑时（凌晨1-3点）才出汗缓解。饮食不进，神志昏蒙欲绝。其虚损程度非常明显，容易识别。于是用大剂量的参、[此处原文缺字，推测为芪或术]、桂、附并配合熟地黄。这是遵循张景岳的治法。
另外治疗中尊陆六息长期患疟疾。病情一天轻、一天重。食欲减退，肌肉消瘦，困倦嗳气。喻嘉言说，这是由于饥饱劳逸所感，受伤在阳明一经。所以饮食减少，而大便反而觉得艰涩，这是因为胃病导致运化机能迟缓。饥饿导致肌肉消瘦，是因为胃主肌肉。形体困倦，是因为胃病导致约束身体的机关不利。口中时时嗳气，是因为胃中不和而显现晦塞之象。一天轻一天重，是因为时日干支的衰旺与人身相关。所以甲、丙、戊、庚、壬为阳日，乙、丁、己、辛、癸为阴日。疟疾日久，饮食减少，胃中的正气已虚，而邪气未尽去除。因此在阳日帮助正气，邪气不能战胜正气，所以病轻；在阴日帮助邪气，正气不能战胜邪气，所以病重。应当用理中汤，帮助胃家中脘之气，使其能够运用，那么下脘的浊气自然能传入肠中，大便就不艰涩，不再上升至胸中，膈间就会宽快舒畅。
俞震按：此条议论通畅，而关于干支衰旺的说法前人从未提及。这可比拟韩愈（昌黎）那种张扬幽深微妙的手法。
张路玉治疗张怡泉，年龄七十五岁。平时常服用参、附、鹿角胶等温阳药物。秋季患疟疾，误用常山止截药一剂，随即导致人事不省，六脉出现歇止。按脉搏则二至一止，举指脉搏则三五至一止。只有在寒热发作之际诊察，脉搏才不歇止。热退后脉搏又恢复如前的歇止状态。这是真气衰微，不能贯通于脉道，所以出现歇止不前。在寒热之时，邪气冲激经脉，所以反而得以开通。这是虚证中伏有邪气的征象。于是用常山一钱，用酒拌过，同人参五钱焙干，去掉常山，只用人参来助益胸中大气以祛除邪气。应当知道因为常山伤犯中气而导致病情加剧，所以仍用常山作为向导。连续服用两剂，便能安睡。但寒热仍未停止，脉搏如前。于是每天进服人参一两，分两次服用，并配合稀粥糜以助胃气。数日后寒热逐渐减轻，脉搏微微接续而安定。
俞震按：此条对歇止脉的论述最有见地。其使用常山的方法，与杨介用冰煎药一样，都是巧妙的做法。然而寒热不止，脉搏歇止如前，即使巧妙也无益处。只有每天进服人参一两，不兼用其他药物，这才是真正的大巧若拙。
又治疗顾大来，年龄超过八十岁。初秋患瘅疟，神志昏热，胡言乱语，气喘乏力，遗尿。有人认为是伤寒谵语，有人认为是中风遗尿，危疑不定。张路玉说：不用担心，这是三阳合病。谵语、遗尿、口舌不仁而面色垢秽，在仲景暑证中，原本就有这样的例子。于是用白虎加人参汤，服用三次而安定。
俞震按：《内经》论瘅疟，完全是实热证。所以推究其未发病时，说是中气充实而不外泄；追溯其受病原因，说是用力出汗后，风寒舍于皮肤分肉之间；探究其发病机理，说是阳气盛而不衰。经文虽然没提脉象，想必脉象洪实有力是显而易见的。此条属于瘅疟，所以谵语遗尿并不致死。然而八十岁以上的人有此证，死者很多。不要轻视将此案作为榜样。
金淳还先生的儿子，八月间患疟疾，发作于辰、戌、丑、未时，而在子、午、卯、酉时每次增加轻微寒热。直至初夏，石顽诊察其六脉如丝，面色青，嘴唇白。于是给予六君子汤加桂枝、附子。四服无效。每服加入人参至一两，桂枝、附子各三钱。又服四服，辰、戌、丑、未时的寒热顿时停止，子、午、卯、酉时的寒热更加严重。这是中土有权力而邪气并入阴经。仍然给与前药四服，而面色红润，进食增加，寒热全部消除。后来用独参汤送服八味丸，调理而安。
飞畴治疗沈子嘉平。向来每到夏天，脐部一接触扇风就腹痛，且不时腹泻。六脉只是微数，没有其他异常。这是肾脏本寒，闭藏不严密，易于招风。下焦寒则虚火上僭，所以脉数。曾给予六味地黄丸去掉泽泻，加肉桂、肉豆蔻、五味子、白蒺藜，制成丸药服用。因此脐部不怕风，脾胃也结实。第二年秋天患疟疾，医生用白虎、竹叶、石膏等药。疟疾寒甚而不甚热，面色青，足冷，脉弦细而数。用八味地黄丸，将桂枝、附子用量增至三倍，煮成汤剂。早晚同时进服四君子汤合保和丸。两天后疟疾停止，调理而愈。
俞震按：腹部的部位，当脐属肾。脐部着扇风即痛泻，自然适宜温肾。但不因六脉带数而畏惧投用温药，这点值得称赞。蒺藜一味，加得更好。至于治疟，不因脉细数而不加倍加用桂枝、附子，更值得称赞。
马元仪治疗工部那公太夫人，年龄七十多岁。恶寒发热如疟疾，迁延月余，神志昏沉，食少，舌苔兼有刺状突起，小腹肿痛，上连胸胁。众医无效。马元仪诊察两手脉弦涩而结，尺中脉倍弱。知道这是内伤重而外感轻，得之于劳倦且郁结。病在肝脾两经。劳倦则伤脾，郁结能伤肝。肝脾气血两伤，邪气独自从内结聚。治病者责备其实证而忘记其虚证，以致加重。现在必须大补元气，微兼治邪，才能见效。用人参三钱，扶助元气；桂枝七分，疏散虚邪；黄连、肉桂，使上下交通；炮姜、半夏，以开痞散结。一剂后脉搏逐渐透达，再剂后神气颇清，右关脉转见滑实。马元仪认为脉有转机值得庆贺。前医怀疑热药太过，想投用白虎汤。马元仪说：这是津液元气两亏的证候，服药后两脉透起，神气清爽，已经养正而透邪。但现在津液尚枯，虚热内甚，应当进服滋燥清热之品。这与阳明实热证可以峻行肃杀者，相差何止天壤之别！仍用人参为主，加生首乌以养津润燥，佐以黄连、枳实、杏仁、神曲，以除热散结而化痰。三天后，大便已行。后加芦根汁、蔗浆，甘寒养阴之品。六七天，右关脉调和，舌刺亦平，微微见利下。前医又怀疑是寒药所致，想用理中汤。马元仪说：数日以来，纯用甘寒清燥之剂，三四日才大便通，六七日才舌刺平。现在津液方才回复，虽见利下，继必自止。何必喜功生事？况且现在胸腹间尚有结气未解，正宜疏畅肝脾，以通和气道。且气道通和，即使不治利，利亦自止。所谓一举而两得。仍用人参、半夏、神曲、广陈皮、茯苓、郁金、佛手等剂。六七日后，气和而利止。周身浮肿，下体不能转移。这是久病后元气大亏，脾虚不运，如同盗贼离去而屋舍空虚之比。复与大剂参、术、苓、草、附、桂，至二十剂而肿平，乃得全愈。
俞震按：《印机草》中所载寒热痞闷中州结痛者，每用人参、桂枝、肉桂、黄连、炮姜、半夏。或合枳实、厚朴，或合枳实、桔梗。继见燥象，即以人参、生首乌、栝楼实、蔗浆、梨汁、芦根汁等，或合黄连、知母，或合橘皮、半夏。若见虚寒象，多用理中加桂汤，或白通加人尿猪胆汁汤。其用人参有一二两至五六两作一剂者，也可谓大手笔。但雷同之案太多，故此集所选独少。
又见其治疗身热胸满喘嗽多痰者，必重用栝楼实、紫菀，佐以半夏、神曲、贝母、杏仁、苏子、枳实、厚朴。或合柴胡、秦艽，或合前胡、干葛。大约相同。惟治疗汪生咳嗽梦遗，面白畏风，两寸浮大而虚，关尺虚小，用玉屏风散，多加人参，为不同。及治疗朱千秩喘嗽，寒热自汗，食减身重，自夏至秋，脉象浮涩，亦用玉屏风加贝母、杏仁、苏子、桔梗，说一剂而脉症和，这我不敢相信。继以六味地黄丸加人参，颇妥当。至于如栝楼实合炮姜及桂枝、生首乌者，不一而足。虽然其运用纯熟，未免数见不鲜，因此一并舍弃。
〔附〕嘉善一个姓张的少年，春季患寒热如疟。开始用发散药，继用养阴药，已痊愈。过了几天，疟疾又发作，且兼白浊不止。用小柴胡汤加首乌、生地、丹皮、萆薢等，无效。又数日，寒热渐重，不能起坐，口渴烦躁，舌赤唇焦。一位老医用白虎汤，而热更甚，发晕，昏沉几死。热气冲开二三尺，两目赤肿，眼屎胶闭，舌红且干，唇焦面赤，两足如烙，惟大便泄泻，脉虚而软。我的朋友沈尧封兄用人参二钱，熟附子三钱，茯苓五钱，白芍一钱五分。一剂而热稍定，遂连服十余日，惟以牡蛎、牛膝、枸杞、生地出入加减。粥进热退，诸证去其六七矣。忽然腹痛大作，连泻二三十次，烦渴又作，懊恼迷闷不安，举家骇泣。沈尧封说：不要怕，这是久积之寒饮，因脾得参附之力以运动之，欲乃大下也。复用附子五钱，干姜二钱，茯苓、白芍、炙甘草。数剂而安。又用参术平补全愈。
俞震选疟疾诸案虽不多，然皆精深高妙，可以启发后学。若浅近之法未载，略为补之。古云：日作者轻，间日者重，此不可拘。若日作而寒热之时短，势又不甚，则诚轻。倘势甚，而时又长，反不如间日者尚有休息之一日也。何可云轻。惟疟发渐早为易痊，渐晏为未止，乃一定之局。间有不一定者。如发渐早而热退之时如旧，则其寒热加长矣。愈长则正气愈虚而加剧，不得引《内经》“其气上行九日出于缺盆之中”为证也。又有发渐晏而热退之时如旧，则其寒热渐短矣。愈短则邪气愈衰而自止，不得引昔贤“自阳之阴者难愈”为证也。隔二日曰三阴疟，较诸疟为最重。有二三年未愈者，亦有二三月即愈者。只看其寒热之轻重短长，以辨其病之浅深。然三阴疟无骤死之理，反不比日作与间日者，有骤死之人也。此皆就予生平所验而言之。
大抵疟疾因风寒者，多初起无汗，必该发散。羌活、紫苏、防风、葛根之类。若有汗，则用桂枝、白芍。兼见热象，则桂枝柴胡各半汤。深秋初冬，寒重无汗，口不渴，脉不数者，麻黄汤小剂用之。兼见热象，则加石膏，即越婢法也。表证而挟里证，有痰食者，加入厚朴、半夏、麦芽之类。向有无痰不成疟，无食不成疟二说，未可全废。疟疾因于暑者，必热多寒少，有汗口渴，桂枝白虎汤、竹叶石膏汤酌用。暑兼湿，则苍术白虎汤、桂苓甘露饮酌用。以上皆疟疾之表证药。而疟发每多呕逆痞闷，又须以草果、知母、藿香、枳实、厚朴、白蔻、姜汁、干姜、竹茹、芦根等，审其寒热加入。亦统属疟疾之实证药也。若素虚人，或病后疮后产后，不可一例论。古云：无汗要有汗，散邪为主；有汗要无汗，扶正为先。汗之一端，尚且严为分别，岂以虚证虚脉而可虚其虚乎？补中益气汤、人参养营汤、参茸归桂饮、理中、八味、真武等方，择其脉证相合者用之。盖温补温通补脾补肾，方义微别耳。惟是大虚必挟寒，昔肾谓治久疟用补者，少加附子，其效如神。故虚疟之用桂、附，与三阴疟之用丁香，俱有奇功可据也。然或虚疟不见寒证，却有热象，脉弦数或洪数者，势难投以温药，则甘寒生津如蔗浆、秋露水、梨藕汁，壮水制火如二地、二冬、阿胶，以及生脉散、何人饮，又堪供我驱策矣。复有虚实参半之热证，则小柴胡原方、人参白虎汤、半夏泻心汤、黄连汤，可以奏功。若虚实参半而寒者，较易治，毋庸再赘。但寒热二字，全在凭之以脉。纵使热多，甚至但热无寒而脉细软者，当以虚治，不得轻用白虎。寒多，甚至但寒无热而脉洪实者，当以热治，不得便用姜、桂。此妙诀也。
夜疟皆云邪入血分，当用血药以提其邪，说固可通。景岳归柴饮、鼓峰香红饮二方俱佳。然初起在夜，嗣后不早不晏，始终发于夜者是也。设趱前渐定日昃，缩后已至日出，皆不得谓之夜疟矣。禁法与截法不同。禁是外为镇厌，其法甚多，效者亦多，即祝由之一类。然轻者效，重者不效，三疟全不效。比之打仗，掠其残兵耳。设用药中綮，何藉此乎？截是服药以截止。常山截三疟有奇效。截止后须谨慎调摄，否则复发增重。用砒者亦然。然砒必大吐，恐至伤人。其间日与日作者，原不须截。欲截则露姜饮最佳，虚加人参尤妙。缪仲淳谓疟由于暑，暑得露而解也。予考古法，要冷冻饮料以存露性。今怕冷饮，隔汤炖温犹可。若着火则露性全失矣。临证指南以秋露煎药，非也。外有胆汁二姜丸、蒜烧[此处原文缺字，推测为姜或参]、草果蒸参、常山炒参诸方，以及景岳云：小柴胡汤加常山二钱，截疟如神，皆在乎人之善用耳。疟母必用鳖甲煎丸，丸中除去人参为大谬。或以参汤送之，汤力已过，丸力才行。譬如悍卒无良将统驭，步伐岂能整齐。又按此丸偏于寒削，若阳虚者不宜。惟仲淳疟母丸重用参、桂为宜。三疟虽属三阴，亦只要辨明寒热虚实，而应以温凉补泻。若谓阳经之方，治之无益，必以仲景治三阴之法为根蒂，似属高谈，实门外汉也。总之，医者多读书多阅历，病者能调摄，能谨慎，斯四难并，二美合矣。
Yu Zhen noted: Gao Gufeng treated the father of Cheng Jixian from Xin'an who suffered from malaria. The description of this case is derived from this record. The patient experienced severe chills every day at Chen hour (7-9 AM) and severe fever at Wu hour (11 AM-1 PM). During the fever, he exhibited cold extremities, fixed gaze, inability to speak, a sensation of jaw dislocation, and continuous overflow of saliva from the corners of his mouth, amounting to several liters per day. He only sweated and found relief at Chou hour (1-3 AM). He refused food, and his spirit was confused and nearly exhausted. His deficiency was very obvious and easy to identify. Therefore, large doses of Ginseng, [character missing in original, likely Astragalus or Atractylodes], Cinnamon Twig, and Processed Aconite Root were used together with Prepared Rehmannia Root. This follows the method of Zhang Jingyue.
Additionally, he treated Lu Liuxi, a person of high status, who had long-standing malaria. The condition was mild one day and severe the next. Appetite decreased, muscles wasted, fatigue increased, and belching occurred frequently. Yu Jiayan said this was caused by irregular diet and overexertion, injuring the Yangming channel. Thus, food intake decreased, and bowel movements became difficult because stomach disease delayed the mechanism of transportation and transformation. Hunger led to muscle wasting because the Stomach governs the muscles. Physical fatigue occurred because stomach disease impaired the mechanisms that constrain the body. Frequent belching indicated disharmony in the Stomach manifesting as turbid obstruction. The alternation between mild and severe days corresponded to the waxing and waning of Heavenly Stems and Earthly Branches relative to the human body. Jia, Bing, Wu, Geng, Ren are Yang days; Yi, Ding, Ji, Xin, Gui are Yin days. After prolonged malaria and reduced intake, the righteous Qi in the Stomach was deficient, while pathogenic factors remained. On Yang days, righteous Qi was assisted, pathogens could not overcome it, so the illness was mild. On Yin days, pathogens were assisted, righteous Qi could not overcome them, so the illness was severe. Zhili Tang (Regulate the Middle Decoction) should be used to assist the Qi of the Zhongwan point in the Stomach, enabling its function. Then, turbid Qi from Xiawan will naturally transmit to the intestines, making bowel movements unobstructed, preventing ascent to the chest, and bringing relief to the diaphragm.
Yu Zhen noted: This discussion is coherent, and the theory regarding the waxing and waning of Heavenly Stems and Earthly Branches has never been mentioned before. It can be compared to Han Yu's (Changli) style of highlighting profound and subtle matters.
Zhang Luyu treated Zhang Yiquan, aged 75. He usually took warming Yang medicines such as Ginseng, Aconite, and Deer Antler Glue. In autumn, he contracted malaria and mistakenly took one dose of Houttuynia (Changshan) to stop the attacks. This immediately led to unconsciousness and intermitted pulses. Pressing the pulse showed two beats followed by a pause; lifting the finger showed three to five beats followed by a pause. Only during the chills and fever did the pulse not intermit. After the fever subsided, the intermission returned. This indicated severe depletion of True Qi, unable to flow through the vessels, causing the pauses. During chills and fever, pathogenic factors agitated the meridians, allowing temporary patency. This is a sign of latent pathogens within a deficiency pattern. One qian of Houttuynia was mixed with wine and processed with five qian of Ginseng (roasted dry), then the Houttuynia was discarded, using only Ginseng to boost the Great Qi in the chest to expel pathogens. It should be known that Houttuynia injured the Middle Qi, worsening the condition, so it was still used as a guide. After two doses, he slept peacefully. However, chills and fever persisted, and the pulse remained intermittent. Therefore, one liang of Ginseng was administered daily in two doses, accompanied by thin gruel to support Stomach Qi. After several days, chills and fever gradually decreased, and the pulse slowly resumed regularity.
Yu Zhen noted: This commentary on intermitted pulses is insightful. The use of Houttuynia here, similar to Yang Jie's method of decocting medicine with ice, is ingenious. However, if chills and fever persist and the pulse remains intermittent, ingenuity is useless. Administering one liang of Ginseng daily without other herbs represents true "great skill appearing like clumsiness."
He also treated Gu Dalai, over eighty years old. In early autumn, he suffered from Dan Malaria (febrile malaria), presenting with confusion, delirium, panting, weakness, and urinary incontinence. Some attributed the delirium to Cold Damage (Shanghan), others to Wind Strike (Zhongfeng), leading to uncertainty. Zhang Luyu said: Do not worry. This is a combined disease of the Three Yang channels. Delirium, incontinence, oral insensitivity, and facial greasiness are examples found in Zhang Zhongjing's descriptions of Summerheat syndromes. He prescribed Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction). After three doses, the patient stabilized.
Yu Zhen noted: The *Neijing* describes Dan Malaria as purely excess heat. Investigating pre-onset, it states "Middle Qi is solid and does not leak outward." Tracing the cause, it says "after exertion and sweating, Wind-Cold resides in the skin and muscle layers." Investigating onset, it says "Yang Qi is abundant and does not decline." Although the text does not mention the pulse, a surging and forceful pulse would be evident. This case is Dan Malaria, hence delirium and incontinence were not fatal. However, for those over eighty, such symptoms often lead to death. This case should not be taken lightly as a model.
The son of Jin Chunhuan contracted malaria in August, occurring at Chen, Xu, Chou, and Wei hours, with slight increases in chills and fever at Zi, Wu, Mao, and You hours. This continued until early summer. Shiwen diagnosed silk-like pulses, blue complexion, and white lips. He prescribed Liu Junzi Tang (Six Gentlemen Decoction) plus Cinnamon Twig and Aconite. Four doses yielded no result. Each dose was increased to include one liang of Ginseng, and three qian each of Cinnamon Twig and Aconite. After another four doses, chills and fever at Chen, Xu, Chou, and Wei stopped abruptly, but those at Zi, Wu, Mao, and You worsened. This indicated that the Central Earth had authority while pathogens merged into the Yin channels. The same prescription was given for four more doses. The complexion became ruddy, appetite improved, and chills/fever disappeared. Later, Dushen Tang (Single Ginseng Decoction) was used to deliver Bawei Wan (Eight Ingredient Pill) for conditioning, resulting in recovery.
Yu Zhen noted: Reading this case alongside Yu Huaxi's reveals the subtleties of severity and lightness.
Feichou treated Shen Zijiapin. Every summer, exposure of the umbilicus to fan wind caused abdominal pain and frequent diarrhea. The six pulses were merely slightly rapid, with no other abnormalities. This indicated innate Kidney Cold and insecure closure, making him susceptible to wind. Lower Cold causes deficient Fire to flare upward, explaining the rapid pulse. He was given Liuwei Dihuang Wan (Six Flavor Rehmannia Pill) minus Alisma, plus Cinnamon Bark, Myristica Seed, Schisandra Berry, and Tribulus Fruit, made into pills. Consequently, the umbilicus became resistant to wind, and the Spleen and Stomach strengthened. The following autumn, he contracted malaria. Physicians used White Tiger, Houttuynia, Bamboo Leaves, and Gypsum. The malaria presented with severe chills and mild fever, blue face, cold feet, and wiry-thin-rapid pulses. Baye Dihuang Wan (Eight Ingredient Rehmannia Pill) was used, with Cinnamon Twig and Aconite dosages tripled, decocted as soup. Simultaneously, Sijunzi Tang (Four Gentlemen Decoction) combined with Baohe Wan (Harmonize the Stomach Pill) was given morning and evening. After two days, malaria ceased, and he recovered with conditioning.
Yu Zhen noted: The area of the abdomen corresponding to the umbilicus belongs to the Kidney. Pain and diarrhea upon wind exposure at the umbilicus naturally warrant Kidney warming. Not fearing warming herbs despite the rapid pulse is commendable. Adding Tribulus was excellent. Regarding malaria treatment, doubling Cinnamon Twig and Aconite despite thin-rapid pulses is even more commendable.
Ma Yuanyi treated the Dowager Lady of the Ministry of Works, over seventy years old. She had chills and fever resembling malaria for over a month, with confusion, poor appetite, prickly tongue coating, lower abdominal swelling and pain radiating to the chest and hypochondrium. Other physicians failed. Ma diagnosed wiry-choppy-intermitted pulses bilaterally, with significantly weak Chi positions. He determined this was severe internal injury with mild external contraction, caused by fatigue and depression. The disease involved the Liver and Spleen channels. Fatigue injures the Spleen; depression injures the Liver. Both Liver and Spleen Qi and Blood were damaged, allowing pathogens to knot internally. Previous treatments focused on excess and ignored deficiency, worsening the condition. Now, great attention must be paid to supporting Yuan Qi while slightly addressing pathogens. Three qian of Ginseng supported Yuan Qi; seven fen of Cinnamon Twig dispersed deficient pathogens; Coptis and Cinnamon facilitated communication between upper and lower; Processed Ginger and Pinellia opened stagnation and resolved knots. After one dose, pulses gradually penetrated; after two doses, spirit cleared, and the Right Guan position became slippery and solid. Ma celebrated the pulse shift. Previous physicians suspected excessive heat herbs and wanted to use White Tiger Decoction. Ma said: This is a syndrome of dual deficiency of Body Fluids and Yuan Qi. The pulse penetration and mental clarity indicate righteousness is nourished and pathogens are expelled. However, fluids are still dry, and deficient heat is intense. Nourishing and clearing heat is required. This differs vastly from Yangming Excess Heat where harsh purgatives are used. Ginseng remained the main herb, supplemented by Raw Polygonum Multiflorum to nourish fluids and moisten dryness, assisted by Coptis, Immature Bitter Orange, Apricot Kernel, and Fermented Soybean to clear heat, resolve knots, and transform phlegm. After three days, bowels moved. Reed Rhizome juice and Sugarcane juice (sweet-cold yin-nourishing agents) were added. By day six or seven, the Right Guan pulse harmonized, tongue prickle flattened, and slight diarrhea appeared. Previous physicians suspected cold herbs and wanted Lizhong Tang. Ma said: For several days, pure sweet-cold drying-clearing agents were used. Bowels moved on day three-four, tongue prickle flattened on day six-seven. Fluids have just returned. Diarrhea will stop spontaneously. Why seek merit and create trouble? There is still stagnant Qi in the chest and abdomen. We should soothe the Liver and Spleen to harmonize the Qi mechanism. Harmonized Qi mechanism stops diarrhea without direct treatment. This achieves two goals with one move. Ginseng, Pinellia, Fermented Soybean, Tangerine Peel, Poria, Curcuma, and Bergamot were used. After six-seven days, Qi harmonized, diarrhea stopped. Generalized edema and immobility of the lower body ensued. This was severe post-illness Yuan Qi depletion and Spleen failure to transport, like an empty house after robbers leave. Large doses of Ginseng, Atractylodes, Poria, Licorice, Aconite, and Cinnamon were given. After twenty doses, edema subsided, and full recovery occurred.
Yu Zhen noted: *Yinji Cao* records cases of chills/fever, bloating, and central pain using Ginseng, Cinnamon Twig, Cinnamon Bark, Coptis, Processed Ginger, and Pinellia, sometimes combined with Immature Bitter Orange/Hawthorn or Immature Bitter Orange/Magnolia Flower. If dryness signs appear, Ginseng, Raw Polygonum, Trichosanthes Fruit, Sugarcane juice, Pear juice, Reed Rhizome juice are used, possibly with Coptis/Anemarrhena or Tangerine Peel/Pinellia. For deficiency-cold, Lizhong Jia Guizhi Tang or Baitong Jia Niandu Zhu Danzhi Tang are used. Using one to five or six liang of Ginseng per dose shows boldness. However, due to too many similar cases, few were selected here.
He also treated fever, chest fullness, panting, cough, and profuse phlegm by heavily using Trichosanthes Fruit and Asterae Radix, assisted by Pinellia, Fermented Soybean, Fritillaria, Apricot Kernel, Perilla Seed, Immature Bitter Orange, and Magnolia Flower, or combined with Bupleurum/Gentian or Peucedanum/Pueraria. Generally similar. Distinctively, for Wang Sheng's cough and nocturnal emission, with pale face, wind aversion, floating-large-empty Cun pulses, and small-empty Guan/Chi pulses, Yupingfeng San (Jade Windscreen Powder) with extra Ginseng was used. For Zhu Qianzhi's panting/cough, chills/fever, spontaneous sweating, poor appetite, heavy body, floating-choppy pulses from summer to autumn, Yupingfeng San plus Fritillaria, Apricot Kernel, Perilla Seed, and Platycodon was used, claiming pulse/symptom harmony after one dose. I do not believe this. Subsequently, Liuwei Dihuang Wan plus Ginseng was appropriate. Combinations of Trichosanthes with Processed Ginger/Cinnamon/Raw Polygonum were common. Though skilled, they were commonplace and thus omitted.
[Appendix] A young surnamed Zhang from Jiashan had chills/fever like malaria in spring. Initially treated with dispersants, then yin-nourishers, and cured. Days later, malaria recurred with persistent leukorrhea. Xiaochaihu Tang plus Polygonum, Rehmannia, Moutan, and Dioscorea Hypoglauca was ineffective. Days later, chills/fever worsened, inability to sit/rise, thirst, irritability, red tongue, scorched lips. An old physician used White Tiger Decoction, worsening heat, dizziness, near-death coma. Heat radiated two to three chi. Eyes red/swollen/gummed, red/dry tongue, scorched lips/red face, burning feet, but loose stools, empty-soft pulse. My friend Shen Yaofeng used two qian Ginseng, three qian Prepared Aconite, five qian Poria, one qian five fen White Peony. Heat settled after one dose, continued for ten-plus days with Oyster Shell, Achyranthes, Goji, Rehmannia adjustments. Gruel intake reduced heat, resolving six or seven of ten symptoms. Suddenly, severe abdominal pain and thirty diarrheal episodes occurred, returning thirst/irritation/confusion. Family panicked. Shen said: Fear not. This is accumulated cold-fluid moving due to Ginseng/Aconite strengthening the Spleen, causing massive evacuation. Five qian Aconite, two qian Dried Ginger, Poria, White Peony, Roasted Licorice were given. Peace restored after several doses. Finally, Ginseng/Atractylodes gentle tonification completed recovery.
Yu Zhen selected few malaria cases, but all are profound, inspiring students. I supplement shallow methods. Ancients say: Daily attacks are light, alternate-day are heavy. This cannot be rigidly applied. If daily attacks are short and mild, truly light. If severe and long, worse than alternate-day which allows rest. Only earlier onset indicates easier cure; later onset indicates persistence. Fixed rule. Exceptions exist. Earlier onset with unchanged fever duration means longer chills/fever, worsening deficiency. Cannot cite *Neijing* "Qi rises nine days to Quepen." Later onset with unchanged fever duration means shorter chills/fever, pathogen decline. Cannot cite ancients "Yang-to-Yin is hard to cure." Triad malaria (every third day) is heaviest. Some last years, some months. Judge depth by severity/duration. Triad malaria rarely causes sudden death, unlike daily/alternate types. Based on my experience.
Generally, Wind-Cold malaria starts without sweat, requiring dispersal: Notopterygium, Perilla, Saposhnikovia, Pueraria. With sweat: Cinnamon Twig, White Peony. With heat signs: Guizhi Chaihu Banxia Tang (Half-and-Half Decoction). Late autumn/winter, severe cold/no sweat/thirstless/non-rapid pulse: Small dose Mahuang Tang (Ephedra Decoction). With heat: add Gypsum (Yuebi method). Exterior with interior phlegm/food retention: add Magnolia Bark, Pinellia, Malt. "No phlegm, no malaria; no food, no malaria" is not entirely invalid. Summerheat malaria: more heat/chills, sweat/thirst. GuiZhi Baihu Tang or Zhuye Shigao Tang酌情. Summerheat-damp: Cangzhu Baihu Tang or Guiling Ganlu Yin酌情. These are exterior malaria drugs. Malaria often involves vomiting/bloating. Caoguo, Anemarrhena, Agastache, Immature Bitter Orange, Magnolia Bark, White Cardamom, Ginger Juice, Dried Ginger, Bamboo Shavings, Reed Rhizome are added based on cold/heat. These are excess-type malaria drugs. For chronic deficiency or post-illness/post-wound/postpartum, do not apply uniformly. Ancients: "No sweat requires inducing sweat to scatter pathogens; existing sweat requires stopping sweat to support righteousness." Sweat management is strict. How can deficiency patterns be treated with deficiency-inducing methods? Buzhong Yiqi Tang, Renshen Yangying Tang, Shenrong Guigui Yin, Lizhong, Bawei, Zhenwu are chosen based on pulse/symptoms. Warming-tonifying spleen/kidney nuances differ. Severe deficiency implies cold. Ancient texts say adding Aconite to tonics for chronic malaria is miraculous. Thus, Cinnamon/Aconite for deficiency malaria and Clove for triad malaria have proven efficacy. However, if deficiency malaria shows heat signs (wiry-rapid or surging-rapid pulse), warming herbs are contraindicated. Sweet-cold fluid-generating agents (Sugarcane juice, Autumn Dew, Pear/Lotus Root juice) or water-nourishing fire-suppressing agents (Rehmannia, Ophiopogon, Donkey-hide Gelatin), plus Shengmai San or Heren Yin, are suitable. Mixed excess-deficiency heat: Xiaochaihu Tang, Renshen Baihu Tang, Banxia Xiexin Tang, Huanglian Tang. Mixed excess-deficiency cold is easier, no need to elaborate. Key is pulse assessment. Even with heat dominance, if pulse is fine-soft, treat as deficiency; do not lightly use White Tiger. Even with cold dominance, if pulse is surging-solid, treat as heat; do not immediately use Ginger/Cinnamon. This is a secret technique.
Night malaria is said to involve blood level pathogens, requiring blood-invigorating herbs to lift pathogens. Jingyue's Guichai Yin and Gufeng's Xianghong Yin are good. Night malaria occurs only at night. If timing shifts earlier/later, it is no longer night malaria. Suppression (external exorcism/Zhuyou) differs from interception (drugs). Suppression works for mild cases, fails for severe/triad. Interception uses drugs. Houttuynia intercepts triad malaria effectively. Post-interception requires careful care to prevent relapse. Arsenic causes severe vomiting, risky. Daily/alternate malaria need not be intercepted. Luxiang Yin (Dew Ginger Drink) is best for interception; adding Ginseng for deficiency is superior. Miao Zhongchun said malaria stems from Summerheat, resolved by dew. Ancients used frozen drinks to preserve dew properties. Modern fear cold drinks; warm via water bath is acceptable. Heating destroys dew property. *Linzheng Zhinan* using autumn dew to decoct herbs is incorrect. Other formulas: Danzhi Erjiang Wan, Garlic-Roasted [missing char], Steamed Ginseng with Caoguo, Stir-fried Ginseng with Houttuynia. Jingyue said Xiaochaihu Tang plus two qian Houttuynia intercepts malaria miraculously. Success depends on proper use. Malaria Mother (mass) requires Biejia Jian Wan. Removing Ginseng from this pill is a major error. Sending with Ginseng soup is ineffective as pill action lags. Like soldiers without a general. This pill is cold-cutting, unsuitable for Yang deficiency. Zhongchun's Mumo Wan with heavy Ginseng/Cinnamon is better. Triad malaria, though Yin-channel related, requires distinguishing cold/heat/excess/deficiency for warming/cooling/tonifying/purging. Claiming Yang-channel formulas are useless and insisting on Zhang Zhongjing's Yin-channel methods is empty talk and ignorance. Ultimately, physicians must read and gain experience; patients must regulate and be cautious. Combining these four difficulties yields beauty.