The pulse is suddenly large, then suddenly small
Wáng Xùgāo's chapter on malaria
Last week the Florida Department of Health sent out an advisory to all licensed health practitioners in the state about four confirmed cases of malaria in the Sarasota area. The CDC issued its own advisory a few days ago.
Malaria is nowadays effectively treated by biomedicine, but it was a vexing problem in many areas of the world since ancient times. Over the past few days I have been delving into the Chinese medicine literature around treating this malady, and since I have been working on translating various writings of Wáng Xùgāo (王旭高, 1798-1862), I thought I would post his chapter on malarial diseases (nüè jí) from Yī Xué Chú Yán (Medical Ruminations, 1862). Any mistakes or misinterpretations are mine.
第二十章 瘧
瘧疾，寒熱往來有定候。一日一發者邪淺；二日一發者邪深；三日一發者邪更深。先寒後熱者為順，先熱後寒者為逆。發於子後而至午退者為陽；發於午後而至夜半退者為陰；發於午前而至酉戌退者，陽經連及陰經也。但寒而無熱者為牝瘧；但熱而無寒者為癉瘧；因勞而發者為勞瘧；因食而發者為食瘧；更有鬼瘧、瘴瘧，總不離乎少陽一經。以少陽為半表半裡，邪踞其界，入與陰爭則寒，出與陽爭則熱。偏陽者熱多；偏陰則寒多；陰陽俱病，則寒熱等焉。治方如清脾飲（清脾飲：青皮、厚朴、草果、白朮、柴胡、黃芩、製半夏、茯苓、炙甘草各五分，加姜煎。治妊婦瘧疾《婦人良方》方。）、小柴胡湯，治瘧初起之正法也。初起熱甚無汗，加紫蘇葉、防風；寒多者，加桂枝，重用老薑；熱多者，加知母、貝母、蘆根；大渴、大煩、大熱，加石膏、麥冬、竹葉。
癉瘧治法 癉瘧，以石膏、知母、粳米為正方。先熱後微寒者，亦同癉瘧例，白虎加桂枝湯。
鬼瘧治法 鬼瘧，脈乍大乍小，其人時清時渾，不換金正氣散（不換金正氣散：厚朴、藿香、甘草、半夏、蒼朮、橘皮各等分。為粗末，每服三錢。加薑、棗煎。治濕濁內停，兼有外感。《太平惠民和劑局方》方。）
勞瘧治法 勞瘧，小柴胡湯加瓜蔞根；口渴甚，去半夏，或補中益氣湯。
食瘧治法 食瘧，平胃散及柴胡。
久瘧、三陰瘧治法 久瘧及三陰瘧，日久諸藥不效，用白朮一、二兩，生薑五、六錢，水煎一杯，寅時服之，渣至午後再煎服。如熱多者，以當歸一兩代白朮。
三陽瘧治少陽膽，三陰瘧治太陰脾。
胎瘧治法 胎瘧久不愈，用六君子湯加草果、烏梅，合小柴胡湯。
久瘧不愈，亦用六君子湯、補中益氣湯，兼送服附桂八味丸三錢，服之自效。
凡一切瘧疾，欲急於取效之法，三發之後，以小柴胡湯加常山三錢，寅時服，渣再煎，辰時再服。如吐，任其吐去痰涎自愈。
Chapter 20 Malaria
In malarial disease, (aversion to) cold and heat (effusion) alternate at fixed times. If there is one episode a day, the evil is superficial; if one episode every two days, the evil is deep; if one episode every three days, the evil is deeper still. Cases with aversion to cold first and heat effusion after are favorable, and those with heat effusion first and aversion to cold afterwards are unfavorable. If it arises after midnight (zǐ, branch 1, 23:00-01:00) and recedes at noon (wǔ, branch 7, 11:00-13:00), it is yáng; if it arises after noon and recedes at midnight, it is yīn; if it arises before noon and recedes during yǒu-xū time (branch 10-11, 17:00-21:00) it is in the yáng channels as well as the yīn channels.
If there is aversion to cold but no heat effusion it is female malaria; if there is heat effusion but no aversion to cold it is pure-heat malaria; if it arises because of taxation (i.e., overwork) it is taxation malaria; if it arises from food it is food malaria. Furthermore, there is ghost malaria, and miasmic malaria. Generally it doesn’t depart from the single channel of shào yáng. Because shào yáng is half exterior and half interior, evil squats on the boundary, as it enters and struggles with the yīn the result is aversion to cold, as it exits and stuggles with the yáng the result is heat effusion. If it inclines toward yáng then there will be much heat effusion; if it inclines toward yīn then there will be much aversion to cold; if the illness is both yáng and yīn, then there will be cold and heat in equal measure.
Use treatment formulas such as Qīng Pí Yǐn (Clear the Spleen Beverage): Qīng Pí (Pc Citri Reticulatae Viride), Hòu Pò (Cx Magnoliae), Cǎo Guǒ (Fr Amomi Tsaoko), Bái Zhú (Rz Atractylodis Macrocephalae), Chái Hú (Rx Bupleuri), Huáng Qín (Rx Scutelleriae), Zhì Bàn Xià (Rz Pinelliae Praeparatae), Fú Líng (Poria), Zhì Gān Cǎo (Rx Glycyrrhizae Praeparatae), five fēn each, adding fried Jiāng (Rz Zingiberis Recens). To treat pregnant women’s malarial disorder use formulas from Fù Rén Liáng Fāng (Women’s Fine Formulas, Chén Zìmíng, 1237) Using Xiǎo Chái Hú Tāng (Minor Bupleurum Decoction) is the correct method for treating initial stage malaria. At the initial onset of heat effusion, if there is no sweating, add Zǐ Sū Yè (Fm Perillae) and Fáng Fēng (Rx Saposhnikoviae). For abundant chills use Guì Zhī (Rm Cinnamomi), if they are severe use Lǎo Jiāng (Rz Zingiberis Vetum). In cases of abundant heat effusion, add Zhī Mǔ (Rx Anemarrhenae), Bèi Mǔ (Blb Fritillariae), Lú Gēn (Rz Phragmitis) ; if there is great thirst, great agitation and great fever, add Shí Gāo (Gypsum), Mài Dōng (Rx Ophiopogonis), Zhú Yè (Fm Bambusae).
Pure-heat malaria treatment method: The correct prescription uses Shí Gāo, Zhī Mǔ, and Jīng Mǐ (Fr Oryzae). Cases with heat effusion first followed by slight aversion to cold are also called pure-heat malaria; use Bái Hǔ Jiā Guì Zhī Tāng (White Tiger Decoction plus Cinnamon Twig).
Ghost malaria treatment method: In ghost malaria the pulse is suddenly large and then suddenly small, and the person is sometimes clear and sometimes turbid. Use Bù Huàn Jīn Zhèng Qì Sàn (Priceless Qi-Righting Powder): Hòu Pò, Huò Xiāng (Hb Agastachis), Gān Cǎo (Rx Glycyrrhizae), Bàn Xià (Rz Pinelliae), Cāng Zhú (Rz Atractylodis), Jú Pí (Pc Citri Reticulatae), each an equal amount. Grind to a coarse powder, three qián each dose. Add Jiāng, Zǎo (Fr Jujubae) and decoct. It treats damp turbidity collecting internally, with concurrent external contraction; it is a Tài Píng Huì Mín Hé Jì Jú Fāng (Tai Ping Imperial Grace Formulary, 1078) formula.
Taxation malaria treatment method: For taxation malaria, use Xiǎo Chái Hú Tāng adding Guā Lóu Gēn (Rx Trichosanthis); if there is thirst, remove Bàn Xià, or use Bǔ Zhōng Yì Qì Tāng (Center-Supplementing Qi-Boosting Decoction).
Food malaria treatment method: Food malaria, use Píng Wèi Sàn (Stomach-Calming Powder) with Chái Hú.
Enduring malaria and three- yīn malaria treatment method: If over the course of time the medicinals are not effective, use 1 or 2 liang of Bái Zhú, 5 or 6 qian of Shēng Jiāng, decoct in water to one cup, take it at yín hour (03:00-05:00, branch 3), and decoct the dregs until the afternoon and take it. If there is abundant heat effusion, use 1 liang of Dāng Guī (Radix Angelicae Sinensis) in place of Bái Zhú.
For three-yáng malaria treat shào yáng gallbladder, for three-yīn malaria treat tài yīn spleen.
Fetal malaria treatment method: If fetal malaria does not recover after a long time, use Liù Jūn Zǐ Tāng (Six Gentlemen Decoction) with added Cǎo Guǒ and Wū Méi (Fr Mume), combined with Xiǎo Chái Hú Tāng.
Enduring malaria that will not recover, also use Liù Jūn Zǐ Tāng or Bǔ Zhōng Yì Qì Tāng, simultaneously wash it down with a 3 qián dose of Fù Guì Bā Wèi Wán (Eight-Flavor Pill with Aconite and Cinnamon, also known as Jīn Guì Shèn Qì Wán), taking it is certainly effective.
In general for all kinds of malarial disease, if you are anxious to get the treatment method’s effects, after three episodes take Xiǎo Chái Hú Tāng, add three qián Cháng Shān (Rx Dichroae), take it at yín hour, decoct the dregs again, and take it again at chén hour (0700-0900, branch 5). If they vomit, let the vomiting remove the phlegm-drool and they will spontaneously recover.
Stay safe, folks, and thanks for reading.
Note: this newsletter is for information purposes only and is not intended as medical advice. Please seek the opinion of a health care professional for any specific medical issues you may have. If you think you may have malaria, please seek immediate medical attention.
References
Fratkin, J. (2014). Classical texts reference. https://drjakefratkin.com/wp-content/uploads/2014/03/ECF-Classical-Texts-Appendix.pdf
Wáng, X. (1862). Yī xué chú yán. https://jicheng.tw/tcm/book/%E9%86%AB%E5%AD%B8%E8%8A%BB%E8%A8%80/index.html.
Nice translation! The thing about a pulse that is 乍大乍小 suddenly large then suddenly small... that is specifically associated with ghosts (above, it is for ghost malaria). I have come across it a few times. Here is a case where it occurs:
吕滄洲治一女在室，病不月，諸醫療皆不得其狀。視之，腹大如娠，求其色脉即怪，語之曰：汝病非有異夢，則鬼靈所憑耳。女不答，趨入卧內，密語其侍嫗曰：我去夏追凉廟廡下，薄暮，過木神心動，是夕夢一男子，如暮間所見者，即我寢親狎，由是感病。我慚赧，不敢以告人，醫言是也。
Lǚ Cāngzhōu treated an unmarried girl whose disease was amenorrhea. Various doctors had treated her but none had figured out her condition. Lǚ looked at her and saw that her abdomen was enlarged like she was pregnant. He found her complexion and pulse to be strange so he said to her, “Your disease is not from having unusual dreams; it is due to ghosts and spirit-beings.” The girl did not reply and hurried back into her bedroom. She talked privately with the old woman who waited upon her, saying, “Last summer, I went under the veranda of the temple at twilight to get cool. I passed by a wooden deity and my heart stirred. That evening, I dreamed of a man who looked like [the deity] that I saw him at twilight, and I slept with him intimately. I fell ill from this. My face became red from shame and I didn't dare tell anyone. The doctor talked about this.”
嫗以告吕，吕曰：女面色乍赤乍白者，愧也；脉乍大乍小者，祟也。病因與色脉符，雖劇無苦。乃以桃仁煎，下血類豚肝者六七枚，俱有竅如魚目，病已。
The old woman then told Lǚ, and Lǚ said, “The girl's facial complexion is suddenly red then suddenly white; this is shame. Her pulse is suddenly large then suddenly small; this is a haunting.” The disease cause tallied with the complexion and pulse. Even though it was severe, she was not suffering. He then boiled táorén for her, and then she passed blood and six or seven pieces of something that looked like pig liver, all with orifices like fisheyes. The disease recovered.
from Volume 11 of 江瓘《名醫類案》 Míngyī Lèi’àn (Categorized Cases of Famous Doctors) by Jiāng Guàn (Míng)