Discussion on Malaria

The Yellow Emperor asked: Malaria is all caused by wind-evil, yet its onset and remission have fixed times. What is the reason for this? Qi Bo replied: When malaria begins to attack, it starts with the fine hair standing on end, followed by stretching and yawning, then shivering and chattering of the jaws, with pain in the lower back and spine. After the cold passes, the entire body, both inside and outside, becomes hot, the head aches as if splitting, and there is thirst with a desire for cold drinks.

The Yellow Emperor said: What kind of qi causes this? I wish to hear the reasoning. Qi Bo said: This is due to the mutual struggle of yin and qi above and below, the alternate onset of deficiency and excess, and the mutual shifting of yin and yang. When yang qi enters the yin aspect, the yin aspect becomes replete and the yang aspect becomes deficient. When the yang brightness channel is deficient, there is shivering and chattering of the jaws. When the greater yang channel is deficient, there is pain in the lower back, back, head, and nape. When all three yang channels are deficient, yin qi becomes predominant. When yin qi becomes predominant, there is cold pain in the bones and joints. Cold arises from within, so both the interior and exterior become cold. When yang qi is predominant, the exterior becomes hot. When yin qi is deficient, the interior becomes hot. When both interior and exterior are hot, there is panting and thirst, hence the desire for cold drinks. This all results from injury by summer heat-evil during summer, when hot qi is abundant and hides within the skin but outside the intestines and stomach, in the place where nutritive qi resides. This causes the pores to become loose and the interstices to open. Therefore, when encountering autumn qi, sweating meets wind, or due to bathing, water qi lodges within the skin, residing together with defensive qi. Defensive qi moves in the yang aspect by day and in the yin aspect by night. This evil qi, when encountering yang qi, disperses outward, and when encountering yin qi, presses inward. The mutual pressing of interior and exterior causes an attack every day.

The Yellow Emperor said: What is the reason for attacks that occur every other day? Qi Bo said: This is because the evil qi resides in a deeper location, pressing inward toward the yin aspect. Yang qi alone disperses outward, while yin evil attaches inward. Yin and yang struggle with each other and cannot emerge outward, so attacks occur every other day.

The Yellow Emperor said: Well said. What causes attacks that occur later each day, or earlier each day? Qi Bo said: The evil qi enters the wind mansion and moves downward along the spine. Defensive qi meets at the wind mansion once every day and night. The next day, the evil qi moves downward one segment, so the time of attack is delayed. This is because the evil qi first invades the back. Whenever defensive qi reaches the wind mansion, the interstices open. When the interstices open, the evil qi invades. When the evil qi invades, the disease attacks. Therefore, the attack time is slightly delayed day by day. The evil qi starts from the wind mansion and moves downward one segment each day. After twenty-five days, it reaches the sacrum. On the twenty-sixth day, it enters the spine and flows into the fu-pulse of the spine. The evil qi then moves upward and after nine days emerges in the supraclavicular fossa. Because the evil qi moves upward day by day, the attack time becomes earlier each day. For those attacks that occur every other day, it is because the evil qi presses inward toward the five viscera, connecting horizontally with the membrane source. Its pathway is distant, its location is deep, and its movement is slow. It cannot keep pace with the movement of defensive qi and cannot emerge at the same time, so attacks occur every other day.

The Yellow Emperor said: You said that whenever defensive qi reaches the wind mansion, the interstices open. When they open, the evil qi invades. When the evil qi invades, the disease attacks. Now, defensive qi moves downward one segment each day, and the evil qi's attack does not occur at the wind mansion. How, then, does the daily attack occur? Qi Bo said: This is because the evil qi invades the head and nape and moves downward along the spine. Therefore, because the body's deficiency and excess differ, and the location where the evil qi attacks differs, it does not necessarily manifest at the wind mansion. Thus, when the evil qi attacks the head and nape, the disease attacks when defensive qi reaches the head and nape. When it attacks the back, the disease attacks when defensive qi reaches the back. When it attacks the lower back and spine, the disease attacks when defensive qi reaches the lower back and spine. When it attacks the hands and feet, the disease attacks when defensive qi reaches the hands and feet. Wherever defensive qi is located, when it meets the evil qi, the disease attacks. Therefore, wind-evil has no fixed location. Wherever defensive qi reaches, it inevitably causes the interstices to open. The place where the evil qi meets it is the site of the disease.

The Yellow Emperor said: Well said. Wind-evil and malaria are similar and of the same category, yet wind-evil often persists continuously, while malaria sometimes attacks and sometimes remits. What is the reason? Qi Bo said: Wind-evil stays in the place where it invades, so it persists continuously. Malarial qi follows the channels and vessels, sinking inward and pressing deep, so it waits until defensive qi responds before attacking.

The Yellow Emperor said: In malaria, cold occurs first, followed by heat. What is the reason? Qi Bo said: In summer, injury from great summer heat causes profuse sweating and the opening of the interstices. Because one encounters the cool water-cold qi of summer, it hides in the interstices and skin. In autumn, one is again injured by wind-evil, and the disease is formed. Cold is yin qi; wind is yang qi. First injured by cold, later injured by wind, so cold occurs first, followed by heat. The disease attacks at fixed times and is called cold malaria.

The Yellow Emperor said: What is the reason for heat occurring first, followed by cold? Qi Bo said: This is because one is first injured by wind, later injured by cold. So heat occurs first, followed by cold. It also attacks at fixed times and is called warm malaria.

For those who have only heat without cold, it is because yin qi has already become exhausted first, and yang qi alone is predominant. This results in shortness of breath, vexation, heat in the hands and feet, and a desire to vomit. It is called dan malaria.

The Yellow Emperor said: The classics say that for excess, use draining; for deficiency, use supplementing. Now, heat is excess, and cold is deficiency. When a malaria patient has chills, even hot soup and fire cannot warm them. When they have fever, even ice and water cannot cool them. Both are within the categories of excess and deficiency. At such times, even a skilled physician cannot stop it. One must wait until the disease's force naturally declines before needling. What is the reason? I wish to hear your explanation. Qi Bo said: The classics say: Do not needle patients with blazing high fever; do not needle patients with chaotic pulse patterns; do not needle patients drenched in sweat. This is because the disease qi is reversed and not yet treatable. When malaria first attacks, yang qi enters the yin aspect. At this time, yang qi is deficient and yin qi is abundant. Externally, there is no yang qi, so shivering and chattering of the jaws occur first. When yin qi reaches its extreme of reversal, it again emerges to the yang aspect. Yang and yin combine again in the exterior. Then yin qi becomes deficient and yang qi becomes replete, so heat occurs first, followed by thirst. When malarial qi combines with the yang aspect, yang becomes abundant. When it combines with the yin aspect, yin becomes abundant. When yin is abundant, there is cold. When yang is abundant, there is heat. Malaria is a disorder of wind-cold qi that is inconstant. When the disease reaches its extreme, it turns toward the opposite. At the time of attack, it is like blazing fire, like wind and rain that cannot be withstood. Therefore, the classics say: When the evil qi is flourishing, it inevitably damages the upright qi. If one takes advantage of its decline, the matter will certainly succeed greatly. This speaks to this principle. Before malaria attacks, yin qi has not yet combined with the yang aspect, and yang qi has not yet combined with the yin aspect. Thus, if one regulates at this time, the upright qi can be at peace, and the evil qi will dissipate. Therefore, a physician cannot treat it when it has already attacked, because at that time the qi is reversed.

The Yellow Emperor said: Well said. How should it be treated? What is the proper timing, early or late? Qi Bo said: When malaria is about to attack, yin and yang are about to shift mutually. This inevitably begins from the extremities of the four limbs. Yang qi has already been damaged, and yin qi follows in motion. Therefore, before the attack, bind the extremities of the four limbs tightly with a belt, so that the evil qi cannot invade and yin qi cannot emerge. Examine carefully. Where the collateral vessels are seen as full and firm with blood, all are needled to let blood. This is the method of treatment before the true qi has combined with the evil qi.

The Yellow Emperor said: When malaria is not attacking, what are its manifestations? Qi Bo said: The malarial qi inevitably alternates between abundance and decline. It depends on the location of the evil qi. When the disease is in the yang aspect, there is heat and a rapid pulse. When in the yin aspect, there is cold and a sinking, quiet pulse. When the disease reaches its extreme, both yin and yang decline. Defensive qi separates from the evil qi, so the disease remits. When defensive qi gathers again, the disease attacks once more.

The Yellow Emperor said: Sometimes attacks occur every two days, or even every several days. Sometimes there is thirst, sometimes no thirst. What is the reason? Qi Bo said: For attacks every other day, it is because the evil qi and defensive qi both reside in the six fu-organs. Sometimes they miss each other and do not meet, so they rest for several days before attacking. Malaria is a disease of alternating predominance of yin and yang. Sometimes the predominance is severe, sometimes not severe. Therefore, sometimes there is thirst, sometimes no thirst.

The Yellow Emperor said: The medical treatises say that injury by summer heat in summer inevitably leads to malaria in autumn. Now, some cases of malaria do not correspond to this. What is the reason? Qi Bo said: This refers to the pattern corresponding to the four seasons. For those whose disease manifestations differ, it is a violation of the four-season pattern. For example: when the disease occurs in autumn, the cold is severe. When it occurs in winter, the cold is not severe. When it occurs in spring, there is fear of wind. When it occurs in summer, there is profuse sweating.

The Yellow Emperor said: "Warm malaria and cold malaria—where do they reside? In which viscera do they dwell?" Qi Bo replied: "Warm malaria is due to wind evil being contracted in winter, with cold qi hiding deep in the marrow. By spring, when yang qi surges vigorously, the evil cannot exit on its own. Then, encountering great summer heat, the brain marrow withers, muscles become emaciated, the interstices and striae open and discharge, or there is exertion. The evil qi exits together with sweat. This disease hides in the kidney, and the evil qi first emerges from the interior to the exterior. In this way, yin qi is deficient while yang qi is abundant; yang qi abounding generates heat. When the heat force declines, the qi returns and enters inward; upon entering inward, yang qi becomes deficient, and yang qi deficiency generates cold. Therefore, heat appears first and cold follows; this is called warm malaria."

The Yellow Emperor said: "What about dan malaria?" Qi Bo replied: "Dan malaria is due to the lung having long-standing heat qi; this heat qi fills and abounds throughout the entire body. The qi rebels and rushes upward, and the central qi is replete and does not leak outward. Because of exertion, the interstices and striae open and discharge; wind-cold settles and lodges within the skin and between the flesh and the sinews, and thus the disease arises. When the disease arises, yang qi is abundant; yang qi is abundant and does not decline, and so this disease forms. The evil does not involve the yin aspect, therefore there is only heat and no cold. The evil qi hides internally in the heart and lingers externally between the flesh and sinews, causing the flesh to be consumed and the body to become emaciated. Hence it is called dan malaria." The Yellow Emperor said: "Well spoken."