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Chapter 35 of 78
黄帝内经·素问
I. Manifestations of Malaria Attacks and Basic Pathogenesis
The Yellow Emperor asked: Malarial diseases are all said to be caused by wind-evil. Why is it that they sometimes lie latent and sometimes manifest, following a regular time pattern?
Qi Bo replied: When malaria first begins, it starts with the hair standing on end, stretching and yawning. Then comes shivering and trembling, the lower jaw chattering, and pain in the lower back, spine, and head. After the chills subside, the body becomes hot both internally and externally, the head aches as if splitting open, and there is thirst with a desire for cold drinks.
The Yellow Emperor asked: What qi causes these manifestations? I wish to understand the underlying principles.
Qi Bo said: This results from the yin and yang contending above and below, the alternation of vacuity and repletion, and the mutual transfer between yin and yang. When yang-evil merges into the yin aspect, there is yin repletion with yang vacuity: when yang brightness [Stomach/Large Intestine] is vacuous, there is shivering with chattering of the jaw; when greater yang [Small Intestine/Bladder] is vacuous, there is pain in the lower back, back, head, and nape; if all three yang are vacuous, yin qi becomes predominant, and the bones and joints become cold and painful. Cold arises from within, so both the interior and exterior feel cold. When yang qi becomes predominant, the exterior becomes hot; when yin qi is vacuous, the interior also becomes hot. When both interior and exterior are hot, there is panting and thirst, hence the desire for cold drinks.
These diseases are mostly caused by injury from summerheat in summer. When heat qi is very strong, it lies latent within the skin and external to the stomach and intestines—namely, in the place where the constructive qi (qi that circulates within the vessels and nourishes the whole body) resides. This causes the sweat pores to become loose and the cou li (the striae and interstices of the skin and flesh, the portals through which qi and sweat move in and out) to open and discharge. When autumn arrives, one encounters wind-evil while sweating, or encounters water, dampness, and cold qi while bathing. The cold-water qi lies latent within the skin, dwelling together with the defensive qi (qi that circulates outside the vessels and provides defense and protection). Defensive qi moves through the yang aspect by day and through the yin aspect by night. When the malarial evil encounters the yang aspect, it issues externally; when it encounters the yin aspect, it binds internally. The interior and exterior mutually oppress each other—hence the disease attacks once each day.
II. Interval Between Attacks and Variations in Timing
The Yellow Emperor asked: Why do some cases attack only every other day?
Qi Bo said: This is because the evil qi lies latent more deeply, pressing internally into the yin aspect. Yang qi alone issues externally, while the yin evil attaches itself within. Yin and yang contend without being able to exit smoothly, so the disease attacks every other day.
The Yellow Emperor said: Good. Then why do some attacks occur later day by day, while others increasingly earlier? What qi causes this?
Qi Bo said: The evil qi enters the wind mansion (the point at the center of the back of the head where wind-evil tends to gather), then travels downward along both sides of the spine. Defensive qi, which brings yin and yang together at the wind mansion once per day, moves downward one joint each subsequent day. Therefore, the time when evil qi and defensive qi meet becomes progressively later, and the attacks correspondingly become increasingly late. This is the pattern when the evil first invades the back. Whenever defensive qi reaches the wind mansion, the cou li open; when the cou li open, the evil qi enters; when evil qi enters, the disease manifests. Hence, the attacks occur later day by day.
When the evil qi emerges from the wind mansion, it descends one joint each day. After twenty-five days it reaches the sacrum; on the twenty-sixth day it enters the interior of the spine, flowing into the vessel of the hidden flesh (the deep vessels alongside the spine). Thereafter, the evil qi again ascends, emerging after nine days from the supraclavicular fossa (the hollow above the collarbone). Because the evil's position becomes higher day by day, the time of attack also becomes correspondingly earlier day by day.
For attacks occurring every other day, the evil qi internally presses against the five viscera and laterally connects with the pleural membranes (the membranous connections between viscera). Because the route is distant, the evil is deep, and the movement is slow, it cannot keep pace with the circulation of defensive qi and cannot exit at the same time—thus the disease attacks every other day.
The Yellow Emperor asked: You said that when defensive qi reaches the wind mansion, the cou li open; when they open, evil qi enters; and when evil qi enters, the disease manifests. Now if defensive qi moves down one joint each day, yet the disease attacks every day even when the attack does not coincide with the wind mansion—why is this?
Qi Bo said: This concerns the pattern where evil qi invades the head and nape, traveling downward along the spine. Because people's vacuity and repletion differ, the places the evil qi invades also differ, so the attack does not necessarily coincide with the wind mansion. When evil qi invades the head and nape, the disease manifests when defensive qi reaches the head and nape; when it invades the back, the disease manifests when defensive qi reaches the back; when it invades the lower back and spine, the disease manifests when defensive qi reaches the lower back and spine; when it invades the hands and feet, the disease manifests when defensive qi reaches the hands and feet. In general, wherever defensive qi is located, if evil qi combines with it, the disease manifests. Thus, wind-evil has no fixed "mansion"; wherever defensive qi arrives, it inevitably opens the cou li, and wherever evil qi and defensive qi combine is the "mansion" where evil qi accumulates.
III. The Difference Between Wind-Evil and Malarial Evil
The Yellow Emperor said: Good. Wind-evil and malarial evil are similar and belong to the same category, yet wind disease persists continuously while malarial disease sometimes manifests and sometimes subsides. Why is this?
Qi Bo said: Wind-evil remains at the place it struck, so the symptoms are always present. Malarial evil, on the other hand, travels deep along the channels and presses inward, and only manifests when defensive qi responds to it.
IV. Cold Malaria, Warm Malaria, and Heat Malaria
The Yellow Emperor asked: Some cases of malaria involve cold first and then heat. Why?
Qi Bo said: In summer, being injured by severe summerheat, with profuse sweating and open cou li, if one encounters cold-damp qi from cold water in summer, the cold qi lies latent within the cou li and skin. When autumn comes, one further receives wind-evil, and the disease takes form. Cold belongs to yin qi, and wind belongs to yang qi. Being first injured by cold-evil and later by wind-evil, there is cold first and then heat. This disease attacks at regular times and is called cold malaria.
The Yellow Emperor asked: Those with heat first and then cold—what is the reason?
Qi Bo said: This is being first injured by wind-evil and later by cold-evil, so heat comes first and cold follows. This also attacks at regular times and is called warm malaria.
There is also a type where only heat manifests without cold. This is because yin qi has already declined absolutely and yang qi alone vents outward. The patient experiences shortness of breath, oppression, heat in the hands and feet, and a desire to vomit. This is called heat malaria.
V. Timing of Treatment
The Yellow Emperor said: The medical classics state that repletion should be drained and vacuity should be supplemented. Now, fever appears to be repletion and chills appear to be vacuity. Yet during the cold phase of malaria, neither hot water nor fire can warm the patient; during the fever phase, neither ice water can cool the patient down. These all seem to belong to the categories of repletion and vacuity. Under these circumstances, even a skilled physician cannot immediately arrest the disease and must wait until it naturally subsides before needling. What is the reason? I wish to understand the principle.
Qi Bo said: The medical classics state: do not needle when heat is blazing; do not needle when the pulse is confused; do not needle when there is profuse sweating like leaking rain. At these times, the disease momentum is chaotic and one must not treat rashly.
When malaria first begins, yang qi merges into the yin aspect. At this time yang is vacuous and yin is exuberant, with insufficient yang qi on the exterior—thus cold and shivering appear first. When yin qi has reached the extreme of rebellion, it re-emerges into the yang aspect, and yang together with yin merge externally. At this time yin is vacuous and yang is replete—thus heat and thirst appear first. When malarial evil merges into the yang aspect, yang prevails; when it merges into the yin aspect, yin prevails. When yin prevails, there is cold; when yang prevails, there is heat. Malarial evil results from the unpredictable transformation of wind-cold qi, and when disease reaches its extreme, it transforms into its opposite. When the disease attacks, it is hot like fire and as unstoppable as wind and rain. Therefore the medical classics say: treating while evil qi is flourishing inevitably injures the upright qi; regulating when the disease momentum declines yields good results. This is precisely what is meant.
When malaria is not yet manifesting, yin qi has not yet merged into the yang aspect, and yang qi has not yet merged into the yin aspect. At this time, if one regulates, the true qi can settle and the evil qi can retreat. Hence a physician should not forcefully treat during an acute attack, for the qi movement is then in rebellion.
The Yellow Emperor said: Good. Then how should one treat? How should the timing, early or late, be grasped?
Qi Bo said: When malaria is about to manifest, and yin and yang are about to shift, it always begins from the extremities of the four limbs. When the yang aspect has already been injured, the yin aspect will also be affected accordingly. Therefore, before the attack, bind the extremities with cords so that evil qi cannot enter inward and yin qi cannot leak outward. Then carefully examine, pricking and letting blood from where the minute collateral vessels (the smallest collateral vessels) are full, firm, and congested with blood. This is a method of regulating before true qi has merged with evil qi.
These are all ancient needling methods, provided for scholarly study only and not to be performed on one's own.
VI. Remission and Recovery in Malaria
The Yellow Emperor asked: When malaria is not manifesting, what are its characteristics?
Qi Bo said: Malarial evil necessarily alternates between flourishing and declining. When the evil is in the yang aspect, there is heat with a stirring pulse; when in the yin aspect, there is cold with a quiet pulse. After disease reaches its extreme, both yin and yang decline, and defensive qi separates from evil qi—thus the condition temporarily subsides. When defensive qi gathers again, the disease attacks once more.
VII. Attacks Several Days Apart and Differences in Thirst
The Yellow Emperor asked: Some cases attack every two days, even every several days; some patients are thirsty, others are not. Which factors produce these differences?
Qi Bo said: For attacks every other day, the evil and defensive qi lodge in the six bowels, sometimes missing each other and unable to meet—hence they pause for several days between attacks. Malaria represents alternate predominance of yin and yang, sometimes marked and sometimes not—hence some patients experience thirst while others do not.
The Yellow Emperor asked: The medical treatises say that summer injury from summerheat necessarily produces malaria in autumn. But now malaria does not always manifest this way. Why?
Qi Bo said: This concerns correspondence with the four seasons. When the pattern of disease differs from the seasons, it contradicts them. When disease manifests in autumn, cold is more severe; in winter, cold is more mild; in spring, there is fear of wind; in summer, there is profuse sweating.
VIII. Latent Locations of Warm Malaria and Heat Malaria
The Yellow Emperor asked: Where do the evils of warm malaria and cold malaria lie latent? In which viscus are they stored?
Qi Bo said: Warm malaria results from receiving wind-evil in winter, with cold qi lying latent in the bone marrow. When yang qi flourishes greatly in spring, the evil cannot exit on its own. When the time of great summer arrives, the brain marrow is scorched by heat, the flesh becomes wasted, the cou li open and discharge. Or, by exerting one's strength in labor, the evil exits together with sweat. This disease-evil is stored in the kidney, its qi first venting from within outward. In this manner, yin becomes vacuous and yang exuberant—with yang exuberant, there is heat. When the heat momentum declines, the evil returns within, and the internal yang becomes vacuous—with yang vacuity, there is cold. Hence heat comes first and cold follows—this is called warm malaria.
The Yellow Emperor asked: What about heat malaria?
Qi Bo said: Heat malaria results from the lung harboring heat at ordinary times. Heat qi fills the entire body and surges upward in rebellion, rendering the chest qi replete without outward discharge. If unity triggered by exertion opens the cou li, wind-cold evil invades the skin and enters between the fleshy portions (between the muscles), where disease takes form. During attacks, yang qi predominates and exuberant yang does not decline—forming this condition. Its evil does not involve the yin aspect, so it manifests only heat without cold. Heat qi is stored within the heart and lodged between the fleshy portions externally, causing the flesh to wither and the body to waste away—hence it is called heat malaria.
The Yellow Emperor said: Good.
The core of this chapter is incorporating the cold-heat alternation, timed manifestation, remission and recurrence of malaria into the explanatory framework of "yin-yang contention, vacuity-repletion alternation, and upright-evil struggle."
The essence of cold-heat alternation is yin-yang excess and deficiency
The ancients believed that malaria presenting cold then heat, or heat then cold, does not simply entail external contraction but rather the mutual transfer between yin qi and yang qi. When yin prevails, there is cold; when yang prevails, there is heat. The intersection of yin and yang creates the alternation of hot and cold. This "interchange of yin and yang" is the key to understanding the rhythm of malarial cold and heat.
Timing of attacks relates to the circulation of defensive qi
This chapter particularly emphasizes the daily-nights cycle of defensive qi: moving through the yang aspect by day and the yin aspect by night. Depending on whether the latent evil is superficial or deep, when the defensive qi reaches the place where the evil resides, upright and evil engage, and the disease manifests. Consequently, daily attacks, every-other-day attacks, and multi-day intervals are all explained through differences in the depth of latent evil and defensive qi rhythm.
Disease location determines attack features
The evil's invasion of the head and nape, back, lower back and spine, or hands and feet determines the corresponding symptoms that appear when each site is struck. This demonstrates that the ancients had recognized symptoms relate in record of ten associated with position on which an individual had drawn map precisely, not their general involvement.
Classification of malaria reflects differences in disease cause and constitution
The differentiation of cold malaria, warm malaria, and heat malaria relates not only to receipt and sequencing evils but also to the individual's preexisting state. For instance, heat malaria features "lung heat at ordinary times" and "chest qi replete without outward discharge," showing that the ancients viewed constitutional and internal environmental factors as influencing the type of disease.
Treatment timing: do not treat at the peak, regulate during decline
This chapter clearly specifies that when malaria erupts with high fever, pulse chaos, and profuse sweating, forced needling must be avoided; instead one should regulate when the affliction qiu declines severe abnormal both before union remain absent involved opposing extremes events during "Avoid exuberance, follow decline". Its original principle has profoundly influenced pattern ideas toward "cuts time with never attack method" approach treat have enduring impact on subsequent generations.
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This content is organized by Bu Gua, based on classic traditional Chinese medicine dictionaries, for cultural scholarship and study purposes only. It does not constitute any medical diagnosis, prescription, or treatment recommendation; if unwell, please seek timely medical attention.