素问·疟论 Treatise on Malaria

Huangdi asked: All forms of malaria arise from wind, yet their accumulation and onset occur at fixed times — why is this so? Qibo replied: When malaria first breaks out, it begins in the fine body hairs; the patient stretches and yawns, then the attack comes on, with shivering cold and chattering of the jaw, and pain throughout the lower back and spine. When the cold passes, heat rises both within and without, the head aches as though splitting, and the patient thirsts for cold drink. Huangdi asked: What qi brings this about? I wish to hear the explanation. Qibo said: Yin and yang contend with one another above and below, deficiency and excess alternate, and yin and yang displace each other. When yang joins with yin, yin becomes excess and yang becomes deficient; when yang brightness is deficient, there is shivering cold and chattering of the jaw; when greater yang is deficient, there is pain in the lower back, upper back, head, and neck; when all three yang are deficient, yin qi prevails, and when yin qi prevails the bones grow cold and ache. Because the cold arises internally, both the interior and exterior are cold. When yang is exuberant, the exterior grows hot; when yin is deficient, the interior grows hot; when both interior and exterior are hot, the patient pants and is thirsty, and therefore craves cold drink. All this comes from having been injured by summer heat: the heat qi, being exuberant, lodges within the skin and outside the intestines and stomach — this is the dwelling place of the nutritive qi. This causes the sweat pores to become loose and the striae and interstices to open; then, on encountering the qi of autumn, the patient sweats and meets with wind, or bathes in water, so that water qi lodges within the skin and dwells together with the defensive qi. Now the defensive qi circulates through the yang by day and through the yin by night; this qi, on reaching yang, moves outward, and on reaching yin, presses inward; when the inner and outer clash, the attack occurs daily.

Huangdi asked: Why do some attacks occur every other day? Qibo replied: When the qi lodges deep and presses inward upon yin, the yang qi alone breaks forth while the yin evil remains lodged within; yin and yang contend but the evil cannot get out, and so the attack comes every other day. Huangdi said: Good. What qi causes the attack to come later on some days and earlier on others? Qibo said: The evil qi lodges in the wind mansion (fengfu) and travels downward along the spine. The defensive qi gathers greatly at the wind mansion once each day and night; on the next day it descends one vertebral segment, and so the attack comes later — this is because the evil first lodged in the spine and back. Each time the defensive qi reaches the wind mansion, the striae and interstices open; when they open the evil qi enters, and when it enters the disease erupts. This is why, day by day, the attack comes a little later. As the qi issues from the wind mansion and descends one segment each day, by the twenty-fifth day it reaches down to the sacrum, and on the twenty-sixth day it enters the spine and pours into the fu-lü vessel that runs along the spine; its qi then travels upward, and after nine days emerges at the supraclavicular fossa. As its qi rises higher day by day, the attack accordingly comes earlier and earlier. As for attacks occurring every other day, this is because the evil qi presses inward upon the five viscera and connects laterally with the membrane source; its path is long, its qi lies deep, and its movement is slow, so that it cannot travel together with the defensive qi nor emerge all at once — hence the attack comes only every other day.

Huangdi asked: You, Master, say that whenever the defensive qi reaches the wind mansion, the striae and interstices open, and when they open the evil qi enters, and when it enters the disease erupts. But now if the defensive qi descends one segment each day, its emergence does not always coincide with the wind mansion — how then can the attack still occur daily? Qibo replied: This is because the evil qi lodges in the head and neck and travels downward along the spine; deficiency and excess differ from case to case, and the evil strikes different places, so it need not coincide exactly with the wind mansion. Thus when the evil strikes the head and neck, the disease appears when the qi reaches the head and neck; when it strikes the back, the disease appears when the qi reaches the back; when it strikes the lower back and spine, the disease appears when the qi reaches the lower back and spine; when it strikes the hands and feet, the disease appears when the qi reaches the hands and feet. Wherever the defensive qi happens to be, if it meets there with the evil qi, the disease erupts. Hence wind has no fixed lodging place; wherever the defensive qi issues forth it must open the striae and interstices, and wherever the evil qi unites with it, that becomes its lodging place. Huangdi said: Good.

Now wind and malaria resemble one another and belong to the same category, yet wind alone persists constantly, while malaria has fixed times when it subsides — why is this? Qibo said: Wind qi lingers in the place it occupies, and so it persists constantly; the qi of malaria follows the channels and vessels, sinking inward and pressing against the interior, and only when the defensive qi responds to it does the attack occur. Huangdi asked: Why does malaria sometimes bring cold first and heat afterward? Qibo said: If one is injured by the great heat of summer, sweating profusely so that the striae and interstices open wide, and then encounters the chill and dampness of summer water-cold, which lodges within the striae and skin, and in autumn is further injured by wind, the disease is thereby formed. Now cold is a yin qi and wind is a yang qi; since the patient was first injured by cold and afterward injured by wind, cold comes first and heat comes afterward. The disease erupts at fixed times, and this is called cold malaria. Huangdi asked: Why does heat sometimes come first and cold afterward? Qibo said: This is because the patient was first injured by wind and afterward injured by cold, so heat comes first and cold comes afterward; this too erupts at fixed times and is called warm malaria. When there is only heat without cold, the yin qi is exhausted first and the yang qi alone breaks forth, so that the patient suffers shortness of breath and vexation, with hot hands and feet and a desire to vomit; this is called dan malaria (heat malaria).

Huangdi said: The classics say that what is in excess should be drained, and what is deficient should be supplemented. Now heat represents excess and cold represents deficiency. Yet in malaria, when the patient is cold, hot soup and fire cannot warm him, and when he is hot, ice water cannot cool him — these too belong to the categories of excess and deficiency. At such times, even a skilled physician cannot halt the attack; one must wait until it declines of itself before needling. What is the reason for this? I wish to hear the explanation. Qibo said: The classics say: do not needle blazing heat, do not needle a chaotic pulse, do not needle profuse sweating — for in these the disease runs counter to treatment and cannot yet be cured. When malaria first breaks out, the yang qi joins with the yin; at this time yang is deficient and yin is exuberant, and there is no qi in the exterior, so shivering cold comes first. When the yin qi's counterflow reaches its extreme, it turns and re-emerges as yang; yang then rejoins with yin in the exterior, so that yin becomes deficient and yang becomes replete, and heat and thirst follow. Thus in the qi of malaria, when it joins with yang, yang prevails, and when it joins with yin, yin prevails; when yin prevails there is cold, and when yang prevails there is heat. Malaria arises from the irregular qi of wind and cold; when the disease reaches its extreme it reverses. When the disease breaks forth it is as fierce as fire, as unstoppable as wind and rain. Hence the classics say: "At the height of its exuberance it must be avoided; once it has declined, treatment will surely succeed greatly" — this is what is meant. Before malaria has broken out, yin has not yet joined with yang, nor yang with yin; if one regulates the patient at this time, the true qi can be settled and the evil qi will perish. This is why the skilled physician cannot treat the disease once it has already erupted, for its qi is then in counterflow. Huangdi said: Good. How should one attack it — early or late? Qibo said: Just as malaria is about to erupt, yin and yang are about to shift; this always begins at the four extremities. Once yang has been injured, yin follows it. Therefore, before the appointed time, one should bind the limbs firmly so that the evil qi cannot enter and the yin qi cannot escape. Carefully observe and, wherever the grandchild vessels are found engorged, hard, and full of blood, one should drain them all — for the true qi has not yet gone forth to join with the evil. Huangdi asked: When malaria is not erupting, what is its condition then? Qibo said: The qi of malaria must alternate between exuberance and deficiency, according to wherever the qi currently resides. When the disease is in the yang, there is heat and the pulse is agitated; when it is in the yin, there is cold and the pulse is quiet. At the extreme, both yin and yang decline together and the defensive qi separates from the evil, so the disease finds respite; when the defensive qi gathers again, the disease returns.

Huangdi asked: Sometimes an attack skips two days, or even comes only after several days, and sometimes there is thirst and sometimes not — why is this? Qibo replied: When the attack skips days, it is because the evil qi and the defensive qi lodge in the six bowels and at times miss one another, unable to meet, so the patient rests for several days before the attack recurs. In malaria, yin and yang alternately prevail, sometimes severely and sometimes mildly, and so there is sometimes thirst and sometimes none. Huangdi asked: The treatises say that injury by summer heat must result in malaria by autumn, yet malaria does not always follow this pattern — why is that? Qibo said: This describes the disease as it corresponds to the four seasons; cases whose manifestations differ run contrary to the seasons. Malaria contracted in autumn brings severe cold; contracted in winter, the cold is mild; contracted in spring, the patient dislikes wind; contracted in summer, there is profuse sweating.

Huangdi asked: In warm malaria and cold malaria, where does the disease lodge — in which viscus does it reside? Qibo said: Warm malaria is contracted when one is struck by wind in winter; the cold qi is then stored within the bone marrow. When spring arrives, the yang qi bursts forth greatly, yet the evil qi cannot emerge of itself. Then, on encountering the great heat of summer, the brain and marrow are scorched, the flesh wastes away, and the striae and interstices open and discharge; or perhaps through some exertion, the evil qi and sweat both issue forth together. This disease is stored in the kidney, and its qi first moves from within outward. In such a case, yin is deficient and yang is exuberant; when yang is exuberant there is heat, and when it declines the qi turns back inward again — once it re-enters, yang becomes deficient, and when yang is deficient there is cold. Hence heat comes first and cold comes afterward; this is called warm malaria. Huangdi asked: What of dan malaria (heat malaria)? Qibo said: In dan malaria, the lung has habitually held heat, its qi exuberant throughout the body; there is counterflow surging upward, while the qi within is replete and does not discharge outward. Then, through some exertion, the striae and interstices open, and wind-cold lodges within the skin and between the flesh, and the attack erupts. When it erupts, the yang qi is exuberant, and being exuberant without declining, the disease results. Since its qi does not reach the yin, there is only heat without cold; the qi is stored internally in the heart and lodges externally between the flesh, causing the patient to waste away and lose flesh. Hence it is called dan malaria. Huangdi said: Good.