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The Yellow Emperor asked: The classic texts state that for excess conditions, one should use the draining method; for deficiency conditions, one should use the tonifying method. It is generally considered that heat syndromes belong to excess, and cold syndromes belong to deficiency. However, in malaria, the chills are so severe that hot water or fire cannot warm the patient; when the fever occurs, ice water cannot cool the patient. These cases fall under the categories of excess and deficiency. At such times, even a skilled physician cannot forcibly stop the attack and must wait for the pathogenic factor to naturally decline before applying acupuncture. What is the reason for this?

Qibo replied: The classic texts state: "Do not needle patients with intense heat," "do not needle those with chaotic pulse qualities," and "do not needle those with profuse sweating." This is because these conditions represent rebellious pathogenic qi, which are temporarily untreatable. When malaria first begins to manifest, the Yang qi merges into the Yin. At this moment, Yang is deficient and Yin is exuberant, leaving the exterior without Wei (defensive) qi protection, hence the initial chills. When Yin qi becomes rebellious to an extreme, it emerges back into Yang. Yang and Yin both re-emerge to the exterior, resulting in Yin deficiency and Yang excess, hence the subsequent fever and thirst. The malaria pathogen, when merging into Yang, causes Yang to prevail; when merging into Yin, causes Yin to prevail. Yin prevailing leads to cold; Yang prevailing leads to heat. The wind-cold pathogen of malaria is not constant; when the disease reaches its extremity, it recurs. Upon onset, the condition is like the heat of fire or the onslaught of wind and rain, unstoppable. Therefore, the classics say: "Treating during peak intensity will surely damage the healthy qi; treating as the pathogen declines ensures great success." This refers to the principle mentioned above. Before malaria manifests, Yin has not merged with Yang, nor has Yang merged with Yin. By regulating at this time, the Zhen (true/healthy) qi can be stabilized, and the pathogenic qi will cease. Thus, skilled physicians do not treat after the attack has started, because the qi is then rebellious.

Ancient texts state "drain the excess, tonify the deficiency" to restore balance, which is a fixed rule. However, although the severe chills and high fevers of malaria also fall under excess and deficiency, skilled physicians cannot immediately apply tonification or drainage methods. One must wait for the qi to naturally decline before needling. This is because the classics also warn: "Do not needle intense heat, chaotic pulses, or profuse sweating." Terms like Hunhun (chaotic/disordered) and Lulu (profuse/dripping) describe the struggle between pathogenic and healthy qi, the intermingling of Yin and Yang, and the boiling turmoil of blood and qi. In such states, not only is needling contraindicated, but medication should also be avoided. Administering drugs might suppress the pathogenic momentum or lead to sudden collapse of Yuan (original) qi and death. This is a critical point to understand. In malaria patients, Yin and Yang qi engage in mutual contention and merging, each gaining or losing dominance. When Yang merges into Yin, Yin prevails causing chills; when Yin merges into Yang, Yang prevails causing fever. During an attack, the condition is as abrupt and unstoppable as fire or storms. Hence, the classics advise against treatment during peak intensity to avoid damaging healthy qi, recommending regulation during the declining phase for optimal outcomes. Proper timing stabilizes Zhen qi and halts pathogenic qi. Thus, skilled physicians avoid treating active attacks due to the rebellious nature of the qi.

The Yellow Emperor asked: How should it be attacked? What about the timing (early vs. late)? Qibo replied: When malaria is about to manifest, Yin and Yang qi are about to shift, starting from the four extremities. If Yang is injured, Yin follows suit. Therefore, before the onset, firmly bind the affected area to prevent pathogenic qi from entering and healthy qi from escaping. Carefully observe; if Sunluo (collateral vessels) appear full, firm, and show blood color, puncture them. This allows Zhen qi to proceed without merging with the pathogen. Since treatment during an active attack is contraindicated, there must be a specific time for intervention. Malaria pathogens mix within blood and qi, circulating along meridians, causing disharmony among Ying (nutritive), Wei (defensive), Yin, and Yang. When the pathogen encounters Wei qi, they contend, triggering the disease. The Yin-Yang qi of the twelve meridians circulate and intersect at the extremities. As the pathogen prepares to manifest, it disrupts Yin-Yang shifts. Thus, malaria attacks often begin at the intersection points of Yin and Yang in the extremities, with coldness starting in the fingertips. Once Yang is injured, Yin is inevitably injured too. Therefore, before onset, while the pathogen is still dormant, firmly bind the fingertips of the four extremities to prevent Yin-Yang displacement, trapping the pathogen in one place so it cannot enter or exit Yin-Yang to disturb blood and qi. Then, carefully examine the Sunluo; if the pulse is full, firm, and shows blood color, this indicates the pathogen's location. Use needles to remove the pathogen. Then Zhen qi returns to its proper position without merging with the pathogen, preventing the disease from manifesting.

The Yellow Emperor asked: What are the manifestations when malaria is not manifesting? Qibo replied: The malaria pathogen alternates between excess and deficiency depending on its location. If the pathogen is in Yang, there is fever and a restless pulse; if in Yin, there is chills and a quiet pulse. When the condition reaches its extreme, both Yin and Yang become depleted, and Wei qi separates from the pathogen, so the disease pauses. When Wei qi gathers again, the disease recurs.

In the human body, Yin and Yang qi are originally in communication and harmony. The malaria pathogen occupies this space, causing imbalance. If the pathogen is in Yang, Yang becomes exuberant and Yin deficient, leading to fever and a restless pulse. If in Yin, Yin becomes exuberant and Yang deficient, leading to chills and a quiet pulse. The pathogen enters and exits Yin and Yang, causing mutual contention and disruption. When the disturbance is extreme, both pathogenic and healthy qi become depleted, and Wei qi separates from the pathogen, causing the disease to pause. When Wei qi gathers, the disease recurs.