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(Full text of *Suwen: Lun Nue* [Treatise on Malaria from the Basic Questions])

Huangdi asked: All malaria diseases arise from wind pathogenic factors, yet their accumulation and manifestation occur at specific times. Why is this? ("Nue" implies cruelty and tyranny. Although there are many types of malaria, they are all referred to as "Nue," hence the name. Since Wang Bing, various interpretations have differed, none having grasped the true meaning. Observing the phrase "All malaria arises from wind," it speaks generally of all malaria types; the meaning of the word "all" here is clear. "Xu" refers to pathogens accumulating in the meridians, lying dormant for a time. "Zuo" refers to the disease manifesting externally, erupting without prior warning. "Xu" is pronounced like "Jie".) Qibo replied: When malaria first begins to manifest, it starts with the erection of fine body hairs (Haomao), followed by stretching and yawning. Then chills and trembling of the jaw (Hanli Guhan) occur, accompanied by pain in the waist and spine. After the cold subsides, both the interior and exterior become hot, causing severe headache as if splitting, thirst, and a desire for cold drinks. ("Starting from Haomao" indicates aversion to cold with hair standing erect. "Stretching" refers to extending the limbs, indicating pathogenic disturbance in the meridians. "Yawning" is due to the struggle and traction between Yin and Yang Qi. Other explanations follow below. "Han" refers to the cheeks/jaw, pronounced 'he gan qie'.) Huangdi said: What Qi causes this? I wish to hear the principle. Qibo said: It is because Yin and Yang Qi struggle above and below, alternating between deficiency and excess, as Yin and Yang shift positions. (Yang Qi descends to its extreme then ascends; Yin Qi ascends to its extreme then descends. When pathogenic Qi enters, Yin and Yang struggle above and below. Yang deficiency leads to external cold; Yin deficiency leads to internal heat. Yang excess leads to external heat; Yin excess leads to internal cold. Wherever the pathogen resides, it is excess while Zheng Qi is deficient. Thus, entering Yin results in Yin excess and Yang deficiency; entering Yang results in Yang excess and Yin deficiency. The alternation of deficiency and excess is due to the mutual shifting of Yin and Yang.) When Yang merges into Yin, Yin becomes excess and Yang deficient. Deficiency of Yangming Qi leads to chills and jaw trembling. (When Yang merges into Yin, Yin pathogens prevail, leading to cold. Yangming is the source of Stomach Qi, governs muscles, and its meridian circulates around the cheeks; thus, Yangming deficiency causes chills and jaw trembling. "Gu" means trembling or fright.) Deficiency of Juyang (Taiyang) leads to pain in the lower back, back, head, and neck. (The lower back, back, head, and neck belong to the Taiyang meridian. Yang deficiency allows cold pathogens to reside there, causing pain.) When the Three Yang meridians (Taiyang, Yangming, Shaoyang) are all deficient, Yin Qi prevails. Prevailing Yin leads to cold bones and pain. (Three Yang includes Yangming and Shaoyang. Yin excess obstructs Yang Qi, causing blood vessel stagnation, leading to cold bones and pain. The *Zhongshi Pian* states: "Painful conditions belong to Yin.") Cold generates internally, so both interior and exterior are cold. (Both exterior and interior Yin pathogens prevail.) Yang excess leads to external heat; Yin deficiency leads to internal heat. When both interior and exterior are hot, there is panting and thirst, hence the desire for cold drinks. (This occurs when pathogens move from the Yin aspect to merge into the Yang aspect. Merging into Yang causes Yang excess, leading to internal and external heat, panting, thirst, and preference for cold.) These conditions result from summer injury by summer-heat, where intense heat lingers inside the skin but outside the stomach and intestines, which is the abode of Ying Qi (Nutritive Qi). (Summer heat injury occurs when heat is intense; the pathogen is actually wind-cold in nature. As stated above: "All malaria arises from wind." The *Jingui Zhenyan Lun* says: "Those who do not sweat during summer heat will develop wind-malaria in autumn." This clarifies the meaning. Wind-cold on the exterior must stagnate and transform into heat. Lurking inside the skin but outside the stomach and intestines, it resides within the meridians. Ying Qi circulates within the vessels, hence it is called the abode of Ying Qi. Summer-heat has Yin and Yang distinctions, detailed in the preceding sections of this category. Rong and Ying are interchangeable.) This causes pores to open and Cou Li (skin texture) to relax. (Summer-heat opens the muscle surface.) Subsequently, encountering autumn Qi, sweating while exposed to wind, or bathing allows water Qi to settle inside the skin, residing together with Wei Qi (Defensive Qi). (Lurking summer-heat is a Yin pathogen. Autumn Qi and water Qi are also Yin. New pathogens residing with Wei Qi combine internally with latent summer-heat, causing Yin-Yang conflict and malaria onset. Note: Summer-heat injury causing malaria is considered a Yin pathogen because Yang summer-heat damages Qi, causing profuse sweating and immediate onset, preventing pathogen retention. Only Yin summer-heat remains latent due to lack of sweating. Therefore, those contracting malaria usually indulge in cooling behaviors during peak summer, avoiding wind and cold, using cool water for bathing, swimming in rivers, or eating raw/cold foods. Robust individuals may not retain the pathogen, but frail individuals accumulate it in Ying and Wei, inevitably becoming ill. External cold injury often leads to malaria, while internal cold injury often leads to dysentery. If one avoids these two, how would malaria and dysentery arise?) Wei Qi travels through Yang during the day and Yin at night. This Qi moves outward upon encountering Yang and inward upon encountering Yin. The interaction between interior and exterior causes daily attacks. (Wind-cold enters from the exterior, residing with Wei Qi, thus following Wei Qi's entry and exit. Wei Qi completes one cycle per day and night; therefore, newly contracted malaria attacks once daily. Thus, daily malaria involves pathogens in the Wei level, which is superficial and easier to treat.)

Huangdi asked: Why does some malaria attack every other day? Qibo replied: The pathogen resides deeply, pressing inward on Yin. Yang Qi alone activates, while Yin pathogens remain fixed internally. Yin and Yang struggle but cannot exit together, resulting in every-other-day attacks. (Deep residence places the pathogen between Ying Qi and the Zang organs. Ying is Yin, Wei is Yang. Yang activation is fast; Yin pathogen fixation is slow. The disparity in speed causes resistance and struggle, preventing Yin pathogens from exiting with Wei Qi, hence every-other-day attacks.) Huangdi asked: Why do some attacks occur later or earlier each day? Qibo replied: Pathogens lodge at Fengfu (Governor Vessel Acupoint), descending along the Lu (spine/muscles between spine and shoulder). (Fengfu is an acupoint on the Du Meridian. "Lu" refers to the spine or muscles flanking the spine. "Descending" means moving down to the coccyx.) Wei Qi gathers at Fengfu once every day and night. The next day, it descends one vertebral segment. Thus, attacks are delayed. (Wei Qi emerges from Jingming (BL1) of the Bladder Meridian at dawn and gathers at Fengfu, completing its daily cycle. If pathogens lodge at Fengfu and descend along the spine, deepening daily by one segment, moving from Yang to Yin, the gathering time delays, causing progressively later attacks.) This is because pathogens initially lodge in the back. Each time they reach Fengfu, Cou Li opens; opening allows pathogen entry; entry triggers the attack, causing progressively later daily attacks. (Fengfu is not singular; see below. "Initially lodging in the back" refers to latent pathogens from initial infection. Reaching Fengfu opens Cou Li, signifying the meeting of Wei Qi and pathogens. Meeting triggers the attack; delay is due to daily pathogen descent.) From Fengfu, descending one segment daily, after twenty-five days it reaches the coccyx. On the twenty-sixth day, it enters the spine interior, injecting into the Fulu Meridian. (Three cervical vertebrae, twenty-one thoracic/lumbar vertebrae, totaling twenty-four segments. Descending one segment daily from Fengfu, it reaches the coccyx on day 25. Moving posteriorly to anteriorly, it enters the spine interior on day 26, injecting into the Fulu Meridian. According to the *Suilu Pian*: "Enters spine interior, injects into Fuchong Meridian." The Chong Meridian running along the back lies hidden between the spine and muscles, hence called Fulu. See Meridians Category 27 for Chong details. "Di" is pronounced dǐ.) The Qi ascends, emerging from Quepen (ST12) after nine days. As the Qi rises, attacks occur increasingly earlier. (Pathogens in Fulu ascend along the spine without joint obstruction, emerging from Quepen in nine days. Rising Qi indicates moving from Yin to Yang, retreating pathogens, causing earlier attacks.) Every-other-day attacks occur because pathogens press inward on the Five Zang organs and connect horizontally to Muyuan (Moyuan/Epigastric Region). The path is long, the Qi is deep, movement is slow, unable to travel with Wei Qi or exit fully, hence every-other-day attacks. (Reiterating previous points. Muyuan Qi connects internally to Zang organs; pathogens in Yin cause long paths and slow movement, resulting in every-other-day attacks. "Mu" is pronounced mù. *Jutong Lun* and Quan Yuanqi's version write "Moyuan".)

Huangdi asked: You stated Wei Qi reaches Fengfu, opening Cou Li, allowing pathogen entry and attack. Now Wei Qi descends one segment daily, so its opening is no longer at Fengfu. Why do attacks still occur daily? (Previous text said pathogens lodge at Fengfu and descend with Wei Qi, increasing distance from Fengfu daily. How can they meet to cause daily attacks? Hence the doubt.) Qibo replied: Pathogens lodge in the head and neck, descending along the spine. Thus, deficiency/excess differs, and pathogen location varies, not necessarily coinciding with Fengfu. (Pathogens in head/neck always descend along the spine. However, invasion sites vary based on body deficiency/excess, not strictly Fengfu. Thus, "daily descent" applies only to pathogens. Wei Qi circulates globally; it does not descend daily. But when Qi arrives and meets, the attack occurs, so both pathogens and Wei Qi appear to descend one segment daily.) Therefore, if pathogens strike the head/neck, the attack occurs when Wei Qi reaches the head/neck; if striking the back, when it reaches the back; if striking the waist/spine, when it reaches the waist/spine; if striking hands/feet, when it reaches hands/feet. (Qi arrival refers to Wei Qi arrival. Attack occurs upon combination with pathogens, ensuring timed accumulation and eruption.) Wherever Wei Qi is located, if it combines with pathogens, an attack occurs. Thus, Wind has no fixed Fengfu. Wherever Wei Qi activates, it opens Cou Li; wherever pathogens combine, that is their "Fu" (Abode). ("Fu" gathers substances; thus, wherever Wind resides is Fengfu. Wei Qi arrival opens Cou Li, allowing pathogen re-entry. Thus, regardless of direction, pathogens can invade anywhere, and any invasion site can be called Fengfu, hence "Wind has no fixed Fengfu".) Huangdi said: Excellent. Wind and malaria are similar and of the same category, yet wind persists constantly while malaria has remissions. Why? (Here, "Wind" refers to Wind diseases. Both arise from Wind, appearing similar; however, Wind is continuous, while Malaria has pauses, requiring differentiation.) Qibo replied: Wind Qi remains in its location, hence constant; Malaria Qi follows meridians, sinking and pressing inward, hence triggered by Wei Qi response. (Wind stays fixed; Malaria flows and changes. "Sinking and pressing inward" denotes depth, i.e., pressing Zang organs and connecting to Muyuan, requiring Wei Qi response to trigger attacks.)

Huangdi asked: Why does some malaria present with cold first, then heat? Qibo replied: Summer injury by intense heat causes profuse sweating and open Cou Li. Encountering cool/cold water in summer, pathogens hide in Cou Li and skin. Autumn wind injury completes the disease. (Cool/cold water refers to bathing/cooling. Heatstroke combined with cold closes Cou Li, stops sweating, hiding cold pathogens in skin. Autumn clear air brings external wind, triggering disease.) Cold is Yin Qi; Wind is Yang Qi. Injury by cold first, then wind, causes cold first, then heat, occurring at set times, named Cold Malaria (Han Nue). (First Yin, then Yang pathogen; hence cold then heat. Most malaria cases fall into this type.)

Huangdi asked: Why does some malaria present with heat first, then cold? Qibo replied: Injury by wind first, then cold, causes heat first, then cold, occurring at set times, named Warm Malaria (Wen Nue). (First Yang, then Yin pathogen; hence heat then cold.)

Only heat without cold occurs when Yin Qi is exhausted and Yang Qi acts alone. Symptoms include shortness of breath, oppression, hot hands/feet, and nausea, named Dan Malaria (Damp/Hot Malaria). ("Dan" means heat. Solitary Yang excess causes heat without cold and oppression. Interior/exterior involvement causes hot extremities and nausea due to heat affecting the Stomach. "Dan" is pronounced dān, also shǎng/qù tones.)

Huangdi asked: Classics state: Excess requires draining, deficiency requires tonifying. Heat is excess; cold is deficiency. In malaria, cold cannot be warmed by fire/water; heat cannot be cooled by ice/water. These are excess/deficiency patterns. At such times, even skilled physicians cannot stop the condition; treatment must wait for natural decline before acupuncture. Why? I wish to understand. (This section discusses malaria variations. Waiting for natural decline means not treating during active attack.) Qibo replied: Classics say: Do not needle when heat is blazing (citing *Lingshu: Nishun Pian*. "He" indicates peak heat. Avoiding needling prevents confronting sharp pathogenic force. "He" is pronounced hè/xiāo/hū mù). Do not needle when pulse is turbid (turbid pulse indicates indeterminate Yin/Yang deficiency/excess; uncertainty risks error). Do not needle when sweating profusely (Lulu indicates heavy sweating; pathogen/Zheng distinction unclear). Treating these three ways opposes pathogenic Qi and is untreatable. (At malaria onset, Yang merges into Yin; Yang is deficient, Yin excess, exterior lacks Qi, causing chills. This is Yin excess/Yang deficiency. Wei Qi merging into Yin causes exterior deficiency. Extreme Yin reversal exits to Yang; Yang/Yin merge externally, causing Yin deficiency/Yang excess, leading to heat/thirst. Qi extreme internally returns externally; Yin deficiency/Yang excess causes heat/thirst. Malaria Qi: merging Yang causes Yang excess; merging Yin causes Yin excess. Yin excess = cold; Yang excess = heat. This explains cold/heat variations. Malaria wind-cold is irregular; extreme conditions reverse. Yin/Yang fluctuate; cold-then-heat is Yin extreme returning to Yang; heat-then-cold is Yang extreme returning to Yin. Attacks are fierce like fire/storms. Hence classics say: Needling during peak causes damage; treating during decline ensures success. This means waiting for decline before needling. Before attack, Yin hasn't merged into Yang, Yang hasn't merged into Yin; regulating then allows Zheng Qi to rest and pathogens to vanish. Physicians cannot treat active attacks due to Qi reversal.) Huangdi asked: How to treat? Timing? Qibo replied: Before attack, Yin/Yang shift begins at four extremities. Yang injured, Yin follows. Bind firmly before onset to block pathogen entry and Yin exit. Observe Sun Luo (collateral vessels); needle those full, hard, and bloody. This preserves Zheng Qi before pathogen merger. (Shift begins at extremities because Jing-Yuan Qi of twelve meridians originates there. Pre-attack chill in limbs is the sign. Binding at Four Gates prevents pathogen flow. Needle full Sun Luo collaterals. Northern people practice this, bleeding to release cold, aligning with this principle. Allows Zheng Qi circulation, blocking pathogen merger.) Huangdi asked: What are signs when malaria is not attacking? Qibo replied: Malaria Qi alternates excess/deficiency. Where Qi resides: Yang location = heat/restless pulse; Yin location = cold/quiet pulse. (Non-attack phase requires observing Qi location. Cold/heat and pulse restlessness/quietness distinguish Yin/Yang pathology.) At extremes, Yin/Yang both decline, Wei Qi separates, disease rests; Wei Qi gathers, disease recurs. (Whether in Yin or Yang, extreme excess leads to mutual decline, separating from Wei Qi, causing rest. When Wei Qi arrives, pathogen/Zheng struggle resumes disease.) Huangdi asked: Why some attack every two days or several days, some thirsty, some not? Qibo replied: Every-other-day attacks occur because pathogens and Wei Qi reside in Six Fu organs, sometimes missing each other, causing multi-day rests. ("Ke" means meeting. Pathogens in Fu organs are distant/rare meetings, causing 2-day or multi-day intervals. Note: Zhu Danxi linked attack days to Yin meridians (Zi/Wu/Mao/You = Shaoyin; Yin/Shen/Si/Hai = Jueyin; Chen/Xu/Chou/Wei = Taiyin). This uses Six Qi theory but is flawed (e.g., Mao/You are Yangming, not Shaoyin). Applying this rigidly is erroneous. Learners should not follow blindly.) Malaria involves Yin/Yang alternation; severity varies, hence thirst variation. (Yang excess = severe heat = thirst.) Huangdi asked: Classics say summer heat leads to autumn malaria. Why not always? (Referring to *Shengqi Tongtian Lun* and *Yinyang Yingxiang Dalun*.) Qibo replied: This follows seasons. Atypical forms oppose seasons. (Summer heat -> autumn malaria follows seasons. Malaria in spring/summer/winter has different forms because seasonal Qi (cold/heat) varies and can cause malaria.) Autumn malaria: severe cold (post-summer heat, new coolness binds, Yin/Yang clash). Winter malaria: mild cold (Yang hides internally). Spring malaria: aversion to wind (Yang escapes, Cou Li opens, residual cold remains). Summer malaria: profuse sweating (intense heat steams surface). Huangdi asked: Where do Warm Malaria and Cold Malaria lodge? Which Zang? ("An she" asks for location.) Qibo replied: Warm Malaria arises from winter wind-cold. (Wind is Yang but has cold nature; wind-cold are grouped.) Pathogens hide in bone marrow. Spring Yang expansion traps pathogens. Summer heat scorches brain/marrow, consumes muscles, opens Cou Li, or exertion forces pathogens out with sweat. Disease lodges in Kidney, emerging from interior to exterior. (Kidney corresponds to winter/bone marrow. Winter wind-cold latent in marrow triggers in spring warmth or summer heat, emerging internally to externally.) Such cases have Yin deficiency/Yang excess, causing heat. (Emerging Yin to Yang creates Yin deficiency/Yang excess.) Decline causes Qi to return inward; inward return causes Yang deficiency, leading to cold. Hence heat first, then cold, named Warm Malaria. (Yang extreme declines, returning to Yin, hence heat then cold...