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Qibo said: When humans are injured by cold pathogens, they develop febrile diseases. Although the heat may be severe, it is not fatal. (Supplement: Cold toxins invade the skin and muscles, preventing the dispersal of yang qi, which becomes internally constrained; thus, cold injuries manifest as heat.) However, if both exterior and interior meridians are simultaneously affected by cold, death is inevitable.

Huangdi said: I wish to understand the manifestations of this condition.

Qibo said: On the first day of a cold injury, the Taiyang meridian (Foot-Taiyang Bladder Meridian, the commander of all yang meridians) is affected. The Taiyang meridian governs the qi of all yang meridians because its collaterals, blood, qi, ying, and wei circulate throughout the body. Its vessels connect to the Fengfu acupoint, making it the master of yang qi. Consequently, symptoms include headache, stiffness of the neck and back, and pain in the waist and spine.

On the second day, the Yangming meridian (Foot-Yangming Stomach Meridian) is affected. Yangming governs the flesh; its vessels run along the nose and connect to the eyes. Symptoms include fever, eye pain, dryness of the nose, and inability to sleep. (Supplement: Fever arises because the flesh is invaded by pathogens, causing irritability and heat in the stomach.)

On the third day, the Shaoyang meridian (Foot-Shaoyang Gallbladder Meridian) is affected. Shaoyang governs the gallbladder; its vessels traverse the hypochondrium and connect to the ears. Symptoms include pain in the chest and hypochondrium, and deafness. If the disease affects these three yang meridians but has not yet entered the zang organs, it can be cured by inducing sweating.

On the fourth day, the Taiyin meridian (Foot-Taiyin Spleen Meridian) is affected. Taiyin spreads through the stomach and connects to the throat. Symptoms include abdominal fullness and dryness of the throat.

On the fifth day, the Shaoyin meridian (Foot-Shaoyin Kidney Meridian) is affected. Shaoyin passes through the kidneys, connects to the lung system, and reaches the root of the tongue. Symptoms include dry mouth, dry tongue, and thirst.

On the sixth day, the Jueyin meridian (Foot-Jueyin Liver Meridian) is affected. Jueyin traverses the genitalia and connects to the liver. Symptoms include vexation, abdominal fullness, and contraction of the scrotum.

Huangdi asked: How should this be treated?

Qibo replied: Treatment should focus on unblocking the meridians of the respective organs. As the pathogenic factors decline, the illness will resolve. If the duration is less than three days, induce sweating. If it exceeds three days, use purgation.

In cases where exterior and interior meridians are simultaneously affected: On the first day, Taiyang and Shaoyin are both diseased, presenting with headache, dry mouth, and vexation/fullness. On the second day, Yangming and Taiyin are both diseased, presenting with abdominal fullness, fever, anorexia, and delirium (supplement: referring to incoherent speech or excessive talking). On the third day, Shaoyang and Jueyin are both diseased, presenting with deafness, scrotal contraction, cold limbs, inability to swallow fluids, and unconsciousness. Death occurs by the sixth day (Note: "Sixth day" likely refers to the third day based on subsequent text). If all three yin and yang meridians and the five zang and six fu organs are affected, and the circulation of ying and wei qi ceases while the five zang organs become blocked, death ensues.

Huangdi asked: If the five zang organs are damaged, the six fu organs are blocked, and ying and wei qi do not circulate, why does death occur three days later?

Qibo explained: The Yangming meridian is the leader of the twelve meridians (the sea of blood and qi of the twelve meridians). Its blood and qi are most abundant. Therefore, after a person loses consciousness for three days, when their qi is exhausted, they die.

For those not suffering from simultaneous exterior-interior infection: On the seventh day, the Taiyang disease declines, and headache improves slightly. On the eighth day, Yangming disease declines, and body heat subsides slightly. On the ninth day, Shaoyang disease declines, and hearing improves slightly. On the tenth day, Taiyin disease declines, abdominal fullness resolves, appetite returns. On the eleventh day, Shaoyin disease declines, thirst stops, bloating ceases, tongue dryness resolves, and sneezing occurs. On the twelfth day, Jueyin disease declines, the scrotum relaxes, lower abdominal discomfort subsides, and major pathogenic factors are expelled, leading to recovery.

Regarding cold injuries transforming into warm diseases: Those occurring before the Summer Solstice are called Warm Diseases (Wen Bing); those occurring after are called Summerheat Diseases (Shu Bing). Summerheat diseases should be treated by allowing sweat to escape; do not forcibly stop sweating. (Summerheat differs from thirst-related conditions; summerheat requires sweating, whereas thirst does not.)

Huangdi asked: Why do residual heat persist after a febrile disease has seemingly resolved?

Qibo answered: Residual heat occurs when food is consumed forcefully while heat is still intense. Even if the pathogen has declined, heat remains latent. The qi from food interacts with residual heat, combining to create lingering heat.

Huangdi asked: How should residual heat be treated?

Qibo replied: Assess deficiency and excess, and regulate the reversal and normal flow of qi. This ensures recovery. (Supplement: By examining deficiency/excess and applying tonification or drainage, recovery is guaranteed.)

Huangdi asked: What dietary restrictions apply to febrile diseases?

Qibo stated: If meat is eaten when the fever begins to subside, the disease will relapse. Overeating causes residual heat. These are the prohibitions. (Supplement: This warns against dietary indiscretion. Although heat subsides slightly, spleen and stomach qi are weak and cannot digest tough meat, leading to stagnation and regeneration of heat.)

Huangdi asked: There is a condition called Warm Disease where sweating is followed immediately by renewed fever, rapid and restless pulse that does not slow with sweat, delirium, and an inability to eat. What is this disease named?

Qibo replied: This is called Yin-Jiao (Yin-Yang Intersection), which is a fatal condition. (Jiao means intersection, where yin and yang qi mix without separation.)

Sweat is generated from grain qi transforming into essence. Now, if pathogens contend with essence in the muscles and bones, and sweat is produced, it indicates that pathogens are retreating and essence is victorious. If essence is victorious, the patient should be able to eat and not have recurrent fever. Recurrent fever indicates pathogenic victory. Sweat is derived from essence; if fever recurs after sweating, it shows pathogen victory. Inability to eat means essence has no source for replenishment (Supplement: Grain transforms into essence; inability to eat means essence lacks support). If the disease lingers, life will soon end. Furthermore, the *Heat Treatise* states: If pulse remains rapid and full after sweating, death is certain. Here, sweat and pulse are discordant, indicating righteous qi cannot overcome pathogenic qi. Death is evident. Delirium indicates loss of Zhi (will/mind), which is fatal. Seeing three signs of death and no sign of life means death is inevitable despite temporary improvement.

Huangdi asked: Malaria is caused by wind, yet it has periodic attacks and remissions. Why?

Qibo explained: Malaria initially presents with piloerection, yawning, followed by chills and shaking of the jaw, pain in the waist and spine. After chills cease, internal and external heat arise, causing severe headache, thirst, and desire for cold drinks.

Huangdi asked: What qi causes this?

Qibo replied: It is due to the contention between yin and yang, shifting between deficiency and excess, and the migration of yin and yang qi. When yang qi merges into yin, yin becomes full and yang deficient. Yangming deficiency causes chills and jaw shaking. Taiyang deficiency causes pain in the waist, back, head, and neck. If all three yang meridians are deficient, yin pathogens prevail, causing bone cold and pain. Internal cold leads to external cold. Yang excess causes external heat; yin deficiency causes internal heat. External and internal heat cause panting, thirst, and desire for cold drinks.

This results from summer heat injuring the body during summer. Heat resides inside the skin and outside the intestines/stomach, where ying qi dwells. This makes pores loose and interstices open. Autumn coolness, wind encountered during sweating, or water from bathing enters the skin and resides with wei qi.

Wei qi travels through yang during the day and yin at night. This malaria qi follows wei qi outward to yang (early onset) or inward to yin (late onset). Their interaction causes daily attacks.

Huangdi asked: Why do some cases attack every other day?

Qibo replied: The malaria qi hides deeply, pressing against yin. Only wei qi moves independently. Yin pathogens reside internally, contending with yang (wei qi), unable to exit, causing every-other-day attacks. (Supplement: Pathogen strength varies with righteous qi. When righteous qi is strong, pathogens thrive; when weak, they recede. Eventually, organ qi weakens, malaria qi also weakens, unable to contend with wei qi. It takes two to three days for qi to accumulate, allowing pathogens to thrive again, leading to recurrence.)

When malaria qi merges with yang, yang prevails; when it merges with yin, yin prevails. Yin prevalence causes cold; yang prevalence causes heat.

Huangdi asked: Why does some malaria start with cold then heat?

Qibo replied: Summer heat causes profuse sweating and open pores. Winter cold hides in the interstices. Autumn wind completes the pathology. Cold is yin, wind is yang. Injury by cold first, then wind, results in cold preceding heat. This is called Cold Malaria.

Why does some malaria start with heat then cold?

Qibo replied: Injury by wind first, then cold, results in heat preceding cold. This is called Warm Malaria.

What about malaria with only heat and no cold?

Qibo replied: This is Dan Malaria. Yin qi is exhausted, and yang qi acts alone. Symptoms include shortness of breath, vexation, hot hands and feet, and nausea.

Huangdi asked: Why can neither fire nor ice control the temperature fluctuations in malaria? Why must treatment wait for natural decline?

Qibo replied: Classics state: Do not needle when heat is extreme, pulse is chaotic, or sweating is profuse. At these times, pathogenic qi is rebellious. Needle when qi is盛 (excessive/strong) damages righteous qi; needle when qi is declining ensures success.

At the onset of malaria, yang merges into yin, causing external cold. When yin reverses and merges with yang externally, yin becomes deficient and yang excess, causing heat and thirst. Treatment should occur before onset when yin and yang are not yet merged, allowing righteous qi to rest and pathogens to vanish. Treating during发作 (attack) fails because qi is rebellious.

To treat: Bind the extremities firmly before onset to prevent pathogen entry and righteous qi exit. Observe for full and hard sun-collaterals with blood stasis, and puncture them. This targets the pathogen before it merges with righteous qi.

When malaria is not attacking, what is the pulse like?

Qibo replied: Malaria qi fluctuates between excess and deficiency. When in yang, heat and rapid pulse occur; when in yin, cold and quiet pulse occur. At extremes, both yin and yang decline. Wei qi separates from pathogens, and the disease rests. When wei qi gathers, the disease recurs. Malaria involves alternating yin-yang victory. Thirst depends on whether yang overcomes yin significantly.

Huangdi asked: You said summer heat leads to autumn malaria. Why don't all cases follow this?

Qibo replied: Most follow the four seasons. Deviations occur due to different pathological forms. Autumn cases have severe cold; winter cases have mild cold; spring cases involve aversion to wind; summer cases involve profuse sweating.

Huangdi asked: Where does the pathogen of Warm Malaria reside? Which zang organ?

Qibo replied: Warm Malaria originates from winter wind-cold hiding in the bone marrow. In spring, rising yang qi cannot expel the pathogen. Summer heat burns brain marrow, consumes muscle, opens pores, or physical exertion forces pathogen out with sweat. The pathogen resides in the Kidney, moving from interior to exterior. Yin deficiency and yang excess cause heat. Decline allows qi to re-enter, causing yang deficiency and cold. Thus, heat precedes cold: Warm Malaria.

What about Dan Malaria?

Qibo replied: Dan Malaria patients have prior lung heat. Qi rushes upward, middle jiao is full but cannot vent externally. Physical exertion opens pores, allowing wind-cold to lodge in skin and muscle layers. Attack causes isolated yang excess without decline, leading to disease. Qi does not reach yin, so only heat occurs without cold. Cold resides in the Heart, exteriorly in muscles, consuming flesh. Hence, Dan Malaria.

Huangdi asked: Why do some heat/cold patterns resemble malaria but vary in frequency?

Qibo replied: It depends on the meeting of winning and retaliatory qi. More yin/fewer yang means distant intervals; more yang/fewer yin means close intervals. Malaria follows similar laws of盛衰 (excess/decline).

Huangdi asked: Why does the Lung cause cough?

Qibo replied: All five zang and six fu organs can cause cough, not just the Lung.

Huangdi asked: Explain the details.

Qibo replied: Skin and hair are the exterior of the Lung. Pathogens enter via skin/hair. Cold food entering the stomach travels up the Lung meridian, cooling the Lung. Internal and external cold combine, lodging in the Lung, causing Lung Cough. Each zang is susceptible in its ruling season. If not the ruling season, transmission occurs. Humans resonate with heaven and earth. Mild cold causes cough; severe cold causes diarrhea or pain.

Autumn: Lung affected first. Spring: Liver. Summer: Heart. Late Summer (Earth): Spleen. Winter: Kidney.

How to distinguish?

Lung Cough: Cough with wheezing, sounds in throat, hemoptysis in severe cases.
Heart Cough: Cough with heart pain, sensation of obstruction in throat, severe sore throat/pharyngitis.
Liver Cough: Cough with hypochondriac pain, inability to turn, severe distension.
Spleen Cough: Cough with right hypochondriac pain radiating to shoulder/back, worsened by movement.
Kidney Cough: Cough with pulling pain in waist and back, severe salivation.

What about Six Fu Coughs?

Prolonged Spleen Cough transmits to Stomach. Stomach Cough: Cough with vomiting, severe expulsion of parasites.
Prolonged Liver Cough transmits to Gallbladder. Gallbladder Cough: Cough with bitter bile vomiting.
Prolonged Lung Cough transmits to Large Intestine. Large Intestine Cough: Cough with fecal incontinence.
Prolonged Heart Cough transmits to Small Intestine. Small Intestine Cough: Cough with flatus.
Prolonged Kidney Cough transmits to Bladder. Bladder Cough: Cough with urinary incontinence.
Prolonged cough transmits to Sanjiao (Triple Burner). Sanjiao Cough: Cough with abdominal fullness and anorexia.

These conditions gather in the Stomach and relate to the Lung, causing excessive phlegm/saliva, facial edema, and rebellious qi.

Huangdi asked: How to treat?