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Huangdi asked, "Malaria is all caused by wind pathogen. Why does it have a specific time for its accumulation and recurrence?" Qibo replied, "When malaria first begins to manifest, it starts with the erection of fine hairs, followed by stretching and yawning. Then chills occur, with trembling of the jaw, and pain in the waist and spine. When the cold subsides, both the interior and exterior become hot, causing severe headache as if splitting, and thirst for cold drinks." The Emperor said, "What qi causes this? I wish to hear the principle." Qibo said, "It is due to the contention between Yin and Yang above and below, the alternation of deficiency and excess, and the shifting of Yin and Yang. When Yang merges into Yin, Yin becomes full and Yang becomes deficient. Deficiency of the Yangming meridian leads to chills and jaw trembling; deficiency of the Greater Yang (Taiyang) meridian leads to pain in the back, head, and neck; when all three Yang meridians are deficient, Yin qi prevails. Prevailing Yin qi causes bone coldness and pain. Cold generated internally results in coldness inside and out. Excess Yang causes external heat, while Yin deficiency causes internal heat. When both interior and exterior are hot, panting and thirst occur, hence the desire for cold drinks. All these result from summer damage by summer-heat. The intense heat qi hides within the skin but outside the stomach and intestines, where Ying Qi resides. This causes sweat pores to be open and interstices to relax. Consequently, autumn air can invade; sweat exposed to wind, or bathing water entering the skin, allows water qi to reside within the skin, coexisting with Wei Qi. Wei Qi travels through Yang during the day and Yin at night. This pathogen moves outward when encountering Yang and presses inward when encountering Yin. The mutual pressing of interior and exterior pathogens results in daily attacks." The Emperor said, "Why do some cases attack every other day?" Qibo said, "Because the pathogen resides deeply, pressing inward on Yin. Yang Qi alone erupts externally, while Yin pathogen adheres internally. Yin and Yang contend but cannot exit together, hence the every-other-day attack." The Emperor said, "Good. Why do some attacks occur later each day, while others occur earlier? What qi causes this?" Qibo said, "The pathogen lodges in Fengfu (GV16) and descends along the Du meridian. Wei Qi gathers at Fengfu once every day and night. The next day, it descends one vertebral level. Thus, the attack is delayed. This is because the pathogen first lodged in the back. Whenever it reaches Fengfu, the interstices open. When interstices open, the pathogen enters. When the pathogen enters, the disease manifests. Therefore, the attack time gradually delays. From Fengfu, descending one level daily, after twenty-five days it reaches the sacrum. On the twenty-sixth day, it enters the spine, pouring into the Fu Lü vessel. Its qi ascends, emerging from Quepen (ST12) after nine days. As the qi rises daily, the attack occurs earlier each day. For every-other-day attacks, the pathogen presses inward on the Zang organs and connects horizontally to the Mu Yuan (sea of origin). The path is long, the qi is deep, and its movement is slow. It cannot move with Wei Qi nor exit together, so it manifests only every other day." The Emperor said, "You stated that whenever Wei Qi reaches Fengfu, the interstices open, allowing the pathogen to enter and cause disease. Now, since Wei Qi descends one level daily, its eruption no longer corresponds to Fengfu. Why does it still attack daily?" Qibo said, "This is because the pathogen lodged in the head and neck and descended along the Du meridian. Thus, deficiency and excess differ, and the site of pathogen invasion differs, so it does not necessarily correspond to Fengfu. Therefore, if the pathogen invades the head and neck, disease manifests when Qi reaches the head and neck; if it invades the back, disease manifests when Qi reaches the back; if it invades the waist and spine, disease manifests when Qi reaches the waist and spine; if it invades the hands and feet, disease manifests when Qi reaches the hands and feet. Wherever Wei Qi is located, if it combines with the pathogen, disease manifests. Thus, Wind has no fixed abode. Wherever Wei Qi erupts, opening the interstices, and where the pathogen combines, there lies its abode." The Emperor said, "Good. Wind and Malaria are similar and of the same category, yet Wind persists constantly, while Malaria has periods of rest. Why?" Qibo said, "Wind pathogen remains in its location, thus persisting. Malaria pathogen follows the collaterals and sinks inward, thus manifesting only when Wei Qi responds." The Emperor said, "Why does some Malaria begin with chills followed by fever?" Qibo said, "Summer damage by extreme heat causes profuse sweating and open interstices. Encountering cold water qi from summer, cold pathogen hides in the interstices and skin. Autumn damage by wind completes the disease. Cold is Yin Qi; Wind is Yang Qi. Injury by cold first, then by wind, results in chills first, then fever. Manifesting at regular times, it is named Han Nüe (Cold Malaria)." The Emperor said, "Why does some Malaria begin with fever followed by chills?" Qibo said, "Injury by wind first, then by cold, results in fever first, then chills. Manifesting at regular times, it is named Wen Nüe (Warm Malaria). If there is only fever without chills, it is because Yin Qi is exhausted first, and Yang Qi erupts alone. This causes shortness of breath, vexation, heat in the hands and feet, and desire to vomit. It is named Dan Nüe (Intense Heat Malaria)."

The Emperor said, "The Classics state: excess is drained, deficiency is tonified. Now, heat is excess, and cold is deficiency. In Malaria, chills are such that soup and fire cannot warm them; fever is such that ice and water cannot cool them. These belong to excess and deficiency. At such times, even skilled physicians cannot stop it; they must wait for spontaneous decline before needling. Why? I wish to hear the explanation." Qibo said, "The Classics state: Do not needle when heat is high; do not needle when the pulse is chaotic; do not needle when sweat is dripping. Because the disease pattern is reversed, treatment is not possible. When Malaria first manifests, Yang merges into Yin. At this time, Yang is deficient and Yin is abundant. There is no Qi on the exterior, hence chills and trembling occur first. When Yin Qi reverses to its extreme, it returns to Yang. Yang and Yin merge again on the exterior, resulting in Yin deficiency and Yang excess. Hence, fever and thirst occur first. The Malaria pathogen, merging into Yang, makes Yang prevail; merging into Yin, makes Yin prevail. Yin prevailing causes cold; Yang prevailing causes heat. The wind-cold qi of Malaria is not constant; when the disease reaches extremity, it recurs. When Malaria manifests, the heat is like fire, fierce like wind and rain. Thus, the Classics say: 'When the pathogen is strong, attacking will destroy [the patient]; when it is weak, treating will prosper.' This refers to this situation. Before Malaria manifests, Yin has not merged into Yang, and Yang has not merged into Yin. Regulating at this time allows True Qi to settle and Pathogenic Qi to perish. Thus, skilled physicians cannot treat after manifestation because the Qi is reversed." The Emperor said, "Good. How should it be attacked? When should it be treated?" Qibo said, "When Malaria is about to manifest, Yin and Yang are about to shift. It must start from the four extremities. Yang is already injured, and Yin follows. Therefore, bind the area firmly before the onset, preventing pathogen entry and Yin Qi exit. Carefully observe and take any Sun Luo (collaterals) that are full, hard, and bloody. This is when True Qi goes forth but has not yet been merged by the pathogen." The Emperor said, "What is the response when Malaria is not manifesting?" Qibo said, "Malaria pathogen alternates between abundance and deficiency. Depending on its location: if in Yang, there is heat and a restless pulse; if in Yin, there is cold and a quiet pulse. At the extreme, both Yin and Yang decline, and Wei Qi separates, so the disease rests. When Wei Qi gathers, the disease recurs." The Emperor said, "Sometimes Malaria occurs after two days or several days, sometimes with thirst, sometimes without. Why?" Qibo said, "For those occurring after intervals, the pathogen and Wei Qi reside in the Six Fu organs but sometimes miss each other, unable to interact, hence resting for several days before manifesting. Malaria is the alternating prevalence of Yin and Yang. Sometimes it is severe, sometimes not, hence sometimes thirsty, sometimes not." The Emperor said, "Discourses state: Summer damage by summer-heat leads to Autumn Malaria. Why do current cases not always correspond?" Qibo said, "This corresponds to the Four Seasons. Cases with different manifestations go against the seasons. Those manifesting in Autumn have severe cold; those in Winter have mild cold; those in Spring fear wind; those in Summer sweat profusely." The Emperor said, "Where do the pathogens of Wen Nüe and Han Nüe lodge? Which Zang organ?" Qibo said, "Wen Nüe originates from winter wind injury. Cold qi hides in the bone marrow. By spring, Yang Qi erupts greatly, but the pathogen cannot exit spontaneously. Encountering great summer heat, the brain marrow melts, muscles waste, interstices vent, or due to exertion, the pathogen exits with sweat. This disease lodges in the Kidney. Its Qi first emerges from the interior to the exterior. In such cases, Yin is deficient and Yang is excessive. Yang excess causes heat. When it declines, Qi returns inward. Inward return causes Yang deficiency, leading to cold. Hence, fever first, then chills, named Wen Nüe." The Emperor said, "What about Dan Nüe?" Qibo said, "Dan Nüe patients have pre-existing heat in the Lungs, with heat filling the body. Rebellious Qi rushes upward, Middle Jiao Qi is full but does not vent outward. Due to exertion, interstices open, and wind-cold lodges between the skin and muscle layers. Upon manifestation, Yang Qi becomes excessive. If Yang excess does not decline, disease occurs. Its Qi does not reach Yin, hence only fever without chills. The Qi lodges internally in the Heart and externally in the muscle layers, causing wasting and emaciation. Hence named Dan Nüe." The Emperor said, "Good."