《黃帝內經素問補註釋文》Vol. 22

The Yellow Emperor asked: when a person suffers from warm disease, sweats, and then quickly develops fever again, with a rapid and agitated pulse, and the illness does not ease after sweating, with delirium and an inability to eat, what is this disease called?

Qi Bo replied that this disease is called "yin-yang jiao" (the crossing of yin and yang), and that anyone who contracts it will die. "Jiao" refers to yin and yang qi mixing together until they can no longer be distinguished.

The Emperor said, "Please explain the principle behind this."

Qi Bo said that a person is able to sweat because of the grain qi (guqi) produced from food and drink, and grain qi in turn generates essential qi (jingqi). When essential qi is abundant, it can be transformed into sweat. When pathogenic qi contends with the body's flesh and bones, sweating shows that the pathogen is retreating and essential qi has gained the upper hand. This describes the initial stage of sweating.

When essential qi prevails, the patient should be able to eat, and fever should not return. If fever returns, the pathogen is still present. Sweat is formed from essential qi, so if sweating is immediately followed by fever again, the pathogen has the upper hand. The inability to eat indicates that essential qi is insufficient and lacks the strength to produce sweat. "Lacking strength" here means there is no essential qi available to mobilize and transform into sweat. When food and drink cannot be digested, essential qi cannot be generated.

If the pathogen lingers and does not leave, the patient's life will soon be in danger. In other words, if the illness persists without subsiding, the patient will quickly face a threat to life. The New Collation notes that the character "bing" (illness) in Wang Bing's commentary may instead be "ji" (sickness), and that the Jiayi Jing writes this passage as "and the heat remains."

The Treatise on Warm Diseases states: "After sweating, if the pulse remains agitated and forceful, the patient will die." The Treatise on Warm Diseases refers to the ancient text of that name. Ordinarily, after sweating, the pulse should become slow and calm. If instead it remains rapid, agitated, and full, this shows that upright qi is exhausted while pathogenic qi still prevails, and so the condition is judged to be critical.

Now the pulse has not calmed with sweating, which shows that the body cannot overcome the pathogen, and the signs of death are already evident.

Speaking nonsense indicates a disturbance of shen (spirit), and a person whose shen is disturbed will die. Shen depends on essential qi. Now that essential qi is insufficient, shen has nothing to rely upon, and without a stable base it cannot remain settled, so it becomes disordered.

Three dangerous signs have now appeared, and not a single sign of vitality can be seen. Even if the symptoms temporarily improve, the patient will ultimately die.

If there is sweating together with a pulse that is agitated and surging, this is the first kind of death sign. When the illness exceeds what the body can bear, this is the second. When a person speaks wild words and loses clarity of mind (shen, spirit), this is the third.

The Yellow Emperor asked: Suppose someone has a fever and sweats, and also feels vexation and fullness, but the vexation and fullness are not relieved by the sweating. What illness is this?

Qi Bo replied: Fever with sweating means the person has been struck by wind pathogen. Vexation that persists after sweating is reversal (jueni), meaning the qi (vital energy) has risen against its proper course. This illness is called "wind reversal" (fengjue).

The Yellow Emperor asked: Please explain the reasoning in detail.

Qi Bo said: The Foot Taiyang channel, here the Foot Taiyang Bladder channel, governs the qi of the body, so it is the first to be invaded by pathogenic qi. The Foot Shaoyin channel, here the Foot Shaoyin Kidney channel, is interiorly and exteriorly related to the Taiyang. When heat pathogen enters, the qi of Shaoyin rises along with it. When the qi rises against its course, reversal forms. The "rising" mentioned here means that the qi of Shaoyin moves upward following the qi of Taiyang.

The Yellow Emperor asked: How should it be treated?

Qi Bo replied: Needling should address both the interior and the exterior, and decoctions should also be given. Needling both the interior and exterior means draining the Taiyang channel and tonifying the Shaoyin channel. Giving decoctions is meant to calm the kidney qi that is surging upward.

The Yellow Emperor asked: What kind of illness is laofeng (wind from exhaustion)?

Qi Bo replied: Laofeng lies beneath the lungs. It arises when exhaustion weakens the body and then wind pathogen is contracted, which is why it is called "laofeng." Here, "lao" refers to depletion of the kidneys. The Kidney channel runs upward from the kidneys, passes through the liver and diaphragm, and enters the lungs. Therefore, once the kidneys are depleted, wind pathogen can rise, disturb the body, and lodge beneath the lungs.

This illness causes stiffness of the head and neck, a tendency to tilt the head back, and dim, unclear vision. The commentators explain that "mingshi" means being unable to see clearly even with the eyes closed, while the Qianjin Fang (Thousand Gold Prescriptions) gives it as "dizziness" (muxuan). The patient also coughs up phlegm and mucus resembling nasal discharge, is averse to wind, and may develop chills and shivering. This is because the Bladder channel begins at the inner corner of the eye, rises over the forehead and crown, enters the brain, then descends through the neck and nape, down the shoulders and back, along the spine to the lumbar region, and connects with the kidneys. When kidney essence (jing) is insufficient, the qi of the Bladder cannot rise to nourish the head and eyes, so the head and neck become stiff and vision becomes unclear. When wind pathogen invades the lungs and the exhausted qi steams upward, it produces phlegm resembling nasal mucus. When kidney qi is deficient, yang qi stirs and attacks from within, and the exhaustion-heat combines with it, so the patient becomes averse to wind and develops chills and shivering.

The Yellow Emperor asked: How should it be treated?

Qi Bo replied: The patient must be stopped from bending forward, leaning back, and performing other repeated movements. Here, "jiu" (rescue) means to stop. In other words, the patient should cease bending and stretching so that the exhausted qi does not grow worse.

When the Taiyang channel stirs the jing (essence), if the patient is in the prime of life, changes will appear within three days. If the patient is older, changes appear in five days. If the jing is deficient, seven days are needed. The commentators note, citing the Jiayi Jing (Classic of Acupuncture and Moxibustion), that this passage also has a variant reading: "within three days, or five days."

Coughing up thick, greenish-yellow phlegm that resembles pus, about the size of a pellet, and expelling it from the mouth or nose. If it cannot be expelled, the lungs are injured, and when the lungs are injured, the person dies.

"Juyang" (Greater Yang) refers to the Bladder channel. The Bladder and the Kidney are interiorly and exteriorly related, so the Greater Yang can guide jing (essence) qi. This passage says that the qi of the Greater Yang channel draws jing qi upward until it surges into the lungs. In a person of robust constitution, thick phlegm may be coughed up after three days; in an elderly or frail person, after five days; and in one who does not usually nourish the body with jing, after seven days. The phlegm is greenish-yellow, like pus. When the illness is mild, coughing brings the phlegm up through the throat and out the mouth. When a sudden, violent cough occurs, the breath strikes the "Xumen" (Storage Gate) inside the body and is expelled through the nose. In every such case, the cause is excessive depletion of kidney qi, internal deficiency of lung qi, and urgent yang qi surging upward. If the phlegm cannot be expelled, the lungs are injured. Once the lungs are injured, yingqi (nutritive qi) and weiqi (defensive qi, the qi that sustains bodily movement and guards against external pathogens) become scattered, and the po (the aspect of spirit tied to the body's instinctive activities) cannot remain secure, so death follows.

The Xin Jiaozheng (New Collation) notes that Wang Bing's commentary states that during a sudden, violent cough, qi surges into the "Xumen" and is expelled through the nose. However, the Nanjing (Classic of Difficulties) contains no term "Xumen," and it is suspected that the correct term here is "Benmen" (Cardiac Gate, or Surging Gate). Yang Cao explains that "ben" is related to the diaphragm, and that stomach qi circulates out from this point. The stomach transmits the qi transformed from grain up to the lungs, and since the lungs lie above the diaphragm, the stomach is called the "Benmen."

Huangdi (the Yellow Emperor) asked: Someone suffers from kidney wind, with swelling of the face and impaired speech. Can acupuncture treat this?

"Mengran" describes a state of swelling, and "yong" refers to swelling below the eyes, like a reclining silkworm. The kidney channel rises from the kidney, passes through the liver and diaphragm, enters the lungs, and then runs along both sides of the throat to the root of the tongue. For this reason, when the kidney channel is diseased, speech may be impeded.

Qibo replied: This is a deficiency pattern and is not suited to needling. If needling is applied where it should not be, the pathogenic qi will surely manifest on the fifth day.

The "zhi" here means the manifestation of pathogenic qi. The theory that correlates the five phases with the viscera and the days holds that pathogenic qi will reach the kidney on the fifth day. The kidney is already deficient, and wind has invaded it. Although the exterior is swollen and resembles a repletion pattern, forceful draining by needling would damage the qi of the zang organs. Once upright qi is depleted, recovery is difficult, so the pathogenic qi will certainly erupt five days after needling.

Huangdi asked: When the pathogenic qi erupts, what happens?

Qibo replied: When it erupts, there is shortness of breath and intermittent fever. The heat rises from the chest and back to the head, accompanied by sweating. The palms feel hot, the mouth is dry and thirsty, and the urine is yellow. The swelling below the eyes persists, the abdomen rumbles, and the body feels heavy and difficult to move. Menstruation fails to come, and the patient is irritable...

Patients cannot take food and cannot lie flat; whenever they lie down, they cough. This illness is called wind-water (fēngshuǐ).

The Cì Fǎ Piān (Chapter on Needling Methods) is the title of a chapter whose text has since been lost.

The Yellow Emperor said, "I would like to hear the principles behind this."

Qi Bo said, "Where evil qi gathers, upright qi must be deficient. When yin is deficient, yang qi gathers there, so the patient has little qi, frequent fever, and sweating. Yellow urine indicates heat in the lower abdomen. Inability to lie flat indicates disharmony in the stomach. Coughing that worsens when lying down indicates that evil qi is pressing upward into the lungs. In all patients with water qi, mild swelling appears first beneath the eyes."

The Yellow Emperor asked, "Why is this so?"

Qi Bo replied, "Water belongs to yin, and the area beneath the eyes also belongs to yin. The abdomen is the place of utmost yin, so when there is water in the abdomen, swelling must appear beneath the eyes. When true qi counterflows upward, the patient has a bitter mouth and dry tongue and cannot lie flat; lying down brings up clear fluid in coughing. All patients with water disorders cannot rest supine. They become restless when they lie down, and the cough worsens once they are disturbed. When the abdomen gurgles, the root of the disease lies in the stomach. When water qi invades the spleen, the patient becomes vexed and cannot eat. If food is taken, it cannot be swallowed, which means the upper opening of the stomach (the wǎnkǒu, or cardia) is obstructed. Heaviness of the body and difficulty walking arise because the stomach channel runs through the leg. Amenorrhea means that the bāo mài (uterine channel, linked to the female reproductive organ) is blocked. The bāo mài belongs to the heart and connects with the uterus. Now that qi presses upward into the lungs, heart qi cannot descend and circulate, and so menstruation fails to come."

"Examining the meaning of the explanation above, it still does not account for the symptoms of heat rising from the chest and back to the head, sweating, hot hands, and dry, bitter thirst. Perhaps the ancient texts have lost some bamboo slips, so the wording here does not fit. Why is this? The kidney Shaoyin channel ascends from the kidney, passes through the liver and diaphragm, enters the lungs, runs alongside the throat, and flanks the root of the tongue. The bladder Taiyang channel rises from the inner corner of the eye to the forehead and meets at the vertex. One branch runs from the vertex to the upper corner of the ear. The straight channel enters the vertex and connects with the brain, then emerges and descends through the neck, runs along the inner edge of the shoulder blade beside the spine, reaches the lumbar region, and enters and travels along the muscles beside the spine. Now yin is insufficient while yang is in excess, so heat rises from the chest and back to the head, producing sweating, dry mouth, and bitter thirst. The heart is a yang organ, and the heart channel runs through the arm. The kidney is a yin organ, and the kidney channel runs through the chest and the foot. When kidney qi is insufficient, heart qi appears to be in excess, and so the hands feel hot. Moreover, both the heart channel and the kidney channel belong to the Shaoyin channels."

The Yellow Emperor said, "Well said."

Treatise on Counter-Regulation (Nì Tiáo Lùn Piān)

The Yellow Emperor (Huangdi) asked: The body is not any warmer or hotter than usual, yet there is fever, vexation, and fullness and distension. Why is this?

The word "unusual" here means a condition different from the body's normal state. The Song-dynasty collators (Xinjiao Zheng) note that the Systematic Classic of Acupuncture and Moxibustion (Jiayi Jing) lacks the three characters "wei zhi re" (for it becomes hot).

Qi Bo replied: This comes from insufficient yin qi and excessive yang qi, which produces fever, vexation, and fullness.

The Emperor then asked: Some people are not dressed thinly, and there is no cold qi inside the body, yet they feel cold rising from within. Why is this?

This asks what causes cold to arise from inside the body.

Qi Bo replied: People of this kind often have bi qi (obstruction qi, a condition in which the circulation of qi and blood is impeded, causing numbness or pain). Yang qi is scarce and yin qi is abundant, so the body feels cold, as if just come out of water.

In other words, the coldness results from an imbalance of yin and yang in the physical form and in the movement of qi. It is not caused by thin clothing, nor by cold qi actually entering the body.

The Emperor asked: Some people have heat in the limbs, yet when they meet wind and cold, they feel as if they were being roasted by fire. Why is this? The Xinjiao Zheng notes that the Quanyuanqi edition (Quanyuanqi Ben) lacks the words "ru huo" (like fire). The Taisu (Plain Essentials) reads "ru zhi yu huo" (like roasting over a fire), and this reading should be followed.

Qi Bo replied: People of this kind have deficient yin qi and excessive yang qi. The limbs belong to yang, and the yang qi of the two places meets there, while yin qi is deficient and scarce. When water is scarce, it cannot extinguish a blazing fire, so yang qi alone holds sway. When yang qi is in excess alone, it cannot nourish the body in its normal growth, and it only becomes temporarily excessive.

Here water is compared to yin and fire to yang. Because yang qi is in surplus and yin qi is insufficient, the text says "water is scarce and cannot extinguish a blazing fire." "Zhi" (governs) means to preside over and hold the upper hand, and "sheng" (prevail) means to be vigorous.

Those who feel heat in their limbs as if roasted by fire when they meet wind will, over time, waste away in their flesh. "Shuo" (melt away) means to be consumed and diminished. The Xinjiao Zheng holds that "ru zhi ru huo" should be corrected to "ru zhi yu huo" according to the Taisu.

The Emperor asked: Some people have cold throughout the body. Soup, water, and fire cannot warm them, and thick clothing cannot keep them warm, yet they do not shiver. What illness is this?

Qi Bo replied: People of this kind usually have excessive kidney qi and strong desire. The yang qi of the Taiyang channel is weakened, and the kidney marrow is dried up and cannot nourish growth. The kidney belongs to water, and water is insufficient to restrain the fire qi of the two places. The kidney governs the bones; when kidney qi cannot nourish them, the marrow cannot fill them, so cold penetrates deep into the bones.

"Yi shui wei shi" (taking water as one's affair) here refers to strong desire. The reason they do not shiver is that the liver belongs to one yang, the heart belongs to two yang, and the kidney stands alone as a single organ. One portion of water is not enough to restrain the fire qi of the liver and heart. This illness is called gu bi (bone obstruction), a bi syndrome in which cold evil lodges deep in the marrow and affects the bones and joints, and the patient develops contracture of the joints.

Insufficient kidney qi cannot generate and send forth growth, so the marrow cannot be filled. When the marrow is not full, the sinews dry out and contract, which produces joint cramping and difficulty bending and straightening.

Huangdi asked: some people have muscles that feel numb and heavy (ke, meaning numb and heavy muscles with dulled sensation), and even when touching clothing or cotton padding they feel numbness and discomfort. What disease is this?

(Note: ke means a skin ailment marked by pain, numbness, and discomfort.)

Qi Bo replied: this is yingqi (nutritive qi, the essential qi that travels within the vessels and nourishes the whole body) being deficient while weiqi (defensive qi, the yang qi that travels outside the vessels and guards the surface of the body) is in excess. When yingqi is deficient, the skin becomes numb and loses sensation. When weiqi is deficient, the limbs cannot move. When both yingqi and weiqi are deficient, the body is both numb and immobile, and the muscles seem to have lost their vitality. If the body and the mind cannot coordinate with each other, this is a fatal sign.

(Note: when the body can move but the mind does not respond, the mind wants to direct the body and the body does not obey, as if the two were unrelated. The New Collation Notes say that the Jiayi Jing (Classic of Categories) gives death within thirty days for this condition.)

Huangdi asked: some people have qi rising against them, so they cannot lie flat, and their breathing makes sound. Some cannot lie flat but breathe silently. Some live normally but breathe audibly. Some can lie down but gasp when they walk. Some can neither lie down nor walk and gasp at any movement. Some cannot lie flat and gasp as soon as they do. Which zang-fu organs cause each of these? I would like to hear the reasons.

Qi Bo said: those who cannot lie flat and breathe audibly have the qi of the Yangming channel (the stomach channel) rising upward. The qi of the three yang channels of the foot should flow downward, but here it runs counter upward, so the breath is audible. Yangming is the stomach channel, and the stomach is the sea of the six fu organs, the place where water and grain converge. Its qi too should move downward. When Yangming qi rises against its proper course and cannot follow the normal path, one cannot lie quietly. The Xia Jing (Lower Classic) says, "When the stomach is disharmonious, lying down is unquiet," and this is the principle meant.

(Note: the Xia Jing is an ancient medical classic.)

Those who live normally but breathe audibly have the luo vessels (the fine branches of the channels) of the lung rising upward.

"Jie" means aging and emaciation.

The Xinjiaozheng (New Collation) notes that the Jiayi Jing (Classic of Systematic Acupuncture and Moxibustion) records: "Malaria is all caused by wind-evil. Why does it arrive on a fixed day and at a fixed hour?" This passage differs from the text here. The Taisu (Plain Questions) agrees with the current edition. Yang Shangshan's commentary says some hold that a fever arriving every other day is called "jienüe." But this classic says only that one is struck by summer heat and falls ill in autumn. Some call the illness "jienüe," others simply "nüe," and the distinction does not necessarily depend on whether the fever comes every other day. "Jie" simply describes how its onset corresponds to the seasons and how its presentation differs somewhat.

Qi Bo replied: When nüe is about to begin, one first feels the body hairs stand on end, then stretches, yawns, and then breaks out in chills and shivering, with the teeth chattering.

"Li" means trembling with cold, and "gu" means vibration.

The lower back and spine ache together. After the chill recedes, the body becomes hot inside and out, the head aches as though it would split, there is thirst, and one wants cold water. The Yellow Emperor asked: "What evil qi causes this? Please explain the principle." Qi Bo answered: "This is Yin-Yang qi contending back and forth between upper and lower, with deficiency and excess alternating as Yin and Yang qi transform into one another."

When Yang qi runs to the extreme of the lower region, it turns upward. When Yin qi runs to the extreme of the upper region, it turns downward. Hence it is said that Yin and Yang qi contend between upper and lower. When Yang qi is deficient, the exterior of the body feels cold. When Yin qi is deficient, the interior feels hot. When Yang qi is in excess, the exterior is hot. When Yin qi is in excess, the interior is cold. Thus, cold retreating and heat arising is the manifestation of deficiency and excess alternating and of Yin and Yang qi transforming.

When Yang qi enters the Yin division, the Yin division becomes excessive and Yang becomes deficient. When the qi of the Yangming (Yang Brightness, Stomach) channel is weak, one feels cold, shivers, and the jaw trembles.

"Yang qi entering the Yin division" means that Yang qi enters the Yin aspect. The Yangming channel passes through the lower jaw and branches down along the cheeks. One branch passes in front of Daying (Great Welcome) and descends to Renying (Human Welcome). Therefore, when stomach channel qi is insufficient, one feels cold and shivers, and the jaw also trembles.

When the qi of the Taiyang (Greater Yang) channel is weak, pain arises in the lower back, spine, head, and neck.

The Taiyang channel is the Bladder channel. Its pathway branches from the head, runs down the back of the neck and the inner side of the shoulders and back, and along both sides of the spine reaches the lower back. Therefore, when its qi is insufficient, the lower back, spine, head, and neck ache.

When the qi of all three Yang channels is weak, Yin qi prevails. When Yin qi is in excess, the joints feel cold and painful. Cold arises from within, so both inside and outside feel cold. When Yang qi is in excess, the exterior is hot. When Yin qi is weak, the interior is hot. When both inside and outside are hot, there is panting and thirst, so one wants cold water. Heat damages qi, so when heat is present both inside and outside, there is panting and thirst.

These are all cases in which, in summer, one contracts the heat-evil (shuxie). Because the heat-Qi is vigorous, it lodges in the skin and in the space outside the intestines and stomach. That space is where the nutritive Qi (yingqi), which circulates within the vessels and nourishes the body, comes to rest, so the text says the yingqi "she" (lodges) there. Here she means to dwell or to remain.

This loosens the sweat pores. The New Collation (Xin Jiaozheng) notes that the Quan Yuanqi edition reads "sweat-pores open and loose," and that the Zhenjiu Jiayi Jing and the Huangdi Neijing Taisu say the same. The interstices of the skin and muscle (couli) are thereby opened. When autumn Qi arrives, or when one sweats and is then struck by wind, or when one bathes and comes into contact with water-Qi, the evil Qi stays in the skin and dwells alongside the protective Qi (weiqi), which circulates outside the vessels and guards the body.

The weiqi circulates on the exterior of the body by day and within the interior by night. When the evil Qi meets yang Qi, it erupts outward; when it meets yin Qi, it presses inward again. Yin-Yang Qi and the evil Qi struggle against one another inside and outside the body, which is why the illness recurs each day.

The Yellow Emperor (Huangdi) asked: "Why does it sometimes attack only every other day?"

"Geri" means every other day, that is, separated by one day. Qibo replied: "The evil Qi lodges deeply and presses toward the yin level. When yang Qi acts alone, the yin evil still remains within. The yin evil struggles with yang Qi but cannot be expelled outward, so it attacks every other day. This is because the evil Qi has not met and joined the weiqi, and therefore it attacks on alternate days."

The Yellow Emperor further asked: "Sometimes the attacks come late and sometimes early. What Qi causes this?"

"Yan" means dusk, the close of day. Qibo replied: "The evil Qi lodges at the Fengfu (an acupoint at the nape of the neck) and moves downward along the spine."

The Fengfu point lies within the hairline at the back of the neck, about two cun in, in the hollow between the two large tendons. The lü mentioned here refers to the muscles on either side of the spinal column.

The weiqi circulates day and night and meets at the Fengfu once each day. From the second day onward, it descends one vertebral segment (jie) each day along the spine. As a result, the time of the attacks is gradually delayed. This evil Qi first lodges in the back. Each time it reaches the Fengfu, the couli open, and when they open, the evil Qi seizes the opportunity to enter, and illness arises. As the evil Qi descends day by day, the attacks come later and later.

Here jie refers to the vertebrae. The farther the evil Qi lodges from the Fengfu, the later it meets the weiqi, and so the attacks come closer to dusk.

Starting from the Fengfu, the evil Qi descends one segment each day. On the twenty-fifth day it reaches the sacrum (digu, where the lower spine joins the pelvis). On the twenty-sixth day it enters the interior of the spine and pours into the fulü vessel (the kidney vessel that runs hidden between the muscles of the back).

From the neck down to the tailbone there are twenty-four segments, so the evil Qi descends one segment each day, reaches the sacrum on the twenty-fifth day, and enters the interior of the spine on the twenty-sixth day, pouring into the fulü vessel. The so-called fulü vessel is the kidney vessel that runs concealed between the muscles of the back.

The kidney channel runs through the spinal column and connects with the kidney. Its straight branch rises from the kidney, passes through the liver and diaphragm, and enters the lungs.

This vessel runs through the spine but does not correspond to any shu-point on the channels. It creeps deep along the back, so it is called fulü mai (the vessel lying hidden along the spine). The Xinjiao Zheng (Newly Collated Edition) notes that the Quan Yuanqi edition writes "twenty-five days" as "twenty-one days" and "twenty-six days" as "twenty-two days," and that the Jiayi Jing (Classic of Acupuncture and Moxibustion) and the Taisu agree with this. The Jiayi Jing calls the vessel the taichong zhi mai (the vessel of the Great Surge), while Chao Yuanfang calls it fuchong (the hidden surge).

This Qi moves upward and appears from the quepen (the hollow above the collarbone) on the ninth day. It rises a little higher each day, so the illness also appears a little earlier each day.

The kidney vessel runs through the spine, connects with the kidney, and then ascends into the lung. The lung uses the quepen as its passage. Because this Qi moves quickly, it rises to the quepen and appears there on the ninth day.

An illness that strikes every other day occurs because the evil Qi has penetrated the five viscera and also spreads laterally to join the muyuan (the membranous region between the viscera and the chest and abdomen). The evil Qi travels a long distance, lies deep, and moves slowly. It cannot travel together with the defensive Qi (weiqi), so the illness does not strike every day but only on alternate days.

The Xinjiao Zheng notes that the Quan Yuanqi edition writes the mu of muyuan as mo, as do the Taisu and Chao Yuanfang's work. The Ju Tong Lun (Discourse on Pain) likewise writes moyuan.

The Yellow Emperor asked: "You, Master, have said that whenever the defensive Qi reaches the fengfu (the point at the nape), the couli (skin striations and pores) opens. Once the striations open, the evil Qi invades, and once it invades, the illness arises. Now the defensive Qi moves down one section each day. Then the place where the illness arises should not always be at the fengfu. Why is it still called an onset?"

Qibo replied:

The Xinjiao Zheng notes that the Quan Yuanqi edition, the Jiayi Jing, and the Taisu omit the eighty-eight characters from "the evil Qi lodges in the head and neck" through "then the illness arises below."

The evil Qi may remain in the head and neck and then travel downward along the spine. Because the constitutions of the body differ in fullness and emptiness, the place where the evil Qi enters also differs, so the illness does not necessarily arise exactly at the fengfu. If the evil Qi invades the head and neck, the illness arises when the defensive Qi reaches the head and neck. If it invades the back, the illness arises when the defensive Qi reaches the back. If it invades the lumbar spine, the hands, or the feet, the illness likewise arises when the defensive Qi reaches the corresponding part.

For this reason, the next chapter explains how to needle according to the part where the evil Qi lodges.

Wherever the defensive Qi travels and meets the evil Qi, the illness breaks out there. So the place where wind evil invades has no fixed location. When the defensive Qi arrives, it must open the couli there, and the place where the evil Qi joins the defensive Qi is the place where the evil Qi dwells.

Wind pathogens invade the human body at different locations, and the sites they invade differ; when wind pathogens meet defensive Qi, illness breaks out. Therefore, malaria does not necessarily always begin at the Fengfu acupoint.

New Correction says: According to the Zhenjiu Jiayi Jing (A–B Classic of Acupuncture and Moxibustion), “its site” here should be “its disease.”

The Yellow Emperor said: “Well said. Wind disease and malaria resemble each other and belong to the same category of illness, but wind disease always persists and does not go away, whereas malaria, after an attack, temporarily stops. Why is this?”

Wind disease and malaria both have waxing and waning of the disease force, so they are said to be similar and of the same kind.

Qibo replied: “Wind pathogens remain where they invade, so the illness is constantly present; malaria pathogens, by contrast, penetrate deeper along the meridians and lie hidden within the body.”

New Correction says: According to the Zhenjiu Jiayi Jing, this should read “gradually transmit inward along the meridians.”

When defensive Qi circulates to the point where it meets the malaria pathogen, malaria breaks out. “Remain” means to stay in place; “follow” means to follow along.

The Yellow Emperor asked: “Why does malaria first cause chills and afterward fever?”

Qibo replied: “In summer, when one is affected by summerheat, one sweats profusely, and the skin and couli (skin interstices and sweat pores) therefore open; afterward one encounters the chilling water-cold Qi of summer.”

New Correction says: According to the Zhenjiu Jiayi Jing and the Taisu, “water-cold” here should be “minor cold,” meaning invasion by cold Qi.

“Cold Qi hides in the couli and skin, and in autumn, when wind pathogens invade again, the disease is formed. Summerheat belongs to yang Qi; when autumn wind invades, yang Qi is affected; when one is exposed to wind in autumn, the disease breaks out.

“Cold belongs to yin Qi, and wind belongs to yang Qi. First affected by cold pathogens and afterward by wind pathogens, one therefore first has chills and then fever. This disease, which attacks at regular times, is called ‘cold malaria.’ If a person exposes the body and is exposed to wind and cold, wind-cold will injure the body.”

The Yellow Emperor asked: “Why does one first have fever and afterward chills?”

Qibo replied: “This is because one is first affected by wind pathogens and afterward by cold pathogens, so fever comes first and chills afterward. It too attacks at regular times and is called ‘warm malaria.’ Because fever comes first, it is called ‘warm.’

“If there is only fever and no chills, it is because yin Qi has first declined and yang Qi acts alone, thereby producing symptoms such as shortness of breath, vexation in the chest, hot hands and feet, and a desire to vomit. This is called ‘dan malaria.’ ‘Dan’ means heat, indicating an extremely intense heat.”

The Yellow Emperor asked again: “The medical classics say that when pathogenic Qi is excessive, one should reduce it, and when upright Qi is insufficient, one should supplement it. Now fever seems to be excess, and chills seem to be deficiency; yet when malaria causes chills, even hot soup and fire cannot warm the patient, and when it causes fever, even ice water cannot cool the patient. These symptoms seem to be both excess and deficiency. In such cases, even a good physician cannot immediately stop the disease force and must wait until it subsides on its own before applying acupuncture. What is the reason for this? Please tell me the principle.”

You asked: why not act before the illness reaches its peak, and let it subside on its own early?

Qibo said: "The medical classic says: do not needle while the heat is blazing (hè hè), do not needle while the pulse is chaotic and without order (hún hún), and do not needle while sweat is pouring out (lù lù). At such times the disease is in reverse disorder and is not yet suitable for treatment."

Hè hè describes vigorous heat, hún hún describes a pulse that is chaotic and without clear pattern, and lù lù describes profuse sweating.

When nüè (malarial fever) first begins, yang qi gathers and merges into the yin sphere. Yang is then relatively deficient and yin relatively excessive, so the exterior lacks yang's warmth, and chills and shivering come first. When yin qi reaches the extreme of its disorder, yang breaks out again from within. Once yin and yang gather again at the surface, yin becomes weak and yang dominant, so heat appears first, together with thirst.

When yin qi predominates, the stomach becomes cold, which is why chills come first. When yang qi predominates, the stomach becomes hot, which is why fever and thirst come first.

When the nüè qi gathers in the yang sphere, yang prevails; when it gathers in the yin sphere, yin prevails. Yin dominance produces chills, and yang dominance produces fever. Nüè arises from wind-cold qi. Its onset is irregular, and when the disease reaches its extreme, it returns to its former state.

Here "return" (fù) means restoration to the original condition: after the illness qi has reached its peak, it reverts to its earlier state.

The New Collation commentary (Xinjiao Zheng) notes that, according to the Jiayi Jing (Systematic Classic of Acupuncture and Moxibustion), this sentence reads: "Nüè is a sudden surge of wind-cold qi; it is irregular, and when the disease reaches its extreme, it returns." The Quan Yuanqi edition and the Taisu (Great Simplicity) also read: "Nüè is wind-cold qi; it is irregular, and when the disease reaches its extreme, it returns." Here the character "return" (zhì) attaches to the preceding clause, which gives a meaning different from Wang Bing's interpretation.

During a nüè attack, the heat is like a raging fire, and the onslaught is as hard to withstand as a sudden storm of wind and rain. The illness is at its most intense, so it is difficult to respond effectively at that time.

Therefore the medical classic says: "While the disease is at its height, do not force an attack; once it declines, treatment will achieve great results."

Fāng (fāng) means "just" or "in the very midst of." When the illness is at its height, using purgation may damage the true qi of the body, which is why it is said to cause harm. After the illness qi has declined, supplementing the proper qi of the corresponding channels will drive out the pathogenic qi, and the proper qi will regain stability, which is why treatment is said to achieve great results.

Before a nüè attack begins, yin qi has not yet merged into the yang sphere, and yang qi has not yet merged into the yin sphere. If one treats in accordance with this natural tendency at that stage, the true qi will be stabilized and the pathogenic qi will recede. Purgation must be applied with precision, and supplementation must be applied appropriately, so that the true qi is stabilized and the pathogenic qi dispersed.

For this reason, practitioners often find it difficult to treat nüè once the attack has begun, because at that point the illness qi is in a state of reverse disorder.

When true Qi (zhen qi) weakens and ceases, pathogenic Qi (xie qi) will greatly flourish. When healthy Qi cannot withstand pathogenic Qi, this is called "ni" (adverse reversal).

The Yellow Emperor said, "Excellent. How should malaria be treated, and when is the right time to begin?" Qi Bo replied, "When malaria is about to erupt, the Yin and Yang Qi are on the point of transformation, and the change always begins at the extremities of the four limbs. Yang Qi has already been harmed, and Yin Qi changes along with it. Therefore, one should act before the attack, firmly binding the corresponding regions so that pathogenic Qi cannot invade and Yin Qi cannot escape outward. Observe carefully. If the sunluo (the fine collateral vessels distributed just beneath the skin) are full and hard and contain stagnant blood, then prick out that blood. At this moment the pathogenic Qi is just about to depart and has not yet merged with healthy Qi."

"Firmly binding the four limbs" (lao fu si zhi) means tightly binding the four limbs so that the Qi stays in place, and the site where the pathogenic Qi lies is thereby revealed. Once it is found, the blood there is drawn out with a needle. "Wang" carries the sense of departing. The New Collation notes that the Jia Yi Jing writes "zhen wang" as "qi wang," while the Tai Su writes it as "zhi wang."

The Yellow Emperor asked, "Before malaria erupts, what reactions does the body show?" Qi Bo replied, "Malarial Qi causes healthy Qi to surge at some times and weaken at others, and wherever the disease lodges, the body shows signs there. If the disease lies in the Yang aspect, there is fever and the pulse is restless. If it lies in the Yin aspect, there is chills and the pulse is quiet. When Yin is quiet and Yang is restless, the pulse changes accordingly. When the disease reaches its extreme, both Yin and Yang Qi weaken. The wei Qi (the defensive Qi that circulates across the body surface and guards it) separates from the pathogenic Qi, and the illness temporarily stops. When the wei Qi gathers again, the illness recurs."

When Yin and Yang Qi strike against each other and reach their extreme, they turn toward the opposite side. This is why, at the height of the illness, both Yin and Yang Qi grow weak.

The Yellow Emperor asked, "Sometimes the illness strikes every other day, and sometimes only after several days. Some patients are thirsty and some are not. Why is this?" Qi Bo replied, "Attacks every other day occur because the pathogenic Qi and the wei Qi lodge in the six fu organs (the gallbladder, stomach, large intestine, small intestine, bladder, and triple burner). Sometimes the two cannot meet, so the illness pauses for a time and returns after some days. If the Qi dynamics do not converge, the illness may recur only after several days."

Malaria is the alternating dominance of Yin and Yang Qi. At times one side is far stronger, and at other times its strength is not marked, so some patients are thirsty and others are not. When Yang Qi overcomes Yin Qi and its strength is clearly marked, thirst arises. When Yang is dominant but not markedly strong, there is no thirst. The term "sheng" (prevailing) here means that the Qi of one side is stronger than that of the other.

The Yellow Emperor asked, "Medical texts say that one who is struck by summer heat will surely suffer jie nüe (ague-malaria) in autumn. Yet malaria does not always appear in autumn. Why is this?" The New Collation notes that both the Shengqi Tongtian lun and the Yinyang Yingxiang dalun state, "Injury by summer heat leads to jie nüe in autumn." The Yellow Emperor's question means: if this is so, why does not everyone who is struck by heat necessarily fall ill?

Qi Bo replied, "This is the common pattern that corresponds to the four seasons. If the form of the illness differs, it belongs to the cases that run counter to the seasonal rule. Those who fall ill in autumn often have more pronounced chills." In autumn the climate is cool and Yang Qi gathers downward, so the summer heat remains hidden between the muscles, and the chill is therefore more marked when the illness begins.

People who fall ill in winter often do not feel much cold. Winter is severely cold and yang Qi lies hidden within the body without contending with the cold, so the signs of cold are not prominent.

People who fall ill in spring tend to be averse to wind. In spring the climate is mild and yang Qi disperses outward, so the couli (the texture of the skin and the channels through which sweat passes in and out) relaxes and opens, and one easily feels averse to wind.

People who fall ill in summer often sweat heavily. Summer is hot, the body fluids are abundant and are driven out to the surface, and so sweating is more pronounced.

The Yellow Emperor asked: for warm malaria (wēn nüè) and cold malaria, where does each lodge, and in which zang organ does each hide? "An" means "where," "she" means to lodge or dwell, and "zang" refers to the five zang organs, which Chinese medicine describes as the storehouses of the five spirits.

Qibo replied: Warm malaria arises when a person contracts wind-cold in winter, and the pathogenic Qi hides within the marrow of the bones. In spring yang Qi flourishes greatly, yet the pathogen still cannot emerge on its own. Later, in the intense heat of summer, the brain marrow is steamed by heat, the muscles waste away, and the couli open. If one also labors at this time, the pathogen is expelled along with the sweat. The root of this disease lies in the kidney: the pathogen first emerges from within the body and then reaches the surface.

The kidney corresponds to winter, and winter governs the bone marrow. The brain is where the marrow gathers, and it corresponds above and below with the bone marrow. When the rebellious heat rises upward and steams the brain, the brain marrow is consumed; once the brain marrow is consumed, the heat is driven to the surface and the muscles waste away. This is why the root is said to lie in the kidney.

In this condition, yin is deficient while yang is excessive. Yin deficiency means that the Qi of the kidney is insufficient; yang excess means that the taiyang Qi of the bladder channel is predominant. When yang Qi declines, the pathogen returns and re-enters the yin vessels of the kidney, and yang then becomes insufficient. When yang is insufficient, one feels cold. Thus this disease first produces fever and then chills, and it is called "warm malaria."

Here "declines" (shuai) refers to the abatement of the disease's course, and "returns and re-enters" (fù fǎn rù) refers to the pathogen re-entering the yin vessels of the kidney.

The Yellow Emperor asked: what is the condition of dan malaria (dān nüè)?

Qibo replied: In dan malaria, the lungs already harbor heat, yang Qi is excessive and surges counter-upward, and the Qi of the middle jiao is full but cannot disperse outward. Later, labor opens the couli, and wind-cold lodges just beneath the skin, between the muscles. When the pathogen attacks, yang Qi is vigorous; if yang never declines, the disease keeps recurring. Its pathogenic Qi does not reach the yin level.

The Song-era editorial notes (Xin Jiaozheng) state that the Quan Yuanqi edition and the Taisu write "a yin that does not return" (bù fǎn zhī yīn), while the Chao Yuanfang edition writes "a yin that is not reached" (bù jí zhī yīn).

Therefore dan malaria produces only fever without chills. The pathogen lodges in the heart and also remains between the muscles, causing emaciation and muscle wasting, and for this reason it is called "dan malaria."

The Yellow Emperor said: Well spoken.