Keywords: Chinese medicine, acupuncture-moxibustion, malaria

In Chinese medicine, malaria is called nue. This disease category covers true malaria (i.e., infection by various species of Plasmodium protozoa), as well as malaria-like conditions that resemble malaria in their clinical presentation. Nue is defined as a recurrent disease characterized by shivering, vigorous heat, and sweating and is classically attributed to external contraction of summerheat evils during the hot season, contact with so-called "mountain forest miasma," or external contraction of cold and dampness. The relapsing-remittent nature of malaria is explained as evil qi latent or deeply lying in the half exterior-half interior stage. This means that some of the externally contracted evil qi has remained in the exterior part of the body (i.e., the skin and hair, muscles and flesh, and sinews and bones), but some also invaded the interior or viscera and bowels. This is equivalent to the shao yang aspect of a cold damage disorder.

Explaining the recurrent nature of nue conditions, the Yellow Emperor in the Huang Ti Zhen Jiu Jia Yi Jing (Yellow Emperor's Acupuncture-moxibustion Systematic Classic, circa 270 CE) says the following:
[Nue] is contracted in summer as a result of damage done by summerheat. The heat qi, which is exuberant, is then hidden in the skin, outside the stomach and the intestine [or more exactly] in the dwelling place of the constructive qi. It causes people to perspire. This leaves a void behind and forces the interstices to open. [Later, they] may contract autumn qi, be caught in wind while sweating, or contract water qi while taking a bath. [These evil qi then] lodge in the skin, residing in the defensive qi. Because the defensive qi moves in the yang during the day and in the yin during the night, the [evil] qi emerges during the yang [phase] and oppresses internally during the yin [phase]. Because [the evil] oppresses [alternately] internally and externally, the nue episodes occur once a day.¹

The Jia Yi Jing (The Systematic Classic) similarly explains why some nue episodes attack every other day or earlier or later than the preceding day. It also clarifies why nue episodes present alternately cold and heat. At roughly the same time, Wang Shu-he explained the bowstring pulse characteristic of malaria-like conditions.

The pulse of nue is typically bowstring. A bowstring and rapid pulse points to abundant heat, while a bowstring and slow pulse points to abundant cold. If the pulse is bowstring, small, and tight, precipitation [i.e., purgation] is allowed. If the pulse is tight and rapid, diaphoresis, needling, or moxibustion is allowed. If the pulse is floating and large, ejection [or vomiting] is allowed. If the pulse is bowstring and rapid, [nue] has been started by wind and can be checked by balancing the diet.²

In actuality, Chinese medicine identifies a number of different subtypes of malaria or malaria-like diseases, with different authors giving different lists ranging from seven to 12. For instance, wind malaria is distinguished by fever and spontaneous perspiration; summerheat malaria is distinguished by high fever, vexation, and thirst; damp malaria is distinguished by chest oppression, nausea, and aching and heaviness in the body and limbs; cold malaria is distinguished by severe aversion to cold, followed by mild fever; and warm malaria is characterized by marked fever, followed by mild aversion to cold. Chinese medicine also recognizes tertian malaria with attacks every third day and quartan malaria with attacks every fourth day. Also, four other types of malaria-like disease are defined by their triggering causes. These are taxation malaria, whose attacks are triggered by fatigue; food malaria, whose attacks are triggered by dietary irregularities; miasmic malaria caused by mountain forest miasmic qi; and epidemic malaria caused by epidemic qi.

In terms of treatment, practitioners of Chinese medicine generally treat the initial stage of malaria by harmonization. In this case, harmonizing means harmonizing the exterior with the interior. Practically speaking, this means dispelling those evils residing in the exterior at the same time as draining or clearing any evils that have made it into the interior. In the middle stage of the disease, the treatment principle is to interrupt the malaria: this means, treat in order to prevent the occurrence of an imminent attack. If the attacks are regular, needling is done with draining hand technique two to three hours before the expected episode. If attacks are not so regular, acupuncture treatment may be given two to three times per day in an attempt to break the cycle. In the advanced stage, the emphasis is on supplementing the vacuity caused by enduring disease with the understanding that if the righteous qi is exuberant, it will automatically attack and negate any remaining deep-lying or latent evils.

Up until the mid 20th century, most acu-moxa books discussed the treatment of malaria primarily based on its Chinese medical disease diagnosis (i.e., nue). For instance, in the late 1500s, Yang Ji-zhou devoted a chapter to nue in the therapeutics section of his famous Zhen Jiu Da Cheng (Great Compendium of Acupuncture & Moxibustion). The following is that pithy chapter in its entirety:
[For] nue, [use] Bai Hui (GV 20), Jing Gu (Lu 8), [and] Qian Gu (SI 2).
[For] warm nue, [use] Zhong Wan (CV 12) [and] Da Zhui (GV 14).
[For] quartan nue, [use] Yao Shu (GV 2).
[For] nue with cold [and] heat, [use] He Gu (LI 4), Ye Men (TB 2), [and] Shang Yang (LI 1).
[For] phlegm nue with cold [and] heat, [use] Hou Xi
(SI 3) [and] He Gu (LI 4).
[For] nue with quivering with cold, [use] Shang Xing (GV 23) and Xian Gu (St 43).
[For accompanying] headache, [use] Wan Gu (SI 4).
[For] cold nue, [use] San Jian (LI 3).
[For accompanying] heart vexation, [use] Shen Men (Ht 7).
[For] cold nue with inability to ingest, [use] Gong Sun (Sp 4), Nei Ting (St 44), [and] Li Dui (St 45).
[For] enduring nue, [use] Zhong Zhu (TB 3), Shang Yang (LI 1), [and] Qiu Xu (GB 40).
[For] more heat than cold, [use] Jian Shi (Per 5) [and Zu] San Li (St 36).
[For] nue initiated by spleen cold, [use] Da Zhui (GV 14), Jian Shi (Per 5), and Ru Gen (St 18).³

However, in the mid-20th century, with the advent of provincial and metropolitan colleges and universities of Chinese medicine, the methodology of treating based primarily on pattern discrimination was extended to the practice of acupuncture and moxibustion. Therefore, the following is a more detailed, contemporary discussion of the disease causes and mechanisms of alternating cold and heat and the acupuncture treatment of this main distinguishing feature of malaria. Nevertheless, general malaria-terminating treatment is still based mainly on points located on the governing vessel, pericardium, and small intestine channels.

Disease Causes & Mechanisms:
The shao yang is known as the pivot. In fact, a shao yang pattern describes a situation where evils are in two places in the body at the same time. Half the evils are located in the exterior, and half are located in the interior. In other words, evils are neither entirely in the exterior nor entirely in the interior. This pattern is frequently seen in a number of febrile diseases. In the struggle between the righteous qi and evils, the battle may swing back and forth. When evils are relatively victorious, the defensive qi will be depressed and blocked. Hence, the exterior is deprived of warming, and chills occur. When the righteous qi is relatively victorious, heat will form leading to fever, since yang added to yang engenders heat. As a result, alternating chills and fever are seen.

Treatment Based on Pattern Discrimination:
1. Evils entering the shao yang
Symptoms: Alternating fever and chills, chest and rib-side distention and pain, a bitter taste in the mouth, a dry throat, no desire to eat, heart vexation, frequent retching, nausea, possible deafness and vertigo, white or yellow tongue fur, and a bowstring pulse

Therapeutic principles: Harmonize the constructive and defensive and resolve the shao yang.

Acupuncture & moxibustion:
Wai Guan (TB 5) Together, these points harmonize and resolve the shao yang when needled
Qiu Xu (GB 40) with even supplementing and draining method.
Qi Men (Liv 14)
Jian Shi (Per 5) Together, these points clear heat and eliminate vexation when needled with He Gu (LI 4) draining method.

Additions & subtractions:
For deafness and vertigo, add Jin Men (GB 25) and Ting Hui (GB 2).
For vexatious pain in the joints, add Yang Fu (GB 38) and Da Shu (Bl 11).
For vomiting, add Zhong Wan (CV 12).
For constipation, add Zhi Gou (TB 6) and Shang Ju Xu (St 37).
For predominant fever, replace Wai Guan with Zi Lin Qi (GB 41).

2. External contraction of malaria evils
Symptoms: Alternating fever and chills that occur at a fixed times, possibly once a day, every other day, or every third day. At the beginning, there are chills that cannot be relieved even with double quilts. Then there is high fever, vexatious thirst with a desire for lots of drinking, red lips and face, and, finally, sweating followed by a normal body temperature. The pulse is deep and bowstring during the shivering, and surging, large, and rapid when there is fever. The pulse becomes normal again after sweating.

Therapeutic principles: Dispel evils and eliminate malaria.

Acupuncture & moxibustion:
Da Zhui (GV 14) Together, these points arouse the yang and eliminate the evils when needled
Hou Xi (SI 3) with draining method.
Zhong Zhu (TB 3) Together, these points harmonize the constructive and
Jian Shi (Per 5) defensive when needled with even supplementing and draining method.

Note: Da Zhui, Hou Xi, and Jian Shi are all traditional points for the treatment of malaria-like conditions.

Additions & subtractions:
For splitting headache, add Feng Chi (GB 20) and Tai Yang (M-HN 5).
For profuse sweating and thirst, add Fu Liu (Ki 7).
For nausea and vomiting, add Zhong Wan (CV 12).
For high fever, prick Shi Xuan (M-UE-1) to bleed.
For enduring malaria, add Pi Shu (Bl 21) and Zu San Li (St 36).

3. Deep-lying summerheat & dampness invading the shao yang
Symptoms: Alternating fever and chills, sweating that does not abate the fever, thirst but drinking just a little, heart vexation, possible headache, possible sour vomiting, chest and stomach glomus and oppression, possible rib-side and abdominal distention, short voidings of dark-colored urine, red tongue edges with slimy, white fur, and a bowstring pulse

Therapeutic principles: Clear heat, transform dampness, and disinhibit the qi mechanism.

Acupuncture & moxibustion:
Da Zhui (GV 14) Together, these points clear heat when needled with draining method.
Tao Dao (GV 13)
Qu Chi (LI 11) Together, these points clear heat and prevent contrary shifting of evils to the
Hou Xi (SI 3) pericardium when needled with draining method.
Zhi Gou (TB 6) Together, these points transform dampness and disinhibit the qi mechanism
Zhong Wan (CV 12) when needled with draining method.

Additions & subtractions:
For nausea and vomiting, add Nei Guan (Per 6).
For inhibited defecation, add Tian Shu (St 25).
For loose stools, add Gong Sun (Sp 4).

Author's Commentary
While most people who become infected with malaria in developed countries will seek the care of a Western medical doctor, malaria has become resistant to some standard Western drug treatments. And, although there are also Chinese herbal treatments for all the patterns listed above, some people prefer acupuncture therapy because it does not involve ingesting another substance that has to be processed by an already sensitive digestive system. In either the case of Chinese herbal or Western medical treatment, acupuncture therapy can be an important and effective adjunct. In Third World populations of patients, acupuncture is an inexpensive and low-tech option that might be useful where drugs may not be available.

Honora Lee Wolfe, DiplAc, LicAc, FNAAOM
c/o Blue Poppy Press
5441 Western Ave. #2, Boulder, Colorado 80301 USA
www.bluepoppy.com

Notes
1. Huang-fu Mi. (Yang Shou-zhong, Charles Chace, translators). The Systematic Classic of Acupuncture & Moxibustion. Boulder, Colorado: Blue Poppy Press, 2004, p. 263.
2. Wang Shu-he. (Yang Shou-zhong, translator). The Pulse Classic. Boulder, Colorado: Blue Poppy Press, 1997, p.291.
3. Yang Ji-zhou. (Yang Shou-zhong, Liu Feng-ting, translators). The Divinely Responding Classic. Boulder, Colorado: Blue Poppy Press, 1994, p. 55-56.