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Chen Wuyue stated in *San Yin Fang* (Three Causes): Malaria involves three categories of causes. Externally, it is caused by contracting the four climatic pathogens: wind, cold, summerheat, and dampness. Internally, it is triggered by the seven emotions. Irregularities in diet (such as hunger or overeating), excessive sexual activity, or imbalance between work and rest can all lead to this disease. The classic texts mention "summer injury by summerheat leading to autumn malaria," which is merely a description based on seasonal timing and should not be taken as the sole explanation. Regarding external causes, there are Cold Malaria (characterized by predominant chills), Warm Malaria (predominant heat followed by chills), and Dan Malaria (pure heat without chills), consistent with the *Su Wen*. There is also Damp Malaria, characterized by alternating chills and fever, heaviness of the body, painful joints, abdominal distension, spontaneous sweating, and frequent vomiting. This occurs when bathing after sweating allows dampness to lodge in the skin, or from exposure to rain and dampness. There is also Pin Malaria (Yin Malaria), characterized by severe chills with little or no fever, accompanied by a miserable demeanor and tremors occurring at specific times. This is often due to contracting yin-damp pathogens, where yang qi fails to control yin. These five types of malaria result from external contraction of wind, cold, summerheat, and dampness combining with defensive qi (Wei Qi). Except for Dan Malaria (pure heat), Warm Malaria (heat precedes chills), and Pin Malaria (no heat), most malarial cases present with chills preceding fever.

Regarding internal causes, if a patient suffers liver injury from suppressed anger, causing qi stagnation, it is named Liver Malaria. If joy injures the heart, causing dispersion of heart qi, it is named Heart Malaria. If excessive thinking injures the spleen, causing qi stagnation and phlegm-fluid retention, it is named Spleen Malaria. If sorrow injures the lungs, causing lung qi stagnation and phlegm formation, it is named Lung Malaria. If loss of will injures the kidneys, it is named Kidney Malaria. These manifestations align with the *Su Wen*. These five types arise from climatic disharmony, qi stagnation, and phlegm-fluid retention.

Regarding non-internal/non-external causes, there is Epidemic Malaria, affecting people of all ages similarly within a year; Ghost Malaria, involving ominous dreams and intense fear; Zang Malaria, characterized by intermittent chills and fever, common in southern regions; Stomach Malaria, caused by dietary irregularities damaging stomach qi, commonly known as Food Malaria; and Labor Malaria, which persists for years, recurs, and cannot withstand even slight exertion. If it persists for years and forms a mass in the abdomen or hypochondrium, it is called Old Malaria or Mother Malaria (Malaria Mass). Each of these conditions has specific treatments that should be applied after careful deduction.

I believe that regarding malaria, the *Nei Jing* (Inner Canon) has already provided exhaustive explanations, leaving nothing to add. Later discussions have become overly complex, creating confusion. I cite Chen’s theory of the Three Causes to illustrate its general outline. For instance, his claim that Damp Malaria results from bathing while sweaty, allowing dampness to lodge in the skin, is one perspective. However, if one bathes with hot water and avoids drafts, malaria would not occur; it only happens with cold water. Thus, this is still essentially cold pathogen, akin to the *Nei Jing*'s description of encountering cold water in summer. While plausible, one must distinguish between cold and heat. Furthermore, the concept of Pin Malaria having no heat is absent from the *Nei Jing*. The *Jin Gui Yao Lue* states, "Malaria with predominant chills is called Pin Malaria, treated with Shuqi San," but does not claim absence of heat. If there is absolutely no fever, only chills, this indicates true cold and yang deficiency, belonging to a different category, and cannot be classified as malaria.

Regarding the Five Zang Malarial syndromes, the *Ci Ma Lun* chapter in the *Nei Jing* discusses six meridians and five zang organs to identify the location of the pathogen, not to suggest that emotional injuries directly cause malaria. Claiming these match the *Su Wen* is inaccurate, as the *Su Wen* does not state this. Moreover, since emotional injuries vary greatly in excess and deficiency, they cannot all be attributed to phlegm-fluid retention. As for Ghost Malaria, perhaps malaria pathogens disturb the spirit, causing delirium resembling hallucinations, but ghosts do not literally cause malaria. Regarding Stomach Malaria, although linked to diet, it is clearly an internal injury. While malaria can lead to food stagnation, there is no case of food alone causing malaria without external pathogens. Disease always has a root (ben) and branch (biao); misidentifying them leads to treatment failure. Chen’s elaboration on the Three Causes appears impressive but is likely speculative. Such vague theories not only fail to help patients but also confuse clinicians, leading to hesitation and harm.

Zhu Danxi stated: Malaria can be caused by summerheat, wind, dampness, phlegm, or food stagnation. Persistent malaria is called Old Malaria; if it forms a mass, it is called Mother Malaria. Wind-summerheat malaria often results from resting in cool, breezy places during summer, closing the pores and preventing sweat excretion, trapping summerheat internally. Therefore, the primary treatment is diaphoresis (sweating method). If malaria is accompanied by aversion to food, it stems from dietary issues and should be treated by regulating digestion. The folk term "Spleen Cold" confuses the name with the actual pathology. Even if caused by dietary injury, it is not necessarily cold, let alone other causes.

Yan Yonghe said: Exposure to cold, drinking chilled liquids, lying in dampness, or irregular eating habits can disrupt spleen and stomach harmony, causing phlegm accumulation in the middle jiao, resulting in this disease. Hence the saying, "No phlegm, no malaria."

Zhang Zihe argued: Since the *Nei Jing* attributes malaria to summerheat injury in summer, why do later physicians treat it as Spleen Cold using warming herbs like dried ginger, prepared aconite, and sulfur? Some even attribute it to demonic influence, which is ridiculous. Others blame summer consumption of raw/cold foods, calling it Food Malaria, which is also incorrect. The *Nei Jing* teaches that summerheat injury combined with autumn wind-cold triggers the disease. Shallow heat causes daily attacks; deep heat causes every-other-day attacks. Pathogens entering the interior cause chills; those in the exterior cause fever. This mechanism has nothing to do with the spleen. In peaceful times, when people are calm, toxic herbs like realgar and cinnabar used in hot-to-treat-hot methods can be effective. In turbulent times, when people are exhausted and internal/external fire are active, using heat to attack heat may cause dysentery, hematemesis, sores, or vomiting. Treatment must differ based on the context. I have successfully treated many malaria cases using Zhang Zhongjing’s methods of inducing sweating, vomiting, and purgation, strictly avoiding treating it as Spleen Cold.

I maintain that malaria originates from external pathogens like wind, cold, water, and dampness. Even thin clothing causing chill in weak constitutions can trigger it. As the disease deepens, it affects meridians and zang organs, moving from exterior to interior. Neglecting diet or labor can exacerbate it. Ultimately, the root is external pathogens; it is not truly caused by food or phlegm alone. Zhu Danxi listed phlegm and food together, and Yan Yonghe attributed it entirely to phlegm, deviating from the *Nei Jing*’s true meaning due to Chen’s influence. Zhang Zihe rightly mocked demonic attributions and rejected Food Malaria, emphasizing contextual treatment. However, equating summerheat solely with fire and applying harsh methods (sweating, vomiting, purgation) to exhausted populations during turmoil seems biased. In prosperous times, I was unaware of such turmoil, but for those injured by overwork, deficiency is severe. They may exhibit exhaustion of the three yang meridians and should not all be treated as fire patterns with harsh methods. This highlights the difficulty of accurate medical discourse and the challenge of achieving balanced, appropriate treatment.