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Yan Yonghe stated: The *Suwen* (Basic Questions) mentions that malaria arises from wind pathogens, and also states that it results from summer heat injury. These are influences of the qi of the four seasons. Some people cool themselves, drink cold substances, lie in the wind, dwell in dampness, or suffer from irregular eating habits, leading to disharmony of the spleen and stomach and accumulation of phlegm-dampness in the middle jiao (middle burner), thus forming this disease. This is what is meant by "no phlegm, no malaria." Malaria occurring once a day is easy to treat; occurring every other day is difficult to cure; occurring every three days is even more difficult to cure.

Commentary: Here, it is said that malaria is formed due to disharmony of stomach qi and accumulation of phlegm in the middle jiao, meaning illness originates internally and manifests externally. Although different from the *Suwen*'s description of wind and summer heat invading from the exterior, once the exterior is injured, internal qi must become stagnant, which also generates phlegm; this means illness originates externally and affects internally. It is true that malaria can be complicated by phlegm, but citing the phrase "no phalkm, no malaria" is biased. The medication and treatment methods are not detailed.

*Bingji Jiyao* (Essentials of Pathogenesis) states: The classic says, "Summer injury by summer heat leads to malaria in autumn." If the injury is shallow, onset is near and sudden; if severe, onset is distant and prolonged. Thus, it is known that summer heat qi becomes closed and cannot vent outward; the pathogen moves inward, and upon reaching autumn, malaria erupts. There are cases involving the Three Yang meridians and those involving the Three Yin meridians, with distinct syndromes, similar to Cold Damage (Shanghan). Involvement of the Taiyang meridian is called Cold Malaria, treated mostly with sweating methods; involvement of the Yangming meridian is called Heat Malaria, treated mostly with purgation methods; involvement of the Shaoyang meridian is called Wind Malaria, treated mostly with harmonizing methods. Illness in these Three Yang meridians is called Sudden Malaria, occurring between Summer Solstice and End of Heat, representing shallow injury with near and sudden onset. Involvement of the Yin meridians, regardless of the specific meridian, is collectively called Damp Malaria, discussed primarily through the perspective of the Taiyin meridian. Occurring between End of Heat and Winter Solstice, this represents severe injury with distant and prolonged onset. Those residing in the West are suitable for treatment with toxic drugs.

Commentary: This distinguishes the differences in yin/yang, depth/shallowness, and severity of wind and summer heat injuries, expounding on points not previously discussed. See further discussion below.

Zi He (Zhang Congzheng) said: Since the *Neijing* (Inner Canon) attributes malaria to summer heat injury in summer, why do later physicians all treat it as Spleen Cold? Using herbs such as Ganjiang (Dried Ginger), Fuzi (Prepared Aconite Root), and Liuhuang (Sulfur), and in severe cases attributing it to demonic influence, is truly laughable!

Furthermore, some attribute it to Food Malaria because of consuming raw and cold foods in summer, which is also incorrect. Does one not know that the *Neijing* does not say this? All cases involve summer heat injury followed by onset upon encountering autumn wind-cold. If pathogenic heat is shallow, it occurs daily; if deep, it occurs every other day. Entering interior causes chills; entering exterior causes fever. Such explanations have nothing to do with the Spleen. In times of peace, when people are tranquil, even using toxic drugs like Pishi (Realgar) and Chensha (Cinnabar) to treat heat with heat can yield results. However, in times of turmoil, when people are laborious and suffering, internal fire and external fire move together; treating heat with heat may turn into hematemesis, hematochezia, sores, ulcers, and vomiting. How can they be treated the same as tranquil people? I once used Zhang Zhongjing's sweating, vomiting, and purging methods to cure many malaria patients. It is strictly forbidden to mistakenly treat it as Spleen Cold.

Commentary: This states there is no Spleen Cold or Ghost Malaria, but rather acquisition from summer heat, and that treatment differs between peaceful and turbulent times; these are accurate discussions. However, Food Malaria does exist in the world. Observing his medications, such as Baihu Jia Renshen Tang (White Tiger Plus Ginseng Decoction), Xiaochaihu Tang (Minor Bupleurum Decoction), Wuling San (Five-Ling Powder), Guiling Ganlu Yin (Cassia Twig and Poria Sweet Dew Drink), these are regulating agents. For severe cases, Chengqi Tang (Chengqi Decoction) or Dachaihu Tang (Major Bupleurum Decoction) are used for purging; if still uncured, Changsan San (Changshan Powder) is used to induce vomiting. All are cold-natured drugs that descend fire, likely because malaria transforms from fire. There is also a theory that treating poor/commoners differs from treating wealthy/nourished individuals. While correct, using Wenspi San (Warm Spleen Powder) and Chensha Dan (Cinnabar Pill), which are coercive drugs, on poor people—can they be treated the same as ordinary people? Poor people have deficient-cold spleen and stomach; how can coercive drugs be used? This is likely not written by Zi He; students should ponder this.

A question was asked: Why do common people consider malaria to be Spleen Cold? The answer is: There is reason for this. Among all regions under heaven, only Wu, Chu, Min, and Guang regions have the highest incidence, because these are places where yang qi is abundant, terrain is low and damp. During late summer, people often suffer from malaria, cholera, and dysentery, damaging them with damp-heat. At this time, summer heat is extreme; extreme yang implies hidden yin within, causing spleen stagnation and fatigue, and opening of the cou li (pores). Some cool off by water, rest in tree shade, or bathe in springs, allowing slight cold to lodge in the muscles. This is what the Classic calls "encountering the chilling small cold of summer air pressing upon one." Or, illness arises immediately due to internal injury from labor or irregular diet. Therefore, muscles are attributed to the Spleen; during attacks, there is often aversion to cold and shivering, hence called Spleen Cold. Actually, it is caused by wind-cold-damp pathogens stagnating in the cou li. In summer, pores are open and no disease occurs; when autumn qi converges, exterior pathogens cannot vent, so they advance and retreat endlessly, causing alternating chills and fever. The condition feels like the person is being tormented, hence named Malaria, which is essentially Cold Damage of the four seasons; thus, all twelve meridians can be affected. Ancient formulas often combine regulation of internal injury. Efficacy lies in harmonizing the spleen and stomach, unblocking essence and qi, reconciling yin and yang, and dispersing all pathogens. This is truly not a disease of the Spleen itself. Only the pathogenic qi ascends and descends along the meridians, with varying onset times. The *Neijing* details these cases thoroughly. People generally use only exterior-releasing, muscle-relaxing, meridian-warming, and cold-dispersing methods, without adhering strictly to drying-spleen coercive agents. Another question: Since malaria is fundamentally caused by summer heat injury in summer, why do some stop the disease without medicine, or by having others chant spells to suppress it? The answer is: This is because in summer, heaven and earth qi interact, all things grow, damp-heat steams, and birds/insects release toxins. Due to summer heat and sweating, spirit and qi are depleted; one contracts erratic qi from the environment. Thus, suppression methods can also stop it, which is referred to as "shifting spirit and changing qi." However, ancients stated malaria should not be considered Spleen Cold precisely to prevent people from exclusively focusing on warming the spleen, failing to understand the source of creation, and missing the essentials of pathogenesis and qi suitability.