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In the southern regions, the changes of cold and heat are irregular. During spring and summer, excessive rain leads to an abundance of cold; morning and evening fog creates a humid atmosphere with dampness steaming from the ground, causing Yin-damp Qi to be often prevalent. In autumn and winter, prolonged sunshine results in excessive heat, where grasses and trees do not wither but bloom, causing Yang-warm Qi to frequently dissipate. Days are hot, nights are cold; sunny days are hot, rainy days are cold. Humans living in such environments, due to the prevalence of cold-damp Qi, experience heaviness and dampness in the lower body and generate more phlegm. The production of phlegm is attributed to the heat of autumn and winter; excess heat tends to obstruct upwards. The skin sweats easily, leading to loose *Couli* (pores and interstices), with Yang floating outward and Yin closing inward, Yang drifting and Yin blocking. At this time, if dietary habits are irregular, daily routines are untimely, or raw/cold foods and roasted/dry foods are consumed, phlegm and food stagnation accumulate together in the stomach, triggering alternating chills and fever. One might not avoid the heat, running under the sun, or seek shade while sitting/lying in the wind, closing sweat pores and preventing perspiration, which also induces this disease. Or, due to morning mist and cold, one drinks alcohol to ward it off; shortly after sunrise, heat arises, causing wine and phlegm to stagnate above the diaphragm, inducing this disease. Or wearing too little in the morning cold, or too thin quilts at night, causing cold and phlegm to combine, resulting in chills and fever. Or wearing too much in the morning cold and not removing it by noon, causing summer-heat and phlegm to combine, also resulting in chills and fever. Essentially, the root of this disease lies in the heavenly heat causing constant leakage of primal Yang Qi; human Yang Qi fails to descend, and internal phlegm is abundant. Without proper care, contracting pathogenic factors, symptoms of upper heat and lower cold naturally arise. This is what is meant by "no phlegm, no malaria." Those who practice health preservation can avoid this even toxic miasma by avoiding sexual activity, reducing labor, abstaining from raw/cold and roasted foods, avoiding early drunkenness, not overeating at dinner, not walking in summer heat, and not sitting/lying in drafts. Adjusting clothing according to temperature changes throughout the day allows one to largely escape the disease.

The symptoms of external cold invasion and zhang-malaria both present with chills and fever. Physicians often mistake zhang-malaria for shang-han (cold damage) and indiscriminately use sweating, vomiting, or purging methods. Countless patients have died wrongly due to this failure to distinguish between cold and heat patterns. Now, let us differentiate them clearly. The Classics state: "Winter injury by cold leads to epidemic fevers in spring." If illness occurs immediately in winter, it is called Shanghan. If delayed until spring, it becomes a Wenbing (warm disease); if delayed until summer, it becomes a Rebing (heat disease). Such diseases usually begin in the Taiyang Meridian. Thus, there is fever, aversion to cold, headache, stiff spine, absence of sweating, a normal mouth without bitterness, normal appetite, and a floating-tight pulse—this is Shanghan. Or, with aversion to wind, spontaneous sweating, and a floating-slow pulse—this is Shangfeng (wind injury). If the heat persists and transmits to the Yangming Meridian, symptoms include eye pain, dry nose, insomnia, and a long pulse. If transmitting to the Shaoyang Meridian, symptoms include deafness, hypochondriac pain, bitter taste, vomiting, white tongue coating, and a wiry pulse. If entering the Yangming Fu-organs (interior), symptoms include yellow tongue coating, thirst, mental restlessness, dry tongue, aversion to heat rather than cold, restless tossing, removing clothes/bedding, delirious speech, and a flooding-rapid pulse indicating interior excess. Purging agents are indicated. Delayed purging allows entry into the Yin meridians, presenting with a black, enlarged tongue. Shanghan heat is continuous until transmitted to the interior and purged. The Classics state: "Summer injury by summer-heat leads to malaria in autumn." Summer-heat without sweating leads to wind-malaria in autumn. Thus, malaria often originates from summer-heat. In miasma-prone areas, seasons resemble summer year-round. This disease does not transmit through meridians. Cold-zhang presents with chills and fever, headache, weak legs, heavy waist, oral discomfort, vomiting or not, wiry-numerous pulse (6-8 beats per respiration), alternating chills/fever. During chills, the pulse is deep-slow-hidden; during fever, it is 6-7 beats, wiry-flooding, with thirst for water, vomiting after drinking, restlessness, resolving upon sweating. Or no sweat but heat subsides eventually, occurring every other day or daily (mild cases). Hot-zhang presents with no chills, only high fever, headache, fatigue, heavy waist/legs, irritability, chest oppression, vomiting or not, diarrhea or not, dark-scanty urine, thirst, flooding-wiry pulse (7-8 beats), continuous heat. Within 1-2 days, the tongue turns black, eyes red, face red, craving cold water (drinks it), delirium, constipation worsening at dusk. This resembles Shanghan interior excess. Careful palpation reveals uneven heat: forehead very hot, face slightly hot, nasal tip cool, chest/abdomen very hot, back slightly hot, lower body less hot. Severe cases feel constantly cold or have cold limbs with delirium. Palpating the chest shows curling up then rising wildly. Why are legs heavy? Zhang disease is upper heat/lower cold, hence lower body is cool and heavy. Upper body symptoms appear Yang but hide Yin. The nasal tip is the Nienshou Palace, belonging to the Spleen; spleen cold makes the nasal tip cool. This is exterior heat/internal cold; exterior heat masks internal cold, verified by cool nasal tip. Curling up and crossing hands indicates hidden stomach/chest issues. Some call this Yin-pattern resembling Yang, but it is not. Yin-resembling-Yang craves cold water but refuses it when given. Zhang patients drink cold water. Proper medication resolves heat. If intermittent, pulse becomes weak upon resolution, no longer flooding/wiry/rapid. Generally, Zhang differs greatly from Shanghan. Shanghan stems from cold, has meridian transmission, transformations, and contagion. Zhang stems from summer-heat, has no transmission, no transformation, and no contagion. Mistaking chills/fever for exterior syndrome and using Shanghan sweating herbs, or mistaking delirium/constipation/black tongue for interior syndrome and using purging herbs, will lead to rapid deterioration and death.