This article is the third in a series of articles which begins with the question:

Considering Chinese medicine regards ancient medical texts as having practical value in modern times, does this imply that it has a faith-based perspective rather than a scientific one?

I attempted to answer this question by following the history of the Shanghan Lun, an ancient text dated back to the second century that has had a great impact on the development of Chinese Medicine and continues to be influential to this day.

In the first article, Chinese Medicine: Science or Faith?, I focused on the vision of Zhang Zhongjing, the author of the text.  In the preface to his doctrine he appeals to scholars, expressing his wish to inspire a medicine based on education, knowledge, critical thinking and clinical observation.

In the second article, Shanghan Lun’s Role in the Evolution of Chinese Medicine – part 1, I review the first millennium in remarkable historical journey of the Shanghan Lun. Written in the second century, it had almost no theoretical or practical impact for hundreds of years afterward. It miraculously survived the turmoil of wars, natural disasters, political and social upheavals as well as the passage of time, eventually resurfacing in the eleventh century as the clinical guide intended by its author. It has since grown in popularity and clinical value, ultimately establishing itself as the single most influential text in the history of Chinese medicine.

In this article, I will discuss the effect this text has had on Chinese Medicine since the eleventh century until the modern era. The Shanghan Lun was chosen for official publication in 1065 by the Song dynasty government as part of a larger endeavor to reform medicine according to scholarly standards. Its publication marks the start of a lengthy and ongoing quest to unravel its theoretical principles and complex clinical instructions.

Discourse is a fundamental pillar for progress. Discourse for sharing ideas and experiences, discourse for argumentation and for challenging perceptions, discourse for brainstorming leading to new insights and innovation.

The publication of the Shanghan Lun provided, for the first time in the history of Chinese medicine, the foundation for a genuine and productive discourse among doctors. Because of developments in print technology, the text was widely available, and everyone was using the same version. This discourse was capable of transcending geographical boundaries and historical periods. Most of this discourse was conducted through the publication of books that examined the Shanghan Lun‘s interpretations and clinical applications. According to Stephen Boyanton:

“From the Song onward, the Treatise became the single most written-about text in the Chinese medical literary corpus”¹.

This would not have happened if Shanghan Lun’s content had not been so thought-provoking and inspiring. In this article, I will demonstrate how much of an impact this doctrine has had on the evolution of Chinese medicine.

Commentaries of the Shanghan Lun

The Shanghan Lun is not an easy text to understand. It introduces a systemic diagnosis and treatment model for the body based on the six conformations. However, it does not provide an organized explanation of the underlying principles. To form a comprehensive analysis of the Shanghan Lun it is necessary to deduce from the clinical descriptions and the formulas listed in the text, and combine different lines scattered throughout the text. When I asked my teacher in Taiwan, Dr. Li Zhengyu, to teach me the Shanghan Lun, he said there was no point in teaching me until I read it from beginning to end at least 7 times. I was told that the first 3 times I would not understand much, but beginning from the 4th time, I will start to see the connections between the different parts of the text and the underlying pattern of the 6 conformations would begin to reveal itself to me.

This complexity benefited scholarly physicians, who established their standing by claiming that the depth and wisdom required to be a doctor cannot be realized without an educated background. This intricacy also provided fertile ground for discourse and innovation.

However, for the physicians trying to implement the Shanghan Lun in clinical practice, the complexity was an obstacle. The doctrine needed to be more approachable if it was going to become a widely used clinical guide. Commentaries were desperately needed.

The first full commentary on the Shanghan Lun, and the most famous one to date, was published in 1144 by Song dynasty physician Cheng Wuji 成無己 (1063-1156), called: Annotated Treatise on Cold Damage ( Zhujie Shanghan Lun)  注解傷寒論.

This comprehensive commentary explains the Shanghan Lun line by line, using theoretical principles derived from the Huangdi Neijing, a foundational medical text written about a century earlier. The Neijing was widely accepted as the theoretical foundation for the Shanghan Lun for several reasons. The six conformations as well as the specific names given to each one of them appear in the Neijing. The Shanghan Lun itself mentions the Neijing as one of the textual sources in the preface of the text (The other sources mentioned include the Nanjing and three additional texts that are no longer extant and their content is unknown).

From a historical perspective, the newly emerging status of scholarly physicians required a canonical base for determining standards of education and knowledge. This was accomplished by the consolidation of ancient medical doctrines into a unified medical system. Asaf Goldschmidt has remarked on this: “Cheng provided Song medicine, for the first time, a unified nomenclature that enabled physicians to comprehensively understand medical doctrines originating from different medical approaches. In other words, this was one of the first instances in which Song medicine had a unified theoretical basis for physiology and pathology.”²

Cheng’s commentary continues to be widely recognized, and has had a significant impact on the understanding and practical application of the Shanghan Lun. However, this commentary did not remain unchallenged. In later centuries the direct association between the Neijing and the Shanghan Lun was criticized. This criticism stemmed from clear fundamental conceptual discrepancies between the two texts. In the Neijing each of the six conformations is linked to specific organs and their correlating circulatory tracts. There is no such correlation in the Shanghan Lun. In Neijing, Suwen chapter 31 the six conformations appear to represent successive stages of febrile disease, illustrating the damage that results as the disease penetrates the different stages and progresses from a superficial level to a life-threatening illness. In the Shanghan Lun, there are multiple pathways for disease to progress, depending not only on external pathogenic influences but also on individual internal bodily factors. Modern-day scholar Otsuka Keisetsu concluded following extensive research into the Shanghan Lun: “Zhang was a physician in the tradition of the Inner Canon who acknowledges (in his preface) the importance he accorded to the world view – absent from the text of the Treatise.”³

Epistemological bifurcation in the interpretation of the Shanghan Lun emerged in the late 16th century. This is marked by the publication of a book by Fang Youzhi in 1593 titled: A Critical Essay on the Clauses of the Treatise of Cold Damage (Shanghan Lun Tiaobian) 伤寒论条辨.⁴

Fang suggests that the traditional interpretation of the Shanghan Lun based on the Neijing is incorrect. He advocates against the correlation of the six conformations with the circulatory tracts, stating: “The [term] Jing of the six Jing [of the Shanghan Lun] and the [term] Jing of the channels and network vessels [of the Neijing] is not the same.”⁵
By breaking from the traditional perception of the Shanghan Lun as a direct continuum of the Neijing, Fang opened the door to novel interpretations based on textual research of the ancient text combined with concurrent clinical observations. An example of this is the 1706 publication of the highly influential book written by the Qing physician Ke Qin titled Anthology for the Revival of Cold Damage (Shanghan Laisu Ji) 傷寒來蘇集.
In his book Ke Qin wrote:

“Although it took the six divisions as its overarching scheme of organization, each division referring to a specific ‘bounded domain’, it did not thereby restrict itself to the conduits and collaterals, neither was it delimited solely by wind and cold. That is, although [Zhang] Zhongjing employed the terminology of the Inner Canon, he extended the meaning of the six divisions concept.”⁶

“[Zhang] Zhongjing’s formulas were composed because of the symptoms [they treat], not because of the conduits [they enter]. Whenever one sees a specific manifestation pattern, one employs the [corresponding] formula. This is [Zhang] Zhongjing’s simple yet flexible method (huofa 活法).”⁷

During my studies of the Shanghan Lun I often observed my teachers using a formula in situations that didn’t seem to correspond to the instructions of the original text. Whenever I asked for an explanation, it would often begin with the saying: “grasp the mechanism of disease, to flexibly apply the formulas” – 抓病机，活用经方. This saying mirrors the words of Ke Qin quoted above. It embodies the living spirit of the Shanghan Lun as a clinical guide. This perspective has given us the tools to investigate the conformations as patterns of Yin-Yang dynamics that are responsible for the various bodily functions and bodily reactions to pathological conditions. It has provided Chinese medicine practitioners in modern times the necessary tools to explore the teachings of the Shanghan Lun in relation to a wide range of ailments, both external as well as miscellaneous.

The complexity of the text, allowing the possibility for various interpretations and commentaries, prevented the Shanghan Lun from becoming fixed in theory and practice. The discussion and constant quest to understand the meaning of the text are part of the living spirit of this text. It is a discussion that communicates theory with practice, ensuring that the text remains relevant.⁸

Case studies

Books describing clinical case studies are an important tool in the transmission of practical medicine. Publication of case histories provided a setting for physicians to showcase their personal interpretations, experience and present novel insights that diverge from traditional theoretical conceptions.⁹

The diagnostic model and herbal formulas of the Shanghan Lun are often discussed through this literature, enriching the understanding of the doctrine and expanding its practical applications. The first book of this sort was published in the 12th century by Xu Shuwei. The book is called Ninety Discourses on Cold Damage (Shanghan Jiushi Lun) 傷寒九十論.

The title of the book describes the content: 90 case studies from the clinical experience of Xu Shuwei. The case studies, meant as instructive guides for doctors, are used to clarify the diagnostic and treatment principles of the six conformations. Each case details the clinical manifestations, explains the diagnosis and analyzes the treatment while explaining relevant theoretical issues deriving from the Shanghan Lun. Xu Shuwei did not leave much room for doubting his admiration towards the Shanghan Lun as demonstrated by the following quote from case study number 15:

“How can anyone not well versed in Zhongjing’s methods cure this?”¹⁰

Modern books have also continued this tradition of transmission by demonstrating how the combination of knowledge derived from the Shanghan Lun together with clinical experience and modern medical perspectives can contribute to greater understanding and precision in the treatment of a wide range of diseases.¹¹

Shanghan Lun for internal diseases

Initially, following the official eleventh century publication, the Shanghan Lun was applied mainly to febrile diseases, focusing on the concept of “shanghan” 伤寒 as diseases of external origin. However, this book was originally titled the Shanghan Zabing Lun, “zabing” meaning complicated diseases with internal origin. It is plausible to assume that as a physician Zhang compiled a doctrine that attests to his diverse and complex clinical experience which was not limited only to febrile diseases. The preface to the doctrine also implies that Zhang Zhongjing did not intend the six-conformation model solely for febrile illnesses:

“Although it is not possible to completely cure all diseases, you can observe a disease to know its origin. If one can employ what has been collected [in this book], then they can deliberate over more than half [of the diseases].”¹²

Early indications of application of the Shanghan Lun to non-febrile internal diseases are present in the writings of the physicians of Jin-Yuan dynasties (1115-1368).
Zhang Zihe (1156–1228) for example, one of the renowned Jin dynasty medical masters, documented a treatment of a mental condition which he described as “heart wind”, using the formula Tiao Wei Cheng Qi Tang.¹³

Another one of the Jin-Yuan masters, Li Dongyuan, offers additional examples. Li survived the Mongol invasion, witnessing both the atrocities of the invasion, as well as the accompanying pandemic. Considering the unbearable living conditions and malnourishment that many of his patients suffered from, Li emphasized the internal condition of the body that allowed it to defend itself from external influences, including aggressive influences such as those causing pandemics. In his famous book Pi Wei Lun he stresses the importance of treating the internal condition of the body:

“…Thieving evils [from outside] alone can do no harm to people. Thus it is evident that disease starts from the spleen and stomach.”¹⁴

Li Dongyuan was a well-known expert in the Shanghan Lun, and his teachings were influenced by the principles and formulas in this ancient text. He occasionally mentioned Zhang Zhongjing directly as a basis for his therapeutic decisions:

“It may be questioned why the sweet and warm can engender the blood since they are not blood medicinals. The answer is as follows: Supplementation of blood vacuity with Ren Shen is (Zhang) Zhongjing’s method, when yang is made effulgent, yin blood is engendered.”¹⁵

Wang HaoGu, a student of Li Dongyuan, summarized this in a simple and straightforward statement that he:

“Uses cold damage prescriptions to treat miscellaneous diseases”¹⁶

In modern times the application of the methods of the Shanghan Lun to miscellaneous diseases has become common practice. This is demonstrated by the numerous research conducted on the use of formulas from the Shanghan Lun to a wide variety of diseases.

Shanghan Lun for the treatment of febrile diseases

The Song dynasty (960–1279) initiated the publication of medical texts as part of an official effort to improve and regulate the field of medicine. One of the reasons the Shanghan Lun was chosen to be among the few texts published was the assertion that it contained a much-needed systemic approach for treating epidemics and febrile diseases. It is therefore not surprising that the difficulties in the treatment of epidemics was one of the focal points in the discussions surrounding the Shanghan Lun.¹⁷

In the preface to his doctrine, Zhang Zhongjing attests to his own failure in saving his family members from an epidemic disease. In line six of the Shanghan Lun there is a detailed description of what appears to be a description of desperate and unsuccessful attempts of a doctor trying to treat a pathology called “wenbing” 温病:

“When in greater yang disease [there is] heat effusion and thirst, without aversion to cold, [this] is warm disease. If after sweating has been promoted, there is generalized scorching heat, this is called wind warmth. [When] wind warmth causes disease, the yin and yang pulses are both floating, [there is] spontaneous sweating, generalized heaviness, an tendency to sleep, the breath [from the] nose will [make a] snoring [sound], and speech is difficult. If precipitation has been use, [there is] inhibited urination, forward staring eyes and fecal incontinence, if fire has been use, [there is] is light yellowing , and in acute cases [there is] fright epilepsy, periodic tugging and slackening, and [the skin] appears as if fumed by fire; one [instance of] adverse [treatment] will lead to the term of life.”¹⁸

In this long and depressing paragraph, Zhang Zhongjing expresses only failure with no clue to an appropriate strategy that might be able to successfully treat this condition of “wen bing”. The term “wenbing”, lit. warm disease, is a term taken from the Neijing. It is not clear whether Zhang Zhongjing was referring in this clause to the epidemic that killed his family members. Nonetheless, “wenbing” is often associated with pandemics and febrile diseases. With this line, Zhang Zhongjing, in effect, fired the opening shot to one of the main issues that has troubled countless physicians for many generations and is as relevant today as it was 2000 years ago: how to treat epidemic diseases efficiently.

This heated discussion led to diversity of opinions, initiating in the Jin-Yuan dynasties (1115-1386). The medical Masters of Jin-Yuan sought solutions within the framework of the six-conformation model. They were all experts of the Shanghan Lun, and expressed great appreciation for it, quoting from the text and applying its principles in their teachings.

However, they realized there was a gap between the teachings of the ancient doctrine and the clinical reality they were dealing with. In the Shanghan Lun cold and wind are the main pathological influences. The Tai Yang conformation, that is the body’s first defense in cases of external pathogenic influences, provides mainly formulas with warm and acrid properties. Concerning internal damage, the book focuses mainly on damage to the Yang qualities with almost no reference to damage to the Yin qualities. In their clinical reality, the Jin-Yuan masters observed febrile diseases manifesting as diseases of heat and fire. This was by no means a rejection of the Shanghan Lun, but rather a conscious effort to complement the doctrine.¹⁹

During the Ming dynasty (1368-1644) there was a dramatic change in the perception of epidemic diseases. There was increasing exposure to diseases originating in the Southern areas. The tropical climate and local tribes and customs were strange to the Chinese and the diseases endemic to the South did not comply with traditional medical perceptions, including the doctrine of the Shanghan Lun. As epidemics from the South spread throughout China it was increasingly apparent that existing medical strategies were useless²⁰. At the end of the Ming dynasty amid the crumbling dynastic rule, accompanied by another horrific pandemic, a new doctrine was beginning to form. In 1642 Wu Youxing published his book Wenyi Lun 溫疫論. In his book, Wu Youxing expressed harsh criticism towards the Shanghan Lun and its followers. In the preface to his book he wrote:

“In Zhang Ji’s Cold Damage Treatise…because (his method was) based on exogenous Wind and Cold qi factors, his account of transmission was entirely different from that of Warm epidemics. Dozens of his successors discussed (his work), always using the terminology of Cold Damage… They did not realize they had mastered butchering dragons, a useless art; they could not avoid calling a deer a horse… How different is what we learn from experience about Cold Damage and Warm epidemics! They are as different as Heaven and Earth.”²¹

One of the main differences that Wu Youxing emphasized was the source of disease. He claimed that the source of epidemics was not external seasonal influences, but rather poisonous influences endemic to specific geographical and climatic conditions, which are extremely contagious in nature, leading to extensive spread of the disease to places far from the source. In his opinion, the attempt to force the traditional shanghan disease model was fundamentally erroneous.

This new perception of epidemic diseases continued to develop during the following Qing dynasty (1644-1911). Prominent figures contributing to its formation as an independent doctrine were Ye Tianshi (1666-1745) and Wu Jutong (1758-1836). The Wen Bing school continued to develop during the 19th and 20th centuries, with accumulating experience and literature. It was the leading medical approach in the efforts to deal with the SARS pandemic in the years 2002-2003.²²

As befitting a medical tradition that was transmitted through critical discourse, this was not a refutation of the Shanghan Lun. Even the founding fathers of Wenbing School were not unanimous in their approach. While Wu Youxing rejected the Shanghan Lun, Ye Tianshi and Wu Jutong combined diagnostic principles and formulas from the Shanghan Lun in their practice and teachings. The relationship between Shanghan Lun and the Wenbing school is also reflected in modern day China evident in the treatment protocols for treating Covid-19. Both models are utilized, with emphasis not on a particular doctrine, but rather on one of the most important principles that stemmed out of the Shanghan Lun and continues to guide practitioners from every school of thought: The principle of differential diagnosis.

Diagnosis in the Shanghan Lun

The Shanghan Lun mentions repeatedly the dangers of misdiagnosis. However, the text did not offer an organized explanation of the underlying diagnostic principles other than one general reference in line 16A that calls the physician to seek the answer from within the symptomatic manifestation of the disease:

Line 16A:

“。。。观其脉证，知犯何逆，随证治之。”

“…Observe the pulse and signs, know what error (you) have committed, (and then) treat according to the signs…”²³

The text then proceeds to guide according to this principle of observation of symptoms by giving numerous examples of clinical manifestations and their appropriate treatment choice.

This has become a basic principle in Chinese Medicine. Even when coping with an epidemic disease, doctors emphasize not only the identity of the pathogenic influence, but also individual differential diagnosis based on  the specific clinical manifestation, and influenced by body constitution, lifestyle, living conditions, emotional state, etc. All these complete the understanding of the patient’s condition and are necessary to effectively treat each individual according to their particular needs and abilities.

Conclusion

The official publication of the Shanghan Lun paved the way for this text to stimulate the minds of scholars in generations to come, becoming not only influential in the formation of a medicine based on education, but also a medicine based on analysis and research leading to change and innovation. The Shanghan Lun is not meant to be read as a text frozen in time, but as a dynamic flexible doctrine that teaches us to think and adapt. It provides guidelines to understanding Yin-Yang dynamics of a pathology and healing. This is the reason why formulas that were written 2000 years ago continue to prove beneficial for the treatment of diseases in modern times.

In the words of Li Dongyuan:

仲景藥為萬世法，號群方之租，治雜病若神，後之醫家，宗《內經》法，學仲景心，可以 為師矣。
“Zhongjing’s medicinals are the method of the myriad generations. They are called the ancestors of all formulae. If later physicians take the methods of the Inner Classic as a model and study the intent of Zhongjing, then they can be taken as teachers.”²⁴

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Bibliography:

1. Boyanton, Stephen. 2015. The ‘Treatise on Cold Damage’ and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000–1400. Ph.D. Dissertation. Columbia University: p. 11.

2. Goldschmidt, Asaf. 2009. The Evolution of Chinese Medicine: Song Dynasty, 960–1200. London and New York: Routledge: p. 169.

3. Quoted from: Sivin Nathan. 1987. Traditional Medicine in Contemporary China. Science, Medicine, & Technology in East Asia 2. Ann Arbor: Center for Chinese Studies, The University of Michigan: 87-88.

4. For more on this book see: Scheid Volker. 2013. “Transmitting Chinese Medicine: Changing Perceptions of Body, Pathology and Treatment in Late Imperial China.” Asian Medicine: Tradition and Modernity 8: 299–360.

5. Fang Youzhi. (1593) 2009. Shanghan Lun Tiaobian 伤寒论条辨 [A Critical Essay on the Clauses of the Treatise of Cold Damage]. Reprint Beijing: Xueyuan Banshe 学苑版社: p. 11.

6. Translation from Scheid Volker. 2013. “Transmitting Chinese Medicine: Changing Perceptions of Body, Pathology and Treatment in Late Imperial China.” Asian Medicine: Tradition and Modernity 8: p. 336-7.

7. Translation from Scheid Volker. 2013. “Transmitting Chinese Medicine: Changing Perceptions of Body, Pathology and Treatment in Late Imperial China.” Asian Medicine: Tradition and Modernity 8: p. 342.

8. An example of modern-day adaptation of the Shanghan Lun is: Huang Huang, translated by Michael Max. 2009. Ten Key Families in Chinese Medicine. Seattle: Eastland Press.

9. For more on the genre of case studies see: Furth Charlotte. 2007. “Introduction.” In Thinking with Cases : Specialist Knowledge in Chinese Cultural History, edited by Charlotte Furth, Judith T. Zeitlin and Ping-chen Hsiung, 1-27. Honolulu: University of Hawaii Press.

10. Translation modified from Goldschmidt Asaf. 2019. Medical Practice in Twelfth century China. A Translation of Xu Shuwei’s Ninety Discussions (Cases) on Cold Damage Disorders. Switzerland: Springer International Publishing: p. 77-79.

11. Examples of case studies used to enhance the understanding of the Shanghan Lun can be found in: Zhang, Zhongjing, Greta Young Jie De, and Robin Marchment. 2009. Shang Han Lun Explained : A Guided Tour of an Ancient Classic Text Written by Zhang Zhong Jing in 200 AD and Its Modern Clinical Applications. Chatswood, NSW: Elsevier Australia.

12. Original text taken from Mitchell Craig, Feng Ye and Nigel Wiseman.1999. Shang Han Lun On Cold Damage. Brookline, MA: Paradigm Publications: p. 12.

13. Boyanton Stephen. 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 200-3.

14. Translation from Flaws Bob. 2004. Li Dong Yuan’s Treatise on the Spleen and Stomach, A Translation of the Pi Wei Lun. Boulder Colorado: Blue Poppy Press: p. 10.

15. Translation from Boyanton Stephen. 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 208-9.

16. Translation from Boyanton Stephen. 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 212.

17. For more on the Song publication of the Shanghan Lun see: Goldschmidt Asaf. 2009. The Evolution of Chinese Medicine: Song Dynasty, 960–1200. London and New York: Routledge.

18. Translation taken form from Craig Mitchell, Feng Ye and Nigel Wiseman.1999. Shang Han Lun, On Cold Damage Translation and Commentaries. Brookline MA: Paradigm Publications: p. 47.

19. For more on the influence of the Shanghan Lun on the teachings of the Jin-Yuan masters see: Boyanton Stephen. 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 191-218.

20. Hanson Marta E. 2012. Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China. London and New York: Routledge. Chapter 4.

21. Translation taken from Hanson Marta E. 2012. Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China. London and New York: Routledge. p. 95

22. Hanson Marta E. 2012. Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China. London and New York: Routledge: p. 162-68.

23. Translation from Craig Mitchell, Feng Ye and Nigel Wiseman.1999. Shang Han Lun, On Cold Damage Translation and Commentaries. Brookline MA: Paradigm Publications: p. 132.

24. Translation from Boyanton Stephen. 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 204.