Shang Han Lun’s Role in the Evolution of Chinese Medicine – part 2

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

Does the fact that Chinese medicine consider ancient texts to be of practical value in modern times, indicate it has a concept of a faith rather than a science?

I attempted to answer this question by following the history of the Shanghan Lun, an ancient text which 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 the author of the text, Zhang Zhong Jing, based on the preface he wrote to the Shanghan Lun. In the preface he appealed to the scholars expressing his wish to inspire a medicine based on education, knowledge, critical thinking and clinical observation.

In the second article – Shang Han Lun’s Role in the Evolution of Chinese Medicine – part 1 – I observed the impact of the Shanghan Lun on the development of Chinese Medicine in the centuries following its appearance in the 2nd century. I detailed the remarkable journey of this text, which was broadly ignored, and would have surely been lost had it not been for the conscious effort of a small number of individuals, and which resurfaced in the 11th century as the clinical text it was intended to be by its author. It has since continuously gained popularity and clinical significance and has ultimately established its place as the one 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 its official publication in 1065 until the modern era.

From its publication onward it has been the center of productive discourse, contributing greatly to the development of Chinese Medicine. Being a clinical guide, it has inspired the important discourse on the mutual relation between theory and practice.

Discourse is a fundamental pillar for progress. Discourse for sharing and transmitting ideas and discoveries, discourse for argument and questioning of unfounded perceptions, discourse for brain storming leading to new insights and innovation.

The publication of the Shanghan Lun created, for the first time in the history of Chinese Medicine, the basis for a real and fruitful discourse between doctors. Thanks to the technological advances of print, this discourse was able to transverse geographical areas and time frames. Most of this discourse was done through publication of books which discussed the clinical understanding of Shanghan Lun, detailed interpretations of the text, insights stemming from the text and arguments raised confronting the text, sometimes to the point of refuting it. In fact,

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

From the 11th century to modern times, for nearly 1000 years, the Shanghan Lun has provided an endless source for productive and creative discourse. The 1065 publication was an essential step in creating the circumstances for creating a discourse. For the first time in history the text was widely available, and everyone was using the same version. However, this would not have happened if the content of the Shanghan Lun had not been such an abundant source for ideas and inspiration.

I shall demonstrate the extent and influence of the discourse it created by presenting the different discussions that evolved from it:

Commentaries

The Shanghan Lun is not a simple text to understand. It involves principles of systemic diagnosis and treatment but does not offer an organized explanation of the underlying principles. In order to form a systemic analysis of the Shanghan Lun it is necessary to deduce from the clinical descriptions and the formulas given in the text, and combine different lines scattered throughout the text. When I requested to study Shanghan Lun from my teacher in Taiwan, Dr. Li Zhengyu, 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 starting from the 4th time, I will start to realize the connection between the different parts of the text and the underlying pattern of the 6 conformations would begin to reveal itself to me.

This complexity played into the hands of the scholar physicians, establishing their status on the grounds that without necessary educational background the depth and wisdom of Chinese Medicine cannot be realized. It is also this complexity that contributed to the fertile ground for discourse and innovation.

However, if the Shanghan Lun were to become a popular clinical guide for the growing status of scholar physicians, it needed to be more approachable. There was a critical need for a commentary.

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

This extensive commentary contains an explanation of the Shanghan Lun line after line, based on the theoretical principles stemming from the Huangdi Neijing. The understanding of the Neijing as the theoretical foundation for the Shanghan Lun is not coincidental. In the preface to his book, Zhang Zhongjing mentions the textual sources he used to compile his doctrine, which include the Neijing along with the Nanjing and 3 additional texts who are no longer extant, and their content is unknown.

The discussion concerning the theoretical basis and the practical application of the Shanghan Lun did not end with the publication of this commentary. In 1593 Fang Youzhi 方有执 published a book called: A Critical Essay on the Clauses of the Treatise of Cold Damage – Shang Han Lun Tiao Bian – 伤寒论條辨.

The book challenged both the authentication of specific sections of the official Song version of the text, as well as core concepts key to the interpretation of the text, such as its focus on febrile diseases and the widely accepted body image based on the Huangdi Neijing. Fang Youzhi did not question the great significance of the Shanghan Lun nor the knowledge attributed to Zhang Zhongjing. He was in fact attempting to prove that it is of even greater importance than attributed to it during his time. In his book he wrote:

“前乎仲景 有法无方,后乎有方无法,方法俱备惟仲景此书。“

“Prior to Zhongjing there was strategy without formula, following [Zhongjing] there was formula without strategy, formula and strategy are together only in this book of Zhongjing.”2

By doing this Fang Youzhi initiated a new current of learning that was later named Cuojian Zhongding Xuepai 错简重订学派. This current was continued through prominent physicians in the late Ming and Qing dynasty, and greatly influenced the understanding and application of the Shanghan Lun. In the words of Ke Qin, an influential commentator from the 17th century:

“although [Zhang] Zhongjing employed the terminology of the Inner Canon, he extended the meaning of the six divisions concept.”3

These commentators differentiated between the meridians and organ system of the Neijing and between the 6 conformations body system of the Shanghan Lun. They explained the conformations were anatomical zones with characteristic patterns of manifestation in pathological conditions.

“[Zhang] Zhong Jing’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] Zhong Jing’s simple yet flexible method (huofa 活法).”3

This interpretation of the conformations allowed the examination of modern medicine through analysis of zones and patterns of dynamics. This is in fact the application of “huo fa” that Ke Qin referred to in the above quote, the flexible application that combines insights from ancient sources together with modern time discoveries.

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 is part of the living spirit of this text. It is a discussion that communicates theory with practice. The theory affects the practice and the practice will in return affect the theoretical understandings. This is a legitimate and essential discussion which continues to this day. Examples of modern-day commentators include Huang Huang4 and Liu Lihong5.

Case studies

The discourse that developed concerning the clinical application of the Shanghan Lun, evolved into a publication of books based on analysis of clinical case studies. Today this sort of literature is prevalent with numerous publications of case histories based on theory and practice of Shanghan Lun. The first book of this sort was published in the 12th century by Xu Shuwei. The book is called Ninety Discourses on Cold Damage – Shang Han Jiu Shi 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, were an attempt to clarify the diagnostic and treatment principles of the 6 conformations. Each case illustrates the clinical manifestations, details the diagnosis and the treatment and the reaction to the treatment. Each case study ended with an analysis and explanation of the treatment choices that were made, while explaining relevant theoretical issues of the Shanghan Lun model, often accompanied with quotes from the text itself. 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:

“不熟讀仲景方法,何能治? ” – “How can anyone not well versed in the Treatise cure this?”6

The following quote from case 23 is an example of his repeated emphasis on differential diagnosis as a key to the success of a treatment:

“予見世醫論傷寒, 但稱陰證陽證。蓋仲景有三陰三陽, 就一證中, 又有 偏勝多寡, 須是分明辯質, 在何經絡, 方與證候相應, 用藥有準。”

“I [often] observe time-serving doctors discuss Cold Damage [disorders]. They speak only of yin and yang manifestation types. It would seem that the Treatise uses three yin and three yang [manifestation types], and within each type there are also many variations. These must be clearly differentiated.”6

While Xu Shuwei is basing his treatments on the Shanghan Lun, there are also 3 cases where he chooses to apply a different treatment. These are the cases in which he demonstrates that the Shanghan Lun is not a complete clinical guide to be memorized and applied automatically, but rather teaches us tools of diagnosis and treatment strategy which we can combine with our own clinical experience to develop new understandings and innovative treatment options.

Modern case study books have also continued this tradition of transmission by demonstrating how the combination of ancient knowledge with clinical experience and modern medical perspectives can contribute to greater understanding and precision in the treatment of a wide range of diseases.

The application of the Shanghan Lun to internal diseases

Originally the Shanghan Lun was applied mainly to febrile diseases, with focus on the meaning of “Shanghan” – 伤寒 as pathologies due to external influences. However, this book was originally written as the Shanghan Zabing Lun, Zabing meaning complicated diseases with internal origin. In the preface to the text, there is no reason to believe that Zhang Zhongjing intended his text to focus only on febrile diseases with external origin:

“Even though you will not yet be able to exhaustively cure all the various diseases, you may be able to look at a disease and know its origin. If you can unravel what I have collected here, you will have thought through more than half [of all problems you might face].”7

Early indications of application of the Shanghan Lun to non-febrile internal diseases are in case descriptions of Zhang Zihe, one of the Jin-Yuan Masters. One example of this is the treatment of a female patient suffering from a mental condition which he described as “heart wind”, Zhang used the formula Tiao Wei Cheng Qi Tang.8,9

Li Dongyuan, another Jin-Yuan Master, also relied on insights from the Shanghan Lun to treat internal diseases. Li survived the Mongol invasion, witnessing both the atrocities of the invasion, as well as the accompanying pandemic.10 Considering the unbearable living conditions and malnourishment which all his patient 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:

“ 賊邪不能獨傷人,諸病從脾胃而生明矣”

“Thieving evils (from outside) alone can do no harm to people. Thus it is evident that disease starts from the spleen and stomach.”11

Li Dongyuan was a well-known expert in the Shanghan Lun, and his teachings were influenced by the principles and formulas in this ancient text12. He occasionally mentioned Zhang Zhongjing directly as a basis for his therapeutic decisions:

“或曰:甘溫何能生血,又非血藥也。曰:仲景之法,血虛以人參補之,陽旺則能生 陰血也。”

“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.”13

Wang Hao Gu, a student of Li Dongyuan, summarized this in a simple and straightforward statement:

“以傷寒之劑,改之雜病”

“Use cold damage prescriptions to treat miscellaneous diseases”14,15

The aforementioned commentaries of Fang Youzhi in the 16th century and Ke qin in the 17th century consolidated the importance of the 6 conformations model in the treatment of internal diseases. Doctors started to relate to the conformations as spheres of influence with characteristic physiological and pathological dynamics. The origin of the disease, whether external or internal, was of less importance, emphasis was on accurately identifying the location and dynamics of the pathology in the body and restoring proper function to the conformation(s) involved.16

Discussion on the Shanghan Lun for the treatment of febrile diseases

The Song dynasty 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.17,18

It is therefore not surprising that the difficulties in the treatment of epidemics was one of the focus points in the discussions surrounding the Shanghan Lun.

This particular discussion can be understood as a discussion initiated by Zhang Zhongjing himself. In the preface he attests to his own failure in saving his family members from an epidemic disease, and in line 6 of the Shanghan Lun there is a detailed description of the desperate and unsuccessful attempts of a doctor trying to treat a pathology called wenbing 温病:

“太阳病, 发热而渴, 不恶寒者, 为温病。 若发汗已, 身灼热者, 名风温。 风温为病, 脉阴阳俱浮, 自汗出, 身重, 多眠睡,鼻息必鼾, 语言难出。 若被下者, 小便不利, 直观失溲。 若被火者, 微发黄色, 剧则如惊痫, 时痸疭若火熏之:一逆尚引曰, 再逆促命期。”

“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) slight 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.”19

In this long and depressing paragraph, Zhang Zhongjing expresses only failure with no clue to the strategy that might be able to properly treat this condition of “warm disease”. With this line, Zhang Zhongjing, in effect, fired the opening shot to one of the main issues that has occupied countless physicians for many generations, and is as relevant today as it was 2000 years ago: how to efficiently treat epidemic diseases.

The term “wenbing” is a term taken from the Neijing. But what exactly was the nature of this disease that Zhang Zhongjing is calling wenbing? It is not clear from the text. Personally, I see a direct connection between this line and the frustration expressed in relation to loss of his family to an epidemic.

Whether this line is connected to his personal tragedy or not, the question of wenbing became identified with the continuous attempts to effectively deal with the recurring episodes of ravaging pandemics throughout the history of China.

This discussion led to diversity of opinions initiating in the Jin-Yuan dynasties (1115-1386). The 4 Masters of Jin-Yuan20 challenged the clinical application of the 6 conformation model for febrile and epidemic diseases. They were all experts of the Shanghan Lun, and expressed great appreciation for it, quoting from the text and applying its principles in their own teachings21.

However, while the Shanghan Lun emphasized cold and wind as pathological influences they all emphasized heat and fire. This was by no means a rejection of the Shanghan Lun. The name of the book, translated as “cold damage” implies it is concerned only with cold, this is in fact not the case. The book refers to all 6 pathogenic influences, and the term “shanghan” should be understood in reference to the explanation in the Nan Jing, 58th difficulty:

“There are five types of cold damage: wind-strike, cold damage, damp warmth, heat disease and warm disease”22

The 4 masters still considered the six pathogenic influences to be responsible for epidemic diseases, and therefore saw no contradictions between their teachings and the doctrine of the Shanghan Lun. They did however feel a need to complement the therapeutic strategies when it came to diseases of heat and fire.

They felt there was a gap between the ancient text and the clinical reality they were dealing with. The Tai Yang conformation, which is the body’s first defense in cases of external pathogenic influences, offers mainly formulas with warm and acrid properties. In relation to internal damage, the book is concerned mainly with damage to the Yang qualities with almost no reference to damage to the Yin qualities.

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 useless23. 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 Wen Yi 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.”24

One of the main differences that Wu Youxing emphasized was the source of disease. He claimed that the source of epidemics were not the 6 pathogenic 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. A prominent figure contributing to the formation of the new doctrine was Ye Tianshi (1666-1745) who established a diagnostic model for febrile diseases based on 4 levels (wei, qi, ying, xue). He also further developed the sanjiao differentiation model for the diagnosis and treatment of febrile diseases. A defined and independent diagnosis method was a significant step in the formation of the new doctrine.

In 1812 Wu Jutong (1758-1836) published Wen Bing Tiao Bian 溫病條辨, the first book to present the Wen Bing as a defined and consolidated doctrine. The book presented a systemic diagnostic and treatment approach with new formulas addressing the new treatment modalities. Wu Youxing, Ye Tianshi and Wu Jutong, thus became the founding fathers of a new and increasingly popular medical current. 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 2002-2003.25

As befitting a medical tradition that was transmitted through critical discourse, the refutal of the Shanghan Lun was not accepted by everyone. Alongside growing support of the Wenbing school as an independent doctrine, there were also doctors maintaining the opinion that heat diseases are an integral part of Shanghan Lun and should be analyzed through this model.26 Even the founding fathers of Wenbing school were not unanimous in their approach. While Wu Youxing rejected the Shanghan Lun model, Ye Tianshi and Wu Jutong combined diagnostic principles and formulas from the Shanghan Lun in their practice and teachings. The relation between Shanghan Lun and Wenbing Lun 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

The Shanghan Lun is a systemic clinical guide that instructs an organized working procedure of treatment strategy based on differential diagnosis. This is demonstrated in almost every line of the text and reflects the importance Zhang Zhongjing attributed to differential diagnosis. In addition to the many examples demonstrating how symptoms lead to a pattern of pathology, there is also a direct statement referring to this process:

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…”27

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 the body’s constitution, the lifestyle, the living conditions and the overall state of the Qi of the body. All these complete the clinical understanding of the patient’s condition and are necessary to effectively treat each individual according to their needs and ability.

Conclusion

“Traditional medicine survives because it is able to adjust to constantly changing environments of practice.”28

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 4 masters of Jin-Yuan taught us that the Shanghan Lun is not a text that dictates fixed ideas and conceptions, but rather a text that is to be studied as a living document. Generations of doctors have since continued to study the Shanghan Lun and use it as a tool to grasp their reality by identifying the changes in the dynamics of Yin and Yang according to the conformations, recognizing different patterns of disease, and incorporating modern knowledge to enhance the understanding of the conformations: their benefits as well as their limitations.

The guiding principle can be summed in the popular saying:

抓病机,活用经方

grasp the mechanism of disease, to use the formulas in a dynamic way

The Shanghan Lun should not be read as a text frozen in time, but as dynamic flexible doctrine which teaches us to think and to adapt. It offers us tools for understanding the world, not definitive answers. The solutions it offers should be used the same way, a formula should not be understood only in terms of the symptoms it is related to in the text, but as clues that lead us to the underlying mechanism of a pathology. 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.”29,30


References:

1. Boyanton S., 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: Columbia University. p. 11

2. Fang Youzhi. 1593. Shanghan Lun Tiaobian, juan 8

3. Ke Qin, 1706 under the title Anthology for the Revival of Cold Damage (Shanghan laisu ji 傷寒來蘇集), translated by Volker Scheid in Transmitting Chinese Medicine: Changing Perceptions of Body, Pathology, and Treatment in Late Imperial China . Asian Med (Leiden). 2013 ; 8(2).

4. Huang Huang, 2009. Ten Key Families in Chinese Medicine, Eastland Press.

5. Liu Lihong, 2019. Classical Chinese Medicine, The Chinese University Press.

6. Translated by Asaf Goldschmidt in: Asaf Goldschmidt. 2019 Medical Practice in Twelfth century China. A Translation of Xu Shuwei’s Ninety Discussions (Cases) on Cold Damage Disorders. Springer International Publishing.

7. Translated by Sabine Wilms. Taken from: https://www.happygoatproductions.com/translation-files

8. Fabien Simonis, 2010 Mad Acts, Mad Speech, and Mad People in Late Imperial Chinese Law and Medicine,” 87. Princeton Univesity.

9. Boyanton S., 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 200-203

10. Li Dong Yuan, Nei Wai Shang Bian Huo Lun (Clarification of Confusions in Internal and External Injury)

11. Translation by Bob Flaws in 2004. Li Dong Yuan’s Treatis on the Spleen and Stomach, A Translation of the Pi Wei Lun, book 1: Treatise on the Transmutation of Vacuity and Repletion of the Spleen and Stomach. Blue Poppy Press.

12. Boyanton S., 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: 203-211.

13. Translation by Bob Flaws in: 2004. Li Dong Yuan’s Treatise on the Spleen and Stomach, A Translation of the Pi Wei Lun, book 2: Treatise on the use of Qing Shu Yi Qi Tang in case of the stomach troubled particulary profoundly by damp heat in long summer. Blue Poppy Press.

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

15. Taken from Wang Hao Gu, preface 1238 preface to his Materia Medica for Decoctions (Tangye bencao 湯液本草, 1248).

16. Volker Scheid, 2013. Transmitting Chinese Medicine: Changing Perceptions of Body, Pathology, and Treatment in Late Imperial China. Asian Med (Leiden); 8(2): 299–360.

17. Goldschmidt, Asaf. 2007. Epidemics and Medicine during the Northern Song Dynasty: The Revival of Cold Damage Disorders (Shanghan). T’oung Pao 93, no. 1/3 (2007): 53–109.

18. Goldschmidt Asaf, 2009 The Evolution of Chinese Medicine: Song Dynasty, 960–1200. Routledge.

19. Translation from Craig Mitchell, et al. 1999. Shang Han Lun, On Cold Damage Translation and Commentaries. Paradigm Publications.

20. The 4 Masters of Jin-Yuan are: Liu Wansu (1120-1200) who emphasized the use of cold herbs to treat febrile diseases. Zhang Zihe (1156-1228) who emphasized aggressive treatments for purging harmful qi with cold and bitter herbs. Li Dongyuan (1182-1251) who developed the theory of Yin Fire that demonstrates why harmful fire develops in the body with internal deficiency. Zhu Danxi (1281-1358) who developed treatments for heat and fire due to deficiency of Yin.

21. Boyanton S., 2015. Dissertation. The Treatise on Cold Damage and the Formation of Literati Medicine: Social, Epidemiological, and Medical Change in China, 1000-1400: p. 167-179.

22. Translation from: Liu Li Hong, Classical Chinese Medicine. P. 83

23. Marta E. Hanson, 2012. Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China. Chapter 4. Routledge.

24. Translation from Marta E. Hanson, 2012. Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China: p. 95

25. Marta E. Hanson, 2012. Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China. P. 162-168. Routledge.

26. Marta E. Hanson, 2012. Speaking of Epidemics in Chinese Medicine: Disease and the Geographic Imagination in Late Imperial China. Chapter 6. Routledge.

27. Translation from Craig Mitchell, et al. 1999. Shang Han Lun, On Cold Damage Translation and Commentaries. Paradigm Publications.

28. Volker Scheid, 2013. Transmitting Chinese Medicine: Changing Perceptions of Body, Pathology, and Treatment in Late Imperial China. Asian Med (Leiden). 8(2): 299–360.

29. Li Dong Yuan, 1247. Nei Wai Shang Bian Huo Lun (Clarification of Confusions in Internal and External Injury).

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

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