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By Marta HansonTranslating traditional Chinese medical terms into modern English forces one to consider dramatic changes in medicine over the past two centuries. Take, for example, the modern Chinese phrase fa re for “fever,” which literally means “to produce (fa) heat (re).” Although today it refers to elevated body temperature, traditionally it referred to the preternatural heat that patients experienced dispersed throughout their bodies and only sometimes referred to elevated skin temperature.[1] In fact, before the late 19th-century, the English term “fever” also contained multivalent meanings and multifarious patterns of excessive heat.[2] Fever in the sense of having a temperature above the 97.3 to 99.5 °F human range was not even defined in western medicine, nor a convenient clinical thermometer invented to measure it, until the late 1860s.[3] Although many of the febrile-related symptoms that fall under the Chinese disease concept “Hot diseases” (rebing) could fit under the biomedical umbrella of acute-infectious diseases, in classical Chinese medicine they were originally conceptualized as caused by climatic configurations of qi (i.e., vital energy/matter).[4]The Yellow Emperor’s Inner Canon: Basic Questions (ca. 1st c. BCE) originally distinguished two types of Hot diseases related to different types of climatic qi. The first included an acute-onset febrile disorders caused by external pathogenic qi related to changing seasons or local weather. The second was a type of “Cold Damage” (shanghan) acquired in the winter but which went dormant until the heat of the spring or summer manifested it as excessive heat and internally impairing dryness. The first Inner-Canon definition that Hot diseases could be due to other types of pathogenic climatic qi also facilitated conceptualizing epidemics as due to pathogenic environmental qi unrelated to the winter cold or local climate.[5] Nonetheless, no matter the original cause when excessive heat was the result, it had to be expelled.An interesting case of disagreement on how best to “treat the heat” occurred in Beijing during a febrile epidemic (wenyi) in the spring and summer of 1793. The Qing official, Ji Yun (1724–1805) unusually responded to this epidemic by comparing the success rate of three therapeutic drug strategies. The first, associated with Zhang Jiebin (1563-1640), resulted in 80–90% mortality. The second, promoted by Wu Youxing (1582?-1652), was no more effective. But a third formula created by the living doctor, Yu Lin (ca. late 18th cent.), had successfully cured the concubine of the Chief Minister of the Court of State Ceremonies, Feng Yingliu (1741–1801) with a strong gypsum-based formula.[6] Ji noted that those who witnessed this were shocked but those who followed his method ended up saving countless lives.[7]The three competing cures in Ji’s short anecdote illustrate well how Cold and Heat were the main metaphors used to understand the cause of epidemics and legitimate drug choices for treating them. Zhang’s “warming and tonifying” (wenbu) tonics were based on what the Cold Damage Treatise (Shanghan lun, ca. 220 CE) recommended for treating Hot diseases (believed to have their origin in winter Cold manifested in the summer). These included warming herbs such as Cassia twig (guizhi) and Ephedra (mahuang) to release cold via the exterior and Aconite (fuzi) to warm the exterior and expel cold.  [See rebing entry to far left in Figure 1][caption id="" align="alignnone" width="800"] Medication chart from the Gold-Dusted Cold Damage [Treatise] (Shanghan diandian jin, completed 1341, date of this printing unknown). Image credit: Wellcome Collection.[/caption] Wu’s “purgative” (gongxia) formulas contained Rhubarb root and rhizome (dahuang) to purge downward, and even Betel Nut (binglang) to expel pathogenic qi.  Wu termed this anomalous qi (yiqi), deviant qi (liqi), or pestilential qi (liqi) in his Treatise on Febrile Epidemics (Wenyi lun, 1642). [See figure 2] As He Bian has written on this blog, Chinese rhubarb had its heyday in the eighteenth century, yet not all physicians were in accord with its suitability during epidemics.&#160;[caption id="attachment_11640" align="aligncenter" width="402"] Rhubarb from Li Shizhen's Systematic Materia Medica (Bencao Gangmu) printed in 1596.[/caption]The third author named in this story, Yu Lin, later became famous for his recipe titled: “Epidemic-Clearing and Toxin-Dispersing Beverage” (Qing wen bai du yin). [8]  The fourteen-ingredient recipe was based on a combination of the White Tiger Decoction (baihu tang) that cleared out heat on the exterior with two other formulas.[9]  Yu’s recipe, however, featured crude gypsum (i.e., the “White Tiger”) in quantities at least three times the other main ingredients (raw foxglove root, rhinoceros horn, and coptis root). This made it an extremely Cold formula, and potentially life-threatening for those who thought Cold was the underlying cause and so used Zhang’s formulas. For Yu, however, Gypsum’s cold-cooling quality cleared excessive heat accumulated in the stomach system. [Figure 3 depicts this heat-clearing function of gypsum at the center of the man’s chest).[caption id="" align="alignnone" width="800"] Depiction for White Tiger Decoction in Illustrations and Explanation of the Major Formulas of the Cold Damage Treatise (Shanghan lun dafang tu jie, 1833). Image credit: Wellcome Collection.[/caption]Expelling pathogenic Cold qi and warming the interior with aconite and cassia twigs, purging pestilential qi through the bowls with rhubarb, and clearing out the pathogenic Heat from the stomach with gypsum were thus all therapeutic strategies at play during the 1793 epidemic in the capital. The first framed the cause of the epidemic in latent winter cold that had to be dispersed. The second saw it as externally contracted pestilential qi that needed to be purged. Finally, the third considered it excessive heat that had to be cleared. Despite these major differences all three approaches nonetheless treated the febrile symptoms subsumed under fa re or, in the modern term, “fevers” as something that drugs could manage by adjusting the internal balance of Hot and Cold.~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~Translations for Figures 1 and 3Figure 1: From right to left are listed three disease concepts – Cold Damage, Wind Damage, and Hot Diseases. Their commonly used formulas are written below. The six formulas listed under rebing are from right going down and then to left going down: With sweat cassia twig decoction (han guizhi tang), Cassia twig and gypsum decoction (guizhi jia shigao), Cassia twig decoction together with gypsum, anemarrhena, cohosh, and ephedra (guizhi jia shigao zhimu sheng[ma] ma[huang], Without sweat ephedra decoction (wuhan mahuang tang), Evening produced (i.e., heat) gardenia, cohosh, and ephedra decoction (wan fa zhizi sheng[ma] ma[huang]), and Cassia twig decoction with ephedra and gypsum (guizhitang jia mahuang shigao).Figure 3: From the right to left across the top is written. 1) “The assistant [drug] Amemarrhena (zhima) disperses dryness [and] produces jin [fluids].” 2) the space below the chin reads “protects the lungs.” 3) and to the left is written “licorice (gancao) harmonizes the stomach and rice (gengmi) assists the stomach qi.” 4) The 5-character phrases on either side of the oblong circle together state the therapeutic strategy “[When] the pathogenic [qi] has already changed into Fire, then clear, cool, and make it disperse.5)  In the long oval at the center of the body, the phrase instructs: “When it [i.e., the Fire} enters the stomach, use gypsum.”[1] Nathan Sivin, Traditional Medicine in Contemporary China, Science, Medicine, &#38; Technology in East Asia 2 (Ann Arbor: The University of Michigan Center for Chinese Studies, 1987), xxiv-xxv, 86, 108.[2] Christopher Hamlin, More Than Hot: A Short History of Fever, Johns Hopkins Biographies of Disease (Baltimore: John Hopkins University Press, 2014).[3] J.M.S. Pearce, “A brief history of the clinical thermometer,” QJM: An International Journal of Medicine 95.4 (1 April 2002): 251-52. Thomas Clifford Allbutt (1836-1925) invented the 6-inch thermometer that was first able to record a temperature in 5 minutes in 1866 and in 1868 Carl Wunderlich, using a foot-long thermometer put in the axilla (i.e., armpit), established the normal range from 36.3 to 37.5 °C or 97.3 to 99.5 °F.[4] Shigehisa Kuriyama, “Epidemics, Weather, and Contagion in Traditional Chinese Medicine,” in Lawrence I. Conrad and Dominik Wujastyk, eds., Contagion: Perspectives from Pre-Modern Societies, (Aldershot, Hampshire: Ashgate Publishing Limited, 2000), 3-22.[5] Marta Hanson, Speaking of Epidemics in Chinese Medicine: Disease and the geographic imagination in late imperial China (London: Routledge, 2011), 16-17.[6] Gypsum is monoclinic calcium sulfate. See discussion of this episode in Hanson, Speaking of Epidemics, 2011, 126-27.[7] Ji Yun 紀昀, Yuewei caotang biji 閱微草堂筆記(Jottings from Yuewei Hall), printed 1800. Repr. Shanghai: Shanghai guji chubanshe, 1980. Passage in juan 18, jotting #24, 458-9. Online access https://ctext.org/library.pl?if=gb&#38;file=36038&#38;page=45&#38;remap=gb[8] Jian Min Wen and Garry Seifert, translators, Warm Disease Theory, Wēn bing xúe (Brookline, Mass.: Paradigm Publications, 2000), 141.[9] White Tiger Decoction is used to treat an illness pattern with great heat, thirst, and sweating and a surging and large pulse. For analysis of the logic of the formula see Craig Mitchel, Feng Ye, Nigel Wiseman, Shang Han Lun: On Cold Damage: Translations &#38; Commentaries (Brookline, Mass.: Paradigm Publications, 1999), 316-24