A Brief Discussion on How to Self-Study the Shanghan Lun

I began self-studying the Shanghan Lun (Treatise on Cold Damage) in 1998, and after 21 years I still now and then go through its various annotated editions. Since last year I have also been teaching the Shanghan Lun to my students. In the process of teaching it, I read more materials on studying the Shanghan Lun. Drawing on my own insights, I will discuss how to self-study this work.

The Shanghan Lun is one of the four great classics of Chinese medicine and the clinical work that best embodies TCM's emphasis on pattern differentiation and treatment, and on disease differentiation and treatment.

Throughout history, quite a few TCM scholars have criticized the Huangdi Neijing (Yellow Emperor's Inner Canon)—some Japanese physicians, and Lu Yuanshui of the Republican era, for example, all considered the Inner Canon of little value. But few TCM scholars have criticized the Shanghan Lun, because it is a medical work that can guide clinical practice and whose efficacy can be verified in the clinic.

This is because its author, Zhang Zhongjing, was a thoroughgoing clinician. Zhang Zhongjing wrote the Shanghan Lun mainly to record his own experience treating disease. So the book's value is beyond doubt.

But how should we assess Zhang Zhongjing? As the "Medical Sage" of Chinese medicine, he has always been deified. His position in TCM is as lofty as Confucius's in Confucianism. Objectively speaking, Zhang Zhongjing deserves this esteem, because he pioneered evidence-based clinical treatment in Chinese medicine.

But when it comes to the efficacy of Zhang Zhongjing and the formulas recorded in the Shanghan Lun, later TCM scholars' assessments may not be objective. Personally, I think the efficacy of Zhang Zhongjing and the classical formulas of the Shanghan Lun has been deified by later students of TCM.

Once any person or thing is raised onto an altar, many exaggerated and untrue parts attach to it. It is well known that we Chinese have a tradition of revering the ancients, which leads us to overrate them.

It is said that Fang Zhouzi once remarked that Zhang Zhongjing's clinical success rate could not match that of an ordinary modern internist. This may anger many TCM enthusiasts, but personally I think the statement is correct.

In the preface to the Shanghan Lun, Zhang Zhongjing himself wrote: "My clan has long been large, numbering over two hundred. Since the Jian'an era, in fewer than ten years, two-thirds have died, and seven out of ten of them from cold damage." If this account is true, then the infectious diseases of the time dealt a nearly devastating blow to Zhang Zhongjing's clan.

And Zhang Zhongjing began studying medicine very young, his skill already high in his teens. I do not believe that, with so many of his clan dying of infectious disease, he never took part in treating them. So many kinsmen dying of cold damage indicates that his effectiveness against this disease was not high.

In modern society, epidemic infectious diseases would not cause such casualties. So on the whole, the effectiveness of traditional Chinese medicine is still limited.

Of course, this is not to say that traditional medicine is ineffective, or that the Shanghan Lun is worthless. I advocate studying the Shanghan Lun and viewing Zhang Zhongjing with an ordinary, level mind, not enshrining them on an altar. Otherwise one becomes blind and unrealistic.

Many TCM scholars will disagree with me, perhaps feeling I have forgotten my roots. That cannot be helped; my understanding on this issue is what it is, and I cannot change it for now, perhaps not in my whole life. I believe there is much of value in our national heritage, but it needs someone to sift out the dross and keep the essence; it cannot simply be used as-is.

Reading Professor Liu Duzhou's medical cases and talks, I see that he especially revered the ancients, believing that some brilliant ancient physicians could hit the mark a hundred times out of a hundred. I think Professor Liu was mistaken on this point, and that writing such articles set a bad example.

Throughout history, and into the future, I believe there will never be a physician who hits the mark a hundred times out of a hundred for every disease. To call any physician divinely skilled or infallible is exaggeration. Ordinary people's expectation that doctors must solve their problems is also mistaken.

Chinese medicine is a great treasury, but this treasury is not without its refuse. The Shanghan Lun is a highly valuable clinical work, but one cannot say that mastering it alone cures every disease. So in my own study I treat it as just one of several clinical works, not as a supreme, unquestionable scripture. I convey this attitude to my students as well.

Many formulas in the Shanghan Lun, viewed in today's era, have questionable safety. For example, formulas like Gualdi San (Melon-Diabetes Powder) and Shizao Tang (Ten-Jujube Decoction) are best not used recklessly by modern doctors and patients. There have been quite a few reports of patients dying from Gualdi San and Shizao Tang; such formulas are unsafe not only for patients but also for doctors. Once a medical accident occurs, the doctor is in grave danger too.

Some drugs habitually used in the Shanghan Lun could not, in the past, have their side effects fully researched due to limited conditions. Modern pharmacology has advanced and uncovered those side effects, so we must be careful when using them now. For example, as arum (xixin), which Zhang Zhongjing loved to use, was found by researchers as early as the 1980s to cause liver cancer in experimental mice. Because our understanding of Chinese herbs had not then reached this level, we thought those classical formulas containing asarum were wonderfully effective. Now we must take this into account and no longer long-term abuse such formulas, leaving patients with future harm.

Many formulas in the Shanghan Lun have certain advantages in treating difficult conditions that modern medicine cannot handle, and even in treating some common diseases they outperform modern medicine—this is also an undeniable fact. Anyone who has practiced TCM, having experienced the effectiveness of the Shanghan Lun's formulas, mostly builds confidence in the work and in Chinese medicine; I myself am a case in point.

But the problems the Shanghan Lun can solve are also limited. A physician encounters many diseases in a lifetime, so spending one's whole career only delving into the Shanghan Lun is rather too narrow. We should study the Shanghan Lun, but also broaden our horizons and learn more medicine.

I personally oppose sectarianism among medical students. Throughout my life I will study classical formulas, but I will not call myself a member of the classical-formula school.

Having discussed these points to note, let me now share some of my own experience in studying the Shanghan Lun and introduce some of the reference works I commonly use.

Because of the great passage of time, we modern readers face many obstacles in the classical language of the Shanghan Lun. So studying it requires both clearing the language barrier by learning medical classical Chinese and drawing on reference books to deepen our understanding. TCM practitioners should memorize the Shanghan Lun, but such memorization is best built on understanding.

Among contemporary great authorities on the Shanghan Lun, three stand out: the first is Professor Liu Duzhou, mentioned above; the second is Professor Hu Xishu; the third is Professor Ye Juquan. Hao Wanshan and Chen Yiren are also famous Shanghan scholars. But one cannot study all of them; I myself focus on the works of these three masters as references for study and teaching.

Professor Liu Duzhou teaches the Shanghan Lun from the perspective of six-meridian pattern differentiation; Professor Hu Xishu has deep insight into studying it through eight-principle pattern differentiation; and Professor Ye Juquan leans toward the "formula-pattern" and "herb-pattern" schools.

Although these three masters each emphasize different aspects, they have much in common. Among themselves they did not define themselves so sharply. Referring to their works helps deepen understanding of the original text of the Shanghan Lun and of TCM clinical medicine.

Personally, I also like the Japanese kampo physician Dōmoto Shinkyū's Kōkan Igaku (Imperial Chinese Medicine) and the Republican-era famous physician Lu Yuanshui's Shanghan Lun Jinshi (Modern Interpretation of the Shanghan Lun). Although Lu Yuanshui's Shanghan Lun Jinshi is not as well written as his Zhi Huangdi Neijing (Questioning the Inner Canon) or Jingui Yaolüe Jinshi (Modern Interpretation of the Golden Cabinet), given Lu's erudition it is still very valuable.

Reading Dōmoto's Kōkan Igaku and Lu Yuanshui's Shanghan Lun Jinshi lets us understand the Shanghan Lun more deeply and scientifically. But, limited by their era, these two masters who bridged Chinese and Western medicine inevitably held some views outdated today. There is now a real need for new masters to take up the task and, integrating current medical advances, produce works comparable to Dōmoto's Kōkan Igaku and Lu's Shanghan Lun Jinshi.

Beyond this, I personally recommend that learners prepare some Shanghan Lun medical cases, studying the treatise alongside cases while reading the original text and commentaries. I use Dr. Chen Ming's edited Shanghan Lun Mingyi Yan'an Jingxuan (Selected Proven Cases of Famous Masters on the Shanghan Lun) as a textbook alongside the original when teaching my students.

We must not only understand the literal meaning of the Shanghan Lun but also learn how other doctors used its formulas to treat disease. Learning medical cases is no worse than doing clinical rounds with a teacher; in clinical rounds with a teacher we may not systematically encounter so many patients with the indications for a single classical formula. Concentrated study of cases helps raise our understanding of the Shanghan Lun and our clinical skill.

Reading the above works lays the foundation for studying the Shanghan Lun. With that foundation, then reading the commentaries of scholars through the ages, we can find our way in and no longer find it so difficult. There are simply too many commentators on the Shanghan Lun for us to read them all in a lifetime. Selecting a few key ones to study, reviewing the original text ourselves and practicing often, we gradually form our own understanding.

I often study and teach the Shanghan Lun in a cross-cutting way: I frequently compare formulas of the same type side by side, and compare very similar "disease patterns" side by side. My teaching is also threaded with this "comparative study" approach, because it helps deepen memory and raise the level of pattern differentiation and treatment in clinical practice.