Pattern Differentiation in Zhang Zhongjing's Shanghan Lun Is the Most Primal Evidence-Based Medicine

Evidence-based medicine (EBM), also known as evidence medicine, is an attempt to uniformly apply scientific methods to gather evidence and thereby confirm the effectiveness of medical interventions. To this day, EBM seeks to evaluate the risks and benefits associated with various forms of medical care (including the choice to forgo treatment). According to the Centre for Evidence-Based Medicine, "Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." EBM is the mainstream direction of modern medicine.

The route taken by the most ancient clinical Chinese medicine bears a striking resemblance to modern evidence-based medicine. The Shanghan Lun (Treatise on Cold Damage) author Zhang Zhongjing may well be regarded as the originator of evidence-based medicine. The reason the Shanghan Lun has been valued by every dynasty is closely tied to the empirically oriented pattern-differentiation thought it advocates. Judging from the text of the Shanghan Lun, Zhang Zhongjing was a clinician of considerable experience—this is beyond doubt.

Precisely because Zhang Zhongjing was such an experienced clinician, he constantly emphasized the patient's signs and symptoms throughout the Shanghan Lun. In ancient times there were no diagnostic instruments as advanced as today's, so clinicians could only rely on observing the patient's various symptoms to determine the disease and the appropriate treatment.

The six-meridian pattern differentiation of the Shanghan Lun classifies the various cold-damage diseases into categories, summarized by the six-meridian symptom complexes; beneath each meridian's symptom cluster there are further subdivisions. For example, within Taiyang disease there are Taiyang wind-stroke and Taiyang cold-damage. Later physicians further subdivided Taiyang disease into Taiyang channel pattern, Taiyang bowel (fu) pattern, and Taiyang visceral (zang) pattern. Each subdivision was made strictly according to differences in concrete symptoms.

This method of classifying diseases and treating them by pattern is highly scientific: it adopts different measures (including prescriptions, acupuncture protocols, etc.) for different symptoms, is extremely operational, and uses objective criteria. This is worlds apart from the later claim that Chinese medicine's standards are idealistic.

Regrettably, however, in the course of its development, Chinese medicine became contaminated with too much classical Chinese philosophy. Some medical experts who were not themselves clinicians, influenced by their education, over-imported classical Chinese philosophical thought into Chinese medicine writings; some even sank into sophistry, paying no heed to actual clinical data, gradually steering TCM's development away from the clinic and away from empirical evidence. The lingering poison of this persists to this day.

When I first began studying Chinese medicine, as I read more books I grew increasingly confused and found learning TCM deeply difficult. Guided by the various TCM theories in treating the clinic, I failed frequently and gradually lost confidence in Chinese medicine. After a period of settling, I started from the simple, entering through empirical data I could actually understand, and using that understandable content to guide the clinic; my clinical results improved dramatically. Only then did I realize how vast and elaborate the dross within Chinese medicine really is.

From then on it was as if a door to studying Chinese medicine had opened, and I acquired the ability to pan for gold among TCM ancient texts. I also developed the ability to judge the relative practical value of various TCM works. Presuming to offer my humble thoughts, I hope to gather my insights from studying the Shanghan Lun and treating disease in the clinic into a series of articles, to cast a brick to attract jade, in the hope of receiving guidance from learned experts.

I venture to think that the future development of Chinese medicine must follow the path of evidence-based medicine guided by scientific spirit. And for Chinese medicine to take that path, it must build on the empirical spirit Zhang Zhongjing embodied in writing the Shanghan Lun, rise one level higher, and carry this evidence-oriented spirit even more thoroughly and modernly. Establishing a complete TCM empirical database, aggregating the clinical experience of large numbers of frontline TCM practitioners, and combining empirical spirit with collective wisdom may yet allow Chinese medicine to shine once more and make a greater contribution to human health.

I admire Zhang Zhongjing's pragmatic, truth-seeking spirit; I believe that to truly be a good clinician one simply cannot do without this empirical spirit. But I oppose the dogmatic cold-damage school, which claims that the treatment of every disease must take the Shanghan Lun as its sole standard, rejecting later generations' experience and insights—conservative, stubborn, and deeply flawed.

Human diseases are inexhaustible, and the insight of a single Zhang Zhongjing is, after all, limited; even devoting his entire life he could not have encountered all human diseases. Medicine has always been, and always will be, the crystallization of collective wisdom. Respecting the discoveries of clinicians across the dynasties, broadly studying and drawing on the experience of predecessors, and adding continuous self-exploration—that is what a clinician should really do.

Li Dongyuan, one of the Four Great Masters of the Jin-Yuan dynasties, when teaching his disciples, required them to study materia medica first, and only afterward medical theory and formulas. Li Dongyuan's intention was to prevent his students from falling into the whirlpool of theoretical sophistry and impracticality. Today there are many Chinese medicine professors who can discourse eloquently on theory but achieve no results when treating disease. The reason is that these professors are deeply mired in TCM theory and cannot extricate themselves. Many of them have rarely considered that a great deal of TCM theory is itself wrong; in particular, the over-interpretation of certain theories is simply treating human life as a game. When a doctor does not start from clinical evidence to study medicine but instead plays word games with pure theory, it is a disaster.

The Shanghan Lun not only has high clinical guidance value; it also offers the way of thinking behind its words as a model to learn from. Mastering the Shanghan Lun is highly enlightening for elevating a clinician's medical literacy. But if one studies the Shanghan Lun rigidly, the drawbacks may outweigh the benefits; that would certainly not be what Zhang Zhongjing himself would have wanted.