The Pattern-Differentiation Thought in Shanghan Lun Is the Most Primitive Evidence-Based Medicine
Evidence-based medicine, also known as empirical medicine, is an attempt to use scientific methods uniformly to gather evidence in order to confirm the outcomes of medical care. To this day it seeks to evaluate the risks and efficacy of various medical approaches, including forgoing 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." Evidence-based medicine is the mainstream direction of modern medicine.
The route taken by the most primitive clinical Chinese medicine bears a striking resemblance to modern evidence-based medicine; Zhang Zhongjing, author of the Shanghan Lun (Treatise on Cold Damage), may be called the founder of evidence-based medicine. The reason the Shanghan Lun has been valued through the dynasties is closely tied to the evidence-based pattern-differentiation thought it pioneered. Judging from its entries, Zhang Zhongjing was a clinician of considerable experience—this is beyond doubt.
Precisely because Zhang Zhongjing was such an experienced clinician, the Shanghan Lun everywhere emphasizes the patient's signs and symptoms. In antiquity there were no diagnostic instruments as advanced as today's, so clinicians could only judge the disease and the treatment to be adopted by clinical observation of the patient's various symptoms.
The six-meridian pattern differentiation of the Shanghan Lun classifies the various cold-damage diseases, summing them up under six-meridian syndromes; within each meridian's symptom cluster there are finer subdivisions. For example, among taiyang diseases there are taiyang wind-stroke and taiyang cold-damage. Later physicians further subdivided taiyang disease into taiyang channel pattern, taiyang fu-organ pattern, and taiyang zang-organ pattern. Each subdivision was made strictly according to differences in concrete symptoms.
This method of classifying and treating diseases is very scientific: it adopts different measures (including prescriptions and acupuncture protocols) according to different symptoms. It is highly operable and its standards are objective—entirely contrary to the later claim that TCM standards are idealistic.
Regrettably, in the course of its development Chinese medicine became mixed with too much classical Chinese philosophy. Some medical experts who were not themselves clinicians, under the influence of their education, over-imported classical philosophy into TCM writings; some even degenerated into sophistry, paying no heed to actual clinical data, so that TCM gradually drifted away from the clinic and from evidence. The lingering poison has not abated to this day.
When I first studied Chinese medicine, the more I read the more confused I became, and I deeply felt that learning TCM was very difficult. Guided clinically by the various TCM theories, I made many mistakes and gradually lost confidence. After a period of settling, I began from the simple, entering through the empirical data I could 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 of TCM is—it is staggering.
From then on it was as though a door to learning Chinese medicine had opened; I acquired the ability to sift gold from the sand of ancient TCM texts, and the ability to judge the practical value of TCM works. Presumptuously, I hope to gather my personal insights from studying the Shanghan Lun and from clinical practice into a book, throwing out a brick to attract jade, in the hope of receiving guidance from experts.
I venture to think that the future development of Chinese medicine must follow the evidence-based route guided by scientific spirit. To take that route, TCM must build on the empirical spirit with which Zhang Zhongjing wrote the Shanghan Lun and go a step further, carrying this respect for evidence more thoroughly and more modernly. Building a complete TCM empirical database, pooling the clinical experience of large numbers of frontline TCM doctors, and combining empirical spirit with collective wisdom may yet allow Chinese medicine to shine again and make a still greater contribution to human health.
I esteem Zhang Zhongjing's seek-truth-from-fact spirit; I believe that without this empirical spirit it is utterly impossible to be a truly good clinician. But I oppose the dogmatic Cold Damage school, which claims that the treatment of every disease must take the Shanghan Lun as its sole canon, rejecting later experience and insight—conservative and stubborn, with great drawbacks.
Human diseases are endless, and Zhang Zhongjing's own vision was after all limited; with all his life he could not have seen every human disease. Medicine has always been, and always will be, the crystallization of collective wisdom. Respecting the discoveries of clinicians across the dynasties, broadly learning from and drawing on the experience of predecessors, and adding one's own constant exploration—that is what a clinician should actually do.
Li Dongyuan, one of the Four Great Masters of the Jin-Yuan, when teaching disciples required them to study materia medica first, and only afterward medical theory and formulas. His aim was to prevent disciples from falling into the whirlpool of theoretical sophistry and becoming impractical. Today many TCM professors discourse glibly on theory yet achieve no curative effect. The reason is that these professors are sunk in TCM theory beyond extraction. Many of them have scarcely considered that a great deal of TCM theory is itself wrong, and some over-interpretations are simply playing with human life. When a doctor does not study medicine from clinical evidence but merely plays word games in theory, it is a disaster.
The Shanghan Lun has not only high clinical guiding value but also the way of thinking behind its words, from which we can learn. Studying it well is highly enlightening for raising a clinician's medical literacy. But studying it rigidly may do more harm than good, which Zhang Zhongjing himself would hardly have wished to see.