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Modern use of Chinese herbal formulae from Shang-Han Lun

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DOI: 10.3760/cma.j.issn.0366-6999.2009.16.010 · Source: PubMed

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Chinese Medical Journal 2009;122(16):1889-1894 1889

Original article
Modern use of Chinese herbal formulae from Shang-Han Lun
CHEN Fang-pey, CHEN Fun-jou, JONG Maw-shiou, TSAI Hui-lin, WANG Jen-ren and HWANG Shinn-jang

Keywords: Shang-Han Lun; six-channel transition; traditional Chinese medicine; ZHANG Zhong-Jing

Background The Chinese medical archive, Shang-Han Lun, is said to be written by ZHANG Zhong-jing (150–219 A.D.).
This great influential work introduced the specific symptoms of six-channel disorders (Tai-Yang, Yang-Ming, Shao-Yang,
Tai-Yin, Shao-Yin, and Jue-Yin) and their corresponding treatments, the combined syndromes, deterioration due to
malpractice, and the concept of six-channel transitions. The concept of Shang-Han Lun is widely accepted by Chinese
herbal doctors. However, no clinical data about Shang-Han symptoms are described in oriental or western medical
reports.
Methods The clinical prescription data of traditional Chinese medicine visits were extracted under the National Health
Insurance in Taiwan. The application rate of 42 Shang-Han formulae in clinical practice was analyzed in detail with the
software SPSS.
Results Between 1999 and 2002, the prescription rate of Shang-Han formula was only 5.22% among a total of 528
889 576 Chinese herbal formula prescriptions. The most frequently used formula was Tai-Yang formulae (71.31%),
followed by Shao-Yang formulae (17.49%) and the most commonly prescribed individual Shang-Han formulae were
Ge-Gen Tang (16.11%), Shao-Yao-Gan-Cao Tang (12.97%), Xiao-Qing-Long Tang (11.79%), Ban-Xia Xie-Xin Tang
(10.24%), and Xiao-Chai-Hu Tang (9.11%), which comprised 60.22% of the utilization rate of total Shang-Han formulae.
Conclusions From the prescription patterns of Shang-Han formulae, there was no evidence of transitions among the
six channels. Despite the fundamental role of Shang-Han Lun in traditional Chinese medicine, prescription of Shang-Han
formulae was limited in clinical practice.
Chin Med J 2009;122(16):1889-1894

S hang-Han Lun (Treatise of Exogenons Febrile

Diseases or Discourse on Cold-Damage Disorders),
citing 397 articles and including 112 Chinese herbal
Nei-Jing (also known as Nei-Jing),4 and was complied by
two volumes, Su-Wen and Ling-Shu. It was found that the
five-element and other numerologic theories (ascribed to
formulae, is said to be written by ZHANG Zhong-jing Nei-Jing) were not in Zhang′s discussions on diseases.
(also named ZHANG Ji, 150–219 A.D.).1 This book Furthermore, it was suggested that many of the passages
covers the specific symptoms of disorders with the dealing with pulsation may have been inserted by WANG
corresponding treatments, as well as the elucidation of the Shu-he, while Wang lived a century after Zhang′s death
transitions of the six-channel diseases (Tai-Yang, and was the first editor of Shang-Han Lun.1 Moreover,
Yang-Ming, Shao-Yang, Tai-Yin, Shao-Yin, and Zhang stated in his preface that the contents of six
Jue-Yin).2 Shang-Han Lun is the innovator of the four channels cited many concepts from Su-Wen (Plain
standards (the reason, method, formula, and drug) and Questions); therefore, many scholars assumed that the
also the pioneer of internal medicine in traditional preface was not written by Zhang himself or alone. Also,
Chinese medicine (TCM). The importance of Shang-Han Yun5 claimed that many diseases cited in Shang-Han Lun
Lun to TCM is similar to Huang-Di Nei-Jing (Yellow were seldom found in the later generations and Liu6 also
Emperor's Canon of Internal Medicine) to the physiologic indicated that the modern applications of Shang-Han
dissection of the human body, and Shen-Nong Ben-Cao formulae has surpassed the applications described in the
Jing (Agriculture God′s Canon of Materia Medica), the
earliest book on Chinese herbs, to the TCM book of DOI: 10.3760/cma.j.issn.0366-6999.2009.16.010
clinical practice. Together with Wen-Bin (Warm Diseases), Center for Traditional Medicine (Chen FP, Jong MS, Tsai HL, and
these four books, therefore, are regarded as the four Wang JR), Department of Family Medicine (Hwang SJ), Taipei
fundamental textbooks of TCM.3 Moreover, Shang-Han Veterans General Hospital, Taipei 11217, Taiwan, China
Graduate Institute of Integration Chinese and Western Medicine,
Lun is widely studied by the followers of TCM. It is Chinese Medical University, Taichung, Taiwan, China (Chen FJ)
designated as one of the examination materials for the National Yang-Ming University School of Medicine, Taipei,
TCM doctoral certification in Taiwan. Taiwan, China (Chen FP, Jong MS and Hwang SJ)
Correspondence to: HWANG Shinn-jang, Department of Family
However, scholars disputed much of Shang-Han Lun in Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan,
recent decades. For instance, the way in which ZHANG China (Tel: 886-2-28757460. Fax: 886-2-28737901. Email:
[email protected])
Zhong-jing (hereafter referred to as Zhang) summarized This study was supported by a grant from Chinese Medical
the six channels was different from Fever theory and Committee of the Health Minister of Executive Yuan (No.
simpler than the concept of 12 channels in Huang-Di CCMP93-RD-024).
1890 Chin Med J 2009;122(16):1889-1894

original context. Health Insurance Research Database (NHIRD;

http://www.nhri.org.tw/nhird/). The data were saved in
In Western countries, there has been a long interest in two major categories, the linked visiting information and
distinguishing between heresy and orthodoxy in medical the prescription (such as CM_CD2002.DAT and
theories and research, particularly with respect to the CM_OO2002.DAT, the so called CD files and OO files,
gradual exclusion of theories that do not conform to the respectively). The visit files, CM_CD2002.DAT, etc.
new paradigm.7 However, in Chinese society, the classical recorded data including date of encounter, medical care
TCM textbooks still hold a consecrated position in the facility and specialty, patient′s gender, date of birth, and
delivering medical concepts and treatments to the health the most recent three diagnoses in the coding of
care system. Whether Zhang initiated Shang-Han Lun or International Classification of Disease, 9th Revision,
not is thus worthy of discussion. If Zhang was the Clinical Modification (ICD-9-CM). The prescription files,
follower of Nei-Jing Su-Wen, he would have followed the CM_OO2002.DAT etc, contained prescriptive orders and
concept of 12 channels and would have applied the Chinese herbal drugs or formulae. A prescription may
contain several Chinese herbal drugs or formulae.
theories to the treatment of internal organ disorders.
Chinese herbal drugs or formulae were made of powder
Nevertheless, he differed from other medical writers who
or fine granules and could be easily mixed in a single
were strongly influenced by those theories.1 Some
prescription in Taiwan. For privacy protection, the
researchers in Japan protested that Zhang had referred to identification data of patients and institutions had been
many references, such as the Tang-Yi-Jing-Fa (Canon of scrambled cryptographically to attain anonymity.
Decoction and Liquid Methods; written by I-Yin in Shang
Dynasty).8 We usually ascribed those to Zhang′s All TCM treatments were provided only in ambulatory
experiences. However, based on some newly uncovered clinics, not inpatient care. In addition, only licensed TCM
ancient documents, we queried whether these old physicians were qualified for the NHI reimbursements.
formulae were written according to some previous
archives and not the innovation of Zhang.9,10 We therefore Study design
proposed that all the formulae or the prescriptions in From the 112 formulae listed on Shang-Han Lun, we
Shang-Han Lun are worthy of careful investigation focus on the 42 formulae which were approved by the
nowadays. NHI. Although there were 337 standard remedies agreed
by the government and 42 Shang-Han formulae were
Over the last several decades, TCM has been increasingly within the group. The decision was under the
accepted as a form of complementary and alternative consideration of marketing requirement (Committee on
medicine (CAM) by patients in Europe and North Chinese Medicine and Pharmacy, Taiwan).
America. Better education for both patients and
physicians is necessary to extract the best of TCM and to In computing the usage of Shang-Han formulae, we
complement existing conventional medicine for the identified the percentage of 42 Shang-Han formulae in
optimal delivery of healthcare.11 In this current study we the database. In addition, we also examined whether there
thus aimed to explore the modern practicality of the were any statistical differences among four seasons. The
symptoms delineated in Shang-Han Lun by analyzing the four seasons are defined in Taiwan by solar calendar, as
utilization rate of Shang-Han formulae among the TCM spring (including March, April and May), summer
prescriptions under the National Health Insurance (NHI) (including June, July and August), autumn (including
in Taiwan. September, October and November), and winter
(including December, January and February).
METHODS
Statistical analysis
The database software of Microsoft SQL Server 2000
Data sources (Microsoft Corp., Redmond, WA, USA) was used for the
In Taiwan, a unique National Health Insurance (NHI) data linkage and processing. We then performed the plain
program was started in 1995. By the end of 2002, there description statistic to classify Shang-Han formulae with
were 21 869 478 beneficiaries included in this program, the description statistical function in SPSS (SPSS, version
which covered 97.7% of all inhabitants.12 People in 12.0, SPSS Inc., Chicago, USA). The statistical results
Taiwan are free to visit TCM, Western medicine, or a were examined by cross-tabulation to see whether there
combination of the two. Treatments of TCM, including were any significant differences in prescriptions among
Chinese herbal medicine and acupuncture for outpatients, four seasons. The P-values less than 0.05 (two-tailed)
have been reimbursed by the NHI program since 1996.13 were considered statistically significant.
With the advantage of the available claim data for
researchers interested in data mining, we could RESULTS
investigate the utilization rate of Chinese herbs formulae
in Taiwan by analyzing such huge NHI database. Between 1999 and 2002, there were 528 889 576 Chinese
In the current study, we analyzed the complete database medicine formulae prescribed in the TCM office visit
(from 1999 to 2002) of TCM claims from the National under the NHI in Taiwan. Among these formulae, only
Chinese Medical Journal 2009;122(16):1889-1894 1891

25 895 689 formulae were belonged to the 42 Shang-Han Table 3. The top 20 Shang-Han formulae commonly used in
formulae. Thus, the mean utilization rate of Shang-Han traditional Chinese medicine office visits between 1999 and 2002
in Taiwan
formula was only 5.22% per year (range from 5.15% to
Rank Shang-Han Formula (six channel category) Utilization rate (%)
5.35%) during the 4-year period (Table 1). Comparing the 1 Ge-Gen Tang (Tai-Yang) 16.11
prescription rates of Shang-Han formula among the four 2 Shao-Yao Gan-Cao Tang (Tai-Yang) 12.97
seasons, these formulae were prescribed significantly 3 Xiao-Qing-Long Tang (Tai-Yang) 11.79
more often in autumn (5.25%) and winter (5.34%) than in 4 Ban-Xia-Xie-Xin Tang (Tai-Yang) 10.24
summer and spring (5.11% and 5.22%, respectively, P < 5 Xiao-Chai-Hu Tang (Shao-Yang) 9.11
6 Zhi-Gan-Cao Tang (Tai-Yang) 4.62
0.05; Table 2).
7 Gui-Zhi Tang (Tai-Yang) 4.14
8 Cai-Hu plus Long-Gu Mu-Li Tang (Shao-Yang) 3.43
Table 1. The yearly utilization rate of Shang-Han formulae 9 Cai-Hu Gui-Zhi Tang (Tai-Yang) 3.20
prescribed by traditional Chinese medicine doctors between 1999 10 Si-Ni San (Shao-Yin) 2.76
and 2002 in Taiwan 11 Wu-Ling San (Tai-Yang) 2.30
Prescriptions with Shang-Han 12 Da-Chai-Hu Tang (Shao-Yang) 1.86
Year Total TCM prescriptions
formula (n (%)) 13 Xiao-Jian-Zhong Tang (Tai-Yang) 1.76
1999 130 810 887 7 006 977 (5.35) 14 Bai-Hu Tang (Yang-Ming) 1.42
2000 130 373 114 6 793 470 (5.21) 15 Ma-Huang Tang (Tai-Yang) 1.40
2001 131 462 363 6 784 479 (5.16) 16 Zhen-Wu Tang (Shao-Yin) 1.34
2002 136 183 212 7 014 289 (5.15) 17 Dang-Gui Si-Ni Tang (Jue-Yin) 1.33
Total 528 829 576 27 599 215 (5.25) 18 Xuan-Fu Dai Zhe-Shi Tang (Tai-Yang) 1.32
19 Jie-Geng Tang (Shao-Yin) 1.30
Table 2. The prescription percentage of Shang-Han formulae 20 Ge-Gen Huang-Qin Huang-Lian Tang (Tai-Yang) 0.99
among total prescriptions by traditional Chinese medicine doctors A total of 25 895 689 prescriptions contained Shang-Han formula in traditional
at different seasons during 4 years Chinese medicine office visits between 1999 and 2002.
Year Yearly Spring Summer Autumn Winter
1999 5.35 5.29 5.25 5.38 5.50 According to the original theory of Shang-Han Lun, the
2000 5.21 5.17 5.12 5.23 5.32 main reason for patients to get febrile diseases was a
2001 5.16 5.13 5.03 5.18 5.29
result of exposure to cold weather and the main route of
2002 5.15 5.10 5.05 5.20 5.26
Average 5.22 5.17 5.11 5.25 5.34
the cold was through the Tai-Yang channel, or the
superficial back of the body, that is skin in other word.
The top five Shang-Han formulae commonly prescribed Our study revealed that the most popular Shang-Han
were: Ge-Gen Tang (16.11%), Shao-Yao-Gan-Cao Tang formulae were Ge-Gen Tang and Xiao-Qing-Long Tang,
(12.97%), Xiao-Qing-Long Tang (11.79%), Ban-Xia both containing the herbal compounds of Ma-Huang
Xie-Xin Tang (10.24%), and Xiao-Chai-Hu Tang (9.11%), (Ephedrae herba), Gui-Zhi (Cinnamoni ramulus), and
which comprised 60.22% of the utilization rate of total 42 Shao-Yao (Paeoniae radix). Hence, they might be
Shang-Han formulae. The top 20 Shang-Han formulae regarded as derivatives from Gui-Zhi Tang and
accounted for 93.39% of the total Shang-Han formula Ma-Huang Tang, the top two formulae mentioned in the
(Table 3). According to the categories of six-channel, original Shang-Han Lun. Zhang used Ge-Gen Tang for
Tai-Yang formulae were used the most frequently during sweating in an effort to relieve superficial syndromes. In
these four years (averaged 71.31%), and followed by modern times, it can be adopted to treat respiratory
Shao-Yang formulae (average 17.49%), then Shao-Yin diseases, such as common cold and asthma. Similarly,
(6.05%), Yang-Ming (3.31%) and Jue-Yin (1.74%). The Xiao-Qing-Long Tang is known nowadays to have an
least used formulae belonged to Tai-Yin, rated only effect on allergic diseases, such as allergic rhinitis and
0.10% (Table 4). bronchial asthma.14 On the other hand, since the major
use of TCM in Taiwan is for diseases of respiratory
DISCUSSION system,15 we might postulate that the Shang-Han
formulae were commonly used for respiratory
Since no literature exists mentioning the clinical statistics tract-related febrile diseases which were encountered
pertaining to the use of Shang-Han Lun′s formulae so far, more often in autumn and winter.16
our study serves as an initial report. According to our
results, the utilization of Shang-Han formulae only As it is known that the so-called traditional Japanese
comprised 5.22% of all Chinese herbal formulae in medicine, including herbal (Kampo) medicine and
Taiwan. To be a primary internal medicine textbook for acupuncture has been used for 1500 years and is fully
TCM education, the utilization rate of Shang-Han integrated into the modern health-care system in Japan.17
formulae was not as high as we expected. Nevertheless, There are two schools of TCM practice, the Traditional
we may attribute the reason to the lack of typical Formula School and the Posterity School.18 The former is
symptoms of Shang-Han Lun in clinical practice or other the mainstream in Japanese Kampo medicine, which
formulae being favoured by TCM doctors due to their simply uses the ready-made formulae in Shang-Han Lun.
personal experiences, or in part, due to the brevity of They might neglect eight-schemas (yin, yang, exterior,
Zhang′s descriptions and somewhat disjointed organization interior, deficiency, excess, cold, and heat), and thus
in his book.1 doctors could match their prescriptions simply based
1892 Chin Med J 2009;122(16):1889-1894

Table 4. The prescription frequency of Shang-Han formulae distributed in six channels within the National Health Insurance database
between 1999 and 2002 in Taiwan
Formula in six channel categories 1999 2000 2001 2002 Subtotal %
Tai-Yang 5 076 333 4 852 122 4 812 413 4 941 235 19 682 103 71.31
Yang-Ming 209 681 222 211 233 241 248 332 913 465 3.31
Shao-Yang 1 214 829 1 191 748 1 181 814 1 237 635 4 826 026 17.49
Tai-Yin 7011 6601 7080 8236 28 928 0.10
Shao-Yin 385 102 411 605 424 991 447 028 1 668 726 6.05
Jue-Yin 114 021 109 183 124 940 131 823 479 967 1.74
Total 7 006 977 6 793 470 6 784 479 7 014 289 27 599 215 100.00

on the manifesting symptoms without considering about note these situations. He also thought that since the
the TCM theories. This type has easily been accepted by transitions of symptoms were not easy to be understood
most doctors who practice Chinese medicine in Japan;19 thoroughly, the erroneous diagnoses happened easily. The
while the School of Posterity is more complicated and same vagueness confused many current Shang-Han Lun
emphasizes the pulse diagnosis, the selection of followers as well. Yet, it is not always easy to discern
treatments based on the diagnoses, and it is similar to the Zhang′s reasoning when he would confidently classify
one most often practiced in TCM in Taiwan. It was syndromes as one disorder or another. It was used to
reported that the Shang-Han formulae occupied 46% of explain the entire course of a disease over a period of
the 130 Chinese herbal formulae approved by the days by relating the succession of symptoms to a spread
Japanese government.19 In comparison, there are only 42 from one part of the body (not the same meaning as
Shang-Han formulae (12.5%) among a total of 337 channel in Nei-Jing School) to another.1 The emphasis
Chinese herbal formulae approved in Taiwan. These may was primarily on the positive qi and the various changes
also account for the low utilization rate of Shang-Han induced in it by the agent or cause of the disease. A
formulae in Taiwan. disease could also result in just a single channel or body
part which might not be always the Tai-Yang, and did not
Of all the traditional and developing nations, only in require any transition (or transmission). Actually, the
China and India with their millennium-old, well- concept of 12-channel was developed in Nei-Jing School,
established, holistic philosophy, have the independence but the idea of Zhang′s channel described the different
and respect of traditional health concepts and practices be levels of body parts, from three Yang (Tai-Yang,
preserved. This is largely the results of the internal Shao-Yang, Yang-Ming) to three Yin (Tai-Yin, Shao-Ying,
consistency of the pathophysiologic mechanisms Jue-Yin), namely, from superficies (skin) to deeper organs.
manifested through traditional practices there.20 In the This indicates again that the followers of Shang-Han Lun
West, the history of science is a tale of multifarious should not confuse about the names of 6-channel, instead
shifting of allegiance from theory-to-theory,21 and of understanding the exact significance of Zhang′s
Chinese medicine also presents itself as a composite of passages.
disparate, often contradictory elements, rather than as a
cohesive system.22 Unschuld23 also stated that Chinese Generally speaking, the theory of disease etiology in
medicine can only refer to a broad range of ideas and Chinese medicine is distributed into three branches:
practices related to healthcare and illness intervention that internal, external, and others. The external etiology comes
was developed or adopted from abroad, and practiced in from the six excesses or weather forms:24 wind, cold,
China over the past few millennia. One of the prominent summerheat, dampness, dryness, and fire. The seven
examples was that Zhang has used two systems of emotions for internal etiology are: anger, anxiety, thought,
classifications, that is, specific symptom- and sorrow, fear and fright. The internal impairments or
channel-classified disorders, which were not fully various diseases are thus mostly induced by internal
integrated and interspersed at random. It should be noted emotions, while the external infected diseases are the
that neither system, nor the limited synthesis between result from the outside environments. Currently, the
them originated with Zhang; all are found, with some transitions of channels could be compared with the
differences, and scattered through-out earlier text.1 Thus, different stages of febrile infections disease, and the
Chen10 has mentioned that Zhang might represent the followers might be learned that the names of Yin-Yang is
other ancient school in TCM, instead of the Nei-Jing just a kind of classification developed in ancient time.
School.
Though the modern etiologies are known to be
Based on our observations, it seems hard to see the complicated, TCM doctors still regard Shang-Han Lun as
transitions following the order of six channels. If the the tenet of internal Chinese medicine, due to its most
transitions happen frequently, the usage rate of ancient position to present the discriminating thoughts of
Shang-Han formulae for each channel should decrease different symptoms around that time,25 which is an
with the order of Tai-Yang, Yang-Ming, Shao-Yang, important step for us to understand the progress or
Tai-Yin, Shao-Ying, Jue-Ying. Yun5 had pointed out that formation of the TCM in such a long era. Zhang
although Zhang′s Shang-Han Lun described the transition succeeded in drawing together and adapting this earlier
of symptoms for a certainty, in follow-up, doctors seldom material, perhaps adding some of his own, to present a
Chinese Medical Journal 2009;122(16):1889-1894 1893

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