The Legacy of Zhang Zhongjing

Chinese Medicine is largely based on ancient texts that were written about 2000 years ago. These classical texts include:

Huang Di Nei Jing, Shen Nong Ben Cao Jing, Nan Jing, Shang Han Lun

These texts are considered to be the theoretical as well as practical basis for Chinese Medicine from ancient times to present times. The great importance attributed to these texts, as well as the significant influence they still have on clinical practice, raises the following questions:

Considering the developments in science and technology, mainly in the past 150 years, and considering the immense amount of knowledge that has been added to the understanding of the human body in the past century, how is it possible that texts that were written 2000 years ago are still relevant?

Is the fact that Chinese Medicine continues to rely heavily on ancient texts, an indication that it has a quality of a faith as opposed to scientific thinking?

In order to address these questions, there is a need to define the basic difference between science and faith. Faith generally does not require proof, we assume it to be correct and act according to our faith without questioning and testing it. Science, on the other hand, is an ongoing process of criticism and attempts to prove or disprove theories by experiments and observations. When a theory is disproved, it is subsequently abandoned and replaced by new theories.

Does the fact that Chinese Medicine still adheres to ancient texts indicate that it has the quality of a faith? Or alternatively, have the theories described in these ancient texts successfully passed the process of experiment and observation, and therefore there is no reason to disregard them?

The answer is: Chinese Medicine can in fact have the quality of both a faith and a science. It is essentially up to the practitioners to choose the character of the Chinese Medicine they practice.

In this article, I would like to illustrate the legacy of Zhang Zhongjing – a Chinese Medicine doctor from the 2nd century AD, and one of the most influential masters in the vast history of Chinese Medicine. In the preface to the text he wrote – Shanghan Zabing Lun – he offers us an intriguing insight to the quality of Chinese Medicine he is aspiring to establish through his text. In the preface he explains his motivation for writing the text, as well as textual references and sources of inspiration.

As the motivational force for writing his text, he mentions the great tragedy of the death of two thirds of his extended family due to an epidemic.

From the Preface:

“Deeply affected by this ruinous loss in my past and by the failure to rescue them from damage and premature death, I have diligently sought out the ancient instructions and collected a great number of methods far and wide.”¹

It is worth noticing that his motivation was not success and complete faith in his actions, but a deep and agonizing sense of “failure to rescue”. From within this failure he embarked on a journey of study and investigation, a process which resulted in the writing of Shanghan Zabing Lun, which would later be divided into 2 separate texts:

• Shanghan Lun: detailing a physiological model of 6 conformations composing the body, their pathologies and treatments.
• Jingui Yao Lue: detailing complicated diseases, with a chapter dedicated to women’s disease and a chapter dedicated to children’s diseases.

In defining his motivation as failure and disappointment, he applies a scientific approach of acknowledging proof of the limitations and flaws of a theory, leading to the search of other theories to better fit the unfolding reality.

The texts mentioned as references for the information in Shanghan Lun also offer an insight to Zhang Zhongjing’s working process. He mentions 6 references, out of which 3 are still known to us, and 3 have disappeared early in history and we are therefore unfamiliar with their content. The 3 texts that have been preserved are the 2 parts of Nei Jing – Su wen and Ling Shu (Internal Cannon of the Yellow Emperor) and Nan Jing (Cannon of Difficult Questions). When comparing Zhang Zhongjing’s 6 conformations model to the theories mentioned in these texts, it is evident that he drew ideas and inspiration from them, but also changed and developed ideas. One example of this is the direct association in Nei Jing between each conformation and specific channels and organs; This association is almost entirely absent in the 6 conformation model of Shanghan Lun, a difference with significant implications to the diagnostic and treatment application of the model. It is thought that he embraced the theories which proved to be of clinical value, while neglecting those that failed to demonstrate effective clinical results. This is also an example of the scientific process he seems to have followed.

Among his inspirational sources, Zhang Zhongjing mentions Confucius and the learning and moral values of Confucianism. He illustrates the situation of medical practitioners of his time, an illustration which is also relevant to our time. He describes different qualities of doctors, which include charlatans that only have empty and baseless promises to offer, alongside doctors with limited knowledge that do not expand their education and do not examine themselves or conclude on the measure of efficiency of their treatments.

From the Preface:

“When I look at today’s doctors, they do not study and ponder the meaning of the classics in order to advance what they know. Each has inherited his family’s skills and from beginning to end merely follows along in the old ways. In examining the illness and inquiring after the disease, their service is limited to fancy words, and after just an instant of face-to-face interaction, they prescribe decoctions and medicines…. This is what I call looking through a narrow tube of bamboo and that is all!” ¹

In this paragraph Zhang Zhongjing expresses his frustration with the doctors who are satisfied with the knowledge they inherited; They do not seek to deepen or widen their knowledge, they do not ask questions or search for clinical evidence of success or failure, they simply treat in the same way they were taught. He is disappointed by the lack of interest in the immense sources of knowledge in the classics, which in his opinion, has the ability to turn a mediocre doctor into an incredible healer.

From the Preface:

“When suddenly faced with the disastrous qì of evil wind and ensnared by extraordinary illness, they worry only that disaster has struck and are reduced to trembling and shaking. They surrender their willpower and bend their integrity, admiringly look to shamans and other officiants, and declare their desperation and return their fate into Heaven’s hands, awaiting defeat as if with hands tied behind their back.” ¹

In this paragraph, Zhang Zhongjing refers to the scholars that have made the effort to study and educate themselves. However, instead of using their knowledge to serve others, they use it to gain money, power and prestige. When they become ill, they do not turn to doctors educated in the classics for help, but rather to charlatans which offer them only unfounded remedies that bring with them more suffering and ultimately an untimely death. He expresses his disappointment that despite the knowledge they have acquired, they do not appreciate its great value. They do not use it to benefit others, and ultimately, they do not use it even to benefit themselves.

Zhang Zhong Jing is asking the future Chinese Medicine doctors not to follow in the path of the charlatans or those with narrow perspective. In the preface, as well as throughout the text, he is making the effort to emphasize the essential co-existence of respect and honor for the wisdom of the ancient doctrines, alongside the traits of curiosity, criticism, search of knowledge and independent thinking. He is trying to guide us towards choosing a “scientific” approach towards Chinese Medicine.

From the Preface:

“Even though you will not yet be able to exhaustively cure all the various diseases, you may be able to look at a disease and know its origin. If you can unravel what I have collected here, you will have thought through more than half [of all problems you might face].” ¹

The Chinese word xun 寻, translated here as unravel, has the meaning of ‘to seek’, as opposed to just learn and repeat. This, for me, is the legacy that Zhang Zhongjing passed on to the doctors who followed him. He is very much aware that Chinese Medicine is not a complete and finished doctrine. He does not assume he has all the answers, or in his words – he suggests he might have the answer to more than half the problems. He is essentially indicating to the doctors of the future to continue with the process of study, research and development of Chinese Medicine.

Chinese Medicine doctors throughout history have risen to the challenge. Through expansion of knowledge, critical exploration of the classics and careful clinical observations, they have continued to develop and master the healing potential of Chinese Medicine. Through this process many ancient theories have been repeatedly proven to be of practical value, and many have been abandoned, leading the way for new models of diagnosis and treatment to be created. This is the living spirit of Chinese Medicine, a medicine that acknowledges that the ancient classics are to be studied and examined, not as an excuse to freeze in time, but as a necessary base to move forward, develop and improve.

Finally, I would like to address the question presented at the beginning of this article:

Considering the developments in science and technology, and considering the wide understanding of physiological and pathological mechanisms that have been revealed in the modern era, how is it possible that medical doctrines that were written 2000 years ago are still relevant?

It is a fact that Zhang Zhong Jing did not have access to MRI or to blood tests, he did not know about hormones or the biochemistry of the cell. However, this does not mean his understanding of the human body is invalid. Technology has significantly changed our daily reality, but let’s not be mistaken: man is exactly the same as he was 2000 years ago, and the universe is exactly the same universe. Zhang Zhonggjing  understood the body by utilizing the tools he had, tools of the wisdom of those who preceded him, and the tools of observation and clinical trial and error. These tools enabled him access to unravel the mechanisms of sickness and health.

An example of the deep understanding of the body that the ancient texts contain, are the following quotes of a text from the 2nd century BC, compared with a medically related document from 2017. Terminology aside, the ideas portrayed are strikingly similar:

Huang Di Nei Jing: Su Wen, ch.2 (2nd century BC)2:	Press Release for 2017 Nobel Prize in Physiology of Medicine3:
“The yin and yang [qi] of the four seasons, they constitute root and basis of the myriad beings. Hence, the sages in spring and summer nourish the yang and in autumn and winter nourish the yin, and this way they follow their roots.”	“Life on earth is adapted to the rotation of our planet… The clock regulates critical functions such as behavior, hormone levels, sleep, body temperature and metabolism.”
“If one follows yin and yang, then life results; if one opposes them, then death results. If one follows them, then order results; if one opposes them, then disorder results.”	“There are also indications that chronic misalignment between our inner timekeeper is associated with increased risk for various diseases.”

Zhang Zhongjing explored such classics, using them as theoretical guidelines to be tested in the clinical reality, accomplishing the first systematized clinical guide in the history of Chinese Medicine to merge theory with practice. Throughout history his theories were criticized, scrutinized and tested by Chinese doctors of different centuries; This process would often result in the confirmation of his accurate observational conclusions, but at the same time, some of his assumptions and believes were proven to have no clinical value. This does not minimize his achievements, Zhang Zhongjing was the first to admit he did not find the solution to all pathological situations.

The new discoveries do not mean that we need to create new doctrines, the old doctrines that have survived 2000 years of examination and testing are still very much relevant. By using the new discoveries to correct and develop the old doctrines, we might be able to unveil (almost) all of the body’s intrinsic mechanisms.

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References:

[1] Translated by Sabine Wilms. Taken from: https://www.happygoatproductions.com/translation-files

[2] Translated by Paul U. Unschuld

[3] Press Release for 2017 Nobel Prize in Physiology of Medicine: https://www.nobelprize.org/prizes/medicine/2017/press-release/