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

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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 (150219 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

hang-Han Lun (Treatise of Exogenons Febrile Diseases or Discourse on Cold-Damage Disorders), citing 397 articles and including 112 Chinese herbal formulae, is said to be written by ZHANG Zhong-jing (also named ZHANG Ji, 150219 A.D.).1 This book covers the specific symptoms of disorders with the corresponding treatments, as well as the elucidation of the transitions of the six-channel diseases (Tai-Yang, Yang-Ming, Shao-Yang, Tai-Yin, Shao-Yin, and Jue-Yin).2 Shang-Han Lun is the innovator of the four standards (the reason, method, formula, and drug) and also the pioneer of internal medicine in traditional Chinese medicine (TCM). The importance of Shang-Han Lun to TCM is similar to Huang-Di Nei-Jing (Yellow Emperor's Canon of Internal Medicine) to the physiologic dissection of the human body, and Shen-Nong Ben-Cao Jing (Agriculture Gods Canon of Materia Medica), the earliest book on Chinese herbs, to the TCM book of clinical practice. Together with Wen-Bin (Warm Diseases), these four books, therefore, are regarded as the four fundamental textbooks of TCM.3 Moreover, Shang-Han Lun is widely studied by the followers of TCM. It is designated as one of the examination materials for the TCM doctoral certification in Taiwan. However, scholars disputed much of Shang-Han Lun in recent decades. For instance, the way in which ZHANG Zhong-jing (hereafter referred to as Zhang) summarized the six channels was different from Fever theory and simpler than the concept of 12 channels in Huang-Di

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 Nei-Jing) were not in Zhangs discussions on diseases. Furthermore, it was suggested that many of the passages dealing with pulsation may have been inserted by WANG Shu-he, while Wang lived a century after Zhangs death and was the first editor of Shang-Han Lun.1 Moreover, Zhang stated in his preface that the contents of six channels cited many concepts from Su-Wen (Plain Questions); therefore, many scholars assumed that the preface was not written by Zhang himself or alone. Also, Yun5 claimed that many diseases cited in Shang-Han Lun were seldom found in the later generations and Liu6 also indicated that the modern applications of Shang-Han formulae has surpassed the applications described in the
DOI: 10.3760/cma.j.issn.0366-6999.2009.16.010 Center for Traditional Medicine (Chen FP, Jong MS, Tsai HL, and Wang JR), Department of Family Medicine (Hwang SJ), Taipei Veterans General Hospital, Taipei 11217, Taiwan, China Graduate Institute of Integration Chinese and Western Medicine, Chinese Medical University, Taichung, Taiwan, China (Chen FJ) National Yang-Ming University School of Medicine, Taipei, Taiwan, China (Chen FP, Jong MS and Hwang SJ) Correspondence to: HWANG Shinn-jang, Department of Family Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan, China (Tel: 886-2-28757460. Fax: 886-2-28737901. Email: sjhwang@vghtpe.gov.tw) This study was supported by a grant from Chinese Medical Committee of the Health Minister of Executive Yuan (No. CCMP93-RD-024).

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original context. In Western countries, there has been a long interest in distinguishing between heresy and orthodoxy in medical theories and research, particularly with respect to the gradual exclusion of theories that do not conform to the new paradigm.7 However, in Chinese society, the classical TCM textbooks still hold a consecrated position in the delivering medical concepts and treatments to the health care system. Whether Zhang initiated Shang-Han Lun or not is thus worthy of discussion. If Zhang was the follower of Nei-Jing Su-Wen, he would have followed the concept of 12 channels and would have applied the theories to the treatment of internal organ disorders. Nevertheless, he differed from other medical writers who were strongly influenced by those theories.1 Some researchers in Japan protested that Zhang had referred to many references, such as the Tang-Yi-Jing-Fa (Canon of Decoction and Liquid Methods; written by I-Yin in Shang Dynasty).8 We usually ascribed those to Zhangs experiences. However, based on some newly uncovered ancient documents, we queried whether these old formulae were written according to some previous archives and not the innovation of Zhang.9,10 We therefore proposed that all the formulae or the prescriptions in Shang-Han Lun are worthy of careful investigation nowadays. Over the last several decades, TCM has been increasingly accepted as a form of complementary and alternative medicine (CAM) by patients in Europe and North America. Better education for both patients and physicians is necessary to extract the best of TCM and to complement existing conventional medicine for the optimal delivery of healthcare.11 In this current study we thus aimed to explore the modern practicality of the symptoms delineated in Shang-Han Lun by analyzing the utilization rate of Shang-Han formulae among the TCM prescriptions under the National Health Insurance (NHI) in Taiwan. METHODS Data sources In Taiwan, a unique National Health Insurance (NHI) program was started in 1995. By the end of 2002, there were 21 869 478 beneficiaries included in this program, which covered 97.7% of all inhabitants.12 People in Taiwan are free to visit TCM, Western medicine, or a combination of the two. Treatments of TCM, including Chinese herbal medicine and acupuncture for outpatients, have been reimbursed by the NHI program since 1996.13 With the advantage of the available claim data for researchers interested in data mining, we could investigate the utilization rate of Chinese herbs formulae in Taiwan by analyzing such huge NHI database. In the current study, we analyzed the complete database (from 1999 to 2002) of TCM claims from the National

Health Insurance Research Database (NHIRD; http://www.nhri.org.tw/nhird/). The data were saved in two major categories, the linked visiting information and the prescription (such as CM_CD2002.DAT and CM_OO2002.DAT, the so called CD files and OO files, respectively). The visit files, CM_CD2002.DAT, etc. recorded data including date of encounter, medical care facility and specialty, patients gender, date of birth, and the most recent three diagnoses in the coding of International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM). The prescription files, CM_OO2002.DAT etc, contained prescriptive orders and Chinese herbal drugs or formulae. A prescription may contain several Chinese herbal drugs or formulae. Chinese herbal drugs or formulae were made of powder or fine granules and could be easily mixed in a single prescription in Taiwan. For privacy protection, the identification data of patients and institutions had been scrambled cryptographically to attain anonymity. All TCM treatments were provided only in ambulatory clinics, not inpatient care. In addition, only licensed TCM physicians were qualified for the NHI reimbursements. Study design From the 112 formulae listed on Shang-Han Lun, we focus on the 42 formulae which were approved by the NHI. Although there were 337 standard remedies agreed by the government and 42 Shang-Han formulae were within the group. The decision was under the consideration of marketing requirement (Committee on Chinese Medicine and Pharmacy, Taiwan). In computing the usage of Shang-Han formulae, we identified the percentage of 42 Shang-Han formulae in the database. In addition, we also examined whether there were any statistical differences among four seasons. The four seasons are defined in Taiwan by solar calendar, as spring (including March, April and May), summer (including June, July and August), autumn (including September, October and November), and winter (including December, January and February). Statistical analysis The database software of Microsoft SQL Server 2000 (Microsoft Corp., Redmond, WA, USA) was used for the data linkage and processing. We then performed the plain description statistic to classify Shang-Han formulae with the description statistical function in SPSS (SPSS, version 12.0, SPSS Inc., Chicago, USA). The statistical results were examined by cross-tabulation to see whether there were any significant differences in prescriptions among four seasons. The P-values less than 0.05 (two-tailed) were considered statistically significant. RESULTS Between 1999 and 2002, there were 528 889 576 Chinese medicine formulae prescribed in the TCM office visit under the NHI in Taiwan. Among these formulae, only

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1891 Table 3. The top 20 Shang-Han formulae commonly used in traditional Chinese medicine office visits between 1999 and 2002 in Taiwan
Rank Shang-Han Formula (six channel category) Utilization rate (%) 1 Ge-Gen Tang (Tai-Yang) 16.11 2 Shao-Yao Gan-Cao Tang (Tai-Yang) 12.97 3 Xiao-Qing-Long Tang (Tai-Yang) 11.79 4 Ban-Xia-Xie-Xin Tang (Tai-Yang) 10.24 5 Xiao-Chai-Hu Tang (Shao-Yang) 9.11 6 Zhi-Gan-Cao Tang (Tai-Yang) 4.62 7 Gui-Zhi Tang (Tai-Yang) 4.14 8 Cai-Hu plus Long-Gu Mu-Li Tang (Shao-Yang) 3.43 9 Cai-Hu Gui-Zhi Tang (Tai-Yang) 3.20 10 Si-Ni San (Shao-Yin) 2.76 11 Wu-Ling San (Tai-Yang) 2.30 12 Da-Chai-Hu Tang (Shao-Yang) 1.86 13 Xiao-Jian-Zhong Tang (Tai-Yang) 1.76 14 Bai-Hu Tang (Yang-Ming) 1.42 15 Ma-Huang Tang (Tai-Yang) 1.40 16 Zhen-Wu Tang (Shao-Yin) 1.34 17 Dang-Gui Si-Ni Tang (Jue-Yin) 1.33 18 Xuan-Fu Dai Zhe-Shi Tang (Tai-Yang) 1.32 19 Jie-Geng Tang (Shao-Yin) 1.30 20 Ge-Gen Huang-Qin Huang-Lian Tang (Tai-Yang) 0.99 A total of 25 895 689 prescriptions contained Shang-Han formula in traditional Chinese medicine office visits between 1999 and 2002.

25 895 689 formulae were belonged to the 42 Shang-Han formulae. Thus, the mean utilization rate of Shang-Han formula was only 5.22% per year (range from 5.15% to 5.35%) during the 4-year period (Table 1). Comparing the prescription rates of Shang-Han formula among the four seasons, these formulae were prescribed significantly more often in autumn (5.25%) and winter (5.34%) than in summer and spring (5.11% and 5.22%, respectively, P < 0.05; Table 2).
Table 1. The yearly utilization rate of Shang-Han formulae prescribed by traditional Chinese medicine doctors between 1999 and 2002 in Taiwan
Year 1999 2000 2001 2002 Total Total TCM prescriptions 130 810 887 130 373 114 131 462 363 136 183 212 528 829 576 Prescriptions with Shang-Han formula (n (%)) 7 006 977 (5.35) 6 793 470 (5.21) 6 784 479 (5.16) 7 014 289 (5.15) 27 599 215 (5.25)

Table 2. The prescription percentage of Shang-Han formulae among total prescriptions by traditional Chinese medicine doctors at different seasons during 4 years
Year 1999 2000 2001 2002 Average Yearly 5.35 5.21 5.16 5.15 5.22 Spring 5.29 5.17 5.13 5.10 5.17 Summer 5.25 5.12 5.03 5.05 5.11 Autumn 5.38 5.23 5.18 5.20 5.25 Winter 5.50 5.32 5.29 5.26 5.34

The top five Shang-Han formulae commonly prescribed 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 42 Shang-Han formulae. The top 20 Shang-Han formulae accounted for 93.39% of the total Shang-Han formula (Table 3). According to the categories of six-channel, Tai-Yang formulae were used the most frequently during these four years (averaged 71.31%), and followed by Shao-Yang formulae (average 17.49%), then Shao-Yin (6.05%), Yang-Ming (3.31%) and Jue-Yin (1.74%). The least used formulae belonged to Tai-Yin, rated only 0.10% (Table 4). DISCUSSION Since no literature exists mentioning the clinical statistics pertaining to the use of Shang-Han Luns formulae so far, our study serves as an initial report. According to our results, the utilization of Shang-Han formulae only comprised 5.22% of all Chinese herbal formulae in Taiwan. To be a primary internal medicine textbook for TCM education, the utilization rate of Shang-Han formulae was not as high as we expected. Nevertheless, we may attribute the reason to the lack of typical symptoms of Shang-Han Lun in clinical practice or other formulae being favoured by TCM doctors due to their personal experiences, or in part, due to the brevity of Zhangs descriptions and somewhat disjointed organization in his book.1

According to the original theory of Shang-Han Lun, the main reason for patients to get febrile diseases was a result of exposure to cold weather and the main route of the cold was through the Tai-Yang channel, or the superficial back of the body, that is skin in other word. Our study revealed that the most popular Shang-Han formulae were Ge-Gen Tang and Xiao-Qing-Long Tang, both containing the herbal compounds of Ma-Huang (Ephedrae herba), Gui-Zhi (Cinnamoni ramulus), and Shao-Yao (Paeoniae radix). Hence, they might be regarded as derivatives from Gui-Zhi Tang and Ma-Huang Tang, the top two formulae mentioned in the original Shang-Han Lun. Zhang used Ge-Gen Tang for sweating in an effort to relieve superficial syndromes. In modern times, it can be adopted to treat respiratory diseases, such as common cold and asthma. Similarly, Xiao-Qing-Long Tang is known nowadays to have an effect on allergic diseases, such as allergic rhinitis and bronchial asthma.14 On the other hand, since the major use of TCM in Taiwan is for diseases of respiratory system,15 we might postulate that the Shang-Han formulae were commonly used for respiratory tract-related febrile diseases which were encountered more often in autumn and winter.16 As it is known that the so-called traditional Japanese medicine, including herbal (Kampo) medicine and acupuncture has been used for 1500 years and is fully integrated into the modern health-care system in Japan.17 There are two schools of TCM practice, the Traditional Formula School and the Posterity School.18 The former is the mainstream in Japanese Kampo medicine, which simply uses the ready-made formulae in Shang-Han Lun. They might neglect eight-schemas (yin, yang, exterior, interior, deficiency, excess, cold, and heat), and thus doctors could match their prescriptions simply based

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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 Tai-Yang Yang-Ming Shao-Yang Tai-Yin Shao-Yin Jue-Yin Total 1999 5 076 333 209 681 1 214 829 7011 385 102 114 021 7 006 977 2000 4 852 122 222 211 1 191 748 6601 411 605 109 183 6 793 470 2001 4 812 413 233 241 1 181 814 7080 424 991 124 940 6 784 479 2002 4 941 235 248 332 1 237 635 8236 447 028 131 823 7 014 289 Subtotal 19 682 103 913 465 4 826 026 28 928 1 668 726 479 967 27 599 215 % 71.31 3.31 17.49 0.10 6.05 1.74 100.00

on the manifesting symptoms without considering about the TCM theories. This type has easily been accepted by most doctors who practice Chinese medicine in Japan;19 while the School of Posterity is more complicated and emphasizes the pulse diagnosis, the selection of treatments based on the diagnoses, and it is similar to the one most often practiced in TCM in Taiwan. It was reported that the Shang-Han formulae occupied 46% of the 130 Chinese herbal formulae approved by the Japanese government.19 In comparison, there are only 42 Shang-Han formulae (12.5%) among a total of 337 Chinese herbal formulae approved in Taiwan. These may also account for the low utilization rate of Shang-Han formulae in Taiwan. Of all the traditional and developing nations, only in China and India with their millennium-old, wellestablished, holistic philosophy, have the independence and respect of traditional health concepts and practices be preserved. This is largely the results of the internal consistency of the pathophysiologic mechanisms manifested through traditional practices there.20 In the West, the history of science is a tale of multifarious shifting of allegiance from theory-to-theory,21 and Chinese medicine also presents itself as a composite of disparate, often contradictory elements, rather than as a cohesive system.22 Unschuld23 also stated that Chinese medicine can only refer to a broad range of ideas and practices related to healthcare and illness intervention that was developed or adopted from abroad, and practiced in China over the past few millennia. One of the prominent examples was that Zhang has used two systems of classifications, that is, specific symptom- and channel-classified disorders, which were not fully integrated and interspersed at random. It should be noted that neither system, nor the limited synthesis between them originated with Zhang; all are found, with some differences, and scattered through-out earlier text.1 Thus, Chen10 has mentioned that Zhang might represent the other ancient school in TCM, instead of the Nei-Jing School. Based on our observations, it seems hard to see the transitions following the order of six channels. If the transitions happen frequently, the usage rate of Shang-Han formulae for each channel should decrease with the order of Tai-Yang, Yang-Ming, Shao-Yang, Tai-Yin, Shao-Ying, Jue-Ying. Yun5 had pointed out that although Zhangs Shang-Han Lun described the transition of symptoms for a certainty, in follow-up, doctors seldom

note these situations. He also thought that since the transitions of symptoms were not easy to be understood thoroughly, the erroneous diagnoses happened easily. The same vagueness confused many current Shang-Han Lun followers as well. Yet, it is not always easy to discern Zhangs reasoning when he would confidently classify syndromes as one disorder or another. It was used to explain the entire course of a disease over a period of days by relating the succession of symptoms to a spread from one part of the body (not the same meaning as channel in Nei-Jing School) to another.1 The emphasis was primarily on the positive qi and the various changes induced in it by the agent or cause of the disease. A disease could also result in just a single channel or body part which might not be always the Tai-Yang, and did not require any transition (or transmission). Actually, the concept of 12-channel was developed in Nei-Jing School, but the idea of Zhangs channel described the different levels of body parts, from three Yang (Tai-Yang, Shao-Yang, Yang-Ming) to three Yin (Tai-Yin, Shao-Ying, Jue-Yin), namely, from superficies (skin) to deeper organs. This indicates again that the followers of Shang-Han Lun should not confuse about the names of 6-channel, instead of understanding the exact significance of Zhangs passages. Generally speaking, the theory of disease etiology in Chinese medicine is distributed into three branches: internal, external, and others. The external etiology comes from the six excesses or weather forms:24 wind, cold, summerheat, dampness, dryness, and fire. The seven emotions for internal etiology are: anger, anxiety, thought, sorrow, fear and fright. The internal impairments or various diseases are thus mostly induced by internal emotions, while the external infected diseases are the result from the outside environments. Currently, the transitions of channels could be compared with the different stages of febrile infections disease, and the followers might be learned that the names of Yin-Yang is just a kind of classification developed in ancient time. Though the modern etiologies are known to be complicated, TCM doctors still regard Shang-Han Lun as the tenet of internal Chinese medicine, due to its most ancient position to present the discriminating thoughts of different symptoms around that time,25 which is an important step for us to understand the progress or formation of the TCM in such a long era. Zhang succeeded in drawing together and adapting this earlier material, perhaps adding some of his own, to present a

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1893 medicine text, The Discourse on Cold Damage Disorders (Shang-Han Lun). J Hist Med Allied Sci 1988; 43: 8-35. Wang QG, Chang HS. A research and developing strategy evoked from the six channel theory and its methodology to discuss the integration of Zhong-Jing academic thought. In: Wang QG, eds. Zhong-Jing academic research. Beijing: Xueyuan Publishing Co.; 2003: 1-8. Lee PS. Shang-Han Lun. Taipei: Chih Yin Publishing Co.; 1999: 1-9. Ke Q (Qing Dynasty). Shang-Han Lai-Su-Ji. In: Yu Bo-Hai eds. Summary of Shang-Han, Jin-Kui and Warm Diseases. Beijng: Huaxia Publishing Co.; 1997: 346-369. Yun ZY. From the aspect of modern medicine to explain and praise Shang-Han Lun. Annual Research Papers of Chinese Medical College 1977; 18: 1-12. Liu YG. The rational of clinical application of Shan-Han formulae. J Chin Med (Chin) 1993; 4: 163-168. Jones RK. Introduction to: heresy and orthodoxy in medical theory and research. Soc Sci Med 2004; 58: 617-617. Motoo N. The Han formulae in Japan and TCM. In: Zhao-Yu D, Zhong-Zhen Z, eds. The Traditional Medicine in Japan, now and the future. Beijing: Huaxia Publishing Co.; 1998: 49-51. Qian CT. Brief history of the circulation and development after the publishing of Shang-Han Lun in Song Dynasty. In: Wang QG, eds. Zhong-Jing academic research. Beijing: Xueyuan Publishing Co.; 2003: 170-204. Chen FP. Whether ancient Chinese medicine could be divided into Yellow Emperor or Shen-Nong Schools? Exploring the origin of Shang-Han Lun. J Chin Med Assoc Acup (Chin) 2004; 7: 83-97. Siow YL, Gong Y, An-Yeung KK, Woo CW, Choy PC, O K. Emerging issues in traditional Chinese medicine. Can J Pharmacol 2005; 83: 321-334. Cheng TM. Taiwans new National Health Insurance Program: Genesis and experience so far. Hlth Aff (Project Hope) 2003; 22: 61-76. Chen FP, Chen TJ, Kung YC, Chen YC, Chou LF, Chen FJ, et al. Use frequency of traditional Chinese medicine in Taiwan. BMC Hlth Service Res 2007; 7: 26. Ikeda K, Wu DZ, Ishigaki M, Sunose H, Takasaka T. Inhibitory effects of Sho-seiryu-to on acetylcholine-induced responses in nasal gland acinar cells. Am J Chin Med 1994; 22: 191-196. Chen FP, Kung YY, Chen TJ, Hwang SJ. Demographics and patterns of acupuncture use in the Chinese population: the Taiwan experience. J Alt Complement Med 2006; 12: 379-387. Heikkinen T, Jarvinen A. The common cold. Lancet 2003; 361: 51-59. Yu F, Takahashi T, Moriya J, Kawaura K, Yamakawa J, Kusaka K, et al. Traditional Chinese medicine and Kampo: a review from the distant past for the future. J Int Med Res 2006; 34: 231-239. Su SB, Li YQ. Clinical diagnosis and research. In: Zhao-Yu D, Zhong-Zhen Z, eds. The Traditional Medicine in Japan, Now and the Future. Beijing: Huaxia Publishing Co.; 1998: 127-138. Sun QR, Wang Z, Hu XZ. The inspection of the clinical

detail picture of febrile diseases. From deliberate investigation, a Japanese scholar already mentioned that the 268 passages from the total 385 of Shan-Han Lun were originated in the book complied by Zhang from other texts, and the other 117 passages were added by WANG Shu-he and other scholars in Tang or Song Dynasties.26 Zhang (a representative doctor) formulated his concepts on the basis of available data to provide a rational explanation both for diseases and treatments. The attempt to relate the manifest symptoms to an underlying physiologic condition is perhaps the most interesting feature of his text.1 Cultural differences in health beliefs and behavior may affect healthcare utilization, and culture-related differences in medication beliefs may be even stronger for older members of the community.27 The traditional Chinese medical academic societies in Taiwan are typical examples of this to keep using Huang-Di Nei-Jing and Shan-Han Lun as the certification materials. Nevertheless, widely social and economic concerns directly impinge on healthcare, so we need a more liberal attitude toward medical knowledge and discovery. Because series of research in Chinese studies have been devoted to an exploration of the contents and foundations of TCM only for a rather short time,23 our viewpoint in this is still considered as preliminary and open to reassessment. Based on the data, the utilization ratio of Shang-Han formulae prescribed among the patients who sought TCM for the medical service in Taiwan was not so high as we expected. There is no six-channel transitions in the prescriptions of Shang-Han formulae, it indicates that although Shang-Han Lun is an essential archive of internal medicine of TCM and the frontier of the reason-method-formula-drug from the aspect of clinical practice, its importance is to revealed an ancient way of thinking about the diseases and formulae, which is different with the classical Nei-Jing system as we usually thought. Further studies to observe on the patterns of Shang-Han disorders should be carried on in order to understand the possibility and the transition after treating with the formulae. We also recommend that the medical education in TCM may reexamine Shang-Han Lun with the reference of the statistical data from clinical practice and the fact that it may not be the follower of Nei-Jing system for the future explanation of its importance.
Acknowledgement: The authors are grateful to Prof. Peter Davis for comments, and Prof. Ling-Ling Tsai, Mr. Yu Chen, Ms. Jing-Huei Shiu, and Ms. Tzu-Feng Hsieh for editing the earlier versions of this manuscript. REFERENCES 1. Epler DC. The concept of disease in an ancient Chinese

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Chin Med J 2009;122(16):1889-1894 tradition and modern medicine dialogue forum. Taipei: Chinese Medical Advancement Foundation; 2004: 66-80. 25. Mitchell C, Feng Y, Wiseman N. Shang Han Lun On cold damage/translation & commentaries. Brookline: Paradigm Publications; 1999: 9-13. 26. Keisetsu O. The comment of Shang-Han Lun on clinical application. Taipei: National Research Institute of Chinese Medicine; 1991: 1-49. 27. Horne R, Graupner L, Frost S, Weinman J, Wright SM, Hankins M. Medicine in a multi-cultural society: the effect of cultural background on beliefs about medications. Soc Sci Med 2004; 59: 1307-1313.

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(Received December 16, 2008) Edited by GUO Li-shao

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