Sì dà jiā: The four masters
Traditional Chinese Medicine is one of the oldest, continually practiced medicinal arts in the world. Arriving at the most current understanding of this art and the forces at work in the body rests on knowledge and contributions made over thousands of years and clearly no individual could be considered the single driving force behind the development of TCM. However, over these millennia, certain figures are still recognized for their contributions to the science. Among such people are four men who lived during the Jin-Yuan era (1115-1368) and who would become known as the Four Great Masters of Chinese Medicine. Each founded a distinct school of thought within TCM and which would shape the approach of Chinese medicine to understanding the causes of, as well as the treatment of, disease.
Liu Wan Su was born in the year 1120. Liu Wan Su is said to have noted that many serious diseases were accompanied by inflammation and fever and proposed using cooling herbs to treat such conditions, leading to his association (and founding) of the Cold and Cooling School of thought as well as the theory of similar transformation, which remains one of the most well-known theories stemming from this school. The thought follows that if human Qi is Yang, humans must possess the base level of “warmness” associated with Yang. The problem then arises when another Qi is introduced, either from an outside source or additional internal imbalance. This Qi, regardless of its initial characterization, will tend to be subjugated to the warm Qi of the host, whereby this new Qi also becomes warm—the transformation to the similar, hence the name of the theory. Combined, these two warm Qi embodiments create “hot”, which is not desirable and the cause of many ailments. Liu Wan Su taught that cooling herbs should be used and created many formulas that included talc, or hua shi, and created Liu Yi San, Yi Yuan San, and Gui Ling Gan Lu Yin, developed to cool the body and promote urination which would aid in expelling warmness. Liu Wan Su did not advocate for cooling herbs universally, arguing that treatments needed to be formulated based on the time, place, patient's overall health, patient's other health conditions, and the characteristics of the disease. However, he noted that febrile diseases (epidemics; viral and bacterial pathogens) were increasingly common and so cool and cold herbs would play a central role in most therapies and often was the correct course of action. This placed a focus on lowering the heart fire, which is a critical Yang Qi but may cause problems when uncontrolled, as well as nourishing the kidney water to send cooling energies throughout the body.
It is important to reiterate that the invading Qi need not be warm itself. In fact, Liu Wan Su believed many externally contracted diseases were “cold”. However, it was the transformation in the body to warm that required the use of cooling herbs, even when set to treat a cooling disease. Prescott (Prescott 2012) notes the Western equivalent is the cold stage of a fever, where the patient is shivering and cold despite having an elevated temperature.
In addition to the Cooling school, the focus on invading Qi and febrile disease set the foundation for others to elaborate on and explore, including by the development of the “Warm” school developed by Wu Youxing in 1644, which incorporated the cooling ideas but also began to codify the idea of transmissible causative agents, the concept of the “epidemic”, a concept which predated the Western notion of the “contagion”. This theory would eventually mature into “germ theory”, a concept reaching near universal acceptance by both Eastern and Western Medicine by the 19th century (Dharmananda 2001).
The second master, Zhang Cong-zhen, was born in 1156 and also focused teachings around the six influences framework—cold, summer heat, dryness, damp, fire and wind—much as his contemporary Liu Wan Su did. Also like Liu Wan Su, Zhang Cong-zhen believed that the current treatments of the time were insufficient to combat the diseases of that time and that medicine should be specifically tailored to the individual. In this tailoring, Zhang Cong-zhen also believed that treatments needed to not only consider the patient, but also the season as well as social influences (Dharmananda 2001).
Perhaps because of his military training, Zhang Cong-zhen’s approach to medicine was that of a soldier’s. The body was a fortress and keeping the body in good repair would make it impossible for disease to enter. He diminished the idea of internal or inherent disease, instead promoting the idea that all disease—or at least most disease—was caused from external factors. However, he also believed that these external disease-causing agents came not just from the heavens and the earth (the six influences indicated above), but also from one’s own actions. He believed that disease could be caused by what foods one ate as well as indulgence in vice; these weakened the “fortress” of the body—the Wei Qi—and invited disease, which must then be forced out. This led to the founding of the Attacking and Purging school of thought. This school placed emphasis on three methods of treatment: sweating, vomiting, and purging, i.e., bowel movements, though these functions were not limited in the same way a modern definiton might suggest. Rather than external Qi being assimilated into the host Qi, Zhang Cong-zhen felt that disease was caused by toxins: entities which remained separate from the host and which could be forcibly expelled. By expelling the body’s fluids through sweat, vomit, and bowel movements, the toxins would be carried away from the body as well. Among his formulations were Schizonepeta (Jing Jie) to address wind and dampness heat as well as Angelica dahurica (Bai Zhi) for wind heat and toxins. In addition to herbs themselves, Zhang Cong-zhen also advocated for the use of washing and exercising, practices now known to Western Medicine to be conducive to a healthy lifestyle which in turn leads to less illness.
This focus on “attacking” the disease—of directly intervening and interacting with the source of disease—represents a departure from the more indirect treatments of the time, now considered to be “supporting” treatments meant to disperse or tonify the condition. This change in thought did not overwrite the works of those who came before these masters, but rather served to supplement them, fleshing out theories within Traditional Chinese Medicine and offering additional tools and ways of thinking to combat disease and heal the sick.
The third master, Li Dong Yuan, also known as Li Gao, was born in 1180. Li Dong Yuan advanced the theory of Yin Fire, the idea that symptoms of disease are caused by Fire stemming from Yin conditions such as damp and sharing many similarities with the “Evil Heat” of Liu Wan Su’s theory of similar transformation. In fact, Li Dong Yuan's theory of Yin Fire may be seen as accepting Liu Wan Su's theory but elaborating on the sources of Evil Heat—coming not just from outside or alien Qi but also coming from internal sources generated by “eating, drinking and living environment, yin and yang [intercourse], joy and anger” (Flaws 2004, p.7).
Also, like Zhang Cong-zhen, Li Dong Yuan believed that many diseases were “allowed” to enter the body through a failure of the patient. Li also focused on nutrition, noting that under-eating may be just as dangerous as overeating. Li Dong Yuan taught that even the kinds of food one eats is important, as failing to eat the proper foods could result in consuming damp, which could damage the liver and kidneys. Central to his school of thought was that most diseases ultimately stemmed from injury to the digestive system and so spent a great deal of time studying the stomach and spleen, the organs responsible for changing external nutrition into internal Qi. Unlike Zhang Cong-zhen however, Li Dong Yuan also elaborated on the emotional toll of the patient. Exercise might be good, but over exercising might be as dangerous as under exercising. Li also taught that worry and other negative emotions opened one up to disease.
These views led to the founding of the Strengthening Earth School of thought. Because of the focus on nutrition and emotional well-being, Li Dong Yuan focused on the element of Earth as it forms a central place within the five elements and in particular relates to nutrition. In elaborating the importance of emotion, he also described the seven emotions that play a role in disease: anger, joy, concern, sorrow, fear, fright, and cogitation. Li Dong Yuan also wrote the “Treatise on the spleen & stomach” (Pi Wei Lun), which is considered “Li's final book and greatest masterpiece” (Flaws 2004, preface). As discussed above, nutrition was of utmost interest to Li Dong Yuan and so the stomach also interested him. He referred to this organ as “the sea of water and grain”, a place of mixing Qi and blood. This was also the seat of the middle burner where, upon receiving Qi, waste is separated, fluids and humors are steamed, and Qi is transformed from grain into a “purified essence” (Flaws 2004, p.6). This Qi flows out of the stomach/sea via rivers, which flow to the spleen, which in turn spreads the Qi through the lungs and eventually down to the bladder. The spleen-stomach was therefore thought by Li Dong Yuan to be critical in maintaining the proper flow of Qi, since this was essentially the sole source of Qi for the body. As such, Li Dong Yuan held these organs (collectively the “stomach” viscera) above the others, in contrast to the common outlook at the time that all the viscera were equally important. Li Dong Yuan invented the Sheng Mai San formulation—still used today to treat cardiovascular disease—as well as Dang Gui Bu Xue Tang, which was a combination of other herb formulations used to stimulate the Qi and blood after significant blood loss.
The fourth master was Zhu Zhen-heng, also known as Dan-Xi, and was born over one hundred years after the other three masters in 1281. However, Dan-Xi also studied both heat and fire and described the “ministerial fire” or “small fire”, an ever-present Yang Qi flowing through the liver and kidneys and acting to warm the heart fire. He thought that the Yin Fire described by his predecessors was a manifestation of a problem with the ministerial fire, where heat flows upwards and collects in the heart. The ministerial fire also inhibits and counteracts the original Qi, which is stored in the kidneys. Ultimately, it was the position of Dan-Xi that since the natural Qi of humans is Yang, that this Yang energy was generally not an issue in and of itself, but rather that most problems arose because excess Yang caused a deficiency in Yin.
This led to the founding of the Nourish Yin school of thought, stressing the importance of promoting (nourishing) Yin energies as a means of keeping the natural production of Yang Qi in check. If Yang is easy to produce but Yin Qi is difficult to maintain, then the focus of treatment should be on food and herbs which forcefully inject and promote Yin Qi. These included formulations such as Da Bu Yin Wan, which contained rehmannia, phellodendron, and anemarrhena, which would later be developed into a widely used formula to treat Yin deficiency with damp heat in the lower burner, called the “Rehmannia Six” formula. Dan-Xi also advocated for temperance in any activities that would encourage the overproduction of Yang, such as “emotional sensitivity, preference for rich food, [and] overindulgence in wine and women” (Min Li 2017, p.1).
Dan-Xi also took the concept of the Yin Fire and characterized pathogenic problems into the six depressions, or six stagnations. Blood stasis, Dampness accumulation, Phlegm obstruction, and Food stagnation can all lead to Qi stagnation, which itself may result in any of those four depressions, creating a feedback loop which reinforces the generation of Fire (depressive heat) if left untreated.
While others, such as Li Dong Yuan, appreciated and taught that emotions play a role in disease, Dan-Xi took this even further and articulated a theory of chronic psychological disease and initiated one of the first known treatments for what Western science would call “depression” (Gao Qiao Lin 2009). He also taught that the doctor-patient relationship was the foundation for correctly diagnosing and treating a disease, fostering an attitude towards improved mental and physical health as well as open communication with a physician.
The history of Traditional Chinese Medicine in long and full of important people and interesting discoveries which represent the bedrock on which current TCM understanding is founded. However, the Jin-Yuan dynasty represents a time of change in China, where two non-Chinese tribes (Tanguts and Mongols) developed into powerful empires and with that introduced Chinese culture to new ideas and shifting attitudes as well as opening up trade with the Middle East. It is perhaps no wonder then that this period was ripe for changes across more than the political landscape and produced some of the most profound schools of thought which persist to this day in Traditional Chinese Medicine.
References
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