The Essential Teachings of Sasang Medicine An Annotated Translation of Lee Je-ma’s Dongeui Susei Bowon Gary Wagman, PhD, LAc LONDON AND PHILADELPHIA First published in 2016 by Singing Dragon an imprint of Jessica Kingsley Publishers 73 Collier Street London N1 9BE, UK and 400 Market Street, Suite 400 Philadelphia, PA 19106, USA www.singingdragon.com Copyright © Gary Wagman 2016 Library of Congress Cataloging in Publication Data Names: Yi, Che-ma, 1837-1900, author. | Wagman, Gary, 1973- , annotator, translator. Title: The Essential Teachings of Sasang Medicine : An Annotated Translation of Lee Je-ma’s Dongeui Susei Bowon / Gary Wagman. Other titles: Tongu?i suse powo?n | Dongeui susei bowon Description: London ; Philadelphia : Singing Dragon, 2016. Identifiers: LCCN 2016001947 | ISBN 9781848193178 (alk. paper) Subjects: | MESH: Yi, Che-ma, 1837-1900. Tongu?i suse powo?n. | Medicine, Korean Traditional | Longevity | Somatotypes--physiology | Yin-Yang Classification: LCC R627 | NLM WB 55.K6 | DDC 610.9519--dc23 LC record available at http://lccn.loc.gov/2016001947 British Library Cataloguing in Publication Data A CIP catalogue record for this book is available from the British Library ISBN 978 1 84819 317 8 eISBN 978 0 85701 270 8 Contents Acknowledgments .....................................................7 Introduction ........................................................9 Part I: Theory Chapter 1 Theories on Human Nature and Conduct (性命論) .............32 Chapter 2 The Four Basic Characteristics (四端論) ......................51 Chapter 3 Expanding and Fulfilling (擴充論) ..........................67 Chapter 4 The Zhang Fu Organs (臟腑論) ............................83 Chapter 5 The Basic Principles of Medicine (醫源論) ....................93 Part II: Clinical Application Chapter 6 The So Eum Individual’s Illness (少陰人論) ..................104 Chapter 7 The So Yang Individual’s Illness (少陽人論) ..................203 Chapter 8 The Tae Eum Individual’s Illness (太陰人論) .................269 Chapter 9 The Tae Yang Individual’s Illness (太陽人論) .................316 Part III: Additional Topics Chapter 10 The Virtuous Path—Advice for Everyday Life (廣濟說) ........332 Chapter 11 Four Constitutional Classification and Diagnosis (四象人 辨證論) ...............................................340 Useful Resources ....................................................349 Index ...........................................................350 Introduction The last decade has served as a renaissance for the English translation of Chinese medical texts, adding to the integrity and depth of Eastern medical studies in the West. Most, if not all, of these translations were based on a desire to deepen the understanding of Chinese medicine outside the confines of China. While these intentions have been well received, the contributions of other Eastern medicines have yet to be given the attention they deserve. Consequently, it is of common belief in the West that the Chinese approach remains authentic and unparalleled. This text offers one example of how other countries, such as Korea, have contributed significantly to the development of Eastern medicine. As a small country directly adjacent to and approximately 43 times smaller than China, Korea was evidently influenced by its culture and medicine. Yet China and Korea have never considered themselves one and the same, as the Yellow River divided them geographically and culturally. Korea as we know it today is shaped by a delicate balance between Chinese influences and its own intrinsic culture. Its story of creation, which offers the very first reference to herbal medicine in Korean history, involves the tale of a bear and tiger who were given the chance to become human if they survived 100 days in a chilly cave with just 20 cloves of garlic and one bundle of sage. With garlic as a herb to warm the body and sage to promote fertility, this story attests to the fact that Korea historically regarded the use of herbal medicine as a central aspect of its existence. The first recorded Korean medical texts—A Collection of Formulas from the Korean Elders of the Goguryeo Dynasty (高麗老師方), written during the Goguryeo Dynasty (37 bc–668 ad), and the Revised Collection of Baekje Formulas (百濟 新集方), written during the Baekje Dynasty (18 BC–660 ad)—both contain numerous remedies such as Mu Gua (Fructus Chaenomelis Lagenariae), Huang Qi (Radix Astragali Membranacei), and Ju Hua (Flos Chrysanthemi Morifolii) for lung tumors, boils, beriberi, influenza, and other ailments. Although neither of these texts survived in its entirety, what remains is a hint of the use of both Chinese and indigenous approaches to healing. 9 The Essential Teachings of Sasang Medicine A series of epidemics during the later Silla period (668 BC–995 BC) forced Korean doctors to develop their own domestic herbal approaches, not previously given in the Chinese medical texts. To accompany this effort, the Silla government legalized the use of Ayurvedic medicine brought back by Korean scholars returning from India. The widespread use of Ayurvedic medicine in Korea paved the way for later approaches such as Sasang medicine, which emphasize the significance of one’s innate emotional and physical tendencies in the healing process. Korea’s first discernible rift from an emphasis on Chinese medicine came under the rule of King Saejeong (1418–1450), who ordered a countrywide survey of native Korean plants, trees, shrubs, and flora with the belief that locally derived herbs would be more appropriate for the treating of local diseases. This survey resulted in the publication of A Comprehensive Inventory of Local Korean Herbs (鄕藥集成方), which includes herbal preparation methods and acupuncture techniques and consists of 30 volumes and 85 chapters. In this text, herbs such as Dang Gui (Radix Angelicae Sinensis) and Shi Gao (Gypsum Fibrosum) from China and Korea, and in some cases Japan, were given different characteristics and functions depending on their country of origin. Following these developments came the Mirror of Eastern Medicine (東醫寶 鑑), its authorship attributed mainly to Heo Jun (1610). This 25-volume, several- thousand-page text offers detailed herbal and acupuncture approaches to numerous health conditions and is the most comprehensive source of medical knowledge written throughout Korean history. The Mirror of Eastern Medicine elaborates on the medical theories and prescriptions included in The Yellow Emperor’s Classic and teachings from the Qin and Yuan Dynasties of China. It contains, too, indigenous folk remedies, offering detailed descriptions regarding preparation, dosage, and usage. Among the numerous contributions made by doctors of Korean medicine, the text entitled Eastern Medical Perspectives on Longevity and Wellbeing, or Dongeui Susei Bowon (東醫壽世保元), written by Lee Je-ma (1837–1900), is perhaps the most distinctive. In this text, he reignites the classical Chinese medical emphasis on Yin and Yang theory while establishing an entirely new approach referred to as Sasang Constitutional Medicine, or Sasang Eui Hak (四象醫學). This method stands alone as being uniquely Korean in origin and yet deeply rooted in the Eastern classics such as the I Ching, Confucian Analects, Doctrine of the Mean, The Great Learning, Mencius, and the Shang Han Lun. It breaks away from the predominant Daoist theory of Wu Wei (無爲), which emphasizes man’s relationship with nature often at the cost of fulfilling one’s societal role, and delves into the realm of Confucian theory and philosophy, which accentuate the role of social interaction. Lee Je-ma’s text conveys how the Sasang approach is a medical system and philosophy in its own right. 10 Introduction A Translation of the Title A closer look at the title, Dongeui Susei Bowon, helps forge a deeper understanding of Lee Je-ma’s desire to establish his innovative form of medicine. The characters “Dong” (東) and “Eui” (醫) translate together as Eastern medicine. The character “Su” (壽) translates as “longevity.” Lee Je-ma was less concerned with the extension of life than with the quality of life. Yet he believed that the preservation of health will naturally lead to longer life. Hence the character for “Bo” (保) in the above title translates as “preservation.” Health preservation according to Lee Je-ma, as will soon be shown, depends on the ability to polish one’s inner self and fulfill one’s purpose in life. According to Sasang medicine, polishing one’s inner self can therefore be viewed as the source, or “Won” (元—the last character in the above title), of health and wellbeing. Finally, the third to last character, “Sei” (世), translates as spreading or cultivating, and refers to the action of promoting health and wellbeing in society through the above means. The Birth of Sasang Lee Je-ma derived the title Sasang from the I Ching, which states: “The Tai Qi gives rise to Yin and Yang, which in turn become the Sasang” (太極生兩儀, 兩儀生四象). The Tai Qi, translated as “Great Ultimate,” is a vast force that permeates all things and consists of two opposing energies referred to as Yin and Yang. In their pure and isolated form, each of these energies is without significance, since all phenomena consist of varying combinations of Yin and Yang engaged in a dance of life. These combinations, in their simplest form, are referred to as Sasang or “Four Symbols.” The Four Symbols are also referred to as Yin within Yin (Greater Yin), Yang within Yin (Lesser Yin), Yin within Yang (Lesser Yang), and Yang within Yang (Greater Yang). In Korean, the Four Symbols are pronounced Tae Eum (태음), So Eum (소음), So Yang (소양), and Tae Yang (태양). Lee Je-ma adapted these names for each of his four constitutions. He believed that these four combinations symbolize four fundamental differences between each person, which result from varying degrees of bodily Yin and Yang energy, where the Tae Yang (Greater Yang) type has the most abundant Yang and the Tae Eum (Greater Yin) type has the most substantial Yin energy. Furthermore, he equated the Four Symbols with the four major organ systems of the lungs, spleen, liver, and kidneys, and the heart with Tai Chi, since it feeds energy and blood to the entire body. Lee Je-ma’s Sasang theory was heavily influenced by the I Ching, as this text will make further apparent. Comparison between Chinese and Sasang Medicine There are as many similarities as there are differences between traditional Chinese and Sasang medicine. While the Sasang approach is a distinct medical system, it is still 11 The Essential Teachings of Sasang Medicine based on the same basic principles of Yin and Yang as traditional Chinese medicine. Without the influence of Chinese medicine, Sasang medicine would not exist. Lee Je-ma, in a sense, may therefore be considered a reformer of Chinese medicine, who examined hundreds of formulae and their herbal constituents, acknowledging their merits, criticizing their shortcomings, and adapting them to specific energetic patterns within each of the four constitutions. In situations that did not call for the use of a traditional formula, Lee Je-ma developed his own according to Sasang principles. Sasang medicine is born from Lee Je-ma’s dissatisfaction with the standard approach to medicine, emphasizing as it does the influence of external pathogens, as proposed by the most widely utilized medical text of his time, Zhang Zhongjing’s Shang Han Lun. He believed that all illness is directly related to one’s emotional wellbeing. Lee Je-ma repeatedly witnessed how the doctors of his time would often make matters worse by prescribing medicine based on symptomatic presentation rather than an imbalance of the four constitutional temperaments: sorrow, anger, joy, and calmness, which lead to imbalance of the organs. The Yellow Emperor’s Classic, the earliest known treatise in Chinese medicine, also mentions the influence of the Seven Emotional Disorders (joy, anger, worry, contemplation, sorrow, fear, and shock), but it aimed at addressing the Six Climatic Factors (Heat, Cold, Dryness, Dampness, Summer Heat, and Wind) and balancing one’s health according to the season. Hence in Chinese medicine, diseases caused by emotional imbalance were often considered difficult to treat and, although discussed, were not given precedence. Similar to Chinese medicine, Lee Je-ma classifies illness into two major categories: Exterior and Interior. Yet he explains how the etiology of Exterior and Interior illnesses differs according to each constitution and the state of mind. In Chinese medicine, Exterior disorders are principally associated with a pathogenic attack that, if powerful enough, could penetrate the immune system of an otherwise healthy person. Exterior disorders, according to Lee Je-ma, are due to an imbalance of one’s temperament, referred to as Song (性), while Interior disorders result from explosive and overwhelming emotion, called Jung (情). Sasang medicine focuses primarily on balancing the constitutionally specific Song nature and Jung emotions to enhance health and address illness—a task carried out through self-cultivation and, if necessary, herbal treatment. Lee Je-ma strongly believed that no matter how powerful a pathogenic influence may be, it would be no match against a balanced and cultivated heart and mind. The Dongeui Susei Bowon repeatedly gives credence to both Exterior pathogenic attack and Exterior syndromes, where the latter refers to an imbalance of the Song nature and the former, an external influence that takes advantage of the situation. Hence Lee Je-ma maintained that an imbalance of one’s Song nature is what provokes illness from an External pathogenic attack. 12 Introduction Each of the four constitutions in Sasang medicine is born with a stronger and a weaker organ system influenced by inherent emotional inclinations. A propensity for sorrow, for example, stimulates lung development in utero, while calmness stimulates the kidneys. Excessive sorrow, however, may over-stimulate and stagnate the lung energy. Sorrow in Sasang Medicine is negatively correlated with joy, the emotion of the liver. Hence excessive sorrow decreases joy, resulting in liver deficiency, and excessive joy (ecstasy) decreases sorrow, causing lung deficiency. Although organ excess and deficiency are a central aspect of the Five Yin and Six Fu Organ (五臟六腑) Theory in Chinese medicine, emotion is not considered the source of inherent organ strength or weakness. Instead, organ strength is affected by one’s Pre-Heaven energy within the kidneys transferred from parent to offspring. According to this principle, the health of the offspring depends primarily on the parents. Weakened Pre-Heaven energy causes insufficient development of the organs in utero. In Sasang medicine it is the parents’ emotional not physical health that primarily influences the organ development of their offspring. While organ theory plays a central role in both Chinese and Sasang medical diagnosis, each holds its own interpretation. In Sasang medicine, for example, each of the Four Major Organs is considered the governor of its own domain, controlling the function of other organs in its vicinity. Along with the Four Major Organs are the four sections of the body, referred to as Cho (焦). The Upper Cho is governed by the lungs and the emotion of sorrow, the Mid-Upper Cho is governed by the spleen and the emotion of anger, the Mid-Lower Cho by the liver and the emotion of joy, and the Lower Cho is governed by the kidneys and the emotion of calmness. Chinese medicine describes three Jiao (pronounced Cho in Korean). The Upper Jiao consists of the heart and lungs, Middle Jiao the stomach and spleen, and Lower Jiao the liver, small intestine, large intestine, and bladder. Although Chinese medicine associates each organ with an emotion, it doesn’t emphasize the role of emotions in controlling the function of their respective organs or the Jiao in which they are located. Table I.1: The Chinese medical organ system Yin organ Location Yang correlate Location Emotional correlate Lungs Upper Jiao Large intestine Lower Jiao Sorrow Heart Upper Jiao Small intestine Lower Jiao Anxiety Spleen Middle Jiao Stomach Middle Jiao Contemplation Liver Lower Jiao Gall bladder Lower Jiao Anger Kidney Lower Jiao Urinary bladder Lower Jiao Fear 13 The Essential Teachings of Sasang Medicine Table I.2: The Sasang medicine organ system Yin organ Location Yang correlate Location Emotional correlate Lungs Upper Jiao Esophagus Upper Jiao Sorrow Spleen Mid-Upper Jiao Stomach Mid-Upper Jiao Anger Liver Mid-Lower Jiao Small intestine Mid-Upper Jiao Joy Kidney Lower Jiao Large intestine and Lower Jiao Calmness/ urinary bladder complacency Lee Je-ma held that each Sasang constitution has its own specific group of herbs and formulae that promote the flow of Yin and Yang between the stronger and weaker organs. Herbs for the So Eum Individual, for example, promote upward Yang energy movement from their excessive kidneys to the deficient spleen, while the So Yang’s herbs promote downward Yin energy movement from their excessive spleen to the deficient kidneys. This illustrates how, in Sasang medicine, emphasis is placed on the flow of each herb from origin to destination (i.e. kidney to spleen, lung to liver). In Chinese medicine, even though most herbs are associated with one or more organs, emphasis is given to organ destination (kidney herbs, spleen herbs, etc.). The former approach accentuates a non-static, dynamic approach to herb function, emphasizing a fundamental bond between excessive and deficient organ energies. Most of the herbs in Sasang medicine are also used in Chinese medicine but often associated with different characteristics. In Lee Je-ma’s text Dongmu Yugo (Lee Je-ma’s Posthumous Treatise) he includes a comprehensive list of herbs utilized in Sasang medicine, categorizing them by taste, temperature, and function. In general, he incorporates the Chinese medical interpretation of the Five Flavors (Bitter, Acrid, Sweet, Salty, and Astringent) and temperature (Warm, Hot, Cool, Cold, and Neutral), but function and organ affiliation are interpreted according to Sasang standards. To illustrate, Lee Je-ma describes Da Huang (Radix et Rhizoma Rhei) as a herb that promotes the flow of lung energy and regulates bowel movement. Chinese medicine also associates this herb with bowel regulation, but not with lung function. In the Dongmu Yugo, Lee Je-ma categorizes Da Huang as a lung-affiliated herb that benefits the Tae Eum Individual, born with weaker lungs. He also describes Chuan Xiong (Radix Ligustici Chuanxiong) as a herb that benefits the spleen and promotes the release of pathogen from the Exterior, benefitting the So Eum Individual with External illness. Although its Exterior releasing function is the same in Chinese medicine, it does not associate Chuan Xiong with the spleen. 14 Introduction Table I.3: Herb affiliation in Sasang medicine Organ of primary affiliation Prescribed for the… lungs Tae Eum Individual, since they are born with weaker lung energy spleen So Eum Individual, since they are born with weaker spleen energy liver Tae Yang Individual, since they are born with weaker liver energy kidney So Yang Individual, since they are born with weaker kidney energy Sasang Constitutional Theory and the Four Humors The concept of four humors is deeply embedded in Western medical philosophy, serving as the dominant view of medicine up to the advent of modern science. This theory, promoted by the teachings of Hippocrates (c. 460–c. 370 bc) and Galen (129–201 ad), is dismissed by mainstream Western medicine, as it adheres to a physiological vs. metaphysical view of the human body. As far back as ancient Greece, the significance of four humors influenced which foods, exercises, and herbs were selected to improve health. Hippocrates himself claimed that it is more important to know the characteristics of the individual than the disease they present. He introduced the concept of four humors (blood, phlegm, yellow bile, and black bile) and the importance of balance between them. The four humors were later elaborated upon by Galen who associated them with psychological temperaments (blood-sanguine, black bile-melancholic, yellow bile- choleric, and phlegm-phlegmatic). This contribution was based on his belief that health depends on a balance of temperament and that disease resulted from an imbalance of humors, a concept referred to as dyscratia. Although they came from different backgrounds and traditions, Galen and Lee Je- ma both held the four constitutional concept as the main premise of their teachings. They also shared a belief that certain foods and herbs with different characteristic temperatures could facilitate or impede balance within the body. Galen prescribed Cold-natured herbs to treat Heat-related conditions (i.e. biliary disorders) and Hot- natured herbs to address Cold-related issues (i.e. phlegmatic disorders). Lee Je-ma also applies the principle of treating Cold conditions with Hot-natured herbs and Heat-related situations with Cold-natured herbs, but adds that each constitution benefits from different temperatures. The So Yang’s stronger spleen, for example, produces abundant Heat, while the So Eum’s stronger kidneys produce abundant Cold. Hence the So Yang’s illnesses are often Heat-related and are commonly addressed with Cold-natured herbs, while the So Eum’s are Cold-related and are addressed with Hot-natured herbs. 15