Li Dongyuan: A Medical Great Master Forged in War and Plague
During the Jin-Yuan period in China, society was turbulent, with wars and plagues following one after another. The common people suffered terribly, illness was widespread, and the population dropped sharply. This particular historical period, however, also stimulated the development of medicine. Li Dongyuan, one of the Four Great Masters of the Jin-Yuan, was exactly the kind of medical great master who grew up in just such a social environment.Li Dongyuan was born in 1182 (the 23rd year of the Dading era of Emperor Shizong of Jin) and died in 1251 (the first year of the Mongol Xianzong era), at the age of 69. In the 150 years from 1213 to 1362, large-scale plagues erupted in China on fifteen occasions. In Li Dongyuan's lifetime, the Southern Song and the northern Jin stood opposed, and the Han, Jurchen, and Mongol peoples fought year after year. Plague combined with war caused countless deaths and injuries among the common people.In his work Discrimination of Internal and External Damage (Neiwaishang Bianhuo Lun), Li Dongyuan wrote: "Earlier, in the ren-chen year when the era was changed (1232 CE), the capital was placed under martial law. By the third ten-day period of the third month, the enemy had besieged us for half a month. After the siege was lifted, among the capital's residents not one in ten thousand escaped illness. Of those who fell ill, the dead followed one upon another without cease. At the capital's twelve gates, each gate sent out, on most days, two hundred corpses, and on the least, no fewer than one thousand; this went on for three months. How could these million people all have contracted wind-cold external damage? Generally, people in a besieged city suffer from irregular diet and from exhaustion and toil—this is plain to see. With hunger in the morning and overeating at night, irregular rest, and improper warmth and cold, often for two or three months, the stomach qi had long been depleted. Then, once they ate to excess, illness struck them down, and because treatment was improper, their death was beyond doubt. It was not only in Daliang; as far back as the Zhenyou and Xingding eras, places such as Dongping, Taiyuan, and Fengxiang—after their sieges were lifted, all saw people sicken and die in the same way."These words of Li Dongyuan faithfully record the suffering of the common people of that time under war and plague. The capital Bianliang was jointly besieged for three months by the Mongol army led by Tolui and the Song army. After the siege was lifted, nearly everyone in the capital fell ill, and the numbers who died of severe illness were beyond counting; over three months, the dead reached a million. The capital had ten gates, and each gate carried out a thousand or two thousand corpses every day, a sight that persisted for three months.Li Dongyuan believed these people did not die purely from externally contracted disease; he thought many died of damage to the spleen and stomach. His view has some merit: after the war broke out, the capital was under long lockdown; the next year Bianliang fell, and the common people could barely feed themselves, so damage to the spleen and stomach was certain.But the main reason so many people suffered and died in such a short time was the great epidemic recorded in history as the "Bianjing Great Plague." The History of Jin, in the Annals of Emperor Aizong, records this great plague: "In the great Bianjing plague, for fifty days, over nine hundred thousand dead were carried out through the various gates, and those too poor to be buried are not counted among this number." That is, the countable dead alone exceeded nine hundred thousand, and many more could not be buried for poverty. This figure is quite close to Li Dongyuan's account.Although Li Dongyuan had already achieved medical skill, he did not originally practice medicine for a living. His ancestors were wealthy merchants from Zhengding in Hebei, and the family was well-off; at that time the social status of physicians was very low, so Li Dongyuan was not content to be a doctor and hoped instead to make his career as a Confucian scholar. He even paid money to buy a post as a tax superintendent and served for a time as a tax superintendent in Jiyuan, Shandong.But war and plague struck Li Dongyuan a heavy blow, and he too was displaced. As early as when he was tax superintendent in Jiyuan, he witnessed the horrific death toll of an epidemic called "big-head plague" among the common people; grieving, he studied its treatment and created the famous formula "Puji Xiaodu Yin" (Universal Relief Detoxification Beverage), which is still widely used today and saved many lives.After the great Bianliang plague, Li Dongyuan took in large numbers of patients, and because of his outstanding clinical results his fame spread far and wide. In clinical practice he deeply experienced the harm that plague does to human life and health. This great plague was in fact an infectious disease that mainly attacked the respiratory tract. Li Dongyuan recorded the patients' main symptoms: "Among the people struck by the dry-heat qi, most develop fever, with phlegm binding and cough." That is, after contracting the illness, patients mostly had fever and cough, followed by sequelae such as indigestion and fatigue.Li Dongyuan himself says that the first draft of his Discrimination of Internal and External Damage was completed in 1231 CE, when he began taking in large numbers of patients and so had accumulated some clinical experience—though not yet rich experience, and his heavy clinical workload left him no heart for writing. Sixteen years later, in the ding-wei year, his clinical experience had grown richer, and at the urging of Fan Zun, a descendant of Fan Zhongyan (his teacher's family), he perfected this outstanding work while himself ill.Judging from Li Dongyuan's own practice, the Discrimination of Internal and External Damage can be regarded as an outstanding work on treating the sequelae of plague. After the great Bianjing plague, many people's stamina was greatly reduced; the doctors of the time treated these sequelae as externally contracted diseases, applying the TCM sweating, purging, and emetic methods, which left patients even weaker and some died rapidly after taking the medicine.Li Dongyuan believed these patients did not suffer from excess disease caused by external wind-cold, but from deficiency disease caused by internal damage. He therefore created the treatment principle of "expelling great heat with sweet-warm herbs," emphasizing warming and tonification. His first formula for treating these patients was "Buzhong Yiqi Tang" (the Middle-Tonifying and Qi-Boosting Decoction), a classic famous formula that profoundly influenced later medicine. To this day, Buzhong Yiqi Tang remains a must-learn classic formula for TCM students, and the patent medicine Buzhong Yiqi Wan is widely used to treat the fatigue and listlessness caused by various chronic diseases.In the Discrimination of Internal and External Damage, Li Dongyuan explains in detail the combinatorial logic of Buzhong Yiqi Tang and sets out how to modify the herbs according to the patient's clinical symptoms. If in the past we did not fully grasp this book of Li Dongyuan's, I think the Omicron variant that is about to spread widely in China will make us look at this outstanding work in a new light. Fatigue, brain fog, cough, depression, insomnia, and the various other symptoms of long COVID are all recorded in this book, and Li Dongyuan also provides solutions.The medical burden caused by long COVID will gradually become apparent over the coming years, and the state will surely invest human and material resources into studying integrated Chinese-Western methods for treating long COVID. Although the great Bianjing plague was not caused by today's COVID virus, its clinical symptoms and sequelae are quite similar to those of COVID and its aftereffects. TCM has always emphasized treatment based on pattern differentiation—this is in essence symptomatic treatment. So studying Li Dongyuan's works may bring us much insight.