Pain Between One Breath and the Next

Doctor zhou January 12, 2023

The Buddha asked a monk: "How long is human life?" The monk replied: "Between a few days." The Buddha said: "You have not yet understood the Way." He asked another monk: "How long is human life?" The reply: "Between meals." The Buddha said: "You have not yet understood the Way." He asked a third monk: "How long is human life?" The reply: "Between one breath and the next." The Buddha said: "Excellent! You have understood the Way."

—— From The Sutra of Forty-Two Sections Spoken by the Buddha

Last Sunday afternoon, I finally managed to spare some time to cycle to Yujiao Country Park at the foot of Yuquan Mountain. This was my first outing for exercise since November 1, 2022. Since November last year, work had become busier day by day—the pandemic peak, the severe-illness peak—each peak pressing down until one could barely breathe.

On the park's lake and on the river outside, adults and children were everywhere skating and playing on the ice. For many people, life had returned to normal. The paper spirit money burned on the roadside was noticeably more than before, and many people had left the world forever this winter.

Hospitals were packed with patients; the number of severe cases was frightening. Many patients whose symptoms had been mild at the start of infection had let things slide and worsened, and were now arriving at hospitals one after another. A great many patients with mild pneumonia could not be hospitalized because of medical overload. Healthcare workers were mostly dragging exhausted bodies to work while ill. The patients' problems were thorny. Wherever we went, the sound of coughing rose and fell.

When one breath cannot connect to the next, another person has passed away. My father no longer lives in the village; he lives in the county town with my sister's family, so he does not know much about recent events in the village. He only knows that an elderly lymphoma patient in the village died yesterday. I mentioned this person in an earlier article; he was very optimistic, and on my last visit to the village I chatted with him about everyday matters in the fields. He had been lucky enough to escape the clutches of lymphoma, but in the end he could not withstand the blow of COVID.

Cancer patients are a high-risk group for COVID death. Many of the cancer patients I treat developed severe conditions after infection. We have watched over each other for years; at a time like this, I must stand guard over their lives. Any physician who abandons his patients at such a time and flees the battlefield will never again gain the trust of patients and their families.

I too long to rest, but whether from a sense of duty or from emotion, I cannot set aside my old patients and go off to live a carefree life. Even this one secret stroll in the park makes me feel guilty. In fact, along the way I was constantly being consulted; I had to stop again and again to answer questions from patients and their families.

I very much hope all this will return to normal soon, that I can once again cycle, grow vegetables, read, and play music in my spare time as before. But that wish may be hard to fulfill. Watching foreign healthcare workers going on strike one after another from exhaustion, I feel a deep sympathy. What they went through over the past three years, we too will go through for a long time to come. Just among this first wave of infected people, the 8% who developed pneumonia and then chronic respiratory disease are enough to keep doctors busy for several years.

These days I often think of two people: Zhang Zhongjing of the Han dynasty, and Li Dongyuan of the Jin-Yuan period.

Zhang Zhongjing lived during the Jian'an era, in the same age as Cao Cao, Cao Zhi, and Cao Pi—a time of turmoil and rampant plague. Of his clan of more than two hundred people, about two-thirds died of plague within ten years.

We can imagine what a terrible thing it would be if, in a small village of only two hundred people today, 130–140 people died within ten years.

Cao Cao and his two sons Cao Zhi and Cao Pi all left heart-rending descriptions of the plagues of that age.

Cao Cao wrote in Song of the Caoli: "White bones lie exposed on the wild; for a thousand li no cock crows. Of a hundred people only one survives; thinking of it breaks one's heart." This scene can only be described as utter catastrophe.

Cao Zhi wrote: "Every household has its dead; every room has its wailing. Some whole families perish; some entire clans are lost. Some say plague is the work of ghosts and spirits. Those who suffer it are all people in coarse cloth eating weeds, dwellers of thatched huts! As for the houses of the great, who feast from ding cauldrons and wear furs on furs, such victims are rare."

In Letter to Wu Zhi, Cao Pi, thinking of his departed friends, was equally sorrowful: "I have read through the writings of the gentlemen, wiping tears as I face them. I grieve for the departed, and think of myself…… In the past, Boya broke his strings after Zhong Ziqi died; Confucius overturned his sauce after Zi Lu died, grieving that a kindred spirit was so hard to meet and that his disciples could not be replaced. The gentlemen, though not equal to my old friends, were talents of their age. Those who remain today can no longer match them. The young are to be feared; those to come cannot be dismissed. Yet I fear you and I will not live to see them."

Wang Can (Zhongxuan), one of the Seven Masters of the Jian'an period, wrote in Seven Sorrows: "I went out the gate and saw nothing but white bones covering the plain. On the road a starving woman held her child and abandoned it in the grass. She turned at its crying, wiped her tears, and did not return. 'I do not know where my own death shall be; how can we two both survive?' I whipped my horse and rode away, unable to hear these words. To the south I climbed the slope of Baling and looked back at Chang'an. Understanding the poet of Xia Quan, I sighed until my heart broke."

We can see how severe the plague was; this decade of plague deeply moved Zhang Zhongjing. "Mourning the loss of those who had gone before, grieving that premature death could not be rescued," he reflected deeply and wrote his clinical experience into a medical classic—Shanghan Lun (Treatise on Cold Damage), one of the Four Great Classics that every later TCM student must read. Astonishingly, the formulas recorded in Shanghan Lun have again played a huge role in today's plague; we have used these formulas to solve many patients' problems.

Li Dongyuan lived in the era when the Song, Jin, and Yuan warred against one another; that age mixed warfare and plague, and living beings suffered. The horrors Li Dongyuan witnessed were no less than those Zhang Zhongjing heard and saw.

In his book Discrimination of Internal and External Injuries, Li Dongyuan wrote: "In the ren-chen year (1232 CE), the capital was placed under martial law. By the third ten-day period of the third month, the enemy had been besieging us for half a month. After the siege was lifted, of the capital's inhabitants not one or two in ten thousand escaped illness. Those who fell ill and died followed one after another without end. At each of the capital's twelve gates, the number of corpses taken out daily was at most two thousand and at least a thousand, and this continued for three months."

The plague Li Dongyuan described is the famous Kaifeng Great Plague in history. The History of Jin, Annals of Emperor Aizong, records it: "A great plague in Kaifeng lasted fifty days; more than 900,000 corpses were carried out through the various gates, and those too poor to be buried are not counted."

More than a million people died in just one city, the capital Kaifeng; in the whole capital, not one or two in ten thousand escaped illness. We can see that this plague was far more severe than the COVID we face today.

Li Dongyuan too reflected deeply, organized his clinical experience, and wrote Discrimination of Internal and External Injuries. Many of the formulas recorded in that book were created by himself; these formulas can also play a great role in rescuing long-COVID patients.

One could say: the formulas of Shanghan Lun greatly help patients during the infection phase, while the formulas of Discrimination of Internal and External Injuries greatly help long-COVID patients who survived the pandemic but are left with many sequelae.

This is not surprising. What Zhang Zhongjing recorded was mainly the experience of rescuing patients during the infection phase; what Li Dongyuan recorded was mainly the experience of helping survivors in the capital recover after the plague. The two have different emphases.

Both Zhang Zhongjing and Li Dongyuan were great clinicians who grew up in an age of plague; both were outstanding physicians. Their practical experience was gained on countless patients; experience is produced in the process of solving problems. Without plague, without the clinical opportunities brought by large numbers of patients, such great medical classics could not have been created.

Plague is an enormous trial for physicians; the problems we face are almost all new. Every plague catches us off guard; the number of patients rises to a level unbearable for healthcare workers. Many doctors die in plagues or are left with serious chronic illness.

The father of Zhao Shaoqin, a great modern master of warm-disease medicine, was Dr. Zhao Wenkui, who in his lifetime was the last director of the Imperial Medical Academy in the Qing dynasty (equivalent to today's head of the National Health Commission); he literally worked himself to death treating patients during a plague.

Whether Zhang Zhongjing himself fell ill from overwork during the plague, we do not know; I lean toward thinking he was one of the lucky ones without sequelae. Li Dongyuan, on the other hand, definitely did. In his Pi Wei Lun (Treatise on the Spleen and Stomach), in the section "Keeping Away from Desire," he wrote: "This remnant body is sixty-five; ears and eyes half fail to hear and see; the hundred vessels seethe and trouble the heart; the body drifts as on a hundred currents; when I close my eyes the soul departs like a wave; spirit-qi has declined from days before." Reading this passage, one cannot help but grieve; Li Dongyuan was deeply depressed in his later years.

In the "Regimen" section of Pi Wei Lun he wrote: "If clothing is thin and breath becomes short, add clothes and stay in a windless place. If breath is still short, steam the nose and mouth with a bowl of boiling water, and it will no longer be short."

Putting these two passages together, we can easily guess that Li Dongyuan's later years were tormented by chronic respiratory disease: frequent shortness of breath, fatigue, tinnitus, deafness, and head ringing, even needing to steam his nose and mouth with boiling hot water to relieve breathing difficulty.

Steaming the nose and mouth with boiling water may be the earliest record of nebulization therapy in human medical history; this was likely a method Li Dongyuan himself derived from his long struggle with stubborn illness. In the Kaifeng Great Plague he was left with sequelae and also fell ill from overwork due to the sheer number of patients, so that by only sixty-five he was so weak, and spent his entire later years tormented by illness.

The shortcomings of Li Dongyuan's doctrine are also visible in these two passages. From Li Dongyuan's own symptoms, he had unresolved lung qi and lung dryness throughout his later years; why could he not solve this? Later critics said he overused warm-drying herbs, leading to lung yin deficiency; this has some truth.

The Ming physician Wang Qishi, in his Principles of Regulating Exhaustion, proposed that deficiency-exhaustion diseases should be treated by simultaneously addressing the lung, spleen, and kidney. Thus, while fortifying the spleen and kidney, he often used sweet and cold yin-nourishing herbs such as Maidong and Tiandong to supplement lung yin and moisten lung dryness; his doctrine went a step further than Li Dongyuan's.

Plague is a heavy topic. Humans live on Earth and have repeatedly fought plagues; we have never truly defeated microorganisms. Again and again, humans have paid a terrible price, and each plague ends in cruel death and injury.

Darwin's law of natural selection and survival of the fittest is both realistic and cruel. Each wave of plague eliminates a group of people; the survivors too are tormented by sequelae. This continues until, through generations or even dozens of generations of evolution, we use the power of nature to find the optimal solution and gradually develop adaptation to the new pathogen.

In the human gene pool, more than a thousand genes are viral fragments. This means we have been attacked by viruses at least a thousand times, and in the end those viruses remade our genome. We also domesticated viruses, ultimately truly coexisting with them, the two becoming one, each within the other. The COVID virus too will leave similar traces in our genome. The famous microbiologist Pasteur once said that everything is decided by microorganisms; our power in the face of microorganisms is limited.

Humans living on this planet: being ill is the norm, being well is the rarity; we must learn to coexist with disease. I have coexisted with chronic respiratory disease for more than twenty years. In my first year of high school I had pneumonia, and ever since, I cough whenever I become tired.

About 15% of people worldwide have a story similar to mine; we spend our whole lives tormented by cough and wheezing that cannot be cured. We can only find ways to adapt to it, coexist with it, and avoid letting it affect our lives and emotions.

Without a doubt, while COVID kills one group of people, it will add another group to our camp of chronic cough-and-wheezing patients, who will say goodbye forever to free and unobstructed breathing.

I have gradually accepted reality and adapted to chronic cough and wheezing, relieving it through exercise, rest, and simple heat therapies—just as Li Dongyuan often steamed his nose and mouth with boiling water.

Long illness makes a good physician; every chronic respiratory patient may eventually work out his own regimen. Some of them will even, like me, take up the study and practice of medicine because of illness, saving themselves while also saving others.

Slowly learn to face it, accept it, solve it, and when it cannot be fully solved, let it go—thorny problems can usually only be partly solved; do not pursue perfection. Life is an imperfect existence.

I hope that in the face of disease we can still live out our lives in the sunshine and enjoy life. After all, life happens only once and is precious; we should not be crushed by disease like this.

Believe me: the lung sits securely in the chest cavity, protected by bone and muscle; it is not so easy to cough it out. From my twenty-plus years of fighting cough and wheezing, as long as I avoid fatigue and wind-cold and keep up sweating exercise, there are many times when I cough not at all and am just like a normal person. Because I have kept up my regimen, I once went more than ten years without coughing much, to the point that I suspected I was cured.

After this peak passes, I will certainly ride my bicycle again, speeding through the countryside of Beijing, seeking my joy in nature. Or, with my clumsy skill on the qin, I will play Immortal Wielding the Tonal Pouch and Autumn Moon over the Han Palace for myself. A friend once said that if one learns music, the instrument one should learn is the guqin, because of all instruments it is almost purely for self-enjoyment—one need only please oneself, not please others.

What a wonderful phrase—"only please oneself, not please others." When we are entangled by illness and have not enough energy to spend, reducing unnecessary socializing lets us live more lightly; being alone also lets us concentrate better on our own work. Every loss also brings us some gain; as Laozi said: when the old man of the frontier lost his horse, who could have known it was a blessing in disguise?

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