Abstract
Sasang constitutional medicine (SCM) is a holistic typological constitution medicine which balances psychological, social, and physical aspects of an individual to achieve wellness and increase longevity. SCM has the qualities of preventative medicine, as it emphasizes daily health management based on constitutionally differentiated regimens and self-cultivation of the mind and body. This review's goal is to establish a fundamental understanding of SCM and to provide a foundation for further study. It compares the similarities and differences of philosophical origins, perspectives on the mind (heart), typological systems, pathology, and therapeutics between SCM and traditional Chinese medicine (TCM). TCM is based on the Taoist view of the universe and humanity. The health and longevity of an individual depends on a harmonious relationship with the universe. On the other hand, SCM is based on the Confucian view of the universe and humanity. SCM focuses on the influence of human affairs on the psyche, physiology, and pathology.
1. Introduction
Interest in the use of complementary and alternative medicines (CAM) as alternatives to conventional Western treatments is increasing worldwide. The 2002 WHO West Pacific Region survey reported that 90%, 69%, 49%, and 45% of individuals in China, Korea, Japan, and Singapore, respectively, used traditional methods in personal medical care [1]. In the USA, an individual’s CAM usage level including spiritual therapies increased from 33.8% in 1990 to 42.1% in 1997 and to 62.1% in 2002 [2]. In Europe, CAM treatment is common protocol for cancer patients, with over a third of the entire population reported using CAM methods, including herbal medication, homeopathy, and vitamin and mineral supplements [3]. In Europe, as in Asia, the range of CAM utilization varies from country to country, whereas approximately 15% of the population of Greece utilizes CAM, nearly 75% of the population of Italy uses CAM [3].
Of medical traditions categorized as CAM, traditional chinese Medicine (TCM) is prominently recognized. Yet, TCM is only one of numerous CAM modalities being utilized worldwide. Other significant medical traditions such as Sasang constitutional medicine (SCM) from Korea, Ayurveda from India, traditional Mongolian medicine, and traditional Vietnamese medicine are noteworthy. Sasang constitutional medicine is a unique system of medical constitutional typology that was developed towards the end of the 19th century by the Korean physician Lee Jema (1837–1900), whose life work is concisely summarized in two manuscripts, “Dongeuisoosebowon (Longevity and Life Preservation in Eastern Medicine)” and “Gyeokchigo (Manuscript on Science).” In these works, Lee Jema delineates a medical constitutional typology which identifies an individual as one of the following four constitutional types: a Taeyang person, a Taeeum person, a Soyang person, or a Soeum person [61]. Contemporary applications for the field’s rich tradition are being expanded extensively through research and development. Researchers are studying methods of diagnosis [62], conducting randomized clinical trials of constitutional acupuncture [63], and exploring approaches integrating western genetics into the eastern SCM framework [12].
Generally, over the course of world medical history, both eastern and western medical practitioners have been aware of or have used constitutional categorization as a tool to understand disease. Today practitioners prefer a standardized diagnostic approach which by principle assumes all individuals identical. Yet, awareness of unique constitutional characteristics is conducive to the prevention of disease, increasing effectiveness of treatment as well as decreasing adverse reactions to pharmaceuticals. For example, each individual’s constitutional make-up determines weaknesses and strengths with respect to a hypoactive or hyperactive internal organ scheme, pathological developments, and an individual’s reactions to herbal medicines. Disease prevention and health preservation regimens, therapeutic principles, and medicinal protocol are modified and personalized according to the individual’s constitutional characteristics to provide the best health management. A well-developed system of constitutional typology will have medical benefits [62].
2. Methods
2.1. Search Strategy and Data Sources
The objective is to present a comprehensive introductory understanding of SCM. For this purpose, we reviewed the difference between TCM and SCM comparing medical philosophy, perspectives on the mind (heart), typological systems, pathology, and therapeutics of TCM and SCM. The following electronic databases were searched: Pubmed (http://www.pubmed.org/), DBPIA (http://www.dbpia.co.kr/), Research Information Service System (RISS, http://www.riss4u.net/), and Korean Studies Information Service System (KISS, http://kiss.kstudy.com/). Search terms were Korean and English words relevant to Sasang typology such as Sasang typology, constitution, and Sasang medicine. In addition, we manually searched five Korean traditional oriental medical journals (Journal of Sasang Constitutional Medicine, Journal of Oriental Medicine, Korean Journal of Oriental Physiology & Pathology, The Korean Society of Oriental Medical Classics, and The Journal of Korean Oriental Internal Medicine (searched from their first publication date through December 2009)). To ensure accuracy, TCM and SCM primary source classical literature was also searched.
2.2. Article Selection and Data Extraction
2.2.1. Article Selection
Peer-reviewed research articles on review papers and literature pertaining to medical philosophy, perspectives on the mind (heart), typological systems, pathology, and therapeutics were included. Articles that provided only clinical analysis, basic science, clinical case studies, translated text(s) or commentary on the history of SCM and Lee Jema, and constitutional symptoms or pharmacology of prescriptions were excluded.
2.2.2. Data Extraction
All articles were reviewed by two independent reviewers (Hyensu Jang and Jiwon Lee), and data from the articles were extracted according to the predefined criteria. Information pertaining to medical philosophy, perspective on the mind (heart), typological system, pathology, and therapeutics was collected.
3. Results
The search identified 954 potentially relevant articles. Seven hundred seventy-seven studies which were clearly irrelevant titles or duplicates were excluded. The majority of the excluded studies did not incorporate theoretical Sasang typology in their research question. One hundred seventy-seven remaining studies’ abstracts were reviewed. Of those studies, 107 were excluded according to the exclusion criteria. Hard copies of 70 articles were obtained and read in full. After a full text review, a total of 50 studies were included in the current review (Figure 1).
3.1. Philosophy: Nature-Centered TCM Based on the Yin-Yang Theory and Five-Phase Theory, and Human-Centered SCM Based on the Sasang Theory
Complex scientific and philosophical concepts are the foundation for many medical traditions. TCM is rooted in the Taoist view of nature and humanity introduced in the ancient Chinese manuscript, Huangdi’s Internal Classic [6, 7]. The Yin-Yang theory and Five-Phase theory [8, 30] are fundamental principles of Taoism and are the theories from which TCM developed. SCM’s development was influenced by most of the same philosophical theories as TCM. Yet, SCM can be distinguished as a separate medical system because SCM emphasizes and innovates upon certain principles and aspects of shared East Asian philosophies.
TCM is based on central philosophical concepts. First, it perceives qi as the basic substance of the universe [15, 16]. Second, TCM is focused on the physical universe and its nature rather than on humanity or human nature [8]. Third, it states that the nature of the universe changes constantly. These changes are governed by the Yin-Yang theory and the Five-Phase theory; therefore, changes can be observed and predicted [16]. Fourth, an individual’s health and longevity is determined by their conformity to nature [29]. In other words, the Taoist idea of wu wei (letting it be) is central to TCM treatment principles and preventive medicine (Table 1) [30].
SCM, first introduced in Dongeuisoosebowon, is fundamentally based on the Neo-Confucian views of nature and humanity. The theoretical rationale supporting SCM is derived from Sasang philosophy [4, 5, 9–11, 13]. Sasang philosophy adheres to the following concepts. First, SCM emphasizes the importance of humans and humanity over the importance of nature [8, 19]. Humans exist independent from nature and are influenced by two factors, their social environment and human affairs, which comprise of matters concerning self and others [8, 29]. Second, SCM is fundamentally grounded on the Sasang philosophy, which perceives that all phenomenon and all matter of the universe including humans can be classified on a four-axis schema (Sasang) of which one of the axis is activity, mind, body, or matter (AMBM) [20, 21]. Sasang theory initially separates human beings into two aspects: the mind and the body. The mind is subdivided into four concepts. The mind aspect focuses on sorrow, anger, joy, and pleasure, which as singular concept is defined as the Seong-Jeong (Innate Nature-emotional disposition). The body is subdivided into four regions. The body is divided into the lung, spleen, liver, and kidney systems. This SCM organ scheme theory forms the outline for human physiology based on this four-point scheme of the Sasang theory [22–26, 28]. Third, SCM takes individual variability into account. The mental and physical characteristics of an individual can manifest on the broadest level in four different ways. Highlighting physical characteristics as an example, the human body has a predetermined congenital four-organ systems that control the functional balance of physiology and pathology [8, 15, 17]. Fourth, SCM strives to preserve health and longevity through constitutional management. For example, SCM advocates lifestyle and behavioral changes. Thus, SCM extends beyond simple medical methodology. It emphasizes the importance of self-cultivation, health preservation, and disease prevention, the key to which can be found in lifestyles compatible with a given constitutional makeup [19, 29, 31, 32].
3.2. Mind (Heart): The Heart as One of the Five Viscera in TCM and the Heart as the Mental Body Controlling the Physical Body in SCM
In TCM, the heart is one of the five zang viscera representing the fire element. According to TCM theory, the heart is positioned in the thorax and connected to the small intestine via the meridian and collateral in what is termed the internal-external relationship. The term heart is used to designate the general outward manifestation of internal vital activities in the broader sense or the human consciousness associated with spiritual activity and cogitative processes in the narrower sense [33]. The concept of the heart carries a different multifaceted connotation in SCM.
First, the heart (mind) governs the entire body, as the mental aspect that controls the physical aspect [19, 20, 34]. The heart (mind) functionally supervises the body by coordinating and controlling the body’s physical system composition and function [19]. Furthermore, from the SCM perspective, the heart (mind) embodies many different associations. The Taiji-associated mind can be understood as the overall fundamental force that controls all things [13, 35–38, 41]. Through the Yin-Yang association, the mind can be understood as the mental aspect as opposed to the physical aspect. For example, the mental aspect can refer to the virtuous mind defined as the quaternary set of values: benevolence, righteousness, propriety, and wisdom; as opposed to the physical aspect such as selfish desires exemplified by a quaternary set of characteristics: crudeness, superficiality, greed, and indolence. Finally, in the Sasang association, the mind represents the mind axis of the AMBM scheme in the Sasang philosophy (Table 2) [20].
Secondly, while physical functions are carried out through the four physical organs of the lungs, spleen, liver, and kidneys, the mental functions manifest through the four mental components of sorrow, anger, joy, and pleasure (the Seong-Jeong). Lee Jema compartmentalized the mind into Seong (Innate Nature) and Jeong (emotional disposition), each of which manifests in four different forms, namely, sorrow, anger, joy, and pleasure [17, 19, 35].
Thirdly, variations in Seong-Jeong arise due to the infinitely unique combinations and permutations of human affairs and interactions. An individual’s goal is to remain balanced through all circumstances internally and externally. Excessive deviation will exert physical damage on the body as a major contributing cause of pathogenesis [19, 42, 43].
3.3. Typology: Pattern Typing in TCM and Constitutional Typing in SCM
Constitution can be defined as “the aggregate of physical attributes and functional characteristics that is comprehensively forged by hereditary determinants and environmental factors” [17, 61]. Though the definition of constitution can vary from person to person, constitutional typing itself had been met with great interest and attention in medical circles, especially in TCM and SCM. Zhang Zhongjing (150–219), a renowned TCM physician, had categorized individuals into Yang-organ types and Yin viscous types. Kuang Tiaoyuan (since 1931 present), another TCM physician, developed a typological system that placed individuals into one of six somatotype categories (normal, dark and stringent, congestive and stagnant, dry and ruddy, slow and cold, and languid and shiny) depending on prominent clinical features [44]. Typology has been used as a tool not only in the past, but currently in fields related to human behavior such as psychology and anthropology.
A TCM typology system was first introduced in Huangdi’s Internal Classics, which was presumably compiled in the 3rd century BC. Its second book in the two-volume collection, Lingshu (Spiritual Pivot), contains material relevant to a pattern typology, including the theory of the Five Body Types (based on the Yin-Yang theory) and the theory of the Twenty-five Body Types (based on the Five-Phase theory) [30]. Lingshu also mentions morphological attributes of the five viscera and the six bowels in reference to physiology and pathology. Therefore, TCM typology is essentially a typological pattern system that groups similar symptoms into specific pattern types (Table 3).
In contrast to TCM, SCM has a philosophical basis that explains the composition and movements of the universe through the AMBM schema and interprets the natural, social, and physical phenomena from a human-centered perspective. When applied to medicine, this Sasang philosophy compartmentalizes humans into two aspects—the mind (heart) and the body (lung, spleen, liver, and kidney). The functional strength and weakness of the organ systems are the physical aspect, and the natural state of the mind that manifests as four constitutional variations is the mental aspect. In other words, the physiology and pathology of the organ systems (lung, spleen, liver, and kidney systems) and the core principle Seong-Jeong (sorrow, anger, joy, and pleasure) are congenitally influenced differently for different constitutional types. Therefore, four constitutional types, Taeyang person, Soyang person, Taeeum person, and Soeum person, in SCM stem from variations of the aforementioned four physical and four mental differentiations. Indeed, SCM explains the constitutionally unique attributes (including physiology and pathology) and uses the same rationale to apply differentiated therapeutics to different constitutional types (Table 4) [13, 17].
3.4. Pathology: TCM Pathology Based on the Meridian and Collateral Theory and the Visceral Manifestation Theory, and SCM Pathology Based on the Fourfold Energizer Center Theory and the Four-Energy-Center Theory
In TCM, the causes of diseases are generally identified as external etiology or internal etiology. The theoretical basis for TCM pathology can be summarized by the meridian and collateral meridian theory, which is based on the twelve meridians and collaterals, and the visceral manifestation theory, which is based on the internal and external organs [30, 39]. TCM pathology has certain features that distinguish it from SCM pathology. TCM and SCM have different perspectives concerning the internal or external nature of the disease at the site of pathogenesis. The first feature is that pathological conditions occurring in the meridian and collateral meridian are generally understood to be external, whereas those occurring in the organ systems are considered to be internal [33]. Second, when describing the characteristics of the pathological condition, diseases of the meridian and collaterals are referred to in terms of heat or cold-related pathology, and diseases of the viscera and bowels are defined as excessive or deficient [30, 51]. Third, the diagnosis is dependent on the eight principles, namely, the exterior, interior, yin, yang, cold, heat, excess, and deficiency determinants. The eight principles are used as tools for the four examinations process. Both traditional Chinese and Korean diagnosis begins with the four inspections: observing, listening, smelling/tasting, and palpating/pulse taking. Finally, through inductive analysis of the data, the practitioner determines the pathological condition using the eight principles as diagnostic terminology [14, 33, 55].
SCM maintains a different outlook on the cause of illness. TCM emphasizes its five-organ theory while SCM emphasizes its four-organ theory [13, 17]. According to SCM pathogenesis, illnesses arise from a disruption of balance between the larger hyperactive and smaller hypoactive organ systems, schematically speaking. Lee Jema explained that Sasang pathological syndromes are caused by variations in the qi that arise from the inherent differences in the sizes of the internal organs and the imbalance of the rising and descending qi of the Seong-Jeong. Furthermore, in SCM, the mind aspect must be taken into account when examining pathogenesis. An emotional disruption of the Seong-Jeong physiological impacts the fourfold energizer centers, thus disrupting the proper larger hyperactive and smaller hypoactive four-organ-system scheme of the fourfold energizer centers resulting in pathogenesis [11, 39, 40, 46–50]. Second, the external-internal properties are determined by frontal/dorsal, upper/lower, and inner/outer qualities. The internal organs are assigned to the dorsal side, and pathological conditions associated with this site are recognized as external. Conversely, the external organs are assigned to the frontal side and pathological conditions associated with this site are recognized as internal [34, 40, 51]. Third, physical metabolism is bifurcated into Qi-Humor metabolism and Water-Food metabolism. The lungs and liver are associated with Qi-Humor metabolism, with the lung being the dispersive force of the body responsible for expiration, and the liver the convergent force of the body responsible for inspiration. The spleen and kidneys are involved in the Water-Food metabolism, with the spleen being the ascending body and the kidneys being the descending body. Therefore, given the corresponding organs, Qi-Humor metabolism pathology is common in a Taeyang person or a Taeeum person, whose organ functions rely on the balance between the lungs and the liver system. Water-Food metabolism pathology is common in a Soyang person or a Soeum person, whose organ functions rely on the balance between the spleen and the kidneys [19, 45, 46]. Fourth, SCM eight principles are exterior/interior, yin/yang, ascending/descending, and dispersive/convergent determinants. In SCM, a patient is scanned for signs and symptoms that suggest disharmonies in the ascent/descent or dispersion/convergence processes of the yin or yang energies in the external or internal systems (Table 5) [15, 17, 52].
3.5. Therapeutics: Fortifying Healthy Qi and Eliminating Pathologic Qi in TCM, and Regulating the Mind to Control Disease in SCM
Since approaches and perspectives to pathology differ, TCM and SCM use different treatment methods and therapeutic principles. For example, SCM therapeutics is not centered on fortification or reductions, which are important concepts in TCM. TCM explanations of pathology revolve around the eight principles: exterior/interior, yin/yang, cold/heat, and deficiency/excess. In TCM, excess and deficiency factor is most significant. Deficient healthy qi or excessive pathogenic qi can both cause pathogenesis. Following the same rationale, therapeutic methods most often take the form of fortification of a deficient condition or reduction of an excess condition [30].
However, according to SCM, the primary cause of disease lies in an innate imbalance between the functional strengths of the organ structures, the default schematic setting of which is congenitally different among different constitutional types [8, 53]. The goal of therapy is to restore the original constitutional balance [34, 56, 57]. After the energy levels of the organ systems are balanced, the deficiency or excess are easily regulated, which is why SCM does not necessarily stress fortification or reduction in its herb prescription and therapeutic techniques. SCM combines all disease symptoms and indicators into a comprehensive set within the framework of a constitution to manage an individual’s health, to develop the basis for treatment, and to prevent disease.
Imbalances in both the body and mind are another primary factor that instigates the loss of health. SCM does not limit therapy to externally caused diseases or rely solely on herbal medication as its therapeutic method. Compared to other CAM modalities, it emphasizes the therapeutic significance of psychological factors; therefore, its techniques are designed to control and contain joy, anger, sorrow, pleasure, love, hate, and desire. In other words, the mind is controlled to regulate the illness manifesting symptomatically in the body [12, 17, 58, 59]. Regulation is possible through interaction with others and rectification of self, which enables the mind to regulate illness [18].
Although it is important to regulate one’s self since this is not always possible, Lee Jema also developed intricate prescriptions to help each constitution with naturally weak areas prone to imbalance and disease. When applying acupuncture and herbal prescriptions, the primary therapeutic goal is to balance one's healthy energy. Therefore, SCM herbs are used for regulating and balancing the healthy qi of the body whereas TCM methods emphasize tonifying and sedating according to strengths of the pathogenic qi and the healthy qi [8, 27].
Furthermore, Lee Jema provided several examples of the limitations of TCM therapeutics, especially when addressing Taeeum persons and Taeyang persons pathologies [19]. While treating patients of the Soyang type and Soeum type, Lee Jema found that many TCM approaches effectively addressed concerns. However, TCM therapeutics and herb prescriptions delivered minimal results for the Taeeum person and Taeyang person types. Lee Jema created new therapeutics and prescriptions for individuals of this constitutional type.
Finally, SCM shares the same vision as tailored medicine. Individuals are cared for with individualized treatment plans, which takes into complete account their unique health factors. SCM also promotes individualized self-regulation as a preventative measure for that individual’s specific susceptible high risk chronic diseases. For example, the natural limitations of an individual due to the hypoactive “small” visceral organ should regulate given situation through specific constitutional medication, diet, physical training, and psychological caution (Table 6) [13, 60, 64].
4. Discussion and Conclusions
TCM and SCM are medical traditions originating from oriental philosophical perspectives. TCM is based on the Taoist views of the universe and humanity introduced in Huangdi’s Internal Classic. Briefly, qi are the basic substance of the universe, and the generation, degeneration, variation, and operation of qi is governed by the Law of Yin-Yang and the Five-Phase theory. Thus, the healthiness and longevity of an individual, a microcosm of universe, depends on a harmonious relationship with the universe, the macrocosm. SCM is based on the Neo-Confucian views of the universe and humanity introduced in Dongeuisoosebowon. Neo-Confucianism also played an important role in the development of TCM as well. The work of the Yuan dynasty physician Zhu Danxi (1280–1358) is often cited as a typical example of Neo-Confucianism influencing TCM. His medical writings state that emotions are a key factor in the causation of illness, Yet, he did not further develop a pathophysiology and typological system from his understanding of emotions as a key factor in the causation of illness [13, 18].
The fundamental concepts of SCM include both emotional and physical aspects. The emotional and physical factors are integrated to the extent that the concept of “heart” and “mind” are viewed as nearly being synonymous. The concept of the mind (heart) is distinctly different in SCM and TCM. In TCM, the heart is one of the internal organs representing the fire element. In SCM, the mind (heart) governs the entire body, which suggests that the mental component controls the physical component. The mind is compartmentalized into the Seong and the Jeong that manifests in four forms, sorrow, anger, joy, and pleasure. In SCM, the primary cause of illness is disruptions to the Seong-Jeong (Innate Nature and emotional disposition) of sorrow, anger, joy, and pleasure that arise from human interactions and self-control. SCM emphasizes preservation of health through daily health management based on constitutionally differentiated regimens. Additionally, SCM has qualities of preventive medicine through emphasis of patient-centered self-cultivation of the mind and body.
In TCM, individual unique characteristics are explained by a pattern typology, which is categorized by somatotype, disposition, symptomology, and pathology according to outward similarities. Conversely, in SCM, individual unique characteristics are explained by a systemic typology that combines somatotype, disposition, symptomology, physiology, pathology, therapeutics, and prevention into a comprehensive picture based on the constitutional differentiations of each individual. For this reason, the TCM typology is a pattern typology, whereas the SCM typology is defined as a constitutional typology. Overall, SCM is a well-developed and comprehensive system of constitutional typology that explains the distinct constitutional qualities of each constitutional type, including the physical form, mental disposition, physiology, pathology, symptomology, diagnostics, therapeutics, and preservative methods, with a consistent rationale.
TCM established the “Differentiation of the Syndrome Theory” and analyzed each symptom, classifying it into symptomatic types. If patients with the similar dominant complaint showed different symptomatic types, they were treated with different therapies. Although traditional Korean medicine was influenced by TCM in many aspects, it progressively developed a unique constitutional view that mind and body are inseparable and the physical state of the human body can be remarkably changed by mental factors. This belief of traditional Korean medicine led to SCM in the latter half of the nineteenth century [34].
TCM pathology is based on the meridian and collateral meridian theory, which is related to the twelve meridians and fifteen collaterals, and the visceral manifestation theory, which is related to the five viscera and the six bowels. Diagnostics begin with the four examinations, after which clinical data is inductively analyzed before proceeding to the eight principles. The eight principles is then used to determine the therapeutic principle and method. The SCM pathology is based on disruptions of the fourfold energizer centers arising from deviations of Seong-Jeong. The fourfold energizer centers house the four organ systems, which each has a correspondence system including the internal and external organs carrying out vital metabolic processes. In the SCM, there are two metabolic systems, the Qi-Humor metabolism, which is controlled by the lungs and the liver, and the Water-Food metabolism, which is controlled by the spleen and the kidneys.
TCM therapeutics is based on fortification of the healthy qi and elimination of the pathological qi. On the other hand, the SCM therapeutics is designed to regulate the mind to control the illness. In SCM, interacting with others and rectifying oneself allows the Seong-Jeong of sorrow, anger, joy, and pleasure to be controlled and contained through self-cultivation, which enables regulation of the mind to regulate the body.
When the current study reviewed the differences between the TCM and the SCM, it included all peer-reviewed articles and included only information relevant to the objectives of the study. Future reviews should be conducted to systematically organize SCM beyond an introductory level. In addition, we could not provide enough solid peer-reviewed references for the claims in SCM not to mention the TCM. We hope that interest in SCM stimulates more studies addressing areas that have not been peer reviewed.
Acknowledgment
This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2009-351-E00040).