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TCM Treatments of COVID-19

Written in Chinese by Dr. Andy Lee, March 7, 2020 (http://andylee.pro/wp/?p=7660)

Translated to English by Dr. James Yeh, March 13, 2020

I published an essay “From SARS to Novel Coronavirus” in Chinese on January 21, 2020 (http://andylee.pro/wp/?p=7169). At that time, I tried to discuss possible Traditional Chinese Medicine (TCM) treatments of Novel Coronavirus based on my clinical experience of treating many severe cases of pneumonia caused by various influenza and other diseases. Since then, I have directly and indirectly participated in treating patients of Novel Coronavirus successfully, had discussions with many doctors fighting the epidemic at the front line and many researchers conducting related researches, and read many reports on this subject. Although the “Novel Coronavirus Pneumonia” has been renamed to “COVID-19” (coronavirus disease 2019) and the name of the virus has officially named from “2019-nCoV” to “SARS-CoV-2”, I now firmly believe that my original judgment, views, and interpretations are correct. For the sake of easiness for people to read and share, in this essay, I am reorganizing my previous discussions and including some explanations on certain confusions as well.

First, there are numerous provinces and cities in China using TCM to fight the “COVID-19” (I will use the term “Coronavirus” from now on.) No matter whether the treatments were primarily using TCM or the combination of TCM and the methods of Western medicine, there have been a significant amount of positive outcomes. On the other hand, the views of how to use TCM to treat and the use of corresponding herbal formulas vary quite a bit. Even when TCM remedies were effective, why did some patients fully recover and were discharged from the hospitals but other patients still could not get the virus-free “negative confirmation” from virus DNA tests?

Many TCM doctors participating in the treatments and discussions often look at the Coronavirus issue from a single “Point” or the condition of the patient at that specific moment. Some interpreted the disease as “Dampness” (濕), “Dryness” (燥), “Cold” (寒), or “Heat” (熱). (Translator’s note: These interpretations are often the opposite ends of the spectra, like Dampness is opposite to Dryness; and Cold is opposite to Heat.) From the clinical practice point of view, those treatments based on such conflicting interpretations all had positive effects to some degrees. Then, which interpretation is the “correct one”? In fact, those simple interpretations all have some merits but don’t fully cover the subject in hand. Although TCM is based on “Dialectical Treatment” (辯證論治), i.e. treatment is derived from “observation and diagnosis” of patients’ complex symptoms, the most important thing is that disease shouldn’t be viewed as an isolated problem at a specific time, but the whole development of symptoms along a timeline. Not only we need to observe and diagnose the current ailment but also we have to understand the development history of the disease and to project how the disease will develop in the future. For a single patient, we might be able to focus on the clinical results of this patient. But for epidemics, we have to look at a bigger picture and take into account how this Coronavirus develops health issues inside the human body from TCM’s perspective. And, in clinical treatments, we also need to consider many variants caused by each patient’s preconditions and one’s strength to fight off the disease.

From my experience of curing many patients who were inflicted with flu-induced pneumonia and complications, and the recent participation in treating and curing Coronavirus patients, it is proper to summarize that no matter whether the virus is Coronavirus, bird flu, swine flu, or the “common” flu, we found that the bodily deterioration caused by the virus, in general, follows the description from the TCM theory first covered in the ancient literature “Treatise on Cold Damage on Miscellaneous Disease ” (傷寒雜病論). However, the progressions of the disease from such special viruses are much faster, more severe, and/or more persistent than that of the common flu. Patients’ own original “health” condition also complicates the progression. (Translator’s note: For example, the infliction rate of young children is much smaller than that of adults for Coronavirus.)

As I explained before, the TCM theory discussed that for the common flu or “catching a cold”, the disease starts with “Exterior Deficiency or Weakness” (表虛). That is, the “exterior” of the body is invaded by the “External Pathogen” (外邪), like virus, and has adverse reactions. (Translator’s note: Here the exterior doesn’t mean just the outside surface of the body like the skin, but all the surfaces topologically exposed to the outside like lining of throat, nose, and bronchus of the body.) This is the first stage of the whole episode and often can be effectively treated with the herbal prescriptions such as “Gui Zhi Tang” (桂枝湯). If the patient is not properly treated, the body fluids within the surface and muscles could not function properly. It will cause the transition to the next stage “Exterior Excess” (表實). (Translator’s note: The word Excess has various meanings: excessive reactions all the way to neoplasm, excessive wasteful things, etc.) Viral infection at this stage is matched to one of the several syndromes named with the corresponding herbal remedies such as “Ge Geng Tang” (葛根湯), “Ma Huang Tang” (麻黃湯證), and others. The TCM theory calls this stage “Exterior Coldness” (表寒). In history, many TCM doctors considered this stage as the body being hurt by outside coldness (傷於寒) or in plain words “Catching Cold”. However, that is a misunderstanding. While outside coldness is one of the causes leading to the stage “Exterior Coldness”, it is not the only cause. When the body fluids could not function properly, the normal body fluids which had proper fluidity to circulate and to fulfill vital functions (活水) became a pot of “Dead Water” (死水), i.e. wasteful water which can’t fulfill vital functions. In other words, the ancient literature “Treatise on Cold Damage on Miscellaneous Disease” (傷寒雜病論) is much beyond the simple interpretation of how to treat the ailment caused by “cold damage”, but a classical literature of explaining both the physiology and pathology of human body functions.

Normally, the ailment or symptoms of the common flu would be limited at this stage of “Exterior Coldness”. Even without any treatment, the human body often could fight off the virus with an immune response and fully recover. But when the effects of Exterior Coldness started to penetrate into the interior of the body, the first common organs to be affected will be the organs that have a short path to the outside. (Translator’s note: Topologically, trachea and lung are only a membrane distance away from the outside air.) Then the Exterior Coldness gets transformed into the next stages such as “Interior Coldness” (裡寒) and “Lung Coldness” (肺寒). (Translator’s note: Here “Lung” means the whole respiratory system, not only the lung organ.) Clinically, the patients start to show symptoms of the syndrome named after its herbal remedy “Xiao Qing Long Tang” (小青龍湯). At this stage, the patients have serious coughing and running nose. When the respiratory system is “affected by the coldness”, the body fluid function of the respiratory system gets affected. Just like when the cooling system of a car malfunctions, the engine would overheat. The circulation function of the lung becomes “Dry and Overheated” (燥热). This would lead to the next stage of “Heated Interior” (入裡化熱) and often be matched to its herbal remedy “Da Qing Long Tang” (大青龍湯). At this stage, it does not mean that the whole lung is “dry and heated”. In fact, many pneumonia patients exhibit “mixed coldness and heat” (寒熱夾雜) in the lung. For example, while the upper part of the lung is “dry and heated”, the lower part of the lung might suffer excessive mucus of a high density. Pleural effusion and hydronephrosis might start to develop quickly.

Such a complex situation was extensively discussed in Chapter 7 of the ancient literature “Synopsis of Prescriptions of the Golden Chamber” (金匱要略肺痿肺癰咳嗽上氣病脈證治第七篇). At this complex stage, the illness development varies significantly among patients of different preconditions and other variants. It is no longer the situation that a simple herbal remedy can be applied to all the situations. The TCM theory illustrates various treatments by those herbal remedies such as “She Gan Ma Hung Tang” (射干麻黃湯), “Ting Li Da Zao Xie Fei Tang” (葶藶大棗瀉肺湯), ”Ze Qi Tang” (澤漆湯), “Xiao Qing Long Jia Shi Gao Tang” (小青龍加石膏湯), and others. It doesn’t mean that one of the herbal remedies should be selected to treat a patient directly. Instead, the TCM Theory used these herbal remedies to teach its practitioners how to “think” and create a proper herbal remedy based on the conditions of a specific patient.

For example, the Coronavirus has quite a puzzling situation that many Western medicine doctors haven’t yet fully understood. Some severely affected patients exhibited fibrosis of the lung like the SARS phenomenon. Other severely affected patients did not have SARS-like lung fibrosis but had massive liquid cumulated in the lung, which even “drown” some patients to death. From the TCM point of view, it is not strange at all. Fibrosis of the lung is the typical following stage of Heated Interior matching to “Da Qing Long Tang” (大青龍湯). It was named as “Lung Atrophy” (肺痿) in the TCM theory. And the situation that one suffers from massive dense liquid accumulation is matched to symptoms of severe development after the stages matched to “She Gan Ma Hung Tang”( 射干麻黃湯) , “Ting Li Da Zao Xie Fei Tang” (葶藶大棗瀉肺湯), and others as discussed earlier. The TCM theory called it “Lung Abscess” (肺癰). In the TCM theory, Lung Atrophy and Lung Abscess are two progression paths of this virus depending on which path develops faster or even simultaneously. From the past and current reports, SARS virus tilts toward the path of Lung Atrophy, while the Coronavirus tilts a little more toward Lung Abscess.

The above explained the progression of flu and other epidemic virus infections. Now you might understand how different TCM doctors had different views or treatment methods, but all of the treatments had some partially positive effects. If a TCM doctor’s diagnosis at one particular moment was slight hotness of the lung, some mild herbs to “clean up the heat” (清熱解毒輕劑), often used by the “Southern School” doctrine (溫病派), might relieve the patient’s symptoms. But if a TCM doctor’s diagnosis at a different point of the progression was massive mucus accumulation, heavy dosage of strong herbs, often used by the “Northern or Classic School” doctrine (經方派) might be needed to treat Lung Abscess (肺癰). That is why we saw some reports that the “Pneumonia Formula One” (肺炎一號) used in Guangzhou city, which was based on mild herbs to reducing the “heat”, had some positive effects in Guangzhou but not so effective in Shanghai. In Shanghai, many TCM doctors had to switch to stronger herbal ingredient often found in “Da Qing Long Tang” (大青龍湯) and “She Gan Ma Hung Tang”( 射干麻黃湯) as discussed earlier. This was due to different weather patterns and different patients, i.e. different progression paths described in the previous paragraphs. In other words, from the specific moment of the doctor’s diagnosis, both views were correct. But neither of them grasped the progression timeline of this severe illness.

Another point raised earlier was why did some patients fully recover while others did not? According to the information given by the doctors on the front line, there were so-called “Western medicine and TCM combined treatments” in which Western medicine drugs were continuously given to the patients and TCM herbs were used as supplements. When adding TCM herbs had a positive effect and made a speedier recovery, it was all goodness. But when adding TCM herbs did not have positive results, then what? According to the doctors on the front line, the medical team did not really think through the stages of disease progression as discussed earlier and switch to different TCM remedies, but only increased the dosage of Western medicine drugs such as Interferon (干擾素), Chloroquine phosphate (磷酸氯喹) used to treat malaria (抗瘧疾藥物), Arbidol (阿比多爾) used to treat influenza (抗流感藥物), and others. Heavy dosages of such drugs had severe side effects and sequelae. In those “combined” treatments, the medical teams didn’t have enough TCM expertise to make sound decisions on herbal remedies. Instead, they simply used TCM herbs as “extra help”.

How about treatments primarily with TCM remedies? The chief Western medicine expert who leads the fight against the Coronavirus, Dr. Nanshan Zhong, admitted under political pressure that TCM was useful against light or even medium threat situations of Coronavirus but insisted that TCM could not cure severe cases. His statement was based on his belief that there is no ingredient in TCM herbs that could kill Coronavirus. I am sorry to say that Dr. Zhong is incorrect in this aspect. With solid patient cases as proof, TCM can actually cure severe cases of Coronavirus infection and other flu-related infections. When it did not, it is the particular TCM doctors who had not mastered the whole theory and methodology of TCM. But one thing that Dr. Zhong said correctly was that no ingredient in TCM herbs can “kill” the virus. However, the TCM treatment isn’t based on the ability to kill the virus. (Translator’s note: Western medicine drugs could not kill the virus either.) Many people still have the level of limited understanding that TCM can only improve the immunization ability or some herbs such as the root of Isatis tinctoria (板藍根) has some natural antibiotic chemicals. Such understanding is unfortunately poor and very limited. Although modern medical science still could not fully comprehend TCM theory and its clinical outcome, against Coronavirus, the better explanation is that TCM remedies can “improve the internal environment of the human body”. (Translator’s note: So that the patient would not fall into the adverse conditions that the organs fail to function.) In plain words, when the virus causes more mucus, TCM remedies reduce the mucus. When the virus causes fibrosis, TCM remedies reduce the “heat level” of the lung. TCM remedies tend to push the body and organs back to the original healthy states. Once the environment is unfriendly for the virus to keep replicating, the patients will have higher chances to eradicate the virus by themselves and recover. One can probably say that this explanation and method is similar to the idea of using Western medicine Interferon but without severe side effects. That is, TCM can cure not because it has the ability to “kill” virus by some ingredients but to help to restore patients’ “internal environment” to healthier conditions that prevent the virus from replicating quickly. (Translator’s note: If one buys the same argument made by Dr. Zhong that a medication needs to have ingredients to kill the Coronavirus, then all the medications used today would not qualify. Then do we give up? In fact, why TCM was not selected to treat severe cases was because those stronger and less commonly used herbs were not applied properly or the TCM doctors at hand had less confidence for doing so. )

Now, we can go back to discuss how clinically TCM can treat and cure Coronavirus patients. For light to mild cases, most of the different TCM treatment methodologies could help. For medium to severe cases, as I discussed in my previous essay, we need to utilize the strength of certain herbs:

- Sheng Shi Gao (Gypsum, 生石膏): To reduce heat inside the lung (清肺熱) and enhance the liquid circulation in the respiratory system (加強肺津液運作)

- She Gan (Belamcanda chinensis, 射干)、Zi Wan (Aster tataricus, 紫菀) 、Kuan Dong Hua (Tussilago farfara flower, 款冬花)、Sheng Ban Xia (Pinellia ternate, 生半夏)、Ting Li (Sisymbrium indicum, 葶藶)、Da Ji (Euphorbia pekinensis Rupr., 大戟), etc.: To reduce accumulation of excessive mucus and wasteful fluids inside the respiratory system (去肺下方濃稠痰飲、肺積水、胸腔積液等)

- Ma Huang (Ephedra sinica Stapf., 麻黃), etc.: To enhance the lung function (宣肺、發陽)

- Mai Men Dong (Ophiopogon japonicas, 麥門冬)、Xing Ren (Prunus armeniaca, 杏仁): To moisturize the lung (潤肺)

That is, we need to combine the theory and targeted responses of the various herbal remedies such as “Da Qing Long Tang” (大青龍湯), “She Gan Ma Hung Tang” (射干麻黃湯) , “Ting Li Da Zao Xie Fei Tang” (葶藶大棗瀉肺湯), ”Ze Qi Tang” (澤漆湯)“, etc. as discussed earlier, and properly adjust the dosages and ratios of ingredients to fit the requirements of individual patients based on their conditions. In addition, if the patients have other ailments, those conditions need to be taken into account also, such as:

- For “Coldness and Wetness of the Middle and Lower Abdomen“ (中下焦寒濕) or “Deficient Kidney Function” (腎陽不足): Add Bao Fu Zi (processed Aconitum carmichaelii Debx root, 炮附子)、Xi Xin (Asarum sieboldii, 細辛), etc.

- When the liver function is weak or damaged by heavy dosages of Western medicine drugs such as interferon: Add Chai Hu (Bupleuri Radix, 柴胡)、Huang Qin (Scutellaria baicalnsis Geprgi root, 黃芩), etc.

There is no question that it is very challenging to fight off the Coronavirus. The clinical treatments will seriously test TCM doctors’ thorough understanding of TCM and their ability and courage to call the right shots under a great amount of pressure. On the other hand, it is also a good time to prove that TCM can be effectively used to fight various viruses in a superb and speedy fashion with little sequelae and at a much lower cost.

For fighting such a new and aggressive virus epidemic, there is no single TCM herbal formula that can treat all situations. One must have deep knowledge of the stages of the disease, along with close examinations on patients’ preconditions, so one can use the most effective prescription to intercept and turn the symptoms around. On the other hand, many provinces and cities in China provided TCM guidelines on Coronavirus treatments and pre-fixed herbal formulas to address people’s demands on a herbal remedy for “common usage”. Among them, I found the current recommendation from the Chinese National TCM Administration the most appropriate for a good percentage of Coronavirus patients. The herbal remedy was recently named as “Qing Fei Pai Du Tang” (清肺排毒湯), which could probably be translated to “clean up the lung and get rid of the toxic”. In line with the discussion above, this specific herbal formula includes Ma Huang (Ephedra sinica Stapf., 麻黃), Zhi Gan Cao (processed Glycyrrhiza uralensis Fisch., 炙甘草)、Xing Ren (Prunus armeniaca, 杏仁)、Sheng Shi Gao (Gypsum, 生石膏)、Gui Zhi (Ramulus Cinnamom, 桂枝)、Ze Xie (Alisma orientalis, 澤瀉)、Zhu Ling (Polyporus umbellatus, 豬苓)、Bai Zhu (Atractylodes macrocephala Koidz., 白朮)、Fu Ling (Poria, 茯苓)、Chai Hu (Bupleuri Radix, 柴胡)、Huang Qin (Scutellaria baicalnsis Geprgi root, 黃芩)、Jiang Ban Xia (Pinellia ternate, 薑半夏)、Sheng Jiang (Ginger, 生薑)、Zi Wan (Aster tataricus, 紫菀)、Kuan Dong Hua (Tussilago farfara flower, 款冬花)、She Gan (Belamcanda chinensis, 射干)、Xi Xin (Asarum sieboldii, 細辛)、Shan Yao (Dioscorea oppositifolia, 山药)、Zhi Shi (Citrus aurantium, 枳實)、Chen Pi (Citrus reticulata Blanco, 陳皮)、and Huo Xiang (Pogostemon cabin, 藿香). Since such an herbal remedy was designed for “common usage”, it has to consider all degrees of disease severity. Therefore, the dosages can’t be too heavy, as the majority of the patient cases are light to mild. As the result, “Da Qing Long Tang” (大青龍湯) discussed earlier became a lighter herbal formula named as “Ma Xing Gan Shi Tang” (麻杏甘石湯). The stronger herbal ingredients such as Ting Li (Sisymbrium indicum, 葶藶) and Da Ji (Euphorbia pekinensis Rupr., 大戟) to treat pleural effusion and hydronephrosis are not included. Hence, for severe cases, the herbal remedy from the Chinese National TCM Administration needs to be enhanced with additional ingredients and larger dosages.

In summary, as long as the TCM doctors have sufficient knowledge and clinical experience, by applying the proper methodology, TCM alone is capable of dealing with severe Coronavirus infections. (Translator’s note: There is much to do to develop a comprehensive diagnostic and treatment methodology which can help many TCM doctors to pinpoint the patient’s condition and stages of the infection to make the proper decision, especially when fully qualified TCM doctors are of short supply.) At this moment, there is no “special drug” in Western medicine to cure Coronavirus, but to resort to cortisone, antibiotics, interferon, anti-malaria, anti-flu drugs to maintain the lives of patients and passively wait and hope that the patients’ bodies can find their own way to turn the situation around. Even then, the Western medicine drugs mentioned above all potentially have significant side effects and sequelae. Patients with severe cases might be able to get out of the deathbed but most likely live with some permanent damages to the body. Dr. Zhong, China’s chief Western medicine expert on the Coronavirus epidemic, also warned that the current path of developing the “special drug” would most likely lead to severe sequelae to the patients. Given that is the case, why don’t we put much more effort to fully develop the TCM treatment of viral infection, not just for Coronavirus but also for future viruses which will bound to happen in the future?

(Translator’s note: As China is getting good control of the virus spread and gradually recovers from this epidemic, the knowledge learned will be invaluable to the rest of the world. Europe and the United States are on the exponential rise of new cases as of the writing on 3/14/2020. Various models predict that in the US alone Coronavirus infections can reach millions, as discussed in the Opinion Column of New York Times, “How Much Worse the Coronavirus Could Get, in Charts” by Nicholas Kristof and Stuart A. Thompson, March 13, 2020. China should continue to put efforts to develop TCM diagnostic and treatment methodology so that millions of people in the rest of the world can be helped and saved. TCM is not just for science, it is for humanity.)

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