A Chinese-Medicine Reflection on the Atypical Pneumonia Outbreak
Just after Spring Festival 2003, an outbreak of "atypical pneumonia" broke out in the Guangzhou region. Within the city, banlangen granules were swept off the shelves; edible white vinegar suddenly sold out; masks were everywhere; many households stayed home; the hospital was treated as a high-risk zone; even doctors on duty were uneasy; with relentless media coverage, the whole city felt under siege and the public was in a turmoil.
By peak-period reports of February 12: from February 7 onward, over 300 fell ill in the region; over ten died from pneumonia and secondary disease after onset. Symptoms: aversion to cold, fever, body-and-skin aches, no sweat, dry mouth; cough and chest pain not obvious; X-ray showed pulmonary inflammation. These resemble the early pulse-pattern of Shanghan and Wenbing in Chinese medicine, and are not far from common viral flu in the Western sense. After the peak, cases declined; the whole episode lasted about three weeks.
How to view this phenomenon afterward deserves serious reflection in TCM and in society.
1. For epidemics of outside-qi disease, one must first know the heavenly time
Heaven and the human in correspondence, Heaven and human as one — these are TCM's first medical views, especially on outside-qi disease.
First, of the 24 solar terms, Winter Solstice is yin spent, yang born — the turning-point in the year's cycle. Suwen · Discussion on Pulse and Essential: "45 days after Winter Solstice (i.e. Beginning of Spring), yang qi rises slightly, yin qi sinks slightly." Jinkui Yaolüe: "After Winter Solstice, at the jia-zi midnight (i.e. Rain Water), lesser yang begins; with lesser yang, yang begins; Heaven turns warm." Beginning of Spring opens the three months of spring; TCM holds spring's three months are the time of yang's rising. Wind governs; the climate is "swift in motion, much in change." The body's yang turns vigorous; nature's qi turns from cold to warm; inner and outer combined, spring's outside-qi disease is often wind-warm or spring-warm.
Second, this year's Spring Festival fell on February 1, just days before Beginning of Spring. During the long holiday, people travel and visit, and indulge in rich-greasy food and heavy drink — accumulating inner damp-heat. Neijing: "Yang qi — when over-labored, it stretches"; "rich-greasy food, enough to breed a great boil". Such state coincides with spring's qi — easily inducing a state of inner yang-heat in excess.
Third, last winter was unusually cold across the Northern Hemisphere — rare in a decade. Difference: in our north, heavy snow; in the south, cold-cool with little rain. Even after Beginning of Spring, coastal Guangdong's cold qi did not retreat. Nearly two months after Winter Solstice, the Heaven turns warm of the three months of spring was coming but not coming.
In spring's three months wind governs and yang would rise; but the major trend was masked by cold-evil — yang wants to rise and cannot. The two contend; the weather flips cold and hot; opportunity for outside-qi disease grew large in coastal Guangdong. With damp-heat banked inside and the pores opening in spring in southern climates — when struck by outer cold, outer-cold inner-heat easily forms.
So by Heaven and human in correspondence and the principle the pivot stirs before disease, this outbreak's character could have been estimated in advance, and even forecast to the public for self-prevention.
2. Knowing the time to seek oneself — maintaining yin at peace, yang tightly held is the root of prevention
Human health follows two laws: nature's great law, and the body's own integrated-organism law. In abnormal natural climate, strengthening self-protection and maintaining bodily equilibrium — that is the real meaning of Heaven and human in correspondence for prevention.
In Guangzhou's outbreak, several hundred fell ill — under 0.1‰ of the population. Even with the "medical workers more affected" point, this is no great outbreak. The disease is not to be ignored; but with no Western specific drug, prevention before illness from the yin at peace, yang tightly held perspective is the more important.
Note: in Guangzhou's outbreak, those untouched accounted for over 99.9%. That the vast majority resist disease shows the body's inner capacity is decisive — close to Western viral-immunology. With no specific anti-viral drug, drug-based prevention by the people is of limited use — even placebo. So keeping the body in yin at peace, yang tightly held — lifting inner resistance — is what cannot be neglected, and the key is what each person does.
TCM says: where evil gathers, the qi must be empty. Empty has two senses; to keep the body non-empty needs two:
First, the five storehouses and six bowels, qi-blood, yin-yang in vigor and dynamic balance — health.
Second, a strong sense of correspondence with Heaven-and-Earth — moderate diet, careful living-and-rising, adapt to cold and warm — leaving no opening for evil. In an epidemic, leaving no opening matters most.
For the outer-cold inner-heat pattern, do: moderate diet — eat less rich-greasy, avoid inner damp-heat; careful living-and-rising — labor-rest measured; adapt to cold and warm — adjust clothing, keep dwelling ventilated. To the very large extent, this closes the gap. The frail and chronically ill should have stronger self-protection. So even with lower baseline health, by balancing self with self and with nature, one can prevent atypical pneumonia. Each person, by TCM thought, takes the initiative. Why be drug-slave for prevention? Without specific anti-viral drugs, medicine should make popular science work — especially introduce Heaven and the human in correspondence to the public, and scientifically guide self-regulation.
TCM also values stool and urine flow. For a relatively healthy person, daily smooth elimination broadly signals normal metabolism. For outer-cold inner-heat, drink plenty of plain boiled water so accumulated damp-heat is voided in time — a key measure. From this angle, plain boiled water is the best preventive.
In TCM, the virus is fearsome — but the virus also fears the person. So long as the person keeps yin at peace, yang tightly held, in abnormal natural environment more so, the virus is brought low under the human hand. Prevent disease before disease.
3. Pattern-discernment and treatment — TCM's strength
TCM stresses biàn zhèng lùn zhì; the core: treatment by person, time, place; individualized features of disease across persons and disease-stages — under the natural macro-law.
In Guangzhou's early days the media said: TCM regards this as latent summer-heat and proposes Qianjin Weijing Decoction. This does not accord with TCM theory or practice. Wu Jutong's Wenbing Tiaobian (Qing): "Summer-heat received in long-summer, breaking out late, is called fu-shu (latent summer-heat). Before Frost Descends it is lighter; after Frost Descends , heavier; in winter, heaviest." So fu-shu breaks out around Frost Descends, at latest in that winter — not lying dormant to break out the next spring. And: "Summer-heat must come with damp. Summer-heat-with-fire is shu-wen , hand-taiyin pattern, treat with cooling; summer-heat-with-damp is shi-wen , foot-taiyin pattern, treat with warming." Qianjin Weijing Decoction is sweet-cold-clearing — for lung-abscess's pus stage or lung-heat with yin-deficiency. Never for summer-heat or summer-damp.
For more than a month before and during the Guangzhou outbreak, Hong Kong influenza was steady. Two regions in similar geography and climate — both outer-cold inner-heat patterns prominent. Holding this, then by person and time, the framework is clear. In my clinic I often modify the Xiao Chaihu Decoction — with satisfying effect.
Spring is yang's rising; shaoyang governs. Yang covered by outer cold cannot rise — but one need not, as in deep winter, use the heavy pungent-warm Daqinglong or Mahuang to force sweating; only mediate shaoyang — yang opens itself, outer cold falls off. Xiao Chaihu Decoction has huangqin to clear pent-heat; with the pivot opened, evil-heat has its own road out. So for outer-cold inner-heat in this season, the Xiao Chaihu Decoction is the representative formula.
Variations per pattern:
(1) Mild type. With outer cold heavier and surface closed — Guizhi-Mahuang Geban Decoction; with inner heat — same with Guizhi removed and Chaihu, Huangqin added.
(2) Common type — typical outer-cold inner-heat: Chaihu-Guizhi Decoction with Renshen removed and Gegen added; if inner heat heavy — reduce Guizhi, add raw gypsum, Chantui, Jiang Can.
For obvious cough and sputum: white sputum — Xiao Chaihu with Fuling, Xingren, Gegen; cough with sputum hard to clear — Xiao Chaihu (no Renshen) combined with Ma-Xing-Shi-Gan Decoction; cough with yellow viscid sputum hard to bring up — same with Xiao Xianxiong Decoction added; constipation — small Dahuang added to open the bowels and relieve lung-clogging.
In early March, our Baptist University TCM students returning from Guangzhou brought the Guangdong Provincial TCM Hospital's atypical-pneumonia protocol. Its thinking and herbs broadly match my own in Hong Kong this period. That confirms: in adjacent regions and similar climates, the pathogenesis of seasonal outer-qi disease is similar. Whether Western medicine calls it atypical pneumonia or influenza — for TCM pattern-discernment-and-treatment, this distinction is not key.
Maybe this approach in spring 2003 will be of some reference to the prevention and treatment of the atypical pneumonia just arrived in Hong Kong.
4. Don't confuse virus, jiedu (release toxin), and toxicity
In Guangzhou's outbreak the public rushed banlangen granules — rumor said anti-virus. But the public did not know what virus and jiedu mean.
Banlangen rose to fame in the barefoot-doctor mass-movement of the Cultural Revolution. Against viral diseases Western medicine could not treat, banlangen and various banlangen-based forms rose in the movement. 40 years on, banlangen granules have repeatedly grown "popular" with publicity. Their commercial profit makes mouths water. Whether too little to be effective, ineffective but safe, or safe — held to be placebo — all deserve serious, scientific reflection from the standpoint of medicinal seriousness and purity.
Virus is a Western-medical concept. If banlangen granules are anti-viral, the package should — by Western drug standards — state chemical components, structure, anti-viral mechanism (pharmacology), indications, contraindications. If a Chinese patent, then — by Chinese-patent standards — formula, manufacture, and TCM pathogenetic indications. Long-running, the banlangen package was both-Chinese-and-Western on the surface, neither in fact — mixing Western virus with TCM jiedu.
In TCM, du (toxin) has two senses. (1) Evil-qi: harmful factors or one's own pathological products — heat-toxin, damp-toxin, pestilential-toxin. (2) Drug efficacy: by potency — great-toxic, moderate-toxic, small-toxic. The Neijing: "With great-toxic medicines treat illness, take six in ten and stop; with ordinary-toxic, seven in ten; with small-toxic, eight in ten; with non-toxic, nine in ten; then grain, meat, fruit, vegetables — food's nurture finishes; do not exceed, lest the right qi be injured." So TCM treatment is called use toxin to attack toxin — the first toxin is drug efficacy; the second, pathogenic evil; different meanings, not to be confused. If herbs are used outside TCM pattern-discernment, the same herb may become a toxic substance — toxicity there is not TCM's responsibility; TCM has always opposed reckless use of herbs.
Western virus is a pathogen entering from outside. Whether it causes disease ties to immune-system function. As the West still researches virus understanding and control, with no ideal specific drug, this remains a key topic.
As everyone knows: science arises from experience, but experience is not science. Experience is preliminary; science is universal-valued. Banlangen in TCM is heat-clearing-and-toxin-resolving — effective against heat-toxin in TCM sense; not against damp-toxin or cold-toxin. Pestilential disease has cold-damp and summer-dry distinctions; TCM does not use banlangen across the board. If banlangen or its preparations are used for one viral disease and clinical proof shows efficacy, that is still experiential to Western medicine. Experience is not science; it must be further studied, pass Western pharmacology, before — like qinghaosu (artemisinin) — it becomes a new Western drug. Even then, the TCM banlangen and the new Western drug extracted from it have different scientific contents in the two systems, not interchangeable.
This points to the "Chinese-herb modernization" tide whose mainstream is "westernizing Chinese herbs." If Chinese herbs leave the TCM scientific system and become experiential drugs in Western hands, the cost is losing TCM. If they become like the neither-Chinese-nor-Western banlangen granules — losing even the placebo place when scientific intelligence catches up — where does modernization go?
Before science: right is right, wrong is wrong. No concept-swapping, no edge-balls.
(Hong Kong Baptist University, March 12, 2003)