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Source｜China Traditional Chinese Medicine News
Written by｜Lu Hongrong, Zhao Chenxi, Fu Yujuan, Hao Gaimai, Tong Hongxuan, Institute of Basic Theory of Traditional Chinese Medicine, China Academy of Chinese Medical Sciences
Epidemic toxins and the Six Excesses are both external pathogens that originate from nature. Epidemic toxins differ from the Six Excesses as they are a specific pathogenic factor with strong infectiousness. The relationship between epidemic toxins and the Six Excesses is close; the Six Excesses provide external conditions for the emergence of epidemic toxins, which are a specific pathogenic factor that arises from extreme abnormal climatic conditions, often coexisting to cause disease.
Acute respiratory infections can be divided into upper and lower respiratory tract infections, with pathogenic microorganisms including viruses, bacteria, fungi, mycoplasmas, and chlamydia, with viruses being the most prevalent. Based on the clinical manifestations of acute viral respiratory infectious diseases, they can be categorized in TCM as “exterior contracted febrile diseases,” “seasonal colds,” “warm diseases,” “plagues,” and “epidemics.” However, not all acute respiratory infectious diseases fall under the TCM category of “epidemic diseases.” Scholars from ancient to modern times have extensively discussed the etiology of “epidemic diseases” such as “epidemic qi,” “malignant qi,” and “mixed qi,” but there are still some misconceptions in clinical practice. Therefore, clarifying the misconceptions regarding the etiology of TCM epidemic diseases and deepening the research on epidemic disease etiology is of great significance.
Coexistence of Epidemic Toxins and Six Excesses as Causes
In recent years, the outbreaks of diseases such as SARS, H1N1, and COVID-19 have posed serious threats to public health safety, falling under the category of “new pulmonary epidemic diseases.” The viral characteristics causing these infectious diseases vary, but they all share strong infectiousness, rapid transmission, and significant harm, classified as TCM “epidemic toxins.” Epidemic toxins, commonly referred to as “malignant qi,” “pestilential qi,” or “strange qi,” are characterized by strong infectiousness, pathogenicity, and harm. The onset of epidemic toxins is acute, progresses rapidly, and symptoms are generally severe, with high fever being common, and some cases may develop pneumonia or multiple organ failure, leading to death.
From current clinical reports, the TCM etiology of H1N1 can mainly be summarized into two aspects: “Six Excesses of Evil Qi” and “seasonal epidemic toxins.” Wind, cold, heat, dampness, dryness, and fire can all be causes of H1N1; the Six Excesses can independently cause influenza or coexist as a disease. Another category of etiology for H1N1 is seasonal epidemic toxins, which can be further classified into cold damp epidemic toxins, wind-heat epidemic toxins, and wind-heat epidemic evils combined with dampness.
Regarding the etiology of SARS, it is believed that if the epidemic is sporadic, it is caused by wind-heat pathogens; if it has strong infectiousness and occurs on a large scale, it is due to wind-heat combined with dampness or wind-heat epidemic toxins. Some scholars believe that the etiology of SARS is epidemic toxins with damp-heat or wind-heat characteristics, but distinct from the wind-damp-heat evils of the Six Excesses. The etiology of COVID-19 also has two viewpoints: one related to the Six Excesses and the other to epidemic toxins. Additionally, due to regional differences, epidemic toxins may be combined with different Six Excesses, manifesting as wind-cold epidemic toxins, wind-heat epidemic toxins, cold-damp epidemic toxins, and damp-heat epidemic toxins.
For the TCM etiology of pulmonary epidemic diseases such as SARS, H1N1, and COVID-19, most scholars hold the viewpoint of “epidemic toxins,” while a minority adhere to the Six Excesses etiology. The coexistence of these two viewpoints may be due to the following reasons: First, epidemic toxins can harm individuals, with some cases coexisting with the Six Excesses, while others do not. In cases where epidemic toxins coexist with the Six Excesses, the properties of the Six Excesses may obscure the inherent cold-heat-dryness-wetness properties of the epidemic toxins, leading to insufficient understanding of the properties of epidemic toxin etiology. Second, there is confusion between epidemic toxins and evil toxins. The transformation of the Six Excesses can lead to toxicity; when the Six Excesses reach their extreme, they can transform into toxins, which are referred to as the most severe evils. Toxins are evils, and evils are toxins; the extreme of the Six Excesses can transform into toxins. The transformation of the Six Excesses into toxins has a violent nature, similar to the violence of epidemic toxins, making it easy to confuse the Six Excesses with epidemic toxins.
Relationship Between the Six Excesses and Epidemic Toxins
The Six Excesses and epidemic toxins are both external evils from nature. From the perspective of the formation of the Six Excesses and epidemic toxins, the two are closely related; abnormal climatic conditions provide the necessary environment for the emergence of epidemic toxins, which are derived from the extreme manifestation of abnormal climatic changes.
The Six Excesses provide conditions for the emergence of epidemic toxins.
Abnormal climatic conditions are a prerequisite for the emergence of epidemic toxins. As stated in the “Treatise on the Origins and Symptoms of Various Diseases”: “If there is qi that is not in its proper season, all will be harmed; regardless of age, the diseases will be similar, often accompanied by toxins. This disease arises from the disharmony of seasons, the imbalance of warmth and coolness, and the invasion of strange qi, leading to illness, thus the disease qi easily infects one another.” This indicates that “if there is qi that is not in its proper season” or “the seasons are not harmonious, and warmth and coolness are out of balance,” it leads to the emergence of “toxins” and “strange qi,” among which epidemic toxins arise. Prolonged drought, extreme heat, floods, and damp mists are all abnormal climatic changes that provide conditions for the emergence of epidemic toxins. Abnormal climatic changes, such as excessive cold, excessive warmth, and excessive dampness, provide a breeding ground for viruses, bacteria, and other microorganisms, as stated by Wu Youke in the “Treatise on Warm Epidemics”: “The so-called mixed qi, although it is said to be the qi of heaven and earth, is actually derived from the qi of the local soil.” Epidemic qi is also one of the mixed qies, but it is more severe than other qies, hence the disease is more serious, thus it is named pestilential qi. The emergence of epidemic qi and epidemic toxins is caused by environmental and climatic changes; abnormal climatic changes provide the environmental conditions for the emergence of epidemic toxins, which are the derived evil qi from abnormal climatic changes. TCM believes that when evils are strong, they can transform into toxins; the extreme of the Six Excesses can also transform into toxins. Epidemic toxins and the extreme transformation of the Six Excesses both belong to the category of toxic evils, but epidemic toxins differ from the commonly referred to Six Excesses, blood stasis, phlegm turbidity, and the extreme transformation of heat evils. Epidemic toxins are characterized by their violent, stubborn, and difficult-to-treat nature, along with their specific infectiousness, epidemic nature, and unique pathogenicity.
Epidemic toxins are the evil qi transformed from the Six Excesses.
Regarding epidemic toxins, ancient and modern sages have long recognized them. Wu Youke in the “Treatise on Warm Epidemics” states: “Epidemic refers to the pestilential qi of heaven and earth.” Where do epidemic toxins come from? The “Plain Questions: The Great Discussion on the True Essentials” states: “All diseases arise from wind, cold, heat, dampness, dryness, and fire, which transform and change.” Wind, cold, heat, dampness, dryness, and fire are normally referred to as the Six Qi, and abnormally they are referred to as the Six Excesses. Transformation refers to normal biochemical processes; change refers to abnormal changes. When heaven and earth are out of order, and cold and warmth are unbalanced, the Six Qi can transform into the Six Excesses, which can further develop into epidemic toxins.
There are many discussions in ancient and modern medical texts regarding the abnormal changes of the Six Excesses. The external invasion of the Six Excesses can transform into wind, fire, toxins, dryness, etc., depending on the strength of the body’s righteous qi, the individual’s constitution, and the different treatment methods, leading to different disease patterns. In addition, the “Plain Questions” also mentions another type of change resulting from the extreme of the Six Excesses. For example, the “Plain Questions: The Discussion on Vitality and Heaven” discusses “great wind and harsh toxins.” “Great wind” refers to severe wind evils, which gradually arise from wind evils, while “harsh toxins” emphasizes that its toxicity is greater, not merely the toxins transformed from the extreme of the Six Excesses. Whether it is great wind or harsh toxins, both describe the severity and ferocity of the pathogenic evils. Since wind is the leader of all diseases, wind evils can transform into great wind and harsh toxins; similarly, cold evils, damp evils, and dry evils can also transform into great cold and harsh toxins, great damp and harsh toxins, and great dryness and harsh toxins, respectively. When the Six Excesses reach a certain level of accumulation, epidemic toxins will arise, transforming into great wind and harsh toxins, great cold and harsh toxins, great damp and harsh toxins, etc.
Epidemic toxins and the Six Excesses coexist as diseases.
The Six Excesses provide the environment and conditions for the emergence of epidemic toxins, while epidemic toxins are a special evil qi derived from the accumulation of Six Excesses to a certain stage. Epidemic toxins are pathogenic evil qi that arise under abnormal climatic conditions; when pathogenic, they not only exhibit the violent and easily transmissible properties of epidemic toxins but also retain the original properties of the Six Excesses. Furthermore, after the emergence of epidemic toxins, they can manifest as diseases independently or coexist with the Six Excesses, with epidemic toxins leveraging the power of the Six Excesses, and the Six Excesses assisting the force of epidemic toxins. The two are closely related and jointly invade the human body to cause disease, presenting different types of epidemic toxins such as wind-heat epidemic toxins, damp-heat epidemic toxins, cold-damp epidemic toxins, and dry-heat epidemic toxins.
The coexistence of epidemic toxins and the Six Excesses, as well as the transformation of the Six Excesses into toxins, both fall under the category of “toxic evils.” Both can exhibit the violent nature of “toxins” after causing disease, often resulting in severe conditions, while also displaying characteristics of the Six Excesses. However, the transformation of the Six Excesses into toxins does not have the mutual infectivity of epidemic toxins, which is a distinguishing factor between the two.
Research on Epidemic Toxin Theory
Epidemic toxins are special pathogenic evils existing in nature, characterized by strong infectiousness, epidemic nature, and unique pathogenicity, with severe, stubborn, and difficult-to-treat pathogenicity. Various editions of the “Treatise on Warm Diseases” have already dedicated a chapter to discussing warm toxins and pestilential qi, distinguishing epidemic toxins from the Six Excesses, but there are still some issues that require further research.
Research on the properties of epidemic toxins
As an external evil, the properties of epidemic toxins are crucial factors determining the development of the disease and treatment principles. The prevailing view regarding the properties of epidemic toxins is that they are mostly of warm-heat nature, with some being cold in nature; there are also opinions that epidemic toxins do not inherently possess cold or heat properties. Of course, some scholars suggest that it is unnecessary to be rigid about the cold or heat properties of epidemic toxins, but rather to focus on the changes in cold or heat properties experienced by the body when exposed to epidemic toxins.
Epidemic toxins or pestilential evils, as a concept of a common cause of epidemic diseases, highlight the infectiousness and epidemic nature of epidemic diseases, but simultaneously present uncertainties regarding cold, heat, dampness, and dryness, leading to difficulties in clinical differentiation and treatment. This is a shortcoming of the etiology of epidemic toxins. In research, large-scale data from recent outbreaks of H1N1, SARS, and COVID-19, which are acute respiratory infectious diseases, should be utilized to conduct cohort studies or randomized controlled trials on mild patients in makeshift hospitals. Since mild cases are in the early stages of the disease, the evil qi has not yet deeply penetrated and has not yet transformed with the individual’s constitution into heat or cold. Based on TCM’s method of determining etiology from symptoms, the cold, heat, dryness, and dampness properties of epidemic toxins can be assessed according to the clinical manifestations of mild patients. Experimental animal models can also be used to explore whether there are distinctions in the cold, heat, warmth, coolness, dryness, and dampness properties of epidemic toxins based on the behavioral characteristics of experimental animals after viral inoculation.
Furthermore, from a clinical perspective, different epidemic toxins each have their characteristics. For instance, the epidemic toxins causing SARS, H1N1, and COVID-19, while all classified as epidemic toxins from a TCM etiology perspective, share early-stage symptoms of lung defense and surface syndrome, and in the later stages, they all transform into heat and enter the interior, affecting the blood and nutrients. There are commonalities in the evolution of the disease mechanism, but differences are also evident, such as the early wind-heat manifestations of SARS epidemic toxins, while COVID-19 epidemic toxins exhibit significant dampness. What accounts for these differences? Is it due to the epidemic toxins themselves, the different accompanying evils, or the interaction between epidemic toxins and accompanying evils? These questions require further research to clarify. The pathogenicity and infectiousness of epidemic toxins when combined with the Six Excesses, the criteria for assessing the pathogenicity and infectiousness of epidemic toxins, the influencing factors of the pathogenicity and infectiousness of epidemic toxins, and the conditions and influencing factors for the formation of different epidemic toxins, all need further investigation. Research should be conducted based on the traditional classification of epidemic toxins, combined with modern virology advancements, utilizing the global characteristics of COVID-19 infections, and integrating meteorology, geography, environmental science, sociology, and other disciplines to explore the meteorological, environmental, and social factors influencing the occurrence, transmission, and mutation of epidemic toxins, analyzing the clinical manifestations of different ethnic groups and populations worldwide after infection with epidemic toxins, and clarifying the characteristics of different types of epidemic toxins.
Development of Specific Drugs for Epidemic Toxins
Epidemic toxins have strong pathogenicity and a wide transmission range, affecting individuals from youth to the elderly and children. In the face of newly emerging and sudden epidemic diseases, and unknown pathogens, the development of specific drugs involves a complex exploratory process. In the prevention and treatment of epidemic toxins, in addition to the widely recognized measures of enhancing righteous qi, avoiding toxic qi, isolating sources of infection, cutting off transmission routes, and actively immunizing through vaccination, ancient TCM sages have also conducted extensive explorations and accumulated a wealth of medicinal herbs and formulas. For instance, during the COVID-19 pandemic, the “Three Medicines and Three Formulas” proposed by TCM achieved good clinical efficacy. The results of a prospective randomized controlled study on Huashi Baidu Granules for treating COVID-19 patients showed significant improvement in clinical symptoms and lung inflammation, with good safety, providing effective evidence for the differential treatment of COVID-19 infection with Huashi Baidu Granules.
In addition, there are numerous potential anti-epidemic toxin drugs within traditional Chinese medicine and formulas waiting to be developed and explored. The 2020 edition of the “Chinese Pharmacopoeia” includes a total of 2711 types of Chinese medicinal materials and decoction pieces, plant oils and extracts, prepared formulas, and single herb preparations. The “Great Dictionary of TCM Formulas” (2nd edition) contains over 90,000 formulas. Some of these drugs have been explicitly mentioned by ancient sages as effective against epidemic qi, such as the “Zheng Lei Ben Cao” which records: “Renshen, strengthens the spleen, treats kidney qi, stops cholera, relieves abdominal pain, expels evils, dispels warmth, removes toxic evils, treats labor malaria, cold wind, and epidemic qi…” and “Bai Zhang Qing, is effective against seasonal epidemic diseases, warm epidemic toxins, and can be taken as a decoction or fresh juice.” The “Shennong’s Classic of Materia Medica” states: “Guanzhong, when ground into fine powder and mixed with water, is effective for treating nosebleeds. When epidemic qi arises, placing this medicine in water for drinking prevents transmission.” The “Compendium of Materia Medica” states: “Qianli Ji, is effective against epidemic qi, boiled into juice for purging.” Formulas for treating damp-heat epidemic diseases include Ganlu Xiaodu Dan, Yiyin Sanhuang Decoction, and Pujie Jieyi Dan; for treating cold epidemic diseases, there are Shishen Decoction, Jinfeicao San, and Fangfeng Tongsheng San; for prevention, there are Bifeng San and Biyi Jiu. Based on the rich medicinal herbs and formulas for treating epidemics found in ancient medical texts, combined with the properties of epidemic toxins, further efforts should be made to screen effective single herbs and empirical formulas for epidemic toxins, and under the support of modern scientific conditions, develop specific TCM drugs for treating different epidemic toxins, utilizing metabolomics, network pharmacology, and other drug research methods to clarify the mechanisms and targets of TCM, so that targeted TCM specific drugs for epidemic toxins can be used based on differential diagnosis.
Establishment of a Classification and Treatment System for Epidemic Diseases
Currently, various acute infectious diseases frequently occur, with diverse symptoms and complex conditions. The traditional classification of warm diseases cannot fully encompass or summarize current infectious diseases. In clinical practice, the TCM naming of infectious diseases is relatively vague, and the understanding of the laws of epidemic diseases is mostly described using Western medical disease types and characteristics, lacking recognition of the unique TCM characteristics of epidemic diseases. Therefore, it is necessary to strengthen the summary of TCM treatment experiences for acute and severe respiratory infectious diseases such as COVID-19, further refine the classification of epidemic diseases in the existing epidemic disease prevention and treatment theoretical system, and integrate infectious diseases such as H1N1, SARS, and COVID-19 with the ancient TCM epidemic disease prevention and treatment theories. Multidisciplinary research involving literature studies, clinical epidemiology, and meteorology should be conducted. The principles and methods of evidence-based medicine should be integrated into the research of the TCM epidemic disease classification and treatment system, producing high-quality clinical research evidence, utilizing modern research methods such as artificial intelligence, data mining, and model construction to compare the TCM etiology, pathogenesis, transmission laws, and treatment laws of different acute viral respiratory infectious diseases, analyzing the characteristics of syndromes at different stages of epidemic diseases, and summarizing the evolution laws of pathogenesis, syndrome evolution, and effective formulas for different epidemic diseases, forming a more complete prevention and treatment system for epidemic toxins.
Epidemic toxins are the etiology of new pulmonary epidemic diseases. The “Shuo Wen Jie Zi” describes: “Epidemic refers to the illness of the people.” Whether epidemic toxins invade and cause disease is related to the strength of the epidemic toxins and the degree of infection, and is closely related to the body’s righteous qi. The “Plain Questions: The Discussion on Needling Methods” states: “Those who are not infected have righteous qi stored within, and evils cannot harm them; avoid their toxic qi, and the heavens will protect them…” In the face of epidemic toxins, it is essential to not only strengthen the righteous qi within but also to reasonably prevent and avoid contact with epidemic toxins. How to avoid their toxic qi, in addition to the universally applicable methods of maintaining hygiene, staying away from sources of infection, and cutting off transmission routes, understanding the properties of epidemic toxins and providing targeted protection for susceptible populations, as well as taking preventive medications, is one effective approach. Therefore, strengthening research on the properties and characteristics of epidemic toxins, the research of the epidemic disease prevention and treatment system, and developing specific TCM drugs targeting epidemic toxins are all significant for the prevention and treatment of newly emerging and sudden pulmonary epidemic diseases.
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