Standardizing the Prevention and Treatment System for Exogenous Diseases in Traditional Chinese Medicine: Strengthening Clinical Fundamentals
—— Xiao Xiangru Discusses Reforms in TCM Education
Developing New Medical Theories and Summarizing New Clinical Experiences
Every infectious disease is unique, and there are no ready-made solutions available; thus, each infectious disease tests the medical field and physicians. It tests the physician’s mastery of existing medical theories and clinical experiences; it tests the physician’s ability to apply existing medical theories and clinical experiences to propose correct diagnosis and treatment plans for new infectious diseases, thereby developing medical theory. Regarding the recent COVID-19 pneumonia, there are many aspects that exceed existing medical theories and experiences.
1. The Concept of “Epidemic” Must Be Standardized
Wu Youke’s book is titled “Wen Yi Lun” (Treatise on Warm Epidemics), and evidently, the “epidemic” discussed by Wu Youke refers to febrile diseases.
Yu Shiyu refers to it as “plague” in the preface of “Yizhen Yide” and calls Wu Youke’s “Wen Yi Lun” as “Plague Treatise”; at the same time, Yu Shiyu’s “Yizhen Yide” discusses “heat epidemic,” with gypsum as the main herb; he also refers to Wu Youke’s “Wen Yi Lun” as “Plague Treatise” and calls “Wen Yi” as “Plague.” It is evident that Yu Shiyu’s “epidemic” also refers to febrile diseases.
Wu Jutong’s “Wen Bing Tiao Bian” states in the first section of the upper jiao: “Warm diseases include wind warmth, warm heat, warm epidemic, warm toxin, summer warmth, autumn dryness, winter warmth, and warm malaria.” Among the nine types of warm diseases, the first major category is warm heat, which includes wind warmth, warm heat, warm epidemic, warm toxin, and winter warmth. Clearly, warm epidemic is also febrile.
The recent novel coronavirus pneumonia is evidently cold and damp, not a febrile disease, and thus cannot be termed as “Wen Yi.”
The concept of “epidemic” should be based on the “Neijing” (Inner Canon), specifically the “Suwen: Yipian: Acupuncture Methods” which states, “When the five epidemics arrive, they are all contagious, regardless of size, and the symptoms are similar.” Any infectious exogenous disease is termed as “epidemic.” “Epidemics” can be febrile or cold in nature.
2. Pathogenic Factors are Cold and Damp
It has become a consensus that the pathogenic factor of the recent COVID-19 pneumonia is cold and damp. However, cold and damp manifest in the lungs, primarily presenting as dry cough without much clear and thin phlegm, which contradicts existing theories. With cold and damp as the main factor and the disease location in the lungs, it should be more aligned with the Xiao Qing Long Tang (Minor Blue Dragon Decoction) pattern. If the patient presents with dry cough and lacks the typical clear and thin phlegm, according to existing theories, the evidence for using Xiao Qing Long Tang is insufficient. Therefore, I propose a new standard for using Xiao Qing Long Tang for COVID-19 pneumonia: if the tongue is pale with a white slippery coating and the chest X-ray shows ground-glass opacities, Xiao Qing Long Tang can be used. Clinical practice has proven that for this COVID-19 pneumonia, warming the lungs and transforming phlegm, especially with formulas containing Ma Huang (Ephedra), is effective. This clearly breaks through existing medical theories.
3. Dampness Attacks the Lungs First
Ye Tianshi states in “Wen Re Lun”: “When warm pathogens attack, they first invade the lungs.” This is a classic theory in warm disease studies. Dampness primarily harms the spleen and stomach, which is a consensus in existing theories, but the etiology of the recent COVID-19 pneumonia is mainly cold and damp, with the primary disease location in the lungs, i.e., “dampness attacks the lungs first.” This also breaks through existing medical theories and requires a re-evaluation.
In the “Wen Yi Lun: Original Preface,” it states: “The disease of warm epidemic is not caused by wind, cold, heat, or dampness, but by a different kind of qi in the world.” The “different qi,” as Wu refers to it in his book, is also called miscellaneous qi, pestilential qi, or epidemic qi. Wu Youke believes that the etiology of warm epidemic differs from non-contagious exogenous diseases; it is a different qi, not one of the six excesses, and its clinical manifestations also differ from non-contagious exogenous diseases, thus cannot be understood using the rules of the six excesses.
Wu’s initial treatment for warm epidemic is Da Yuan Yin (Great Source Decoction), which is evidently different from non-contagious exogenous diseases. For the recent COVID-19 pneumonia, it should also be interpreted as such, i.e., “epidemics” do not follow common logic, whether it is cold phlegm in the lungs without presenting with cough and thin phlegm, or “dampness attacks the lungs first,” both are characteristics of “epidemics.” This is also a key and challenging point in the diagnosis and treatment of infectious diseases.
Wu Youke mentions “miscellaneous qi” in “Wen Yi Lun”; modern Western medicine has identified pathogenic microorganisms that cause infectious diseases, and the cause of this COVID-19 pneumonia is the novel coronavirus, which should belong to the “miscellaneous qi” described by Wu. The protein shell of the coronavirus contains a specific protein that can bind to human angiotensin-converting enzyme 2 (ACE2). This enzyme is primarily distributed in human respiratory epithelial cells, and also in intestinal epithelial cells, thus the main invasion site of this virus is the human respiratory tract, causing pneumonia, while the digestive system may also be attacked, leading to diarrhea. This also provides a new understanding of “dampness attacks the lungs first.”
Due to the specificity of the pathogenic microorganisms of each infectious disease and their determined binding ability to specific parts of the human body, it also determines that each infectious disease has new characteristics, which in medical terms is illogical, both in Chinese and Western medicine. Wu Youke’s statement that “the disease of warm epidemic is not caused by wind, cold, heat, or dampness, but by a different kind of qi in the world” should be understood in this context. That is, “epidemics” always have special aspects, always have places that existing medical theories cannot explain, and how to use existing medical knowledge and the wisdom of physicians to correctly assess these aspects is the key to formulating correct prevention and treatment plans.
4. Severe and Critical Cases May Have Low Fever or Even No Fever
In the process of exogenous diseases, especially infectious diseases, those with fever are severely ill, while those without fever are critically ill.
In the “Shang Han Lun” (Treatise on Cold Damage), it states: “If a patient has fever and aversion to cold, it is due to yang; if there is no fever and aversion to cold, it is due to yin.” Fever is a manifestation of the body’s righteous qi fighting against evil; high fever indicates strong righteous qi, suggesting that the evil is real and the righteous is not too weak; low fever or even no fever indicates the body’s righteous qi is weak against evil, suggesting that the evil is strong and the righteous is weak, indicating a poor prognosis.
The occurrence of infectious diseases and the prognosis after falling ill are based on the body’s righteous qi. This has been discussed in the “Huangdi Neijing” and by physicians throughout history.
In the “Suwen: Yipian: Acupuncture Methods”: “Huangdi said: When the five epidemics arrive, they are all contagious, regardless of size, and the symptoms are similar. If no treatment is applied, how can one avoid contagion? Qibo said: Those who do not get infected have their righteous qi preserved within, and the evil cannot invade; they avoid the toxic qi, and the righteous qi returns, thus the qi exits from the brain, and the evil does not invade.”
In the “Wen Yi Lun: Volume One: Pathogen”, it states: “All human nasal and oral qi communicates with the weather; the primary qi is full, and the evil cannot easily enter. When the primary qi is deficient, the external evil can invade. In the past, there were three people who walked in the fog early on an empty stomach; one died, one became ill, and one who was full did not get sick. How is this different from the epidemic evil?”
Western medicine believes that cytokine storms may be a significant cause of death in this COVID-19 pneumonia. A cytokine storm is a desperate, suicidal resistance of an impending collapse of the immune system against viral attacks, mobilizing various immune weapons indiscriminately, resulting in attacks on all systems of the body, especially when the disease location is in the lungs, where early acute inflammation from cytokine storms accompanied by massive exudation can lead to the respiratory tract being completely flooded with exudate, losing respiratory function, and easily leading to death. Therefore, preventing the occurrence of cytokine storms is key to reducing mortality.
The premise for the occurrence of cytokine storms is the weakening of the body’s immune function; only by enhancing the body’s immune function can the occurrence of cytokine storms be avoided. This also provides a clear direction for TCM treatment, which is to always pay attention to protecting the righteous qi. Severe patients and death cases are mostly among the elderly and those with underlying diseases, indicating the importance of supporting the righteous qi. This also explains why Ren Shen Bai Du San (Ginseng Decoction to Overcome Toxins) is effective for some patients. In the treatment of COVID-19 pneumonia, how to apply methods to support the righteous qi can refer to “How to Save Severe COVID-19 Patients? — What Are the TCM Strategies for the ‘Causes of Death’ in COVID-19?” published on February 24, 2020, in my WeChat public account “Xiao Xiangru Channel” (ID: xiaoxiangru0011).
5. “Epidemics” Often Accompany Filth and Turbidity
In addition to the aforementioned illogical aspects, another important characteristic of “epidemics” is that they often accompany filth and turbidity.
In the “Wen Bing Tiao Bian”, the first section of the upper jiao states: “Warm epidemics are caused by the flow of pestilential qi, often accompanied by filth and turbidity.”
Da Yuan Yin, the first formula in “Wen Yi Lun”, is aromatic and transforms turbidity.
Wu Youke states: “Betel nut can dissolve and grind, eliminate hidden evils, and is a medicine for dispersing and benefiting; it also eliminates the pestilential qi of Lingnan; Hou Po (Magnolia Bark) breaks the qi of stagnation; grass fruit has a pungent and fierce qi, eliminating hidden evils… Those who are heavily affected have a tongue coating like accumulated powder, completely covered without gaps.” The fundamental characteristic of Da Yuan Yin is its aromatic and drying nature, dispelling filth and transforming turbidity. In the treatment of this COVID-19 pneumonia, the shadow of Da Yuan Yin can be seen everywhere, which originates from the fact that “epidemics” often accompany filth and turbidity.
Ancient discussions on the source of “epidemics” often refer to mountain mists and the pestilential qi of Lingnan, believing it to be the result of being affected by the filth and turbidity of deep mountains and forests. This coincides with modern Western medicine’s research that the intermediate hosts of viral infectious diseases are often animals.
6. Internal Closure and External Escape
The concept of “internal closure and external escape” is erroneous; specific references can be found in “Discussion: The Concept of ‘Internal Closure and External Escape’ in the Prevention and Treatment Plan for COVID-19 is Erroneous,” published on February 12, 2020, in my WeChat public account “Xiao Xiangru Channel”.
7. Mutual Learning Between Chinese and Western Medicine is Crucial
In the prevention and treatment of COVID-19 pneumonia, TCM has played an important role, which is evident, but the role of Western medicine is irreplaceable, and TCM must learn from Western medicine.
The prevention and treatment system for infectious diseases in Western medicine is very important. Although the “Neijing” mentions “avoiding toxic qi,” it does not have a systematic and operable framework. Western medicine, on the other hand, has a complete and operable procedure from identifying pathogenic microorganisms, determining their intermediate hosts, identifying sources of infection, establishing effective disinfection measures against pathogens, to isolating, observing, and treating confirmed patients, suspected patients, and close contacts, as well as protecting medical staff, which can effectively control the spread of the disease.
Western medicine’s clear diagnosis of infectious diseases can distinguish between infectious and non-infectious patients, allowing for appropriate measures to be taken for different populations, effectively reducing medical costs and improving efficiency. At the same time, disease diagnosis and imaging evidence can also guide TCM in medication; as mentioned earlier, confirmed COVID-19 pneumonia patients with chest X-rays showing ground-glass opacities and a tongue that is pale with a white slippery coating, even without presenting with cough and thin phlegm, can still use Xiao Qing Long Tang.
Support and symptomatic treatment for severe patients are also very important; for patients with respiratory failure and circulatory failure, using respiratory and circulatory support can maintain the patient’s life, buying time for TCM treatment, i.e., keeping the patient alive to treat them.
From the treatment situation of this COVID-19 pneumonia, TCM has shown excellent results in treating mild and moderate patients, while in severe cases, active TCM treatment alongside Western medical support has also played an important role, significantly improving efficacy, indicating that mutual learning between Chinese and Western medicine is crucial.
Standardizing the Diagnosis and Treatment System for Exogenous Diseases in TCM
Misdiagnosis of exogenous diseases continues to exist, severely and widely.
1. From the Era of Zhang Zhongjing to the Ming and Qing Dynasties
Zhang Zhongjing states in the preface of “Shang Han Lun”: “My clan has many members, and since the Jian’an era, there have been fewer than two hundred; since then, more than two-thirds have died, and seven out of ten were due to cold damage.” This is the main reason for writing “Shang Han Za Bing Lun” (Treatise on Cold Damage and Miscellaneous Diseases). From the initial stages of cold damage in “Shang Han Lun”, specifically the Tai Yang disease treated with Ma Huang (Ephedra) and Gui Zhi (Cinnamon Twig), it can be seen that before Zhang Zhongjing, misdiagnosis of exogenous diseases was very serious, and it cannot be ruled out that the cold evil was received, treated with cold and cool herbs. This situation may have persisted until the Tang Dynasty, as Sun Simiao wrote in “Qian Jin Yi Fang: Volume Nine: Upper Cold Damage”: “I have seen many doctors treat cold damage, only using Da Qing Zhi Mu (Radix Anemarrhenae) and other cold substances, which is completely contrary to Zhongjing’s original intention. Although the decoction was administered, it was ineffective.”
When treating exogenous cold evil with Ma Huang and Gui Zhi, the effect is certainly immediate, thus many doctors may have treated all exogenous diseases with Ma Huang and Gui Zhi, including those caused by heat evil (cold damage), which should have become increasingly serious from the Eastern Han to the Song Dynasty.
During the Northern Song Dynasty, Pang Anshi in “Shang Han Zong Bing Lun” states in the “Narrative”: “Gui Zhi Tang (Cinnamon Twig Decoction) is effective for people living in the northwest during all seasons. In the warmer regions of Jianghuai, it can only be used in winter and spring. From late spring to before summer solstice, it is appropriate to add Huang Qin (Scutellaria) to Gui Zhi. After summer solstice, if there is a Gui Zhi pattern, it is necessary to add Zhi Mu (Anemarrhena) and Shi Gao (Gypsum) or Sheng Ma (Cimicifuga) to induce sweating.” A little later, Zhu Gong in “Liu Zheng Huo Ren Shu” also has similar statements: “From late spring to before summer solstice, Gui Zhi patterns can add half a tael of Huang Qin; after summer solstice, if there is a Gui Zhi pattern, it can add one tael of Zhi Mu, two taels of Shi Gao, or half a tael of Sheng Ma.” Although the thoughts of both are not clear, i.e., adding heat-clearing herbs to Gui Zhi Tang is to resolve exterior and clear interior, the appropriate pattern should be exterior cold and interior heat, it is evident that they discovered that using Zhongjing’s Ma Huang and Gui Zhi for initial treatment of exogenous diseases was ineffective for some patients, and even worsened the condition, indicating that heat evil was received, and treating with Ma Huang and Gui Zhi was evidently a misdiagnosis.
During the Jin Dynasty, Liu Wansu believed that “all six qi can transform into fire” and that “the transmission of the six meridians, from beginning to end, is all heat syndrome.” Thus, he believed that cold and cool herbs could be widely applied to any stage of exogenous diseases. Liu even believed that both Tai Yang cold damage and Tai Yang wind cold could be treated with Tian Shui San (Six One Powder) or Shuang Jie San (Double Relief Powder), where Tian Shui San is the Six One Powder, and Shuang Jie San consists of warm exterior-releasing herbs combined with heat-clearing herbs. Liu even broadly stated: “Bai Hu (White Tiger Decoction) combined with Liang Ge San (Cool the Diaphragm Powder) is the best medicine for treating cold damage.” Liu had a tendency to be biased towards cold and cool treatments, as he himself received cold evil and misused cold and cool herbs, ultimately being saved by Zhang Yuanshu’s correction. However, he certainly observed many cases of heat evil being misused with Ma Huang and Gui Zhi, indicating that misdiagnosis of exogenous diseases has always existed. At the same time, starting from Liu, the treatment of exogenous diseases has clearly shifted to a focus on cold and cool methods.
In the late Ming Dynasty, Wu Youke observed during the widespread plague in the Chongzhen year that many doctors used the “cold damage method” (specifically referring to Ma Huang and Gui Zhi and other warm exterior-releasing methods) to treat patients, and many patients often died due to misdiagnosis. Therefore, Wu emphasized in “Wen Yi Lun” that at the onset of warm epidemics, “even if there is headache and body pain, this evil is heat floating above the meridians, and should not be mistaken for cold damage exterior syndrome, and should not hastily use Ma Huang and Gui Zhi to induce sweating.”
Subsequent warm disease literature often mentions the serious situation of misdiagnosis in warm diseases, and many are personal accounts of relatives suffering from warm diseases and dying due to misdiagnosis, such as Yu Shiyu and Wu Jutong.
It is likely that during the Ming and Qing Dynasties, exogenous diseases were predominantly febrile, thus initiating an era where TCM treatment for exogenous diseases focused on cold and cool methods, leading to the prevalence of misdiagnosis of exogenous cold evil being treated with cold and cool methods, from the Ming and Qing Dynasties to the Republic of China, and even to the present. This should be similar to the cycle of misdiagnosis of exogenous diseases between cold and heat. During the Republic of China, the three children of Yun Tieqiao all died due to misdiagnosis of exogenous cold evil being treated with cold and cool methods, which is the most tragic example. Currently, the use of cold and cool herbs to treat exogenous diseases is even more common, with numerous commonly used TCM formulas such as Qing Kai Ling, Ban Lan Gen, and Lian Hua Qing Wen. It is likely that after this COVID-19 pneumonia, the treatment of exogenous diseases will shift to a focus on warm and pungent methods, and misdiagnosis will likely be unavoidable, as some people have already begun to treat all diseases with Zhongjing’s formulas.
2. Why is Misdiagnosis of Exogenous Diseases Inevitable?
Because the theories of TCM exogenous diseases are numerous and mixed, many concepts are not standardized, primarily stemming from individual writings. To this day, there is still no systematic, complete, and standardized textbook on exogenous diseases; after completing the current TCM college textbooks, what students can derive about exogenous diseases is primarily the cold-heat debate. Because the “Neijing” states, “Now, all febrile diseases are of the cold damage type”; the “Nan Jing” states, “Cold damage has five types”; the textbook of “Shang Han Lun” states that cold damage is broadly defined; Wu Jutong’s “Wen Bing Tiao Bian” states that warm diseases have nine types. So the question arises: should cold damage include warm diseases, or should warm diseases include cold damage? Therefore, TCM must clarify the treatment methods for exogenous diseases, at least by thoroughly reading the “Neijing”, “Shang Han Za Bing Lun”, “Wen Yi Lun”, “Wen Re Lun”, “Wen Bing Tiao Bian”, “Shi Wen Tiao Bian”, and “Wen Re Jing Wei” and developing one’s own thinking and discernment abilities, as these texts together can provide a more complete understanding of the treatment methods for exogenous diseases. However, there are many errors in these texts, and without the ability to identify errors, using incorrect methods will inevitably lead to misdiagnosis.
To give a simple example, the first and sixth sections of “Shang Han Lun” are contradictory; the first section states that Tai Yang diseases all have aversion to cold, while the sixth section states that warm diseases, also called Tai Yang diseases, do not have aversion to cold. Ye Tianshi states, “It can be in the Wei sweat”, but he also states, “When warm evil attacks, it first invades the lungs”, which is also self-contradictory; if warm evil first invades the lungs, it is a lung heat syndrome, is the treatment method to induce sweating? Wu Jutong’s understanding of “aversion to cold” in the early stages of warm diseases is also self-contradictory; the third section of “Wen Bing Tiao Bian” states that “slight aversion to wind and cold” is a characteristic of warm diseases, while the fourth and fifth sections state that “aversion to cold” is accompanied by external cold evil. It is precisely because these important texts regarding exogenous diseases contain uncorrected errors that a larger erroneous concept has emerged in textbooks, namely the wind-heat exterior syndrome and the warm-cool exterior-releasing method, which is a significant reason for the difficulty in distinguishing cold and heat in the early stages of exogenous diseases and the prevalence of misdiagnosis.
What I mean is that whether the classic formulas represented by Zhongjing’s formulas can play their due role in the prevention and treatment of diseases, especially in the prevention and treatment of severe infectious diseases like SARS and COVID-19, the premise is to systematically and standardize the research and organization of the theories of exogenous diseases, at least to ensure that TCM college students learn the correct concepts and methods.
I have a very deep feeling about this; after becoming a doctor, for a long time, I was afraid to treat colds because according to the methods in the textbooks, there was no way to distinguish between the cold and heat of exogenous diseases. If one cannot distinguish between cold and heat, how can one treat? Therefore, after decades of thinking, I spent ten years researching the early stages of exogenous diseases and published a small booklet titled “Reconstructing the Diagnosis and Treatment System for Early Exogenous Diseases”, proposing some common conceptual issues and some solutions. However, this is far from enough; I hope to organize efforts to conduct specialized research on the theories of exogenous diseases and compile a systematic, complete, and standardized textbook on exogenous diseases.
Advancing Reforms in TCM Education and Strengthening Clinical Fundamentals
The fundamental issue in TCM is the issue of efficacy; the basis for achieving efficacy is the fundamental skills of the physician; the fundamental skills of the physician depend on the level of TCM education.
For undergraduate TCM education, students should be required to master the core knowledge system of TCM, namely the four great classics, basic TCM theory, TCM diagnostics, pharmacology, formula studies, and acupuncture. The basic standard is to reach a level of memorization by graduation. For “Shang Han Lun”, my requirement for all students is consistent: they must memorize it; it is not acceptable to not memorize it. I believe that mastering “Shang Han Lun” involves three steps: memorizing the original text; grasping the formulas and patterns, especially the specific formulas and patterns; thoroughly understanding the original meaning of “Shang Han Lun” and then expanding its application based on one’s clinical practice (detailed content can be referenced in “Mastering the Three Steps of ‘Shang Han Lun'”, published on July 17, 2016, in my WeChat public account “Xiao Xiangru Channel”).
My requirements for graduate students and disciples are also very simple: memorize “Shang Han Lun”, “Jin Gui Yao Lue” (Essentials from the Golden Chamber), and “Wen Bing Tiao Bian”; while memorizing the entire “Huangdi Neijing” is difficult, it should be read repeatedly, and important chapters should be memorized.
Current issues in TCM education are numerous and can be improved step by step. I believe that we can start with the graduation requirements for core TCM courses, which is to raise the standards a bit on the current credit system, requiring that students must memorize the core courses to obtain corresponding credits, rather than just passing classroom exams to earn credits. If TCM college undergraduates can reach a level of memorization in nine core courses by graduation, the clinical efficacy of TCM will significantly improve.
TCM education also faces a serious issue, namely textbooks. Current textbooks are filled with erroneous, non-standard, and contradictory concepts, so it is urgent to compile high-quality textbooks based on the standardized research and organization of TCM theories. For example, in the current textbook of “Shang Han Lun”, the Shao Yang disease is referred to as “half exterior and half interior syndrome”, and the Ma Zi Ren Wan (Hemp Seed Pill) syndrome is referred to as “spleen knot”, which do not conform to Zhang Zhongjing’s original intention and cannot withstand scrutiny. Currently, some textbooks have more than one chief editor, and many deputy editors, with editorial committees numbering in the dozens; imagine how a textbook compiled by dozens of people can ensure quality? Who is ultimately responsible? Therefore, I believe that textbooks should ideally be compiled by individuals; if one has the ability and level, they should compile their own textbooks, and must be responsible for the content, which will significantly reduce the number of low-quality textbooks. High-quality textbooks are the foundation for cultivating high-quality talents. I have previously attempted to compile a textbook titled “Xiao Xiangru’s Lecture on Shang Han Lun”, which can be referenced, aiming to discuss concepts on a basis of standardization and unity. Standard, accurate, and straightforward expression is very important, and it should start from textbooks.
Introduction: Xiao Xiangru, Professor at Beijing University of Chinese Medicine, Chief Physician, Doctoral Supervisor. Born into a family of TCM practitioners, he learned medicine from his father, Xiao Liwei, from a young age, and later studied under Professors Li Peisheng and Mei Guoqiang at Hubei University of Chinese Medicine, and Professor Shi Zhensheng at the China Academy of Chinese Medical Sciences. He is the author of “Xiao Xiangru on Treating Kidney Diseases”, “Xiao Xiangru’s Lecture on Shang Han Lun”, and others.
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