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In the 1960s Bong Han Kim discovered and characterized a new vascular system. He was able to differentiate it clearly from vascular blood and lymph systems by the use of a variety of methods, which were available to him in the mid-20th century. He gave detailed characterization of the system and created comprehensive diagrams and photographs in his publications. He demonstrated that this system is composed of nodes and vessels, and it was responsible for tissue regeneration. However, he did not disclose in detail his methods. Consequently, his results are relatively obscure from the vantage point of contemporary scientists. The stains that Kim used had been perfected and had been in use for more than 100 years. Therefore, the names of the stains were directed to the explicit protocols for the usage with the particular cells or molecules. Traditionally, it was not normally necessary to describe the method used unless it is significantly deviated from the original method. In this present work, we have been able to disclose staining methods used by Kim.
Choi Seung-hoon thought he had an impossible assignment. On a grey autumn day in Beijing in 2004, he embarked on a marathon effort to get a couple of dozen representatives from Asian nations to boil down thousands of years of knowledge about traditional Chinese medicine into one tidy classification system.
Because practices vary greatly by region, the doctors spent endless hours in meetings that dragged over years, debating the correct location of acupuncture points and less commonly known concepts such as ‘triple energizer meridian’ syndrome. There were numerous skirmishes between China, Japan, South Korea and other countries as they vied to get their favoured version of traditional Chinese medicine (TCM) included in the catalogue. “Each country was concerned how many terms or contents of its own would be selected,” says Choi, then the adviser on traditional medicine for the Manila-based western Pacific office of the World Health Organization (WHO).
But over the next few years, they came to agree on a list of 3,106 terms and then adopted English translations — a key tool for expanding the reach of the practices.
And next year sees the crowning moment for Choi’s committee, when the WHO’s governing body, the World Health Assembly, adopts the 11th version of the organization’s global compendium — known as the International Statistical Classification of Diseases and Related Health Problems (ICD). For the first time, the ICD will include details about traditional medicines.
The global reach of the reference source is unparalleled. The document categorizes thousands of diseases and diagnoses and sets the medical agenda in more than 100 countries. It influences how physicians make diagnoses, how insurance companies determine coverage, how epidemiologists ground their research and how health officials interpret mortality statistics.
The work of Choi’s committee will be enshrined in Chapter 26, which will feature a classification system on traditional medicine. The impact is likely to be profound. Choi and others expect that the inclusion of TCM will speed up the already accelerating proliferation of the practices and eventually help them to become an integral part of global health care. “It will definitely change medicine around the world,” says Choi, now the board chair of the National Development Institute of Korean Medicine in Gyeongsan.
Whether this is a good thing depends on whom you talk to. For Chinese leaders, the timing could not be better. Over the past few years, the country has been aggressively promoting TCM on the international stage both for expanding its global influence and for a share of the estimated US$50-billion global market.
Medical-tourism hotspots in China are drawing tens of thousands of foreigners for TCM. Overseas, China has opened TCM centres in more than two dozen cities, including Barcelona, Budapest and Dubai in the past three years, and pumped up sales of traditional remedies. And the WHO has been avidly supporting traditional medicines, above all TCM, as a step towards its long-term goal of universal health care. According to the agency, traditional treatments are less costly and more accessible than Western medicine in some countries.
Many Western-trained physicians and biomedical scientists are deeply concerned, however. Critics view TCM practices as unscientific, unsupported by clinical trials, and sometimes dangerous: China’s drug regulator gets more than 230,000 reports of adverse effects from TCM each year.
With so many questions about TCM’s effectiveness and safety, some experts wonder why the WHO is increasing support for such practices. One of them is Donald Marcus, an immunologist and professor emeritus at Baylor College of Medicine in Houston, Texas, and a prominent TCM critic. In his opinion, “at some point, everyone will ask: why is the WHO letting people get sick?”
TCM is based on theories about qi, a vital energy, which is said to flow along channels called meridians and help the body to maintain health. In acupuncture, needles puncture the skin to tap into any of the hundreds of points on the meridians where the flow of qi can be redirected to restore health. Treatments, whether acupuncture or herbal remedies, are also said to work by rebalancing forces known as yin and yang.
Practitioners of TCM and Western-trained physicians have often eyed each other suspiciously. The Western convention is to seek well-defined, well-tested causes to explain a disease state. And it typically requires randomized, controlled clinical trials that provide statistical evidence that a drug works.
From the TCM perspective, this is too simplistic. Factors that determine health are specific to individuals. Drawing conclusions from large groups is difficult, if not impossible. And the remedies are often a mix of a dozen or more ingredients with mechanisms that cannot, they say, be reduced to a single factor.
There has, however, been something of a détente. Organizations steeped in the Western conventions, such as the US National Institutes of Health (NIH), have created units to research traditional medicines and practices. And TCM practitioners are increasingly looking for proof of efficacy in clinical trials. They often speak of the need to modernize and standardize TCM.
Chapter 26 is meant to be a standard reference that all practitioners can use to help diagnose disease and assess possible causes. For example, ‘wasting thirst syndrome’ is characterized by excessive hunger and increased urination and explained by “factors which deplete yin fluids in the lung, spleen or kidney systems and generate fire and heat in the body”. On the basis of those observations, physicians can work out how to treat them. The patient, who would probably be diagnosed as diabetic by a Western doctor, would probably be prescribed acupuncture, various tonics and moxibustion — in which practitioners burn herbs near the skin of the patient. Spinach tea, celery, soya beans and other ‘cooling’ foods would also be recommended.
TCM practitioners around the world are gearing up for Chapter 26, which is set to be implemented by WHO member states in 2022. “For the first time in history, ICD codes will include terminology such as Spleen Qi Deficiency or Liver Qi Stagnation,” reads a post on the website of Five Branches University, a TCM training and research institution based in San Jose, California, which worked with the WHO on a field trial of the diagnostic criteria in Chapter 26.
Critics argue that there is no physiological evidence that qi or meridians exist, and scant evidence that TCM works. There have been just a handful of cases in which Chinese herbal treatments have proved effective in randomized controlled clinical trials. One notable product that has emerged from TCM is artemisinin. First isolated by Youyou Tu at the China Academy of Traditional Chinese Medicine in Beijing, the molecule is now a powerful treatment for malaria and won Tu the Nobel Prize in Physiology or Medicine in 2015.
But scientists have spent millions of dollars on randomized trials of other TCM medicines and therapies with little success. In one of the most comprehensive assessments, researchers at the University of Maryland school of medicine in Baltimore surveyed 70 systematic reviews measuring the effectiveness of traditional medicines, including acupuncture. None of those studies could reach a solid conclusion because the evidence was either too sparse or of poor quality1. The NIH’s National Center for Complementary and Integrative Health in Bethesda, Maryland, concludes that “for most conditions, there is not enough rigorous scientific evidence to know whether TCM methods work for the conditions for which they are used”.
In response to queries by Nature, the WHO said that its Traditional Medicine Strategy “provides guidance to Member States and other stakeholders for regulation and integration, of safe and quality assured traditional and complementary medicine products, practices, and practitioners”. It emphasized that the goal of the strategy “is to promote the safe and effective use of traditional medicine by regulating, researching and integrating traditional medicine products, practitioners and practice into health systems, where appropriate”.
China’s support of TCM started with former leader Mao Zedong, who reportedly didn’t believe in it but thought it a could reach under-served populations. Current Chinese President Xi Jinping has strongly supported TCM and, in 2016, the powerful state council developed a national strategy that promised universal access to the practices by 2020 and a booming industry by 2030. That strategy includes supporting TCM tourism, which steers large numbers of people to clinics in China. Every year, tens of thousands of mostly Russian tourists flock to Hainan off the southern coast seeking relief through TCM. The government has plans to build 15 TCM ‘model zones’ similar to the one in Hainan by 2020.
The country also has global ambitions. China’s Belt and Road trade initiative calls for creating 30 centres by 2020 to provide TCM medical services and education, and to spread its influence. By the end of 2017, 17 centres had sprung up in countries such as the United Arab Emirates, Hungary, Kazakhstan and Malaysia.
The ties are paying off. Sales of TCM herbal medicines and other related products exported to Belt and Road countries surged by 54% between 2016 and 2017, to a total of US$295 million.
The WHO’s support applies to all traditional medicines, but its relationship with Chinese medicine, and with China, has grown especially close, in particular during the tenure of Margaret Chan, who ran the organization from 2006 to 2017. In Beijing in November 2016, Chan gave an address full of praise for China’s advances in public health and its plans to spread traditional medicine. “What the country does well at home carries a distinctive prestige when exported elsewhere,” she said.
Chan has supported traditional medicines, and specifically TCM, and has worked closely with China to promote this vision. In 2014, the WHO released a ten-year strategy that aims to integrate traditional medicines into modern medical care to achieve universal health coverage. The document calls on member states to develop health-care facilities for traditional medicine, to ensure that insurance companies and reimbursement systems consider supporting traditional medicines and to promote education in the practices.
In the same year, Chan wrote an introduction to a supplement that ran in Science and was sponsored by the Beijing University of Chinese Medicine and Hong Kong Baptist University2. (Nature ran a similar paid-for supplement in 2011.) Chan wrote that traditional medicines are “often seen as more accessible, more affordable, and more acceptable to people and can therefore also represent a tool to help achieve universal health coverage”. In a 2016 speech in Singapore, Chan said that TCM has excelled at preventing or delaying heart disease because it “pioneered interventions like healthy and balanced diets, exercise, herbal remedies and ways to reduce everyday stress”.
But many Western physicians and scientists doubt that the herbal remedies and various other components of TCM or other traditional medicines have much to offer in their current use. They grant that TCM herbs might turn up useful molecules (many Western drugs are derived from plants, after all), but worry that TCM could replace proven drugs or be potentially dangerous.
Arthur Grollman, a cancer researcher at Stony Brook University in New York, has published work showing how aristolochic acid, an ingredient in many TCM remedies, can cause kidney failure and cancer3. He thinks that WHO documents should pay more attention to the risks of remedies that contain the chemical, which are still widely used.
For some scientists, the WHO’s embrace of TCM is perplexing. “I thought the WHO was committed to evidence-based medicine,” says Richard Peto, a statistician and epidemiologist at the University of Oxford, UK.
Many physicians and researchers also find the WHO’s declarations about traditional medicine hard to parse. Various WHO documents call for the integration of “traditional medicine, of proven quality, safety and efficacy”. But the agency does not say which traditional medicines and diagnostics are proven. Wu Linlin, a WHO representative in the Beijing office, told Nature that the “WHO does not endorse particular traditional and complementary medicine procedures or remedies”.
But that stands in sharp contrast to the WHO’s actions in other areas. The agency gives member countries specific advice on what vaccines and drugs to use and what foods to avoid. With traditional medicines, however, the specifics are mostly omitted. The WHO website carries some warnings and states that aristolochic acid is a carcinogen. But with the repeated emphasis on integrating traditional medicine, the message is clear, says Marcus. In his view, “the WHO is clearly saying these are safe and effective medicines”.
Nature tried to contact Chan multiple times through the WHO, but the agency says that she is not answering questions on matters related to the WHO.
Despite the concern over the WHO’s decision to include TCM, even critics of the practices say that Chapter 26 could serve a constructive purpose. Peto says that Chapter 26 could help researchers to gather data on adverse reactions and what kinds of traditional treatments people are getting. “But if the aim is to endorse these things, it is inappropriate,” he says.
For those steeped in Western medicine, the continued spread of traditional treatments is worrisome. TCM practitioners increasingly talk of replacing proven Western medicines with traditional substitutes, where there is a cost advantage. Grollman thinks that ICD-11 is heading in that direction. Seventy per cent of money spent on health care globally is reimbursed or allocated on the basis of ICD information. Now TCM will be part of that system.
“The thing they want is to make it sound official and be recognized by the insurance companies. Because it’s relatively low cost, insurance companies will accept it,” says Grollman.
Many others agree that the WHO’s decision will help the spread of TCM. Inclusion in ICD-11 is “a powerful tool for [health-care] providers to say this is legitimate medicine” to insurers, says Ryan Abbott, a medical doctor who has also trained in TCM and is a faculty member at the University of California, Los Angeles, Center for East–West Medicine. The WHO’s action regarding TCM, he says, “is a mainstream acceptance that will have significant impact around the world”.
The COVID-19 belongs to plague in TCM with the etiology of epidemic factor exposure. Different regions can refer to the following plans for syndrome differentiation and treatment, according to the disease, local climate characteristics and different constitutions. Prescriptions which exceed maximum dose according to pharmacopoeia should be used under the guidance of a physician.
(1) Medical observation period
1.1 Clinical manifestation: fatigue with gastrointestinal discomfort
Scope of application: in accordance with the clinical observations of doctors in various locations, it is suitable for mild, moderate and severe cases, and can be used reasonably with the consideration of the actual conditions of critically ill patients.
The basic formula: Ma Huang (Ephedrae Herba) 9g, Zhi Gan Cao (Glycyrrhizae Radix) 6g, Xing Ren (Armeniacae Semen) 9g, Sheng Shi Gao (Gypsum fibrosum) (decocted first) 15-30g, Gui Zhi (Cinnamomi Ramulus) 9g, Ze Xie (Alismatis Rhizoma) 9g, Zhu Ling (Polyporus) 9g, Bai Zhu (Atractylodis macrocephalae Rhizoma) 9g, Fu Ling (Poria) 15g, Chai Hu (Bupleuri Radix) 16g, Huang Qin (Scutellariae Radix) 6g, Jiang Ban Xia (Pinellinae Rhizoma Praeparatum) 9g, Sheng Jiang (Zingiberis Rhizoma recens) 9g, Zi Wan (Asteris Radix) 9g, Kuan Dong Hua (Farfarae Flos) 9g, She Gan (Belamcandae Rhizoma) 9g, Xi Xin (Asari Radix et Rhizoma) 6g, Shan Yao (Dioscoreae Rhizoma) 12g, Zhi Shi (Aurantii Fructus immaturus) 6g, Chen Pi (Citri reticulatae Pericarpium) 6g, Huo Xiang (Pogostemonis Herba) 9g.
Administration: traditional Chinese herbal pieces in decoction. One package per day. Take warm twice (40 minutes after meal in the morning and evening). One course of treatment is for three packages.
If possible, half bowl of rice soup after taking the decoction is advised. For the patients with dry tongue due to fluid depletion, one bowl of rice soup is suggested. (Note: If no fever, the dosage of gypsum should be reduced. In case with fever or high fever, the amount of gypsum can be increased. If the symptoms improve but not toally recovered, continue the second course of treatment. If the patient has a special condition or other underlying diseases, the formula can be modified according to the actual situation in the second course. If the symptoms disappear, the drug should be discontinued.
Reference: The General Office of the National Health Commission of the people’s Republic of China The Office of the National Administration of Traditional Chinese Medicine “Notice on Recommending the Use of Qingfei Paidu Decoction in Pneumonia Treated with Integrated Chinese and Western Medicine for the COVID-19 Infection” (National Administration of Traditional Chinese Medicine Office Medical Letter  No.22)
2) Mild case
① Cold-damp constraint in the lung pattern
Clinical manifestation: fever, fatigue, generalized body aches, cough, expectoration, chest tightness and labored breathing, poor appetite, nausea, vomiting and sticky stool, pale enlarged tongue with tooth marks or light red tongue and coating which is white, thick, curd-like, and greasy or white and greasy, and soggy of slippery pulse.
Recommended formula: Sheng Ma Huang (Ephedrae Herba) 6g, Sheng Shi Gao (Gypsum fibrosum) 15g, Xing Ren (Armeniacae Semen) 9g, Qiang Huo (Notopterygii Rhizoma seu Radix) 15g, Ting Li Zi (Lepidii/Descurainiae Semen) 15g, Guan Zhong (Cyrtomii Rhizoma) 9g, Di Long (Pheretima) 15g, Xu Chang Qing (Cynanchi paniculati Radix) 15g, Huo Xiang (Pogostemonis Herba) 15g, Pei Lan (Eupatorii Herba) 9g, Cang Zhu (Atractylodis Rhizoma) 15g, Yun Ling (Poria) 45g, Sheng Bai Zhu (Atractylodis macrocephalae Rhizoma) 30g, Jiao San Xian (Jiao Shan Zha (Crataegi Fructus), Jiao Shen Qu (Massa medicate fermentata), and Jiao Mai Ya (Hordei Fructus germinatus)) 9g each, Hou Po (Magnoliae officinalis Cortex) 15g, Jiao Bing Lang (Arecae Semen) 9g, Wei Cao Guo (Tsaoko Fructus) 9g, Sheng Jiang (Zingiberis Rhizoma recens) 15g.
Administration: one package daily, 600ml after decocting, divide into three times, equally in the morning, afternoon and evening, take before meal.
② Damp-heat accumulation in the lung pattern
Clinical manifestation: low-grade fever or absence of fever, slight aversion to cold, fatigue, heavy sensation in the head and body, muscle soreness, dry cough with little sputum, sore throat, thirst without desire to drink, or accompanied with chest tightness and epigastric fullness, absence of sweating or disturbed hidrosis, or vomiting with anorexia, loose stool or sticky stool. The tongue is light red and coating is white, thick and greasy or thin and yellow. The pulse is slippery and rapid or soggy.
Recommended formula: Bing Lang (Arecae Semen) 10g, Cao Guo (Tsaoko Fructus) 10g, Hou Po (Magnoliae officinalis Cortex) 10g, Zhi Mu (Anemarrhenae Rhizoma) 10g, Huang Qin (Scutellariae Radix) 10g, Chai Hu (Bupleuri Radix) 10g, Chi Shao (Paeoniae Radix rubra) 10g, Lian Qiao (Forsythiae Fructus) 15g, Qing Hao (Artemisiae annuae Herba) (added later) 10g, Cang Zhu (Atractylodis Rhizoma) 10g, Da Qjng Ye (Isatidis Folium) 10g, Sheng Gan Cao (Glycyrrhizae Radix) 5g.
Administration: one pack daily, 400ml after decocting, divide into twice, and half in the morning and half in the evening.
3) Moderate case
① Damp-toxin constraint in the lung pattern
Clinical manifestation: fever, cough with little sputum or yellow sputum, chest tightness and shortness of breath, abdominal distension, and constipation with difficult defecation. The tongue body is dark-red, and tongue shape is enlarged. The cotaing is yellow greasy or yellow dry. The pulse is slippery and rapid or wiry and slippery.
Recommended formula: Sheng Ma Huang (Ephedrae Herba) 6g, Ku Xing Ren (Armeniacae Semen) 15g, Sheng Shi Gao (Gypsum fibrosum) 30g, Sheng Yi Yi Ren (Coicis Semen) 30g, Mao Cang Zhu (Atractylodis Rhizoma) 10g, Guang Huo Xiang (Pogostemonis Herba) 15g, Qing Hao Cao (Artemisiae annuae Herba) 12g, Hu Zhang (Polygoni cuspidati Rhizoma) 20g, Ma Bian Cao (Verbenae Herba) 30g, Gan Lu Gen (Phragmitis Rhizoma) 30g, Ting Li Zi (Lepidii/Descurainiae Semen) 15g, Hua Ju Hong (Citri grandis Exocarpium rubrum) 15g, Sheng Gan Cao (Glycyrrhizae Radix) 10g.
Administration: one package daily, 400ml after decocting, and equally divide into twice, in the morning and evening.
② Cold-damp obstructing the lung pattern
Clinical manifestation: low-grade fever, unsurfaced fever or no fever, dry cough with little sputum, lassitude and fatigue, chest tightness, stomach discomfort, or nausea, and loose stool. The tongue is pale or light red and coating is white or white greasy. The pulse is soggy.
Recommended formula: Cang Zhu (Atractylodis Rhizoma) 15g, Chen Pi (Citri reticulatae Pericarpium) 10g, Hou Po (Magnoliae officinalis Cortex) 10g, Huo Xiang (Pogostemonis Herba) 10g, Cao Guo (Tsaoko Fructus) 6g, ShengMa Huang (Ephedrae Herba) 6g, Qiang Huo (Notopterygii Rhizoma seu Radix) 10g, Sheng Jiang (Zingiberis Rhizoma recens) 10g, Bing Lang (Arecae Semen) 10g.
Administration: one package daily, 400ml after decocting, and equally divide into twice, in the morning and evening.
4) Severe case
① Epidemic toxin blocking the lung pattern
Clinical manifestation: fever with red face, cough with little yellow and sticky sputum, or blood-stained sputum, chest tightness and short of breath, lassitude, dryness, bitterness and stickiness in the mouth, nausea and loss of appetite, difficult defecation, and scanty dark urine. The tongue is red with yellow greasy coating. The pulse is slippery and rapid.
Recommended formula: Huashi Baidu Formula
The basic formula: Sheng Ma Huang (Ephedrae Herba) 6g, Xing Ren (Armeniacae Semen) 9g, Sheng Shi Gao (Gypsum fibrosum) 15g, Gan Cao (Glycyrrhizae Radix) 3g, Huo Xiang (Pogostemonis Herba) (added later) 10g, Hou Po (Magnoliae officinalis Cortex) 10g, Cang Zhu (Atractylodis Rhizoma) 15g, Cao Guo (Tsaoko Fructus) 10g, Fa Ban Xia (Pinellinae Rhizoma Praeparatum) 9g, Fu Ling (Poria) 15g, Sheng Da Huang (Rhei Radix et Rhizoma) (added later) 5g, Sheng Huang Qi (Astragali Radix) 10g, Ting Li Zi (Lepidii/Descurainiae Semen) 10g, Chi Shao (Paeoniae Radix rubra) 10g.
Administration: 1-2 packages daily, decoction, 100-200ml each time, 2-4 times per day, oral administration or nasal feeding.
② Blazing of both qi and ying pattern
Clinical manifestation: high fever with polydipsia, tachypnoea and shortness of breath, delirium and unconsciousness, blurred vision or accompanied with macules and papules, or hematemesis, epistaxis or convulsion of the four limbs. The tongue is crimson with little or no coating. The pulse is deep, thready and rapid, or floating, large and rapid pulse.
Recommended formula: Sheng Shi Gao (Gypsum fibrosum) (decocted first) 30-60g, Zhi Mu (Anemarrhenae Rhizoma) 30g, Sheng Di (Rehmanniae Radix) 30-60g, Shui Niu Jiao (Bubali Cornu) (decocted first) 30g, Chi Shao (Paeoniae Radix rubra) 30g, Xuan Shen (Scrophulariae Radix) 30g, Lian Qiao (Forsythiae Fructus) 15g, Dan Pi (Moutan Cortex) 15g, Huang Lian (Coptidis Rhizoma) 6g, Zhu Ye (Phyllostachys nigrae Folium) 12g, Ting Li Zi (Lepidii/Descurainiae Semen) 15g, Sheng Gan Cao (Glycyrrhizae Radix) 6g.
Administration: one pack daily, decoction, Shi Gao and Shui Niu Jiao should be decocted first, 100-200 ml each time, 2-4 times per day, oral administration or nasal feeding.
Recommended Chinese patent medicines: Xiyanping injection, Xuebijing injection, Reduning injection, Tanreqing injection, and Xingnaojing injection. Drugs with similar effects can be selected according to individual conditions, or can be used in combination according to clinical symptoms. Traditional Chinese medicine injection can be used together with TCM decoction.
5) Critical case
① Internal blockage and external desertion pattern
Clinical manifestation: Dyspnea, panting on exertion or mechanical ventilation required, accompanied with unconsciousness and dysphoria, sweating, cold extremities. The tongue is dark and purple with thick greasy or dry coating. The pulse is floating and large without root.
Recommended formula: Take Su He Xiang Wan or Angong Niuhuang Wan with the following decoction composed of Ren Shen (Ginseng Radix) 15g, Hei Shun Pian (Aconiti Radix lateralis praeparata) (decocted first) 10g, Shan Zhu Yu (Corni Fructus) 15g.
If there is mechanical ventilation with abdominal distension, constipation or difficult defecation, 5-10g of Sheng Da Huang (Rhei Radix et Rhizoma) can be considered. If patient-ventilator asynchrony occurs, 5-10g of Sheng Da Huang and 5-10g of Mang Xiao (Natrii Sulfas) can be used together with sedation and muscle relaxant.
Recommended Chinese patent medicines: Xuebijing injection, Reduning injection, Tanreqing injection, Xingnaojing injection, Shenfu injection, Shengmai injection, and Shenmai injection. Drugs with similar effects can be selected according to individual conditions, or can be used in combination according to clinical symptoms. Traditional Chinese medicine injection can be used together with TCM decoction.
Note: Recommended usage of TCM injections for severe and critical cases
The use of TCM injections follows the principle of starting from a small dosage and modifying based on pattern identification in the instructions. The recommended usage is as follows:
Viral infection or combined with mild bacterial infection: 0.9% sodium chloride injection 250ml with Xiyanping injection 100mg (bid), or 0.9% sodium chloride injection 250ml with Reduning injection 20ml, or 0.9% sodium chloride injection 250ml with Tanreqing injection 40ml (bid).
High fever with disturbance of consciousness: 0.9% sodium chloride injection 250ml with Xingnaojing injection 20ml (bid).
Systemic inflammatory response syndrome (SIRS) or / and multiple organ failure (MOF): 0.9% sodium chloride injection 250ml with Xuebijing injection 100ml (bid).
Immunosuppression: glucose injection 250ml with Shenmai injection 100ml or Shengmai injection 20-60ml (bid).
① Lung-spleen qi deficiency pattern
Clinical manifestation: shortness of breath, lassitude and fatigue, poor appetite with nausea and vomiting, abdominal fullness, a sense of incomplete evacuation, and sticky loose stool. The tongue is pale and enlarged with white greasy coating.
Recommended formula: Fa Ban Xia (Pinellinae Rhizoma Praeparatum) 9g, Chen Pi (Citri reticulatae Pericarpium) 10g, Dang Shen (Codonopsis Radix) 15g, Zhi Huang Qi (Astragali Radix) 30g, Chao Bai Zhu (Atractylodis macrocephalae Rhizoma) 10g, Fu Ling (Poria) 15g, Huo Xiang (Pogostemonis Herba) 10g, Sha Ren (AmomiFructus) (added later) 6g, Gan Cao (Glycyrrhizae Radix) 6g.
Administration: one package daily, 400ml after decocting, and equally divide into twice in the morning and evening.
② Deficiency of both qi and yin pattern
Clinical manifestation: fatigue, shortness of breath, dry mouth, thirst, heart palpitation, profuse sweating, poor appetite, low-grade fever or no fever, dry cough with little sputum. The tongue is dry tongue with scanty fluid. The pulse is thready or weak and forceless.
Recommended formula: Nan Sha Shen (Adenophorae Radix) 10g, Bei Sha Shen (Glehniae Radix) 10g, Mai Dong (Ophiopogonis Radix) 15g, Xi Yang Shen (Panacis quinquefolii Radix) 6g, Wu Wei Zi (Schisandrae Fructus) 6g, Sheng Shi Gao (Gypsum fibrosum) 15g, Dan Zhu Ye (Lophatheri Herba) 10g, Sang Ye (Mori Folium) 10g, Lu Gen (Phragmitis Rhizoma) 15g, Dan Shen (Salviae miltiorrhizae Radix) 15g, Sheng Gan Cao (Glycyrrhizae Radix) 6g.
Administration: one package daily, 400ml after decocting, and equally divide into twice in the morning and evening.
Translated by Beijing University of Chinese Medicine
Dr. Andy Lee 汉唐经方再传承4天前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, 2020I 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 a 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 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 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 Qin 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 cold”, 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 Qin 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 heavily discussed in Chapter 7 of the ancient literature “Synopsis of Prescriptions of the Golden Chamber” (金匮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 Qin 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 Qin 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 Qin 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 some patients did 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 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 CM 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)、Zhi 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 rrespiratory 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)、Xin 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 Qin 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 “Qin 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 (炙甘草)、Xin 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)、Zhi 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 Hua Xiang (Pogostemon cabin, 藿香). Since such a herbal remedy was designed for “common usage”, it had 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 Qin Long Tang” (大青龍湯) discussed earlier became a lighter herbal formula named as “Ma Xin 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 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 infectsions 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.)欢迎大家转发给国外的友人，共同抗击疫情！
Chinese Clinical Guidance for COVID-19 Pneumonia Diagnosis and Treatment (7th edition)
Chinese Clinical Guidance for COVID-19 Pneumonia
Diagnosis and Treatment (71h edition) published by China
National Health Commission on March 4, 2020)
中国国家卫生健康委《新型冠状病毒肺炎诊疗方案（第七版沛，发布时间：2020年3 月 4 日)
Since December 2019, a novel coronavirus pneumonia epidemic has appeared in Wuhan City, Hubei Province. With the spread of the epidemic, other cities in China and many countries abroad have also found such cases. As an acute respiratory infectious disease, the disease has been included in the Class B infectious diseases stipulated in the Law of the People’s Republic of China on the Prevention and Control of Infectious Diseases, and is managed as a Class A infectious disease. Through the adoption of a series of preventive control and medical treatment measures, the upward trend of the epidemic situation in China has been contained to a certain extent. The epidemic situation in most provinces has eased, but the number of outbreaks abroad is on the rise With the deepen understanding of the clinical manifestations, pathological features of this disease and the accumulation of experience in diagnosis and treatment, in order to further strengthen the early diagnosis and early treatment of the disease, improve the cure rate, reduce the mortality rate, and avoid in-hospital infection, and alert for the disease transmission caused by overseas input cases, we revised the previous clinical guidance to form this 7th version.
The novel coronavirus (termed as COVID-19 by World Health Organization) belongs to the coronavirusβgenus, which is encapsulated in round or oval shape, and 60-l 40mm in diameter. The genetic characteristics of COVID-19 are significantly different from SARS-Co V and MERS-Co V. It shares more than 85% homology with SARS-like coronavirus isolated from bat (bat-SL-Co VZC45). The COVID-19 can be detected in human respiratory epithelial cells for about 96 hours in vitro, but it takes about 6 days to isolate and culture in Vero E6 and Huh-7 cell lines
Our current understandings on the biochemical features of COVID-19are mostly derived from previous studies on SARS-Co V and MERS-Co V. COVID-19 is fragile to ultraviolet and heat (56 °C for 30 minutes). It can also be inactivated by liposoluble solvents, such as ether, 75% ethanol (w/v), chlorine-containing disinfectant and chloroform. However, chlorhexidine has been proved generally ineffective.
a) Source of infection
Infected patients (symptomatic or asymptomatic) are the main source of infection.
b) Route of transmission
COVID-19 is transmitted through respiratory droplets and close contact. Aerosol transmission is plausible when patients are exposed to high concentration virus-containing aerosols for a long period of time and in a relatively closed environment. In addition, because COVID-19 has been isolated from stool and urine specimens, special attention should be paid to human waste disposal to avoid direct contact and/or environment contamination.
c) Susceptible population
Human beings are generally susceptible to COVID-19
The following summary is based on limited numbers of autopsy and biopsy findings.
Lung consolidation was observed in various degrees.
Fibrinous exudation and hyaline membrane formation were filled in alveolar cavity.
Exudative cells mainly consist of mononuclear cells and macrophages. Polynuclear giant cells were prominent. Type II alveolar epithelial cells were markedly proliferated, and some were detached into alveolar cavity. Inclusion bodies were found in type II alveolar epithelial cells and macrophages. Hyperemia and edema were apparent in alveolar septal areas Mononuclear cell and lymphocyte infiltration, intravascular hyaline thrombosis, focal hemorrhage and necrosis of
lung tissue could be seen, and hemorrhagic infarction occurred Pathological features of organizing pneumonia and pulmonary interstitial fibrosis could be observed in pulmonary parenchyma.
Intrapulmonary bronchial epithelial cells were detached, and bronchial cavity was filled with mucus plugs. In some area, pulmonary alveoli were hyperinflated, alveolar septa fractured, and cystic cavities formed.
Coronavirus particles were found in the cytoplasm of bronchial epithelium and type II alveolar epithelial cells under electron microscope. Immunohistochemical staining showed that some alveolar epithelial cells and macrophages were positive for COVID-19 antigens COVID-19 nuclear acids were detected through RT-PCR.
b) Spleen, hilar lymph nodes, and bone marrow
Spleen was markedly shrunk, in which lymphocytes were significantly reduced m numbers, with apparent focal hemorrhage and necrosis. Macrophage proliferation and phagocytosis were also observed. In lymph nodes, lymphocytes were also depleted and necrotized. In addition, immunohistochemical staining showed that the number of CD4+ T and cos+ T cells in both spleen and lymph nodes were significantly decreased. All hematopoietic cell linages were reduced in bone marrow.
c) Cardiovascular system
It was found that some cardiomyocytes were degenerated and necrotized, and a small number of monocytes, lymphocytes and/or neutrophils are infiltrated in the myocardium. In some areas, vascular endothelial cells were detached where inflammation and thrombosis occurred.
d) Liver and gallbladder
Liver was characterized by increased volume, dark red color, hepatocyte degeneration, focal necrosis with neutrophil infiltration, hepatic sinus congestion, infiltration of lymphocytes and monocytes in the portal area, and microthrombus formation. Gallbladder was also significantly increased in size.
Protein exudate was found in Bowman’s capsules. Renal tubular epithelium was denatured and exfoliated, and hyaline cast was formed. Interstitial hyperemia, micro thrombus and focal fibrosis could be seen.
f) Other organs
The brain tissue was congested and edematous, and some neurons were degenerated. Focal necrosis was observed in the adrenal gland. The epithelium of esophagus, stomach and intestines were denatured necrotic and exfoliated with different degrees.
Based on the current epidemiological survey, the incubation period of COVID-19 is 1-14 days. Most patients show clinical symptoms in 3-7 days.
Fever, dry cough, and fatigue are the main manifestations. Other symptoms include nasal obstruction, runny nose, sore throat, myalgia and diarrhea. In severe cases, patients presented dyspnea and/or hypoxemia within one week after onset. Some of them rapidly deteriorated to acute respiratory distress syndrome (ARDS), septic shock. Refractory metabolic acidosis, coagulation dysfunction, and multiple orgru1 failure. Notably, some severe patients only presented mild- to moderate-grade fever in their entire course of disease, and some even did not show fever at all.
Some children and newborns presented atypical symptoms, such as vomiting, diarrhea and other gastrointestinal discomfort, or only exhibited drowsiness and shortness of breath.
In mild cases, patients only presented low-grade fever and slight fatigue, without evident pneumonia.
From our current observation, most patients have a good prognosis, and only a few patients arc critically ill. The prognosis for the elderly and those with chronic comorbidities is relatively worse. The clinical course of COVID-19 pneumonia in pregnant women is similar to that of the same age group. The severity of symptoms in children is relatively mild.
In the early stage of the disease, the total count of peripheral leukocytes could be normal or decreased, and the lymphocyte decreased. In some patients, liver transaminases, lactate dehydrogenase (LDH), creatine kinase and myoglobin were elevated. In some critically severe patients, troponins were also increased. In most patients, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were increased, while procalcitonin generally remains in normal range. Notably, D-dimer was significantly increased in severe patients, and peripheral lymphocytes were progressively decreased. Inflammatory biomarkers are often elevated in severe and critically severe patients.
ii. Etiological and serological examination
Etiological examination: COVTD-19 nucleic acids can be detected in nasopharyngeal swabs, sputum and other lower respiratory, tract secretions, blood and feces by using RT-PCR and next generation sequencing technology (NGS). It is more accurate to detect the lower respiratory tract specimen (sputum or airway extract). Once collected, specimen examination should be performed as soon as possible.
Serological examination: the COVID-19-specific IgG antibody starts to show positive after 3-5 days from onset. In comparison, the titer of COVID-19-specific IgG antibody is 4 times higher in recovery period than that in acute phase.
iii. Chest imaging
At the early stage of the disease, multiple small patchy shadows and interstitial changes appear, which are more obvious in the periphery of the lung. Then it developed into multiple ground-glass shadows and infiltrates shadows. In severe cases, pulmonary consolidation may occur. Pleural effusion is rare.
Comprehensive analysis of the following epidemiological history and clinical manifestations:
Travel or residence history of Wuhan and surrounding areas, or other communities with documented COVID-19 positive cases within 14 days before the onset of illness.
History of contact with COVID-19-infected persons (positive for nucleic acid detection) within 14 days before the onset of illness.
History of contact with the patients presenting fever or respiratory symptoms, who travel to or reside in Wuhan and surrounding areas, or in other communities with documented COVID-19 positive cases within 14 days before tl1e onset of illness.
Clustering onset (2 or more cases of fever and/or respiratory Symptoms within 2 weeks in small areas such as home, office, school class, etc.)
Presenting with fever and/or respiratory symptoms.
With imaging features of above mentioned COVTD-19 pneumonia.
In the early stage of the disease, the total number of leukocytes was normal or decreased, and the lymphocytes count was normal or decreased.
A case that meets any one of the epidemiological history criteria and any two of the clinical manifestations can be identified as a suspected case. If there is no clear epidemiological history, 3 of the clinical manifestations is required.
Suspected cases with one of the following etiology or serological evidence can be identified as confirmed cases:
Real-time RT-PCR detection is positive for COVID-19 nucleic acid.
The viral gene identified by gene sequencing is highly homologous with known COVID-19.
The COVID-19-specific lgM and IgG antibodies are tested positive. The titer of COVID-19-spccific IgG antibody is 4 times higher in recovery period than that m acute phase.
The clinical Symptoms are mild, and there was no sign of pneumonia on chest imaging.
These patients had fever and respiratory symptoms. Radiologic assessments found signs of pneumonia.
At high altitudes (above 1000 meters), PaO₂/FiO₂should be corrected according to the following formula: PaO₂/FiO₂x [ Atmospheric Pressure (mm Hg)/760 ].
Patients whose pulmonary imaging showed significant progression of lesion> 50% within 24-48 hours should be treated as severe type.
Children meet any of the following criteria:
Shortness of breath (<2 months of age, RR ≥ 60 beats/min; 2 to 12 months of age, RR ≥ 50 beats/min; 1 to 5 years old, RR ≥ 40 beats/min; > 5 years old, RR ≥ 30 beats/min), excluding the effects of fever and crying.
In the resting state, the oxygen saturation is ≤ 92%;
Patients combined with other organ failure needed ICU monitoring and treatment.
7.Warning signals for severe and critically severe types
(l) Progressive decline in the number of peripheral lymphocytes.
(2) Progressive increase in the levels of peripheral inflammatory biomarkers, such as TL-6 and CRP.
(3) Progressive increase in lactic acid concentration.
(4) Pulmonary lesions progress rapidly in a short time.
(1) Increased respiration rate.
(2) Poor mental responsiveness and drowsiness.
(3) Progressive increase in lactic acid concentration.
(4) Imaging showed bilateral or multilobes infiltration and pleural effusion, or pulmonary lesions progress rapidly in a short time.
(5) Infants under 3 months of age, or children having coexisting conditions (congenital heart disease, bronchopulmonary dysplasia , respiratory deformity, abnormal hemoglobin, severe
malnutrition, etc), or children with immunodeficiency or under immunosuppressive state (long-term use of immunosuppressants).
a) The mild manifestations of COVID-19 i1ifections need to be distinguished from upper respiratory tract infections caused by other viruses.
b) The COVID-19 pneumonia needs to be distinguished from other known viral pneumonia or mycoplasma pneumonia infections, such as influenza virus, adenovirus and respiratory syncytial virus. For suspected cases, technique such as rapid antigen detection and multiplex PCR nucleic acid detection should be taken to detect common respiratory pathogens.
c) It should also be distinguished from non-infectious diseases such as vasculitis, dermatomyositis, and organizing pneumonia.
Identifying cases and filing reports
When a COVID-19 suspected case is found by any medical practitioners, it is critical to immediately isolate the suspected person in a solitary cell for further monitoring and treatment. If COVID-19 infection is still suspected after comprehensive evaluation by medical experts and/or physicians, a case report should be submitted through internet to Centers for Disease Control (CDC) within 2 hours after the initial suspicion. In addition, specimens should be collected for COVJD-19 nucleic acid test. Meanwhile, the suspected person should be immediately transferred to a predesignated hospital with secured transportation modalities. If the suspected person has a close contact history with patient(s) already diagnosed with COVID-19 pneumonia, COVID-19 nucleic acid test should be performed, even if his or her common respiratory pathogen detection test has shown positive result(s).
If COVID-19 nucleic acid tests arc negative for two consecutive times (with at least 24 hours interval between each test), and if COVID-19-specific IgM and IgG antibodies remain negative after 7 days from onset, the suspected diagnosis ofCOVID-19 cat1 be ruled out.
Determine the treatment place according to patients’ condition.
(1) Suspected and confirmed cases should be isolated and treated in designated hospitals with effective isolation and protection conditions. Suspected cases should be isolated in a single ward. while confirmed cases can be admitted to multiple bedded ward.
(2) Critically severe cases should be admitted to ICU as soon as possible.
b) General treatment.
(1) Rest in bed with supportive treatment to ensure sufficient energy supply. The water and electrolyte balance should be noticed to maintain internal environment stability. Vital signs and oxygen saturation should be closely monitored.
(2) Monitor the blood routine, urine routine, CRP, biochemical indicators (liver enzyme, myocardial enzyme, renal function, etc.), coagulation function, arterial blood gas analysis, chest imaging according to the condition. If possible, cytokine test should be performed.
(3) Effective oxygen therapy measures should be given in time, including nasal cannula, mask oxygen and high-flow nasal cannula oxygen therapy. Hydrogen-oxygen inhalation (H2/O2: 66.6%/33.3%) treatment can be considered for use.
(4) Antiviral therapy: a-interferon (5 million U or equivalent for adult, add 2ml of sterile water, 2 times daily inhalation), lopinavir / ritonavir (200 mg/50 mg/capsule, 2 capsules each time for adults, twice a day, the course of treatment should not exceed 10 days). Ribavirin (combination with interferon or lopinavir/ritonavir is recommended, 500 mg each time for adults, 2 to 3 times intravenous infusions per day, the course of treatment should not exceed 10 days), chloroquine phosphate (for adults whose weigh over 50 kg, 500 mg each time, twice daily for 7 days, for those whose weigh less than 50 kg, 500 mg each time, twice daily for day 1 and day 2, once daily for day 3- day 7), Abidol (200 mg each Lime, three times a day for adults, the course of treatment should not exceed 10 days) can be tried. Attention should be paid to the adverse reactions of the
above drugs, contraindications (such as chloroquine should not be used in patients with heart disease), and interaction with other drugs. It is not recommended to use 3 or more antiviral drugs at the same time. The use of related drugs should be stopped when intolerable side effects occur. The treatment of pregnant women should consider the number of weeks of gestation and choose drugs that have less impact on the fetus.
(5) Antibacterial drug treatment: inappropriate use of antibacterial drugs should be avoided, especially the broad-spectrum antibacterial drugs.
c. Treatment of severe and critically severe cases.
(1) Principles of treatment:
In addition to symptom treatments, it is important to actively prevent complications, treat underlying diseases, prevent secondary infections, and provide organ function support.
Oxygen therapy: Severe patients should receive nasal cannula or mask to inhale oxygen, and evaluate in time whether respiratory distress and/or hypoxemia is relieved.
High-flow nasal cannula oxygen therapy or non-invasive mechanical ventilation: When patients with respiratory distress and / or hypoxemia cannot be relieved after receiving standard oxygen therapy, high-flow nasal cannula oxygen therapy or non-invasive ventilation can be considered. If the condition does not improve or worsens within a short time (1-2 hours), tracheal intubation and invasive mechanical ventilation should be performed in time.
Invasive mechanical ventilation: Using lung protective ventilation strategy, that is, small tidal volume (6-8 mL/kg ideal body weight) and low level of airway plateau pressure ( ≤30cm H2O) for mechanical ventilation to reduce ventilator-related lung injury. When the airway plateau pressure is ≤ 35 cm H2O, high PEEP can be appropriately used. Keep the airway warm and humid, avoid prolonged sedation, and awaken patients early and perform pulmonary rehabilitation treatment. For those patients with problem of man-machine synchronization, sedation and muscle relaxants should be used in time According to the airway secretions, closed sputum suction should be considered, and bronchoscopy should be performed if necessary.
Salvage treatment: For patients with severe ARDS, it is recommended to perform lung expansion. Prone ventilation should be performed for more than 12 hours per day. When prone position mechanical ventilation is not effective, if conditions permit, extracorporeal membrane pulmonary oxygenation (ECMO) should be considered as soon as possible. Related indications: ① When FiO2> 90%, the oxygenation index is less than 80mmHg, which lasts more than 3-4 hours; ② Patients with simple respiratory failure with airway plateau pressure ≥ 35 cm H2O, the VV-ECMO mode is preferred; if circulatory support is needed, then VA-ECMO mode will be selected. When the underlying disease is under control and cardiopulmonary function shows signs of recovery, weaning trials should be considered to begin.
Based on adequate fluid resuscitation, improvement of microcirculation and use of vasoactive drugs may be considered. Changes in patients’ blood pressure, heart rate, and urine output, as well as lactic acid and alkali residuals in arterial blood gas analysis should be closely monitored. Noninvasive or invasive hemodynamic monitoring, such as Doppler echocardiography, echocardiography, invasive blood pressure or continuous cardiac output (PiCCO) monitoring, is necessary. In the process of treatment, attention should be paid to the liquid balance to avoid excess and deficiency.
When the patient’s heart rate suddenly increases over 20% of the baseline value or the blood pressure has dropped by more than 20% of the baseline value, accompanying symptoms such as poor skin perfusion and decreased urine output, it should be alert whether patients have septic shock, gastrointestinal bleeding, or severe heart failure.
Renal failure and renal replacement therapy
When renal insufficiency occurs in critically severe patients, the causes of renal function insufficiency, such as hypoperfusion and drugs, should be analyzed The treatment of patients with renal failure should pay attention to fluid balance, acid-base balance and electrolyte
balance. For nutrition support treatment, attention should be paid to nitrogen balance, and supplement of caloric and minerals. Renal replacement therapy (CRRT) can be considered in severe patients. The indications include: ① hyperkalemia; ② acidosis: ③pulmonary edema or excessive water load; ④ fluid management when multiple organ dysfunction occurs.
Recovered patients’ plasma therapy
It is suitable for severe and critically severe patients with rapid disease progression.
Blood purification treatment.
The blood purification system includes plasma exchange, adsorption, perfusion, blood/plasma filtration, etc., which can remove inflammatory factors and stop the “cytokine storm”, thereby reducing the damage to the body caused by the
inflammatory response. It can be used for treatment of early and mid-term cytokine storms in severe and critically severe patients.
For patients with extensive lung lesion and severe patients with elevated TL-6 levels. tocilizumab treatment can be tried. The first dose is 4-8mg/kg, the recommended dose is 400mg with dilution of 0.9% physiological saline to 100mL, and the infusion time should be more than 1 hour. If the first medication is not effective, it can be applied once more after 12 hours (the dose is the same as before), cumulative number of administrations should not be more than 2 times, and the maximum single dose should not exceed 800 mg. Pay attention to allergic reactions. It is not recommended for people with active infections such as tuberculosis.
Other treatment measures
For patients with progressive deterioration of oxygenation indicators, rapid imaging progress, and excessive activation of inflammatory response, the use of glucocorticoids in the short term (3 to 5 days) should be considered. The dosage of methylprednisolone should not be over l -2mg /kg/day. It should be noted that large doses of glucocorticoids will delay the removal of coronavirus due to immunosuppressive effects. Intestinal microecological regulators can be used to maintain intestinal microecological balance and prevent secondary bacterial infections.
For severe and critically severe children patients, intravenous gamma globulin should be considered.
Pregnant women with severe or critically severe COVID-19 pneumonia should consider pregnancy termination, and cesarean delivery is preferred.
Psychological counseling should b3 strengthened in patients with anxiety and fear.
d)Traditional Chinese medicine treatment
According to the local climate characteristics, patients’ illness states and physical conditions, traditional Chinese medicine treatments can be used under the guidance of doctors. Huoxiang Zhengqi Capsules, ect. are recommended for patients with asthenia and gastrointestinal discomfort. Jinhua Qinggan granules, Lianhua Qingwen capsules and Shufeng Jiedu capsules,etc. are recommended for patients with asthenia and fever.
Discharge criteria and precautions after discharge
The body temperature returns to normal for more than 3 days.
Significant improvement in respiratory symptoms.
Pulmonary imagining shows a marked improvement in acute exudative lesions.
Negative nucleic acid test for sputum, nasopharyngeal swabs and other respiratory specimens for two consecutive times ( at least 24 hours interval between each test).
Those who meet all the above conditions can be discharged.
Precaution after discharge
The hospital should make good contact with the basic medical and health institutions where the patients live, share the medical records, and timely send the discharged patients’
information to the residential committee and the basic medical and health institutions.
After the patients is discharged from the hospital, it is recommended to continue the isolation management and health monitoring for 14days, wear a mask and live in a well-ventilated single room, reduce close contact with family members, wash hands frequently and avoid going out.
It is recommended to follow up and return to the hospital in the 2nd and 4th week after discharge.
Clinical Observation 1: Fatigue accompanied with stomach and intestine discomfort
Recommended patent: Huo Xiang Zheng Qi capsule ( pill, liquid, or tea)
Clinical Observation 2: Fatigue accompanied with fever
Recommended patent: Jin Hua Flu-cleared Powder, Lian Hua plague-cleared Powder, Wind Dispersed and Toxic Cleared Capsule(Powder) and Fang Feng Tong Sheng Pills
II Clinical Treatment Stages
a. Initial Stage: Cold and dampness trapped in the Lung
Clinical demonstration:Aversion of cold, fever or without fever, dry cough, fatigue, chest tightness, stomach fullness, or nausea and vomiting and diarrhea. Tongue body pale or light red, tongue coating greasy and pulse is soft.
Recommended formula: Chang Zhu 15g, Chen Pi 10g, Hou Po 10g, Cao
Guo 6g, Raw Ma Huang 6g, Qiang Huo 10g, Sheng Jiang 10g, Bin Lang 10g.
b. Mid-term Stage: Plague-virus Obstructing the Lung
Clinical demonstration:Fever continuing, or fever and chills alternatively shown up, coughing with little phlegm, or with yellow phlegm, bloating and constipation. Chest tightness and shortness of breath, coughing and Chest obstruction, out of breath with movements. Tongue body red, tongue coating greasy or yellow dry coating, pulses are slippery and rapid.
Recommended formula: Xing Ren10g, Raw Shi Gao 30g, Gua Lou 30g, Raw DA Huang 6g ( later added), Raw Ma Huang and Broiled Ma Huang each 6g, Ting Li Zi 10g, Tao Ren 10g, Cao Guo 6g, Bin Lang 10g, Cang Zhu 10g.
Recommended Herbal Injection: Xi Yan Ping Injection and Xie Bi Jing
(Blood Clearing Injection)
c. Critical Stage: Inner Obstruction and Outer Separation
Clinical Demonstration: Breathing difficulty, out of breath with movements, or with aid of ventilation, fainting, irritability, cold limbs after sweating. Tongue body dark purple, tongue coating greasy or dry, pulses are floating, large and rootless.
Recommended formula:Ren Shen 15g, Black shun Pian 10g, Shan Zhu Yu
15g, taken with Su He Xiang Wan, or An Gong Niu Huang Wan
Recommended Herbal Injection: Xie Bi Jing Injection, Shen Fu Injection, Sheng Mai Injection
d. Recovery Stage: Spleen and Lung Deficiency
Clinical Demonstration: Short of breath, fatigue, poor appetite and vomiting, fullness, weak stool, diarrhea without completion. Tongue body pale and fat, tongue coating white and greasy.
Recommended formula: Fa Ban Xia 9g, Chen Pi 10g, Dang Shen 15g, Broiled Huang Qi 30g, Fu Ling 15g, Huo Xiang 10g Sha Ren 6g(later added)
Question 1: TCM doctor mentioned spleen deficiency to me. Do I have a problem with my spleen?
Spleen deficiency is one of common TCM patterns. It can be treated with Chinese herbal medicine and acupuncture. Should you worry it in Western Medicine way? The answer is No. The organ TCM mentions in the diagnosis and treatment is not specifically for the organ. Spleen, for example, is the whole digestive system and part of body fluid metabolism. It would less confused if we call spleen as TCM spleen system.
The list of below are the major functions of TCM spleen system
Transformation. Spleen can transform the food into fine material that can be used to produce vital energy in the body. People with spleen deficiency often shows tiredness or chronic fatigue because the vital energy is not replenished properly.
Adjusting water metabolism. Unused or excessive water can be removed from the body through TCM spleen system.
Controlling the blood movement. If TCM spleen does not work well, bleeding may occur. Some bleeding can be arrested through strengthening TCM spleen functions.
Uplifting the clear yang. Organ prolapses and chronic diarrhea often occur if TCM spleen is losing its uplifting clear yang function.
Nourishing the muscles. Good TCM spleen function makes muscles plumpy and four limbs strong.
Dragon Global Herb Supply (DGHS) focuses on share the knowledge and information of overseas herb consumers. We have been sourcing and supplying herbs to overseas clinics and individuals for over five years. During this special time of human history, We are dedicated to help people from the world who are in needs of herbs to combat COVID-19. Now our client or anyone in the world who is willing to try alternative herb recipes is able to order any herbs from us.
Why do we do this?
To help people fast and efficiently who are suffering from COVID-19 threat.
To share the successful treatment used in China with herb recipes.
To share the knowledge of herbs as alternative treatment.
Although you may order anything with herbs available in China we strongly suggest raw herbs as they can achieve a better outcome. Raw herb tea is the most used format in combating COVID-19 in China.
There is a general cooking and intake method with no much difference from when you prepare a soup.
How to cook this herb tea?
Cook for the first time: Soak with water for 30min (water is 2-3cm above the herb tea), Cook with medium heat for 30-50min after bringing to boil, in order to get 800ml-1000ml decoction left. Use a strainer to filter the tea.
Cook the second time: Add water into the herb (water is 2-3cm above the herb tea), Cook with medium heat for 30-50min after bringing to boil, in order to get 500ml tea left. Use a strainer to filter the tea.
Mix both tea together and put in the fridge.
How to intake the herb tea?
Take 100-150ml/person/time, twice a day. Start with 5 days then stop for 2 days before restart. Try to take it for one month.