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— updated 2003-07-15

Herbalist Review, Issue 2003 #3: SARS and TCM theories of epidemic illness

by Roger W. Wicke, Ph.D.

Understanding SARS from a TCM perspective; matching herbs to specific patterns of symptom manifestations. Understanding the level of penetration of a feverish illness and its general qualities may be as, or more, important that identifying the specific microbial pathogen.

Subtopics on this page…

Copyright ©2003 by RMH-Publications Trust; all rights reserved.




Trends in epidemic illnesses worldwide

Increased world travel, metabolic stress from pollutants and heavy metals, poor diet (either due to malnutrition/starvation in the third world or due to junk food in the industrialized and developing nations), overuse of antibiotics, administration of ineffective and contaminated vaccines, and possible release (either accidental or intentional) of biological agents from bio-warfare labs has resulted in a worldwide pandemic of drug-resistant pathogens.

SARS is only one of a long list of infectious illnesses that have spread on an international scale. In spite of the heavy publicity SARS has received, there is controversy regarding the true magnitude of this epidemic, ranging from claims that SARS is being under-reported for fear of panicking the public, to claims that the severity of the SARS epidemic has been exagerrated as a means to terrify the population into accepting future restriction of constitutional rights and civil liberties. In any case, it is clear that SARS never approached the magnitude of a true worldwide epidemic, as happened during the influenza epidemic of 1917, for example.

During the recent SARS panic, however, public fear did result in significant reduction in world travel and a flurry of sales for purported remedies or preventive aids, including herbal formulas. Since the early 1990's, when it was not yet fashionable to panic over epidemic illnesses, RMHI has held advanced seminars for our own graduates in various aspects of handling epidemic illnesses. Existing trends in epidemiology have for many years indicated a growing problem of antibiotic-resistant organisms, and it was only a matter of time before this problem would manifest as a series of increasingly severe worldwide epidemics.

Unfortunately, it is human nature to tend to wait until the last possible minute to prepare for disaster, and the SARS epidemic resulted in many people flocking to purchase purported herbal remedies for SARS that they had neither the time nor the patience to investigate. Many herbs that have been shown to have either in vitro (in a test tube) or in vivo (in the human body) anti-microbial activity also have side effects, and the negative consequences of taking potent anti-microbial herbs or drugs preceding manifestation of any acute illnesses may vary depending upon the metabolic and constitutional predispositions of each individual user. One of the most serious risks of using such herbs or medications is the disruption of normal bowel flora. Herbs such as Rhizoma Coptis (Coptis spp., huang/ lian/), goldenseal, Folium Daqingye (Isatis tinctoria, da\ qing- ye\), and Fructus Forsythia (Forsythia suspensa, lian/ qiao/) may all inhibit normal bowel flora to varying degrees; this corresponds to what TCM theory refers to as inhibition of the normal Spleen Qi and Middle Burner Fire of digestion. Yeast and candida overgrowth are a common consequence of such inhibition of normal intestinal flora. According to TCM, a healthy Spleen will protect one from invasion by "External Evils" or pathogens. Functions of the normal intestinal population of microbes (bifidobacteria, E. coli, lactobacillus, etc.) include preventing colonization by pathogens by competitive inhibition and by stimulating normal immune system responses. When the normal microbes are underpopulated or absent, pathological micro-organisms can multiply rapidly, placing a strain on the immune system. It is possible, therefore, that taking anti-microbial herbs prematurely will result in a weakening of one's Spleen, resulting in aftereffects of increased susceptibility to infection.

To use Chinese herbs, or any herbal product, for that matter, in an intelligent and effective manner requires that one match the herbs to the entire health context at the moment, including the entire pattern of symptoms and clinical signs (fever, appearance of the tongue tissue and coating, pulse qualities, skin color, etc.). Even if one is beginning to manifest signs of acute feverish illness, there are a wide range of clinical patterns to consider, each of which requires a different herbal strategy. For example, herbal formulas appropriate for the initial phases of a typical feverish illness (low fever, chills, body aches and malaise) may be contraindicated or ineffective for more advanced phases (high fever, delirium, rashes, hemorrhaging, abnormal bowel patterns, etc.).

The Theory of Virulent Heat (Wen Bing) Illnesses

In Chinese herbology, while anti-microbial herbs certainly play a role in the design of herbal formulas for Virulent Heat illnesses (Wen Bing), it is considered of utmost importance to also balance the entire formula to match the general state of the individual who has contracted such an illness. Table 1 summarizes the basic patterns of symptoms and clinical signs (tongue, pulse, physical appearance) that help one to differentiate which pattern most closely describes the condition. In rapidly progressing illnesses, it may be necessary to change the herbal strategy every few hours. A formula appropriate in the Wei stage, when low fever and chills (aversion to cold) are present, may be inappropriate or contraindicated if the illness becomes more severe and penetrates the Qi stage. The 4 stages of Wei, Qi, Ying, and Xue can be considered as a metric of the depth of penetration of the illness, from mild to very severe. Pericardium-stage illness occurs when the illness leads to severe mental derangement or possibly coma.

At each stage, an illness must also be characterized by whether the symptoms suggest a predominance of either "Dampness" or "Dryness" (or neither). Examples of Dryness symptoms include thirst, thready pulse, dry skin and generalized symptoms of Deficiency of Yin. Examples of Dampness symptoms may include nausea, vomiting, watery or oozing type eruptions, foul-smelling diarrhea, full distended abdomen or chest, expectoration of copious sticky phlegm, greasy tongue coating ("fur"), and slippery pulse profile.

To avoid side effects, it is crucial that the herbal formula be tailored for not only the level of penetration (Wei, Qi, Ying, Xue, Pericardium), but that the herbs are chosen to counteract the overall Dryness or Dampness qualities that may be present. If a formula is too sweet-tasting and rich, it will almost certainly aggravate Dampness; the individual is likely to vomit up the herb tea soon after drinking, or if not, the tea will settle uncomfortably in the stomach and may severely aggravate the illness. In contrast, if the formula is too bitter and/or spicy it will aggravate Dryness and Deficiency of Yin, leading to side effects such as thirst, delirium, agitation, restlessness, and night sweats.


Table 1. General categorization of Virulent Heat illnesses. Roughly, illnesses can be categorized by the depth of penetration, or severity, and the "Dry" vs. "Damp" quality of the illness. Wei-stage illnesses are the mildest forms, and are typical during the onset. Qi-stage illnesses are a common climax phase for many feverish infectious illnesses. (Qi-stage general Evil can be further differentiated into 4 sub-categories: Qi-stage onset, Qi-stage Excess Heat of Stomach and Lungs, Qi-stage Extreme Heat, Qi-stage Heat Congestion of Stomach and Intestines.) However, if an individual's immune system is compromised, certain virulent organisms (Ebola, yellow fever, dengue fever, Q-fever, SARS, etc.) may overcome one's defenses and the illnesses will progress to Ying or Xue-stage illnesses (such as the climax or end stage of hemorrhagic fevers) and Pericaridium-stage illnesses, which are severe and often life-threatening. (It is probable that even such virulent microbes as Ebola may result in either no illness or mild upper respiratory illness in relatively healthy individuals, depending upon the level of exposure, which underscores the importance of maintaining a healthy immune system.)
Dry Neutral Damp
Wei   Wei-stage Wind Heat:

· Acute; feels or dislikes cold; dislikes draft; fever low; perspiration excessive.

· Slight thirst.

· Sinus congestion; sinus discharge; cough severe.

· Pain; of head; of shoulders; soreness or ache; itching; of throat.

· Tongue: reddish; spots, red, near tip.

· Fur: normal.

· Pulse: floating; rapid.

  Wei-stage Wet Heat:

· Acute; feels or dislikes cold; dislikes draft; fever low; perspiration excessive.

· Thirst but no desire to swallow.

· Sinus congestion; sinus discharge; cough; nausea.

· Soreness or ache; of head; of shoulders; itching; of throat; distention; discomfort; of chest; heavy, dragging pain or discomfort; of whole body.

· Tongue: reddish; spots, red, near tip.

· Fur: greasy-wet; thick.

· Pulse: floating; rapid; slippery.

Qi Qi-stage Evil, general:

· Acute; becoming more severe; feels or

dislikes heat; fever moderate to high; perspiration difficult to excessive.

· Respiration: exaggerated; rasping.

· Thirst, extreme; prefers cold drinks.

· Urine dark-colored.

· Pain; discomfort; of torso; relieved by

cold; aggravated by pressure or touch.

· Tongue: red.

· Fur: yellow or part-white, part yellow.

· Pulse: rapid.

Qi-stage Wet Stagnation of 3 Burners:

· Acute-chronic; becoming more severe;

fatigue-lethargy; torpor; feels or dislikes heat; fever persistent, low.

· Respiration: exaggerated; labored.

· Appetite, lack of; thirst, lack of;

[or] thirst but no desire to swallow; prefers cold drinks.

· Urine dark-colored; urination scanty;

diarrhea or BM loose; diarrhea alternating with constipation; stools with foul odor; nausea; vomiting.

· Oppressive, distended pain; of

subcostal; of epigastrium; of upper abdomen; relieved by cold; aggravated by pressure or touch.

· Motion: ponderous, sluggish.

· Tongue: red.

· Fur: yellow; thick; greasy.

· Pulse: rapid; sinking; slippery.

· complexion orange-yellowish.

Ying Ying-stage Wind Heat:

· Acute; becoming more severe; feels or

dislikes heat; fever high, peaks at night; perspiration excessive.

· Respiration: rapid; exaggerated; rasping.

· Thirsty; prefers cold drinks.

· Urine dark-colored; eruptions, reddish.

· Pain; discomfort; of torso; relieved by

cold; aggravated by pressure or touch.

· Insomnia.

· Agitated or restless; apprehensive;

incoherent; stupor, semi-conscious.

· Tongue: red or scarlet.

· Fur: absent, often in patches, or very thin.

· Pulse: rapid; tidal; strong.

Ying-stage Wet Heat:

· Acute; becoming more severe;

fatigue-lethargy, severe; torpor; feels or dislikes heat; fever high, peaks at night; perspiration excessive.

· Respiratory: rapid; exaggerated; labored.

· Appetite, lack of; thirst, lack of;

[or] thirst but no desire to swallow; prefers cold drinks.

· Urine dark-colored; urination scanty;

diarrhea or BM loose; diarrhea alternating with constipation; stools with foul odor; nausea; vomiting; eruptions, reddish.

· Oppressive, distended pain; of

subcostal; of epigastrium; of upper abdomen; relieved by cold; aggravated by pressure or touch.

· Insomnia.

· Motion: ponderous, sluggish.

· Agitated or restless; apprehensive;

incoherent; stupor, semi-conscious.

· Tongue: red or scarlet.

· Fur: yellow; thick, absent in patches;

greasy.

· Pulse: rapid; sinking; slippery.

· Complexion orange-yellowish.

Xue Xue-stage Yin Damage:

· Acute; becoming more severe; feels or

dislikes heat; fever low, peaks at night; perspiration during sleep.

· Respiration: rapid; labored.

· Thirsty; prefers cold drinks.

· Urine dark-colored; eruptions, reddish;

eruptions, purplish-red; blood in sputum, vomit, feces, or urine; bloody nose (epistaxis); bleeding of the skin; bruises easily; menses excessive (menorrhagia); uterine bleeding (metrorrhagia).

· Pain; discomfort; of torso; relieved by

cold; aggravated by pressure or touch.

· Insomnia.

· Spasms and convulsions of extremities.

· Agitated or restless; apprehensive;

incoherent; stupor, semi-conscious.

· Tongue: dark red.

· Fur: absent, with shiny gloss.

· Pulse: rapid; small-thready.

Xue-stage Excess Heat:

· Acute; becoming more severe; feels or

dislikes heat; fever high, peaks at night; perspiration excessive.

· Respiratory: rapid; exaggerated; rasping.

· Thirsty; prefers cold drinks.

· Urine dark-colored; eruptions, reddish;

eruptions, purplish-red; blood in sputum, vomit, feces, or urine; bloody nose (epistaxis); bleeding of the skin; bruises easily; menses excessive (menorrhagia); uterine bleeding (metrorrhagia).

· Pain; discomfort; of torso; relieved by

cold; aggravated by pressure or touch.

· Insomnia.

· Agitated or restless; apprehensive;

incoherent; stupor, semi-conscious.

· Tongue: very dark red.

· Fur: absent, often in patches, or very thin.

· Pulse: rapid; tidal; strong.

Pericardium Percardium-stage Heat:

· Acute; becoming more severe; feels or

dislikes heat; fever high, peaks at night; perspiration excessive.

· Respiratory: rapid; exaggerated; rasping.

· Thirsty; prefers cold drinks.

· Urine dark-colored; [possibly]

constipation; eruptions, reddish.

· Pain; discomfort; of torso; relieved by

cold; aggravated by pressure or touch.

· Comatose.

· Convulsions.

· Tongue: red-scarlet, intense.

· Fur: absent, often in patches, or very thin;

yellow; dry.

· Pulse: rapid; bowstring-thready.

Percardium-stage Mucus Fire:

· Acute; becoming more severe;

fatigue-lethargy, severe; torpor; feels or dislikes heat; fever moderate; perspiration excessive.

· Respiratory: rapid; exaggerated; labored.

· Appetite, lack of; thirst, lack of;

[or] thirst but no desire to swallow; prefers cold drinks.

· Urine dark-colored; urination scanty;

diarrhea or BM loose; diarrhea alternating with constipation; stools with foul odor; nausea; vomiting; eruptions, reddish.

· Oppressive, distended pain; of

subcostal; of epigastrium; of upper abdomen; relieved by cold; aggravated by pressure or touch.

· Insomnia.

· Motion: ponderous, sluggish.

· Comatose; stupor, semi-conscious; [if

still conscious:] agitated or restless; apprehensive; incoherent.

· Tongue: red or scarlet.

· Fur: yellow, perhaps white; thick; greasy.

· Pulse: rapid; soggy-slippery.

· Complexion orange-yellowish.

Typical symptom manifestations of SARS

Because the microbial cause of SARS is the subject of ongoing research and debate, it is still classified as a syndrome, and as such, the definition is subject to arbitrary qualifications and restrictions in order to allow classification of patients. According to the CDC, to qualify as SARS, the fever must be greater than 100.4 deg.F. "Other symptoms may include headache, an overall feeling of discomfort, and body aches. Some people also experience mild respiratory symptoms. After 2 to 7 days, SARS patients may develop a dry cough and have trouble breathing." In the early stages, therefore, this definition of SARS would be classified as Wei-stage Wind Heat.

According to Health Canada, SARS may also include the following symptoms: headache, myalgia, loss of appetite, malaise, confusion, rash and diarrhea. Malaise, diarrhea, and confusion are potential symptoms of Interior Dampness, so if these symptoms are also present in the early stages, along with a greasy tongue fur, Wei-stage Wet Heat would more accurately describe the condition. Considerable variations in individual symptoms are possible; the same infectious organism may affect different people differently within a range of possibilities.

According to reports from Chinese hospitals, combined therapy with western drugs (including Ribavirin as an antiviral, other antibiotics to handle mycoplasma infections) and Chinese herbal formulas tailored to the individual TCM pattern has resulted in significantly greater survival rates. Corticosteroids are often administered to prevent the destructive effects of inflammation, although side effects include immune system suppresion, aggravated spread of infection, and induction or aggravation of ulcerative bleeding. The Chinese herb Rx Glycyrrhizae (licorice root, gan- cao~) has significant anti-inflammatory effects without the severity of side effects of corticosteroids, and is included in many herbal formulas for Virulent Heat illnesses; however, it is also not as potent.

Inflammation and tissue destruction may result in Stagnation of Blood, which may manifest on the tongue as a dusky or purplish-reddish coloration, and in the pulse as a choppy, irregular quality to the pulse profile. In such cases, herbs to clear Heat and resolve Blood Stasis are often included, such as Rx Paeoniae Rubra (chi\ shao/) and Rx Salviae Miltiorrhizae (dan- shen-). Damage to the Blood, with both Blood Stasis and possible hemorrhage, is more likely to occur as the illness becomes more severe and enters the Xue stage. Lungs becoming congested with fluid and impeding breathing is one common problem in SARS, and according to TCM theory, if the Blood pathways are blocked, this may create an obstruction to the flow of Qi and of Fluids, resulting in Fluid Stagnation in the Lungs. The solution requires the use of herbs to unblock the flow of Blood, as well as herbs to drain Fluids and Dampness, and resolve Lung Phlegm.

The use of Chinese herbs together with drugs should always be done with caution and attention to possible drug-herb interactions. It is best to administer herbs at a time of day several hours before and after administration of drugs. Interactions may be minimized this way, but not completely eliminated. According to Chinese hospitals, for example, certain Chinese herbs may inhibit the effectiveness of steroids, and if large amounts of steroids are required, Chinese herbs may be best avoided.

The clearest examples of the effectiveness of Chinese herbs I've witnessed is with individuals for whom the doctors have given up hope after trying all standard drug treatments. I know of several such individuals who have recovered from life threatening infectious illnesses after taking only Chinese herbs following the failure of standard medical therapies. Before the era of antibiotic resistance, these cases were rare, but are becoming more common in America as doctors and hospitals give permission for family to bring in herb teas to relatives who have received standard therapy with little or no effect.

Miscellaneous factors in SARS

There has been speculation about the microbes responsible for the SARS epidemic. Coronaviruses are thought my many epidemiologists to be a likely factor, and there is circumstantial evidence that the specific coronavirus responsible for SARS shows signs of significant genetic engineering, possibly as a consequence of a bio-weapons research. Other opinions suggest the possibility that people who contract SARS may actually be infected by multiple pathogenic organisms simultaneously, and that the severity of the illness in some is due to the combined stress on the body's immune system from all these microbes. Mycoplasmas are one of the hypothesized organisms, and for many decades mycoplasmas have also been the subject of genetic engineering and bio-warfare research. Mycoplasmas have been the focus of investigation by private physicians and researchers, such as Garth Nicolson and Joyce Riley, who have exposed its role in Gulf War Syndrome and have accused the U.S. government, especially the Veterans Administration, of covering up the seriousness of mycoplasma infections.

Mycoplasmas are small organisms that can invade human cells and sequester themselves from attacks by the immune system. This is one of the reasons why they are so difficult to counteract using a conventional anti-microbial strategy. The immune system often becomes "confused" in its attempt to deal with the infection, which is how autoimmune-type disorders may be triggered in mycoplasma infections. The failure of SARS to respond to conventional antibiotics, plus its seeming ability to trigger a vigorous, but futile immune reponse in many cases is very similar to the types of crises that may occur in chronic mycoplasma infections. Corticosteroid administration in such situations is understandable to avoid such lethal hyper-immune responses, even though they also may suppress healthy and functional immune responses and may prolong the infection. The lessons learned over the years by private investigators and health professionals from the mycoplasma phenomenon suggest that eating a healthy diet and taking herbs that strengthen and/or regulate the immune system ("adaptogenic" herbs) before an acute crisis or virulent infection occurs is the best way to protect against such possibilities. According to time-tested experience of TCM herbalists, the best way to strengthen each individual's immune system will depend upon individual constitutional factors — "One man's poison may be another's medicine" — and is the subject of entire textbooks of Chinese herbology (such as RMHI's Self-Study Reference, see below).

The suggestion that severe cases of SARS may be due to infection by multiple microbes is eerily reminiscent of the principle behind binary weapons. A binary weapon, in general, is defined as a pair of chemical or biochemical compounds which must react, either in a direct chemical reaction preceding exposure, or indirectly in the body of a victim. As an example of the latter, suppose that a subgroup of people in an area are exposed to substance "A". Later, the entire region is exposed to substance "B". Only the individuals exposed to both A and then B will become ill. People exposed only to A or to B, but not both, will remain healthy. The principle of operation of indirect binary weapons is very closely related to the principle of drug interactions, in the sense of using a substance to enhance or magnify the toxicity of another substance or biological agent.

In the early 1990's, I was contacted by a source who claimed to have worked in chemical warfare research. At that time he informed me about the general principles of binary weapons, years before articles on the subject appeared on the Internet. He also suggested that caffeine and methylxanthine compounds generally (theophylline in black and green tea, theobromine in chocolate) were commonly assigned the role of substance "A" in designing binary weapons. (Presumably, if this were true, people with inside knowledge would simply avoid consuming foods and drinks containing these compounds.) In the intervening years since that time, I have observed a steady increase in the number of people with severe hypersensitivities to methylxanthines. Joint pain, arthritic-type illnesses, fibromyalgia, lowered general immunity, and allergies are some of the conditions that may be aggravated by methylxanthines. The correlation between fibromyalgia and other connective tissue disorders and mycoplasmas, and the suspicion that mycoplasmas may play a role in both SARS and in Gulf War Syndrome, plus the suspected methylxanthine connection should lead investigators to further examine the relationships among all these factors.

During an acute feverish illness, it is my experience that while choice of herbs and herbal formulas must be tailored to the individual and the stage of the illness, there are certain general principles that apply broadly to most types of acute feverish illnesses:

  • Get plenty of rest and sleep; stress and lack of sleep are well known to seriously compromise immune function.
  • Drink fluids: warm or hot liquids during the early phase of chills and low fever, room temperature liquids as fever rises. (Cold liquids damage the "Spleen and Stomach".)
  • Avoid heavy, complex meals in favor of soups made of vegetables, rice or potatoes, and only moderate amounts of meat; in certain cases, especially those involving "Dampness", consume only the meat broth. "Avoid tonifying the Excess" is the TCM principle followed here; nutrient-rich foods such as eggs, cheese, milk, red meats, and nuts may aggravate an acute "Excess" illness. I've witnessed many cases of rapid recovery from acute illness following temporary simplification of one's diet.
  • Hot-spicy foods such as garlic, ginger, and cayenne pepper may be beneficial during the early stage of chills and low fever, but are to be strictly avoided if the illness becomes more severe and the fever increases. (One does not use hot-spicy herbs for Interior Heat conditions; this is like adding fuel to the fire.)
  • Turn off the television and radio. Listening to lies and propaganda will only add to one's stress levels. Instead, put some Haydn or Mozart on your stereo. (There is a lot of research confirming the beneficial effects of good music, and an increasing number of hospitals are putting this research to work.)
  • Avoid taking antibiotic drugs or herbs in the absence of any signs of fever and infection, as these may only compromise one's intestinal flora, which is an important component of one's immune system.

For more information

Design of formulas for Virulent Heat illnesses is usually considered an advanced topic in many TCM training programs. This article should be considered as a general introduction to this topic; it would be irresponsible of us to list herbal formulas "for SARS" here, as these as likely to do harm as to help without a moderate amount of self-study and investigation.

The best way to minimize your risk of contracting a serious illness is to eat a healthy diet, which will vary for each individual, listen to good music, enjoy life, and leave the fear-mongers behind. Fear, panic, and general stress are important factors in immune system suppression, so to avoid this, turn off your television, take common sense actions appropriate to prepare for crises, and then sleep well, knowing that you have taken responsibility for preparing yourself and your family as best you can. Often, the people most responsible for panic are those who do not wish to investigate what is happening in the world and fail to take appropriate action; these are the people who will become a burden to those of us who have done what we can.

References

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