Report from the Front Line in Wuhan
刘力红 | 深入一线后的一点思考
By LIU Lihong
On the evening of February 21, carrying the mandate of my teachers Lu Chonghan, Yang Haiying and Yang Zhenhai as well as the expectations of the Tongyou Sanhe community of Chinese medicine practitioners, I arrived in Hankou together with Dr. Lei Ming. The 3rd member of our coronavirus treatment team, Dr. Zhao Jiangbin, arrived the next day.
怀揣着卢师和二位杨师（海鹰师、真海师）的嘱托及所有三和人的期望，我与雷鸣医生21号晚抵达汉口（赵江滨医生次日抵达）。
During the first three days, we underwent intensive training about hospital rules and protective gear at Hankou Hospital No. 8. In the afternoon of February 24, we entered into the clinical section of the hospital. The inviting unit, the Hemorrhoid Department No. 3 at Hankou Hospital No. 8, had so far received 20+ patients in all stages of COVID-19 pneumonia. Some of them had been there for almost 2 months, while on the shorter end some had been in inpatient care for about 3 weeks. Quite a few of them never tested positive for the virus, but all CT images revealed typical signs of coronavirus-based pneumonia.
前三天对接汉口八医院医务科及痔三科相关事宜，并作认真的防护培训。24日下午进入病房。痔三科收治了20多位病人，病程长短不一，有近两月的，也有二十多天的。虽然大部分核酸检测不呈阳性，但CT片都示典型的新型肺炎改变。
Altogether, we have so far diagnosed and treated more than 10 patients with obvious signs of discomfort. The others either didn’t exhibit any symptoms, or they did not wish to be treated with Chinese medicine modalities. According to our own observations and those of other practitioners reporting from the front lines of the outbreak, it has become clear that the initial stage of the infection is not at all characterized by typical pneumonia symptoms such as fever and coughing. Many coronavirus patients cough only little or not at all, while their X-ray images show clear evidence of pathological changes due to COVID-19 pneumonia.
我们具体查治了有不适表现的十余例患者（其余有的无身体不适，有的无中医治疗的意愿，故未作查问），结合其他一线同仁提供的信息，发病初期呈现典型发热咳嗽的并非全部，相当一部分病患完全没有或很少咳嗽，但CT却呈现新冠肺炎改变。
Although I have published a variety of opinions and recommendations on potential approaches to the epidemic in recent weeks, I have to admit that after seeing actual patients for 6 days now things have turned out a bit differently from my initial thoughts. I am very aware that all of my friends, colleagues and students are eager to receive news from our treatment team in Wuhan about the actual nature of the epidemic. Therefore, please find our initial impressions below:
虽然，前期在我个人的微博上及同有三和的各种平台上发表过一些建议和看法，但真正深入一线，经历六次的查房治疗，感受还是不一样的。我相信关注三和及我本人的朋友，也非常期待着我们的感受。下面分两方面来简要地谈一谈：
I. Understanding the Nature of the Disease and Developing Appropriate Treatment Approaches
其一，病情的认识及对治
• Dampness (shi): Almost everyone agrees that dampness is at the core of this disease. All of the cases we have encountered so far display a thick, white, sticky tongue coating. Since our arrival in Wuhan, every one of us has observed an increase in sticky coating on our own tongues, as well as the onset of incomplete bowel movements.
1.湿 湿或湿浊几乎是一致的看法，我们看到的这些案例，全都是白厚腻苔，而我们一行四人（另一位芳华兄做协调保障）进入武汉后全都大便不畅，并且舌苔也变得比原来腻一些。
• Pulse (mai): The biggest common denominator among patients has been the fact that virtually everyone exhibits a slippery pulse in the cun position of the right hand. This phenomenon signifies that turbid damp obstructing the Lung is the main characteristic of this epidemic.
2.脉 从我们接触的这些案例看，最为共性的是右寸脉滑，几乎每人都一样。这说明肺上的痰浊成为此次肺炎的共性特征，而上述的腻苔除湿浊的因素外，肺蕴的痰浊也是厚浊腻苔的主因。
• Absence of Phlegm (wutan) or Low Phlegm Production (shaotan): Typical symptomology includes either a dry cough or no cough. Because on one hand the normal way of phlegm expulsion by coughing is missing and on the other turbid damp pathogens are obstructing the middle burner, the resultant blockage of normal transformative pathways causes turbid phlegm to congeal into a rubbery and glue-like material that severely interferes with proper airway function and has no way out. This is the most important reason for the lingering “stalemate” quality of the disease, as well as the tendency to take a sudden turn for the worse.
3.无痰或少痰 普通的现象是干咳甚或不咳，一方面藉由咳嗽而排痰的重要路径缺失，另一方面，湿浊又困阻中焦，使运化的路径受阻，痰浊胶粘阻塞气道甚至肺泡，无有出路，这是病情缠绵僵持甚或形成急转直下的重要原因！
• Complexity Syndrome (hebing) and Dual Affliction (lianggan): According to my own observations, from the very beginning of the epidemic all the way until now at the front line, as well as the opinions shared by my Chinese medicine colleagues working in Wuhan, the etiology of COVID-19 pneumonia is very much a manifestation of Zhang Zhongjing’s classical theory of syndrome complexity and dual pathogenesis. In other words, one can confidently say that this particular epidemic from beginning to end bears the characteristics of what is called Complexity Syndrome and Dual Affliction in the Shanghan zabing lun (Treatise on Disorders Caused by Cold and Miscellaneous Disorders).
4.合病与两感 从疫情发生以来的关注，到此次亲上一线，及与一线中医同仁们的沟通交流，此次疫病充分彰显了仲景《伤寒论》对合病及两感论述的意义。也可以说这次的疫病自始至终都伴随着合病与两感。
None of the cases we encountered manifested with simple Taiyang Syndrome in the initial stages of the disease, but they all came down right away with Taiyang Yangming Combination Syndrome, or even a situation where all three yang channel systems (taiyang, yangming, shaoyang) were involved. Many patients exhibit signs of dual pathogenesis right from the get-go, by coming down with a rapidly progressing respiratory infection with signs of both taiyang and shaoyang disease. In some instances, the disease lingers at the yangming taiyin dual affliction stage, while others suffer from taiyang shaoyang dual affliction that is further complicated by yangming taiyin issues. Comparatively speaking, shaoyang jueyin dual afflictions are rare. As for the Complexity Syndrome (hebing) variant, which specifically refers to a situation where both the surface and the interior and zang and fu organ systems are involved at the same time, an example would be the simultaneous affliction of the Lung and the Large Intestine.
从初发生就没有单纯的太阳（或卫分）证，而是太阳阳明合病，甚或三阳合病。两感亦是，有的初发生就进入太少两感，进而危急生命。有的则僵持在阳明太阴两感的阶段，有的则太少两感、阳明太阴两感混杂，相对而言，少阳厥阴两感较为少见。有的则属表里脏腑两感（或曰合病），如肺与大肠合病。
An appropriate prescription needs to take all of these aspects into consideration. Many of the recently publicized anti-COVID-19 formulas display this characteristic of complexity. The Cinnamon Method (Guizhi Fa) approach suggested by my Fire Spirit School mentor Dr. Lu Chonghan, furthermore, represents a typical approach to Taiyang Yangming Complexity Syndrome. Other suggestions, such as Ma Xing Shi Gan Tang (Ephedra, Apricot Seed, Gypsum, and Licorice Decoction) and similar remedies, or Mahuang Tang (Ephedra Decoction) plus Weijing Tang (Phragmites Decoction) are all examples for approaches to more complex syndromes.
因此，于处方用药上需综合考量这些因素。如国家颁布的中医治疗方案中，实际上就体现了上述因素的关照。而卢师给出的桂枝法化裁，便是太阳阳明（阳明偏在脏）合病的典型方法。其余如麻杏石甘类，麻黄汤合千金苇茎类等，皆属合病对治的范畴。
For dual affliction (lianggan) conditions, moreover, the Aconite Method (Sini Fa) of the Fire Spirit School is also an important method to consider. Especially in situations where “dampness is pronounced and yang is feeble” (shisheng yangwei) the inclusion of aconite containing formulas is particularly appropriate. Aconite, of course, should always be used cautiously—proper differential diagnostics is always the most important prerequisite for any prescription!
而对于两感患者，四逆法无疑是重要的法，尤其对于“湿胜阳微”的病况而言，附子的应用更显重要。当然，附子绝不能滥用，辨证是前提的前提！
• Moisten Dryness and Transform Phlegm, Remove Zang Disease via the Corresponding Fu Organ
5.润燥化痰与脏病腑除
How is it possible to liberate the airways by expelling the sticky, rubbery, glue-like phlegm that is obstructing the lungs all the way into the alveoli? This question is most relevant for the eventual outcome of the disease process! Why is the typical COVID-19 patient hardly coughing or not coughing at all?
粘稠胶着塞满了气道甚至肺泡的痰如何化解，如何排除？直接关系到病情转归。为什么病人只有干咳甚至不咳？
I believe that this specific characteristic of the disease is mostly due to the presence of sticky phlegm, which occupies the available airway space normally required for the generation of a productive cough. From the perspective of Chinese medicine, this phenomenon belongs to the category of dry phlegm (zaotan). This kind of issue requires an approach that involves moisturizing dryness and transforming phlegm (runzao huatan). The herb Dongguaren (Benincasa), for instance, from the afore-mentioned remedy Weijing Tang is a representative herb in this category. Many other seeds possess this type of therapeutic function, i.e. Gualouren (Trichosanthes seed), Laifuzi (Radish seed), Baijiezi (Mustard seed), etc.
痰的粘稠胶着使气道完全丧失空间让咳嗽来排解，应是重要的原因。这于中医来说，属于燥痰的范畴，必须通过润燥化痰的方法解决。如上述千金苇茎中的冬瓜仁便属此类药的代表。另外，种子或仁类的化痰药基本具备这类功用，如瓜蒌仁、莱菔子、白芥子等。
However, this type of super-sticky phlegm cannot necessarily be completely expelled via the prescription of moisturizing and phlegm transforming herbs. This is where the maneuver of utilizing the zang-fu relationship of Lung and Large Intestine comes into play, by removing zang disease by way of the associated fu organ; by addressing yin disease via its yang counterpart. This approach has often been used within the versatile arsenal of Chinese medicine modalities. Examples can be found in historical case studies.
当然，如此㬵着的痰未必全能通过润燥化痰而由气道排除，那么接下来的妙招是透过肺与大肠的表里关系，脏病腑除，阴病转阳，这在中医的治法中当属变法中的常法，其历史的经验丰富可参。
Specifically, this means that the seed varietals of phlegm transforming herbs, if used in sufficient amounts, can expel residual glue-phlegm from the Lung via the Large Intestine. In the arena of acupuncture, the corresponding method would be to needle Taiyuan (LU9) all the way connecting to Yangxi (LI5), or Yangxi all the way to Taiyuan.
而上述诸籽仁类的化痰药，只要剂量合适，是足以能将肺中的胶痰通过大肠排除的。若用针剌，则太渊透阳溪或阳溪透太渊即属上法的灵活运用。
II. The Importance of Acupuncture Therapy
其二，针刺治疗的必要性
Our team began treating every single patient with acupuncture starting on our first day in the coronavirus section. Because of the logistics associated with buying and preparing herbs, our patients started imbibing herbal decoctions only 3 days later.
从我们查治的这十余例病人看，除个别畏惧针灸外，第一次查房就全部用上了针刺（中药因为联系煎药等事项，第三天才吃上）。
I remember how I felt slightly awkward when approaching my first patient with a needle. For one, the protective gear with its plastic eye goggles blurs the vision. Secondly, three layers of gloves greatly dull sensitivity in the needling hand. And thirdly, I was worried that the patient would trust me, a doctor who had never treated this kind of disease before. I was therefore completely taken by surprise when the patient exclaimed: “This works like a miracle! The stuffy feeling in my chest is completely gone!” And another patient said shortly thereafter: “My throat and chest area used to feel as blocked as a road during rush hour—now it has become like an open road without a single soul on it.”
记得给第一位病人针刺，心中还是稍有忐忑的。一则严密的防护下，眼睛因为护目镜的影响看不太清楚，二则戴上三层手套后的手已远不如之前灵巧，三是第一次给这样的病人下针，不知买不买账？不料针下去以后，病人愣住了，“怎么会有这么神？！胸完全打开了，不闷了！”而另一位病人述说道“之前的咽胸，就像过去上下班高峰期的马路一样堵得慌，怎么针下去就变成现在的马路了，空无一人。”
This sort of feedback was a pleasant and unexpected surprise for us, providing us with hope and strength at the same time. Most of the accompanying symptoms, such as stuffiness in the chest, shortness of breath, abdominal discomfort, itchy throat with the urge to cough, dizziness, cold sensation in the upper back, connective tissue pain, sweating, etc, did either decrease with the acupuncture treatments or resolve entirely.
病人的反馈既给了我们惊喜，也给了我们信心和力量。病人所描述的不同症状，如胸闷、短气，如胃脘和肚子不舒服，如咽痒咳嗽，如头晕、背寒，如肌肉酸痛、汗出等等，皆能随针缓解或消失。
This experience proved that my earlier suggestion to “use acupuncture and herbal medicine together” in the treatment of this epidemic was realistic. Perhaps the greatest benefit of acupuncture is the immediate improvement in the emotional outlook of patients, since they get to experience a noticeable improvement in a short period of time. This aspect cannot be underestimated in the process of curing this disease.
这证明了我们之前提出的对于此次疫情“应针药并用”是有现实意义的。用针的另一层意义在于，随着不适的迅速缓解或消除，病人沉闷的心境被打开了，这会大有利于病的向愈。
Overall, however, the term “cure” needs to be used with extreme caution in the context of this pneumonia epidemic. This is definitely not the kind of situation where one is all better once the fever has broken, or one is OK once the coughing spells come to an end, or when the virus test turns from positive to negative. There are at least 3 additional elements that are prerequisites for a complete cure of COVID-19 related issues: 1) The complete remission of pneumonia signs on CT images; 2) The normalization of all Lung channel abnormalities; 3) The disappearance of sticky tongue coating. Otherwise, the disease may come roaring back for another round!
综上所述，对于此次的肺炎，“治愈”二字实不可轻言。不是烧退就好了，也不是不咳就ok了，更不是核酸阴性就万事大吉，关照真正的痊愈至少还有三个方面：一是CT胸片的彻底改观；一是肺脉的转常；一是舌苔退净。否则，卷土重来的可能性是随时存在的！
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