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The epidemiological data of influenza can serve as a basis for effective use of wenbing theory in the management of the 2009 H2N1 influenza. The long history of Chinese medicine in general and of the wenbing school specifically holds much evidence on adapting and responding t changes in the climate, environment and newly emerging diseases. Uncovering and comparing these data and information from Chinese medicine with modern epidemiological ones can perhaps offer another legitimate and valid way of understanding and treating contemporary diseases. Such a methodology may also be another strategy for integrating biomedicine with Chinese medicine. This paper will examine some of the epidemiological features of the 2009 H1N1 influenza and their similarities with the main characteristics of wenbing or warm diseases in Chinese medicine. It is suggested that the 2009 H1N1 influenza can be managed from a wenbing perspective using a four phase approach.
Australian Journal
of Acupuncture and Chinese Medicine 23
Aust J Acupunct Chin Med 2010;5(2):23–29
* Correspondent author; e-mail:
Andrew Koh* MA, BA(Hons), DipNursing, RN
Sydney Institute of Traditional Chinese Medicine
Wen Bing
(Warm Diseases)
and the 2009 H1N1 Influenza
wen bing 温病 or warm diseases in Chinese medicine (CM).
Some epidemiological data will be used to underscore the
theoretical foundations and practice of wen bing. It is suggested
that the 2009 H1N1 influenza can be managed from a wen
bing perspective using a fourfold management approach.
Influenza – warm diseases
Influenza is categorised in CM as an exogenous warm
disease or wen bing; the 2009 H1N1 virus falls into the same
classification.10-12 However, the treatment of such diseases
is based on the pattern differentiation fundamental to the
practice of CM. It involves diagnosing from a presenting set
of signs and symptoms and treating the condition according
to CM principles.
Epidemic diseases have been recognised by CM physicians
since the Han Dynasty, as evidenced in the Shang Han Lun
寒论 of Zhang Zhong Jing 张仲景 (150–219 CE), a text that
predates the biomedical appreciation of epidemic by several
hundred years.11,13 The Chinese medical theory of epidemic
diseases, however, was developed by Wu You Xing 吴有性
(1582–1652), who proposed that such diseases were caused
I had a little bird
And its name was Enza
I opened the window
And in-flew-Enza
(An anonymous schoolgirl’s poem from the time of
the 1918 H1N1 Spanish Influenza)
Epidemiology of the 2009 H1N1
The 2009 H1N1 (swine flu) is the first influenza pandemic of
the twenty-first century. Its rapid spread across the globe has
caused considerable panic among health authorities and the
general public worldwide.1 The pandemic raised the spectre
of the 1918 Spanish flu, which killed between 20 and 50
million people.2-5 As of 17 October 2009, the World Health
Organization reported 414 000 laboratory-confirmed cases
of 2009 H1N1 and nearly 5000 deaths.6 The US president
declared a national emergency on 23 October 2009 with
regard to the H1N1 pandemic.7-9 This reflects the seriousness
with which various world governments viewed the situation.
This paper will examine some of the epidemiological features
of the 2009 HIN1 influenza with the main characteristics of
The epidemiological data of influenza can serve as a basis for the effective use of wen bing 温病
theory in the management of the 2009 H1N1 influenza. The long history of Chinese medicine in
general and of the wen bing school specifically holds much evidence on adapting and responding
to changes in the climate, environment and newly emerging diseases. Uncovering and comparing
these data and information from Chinese medicine with modern epidemiological ones can perhaps
offer another legitimate and valid way of understanding and treating contemporary diseases. Such
a methodology may also be another strategy for integrating biomedicine with Chinese medicine.
This paper will examine some of the epidemiological features of the 2009 HIN1 influenza and
their similarities with the main characteristics of wen bing or warm diseases in Chinese medicine.
It is suggested that the 2009 H1N1 influenza can be managed from a wen bing perspective using
a four phase approach.
KEYWORDS wen bing, pandemic, H1N1, swine flu, influenza, lingering pathogens,
Australian Journal
of Acupuncture and Chinese Medicine
24 2010 VOLUME 5 ISSUE 2
A Koh
Wen Bing Xue and
2009 H1N1
Within clinical settings, CM physicians are likely to note that:
• The onset of the warm disease is acute;
• Heat signs, especially fever, are certainly present at the initial
• Manifestation of the disease changes frequently due to heat
injuring body fluids and yin.11-12,14-15
When influenza, including the 2009 H1N1, is examined, the
characteristics and features closely resemble those described of
warm-heat pathogenic qi above (see Table 1).
by pestilence qi or li qi 疠气, and expanded by various wen
bing physicians through the centuries.11-12 The development
of various schools of CM practice is a direct recognition that
diseases change over time and space. In the time of Zhang
Zhong Jing and his contemporaries, cold pathogen was the
main theoretical focus in northern China. The major cause of
diseases came to be seen as warm pathogen by the sixteenth
century, an approach that was dominant in central and
southern China. Such a shift in perspective nevertheless makes
use of the same CM principles. While some of the wen bing
physicians seem to distinguish between warm diseases and
pestilence qi, the contemporary CM approach is to treat the
two concepts as equivalent.12 The main reason is that ‘pattern
identifications and treatment determinations are too similar to
those of the four season warm diseases’.12 Accordingly, in this
paper both terms will be used interchangeably.
Warm diseases are characterised by the following:
1. They are caused by warm-heat pathogenic qi, contracted
externally through the nose and mouth as opposed to
through the skin as taught by Zhang Zhong Jing.
2. They are infectious diseases that can become epidemic
under certain conditions, seasonal and geographical,
though they are not bound by either. Seasonal influences
do, however, play an important role in the rise, spread,
virulence and mutability of the diseases. Hence, the warm
diseases bear names such as spring warmth 春温, latent
summerheat 伏暑, and autumn dryness 秋燥.11-12
3. They are diseases that penetrate according to a standard
rhythm or levels, i.e. through the wei (defensive),
qi , ying (nutritive), xue (blood). The speed at
which a warm disease progresses from one level to another
is not necessarily constant, gradual or sequential, as it is
predicated on the constitution of the individual and the
virulence of the pathogenic qi.
4. Such diseases have special clinical characteristics, one of
which is the presence of fever throughout all four stages.
Others include cough, sore throat, tiredness, headache,
and bodyache.11-12,14
The three key features of warm-heat pathogenic qi are:
1. Symptoms appear very quickly;
2. Heat signs and symptoms often predominate;
3. The hot nature of the pathogenic qi readily injures body
fluids and yin.11-12,14
TABLE 1 Features of
Wen Bing
Disease and
H1N1 2009
Wen Bing H1N1 2009 virus
Pathogenic qi enters via nose
and mouth into the lungs
Virus spreads through
coughing or sneezing,
eventually settling into the
lungs causing respiratory
Sore throat
Runny nose
Sore throat
Runny or stuffy nose
Bodyache, myalgia
Signs and symptoms appear
quickly Acute presentation
Hot nature; yin and body
fluids readily consumed Fever is a key symptom
The Centre for Disease Control and Prevention notes that
influenza viruses of all known types, including the 2009
H1N1, are ‘spread mainly from person to person through
coughing or sneezing by people with influenza. Sometimes
people may become infected by touching something – such as
a surface or object – with flu viruses on it and then touching
their mouth or nose.’16 The signs and symptoms of influenza
are fever, cough, sore throat, runny or stuffy nose, body aches,
headaches, myalgia, chills, fatigue, possibly nausea, vomiting
and diarrhoea.17-19
Australian Journal
of Acupuncture and Chinese Medicine 25
A Koh
Wen Bing Xue and
2009 H1N1
Severity depends on how deeply the pathogen has invaded the
body in a given geographical setting and climate. The signs,
symptoms and transmission route ascribed to influenzas are
strikingly similar to those described by the wen bing school
病派. Thus, the condition that biomedicine calls ‘influenza’ has
been identified by the wen bing school several hundred years
earlier. The treatment methods and strategies used by the wen
bing school have been and continue to be applied successfully.
On looking at historical evidence, Cheng and Leung observed
that the 1918 H1N1 pandemic had significantly less impact in
China than in the rest of the world. They pointed out that early
twentieth-century China was ‘an underdeveloped and closed-
door country at that time, and it is not likely that China’s
general population used western medicine as the main means
of disease treatment. Traditional Chinese medicine would have
been the only form that the public relied on’.10
Cheng and Leung seem to suggest from the epidemiological
data that traditional Chinese medicine is just as effective (if
not more so) as biomedicine, in treating virulent influenza.10
Although the authors did not mention the wen bing school
specifically, this paper asserts the likelihood that the school’s
theories and treatment strategies underpinned the CM
approach to the 1918 influenza.
The Importance of Zheng Qi
According to the wen bing school of thought, warm diseases
take the path of least resistance. Individuals with a weak or
weakened zheng qi 正气 (vital qi, also translated as upright qi)
are most likely to be among the casualties.11-12,14,20 Zheng qi can
be damaged and drained away by a poor lifestyle, unbalanced
diet, overwork, and emotional upheavals. Zheng qi can also be
compromised if there is a constitutional weakness, that is, if a
person’s jing was not strong at birth.20 Epidemiological studies
of the 2009 H1N1 appear to support the wen bing school in
this regard. The World Health Organization reports that the
very young, the elderly and the immuno-compromised are
subject to attacks of seasonal influenza and these groups are
at particular risk of severe development when infected with
the 2009 H1N1 virus.19 In severe cases, most patients needed
immediate respiratory mechanical support upon admission
to a hospital. From the wen bing school’s viewpoint, the
organ system that is most severely affected by influenza is the
respiratory. Thus, warm pathogen first attacks via mouth and
nose, entering into the lungs, causes damage there and then
progresses to the stomach and in some cases directly to the
pericardium.11-12,14,20 The WHO further points out that in
severe cases, co-morbidity is commonly present, whether in
the form of chronic lung disease or neurological disorders. Two
other groups were singled out as at risk, namely, minority and
indigenous groups, where poor nutrition, lifestyle and access
to healthcare are the key factors. From a wen bing perspective,
in all these groups of people, zheng qi is already weak and
therefore, the body is unable to resist any exogenous pathogen.
The wen bing perspective suggests that as members of these
groups are more likely to suffer from deficient zheng qi, they
are often already weak and therefore, unable to resist the attack
of an external pernicious agent.
The 2009 H1N1 influenza distinguishes itself from seasonal
influenza in the relatively high number of apparently healthy
and fit young people infected.21 However, the appearance
of health does not in CM’s view necessarily imply health
itself. What dictates health according to CM is the internal
constitution of the individual, the strength of the qi and blood,
and so forth. The wen bing school postulates that previously
healthy young people who are infected with the 2009 H1N1
influenza virus probably have weak Zheng Qi.
On the other hand, wen bings pestilence qi can also be
overwhelmingly powerful so that even individuals with strong
zheng qi can succumb to the disease. In such cases, however,
these individuals are far more likely to recover from the disease
and do so in a shorter time than their weaker counterparts.11-12,14
In applying this approach, the wen bing school can account for
the unusual number of presumably healthy young people who
were infected with the 2009 H1N1. The concept of zheng qi
and its role in resisting exogenous pathogens also explains why
in this pandemic, most people only experienced a mild form of
the disease, lasting three to five days.1
With these wen bing concepts and epidemiological data in
mind, a four-phase CM wen bing approach to managing 2009
H1N1 is proposed. The strategy will include tools of CM that
are not specifically related to the wen bing school.
Managing the 2009 H1N1 Influenza
Zheng qi is pivotal in resisting any exogenous disease. There are
several methods for strengthening one’s zheng qi.
(i) Diet: maintain a balance in the various types of food, eat
according to the seasons and one’s constitution, avoid
overeating, eat up to 70–80% of what is needed, and keep
everything in moderation. Cooked food is preferred as it
is easier to digest.22
(ii) Exercise: workouts, brisk walks, taijiquan 太极拳, qigong
, yoga, slow running, gardening, any physical activity that
causes mild sweating and exerts the body’s system will help
improve one’s condition and strengthens one’s zheng qi.20
(iii) Stress management: while a little mental and emotional
stress can be beneficial, too much of either becomes
Australian Journal
of Acupuncture and Chinese Medicine
26 2010 VOLUME 5 ISSUE 2
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Wen Bing Xue and
2009 H1N1
detrimental. Over-thinking injures the spleen and
sustained emotional upheaval injures the lungs, heart,
kidneys and liver.
(iv) Acupuncture: it is common knowledge in CM that
stimulation of the acupuncture point ST 36 Zusanli
strengthens one’s constitution.20,23 This can be done daily
or for three consecutive days each week. Stimulation can
take the form of either needles or 100 moxa cones in each
session.23 Other acupuncture points to consider are CV 6
Qihai, CV 4 Guanyuan and KI 1 Yongquan.20
(v) CM herbal decoctions: take herbal formulae appropriate
to one’s constitution for tonification, such as Bu Zhong
Yi Qi Tang 补中益气汤 (tonify the middle to augment
the qi decoction), Gui Pi Tang* 归脾汤 (restore the
spleen decoction), Si Jun Zi Tang 四君子汤 (four
gentlemen decoction), Ba Zhen Tang 八珍汤 (eight
treasure decoction), and Liu Wei Di Huang Wan 六味地
黄丸 (six ingredient pill with rehmannia). However, tonic
herbs should be avoided at the first sign of any illness and
professional CM advice should be sought. It may also
be beneficial to take Yin Qiao San 银翘散 (honeysuckle
and forsythia powder) occasionally to ensure that no
pathogenic qi has a hold in one’s body.20,24 [*See Editor’s
Comments on page 29 regarding endangered species]
(vi) Fumigation: this is a practice that has been used by past
wen bing physicians. One such formula used in ancient
times is called Tai Yi Liu Jin San 太乙流金散 (supreme
unity flowing gold powder).12 These days, however,
vinegar is the favoured product for fumigating one’s abode
rather than a complex formula.20
Biomedical physicians are likely to encourage the uptake of
vaccination as a preventative measure. Since December 2009,
there has been an approved vaccine for adults (single dose) and
children (two doses).25 However, from the wen bing school’s
perspective, modern day vaccination itself can be a cause of
illness.11,26 The intramuscular delivery of the attenuated virus
circumvents the exterior defences of the body and enters
directly into the interior, into the qi level (of the four levels
in Ye Tian Shi’s 叶天士 diagnostic model: wei defensive,
qi , ying nutritive, xue blood), resulting in internal
latent heat.11,26 When faced with an exogenous pathogen later
on, the heat then manifests itself.11-12,26-27 Although inoculation
is not a novel concept in CM, with the practice first recorded
in China around the tenth or eleventh century, the way ancient
CM physicians administered it differs significantly from the
modern biomedical approach.28 Ancient records show that
pathogenic material was introduced into the patient either
via the nose or via a scratch on the skin.28 In both methods,
the pathogen was not delivered directly into the interior but
on the exterior. This allows the body to respond in a natural
manner and build up its defence. In other words, one’s zheng
qi, in particular, one’s wei qi, must be strengthened as part of
an illness prevention measure. Vaccination as an aspect of that
strategy is not rejected by CM but the biomedical method
of deep intramuscular delivery is questioned by some CM
The wen bing school has more than 1000 formulae for treating
over 60 types of syndrome.11-12,14 The use and modification
of formulae for a patient will depend on a CM practitioner’s
pattern differentiation of the individual. Influenza falls under
the category of wind warmth 风温, based on the signs and
symptoms and natural history of the disease.11,14,20 Sang Ju
Yin 桑菊饮 (mulberry leaf and chrysanthemum drink) is the
preferred formula in the initial stage of wind warmth.11-12,14,29
It is good for ‘coursing wind, dissipating heat, and treating
cough’.29 The other commonly used formula is Yin Qiao San
(honeysuckle and Forsythia powder).11-12,20,29 The latter is better
than Sang Ju Yin in ‘out-thrusting the exterior with acridity and
coolness and for clearing heat and resolving toxins’.29 The key
symptoms in this scenario are fever and aversion to cold.14
If the patient delays seeking treatment, the pathogen may enter
the qi level. Alternatively, the pathogen may penetrate from the
upper jiao to the middle jiao (of the three burner differentiation
system, also part of the wen bing school). The key symptoms in
this stage are fever, constipation and damage to body fluids, i.e.
dryness.14 The appropriate formulas include Bai Hu Tang
虎汤 (white tiger decoction), Zeng Ye Tang 增液汤 (increase
the fluids decoction), Tiao Wei Cheng Qi Tang 调胃承气汤
(regulate the stomach and order the qi decoction), Zeng Ye
Cheng Qi Tang 增液承气汤 (increase the fluids and order the
qi decoction).11-12,14,20
The wen bing school teaches that if wind warmth disease is
left untreated it will penetrate into the ying (nutritive) and
xue (blood) levels. The patient may experience symptoms
including confusion, delirium, loss of consciousness, macules,
and high fever. These signs and symptoms are similar to those
delineated by biomedicine regarding the more severe cases of
2009 H1N1, which include confusion, sudden dizziness, pain/
pressure on chest/abdomen, severe/persistent vomiting.30 The
wen bing school argues that warm diseases first attack the lungs,
then frequently the stomach and intestines which accounts for
the nausea and vomiting and abdominal symptoms.11-12,14,20 In
some instances, the disease proceeds directly from the lungs
into the pericardium, accounting for the delirium, confusion
and loss of consciousness.11-12,14,20 There are several formulae
available for the latter cases and their application depends on
Australian Journal
of Acupuncture and Chinese Medicine 27
A Koh
Wen Bing Xue and
2009 H1N1
more precise diagnoses. The commonly used formulae are
Qing Ying Tang* 清营汤 (clear the nutritive level decoction),
An Gong Niu Huang Wan* 安宫牛黄丸 (calm the palace pill
with cattle gallstone), Xi Jiao Di Huang Tang* 犀角地黄丸
(rhinoceros horn and rehmannia decoction), Qing Hao Bie Jia
Tang 青蒿鳖甲汤 (sweet wormwood and soft-shelled turtle
shell decoction) and San Jia Fu Mai Tang 三甲复脉汤 (three-
shell decoction to restore the pulse). These herbal prescriptions
are calculated to restore consciousness, clear heat strongly,
open orifices, extinguish wind, stop bleeding and nourish
yin.11-12,14,20,24 [*See Editor’s Comments on page 29 regarding
endangered species]
When a warm disease invades a body and it is not cleared
completely, there remains some pathogenic factor. This
pathogenic factor is referred to as lingering pathogens or fu
xie.11-12,14,20,26 Liu states, ‘remnants of heat’ refers to a situation
where heat from excess has been fighting with the body’s
yin.11 In the process both sides are injured and the heat thus
become less forceful due to the yin’s moderating influence.
Maciocia notes that a pathogenic factor ‘may appear to have
been expelled, and the patient appears to recover, but actually
a residual pathogenic factor has been formed’.31 The Chinese-
English Dictionary of Traditional Chinese Medicine defines
fu qi/fu xie as:
the syndrome of pathogen incubating in the body for a
long period before the onset of the disease. The affected
regions are deeper or shallower. The more deeply the
pathogen incubates, the more severe the illness will
be. The onset of the illness starts from the interior and
slowly extends to the exterior, usually with long and
various course.32
After the resolution of the acute symptoms, the patient may
not be conscious of any adverse result of fu xie and be under the
impression that all is well. However, fu xie has consequences
and can manifest itself in common signs and symptoms, from
allergies to persistent intermittent low-grade fevers.31 The
chronic allergies/sensitivities may be dismissed as hay fever.
The persistent intermittent low fever may be ignored or put
down to stress. The constant shortness of breath on exertion
where none existed prior to the disease may be ignored or
regarded as a part of ageing. Fu xie, however, predisposes the
patient to exogenous pathogens causing them to fall ill more
easily. It can act as a Trojan horse and allow warm pathogens to
enter more rapidly than normal into the interior of the body
causing a more severe disease state.11-12,14,20,26,32
It is vitally important in treating warm diseases to ensure that
the pathogens are fully and completely expelled. In this, CM
differs from biomedicine. In the latter, antibiotics and antivirals
are used to kill or inactivate the bacteria and viruses. The
implication is that these dead microbes are still left in the body
and may in time be removed by the body’s system altogether
or they may not be removed at all.26 CM, however, is insistent
that pathogens must also be expelled from the body.11,26 It was
the wen bing school that first proposed the concept of fu xie
or fu qi wen bing 伏气温病, variously translated as lingering,
lurking, residual warm pathogen disease.
Thus, in the treatment of someone who presents with flu-
like symptoms, a comprehensive and in-depth history of the
patient is essential in drawing out any previous fu xie. This
suggests that post-resolution treatment strategies are essential
once the acute signs and symptoms are gone.
It can be difficult to convince a patient of the need for
follow-up treatment once their presenting condition has
been rectified. The above discussion of fu xie underscores the
need to educate patients in the concepts of CM. The follow-
through for the clinician is to ensure that (1) the treatment
prescription was correct and effective in resolving the disease;
(2) the herbal prescription has been taken correctly and
consistently by the patient; (3) the patient has had ample rest,
physically, emotionally, mentally; and (4) the patient has been
eating a proper diet.20,27 If any of these four aspects has been
compromised, the physician should consider that some warm
disease pathogen may still remain. If left untreated, this can
then result in a cycle of illness followed by a short period of
recovery and then illness again, a cycle that will surely drain
the patient’s qi and damage the blood over time. Perhaps this
is what epidemiologists allude to when they ‘long puzzled over
why seasonal infectious disease outbreaks occur when they do.
Perhaps the more important question is why they do not occur
when they do not. Is the human population already relatively
resistant for 6–9 months each year?’33 Dowell, from whom the
previous observation comes, further notes that
pathogens do not physically migrate across the equator
and that nationwide epidemics do not necessarily result
from chains of person-to-person transmission. Rather,
the pathogens may be present in the population year-
round, and epidemics occur when the susceptibility
of the population increases enough to sustain them.
Perhaps the most significant prediction is that people
are relatively resistant to disease if exposed in the off-
season and that the specific physiologic process leading
to seasonal resistance should be identifiable and perhaps
The trend that epidemiologists have discerned recently would
appear to fit in neatly with the concept of fu xie proposed
some three hundred years ago, a concept that continues to
be developed by the wen bing school.11 It would seem that
modern epidemiological data supports the theory and clinical
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Wen Bing Xue and
2009 H1N1
practice of an ancient school of thought in traditional Chinese
medicine. It would also reinforce to CM physicians the vital
need to follow through the treatment of the acute stage of the
2009 H1N1 influenza, or for that matter, any disease.
A well-known herbal prescription for expelling fu xie is Xiao
Chai Hu Tang 小柴胡汤 (minor bupleurum decoction).
Herbal formulae used to treat the acute stage of 2009 H1N1
or wind warmth disease at the qi, ying and xue levels can also
be prescribed with modifications. Herbs such as Chantui
(Cicadae periostracum), Dandouchi 淡豆豉 (Sojae semen
praeparatum) Bohe 薄荷 (Menthae haplocalycis herba), Jingjie
荆芥 (Schizonepetae herba) and Niubangzi 牛蒡子 (Arctii
fructus) can be added to guide the fu xie to the exterior for
The last phase of managing someone with the 2009 H1N1
influenza, or in the language of wen bing, wind warmth, is
reinforcing the constitution of the patient. In any disease
process, qi would be used up in overcoming the pathogen. The
more severe the disease is, the more qi is consumed, the more the
damage needs to be arrested and repaired and the constitution
rebuilt. The attention to repairing damages and building up qi is
of particular need in those with prenatal qi deficiency. Where the
disease is not so severe, the measures enunciated in phase one,
prevention, can be applied to restore a patient’s constitution.
Obviously, tonic herbs should only be used if the physician is
satisfied that there is no lingering pathogen. Otherwise, the
latter can be strengthened and so embed itself even more deeply
in the body, rendering it harder to expel.
The reinforcing phase may involve an honest discussion
between the physician and the patient on changing lifestyle,
addressing harmful habits and adopting a different outlook on
health. It is also a great opportunity for educating the patient
on the various aspects of Chinese medicine to encourage a
deeper understanding. This extends to what is traditionally
called yang sheng 养生, literally cultivating life. The build-up
phase overlaps with many aspects of the prevention phase.
The epidemiological data for influenza presented above serve
as a basis for the effectiveness and historical and empirical use
of wen bing theory and treatment methods in the management
of the 2009 H1N1 influenza. This paper does not offer
‘evidence’ in the same mode as those espoused by biomedical
science. A Cochrane meta-analysis by Chen et al.36 suggests
that the application of that model of evidence to CM is
filled with difficulties due to the different natures of the two
medical systems. Chen et al. conclude that the ‘present existing
evidence is too weak to support or reject the use of any Chinese
Medicinal herbs for preventing or treating uncomplicated
influenza’.36 However, they recognise that the aim in CM in
treating influenza is ‘not only to cure the respiratory syndrome,
but also to treat the whole body’.36 Thus, they acknowledged
that the use of standard biomedical trials to assess CM is difficult
due to the differences in herbal prescription, pharmacological
agents used and the diagnostic pattern differentiation. The
same conclusion is applicable to wen bing and its use on the
2009 H1N1 influenza. Chen et al. assert that one ‘must accept
that the overall treatment concept for TCM is different to that
used in western medicine’. 36
It can be argued that experiential evidence can be offered on
the use of wen bing theory in treating 2009 H1N1 influenza.
As discussed above, the mild form of 2009 H1N1 did not
require hospitalisation. Most patients either would have sought
assistance from their general practitioners or would have
recovered from the illness on their own, if their constitution
was strong. Others would have been treated by their CM
practitioners for influenza. In late June 2009 in New South
Wales, routine laboratory testing for the 2009 H1N1 virus
was restricted to those hospitalised with the severe form of the
illness. 37 It would have been difficult to gather evidence for the
CM treatment of the mild form of 2009 H1N1 in that climate.
It is not a matter of subordinating CM to biomedicine but rather
using what is relevant from biomedicine to expand and deepen
CM theory and practice. The long history of Chinese medicine
in general and of the wen bing school specifically holds much
evidence on adapting and responding to changes in the climate,
environment and newly emerging diseases. Uncovering these
huge bases of data and information from CM and comparing
them with modern epidemiological ones can perhaps offer
another legitimate and valid way of understanding and treating
contemporary diseases. Such a methodology would also provide
another strategy for integrating biomedicine with Chinese
medicine. There is surely no need to reinvent the wheel.
Clinical Commentary
The 2009 H1N1 inuenza is the rst u pandemic of the
twenty-rst century. It has caused considerable panic
and anxiety in the public and medical establishment.
The aetiology and presentation of the inuenza are
remarkably similar to those patterns enunciated by
wen bing
School of traditional Chinese medicine.
On that basis, TCM practitioners can use
wen bing
theory as a foundation to manage the 2009 H1N1
inuenza effectively. This paper examines the similar
manifestations of warm diseases and swine u and
offers a working framework covering their prevention
and treatment.
Australian Journal
of Acupuncture and Chinese Medicine 29
A Koh
Wen Bing Xue and
2009 H1N1
16. CDC. H1N1 flu (‘swine flu’) and you [online]. 12 Jan 2010 [cited 16
Jan 2010]. Available from:
17. CDC. Caring for someone sick at home: know the symptoms of flu
[online]. ca 2009 [cited 16 Jan 2010]. Available from: http://www.cdc.
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* These formulas (pages 26 and 27) contain muxiang, xijiao
shexiang and niuhuang, substances that are listed in Appendices
I, II or III of the Convention on the International Trade in
Endangered Species of Wild Fauna and Flora (CITES).
International trade in such substances is banned (Appendix
I) or requires relevant permits from the CITES authorities in
the exporting and importing countries (Appendices II and III).
The use of these traditional names are for academic reference
only and effective substitutes are available. The Australian
Acupuncture and Chinese Medicine Association Ltd and the
AJACM oppose the illegal use of endangered species of wild
flora and fauna. For further information, please refer to http:// and
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... Many see TCM as delivering more personalized care, better at addressing the root causes of disorders, and 'easier on the body' with fewer side effects (Chung et al., 2014). For serious illnesses, TCM can complement biomedicine by 'cutting the tail of the illness' and 'clearing the root of the disease' (Chung et al., 2014;Koh, 2010;Lam, 2001). In China, integrating biomedicine and TCM is seen to have synergistic advantages, particularly for chronic or serious disorders, and so patients with serious or even terminal diseases like cancer receive TCM alongside biomedical treatment (Chung et al., 2014;Harmsworth & Lewith, 2001). ...
... Traditional Chinese Medicine emphasizes continually reinforcing balance even when in good health. Yangsheng (養生/养生/yang shēng, nurturing life) is practiced to make small adjustments to maintain balance (Koh, 2010;Wilms, 2010), and medical treatment is only resorted to when less drastic measures cannot address disharmony (Liu et al., 2013). Thus, the consumption of medicinal ingredients is not always of immediate medical necessity, as some are consumed as food or tonics to boost overall health (Chau & Wu, 2006;Koo, 1984;Smith, 2018a). ...
... If a cold pattern of disharmony presents as fever, rhino horn is unsuitable. As a potent cold-type CMM, it would only be suitable for addressing a severe heat-based disharmony (Hanson, 2011;Koh, 2010). One such severe heat-based disharmony is severe acute respiratory syndrome, the outbreak of which was considered an infectious warm-disease epidemic or wenyi (溫疫/温疫/wēn yì; epidemic of wenbing, 溫病/温病/wēn bìng). ...
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Numerous treatments in Traditional Chinese Medicine (TCM) involve the use of wildlife products, including some that utilize ingredients derived from endangered flora and fauna. Demand for such endangered wildlife products in TCM can threaten the survival of species and pose serious challenges for conservation. Chinese medical practice is embedded in the cultural fabric of many societies in East and Southeast Asia, and remains an integral part of everyday life and knowledge. It is grounded in principles and theories that have grown over hundreds of years and differ substantially from those of mainstream allopathic biomedicine. In order to address the threats posed by the medicinal consumption of endangered wildlife, conservation scientists and practitioners will benefit from a basic understanding of TCM. Such knowledge will enable conservationists to craft culturally nuanced solutions and to engage constructively with TCM stakeholders. However, conservationists typically lack familiarity with TCM as the incompatibility of many TCM concepts with those of the biomedical sciences poses a barrier to understanding. In this paper, we examine the core theories and practices of TCM in order to make TCM more accessible to conservation scientists and practitioners. A better understanding of TCM will enable conservationists to deliver more effective and lasting conservation outcomes. A free Plain Language Summary can be found within the Supporting Information of this article.
... In recent years, the whole world has witnessed many public health emergencies that greatly influence human society, including SARS in 2003 [17], avian influenza in 2004 [7], H1N1 influenza in 2009 [20], H7N9 influenza in 2013 [19], West Africa Ebola virus in 2014 [15], and COVID-19 in 2020 [9]. An effective response to and governance of public opinions during epidemic situations are important in social emergency management [52]. ...
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The Dynamic Zero-COVID Policy in China spanned three years and diverse emotional responses have been observed at different times. In this paper, we retrospectively analyzed public sentiments and perceptions of the policy, especially regarding how they evolved over time, and how they related to people's lived experiences. Through sentiment analysis of 2,358 collected Weibo posts, we identified four representative points, i.e., policy initialization, sharp sentiment change, lowest sentiment score, and policy termination, for an in-depth discourse analysis through the lens of appraisal theory. In the end, we reflected on the evolving public sentiments toward the Dynamic Zero-COVID Policy and proposed implications for effective epidemic prevention and control measures for future crises.
... Use of CHM to address the symptom burden of infectious disease, within the ''epidemic disease'' and associated frameworks, is reported from the 17th century through the SARS outbreak of 2009. 8,9 Contemporary Chinese medicine has additionally incorporated substances selected for antiviral or antimalarial properties through bench research informed by historical usage, as in the case of artemisinin. 10 Today, biomedicine is operating largely ''off-label'' as it struggles to understand and address C19's impact on multiple body systems. ...
Editor's Note: This column continues the JACM commentary series from the Society for Acupuncture Research (SAR). The authors, Claudia Citkovitz, PhD, LAc, from NYU Langone Hospital - Brooklyn and Rosa N. Schnyer, DAOM, LAc, from the University of Texas, are both licensed East Asian Medicine (EAM) clinicians as well as researchers. The dual roles inform this commentary. As clinicians, they respect development over the centuries of strategies toward epidemics by the Chinese and are intrigued by the high use of Chinese herbal medicine to treat COVID-19 in China. As researchers, they are aware of the robust exploration of integrative strategies in China and the dearth of such interest of exploration by most agencies in the West. In their column, Citkovitz and Schnyer highlight what self-respecting clinician researchers are doing to fill the knowledge gap. They provide background on three separate data gathering initiatives that have collaborated to keep their reporting structures comparable in order to "improve clinical practice in real time": one for detailed case reports, a second via a registry, and the third an observational study that provides quantitative and qualitative data regarding clinical reasoning and patient response. At JACM, we look forward to seeing the kinds of reports these initiatives can cast on the widespread patient experience with integrative and EAM COVID-19. -John Weeks, Editor-in-Chief, JACM.
... All interviewees attested to rhino horn's ability to dispel heat from the body, and all but one agreed to its ability to detoxify blood. Ten interviewees claimed that it is suitable for treating wen bing ( ; infectious diseases caused by oronasally contracting warm-heat pathogenic qi energy; Koh, 2010). As one interviewee explained: ...
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Rhino poaching in Africa has risen alarmingly over the last decade, driven by illegal trade and demand for horns in Asia, where it is used medicinally. Traditional Chinese medicine (TCM) has deep cultural roots, and understanding demand drivers will inform conservation decision-making. We interviewed 15 TCM practitioners in Hong Kong, investigating their familiarity with rhino horn, prescription experiences, and perspectives toward its use and trade. All interviewees believe that rhino horn possesses medicinal properties, despite general unfamiliarity with its chemical composition or any active ingredient. We compiled a list of 16 substitutes, finding that dosage adjustments produce equivalent treatment outcomes that compensate for potency differences. While most interviewees expressed support for trade legalization, most would prefer to continue prescribing substitutes. Further research into TCM stakeholder perspectives and preferences for rhino horn can inform conservation policy.
... Traditional herbal medicine remains an underexplored, yet potentially fruitful basis for antiviral discovery [8]. In ancient China, some Chinese prescriptions were used to treat Wen Bing (Warm Disease), which is considered as influenza in modern time, with influenza-like symptoms, such as high fever, thirsty and anxiety [9]. To date, these prescriptions are still used in clinics by traditional Chinese medical practitioners. ...
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Background: Sheng Jiang San (SJS), a multi-herb formulation, is used in treating high fever, thirsty and anxiety in ancient China and it is sometimes used to treat seasonal influenza nowadays. However, there is no evidence-based investigation and mechanism research to support the anti-influenza efficacy of SJS. This study aims at evaluating the anti-influenza effect of SJS and investigating its possible mechanism. Methods: The inhibitory effect of SJS against different influenza virus strains on MDCK cells was examined. Influenza virus infected BALB/c mice were employed to evaluate the efficacy as in vivo model. Mice challenged with A/PR/8/34 (H1N1) were orally administrated 1 g/kg/day of SJS for seven days and monitored for 14 days. The survival rate, body weight changes, lung index, lung viral load, histopathologic changes and immune regulation of the mice were measured. The underlying anti-influenza virus mechanism of SJS was studied by a series of biological assays to determine if hemagglutinin, ribonucleoprotein complex or neuraminidase were targets of SJS. Results: Results showed SJS exerted a broad-spectrum of inhibitory effects on multiple influenza strains in a dose-dependent manner. IC50 of SJS against A/WSN/33 (H1N1) was lower than 35 μg/ml. SJS also protected 50% of mice from A/PR/8/34 (H1N1) infection. The lung index and the lung viral load of SJS treated mice were significantly decreased compared with untreated mice. Meanwhile, SJS targeted on neuraminidase of influenza virus as SJS at 2 mg/ml inhibited 80% of neuraminidase enzymatic activity. SJS also significantly down-regulated TNF-α and up-regulated IL-2 of influenza virus induced mice. Conclusions: Thus, SJS is a useful formulation for treating influenza virus infection.
With the advanced desire to look more into the traditional view and its possible health advantages, it is necessary to primarily understand the theoretical concepts of this perspective and then find ways to relate those concepts to conventional medicine through modern technologies. Traditional Chinese Medicine (TCM) is one of the main traditional medicines that has been spread worldwide and showed potentials to bring new insights into the conventional medical approach. One of the important concepts to be clarified in TCM is Heat and Cold. This article reviews the significance and importance of TCM-related heat/cold in relation to TCM philosophy and disease pathophysiology, diagnosis, and treatment. Likewise, the findings from published articles focused on the concept of heat/cold are reviewed in the hope of opening new doors into recognition of this work and fostering insights toward unifying the old and new.
Ethnopharmacological relevance: According to Traditional Chinese Medicine theory, influenza is categorized as a warm disease or Wen Bing. The Wen Bing formulas, such as Yin-Qiao-San and Sang-Ju-Yin, are still first-line herbal therapies in combating variant influenza virus. To continue our study on the pharmacokinetic and pharmacodynamic interactions between Wen Bing formulas and oseltamivir (OS), the first-line western drug for the treatment of influenza, further interactions between OS and the eight single herbs and their relevant marker components from Wen Bing formulas were investigated in the current study. Aim of study: To establish an in-vitro screening platform for investigation of the potential anti-influenza herbs/herbal components that may have pharmacokinetic and pharmacodynamic interactions with OS. Materials and methods: To screen potential inhibition on OS hydrolysis, 1 μg/mL of OS is incubated with herbs/herbal components in diluted rat plasma, microsomes and human recombinant carboxylesterase 1(hCE1) under optimized conditions. MDCK-WT and MDCK-MDR1 cell lines are utilized to identify potential modification on P-gp mediated transport of OS by herbs/herbal components. Caco-2 cells with and without Gly-Sar inhibition are performed to study the uptake of OS via PEPT1 transporters. Modification on OAT3 mediated transport is verified by the uptake of OS on HEK293-MOCK/HEK293-OAT3 cells. Anti-virus effects were evaluated using plaque reduction assay on H1N1 and H3N2 viruses. Potential pharmacokinetic and pharmacodynamic interaction between OS (30 mg/kg) and the selected herb, Radix Scutellariae (RS), at 300-600 mg/kg were carried out on rats. All samples are analyzed by an LC/MS/MS method for the contents of OS and OSA. A mechanistic PK model was developed to interpret the HDI between OS and RS in rats. Results: Our developed platform was successfully applied to screen the eight herbal extracts and their ten marker components on metabolic inhibition of OS and modification of OS transport mediated by P-gp, OAT3 and PEPT1. Results from six in-vitro experiments were analyzed after converting raw data from each experiment to corresponding fold-change (FC) values, based on which Radix Scutellariae (RS) were selected to have the most HDI potential with OS. By analyzing the plasma and urine pharmacokinetic data after co-administration of OS with a standardized RS extract in rats using an integrated population pharmacokinetics model, it is suggested that RS could inhibit OS hydrolysis during absorption and increase the absorbed fraction of OS, which leads to the increased ratio of OS concentration versus that of OSA in both rat plasma and urine. Never the less, the anti-virus effects of 2.5 h post-dose rat plasma were not influenced by co-administration of OS with RS. Conclusion: A six-dimension in-vitro screening platform has been developed and successfully applied to find RS as a potential herb that would influence the co-administrated OS in rats. Although co-administered RS could inhibit OS hydrolysis during absorption and increase the absorbed fraction of OS, which lead to the increased ratio of OS concentration versus that of OSA in both rat plasma and urine, the anti-virus effect of OS was not influenced by co-administered RS.
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Seasonal cycles of infectious diseases have been variously attributed to changes in atmospheric conditions, the prevalence or virulence of the pathogen, or the behavior of the host. Some observations about seasonality are difficult to reconcile with these explanations. These include the simultaneous appearance of outbreaks across widespread geographic regions of the same latitude; the detection of pathogens in the off-season without epidemic spread; and the consistency of seasonal changes, despite wide variations in weather and human behavior. In contrast, an increase in susceptibility of the host population, perhaps linked to the annual light/dark cycle and mediated by the pattern of melatonin secretion, might account for many heretofore unexplained features of infectious disease seasonality. Ample evidence indicates that photoperiod-driven physiologic changes are typical in mammalian species, including some in humans. If such physiologic changes underlie human resistance to infectious diseases for large portions of the year and the changes can be identified and modified, the therapeutic and preventive implications may be considerable.
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Three worldwide (pandemic) outbreaks of influenza occurred in the 20th century: in 1918, 1957, and 1968. The latter 2 were in the era of modern virology and most thoroughly characterized. All 3 have been informally identified by their presumed sites of origin as Spanish, Asian, and Hong Kong influenza, respectively. They are now known to represent 3 different antigenic subtypes of influenza A virus: H1N1, H2N2, and H3N2, respectively. Not classified as true pandemics are 3 notable epidemics: a pseudopandemic in 1947 with low death rates, an epidemic in 1977 that was a pandemic in children, and an abortive epidemic of swine influenza in 1976 that was feared to have pandemic potential. Major influenza epidemics show no predictable periodicity or pattern, and all differ from one another. Evidence suggests that true pandemics with changes in hemagglutinin subtypes arise from genetic reassortment with animal influenza A viruses.
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Influenza has been, and continues to be, a serious threat to human life. The 1918 influenza pandemic infected nearly one quarter of the world's population and resulted in the deaths of 100 million people. Most of the countries in the world were heavily impacted. What happened in China during this period? Compared with other countries, the severity of infection in China was relatively mild. Did traditional Chinese medicine (TCM) play any role, either in the prevention or treatment of the epidemics? This paper explores the situation in China at that particular time.
The evidence in this review was far from conclusive for clinical decision making about traditional Chinese medicinal herbs in the treatment of influenza. This review assessed the therapeutic effect of traditional Chinese medicinal herbs as an alternative to other commonly used medicines. Traditional Chinese Medicines (TCMs) as a whole may have some efficacy, but the weak evidence was far from conclusive for practice. There was not enough evidence to reach a conclusion as to which herbal preparation was a better choice, and there was too little information on possible adverse effects.
Caring for someone sick at home: know the symptoms of flu
CDC. Caring for someone sick at home: know the symptoms of flu [online]. ca 2009 [cited 16 Jan 2010]. Available from: http://www.cdc. gov/h1n1flu/homecare/symptoms.htm.
Interim recommendations for clinical use of influenza diagnostic tests during the 2009-10 influenza season
CDC. Interim recommendations for clinical use of influenza diagnostic tests during the 2009-10 influenza season [online]. ca 2009 [cited 16 Jan 2010]. Available from: guidance/diagnostic_tests.htm.