Introduction and Comparison of TCM Treatment Guides on COVID-19
Since the outbreak of the coronavirus epidemic in China in January 2020, the National Health Commission and almost every provincial health authorities have published TCM treatment guides on COVID-19，but it seems a bit confusing that the guides are all somewhat different. Why are these opinions so different in the judgment and treatment advice of the same disease? This is not surprising at all, as it actually reflects the fact that the clinical findings of this disease changes and shows the characteristics of TCM that the treatment should adapt to seasons, areas and individuals. China has a vast territory, and the natural geographic conditions and climates vary from area to area. Each regional treatment guide is based on real local clinical cases and the identification of syndrome types and the prescriptions should cope with the impact of local geographic and climatic conditions.
Ancient doctors had a clear understanding of the need to manage diseases and epidemics according to the conditions of the particular season, geographic feature and the patient’s constitution. For example, the Direct Guide on Cold Damage (《伤寒直指》Sháng Hán Zhí Zhǐ) quoted XU Zhike, a famous doctor of the Song Dynasty in the 12th century, that “The epidemic disease should not be treated invariably but flexibly according to the season, the cold or warm weather, and the strong or weak body of the patient. If the epidemic comes after a long-term drought and shows symptoms of dryness and fever, the treatment is not drying agents but detoxing and moisturizing agents. After time of excessive rain, when dampness is in dominance and causes disorder of the Earth Zang-organ, the Spleen, the people infected by cold-epidemic would be suffering from diarrhea. Not the moisturizing herbs but the Spleen-strengthening and moisture-drying herbs are suitable for the treatment. Epidemics often come in the year of famine as the consequence of flood or drought, because the disharmony of the cold and hot weather and the lack of food makes people vulnerable to contagious diseases.” In the 17th century in Ming Dynasty, Dr. LI Shicai also presented similar opinion in the Revised Edition of the Theory for Health（《删补颐生微论》Shān Bǔ Yí Shēng Wēi Lùn）: “Within a hundred miles there could be different weathers of sunshine or rain. Afar to a thousand miles away, there could be different climates with cold or heat. The regions and the lands are different and the diseases are under different influence. These are extra thoughts besides the given method.”
We briefly analyzed and compared the general characteristics of various guidelines and found that each published document not only holds the basic consensus that the novel coronavirus pneumonia is caused by external dampness-toxin but also indeed reflects local climate features with different levels of cold, heat and humidity.
The National Health Commission’s Treatment Guideline to the Novel Coronavirus Pneumonia (3rd Edition) added TCM treatment for the first time , which is set upon the basic understanding of the coronavirus infection as a dampness-toxin epidemic. There gives four types of syndromes for differentiation and treatment and the first two types are of the onset stage, the cold type and the heat type.
“Type 1: confined dampness in lungs
Clinical manifestations: low fever or no fever, dry cough, little phlegm, dry throat, sore throat, fatigue, chest tightness, nausea or vomiting, diarrhea, pale or pink tongue with white or creamy white fur, soft and thin pulses.
Treatment principle: clearing dampness and detoxing, opening lungs and dispelling the pathogen.
Recommended formulas: Má Xìng Shí Gān Decoction, Shēng Jiàng Powder, Dá Yuán Drink.
Basic prescription: Herba Ephedrae, Semen Armeniacae Amarum, Fructus Tsaoko, Semen Arecae, Periostracum Cicadae, Fructus Forsythiae, Rhizoma Atractylodis, Radix Platycodonis, Scutellaria Baicalensis, Fructus Arctii, Radix Glycyrrhizae.” 
“Type 2: pathogenic heat in lungs
Clinical manifestations: fever, being thirsty but reluctant to drink, chest tightness, dry throat, little phlegm, poor appetite, constipation or loose bowels, tongue with red tip and yellow fur, floating pulse.
Treatment principle: clearing heat and detoxing, opening the lungs and dispelling the pathogen
Recommended formulas: Má Xìng Shí Gān Decoction, Yín Qiào Powder.
Basic prescription: Herba Ephedrae, Semen Armeniacae Amarum, Gypsum Fibrosum, Cortex Mori, Flos Lonicerae, Fructus Forsythiae, Radix Scutellariae, Bulbus Fritillariae Thunbergii, Radix Glycyrrhizae.” 
“Type 3: pathogenic toxin blocking lungs”, the type of the progressing stage.
“Clinical manifestations: high fever, cough with little sputum or yellow sputum, chest tightness, shortness of breath, abdominal distension, constipation, red tongue with yellow creamy fur or yellow dry fur, slippery and rapid pulses.
Treatment principle: detoxing and opening lungs, laxative to reduce heat.
Recommended formulas: Xuān Bái Chéng Qì Decoction, Huánglián Jiě Dú Decoction, Jiě Dú Huó Xuě Decoction.
Basic prescription: Semen Armeniacae Amarum, Gypsum Fibrosum, Fructus Trichosanthis, Radix et Rhizoma Rhei, Herba Ephedrae, Semen Lepidii, Semen Persicae, Radix Paeoniae Rubra, Radix Glycyrrhizae. ” 
“The 4th type, syndrome of internal blockage and external collapse”, is equivalent to the critical stage.
“Clinical manifestations: unconsciousness, dysphoria, high fever in chest and abdomen, deadly cold hands and feet, shortness of breath or need of mechanically assisted breathing, dark purple tongue with dry brown fur, hollow and floating pulses.” 
The pathological judgment by traditional Chinese medicine should be the collapse of Yang Qi and the pathogenic heat caused blockage and coma. Thus the Sì Nì Decoction with added Ginseng is used to save Yang Qi and the Ān Gōng Níuhuáng Pills or Zǐ Xuě Powder is used to clear the heat, unblock the orifices and awaken the consciousness.
该版本中的中药都没给出剂量，可能是希望给临床医生预留个体化治疗的弹性空间。虽然许多个省的方案都沿用了这个证治方案，如河北、湖南、甘肃、江西、广西、新疆等     ，基本分型和方药均与之相同或类似，对进展期的邪毒闭肺和危重症内闭外脱证治，各地方案也都大同小异，与卫健委方案出入不大，但我们也注意到有几个地区的方案表现出明显的地域性气候特点，尤其体现在最能反映病邪特质的发病初期的证型上，如：
In this version the Chinese medical herbs are listed without dosages, probably to keep the flexibility of the prescription for individualized treatment. Although the guidelines from many provinces follow the 3rd version of the national guideline, such as Hebei, Hunan, Gansu, Jiangxi, Guangxi, Xinjiang, etc.       the basic syndrome types and the prescriptions are the same or similar, but we also noticed that there are advices from other health authorities showing obvious influence of the regional climate, especially in the instructions to the earliest stage of the infection which reflects the characteristics of the disease to the most.
Wuhan in Hubei province, the city of the outbreak started from, is located in central China with many rivers and lakes and is the city with the most water covered land in China. There were excessive rainfalls in this area in the second half of the year 2019 and the early cases of the infection were from a fish market. In a word, the epidemic broke out within a humid environment. Thus the TCM department of the Tongji Hospital in Wuhan set the guidelines according to the recognition of the pathogenic dampness. In this guide, early-stage patients are managed in two groups, with fever or without fever. The fever group includes three types: “cold-dampness blocking lungs”, “warmth -dampness blocking lungs” and “pathogen confining Shaoyang”. The first two types are treated respectively with Huòxiāng Zhèng Qì Pills and Sān Rén Decoction as the basic herbal formula. Although the latter one does not include the word “dampness” in name, the prescribed Minor Cháihú Decoction and Huòxiāng Zhèng Qì Pills indicate that it is actually also considered to be a syndrome with pathogenic dampness. Those who have no fever in the early stage are grouped as the type of “epidemic dampness damaging lungs” and the herbal prescription includes “Herba Ephedrae 10g, Rhizoma Atractylodis 10g, Semen Coicis 15g, Herba Pogostemonis 10g, Fructus Tsaoko 10g, Radix Codonopsis 10g (or Radix Ginseng 10g), Pericarpium Trichosanthis 15g, Rhizoma Pinelliae Preparatum 10g, Herba Artemisiae Scopariae 10g, Radix Salviae Miltiorrhizae 30g, and Pericarpium Citri Reticulatae 10g”. The basic formula is not provided, but it could be the altered combination of Dá Yuán Drink and Má Xìn Yǐ Gān Decoction. Two types of syndrome are set for the progressing stage: the “cold pattern due to dampness-toxin” and the “heat pattern due to dampness-toxin”, showing the dampness is still the cardinal pathogen. 
在北方气候比较寒冷的山东，采取的是国家第五版（同第四版）方案，该方案中体现该病最基本特征的初期证型是寒湿郁肺，用治疗寒湿疟疾的传统方达原饮加减：“苍术 15g 、陈皮 10g、厚朴 10g 、藿香 10g 、草果 6g 、生麻黄 6g 、羌活 10g 、生姜 10g 、槟郎 10g 。”可见其用药一派温燥。山东方案在国家方案基础上补充了一条加味法，“口咽干燥重者加知母 10g、白芍 10g”，兼顾了某些病例阴虚口干或邪热伤阴的可能性。类似的还有山西方案，对初期分湿阻肺胃和寒湿郁肺两型，也没有设热证证型，中期设痰热壅肺和疫毒闭肺两型，显然系疫邪入里化热的表现。这两个地区的方案选择显然考虑到了本地的气候特点。
In Shandong province, where the climate is typically as cold as other northern areas in winter, the 5th edition (same as the 4th edition) of the national guidelines  is adopted. The syndrome type for the initial stage, which reflects the basic characteristics of the infection to the most, is “cold-dampness in lungs” and the adjusted formula of Dá Yuán Drink (a traditional treatment of cold-dampness type of malaria) is recommended，including herbs such as “Rhizoma Atractylodis 15g, Pericarpium Citri Reticulatae 10g, Cortex Magnoliae Officinalis 10g, Herba Pogostemonis 10g, Fructus Tsaoko 6g, Herba Ephedrae 6g, Radix Notopterygii 10g, Rhizoma Zingiberis Recens 10g, and Semen Arecae 10g.” The herbs used are all warm and dry in property. The guide in the same time provides a further adjustment of the prescription that “Rhizoma Anema -rrhenae 10g and Radix Paeoniae Alba 10g should be added for very dry mouth and throat”, taking it into account the possible condition of dryness due to Yin deficiency and that of pathogenic heat damaging the Yin . Similarly, the Shanxi edition also does not list any heat syndrome for the early stage but only two cold patterns as of the “dampness in lungs and stomach” and “cold-dampness in lungs”. There are two syndrome types listed for the progressing stage: the “phlegm-heat blocked in lungs” and “epidemic toxin blocked in lungs”, which are obviously caused by secondary produced heat from the pathogen deep in the lungs . The options advised in the two guides are obviously under the awareness of the local climate features.
In Guangdong province, the southernmost part of the mainland, the syndrome pattern of the early stage of the coronavirus infection is summarized to be “damp-heat stagnated in lungs” with two subtypes of “dampness predominating over heat” and “heat predominating over dampness” , which are exactly the types of Dampness-Warmth Disease. In both recommended prescriptions cooling herbs are more than half of the components, reflecting the impact of the local hot climate rather than cold.
“Dampness-heat blocked in lungs: low fever or no fever, mild chills, fatigue, heavy head and body, muscular aches, dry cough with little phlegm, sore throat, dry mouth but reluctant to drink, possible chest tightness, a little sweat or without sweat, possible nausea and fullness of stomach, loose and sticky stools, pink tongue with white thick creamy fur or thin yellowish fur, slippery and quick pulses or soft and thin pulses
Treatment principle: clearing heat and dampness, unblocking the Mo Yuan, and removing the dirt and turbidity
(1) Formula for syndrome of dampness pre -dominating over heat: adjusted Dá Yuán Drink
Semen Arecae 10g， Fructus Tsaoko 10g， Cortex Magnoliae Officinalis 10g, Rhizoma Anemarrhenae 10g， Scutellaria baicalensis 10g， Radix Bupleuri 10g，Radix Paeoniae Rubra 10g，Fructus Forsythiae 15g， Artemisia annua 10g， Rhizoma Atractylodis 10g， Folium Isatidis 10g，Radix Glycyrrhizae 5g” 
“(2) Formulas for heat predominating over dampness: adjusted Yín Qiào Powder and Sān Rén Decoction
Flos Lonicerae 15g, Fructus Forsythiae 15g, Radix Platycodonis 10g, Fructus Arctii 10g, Rhizoma Phragmitis 20g, Herba Menthae 10g, Semen Armeniacae Amarum 10g, Fructus Ammomi Rotundus 6g, Semen Coicis 20g, Medulla Tetrapanacis 10g, Radix Paeoniae Rubra 10g, Rhizoma Pinelliae 10g, Talcum 20g, Semen Arecae 10g, Fructus Tsaoko 5g, Scutellaria baicalensis 10g, Radix Glycyrrhizae 5g.
Adjustment: For fever, add Gypsum Fibrosum 30g, Radix Bupleuri 10g, and Fructus Gardeniae 10g; for sore throat, add Radix Ilicis Asprellae 25g, Rhizoma Paridis 10g, Rhizoma Belamcandae 10g; for cough, add Folium Eriobotryae 15g and Radix Peucedani 10g; for headache and painul eyes, add Radix Notopterygii 10g and Radix Puerariae 20g; for nausea and vomiting, add Caulis Bambusae in Taenia 10g and Rhizoma Zingiberis Recens 5g; for Qi deficiency, add Radix Astragali seu Hedysari 30g and Radix Pseudostellariae 30g. ” 
Hainan, China’s the southernmost province on the Hainan island, is of a subtropical marine climate and is warm and humid in winter. The treatment guide published by the provincial health authority lists “Heat-Toxin affecting the Lung” as the first syndrome of the COVID-19 and advises Yín Qiào Powder and Qīng Wēn Bāi Dú Drink as the treatment . Yín Qiào Powder is normally a formula for early treatment of exogenous wind-heat, as a pungent-cool agent. The formula of Qīng Wēn Bāi Dú Drink came in Qing Dynasty from YU Shiyu’ book Experience on Epidemic Diseases (《疫疹一得》Yì Zhěn Yì Dé) and is often used to detoxify the blood and Qi and to clear heat in treatment of epidemics, as the book quoted it that “it is the fire-clearing medicine for all twelve meridians”. The formula includes Radix Rehmaniae Recens, Coptis Chinensis, Cotinus Coggygria, Paeonia, Gypsum Fibrosum, Gardenia, Radix Glycyrrhizae, Folium Bambusae, Radix Scrophulariae, Cornu Rhino, Fructus Forsythiae, Paeonia Lactiflora, Rhizoma Anemarrhenae, and Radix Platycodonis. Except for Platycodon and Licorice, the other twelve herbs are all cooling agents. Hainan’s guide lists it as the first prescription for the first pattern of symptoms and shows that the local COVID-19 cases are mostly of heat syndrome.
Shaanxi province is usually cold and dry in winter, but there was much more rainfall in last winter than usual. Therefore its treatment guide also reflects the characteristics of the local climate of the very year which tend to cause exogenous wind-cold contraction with mixed dampness. Among the syndrome types of mild onset cases, apart from the same type of “heat-toxin in lungs” as listed in the 3rd edition of the national guide, pungent-warm herbs are used for all the other types to release the exterior and to dry the dampness. Gān Lù Xiāo Dú Pills and Huòxiāng Zhèng Qì Powder are advised for the pattern of “cold-dampness fettering the exterior”, and Rénshēn Bài Dú Powder is used for “exterior wind-cold” and “dampness with Qi deficiency”, while Greater Qíng Lóng Decoction and Qiān Jīn Wěi Jǐng Decoction are recommended for the syndrome of “exterior cold and interior heat” . Among them, Rénshēn Bài DúPowder is a well-known formula which was widely used for cold-epidemics in the Song, Jin and Yuan Dynasties. It is taken as a standard-like prescription for cold-epidemics and adopted by many COVID-19 treatment guides, considering the outbreak emerged during the time of Greater Cold (大寒 Dà Hán) in this winter. For example, in Zhejiang’s guideline it is used to treat moderate symptoms of pneumonia in onset stage , and the Jīng Fáng Bài Dú Powder, an revised formula of it, is listed with Huò Pǔ Xià Líng Decoction for the pattern of “exterior wind-cold with dampness” in early stage of the infection. 
Guizhou is located in the southwest of China where is full of mountainous forests and the climate is warm and humid. According to the guide from its health authority, the novel coronavirus infection is considered a kind of “Damp Epidemic” disease. “According to the features of it, showing both cold and heat symptoms, progressing rapidly, seeing critical conditions and being difficult to cure by herbal treatment, it should be managed from the focus of the disease, the Triple-energizer and the Mo Yuan.” The diagnostic system of “the Triple-energizer Syndrome Differentiation” is adopted and the disease is managed in four stages: “toxin stagnated in upper-energizer (common type / early stage)”, “toxin stagnated deeply in Mo Yuan (severe type / middle stage and progressing stage)”, “toxin full of Triple-energizer (critical type / critical stage)” and “toxin dissipating from Mo Yuan (recovery stage)” . Comparing with the guides from other provinces, the Guizhou version is the one the most strictly following the epidemic pathological theory of Triple-energizer and Mo Yuan, and makes itself a considerate solution to the local geographic and climatic characteristics.
We believe that the variations of the treatment guides on COVID-19 are decided by the different levels of the mixed pathological factors of cold, dampness and heat shown in cases of different areas, and also by the difference of individual body constitution of the patients that could lead to the pathologic changes from cold features to heat features. Following the same thought, the latest edition of the Treatment Guideline to the Novel Coronavirus Pneumonia by the National Health Commission, after several rounds of revisions, has shown more awareness of the regional differences and individual differences and made it more widely applicable and more look like a national guide rather than a guide mainly for the situation in Wuhan.
比如其新增的通治方清肺排毒汤，可以说将该次疫病的寒湿为本、标热为变、肺为主要受损器官且太阳少阴及脾胃三焦皆受其病的特点都照顾到了。“适用于轻型、普通型、重型患者，在危重型患者救治中可结合患者实际情况合理使用。基础方剂：麻黄 9g、炙甘草 6g、杏仁 9g、生石膏 15～30g(先煎)、桂枝 9g、泽泻 9g、猪苓 9g、白术 9g、茯苓 15g、柴胡 16g、黄芩 6g、姜半夏 9g、生姜 9g、紫菀 9g、冬花 9g、射干 9g、细辛 6g、山药 12g、枳实6g、陈皮 6g、藿香 9g。如有条件，每次服完药可加服大米汤半碗，舌干津液亏虚者可多服至一碗。(注如患者不发热则生石膏的用量要小，发热或壮热可加大生石膏用量)。”服法中推荐的大米汤是清养肺胃的传统方法，能补充胃气津液、平养气阴而无留邪之患，石膏用量的调节则可以弥补组方中清热药偏少的不足，这两方面的措施都源自治疫名方白虎汤的心法，应该说完全可以应对普通病例肺胃气分邪热炽盛和初伤津液的情况。
For example, the lately added formula for wide application to moderate cases and severe conditions or even critical conditions, Qīng Fèi Pái Dú Decoction (清肺排毒汤), is well adapted to the principal pathological features of the COVID-19, a cold-dampness epidemic disease with the lungs as the main damaged organ and the Taiyang, Shaoyin, Spleen, Stomach and Triple-energizer as the affected meridians and Zang-fu organs. The basic formula includes “Herba Ephedrae 9g, Radix Glycyrrhizae 6g, Semen Armeniacae Amarum 9g, Gypsum Fibrosum 15-30g, Ramulus Cinnamomi 9g, Rhizoma Alismatis 9g, Polyporus Umbellatus 9g, Rhizoma Atractylodis 9g, Poria 15g, Radix Bupleuri 16g, Scutellaria baicalensis 9g, Rhizoma Pinelliae 9g, Rhizoma Zingiberis Recens 9g, Radix Asteris 9g, Flos Farfarae 9g, Rhizoma Belamcandae 9g, Herba Asari 6g, Rhizoma Dioscoreae 12g, Fructus Aurantii Immaturus 6g, Pericarpium Citri Reticulatae 6g, Herba Pogostemonis 9g. If it is possible, a half bowl of the juice of rice soup is advised after the herbal drink, or up to one bowl of it for dry throat and thirst. (Notice: the dosage of Gypsum Fibrosum should be reduced if there is not a fever and increased for high fevers).” Juice of rice soup is a good nourishment in tradition for weak lungs and stomach. It can replenish the stomach Qi and body fluid and to boost both of the Qi and Yin without fueling the pathogen. To adjust the amount of the Gypsum could make up for the shortcoming of heat-reducing herbs in the formula. Both complementary measures are from the famous epidemic-tackling formula, Bai Hu Decoction, and should help to get the prescription more adapted to the conditions of the “excessive heat of Qi aspect in the Lung and Stomach” and the “damage of body fluid”.
The new version divides mild and common conditions into syndromes of cold-dampness and heat-dampness (dampness-toxin) and increased the use of herbs specified in epidemic, such as Semen Arecae, Fructus Tsaoko, Rhizoma Dryopteris Crassirhizomatis, Folium Isatidis, and Herba Pogo- stemonis, etc. and shows a deeper understanding of the particularity of the epidemic disease. In addition to the type of “epidemic toxin blocking the Lung”, the syndrome type of “blazing of both Qi and blood” in the severe stage is listed to make the instructions more comprehensive. It is quite noticeable that there has made a change of the clinical strategic thinking, from using the Cold Damage method only to being combined with method of the Warm Disease.
生石膏 30～60g(先煎)、知母 30g、生地 30～60g、水牛角 30g(先煎)、赤芍 30g、玄参 30g、连翘 15g、丹皮 15g、黄连 6g、竹叶 12g、葶苈子 15g、生甘草 6g。”
“Clinical manifestations of the blazing of both Qi and blood: fever, thirst, shortness of breath, delirium and illusion, macula and rashes, vomiting blood or nose bleeding, convulsions, dark red tongue with little or without coating, rapid weak and sinking pulses or rapid floating hollow pulses.
Recommended formulas: Bái Hǔ Decoction, Qīng Yíng Decoction and Xījiǎo Dìhuáng Decoction
Gypsum Fibrosum 30-60g, Rhizoma Ane- marrhenae 30g, Radix Rehmaniae Recens 30-60g, Cornu Bubali 30g, Radix Paeoniae Rubra 30g, Radix Scrophulariae 30g, Fructus Forsythiae 15g, Cortex Moutan Radicis 15g, Rhizoma Coptidis 6g, Folium Bambusae 12g, Semen Lepidii 15g, and Radix Glycyrrhizae 6g. ”
Furthermore the latest version provides more options of patent Chinese medicines, especially the injections for severe and critical conditions, such as Xǐ Yán Píng Injections, Xuě Bì Jìng Injections, Rè Dú Níng Injections, Tán Rè Qīng Injections, Xǐng Nǎo Jìng Injections, Shēn Fù Injections, Shēng Mài Injections, and Shēn Mài Injections, etc. to meet the urgency of critical cases and the limited drug access .
The guides from Tianjin and Shanghai are basically set according to the contents of the 6th version of the national guide  , while the Sichuan edition lists not only syndrome types similar with the national ones but also additional types to meet more clinical variations, especially for the exterior patterns in the onset stage. There listed three exterior patterns: for the type of “wind-heat setting on the Lung”, Sāng Jú Drink and Yín Qiào Powder are the basic formulas; for the “wind-heat with dampness syndrome”, Yín Qiào Powder and Huò Pǔ Xià Líng Decoction is the choice; and for the type of “wind-cold with dampness”, Jīng Fáng Bài Dú Powder and Huò Pǔ Xià Líng Decoction is combined for personalized adjustment. 
Through the above comparison and analysis, we believe that the various guides on TCM diagnosis and treatment for the novel coronavirus infection not only show the common acknow- ledgement of the main features of the current epidemic, but also show the awareness of the differences in regional climate and the individual constitutions of the patients. It is a clear reflection of the principle of the traditional Chinese medicine in treatment according to the time, the place and the person, and it as well shows the clinicians’ attitude in “seeking the truth from facts” and “to get knowledge from practice”. The nationwide anti-epidemic action has once again proved the great value and contributions of TCM, and the clinical practice also reminded us again that the vitality of Chinese medicine lies in the real therapeutic effects and flexible management of the treatment while hold the principal lines.
11.山东省卫生健康委员会. 山东省新型冠状病毒感染的肺炎中医药诊疗方案. 2020-1-31
12. 山西省卫生健康委员会.山西省新型冠状病毒感染的肺炎中医药防治方案(试行). 2020-2-1
14．海南省新型冠状病毒感染的肺炎疫情防控工作指挥部.海南省新型冠状病毒感染的肺炎中医药防治方案(公众版 试行第二版）. 2020-2-27