One of the best reports I’ve heard has come from US-born herbalist and practitioner of Traditional Chinese Medicine, Thomas Avery Garran, PhD. Garran is currently living in Beijing, pursuing graduate work in pharmacology of herbs. He has been working with a team of translators in China to make available protocols being used in Chinese hospitals for infectious disease management at different stages of the COVID-19 disease progression. I want to share some of what I learned from Mr. Garran through a seminar which took place on April 4, 2020, presented by the good folks at the Oakland-based herbal pharmacy, Five Flavors Herbs.
Please note: I’m sharing these ideas for educational purposes only, to advocate for the skillful application of Chinese medicine. Please do not self-prescribe Chinese herbs unless you are a licensed professional. If you are interested in taking Chinese herbs for a medical condition, please consult with a licensed Traditional Chinese Medicine practitioner.
Chinese herbs are not traditionally selected based on their efficacy in killing viruses. And there is certainly not a one-size-fits-all formula to treat or prevent coronaviruses. Chinese herbal formulas are constructed on the basis of pattern diagnosis, in order to optimize the body’s ability to fight the virus and recover. (For more about the construction of Chinese herbal formulas, click here.)
To construct a formula for a COVID-19 patient, we need to take into account the details of his or her symptoms and select herbs based on the presenting symptom-pattern. So, what symptom-patterns are we seeing in COVID-19 patients?
Damp-Phlegm and Toxic Heat as a Key Diagnostic Features:
Thomas Avery Garran reports from China that the typical symptoms of hospitalized patients in the early stages of infection (pre-pneumonia) in Hubei Province (the Province where Wuhan is located and where COVID-19 originated) are:
In Chinese medicine theory, the dominant pattern in this set of symptoms is Dampness and Phlegm. (I will capitalize words like Dampness, Phlegm, when they represent concepts in Chinese medicine theory.) Dampness & Phlegm account for fatigue, muscle soreness, subjective heavy feeling, poor appetite, loose stools, chest pressure, difficult breathing and a greasy tongue coating.
A further verification of a Phlegm-based diagnosis comes, sadly, from the autopsies of patients who did not survive COVID-19 infection. Garran reports that Chinese physicians, observing the lung tissue of deceased COVID-19 patients, found the alveoli caked with thick phlegm (what is being called ground-glass opacity seen in CT scans of the lungs.) It is this phlegm that causes suffocation during advanced stages of COVID-19 infection, by preventing absorption of oxygen through the lung tissue. Some of the difficulty that has arisen in putting COVID-19 patients on ventilators, in fact, seems to come from this accumulation of phlegm around the alveoli.
Based on these observations, Chinese herbal physicians in China concluded that to mitigate symptoms of COVID-19 and slow disease progression, it was imperative to stop or slow the production of Phlegm in the body. In Chinese medicine theory, Dampness is the result of a weak Spleen (roughly equivalent to poor digestion.) Dampness, especially in the company of Heat, tends to congeal into Phlegm. There is a saying the Dampness (as a pathogenic factor) is produced by the Spleen and stored in the Lung. The treatment principles employed to decrease Dampness are to Support the Spleen and Aromatically Transform Dampness.
The fact that digestive symptoms like poor appetite, loose stools, diarrhea and loss of appetite often accompany the early stages of COVID-19 infection supports the idea that Spleen weakness and Dampness are part of the diagnostic picture of COVID-19, and that support for the Spleen must be part of the treatment.
In addition to supporting the Spleen and transforming Dampness and Phlegm, Garran says, it is important to “give the Phlegm a place to go.” This means we need to use herbs that will loosen the Phlegm in the chest and allow it to be expelled or expectorated.
An important note is that, in early stages of COVID-19 infection, cough should not be suppressed. So we don’t want to use herbal Lung astringents or over-the-counter pharmaceutical cough suppressants. We want to loosen the phlegm in the chest and actually encourage coughing, thereby allowing the phlegm to be coughed out of the lungs. (At later stages of COVID-19, when the patient is more debilitated, however, there may be a need to suppress cough.)
The idea that COVID-19 infections tend to be characterized by Phlegm & Dampness has been a little confusing to western audiences, since many of us have heard that one of the symptoms of the illness is a dry cough. Garran clarifies that even if the cough is dry, there is still a lot of very sticky, difficult-to-expectorate phlegm coating the insides of the lungs. (This appears to be generally true, though individual cases will vary depending on patient’s constitution, surrounding climate, etc.)
In addition to Dampness & Phlegm, Garran states that Toxic /Pathogenic Heat is also a diagnostic pattern typically seen in COVID-19 patients in China (as opposed to cold damp-phlegm.)
Finally, in terms of Chinese medicine theory, Garran observes that the COVID-19 virus is very aggressive and quick-moving. Symptoms of infection change rapidly. From a Chinese Medicine "levels-of-infection" perspective (more about that in this article), the virus is said to initially penetrate the exterior defenses or Wei Qi, then move to the organ level where it constrains the Lung and what we call the Middle Burner (or the Spleen/Stomach/digestive organs.) This is where the skillful application of herbs comes in: to slow the progression of the virus from initial to more severe stages.
Herbal Formula for Initial-Onset Stage of COVID-19 Infection from Hubei Province, China:
To illustrate how Chinese herbs are used to combat COVID-19, I’ll share an analysis of a formula being used in hospitals in Hubei Province, China, to treat patients at the early-onset stage of infection. I do this to share information about the beauty and sophistication of Chinese herbal medicine. Again, if you are not a trained herbalist, please do not self-prescribe. Please consult with a licensed practitioner if you’re interested in herbs for prevention or treatment.
A typical pattern observed in Hubei Province in early-stage COVID-19 patients has been Pathogenic Heat Toxin Penetrating the Exterior and Entering the Lung. As it attacks the Lung, the the pathogenic toxin has qualities of heat and constraint, i.e. it hampers free circulation of Qi. The formula being applied for this condition is a modification of a classic formula called Chai Ge Jie Ji Tang, or “Bupleurum and Kudzu Decoction to Release the Muscle Layer.” The formula has its origins in the Shang Han Lun, or Treatise on Cold-Induced Disorders, compiled during a period of frequent epidemics in the the Late Han Dynasty period in China. (For more information, click here.)
The herbs used in this formula modification are:
(I will list both the Chinese pin yin name and the Latin or common botanical name.)
First, let’s look at the the two chief ingredients in the formula: bupleurum and pueraria roots. Both of these herbs are employed in the treatment of colds and flus, at the stage when the pathogen is considered to be at the defensive surface (the Wei level) of the body. Together they open constraints at the surface. They “open the doors,” so to speak, so the pathogen can be kicked out. Both of these ingredients are cool in nature (as opposed to warm herbs that open the surface, like ginger or cinnamon.) They are are used because the COVID-19 virus quickly manifests with heat signs and symptoms. Pueraria’s special quality is that it relieves muscle aches, headache, and back/neck stiffness related to early-stage viral infection. Both herbs relieve fever. Bupleurum particularly addresses alternating fever and chills. As opposed to suppressing fever or suppressing the body’s natural immunity, they open the surface to clear the invading pathogen through the surface level. (In western herbal theory, these herbs would be considered diaphoretics.)
The next pair of herbs to consider are Notopterygii and Angelicae pubescentis roots. These two herbs are especially effective together for pushing out Dampness. Like bupleurum and pueraria, notopterygii and Angelica pubescentis work at the surface/exterior defensive level of the body, but unlike the former two, notopterygii and angelica are warm to effectively dispel cold-dampness. They also helps relieve symptoms like headache, body aches, chills, fever, along with fatigue and a subjective heavy feeling, as is commonly seen in the early stages of COVID-19 infection.
So far we have bupleurum and pueraria, which are cool and open the surface to expel heat-pathogen. And we have notopterygii and Angelica pubescentis which are chase out dampness. These four herbs work on the surface, defensive layer of the body, opening the doors and expeling damp-pathogen.
Because the typical COVID-19 progression is to move from the surface level of the body into the interior, and specifically to attack the Lung and Stomach organs, creating a “constrained heat” quality around the Lung (difficult breathing, wheezing, cough, etc.) and interfering with the digestive process, the next two herbs specifically address heat at the level of the Lung and Stomach organs (no longer at the surface level.) These are gypsum and raw licorice root.
Gypsum (which is a mineral and has to be cooked longer than the other herbs,) clears Heat from the Lungs and Stomach. It particularly addresses cough and wheezing with fever and thick, viscous Phlegm in the Lungs. Raw licorice is most often used in formulations as a Spleen Qi tonic. But here it is used clear heat toxin from the Lungs, stop cough and wheezing.
The next pair of herbs, forsythia fruit and isatis root, have yet another function. According to their Chinese medicine classification, these herbs “Clear Toxic Heat.” They are known to have constituents that are particularly effective in fighting virus. ("Anti-viral" is not a particularly traditional consideration in Chinese herbalism, but a nod to modern pharmacological considerations and the virulent nature of the COVID-19 virus.)
Coming to the end of this list of herbs, Radix Scutellariae Baicalensis also has an affinity for the Lung and Stomach organs. It’s function is to Clear Heat and Dry Dampness. It treats high fever, irritability, thirst, and cough with thick yellow Phlegm, as well as diarrhea or stomach upset due to toxic infection. Scrophularia helps clear Toxic Heat and Transform Phlegm in the Lungs. Scrophularia has a unique quality that while it helps clear Toxic Heat infection, it also has the capacity to nourish Yin. The idea here is that it may help soften and loosen the thick, viscous Phlegm coating the lung surfaces, making the Phlegm easier to expectorate.
The final group of herbs, white peony root, together with the already mentioned Scrophularia and raw licorice, have a forward-looking quality. Each of these three have a quality of nourishing and moistening. Peony root protects the Yin and Blood of the Liver. Scrophylaria nourishes Yin. Raw licorice moistens tissues, tonifies Qi, harmonizes the herbs in a formula and moderates the harsh effects of other herbs. The primary herbs in this formula have strong anti-infectious, heat-clearing qualities. They are generally meant to be taken short term because they can deplete energies of the body. Also, viral infection tends to damage the Yin and Qi of the body. Fever, while it helps clear infection, can result in lingering dryness, irritability, constipation, etc. The final three herbs help mitigate these negatives to promote long-term recovery.
On a final note, the traditional form of this formula, Chai Ge Jie Ji Tang, contains Jie geng, or Radix Platycodi Grandiflori as a significant ingredient. Platycodon root is regularly used in Chinese medicine to open the Lung, treat cough and clear Phlegm. Why is it not favored in treating early-stage COVID-19 patients? Thomas Avery Garran proposes that it is not used because it suppresses cough. As mentioned before, we do not want to suppress cough, rather we want to open the Lung, loosen Phlegm and allow it to be coughed out.
Keep in mind that this is only one of many formulas being used to treat COVID-19 patients, in China, at an early stage. I wanted to describe it as an example of the nuanced way Chinese herbs are used in formulas. If you are interested in using Chinese herbs in the context of the pandemic, please consult a licensed Chinese herbalist.
Damp-Phlegm and Toxic Heat as a Key Diagnostic Features:
Thomas Avery Garran reports from China that the typical symptoms of hospitalized patients in the early stages of infection (pre-pneumonia) in Hubei Province (the Province where Wuhan is located and where COVID-19 originated) are:
- Fever (in some cases, not all)
Image Courtesy of Wikipedia - Fatigue
- Sore Muscles
- Heavy Feeling in the Body
- Poor Appetite
- Loose Stools
- Cough (most, not all)
- Chest Pressure
- Panting, Urgent Breathing
- Greasy Coating on the Tongue.
In Chinese medicine theory, the dominant pattern in this set of symptoms is Dampness and Phlegm. (I will capitalize words like Dampness, Phlegm, when they represent concepts in Chinese medicine theory.) Dampness & Phlegm account for fatigue, muscle soreness, subjective heavy feeling, poor appetite, loose stools, chest pressure, difficult breathing and a greasy tongue coating.
A further verification of a Phlegm-based diagnosis comes, sadly, from the autopsies of patients who did not survive COVID-19 infection. Garran reports that Chinese physicians, observing the lung tissue of deceased COVID-19 patients, found the alveoli caked with thick phlegm (what is being called ground-glass opacity seen in CT scans of the lungs.) It is this phlegm that causes suffocation during advanced stages of COVID-19 infection, by preventing absorption of oxygen through the lung tissue. Some of the difficulty that has arisen in putting COVID-19 patients on ventilators, in fact, seems to come from this accumulation of phlegm around the alveoli.
Based on these observations, Chinese herbal physicians in China concluded that to mitigate symptoms of COVID-19 and slow disease progression, it was imperative to stop or slow the production of Phlegm in the body. In Chinese medicine theory, Dampness is the result of a weak Spleen (roughly equivalent to poor digestion.) Dampness, especially in the company of Heat, tends to congeal into Phlegm. There is a saying the Dampness (as a pathogenic factor) is produced by the Spleen and stored in the Lung. The treatment principles employed to decrease Dampness are to Support the Spleen and Aromatically Transform Dampness.
The fact that digestive symptoms like poor appetite, loose stools, diarrhea and loss of appetite often accompany the early stages of COVID-19 infection supports the idea that Spleen weakness and Dampness are part of the diagnostic picture of COVID-19, and that support for the Spleen must be part of the treatment.
In addition to supporting the Spleen and transforming Dampness and Phlegm, Garran says, it is important to “give the Phlegm a place to go.” This means we need to use herbs that will loosen the Phlegm in the chest and allow it to be expelled or expectorated.
An important note is that, in early stages of COVID-19 infection, cough should not be suppressed. So we don’t want to use herbal Lung astringents or over-the-counter pharmaceutical cough suppressants. We want to loosen the phlegm in the chest and actually encourage coughing, thereby allowing the phlegm to be coughed out of the lungs. (At later stages of COVID-19, when the patient is more debilitated, however, there may be a need to suppress cough.)
The idea that COVID-19 infections tend to be characterized by Phlegm & Dampness has been a little confusing to western audiences, since many of us have heard that one of the symptoms of the illness is a dry cough. Garran clarifies that even if the cough is dry, there is still a lot of very sticky, difficult-to-expectorate phlegm coating the insides of the lungs. (This appears to be generally true, though individual cases will vary depending on patient’s constitution, surrounding climate, etc.)
In addition to Dampness & Phlegm, Garran states that Toxic /Pathogenic Heat is also a diagnostic pattern typically seen in COVID-19 patients in China (as opposed to cold damp-phlegm.)
Finally, in terms of Chinese medicine theory, Garran observes that the COVID-19 virus is very aggressive and quick-moving. Symptoms of infection change rapidly. From a Chinese Medicine "levels-of-infection" perspective (more about that in this article), the virus is said to initially penetrate the exterior defenses or Wei Qi, then move to the organ level where it constrains the Lung and what we call the Middle Burner (or the Spleen/Stomach/digestive organs.) This is where the skillful application of herbs comes in: to slow the progression of the virus from initial to more severe stages.
Herbal Formula for Initial-Onset Stage of COVID-19 Infection from Hubei Province, China:
To illustrate how Chinese herbs are used to combat COVID-19, I’ll share an analysis of a formula being used in hospitals in Hubei Province, China, to treat patients at the early-onset stage of infection. I do this to share information about the beauty and sophistication of Chinese herbal medicine. Again, if you are not a trained herbalist, please do not self-prescribe. Please consult with a licensed practitioner if you’re interested in herbs for prevention or treatment.
A typical pattern observed in Hubei Province in early-stage COVID-19 patients has been Pathogenic Heat Toxin Penetrating the Exterior and Entering the Lung. As it attacks the Lung, the the pathogenic toxin has qualities of heat and constraint, i.e. it hampers free circulation of Qi. The formula being applied for this condition is a modification of a classic formula called Chai Ge Jie Ji Tang, or “Bupleurum and Kudzu Decoction to Release the Muscle Layer.” The formula has its origins in the Shang Han Lun, or Treatise on Cold-Induced Disorders, compiled during a period of frequent epidemics in the the Late Han Dynasty period in China. (For more information, click here.)
The herbs used in this formula modification are:
(I will list both the Chinese pin yin name and the Latin or common botanical name.)
- Chai hu / bupleurum root
- Ge gen /puerariae root (aka kudzu)
- Qiang huo / Notopterygii root & rhizome
- Du huo / Angelicae pubescentis rhizome
- Gan cao / Radix glycyrrhizae Uralensis (aka raw licorice root)
- Shi gao / gypsum (calcium sulfate)
- Lian qiao / forsythia fruit
- Ban lan gen / isatis root
- Huang qin / Scutellariae baicalensis root
- Xuan shen / Scrophulariae ningpoensis root
- Bai shao / white peony root
 |
| Bupleurum Root Photo Credit: Sacred Lotus Chinese Herbs |
There is a Chinese medicine tradition of pairing herbs (known in Chinese as "dui yao") whose qualities work well in synergy and balance one another. This formula is an excellent example of this type of pairing. I'll analyze the herbal constituents in pairs.
First, let’s look at the the two chief ingredients in the formula: bupleurum and pueraria roots. Both of these herbs are employed in the treatment of colds and flus, at the stage when the pathogen is considered to be at the defensive surface (the Wei level) of the body. Together they open constraints at the surface. They “open the doors,” so to speak, so the pathogen can be kicked out. Both of these ingredients are cool in nature (as opposed to warm herbs that open the surface, like ginger or cinnamon.) They are are used because the COVID-19 virus quickly manifests with heat signs and symptoms. Pueraria’s special quality is that it relieves muscle aches, headache, and back/neck stiffness related to early-stage viral infection. Both herbs relieve fever. Bupleurum particularly addresses alternating fever and chills. As opposed to suppressing fever or suppressing the body’s natural immunity, they open the surface to clear the invading pathogen through the surface level. (In western herbal theory, these herbs would be considered diaphoretics.)
 |
| Pueraria Root Photo Credit: Little Flowers |
So far we have bupleurum and pueraria, which are cool and open the surface to expel heat-pathogen. And we have notopterygii and Angelica pubescentis which are chase out dampness. These four herbs work on the surface, defensive layer of the body, opening the doors and expeling damp-pathogen.
 |
| Notopterygii Photo Credit: Sacred Lotus |
Gypsum (which is a mineral and has to be cooked longer than the other herbs,) clears Heat from the Lungs and Stomach. It particularly addresses cough and wheezing with fever and thick, viscous Phlegm in the Lungs. Raw licorice is most often used in formulations as a Spleen Qi tonic. But here it is used clear heat toxin from the Lungs, stop cough and wheezing.
 |
| Raw Licorice Root Photo Credit: Shen Clinic |
Coming to the end of this list of herbs, Radix Scutellariae Baicalensis also has an affinity for the Lung and Stomach organs. It’s function is to Clear Heat and Dry Dampness. It treats high fever, irritability, thirst, and cough with thick yellow Phlegm, as well as diarrhea or stomach upset due to toxic infection. Scrophularia helps clear Toxic Heat and Transform Phlegm in the Lungs. Scrophularia has a unique quality that while it helps clear Toxic Heat infection, it also has the capacity to nourish Yin. The idea here is that it may help soften and loosen the thick, viscous Phlegm coating the lung surfaces, making the Phlegm easier to expectorate.
 |
| Gypsum Photo Credit: Herbal Shop |
 |
| Forsythia Fruit Photo Credit: Sacred Lotus |
Keep in mind that this is only one of many formulas being used to treat COVID-19 patients, in China, at an early stage. I wanted to describe it as an example of the nuanced way Chinese herbs are used in formulas. If you are interested in using Chinese herbs in the context of the pandemic, please consult a licensed Chinese herbalist.
If time allows, in the coming days, I'll share some notes about formulas for prevention of COVID-19 infection, as well as for later stages of infection and recovery phase. In the mean time: Stay safe! Stay healthy! Let's get through this!
