An Analysis of the Function of Zhiyi Tongzhi Recipe in the History of TCM Epidemic Prevention and the Guarantee of Curative Effect

ZHANG Yu-hui (张玉辉), ZHAO Kai-wei (赵凯维), LIU Li-xiang (刘理想)

Institute of Basic Theory for Chinese Medicine,China Academy of Chinese Medical Sciences, Beijing 100700, China

ABSTRACT Zhiyi Tongzhi Recipe (治疫通治方) in Traditional Chinese Medicine plays an important role in the history of anti-epidemic. When an epidemic is widespread, formulating accurate prescriptions will play a key role in controlling the spread of the epidemic, improving clinical symptoms, preventing the spread of the disease, and promoting prognosis and recovery. This paper performed an objective analysis of the historical role played by Zhiyi Tongzhi Recipe in the history of infectious diseases in China, and summed up the experience and lessons of the application of Zhiyi Tongzhi Recipe. Meanwhile, this paper conducted a theoretical discussion on how to ensure the efficacy of Zhiyi Tongzhi Recipe, with a view to provide useful enlightenment for the better application of Zhiyi Tongzhi Recipe to fight against epidemics in the future.

KEYWORDS Zhiyi Tongzhi Recipe; Traditional Chinese medicine

In the struggle against diseases for thousands of years, traditional Chinese medicine (TCM) has accumulated rich experience. In history, when an epidemic spreads on a large scale, doctors formulate accurate Zhiyi Tongzhi Recipe to control the spread of the epidemic, improve the clinical symptoms,prevent from the spread of the disease, and promote the prognosis and recovery. It plays a key role in cutting off the development of the epidemic and reversing the situation of prevention and treatment.The application of Zhuanbing Tongzhi Recipe (专病通治方) has a long history of application. As early as inInner Canon of Yellow Emperor(《黄帝内经》), there are prototypes of Zhuanbing Tongzhi Recipe, such as Jishi Li (鸡矢醴) to treat bulging,and Shengtieluo Decoction (生铁落饮) to treat manic psychosis. The laterTreatise on Cold Pathogenic and Miscellaneous Diseases(《伤寒杂病论》),Handbook of Prescriptions for Emergency(《肘后备急方》),Essential Recipes for Emergent Use Worth A Thousand Gold(《千金要方》),Arcane Essentials from the Imperial Library(《外台秘要》) and other medical books have a large number of records of Zhuanbing Tongzhi Recipe, and the theory and practice of Tongzhi Recipe have gradually enriched and developed. This paper performed an objective analysis of the historical role played by Zhiyi Tongzhi Recipe in the history of infectious diseases in China,and summed up the experience and lessons of the application of Zhiyi Tongzhi Recipe. Meanwhile,it conducted a theoretical discussion on how to ensure the efficacy of Zhiyi Tongzhi Recipe, with a view to provide useful enlightenment for the better application of Zhiyi Tongzhi Recipe to fight against epidemics in the future.

ZHIYI TONGZHI RECIPE PLAYS AN IMPORTANT ROLE IN THE HISTORY OF TCM EPIDEMIC PREVENTION

TCM has long recognized that epidemics are highly contagious, and they are shown "one Qi (气)with one disease". Therefore, different diseases have unique clinical manifestations, while the same disease has very similar clinical manifestations and pathological characteristics. As WU You-ke said[1], "Its hot and exogenous Qi floats over a certain meridian,that is, it can show the syndrome of a certain meridian. If it floats over Taiyang (太阳) meridian,there will be head and neck pain and low back pain. If floating over Yangming (阳明), there will be eyebrow pain, forehead pain, and dry nose. If floating over Shaoyang (少阳), there will be hypochondriac pain,deafness, cold and heat exchanges, vomiting and mouth pain." It is precisely because of the similarities in the symptoms of the epidemic that provide the possibility for the creation and widespread use of Zhiyi Tongzhi Recipe for treating epidemics.

In the struggle against the epidemic for thousands of years, the ancestors of the past dynasties have paid more attention to the creation,application and promotion of Yibing Tongzhi Recipe (疫病通治方), and formed epidemiological monographs and medical records. For example,in the end of the Eastern Han Dynasty epidemic,ZHANG Zhong-jing, who was honored as a "medical saint" by the later generations, shocked by most of tribe died of typhoid fever. "The population of my clan was originally a lot, and there used to be more than 200 people. It has been less than 10 years since the first year of Jian'an, two-thirds of the people died, and typhoid fever accounted for seven-tenths of them." Diligent in seeking ancient teachings, learning from all sources, and he composedTreatise on Cold Pathogenic and Miscellaneous Diseases[2]. In the Jin Dynasty, LI Dong-yuan served in Jiyuan. In the second year of Taihe (1202), it coincided with the epidemic of Da Tou Tian Xing (big head plague), so he created Puji Xiaodu Decoction (普济消毒饮) to treat the disease[3]. Because of its excellent curative effect, he won praises from later generations. "The past cannot be chased, the comer is still within reach. All sick people are given prescriptions, and the life is saved.Everyone said that this prescription was developed by great person. Therefore, it was caved in the stone for eternity."[4]In the face of the epidemic, doctors of past dynasties witnessed the tragedy and actively sought methods of treatment and containment,including the exploration, creation, application, and promotion of Zhiyi Tongzhi Recpit. For example, in theEncyclopedia of Medical System of Ancient and Modern Medicine·Volume 25(《古今医统大全 · 卷之二十五》), the section "Plague Remedy" is listed in the "Plague Gate", and 16 prescriptions such as Baidu Powder (败毒散), Huoren Xintong Recipe (活人心统方) and Huoxiang Zhengqi Powder (藿香正气散) are listed[5]. During the cholera prevalence period, ZHANG Xi-chun created Jijiu Huisheng Pills(急救回生丹), Weisheng Fangyi Baodan (卫生防疫宝丹), etc. "In the autumn of Jiwei (1919), cholera prevailed in Fengtian. In Fengtian Lida Hospital, I made this prescription (Jijiu Huisheng Pills), which is very effective."[6]Later, the General Office of Epidemic Prevention commissioned the preparation of multiple doses and distributed them to the Fourway Epidemic Prevention Station, reflecting that"the efficacy of this prescription was abnormal"and ZHANG Xi-chun published this prescription in newspapers and widely promoted it. It can be seen that in hundreds of pandemics over thousands of years, Fangyi Tongzhi Recipe has played an active and important role.

LIMITATIONS OF FANGYI TONGZHI RECIPE

Tongzhi (通治) is a common and programmed treatment method for certain diseases. Therefore, in the process of differentiating and treating diseases,the specific conditions of each disease cannot be fully considered, nor can individual differences be taken into account. Therefore, there are certain limitation. Ancient physicians also recognized the drawbacks of this method. For example, in the Southern Song Dynasty, physician CHEN Ziming stated inComplete Effective Prescriptions for Women's Diseases·Volume Two(《妇人大全良方 ·卷之二》). "The common and effective prescriptions are commonly used, but they cannot be used with unchanged".[7]In the process of preventing and curing epidemic diseases in ancient times,there have been lessons of delaying illness by distributing a large number of Zhiyi Tongzhi Recipe.GONG Ting-xian of the Ming Dynasty pointed out inLongevity and Life Preservation Volume Seven(《寿世保元 · 卷七》). "It can cure dozens of diseases by one prescription, and it is not allowed to be specialized. They are all effective in the basic test. Although it is called general treatment, it is not allowed to treat all diseases."[8]XU Ling-tai in the Qing Dynasty also emphatically warned people."Although Tongzhi Recipe can be used for all treatments, it should also be carefully applied with difference conditions[9]."

The formulation of Zhiyi Tongzhi Recipe has high requirements on the medical skills of the makers. Accuracy of syndrome differentiation is the key to effect. If the medicine is not correct,the syndrome differentiation is inaccurate, or the flexibility of addition and subtraction is not known, it will affect the efficacy of prescription. For example,in the forty-fourth year of Jiajing in the Ming Dynasty(1565), when the epidemic of the refugees in the capital was treated, there were cases of incorrect medicine. According to historical records[10], "I was ordered to send rice porridge and medicine to the refugees of the capital. It has been heard that they were illegally given, and the Ministry of Households said: 'I heard that the decoction is not correct,and that hurts body'." There are many classic prescriptions for the treatment of epidemic diseases recorded in ancient books, but each prescription has a clear indication. Failure to distinguish the deficiency of cold and heat will delay the treatment time. WANG Meng-ying also said: "Sha medicine (痧药方) has the most prescriptions, but treat different syndromes. There are those who are suitable for heat disease and those who are suitable for cold and dampness. How can you just randomly try it?There are even more casual methods, with strong medicines together. Boasting that all diseases can be cured, and the prescription is widely distributed.There are those who take the same effect. ...To be applied to others, and patients with mild symptoms become serious, and the serious ones died."[11]In view of history, in the application process of Zhiyi Tongzhi Recipe, due to ignoring individual differences, it cannot fully reflect the advantages of individualized diagnosis and treatment of TCM, and it is also prone to syndrome differentiation errors,so there are certain limitations and risks. With medical conditions permit, specific issues need to be analyzed in detail for special physical conditions and critical illness.

During the Northern Song Dynasty, a pandemic was prevalent in Huangzhou (now Huanggang,Hubei) and neighboring counties. CHAO Gu used the family secret recipe "Sheng San Zi (圣散子)"as a general remedy to cure many patients who were on the verge of life and death. SU Shi's essay praised and said, "If you use Sheng San Zi, you don't care about the disease. The toxin in Yin (阴)and Yang (阳) are relieved for men and women.Those who are in critical condition take several doses, with sweating and smooth Qi movement.The others with mild condition will sweat slightly in heart and forehead, and the disease is cured."[12]Sheng San Zi was not only removing the threat of Huangzhou disease, but also playing a good role in plague when SU Shi was appointed as Hangzhou Zhizhou. It can be said that the prescription saved countless lives. "Sheng San Zi treating diseases has more than one effect. In last spring, the people of Hangzhou City were ill, and the number of people who had this medicine survived is innumerable.The medicines used are all low-grade medicines,but it cured thousands of people." CHAO Gu gifted Sheng San Zi to SU Shi, and SU passed it on to the famous doctor PANG An-Shi. PANG recorded this prescription in his bookTreatise on Cold Pathogenic and General Diseases(《伤寒总病论》) and was later included inEffective prescriptions of Su and Shen(《苏沈良方》). Since then, Sheng San Zi has been widely known because of the names of SU Shi and PANG An-Shi.

However, in the following period of time, the application of "Sheng San Zi" continued to deviate.The conversion from saving countless lives to causing many dead and wounded was precisely because of the failure to achieve flexible syndrome differentiation and missed the essence of TCM to save people. YE Meng-de'sBi Shu Lu Hua(《避暑录话》) records: "CHAO Gu in Sichuan, who developed Sheng San Zi, was not seen in the world's medical books for the first time, and said that it was from a stranger. For typhoid fever, regardless of the syndrome, one can treat it with cure... the disease is not worse than typhoid fever. If the medication is wrongly used, there will be death. Anyone who can use it regardless of the syndrome? After Xuanhe period, this prescription became popular in the capital, people blindly believe it and many patients were dead."[13]YE's questioned the application of the deified "Sheng San Zi", thinking that it did not differentiate the syndromes of cold and heat, and promoted them, which violated the principle of TCM syndrome differentiation and treatment, resulting in"countless death" tragedies. Sheng San Zi is made up ofSemen Myristicae,Polyporus Umbellatus,Rhizoma Acori Tatarinowii,Rhizoma Alpiniae Officinarum,Radix Angelicae Pubescentis,Radix Aconiti Lateralis Preparata,Herba Ephedrae,Fructus Evodiae,Magnnolia Hypoleuca,Radix Paeoniae Alba,Fructus Aurantii,Radix Bupleuri,Rhizoma Alismatis,Rhizoma Atractylodis Macrocephalae,Herba Asari,Radix Saposhnikoviae,Herba Pogostemonis,Rhizoma Pinelliae,Poria,Rhizoma Ligustici,Radix Glycyrrhizae, etc. In the prescription,Radix Aconiti Lateralis Preparata,Rhizoma Alpiniae Officinarum,Evodia,Fructus Evodiae,Fructus Ammomi Rotundus,Herba Ephedraeare herbs with great heat and great pungent, so the scope of application should be cold or dampness. In case of febrile disease, it does not distinguish between Yin and Yang, regardless of cold and heat, which is no difference of killing people. The lesson of Sheng San Zi's transformation from a "prescription"that saves countless people to a "prescription for killing" enlightens us that any treatment prescription,including Zhiyi Tongzhi Recipe, has certain indications, and if beyond the scope of its treatment,it may go to the opposite side.

GUARANTEE OF CURATIVE EFFECT OF ZHIYI TONGZHI RECIPE FOR PREVENTION AND CONTROL OF EPIDEMIC

Analysis of Limitations of Zhiyi Tongzhi Recipe

In the process of epidemic outbreaks and mass infections, when the supply of normalized medical resources is insufficient, it is impossible to rely on doctors to prescribe pulses one by one in the face of a large number of patients. When it is difficult to achieve "one person and one prescription",Zhiyi Tongzhi Recipe can control or block the development of the disease on a large scale, which is irreplaceable advantage. However, compared with the more flexible and targeted individualized syndrome differentiation treatment, the general treatment method has certain limitations and requires us to have a clear understanding.

First, Tongzhi Recipe cannot include many specific factors. Tongzhi is a common and programmed treatment method for a class of diseases. Therefore, in the process of differentiation and treatment, the specific conditions of the disease cannot be fully considered and flexible countermeasures cannot be adopted for many changes. In different regions, due to regional differences in temperature, humidity, and air pressure, coupled with differences in patient age and physical fitness, etc., the types and symptoms of the disease have different characteristics, that is, the syndromes are not all the same, so Zhiyi Tongzhi Recipe cannot take many factors into consideration.

Second, compared with the instant prescription of individualized differentiation and treatment, Zhiyi Tongzhi Recipe has a certain lag in time. Generally,in the event of an outbreak, experts (groups)determine the treatment rules and give prescriptions based on the pre-clinical medical records, and sometimes require a period of clinical observation.After many cases are effective, they can be promoted and applied. Therefore, Zhiyi Tongzhi Recipe is established on the basis of individual differentiation and treatment, and it is difficult to implement at the beginning of the epidemic, and it has a certain lag in preventing and controlling the spread of the disease. However, once enough cases are passed to form a detailed plan and Tongzhi Recipe, it can be widely and quickly popularized and applied, and it will show its advantages in terms of use and operability.

The Key to the Effectiveness of Zhiyi Tongzhi Recipe Is to Grasp the Core Pathogenesis

Each disease is a dynamic process composed of many internally connected pathological links and interconnected in a certain time sequence.Therefore, its diagnosis and treatment must also take into account the basic contradictions in the overall development trend and the phased main contradictions. In TCM, "disease" reflects the overall characteristics of the entire process of disease occurrence and development, and has overall characteristics. While "syndrome" is a pathological summary of a certain stage of the disease process,mainly reflecting the pathological changes of disease at that stage, which are characterized by stages and variability. The fundamental purpose of "disease differentiation" and "syndrome differentiation" is to fully understand the pathogenesis.

Pathogenesis is the mechanism of disease occurrence, development and change. It is a high-level summary of the pathological state and pathological changes presented by the diseased body as a whole and in the dynamic. It reveals the essential characteristics and basic laws of the occurrence, development, change and outcome of the disease. It is also the internal basis and theoretical guidance for people to recognize the disease and the symptoms and perform diagnosis, differentiation, and preventive treatment.Shennong's Classic of Materia Medica(《神农本草经》) records: "Whoever wants to treat a disease,first, its source was checked, and its pathogenesis was examed." The key to clinical syndrome lies in grasping the pathogenesis[14]and mastering the basic laws of the disease, that is, the "overall pathogenesis" or "core pathogenesis". The general treatment method takes this as a guide, on the basis of summarizing the common characteristics of new and sudden infectious diseases, such as the cause, disease nature, and disease location,explores the rules of medication for the treatment of diseases, and forms Zhiyi Tongzhi Recipe with strong operability and wide application. Syndrome differentiation emphasizes dynamic development,focusing on understanding the individualized characteristics of the disease, reflecting the "stage pathogenesis", and personalized differentiation and treatment emphasizes individualized factors.Under the premise of determining the disease type and syndrome type, the prescription can be flexibly adjusted according to the increase or decrease of the patient's symptoms and changes in severity.

In the treatment of the epidemic, the Tongzhi Recipe is formed on the basis of individualized diagnosis and treatment, grasping the core pathogenesis of the epidemic. On the other hand,the epidemic is caused by the common epidemic, so it is necessary to formulate a Tongzhi prescription targeting the pathogenesis of each disease. In history, TCM has repeatedly used the same one or several prescriptions to prevent and cure diseases in the fight against the plague. After solving the common problems, and then according to the specific disease, the best treatment effect can be achieved. Zhiyi Tongzhi Recipe is the basis for the prevention and treatment of similar diseases, which can provide a range of options for individualized differentiation and treatment, and under the guidance of Tongzhi method (prescription), individualized differentiation and treatment can further reduce the error or bias of syndrome differentiation and improve the accuracy of syndrome differentiation, so as to maximize the advantages of individualized TCM syndrome differentiation, and provide guarantee for better clinical efficacy. The combination of Zhiyi Tongzhi Recipe (methods) and individualized differentiation and treatment can provide the most optimal choice for the clinical treatment of new and sudden infectious diseases.

The primary task of TCM intervention in disease prevention and control is to clearly see the "disease",grasp the "pathogenesis" and give effective"prescriptions", that is, to understand the nature of the disease and grasp the core pathogenesis of the disease. Then we formulate a TCM diagnosis and treatment plan (Tongzhi method), accurately formulate Tongzhi Recipe, and promote and apply them on a large scale. Tongzhi Recipe should also be adapted according to the cause, region, season and condition of the disease, so that the theoretical treatment method is more compatible with the prescription of the medicine. This is the thinking and method of "syndrome differentiation and treatment"in the "disease differentiation and treatment"[15].

Facing the treatment of emerging and sudden diseases, Western medicine cannot quickly develop effective medicine, nor can it develop vaccines in a short period of time. In the window period of Western medicine treatment, TCM is not trapped by the "vaccine" thinking. It can intervene as soon as possible, to quickly find out the common laws of the disease through inspection, inquiry,listening and smelling and palpitation, to pinpoint the core pathogenesis, and to formulate a common prescription, namely Tongzhi Recipe, which is of great significance for cutting the epidemic situation and controlling the situation. From this perspective,Zhiyi Tongzhi Recipe is no different from a "special effect medicine." By promoting Zhiyi Tongzhi Recipe, high-risk groups can prevent from infection.Mild disease will not become severe, and severe disease will not die, leaving a buffer zone for the treatment of infectious diseases, which can play a good role in prevention and control. This helps us to more clearly understand the characteristics and advantages of Zhiyi Tongzhi Recipe, and it will also help us to better understand the role of Zhiyi Tongzhi Recipe in the prevention and treatment of emerging infectious diseases in the future, and make greater contributions to protecting people's health by TCM.