by Noach Nestor Bittelman, LAc
The success of any medical treatment is dependent, to a very large extent, on an accurate diagnosis. Correctly understanding the disease mechanism, how it is currently manifesting in the patient, the stages the disease is known to go through, and the strength of the patient who is engaging with the illness are all important factors which contribute to a successful medical intervention. Treatment strategies, whether they be herbal treatments, acupuncture/moxabustion, nutraceutical, pharmaceutical, or massage and other body manipulation techniques, all need to be directed towards accomplishing specific goals which have been determined by the working diagnosis.
Epidemics or pandemics are no different in this regard than any other kind of illness. In allopathic medicine epidemics are described as being caused by either a virulent bacteria or virus, and treatment is generally pointed towards eradicating the bacteria or virus. In Chinese medicine each epidemic is differentiated according to how, where, and when it manifests, and who it tends to strike. Treatment strategies are arrived at and adjusted primarily according to these factors.
An analysis of two different pandemics from a Chinese medicine perspective, the Spanish Flu of 1918-1920 and the current COVID-19 Coronavirus pandemic, can illustrate how each epidemic is differentiated medically and how successful treatment strategies are achieved.
The Spanish Flu of 1918
The Spanish Flu, which ran from 1918-1920, decimated huge portions of the world population, killing anywhere from the most conservative estimate of 17 million people, to upwards of 100 million people. If we choose a middle ground and go with one of the figures suggested by medical historians, 50 million people killed, we still have a pandemic of horrible consequence. (As of this writing there have been over 200,000 deaths worldwide from the COVID-19 Coronavirus, which is of course terrible, but the number pales in comparison to the destruction wrought by the Spanish Flu.)
An examination of how and when the Spanish Flu manifested and who it tended to strike will reveal to us its nature, and will point us in the direction of a working treatment strategy.
The Spanish Flu, in contrast to what we might think, did not primarily attack and strike down the weak and vulnerable populations—the elderly and the very young. The primary victims were young adults—those between the ages of 20-40 years old accounted for half of all deaths from the Spanish Flu in the United States between 1918-1919, and 99% of all deaths in the USA from that same time period occurred in people under 65 years old. This is our first diagnostic clue—the flu’s mortality was directed primarily at young people.
The timing of the Spanish Flu is also a paradox. Generally speaking, “flu season” takes place during the colder, winter months, yet the Spanish Flu was most virulent during the summer and fall months, with the second wave beginning in August and extending into the autumn. This timing is a second diagnostic clue about the nature of the Spanish Flu, or at least the nature of this flu during that time period.
The third major clue as to how to correctly diagnose the Spanish Flu is the unusual symptoms. Hemorrhaging from the nose, stomach, intestines, and lungs were significant, remarkable symptoms associated with the Spanish Flu. Likewise, medical reporting noted bleeding from the ears as well as “bruising” or bleeding under the skin.
If we examine these various clues and symptoms from a Chinese Medicine perspective we can arrive at a generally decent understanding of the nature of the pathogenic factor or factors responsible for the carnage wrought by the Spanish Flu. This diagnostic understanding is essential in order to arrive at an accurate treatment direction and strategy.
First question: When did the Spanish Flu strike?
As mentioned above, the Spanish Flu struck most virulently, in its second wave, from August through October and into November. In Chinese Medicine this timing is characterized as a time of heat and dampness; the summer months are the months of heat, and what is called “Long Summer”, the period extending basically from August through September, is the time of the year when humidity and dampness predominate. That the flu manifested dominantly at this time strongly points to the nature of the Spanish Flu, at least at that time period, as consisting of Dampness and Heat.
In general, illnesses which historically occur in the winter tend to be “cold” in nature, while those which occur in the summer tend to be hot, or hot and damp. For example, the phrase “I caught a cold” is an expression found in many languages; in some languages “I caught a wind” is also used. Chinese Medicine describes six different types of external pathogenic factors which can penetrate the body and cause problems—wind, heat, dampness, dryness, cold, and sunstroke-type intense heat. Each season has its own particular quality or nature which influences the illnesses occurring in that season.
(The actual practice of Chinese Medicine is more complicated than what is being presented here, since there are many other factors which go into an illness manifesting at any one time. There are latent pathogenic factors which can lay quiet in the body and then come out at a time quite distant from when they were contracted, there is the modern day influence of air conditioning, the consumption of cold or even frozen food and drink, etc., etc., all of which can contribute to a pathogenic factor manifesting even in its off-season.)
Second question: How did the Spanish Flu manifest? What were the dominant symptoms?
One of the outstanding symptoms associated with the Spanish Flu was the hemorrhaging, both internal and external, which often occurred when someone contracted the illness. Hemorrhage, or any kind of bleeding, is not something which is normally associated with a flu, particularly the types of flus with which we are familiar nowadays. That the Spanish Flu had bleeding or hemorrhage as a strong symptom calls for us to answer the diagnostic question—what kind of pathogenic factor can cause bleeding/hemorrhaging?
Chinese Medicine attributes the symptom of hemorrhage during flu as being a result of heat. The flu pathogenic factor enters the body and either quickly and directly penetrates to the blood level, or it enters the body and at a certain stage transforms from its original nature—damp, cold, wind, etc.—into heat and then penetrates to the level of the blood. If there is excess heat already pre-existing at the blood level then this external pathogenic factor—the flu, which again is either originally hot in nature, or has by now transformed into heat, joins with the pre-existing excess heat at the blood level.
One of the manifestations of excess heat in the blood is that it causes the blood to become “reckless” and leave the pathways within which it is meant to travel, commonly known as bleeding. If there is bleeding or hemorrhaging from the lungs then we know that the heat has penetrated to the blood level of the lungs; if the bleeding or hemorrhaging is from the stomach or intestines then we know the heat is causing the blood associated with the stomach or intestines to become too hot and burst forth from the vessels which usually contain the blood.
The language of Chinese Medicine in describing this pathology may sound strange to the uninitiated or to someone who is only familiar with allopathic terminology. A simple analogy to everyday life might be helpful here: Imagine someone driving a car. Now imagine this person becomes angry, for whatever reason. Chances are very high that this driver will start to drive faster as they become angry and lose self-control, and if they become overtaken completely by their anger they may even accelerate to a dangerous speed, which may well lead them to lose control of the car and go careening off the road. Raw anger, a “hot” emotion, causes the energy of the person to move faster, to move up, and to move out, often in an uncontrolled fashion. This is similar to the effects of the pathogenic heat of the Spanish Flu on the blood which causes it to move in an uncontrolled fashion and leave its “road”, the blood vessels.
Third question: Who did the Spanish Flu strike and what can that tell us about the nature of the pathogenic factors involved?
As mentioned above, the Spanish Flu took as its primary victims not the elderly, the infant, or the weak, but rather the younger and ostensibly stronger population. The age group which was most liable to be killed by the Spanish Flu, the 20-40 year-old younger adult population, is a group which by and large has an abundance of Yang Qi. This means that they tend to run hot, be physically very active, and have a strong metabolism. Illnesses of people in this age group are often conditions of excess rather than deficiency, meaning they will have conditions of too much heat and/or too much phlegm and dampness accumulation in their bodies because of dietary and lifestyle factors, medical interventions, etc. The fast living of the younger city dweller, or the dietary excesses of the rural individual are both significant factors which contribute to situations of excess. (In our current time period situations of deficiency, meaning slower metabolism and a colder body, are fairly common even among the 20-40 year-old age group; there are many factors which have contributed to this but it is not something which I will go into here.)
The abundant Yang Qi of the younger population is easily contrasted with the decline of and insufficiency of Yang Qi in the elderly and weaker population. These populations are often very bothered by cold weather, damp and humid weather, cold food and drink etc. and will tend to want to eat warmer foods and live in warmer climates.
That the Spanish Flu struck the younger, more vibrant, active, Yang excess population points to its nature as being a hot pathogenic factor. The pathogenic heat from the flu, in all likelihood, joined with the excess heat already present in the bodies of the younger population and thus brought on the deadly symptoms associated with the flu. We could also surmise that when this hot pathogenic factor entered the bodies of the older, colder population, it was met by an internal coolness which in effect protected the older or weaker person from the occurrence of a critical situation.
In summary, we are able to conclude, with a decent amount of certainty, from the answers to these three questions, —when the Spanish Flu struck, how it struck, and whom it struck—that the pathogenic factors at play were of a hot and damp nature. Now that we have determined an accurate diagnosis, we are able to devise a correct and effective treatment strategy based on this diagnosis.
After analyzing the Spanish Flu in the above fashion, it becomes relatively simple to compare and contrast the current COVID-19 pandemic and arrive at a Chinese Medicine diagnosis. We can ask the same questions—when, how, and who COVID19 tends to strike—and contrast the answers with the findings from the Spanish Flu.
When and where did COVID-19 appear on the scene and wreak havoc?
The current novel Coronavirus first appeared in force in China in December of 2019, and proceeded to become an epidemic, and then a worldwide pandemic, over the course of the winter of 2020. As of this writing, late April 2020, the pandemic appears to be slowing down.
As far as the timing component of the Coronavirus, we can conclude with a fair amount of certainty that one of the major pathogenic components is cold. Winter is the time when cold is dominant, and pathogenic attacks which occur in the winter almost always involve some degree of cold.
It is useful to add one additional detail about the novel Coronavirus, having to do with location, where the virus began. The novel Coronavirus first showed up, and became very widespread, in the city of Wuhan, located in Hubei Province, China. Wuhan happens to be situated at the confluence of three rivers, meaning the area has a significant amount of water, and consequently dampness.
So the analysis of timing leads us to the concept of a cold pathogenic factor, and the analysis of location adds in the idea of a damp pathogenic factor. Cold and Damp.
How does COVID-19 manifest? What are the dominant symptoms?
Although there are a number of symptoms associated with COVID-19, the classic initial symptoms of the novel Coronavirus infection are fever, cough, shortness of breath, lack of sweating, body aches, loss of appetite. The patient’s tongue is usually white or very pale, with a thick white coating. Over the course of 3-7 days, sometimes less and sometimes more, many patients will start to have extreme difficulty breathing as their lungs fill up with fluid.
The symptoms outlined above are associated in Chinese Medicine with an attack of Cold and Damp pathogenic factors. The cough, shortness of breath, and fever without sweat, in combination with the white or pale tongue all point to a Cold pathogenic factor, while the body aches and loss of appetite are signs of an attack of Damp.
(After the initial illness period the sickness will often rapidly change its nature and transform into heat, causing the fluid in the lungs to congeal into very viscous, thick, sticky phlegm, signaling a dangerous turn of events as the lungs dry out and the phlegm obstructs lung function; use of ventilators at this point can be deadly, as the pressure from the ventilator can force the phlegm into the deepest part of the lungs, where it can coat the alveoli and obstruct the movement of oxygen from the lungs into the blood. More about this problem is available here: https://bit.ly/deadly-ventilators.)
Who does COVID-19 primarily affect?
The population at highest risk of mortality from COVID-19 is the elderly. People with chronic illnesses such as heart disease, pulmonary disease, diabetes, etc., are also at greatly increased risk of being killed by this novel Coronavirus. These populations have a pre-existing lack of Yang Qi, they tend to have general systemic cold (or systems-specific cold, for example the lungs and heart). This is in contrast to the population who suffered as the primary victims of the Spanish Flu, the younger, vibrant, 20-40 year-olds who we assume had pre-existing general systemic excess heat (or systems-specific heat, for example the blood).
The Cold and Damp nature of the novel Coronavirus easily and naturally combines with the pre-existing cold and damp of the elderly, ill, or weaker population, and unfortunately often brings about disastrous consequences. The younger, “hotter” population, on the other hand, is able to more easily fend off the cold and damp pathogenic factors associated with COVID-19 and recover from the infection.
(Again, I wish to stress that the COVID-19 being discussed here is what has generally been occurring in China and around the world, during the early stages of the illness, up to this point in time. There is concern in the Chinese medicine community that the nature of the illness may change as the seasons progress and we may begin to see different manifestations of the illness as a result.)
Each of the two flus analyzed above is treated in Chinese Medicine according to its symptom differentiation, meaning different treatments would be given for each illness even though according to allopathic medicine both flus are the result of infection by a virus.
The hot and damp Spanish Flu would need to be treated using techniques which have the ability to clear and cool heat and resolve and transform dampness. The cold and damp COVID-19 flu would need to be treated using techniques which have the ability to warm and dispel cold and resolve and transform dampness.
Different symptom presentation, regardless of whether the patient has the Spanish Flu, COVID-19, or any other virus or bacteria, would call for yet a different treatment approach than those outlined above, since the treatment must always be suitable for the situation as it presents itself in the present moment. (To read more about prevention and treatment of COVID-19 please see: bit.ly/covid-prevention-and-treatment.
In summary, we can see the importance of having a correct diagnostic framework and understanding in being able to arrive at an accurate and effective treatment strategy. The clinician must also have the ability to be diagnostically dynamic, assessing at all times if there is a need to adjust the strategy as the illness changes its presentation. These factors are crucial in making for successful medical outcomes.
Noach Bittelman, LAc is a direct lineage disciple of Master Young Wei Chieh, who himself is a direct lineage disciple of Master Tung Ching-Ch'ang and the foremost authority in the world on Master Tung Acupuncture. Noach studied Chinese Medicine and Acupuncture in Taiwan and has run a practice in California and Israel for over 30 years. He is fluent in Chinese, Hebrew, Spanish and English and teaches courses in Master Tung Acupuncture internationally. He can be reached at firstname.lastname@example.org.