In the contemporary Chinese medicine practice, doctors are often confronted with patients that feel very unwell, but for whom allopathic medicine can find no diagnosis. They are often patients with diseases like chronic fatigue, fibromyalgia, Epstein-Barr, Lyme and a host of other vague “syndromes”. In the west, many will diagnose these “syndromes” as “Gu” (蠱),  a disease name that refers both to a parasitic infestation and a kind of bewitching, and prescribe either Lightning or Thunder pearls 

Lightning and Thunder Pearls may have a large scope of applicability, but Suhe Tang (蘇荷湯), the formula on which they’re based, was primarily designed to treat parasites in the context of the damp heat of southwestern China where Gu historically predominated. In Zhigu Xinfa (New Approaches to Gu Therapy, 治蠱新法), Lu Shunde (路順德) notes that Suhe Tang and Jiajian Suhe Tang should be used for patients with clear signs of parasite infestation and damp, stagnant heat including “bloating…counterflow…drum-tight abdomen with urgency, internal heat, yellow urine and exacerbation with supplementing herbs.”.  The formulas feature a number of anti-parasitic herbs such as zisu, bohe, chaihu, baizhi, chuanxiong, sanleng, ezhu and guanzhong. These formulas were originally adopted to treat patients with parasites, but over time, parasites and “Gu” in particular were seen to represent a broader phenomenon of being “hollowed out from the inside out by dark yin forces that you cannot see.“ The Suhe Tang formula architecture has since been adapted to treat other diseases including Lyme, autoimmune, etc. that, like parasites, lurk latent in the yin spaces of the body, surreptitiously ravaging the sufferer’s health. 

Given the lack of alternative frameworks for treating these syndromes and given Lightning and Thunder Pearls’ broad scope of application—it’s recommended for any disease “that combines neurological and digestive distress not explainable with Western medicine or [TCM]”—it might be tempting to prescribe them for any patient presenting with these nebulous chronic-bacterial/viral infections or autoimmune diseases, but this runs the risk of diverging from the differential diagnostic spirit of Chinese medicine. Thunder and Lightning pearls can be quite helpful in these illnesses, but one should not forget they were formulas originally designed to treat parasitic infestations in patients living in hot damp areas and thus the limited strategies and herbs selected in the original formula were invariably oriented towards a specific historical usage. Suhe Tang includes several important methods for treating these conditions that should absolutely be studied, but they are not the only effective methods or frameworks that exist. Faced with these new and challenging disease paradigms, it behooves us as practitioners to command a broad palette of strategies to confront the nebulous and protean presentations of these modern ailments. As such, in the following, I will outline Wu Xiongzhi’s (吳雄志) approach to what he calls “latent pathogens” (伏邪, fuxie), a concept analogous to Gu, and discuss his robust framework and novel treatment strategies.

Wu Xiongzhi and Latent Pathogens  

Wu Xiongzhi is a contemporary Chinese physician serving as the Chief of the Integrated Oncology Department at the Tianjin University of Medical Science. Apart from his extensive research on oncology, Wu is a celebrated practitioner-scholar of the jingfang and warm disease traditions, from which he has developed his approach to latent pathogens. 

Defining Latent Pathogen Disease

For Wu Xiongzhi, latent pathogen disease has two primary characteristics:

1. Doesn’t manifest directly upon attack/infection. For instance, someone may not even know that they had lyme disease, but upon testing they are found to have elevated lyme-related antibodies.

2. And/or surfaces occasionally only to submerge again in a reoccurring pattern. To continue with the lyme example, people often talk of having a sudden “flare” of symptoms that then goes away again in a period of time inexplicably.

Additionally, latent pathogen diseases have one secondary characteristic that occurs in a variety of related diseases but not all:

1. During “flares”, there is a tendency to heat symptoms. For instance, in SLE, a flare might present with fever, rashes etc.

Due to this rather broad definition, in addition to treating Gu-like chronic viral and autoimmune conditions using the latent pathogen framework, Wu also uses it to treat PCOS, acne and even cancer, which all exhibit these characteristics.

Acne

Why does Wu view acne in terms of latent pathogen disease? In terms of western medicine, Wu writes, “Acne often appears in the context of a sudden rise in testosterone during puberty leading to excessive secretion of the sebaceous glands and ensuing congestion in the glands causing inflammation. From the perspective of Chinese medicine, a sudden rise in testosterone can be viewed as insufficient yin. As the Inner Canon remarks regarding latent pathogens, ‘If one does not store essence (yin) in winter, they will suffer warm disease in spring.’ Acne is often worst in spring and often appears in flares. All of these factors suggest acne is indeed a product of latent pathogenicity.  

As we will see in coming chapters, the key to treating latent pathogens is to clear the pathogen as it pivots out of shaoyang, this is the logic underlying Wu’s experience formula for acne:

Pipa Qinggan Yin

Pipaye 12g, Yinchen 30g, Zexie 30g, Cangzhu 30g, Kufan 1g, Heye 30g, Haizao 30g, Yujin 30g, Sheng Gancao 3g, Huangqin 9g. If scarring present, add Ruxiang 6g, Moyao 6g, Chuanshanjia 6g. (Note, we do not condone the use of Chuanshanjia and suggest replacing with Wangbuliuxing + Zhebeimu)  

Mechanism of Latent Pathogen Disease

Wu’s framework is based primarily on the six-conformation system of the Shanghan Lun, while also drawing on ideas from warm disease and the Inner Canon.  

Wu describes a 6-step process of the “infiltration” of latent pathogens.

1. Attack from exterior evil. This can be any of the six evils of damp, dryness, heat, fire, cold and wind.

2. Body doesn’t mount a response. This is what he calls a “shaoyin” response. The body does not have sufficient yang qi to push out against the infiltrating evil.

3. Body mounts an insufficient response. This is what he call a “taiyin” response. The body responds, but it is not sufficient to completely void the infiltrating evil.

4. If (2), then subsequent external attacks “activate” or draw out the evil, causing flare ups. If (3), the body continually mounts insufficient responses, causing occasional flare ups.

   1. Importantly, Wu sees these as instances where the evil is pivoting out from the three yin into shaoyang. Shaoyang serves as the primary pivot in this process. This comes from the Inner Canon notion of “If one receives cold damage in the winter, they will be sure to experience warm disease in the spring.” The idea being that the evil pivots out through shaoyang from shaoyin during the spring.

   2. From the Inner Canon: “In the first period of shaoyang, fire qi rules.” That means, that when evil qi pivots out through shaoyang, it manifests in heat symptoms as was mentioned before.

5. Each flare up causes inflammatory cascades and deranged circulatory responses which lead to fibrosis, (blood stagnation, phlegm etc.) which serve as “nests” for the pathogen. This is called the “jueyin” stage. (伏邪成巢)

6. Periods of illness, taxation, external attack as well as seasonal effects (flare-ups prevalent in spring) create an opening for the “nested” pathogen to emerge and wreak havoc.

A classic example is hepatitis. Acute hepatitis takes the form of an exterior attack (often with three yang symptoms presenting). If taiyin and shaoyin are both strong, the virus may be pushed outwards and resolve on its own. If taiyin is weak, the body will mount an insufficient response and chronic hepatitis with occasional episodes may result. If shaoyin is also weak, there may be no salient response, and the patient becomes a symptomless carrier. Flare ups from taiyin, or via external attack activating the pathogen in shaoyin both contribute to hepatic fibrosis, and a more pronounced decline in health. 

Applying Latent Pathogen Theory in Clinic: The Jueyin Stage and Chronic Pelvic Inflammatory Disease

In the jueyin stage of latent pathogenicity, blood stagnation, phlegm and scarring provide the perfect “nests” for latent pathogens to continue thriving. The pelvis, located at the bottom of the thorax, is highly susceptible to blood stagnation. Any injury to the body, be it taxation, external evil etc, can all weaken yang qi, compromising the body’s ability to pump blood and lymph back up from the pelvis. Overtime, this blood and lymph stagnates below, trapping heat and leading to inflammation which causes scarring. This combination of stagnation, phlegm and scarring provides the “nests” of poor circulation where latent pathogens continue wreaking havoc and perpetuating chronic inflammation. The answer? Shengma Biejia Tang.

Shengma Biejia Tang in Chronic PID

Shengma: outbears trapped heat from the blood level of jueyin. The jueyin channel passes directly through the pelvis and networks to the genitals.

Biejia: roots deep into the stagnant network vessels, breaking up congestion and allowing new blood to flow through. 

Danggui: supports biejia in invigorating blood and is also a potent ant-inflammatory

Shujiao: Aromatic warmth to fumigate the pathogen, break up cold phlegm and dampness.

Sheng Gancao: Anti-toxic, supports shengma in outbearing the pathogen.

Yiyiren: drains dampness, anti-toxic, treats Bi (latent cold, damp + wind)

Common dosages: Shengma 30g, Biejia 30g, Danggui 6g, Gancao 30g, Shujiao 3g, Xionghuang .3g, Yiyiren 90g. 

Diagnosis of Latent Pathogen Disease

1. The Shanghan Lun states that latent pathogen disease will manifest primarily with chronic sore throat, chronic digestive distress (diarrhea, bloating etc.) and a weak, faint pulse.

   1. Wu notes that indeed, the sore throat is a very common sign in SLE and a key indicator for using latent pathogen methods. The throat being one of the primary lymph node centers in the body, a good sign of immune activity.

   2. Not all of these may manifest, and they don’t have necessarily have to be present, but taken with other symptoms, can strongly point you towards a diagnosis.

2. Tongue

   1. When in three yin stages. There will be congested sub-lingual veins, redness which is redder than top of tongue and clusters of pearl-like white globules.

      1. Veins, a sign of that deranged circulation and network vessel congestion of jueyin.

      2. Redness: the heat is interior and not able to escape outward.

      3. Globules: sign of laten cold-damp in three yin.

   2. During flare up: look for swollen and red sides of tongue. (shaoyang)

      1. If the coating is white and thin, there hasn’t been a sufficient response. Use huangqi. When turns yellow, use jinyin hua.

3. The key is to distinguish between the three yin conformations, to identify if there is jueyin involvement and to what degree the patient is in a latent or active stage. This will clearly guide treatment.

Case of Lymphoma with Tongue Diagnosis-guided treatment

Patient presents with a pale tongue indicating a lack of clear heat in three yang. The base of the tongue has a slimy thick coating, this indicates the presence of dampness. On the underside of tongue, the sublingual veins are distended, indicated blood stagnation. There are also a number of small globules suggesting phlegm. On the lateral sides of the underside of the tongue, there are a large number of salient bright red blood vessels, indicating latent heat. On both sides of the tongue, there are a large number of white spots. This suggests that upright qi has tried to mount a response but is too weak to prevail against the pathogen. (Wu explains in a yellow coating, white blood cells have captured and broken down bacteria, producing the yellow color) This white coating suggests that the patient has yang deficiency with cold. “If one is damaged by cold in winter, they will suffer warm disease in spring.” Taken together, these signs tell us that the patient has a latent pathogen in combination with cold, phlegm and blood stagnation, allowing for the pathogen to “nest” in concealment. The underside of the tongue is redder than the top, suggesting that the pathogen is producing stagnant in its nested state in the jueyin blood level. 

In such cases, where there is jueyin blood level latent pathogen nesting, Shengma Biejia Tang is used with a number of additions which will make more sense after the next section:

Shengma 30, Biejia 10, Danggui 10, Gancao 6, Shujiao 6, Yiyiren 60, Huangqi 30, Huangqin 10, Wugong 3, Chaihu 25, Taizishen 30.    

Treatment of Latent Pathogen Disease

In Wu’s framework, if the pathogen is latent, the key is to activate upright qi to attack the pathogen and draw it out from concealment (often in spring). Then once the upright qi has been activated and draws the pathogen into the three yang conformations, the “balance method” should be used to outwardly harmonize and clear out the pathogen.

1. Activating upright qi and driving out pathogen

   1. If symptoms present primarily in Taiyin: Baizhu, Fuzi, Huangqi and Yiyiren

   2. In Shaoyin: Fuzi and Xixin

   3. In Jueyin: pathogen has already “nested”, use Shengma Biejia Tang strategy.

      1. Shengma, mudanpi (outbear from blood)

      2. Biejia, Wugong (roots into luo and outer reaches of the “nest” to break up blood and stagnation.)

      3. Shujiao (breaks up cold stagnation)

      4. Danggui (invigorate blood)

      5. Binlang, Houpu, Caoguo (wenbing method for breaking up phlegm of nest)

      6. Rougui (warming jueyin to effuse with yang warmth)

   4. All stages: Use high dose huangqi and taizi shen to activate upright qi.

2. Balance Method

   1. As you drive out, you have to balance with cooling. One aspect is to draw out the pathogen and then attack it, the other is that shaoyang can turn into yang ming and eventually lead to wind and blood diseases. Examples:

      1. Huangqin is most often implicated in the balance method and combined in different harmonizing strategies for instance:

         1. Xiaochaihu Tang: Huangqin + Renshen (taizi shen) (shaoyang)

         2. Chaihuguizhiganjiang Tang, Lizhong Tang + Huangqin (Huangqin + Ganjiang) This is shaoyang/taiyin

      2. If pivots towards yangming, use Dahuang, but while also continuing to activate upright qi for instance Dahuangfuzi Tang. (dahuang, fuzi, xixin. )

         1. Can also use Dachaihutang.

      3. Other common coolers, qingdai, jinyin hua and baihuasheshe cao.

   2. At all stages, dampness is a constant factor. The most important herb is yiyiren. Typically used at 60-90g. Yiyiren works on dampness while also treating Bi syndrome, a kind of latent conglomeration of wind, cold and damp.

3. If patient still not responding, that means there is not enough material to steam out from shaoyin. In such cases, use yinyanghuo, sangjisheng (yinyang shuangbu)

   1. This idea derives from the Inner Canon quote, “if one does not store essence in winter, in spring one will suffer warm disease.”

4. Specific herbal strategies that address the idiosyncrasies of each disease manifestation.

Chronic Hepatitis Case Study

Male, 29 years old.

Patient was diagnosed with Chronic HBeAg Hepatitis B in 2000. The patient’s hepatitis was well controlled with entecavir and adefovir until 2016, when elevated HBV-DNA (4E +3 IU/ML) levels started to indicate resistance to the available drugs. With no other viable options, the patient was relayed to Doctor Wu for further treatment.

The patient was of a skinny build, fatigued, with poor appetite, and epigastric glomus especially upon waking in morning. The patient also reported poor sleep, BMs that were initially hard and on second trip were unformed.

Tongue: Slightly swollen with teeth marks. Underside of tongue redder than topside. A thin greasy white coating.

Pulse: thin and weak. 

Diagnosis: The classics note “in treating the liver, one must first address the spleen”. This patient has a taiyin (spleen) deficiency (skinny, fatigued, poor appetite etc) leading to an insufficient response to the latent viral pathogen in the liver, as such there is a chronic condition marked by occasional flareup and elevated viral load. The weak pulse and fatigue are also signs of an underlying shaoyin deficiency. This case must urgently be treated before the recurrent flare-ups lead to fibrosis and “nesting of the pathogen” in jueyin. 

 Treatment strategy: Emphasis on activating upright qi and drive pathogen from taiyin and jueyin, simultaneously balance and clear in shaoyang.

Sheng Ma 30g, Mudanpi 9g, Rougui 3g (Jueyin: outbear pathogen and warm)

Yiyiren 90g, sheng gancao 3g, sheng huangqi 90g, baizhu 30, dangshen 15g, fuling 9g (Taiyin: activate upright qi, clear dampness, supplement and transform taiyin)

Sangji Sheng 30g, Xianlingpi 30 g (Shaoyin: simultaneous warming and essence-nourishing)

Huangqin 9, Daqing Ye (30g) baishao 9g  (Shaoyang: balance method, clearing pathogen as it pivots through shaoyang)

Next visit: 

Result: HBV-DNA increases to 9.1, patient notes thirst and bitterness in the mouth. Formula should pivot to clearing and deemphasize activation while retaining balance. (HBV-DNA increase indicates pathogen has been drawn out of latency)

Formula: 

Sheng Ma 30g, Mudanpi 9g, Rougui 3g (Jueyin: outbear pathogen and warm)

Yiyiren 90g, sheng gancao 3g, sheng huangqi 30g, (Taiyin: activate upright qi, clear dampness, supplement and transform taiyin)

Sangji Sheng, Xianlingpi (Shaoyin: simultaneous warming and essence-nourishing)

Huangqin 9, Daqing Ye (30g) baishao 9g, Baihua Sheshe Cao 9g.  (Shaoyang: balance method, clearing pathogen as it pivots through shaoyang)

HBV-DNA drops to 1.94 (within normal range) and patient experiences noted increase in energy (liver is foundation of endurance 肝為罷極之本) 

Note, Doctor WU first identifies the location of the pathogen (taiyin, jueyin) and then uses a targeted treatment to powerfully activate upright qi and drive the pathogen outwards to the three yang. Once the pathogen surfaces, the balance method is used to simultaneously clear the pathogen out from shaoyang while continuing to support and push from the three yin.