Webinar: TCM Pathophysiology of Epidemics

Students in Five Branches University, this is Dr. Chi. Last time, held on March 2nd, we had a Lunchtime Forum with the students in Five Branches. Since then, the disease has developed from an epidemic disease to a pandemic disease. Last time, we were talking about this COVID-19 and how China has used TCM to help the patients at different stages. Back then, there were only 89000 recorded cases of COVID-19 in the whole world; now there are 1.6 million people in the whole world affected by this virus, and almost 100000 deaths recorded. In the U.S., the doctors at the front lines are worried because the standard approach of using ventilators is failing the patients. This morning I read articles in the Mercury News. They are talking about how doctors are debating on whether the use of the ventilators are really helping the patients, or hurting the patients. Where exactly is this battlefield? How come the ventilators have failed the patients?

I would like to spend some time to talk about how TCM views this disease that has already become a pandemic. We will talk about the COVID-19, the signs, and symptoms. There is one thing I really need to emphasize one more time; that is the fever. It is only 43% of the patients that present with a fever; the majority of the patients, when they start showing signs and symptoms, are actually without a fever. So only focusing on testing whether people have a fever or not, cannot rule out COVID-19. I highly recommend everyone, if possible, to wear a mask to protect the people around you, and also protect yourself. If we want to end this fast, then we really need to treat everyone as an asymptomatic carrier.

In the first week, usually, the virus levels are very high; but symptoms, such as fever, sore throat, or cough, are mild to moderate. Most of the patients actually have an absence of upper respiratory tract symptoms; they don’t have any runny nose, any sneezing. Some patients don’t even have a sore throat. The immune system can actually fight the virus and target them. People may just feel a little fatigued and tired, but they can recover from it. So those are the symptoms that the patients have in the first week. But after the second week of illness, even though the virus at this moment is starting to taper off, the immune system goes to endanger the lungs with inflammatory cells. That is when people enter the ICU. What happened during those two weeks? Why is it that in the beginning there were not many symptoms, and the body is able to maintain homeostasis?

Today we are going to spend a little time talking about this phenomenon and how TCM views this. There are four classics that all TCM students are required to study: Nei Jing, Shang Han Lun, and also Jing Gui Yao Lue which covers all the miscellaneous diseases that don’t cause a fever. There is one more called Warm Disease, Wen Bing Xue. It is one of the classics missing in TCM education in the United States. But this epidemic disease falls into this Wen Bing category. Huang Di Nei Jing was written about 2500 years ago. It also talks about epidemic diseases. The Emperor said, the characteristic of the Five Yi, or five different kinds of epidemics, is that it is highly contagious. People, whether old or young, will all have similar symptoms. Qi Bo is the doctor that worked with the emperor. He said, if the Upright Qi (which is usually interpreted as our immunity) is strong, the body will not be attacked by the Evil Qi (which represents the pathogen). But most of all, Qi Bo said, you have to avoid the Toxic Qi. Upright Qi is the ability to maintain homeostasis.

We know that in Traditional Chinese medicine, there are no specific herbs that kill bacteria or viruses directly. We focus on balancing our bodies, promoting return to homeostasis. This is also considered as the ability to protect the body from external invasion. So what are the external invasions? There are five different seasonal changes: the wind, the cold, the heat, the dampness, and the dryness. These are the external invasions that can attack our body’s homeostasis and disable us from dealing with the pathogens. The toxic Qi is sometimes also considered as a pathogen. But 2500 years ago, the Chinese did not have a clear view of what a pathogen is. Mainly, what they think about are the seasonal changes. Starting from Shang Han Lun all the way to the Ming dynasty, which is about 800 years ago, people focused on using the Shang Han Lun strategy to treat the epidemic diseases. This is one of the oldest complete clinical textbooks in the whole world that discusses epidemic disease. Zhang Zhong Jing talked about the abnormal seasonal changes causing disease. For example, during the winter time, it suddenly becomes so hot that the body is not able to adjust when it is preparing itself for the winter, or if the weather suddenly becomes so cold in the summertime. They categorized this into six different stages. It starts from Tai Yang, then enters into Yang Ming. Then if it enters into Shao Yang, the patient starts to have alternating chills and fever. That means that the pathogen and your Upright Qi are battling back and forth, and neither side will give in. This is the time when we need to help harmonize the body. In history, there were 156 times of the epidemic diseases in the Song dynasty. But it is not until the Ming dynasty that the Chinese start to realize that there is something more than seasonal changes, that can affect our health. There is something invisible that is different from the seasons, that can cause disease, and is highly contagious. Doesn’t matter whether you are healthy or not, you will get it.

Dr. Wu You Ke is the first one to establish a hypothesis that there is some kind of invisible enemy that can attack us. So Wu You Ke wrote a book called, Wen Yi Lun, “Treatise on epidemics”. During that period, hundreds and thousands of people died due to epidemic diseases. Many doctors of that era were trying to use Shang Han Lun’s formula to treat epidemic disease but they all failed. So he started to realize that there is something different in the air, an invisible Qi that is different from the seasonal change. They called it Yi Qi. Yi Qi enters the human body through the nose and mouth, and these diseases actually have their own pathogens. Where is the battlefield? He says that it attacks our body’s Muo Yuan. This is one of the focal points I want to focus on at this time. What is this Mo Yuan? If you translate it, it literally means “membranous origin.” This Yi Qi attacks our body’s Mo Yuan. He emphasized on tongue diagnosis because during Yi Bing, the tongue changes dramatically. This evil Qi, or pathogenic Qi, enters the body through the nose and mouth, and affects the locations, neither in the organs nor in the viscerals. It did not invade our bodies externally where the channels are located, but it enters and lingers in the in-between areas, the half-interior and half-exterior space, also called Mo Yuan. There is another book that also talked about Mo Yuan. It says, Mo Yuan is a membrane that connects the Spleen and Stomach, in the half-interior half-exterior area. In the Shang Han Lun, half-interior, half-exterior, can also be considered as the Shao Yang. In channel theory, we can say it is a San Jiao channel or Gallbladder channel Shao Yang. Shao yang, or the San Jiao area, can also be considered as the interstitial spaces in our bodies. This is the place where the pathogen lingers and attacks. This is the battlefield where we try to clear and help our patients return to homeostasis.

Where is the Mo Yuan in human anatomy? In the interior are the organs and viscera. The exterior, in Traditional Chinese medicine, is the skin and muscles. The half-interior and half-exterior, are the interstitial spaces, fluid filled areas that surround the cells of a given tissue. The serous membrane is composed of two layers. We know that one covers the organ, and the other covers the body wall. In between, the space is filled with lubricating serous fluid, secreted by the serous membranes. We know that in our body, the serous membrane of the heart is called the pericardium; in the lung, it is called the pleura; and in the viscera, it is called the peritoneum. What is the function of the serous membrane? It protects and allows the frictionless movement of the heart and lungs. We know that our heart is constantly beating, and our lungs are also constantly moving due to breathing. In order to protect them, you need this layer of protection. It also regulates the movement of fluids and other substances across the membrane. Most importantly, I wanted to focus on its control of immune responses; this includes coagulation and the movement of white blood cells whenever there is inflammation, and also the synthesis of the cytokines and other molecules involved in membrane repair and inflammatory responses. This is the place where the inflammatory responses and the immune responses kick in.

The human immune system reacts to the virus by sending out cytokines to attack the virus. But the problem is that this causes serious inflammation. Many COVID-19 patients enter into the critical stage due to this cytokine storm. The virus itself may not kill the host, but the inflammation causes fluids and blood to accumulate in the lungs, causing the patient to drown. This is the reason why patients get killed by the COVID-19. Many doctors now say that maybe it is not the virus itself that kills the patient, but the consequences induced by the virus. The inflammatory response is what causes the death of the patients. This serous membrane is the battlefield of this COVID-19 fight. It is very much connected to what Wu Yuo Ke has shown us.

This is one of the CT-Scan from patients infected with COVID-19. You can see the area affected; it is in the posterior and peripheral part of the lung. There are many patients that are presented with chills and fever, and they feel cold in their back. We know that the back is where the UB channel is located; and these are the Tai Yang symptoms in the Shang Han Lun. So if you start to feel chills and cold in the back, this is the time that warns us that we have to do something to take care of the fluids and not allow them to accumulate too much in the channels and affect the serous membrane.
You may have a question about why the CT scan for COVID-19 patients shows ground-glass opacities in the posterior and periphery of the Lungs? This paper shows ground-glass opacities in the subpleural area. These subpleural areas are where the fluids are accumulating. In our human lungs, Mo Yuan is very similar to the place where we call the pleura; the layer in between the interior and exterior. It is the place where inflammation responses start reacting.

You can see that the alveoli is a place very close to the pleura area. They have a Type II alveolar cell with ACE-2 receptors on them. The researchers believe that the ACE-2 receptor is the place where the virus hack into our body. And once the virus, through these ACE-2 receptors, hack into our human cells, they start to replicate and multiply, until they use up all the resources and the cells die. The virus then starts spreading and then goes to the adjacent alveoli. That’s the place where this battle starts.

So how did Wu You Ke treat the Mo Yuan disease? He said that the pathogen does not invade the exterior. So you cannot simply use releasing-the-exterior methods. The pathogen also does not invade the interior where the viscera organs are, so we cannot only use the purging methods. The pathogen enters the body through the nose and mouth, and then invades and lingers in the Mo Yuan area. Wu You Ke established a new method called Fen Xiao. Fen means to separate; Xiao means to eliminate or to disperse. So it means to eliminate and separate. He used herbs not only to disperse, but also to transform and at the same time, to drain. These three methods all together, disperses, opening the way for fluids to come out of the Mo Yuan area and be released from the exterior; they also help the body transform the dampness inside the organ, and help the body drain the dampness. The three methods together accomplish this.

Wu You Ke invented this new formula, called Da Yuan Yin. The indication is to treat low fever, chills, chest pain, chest tightness, nausea, headache, and a red tongue with a greasy and powdery white coating. This greasy and powdery white coating is an indication of Yi Bing. Why is there a greasy and powdery white coating? It is because the interstitial level is affected by the pathogen so that the fluid in the interstitial level is not able to move around. It then starts to accumulate in the body, presenting as dampness. Bing Lang, Hou Po, and Cao Guo– these herbs are all spicy, warm, and aromatic. We know that aromatic herbs transform dampness; warm is very crucial in this Mo Yuan disease because in the beginning the patient’s tongue is usually very pale and they are very fatigued. So, we have to be very cautious to use too much clear-heat herbs. Dampness is a Yin disease. We cannot use clear-heat herbs too early. That will further damage the patient’s Yang Qi. Bing Lang, Hou Po, and Cao Guo can directly attack the Mo Yuan area, the place that throws the body into an imbalanced state. We need to help disperse the fluids that accumulate in the Mo Yuan area, either through the exterior, through the bowel movement, or through urination. Bing Lang can promote urination and Hou Po can transform dampness through the middle jiao. Cao Guo also warms and transforms in the middle jiao, the fluids that have been accumulating in the interstitial level, because it is draining. He also added Zhi mu to clear heat and at the same time, moisten. Why do you need to clear heat at this time? It is because Qi gets stagnated by fluid, and Qi accumulates into heat. Eventually heat will start accumulating. Of course, a lot of times, the heat is not accumulated at the beginning stage. But slowly, they will build-up because of Qi stagnation. That is why a lot of the COVID-19 patients, in the beginning, don’t present with a fever. They sometimes have a low-grade fever for a while, then slowly turn into a high fever stage. This is because the dampness and the fluid that has been accumulated in the interstitial levels are in the half-interior, half-exterior level, obstructing Qi. Once Qi gets obstructed, heat will slowly start to accumulate, and at a level, they will break into a fever. When we start treating a patient, once they start having a fever, it is already the progression stage. Huang Qin clears Lung heat. It clears heat, drains dampness, especially in the upper jiao. Why do we use Chi Shao here? Because when there is Qi stagnation, there is also blood stasis; and blood stasis will further cause qi stagnation. Chi Shao is used to move Qi. Huang Qin is also used to stop bleeding. When blood can move freely, then we won’t enter into the acute inflammatory response that fast. So Chi Shao can actually prevent the body from entering into the inflammatory response that throws patients into the critical stage.

Of course, we can also create our own formulas that replicate the same strategy, using different herbs. We can use Qiang Huo; we can also use Du Huo. If we don’t have Ma Huang, we can use Fang Feng; we can use Jing Jie. For transforming herbs, we can use Cang Zhu; to clear heat, we can use Chai Hu. The focus for this kind of Mo Yuan disease is that we cannot only use herbs that eliminate by releasing the exterior; we cannot only use the purging method; we also cannot only use the transforming method. We have to use all three together in order to loosen up the Mo Yuan area.

Is Da Yuan Yin the best for COVID-19 then? It provides a strategy to take care of patients at the Mo Yuan stage. But you still need to use pattern differentiation. Wu You Ke, in his book, specifically emphasized “three ones”. He said, one formula for one person, at one stage. One formula is only for one individual, and at one particular stage of the disease. Why is checking the tongue so important? Because once you start using these warm, spicy, drying, and draining dampness herbs, immediately the Qi starts to move. And when Qi starts to move, then your upright Qi starts to have the energy to fight back. If the patient enters quickly into a heat syndrome, then we have to use more heat-clearing herbs instead of only warming herbs. We really have to look at the patient and change the formulas accordingly.

I get a lot of questions from the students on whether Lian Hua Qing Wen Yin can be used to prevent COVID-19. Looking at Lian Hua Qing Wen Yin, we have Lian Qiao; we have Jin Yin Hua; we have Ban Lan Gen; we have Guan Zhong, Yu Xing Cao, Bo He, Da Huang, Shi Gao. All these are very cold herbs. This formula is very good for patients who have a heat syndrome; who have a high fever, a sore throat, a dry throat with a red tongue or a yellow greasy coating. A lot of the doctors in China say that in this particular COVID-19, a lot of patients actually feel cold and dampness at the beginning stages. So we have to be very careful when using this formula as a preventative. In Traditional Chinese Medicine, we believe that if we do not have the symptoms, we should not use the herbs. But if you have the symptoms, then of course, we can apply the formulas. So if you see patients with corresponding heat symptoms, of course, we can use Lian Hua Qing Wen Yin to help them.

Because of time, there are a lot of things I wanted to share with all the students, but we probably need to stop here. If you have any questions about how to treat? Or if you have any patients or friends that have already been diagnosed with COVID-19 and you have questions, I will be more than happy to answer your questions. If you leave your information or your comments, I will go through them and we can contact you and answer your questions. I do believe that Traditional Chinese Medicine can help patients at the beginning stage and prevent them from entering into the critical stage. TCM can help patients recover faster; or if they have already recovered but fall into a stage where they really need to reestablish their Lung Qi, we can also play a good role. Once we know that the battlefield is in the Mo Yuan, we know how to tackle these problems and have a strategy. We will see you in the next video.

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