Show Notes
Tk asks TC about the various patterns that present with Dizziness and Vertigo
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Episode Transcript
[00:00:03] Speaker A: Hi, everyone, and welcome to the Nervous Herbalist, a podcast for Chinese medicine practitioners who like herbs and want to learn more about their function, their history, and treatment strategies to use in the clinic. Let's get into it.
Hello, everybody. Welcome back to the Nervous Herbalist. My name is Travis Kern and I'm
[00:00:22] Speaker B: here with Travis Cunningham.
[00:00:24] Speaker A: And we are here to talk to you today a little bit about dizziness and vertigo.
Is your head spinning a little bit? You're ready to talk to the folks about it?
So, as usual in the podcast, we're going to talk about the theory of a particular condition, and we'll follow up at the next episode release with some case studies. But why don't we step into the sort of theoretical structure of dizziness and vertigo? What do we know about it? Where does it come from? Are we going to start with the classics?
[00:00:56] Speaker B: Yeah. So there's a couple of classical lines from the neijing that can be of service to us when we're looking for understanding the context of dizziness or vertigo.
And the first place that one of the. Actually, one of the only places I was taught to study and I actually had this memorized at one point, was the 19 lines on pathology, which is a chapter in the Nijing.
And this is like these lines, if you've never read them, no worries.
The neijing is not the easiest text to read, but it is a good one to take a look at for kind of getting, let's say, the ground for theoretical rules in Chinese medicine and its pathologies.
So the first line that is of relevance is the very first line in the chapter, which is. I'm just going to give the English translation because I'm. I'm.
[00:02:01] Speaker A: We're not going to attempt to speak Mandarin here. No.
[00:02:03] Speaker B: So the first line is all, wind falling down and dizziness belongs to the liver.
[00:02:10] Speaker A: Wind falling down and dizziness.
[00:02:13] Speaker B: Wind falling down and dizziness belongs to the liver. Okay, Now, I will put a preface here, which is that I was taught to interpret all of these lines extremely broadly.
So when I read belongs to the liver, the way that I was taught to interpret that is, well, kind of the liver and the gallbladder. Like, they're kind of both the liver system. This is a line that's talking about the Zhang organ.
[00:02:41] Speaker A: Right.
[00:02:42] Speaker B: So the next couple of lines are all attributing this stuff belongs to the spleen, this one belongs to the lungs. But you can kind of extrapolate the idea to the other elemental pair. You could say that's how I was taught to interpret It. Anyway. Okay, so then the next line is line four. That's relevant. All heat muddledness and convulsion belongs to fire.
[00:03:08] Speaker A: Okay. Heat, muddledness, confusion, convulsion, Convulsion belongs to fire.
[00:03:15] Speaker B: But this illustrates the effect on someone's awareness specifically being altered.
[00:03:23] Speaker A: Right.
[00:03:23] Speaker B: Which we might broadly say happens when somebody has dizziness or has vertigo. Their clarity of mind is hindered.
So this is something that we can maybe attach to some line like this.
[00:03:39] Speaker A: Okay.
[00:03:39] Speaker B: And then the last line from the text from this particular part of the Nijing that I think is useful is line 11, which says, all rebellion, upward rushing, and upward rushing belongs to fire.
Okay, so we have two lines in reference to fire and one line in reference to the liver. And I would say slash gallbladder.
[00:04:03] Speaker A: Got it. Okay. So that means that from a classical point of view in the neijing, what we are calling dizziness and vertigo likely has something to do with liver, gallbladder and fire.
[00:04:14] Speaker B: Yes, yes. And also, when regard to fire, when we're thinking about fire, we're not just thinking about the fire as a single unit, but also how the other elements could impact fire potentially.
So it's not just like, oh, there's a problem with fire. We need to clear heat. It's not like that. It's like, no, you can have a problem with fire from wood, you can have a problem with fire from water, you can have a problem of fire from earth. Each one has a relationship, but the fire phase is affected in some way, shape or form.
[00:04:49] Speaker A: Got it. Okay. And so that's. Yeah, it's not because there's just an excess of fire that fundamentally has to be cleared.
[00:04:55] Speaker B: Correct.
[00:04:55] Speaker A: It just means that there might be a water problem or an earth problem, like you said. Right.
[00:04:59] Speaker B: Affecting the fire phase or affecting the dynamic of fire in the body.
[00:05:03] Speaker A: Got it. Yep. Okay. But of course, as you said, ning is not the easiest text to use or to interpret. So if we go to.
I mean, some might argue. Still a pretty complicated text, but certainly a more clinical, classical text. Take a look at something like the Shanghan.
[00:05:20] Speaker B: Yes.
[00:05:20] Speaker A: What does it have to say on this idea of dizziness and vertigo?
[00:05:23] Speaker B: Yep. So the Shanghan Lun has multiple formulas that mention dizziness, or sometimes the character is said like dizzy vision, translated as dizzy vision or some kind of visual impairment. Okay, so there's multiple formulas that have that in the lines describing their pathology, but quintessential lines, bigger lines. Within the Shanghan Lun, the one that's mentioned dizziness directly, is the Xiaoyang Ti Gong line, which is the t gung lines are like, if you had one line to describe the pathology in this confirmation or this category of disease, it's this line, the T Gong line.
[00:06:04] Speaker A: Okay.
[00:06:05] Speaker B: And that. That line is in Xiaoyang disease, there is a bitter taste in the mouth, dry throat, and dizzy vision.
[00:06:14] Speaker A: Got it. Okay. So that's an explicit mentioning of dizziness.
[00:06:18] Speaker B: Yes.
[00:06:19] Speaker A: Okay, so the fact that Shang Han Lun is putting this direct mention of dizziness inside of Xiaoyang on some level, of course, that seems to track with Nejing's discussion.
[00:06:34] Speaker B: Right.
[00:06:34] Speaker A: Because we're dealing with liver. Right. And the idea of.
[00:06:37] Speaker B: And gallbladder.
[00:06:38] Speaker A: And gallbladder.
But I don't know that it's immediately apparent if or how fire would be involved in that.
Maybe walk the listeners through a little bit about that.
[00:06:49] Speaker B: Yeah. So Xiaoyang disease, the way that I was taught to understand the pathology, is a pathology of what's called ministerial fire.
So Xiaoyang disease is a case of ministerial fire flaring.
[00:07:04] Speaker A: Right.
[00:07:05] Speaker B: And ministerial fire to be contrasted with imperial fire.
Right. We've learned. Maybe y' all remember learning these two terms in school, but they often kind of get confused clinically. How do we think about them in clinic?
Imperial fire, the way, again, this is all the way that it was taught to me. Is the fire of the essential essence or structure of that person's being connected to, let's say, the organs of the heart and the kidney.
[00:07:38] Speaker A: This is like the Yuan Qi, you know, low back between the kidneys. Fire.
[00:07:45] Speaker B: Yep, you can think of it that way. It's also the fire. So there's kind of two orientations of the imperial fire proper in the body. One is in the upper burner and one is in the lower burner. And there's textual argument and discussion as to which one comes first.
So one of the theories is that the heart is really the central place of that fire.
And another disputing sort of orientation is that the source of that fire is the kidney.
Mingmun. You guys maybe have remembered that term, Mingmun. Right.
And I'm not going to get into the discussion about which one is. It doesn't matter. They're both places where the imperial fire should show up.
[00:08:30] Speaker A: Right.
[00:08:31] Speaker B: And regardless of where, like which one you think of is more important or comes first, it doesn't matter because they're both important areas of the body.
If we get beyond the arguments.
[00:08:42] Speaker A: The debate.
[00:08:43] Speaker B: Yeah, the debate.
[00:08:44] Speaker A: So if the imperial fire is the sort of Yuan Qi kind of original human source fire.
[00:08:51] Speaker B: Yes.
[00:08:52] Speaker A: What then is the ministerial Fire. And how is it related to the liver? Gallbladder.
[00:08:56] Speaker B: Yeah. So the imperial fire emanates from these things. Right.
And we think of the.
So if you were to take the movement of that fire through the body, the way that I was taught to think of that is happening primarily through the blood.
[00:09:16] Speaker A: Okay.
[00:09:17] Speaker B: So the blood is the resource that the heart is connected to primarily. Blood is warm.
And if you put blood into a certain place in the body, it's going to warm up and it's going to function more, which is the very definition of yang.
[00:09:34] Speaker A: Right.
[00:09:35] Speaker B: So the warmth coming off of the blood and the function that the blood provides is the yang.
[00:09:42] Speaker A: Okay.
[00:09:43] Speaker B: The yin component of blood, you could say, is the fluid component. But there's also a different type of fluid that the body has and that we think of as being connected more to true yin fluids, which are a little different than the blood.
And then a portion of that is related to Qi, because in classical diagnosis, Qi is thought to be like a mist moving around the body. So when we say renshen is a Qi tonic, and it's also nourishing the yin fluids, we're actually talking about one function that the body's then using the substance of Ren Shen to create both fluid. But then part of that fluid becomes Qi.
[00:10:28] Speaker A: Right. Because, of course, there's a constant mutual transformation between yin and yang.
[00:10:32] Speaker B: Yin and yang.
[00:10:33] Speaker A: So. So what you're saying is that we're not an electric meat sack.
[00:10:37] Speaker B: That's what you're saying we are not.
[00:10:39] Speaker A: Yeah. That qi is a more complicated mechanism than that. Right. Okay. So why.
So how does the ministerial fire factor into this as a concept? Yep.
[00:10:49] Speaker B: So the ministerial fire, so warmth moving out of the blood vessels has its emanation quality. So the blood vessel is warm.
[00:11:00] Speaker A: Right.
[00:11:00] Speaker B: But the surrounding tissue also warms up by virtue of the heat that's carried in the blood.
That heat has to come out and be. This is Chinese medicine. Right. So the theory is that something has to be the counterpart to that warmth, otherwise the body would burn up.
[00:11:18] Speaker A: Right? Right. Sure.
[00:11:20] Speaker B: So the yin component that complements the blood, the warmth from the blood, is in some places, the true yin fluids, which are a little bit of a different thing. So an example of a place where that would be relevant is the pericardium. The pericardium surrounding the heart. The heart being purifier, the pericardium being a sac around the heart that can hold true yin fluids that will complement the nature of yang fire in the imperial zone.
Outside of that, you have chi.
[00:11:58] Speaker A: Right.
[00:11:59] Speaker B: So you kind of have this layered experience where most core you have blood, then outside, if you're thinking about the blood vessels, it's a little confusing because part of yin fluid is in the blood.
[00:12:14] Speaker A: Right.
[00:12:14] Speaker B: The blood is a fluid. But then outside you have a different kind of fluid in the Qi mechanism, and that's thought to be like a mist.
So one of the earliest ways, I think I remember being taught about Qi is to go, I can remember Michael Berlitz saying, go to a waterfall, watch the waterfall and see the water crash and then the mist come up. That's like Qi.
[00:12:38] Speaker A: Right.
[00:12:39] Speaker B: So how does that work in the body?
Well, when the Qi gets manufactured, it's floating and circulating around all the hollow spaces.
What are the hollow spaces? The hollow spaces are any space in between denser tissue. So everything in between skin and muscle is a hollow space.
Everything between muscle and bone, everything between all the little joint spaces, all of those are hollow spaces.
Something has to move there, according to Chinese medicine. And the thing that moves there is Qi. Okay, what's the chi's function in those tissues? The Qi's function is to do two things. It's to capture the warmth that's coming off of the blood and to spread it out.
So the chi is a little bit warm, but it's not warm because it holds warmth.
It's not the source of warmth. It's ministerial fire, not the imperial fire. So it's taking the warmth from the central structure of the blood and spreading it out.
Does that make sense?
[00:13:47] Speaker A: Yeah. I think it's worth pointing out why we end up with these terms. Right. Because of course, if you were writing Chinese medicine today.
[00:13:55] Speaker B: Yeah.
[00:13:55] Speaker A: You almost certainly would not call it imperial fire, ministerial fire. Right. Because I don't know that that makes sense. Sure. But if you put it into the context of the time period in which it was made, if all truth and goodness and organization and structure emanate from the throne, from the emperor, but the Emperor is just one man. There's no way that he can possibly make all that truth, happiness and goodness exist in the world. He needs ministers to do it.
[00:14:21] Speaker B: Absolutely.
[00:14:22] Speaker A: And so therefore, in this analogy that's used in Chinese medicine, we're taking imperial fire, the Mingman, source of warmth and action and animation in the body.
[00:14:34] Speaker B: Yep.
[00:14:34] Speaker A: It's binding itself with the core yin material that keeps the human in balance, which is like a sort of non specific thing. Right. That we call yin fluids. True yin fluids, because like, you can't like pull out, pull it out, chew yin fluid. Right.
But for all intents and purposes, the blood is the engine of that true yin fluid. Right.
And then of course, qi is handed the heat through the blood, and now it has to minister, it has to go out into the communities and deliver the warmth.
[00:15:11] Speaker B: Exactly.
[00:15:12] Speaker A: That came from Yuan Qi.
[00:15:13] Speaker B: Yes.
[00:15:14] Speaker A: Yeah. And then of course, because of the function of the liver in the body and its relationship to the blood and the gallbladder's relationship to willpower and distribution and all this kind of stuff.
[00:15:26] Speaker B: And the San Jiao. Right. Which is the gallbladder Xiaoyang pair, which is where the, where the Qi is moving through.
[00:15:34] Speaker A: Right? Yeah. And Sanjiao is the full system, Right? The three Jiao distribution system.
[00:15:40] Speaker B: Yes, of course.
[00:15:41] Speaker A: It would be the thing that is the physical manifestation of the ministerial work.
Yeah.
[00:15:47] Speaker B: And what do we always say about San Jiao is that it's a manager of fluids, but it's also a fire phase organ.
[00:15:55] Speaker A: Right.
[00:15:56] Speaker B: So it's managing both of these things together. And for me, the way that those things are managed together is Qi circulation.
[00:16:03] Speaker A: Right, Right, right.
So knowing this as a baseline is helpful because when we see the patient come in from the. From the street with signs of dizziness and vertigo, it gives us an idea of probably where we ought to be looking to start.
[00:16:19] Speaker B: Yes.
[00:16:19] Speaker A: Right. Like where like Disney's in Vertigo likely are occurring because of some breakdown in these particular systems as opposed to the large intestine or metal or something else that could be treated.
[00:16:32] Speaker B: Correct.
[00:16:32] Speaker A: In this case, we need to be looking at liver, gallbladder, Xiaoyang extension to Sanjiao and the fires that are in play here.
[00:16:41] Speaker B: Primarily ministerial, Right, Primarily ministerial. But toward the end we'll talk about the imperial fire a little bit as well.
[00:16:48] Speaker A: Right?
[00:16:49] Speaker B: Yeah.
[00:16:49] Speaker A: So why don't we start then at the top? So if we're looking at the Shanghan and we're looking at Xiaoyang, we're looking at then Xiaoyang disease.
[00:16:56] Speaker B: Yes.
[00:16:57] Speaker A: Probably the first manifestation of dizziness and vertigo.
What does that look like? And how do we treat it?
[00:17:04] Speaker B: Yeah.
So the Xiaoyang Ti Gung lines are a good place to start. Right. If you're going to memorize text, which I know for, for us is a big ask. Chinese education and stuff is quite a bit more directed toward memorizing text first and understanding later.
We're kind of the opposite, or at least I'm the opposite. I'll speak for myself.
[00:17:26] Speaker A: Sure.
[00:17:28] Speaker B: But the line is a pretty good one to know because it does give you direct symptoms that you can ask about.
[00:17:33] Speaker A: Right.
[00:17:35] Speaker B: In addition to those symptoms, which again are bitter or strange taste in the mouth is. I learned to ask that question from Dr. Greg Livingston, right. Who used to sit in his clinical shifts all the time, and he would always ask that, do you ever get a strange taste in your mouth?
Which is a weird question to ask. A lot of people will say no, in which case you just move on. But some people will actually say yes. And you'd be surprised how many people will have that if you don't ask it ever.
[00:18:08] Speaker A: Well, and the thing is that if. If people have one, they know yes. And if they don't have one, they either say no or they go, I don't really think so. That's a no.
[00:18:17] Speaker B: That's a no.
[00:18:18] Speaker A: That's no. If you have a strange taste in your mouth, you know, yes.
[00:18:22] Speaker B: And then dry throat. A dry throat could also be a sore throat or a feeling of discomfort in the throat.
So you want to check for that. That's a little more common for people to have that.
[00:18:33] Speaker A: And something that we use all the time as an indicator for literally treating sore throat. 100% with chow chayutan.
[00:18:40] Speaker B: Yeah, yeah, 100%.
And then dizzy vision is the last symptom. So if they're coming in with a chief complaint of dizziness, that's an easy one to mark.
[00:18:49] Speaker A: Right.
[00:18:49] Speaker B: So you catch that. And then the other symptoms that could happen are, along with the body, trying to regulate the pores of the skin by moving Qi through the San Jiao, using that resource to try to harmonize the body with an external contraction.
Right. Which is the context for which we see Xiaoyang disease present itself.
The body is mobilizing chi to try to get that to happen. That Qi is failing to do that.
The evidence of the failure is that it's stagnating.
The stagnation is going to occur especially it's all over the body, but especially in the tight spots.
We call those pivoting areas.
[00:19:33] Speaker A: Right, right.
So those.
[00:19:35] Speaker B: Do you want me to review those again?
Quickly? The eyes, the ears, the throat, the rib side, diaphragm, the armpits, the groin and the joints all over the body, those areas are particularly going to heat up because the Qi isn't moving well through those, particularly because it's harder for the chi to move there.
[00:19:57] Speaker A: Right. And we have a pivot problem.
[00:19:59] Speaker B: We have a pivot problem.
[00:20:00] Speaker A: Yeah.
[00:20:01] Speaker B: So those are going to heat up temporarily, show signs of heat or fire, but then that fire is going to collapse because, again, it's not imperial fire, it's not a true source of heat.
It's ministerial Fire, it's carrying the heat from somewhere else.
So the alternating symptomology is happening because of that repeated buildup of heat flare and then collapse.
So then you could get alternating symptomology. You could get alternating hot and cold, you could have nausea, you could have strong thirst, you could have any of these kinds of symptoms. Alternating bowel picture.
[00:20:41] Speaker A: And these are the very same symptoms that we see anytime we're talking about Cheyenne.
[00:20:47] Speaker B: Anytime. Like the list.
[00:20:48] Speaker A: The list is always the same list.
[00:20:49] Speaker B: The list is always the same list. We've talked about it probably at you maybe have a xiaoyang pattern. Listening to us talk about this pattern for so many times.
[00:20:58] Speaker A: Well, and I think it does highlight though, why Chinese medicine is so good at diagnosing a variety of problems and treating them. Because person comes in with sore throat, person comes in with alternating bowel pattern, person comes in with dizziness and vertigo. We do the questioning, we take the pulse, we look at the abdomen, and we determine it's a xiaoyang pattern. We treat with xiaoyang herbs. It doesn't matter that it was a sore throat or that it's dizziness.
[00:21:28] Speaker B: Not at all.
[00:21:29] Speaker A: Because the problem is xiaoyang. Right. So, okay, obviously then if we're talking about xiaoyang with all the classic symptoms we talk about all the time, then of course xiaochaiutong's got to be in the mix, right?
[00:21:39] Speaker B: Yeah, 100% it is.
[00:21:41] Speaker A: Okay. And so, and you know, we have. We've gone through xiaochaiutang many, many times and will again many, many more because it is without doubt the workhorse of our medicine area in particular.
But it's not the only formula that's going to be useful for a Disney sun vertigo pattern with Xiaoyang presentation. What else are we looking at?
[00:22:01] Speaker B: So there are seven Chihu Tong variations that are given in their own name in the Shanghan, Lun and Jingwei. We're not going to go through all seven, but I wanted to talk about two that are versions of the pattern that have transformed to a certain degree in opposite directions so that we can get the scope of the Xiaoyang pattern. Okay, so one version of the pattern is the ministerial fire. Flares, stagnates, flares, collapses, flares, collapses. Alternating symptom, alternating symptomology.
[00:22:36] Speaker A: Okay.
[00:22:37] Speaker B: But this happens for. Typically happens for a while.
And the flaring fire again in the five phase cycle, fire becomes excessive, it flares and it over controls metal.
[00:22:51] Speaker A: Okay.
[00:22:52] Speaker B: And the metal organ that it affects the most in this version of the pattern is the lungs.
[00:22:57] Speaker A: Okay.
[00:22:58] Speaker B: Fire. Because it's Hot and dry consumes the fluids of metal.
So the fluids of the lungs and particularly the fluids of the upper burner are going to get dried out.
This is going to cause the fluids that are there to shrink in space.
So it's firstly going to make the fluids heat up.
Then the fluids are going to shrink in their space and they actually get consolidated into little pockets, little pieces of hardness. It's like material, material hardness, which you can palpate. If you palpate lymph nodes, right? Lymph nodes are going to get hard and swollen.
You're also going to get the symptom of thirst because the fluids are getting shocked, heated up, dried out.
[00:23:44] Speaker A: Right.
[00:23:45] Speaker B: If this goes on for long enough, the fluids are going to get into those little pockets and then they're going to be. There's going to be lymphatic swelling, practically speaking, in the pattern.
[00:23:53] Speaker A: Yeah, yeah.
[00:23:54] Speaker B: So the formula that's going to treat this version of the pattern is a formula called Chai Huizhi Ganjiang Tang.
So this is repeated ministerial fire flaring hits the upper burner, consumes those fluids.
And the key symptoms that you're going to be looking for are higher thirst.
The person is also likely not going to be nauseous.
Right.
Because in the postscript for Xiao Cai Hutong, Zhang Zhongjing says if thirst is higher, you make the swap from bansha to tianhua fen as an herb choice.
[00:24:33] Speaker A: Okay.
[00:24:33] Speaker B: In Caihu guidanjiangtang, that choice has already been made. So if you look at the structure of that formula, it's already treating thirst. It's already made that modification.
And then this formula also has muli in the structure, which is the salty flavor that's going to be used to soften hardness.
In this case, the hardness is the congealed fluids. Exactly, exactly.
So this pattern, this version of the Xiaoyang pattern is going to have higher thirst.
It's going to have all the same symptomology as Xiaochai Hutong, minus nausea. So it may not have. The person will likely not have nausea. They may have swollen lymph nodes, and the pattern is usually a little bit more chronic.
[00:25:18] Speaker A: Okay.
[00:25:19] Speaker B: So the time when I began to learn to use this formula was in long COVID patients, people who had no longer acute symptoms, but they had like lingering lymphatic congestion. They still had xiaoyang symptoms or temperatures going all over the place.
And they're thirsty. They're thirsty all the time.
[00:25:39] Speaker A: So the patient comes in, they're reporting dizziness and vertigo. In the process of the questioning, it turns out that they're very thirsty.
Are you going to palpate lymph at that point? Like, look for the lymph nodes to see, like, oh, is that if I
[00:25:50] Speaker B: think they need this pattern, I'm going to go to their neck and palpate the lymph nodes. Absolutely.
[00:25:55] Speaker A: And then so, you know, I'm thinking, anytime I think about thirst and a Xiaoyang situation, I always, of course, think of Chai Lingtong.
[00:26:03] Speaker B: Yes.
[00:26:03] Speaker A: As the thing that we would reach for normally. Like to deal with the thirst pattern that's in play.
And I know Wuling San will be in a water pathology we'll talk about in a bit. But what about, like, you know, what's cueing you to go Chihu Guizhou Ganjiang Tang, as opposed to Wuling San from the set of symptoms?
[00:26:22] Speaker B: That's a great question.
So the one symptom that will show up in Chai Lingtong Xiao Cai Hutong plus Wu Lingsan versus Cai Huizhi Ganjiang Tong is in Chai Lingtong, you will have nausea most of the time. There will be some aspect of nauseousness or upsurge in the stomach. In Chai Hu Guidanjiangtang, there will not be. There shouldn't be no nausea.
And the other thing I would say is the objective findings are different in the two.
You will get more signs of dryness in Chai Huizhiganjung tongue, you won't see those in Chai Lingtong.
[00:27:06] Speaker A: Now, when we say dryness, we're talking like dry skin, nails, hair.
What are we talking about? Dryness in this case?
[00:27:12] Speaker B: Yeah, you'll see some of that stuff.
And you'll also see the abdominal picture looks different usually.
[00:27:21] Speaker A: So, like, the rectus abdominis will be, like, more rigid and hard.
[00:27:26] Speaker B: It's more like.
So if there's obvious water. So if you can hear the intestines clinking. Right. There's borborygmus.
We're thinking more Wuling San is needed.
[00:27:37] Speaker A: Right. More on the water pathology side, if
[00:27:39] Speaker B: you do the water tap over the stomach, the tympanic thing, and it's a splash sound that leans more toward Wuling San.
I also find that in Wuling San, both with Chai Lingtong and with Wuling San in general, the skin of the abdomen tends to be a little bit cool.
So it's notably more cool than in Zhengtang. That's my personal finding.
[00:28:05] Speaker A: Got it.
[00:28:06] Speaker B: The other thing with Caihu Guizhiganjiangtang in Fukushin is because this pattern tends to be chronic, the texture of Skin tends to change a little bit underneath, just below the costal region. There's almost like. It's hard to describe, but there's almost a little bit of crepitus in the skin.
And if you start to pay attention to the quality of skin, you'll notice this on some people.
[00:28:31] Speaker A: So someone's got the Xiaoyang symptoms and they have thirst, the mind then naturally goes to, is this Wuling san?
Like, is it childing tongue, or is it Gui Jiu Gungan tongue? Yep. And that distinction is going to be with how wet the person is or not, basically.
So if I have splash sounds, if I have borborgmus, then we're probably Wuling San, Chai Lingtong direction. If I don't have any of that, probably Chai, Guizhou, Ganjang Tong, especially if there's some added, like, crepitus in the tissue or like other, like, sort of physical, tangible dryness signs.
[00:29:08] Speaker B: Correct.
[00:29:09] Speaker A: Got it. Yep.
That's one side of the Cheyenne presentation.
[00:29:46] Speaker B: Yes.
[00:29:47] Speaker A: What's the other chaihu formula you were thinking about?
[00:29:50] Speaker B: So the other version of this pattern is again, you have Xiaoyang disease, you have Qi stagnation, you have ministerial fire flaring.
The flare this time goes to the metal large intestine instead of the metal lungs.
[00:30:04] Speaker A: Got it.
[00:30:05] Speaker B: So the first version of that would look like a Da Chi hutong pattern where you're treating xiaoyang and Yang Ming.
And then eventually, with repeated flares, you start to see a combination of things. Firstly, the fluids of the large intestine are dried out, which means that you're going to have dry constipation.
[00:30:23] Speaker A: Right.
[00:30:24] Speaker B: You're also going to see a kind of deficiency picture that shows up where the yang starts to float out of the lower burner and starts to harass the heart pericardium. So you're going to see more aggravation than in any of the other Chai hutong patterns, like emotional irritability. Emotional irritability.
Think of, like, you know, this is where you're gonna see mania, potentially, or, like, high anxiety. Like really high anxiety.
You know, this is where, like, the lines describe the person's tearing off their clothes and running around on the roof of houses and stuff like that.
[00:31:05] Speaker A: Yeah.
[00:31:07] Speaker B: And I would say that the version of this pattern that gets particularly like that is if the constipation is also very bad.
So if they're not able to so
[00:31:18] Speaker A: get, like, hard stool and they're skipping two, three days.
[00:31:20] Speaker B: Exactly. Yeah. Then it gets really bad.
[00:31:23] Speaker A: Okay.
[00:31:24] Speaker B: And so the formula that I'M describing here is Chai Hu Ja Longumuli Tong.
[00:31:29] Speaker A: Okay.
So I mean, in both cases the metal is getting affected.
[00:31:35] Speaker B: Correct.
[00:31:36] Speaker A: It's just a matter of which one's getting dried out. Correct. Lung versus large intestine.
[00:31:40] Speaker B: Large intestine.
[00:31:41] Speaker A: Okay. And so fundamentally then, I mean, it's interesting to think about this aspect of xiaoyang in particular, because of course, Xiao Chaiotong is where we're going to Chaytong formulas in general.
Now there's this added dryness component. If it's lungs, then Chayu guizhu Ganjang tong. If it's large intestine, Chayu Jia Longgamuli tong.
But in some ways, again, we're talking about a water issue.
[00:32:06] Speaker B: Correct.
[00:32:07] Speaker A: So what happens then if it's not dry but it's wet.
[00:32:11] Speaker B: Yep.
[00:32:11] Speaker A: Now what?
[00:32:12] Speaker B: Yep.
So you can have. So if somebody's coming in with acute vertigo, this is a good thing to say. Probably.
It's likely not a deficiency pattern.
[00:32:24] Speaker A: Right. So in an acute vertigo, here is like all of a sudden I'm. I'm dizzy.
[00:32:28] Speaker B: Exactly.
[00:32:28] Speaker A: It doesn't happen regularly.
[00:32:30] Speaker B: Doesn't happen regularly. It's sudden and alarming. It's probably either going to be a Xiaoyang pattern or it's going to be a water pattern, probably Wuling san.
So if you're not sure it's acute and you've got to guess, my. My advice would be go for one of those two methods. Do Xiaochai hutong Do Wuling san.
So the Wuling San pattern is going to look a little different.
[00:32:56] Speaker A: Right.
[00:32:57] Speaker B: Which could be. So we would expect thirst to be higher, the person's very dizzy, and there's some kind of problematic urination. Sorry, what were you going to say?
[00:33:10] Speaker A: We would expect the thirst to be greater than in the. Just the plain Xiaoyang presentation.
[00:33:15] Speaker B: Correct.
[00:33:16] Speaker A: Because those people can still be thirsty.
Right. Because that's one of the reasons that we're having to investigate, I guess, on some level. How thirsty. Correct.
[00:33:24] Speaker B: Correct.
[00:33:25] Speaker A: But then it's important to remember that the Wulingsan layer has a problematic urination component.
[00:33:30] Speaker B: Yes. Difficult urination. And when they try to drink water, their body doesn't process it. Well, this is the other sloshy feeling. Some people will actually get phlegm in their throat immediately after drinking water.
If they say that, that's almost 100% Wuling sun.
[00:33:49] Speaker A: Yeah.
[00:33:50] Speaker B: In my experience.
[00:33:51] Speaker A: Yeah. How do you think that plays out with patients who get flemmy like that from. I think it's the same pattern. Like if they have soup and get. Get Flemmy or could be, because, you know, there's a lot of that, like, Flemmy presentation for people who are like, have a fluid metabolism, water pathology problem.
You know, sometimes it shows up with like, Flemmy after dairy or something. A lot of people know that. But like Flemmy after sweet flavor, Flemmy after soup.
But Flemmy after water is very like.
[00:34:22] Speaker B: Yeah. Because one of the. One of the ways that we use wuling san. Right. Is for something called water reversal, where they literally describe somebody drinking water and then vomiting.
But that could also be the case in a minor way where if you drink the water, you get phlegm. It's not quite vomiting, but it's like the same mechanism. Right.
So that's pretty key for wuling san.
And then the other thing is, like wuling san, people cannot quench their thirst.
Like, they just. They're drinking all the time. Caihu guizhi ganjiangtang. People can process water.
[00:34:58] Speaker A: Right.
[00:34:58] Speaker B: To contrast it to what we were talking about before, they're thirsty, but they can process the water because they're actually dry, they're not wet.
Part of the problem with wuling san is the yang isn't in the right place to process the water.
So you put the water in and it almost gets rejected or it stays in the stomach. It's not going to the small intestine bladder. It's getting backed up along the line. Right. So it's just not being used well. So they'll like. You'll ask them and they'll be like, yeah, I can't, like, I'm always thirsty. I can't quite quench my thirst.
[00:35:34] Speaker A: Yeah. In fact, that's usually how they realize that they have the sort of water slosh in the stomach because they're just drinking so much water because. Super thirsty.
[00:35:42] Speaker B: Yes.
[00:35:42] Speaker A: And then it's just like, I feel like, swollen and wet. Like you feel the water sloshing around. Yeah. I mean, I've. I had patients who will just like, put the water in their mouth.
[00:35:52] Speaker B: Yeah.
[00:35:53] Speaker A: And just like hold it there before swallowing it. Just because, like, it alleviates the sensation of being thirsty.
[00:35:58] Speaker B: Yep.
[00:35:58] Speaker A: And then they'll swallow.
[00:36:00] Speaker B: Yep.
[00:36:00] Speaker A: You know, you're like, oh, okay, okay. So this isn't. So now we're in this water pathology. So we started with Xiaoyang. We're now talking more specifically about wet presentations.
As you said, if someone's coming in with like, acute dizziness, vertigo, it's almost certainly not a deficiency problem. It's probably an excess problem. And that's where this Wuling San kind of approach lives is in the excess component of water pathologies.
[00:36:25] Speaker B: Correct.
[00:36:26] Speaker A: But there are other formulas probably too that could come up on the excess side.
[00:36:29] Speaker B: Sure.
[00:36:30] Speaker A: What else are you thinking in that regard?
[00:36:32] Speaker B: Yep. So the other one that would be the next one I would think of that is commonly used that doesn't have the thirst component but is still a water problem is Lingue Jugantong.
[00:36:48] Speaker A: So what about like what cues you that it's a water problem? Because you know thirst is an easy one, right? Because people report it and you're like, well, gotta have a fluid problem here somewhere because weirdly thirsty.
But if thirst is not on the table, what is saying like, hey, this is a water problem.
[00:37:05] Speaker B: So you're going to see a lot of the same symptoms in the abdomen. If you look at the abdomen between Wulingsan and Lingguay Jugantang, they're almost identical. It's really hard to tell the difference from the abdomen alone. The key symptomatic differentiation is the presence of thirst or absence of thirst.
[00:37:22] Speaker A: Got it.
[00:37:22] Speaker B: In addition to that, Lingguay Jugantong tends to have more chest symptoms, shortness of breath, phlegm. You could have phlegm in either case, but Lingui Jugantong people are going to be more phlegmy regularly and there's not obviously urinary symptoms. In Linguay Jugan Tang, there's no mention of difficult urination in the lines.
So Wuling San is much more likely linked to the bladder as an organ versus Ling Guiz is more linked to the spleen and the lungs. The function of the spleen and the lungs. So it's more leaning into Taiyin even though it's in the Taiyang, it's one of the million formulas in the Tai Yang chapter of the Shanghan Lun, it is more of a tie in leaning formula than Wuling San is.
[00:38:15] Speaker A: Right. So key differentiators here are thirst and urinary difficulty Wulingsan, but wet appearing abdomen, water splash sounds, that sort of stuff without thirst, without urinary difficulty. Linguizu Gun Tong.
[00:38:31] Speaker B: Correct.
And both of these formulas can have some kind of palpitation sort of orientation as well. You can see palpitations in the symptomatic picture. The patient has palpitations. You can also see pulsations in the abdominal aorta in both patterns.
[00:38:53] Speaker A: So neither of those things are really differential for the formula.
[00:38:56] Speaker B: Neither are differential from from these two formulas. But the next one we're going to talk about, it is different.
[00:39:02] Speaker A: Okay, so what's the Last one in
[00:39:03] Speaker B: this excess water pattern, the last one is Zishya tongue.
[00:39:07] Speaker A: Okay.
[00:39:08] Speaker B: Zishya tongue is an interesting formula because it basically says under the lines, the person's dizzy. Doesn't give you much more. Doesn't give you much more stuff than that. But it's just two herbs. It's Zishya and Baiju.
[00:39:22] Speaker A: Okay.
[00:39:23] Speaker B: So you would look at the formula, and the automatic thing is like, well, we have Zishya and Baiju and Wulingsan. Why would we just give those two ingredients by themselves?
[00:39:32] Speaker A: Yeah.
[00:39:33] Speaker B: But anytime you consolidate a formula to fewer ingredients, you're giving the body a stronger message in a particular way.
[00:39:41] Speaker A: Yeah, like you're streamlining the direction of the formula.
[00:39:44] Speaker B: Absolutely.
[00:39:44] Speaker A: Yeah.
[00:39:45] Speaker B: So in Zishietong, there's a great book that just came out that is a book written by a guy named Liu Duzhou, who is a famous Shang Han Mun scholar and practitioner. He passed away, I don't know, I think the early 2000s or the 90s. And Aaron Evan just did a translation of one of his works, which is on treating fire and water.
It's this kind of beautiful, quintessential text. And one of the formulas he talks about in the book is Zishyatang, and he says Tzishyatong has a very particular and specialized tongue pattern.
The tongue body in Xishya Tong is so big, it looks like it shouldn't fit in the mouth.
So some cases.
The only time I've ever prescribed Zishya Tong myself is. Is when I've tried the other formulas, they have failed, and I've looked into what else could work, and then I've landed on this formula. So I've only prescribed Zishia Tongue through failure myself.
But I was super excited to read this because now when I see a patient with an acute water pattern that has dizziness, their thirst is not. So it's kind of like normal or whatever. Maybe it's a little lower. So thirst is not really a thing. Probably not. Wuling Sand. So is it Lingguay Jugan tongue? Is it Zixia Tongue?
Well, we can look at the tongue. We can see if the tongue body is huge, and if it's. If it is that pattern, we can go to Zixia Tongue. It's also.
[00:41:20] Speaker A: I bring it up this size question, though. So because it's an acute problem, I wouldn't. I mean, would we expect there to be scallops on the huge tongue? Because it's.
[00:41:29] Speaker B: I think there could be.
[00:41:29] Speaker A: There could be, but it could still just be A really big tongue.
[00:41:33] Speaker B: It could just be a big tongue. Yeah.
[00:41:34] Speaker A: And not just, like, wide, but, like, it looks wet, like. Looks swollen.
[00:41:40] Speaker B: Yep.
[00:41:40] Speaker A: Kind of. Right? Yep. Yeah. Does the patient report that it feels big and swollen?
[00:41:45] Speaker B: There isn't any mention of that in the book.
[00:41:47] Speaker A: Yeah.
[00:41:48] Speaker B: Yeah. So I don't know if I can say that again. I haven't used this yet, but this is something I wanted to mention because I just read it, like, a month or two ago, and I'm excited about this, so.
[00:41:58] Speaker A: Because it could help with.
[00:41:59] Speaker B: Could help with this. Yeah. The other key thing in the abdomen that should be different is the pulsation of the abdominal aorta. And the reason for that is so that that should not be the case in Xi Xiatang.
The reason for that is that pulsation is typically a guager and fooling method combined. So that could occur in Wulingsan, could occur in Lingui Jugantang, but shouldn't occur in xiia tongue.
[00:42:26] Speaker A: Got it.
[00:42:26] Speaker B: So you could have the other water symptoms in the abdomen, but probably not the pulsation.
[00:42:31] Speaker A: And if you did, probably not Xixiitanglan.
[00:42:34] Speaker B: If you did, probably not Xi Xia Tong.
[00:42:36] Speaker A: Okay.
So of course, that's with basically an acute presentation of dizziness and vertigo, which is likely to suggest an excess pattern.
But as we were largely talking about, a lot of times when people come in with this presentation, it's not acute, Right?
[00:42:51] Speaker B: It's not acute.
[00:42:52] Speaker A: They've got. They've been diagnosed with.
What's it called? Benign positional vertigo and Meniere's.
[00:43:00] Speaker B: Yeah, Menieres.
[00:43:00] Speaker A: Those are the. You know, they get dizzy all the time and all this sort of stuff.
So water pathologies, though, are not only excess ones. There's deficiency patterns too.
[00:43:11] Speaker B: Right.
[00:43:11] Speaker A: So what. What distinguishes that? Like, is it just chronic? Like, oh, you have a chronic problem, therefore it's probably deficiency, or is there something else we're looking at to squarely put it in the deficiency category?
[00:43:22] Speaker B: There is a qualitative difference to the dizziness as well.
Typically with acute things, the formulas that we've covered so far, and there's a few that could kind of go either way. So Xiao Cai Hutong is going to be acute dizziness, likely. Caihu Guidanjung Tong Chaihu Jawangumuli tongue could be acute, but could also be a little bit more chronic.
The Wuling San pattern should likely be a more acute pattern. That can be very intense. The Wuling San pattern can be very intense. I think the Zishia tongue could also be very intense. Lingue Jugan Tong could be more acute or more chronic. Okay, so that one's kind of in the middle.
For deficiency water patterns, the key one is gonna be Zhen Wu Tong.
And the qualitative thing to that is more. It's less. Like, so acute would be like room spinning. I'm having a difficult time catching my balance. I fall over and vomit. Like, that would be, like, very strong, very loud.
That's what we're looking at in excess.
In deficiency, it's more like unsteadiness.
I get up, and as I get up to my feet, I feel a little topsy. Turvy.
[00:44:45] Speaker A: Yeah, little wobble.
[00:44:46] Speaker B: A little wobble. We see this pattern a lot in elderly patients. Most elderly patients have some version of this, and they struggle with their balance. They struggle with the steadiness on their feet. They struggle with confidence and movement. Most of them have some version of this pattern.
[00:45:04] Speaker A: Yeah. And I mean, that sort of fits with the sort of classic Bensky description of what Jen Wutang is for. Sort of like, oh, it's older people with water problem.
[00:45:13] Speaker B: Absolutely.
[00:45:14] Speaker A: Even though we use Jen Wu Tong for lots of other stuff. But sure. Yeah. Okay. But then. Okay, so if Jen Wu Tong is in play, then probably Shenchiwan is probably also in here too.
[00:45:24] Speaker B: Absolutely.
[00:45:25] Speaker A: What's going to point us from one to the next?
[00:45:28] Speaker B: So Shenqui, I've gotten two from a few different tracks.
So one of them is in the Jingwei. It describes the usage of Lingguay Jugantang, and it says the person has da da da da da symptoms, and then it says Lingguay Jugantang governs, and then it says Shen Shiwan also governs.
So whenever this distinction is drawn, I like to pay special attention to that. Right. This is like Arnover Sleuth calls this an equivalency.
In the text, there's some kind of connection drawn between two things that we should pay more attention to.
So the way that I understand that connection in this case from Lingui, Jugan, tongue, and Shenchiwan is that Lingguay Jugan tang is more functionally transforming water versus Shenziwan is transforming water. But it's also adding something to the material aspect of the body. It's building some kind of blood because
[00:46:26] Speaker A: there's a deficiency at its core.
[00:46:27] Speaker B: Because there's deficiency at its core. And that's. That deficiency is material. There is some kind of blood. There is some kind of deep material aspect that's. That's missing.
[00:46:59] Speaker A: Wouldn't it be great if when Zhang Zhongjing had written, you Know, symptom. Symptom centum Lingui Jugantong governs and Shinxiwan governs. If he had followed with. Because. Yeah, Shin Shiwan governs. Because there's a material aspect of the stuff that has to be adjusted as well.
[00:47:18] Speaker B: Yes.
[00:47:18] Speaker A: You know, but there's no.
We just love to interpret that.
Well, I mean, that's the beauty of it. Like, we don't have to interpret it. John Sean Jing wrote that a long time ago, and a lot of people have thought about it.
[00:47:30] Speaker B: It's true.
[00:47:31] Speaker A: Like, organized and put it together, you know.
So in that case.
So we have these two deficiency sides of the water pathology, the Shenzhen component.
So basically, like, how are you deciding if we're using Gen wu Tong or Shenchi 1 in. In the deficiency presentation? Like, you've decided it's deficient. Which of those two are you picking?
[00:47:53] Speaker B: Yep.
So they have.
They treat something that's very similar.
[00:47:58] Speaker A: Right.
[00:47:58] Speaker B: They both treat a kind of functional Yang deficiency. Let me explain what that means. The warmth of the Imperial Fire is lacking, so there's a lack of Yang in the lower burner.
That lack of Yang is leading to an inability to transform water.
So that's the case with both patterns for Shenziuan. Additionally, there's a taxation of the blood.
Shenxiwan is in the deficiency taxation of the Jingwei.
So there's a material aspect that's lacking.
Additionally, Shenziwan is famously difficult to get people to take who have digestive weakness. Yes. Right.
So Jen Wutang, on the other hand, is a great formula to help people with digestive weakness. It treats diarrhea. It's one of the key symptoms of Zhen Wu Tong.
[00:48:54] Speaker A: Right.
[00:48:55] Speaker B: So for a lot of cases, you end up leaning into Jen Wu Tong first and then transitioning to Shen Chi Huan second in cases of deficiency.
[00:49:05] Speaker A: So such that the Jian Wutang would help to restore the large, like the deficient fire function so that they could actually digest the Shenxiwan.
[00:49:18] Speaker B: Correct.
[00:49:18] Speaker A: Yeah. Yep. I have a question about the dosages in Zhen Wu Tong, because I know, like, you know, here at the Medicinary, we buy premixed granules in addition to having the singles.
And if you look at the dosage of the various ingredients in general, a lot of them are lower than we would use them at if we were going to write them in singles.
[00:49:39] Speaker B: Yep.
[00:49:40] Speaker A: Why don't you talk a little bit about that? Because sometimes I feel like people, you know, if you're not writing formulas, you don't talk to people about it. You're just sort of pulling the Bensky numbers.
[00:49:48] Speaker B: Yeah.
[00:49:48] Speaker A: Or pulling the Evergreen numbers. But if we were writing Gen Wu Tong, usually we're going to change those numbers. And how would we do that?
[00:49:54] Speaker B: Yeah.
So the fuchsia numbers in every formula that Fuchsia features in is given from a different dosage instruction depending on the line. So sometimes it's like, oh, one piece of aconite, you know, or it's. Or it's talked about in like, a different way, you know, an actual measurement. An actual measurement, yeah. So we're left to interpret what that means.
Generally speaking, the way that people interpret the dosage of Futsa in every case is lower than what I. What I learned to use to get Futza to work in the clinic today.
So if you read that Futza is dosed at 6 or 9 in Zhen Wu Tong, I think it's 9 is usually what people recommend.
I'm gonna start dosing Futza in my formulas at 30 as a relative dosage ratio, or 45 or 60 is going to be the way that I start that. Now, most of the time when I'm using Zhen Wu Tong, I'm using it as a granule. So those dosages are a ratio dosage.
[00:51:05] Speaker A: Right? Right. So the other ingredients are going to have the more expected dosing range of like 6 to 12 grams or whatever. And then Fuca, which if you look again at the Bensky or at the Evergreen numbers, will also be somewhere between 6 and 12 grams, in your case is going to be 30.
[00:51:21] Speaker B: In my case, it's going to be 30, 45, 60. Yeah.
[00:51:24] Speaker A: So relative to the other ingredients, it's three times, four times the value.
[00:51:30] Speaker B: Correct.
[00:51:30] Speaker A: But we're not saying that we're giving people 30 grams of foods of bulk a day.
[00:51:35] Speaker B: No. Yeah, generally not.
[00:51:36] Speaker A: Though I suppose you probably could if that was necessary.
[00:51:38] Speaker B: You could, but today it would be very expensive to do that.
[00:51:42] Speaker A: Very expensive. That's true. Yeah. So again, when we're talking about the dosage of Futsa in General, it's. It's 30. And we mean that relative to the granule ratios.
[00:51:52] Speaker B: Correct.
[00:51:52] Speaker A: So, okay, so if Shenzhen is dealing with a material deficiency beyond just the.
The imperial Fire component that Gen Wu Tong is dealing with, then that means that probably part of this larger dizziness, vertigo presentation has to do with a more severe taxation. Because Shenzhen lives in the Shu Lao chapter, Right?
[00:52:16] Speaker B: Yes. Deficiency taxation 100%.
[00:52:19] Speaker A: So help the listeners understand. Like, if there's a progressive sense of deficiency, it looks more and more deficient. What pushes us over the line into saying this person's made it all the way to Shoe la, as opposed to just, you know, water deficiency.
[00:52:36] Speaker B: So Xu Lau, I would say, is the third reason somebody can be dizzy. Right. So we covered Xiaoyang disease as the first one, water pathology as the second one. The third one is deficiency taxation.
So what is deficiency taxation?
Again? The way that I was taught to interpret deficiency taxation is a fundamental breakdown in the physiology of the blood, which we could also say is connected to the imperial fire.
[00:53:05] Speaker A: Right, right.
[00:53:06] Speaker B: Not the ministerial fire, the imperial fire.
[00:53:08] Speaker A: Because it's a step before we get to ministerial fire.
[00:53:10] Speaker B: Exactly.
[00:53:11] Speaker A: Yeah.
[00:53:12] Speaker B: So if you go through the deficiency taxation chapter, you're going to see formulas like Guizhou, Jia Longgu, Muli Tang, Xiao Zhen, Zhongtang, Shenziwan.
You have the mysterious formula Da Huang Zhetong Wan.
[00:53:31] Speaker A: Right?
[00:53:31] Speaker B: That's a mystery until we jump into that.
But they're all. Tian Chong San is another one, which we'll talk about in a second.
All of these are describing a breakdown in the physiology of the blood, which consists of the quality of the blood lessens over time through taxation, through life, beating a person down.
And then what happens is yin and Yang decline.
And each of these formulas treats a different version of that decline, leaning into one aspect or another.
So what happens is the Yin aspect of the blood declines and dries, the Yang aspect of the blood floats away and causes Yang symptoms, usually in the upper body.
[00:54:24] Speaker A: Like dizziness and vertigo.
[00:54:25] Speaker B: Like dizziness and vertigo? Yes.
And the specific line where dizziness and vertigo is mentioned explicitly is in the line for Guizhe Ja Longgu Mulitang, which is the same line that a second formula is mentioned called Tien Chong Sand. And Tien Chong San is a formula that not a lot of people know about who are not into herbs.
But Tianchong is an herb that we can no longer get. I think it's Realgar or I can't remember what it is, but it's one of the ones we can't use.
So the substitution that I learned to make was to add fuci in its place.
[00:55:03] Speaker A: Right.
[00:55:04] Speaker B: And the formula is Fuci, Longu, Guizhi, and Baiju.
And the formula is dosed very high. So I Learned to go fuci60, longu60, baiju24, and guizhou18.
So this is very high doses of all these ingredients. Yeah, Right.
[00:55:31] Speaker A: But if you were giving that in granule, would you also, like, increase the total quantity of granule that someone was taking to reflect that reality?
[00:55:39] Speaker B: I might.
But the other thing that is that's helpful is it is a san, so you can. There's an argument for dosing it lower than that as long as you keep the ratios the same.
[00:55:56] Speaker A: Yeah.
[00:55:56] Speaker B: Because it's a san. So you can kind of get away with not increasing the dose if you don't want to.
So the way that this practically works is I will work it in and then increase the dose over time if I think it's helping and we're getting good traction. I'll then bump the dose gradually.
[00:56:16] Speaker A: Even in granules.
[00:56:17] Speaker B: Even in granule. Yeah. I'll go from 8 twice a day to 9 to 10. I'll go up to 12 twice a day.
[00:56:24] Speaker A: So if Shenziwan is a sort of like bridge formula between sort of broad spectrum deficiency water pathology into shulao deficiency taxation.
[00:56:33] Speaker B: Yeah.
[00:56:35] Speaker A: What then would cue you that you might need something besides that? What's going to say, I need guer jalongo mulitang or tian chong san. Like what's the, what's the differential?
[00:56:46] Speaker B: So for the lines that talk about gui jalong, Gulitang and tianchong san, remember it's the same symptomatic line.
[00:56:53] Speaker A: Yeah.
[00:56:54] Speaker B: There's a description of the person having vivid dreams, having night sweating, having.
Having some kind of sexual dysfunction or the possibility of dreaming of sex, having vivid dreams. Right. Seminal emissions in men, dreaming of intercourse in women, I think is what it says in the line.
[00:57:19] Speaker A: But this could also be like erectile dysfunction.
[00:57:21] Speaker B: Could be erectile dysfunction. Absolutely. Low libido. It also says something about balding, losing hair on the head. Again. Why is that happening? Well, the blood is weakening. Hair is a reflection of the blood and the yang is floating. So it's cooking the fibers of the hair, essentially.
[00:57:39] Speaker A: Yeah. Yeah.
[00:57:41] Speaker B: So those are the things I'm going to look for. You could see palpitations, you could see looser stools in these patterns because again, yang is floating away from the lower burner.
[00:57:51] Speaker A: But all of these symptoms are for both of these formulas.
[00:57:53] Speaker B: All of these symptoms are for both of the formulas.
[00:57:57] Speaker A: That's tricky.
[00:57:58] Speaker B: Yeah. So how do we pick which one, which one it is?
So the way that I pick is to look at the case and to think, do we need to supplement the material of the body? More or less.
And it could be a sequential question too. Do we sequence one before the other?
[00:58:17] Speaker A: Yeah.
[00:58:18] Speaker B: So if the floating, if the Yang floating symptoms are really bad, if the person has like really bad insomnia, they have anxiety or really bad sweats. Really bad night sweats.
[00:58:31] Speaker A: Yeah.
[00:58:31] Speaker B: I'm going to go With Tian Chongsan first, if the blood is. The material aspect of the blood needs more supplementation, but we still need to anchor the yang. Then I'm going to go Guizhi ja longgu muli tong.
[00:58:47] Speaker A: So what would tell you that the blood needs that relative to the Qianzhongsan version?
[00:58:52] Speaker B: If we look at the abdomen, you will see rikyu or the rectus abdominal tension. In Guizhu Jia longgu mulitang, you won't see that. In Tian Chong san, you won't see it as much for sure. And Tien chongsan will also have.
You could have aortic pulsations in both patterns, but they will be worse in Tian Chong san and they'll be lower down. So they'll be closer to the umbilicus. Below the umbilicus, the quality of upsurge will be greater.
So that's what I would use to make that distinction.
[00:59:28] Speaker A: Is there any concern with. Again, it's kind of like we were talking about how Shinxi won. Some people have a hard time digesting it. I mean, Guiju Longo mulitang is not nearly as wet as Shinji1 is, but, you know, it is a Guijer tongue formula. So it's like Baishan stuff. Do we have concern about digestion there or.
Most people probably can handle it.
[00:59:48] Speaker B: Yeah, most people can probably handle it. And in the lines, loose stool is one of the symptoms. So you could have a picture where somebody's having looser stool and treat with this pattern.
What I have seen, I've actually used these formulas to some degree treating erectile dysfunction.
And typically what I've done is if I think that this is where we're at in the cycle, I'll just give the formula and then see if the digestion gets screwed up.
And if it does, then I'm going to revert back to a digestive formula for those cases, like something like a sinisan with Lijung wan or something like that, boosts digestion. And then I'm going to go into Guizhou Ja Long Guitang, Tian Chong san, et cetera.
[01:00:36] Speaker A: So practically the differential to indicate that the blood needs more support, therefore, choose Guizhu Jia Long Gu Mulitang is abdominal.
[01:00:45] Speaker B: Abdominal, Yep, yep.
[01:00:46] Speaker A: So like, if you've got req, then Guiju Jia Longu mulitang, that's the biggest clear indicator.
[01:00:53] Speaker B: The biggest clear indicator, yep.
[01:00:55] Speaker A: And if they don't, then probably Tien
[01:00:59] Speaker B: chongsan, Tian chongsan and more symptoms of upsurge, just more intense.
[01:01:03] Speaker A: So Tian Chongsan is sort of on a continuum Things have gotten worse, therefore Tian chongsan.
[01:01:09] Speaker B: So the need to anchor is stronger in Tian Zhongshan because that's all you're doing. You're not doing any material tonification at all. You're just anchoring. You're just fuca guizhi long gu. You're really strongly pulling that yang back down. And then the guizhu jia long Gu muitang is still doing that to some degree, but adding material substance to the body.
[01:01:33] Speaker A: Okay, okay. So the Tian Shongsan is I think, less common. I mean, it's in the Shanghai obviously, but like. Or it's Jingui, isn't it, Jingwei.
But it's not something that shows up in Nabinsky. So I feel like a lot of
[01:01:51] Speaker B: people just, yeah, may not come across
[01:01:53] Speaker A: it, you know, unless they've done more. So, you know, all of these other formulas that we talked about today you can find in the classic Materia Medica, but Tian Shuangzan is not one. So what's the herbs and dosage for that again?
[01:02:06] Speaker B: Yep. So the herb, the dosage and herbs that I learned, of course, are futza and longu, both at 60. Okay, 6, 0, Baiju at 24 and Guageer at 18.
[01:02:22] Speaker A: And then if people are taking this in granule, we're using the sort of usual eight twice a day granule structure. And if they're taking it as an actual san, how much powder or grammage are you having them take?
[01:02:34] Speaker B: I would have them take like 30 grams a day.
[01:02:38] Speaker A: 30 a day?
[01:02:38] Speaker B: Something like that. Yeah.
[01:02:39] Speaker A: Which is pretty typical for sun boil over soak method. Mm, yeah.
[01:02:43] Speaker B: Yep.
[01:02:43] Speaker A: Okay.
Well, that's a pretty comprehensive breakdown, I think, of the various ways in which deficiency. Sorry, deficiency. In which dizziness and vertigo show up in the clinic. I think it's important to consider too, if it's chronic versus acute. Right.
[01:02:59] Speaker B: That's definitely really important.
[01:03:00] Speaker A: Beginning portion of the. Of the differential, but helpful to I think have a better idea of the various organs and systems that are in place for, for how that stuff works.
Any final clinical, theoretical kernels that we need to offer folks?
[01:03:17] Speaker B: Yeah, I think some people might say, well, what about Tianma Goteng Yin or Han Xia Baiju Tian Ma Tang?
For me, it's easier to view those.
It's easier to view the pattern from the perspective of the Shang Han Lin and the Jing way. I don't feel the need to include those formulas in the way that I practice.
I have done in years past a deep dive on the flavors and natures in those formulas compared to the flavors and natures in formulas like Chai Hu Jalangu Mulitang. And surprise, surprise, if you look at Tian Ma Gotong Yin and you look at Chai Hu Jalangu Mulitang, the flavors and natures are almost the same.
[01:04:01] Speaker A: Yeah.
[01:04:01] Speaker B: So it's those formulas come from a different time in Chinese medicine history with a different.
That's more using the Zong Fu organ theory to diagnose the pattern.
My tendency is to look through the lens that I'm used to looking through. And I don't find that I need to include those formulas to treat these cases. I find that this strategy set is large enough for me to be successful in clinic.
And if you like those formulas and you want to use those strategies, that's also perfectly fine.
[01:04:37] Speaker A: Yeah, yeah, of course. I mean, you do, you. There's a lot of formulas in Chinese medicine. Right. We've been doing this, humans been doing this for a long time. So of course there's going to be different points of view. I do think it's very telling though, that the deep dive suggests very similar natures and flavors. Right. Because of course, you know, it's important to remember that we live in a time now, you know, tariffs and politics and stuff notwithstanding, where herbs are widely available.
Yes. Basically every herb that's ever been in the materia medica you can almost buy.
But that hasn't really been true historically. So like people had to do the same stuff. Like the pattern didn't change. Right. Like Xiaoyang Water Pathology, Shulao. Those are always the patterns, but the plant material that you have to push against. The pattern would be variable depending on where you lived in the time period you grew up. But you're still going to need the same natures and flavors. But where they come from isn't so specific. It's an important thing to continually remind folks of because we get so focused on the specific ingredients. Like it needs to be Baishao, it needs to be Chaihu, it needs to be Guizhou, it needs to be Fuling. But that's just because those are the plants that we know do these things. But could they be any number of other plants that have the same or similar characteristics? Like, of course it would just be a matter of like identifying that and testing it out to figure it out. And people have done that. And so we end up with a formula like Tian Man Go Tung Yin, that's like basically the same. I mean, not exactly, but flavor wise, the same as these other formulas. Right. So of course it works. Yeah. Yeah. Cool.
Alrighty, guys. Well, thanks as always for listening to the Nervous Herbalist. If you guys have any suggestions for shows or comments or questions, you can find us at thenervousherbalistmail.com thenervousherbalistmail dot com we are always happy to hear from all of you guys. We also really appreciate it if you could rate and review the podcast wherever you listen to it so that other people can find us. And until next time, I'm Travis Kern.
[01:06:30] Speaker B: I'm Travis Cunningham.
[01:06:31] Speaker A: And we'll talk to y' all later.
[01:06:32] Speaker B: Talk to you later.
