Episode Transcript
[00:00:02] 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.
So we are back. My name is Travis Kern.
[00:00:21] Speaker B: And I'm Travis Cunningham.
[00:00:23] Speaker A: And this is the second episode of a yemenite two part or, excuse me, a three part series for the nervous herbalist where we break down how to manage a complex case. In part one, we talked a lot about the case itself, about the ten questions about interviewing, about how to gather information.
And in this episode, we want to talk about, now that we have the information, how do we actually compose the formula itself? What kind of information do you need to know? Where can you reach for it? What are good resources, et cetera?
And then we'll sort of build it out from there. So, to rehash the case, we were talking about a 50 year old female who had come into the clinic for neck pain. In the process of talking to the patient and working through the interview, we realized there's a whole lot more going on besides just the actual neck pain. A lot of constitutional dampness, a lot of sort of spleen weakness, some yang deficiency, a lot of moving parts. But the thing that stood out the most was how wet the patient was. So when I was looking at the case, we were going to, of course, use acupuncture to deal with the acute neck pain while they were in the clinic. But obviously we needed to send them home with a formula. And what I wanted to do was move and circulate the Qi while also drying the dampness and transforming the dampness. So I started with a modified Chihu shu gonsan. So for people out there, if you're unfamiliar with Chihu Shu Gonsan, first of all, all of the sort of basic herb resources that you would have used in school. So Dan Bensky's book, Chen's book, those are the go to's for looking up a formula. But honestly, if you have access to the Internet, americandragon.com, www.americandragon.com is also a great resource. The website itself is a little clunky looking.
[00:02:14] Speaker B: Yeah, the colors are weird.
[00:02:15] Speaker A: Yeah, the colors are weird. It's a little dated, but it's great. I mean, you can get all the individual herbs there. You can find everything you need, so you don't have to buy a resource. I will say, clinically speaking, at our clinic, we use the Binsky app. You can buy an app that has all of the Binsky formulary and the Bensky Materia medica loaded into an iPad app. I assume it's probably also on Android, but I haven't looked. But it's the cost of the text, so it's not a small thing to buy. But the license can be used on multiple devices, and it's handy. It's very good to navigate. It's very easy to look up secondary information. So if you end up using herbs in the clinic, if you already chart on an iPad or you have those resources in front of you, it might not be a bad idea to invest in the Bensky app. If you chart on a computer, you've got american dragon right in front of you. If you have the Internet, so you can look up material. And I want to say on that point, like, I don't have all these formulas memorized.
[00:03:14] Speaker B: Right?
[00:03:15] Speaker A: Yeah, I mean, like, I have a lot of them memorized at this point because, like, we use them a lot. But to be honest, once we left school, I didn't really put a lot of emphasis on memorization, and I don't know if that's like a millennial thing or what, but, like, I just don't, I just don't care about it. Right. Like, I can just look it up. I don't need to memorize it. Now there is, like, a speed thing of having herbs at the ready, but if you're like, well, I just, I don't know what's in those herbs. Well, just look it up like, it's totally fine. I look up formulas all the time. You probably actually have more stuff memorized than I do, I think. But I do.
[00:03:49] Speaker B: Yeah, maybe. But I also, I use maybe a smaller set of formulas than you do, too, with how I prescribe. So I think the more repetition you get with a formula, the more likely you're going to remember it and all the ins and outs of it and stuff like that.
[00:04:07] Speaker A: For sure. For sure. So if you're not familiar with Chihu shugansan and you go and take a look at it in the Bensky, you'll see that it's a chihu formula, as the name suggests. And it's a combination of herbs that are designed to move, dry, damp, and sort of, like, nourish in a way. The thing about chayushuganzan is interesting, though. So chihu, chuanxiang, xiaoyao, baixiao, in most cases, zhike, zhirgan, sao xiang fu, and chenpi. Right. Are the herbs in that formula. And at first glance, I will say, for example, I think chai shugan sounds a pretty dry formula. Formula. What I mean by that is when people take it, they have a tendency to have drying sensations, like drying mouth drying, sinuses, sometimes not necessarily, like, in a pathological way. It's not like, oh, my God, my sinuses are so dry. But, like, in a way that you intend, which is funny, because if you just look at that list of ingredients, you wouldn't be like, oh, my God, this formula is so dry.
[00:05:14] Speaker B: Right, right.
[00:05:15] Speaker A: Because it's not like xining hua and sangurza and a bunch of, like, accurate drying herbs, but the composition of these things together, in my experience, has a drying effect, and I think it's probably a combination of things that are actually dry, like cenpi. And then what happens when you move qi? Right, which is what Chaiyushu gansan does a really good job of. It makes me think actually of, like, setting up a fan over a small, like a. Like a thing of water, and the air moves over the water, and eventually that water will evaporate. Like, it'll just be gone.
And I feel like that's a similar function with chayushugans on. And that is the headspace that I was in for this patient. I was like, okay, we got this damp accumulation. It's causing lots of impediment to the circulation of chi and blood. It's also causing these dermatological conditions. It's not great. There's just too much of it.
And if we recall, the patient has a tendency toward worry and anxiety. And Shihu formulas tend to be really good formulas to reach to for people who have that kind of, like, agitated, irritable, anxious livery disposition. Right. So start with chiyo. Shugansan modified it a little bit to include some stuff that was going to target the neck, because, again, remember, the patient's primary thing is neck pain. But really, I'm writing this formula to deal with qi stagnation and dampness. So I don't want there to be nothing in this formula to address the neck pain, because then maybe I'm leaving the patient hanging. Right. So I include some guggen in there to draw the formula's attention up to the neck, and then I include Eugene, which is a blood mover. Right. So we're mostly leaning into the energy and affect of chayushugansan.
And again, if you look at Nubenski for chayushugansan, you'll see it spreads the liver, qi, harmonizes the blood, alleviates pain. Right. And those are things that we want to do with this patient. So we go ahead and we launch it. Right.
And is well tolerated. But interestingly, didn't really do much for the neck pain, as it turns out.
But I want to take a minute then and ask you. So, you know, you're looking at the case at the same time, you think about this differently than I do.
[00:07:32] Speaker B: Right.
[00:07:33] Speaker A: Where might you have gone instead of this? Chia shoe guns on space.
[00:07:37] Speaker B: Yeah. Well, and for the record, I'm speaking now from experience of five years in the clinic versus, you know, like, less than one.
[00:07:46] Speaker A: Yeah. Yeah.
[00:07:49] Speaker B: So I might have not done something so different from what you ended up doing, but. But, okay, so to think through my process, the first formula that came to mind, as you were describing the case, was chaihuji longumuli, which I think is a formula you could use for this patient.
[00:08:10] Speaker A: What was it about the symptom set that tagged you for that formula?
[00:08:14] Speaker B: So the neck pain, specifically, with a tendency toward headaches and there being.
[00:08:24] Speaker A: Symptoms.
[00:08:25] Speaker B: On the side, difficulty twisting and bending to the side. That's in the lines from the chaihuji Mulitang in the Shanghai.
Which, by the way, if another website I like to use is called TCM warden. W o e r d e n, which has all the Shanghan and jingue yao formulas and the lines.
[00:08:56] Speaker A: I didn't know about this website.
[00:08:57] Speaker B: Yeah.
[00:08:57] Speaker A: So TCM.
[00:08:59] Speaker B: W o e r d e n.
[00:09:02] Speaker A: R d e n t c m. Warden.
[00:09:06] Speaker B: Yes. What a strange word, right? Yeah. Very, very helpful website.
[00:09:11] Speaker A: You can go in.
[00:09:12] Speaker B: It has all of the dosages for all of the.
[00:09:17] Speaker A: It's apparently a town in the Netherlands.
[00:09:18] Speaker B: Yeah.
[00:09:19] Speaker A: TCM warden. I'm literally for the audience, I'm literally googling it right now as it's happening. So that's super cool.
[00:09:27] Speaker B: Right. And so it has all the. All the original lines there and then a little brief description of what each one of the ingredients is doing. So I actually use this because I use mostly jingfeng formulas at this point. This is the main website I use for dosages. I think it's more helpful for me than the Bensky is because, you know, that's it. It's a little bit more true to the text, I think, because the Benski will give, like, ranges for things and stuff. And sometimes it's a little more confusing that way.
[00:09:59] Speaker A: So this is really cool.
[00:10:02] Speaker B: Yeah. Very useful website.
[00:10:04] Speaker A: Just as an example to the listeners. Bancha hopotang line for women. As if with a piece of fried meat stuck in the throat. Bansha hopotang governs.
[00:10:17] Speaker B: Any of you ladies?
[00:10:19] Speaker A: Yeah. Do you have to relate to that. Meat stuck in the throat. Not baked meat or poached meat or vegetables, but specifically fried meat.
[00:10:28] Speaker B: Fried meat.
[00:10:28] Speaker A: Okay. We can make no commentary on the quality of the translation, guys, but it is true to the actual text itself. So I think that's. This is great. And the dosage is cool. Yeah, this is. What a cool resource. How'd you come across this?
[00:10:42] Speaker B: I was just searching for formulas one day, probably, like, you know, on Google or something, I was, like, looking for. It might have even been for the data entry portion of our herbal database, where I was, like, looking for chinese characters to match a new formula that I was putting in. And this website came up, and I was like, oh, man, this is great. There's, like, there's the line and there's the dosage. So I have this open, usually outside of the other things I'm doing when I'm in the clinic.
[00:11:12] Speaker A: Sweet.
[00:11:12] Speaker B: It's really helpful.
[00:11:14] Speaker A: Okay, so backtrack to the lines from the Shanghan is what pinged in your mind to reach for. Chai jalongamulitang.
[00:11:23] Speaker B: Chai yu jia longa mulitang. So chai jia longo mulitang is also one of two formulas that treats all three Yang conformations. And because the patient had fluid metabolism problem, which if you're going yang confirmation, the confirmation that you're thinking of is usually tai yang in the form of, like, a wuling song would be the classic formula, or, like, a lingua jugan tang would be the guager fuling sort of motion would be in that place. So addressing that in a Yang confirmation version would look more like those formulas.
And then the headache, as it was described, right, started off more yang Ming channel.
And the interesting thing about the cases, there's a fluid metabolism stuff, but then there's also a good appetite, and there was thirst, right? Strong thirst, strong ish thirst.
So that, to me, indicates there's some kind of heat that's present.
And in the case of a xiaoyang based pattern, you can have two kinds of heat that happen, essentially as the pattern develops. And you can see that in the progression of the formulas. So if you take base, Xiao chai Hutong and you, and you understand the pathomechanism, which is the qi gets stuck. There's a flaring of the ministerial fire, which is created by the stuckness of the qi. That fire then flares and over controls what fire tends to over control, which is metal. And that can either go to the metal upper burner, the lungs, or it can go to the metal, lower burner, the large intestine, then the resulting heat will do different things. So in Chaihu, Jiilongu Mulitong, the metal that's getting scorched is the metal of the large intestine, because there's, in the traditional pattern, there's constipation.
So Dahuang is in that formula. In this case, she does get constipated, but constipation isn't present. I think in the case, as it's described.
[00:13:50] Speaker A: Right, there's, like, an alternating bowel presentation, but if bowels go off, they tend to actually become loose and more frequent.
[00:13:58] Speaker B: Right. So this would not be a person. And I think if you saw the patient's frame and stuff like that, which we know at this point, you wouldn't typically think of using a dahuang formula for them.
[00:14:12] Speaker A: And that's because the patients, their build is heavier, shorter, softer tissue. You know what I mean? It's not. It doesn't. It doesn't ring dawang. No, it looks.
[00:14:23] Speaker B: Looks more damp, like, on the damp side. So there looks like there's a chi. The chi will tend to fall down as opposed to going up.
[00:14:33] Speaker A: Yeah, for sure.
[00:14:33] Speaker B: For, like, a woody person like myself, she would tend to go more up.
So Chaihu Jialongu Mulitang, when we think about it as a structured formula, is really treating this ascendant Yang pattern that's moving to the upper. But the heat, the way that the five element system is working relative to that pattern is it's scorching the fluids of the large intestine and the lower burner, causing constipation, which isn't happening for this woman.
I would probably remove the dahuang if I was going to use chaihuji longo mulitang, and then it would keep everything else just the same, because the formula already has.
This is a formula that I didn't study closely when I was in school. And then when I got into clinical practice, I realized, like, holy crap, this formula is huge. It's not only xiao chi, Hu Tang plus longu and mulih. There's also Guager, Fu Ling, and daijisher. And they've removed Gansau or jurgan sao in the formula, interestingly enough, which we can talk about why that might be the case. And then there's also dahuang in the formula. Right? So it's quite a few more ingredients than you might expect at first. So the formula already deals with fluid metabolism because it has Fu Ling and Guager in it, so it's dealing with that principle.
One of the chief symptoms is inhibited urination. So that's also in the lines.
So I would probably, if I were starting off and I saw this pattern, I might go with chaihu jialongo mulitang minus dahuangh at first, that's probably what I would have done.
[00:16:25] Speaker A: So the throughput in the logic there is, okay, we've got this neck pain, difficulty bending. Okay, that pings my mind to chai cha langevolitan. So I go look at that formula, I remind myself about what the details of this formula are, and I dive into the sort of pathomechanism that it's addressing, which is what you talked about there with the yang confirmation modifications and the elements of.
[00:16:48] Speaker B: Right.
[00:16:49] Speaker A: And so. But of course, then I see, oh, there's dapong in here. And I feel like a lot of times. So I mentioned how much I love the Bensky, but also sometimes when you read the Bensky, it seems like you could never use any of the formulas. Yeah, right. Because like, they're super specific. It's like, okay, this, this and this and this and this.
[00:17:08] Speaker B: Or it sounds really dramatic.
[00:17:09] Speaker A: Or it's really dramatic. Yeah. Patient is vomiting blood, has worms exploding from their eyeballs, and you're like, well, that's not happening. So I guess it's not this formula, but that's not really the case.
[00:17:20] Speaker B: Right?
[00:17:20] Speaker A: I mean, like, Binsky did this amazing Binski at all. It's not just Bensky. I'm just going to keep saying Binsky, but I actually mean him and all of the authors that worked with him on it. But, you know, they pulled all this stuff from classical sources and they compiled it in this unbelievable way. Yeah, but the truth of the matter is, like, it's a starting point for formulas, right? Like, if you read, if you read the Binski's intro in, like, explanation on Guizhou fouling wan, for example, you would imagine that the only thing you can use Guager fulinguan is for like, fixed abdominal masses, right?
[00:17:51] Speaker B: Uterine fibroid cysts.
[00:17:53] Speaker A: Uterine fibroid cysts, because that's how it's described. But the reality is, like, Guagerfuilinguan is remarkably diverse set of uses, far beyond uterine fibroid cysts. It's also great for that, but like so many other things, you can use it for. So you might hear us say this formula, you go to the Bensky and you see that there's the Dahuang in the formula and you're like, wow, this patient has loose stool and they're damp. There's just no way I can use this formula. Like, no, you can definitely still use this formula. Like you said, you just pull out the dahuang right now. One of the nuances here is there are some formulas that if you just start yanking out all the parts, they won't be that formula anymore.
[00:18:32] Speaker B: Well, and actually, to that end, one of my, one of my mentors in the program that I'm in now specifically cringes when you take Dahuang out of Chihu jalongu Moon. So if you heard, if you heard this, he would be like, no, don't do that. And actually, so I wanted to put that out there first because that's where my mind first went. But if this person was in the clinic today, I would actually do something a little different, which is what I want to talk about real quick.
So the other triple Yang formula that's used, the other one that treats all three Yang conformations is Chaihu Guizhi Ganjiang Tang.
And to compare that to Chaihu Jialongo Mulitang, we talked about the flaring of the ministerial fire. Fire over controlling metal.
The other organ that it can hit is the lungs. Right? Or if we want to think of it more accurately, we might think of scorching the fluids of the upper burner, which would then cause the symptom, principally of thirst.
So there's the line in Xiao Chihu Tong for the modifications that says, if there's no nausea or vomiting, swap out bansha, add Tianhua fentez. Right. It's one of the first modifications you learn when you're learning Xiao chaihu Tang. So in Chaihu Gui, Jurganjiang Tang, you can see this formula is clearly a modification of the base, Xiao chaihu tang, where that's already been done. So we have Chaihu 24, Guizhi nine. We actually have Ganjiang six. So we've changed Xiangjiang to Ganjiang and lowered the dosage to six.
We have Huang Qin nine, Tianhufen twelve. And then.
[00:20:24] Speaker A: So that's the substitution you're talking about. Ban cha's gone.
[00:20:27] Speaker B: Exactly.
[00:20:27] Speaker A: Tianhufen is now in.
[00:20:29] Speaker B: Tianhufen is now in. And instead of, we have jurgon sao six. And then we also have, instead of dadzhou, we have mooli, which is a substitution that's made getting rid of sweet flavor, adding a salty flavor. And that salty flavor is specifically added for ribs pain. If there's rib side pain specific to the xiaoyang formula pattern, then you add the mooli and take out the dads out. The salty flavor is able to. I think of the salty flavor like cracking an egg.
[00:21:03] Speaker A: That's what it does.
[00:21:04] Speaker B: So if there's, like, a congealed fluid in the San Jo, the salty flavor goes in, and it kind of softens that hardness so that then the bitter and the acrid herbs can get in there and move the crud out of the thing. It's really useful if they're swollen lymph nodes. Actually, if you're using chihu formula and you feel that they're swollen lymph nodes, either under the armpits or up in the neck, a good substitution is to swap dots out for muli.
[00:21:34] Speaker A: Right.
[00:21:34] Speaker B: So this is the formula I would actually use, because in her case, this. It sounds like the. There's a xiaoyang pattern. The ministerial fire is scorching more. The upper burner, and the dampness is in the lower burner.
[00:21:50] Speaker A: Yeah.
[00:21:50] Speaker B: It's not the other way around, so, yeah.
[00:21:53] Speaker A: In fact, she easily has, like, seasonal allergies and, like, thick sinus congestion, like, in the nasal passage. As if, like, that upper lung metal.
[00:22:04] Speaker B: Right.
[00:22:05] Speaker A: Is like, the fluids have been cooked.
[00:22:07] Speaker B: Yeah.
[00:22:07] Speaker A: You know?
[00:22:08] Speaker B: Yeah, exactly. So this is what I would start out with, actually.
And I would keep the formula pretty much the same, like, as the base dosage, but I would add some things because there was the night sweating and the.
I'm not sure if you explicitly said vivid dreams or not.
[00:22:30] Speaker A: She does.
[00:22:31] Speaker B: She does have vivid dreams, so that would be an automatic for me. In addition of longu.
[00:22:37] Speaker A: So to anchor.
[00:22:39] Speaker B: To anchor. Right.
[00:22:40] Speaker A: Gotcha. And to a string.
The night sweat.
[00:22:45] Speaker B: So I think of longu more of anchoring. Like, the reason that the sweating is happening is because the yang is going out at night. So the sweet flavor of the langu captures the yang, kind of brings it in, and it. And it softens and moderates the heart. Right. The sweet flavor moderates the fire elements, so it helps to kind of soften that and keep it from going out. So I actually don't think of it as a stringing, but it probably isn't a stringent herb too, and it's, like.
[00:23:13] Speaker A: A powdery mineral, so maybe. But, like, you know, not like other things are astringing.
[00:23:17] Speaker B: Right, right.
[00:23:18] Speaker A: Yeah.
[00:23:19] Speaker B: And I would dose that specifically, but we'll talk about dosage in a minute.
Yeah. And then I think because of the other presentations, the presentation of the fluid metabolism, I would add baiju and fu ling to it to create linguage. Yugon ta.
[00:23:38] Speaker A: Of course, you couldn't add fu ling.
[00:23:39] Speaker B: Right.
[00:23:40] Speaker A: Which means we have a fungus, an antifungus position.
[00:23:42] Speaker B: Right, an antifungus position, which we can also talk about that we would also have to do in Chayogyolongo mulitan, if you're doing that.
[00:23:50] Speaker A: Okay, so draw the through line for me between.
What is it about chaihu jiaolongu mulitang. So that, again, that's where your mind went first.
But then, upon reflection of looking at the formula, you decide at this point, knowing what you know, to not go with that formula, and instead go with Chihu guizhou ganjiang tang.
[00:24:11] Speaker B: Yeah.
[00:24:12] Speaker A: Why?
What drives you from the first to the second?
[00:24:16] Speaker B: The full formula matches the pattern better.
[00:24:19] Speaker A: Without modification.
[00:24:20] Speaker B: Without modification. So the dai gesher and the da huang are specific to, like, really strongly descending a physical blockage in Yangming, whereas in Chaihu, Guizhouganjiang tang, you've got tianhua fen and muli doing that, which are, um. They're doing it higher up in the body. Firstly. So again, the lungs, the bitter flavor of tianhua fens cooling off the fluids that are heating up in the lungs. And the muli is softening the congest, the congealed fluids. So for me, that combination works out a little bit better. Yeah. In this case, I think you would be fine if you did the chaihuji a longumulitang. I just don't think it fits quite as well as the this one.
And I would rather use the whole formula. If there's a whole gesture of a formula that works, I would rather do that than dropping out pieces and kind of like taking it, taking it apart with this formula. I'm actually. The modifications are also other formulas that I'm adding into. So I'm using three whole formulas instead of something else. So if I add longu, we've created Guizhougan sao longu mulitang, which is the four herb formula from the shanghai. So if we add longu, we just add that other a second formula to it. And if we add fuling and baiju, we're adding Lin guizhugantang, because Guizhou and gansao are already in the formula.
[00:25:55] Speaker A: Right.
[00:25:55] Speaker B: And that's a really good formula for basic stuck fluids in the chest and the middle gel.
[00:26:02] Speaker A: So let's talk about that for a second, because I feel like if we were in our first year right now. Yeah, that would seem kind of crazy, right? Like, you literally just off the top of your head pulled all these formulas and like, oh, add this, and now it's this and, like, whatever. Right. So for the listener, firstly, that's a function of experience. So this is where experience does matter. Yeah. Also, we should note that Travis Cunningham does an amazingly prolific amount of continuing ed and reading. He's very, very, very deep into it, which also helps to explain his facility with some of the language. But when you get into herbs, this also just kind of becomes normal. Like, you're reading about stuff at work and thinking about cases and a little bit like what we talked about last time, like, you're doing this thinking. Not in the treatment room.
[00:26:52] Speaker B: Exactly.
[00:26:53] Speaker A: This is not in front of the patient where you have to, like, pull out all the carnival tricks of, like, all these formulas. This is stuff that you're doing in another time and space.
[00:27:02] Speaker B: Right, exactly.
[00:27:03] Speaker A: And if you can do it another time and space, you also have resources in front of you. Books, apps, the Internet. Right. You don't have to be able to pull this out of your mind like he just did there. That will happen naturally once you start doing this. You know, frequently things start to coalesce. I do think it's interesting, though, a lot of times, depending on how people were educated with herbs and how they learned about formulas in particular, not as many people learned formulas in this kind of nested way. Yeah, right. Where. So, you know, a couple minutes back, I was like, yeah, you can definitely take the dawang out and still make that formula work because you can. But if you don't have to, better to stick with a whole composition. Why? Why better stick with the whole composition? Well, it's because these, so really, everything we've been talking about so far, these chaihu formulas are not just shy formulas in general, but they're modifications of xiao chai Hu Tang specifically. Right.
And Xiao Chi Hu Tang in our clinic and many clinics is the workhorse formula. I mean, we use that. We're in Portland, Oregon, so it might be climate, might be our clientele, but we use Xiao chai Tang and its variants.
[00:28:16] Speaker B: Yes, constantly.
[00:28:17] Speaker A: A lot. Like, a lot, a lot. It's the single largest composition of herbs that we buy for our pharmacy. We use them all the time.
And it's important to understand that, like, when Xiao Chaoyutang gets modified into chaihu, jia longa Mulitang and what the changes were to now not have a quote, modified xiao chai Hu Tang. But in fact, a whole nother formula is a function of history for sure, but really a function of the experience of those many doctors who made these modifications consistently enough for disease presentations, consistently enough to say, actually, you know what? This composition, we're going to take out the xiangjiang, we're going to put in Ganjiang, we're going to take out the bansha. We're going to put in Tian wafengeen for specific reasons. One of the things that you mentioned there, for example, and I just, I love this phrase, takeout dots out, sub mooly. Somebody listening to that is like, I'm sorry, what?
You're gonna take out the dates and put in some oyster shells? That doesn't seem like a substitution to me. Right? Like, please hold the pasta, add oyster shells. Like, like, that doesn't make sense. But that's, this is a substitution from a conceptual space, not because Dachau and muli are the same. In fact, they're not at all the same, which is why one got taken out and the other got put in. And that creates a new formula.
[00:29:42] Speaker B: Yes.
[00:29:43] Speaker A: Which is different than, say, I've taken Xiao chihu Tang and I want to add a single herb in because I think it's important for a symptom or for a patient that's a modified shao cha Yu tong. Or I'm gonna play around, futz around with the doses a little bit modified xiao chaiotang. But these kinds of consistent changes help us to understand kind of an umbrella of herbs. These are xiachai Hu Tang family formulas in a way. And they're all modifications to achieve a specific outcome. Right?
[00:30:16] Speaker B: Yes, exactly.
[00:30:17] Speaker A: If I can use the whole formula for which that specific outcome seems to better match the patient, that's what I want to do.
[00:30:25] Speaker B: Right.
[00:30:25] Speaker A: Right. So I want to clarify that for the listeners also. This is Travis and I's.
I mean, other people do this. Right? But this is kind of our personal style. We have an affinity for whole composition.
[00:30:37] Speaker B: Yeah.
[00:30:38] Speaker A: Have an affinity for the tradition and the experience of people beyond us. Right. And I don't mean people living, I mean that, of course, but also, like classics and. And the work that went into this, I mean, we didn't stumble in to Chaihu jalango Mulitang. I mean, that was made as a consistent modification to Xiao chai tang for particular purpose. You know what I mean?
So we have an affinity for that. Not every practitioner out there has that same affinity. Right. Some people build all of their things from singles, from scratch. They're building compositional things out of the air. Right. From their own minds. And just to reemphasize, like, there isn't one way to do this, but this is the way that we do it, and we think that it works pretty well. And it's not just an affinity. We have an affinity for this for sure, but the reason that we do it is also to be able to track clinical outcomes.
[00:31:34] Speaker B: Yes.
[00:31:35] Speaker A: Right. Because if we know that we use this particular modification to achieve this particular result, and we know this as a pattern that's been used in the past, then we compare what happens when the patient takes the formula to this known shift in the herbs, and then we can actually make adjustments or improvements or changes based on that. So it's really all in the service of a clinical outcome.
[00:32:02] Speaker B: Yes.
[00:32:02] Speaker A: Right. It's not just like, oh, we really love classical formulas. So we're only going to use classical formulas?
[00:32:07] Speaker B: No, no, it's much more systematic. So I would say too, like what to add to what you were just saying there.
Writing a formula at this point for us isn't just about writing the first formula. Right. So if a person comes in the first time, we write them an herbal formula. That formula's purpose is not just to achieve positive results the first week or two that they take it, it's to give us a clear idea of what's happening in their. In their body. Because as good as a diagnostician can be in our field, even like doctor Yu, the guy who's in the case study book that's been translated by Andy Ellis.
[00:32:52] Speaker A: Walk along the river.
[00:32:53] Speaker B: Yes, walk along the river. He says in that book, there's a case, I can't remember if it's in the first book or the second book, but there's a case where he himself, this master diagnostician, gets confused and he doesn't know what to do. And so what he does is he writes a formula that's specific and direct so that when the patient takes it and they have a response, he can track how they respond and then he can hit it the next time.
[00:33:22] Speaker A: Right.
[00:33:23] Speaker B: And when we're working with people today in our clinic, we're very rarely working with them for only one treatment. Right.
[00:33:31] Speaker A: Yeah. In fact, that's probably not gonna be great if they only came in for one treatment.
[00:33:37] Speaker B: If they only come in for one treatment, it's usually not unless it's something very acute, you know?
[00:33:43] Speaker A: Right. Or twist an ankle or something, but even then, it's gonna be more than one treatment.
[00:33:48] Speaker B: So mostly we're setting up for multiple weeks or months with a person, and part of this is gonna go into talking to the patient correctly about treatment planning and what to expect.
I had actually a conversation with a woman today on the phone who the first formula that I gave her, I think I wrote it for two weeks ago, was not good. It didn't work out well, which still happens five years into clinical practice, it probably will happen to some degree forever.
[00:34:21] Speaker A: Yeah, for sure.
[00:34:21] Speaker B: So when that happens, how do we talk to patients about it? And the position that we take, usually is that it's in the interest of understanding the case. I would much rather have somebody have a negative reaction to my formula than no reaction at all.
[00:34:38] Speaker A: Yeah. Because that's so useful.
[00:34:41] Speaker B: And a little bit of a plug for using formulas that you're used to using, using strategies that you're used to using diagnostic techniques that you're used to using is that if you use something and it fails and it's something that you've used before, you will often know how to pivot from there. Whereas if you're using something totally, like, abstract, it may hit the mark and you may be great, but it may not. And if it doesn't work out, then you need to know how to pivot. And if it's too abstract, you're not going to know what to do next. So this woman who I missed the target on, you know, two weeks ago, she had a reaction, and I could easily track what happened to know what to do to write the next remedy. And I'm almost sure the next remedy is going to be good for her, like, it's going to be a good one. So that all comes down to the systems that you develop in diagnosis and the formulas that you get used to.
[00:35:47] Speaker A: Writing and to remind yourself that all data is good data, right. In terms of the patient reaction. So, like, you write this formula, you think a lot about it, you talk to people, you give it to the patient, and the patient has awful nausea and super loose stool five times a day. Right. Which was not what you were going for.
[00:36:09] Speaker B: Right.
[00:36:10] Speaker A: And this is what happened. That is useful information to you. Look at the composition of your formula. What in this formula is particularly wet, what in this formula is particularly down bearing or purgative or moving? Like all of those directions and activities of herbs could contribute to this loosening of stool and the frequency of the bowels. So now you have a sense of what the patient's tolerances are. And if you're using formulas, whole formulas, like we're talking about, that have a moist, in this example, I'm talking about a moist downward Qi moving direction. And instead of getting a positive outcome to the condition that was presented to you, you got instead five, eight bowel movements a day of mostly liquid.
It's probably nothing. Just a shift to the individual ingredients.
[00:37:02] Speaker B: Right.
[00:37:03] Speaker A: You probably have the wrong general formula.
[00:37:06] Speaker B: Yeah.
[00:37:06] Speaker A: Right. Because. Because you're dealing with the whole thing, the whole thrust of the formula as a single unit. Right. What does this formula, which is made of many single herbs, do collectively?
[00:37:18] Speaker B: Right.
[00:37:19] Speaker A: It does this thing which you thought was going to be helpful, and instead, loose bowels. Right. Okay. Can you still hold on to some of the parts of that formula and take out, say, the shungdi and the.
I don't know, what. What else is really slick on the bowels? You know, you got, like, shungdi and a bunch of dongwe. A bunch of dongwe and xiangdi in there, because it turns out the patient's yin deficient. And you were using these moistening things, and you thought it would help manage the heat that was there, that was actually causing constipation. But then you gave him this formula, and it turned into liquid stool eight times a day. Can you take out the dongwei and the xiangdi from your formula and still try and achieve? Yeah, you definitely could. Right. But it's also worth considering if, whether or not the whole thrust of your composition is in the wrong direction. Should you be moistening right now? Is that really the best move, or could you tonify in a slightly different way?
So these are the kinds of things that we'll continue to dive into in future episodes as we move on, because these are fun questions to think about.
And what does it mean to modify and shift? But what is important is that don't get discouraged.
[00:38:32] Speaker B: Right.
[00:38:33] Speaker A: Patient comes back with a bad report. I mean, sure, ideally, you'd like to get it right right from the start, but you may not. In fact, as you're getting into it many times, you won't. Right. That's still okay.
[00:38:45] Speaker B: Yeah.
[00:38:46] Speaker A: And you do have to talk about the patient, and you have to manage the patient, you have to manage expectations, and, you know, that's the details of the next episode, but that is essential. But for your headspace, which is what we're talking about right now in composition and approach and prescription, don't get discouraged.
[00:39:03] Speaker B: Yes, 100%.
[00:39:05] Speaker A: It's hard, though.
[00:39:07] Speaker B: It is hard.
One of the things that I think we should do an episode on, our first formulas to learn in the clinic, if you want to treat internal medicine, I think that would be a cool way to do future episodes. But if there was a first formula to learn, it would be Xiao chai Hu Tang. For the most use, the most broadly applied, like, easiest, most applicable to most situations used for me, it would have to be xiao Cai yutan.
[00:39:41] Speaker A: Yeah.
[00:39:42] Speaker B: Common cold and flu, stress and anxiety, fatigue, depression, all kinds of stuff like to really complicated diseases, all the way down to really simple stuff. Very, very useful formula. So one of the things I wanted to do quickly was talk about how you might come up with something similar to what I wrote. If you're just getting started and you don't know that much about the formula prescription, but let's say you know about Xiao chai he Tang, you can identify. Ah xiaoyang is a part of the pattern. I want to use xiao chai Hu Tang, but I don't know about chaihu jialongu muli, I don't know about chai Heiji ganjiang. I just know about chaihu Tong. And let's say I know about one fluid metabolism formulae like Wuling San, which would have to be in my top five if I was going to recommend people learn two of the five top five formulas for internal medicine. Sha Chai Tong and Wuling San would definitely be on the list.
So if you could come up with the Xiao chai Hu Tang as a place to start, and you just did Xiao chai Hu Tang, and you identified that there was a fluid metabolism problem and you added in Wuling San, I think that would be a very good place to start for this patient.
[00:41:05] Speaker A: Sure.
And so you would land at Xiao chai Yu Tang in this case, because the neck, the neck piece of it, the specifically.
[00:41:17] Speaker B: So side symptoms, any kind of side symptoms, I'm thinking xiaoyang. So if there's neck pain, specifically neck pain that deals with, like, the scalene area or something like that. So if you're palpating and you're noticing and they're really tight on the sides, you know, that's, that's a big deal. But that, that would be the main one. And then as you ask the T gong lines, the questions there, bitter taste in the mouth or strange taste in the mouth, soreness or dryness in the throat and dizziness.
[00:41:51] Speaker A: Right.
[00:41:52] Speaker B: So if there's any of those, and she had two out of the three.
[00:41:55] Speaker A: Right.
[00:41:55] Speaker B: I think when we asked those questions, that would be enough to confirm xiao xiaoyotong. And that's without the pulse, that's without the abdomen. You know, if you palpate the abdomen, tender under the ribs, either one of the rib side, that's good evidence for a xiaoyang formula.
[00:42:14] Speaker A: I also, I love alternating symptomology.
[00:42:17] Speaker B: Alternating symptomology.
[00:42:18] Speaker A: Because, you know, if you read the binski, it says, like, alternating chills and fever, because sha chia Tang lives in the exterior formula space, so you're always talking about it in the cold and flu context. But Huang Huang in ten key formula families points out that, like, alternating symptomology of any kind is that xiaoyang indicator. Right. When xiaoyang indicators. So for the listeners in the most rote, rudimentary capacity, xiaoyang indicators say, look at cha cha Yu tongue.
[00:42:47] Speaker B: Yes.
[00:42:47] Speaker A: Right. So alternating symptomology of any kind, like, I feel it, and then it goes away, and then it comes back. And then it goes away, and then it comes back. That can count, right? Actual chills and fever. That can count. Right. Sometimes. Like, hot flashes. Yeah, I'm hot, and then I'm cold. Hot flashes, any of that stuff. Like, if it comes and goes and shifts in direction, like, there's a polar quality to it, a positive, negative, you know, shifting on an axis. That's a xiaoyang indicator.
[00:43:18] Speaker B: Yeah.
[00:43:19] Speaker A: Which is the core understanding of xiaoyang. Right. Is the pivot point. So that's why that matters. Also the same reason that flank side stuff is a Cheyenne indicator, because your flank is the pivot point between your anterior and posterior self. Right. So again, all of this stuff is taking the. The metaphor of the pivot and looking at its presentation in physical symptomology, that indicates the xiaoyang pattern. Thus, Shao Chaitan, does that mean you're going to use sha chai Tan exactly as it is? Just that? No, not necessarily. We've already talked about how it can be modified in all these different ways. But the first place your mind should go when you're seeing these Xiaoyang indicators is xiao zhaoyu tangin. So that's how you get to the place that Travis just described, where we've got Xiao chai Tang. Okay, I've got all the xiaoyang things. Xiao chaiotang. I heard the guy say it. I got the thing. Xiao cha yutang. It's in my mind. But also, she's got this fluid thing.
[00:44:16] Speaker B: Yes.
[00:44:16] Speaker A: And Xiao chai Tang is not a formula that addresses fluids exactly in that way. So what am I gonna reach for? What are the fluid formulas that I know about?
And this is where Wuling San is, what. What you mentioned. So talk a little bit about that. What about Wuling San? Compared to any of the other fluid.
[00:44:34] Speaker B: Formulas we could reach for, Wollongong san is a really basic formula. That's five ingredients. So you've got guager at a lower dosage. You've got Zixia, fuling, baiju, and Julian.
And it's a really good formula. For dealing with stuck transformation of fluids. So we call it bladder chi transformation. So classically, what we're looking for is a presentation where there's dampness in the lower that's not getting transformed and dryness that's happening in the upper burner because the fluids are not being transformed and appropriated correctly. So like the classic description of Wuling san is the person is constantly thirsty, but they don't pee very much, or there's a problem with urination.
Shanghai is not very clear on what is happening with urination. It's just usually that there's difficult urination. So does that mean there's urination that's happening all the time, uncontrollably and urgent and stuff like that? Or does it mean that there's actually, it takes a minute to get started. Right. When you pee, all of that can qualify. Any of those weird deviations can qualify for Wu Ling san, especially when there's thirst.
[00:46:02] Speaker A: So those two, including a lack of frequency, like you mentioned.
[00:46:05] Speaker B: Yeah, lack of frequency is the classic.
[00:46:06] Speaker A: One, because sometimes difficult urination sounds like there's a problem, like you described, difficulty starting and stopping, super amount of, like, urgency and like, incontinence. But just the fact that, like, people are thirsty, so they drink a lot of water and they don't pee very often.
[00:46:22] Speaker B: Yep.
[00:46:23] Speaker A: Right, like that is, that's a good indicator for Wu Ling san.
[00:46:26] Speaker B: Yeah.
[00:46:26] Speaker A: Right. So again, this is the way, guys, when you're thinking about the whole, like, how to approach complex cases, these are some of the indicators that we use to go from the literal hundreds, in some cases thousands of formulas that exist very quickly down into a much smaller subset. Right, right. Xiaom indicators. Xia chai yo tongue. Right, fluid metabolism problem. And by fluid metabolism, we mean a person drinks fluids, but they're not going where they should. Their muscles seem kind of wet, but their skin is kind of dry.
[00:46:58] Speaker B: There's edema.
[00:46:59] Speaker A: There's edema, but then their mouth is always crunchy and dry. There's clearly fluid isn't moving in the body where it needs to be. They're not dry. In fact, they're wet. Yes, but the fluid isn't where it's ought to be. Right, right. That's a fluid metabolism problem. Thus.
Yes, just immediately go there and start to pick that apart and see what you've got.
And then, like Travis said, like, you send the patient out with a, you know, 70% chao chaiu tong and a 30% wuling san as an initial throw, and that's not a bad shot. Right. It's really not a bad shot.
[00:47:40] Speaker B: Yeah.
[00:47:40] Speaker A: And then how the patient reacts to that now is going to shape what you do next.
[00:47:46] Speaker B: Yes.
[00:47:47] Speaker A: So let's talk a little bit about dosage.
[00:47:49] Speaker B: Yeah, let's talk about dosage.
[00:47:51] Speaker A: Because dosage really matters. Dosage is not arbitrary. Let me say some very important things. You look in the binski and it says six to nine and nine to twelve and 15 to 30. Like, these are the standard ranges that come to us through a, frankly, a large and complex translational history.
The old text, for those of you who don't know the original text, did not write the dosages in grams. Obviously, we have a whole different set of weights and measures from ancient China that have not always been the same liangs and chiens and fens, and all of these terms that have, at the time that the book was written, weighed a certain amount and haven't always been that same number of grams over time. So a lot of times when you're looking at dosages, if you care about what Zhang Zhongjing really meant by one liang, you can get in it. Right. There's going to be a deep discussion. There's anthropology involved and history and weights and measures and whatever. I think, practically speaking, for the clinic, that's interesting, but I don't know that it matters. Right.
[00:49:05] Speaker B: Right.
[00:49:05] Speaker A: What you do have to do is rely on reliable ratios of one herb to another herb and modify your dosage based on the patient's sensitivity, age, etcetera. And there are some things like, but if you don't know you're brand new, you don't know, you don't have any resources. Right. Start with a Bensky dose.
[00:49:25] Speaker B: Right.
[00:49:25] Speaker A: Right. Just don't, don't get crazy. Like what? How much by juice? Should I just start with the Bensky dose, man, it's fine. Right. And then let's work out from there.
[00:49:34] Speaker B: Yeah.
[00:49:34] Speaker A: Now, of course, you go to the Bensky, and the dosage is going to be for a bulk formula, and it's going to be a per day dosage. Right. So you're probably not writing your formula in bulk, probably writing your formula in granule. And so now you got to ask yourself, oh, goodness, how do I write this? Okay, let's start with a couple of things. Number one, well, I guess we'll give a little plug for root and branch. We use a piece of software. We use a piece of software that allows that. Basically, you tell the software, how many grams do I want the patient to take, how many times a day for how many days? So let's use an easy one. We have 6 grams twice a day for seven days. That's 12 grams a day for seven days. That's 84 grams total. Right.
[00:50:21] Speaker B: For a week.
[00:50:22] Speaker A: For one week. So you tell, you tell the software 6 grams twice a day, seven days. It says, oh, that's 84 grams. And then when you go to write the formula, you can actually type the formula ingredients using the same exact numbers from the Bensky, the bulk numbers, because the software is going to use all those numbers that you put in there and treat them as ratios.
[00:50:46] Speaker B: Yeah.
[00:50:46] Speaker A: So when you go to write Wuling san and you write Zixie 15, Fu Ling nine, zhu Ling nine, baiju nine, Guager six, which is what it is from the Bensky. Those are not hard numbers for our software. Those are now ratios, proportions to each other. And the system will do the math to make those ratios equal. 84 grams.
[00:51:09] Speaker B: Yep.
[00:51:09] Speaker A: Okay. Now, if you're out there and you're working with a pharmacy that does not have the same sophisticated software. Right. You might have to do some math by hand. If you don't have a pharmacy and you're looking for one, you should go to rootingbranchpharmacy.com and you should sign up for an account, and you should take a look at the way that our software works. Because, frankly, it's one of my favorite things about our software is it takes a lot of the math out of the equation.
[00:51:37] Speaker B: Yeah.
[00:51:37] Speaker A: Right. So if you have to do the math by hand about how much you're going to need in the end, we can talk about that.
[00:51:43] Speaker B: Right.
[00:51:43] Speaker A: Right. I don't want to get too much in the weeds for people who aren't necessarily going to do that. If you have specific questions, you can also always email it to us info infooodinbranchpdx.com, and we'll get back to you if you have a specific question about dosage. But I want to talk about it in terms of how, how we think about this. And that is, firstly, if we're going to talk granules in total grams per day, that's the first thing you need to decide, right. How many grams per day is your patient gonna take? And then, of course, for how many days? And then you're gonna work back from there. So what are you dosing now? Yes, your standard.
[00:52:23] Speaker B: So what I recommend people do, and what we do is we kind of have a starting dosage that we would give to everybody. Right. And then based on certain factors, how they respond, if we think they need more certain kinds of presentations, like if they're acutely ill with a cold, we might have them take more or something like that.
[00:52:49] Speaker A: Right.
[00:52:49] Speaker B: Which we could talk about that in more detail.
You have a base dosage that you start out with, and then you modify from that that you feel comfortable giving to most of your patients so that you have a comfortability that develops over time with this dosage should work for these things for most people. So for me, that dosage in granule is 8 grams twice a day, which is 16 grams per day.
[00:53:15] Speaker A: 16 grams per day.
Some of you out there listening might be like, holy crap, that's so much granule. Right? And the reason I know that is because we fill formulas for a wide variety of practitioners, many of whom will prescribe 6 grams a day or 4 grams a day total.
Let's talk about where this comes from. Okay, so for those of you who don't know much about granules, granules are bulk herbs that have been cooked into decoction and then evaporated into a powder and usually bound with some kind of.
To make the powder into granules. So, like, dextrose or something like that. And they're mixed with hot water, and you drink them like tea. Right. Because of the cooking of the bulk herb into decoction and the evaporation of it into a powder, they're generally considered to be a concentrate. Right. And the general knowledge of granules, sort of across the board, is that they are a five to one concentration, meaning every 1 gram of granules is equivalent to 5 grams of bulk herb. Right. And that's possible because how much bulk herb did we use when we make the tea and how much granule came out in the end? And broadly speaking, there's a five to one ratio between how much bulk went in and how much granule came out. Right. In practice, for the very large granule manufacturing companies, Tianjiang Pharmaceuticals, which is one of the largest granule manufacturers in the world, certainly the largest in mainland China. They have a really sophisticated process, I have to say, where different herbs of different types are cooked in different ratios to yield different concentrations.
To be honest. Like, that's interesting from a granule manufacturer point of view and from a science point of view, but it's not super relevant clinically. I guess if you could, like, if you wanted to, you could get in and be like, well, Jingjie is a 3.2 to one, and baiju is a 5.6 to one. And, you know, daiju sure is a one to one because it's a mineral. Like, you could do that, but, like, honestly, that's granular. And if you're a super nerd like me, you might have fun with that, but otherwise it'll probably just melt your brain and frankly, it doesn't matter. Right.
The thing that you got to keep in mind, though, is that a lot of people will say, well, because the granules are concentrates, I don't need to use that much.
[00:55:36] Speaker B: Right.
[00:55:36] Speaker A: Right. So if I give the patient 4 grams a day of granule, that's four, that's five to one. So I'm really giving them 20 grams of bulk. Right. The thing is, is that if you have any experience in prescribing bulk, 20 grams of bulk is nothing.
[00:55:54] Speaker B: Yeah.
[00:55:55] Speaker A: That is a tiny, tiny formula.
[00:55:58] Speaker B: Yeah.
[00:55:59] Speaker A: Bulk formula composition usually doesn't get much below 45 grams per day and in reality, usually looks more between like 65 and 90.
[00:56:10] Speaker B: Yeah.
[00:56:11] Speaker A: And for a heavy prescriber, 75 to 120. Right. We see formulas that can be over 200 grams a day. Right. So the idea that 4 grams a day of granule as a standard, meaning this is kind of. This is my everyday dose that I give to everyone.
In our experience with the patients that we have seen, may not give you the most therapeutic response.
[00:56:38] Speaker B: Right.
[00:56:39] Speaker A: That is to say, I'm being. I'm being generous here. Like, I don't want to say like that isn't going to work because it works. We see people get work out of it, but for our stuff, it's not going to be as potent a response as you might need in order to get real work out of a patient, especially depending on what you deal with. As Travis said, the key piece here is finding a sort of standard dose for you. In the States, that number is between twelve and 16 grams on average. We have this data from two of the granule manufacturers who distribute in the US, and the data that they've gathered in particular, twelve to 16 grams. Right.
In Australia, it's nine to 12 grams. In China, it's 18 to 24.
[00:57:23] Speaker B: Right.
[00:57:24] Speaker A: Right. Now, what's that about?
Well, some of it's certainly constitution. A lot of it is expectation. And here's the other kicker, and those of you out there who are real hardcore purists about how much granule you can and can't use the third factor, which is perhaps the most important factor. Cost. Yes, cost.
[00:57:44] Speaker B: Cost is important.
[00:57:45] Speaker A: So in Australia, the granules are more expensive than they are in the US, which is more expensive than they are in China. And so, lo and behold, where do we see a higher dosing amount in China? Right. Chinese people, even from our experience, when we were in Nanjing, have a very high expectation of what they should feel when they get acupuncture or when they take herbs. So there's a cultural expectation. Right.
But the reality is dosage can range widely and you can get a lot of results.
But just like we were talking about before, with sort of having a whole composition that you use and then test in the clinic, it's the same idea with a base dosage rate at root and branch. Our base dosage rate is now 16 grams a day. We started, it was more like twelve.
[00:58:31] Speaker B: Yeah.
[00:58:32] Speaker A: And a lot of, and that was because we just picked that twelve to 16 range and we found that a lot of the work that, like, we had to spend more weeks treating a thing or the response was slower and it was like, what's the deal? And we started increasing the dosage and we got results better and faster.
Now, the patient that we've been talking about in this case study, if I gave her 16 grams a day of herb, especially at this .4 years ago when she was in here, it would have blown her out of the water.
[00:59:01] Speaker B: Yeah.
[00:59:02] Speaker A: Right.
She ended up taking, her heavy dosing at that time was 8 grams a day, half. I mean, she was taking 4 grams twice a day. How did we figure that out? Well, I dosed her at 12 grams a day and it blew her out of the water. Right. And she was like, oh, my guts and my head and I'm irritable and like, I feel like she described one time, she's like, I feel like there's a desert in my mouth. Like, it was just really intense. So we reduced it. Right.
I now know that about that patient. And when I deal with her, I. I adjust accordingly.
[00:59:36] Speaker B: Yeah.
[00:59:37] Speaker A: However, we just had an example with this patient. They had an acute cold and flu. You dealt with this in particular?
[00:59:43] Speaker B: Yep. Yeah. Travis K. Was on vacation or. Yeah, you were on vacation, right?
[00:59:47] Speaker A: Yeah, I think I was out of town, yeah. For the summer break.
So what happened? She called. So she called. You knew about this issue with the sensitivity?
[00:59:55] Speaker B: Knew about the issue with the sensitivity.
And she wanted me to write her a formula. And while Travis was away, and so I asked her some questions about cold and flu. We deal with a fair amount of cold and flu stuff for our regular patients, kind of over the phone or like when Covid was happening, we were doing more telemedicine or talking to people on the phone and stuff. So we have a fair amount of experience with that at this point. So I was, you know, thinking about the case and wrote the formula up, and it was some. Some kind of, guess what, chihu tongue modification.
So I wrote her that, and I ended up giving her a third of the dosage that I would normally write in that formula. And I did it in bulk. This was a bulk formula. So acute onset cold and flu. Generally, I like to give people bulk herbs because it's faster, you get to see change more, and, yeah, it's just. It's easier to work with for me. So did that. We cooked it up here. We also do a decoction service for people locally in town. So we cooked up the herbs for her. She came in and she got them, and she took them for, I think it was two or three days. And she got better. She started feeling better, but then by, like, day three, it was starting to cycle back and she was starting to feel worse again. And she called me up and said, hey, this is how I'm doing. And I asked her to report back to me because I know how sensitive she is, and I didn't want to. I wanted to be careful with her.
[01:01:35] Speaker A: While you were away.
[01:01:37] Speaker B: And she explained what happened, and I was like, dang it. The freaking dosage is not high enough. So I ended up doing almost the same formula with her, but at two thirds the normal dosage instead of a third. And that actually, she took that. And that worked.
[01:01:55] Speaker A: And that worked.
[01:01:56] Speaker B: That was the successful one.
[01:01:57] Speaker A: And so to put that into context, we know that she's sensitive, but also some conditions require more force, and acute cold and flu is one of them. Right. If you, in my experience, if you try and dose a classic wind cold invasion with 4 grams a day of guadiaton granules, oh, my God, you might as well just not give them any herbs. Yeah, they'll get better on their own.
[01:02:21] Speaker B: Give them some soup.
[01:02:22] Speaker A: Yeah, you don't need.
[01:02:23] Speaker B: Don't worry about the equator time.
[01:02:25] Speaker A: It's not strong enough. Now, again, there's going to be people out there who are going to argue with us.
My results are great. And look, I'm not saying they're not right, because again, anybody who out there is a chinese medicine practitioner knows you can do this medicine any which way. I'm saying, from our experience, that's not what I would do. Right, right. And I would say, if you're not sure what to do, try it this way first and see what happens. Okay, so our clinical dosage right now is 16 grams a day. You build your granule using the ratios of a bulk formula.
[01:02:58] Speaker B: Yes.
[01:02:58] Speaker A: Right. That's what I do, too. We build from the ratios of the bulk formula. And then you just calculate, using those ratios, how much of each actual herb you need with the total in mind. Right. I want to also talk about an issue that, you know is very near and dear to my heart, which is the difference between weight and volume. Here we go. Let's talk about this. So I apologize ahead of time for the soapbox, you guys, but we deal with this all the freaking time. Firstly, let me say, if you have taken granules, if you prescribe granules, if you have been out in the world with granules, I'm going to say this now, and I need you to hear me. There is no such thing as a 1 gram spoon. Let me say it again. There is no such thing as a 1 gram spoon. Is there a spoon for which a specific granule might. The volume of that spoon of a specific granule might weigh 1 gram? Yes, but spoons are a volume measurement and grams are a weight measurement, which means that there is no way for there to be a consistent relationship across all of the hundreds of different granules between weight and volume in a spoon. So if you just heard that and you're like, what the hell is he talking about? Let me back up. You've probably never had granules before.
We've been talking about dosage here in weight, because that's how we do it, right? We write the dosage and weight, and the patient gets the herbs from us and says, you need to take 8 grams twice a day. But Americans in particular don't have scales at home.
[01:04:31] Speaker B: Right.
[01:04:32] Speaker A: Right. And if they do have a scale, it's like a kitchen scale, and it only measures, like ounces or whole grams. And so, again, not to get too much in the weeds, but I think this is important. If you have a scale at home, a kitchen scale, and it only weighs in whole grams, what that means is when you're at 8.1 gram, 8.5 grams, and 8.9 grams, the scale is still only going to show eight.
So that means you could measure something that's 8.9 grams over and over and over again and think that it was 8 grams when in fact, you were using really nine. Right. So if you use a scale at home for grams, really, frankly, for anything, but especially for grams, it has to go to at least the 10th of a decimal. So, like 8.28.3, it should show that whole thing so that you know how accurate you're really being. But again, most people don't have a scale. So we have these little spoons that we get from one of our granules companies from evergreen. And that spoon for evergreen company herbs has a relatively consistent volume to weight ratio. So if only you bought granules only from evergreen.
When you fill out, when you fill a spoon of evergreen herbs, it weighs about a gram. Yeah, most of the time, I want to insert most of the time. Not always.
[01:05:50] Speaker B: Right.
[01:05:50] Speaker A: But enough of the time for it to not be a big deal.
[01:05:52] Speaker B: Yeah.
[01:05:53] Speaker A: We carry herbs from all kinds of different companies because we can't get everything from one company. And granule companies make their herbs differently, so they don't all have the same shape, they don't have the same density, they don't have the same dust ratio and all this kind of stuff. So when you start mixing and matching types of granules together, there is no longer a consistent relationship between the volume of a spoon and the weight. So the patient looks at their bag of herbs and it says 8 grams. What are they supposed to do? Well, we're gonna give them a spoon and say, hey, go ahead and measure this out using spoons. But on the bag of herbs, we write a conversion of the number of grams into spoons. And that's not universal math. That's not like every 2 grams is one spoon. No, that's specific to the bag of herbs that the patient is holding. Because I can tell you right now, having measured hundreds and hundreds and hundreds of herb formulas, at this point, sometimes 6 grams is six spoons, and sometimes 6 grams is four spoons. And the higher your dosage, the greater the variation. So if you're like 9 grams or 10 grams a day, that could be 10 grams a day, can be five and a half spoons.
[01:07:03] Speaker B: Yeah.
[01:07:04] Speaker A: Right. Yeah, 6 grams. That same formula might only be four spoons because the small variation each time you weigh the spoon is greater and greater and greater the more grams you do at a time. So I just want to say that because people pick up herbs, they think they have a magic 1 gram spoon, and they just start dosing their herbs, and all of a sudden, they use their herbs up way faster than they. Then they thought they got a seven day formula, and they only used it for five days. And that's because they made the mistake of assuming that there is a universal relationship among all granules between weight and, and volume. And that's not true. Soapbox. Done.
[01:07:44] Speaker B: Yeah.
[01:07:45] Speaker A: There you go.
[01:07:45] Speaker B: Now, just one point of clarification. When he says, we weigh out each individual formula and put a gram to dose to spoon dosage, that's root and branch. That's not every pharmacy.
[01:07:59] Speaker A: No, no, that's anything like that.
[01:08:01] Speaker B: That's actually not a common thing to do.
[01:08:03] Speaker A: No, it's not. In fact, if you talk to a lot of pharmacy people, they'll tell you the variation doesn't matter that much. And I will tell you, those people haven't waited very many formulas because it definitely matters.
[01:08:14] Speaker B: It definitely changes.
[01:08:15] Speaker A: If your pharmacy only carries one brand of granules, it doesn't matter. I can say that right now it doesn't matter because there is going to be a consistent weight to volume relationship because the company has the same manufacturing process. But if you have a large pharmacy, like we do, and you serve a lot of different conditions and you need a lot of different herbs, it's hard to maintain that. And so you're gonna have to address this issue because it can be really dramatic.
[01:08:41] Speaker B: Very dramatic. Yep. And with a sensitive patient like that. Just another quick word about sensitive patients. Right. How. What percentage of people would you say are, like, the patient that we were talking about there, that's. That's really sensitive to dosage, just so people get an idea of this.
[01:08:58] Speaker A: I don't know, man. I used to. I would have initially said a lot, but now I feel like it's less.
[01:09:05] Speaker B: I think it's very, very small. Yeah, the reality is very small.
[01:09:09] Speaker A: It's very small. And I don't know why initially. I don't know. Maybe I just was absorbed something from school like.
[01:09:14] Speaker B: Yeah, people.
[01:09:16] Speaker A: Sensitive schools.
[01:09:17] Speaker B: The schools are, I think, the worst place to learn about dosage in a lot of ways, because you get, like, this mash of, like, student input, which are people that don't have enough experience, really, to say. And then I think the number of people that would respond to herbs like that patient are incredibly small. I would say less than 5%.
[01:09:38] Speaker A: Even people. Yeah. And I would agree. Especially even people who report being sensitive.
[01:09:44] Speaker B: That's my next point, is I wanted to say, what percentage of those people do you think the people that come to see us will tell you if you ask them or if it's a somehow prompted, are you sensitive?
Do you respond strongly to things?
[01:10:00] Speaker A: A lot of people.
[01:10:01] Speaker B: A huge percentage. The majority. The majority.
[01:10:04] Speaker A: Many, many people I see will report that they're very sensitive to things.
And, look, we're not saying that that's not their experience. Right? Like, people, whenever people report things to me, that's just true.
[01:10:17] Speaker B: You always listen to what they're saying, but at the same time, you have to put that into context. What do they mean by that? Are they sensitive to supplements? Are they sensitive to pharmaceutical drugs, because herbs are not like pharmaceutical drugs.
[01:10:33] Speaker A: No, they're not even like supplements.
[01:10:35] Speaker B: They're not like supplements. So the only reliable way, and maybe there is a diagnostic way to figure out sensitive patients versus not, but I haven't figured that out yet. So the only way that I found reliably to figure out when this patient is actually sensitive, like this patient we're talking about here in the case, is trial and error, truthfully. And if you start off with a sensitive person dosage, which is going to be about a third sometimes as much as people, you know, tend to be most people in our clinic, I'll speak from our experience, most people will not respond to that dosage. They won't have any change at all, period. And that's the worst possible outcome you can get when you give somebody herbs, is that they experience no change. It's way worse than if they have a negative outcome. Because the negative outcome, again, with a good diagnostic system and a well crafted formula, will point you in exactly to what they need. And then the rest of the time you're treating them, you're on point. So, yeah, just want to put out a caveat there. That's.
[01:11:47] Speaker A: Well, and I mean, that's important clinical. I think it's also super relevant, because, again, this case that we've been talking about this whole time, this patient I first saw four years ago, but now I've been seeing her all this time, and her sensitivity has changed. This is something that's also really significant. And it just happened, really. We were dosing a formula. She had a very strong respiratory reaction to the herbs, which of all the kinds of, like, negative side effects, respiratory ones and cardiac ones, are definitely the ones that catch the patient's attention the most. And certainly that we pay a lot of attention to because they can be dangerous. Right. It's a very strong respiratory response to this formula I had written for a different pain condition, but she was getting huge amounts of result from the pain. Like, the pain was less. So she just kept taking it. She didn't tell me about it. She told me about it later. Right. But she's just like, well, but I feel so much better, so I'm just gonna take it. She pushes through this strong respiratory response using her rescue inhaler and, like, all this kind of stuff. Right. And then on the second day, after just pushing through three doses in, it starts to diminish.
[01:12:50] Speaker B: Yeah.
[01:12:50] Speaker A: And diminish. And now it's gone.
[01:12:52] Speaker B: Yeah.
[01:12:53] Speaker A: Now, you know me, I am skeptical of things that people call, like, healing crises and stuff like that. It's skeptical. I'm skeptical because I think it's easy for that to be crappy medicine that's being wrapped up as like, oh, you're just purging or whatever.
[01:13:09] Speaker B: Yeah.
[01:13:10] Speaker A: And I also think I'm skeptical because it's hard to know whether or not you're helping or just hurting the patient. Right. And obviously experience helps to inform that. But in this case, this was a kind of experience where I think, and I'm loathe to use this term, but I'm going to use it anyway, where there was a kind of healing crisis, where the body, that's what it sounds like, reacted to this formula negatively, but it was actually the right formula.
[01:13:34] Speaker B: Yeah.
[01:13:35] Speaker A: And she pushed through and it was fine. Now, I'm going to say for the newbies out there and the nervous folks out there, that's not something I would recommend that you do. Right. I really want to. And honestly, if she had called me when that was happening, even today, and said, hey, I'm having this reaction, what do you think I should do? I would have said, discontinue the herbs. Discontinue the herbs. Let's talk about it when you come back in. I would not have counseled her to keep doing it, and that's because I'm skeptical of healing crises and because I'm skeptical of this notion of hurting the patient to heal them kind of thing. In general, she did it on her own, and it turned out great. And now this is really useful information for me going forward.
But I also want to point out that the sensitivity of the patient can shift, and you need to, like, stay on top of that. But no matter what, you pick the dosage, you deliver the dosage, and then you see what happens. So to summarize here, what we've been talking about, you've got a complex case that we laid out in the first episode in this series.
You've done your diagnostic work. We've clarified some major pieces that can point you in one direction or another. Specific to this episode is Xiaoyang symptomology. Alternating symptoms, flank pain, thirst, etcetera. Right. Dizziness and fluid metabolism symptoms. The patient is wet but doesn't have moisture in the right place, dry mouth, etcetera. So the xiaoyang symptoms point us to Xiao chai Tang, and the fluid metabolism problems point us to Wuling San. And if you started your formula with xiao chai Tang and Wuling sandhorn as your first thrust, you'd be in a good spot, and we would recommend that you start that at 16 grams a day. Right. For your patient for seven days, and use that as your test balloon.
The ratio of the two, I would say, depends on the presentation of the patient you're looking at. Based on the patient that we had and her primary complaint of neck pain, I probably would have done that at about a 70 30. Xiao cha Yu Tang Wuling San. Yeah, I think you could have leaned a little more into Wuling San if you want. Cause she is super wet, like a 60 40. I would have started with a 70 30 so that I could see what happens.
[01:15:46] Speaker B: Yeah.
[01:15:47] Speaker A: So 70% Shao Chaoyu tongue, 30% wuling San, 18 grams a day, seven days, and then what happens?
And we take that information.
Last bit on that. If you're thinking like, well, what does 70% xiao cha Hu Tang mean?
That is a function of using whole formula dosing.
Our pharmacy, we carry a lot of whole formula granules. So that's, like, all the herbs cooked together, and then those are made into granules. So you can literally just type in Xiao cha Hu Tang 70 and Wuling San 30, and we will fill a formula with the whole composition of those herbs. If you're doing it from singles, you got to do a little bit more math. Right, to figure out which of the parts that are there.
[01:16:33] Speaker B: But that's how I would do it now, actually, from singles is just to it from singles, because I have all these. Our system also allows you to save pairs of formulas. So instead of implementing chihu Huang chin, you know, 24 nine, you just. I have chiling tong. Boom. You know, saved. Click it. Boom. It populates, write dosages. And then because we have the system, we have, it auto calculates the ratios that would go into whatever that would be at the required or at the prescribed dosage that you would set up at first.
[01:17:10] Speaker A: Exactly.
[01:17:10] Speaker B: Yeah.
[01:17:11] Speaker A: Yeah. So there's a lot of, like, if you're out there struggling with the math, if you're like, I can't figure out this math, please send me an email, I will help you with the math. And then I will say, go make an account with our system so you can save this math as a template and you never have to do it again.
[01:17:25] Speaker B: Yeah.
[01:17:25] Speaker A: Right. Because there isn't any reason that you have to struggle with the mathematic. It can be intimidating because there's a lot of moving parts and stuff, but it's totally manageable.
And so the thing that we're going to address in the next episode, the third part of this three part series, is, okay, you did the diagnosis, you compose the formula, you sent it out the door. What do you tell the patient when they leave first, before they even take the formula? And how do you deal with their response? How do you shape their direction? So we're going to talk a lot about case management and patient management. How do we manage expectations? How do we keep patients bought into what we're doing and make sure that we can actually get them where they want to go?
[01:18:11] Speaker B: Yeah. And how do you talk to patients when there might be negative things that happen, too? That's a hugely important skill set.
[01:18:20] Speaker A: Absolutely. All right, everyone, we hope you enjoyed listening to this and we'll catch you next time. Yep.
[01:18:24] Speaker B: See you next time.
[01:18:26] Speaker A: Our.
[01:18:32] Speaker B: Channel.
