Show Notes
TK asks TC about some of his constipation cases and how he decided which herbs to use and why.Â
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Episode Transcript
[00:00:04] 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, and welcome back to the Nervous Herbalist. My name is Travis Kern and I'm.
[00:00:24] Speaker B: Here with Travis Cunningham.
[00:00:26] Speaker A: And we're going to talk to you guys today a little bit about some case studies on constipation.
Everybody's a little bit stopped up.
Things aren't moving as they ought to.
In the last episode, we talked about constipation from a pathology point of view, sort of patterns and formulas. But we always like to follow that up when we can with some case studies to kind of give you an idea of what that looks like with real people in the clinic.
So today we're going to talk about two different cases that TC was able to pull from his caseload. And I know too, that when you were looking for these cases, finding ones that had sort of like an isolated constipation pattern was pretty challenging.
[00:01:07] Speaker B: Yeah. It often occurs alongside of a bunch of other things that people are coming in for.
[00:01:12] Speaker A: Right. So oftentimes someone maybe like their chief complaint isn't necessarily that they're constipated, it's just that it comes up in the conversation and then it's of course, part of the pattern that you're treating overall.
[00:01:24] Speaker B: Yes.
[00:01:25] Speaker A: So why don't you introduce the first case and talk a little bit about that complexity and then peel out the constipation part for us.
[00:01:34] Speaker B: Yeah. So the first case is a 53 year old female. Oh, by the way, before I get into it, the cases that I'm going to talk about are kind of like snapshots in a larger timeline of treatment. So a lot of the time with more chronic cases, there's lots going on. We end up treating people for quite a long time.
And over the course of that time, there's many stages to the treatment where we kind of start off and treat things one way people get better. We go in and sort of treat more constitutionally, you could say, or treat it at a deeper level. And then something happens. They get a cold, they get allergies, they get whatever, and we have to pop back out and treat that. And then that resolves and we go back in and treat the interior thing. And then over the course of time, people get a lot better. But a lot of the time it's not one chief complaint the whole way. There's like a number of things that are getting hit so both of the cases that I've pulled from are cases that are like that.
I also have cases where people come in for more acute constipation, but they're kind of by the book.
And I didn't feel like it would be that interesting to talk about because anybody who's ready the standard presentation of Da Chang chitang may just know what to do when Da chung.
[00:03:00] Speaker A: That's what we talked about last time. You just prescribe Da Chong Qi tongue for two days.
[00:03:04] Speaker B: Yeah. They're moving again and then they're moving again. Exactly.
[00:03:07] Speaker A: Yeah.
[00:03:08] Speaker B: So this is more, I think, in line with what most of us might see clinically.
[00:03:12] Speaker A: Right. Well, and I think that it's also reflective of the idea too that, you know, people come in with one thing until they have experience with Chinese medicine. They don't realize that their one thing isn't really like they have 10 things, but they're thinking them as isolated things.
[00:03:28] Speaker B: Yes.
[00:03:29] Speaker A: Constipation is separate from sleep is separate from, you know, emotional turpitude or whatever. Of course we look at it and it's like, oh, no, those are actually all part of the same thing.
[00:03:39] Speaker B: Right.
[00:03:40] Speaker A: However, as is often the case with chronic and long standing disease, it's not like you're going to write one magic formula that's going to knock out all 17 of a person's problems.
[00:03:49] Speaker B: Right.
[00:03:50] Speaker A: Because they're like layered on top of each other. They're stacked.
[00:03:53] Speaker B: Yes.
[00:03:53] Speaker A: And so when Travis was just mentioning sort of like treating something and then going deeper and then pulling back out, there's sort of this metaphor of kind of concentric problems. You know, like the usual image you'll see is like an onion. Right. So you sort of peel back a layer and now you can see what's underneath. So you start treating that and you peel that back. But then every now and then something's up at the surface, so we gotta pop back up there.
[00:04:17] Speaker B: Yep.
[00:04:17] Speaker A: I think this is also too reflective of what happens when you build good rapport with patients.
[00:04:22] Speaker B: Yeah.
[00:04:23] Speaker A: And they start to think of us as the primary interventionists. Right. I mean, we're not technically able to be primary care in many states in the country, though. If you're in California or New Mexico and I think Florida now, you can be. For the rest of us, though, even though we're not on paper primary care, a lot of folks start treating us that way because our medicine is really well suited to complex problems and also acute ones.
[00:04:48] Speaker B: Yeah.
[00:04:48] Speaker A: And so when you start building that rapport and then people start to trust what you're doing, then they stick with you.
[00:04:54] Speaker B: Yeah.
[00:04:55] Speaker A: And that's great because then you understand the person better and you understand what their norms are. But it also means that when you're mining material for case studies, they can be really quite long.
[00:05:05] Speaker B: Yes.
[00:05:06] Speaker A: You know, I mean, some of these people that you were looking at, we've taught, we've treated for years. Years. Literally years.
Yeah. Okay, so go, let's pop into this first case.
[00:05:14] Speaker B: Okay. 53 year old female, and this person is a self described lifelong constipation. I've been constipated my whole life, even when I was a kid.
And she also has occipital neuralgia, osteoarthritis in all seven of her cervical vertebra.
Neck pain, which would go along with the previous thing, which is at times dull, achy, Sometimes it's sharp, sometimes it radiates down to the scapula, sometimes it radiates up to the head, sometimes it contributes to the headaches, sometimes it doesn't seem related to the headaches.
[00:05:54] Speaker A: Right. But of course, occipital neuralgia and all of the inflammation in the cervical vertebra, like all of that is of a kind.
[00:06:01] Speaker B: Yeah, for sure.
[00:06:02] Speaker A: For sure. Okay.
[00:06:04] Speaker B: Yep. She also has chronic gerd, which she has a prescription for a ppi.
She has chronic insomnia, which she takes trazodone for.
And these are both issues that have been going on for the last five or ten years.
So quite a long time with all of these things.
Her constipation manifests as dry and hard stool, which is passed every three to four days.
She has relatively low thirst and urination seems mostly normal.
[00:06:40] Speaker A: Okay.
[00:06:42] Speaker B: She has headaches that get. She describes them as migraines, but the way they sound, it didn't quite seem like a migraine presentation to me. But very severe headaches.
[00:06:53] Speaker A: Sure.
[00:06:54] Speaker B: And they happen when they start to get worse. They're happening three or four times a week, so pretty severe.
So I did the intake with her, I checked her pulses and her pulses felt very excess overall.
The left side I clocked as being wiry and a little bit slippery, the right side wiry and more tight, but very excess.
Upsurgent, like very loud, you could say.
[00:07:24] Speaker A: Yeah. So like, if I felt it, I wouldn't get any subtlety like you did. But like, that's an excess pulse, right?
[00:07:29] Speaker B: That is an excess pulse and it's right near the surface and it's almost like coming out of the surface. If you. If that makes sense.
[00:07:36] Speaker A: Very clearly.
[00:07:36] Speaker B: Very clearly.
[00:07:38] Speaker A: Yeah.
[00:07:39] Speaker B: When I palpated the abdomen, I found discomfort under both of the costal regions. So both left and right, I felt a hard pee or hard glomus in the epigastric area.
And the overall abdomen felt excess. So the size felt large. And when I pressed in, it was kind of uncomfortable overall.
Right.
[00:08:06] Speaker A: So all of that confirming again, an excess presentation?
[00:08:10] Speaker B: Yeah, there's just a lot of excess.
[00:08:11] Speaker A: Like a surface level excess presentation.
[00:08:14] Speaker B: Yeah.
[00:08:14] Speaker A: Okay.
[00:08:15] Speaker B: And there were pulsations of the abdominal aorta right around the umbilicus, so I noted that as well.
So for that, for that patient, I gave Chaihu jia longu mulitang to just base formula, no modifications. I gave it in granule, and I chose to do 10 grams twice a day. So fairly higher dose for granule.
The patient came back one week later and reported an improvement in sleep and bowel movement. The bowel movements were now happening one time a day. Sleep improved, but was not perfect.
Reflux happened less so less common, but still happens. And she said it was quite severe when it did, but less often. Thirst is more normal. Urine is more normal.
And headaches were happening still and quite severe, but happening fewer than the previous week. So she said, I've had, like, more like one or two this week, as.
[00:09:21] Speaker A: Opposed to three or four.
[00:09:23] Speaker B: Yeah.
[00:09:23] Speaker A: Okay, so let's take those pieces in part, then.
So firstly, she's coming to see you. Did she have, like, a traditional chief complaint of all those things?
[00:09:33] Speaker B: It was really more the headaches that she was coming in to see me for.
[00:09:36] Speaker A: Yeah. Which makes sense because those are really debilitating and particularly at that level of frequency.
And this patient was really busy, right? She was, yeah.
[00:09:45] Speaker B: She's a workaholic.
[00:09:46] Speaker A: Yeah. Working a lot. So that kind of, like, headache presentation just. It's the kind of thing that sends people who work a lot to us because it's actually negatively impacting their productivity.
[00:09:56] Speaker B: Right.
[00:09:57] Speaker A: So headaches was at the top of the list. But of course, you've got all these other pieces, so, yeah, you give her this formula, Chai hu jalongu mulitang unmodified.
And this is just in the first week.
We see an improvement in sleep.
[00:10:10] Speaker B: Yep.
[00:10:10] Speaker A: We see the bowel movement now every day.
[00:10:13] Speaker B: Yeah, quite a big improvement.
[00:10:15] Speaker A: So, you know, for the purpose of this discussion, we're, you know, thinking about the. The constipation piece of it. But of course, there's all these other pieces that are pretty marked improvement in just a single day relative to the constipation. Well, I guess maybe zoom out a little bit in General, like, what do you think was going on that called for chaihu jia longu mulitang? From a.
[00:10:36] Speaker B: A pattern point of view, Chaihu jalongo mulitang is a great formula for if there's a lot of things happening at the same time. So it's a. We call it a triple Yang formula because it treats all three yang confirmations plus a little more, in my opinion.
[00:10:52] Speaker A: Yeah.
[00:10:53] Speaker B: You know, it's kind of like, well, we're anchoring with longumuli. We have guager and dadzao in there, so there's like this anchoring yang, bringing it back into the blood out of a floating position.
We also have chai hu jalonggu. Mulitang is great for dry constipation because it has 12 grams of Dahuang in it and usually 9 grams of Daijish.
I think traditionally it's a different herb that's like, toxic or whatever, qiandan, which we don't use anymore, but good for helping with, let's say, blockages in the stomach. So it's also good for gerd. You can use it for acid reflux successfully.
And I understand that from that lens that it helps Yang Ming to descend from those two herbs. Those are both bitter herbs.
And then you have the combination of guager and fuling in the formula, which is kind of interesting.
And in the classical presentation, there's difficult urination is one of the symptoms mentioned. And the way that I understand that is there's so much happening that the yang is beginning to float there. I mean, Yang Ming can't descend.
Xiaoyang is all messed up. So there's constrained heat in the picture. And then there's just not. There's so much that's happening to put heat or put Yang up that there's not enough Yang in the lower burner to filter urination correctly. So then there's difficult urination, which this patient didn't report, by the way. She didn't report any of that, but she did say her thirst was relatively low. So maybe there's some fluid metabolism trouble there.
[00:12:43] Speaker A: Yeah. Also, I think urination is actually one of the hardest things to get a real objective read on because it's just so variable and it's so reliable. So reliant on people's experience. Right.
[00:12:56] Speaker B: 100%.
[00:12:57] Speaker A: They'll be like, yeah, I mean, there's nothing wrong with my. My urination. I have to pee every 40 minutes.
[00:13:01] Speaker B: Yeah.
[00:13:02] Speaker A: You know, that's how it's always been, you know, versus someone else who, like, pees Three times a day.
[00:13:06] Speaker B: Yeah.
[00:13:06] Speaker A: And they're like, exactly. No, that's fine.
[00:13:08] Speaker B: Yeah.
[00:13:08] Speaker A: It's really tough to get a read on that. But the thirst thing, you know, she noted that it was low.
[00:13:13] Speaker B: Yeah.
[00:13:13] Speaker A: Yeah.
So, I mean, this is a really interesting. I think, touching back on the pathomechanism discussion we had in the last episode. But, you know, this idea that Xiaoyang is incapable of pivoting.
[00:13:29] Speaker B: Right.
[00:13:30] Speaker A: Of sort of like doing the back and forth movement that it's supposed to do. And then that combined with Yang Ming's inability to descend, and of course, like, you know, chicken and egg here. Right. Like, does Yangming unable to descend and therefore backs up the pivot, and therefore Xiaoyang can't move. Like, who knows? I don't know. It doesn't really matter.
[00:13:49] Speaker B: Right.
[00:13:49] Speaker A: Although, interestingly, if she really reported herself as being constipated her whole life, there's also probably a constitutional piece here.
[00:13:58] Speaker B: Oh, yeah.
[00:13:59] Speaker A: You know, inherited from family around that kind of constraint, inability to descend, et cetera. So here comes along Chaiyu, jalango mulitang, which of course has the chaihu pieces in it to help Xiaoyang in its movement. It's got the downward moving bitter herbs like da huang to move Yang Ming along, and then, you know, the longu and the muli. What's the dosage on the langu and muli in that formula?
[00:14:24] Speaker B: 30 and 30.
[00:14:25] Speaker A: 30 and 30. So it's pretty hefty in terms of like a proportion of the formula. And that's of course gonna have the natural anchoring functions of minerals, but also you're gonna have like a salty sweet.
[00:14:37] Speaker B: Yeah.
[00:14:38] Speaker A: Combo. Flavor wise. What do you think? That flavor piece, how does that impact the constipation presentation? Or does it.
[00:14:45] Speaker B: Yeah, I think. I don't think it influences it that much, actually. For the. Specifically the constipation, there is a line that says in the modifications for Xiao Cai hutong, if there's rib side pain, take out dazao and add muli.
So there's this sort of gesture toward using muli if there's more pain in the sides, which I think is just a sign that the fluids are more congested. Right. And the muhli, the salty muhli, is going to help go in and soften the congestion of those fluids, which have hardened, and then make them go back into circulation so that they can move. And when I did the abdominal palpation, it was pretty painful for her when.
[00:15:29] Speaker A: I checked the rib side all over, too.
[00:15:32] Speaker B: All over?
[00:15:32] Speaker A: Yeah. And then especially at the rib side.
[00:15:34] Speaker B: Yeah.
[00:15:34] Speaker A: Okay. Okay, cool. So after a week, just a single week, nice improvement.
[00:15:40] Speaker B: Yeah.
[00:15:40] Speaker A: So what then?
[00:15:42] Speaker B: Yeah, I basically refilled.
Yeah, I did the same formula.
The pulse and the abdomen were the same, by the way.
[00:15:51] Speaker A: Still super tender, still.
[00:15:52] Speaker B: Yeah, yeah. There's not much change in the pulse of the abdomen.
So for me, the objective findings dictate largely when it's time to change or not.
[00:16:02] Speaker A: If the.
[00:16:03] Speaker B: If they're the same and we're getting good results, like the symptoms are changing, then I'm just going to keep the formula the same. I'm not going to change anything about it. It's when those things shift that I know there's some fundamental change in the constitution that would mandate a different picture for the formula.
[00:16:21] Speaker A: Yeah. Because otherwise, I mean, the thing hasn't been resolved yet.
[00:16:25] Speaker B: Right, right, exactly.
[00:16:26] Speaker A: I mean, it's like you could say, oh, well, she's pooping every day. I guess it's good to go.
[00:16:29] Speaker B: Right.
[00:16:30] Speaker A: But if you pulled that formula, it would be 10 seconds before she's back to the old pattern.
[00:16:34] Speaker B: Right. Which we're going to actually see here in a second.
[00:16:37] Speaker A: Ah, tell us.
[00:16:38] Speaker B: Yeah. So three weeks later, I re. So I refilled the formula for two weeks.
[00:16:43] Speaker A: Okay.
[00:16:43] Speaker B: She put a formula or an appointment on the schedule for two weeks. We're checking in another two weeks, and then she had to cancel and move the appointment back a week and went off of the formula for a week.
[00:16:56] Speaker A: Got it. So she didn't refill in the.
[00:16:57] Speaker B: She didn't refill in the interim. Which is another problem. Right. With people who are too busy.
[00:17:03] Speaker A: Yeah.
[00:17:03] Speaker B: I should mention, too, that the first time this person came in, we had a long talk about working too much and being too busy and how, like I very gently pointed out how that is of influence with all of the symptoms. I try to explain the pattern as best as I can in layman's terms and then explain how lifestyle and things like that will influence the picture. And I did talk to her about that. So there was an understanding. This patient, by the way, was also working with, like a qigong person, one on one, which I thought was kind of cool.
[00:17:40] Speaker A: Yeah. And not that common.
[00:17:41] Speaker B: Not that common.
Who actually referred the patient to me because he had come to see me before as well. So. Yeah. So that. I think that is also helpful in this case.
[00:17:53] Speaker A: Yeah, for sure.
[00:17:54] Speaker B: Yeah.
Okay. So she went off the herbs for one week, and the main thing that changed, actually, is the headaches got worse again.
They got more frequent and worse. For the week that she was off the Bowels actually stayed pretty good.
They slowed down a little bit. She's, I think the, the time that she came back in, she was like, yeah, you know, I didn't have a bowel movement yesterday, but. But still, like, definitely not as bad as before.
[00:18:22] Speaker A: Well, and again, that tracks because her primary focus is on the headache. That's why she's seeing you.
[00:18:27] Speaker B: Exactly.
[00:18:28] Speaker A: And she's been constipated, quote, her whole life. So, like, going, just skipping one day is like, that's normal, Right, Sure.
[00:18:35] Speaker B: So I had her basically go back on the formula and then have her come back in in two weeks. I also did acupuncture with this patient. The acupuncture was mostly targeted toward the neck, treating the neck and opening the neck up, which was also very helpful for neck pain. So we did acupuncture, which probably also.
[00:18:54] Speaker A: Could help with the headache.
[00:18:55] Speaker B: Yes, for sure, for sure.
[00:18:57] Speaker A: And interestingly, because, of course, everything's connected and you know, this is the kind of stuff that I like that's sort of like speculative medicine because there's really no way in Chinese medicine to track this directly. But there's so much constraint overall in the person's body. Right. I mean, you have this bowel constraint, but then like the whole neck is crunched up and smashed on itself, basically swollen and inflamed. You've got this occipital neuralgia presentation. Right. So, and then the headaches and then, you know, it's just, it's hard not to see how all of it is deeply connected.
[00:19:34] Speaker B: Yeah, right.
[00:19:35] Speaker A: I mean, for us anyway, like, the biomeds are like, oh, no, that has nothing to do with your bowels. But like, for us, it's like, okay, clearly there's a tightness here that isn't open. Right. There isn't the kind of downward descending that needs to naturally happen.
[00:19:49] Speaker B: Right.
[00:19:50] Speaker A: And so again, the patient's thinking headaches. But that constipation is a key piece here. In fact, it's interesting to wonder too. Like, you know, fortunately, Chayu Jalango Mulitang, as you said, is a really nice kind of kitchen sink formula. Right. It sort of deals with all these aspects, which is, you know, not coincidental. It was designed to be that way. But it's also interesting to think, like, if. If the constipation weren't resolving, would we really expect that the headaches would get better, or would we expect that the sleep would be better if the whole downward moving elimination, natural descent function of the body was stopped up?
[00:20:28] Speaker B: Yeah, it's a really good Point. I wouldn't. I wouldn't expect that it would be better. No.
[00:20:33] Speaker A: I mean, in virtually every case where we deal with constipation as a. As a factor of a more complex disease, there's more than one thing blocked up.
[00:20:41] Speaker B: Absolutely.
[00:20:42] Speaker A: Right. That's sort of always the case. There's. There's more than one thing blocked up. And until we can get the thing's unblocked. Right.
It's going to be really hard to deal with. Even what. In this case, the chief complaint of headache. Like the bowels have got to move if we're going to descend.
[00:20:56] Speaker B: Right.
[00:20:57] Speaker A: Yeah. Yep. Okay. So she goes back on the formula.
[00:21:00] Speaker B: Yeah. So two weeks later, she's back on the formula.
Bowel movements now are happening daily.
There's no reflux.
She actually went off of her ppi.
I didn't tell her to do that. She just did that. She's like, I don't feel like I need it.
[00:21:17] Speaker A: Definitely not mad about that.
[00:21:19] Speaker B: Right.
Sleep was better overall.
And she said she was in the process of reducing her trazodone dosage, which her qigong person mentioned she should do.
[00:21:32] Speaker A: Oh, man.
I mean, again, also not mad about it, but messages to all the herbalists out there. Be very cautious about providing advice on people's pharmaceuticals. As a general rule, we don't do it.
[00:21:46] Speaker B: Yep, yep, yep, yep.
[00:21:47] Speaker A: But, okay, so she's off the PPI and the trazodone is reduced. Reduced. Okay.
[00:21:52] Speaker B: Yeah.
The headaches for, let's see, the first week were quite a bit better. She actually only had one headache, and it wasn't that bad.
[00:22:04] Speaker A: Nice.
[00:22:06] Speaker B: The week that she had come to see me, she had had two. And the last one was pretty intense, but I think overall trending better, especially if it was three or four when she first came in.
[00:22:19] Speaker A: Well, and also notable that three weeks of dosage, she's feeling much better. One week off, there's backsliding. But then just with one additional week of dosage, she's basically right back where she was after three weeks previous.
So it's not like that small amount of backslide completely set her back to the beginning. No, that's one week. And. Okay, back where we were.
[00:22:41] Speaker B: Yep, yep. She also said her neck was doing better. And she said to me, like, my neck has been 90% out of pain.
[00:22:50] Speaker A: Wow.
[00:22:51] Speaker B: Which was pretty big.
[00:22:52] Speaker A: Yeah.
[00:22:53] Speaker B: Now, again, she's working with this qigong guy, acupuncture. So it's not just the herbs in this case. Sure. But still, I mean, there's structural damage to the cervical spine which was confirmed, you know, before she came in. So that's pretty awesome that that's doing better.
And then, let's see here.
Yeah, this is the other difference. So the headaches which were occurring before during a period of acute stress, so when she would overwork, basically it would be a trigger for. The headaches now are not happening when she's working. They're happening actually on the weekend.
[00:23:36] Speaker A: Ah, the end week rebound headache.
[00:23:38] Speaker B: End week rebound headache. So, like, she called it a letdown headache. She used that phrase.
[00:23:43] Speaker A: Interesting.
[00:23:44] Speaker B: That was really interesting.
So I checked her pulses out and this time they were quite different.
They did not feel nearly as excess. They actually felt a little bit on the weaker side, a little bit more moderate.
Um, and then I checked the abdomen. And the abdomen was also really different. It didn't feel as excess overall. Um, the rib side was no longer tender and I didn't even feel any epigastric resistance.
So quite, quite a big difference.
[00:24:19] Speaker A: Yeah.
[00:24:20] Speaker B: What was still there?
I noticed there was the pulsations.
The pulsations around the umbilicus were still there. That was the most prominent thing that was left. And there was.
I didn't. I don't know if I mentioned this before, but there was still an oketsu finding, which is the blood stasis finding below, which I chose not to treat, by the way.
So the formula that I moved her to in this case is called guer jounitang, which is the short version of the formula. This is one of those with like the, like a paragraph long name.
[00:24:55] Speaker A: Oh, sure, yeah. That's also just a list of herbs in it. Yeah, yeah, yeah, yeah, of course.
[00:25:00] Speaker B: So the, the, the list in this formula is it's just Guizhu tong. Right. Just standard Guizhu tong without Bai shao, with longu and muli, and with a. Another herb that we no longer use. So we just use fuca. So it's guiji fucitang. No, Bai Xiao, with longu and mu.
[00:25:20] Speaker A: Got it. Okay. And its full grandiose name.
Do you have that?
[00:25:25] Speaker B: Guijer. Let's see if I can remember. Guijer Chu Xiaoyao Jia Longgu Muli Xiu Qi jiao nitang.
[00:25:33] Speaker A: Right. Which really is just a description of exactly what you just said. Yeah, we took something out, we put some other stuff in. God.
You know, it's funny because I simultaneously love and hate when we get, you know, like, take like Xiao Ya San and like Free and Easy Wanderer powder. Like, okay. But at least it's like a little capturing of a formula. It has. It has a nod to its function. But honestly, so many of the formulas, especially. I mean, I guess in this case, Zhang Zhongjing's formulas are just mostly the names of the herbs in the formula.
[00:26:07] Speaker B: Yeah, yeah, yeah.
[00:26:08] Speaker A: Zhangjiangjing. Clinical genius. Not a poet.
Not a poet.
[00:26:12] Speaker B: Distinctly not a poet.
[00:26:13] Speaker A: Yeah.
[00:26:14] Speaker B: Yeah.
[00:26:14] Speaker A: Okay, so you switch over to this formula.
[00:26:17] Speaker B: Yep.
[00:26:18] Speaker A: And the. And the indicators for the switch were.
[00:26:21] Speaker B: Yeah. Basically, the pulses totally changed.
[00:26:23] Speaker A: Right.
[00:26:24] Speaker B: It went from being very excess to feeling kind of weak.
[00:26:27] Speaker A: Yeah.
[00:26:28] Speaker B: And then the main feature in the abdomen that was still remaining, so costal stuff went away, epigastric stuff went away, but the thing that was remaining is the pulsations of the abdominal aorta, particularly around the umbilicus and. And a little bit underneath.
[00:26:46] Speaker A: So those.
[00:26:46] Speaker B: Those are the features.
So that means to me that you need to switch to a more interior formula. But there's still upsurgent Yang, and I'm interpreting that at this point as being a weak Yang. So we need to strengthen Yang, put it back into the blood so that it's not floating, because weak yang has a tendency to float.
[00:27:10] Speaker A: And that. And that floating Yang, of course, also indicative of things in the body not moving in the direction that they ought to move.
[00:27:17] Speaker B: Yeah.
[00:27:18] Speaker A: Right. So, I mean, yes, Yang moves upward, but in this case, it's moving too far upward. Like, it's not actually anchored in the core places. It needs to be anchored. So it's floating.
[00:27:27] Speaker B: Right.
[00:27:27] Speaker A: And that also means it's probably, in addition to making the headaches happen, it's also contributing to the underlying lack of downward force in the bowels.
[00:27:37] Speaker B: Right.
[00:27:37] Speaker A: Yeah. So, of course, right now, the bowels are pretty good.
[00:27:40] Speaker B: The bowels are good. Yeah. They've been good for a few weeks, actually.
[00:27:44] Speaker A: Yeah. So the. The question then is, like, you know, thinking about this through the lens of constipation, like, if you were to just stopped the chaihuja longamuletang.
[00:27:54] Speaker B: Yeah.
[00:27:54] Speaker A: And, like, let's imagine that the patient didn't have headaches, but, you know, just the constipation was the core issue. You just sort of stop that formula, maybe it would have stuck.
But also, there was probably a more deeper lack of anchoring and nourishment part.
[00:28:10] Speaker B: Right.
[00:28:10] Speaker A: And so that constipation could have snuck back.
[00:28:13] Speaker B: Sure. And. And also, the headaches are not gone.
[00:28:16] Speaker A: Yet, which is the thing that is bothering her.
[00:28:18] Speaker B: Right.
[00:28:18] Speaker A: That's, like, her primary complaint. Yeah. Okay, so you switch over to that formula.
[00:28:23] Speaker B: Yeah.
[00:28:24] Speaker A: How's it go?
[00:28:25] Speaker B: It goes very well. Um, I have her on that Formula for basically three weeks.
And then I talk to her. And the headaches have continued to reduce in frequency. So between the time that I saw her and then the next appointment, she has one headache the whole time in.
[00:28:45] Speaker A: A three week period.
[00:28:46] Speaker B: Three week period.
[00:28:47] Speaker A: Wow, that's amazing.
[00:28:48] Speaker B: Yeah, that's. That's pretty great.
[00:28:50] Speaker A: And I'm assuming that the intensity of the headache was also less.
[00:28:53] Speaker B: Yes. Yeah, yeah, it was way less.
Yep. And the bowels stayed normal.
[00:28:59] Speaker A: Perfect.
[00:29:00] Speaker B: So that was also pretty cool.
[00:29:01] Speaker A: So daily bowels.
[00:29:02] Speaker B: Daily bowels totally fine, easy to pass.
The sleep, she said was still good.
She was still taking a little bit of the trazodone, but still solid. Basically everything that improved continued to improve or stayed.
And the main thing that changed was the frequency intensity of the headaches, which also really improved on that.
[00:29:25] Speaker A: Nice. So the pivot in the formula was, you know, conceptually from switching from this harmonizing multi warp formula. Right. That's looking at Xiaoyang Yang Ming trying to figure out like, okay, how do we descend properly, how do we pivot properly?
Strong indicators for that, of course, were the excess pulse, the abdominal findings, and then the actual constellation of symptoms.
[00:29:51] Speaker B: Yeah.
[00:29:52] Speaker A: So she takes that it works well because, oh, lo and behold, we harmonize a pivot problem.
We re encourage Yang Ming's descent.
But of course, the headaches are still here because the Yang is still floating up out of the blood more than it ought to. Now they're better.
[00:30:08] Speaker B: Right.
[00:30:08] Speaker A: Probably because the descent function has already been restored.
[00:30:11] Speaker B: Right.
[00:30:12] Speaker A: But the Yang has been so aberrant in its movement that it's still.
[00:30:17] Speaker B: Yep.
[00:30:17] Speaker A: Sort of playing outside the sandbox. Y so the other formula that you chose helps to pull that Yang back into the blood.
How does it do that?
[00:30:27] Speaker B: It strengthens. It strengthens the Yang first. So, so the idea is, you know, Chinese medicine, Yang comes from heaven, Yin comes from earth. Right. For us to stay alive, Yang has to descend. Yin has to ascend.
[00:30:43] Speaker A: Right.
[00:30:43] Speaker B: When Yin or Yang start to get weak, they start to run back home. That's how I think of it.
[00:30:49] Speaker A: Yeah.
[00:30:50] Speaker B: So when.
When it's a nice hot day in the summertime, it's easy to jump into the cold water. Right. But if it's in the winter time, it's real hard to jump into the cold water. You want to get as far away from that water as you can. You might run away from it, you know, if you're scared enough or if you're a kid. Right. So that, that represents the Yang running out if it's not warm enough or if it's not strong enough.
[00:31:14] Speaker A: Right.
[00:31:15] Speaker B: So the key combination in any of the Guizhu formulas for tonification of yang in the nijing is acrid, warm, and actually it just says acrid and sweet transform into yang. Right. So guizhi and gansao are the key combination for that, that zhan zhongjing uses.
And then the rest of the formula is layering onto that. So acrid also, you have xianzheng, you also have sweet dazao. So both of those are warming yang, transforming into yang and benefiting the blood.
[00:31:54] Speaker A: Right.
[00:31:55] Speaker B: You take out Bai Xiao because you don't want in guizhu jiany tongue. The yang has been. If you read the shanghan lun, it's like, oh, there was a fire needle, and the yang got hijacked. It basically describes somebody having a PTSD response from being burned with a fire needle.
[00:32:14] Speaker A: Yeah.
[00:32:15] Speaker B: And lots of anxiety, sweating, unrest, disquiet.
You could even see mania, you know, in this type of pattern.
So, but what happened is the yang got pushed out, and now it's weak, and so it's moving in that direction.
So the basic combination of guizhi, gan sau, of sheng zheng, dazao is going to strengthen Yang, and then the longu and muli are going to anchor more, and the futzi is going to warm the yang even more.
[00:32:50] Speaker A: Right.
[00:32:51] Speaker B: So you're benefiting yang, you're putting it into the blood, and then you're kind of encouraging it to descend.
[00:32:58] Speaker A: I think this is a really good opportunity to look at an important clinical feature, because I think a lot of people would imagine that the primary thing that's making the Yang descend is the anchoring effect of the longo muli.
[00:33:14] Speaker B: Yeah.
[00:33:15] Speaker A: And I think, of course, that's playing a part because it's sort of setting the stage of which direction we ought to go.
But the reason that yang descends is because we're making it healthy again.
[00:33:27] Speaker B: Exactly.
[00:33:27] Speaker A: And I think this. It. It's counterintuitive at its first phase. Right. Because you think, like, oh, if yang is really robust, it's gonna flare upward like fire does. Right, Right. And I mean, sure, like a strong yang is warm and fiery and active and all those kinds of things. It's what the fuca is doing in a fuel kind of way. Right. Like, oh, yeah, we need to make sure that there's at least enough stuff here for Yang to. To burn with.
But actually, in a living human, or really, I guess, any living creature, the Yang function descends from heaven to combine with yin, which is rising up from earth.
[00:34:04] Speaker B: Yeah.
[00:34:05] Speaker A: And it's that, it's that Tai Chi symbol.
[00:34:07] Speaker B: Yes.
[00:34:07] Speaker A: Right. That is life.
So by making the Yang healthy, Yang will function like an auto function, which is frankly descending when it needs to descend.
[00:34:17] Speaker B: Yeah.
[00:34:17] Speaker A: And ascending when it needs to ascend and not being like aberrant in one direction or another.
[00:34:22] Speaker B: Right.
[00:34:22] Speaker A: So I think that's again, there's so much emphasis on minerals anchor. And that this formula is like anchoring the Yang.
[00:34:30] Speaker B: Yeah.
[00:34:30] Speaker A: And it is insofar as like, oh, by the way, we should go this way.
[00:34:34] Speaker B: Yeah.
[00:34:35] Speaker A: This way is down.
But Yang's not coming with you no matter how much mineral you put in a formula if it's not healthy.
[00:34:44] Speaker B: Yeah.
[00:34:44] Speaker A: And in fact, you'll put so much mineral in the formula that the patient will feel like they're consciousness has been dragged down. Like if you just keep, you're like, I'm going to make it 100, 100 long movie people. Be like, oh my God, I just don't feel great. Right. Like there's a, there's a, there's an anchoring that's happening, but not in a way that's restorative.
[00:35:03] Speaker B: Yeah.
[00:35:03] Speaker A: So true. I think that's a really good item to, to highlight for folks.
Okay. So in this case, the patient really with, with two formulas.
[00:35:13] Speaker B: Yeah.
[00:35:13] Speaker A: We deal with a complex constellation of problems where for the purpose of this discussion, constipation is really well adjusted by the first formula and then sort of held in place with the second formula. And the patient's chief complaint, which was actually headaches, is also of course resolved because it's important to remember that even though we can see that stuff like constipation and descent are key elements to healing, if you don't treat the patient's chief complaint, they won't keep coming to see you. Absolutely right. I mean, you always have to keep that in the fore of your mind. Even if you know that this is really a digestive problem or whatever problem, you gotta always keep that in mind.
So let's, let's take a look at a different patient that you found for us that has a slightly different sort of combination of underlying factors contributing to their constipation.
[00:36:32] Speaker B: Yep.
So this is another case that has multiple things, multiple spokes, you could say 68 year old male with constipation, peripheral neuropathy, low back pain and is a type 2 diabetic.
[00:36:50] Speaker A: Okay.
[00:36:51] Speaker B: @ this time in the patient's treatment cycle, he's having bowel movements every third day.
They're hard, he reports them as hard. But when I question into it. He says they're a little sticky.
Okay.
[00:37:11] Speaker A: Okay.
[00:37:12] Speaker B: So his hands and feet are very cold.
He has some trouble staying asleep after he falls. And he's having vivid dreams. Occasional night sweatshirt urination is difficult to pass.
Feels like he has to strain to complete the urination cycle.
And he's a little unsteady on his feet, especially when he gets fatigued. Feels kind of lightheaded. Tendency toward lightheadedness.
When I checked the pulses, the pulses were slow.
Meaning?
Well, slow.
[00:37:45] Speaker A: Yeah. Like the actual rate was slow.
[00:37:47] Speaker B: Yeah, yeah.
And weak, like not much force.
And then in certain positions, very deep, some not very deep.
The abdomen, when I checked, the abdomen was fairly tight, like the rectus abdominis muscles, fairly tight on both sides.
There is a water splash sound that I found with elicitation.
There's this sort of. The skin is a little bit cooler around the umbilicus and kind of a circle around the umbilicus.
And then when I press into the epigastric area, there's no obvious hardness on my side. But when I press in, the patient says, I feel something go up into my chest. Feel like a radiating uncomfortable sensation that goes up into my chest.
[00:38:42] Speaker A: Okay.
[00:38:44] Speaker B: So I ended up writing.
[00:38:47] Speaker A: So, yeah, all of those things. I mean, compared to the last patient in particular. But just like thinking about the signs that you've described, I mean, the first thing that's coming to mind is cold wet deficient.
[00:38:59] Speaker B: Yes. Yeah, 100%.
[00:39:01] Speaker A: Which is much different than the excess pulsation that we got both on the abdomen. The roundness, the largeness of the abdomen, the robust over the top pulse.
So of course, immediately then the primary indicators are very different in terms of what the cause of this constipation is.
[00:39:22] Speaker B: Right.
[00:39:22] Speaker A: Okay, so now the formula.
[00:39:24] Speaker B: Formula is Zhen Wu Tong plus Zhi Shi Xie by Guizhitang.
[00:39:29] Speaker A: Okay.
[00:39:32] Speaker B: So do you want me to talk about what's in that?
[00:39:36] Speaker A: Yeah, like let's. Let's break apart Zhen Wu Tong. Well, take it in parts. So why the Jian Wutang as a starting piece?
[00:39:44] Speaker B: So I'm looking at the case as a core Yang deficiency. Water. Cold water picture.
[00:39:49] Speaker A: Okay. For which Zhen Wutang is kind of the.
[00:39:51] Speaker B: Which Zhen Wu Tong is kind of our standard formula.
Zhen Wutong, interestingly, also has Baixou in it.
So it's good for treating tight musculature. So if the rectus abdominis is tight, for example, Zhen Wu Tong can be used to treat that. Yeah, because there's Bai Shao in the formula, that picture where you press into the epigastrium or the epigastric area and it radiates up to the chest doesn't actually have to be the epigastric area. It can be a little bit over, across the rib side and stuff. That is fairly typical for two presentations in Fukushin.
One of them is chest obstruction disease, and then the other one is for basically a ginseng type pattern, certain formulas with ginseng in them, which could also be related to chest obstruction. There's a line in the Jingwei, I believe, that talks about how da, da, da, da, da. Chest obstruction disease by Guizhitong governs. Ren Shentong also governs.
So there's this equivalency line that's drawn in there that's like, wait a minute. So there's a formula that's treated for basically an excess presentation in the chest, and then there's also an equivalency drawn between a deficiency formula for treating the same set of symptoms.
So there's this pointing to like, hey, don't forget they could be deficient. They could be deficient. They may not be excess.
[00:41:29] Speaker A: Right, right, right. Even though on its face, something like a chest obstruction feels excess.
[00:41:34] Speaker B: Feels excess.
[00:41:34] Speaker A: Yeah, yeah. Okay, so the. The Gen Wutong side is dealing with the. The cold water presentation.
[00:41:40] Speaker B: Yep.
[00:41:40] Speaker A: Which is pretty evident both in the. The abdominal findings, the pulse findings, and the sort of like general constitution of this patient.
[00:41:50] Speaker B: Yeah.
[00:41:50] Speaker A: Okay. And then the. The other formula.
[00:41:54] Speaker B: Yeah. Jershuxia by Guizhetong.
[00:41:57] Speaker A: What is the indicator there?
[00:41:58] Speaker B: Jershuxia by Gui Zhitong is.
Well, so it falls into the category. Let's say we were talking last time theoretically, about a mixed constipation pattern because it has both bitter cold jishi in the formula and it has.
Which is bitter warm.
[00:42:16] Speaker A: Okay.
[00:42:16] Speaker B: We also have, in Zhen Wu Tong, we have Baishao and we have Baijiu.
So we have kind of all of these archetypical herbs that are going to treat cold dry constipation, or they're going to treat dry constipation and wet constipation.
And a lot of the time in these more chronic cases, they get mixed. Right. We talked about mixed patterns. So this is one version of a mixed chronic pattern where essentially the core constitutional issue is a tiring out of the yang and the presence of cold water which is then being improperly filtered in through the intestines, which then creates difficulty with movement of the stool.
[00:43:03] Speaker A: Yeah.
[00:43:05] Speaker B: So a simpler way to treat this presentation would have been to just add Jershi into Zhen Wu Tong, which I chose not to do because the presence of the other findings led me to use the formula Jersishie by Gui Zhitang.
And if I had asked some other questions that link me to that formula directly, they would be like, when you have a bowel movement, does the bowel movement feel complete or incomplete? Oh, it's always incomplete. That tends to make me think. J Shisha Bai Gui Zhi Tang.
[00:43:38] Speaker A: Yeah.
[00:43:39] Speaker B: Do you have any tension or pain in your chest?
Yeah, sometimes I feel a little tension there.
[00:43:44] Speaker A: Okay.
[00:43:45] Speaker B: That's another finding for chest obstruction. So those are things that you could ask to point you more to that picture. But I got there mostly because of the abdomen, in this case and the.
[00:43:54] Speaker A: Pressure causing the discomfort in the chest. Yes, yeah, yeah. Cause I think listeners might initially be like, wait, I don't understand how a chest obstruction formula articulates with constipation.
[00:44:07] Speaker B: Chest obstruction is often coinciding with a bowel problem. And what's interesting is the chest obstruction formulas, if you look at them, they treat both.
So you can have basically, no, let's say subjective complaint in the chest.
I'll see this all the time. I'll find something in the objective findings that makes me think, need to treat chest obstruction.
And then I'll ask the patient, do you have any tension in your chest? Do you have any pain? No, nothing. I still give them the formula and it still works.
[00:44:40] Speaker A: Yeah, well, because you had it in the objective findings. Yes, yeah, exactly. This is why having reliable objective findings is really useful, because having only the patient's report might mean you leave stuff off. Yeah, 100%. That could be useful, I think, too, here. I mean, we've talked about this in various contexts on the show before, but here we again have the sort of clinical representation of the teapot lid metaphor, right? Where if there's constraint up at the top, like if there isn't the natural, you know, vacuum release of a hole in the teapot lid, right, You've got to pop the teapot open, you've got to crack the lid, otherwise it can't pour, it can't descend. So if there's chest obstruction up at the top, in the upper burner, right, in the realm of the lungs, in the realm of the bellows of chi, in the thing that's moving things through the body, you got to open it, otherwise you're not going to be able to descend.
[00:45:33] Speaker B: Right.
[00:45:34] Speaker A: So in this case, you combine both of those actions together at Once.
So we're going to warm the cold water with Jen Wu Tong and then we're going to sort of resolve the obstruction at the top and then that's going to allow things to move.
[00:45:49] Speaker B: Yes.
[00:45:49] Speaker A: Okay. So did it work?
[00:45:52] Speaker B: Yes.
[00:45:53] Speaker A: Nice.
[00:45:54] Speaker B: Two weeks later, the bowel movements are better.
Patient reported said they're coming daily instead of every third day, which is great, but they still feel a little incomplete.
Okay. Consistency is more even. So it's not hard and sticky. It's a little more uniform at this point.
[00:46:16] Speaker A: And daily.
[00:46:17] Speaker B: And daily.
[00:46:18] Speaker A: Okay. Which is a big piece when we're talking about constipation.
[00:46:21] Speaker B: Absolutely.
Urination is better. It's easier to flow.
[00:46:26] Speaker A: Good.
[00:46:27] Speaker B: And sleep is also better.
[00:46:29] Speaker A: That's after just one week.
[00:46:30] Speaker B: This is. This is after two weeks, actually.
[00:46:32] Speaker A: Two weeks?
[00:46:33] Speaker B: Yeah.
[00:46:33] Speaker A: Okay.
[00:46:34] Speaker B: Two weeks. Still some difficulty staying asleep, but.
But overall the quality of the sleep is better.
And I don't think I wrote it down this time. But the vivid dreams were also better.
[00:46:49] Speaker A: Yeah.
[00:46:50] Speaker B: Yeah.
[00:46:50] Speaker A: Okay.
So refill.
[00:46:53] Speaker B: Refill. Just refill.
Next appointment was two weeks later and then checked in with the bowel movements. Bowel movements are daily. This time there's no straining and they feel complete.
Urination is still easier and sleep is much better. There's no night sweating or vivid dreams.
So basically the main things in the case were better.
[00:47:22] Speaker A: Yeah.
[00:47:22] Speaker B: Yeah.
[00:47:23] Speaker A: So you didn't have to pivot from that formula to resolve it.
[00:47:26] Speaker B: Nope.
[00:47:27] Speaker A: That's fantastic. It's also a good indicator, too, of picking the right combo of formulas. As I said at the top, there isn't usually one formula that's going to deal with a 14 layered problem. But if you've got a three layered problem, you might be able to.
[00:47:39] Speaker B: Yeah, three layer is easier to do. And again, like, with this, I should have mentioned before, pulse and the abdomen were not that different. So again, the symptoms improved. Right. In the previous. In the previous appointment, but the pulse and the abdomen were pretty much the same. So to me, what that says is we need more time.
[00:48:00] Speaker A: Yeah.
[00:48:00] Speaker B: Need more time in the same approach.
[00:48:02] Speaker A: Yeah.
[00:48:02] Speaker B: So then, you know, we give them more time.
[00:48:05] Speaker A: Right. And then check in again and then check in again and eventually you'll have that pulse and abdomen presentation change.
And so now we know. Okay, we resolved like this formula has done what I was trying to do.
[00:48:16] Speaker B: Right.
[00:48:17] Speaker A: This is why, you know, we talk a lot about abdomen on the show and we've talked about it in various contexts and TC does a lot of sort of continuing education training on the subject with our residents and soon to have some Classes available online.
But, you know, this is in his system. Right. This is. This is evolved and pulled from a variety of different folks. So, like, if you're interested in abdomens, you can, you can find abdomens. Yeah.
But he's done a really good job of clearly linking the abdominal findings with these various herbs. And so then, like, you know, the core question we get from people all the time is like, well, how do I know when to change a formula?
[00:48:55] Speaker B: Yeah.
[00:48:55] Speaker A: Or how do I know when it's done? Yep. And the thing is, is that it's hard to know if you don't have an objective measure.
[00:49:02] Speaker B: Yeah.
[00:49:02] Speaker A: Because then you're like, well, I don't know. And a lot of the classic measures. So, like, I use tongues a lot, but tongues don't change quickly. Right, right. Like, pulses change very quickly, tongues change very slowly. Abdomens are kind of in the middle.
[00:49:14] Speaker B: Yep.
[00:49:15] Speaker A: And so an abdomen is a really useful tool if you don't have facility with pulse. Like, I don't really.
It's much easier and quicker to learn how to read an abdomen. And then you can use it in the way that a lot of pulse people use pulse because it's more reflective. And then tongues are very useful when deciding initial formulas and like, sort of constitutional norms and things like that. But you're not going to be able to tell how. Like, if you're done with the formula just by looking at someone's tongue, you know, you need something else. And so abdomen is the thing that we've landed on, because I think it's the most quick to pick up and widely applicable in clinical context for knowing is a formula done.
[00:49:55] Speaker B: I agree. Yeah. And it's good to. To know 2. To use two things, not just one.
[00:50:00] Speaker A: Yeah.
[00:50:00] Speaker B: Because two diagnostic features will give you a slightly different point of view.
And each diagnostic feature has its strengths and weaknesses. And there will be. Regardless of what case, what, what system you learn, there are going to be cases where you can't use the thing that you want to use.
Like, there are cases where the, like, you know, oh, crap, the art. The arteries deviated and I can't use the pulse findings.
[00:50:29] Speaker A: Right.
[00:50:29] Speaker B: I have a couple of patients with that, but I can still use the abdomen. So thank. You know, thankfully, I can still treat and get objective clarification.
If you have the tongue, maybe you do the tongue in the abdomen or you get really good at facial diagnosis and you do something else. Like whatever it is, do two things.
It's much better. You'll be much more solid in clinic.
[00:50:54] Speaker A: I like it. Okay, well, everybody, thanks for listening in on the case studies on constipation.
If you guys have any topics or things you'd like us to talk about, you can send us an email. We've got a new email address dedicated to the nervous herbalist. You can find [email protected] so that way we can kind of organize your material into one place. It'll make it easier for us to respond acutely.
So thenervousherbalistmail.com send us your topic ideas, your questions, your thoughts. We love to hear from folks. And please, of course, always rate and review and subscribe to this podcast wherever you listen to it. It makes it easier for other people to find us.
And we really appreciate you guys taking the time to hang out with us for a little bit. So I'm Travis Kern.
[00:51:44] Speaker B: And I'm Travis Cunningham.
[00:51:45] Speaker A: And we'll catch you next time.
[00:51:47] Speaker B: See you next time.
