Show Notes
TC and TK talk about the various ways that constipation presents in patients and the various formulas you can use to treat the condition
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Episode Transcript
[00:00:03] Speaker A: Hi, everyone, and welcome to the Nervous Herbalist, a podcast for Chinese medicine practitioners who like herbs and want to learn more about their function, their history, and treatment strategies to use in the clinic. Let's get into it.
Hello, everybody, and welcome back to another episode of the Nervous Herbalist. My name is Travis Kern, and I.
[00:00:25] Speaker B: Am here with Travis Cunningham.
[00:00:27] Speaker A: And we are going to talk to you a little bit about constipation, another favorite topic of folks out there in the world, and this one actually came to us from a listener. So, Trish, if you're listening to this, thanks a lot for your email. We really appreciated it, and we wanted to take some time to talk about constipation from all of the various angles that we can.
[00:00:51] Speaker B: Yes, indeed.
[00:00:53] Speaker A: It's kind of a complicated topic.
[00:00:55] Speaker B: It is, yeah. It's actually pretty complicated.
[00:00:57] Speaker A: Yeah.
When we were prepping for this episode, we sort of sat down, we've got a bunch of whiteboards, and we just sort of work through a bunch of logic propositions to make sure that we can organize the approach for you guys. And what we realized was that the differential gets pretty gnarly pretty quickly.
[00:01:14] Speaker C: Yes.
[00:01:16] Speaker A: But I think that we've been able to kind of simplify it and organize it in such a way that you guys will be able to. To take away some key elements.
And then, of course, like everything we talk about, you can keep going deeper.
[00:01:27] Speaker D: Right.
[00:01:28] Speaker A: I mean, there's really no end to any of these topics. But before we get into the specifics, I think it's important T. Why don't you talk a little bit about what constipation actually is? And some important definitions that we often see get confused both with patients and sometimes even with providers.
[00:01:47] Speaker B: Yeah.
So one of the first things we want to make sure we understand is that the patient's definition of constipation may not be our own or correct from a medical point of view. So a lot of people will say, for example, I feel constipated. But then when you ask them how frequently they're having bowel movements, they'll say, well, multiple times a day.
[00:02:11] Speaker A: Right.
[00:02:11] Speaker B: Which is not constipation. That isn't what the term constipation means medically.
So a medically defined constipation is a lack of frequency with the movement of the bowels.
[00:02:25] Speaker A: Yeah. So, like, you're skipping a bowel movement.
[00:02:27] Speaker B: You'Re skipping a day at least. Yeah. Or more.
And then the next thing we want to find out is when the bowel comes, is the bowel more wet or more dry?
That's really important to know because everything else hinges upon that basic set of information.
[00:02:49] Speaker A: Right. So the confusion that we often see is that when the patient says, I've been feeling constipated or I am constipated, but they're having multiple bowel movements a day, they're usually conflating the quality of the stool with constipation. So they're having a hard stool, they're saying, I'm constipated.
[00:03:07] Speaker C: Yeah.
[00:03:07] Speaker B: Or difficulty with it. Feeling complete is the other thing that people like, oh, you know, I had a.
I just doesn't feel like I can get it all out or I wanna go more, but I can't. Which is also not constipation. Technically it's still good information for us to know and we can help people with that, but it's not technically constipation.
[00:03:30] Speaker A: Right. And I mean, it's not like you need, you don't need to like educate or correct your patients necessarily in the treatment room and be like, actually that's not constipation.
But it's important for you to know because if you're just dealing, and not just, but if you're dealing with two or three bowel movements a day that are sluggish to start, take a while to move and are kind of hard and dry, for sure there's going to be some crossover in the types of formulas we're going to talk about today. But that's probably a different line of logic than the stuff we're talking about today. In this case, we're specifically mentioning that people are skipping at least one day of bowel movements. A lot of times though, when you, by the time you're treating someone for constipation, they're skipping multiple days.
[00:04:17] Speaker B: Yes.
[00:04:18] Speaker A: Yeah. I mean, we've seen people go four or five days.
[00:04:20] Speaker B: Yeah.
[00:04:21] Speaker A: Without a bowel movement.
[00:04:22] Speaker B: I saw a patient, I think the first year we were in practice who had a, had like one bowel movement every two weeks.
Yeah, yeah.
[00:04:31] Speaker A: Which is kind of remarkable because this is one of the earliest things that you learn. Right. About not asking people, so how are your bowel movements? Right. A just open ended question because people will just say, oh, they're fine or they're normal. And that's because this person has skipped five days of bowel movements for their whole life. Right.
[00:04:49] Speaker B: Yeah. Nobody talks about it in our culture, so nobody knows what normal actually is.
[00:04:55] Speaker D: Yeah.
[00:04:55] Speaker A: I literally had a patient earlier this year who for, you know, she's in her 80s and for all of her life she's had a bowel movement once every four or five days.
[00:05:04] Speaker B: Yeah.
[00:05:05] Speaker A: And she's been told by many practitioners that's too infrequent, you know, but she's in good health, relatively speaking. She's in her 80s. She's like, you know, honestly, I can't even imagine what it would be like to go to the bathroom every day to have a bowel movement every day. She's, like, shocked by it.
[00:05:20] Speaker C: Right.
[00:05:21] Speaker A: But we know that there's an imbalance there.
[00:05:23] Speaker D: Yeah.
[00:05:24] Speaker A: Okay. So the differentiator. Once we've clearly established that we're dealing with actual constipation, the next major question that we've got to address that you mentioned was, when the bowel movement comes, is it wet, is it dry, or is it some combination of the two?
[00:05:39] Speaker B: Correct.
[00:05:40] Speaker A: All right, so when we say it's wet, what are we talking about?
[00:05:43] Speaker B: Meaning that when it comes. So let's say we're skipping days, but when the bowel comes, it's sticky, wet, maybe even diarrhea. Some people will literally have diarrhea when it comes, but then they won't go every day. Like, it'll be every two or three days. And then it'll be, like, loose or it'll be wetter or something like that.
[00:06:06] Speaker A: Unformed.
[00:06:06] Speaker B: Unformed, yeah, exactly.
[00:06:08] Speaker A: Okay. And then on the dry symptoms, these are, I think, the ones that most people are familiar with.
[00:06:14] Speaker B: Right.
[00:06:14] Speaker A: So the stool is hard and dry.
[00:06:16] Speaker C: Yes.
[00:06:17] Speaker A: Pellet like, maybe.
[00:06:17] Speaker C: Pellet like. Yeah.
[00:06:18] Speaker A: It's not a consistently smooth and typically difficult to pass.
[00:06:23] Speaker B: Like, very hard.
[00:06:25] Speaker A: Yeah, yeah.
And then the mixed one, which maybe surprises some listeners to hear. So the mixed one is what?
[00:06:32] Speaker B: The mixed one is typically a hard plug.
So the same bowel movement, Hard plug. And then the next part of the movement, which is again, in the same movement, is softer, wetter, possibly even loose.
[00:06:47] Speaker A: Right.
[00:06:48] Speaker B: So in the very same movement, you have both hard and potentially loose.
[00:06:53] Speaker A: Yeah. And that. That can also be really disconcerting to some patients if they've never experienced that before, because they're like, what is going on here? Like, it's like a very hard, difficult to pass initial bowel movement. They think they're going to have a hard, dry stool.
[00:07:06] Speaker B: Yep.
[00:07:06] Speaker A: And then that hard piece passes, and then it's just watery and loose on the back end.
[00:07:10] Speaker B: Right. Yeah.
[00:07:11] Speaker A: Okay, so let's take these one at a time, then, and kind of look at the thought process for each one. So let's start with wet constipation.
[00:07:20] Speaker B: Yep.
[00:07:21] Speaker A: So this is the bowel movement that's you know, again, we're skipping a day or two or more.
[00:07:25] Speaker B: Yep.
[00:07:25] Speaker A: And then when it comes this unformed, loose, watery, could even be diarrhea.
[00:07:29] Speaker B: Yep.
[00:07:30] Speaker A: Just the fact that we're having this kind of wet type stool, what is that cluing in for you? Like, what are you thinking?
[00:07:37] Speaker B: So there's some kind of fluid mismanagement that's taking place in the GI that's impeding the dampness, or the water is impeding the motility of the stool. It's lagging it behind.
So the dampness or the water, depending on which of the patterns it is, is the thing that's obstructing the motility.
[00:08:04] Speaker A: Right. And the motility here, I mean, this is, I guess, more academic than anything. Right. But the motility is what we call motility from a biomed point of view, is essentially like the QI aspect of peristalsis.
[00:08:16] Speaker B: Yeah, yeah.
[00:08:17] Speaker A: So the cheese that's driving the movement of the stool through your digestive tract is being obstructed by an accumulation of water and. Or dampness.
[00:08:27] Speaker B: Correct.
[00:08:28] Speaker A: Okay. And as a byproduct of that, the stool itself isn't becoming hard and dry, as we'll talk about in a minute, because there's all of this excess water and dampness in the actual intestines.
But it's just, you know, this is in contrast to someone who, say, has eight bowel movements a day and they're super watery and wet. In that case, we still have an abundance of dampness, wetness inside the stool itself in the colonial. But there isn't the same kind of obstruction to the peristaltic QI that's moving stuff along.
[00:08:59] Speaker B: Correct?
[00:09:00] Speaker A: Yeah.
[00:09:00] Speaker B: Yep.
[00:09:00] Speaker A: Okay, so the patient, then. We've established that it's wet, We've established that it's constipation.
We know because we've talked on this show before. I think most listeners will know that, you know, we tend to use abdomens as the next piece. Right. We get the details and we're like, okay, pulse abdomen. And I use a lot of tongue.
[00:09:18] Speaker B: Yeah.
[00:09:18] Speaker A: What's happening here? Right. And so if you go to the abdomen and you do the classic exam, you might find yourself finding symptoms in the upper portion of the abdomen. Above umbilicus.
[00:09:29] Speaker D: Yep.
[00:09:29] Speaker A: It's going to give us exterior indications versus below umbilicus. Interior implications.
Talk a little bit about. I mean, we're going to spend most of the time in the show talking about the interior implications, but maybe touch on when we say there's an exterior component to constipation. What are we talking about here?
[00:09:47] Speaker B: Exterior component to constipation is referring to how the physiology on the surface of the body is connected to the organs, basically. So part of what the exterior has to do is open and close efficiently. We have to do that in order to stay in contact with the chi of the external world, which is essential for life according to the Chinese medicine view. So if we have too much of any one of the six chi, eat cold, damp, dry, whatever, we'll die. If we can't adapt to that, we die.
So the exterior is the portion of our body that has to remain in contact with that changing dynamic of chi.
And whatever that chi is one of the six chi.
And so it's very important that strategically the pores of the skin can open and close.
If they can't open and close or they're having trouble opening and closing, a bunch of things can occur as a result of that, one of which is descent on the interior has a difficult time because pressure can't diffuse effectively on the surface.
[00:11:05] Speaker A: Right.
We had a teacher in school, actually, who used this idea of opening the surface in a different context. He was talking about some lung conditions, but he had this image of a teapot.
[00:11:16] Speaker B: Yeah, exactly.
[00:11:17] Speaker A: And so if anybody out there drinks tea or has seen a teapot, you will notice that a modern teapot, like a nice little kung fu teapot, in the lid there's a hole.
[00:11:28] Speaker B: Yes.
[00:11:29] Speaker A: In the center, usually, like in the little lid, lifty part of the lid, there's a hole that goes all the way through.
And the reason that there's a hole there is because if there weren't a hole and the lid just made a nice tight seal on the pot and you went to pour the tea, the tea wouldn't come out.
[00:11:43] Speaker B: Right.
[00:11:44] Speaker A: And you'd be thinking to yourself, like, well, why won't the tea come out? I'm pouring it. And it's because there's a vacuum that's being made by the liquid, the heat and the pressure of the room.
And so in order to get the tea to flow, if you had a pot that didn't have a lid or didn't have a hole in the lid, you'd have to pop the lid. You'd have to make a little crack. As soon as you do that, there it goes, it just pours. So the modern teapots have this little hole in it. And in fact, as you well know, as a person who drinks a lot of tea, you can sort of control the flow of the tea by putting your finger over the Hole, you can. Right. So if you're like, oh, I need to stop for a second so it doesn't drip, you can just literally put your finger over the hole and it'll stop the flow.
[00:12:24] Speaker D: Yep.
[00:12:24] Speaker A: So this is a simple little analogy that touches to the same idea here with your body. So if the pores are snapped shut or they can't open and close correctly, then for lack of a better term, and sticking inside of this metaphor, you're essentially creating a kind of vacuum.
[00:12:39] Speaker B: Correct.
[00:12:39] Speaker A: Internally.
So that the bowels can't release because the surface can't release. Right, right. There's almost like a. It's not to suggest that like your colon and your pores are a single flow through loop, but from a Qi point of view, they are.
[00:12:53] Speaker B: Yeah. They have a relationship.
And it can also be.
Urination can be involved in this defecation and menstruation.
[00:13:03] Speaker A: Any of the downward flows.
[00:13:05] Speaker B: Any of the downward flows. And often if one of them is affected by the surface, the other ones will also be affected to a greater or lesser degree.
So keep that in mind that if there is a surface superficial obstruction or an inability for the physiology to open and close correctly on the surface, it will often not just be defecation that's affected, it'll often be also urination, maybe menstruation, if it's a female bodied person.
[00:13:36] Speaker A: Right. That makes sense. So we mentioned this just to kind of put a placeholder in your thinking about as we talk about the interior presentations, if you're like, I don't know, there seems like there's something else here. And I'm using these abdomens and I keep finding a lot of exterior, sort of upper abdomen, superior abdomen findings is like, okay, then maybe you need to be looking at, frankly, modifications on the formulas that we use for exterior conditions all the time. Right. So that's going to be Xiao Qiutang. That's going to be Hui Zhitong, something like that.
[00:14:06] Speaker B: Exactly.
[00:14:07] Speaker A: But for now, let's stick on the interior side. And the reason we're doing that is because a lot of times constipation is chronic.
[00:14:15] Speaker B: Yeah.
[00:14:16] Speaker A: And it's sometimes constitutional. And so those presentations are more likely, much more likely to be interior than exterior.
[00:14:25] Speaker B: And if there is an exterior component, let's say we'll often treat that first. It clears relatively quickly. And if there's an interior component, then they may still have constipation, but it gets a little better after we help to regulate the surface. And then the pattern starts to move interior. So the pulses will Start to track deeper.
The qualities that we're finding on the abdomen will move away from being significant on the upper portion of the abdomen by the epigastric and rib side. And they'll start to only really be significant findings closer to the umbilicus. Below the umbilicus, Things like that. So the body will tell you where to treat and what order to treat in.
[00:15:11] Speaker A: Yeah, this is sort of classic, like, harmonize the patient first and then move into the interior.
[00:15:16] Speaker B: Yep.
[00:15:17] Speaker A: Yeah. Okay. So if we're still in the wet constipation category and we're thinking about interior presentation, we've assessed the abdomen, and we've found some significant signs that start to help us understand what's going on here that says this is interior. What are some of those signs we might find on the abdomen?
[00:15:37] Speaker B: Yeah. So we'll find maybe a lack of the first things that I. That we talked about. Right. The epigastric or the costal findings. Those will be less significant.
We might find a little bit of rectus abdominal tension. That's possible.
In interior or exterior patterns.
We might find a little bit. Like if we track the ren line closer to the umbilicus, we might find a little hard spot in an interior pattern. That's possible, but it's usually less. It's usually more, let's say, closer to the umbilicus. In my clinical practice, I find it in these patterns closer to the umbilicus as opposed to closer to the ribs.
[00:16:25] Speaker A: Right.
[00:16:25] Speaker B: If it's an interior pattern.
[00:16:27] Speaker A: Yeah. We're just. We're going deeper.
[00:16:28] Speaker B: We're going deeper.
[00:16:29] Speaker D: Yeah.
[00:16:29] Speaker A: Okay. So then you start. You feel into the zone, and then some of the things that are commonly found in this wet constipation presentation that can help confirm your suspicion.
[00:16:39] Speaker D: Right.
[00:16:39] Speaker B: Yeah.
[00:16:40] Speaker A: Is like the abdomen will literally be cold. It'll be.
[00:16:43] Speaker B: Yeah. The skin will be cooler.
[00:16:45] Speaker A: The actual skin itself. Right.
There can often be some water sounds.
[00:16:50] Speaker B: Yes. Either elicited by the bloop, bloop, bloop. Like the tapping that you do over the stomach, basically. Yep. Or it could just be that you hear it when you're palpating or when you're doing acupuncture later, all of that counts as water signs.
[00:17:09] Speaker A: Yeah. So that's like gurgling. Gurgling sounds.
[00:17:11] Speaker B: Yep.
[00:17:12] Speaker A: Okay. And then also when you're feeling the texture of the abdomen, the actual musculature below umbilicus. Right. It tends to be softer.
[00:17:21] Speaker B: Softer. Yep.
[00:17:22] Speaker A: Yep. And so all of this is indicating that there's water slash dampness. That's accumulating in the interior.
[00:17:28] Speaker B: Yeah. And the tendency for more cold, like the tiring out of the Yang system and the movement toward interior and cold.
[00:17:37] Speaker A: Got it.
[00:17:38] Speaker B: Yep.
[00:17:39] Speaker A: So when we think about formulas for interior and cold, the ones that come up to the top of the list are Li Zhongwan and Zhen Wu Tong.
So again, if we're thinking wet constipation, interior, with these cold and. Or wet presentations, we're thinking Li Zhongwan or Jen Wutang.
[00:17:59] Speaker B: Yep.
[00:17:59] Speaker A: So what's the. What's the differentiator? What's going to make us pick Li Zhongwan, for example?
[00:18:04] Speaker B: So Li Zhongwan again, would be.
So one of the first things that cues that I want to use for wet constipation is the bitter warmth of an herb like Baiju. Right. Versus the bitter cold of an herb like Jershi for, like, let's say, a drier pattern or something.
So both of these formulas have Baiju in them. Li Zhong Wan or Renshen Tong, which is another name for the same formula in decoction, and Zhen Wu Tong. They both have Baiju in them.
They both have ginger in them too. So there's a pungent warm situation taking place. So we're moving toward warming and warming earth in both cases.
But the big difference between Li Zhongwuan and Zhen Wu Tong is the difference between cold dampness and cold water.
[00:18:58] Speaker A: Okay. Cold dampness versus cold water.
[00:19:01] Speaker B: Yeah.
[00:19:02] Speaker A: Now, I think for some people who aren't used to thinking about it in those terms, those sound very similar.
[00:19:08] Speaker B: Very similar.
[00:19:09] Speaker C: Yeah.
[00:19:09] Speaker B: I don't remember learning the difference in school, honestly, myself.
[00:19:13] Speaker A: Yeah. I mean, I think it was all just in a single lump. Right, Right. People who tend toward Yang deficiency, therefore cold, tend to accumulate phlegm, fluid dampness.
[00:19:23] Speaker B: Right. Like, you just sort of like all runs together.
[00:19:25] Speaker A: Yeah. All in one thing. But this is why it matters now to talk about it, because it helps you pick the right formula.
[00:19:30] Speaker B: Does.
[00:19:31] Speaker A: Yeah. Okay, so if you're on, let's. Let's start with the water side of it, because I think on some level, at least to me clinically, it feels not exactly like a progression, but kind of like it's sort of like the watery part is. Is different in kind, really, than dampness. Dampness has a different quality to it. So what do we see on the water symptom side?
[00:19:52] Speaker B: Water is going to be less influenced by Yang. So that's the biggest difference. Damp is going to be more influenced, or like Arnaud Versluis likes to say, Ripened by yang.
So like thickened, thickened and made a little bit turbid. Like damp is a little sticky, a little turbid. Water is not. It's just kind of unchecked in a way by Yang, especially in Yang deficiency, which is what we're talking about here in both cases, version of Yang deficiency in both of these patterns.
But water, water symptoms have to do with the movement of water in the body, like, let's say urination.
So urination is not a symptom. Difficult urination is not a symptom of Li Jong Wan, but it is of Zhen Wu Tong.
[00:20:47] Speaker A: Okay.
[00:20:48] Speaker B: And dizziness is also a symptom of Zhen Wu Tong. So this is also a water type pattern or a water type symptom.
[00:21:00] Speaker A: Okay. So dizziness, difficult urination, these are all indicators that there's like again, a non turbid, non sticky water imbalance.
[00:21:12] Speaker B: Yep.
[00:21:12] Speaker A: Okay. On the other side though, on the damp, cold side.
[00:21:16] Speaker B: Yeah.
[00:21:17] Speaker A: Where there's more influence from a kind of pernicious Xie Qi style yang.
[00:21:22] Speaker B: Yeah.
[00:21:23] Speaker A: Right.
The water has now gotten sticky. It's heavy.
[00:21:27] Speaker B: Yeah.
[00:21:28] Speaker A: And it has this kind of weightiness to it that then indicates we need Li Jongwan.
[00:21:34] Speaker B: Yeah.
[00:21:34] Speaker A: Right. So also too, isn't there a different quality to the stool? Like even the smell.
[00:21:40] Speaker B: Yes, Very good. Yeah, that's a good point. So watery diarrhea is going to be more Jen Wutang.
Loose stool diarrhea. That's stinky, smelly, sticky. That's more Li Jong Wan.
[00:21:55] Speaker A: Right, Right.
[00:21:56] Speaker B: So again, damp versus water. Like the water's just flushing through the intestines.
That's Zhen Wu Tong.
The damp is getting transformed a little bit, but not enough.
That's going to be cold, damp. That's Li Zhongguan.
[00:22:11] Speaker A: Yeah. I think this is a really.
The smell piece is actually a really useful indicator because I know if you just ask a patient, so is the stool smelly? They'll be like, it smells like poop.
You have to figure out how to craft that question. And I usually use the phrase, is there any particularly strong odor to a bowel?
[00:22:32] Speaker B: That's a good way to ask that question.
[00:22:33] Speaker A: Particularly strong odor. And the reason is because everyone also knows that not all poops smell the same.
Yes. It was a bowel movement for sure. It's not a pleasant smell. Although there are even some watery diarrheas that have almost no smell.
[00:22:47] Speaker B: Right.
[00:22:48] Speaker C: Yeah, exactly.
[00:22:48] Speaker A: So like that, that's kind of like. You can kind of imagine the question of smelliness on both sides.
[00:22:53] Speaker D: Right.
[00:22:54] Speaker A: It's like. Yeah, literally I had like a kind of unpleasant watery release and it almost made no smell at all.
[00:23:02] Speaker B: Right.
[00:23:02] Speaker A: That is a strong indicator for the water damp side. Excuse me, the water cold side.
Whereas if you've got still a pretty loose stool but a stronger smell. Right now we're looking at the damp, cold side.
[00:23:14] Speaker B: Yep.
[00:23:14] Speaker A: Yeah.
[00:23:15] Speaker D: Okay.
[00:23:15] Speaker A: I think that's a good differentiator. So wet constipation interior.
We're picking two formulas, Li Zhong Wan versus Zhen Wu Tong. And we're differentiating those two primarily from. Is it a damp cold or a water cold? Yes, cold's pervasive in both of these.
[00:23:32] Speaker C: Right.
[00:23:33] Speaker A: And so the quality of the stool, it's stickier, it's smellier. There's a sense of heaviness to the patient.
[00:23:40] Speaker B: The muscle layer is heavy and like.
[00:23:42] Speaker A: It'S that dandy blanket vibe.
On the other side we've got watery stool that has less smell, maybe no smell. And then there's other water symptoms. So there's difficult urination.
So that's starting stopping frequency, urgency, anything.
[00:23:58] Speaker B: Yep.
[00:23:59] Speaker A: Right. And then dizziness, which is that sort of water effusion that's like preventing the shen from staying focused. Right. And that's going to tell us Jen Wu Tong.
[00:24:09] Speaker B: Yeah, that's going to be more Jen Wu Tong. And then the person is more tired in Jen Wutang, they're more fatigued. Right. That's the symptom of somnolence or the desire to always want to sleep. That's a really key factor for Xiaoyin disease, which would be cold water versus tie in disease, which is cold damp.
[00:24:30] Speaker A: Yeah. And that can be hard, I think, for some people to differentiate when you first ask patients about it, because patients don't really know like the quality of their tiredness.
[00:24:39] Speaker B: Yeah.
[00:24:39] Speaker A: Because like Li Zhuang Wan people are also tired, but in a worn out, weighty.
[00:24:46] Speaker B: Think of Eeyore. Eeyore for cold damp.
[00:24:49] Speaker A: Yeah. There's like a heaviness to it, like demotivation. Like, I just can't.
Whereas the Jen Wutang people can just go to sleep.
[00:24:58] Speaker B: Yeah.
[00:24:59] Speaker A: It doesn't necessarily have the same kind of emotional layer to it. It's just like. Yeah, literally if you just put me on a couch, I would just fall asleep.
[00:25:07] Speaker B: Yeah. Or they can't sleep is another version of it. But they really want to like, oh my God. I just. If I could just sleep, I would really be happy, you know?
[00:25:19] Speaker A: Yeah, exactly.
Okay, great. Well, next we're going to take a look at dry constipation obviously, the primary.
[00:25:28] Speaker D: Differentiator just on the front is that the stool is hard and dry.
[00:25:31] Speaker C: Yes.
[00:25:31] Speaker D: Compared to the wet type constitution constipation we were talking about.
But as we mentioned, the constipation part, the infrequency of the stool remains, you know, the thing that the patient is in for. But when the stool comes, it's now hard and dry.
[00:25:47] Speaker C: Yes.
[00:25:48] Speaker D: So when we were talking about wet constipation, we were talking about using herbs that are bitter and warm.
[00:25:54] Speaker C: Yep.
[00:25:54] Speaker D: So bitter to down, move downward.
[00:25:57] Speaker C: Right.
[00:25:57] Speaker D: Drain downward and warm. Because the wet side of things is likely cold and wet needs to be warmed.
[00:26:02] Speaker C: Yeah.
[00:26:02] Speaker D: If we're on the dry side, though, we've got bitter again.
[00:26:05] Speaker C: Yes.
[00:26:05] Speaker D: Because we're still in the downward movement, but now we're talking cold.
[00:26:09] Speaker C: Yes.
[00:26:09] Speaker D: So bitter cold herbs. Yep. What are the herbs that. That sort of mark that those qualities relative to constipation.
[00:26:17] Speaker C: Yeah. The first two herbs I think of are jersey and dahuang, both bitter, both cold, and then maybe secondarily baishao, and we'll maybe talk about that one a little bit later.
[00:26:30] Speaker D: Got it. Okay. So Jershin Dahuang. I mean, I think a lot of people, if they're thinking back to school, they hear Da Huang and they're like, oh, boy, your pants with some dahuang.
[00:26:42] Speaker C: Yeah.
[00:26:42] Speaker D: Right.
It's funny because, you know, poor dahuang.
[00:26:46] Speaker C: Yeah.
[00:26:46] Speaker D: It gets a lot. It gets a lot of bad rap.
[00:26:48] Speaker C: Yeah.
[00:26:50] Speaker D: Because, I mean, yeah, it's purgative for sure, but like, there. I just feel like when we were in school, many people sound like if you just had like 2 grams of dahuang, you'd be like, just strapped to the toilet for days.
[00:27:01] Speaker C: Right.
[00:27:01] Speaker D: But of course, that's not really the case.
[00:27:03] Speaker C: No. And it really depends on the combination of herbs that it's with and the intention of the formula.
[00:27:12] Speaker D: I wonder if that bad reputation comes from Da Huang's primary association with Da Chang Qi tong.
[00:27:20] Speaker C: Right.
[00:27:21] Speaker D: And of course, probably. Yeah. So Da Chung Qi tong here being like, when you think back to school and you're like, what's the formula for dry constipation? You might recall Da Chang Qi Tong.
[00:27:31] Speaker C: Yes.
[00:27:31] Speaker D: Which has dahuang and zhi shi, the two herbs that you mentioned, but significantly also contains.
[00:27:39] Speaker C: Yes.
[00:27:39] Speaker D: Why is that significant here?
[00:27:41] Speaker C: T. Because mung shao is by far the most purgative herb you're going to add into a formula by itself. So mungsha is actually salty, not bitter and salty in the sense that it's going to soften and descend. Right. Soften. Hardness is the language of the Nijing. Right. And when you put that into a formula, basically it's a mineral that's going to not be absorbed in your intestinal tract. So it's just going to flood. It's going to pull out all the water.
[00:28:12] Speaker D: Yeah.
[00:28:13] Speaker C: In your intestine into your intestines. And then that is going to.
Hopefully, if there's a. If there's a hardness, like a dryness that needs to be purged. Right. The dryness that we're referring to is the condition of the stool that's stuck.
So the. The salty flavor of Monk Shao is going to pull the water into the intestines, and. And then the bitter flavor is going to push everything down.
[00:28:37] Speaker D: Right.
[00:28:37] Speaker C: So the combination, it's very much like Ma Huang and Guizhou, both being needed to force a sweat. Whereas if you just use Ma Huang, but you don't have Guizhi, maybe use like Shao, it's not going to cause somebody to sweat. It's the same thing with Dahuang and Meng Xiao. If you just have Dahuang, depending on the case, maybe it does cause some downbearing in the intestines.
[00:29:02] Speaker D: Right.
[00:29:02] Speaker C: Depending on the formula. But especially if you combine it with Mung Shao, it's going to be percative.
[00:29:08] Speaker A: Yeah.
[00:29:08] Speaker D: I mean, Da Huang, big yellow, literally Da Huang. If you look at the. The root, it's a rhubarb root. It's important to remember.
And it's huge. It's a huge root and it's very bright yellow.
[00:29:21] Speaker C: Yeah.
[00:29:21] Speaker D: Right. And of course, we know that yellow herbs tend to be bitter. Yep. And we know the bitter flavor is downbearing, but also bitter clears heat. And so a lot of the power of Da Huang in these formulas, but in many formulas, where it shows up is that there is some large intestine heat that needs to be cleared. And so, like, you know, we don't think about Huangchen, for example, just having people riding the toilet for hours.
[00:29:49] Speaker C: Right.
[00:29:50] Speaker D: Even Huanglian are super bitter and can definitely facilitate a bowel movement through its bitterness. Again, doesn't have the same reputation of like, oh, God, explosive stools.
[00:30:00] Speaker C: Yeah.
[00:30:01] Speaker D: It's really poor Dahuang. It's really Mang Xiao who did this.
[00:30:04] Speaker C: Yeah.
[00:30:04] Speaker D: There's like a hiding in the background. Right. Of Da Chongqi. Because it's the combination of the two together.
[00:30:10] Speaker C: Yes.
[00:30:10] Speaker D: That creates this hyper potency. It's worth noting too, that Dahuang. I mean, there are ways to make Da Huang more Purgative. Right. So if you finely grind it and you short boil it in a bulk decoction, you'll get more downbearing sensation because it is more bitter. In that context, if you long cook it, you'll get much less. If you use powdered da huang, like wine fried da huang or chow da huang, like you'll have less, even less of the purgative quality, but about the same amount of the heat clearing quality.
[00:30:40] Speaker C: Yeah.
[00:30:41] Speaker D: And so again, like there's so much nuance that goes into a single herb, but I just felt the need to defend. Yeah, poor dahuang from its bad reputation that's causing explosive diarrhea.
[00:30:52] Speaker C: Yeah, absolutely.
[00:30:53] Speaker D: Really fair.
So, all right, we're talking here about chung Qi tongs then. Primarily here in the Dahuang context, Da chung Qi tong being that formula that people remember from school.
But you know, when I look at the kinds of formulas we write for this type of constipation, Chung Ti tong's not at the top of the list.
[00:31:10] Speaker C: Right.
[00:31:11] Speaker D: Why do you think that is?
[00:31:12] Speaker C: I think it's because in modern times people have a lot of available purgatives, like at the drugstore or the grocery store, even supplement, you know, department.
So if they have really strong dry constipation, they're usually already self treating in one way, shape or form. I do know people that, that use chung chitangs, especially taohe chung chitang, which is more of a blood level purgation kind of thing. But, but you know, I know people that use chung chi tongs a fair amount in their clinical practice, but those are people that are specializing in GI disorders. And it's still less often than most of these other formulas that we're going to talk about.
[00:32:00] Speaker D: So basically, if you were in a more classical context and you had someone who didn't have access to Miralax or smoothie of tea or whatever over the counter.
[00:32:12] Speaker C: Senna.
[00:32:13] Speaker D: Senna.
[00:32:13] Speaker A: Yeah, exactly.
[00:32:16] Speaker D: So in the classical model, that means that someone maybe hasn't had a bowel movement in four or five days.
[00:32:21] Speaker C: Right.
[00:32:21] Speaker D: And they are feeling really bad.
[00:32:24] Speaker C: Right.
[00:32:24] Speaker D: And so they see the herbalist and they get written a da chung chitang. Now they're not written a da chung chitang for seven days. Right, Right. That's the important thing to remember. This formula is the laxative equivalent. Right. It's like, okay, open up the flow, get out what's there.
But there's probably going to be a different formula that we use to deal with the actual underlying problem.
[00:32:48] Speaker C: Yes.
[00:32:49] Speaker D: Now there are a lot of chung Qi Tongs, you mentioned Taohu Chengjutang, which is more blood oriented. Da. As we mentioned. There's of course a Shao that goes along with it. We've got a Tia Wei.
[00:32:58] Speaker C: Yep.
[00:32:58] Speaker D: There's a whole list. If you get into the Bensky, you.
[00:33:00] Speaker C: Can see the list.
[00:33:01] Speaker D: There's small variations, kind of across the board. Take out Jershi, take out Ho Po, add this in, pull that out. The usual way that happens with families of formulas.
But there is a formula that's based off of Xiao Chung Xitang.
[00:33:15] Speaker C: Yeah.
[00:33:15] Speaker D: That we do see people use, I think, more frequently for the underlying cause of constipation. Remind us about that one.
[00:33:21] Speaker C: Yeah. Mazurin one.
[00:33:22] Speaker D: Mazurin one, yeah. And what about, like, what about the design of that formula, do you think, makes it a more common starting point for the actual underlying mechanism of dry constipation?
[00:33:34] Speaker C: Usually it's dry constipation that's been chronic.
So there's more herbs in Mazu renwan and the herbs that are used are sweeter, whereas in Xiao Chung Chitang, it's pretty much all bitter, sour. You know, it's like. It's very, let's say, streamlined direction.
[00:33:55] Speaker D: Yeah.
[00:33:55] Speaker C: Very universal. Whereas with Mazu renwan, it's a little different than that. It's kind of slowed down.
[00:34:00] Speaker D: The.
[00:34:01] Speaker C: The purgation is slowed down, if you will.
[00:34:04] Speaker D: It doesn't push as hard.
[00:34:05] Speaker C: It doesn't push as hard, exactly.
[00:34:07] Speaker D: Yeah.
[00:34:07] Speaker C: And the other key symptom for Mazaren one is some kind of difficult urination.
There's a strong urinary piece to the condition with that, which. Which differentiates it and which makes it a good formula for a lot of older people, usually.
[00:34:25] Speaker D: Right.
[00:34:25] Speaker C: That's kind of where we see it used a lot.
[00:34:27] Speaker D: Yeah. Because a lot of older people are going to have some kind of difficult urination, as you mentioned, which, by the way, is both ways, like infrequent or too frequent. Though with older people it tends to be more frequent.
[00:34:39] Speaker C: Yeah. More frequent is more common.
[00:34:40] Speaker D: More frequent. We also see some incontinence issues in women that can be accidents with urination, with movement or laughing, crying, coughing. With men, we usually see difficulty starting and stopping.
Dribbling takes a long time to actually stop urinating. There's an ongoing kind of dribble that has a sort of incontinent quality. So, like that. That stuff is, I think, a good indicator that matzer ren1 is where you need to go.
It's interesting, though, because even when we watch people get a lot of lift out of matzo ren 1. It doesn't seem to be the final formula, so to speak, for dry constipation.
Instead, the formula tends to move really away from the Jirshire dahuang model into something that is a little bit more nourishing, moistening. And that's the baisha that you mentioned.
[00:35:35] Speaker C: Yeah.
[00:35:36] Speaker D: What formula is the baishao formula that kind of represents this treatment of dry constipation, but with baisha as the leader?
[00:35:43] Speaker C: Yeah. Xiao Yao Gan sotong for sure.
[00:35:46] Speaker D: Why that one?
[00:35:47] Speaker C: Well, Xiaoya Gansao tong is a two herb formula. Right. So it's just two herbs. It's very, potentially very strong in direction because there's fewer ingredients. So the fewer ingredients you have in a formula, the more streamlined your focus of direction is.
So it's going to be very strong in what it's doing. Xiao Yan sotong represents the najings answer for tonifying yin or transforming into yin would be a, maybe a better way of translating into English, which is sour and sweet. The combination of sour and sweet. Tonify yin or transform into yin. The combination of acrid and sweet. Tonify yang or transform into yang. So if somebody has dry constipation with muscle cramping as a big feature of the case, you could do xiaoya ganso tang right away to treat the problem. Just start with that or what I see in a lot more of these chronic cases, let's say the person is addicted to laxatives, very difficult cases to fully get off of herbs or whatever. Right. But let's say they're addicted to senatee. They've been taking senate for the last decade to try to have a bowel movement. Really tough cases to work.
But you might start off with something like a mazu renwan or even a da chung chitang, moving into a formula that's a little bit more nuanced and sweet, but then trying to get them to end on a xiao yao ganso tang. And if you have a very high dose of bai xiao in Xiao Gansao tong, I've seen up to 60 in bulk herb. So 60 Bai Xiao to like 15 Ji Gan Sao or something like that, Very, very high.
That's more purgative. So the more you. This is what I was taught, that baishao at smaller doses is emphasizing the sour function. Baisha at large doses it's more emphasizing the bitter flavor.
So you can use it as a purgative action at high doses, but you can also use it as a formula that you end on or you try to Work the case to get to in the long term because it's really tonifying at a more like, say, nuanced or equal dosage. The bishop may be a little higher than Jurgon, so is common, but more like low grade and similar dosage is going to be more for nourishing the fluids, nourishing the muscle layer, softening the muscle layer, keeping the motility going in the intestines. And it's a really good place to try to end your treatment on.
It's kind of like the last formula you might go to and when you're finishing one of those long cases.
[00:38:33] Speaker D: Interesting.
[00:38:34] Speaker C: Yeah, yeah.
[00:38:35] Speaker D: The, you know, the idea of baishao. So baishao, of course, is the root of the tree peony.
And if you look at the. The root itself. Yeah, it's very fleshy.
[00:38:45] Speaker C: Yes.
[00:38:45] Speaker D: It's dense, it's fleshy.
Like all roots, I guess it's really wet when you pick it up. But that's not true. Some roots kind of dry even when they're fresh. But like baisha is really wet and even once it's dried, it's not oily like Donggui is. But you look at it and it has a clear density to it.
[00:39:04] Speaker C: Yes.
[00:39:04] Speaker D: That I think is very evocative of its yin function. It's not riddled with holes, it's not powdery.
It has a density to it.
And it's interesting then that the idea of baisha at a much higher dose. So let's say that like the 60 to 15. So 60 baisha, 15 ganzao.
Honestly, irrespective of how much gansao is in that mix, 60 grams of Bai shao is going to move your bowels because it's wet. It's super wet.
Even in formulas outside of the realm of constipation, we use baishao in really common formulas all the time.
Think about just Guizhu Tong or Xiao San or something that's going to have those in there.
The need to be mindful of how much baisha you're giving to a person if they have loose stools.
[00:39:51] Speaker C: Right.
[00:39:51] Speaker D: Wet digestive stuff is an important question because baisha will move things along.
[00:39:57] Speaker C: Absolutely.
[00:39:58] Speaker D: Particularly at that high dose. Right. And so, yeah, it's also interesting because if you just take a piece of baishao, you know, we talk a lot on this podcast about the flavors of herbs. And some flavors are like really obvious, you know, like if you make a tea of just squager, it's very clearly acrid, warm and a little sweet, like you Just taste it and you're like, oh, yeah, it's got a little spice from the cinnamon, but there's that sweetness underneath that we all know from like hot tamale candies and stuff. And obviously it's warm. Very easy to tell if you make a, if you make a tea of baisha and you drink it at any dose, really, you're going to be hard pressed to taste the sour.
[00:40:37] Speaker C: Yeah.
[00:40:38] Speaker D: Like, at least it doesn't taste like shanjuyu tastes or. No. Or weights or something. Right.
You kind of have to like reach for it and you have to really, I think, develop an awareness of sour.
That's a broader idea than like a warhead candy.
[00:40:55] Speaker C: Right.
[00:40:55] Speaker D: You know, it's the same thing with sweet. Like if you, if you brew up just Gonzal on its own sweet, like it's not a pastry, you know.
[00:41:04] Speaker C: Right.
[00:41:04] Speaker D: But it is sweet. But you, again, you have to sort of like train your palate to expand the notion of what sweet really is.
With most fleshy herbs I have found, if you put a lot of it into a tea, so like, let's say you just took 60 grams of Baisha and you decocted it into 8 ounces of liquid, it's going to taste bitter.
[00:41:24] Speaker C: Yeah.
[00:41:25] Speaker D: And honestly, that is true of many, many plants in general. I mean, you could just take like drinking tea like Camellia sinensis and you take 60 grams of tea leaves, brew them into, my God, one cup of tea, even if you flash steeped it. Bitter.
[00:41:42] Speaker C: Yeah, very bitter. Yeah.
[00:41:44] Speaker D: Because the potency, like when you, when you take so much plant substance and you create a dense ball of it, then you end up with something that is going to taste bitter. 100 just sort of how it goes.
[00:41:56] Speaker C: Yep. And with baishao, the other thing that I would say that's, that we know about because we own an herbal medicine area, is the smell of it is actually a place where you get more sour.
[00:42:09] Speaker D: Yes.
[00:42:10] Speaker C: Than the taste. Right.
[00:42:12] Speaker D: And actually that I think is fun for listeners to imagine because I think a lot of people just went, what does sour smell like?
[00:42:17] Speaker C: Yeah.
[00:42:18] Speaker D: Right. Because sour is not like. What do you mean? And honestly, I, you know, this is an audio format, so it's going to be a hard way for me to explain it to you, but the truth is, is that if I, if I took a variety of very sour things, Shanjuyu Wei CI weights is maybe a worse example because there's a peppery quality to the seed. But Shanjuyu in particular I think is a good one.
And if you smell just Deeply dried shanju. You just, you know, whole pound of it or 500 grams of it just out of the bag. And really train your senses on what you're smelling.
You will, the first thing that will clock in your brain is the smell of a fruit, which is mostly actually a sweet smell.
[00:42:58] Speaker C: Right.
[00:42:58] Speaker D: Because it's the flesh of a fruit. But then when you, when you smell more deeply, you can actually start to smell the sourness.
[00:43:05] Speaker C: Yeah.
[00:43:06] Speaker D: And I really. There's no better way to explain it except that, like, you just have to.
[00:43:09] Speaker C: You gotta try, you gotta do it. Yeah.
[00:43:11] Speaker D: Stick your face in a bag full of something very sour and start to train your nose to recognize what your mouth can, can pick up. Because of course, we know that like taste is mostly smell.
[00:43:22] Speaker C: Yes.
[00:43:23] Speaker D: But it's just there are some tastes that we don't spend a lot of time calibrating around smell. So it's a fun exercise. If you have access to some bulk herbs, I think it would be worth taking a look at.
Okay. So Xiao Gansotang, I'm glad you mentioned also the muscle spasm and the muscle tension, because I think a lot of people will recall that formula for that function.
There's like a hypertonicity of the muscles, a tendency toward Charlie Horse muscle contraction.
And so in this case, we may actually see that in dry constipation people, their yin is weak.
[00:43:56] Speaker C: Yes.
[00:43:57] Speaker D: Right. And so their muscle, their flesh tends to be dry, tends to stick to itself, tends to seize. Right.
It's interesting too that biomedically you'll see a lot of folks who have a tendency towards, say, calf leg cramps, like a classic Charlie Horse, they'll start using internal magnesium or topical magnesium. Right. To help with the cramping. And also we'll see people with chronic constipation taking magnesium. Taking to move the bowels.
[00:44:27] Speaker C: Yeah.
[00:44:28] Speaker D: And I always thought, how about that? Yeah, that's interesting. You know, there's even in the Western biomed observation, there's. Now, of course, the biomeds will not link those together. Right. Even though they're using the same.
[00:44:41] Speaker C: Right.
[00:44:42] Speaker D: The same tool to intervene in both of them. But they're not going to link them together. But of course, yet again, the beauty of Chinese medicine is that we actually, we did link those things together before. And so the formula that treats both leg cramps, also choose constipation because the root problem, the pattern that's causing the issue is this deep yin deficiency.
[00:45:01] Speaker C: Yeah.
[00:45:02] Speaker D: Right.
[00:45:02] Speaker C: And if you think about the musculature that's involved in peristaltic Action. Right. That musculature is cramping as well as the, you know, the calf or the thigh.
It's spasmodic, which is why. Partially why the stool isn't coming.
Yeah.
[00:45:20] Speaker D: So if someone.
So, okay, you know, we talked about chung chitang, matzo ren1.
Maybe they go for matzo ren1. Excuse me. To shyogan sao tong might have just started with shyogan satang if you had muscle cramps clearly from the beginning. Right.
But there are other sets of formulas that also have, you know, jersey in them or have some kind of, you know, downbearing movement that we also can see commonly deployed for dry style constipation. Tell us a little bit about those.
[00:45:51] Speaker C: Yeah. So probably closest to xiao yansha tong is going to be sinisan. And I would say sinisan by far is a more common formula for me to start out with for treating dry constipation than any of the ones we've mentioned yet.
[00:46:05] Speaker D: Why is that?
[00:46:06] Speaker C: Because I think it's a much more common pattern. Sinisan is also a formula that likes modification. So Zhang Zhongjing mentions modifications in the postscript for sinisan, which he doesn't do for too many formulas. So that's kind of. I take that to be, hey, don't be afraid to throw some other formulas into this one or throw some other herbs into this one. So sinisan is xiaoya gansao tang plus chaihu plus jershi.
And we've already talked about jershi being one of our archetypical dry constipation herbs.
So to add that into xiao ganso tong plus then chai hu, which, you know, modern Materia Medica classifies chai hu as cool, acrid release the exterior. I think of chihu being bitter and neutral a la the shenang Ben Sao jing.
But the function of chihu is going to be kind of the depending. No matter how you look at it, it's going to be the opposite, let's say, of the jershi, which is going to be pushing more down. The chaihu is going to be a little lighter and floating upward. So it's just helping the chi dynamic in the opposite way as the jershi. So you're kind of like moving chi upward. You're moving chi downward. And then you have the core function of the xiaogan tseo tang, which is doing all the things that we talked about before.
Right.
[00:47:33] Speaker D: So what are you seeing in the patient in the presentation of their symptoms that says, okay, I need to go all the way to tsinisan as the starting point as opposed to just xiaogansotang or frankly, just like with matzah renwan, what are the differentiating factors here in the dry constipation category that are pointing us in one direction or another?
[00:47:56] Speaker C: Matzah renwan is going to have more, let's say, overall. So if we just talk about the abdomens for those three, the Mazarin one's going to have more overall bloating, but like the whole abdomen is going to be more distended usually.
And you may even feel actually in any one of those patterns, you may be able to feel the intestines and the hard places where the stool is stuck in the intestines in some cases, particularly the descending colon.
So if I see any of that, I'm thinking, well, actually when I see that, honestly, what I'm thinking is sinny san.
But it could be any one of those. Right. Mazarin1 is going to have more of a Yang ming feel. So it's going to be a bigger abdomen overall and the whole abdomen is going to be uncomfortable. And then there's going to be a picture that justifies the formula. If I'm going to go with that. So it's going to be more of a chronic case.
There's going to be urinary symptoms.
And yeah, that's what's going to make me go there.
Shaya Ganso Tong the thing that's really going to be emphasized, and this is the same with sinny san actually, is the req or the rectus. Abdominal tension is going to be very profound. So when you palpate the abdomen, you may have to stop yourself from your jaw dropping. There's a couple, you know, because of how rigid, because of how tight it is, you're like, holy crap, that's tight. That's really, really tight.
And before you palpate abdomens a lot, you may not like even know that an abdomen could be that tight. That's how tight it can be.
And there's a couple of formulas, all that have xiaoya Ganso tong in them that could present that way.
The other one is like the Zhen zhongtang formulas, like Xiaojin zhongtang, Dangwe Zhenjongtang, they can also have very, very tight musculature, but they all have xiao yao gang sao tang in them.
So sinisang can have all of that, plus costal stuff. So rib side stuff, usual chaihu indication.
[00:50:07] Speaker D: Yeah.
[00:50:08] Speaker C: And sometimes with sinisan too. There's also.
It's almost like the rectus, the. The Rectal. The rectus abdominis is so tight, it almost creates a glomus that you can feel or a peat that's indistinguishable but is like clearly there in between the musculature. It's almost like the muscles are so tight, there's a place where it overlaps and conglomerates.
[00:50:33] Speaker D: So it's like a. Like a little, for lack of a better term, like a bump. Yes. Like in the tissue.
[00:50:39] Speaker C: Absolutely. And you can. You can see it in these patients, like, even without touching it, you can usually see it.
[00:50:45] Speaker D: Right? Yeah. Okay. Would also. I mean, we've been talking about this in the context of.
Of chronic dry constipation, but.
[00:50:52] Speaker C: Yeah.
[00:50:53] Speaker D: You know, some people will have it come and go. Like they'll be constipated for a while and then they're fine, and then they'll be constipated for four or five, six days and then.
[00:51:01] Speaker C: Exactly.
[00:51:02] Speaker D: Finding it. Yeah. Is that alternating symptomology also? CNN indicator.
[00:51:06] Speaker C: 100%.
[00:51:07] Speaker D: Classic Jehu.
[00:51:08] Speaker C: Yeah. I think typical IBS patient is a sinny san patient. Like, there's. There's such a high corollary with that type, that disease and that formula strategy. Now, that may be a sinny san plus other things.
[00:51:22] Speaker D: Right, right. In fact, in many cases it is. It is.
[00:51:24] Speaker C: Yeah.
[00:51:25] Speaker D: But of course, Chai who's going to be.
[00:51:26] Speaker C: But Chai who is super important. And of course, we have to remember that shaya san is a modification of sinny son. Right, Right. So the. The first formula that came was sinisan, and then it was tweaked to. To make the shaya san method eventually.
[00:51:45] Speaker D: And I would like to point out, since you mentioned shaya san, because I'm going to do this every time someone mentioned shaya san son. It as a. Is at its core a digestive formula. Yes, it's a digestive formula. It's not a stress formula.
So help me God. Everybody just handing. Oh, are you stressed? Have some shao san. Yeah. Why do they have bad poops? Because of their stress, Maybe.
[00:52:09] Speaker C: Yeah.
[00:52:09] Speaker D: In that case, it might be appropriate.
[00:52:11] Speaker C: Yep.
[00:52:11] Speaker D: It's not a stress formula.
[00:52:13] Speaker C: Yep.
[00:52:14] Speaker D: So stressful to hear people just treat it that way. Because there are many other formulas much better for treating quote, unquote stress.
[00:52:21] Speaker C: Yeah.
[00:52:21] Speaker D: But also, what. What is the stress?
[00:52:23] Speaker C: Right.
[00:52:24] Speaker D: We'll do a whole podcast on that. But just since you mentioned it, Shyo san digestive formula.
[00:52:29] Speaker C: Yeah.
[00:52:30] Speaker D: Okay.
So in that case, sinisan, I mean, we've broken down the pieces here. Right. So Matsu ren 1, we got dry constipation with urinary symptomology. Right. And very yangming in presentation. Big abdomen, straight xiao gansao tong. We have, frankly, the muscle indicators, right? So, like, we have heavy rigidity in rectus abdominis, which tracks with this idea of the hypertonicity of the musculature because of the indeficiency. So we're going to straight shyoganzo tone. But then if we reach for sinisan, it's because we have many or all of those other symptoms plus chihu symptomology. So we have costal sensitivity, we have hypochondriac pain, ribsite tenderness, alternating symptomology, etc.
[00:53:14] Speaker C: Right.
[00:53:14] Speaker D: Okay.
But of course, there's one other formula that we need to consider in the chihu space that we will see with some regularity in here, which is Dutch hautong.
[00:53:26] Speaker C: Yeah.
[00:53:27] Speaker D: What's the distinction here? I mean, we kind of rolled over into sinisan.
What's different about Dutch hauteng? And why would we go there?
[00:53:34] Speaker C: Yeah. The dachai hutong picture is very similar to sinisan. First of all, it has almost all of the same ingredients at its base. The one difference is in dachai hutong. And I.
I could make up a reason for this, but I still don't understand why this is the case.
Jurgon sao is taken out for dadzao in da chaotong. So there's literally no jurgon sao in dachai hutong, and there is dadzao.
[00:54:04] Speaker D: That's interesting.
[00:54:05] Speaker C: Yeah, there's. There's some inch. You know, I've heard people say, oh, well, it's because of the.
The jurgon sao is protecting against the pungent flavor that could be. Could aggravate the wood element or encourage the wood element to punish the earth that's protecting against that. So if you really want to bump up or emphasize the quality of shengjiang, in this case, which is in the formula, at a higher dose than normal, you could take out the jurgon sao and add dazao. So it's going to sort of bump up the effect or emphasize the effect.
Take the. Take the pedal off. Take the foot off the petal, so to speak, of the shengjiang.
[00:54:53] Speaker D: Yeah, it's interesting.
[00:54:54] Speaker C: Yeah.
[00:54:54] Speaker D: Because also, dazao is incredibly sweet.
[00:54:58] Speaker C: That's very sweet.
[00:54:59] Speaker D: It's very sweet. And even zhiganzao, which, of course is cooked in honey, is certainly much like palatably sweeter than gansao is. Dazao is still sweeter.
[00:55:09] Speaker C: Yes.
[00:55:09] Speaker D: Dazao is such A sweeter.
[00:55:10] Speaker C: Yeah, absolutely.
[00:55:11] Speaker D: Yeah. Interesting.
So what, what is the indicator for why we would reach for Dachai Utong, then? What's, what's different?
[00:55:18] Speaker C: Dachai Utong is going to have dahuang in it at a lower dose.
It's also going to have bansha and cheongjiang, and bansha is at a typical dose for Chai Hutong dose. So I, I use like 12 of Bansha.
[00:55:35] Speaker D: Yeah.
[00:55:35] Speaker C: But Sheng Zheng is up to 15, so it's, it's higher rather than like say 9.
So the pungent, the acrid warm is a lot more significant in Dachai Utong than it is in sinisan.
So it's going to be better for treating things like nausea or upsurge. So if you have a similar picture Dachai hutong sinisan, and you're not sure which one to do, both can have the costal tenderness, the rib side tenderness. Both can have alternating bowel patterns, but could be dry. Right. In both cases, both can have recu. Both can have rectus abdominal tension. Both can have that hard epigastric obstruction. All of that can be the same Dachai hutong.
If you have nausea, that's one symptom that takes you to Da chi right away.
[00:56:29] Speaker D: Okay.
[00:56:30] Speaker C: Anything where there's stomach upsurge. So if they're hiccuping, nausea, vomiting, any of that kind of stuff, that's when we go to Dachai hutong. That's a pretty quick, clear change.
[00:56:42] Speaker D: So all the other factors can still be in place, but we add on top of that nausea or upsurge symptomology. And so we clearly need to descend more.
[00:56:52] Speaker C: Yes.
[00:56:52] Speaker D: And so that's where we're going to have the Da Huang. The bansha.
[00:56:56] Speaker C: Yeah.
[00:56:56] Speaker D: It's interesting because, you know, bansha as an herb, I think of bansha's dissension kind of like the midline of the body from say, like where Adam's apple is to your waistline.
[00:57:10] Speaker C: Yeah, absolutely.
[00:57:11] Speaker D: And then dahuang descends from your umbilicus to your anus.
[00:57:17] Speaker C: Right, right.
[00:57:19] Speaker D: So it's an interesting kind of like just sort of directional location about like where exactly that dissension is occurring. And so of course, that's why we see bancha, you know, like bancha hoputang, things like that, where there's like stuckness in the throat. We need to descend all of the upbearing sensations, nausea, vomiting, and like every other formula you can think of, bancha serves that function.
[00:57:39] Speaker C: Right.
[00:57:40] Speaker D: And then Da huang has got that dissension in the actual colon itself.
So in this case, again, just like, you know, we started at the top with these Chungxi Tongs, where Dahuang is a big player along with Mangshao, because we need to really force out strongly.
But note that in Da Chihutang, Da Huang is there, Banxa is there, but not Mangsha.
[00:58:00] Speaker C: Right.
[00:58:01] Speaker D: Because we're not trying to like forcibly wet and purge you. Right. We're just trying to descend to restore the physiologic process of dissension.
[00:58:11] Speaker C: Right.
[00:58:12] Speaker D: And I think that's a really important distinction to understand. Right. Like if we.
In many ways, Da Chung Qi Tang is.
It might be a little dramatic to say, but in some ways it's almost like an emergency formula. Like you're super backed up, you gotta get moving. Right.
Here's the Da Chong Qizang. Let's open you up.
[00:58:31] Speaker C: Yep.
[00:58:31] Speaker D: Right. In a similar way that we have like with again, over the counter laxatives. You know, if you haven't pooped in four or five days, someone's going to give you a pretty moving laxative because we got to get you going. You know, if a person had to use Da Chung Chitang regularly because they're constantly getting stopped up, if they did that, let's say kind of like how people use over the counter laxatives, I think we'd see a very similar dependency and exhaustion which result.
[00:58:59] Speaker C: They do in China. Right. There's, there's doctors who are surgeons who will say that the, if you take Da Huang for too long, it will actually change the color of the intestinal wall. What you'll be able to track and see, like they'll be able to go in there and see that it's been like stuff stained brownish black.
[00:59:18] Speaker D: Yeah, yeah. And this again is, this is not to suggest that Dahuang is dangerous or that you should use it.
[00:59:23] Speaker C: It's not dangerous if, if it's done.
[00:59:26] Speaker D: Yeah. It's just that like anytime you have to use a formula as a rescue tool.
[00:59:31] Speaker C: Yeah.
[00:59:32] Speaker D: There's clearly something else going on.
[00:59:34] Speaker C: Yeah.
[00:59:34] Speaker D: So you can't just rely on the rescue tool. And I think this is something that happens with people sort of steeped in a biomed model. Like if you have chronic dry constipation and you're eating enough fiber, your doctor's going to go, well, you know, if you're really stopped up, just take a little smooth move. Like there isn't going to be. There's no mechanism for addressing why you are consistently dry constipated. That would just be like, well, you're old and you should eat more fiber. Yeah, and that's pretty much it. This again is why Chinese medicine really sings is because we actually do have an understanding of this, because we have a much broader and more comprehensive understanding of physical dynamics of human bodies. And so we know what's happening here. You're not just old, right? Being old has something to do with it, but it's not just like, oh, sorry, you're old, you're just going to have dry stools now. Sure.
Okay, so I think that distinction is pretty clear then for the listener in the dry constipation space about when we would make each move right. Between all of these four formulas that we've discussed. So I guess it's really 5 Da Chung Qi tong as your sort of emergency, you know, again, maybe a slightly dramatic term, but you've been, you've been constipated for a while. We need to move things hard, relatively short duration of use and we wouldn't want to use it, you know, every single week, forever. So you got to look at what's underlying it. Matzarin 1, which is a mod of Xiao Chung chitang, is going to have dry constipation with some urinary difficulty and a kind of Yang Ming presentation, big abdomen, that kind of stuff, tenderness, etc.
We're going to shift into a Xiaogan sao formula when we start to see very tight rectus dominus, for example. So we've got this musculature piece that's showing the yin deficiency. Maybe we just go straight to Xiao Ganzao Tong. Or as you mentioned, maybe it's this follow up formula to Matsurin 1 once things have kind of moved along or.
[01:01:25] Speaker C: Sinisan, or even sinny san after sinisan. Yeah, yeah.
[01:01:28] Speaker D: Because of course Xiaogansa tong is a less complicated sinnisan.
[01:01:32] Speaker C: Right.
[01:01:32] Speaker D: Because it's in there. It's always fun to say like a two herb formula is a formula. Because I'm like, how many formulas have Khanao and Shayu in them?
[01:01:40] Speaker C: Right? So many, so many.
[01:01:42] Speaker D: It's a particular ratio of them here, which is also important.
Right.
So if you have all of those abdominal symptoms and dry constipation, but you also have chiu indicators, alternating symptomology, rib side tenderness, hypochondriac discomfort, et cetera. Cinesan is probably the thing that you're going to be looking at. And then if you have all of that or some combination of that, particularly again the chihu symptomology, but you also have nausea or other upsurge symptoms, acid reflux, belching, hiccuping, et cetera. Then probably dot Chihu tong is what you need to start with.
[01:02:16] Speaker B: Yeah.
[01:02:17] Speaker D: Okay. That's a good breakdown.
All right. Now, of course, the trouble is, is that we're never so fortunate as to just have just one thing that walks into the clinic. Oh, is it dry? Is it wet?
[01:02:27] Speaker C: Sure.
[01:02:28] Speaker D: Yes.
[01:02:29] Speaker C: Yeah. Sometimes it's both.
[01:02:30] Speaker D: What if it's both? Okay, so we got it both. We got it mixed. Sometimes the bowel movement comes. It's hard and dry. Sometimes the bowel movement comes and it is wet and loose. What do we do now?
[01:02:40] Speaker C: Yeah, so you may need a mixed formula. That's, that's the quick answer is you may need a mixed one. There's some archetypical mixed formulas and then there's ways we can sort of make our own if another formula, let's say, is largely fitting but requires a little extra push on the other end. So we can talk about that.
[01:03:00] Speaker D: Okay, so let's, let's take maybe, let's go the archetypical position first.
[01:03:06] Speaker C: Yeah. So shay shin tongs, let's talk about those. So shayan tongs.
There's actually six shayan tongs, but three that are used regularly.
So I'm going to talk about those three. The other three are, let's say, modifications of da huang, huanglian, shay shantang, which is just those two herbs steeped as a tea. So that's basically just taking bitters.
[01:03:33] Speaker D: Yeah.
[01:03:34] Speaker C: And that's for a very mild obstruction of the epigastrium. That's a qi layer obstruction. So it's not meant to make you purge, really. It's just moving the qi through the stomach, basically. That's all that. That is.
And it's exactly like taking bitters.
[01:03:51] Speaker D: Yeah. For which there is a long standing tradition in basically every culture on the planet.
[01:03:55] Speaker C: Yes.
[01:03:56] Speaker D: Of using some kind of bitter concoction to help with digestive upset. I love. Actually, this is one of the places where western herbalism still exists, but in a way that people don't think about herbalism in, like bitter liquors. Yeah, herbal liquors. Like, you know, you think of, you know, stuff that gets mixed into fancy cocktails at bars with people with long beards, you know, like that kind of place. Like they're using what we now think of as fancy cocktail liquors that were actually designed as digestive supporters. Because it's one of the ways that you can preserve those bitters for a long time.
There's a really common. Well, really common. I Mean, you can find it in places called Underberg. It's a German blend of bitters that come in these little tiny bottles that are wrapped in paper.
And it's a friend of mine, actually, New Year's Eve this past year, they were like, oh, we gotta. We had a big meal before we went out for New Year's Eve. They're like, oh, you gotta take your underbergs. And they literally had brought like a sleeve of them with them, like, handed them to us, and everyone was just like, take this before we go out, because, you know, it's gonna be a long night and we got some stuff going on. So there is this long standing tradition of using bitter flavor to deal with a kind of like congestion in the middle part of the body.
So the three shayshantongs, the big players are not that they're not that they're much more forceful.
[01:05:18] Speaker C: The other three are just to go over them quickly. Sanhuang Shaishin Tong, which is the addition of Huang Chin to the previous formula. Da Huang, Huanglian Huang Chin, and then fuccessentang, which is the addition of fuci to that. And they're rarely used. Right. In the modern clinic. So I don't think it's worth talking about them in any great detail.
[01:05:39] Speaker D: Table them for your reference.
[01:05:40] Speaker C: Yeah, yeah.
[01:05:41] Speaker D: All right, so let's talk about the three that we do use, probably starting, I guess, with Bansha Shayshan Tong.
[01:05:47] Speaker C: Yeah.
[01:05:47] Speaker D: The one that I think probably most people have heard of.
[01:05:49] Speaker C: Yeah. Bansha Shayshan Tong is the standard shay shintong. And Bancia Shai hintang is also considered a harmonizing formula because it is both an excess and a deficiency formula, A hot formula and a cold formula. It does all of those at the same time.
So it's harmonizing.
Bansha Shay shintong can be modified in two different ways that are done commonly. And then Zhang Zhongjing calls them different formulas. So one is adding to the dosage of gansao, which could start at 6 or 9, depending on how you dose your formula. And he takes it up to 12. Some people take that up to 15 depending on what they're working with.
[01:06:35] Speaker D: So we. We take the ingredients of Bansha xiaotang and then we increase the dosage of gansao to say, 15.
[01:06:41] Speaker C: Right. And now we have Gan Sao Shai Xingtong.
[01:06:44] Speaker D: Imagine that.
[01:06:45] Speaker C: Yeah. Gan sat, Same formula, just different dosage of Gansao.
[01:06:49] Speaker D: More Gansao.
[01:06:49] Speaker C: Yeah.
[01:06:50] Speaker D: Okay, so let's start with the standard one, though. So if we're choosing Banxai Shaishin Tong harmonizing formula, as you said, because it's cold and it's warm, it has this descending and uplifting quality. There's this sort of interesting juxtaposition of opposites that exist inside the formula.
Why would we need a formula like that for someone who has a mixed pattern of constipation?
[01:07:15] Speaker C: So the pattern of constipation that this is going to be will look like they have a late bowel movement, meaning there's time in between. Let's say there's. They go every other day or every third day. When they go, the first part of it is a hard plug. The second part of it is softer.
So if they say that, the first thing that I think of is a shay shinton, usually bansha.
[01:07:40] Speaker D: Yeah.
[01:07:41] Speaker C: So that's a. That's a good example of mixed. A mixed pattern with constipation. Constipation being the time, the frequency of the bowel movement being slow, but then when it comes, the consistency of it is mixed. And this is not separate bowel movements. This is the same movement. The first part of it is like a plug, and then the second part is softer, maybe even loose.
[01:08:05] Speaker D: Yeah. It could actually be water.
[01:08:06] Speaker C: It could be loose. Yeah.
[01:08:07] Speaker D: Yeah. Okay. And of course, like, if someone's having that kind of combined bowel movement, like combined qualities within the same bowel movement.
[01:08:15] Speaker C: Yeah.
[01:08:15] Speaker D: That's why we're picking a formula that has such a broad array of approaches. Yeah. Because there is a hot, problematic old problem.
[01:08:22] Speaker C: Yeah, Right.
[01:08:23] Speaker D: There's a descending and an uplifting problem. Like there's. All of those things are happening.
[01:08:26] Speaker C: Yep.
[01:08:27] Speaker D: So what would lead us then to. To modify Bansha Shayshin Tong and reach for any of these other variations? What's different?
[01:08:36] Speaker C: So for Gansocin tong, which we've mentioned, the key difference is some kind of vexation agitation symptom, which could be the person is agitated.
[01:08:50] Speaker D: Irritable.
[01:08:50] Speaker C: Irritable.
[01:08:51] Speaker D: Yeah.
[01:08:51] Speaker C: Could also be. Has a difficult time sleeping. So if there's a sleep component to the pattern, I think of Gonzalez, the other thing that could happen is the vexation. Agitation could present as a skin problem. So Gan Sautian tongue is actually a fantastic skin formula.
[01:09:11] Speaker D: Interesting.
[01:09:12] Speaker C: Yeah.
[01:09:12] Speaker D: So is that the increase in the gansao? So we're increasing the sweet component of the formula.
[01:09:20] Speaker C: Yep.
[01:09:20] Speaker D: By increasing that kind of sweetness, we would therefore moisten a little more. Tonify, a little bit more.
[01:09:26] Speaker C: Yeah.
[01:09:27] Speaker D: So I'm assuming that, like, some of that vexation is a byproduct of probably an underlying deficiency that's playing around. Is that the. Is that the piece?
[01:09:36] Speaker C: It is, yeah. And the way that I was taught to think of it is the sweet flavor is said to moderate fire.
So it's sort of like if. If the fire is, like, blazing, you know, it kind of like settles it down a little bit. That's what it. That's what sweet does to fire.
[01:09:52] Speaker D: So it doesn't surge as high.
[01:09:53] Speaker C: It doesn't surge as high. Exactly.
[01:09:55] Speaker D: Okay. Yeah, got it. So banja shay shintong as standard presentation of this, like, combined constipation piece. But then if the person has, in addition to the constipation part, some insomnia, some irritability, some kind of mood thing, and. Or a skin layer problem, we switch to gan sa shishentang.
[01:10:16] Speaker C: Yeah.
[01:10:17] Speaker D: Okay. But of course, there's another. There's another shay shintong, Shengjiang shai shintong that we have in here. What's different about that one?
[01:10:24] Speaker C: Shengjiang shai shentong is going to be. So let's talk about the modification first. You take Ganjiang from nine down to three, and you add Sheng Zheng in at 12.
[01:10:35] Speaker D: Got it. So we take original banxai shishingtong, drop the ganjiang add in.
Yep. Okay.
[01:10:41] Speaker C: And you're like, what, we're trading ginger for ginger?
[01:10:44] Speaker D: Yeah.
[01:10:45] Speaker C: And yes, and this is a perfect example of using the doctrine of signatures, the Xiangjiang having fluid left in it. Right. Versus the ganjang being completely dry. So the thing that we're targeting in Shengjung shi shintong is more water or more damp in the intestines.
So the.
The presentation here is going to look more like loose stool. When the stool comes, it's going to be more loose. Maybe there's occasions where they have loose stool in between the previous presentation that we talked about. But there's also a lot of gurgling.
So borborygmus is a textbook symptom of shay shintong patterns in general. If that borborygmus is really pronounced, then I'm thinking more about Sheng Zheng Shai shin tong especially.
And remember, these are just modifications of the same formula. So you can literally give all three quite easily. You know, like, you can just bump the bump the gansao, put down the ganjiang, put in Sheng Zhang, and literally give all three shayshen tongs at the same time. Yeah, no problem. Yeah, yeah.
[01:11:51] Speaker D: So the presentation. And that leads us to reaching for the Xiangjiang mod is. So it's constipation. The frequency problem's still the same.
But when they have the mixed presentation is a little bit hard, stool behind it isn't just soft, but it's like watery and loose.
[01:12:08] Speaker C: Watery and loose. And maybe like the next. They have two or three more bowel movements that day that are also loose.
[01:12:16] Speaker D: Got it, yeah.
[01:12:17] Speaker C: So that's more common for Sheng Zhengshe Hsintong in particular.
[01:12:20] Speaker D: Yeah. Because I'm trying to think for the listener to be like, well, how would I. Because we talked about wet constipation at the front.
Is there a circumstance in which someone who just has the wet constipation presentation could get handed Shangjun shishan?
[01:12:35] Speaker C: They could, they certainly could, yeah. I think it would depend on some other factors. So let's say we're doing abdominal palpation. Right.
If we look at xiangjung shai shintong, we're going to want to see some kind of epigastric obstruction.
We're going to want to see a water splash sound.
And oftentimes in shay shintongs too, the skin temperature will feel different in different places. Classically feels warmer up at the top of the abdomen and colder, lower. So there's actually like palpable heat, cold at the same time. This is one thing that will cue me into the Shayshatang picture. So there's other things. Whereas if it's just wet constipation, there may just be a feeling of cold. There may still be water, but the picture may just look more like water, if that makes sense. There may be more dizziness, there may be more difficult urination. Urination isn't really a symptom of Shangjing shishunta.
[01:13:37] Speaker D: Right. Yeah. Right. But it would be if it was just like cold, wet.
[01:13:40] Speaker C: Yeah.
[01:13:41] Speaker D: Deficiency presentation. Yeah. So in this case, I mean, we, you know, the obvious piece is that someone is having the hard plug start with the wet, follow up on a constipation frequency.
The difference between ba cha sha, shintong, gansa shishing tongue, largely, largely here is this additional component of vexation. Right. Which could also be a skin element of vexation. And then Xiangjiang shishin tong, of course, is modification that still has the mixed pattern but is distinctly more wet.
[01:14:11] Speaker C: Yes.
[01:14:12] Speaker D: And would have elements in the abdominal exam that continue to indicate a mixed pattern. Right. So like, as you mentioned, heat in different locations, cold in one area, hot in another. That's mixed. And that's why we know that we're in a mixed pattern versus just being in the wet constipation pattern, which is fundamentally a cold.
[01:14:31] Speaker C: Right. Fluid, dampness pattern and a lot more borboregness. For shay chitongs, you can have a little bit with the wet patterns, but it's like, again, you might be like, holy crap. If somebody's on your table and you're doing acupuncture and their guts are just, you know, gurgling the whole time.
Think shay shintongs and particularly xiangjiang shai shin tong.
[01:14:54] Speaker D: Well, that's. I mean, that's a great spread of formulas that everybody got here. I want to mention before we close out, just, you know, when we're talking about constipation, we've been spending all this time talking about it in an herbal context, but without doubt, if you are talking about constipation, people are going to want to know about fiber, right?
[01:15:14] Speaker C: Sure.
[01:15:14] Speaker D: Yeah. Should I be eating some fiber?
[01:15:16] Speaker C: Right.
[01:15:16] Speaker D: Yeah, it always comes up.
So I just wanted to take a little bit of a mention on the idea of fiber. Fiber right now. If you, If. If you're at all plugged in to the sort of health and wellness world, fiber, in my opinion, especially if you're plugged up.
There he goes. There he goes.
I think that fiber is likely to be the next macronutrient craze. Yeah, protein has been. Yeah, there's a lot of reasons. It's been burbling for a little while. You know, there's a lot of, like, glycemic index management, blood glucose stuff, fiber this, fiber that, fibers in a lot of places.
So, you know, prepare yourself, practitioners for suddenly being inundated about questions on fiber. The good news is that fiber is actually a macronutrient that we've been studying for a long time in a lot of different contexts biomedically. So when patients come to ask you questions about it, it is actually fairly easy to know what to do about fiber. So a couple of things are just kind of put into your toolkit. So most adults should be consuming somewhere between 28 and 32 grams of fiber in a day. Right. So that's total grams of fiber.
[01:16:27] Speaker C: Yeah.
[01:16:28] Speaker D: Most people who have quote unquote, good diets eat a lot of vegetables.
Probably come nowhere near that number. Yeah, I do a lot of fiber audits for people when I do digestive work and diabetic work and stuff like that.
Most people with quote, unquote, good diets are getting somewhere in the like 14 to 18 range.
[01:16:47] Speaker C: That sounds about right.
[01:16:49] Speaker D: Like almost half, really, of where you need to be.
And that's because food that we eat is not whole grain anymore.
[01:16:55] Speaker C: Yeah, right.
[01:16:56] Speaker D: For. For most of Human history, people got their, their fiber from whole grains and from beans and legumes. So, you know, unless you have someone who culturally eats a lot of beans, right, they're probably not getting enough fiber. And that's because like, yeah, there's a lot of fiber in like apples and broccoli and stuff, but like you just can't eat enough broccoli in a day reasonably to get the fiber that you need to get.
So that means of course, that a lot of people just in general throughout their whole lives have not consumed enough fiber. And so then they get to. Usually the classic presentation is you have someone who's older.
So obviously yin and yang are in decline now as they're older, we usually tend to see a loss of yin substance, particularly in female bodied people, particularly ones who had children. There was a lot of outgoing jing and blood and yin throughout many years of their lives.
And so you'll see this classic sort of hard, dry constipation that presents in women. And so then you'll get this diagnosis of like, oh, you just need to eat more fiber. This sort of the biomed piece. And the truth is that they probably do.
What's actually happening in there is that fiber serves an interesting component when it shapes a stool.
In the case of a dry presentation, the soluble and insoluble fiber that moves through your digestive tract, the insoluble parts are the parts that your body can't absorb, but they will hold on to water.
Think of fiber is a pretty good example. Thin threads that are very, very dry, but can plump up and hold water.
When people eat fiber, the insoluble components of the fiber go into their digestive tract and the water that's being pulled out from their stool as part of the natural process of digestion. We know that there's a sluggishness there and a yin deficiency there. And so when their digestive process goes to pull out moisture, there was less moisture to start because they were yin deficient. And now we have a hard dry stool.
We add fiber into the mix and that fiber is going to hold on to that yin stuff more strongly. So even though the colon is going to pull out water like it normally does, the fiber is going to hold it and keep the stool wetter. Right?
So I did a little combined biomed Chinese medicine explanation there. But basically the fiber that people are consuming when you have a dry presentation is providing anchor point for moisture in the stool.
[01:19:15] Speaker C: Right.
Makes sense.
[01:19:17] Speaker D: On the other side, people have very loose, wet stools, right? And stuff is Moving through the bowels very quickly. Fiber is a little bit trickier in that scenario because what we usually find biomedically when people have wet deficient, damp, cold presentation is that there is an insufficiency of a lot of what the biomeds are calling gut microbiome, gut microbes. Right.
That are able to manage a lot of the digestive things that need to happen in a healthy gut.
So you have this real tension with fiber, with people who have like a wet presentation because they actually do need to eat more fiber. But if they suddenly rapidly increase their fiber intake. Right. All of those little fibers holding on to moisture in the gut, of which there is currently too much, is going to make that bowel even slicker and even more rapid.
[01:20:11] Speaker C: Yeah.
[01:20:12] Speaker D: And will actually result in a lot of gas and bloating and gurgling and all kinds of weird things. Because now what should be providing bulk and substance to the stool is actually facilitating way too much moisture at once.
So in dry people, dry stool people, you can pretty much just be like, yep, go ahead and take some Metamucil, eat some prunes. You can rapidly increase your fiber. It's not going to cause a huge issue in wet presentation deficiency. Cold people, you gotta slowly increase the fiber. So what you do is you do a food journal with someone and you take a look at what they're eating. Do what I call a fiber audit, where I literally am just calculating how much fiber I think they're getting in a day. If you don't know anything about that, you can literally just google what people eat and see how much fiber is in it.
And then let's say they're coming in at what I usually see, 14, 16 grams. We want to get them to 28. You're not going to get them to 28 grams for probably three to six months.
[01:21:05] Speaker C: Yeah. It's got to be real slow.
[01:21:07] Speaker D: Real slow. So we're going to say, okay, you're doing 16 grams, like on the reg. I want you to start doing 20, and we're going to do 20 for two or three weeks until everything feels good. At 20, there's no issues. And then we're going to go to 24 or 25. Right. And when I say increasing like that, what do I mean? You're going to have to give people some advice.
Usually I have folks add more beans into their diet. Not like big bowls of beans, like, oh, here, eat some beans. They'll feel terrible. Everyone knows how gassy you can get if you just eat lots of beans. But, like, you Made a soup, throw a can of beans in there. You know what I mean? You made chili, throw some beans in there.
You want to have a little side of, of lentils that goes with your chicken or whatever. Like you're just trying to slowly add that stuff in. And you can also, of course, do it with supplementation. So you can just use Benefiber, you can use Metamucil, you can use Metamucil crackers. Like, if someone doesn't want to modify their diet, but they want to get the fiber in, you can do it that way. It's always better if it comes from food, in my opinion. But whatever, we work with what we got, you know, and then as you slowly increase that person's fiber intake, the stool will actually shape better. It'll start to have more structure to it because you're building a whole new relationship between the moving parts inside someone's gut, and so you'll end up with a better stool in the long run. So everybody needs fiber. The wet people need fiber, the dry people need fiber. But the way that it's approached needs to be a little bit different because their constitutions are different.
And the rate at which you increase the fiber is, is also a big deal.
And as I said, you know, if you're not tracking the wonderful world of fiber, get in there, read a little bit about it, right? Just, I mean, you can literally, honestly, these days, you could probably chatgpt it and it would be halfway decent. But like, you know, start reading a little bit about the research in fiber, go over to NIH studies, take a look at PubMed, see what people have been talking about with fiber relative to digestion and also to blood sugar management, things like that. I think it's something that we're all going to want to be a little bit more conversational about going forward because patients are going to have questions for us about it, and it's always nice if we have at least some passing idea of what's going on there.
[01:23:05] Speaker C: Yeah, that's a good point.
[01:23:06] Speaker D: Yeah.
Okay, well, that's our long discussion about constipation. So thanks to Trish again for sending us the question. We really appreciate that and hopefully this is been helpful in giving all of you a little bit idea about the various ways to deal with constipation.
As always, you know, this episode being a perfect example. We love questions from the audience. So if you guys have something you're wondering about and you'd like to listen to or hear us talk about, please send it over to infoootandbranchpdx.com that's infoootandbranchpapadeltaxray.com and we'd love to get your questions and make some or more episodes about it.
So until we talk to you next time, I'm Travis Gurn.
[01:23:49] Speaker C: And I'm Travis Cunningham.
