Show Notes
TC and TK get into some specific examples of treating covid and long covid. Listen in for some treatment specific details!
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Episode Transcript
[00:00:02] Speaker A: Hi everyone and welcome to the Nervous Herbalist, a podcast for Chinese medicine practitioners who like herbs and want to learn more about their function, their history and treatment strategies to use in the clinic. Let's get into it.
Hello everybody and welcome back to another episode of the Nervous Herbalist. My name is Travis Kern and I am here with my co host Travis Cunningham. And today we are going to follow up on our discussion of COVID and Long Covid and give you guys a couple of case studies to consider to take a look at it. So maybe let's go ahead and start with the COVID ones and just sort of get a sense of, you know, what does it look like treating Covid these days?
[00:00:44] Speaker B: Sure. Yeah. So I have two quick cases here that I can go over and then if there's any questions or if it makes sense to elaborate, you can kind of cue me a bit. So first case that I'm going to present happened in July of 2023.
This patient is a 64 year old male and he contracted COVID 19, confirmed with a positive test after going to the Oregon Country Fair. Actually I was. This is a phone consult. So I spoke with him on day three of his symptoms. He had no fever, chills or body aches.
He just felt sniffly, had a runny nose, sneezing, was congested. He was able to sweat. After I questioned that out, minor swelling, dry feeling in the throat, very mild cough, no visual or hearing changes, and no temperature changes.
So for him, I ended up giving him kind of standard triple Yang formula which is Xiao Cai Hutong or Caihu Guizhou Tong plus Gagan. But the cough modification of Xiaochai Hutong, which means that I'm going to take out Renshin and Dazao, change Xiangjiang to Ganjiang and add Wu Weizi and then the addition of Guizhi Baishou and go Gun. Right. So I had him take a bulk decoction, one bag per day for four days of that.
[00:02:27] Speaker A: So pause for one second. So why. What about his particular case presentation made you. I mean, the cough, the cough mods. Obvious because he has a cough.
[00:02:39] Speaker B: Right.
[00:02:39] Speaker A: But what, what about the other. What else was in the case that indicated that you were going to include the Guizhu Baisha piece?
[00:02:46] Speaker B: So mostly the. So I'm not just going to add GGEN into the formula because I want to add. I'm thinking of it as adding another formula to it. Right. So if I, if I'm going to add Ggen into Xiaochai Hutong, I'm going to add Guizhu Jia Gagintang into it. So that's really the reason.
Other than that there's no indication given the symptoms that we just heard that he needs guizhi and baisha. But I'm not going to just add an herb. I'm going to add another formula that's a little bit of a safer modification to do it that way. And you never know, like I can't feel his pulse. Right. I'm not able to see him and see kind of what's going on. So maybe there are things that are happening that he's not reporting to me.
[00:03:32] Speaker A: Right.
[00:03:32] Speaker B: I don't know that. Yeah.
[00:03:34] Speaker A: So the, the need for Guizhu Jia Guggan Tang added in is because of the particular symptom presentation.
[00:03:42] Speaker B: Yes. The nasal congestion in particular, sniffly runny nose, sneezing and congested.
[00:03:47] Speaker A: Got it. Yeah, got it. Now if he was here in person and you and you had had opportunity for the physical diagnostics because you know we've talked about before sometimes like how Shao Cai hutang can address a lot of these kinds of things.
[00:04:02] Speaker B: Right.
[00:04:02] Speaker A: Like congestion and stuff like that.
[00:04:03] Speaker B: Yeah.
[00:04:04] Speaker A: So from you, where's the line that says like, okay, we need to go ahead and add in, you know, Guer Gogan tong because the level of congestion is more than I would expect Sha Chaitong to be able to handle. Like where's the line there?
[00:04:19] Speaker B: I think so the thing that pointed me towards Xiaochai Hutong actually is the feeling of dryness or soreness in the throat. So what I'm trying to figure out, like if you just read this list of symptoms off the first formula that comes to mind is Gegentong actually like not a Chihu formula. But what I'm trying to figure out, and this is partially like due to experience I know that most people when they get sick they land in Xiaoyang very quickly if not immediately. So it's day three already. So I'm thinking ah, he probably like time wise it's probably in Xiaoyang. But I want to make sure given the symptoms that it's not if I'm not going to use it. And again I can't feel his pulses. So if I could feel his pulses and I was like, oh, it's really just, it's really just in the Taiyang like it's not penetrating that deeply. The pulses are just a little bit superficial and like, oh, okay, we'll just do Guggen tongue then it'll probably resolve. Guggen tong is very good for resolving nasal congestion, sniffly nose. The other thing that he said, though, that would point me away from needing Gugu Tong is he can sweat.
[00:05:34] Speaker A: Right, right.
[00:05:35] Speaker B: And Guggen Tong by itself has Ma Huang in it. I've actually now seen that you can kind of use gegentong, even if they can sweat a little bit and it just resolves faster. That's all that's going on.
[00:05:49] Speaker A: Well, especially too, because these days, making gauge with Ma Huang can be challenging.
[00:05:53] Speaker B: Right, right, right.
[00:05:54] Speaker A: Yeah.
[00:05:55] Speaker B: So at this point, I'm playing like, if I'm seeing somebody and I'm treating them over the phone, I'm going to be conservative with, like, I'm going to give them what I think is likely to be happening, even if the symptoms are kind of mild. So I. That's why I went to the chaihu, because as soon as it starts to get with to throat involvement, I'm thinking chaihu. And then in order to get to the nasal congestion piece, that's where we need the gagan sort of action.
[00:06:23] Speaker A: Right, right. Okay. All right. So you did it as decoction.
[00:06:28] Speaker B: Did it as decoction, Yep.
[00:06:29] Speaker A: All right. How. How many. How many days?
[00:06:32] Speaker B: Four days.
[00:06:33] Speaker A: Okay, and what did you see?
[00:06:35] Speaker B: Results were the patient felt better after taking the herbs the very first day. He continued to take the herbs until they were finished. Four days later. All of his symptoms had resolved, including the phlegm and con. And I talked to this patient a few weeks later, and there weren't any residual symptoms. So this is basically like a straight up cold and flu case. Like, there's nothing specific in this case even. But we know that he had COVID 19 because he tested for it and he tested positive.
[00:07:05] Speaker A: Right.
[00:07:06] Speaker B: So he did have COVID 19. This person is. Has been vaccinated. I know that.
So the symptoms were pretty mild, but because he tested positive, he was like, I want to get ahead of this thing and treat it and make sure, you know. So we did, and four days later, he was fine.
[00:07:24] Speaker A: Yeah. And then dosage wise, you used your sort of standard.
[00:07:28] Speaker B: Standard dosage, yeah. Chai who, 24, Huang Chin, 9, Bansha, 12, Ganjiang, 9, Wu Wei, 12, Jugan, so 6, Guijer, Baishao, 9, both and Gogan, 15.
[00:07:43] Speaker A: Nice. Okay, that's great. I mean, that's a pretty solid transformation. And it's also good for people who've been listening. We've mentioned it in a couple of different episodes, but the. The cough modification for Xiao Cai Hutong. So that's the removal of Renshen and Dazao.
[00:08:00] Speaker B: Yes.
[00:08:00] Speaker A: Switching the Xiangjiang to Ganjiang.
[00:08:02] Speaker B: Yep.
[00:08:03] Speaker A: Change the dosage there. When you switch the Shengjiang to Ganjiang.
[00:08:06] Speaker B: You keep it the same. I keep it the same, actually.
[00:08:08] Speaker A: Keep it the same.
[00:08:09] Speaker B: So it's still nine.
[00:08:10] Speaker A: Add 12. At 12.
[00:08:12] Speaker B: Yeah.
[00:08:13] Speaker A: Okay. So everything else the same. We even keep the ginger dosage the same. We're just making it warmer.
[00:08:18] Speaker B: Yep.
[00:08:19] Speaker A: Right. And then we'll wait at 12.
[00:08:21] Speaker B: Yep.
[00:08:22] Speaker A: Got it. Yeah. And then we should maybe take a minute and talk about, like, we often are talking about granules when we do shows, but this. You gave in bulk. Why is that?
[00:08:33] Speaker B: Yeah, I have basically stopped trying to give people granules for acute cold and flu presentations. I just don't think they work nearly as well, even if you have the right. I had a case actually, myself, got sick somewhat recently, and I had the granule formula, the exact same granule formula. And. And a bulk San. Actually, it wasn't a full bulk formula, but it was a powder that was the same exact formulation as the granule one. And I took the granule one and I was taking tons of it, like 45, 50 grams of granules a day. And I felt a very little change. And then I switched to the. The bulk San method. Same exact ingredients, and it was very definitive, like, different. I felt different right away. I felt much better. The case changed and.
But yeah, like, I. I just, I think that bulk herbs are much more effective for acute cold and flu presentations. I just, I don't think the granules work as well.
[00:09:38] Speaker A: What. What dosage were you taking the granules at?
[00:09:41] Speaker B: The granules were like. Like, again, I was taking probably 8 grams every two hours. Like for the. Yeah, so a lot.
[00:09:54] Speaker A: Yeah, like, I mean, in the course. In the course of a day, you might have 36, 40 grams.
[00:10:00] Speaker B: 40. Yeah. Something maybe that day. And I felt very little change on those at all. Same exact ingredients with a different method. Way different result.
[00:10:10] Speaker A: So how much of the San powder were you taking?
[00:10:13] Speaker B: I was taking.
Yeah, that's a good question. I think I was taking two and a half tablespoons of it a day, which would. I can't remember what that would translate to.
[00:10:26] Speaker A: Gram wise, it's probably about 30 grams.
[00:10:29] Speaker B: Yeah.
[00:10:29] Speaker A: Maybe ish. They're pretty variable in volume by weight, depending on the mix. But for that mix, that's probably somewhere between like 30 and 40 grams.
[00:10:37] Speaker B: Yeah, yeah.
[00:10:38] Speaker A: Of powder. And so you were putting that into a pot, covering with water, and just.
[00:10:43] Speaker B: Cooking it for between 5 and 10 minutes. Strain and strain and drink. Yep.
[00:10:48] Speaker A: Yeah. Yeah. So this, this is a good case to just. It gives us the opportunity to kind of talk about those three forms of intervention. Right. Like the vast majority of people out there have access to granules.
[00:10:58] Speaker B: Right.
[00:10:59] Speaker A: And their patients are trained to taking granules. But when we're talking about cold and flu, it's hard, it's hard to get the work done with granules. I think particularly at the early stage is what we've observed.
[00:11:12] Speaker B: It's the early stage that makes the biggest difference.
[00:11:14] Speaker A: Yeah, yeah. Because like imagine the circumstance where like someone had this infection but they didn't come to see you, so they just like wrote it out and then it kind of got lodged in their chest and now it's like a, you know, it's been two weeks or something. They don't have chills and fever anymore, they don't really have body aches, but they're still coughing, they have phlegm, they feel kind of run down.
I've seen pretty decent effect with granules at that stage.
[00:11:40] Speaker B: Yes, I have too, interestingly.
[00:11:42] Speaker A: Right. So like you like a Gualo Shia by Ban Cha Tang, like something like that, break up the phlegm and it seems pretty effective.
And I don't, I, I can't tell our listeners like why that seems to be the case. Like, I don't know what it is about acute active infection where it seems like granules don't have the oomph.
[00:12:06] Speaker B: Right.
[00:12:06] Speaker A: Even at a really high dose. Because like what you've described is the same. Like when I have a, when I've tried granules for myself, like a standard Xiao Chai hutong, I'm taking 12 grams every four hours.
[00:12:18] Speaker B: Right.
[00:12:19] Speaker A: And all day.
[00:12:20] Speaker B: Right.
[00:12:20] Speaker A: You know, and I'm taking like, I've taken 60 grams of granules.
[00:12:24] Speaker B: Yeah.
[00:12:25] Speaker A: And I'm like, I mean, I guess I'm a little better.
[00:12:27] Speaker B: Right?
[00:12:28] Speaker A: Like, but it's just not, it's just not clear. Yeah, but if you were drinking just like two cups of Shao Chaotang decoction in that same period, like two 8 ounce cups made with standard dosing, you would notice the difference a hundred percent. Like it's really palpable. So I wish I had a better explanation for the listeners as to why, because I don't know, we're going to continue to experiment and maybe in 20 years we'll have an answer for you.
But for now it's not clear. Real acute stage though.
You really should use bulk if you don't have access to bulk. This is an interesting question one of our residents asked me the other day. I was like, well, what about people who don't have bulk. Is it still better to give them the granules? Yes, and I think probably it's just like it's expensive and in some ways it's kind of like, you know, make sure that they can get access to good quality food and they can stay hydrated and that they can stay warm and like, let's let their immune system fight it out.
[00:13:33] Speaker B: Right.
[00:13:33] Speaker A: And then once the acute infection has subsided, four or five, seven days.
[00:13:38] Speaker B: Right.
[00:13:39] Speaker A: Let's see what it looks like. And then we can probably use granules to deal with it.
[00:13:43] Speaker B: Right.
[00:13:44] Speaker A: That's really too bad because like, it.
[00:13:46] Speaker B: Is, it's, it's really a timing difference, like as far as the. How quickly people get better, that's the biggest thing. So like if I'm going to give somebody herbs for cold and flu, a generally healthy person, even if the person, let's say not perfect health, just an averagely healthy person, if you give them herbs and you give them the right formula with the right dosage, they should be done with their symptoms in five days. Yeah, for sure, for sure. If not sooner.
[00:14:19] Speaker A: Yeah. Three to five is kind of three to five days.
[00:14:21] Speaker B: If they still have symptoms five days on, we either didn't hit it hard enough, we missed the pattern. If they're still sick in a week, that like, that's the same as not taking any medicine for a lot of people.
[00:14:34] Speaker A: Right.
[00:14:34] Speaker B: People will get over a cold in a week. Most people will, maybe with a little congestion or something.
[00:14:40] Speaker A: Exactly.
[00:14:41] Speaker B: So if you intervene with herbs, you want it to do something like you want it to shift it, you want it to give it a direction. So yeah, I think three to five days, you're looking for resolution in that time.
[00:14:55] Speaker A: And that's the thing. Right. So with the, the problem is with granules at a super, like that's the other thing. Granules become very expensive. If someone is taking 40 grams of grams, you're not saving money, you're not saving any money. So it's an accessibility question for sure. Like maybe if you just. You only have granules at your pharmacy, in your clinic, so that's all you can do.
[00:15:15] Speaker B: Right.
[00:15:16] Speaker A: I don't know. These days I kind of are the position, like just have them save their money and let's deal with it after.
[00:15:22] Speaker B: Treat it in a week.
[00:15:23] Speaker A: No, literally, like treat it in a week. They still need it.
[00:15:26] Speaker B: Yeah.
[00:15:26] Speaker A: Because I'm not certain that you're really doing anything. I'm sure there are listeners out there who strongly disagree. Right.
[00:15:32] Speaker B: Like, oh, and to give credence to another perspective, there are Patients who you will give like 6 grams of granules twice a day for their cold and they'll feel better.
[00:15:44] Speaker A: Yeah.
[00:15:44] Speaker B: There are those patients. So not saying that that doesn't work for some people. It just doesn't work for most people.
[00:15:50] Speaker A: Right.
[00:15:51] Speaker B: Like, not the vast majority of people. It is not strong enough to get you to where you need to go if you're intervening with herbs, in my opinion.
[00:15:59] Speaker A: Yeah, yeah. And I think we've seen that a lot. I think we've seen that a lot in the clinic, obviously. And so I feel, you know, feel confident with that position. I think if anything, it really underscores the notion though that like, humans are really diverse.
[00:16:13] Speaker B: Yeah.
[00:16:14] Speaker A: You know, and so we talk about things in norms and most. And probable and common.
[00:16:20] Speaker B: Yes.
[00:16:20] Speaker A: But of course, like depending on who you're self selecting into your clinic, what kinds of people you deal with, like there could be a lot of variation that comes into that. But you know, again, we're talking about things that we've seen and I will say too, just if you have access to bulk, try and use more bulk.
[00:16:38] Speaker B: Yeah.
[00:16:39] Speaker A: This is something we see a lot of our experienced practitioners using with our own medicine area, just using san method we've talked about before for all kinds of stuff.
Many things beyond just cold and flu.
[00:16:52] Speaker B: Right.
[00:16:52] Speaker A: Because there's a kind of potency that's available in really high quality herbs that are fresh and freshly ground and well maintained as they would be in any respectable pharmacy.
And it's obvious to anyone, even without training, that there is more available qi.
[00:17:14] Speaker B: Oh, yeah.
[00:17:15] Speaker A: In a bulk preparation than there is in a granule one.
[00:17:17] Speaker B: Absolutely.
[00:17:18] Speaker A: And it's not a. It's not a knock against granules, conceptually, it's a knock against processing. Like the more you process something, the less available. It's like some of its constituents will be consumed in its transformation. And like that's okay. Like, that's how some stuff goes. But like, if you have the ability to capture more of it, particularly in specific areas where we've seen that needing that extra qi really matters. Because, like, that's the thing, objectively, bulk herbs always have more available qi than granules. But it doesn't always matter.
[00:17:53] Speaker B: It doesn't always matter that much.
[00:17:54] Speaker A: That's the thing. It doesn't always matter.
[00:17:56] Speaker B: It doesn't. And it isn't worth the cost in some cases to push that hard. And yeah, like, we use granules all the time here. We're big fans of granules. There's major advantages to using them. It's just that in this case it's not as good. Definitively not as good.
[00:18:15] Speaker A: Yeah, yeah, yeah. And so if you're, if you're wondering like, oh, well, I'd like to try that, then you just need to get yourself set up with a pharmacy who does bulk herbs. So like we do bulk herbs. Camel on the east coast does bulk herbs. There's a couple of people around the country who do bulk herbs and they mail them, you know, and we're.
[00:18:30] Speaker B: I would say now if I were to treat that patient again today, I would use a san method. I wouldn't be doing standard bulk because it is less expensive and it does seem to be very effective. Yeah, very, very effective. We're going to do. Once we. Once our software hopefully updates.
[00:18:49] Speaker A: Yeah. So. So we're keep getting told we'll do.
[00:18:53] Speaker B: More specifics on how to put those formulas in and. And we'll talk about that more.
[00:18:58] Speaker A: Yeah, exactly. Because it's an important, it's an important tool that I think we're learning more about. Yeah. In broader applications than just like regular sans.
[00:19:07] Speaker B: Yes.
[00:19:08] Speaker A: So I think, I think that's going to be really great to see. Okay, great. So we have an understanding about this formula, why it was modified, the dosage that was used and the outcomes.
[00:19:17] Speaker B: Yep.
[00:19:18] Speaker A: Great. You had another one in your mix there.
[00:19:20] Speaker B: This is another pretty quick one. Okay, so this patient is a 37 year old female who came in actually about a month before the previous case. In June of 2023, this patient caught a cold two weeks prior to coming in and the cold had gotten better and worse. And then she tested for Covid and found out that it was in fact COVID 19 did test positive.
So over the course of two weeks, it's kind of gotten better and then worse again. Better and then worse again. Right. So she comes in to see me and this person I did see in, in person at the time she came in, she had no fever, chills or body aches.
She had low energy and brownish green congestion that felt like it was coming from her chest and still nasally. And she had a sore throat. She had a slight headache, low thirst, like she didn't want to drink water.
Very frequent urination. She felt like she had to keep getting up and peeing.
Tickle in the throat leading to a cough, but no digestive changes. So her digestion was normal.
[00:20:39] Speaker A: Okay.
[00:20:40] Speaker B: I did check her pulses because she was in person and her pulses were in some very superficial and strong feeling. Strong wiry left side, more superficial than the right for sure.
[00:20:58] Speaker A: Okay.
[00:21:00] Speaker B: And so what I did was I again, I did a bulk decoction, and I. I did the Xiao Chahutong cough modification again.
[00:21:12] Speaker A: Okay.
[00:21:13] Speaker B: And then I modified it for chest obstruction. So I added Gualo and Huanglian, which makes Xiao Xian Chong Tang, minor chest obstruction pathogen formula. And then I also added Xiabai, which creates Gualo Xia Bai Ban Sha Tang.
[00:21:35] Speaker A: And then also, just as a point of reference, t's doing a really good job of pronouncing those names clearly, because Xiao Xianxiong Tang is of course not the same as Xiao Jian Zhongtang, Right?
[00:21:52] Speaker B: Definitely not.
[00:21:52] Speaker A: It's a very different form of difference. And if you say them really quickly and you're not Chinese, as we are not, those things can just get, like, mashed together.
[00:22:00] Speaker B: Triple XT is one way we refer to this one.
[00:22:04] Speaker A: Yeah. So shout Xianxiong Tang. That's it. That's the one that we're currently talking about. So just, you know, keep your opinion in check. Okay. So you use the kof mod on the Xiao Caotang.
[00:22:17] Speaker B: Yep.
[00:22:17] Speaker A: We added in Gualo Huanglian.
[00:22:20] Speaker B: Yep.
[00:22:20] Speaker A: To give us xxxt. And then we also added xiebai. And so we ended up in a. We have three core formulas together. Song modified for cough, Xiaoxian Xiongtang, and then also Guolo Xia by Bansha Tang.
[00:22:35] Speaker B: Correct.
[00:22:35] Speaker A: Right.
[00:22:36] Speaker B: Yep.
[00:22:36] Speaker A: Okay.
[00:22:37] Speaker B: That's it.
[00:22:38] Speaker A: And that's it. So what. What happened?
[00:22:40] Speaker B: So I gave her that for.
I actually gave her that only for three days or three doses. I gave her. I gave her bags. So I gave her three bags of that formula, and I had her take one bag for the first two days, and then the third bag, I had her take over the third and fourth day. So that one was split in half, if that makes sense.
[00:23:04] Speaker A: Yeah, yeah. So stronger dose at the front, one bag per day for two days, and then the third bag split over two days.
[00:23:10] Speaker B: Right.
[00:23:10] Speaker A: Okay. Like a little titration.
[00:23:12] Speaker B: Like a little titration, yeah.
And this just to give a little more background on this patient. She's very thin and very light, so I used my standard dosage for her, but I had a feeling that it was going to change more quickly than, let's say, the patient we talked about beforehand.
And I've also worked with her for a while, so I know she responds really strongly to herbs quickly.
[00:23:37] Speaker A: Yeah.
[00:23:39] Speaker B: So the patient felt dramatically better after taking the herbs the first two days. She continued the herbs as we discussed until they were finished. I actually ran into this patient at an event in town somewhere later that week, and she basically completely recovered. So no lingering congestion, no alternating symptomology any longer. She felt pretty good in it. She said it took her about five days.
[00:24:10] Speaker A: Okay.
[00:24:11] Speaker B: Fully.
[00:24:11] Speaker A: Okay. To like, fully feel better.
[00:24:13] Speaker B: Yeah.
[00:24:14] Speaker A: Nice. So the choice to include the chest obstruction components.
[00:24:19] Speaker B: Yeah.
[00:24:19] Speaker A: The gualo, the xia bai. What, what in her case stood out and said, hey, I need to actually do that here.
[00:24:25] Speaker B: So the congestion that was. You could hear the congestion in her chest that crackling when she breathed. Right.
The. The brownish green phlegm sort of idea. And also the tickle in the throat that leads to a cough. We call that wind phlegm. So that's. The phlegm is like sticky and sticking on the bronchials. And then when air passes through it, irritate. Like the bronchials become aware in a way that there's something stuck on them. So it's irritating. So that's why we cough. Right. So the key. That's a key indication for gualo that we need, like some kind of chest obstruction type of thing. I didn't write it down here either, but I'm pretty sure too, she had chest pain. Like a pain in her chest when she coughed. Yeah, because that's my. That's the symptom that I'll look for to add xie bai. So that's the distinction between just xiao xian xiong tang. Right. Which is just guolo bansha and huanglian, and then guolo xiebai banshatang. When you add xiebai in the formula, there's a pain component to the B type of thing.
[00:25:40] Speaker A: So, okay, so that, I mean, that's your clear differentiator. Then when you're looking at the case, like why. Why modify or not? The cough mod's obvious.
[00:25:49] Speaker B: Yes.
[00:25:50] Speaker A: But then the addition of those other components is because we've got what is, I think, from a biomedical point of view, progressing into an upper respiratory tract infection.
[00:25:59] Speaker B: Right.
[00:26:00] Speaker A: So we have like phlegm. We have colored phlegm. People are coughing it up. There's pain and burning in the chest. There's discomfort in that upper bronchial space.
[00:26:08] Speaker B: Yep.
[00:26:09] Speaker A: So it's different than I just have a cough.
[00:26:11] Speaker B: Yes.
[00:26:12] Speaker A: Right. There's like a different layer to what's happening there. Okay. Yeah, that's interesting. Like, it's good to have, like, clear indicators for when to make those changes, you know, because again, we're starting with the same base. Like, we're starting with Xiao Chiutang. Because as you said, like, people rapidly find themselves in a Shaoyang presentation.
[00:26:30] Speaker B: Right. And this is even two weeks later. Right. She's still in Xiaoyang. She's still having alternating stuff, still has a sore throat.
[00:26:39] Speaker A: Well, and the fact that it's two weeks later is also one of the reasons that it's in her chest now.
[00:26:42] Speaker B: Yes.
[00:26:43] Speaker A: Because it wasn't addressed two weeks previously and it's progressed. And this is the kind of case where even among healthy people, you can find someone who's still kind of sick like, two months later because they just never have been able to fully.
[00:26:58] Speaker B: Right.
[00:26:58] Speaker A: Like, purge it from their lungs, and then they'll get another cold. And these are the patients that will tell you, like, yeah, you know, I've basically just been sick all winter.
[00:27:05] Speaker B: Right.
[00:27:06] Speaker A: And that's because we've never really been able to get rid of the whole thing. And those kinds of, like, lingering. Like, in this case, we're dealing with COVID diagnoses in particular. But, you know, the idea, too, of just a general cold and flu that never really resolves can lead to subsequent symptoms that we're in the context of the show and in health right now, talking about long Covid symptoms because Covid has so much attention on it.
[00:27:30] Speaker B: Right.
[00:27:30] Speaker A: But we really never, like, we don't know. We don't have a collection of data to say, like, well, what's long flu symptoms?
[00:27:36] Speaker B: Right.
[00:27:36] Speaker A: What's long regular cold symptoms from people who have, like, reduced immunity. They get sick all the time. Like, we just haven't been thinking about it in those lenses. And what's likely is that people who have unresolved pathogen of any kind from an exterior invasion in particular, have a greater indica, like, a greater likelihood of having seemingly unrelated problems from a biomedical point of view that are actually connected to this unresolved sticky pathogen.
[00:28:04] Speaker B: Right. That's cold damage.
[00:28:06] Speaker A: Right? Cold damage, yeah, yeah, yeah. They built. I think they wrote a book about that.
[00:28:11] Speaker B: You don't say.
[00:28:12] Speaker A: I think they might have.
Okay, so let's pivot then, and let's talk a little bit about some long Covid in particular. So that's like, sort of active Covid.
[00:28:19] Speaker B: Yep.
[00:28:20] Speaker A: So now long Covid's happened, and, you know, people have some of the symptoms like we talked about in the last show.
[00:28:27] Speaker B: Right. You have a case for us?
[00:28:29] Speaker A: I do, yeah. So I have a patient.
We're actually still treating her now.
So this is a patient. She's in her mid-40s.
You know, previous to getting a pretty gnarly COVID infection, she was very active. Right. She had a job that was very demanding, a lot of hours, just Sort of moving, doing, going, you know, but constitutionally history of asthma, some kind of like copd, like respiratory symptoms, even though, like she doesn't have copd. Like, everything is negative, but there's just a kind of the way that her respiration interacts with oxygenation and her heart, like it. There's something there constitutionally been there since she was a kid. Right.
Tendency toward metabolic disorders like weight gain and sort of fatigue and like over the years, because of the sort of biomedical lens that everyone lives in, she's got all these various diagnoses long before COVID Right. So we're testing for Hashimoto's and then we're looking at hypothyroid. And then there's like, is there fibromyalgia and is there chronic fatigue? And then maybe now there's pots and like, there's just. There's sort of like a pylon of various.
[00:29:43] Speaker B: Right.
[00:29:44] Speaker A: Diagnoses from a western point of view that are related to what from our point of view is a constitutional tendency toward weak spleen, damp accumulation. Right. These are like just sort of physical realities. And then combine that with like a lot of modern person inputs of like sweet food, processed food, junk food, like working long hours, not sleeping a lot, like not staying hydrated, high stress. Like, it's really just sort of like a collection of the ills of modernity that we see all the time.
[00:30:17] Speaker B: Yep.
[00:30:17] Speaker A: I just see this all the time in every context. So this patient is based on what we were talking about in the last show, like she's predisposed to negative long term outcomes from toxic damp exposure. Yeah, you know, that's just. That's where we're at. It's sort of starting from scratch. And if it wasn't Covid, it could have been a really nasty other cold. It could have been literal environmental cold exposure. Like going on a hike next to a waterfall in the winter and like getting hard, wet invasion. You know, all of this stuff is sort of part and parcel of a type. And the thing is though, is that the COVID infection that she ended up with was just really nasty, super virulent, and knocked her down for days and days. I mean, she dealt with like an active chills and fever, alternating symptomology, body aches for like nine or ten days.
[00:31:09] Speaker B: Wow.
[00:31:09] Speaker A: It was.
[00:31:10] Speaker B: That's exhausting.
[00:31:11] Speaker A: Absolutely brutal. Yeah. And so post. In, post recovery from that infection. So like the chills and fever go away, the body aches, retreat, sort of full body aches retreat. But then she's got A chronic headache every day, right. Low grade pounding headache that can particularly, like, it can spike to a full, like, stabby temporal kind of migraine feeling. But every day it's. It's chronic. And it's frontal, Right. It's across the forehead, behind her eyes, very clearly in the sinuses. Right. Like, those mucosa are swollen, you know, they're wet. She's got severe congestion with phlegm moving down her throat, but also sneezing. Right. But it's super sticky.
[00:31:53] Speaker B: Yeah.
[00:31:53] Speaker A: So it doesn't come out. It doesn't flow. Even when it flows down her throat, it's like in chunks.
[00:31:57] Speaker B: Yeah.
[00:31:57] Speaker A: Like, she can try and like, swallow it or spit it, but it, like, it's. She described it as being like she can feel it in her nasal passage, like, dangling in her throat, but it's so sticky that she can't, like, try and swallow and pull it out or cough it out. It's just, like, stuck there. She can, like, feel it all the time.
And so this has also led to some visual stuff because, like, she feels this pressure in her eyes all the time. And now she feels like she can't quite focus and she's blinking all the time. And so then she goes to the eye doctor, and the eye doctor's like, oh, there's some kind of swelling in your eye. And, like, what's going on with the retina? And so, like, she's kind of like, starting to rack up. Like, this is what we see with long Covid. It's like a long Covid bingo card, right? Where it's like, all right, chronic congestion, headaches, swelling in retina, cardiovascular limitation, blood oxygenation issues. Right. And so the biomeds are, like, testing all of these things, right?
But they, you know, of course, they don't have any explanation. So she's got a lot of muscle fatigue and weakness. Doesn't feel strong. Feels like, you know, her muscles are weak. And then also they just kind of ache a little bit. When I described the sort of wet blanket metaphor for dampness, she was like, oh, my God, that's me. Like, the blanket is soaked and I can barely get up from underneath it, you know? And then we combine that with gastrointestinal symptoms. So loose stools three to five times daily. Watery or mush, A lot of nausea, nauseated all the time. Frequent bloating. Doesn't matter what she eats. But of course, some things make it worse. So dairy bad, cold bad, raw bad. She figured all this out on her own. She had already started, like, purging those things out. She was working with a naturopath of course and they put her on a, a pretty decent diet from our point of view. Like just get rid of all of this sweet flavor, basically all the raw stuff. Fiber is very low because her guts just really can't handle it.
History of acid reflux that you know, comes and goes. Like if she's doing better on this anti inflammatory diet that the naturopath put her on, then the acid reflux seems less, the bloating is less but like it's still there. Right.
Um, and so now like when she wakes up in the morning, so her lived experience now she wakes up in the morning, feels the headache which never goes away.
Huge amount of phlegm in her throat which she tries to like cough up but she's like gagging and stuff to try to get it cuz it's super sticky. Right. And then she's gonna have like a semi urgent morning bowel movement that's probably watery mush. And then she's gonna have three to five of those total in the day she has just an utter energy crash at least once a day, sometimes twice. Right. Especially of course after lunch. Just like can't function and she can't keep track of stuff like foggy headed, strong mental faculties. So she's actually had to stop working because she couldn't deliver. She's just like, I literally can't do it. She had to take disability to deal with the outcomes.
So you know that that set of symptoms is like. I mean, I said it kind of flippantly. I don't mean to be dismissive of the symptoms but it, but it is really like long coveted bingo. Like it is like she got all of them. You know, it's not one rain like one segment of it, it's like pretty much all of them. And I bet if we put her through an EKG she would have some like weird cardiovascular rhythms.
[00:35:22] Speaker B: Right? Like you know, whatever.
[00:35:24] Speaker A: Yeah, just it's going to be like all the things, you know, that are there. So of course like as we've talked about before, like if you're going to approach a complicated case, like it's easy to get overwhelmed by the complicated case. So let's look at some objective findings. So the tongue is swollen, tooth marks, not a huge coat, but a little bit greasy, pale, not surprising, giving what's there but also not hugely revealing. Right. You're just like, well yeah, that tracks, you know. So then we do abdominal exam and we have strong rib side tenderness on both sides. Um, I would say like kind of a, in the midline, sort of superior to the, to the umbilicus, kind of, you know, between that and sternum. You know, no abdominal aorta pulsations, nothing like that. But like, you know, with strong pressure, it's also uncomfortable. Not as bad as at the sides, but there.
[00:36:20] Speaker B: Yeah.
[00:36:20] Speaker A: You know. And then also though of course, sub umbilicus discomforts, like both, both lower quadrants, like right inside of asis are really tender.
[00:36:30] Speaker B: Yeah.
[00:36:30] Speaker A: And so it's kind of like, well, the abdomen's involved. Like, you know, there's so. There's so much that's like stuff showing up. Yeah, a lot of stuff here. Like, what are we going to do?
And so the patient is not super thirsty, but does drink a lot of water. It was a little. Actually it was one of the few times that I had a hard time fully gauging like, was the patient thirsty or not?
[00:36:53] Speaker B: It's a hard, it's hard questions.
[00:36:55] Speaker A: Yeah, A lot of follow up questions that usually clarify it, but in this case I was like, well, I'm not really sure now.
[00:37:01] Speaker B: You know, I've asked this same question to multiple herbal teachers because it's a point of distinction. Like that's hard to get clinically.
[00:37:09] Speaker A: Yeah.
[00:37:10] Speaker B: And it's also named as a main differentiator between formulas in the Shanghan Lun over and over again.
[00:37:16] Speaker A: Yeah, the thirst thing.
[00:37:17] Speaker B: The thirst thing, yeah.
[00:37:18] Speaker A: Yeah. So in the end I was like, okay, I think, I think she is thirsty is what. Because like the amount of water that she's drinking isn't just like health water. Right, right. Like they're being cued to drink. Right. So like, okay, you are thirsty.
She doesn't have weird taste in the mouth. But eventually I'm like, yes, you have tacky mouth. Like there's dry mouth, like you are thirsty. But what I just want to mention by saying that is like when I asked her like, do you feel like you're thirsty? She was like, well, I drink a lot of water.
[00:37:45] Speaker B: Right.
[00:37:45] Speaker A: Which is what a lot of people say. And I'm like, no, I understand. But like, are you thirsty when you drink the water? She's like, I mean, I don't know, I drink it all the time, so it's hard to know. And I was like, okay. Like, it's just like, keep peeling this back.
[00:37:56] Speaker B: Classic.
[00:37:57] Speaker A: So anyway, she is thirsty. So she's thirsty.
She's got this. She's got abdominal findings in all the quadrants.
She's got a tongue that is, you know, damp, obviously. Fluid retention, Strong sock line edema.
[00:38:15] Speaker B: Yep.
[00:38:16] Speaker A: Like very strong, like deep sock line marks that persisted the whole time she was on my table. Like she laid there for 35 minutes and the sock line was still visible. Right.
And then of course there's like this phlegm that's in her face, but in her throat and in her chest. Like, it's just sort of like in this whole upper jiao zone, sort of like sternum up to the top of her eyeballs. It's just like phlegmy and sticky and gross.
So I'm like, okay, what are we going to do with this? What are we going to do with this? So because of its persistence, because of its like it she know she tried all kinds of different stuff that the code, the original COVID infection was like, like a year ago.
[00:38:54] Speaker B: Yeah.
[00:38:55] Speaker A: Right.
And it's, you know, just doctor after doctor after doctor. So I was like, okay, what I'm going to do is I'm going to give her lingua, jugan tongue, but I want to throw some extra stuff into lingui jugantong. And so what I ended up doing is I added in gualo, tianwafen and xiabai. So I'm going for my gualo xia by banchatang. But I'm using tianwafen instead of bancha because of the thirst. Right. And then because I just can't resist like post covet aromatics I put in. Well, I guess they're not super aromatic. But I added binglong and salgwal into this stuff because whenever I have like sticky, long standing stuff, I include binglong in a lot of these formulas.
And it's mostly inspired actually by one of our teachers who was like, you know, when you look at the cross section of binglong, it has all the tiny little capillaries in it, Right. And he was like, you know, this moves in the luo mai, like in the deep place. Right. And I just use it all the time for stuff like it's one of those herbs that I just will like stick in a formula to be like, hey, I want to drive this forward. And I wanted to start with like a middle of the road aromatic in the form of salgo that wasn't too dry and not too forceful, but could just kind of like maybe start to break up some of this dampness in a subtle way. This is kind of like a test formula. Like, let's see how this goes. We'll get a little bit guager in there, we'll get a little bit fluid transformation in there. And we'll deal with some of the, like, sticky construction constraint with this gualo she had by vaja thing. Right. So she took that for two weeks, and the most telling thing that came out of it in two weeks was her stools got stronger.
[00:40:44] Speaker B: Huh.
[00:40:45] Speaker A: Interestingly so, like, her morning phlegm gagging was reduced. Less phlegm in the chest, thinner and actually easier to swallow or cough up. And I was like, okay, that's good. And then the stools went from being mostly watery to being mostly unformed. So we got like a mushier stool and her, like, irritable gut, like, quick to go off was less irritable. Okay, so okay, great.
But sock line edema untouched. Tongue still super swollen. Pulse, which I didn't mention before because, you know, I don't do a whole lot of differentiation with pulse, but they're deep. They're deep there, but they're not super weak. They're just, like, really deep. Like, you gotta, like, go underneath a lot of layers to, like, get to it. So she took it for two weeks. We got these results. I said, you know what? Go ahead and take it for another two weeks. Just like, keep chipping away at this chest thing. Cause, like, it still was, like, sticky here in the chest. So she takes it for another two weeks as it is, mostly because I honestly just wanted to see what would happen. Yeah, I was like, let's move in the right direction. I don't know. This is the perfect formula, but I want to see how it's going to move. So she takes it for another two weeks, and then the morning gagging flim thing is mostly gone.
[00:41:59] Speaker B: Great.
[00:41:59] Speaker A: Which is great. Stools even more formed. Still not formed, but less frequent. We're at like two to three a day, mostly mush.
Chest constraint seems to be relieved or on the way to being relieved. Great.
Absolutely no change whatsoever to the edema pattern. Tongue looks exactly the same. Flesh is still soft. Abdominal findings are still, like, now, instead of both sides being super tender, one's way less tender and the other is just mildly tender. Both of the sub umbilicus quadrants are still wicked tender.
[00:42:32] Speaker B: Yeah.
[00:42:32] Speaker A: Right. So, like, okay, what do I want to do with this? So what I decided to do was I.
I kept lingue jugan tong as the sort of the base of what we're dealing with. And I added in Wulingsan because there's clearly this water accumulation that I'd like to move irrespective of, like, the phlegm dampy bit. And then I wanted. Because the other thing is of course, her lived problem is this congestion in her face.
[00:42:59] Speaker B: Right.
[00:43:00] Speaker A: Like the headache and the tightness in the face. And I thought, okay, what if I can try and cut through that with an aromatic tool?
[00:43:08] Speaker B: Yeah.
[00:43:09] Speaker A: The Sal Guo has been in there, but like it's not really doing it. So I traded it out for Baidu Ko. So like, if you think of like Sharon, Baidu Ko, Sauo.
[00:43:18] Speaker B: Right.
[00:43:18] Speaker A: They're all of a kind, they're all cardamoms, but they're all like a little bit different.
[00:43:22] Speaker B: Yeah.
[00:43:23] Speaker A: And so like if Sharon is like the most like punchy old man cologne of the, of the cardamoms and Saguo is like sweeter and like still aromatic, but in a more subtle way. Beidou Ko is in between.
[00:43:37] Speaker B: Yeah.
[00:43:37] Speaker A: In my experience.
So let's go a little bit more potent, but I don't want to like slice too hard with the dryness because this is what I found too is like when people have sticky phlegm, you can go for aromatics, but if they're super dry, you can actually make it stickier unintentionally.
[00:43:53] Speaker B: Yep.
[00:43:53] Speaker A: So you're like trying to balance those two. So I picked Baiduko and then I also threw in some Bijer and then added in Wuling sand. Took out the Shia by piece.
[00:44:06] Speaker B: Yeah.
[00:44:06] Speaker A: Right. Left in the gualo though, because I was like this still, there's still stickiness here. And so she's in the process of taking that now. So after a week of take, because I just gave her a week of that as a test because it's like a new shift and I wasn't sure, like, are we going to send her off, like peeing rapidly, increase in urination, but a market change in stool.
[00:44:26] Speaker B: Yeah.
[00:44:27] Speaker A: Right. So which was really nice and like an initial change in the density of the congestion, but not entirely gone.
[00:44:35] Speaker B: Yeah.
[00:44:35] Speaker A: And so this case is of course still in progress. I don't have a full resolution on it yet. And the reason that I decided to offer it to the listeners, even though it's not completed, is because it highlights, I think, a lot of the challenges with a multi tiered presentation. They got a lot of moving parts and there are things that are obvious to me that need to be corrected, but they're not necessarily the thing that's the most concerning to the patient. The thing that she wants gone the most is the headache. Like the headache. The headache and the pressure behind her eyes. And as we know, headaches are hard to treat on their own, much less like inside of this constellation of damp accumulation dynamics.
So as it's moving, like the signs point to. Yes, but one of the things that's been different here is that my modification and substitutions have been, I think, a little less organized than I would want. They feel a little bit like, like, like slap shod. Right. Like, okay, I've got this core mechanic of lingua, jugan tongue, wuling san that's doing a thing. But I had a really hard time resisting adding in aromatics and other mods as sort of like pairs, as dwayao pairs. Right. Just being like, okay, here's a pair of things. Here's a pair of things.
I think, because honestly, I was a little. I was impatient, I was like, I don't want to run another two weeks without getting these aromatics in just to find out that, like, it's working, but it's working too slowly.
[00:45:59] Speaker B: Right.
[00:45:59] Speaker A: And so I jumped ahead. But what has happened now is that the picture is a little bit muddled in terms of like, exactly which direction the formula is moving in. And so when she comes back in another two weeks, she will have taken this formula for three weeks.
If I'm lucky and the stars have aligned, the congestion in the face will have really started to change. And if that's the case, I'll probably leave her on the formula for another two weeks and just really let it move out.
But if it hasn't sufficiently moved, I'm going to have to really clear the board. I'm going to have to sit back, start over, abdominal exam. Like, what does it look like today? Throw out the previous explanations. Because by not using the kind of systemic modifications or systematic modifications that we usually talk about, the formula has gotten mudd.
[00:46:45] Speaker B: Yeah.
[00:46:45] Speaker A: And so now you're like, like, it's hard. It's like you can't. It's hard to pivot now because the formula is too muddy. The substitutions and the modifications haven't been systematic enough to decide, okay, we made this mod and this happened or it didn't happen. So let's go back to base. Like, it's just gotten too sticky. So I use it as an illustrative case because it's interesting and complicated, but also because I think it can help remind the listener that, like, even those of us who have experience, we do this stuff a lot. Like, you know, sometimes you get over your skis a little bit.
[00:47:19] Speaker B: Yeah.
[00:47:19] Speaker A: And you're like, okay, well, we gotta re. Gotta retool and put this back into a position where like, we can figure out how to go forward. And of course the patient is Benefiting this whole time?
[00:47:28] Speaker B: Yes.
[00:47:29] Speaker A: You know, the patient's benefit the whole time. We haven't, we haven't plateaued. We're not wasting time or money. And they don't know anything about this. Right. They don't know. They're just taking herbs. So the complexity of mods and changes, like, that's sort of. That's in my head, in my charts, in this conversation.
So from the patient's point of view, like, things are progressing. They're very pleased with the rate of change because, of course, they've been dealing with this for like a year with no improvement. And here's this improvement happening pretty rapidly from their point of view, like in a three, four week period.
So that's all good. It's just like, you know, we. The whole point of the show and the reason that we, that we talk about these things is to try and give people an understanding of, like, how do you move through complex cases.
[00:48:08] Speaker B: Right.
[00:48:09] Speaker A: In a systematic way so that you can know if things are working. And I think this is just another example of how, like, it's important to always go back to those basic principles because otherwise the picture gets messy and then you don't know what to do.
[00:48:21] Speaker B: Right.
[00:48:22] Speaker A: And. And that can happen to anyone. Yeah. And so it's, you know, I think a good reminder. Keep it simple, keep it repeatable.
[00:48:30] Speaker B: Yeah. Did maybe you said this. Did the headaches shift on the.
[00:48:35] Speaker A: The formula, so. Not really. Not in the first one, no. The headaches, she, you know, it was one of those things where sometimes, you know how patients are trying to almost give you more credit than you deserve?
[00:48:44] Speaker B: Sure.
[00:48:45] Speaker A: Like, she'll be like, I mean, I think maybe they're like, less severe. And I'm like, okay, no, probably not. Like, I appreciate that, you know, but like, if you can't really tell enough to say they're. They're less severe, then it's probably not doing it, you know, so. No, the headaches, like in the first round, the headaches didn't shift much, which is why I was like, let me put some more aromatics to maybe break that up. And then if we manage the fluid side through the wuling sign, maybe that will just take some of the pressure right off of the system by, like, getting the fluids out.
[00:49:16] Speaker B: Yeah.
[00:49:16] Speaker A: And so then maybe the headaches just come down because there's just less pressure in the whole system.
And I think the thing that really cued me to that was like, literally the edema didn't change at all. I mean, not, not that you'd Expect that with Lingua Jugan Tang. It's not exactly designed.
[00:49:29] Speaker B: Right.
[00:49:29] Speaker A: But it does move fluid.
[00:49:31] Speaker B: Right.
[00:49:31] Speaker A: You know, like it thins and moves fluid. So you'd expect some of that, but there's just too much in this system. Lingua Jugan Tong doesn't have the bland oomph to get it going like Wuling San does. So that's why I'm excited to see more about what's going to happen with it. And, and if there's something really revelatory about it, we'll provide a follow up, you know, for other folks to listen to later. But at the moment, I think it's. It's heading in the right direction. My hope is that we can really make some real change. Like I told this patient that, you know, we're really looking at three months as the sort of like minimum real intervention.
[00:50:08] Speaker B: Yeah.
[00:50:09] Speaker A: And then from there, like, we'll have to see how much progress we were able to make and how well she's responding. But I mean, realistically, with all the constitutional stuff, with all the life demands, like with all the stuff that was creating the perfect storm for this toxic dampness to cause so much trouble, like, we would have been working for six months to just deal with all that well before the toxic dampness became part of the presentation. And so now we have both of those things, which are really more like a dozen different things that are sort of all in motion. So it's not fast. But what I want is for her to be able to go back to work, feel like a normal person again, be able to focus, like, deal with her family. Like she just can't do normal stuff.
[00:50:47] Speaker B: Yep.
[00:50:48] Speaker A: You know, so if we can get rid of the headaches in particular, I think we're on that way. Like, mental clarity is, is improving. Bowels are improving, energy's improving. The Flemmy chest piece is also. That's the most dramatic improvement, really, from what we did yet. Again, a win for Guy Bang. Um, and so the next piece is really gonna be the headache.
[00:51:10] Speaker B: Yeah, yeah, yeah. And headache. Like you said, fluid metabolism formulas can be really helpful for headaches. Yeah, that's a big. That's a big way in for treating headaches. Yeah.
[00:51:23] Speaker A: Alrighty, everybody. Well, hopefully that adds a little bit more, a couple more layers to the discussion about different case studies and thinking through more about the movements of things and also reminding everyone to, you know, keep it simple when you make the changes, because otherwise it's hard to track the positive outcomes.
My name is Travis Kern and you've been listening to the Nervous Herbalist with.
[00:51:47] Speaker B: Our co host, Travis Cunningham.
[00:51:49] Speaker A: And we will talk to you guys again soon.
[00:51:51] Speaker B: See you soon.
