[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.
[00:00:11] Speaker B: Treatment strategies to use in the clinic. Let's get into it.
[00:00:18] Speaker A: Good afternoon, good day, good morning to wherever you are. Welcome back to the Nervous Herbalist. My name is Travis Kern and I'm here along with my co host, Travis Cunningham. And we are following up with the last episode where we talked about sleep conditions and insomnia patterns. And so we wanted to kind of flesh that out for you guys a little bit and give you some case examples of how we diagnosed some things, how they were treated. So that way you've got a little bit something to hang the information from the last episode on. So you've got some cases for us. Tell us a little bit about the first one and let's start there.
[00:00:57] Speaker B: Yeah, so the first case is a 41 year old female that I saw earlier this year actually.
She has a chief complaint of neck pain, insomnia and anxiety, which includes panic attacks and a little bit about her history. She had come out of a divorce somewhat recently and it was a pretty difficult relationship, which she didn't get into detail with, but she got emotional when she was talking about it. She started to tear up a little bit.
And since that time, which was months and months before she started coming to see me, she has had difficulty sleeping. And the way that that manifested for her in particular is difficult to fall asleep. And once she fell asleep, she couldn't stay asleep for more than about five hours total per night. So she also wasn't sleeping very long in duration. She'd wake back up, she'd feel anxious, her nervous system would be going like crazy and then she wouldn't be able to fall back asleep.
[00:02:03] Speaker A: Right, right, yep.
The emotional piece that came up in the process, did that stand out to you when she was describing it just as like a sort of added stress factor?
[00:02:15] Speaker B: Yeah, I think that she definitely seemed like. It seemed like she had gone through a traumatic experience. That's the impression that I got. Like it was more than just like a bad something bad. It was like it had shaken her.
[00:02:32] Speaker A: Gotcha. So a higher level of stress than the sort of everyday, certainly. Okay, okay, so tell us a little bit about the key pieces of, of her presentation that led you to your diagnosis.
[00:02:45] Speaker B: Yeah. So asking her to describe a little bit more about the anxiety. She talked about the experience of having panic attacks, which were at the point that I talked to her, happening more rarely than when they first, when she first went through the divorce, but when they happened she had. She experienced chest tightness and she said it felt like an elephant was standing on her chest.
She would also get palpitations that were independent and actually happening more often than a full on panic attack. So that was taking place.
She reported difficulty staying asleep with, I mentioned before, difficulty falling back asleep and vivid dreams when she was asleep. So the dreams were very lively, a lot of content and pretty emotional. She also mentioned she. When she wakes up in the middle of the night, she mentioned feeling heat and not having the symptom of sweating, which I specifically asked about, but feeling hot when she would wake up at night. So I took note of that. In the daytime she generally felt colder overall and talked about how her hands can feel cold sometimes and at night her hands would feel numb. They would like go numb when she'd go to sleep.
I asked her about sweating and she mentioned that she sweats easily and she sweats all over her body. So that's a question I like to ask.
[00:04:33] Speaker A: You mentioned a couple of symptoms there that stand out to me. One is you mentioned that she has really strong dreaming. So you ask a patient that have strong dreaming, what is, what does the answer tell you?
[00:04:45] Speaker B: If they have strong dreaming coupled with symptoms of heat on the surface. I'm looking at that as a, the same, a manifestation of the same dynamic, which is that the Yang is floating. It's not anchoring at night and in the nighttime. Right. The Yang should be anchored, it should be deep in the body. Yin should be on the surface. So the person should be relatively stable, calm of mind.
Their dreaming should be relatively calm. It shouldn't be super active. They shouldn't be sweating and having like heat symptoms.
[00:05:20] Speaker A: Right.
[00:05:20] Speaker B: On the surface.
[00:05:21] Speaker A: Right. Okay. So if they, if you ask the question like are you having strong dreaming? And they're like, meh, I don't really remember my dreams.
[00:05:29] Speaker B: Yeah.
[00:05:30] Speaker A: Is that informative or is it only informative if they've got strong dreams?
[00:05:34] Speaker B: It's only informative if they've got strong dreams. And it's usually not. It's not like one symptom. It's a constellation of things.
[00:05:41] Speaker A: Sure.
[00:05:42] Speaker B: Right. So I'm suspecting that something is up and then I'm asking questions to kind of justify the notion that I'm, that I have about the case.
[00:05:53] Speaker A: Okay.
[00:05:54] Speaker B: Yeah.
[00:05:54] Speaker A: So take us through kind of a little bit of your thought process. So you know you've got a couple of rote questions like, I mean you're going to go through basic 10 questions with this Kind of patient anyway. Right. So then beyond that, what is the first thing that starts to clue you into the pattern? Like, what's what forces you onto a deeper path to ask questions? Like, what would be something in this case that you heard that said, oh, I need to ask more about X.
[00:06:21] Speaker B: So the way that I do my intake is I actually try to ascertain the chief complaint first. Right. So I mostly just ask about what's the person's experience? Like, what are they coming in for? And I try to understand what is it actually like to experience what they're coming in for.
[00:06:41] Speaker A: Right.
[00:06:42] Speaker B: And then after I get that, I actually do my objective diagnosis next. So that's when I will check the pulse. I'll palpate the abdomen. And while I'm doing that, I usually ask more questions. Sometimes I'll ask a few questions before I do that, if it seems like it's related to what they've already told me. But mostly I'm going to ask my questions at the end, so to speak, when I'm already suspecting what the diagnosis is to sort of hone in on the specifics.
[00:07:16] Speaker A: So your objective assessment is what's giving you the first clue of what you think the problem is?
[00:07:21] Speaker B: Yeah, that's like the landscape.
[00:07:24] Speaker A: Yeah. So you've got a chief complaint, which obviously chief complaints have a certain, usually limited cause.
[00:07:29] Speaker B: Right.
[00:07:30] Speaker A: You already have some things that are likely causing, say in this case, sleep problems.
And then you do your objective findings, and based on those objective findings, you're like, okay, based on what I've seen here, it's probably pattern A, B or C. Right. Maybe more pattern A or B. So then you're going to ask questions to clarify further which of those two patterns it was.
[00:07:51] Speaker B: Yeah.
[00:07:51] Speaker A: So do you recall with this patient sort of what that looked like? So what were your objective findings and how did that shift you?
[00:08:00] Speaker B: Yeah, so the objective findings were I found the pulses generally to feel a bit soft, but also a little wiry. So there was a little bit of tension on the pulses. And the abdomen, when I palpated, I found that there was tension in the rib side area, the costal region, that was uncomfortable when I pressed in for her. I also found what we call hard P, which is where there's like the feeling of tight tissue kind of in the epigastric region that when I pressed in was also uncomfortable for her.
I could see the rectus abdominal muscles. Right. So in the fukushin system, this is called riku, which is a sign that we need something to soften the musculature, usually by Xiao in formula. And then periumbilical pulsations, which is where we go to the umbilicus. Right. The belly button. And we feel the abdominal aorta pulsing without really much pressure. Like we're not pressing in deeply. If we press in deeply, you can kind of feel it on anyone. But if it's right near the surface, that tells us that the Yang is being rebellious, has a tendency to be rebellious in nature and not be anchored. And there's a number of reasons why that can be the case, but it shows that that dynamic is happening.
[00:09:32] Speaker A: So your finding of that says, hey, Yang might be rebelling.
[00:09:36] Speaker B: Yes.
[00:09:36] Speaker A: Remind us again, what is the presentation that says Yang might be rebelling?
[00:09:40] Speaker B: So that's the. That's the pulsations. So that's like we're checking the abdominal aorta. So it's kind of like the Ren channel.
[00:09:48] Speaker A: Yeah. So like midline.
[00:09:50] Speaker B: Midline pressing, kind of demon. And you can feel pulsations and pressing with just the light pressure. Not very deep. Because if you press deep, you can feel it on anybody.
[00:10:01] Speaker A: Yeah, because it's there.
[00:10:02] Speaker B: Because it's there.
[00:10:03] Speaker A: Right.
[00:10:03] Speaker B: But if it's. If you. Some people, you can even see it. Like, I'm sure you've had patients where you look at their abdomen and you can see that aorta pulsating. So that's. That shows us that Yang has a tendency to be rebellious and go up. Now, it doesn't tell us why. So you can have pulsations if the person has a type of blood dryness, where the blood is weak and the Yang is coming out of the blood and floating. You can have wet pulsations where there's sort of a functional Yang deficiency. The fluids are accumulating and they're pushing the Yang up.
And generally, for the first type, you will also need the addition of mineral anchoring. So that's often where we'll use longu and mui. With the second type, we'll usually combine guager with fooling or fuzi with fooling. So depending on where it is.
[00:11:06] Speaker A: At this stage, though, when you just feel pulsation.
[00:11:08] Speaker B: Yeah.
[00:11:09] Speaker A: You don't know the answer.
[00:11:09] Speaker B: I don't know the answer to the question.
[00:11:11] Speaker A: You just know Yang is not anchored.
[00:11:14] Speaker B: Yes.
[00:11:15] Speaker A: Okay, so based on those objective measures, you're. You're now suspecting that this. The cause of this particular insomnia is an unanchored Yang presentation.
[00:11:25] Speaker B: Yep. So.
[00:11:25] Speaker A: So now we need to firstly. What. Confirm that that's true and then try and discern which of the various unanchored Yang presentations it could be.
[00:11:34] Speaker B: Right.
[00:11:34] Speaker A: Okay, so what's your next. So what's the next step to make that differential?
[00:11:39] Speaker B: So the next step then is to ask about the specifics of the dreaming, which is what I did.
[00:11:47] Speaker A: Right.
[00:11:47] Speaker B: That's where. Oh, she's having vivid dreams. She's having a difficult time. Like, she wakes up and she feels a little hot. She doesn't have night sweating, but she feels heat. So it's still evidence of this Yang floating type of condition.
[00:12:01] Speaker A: So that confirms your suspicion, based on the objective findings, that it's almost certainly a Yang floating presentation.
[00:12:07] Speaker B: Right.
[00:12:08] Speaker A: Okay, so now you feel confident that it's a Yang floating thing, but we need to figure out what's causing the Yang to float.
[00:12:14] Speaker B: Yeah.
[00:12:15] Speaker A: So now what?
[00:12:16] Speaker B: So then if you look at the other findings. Right. The costal obstruction in the abdomen with the hard glomus shows us that the Qi is having a hard time moving between one of the key pivoting areas of the body, which is kind of like the diaphragm, rib side area. And the pulses are a little softer, but they're wiry, so they have tension to them. So that makes me think we also need to address, in addition to the Yang floating condition, which we would address principally by using something warm, acrid, and sweet together. So like Guizhi and Gansau would be an example. We also need something to move the Qi, because there's likely a dynamic of the Qi getting stuck that's aggravating the condition as well.
[00:13:04] Speaker A: So that's sort of like two elements that are making the sleep bad. So one is the floating Yang, and. And the Yang is anchored by. You said a combination of sweet, acrid, and what else?
[00:13:19] Speaker B: Warm and warm.
[00:13:20] Speaker A: So these should be warm nature, sweet and acrid.
I think if you were listening to that, you might be surprised that acrid would be a useful flavor for anchoring something that is floating and aberrant.
Can you take us a little bit through why those two flavors work here to anchor the young?
[00:13:38] Speaker B: So it has to do with why the Yang is floating, which is the Yang is deficient. Right. So the sweet, warm and acrid flavor combination is the neijing's combination for transforming into Yang, or tonifying Yang.
And if we need to anchor it more, then we add the minerals. Right. So, so the sweet and the warm and the acrid, that's really kind of like the core combination to tonify Yang.
And we can use different herbs to do that at different layers of the body. So if we were Doing the upper jiao or we're focusing on the heart, then we're going to use more guizhi and gansao. That's kind of our standard. Whereas if we're trying to do the middle jiao, Right. Then we're going to use like a ginger and gansao type of formula. And the lower jiao is going to be more fuzzy and ganza or something equivalent. Right. So that flavor combination comes into play in multiple ways. But then to anchor it, if we need more anchoring to the pattern, then that's really going to come from the minerals. So that's going to be. Wangu and muli would be easy examples of that.
How?
[00:14:50] Speaker A: So we're using this particular flavor profile of herbs because the Yang is floating because it's deficient.
[00:14:56] Speaker B: Yes.
[00:14:57] Speaker A: How do we know that it's. That's why it's floating and it's deficient because.
[00:15:02] Speaker B: So when Yang is deficient, it tends to float. This is one of the confusing things in Chinese medicine that when you have two opposite patterns, they tend to create the same symptoms but with a different character quality. So, like, if you have, let's say, a problem with water transformation, you're going to have dampness, but the person may be thirsty.
[00:15:28] Speaker A: Right?
[00:15:28] Speaker B: Right. So you have dryness in a different place than the dampness, but the problem is the fluids aren't transforming properly. Right. In Yang deficiency, you have cold by nature. But in clinical presentations, the Yang tends to be deficient and float. Right. So the person may feel warm, but all of their warmth is on the surface. It's not anchored, it's not deep in the body. So they may say, I feel warm, but then you check their feet and they're freezing cold. Right. So this is again, like, this is where this gets a little bit confusing. In school we learn Yin deficiency. Right. Has a lot of these same symptoms where, oh, thin, rapid pulse, night sweating, five palm heat, insomnia, indeficiency. Right?
[00:16:17] Speaker A: Yep.
[00:16:18] Speaker B: So Yin deficiency has a lot of the same symptoms, but the thing with Yin deficiency is the yin deficiency signs should be more constant. They shouldn't just be at night, they should be constant. The person should constantly be a little bit too warm. And some of these other things, some of the other signs and symptoms will be a little different. They won't have cold signs. And yin deficiency.
[00:16:45] Speaker A: Right. That's a key piece.
[00:16:45] Speaker B: That's a key piece. And the heat or cold that they experience won't be coming and going, it'll be constant. Right. Whether if the person's hot and then cold. Then we're thinking, ah, maybe it's more of a Qi stagnation pattern where we're getting ministerial fire flaring and then collapsing. Flaring, collapsing. Or if they're generally cold the whole time but have a little bit of heat on the surface, when yin is pretty dominant, then we think Yang is deficient, not able to anchor and floating. Right. Because we say Yang comes from heaven, yin comes from earth. So when Yang is weak, it floats, it goes back home, basically.
[00:17:25] Speaker A: Okay, yeah, that's an important distinction. I think it's good to lay out the seemingly contradictory factors there because I think when a lot of people hear Yang deficiency, they just think cold.
[00:17:36] Speaker B: Right.
[00:17:36] Speaker A: Here. Yin deficiency, you think five palm heat, you know, the sort of standard machiocha breakdowns. Right. That are there in place. But the truth is, is that it's of course more. A little bit more complex than that, especially when you get into clinic. So, okay, so we know that in this case, because the symptoms are only at night, because we have this kind of alternating come and go factor, because there is cold in the system, and because we have some confirmation in the dream state of the patient. Patient. We feel very confident that it has a young floating pattern as caused by deficiency.
[00:18:10] Speaker B: Yep.
[00:18:10] Speaker A: Therefore, we will need herbs that are sweet, acrid and warm.
[00:18:14] Speaker B: Yep.
[00:18:15] Speaker A: To tonify the young, strengthen it so that it can anchor like it ought to.
[00:18:19] Speaker B: Right.
[00:18:20] Speaker A: And then that will affect. That will manifest as less strong dreaming.
[00:18:24] Speaker B: Yes.
[00:18:25] Speaker A: Less temperature fluctuation.
[00:18:26] Speaker B: Yep.
[00:18:27] Speaker A: The patient will be more comfortable and less disturbed to sleep.
[00:18:30] Speaker B: Right.
[00:18:31] Speaker A: Now let's talk about the other findings, the ones you just mentioned. So we got the costal findings, and those seem to suggest that we've got a pivot problem.
[00:18:40] Speaker B: Yes.
[00:18:41] Speaker A: Right. So now if we're taking that into consideration, whenever. If anybody's listened to the show before and you hear pivot problem, you should immediately be thinking the Xiao Chaoyutang, because that's what we use all the time. But of course, Xiaoqia Tong belongs to a different cluster of herbs than the ones we were just talking about, these warm, acrid, sweet flavors. So talk to us a little bit about how you balance these two realities. We have this quote unquote, core cause of deficient young floating, but then also a cheese stack pivot problem that is probably contributing to that factor. How do we balance those two things?
[00:19:18] Speaker B: Yeah. Luckily, we've had practitioners come before us who have had. Who've run into these problems. So there's already been formulas created for these scenarios.
So in this particular situation, the Person. The patient also was thirsty. She reported to have herself to have thirst, like stronger thirst and a little bit of urgency with urination.
So the formula that matches the pattern the best with those extra symptoms. Do you want me to get to the formula?
[00:19:52] Speaker A: Yeah, do it. At this point, tell us.
[00:19:54] Speaker B: Is chai huizhe Ganjang tang, which also includes. It has chai hu and huang chin for the movement of qi, but it also includes guizhi and it has gansao. So we have sweet, warm, and acrid. And it already has muli in the formula as well. Right. So we already have half, like 50% of the anchoring component of the formula. And so then my addition to the formula was just to add longu to create Guejigansao Longu mulitang as a whole formula addition, but just with one herb, because the other three are already there.
[00:20:31] Speaker A: Right. And the longu we're adding in because of the sweet flavor of longu and its mineral weight.
[00:20:37] Speaker B: Exactly.
[00:20:37] Speaker A: So you have both things coming in here. Do we expect that the longus sweetness is helping to tonify the yang?
[00:20:44] Speaker B: Yes.
[00:20:45] Speaker A: Right. And then its weight is affecting to just draw it back down.
[00:20:49] Speaker B: Correct.
[00:20:49] Speaker A: Into the body.
[00:20:50] Speaker B: Yep.
[00:20:50] Speaker A: Okay, so effectively then, so that the formula is what again?
[00:20:55] Speaker B: Chai hu, Guizhi Ganjang tang plus longu.
[00:20:59] Speaker A: Right. Which creates effectively, chai hu, which creates.
What is it? Are you guys following out there? There's going to be a quiz later.
[00:21:10] Speaker B: Guizhi Gansao Longu mulitang, which is just those four herbs. There's nothing else.
[00:21:14] Speaker A: Yeah, those are my favorite formulas that are just the name. Like, we're like, oh, you got to make sure to add guizhir Gansao Longu mulitang.
[00:21:21] Speaker B: Gosh, I wonder what's in that.
[00:21:22] Speaker A: I wonder what's in that. Yeah, those forums, those are the ones that are in it.
So essentially then, what we end up with is like, if we were to really analyze the core formula that you land on, I mean, the primary driver is the guizher side of the formula.
[00:21:35] Speaker B: Yes, yes.
[00:21:36] Speaker A: And then we've got Huang Qin and chaihu that are in there, which are really channeling the harmonizing chihu side. That's we're pulling from Xiao Chai Tong, basically. Right. And combining those two together. Why is there. Is there like renshin or other strong tonifiers in a formula like this?
[00:21:56] Speaker B: So in this formula, there's not chai Guanjiang tongue is in lot of ways a more chronic Xiaochai Hu Tong pattern. You see? You see that in a number of ways. It also, if you pay attention to the postscript modifications that Zhang Zhongjing gives us after he talks about Xiao Cai Hu Tang, and you follow those postscript modifications with the symptoms, you basically end up with Cai hueger ganjang tongue. And one of the. There's a couple of modifications that he follows. The first one is if there's thirst and no nausea, sub out ban shaf or Tianhua fen and increase the dose of Ren Shen. That's literally what the line says.
[00:22:43] Speaker A: Right.
[00:22:43] Speaker B: But then one of the other symptoms is if there's heat or fever on the surface, take out Ren shen, add Guizhi.
[00:22:50] Speaker A: Right.
[00:22:51] Speaker B: So in this case, we actually take out Ren Shen and add guager.
[00:22:55] Speaker A: Yeah.
[00:22:56] Speaker B: Right. And then the last one is if there's hardness or under the rib side or costal pain, take out dadzao at Muli.
So basically, Chayuguezhi Ganjang Tang is just a version of Xiaoqia Tong that's followed those modification rules. And it usually happens when there's more chronic Qi stagnation that's had more time to flare the ministerial fire and zap the fluids of the upper burner and create more dryness and more basically, more stagnation. There's just more chronic stagnation.
[00:23:33] Speaker A: So in reality, I mean, we're basically following a Shanghan recipe.
[00:23:38] Speaker B: Yeah.
[00:23:38] Speaker A: Starting with Xochai Tang, modifying it out in such a way that we end up with the guichi ganjang combination.
[00:23:47] Speaker B: Yeah. Yep, yep.
[00:23:49] Speaker A: So that's interesting. Right. Because there's a logic to follow there that clearly exists in the text. But from a diagnostic point of view, because the Yang is deficient as sort of like our primary diagnostic item that stands out the mind, then if we're using this nature and flavor method, first goes to acrid, sweet and warm.
[00:24:11] Speaker B: Right.
[00:24:12] Speaker A: Which really emphasizes the guager aspect of the final formula, though, if you were to really follow how did we get to that final formula in the first place is actually a series of modifications on Xia Caiyutan, which could feel confusing to the user because your mind didn't first go to Xiao Caiutan, it instead went to the Guizhi piece. But I think instead of letting that be confusing, I think it's an opportunity to recognize the beautiful and graceful fluidity of how formulas move one into the other, because we talk about them in categories. There's a Chihu family formula, it's a Gweger family formula, but that's really just a useful tool for organizing information. It's not a reflection, I think, of Rigid boundaries. These are not rigid boundaries. These are core, flavor and nature factors that are constantly mixed and matched in various ways to yield the specific outcome. So even if you worked from the other side, even if you were like, okay, I'm going to build out formula, but I also think because of these costal symptoms, I need a little bit of the energy of Xiao Chai Tong. So I'm going to pull the key pieces of that formula, in this case Chai Hu and Huang Chen. So you could even work from the other side. You'll end up in the same place.
[00:25:21] Speaker B: Yes, you will.
[00:25:21] Speaker A: You'll end up in the same place. So I think that's an important thing to see. Like, it's. It's crafty and clever to see what's in the shanghan and the way that it moves. But the logic of how you get from to the formula in the end could come from either the wager side or from the Chai side.
[00:25:37] Speaker B: Right?
[00:25:37] Speaker A: Yeah.
[00:25:38] Speaker B: Yeah.
[00:25:38] Speaker A: Okay. So you gave this formula to the patient?
[00:25:40] Speaker B: Yep, I gave this formula for two weeks.
She came back two weeks later.
[00:25:45] Speaker A: What. How much did she take?
[00:25:47] Speaker B: She took. This was a granule formula and she took 8 grams twice a day.
[00:25:53] Speaker A: Okay, so 16 grams a day.
[00:25:54] Speaker B: 16 grams a day.
[00:25:55] Speaker A: Two weeks.
[00:25:56] Speaker B: Two weeks.
[00:25:56] Speaker A: What do we get in two weeks?
[00:25:59] Speaker B: She came back and she said her sleep was better. So keep in mind that she was getting no more than five hours of sleep per night before. That's what she said the first visit. She said she's getting six plus hours now. So it's improved, but it's still not ideal.
[00:26:15] Speaker A: Right.
[00:26:17] Speaker B: She said that her. She was now getting night sweats, which is kind of interesting.
She was still having frequency and urination, but she reported her emotions to feel smoother.
And she actually said that she hadn't had any panic attacks since the first appointment.
[00:26:37] Speaker A: So what does that tell you? Like that shift.
[00:26:40] Speaker B: So then what? So then it's like, oh, that's interesting. Let's check the objective findings and see if they're moving as well.
[00:26:46] Speaker A: Got it.
[00:26:47] Speaker B: Right. So then the pulses to me felt a lot less wiry. In fact, I would have classified them then as not wiry, just feeling kind of soft and a little more deficient feeling.
And then when I checked the abdomen, the costal. The discomfort with the costal region was gone. There is no more of that.
And there was actually no more of the hard P. The glomus pattern in the middle, that was also gone.
[00:27:19] Speaker A: God, that word. Glomus.
[00:27:21] Speaker B: I know, I know, I hate using it. But it's what everyone else uses. Who talks about these things in English? So I. I feel like I have to say it so that people don't get confused.
[00:27:30] Speaker A: It's a hard sensation in the abdomen.
[00:27:32] Speaker B: Yes.
[00:27:32] Speaker A: It's just glowmas.
[00:27:33] Speaker B: It's an obstruction in the epigastric.
[00:27:35] Speaker A: I feel like I vomit in my throat a little bit when I have to say glomus. It's such a weird word. Anyway, sorry, I got distracted. Okay, so the costal stuff's gone. The glomus is gone.
[00:27:46] Speaker B: Yes.
[00:27:47] Speaker A: Okay.
How about the pulsation?
[00:27:50] Speaker B: The pulsation is still there. And there's still what's called riku, which is the rectus abdominal tension. You can still feel that start to a rigid rectus. Bit of a rigid rectus abdominis. Yep. Okay, so then at this point, my understanding was more that we had cleared the chi stagnation and that now what's coming up is the deficiency taxation. Like she's just taxed.
[00:28:19] Speaker A: Yeah.
[00:28:20] Speaker B: And that's weighing on her yang's ability to anchor back into the blood at night. So I ended up writing her guizhir jie longu mulitang, which is the full formula of guiji plus longu and muli. And that's all I did.
[00:28:36] Speaker A: So just gave plus longu and muli.
[00:28:40] Speaker B: Right. Which is instead of guid gansau lungu mulitang, which doesn't have the other components of guizhitong in it.
[00:28:48] Speaker A: Right.
[00:28:48] Speaker B: Yeah.
[00:28:49] Speaker A: Okay, so the shift in the objective findings pretty clearly confirm that those sort of xiaochow tang pieces, the pivot problem items, have resolved.
[00:29:03] Speaker B: Yes.
[00:29:03] Speaker A: In addition to the fact that the patient is getting some more sleep, perhaps that is the sweet and warm and acrid components nourishing that yang a little bit. Plus the chai, the. Excuse me. The chi stagnation is reduced.
And we also have her emotions feeling more smooth.
[00:29:22] Speaker B: Yes.
[00:29:23] Speaker A: Less reactionary.
[00:29:24] Speaker B: Yes.
[00:29:25] Speaker A: So that's a good indication that we're basically done with the harmonizing piece.
[00:29:29] Speaker B: Yep.
[00:29:30] Speaker A: Yep. What I love about that too, is it's a really good example of how harmonizing is such a useful strategy when you have complex presentations.
[00:29:38] Speaker B: Totally.
[00:29:39] Speaker A: And that harmonizing kind of always sits on the top.
[00:29:42] Speaker B: Yes.
[00:29:42] Speaker A: Like, you come up to a problem and you're like, okay, there's a lot of moving parts. This person's stressed. Chronic pain, chronic insomnia, whatever it is, living modern life as a person, they probably need to be harmonized. Right. There's just. There's a predictability to harmonizing as a strategy. So you Harmonize for two weeks. And then not only do you have. This is what I love too, about the objective findings. If. If you guys listening out there have not done much with abdomens, it's a really useful tool. It is, in my opinion, a person who doesn't use pulse. Right. Yeah. Don't write in about it. I just don't do it. TC does it. I use tongues. He doesn't really use tongues. It's fine. Get over it. However, with abdomen, what I like about abdomen is it is an objective finding that tells a lot of information that is much easier to learn rapidly. Easier to learn, in fact, in my opinion, than pulses. And it's really. It's really useful. You know, it's really useful. And so not only do you get the questioning response.
[00:30:38] Speaker B: Yep.
[00:30:39] Speaker A: That, like, she's feeling better emotionally, but you have the objective response that says, we don't need. We don't need these herbs anymore.
[00:30:44] Speaker B: Right.
[00:30:44] Speaker A: So you drop them out of the formula with intention.
[00:30:46] Speaker B: Yep.
[00:30:47] Speaker A: And this is what's important to think of. Right. We're not just switching formulas, which is what's happening on paper, but we're actually making some intentional removals and substitutions.
[00:30:56] Speaker B: Right.
[00:30:57] Speaker A: So Chaihu and Huang Chen leave. Right. And then we're left with Gui Zhi, Gansao Longu and Mu Li.
[00:31:05] Speaker B: Yep.
[00:31:05] Speaker A: From our original formula.
[00:31:07] Speaker B: Yep.
[00:31:07] Speaker A: And so we're gonna add the remainder pieces of Guizhitong in there. So we're gonna add in baixao.
[00:31:13] Speaker B: Yep.
[00:31:13] Speaker A: And we're gonna add in. Are we switching to jergansao? Do you switch it over?
[00:31:17] Speaker B: Yeah, yeah, yeah. I use jigan Sao.
[00:31:19] Speaker A: Okay. And then what about the. The dazza and the shengzhang? Those are coming in.
[00:31:22] Speaker B: Put those in. And we had ganjiang in Chai Guijer. Ganjang tongue. Right. But. But it's at. Ganjang is at six in that formula, usually. So we go back up to nine, which is more standard for guizhi.
[00:31:33] Speaker A: Do you leave it as ganjang?
[00:31:35] Speaker B: I. I put in xiangjiang.
[00:31:36] Speaker A: You do in shangjang. Okay. So a little bit less hot.
[00:31:39] Speaker B: Yes.
[00:31:40] Speaker A: Than the ganjang piece. Right. But still warm. Definitely. And we've still got the longu and the muli in there.
Tell the listeners a little bit about dosing longu and muli, because. And we're going to have this conversation in terms of granules, because I feel like that's what a lot of people are writing these days, and I think it's useful to look at the breakdown. So guizhi, your standard numbers On Guizhir tang.
[00:32:02] Speaker B: Yep.
[00:32:02] Speaker A: Are Guizhir.
[00:32:04] Speaker B: Right. So that's a good, that's a good pointer actually. So Guizhir Tang, Guizhir is usually going to be at nine for me. But if there's any type of Yang deficiency or palpitations, then I go up to 12. So in this formula I'm going up to 12.
[00:32:19] Speaker A: Now because you are using classic Weijia Tang, are you also doing 12 with Baixao to keep the equal pair?
[00:32:25] Speaker B: Keeping the Baishao at 9.
[00:32:27] Speaker A: Keeping it at 9.
[00:32:28] Speaker B: So I'm doing it a little lower.
[00:32:29] Speaker A: Okay, so you're doing Guizhi 12, Baixao 9, Zhigan Cao 6. Zhigan Cao 6, Shengzhang, Shengzheng 9. Okay. And then Dazao Dao.
[00:32:39] Speaker B: I usually do 9.
[00:32:42] Speaker A: Okay, now you guys are hearing us list those numbers and they sound like bulk numbers. And that's because when you think about a granular formula, at its core, just use the bulk numbers. Like, there's no reason to like get crazy with doing the math because what you're trying to preserve are the ratios of these herbs to each other. Right. So you've got Guizhou 12, Baisha 9, Shengzheng 9, Zhigan Cao 6, Datsao 9.
[00:33:05] Speaker B: Yep.
[00:33:05] Speaker A: Okay, so that's in place. And then Longu and Muli.
[00:33:09] Speaker B: Yep.
[00:33:09] Speaker A: What are we using here?
[00:33:10] Speaker B: So Longu and muli, I will use three different types of dosages for granule formulas. If I was doing a bulk formula, I wouldn't go as high. But in granule I think they need to be more emphasized for them to really work. So my dosage ratio is I almost always use more Longu than muli or I use them equal at 30 a piece. So if Gueger is at 12 Longu and Muli could be at 30, so it's quite a bit more.
And then if I think they really need more Longu, more sweet flavor, then I'll go up on longu and down on muy. So I'll go 45, 15 longu to muy. And if I really think they pretty much need longu, but it's kind of a Longu muli formula and I still want to put in a little bit of muli. Then I'll do 10 to 1. So I'll go 60 longu 6 mui gotcha. And the increase of Longu really has more to do with Shen based disturbance symptoms. So I'll go higher on longu if the person is more emotionally distraught, if they're having more shun type problems Gotcha. Versus if there's more fluid imbalance, if there's rib side pain, Right. Because of that modification line, if they have swollen lymph nodes, which is a good sign that the fluids are being congested, then I'll go more on muli, so it'll be more like 30. 30.
[00:34:50] Speaker A: Gotcha.
[00:34:50] Speaker B: Yeah.
[00:34:51] Speaker A: So that, I mean, when listeners hear that, it probably stands out kind of dramatically actually. Like, people are probably not used to writing proportionate formula where there's 30 grams of one of these two herbs relative to the rest of it. But I want to put a little bit of context around that. You know, we're talking in, in terms of granules, right. If you were to go into the bulk pharmacy and you were to weigh out 12 grams of guizhi, and you look at the volume that is 12 grams of guiji, and then you weigh out 30 grams of wangu and you look at the volume that Is 30 grams of longu, there will be less volume wise longu in your formula than there will be guizher.
[00:35:29] Speaker B: Right?
[00:35:29] Speaker A: Right. Because longu is incredibly dense and very heavy.
[00:35:33] Speaker B: Yeah.
[00:35:33] Speaker A: And so when you deal with things in the bulk world that are dense and heavy, you are always going to use much higher gramage of those. Because the truth is like one little nugget of longu weighs like 12 grams.
[00:35:46] Speaker B: Right.
[00:35:46] Speaker A: So it seems like a lot on paper, but this is why it's important to not only think about your herbs on paper.
[00:35:53] Speaker B: Right.
[00:35:53] Speaker A: Herbs are not academic things.
[00:35:56] Speaker B: Right.
[00:35:56] Speaker A: They don't, they don't live just like in a, in a substitution of words and numbers. They're real things, Right. I mean, they come from real plants, real animals, real minerals, real roots and sticks and leaves. Right. So that, that is one of the core reasons why these, these differences are so great is because you're trying to actually put in a sufficient amount of sweet and salty flavor in longu and muli. And if you just put in nine grams, you've basically taken like a small pebble, Right. And thrown it into a day's worth of decoction, it's just not enough. Right.
Additionally, your point about increasing it even further on the granule side in particular is because, you know, remember granules are made from cooking herbs into decoction, concentrating them and then evaporating them into a granule with an excipient.
[00:36:45] Speaker B: Yes.
[00:36:46] Speaker A: The excipient is the binder for the decocted liquid in most granules. It's some kind of dextrose or starch that's extracted from potatoes or non GMO Corn. And what that means then is like, for stuff like sweet herbs and things that have lots of flavor and aromatic compounds, there's a lot of stuff floating around in that decoction that gets connected to the excipient. But for minerals, it's a different story. Like you basically just made like a mineral soup. There's not a lot of constituent components, like tangible items that are in that decoction. And so it's just not quite the same.
[00:37:20] Speaker B: Right.
[00:37:20] Speaker A: So if you're going to add granules of a decocted mineral, you're almost always going to have to go even higher than you already would seemingly be doing if you were doing it in bulk.
[00:37:29] Speaker B: Yep.
[00:37:29] Speaker A: Yeah, that's an important distinction.
[00:37:32] Speaker B: Yeah, absolutely.
[00:37:33] Speaker A: Okay, so the patient takes this long.
[00:37:37] Speaker B: Yep.
[00:37:38] Speaker A: At what dosage?
[00:37:40] Speaker B: So, same dosage. I did eight twice a day.
[00:37:42] Speaker A: Okay.
[00:37:43] Speaker B: Yep.
[00:37:43] Speaker A: And then how long?
[00:37:44] Speaker B: And I did the. Just to clarify about the longu muli dosage for her, I did 45 longu, 15 muli because I wanted a little more sweet. But because she had rib side pain before, I wanted to keep. I didn't want to just basically give her only longu. I wanted to include a little bit of the mui.
[00:38:04] Speaker A: Gotcha.
[00:38:05] Speaker B: Yeah.
[00:38:05] Speaker A: Even though it's resolved at this point?
[00:38:07] Speaker B: Because it's seemingly resolved.
[00:38:08] Speaker A: Yeah. It's like lingering under the knee maybe. Yeah, yeah. Just make sure to put it to bed.
[00:38:12] Speaker B: Yeah.
[00:38:13] Speaker A: Okay, so she takes the 16 grams a day for how long?
[00:38:17] Speaker B: Three weeks.
[00:38:18] Speaker A: Three weeks. And then in three weeks time, how does it look?
[00:38:21] Speaker B: So three weeks later, she said that her sleep had improved again. She was getting seven plus hours total. So it's like every time we intervene, there's like another hour that comes back.
Her emotions felt smooth. She had no panic attacks or palpitations since the previous treatment, which she had had some palpitations between the first and the second visit.
[00:38:46] Speaker A: Got it.
[00:38:46] Speaker B: But no panic attacks.
[00:38:47] Speaker A: Got it. So we're still. So we're resolving further the mental emotional piece.
[00:38:52] Speaker B: Yep.
[00:38:52] Speaker A: No palpitations now, no panic attacks. Seven plus hours of sleep. I'm assuming that her dreaming was also less intense.
[00:39:01] Speaker B: The dreaming was a little bit less intense, but she's still having some vivid dreams.
[00:39:06] Speaker A: Okay.
[00:39:06] Speaker B: She said it was kind of. She said occasionally she's having some vivid dream content.
[00:39:13] Speaker A: Got it. Okay, so at that point, what's the move?
[00:39:16] Speaker B: So at this point, I checked the objective findings and I got pretty similar readings. But what I decided to do with the formula was to kind of soup it up a little bit and take it to the next level.
So what I did was I changed the formula from Guizhi long to a formula. You're going to love the name of this. Right. So the abbreviated version is called Guizhi J ni Tang J I U N I T A N G.
But the full length name of the formula is Guizhiao Jia Long.
[00:40:00] Speaker A: God, it's such a stupid name. Give it another name.
[00:40:04] Speaker B: Right.
[00:40:04] Speaker A: I always think like, imagine if we named like western foods by just like what was in them.
[00:40:09] Speaker B: Right.
[00:40:09] Speaker A: So like instead of calling it chili, you'd be like, let's make sure to have some beef, onion, bell pepper, bean, garlic, tomato stew.
[00:40:19] Speaker B: Yes.
[00:40:20] Speaker A: Right. Like that's literally what we're doing there. Okay. So there's a lot of stuff it sounds like in this formula.
[00:40:26] Speaker B: Yeah. But it's. So it's actually quite simple. It's just guid your tongue.
[00:40:30] Speaker A: Okay.
[00:40:30] Speaker B: But you take out baixao, in this case, you keep longu and wooly in and you add fuzzi. That's it.
[00:40:37] Speaker A: That's it.
[00:40:37] Speaker B: That's it. So it's just basically we're changing out the baixa for the fuzzi.
[00:40:43] Speaker A: Okay.
[00:40:44] Speaker B: So it's. Yeah.
[00:40:44] Speaker A: So this maneuver, I mean, so by taking out baixao, we're taking out a kind of wet sour herb.
[00:40:51] Speaker B: Yes.
[00:40:51] Speaker A: And we're putting in a warm, maybe even hot ton of fire. Right. In the form of fuzza, which we know usually works in the lower burner. Okay. So the logic here is like, okay, we're making progress. The yang is clearly being tonified. We're getting more sleep. We're definitely continuing to sort of tie up the loose ends of the chi stagnation disharmony that was there.
[00:41:16] Speaker B: Right.
[00:41:17] Speaker A: Probably the longu doing the heavy lifting there. Right. To help with the sort of shin presentation.
[00:41:21] Speaker B: Yes.
[00:41:22] Speaker A: Sweet flavor in the anchoring. But it's still not done yet.
[00:41:25] Speaker B: Right.
[00:41:26] Speaker A: The yang is not sufficiently restored. So you decide that we need to reach for a little bit stronger of an herb to try and give the yang more of what it needs.
[00:41:37] Speaker B: Yeah. And the other thing with Guizhou jaonitang is that it's in the Fear and fright chapter. So it's, you know, in the, in the Shanghan Lun, it's. It talks about like the person was treated with a burning needle improperly. Right. So somebody heated up a needle, got it red hot and stuck it in someone's body. And it was so alarming that it caused the yang to just fly out of the person's body.
[00:42:03] Speaker A: Yeah.
[00:42:03] Speaker B: Right. So they, they're fearful. It's basically somebody that has ptsd.
[00:42:08] Speaker A: Yeah.
[00:42:08] Speaker B: Prescription. She's traumatized. And because there's the traumatic background, I thought that was the other cue into this formula that, like, oh, maybe instead of just treating taxation, which is really what we're doing with the last formula, we need something a little stronger that's going to push the cold out.
[00:42:29] Speaker A: Yeah.
[00:42:29] Speaker B: And get her to settle a little bit more in a deeper way.
[00:42:33] Speaker A: Okay, so all the ratios, the Guizhou remains at 12.
[00:42:39] Speaker B: Yep.
[00:42:39] Speaker A: Everything else stays the same. 45 and 15. On your longu and muli fuzzi dosage.
[00:42:45] Speaker B: Futza I put in at 45, so I equivocated it with a longu.
[00:42:50] Speaker A: Okay. Why?
[00:42:52] Speaker B: I like to. So generally when I add futsa to a formula in granule, again, emphasis is in granule. My starting dosage is 30. And again, that's just from experience. It's like, if I don't use that kind of dosage, I don't really know if I'm getting much out of it. It's not that clear.
[00:43:11] Speaker A: Yeah.
[00:43:11] Speaker B: If I use 30 or above, then I know. Okay. Like, if it's a foods a pattern, it's going to get better. If it's not a foods a pattern, it's going to get worse. And I want to know if it gets worse because that gives me really valuable information.
So there's a bunch of formulas where fuci is in the formula and longu is in the formula. And typically when they're together, they're equivocated in dosage. That's what I've noticed. So I just tend to do that.
I also will tend to go up with fuchsia. It's almost like you feel into a space to see if it's okay. Like, ooh, that water's cold. Put your. Put your toe in. Right. And then you put your foot in and it's like, oh, it's not so bad. Put your leg in. So that's kind of how I do the futza. So if it's. If I'm not sure and I start like at 30, but I think they really need more. Like we can go up to maybe 60 or something. I'll. Then the next time I'll do 45. The next time I'll do 60. So start bumping it up a little bit every time.
[00:44:17] Speaker A: Titrating it up.
[00:44:17] Speaker B: Really titrating it. But in this case, we already have high mineral content with longu and muli. So I just put it at the dosage of the longu.
[00:44:26] Speaker A: Yeah, yeah. So again, remember, of course, everyone, this is in granules. So you know, these are all ratios to each other. So you've got your guitar at 12, you've got your xiangzhang at 9, your jirgan sao at 6, your datsao at 9, longu 45 futza 45 muli 15. Yep. And the patient is taking again 16 grams a day. Yep, yep. So I'm not going to do that math for you guys, but if you do the math, you know, add up all the total grammar and the ratios we just gave you and the patient's taking 16 grams of that. Like you could get a percentage of that formula that is the futza and then what percentage of their dosage is the futsa? And that would give you a better idea of how much actual FTSE equivalent they were taking. As we've discussed in previous episodes, you know, it's not so simple as like a five to one, three to one kind of ratio. It's not like that. It's important when you're working in granules to keep these pieces in mind that you're, you're balancing between the ratios of your individual herbs to each other and then combining that with the total daily dose.
[00:45:34] Speaker B: Right.
[00:45:35] Speaker A: And that's really how you're modulating like you're modulating potency of the experience by daily dose.
[00:45:41] Speaker B: Yes.
[00:45:41] Speaker A: And you're modulating the design of the constituent components by changing the numbers in the formula.
[00:45:48] Speaker B: Yep.
[00:45:49] Speaker A: So like when Travis moves from, say, let's say he increased from 45 grams of Futza to 60. Okay.
A larger percentage of the formula that the patient will take was now futza. But it's not going to be an equivalent step up in total FTSE consumption because the daily dose will remain the same.
[00:46:07] Speaker B: Right. And the other ingredients will go down in percentage.
[00:46:10] Speaker A: Right, exactly, exactly. So remember, it's those two things together. Daily dose and the composition of the formula. Okay, so we give, you give the patient this new, I'm just going to call it Guizhou Jalong with food salt.
I recognize that there's one other ingredient that's different, but that is just a little long ass name.
So you give them this new version, this more punched up version of the formula.
[00:46:34] Speaker B: Yeah.
[00:46:35] Speaker A: And what do we see?
[00:46:36] Speaker B: So I saw them the next time that I track this in the cases six weeks later, but I saw her in between that. So I've been, we're doing acupuncture. It was also treating her for neck pain, which is honestly at this point mostly gone.
[00:46:50] Speaker A: Yeah, sure.
[00:46:51] Speaker B: But we're still following up with the herbs and stuff like that.
[00:46:54] Speaker A: So.
[00:46:55] Speaker B: So by the time we get to six weeks, that's when I make the decision.
We're good. Like we're going to try no herbs.
[00:47:04] Speaker A: Yeah.
[00:47:05] Speaker B: So at this point, she's getting eight plus hours of sleep. She's sleeping every night. She's not waking up with interruption. She's had no palpitations or panic attacks since like the second visit.
And basically she's doing well.
[00:47:22] Speaker A: So initial formula, two weeks, second formula, three weeks, final formula, six weeks. So you're looking at a total of 11 weeks, almost 12 weeks, which is three months. So in terms of timing, when we're talking about making a transition from someone who is getting really poor sleep, really having a hard time sleeping well and getting them from that to what looks like mostly normal sleep most of the time was basically three months.
[00:47:54] Speaker B: Basically three months. And I did do a follow up appointment with her two weeks later without her taking the herbs.
[00:48:01] Speaker A: With no herbs.
[00:48:01] Speaker B: With no herbs.
[00:48:02] Speaker A: Right.
[00:48:02] Speaker B: Because I wanted to see.
[00:48:03] Speaker A: Yeah. Did it stick?
[00:48:04] Speaker B: Did it stick? And she came back in and it was still good.
[00:48:08] Speaker A: Great.
[00:48:08] Speaker B: It was still awesome. Yeah.
[00:48:10] Speaker A: I love that. I think that's so. It's so likely actually, with insomnia formula, it takes a while. Three months is not a small amount of time. But also people end up with insomnia patterns for decades.
[00:48:22] Speaker B: For decades. Yep.
[00:48:23] Speaker A: And the damage to bodies and minds and spirits when we don't sleep, just it, it's exponential. It gets worse and worse and it compounds on itself. And while three months of treatment might sound long, it's not long.
[00:48:37] Speaker B: Right.
[00:48:37] Speaker A: Not. Not considering what it is that we're trying to change and what it takes to change it. And the end result. And this is one of the things we tell patients all the time. Right. Like if a patient has to take herbs in perpetuity, we have missed something.
[00:48:50] Speaker B: Right?
[00:48:50] Speaker A: Right. I mean, we have made an error. We haven't quite gotten it. Like, there's virtually no circumstance in which a person would be taking herbs, especially the same formula in perpetuity.
[00:49:00] Speaker B: Right.
[00:49:01] Speaker A: That's crazy.
[00:49:01] Speaker B: Yeah.
[00:49:02] Speaker A: So if, you know, you had given the formula and it hadn't stuck, then maybe we go back to the last formula, we run it for what, a couple more weeks?
[00:49:09] Speaker B: Right.
[00:49:09] Speaker A: See if it actually will stick this time. Push. Push the pattern a little further.
[00:49:13] Speaker B: Right.
[00:49:14] Speaker A: But ultimately the goal is for the body to just take over where the herbs have brought it.
[00:49:19] Speaker B: Or maybe we need to treat the layer, the next layer, the next layer, to reinforce the layer that we were treating.
[00:49:26] Speaker A: That's also possible. Yeah.
[00:49:27] Speaker B: Yep.
[00:49:28] Speaker A: Though, in this case, I mean, we were kind of. Your formula was really at the sort of deeper layer at that point. I mean, with the futza. With the warm flavors, the sweet flavors. I mean, you were in that space.
[00:49:37] Speaker B: Yes.
[00:49:38] Speaker A: Well, that's. That's really great. It's so good to hear that the outcomes in the end were so useful, so positive.
[00:49:45] Speaker B: Yeah. I think it's fun to work with cases to people who are having mental emotional stuff that goes along with the pattern that we see, because it's easy to think that, well, the problem is their emotions, but actually the way that we look at the person is as a whole person. Right. So their emotions are being affected by everything else about them.
[00:50:10] Speaker A: Yeah.
[00:50:11] Speaker B: So if we help to reinforce and stabilize these other resources that they have, we may not be doing talk therapy or doing, I don't know, like a somatic. Some kind of somatic intervention, unless we're doing acupuncture, of course, which is a whole nother discussion. But we can still provide an incredible support to their system that then allows more resources to go in and deal with the transitional process with these really serious life events that affected this person, you know?
[00:50:46] Speaker A: Yeah. Okay. Well, I think let's put a pin in it there on this. On this case study because I think that that's a lot for the. For you listeners out there to think about and digest. So we are kind of working our way through season three here of the Nervous Herbalist. And if you guys have any suggestions for things you'd like to hear, definitely reach out to us at info
[email protected] that's rootnbranchpapa deltaxray.com and we'd love to hear your suggestions. Also. If you've been listening to the show, please subscribe to the to the channel. Please leave us a review. Let us know what you think of the show. It's a lot easier for other people to find us if we've got some reviews out there. So it's always nice to have folks do that. So we appreciate you listening to us. We'll be back with another episode. More things to learn, more case studies to explore. And my name is Travis Kern here with Travis Cunningham. We'll talk to you guys next time.
[00:51:46] Speaker B: See you next time.
