Episode Transcript
[00:00:03] Speaker A: Hi, everyone, and welcome to the Nervous Herbalist, a podcast for Chinese medicine practitioners who like herbs and want to learn more about their function, their history, and treatment strategies to use in the clinic. Let's get into it.
Hello, everybody, and welcome back to another episode of the Nervous Herbalist. My name is Travis Kern, and I.
[00:00:24] Speaker B: Am here with Travis Cunningham.
[00:00:26] Speaker A: And we are here to talk to you guys today a little bit about pain conditions.
[00:00:32] Speaker B: Yes.
[00:00:33] Speaker A: Everybody's favorite topic, pain conditions. Pain, the bread and butter of Chinese medicine offices. The thing that the research says, acupuncture is only good for treating only pain, nothing else. Of course, you guys are listening to us because we're talking about herbs, and that's really our focus for today, is to take some time and think about how herbs factor into dealing with pain conditions. Because, of course, a lot of us out there are dealing with pain in all types and forms. And some folks, you know, we hear from folks and they say, like, well, I'm not really sure. Like, I just run a musculoskeletal clinic. I don't know that herbs really factor into what I do.
[00:01:10] Speaker B: Right.
[00:01:11] Speaker A: And of course, you know, this will surprise no listener to this show, but we think that's a missed opportunity to not include herbs. Right. In a pain presentation.
If for no other reason, then you can probably resolve the condition more quickly. Yep. And in some cases, depending on the type of pain that you're dealing with, particularly chronic pain, autoimmune pain, idiopathic pain, the ability to make the changes there with acupuncture, while possible, is a much heavier lift if you don't have herbs in the mix.
[00:01:43] Speaker B: And.
[00:01:43] Speaker A: Yeah. So we wanted to kind of break it down for you today. So t. When you are first approaching a pain differential, let's walk folks through a way of thinking about it and maybe let'swhyn don't you mention to the listeners, like, why are we using this particular lens we're going to talk about today? Yeah.
[00:02:01] Speaker B: So there's a few things to consider with pain, and if you carefully consider the picture from an herbal lens, you'll end up doing just what you said. You'll be able to treat people faster for stuff that they would normally be able to treat, but it would take longer. You can also treat stuff that you wouldn't be able to treat. Right. And there's a connection in osteopathic medicine, actually, which is one of the famous osteopaths is French osteopath Jean Pierre baral, says that 80% of orthopedic problems have a visceral component to them. And what that means by viscera is kind of the fancy word in osteopathic medicine for organs. Right. So this guy is in his 80s. I actually just looked up his birthday. He's 80 years old. He's been doing musculoskeletal treatments for most of his life. And he's kind of a master physician. So if he says that 80% of conditions have a component of organ pathology, it says something to maybe the cases that we're having trouble making progress on. Right. So there's that hip pain, shoulder pain, low back pain case that 99% of the time we're treating. And it works. What we do works, but for this person, it doesn't.
And if you include herbs and you include some of these other points of view, you can treat that case, you know, potentially. And it's great when you're able to find an answer to a difficult case, especially because that person has likely gone to lots of other people and found little to no help.
[00:03:55] Speaker A: Yeah.
[00:03:56] Speaker B: So this stuff is powerful. And if we understand a little bit more about how pain can be managed with herbs and treated, we can get some of these cases and we can be better clinicians.
[00:04:11] Speaker A: So there's a lot of ways that you can organize a differential when it comes to pain. We're going to lay out what's essentially a sort of jingfenger logic here. Why have you chosen this particular lens?
[00:04:24] Speaker B: Yeah, it's interesting because I think Jing Fung as a style is maybe not the best style of herbal medicine to treat orthopedic pain. But the advantage that we have when we think of the formulas and the strategies is the lines and the delineations between what we're trying to do with this formula versus that formula are very clear. And so we can understand pathomechanism really easily.
[00:04:52] Speaker A: That's an important distinction. I think a lot of people who maybe have come across jingfeng style stuff are thinking Shanghan classic formulas, and they're going, yeah, I don't really know that Zhang Zhongjing had a lot of lines for to treat shoulder pain in the summer, please use these herbs. And you're right, that's not in the text. But of course, the genius of Zhang Zhongjing's work and the many commentators over the years afterward is that it's an adaptable system with clear delineations, as you said, between this formula for this, looking for this particular outcome. And that's how we'll know if we're using the right formula set or not.
So let's go ahead and break it down from the top then. So we've got a pain condition that comes in, and there's a lot of initial differential questions. But I think for us here, we're looking at is this problem an acute problem and. Or a chronic problem?
[00:05:45] Speaker B: Yes.
[00:05:46] Speaker A: So let's start on the acute side. So someone walks in with an acute pain problem. Firstly, what do we mean by acute?
[00:05:52] Speaker B: Yeah. Within the last few weeks.
[00:05:55] Speaker A: Yeah. So last couple of weeks, someone's had a pain problem that popped up.
[00:05:58] Speaker B: Yep.
[00:05:59] Speaker A: So what's the next question we need to ask?
[00:06:01] Speaker B: Is there an obvious reason or has there been a traumatic injury? Is really what we're trying to find out.
[00:06:08] Speaker A: So someone was walking their dog, and the dog yanked the leash and it jacked up their left arm. And so now their shoulder hurts.
[00:06:14] Speaker B: Yep.
[00:06:15] Speaker A: Okay, now we have a traumatic injury.
[00:06:16] Speaker B: Yes.
[00:06:17] Speaker A: Same as they got in a car accident. Same as they twisted their ankle. Same as they got hit in the head with a soccer ball, like any. Any event.
[00:06:23] Speaker B: Exactly.
[00:06:24] Speaker A: That's notable.
Okay, so if we do have that. So we have a. You know, and this is in many ways, a lot of the way, A lot of the paths that bring people to our clinics. Someone throws out their shoulder, messes up their back, lifting bags of concrete or something. And someone said, hey, you know, I think acupuncture can help with that. So of course, that's how they end up in our office. And then we are like, oh, yeah, definitely, we can help without acupuncture. Also herbs, though, are going to need to get in it. So if we're in the acute side and there is a traumatic injury, what's next?
[00:06:54] Speaker B: Next is, is there a skin break that's still live, meaning is there a possibility for infection? Or is part of the physiology of that person's body being, let's say, recruited to try to heal an open wound?
[00:07:12] Speaker A: So practically, this would be like, if someone broke a bone, there was a compound fracture, and so the bone is poked out of the skin. Right. Or if. What about, like, surface level damage? Like, if they fell and, like, really scraped up their leg and it's like scabby and stuff.
[00:07:30] Speaker B: Exactly.
[00:07:30] Speaker A: That counts too.
[00:07:31] Speaker B: Or surgery.
[00:07:32] Speaker A: Or surgery.
[00:07:33] Speaker B: Yeah. Even post surgery would. Would be counted in this. Even if it's not a very big incision, like the site isn't very big, it's still worth. If. If there's an open. There's an open wound or a healing wound, it's worth it to treat that part first because there's some part of the physiology that's working on that.
[00:07:53] Speaker A: Well, and it's important. I think it's. It's good you bring that up because that way the listeners can be reminded that surgery, even non, like injurious surgery, like, it's not like they're sewing your arm back on, but like you had an appendectomy or, you know, there was some other sort of routine surgical process that was involved. We're still thinking of that as an acute traumatic injury.
[00:08:14] Speaker B: Absolutely.
[00:08:15] Speaker A: Yeah. Because, I mean, okay, we. Someone cut you open, even if it's laparoscopic, you know, a little pin prick, there's still been a puncture to the system.
[00:08:22] Speaker B: Yep.
[00:08:23] Speaker A: Okay, so there's some kind of skin break. Let's go on that side.
[00:08:25] Speaker B: So.
[00:08:26] Speaker A: So it's acute. There is a knowable incident that made the pain happen, and there's a skin break of some variety. What do we do then?
[00:08:36] Speaker B: So the. I use the same formula. If, if all of those things are in place, doesn't matter what the condition is per se or where it is on the body. I'm going to use a formula called Wang Bu Liu Xing San.
[00:08:52] Speaker A: Huang Bu Liu Xing San.
[00:08:54] Speaker B: Yep.
[00:08:54] Speaker A: Which of course features the king herb. Huang Bu Liu Xing. That's it. I'm imagining why that formula, that formula.
[00:09:03] Speaker B: Is in the Jingwei for.
It just says for metal sores, use this formula. And so what, what we think scholars think that means today is if you were cut, let's say you were in a fight and you got knifed, or you, you know, you were chopping up wood and the ax came down on your leg or your foot or something like that. And it's. There's a potential for infection.
[00:09:33] Speaker A: Yeah.
[00:09:33] Speaker B: But there's also the need to.
So it's an abscess formula or an abscess preventing formula would be another way to think about it. So it's going to prevent infection. There are herbs in there specifically for that.
And it's also going to move blood, though. So it is a blood stasis formula. It's just going to do other things as well. And there's things that are naturally in there that can be handy today.
[00:10:03] Speaker A: Let'S.
[00:10:03] Speaker B: Say Baishao hope or things like this to help the intestinal tract to move a little bit in case people have bloating. So we know somebody recently who had an appendicitis and had an appendectomy, and then we use this formula afterwards for that person.
And part of the logic for that was, oh, well, it'll help the peristaltic action regain in the intestines. So there's some added benefit to the formula that way as well.
[00:10:36] Speaker A: It's worth noting that if you're relying on classic Western English sources for formulas, Wang Bu Liu Xing San is not in the Bensky. And so if you're wondering, like, what's in it? What's in it? Well, it's Wang Bu Liu Xing, as the name would suggest. Yinchenghao Sangbaipi Zhiganzao Huajiao, which, if you're not recalling, is the Sichuan peppercorn.
[00:11:04] Speaker B: Yep.
[00:11:04] Speaker A: Huajiao Ganjiang Popo Huang Chin Baisha.
[00:11:11] Speaker B: Yep.
[00:11:12] Speaker A: Right. The doses of which we'll post in the. In the show notes, so you can.
[00:11:18] Speaker B: See they're quite dramatically different. Some things are very high, some things are very small.
[00:11:23] Speaker A: Exactly. So we'll. We'll post them in the show notes or a link to the formula so you can see the actual breakdown. But if you're listening to us and you go to the Bensky and you type Wang Buliu Shingsan and you won't find it.
So that's where that's coming from. So the components of that formula. It's worth noting, when people hear pain in school, we just learn blood stasis. If there's pain, there's blood stasis pain, there's blood stasis. And I mean, that's true for sure. But often there's a lot of other stuff happening besides just blood stasis.
[00:11:52] Speaker B: Absolutely.
[00:11:53] Speaker A: So in this case, acute injury skin break picking Wang Bu Liu Xing San to help move the blood, but also to help manage the potential for infection.
[00:12:04] Speaker B: Yes.
[00:12:04] Speaker A: Okay, so what if we have an acute problem with a known injury, but we don't have, like a skin break? Like I mentioned, I had a patient who was walking their friend's dog. It was a really big dog. The dog sees a cat, jerks the leash, and like, literally, I mean, it almost pulled this woman's shoulder out of socket. It was so dramatic. And then she was dealing with, like, shoulder pain for weeks and weeks. So in this case, we don't have a skin break.
[00:12:30] Speaker B: Right.
[00:12:30] Speaker A: But we know there was an incident.
[00:12:31] Speaker B: Yes.
[00:12:32] Speaker A: How do we approach that?
[00:12:33] Speaker B: So that's where our more standard blood stasis formulas are going to come in play. And for us, like, that's going to go more toward the Jiu Tong family of formulas.
Excuse me, the.
I think with the Gu Tongs, if, especially if you're starting out and you want to use fewer formulas, you really just need two.
Right. And you know those two, the two that we're going to talk about, I mean.
[00:13:04] Speaker A: Yeah, so they're. The jiuyutang is a family of formulas that almost all of them have the words juyutang in the end, but they're based off of shui fujiyutang, which is the starting formula, whose name translates to something like dispelling the stasis in the.
[00:13:19] Speaker B: Mansion of Mansion of blood, which is a modification of sinisan.
[00:13:23] Speaker A: Right, right, right. The mansion of blood being an anatomical concept whereby the sort of center chest, like the upper jiao kind of, you know, north of diaphragm was this mansion of blood. Right. So, excuse me. Shui fu, jiu tong, and then shentong, Jiutang.
[00:13:42] Speaker B: Right.
[00:13:43] Speaker A: Which is a modification of shui fu, whose focus is on the extremities.
[00:13:48] Speaker B: Yes.
[00:13:48] Speaker A: So if you're thinking. Thinking about the break in the two formulas, Shui fu jutong for the. The core of the body.
[00:13:54] Speaker B: Yeah. And that head and head traumatic injury, concussion, stuff like that. Shu, for sure.
[00:14:01] Speaker A: In fact, like, in some ways, it's sort of like sternum up. Right. Like, because if you're in the middle jiao and lower jiao, there's actually other types of formulas, but usually the kinds of pain problems that we're talking about don't present there. Unless someone were to take like a kick in the guts or something. Right. That might be possible, but usually, yeah. Sternum up, shui fu, jiu tong. And then extremities, Shentong, Jiu tong.
[00:14:26] Speaker B: Yep.
[00:14:27] Speaker A: There can be some other formulas that we use. If it's like specifically lower leg or foot, some stuff that drives it lower. But like, generally speaking, it's in the extremities. Shintong, if it's in the core, the northern part of the core, the sort of superior section of the body.
Shui fu.
[00:14:43] Speaker B: Yep.
[00:14:44] Speaker A: Yeah. Okay. So that's an easy breakdown, I think.
[00:14:48] Speaker B: Yeah.
[00:14:49] Speaker A: So someone comes in injury, you're treating it with whatever needle protocols you're going to use, E stem, distal mirroring, whatever you're doing.
[00:14:58] Speaker B: Yep.
[00:14:58] Speaker A: And then you have a skin break for an acute injury. Wangwu liu xing san. No skin break. And it's on the core of the body, chest and upper head, neck, Shui fu jutong, if it's in the extremities. Shentong jiu tong. Yep. Okay. What about my example, though? Is a shoulder the core of the body or is it an extremity?
[00:15:19] Speaker B: More. More of an extremity.
[00:15:20] Speaker A: Yeah, yeah, yeah, yeah. I know. It's a funny thing because it's like, at the juncture. Right. Your shoulder is at the juncture. But if you think of, like. If you think of Those old, like, G.I. joe or Barbie dolls, you could, like, pop the arms off of. If you pop the arm off, the shoulder comes with it.
[00:15:35] Speaker B: That's right.
[00:15:36] Speaker A: That's like the shoulder. Yeah. The upper logic. Just pop it off. The shoulder's part of the extremity. It's not part of the core of the body.
I mean, that's not like an anatomical decision here, but just like when you're picking a formula, that. That's the breakdown.
[00:15:49] Speaker B: Yeah.
[00:15:50] Speaker A: Okay. So those are pretty straightforward formula choices, I think, and obviously you could end up with more differentiation, but to be honest, guys, like, don't overthink it.
[00:15:58] Speaker B: Yeah, this. This will work. And, yeah, could you add in an ER pair if it's a little more chronic or a little more acute? You could, but you could also just give the formula and it will generally work.
[00:16:11] Speaker A: Yeah, just start. Start with the formula unmodified. This is our ongoing advice. Right. If you. If you take a formula and you heavily modify it and you're handing someone a formula that's got, you know, the original formula's got six or seven ingredients in it, but the one you handed them has 15.
[00:16:25] Speaker B: Yeah.
[00:16:26] Speaker A: Are you even handing them that formula?
[00:16:28] Speaker B: Right.
[00:16:28] Speaker A: I mean, not really. You know, so just stick with the basics, give the formula, see what results you get.
[00:16:34] Speaker B: Yep.
[00:16:35] Speaker A: Let's spend some time on the chronic side, though, because I feel like the chronic space is where it's a little bit stickier. Right. The breakdown is not so obvious. So we did our initial differential. Is it acute? Is it chronic? We saying it's chronic? Chronic in this case being three weeks plus.
[00:16:50] Speaker B: Right.
[00:16:50] Speaker A: Although it's worth noting that a lot of times the chronic conditions that we're looking at are very long standing.
[00:16:55] Speaker B: Super long standing.
[00:16:56] Speaker A: Yeah.
[00:16:56] Speaker B: Like decades, potentially. Yep.
[00:16:59] Speaker A: So if we're in the chronic side, then what's the next differential then?
[00:17:04] Speaker B: Yeah. So if. Was there a traumatic injury? Is a good question to ask.
[00:17:08] Speaker A: This is like a historic one.
[00:17:09] Speaker B: A historic one. And traumatic injury includes surgery, so it could be a problem with their gut, you know, but if it's. If they've had eight abdominal surgeries over the last 20 years, that's a traumatic injury.
[00:17:24] Speaker A: Yeah, yeah. It's the same, too, with corrective surgeries. Like, think about people with back pain. So they go in and they're going to have discs fused or they've got some Ongoing sciatica pain that the doctors determine is caused by stenosis. So they're going to go in and like, bore out the stenosis and try and reduce it. Like, all of these are ostensibly corrective actions for the pain, but they are themselves a piece of our differential. Because. Because there's been surgery in the area. It's, you know, particularly when you think about sciatica, carpal tunnel, low back pain. The results from the surgical interventions are quite mixed. Yes. Carpal tunnel probably has the best results.
[00:18:06] Speaker B: As long as it's actually carpal tunnel.
[00:18:08] Speaker A: As long as it's actually carpal tunnel, which seems like that would be, you know, an important distinction before you cut someone's wrist open. But it's hard to, like, to be fair to the Western docs, like, the way that they do their diagnosis is frankly kind of hard to determine. Right. It's sort of like they can't just scan it and be like, oh, yeah, carpal tunnel.
[00:18:27] Speaker B: Right.
[00:18:27] Speaker A: Which, I mean, we could have a whole conversation about whether or not that's an effective way to do diagnosis anyway. But there are some conditions that you can just see. Sure. Carpal tunnel is not really one. There's some indicators, there's some local inflammation issues. There's like numbness and nerve patterns and whatever. There's definitely a list of things that are differential. But sometimes people end up being like, yeah, it's carpal tunnel. Do the surgery. And it didn't help at all. And it's like, oh, well, actually, the carpal tunnel itself wasn't super inflamed thoracic.
[00:18:54] Speaker B: Outlet syndrome, or it was a spinal condition or something.
[00:18:58] Speaker A: Exactly. The problem was way up the chain, you know, than it was in the hand. But anyway, point. Point being that the surgical interventions have mixed results, some of them better than others.
It's rare for me to find a person with chronic low back pain who has had surgical interventions that lasted for any reasonable amount of time.
[00:19:16] Speaker B: Right.
[00:19:17] Speaker A: You know, they'll get three months, five months, six months. If they're young, maybe they'll get a year.
[00:19:22] Speaker B: Yep.
[00:19:23] Speaker A: And then it starts to creep back and then it's bad again.
[00:19:26] Speaker B: Yep.
[00:19:26] Speaker A: You know, and this, this is the struggle for people with these kinds of pains. The reason that there was research, Western biomed research on acupuncture for pain anyway. Because the biomed docs were out of. Out of tricks.
[00:19:39] Speaker B: Yeah.
[00:19:40] Speaker A: They didn't have any tricks left. But of course, like, in all that research, no one was asking about the herbal interventions.
[00:19:46] Speaker B: Right.
[00:19:46] Speaker A: No one was asking about, well, why is it that they're consider consistently having inflammation in their spine. And more importantly, why is it that when they have inflammation, they have pain?
[00:19:55] Speaker B: Yeah.
[00:19:56] Speaker A: Because this is a really important thing to remember, right. Not everyone who has, quote, bone on bone problems in their knee, their elbow, their spine, whatever, has pain.
[00:20:07] Speaker B: Right.
[00:20:08] Speaker A: That's not 100% true.
[00:20:10] Speaker B: Right.
[00:20:10] Speaker A: And it's one of the reasons that we end up in these really sticky situations where someone will go in like a patient will go into the biomeds for some other reason, they'll do a CAT scan or an MRI or even an X ray for some other condition. Right. And they'll be like, oh, my God, your knee is bone on bone. Like, how's your knee pain? Patient would be like, I don't have any knee pain.
[00:20:31] Speaker B: Yeah.
[00:20:31] Speaker A: They'll be like, well, you could have knee pain at any minute, at any moment. This knee pain can just erupt because you're bone on bone.
[00:20:40] Speaker B: Right.
[00:20:41] Speaker A: This person didn't have any knee pain. But now we planted the seed that they could have knee pain at any moment.
[00:20:45] Speaker B: Right.
[00:20:46] Speaker A: And that that becomes its own, oh.
[00:20:48] Speaker B: It hit my deductible this year, so I might as well get knee surgery.
[00:20:53] Speaker A: Yeah, I mean, you say that, but we really had that. Yeah, right. That's why he.
[00:20:56] Speaker B: I've known multiple people with that.
[00:20:57] Speaker A: That's why he brought it up. I literally had a patient that came in, this was in one of our first years working here. Guy came in and he's got pain in his left knee. And I was, you know, talking to him about it, and he was like, oh, I had knee surgery. I had, you know, knee replacement surgery in my left knee. I had knee replacement surgery in my right knee four years ago.
And I said, oh, well, how bad was the pain in the left knee before you had surgery? Because the right knee that he had four years ago is feeling fine. The left knee, he had the surgery a year ago and is hurting. And I said, well, how bad was the pain in your left knee before the surgery? Just to try and get a sense of what does it look like? And he was like, oh, it didn't hurt before the surgery. And I said, what do you mean it didn't hurt?
Why did you replace your knee if you didn't, if it didn't hurt? And he was like, oh, well, I was in a bike accident lo these many years ago, and when they repaired my right knee, which was really damaged from the bike accident, they did all these scans and they were like, hey, your left knee is bone on bone. And you could have pain at any time. And this year I had some other health things that happened. And so I hit my deductible and I thought, well, it's probably a good idea to go ahead and have it replaced this year because if it's. If I haven't hit my deductible, it'll cost me five, six thousand dollars or something out of pocket.
[00:22:07] Speaker B: Right.
[00:22:07] Speaker A: And of course, I didn't. I kept my shock to myself because it's not helpful to be like, what to the patient, but what. Like that. What a messed up system. I mean, I don't need to tell you guys who are listening to the show, like, if you've been listening to the show with any regularity, you know that I keep a lot of open heart and space for our biomed colleagues because, like, everybody, including us, is just working with the toolkit you got.
[00:22:33] Speaker B: Yeah.
[00:22:33] Speaker A: You know, and so you can only make diagnoses as far as you can.
And this choice that the patient made really wasn't the doctor's fault necessarily. It's like the craziness of insurance and deductibles and having to pay for health care. But even still, the idea that, like, a surgeon and an orthopedist would recommend surgery for someone who doesn't have active pain just because the scan says that they could is a little bit problematic to my view.
[00:23:03] Speaker B: Well, it reflects. It reflects a certain understanding of the body that isn't fully accurate. Right. Because if it was, if, if that were the accurate view. Oh, if you're bone on bone, 100% of cases, people are going to be in pain.
[00:23:18] Speaker A: Yeah.
[00:23:18] Speaker B: And that isn't the truth. Then there's got to be some other relationship that that body has adopted to not have pain, to keep the person not having pain in that circumstance. It's figured out some function from a structural point of view. Maybe it's a fascial thing, you know, who knows? But from our point of view, it's a channel thing.
[00:23:41] Speaker A: Right, Exactly.
[00:23:42] Speaker B: The channels have figured out. And it's the same way with scar tissue. Right. The scar is. If we get super hung up on scar tissue, we can forget that. It's really about the communication of the body through the tissue or around the tissue. And if you do acupuncture on scar tissue. Yeah. You can shrink the scar tissue for sure in a lot of cases, but you can also help the communication of the channels around that area. And as long as those channels can communicate, the person shouldn't have pain and they should have function.
[00:24:17] Speaker A: Yeah.
[00:24:17] Speaker B: So that's really the most important thing. It's not that the scar tissue totally go away, it's that it becomes, let's say, a non reactive site because the body's communication can move through or around the area appropriately.
[00:24:32] Speaker A: Yeah, I mean this, this idea, I mean it would be nice, right, if you could just scan people. In the biomed model, if humans really were just like cars, but like. Right, but meat cars, you know, like you could just like change the parts out or whatever. That'd be very convenient because then you could literally just take everyone who walks into the hospital, you put them into a full body mri, you know, every year, scan them and be like, oh, we found these 14 problems and then we'll just stick you in the surgery suite and we'll go ahead and correct them and then you'll be good to go. I mean, like, honestly, the way I described that, it just made me think about doing updates on my computer.
[00:25:13] Speaker B: Right.
[00:25:13] Speaker A: You know, it's like, oh, do a scan. This is out of date. This is whatever, you know. But it sounds ridiculous because it is. And yet at the same time, there is a sort of internal thought process that we as people growing up in the west, growing up with western medicine, growing up with a biomed point of view that we all internalize, that our parts are exchangeable. Right. That you can buy them at the parts store and put them in. And that the way that your physiology works is fundamentally mechanical because it seems to be for a lot of people. Right, but like that phrase it seems to be for a lot of people is about as far as you can really say about those physical realities. And I want to make room for the fact that maybe that's true of all medicine. Right. Like what we observe is mostly true for most people, but there are some people for whom it doesn't seem to work as well either. So there's always room for the mystery of the human condition. I think my primary criticism here is that the biomed viewpoint considers itself without a viewpoint, right. Like it considers itself this objective universal reality, even though their actual data doesn't support that.
[00:26:26] Speaker B: Right? Yeah.
[00:26:28] Speaker A: So these people come to our clinics, they've gone to the biomed path and they've done all this other stuff, particularly for chronic pain conditions. And there hasn't been a good solution either from a sort of osteo kind of point of view, like, oh, they've done the debridements, they've done the steroid injections, they've done the fusions in the spine, like they've Done all this physical medicine, it hasn't really done anything. Or they have conditions like rheumatoid arthritis or fibromyalgia, for which the solutions are vague and not necessarily very effective.
[00:27:01] Speaker B: Yeah.
[00:27:02] Speaker A: So let's break that stuff down then. So we have a chronic condition for which there was a historic injury, maybe a bunch of surgeries and whatever. I'm guessing based on what we just talked about on the acute side, we're probably looking at Jiuyutang style formulas. But what's different about the fact that they're chronic?
[00:27:21] Speaker B: Chronic. There's this idea, I don't actually know where or when it was developed in Chinese medicine, but this idea of pathology moving into the, the tiny channels or the Lomai. Right. And so the idea is like body gets injured. There's a, there's an influence of pathology. It goes into the main channels of the body.
[00:27:47] Speaker A: Yeah.
[00:27:47] Speaker B: As it remains and as it becomes more chronic, it starts to filter into these tiny little cracks and crevices. So when you use medicine, you actually have to get into the micro layers to get it all out. And so in herbal medicine you need herbs that have a certain signature toward that kind of problem.
[00:28:11] Speaker A: To deep places.
[00:28:12] Speaker B: To deep places. Yeah, the tiny places. And so for us that's going to look. I mean, the easiest way to get to that is to use bugs in your formula.
[00:28:24] Speaker A: Yeah. So this is like.
[00:28:28] Speaker B: Two. Like if you're just gonna use two, so don't just use one, use two. And the two easiest ones to use are those two.
[00:28:37] Speaker A: Right. You can add on top of that Chuanxia Scorpion, you've got Centipede.
[00:28:44] Speaker B: Right. Mengtong is.
[00:28:45] Speaker A: Yep. The horsefly.
[00:28:47] Speaker B: The horsefly. But that's harder to find these days.
[00:28:49] Speaker A: Honestly, bugs in general are harder and harder to find. Tube's pretty reliable in both bulk and granule.
[00:28:56] Speaker B: Yes.
[00:28:57] Speaker A: That's a roach. And then Shuager is leech. Leech Shwayger is fairly reliable in granule. Harder and harder to find in bulk. Yeah.
[00:29:07] Speaker B: More expensive.
[00:29:08] Speaker A: And both of them are expensive. Tube is definitely the cheapest of the bugs.
[00:29:12] Speaker B: Yeah.
[00:29:12] Speaker A: Oh, we should also not forget though, it's a different type of bug. Jiangsan, the silkworm.
[00:29:18] Speaker B: And Dilong.
[00:29:19] Speaker A: Dilong. Yeah, Dilong also very form. In fact, Dilong is in some of the Jiu Tong formulas.
[00:29:24] Speaker B: Yes.
[00:29:25] Speaker A: Just sort of by default as a base.
[00:29:26] Speaker B: Yeah, yeah.
[00:29:27] Speaker A: So you've got, you've got bugs. Okay. So if we say in general, because we kind of talk casually around here, it's like, oh, Jiu tongue plus bugs. Sort of like a concept. Right. So when we say plus bugs, what are we really talking about?
[00:29:40] Speaker B: Yeah. Do I do nine? Nine. So nine grams of each one.
[00:29:44] Speaker A: Yeah.
[00:29:45] Speaker B: And two Bengals. If you don't have that, then you can use Dilong. Jiang San is a little different.
[00:29:52] Speaker A: Yeah. Because that's Flemmy.
[00:29:53] Speaker B: Because it's more phlegm. Yeah.
But you can kind of use any of them. Like, if you pick two of them, you can pretty much use them and it's. It's going to help.
[00:30:04] Speaker A: Yeah, yeah. So the idea here is that the Jyutang formula is getting into the. The specific part of the body where the blood stasis is.
[00:30:12] Speaker B: Yeah.
[00:30:13] Speaker A: But if we don't include the bugs, probably the patient still feels better. Yeah, but it doesn't. It doesn't get down into the.
[00:30:20] Speaker B: Into the nitty gritty place. Yep.
[00:30:22] Speaker A: Yeah. I mean, the metaphor here is, is that like, stuff settles over time. Right. Like if the pathology is like water and it's moving down through soil. Like if you came in with a backhoe and you like dug up the first foot of soil. Right. But if this water has been trickling down for a long time, it's going to be deeper than that.
[00:30:40] Speaker B: Yeah.
[00:30:41] Speaker A: You got to get. You got to get all the way down to hard pan, like where it's down there. And so the easiest way to do that, I mean, you could build a blood moving formula with every blood mover you could think of. Right. And like big heavy doses of the starter blood movers like Hong Khua and Tao Ren. And then you throw in the Sanlang and the.
And then you pile in a bunch of like, resins, you know, and you start putting all this stuff together. But what will happen is that formula becomes unwieldy, it's a little unbalanced, and frankly, it's hard to digest.
[00:31:16] Speaker B: It's hard to digest?
[00:31:17] Speaker A: Yeah, really hard to digest. So people end up with really loose stool, nausea, indigestion.
And look, the bugs don't taste great.
[00:31:25] Speaker B: Right.
[00:31:25] Speaker A: You put them in the formula, you can taste them. They taste like animal dirt. That's what they taste like.
But you don't need as much of them. You don't need to throw in mounds and mounds and mounds of other herbs and you can still get down into the deep places without having to pile on. Formulas make it hard to digest.
[00:31:44] Speaker B: Yeah. And I would say if you're reticent to add those into the formula, try it once and watch what the results are. I mean, it's dramatic when you have somebody that needs Them and you use the same exact formula without and then with. It's hugely different.
[00:32:05] Speaker A: Yeah, yeah. It's also worth noting that it's very difficult, maybe impossible to reproduce this effect with non animal based herbs.
[00:32:15] Speaker B: Yeah. I haven't found anything that will do it. You have, you have other herbs that are said to course the Lomai, but not in the same word, not in the same way.
[00:32:23] Speaker A: Right. Like Binglong is the, the one I always think of. Sure. Like if you look at a cross section of Binglong, Segua Lo, I mean even Hong Khua to some degree because it's the small little beach pieces. But the, the truth is, is like they do get into the l. My space. But not at this blood level.
[00:32:41] Speaker B: Right. The blood level is the thing that's the most, the most difficult to get at. Yeah.
[00:32:46] Speaker A: Binglong might be the closest in that realm, signature wise, but it's, it's just not there.
[00:32:52] Speaker B: Right.
[00:32:52] Speaker A: Not compared to the bugs.
[00:32:53] Speaker B: Yeah.
[00:32:53] Speaker A: You know, so if you've got someone who doesn't eat animals and they can't be convinced to take these bugs into the formula, you just need to have a conversation about them with them, about what the limits are.
[00:33:07] Speaker B: Right.
[00:33:07] Speaker A: You know, probably we won't necessarily be able to get to the base here if we can't include these, these animal products. Unless I know off the top of my head that someone is a vegan, I'm not going to mention that there's bugs in their formula.
[00:33:20] Speaker B: Right.
[00:33:21] Speaker A: And I don't mean that as like a deceptive thing. It's just like I don't tell people all the stuff that's in their formula. In general, they get an info sheet from us, the name is there and they'll read it later, they'll see leech on the formula and then usually the next week they're like, were there leeches in my formula? Like, yes, they're very helpful for dealing with chronic pain. And they go, oh, okay. But if you're like, so I'd like to put in some bugs into your formula. I'm just checking to see if that's okay with you.
[00:33:48] Speaker B: Are you open to that?
[00:33:49] Speaker A: Are you open to bugs? Like, don't do that. Like you are the expert. You know what the patient needs. You're also not trying to trick them. Like if someone's a vegan, you don't want to like sneak in the bugs. Like that's going to damage your patient relationship. But if you don't like, if they're not a vegan, then just put it in the Formula.
[00:34:07] Speaker B: Yeah.
[00:34:07] Speaker A: Right. If they are and they've. And that's. And you know that, and it's come up in your discussion, which probably would. Usually when you're talking about pain conditions and things like that, then obviously you need to have a conversation about what you can and can't achieve.
[00:34:19] Speaker B: Right.
[00:34:20] Speaker A: Okay, so that's on the chronic injurious side.
[00:34:24] Speaker B: Yeah.
[00:34:25] Speaker A: Okay. Chronic no known injury. What do we do with that?
[00:34:30] Speaker B: Chronic no known injury is going to fall more into, let's say, a combination of external contraction, multiple external contractions over the course of life, which then results in a kind of core resource deficiency.
So if you notice, a lot of the arthritis formulas that we learn in school are called wind, cold, damp, B syndrome. Right. There's like these list of two or three different pathogenic terms. Right. And wind is almost always amongst them. So what wind means, I mean, you can differentiate it out in patterns to like, oh, wind is wandering pain and all of these other things. But wind for me really signifies that there's been damage from the outside by the body having to adapt and not knowing what to do. And then over time, the resources of the body being depleted because of its inability to adapt, essentially. And then there's the resulting deficiency which can happen. This is more like the chronic conditions are going to be like chronic pain, body pain, arthritis, acute. You can also have an acute version of this, which is going to look a little different in treatment.
[00:35:54] Speaker A: Do you think so? Whenever we, Whenever I talk to patients about this idea.
[00:35:59] Speaker B: Yeah.
[00:36:00] Speaker A: And you know, just the way that you phrase it. Right. So, like it's a chronic condition. There's probably been repeated external invasions that have been poorly resolved or unresolved or whatever, and they've kind of stacked up Right. Over time. And this is why we now have a chronic problem. I have noticed that a lot of patients want to kind of do a historical assessment to try and find the cause.
[00:36:26] Speaker B: Sure.
[00:36:27] Speaker A: Which I feel like is a totally natural thing to do. But I'm wondering what your thoughts are on how useful that is or not to kind of do a historical inventory. To be like, okay, When I was 7, this happened. When I was 15, this happened. All these things together. Now why I have rheumatoid arthritis.
[00:36:43] Speaker B: Yeah. I think it's not relevant for bianzung other than to know that there's been some stuff.
[00:36:50] Speaker A: Yeah.
[00:36:51] Speaker B: And if we rule out the traumatic injury piece, or let's say there is a traumatic injury piece, and we decide we're going to do the blood stasis method first the one thing that I wanted to say about that actually is that at some point you'll probably have to change your approach away from moving blood, even in that condition. So chronic thing with definite traumatic injury history. I'm going to decide to move the blood first, and I do that for six weeks, a few months. The pain gets better, the condition gets better. You're going to reach a plateau at some point that you won't be able to cross if you continue to just move the blood. You're going to have to work on the internal resources of the body at some point. And one of the challenges with using the blood stasis piece as the primary method of treatment is you sort of feel reluctant to take them off of the blood stasis formula because they've gotten such good results.
So at some point you will have to change that.
Another condition where this is true is in when you're treating diabetic neuropathy. A lot of diabetics can do really well on these blood moving formulas for a few weeks or a few months, and their neuropathy gets a lot better, but then it plateaus. And if you keep them on that formula, it won't continue to get better. You have to change the approach and work on the core resources of the body.
[00:38:16] Speaker A: Yeah. And that's, that's because the chronic illness is damaging to resources. Right. It consumes resources to be ill. Yep. Anyone who's had any kind of chronic pain or chronic illness knows this. Right. I mean, you are more tired, your attention is less, your emotional bandwidth is smaller because it's being ill consumes those resources. So this is very true. Also, if a chronic problem has been chronic for years, you know, you're not going to completely resolve this problem by just moving the blood, even if it was an injury, like you said.
[00:38:48] Speaker B: Right.
[00:38:49] Speaker A: So in this case, we don't have an injury. Now, we're talking about this wind idea. Wind here is essentially a sort of diagnostic conceptual tool that lets us know, okay, this has come from the outside, and because we're in a chronic position, has likely come from the outside many times.
[00:39:07] Speaker B: Yeah, wind is change.
[00:39:09] Speaker A: It's change.
[00:39:10] Speaker B: It's an initiated adaptation response in the body. You can think about it that way.
[00:39:15] Speaker A: Okay, so once we have sort of now in this headspace of like, okay, we've had this ongoing chronic problem, there's been a wind piece of it, what do we do? What's the next differential to decide where we need to go with herbs?
[00:39:29] Speaker B: Right. So then we can go back to acute chronic. Right. If it is acute, let's say it's been happening for two to six weeks, something like that, and there isn't a traumatic injury piece, we may decide we need to treat through standard external contraction model. So that could be all of our normal Shanghan Lun formulas, for instance.
And if you've noticed, if you read, if you at all read the lines, you may notice that pain is mentioned in a few of them particularly. So the formula that I would say, if we're going to mention just one, would be Caihu Guizhetong, because Chao Guizhutong, joint pain is mentioned in one of the lines for that formula. And so let's say like the person has body pain or joint pain that happens, that happened a few weeks ago, could be a headache, even something like this, but there's no known injury or there's no known traumatic thing. They just woke up one day and they started to have this problem. It's worth treating through external contraction first.
[00:40:39] Speaker A: Yeah.
[00:40:39] Speaker B: Because a lot of the time and the reason that there's pain, by the way, in that case is because the surface is dysregulated. We should say that. So if you try to like move the blood and stuff, it doesn't really work because the surface is where the problem is.
[00:40:53] Speaker A: Yeah, yeah. So that, that's an interesting idea here because I think a lot of people would not, would not consider the idea that this is like an external. Because it's not a cold. Right. Like people. Not a cold. Yeah, like, oh, external things. Cold. Cold and flu. Cold and flu is like. Yeah, definitely. Those formulas are great for cold and flu. But these are the types of, in fact, and when I mentioned earlier, the sort of historical analysis that patients will want to do, this is why, in my opinion, it's not a very useful activity. Right. Neither for diagnosis nor for really just cataloging. And the reason is because it is impossible to track the number of times that a patient, especially say a patient in their 50s or 60s who's had rheumatoid arthritis for the last 15 years. There's. It's impossible to track the number of times that that patient could have had a situation like you just described a pain related condition that was externally generated because they are not like plugged into Chinese medicine, primary care. That was not treated.
[00:41:58] Speaker B: Right.
[00:41:58] Speaker A: With herbs.
[00:41:59] Speaker B: Right.
[00:41:59] Speaker A: They just dealt with it and it probably, you know, I'm using air quotes here. Went away.
[00:42:04] Speaker B: Yeah.
[00:42:04] Speaker A: Okay. But it actually, it didn't go away.
[00:42:07] Speaker B: Right.
[00:42:07] Speaker A: It lodged.
[00:42:08] Speaker B: Yeah.
[00:42:09] Speaker A: Somewhere in the system. But because bodies are amazing. Right. It figured out a way to work around it.
[00:42:15] Speaker B: Right. I put. Yeah, put it away. Put it into latency.
[00:42:17] Speaker A: Yeah. Move on, move on. Reroute these channels. It's in the way. It's fine. Particularly when you're young and there's only one little roadblock that's in the way. No problem to reroute around it.
[00:42:28] Speaker B: Right.
[00:42:29] Speaker A: Repeat this pattern over and over and over again. Right. Particularly with a person with a constitution to accumulation or a constitutional need or a constitutional tendency toward stagnation. Right. And now all of these tiny little roadblocks that the body has consistently tried to work around, work around, work around, because none of these things were addressed because people didn't think that they needed to address them, especially because they didn't show up later. It got dealt with. Now they've accumulated, and now you have a chronic problem. The thing is, is that it's not useful to track that. You can't.
[00:43:05] Speaker B: No, you can't track that.
How would somebody track it?
[00:43:08] Speaker A: You can't track it. Also, it can create in the patient this idea that this is their fault.
[00:43:12] Speaker B: Right, Right.
[00:43:13] Speaker A: Like, ugh, if only you had gotten treatment. And I mean, okay. In the most, like, pure vacuum. I suppose that's true, but we can't prove the negative. I can't prove that if you had gotten treatment for all of these things, you wouldn't have gotten rheumatoid arthritis. I don't know that. And it'd be ludicrous for me to assert that. But there is this idea that these small things should be addressed. It's why, as you well know, if I had my druthers, we'd all be primary care. Yeah. We would be able to use Chinese medicine as a primary care intervention so that people know that they shouldn't just let their bronchitis run until eventually their body gets rid of it. It's like. No, because it probably won't. It's like lingering in there.
[00:43:55] Speaker B: Yeah. Another. Another quick case situation. That's important. So wind is this change idea. Right. So it forces the body to adapt so acutely, like we can think of, if there's been body pain and it's acute and there's no traumatic injury, we can use something like chihu gui zhong to treat it. Another instance where this might be useful is if you're treating a chronic pain pattern like rheumatoid arthritis you mentioned. Right. And our sort of the classic formula for rheumatoid arthritis, if you're going to pick one, is guizhi xiaoya zhu Muton. So you can have a patient on a formula like that, and then suddenly it stops working.
[00:44:37] Speaker A: Mm.
[00:44:38] Speaker B: What do you think happened?
[00:44:40] Speaker A: Wind.
[00:44:40] Speaker B: Wind, Right. The neijing says all sudden disease belongs to wind. Right. In the 19 lines in pathology. So there's this idea that, oh, there's another external contraction. Now, the resources of that person's body have gone to the surface. So if we're doing good diagnosis, we're gonna match the movement of those resources. We're not gonna continue to treat the interior. We're going to go to treat the exterior. And usually in a deficient patient, the most exterior manifestation that they can do is a xiaoyang type of pattern, because it's the deepest of the exterior patterns. Right. So it's going to be chihu guizutang. It's going to be caiu guigi ganjung tong. And you do that, you harmonize for two weeks or something. And then huizhio ger mutong works great again for the joint pain. So that's another situation where you might want to treat surface. It can be inside of a chronic treatment strategy, if that makes sense.
[00:45:39] Speaker A: This is the kind of agility that I do think practically is very hard to maintain in a modern clinic.
[00:45:45] Speaker B: It is, yeah.
[00:45:46] Speaker A: Because, you know, especially for a chronic condition, you might have put someone on their. We'll call it their constitutional formula. Right. Chai gui ji jar mutong that they're taking regularly. And maybe you're just writing that formula, like, once a month. You know, they're, like, picking it up for you because, like, it's chipping away. They got some work to do, and so they may not. Like, maybe they've got four weeks worth of herbs. Right. And then it plateaus on week two.
[00:46:13] Speaker B: Yeah.
[00:46:14] Speaker A: And they're like, well, I mean, I have an appointment with Travis, like, in a couple of weeks, and it's fine. So then you've missed these two weeks where if they had been coming in more regularly, you would have been able to be like, oh, so, yeah, actually, it feels like the herbs have plateaued, and you see that, and you're able to intervene and say, oh, actually looks like something's shifted here. Let's modify your formula.
[00:46:37] Speaker B: Right.
[00:46:38] Speaker A: This is very challenging, y'all, because, like, you have all of these practical realities that have nothing to do with. With really good diagnosis. Like, how much insurance coverage do they have? How much time can they take off of work? How much money do they have to come in and see you? Like, there's all of these things that stand in the way of being able to do what we're talking about doing. So we're giving it to you in a sort of purely conceptual framework. But I want to make space for it and acknowledge the fact that it is very challenging to achieve this level of specificity because of the way the system is organized.
[00:47:11] Speaker B: Yeah. But we do have a way to address it. Whereas in biomedicine, there's no way to address this.
[00:47:17] Speaker A: That's true.
[00:47:18] Speaker B: They don't have any idea what's going on when this kind of stuff happens. Oh, like, maybe we need to change the steroid. Are we, like, we need a new biology. Yeah. We need new biologic. Throw an antibiotic and a steroid. Like, they don't have any idea when they're on. Their patients are on medication like this, and the situation changes, what to do. They don't. There's no room in biomedicine, at least currently. They don't have any idea, like, what to do about this unless it's, like, really clear. Like, let's say that patient got a sore throat and they started to get sick. Then it would be clear, like, oh, there's a difference here. The person's sick.
[00:47:56] Speaker A: Yeah, but, you know, they wouldn't even relate that well. They.
[00:47:58] Speaker B: No, they would.
[00:47:59] Speaker A: Right. They wouldn't be like, oh, but here's.
[00:48:00] Speaker B: But they might understand why the pain got worse, right?
[00:48:03] Speaker A: Oh, sure, yeah.
[00:48:04] Speaker B: They have a fever, but. But a lot of these patients, they don't. They don't have that. They don't spike a fever. They don't even have a sore. Maybe their throat's a little dry.
But they don't have any obvious changes, except they come into the clinic, you check their pulse, Their pulse is more superficial. They're gonna show signs of external. Oh, have you been a little averse to drafts? Or they may have a scarf on that time you look at that, there's changes that we'll see if we're paying attention and if we can train our patients to communicate when stuff like this happens. If you're treating somebody for rheumatoid arthritis and they're doing a lot better, you. You can say, if this formula stops working, contact me immediately. Right. And you can have a secondary formula for them to go on because you can almost predict what they're going to need. Like I said, it's usually chihu formula, Chai huizhu tong chai huizhi ganjiangtang. And you give that to them for a week or two. That formula then improves their joint pain. And then after a Week or two, switch them back to the other one, you know, and it works.
[00:49:12] Speaker A: This point, I think, is extremely important around patient training.
[00:49:16] Speaker B: Yes.
[00:49:16] Speaker A: And you can't do it all at once. But if you've worked with someone, you've built rapport and trust with them to deal with a chronic pain condition, then part of your ongoing work with them is to continue to train them about how to respond if things change, what to do if they get sick. I mean, this can even just begin with. The most basic statement that I give to all, almost all of my patients who are, I'm working with for chronic conditions is like, look, this formula that you have is designed for you as you are right now, but if you get sick, okay, you need to call me and let me know, because maybe the formula that you're on is fine for you to keep taking while you're sick, and maybe we need to change it so we can deal with that. Because, you know, you're probably not going to hurt yourself by taking this formula, but frankly, you might just be wasting two weeks of herbs that are, that are not going to be doing anything while your body's dealing with this other pattern.
[00:50:05] Speaker B: A hundred percent.
[00:50:05] Speaker A: I'd rather you just hold them. Let me write you a formula for what you need. You'll feel better, and then you go back to it. Now, we haven't wasted any herb.
[00:50:12] Speaker B: Exactly.
[00:50:13] Speaker A: You know, and that, that basic conversation then opens the window for this, like, more nuanced approach that says, like, hey, you know, you're on this formula. Part of this. It's, it's not, you know, you've got to keep checking in with your body periodically, et cetera, you know.
[00:50:27] Speaker B: Yep.
[00:50:28] Speaker A: Okay, so we're in this chronic space now. So we, we mentioned that you could have an acute presentation that doesn't have an injury. Yeah, right. We're using these, these classic external formulas in the chronic space. We're looking at this again, the same sort of wind dynamic change piece.
[00:50:47] Speaker B: Yep.
[00:50:47] Speaker A: But there's a little bit further differentiation there. Right?
[00:50:50] Speaker B: Yes.
[00:50:50] Speaker A: So what do we. How can we break out some choices when you're in that zone?
[00:50:54] Speaker B: So you're in more of a deficient condition. The constitution is more deficient. Right. And there's been repeated insults to the surface, a repeated need to change, and the body has deteriorated around trying to adapt and not fully adapting and not being able to fully recover.
So these cases are going to be more chronic pain cases, cases where there's maybe a fibromyalgia diagnosis, a diagnosis of ms, a diagnosis of Arthritis, something like that. Right. And this is where we hear the phrase wind, cold, damp, bee syndrome. We hear these kinds of ideas. Wind, heat, all of these different things. Wind, hot, damp or damp heat. And there's in school we learned like, oh, it's wandering pain, it's wind. If it's sharp and stabbing, it's blood stasis. Right. We learn these kind of differentiators for understanding, but I think it's hard to understand why they occur.
So the model that I'm explaining here is a little bit better at understanding why these things specifically occur. And generally there are two types of constitutions. If you want to break it up, super simply a yin constitution and a yang constitution.
Or we could say a blood constitution and a qi constitution. And when each type of constitution becomes deficient over time, they tend to have depleted vitality or depleted yang. It just manifests differently. Excuse me. So one person will manifest with a blood deficiency cold side, and one person will manifest with a cold plus water accumulation side.
[00:52:54] Speaker A: Okay.
[00:52:54] Speaker B: And there can be a little bit of both as well in some cases, but generally this is how people become deficient over time, especially for arthritis and arthritic type presentations for pain.
[00:53:10] Speaker A: So what are the symptom differentiators for a person who's more cold blood type versus cold wet water type?
[00:53:18] Speaker B: Yeah, so the easiest one to note is that somebody who has cold blood is going to have a really hard time sweating because the warmth of the blood is needed to force a sweat.
So somebody with cold plus water accumulation cold damp type will generally be able to sweat, but the person who has a cold blood type will not. So that's the easiest differentiator as far as symptomology goes. Cold blood type people tend to be a little thinner, they tend to be a little more raily, rail thin. In some cases, cold yang type people tend to be a little thicker, a little bit heavier, a little more damp looking. Right.
[00:54:02] Speaker A: And the cold yang is the water. The water people.
[00:54:05] Speaker B: The water people, yeah.
[00:54:06] Speaker A: So what's the formula for the cold blood type then?
[00:54:09] Speaker B: The cold blood type signature formula is Dangwe Sinitang. Yeah.
[00:54:14] Speaker A: Okay, so we've got chronic pain condition without a physical injury.
And we're looking at the, we're asking questions and we're differentiating here. And one of the major breaks is this sweat pattern, the sweat pattern. So the person can't sweat. You know, they, you know, with activity, with vigorous activity, they just don't sweat. They're just not sweat people.
And coupled with the potential that their physical constitution could look a little bit more thin, a little more willowy. Right. That kind of design.
Probably. Then Dangui Sinitang, Dangwe Sinitang is going.
[00:54:50] Speaker B: To be the first formula, first starting point.
[00:54:52] Speaker A: Yeah. On the other side.
So someone can sweat. Then we're probably looking in this other range. Right. This sort of cold, young, wet water accumulation pattern. What kind of formulas are we looking at there?
[00:55:05] Speaker B: That's going to be our Futsa type patient. So that could be Futzi inside of a Guizhetong structure. There's a bunch of different versions of how that can look.
Or it could be Futang, which is another type of structure. Futang is very close to Zhen Wu Tong. Both of them can treat pain, but Futang is a better pain formula, so it's worth mentioning by itself.
Yeah, that's the type of place we're going to go with that.
[00:55:34] Speaker A: Are there any other besides the sweat piece?
You know, is it possible that someone can sweat but is still actually a cold blood person? Like, is that a thing?
[00:55:43] Speaker B: It's very unlikely. If that person can sweat, what will happen is so cold blood people will be. Both people will be cold overall, especially their feet will be cold because that's more lower Jiao reflection is the feet. But usually the hands and the feet are both cold.
But cold blood people will also be super averse to heat. And the reason is they can't sweat. So their body, when they're exposed to warmth, their body can't regulate because they can't sweat. So they're also very averse to heat. If they go into a place that's too hot for them, they're going to be really uncomfortable.
[00:56:22] Speaker A: Or like hot summer weather.
[00:56:23] Speaker B: Hot summer weather is a great example. Being in a hot room, something like that.
[00:56:28] Speaker A: This is actually a really important distinguisher because a lot of times when you're talking to people and they have cold hands and feet.
[00:56:33] Speaker B: Yeah.
[00:56:33] Speaker A: And maybe you live in a climate. So we're in Portland, Oregon. Right. So it's cool and damp here most of the year.
[00:56:38] Speaker B: Yeah.
[00:56:39] Speaker A: And so you'll be seeing someone in, you know, November and it's cold out and they'll be like, I have cold hands and feet. And then I will say something like, oh, you know, do you prefer warm weather then? And this, the first time someone said this to me, it really surprised me because a lot of people go, oh, yeah, I much prefer that it's warm. But someone who has what you're talking about, like can't sweat and stuff.
[00:56:56] Speaker B: Yeah.
[00:56:57] Speaker A: They'll say, well, I mean, but I kind of. But I sort of hate the summer.
[00:57:01] Speaker B: Yeah.
[00:57:02] Speaker A: And you're like, what do you mean you hate the summer? And they're like, the heat just makes me angry.
[00:57:05] Speaker B: Yeah, exactly.
[00:57:06] Speaker A: Now you're looking at exactly this pattern, right? Because you would think someone who tends to be cold and has cold hands and feet would just be like a sun worshiper. Right. They would just be out all the time. And if they can sweat, then they will.
[00:57:19] Speaker B: Then they will.
[00:57:19] Speaker A: They will. They're like, oh my God, please send me to Palm Springs. But if they can't sweat, then they won't. Right, Right. And so that's an interesting, I think, distinguisher there that can be surprising. Like, you'd be like, what? That seems shocking to me. But that's why. Because the surface can't open, the heat can't escape.
[00:57:35] Speaker B: Right.
[00:57:36] Speaker A: It feels terrible.
[00:57:36] Speaker B: Yep.
[00:57:38] Speaker A: So, okay, we're talking about all these cold problems, though. But I mean, you know, a lot of arthritic conditions will present with red hot joints.
[00:57:47] Speaker B: Right.
[00:57:47] Speaker A: And there's this idea that, like, there's a heat component to the pain presentation. What are we looking at here? When we see that kind of stuff.
[00:57:55] Speaker B: It'S possible for there to be more of a true heat picture in some cases.
A lot of those cases are going to be less chronic, and they're going to be treated by the type of formula approach that we see in UAB Tong, which is, if you don't know what that is. I didn't know what UAB tongue was for a long time. It's Guizhitang minus Guizhi and Bai Shao plus Ma Huang and Shi Gao.
So it's just like a key formula. And it's a formula that's mentioned for swelling especially particularly in the upper body. So if there's swelling in the face and the hands and the joints of the upper body, that formula works really well. There's also a version of it where you add baiju or sju into it and there's even more damp then and there's some symptom differentiators. But that's kind of like how the. How it could be. Let's say the classical formulas address this sort of heat damp, this hot damp picture.
[00:59:01] Speaker A: Right.
[00:59:01] Speaker B: That could be an arthritic type of problem. Vast majority of chronic arthritis is a cold problem underneath and then manifesting with hot joints on top. And that combination is why we get weird formulas like Wei Zhiyao Zhi Mutong, because we have primarily a very cold constitution where the circulation is slowing. Down. But because the circulation is having a difficult time moving through the joints, stagnation gets created and then there's heat that appears locally in the joints.
[00:59:34] Speaker A: From the stagnation.
[00:59:35] Speaker B: From the stagnation, exactly. So then we need something overall that's going to warm and circulate and then cool.
But only in special places, like locally. Locally.
[00:59:47] Speaker A: Yeah, exactly. Because you don't want to cool someone's like yuan qi. You don't want to like, diminish, like the warmth of digestion, like core levels. We're not going to pump somebody full of, I don't know, Huanglian.
[00:59:59] Speaker B: Exactly. It's a really good example for. We have to be careful with this idea of inflammation. Right. Because we have this sort of language. Oh, inflammation. Everyone's too inflamed, there's too much fire. Right. Which from a Greek medicine point of view may be true. I don't know. But from our medicine point of view, inflammation is so often related to cold. We have to be very careful when we treat these pain conditions not to just cool people off too much because it doesn't actually work.
[01:00:30] Speaker A: Yes. Yeah. In fact, when I think about inflammation, especially when you put it in the context of autoimmune inflammation problems. Right. So just take the logic, the Western logic there. So a person's immune system is attacking itself.
[01:00:46] Speaker B: Yeah.
[01:00:47] Speaker A: And it's idiopathic.
[01:00:48] Speaker B: Right.
[01:00:49] Speaker A: We don't know why. From a biomed point of view, when I see that, what I fundamentally see is a dysfunctional human physiology.
[01:00:59] Speaker B: Yes.
[01:01:00] Speaker A: That is largely happening because of the erratic outcomes of.
Of a poorly resourced system.
[01:01:09] Speaker B: Yeah.
[01:01:10] Speaker A: Right. So like, the reason that your immune system is not acting how it's supposed to act is because you don't have the resources that you need to have for your immune system to behave the way it's supposed to act.
[01:01:18] Speaker B: Absolutely.
[01:01:19] Speaker A: You could run any number of, like, different, you know, metaphors here to try and like, explain why one thing is happening versus another. But at its core, the reason that your body is not behaving as it should is because it is under resourced.
[01:01:33] Speaker B: Absolutely.
[01:01:34] Speaker A: And an under resourced body is almost always cold.
[01:01:37] Speaker B: Yes.
[01:01:37] Speaker A: Right. Like, yeah, it has surface level heat, but the, the lack of resources is a cold problem.
[01:01:42] Speaker B: Right.
[01:01:43] Speaker A: Of course. And I think you mentioned this a second ago, the heat pain presentation is probably also not a chronic one.
[01:01:51] Speaker B: It's usually not a chronic one.
[01:01:53] Speaker A: Yeah.
There are infectious conditions. Think of like dengue fever and stuff. Right. Where people will have incredible body pain. Joint pain. Dengue fever is almost certainly a heat pathology. And just the way.
[01:02:09] Speaker B: Or it could be a surface closure. Right. It could be like that and it could be a heat and a certain. Like, it could be dot, chinglong tong type of pattern.
[01:02:18] Speaker A: Exactly.
[01:02:19] Speaker B: Yeah.
[01:02:19] Speaker A: But again, those are acute things that people come across. It's probably not the case that your chronic 15 year rheumatoid arthritis is a heat problem.
[01:02:29] Speaker B: Very, very unlikely.
[01:02:30] Speaker A: Very unlikely. Yeah. So I think that's an important thing to keep in mind is like, there are plenty of ways in which there could be heat signs, but they're probably not true heat signs. They're probably cold signs.
[01:02:42] Speaker B: Yes.
[01:02:42] Speaker A: Yeah.
[01:02:43] Speaker B: Yep.
[01:02:43] Speaker A: Okay, well, anything else we need to add into the differential here?
[01:02:48] Speaker B: The only other thing is there are a few other parts of physiology that could be off, that could be contributing to pain. And it's good to just remember this. So if you're trying to treat somebody for pain with herbs and you're having a difficult time, there's a couple of other things to consider. First, some people will have such bad digestive disharmony that it creates problems in the muscle layer or the joints or something else. So if you just treat the digestive piece, it actually helps with the pain.
I had a case not that long ago where there was a significant digestive component to the pattern. This woman came in for knee pain, and I treated her with Gansao Shishingtong, just not modified at all. And the knee pain almost completely went away in a week just on the formula.
So that knee pain for me wasn't really related very much to the knee. It was related to the visceral component of the digestive system.
Another possibility for difficult resolution of pain is that the patient has a bleeding condition. Right. So that could be an intestinal bleed. It could be a bleed like a hemorrhoid or something like that.
And if the patient is losing resources through bleeding, it can be difficult to treat, let's say a chronic joint pain type of thing. So I think I've mentioned before that I had a case where a patient had shoulder pain for like six months or whatever, and it was really hard for him to get it resolved. He had been to see a bunch of different people. And when he came to see me, one of the things we talked about within the first couple of sessions was these hemorrhoids that he had really bad hemorrhoids. And so with the herbs, we just treated the hemorrhoids. We got the hemorrhoids to stop bleeding, and his shoulder pain immediately started getting better.
And so the blood loss from that or if you think you're treating a female bodied patient and there's heavy menstrual bleeding and you're trying to treat their elbow pain. Right. It could be a barrier. Their heavy menstrual bleeding could be a barrier to treating their joint pain because they're super blood deficient. They're losing all these resources through bleeding. So I just wanted to mention those as some things that we can think about that could be a barrier to treatment. If you're normally good with acupuncture and you know what you're doing, these are things that might be harder to treat, let's say without herbs or without addressing them. If you can address them with acupuncture, great. But yeah, some other things to think about.
[01:05:36] Speaker A: I think there's a. I'd also add to the digestive piece in particular that if people's digestive harmony is substantially unbalanced, they've got a lot of problems there. Not only do you have like the pain could be stemming from that issue.
[01:05:51] Speaker B: Yes.
[01:05:51] Speaker A: But on top of it, the ability to actually metabolize and transform an herbal formula into something useful for the body.
[01:06:01] Speaker B: Right.
[01:06:01] Speaker A: A blood, like a blood stasis is really limited.
[01:06:03] Speaker B: Yeah.
[01:06:04] Speaker A: Right. So like I'm gonna hand you a formula that's like pretty demanding on your digestive system to transform these herbs into usable qi to like repair this pathology. Your digestion is so weak that we end up with loose stool, nausea. And what I see a lot with blood stasis formulas actually is acid reflux.
[01:06:19] Speaker B: Yes.
[01:06:20] Speaker A: People will take it and they're like, ugh, just a terrible acid reflux because their guts are actually quite weak.
[01:06:25] Speaker B: Right.
[01:06:26] Speaker A: So that there's a, there's a component whereby the pain is actually stemming from the digestive disharmony. But also, even if that isn't the case and the digestive system is quite weak, you might have a hard time getting the patient to get results because they literally aren't metabolizing the formula 100%. So digestive components, I think can never, like anytime we're dealing with herbs, you really can never afford to just disregard the digestive state of the patient because that is our pathway to transforming herbs into useful qi. Right. It has to go through the middle joust process. So I think it's always important to remember that.
All right, well, I think we've hit the end of what we wanted to talk about with pain stuff today. So as always, you can send us an email with your ideas@infoootandbranch pdx.com that's info root and branch, papa delta x ray dot com. And we love to hear from you. We'd love to hear some thoughts on the show. As always, please rate and review us so that other people can find us. And with that, my name is Travis Kern.
[01:07:27] Speaker B: I'm Travis Cunningham.
[01:07:28] Speaker A: And we will talk to you guys next time.
[01:07:30] Speaker B: See you next time.
