SomaSandwich

Layered Insights into Digestion and Healing

Category: Irritible Bowel Syndrome (IBS)

  • IBS and the McDonald’s of Healthcare

    In 2006, Cochrane Reviews put out a systematic analysis of herbal treatment for Irritable Bowel Syndrome (IBS). I was finishing chinese Medicine school and had entered into an apprenticeship at the time, and that Cochrane review made my future seem so bright. 

    “Now” there is proof that some herbs work for IBS, I thought, published by a highly respected, charity organization. If regular doctors and their patients want Evidence Based Medicine, here is the evidence. I recall bringing that study to my mentor, who was less enthusiastic than I expected. Already in his 60’s, he was not open to the idea that things would change, vis-à-vis TCM. Of course, things haven’t changed since that time – not really – and I am left to think about why. 

    Little did either of us know that we were entering into a period – starting around 2007 – when top-down perspectives – cultural, economic, medical, etc. – would increase in dominance. Since that time and until recently, for example, many companies have demonstrated that they can increase prices – Apple, Starbucks, Coca-Cola, Louis Vuitton, McDonald’s – without reducing customer loyalty to their brand. This collective loyalty also appeared in relation to celebrities, musicians, political movements, and even renowned doctors and medical institutions, like the Mayo Clinic. 

    In hindsight, I was naive to think that a low-profit practice like herbal medicine, with no scalability and limited mass production, could penetrate the business of corporate healthcare. But, I was imbued with hope by that Cochrane review. Their statements were grand. When it came to comparison with placebos, the research on various TCM herbal formulas “showed significant improvement of global symptoms [of IBS].” When it came to comparison with prescription drugs, they showed that across 65 research trials, a variety of herbal formulas did well. 22 herbal medicines beat the pharmaceuticals, and 29 did as well as the pharmaceuticals. Most of these trials used TCM. 

    Of course, IBS research didn’t stop in 2006. There have been several large-scale systematic reviews since. Recently, a Korean research group did a systematic review, which they published in Frontiers in Pharmacology, for example. They concluded that [TCM] “can be considered as an effective and safe treatment for IBS.” Eighteen of the research studies they included were rated to be of high or moderate quality. So, continued work like this has broadly confirmed that herbal therapies – at the very least, and I’m being very conservative here – show promise for IBS, in all its forms. However, who knows about this? I believe the tragedy is that almost no one in the West who has IBS knows about this. Again, I wonder why. 

    Actually, this post was prompted because I recently received a comment from someone, as I have before, that there is no research supporting the use of TCM. That person has IBS, and they were so certain about their perspective – that there is no research. We could chalk this up to that person being outside of the scientific and medical communities, of course. However, I’ve heard this sort of thing from the mouths of researchers, too. I was once at a party, when a very loud-mouthed researcher, who was trying to impress the group, began spouting out that there is no research support for the use of TCM. I couldn’t hold back at this and opened my mouth loudly too. For the sake of the party, the host intervened. 

    To be fair, critics would point out that the research on TCM is often smaller in scale and of lower quality. The number of participants in a study may fall in the low hundreds, whereas studies for an IBS drug like Linaclotide (Linzess) had over 1,600 participants. This much money and focused attention on one drug leads to government approval, usually in numerous countries. The healthcare machine starts to turn. Never mind that the total number of participants across TCM studies for IBS number in the thousands (the Cochrane Review from 2006 covered 7,957 participants). Faced with great financial, governmental, and academic barriers, TCM researchers are more-or-less required to enter a very precious sentence of modesty and equipoise in their research, and it always goes something like this: “More rigorous trials are needed.” 

    Every single scientific paper about TCM ends with that little sentence. We can all appreciate researchers who call for better research, but it loses a little authenticity when the same thing is repeated, robotically. What outside factors could contribute? Maybe researchers are just angling for more funding, but it begins to sound like lip-service after a while, like speaking to one’s boss – the dominant perspective – not to the reality of the situation. After all, it is a bland, politically safe, and statistically neutral thing to say, because it does not rock the boat. 

    Researchers have difficulty speaking their mind because the clinical use of TCM already far exceeds the threshold of practical testing. The result is hypocrisy. Modern medicine (or science), which has much less actual clinical validation, is calling the shots, and it is fascinating – and a real lesson in how the world sometimes works – that doctors in the Far East (and outside of it) are using TCM with millions of patients on a daily basis, yet they cannot assert their own pride and professional standard as doctors. Instead their nations’ research basically says – with its face turned towards the Western expectation – “We don’t have enough evidence yet!” 

    Can you see the split in consciousness and what is lost in translation? Have you personally ever felt forced to say one thing, while you are thinking another? The situation brings images to my mind – a water jug with no bottom, for example – one that can never be filled. There can never be enough research to prove to a Western audience that TCM is effective medicine. It has nothing to do with the evidence base. To suggest that TCM is efficacious simply provokes disbelief and leads to a loss of authority, which then becomes the grounds for dismissing anything else that is said. By expressing clarity, or suggesting something different to expectation, you’ve already lost the argument. Why should it be this way, if our concern is with finding the best treatments?

    That 2006 Cochrane review ends with the unprovocative, “It is premature to recommend herbal medicines for routine use in Irritable Bowel Syndrome,” even after reporting good evidence. A sentence like that will be taken as the most up-to-date, knowable information, case closed. However, I’d like to share with you what most researchers of TCM are actually thinking: Their research is better than the credit it is given. For example, if you were to track IBS treatment results in a busy hospital setting, with different patients receiving a variety of treatment options, plus dietary recommendations, maybe some exercise and lifestyle recommendations, and then looked at the total effect for that group, would you consider it good research? If you have IBS, would you like to know whether those hundreds or thousands of patients improved at that hospital or not? Would this tell you something about whether or not TCM works?    

    The answer from modern science is that it does not tell us anything. The kind of research that I mentioned above is common in China, where their hospitals treat many people using TCM (including for IBS), but that sort of research gets categorized as being of “low” quality in the West. Instead, the research that is considered high quality must be an RCT (Randomized Controlled Trial). In RCT’s, there is a control group or placebo group. There is “blinding” about who is in which group. There is standardization of the participants, who cannot have more than one condition. No complex cases are allowed. No complex interventions are allowed. The specific outcomes – what constitutes a result – are predefined. 

    RCT’s were developed mostly for drug research, and this limits what they can handle. The problem with leaning on them to research other medical systems is that their research questions are asked in a way that prefaces the acceptable answers. It is sort of like leading the witness or putting words in the mouth of your suspect. If you are a participant, they will decide whether you have been helped or not, you won’t be telling them. RCT’s are famous for assuming that treatment has a linear cause-and-effect mechanism, based on a single drug and set of measurable outcomes. In simpler language, what they assume – as their forefathers the Naturopaths did – is that there should be a best, single medication for every disease or condition. 

    As I’ve sort-of mentioned already, this has nothing to do with how TCM is actually practiced. Besides the diet and lifestyle advice, patients are given complex formulas containing many thousands of chemicals (as herbs). The formulas are custom made and different from patient to patient, even if they have the same diagnosis. Then their medicine is changed or modified often – even daily or weekly – based on how they respond and change. It is called a “complex intervention,” and an RCT cannot handle it. When we force TCM into an RCT, we cut off most of its efficacy, and even then, it still somehow shows itself to be better than placebo or standard medication, in some instances.   

    Yesterday, I saw a scientific paper from China, which started by saying, “Irritable Bowel Syndrome (IBS) is a common refractory disease.” Refractory is an interesting word. It is often used to describe cancers. It means the condition is stubborn, difficult to treat, and likely to reoccur. Notice that those sound like the words of someone who actually works with illness. They are grounded, pragmatic, and experienced. There is no fantasy in those words. They portray medicine as a practical discipline, challenged by the real-life impossibility of anyone staying well forever. However, the very next sentence in that research expresses the actual consensus – among both doctors and researchers in the Far East: “Chinese medicine has remarkable efficacy and advantage [in] the treatment of IBS.”

    I think, as we consider the need for rigorous research and its limitations, it’s essential to reflect on real-world cases where TCM has helped patients with IBS. These days, we can glimpse people’s direct experience, just by using reddit:

    “Chinese medicine is the only thing that has helped my IBS. I use Bu Zhong Yi Qi Wan. … cloudy and mucus like poops have went away for two-three months now.” reddit

    “… Switched to raw herbs recently and while it has helped, the symptoms haven’t gone away … But there is less ‘upward agitation’ and overall ‘less rebellion.’ … I am much calmer and don’t overthink stuff.” reddit

    “I was very skeptical of TCM … did acupuncture- and brought a 3 week supply of herbs home. It’s day 3 now and … for the first two days my poops were perfect solid first thing in the morning compared to the soft/diarrhea … I seem to release more gas instead of storing it up over the day so my tummy is flatter … feel quite light in general.” reddit

    “My tcm doc checked my tongue, eyes, pulse … gave me a recipe for some very special herbs … for me a flare usually lasts way longer … I got out of a bad flare very quick and the red ginseng is very helpful … People, my new diet and that red ginseng is giving me my energy back.” reddit

    If you would like to read about one of my IBS cases, I wrote about it here. Alex (the patient in that case) did not have abdominal pain, but I would still see his condition as IBS. 

    It is now 21 years since the publication of that Cochran Review (I can’t believe it!), and I can better see my old mentor’s unspoken perspective. He knew that a change in people’s viewpoint was going to take more than research. However, I continue to wonder why this is true. I sometimes hear people refer to the necessity of a “tidal shift” – in which, what has come in, is now going out, governed by invisible forces much larger than ourselves (like gravity). The tension of that moment, when the water slows and slows and then stops proceeding, eventually reaching a balance point with no movement – I do ask whether we are at that precise moment in history today. 

    It may be time to rediscover what has been lost. In our race to put the “best” ideas and people at the top, their shadows have eclipsed everything else of value. With its in-and-out service, high costs, mediocre product, and insistence that it is the best, modern Medicine now looks to me like the McDonald’s of healthcare. They have the process down pat, but is there not a better burger in town? What is the cost of one’s allegiance? If I can say it simply, looking up towards them has become a pain in the neck, for all of us. It’s time to look around. If that turns out not to be TCM for you, I say fine. If you tell me that there’s no evidence to support the use of TCM, well then, we really do have something to talk about. 

  • How I Healed

    Mochi rice, hijiki with garbanzo beans, lightly steamed snow peas, miso soup, and a whole mackerel. I sat down to this meal and felt for the first time, in almost two years, that I was well. My friend from school was there and, looking at this spread, all he said was, “you have a good woman.” And I did – not in some pejorative sense – but a person who was taking care of me and I of her. She had taught me so much about my health – how to live a more moderate life, how to enjoy this food from her home country of Japan, and how to eat according to my body’s needs.

    6 months earlier

    I was at the end of my second semester of chinese Medicine school, everything was collapsing, and I was going to have to transfer. The school was losing its accreditation, mostly because it looked like a forgotten outpost of the Cultural Revolution – yellowed walls, weeds filling the parking lot, and crumbling stucco. Some classrooms could not be entered without crossing through other classrooms. Some classrooms were tiny boxes. The bureaucrats were throwing up their hands, but they missed that this was actually an incredible college. They didn’t notice that every teacher there had been a top teacher or researcher, coming from various prestigious medical schools in China. At those schools, competition for a slot didn’t number in the thousands, it numbered in the millions. These doctors were willing to put down their career in China for a teaching visa in the US. So within that falling down college, I met some of the brightest people I have ever known.

    I volunteered to be assessed, as a Guinea Pig, for one of our classes. The teacher – Dr. Liu – did the whole workup in front of everyone, and I felt quite embarrassed. At that point my 6’3” frame was holding barely 120 lbs. How could someone so unhealthy be pursuing a career in this field? Then Dr. Liu wrote the herbal formula that would change my life. 

    6 months earlier

    I walked in late to my first semester class on “Chinese Medicine and Psychology.” Sitting along one wall, distant from the rest of the group, was a young Japanese woman who I had never met before. To this day, I have no idea why I did or said this. It wasn’t in my character to be rude – plus I had walked into class late – but I said to her, “If you’re going to visit this classroom you’re going to have to come and sit here with the rest of us.” Then I pulled out a chair and put it next to mine. She thought I was a skinny punk, and she liked one of my friends much better. He also pulled out a chair, and that’s the one she took.

    Thinking about it now, I was feeling so unwell. There was a constant feeling of fullness that I couldn’t escape. There were still very few foods that I could reliably eat. I was tense, unfocused, and pressuring myself to memorize every bone and muscle in the body (among other things). As classmates, we were learning to palpate, but my hands were the temperature of ice – always. Entering that school and taking on the four year commitment had been decided in only two months, and I wasn’t ready.

    2 months earlier

    Some things just shouldn’t be shared. Turning one’s life into a commodity or category, well, it isn’t for me. It was summer 2002. I had been up late reading a forum for IBS sufferers, and I could relate to them so much. I remember I was reading the emotional writing of a mother who could not put her children on her lap because of her severe bloating. Suddenly, something occurred inside of me that I’ll never forget. It was visceral. The end result is what matters. I instantly saw the world in a completely different way, and I knew that I had to start studying medicine. For about five minutes I wanted to go to standard medical school, but then I remembered that standard medicine had not helped me at all. Clearly, it wasn’t helping people on the IBS forum either.

    My neighbor was attending a chinese Medicine school on the outskirts of town. The next morning I knocked on her door. For the most part, we assume that successful people try to lead their lives. However, when things are out of control, sometimes it is better to let your life lead you. 

    2 months earlier

    The doctor came to tell me that my tests were negative. She was the third doctor I had been to, and I was reaching a tipping point. I blurted out about my life to her and how unlivable it had become – how my basic functions were uncontrollable – how I had lost so much weight. I was exasperated, desperate even. We made eye contact, and she grinned for a moment, just a little, but it said everything to me. I perceived that she smiled at my pain. It was her defense. She found me cute and outside of her responsibility, since all the tests had been negative. 

    I’ve often wondered at the difference between people in this same situation. Many people have experienced something similar. Some people double or triple or quadruple down on standard medicine. They go to other doctors, even the Mayo clinic, looking for that answer. I didn’t. For me, the illusion had been cracked. It was like Humpty-Dumpty. For the first time, I opened a little wider to let something broader come into my life. Despite misgivings and doubt, I called an acupuncturist.

    My acupuncturist was experienced. This was my luck. He had started his training and practice in the late 70’s, when doing so was still illegal. Today, I have a mixed-feeling about practitioners like this. They were pioneers, but they learned at a time when information was limited and poorly translated. However, my acupuncturist had learned from an actual Japanese sensei. He was – and not everyone is – a real healer. Similar to the dilapidated school I would later attend, his office was old wood panel with documents and licenses carelessly thrown into cheap frames. He wrote on a government desk from the 1950’s.  

    I lay down and when I left forty-minutes later, I felt like I was on another planet – completely spaced out. Sleep was the only option. The next day, my bloating had reduced by fifty-percent, and my bowels were moving. I was so happy that I went out and pounded a hamburger – big mistake.

    6 months earlier

    I worked at a shop restoring antique furniture from Europe. It would come in by the truckload, in all sorts of condition. One day, I was waxing a piece when the most horrendously smelling gas came from my body. It filled the two-thousand square foot building in seconds. My boss came from the back with an intense look of anger on his face, as if I had violated some sacred code among men. From that day forward, I worked only outside, and it was winter. 

    My coworker was a retiree, who had been independently wealthy since leaving the stock market game when he was only thirty-five. He told me about his golfing buddy, the gastroenterologist. “Bo will fix you,” he smiled at me broadly, and so I scheduled that day.

    Well, Bo didn’t fix me. Instead he gave me Flagyl. This powerful antibiotic, meant for bacteria and even parasites turned my world upside down. It’s for this reason that I suspect that I developed SIBO, even though no one was testing for it back then. What I can say with certainty is that everything became worse. This was when I developed bloating, nausea, intolerance to most foods, highly variable stools, and later, depression. 

    3 months earlier

    My small, underground publication failed. The artist’s cooperative along with it had dispersed. 9/11 was going to be the topic of our next issue, and we felt passionate about it, but funds had been depleted, and I was broke. People stopped coming around. I took the last bit of money I had and recklessly paid off the rest of my undergraduate student loan. Determined not to reach out to my parents, I worked as a bell ringer for the Salvation Army that holiday season. They paid me $7.15 an hour and gave me a baloney sandwich every day. Standing outside while ringing a tiny bell, for forty-hours a week, drove me insane, but when I was picked up by the van, the other guys would talk about how it was the best job they had ever had: “Man, all you have to do is stand there!” Most of these guys were homeless. Financially, I barely made it through.

    Today

    At this point, I’ve pushed to have a career in chinese Medicine, and it hasn’t been easy. As a profession (and society), we haven’t come as far as we could have, since the late 1970’s. By treating those who came for help and sharing as often as I could, I’ve treated thousands of people. My estimate, from a few years ago, is that I’ve designed and assembled more than ten thousand custom herbal formulas for patients. For me, the opportunity to do this work is the meaning behind my illness.

    A number of people have asked me to explain how I “got better” using TCM or even asked “what did you take?” Really, those sorts of questions have prompted this post. The formula by Dr. Liu, all those years ago, was a starting point, but it wasn’t a final answer. We aren’t static, and what we need changes, even from week to week. You don’t set a boat on the river and then just let go, do you, with no one steering? We’re also all unique in our health problems, and TCM follows the precept of “same disease, different treatment.” So, from these points of view, sharing the details of Dr. Liu’s formula doesn’t matter to helping others, not one little bit.

    In hindsight, if I had known what I know now, I could have healed myself in a week or two, at least before I took the Flagyl. My digestive problem was actually stress-induced, incurred through the loss of my project, my friends, and my savings. However, Flagyl took my issues to another level, causing a real organic imbalance. Today, I would have treatment for this circumstance too, but back then, I was a rat in a maze. I lost trust in gastroenterology – because of this experience – but also because of the experiences of many of my patients, over the years. Except in acute cases, the profession of gastroenterology is far less substantial than it seems to be.

    The Japanese young woman from class miraculously became my girlfriend and then my wife, and we have a daughter together. Dr. Liu moved on, and the last I heard of him, he was practicing somewhere in the US. Neither of the friends who I mentioned became successful practitioners, although they both had intelligence and talent. 

    If you’re lost, try following something deeper inside of yourself. It isn’t easy. Actually, it can be quite terrifying to take control away from your conscious mind. However, we are not just our consciousness. The path may meander, but as studies with robots have shown, programming them to directly go towards an exit does not get them through a complex maze. Other computer research has shown that – in most cases – the right stepping stone does not reveal itself as a logical choice until after we are standing upon it. 

    Best regards to all of those who are suffering from a chronic illness right now. I have some understanding and wish you the best.  

  • Psychosomatic Placebos and The Inside-Outside Case

    I cannot forget a patient from 2008 who I almost refused to help. What would you think, if a patient came to you explaining that he has terrible, uncontrollable diarrhea, but only when he crosses the threshold of his front door to go outside? In other words, he has no problem at all, when he just stays at home. I can tell you what I thought: This is a mental health case, and I should refer this person out to a therapist or even a psychiatrist. However, I was wrong. 

    Anger, sadness, worry and fear – I factor basic emotions into my diagnoses but not the inability to go outside. Content like that is the domain of psychotherapists, and they will ask follow up questions about those sorts of things. Should a thought like, “I am now leaving my house,” trigger a physical reaction in someone, conventional wisdom is that they need a therapist.  

    I have to say, though, and I think many people with a history of digestive problems will agree, that I really dislike the word “psychosomatic.” It has been used to dismiss the physical experiences of millions of people with unexplainable digestive disorders. In addition – almost like salt to the wound – it is a limited diagnosis because our understanding of the mind, as well as the mind-body axis, is limited. The phrase “placebo effects” has been used in a similar, dark way, so I believe these two terms – psychosomatic and placebo effects – are worth comparing.  

    At a party, I once shared this inside-outside case with a couple of research scientists. Really, I’m embarrassed that I privileged them with the story, because they nonchalantly called the result of my treatment a “placebo effect.” They blew it off. Now, please understand, the fact of placebo effects does not bother me at all. They are a natural part of Medicine, and I know a great deal about them, actually a great deal more than those scientists do. Their use of “placebo effects,” similar to how many professionals use “psychosomatic,” was as a dismissive catch-all – sort of like a kitchen junk drawer. If a treatment result cannot be easily explained, well then it must be a placebo effect. If a condition does not show up on a lab result or imaging, then let’s dismiss it as psychosomatic and be done with it (at least on our end, thinks the doctor) and put it into the junk drawer. 

    Both placebo effects and psychosomatic illnesses are descriptors of real phenomena. I won’t be dismissive of them as concepts. Their ubiquitous overuse is another story. The imprecision displayed by those scientists at the party is just lazy and appalling. One should not go around dismissing people’s experiences just because it does not fit easily into one’s cozy little universe. You see, this patient – let’s call him “Alex” – had already taken his diarrhea problem to a primary care, a psychiatrist, and a psychotherapist. It had persisted for a year, while they tried to do something about it. 

    If you know anything about placebo effects, then you know it matters who gives you the placebo. When your doctor gives you a sugar pill, it is not the same as a stranger on the corner giving you a sugar pill, because it does not carry the same meaning. So, are we to assume that these esteemed professionals could not pull off a placebo effect for Alex, using prescription drugs, while someone on the fringes of medicine – a last resort practitioner like me – could? Nonsense. Alex’s cure cannot be explained as a placebo effect. Sure, he was polite to me, but he had no reason to respect me. Frankly, I was his last choice. This goes for all acupuncturists and TCM herbalists everywhere, who are often accused of making a living by dishing out placebos. At the time, I wasn’t even much older than Alex was – not exactly representing “doctor” material.

    Alex said “When I leave my house, I can’t stop going to the bathroom… I can’t stop shitting my pants” – these were the words he used, and they were a self-condemnation. He was vulnerable and embarrassed. “And when you stay home?” I asked. “Well, then I’m okay, there’s no problem.” Alex went on to tell me of the ways this problem had ruined his life: “I’ve lost everything – my job, my car, my friends, and my girlfriend. I’m also broke.” He was completely matter-the-fact and flat affected as he said all of this. He took a deep breath – shifted a little. “I’ve tried everything, all I can do is stay at home.” 

    The other medical professionals had tried various antidepressants, antidiarrheals, and some medications that Alex could not remember. However, the inside-outside problem did not budge. His therapist had became frustrated, and I can see why. Alex’s thoughts about his problem didn’t exactly scream “insight,” and he wasn’t even much of a talker.  

    I asked some questions, looked at his tongue, took his pulse, and felt his abdomen. His hands and feet were freezing. I left him in the treatment room, went to my desk, leaned back, and sighed. Fine at home but unable to stop going as soon as he crossed the threshold of his door? I was already dismissing him in my mind. So strong are our cultural assumptions about mental and physical health that I could not see past them or even realize that I should look. It was as if “psychosomatic” had been written in big, red letters on a billboard outside of my window. I was forgetting my eduction. What about the good data that I had already collected? What about his frigid extremities, his wiry pulse, his purple tongue – and all the rest? 

    I wanted to go and tell Alex that there was nothing I could do. Then I considered that he had nowhere else to turn. Out of obligation, a doing-what’s-right, and a whim – I decided to try. As I sat there, I saw a formulation already written up, pinned to my wall. It was Si ni san (“four reversals powder”), which I had been studying. An MD friend once commented that the moment he learns something new, patients with that problem (or solution) begin showing up. After decades of practice, I know that he’s right, and it happened that day. 

    The “four reversals” refers to the hands and feet, which are cold in these patients. Symbolically, this is because what should be flowing outward – blood, heat, qi, prana, friendship, whatever – is reversing and only flowing inward. It is like venous valves, should there be no arteries. What had once circulated freely is now on a single, one way street. The analogy of being stuck inside and not flowing outside suddenly came to me. It was like a physical parallel to introversion. For the first time in that case, I put aside my skepticism and went all in on formulating an answer. 

    Traditional herbal formulas have internal logic of one sort or another. Some can be purely scientific, but most of these do not work well. Si ni san is ancient, having been published 1,800 years ago. Formulas from that time useally have four herbs in them, between which there is strong internal organization. Within Si ni san each of the four herbs moves within the body in a different direction:

    Si ni san (four reversals powder):

    Chai hu (Bupleurum) — Moves out
    Zhi shi (unripe Bitter Orange) — Moves down
    Bai shao (Peony root) — Moves in
    Zhi gan cao (honey fried Licorice)— Moves up and to the center

    This isn’t as abstract as it seems. For examples, Chai hu moves out because it causes sweating, and Zhi shi moves down because it promotes bowel movements. What occurred to me is that Alex needed movement not containment (the very opposite of antidiarrheals). In a sense, he already had too much limitation. A treatment principle popped into my mind, which is called “stopping by going.” In recent visits to health subs on reddit, I’ve noticed that many people with diarrhea are utilizing this principle by taking laxatives to firm up and decrease the frequency of their stools. This is precisely the same treatment principle but without the great moniker. 

    At the time, green-newbie that I was, I was very concerned about giving an herb like Zhi shi to Alex, which is typically used to treat constipation. Still, I prescribed Si ni san as you see it below, modifying the original formula by adding a couple of herbs and increasing the dose of herbs that move downward and outward:

    Chai hu 12 g
    Zhi shi 12 g
    Bai shao 4.5 g
    Zhi gan cao 3 g
    Chuan xiong 6
    Mu xiang 9

    This formula increases movement within the body, especially out and down, because the last thing Alex needed was further blockage. I gave it to Alex and asked him to come back in a week. At the following appointment, Alex had completely changed. He said, “that stuff you gave me tastes terrible, but it really works.” He was energetic and upbeat, explaining that within a day of starting the formula his symptoms had improved. Within a few days, he no longer had diarrhea and was able to come and go from his house as he pleased. I prescribed another batch of herbs, and Alex agreed to come back, but he cancelled the next appointment. He told the receptionist that he no longer needed treatment. I called him up a month later, just to see how he was doing. He was doing great, and he thanked me. 

    These days we have research to support the use of Si ni san for many conditions – clinical trials, basic research, -omics research, etc. A search on pubmed (just search up “sinisan”) returns 90 scientific papers. This is far more than what was available in 2008. However, none of those papers speak specifically to Alex’s case, and none ever will. Yes, there may be some research on depression, on IBS, on cold hands and feet – yet, none of this really calls to mind precisely the right specifics of that case. Furthermore, there can be no rationale, based on research, for modifying Si ni san the way that I did. What I prescribed was individualized. Should someone decide to prescribe herbs based entirely on research, I am certain that they will never be able to handle a case like Alex’s, not to mention many other digestive disorders.

    What one sees as proof or perspective can turn into limitation, just like a turn of the hand. Nature is complex. It is fickle. Finding inroads requires flexibility within our own frames of mind. The choice of vantage changes what is possible. It changes the outcome, and it may facilitate or fail us in getting the right medicine to the right patient at the right time. Do I always approach my cases in terms of analogy? No, of course not – that would be rigid. Here, though, it worked.

    Meanwhile, there is a self-satisfying cult of perspective in the use of both “placebo effects” and “psychosomatic.” In this instance, they are pat, junk-drawer answers. They are conveniently used as glue – to hold together a patchwork worldview and prevent the mental expansion that comes from having one’s ideas challenged. Poor Alex, should he have lived not one but ten years within that perspective. Poor me, should I have dismissed him and sent him back to the dogs.‡

  • War between paragraphs and words

    Through obscure communications, Paragraphs formed a partnership with Symbols. This was for the purpose of mobilization. Within weeks, Paragraphs had declared a war on Words.

    Being Symbols themselves, this put a great strain on Letters, who felt a need to refrain from the battlefield. They remained neutral. However, a secret alliance saw Sentences pulled into the fray, and together, Words and Sentences put up a defensive front against Paragraphs and Symbols, who began to roam with hostility across the landscape.