From This Practice: Form and Function

Marcus felt cornered.

His stomach acid had become like some wild animals — unpredictable and destructive. He was suffering, despite a fundoplication surgery years before, meant to repair a hiatal hernia and reinforce the dysfunctional barrier between his stomach and esophagus. Unfortunately, the barrier continued to fail, and acid continued to leak through. 

Of course, surgery had not been the first choice. Proton pump inhibitors (PPIs) are standard care for reflux disease, and they had been tried first, in an effort to suppress the acid and quell Marcus’s suffering. They were meant to protect his tender esophagus from corrosion.  

However, there is a difference between suppressing an animal and helping it to live more fully, according to its nature. Stomach acidity is not inherently harmful, and it has important digestive and immunologic functions. From that standpoint, the culprit was not really the acid. It was the reflux. The issue is that standard medicine has surprisingly few tools for preventing it without suppressing normal gastric acidity. This is the essential compromise. 

When surgery did not help Marcus, the gastroenterologist had no choice but to return to reducing acid production. When I finally met Marcus, he was on twice the normal dose of Omeprazole. It eased but did not stop a daily, burning pain. For Marcus, though, what caused him to schedule a consultation was not his thirty years of reflux disease. It was that years of reflux had produced esophagitis and eventually Barrett’s esophagus — a form of pre-cancer. This diagnosis worried him deeply.

When our appointment started, Marcus seemed relaxed and easy-going. Yet, beneath this appearance, he had been struggling for a long time. Besides the upper digestive symptoms mentioned, he also had chronic constipation and had been diagnosed with IBS-C. 

A dysfunctional esophageal sphincter, chronic constipation, and ironically, low stomach acid — all are known contributors to reflux disease and likely were in Marcus’s case. The question easily becomes: How can these distinct issues be approached, as parts of a broader decline in digestive function? We might expect a question like this to be answered through comprehensive and holistic treatment. 

Interestingly, though, the treatment that helped Marcus did not focus on any of these issues directly. It didn’t even focus on reflux. Instead, it was designed to improve a broad physiological pattern across organ systems. 

Marcus’s tongue before treatment:

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Tissue Issues

Marcus’s tongue was red and peeled.  Most of its normal papillae (“tongue coat”) were missing, and a long, deep midline crack with transverse cracks had formed. Some swelling could be seen through the middle. It was looking dry, stiff, and poorly nourished. Traditionally, they would say that it lacked “spirit.”

Our digestive tract should be flexible and resilient. The actual tissue — the cell walls of a person’s stomach, intestines, etc. — must maintain their integrity and barrier function while continuously handling food, digestive chemicals, microorganisms, mechanical forces, and inflammation. One impediment in the treatment of chronic digestive cases is that we can measure aspects of the tissue, but there is no single measure of its overall condition — how well it is nourished, protected, regulated, and able to repair itself. These qualitative aspects often go uncharacterized, but they affect digestion. 

In contrast to the ideal of flexibility and resilience, Marcus’s tongue was beginning to look like an old, dried-out piece of meat. The word that comes to mind is “depleted.”

Is it possible that the tissue of Marcus’s digestive tract (upper and perhaps lower) was losing the ability to properly produce important digestive chemicals, maintain a protective mucosal layer, handle stress-induced inflammation, support normal motility, and that aspects of these pathologies could be perceived through the depletion and dry-malnourishment visible on his tongue? 

What happened during the first month of treatment gave considerable support to this interpretation.

The First Formula

Marcus’s concerns were primarily: burning pain, Barrett’s esophagus, and constipation.

However, his tongue image and many of his other symptoms pointed towards a broad pattern of dryness and malnourishment, especially in the upper digestive tract. This is often called Stomach yin deficiency with Fire in Eastern medicine, and in this case, it was the low-hanging fruit. More importantly, it seemed to be a clear point of entry into an otherwise complex situation. 

The immediate strategy was to clear the excessive heat while restoring fluids and nourishing the depleted tissue. To do this, I prescribed Yu Nu Jian — Jade Woman Decoction — substantially adapted for Marcus’s case. 

This was the initial custom formula in grams of 5:1 powdered extract per week — Rx: 1.1

Shi gao	Gypsum	12.4
Mai dong	Ophiopogon	12.4
Di huang	Rehmannia	9.9
Shan yao	Dioscoria	9.9
Zi su zi	Perilla seed	5.4
Zhi mu	Anemarrhena	5
Mu dan pi	Moutan	2.5

Initial Improvement

After two weeks, Marcus reported that the formulation was having an effect.
Specifically he saw:

• Improved mood, sleep, and energy
• Bowels moving daily
• Less pain in the abdomen
• Less bloating
• Continued hunger in the middle of the night
• Much less burning stomach at night; less feeling of heat at night
• Continued dry mouth at night
• Decreased phlegm in his throat
• Urine flowing better

The tongue became less red. It began to look moist, and even wet. Papillae began to emerge. Unfortunately, the middle swelled even more and that crack down the center had only improved a modicum.

Although the formula was working, that swelling through the middle and the overall wetness suggested that side effects were just around the corner. Marcus’s body had worsened in its accumulation of fluids, even though there were no symptoms yet. I adjusted the formulation by adding one herb — Fu shen/Poria fungus — and prescribed it for another two weeks. This herb is a diuretic that percolates dampness from the body via the urine, essentially draining the swamp. It has the added benefit of “calming the spirit” and reducing irritability. At this point, because he had long worried about being on a high dose of Omeprazole, Marcus also started decreasing that dose. 

After four weeks, the tongue had become a pale red. Swelling in the middle had gone down again, which seemed to also make the center crack shallower. Now the tongue wasn’t wet, but it showed a healthier moisture, as if his body was integrating fluids rather than just moving them to the surface. The lips were also less purple. These changes are mostly positive and occurred simultaneously with improvements in Marcus’s condition. 

Because burning pain was the “main complaint” in this case, it is worth noting that it was substantially improved, despite cutting the dose of Omeprazole in half. 

Some Useful Patterns for Understanding the Case

Marcus already had several diagnoses — GERD, IBS-C, and Barrett’s Esophagus — and we might have speculated about some of the underlying physiological causes involved. However, this was not enough scaffolding to improve his health.

Patterns are recognizable physiological states, usually identified through constellations of symptoms and signs, and they can provide additional framing to more fully build out a case. A chronic condition will typically present with 3-5 patterns simultaneously. However, two patterns stood out for Marcus in particular: Stomach yin deficiency with fire, which has already been mentioned, and Spleen qi deficiency.

What East Asian medicine calls Stomach yin is not a substance. It is a label that circumscribes a network of activities that keep digestive tissue nourished, hydrated, protected, regulated and repaired. These include glandular secretion, mucosal barriers, adequate blood flow, epithelial regeneration, digestive motility, and inflammatory regulation. Its depletion is most easily seen as a dry mouth, dry stool, and a “gnawing” feeling improved after eating. Yin deficiency symptoms are also often worse at night.

Fire describes another side of the picture: it describes iterative processes that irritate, excite, inflame and consume those same resources. Chronic emotional stress can contribute to this state, and Marcus was chronically stressed. On the psychological side of things, fire can show as anger, agitation, and a short-temper. Physically, there is often gum inflammation, burning pain in the stomach or chest, insomnia, and an unusually strong appetite. 

The other primary pattern was Spleen qi deficiency. When Marcus first came, this deficiency was both difficult to perceive and inappropriate to treat directly. I added one herb to “protect” qi, which was Shan yao/Dioscoria; however other herbs to improve Spleen qi deficiency can be warming and drying. Giving them to Marcus would have fanned the fire and further damaged Stomach yin. Although Spleen qi deficiency was a useful way to elaborate on Marcus’s root issues, its treatment would have to wait. Until the heat was cleared and the yin was protected, Marcus’s system could have responded poorly to any attempt to address this pattern.

What Came Next

After the initial treatment, I had the opportunity to speak with Marcus’s wife. She said that I “gave Marcus himself back.” In the context of his improvement, however, she did not know the extent to which treatment had only just begun. The clearing of symptoms does not, in itself, mean a person has become well or that their body can maintain a positive outcome.

For example, in the last image above, the tongue had become too pale. Unlike the tongue’s swelling and wetness earlier, this was not so easily fixed. The paleness was a sign that the initial treatment had already run its course and reached its limits. Stopping would have led to regression, but continuing was also problematic. The strategy was already beginning to overshoot, and this pallor was an early warning sign that the treatment could become harmful. 

A medicine that was exactly right in January can be wrong in March, precisely because it worked. Treatment can change the patient, and it is often wise to change the medicine in response. 

Complex digestive conditions may not yield to treating one symptom or diagnosis at a time. If your digestive condition has become difficult to understand and has not moved forward, a consultation provides an opportunity to look at larger patterns and determine whether this approach is appropriate for your case. Schedule a consultation

Marcus’s case will continue in part II (soon to be posted)