Two Immortals- Help with Menopausal Symptoms and Hypertension

Er Xian Tang (Two Immortals Teapills)

TCM action: warm kidney yang, tonify kidney essence, and drain deficient fire

Last year one of my esteemed herbal teachers, Leslie Tierra, talked about the great results that she was getting treating women with Er Xian Tang who had yin deficiency with deficient fire. This peaked my interest and I started to look at the history and herbs that comprised the formula. In a nutshell, deficient fire is often seen in women who are experiencing pre and post menopausal symptoms which might include hot flashes, night sweats, facial and malar flushing, irritability, palpitations, insomnia, decreased sex drive and vaginal dryness to name a few.

The formula Er Xian Tang was developed in the 1960’s at a hospital affiliated with Shanghai College of Traditional Chinese Medicine. Er Xian Tang was designed as a treatment for cases of hypertension (Western terminology) where there was a combination of kidney yang deficiency and deficiency fire of the kidney, two seemingly contradictory conditions. Yang deficiency include signs of internal cold and weakness including coldness, lassitude, edema of the legs, loose stools, sterility or infertility, frequent urination, urinary incontinence, while the signs listed above indicate deficiency of Kidney fire.

A comparison of the role of the heart and kidney in allopathic and TCM can be helpful in understanding the intent of the formula. Er Xian Tang treats renal hypertension.   Renal hypertension from an allopathic perspective results impaired functioning of the kidneys, reduced urinary elimination and excessive renin (a protein and enzyme secreted by the kidneys) production. The heart sends a continuous supply of oxygenated blood around the body. The kidney filters the blood, extracting waste in the form of urine, and also helps regulate the water and salt levels to control blood pressure. When the heart is no longer pumping efficiently it becomes congested with blood, causing pressure to build up in the main vein connected to the kidneys and leading to congestion of blood in the kidneys. The kidneys suffer from the reduced supply of oxygenated blood. When the kidneys become impaired, the hormone system, which regulates blood pressure, goes into overdrive in an attempt to increase blood supply to the kidneys resulting in renal hypertension. This eventually damages the heart, which has to pump against higher pressure, in the arteries.

In TCM Er Xian Tang treats kidney yang deficiency and deficiency fire of the kidney. In TCM, according to the five elements theory, the Heart is categorized as yang and the Kidneys are considered yin. Normally, the Heart yang (fire) descends and joins with the Kidney-yang to warm and propels kidney-yin (water) to ascend to nourish heart yang (fire) to prevent it from hyperactive. Think of it as a continual loop with fire warming the kidneys, while water helps to contain heart fire. Or as Western medicine describes: the heart sends a continuous supply of oxygenated blood to organs including the kidneys that help to regulate water and salt levels to control blood pressure. In both systems the heart and the kidneys are closely related, with a mutually dependent function. If this functional relationship becomes abnormal in TCM it results in a condition termed “non-coordination between the heart and the kidney”.

This gets us back to yin deficiency with deficient fire. In Chinese medicine, the Heart and Kidney energies should work together. The Heart sends Fire down to warm the Kidneys: in return, the Kidneys send pure fluids up to nourish the Heart. In Heart and Kidney Yin deficiency with Deficient Heat the downward action or upward action is severely reduced. This leaves too much Yang (fire), due to lack of cooling Yin (water), hence deficient heat, resulting in night sweats, insomnia, and steaming bone syndrome. Normally you expect to see symptoms of deficiency fire of the kidney associated exclusively with yin deficiency, yet in this case, this type of fire is described as yang excess which arises from an imbalance of yin and yang (the deficient yin can not control the yang). When yin and yang are both deficient, one can experience symptoms of each deficiency, which may either flip back and forth between the two or manifest simultaneously.

Er Xian Tang, Two Immortals

Xian Mao-Curculigo, Golden Eye-Grass Rhizome

Tastes and Energies: spicy-hot,

Category: Tonify the Yang

Actions: Warm Kidney yang and tonify Kidney essence,

Contraindications: Yin Deficiency w/ Heat

Yin Yang Hou-Epimedium Leaf

Tastes and Energies: spicy, sweet, warm,

Category: Tonify the Yang

Actions: Warm Kidney yang and tonify Kidney essence, tonify Yin, harnesses Liver yang,

Contraindications: Yin deficiency w/ Heat

Ban Ji Tian-Morinda Root

Tastes and Energies: spicy, hot, toxic,

Category: Tonify the Yang

Actions: warm Kidney yang and tonify Kidney essence,

Contraindications: Yin deficiency w/ Heat amp heat

Huang Bai-Phellodendrum Bark, Amur Cork-Tree Bark

Tastes and Energies: bitter, cold

Category: Clear Heat Dry Dampness

Actions: nourish Kidney yin and drain fire from deficiency, used for steaming bone disorder, night sweats.

Contraindications: Spleen Qi Deficiency w/ Cold

Zhi Mu-Anemarrhena Rhizome

Tastes and Energies: bitter, sweet, cold

Category: Clear Heat, Drain Fire

Actions: nourish Kidney yin and drain fire from deficiency, nourish yin and moistens dryness, generates fluids and clears heat.

Contraindications: Spleen Qi Deficiency, diarrhea

Dang Gui-Angelica Sinensis Root

Tastes and Energies: sweet, spicy, warm

Category: Tonify the Blood

Actions: Moistens and nourishes the blood and regulates the penetrating and conception vessels. Invigorates blood, moistens the intestines, increases circulation

Contraindications: Spleen Qi Deficiency, dampness

Er Xian San cautions:  during pregnancy, during early states of acute illness, loose stools, diarrhea, poor appetite or chronic digestive weakness.

The intriguing aspect of Er Xian Tang is that it contains herbs that are contraindicated (not used) in cases of yin deficiency with deficient fire. It contains hot natured herbs, Xian Mao, Yin Yang Hou, and Ban Ji Tian, which tonify yang but can also increase fire. The formula also contains Huang Bai and Zhi Mu that are bitter and drying, which may damage yin. Huang Bai and Zhi Mu are considered a traditional Dui Yao, or herbs that are often used together to reinforce and complement each other. Together they clear heat, enrich yin and drain deficient fire. Huang Bai is bitter, cold, consolidates yin, drains deficient fire, while Zhi Mu, is sweet, cold, enriches yin, moistens dryness, and supplements the kidneys. Dang Gui builds blood, increases red cell proliferation, normalizes heart contractions and dilates coronary blood vessels increasing peripheral blood flow. Huang Bai and Zhi Mu are cold energetically and help to balance the spicy and heating energies of Xian Mao, Yin Yang Hou, and Ban Ji Tian.

Er Xian Tang serves as an example of evolving TCM formulation, where a new formulations are being utilized to address modern disharmonies by combining strongly warming yang tonics with cold, fire-purging herbs. In this case and the studies that have been conducted the formula appears to be effective for hypertension and for some other applications, such as menopausal syndrome and male infertility.

Additional notes:

Xian Mao and Yin Yang Huo are used to tonify the kidney and according to the Taoist’s aid in prolonging life. The name “Two Immortals” references the use of the word Xian.   Xian Mao was named in the Bencao Gangmu (by Li Shizhen; 1596) as one of the herbs believed to contribute to immortality. Xian Ling Pi (Epimedium, now know as Yin Yang Huo) alludes to the immortals’ intelligent nature, boosts the qi and strengthens the will. Around 100 B.C., a poem about attaining immortality, the ode Yuan Yu (Journey to Remoteness, or Roaming the Universe) was written. It depicts the transition to immortality:

Having heard the precious teaching, I departed,

And swiftly prepared to start on my journey.

I met the feathered ones at Cinnabar Hill,

I tarried in the ancient Land of Deathlessness.

In the morning, I washed my hair in the Hot Springs of Sunrise,

In the evening, I dried myself where the suns perch.

I sipped the subtle potion of the Flying Springs

And held in my bosom the radiant metallous jade.

My pallid countenance flushed with brilliant color,

Purified, my Jing began to grow stronger,

My corporeal parts dissolved to a soft suppleness,

And my spirit grew lissome and eager for movement.

 

Comfrey, Maggot Therapy and Cell Regeneration

I recently when down the research rabbit hole the other day when looking for comfreyinformation on comfrey (Symphytum officinale) finding an article about allantoin in the Society of Cosmetic Chemist, vol. 9, no 1, in 1958. The article was a survey of literature dealing with the therapeutic and cell proliferate action of allantoin, which of course, we know is an active chemical constituent in comfrey. What I did not know, was that maggots specifically Licilia sericata (sheep blowfly), were used during and immediately after World War I in the treatment of hard to heal wound infections.

Allantoin was first isolated and synthesized from uric acid in 1800. Naturally, it is found in comfrey, in small amounts in the urine of most mammals (with the exception of humans) and in greater amount in the urine of pregnant women.index It is a normal by-product of the oxidation process of uric acid by purine catabolism. Allantoin, in both maggot therapy and comfrey, works by increasing the water content of the extracellular matrix and enhancing the skin peeling or desquamation of upper layers of dead skin cells, increasing the smoothness of the skin, promoting cell proliferation and wound healing. Allantoin’s synthesized version is purported to be chemically equivalent to natural allantoin. It is deemed safe, non-toxic and is used in cosmetics, with over 10,00 patents. It is used extensively in the cosmetics industry primarily in moisturizers, toothpaste and in topical drugs to remove warts.

Maggot therapy or the use of maggots in healing have historical roots in use by aboriginal tribes, as did physicians during the Renaissance, and American Civil maggotsWar. Secretions from maggots have been found to have broad-spectrum antimicrobial activity including allantoin, urea, phenylacetic acid, and proteolytic enzymes. The resurgent interest in maggot therapy is currently underway with the U.S. Food and Drug Administration granting permission to produce and market maggots for use in humans and animals in 2004. In fact, a company in Wales is now marketing teabags filled with maggots for wound healing.tea-bags-maggots

This brings us back to comfrey. In 50 AD, Dioscorides’ Materia Medica prescribed comfrey to heal wounds and broken bones. Comfrey, has long been viewed as a herb for treating broken bones, bronchial and respiratory issues, sprains, arthritis, healing wounds, and tissues. The plant contains allantoin, along with mucilage, saponins, tannins and pyrrolizidine alkaloids (PA’s). Unlike maggot therapy, the presence of pyrrolizidine alkaloids prevents comfrey’s use the treatment of open wounds, where it is thought that it is absorbed. In fact, there is some speculation that the PA’s in comfrey are also absorbed through the skin, so harmful amounts may build up in the body. Comfrey is no longer sold in the U.S., except in creams or ointments. The United Kingdom, Australia, Canada, and Germany also have banned the sale of oral products containing comfrey. It is advised to not use comfrey on open woods or broken skin, consume internally if you have liver disease, a history of alcoholism or cancer. Furthermore, it is contraindicated for the elderly, children, pregnant or breastfeeding women. Leslie Tierra in an article “Comfrey Comfort” states, in an article “it is important to realize that a constituent with a negative effect may be neutralized, or greatly diminished when combined with other herbs in formulas”. This is true for many plants and might be considered in this instance. In both maggot therapy and comfrey, there are indications that both contain other substances that aid in the healing process.

Medicine making: Allantoin is slightly soluble in hydroethanolic solutions, but can be made to dissolve in an oily solvent with the use of an emulsifier, which comfrey naturally contains. It also is very soluble in alkaline or hot water. It can be decomposed by acids should be kept at a slightly acid Ph value. The roots contain higher amounts of PA’s than the leaves and flowers.

Resources:

Allantoin-Its properties and uses. A. M. Posner. http://journal.scconline.org/pdf/cc1958/cc009n01/p00058-p00061.pdf

Comparative Study of the Biological Activity of Allantoin and Aqueous Extract of the Comfrey Root

Savić VLj1, Nikolić VD2, Arsić IA1, Stanojević LP2, Najman SJ3, Stojanović S3, Mladenović-Ranisavljević II2.

https://www.ncbi.nlm.nih.gov/pubmed/25880800https://www.ncbi.nlm.nih.gov/pubmed/25880800

Controversial Comfrey: Super Healer or Lethal Poison. https://simpleunhookedliving.wordpress.com/2012/07/30/controversial-comfrey-super-healer-or-lethal-poison-3/

East West School of Planetary Herbology, Leslie Tierra “Comfrey Comfort”.

https://www.planetherbs.com/lesley-tierras-blogs/comfrey-comfort.html

 

Tinnitus-Ringing in the Ear, Treatment Options From Many Traditions

The Western allopathic approach to tinnitus is dramatically different from either Western Herbalism or Traditional Chinese Medicine in addressing this condition.

Western Allopathic Medicine: Tinnitus is the perception of sound when no actualindex3 external noise is present. Tinnitus is a non-auditory, internal sound that can be intermittent or continuous, in one or both ears, and either a low or high-pitch sound. The sounds of tinnitus have been described as whistling, chirping, clicking, screeching, hissing, static, roaring, buzzing, pulsing, whooshing, or musical. The volume of the sound can fluctuate and is often most noticeable at night or during periods of quiet. Tinnitus is often accompanied by a certain degree of hearing loss.

Tinnitus can be either an acute or temporary condition, or a chronic health malady. Millions of Americans experience tinnitus, often to a debilitating degree, making it one of the most common health conditions in the country. The U.S. Centers for Disease Control estimates that nearly 15% of the general public, over 50 million Americans, experience some form of tinnitus. Roughly 20 million people struggle with burdensome chronic tinnitus, while 2 million have extreme and debilitating cases.

In general, there are two types of tinnitus:

  • Subjective Tinnitus: Head or ear noises that are perceivable only to the specific patient. Subjective tinnitus is usually traceable to auditory and neurological reactions to hearing loss, but can also be caused by an array of other catalysts. More than 99% of all tinnitus reported tinnitus cases are of the subjective variety.
  • Objective Tinnitus: Head or ear noises that are audible to other people, as well as the patient. These sounds are usually produced by internal functions in the flow of blood or muscular-skeletal systems. It is often more like the sound of a heartbeat or pulsating. This type of tinnitus is very rare, representing less than 1% of total tinnitus cases.

index2Some medications such as aspirin, ibuprofen, certain antibiotics, and diuretics can be “ototoxic” or cause damage to the inner ear, resulting in tinnitus.

Other possible causes of tinnitus are:

  • Head and neck injuries
  • Loud noises,
  • Ear infections
  • A foreign object, or earwax touching the eardrum
  • Eustachian tube (middle ear) problems
  • TMJ disorders
  • Stiffening of the middle ear bones
  • Cardiovascular disease
  • Diabetes
  • Traumatic brain injury

There are also potential risk factors including the following:

  • Noise exposure from work, headphones, concerts, explosives
  • Smoking
  • Gender – men are affected more than women
  • Hearing loss
  • Age – older individuals have a higher likelihood of developing tinnitus

There is currently no scientifically valid cure for most types of tinnitus. There is, however, remedies that focus on diverting attention, addressing the emotional impact, and or cognitive therapy.

Western Herbalism: Tinnitus can serve as an important marker pointing to other potential health issues, since it a symptom and not a disease. Whatever the cause it tends to worsen in times of tension, stress and or muscle spasms. Stimulates like caffeine or nicotine, which increases vasoconstriction, can exasperate it. Furthermore, it can be caused by damaged fine hair cells of the inner ear. Although this cannot be reversed there might we some reduction felt in using some of the suggestions below. Stress reduction can often be helpful. Some herbs have been used to address tinnitus including black cohosh (Cimicifuga racemosa), goldenseal (Hydrastis canadensis) and more recently ginkgo (Ginkgo biloba).

Traditional Chinese Medicine (TCM): In TCM we know that the images6kidney qi communicates with the ears and that as we age or because of various states of health this can affect our qi, therefore the kidneys are often identified as root causes of tinnitus.

In approaching treatment of tinnitus, it is important to distinguish between an acute or sudden occurrence or a long-term tinnitus that gets worse over time or comes and goes. Furthermore, it is important to determine whether it is an excess-type or a deficiency-type of tinnitus. A key to this determination is that an excess type of tinnitus is often experienced in only one ear, while a deficiency based tinnitus tends to develop in both ears. The deficiency type usually gets better during the day and gets worse at night. A combination of deficiency and excess syndromes is possible, especially in persons with other illnesses or with tinnitus that has persisted for several years.

The following is a description of excess and deficiency patterns that might be able to better pinpoint treatment principles to be used.

Excess type #1, Hyperactive liver and gallbladder fire:

  • Sudden onset
  • Continual sound
  • Excess symptoms (a headache, flushed face, irritability)
  • Excessive anger, fright
  • Excessive use of alcohol

TCM formula: Long dan Xie Gan Tang (Gentiana Comb) with the addition of moutan, ligustrum, for persistent liver fire weakening the Kidney water.

Excess type #2, Phlegm Fire Syndrome

  • Intermittent ringing in the ears
  • Feeling of blocked ears
  • Chest stuffiness
  • Excess phlegm
  • Dizziness
  • Blockage manifesting as difficult urination or constipation

TCM formula: Wen Dan Tang (Bamboo and Hoelen Comb)

  • with the addition of pear, haliotis, uncaria (liver)
  • with lapis, scute, rhubarb and aquilaria (blockage of chest, constipation)
  • with dampness (Ban Zia Bai Zhu Tian Ma Tang)

Diet: avoid fat or spicy food

Deficiency type #1, Deficient Kidney Jing

  • Gradual worsening ringing
  • Dizziness
  • Backache
  • Deficient heat symptoms

TCM formula: Liu Wei Di Huang Wan (Rehmannia Six Formula) and schizandra.

TCM formula Er Long Zuo Ci Wan (Tinnitus Left Supporting Pills)

Deficiency type #2, Sinking Spleen Qi (yang def.)

  • Intermittently occurring tinnitus that is relieved through rest and reduced stress
  • Low energy
  • Poor appetite
  • Loose stools

TCM formula: Yi Qi Chong Ming Tang (Ginseng, Astragalus and Pueraria Comb.)

Lifestyle: stress reduction, adequate kidney and spleen building dietimages5

Ear Massage: There are several sites that have detailed directions for addressing tinnitus through massage:

The bottom line is that the early intervention is necessary for long-term success. If you are experiencing any of the symptoms outlined in any of the treatment options, seek the advice of a Physician or Clinical Herbalist (http://www.americanherbalistsguild.com/herbalists-and-chapters-near-you)

Sources:

Davis, Kathleen FNP. 2016. Tinnitus: Causes, Symptoms, and Treatment. The University of Illinois-Chicago, School of Medicine. Available from

http://www.medicalnewstoday.com/articles/156286.php

Flaws, B Sionneau P. 2001. The Treatment of Modern Western Medical Disease with Chinese Medicine. Blue Poppy Press. p. 55-56.

Hoffmann, D. 2003. Medical Herbalism. Healing Arts Press. P372-373.

Dharmananda, S. Ph. D. 1998. Treatment of Tinnitus, Vertigo, and Meniere’s disease with Chinese herbs. Institute for Traditional Medicine. Available from http://www.itmonline.org/arts/tinmen.htm

 

 

Crack Leather: Fermented Fruit and Herb Leather

img_1635What do you get when you mix together a sprouted cracker recipe with a fruit leather recipe.  You get crack leather. Recently I was playing around with making fruit leather, based on another blog which I had written a while back, https://herbalgoddessmedicinals.wordpress.com/2015/04/18/making-medicinal-herbal-fruit-leather/.

I teach a class on cooking with medicinal herbs and am always trying to push the envelope with different creations.  In the class, we explore how one can incorporate medicinal herbs into cooking.  The use of tonic herbs (gentle food like herbs) into everyday cooking is prevalent in food from China and India.  One of the easiest techniques  is to combine astragalus in cooking broths and soups.

Now to get back to crack leather. For this experiment, I decided to incorporate sprouted seeds and nuts into the fruit leather along with some powdered medicinal herbs.  Sprouting of seeds and nuts replicates germination, which activates and multiplies nutrients (particularly Vitamins A, B, and C), neutralizes enzyme inhibitor’s, and promotes the growth of vital digestive enzymes. Taking it a step further,  I also opted to ferment the leather before I dried it.  After checking in my with local fermentation expert, Kristy Shapla the author of the Brew Your Medicine, on whether fermentation would destroy the healthy probiotic fermentation, she assured me that if I kept the temps below 110 degrees it would be fine.  I am a firm believer that the fermentation of herbs assists with the bioavailability of their chemical constituents, not to mention the added benefit of incorporating fermented food into your daily diet. The fermenting of herbs is increasingly finding its way into supplements and has been shown to increase the herbs bioavailability,

I am a firm believer that the fermentation of herbs assists with the bioavailability of their chemical constituents, not to mention the importance of incorporating fermented food into your daily diet. The fermenting of herbs is increasingly finding its way into supplements and has been shown to increase the herbs bioavailability, http://onlinelibrary.wiley.com/doi/10.1002/ptr.2758/abstract

The results were delicious.  This recipe is fairly loose and is open to lots of substitutes including the addition of other herbal powders, nuts, and dried fruits.  The secret is to make sure the mixture is not too liquid or too thick, rather the consistency of thick pancake batter.

Equipment:

  • Food dehydrator or lowest temperature in the oven
  • Fruit leather latex sheets or cookie sheet
  • Large mixing bowl
  • Wooden spoon

Ingredients:

  • 2 cup flax seeds
  • 1/3 cup tbsp chia seeds, sprouted
  • 1 to 1-1/2 cup herbal tea (I used nettle, ginger and rose hips)
  • 1 Tablespoon maca and Shatavari (you can use any combination of herbal powders)
  • 1/3 cup sunflower seeds, sprouted
  • 1/3 cup pumpkin seeds, sprouted
  • 1 1/2 cup of chunky applesauce
  • 1/4 cup of yogurt
  • 1½ tsp salt (or to taste)
  • 3 tbsp za’ atar

Instructions:

Combine all ingredients together in large bowl, adding more herbal tea or water to the mixture so it is the consistency of pancake batter.  Cover the bowl with a tea towel and let sit in dark warm place for 24-48 hours. When ready heap a couple of large spoonfuls of mixture onto food dryer sheets or  cookie sheet.  Spread evenly to about 1/4 of an inch thick. The secret of spreading the thick mixture is to use a wooden spatula that you keep dipping in water.  Dry thoroughly, 110 degrees or less, to preserve the lactobacillus. When done it will still be flexible, so it is easy to bend and break into crackers.  Enjoy.

 

 

Herbal Tinctures: Getting or Giving the Right Dose

tincturesHerbal tinctures are the backbone of Western herbalism.  Generally, herbal tinctures are made from herbs extracted with a combination of alcohol and water, although glycerine and vinegar can also be used.  They are widely available, economical to produce and use, compact enough to stock in considerable variety and have a good shelf life. They can be combined and are convenient to take.   Dried herbs start to loose their potency after 6 months yet tinctures can last up to 10 years or more.  As a primarily Traditional Chinese Medicine herbalist, I mostly rely on concentrated decoctions, but in some cases when I am working with aerial parts of  plants, or herbs that could benefit from the effects of alcohol, increasing circulation, tinctures are more appropriate.

This posting is based on tinctures made using the weight to volume method.

Understanding dosage rates are important in achieving therapeutic outcomes.  I find that if someone isn’t responding to an herbal formula then analyzing their dosages can be helpful.

As a starting point most commercially available herbal tinctures indicate the weight to volume ratio.  For example, if the label states that it is a 1:5 extraction, this indicates that 1 gram (weight) of herb is equivalent to 5 milliliters (volume) of liquid.

A tincture formula will state the herb and the ratio of herb (by weight) to solvent (by volume), and the % alcohol (ethanol) in water.

Having this information is crucial in understanding the amount of herb that you are recommending or taking per dose.  Furthermore, this information is required by law to appear on the label. along with the serving size suggestion, which we will discuss further on.

In trying to communicate dosage equivalencies I have developed the following chart based on weight to volume ratios.  The side column indicates the common ratios and the top row indicates the volume of tincture consumed (in milliliters).  For example, if you took 1 milliliter of liquid made at a ratio of 1:2 then you would be ingesting a half of a gram of herb.

Tincture Dosage Equivalencydosage ratioSuggested Use:  Different companies have different suggested dosage rates.   Some companies suggest taking a dropper full and others recommended taking a range of drops as a serving size, for example, 20-60 drops.  When a dropper full is suggested the amount consumed depends on the size of the bottle and dropper.  When the suggested dosage on the bottle indicates a number of drops per dose, the amount consumed depends on the viscosity of the liquid.  Since this can change from one company to the next the best we can do is to have an understanding of some equivalents  recognizing that this is an approximation:

  • 20 drops = 1 ml
  • Dropperful from a one-ounce bottle—30 drops
  • Dropperful from a two-ounce bottle—40 drops
  • 5 ml = 1 teaspoon
  • A one-ounce bottle holds approximately 30 ml, 6 teaspoons, 30 dropper full, and 900 drops.

For example if using the suggested serving of 40 drops, and 20 drops = 1 milliliter, then you are taking approximately 2 milliliters of a 1:5 tincture and getting approximately .4 grams of herb per dose.  Most commonly it is recommended to take the tincture two to three times a day, so using this same example you  would be consuming between .8 and 1.2 grams of herb per day. Knowing the actual amount of herb that is recommended on a daily basis will help with putting the this into context.  Below is a partial list of recommended daily dosage of some common herbs.

Examples of dosages of some common herbs*:

Herb Daily Dosage
Angelica archangelica 3-9 grams
Ashwagandha 3-12 grams
Astragalus 6-15 grams
Black Cohosh 3-9 grams
Burdock 3-10 grams
Codonopsis 9-30 grams
Dandelion 9-30 grams
Dang Gui 3-15 grams
Echinacea 3-9 grams
Grindelia 3-6 grams
Hawthorn Berry 6-12 grams
Lemon Balm ½-6 grams
Motherwort 10-30 grams
Oregon Grape Root 3-9 grams
Passion flower 3-9 grams
Skullcap 3-9 grams
St. Johns Wort 3-9 grams
Uva Ursi 3-6 grams
Valerian 3-6 grams

* Planetary Herbology, Michael Tierra

In some circles there has been a discussion that the use of alcohol potentizes the action of the herbs, therefore less herb is needed.  Furthermore, the synergistic action of herbal combinations or formulas also increases effectiveness requring less herb.  These are great discussions but I work with aspiring herbalists who are often confused as to how to determine or convert tinctures to actual grams of herbs.  I hope that this helps and would encourage you to take a moment to actually consider that you might not be taking enough herbs to be effective.

Related blog post:  https://herbalgoddessmedicinals.wordpress.com/category/herbal-preparations/

Up coming blog:  How to make tinctures using the weight to volume method.

 

 

More Than Medicinal: Herbal Love Medicine

I recently finished teaching a wildcrafting class on medicinal herbs of Central Oregon. This year I incorporated other cultural uses of plants, in particular, focusing on “Love Medicine”.love   Native peoples used plants, not only as medicine, but also for their ability to affect an outcome. Daniel Moerman, author of Native American Ethnobotany, offers a compilation of ethnographies with over a hundred stories of tribal use of plants including ceremonial, hunting, witchcraft and love medicine.

The term love medicine was used for plants that were often suggested by tribal healers, elders or through the oral transfer of information to have powers beyond their medicinal attributes. Both men and women would use various plants as love charms to lure potential suitors or hold the attention of a “special person”.   In researching this topic it is a bit murky how the plants were utilized. In some cases special perfumes were prepared, in others, rituals were conducted with specific plants. In the book Plains Apache Ethnobotany by Julia A. Jordan people spoke about tribal members who specialized in preparing “love medicines”. In this book, the author describes the use of perfumes that were worn during certain times and specific places. In Daniel Moerman’s book he briefly describes how various plants were used or prepared. As contemporary herbalism as evolved over the last century, many of these spirit-based uses are being lost to us. With that in mind, here are some plants surrounding Central Oregon and how they were used as “love medicine”.

Aquilegia formosa

Aquilegia formosa

Various species of columbine were used as Love medicine. Western Columbine (Aquilegia formosa) was used by the Thompson Indian’s who used it as a charm for women “to gain the affection of men”. The Pawnee along with the Ponca’s used the crushed seeds of columbine, as a love charm also used columbine as love medicine.

larkspur

Delphinium menzieessi

Larkspur, (Delphinium menziessi)- a plant that was toxic to livestock and considered poisonous ironically was used for love medicine. The Thompson tribe’s women used it “to help them obtain and hold the affection of men”, although it wasn’t clear on how it was utilized.

MeadowrueMeadowrue, of which Central Oregon has a few species was not used by local tribes but was used by the Potawatomi as both hunting and love medicine. The seeds were mixed with tobacco by and smoked by men when going to call upon a favorite lady. Meadowrue, (Thalictrum occidentale), was used by the Thompson as a poultice on open wounds for healing. Meadowrue’s root contains berberines, one of the few plants aside from Oregon Grape Root to contain that particular constituent. It was used to loosen phlegm, as blood medicine, and as an analgesic. The powdered fruits were mashed into a paste with water and used on the skin and hair.

spreading-dogbane-apocynum-androsaemifolium-01

apocynum-androsaemifolium

Spreading Dogbane (Apocynum androsaemifolium)-although considered toxic was used extensively by Native Americans as love medicine. The Okanagan-Colville tribe chewed the leaves and the juice, as well as, smoked the dried leaves as an aphrodisiac (Not advised). If you break a spreading dogbane stem or leaf, you will see that the plant contains a bitter, sticky, milky white sap. The sap contains cardiac glycosides that are toxic to humans. The root also contains a potent cardiac stimulant, cymarin. These toxic compounds help protect spreading dogbane from grazing animals. Despite its toxicity, the plant has been used medicinally for a variety of ailments. However, this plant is best enjoyed for its beauty and not as a medicine. Native Americans used the tough fibers of this and other native dogbanes to make threads and cord.

Platanthera leucostachys_Mono Lake Cty Park_2002-07.05

Platanthera leucostachys

Bog Orchid (Platanthera leucostachys)-a plant we recently identified in the Ochoco Mountains, was used extensively by the Thompson tribe as a wash for various joint and muscle aches. It was used in the sweat lodge for rheumatism. Women “hoping to gain a mate and have success in love” used the Bog Orchid as love medicine as a wash. Although I could find no report of its toxicity, it was only used externally, so beware.

arrowhead

Sagittaria latifolia

Arrowhead, (Sagittaria latifolia) which is found in northern Jefferson County and on the west side crest of the Cascades was used as love medicine by the Thompson is usually found at the margins of ponds or marshes. The enlarged rounded starchy tubers from the plant form at the ends of underground plant runners (rhizomes). When dislodged from the mud, these tubers will float to the surface. They are edible, and may be boiled or baked and eaten as a potato-like food. Native Americans harvested and consumed these tubers, which in some areas were known as wapato. The Thompson spoke about its use as a love charm and for witchcraft.

pineappleweek

Matriciaria disoidea

Pineappleweed (Matriciaria disoidea)- was used by native peoples ranging from Alaska to Montana. A close relative to German Chamomile it had similar uses for digestion and fevers.   Native peoples used the aromatic plants as perfume, sometimes mixing them with fir or sweet-grass and carrying the mixture in small pouches to concentrate the fragrance. Pineappleweed, provided a pleasant smelling insect repellent, and the fragrant dried plants were used to line cradles and stuff pillows.  The Okanagan-Colville buried the tops of Pineappleweed mixed with human hair to prevent loved ones or relations from going away.

prairie smoke

Geum triflorum

Prairie Smoke or three-flower avens (Geum triflorum)-is in the rosaceae family; so that tells us that it probably has astringent actions. Avens were used by many native peoples ranging from toothache remedies, fevers, antidiarrheal, gastrointestinal and as a gynecological aid. Primarily the roots were used. Several tribes used it for love medicine, including the Iroquois, who used the compounded roots as an emetic to vomit and cure themselves of love medicine. The Okanagan-Colville used and infusion of the roots as a love potion by a woman who wanted to win back the affection of a man. Mathew Woods wrote about it in his book The Earthwise Herbal: A Complete Guild To New World Medicinal Plants. He spoke about the roots of avens containing phenols, tannins and essential oil, along with noting that he felt Prairie Smoke has an affinity to the female system: the latter for Stagnant blood .

sierra shoot star

Dodecatheon jeffreyi

Last but not least Sierra Shooting Star or Tall Mountain Shooting Star (Dodecatheon jeffreyi) was used as love medicine by the Thompson tribe. Women used the flowers “to obtain the love of men and to help them control men”.

This is just a small sampling of the vast number of plants that were utilized. As the profession of herbalism evolves in North America there is greater and greater emphasis being put on evidenced based medicine and a movement away from traditional knowledge along with the reduction in the number of the plants that are used in commerce. Despite this tendency towards retraction, my hope is that we continue to keep love 2plant stories, and other cultural values which plants offer, alive.

Traditional Chinese Medicine: Erectile Dysfunction (ED) and alternatives to Viagra

I recently saw my first client with ED and spent time researching how Traditional Chinese Medicine (TCM) approaches working with this condition.  Erectile dysfunction (ED) or impotence occurs when a man has consistent and repeated problems sustaining an erection. Erectile dysfunction (ED) is the inability to get or keep an erection firm enough to have sexual intercourse. It is also sometimes also referred to as impotence.   Several studies have looked at the prevalence of ED including one, the Massachusetts Male Aging Study, that reported that ED is increasingly prevalent with age. At age 40, approximately 40% of men are affected. The rate increases to nearly 70% in men aged 70 years.  Age was the variable most strongly associated with ED, although there are emotional and physiological reasons attributed including: diabetes, obesity, heart disease, high blood pressure and atherosclerosis, endocrine diseases, lifestyle, diet, neurological and nerve disorders, medications, drug abuse, anxiety and depression. Additionally men may have difficulty obtaining or maintaining erections after various forms of cancer treatment. Surgery and radiation therapy to the pelvic area, hormonal therapy, chemotherapy, and various medications may all significantly impact a man’s ability to obtain or maintain an erection. Viagra is the leading medication prescribed for ED, although as with all medications,  it is not without its associated side effects:

  • HeadacheUntitled1
  • Flushing in the face, neck, or chest
  • Upset stomach, indigestion
  • Abnormal vision
  • Nasal congestion
  • Back pain
  • Muscular pain or tenderness
  • Nausea

If considering options than Viagra, such as those explored below, it would be advised see a TCM trained specialist.

Traditional Chinese Medicine (TCM) considers that the strength or weakness of men’s sexual function is associated with the energy of certain internal organs, including the kidneys, liver and heart. The Kidneys are one of the major organs to support the body’s sexual function by storing essence (Jing), controlling human reproduction, growth and development. Essence or Jing rules the production of sperm. The heart plays an important role in erection and arousal. Kidney essence is classified as yin, while qi is yang, yet they depend on each other to maintain a dynamic balance, if out of balance it can result in ED/impotence. Excessive sexual activities and frequent masturbation can deplete the kidney essence.

The Ming Men (located on the middle of the lower back) is an essential part of traditional Chinese physiology. Called the “Gate of Life,” it holds the Genuine Yin and Yang of the body from which all substances and functions develop. The term Ming Men refers to one of the body’s two kidneys, where the male’s “essence” is stored. In Kidney Deficiency cases, warming the Ming Men and Kidney Yang are necessary to balance the body.

index4Men’s sexual function disorders have been strongly associated fast paced life styles. This state of chronic stress restricts the flow of the qi through the Liver channel which travels through the pubic area and reproductive organs. When the Liver is affected by stress and the Liver channel is blocked then qi cannot flow smoothly leading to sexual dysfunction and disorders.

The process by which the penis becomes erect is complex, involving not only the nerves, muscles, blood vessels, and other tissues in the penis itself, but also includes factors such as emotion, lifestyle and general health. During arousal nerve impulses are sent to nerves in and around the penis, which cause an increase of blood flow into that organ, causing it to become firm and erect. If there is insufficient blood the penis is unable to achieve erection.

The Heart plays a crucial role in erection, orgasm and ejaculation. In TCM the ability to have an erection and ejaculation depend on the communication between the heart and kidneys. The Heart-Qi needs to descend to communicate with Kidney-Qi. Vice versa, Kidney-Water needs to ascend towards the Heart and contain Heart-Fire, the coordination between the descending of Heart-Fire and ascending of Kidney-Water ensures a normal sexual cycle in men. During the excitement phase of sexual response the Minister Fire within the Kidneys is aroused and flows up towards the Pericardium and Heart: for this reason the person becomes flushed in the face (the complexion is a manifestation of the Heart) and the heart rate increases during sexual excitation. With orgasm and ejaculation, there is a downward movement of Qi, which releases the accumulated Minister Fire downwards: in order for this to occur normally the downward movement of Heart-Qi is crucial. If there is deficiency of Minister Fire within the Kidneys it will result in decreased libido and ED or impotence in men. If Heart-Qi and Heart-Blood are deficient or not descending to communicate with the Kidneys, there may be ED, impotence or premature ejaculation.

tongue blood stasisThere are several other common patterns in ED including blood stasis and damp heat. In cases of Blood Stasis, the flow of energy (called Qi) and Blood is blocked or obstructed in the lower abdomen preventing needed blood flow to create and maintain an erection. This condition often presents with signs of a tight and tender to palpitation lower abdominal area. Treatment will focus on breaking the stagnation in the lower abdomen, returning the proper flow of Blood though the affected area.

Another reason for ED or impotency is the presence of damp heat. Whenindex5 damp heat accumulates it acts creases stagnation or impedes the free flow of Qi. There are many causes of damp heat including unresolved health issues, unresolved low-level pathogens, and or excessive alcohol intake. Signs that point to the presence of damp heat include itching, pain, and swollen prostate, sweating in the genitals, heaviness and aching in the lower limbs, greasy yellow coating on tongue. Treatment includes clearing heat and nourishing any underlying deficiencies.

In determining treatment for ED it is important to utilize the four basic techniques of assessment: questioning, smelling/listening, palpitation and inspection. Furthermore the constitution of the client is taken into account at the same time as TCM pattern differentiation. The following is a summary of pattern differentiation taken from Giovanni Maciocia and Shen-Nong.com, as well as, several other authors.

Primary Patterns:

Kidney Deficiency:

  • Weakness of Life-Gate Fire/Ming Men
  • Deficiency of Kidney Yang Deficiency
  • Deficiency of Kidney Yin Deficiency
  • Damage of the kidneys by fear

Damp Heat:

  • Downpour of Damp Heat into the Lower Burner
  • Damp Heat in Lower Burner
  • Damp Heat in Liver-Gallbladder Channel

Blood Deficiency/Stagnation:

  • Liver-Blood Deficiency
  • Heart and Gallbladder Qi Deficiency
  • Heart-Blood Deficiency
  • Damage of the heart and spleen
  • Blood Stasis

Qi:

  • Liver Qi Stagnation

Untitled2Weakness of Life-Gate Fire-The Gate of Life or Ming men is (located on the middle of the lower back) is an essential part of traditional Chinese physiology. Called the “Gate of Life,” it holds the Yin and Yang of the body from which all substances and functions develop. Along with the Yin-Yang theory, one of the most fundamental principles in Chinese medicine is that of the “Three Treasures.” The Three Treasures consist of jing (essence/potential energy), qi (energy/function), and shen (spirit or spirits). In terms of understanding the Ming Men the concepts of jing and qi are primary. Original Qi is stored in an energetic center called Ming Men. The relationship between the Kidney organ-system and Ming Men is defined by the relationship between the elements of Water and Fire, or Kidney and Heart as explained above. Strengthening Jing and the Life-Gate are often the first approach when working with ED/Impotency.

  • ED/Impotence
  • Seminal discharge, white/cold
  • Dizziness/vertigo
  • Tinnitus
  • Pale complexion,
  • Cold extremities
  • Listlessness of spirit
  • Weak aching lower back and legs
  • Frequent urination
  • Pale Tongue with white coating
  • Deep thready pulse

Formulas:

  • Wu Zi Yan Zong Wan (Five Ancestors Teapills)
  • Zan Yu Dan (Procreation Elixir)
  • Right-Restoring Pill combining with Procreation Elixir
  • Jin Suo Gu Jing Wan (Golden Lock Teapills) Kidney Yin and Yang deficiency with leakage of fluids creating instability at the Gate of Life.
  • Cong Rong Bu Shen Wan (Cistanches Tonify Kidney Pills)
  • Er Xian San (Two Immortals Teapills) regulates the chong and ren channels
  • Ge Jie Da Bu Wan (Gecko Tonic Teapills)

Deficiency of Kidney Yang symptoms: Yang is responsible for our physiological functions and energy. A deficiency of Kidney Yang is an internal condition results in cold and weakness, along with ED or impotence. A deficiency of Kidney Yang indicates a deficiency in the “Life Gate” or Ming Men. This coldness results in the lower libido, ED or Impotence. It is

  • ED/Impotence
  • frequent clear urination,
  • cold limbs,
  • dizziness,
  • tinnitus,
  • fatigue,
  • lower back weakness
  • Deep-Weak pulse
  • Pale tongue

Formulas:

  • You Gui San (Right side Replenishing teapills)
  • Wu Zi Yan Zong Wan (Five Ancestors Teapills)
  • Jin Gui Shen Qi San (Golden Book Teapills)
  • Ba Ji Yin Yang Teapills (Morinda Pills to Balance Yin and Yang)
  • Huan Shao Dan Wan (Return to Spring Teapills)
  • Ge Jie Dan Bu Wan (Gecko Tonic Teapills)

Deficiency of Yin Deficiency

  • ED/Impotence
  • Dizziness
  • Scanty urination
  • Night-sweating
  • Insomnia
  • Tinnitus
  • Floating-empty pulse
  • Red tongue w/o coating

Formulas:

  • Zuo Gui Wan (Return Left Pill)
  • Zhi Bai Di Huang Wan (Eight Flavor Rehmannia Teapills) with deficient heat
  • Liu Wei Di Huang San (Six Flavored Teapills)

Damage of the kidneys by fear-Fear can shock or injure the Kidney-Adrenals, along with leading to the disordered movement of qi.

  • ED/impotence
  • soft erection
  • timidity
  • tendency to doubt and suspicion
  • palpitations
  • susceptibility to fright
  • restless sleep
  • thin and slimy tongue coating, string-like
  • thready pulse.

Formula: Huan Shao Dan Wan (Return to Spring Teapills)

Downpour of Damp Heat into the Lower Burner

  • ED
  • Premature ejaculation
  • Sweatiness of the scrotum
  • Heavy aching lower limbs
  • Thirst
  • Bitter taste
  • Dark burning urine
  • Yellow slimy coating on Tongue
  • Pulse is Slippery and rapid

Formula: Long Dan Xie Gan Tang (Gentian Liver-Draining Decoction

Damp Heat in Lower Burner

  • ED/Impotence
  • Difficult-painful urination
  • Deep yellow urine
  • Itching of genitals
  • Urethral discharge
  • Sticky-yellow coating on tongue, with red spots on root
  • Slippery pulse

Formula: Long Dan Xie Gan Tang (Gentian Liver-Draining Decoction

Damp Heat in Liver-Gallbladder Channel

  • ED/Impotence,
  • Difficult-painful urination
  • Rash external genitalia
  • Irritability
  • Sticky-yellow coating on tongue, with red spots on root
  • Wiry pulse

Formula: Long Dan Xie Gan Tang (Gentian Liver-Draining Decoction

Liver-Blood Deficiency

  • ED/Impotence
  • Dizziness
  • Blurred vision
  • Depressed mood
  • Insomnia
  • Pale tongue
  • Choppy pulse.

Formula:

  • Shao Yao Gan Cao Tang Jia Wei (Peony and Licorice Teapills)
  • Si Wu Tang (Dang Gui Four)

Heart and Gallbladder Qi Deficiency

  • ED/Impotence
  • Premature ejaculation
  • Depressed mood
  • Timidity, sighing
  • Insomnia
  • Palpitations
  • Easily startled
  • Pale tongue
  • Weak pulse

Formula: Da Bu Yuan Jian

Heart-Blood Deficiency

  • ED/Impotence
  • Palpitations
  • Dizziness
  • Depressed mood
  • Insomnia
  • Pale tongue
  • Choppy pulse

Formulas:

  • Gui Pi Tong (Ginseng and Longan Combination)
  • Si Wu Tang (Dang Gui Four)

 Damage of the heart and spleen

The Spleen is the source of Blood production along with ensuring its flow within the vessels. If the spleen is operating properly then it transports and transforms sufficient nutrients for plentiful heart blood. Vise versa, according to the five-element theory, the Heart is the mother of the Spleen. If there is deficiency of Heart Blood or Qi it impairs the function of the Spleen to transport and transform. This domino effect will impede the Spleens ability to transport sufficient nutrients to keep Blood flowing in the vessels (ability to achieve and maintain erection).

  • Inability to achieve and/or maintain erection
  • Lassitude
  • Palpitations
  • Poor memory
  • Restless sleep
  • Poor appetite/eating habits
  • Colorless facial complexion
  • Thin and slimy tongue coating, pale tongue,
  • Fine or choppy pulse.

Formula:

  • Gui Pi Tong (Ginseng and Longan Combination)
  • Spleen-Restoring Decoction

Blood Stasis-Surgery, cancer, radiation and chemotherapy can potentially result in creating stagnation of blood to the perineum, which can impede the flow of blood and qi.

  • Prickling pain in testes
  • Pain or distention in chest and hypochondria
  • Stabbing pain
  • Dark complexion
  • Dry skin
  • Purplish dark tongue
  • Thready, uneven pulse

Formulas:

  • Xue Fu Zhu Yu Tang (Stasis in the Mansion of Blood Decoction)
  • Wen Jiang Tang Wan (Warm Cycle teapills)

Liver Qi Stagnation-Normal flow of liver qi ensures that all emotional processes are in harmony and blood is flowing sufficiently. If there is a stagnation of liver qi then this can result in the lack of nourishment to tendons including genitalia.

  • ED/impotence
  • Depression
  • Anxiety and irritability
  • Discomfort of the chest and stomach
  • Distension and oppression of the hypochondriac region
  • Poor appetite/eating habits
  • Loose stool
  • Thin tongue coating
  • String-like pulse.

Formula:

  • Xiao Yao San (Bupleurum and Dang Gui Formula
  • Jai wei xiao yao san (Bupleurum and Peony Formula) clears deficient heat
  • Chai Hu Shu (Disperse Vital Energy in Liver), for liver qi stagnation and Liver Blood Stasis

Traditional Formulas used for ED/Impotence:

Ge Jie Da Bu Wan (Gecko Tonic Teapills), Qi, Yang, Blood and Jing deficiency

Symptoms:

  • Weakness or pain in low back knees
  • Joint pain and stiffness
  • Difficulty walking
  • Weakness, fatigue, exhaustion, listlessness
  • Weak voice, pale face
  • Spontaneous sweating
  • Occasional chills and feverishness
  • Dizziness, vertigo, tinnitus, hearing loss
  • Forgetfulness, poor memory,
  • Frequent urination, nighttime urination
  • Edema,
  • Chronic diarrhea w/undigested food, abdominal distention, poor appetite
  • Cold limbs, cold intolerance
  • Decreased sex drive, impotence
  • Shortness of breath, wheezing, shallow breathing aggravated by exertion, shallow breathing aggravated by exertion, chronic persistent cough
  • Palpitation
  • Insomnia

Jin Suo Gu Jing Wan (Golden Lock Teapills), Kidney Yin and Yang Deficiency creating instability at the Gate of Life

Symptoms:

  • Chronic leakage of fluids, spermatorrhea, nocturnal emissions, premature ejaculation, impotence,
  • Urinary frequency, night urination, urinary dribbling or incontinence
  • Fatigue, weakness, listlessness
  • Excessive sweating
  • Weakness and rapid fatigue in muscles, sore and weak low back and limbs
  • Chronic watery diarrhea
  • Tinnitus

Wen Jiang Tang Wan (Warm Cycle teapills) * deficiency and cold in Chong and Ren channels causing blood stasis

Symptoms:

  • Five palms heat
  • Dry lips and mouth
  • Dry skin or hair
  • Fatigue, weak or cold limbs
  • Impotence
  • Pain in the testicles
  • Urinary incontinence

*primarily used for women in the category of warm the menses and dispel blood stasis, but can be used for spermatorrhea, erectile dysfunction, orchialgia, seminal insufficiency.

Supplementary herbs and formulas:

  • Wu Chi Pai Feng Wan (Black Chicken White Phoenix Pills)
  • Tonic wine: soak red deer antler, ginseng roots, lycii berry and schizandra in rise wine. Take 1 tsp 3 times a day, especially for winter.
  • Planetary Herbs: Damiana Male Potential
  • Ashwagandha
  • Shilajit
  • Damiana
  • Yohimbe
  • Ginseng

Moxibustion and Qi Gong: In cases of Kidney deficiency that require warming, moxibustion can also be performed at index6these acupuncture points. The moxibustion treatment involves the burning of a herb, Ai Ye-mugwort, to warm and circulate the energy in the local area, strengthening the Life Gate fire.

Qi Gong has specific movements to strengthen the Gate of Life (http://www.funwithqigong.com/2009/07/open-and-move-from-the-gate-of-life/)

References:

http://www.shen-nong.com/eng/exam/specialties_menimpotence.html

https://www.jcm.co.uk/liver-gallbladder-based-erectile-dysfunction-treatment-by-chinese-medicine-part-1.html

http://www.altmd.com/Articles/TCM-for-Erectile-Dysfunction

http://maciociaonline.blogspot.com/2013/06/the-treatment-of-male-problems-in.html

http://www.itmonline.org/5organs/kidney.htm

http://www.tcmtreatment.com/images/diseases/impotence.htm

http://www.theacupunctureclinic.co.nz/male-sexual-dysfunction-by-will-maclean/

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