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Case By: Jason Blalack

Intro: This is a somewhat informal presentation of a recent case that I found quite educational for myself. It is definitely not the cleanest case (easy success) but that is why I like it. I am still working out the best way to present these cases and if anyone has any suggestions please let me know. I also welcome others to submit their cases for us to learn from. I hope you enjoy it and welcome any feedback or criticisms.

Case: 55 year old male presented with testicular and perineal pain, sensation of “peeing glass”, strong sensation heat in the lower burner, unable to sit due to the pain, and frequent urination in both night and day. This had persisted for many months and had been labeled “chronic prostatitis.” He also presented with a painful left big toe, dry mouth, and very strong emotions (anger, anxiety, fear etc.). The pulse was cloudy (模糊,mó hú mài) and wiry, and his tongue was dark red/purple with a thick coat. The diagnosis was damp-heat stasis in the lower with the treatment principle of transform damp, clear heat, promote urination, and promote the movement of blood.

  • Long dan cao6
  • Che qian zi9
  • Huang qin9
  • Zhi zi 9
  • Sheng di 9
  • Ze xie9
  • Dang gui 6
  • Mu tong 6
  • Chai hu 6
  • Gan cao6
  • Huang bai6
  • Ku ding cha2

Instructions: 1 bag=2 days. Cook time =45 minutes. Take 2-3 times a day.

Visit #2: Heat was 40-50% better. Pain had improved. Started a course of Cipro for 1 month. Tongue was red.

Visit #3: In the previous three days the pain was severe. Dx: damp heat + toxin pouring into the lower burner.

Visit #4: Feels very hot, insomnia, urine is yellow, very angry, dry mouth, thirst, and feels energy shooting up. Uncomfortable sensation over his liver. Red tongue, wiry pulse. Diagnosis: Liver Fire.

Visit 5-6: more of the same.

Commentary: Throughout all of these visits a modified Gentian Decoction to Drain the Liver (lóng dân xiè gän täng) was used with various additions to emphasize more blood invigorating (e.g. Vaccariae Semen (wáng bù liú xíng), Manitis Squama (chuän shän jiâ)), pain relieving (e.g. Corydalis Rhizoma (yán hú suô)), toxin clearing (e.g. Patriniae Herba (bài jiàng câo),Taraxaci Herba (pú göng yïng)) , cooling the blood (e.g. Paeoniae Radix rubra (chì sháo)), protecting the yin (e.g. Dendrobii Herba (shí hú)), and descending the yang and calming the spirit (e.g. Fossilia Ossis Mastodi (lóng gû), Poriae Sclerotium pararadicis (fú shén)). But the overall presentation had hardly budged. Pain and heat was certainly still an issue as well as the severe emotions (anger, fear, sadness etc.). Other modalities were also used at this time by other practitioners.

Visit 7: Due to unclear results, I decided to switch to a more modern prostatitis formula:

  • Huang qi10
  • Yan hu suo6
  • Di long 4.5
  • Zhi gan cao6
  • Hu zhang9
  • Bai hua she she cao9
  • Huang bai9
  • Sheng di huang 12
  • He huan pi9
  • Wang bu liu xing9
  • Nu zhen zi12
  • Ze xie6

Visit 8-9: “prostate” seems better. He has noticed that stress makes it worse. Anxiety is less. Pain is 5/10 (was 8/10). Feels like the muscles are very tight/pulled muscle around the perineum. Added 20 grams of Paeoniae Radix alba (bái sháo).

Visit 10: Urethral pain is still severe, pelvic pain is getting better. Lots of emotion. Pulse is very tight and wiry. Fatigue (mentioned that had been going on for awhile).

  • Chao Chuan lian zi6
  • Mai dong9
  • Bai zi ren9
  • Tao ren9
  • Dang gui6
  • Huang bai9
  • Yan hu suo9
  • He huan pi9

Commentary: Over the last 10 visits the pain had gone up and down many times. However even though the pain had decreased it was still significantly present. The heat was also very obvious. Due to the unclear results from the above more straightforward approaches. I decided to consider the underlying mechanism for the fire/heat. Taking inspiration from Ye Tian-Shi, I prescribed the above formula (see his constraint case). Notice the more softening approach.

Visit 11: significant improvement, pain and pelvic floor tension was much less. 3 bags of previous. Of Note: Almost all of the previous formulas contained Corydalis Rhizoma (yán hú suô)..

Visit 12: + Paeoniae Radix alba (bái sháo) 25.

Visit 13: It was unclear if Paeoniae Radix alba (bái sháo)made any difference)“ feeling much better.

Visit 14: Common cold / flu (gan mao), stopped herbs, pain became worse. Thought there might be a lurking pathogen and switch strategies to a yin deficient venting idea. (I was wrong)

Visit 15: Pain became much worse, went back to previous formula (visit 12-13) and pain continued to decrease once again. This confirmed that addressing the underlying mechanism, causing the fire was actually effective. Over the next few weeks the pain completely resolved.

Visit 16: Although no pain remained, there was anxiety, fear, pressure in the chest, and palpitations. This had been going on for many years since the death of his wife. He (and I) thought that this was the underlying cause of all his problems including the fire/prostatitis. This was qi and blood stagnation in the collaterals. The treatment principle was to dredge the liver and open the collaterals. I decided to use a modified Inula Decoction (xuán fù huä tang) from the Essentials from the Golden Cabinet.

  • Xuan fu hua9
  • Hong hua6
  • Tao ren9
  • Dang gui wei6
  • Ze lan3
  • Lu lu tong3
  • Wang bu liu xing6
  • Mei gui hua3

Note: Carthami Flos (hóng huä) sub for New crimson (xïn jiàng).

Emotional symptoms, energy, sensation in the chest all dramatically improved over the next couple weeks.

Location: Boulder, Colorado

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Showing 7 comments
  • Trevor Erikson
    Reply

    Great case Jason,

    Thanks for sharing this. I actually had a similar situation in clinic this past year. I even used a similar “prostate” Rx as you. (Was this from Bob Damones andrology book?). I found though, as you did above, that the symptoms were slow to change and respond.

    The patients urologist had originally diagnosed him with chronic prostatitis and then later to chronic pelvic inflammatory disease, saying though that the Diagnosis was more of a guess.

    In the end, what I found greatly helped this patient was a formula like the following:
    Bai Shao 18
    Wu Yao 9
    Ze Xie 9
    Fu Ling 12
    Huang Bo 9
    Yi Mu Cao 24
    Gan Cao 6

    A teacher recently explained this idea to me of IBS, or irritable Bladder syndrome, where by the urethra is in a state of “unregulation”- ie Qi stagnation. The high dose of Yi Mu Cao is a specific for this condition (as well as for irritable bowel syndrome). Overall, I focused on coursing Qi in the pelvis, relaxing spasm, and draining damp heat. The result was excellent. I now have another patient presenting with a similar presentation and he finds results with this type of Rx within hours of taking it.

    One note to your case study that I am interested in is the fact that you use very low dosages. One bag to last 2 days means your above dosages are cut in half. Plus your cooking time is also long, 45 mins, meaning many of the subtle medicinal components may be destroyed. I was taught and now use the method of cooking the herbs 2 times. The first cook is 15 mins long, which preserves the essence of the medicine. The second cook is around 25-30 mins long, which goes after the deeper set medicines. The two are then obviously mixed together.

    Of course if you are used to getting results with the way that you prescribe then wonderful. For me, if I do not see results then I usually look at my dosages and cooking method first, before trying a completely different formulation.

    Another question I have is in regards to the classical case studies that you present. What are you dividing the Qian by to get the grams? 3, 3.7, something else?

    Again thanks for sharing this. Case studies are the best way for all of us to learn and grow together. I admire the honesty in your presentation (kept it raw and not focused through rose colored glasses!) and the commitment to our medicine. Keep up the awesome work!

    Best
    Trevor

    • Jason Blalack
      Reply

      1. Thanks for sharing your case! I love to see different peoples prescribing styles. I would like to hear more about the yi mu cao (e.g. where it is from?). Also, are you saying it is specific for irritable bladder syndrome due to qi stagnation? Are you using one bag per day?
      2. In general I tend towards low doses . My experience is if you hit the pattern correctly, rarely do you need a large dose. I almost always use one bag for two days. However I do agree that sometimes one needs to increase (or decrease) the dose depending on how the patient responds. In this case I did slightly increase various herbs from the initial formula, e.g., long dan cao to 9 for a short period of time. However he was not responding in a way that warranted to blast him any harder with the bitter cold medicinals. Things were very erratic with his pain levels and I was fairly certain that it was just my approach that was incorrect. As you’ll notice the following formulas from visit 10 and 16 were much smaller but clearly much more effective.
      3. The cooking time is a very valid point. Years ago I used to have patients double cook the herbs. I do think this is the best method. However, this was a major hurdle for compliance and switching to a one-time 45 minute cook seems to not make that much of a difference for efficacy (maybe I get used to it) and the compliance was much higher. Of note is we have a large number of herbs that we end up having the patient add in the last 10 minutes or steep for five minutes after cooking. This gives us a bit more flexibility. I have to admit, I do not look at cooking time very frequently when I don’t get results. Thanks for bringing this up and will consider it in the future.
      4. As far as dosage (qian conversion), check out the note at the bottom of the following page: https://www.chinesemedicinedoc.com/case-studies/ye-tian-shi-constraint4/
      If that is not clear, please let me know.

  • Trevor Erikson
    Reply

    Hi Jason,

    I learned about Yi Mu Cao during a lecture with Mazin Al Khafaji. As usual his teaching method is based purely on what he has seen work effectively in clinic and will not teach anything but his own clinical success (something that I admire greatly and find as a good source of relief to the many clinical philosophers out there!). His usual source for gathering ideas to use in clinic comes from both famous Doctor writings and modern published research. I could ask him where he originally sourced this out.

    The lecture was on inflammatory bowel disease and IBS. He found that Yi Mu Cao, in the dose range of 12-24, was good for those cases of peristaltic dysfunction in either the bowel or urethrea, where by there was either over or under activity. So in the bowel, there will be the classic signs of IBS- fluctuating diarrhea and constipation, and in the bladder/ urethrea, signs of chronic UTI symptoms- dribbling, painful urine, increased and/or decreased frequency, etc. Mazin pointed out that these symptoms of unregulated peristalsis can be a form of Qi stagnation and that the Yi Mu Cao is a specific for this.

    For the irritable bowel symptoms, when other Qi stagnation signs are present, then the usual method was to add Yi Mu Cao to either a Si Ni San or Tong Xie Yao Fang type formula. For the irritable bladder symptoms, then a Si NI San type formula could also be used, but with the addition of some draining herbs like Fu Ling, Ze Xie, and Che Qian Zi.

    Can’t find it in Chen and Chen, but so far I have seen good success in two cases over the past couple months. Particularly, as I mentioned, with one patient with whom I struggled to find an effective treatment route for many months. Again, I will post on Mazin’s forum and see if he can clarify where he learned about Yu Mu Cao’s usage.

    Yes, I do dose at one bag per day. It is how I was taught and it is what I see works. I think that I am hesitant to use lower dosages particularly because I used granule medicines for a few years, finding the results intermittent. I always blamed the poorer results, or slower results, with granules on the low dosage that is commonly used with them, as well the fact that some medicinal components may have been lost in processing. So now I stick with the herbs original per day dosage. I sometimes use quite high dose ranges, upwards of 200 grams per day overall, and I rarely see people become ill or suffer with any type of upset due to this. I find, as my teachers have found, that if the diagnosis is correct then the patient is able to just soak up the medicine and utilize it to correct change quickly.

    As for cooking times, I used to cook the same as you, 45 mins one time, fearing uncompliance, but I have actually found that patients are quite adept to figure it out. I rarely have a client that cannot do it, as most are happy to do what ever it takes to become well. One thing I do that I find helps though, is to give them my email so that they can contact me if they have struggles or concerns. Many will utilize this with the first cook, as most add way too much water in the beginning, but afterwards most are fine on their own. I also have them cook three days at once, store in jars while still hot, and then keep in fridge. This helps greatly with compliance.

    Thanks for the clarity on Qian. The local China town shop that I use for my prescriptions uses Qian and so I have been dividing everything by 3.7. This seems to be in line with what you have mentioned.

    I would love to see more of your own cases, where by you used low herbal dosages to treat chronic and difficult cases. Perhaps I will become converted myself someday 🙂

    Thanks again,
    Trevor

  • Trevor Erikson
    Reply

    Jason,

    Mazin replied on the use of Yi Mu Cao for IBS, for which he claims it was a clinical finding of his own. He remembers having a patient who suffered with IBS (both urinary and bowel), who also had irregular menstruation. The formula he used was basically modified Tong Xie Yao Fang with urine activating herbs like Ze Xie, Qu Mai, and with Yi Mu Cao 12g. The patient returned with a slight decrease in IBS symptoms, but no change in the menstrual signs. His favorite herb combo for menstrual irregularity is Xiang Fu with Yi Mu Cao, but he was out of stock of Xiang Fu, so decided to double the dose of Yi Mu Cao to 24 grams. When The patient return, her menstruation was more regular and her IBS symptoms had calmed down.

    Mazin has then tried this higher dose of Yi Mu Cao on many patients over the years and has found it to be a very useful herb for IBS. I guess Yi Mu Cao is classically known to be good for urinary symptoms, but not so much for the Bowels. Years later, Mazin found a research study in Chinese where Yi Mu Cao in higher dose ranges helped 97% of patients suffering with watery diahrea.

    Anyways, it seems Yi Mu Cao could be viewed as a useful herb to calm IBS, either bladder or Bowel or both, particularly when there is Qi stagnation symptoms. I think this could be understood via its ability to help regulate the menses, and thus affect the Qi mechanism. It also seems to have direct dampness draining abilities.

    Best
    Trevor

  • Jason Blalack
    Reply

    Thanks Trevor, this is very interesting.

  • Michael D. oiae
    Reply

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  • Nijinsky gim
    Reply

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