Sometimes you have to treat the GB

Shanlarson: May 17, 2019, 5:07am
I had a patient come in today who had this strange sensation in his ear that he described as being the opposite of
clogged. He said it felt too open and a little cold.
He’s in his 40s. Went through chemotherapy in his 20s for prostate cancer. His tongue is purple, stiff, glossy with a
wet coat. He is always well put together, goes to the gym regularly. He has a history of heartburn but that seems to
be a lot better these days. His sleep has been good. His digestion is good. He feels he is at a moment where he has
the least amount of stress in a long time. He feels great except his ear.
He did have a very wiry pulse on both sides and some rib side tension upon abd dx.
I first decided to treat PC on the opposite side and GB 8 as a local point. (I know this is frowned upon but
sometimes getting my regular patients on board with Saam I do a VERY gentle needle at the local point… I hang
my head in shame). Anyway once the needles were in he got this cold sensation run down his shoulders and he
thought it made it worse. I took out the needles and then strengthened GB. When I put in the last needle he said
that changed things. I left him for 5 min and came back. I was feeling hesitant strengthening the GB. He had some
tears in his eyes and said he was doing really really well and just having an emotional release. At the end of the
treatment he said he was thinking about how his therapist says he needs to express his anger and then he had all
these childhood memories where he suppressed his anger. His ear felt better when he left and he seemed super
happy. SA’AM is so fascinating.

KristinWisgirda: May 20, 2019, 1:23am
Thanks for sharing this case. Opportunities to supplement gallbladder are rare in my practice so it is fun to hear
about them.
In hindsight, are there any Pericardium excess signs in his presentation that explain why treatment worked out as it
did. Is he very intellectual, deliberate and grounded in his movements, concave in any way? You could never
imagine a P excess person using a their physicality if they were to have an argument, which they likely would
never start anyway.

Shanlarson: May 21, 2019, 2:08am
I was a little on the fence with him. His pulse was very wiry and he had strong rib-side tension. He also described
his ear as feeling cold which made me think PC could bring some warmth to the GB channel but it did cross my
mind that “too open” feeling in his ear that he was describing was more def in the channel. He is a very muscular
guy who clearly lifts weights at the gym and could look intimidating from far away but he does have a calm energy
and is a counselor for addiction so I would say he has a thoughtful deliberate demeanor about him. It was a good
lesson for me. I think because I was apprehensive with GB it made me jump to a conclusion and lead me to tonify30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
https://forum.qiological.com/t/sometimes-you-have-to-treat-the-gb/230/print2/12
PC first. The nice thing however was it became very obvious it was the wrong direction and I quickly changed the
treatment with great results.

KristinWisgirda: May 21, 2019, 2:49pm
As Sa’am newbies who have many good tools in our tool belt already, it is tempting to mix in other diagnostic
systems. For instance, in Sa’am, ribside tension is diagnostic for Lung(St) when on the right and Liv(SJ) when on
the left. Nothing about GB/P with this area. There aren’t any pulse indications for Sa’am so the wiry pulse doesn’t
get you anywhere with this system.
When you are working with Sa’am, it is really helpful to weight the Sa’am specific parameters most strongly.
You’ve had a memorable experience with a solid P excess archetype that will help you use the system on its own
terms.
Shanlarson:
He also described his ear as feeling cold which made me think PC could bring some warmth to the GB channel
This weekend in Tucson, Toby clarified that he thinks of P+ as slightly cooling, rather than warm- the cool inner
wind of jueyin- and that GB is on the warmer side though its outward movement doesn’t necessarily warm per se. I
had previous thought of P as warmer as well. So many nuances!

michaelmax: May 21, 2019, 3:24pm
Hi @Shanlarson
Thanks for this interesting case!!
Like @KristinWisgirda I rarely see opportunities to +GB. But it sounds like you were spot on with this. Checked
in with your patient to be sure things are ok and then followed through with making a change. A bit of a gutsy
change at that.
And you were spot on with “oh this is not working, better reverse it”
Sounds like he is working with expressing outward his feelings, GB can certainly put some fuel on the “outward
thrusting” of what is inside.
Keep us posted!

Ryan_Gallagher: May 21, 2019, 5:50pm

30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
https://forum.qiological.com/t/sometimes-you-have-to-treat-the-gb/230/print3/12
Just want to ask for clarification here, @KristinWisgirda:
Do you treat the LU for R rib-side tension, or is it a LU excess (and thus you tx the ST)?
Do you treat the LR for L rib-side tension, or is it a LR excess (and thus you tx the SJ)?
Also, while I’m at it, I’ll ask a random question: I think I heard Toby say at one point that in Sa’am, you insert the
needles from top to bottom on the body (so, for instance, the order for +SP would be +HT8 +SP2 -SP1 -LR1). Is
this the case, or is another order recommended?

KristinWisgirda: May 22, 2019, 1:44pm
Ryan_Gallagher:
Do you treat the LU for R rib-side tension, or is it a LU excess (and thus you tx the ST)?
Do you treat the LR for L rib-side tension, or is it a LR excess (and thus you tx the SJ)?
The right tends to indicate Lung deficiency/Stomach excess to be treated by Lung+. But it can also be Lung excess.
In my limited experience, I’ve seen it present more as Lung excess, maybe because I have many more Lung excess
patients than St excess.
Same thing on the left- it tends to be Liver deficiency/SJ excess requiring Liv+, but it can also be Liver excess.
The ribside/subcostal can be subjectively/objectively tight or be painful or have lumps or other unusual features.
Ryan_Gallagher:
I think I heard Toby say at one point that in Sa’am, you insert the needles from top to bottom on the body
Toby’s teacher said that there was a recommended needling order but that it didn’t really matter, so he never taught
it to Toby. Toby said that he tends to needle from top to bottom, just as a habit.
1 Like30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
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michaelmax: May 22, 2019, 2:53pm
KristinWisgirda:
Toby’s teacher said that there was a recommended needling order but that it didn’t really matter, so he never
taught it to Toby. Toby said that he tends to needle from top to bottom, just as a habit.
Yes, Toby follows his teacher on that. My habit has to be first tonify, then disperse. But I’m trying the top to
bottom method to see if things feel different to me.

Ryan_Gallagher: May 27, 2019, 3:55pm
KristinWisgirda:
This weekend in Tucson, Toby clarified that he thinks of P+ as slightly cooling, rather than warm- the cool
inner wind of jueyin- and that GB is on the warmer side though its outward movement doesn’t necessarily
warm per se. I had previous thought of P as warmer as well. So many nuances!
I’d like to clarify the temps of the channels in Sa’am. This is how I picture them—please let me know where I’m
off!
Taiyin/Yangming: SP is the most warming, then ST (mildly warm?), then LU (mildly cool?), then LI (cooling)
Shaoyin/Taiyang: HT is the most warming (hot), then KD (?), then SI (?), then BL (cold)
Jueyin/Shaoyang: SJ is the most warming, then GB (mildly warm), then PC (mildly cool), then LR (cooling)
Looking at the warmest channels from each group, I’d assume the hierarchy would be HT first, then SJ, and then
SP?
And for the coldest: BL, then LR, then LI?
Thanks! I continue to be really grateful for all the insights shared on this site.

KristinWisgirda: May 28, 2019, 5:32pm
We discussed relative temps in Tucson. It was really helpful to have Toby clarify his understanding.
Ryan_Gallagher:
then KD (?), then SI (?),30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
https://forum.qiological.com/t/sometimes-you-have-to-treat-the-gb/230/print5/12
Both Kidney and SI are mixed fire and water, one consolidating and one moving. Both can be used for mixed hot
and cold patterns.
So far in my limited clinical experience, it has been useful to keep SI supplementing in mind when heat is a
significant part of the picture, especially if there is mixed hot and cold. SI has been so helpful for hotflashes and
feverish situations that don’t require full on UB+.
Ryan_Gallagher:
then ST (mildly warm?), then LU (mildly cool?),
Toby’s teacher refused to say anything about the temperatures of St and Lung. Toby said consider them
“neutralish”.
So hot to cold:
Heart
SJ
Spleen
GB
(K/SI), (Lung/Stomach)
Pericardium- slightly cool
LI- slightly cool
Liver- cool
UB- cold

dcantor: May 28, 2019, 11:32pm
Just to add in my two cents –
T told me that supplementing LI slightly decreases heat and supplementing ST slightly increases heat.
He also said to think of Ki excess as a “tight, condensed ball of liquid fuel on fire.”
In general the 6 conformation designation quality contribution is a little stronger than the 5 phase quality.
Finally, he cautioned that since both SI and Ki are half fire, “be careful” with significant Heat presentations – even
though SI is Tai Yang, sometimes either can be too warming for someone with a lot of Heat.
In my experience so far, I’ve felt that Pc is a little warm for folks too, so that is interesting to hear that he actually
considers it slightly cool. I’ll have to keep observing that one.

George_Mandler: May 29, 2019, 12:59am

30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
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dcantor:
In my experience so far, I’ve felt that Pc is a little warm for folks too, so that is interesting to hear that he
actually considers it slightly cool. I’ll have to keep observing that one.
On of of the podcasts (I believe?) Toby said how he and maybe his teacher said how warming Liver 1 can be. That
put the image of warmth into my mind when I needle Liver 1, although when I supplement PC for my own Tyson
moments I do not experience that warmth.
I wonder too if there is a ‘cool’ that is more metaphorical rather than temperature – to cool a hot headed person.

KristinWisgirda: May 29, 2019, 3:13pm
George_Mandler:
I wonder too if there is a ‘cool’ that is more metaphorical rather than temperature – to cool a hot headed person.
Good point. Direction here is what creates the net effect of temperature. Strengthening the inward movement of
Jueyin Pericardium is going to “cool” the “hot headed” GB excess.
Contemplating the 12 channels in relation to temperature brings me back to the importance of directionality and
other qualities for each.For instance, the flames of Heart heat reach out and embrace versus the bright focus on SJ.
Etc.

pattycakes: May 29, 2019, 6:58pm
George_Mandler:
I wonder too if there is a ‘cool’ that is more metaphorical rather than temperature – to cool a hot headed person
My impression is that SJ is like this too – it isn’t used to warm the body so much as to warm the cool nature of
Liver. Other’s opinions?

KristinWisgirda: May 29, 2019, 8:56pm
pattycakes:
My impression is that SJ is like this too – it isn’t used to warm the body so much as to warm the cool nature of30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
https://forum.qiological.com/t/sometimes-you-have-to-treat-the-gb/230/print7/12
Liver. Other’s opinions?
My understanding is different. Supplementing SJ can be considered when warmth is needed anywhere, but when
the Heart fiery heat isn’t required. Sj can be used to warm the whole gi tract when there is a strong preference for
warm drinks or symptoms are better with warmth or if the patient complains of cold but isn’t cold to the touch.
So just like supplementing SI can be considered for blood stasis or pain, even if there isn’t a clear Kidney excess,
SJ warmth can be considered when there is cold but not necessarily a full on Liver excess.

dcantor: May 29, 2019, 10:09pm
pattycakes:
My impression is that SJ is like this too – it isn’t used to warm the body so much as to warm the cool nature of
Liver. Other’s opinions?
I think it’s true that SI, SJ, etc aren’t always used to warm or cool per say, unlike Ht and BL, but the fact is that SJ,
Ki, SI, and Pc are all half Fire. So that does come into play when supplementing those Organs and may have an
unintended influence on someone for whom Heat is a strong pathological factor.
As an example, I had a young patient last fall present with shoulder pain from a recent injury, but also complained
of anxiety and insomnia that I suspected were Heat-related. Supplementing Ki and SI both made her heart race on
the table and the anxiety worse. This was when Toby initially said to “be careful” of the half-Fire quality in
significant Heat presentations, and that sometimes when he really wants to supp SI or Ki for someone with a lot of
heat, he may even add BL if appropriate.30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
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michaelmax: May 31, 2019, 2:22am
KristinWisgirda:
Good point. Direction here is what creates the net effect of temperature. Strengthening the inward movement of
Jueyin Pericardium is going to “cool” the “hot headed” GB excess.
Oh @KristinWisgirda yes yes yes…
Direction is an aspect to consider. I’d not really thought about it until I read your words and it ring a deep sense of
“yes, that’s right!”
Of course, I could be wrong. I often am. But this is something I can easily investigate in my clinical work. And I
have a sense now of how directionality needs to be considered with tempreature. Just like we consider that
yangming stomach has a certain character which is moister than the ultra dry yangming lg intestine. Taking into
account motion adds a new dimension.

George_Mandler: May 31, 2019, 11:22am
KristinWisgirda:
Supplementing SJ can be considered when warmth is needed anywhere, but when the Heart fiery heat isn’t
required. Sj can be used to warm the whole gi tract when there is a strong preference for warm drinks or
symptoms are better with warmth or if the patient complains of cold but isn’t cold to the touch.
So just like supplementing SI can be considered for blood stasis or pain, even if there isn’t a clear Kidney
excess, SJ warmth can be considered when there is cold but not necessarily a full on Liver excess.
This is a completely new concept to me and I am wondering where I wasn’t paying attention or if there was an
example in Tucson that Toby brought up. I’ve thought of using SJ+ if cool in the upper part of the body but not
only upper you say. This adds a new dimension to iSJ+ use (maybe this is almost 1st grade material using Toby’s
Kindergarten analogies).
How does the “complains of cold but doesn’t feel cold to touch” fit into the SJ+ archetype? Sudden changes in
temp is part of an excess SJ pattern with a warm upper body so I am confused how to make sense of this
information within the supplied framework.

KristinWisgirda: May 31, 2019, 12:50pm
George_Mandler:
How does the “complains of cold but doesn’t feel cold to touch” fit into the SJ+ archetype?30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
https://forum.qiological.com/t/sometimes-you-have-to-treat-the-gb/230/print9/12
My understanding is that this an aspect of relative Liver excess that is a step down from UB excess. This isn’t ice
cold but more a cool density. There is cool/coldness but not enough to bring out the blow torch of Heart.
George_Mandler:
Sudden changes in temp is part of an excess SJ pattern with a warm upper body so I am confused how to make
sense of this information within the supplied framework.
This came up in Tucson. An aspect of SJ excess is an openness to the environment, a lack of shielding, that the
patient has a hard time regulating body temperature. They will be more cold in cold environments and hot in hot
environments. The tendency is to be warmer in the upper and cooler in the lower.
It seems the trick clinically is to differentiate this lack of temperature regulation from the mixed hot/cold patterns
of Kidney and SI excess. With Kidney excess there will be more stagnation signs and with SI excess there will be
more lack of consolidation signs.

michaelmax: June 3, 2019, 1:58am
KristinWisgirda:
This came up in Tucson. An aspect of SJ excess is an openness to the environment, a lack of shielding, that the
patient has a hard time regulating body temperature.
It’s also seen in herbal medicine. When you have ???? alternating heat and cold, which can be another way to
say trouble with temperature regulation. Then you are looking at a shaoyang condition. (xiao chai hu tang treats
this)
One of the helpful things about the Saam method is that it helps me to “see” and bring my herbal training into the
acupuncture realm. Moreover, I’m beginning to see how I “paid attention” to the six jing in herbal medicine really
is key to using the Saam system.

Shanlarson: June 3, 2019, 9:33pm
I too am finding the SAAM acupuncture really connects and informs my understanding of herbal formulas.
To add to that thinking from a herbal perspective the heat above cold below makes me think of Jue yin formulas
which is interesting because the tx for SJ xs is +Liver Jue yin.

michaelmax: June 4, 2019, 10:48pm

30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
https://forum.qiological.com/t/sometimes-you-have-to-treat-the-gb/230/print10/12
It is interesting @Shanlarson how often the Saam diagnosis has helped me to clarify my herbal Rx. And more
than that… to really get a glimpse of the six jing in action.

Alvaro: July 6, 2019, 6:59pm
michaelmax:
It’s also seen in herbal medicine. When you have ???? alternating heat and cold, which can be another
way to say trouble with temperature regulation. Then you are looking at a shaoyang condition. (xiao chai hu
tang treats this)
Maybe I misunderstood, but I’m having trouble equating XCHT as the herbal equivalent of Liver Suppl to treat SJ
Excess. Based on the herbs in the formula, my limited understanding is that XCHT treats more of a Shao Yang qi
stagnation scenario where the alternating heat cold is secondary to the qi stagnation and not a true excess.
Supplementing Liver to me might look more like a blood building formula…I would think
michaelmax #24July 7, 2019, 3:08pm
Yes, @Alvaro a blood building formula would likely fall more within Liver supplementation.
I’m looking at XCHT as a harmonizing prescription. So it can be seen as adjusting the LV/TB relationship.

Jeffrey: August 20, 2019, 1:25pm
I agree Michael. I would always use XCHT for ANY hot/cold alternating )and even good for confused symptoms
)in the fang jia fang style of formulation, I’d use 15-35% XCHT

adambroder: October 4, 2019, 11:50pm
I just used GB+ to help someone with insomnia (!). I know insomnia is a defining trait of GB excess but I’m
hoping it’s one of those “anything can be anything” sorts of things. I did a pretty thorough intake and the loudest (if
you can call it that) thing in the room was PC excess. Intelligent individual. When asked if he ever gets
angry/irritable/frustrated he says he’s very even keel but when fatigued he can have a short temper and become
irritated. When asked if he ever expresses that irritation he said no. When asked what he likes to do in his spare
time the first thing he said was to read. Says his wife and children would describe him as introverted. I can provide30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
https://forum.qiological.com/t/sometimes-you-have-to-treat-the-gb/230/print11/12
a more thorough writeup if anyone is interested, but this was another case where, as the title of this thread states,
sometimes you have to do GB+.

Jeffrey: October 16, 2019, 12:55pm
@adambroder, how did GB+ work out on this patient?curious

michaelmax: January 17, 2020, 2:12pm
HI @adambroder I’m curious about it too. +GB is a gutsy move, but one of the great things about this system is
we have some pretty helpful clinical parameters to help us in our diagnosis.

adambroder: January 17, 2020, 6:36pm
Following the first tx he had some improvement with the insomnia and seemed pleased with the results however
being PC excess he’s not a very expressive person so I don’t know what it would look like if he wasn’t pleased. I
repeated GB+ and saw him for a third time a week or two later. At that visit it didn’t seem like much had changed.
Based on some back and forth I had with Kristin on this case in another post from this forum, I chose SI+ for the
third tx and I have not seen him since.
I can also share a personal case of a strange and persistent spasm I have in my left shoulder, most likely in the teres
major muscle. I don’t know the cause beyond some minor misalignment in that shoulder. I have no pain but the
spasm is recurring and can be up to a 10/10 on the annoying scale. I suspect there may be a problem at the spinal
level but I don’t know how to confirm that. Until I can find someone I trust to assess me and treat my HTJJ’s I’m
relying on Sa’am to help. I’ve tried all channels except LU, KI, and SP. The only one that’s provided consistent and
lasting results is GB+. This seems strange based on the spasm having a vibrating, aggressive quality. I would think
PC+ or LR+ to be more appropriate, and they have helped a bit and it might be wise to alternate between those and
GB+. But the problem is on the GB channel (among others), and I’m probably a bit PC excess in my personality.
Go figure.

michaelmax: January 19, 2020, 4:43am
adambroder:
But the problem is on the GB channel (among others), and I’m probably a bit PC excess in my personality. Go
figure.30/01/2024, 11:52Sometimes you have to treat the GB – Sa’am Clinical Insights – Qiological Community
https://forum.qiological.com/t/sometimes-you-have-to-treat-the-gb/230/print12/12
As I’ve heard @Tobydaly1 say “sometimes channel, sometimes quality.”
And if some works, then we can take that as useful information to clarify our diagnosis.