ngmatthews: October 4, 2021, 5:15pm
This patient is a 93 year old man, quite athletic. I often find him exercising in the treatment room when I come in.
He is quite thin, really bony, and likes to walk great distances daily if he can, for example 2-3 miles. Since I have
known him, which is over 10 years, he has liked to golf daily if he can. He is a retired dentist and is financially
very well off. I have been seeing him for many years so I don’t have all the details of his case in my head at the
moment.
Most of the time in the past 2 years he has asked for help with anxiety and insomnia. I would say he tends to be
irritable as well, especially towards his wife. It took quite a while, but I got him to admit that what kept him awake
at night were feelings of great shame about some little thing or other that had happened during the day. He would
go over and over something that had happened that he felt guilty about and it would keep him awake. Even during
the day sometimes he would continue to obsess and feel anxiety about it. He was raised in a very repressive home
by a stern mother. He tends to obsess about many things, most of which is his health. He has always exercised
obsessively and takes a great many supplements, many of which he does not seem to understand. His diet is mostly
vegetarian with a little fish and he does most of the cooking in his home, which he shares with his wife. He seems
to have no mental impairment as one would expect with age, and he has a lot of energy. His skin is thin and dry and
paper-thin with many dark patches, as one would expect in a person of this age. Due to the papery quality of his
skin he frequently comes in with bandaids where there has been a wound. His bowel movements are normally
formed and daily. He denies constipation or difficulty passing stool. He frequently has bruising on hands and arms
but denies being on anti-coagulant medication. His insomnia has been very chronic, and acupuncture seems to help
a lot. In Saam I have used Pc supplementation with good success, alternating with Liver supplementation for this.
Interestingly, at one point PC supplementation made him sleep deeply during a treatment, and at a subsequent visit
where I supplemented PC he seemed greatly energized during the treatment and thrashed about in the room while I
was gone. This is key to my story. Like many elderly people, he seems to be cool a lot. Yesterday he came in
wearing sweat pants and a flannel shirt when it was about 65 degrees out. He usually wears a little more clothing
than others, but he is extremely thin and I have assumed that contributes to his difficulty with keeping warm.
His new complaint is urinary frequency and urgency. He has often needed to get up in the middle of a treatment to
urinate, but never asked for help with it. Again, I have assumed that in a 93 year old man an enlarged prostate is
pretty much normal. But now he has come to the realization that getting up to urinate 2-4 times per night is
interfering with his sleep and wants me to help. So yesterday was our first go. Due to the fact that he seems so
worried about so many things, I diagnosed him with Bladder excess, and chose to supplement Heart. I came back
in to the room 5 minutes after beginning and found he had lost two of the needles so I replaced them. The Jing
points, of course. He seemed fine at the time and felt guilty about losing the needles. When I came back 15 minutes
later, he had lost all the needles, even Kidney 10 and Heart 3, which I had buried pretty well. So I asked what had
been going on. The sheets on the table were a mess, and he was pretty rumpled. He said that he could not be still
during the treatment and had been flailing around. This reminded me of another time when I had supplemented PC
a second time for insomnia and he flailed around during the treatment. He needed to urinate urgently so I let him
get up and he headed out. However, he did reschedule for next week.
So, now I am thinking back over the case and see that there may be a heat excess here, which can explain why Pc
and Ht both made him extremely restless during treatment. However, with a cold old man who has frequency and24/01/2024, 12:13Frequent Urination in elderly man – Sa’am Clinical Questions – Qiological Community
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urgency, I did not want to tonify Bladder. He seems so worried all the time and fearful of everything that Bladder
seems the worst choice.
Another choice would be to see him as LI excess because of the fact that he is so skinny and dry. However, he is 93
years old, financially very well off, and has no other signs of that. But I had thought that the containing function of
Lung might be useful here. Hopefully to enable him to contain urine more effectively. His thenar eminences are a
bit thin, just like the rest of him.
I know for sure he is SJ excess because of his obsession with every little thing, but I’m not sure how we can see
supplementing Liver as assisting with urgent/frequent urination, even though the Liver meridian goes to the
genitals and supplies that area.
As for Kidney, his medial heels are dry, just like all the rest of him. He is so old and thin that I could not say he is
symmetrical or attractive at all. In fact, one eyelid droops badly. I assume he was attractive in his youth, but now he
is not. Perhaps with all the easy bruising I see he is really SI excess. That could explain the bad reaction to
warming treatments with the Pc and Ht.
I guess I have not wanted to tonify Ki because it seems like the most obvious short-sighted mistake I could make,
relapsing into the old TCM way of thinking about this and losing track of my Saam vision. I think I also have
hesitated because of his reaction to the Pc and Ht treatments which seemed too warm. I have been looking for
consolidation, however, and it seems like Ki might be just the thing.
Feedback?
KristinWisgirda: October 21, 2019, 4:14pm
Thanks for the case. Are you aware of the suggested case study format?
Case Study Format
Here is a proposal for case a case study format for our forum. I welcome any and all feedback. The goals are to
help you sharpen your Saam diagnostic skills, help your readers see your patient and stimulate conversation
that will helps us grow as Saam practitioners. When presented with the idea of a case study format/intake sheet,
this was Toby’s response: Great idea, basically the Saam diagnosis is interested in everything. I think the Shen
Kuo quote from the lecture is a good starting framew…
The tools therein make it easier to see your patient. Formatting with long paragraphs and so much expository
information are much more tedious to read and harder to develop a clear picture of the patient for you and your
readers.
ngmatthews:
I know for sure he is SJ excess because of his obsession with every little thing, but I’m not sure how we can
see supplementing Liver as assisting with urgent/frequent urination, even though the Liver meridian goes to the
genitals and supplies that area.24/01/2024, 12:13Frequent Urination in elderly man – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/frequent-urination-in-elderly-man/699/print3/9
I have used Liver+ for urinary issues, including frequency. When the bladder sphincter is too tightly held, there can
be frequency. The SJ excess could also explain why he is cold but H+ was too much for him. Could the cold
possibly be because he is too tightly held as well? Liver+ can warm tight patients up, even though it is cooling.
Liver+ and H+ might be a combo for further down the road if you determine he really needs to be warmer. The
Kidney/SI axis could be considered to warm him up too.
ngmatthews:
I could not say he is symmetrical or attractive at all. In fact, one eyelid droops badly.
Clear SI excess.
ngmatthews:
Perhaps with all the easy bruising I see he is really SI excess.
The bruising is blood stasis so more a Kidney excess sign by itself. It wounds like the SI excess is more prominent.
ngmatthews:
Another choice would be to see him as LI excess because of the fact that he is so skinny and dry. However, he
is 93 years old, financially very well off, and has no other signs of that.
Being financially well off is more a Lung excess sign, not LI. His obsessive activity sounds like it could have a LI
excess aspect. And he is so, so, so dry in and out. Consider SP+ definitely. One of my very dry patients came in
with what she thought was a uti- frequent burning urination. One SP+ treatment and all of the urinary symptoms
disappeared.
ngmatthews: October 4, 2021, 5:15pm
Sorry about the formatting issue. I am aware of the suggested format, just being lazy.
These are all helpful suggestions. One of the reasons I presented this case was that it was so difficult to sort and I
was looking for some non-obvious ideas, such as Liver ton and Sp ton for this man. It was interesting to me to see
how tempted I was to work along the Bl-Ht axis due to our usual thinking about urination issues. Or looking for Ki
deficiency, which would be so TCM-ish. I resisted. And the contradictory presentation on the Lu/LI axis when the
person is 90 something and just skinny and dry as so many can be at that age. When we discuss our cases on this
forum we are rarely talking about people in this age range and I was curious about how the factors of aging might
or might not change our diagnostic thinking. It seems that we must ignore the aging as a factor and just stick to our
Saam process.24/01/2024, 12:13Frequent Urination in elderly man – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/frequent-urination-in-elderly-man/699/print4/9
ngmatthews: October 4, 2021, 5:15pm
Of course, I know that financially well off is a Lung sign, but I thought it was interesting since he is so skinny and
dry. Attempting here to show that it can be easy to get “hooked” by one symptom or another. Also slightly
shrunken thenar em. But a 93 year old man. So, again, not clear.
KristinWisgirda: October 22, 2019, 1:33pm
ngmatthews:
One of the reasons I presented this case was that it was so difficult to sort a
It is really helpful to methodically go through all of the channels and see all of the possibilities. This helps frame
the patient outside of other systems that you are used to using. It sounds like he could benefit from any of the 12
channels at some point, except for LI+.
ngmatthews:
It seems that we must ignore the aging as a factor and just stick to our Saam process.
This sounds right but in general it is common to need to toggle between SI and K with the elderly. This patient is
no exception.
Toby has mentioned that he rarely supplements K at the first visit, preferring to clean up other areas first.
ngmatthews: October 4, 2021, 5:15pm
Since I’ve been seeing this man for 10 years or so, I would not be treating Ki at the first visit. We’ve been doing
Saam with him for about a year now. I like the idea of toggling between SI and Ki.
One other comment is that when the person has a symptom that is really bothersome and does not get the results
they are hoping for from a session or two of Saam, it is challenging to manage their expectations and help them
stick with us as we work toward improvement of symptoms. I am having to work hard to help people understand
the process nowadays so they can attend long enough to get what they are seeking. Always a challenge.
ngmatthews: October 4, 2021, 5:15pm
Saw this man again this afternoon. He is still getting up 3-4 x nightly to pee. I decided to try to supplement SI… I
left him in the room and he called to me 5 minutes later. He was writhing around as before. So I switched to the24/01/2024, 12:13Frequent Urination in elderly man – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/frequent-urination-in-elderly-man/699/print5/9
opposite pattern: Ki supplementation. Left the room and again 5 min later he was writhing around. He was
unhappy. So I decided to abandon Saam and do some old fashioned stuff to calm him down, including a bunch of
scalp and ear needles to do that. This is my usual elixer to make people very sleepy. It did not work. He was raising
up his pelvis alternating with kicking either leg and waving his arms when I came in 5 minutes later. He was
unhappy that he was not sleeping deeply during the treatment as he had at prior sessions.
I decided to do some questioning. It turns out that he is very angry because they have just moved to a new senior
living facility and the move, and the process of emptying and selling their condo has got him off his routine. He
usually works out at the gym 5 days a week, plays bridge 2-3x weekly, and has his routine. He had lived in his
prior home for 11 years. He admitted to being angry and irritated by the whole thing. He, at 93, is having to take
more care of his 90 year old wife who is having some dementia now. He is angry…
So, I have determined that all the writhing and kicking during the treatment is his anger, and probably what is best
for him now is PC, even though his personal goal is fewer trips to the bathroom at night. He is still covered with
bruises, skinny, dry, thin skinned and asymmetrical, but he is angry. I was afraid he would leave care, but he has
scheduled for 3 weeks out, and hopefully I can do him some good at that point.
I posted this case originally because I thought it brought up a lot of interesting questions. I’m putting in this last
entry again because it was so interesting.
michaelmax: November 19, 2019, 12:01am
Hey @ngmatthews, thanks for the update here.
Such a good point that there are things our patients tell us they want, and then there is what is actually happening
that we might not know about.
I’ve got a patient on the table now. Common garden variety shoulder pain on the right (LI channel) and she is damp
af. Dry on the outside too.
So pop in right +ST and left +SI. Then I notice her face has gone purple red and when I go to feel for the yang
rhythm she is objectively shaking. Opps…
Long story short… she tells me that is ANXIOUS. she’s always ANXIOUS. Oh…now it’s clear that anxiety is the
elephant in the room
I do a partial LV tonification, and tonify LI on the left. Shaking settles down. Shoulder pain… gone.
Note to self… double check for san jiao excess, she did have shiny eyes. And she might need some shielding
before we dig into the dampness.
adambroder: November 23, 2019, 8:45pm
ngmatthews:
That could explain the bad reaction to warming treatments with the Pc and Ht.24/01/2024, 12:13Frequent Urination in elderly man – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/frequent-urination-in-elderly-man/699/print6/9
It has been my understanding that PC is cooling, as a counter to the heat from GB. Could someone please clarify?
KristinWisgirda: November 24, 2019, 3:31pm
Toby ran through the cold-heat spectrum in a class. This was fully discussed in this thread
Degrees of heat and moisture
In the discussion time between clinical observation in Tuscon, we went through the channels in terms of heat. I
find this useful in clinic so thought I would share. (Kristen or anyone else who was there, please correct me if
I’m wrong). They were: HOTTEST Heart (double fire) San Jiao (bright warmth) Spleen (warm swamp –
dampness can contain heat) Gall Bladder Lung and Stomach > both neutral. Toby’s teacher wouldn’t commit to
their temperatures Pericardium (slight cool breeze) Large Inte…
P/GB aren’t really about warming or cooling but if you have to put them on the spectrum, Gb is warmer than
neutral, but doesn’t really warm. P is cooler than neutral but not really cooling. When Toby was asked if P was too
cooling for someone who was really cold, T specifically said “No” for the reasons discussed above.
ngmatthews: October 4, 2021, 5:15pm
I am sorry about the confusion. I had posted that comment before seeing the continuum of heat. Of course, now I
know that Pc is not cooling. However, since it is a fire element, it is certainly not very cold.
michaelmax: November 26, 2019, 6:56am
ngmatthews:
Of course, now I know that Pc is not cooling. However, since it is a fire element, it is certainly not very cold.
Good point @ngmatthews about the PC being a fire organ. And this is not “Saam” per say, but I do tend to think
of it as having a cooling/calming influence on the outward energy of the Gall Bladder.
Excess PC types seem levelheaded and collected. They use their intelligence more than their fire. Really excessive
PC would perhaps be a bit dissociated from their feelings as they prefer the intellect.
In the people I’ve tonified GB (by definition an excessive PC type) they tend to be caring of others and are
constantly trying to figure out how to manage or control others by creating certain kinds of situation. Unlike the
GB excess that just blast down the walls.
For me, getting to better understand the PC type is by looking at when I tonify the GB, and kind of reverse
engineer.24/01/2024, 12:13Frequent Urination in elderly man – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/frequent-urination-in-elderly-man/699/print7/9
Again, this is my rambling and clinical observation, and working on sorting out the “personality” of various types.
KristinWisgirda #13November 26, 2019, 3:29pm
michaelmax:
For me, getting to better understand the PC type is by looking at when I tonify the GB, and kind of reverse
engineer.
As we try to understand Saam better, I can totally understand the temptation to reverse engineer by looking at the
qualities of the people who get helped by certain treatments. BUT, because patients’ mixed presentations muddle
the usefulness of this approach.
michaelmax:
n the people I’ve tonified GB (by definition an excessive PC type) they tend to be caring of others and are
constantly trying to figure out how to manage or control others
Desire to manage and control others is a SJ excess quality. Caring for others can be SI or Heart excess. Instead,
repeated returning to the basic teaching is more useful. P excess is a rule follower, intellectual, moves slowly and
deliberately, avoids physically asserting themselves. If they are so P excess that they can’t take a stand for
themselves, can’t assert themselves, or are so stuck in their heads that they can’t act righteously, Gb+ is the way to
go.
michaelmax: November 30, 2019, 4:28pm
KristinWisgirda:
As we try to understand Saam better, I can totally understand the temptation to reverse engineer by looking at
the qualities of the people who get helped by certain treatments. BUT, because patients’ mixed presentations
muddle the usefulness of this approach.
I disagree @KristinWisgirda, and at the same time your point about people do have mixed presentations most
assuredly adds to the dilemma. That said, because the counter-balances between organs is something that we can
rely on in terms of know too of something on one side means there must be a deficiency on the other. The this
reverse engineering is one way to work out some nuance.
Again, we can not rely on it alone, but the counter-balances are a reliable dynamic that can help to guide our
inquiry.
After all… clinic is hard! 24/01/2024, 12:13Frequent Urination in elderly man – Sa’am Clinical Questions – Qiological Community
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Daniel #15November 30, 2019, 7:31pm
I’d suggest that ultimately . . . . “PC Excess” or “San Jiao Excess”(etc etc etc) are whole phenomena that words,
symptoms, signs can only very imperfectly describe, translate, communicate, teach us about . . . . at some point,
presumably, if we diligently cultivate our clinical selves within this system, we approach a clinical point of just
seeing the pairs, the channels as phenomena in and of themselves and all the gymnastics of collating, correlating,
engineering, reverse engineering, toggling, nuancing fade away as games we played on our way up the mountain . .
.
michaelmax: November 30, 2019, 7:42pm
Indeed @Daniel!
One mountain, many methods.
And one of the beautiful experiences for me in allowing myself to engage with the perspective offered to us with
Saam, is that the principles and practices help me to learn more clearly from my clinical experience.
And not just my clinical experience. But the sensibility of how the 5 and 6 intertwine. How my attention has
become both more focused and yet broader and inclusive. There is a play of complimentary opposites that helps me
to better see the “coin” as well as the sides.
KristinWisgirda: December 1, 2019, 4:37pm
Daniel:
if we diligently cultivate our clinical selves within this system,
This to me means frequently checking the way we organize our understanding against the basic teachings presented
in the intro course. Toby himself is careful abut distinguishing between the jewels his teacher gave him and the
rocks that he has come up with. We would be wise to acknowledge our kindergarten status and do the same.
Daniel: December 2, 2019, 10:35pm
I agree with your sentiments entirely.24/01/2024, 12:13Frequent Urination in elderly man – Sa’am Clinical Questions – Qiological Community
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