rebeccajillparker: November 18, 2019, 2:20pm
77 year old man
Chief complaint: Poor balance began around 8 years ago caused by shuffling gait from normal pressure
hydrocephalus (an excess of fluid in the brain causing problems with the nerves sending messages to the legs).
Discontinued treatment (removal of CSF from spine) due to fear of med students making a mistake with lumbar
puncture. Refused stent procedure due to fear of stroke. (Has history of pulmonary embolism 2x in last 7 years).
Fear of falling down due to balance issues. Walks with 2 canes or a walker, difficulty picking up legs.
Secondary complaint: Intermittent R hip pain 4/10 worse at night contributing to poor sleep worse with inactivity,
better with movement.
Appearance and demeanor: Good bone symmetry, strong jaw, stooped posture that causes head to go forward and
eyes to look up. Polite +6, good sense of humor, likes to talk about history at length, very intelligent +7. Gets
irritable at wife +4. Eyes dull +1. Owns several properties.
Lifestyle: Retired. Lives with wife, daughter, son-in-law and 2 granddaughters. Cared for by the family. Does not
get out much, difficulty exercising due to poor balance. I treat him in his home, which is full of books and
newspapers.
Body Morphology and Flesh Quality: Large bones +5, average weight with more around middle +3. Droopy flesh
on upper body +5 and face with pitting edema and swelling in legs +7.
Skin Quality: Dark skin on feet and ankles +5. Dry flaky skin +7. Red itchy skin on L side of face +3
Body Temp: Runs warm +2
GI: Constipation managed by prune juice +2
Sleep: 2 hours at a time, awakened by pain or need to urinate. 4-5 hours total. +6
Emotions: Fear +6 Irritability (only with wife) +4 Appears easy going and jovial despite his difficulties, likes to
make jokes often at his own expense.
Urination: Frequent +7 Urgent +7 (effect of hydrocephalus and enlarged prostate)
Other body: occasional broken blood vessels in eyes due to warfarin. High blood pressure managed by medication.
Tongue: pale red, little coat, average size and shape, smooth.
Excess presentations:
Heart: runs warm +2
UB: fear +6 incontinence +7 low back pain24/01/2024, 11:52Normal Pressure Hydrocephalus Case Study – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/normal-pressure-hydrocephalus-case-study/744/print2/6
GB: irritable at wife +4 poor sleep
P: intelligent, surrounded by books and newspapers +7 slow deliberate movements, concave posture (?)
SJ: jokes at expense of self, red skin on face, controlling of wife
LV: Dull eyes +1
LU: dry skin, accumulation of fluid inside (edema, hydrocyphalus) +7
ST: none
LI: none
SP: constipation +2 ?
SI: none
K: pain, blood stasis, itchy face, good bone structure, damp accumulation +7
The grossest things in the room: dry outside/wet inside (very dry skin and swelling in legs), pain
Main treatment ideas: +ST on L +SI on L
Other treatment ideas +HT on L
Treatment 1: +ST on L no change except a headache similar to the type he experienced with the removal of CNF
fluid after the treatment. Patient expressed fear about meddling with the fluid in the brain
Treatment 2: +SI on L pain reduced the day after the treatment, then returned. Otherwise no change.
Treatment 3: +HT on L patient reports no change, though he slept more deeply during this treatment than previous
ones.
Notes: I used the biggest needles I have, DBC 25×30 s. Maybe these aren t big enough?
KristinWisgirda: November 27, 2019, 10:03am
Thanks for a rewrite of the case. I know it takes lots of time and effort. Here are some things to consider.
rebeccajillparker:
Heart: runs warm +2
UB: fear +6 incontinence +7 low back pain
At what back shu level is the low back pain? If it is a large area, palpation for tender spots can often be really
helpful. You correlate the pain (or pressure pain) with the channel related to the back shu AND its counterbalancer.
For instance, if it is at the level of UB23- that makes you consider Kidney or SI excess.24/01/2024, 11:52Normal Pressure Hydrocephalus Case Study – Sa’am Clinical Questions – Qiological Community
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The difficulty lifting his legs is a hypofunction consistent with UB excess. Not surprising that he settled in deeply
with H+ treatment.
Also with the hip pain, what channels are involved?
rebeccajillparker:
SI: none
K: pain, blood stasis, itchy face, good bone structure, damp accumulation +7
For possible SI excess, you can put incontinence and poor balance. In SI excess (relative Kidney deficiency) the
patient has a hard time holding themselves together. The stooped gait besides being P excess concavity, can also be
a collapse consistent with SI excess. He has a K/SI mixed excess and likely you will need to toggle. I recently had
a patient 2 weeks postpartum complaining of being wobbly with poor control of her legs. One Kidney+ treatment
and her legs became sturdy again so she could carry her baby with confidence.
In Saam, the primary treatments for dampness are LI+, ST+, Lung+. As well you can consider SI+, when you need
more dynamic movement to process damp, and H+ when there is significant cold or yang xu and you need double
fire to steam it away. For pitting edema, Heart + in particular is important. (Just confirmed this one with Toby).
In rare cases, with strong SI excess signs, when other methods haven t given good results, you can consider K+ for
a Shaoyin kind of damp like pitting edema. With K+, there is a risk of consolidating stickly fluids/phlegm too
much so you really need to use it cautiously.
Hydrocephalus is clearly internal damp- so the diagnosis can be Spleen excess or Lung excess. The location of the
edema is in the brain/sea of marrow so the channels potentially involved are UB, and counterbalancer H, and K,
and counterbalancer SI.
Edema can be internal or external damp. Toby s teacher never gave a dividing line between internal and external.
Diagnoses include Spleen excess, Lung excess, Stomach excess. Kidney excess because there are blood stasis signs
in the area (dark skin). And UB excess because it is pitting.
Even though the skin is so very dry, sometimes there is a mix of damp/dry in the interior or exterior. I had a patient
with super dry skin, lots of edema and a large open non-healing sore on her leg. Once treatment of Lung+ closed
up the sore in a day. She was amazed.
Just to be a nit picker :), you can put polite 6+ under SJ excess. Accounting for all the signs and symptoms under
the channels can help you see your patient better.
rebeccajillparker:
I used the biggest needles I have, DBC 25×30 s. Maybe these aren t big enough?
Needle size, diameter and length, make a huge difference. Use a 40-50mm needle on points like H3/P3, K10,
Gb41-42, Liv8, ST43, etc. Get .35-.40 mm diameter needles. Using smaller needles, you will always have reason
to second guess your treatment results.
You know for sure that ST+ is not the right way forward. He is complicated and despite some Kidney excess, he is
not that hearty right now. Get bigger needles, observe him closely, take good notes, and expect slow miracles.24/01/2024, 11:52Normal Pressure Hydrocephalus Case Study – Sa’am Clinical Questions – Qiological Community
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rebeccajillparker: November 25, 2019, 7:08pm
Thank you Kristin for this incredibly helpful response. This clarifies a lot. I so appreciate your time!
KristinWisgirda: November 27, 2019, 12:27pm
You re welcome @rebeccajillparker. Learning a whole new system is a big undertaking.
I do need to correct what I have wrote in the previous post. I have edited it above but will copy it here.
KristinWisgirda:
Putting damp accumulation +7, presumably meaning edema and hydrocephalus, under Kidney excess is ok, but
you should also put it under SI excess and SP excess.
This is incomplete, incorrect in some ways, and just plain sloppy. Sorry for not doing a better job the first time.
In Saam, the primary treatments for dampness are LI+, ST+, Lung+. As well you can consider SI+, when you need
more dynamic movement to process damp, and H+ when there is significant cold or yang xu and you need double
fire to steam it away. For pitting edema, Heart + in particular is important. (Just confirmed this one with Toby).
In rare cases, with strong SI excess signs, when other methods haven t given good results, you can consider K+ for
a Shaoyin kind of damp like pitting edema. With K+, there is a risk of consolidating stickly fluids/phlegm too
much so you really need to use it cautiously.
Hydrocephalus is clearly internal damp- so the diagnosis can be Spleen excess or Lung excess. The location of the
edema is in the brain/sea of marrow so the channels potentially involved are UB, and counterbalancer H, and K,
and counterbalancer SI.
Edema can be internal or external damp. Toby s teacher never gave a dividing line between internal and external.
Diagnoses include Spleen excess, Lung excess, Stomach excess. Kidney excess because there are blood stasis signs
in the area (dark skin). And UB excess because it is pitting.
Another piece that I failed to address was
rebeccajillparker:
LI: none
SP: constipation +2 ?
Constipation seems like the least of his problems but I just want to help you clarify Saam thinking: Constipation is
very unlikely to be caused by double damp Spleen excess. All we know about constipation for sure is that stool
isn t coming out. That it is helped by moistening prunes means that there is some dryness in the intestine. Internal24/01/2024, 11:52Normal Pressure Hydrocephalus Case Study – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/normal-pressure-hydrocephalus-case-study/744/print5/6
dryness can be from LI excess or St excess. Stool not going down can be treated by ST+. If constipation is worse
with stress or from the patient holding himself too tightly, consider Liver+ as a treatment.
rebeccajillparker: December 23, 2019, 2:46pm
Update on this case with some very interesting results:
The week after the +HT treatment, it seemed like there was less swelling in the legs.
Then I did the following 3 treatments:
+K patient reported improved pain, dry skin on the face better
+HT no change
+SI no change, patient did not seem to rest as deeply during this treatment.
Then I did +K again. This was possibly a mistake because when I saw him the following week he reported that he
had blood taken the day after as per routine every two weeks to monitor his warfarin dose. The doctor called later,
alarmed, asking if he had stopped taking the medication or changed his diet in some way. The patient said it s
possible he could have forgotten some doses, as the various medicines he takes all look the same and the dosages
change from time to time, but that he doesn t usually forget and it would be unlike him. No change in diet. His
dose of warfarin was temporarily increased and blood to be monitored more frequently.
Could this thickening of the blood be a result of a +K treatment? I m curious if others have seen results that
suggest this could be the case. This possibility is very sobering, as it means getting it wrong is more dangerous than
I realized.
KristinWisgirda: December 24, 2019, 9:39pm
Thanks for the update on this interesting case @rebeccajillparker.
rebeccajillparker:
Could this thickening of the blood be a result of a +K treatment?
Yes. Saam 101 says that K excess signs include blood stasis.
Mistakes are how we learn. Good to look back and see that this fellow had some significant K excess signs- good
bone structure and blood stasis. That by itself is reason not to repeat K+ twice in a row or without toggling SI+ and
watching signs and symptoms very, very closely.
It is so tempting to repeat what seems like a successful treatment. For many, many patients, it really is better not to,
unless the overall presentation shouts that repeating is really the way to go. And even then- be cautious with
patients who are more deficient overall. They are much more susceptible to being pushed too far off center when
pushed in 1 direction more than once.
In your case, it seems like the strength of his K excess constitution was the problem.24/01/2024, 11:52Normal Pressure Hydrocephalus Case Study – Sa’am Clinical Questions – Qiological Community
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naniec: February 11, 2020, 4:02pm
KristinWisgirda:
The difficulty lifting his legs is a hypofunction consistent with UB excess.
Hi Kristin,
I m curious about this statement. Is this based solely on the channel pathway? Or am I missing something else? I m
asking bc this patient sounds a lot like my mother. You may remember her. She was a patient at the Tucson Saam
class. Her unstable gate and difficulty to start walking are her main complaints. She does have other issues but her
ability to get around is what she bases her quality of life on. Overall she is doing much better since using Saam
with her. I am mostly toggling btwn SI, Lv, Sp & Lu with her. Sometimes using UB, Ht, P and even St & GB. I
think I may have used all channels with the exception of LI. This case has been a good reminder of many details.
Thank you so much for all your work and time on this site.
KristinWisgirda: February 11, 2020, 5:19pm
Hi Nanie,
Nice to see you on the forum. Of course, I remember you and your spirited mom.
The reasoning behind difficulty lifting legs suggesting a UB excess is not because of channel location but instead
because of quality. A hallmark of UB excess is hypofunction, things moving too slowly or not all all. UB excess
cold freezes function. This may bee seen as weakness or immobility- post-stroke or otherwise. Sometimes this
hypofunction can be seen where substances aren t being held- as in Toby s case of the young woman with
prolonged bleeding after abortions. Her body was cold. Toby successfully treated her with H+ and Liver +(because
of the extreme blood loss).
In contrast Heart excess presents hyperfunction because fire/heat makes things move- lots of talking, rapid
movement, agitation.
Of course, you have to consider the overall picture. And use H+ and UB+ cautiously as they are double fire and
double cold. Winter is a safer time to use H+ and summeris a safer time to use UB+ if the patient s constitution
isn t a perfect match.