dcantor: May 25, 2019, 2:10am
Patient is a 38 yo female who has been seeing me since December and has responded beautifully to Sa’am
treatments over the last several months. When she first came in she complained of deep aching pain in her lower
abdomen, inguinal area and thighs, shooting nerve pain down her legs, intermittent numbness in R hip and face,
and had episodes of itching/burning in her R side face, flank, and both arms. She was dxed with post-herpetic
neuralgia after a shingles outbreak, adenomyosis and endometriosis for which she’s had multiple surgeries and a
hysterectomy, interstitial cystitis, and a severe case of lichen sclerosis.
She ran super hot, said she gets flu-like sx with too much sun exposure, tends toward constipation with hard dry
stools and sometimes several days between BMs, had regular night sweats from the groin down and the neck up
and sweat easily during the day as well. Extremely polite, very giving/motherly energy, tends toward over-giving
or tending to others at her own energetic expense, bright eyes and energy, though also gets depressed particularly in
PNW climate. She has a larger, puffy body and dry skin.
Pulse is “big” but diffuse with reduced substance.
Early on, the channels I most often used were BL+ and SI+ and she responded fantastically. For several months she
has had virtually no deep aching pain and no nerve-pain. She was able to get off Gabapentin completely, which she
was taking nightly before. Night sweats were also minimized and constipation improved to the point of daily BMs
and normal soft stools most of the time. I’ve also had her on a Gui Zhi Fu Ling Wan – Ma Zi Ren Wan modified
formula, which has been a good fit.
I’ve also done a lot of Lv+, Pc+, and ST+. Interestingly BL+ was the most successful for the deep aching pain in
the beginning and for her constipation.
In the last couple weeks she has had a flare-up of various sx, and I’ll share my txs:
About 10 days ago she presented with a return of deep achey pain in her groin and anterior thighs – it had come on
a few days before and was the first intense muscle pain she had experienced in a long while. She had had a very
busy weekend with family, was outside in the sun a lot, and physically and emotionally over-extended. I chose R)
BL+, but after I placed the needles, she scrunched up her face and said that her thighs and groin felt better but her
low back hurt (which had never occurred on the table before). I removed the needles and supplemented Ht on the
opposite side, which immediately relieved the back pain. I added R) Lv8+ and Ki10+ so as not to over-heat. She
left feeling good and pain-free.
At her next visit, she reported that her back pain had resolved and she had not had any deep aching pain in her
lower abdomen or thighs. However, she had been experiencing numbness on the R side of her face, primarily chin,
lower lip and forehead as well as intense itching at her cubital fossas and her arms. No neuropathy in her groin or
legs. Also significant night sweats at chest, head, and neck, deeply fatigued and she was concerned that her lichen
sclerosis was returning.
Among all her complaints, she said itching and numbness were of greatest concern to her.
I considered Lv, SI, and ST and ultimately chose R) SI+ and L) ST+ with ST 36 subbed for ST 41. The itching
resolved on the table and numbness was significantly better.26/01/2024, 12:11Pain, Itching, & Numbness, oh my – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/pain-itching-numbness-oh-my/257/print2/5
At her next visit, she reported that the itching of her arms was 90% gone, though she was experiencing some
itching at groin and torso, and some lingering itching and numbness at chin. Both itching and numbness worse on
the right side with itching more significant than numbness. Lichen sclerosis was way better and had not been
bothering her(!), and sweating at night had improved. However, digestion was slower and stools were harder.
I decided to repeat the previous treatment one more time with the hope of fully resolving the itching and numbness
that had improved so much after the last tx, though with SI+ on the L since itching on the R was her most
bothersome complaint.
Patient felt much better on the table and stated that she was feeling no itching or numbness when I removed the
needles.
Finally, today she presented with basically all complaints flared up again. Itching of right side face, arms, torso,
aching in R thigh, night and day sweats from neck up though doesn’t feel especially hot, hard dry stools, and
complained of low mood though also lots of obsessive thinking/rumination about the struggles her family members
are having.
This time, I decided to do R) Lv+
When I came back in the room she felt more settled emotionally and itching was gone, but she complained of
aching in her R eye and at the top of her head.
I added L) SI+
Came back in the room and she looked super peaceful and at ease and reported that at that time she was pain and
itch-free. We’ll see where she’s at next week…
SO. It’s been an interesting run, and has brought up the following questions:
1. What are some possible reasons why BL+ was not a good fit at her visit 10 days ago?
In considering this, I’ve suspected there was some anxiety/fear in some of her family interactions that
weekend that might have created a relative excess in BL, though there was definitely still a lot of heat, and a
social/emotional frenzy of energy I associated with Ht Excess.
I’ve also thought that I could have mistaken SJ excess for Ht excess and should have supplemented Lv from
the get go. I can see how the excess outward energetic focus and the potential Yin and fluid deficiency from
sun and heat could have been primary, but am still confused by how BL+ was received (helped her leg pain
but caused back pain) especially given its positive impact in the past.
2. In true cases of Ht Heat/Excess, if BL+ is not appropriate (due to excess fear, etc), can Ki+ be used in
certain situations to anchor ShaoYin Fire as one might do herbally, even given the warmth of Ki?
If not, is Lv+ the next best option as it at least cools and moistens?
3. Given that this patient has clear internal damp and external dryness, suffers from these episodes of
numbness, but also has constipation with hard dry stools, what is the best way of drying Damp and not
exacerbating her constipation? My plan was the two treatments of ST+ and SI+ and then switch to
moistening/cooling Lv, which she seemed to tolerate well despite a little exacerbation of constipation…but
curious what others think.
Thanks!
KristinWisgirda: May 27, 2019, 5:00pm
26/01/2024, 12:11Pain, Itching, & Numbness, oh my – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/pain-itching-numbness-oh-my/257/print3/5
Wow! Sounds like you have been doing a great job dancing with her myriad complexities. One note that is even
though she has responded well to you treating 2 sides at times, you will deepen your understanding of the system
by just treating 1 channel at a time. In my experience, my good results got even better when I limited treatments to
one side. Results of 1 sided treatments also gives clearer insight into the pathodynamics.
dcantor:
What are some possible reasons why BL+ was not a good fit at her visit 10 days ago?
I agree that the shielding of a Liv+ might have been more suitable. Not sure why the UB+ treatment was
aggravating to her back except that the ice cold water of UB could cause stagnation. Anyway, her body was saying-
enough UB.Differentiating the indications for the shielding of the Liver versus the cold water of the UB is an area
for lots of contemplation and observation. It might have been interesting to figure out if the back pain she
experienced on the table had a center point corresponding to a back shu level.
dcantor:
In true cases of Ht Heat/Excess, if BL+ is not appropriate (due to excess fear, etc), can Ki+ be used in certain
situations to anchor ShaoYin Fire as one might do herbally, even given the warmth of Ki?
If not, is Lv+ the next best option as it at least cools and moistens?
Toby has repeated that if he unsure if a patient can handle the full on ice water of a UB+ treatment, he will start
with a Liv+ treatment and see how they respond. At least this is how he is teaching it to us kindergarten
Sa’amsters. I suspect he has more sophisticated strategies.
dcantor:
Given that this patient has clear internal damp and external dryness, suffers from these episodes of numbness,
but also has constipation with hard dry stools, what is the best way of drying Damp and not exacerbating her
constipation?
How much internal damp does this patient have given her the chronic hard dry stools? With chronic hard dry stools
that sounds like requires ongoing management with a strongly moistening formula (ma zi ren wan), you should
consider supplementing Spleen at some point. I wrote up a case of chronic hard dry constipation in an overweight
woman where supplementing Spleen improved her bowels like no other acupuncture or herbal treatment. I did
make the mistake of doing it twice.
A case of constipation and supplementing Spleen
It is easy to think of supplementing Spleen in patients with the classic LI excess morphology- dry inside and
out. A couple of patients have shown me that overweight patients can at times benefit from the moistening milk
of Mama Spleen- cautiously. One obese patient with severe dry mouth from Sjogren’s (causing rapid weight
loss) felt fluids return to her mouth during a Spleen+ treatment. Here’s another case: A 51 year old woman
moderately overweight and with mildly dry skin. She has a history …26/01/2024, 12:11Pain, Itching, & Numbness, oh my – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/pain-itching-numbness-oh-my/257/print4/5
I’ll have to write a follow up to this case, because many other nagging symptoms improved after the Sp+ treatment,
as well. It might be interesting to see if improving your patient’s bowels at a different level makes her less
susceptible to overheating.
Since this patient is so intolerant of heat, I wonder how much of the damp is the body’s attempt to shield or protect
itself.
Thanks for the lengthy write up. Please let us know what happens.
dcantor: May 28, 2019, 4:32pm
KristinWisgirda:
Results of 1 sided treatments also gives clearer insight into the pathodynamics.
Hi Kristin. The majority of my treatments are one channel/one side, including the channels I mentioned using over
several months on this patient. I may combine once I have a good sense of how someone responds to two
individual channels and if I feel the effect will be more therapeutic for that person.
I began learning this system when Toby was a bit more relaxed with suggesting two channel treatments, before
teaching the larger classes. I have taken to heart the wisdom of getting to know channel qualities through treating
them individually, but also can’t unlearn things, especially when they work well for me in clinic. In this case, I am
interested in better understanding these four particular treatments, and can speak to this patient’s typical response
to the individual channels mentioned if it would be helpful.
dcantor: May 28, 2019, 4:32pm
KristinWisgirda:
It might have been interesting to figure out if the back pain she experienced on the table had a center point
corresponding to a back shu level.
Good suggestion – I rarely think to do that.
dcantor: May 28, 2019, 4:33pm
KristinWisgirda:
Toby has repeated that if he unsure if a patient can handle the full on ice water of a UB+ treatment, he will start
with a Liv+ treatment and see how they respond.26/01/2024, 12:11Pain, Itching, & Numbness, oh my – Sa’am Clinical Questions – Qiological Community
https://forum.qiological.com/t/pain-itching-numbness-oh-my/257/print5/5
Lv+ has been a well-received treatment for this patient, and I actually feel SJ Excess is her most significant
imbalance. However, Lv doesn’t always address her presenting sx, and in the case of her last treatment, resulted in
some localized discomfort in Liver-related areas. This is why I began wondering about the Ht-Ki dynamic with her
as another way of working with the Ht.
dcantor: May 28, 2019, 4:40pm
KristinWisgirda:
How much internal damp does this patient have given her the chronic hard dry stools? With chronic hard dry
stools that sounds like requires ongoing management with a strongly moistening formula (ma zi ren wan), you
should consider supplementing Spleen at some point.
The channel this patient has best responded to in terms of her constipation is BL+. I took this to mean that Heat is
primary in causing her hard, dry stools and infrequent BMs.
Numbness is a significant sx for this patient, and Toby has stated that numbness in the Sa’am system is understood
as Dampness occluding feeling – indeed, ST+ has been helpful for the numb sensation. That alone would make me
very hesitant to supplement Sp. In addition, she has other Damp indicators including but not limited to a slippery
pulse in the R middle, pelvis-lower body and special Lung positions, cyst formation in her ovaries, and occasional
swelling in the lower legs.
KristinWisgirda: May 28, 2019, 4:57pm
dcantor:
I have taken to heart the wisdom of getting to know channel qualities through treating them individually,
Obviously! I’ve enjoyed your thoughtful discussion of this case.
Part of my job as forum moderator is to remind readers and writers of all levels how Toby recommends engaging
this system as we are learning.