To view Issue 51 of the WATCVM Newsletter in its entirety, please click here.

Lead Article
Why We All Should Be Using TCVM and Integrative Food Therapy
Margaret Fowler DVM, CTCVMP, MSTCVM

WATCVM Updates

• BOD Meeting
• 2023 New Member Benefits
• Conference Awardees
• TCVM Around the World 

Case Reports
Integrative Treatment of Urinary Bladder Atonia in a Miniature Pony
Breanthony Humphrey DVM

TCVM for Epilepsy and IVDD in a Dog
Grace Shelley Flynn DVM

Sponsors and 2023 TCVM Webinars

Moxibustion for Cold Colic in an Appaloosa Gelding

Emily Mangan, DVM, CTCVMP, CCRV, CVMMP

The Magic of Moxibustion

December is here and as the winter rolls in (at least in the Northern hemisphere), it brings with it the cold and the damp and it makes me think of one thing: how much I really love moxibustion.

Moxibustion is a wonderful tool that seems to be underutilized in the West. Moxa is considered a topical herb, and consists of dried mugwort (Artemisia siensis or vulgaris) that is ground into a powder and used as is or is formed into cones or sticks. The moxa is then burned above the skin or on top of an acupuncture needle where the warmth and herbal effects are absorbed transdermally. Moxa promotes the circulation of Qi and Blood, relieves Stagnation and pain, and reduces swelling. In horses, it is commonly used for musculoskeletal pain as well as for stocking up in the distal limbs. In geographical regions that see freezing temperatures, the warmth of moxibustion is a welcome addition for both the patient and the practitioner. It can be used to stimulate acupuncture points and channels and warm the body to dispel Cold, and is especially useful for stimulation of abdominal points. Speaking of which, let’s talk about Cold Colic.

What is Cold Colic?

TCVM Etiology and Pathology

In TCVM, the direct cause of colic is simply Qi/Blood Stagnation in the abdomen, which may result from one of five common Patterns: Cold, Damp-Heat, Qi Stagnation, Food Stagnation, and Obstruction. Cold Colic results with invasion of exogenous pathogenic Cold via cold food, water, environment, and weather, and is therefore most common in the winter months and in areas of the world with severe cold weather. Animals with deficient Qi or Yang, geriatrics, and those with comorbidities are more susceptible to invasion of Cold. Cold causes contraction, and when Cold invades the stomach, it causes Stagnation and pain which result in colic signs.

Clinical Signs

Clinical signs of Cold Colic include acute onset of colic or intermittent abdominal pain with classic colic signs (repeatedly lying down and standing up, pawing, kicking or biting at the abdomen, looking at the flank, or rolling).

TCVM Examination

The tongue is typically pale or purple, and the pulse is slow and deep. The ears and body may feel cold, especially over the back and abdomen.

Treatment Prinicples

Treatment principles are to warm the middle Jiao, dispel the Cold, promote Qi flow, and move Stagnation to stop pain.

A Case of Cold Colic

History

Zippy, a 26-year-old Appaloosa gelding, presented for acute onset of colic signs at the 6pm feeding. Zippy had eaten his breakfast and lunch normally, and upon coming in from pasture for dinner, took one bite of hay, lost his appetite, and displayed a flehmen response. He moved to the far side of his stall where he repeatedly watched his flanks and shifted his weight.

Zippy had history of two previous episodes of spasmodic colic, 14 years and 12 years ago respectively, that resolved with conventional medical management. He had a history of a good appetite, intermittent fecal water in the summertime, chronic right hindlimb lameness, and chronic recurrent airway obstruction. His diet consisted of a mix of valley and orchard grass hays, free access to pasture, a ration balancer, and flax oil. The whether had been colder than expected for the region with recent and unexpected snowfall. He had 24/7 access to the barn and heated water supply.

Zippy had historical diagnoses of Lung Yin Deficiency, Kidney Qi Deficiency, and Bony Bi Syndrome, managed with herbal medicine and acupuncture.

Examination

The gelding was a Wood/Metal constitution, as evidenced by a history of aloofness, desire for routine, tidy stall, and very strong opinions. His ears and back were cold to the touch, his tongue was pale purple and wet, and his pulses were slow and deep bilaterally. His temperature was 99.8 °F (37.7 °C), his respiratory rate was 12 breathes per minute, and his heart rate was 28 beats per minute. He displayed abdominal tucking, intermittent flehmen response, and intermittent flank watching. He had increased borborygmi in all quadrants. As his body felt cold, especially around the middle Jiao, his tongue was purple, and his pulses were slow and deep, as well as history of recent onset of cold weather, he was diagnosed with Cold Colic.

TCVM Treatment

Treatment principles were to warm his middle Jiao, dispel Cold, and move Qi, and relieve Stagnation. The gelding received acupuncture at Bai-hui, GV-4, Jiang-ya, BL-20, BL-21, ST-36, ST-37, and SP-4, with electroacupuncture at 80/120Hz at BL-20 + BL-20, BL-21 + BL-21, and GV-4 + Bai-hui. He received moxibustion 3-5 minutes per acupoint at GV-4, Bai-hui, BL-20, BL-21, and CV-12.

He also received 500mg flunixin meglumine IV at the beginning of treatment.

He was prescribed 2 teaspoons ground dried ginger to his food twice daily to warm the Stomach, and continued moxibustion treatment daily.

TCVM Outcome

Zippy’s colic resolved within 45 minutes of treatment. He was fasted the remainder of the night, and provided a warm mash the following day that he ate with vigor. At recheck examination one week after his colic episode, his ears and back were warm despite the ambient temperature being similar to the night of presentation. His pulses were bilaterally weak and deep, but with regular rate, and his tongue was pale and wet but not purple. He had normal manure and appetite with no recurrence of colic signs. He continued treatment for his chronic deficiencies.

Summary

This gelding is an example of how the invasion of exogenous Cold can result in abdominal Stagnation and colic. As Zippy was an older gelding with known Qi Deficiency, he is more susceptible to invasion of exogenous pathogens. Warming of his middle Jiao with moxibustion and food therapy, along with acupuncture, dispelled the Cold and relieved his colic. While his colic resolved with these therapies alone, in a patient that has repeat colic episodes due to Cold or severe Cold Colic, the herbal medicine of choice would be Ju Pi San.

References

1. Xie H, Preast V. Xie’s Chinese Veterinary Herbology. Wiley-Blackwell; 2010.

2. Xie H, Preast V. Xie’s Veterinary Acupuncture. Blackwell Publishing; 2007.

3. Pellegrini DZ, Müller TR, Fonteque JH, et al. Equine acupuncture methods and applications: A review. Equine Vet Educ 2020;32:268–277.

To view Issue 50 of the WATCVM Newsletter in its entirety, please click here.

Lead Article
Modified Scape Acupuncture to Treat Neurology Condition in Dogs and Cats
Chee May Wong DVM, MSTCVM; Deng Shan Shiau PhD

WATCVM Updates

• TCVM in Nepal
• October Webinar - Food Therapy for Spleen Qi Deficiency  

Case Reports
Integrative Treatment of Hind Limb Ataxia with Acupuncture
Sonja Schirmer DVM

TCVM for Epilepsy in a Young Cat
Ming-Hsien Chou, DVM, MS

AJTCVM
Is now online with a new website

Treatment of Fibrocartilaginous Embolism in a Dog with TCVM
Rosemarie Niznik, DVM, CVA, CVSMT, CVFT. FCoAC

ABBREVIATIONS
CSF - Cerebral Spinal Fluid CP Conscious proprioception
FCE Fibrocartilaginous embolism MRI Magnetic resonance imaging
TCVM - Traditional Chinese Veterinary Medicine

Fibrocartilaginous Embolism (FCE) and infraction of the spinal cord is the most common nervous system vascular disorder of dogs. Young, large breed dogs, Miniature Schnauzers, and very rarely cats are presented with acute asymmetrical quadriparesis, hemiparesis, with paralysis for no apparent reason. Infarction of the spinal cord is due to the occlusion of other arteries of veins with fibrocartilage. The origin of the cartilage is unknown, although most theories suggest that is arise from degenerated intervertebral disk material that gains entrance to the spinal cord. A history of acute collapse with or without vigorous exercise in common.1

TCVM Etiology and Pathology

From a TCVM perspective, spinal cord ischemia results in Stagnation of Qi/Blood flow with Qi Deficiency locally that affects the spinal cord function. The Deficiency and Stagnation of the Qi/Blood depletes Gu Qi that nourishes the neurons and other cells of the region and degeneration and demyelination occurs. Kidney Qi Deficiency is also present if the animal has pelvic limb or generalized limb paresis or paralysis, Tan Huan Syndrome. 1

TCVM Pattern

Spinal Cord Qi/Blood Stagnation and Kidney Qi Deficiency

TCVM Treatment Principles

1. Resolve Qi/Blood Stagnation to return proper Qi/Blood flow and resolve hemiparesis, quadriparesis, paraparesis, or paraplegia

2. Tonify Kidney Qi to resolve hemiparesis, quadriparesis, paraparesis, or paraplegia1

Case Report

A 3 yr old MN Labrador retriever, “Buckeye”, was referred for treatment for acute tetraparesis and flaccid paresis. There was mild tremoring and and right third eyelid elevation. He was found by the pet sitter in the home unable to rise after running and playing ball outside on a golf course . Rule outs by the ER veterinarian were FCE, IVDD, acute toxicicosis of lawn chemicals or plants. Routine radiographs did not show any bone or disc abnormalities. The dog was treated with IV intralipid therapy with no improvement of clinical signs. The right side was affected more than the left side. Blood tests were done after intralipid infusion and the results were normal. MRI results showed a C6-7 intramedullary lesion, right side affected more than left side. . CSF tap results were consistent with an inflammatory process.

Conventional exam: Cranial nerve exam was normal No cervical or thoracolumbar pain. Non ambulatory all 4 limbs. Increased Right patellar reflex and decreased muscle tone and reflexes of the forelimbs. The withdrawal reflex and superficial reflex were WNL. Conscience proprioception (CP) was lost on right hind limb and delayed on right front limb. Absent panniculus. Gait with support was choppy in forelimbs and dysmetria in right rear limb. Diet: Purina One True Instinct and cooked chicken. The dog was not on any medication or supplements. He was supported with a Help ‘Em Up Harness for walks in the home and outdoors.

TCVM exam:

Earth Personality. Shen was excellent. Voice was strong. Appetite was good. There was normal urination and defecation.

Pulses: Bounding, stronger on left side

Tongue color: pink edges with lavender center, moist, clear coating

TCVM DX:

Qi/Blood Stagnation cervical spine with Kidney Qi Deficiency

TCVM Treatment

Dry Needle Acupuncture treatment: GV-14, GV-20, Bai Hui, BL-23, GV-4, BL-54R, ST-36R, BL-60 to KID3, GB-29R, KID 1, PC-8, LI-11R, SI-9 R,

Liu Feng all feet (easy to needle this points)

Electrical Acupuncture at 20 Hz for 10 minutes and 80 to 120 Hz for 20 minutes: GV-20 to GV-14, GV-14 to Bai Hui, Bai Hui to BL-60, GV-14 to LI-11R

Aqua Acupuncture with 0.2 ml of diluted B12 with saline at GV-14, BL-40, BL-23, BL-24, BL-26, ST- 36, BL-602

Tui-na Home care:

Mo-fa along sides of body and limbs for 2 to 5 minutes

Tui Na along the Jing-jai-ji or Bladder Channel three times a day working up to 12 times per day

Nie-fa along Governing Vessel three times a day working up to 12 times per day

Duo-fa all 4 limbs three times a day working up to 12 times per day1,3

TCVM Food Therapy: Neutral to cool food items to support Qi and Blood: beef, eggs, carrots, sweet potatoes, squash

Food to support Kidney Qi Deficiency such as beef, chicken, sweet potatoes, carrots, squash, dates, figs.1

Reommended to top dress kibble diet with a few food items daily but no more than 10% of the daily calories.

Recommendation was Jing Tang Double P IIa and Jing Tang Cervical Formula.4,a Herbal Formulas were declined.

After treatment, Buckeye was taken outside and normal urination and defection noted! Owners were very happy as they were concerned dog was not defecating on a routine basis.

Treatments:

Buckeye was treated with acupuncture weekly for 6 treatments in March and April and then monthly in May and June. He was prescribed a home exercise program. He was also going for underwater treadmill session at local veterinary rehabilitation center. He steadily improved in neuromuscular function after each acupuncture treatment.                                                      

In subsequent appointments, the dog resisted acupuncture at Lui-Feng classical acupuncture points. This resistance coincided with increased function to the hind and forelimbs.

Additional acupuncture points utilized: LU-7, BL-20, BL-21, LI-10, GB-21, GB-30, GB-34, LIV-3

Additional Electrical Acupuncture Pairs: GV-14 to. SI-9, GB- 20 to SI-9, GB-21 to LI-11

Additional injections with 0.2ml diluted B12: GB-21, SI-9, An-Shen

The owner built a walker with PVC pipes and support ropes to allow Buckeye to stand and walk assisted in the home.

Follow up 3 months: Buckeye transitioned from underwater treadmill therapy to swim therapy. He was reluctant to use left back leg and held it flexed when swimming. He is walking assisted in house. He will walk around the yard and even chase squirrels. Stance: standing on all 4 feet with weight shifted to left side with left rear limb held rigid.

Follow up 4 years later - September 2022 - 60% better Conclusion

Acupuncture increases blood flow. Circulatory changes can also occur

local and distal to the acupuncture points stimulated.5 It is believed that increased blood flow caused by acupuncture flushes out the algesic substances and therefore relieves pain.In TCVM, this is interpreted as moving Qi and Blood Stagnation to provide pain relief.6

In FCE cases, the TCVM principles of treatment are to move stagnated Qi and Blood. If Qi and Blood are allowed to accumulate for a prolonged period of time, it can lead to Qi and Blood Deficiency. Since FCE leads to infarction of small arteries and veins and blockage of the free flow of Qi and Blood within the area, the main treatment goal is to unblock the Stagnation. This is done by treating acupuncture points local, cranial and distal to the lesion. In addition there are specific points that resolve Stagnation such as LIV-3 and GB-34.6

Since some dogs recover some degree of function with no specific treatment, the impact of the TCVM and other treatments on the recovery of this case is unknown. However since acupuncture, herbal therapy and

Tui-na have been shown to increase blood flow, the addition of these therapies to the treatment regime may reduce long-term residual damage in dogs with FCE. 6

About the Author

Dr. Rosemarie Niznik received her Bachelor of Science Degree with Honors from the Pennsylvania State University in 1984 and her DVM degree from the University of Georgia in 1990. Dr. Niznik is certified in Mixed Animal Veterinary Acupuncture and Food Therapy from the Chi University and Veterinary Spinal Manipulative Therapy from the Healing Oasis Wellness Center. She founded Harmony Rose Animal Wellness, a housecall integrative practice in 2015 that serves clients in Illinois and Wisconsin. She currently is a Chi University MS-TCVM student and Acupuncture Lab Teaching Associate and President-Elect of AHVMA. She goes by the nickname of “Dr. Rose” and lives on a 5-acre farm in Wisconsin with Chip, her husband, Grace, a Bernese Mountain Dog, and Wendy and Willa, two rescue cats. She is an  PSIA Level 1 Alpine Ski Instructor and teaches downhill skiing at Wilmot Mountain Ski Resort, a Vail Property,  in the winter months. 

FOOTNOTES

a.   Dr. Xie Jing Tang Herbal, Inc. Ocala, Florida, USA

References

1. Xie, , Wedemeyer, L., Christman, C., Trevisanello, L., Practical Quide to Traditional Chinese Veterinary Medicine - Small Animal Practice, Chi Institute Press, Reddick, FL 2014, p. 158, 198-201
2. Xie, , Preast V., Xie’s Veterinary Acupuncture, Blackwell Publishing, Iowa, 2007, p 143-234
3. Xie, H., Ferguson, B., Deng, X., Application of Tui-na in Veterinary Medicine, 2nd Edition, Tianjin Jincal Arts Printing Co., Ltd, 2008, p. 9-47
4. Ma, , Clinical Manual of Chinese veterinary Herbal Medicine, Fifth Edition, Ancient Art Press, Florida, 2020, p. 196, 203
5. Schoen A. Veterinary Acupuncture Ancient Art to Modern Medicine, 2nd Ed. St. Louis, MO:Mosby Inc 2001:183-185.
6. Medina, C., An Integrative Approach for the Treatment of Suspected Fibrocartilaginous Embolism of the Spinal Cord in a Dog, AJTCVM Vol 5, No.2, August 2010, p 55-60

September: Pain Awareness Month – What is Pain in TCVM?

Emily Mangan, DVM, CTCVMP, CCRV, CVMMP

The use of acupuncture for analgesia is one of the best-supported and widely-studied benefits of acupuncture. From the early 1970s, when scientific inquiry started investigating acupuncture in the West, early studies identified that acupuncture had analgesic effects. Over the last 50 years, as the scientific method matured, so did our understanding of the complex cascades and neuromodulatory effects that resulted in diminished pain in animals.

The Gate Control Theory of Pain, popularized by Ronald Melzack and Patrick Wall in 1965, is one of the fundamental theories of pain suppression.^1,2 While we know acupuncture has various mechanisms within the body, the Gate Control Theory explains how stimulation of A-β fibers by acupuncture needles leads to stimulation of an inhibitory interneuron within the spinal cord. This interneuron inhibits transmission of C nociceptive fibers, which classically transmit pain signals. Thus, inhibition of C nociceptive fibers decreases pain.

Beyond the Gate Theory, we now know there are also a host of other local, segmental (spinal cord), and suprasegmental (brain) effects of acupuncture that function to decrease nociceptive signaling and pain perception in the body.² These effects include mast cell degranulation, ATP release, release of endogenous opioids, suppression of NMDA receptors and inhibition of substance P release, all of which have well-documented analgesic effects.^2,3

While the World Health Organization identified acupuncture as a useful modality for management of post-operative pain in humans in 2002, recent studies have identified efficacy for pre-, intra-, and post-operative pain relief for dogs undergoing ovariohysterectomy,⁴ hemilaminectomy,^5,6 and a variety of other surgical interventions. Acupuncture has also been recognized as pain management for naturally-occurring orthopedic or musculoskeletal disease, including coxofemoral osteoarthritis in dogs and thoracolumbar and gluteal pain in horses.

With all this information, it is no surprise that acupuncture is quickly being integrated into multimodal pain management plans in veterinary medicine.

What is pain from a TCVM perspective?

In the simplest terms, pain is felt when there is Stagnation of Qi or Blood. There can be a variety of causes of Qi and/or Blood Stagnation, but the end result is often pain.

The treatment principle of pain in TCVM is therefore straightforward: Clear Stagnation and the pain will be resolved. It’s important to remember that Stagnation is often not the primary diagnosis and that there are frequently underlying pattern diagnoses that predispose the animal to developing areas of Stagnation. Treatment of the Stagnation as well as the underlying patterns are paramount to success.

Pain of any type is debilitating. Chronic pain not only impacts quality of life, but also results in central sensitization or “wind up” pain that can become intractable and even more difficult to manage. Creating a multi-modal pain management plan is therefore vital for ethical and conscientious care of our companions and patients.

Pain Management Case Study

History

Connie, a 12-year-old black Labrador Retriever, presented for progressive hindlimb weakness and difficulty rising. She was previously diagnosed with hip dysplasia as a young dog and she had been receiving carprofen daily for the last several years. A few days before presentation, after a midmorning nap, she had been unable to rise without assistance, which prompted her visit.

TCVM Evaluation

Connie was a balanced Earth constitution. Her tongue was red and wet, and her pulses were thready, choppy, and weaker on the right. Her head and back were warm and she panted constantly. She was sensitive to palpation of BL-54 bilaterally, and resented hip extension. Coxofemoral crepitus was appreciated on hip range of motion. She was also sensitive to palpation of iliopsoas and other hip flexors and she had bilateral hind limb atrophy with a local muscle condition score of 1/3.

Pattern Diagnosis: Kidney Qi and Yin Deficiency Bony Bi Syndrome with Local Qi/Blood Stagnation at bilateral coxofemoral joints.

TCVM Treatment Principles: Clear Local Qi/Blood Stagnation and tonify Kidney Qi and Kidney Yin

Acupuncture Point Prescription

GV-20, GV-14, Bai-hui, Shen-shu, LIV-4, LIV-3, ST-36, SP-6, KID-3, BL-11, BL-23, BL-40, BL-54, GB-29, GB-30

GV-20 – Permission, calming

GV-14 – Clear Heat

Bai-hui – Permission point, local to hind end

Shen-shu– Tonify Kidney, local to the hind end

LI-4 and LIV-3 – The Four Gates to clear Stagnation

ST-36 – Tonify Qi

SP-6 – Tonify Yin

KID-3 – Yuan source point for the Kidney

BL-11 – Influential for Bone

BL-23 – Back-shu Association for Kidney

BL-40 – Master point for hips and low back

BL-54 – Master point of the hind limb

GB-29 and GB-30 – Local to the hip to clear Stagnation

Herbal Formula prescription

Di Gu Pi^†

• Tonify Kidney Qi and Yin
• Clear Deficient Heat
• Dispel Wind-Damp
• Dose at 100mg/kg by mouth twice daily

Treatment Outcome

After the first treatment, Connie slept most the day. The second day, she was able to rise on her own and navigate the steps from the porch to the lawn and back. She was also prescribed therapeutic exercises to strengthen the hind limbs. After her 2^nd treatment, she was more comfortable and her tongue was less red and began to show more purple. At the 3^rd treatment, she was panting less and seemed more comfortable and content, and was able to consistently navigate around her home environment and the steps to the yard. Her owners remarked that she was acting like her younger self.

Summary

Connie’s case is a good example of underlying pattern diagnoses of Kidney Qi and Yin Deficiency contributing to the formation of Bony Bi Syndrome, Local Qi/Blood Stagnation and ultimately, pain. Connie also had a component of Kidney Jing Deficiency (early onset of hip dysplasia predisposing her to Bony Bi), as well as Spleen Qi Deficiency, and both of these diagnoses did become apparent in her TCVM exam after the initial Stagnation and False Heat had been cleared. She was initially brought for TCVM consultation due to weakness in the hind end, but it turns out that her weakness was actually secondary to severe osteoarthritis pain due to hip dysplasia. Once her pain was adequately managed, she was able to strengthen her hind limbs and regain the ability to rise.

^†Dr. Xie's Jing Tang Herbal

References

1. Mendell LM. Constructing and Deconstructing the Gate Theory of Pain. Pain 2014;155:210–216.

2. Huntingford JL, Petty MC. Evidence-Based Application of Acupuncture for Pain Management in Companion Animal Medicine. Vet Sci 2022;9:252.

3. Dewey CW, Xie H. The scientific basis of acupuncture for veterinary pain management: A review based on relevant literature from the last two decades. Open Vet J 2021;11:203–209.

4. Luna SPL, Martino ID, Lorena SER de S, et al. Acupuncture and pharmacopuncture are as effective as morphine or carprofen for postoperative analgesia in bitches undergoing ovariohysterectomy. Acta Cir Bras 2015;30:831–837.

5. Machin H, Taylor-Brown F, Adami C. Use of acupuncture as adjuvant analgesic technique in dogs undergoing thoracolumbar hemilaminectomy. Vet J 2020;264:105536.

6. Laim A, Jaggy A, Forterre F, et al. Effects of adjunct electroacupuncture on severity of postoperative pain in dogs undergoing hemilaminectomy because of acute thoracolumbar intervertebral disk disease. J Am Vet Med Assoc 2009;234:1141–1146.

Liver Qi Stagnation with Wood Overcontrolling Earth in a Warmblood Mare

Emily Mangan, DVM, CVA, CVCH, CVFT, CVTP, CCRV, CVMMP

History

A 26-year-old Warmblood mare presented for progressively abnormal behavior of five months duration. The mare has always been opinionated and had a history of kicking fences. She was previously used for eventing before suffering a career-ending injury in 2011 where she kicked a fence and sustained a superficial digital flexor injury and septic pastern joint.

Five months prior to presentation, she was moved from the boarding barn to the barn on her owner’s property. The two properties are adjacent, and the mare had lived in the area since 2013. After the move, she began showing anxious and aggressive behavior in her stall and towards her owners and barn mates, and developed fecal water with intermittent soft manure. She had daily pasture turnout, but after about 2.5 hours, would gallop around the field, work herself into a sweat, neigh, and would run into fences, kick fences, or kick her turnout mate. These episodes were being managed by limiting her pasture turnout to 2 hours daily, trying different stall assignments between the horses, and acquiring a mule to hopefully bond with her, which she reacted to poorly initially but has started to warm up. She had also previously failed trials of phenylbutazone, gabapentin, firocoxib, trazodone, Shen Calmer, ¹ and Liver Happy. ¹ She underwent various diet changes and supplement trials over the last few months.

She had a history of granulosa thecal cell tumor with subsequent right-sided ovariectomy in 2007, several mild colic episodes over the last few years, and Pars Pituitary Intermedia Dysfunction (PPID) diagnosed in 2021 and controlled with pergolide.

She was sensitive to touch of her chest and hypochondriac region and had previously bitten the owner for touching these areas. She had a picky appetite and showed recent weight loss despite additional supplementation.

TCVM Evaluation

The mare was an unbalanced Wood constitution, with strong opinions and tendency towards aggression. Her conjunctiva were red, her ears were 3-fingers warm, and her body was warm. Her tongue was red and purple in the Liver position, and her pulses were wiry and weaker on the right. She was sensitive on palpation of her chest and hypochondriac region, as well as 3+ sensitive bilaterally over BL-18 and BL-54 on acupuncture point scan. She was diagnosed with Shen Disturbance due to Liver Qi Stagnation leading to Liver Heat, as well as secondary Spleen Qi Deficiency due to Wood Overcontrolling Earth.

TCVM Treatment

TCVM treatment principles were to soothe Liver Qi and calm Shen, clear Heat, and tonify Spleen Qi. She received acupuncture with dry needles at ST-36, HT-7, BL-15, BL-18, BL-20, BL-21, BL-44, BL-47, BL-54, GB-20, GB-21, LIV-3, GV-14, Da-feng-men. She received acupuncture treatment twice, two days apart. Concentrated Xiao Yao San¹ was prescribed, at a dose of 3 grams by mouth twice daily. Owner also started a diet trial of increased hay pellets.

Treatment Outcome

After the first treatment, she was able to be out on pasture for 3.5 hours before she became anxious. After her second treatment, she had improved appetite and was able to be out to pasture longer, up to 5 hours. She would still run around the pasture when she had reached her limit, but not enough to break a sweat, and without danger to herself or other horses.

Follow up acupuncture treatment was recommended, and continuation of Xiao Yao San¹ for 4 weeks past resolution of clinical signs.

Summary

This mare is an example of environmental stress unbalancing a Wood constitution mare resulting in Liver Qi Stagnation. Over time, the Liver Qi Stagnation condensed into Heat and disturbed the Shen, and also overcontrolled the Earth element, resulting in Spleen Qi Deficiency. This interaction between the elements is what was responsible for her decreased appetite, weight loss, historical colic episodes, and loose manure.

¹Dr. Xie's Jing Tang Herbal

Photos courtesy of Pepa Roth, DVM CVA CVMMP

To view Issue 49 of the WATCVM Newsletter in its entirety, please click here.

Lead Article
Feline Tui-na: Techniques for Cats
Cindy West DVM, CVA, CVTP

WATCVM Updates
IVM-GO Visits and TCVM Webinars

Case Reports
Food Therapy for a Dog with Heart Disease, Deafness
Judith Lombardi VMD, CVA, CVFT

Acupuncture for Horse Tail Atrophy
Cara Edwards Bankson DVM, CVA

Commentary
The Gift That Keeps on Giving
Gregory Todd DVM, CVA

TCVM Case 1

Canine adverse effects of poisoning treated integrally with Chinese Herbal Medicine

Melissa Alvarenga Haddad. MV. MS-TCVM
Alivio Animal Veterinary Clinic, Tegucigalpa, Honduras

History:

One year and 5 month old canine, cocker spaniel, neutered, with 10.8kg of body weight, was presented at clinic after a few hours of been reported as found unconscious and hypothermic (August 17^th, 2015).

Owner related that around 5:30am patient was found unconscious, cold on extremities and surrounded by several amounts of vomit. Owner was suggested to come to the clinic as an emergency.

After two additional hours, patient was evaluated. Clinical signs were: low temperature (37.2°C), tongue with slight cyanosis and more salivation than normal, capillary refill time was increased to 3-4 seconds, heart rate was arrhythmic 60 beats per minute, with signs of recent vomiting, pupils were responsive to light and intestinal movements were absent

Catheter was place immediately and a blood sample withdrawal to have more specific signs of the patient.

Hematology and blood chemistry results were as shown on Table 1 and Table 2 respectively.

Treatment:

Patient was placed on lateral recumbency over a thermal blanket to receive medication and fluid therapy. Medication used to stabilize patient (only once): Glucose 5% + NaCl 0.9% (60mL/kg/24h) IV fluid therapy, ozone therapy within fluids at 26µg/mL, 50mL, Aminoplex® (glucose, aminoacids and electrolites) 1mL/5kg IV, metoclopramide 1mg/kg, ranitidine 0.5mg/kg, dexamethasone 0.2 mg/kg IV.

Temperature control was better every hour (Table 3). Patient started urination after four hours of fluid therapy and by this time was on sternal recumbency by himself, intestinal movements were present as well (5 hours after presentation at clinic).

After four hours of treatment patient recover conscious, urinated and was able to give a few steps then was release to go home only with Chinese herbal medication and low fat prescription diet.

Chinese herbal formula used was Yi Guan Jian® 4 capsules (0.5g) / day / 12 days. Within 3 days of treatment ALT values lowered 61% and were normal within 11 days (Table 2).

Table 1. Hematology results of a canine after chemical poisoning.

Table 2. Blood Chemistry results of a canine after chemical poisoning.

Table 3. Temperature control of a canine after chemical poisoning.

Discussion

As clinicians urge to educate clients about life threatening with chemical products close to their pets, may be families living in the city or at the countryside. This family lives outside the city, and was not able to identify specific product, plant or animal which could affect their pet. Pyrethrin intoxication was more likely in behalf of recent fumigation applied at the surrounding area. Clinical signs were treated conventionally only for one day then in behalf of the patient’s improvement, was release within one day, with Chinese Herbal medication and a liver support medication Proteliv®, but with a surprising rapid effect. Thus, Chinese herbal treatment can be used for support of critical cases and in this case, normal values of liver affection were achieved.

Since this incident, owners are more alert when fumigations of the area are done.

Yi Guan Jian Formula® (Jing Tang Herbal)

TCVM Indications: Liver-Kidney Yin Deficiency, Increased Liver enzimes, Hyperactivity

Tongue : red and dry

Pulse: Thin and fast

Aituan Ma. Clinical Manual of Chinese Veterinary Herbal Medicine. Fifth Edition. 2020. P. 145-146.

 Bruno playing happy at home (Sept.29^th 2018).

TCVM Case 2

A Case of Mushroom Poisoning
Cindy Lankenau, DVM

Benny, a male Golden Retriever, 11 weeks of age, ate a whole ring of a white caped mushroom as per observations by his owner.  (11/2/13) Within three hours, Benny was delirious running into things, appeared to be blind, and going into an almost clonic seizure.  At that time, the owner called.  With the history of a white capped mushroom ingestion, a presumptive diagnosis of a toxic ingestion of Amanita bisporigera, destroying angel. The toxin responsible for this is amatoxin, which inhibits RNA polymerase II and II, which suppresses RNA production and protein synthesis resulting in rapid cellular necrosis. This process results in severe acute liver dysfunction and, ultimately, liver failure.  Benny was hours away from any veterinary facility.  The owners were instructed to give a Milk Thistle, Silybum marianum, capsule every five minutes, and drive to nearest veterinarian facility.  (The owner had a bottle of Milk Thistle with her, brand unknown) Four hours later the owner arrived at an emergency center, but Benny had stabilized, and was only slightly ataxic.  All liver functions were within normal limits.  He was hospitalized, received supportive care.  The emergency hospital discontinued the Milk Thistle replacing it with synthetic Denemarin. The following day, he was discharged from the referral hospital, and brought in for an examination.  He was acting normal, but his ALT had increased to 39 U/L  (5-18).  His pulse was wiry, and rapid with a slightly red/lavender tongue.  He was restarted on Milk Thistle, Silybum marianum; 30 drops of a 1:5 tincture four times a day, with Xiao Chai Hu Tang (EG) ½ tsp twice a day.  It was felt that even though he was saved by the Milk Thistle, he had developed an obstruction in his Triple Heater.  Within two weeks, all liver functions were normal.

When Benny was 5-year-old. Winter of 2018

TCVM Case 3

Integrative Medicine: TCVM and Rehabilitation in a case of a coral snake bite in a dog.

JOSÉ ZILBERSCHTEIN JUFFE, ^{1, 2}

DVM, MS, CVA, CHVM, CCRP, Universidad de Murcia. Departamento de Medicina y Cirugía Animal. Facultad de Veterinaria. Hospital Clínico Veterinario. Campus de Espinardo. 30071 Murcia.
University of College of Veterinary Medicine. Veterinary Teaching Hospital. USA.

INTRODUCTION

North American coral snakes are a distinctively colored beginning with a black snout and an alternating pattern of black, yellow, and red. They have fixed front fangs and a poorly developed system for venom delivery, requiring a chewing action to inject the venom. The severity of a coral snake bite is related to the volume of venom injected and the size of the victim. ^{26, 27}

The length of the snake correlates positively with the snakes venom yield. Coral snake venom is primarily neurotoxic with little local tissue reaction or pain at the bite site. The net effect of the neurotoxins is a curare like syndrome. In canine victims there have been reports of marked hemolysis with severe anemia and hemoglobinuria. ^{40, 83}

The onset of clinical signs may be delayed for as much as 10 to 18 hours. The victim begins to have alterations in mental status and develops generalized weakness and muscle fasciculation. ^{51, 53}

Progression to paralysis of the limbs and respiratory muscles then follows. The best flied response to coral snake envenomation is rapid transport to a veterinary medical facility capable of 24 hour critical care and assisted ventilation. ^{74, 75, 83}

First aid treatment advocated in Australia for Elapid bites is the immediate use of a compression bandage. The victim should be hospitalized for a minimum of 48 hours for continuous monitoring. ^{83, 106}

The only definitive treatment for coral snake envenomation is the administration of antivenin (M. fulvius). Once clinical signs of coral snake envenomation become manifest they progress with alarming rapidity and are difficult to reverse. ^{40, 88}

If antivenin is not available or if its administration is delayed, supportive care includes respiratory support. Assisted mechanical ventilation can be used but may have to be employed for up to 48 to 72 hours. ^{75, 79}

Acupuncture is a therapeutic system within traditional Chinese medicine characterized by inserting needles of different metals into specific parts of the body, called acupoints, in order to cure, relieve or eliminate pain. ^{1, 14, 25, 54, 90,107, 115}

It is used in both human and veterinary medicine. In animals, these acupoints form currents of energy known as acupuncture meridians. These meridians constitute the basis of acupuncture and their description originated due to the knowledge of the topography of the acupoints. ^{35, 36, 42, 73, 80}

They are situated symmetrically with respect to the sagittal axis of the body, and are found throughout the head, the trunk, the abdomen and the limbs, both in the anterior as well as in posterior part of the body, forming a closed system of circulation. ^{12, 107, 114} Each one has its own distribution, a specific energy timetable, and corresponds to an organ.^{7, 107, 114}

The Renzhong acupoint (Jenchung, GV-26 or 26 Du in Du Mai Chinese) belongs to other governing meridian vessels (GV). In all species this meridian runs in the following directions: it begins in the coccyx and ascends the middle dorsal line to the neck. It then runs along the middle line in the head towards the forehead and the nose and the finishes below the upper lip. ^{7, 107, 111, 114}

The Renzhong acupoint is found at the border of the middle and upper third of the distance between the nose and the upper lip in humans 85 and in animals such as horses at the upper lip, at the midpoint of the philtrum nasale. ^{31, 54, 111} In dogs and cats in the philtrum (vertical line in the upper lip and between the nares) at the level of the ventral limits of the nares^{54, 80, 107,111}

The Renzhong acupoint (Jenchung, GV-26 or 26 Du) is one of the most widely used in the emergency ward, in both animals and humans. A bibliography of more than 700 articles (1973-2016) documents the effects and clinical efficacy of the stimulation of this acupoint and leads one to speculate other physiological and clinical applications. ^{1, 14, 17, 19, 29, 31, 32, 49, 57, 60, 61, 65, 68, 71,72, 86, 87, 89, 94, 96, 101, 107, 109, 110, 111}

Very few studies exist on the microscopic structure of the acupoints in domestic animals. The main works refer to cattle and dogs. ^{36, 37, 38, 55, 56, 112}

The structures found at the acupoints are not unique. Many of them are found in depressions situated in muscular zones. ^{43, 44, 45} These are areas of the skin containing a high concentration of nerve endings, nerve plexuses, mast cells, lymphocytes, capillaries and venules. ^{35, 37, 38}

It has been suggested that the size of the acupoints is 1 mm². Histologically, they have their own structure characterized by a thinning of the skin due to a modification of its collagen’s fibres of the dermis, this explains why they can be felt as a depression (She); they also present a spiral vascular network, surrounded by a dense network of cholinergic-type amielinic nerve fibres revealed that 80% of acupoints correlated with perforations in the superficial fascia of human corpses. A nerve vessel bundle and vessels penetrated the skin through these orifices. ^{42, 43, 44, 80}

Studies carried out in cows ^{55, 73} and in dogs and cows ^{36, 112} have verified the correlation between acupoints and perforations in the superficial fascia by sensitive cutaneous nerves. ^{37, 38}

Macroscopic examination of 27 points of the bladder meridian in a cow revealed much defined perforations in the thoracolumbar fascia through which nerve-vessel structures ran at 19 points. The remaining eight acupoints (B18-25) were situated at the entrance points of the middle cutaneous branch in the skin of the back of the animal. ^{36, 37}

There were no perforations of the fascia, which was a new discovery. Fascia perforations with nerve-vessel structures were found at the five points of the gall bladder meridian, which were examined. ^{38, 37}

Histologic examination revealed a special disposition of the connective tissue, surrounding the nerve, with concentric laminas and loss of connective tissue composed of fine fibres of collagen. ^{37, 111}

A more compact sheath of connective tissue surrounded the nerve-vessel structure at the point where it perforates the fascia. 34 These results are valid for other points with reduced electrical resistance at the base of the teat. ⁷³ A high concentration of mast cells was also found in the area adjacent to the point. ¹⁰⁸

The anatomic and histologic characteristics of acupoint Renzhong GV-26 in ten Spanish horses show that the acupoint Renzhong GV-26 is situated in the intermediate area of the upper lip, represented by several structures of dense connective tissue, skeletal muscle tissue, nerve fibres and vascular structures. Therefore, numerous structures conform part of the acupoint Renzhong GV-26 in the horse. ¹¹¹

In reference to the vascular structures in the areas of the acupuncture, several authors stress the importance that they play in the regulation of local temperature. ^{100, 111}Talukdar et al., in a study performed on the skin of the horse describes special vascular structures in 43 areas of the skin. ^{100, 111}

They consist of arterio-venous anastomosis in rings or spirals forming canals between arterio-venous, arterioles with ephiteloides cells on the walls and glomus. These glomus might be related to the conservation of the heat and temperature regulation. Other authors focus the subject on the components of the connective tissue, lymphatic vessels, arterioles and veins at the acupoints, describing vascular structures surrounding cholinergic amielinic nerve fibres. ^{100, 111}

Research is showing that the Renzhong GV-26 acupuncture is not composed of a single structure. The loose connective tissue has a different spatial configuration to the rest of the skin. Thermo graphic studies in different species (Horses, dogs, turtles) show different patterns at the moment of their stimulation. ^{111, 112}

Its effectiveness and excellent response in shocks and respiratory apneas in all the species studied, show that the stimulation of the acupoint VG-26, as the entry way and shorter connection, to the respiratory center. ^{1, 14, 17, 19, 29, 31, 32, 49, 57, 60, 61, 65, 68, 71, 72, 86, 87, 89, 94, 96, 101, 107, 109, 110, 111}

Case report

A dog named Tiki was bitten by a coral snake. When we got the case the dog presented a paralysis of the muscles of the diaphragm and intercostal which prevented it from breathing on his own. The dog had been connected to an assisted ventilation apparatus for five days at ICU Service at the Veterinary Florida University Hospital.

It was decided to apply Integrative Medicine: TCVM and Rehabilitation techniques for his condition.

The selection of acupoints was made according to the Theories of Traditional Chinese Medicine.

We decided to start stimulating the acupuncture point GV- 26 and the response was excellent. Its breathing rate and heart rate improved, so we decided to stimulate other acupoints to carry on improving its condition. When Tiki started breathing on its own it was disconnected and we decided to start a rehabilitation protocol as it had been in a sternal recumbency posision for 5 days.

The protocol consisted of passive movements of the joints through active movements walker, water treadmill and other therapies through which we obtained a full recovery.

Results and conclusions:

While considering that Integrative medicine: TCVM and Rehabilitation Therapy are difficult to perform because of its high complexity in diagnosis and the choice of appropriate protocols, the results showed to be an important therapeutic way in the treatment of Emergency case, especially in patients who had not responded to medical treatment. The combination of treatments showed to be safe and not have undesirable side effects and was therefore very effective.

Keywords: Integrative Medicine, TCVM, Rehabilitation, GV-26; Coral Snake, Dog.

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Wei Syndrome in a Geriatric Equine

John A. Perdrizet DVM, PhD, MS-TCVM, DACVIM(LA)

HISTORY

In the early winter of 2021, I was asked to provide TCVM care to a 750 lb., 32 yr.-old Appaloosa Mare on a small farm in western New England.  The owner was concerned that ‘Molly’ was having more difficulty getting up from a prone position and her movement around the pasture had gradually decreased in the past few months.  Molly would spend most of the day within 10 meters of the entrance to her stall, and half of that time she was recumbent. She had been provided with nutrition consultation and the diet had been amended 3 months earlier, but the owner had not noticed any change in energy or body weight. In fact, her appetite had decreased, and her body condition score had suffered (now a 3/9).

EXAMINATION

Molly was alert and had normal sensorium (appeared to hear well, could see, and carried her extremities in a normal posture).  Generalized muscle loss was the most remarkable finding – especially her gluteals, upper forelimbs, and back. Her teeth were worn but no significant dental or oral lesions were found. She had received routine dental care twice yearly for many years. She had normal heart and respiratory sounds on thoracic auscultation. Her feet were trimmed every 2 months and were in good condition. There was decreased range of motion detected upon palpation and manipulation of all four of her limbs. A CBC and serum chemistry screen showed all parameters within normal limits.

CONVENTIONAL DIAGNOSIS

A conventional diagnosis of old age resulting in less-than-optimal nutrient assimilation by the GI tract with subsequent weight loss and decreased muscle-mass was made. These were assumed to cause an overall decrease in her energy.  This combined with polyarthritis had contributed to her lack of mobility and recumbency.

TCVM EXAMINATION

 A TCVM examination revealed a pale, enlarged, wet tongue with minimal coating.  A deep, slow, and weak pulse was evident bilaterally. Molly’s back and ears were cold to the touch.  A Body Scan showed +2/5 sensitivity over BL-20-23 on both sides.  All these findings were consistent with Spleen and Kidney Qi/Yang Deficiency…Wei Syndrome.

TCVM THERAPY

 The TCVM therapeutic plan consisted of weekly Acupuncture sessions, Herbal supplementation, Tui na, and Food Therapy.  The goal was to Tonify Spleen and Kidney Qi/Yang and warm the Middle Jiao.  (The reader should remember that it was cold and dark [season of Yin] in New England).

HERBAL:  Molly was placed on the herbal Eight Gentlemen at 15gm twice daily to tonify Spleen Qi and Rehmannia 14 at the same dose to tonify Kidney Qi/Yang.

FOOD THERAPY:  Molly was given steamed whole oats with cinnamon, ginger, thyme, rosemary, walnuts, and seaweed in addition to her conventional chopped hay and senior feed. These were intended to Warm the Interior, and the seaweed was to Tonify the Kidney Qi.  The walnuts are also believed to strengthen cognition.

MOXA: The owner was instructed on how to use a Moxa stick; the Conception Vessel was to be warmed twice daily for 10 minutes from CV-3 to CV-21.

TUI NA:  The owner was taught to perform whole body Ca-fa, and Cuo-fa on Molly’s limbs twice a day for 10 minutes.

ACUPUNCTURE:  Dry needle acupuncture focused on tonifying Spleen and Kidney Qi, as well as overall Qi and Blood.  The following acupoints were used:

 Bai hui – Hundred meetings - Yang Tonification

Da-feng-men – Great Wind Gate – Brighten Shen

Long hui – Dragon Meeting – Brighten Shen

Shen Shu – Kidney Assoc. Point – Kidney Qi/Yang Tonification

BL-11 – Big Shuttle – Influential Point for Bone (Arthritis)

BL-17 – Diaphragm Assoc. Point – Influential Point for Blood

BL-23 – Kidney Assoc. Point – Kidney Qi/Yang Tonification

BL-20 & 21 – Spleen & Stomach Assoc. Point – Tonify Middle Jiao

BL-24 – Sea of Qi Assoc. – Global Qi Tonification

BL-54 – Attach to Mountain – Hind Limb Lameness, Muscle Atrophy, Arthritis

BL-40 – Bend Middle – Master Point for Lumbosacral and Hips, He-Point, Earth

LI-4 – Union Valley – Master Point Face & Mouth, Yuan Source Point

LI- 10 – Arm Three Mile- Front Three Mile Point, General Weakness

LI-11 – Pool on the Bend – He-sea Point (Earth)

ST-36 – Leg Three Mile – Master Point for GI Tract and Abdomen, He-Point, Earth

CV-17 – Chest Centre - Influential Point for Zhong Qi

CV-12 – Central Stomach Duct – Influential Point for Fu Organs

LIV-13 – Completion Gate – Influential Point for Zhang Organs

SP-21 – Great Embracement - Wei Syndrome, Major Luo Connecting Point

GB-34 – Yang Mound Spring – He-sea Point (Earth), Influential Point Tendon/Ligament

10 – 15 acupoints were used at each session but varied with each session depending on any subtle changes in the Bian Zheng. Many of these points received heating with Moxa, as well as tonifying techniques (e.g., thrusting and twirling).

OUTCOME

Over the next month, with weekly acupuncture sessions and continued owner-assisted therapies, Molly’s condition improved, and she became stronger.  The owner was delighted with her progress. Driving back from the last session, I felt gratified with Molly’s progress. Little did I know that the Dao was soon to teach me a valuable lesson….

Four days after Molly’s last acupuncture session, I received a frantic call from the owner on a Sunday morning.  Molly had wandered a considerable distance from the barn, as it was a sunny, calm, but frigid day.  She was feeling much more energetic and happier.  Alas, she had gotten into a low area near the stream that transected the pasture.  The ground, though snow covered, had not frozen, and she was stuck in the mud. By the time I arrived 45 minutes later, Molly was exhausted from attempting to stand, and the local fire department had succeeded in dragging her to dry ground.  Unfortunately, the story did not end well for Molly, as she never regained her feet.

TAKE HOME LESSON:

 Sometimes even success can turn to failure. We must stay vigilant and anticipate the results of our treatments.  As the Dao De Ching instructs us – pay as much attention to the end as to the beginning of any endeavor! If only I had warned the owner to keep Molly from wandering too far, if only we had erected a temporary fence, if only… it is a common and human response to doubt ourselves, question our abilities, and lose sight of the good we do as practitioners in a profession where we must contend with the vagaries of Nature.

 I came across the Daoist Tale of The Old Farmer, shortly after Molly passed, and found it applicable to our everyday lives and professional challenges. So, I will share it with you here:

There was once a farmer in ancient China who owned a horse. “You are so lucky!” his neighbors told him, “To have a horse to pull the cart for you!” “Maybe,” the farmer replied.

One day he didn’t latch the gate properly and the horse ran off. “Oh no! What a disaster!” his neighbors cried. “Such terrible misfortune!” “Maybe,” the farmer replied.

A few days later the horse returned, bringing with it six wild horses. “How fantastic! You are so lucky,” his neighbors told him. “Now you are rich!” “Maybe,” the farmer replied.

The following week the farmer’s son was breaking-in one of the wild horses when it kicked out and broke his leg. “Oh no!” the neighbors cried, “such bad luck, all over again!” “Maybe,” the farmer replied.

The next day soldiers came and took away all the young men to fight in the war. The farmer’s son was left behind. “You are so lucky!” his neighbors cried. “Maybe,” the farmer replied.

And, so, my fellow colleagues, accept your present circumstances with equanimity! Keep to the center; balance is the goal.

REFERENCES

Xie H, Preast V. Traditional Chinese Veterinary Medicine: Fundamental Principles 2^nd ed. Reddick; Chi Institute Press. 2013.

Xie H, Preast V. Xie’s Veterinary Acupuncture. 1^st ed. Reddick: Blackwell Publishing; 2007.

Xie H, Ferguson B, Deng X. Application of Tui Na in Veterinary Medicine. 2^nd ed. Reddick: Chi Institute of Chinese Medicine; 2008.

Fowler M, Xie H, editors. Integrative and Traditional Chinese Veterinary Medicine Food Therapy. 1^st ed. Reddick; Chi University Press. 2020.

Ma A. Clinical Manual of Chinese Veterinary Herbal Medicine.4^th ed. Gainesville; Ancient Art Press. 2016: 103-105, 121-123.

Tsu L. Tao Te Ching. Feng G-F, English J.; Translators. New York (NY); Random House Inc. 1972.