The clinical effectiveness and application of veterinary acupuncture, EG Gulanber

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Content: Retrospective Study
The clinical effectiveness and Application of Veterinary Acupuncture
Erol Gьзlь Gьlanber, Ass.Prof., DVM, Ph.D. ABSTRACT The effectiveness of acupuncture therapy for a variety of clinical problems in veterinary medicine was evaluated in 86 animals (62 dogs, 9 cats, 11 horses, 3 cows and 1sheep). Diseases were separated by systems and included: 37 musculoskeletal, 25 neurological, 4 internal medicine, 2 reproductive disorders, 6 emergency respiratory arrest cases and 12 cases of intra-operative analgesia. Following the prescribed number and frequency of acupuncture treatments, complete recovery was recorded in 20/37 musculoskeletal disorders, 11/25 neurological disorders, 3/4 internal medicine disorders, 2/2 reproductive disorders, and 4/6 cases of respiratory arrest. Good improvement without full recovery was reported in another 7 musculoskeletal disorders, 3 neurological disorders, and 1 internal medicine disorder. Acupuncture anesthesia resulted in excellent analgesia in 1 dog and 1 sheep and good analgesia in 4 dogs, 1 cat, and 2 cows. The recommended number of treatments was not completed in 4 musculoskeletal cases and its use for anesthesia was not continued in 3 cases. There was no improvement in 3 musculoskeletal cases and 6 neurological cases and 2 respiratory arrest cases did not respond to treatment. The remaining cases had a minimal response to treatment. Acupuncture can be effective for many different clinical problems in veterinary medicine. Key words: acupuncture, electroacupuncture, moxibustion , veterinary, dog, cat, horse, cattle.
Stimulation of acupuncture points associated with the peripheral nervous system produces analgesia, anesthesia, and other physiological effects through central nervous system, neurohumoral, neuromuscular and musculoskeletal mechanisms.1 Many clinicians support the notion that the meridian system and acupuncture points in humans can be applied to animals, others suggest that anatomical differences preclude simple transposition.1 The Chinese names for acupuncture points carry anatomical, physiological, therapeutic or symbolic meanings. Today, however, there is no Erol Gьзlь Gьlanber ; Ass.Prof., DVM, Ph.D.; University of Istanbul, Faculty of Veterinary Medicine, Department of Surgery, Avcilar 34851, Istanbul TЬRKYE This work was supported by Research Fund of The University of Istanbul. Project number is B-230/0707999. AJTCVM Vol 3, No.1, Summer 2008
standard for naming points in veterinary acupuncture.2-10 In classical Chinese veterinary acupuncture books, 740 points are described. Of these, 173 are in horses, 103 are in ruminants, 84 are in pigs, 77 are in camels, 75 are in sheep and goats, 76 are in dogs, 51 are in rabbits, 34 are in chickens and 35 are in ducks.6,11,12 Indications for acupuncture in horses are often divided into 6 main systems. 2, 13-17 1. Musculoskeletal: Pain in the thoracic, lumbar and sacral areas, shoulder lameness, elbow and carpal lameness, laminitis, navicular disease, hoof abscess, tendonitis and paralytic myoglobinurea. 2. Neurological: Peripheral nerve paralysis including radial and facial paralysis and cervical ataxia (Wobblers Syndrome). 3. Gastrointestinal: Colic and cribbing. 4. Respiratory: Bronchospasm, hemorrhage, epistaxis, rhinitis and sinusitis. 5. Reproductive problems: Anestrus, ovarian 9
cysts, infertility despite multiple inseminations, and sperm abnormalities in males. 6. Other clinical uses: Uneasiness, anxiety, fear, nervousness and skin problems. Positive results have been demonstrated in acupuncture studies of horses with paralytic myoglobinuria, laminitis, air-swallowing, radial paralysis, bronchitis, chronic respiratory diseases, anorexia, epistaxis, anestrus, ovarian cysts, repeated insemination, dermatitis, corneal ulcers, navicular disease, tetanus, and cribbing.2-4, 8, 12-45 Reported indications for acupuncture in ruminants include: pneumonia, pulmonary emphysema, cardiac and respiratory disorders, indigestion, motility disorders of the rumen, colic, hepatitis, ketonuria, functional ovarian disorders, infertility, retained placenta, testicular disorders, nephritis, renal disease, mastitis, paralysis of the hind legs, convulsions and embryo transfer. 2-4, 8, 10, 12-22, 46-50 Successful results have been reported using acupuncture for treating infertility cases in ruminants and improving low ejaculation density and motile spermatozoa numbers in bulls.2, 3 Altman applied acupuncture to 216 small animal cases and listed indications such as intervertebral disc herniation, hip dysplasia, degenerative myelopathy, dermatological disorders, nerve trauma, osteochondrosis dissecans, pain syndromes, chronic arthritis, chronic respiratory system problems, traumatic peripheral nerve injuries, lick granulomas, chronic gastrointestinal problems and emergency cases.51 Good results with acupuncture have been reported in cats and dogs with hygroma, luxated patellas, systemic lupus erythematosus, leukorrhea, rectal prolapse, coccidiomycosis, behavioral disorders, urinary incontinence, keratoconjunctivitis sicca, megaoesophagus, paresis and paraplegia, quadriplegia, cervical pain, epilepsy and skin problems. 2-4, 8, 12 -22, 52- 72 In classical Chinese acupuncture books it is also stated that some clinicians have successfully applied acupuncture to birds.4, 8, 12, 73, 74 In the West, the first recorded use of acupuncture analgesia was in a human tonsillectomy. Acupuncture analgesia was first used in veterinary medicine in 1975 for a cesarean section on a cow. It has since been reported to have been used in castration and cesarean sections in cats.75, 76 Acupuncture analgesia has not been 10
widely used in veterinary surgery due to its disadvantages and difficulties but some authors indicate in the future it could be used as a surgical anesthetic in combination with decreased doses of local and general anesthetics. 1, 3, 4, 8, 12, 77- 82 Case Selection and Procedures The following is a review of the presentation, treatment and subsequent outcome of 86 clinical cases brought to the Surgery Department Clinic of the Istanbul University Veterinary College. Of the 86 cases, 62 were dogs, 9 were cats, 11 were horses, 3 were cattle and 1 was a sheep. All were of different ages and either gender. All cases were first examined clinically and in many cases radiological and laboratory evaluations were also done. Subsequently, a record was kept to follow the acupuncture treatment for each case throughout the treatment and the final results recorded. POINTER PALa acupuncture point detectors were used for finding acupuncture points. Electronic acupuncture stimulators (ACUSET SMS-205b and WQ-6Fc), were used for electroacupuncture applications. Needles from classical Chinese veterinary acupuncture sets and single use human acupuncture needles were used. All these needles were stainless steel products. Needles were chosen according to the type and anatomical site of the points and the size and species of the animal. After determining the location of the acupuncture point, the region was cleaned with cotton soaked in alcohol, the needle was placed in to the appropriate depth and the skin reaction was observed. Stimulation was carried out for 5-10 minutes by twisting the needles by hand, moving them upwards and downwards and by flicking them. The same stimulation was repeated after an interval of 5-10 minutes. After this, the needles were left in place for 10 minutes. The treatment lasted for 20-30 minutes and at the end of this period the needles were removed by pressing around them. This treatment was continued once or twice a week. In scalp acupuncture, after wiping the acupuncture points chosen on the scalp with cotton and alcohol, stainless steel acupuncture needles with a diameter of 0.32 mm and 13mm long were inserted. Stimulation was done by twisting the needles by hand or by slightly moving them AJTCVM Vol 3, No.1, Summer
upwards and downwards and they were left in place for 15 minutes. This was done once a day for five days. In paralysis cases, electric currents of 20-30 Hz were applied for 30-35 minutes for at least 3 days a week or every day. The current was increased until local muscle contractions were observed. For intraoperative electroacupuncture analgesia, both current and frequency were increased to a peak according to the animal's pain threshold and reactions for the 20-25 minute induction period. During the treatment when symptoms such as hot ears, dry nose, increased pulse, Anxiety and fear, and sweating in horses were observed, the treatment was stopped and needle acupuncture alone was continued. At the end of the treatment time, the electrostimulation was discontinued, and the needles were removed. For laser acupuncture applications a Helium-Neon (He-Ne) gas laser with a constant frequency of 12 miliwatt and an infrared laser machine with a variable frequency of 50 milliwatt was used. The hair was shaved off the point region and a chlorhexidine antiseptic solution was used to scrub the area. Infrared laser was applied vertically to each point for 2 minutes. To increase its effect, the frequency was raised to 12.04 Hz. He-Ne laser was applied to each point for 5-10 minutes from a distance of 30 mm. Results Of the cases included in this study, 37 were disorders of the musculoskeletal system, 25 were neurological system disorders, 4 were internal disorders and 2 were reproductive disorders. Diagnosis, treatment methods, treatment period, amount of treatment and need for further treatments are listed in Tables 1- 3. Tables 4 and 5 contain descriptions of 6 emergency cases and 12 intraoperative analgesia cases. Overall following the prescribed number and frequency of acupuncture treatments, complete recovery was recorded in 20/37 musculoskeletal disorders, 11/25 neurological disorders, 3/4 internal medicine disorders, 2/2 reproductive disorders, and 4/6 cases of respiratory arrest. Good improvement without full recovery was reported in another 7 musculoskeletal disorders, 3 neurological disorders, and 1 internal medicine disorder. Acupuncture anesthesia resulted in excellent analgesia in 1 dog AJTCVM Vol 3, No.1, Summer 2008
and 1 sheep and good analgesia in 4 dogs, 1 cat, and 2 cows. The recommended number of treatments was not completed in 4 musculoskeletal cases and its use for anesthesia was not continued in 3 cases. There was no improvement in 3 musculoskeletal cases and 6 neurological cases and 2 respiratory arrest cases did not respond to treatment. The remaining cases had a minimal response to treatment. Out of 15 cases of hip dysplasia, electro acupuncture was used in 13 and gold implantation was used in 2 cases. Of 13 cases treated with electroacupuncture, complete resolution of clinical signs occurred in 8 cases, good improvement in 3 cases and fair improvement in one case. One other case did not continue the treatment. Of the outcomes of 2 cases in which implants were applied to the acupuncture points, one had resolution of the clinical signs and the other had mild improvement. In dogs with osteoarthritis of the hip joint, 1 case had resolution of clinical signs, 1 had good improvement, 1 had some improvement, 2 did not improve and 1 did not continue the treatment. Complete recovery occurred after acupuncture in a horse with osteoarthritis of hip joint and the horse returned to racing. Significant improvement was seen in 2 horses with flexor tendonitis. After treatment these horses won their races. A case of sore shins, another with shoulder lameness, and 2 horses with back soreness has resolution of clinical signs following acupuncture. Significant improvement occurred in another horse with back soreness. Six cases of intervertebral disc herniation were presented: 3 cats and 3 dogs. While 1 case treated with electroacupuncture did not respond, 3 out of 4 cases treated with needle acupuncture had resolution of clinical signs and one improved significantly. One case in which both needle acupuncture and laser acupuncture were combined also improved. The 4 cases with suspected degenerative myelopathy had different degrees of weakness in the hind limbs and incontinence. With electroacupuncture we had mild improvement in 2 cases and no improvement in another case. Two cases were euthanized according to the client's wishes. In one case, which was treated with classical needle acupuncture, symptoms of quadriplegia resolved after 2 sessions of treatment and the animal started walking. One animal with 11
Table 1: Musculoskeletal system cases
No
Species, Breed, Age, Sex
Diagnosis
Treatment Method
Treatment Period and Frequency
Additional Treatment
Result
1
3 year old F Thoroughbred
Flexor tendonitis
He-Ne Laser acupuncture
One session a day for 10 days
Resting
+++
2
4 year old F Thoroughbred
Flexor tendonitis
Infrared laser acupuncture
One session a day for 10 days
Resting
+++
3
4 year old F Thoroughbred
Sore shins
He-Ne Laser acupuncture
One session a day for 10 days
-
+++
4
2 year old M Arab Left shoulder
Horse
lameness
Electroacupuncture
A total of 5 sessions twice a week
Resting
+++
5
1.5. year old F Kangal
Tendon contracture and Electroacupuncture muscle atrophy
A total of 6 sessions once a week
-
++
Inflammation
6 3 year old F Pointer of the knee
Electroacupuncture A total of 9 sessions Resting
+++
joint
7
1.5 year old F mixed Breed Dog
Inflammation of the knee joint
Electroacupuncture
Once a week. 2 irregular sessions
Resting
Did not continue treatment
8
6 month old M Boxer
Inflammation
of the knee
Electroacupuncture A total of 3 sessions Resting
+++
joint
9
1 year old M mixed Breed Dog
Myositis
Electroacupuncture Once every 3 day Resting
+++
10
4 year old F Arab Horse
Osteoarthritis of hip joint
Electroacupuncture A total of 5 sessions Resting
+++
11
3 year old M Thoroughbred
Pain in lumbar and sacral areas
Electroacupuncture
Twice a week
Resting
++
12
5 year old M Arab Horse
Pain in lumbar and sacral areas
Electroacupuncture
A total of 6 sessions once a week
Resting
+++
13
4 year old F. Thoroughbred
Pain in lumbar
and sacral
Electroacupuncture A total of 5 sessions Resting
+++
areas
14
2 year old M. mixed Tendon
Breed Dog
contracture
Electroacupuncture A total of 5 sessions -
++
15
1 year old M. Kangal
Hip Dysplasia
Electroacupuncture
A total of 8 sessions twice a week
-
+++
16
11 month old M. Labrador
Hip Dysplasia
Electroacupuncture
A total of 4 sessions He-Ne
once a week
Laser
++
17
4.5 year old M. Sheepdog
Hip Dysplasia
Electroacupuncture
A total of 4 sessions once a week
-
+++
4.5 year old M. 18 mixed Breed Kangal
Hip Dysplasia
Electroacupuncture
A total of 4 sessions once a week
-
+++
1 year old M. 19 German Shepherd Dog
Hip Dysplasia
Electroacupuncture
A total of 3 sessions He-Ne
once a week
Laser
++
12
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20
6 month old M. Kangal
Hip Dysplasia
Electroacupuncture
A total of 13 sessions once a week
-
10 month old F. 21 Mixed Breed Kangal
Hip Dysplasia
Electroacupuncture
A total of 6 sessions once a week
-
22
10 month old M. Newfoundland
Hip Dysplasia Electroacupuncture A total of 8 sessions
-
23
1 year old M. Saint Bernard
Hip Dysplasia Electroacupuncture Once a week
-
24
2 year old M. Mixed Breed Dog
Hip Dysplasia Electroacupuncture
4 irregular sessions
-
25
10 month old M. Kangal
Hip Dysplasia Gold implantation
-
-
26
1 year old M. German Shepherd Dog
Hip Dysplasia Gold implantation
-
-
27
1 year old M. Mixed Breed Dog
Hip Dysplasia Electroacupuncture
3 irregular sessions
-
28 7 year old M. Collie
Osteoarthritis of hip joint
Electroacupuncture
A total of 10 sessions once a week
-
29
6 year old M. Mixed Breed Dog
Osteoarthritis of hip joint
Electroacupuncture
A total of 4 sessions once a week
-
30
7 month old F. Terrier
31
5 year old F. Poodle
Aseptic necrosis
Laser acupuncture A total of 4 sessions and implantation once a week
-
Osteoarthritis of hip joint
Laser acupuncture
A total of 4 sessions once a week
-
32
6 month old Pekinese Dog
Aseptic necrosis
Needle acupuncture
A total of 5 sessions once a week
-
33
10 year old F. Mixed Breed Dog
Osteoarthritis of hip joint
Needle acupuncture
A total of 2 sessions once a week
-
34
7 year old M. Mixed Breed Dog
Osteoarthritis of hip joint
A total of 10 Needle acupuncture sessions once a week
-
35
4.5 year old M. Terrier
Osteoarthritis of hip joint
Electroacupuncture
A total of 8 sessions
-
36
10 month old F. Newfoundland
Hip Dysplasia
Electroacupuncture
Once a week A total of 3 sessions
-
37
1 year old M. Chow-chow
Hip Dysplasia Electroacupuncture A total of 8 sessions
-
+++ +++ +++ Did not continue treatment + +++ ++ + _ _ _ + Did not continue treatment Did not continue treatment +++ ++ +++ +++
(+++) very good result: complete resolution of clinical signs, (++) good result: clinical improvement but rarely some symptoms were seen due to other factors ( cold, rain, work, trauma,etc..) , (+) incomplete result: no symptoms according to animal's owner but no clinical improvement according to us, (-) negative result: no clinical improvement
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Table 2: Cases in which acupuncture was used for neurological problems
No Species, Breed, Age, Sex
Complaint
Diagnosis
Treatment Method
Result
1 9 Month old M. Collie
Inability to use leg
Paralysis of N. Radialis
EA**
_ Amputation
2
14 Year old F. Mixed Breed Swaying gait and urinary Intervertebral disc
Cat
incontinence
herniation
3
4 Month old. F. Mixed Breed Cat
Sudden inability to use back legs
Intervertebral disc herniation
Needle acupuncture
++
EA
-
4 13 year old M. Collie
Inability to use back legs
Suspected degenerative myelopathy
EA
Euthanasia
5
2 Year old F. Mixed Breed Dog
Traffic accident
Hemiplegia
Scalp acupuncture
+++
6
13 Year old M. German Shepherd Dog
Lameness in back legs for a year
Spondylosis deformans
EA
+
7 5 year old M. Arab Horse Facial paralysis
Paralysis of N. Facialis
EA
+++
8 7 Year old F. Poodle
Inability to use all 4 legs for 3 days
Intervertebral disk herniation
Needle acupuncture
+++
9
3 Year old F. Mixed Breed Dog
Inability to use back legs
Paraplegia unknown cause
EA
+++
10
4 Month old F. Mixed Breed Dog
Traffic accident
Paralysis of N. Radialis
EA and Aquapuncture
+
11*
1 Month old M. Mixed Breed Dog
Squashed in a door
12
13 Year old F. Mixed Breed Dog
Dragging left back leg
13 1.5 Year old F. Setter
Traffic accident
Paralysis of N. Radialis
EA
-
Paralysis of N. Ischiadicus Paralysis of N. Ischiadicus
EA and Laser acupuncture
++
EA and Aquapuncture
+++
14 1 Year old F. Doberman Traffic accident
Paralysis of N. Radialis
EA
-
15 5 Year old F. Pekinese
Inability to use back legs
Intervertebral disc herniation
Needle acupuncture
+++
16 1 month old foal
Swinging gait and falling Wobbler Syndrome
Laser acupuncture
-
17
1.5 Year old F. Mixed Breed Cat
Fallen from a high place Brain Contusion
Needle acupuncture
+++
18
8 Year old M. Belgian Sheepdog
Inability to use left leg and Susupect degenerative
EA and
+
suddenly falls
myelopathy
Aquapuncture Euthanasia
19
1 Year old F. Mixed Breed Cat
Swinging gait
20
1 Year old M. Mixed Breed Suddenly falls while
Dog
walking
21
1.5 Year old M. Mixed Breed Cat
Inability to use back leg
Intervertebral disc herniation Motor disorder of unknown cause Paralysis of N. Ischiadicus
Acupuncture
and Laser
++
acupuncture
EA
+
EA
+++
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22
2 Year old F Mixed Breed Dog
Inability to use back leg
Paralysis of N. Ischiadicus
EA
_
23 5 Year old F. Dachshund Inability to use back leg
24
2 Year old F. Mixed Breed Cat
Inability to use bladder
25
5 Year old M. Belgian Sheepdog
Inability to use all 4 legs
Intervertebral disc herniation Bladder spasm Spondylitis
Needle acupuncture
+++
EA
+++
Needle acupuncture
+++
* Died during treatment due to distemper. ** Electroacupuncture (+++) very good result: no symptom and full clinical improvement, (++) good result: clinical improvement but rarely some symptoms were seen due to some factors( cold, rain, work, trauma,etc..) , (+)incomplete result: no symptoms according to animal's owner but no clinical improvement according to us, (-) negative result: no clinical improvement
Table 3: Cases with internal medicine and reproductive disorders
Species, No Breed, Age, Sex
1
1 year old M. Boxer
3 year old, F., 2 Kangal Sheepdog
Diagnosis
Symptoms and Duration
Method Used
Treatment Period and Frequency
Result
Relapse
Aquapuncture
Colitis
Bloody diarrhea for 8-9 months
Laseracupunc- A total of 20 ses-
ture
sions once every
Needle acu- two days
++
+
puncture
Megaoesephagus
Vomiting for 4 months
Electroacupuncture
Only one session
+++
+
8 month old, 3 M.,Mixed Breed, Dog
Enteritis
Diarrhea for 2 days
Needle acupuncture Aquapuncture
2 treatments once every 2 days
+++
-
4,5 year old, 4 M., Kangal Sheepdog
Mating with the
Infertility
same female for 2 years but no puppies
Needle acupuncture
A total of 4 sessions twice a week
+++
-
1.5 year old, 5 M., Mixed Breed, Cat
Libido
very high sexual activity for 1 month
Laseracupuncture
A total of 4 sessions twice a week
+++
+
7 year old, 6 M., Mixed Horse
Pain
Pain continuing Hemoacu-
for 1 hour
puncture
only one session
+++
-
(+++) very good result: complete clinical improvement, (++) good result: clinical improvement but rarely some symptoms were seen due to other factors ( cold, rain, work, trauma,etc..) , (+) incomplete result: no symptoms according to animal's owner but no clinical improvement according to us, (-) negative result: no clinical improvement
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Table 4: Cases in which acupuncture was used for an emergency problem.
No
Species,Breed, Age , Sex
Emergency Problem
Method Used
1 1.5 Year old M. Mixed Breed Dog Respiratory arrest
GV-26 needle acupuncture
2 2 Year old M. Mixed Breed Cat
Respiratory arrest
GV -26 needle acupuncture
3 1.5 Year old M. Collie
Respiratory arrest
GV -26 needle acupuncture
4 3 Year old F. Mixed Breed Dog
Respiratory arrest
GV -26 needle acupuncture
5 1 Year old F. Poodle
Respiratory arrest
VG-26 needle acupuncture
6 1.5 Year old F. Mixed Breed Dog
Respiratory arrest
VG-26 needle acupuncture
(+++) very good result: improvement, (-) negative result: no improvement
Result +++ +++ +++ +++
Table 5. Cases in which acupuncture anesthesia was applied for surgical procedures.
Analgesia degree
No** Species, Breed, Age, * Sex 1 10 Year old M. Poodle
Operation Perineal hernia
Method Time of and OperaTime tion
E.A.* 15 min
1 hour
Skin- Muscle-Traction- Suture
+ ++ --
++
2
5 Year old M. Poodle
Removal of hyperplastic tissue
E.A 1520 min.
20 min.
++
Absent
Absent
+++
3
1.5 Year old F. Mixed Breed Dog
Inguinal hernia
E.A 20 min + 15 min
1 hour
_
Ab- Absent sent
4
1 Year old M. Mixed Breed Dog
Tail Amputation
E.A 25 min.
15 min.
++
Absent
Absent
Absent ++
5 3 Year old F. Sheep
Evisceration
E.A 20 min.
1.5 hour
++
+++
++
+++
6 2 Month old M. Calf
Umbilical Hernia
E.A 20 min.
1.5 hour +++
+
+
+++
7
5 Year oldli F.Holstein Cow
Rumenotomy
E.A 20 min.
2 hour
++
+++
++
++
8
1.5 Year old M. Mixed Breed Dog
Removal of the Steinmann pin
E.A 15 min.
15 min.
_
Ab- Absent sent
Absent
9
5 Year old M. Mixed Breed Dog
Tumor removal
E.A 20 min.
30 min.
++
+
--
++
10
3 Year old F. Mixed Breed Dog
Wound revision
E.A 15 min.
20 min
++
Absent
Absent
++
11** Calf
Atresia recti
E.A 15 min.
5 min +++ +++
12
1.5 Year old F. Mixed Breed Cat
Prolapsed rectum
E.A. 15 min.
10 min
Absent
Absent
++
+++
Result ++ +++ Did not continue ++ +++ ++ ++ Did not continue ++ ++ Did not continue ++
* Electroacupuncture ** Calf was send to slaughterhouse due to negative prognosis. *** Not use any premedication (+++) excellent analgesia, (++) good analgesia, (+) not complete analgesia but operation can be continue, (- )incomplete analgesia
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hemiplegia was in advanced pregnancy. She recovered completely after the scalp acupuncture treatment and gave a normal birth. In a case paralyzed after being hit by a car, we applied a total of 20 acupuncture treatments twice a week for 10 weeks. In respiratory arrest during anesthesia, we applied classical needle acupuncture to GV-26 in 5 dogs and 1 cat. Out of a total of 6 cases respiration returned approximately 1 minute after acupuncture in 4 cases and there was no response in 2 cases. Electroacupuncture was applied to 12 cases intraoperatively for analgesia. The minimum induction period was 15 minutes and the maximum was 25 minutes. Excellent analgesia was obtained in 3 cases and good analgesia in 6 cases. Alternative anesthesia methods were used in 3 cases, because acupuncture analgesia was inadequate. For acupuncture analgesia to be successful, factors such as silence of the personnel in the operating theater, gentle and quick movements from the surgeon and minimum traction were important. Especially during organ traction, complete analgesia was unobtainable. In some cases, especially in large animals, moderate analgesia was obtained in the skin and the operation was performed. In 86 cases, the maximum treatment was 20 times and the minimum was once. The longest treatment lasted for 13 weeks and is listed as case No. 20 in Table 1. The total number of treatments given to 86 cases was 404. DISCUSSION The aim of this study was to further examine the clinical applications and effectiveness of acupuncture and add the results of more cases to the literature. All cases in which acupuncture was used were included. Difficulties were encountered choosing cases, because animal owners were not familiar with acupuncture or had misconceptions about acupuncture treatment. Owner compliance for regular acupuncture treatment was sometimes difficult to attain, and so some cases had very irregular treatment periods and some owners discontinued treatments. Most of the cases chosen for this study were those in which no response was seen with conventional treatments. Thus our database consists mostly of chronic cases and those that were difficult to manage. Although Pin-Yin nomenclature is usually AJTCVM Vol 3, No.1, Summer 2008
adequate in large animals, we observed that the acupuncture points in the Pin-Yin system were not appropriate for cats and dogs. Although there are 76 points for dogs in the Pin-Yin system, while searching points using the acupuncture detector, we found many points following the human meridian system which have also been defined by many researchers. 1, 2, 4, 6, 5, 7, 9, 10 11, 12 While electroacupuncture has been frequently documented, classical needle acupuncture, laser acupuncture, aquapuncture and implantation techniques can also be used in veterinary medicine. 1-4, 8, 13-22, 38, 78 It might be practical to use an implantation acupuncture technique on patients that are unable to continue classical acupuncture treatments. Like other clinicians, we too have seen that implantation has been successful in hip dysplasia.67, 69 However, in a case of severe aseptic necrosis, use of the leg did not occur following gold implantation and excision arthroplasty was performed. This situation was probably due to the fact that muscle atrophy was severe and the progress of this atrophy could not be stopped by gold implantation. Even if the pain in the hip joint disappears, the muscle group may not be able to carry the weight due to the atrophy. Laser acupuncture has been used in veterinary acupuncture more.27, 32, 83-85 Laser acupuncture was also used in this case series, especially in cases such as tendonitis, hip dysplasia, myoatrophy, paralysis and in aggressive animals that would not allow needle acupuncture. Because of wavelength and power, infrared lasers need less treatment time than Helium-Neon lasers, and it would be preferable to use them in veterinary acupuncture.4, 83 Aquapuncture with vitamin B12 injectable solution was also used. This facilitated treatment of small animal cases when the pet owner did not have enough time, the animal was aggressive and difficult to restraint or the acupuncture point chosen for treatment was dangerous for needle application. As other clinicians have discussed and also observed in this study, electroacupuncture is more beneficial and much faster in producing results than needle acupuncture.4,12 Electroacupuncture was used in many cases, especially for its rapid onset of pain relief and its ability to stimulate peripheral nerves easily. Electroacupuncture was not used in anxious and frightened animals or pregnant animals 17
as application in these cases is contraindicated.1, 2, 4, 8, 12 Hemoacupuncture as described in classical books was difficult to perform in horses with pain as it was hard to restrain the animals. It is necessary to restrain an animal in pain during acupuncture. Kenny, et al, have stated that they have tried the same treatment with aquapuncture but were unsuccessful.44 The successful results obtained following electroacupuncture in 3 race horses with lumbar and sacral pain had pain relapse for a year follow-up period. 25, 27, 32, 45 A-Shi points should be treated. These are points that are sensitive when compression is applied by finger, are not normally present in the back region, but develop in cases where there is pain. As reported by other authors, relapse was seen within a month following electroacupuncture in race horses with shoulder lameness. 2, 8, 32 The relapse resolved after 2 further treatments and was not observed for another year. It is thought that the relapse may be because the animal will prematurely bear weight on the pain free limb. Like Cain, we applied laser acupuncture to 2 racehorses with flexor tendonitis and both of them came first in their respective races after acupuncture treatment.2 No differences in outcome were observed between the Helium-Neon and infrared lasers. Two cases of aseptic necrosis of the femoral head did not improve. The main reason for this was that although the implants stopped the pain in the case where implantation was used, muscle atrophy had progressed and the animal could not use its leg. Owner compliance and lack of return for subsequent treatments occurred in one case. Electroacupuncture was applied to 2 cases with inflammation of the knee joint with similar results as previously reported. 1, 4, 8, 12, 14, 16 Although there was no radiological difference before and after the treatment, both cases started using their legs again because the pain had stopped. Care must be taken to minimize trauma while applying needles to acupuncture points around the knee joint. In cases of tendon contracture, acupuncture relieved muscle spasm and increased microcirculation. Because of these characteristics acupuncture might be used alternatively or in addition to physiotherapy programs. The leg was used in 1-1.5 months in cases of tendon contracture. In one case with no skeletal lesions that had been treated unsuccessfully with anti-inflammatory 18
drugs for almost a month, that the pain ceased and the animal began using the leg after a 3-week course of acupuncture. The relief of pain is associated with both a local effect and the release of endogenous endorphins. 68, 86-89 Contrary to some researchers and classical acupuncture books, no positive results were obtained with acupuncture in cases of radial nerve paralysis.3, 4, 8, 12, 72, 90 One explanation may be that patients did not receive regular treatments or nerve damage was complete. Like other reports, good results were obtained in cases of intervertebral disc herniation.1, 8, 51, 61 Acupuncture was not helpful in cases of suspected degenerative myelopathy. We used scalp acupuncture in a hemiplegia case. We applied the treatment by choosing the coinciding points on the cranium to the motor areas of the brain as defined in veterinary literature. 91, 92 Due to pregnancy, we used needles only in this case, as some clinicians have suggested that acupuncture is contraindicated in pregnant animals.4, 8, 12, 86 As a result of needles being applied to acupuncture points on the head and these needles being twisted, muscle relaxation in the paralyzed limb and trembling in the neck muscles were observed. Respiration returned in 4/6 cases in which needle acupuncture was applied to the GV-26 point in cases of respiratory arrest.93, 95 GV-26 has a sympathomimetic effect on cardiac, circulatory and respiratory systems.94, 95 Acupuncture in conjunction with conventional resuscitation treatments is usually recommended, but acupuncture alone may be used when no medical facilities are present. In this study and in others, the success of acupuncture for intraoperative analgesia is greatly affected by the temperament of the animal.4, 12, 77, 79 Good results were not obtained in nervous or frightened animals. No cases in this study were sedated so acupuncture analgesia alone could be evaluated. However, for routine use, sedation is recommended along with acupuncture. As in other reports, the best analgesic results were found in ruminants.4, 8, 12 The author agrees that the surgeon should work quickly but gently, the personnel in the operating theater should not make any noise and organ traction should be kept at a minimum.1, 4, 8, 12, 75-77, 78, 80-82 Noise negatively influenced analgesia. No recovery injuries occurred after acupuncture analgesia intraoperatively. In conclusion, AJTCVM Vol 3, No.1, Summer
acupuncture was effective for many different clinical problems in veterinary medicine and can be useful alone or in conjunction with other conventional treatments. a. Zhongyan Taihe Medicine Co. LTD, Beijing, China. b. Saglam Electronic, stanbul, Turkey. c. Donghua Electronic Instrument Factory, Beijing, China REFERENCES 1. Schoen AM. Veterinary Acupuncture. Ancient art to Modern Medicine. American Veterinary Publications Inc. Mosby. New York 1994, pg 707 2. Janssens, L.A.A.. Some Aspects of Small Animal Acupuncture: The Clinical Scientific Approach 176. Belgian Vet. Acup. Society, 1988. 3. Altman, S. (1981) : Clinical Use of Veterinary Acupuncture. Pet Practice. September, 1307, 1312. 4. Anon (1982) : Proceedings of the 8th Annual International Conference on Veterinary Acupuncture. 312. Forth Mitchell, Kentucky, USA. 5. Anon (1986) : Proc. of the 12th Ann. Int Conf. on Vet Acup. 233. USA. 6. Anon (1989) : Proc of the 17th Ann. Int. Conf. on Vet. Acup.163. Seattle, Washington State, USA 7. Anon (1990) : Proc. of the 16th Ann. Int. Conf. on Vet. Acup. 299. Noordwijk, Holland. 8. Anon (1991) : Chinese Veterinary Acupuncture and Moxibustion. Lecture Notes. 215. Beijing Agricultural University. 9. Anon (1991) : Proc. of the 17th Ann. Int. Conf. on Vet. Acup. 107. Decatur, Georgia, USA. 10. Anon (1992) : International Veterinary Acupuncture and Moxibustion training course. Lecture Notes.300. Beijing Agricultural University. 11. Anon. (1983) : Proc. of the 9th Ann. Int. Conf. on Vet. Acup. 79. Forth Mitchell, Kentucky, USA. 12. Anon. (1984) : Proc. of the 10th Ann. Int. Conf. on Vet. Acup. 213. Austin, Texas, USA. 13. Anon. (1985) : Proc. of the 11th Ann. Int. Conf. on Vet. Acup. 103. San Francisco, CAlifornia, USA. AJTCVM Vol 3, No.1, Summer 2008
14. Anon. (1987) : International Conference On Veterinary Acupuncture. 158. China Academic Publishers. Beijing, China. 15. Anon. (1987) : Proc. of the 13th Ann. Int. Conf. on Vet. Acup. 165. Belgium. 16. Anon. (1988) : Proc of the 14th Ann. Int. Conf. on Vet. Acup. 135. Milwaukee, Wisconsin, USA. 17. Artmeier, V.P.; Kцnig, H.E. (1978) : Zur ohrakupunktur beim Hund. Kleinter-praxis, 23, 299-306. 18. Bachmann, B. (1989) : Acupuncture and Infertility in a Cow. Vet. Acup. Newsletter. 15 (1), 4. 19. Burton, C.D. (1988) : Acupuncture As Adjunct Therapy for Coccidomycosis. Vet. Acup. Newsletter. 14(4), 10-12. 20. Burton, C.D. (1989) : Treating incomplete Rectal Prolapse with Acupuncture. Newsletter. 15(1), 4. 21. Chadwick, M. (1979) : Acupuncture treatment of cats. The Vet. Record. 8, 541. 22. Cheng, X. (1987) : Chinese Acupuncture and Moxibustion. 544. Foreign Languages Press. Beijing. 23. Craige, J.E. (1985) : Acupuncture for fleabite allergic dermatitis. JAVMA. 187 (2), 127. 24. De Lahunta, A. (1983) : Veterinary Neuroanatomy and Clinical Neurology. 471. W.B. Saunders Company. Philadelphia, London, Toronto, Mexicocity. 25. Dill, S.G; Gleed, R.; Mathews, N.S.; Erb, H.N.; Miller, J.K. (1988) : Cardiovascular effects of Acupuncture Stimulation at point Governing Vessel 26 in halothane anesthetized ponies. Am.J. Vet. Res. 49 (10), 1708, 1712. 26. Dodd, G. (1982) : Part-III- Veterinary Acupuncture. Treatment of Quadriplegia in a Dog Using Electroacupuncture. California Veterinarian. 3, 23-26. 27. Dodd,G. (1982) : Part-I - Introduction and Philosophy of EAV Electroacupuncture. California Veterinarian. 1,19-22. 28. Doo,Seok, S.; Nam-Yang, P.; Oh-nam, K. (1984) : Experimental Studies on the wound healing under Medicament and Acupuncture Anesthesia in Dogs. Korean J. Vet. Res. 24 (1), 110-119. 29. Doo-Seok, S.; Oh-nam, K. (1978) : A case of 19
canine paresis. Treated by Acupuncture. J. Korean Vet. Med. Ass. 14 (4), 227-231. 30. Ettinger, S.J. (1989) : Textbook of Veterinary Internal Medicine Disease of the Dog and Cat. 2399. W.B.Saunders Company, Philadelphia, London, Toronto, Montreal, Sydney, Tokyo. 31. Gideon, L. ( 1977) : Acupuncture clinical trials in the Horse. JAVMA: 170 (2), 220-224. 32. Glinski, M.H. (1989) : Acupuncture Treatment for Generalized Arthritis Caused by Lyme Disease in a Miniature Schnauzer. Vet. Acup. Newsletter. 15 (3), 4-5. 33. Griffth, D.W: (1988) : Acupuncture for the Treatment of Lumbal Disc Disease. Vet. Acup. Newsletter. 14 (4), 13-14.is lumbal disc a valid term? 34. Grob, P. (1989) : Chronic Respiratory Disease in an Iceland Pony. Vet. Acup. Newsletter. 15 (3),11. 35. Hall, B.J. (1989) : Acupuncture Therapy for Hygroma. Vet. Acup. Newsletter. 15 (3), 5-6. 36. Ho, S.T.; Lu, L.K. (1981) : The Principles and use of Accupuncture Anesthesia. 340. HongKong Medicine and Health Publishing CO. HongKong. 37. Holiday, R.J. (1988) : Acupuncture Treatment of Mastitis. Vet. Acup. Newsletter. 14 (4), 1718. 38. Holiday, R.J. (1989) : Acupuncture in an Anestrous Cow. Vet. Acup. Newsletter. 15 (1), 8-9. 39. Hua, X. (1987) : On Animal Acupoints. Journ. of traditional Chinese medicine. 7(4). 301304. 40. Janes, W.E. (1989) : Equine Sports Medicine. 329. Lea & Febiger. Philadelphia. 41. Janssens, L.A.A. (1984) : Acupuncture Points and Meridians in the Dog. Int. Vet. Acup. Ass. (Chart). 42. Janssens, L.A.A. (1988) : Some Aspects of Small Animal Acupuncture: The Clinical Scientific Approach.176. Belgian Vet. Acup. Society. 43. Janssens, L.A.A. (1989) : Acupuncture Treatment of Experimental Spinal Cord Trauma in the Rat. Scand.Journ of Acup. and E.T. 4, 43-48. 44. Janssens, L.A.A. ; Rogers, P.A.M.; Schoen, A.M. (1988) : Acupuncture Analgesia : A 20
review. The Veterinary Record. 122, 355-358. 45. Janssens, L.A.A.; Altman, S.; Rogers, P.A.M. (1979) : Respiratory and cardiac arrest under general anaesthesia: Treatment by acupuncture of the nasal philtrum. The Veterinary Record. 105, 273-276. 46. Kenney, J. (1988) : Acupuncture for Treatment of a Gastric Ulcer in a Thoroughbred colt. Vet. Acup. Newsletter. 14 (4), 17. 47. Kenney, J. (1988) : Acupuncture for use in the treatment of postpartum Uterine Hemorhage in an Aged Thoroughbred Mare. Vet. Acup. Newsletter. 14 (4), 18-19. 48. Kenney, J. (1989) : Acupuncture for the Symptomatic Relief of Colic Pain. Vet. Acup. Newsletter. 15(1), 9. 49. Kenney, J. (1989) : Acupuncture for Treatment of Lumbosacral Pain in a Thoroughbred Colt. Vet. Acup. Newsletter. 15 (3), 12. 50. Khalsa, D.K (1989) : Acupuncture For Senility in a Dog. Vet. Acup. Newsletter. 15 (3), 6-7. 51. Kleinkort, J.A.; Folley, R.A. (1984) : Laser Acupuncture : It's use in Physical Therapy. Amer. Journ of Acup. 12(1), 51-56. 52. Klide, A.M.; Farnbach,G.C.; Gallagher,S.M. (1987) : Acupuncture Therapy for the Treatment of Intractable Idiopathic Epilepsy in Five Dogs. Acup. and Electrotherapeutics Res. Int. Journ. 12, 71-74. 53. Klide, A.M.; Kung, S.H. (1977) : Veterinary Acupuncture. 297. University of Pennsylvania Press., USA. 54. Klide, A.M.; Martin, B.D. (1989) : Methods of stimulation acupuncture points for treatments of chronic back pain in horses. 55. Kothbauer, O.; Meng, A. (1990) : Grundlagen der Veterinar- Akupunktur spezielle Akupunktur bei Rind, Schwein und Pferd. 335. Verlag Welsermьhl. wels. 56. Kuussaari, J. (1983) : Acupuncture Treatment of Aeorophagia in Horses. 11 (4), 363-370. 57. Lambardt, L.A. (1985) : Bioelekronishe Funktiondiagnostik in der Veterinarmedizin. (Kleinterpraxis). Der praktische Tierarztl. 9, 545-559. 58. Lee, K.; Tin, S. (1985) : A Handbook of Acupuncture Treatment for dogs and cats. 50. HongKong Medicine and Health Publishing CO, Hong Kong. AJTCVM Vol 3, No.1, Summer
59. Maeno, N.; Kameya, T.; Yamada, H.; Abe, N. (1989) : Effects of LLLT using Helium Neon Laser on Infectious Bovine Keratoconjunktivitis. L.L.L.T. Original Articles, 79-82. 60. Martin, B.; Klide, P.A.M. (1987) : Treatment of Chronic Back Pain in Horses-Stimulation of Acupuncture Points with a Low Powered Infrared Laser. Veterinary Surgery. 16 (1), 106110. 61. Martin, B.; Klide, P.A.M. (1991) : Acupuncture for the Treatment of Chronic Back Pain in 200 Horses. G.G.E.P. 62. May, K. (1989) : Acupuncture Therapy : Navicular Disease. Vet. Acup. Newsletter. 15 (1), 10-13. 63. Mc. Cormick, W.H. (1989) : Acupuncture Therapy for chronic pain Referable to Mc II or Medial Splints in a Horse. Vet. Acup. Newsletter. 15 (2), 13-13. 64. Mc. Cormick, W.H. (1989) : Acupuncture Treatment for Bilateral Indolent Corneal Ulcers in a Horse. Vet. Acup. Newsletter. 15 (2), 1314. 65. Mc. Cormick, W.H. (1989) : Acupuncture Treatment of a Case of Chronic Heal Lameness with Gold Implants. Vet. Acup. Newsletter. 15 (3), 12-13. 66. Mc. Kibbin, L.S. (1984) : Use of Laser Light to Treat Certain Lesions in Standartbreds. Modern Vet. Practice. 210-214. 67. Montgomery, R.A. (1989) : Acupuncture for Chronic Cervical Pain. Vet. Acup. Newsletter. 15(2), 7-8.. 68. O'connor, J.; Bensky, D. (1988) : Acupuncture : A comprehensive Text. 741. Eastland Press. USA. 69. Partington, M. (1989) : Acupuncture Treatment for Depressive mental disorder in an Umbrella Cackatoo. Vet. Acup. Newsletter. 14 (4), 9-10. 70. Partington, M. (1989) : Aquapressure is this correct ? Treatment for Medial Patellar Luxation. Vet. Acup. Newsletter. 15 (3), 7-8. 71. Partington, M. (1989) : Auricular Shenmen Implant for the Treatment of Idiopathic Epilepsy in a Dog. Vet. Acup. Newsletter. 15 (3), 7-8. 72. Partington, M. (1989) : Gold Implants for Hip Dysplasia. Vet. Acup. Newsletter. 15(1), 5-6. AJTCVM Vol 3, No.1, Summer 2008
73. Pei, C.T. (1974) : Essai d'electroanesthesie chez le chien. Federation Proceedings. 3, 382. 74. Poulton, P. (1991) : Acupuncture Treatment of a Dog with Osteoarthritis of the Elbow. Vet. Acup. Newsletter. 17(1), 11. 75. Rogers, P.A.M. (1988) : Suspect peptic ulcer in two foals. Acupuncture Therapy Successful. Vet. Acup. Newsletter. 14(4), 15-16. 76. Scanlan, N. (1989) : Acupuncture in a Case of Limb Trauma and Ringbone in a Horse. Vet. Acup. Newsletter. 15(2), 14-15. 77. Schneideman, I. (1988) : Medical Acupuncture. 331. Mayfair Medical Supp. Ltd., Hong Kong. 78. Schoen, A.M. (1994) : Veterinary Acupuncture. Ancient art to Modern Medicine. 707. American Veterinary Publications Inc. Mosby. NewYork. 79. Schwartz, C. (1990) : Treatment of Systemic Lupus Erythematosus. Amer. Journ. of Acup. 18 (3), 247-249. 80. Short, C.E.; Poznak, A.V. ( 1992 ) : Animal Pain. New York, Churchill Livingston. 81. Still, J. (1987) : Acupuncture Analgesia for Laporotomy in dogs and cats : An Experimental Study. Amer. Journ. of Acup. 15 (2), 155-165. 82. Still, J. (1988) : A comparison of respiratory stimulant effects of acupuncture at the philtrum point VG-26 with noradrenalin in thiopental induced apnea in dogs. Scandinavian Journ. of Acup. 3(4), 129-136. 83. Still, J. (1988) : Relationship Between Electrically Active Skin Points and Acupuncture Meridians Points in the Dog. Amer. Journ. of Acup. 16(1), 55-71. 84. Thoresen, A.M. (1989) : Equine Acupuncture Based on Twelve Points : An effective Diagnostic and Therapeutic Method for Veterinarians with no Acupuncture Knowledge. Amer. Journ. of Acup. 17(2), 160-170. 85. Weintrub, G.B. (1989) : Acupuncture for Treatment of Leukorrhea. Vet. Acup. Newsletter. 15(3), 9-10. 86. Weintrub, G.B. (1989) : Acupuncture Therapy for Megaesophagus. Vet. Acup. Newsletter. 15 (2) 10-11. 87. Weintrub, G.B. (1989) : Acupuncture Therapy for Radial Nerve Paralysis. Vet. Acup. Newsletter. 15(1), 6-7. 88. Westermayer, E. (1979) : The Treatment of 21
Horses by Acupuncture.42. CW. Daniel Co.Ltd. England. 89. Westermayer, E. (1983) : Acupuncture Meridians and Ancient Points Especially in Cattle. Amer. Journ. of Acup. 11(3), 259-267. 90. White, S.S.; Bolton, J.R.; Fraser, D.M. (1985) : Use of Electroacupuncture as an analgesic for laporotomies in two dairy cows. Australian Vet. Journ. 62(2), 52-54. 91. White, S.S.; Christie, M. (1984) : Traditional Acupuncture and Tetanus in the Horse. Amer. Journ of Acup. 12(4). 359-365. 92. Wiebicke, V.G. (1986) : Lasertherapie in der Veterinarmedizin. Der praktishe Tierarztl. 11, 958-961. 93. Wright, M.; Mc. Grath, C.J. (1981) : Physiologic and Analgesic Effects of Acupuncture in the Dog. JAVMA. 178(5), 502-
507. 94. Wurth, U. (1991) : Treatment of a Dog with a Vital Neck Abnormality. Vet. Acup. Newsletter. 17 (1), 11. 95. Wurth, U. (1991) : Urinary Incontinence. Vet. Acup. Newsletter. 17(1), 11. 96. Wurth. U. (1991) : Cat with a Skin Problem. Vet. Acup. Newsletter. 17(1), 12. 97. Yamada, H.; Kameya, T.; Abe, N.; Miyakara, K. (1989) : Low Level Laser Therapy in Horses. LLLT Original Articles. 31-35. 98. Zhang, E. (1988) : Chinese Acupuncture and Moxibustion. 624. Publishing House of Shanghai College of Traditional Chinese Medicine. 99. Zhang, W. (1981) : Painless Surgery for Animals. California Veterinarian. 12, 19-20.
TCVM NOTES What's the meaning of "detoxifying"in TCVM? In TCVM, detoxifying is called "Jie Du". Jie means "anti" and Du refers to poison or toxin. The term "detoxifying" or "Jie Du" is often combined with "clearing Heat (Qing Re)". Extreme Heat (Re Ji) and Heat Toxin (Re Du) are similar TCVM terminologies. Both of them are Excess Heat. Extreme Heat is 100% pure excessive heat (red tongue, fast/strong pulse, yellow coating, high fever etc.) and Heat Toxin refers to the infectious or epidemic Excess Heat, such as flu, or other viral infections. Because of their difference, two separate herbal categories are designed for these conditions: 1) The herbs to clear Heat and drain Fire (Qing Re Xie Huo) are used for Extreme Heat. Individual herbs include Gypsum Shi Gao and Anemarrhena Zhi Mu to clear Heat and drain Fire. 2) The herbs to clear Heat and detoxify (Qing Re Jie Du) are used for Heat Toxin (infectious Excess Heat). Individual herbs include Lonicera Jin Yin Hua and Forsythia Lian Qiao. Herbal formulas include Yin Qiao San. Their actions are to clear Heat and Detoxify. (Huisheng Xie DVM, PhD)
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AJTCVM Vol 3, No.1, Summer

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