1. A Short History of Medicine 2000 B.C. Here, eat this root 1000 A.D. That root is heathen. Here, say this prayer. Here, say this prayer. 1850 A.D. That prayer is superstition. Here, drink this potion. Here, drink this potion. 1940 A.D. That potion is snake oil. Here, swallow this pill. Here, swallow this pill. 1985 A.D. That pill is ineffective. Here, take this antibiotic. Here, take this antibiotic. 2000 A.D. That antibiotic is artificial. Here, eat this root. Here, eat this root.

2. TCM Kidney Disease  Kidney Physiology  Kidney Jing  Pediatrics  Ear Diseases

3. Water  Sound groaning groaning  Emotion fear fear  Climate cold cold  Season winter winter  Direction north  Opening ears  Body Part bones  Zang/Fu KID/BL

4. According to Plain Questions (Su Wen), fear leads to Qi leakage. Fear allows the Qi to flow downwards and leak. When this happens, the Kidney Qi is not firm, thus resulting in incontinence, hind limb weakness, and abortion. The Chinese word kong refers to Fear which is associated with the Kidney. An animal that experiences Fear will become scared and run away. Qi goesKidney QiUrinary incontinence FEARdownwardnot firmHind limb weakness FEARdownwardnot firmHind limb weakness & leaksPremature ejaculation Abortion FEAR

5. WATER TYPE  Personal Characteristics: Introverted Introverted Terrified or fearful about everything Terrified or fearful about everything Quiet, but a good observer Quiet, but a good observer Skilled at planning and scheming Skilled at planning and scheming Good advisor or supervisor Good advisor or supervisor Prefers deep thought Prefers deep thought Willing to live alone Willing to live alone Very consistent, but slow when doing something Very consistent, but slow when doing something Sinister or insidious if evil Sinister or insidious if evil Fear biter Fear biter  Physical Characteristics: Thin, middle sized body Thin, middle sized body Black hair on the head Black hair on the head Deep, big eyes and big ears Deep, big eyes and big ears Cold intolerance: Prefers to stay in a warm area Cold intolerance: Prefers to stay in a warm area Pulse: Deep Pulse: Deep Not a favorable type for a stallion Not a favorable type for a stallion  Disease Predispositions: Edema Infertility Back pain Urinary infections Diarrhea at dawn Depression  Life Span: Very long

6. Kidney  Storing Jing (Essences) Congenital Jing Congenital Jing Acquired Jing Acquired Jing  Governing Water Metabolism Acts as the gate of water Acts as the gate of water  Controlling the Reception of Qi Holds or pulls Qi down from Lung Holds or pulls Qi down from Lung It is in charge of inhalation It is in charge of inhalation  Dominating Bone, Producing Marrow, and Filling up the Brain Influences bones and the central nervous system Influences bones and the central nervous system The Kidney is the Minister of the Water pathway. The Kidney is the root of prenatal life. With age, the Kidney essence gradually diminishes. Kidney essence should be always conserved. If there is a disorder, the Kidney is almost always deficient.

7. TCM 24 Hour Clock

8. Water Balance  Sheng cycle nourishes it  Ke cycle restrains it Provides the tension Provides the tension

11. Patterns of Kidney Disharmony  Lower back pain  Frequent urination (bedwetting)  Ringing in the ear  Lack of hearing acuity/deafness  Excessive fear  Lack of willpower

12. Kidney Physiology  Genetics ruled through kidneys (base intelligence)  Houses & governs the essence, rules the senses (jing) Jing of heart rules tongue, speech, consciousness, intelligence Jing of heart rules tongue, speech, consciousness, intelligence Jing of spleen rules taste, development of flesh Jing of spleen rules taste, development of flesh Jing of lung rules smell, acceptance Jing of lung rules smell, acceptance Jing of kidneys rules hearing (listening), willpower (discipline) Jing of kidneys rules hearing (listening), willpower (discipline) Jing of liver rules vision, creativity, decision making Jing of liver rules vision, creativity, decision making  Rules growth & development

13. Genetic Control of Life  Obtain one pair of DNA from each parent  Some areas are imprinted Suppressed so that only one gene is active Suppressed so that only one gene is active No back up if something damages remaining gene No back up if something damages remaining gene  Suspect 200 regions Responsible for many later life diseases Responsible for many later life diseases

14. Kidney Physiology  Storing Jing (Essences) Congenital Jing: Congenital Jing: Inherited from the parentsInherited from the parents Congenital foundation of life (Genetic materials: DNA, genes)Congenital foundation of life (Genetic materials: DNA, genes) Nourishes the fetus before birthNourishes the fetus before birth Regulates development, growth, aging, and reproduction after birthRegulates development, growth, aging, and reproduction after birth Deficiency of Kidney Jing Infertility and retarded growthDeficiency of Kidney Jing Infertility and retarded growth Controls the 7-year (female) and 8-year (male) cycles of development and growthControls the 7-year (female) and 8-year (male) cycles of development and growth Acquired Jing: Acquired Jing: Also called Essence of Zang-FuAlso called Essence of Zang-Fu Basic substance for maintenance of the vital activitiesBasic substance for maintenance of the vital activities Extracted from Food Qi by SpleenExtracted from Food Qi by Spleen

15. Kidney Essence Impowers  Kidney provides initial spark to all other organs During prenatal life of fetus During prenatal life of fetus  Timing & genetics dictate the resulting disease Which organ is affected Which organ is affected

16. Spleen for Postnatal Essence  While kidney is central for prenatal life, Spleen is central for postnatal life Maintains vitality of other organs Maintains vitality of other organs Helps protect and replentish prenatal essence Helps protect and replentish prenatal essence

17. The Jing Candle  Candle bruning at both ends Original Kidney Jing Original Kidney Jing Acquire Spleen Jing Acquire Spleen Jing  Candles are different sizes based upon Kidney Jing Replenished slowly by spleen Replenished slowly by spleen JING Gu Qi

18. Telomeres  Highly repetitive region ofDNA at the end of a chromosome DNAchromosomeDNAchromosome  DNA polymerase complex is incapable of replicating all the way to the end DNA polymerase DNA polymerase Pretects from loss of vital genetic information, which is needed for cell's activities Pretects from loss of vital genetic information, which is needed for cell's activitiesgenetic informationcellgenetic informationcell  Every time a cell with linear chromosomes divides Lose a small piece of one of its strands of DNA. Lose a small piece of one of its strands of DNA. This process has been referred to by James Watson and Alexei Olovnikov as the "end replication problem" (1971) This process has been referred to by James Watson and Alexei Olovnikov as the "end replication problem" (1971) James Watson James Watson  Have a function in the ageing process. ageing processageing process

19. What does this mean?  Clones are inherently deficient  Adult stem cells are less robust  Artificial increase in telemeres leads to cancer  When the telemeres are gone, life ends

20. Life is Balance  Hope you get the best Jing  Protect it with diet  Live well and enjoy what you are given  Make lemonade

21. Yuan Qi  (Primary Qi, Source Qi, Original Qi) Derived from the Kidney Essence or congenital Essence Derived from the Kidney Essence or congenital Essence It is Essence in the form of Qi, rather than fluid. It is Essence in the form of Qi, rather than fluid. Requires supplementation and nourishment by the Food Essence (Gu Qi) Requires supplementation and nourishment by the Food Essence (Gu Qi) Comprises the Primary Yin (Kidney Yin) and the Primary Yang (Kidney Yang) Comprises the Primary Yin (Kidney Yin) and the Primary Yang (Kidney Yang) It is the original dynamic motive force of normal activities. It is the original dynamic motive force of normal activities. Distributed to the whole body by the Sanjiao Distributed to the whole body by the Sanjiao Impels the Zang-Fu organs to bring normal activities into play Impels the Zang-Fu organs to bring normal activities into play Maintains normal growth and development of the body Maintains normal growth and development of the body Pathology: Yuan Qi Deficiency results in decreased disease resistance Pathology: Yuan Qi Deficiency results in decreased disease resistance

22. Energy of Life  Yuan Qi impels the function of the organs

23. JING PATHOLOGY  Signs of Jing Deficiency Retarded or poor growth Retarded or poor growth Developmental orthopedic diseases Developmental orthopedic diseases Loss of vitality Loss of vitality Infertility Infertility Early aging Early aging

24. Jing Pathology  Can be acquired from too much strain on the candle  One of the problems of the Chinese emperors

25. Pathology of Kidney Kidney Fear or Stress or Pathogens Jing Deficiency (original or acquired) Child LIV- -joint disease HT/PC- -shen Grandchild KID- -nephritis Organ Channel Bone, Marrow, Head Ears BL LU/LI- -asthma & edema Parent SP/ST- -damp Grandparent Incontinence

26. CAM Use in Kids  1992-2005, 66 pediatric utilization studies US, Canada, UK, Australia, Turkey, Norway…  General and subspecialty populations  Use increasing Complementary and Alternative Research and Education Program

27. Pediatric Epidemiology  Spiegelblatt ’94 Pediatrics ; 11% used prof. CAM  Ottolini, et al, W, DC, ‘98: 20% of kids in 4 practices  Taylor, et al, Seattle, ‘98: 30% -50% use echinacea or vitamin C for kids’ colds  Indiana teens ‘98: 20-30% of athletes take supplements  Crow, et al. Ped Res, ’03: 46% w/vitamins; 15% wo/vitamins in Chicago PPRG  Wilson, et al AmbPeds ’02: 53% of Rochester teens  Lin, et al J Clin Anesth ’04: 30% pediatric pre-op pts use herbs  Breuner APAM ‘98: 70% homeless teens

28. Children with other conditions  Autism: 30%;  Asthma: 72%-81% of minority (H and Af.A.) families;  Cancer: 47% of kids at WFUSM in 2003; 73% of kids in Washington state in 2001;  CF: 65%, mostly prayer  Cerebral palsy: 56% of 235 families in Ann Arbor  ED: 53% used herbs, Atlanta  IBD: 41% of kids in Boston, Detroit, London  Rheumatology: 64% of 141 in Toronto, 2003  Special needs: 24% for kids with correctable condition vs. 76% for kids with non-correctable condition

29. Which CAM therapies most commonly used?  Prayer – most common, least worrisome to MDs  Herbal therapies, vitamins, minerals and other dietary supplements – most worrisome to MDs  Chiropractic – most common professionally provided to adults; historical competitive threat  Massage – most common professionally provided to kids; often taught to parents or provided informally  Homeopathy – not well enumerated; confusion with herbs  Yoga, Tai Chi  Acupuncture/acupressure  Biofeedback, hypnosis

30. What are pediatricians most often asked about CAM?  Herbs, dietary supplements (67%)  Chiropractic (59%)  Nutrition and special diets, vegetarian, macrobiotic diets (46%)  Homeopathy (36%)  Therapeutic exercise, yoga (34%)  Hypnosis, biofeedback or meditation (23%)  Massage or other bodywork (17%) ….  Prayer (13%) Kemper, O’Connor. Amb Peds, 2004

31. Only 40% tell docs about CAM  “Natural”, not medical; irrelevant, “not important for the doctor to know” 61%  Docs not interested; “the doctor never asked” 60%  “None of the doctor’s business” 31%  “Doctor would not understand” 20%  Cultural practice - embarrassing or private, <20%  Fear of physician reaction (disapproval, abandonment, worse medical care) < 15% Eisenberg DM, et al. Arch Intern Med, 2001; 135: 344-51

32. Pediatric AP  A BDOMINAL P AIN  A NOREXIA  C HILDHOOD D IARRHEA  C OUGH  O TITIS  I CTERUS N EONATORUM  C ONVULSIONS  P ARALYSIS

33. Pediatric Colic  Patterns Cold in the middle- jiao Cold in the middle- jiao Retention of food Retention of food Blood stagnation Blood stagnation Yang deficiency Yang deficiency

34. Consequences of Jing Deficiency  Leads to disease of organs Heart Heart GI tact GI tact Lung Lung Kidney Kidney Liver Liver  Severe disease Early affects Early affects  Mild disease Later effect Later effect

35. Chance  8 month M Lhasa apso  Seizures for 1 month  Tongue: red purple  Pulse: deep & weak Di Tan Tang and Epimedium Powder

36. Kidney Jing Deficiency Fails to Nourish Jin (sinews) Blood Deficiency Internal Wind Seizures Kidney Yin Deficiency Liver Yin Deficiency

37. Kidney Jing Deficiency  Hz: Seizures < 1 year of age Seizures < 1 year of age Dry nose & mouth Dry nose & mouth  Tongue Pale or red Pale or red  Pulse Weak & thready Weak & thready  Rx Principle extinguish the wind and astringe or nourish the kidney jingextinguish the wind and astringe or nourish the kidney jing  AP KID-3, BL-23, SP-6, GV- 20, ST-36, HT-7, GB-20, An Shen, Da Feng Men  TCM Herbal Di Tan Tang and Epimedium Powder

38. Epimedium Powder Epimedium Yin Yang Huo Tonify Kid Yang/Jing, Promote Sexual Desire Cuscuta Tu Si Zi Tonify Kid Yang, Jing & Yin Cistache Rou Cong RongTonify Kid Yang & Yin Paeonia Bai Shao Yao Nourish Liver Yin & Blood Polygonum He Shou Wu Nourish Blood & Jing, Benefit Hair Actinolite Yang Qi Shi Tonify Kid Yang Cynomorium Suo Yang Tonify Kid Yang Psoralea Bu Gu Zhi Tonify Kid Yang & Strengthen Bones Dipsacus Xu Duan Tonify Kid Yang & Promote Fracture Healing Lycium Gou Qi Zi Nourish Liver Yin, Benefit Eyes Condonopsis Dang Shen Tonify Qi Astragalus Huang Qi Tonify Qi Rehmannia Shu Di Huang Nourish Kid Yin & Jing Angelica Dang Gui Nourish Blood Ophiopogon Mai Men Dong Moisten & Nourish Yin Scrophularia Xuan Shen Cool Blood & Clear Heat Citrus Chen Pi Move Qi & Relieve Pain

39. Jocko

40. Jocko  Problem List Shen Disturbance Shen Disturbance Hydrocephalus Hydrocephalus Confirmed ultrasoundConfirmed ultrasound Hepatoencephalopathy Hepatoencephalopathy Confirmed BWConfirmed BW Overall poor development Overall poor development  TCVM Tongue Tongue thin-redthin-red Pulses Pulses Deep, weak fast particularly on right sideDeep, weak fast particularly on right side  Diagnosis Jing Deficiency Yin deficient  Treatment Hydrocephalus formula Liu Wei Di Huang Epimedium powder

41. Ear Disease  One of most common complaints for dogs & cats  Poor design  Lack of essence Decreased immunity Decreased immunity Failure to support child Failure to support child Passes heat to earsPasses heat to ears

42. God’s Boo Boo  Poor design  No drainage  Covered with flap  No air circulation  Deep, Dark Hole

43. Infections in Children  Some feel that the cause is the use of antibiotics  Find that CAVM methods have a more effective longterm outcome Chiropractics Chiropractics Craniosacral techniques Craniosacral techniques TCM TCM

44. How Ears Help in TCM Exam

45. Otitis Externa  Itchy  Red  Painful  Damp- -Heat with Wind External pathogen External pathogen Liver yin deficiency Liver yin deficiency

46. Patterns

47. Channels Near the Ear SI, TH, GB, BL, GV

48. AP for Ear Disease  Local points on SI, TH, GB, BL, GV medians  Influential points  Points for excess or deficiency

49. Excess Patterns  Damp Heat for Otitis Red tongue Red tongue Fast, superficial pulse Fast, superficial pulse

50. Otitis Patterns

51. Pathology of Liver Heat Liver Heat Heat & Damp Liver Blood & Yin Deficiency Child Shen Disturbance SP/ST Grandchild LIV Organ Channel Feet Eyes GBEars KID/BLParent LU/LI Grandparent

52. Ear exam  Don’t forget to look!  May find a cause Foxtail Foxtail Polyp Polyp Tumor Tumor Parasite Parasite  Can culture

53. TCM Herbals  Clear Damp-Heat Long Dan Xie Gan Long Dan Xie Gan Ear Damp-Heat Ear Damp-Heat  Treat Topically TCM Ear Drops TCM Ear Drops Western Ear Formula Western Ear Formula  Improve immunity Canine Antioxidant Formula Canine Antioxidant Formula Canine Cancer Formula Canine Cancer Formula Garlic (fresh) orally Garlic (fresh) orally Westlab Pharmacy 1-800-4WESTLA

54. Long Dan Xie Gan Tang Gentiana Long Dan Cao Clear Liver Heat, Clear Damp- Heat Gardenia Zhi Zi Clear Damp Heat Scutellaria Huang Qin Clear Damp-heat Plantago Che Qian Zi Drain Damp-heat Alisma Ze Xie Drain Damp Akebia Mu Tong Drain Damp-Heat Angelica Dang Gui Nourish Blood Rehmannia Sheng Di HuangNourish Yin, clear Heat Bupleurum Chai Hu Soothe Liver Qi transporter Licorice Gan Cao Harmonize

55. Ear Damp-Heat Artemisia Qing Hao Clear Damp-Heat Bupleurum Chai Hu Soothe Liver Qi Scutellaria Huang Qin Clear Damp-Heat Moutan Mu Dan Pi Cool Blood Prunulla Xia Ku Cao Clear Heat Lophatherum Dan Zhu Ye Clear Heat Tribulus Bai Ji Li Clear Heat Luffa Si Gua Teng Transform Phlegm, Resolve Stagnation Melia Chuan Lian Zi Move Qi

56. TCM Ear Drops Coptis Huang Lian Clear Heat, Detoxify Alum Bai Fan Dry Damp, Transform Phlegm, Stop Bleeding, Relieve Itching Borneol Bing Pian Clear Heat, Relieve Pain, Open Orifices, Dissipate Swelling GlycerolGan You Carrier

57. Western Ear Drops  Detergent Solution: 1 drop of “free” dishwasher soap 1 drop of “free” dishwasher soap 8 ounces of water 8 ounces of water  Vinegar Solution: 1 ounce apple cider vinegar 1 ounce apple cider vinegar 3 ounces of water 3 ounces of water  Vitamin E/garlic oil: crush one clove of garlic (use press) into crush one clove of garlic (use press) into 1 ounce of extra virgin olive oil 1 ounce of extra virgin olive oil let sit overnight at room temperature let sit overnight at room temperature pour oil into dropper container pour oil into dropper container add content of a 1000 IU vitamin E capsule add content of a 1000 IU vitamin E capsule use 2-3 drops in the ear canals, plus 1-2 on the pinnae use 2-3 drops in the ear canals, plus 1-2 on the pinnae

58. Sheena  7 yr, FS GSHP  History of chronic otitis externa Rx Atbs/Tramadol Rx Atbs/Tramadol  Neuroexam Mild CP LRL Mild CP LRL Mild Babinski LRL Mild Babinski LRL Eye Drop LS Eye Drop LS

59. Sheena

60. Sheena  Pseudomembranous coating of left ear canal and mouth  Dx Candida Infection Candida Infection Invasion of Damp- Heat secondary to Wei Qi deficiency Invasion of Damp- Heat secondary to Wei Qi deficiency

61. Sheena  Treatments Western Western FluconazoleFluconazole Ear SolutionsEar Solutions Aleo Vera gelAleo Vera gel Diet changeDiet change Purina JM Purina JM  Treatments TCVM AP Shan Gen, LI-4, GV- 14, ST-4, ST-36, TH- 5, and ST-44 Herbal Long Dan Xie Gan Ku Shen Si Wu Tang Wei Qi Booster

62. Inner Ear Disease  8th Nerve Signs  7th Nerve Signs ear & lip droop ear & lip droop lack of palpebral reflex lack of palpebral reflex nose turn nose turn nostril flaring nostril flaring  Horner’s Syndrome

63. Horner’s Syndrome  Small Animals Ptosis Ptosis Myosis Myosis Enophthalmos Enophthalmos  Large Animals Facial sweating (horse) Facial sweating (horse) Lack of muzzle sweating (cow) Lack of muzzle sweating (cow)

64. Inner Ear Disease  Most cases are secondary to bacterial infection (otitis media & interna) extension from otitis externa extension from otitis externa pharyngitis with extension up the Eustachian tube pharyngitis with extension up the Eustachian tube hematogenous spread hematogenous spread

65. Dx of Inner Ear Disease  PE, NE, OE Schirmer’s tear test Schirmer’s tear test  CBC  UA  Skull Radiographs  Other (if indicated) Chest & Abdominal Radiographs Chest & Abdominal Radiographs Ear Culture Ear Culture Cardiac Exam Cardiac Exam Normal bulla radiograph Note: sharp bone edges with symmetrical appearance.

66. Inner Ear Infection Right-lateral and DV radiograph of dog with unilateral otitis interna showing sclerosis of the tympanic bulla on the right side with loss of detail in the region of the osseous petrous-temporal bone. RR L

67. Inner Ear Infection  Treat with bacteriocidal drugs which penetrate bone and blood-tissue barriers Combination therapy Combination therapy cephalosporinscephalosporins sulfa drugssulfa drugs Enrofloxacin Enrofloxacin  Must treat 6-8 weeks

68. Inner Ear Disease  Treat with antibiotics and recheck in 2 weeks if better, continue if better, continue if worse, reassess if worse, reassess  Recheck in 1 month if normal, stop antibiotics if normal, stop antibiotics if still residual problems, continue 2 more weeks if still residual problems, continue 2 more weeks  Recheck at 6 months re-examine any abnormalities (such as abnormal bulla radio- graphs)  If problems worsens or persists without change for 4 weeks, consider referral.

69. Inner Ear Disease  Other Neoplasia neurofibromas neurofibromas osteosarcomas osteosarcomas FeLV FeLV  Prognosis is Poor  Other Infections Fungal  Prognosis Guarded to Poor

70. Inner Ear Disease  Consider Advanced Imaging Techniques Bone Scan Bone Scan MRI Scan MRI Scan  Consider Surgical Drainage of Bulla  If owner can not afford additional tests or referral, may try changing antibiotics.  Main reason for failure is not treating long enough.

71. Myringotomoy  Chance to look at the middle ear and get culture  Personally, I do not think it is that necessary  Most ear problems (like sinusitis) are from failure of immunity not infection

72. Inner Ear Infection

73. Inner Ear Neoplasia

74. B.A.E.R. test  Provides indication of the ability of the auditory portion of the 8th nerve to function and relay that information through the brainstem toward the cerebral cortex.

75. Ear Polyps in Cats  Benign growth in the external ear canal which causes signs by extension.  Can also be pharyngeal mass which grows into middle ear via the eusthasian tube.

76. Ear Polyps in Cats  Treatment is surgical removal.  Damage can be permanent, if pressure necrosis has destroyed the inner ear structure.

77. Bilateral I.E. Disease  No Head Tilt  No Nystagmus spontaneous or spontaneous or physiologic physiologic  Wide head excursions due to inability to fix eyes on vertical with movement. Open mouth radiograph with chronic changes in both bullas

78. Bilateral I.E. Disease  MRI image shows bilateral disease in middle and inner ear.  May respond to aggressive antibiotic therapy.  Some patients will also be deaf.

79. Bilateral Vestibular  Lacks classical signs  Wide head excursions  No physiologic nystagmus

80. Inner Ear Disease -- TCM  Invasion of external pathogen leading to wind, heat, damp or GB heat from liver yin deficiency  Heat boils the fluids leading to the accumulation of phlegm.  Quiet the wind, reduce heat, disperse damp and activate the blood to dissolve stagnation.

81. Inner Ear Disease -- TCM  Points Constitutional points Constitutional points Clear wind & heat Clear wind & heat GB20, LI4, LI11, GV14GB20, LI4, LI11, GV14 Calm the shen Calm the shen PC6, HT7, GV17, GV20, GV21PC6, HT7, GV17, GV20, GV21 Eliminate damp Eliminate damp SP9SP9 Activate Qi & blood Activate Qi & blood ST36, ST40, Xin shu (BL17)ST36, ST40, Xin shu (BL17) Local points Local points TH17, TH18, TH21, SI19, GB2, Er jian, An shenTH17, TH18, TH21, SI19, GB2, Er jian, An shen

82. Hope  Even without Jing, life can be full  Dogs live in the now  One message they teach us is that it does not matter how long we live, only that we live well