An Insight into Integrated Veterinary Practice
TCM diagnosis poses new challenges. As vets, we are used to gathering information indirectly through asking questions of owners, through observation with our eyes, listening with a stethoscope, and even smelling greasy yeasty ears. We also routinely use palpation to feel enlarged or painful abdominal organs, to detect the heat of acute inflammation or pyrexia, or the soft fluctuant swelling of abscesses. However since beginning to learn TCM several years ago, Iíve had to modify my skills.
The classical observations in TCM are: looking, listening, smelling, asking and palpating. Usually, a session begins with a TCM examination and history taking. This allows the patient to relax, and gives me time to observe him or her from a distance, so to assess their Shen or Vitality, their body constitutional type, any obvious hair loss or limb asymmetry.
Body shapes vary according to breed in dogs, and to a certain extent in cats. An obese labrador with benign fatty tumours has Spleen Damp. A runty puppy has Kidney Jing deficiency. Vets can assess hair coat in the same way human practitioners assess scalp hair. Excess hair loss might mean Liver Blood deficiency. A dog with a premature grey muzzle may have reduced Kidney Essence.
If a patient happens to open their mouth, try to observe their tongue without any invasive examination. A tense or angry pet will have a darker tongue than usual. A dog that has enjoyed too many liver treats in the waiting room with have a moist tongue.
History taking can be difficult, but it is where animal TCM practitioners derive much of their information. Owners can be particularly observant, right down the minuetís detail of description and frequency of bowel motions, (which seems much more relevant in TCM than conventional medicine). However they are also capable of drawing their own conclusions. They will frequently try to interpret an observation e.g. when I ask about thirst, they will often reply they donít think their cat has diabetes or kidney disease. Owners can let me know if their pet prefers a cool or warm place to rest, whether they sleep well or are restless, and whether their pet tends to dream.
Afterwards, it is possible to begin a more detailed and up close examination of the patient. Whenever possible this is carried out on the floor or on a comfortable mat. Even most cats are more amenable to examination this way, and most animals are far less threatened or stressed than when placed on a stainless steel table.
Ideally as a TCM practitioner, an initial TCM examination would involve carrying out a pulse and tongue exam, before the findings are influenced by either stress or physical contact. Many TCM veterinarians do this by proxy, checking their own pulse, then briefly touching the patient and rechecking their pulse for changes. I prefer to use the femoral pulse, on the inside of the hind legs, just above the stifle. Here it is possible to easily assess the pulse rate, its width or broadness, its rhythm, its texture, amplitude, tone and depth. In conventional medicine, the pulses are felt with a firm pressure, to just get a feel for heart rate and pulse pressure. With the more subtle palpation used in TCM, it is possible to learn much more about the patient.
It is important to always observe the tongue, even if having to resort to manually opening the patientís mouth or giving them a treat. Although I realize both these activities will alter the colour and moisture of the tongue, I usually find if Iím quick, Iíll get the information required. At the same time, it is important to assess the gums for inflammation, colour, refill time, moistness and also carry out a dental exam (both TCM and conventional,) and assess the smell of the breath.
Smelling is a skill Iíve had to relearn since beginning TCM practice, after years of training my nose to ignore the often unpleasant smells of veterinary medicine. I confess Iím not sure I can differentiate rancid, rank, putrid rotten or just plain bad breath. I might just be able to identify sweet. I will frequently ask the owners questions about the smell of bowel motions or urine. It is also useful to smell ears, and skin.
Itís important to always listen to the sounds of lungs, heartbeats, and abdominal sounds, using a stethoscope and assess the loudness of the bark or meow, the moistness or dryness of breathing, the loudness and pitch of a cough. Itís also useful to know the sounds of vomiting or diarrhoea.
Palpation is used in conventional medicine to assess for pain or sensitivity, abdominal organ enlargement or irregularity, skin lesions or masses, asymmetry, heat and inflammation. Conventional veterinarians are taught to palpate using firm pressure, but this method wonít detect the subtle changes we look for in TCM. To relearn my palpation skill, Iíve spent hours with a large volume of Maciociaís Foundations of Chinese Medicine, learning to palpate a single strand of hair under one, then two, then four, then twenty pages. This has improved my ability to detect the subtle swelling or turgidity of active Alarm Points or Back Shu points. Itís also possible to localise more chronic sources of musculoskeletal pain such as trigger points. During this time, it is possible to assess the dryness and vitality of skin, the condition of the coat, and see if there is any subtle pain along the mandible consistent with periodontal disease thatís not always obvious during an oral examination.
As a conventional vet I have access to diagnostic aids such as laboratories, and imaging such as radiographs or ultrasound. This information can be interpreted medically, as well as form part of the pattern differentiation in TCM. For example, renal azoteamia may suggest Kidney Yin or Kidney Yang deficiency. Low red blood cell count may be consistent with Blood deficiency. A high white cell count suggests Heat or even Damp. A small liver on x-rays may be consistent with Liver Blood deficiency, while an enlarged or irregular shape may suggest Damp Heat of the Liver, or Blood stagnation.
All this information is assessed within the parameters of Eight Principles, Blood and Qi pattern, and Zang Fu pathology. It is also possible to consider the Five Elements as a clue to the underlying root imbalance, which lead to the current problem.
Let me use Teddy as an example. Teddy is a senior (geriatric) overweight male castrated Cavalier King Charles Spaniel. Most of the patients I treat have been desexed, and this may, at a root level, affect their balance of Yin and Yang, and hence be a predisposing factor to many of the geriatric illnesses we see, particularly those associated with weight gain or Damp accumulation.
When he walks into the exam room, he usually waits hungrily for a treat, and then wanders slowly over to the mat and goes to sleep. His back legs are stiff, and he will not stand for long. He often snores while he sleeps. At home he doesnít have much energy. He loves his food, but does not drink much. He often has smelly diarrhoea, and is not all that enthusiastic about exercise. At night he may have a moist cough, especially in wet weather. His ears are constantly red and smelly, his coat is greasy and he incessantly scratches all over.
On examination, his tongue is swollen with a think yellow coat. His pulses are deep, with a small amplitude, and feel quite slippery. His skin is red and thickened, with a yellow greasy coat, and his ears are full of smelly yellow exudate. His breathing sounds loud and moist. With a stethoscope, it is possible to hear a loud regurgitant heart murmur and moist crackles over all his lung fields. His abdomen is loud and gurgles. His hips and stifles are stiff and painful, as his lower back, especially at Pishu BL 20.
His Eight Principle diagnosis is: Hot Deficient Internal and more Yin than Yang. His Zang Fu Pattern is Deficient Spleen Qi, with Heat and Damp accumulation. Heís and Earthy boy, and shouldnít have too much sweet (carbohydrate) in his diet.
Teddy is on conventional cardiac mediation. If he is fed a homemade diet with no dry food (i.e. reduced cereals) he loses weight, and his joint pain improves. He also responds well to acupuncture, using local points such as Huantiao GB 30, Juliao GB 29, Yanglingquan GB 34, Zusanli ST 36, Kunlun BL 60, Dazhu BL 11 and points to support the spleen such as Pishu BL20, Sanyinjiao SP 6 and Yinlingquan SP 9, points to reduce Damp Heat such as Quchi LI 11 and points to remove Damp and Phlegm such as Fenglong ST40.
His ears require daily cleaning with a gentle ear cleaner to remove the debris and dry them out. Probiotics, and the TCM formula Si Miao San (Four Marvel Pill) improve his bowel motions, his skin and also reduce his nocturnal cough. When he runs out of these, and his owner puts him back on dry food, many of his signs return.
Although he is not disease free, or even completely symptom free, using a combination of Traditional Chinese Medicine (herbs and acupuncture), as well as conventional medications, it is possible to keep Teddy comfortable and happy for several years. In keeping the conventional medications to as low a dose as possible, and avoiding polypharmacy (the use of multiple medications), we avoid many of the side effects seen in conventional medicine.
TCM diagnosis can be challenging but fun in small animal practice. It assists conventional diagnosis because it allows the clinician a unique insight into perceived underlying causes (or root imbalances) of a problem. These can then be addressed using either conventional or TCM treatments, or both. It also gives us more treatment options, and allows us to minimize side effects from many of our conventional medications. I feel I can offer most of my patients a much better quality of life as a holistic veterinarian.
Karen Goldrick is a veterinarian who has worked in mainly small animal practice for over 20 years. She has practiced herbal veterinary medicine for the last five years. Three years ago Karen joined All Natural Vet Care, a veterinary practice dedicated to Holistic Veterinary Medicine. She studied acupuncture through the International Veterinary Acupuncture Association, and Veterinary TCM courses at the Sydney Institute of Traditional Chinese Medicine and is a member of the AVA (Australian veterinary Association), AVAG (Australian Veterinary Acupuncture Group), IVAS (International Veterinary Acupuncture Association) and VBMA (Veterinary Botanical Medicine Association).