A Case Report of Kidney-Spleen Yang Deficiency in a Post-Partum Mare
William H. McCormick VMD
Abstract An eighteen year old Thoroughbred post-partum broodmare was presented with a combination of weight loss, edema, swollen joints, a draining tract, and recurrent infections. Over the course of several months of acupuncture and herbal therapy, the horse was successfully treated. She subsequently conceived and eventually delivered a healthy foal the following spring. History, Clinical Signs, Conventional Diagnosis and Treatment An eighteen year old Thoroughbred mare had foaled with great difficulty in early April. Post-partum hemorrhage had persisted for seven days. When a mucopurulent uterine discharge developed, she had been treated with systemic and intra-uterine antibiotics. During this time the horse had lost approximately 150-200 pounds. Her lower hind legs carried edema and the tibio-tarsal joints were distended. She had a propensity to frequently develop infected wounds. Due to the persistent weight loss and uterine discharge, in late May the mare was shipped to a university referral hospital. Her temperature, heart and respiratory rates were normal. There was a productive draining tract ventral to the sternum between the front legs. Both metatarsi were edematous and the tarsi showed bilateral synovial effusion. Uterine biopsies showed histologic evidence of acute, moderate hemorrhagic endometritis and endometrial gland hyperplasia. The uterus cultured Strep. Zooepidemicus and Enterobacter agglomerans. The sternal tract had a negative culture. The plasma protein was elevated to 8.2 gm/dl. The fibrinogen was normal (300 mg/dl). Electrophoresis showed hypergammaglobulinema consistent with chronic inflammation. Likewise the protein concentration of the tibiotarsal joints was elevated at 4.6 gm/dl with a cell count of 3080 wbc/μl. A titer for Lyme Disease (Borrelia burgdorferi) was negative. The vaginal discharge resolved with daily lavages of 1 L of 30% DMSO and gentamicin (1 gm). The joint effusion did not resolve, and no definitive western diagnosis was proposed. Other than chronic uterine infection, no explanation was offered for the weight loss and debilitated condition of this individual. Clinical Signs/Diagnosis-TCVM In early June the mare was referred for alternative medicine therapy. The horse was markedly underweight with prominent ribs and a pendulous abdomen giving her a pear shape when viewed from behind. The lower hind legs were edematous and the tibiotarsal joints were distended. There was a draining tract between the front legs. Pulse: Floating and wide in the right guan and chi positions and deep and forceless in the left guan and chi positions. Channel Palpation: There was palpable reactivity at BL 23, BL 21 and GB 25. Tongue: Pink and moist with a 10mm nodule of phlegm nodulation on the dorsal midline of the tongue in the ST/SP position. The reactivity could have been reflective of
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somatovisceral abnormality or Bi Syndrome affecting the hind legs whose tbiotarsal joints were distended. There was also a Qi Deficiency tongue quiver. Diagnosis: The mare had undergone a significant loss of Qi and Blood from foaling and the subsequent hemorrhage. Both edema of the hind legs and loss of abdominal muscle tone are consistent with Spleen Yang Deficiency. Spleen is also the root of Phlegm engenderment. In this horse there was evidence of Phlegm in the uterine discharge, sternal tract, distended joints and tongue nodule. The right guan position was floating and wide, indicative of at least Qi Deficiency. The persistent uterine discharge, weight loss, floating right chi position as well as the reactivity at BL 23 suggested KI Deficiency. TCVM Treatment: The treatment principles were to warm and supplement the Spleen-Kidney Yang and strengthen the Mingmen, to supplement the Qi and Blood and ultimately to transform Phlegm. On 7 June the mare was treated with bilateral Sakamura® gold ball implants at ST 36 (Hou San Li) and BL 20 (Pi Shu) and Bai Hui. Bilateral 2mm PDS (#O PDS II®, polydioxanone suture, Ethicon) implants were placed at SP6 and KI 3. Furthermore the mare was treated with moxa daily for ten days at Bai Hui, BL 21 and Mingmen. CV 4 and 6 were also treated for ten days with a laser. A heat lamp was used for the same period at night, which had been abnormally cold for that time of year. ST 36 (Hou San Li) on the dorsolateral aspect of the tibial process, 3.5 cm distal to the lateral condyle of the tibia1. ST 36 regulates and supplements Spleen Qi and Yang as well as Kidney Yang and source Qi. It also transforms Dampness2. BL 20 (Pi Shu) is 3 tsun lateral to the midline in the seventeenth intercostal space in the muscular groove between the m. longissimus dorsi and the iliocostalis3. BL 20 regulates and supplements Spleen Qi and Yang, supplements nutritive Qi and Blood and transforms Dampness4. Bai Hui is located in the lumbosacral space and it warms Yang and restores collapsed Yang5. Spleen 6 (San Yin Jiao) is located 3 tsun proximal to the tip of the medial malleolus of the tibia, caudal to the tibial border, and cranial to the lateral head of the deep digital flexor tendon6. SP 6 functions to regulate and supplement Spleen Qi and Yang, resolves Dampness and supplements Kidney Essence7. Kidney 3 (Tai Xi) is between the tip of the medial malleolus of the tibia and the tendocalcaneus8. KI 3 supplements the Kidney QI and Yang as well as source Qi and Blood and warms Cold9. Ming Men is located between the second and third lumbar dorsal spinal processes10. Ming Men supplements the Kidney Qi and Yang, warms Yang and source Qi11.
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CV 4 (Guan Yuan) is located 3 tsun caudal to the umbilicus. CV 4 supplements Kidney Yang, source Qi, and supplements Qi and Blood12. CV 6 (Qi Hai) is located 1.5 tsun caudal to the umbilicus. CV 6 supplements the Kidney Qi , the source Qi, Qi and Blood, and dries Dampness13. The herbal formula Gui Fu Li Zhong Tang Jia Jian or Cinnamon and Aconite Rectify the Center Decoction with additions was used at a dose of 250 Gm per day administered by stomach tube for five days14. The formula is as follows: Gui Fu Li Zhong Tang Jia Jian: Radix Praeparatus Aconiti Carmichaeli (Fu Zi) Cortex Cinnamomi (Rou Gui) Rhizoma Atractylodis Macrocephalae (Bai Zhu) Sclerotium Poriae Cocos (Fu Ling) Radix Panacis Ginseng (Ren Shen) Rhizoma Zingiberis (Sheng Jiang) Albus Paeoniae Lactiflorae (Bai Shao) Radix Angelicae Sinensis (Dang Gui) 7 Gm Interior warmer 13Gm Warms the channels 20 Gm Fortifies the Spleen 15 Gm Seeps Dampness 5 Gm Supplements Source Qi 10 Gm Warms the middle burner t15 Gm Supplements Blood 15 Gm Supplements Blood
After five days the horse was put on 30 Gm BID oral Ba Jun Zi Tang to supplement Qi and Blood. Ba Jun Zi Tang is a combination of Si Jun Zi Tang and Si Wu Tang15. After one month Shi Quan Da Bu Tang16 was substituted for Ba Jun Zi Tang. Ba Jun Zi Tang: Radix Panacis Ginseng Rhizoma Atractylodis Macrocephalae Sclerotium Poria Cocos Radix Glycyrrhizae Radix Angelicae Sinensis Rhizoma LigusticiWallichii Radix Albi Paeoniae Lactiflorae Radix Rehmanniae Shi Quan Da Bu Tang: Add the following herbs to Ba Jun Zi Tang: Cortex Cinnamomi Radix Astragali Membranacei (Rou Gui) (Huang Qi) 3 Gm 20 Gm (Ren Shen) (Bai Jhu) (Fu Ling) (Gan Cao) 10 Gm 9 Gm 9 Gm 6 Gm
(Dang Gui) 10 Gm (Chuan Xiong) 8 Gm (Bai Shao) 12 Gm (Shu Gan Di Huang) 12 Gm
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By the end of June the horse had strikingly improved. She was bred and conceived. Later in October, after three months of treatment with Ba Jun Zi Tang and eventually Shi Quan Da Bu Tang, the pregnancy was ongoing. Total Protein was 8.2 Gm / dl and the fibrinogen was 200 mg /dl. The pulse was slightly slippery, which was thought to be normal for pregnancy. The mass on the dorsum of the tongue was flattened and greatly reduced. The tract between the front legs would dry up while on Shi Quan Da Bu Tang and open up when the formula was withdrawn. The following spring the mare delivered a normal foal. Discussion: The mare was presented with no definitive western diagnosis other than not doing well, looking somewhat worse than Don Quixote’s horse, having big joints and draining tracts. It would seem that the descriptive methodology of TCVM provided a superior way of depicting the status of this individual. The therapeutic regime that followed is strictly a logical extension of the original clinical assessment. The severely depleting events of parturition can explain the marked loss of Qi, Blood and Essence in this individual. One suspects that the horse at least had a significant Spleen Qi Deficiency before giving birth, since athletes tend to preferentially deplete their Spleens as a matter of course17. Also at eighteen years of age this individual would have been expected to be predisposed to Qi Vacuity. Although this individual was presented in a markedly debilitated state, she could still aggressively defend herself and did not like needles, especially in Command points, such as Hou San Li. Therefore, while the horse was under tranquilization, some Sakamura® gold implants were placed at a few key acupoints, ST 36, BL 20 and Bai Hui. The implants would insure a long term Spleen supplementing effect. The more neutral PDS implants were used at SP 6 and KI 3. Other points, CV 4, 6 to support the uterus, were treated with the painless laser. Bai Hui, Mingmen, and BL 20 were treated with a moxa stick. Most horses will accept moxa stick therapy or at least will define what they will and will not tolerate. Large volumes of herbs must be delivered by stomach tube. Initially Gui Fu Li Jhong Tang was administered daily via tube. Subsequently Ba Jun Zi Tang and eventually Shi Quan Da Bu Tang, neither of which is bitter, were given in the feed at lesser volumes. The internal warmers, Fu Zi and Rou Gui initially supported and warmed the middle. The warming herb, Moxa, was also used at Bai Hui, BL 21 and Mingmen. Subsequently Ba Jun Zi Tang and Shi Quan Da Bu Tang provided supplementation of Qi and Blood over time. The combination of herbal and acupuncture treatment was precise and flexible for the treatment of this case. Conventional medicine did not seem to support this patient after the categories of western diseases had been treated. It could be argued that antibiotic therapy had healed the uterus and the horse simply needed some time to recover. However, the horse thrived only after being treated with acupuncture and herbal therapy. The draining tract would dry up only while the horse was treated with Shi Quan Da Bu Tang. When taken off the herbal formula the tract would open again. The immune stimulating and supplementing use of this herbal formula is supported by a number of western designed papers in the Japanese literature 18. The effects are thought to be due to the immune modulating effects of several different pectic polysaccharides. “It
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significantly enhanced antibody responses to SRBC (Komatsu, 1986), phagocytosis (Maruyama, 1988), and mitogenic activities against splenic B cells in mice (Takemoto et al. 1989). Peripheral blood cell counts in patients treated concomitantly with JTT (Shi Quan Da Bu Tang) orally and the antineoplastic drug mitomycin C were higher in patients treated with the antineoplastic drug alone (Nabeya and Ri, 1983)17.”
References: 1. Huang, Yann-Qing, Handbook on Chinese Veterinary Acupuncture and Moxibustion, FAO/APHCA Publication, Bangkok 1990, p 72. 2. Lade, A., Images and Functions, Cushing-Malloy, Inc., Ann Arbor, MI 1989, p 72-73. 3. Flemming, P., Transpositional Equine Acupuncture Atlas, Veterinary Acupuncture 2nd Ed., Schoen, Allen ed., Mosby Inc., St. Louis, 2001, p 414. 4. Lade, A., Images and Functions, Cushing-Malloy, Inc., Ann Arbor, MI 1989, p 140. 5. Lade, A., Images and Functions, Cushing-Malloy, Inc., Ann Arbor, MI 1989, p 288. 6. Flemming, P., Transpositional Equine Acupuncture Atlas, Veterinary Acupuncture 2nd Ed., Schoen, Allen ed., Mosby Inc., St. Louis, 2001, p 408. 7. Lade, A., Images and Functions, Cushing-Malloy, Inc., Ann Arbor, MI 1989 p 90. 8. Flemming, P., Transpositional Equine Acupuncture Atlas, Veterinary Acupuncture 2nd Ed., Schoen, Allen ed., Mosby Inc., St.Louis, 2001, p 417. 9. Lade, A., Images and Functions, Cushing-Malloy, Inc., Ann Arbor, MI 1989 p 181. 10. Flemming, P., Transpositional Equine Acupuncture Atlas, Veterinary Acupuncture 2nd Ed., Schoen, Allen ed., Mosby Inc., St. Louis, 2001, p 427. 11. Lade, A., Images and Functions, Cushing-Malloy, Inc., Ann Arbor, MI 1989, p 275-6. 12. Lade, A., Images and Functions, Cushing-Malloy, Inc., Ann Arbor, MI 1989, p 253-4. 13. Lade, A., Images and Functions, Cushing-Malloy, Inc., Ann Arbor, MI 1989, p 256. 14. Flaws, B., Seventy Essential TCM Formulas 2nd Ed., Blue Poppy Press, Boulder, CO., 1997, p 70-71. 15. Flaws, B., Seventy Essential TCM Formulas 2nd Ed., Blue Poppy Press, Boulder, CO., 1997, p 81. 16. Flaws, B., Seventy Essential TCM Formulas 2nd Ed., Blue Poppy Press, Boulder, CO., 1997, p 81. 17. Flaws, B., personnal communication. 18. Leang-Shin Wu, Jen-Hsou Lin, Rogers, PAM, Pharmacological Effects of Chinese Medicinal Formulas, Proceedings of the Twenty-Third Annual International Congress on Veterinary Acupuncture, St. Sauveur, Quebec, Canada. 1997, p.32.
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