142
I OBSERVATIONS ON ACUPUNCTURE
Tropical Doctor, July I976
Personal Experience
Observations on acupuncture Dr Bernard Haspel, MBE Herzlia B, Israel TROPICAL DOCT6R,
1976,6, 142-144
My interest in acupuncture was aroused mainly by two considerations. First, the recent rapid reputation it gained of being able to cure illness in a simpler and cheaper way than modern medicine, especially where our resources are still unsatisfactory - e.g. in chronic diseases, malignancies, or in conditions of severe pain as in migraine. The second consideration was the frequent request from patients to avail themselves of this cure when modern therapy proved inadequate. Instinctively, I was prejudiced against this "magic cure" of acupuncture, but could not authoritatively advise my patients against it. Some of them spent considerable amounts of money and, more important, their last physical reserves to seek reliefby acupuncture in far-away countries. Alas, on their return I could observe no improvement in their condition. Nevertheless I felt it necessary to investigate acupuncture further, in case it does have a therapeutic value. With a generous grant from the Rad Family Foundation it was possible for me to make a study tour for seven weeks taking me to Geneva, London, Hong Kong, and Taiwan. I saw the methods of traditional Chinese medicine applied by Chinese doctors to the Chinese and also to European patients. I observed European doctors treat Chinese and Europeans. I considered that the effectiveness of acupuncture may depend heavily on the emotional make-up of the patient (e.g. Chinese do not express pain by crying or outward signs of grief) but equally important, I considered the motivation of the acupuncturist. The latter may be motivated by genuine scientific interest, or may be politically prompted or unfortunately influenced by prospects of more worldly rewards. Before leaving for my study tour I read extensively all available literature and consulted colleagues who have observed or are themselves practising acupuncture. Opinions varied as to the effectiveness of acupuncture. At the Chinese Medical Research Centre in Hong Kong and in three hospitals in Taipei (the Veteran's General Hospital, the University Hospital,
and the Triservice Hospital) I was taught the theory and practice of acupuncture and finally myself treated and observed others, having seen over 200 cases. Additionally I had access to patients' records and statistics. The concept of acupuncture is fascinating in its simplicity. It is based on the hypothesis that an energy system with negative and positive poles flows through the body where it is divided by lines called meridians. These meridians have defined pathways, each one controlling a certain part of the organism. There are 14 major meridians some of which are interconnected by minor branches. They are named after the vital organs - e.g. lung meridian, kidney meridian, heart meridian, etc. The meridians vary in length. For instance, the pathway of the lung meridian extends from below the clavicle, arches over the front of the shoulders to descend along the anterior outer surface of the arm terminating at the tip of the thumb. The kidney meridian starts at the sole of the foot, ascends the anterior median surface of the leg, over the abdomen and chest terminating near the sternoclavicular joint. Two meridians are placed centrally while the other 12 are symmetrically arranged on either side of the body. Within this concept, normal health depends not only on the continuous and even flow of energy ("Chi") through the body, but it must also be in equilibrium with external energy sources, that is, water, fire, wood, metal, earth, and also cosmic forces such as wind, heat, dryness, moisture. In disease this flow of energy is weakened or disrupted and therefore is no more in harmony with the other elements. Along the major meridians are certain points which when pierced affect specific smaller areas of the organism thus restoring normal flow of energy (Figs. I and 2). The piercing of these points is asswned to be effective regardless of the nature of the disease and its degree of intensity. The same insertion will cure hyper - as well as hypotension, hyperthyroidosis as well as hypothyroidosis etc. In Western medicine ill health depends on the malfunction of our various body systems. In Chinese traditional medicine, wellbeing depends on the flow of energy. The technique of acupuncture treatment is simple. The skin is pierced with needles of varying length and width inserted at different depths into specific points. Some maintain that they can feel these points manually and appear to have histological evidence for this. Others have declared that this evidence is an artefact.
Tropical Doctor, July uJ70
OBSERVATIONS ON ACUPUNCTURE
I 143
pain, numbness, and soreness. Only then is vital energy restored to its normal flow. Piercing alone is not enough. The needle must be twisted, turned, or tapped for a considerable length of time lasting minutes to hours as, for example, during an operation. One can also activate the movement of the needle by electric current which allows for more accurate control of the needle insertion and also gives the possibility of applying treatment with more than one needle at the same time. So far I have attempted to give information about the concept and the techniques of application, and now about the results as seen during and after treatment. The conditions were different in London, Hong Kong, and Taipei, but in all three places the cases comprised mostly muscle-joint diseases with a few other general diseases like migraine, menstrual disorders or vague abdominal pains, enuresis, or sexual neuroses. No serious attempt was made to arrive at a correct diagnosis and treatment was given on a purely symptomatic basis. To answer my question why no proper examination is done in order to arrive at a correct diagnosis, the answer was "the patients surely had been thoroughly investigated before by other doctors who had not found the cause and not given relief, so why do it all over again?" In Hong Kong where I saw poor Chinese being treated as well Fig. I. The stomach "meridian" and the "meridian as patients from Australia, America, and Israel, I points" as represented in an old Chinese textbook of received the same reply. An exception to this is made in Taipei where acupuncture is respectable, supported acupuncture (Courtesy: Abbottempo). by the Government, and is officially practised in three hospitals already mentioned. In these hospitals, which as regards space, organization, and medical standards are certainly as good as many European or American hospitals, the treatment is given solely for research purposes and is carried out under the direct supervision of departmental chiefs, most of whom are American trained. It was there that I myself treated and observed about 160 cases, mostly of bone and muscle diseases. I was shown films of a study of 90 cases of cervical spondylosis carried out by Dr Teng of the PhysioFig. 2. Modern presentation of "meridians" and therapy Department. I saw the treatment of deaf and "meridian points" for treatment of gynaecological deaf mutes and went over statistics with Professor Ling of the University Hospital. I witnessed a tooth disorders (Courtesy: Abbottempo). extraction in one old man (whose teeth were loose anyway), and heard him scream, and the result was According to the site of the point, there are many not recorded as excellent, but as only "fair". I saw ways of introducing the needle. On the scalp it will be an Australian doctor being prepared for dentistry with horizontal or slanting while on the abdomen and the needle (not in Taipei) and after 20 minutes he legs mostly perpendicular. Sometimes two points can declared that he did not feel free enough from pain to be pierced by one needle. This is the "point to point" undergo the experiment. All in all, 900 extractions treatment. If the correct point has been pierced the have been done and very well recorded. According to patient should feel and report a sensation of shooting the statistics, the results are good.
144
I OBSERVATIONS ON ACUPUNCTURE
The Chief Anaesthetist at the University Hospital (Professor King) who had carried out 144 operations under acupuncture anaesthesia, does not recommend abdominal operations under this method because of the lack of relaxation - which makes the surgeon nervous. Of the 144 operations, mainly tonsils, sinuses, polyps, 24% were successful. Full success was reported by the Head of the Obstetric Department on curettage and induction of labour, but there was no chance of personally verifying this. My impressions and conclusion are that as far as it concerns relief of pain, acupuncture by itself is not the answer. It seems that in combination with chemotherapy and physiotherapy results are slightly better than when treated with each method separately. Dr Tang, the Veteran's Hospital in Taipei's chief driving force, has shown this in a detailed study treating the aforementioned 90 cases of cervical spondylosis. The same holds for general diseases. In the deaf and deaf mutes, treatment is advised daily
Tropical Doctor, July I976
for three to 12 months and then is given up if there is no improvement. In Taipei nine cases of congenital deafness were treated with no success. The claims of doctors in mainland China are better, but I have seen no improvement in any of the cases - I I in all, in addition to the previously mentioned nine. In conclusion I would like to say that I am prepared to give acupuncture the benefit of the doubt. We have seen too often that yesterday's doubts are tomorrow's certainties. Therefore I believe that at this stage we ought to examine the subject further and study it. We should certainly promise no spectacular cures. Finally I should like to state that I am not converted to acupuncture - nor do I deny it completely. Therefore I think it our duty to continue investigating. Note: Figs. I and 2 are from an article by Dr. Masayoshi Hyodo published in Abbottempo 1972, :10, 14. Permission to reproduce these figures is gratefully acknowledged.
Occasional Correspondence NEONATAL JAUNDICE
Dr Peter Magnus writes: I thoroughly enjoyed the succint article by Dr C. E. Effiong - "Management of neonatal jaundice in the tropics" (Tropical Doctor, 1975, 5, 33-35). I would like to take this opportunity to make the following suggestions and commentary: I. The signs and the symptoms of severe jaundice and kernicterus are indeed very important to ascertain. The accuracy of bilirubin levels as determined by various laboratories in the tropics will vary from country to country, however. I think we have to be wary that "moderate" cases of jaundice are between 10-15 mg of bilirubin and that the "main indication for exchange transfusion is an unconjugated bilirubin level of 20 mg per 100 ml and above in a normal birth weight baby, and of 15 mg per 100 ml for those weighing less than 2.5 kg". Although these numbers represent good guidelines, we have to take into account the baby's total protein status and his or her acid-base balance. In hypoalbuminaemic and acidotic infants the danger of unconjugated bilirubin moving intracellularly into brain cells is greater and occurs at lower levels than the normal newborn. It is only the unconjugated bilirubin bound to albumin which is decreased by phenobarbitone and broken down by ultraviolet light respectively; therefore, the greater the albumin level, the less chance the bilirubin can move intracellularly. Sulpha medicines
and aspirin, for example, compete for albumin binding sites with bilirubin, and serum levels of these agents will predispose the icteric newborn to kernicterus. 2. Other good places for studying infection besides blood cultures and cord swabs are swabs of the external ear canal in the newborn, fetal side of placenta, and a culture of cerebrospinal fluid. Spinal taps should be done on every baby suspected of sepsis, when possible. Examination of the gastric fluid of the suspected infected newborn for neutrophils (greater than 5/HPF indicative) is an inexpensive rapid adjunct. 3. I question the advisability of giving chloral hydrate or phenobarbitone orally 30 minutes before the procedure since one of the complications of exchange transfusion is respiratory or cardiac embarrassment, and although these dosages are not overwhelming, they may help mask an impending crisis. 4. If penicillin and streptomycin are given routinely in prophylactic fashion after an exchange transfusion for five days, I would suggest doing a blood culture (and bilirubin) on the last moiety to be removed at the end of the exchange. PETER D. MAGNUS, MD
Presently Peace Corps Physician B.P. 537 Niamey, Niger Corresponding address: 510 E. 86th St. Apt. IIC New York City, NY 10028, USA
I OBSERVATIONS ON ACUPUNCTURE
Tropical Doctor, July I976
Personal Experience
Observations on acupuncture Dr Bernard Haspel, MBE Herzlia B, Israel TROPICAL DOCT6R,
1976,6, 142-144
My interest in acupuncture was aroused mainly by two considerations. First, the recent rapid reputation it gained of being able to cure illness in a simpler and cheaper way than modern medicine, especially where our resources are still unsatisfactory - e.g. in chronic diseases, malignancies, or in conditions of severe pain as in migraine. The second consideration was the frequent request from patients to avail themselves of this cure when modern therapy proved inadequate. Instinctively, I was prejudiced against this "magic cure" of acupuncture, but could not authoritatively advise my patients against it. Some of them spent considerable amounts of money and, more important, their last physical reserves to seek reliefby acupuncture in far-away countries. Alas, on their return I could observe no improvement in their condition. Nevertheless I felt it necessary to investigate acupuncture further, in case it does have a therapeutic value. With a generous grant from the Rad Family Foundation it was possible for me to make a study tour for seven weeks taking me to Geneva, London, Hong Kong, and Taiwan. I saw the methods of traditional Chinese medicine applied by Chinese doctors to the Chinese and also to European patients. I observed European doctors treat Chinese and Europeans. I considered that the effectiveness of acupuncture may depend heavily on the emotional make-up of the patient (e.g. Chinese do not express pain by crying or outward signs of grief) but equally important, I considered the motivation of the acupuncturist. The latter may be motivated by genuine scientific interest, or may be politically prompted or unfortunately influenced by prospects of more worldly rewards. Before leaving for my study tour I read extensively all available literature and consulted colleagues who have observed or are themselves practising acupuncture. Opinions varied as to the effectiveness of acupuncture. At the Chinese Medical Research Centre in Hong Kong and in three hospitals in Taipei (the Veteran's General Hospital, the University Hospital,
and the Triservice Hospital) I was taught the theory and practice of acupuncture and finally myself treated and observed others, having seen over 200 cases. Additionally I had access to patients' records and statistics. The concept of acupuncture is fascinating in its simplicity. It is based on the hypothesis that an energy system with negative and positive poles flows through the body where it is divided by lines called meridians. These meridians have defined pathways, each one controlling a certain part of the organism. There are 14 major meridians some of which are interconnected by minor branches. They are named after the vital organs - e.g. lung meridian, kidney meridian, heart meridian, etc. The meridians vary in length. For instance, the pathway of the lung meridian extends from below the clavicle, arches over the front of the shoulders to descend along the anterior outer surface of the arm terminating at the tip of the thumb. The kidney meridian starts at the sole of the foot, ascends the anterior median surface of the leg, over the abdomen and chest terminating near the sternoclavicular joint. Two meridians are placed centrally while the other 12 are symmetrically arranged on either side of the body. Within this concept, normal health depends not only on the continuous and even flow of energy ("Chi") through the body, but it must also be in equilibrium with external energy sources, that is, water, fire, wood, metal, earth, and also cosmic forces such as wind, heat, dryness, moisture. In disease this flow of energy is weakened or disrupted and therefore is no more in harmony with the other elements. Along the major meridians are certain points which when pierced affect specific smaller areas of the organism thus restoring normal flow of energy (Figs. I and 2). The piercing of these points is asswned to be effective regardless of the nature of the disease and its degree of intensity. The same insertion will cure hyper - as well as hypotension, hyperthyroidosis as well as hypothyroidosis etc. In Western medicine ill health depends on the malfunction of our various body systems. In Chinese traditional medicine, wellbeing depends on the flow of energy. The technique of acupuncture treatment is simple. The skin is pierced with needles of varying length and width inserted at different depths into specific points. Some maintain that they can feel these points manually and appear to have histological evidence for this. Others have declared that this evidence is an artefact.
Tropical Doctor, July uJ70
OBSERVATIONS ON ACUPUNCTURE
I 143
pain, numbness, and soreness. Only then is vital energy restored to its normal flow. Piercing alone is not enough. The needle must be twisted, turned, or tapped for a considerable length of time lasting minutes to hours as, for example, during an operation. One can also activate the movement of the needle by electric current which allows for more accurate control of the needle insertion and also gives the possibility of applying treatment with more than one needle at the same time. So far I have attempted to give information about the concept and the techniques of application, and now about the results as seen during and after treatment. The conditions were different in London, Hong Kong, and Taipei, but in all three places the cases comprised mostly muscle-joint diseases with a few other general diseases like migraine, menstrual disorders or vague abdominal pains, enuresis, or sexual neuroses. No serious attempt was made to arrive at a correct diagnosis and treatment was given on a purely symptomatic basis. To answer my question why no proper examination is done in order to arrive at a correct diagnosis, the answer was "the patients surely had been thoroughly investigated before by other doctors who had not found the cause and not given relief, so why do it all over again?" In Hong Kong where I saw poor Chinese being treated as well Fig. I. The stomach "meridian" and the "meridian as patients from Australia, America, and Israel, I points" as represented in an old Chinese textbook of received the same reply. An exception to this is made in Taipei where acupuncture is respectable, supported acupuncture (Courtesy: Abbottempo). by the Government, and is officially practised in three hospitals already mentioned. In these hospitals, which as regards space, organization, and medical standards are certainly as good as many European or American hospitals, the treatment is given solely for research purposes and is carried out under the direct supervision of departmental chiefs, most of whom are American trained. It was there that I myself treated and observed about 160 cases, mostly of bone and muscle diseases. I was shown films of a study of 90 cases of cervical spondylosis carried out by Dr Teng of the PhysioFig. 2. Modern presentation of "meridians" and therapy Department. I saw the treatment of deaf and "meridian points" for treatment of gynaecological deaf mutes and went over statistics with Professor Ling of the University Hospital. I witnessed a tooth disorders (Courtesy: Abbottempo). extraction in one old man (whose teeth were loose anyway), and heard him scream, and the result was According to the site of the point, there are many not recorded as excellent, but as only "fair". I saw ways of introducing the needle. On the scalp it will be an Australian doctor being prepared for dentistry with horizontal or slanting while on the abdomen and the needle (not in Taipei) and after 20 minutes he legs mostly perpendicular. Sometimes two points can declared that he did not feel free enough from pain to be pierced by one needle. This is the "point to point" undergo the experiment. All in all, 900 extractions treatment. If the correct point has been pierced the have been done and very well recorded. According to patient should feel and report a sensation of shooting the statistics, the results are good.
144
I OBSERVATIONS ON ACUPUNCTURE
The Chief Anaesthetist at the University Hospital (Professor King) who had carried out 144 operations under acupuncture anaesthesia, does not recommend abdominal operations under this method because of the lack of relaxation - which makes the surgeon nervous. Of the 144 operations, mainly tonsils, sinuses, polyps, 24% were successful. Full success was reported by the Head of the Obstetric Department on curettage and induction of labour, but there was no chance of personally verifying this. My impressions and conclusion are that as far as it concerns relief of pain, acupuncture by itself is not the answer. It seems that in combination with chemotherapy and physiotherapy results are slightly better than when treated with each method separately. Dr Tang, the Veteran's Hospital in Taipei's chief driving force, has shown this in a detailed study treating the aforementioned 90 cases of cervical spondylosis. The same holds for general diseases. In the deaf and deaf mutes, treatment is advised daily
Tropical Doctor, July I976
for three to 12 months and then is given up if there is no improvement. In Taipei nine cases of congenital deafness were treated with no success. The claims of doctors in mainland China are better, but I have seen no improvement in any of the cases - I I in all, in addition to the previously mentioned nine. In conclusion I would like to say that I am prepared to give acupuncture the benefit of the doubt. We have seen too often that yesterday's doubts are tomorrow's certainties. Therefore I believe that at this stage we ought to examine the subject further and study it. We should certainly promise no spectacular cures. Finally I should like to state that I am not converted to acupuncture - nor do I deny it completely. Therefore I think it our duty to continue investigating. Note: Figs. I and 2 are from an article by Dr. Masayoshi Hyodo published in Abbottempo 1972, :10, 14. Permission to reproduce these figures is gratefully acknowledged.
Occasional Correspondence NEONATAL JAUNDICE
Dr Peter Magnus writes: I thoroughly enjoyed the succint article by Dr C. E. Effiong - "Management of neonatal jaundice in the tropics" (Tropical Doctor, 1975, 5, 33-35). I would like to take this opportunity to make the following suggestions and commentary: I. The signs and the symptoms of severe jaundice and kernicterus are indeed very important to ascertain. The accuracy of bilirubin levels as determined by various laboratories in the tropics will vary from country to country, however. I think we have to be wary that "moderate" cases of jaundice are between 10-15 mg of bilirubin and that the "main indication for exchange transfusion is an unconjugated bilirubin level of 20 mg per 100 ml and above in a normal birth weight baby, and of 15 mg per 100 ml for those weighing less than 2.5 kg". Although these numbers represent good guidelines, we have to take into account the baby's total protein status and his or her acid-base balance. In hypoalbuminaemic and acidotic infants the danger of unconjugated bilirubin moving intracellularly into brain cells is greater and occurs at lower levels than the normal newborn. It is only the unconjugated bilirubin bound to albumin which is decreased by phenobarbitone and broken down by ultraviolet light respectively; therefore, the greater the albumin level, the less chance the bilirubin can move intracellularly. Sulpha medicines
and aspirin, for example, compete for albumin binding sites with bilirubin, and serum levels of these agents will predispose the icteric newborn to kernicterus. 2. Other good places for studying infection besides blood cultures and cord swabs are swabs of the external ear canal in the newborn, fetal side of placenta, and a culture of cerebrospinal fluid. Spinal taps should be done on every baby suspected of sepsis, when possible. Examination of the gastric fluid of the suspected infected newborn for neutrophils (greater than 5/HPF indicative) is an inexpensive rapid adjunct. 3. I question the advisability of giving chloral hydrate or phenobarbitone orally 30 minutes before the procedure since one of the complications of exchange transfusion is respiratory or cardiac embarrassment, and although these dosages are not overwhelming, they may help mask an impending crisis. 4. If penicillin and streptomycin are given routinely in prophylactic fashion after an exchange transfusion for five days, I would suggest doing a blood culture (and bilirubin) on the last moiety to be removed at the end of the exchange. PETER D. MAGNUS, MD
Presently Peace Corps Physician B.P. 537 Niamey, Niger Corresponding address: 510 E. 86th St. Apt. IIC New York City, NY 10028, USA
