e-19th century

Papers from the early 19th century

Inspired by Cloquet, Sarlandière, Pelletan, Carraro, and Pouillet, on Acupuncture. Edinburgh Med Surg J 1827;27:190–200.

On the 25th October 2018 three rather unusual papers appeared on my PubMed search.[1–3] They were remarkable because they were nearly two centuries late! So I guess there is an ongoing process of digitising journal archives, and it happens that the word ‘acupuncture’ or ‘acupuncturation’ appeared in the titles of these old papers. I often use the search term ‘acup*’, where the asterisk is a wild card – meaning it can stand for any letter or combination of letters. Generally, that means I will get ‘acupuncture’ or ‘acupressure’… I never expected, in the modern era to get ‘acupuncturation’!

I was very pleased to find that the full text of these papers was hosted on PubMed Central (PMC), although they are reasonably big files since they are page images. The oldest of the three was published in 1827, and it is this paper to which the following extracts and comments are attributed.

The Edinburgh Medical and Surgical Journal was published in Edinburgh from 1805 to 1855, and was described as: …exhibiting a concise view of the latest and most important discoveries in medicine, surgery, and pharmacy.

EMSJ 1805

It was clearly a quite prestigious and conservative journal, as the opening paragraph of the earliest paper reveals:[1]

Those of our readers who have perused the essay of Mr Churchill on acupuncture and his papers in the London Medical Repository, and who are aware that investigations have been lately made on the same subject in various parts of the Continent, may be surprised that hitherto no notice has been taken of it in this Journal. Our reason has been, that the first accounts given of the virtues of the new remedy were so marvellous, and therefore seemed to savour so much of quackery, that, coming, as they did, from persons not of the highest authority, we could not but follow the general example, and decline giving implicit credit to their assertions.

The same paragraph goes on to describe the editors’ change of heart – dare I say u‑turn on the matter:

But these assertions have been re-echoed from almost every quarter of Europe; observations have been made on the subject at many continental schools of eminence; the several accounts given by unconnected writers agree very remarkably in every essential particular; the alleged facts have at length been put to the test of a full and minute train of experiments by one of the most scientific of the Parisian physicians, in a great public hospital, and under the eyes of its pupils; the results of these experiments, as published by his hospital assistants, harmonize exactly with the statements made by those who introduced the remedy into Europe; and under such circumstances we cannot any longer delay presenting a summary of the interesting information which has been accumulated in its favour.

So how about that then?

The acuphiles jump for joy…
(my neologism – ‘acupuncture lovers’) 

But wait:

It must be confessed, however, that after all we cannot approach this singular topic without hesitation.

What now? I love the use of the term ‘singular’ here, meaning remarkable, which has fallen out of common use. It is the word I have noticed jumping out with great regularity from the text of Conan Doyle’s Sherlock Holmes, as reanimated by the wonderfully expressive voice of Stephen Fry.

It is true, that, in the hands of M. Cloquet, the remedial virtues of acupuncture have passed triumphantly through an ordeal, to which no remedy, whose claims were false, could be submitted without detection. But, at the same time, the utmost ingenuity of its favourers has been unable to discover, in a long course of minute inquires, any rational way of accounting for its effects; and, what is perhaps of more consequence, they have been unable to detect any physiological change or phenomenon co-ordinate with its operation. There is in short a total want of every sort of evidence in its favour as a remedy, except that most treacherous kind, the evidence of succession; and consequently, a philosophical mind, especially considering the diseases in which the greatest success has been obtained, will naturally feel inclined to attribute the cures which have been accomplished to the influence of the imagination, and to sentence acupuncture to banishment from regular practice, as being nothing else than a variety of animal magnetism.

…a total want of every sort of evidence in its favour as a remedy, except that most treacherous kind, the evidence of succession!

Could it be:

…nothing else than a variety of animal magnetism!

Well the piece goes on to say that the journal is not the place to discuss evidence, and proceeds to describe the experiences of the fellows who have written about the technique. It is interesting to note the common opinion of where the technique works best, or should I say, where it doesn’t!

It is applied to all manner of maladies; but those in which it is accounted most applicable and is in reality most successful, are evidently such as do not belong to the active inflammatory disorders.

The paper describes the fine needles used, the fact that they simply do not hurt at all to insert, and that they are often retained for only 5 to 6 minutes; but a chap called Cloquet describes having left them in for over an hour.

Sewing needles could be used apparently, but only after passing a thread through the eye so that the needle did not get lost inside the body. Longer needles are also described – three inches in length and one fortieth of an inch in diameter (the latter is just over 0.6mm, so not too fat).

Louis Berlioz, the father of the famous composer, is credited as having first written about its use in the contemporary practice of the time as a ‘memoire to the Parisian Society of Medicine’. Berlioz is also credited as being the first to use electrical stimulation of needles in the form of galvanism.

Rather alarming is the description of how there is no damage to tissues or organs, including the heart and lungs, followed immediately by a description of a fatality that seems to have resulted from the terror caused by the accidental disappearance of needles into the abdomen.

In regard to the accidents arising from acupuncture, it is only necessary to add, that in a few cases the operation has been followed by a tendency to fainting, and that in one instance, which occurred at the Hotel-Dieu of Paris, the accidental disappearance of the needles in the skin of the belly was followed by such extreme and uncontrollable terror, that the patient expired soon after.

After a long description of the effects observed in patients, this paper finishes with some conjecture over the mechanism. They include the possibility that it ‘operates through the mind’, but my favourite idea of theirs is that it acts by:

…rectifying an aberration of the nervous fluid.

References

  1. Cloquet, Sarlandière, Pelletan, Carraro, and Pouillet, on Acupuncture. Edinburgh Med Surg J 1827;27:190–200.http://www.ncbi.nlm.nih.gov/pubmed/30330050 (accessed 25 Oct2018).
  2. Renton J. Observations on Acupuncture. Edinburgh Med Surg J 1830;34:100–7.http://www.ncbi.nlm.nih.gov/pubmed/30330219 (accessed 25 Oct2018).
  3. Banks JT. Observations on Acupuncturation. Edinburgh Med Surg J 1831;35:323–8.http://www.ncbi.nlm.nih.gov/pubmed/30329900 (accessed 25 Oct2018).

Declaration of interests MC

Another fatality

Inspired by Jian et al. Medicine 2018

pubcrawlerLast Saturday (3rd November 5, 2018) I was lecturing on the BMAS Foundation Course, and during the morning coffee break I received one of my regular email alerts from PubCrawler – an Irish website that searches (or crawls) PubMed (the US National Library of Medicine) leaving you free to go to the pub! It was somewhat ironic that I was about to give the Safety Brief for the course, when I received notification of this fatal case report – a death from bilateral tension pneumothorax in Shanghai, China.[1]

Reports of deaths from acupuncture are very rare, but there may be a degree of under-reporting, as can be inferred to some degree by this case. The last fatality reported was a curious one, possibly related to strong needling around the vagus nerve in the neck,[2] and prior to that there had been no reports for 10 years.[3]

…why emphasize this risk of which we should all be very aware?

So this is another report of pneumothorax – why emphasize this risk of which we should all be very aware? Well it was fatal, and most are not, but the remarkable features of this case relate to the postmortem diagnosis and the wonderful images provided by the authors.

A 52 year old man of apparently normal constitution received acupuncture and cupping treatment at an ‘illegal’ Chinese medicine clinic some 30 hours before being admitted to hospital with severe dyspnoea. He had been treated with 0.25x75mm needles to a variety of points on the dorsal and low back, some of which were clearly over the lung fields. It is not clear how deep the needles were inserted, but 30mm needles are long enough to reach the lung in some of the points used, so there is no question that the lungs were within easy reach of 75mm needles.

…there is no question that the lungs were within easy reach of 75mm needles.

It was not clear that he had acupuncture, so the early suspicion was of airway blockage. The patient collapsed 30 minutes after admission and cardiopulmonary resuscitation was attempted for an hour, although tension pneumothorax was clearly not suspected.

The body was frozen after death and then thawed before being subject to postmortem computed tomography (PMCT), some 207 hours after death. The CT images demonstrate dramatic collapse and compression of both lungs as well as severe compression in the upper mediastinum. The trachea appears to be only mildly deviated because of bilateral tension, so this important sign in unilateral tension pneumothorax would not have been apparent on resuscitation.

Jian 2018 Fig 1.png
PMCT findings in (A) the lung window, (B) the mediastinal window. Both lungs were collapsed and the density of both lungs was significantly elevated. Mediastinal compression and compression of heart and major vessels were also detected.
Jian 2018 Fig 2.png
Screen images of 3D reconstructions of lungs. Views in the coronal (A), axial (B) and sagittal (C) planes showed the collapsed lungs (purple) and gas in the pleural space (blue). 3D reconstructions (D) showed the collapsed lungs (red) and gas in pleural space (translucent).

Full body PMCT was a new concept to me, and in this case it was highly instructive. It lead the forensic examiners to perform a pneumothorax test – making a small opening into each side of the chest underwater to look for formation of bubbles. I spent a whole summer in the pathology department in Leeds, and assisted at many post mortems, but I had not seen nor heard of this test before, so clearly it is not routinely performed.

Jian 2018 Fig 4
Results of bilateral pneumothorax test.

This is a very well described and wonderfully illustrated forensic case report, but most importantly it is a reminder to all of us who needle over the thorax to be vigilant in our techniques. The BMAS has published guidelines on safe needling over the thorax.

References

  1. Jian J, Shao Y, Wan L, et al. Autopsy diagnosis of acupuncture-induced bilateral tension pneumothorax using whole-body postmortem computed tomography: A case report. Medicine (Baltimore) 2018;97:e13059. doi:10.1097/MD.0000000000013059
  2. Watanabe M, Unuma K, Fujii Y, et al. An autopsy case of vagus nerve stimulation following acupuncture. Leg Med (Tokyo) 2015;17:120–2. doi:10.1016/j.legalmed.2014.11.001
  3. Chang S-A, Kim Y-J, Sohn D-W, et al. Aortoduodenal fistula complicated by acupuncture. Int J Cardiol 2005;104:241–2. doi:10.1016/j.ijcard.2004.12.035

Declaration of interests MC