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James Reston’s Appendectomy

For many Americans, the current wave of public fascination with “complementary and alternative medicine ( CAM )” can be traced to a single event: New York Times columnist James Reston’s appendectomy in China during the summer of 1971, which Reston reported in an interesting and amusing article on July 26 of that year. Many of those who noticed the publicity following this event erroneously concluded that Mr. Reston had undergone “acupuncture anesthesia.” A few years ago, a Google search for “acupuncture and Reston” revealed that approximately 50% of the numerous “hits” reported this, as though it were an uncontroversial fact. Other sources have suggested the same, but in veiled language. Here are examples of each:

In the 1970s, interest in the procedure was sparked when New York Times editor James Reston wrote an article about his experience with acupuncture. Reston was covering Richard Nixon’s visit to China when Reston needed an emergency appendectomy, and acupuncture was used as an anesthetic.—UPenn News 1995

In 1972 President Nixon opened the doors to China. A New York Times journalist James Reston was in China at the time and had an emergency appendectomy with acupuncture used as the anesthetic.—American Acupuncture

[Acupuncture] made its official appearance in the U.S. in 1971 when an article by J. Reston was published in the New York Times describing his personal experience with acupuncture. While in Beijing reporting on a Ping-Pong tournament, he underwent an emergency appendectomy. Acupuncture was used as surgical anesthesia and to relieve post-operative pain. —Center for the Healing Arts, P.C.

The first US national media coverage concerning Acupuncture was in 1971 during President Nixon’s visit to China. There, visiting columnist James Reston told of his emergency appendectomy performed under Acupuncture anesthesia.— AZ Multicare

When New York Times columnist James Reston underwent an appendectomy while accompanying the Nixon entourage to Beijing in 1971, he wrote about a medical discovery called “acupuncture anesthesia.” Eisenberg, David, with Thomas Lee Wright: Encounters with Qi (p. 28)

About a month after his appendectomy, Reston did write about acupuncture anesthesia—but not referring to his own operation.

Those who don’t report that Reston had acupuncture anesthesia are likely to write, also erroneously, that his “intense post-operative pain was relieved by acupuncture”:

In 1971, a journalist named James Reston was travelling in the People’s Republic of China. He had received an emergency appendectomy and was suffering from extreme post-surgical pain. To his surprise, acupuncture relieved the pain.— http://www.acupuncturehealingarts.com/pain.html

New York Times reporter James Reston’s account of how physicians in Beijing eased his post-surgery abdominal pain with needles.— http://www.nih.gov/news/pr/nov97/od-05.htm

After the emergency operation was completed, Reston was in extreme discomfort and pain. To give him relief, the Chinese doctors performed an ancient practice of inserting needles into special areas of the skin to safely deaden the pain. This is called acupuncture.— http://www.school-for-champions.com/history/acupuncture.htm

Reston wrote a front-page story in the Times—”an obituary to his appendix,” as Eisenberg recalls it—that described how his intense postoperative pain was relieved by acupuncture, an ancient technique of Chinese medicine then unknown in the West. “This was an intellectual shot heard round the world,” Eisenberg says. “It resulted in NIH sending teams of scientists and clinicians to China to see if acupuncture anesthesia had any validity.” The 17-year-old Harvard freshman was fascinated. “It was something out of Star Trek—the idea that acupuncture needles could change pain sensations in a human being was like magic,” Eisenberg recalls. (Harvard Magazine, March/April 2002)

The “Intellectual Shot” was a Blank

What is the reality of Reston’s report and of “acupuncture anesthesia” in general? The front-page article, “Now, About My Operation in Peking,” appeared in the New York Times on July 26, 1971. Aside from the removal of Reston’s appendix, the account is quite different from what is commonly believed. There are only two passages pertaining to the anesthetic itself:

…removed my appendix on July 17 after a normal injection of Xylocain and Benzocain, which anesthetized the middle of my body. …and then pumped the area anesthetic by needle into my back.

Thus the anesthetic was a standard regional technique, most likely an “epidural.” There is only one passage that pertains to the treatment of Mr. Reston’s post-operative incisional pain:

I was back in my room…by 11 [PM]. The doctors came by to reassure me…gave me an injection to relieve the pain…

In other words, he got a standard injection of narcotic. This may have been repeated, but he didn’t report this. Only during the following night, more than 24 hours after the operation, did Mr. Reston have his brief encounter with qi:

I was in considerable discomfort if not pain during the second night after the operation, and Li Chang-yuan, doctor of acupuncture at the hospital, with my approval, inserted three long, thin needles into the outer part of my right elbow and below my knees and manipulated them in order to stimulate them and relieve the pressure and distention of the stomach. That sent ripples of pain racing through my limbs and, at least, had the effect of diverting my attention from the distress in my stomach. Meanwhile, Dr. Li lit two pieces of an herb called ai, which looked like the burning stumps of a broken cheap cigar, and held them close to my abdomen while occasionally twirling the needles into action. All this took about 20 minutes, during which I remember thinking that it was rather a complicated way to get rid of gas on the stomach, but there was a noticeable relaxation of the pressure distension within an hour and no recurrence of the problem thereafter.

So, at a time when his incisional pain was waning, Mr. Reston experienced a “discomfort.” Not “pain,” not “severe,” not even “cramping”–descriptions that are common in others’ accounts of the event, offering only the Times article as a reference. The discomfort passed within an hour, during the first 20 minutes of which Reston was needled and subjected to “moxibustion.” We can’t be certain of the cause of the discomfort, but bowel distention is a reasonable guess, and is consistent with its timing after the appendectomy. If this had been the case, it would be surprising only if the discomfort had not been transient. There is no need to invoke acupuncture in its resolution, other than Reston’s reasonable suggestion that the pain from the needles was, at first, a distraction.

Actual Accounts of Acupuncture Anesthesia

Wide-eyed Westerners have offered several extraordinary accounts of acupuncture anesthesia. Dr. Eisenberg, in his book Encounters with Qi, reported having observed a brain operation performed with acupuncture and moderate sedation, and two thyroidectomies performed with acupuncture alone. He wrote that the Chinese had explained to him that the first open-chest operation with acupuncture had been performed in Liuzhou in 1957. He wrote that abdominal and chest surgeries had originally required several acupuncturists and more than 100 needles, but that over a period of a few years the number of needles was markedly reduced, sometimes to only one. He reported that according to Chinese sources, “acupuncture failed to give adequate pain relief in 20 to 30 percent of all abdominal, gynecological, or chest surgery.”

Typical of accounts by westerners, shortly after Nixon made his rapprochement with China, was this one by E. Grey Dimond, published in JAMA in 1971:

This patient was a 40 year-old man with a large non-toxic adenoma of the thyroid. On the night before surgery he had received at bedtime 400 mg of meprobamate (Miltown). There were no preoperative medications. The patient walked into the operating room, took off his pajama top, retaining the pants, and stretched out on the operating table. One stainless steel acupuncture needle was inserted in the extensor aspect of each forearm, at a point approximately 4 inches proximal to the wrist, at a depth of 1 to 11/4 inches, between the radius and ulna. This point was carefully selected and identified as the most effective for anesthesia in thyroid surgery. A small clip was attached to the shaft of each needle and then connection made to a direct current battery power unit delivering 9 volts at 105 cycles per minute. Details of the wave form, current, or circuitry could not be supplied by the anesthetist. An intravenous drip of 5% dextrose was begun and to it was added 50 mg of meperidine hydrochloride (Demerol). Typing and crossmatching had been done. During a 20-minute “induction” period surgical preparation and draping were done. No other anesthetic agent was added. The patient remained fully conscious and normally alert. He advised me, through the interpreter, that he was noting numbness and tingling of both hands; no motor change occurred. After 20 minutes surgery began and a skillful team moved rapidly through the operating procedure. At one point the patient took a sip of water. A large adenoma, approximately 2 cm by 3 cm in size, was removed and the wound closed. The patient sat up, had a full glass of milk, held up his little red book, and said in a firm voice: “Long live Chairman Mao and welcome American doctors.” He then put on his pajama top, stepped to the floor, and walked out of the operating room.

Isidore Rosenfeld, the grandfatherly cardiologist and health editor of Parade magazine, reported having observed an open-heart operation in China in the 1970s. Several other American physicians accompanied him. The patient was a 28-year-old woman. According to Dr. Rosenfeld, who took a photograph of the patient during surgery, her only anesthetic had been a single acupuncture needle in the right ear, connected to an electrical source. Dr. Rosenfeld reported that she underwent repair of her mitral valve through a midline sternal (breast bone) incision and remained awake throughout the procedure. He also wrote that the patient had “no intravenous needle in her arm.”

Skeptic Gary Posner, an internist, read Rosenfeld’s account in the August 16, 1998 issue of Parade and immediately recognized a problem in physiology: even if the patient had experienced no pain whatsoever, Star Trek style, she wouldn’t have been able to breathe after her chest was opened because of an inability to generate negative intrathoracic pressure. This phenomenon, known as “flail chest,” would also have been a problem for the 1957 Liuzhou patient reported by Eisenberg.

Posner and our fellow blogger Wally Sampson, the editor of the Scientific Review of Alternative Medicine, offered a plausible explanation. Their examination of Rosenfeld’s photograph suggested that the operation was not open-heart surgery, but a “closed” mitral valve commissurotomy through a small subcostal (below a rib) incision. This would have allowed the patient to breathe spontaneously, while also requiring minimal analgesia.

But doesn’t acupuncture offer some analgesic or anesthetic effect that can’t be explained by ordinary phenomena? One of the first accounts to cast doubt on that assertion, and still the most rational early Western assessment of “acupuncture anesthesia,” was that of cardiac surgeon Michael DeBakey in The Reader’s Digest of September, 1973. After witnessing actual open-heart surgery in Shanghai on a 21 year-old boy who “apparently had been anesthetized with acupuncture needles,” DeBakey wrote that he was

as doubtful of [acupuncture’s] importance to medicine today as I was before I visited China. It is understandable that many observers have been startled by what they have seen of acupuncture. The sight of a fully conscious “needled” patient submitting to a surgeon’s knife without flinching is awe-inspiring. But, to a trained surgeon, the procedure is not so astonishing.

Dr. DeBakey explained that prior to the operation the patient was drowsy, having been given phenobarbital and morphine. Several acupuncture needles were then inserted in various places and connected to an electrical source, which caused the patient’s muscles to twitch. The next step was more revealing:

But before the surgeon reached for his scalpel, he injected a local anesthetic into the skin and tissues about the young man’s breastbone. Other members of the surgical team said later that such locals were often used, because otherwise patients felt the pain of the first surgical incision in their skin. This was the only time I saw a local used before the initial incision. If it was used in every operation, there would be no mystery to acupuncture at all—it would be virtually identical to operations that we performed routinely many years ago using only local anesthetics.

Although DeBakey didn’t make this point specifically, the infiltration of local anesthetic explained not only the patient’s insensitivity to the skin incision, but also to the splitting of the sternum: the description suggests that the surgeon anesthetized the intercostal nerves, which would have served to block all sternal sensation.

DeBakey’s account also provides an alternative explanation for the problem of “flail” chest in an awake, spontaneously breathing patient undergoing open-chest surgery: in this case the patient had cardiopulmonary bypass accomplished via the “fem-fem” route. If this had begun prior to the chest being opened, it would have provided adequate gas exchange for the patient even in the absence of spontaneous ventilation. Although DeBakey reported that the patient “actually talked occasionally to the anesthetist while the heart was stopped,” the ability to make small tidal volumes—enough to make soft utterances, but not to sustain adequate ventilation—would not be surprising in this circumstance.

DeBakey also reported other facts of “acupuncture anesthesia” that were later confirmed by others. Not only were most patients who underwent acupuncture for surgery given sedatives, narcotics, and local anesthetics, but they were a carefully selected group who “met very strict criteria.” DeBakey’s hosts told him that “most people can’t take it” and that those even willing to try ranged from only 7 to 30 percent of the population, depending on the location. These percentages are remarkable in light of the intense political and cultural pressure to showcase traditional Chinese medicine that existed at that time, as will be discussed in Part II of this series.

This was Nothing New

As surprising as it may sound to the modern ear, it had been known for centuries that a small percentage of people can undergo surgery or other typically painful procedures, such as tooth extractions, with minimal or no apparent pain. Melvin Gravitz, writing about hypnosis or ‘Mesmerism,’ cited numerous such examples from the 19th and 20th centuries. Petr Skrabanek, writing in Stalker and Glymour’s Examining Holistic Medicine, cited others that were strikingly similar to the case reported above by Dimond:

Formal hypnosis, however, is not necessary. Parker operated on many patients in China without any anesthesia (or acupuncture) and was astonished by their apparent insensibility to pain. In 1843, he performed a mastectomy on a patient, who, when the operation was over, “raised herself from the table without assistance, jumped on the floor and made her bow to the gentlemen present, in the Chinese style, and walked into another room as though nothing had occurred.” Similar observations were made by other Western surgeons in China, such as Lockhart, McPherson, and others. “The manner in which they bear the pain of an operation is perfectly astounding,” wrote Gordon in 1863, “a large proportion of those upon whom operations were performed had no chloroform…some did not even clench their hands or teeth, but lay upon the table perfectly motionless, while their muscles were being cut by the knife and their bones divided by the saw.”

Next: An anesthesiologist’s perspective

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The ‘Acupuncture Anesthesia’ series:

1. “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part I)

2. “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part II)

3. “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part III)

4. “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part IV)

5. ‘Acupuncture Anesthesia’ Redux: another Skeptic and an Unfortunate Misportrayal at the NCCAM