(An edited version of the original in the American Journal of Acupuncture
Oct-Dec 1981: 9(4); 347-351).
Abstract
Acupuncture has received adverse comments in the medical literature on the basis that it may have serious complications involving neurological damage, pneumothorax, cardiac tamponade, serum hepatitis, auricular chondritis, local and systemic infections, puncture of body cavities and vital organs, second and third degree burns, and mental trauma. It is shown that serious complications can arise only from the improper use of acupuncture or from its gross abuse by incompetent practitioners. The safety of a technique must be judged on its results in the hands of competent practitioners who use it properly. If this criterion is accepted, acupuncture is seen as an extremely safe therapeutic system whose complications very rare and are easily avoided or rectified.
Introduction
During recent years, acupuncture has from time to time received adverse publicity on the grounds that it may have serious complications. Some of these assertions are discussed. It will be shown that serious complications can arise only from the improper use of acupuncture or from its gross abuse by incompetent practitioners.
A recent article described a patient in which acupuncture needles were implanted permanently in the soft tissues of the neck for the treatment of migraine1. The patient fell on the stairs, striking the back of his neck. As a result, one of the implanted needles was driven into the spinal cord. This caused serious neurological damage which persisted despite surgical removal of the needle.
Other serious complications of acupuncture have been described by many workers, including pneumothorax2-7, cardiac tamponade8, auricular chondritis9, serum hepatitis10, local and systemic infections, puncture of body cavities and vital organs, mental trauma and second or third degree burns (from cautery)11. One report described hypertension in rats following repeated deliberate acupuncture of the adrenal glands11. In standard textbooks of acupuncture, such as those printed in Peking12, Taiwan13 or other Chinese sources14, additional complications are described, including syncope, nausea, vomiting, abortion, broken needles, and "needle lock" due to muscle spasm.
Authoritative textbooks stress the following principles to be kept in mind for the use of the acupuncture needles:
Needle quality and sterility
Acupuncture needles should be of very high quality material, preferably stainless steel. They are usually 28-32 gauge. All needles should be regularly inspected. Twisted, rusty or imperfect needles should be discarded. Because of their quality, these needles are expensive and are routinely used many times, even for a year or so. However, they should always be sterilised before use.
Aseptic techniques
The skin is cleansed and then swabbed thoroughly with an approved antiseptic preparation before sterile needles are inserted. Some textbooks recommend that the fingers be used to steady the needle, especially where long needles (2-2.5 inches) are used such as in heavy muscle groups, as for example, over the sciatic nerve. This practice is not necessary and should be avoided. It may cause contamination of the needle from the fingers of the acupuncturist. The use of a sterile cotton wool bud to steady the needle or of a needle guide tube facilitates aseptic needling techniques. Dirty needles or improper preparation of the skin before needling may introduce infection, including serum hepatitis. This applies to the hypodermic needles used by orthodox practitioners as much as to the solid needles used by acupuncturists.
Puncture of body cavities and vital organs
Special care is necessary when needling points on the thorax and shoulder muscles. Puncture of body cavities and vital organs must be avoided. The needles should be as short as possible and are inserted at an angle of 45 degrees rather than 90 degrees in areas where the body wall is thin. The patient is warned not to cough during insertion, or to indicate if a cough is imminent.
If this principle is followed, pneumothorax or peritonitis cannot arise. Cardiac tamponade as a complication of acupuncture undoubtedly must occur less frequently than sudden death during routine sampling of cerebrospinal fluid in neurological clinics. No competent acupuncturist in his right mind would use a needle long enough to reach the heart when needling over the cardiac area. Similarly, puncture of the kidneys or adrenal glands in skilled acupuncture therapy would arise in about the same frequency as a competent physician might administer a convulsive dose of strychnine (mistaking it for a sedative) to a convulsing infant.
Puncture of ear cartilage
If basic aseptic technique is used and if the needle is inserted subcutaneously at an angle of 15 degrees or less, avoiding the cartilage, chondritis is most unlikely to arise. Although some sources recommend penetration of the ear cartilage, and some practitioners shoot special staples into the ear for long-term acupuncture stimulation, these techniques should be avoided.
Implantation techniques
In chronic disorders a variety of subcutaneous implants are recommended by authoritative sources in order to effect long term stimulation of reflex points. Usually an absorbable (sterile) material such as catgut, placental tissue or foetal tissue is used, and aseptic techniques are followed. Occasionally, needles are implanted intradermally or subcutaneously and are taped in position for easy removal. In the rare instances where needles are to be buried completely, they are anchored in the tissue by a bead or loop at the outer end. This prevents their migration through the tissues. In the Japanese report1, the needles were not anchored. Instead, ordinary acupuncture needles were inserted deeply and cut off at the skin, leaving 1-1.5 inches of sharp steel free to move in the tissues. This is extremely bad practice, but many Japanese acupuncturists are said to use it1. One must surely question the scientific and medical competence of practitioners who employ this dangerous method. However, one would hardly deem appendectomy to be a dangerous technique just because an incompetent surgeon makes a fatal blunder during an otherwise simple operation.
[Notes added September 1998: This article was written in 1981, before implantation of 1 mm diameter gold beads, or 2 mm lengths of 1 mm diameter 24 carat gold wire, became commonplace in veterinary acupuncture. This technique is used widely to treat hip dysplasia, chronic arthropathy and other chronic diseases in animals, especially dogs. The implants are inserted, under general anaesthesia, into acupuncture points near, or related to, the affected joint, organ, or area. Personal communication with veterinarians who have used the technique suggest that the clinical results are excellent and that migration of the implants from the original sites of insertion is minimal. However, great care must be taken to avoid insertion of those implants in, or near, joint capsules. In very rare cases, such implants may accidentally enter the joint-space and exaggerate the pain and stiffness. Should that happen, the offending implant(s) must be removed surgically].
Precautions during cautery
Various types of cautery are effective in many diseases treatable by acupuncture. Modern textbooks explain in depth the techniques to be followed to avoid burning or hurting the patient seriously. The older techniques of heavy cautery are regarded by modern, competent acupuncturists as of historic interest only.
Syncope, nausea, vomiting
Certain acupuncture points, especially those over nerve trunks (such as Hoku, Tsusanli, Yanglingchuan), or in highly innervated areas (such as the anti-shock or emergency points Jenchung, Yungchuan and the fingertip points), and certain points on the face and ears have powerful effects on the autonomic nervous system. Standard textbooks of acupuncture warn against over-stimulation of these points and discuss the measures to be followed should weakness etc., occur. In competent hands, these side effects happen in <10% of cases and usually are seen at the first visit only. They are less likely to arise in humans if they are needled while lying down.
Abortion
Western physicians may not be aware of the fact that strong needling of certain points (Hoku, Sanyinchiao, Tsusanli, lumbar and abdominal points, and several others) can cause strong uterine contractions and expulsion of the foetus. Acupuncture by itself may be used to induce birth or to cause abortion from nineteen weeks of pregnancy onwards12-20. Standard textbooks warn against the use of these points in pregnant women, or advise special care and gentleness if they must be used for therapeutic purposes other than induction of birth or abortion.
"Needle lock" and broken needles
Occasionally a needle imbedded in a muscle may be twisted into bizarre shapes (right angles, s-shapes etc.) if the muscle goes into spasm during acupuncture therapy. This is called "needle lock", as the needle is somewhat difficult to extract. Standard textbooks describe the methods to relax the muscle and to withdraw the locked needle. It is a very minor problem. If faulty needles are used (rust spots, weak spots due to a twisted needle having been used after straightening it out) they may break off in the tissues. This complication does not arise if perfect needles are used. If the broken end cannot be grasped by a forceps or manoeuvred above the skin by mobilisation of the tissue, it must be removed surgically.
[Notes added September 1998: This article was written in 1981, before methods of transmission of Acquired Immunodeficiency Syndrome (AIDS) and Creutzfelt-Jakob Disease (CJD) were known. Now it is known that infected fluids, tissues, needles and surgical equipment can readily transmit viral hepatitis, AIDS and CJD. It is very difficult to guarantee total sterilisation of equipment which may have been infected with these agents. Meanwhile, the cost of disposable acupuncture needles has fallen. Today, such needles cost only a few cents each. Thus, in contrast to what was stated under the section on Needle quality and sterility (above), best practice would tolerate only single-use disposable acupuncture needles; it would consider the sterilisation of needles between human patients to be unsafe. Also, if Plum-Blossom-, Seven-Star-, or "Hammer-Type-" needles, or other invasive instruments are used, only those with disposable heads would be considered safe from the risk of cross-infection. Therefore, in the section on Needle lock and broken needles, above, the comments on rusted or damaged needles as causes of needle breakage are now irrelevant].
Other side effects
Occasionally the acupuncturist may forget to remove a needle. This is a minor matter in human patients because they usually discover the error and remove the needle. However, the error can happen easily in long-haired animals. It is advisable that the case notes should record the location of each needle used. This record facilitates a quick check that all needles are removed as well as introducing a permanent record of which points were used for future reference.
Occasionally, in treating muscle spasm, strong twirling of the needle or electroneedling in the area of the spasm may precipitate more severe spasm. If this occurs, stimulation should be stopped and the muscle spasm should be eased by manual stretching and massage techniques and removal of the offending needles. Care must be taken in subsequent sessions with this particular patient to stimulate the problem area with care and gentleness.
Exaggeration of symptoms may occur in humans and animals after acupuncture. In humans, the exaggeration rarely lasts more than one or two days after the acupuncture session. In dogs, exaggeration may last longer, up to 5 days in rare instances. Patients and animal owners should be warned that this may occur. Many acupuncturists take it as a good sign, indicating that acupuncture has been successful in stimulating some response and they expect success following further sessions.
Drug-like sensation ("being high') can arise in humans, probably due to endorphin release. Before attempting to drive a car or do work in which eye-to-hand co-ordination is important patients should relax for 20 minutes after acupuncture.
This narcotic-type effect is very common in dogs but also occurs in other species. The animals may appear calmer or sleepier than animal usual. Dogs often let the head hang down. They may appear to be in a light sleep. A watery nasal discharge may occur.
Neuritis may arise by direct injury to a nerve. It is very rare if correct needling methods are used and if the same points are not needled too vigorously, or too frequently.
Post-analgesia paralysis may arise on very rare occasions in humans and animals when surgery has been done under strong acupuncture stimulation. This phenomenon may be local or spinal and is due to excessive stimulation (especially by manual pecking and twirling of the needle) of the nerve. Many of these cases respond to massage of the acupunctured area and needling nearby points. Care should be taken when needling points over major peripheral nerves that excessive pecking and twirling of the needle does not cause physical damage to the nerve.
Conclusion
Unfortunately, every profession has its incompetents, quacks and confidence tricksters. Acupuncture practitioners may have more than their fair share of these because there is as yet no agreed standard of training which must be reached before one may practice acupuncture.
On the other hand, many complications (some of which may be very serious, if not fatal) can arise as a result of the use and misuse of orthodox medicaments (narcotics, tranquillisers, psychoactive drugs, steroids, analgesics, glycosides, alkaloids, chemotherapeutics, antibiotics), surgical intervention, therapeutic irradiation and exploratory tests (X-irradiation, collection of cerebrospinal fluid, liver biopsy, exploratory surgery etc.). When one considers all these complications, one might be tempted to conclude that the disadvantages of Western medicine may well outweigh its advantages. However, this conclusion would show a great ignorance of the extremely valuable role which allopathic medicine has played in treating and preventing disease. To judge any system as being fraught with serious complications because of the incompetence, ignorance or negligence of a small number of its practitioners, is unjust. The safety of a technique must be judged on its results in the hands of competent practitioners who use it properly. If this criterion is accepted, acupuncture per se must be seen as a very safe therapeutic system, whose complications are very rare and are easily avoided or rectified. If it does no good, at least it does no harm either.
Those who reject the integration of acupuncture into Western medicine have many reasons for doing so. I believe that two of the most important stumbling blocks to Western acceptance of this valuable technique are ignorance of the mechanism by which acupuncture activates the homeostatic mechanism of the body, and misconceptions as to what techniques are accepted as standard practice by competent practitioners. The mechanisms of acupuncture are rapidly being revealed by research in the West, as well as in the East. They need not be discussed here. As for the safety or otherwise of standard acupuncture practice, I hope that this report will dispel some of the misconceptions.
Acknowledgement: Thanks are due to Dr. Luc Janssens DVM, (Wilrijk, Belgium), who made valuable additions to the original manuscript.
References