Emanuel M. Papper, M.D., Ph.D.

A Diary of a Visit to China

By E.M. Papper, M.D.

1-22 May 1974

FIRST DAY IN CHINA - 1 May 1974

The entrance into the City of Canton was by train. We had a rather spectacular and interesting experience in many ways. We crossed the frontier with very great friendship on the part of the Chinese Medical Association representatives who met us, and guided us across the famous frontier bridge. From there we had a magnificent two-hour ride in an air-conditioned train in contrast to the rather hot and unpleasant ride in the train in Hong Kong. We had a marvelous lunch at the Frontier Train Station and the trip itself was through magnificent rice paddied countryside in which much farm labor was being done.

In Canton we were taken through a trade fair which is held twice a year and a rather spectacular one indeed. There is a strong and dedicated feeling towards self-efficiency in almost all areas of activity by the Chinese. We saw interesting evidence of modern technology, ancient handi­craft and similar things. It was special indeed. We were then taken to the airport to fly to Peking but the flight was cancelled. As I dictate this information, I am in a large old fashioned but magnificent suite. As Chairman of the Delegation I am honored with the best accommodations. It is more than I require, but certainly welcome. I am also given the best interpreter and the most senior members of the reception party as my hosts. Our automobile is always in the lead.

SOME OBSERVATIONS IN PASSING - MAY DAY 1974

The Chinese talk about minority peoples in much the same spirit that we do in the United States. However, there is a notable exception in the implications, if I understand them correctly. The minority peoples seem to be dealt with proudly by the Chinese and are given a considerable amount of local autonomy in many ways. Their languages, customs, dress and other distinguishing features have been preserved. This phenomenon was quite apparent at the Canton trade fair. Also, the minorities are shown on the map of China in very much the same way that the Soviet Union includes autonomous Republics with the same kind of respect for minority interests.

With respect to my personal situation, the large and grand suite in which I slept on the first night in China on May 1st was hot, despite some fans. There were no insects and there was every other comfort. I perspired freely because of the heat. My accommodation to the heat is fairly rapid because I am basically healthy and physically fit.

While waiting at the airport, I had some abdominal pain probably due to salt and water loss from sweating. I was compassionately looked after by our Chinese colleagues and received the benefit of the traditional medical care as well as a modest amount of Western medical care. One of the traditional doctors applied heat to the web of my left interspace between thumb and forefinger and also applied pressure acupuncture in both web spaces, as well as in the area between tibia and fibula on both sides approximately one-third of the distance between the ankle and the knee and below the knee. I was also given Atropine by mouth.

After we settled in our hotel, Arthur Taub and Francis Foldes looked in. Arthur examined my abdomen both by palpation and auscultation and thought there were no abnormalities. Actually I agreed with him. I arose early on the morning of the 2nd of May, something like 3:00 to 3:30 in the morning. At 5 A.M. I shaved and got partially dressed waiting for the group to collect for breakfast and to take the flight to Peking .

Our group is rapidly uniting into a good working unit and I anticipate that we will be able to do justice to this visit so important both for the United States as well as for China . The scientific and medical tasks are uppermost, but the relation of people to people is equally or more important.

2 MAY 1974

On the 2nd of May we left Canton at the end of a subtropical rain storm and flew from Canton twelve hundred miles to Peking with two intermediary stops, one of them Shanghai. It was a beautiful flight over lovely country in a Boeing 707 configured for tourist class passengers. Besides our own group, the remaining passengers were small numbers of Chinese and many Japanese which are there on business with the Chinese government. We had some interesting discussions en route which was productive since we spent the better part of the day from very early morning traveling. We were met at the Peking Airport by a delegation from the China Medical Association and Dr. Fu, the Responsible Person, who is my counterpart and who is also the Deputy Secretary General of the China Medical Association. The climate and geography of Peking is similar to the Northeast of the United States. We drove from the airport to the hotel in the usual sequence of the Responsible Person, the Chief Interpreter and myself and Fred Kerr, the Deputy Chairman and two of our hosts riding in the lead car. The apple blossoms on all of the trees made me nostalgic for the time when I lived in the Northeastern United States. As a matter of fact, there were considerable similarities in climate in traveling from Canton to Peking, as would be found in traveling from Miami to New England during the summer.

When we arrived at our hotel, as usual I was given the largest suite with the usual overstuffed, early Victorian period furniture. These arrangements are quite comfortable, but they are certainly not luxurious in the Western sense of the word.

We had our first meeting with the delegations from the China Medical Association to review our program while in China. It will be a busy visit and it is going to require much work, at least as it appears at this moment, for us to achieve penetrating insights into the value and mechanisms of acupuncture for surgical anesthesia. I think time will run short and the opportunities for seeing and getting into real depth on the patients or experiments that we will observe will be somewhat limited in time for total "immersion" into this complex pool of knowledge that is acupuncture.

We did have some difference of opinion with the China Medical Association as to the things we would like to see. Understandably, were I in their position I would do the same, since they do wish us to see a good many procedures that are unrelated to acupuncture for surgical anesthesia. These are major advances in the control of public health, preventive medicine and similar emphasis, e.g., food and lodging at which the Chinese have excelled in the service of the people. Hopefully, we shall work out some compromise in which we can satisfy more of our interests and that they will be able to demonstrate to us the most impressive advances in acupuncture which have been made in China since the Liberation in 1949, i.e., the formation of a Communist regime.

Tonight (2 May 1974) we had our first real Chinese dinner together and enjoyed it exceedingly. We are planning to have research seminars continuously to update our views on what we see. These will be 3 or 4 a week, led by different members of the Study Group. On Saturday night (4 May 1974) at the end of two full days of visiting various acupuncture installations we will have another session to determine whether our approaches to information gathering are effective or whether we need to change them. It is my understanding now that it will be possible for us to write home but I did not know this before leaving and will not have any communication from home or the office.

RANDOM THOUGHTS

I am dictating as we are driving through a wide boulevard in Peking with constant horn blowing at bicycle riders and pedestrians. The automobile traffic is very light and the horn sounding grossly disproportionate. The large amounts of street lighting we saw on the night of May 2nd in Peking and on all the important buildings occurs only on important holidays and is not present all the time. To our right as we drive is the Great Hall of the People, the Monument to the People's Heroes is also to the right and we are passing by the enormous square - probably larger than Red Square in Moscow from the looks of it.

SOME QUESTIONS FROM ME TO OUR INTERPRETER

Is your house your own? - No I rent it from the Government. In my own hometown I do have a house of my own. All cars are owned by the State. How many Chinese in Peking have a television set? Very few - if you saved your money the government would not allow you to buy one - not until the production of this country gets larger will we have more things of this sort. It means that there is more equality - that nobody can get too much, and nobody can have nothing. We considered it is our duty to work hard - the main purpose of our work is not to make money - but to serve the people.

3 MAY 1974

The morning of 3 May 1974 began with breakfast. Since there was a great deal of effort made to get postcards and such, stamped and mailed, we had a period of emporium. It is necessary to glue one's own stamps and airmail stickers because they do not come with glue. After breakfast, we went to see the Traditional Medical Institute where a lecture was given to us on acupuncture, its history, its different needles, its purposes and what the various meridians and the points of injection mean. We then saw a fair number of patients who were treated with acupuncture including a partially recovered hemiplegic patient from hypertensive cerebral hemorrhage, two myocardial infarction patients, a child with myopia and with some paralysis, and a wide variety of neurological problems, some organic and some not. The range was from things like vascular tension headaches to serious neurological problems. The success rate with acupuncture for these various diseases was of the order of magnitude of 80% or so according to our hosts. They also pointed out that some ailments responded poorly and not at all to acupuncture, e.g., stroke.

Lunch - then to the Peking Medical College. The pattern of reception was the same except for the fact that the President of the College was Professor Hans Mueller - a German educated in Switzerland who has lived in China since 1939. He is obviously very important in the Communist Party and evidently has been with Chairman Mao in other high positions.

The physiological studies of pain and pain threshold in man which were shown to us were most impressive. Normal man and the rabbit were used. Radiant heat stimulus was the provocative injury against which acupuncture analgesia was measured. The evidence in normal man and in the rabbit is that acupuncture appeared to produce elevation of pain threshold in better than 80% of the trials. Its mechanism is unknown. Its potential use and value in surgical anesthesia is under intensive study where it is said to be used in 20-30% of all operations in the teaching hospitals. We should set up controlled studies in U.S.A. on this point. (to be enlarged upon later)

MEDICAL EDUCATION

Over 40% of students are women. The students seemed quite happy. The selection process for admission is designed to provide health care to most people for the most common ailments. The problem is to get medical workers to the country. Hence, the people in the country make the preliminary selection and the Party and College committees complete the process. There is a clear commitment to serving the people. All are paid alike regardless of work - and the motivation is hard work and service. It seems most sincere to a visitor to China .

We are guests of the China Medical Association - and are warmly received in every respect. Foreign Caucasians - even in Peking - the Capital City - elicit stares and small crowds. Many blacks from the countries of the "3rd world" are seen and taken for granted.

4 May 1974

I took an early morning walk. Most Chinese ride to work by bicycles in vast numbers. Many people of all ages are in the street doing the "soul and body" harmony exercises - they are characterized largely by slow, graceful and carefully controlled movements of the body. I had a conversation with an Australian sightseeing group at breakfast - they are having a marvelous time.

One cannot but be impressed over and over again at the enormous progress in providing health care for the people. They work hard, have all the common ailments, but believe firmly that they are much better off than before the Revolution. There appears to be genuine respect for work as an intrinsic virtue, regardless of its nature. There is a clear evidence of justified pride in the achievement of Modern China coupled with the classical Chinese modesty of minimizing their achievements.

One wonders whether this may not be the best way of life for other poor countries of large size, especially in the Orient or Africa - given similar problems. This Chinese experience certainly questions many of my values. It is moving, disturbing, and delightful and suggests that the "problems" we must solve at home are "easy" by comparison. It is not completely clear in my mind as yet - but the idea of "serve the people" as the major motivation of the Chinese in a hard life increasingly emerges. The Chinese demonstrate a fantastic effort to become self-sufficient in every way - not only because of Socialist pride, but because of previous foreign exploitation, as they view it. Their own aristocracy and nobility were no better to them in Imperial times. There are no visible signs as yet of foreign products, but there is also no homogenization in Chinese products, e.g., there are many flavors of tooth pastes to suite many tastes.

In the morning we went to the Third General Hospital, affiliated with the Peking Medical College - a 606 bed hospital. We had a formal briefing session and then wore sandals, caps, masks and white coats to observe surgery during acupuncture anesthesia. We saw patients for gastrectomy, for duodenal ulcer (1), thyroid adenoma (1), ovarian cystectomy (1), anterior cervical disc removal and spinal fusion (1), and three dental extractions. All except the dental patients received I.V. Demerol 25-50 mgs. in addition to acupuncture.

We had worked out a detailed protocol in our meetings in Hong Kong, which served us well for all our observations, but some generalizations can be made this early.

1. Acupuncture appears to provide pain relief.

2. It is an imperfect anesthetic - local procaine was used for the patient with the disc problem and to the one having a gastrectomy. Acupuncture required continuous encouragement of the patient by the anesthesiologists or the surgeon.

3. No preparation was made for supplementation of acupuncture by general anesthesia.

4. We were told by our Chinese colleagues that it takes 3-6 months to learn the clinical use of acupuncture anesthesia after being medically qualified.

5. Many acupuncturists were women.

6. There is little doubt that it will be wise to plan

•  An American clinical experiment with trained acupuncturists in about 10-12 centers in the United States.

•  We probably should recommend long term (6 months - 1 year) exchanges between the United States and China for specific purposes like acupuncture practice or research.

7. Acupuncture needles are often, but not always, inserted near the incision.

8. Surgical technique is excellent - as is the behavior of surgeons and women nurses in the O.R. We have developed incredible respect for their "cool" even during all our milling about - photographing and recording.

9. At the end of the sessions they asked us to submit questions, about the proceedings of the day.

Afterwards we went to the Forbidden City or the Palace Museum as it is now called. It is incredibly beautiful and sumptuous. The great wealth of the Chinese emperors makes European princes of the same periods look like paupers. It seems that little was destroyed with the Revolution. It was interesting to observe that our hosts knew little of Imperial times; they stressed the fact that the Palace belonged to the people - which it does and which they enjoy for a nominal charge.

The "wake up" sounds are about 7 A.M. with music! - pleasant.

At night we saw two ballets. The themes were Revolutionary, the music new and quite Western in sound and in instrumentations. There was no elegant dressing - tickets are hard to get, but inexpensive. The dancing was beautiful - mostly classical ballet (European) with modern "over acted" socio-economic movements. We also saw again (and again) the Great Hall of the People, the Monument to the Heroes of the Revolution, and the huge Great Square which can hold at least 1/2 million people.

All of our professional visits began with sitting down at a long table, one side for us and one for our Chinese colleagues and hosts. In the introductory session tea and cigarettes were served and a description of what we were about to see was presented after introductions all around. At the concluding session after the visit we had questions and discussions. The discussion revealed, for instance, that stroke was very badly managed by all forms of therapy, acupuncture included. It was obvious that stroke is very difficult to treat in any part of the world by any method.

EARLY IMPRESSIONS THUS FAR - 4 May 1974

We will be getting slides, summaries, written matter, tape recordings, and similar material from all the members of the group. It will take, therefore, some time to compile and edit either a single report, or, depending on our final decision, a collection of reports for which I will write the overall aspects and recommendations and preliminary judgments.

5 May 1974

On the 5th of May, 1974 which was Sunday, we had a most spectacular day. We left the hotel at 8 o'clock with our Chinese hosts and drove approximately forty-five minutes into the countryside to the Great Wall, which is 30 miles north of Peking . I climbed the Great Wall and took numerous photographs, and I will also get other photographs taken by my colleagues.[Photo] It has become a place of Sunday holiday for the people of China. The Great Wall in itself was a fantastic experience!

We then drove to the Ming Dynasty Tombs not too far away from the Great Wall. The avenue of approach is lined with fabulous and fantastic stone animals, some of which are replicas of real animals [Photo] and some of which are imaginary. These were created by unknown sculptors. There are a scattering of tombs in the countryside at the foothills of mountains which look startling like the barren tops of the Western mountains of the United States. In contrast to that view, there is a reservoir which traps rain, to prevent flooding. The area is under intensive cultivation for the production of crops for the people. It looks though what might easily have become desert, has been converted into fertile farmland for the production of food and other necessities of life for the people - not unlike Israel.

There were fifteen emperors of the Ming Dynasty. Thirteen are buried in the area I described. One is buried in Nanking and the whereabouts of the fifteenth is unknown. One of the burial sites has been completely excavated and the tombs of the emperor, his empresses and his various precious possessions were seen. It was an incredible display of inordinate luxury from the present point of view of materialistic Marxism in China. One could not help but marvel at the gross extravagance. It was estimated, for instance, in some of the Socialist slogans which we saw in and near the tombs, that the emperors easily spent enough money both before and after their deaths to feed one million people for a period of six years. It is a fantastic study in contrast. Although this was a feudal period of China, there were no slaves, but in effect the people were serfs to serve the emperor, the nobility and the aristocracy of this period. There was a great contrast between the gross poverty of the masses of people and the fabulous luxurious living of a very small number of the population. We had a well-prepared box lunch at the Tombs.

After the Ming Tombs, we came back to Peking and there we went sight­seeing in the Great Square. The Palace of the Emperors could be seen on one side, the Revolutionary Museum on the other. Completely across the Square was the Great Hall of the People where the equivalent of the American Congress meets to deliberate on matters of State and pass legislation. In the middle of the Square is a monument of enormous beauty dedicated to the revolutionary heroes who gave their lives to the success of the Revolution.

From there we went back to the hotel for a quick bath, a change of clothes and a visit to the Liaison Office, which is headed by His Excellency, the Ambassador-at-large, Mr. David K. Bruce. I had a letter of introduction and several letters of introduction to David and Evangeline Bruce from Mrs. Jayne Wrightsman. The Wrightsmans and the Bruces are good friends and I gather that Evangeline Bruce and Jayne Wrightsman are particularly close.

We spent a most pleasant cocktail hour at the Bruce living quarters which one day may be an Embassy from the United States of America to the People's Republic of China. Mr. Bruce was most interesting, and most brilliant about the situation in China as he found it. He made the same points that many of us had observed, i.e., the people of China are very friendly to foreigners. Their courtesy is absolutely unfailing and their attempts to please are large.

The usual characteristics of a socialist state do exist and they are in rather pristine form. Their quarrel with the Soviet Union is that the latter has abandoned the purity of Leninist-Marxism. There are slogans and photographs all around Peking, which show Lenin, Marx, Engels and Stalin. As is well known, the Stalinist influence in the Soviet Union has not only disappeared but has been disavowed for some years. The concern in China about the Soviet Union is extremely real and very frankly stated by the people.

There is little doubt that the People's Republic of China wishes to become close and friendly to the United States of America, and it is generally believed here that there may be full diplomatic relationships between the two countries before long. A real bone of contention at the present time is the question of Taiwan. China according to our hosts, views Taiwan as a province belonging to China which is occupied unlawfully by the regime of the Kuomintang headed by Chaing-Kai-shek. How that problem will ultimately be resolved is, of course, beyond my knowledge and comprehension.

We came back to the hotel to have a quick dinner and then we had a seminar under the leadership of Dr. Kenneth Casey in which the basic scientific observations and experiments that had been presented to us thus far were analyzed, discussed and summarized. The discussion was extraordinarily lively. The meeting lasted for 2 1/2 hours. The next seminar will be either tonight, May 6th or tomorrow night, May 7th and will deal with our clinical observations. This will be led by Francis Foldes.

Of the twelve members of our delegation, at least eight of them have come down with a viral pharyngitis including me. We have learned that this is quite common for foreigners who come to China. We come into contact with a different viral pool and infection is likely to occur. I am given antibiotics in the hopes and expectations that a secondary bacterial invasion can be prevented. Then to sleep.

Addendum -- I have been taking nothing but cold baths and cold shaves. It is difficult for me to get accustomed to the austere living conditions of the East and I realize how much I take for granted all the true luxuries I am accustomed to at home. It is still no great joy to take cold baths. No matter what the time of day I have tried bathing, it is always cold, but I have learned to shave with cold water!

6 May 1974

The sixth of May was a fascinating experience for us. We left at 8:00 A.M. for a tuberculosis hospital. We passed a military checkpoint. Mr. Huang, our guide and interpreter, showed some papers to the sentries, all went well and we were waved on our way to the hospital. On arrival, we had a short briefing session given by the Responsible Person who was an elderly, distinguished looking gentleman. We were to see two patients who were going to have a thoracotomy, one for a tuberculosis cavity in the right upper lobe and one for a cavity in the left lower lobe. Both individuals were young, in their early twenties. Both operations went on simultaneously.

The acupuncture needle in the one that I watched was inserted on the posterior or dorsal surface of the left forearm. Throughout the entire procedure, this needle was manually manipulated by the acupuncturist. It was explained to us that adequate pain relief inside the chest was accomplished by this method. There were electrical acupuncture needles in the location of the incision. Needles were joined by electrical energy whose parameters I do not know. This was maintained only during the opening of the chest wall and the closing. It was explained to us that electrical acupuncture was required for chest wall anesthesia but not for operation inside the chest.

The main characteristics of what we saw differed in the two rooms. In one room, a right upper lobectomy was completed rapidly without rib resection and as far as any of the observers could tell there was either no dis­comfort or a minimum of discomfort. The only supplement appeared to be five milligrams of morphine in 2 places, one near the occipital protub­erance and the other site was not known to me. The second patient did not fare so well, largely for technical reasons. There was an incomplete interlobar fissure and very many adhesions both around the cavity and around sites near the hilum. Considering the technical difficulties of that situation, the surgeon was brilliant in the manner and finesse with which he accomplished the lobectomy.

As I watch these patients, there is increasingly less and less doubt that acupuncture does "something" of importance in providing analgesia or analgesia-like conditions for surgical procedures, i.e., prevention of pain where pain would be expected to be induced by the trauma of surgery. We do not, of course, know its mechanism nor do the Chinese. In the thoracic hospital all patients were given a week of breathing exercises prior to operation to teach abdominal breathing.

During the pulmonary resection, the patients received supplementary 100% oxygen in a system with some considerable leakage and overflow but at high gas flows. There were neither closed nor non-rebreathing systems used. In one patient, the unoperated lobe was reasonably expanded and the other was allowed to deflate. The "end tidal" CO 2 tension was measured in one patient and at the time of the incision in the lateral position was found to be approximately 40 torr and it increased to about 48 or 50. We had no measurements of blood oxygen tensions. In the lobectomy patient whose operation was less successful than the other, there was need to infiltrate the skin with 1.5% procaine. It was also necessary to do a paravertebral block for a rib resection which was not required in the other patient.

During the course of operation two injections of procaine were made in the peribronchial area, because the patient seemed to be uncomfortable, with a sense of dyspnea and possibly some pain. It was difficult to determine with accuracy. What was astounding in the more successful case, was the apparent absence of vagal reflexes, and only one short cough occurred with the transsection of the bronchus to the upper lobe which was then removed. It is my opinion that there would be relatively few patients in the United States able to tolerate these circumstances of operation and certainly very few surgeons with the extraordinary technical skill and patience to do these kinds of lobectomies in the United States.

After this session, we asked some questions and were told that approximately 50% of the major intrapleural operations at this hospital were performed with acupuncture anesthesia. The total is not large, approximately two hundred operations per year, and that in itself is an interesting achievement. In those instances in which acupuncture is not used, general anesthesia with a Carlens tube is employed and induction is accomplished with a rapid acting barbiturate and muscle relaxation is produced with muscle relaxants known in the West.

All the Chinese staff who were concerned seemed to think that in those instances where acupuncture was suitable, it was vastly superior, because of the rapid recovery, the lack of complications and the absence of ventilatory problems in the post-operative period. In those patients in which ventilatory problems did occur Bird Respirators were available for treatment.

A healthy, but elderly horse, at Veterinary Hospital, had an exploratory laparatomy during acupuncture anesthesia. The operation was performed for our benefit. During the discussion after the operation, which did not go well, we were told that 70% of operations on large animals were performed during acupuncture anesthesia with a 90% success rate. Prior to the advent of acupuncture anesthesia at this institution in 1970, general anesthetics were used and it was stated quite definitely that there were major complications in the animals and a relatively high mortality from the anesthesia alone.

On the way home from the Veterinary Hospital, we stopped at the Friendship Store, which is available only for foreigners. I bought a tunic of cotton for approximately $4.50 and replaced my razor with a simple one. I have had to replace three shirts and was able to purchase simple drip-dry permanent press short sleeved shirts.

In the evening after dinner we had a seminar, under the Chairmanship of Francis Foldes, in which we reviewed the clinical cases seen thus far. The general consensus was that there was little doubt that we had seen clinical success with acupuncture anesthesia. There was also a discussion as to what the mechanisms of acupuncture anesthesia might be and how we might consider planning further studies.

At this point, I am now convinced that we must recommend ten to twelve center studies on a clinical level in the United States to determine, what if any, the role of acupuncture anesthesia in the United States might be. We certainly also should encourage our scientific colleagues to look into the mechanism of action, with respect to the pain problem induced by surgical operation. There is little question that something happens with acupuncture, of significant biological and clinical importance, but we don't know yet what it is. These seminars that we hold in the evening are going very well.

We will see some neurological and cardiac surgery with acupuncture soon. We plan a Peking "wrap up" session on Friday, the 10th of May 1974, in the afternoon and we are going to give a banquet of appreciation to our hosts in the China Medical Association and those other individuals who have been most helpful in showing us what they were doing.

As I dictate this part of the report I have a bad cold with hoarseness. Most of the members of the delegation have also come down with respiratory infections. We are going to carry on with all of the scheduled events nevertheless.

7 May 1974

Yesterday morning, we were in a General Hospital in the city, obviously one of its best, specializing in neurosurgery. 25% of the patients were neurosurgical. We saw three operations during acupuncture, one for a glioma, one for a meningioma and one for a pituitary tumor.

It was not possible for me to judge the degree of surgical anesthesia since the patient with the glioma whom I watched was semicomatose. In the other two - they lay perfectly still and as far as I could observe, the conduct of both the surgery and the anesthesia was excellent. The acupuncture needles were inserted in places that seemed empirically desirable. However, it is well known elsewhere that anesthesia in neurological surgery is a minimal need from the standpoint of pain relief. The scalp was infiltrated with epinephrine in saline solution and successful flaps were turned down with a degree of anesthesia which would be usual anywhere.

We were informed by our interpreter, Mr. Huang, that in order to prepare for the large scale discussion, which was planned for this forthcoming Friday afternoon, the 10th of May, written questions would have to be submitted. Despite the short notice, and with some difficulty, we were able to put together a list of questions from the clinical and basic science groups, both of which will meet separately at the request of our Chinese hosts. We did much of this question preparation during lunch and particularly after dinner. The group responded magnificently to an unexpected and very large amount of pressure in timing and we got it accomplished. We felt it behooved us to accommodate our Chinese hosts, since they have done all the things that we have requested of them.

After lunch, we went to a County Hospital, a drive of approximately one hour and a quarter from Peking. It was a new one, built since the Great Cultural Revolution although a large part of it was started earlier. It grew from a 15 bed hospital with a small out-patient clinic, to a substantial hospital of over 200 beds and a very large clinic. It serves a population of 450,000 people. Our group were shown patients both pre and postoperative on the surgical wards and we also saw medical patients and dental patients. We saw three operations. One was a thyroid adenoma, which went very easily with acupuncture. Extremely short needles were used, about 1-1/ 2 cm. in length and 25 gauge in width. Electrical stimulation was used in this instance. The needles were put along side the adenoma itself. This is now the second thyroidectomy we have seen done very well. There appears to be goiter in China, as there is everywhere else when insufficient iodine is available in the diet. Apparently we are in such an area. The next patient was a young woman whose ovarian cystectomy went well also.

We next saw an inguinal herniorrhaphy on a man of approximately 70, with acupuncture needles, one placed near the anterior-superior spine of the iliac crest on the left and the other placed near the pubic spine on the left, i.e., on the top and the bottom of the incision line. The patient had much pain and the operation was performed under the most trying circumstances, both for patient and surgeon.

We were told this was a grade II result. A grading system was developed for acupuncture anesthesia in which Grade I, the results are excellent in every way. Grade II, results are good but there are minor analgesia problems. Grade III require supplementation usually of local anesthesia of more than 10 cc. in volume. Grade IV is a failure of anesthesia that requires a change over to local anesthesia defined as using more than 10 cc. of local anesthetic solution. The concentration used ranged from 0.5% to 2% with 1% being the most common. The drug of choice was procaine but lidocaine was also used. When acupuncture anesthesia is not used, much of the surgical work is done during epidural block

After dinner, we reviewed our questions and prepared them to be presented to Mr. Huang at his request at 7:30 P.M.

It is now approximately 7:10 A.M. and we are getting ready to see cardiac surgery during acupuncture anesthesia. In the afternoon, we will see a handicraft exhibition. In the evening, a volley ball game between China and Senegal is planned and I think I shall omit because of my cold.

WEDNESDAY - May 8, 1974

This morning we went to a hospital which specializes in cardiovascular diseases. It is a large institution built in 1958 serving the community in general since it provides for illnesses other than cardiovascular. Generally speaking, the patients are referred in from elsewhere. I could not determine from the discussion as to how far away an area they served, but I got the impression that it was in the Peking area and its fairly immediate vicinity.

We saw, this morning, a mitral commissurotomy done with acupuncture anesthesia in one point on the forearm of the hand. The incision was a transpleural thoracotomy, the pericardium was opened and the commissure was dilated with a metallic instrument from the left ventricle toward the atrium. There was local anesthesia of 1% Lidocaine used in the skin. Local anesthesia of the skin is done in all such thoracotomies in this hospital. The other patient of the day had a mediastinal tumor who was also operated upon in about the same fashion.

The surgery was extraordinarily skillful; the patient appeared to have no pain whatever. During the discussion later, it turned out that approximately 10-15% of their patients are anesthetized with acupuncture anesthesia and they are selected on the basis of strength of character, determination, personality and the fact that the surgery is not complex. They do not consider, in this hospital, that a mitral commissurotomy of the sort I have described to be an important or a large operation. They stress the breathing exercises which were given the patient for one week to prepare for diaphragmatic breathing. In the preparation process, weights are placed on the abdomen and the patients are taught to relax, to breath quietly and to try to reduce their rate of breathing to 5 or 6 per minute. During the operation, it was obvious that those two things had worked well and the patients were largely breathing diaphragmatically. There was no mediastinal swing of any importance, the lung was sometimes collapsed and sometimes not, and was reinflated at the end of operation by the patient blowing into a test tube as the chest was made tight by layered sutures. There was a chest tube put in through an anaesthetized area without any problem. The usual underwater suction seal was established.

We saw these patients postoperatively. They appeared to be fine. It was said that approximately 40% of them received pain relieving drugs in the postoperative period and the others required none. It was a very impressive demonstration indeed and makes the understanding of what we are seeing increasingly complex and difficult. Immediately after we watched the operations, we had the pleasure of meeting Dr. Ma Hatim. Dr. Ma is very internationally known to those people who study China. In addition, John Bonica, who had met him on his trip here, had written a letter of introduction on my behalf and that of Francis Foldes. We had a very good talk.

Dr. Ma suggested that his quarters were too small to entertain us and that he would be delighted to come to visit me at the hotel. He was free on Wednesday and Friday nights of that week. Tentative arrangements were made to do so but he found that he was unable to keep his appointment Wednesday night and it was something of a disappointment to both Francis and myself, so we spent a quiet evening talking.

My laryngitis is now very bad but systemically I feel a little bit better. After lunch, we went to the Chinese shopping street and we were very much interested in the developments there. We looked at several shops. In shopping, the articles on display were fairly comparable in price to similar merchandise in the United States. With the income of the average Chinese, many articles were considerably beyond his means. Shopping for the Chinese seemed, therefore, to be an exercise in browsing, although some people bought things.

FRIDAY - May 10, 1974

The 10th of May, I awakened in the morning with almost complete aphonia and with a very marked exacerbation of the tracheobronchitis. I felt so rotten that I could not go to the hospital in the morning. Fred Kerr, bless his noble heart and knowledgeable brain, took charge of things that morning. More acupuncture was seen and it was apparently highly successful. After lunch, there was a discussion period scheduled with all of the key people we had met in Peking and it began at 2:30 P.M., and lasted until approxi­mately 6:00 P.M. I missed the first half of the discussion and was briefed by Ken Casey on what happened. By all the ironic quirks of fate, I was brought to The Capital Hospital for examination where the diagnosis of laryngitis and tracheobronchitis was confirmed. The examination was interesting in that I had a thorough history but the only physical examination I had was indirect laryngoscopy. No chest film was taken.

This was the hospital which our study group tried to see without success. It is actually the former Rockefeller endowed Peking Union Medical College and has now become a very busy hospital facility. Half of it, approximately, is for foreigners and half for Chinese. It has both ambulatory and inpatient facilities. I received a combination of traditional Chinese herbs and Western antibiotics for treatment. The parenteral injection of penicillin and the amount of penicillin that Francis Foldes and Ken Casey had insisted that I take orally probably gives me the world's highest blood level of penicillin. I also had some fever for the first time on that particular Friday evening and yet felt obligated to be the host of a very wonderful and pleasant dinner in the Capital Restaurant in Peking.

The food was absolutely marvelous. To my immediate right was Mr. Yen, who is a Vice Minister for the Department of Public Health under which all medical affairs come in China and is also the Responsible Person, i.e., the leading individual, in the China Medical Association. To my left was Miss Yu, who works at the United States desk of the Chinese Foreign Ministry. She is not medically qualified, but is brilliant and very well informed about our country, including the essentials of medical care in the United States.

SATURDAY - May 11, 1974

On Saturday, May 11, we had a rare opportunity to have an excellent discussion with Professor Chang, who is probably China's foremost scientist in the neuro­physiology field. Professor Chang had studied with John Fulton at Yale years ago and his laboratory, which is in Shanghai, is very substantially devoted to attempt­ing to work out the physiological basis for the "success" of acupuncture. The discussion I could not hear in its entirety because of some scheduling problem I had to straighten out and was briefed by Ken Casey on what took place later. It seems inevitably clear, however, that in the minds of the Chinese scientists and clinicians, as well as our minds, there are still very many problems in understanding the underlying mechanisms of acupuncture or dealing with its clinical application.

After this discussion was completed, we had an early lunch with Professor Chang, at which our neuroscientists were at his table and the clinicians at another table. We then took off in a Boeing 707 for Shanghai, which is approximately one hour and twenty minutes by air from Peking. We were greeted by the Responsible People in Shanghai's medicine, i.e., the Shanghai delegates to the China Medical Association and their colleagues. We were taken to the hotel which looked remarkably Edwardian in its furnishings and probably was part of the old international settlement of Shanghai, which of course no longer exists. This was the area in which Europeans and the Japanese exploited the Chinese economically and socially, according to our hosts. This ultimately led to a natural reaction in which, it is said by many Chinese, that the most militant and the strongest parts of the new China "liberation movements" have either originated or been strengthened in Shanghai.

I was brought to a hospital where I had a chest film, another laryngoscopy, and a complete physical examination. I was again given many herbs and also antibiotics for the tracheal bronchitis which is somewhat better, but is still there. We had a very pleasant evening meal, which was held up for 1 hour because of my therapy at the hospital, i.e., the Secretary General of the Shanghai branch of the China Medical Association would not begin the briefing session on what we were to do in Shanghai until I was present. During the evening we had an analysis by Jim Townsend of our interaction with our Chinese hosts. He made some important suggestions for how interpersonal relationships could continue to be improved. There is no doubt that our trip is shaping up very well. Although I feel we are doing an excellent job, we do have many things to learn.

We then began a seminar in "hypotheses of acupuncture" under the direction of Arthur Taub in which we were trying to sort out our experiences and to develop a series of hypotheses about the nature of acupuncture and its possible mechanisms. The first speaker was Francis Foldes who made a strong case for cultural, ethnic and other differences between the Chinese and the American people, which would enable the Chinese to withstand the trauma of surgery with much greater serenity than would be true in the United States. There was discussion on this point only in its beginning phases. Arthur Taub then made the point that there could very well be some anesthesia developing in an electrical field from the direction of the nerve fibers. Arthur then described the possibility of a segmental production of anesthesia via electrical stimulation. We stopped at this point, although there is obviously much more to discuss and we will do so in future seminars.

It seems to me at this stage of our knowledge that acupuncture anesthesia is a collection of various physiological, psychological and other phenomena and possibly, in that respect, not totally different from some forms of conventional western anesthesia. It will be most interesting to see how the future observations and discussion develop.

SUNDAY - May 12, 1974

We are in Shanghai. In the morning we went to see an exhibition of heavy industrial products like tractors, trucks and similar vehicles. There was also an ad-mixture of a small amount of medical and pharmaceutical materials, as well as consumer products of a modest nature. After lunch we drove to a commune approximately an hour and a quarter's distance from Shanghai and were very cordially and warmly received. We saw a peasant's house, the various types of shops, the commune hospital and clinics and we learned how production brigades and communes operated to increase production under the Communist Regime. We were also told of the increased benefits of the New China in bringing health care to the masses of people. On Sunday night we had another scientific seminar with our own group.

MONDAY - May 13, 1974

In the morning a county hospital was visited. (All of our acupuncture anesthesia records are now being analyzed so I cannot recall from memory exactly how things went.) In the afternoon the group went to a physiological institute which is headed by the distinguished neurophysiologist Professor Chang, whom we had met earlier in Peking. I did not go because I am now nearing the worst part of my respiratory infection.

TUESDAY - May 14, 1974

Most of us went to sleep at a reasonable hour and rested.

WEDNESDAY – May 15, 1974

Wednesday morning was the most remarkable experience we had had thus far. We went to the First People's Hospital in Shanghai, which was founded in 1864 and had been rebuilt and remodeled many times. The director of this hospital was educated in the German school of Shanghai and was extraordinarily able and multi-lingual. We saw 11 operative cases and with some exceptions they went extremely well with acupuncture.

The surgeons made the point continuously that the inadequacies of acupuncture anesthesia require two lines of research. One is to improve the accuracy of the points selected for acupuncture and secondly, to improve their surgical technique so that they can ultimately increase the scope and vitality of acupuncture anesthesia and decrease general anesthesia and epidural block, since the post­operative convalescence of the acupuncture patients is so much superior to the other, in their opinion.

At lunch we met a delegation of 6 governors from the United States, together with personnel from the White House and the State Department. They are on a short visit to China and we did not learn the nature of their visit here. They were very warm and friendly and were obviously glad to see other Americans.

In the afternoon the entire group went to an interesting institution which rather resembles a huge day-care center called the Children's Palace. In this institution, after school for approximately 2 hours, once or twice a week for a period of several months to two years, selected gifted children, who are also correctly educated from the Marxist point of view attend this institution. It has a wide range of activities including drama, arts and crafts, ballet, music (both vocal and instrumental), athletics, and electronic shop for scientific experiments and almost any other activity of which you could conceive. The children are quite accustomed to visits from foreigners and we were warmly received with the usual hand-clapping. Each of us had a personal guide and mine was a charming 10 year old little girl [Photo] who on completion of our visit gave me her red neckerchief, which designates her as a Young Pioneer, with her request that I present it to "the children of America''.

Many of the songs were either folk songs or those dedicated to socialist themes. The physical activities, including the dances, were very definitely and frankly designed for military preparedness. There was also a miniature obstacle course to prepare 12 year old youngsters, both boys and girls for future military service. It was a delightful experience to see so many warm, charming and sweet children, but one also remembers that their social dominant Communist structure is quite real and that they are the fourth generation of young people being trained since the Liberation of 1949.

THURSDAY - May 16, 1974

We went to a hospital in Shanghai which is a traditional one in the sense that its major effort is to take care of patients with traditional Chinese medical remedies. However, there is a local infusion of Western practices as well. We saw three patients subjected to gastrectomy, colostomy and appendectomy respectively and anesthetized with acupuncture anesthesia. There was a different attitude here about acupuncture in that mechanical twirling of the needles was practiced by the physician in the operating room, rather than with the aid of electrical stimulation. Electrical current was used only when other needles were inaccessible because of the position of the draping of the patient for the operation.

As has been the case in the major hospitals in China, the surgical technique was most skillful and gentle in all instances. The attitude of fitting the surgical technology to a combination of Traditional with Western medicine, continues to prevail and surgeons are more than willing to change the size of incisions, as well as make other accommodations, to make acupuncture anesthesia work well. The reasons most often given for the need to combine Traditional and Western medicine were the teachings of Chairman Mao, and also the fact that the patients do so much better postoperatively when acupuncture anesthesia is used. This is our next to the last day in Shanghai that I am summarizing. We also saw a clinic in which the majority of patients were afflicted with various self-limited neurological diseases and, as one might expect, the best results in acupuncture therapy were obtained in these patients. Other patients, who were more sick, took longer to show improvement and some of them did not. The Chinese view this to mean there is a need to learn more about acupuncture.

A short nap after lunch and then we went to a Workers' Village. It was built in approximately 1960 and is a rather self-contained community, governed by the Street Committee, which in turn is responsible to the district groups. The Chinese workers and our hosts were extremely proud of this development. There is no doubt of its cleanliness and of their pride and willingness to work hard and share with each other. One can only imagine how dreadful the conditions must have been before the Revolution, if these very modest apartments we saw and the activities we watched were such a source of pride for them. The poverty in the older parts of Shanghai, insofar as housing is concerned, is incredible. The government realizes this problem and is building new quarters as fast as it can for the workers, the peasants and the soldiers. The development that we saw was a vast improvement on the whole situation, but makes one again feel very fortunate indeed to have been born and brought up in the Western World.

On the way back from the Workers' Village, Mr. Liu, who was our chief host in Shanghai and is the Deputy Secretary General of the Shanghai Branch of the China Medical Association, although he is not himself a physician, continued to discuss his own experiences and his views of others. He himself began as a worker and had little or no opportunity for education and joined the Communist 8th Route Army at the age of 15. This army was, eventually, to become the Peoples' Liberation Army. Mr. Liu, was in a sense at first, a self-taught Communist who still continues his studies even in his present level of responsibility.

There is convincing evidence of the freedom and equality of women in China from an economic, professional and work standpoint. They get equal pay for equal work and in most households it is very common for both man and wife to be working. Their small children are cared for in day-care centers, either in the factories or, for children who are older, in special kindergarten and primary schools. We talked to one such woman who told us that the women of China chose, as a national holiday for women, the 8th of March. This is the day that American women, who were militant in the late 60's to disengage the American Armed Forces from the Vietnamese conflict, staged a strike in the U.S.A. The women in China know of this experience and use it as a symbol of their equality with men. The leaders of the country indicate that the writings of Lenin and Marx clearly point out the importance of the equality of women in every respect. It is interesting to note that the household work is also shared. It is common to find the men and women dividing the responsibilities, providing the women is also working.

In some contrast to this, later on Thursday the 16th, we once again met the leader of the Revolutionary Party of the Shanghai Branch of the China Medical Association, Mr. Liu. We had a delightful banquet in which the usual toast was proposed to the eternal friendship of the Chinese and American people and the importance of the work of our delegation in achieving improved lives and friendship for both peoples. It was noticeable, however, that the wives of none of our hosts were present at this banquet. This question was discussed quite candidly and it was pointed out by the Chinese that there were some purely male and some purely female activities. However the Chinese consider social, political and economic equality to be more important than who comes to a banquet!

During the discussion period in a Shanghai Hospital the next day, Fred Kerr asked questions which were designed to determine whether the devotion to Chairman Mao, to Communism and to the idea of serving the people, could explain some of the good results of acupuncture anesthesia. The questions were also asked of our Shanghai hosts whether there were any differences among European, American and Chinese patients. The reason for asking the question here was based upon the fact that several of the members of the staff of this hospital had worked in Europe or the United States. They were of the opinion that there were no cultural or ethnic differences between Chinese and Western patients in that the manifestations of pain were similar. They had no experience of operating without any anesthesia in China. They found the question of interest and thought that they should ponder it, but this was probably a polite way of saying that they did not wish to discuss it any further.

The afternoon was spent in a personal way, i.e., the buying of presents, for families and friends by our group in the Friendship Store, which is reserved for Foreigners. I could find nothing of interest to buy except a pair of commonly worn shoes which are sort of half sneaker and half slipper. These are only $2.25 in American money and I thought it would be a good memento of this trip.

After dinner we took off for a resort which was considered to be a workers' paradise. The accommodations are extremely crude and I must say that I have not been so hot or so uncomfortable in a very long time. After 5 hours sleep I woke up with daylight bursting into the room. The scenery from my hotel bedroom was surprisingly beautiful. The plans are to go sightseeing today - after the usual discussions. We had a long train ride of 3 1/2 hours getting here in a non-air-conditioned but otherwise luxurious train. It is going to be very rough from here on until we leave China since we are now in the hot and humid belt and there are no sensible means of dealing with it since air conditioning does not exist and fans are both noisy and relatively inefficient.

We have now seen acupuncture anesthesia used on a substantial number of patients and Kenneth Casey will analyze the data and will present the results in our seminars, which we try to have on rainy nights and occasionally late afternoons. Recommendations to the Committee on Scholarly Communication with the Peoples' Republic of China will be based on those matters upon which the group can agree.

This group of 12 have worked in fabulous harmony after a few early scratchy days in the shake-down period of our getting to know each other better. I believe these friendships, on both personal and professional levels, will continue for a very long time, probably permanently.

My respiratory infection is still not under total control, but I do hope that it will straighten itself out. I continue to sleep well and somewhat longer than previously without the need for antibiotic medication.

FRIDAY - May 17, 1974

This is our last day in Shanghai. This morning we went to the Third Peoples' Hospital, where we saw an open-heart operation, a pyelolithotomy, and a acoustic neuroma removed. We also watched a nasal septum corrected, all with acupuncture anesthesia. One committee of the group is collecting all the statistics and observations that have been obtained thus far. I was delighted at how well the open-heart operation went with ventricular septal defect repair and the nasal septum sub-mucous resection went very well also.

I am rather concerned because our plans of having a seminar to discuss what we have seen and to make recommendations is going to inevitably be colored by the irritabilities and difficulties of 12 people subjected to high temperatures, high humidity, and inadequate accommodations by Western standards. The night of the 17th of May was unbelievably hot for sleep, but I managed about 5 hours of good sleep with a fan blowing even though the temperatures and the humidity were extremely high.

SATURDAY - May 18, 1974

In the morning our very cordial and friendly Chinese hosts took us sightseeing to a variety of places including an ancient pagoda, about 1700 years old, and an ancient spring which legend reports to have been started by 2 tigers. We also saw a tea plantation under cultivation by a predominantly female work force. This work force was a production brigade, and there are approximately 15 production brigades in one commune. In the afternoon we had a boat ride, and then went for a very long walk through a beautiful park. We saw an ancient and extremely ornate Buddhist Temple which is being kept as a museum for the people in the park. Our interpreters and guides knew very little, if anything, about Buddhism and nothing about the temple. Atheism seems to have prevailed in China.

We have had 3 meetings in this resort to try to hammer out our views about acupuncture. At the present time, it looks as though our data shows some 52% success by any standards for the surgical experiences. We are at present agreed to describe those things we can agree upon and those things on which we cannot agree, in preparation for a report to the Committee on Scholarly Communication of the Peoples' Republic of China. We have also agreed on a minimal press release, which each individual may amplify, or cut providing he did not distort the main thrust of the report. We have also decided, possibly too optimistically, to write a mono­graph on our experiences. There is absolutely no question that we have seen more surgery performed during acupuncture than any other group in the Western world.

The problem of acupuncture anesthesia is extremely complex and is woven into the fabric of the belief of China that Traditional and Western medicine must be welded into one. Acupuncture is the prime prototype of such a large and disciplined spirit. Chairman Mao has advocated this procedure and, as far as we can tell, it is believed by all. This is a thoroughly dedicated society and individuality is at a minimum.

Our plans for the group are also to meet in Washington for a "wrap-up" session early in July or at the end of June 1974. (This meeting took place 7/1/74).

If I were pressed at this point, I would say that acupuncture does not produce surgical anesthesia as it is understood in the West, but it certainly is believed to be effective by the people of China and apparently by Chinese surgeons and clinicians, with the greatest doubt remaining among the scientists. The mechanism of its action is acknowledged by the Chinese to be unknown. As I dictate in the early morning of May 19th, on Sunday, I am more perplexed than ever at the experiences I have seen. The Communist approach to living certainly has a bearing on clinical medical events. Communication about health is wide-spread. A patient in an operating room in Shanghai once gave us a lecture on the importance of bringing Traditional and Western medicine together, as taught by the Revolutionary Line of Chairman Mao. What is apparently indicated is much more discussion and some separation of the influence of politics and the "religion" of Communism in our own discussions.

We will go sightseeing on Sunday, the 19th of May, in this resort town in the morning. Then we take off by airplane for Canton , where we will do some further clinical observations on Monday the 20th. We have an all day session planned on Tuesday the 21st for discussion about the interpretation of what we saw and plans for possible publication and reporting in the U.S.A. We will then go back to Hong Kong on Wednesday the 22nd. It will be a welcome experience to have a few hours of air-conditioning in Hong Kong. Despite the rigors of the trip home, I have decided to fly straight through on Thursday the 23rd of May. I do want to be home and I want to try to get things better sorted out. I have been without communication from anybody at home and so has everybody else in the party except Foldes. I told Barbara and Dick and the people at the office erroneously that they couldn't communicate with me. Theoretically this is the case, but actually it has turned out not to be true. I have written many postcards and letters to various people, including the children, and I hope they have arrived. I hope I will have the time to stay at home for a few days to recover from the fatigue of this interesting and thrilling trip to China.

We arrived in Canton late in the afternoon of May 19th and did a bit of sightseeing. In the morning we did some sightseeing and then flew down to Canton on a rather turbulent flight. It was interesting that we flew in an old-fashioned Boeing 727. It appears as though the Chinese are buying American aircraft in more than small numbers. We have now been on a Boeing 707 and a Boeing 727 and have seen several of each type at various airports.

The impressions of crushing poverty still come through hard, fast and clear but offsetting these impressions are the others that the Chinese are so much better off now than they were before 1949, at the time of the Liberation in China, that there is no comparison between now and then. I increasingly get the feeling of an enormous, powerful nation of more than 800,000,000 people who are rapidly being educated and strongly indoctrinated into classical Leninist, Marxist philosophy with a puritanical purity of life style that is quite intense. There are slogans everywhere urging the peoples of the world to unite, with written and graphic reminders of their capitalist oppressors. There are pictures of Stalin everywhere and there are trans­lations in the press, in English in Peking, which indicate denunciations of the "revisionist" Soviet Government at present.

Today, for the first time, I learned from our magnificent and friendly guide, Mr. Huang, that the friendship with the American people and all the peoples of the world is also classical Marxist. The Chinese make a very careful differentiation between the governments and the people. For the first time also, he indicated to me that he could not believe that the ruling classes who are not workers, peasants, or soldiers would voluntarily give up their "riches" and that peaceful Revolution could occur. In short, he indicated his belief in classical Marxist philosophy, that there will be a violent struggle and that the proletariat will have to win by military measures and a physically violent upheaval everywhere. They also believe that there will have to be a transition period during which personal liberties are sharply curtailed on the way toward Communism. Eventually there will be economic, political and personal liberties for all. China, is the best example of a pristine, puritanical and classical militant Marxist nation.­

There is a significant and important problem for the non-communist world in this respect. If the world is to become Communist, as the Chinese believe it must, and they are 1/3 of the world's population, and if the means are to be bloody and violent, there could be serious problems ahead for the West should China become aggressive in a military sense. Despite these gloomy forebodings of mine, the usual friendship was displayed to us by our Chinese colleagues. We were met at the airport and escorted to a hotel near the Canton Trade Fair. They are very cordial indeed now.

Canton is quite hot. The humidity is very high and the temperatures range between 85 and 90°F. We will be seeing some surgery on Monday morning the 20th of May and then we will hold our own seminar in the afternoon to review the many issues that we have to resolve. There will be an opportunity for shopping in the Friendship shop. On Tuesday, the plan is to divide the group into Scientists and Clinicians with the latter seeing surgical procedures and the former visiting the Physiological Institute of one of the Medical Colleges. On Wednesday, early in the morning of 22 May 1974, we leave for Hong Kong and, with an overnight stay, I go home.

THOUGHTS AT RANDOM WAITING FOR BREAKFAST - May 20, 1974

1. The Chinese Medical Association have been most solicitous and have taken very good care of us. They have been unbelievably punctual, and have made excellent arrangements for transport to and from train stations and airports with astonishing efficiency. All of the ordinary expenses are borne by them, as are their expenses borne by us when Chinese delegations visit the United States. Both ordinary meals and transportation costs are paid for by them. Any other personal shopping is paid for by us.

2. The China Medical Association is composed of branches run by Revolutionary Committees. The leader of the committee often is not a physician. If he is a physician, it is unlikely that he is active in either medical or scientific work, although in one instance we saw this pertain.

3. Without any question, there appears to be devotion and loyalty to the present regime. It is Marxist, radically, leftist and "non-revisionist".

4. These kinds of governments have the interesting problems of being very effective in mobilizing public opinion for "good" if the leader is good. Such a society, of course, has all the potentials of being eventually led by someone even like Hitler, in which case the story could become dramatically different.

5. It is unsure, but entirely conceivable, that China will devote her energies into rebuilding by a combination of austerity combined with their enormous work force. It proved true, military offensive activities against the non-communist governments (not the people) are unlikely to occur soon.

6. However, if for any reason, it is decided that revolution by force is necessary to bring Communism and its "benefits" to all people of the world, I have little doubt that this regime, or its potential successors, would not hesitate to use whatever force is needed. They have little to lose in any change in world order from the standpoint of material possessions, or for that matter any other standpoint, and they have much to gain. They are populated by 1/3 of the world's people and can certainly afford to lose proportionately more than many other countries.

7. Although their personal and organization friendship was overt and warm, they nonetheless have the Marxist belief in the inevitability of revolution of the masses against oppression. I can see no real change from this point of view toward the United States as a government. On a people-to-people basis the attitude would be friendly provided the people of the United States were willing to adopt the classical form of Communism that exists in China - a most unlikely possibility.

8. Chinese society is clearly closed. There are few television sets or radios, and communication from the outside world is almost impossible. It is possible, of course, to write to and from China and to telephone, but it is my belief that such communications are monitored.

9. There was no obvious evidence of "bugging" in any of our meeting rooms, nor have we had any repercussions from any of our rather frank discussions. However, the question of taping and observation is certainly not one in which Americans can feel free to criticize when the President of the United States also indulges in this practice.

10. Although the warmth and friendship of the Chinese is apparent, their protocols and formalities must be respected in order to sustain this attitude. Every time we went to a hospital or institution or to any kind of reception, we always sat at long tables in reception rooms, where they served tea and cigarettes before the discussion. Many Chinese are fluent in English and other European languages. When it is decided not to deal with a problem it is simply ignored. A difficult or embarrassing question is simply not answered. The custom, generally, is to collect all the questions and answer them at once. Discussion is minimal, and the answers to questions are almost identical from place to place. It follows the classical dogma of the country. In our particular case, the decision to weld traditional Chinese Medicine, in the form of acupuncture with Westen medicine in the form of surgical operations, is accepted readily everywhere we have gone. As a matter of fact, this is the modern position since 1958 when Chairman Mao recommended the doctrine to add electrical forces to the acupunc­ture needles. However, there is a possibility that electrical impulses under the skin may result in a possible nerve trunk spasm. It also exposes the patient to the danger of damage to tissue from an unknown electrical force.

11. Another evidence of the formality, which goes on, is seen in our inter­preter guides. Miss Chang, Mr. Huang, along with Dr. Fu, who is the second ranking person in the hierarchy of the China Medical Association, have accompanied us on the entire trip. Dr. Fu understands English but does not speak it and the other two are fluent interpreters. However, despite the obvious warmth of our friendships, there is no doubt that the formality of calling them Miss, Mr. and Dr. respectively will always pertain. They do not form intimate and informal attachments in the same way that we do in the West, but their warmth and friendship leaves absolutely no doubt as to its sincerity.

12. Absolutely nothing is ever stolen. It is safe to leave anything completely unlocked and open. Although we are told there is crime of various sorts, we have witnessed no problems whatever. They never in any way molested, touched or removed any of our possessions.

MONDAY - May 20, 1974

This morning we went to a provincial hospital in Canton. It was to some extent like many other hospitals of its kind, which we have seen, in relatively poor repair, but very clean. We saw two operations using acupuncture. One a thyroid and the other a transpleural closed heart mitral-commissurotomy. We then had a rather lively discussion about many of the same things that have come up before. It turned out that the director of the hospital had been the surgical resident at the Massachusetts General when I was a visiting professor there in the late 1940's and, of course, he knew Francis Foldes who was also on the staff then. It was very good to see him after all these years. We returned to the hotel for lunch and I had a second haircut in China . This one cost 52¢ in American money and was somewhat more expensive than the one I had in Peking .

This afternoon we held a seminar which began with a talk to us by Dr. Fu, the Secondary Deputy Secretary General in the Canton China Medical Association, about the use of acupuncture anesthesia in the kinds of hospitals we had not seen. He pointed out that the hierarchy began at the production brigade, which was usually staffed by two or three barefoot doctors, then the commune hospital, then by the provincial hospital and the county hospital and then the major teaching hospitals. It was his belief that approximately 2/3 of the commune hospitals were using acupuncture anesthesia, either in connection with their mobile medical units or by the staff doctors in those institutions.

After Dr. Fu's discussion, he left and we began to try to hammer out our areas of agreement and to summarize our weeks in China. We began with the presentation by Arthur Taub of the list of those things on which we agreed in general. This presentation followed Kenneth Casey's up-date on the data we had collected in which the total surgical experience was found to be either excellent or satisfactory in some 70+% of the total cases in which 52% were rated as excellent. He will distribute the data, both oral and summarized, to each of us. In Arthur Taub's presentation, those matters of general agreement included the Casey classification of good cases and bad ones, and some of the reasons for the problems were mentioned. The consensus was that the Chinese were correct when they stated that acupuncture anesthesia was still in the experimental stage and that it had at least 3 unsolved problems, i.e., incomplete anesthesia, poor muscular relaxation and discomfort during traction of viscera. Other matters will be sent to us by him on his return so that we will have a document of conclusions that we all agreed upon. These conclusions will be incorporated into the bodies of scientific reports that we have agreed to do. There was a decision made that we would write, either a substantial paper or perhaps a monograph on our experiences and our data.

This discussion was then followed by the recommendations which will be sent to Denise Emory for presentation to the Committee of Scholarly Communication of the Peoples' Republic of China. These were presented by Jerry Modell and will also be circulated to all of us. The major thrust of the recommendations was that careful selective clinical trials and encouragement to scientific research in the United States be made and that we have an in-depth exchange of scholars in anesthesiology. The point was also made that those anesthesiologists and other individuals who might be chosen for bilateral exchange should be, if possible, competent in both languages or if that is not possible there must be an interpreter with them. The difficulties of doing things this way, i.e., for 3 months to a year were pointed out and were fairly obvious.

TUESDAY - May 21, 1974

In the morning the clinicians made post-operative rounds on the two patients we had seen operated on before. A patient subjected to a hemi-thyroidectomy and removal of abnormal tissues had had no pain post-operatively. The drain was taken out earlier than 24 hours before the end of the first post-operative day. She had total recall of the entire anesthetic and surgical experience including the painful parts and found that they were not objectionable and would be willing to have acupuncture again.

The other patient had a mitral-commissurotomy performed transpleurally through the left chest and instrument dilatation of the mitral valve through the left ventricle. She was having very little pain or discomfort and also had total recall of the anesthetic and surgical experience including those parts that were painful. She too would have the procedure again with acupuncture anesthesia. Her breathing was 55 or 56 times a minute and her nostrils were flaring slightly. This appearance was interpreted as evidence of some discomfort by the surgeons. However, the chest tube was not fluctuating too well and it could be that there was a collection of blood or some other similar problem in the left chest.

When post-operative analgesic drugs are needed, usually Demerol is used in doses of 50 mgs. and is injected into the acupuncture site Hoku which is in the interosseous space between the thumb and forefinger or in an acupuncture site on the volar surface of the lower third of the forearm. The patient had had one such dose post-operatively and was doing quite well. After rounds, the clinicians went to the medical college and listened to a review of medical education and also saw some patients.

We were told how the process of admission to medical school occurs. There are applicants among the peasants, workers and soldiers, sometimes as many as 8 or so for a position in the College of Medicine. The workers and peasants select that number out of the group who apply, whom they consider to be reliable and useful, from a medical as well as a working standpoint. These individuals are destined in the main, although not entirely, to go back to the places from which they came. The leadership in the Party then approves or disapproves the selection, and if approval is obtained the next layer of approval is the Admissions Committee of the Medical College itself.

Approximately 600 individuals were admitted to the School which we visited and a 3 year course of study was followed. It was preceded by 6 months preparation in such subjects as Physics and Chemistry. The 3 year course was, in subject matter, identical to the ones that we are accustomed to, but shortened in duration. There was also much emphasis placed upon learning all about the common diseases and also indoctrination in courses of Marxism, Leninism and the thoughts of Mao to "serve the people". Upon graduation, most of the students go back to the places from which they came. However, some are selected to teach in the Medical College and others are given other positions, depending on the needs of the State. The decision as to specialization and the nature of it is determined by the needs of the country and appreciation of the individual doctor. Because of the great Cultural Revolution in 1966, degrees and titles have been abolished. There are no degrees of Doctor of Medicine or Doctor of Philosophy. A certificate is given when an individual has pursued a course of study satisfactorily. There are examinations but they are almost entirely learning exercises and would be classified in our country as "open book" in type.

In the afternoon we had our own seminar in which the essential point we arrived at was the fact that acupuncture anesthesia is not truly surgical anesthesia, but an important and useful part of the total surgical experience. The mechanisms for the prevention of pain were admitted to be unknown both in China and the United States. Further questions of trial, both clinical and experimental, were proposed and some of them agreed upon and they will be described in greater detail later. We had a farewell dinner party by the Canton Branch of the China Medical Association which was very pleasant indeed. I slept under mosquito netting for the first time and found it quite agreeable and comfortable, even though the period of sleep was very short.

WEDNESDAY - May 22, 1974

We arose early in the morning to be taken to the train from Canton to the frontier. The formalities very quickly disposed of, really quite unlike our entrance into China, because we were not then "Friends of the Peoples' Republic of China". All our Chinese paper currency was changed into Hong Kong currency. The trip to Hong Kong was once again over the famous frontier bridge, which was crossed in record time. We got on the train from the Chinese frontier to Hong Kong, through the new territories, and in one hour and a quarter were in Hong Kong .

The train going to the frontier in China was air-conditioned and beautiful and we had much company, including many Chinese and an attractive group of Australian girls who were playing basketball with the basketball team of the Peoples' Liberation Army of China. This was the first time, as a matter of fact, that we saw any Chinese women in skirts. The skirts however, went well below the knees. The impression of a puritanical society was not in any way changed up to the very last minute. We barely got on the train from the frontier to Hong Kong and the contrast was noticeable. It might be the Chinese way of underlining the difference. The British owned train to Hong Kong from the frontier was dirty, not air-conditioned and stopped frequently.

When we got to Hong Kong, I immediately checked in at the Peninsula Hotel and had a 2 hour nap, a delicious warm bath, a wonderful air-conditioned room and although I am fantastically tired, I must say the trip to China was one of my most wonderful experiences. We all learned very much indeed and we will undoubtedly be of use to both the scientific and the clinical fraternities in the Western world, since we saw much more of acupuncture by anesthesia than any other group. Our frequent seminars were a fine method of learning from each other. The scientists were deeply impressed by the problems the clinicians had to solve and the clinicians were also impressed by the splendid work that the scientists in our group were doing. That evening the 12 of us plus Jack Emery, Denise's husband, had dinner at Gaddi's. This is alleged to be the best restaurant in Hong Kong and I must confess the food, not the company, was somewhat disappoint­ing. I did eat too much however.

I will be taking off at 9:30 this morning, which is the 23rd of May, Thursday, via Pan American Flight 2, first Tokyo and then San Francisco and on to Los Angeles and then to Miami. I have decided to go straight on through, even though it may be a devastatingly fatiguing experience because I just want to get home at this point. There is no question that the trip to China, aside from those advantages I have mentioned, which are fairly obvious, was great for me. I now more than ever believe that my lot in life must include working, reading and getting things done for others. There is a great validity to the Chinese motto of Mao, in the slogan of “serve the people”. It is probably not only the best thing for the people, but it is even better for those who serve them.

I am not looking forward to the very long flight which will be almost 25 hours in duration, but the alternative to going home from Canton via Karachi, Cairo and Paris just seemed not only unacceptable to me, but it would have been impossible to get arranged in time with the rigidity of the Chinese system of dealing with change. There probably will be one more note in this dictation and I will have to get going with Fred Kerr and others to get the overall report into the Committee of Scholarly Communications with the Peoples' Republic of China. It was indeed an exciting and wonderful experience to have been done once. I am not quite sure that I wish to go back to China. In this respect I differ from many of our people. However, I wouldn't have missed it for the world. The paradox is obvious but there it is.

THURSDAY - May 23, 1974

We took off at 9:30 A.M. from Hong Kong for home. I am now dictating in the lobby of the San Francisco waiting room for Pan American Flight 2 to go into Los Angeles where I shall connect with National Airlines to come to Miami. I did have 4 hours of sleep, but feel quite tired understandably. I had the equivalent of a 10 hour jet lag plus very little sleep last night. I am hoping that my going home directly, despite the enormous fatigue involved, will be an easier opportunity to really get things lined up and going on to what has to be a new life. I have been out of touch with everybody since I left for China and it will be good to try to catch up and to get back to as normal of a life as possible.

China was very good for me in many ways. It was capped by our "last supper" in Hong Kong . The people in the delegation were as devoted to me as I to them and there is no doubt of this fact.

I bought some jade studs and a very good watch for Andy. I just felt that while I was in Hong Kong I should enjoy it. I also sent home some jade figurines which are quite good but have slight imperfections, but they are really beautiful. I also bought small trinkets for the girls in the office and for the family since there really is very little to buy in China and the prices are enormous in Hong Kong .

This is the end of the story. I now await the reboarding of our Pan American airplane for Los Angeles and then on home.

FRIDAY - May 24, 1974

I am now home after nearly 24 hours of flying from Hong Kong, with the last dictation done in the San Francisco airport while waiting the return home. I am incredibly fatigued, but have already talked both with the office and with Bernie Fogel and everything has gone well during my absence. This accomplishment is in no small measure due to Bernie's skill and to the cooperation of members of the faculty and the students. I am eternally grateful for all and will do my best to justify the strong measure of support they have provided while I was gone. End of Diary.

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