The following is an email from a Malaysian received by Dr JB Lim

>To: All my dear friends be extra cautious when you need to help others, be very smart and alert at all times.
>
>It's a pity that things like this occur nowadays … you are warned to be cautious and do not take everything for granted.
>
>A NEW KIND OF RAPE (LADIES BE WARNED)
>
>This is a true story.
>
>The woman left the office after working hours and saw a little child crying on the road. Feeling pity for the child,


She went to ask what happened. The child said, 'I am lost. Can you take me home please?' Then the child gave her a slip of paper and tells the woman where the address is. The woman, being an average kind person who didn't suspect anything took the child there.

And then when they arrived at the child's 'home', the kind hearted woman pressed the door bell and she was electrocuted as the bell was wired with high voltage, and fainted..

>The next day when she woke up, she found herself in an empty house up in the hills, naked. Condoms were all thrown around with semen all over her and flowing from her body. There were at least about 20 condoms! She has not even seen her assailants. That's why nowadays crimes are targeted on kind people like her.

>Next time if the same situation occurs, never bring the child to the intended place.. If the child insists, then bring the child to the police station.

>Lost children are best sent and/or taken to police stations. Please send this to all your female friends/colleagues, and your male friends with girlfriends and wives. It is better to receive this email a thousand times than be a victim once!

>To keep my Identity and job safe I will just say that I am Officer Justice.

Keep safe Ladies!

>Please pass this on to family members. It is better to be informed. It is sad that we can't even help children now!
-----------------------------------------

Comment by Lim Ju Boo

How can it be possible for a person to be electrocuted and merely faint and able to wake up later? When a person is electrocuted, electricity passes through the body, and the heart is seriously affected. It goes into what we call ‘ventricular fibrillation’. This means the ventricles just quiver or shiver instead of contracting and pumping blood to the body.

Within minutes of electrocution the heart ceases to function, and without adequate blood flow to the brain the brain is dead within 3 minutes. The only way to revive the person is to instantly shock the heart back into normal rhythm using a defibrillator delivering several shocks between 150 -300 Joules of energy. There is an algorithm for this.

Applying CPR alone to restart the heart is normally not effective. In other words, when anyone is electrocuted, he simply dies. It is not a matter of just fainting and waking up later. I am not aware of any documented case where this is possible?

Who is this ‘Officer Justice’ the sender of this warning circular trying to bluff? She is sending pure rubbish to her friends and to other ignorant people. Ask her to speak to me. Just delete her ‘warning’ about her new form of rape.

lim ju boo

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Comments by Ir. KS Tan

Dear Dr Lim,

This is not logical. When a person presses an electrified door bell, the immediate reaction will be that the hand will fly off. Anyone who touches an electrified circuit will instantly fling off his hand. So the electric circuit is broken and no effect. Many people would have experienced this.
People die only when they are unable to get away from the electrified object. It is like holding the door of the fridge. You cannot remove your hand because the muscle seize by the electric current, involuntarily clamp on to the fridge handle. . Or the electric cable fall on your body and you go helpless into convulsion.

Rgds,
Khoon.

--------------------------
Dear Ir. Khoon,

Thank you for your comment.

Unfortunately your half right, half wrong notion on electrocution has forced me here to lengthen my original short explanation.

You were right and also wrong at the same time. You have explained it half correctly. But because I wanted to make my explanation as short as possible without unnecessarily going into the complicated mechanism of reflex action, etc, I just gave the barest minimum about the effects of electricity on the heart. I am fully aware of what you said, but I did not want to make my comment too long with unnecessary physiology about reaction time, reflex action, etc.

Protective mechanisms operative:

Since you mentioned it, let me elaborate a little more on what you said. The body is always ready to protect itself from any danger, whether from electrocution, fire, falling body, infection, sudden threats of any kind…etc. Anybody who understands how the human body works, and the protective mechanisms always there in place, understands and appreciates this.

Overriding the body responses:

What is dangerous about touching and holding on to a electrified door handle, door bell, fridge handle (as illustrated by you) is that we always use the palm of the hand (palmar) to hold any object. Nobody ever grasp an object on the dorsum side (back of hand) because the fingers can flex from the dorsum position to the palmar position in order to grip on to the object on the palm. In short, we hold an object with the palm.

Anatomy of hand:

Unfortunately the joints, ligaments, tendons flexors and extensors of the extrinsic muscle of our finger are such that they restrict movements only in one direction – towards the palm. In other words the fingers anatomically cannot bend backwards away from an object. At best it can do is to open the fingers to their limits or flex the entire hand away from the object voluntarily by reflex action.

All or none law:

Unfortunately also, if an electric current is applied to any muscle it will contract automatically and this is not dependent on the strength of the current, except that the strength of the current need to reach a certain threshold to elicit a contraction. In physiology, we call this ‘all or none law’. I remember learning this in my physiology class as an undergraduate.

Muscles instantly contract:

Unfortunately also, if you hold on to a door handle, door bell, fridge handle, or any object which is electrified, it will instantly cause all the muscles of your fingers to contract towards the palm, causing you to hold on to the electrified object even tighter instead of relaxing your finger muscles outwards. This is an automatic instant response to an electric current.

Reflex Action:

But you were right if you only lightly touch the object with your finger tips. The reflex action will take a fraction of a second as the impulse will have to travel from the finger tips to the spinal cord where it will synapse across the cord, and travel back to the motor part of the fingers and muscles of the hands to ‘ask’ you to remove it.

But this takes some time because part of the message has to go to the brain also to let the brain interpret the stimulus on what to do. The brain has the discretion on what to do, although most of the reflex actions are involuntary to allow the body to react first, and the information can later be sent to the brain on ‘what happened’ and how did the body react to it. In order words, the reflexes takes over with the evasive action and the brain informed of the action taken later.

Speed of contraction faster than reflexes:

So far so good! But unfortunately the contraction of the muscles to an electrical current is so fast, much faster than impulses relayed to the spinal cord, and back again for the motor responses. Some of the impulses will ascend up the spinal cord to the brain of course for more decisive actions.

This is how the muscles react when stimulated by an electric current. Unfortunately it can only contract in one direction – towards the palm making the grip and the contact with the current even stronger.

Speed of nerve transmission:

When a stimulus is applied to the sensory receptor, the impulses travel to the efferent neuron to the interneuron junction in the spinal cord where the stimulus synapse across to the afferent neuron onwards to the muscles to contract (withdrawal reflex). The speed of this nerve transmission varies tremendously, and is between 0.9 - 89.41 m/s.

Speed of nerve reaction time vs. speed of electricity:

Even with the fastest transmission speed, it is still some 3 million times slower than the speed of electricity through a wire. It is slightly slower through a human body. The speed of electricity which is just a flow of electrons or ions through a conductor is some 96 % the speed of light through a copper wire. It may be about 240 000 km (240 000 000 meters) per second through a human body.

This means the body has no time to react at all because of the much, much slower reaction time. By the time even if the fingers or hand managed to withdraw by reflex reaction, the electricity would have already surged through the entire body at near (80 %) the speed of light. Instantly this would already affect the heart into ventricular fibrillation even if you managed to withdraw your hand.

Latent time:

Of course I do agree that there is a latent time. This means the muscle does not immediately respond to a stimulus, but that a period elapses between the stimulus and the commencement of the contraction, which is on the average is about the 100th of a second. This is termed the latent period. But since the stimulus (electricity) has already been applied, the muscles – skeletal as well as cardiac muscles will still respond accordingly - about 100thof a second later even if the hand has already withdrawn by reflex response. So there is no escape. The person will still suffer electrocution unfortunately.

Reaction time (RT):

This is time elapsed between the presentation of a sensory stimulus and the subsequent behavioral response. This time is between 150 - 200 milliseconds. On average, humans have a reaction time of 0.25 seconds to a visual stimulus, 0.17 for an audio stimulus, and 0.15 seconds for a touch stimulus. Reaction times vary from individual to individual. Because of the higher degree of neural processing, reaction times can be influenced by a variety of factors such as sleepiness, emotional distress, or consumption of alcohol. Still, no matter how fast the body reacts, it still is far, far, far slower than the speed of electricity through the body.

Electromyoneurophysiology:

I would not want to go too deep into electromyophysiology, signal strength, neurotransmission, neurochemistry of muscle contraction, (actin, myosin, ATP, etc), comparative speeds of nerve transmission, polarization and depolarization, migration of ions within the cells etc, etc. They would not only be too technical, but boring to others. Moreover, I am not a specialist in electro-neuro-myo-physiology to understand such intense technical complexity.

My simple original message:

My original comment is to make it as sweet, short and simple as possible for the lay readers about the effects of electrocution on cardiac rhythm (ventricular fibrillation) rather than trying to explain neurological effects and protective reflex responses.

My simple advice:

But if you suspect an object is electrified, always use a test pen, never touch it. But if you have none, but must test it with your hands, then always test it with the dorsum (back) of your hand. Using this technique, the fingers will contract towards the palm – away from the object. This way you will never be able to seize it even more firmly. Again, I have to repeat, the electricity would have already affected your heart if it is above the threshold to elicit the ‘all or none law’ (see above).

Death from electrocution is common:

Hence, death from electrocution is quite a common form of accidental death. Else, if your explanation is as simple as that, and completely right, then nobody can ever get electrocuted. They just remove their hands as you explained.

But it is not as simple as that when the speed of electricity is almost the speed of light. Your body’s reaction, speed of nerve transmission, and hence reflex action is tens million times slower than the speed of electricity.

Electricity is entirely different:

It is not like touching a hot iron where you only respond to a heat stimulus that hardly travels through the body. This is electricity that travels at near the speed of lights throughout the body, and your protective reflexes never be as fast as that.

You will still get electrocuted even if you managed to withdraw your hand. Your heart will already be in fibrillation. Someone needs to apply CPR instantly in the event of a cardiac arrest and shock your heart with a defibrillator once available as I have already explained in the last letter.

I hope my simple explanation here will help you to understand better, and also reach out to the lay people. Your comment has unnecessarily lengthened my original message.


Lim Ju Boo BSc PG Dip Nutr MSc MD PhD FRSPH FRSM

Special Medical and Science Adviser
----------------------------------------------------------
Dear Dr Lim,

Wow. Your writing is fantastic and awesome. May I borrow it for my PhD thesis?

However, not everything is correct. Not every time you touch an electric cable, you get electrocuted. Certainly not for the girl who rang the door bell with her index finger.
You need to understand electricity to understand why the girl is OK.

The electric equation V = IR means when the girl is wearing a high heel + rubber sole + a small push on the door bell button which is normally plastic, but now fixed up into metal by the bad guys, it means R is very, very big. So current is very small. The girl
just get a jolt. So nothing serious happened.

Rgds,
Khoon.

------------------------------


Comment from Professor Dr Lee Chai Peng, Dept of Geology, University of Malaya

Have you not heard of taser or stunt-gun used by law enforcement officers in US and other places? Maybe the lady could not express herself so well but to a lay person that's how it appears when someone is hit by a stun-gun.

C.P.Lee

------------------------------------
Comment by Perry Tan

Wow! Thanks Dr. Lim for the lengthy and highly academic explanation of electrocution supported by the argument of the human anatomy of the hands and physiological thesis on the effects of strong electrical current through the human bodies that might and actually can cause tissue damage, cardiac arrest leading to ventricular fibrillation and in most cases, sudden death, which is obviously, irreversible.

It is such a professional presentation so well presented that, myself, as a common lay man, not only found it interesting but admittedly, it added on to my minisculte knowledge of both the human physiology and the incidence of electricity through the body.

Very Important Rule

Nevertheless, it reminded me of a VERY IMPORTANT RULE, OHM's Law. V = IR Where, V is inversely proportional to I if R is constant

Body and Skin Resistance

Can I confidently say that, the human body got its own Resistance, and there is such thing called Skin Resistance?

Applying Ohm's Law, the current drawn through the body depends on the resistance of the body. The resistance of human skin obviously varies from person to person and fluctuates at different times of the day, depending on the concentration of the bodily fluid and is probably proportional to the salt contents.

If the skin is dry, it is a poor conductor, and the resistance can be as high as R=100k Ω. If the skin is broken or wet, the resistance can be as low as 1 k Ω

(It is generally estimated that currents approaching 100 mA are lethal if they pass through sensitive portions of the body)

Assumptions and Calculations

Assuming that the door bell is connected to the domestic supply of 240 V AC, and the body resistance is 100k Ω, applying the V=IR,,, give us an I =0.0024 Amp which may cause electric shocks and convulsions but may not amount to a full electrocution.

Taking the average body resistance of 50k Ω, the current passing through the body works out to be I=0.0048 Amp which is still well below the threshold of 100mA =0.1 Amp.

Moreover, if the would be rape victim happens to wear platform shoes of 3 inches high heel, which is wood and with rubber soles, the chances of complete electrocution is further prevented. The shoes and rubber soles are poor conductors of electricity and the flow of electricity from the finger to the ground is incomplete.

Conclusion:

The chances of the rape victim to enter an electro-convulsion and survive the electric shock is high

As a layman, I believe, the would be rape victim wont die of electrocution.
The would be rapist wont want a dead body, and i guess they are knowledgeable enough to conduct a simple cpa, if not defibrillation, just to revive the victim to semi-conscious state.

Original Article and advice:

Prevention is better than cure, and the original advice to the ladies are of utmost importance.

Layman Disclaimer:

I may be wrong, and I sincerely hope my Ir friends from IEM can make some comments on electric calculation and prevention of electric shocks

Thanks Dr Lim

Perry Tan
----------------------------------
Dear Ir Rocky Wong,

You are the right person to comment on the Electric current issues.
Could you kindly give us your expert opinion please?

Warmest regards,
C K Cheong

----------------------
To All the Learned Gentlemen,

I am fascinated and at the same time amazed at the sudden landslide of volcanic eruption of information and knowledge derived from this forum that i may present this subject to my friends at a coffee talk discussion.

But one thing is sure; I would not want to be at the receiving end of an electrocution whether it is an accident or by intrusion through an assault.

Encore to all the parties who are giving so much enlightenment of the subject though.

Best wishes

An ordinary layman
David
-------------------------------------
Hi Perry,

Your threshold figure of 100 mA is far too big. To feel an electric current, it must exceed 1 mA. To die by electrocution current through body must exceed 30 mA.
Your analysis of the girl surviving the door bell electrification is agreeable.
The girl may get an electric shock but will not die.

Rgds,
Khoon

-----------------------------
HI David,

Don’t try this at home.

But one thing is sure, I would not want to be at the receiving end of an electrocution whether it is an accident or by intrusion through an assault.

Yes. Nobody enjoys to be electrocuted. But there was a case in Brazil some time ago. The police came to investigate a death from electrocution. The man uses electricity to stimulate his sexual activity. Probably he steps down the electricity current for a tingling stimulating shock. But things went wrong and he got electrocuted instead. Cardiac arrest leading to ventricular fibrillation

Rgds,
Khoon.

Burundanga Drug used for Raping and Robbing?

Dear Uncle Ju Boo,

This is about using "Burundanga Drug" to rob. Please do tell us more about "Burundanga Drug" and "what we should do, if we are one of the victims?" I am pretty sure, every one of us would be interested to learn more from you.

Thks and send my warmest regards to Auntie Sally.

----- Forwarded Message ----
From: Karen
Sent: Tue, May 4, 2010 9:04:52 AM
Subject: Fwd: FW: BURUNDANGA - to rob

---------- Forwarded message ----------
Subject: Fwd: FW: BURUNDANGA - to rob

From: Chong Kok Kuan
Date: 3 May 2010 10:17
Subject: FW: BURUNDANGA - to rob
To:

Subject: BURUNDANGA - to rob

NAME CARDS

Please be careful. Yesterday, a friend was at the Carrefour carpark after shopping and about to start the car engine. Suddenly, one man appeared holding a name card and asking me to wind down the window to give me the name card. She refused using the sign language but he kept on pestering. She was terrified and quickly started the engine and sped off. Fortunately, she locked the car doors immediately after she got in...

Thank you for the warning email I received earlier.
Rgds,
May

Subject: NAME CARDS

Must Read and Please be careful out there!!

A man came over and offered his service as a painter to a female putting gas in her car and left his card. She said no, but accepted his card out of kindness and got in the car. The man then got into a car driven by another gentleman.

As the lady left the service station, she saw the men following her out of the station at the same time.
Almost immediately, she started to feel dizzy and could not catch her breath. She tried to open the window and realized that the odor was on her hand; the same hand which accepted the card from the gentleman at the gas station.

She then noticed the men were immediately behind her and she felt she needed to do something at that moment. She drove into the first driveway and began to honk her horn repeatedly to ask for help.The men drove away but the lady still felt pretty bad for several minutes after she could finally catch her breath. Apparently, there was a substance on the card that could have seriously injured her.

This drug is called 'BURUNDANGA' and it is used by people who wish to incapacitate a victim in order to steal from or take advantage of them.

This drug is four times more dangerous than the date rape drug and is transferable on simple cards.

So take heed and make sure you don't accept cards at any given time alone or from someone on the streets. This applies to those making house calls and slipping you a card when they offer their services.

PLEASE SEND THIS E-MAIL ALERT TO EVERY FEMALE, OR EVEN MALE THAT YOU KNOW

Regards,

HC Goh


REPLY FROM DOCTOR JB LIM

Dearest Niece Ai Lian and to all your girl friends and other concerned girls too,

Thanks for referring to me for advice.

Pharmacology:

The pharmacology and toxicity of this agent you are referring to is very complicated and highly technical, and I do not expect you and your friends to understand the
pharmacodynamics, pharmacokinetics, clearance, volume of distribution, t ½ values, L50, and all those technical jargon of this agent we, as research and R&D scientists in the drug industry, would normally present or publish in scientific papers. But it is not necessary to explain all that for lay people to answer your question.

Simple info only:

So instead of that, I will very, very briefly in layman’s language explain to you what I know about this agent (drug).

This agent called Burundanga Drug or more correctly ‘Scopolamine’, also known as levo-duboisine, and hyoscine, is sometimes, but more rarely used in Malaysia for the folowing:

• Treatment of nausea and motion sickness
• Treatment of intestinal cramping
• For ophthalmic (eye) purposes
• As a general depressant and adjunct to narcotic painkillers

Less often used as:

• As a preanesthetic agent (sedative before given anesthesia)
• As a drying agent for sinuses, lungs, and related areas.
• To reduce motility and secretions in the GI tract
• Uncommonly used for some forms of Parkinsonism.
• As an adjunct to opioid analgesia, such as in the product Twilight Sleep


Unfounded reports:

However, according to reports circulating around, this drug (scopolomine) in the form of burundanga is also in "epidemic use" in Bogota Colombia in 1995.

What this means was that the drug has been given to unwitting victims who were not only robbed, but were put to work as "mules" carrying smuggled cocaine across the border, only to wake up with very little memory of the event. It is a form of "chemical hypnosis", and the victim can talk, drive a car and navigate while still under its influence.

As far as scientists know, such effects are only stories carried around, but have not been proven scientifically. It was just some rumours.

Business cards to rape victims:

Then again, there are also unfounded rumors circulating around in the Internet and e-mails that a transcutaneous (over the skin) delivery mechanism of Burundanga into the body was possible by using business cards, pamphlets or flyers laced with the drug. It was then used on girls to rape them. I have received such e-mails before.

In my professional opinion as a Special Medical and Science Adviser to an international group of drug companies, I do not think that the drug is as potent as that to have such a powerful effect on the human body by merely touching the card. I do not know of any drug, chemical or poison that can have such powerful effects by merely touching a paper laced with such agent.

No documents:

I have not read in any literature of any drug in existence that can have such stunning effect by merely touching of a piece of paper for a few seconds laced with the drug?

A lot of drugs may be delivered subcutaneously (under the skin) by skin patch – but they have to be literally pasted over a period of 24 hours or longer for slow released absorption over a larger area of skin where the epidermis is thinner, such as the back, or inner thighs, etc, and not over horny parts like the soles of the feet, or the finger tips.

This mode of delivery is transdermal or transmucosal. Sometimes it is called "topical" administration. But such effect is much slower than via enteral – meaning systemic through oral, rectal, sublingual, sublabial (between the teeth and gingiva). Even faster is via bolus, IV, IM, which would-be-rapists would not understand or able to do.

Dose related toxicity:

The quantity of toxin diffusing through the skin after one short contact of the fingers with an object like a business card is much too small to be readily absorbed in the body and to have any significant effect. The use of burundanga (scopolamine) impregnated into visiting cards to attack and to rob isolated people is often propagated by chain emails. In my opinion they are just hoaxes.

Enteral route:

But spiked alcoholic drinks (direct ingestion into the gastrointestinal tract) could have been occasionally used, and this may have effect because the drug is actually ingested, and enters into the system via the gastrointestinal tract. It is not by merely touching it with the fingers.

Suggestions only, but unnecessary:

However, if girls are that scared as that, I would then suggest that if any strangers in lonely places, or those whom they do not know, and for no rhyme or reason they give you a card, it is advisable to use a piece of folded tissue paper or a glove or handkerchief to hold it. But if you have none, do not worry. Just hold the card or pamphlet at the edge using her two fingers. This way almost no substance can ever be absorbed by the fingers.

Bear in mind the skin over the fingers are quite thick, and it is very difficult for anything to penetrate except poked by a needle, a sharp point of a knife, or a piece of broken glass.

Only through these cuts in the skin can things enter into the blood stream. But definitely no drug can penetrate the skin over such a tiny area, especially holding it for just a few seconds or even an hour or even longer.

Ventilate:

One more thing! If you are in a car, and if you are afraid of inhaling anything including burundanga, then do not close your car window as you drive off. Switch off the air-conditioner, and open all the car windows, and let in a lot of air from outside as you drive. Actually even this is unnecessary. How is it possible for a simple card to pour out so many fumes? A card is not a nebulizer machine, steam or smoke emitter.

Calculate out diffusion rate:

You can actually calculate out the amount of molecules of any substance emitted from a card of a certain square area into a cubic meter of air. From there it would be possible to determine how much of the substance is inhaled and circulated into the blood stream as we know the vital capacity of the lungs and the respiration rate. Hence from the concentration in the blood, it is possible to determine if the substance can affect a person since its concentration in the blood can easily be calculated out through respiratory exchange of gases in the lungs.

If I have the data I can easily calculate this out for you without problem from my simple undergraduate training in physics, chemistry and in physiology – I have not forgotten them even though I have since
specialized in medical research with doctorate degrees and post-doctoral Fellowships in other areas.

Scientific logic:

Use your simple scientific logic. If that card can affect you, it can even more affect the person who has been working on them. He probably has been touching it (them) all day long while looking for victims. His exposures of making, storing, smearing the drug on the cards – probably hundreds of them all day long would have knocked him off instantly (if it was so powerful), and he would probably remained unconscious for as long as he still holds and inhales all those impregnated cards – before he could even hand a single one to you.

Use your brains:

Use your simple intelligence to logically and scientifically think. Do not believe everything people send you by e-mails like an idiotic mule. The Internet is full of hoaxes and rubbish ‘information’ written by
unqualified human mules and donkeys. I receive tens of thousands of such mails even from strangers. Listen to me as your uncle.

Love & Regards

Uncle lim ju boo

Comments from others

Dear Dr Lim,

Fully agree with you, sir.

I have observed, some are logically born with others may need some guidance and practice to gain logical skill....

Best regards,
C K
- Hide quoted text -

On Mon, May 17, 2010 at 3:20 AM, JB Lim wrote:

Dear Ir Cheong,

You may share it with anyone you wish. It is just a simple explanation. The only thing I forgot to add is that, if girls are so afraid of some non-existence ‘magical scent' coming from the card while viewing it, I suggest they hold it far away from their nose at full arm's length, and better still, if there is a wind or even a small breeze around, they let their back face the wind blowing from behind, so that the wind will blow the 'magic scent' well away from their body. As simple as that!

We don't require a PhD to understand simple logic.

Regards

lim ju boo

On Fri, May 14, 2010 at 9:23 AM, AE Consultant wrote:

Dear Dr Lim,

Thank you very much for the detail and systematically arrive at the conclusion. I am able to learn from the way your presentation of a highly technical issue in the moat direct and simple way for a lay person's understanding & information.

How a researcher's view with logic is amazing.

Thank you again, I would like to share this information
of yours with my family and friends, hope it is okay with you

SIR.

Warmest regards,
C K Cheong

Reply from Dr JB Lim to Ir CK Cheong,

Dear Ir Cheong,

You may share it with anyone you wish. It is just a simple explanation.

The only thing I forgot to add is that, if girls are so afraid of some non-existence ‘magical scent' coming from the card while viewing it, I suggest they hold it far away from their nose at full arm's length, and better still, if there is a wind or even a small breeze around, they let their back face the wind blowing from behind, so that the wind will blow the 'magic scent' well away from their body. As simple as that!

We don't require a PhD to understand simple logic.

Regards

lim ju boo

Patients letters to Dr JB Lim

The following was a letter, actually two separate letters from two persons I received from a lady. It was sent to me by e-mail. I then replied hurriedly to her. But their names were changed to ethically protect their identities as patients before I post their letters and my reply into my blog for educational purpose only.

First letter

Dear Dr. JB Lim,

I had this back problem (S4 & S5) which recur last year.

After the MRI, I was only put on observation and some physiotherapy. I secretly did some pelvic exercise like lying flat on my back, bending both legs (in crouching position) swaying from left to right and some light leg movements. This help tremendously in my healing process and I was back on my feet in a week.

The only thing that worries me is the jab which my family doctor gave me during my first treatment is still down there in my buttock. It's been there for 4 years now. This lump did not worry me until my cousin brother's wife had a pelvic and spinal bone recurring problem.

Even in Singapore there isn't much help or enough doctors to go about the operation. (Maybe only happen in that hospital.)

My question is how are we going to tackle this bone loss degeneration as osteophrosis normally attack women faster than men. My mother is 89, her back is now almost ''r'' shape but I don't hear her complaining much about her backache.

I guess the rest would also want your expertise reply as precaution is always better than cure. Please advice on the drug Tramadol administration and other side effects too.

Following is the extract of the mail.

Best regards always

Ms Christine (name changed)

Second letter

I was having a difficult time for the last 3 weeks or so after my wife had a recurring spinal bone problem and a pelvic bone problem which came on suddenly about 3 weeks causing her so much agony that she had to stop baby sitting and and wanted a specialist to attend to her immediately as she was in tears due to her pain.

I was having a harrowing time shuttling her to hospital for so many days while keeping my work in balance.

Just a brief outline of what she went through. Her family strongly recommended that she went back to see her old bone specialist who had operated on her before some 13 years ago but this doctor had retired. Her sister recommended the next best thing to do was to see a bone doctor in Mount Elizabeth Hospital (recommended by her boss). We were all hoping to seek early and fast treatment as she could not bear with the pain and was weeping everyday. X-ray and MRI scan was done at Mt. E and she was asked to go for Physiotherapy instead of surgery first to see if it works.

After about 4 days, nothing seems to work and it was waste of time, money and resources to go to Mt Alvernia hospital for this physio therapy. I now strongly suspected that there wasn't enough operating theatre time slot for her for that week and this doctor was playing for more time.

On the second appointment to see him, he finally agreed that 2 places on her body need to be operated on Spinal and Pelvic bone.

All these came about because of bone degeneration in her spinal and then there was this muscle tissue tear which were all having a friction or rubbing effect on her nerves thereby causing her to be in great pain whenever she stands, let alone walk. I even had to go borrow a wheelchair from a past neighbour who now stays in Ang Mo Kio for her to use.

My shock came when this so called specialist doctor admitted that he was not qualified to operated on back bone or pelvic bone and he only can do surgery on knee cap. I was disgusted deep inside. He only knows of 2 doctors in Singapore who can operate on Pelvic bone (One Private one in Mt.E but he was out stationed for another week and the other one was Doctor Paul Chang at SGH). We were left with no choice but to make appointment to see Paul Chang and had to go to SGH as a private hospital patient paying the higher private medical fees for treatment. Another setback was earliest appointment had to be a week later.

We could not wait for 1 more week as the Pelvic bone pain was almost killing her. Very strong pain killer was given to her so much so that she developed very severe skin rashes. Don't take this strong painkiller drug called Tramadol if it was ever prescribed for you. You may end up scratching yourself non stop from head to toes like a monkey and the rashes are like big mosquitoes bites on the whole body. She poured half a bottle of medicated oil on her body when the rashes were coming on that day.

Luckily for me, I contacted a friend who knew Dr.Paul Chang well and managed to squeeze in an appointment at SGH on the same day after seeing the Mt.E hospital doctor. Dr. Paul Chang gave her an injection to immediately neutralise the Tramadol effect on her and it works well. Next problem was the Operating theatre time slot for her has to be about 5 days later and again she has to bear with the pain again. They said we could only book B1 class bed for her otherwise if we insist on B2 wards the operation date could be as long as 4 to 6 weeks later as they only allocate for 2 B2 beds each day. What kind of medical infrastructure and facilities are we having in this First World country called Singapore?

It was another long nightmare for her to bear with the pain for 5 days before she was finally operated on.
The operation was actually strongly recommended to be aborted due to her persistent cough , but she had begged the doctors to operate on her immediately without any more delay. She was operated by robot with 2 doctors doing the operation just moving their hands near a computer screen. More like the latest Wii game console. It is called keyhole operation with smaller cut and smaller wound and therefore less bleeding.

She stayed for 2 nights at B1 ward before she was discharged. Total cost spend on all her medical so far was S$13,000 and still counting. She is now recuperating at home. She is in less pain now but she could not stand for long because a second operation on the spinal bone may be due soon depending on her coming appointment on 25th May with Dr. Paul Chang.

She admitted she still need another operation as the pain in her legs are coming from the back bone vertebra abnormal growth getting on to her nerves. Seems like there is another Part 2 of medical nightmare for me to go through with her.

Seems like I will not be able to go head north so soon. I will let you know again as there are times when my colleague will need my help at JB and I may just go up there without much planning. I will try my best to make a trip maybe on the 26th or 27th of this month.

Meanwhile you take care and I will contact you again.

Best Regards

William (name changed)

--------------------------------------------


Doctor JB Lim’s reply:

Dear Ms Christine (name changed to protect patient’s identity),


I am unsure if you needed my advice, or was it another person there called William (name changed to protect patient’s identity as given in e-mail) as there are two letters in your letter with back bone problems. I have just opened your mail, and I have made a very quick scan of both letters. I have not made a detailed study of both letters as yet as I have a lot of other reports attend to

Anyway, I am just giving you or your friend a very fast emergency reply since both of you seemed to be in pain with some back problem. I shall read your letter a little slower later for the details.

Wrong and Right Doctor:

I think your friend in Singapore has gone to the wrong type of doctors for spinal and bone problems. The best type of doctor to treat neuromuscular and skeletal pain such as spinal problems is the osteopath. I think William went to see an orthopedic surgeon in Singapore, which is not the right doctor to go to as they are only interested in operations, and more operations that’s all.

An osteopath or osteopathic doctor is the best alternative doctor to consult for backbone problems. This type of doctors is fully qualified who uses alternative medicine called osteopathy to treat such cases as spinal problems. They do not use powerful pain killers like Tramadol and other powerful drugs merely to suppress the problem like the doctor who treated William did in Singapore. Neither do they use surgery and other invasive methods. They just align the body and musculoskeletal systems into good shape and correct order to solve the problem.

Osteopathic Doctors are more appropriate:

Osteopaths employ manual therapies for the treatment of many muscles, bones and skeletal pains such as lower back pain with excellent results. They neither use invasive procedures like surgery, nor drugs to mask the symptoms. Instead, they use therapies like dietary, posture alignment, occupational advice, as well as counseling to help patients recover from illness and injury to minimize and manage pain and disease quite effectively.

Unsure if Osteopathic Doctors available in Singapore?

However, I am unsure if there are osteopathic doctors practicing in Singapore? But there are a number of American osteopaths and Australian university trained osteopathic doctors in practice here in Kuala Lumpur. They are alternative medical doctors who can do a very good job with all sorts of muscles, ligaments, muscle, spinal (backbone) problems without using all sorts of unnecessary surgeries, harsh drugs and pain killers.

Chiropactic Doctors:

There is also another kind of alternative doctors called chiropractors. They too are very good for this sort of problems. They treat by aligning the bones and musculoskeletal systems. It is very lengthy for me to explain all these to you. It takes a lot of my time.
Types of spinal disorders:
Briefly, there are many types of spinal conditions that can cause a lot of pain. Most of them are degenerative spinal diseases. Degenerative spinal disease is related to chronic wear and tear on the spine due to aging and physical activity. It can lead to a number of different spine disorders such as Herniated Disc. This includes the following:

• Cervical Herniated Disc
• Thoracic Herniated Disc
• Lumbar Herniated Disc
• Spinal Stenosis
• Cervical Stenosis
• Lumbar Stenosis
• Foraminal Stenosis
• Spinal Instability
• Osteoporosis (as in women in post-menopausal stage due to bone loss from hormonal imbalance)
• Osteomalacia (example in rickets)


Actually I cannot give you any elaborate advice via e-mails as I need to have a look at the patient, see his / her medical records, understand his / her medical history, lifestyles, dietary habits, body weight, genetics, age, gender, family history, current treatment given, medication, lab results, radiological scans (X-rays, MRI, CT, etc). Without all these, I really cannot diagnose and suggest any specific treatment. This is just a general discussion to your possible problem.

Tramadol:

As to your question about Tramadol, yes this is a very powerful analgesic (pain killer drug). It is much more powerful as a pain reliever than paracetamol (Panadol). In fact Tramadol belongs to the opioid group of drugs like morphine, but it is slightly less powerful and a little safer than morphine. But it is a narcotic-like pain reliever acting centrally on the brain and central nervous system and it is used for managing moderate to moderately severe pain.

Adverse Drug Reactions:

Unfortunately like all chemical drugs, Tramadol do have moderate to severe side-effects even though normally it is well tolerated. Some of these side-effects may include sweating, drowsiness, diarrhoea, constipation, appetite loss, nausea, breathing difficulties, tightness in the chest, restlessness, chest pains, disorientation, mood changes, swelling and redness of the skin, giddiness, swelling of the face, mouth, lips, etc, and in some cases as in William’s case, there is severe allergic reactions such as pruritus (itchiness), rashes and beehives.

I think William’s case was severe allergic reaction to Tramadol. This can subside by just withdrawing the drug, or by an injection of an antihistamine. Drugs are all chemical substances foreign to the body, and being a foreign chemical when ingested, the body reacts badly to some drugs by trying to reject them. That is how the body cries out with all these symptoms. The symptoms are just the body’s reactions trying to reject the chemicals.

Most drugs hence give side effects in one way or another. The only way is to take them off instead of trying to suppress the symptoms by giving yet another drug such as an antihistamine. To use another drug to suppress the symptoms due to another drug is exactly like sweeping dirt under a carpet. This was exactly what William received and underwent when another doctor gave him an injection to suppress the itch caused by the first doctor. This is the tragedy of conventional drug-based medicine. Mainstream hospital type of medicine is like that.

Alternatives modalities of managing pain:

There are so many much safer, non-drug ways to treat pain rather than giving harsh and powerful drugs like Tramadol. Non pharmacological and much safer ways are (examples):

• Acupuncture
• Aromatherapy
• Breathing exercises
• Biofeedback
• Hot and cold compresses
• Guided imagery
• Massage
• Self-hypnosis
• Transcutaneous Electrical Nerve Stimulation (TENS)
• Touch energy therapies
• Spinal cord stimulation
• Physical therapy
• Distraction therapy
• Laughter therapy, etc.

Drugs are foreign substances to the body:

I do not recommend drugs to solve health problem. Many drugs merely suppress the symptom temporarily, but in the long run damage the liver, kidneys, nervous system, haematological (blood) and circulatory systems. All drugs are like that. They only temporary suppress and mask the problem, but do not cure the disease. To properly treat a medical problem you need to treat the root causes, not suppress the symptoms with harsh and powerful chemical drugs.

Unfortunately that is how modern conventional medicine treats an ailment. The drug company works hand in glove with the medical profession to promote their products, because the doctor does not know how to treat without the drugs, and the drug industry depends on the medical profession to sell them to the patients, and the patient has to pay to both of them. Unfortunately I am from the drug industry as their Special Medical and Science Advisor, but I am extremely honest and very ethical about this.


Medical Professor who opted for Natural Medicine:

A very good and old friend of mine who is actually a medical specialist - a Professor of Psychiatry at the former University Hospital, University of Malaya, but now in private practice, recently told me he had the same knee and bone problem but did not respond to treatment using conventional medical treatment with drugs, surgery and pain killers. He then sought alternative natural therapies using a number of herbs, and nutritional approaches which other doctor relatives bought for him from Australia and New Zealand.

These natural medicines finally gave him a lot of relief. I also advised him further what to do. All these have helped him tremendously.

I think I have spent a lot of time writing this letter. I hope you appreciate the time and effort I have spent.

Relatives and colleagues at SGH:

By the way, my youngest brother Professor Dr Lim Yew Cheng, a Professor of Cardiothoracic and Vascular Surgery was previously from Singapore General Hospital (SGH) before he came here to the University Hospital, University of Malaya. He is now in Gleneagle Intan Medical Centre, Kuala Lumpur.

But one of my nieces, Dr Hsu Anne Ling, a Senior Consultant Respiratory Physician is still there at the SGH, Singapore where Willie was treated. I have other doctor friends also working at SGH.

I shall read your two letters later as I have other things to attend as it is now nearly 1:00 a.m. in the morning.

Regards,

Lim Ju Boo BSc (Physiol), Postgrad Dip Nutrition, MSc, MD, PhD (Medicine) FRSPH, FRSM

Special Medical & Science Adviser &
Head of the Technical Advisory Board
The Dynapharm Pharmaceutical Int’l Group

http://www.diamondinterest.com.my/technicalboard.htm
http://dng.com.my/

Reply from patient

Dear Doctor Lim

Thank you for the quick respond and your reply had greatly opened my choices of alternative medication for precautionary measures.
I shall forward your email to William separately.

best regards always

Christine
(This is not her real name to protect patient’s confidentiality. Professional ethics is observed)

Hi doc,

One slight change, it's William’s wife. Thanks so much.

best regards always

Christine

FOUR MOST IMPORTANT ACHIEVEMENTS IN MY LIFE AS A HEALTH CARE PROFESSIONAL

FOUR MOST IMPORTANT ACHIEVEMENTS IN MY LIFE AS A HEALTH CARE PROFESSIONAL

In my 25 years of my professional career as a medical researcher at the Institute for Medical Research from 1969 – 1994, it was not the result of some 4 dozens research papers published, or was it some few hundred patients who consulted me for treatment after my retirement from the Malaysian Civil Service, that were my best contributions, but I consider four achievements below to be my best golden goals.

1. Food Laws: I was one of the experts sitting in numerous Technical Committees to establish Food Standards for Malaysia. I have to attend countless technical meetings from 1969 – 1990 at SIRIM to do this. Our efforts finally culminated in the establishment of the Food Act 1983, and the Food Regulations 1985 for Malaysia. So if you see the compulsory food labels on every packet of food product you buy in the supermarkets or shops today you may think of me. Rest assured most of the foods ingredients declared in the food labels are legally obligatory to ensure the food you buy on the supermarkets contains the ingredients as declared and conform to safety standards we recommended.

2. TCM degrees from Chinese universities recognized: My team of 3 doctors, supporting staff and I pioneered in helping the Government integrate Traditional Chinese Medicine (TCM) into the mainstream health care system in the country. Thus today, we can see doctors trained in TCM from China practicing TCM in many government hospitals. Their presence in other hospitals is widening since the initial trial basis was a success. Additionally, our doctors are being sent to China to learn TCM. A number of universities in China, such as Shanghai Medical University of TCM, Beijing University of Chinese Medicine and Nanjing Universities offering the Bachelor’s degree in Medicine (TCM) have been recognized since the beginning of this year. Malaysian Health Minister Datuk Liow Tiong Lai said that 2 more Chinese universities, the Tianjin University of Traditional Chinese Medicine and the Guangzhou University of Chinese Medicine which he would be visiting will be added for recognition soon. All these universities in China offer a 5 years degree course in TCM which is similar in duration to the MBBS course elsewhere. Graduates from these universities in China are recognized by the Public Service Dept. which allows these doctors to practice both in government and private hospitals in the country. This recognition by the government has also stimulated a number of private universities in the country, example INTI University College, International Medical University, Management and Science University etc to offer similar degree courses in TCM besides courses in conventional medicine. TCM graduates are now working side-by-side with allopathic doctors in government and private hospitals, and they now enjoy the same salaries and work benefits as their allopathic medical counterparts. There were very good responses given to traditional and complementary medicine services introduced initially in three government hospitals — Putrajaya Hospital, Kepala Batas Hospital, Penang, and Sultan Ismail Hospital, Johor — under a pilot project by the Health Ministry a few years ago. Currently another 3 more government hospitals are having TCM doctors practicing there because of the tremendous acceptance and success of the program. This is an achievement for me and my medical colleagues to see alternative medicine being slowly recognized.

3. The establishment of SugaI Buloh hospital: My other colleagues consisting of 4 doctors, an anthropologist, nurses, medical technologists and I were commissioned by the MOH to do a study on the feasibility of replacing the old Sungai Buloh Leprosy Hospital into a modern general hospital. Our efforts and recommendations in the late 1980s finally resulted in the establishment of a multi-million ringgit ultra-modern General Hospital in Sungai Buloh we see today. We were commissioned to do this study by the Ministry of Health (MOH) when we were working at the Institute for Medical Research. The result of our 2-year study resulting in 3 big volumes of Technical Report, and 2 smaller volumes of Executive Report containing numerous recommendations to the Ministry of Health has resulted in this brand new ultra modern hospital in Sg. Buloh. This General Hospital in Sg. Buloh can be clearly be seen by anyone who uses that hospital today for treatment, or can be seen by anyone who passes that area. I feel so proud to see the fruits of our effiorts.

4. Clinical trial on Palm Oil: A team of scientists and specialist doctors led by me helped to prove that Palm Oil does not damage health or raise blood cholesterol as claimed by the American Soybean Association in the 1980s. It was a clinical trial with human subjects, and a very difficult one to conduct as we have to deal with hundreds of students involved in the study. We finally managed to publish our findings in the American Journal of Clinical Nutrition – a scientific journal no Malaysian has ever managed to get his paper published there. But we did – the first for Malaysia. So almost all the vegetable cooking oil we buy today contains palm oil, and it is one of the best oil to use for health reasons, and we assure you palm oil does not raise blood cholesterol.

Taking it easier now:

But I hardly practice these days after my retirement. Currently I am a Special Medical and Science Adviser, and Head of the Technical Advisory Board to the Dynapharm Pharmaceutical Group. But occasionally, I do see patients as a favour for my former medical colleagues and their patients. Sometimes it was for relatives and friends. But my interest is mainly in research, writing articles like this one, and not doing something else which is routine and boring.

Hobbies:

Astronomy and music (violin) are very much in my vein. I play the violin often and have performed at the Kuala Lumpur Symphony Orchestra. But I try to spread out my interest as broadly as possible to make life more balanced and holistic. My friends constantly remind me I am wasting all my talents, university training, and the very huge investments I put in for my education but was unable to churn out money.

But fortunately it was not just my money, but also the British tax-payers’ money that I was investing. I got a few scholarships from the Britain Government to do my postgraduate at British universities. It was based entirely on academic merits. They condition of the scholarship was that I must return to Malaysia to help the country, but later they changed the condition based on my performance. They cancelled that condition that I need to return to Malaysia. Instead, they asked me to stay back in England by offering me a job there.

Opportunities have already came and gone by me. My friends saw me as one who was, and still is, more interested in counting the number of stars in heaven, than counting ringgit and cents on Earth. They forgot that if I were to be given another chance in life, I would immediately choose to become an astronaut, or a pilot and nothing else.

My interest in astronomy and aviation enable me to go high up there above the irritating clouds and city lights to behold before my eyes, a 3 dimensional panoramic view of all the stars and galaxies, all the creations of God, and the heavens, glittering against an immensely deep, void and dark space. There I shall stay, not wanting to return to Earth to do anything else, but to gaze and gaze at the endless wonders of heavenly wealth that far surpass the ringgit, dollars and cents on Earth. It shall truly be first-hand view of something so immensely huge, unprecedented by anything else on Earth.

NATUROPATHIC MEDICINE

Naturopathic Medicine, Natural Medicine, or Natural Therapeutics

Naturopathic Medicine, Natural Medicine, or Naturopathy in short, is an alternative system of medicine which essentially uses drugless modalities to coax, needle, rehabilitate, nourish, stimulate and encourage a diseased body back into health. It uses the principle that a living body has an inherent ability to heal itself again if it is properly stimulated in the right direction. A cut or an injury to the body for instance, will never heal if the body’s highly complex repair mechanisms refuse to cooperate, no matter how much of first-aid, bandages, stitches, surgery, medical intervention with antibiotics, anti-inflammatory drugs, analgesics and medications we pump into it. These agents do not heal the body. Drugs only suppress the symptom and do not do the healing. Only the body can heal itself as doctors watch hopefully from outside. The body will not heal if the body refuses to self-repair the injury. The healing must be done only by the body, while the doctor can only watch hopefully from outside.

Therapeutic modalities in natural medicine make use of this principle that the body can rectify itself when appropriately nourished, stimulated, coaxed, needled, and rested. Treatment by a doctor using natural medical approach include proper diet (dietotherapy), exercise, approaches in preventing and counteracting further environmental damage to the body, such from free radical damage, pollutants in food, water, air and soil, elimination of waste from the body, such as through special therapeutic baths (steam bath, Sitz bath etc), colon cleansing, physiological fasting (the application of special dietotherapeutic regime and fruit juice fasting), the use of clean air and clean water, sunlight, positive lifestyle, and lifestyle modifications, positive thinking, psychosomatic medicine and psychotherapy, meditation techniques, behaviour therapy, phototherapy, hydrotherapy, steam application and cryotherapy (similar to the use of ice-packs in soft tissue injuries which first-aiders are more familiar with, but done in very much greater details, using very much more advanced techniques), rest and relaxation (like the bed rest a doctor would prescribe, but the rest techniques are done in much more elaborate ways than merely going to sleep).

Treatment also includes phytotherapy with herbal and botanical medicine as well as enhancing and supporting other treatment modalities through multi-directional and integrated approach. Naturopathic doctors do not use drugs like allopathic doctors just to suppress the symptoms of the disease, and pray for the body to naturally overcome the problem.

These are some of the many lines of management available to a practicing naturopathic doctor who may decide either to treat conservatively and singly, such as prescribing only bed rest or use multiple prone approaches. In the event of a simple fever, sponging, increased fluid intake, such as the intake barely water (a diuretic), and bed rest may be all that are necessary. A patient may be put on a day or two of fasting on rice water, fruit or vegetable juice or coconut water, which is equivalent to giving ORS (oral rehydration salts) as practised in conventional medicine for an uncomplicated case of diarrhoea due to food poisoning. On the other hand the naturopath (a doctor who practices naturopathic (natural) medicine may decide to treat very aggressively through multiple approaches including dietary, behavior and lifestyle modifications, physiotherapy, rehabilitation therapy and / or herbal medication for long-standing cases.

During the training of a naturopathic doctor, a very deep and detailed understanding of human body structure (anatomy), its functions (physiology), and its chemistry (biochemistry) were taught for two years at exactly the same level as taught in conventional medical schools. The syllabus also included among many, the principles of pharmacology and phyto-pharmacology (botanical medicine), their chemistry, metabolism and mode of action, clinical phytotherapeutics, clinical nutrition, and dietetics (dietotherapeutics), pathogenesis and disease recognition and classification, diagnostic procedures, and their diagnostic comparison with modalities in conventional medicine, general medicine, natural child-birth, comparative medicine, minor surgery, rehabilitative medicine, radiology, osteopathy and postural alignment, hydrotherapy, relaxation and visual therapeutic techniques, the application of acupuncture and acupressure, botanical medicine, psychotherapy etc., etc,

These were taught during class-room lectures and during clinical training. After completing their basic practicing degree and clinical training, graduates who wish to continue further for their Masters and PhD degrees will be required to submit, in addition to higher course work followed by examinations, an original research thesis of no less than 40,000 words. Their integrated therapeutic approaches will all be integrated into the practice of natural medicine. Thus a doctor of natural therapeutic is very well trained, well-versed and very knowledgeable on the best therapeutic modality to use to treat a patient.

They take the best integrated approach drawn from the best of each medical system, and try to combine them into their practice. This gives the patient the best chance since the best features from every medical system is put together into the treatment..

Having been in medical research for 25 years of my life, and finding we have opened up more questions than we could solve, I strongly believe we need to approach the problems of health from a very broad spectrum of human behaviour, and the environment. We cannot solve them at looking at cells and tissues through a microscope, and merely prescribing some medicines to try to solve health problems.

I see health problems now as very big and extremely complex problem. I have even undergone a 3-months formal course in epidemiology and tropical medicine in 1991, as well as in medical biotechnology to study tiny and complex entities like DNA molecules (molecular medicine). They were all part of our postgraduate and post-doctoral training meant for doctors and medical researchers from various ASEAN countries through inter-Governments technical exchange. But all these have not solved any problem. We need to be trained holistically and look at patients as a person, and not as a collection of DNA and chemistry.

Article 10


FIRST-AID FOR APPEDICITIS?

Lim Ju Boo


Occasionally when friends come a visiting when I am busy typing out a story for the newsletter, they come with weird products, bizarre ideas, and ask me cranky questions which I do not know how to answer. This happens to me right now, with my eccentric, but well-loved friend of many years sitting right beside me seeing me type. He has a very kind heart, and is one whom I can joke and tease a lot harmlessly. I am very fond of him. His presence has not stopped me from writing, but instead makes me continue even more just to answer his chronic questions. Strange behaviour for both of us you might wonder? Actually, I have already planned to stop writing with the last one on ‘bends’, when this friend of mine came to find out exactly what am I typing the whole day. He said he was in fact trying desperately to contact me over the last 5 days without success. He had wanted to ask me to do some direct selling business with him. He said he is going to sponsor me for some big money with some of his weird products.

When I told him I have been busy writing articles about first-aid for our St John’s newsletter, he immediately got excited, and suddenly asked me out of the blue what the first-aid for appendicitis is? I was completely thunderstruck by his question. Never have I got a greater shock of my life …. I mean emotional shock, not one of those cardiogenic or hypovolemic shock (or almost) we have been learning in trauma cases all along. I have never even dreamt such question could even be asked even in my nightmares, let alone provide him the answer. Now he got me completely stuck.

At least he has now temporary forgotten his ‘direct selling business’, as he is more preoccupied that I give him the answer. At the moment I have no clue what is he trying to sell me directly. Whatever it is, I assure you I am not going to give my friend any commission, because he said he is now doing direct selling, which means there is no middle man involved. He broke into a broad smile when he saw me typing this. ‘Now, why are you smiling as if you have not seen daylight before my dear friend?’, I asked him. I told him there is no first aid for appendicitis, not that I know of, and even if there is, I do not know the answer, because I have not read it anywhere. But he insists that there is, and that I should give him the answer straight away. He said he won’t go away, until I am able to answer. He makes a good interrogator if he is in the Police Force. I asked him why of all things, he must ask me the first-aid for appendicitis as if it is some kind of urgency. He then told me it all happened like this.

It was only just yesterday his brother-in-law was discharged from the hospital after an appendix operation. A week ago he said his brother-in-law had a fever, vomited, was pale and had great pains ‘here and there’, somewhere all over his the ‘stomach’. His sister sent him to several doctors, but the pain and some vomiting persisted until he could no longer bear it any longer. So they were quite desperate, and finally they had to call an ambulance and bundled him to hospital where he was subsequently diagnosed and operated on. That’s the entire story he has to say, but the problem is, he insists to know the first aid for appendicitis before the ambulance arrives? It set me thinking a while, and finally I still told him there is no effective first-aid for this condition. I have not read it anywhere. I told him he has to get the patient straight to hospital for definitive treatment, since first-aid is only the administration of emergency assistance to an individual who have been injured or otherwise disabled before the arrival of a physician or transportation to a hospital. I told him appendicitis is a medical condition, relatively quite a ‘cold case’ but for which he still need to send the patient straight to a hospital. He will not die just because of the pain. But according to his whacky theory, he demanded that all the diseases and problems of this world, acute, chronic and terminal ones must have a first-aid first before the ambulance can be called. What Am I going to say to this eccentric friend of mine? I am at the moment getting very crazy myself listening to his argument in complete silence, so and I am now only forced typing out the answer in front of him as he talks to satisfy himself. And he is just grinning away. My answer to his question is still a big NO. ‘No to you crazy, I do not know any first-aid for appendicitis. You still have to send him straight to a hospital for investigations and treatment. No first-aid is required. The only thing is, don’t delay’ I warned.

‘Who wouldn’t get shaken when meeting weird friends like you, my spooky friend?’ I asked him. He broadened his smile into laughter. ‘I think you better join St John to understand what first-aid is all about, and our work better, okay?’ I told him. ‘How am I going to tackle such question like yours?’ I retorted. ‘The answer is I do not know, and I do not know a thousand times okay? I said to him. ‘In any case, appendicitis, unlike a cardiac arrest is not an immediate life-threatening situation that requires immediate first-aid assistance before you reach the doctor. Even if there is, you still cannot substitute definitive medical care with first aid or a home remedy. This is very important. Your only real risk in the acute stage of the condition if you delay medical treatment is a perforated appendix, with infected materials spilling into the peritoneal cavity’ I told him. But he still insisted that there is a first-aid to relieve the pain first. ‘Alright, you beat me. You beat me all the time, okay, as you always do okay, okay? Why don’t you argue with your sister? Your sister did a splendid job by sending her husband straight to the hospital without any first-aid, and he is now recovering uneventfully. Why do you pick me to hammer and bully all the time?’ I said to him. My friend laughed. He seems satisfied for a while, but not for long.

Now my friend was aware that I was formerly working for 25 years as a medical researcher and nutritionist at the Institute for Medical Research, Ministry of Health, Malaysian Government. He was also aware I am also interested in naturopathic (natural) medicine besides conventional allopathic (drug based) medicine.

My friend put it to me whether or not there was a naturopathic medical treatment for appendicitis? I still told him no again if he meant acute appendicitis. I told him a naturopathic doctor, just like his allopathic doctor counterpart still refers the patient to a hospital if it was an acute case of appendicitis. Definitive treatment by appendicectomy (surgical removal of the appendix) is usually the only answer. Naturopathic treatment is only offered for the sub-acute and chronic stages of the disease. All doctors whichever systems of medicine he practices have to stage the condition first before they offer any treatment.

It is just too risky to treat the acute stage of the disease through natural medicine only because of the risk of perforation and peritonitis. Briefly, from the naturopathic medical view point, I shall explain what appendicitis is all about.

Appendicitis is an inflammation of the vermiform appendix. This can occur in all ages, but generally in the younger age group between about 15 an 25. The condition may be staged as acute, subacute or chronic. ‘In your brother-in-law’s case, I believe it may have been an acute appendicitis from the symptomatology you described’, I told him. This is normally obstructive, with the lumen of the appendix narrowed by swelling of the lymphoid tissue in the region, or stricture from previous inflammation. There may be total obstruction by impaction of a faecolith that may result in gangrene, perforation and a local abscess, which may burst, and all the infected material and faecal matter released into the abdominal lining (peritoneum) causing infection and generalised inflammation in the area (peritonitis). Another outcome may be the formation of an oedematous inflammatory appendix mass.

The clinical feature is a history of sudden onset of vague central abdominal pain, followed by a shifting of pain to the right iliac fossa (the right concavity of the iliac bones of the pelvis) until it becomes localized to the McBurney’s point. During a naturopathic examination, the doctor presses over the McBurney’s point and look for what we called rebound tenderness. ‘Here is the McBurney’s point, this part my dear friend, one third the distance along the line from the anterior superior iliac spine to the umbilicus’ I said as I showed it to my friend. Generally in the acute phase, there is nausea and malaise as in your brother-in-law’s case. Sometimes, there may be vomiting. In the initial stages there may be little elevation of body temperature, and the presence of chills and high fever make the diagnosis of appendicitis unlikely. There is tenderness and guarding in the right iliac fossa, which may progress to rigidity as peritonitis sets in.

However these classical features occur in just half of the patients because of variations in the anatomical sites of the inflamed appendix. Thus it is important to make a differential diagnosis to differentiate it from other abdominal diseases such as acute mesenteric adenitis, perinephric abcess, Meckel’s diversion, irritable bowel syndrome, Crohn disease, pyelonephritis (inflamation of the kidney), and disorder of the fallopian tube and ovary, if you are a female. That makes diagnosis very difficult because you cannot depend on symptomatology only, because there are other conditions that mimic appendicitis. The doctor, whether he is an allopathic or a naturopathic doctor may do a rectal examination, or even an exploratory laparotomy to confirm or exclude a diagnosis of appendicitis, while a naturopathic physician will examine for certain tell-tale signs in the iris of the eyes, and palpate for rebound tenderness over the McBurney’s point.

‘Here, let me examine your eyes, and let me also palpate over the McBurney’s point over here’. I said to him. You are sitting, but if you are in the supine position (lying flat facing upwards) and I press down here at the McBurney’s point, and suddenly release my hands, you might feel a sudden increase in pain over the area (rebound tenderness). ‘Did you feel any sharp pain here when I pressed and released my hand?’ I asked. ‘Oh, you were just giggling away instead of saying ‘Ouch’, I remarked as I pressed and released the lower right part of his abdomen once again. Oh well, you have no appendicitis I told him. If a blood test is taken, the leukocyte (white cell) count may be increased, especially the polymorphonuclear cells. This condition we call polymorphonuclear leucoytosis.

If a diagnosis for acute appendicitis is confirmed, an appendicectomy has been done to avoid the risk of perforation and peritonitis. This procedure is mandatory. There is no substitute for this. But from the naturopathic medical stand point of view, the application of a hot bottle/bag, or a cold compress over the area, or the application of Transcutaneous Electrical Nerve Stimulation (TENS), is useful; whichever is most suitable or comfortable to the patient for relief pain. This is the only first aid I know from the naturopathic medical point of view until more definitive treatment is available.

Again, there is also a big definite big ‘NO’ to laxative, food or even water, or anything to be given by mouth. In naturopathy, we encourage fasting, because we don’t want to encourage peristaltic (intestinal) hurry, which will cause waves of intestinal contraction that can aggravate the pain. Intestinal hurry itself may encourage perforation. If we are taking about first-aid in naturopathic medicine, we encourage FASTING AND COMPLETE BOWEL REST because we want to IMMOBILIZE COLONIC MOVEMENT as much as possible until a surgical approach becomes available. Remember this is like putting a splint over an injured limb to restrict movement. I am sure you understand this in first-aid.

That is why from the naturopathic stand point of view, the accompanying vomiting, sometimes associated with the condition is a natural physiologically protective mechanism to prevent more food from reaching the colon. Finally, no pain killers to mask the condition please. Keeps the patient warm and comfortable while waiting for an ambulance? But the treatment is quite different for sub-acute and chronic stages of the disease, where an operation may be unnecessary. In such cases there are lots of naturopathic options, but I shall not discuss them here because it is very lengthy and unnecessary.

McBurney’s point:

‘That’s all I need to tell about first-aid method for appendicitis, my dear nosy friend. But please don’t ask me now what is the first-aid for cancer before the ambulance arrives. I will be sunk straight away’. I told my friend ‘Why are you continuously wearing that mysterious Mona Lisa smile as I type out these sentences to answer to your cheeky, eccentric question ? It’s more like the grin of an alley cat to me.’ I remarked.

My stars gave me no luck:

‘Now let me see what’s inside this dirty old treasure bag of yours which you said contains some products to make me rich right away? I hope it’s an old Aladdin Magic Lamp which I can rub straight away. I have always been looking for a genie, or something like that to get rid of my bad luck. You know, I was born without any stars in heaven. It was completely blank, and a washed out for me - all blank with rain clouds everywhere, so I was told by my mother. I was born near midnight in driving rain when our faithful and dedicated family midwife rushed to our pre-war colonial shop house to deliver me on March 20, 1939.

The whole sky was completely in thunderstorm. I hope your ‘direct product’ can dry out all that, and bring me some ‘direct luck’ this time. That why I have never bought a horoscope book to read to find out what’s inside, nor have I consulted a fortune teller. Whatever for I buy a horoscope. It is all full of rainstorms inside, page after page’. I told my friend, as he busted out in loud laughter. ‘I bought a copy now only because I am curious about my Commander-in-Chief horoscope, as well as those of my Regional Commander, Dr. Lee Hoo Teong, and Mr Abu Hassan, the Chief Surgeon’. I assured him.

Wow! There you are, my friend. I won’t tell my readers what you brought for me I remarked.

LOOK, LISTEN AND FEEL

Article 9


Look Listen and Feel

(On Signs, Symptoms and Syndromes)


Lim Ju Boo



I am sure all of us are familiar with the first-aid (primary) assessment of the unconscious victim with the golden rule of the thumb “Look, Listen and Feel’ for breathing, and we may also feel the pulse for circulation. We also encounter signs and symptoms in other aspect of first-aid, and also in medicine, whether in the practice of conventional or naturopathic medicine. Occasionally patients and lay people (hopefully not the first-aiders) get confused between signs and symptoms. Although related from a diagnostic point of view, they are two separate entities. Signs, symptoms and syndromes are part of presenting features that aid in a diagnosis. Symptoms are what the patient can feel and tell, such as a headache, itchiness, discomfort and nausea, whereas signs are what a first-aider, doctor, or a naturopath can see, feel, listen, measure or elicit a response. There are several hundreds of examples, but let me illustrate with just a few examples below:

Presentation:

In first aid we recognize that distortion, swelling, and perhaps bruising are signs of a fracture, while the pain associated with them is a symptom. Similarly, a first-aider can recognixe that a bluish discoloration of the skin and mucous membrane called cyanosis is seen in choking and asphyxia. This is due to an increased carbon dioxide (hypercapnia / hypercarbia), and a decreased in oxygen levels in the blood. Low oxygen levels may be caused by both low SaO2 (oxygen saturation in arterial blood), and/or low PaO2 (partial pressure of arterial oxygen). But first-aiders must not think that only choking can cause cyanosis. Cyanosis can also be associated with heart failure, lung diseases, the breathing of oxygen-deficient air, or in congenital heart defect (tardive and congenital cyanosis which may also be associated with clubbing of the fingers).

Auscultation:

Another example of what can be seen is the presence of Koplik’s spots in the inner cheek, which is a sign indicative of common measles, to differentiate it from German measles which a doctor/naturopath can detect. . The sounds of a mid-systolic or pansystolic (holosystolic) murmur may be indicative of a mitral valve prolapse, ASD (atrial sepal defect), or VSD (ventricular septal defect), or Tetralogy of Fallot (a congenital heart defect). Similarly, a physician is able to hear the machinery murmur in PDA (patent ductus arteriosus). PDA is a congenital vascular problem where the communicating vessel between the aorta and the pulmonary vessel remains patent (open) even after birth, when it should be closed. As a result, there is a mixing of oxygenated blood from aorta with the deoxygenated blood going to the lungs for oxygenation when the ventricles contract. The higher pressure from the aorta is shunted into the lower pressure exerted in the pulmonary vessels causing turbulence in the blood flow through the narrow anastomosis (connecting vessel). This is heard as a murmur (machinery, crescendo-decrescendo type). In fact the various types, grades and characteristics, and positioning (areas over the precordium the sounds are best heard) of murmurs heard are the result of some abnormality in the haemodynamics of blood flow which a doctor can recognize for a provisional diagnosis, apart from using 2-D echogram for confirmation. Murmurs are blowing sounds, similar to the rhythmic sounds of flames being blown by a bellow in a furnace, or the purring sounds of a cat’s breathing. The normal ‘lup dup’ (systolic/diastolic or 1st and 2nd) sounds of a heart beat is replaced by regurgitating sounds of mitral / tricuspid or pulmonary/aortic valve incompetence (does not close tightly), or a septal defect (‘hole-in-the-heart’). Of course not all murmurs are pathological. Some are just innocent or physiological murmurs heard in young children, or the haemic bruits heard in severely anaemic persons due to a lower viscosity of blood, and a resultant greater turbulence in the blood flow. These are examples of some kinds of sounds that can be heard, and they are signs, and not symptoms. We will not go further into the pathophysiology how these sounds are generated in health and in disease.

Abnormal sounds:

Similarly, the sounds of crepitation, rales and rhonchi can be heard in certain lung disorders, such as crepitations (soft fine cracking sounds, like fine soap foams bursting) in pneumonia on auscultation. The appearance and the disappearance of the sounds of Korotkoff (named after a Russian physiologist/physician) is used in the measurement of blood pressure, and so are some abdominal sounds heard in peristaltic action of the intestines, aneurysm of abdominal aorta, foetal heart sounds, and vascular sounds from the placenta. Intestinal sounds for example may be absent in paralytic ileus. Not all sounds heard denote a pathological condition. The body emits a lot of sounds, most of which are physiological. The rhythmic ‘lup dup’ are the sounds of a normal heart beat.

So are the soft vesicular sounds of respiration, and the gargling abdominal sounds of peristalsis in the intestines. Likewise, noisy breathing like snoring while asleep does not mean the sleeping person is choking. There are other ways to recognize acute laryngeal or partial airway obstruction other than snoring, such as gurgling noises, crowing, wheezing, cyanosis and laboured breathing, besides displaying the universal signs of choking called the Heimlich sign or the Café Coronary Syndrome. Normal physiological sounds of snoring when a person is asleep, is due to vibration of the soft plate, uvula, pharyngeal walls, or epiglottis when they are relaxed at sleep. It is only when normal physiological sounds deviate from the norm, that there may be an underlying cause or disorder.

Stridor:

In trauma cases, we can also assess the ventilatory status by listening for air entry, abnormality in the breadth sounds, heart sounds and a displaced apical beat. Noisy, harsh and high pitched sounds of breathing (stridor), snoring and gurgling noises are indicative of partial obstructions to the airways, while hoarseness of voice may be diagnostic for laryngeal obstruction. Still on sounds and listening, we can also percuss the chest walls on both sides to listen for resonance, namely for high or low-pitched percussion notes. In severe tension pneumothorax a high resonance is heard on percussion, with reduced or absent breath sounds, in contrast with dullness in the percussion notes with severe haemothorax. This is understandable, since if air enters the pleural spaces of the lungs as in pneumothorax, the percussion notes sounds hollow and empty, but if there is blood, fluid or pus to congest the lungs, the sounds are solid and dull. This is common sense. Percussion is an examination technique whereby an examiner taps the body lightly but firmly to determine the position, size, and consistency of an underlying structure, and the presence of fluid, such as blood or pus in a cavity. These conditions are established by variations in resonance and pitch of the sounds emitted, vibrations elicited and resistance encountered. Another example of signs detected is an assessment manoeuover designed to detect subluxation or dislocation of the hips. The examiner places the infant on the back with hips and knees flexed, at the same time abducting and lifting the femur. A palpable click may be felt as the femur enters the dysplastic joints (Ortolani’s sign). We can also palpate (feel) various parts of the body for any abnormality, say for broken bones. For instance, a physician can feel for hepatomegaly (liver enlargement), by palpating the upper right quadrant of the abdomen (below the border of the rib cage) over the lateral to rectus muscle. He may feel for tenderness, resistance and mass, especially during inspiration when the liver comes down from the diaphragm to meet the finger-tips. Likewise, for spleenomegaly (spleen enlargement) on the left side, and for any kidney enlargement (a bit more difficult, especially if patient is obese) etc, tenderness may be felt.

Signs:

As for measurement as a diagnostic sign, the measurement of blood pressure is a fine example that will provide us information (signs) of blood pressure status and is useful in monitoring the state of shock. We can also measure, (or simply look at it, if a physician is experienced enough) for tale-tale signs of any increase in the CT (cardiothoracic) ratio in cardiomegaly (heart enlargement), say in LVH (left ventricular hypertrophy) as seen on a CXR (chest x-ray). The normal transverse CT ratio is between 0.3 and 0.5. We can also elicit a response, such as the absence of abdominal skin reflex in intestinal inflammation or hemiplegia (Rosenbach’s sign), or signs of inability to maintain balance when the eyes are shut, and the feet close together (Romberg’s sign for ataxia), or elicit triceps reflex to detect spinal tract lesions at the cervical levels of C6, C7 and C8. All first-aiders and paramedics should be familiar with AVPU and the 15 point GCS score in assessing level of consciousness, or the Look, Listen and Feel signs for breathing. All these are diagnostic signs, as opposed to say a symptom of pain in a sprain, cramps, and in bends, or the sensation of giddiness in postural hypotension and low blood pressure in shock and severe anemia, or vertigo and tinnitus (ringing in the ears) due to disturbances in the equilibratory apparatus of the ears.

Syndromes:

A syndrome is a group of related signs and/or symptoms characterizing a particular disorder. In other words, syndromes mean ‘running together’. All the signs and / or symptoms are running together at the same time to form a distinctive clinical picture of a particular disorder. Most of the syndromes have names attached to them after the discoverer who first describe their clinical features associated with a disease. One or two examples are, Fanconi’ syndrome (a renal tubular disorder), and Dubin-Johnson syndrome (a chronic idiopathic jaundice) or Turcot’s syndrome (polyps in the colon and brain tumors, inherited as a recessive traits). Some have no names attached, such as orogenital syndrome (a nutritional deficiency disease), and foetal face syndrome. In trauma, very few examples can be cited. Syndromes generally don’t suddenly appear in trauma cases or in a sudden injury. Syndromes are more generally encountered in medical cases rather than in trauma cases or in injuries. Classical clinical features normally appear one after another during the natural course of a disease. It takes some time for these signs and symptoms to develop until they become the full blown features of the disease. Trauma and injuries like child-birth are not diseases per sec. Nevertheless, certain features do appear as post-trauma (medical) complications.

Acute Respiratory Distress Syndrome:

One example I can think of at the moment is adult or acute respiratory distress syndrome (ARDS) as a result of multiple fractures to the pelvis and long bones in adults. Fat emboli enters the lungs causing alveolar-capillary damage, thus giving rise to increased permeability and plasma leakage, with resultant non-cardiogenic pulmonary oedema. Signs and symptoms are rapid shallow breathing progressing to frank dyspnoea, cough, crepitation and cyanosis. Chest X-ray shows alveolar and interstitial infiltration, similar to pulmonary oedema, except there is no cardiomegaly (heart enlargement). PaO2 (partial oxygen) is less than 60 mm Hg. The profound impairment of oxygenation is largely due to shunting through the non-ventilated lung compartments. Another example is compartment syndrome associated with say an abdominal or a limb injury.

Compartmental syndrome:

Compartmental syndrome is a condition in which increased pressure in a confined anatomical space say in the chest or abdominal cavity adversely affects the circulation and threatens the function and viability of the tissues therein. Compartment syndrome in a limb injury for instance is characterized by an increasing pain, even though the fracture has been immobilized. There may be altered sensation in the dermatome of the nerves passing through that compartment. There is a palpable elevated tension and tenderness of the muscle compartment. There is also pain on passively stretching the muscles within the compartment. Another example is the anterior/central/posterior cord syndromes due to injuries of the spinal cord, each area giving rise to various sensations and pain. One example of a syndrome that I can think of that lies midway between a medical cause, and an effect similar to a shock in trauma, is toxic shock syndrome. The cause is actually due to staphylococcal endotoxic infection in the vagina of menstruating women using superabsorbent tampons. The condition is characterized by high fever, vomiting, diarrhoea, a scarlatinaform rash followed by desquamation. This is followed by decreasing blood pressure and shock, and possible death if not immediately treated.
The first-aid is to treat for shock if necessary even if it is a medical case, and not one due to an injury.

Other features:

There are other more complex definitions of signs, symptoms and syndromes of course, but we shall not go into them. Signs and symptoms in a patient / casualty are commonly encountered in the practice of conventional and naturopathic medicine, and also in first-aid. Patients come to you presented with all these signs, symptoms and syndromes (the 3S), and you just have to identify and sort them out, (differentially diagnose them from certain other conditions or diseases) before treating them. I just casually mention their differences here because I accidentally use the word ‘symptom’ when I started my article on bends, and I know of patients and lay people who were really confused by the usage of these words. So I thought to be on the safe side, I better mention some of their differences here with a few examples.


References:

1. Wenling, J. Normobaric Oxygenation as A First-Aid Measure In Decompression Sickness. Schweiz-Z-Sportmed. (1993 Dec.); 41 (4) : 167-72

2. de-Watteville, G. A Critical Assessment of Trendelenburg’s Position in the Acute Phase after a Diving Accident. Schweiz-Z-Sportmed. (1993 Sept; 41 (3): 123-5.