Wednesday, August 18, 1999

Massage — the forgotten therapy
By Dr K. C. Kanwar
Despite the sleazy image of the massage parlours, professional massage has entered the hospitals and the health clubs of the day and is very much a part of health and fitness. Massage is one of the oldest therapies known to man and has been practised since 300 BC. Hindus and Chinese scriptures in particular refer to a well-developed system of massage as a part of their ancient medical practices. Message as a curative therapy was also advocated by Greek physician Hippocrates.

The way to arsenic hell
By Moslemuddin Ahmed
DHAKA: In the wake of "the world's largest mass chemical poisoning of a population", hundreds of thousands of Bangladeshis and Indians face an agonising choice about their next drink of water.

Cutting edge of medicine

Taming diabetes in the young
By Dr R.J. Dash

Diabetes in the young is not uncommon and the number of the sufferers is increasing day by day. From an estimated 3.5 million in 1997, it will increase to over six million in the world by 2010. This increase is not strictly related to the projected rise in the younger population.

In Indians, the prevalence of diabetes in the young is only 1-2 per cent compared to that in the Caucasians — 20-40 per cent. A study in South Hall, London, has, however, revealed a comparable incidence in Indians and Caucasians. This speaks volumes for the environmental influence on the occurrence of diabetes in the young.

The classical disease occurs due to the destruction of the insulin-producing beta cells in islets of the pancreas. Obesity-related diabetes in the younger people (under 20 years of age), with a strong family history of diabetes is increasing in all ethnic populations.

The onset of diabetes in the young is explosive. Feelings of being unwell, rapid weight loss, passing large volumes of urine throughout the day and the night, excessive thirst, the dryness of the mouth and listlessness are recognised by all patients. Over one third of them are brought to hospital in coma caused by diabetic ketoacidosis. Unless promptly recognised and effectively treated, this alone carries over 20 per cent mortality. Left to ineffective treatment, most patients develop blindness, kidney failure, nerve damage and heart attacks. Normal longevity is generally reduced by 20-30 per cent. Effective treatment reduces the complications by more than 60 per cent and restores longevity in the majority of the sufferers.

For the total care of diabetes in the young a co-ordinated effort by the family, the patient, the family physician and the specialist is necessary. The family (parents or guardians) must view the illness as patently life threatening but effective treatment for it is within their reach. This will obviate any misguidance from untrained medical practitioners, the lure of "alternative" medicine and the long search for faith-healers. The feelings of helplessness, apprehension and divine appeasement should be replaced by basic education about diabetes, insulin treatment, the recognition of symptoms of uncontrolled diabetes and low blood sugar.

Grown-up children should learn about the insulin therapy, including the storage of insulin, the mixing of stored insulin, the proper care of the injection device (syringe, pen and pump), the injection technique and the way of self-monitoring of blood glucose by hand-held glucometers.

The family should be fully supportive of the prescribed diet and timely follow-up both by its family physician and diabetes specialist. It should also encourage children to do outdoor exercise and participate in diabetic camps. Physicians need to emphasise to the patient and the family the need for multiple insulin injections, food-timings in relation to the injection, exercise schedules and the care of minor ailments.

In the event of a diagnosis of diabetic ketoacidosis, they should arrange to shift the sick child to a specialised hospital for care without delay.

The loss of life due to diabetic ketoacidosis is distinctly linked to the delay in the institution of the appropriate therapy in a hospital setting. The expert physician should take the responsibility for the periodic review of diabetes-control and instituting measures for the prevention of diabetes-specific problems of the eyes (retinopathy), the kidneys (nephropathy), the peripheral and autonomic nerves and the heart.

Insulin treatment is the mainstay of the management for the majority of the patients. Obesity-related diabetes in the young with a strong family history of diabetes needs treatment through active attempts at weight reduction through diet modification, maintaining the ideal body weight and making an increase in physical activity. Blood-sugar-lowering drugs and/or insulin are required only when their diabetes remain uncontrolled despite optimum physical activity and the maintenance of the ideal body weight.

Today, all forms of insulin (soluble, mixed, long and intermediate-acting) and species-specific (human, porcine, bovine, bovine-porcine mixed) are available in India. The potency of human and animal insulin is similar. Animal insulin is relatively cheap. In many western and industrialised or rich Asian countries insulin extracted from animal pancreas has been withdrawn and biosynthetic human insulin is available. Although, the use of animal insulin provokes the formation of antibodies to insulin in man, this very rarely alters the insulin effect.

The effect of injected insulin differs from that of insulin secreted by our pancreas. The injected insulin is slow to act and its blood-sugar-lowering effect stays longer. It thus fails to reduce the post-meal rise in a timely way in glucose and may cause late-post-meal hypoglycaemia. By giving the insulin injection 30-45' prior to mealtime, the peak effect of insulin is matched with the maximum rise in blood glucose after a meal. Children being selective and fussy about food, the insulin effect is sometimes mismatched to the quantity of the food ingested. This carries the risk of hypoglycemia, overeating and weight gain. The problem has been largely reduced with the availability of insulin Lys-pro (Humalog). This novel insulin analogue has an early onset and a shorter duration of action. So, this can be injected even after the meal is taken by a child, reducing the risk of hypoglycaemia.

Besides frequently monitoring fasting and post meal blood glucose by hand-held glucometeres and glycated haemoglobin at three months' intervals, plasmal lipids, protein loss in the urine and eye examinations need to be undertaken once a year. The child's growth and development also need a close follow-up. In fact, the increase in age-adjusted height is a good marker of diabetes control.

In adolescent girls, diabetes control generally becomes difficult requiring expert guidance.

Sometimes, blood glucose remains normal without any insulin injection for weeks or months. This is described as a "honeymoon phase" in the course of diabetes. Parents mistake this as the cure of diabetes and ignore the scheduled visits to the diabetic clinics. During this period, instead of the total omission or insulin, the patient needs to be given the medicine in small quantities to provide rest to the surviving insulin-producing cells. This may prevent diabetic ketoacidosis in the long run.

Psychosocial management of diabetes in the young needs a special mention. It is common knowledge that stress hormones increase blood glucose, offsetting control. Altered eating habits or growing children, together with the stress of adolescence, cause fluctuations in blood glucose from hypoglycaemia to dangerously high hyperglycaemia. Such children require composite advice by the psychiatrist, the family physician and the diabetes specialist for the optimum care of his or her diabetes.

The author is the Professor and Head of the Department of Endocrinology at the PGI, Chandigarh. He has been an honorary consultant to the Armed Forces, besides being a philanthropic adviser to several Indian and foreign institutions.

Massage — the forgotten therapy
By Dr K. C. Kanwar

Despite the sleazy image of the massage parlours, professional massage has entered the hospitals and the health clubs of the day and is very much a part of health and fitness. Massage is one of the oldest therapies known to man and has been practised since 300 BC. Hindus and Chinese scriptures in particular refer to a well-developed system of massage as a part of their ancient medical practices. Message as a curative therapy was also advocated by Greek physician Hippocrates.

How do we define massage ? The treatment of superficial parts of the body for therapeutic purposes by systematic rubbing, stroking, kneading or slapping, applied manually or with the help of electronic devices, comprise massage. Manual massage to be curative, however, requires the skilled hands of a physiotherapist or of a qualified massager (masseur).

Allopathy — the widely accepted system of medicine — ignored for quite some time the curative efficacy of massage. However, in view of the convincing physical, physiological and psychological explanations now available as to what massage can and cannot achieve, lately even allopaths have started patronising it. Physiotherapists, in particular, depend heavily on massage for keeping the bodies of athletes and players maximally agile and supple.

Physiologically, massage achieves many things. Gentle massage relieves tension and anxiety, provides relief from headaches, overall body stiffness and even from chronic neck and back pains. It relaxes muscle spasm, relieves muscular twitching, and improves the muscle tone. It also restores the increased motion of the joints, muscles and tendons. It softens intramuscular adhesions, formed by disease, injury or as a consequence of ageing. It even lessens fibrosis which inevitably develops in immobile, injured or denervated muscles.

Regular massage even adds to the muscle mass and makes these firmer, stronger and more elastic. It is also effective in fighting muscle fatigue, making these withstand repeated exercisal rigours which, in turn, increases muscular strength and endurance. Further, massage-relaxed muscles reportedly heal faster and get less prone to fatigue. With massage, muscles stay in the best possible state of nutrition, and flexibility thus minimising the effect of trauma or disease on muscle functions. However, massage does not prevent atrophy of the denervated muscles.

Massage does not only improve blood and lymph circulation; it also acts as a mechanical cleanser hastening the elimination of the accumulated metabolic waste. Besides, it tones up contraction as well as relaxation of the muscular walls of the blood vessels elsewhere by improving nerve reflexes.

Even though massage per se does not heal the bones, as mentioned in folklore, it has been widely used in the management of fractures — in fact, it is still being used in traditional systems of medicine. Even allopathy accepts that massage is beneficial in repairing the injuries in the soft tissues accompanying the fracture.

Following gentle massage over a few weeks by a trained masseur, the skin reportedly improves both in texture and appearance. Massage does produce useful effects on the skin surface primarily by hastening the removal of the superficial dead cells and by improving skin circulation which, in turn, tones up the functioning of the sebaceous and sweat glands vital for healthy skin.

Massage reportedly increases haemoglobin and improves the RBC count and so is recommended for the convalescents and the aged. As to how this is achieved is difficult to explain. The local massage for the viscera, if done by a trained massager, is effective in increasing peristaltic action to promote evacuation. Appropriate abdominal massage may also improve portal circulation and thence liver functioning. However, an untrained massager should desist from undertaking abdominal massage ; it could be counterproductive.

Anointing (massage) using oily lubricants had been in use as an ausager of pain ever since massage was accepted as a therapeutic tool. Many oils and bizarre animal fats have been used for increasing the curative efficacy of massage. Medical opinion, however, is against it. Oils are considered beneficial only when the skin is dry and scaly or when massage is being done for mere relaxation. The majority of the workers seem to favour dry massage for the simple reason that it is non-messy and provides the real touch of the fingers of the massager, making it more stimulatory. Those who favour the use of the lubricants hold

the view that these make skin soft, smooth and the massage more relaxing. The selection of emollients is a personal choice, since there is not much medical efficacy attached to it anyway.

In order to derive the maximal benefit, massage should be performed only by those skilled in the technicalities of it and also those who have the basic knowledge of the human anatomy. Much harm can be done to muscles and joints, if massage is too strenuous and also if it is done wrongly. Massage in legs and arms, in particular, should be applied in the direction of venous blood flow, i.e. it should start from the extremities (distally) and directed towards proximal ends. Generally, we indulge in longitudinal stroking in the opposite direction which interferes with the returning venous flow of blood. For the fatigued legs, gentle rubbing, squeezing and kneading of calf and thigh muscles with the thumb and fingers with or without revitalising products is beneficial.

It is said that “ nothing more destroys an otherwise good massage than physical coldness and hence, ideally speaking, massaging should be done in a room which is warm and free of drafts.

There are certain things which cannot be accomplished through massaging.

(i) Massage, as erroneously claimed, cannot remove undesirable deposits of fat nor can it reduce weight. (ii) Massage is contraindicated in an area of inflammation radiating pain. Massaging in such cases facilitates the spread of the infection. (iii) Massage is not effective in managing baldness. However, light stroking with finger tips on the scalp, improves the blood supply to the area, thus energising the hair follicles which could stimulate the growth of the hair already present.

The miraculous healing effects of massage, as reported by a few, are attributable to the so-called “faith therapy”. Even science acknowledges faith healing provided by the “ touch of the divine”. Massage, in fact, is an extension of touch and pressure. Apparent cures in this area are considered akin to the placebo effect — some people feel better even when administered a pill having no medicine in it. Faith therapy works as meditation or prayer does.

lately, new physiological explanations have been advanced in favour of massage. Gentle massage is considered soothing to the sensory nerves and is relaxing. Massage reportedly increases body oxytocin levels which, in turn promote the feelings of affection, elation and well-being. Body massage is also said to increase the levels of endorphins — the body's transient pain (tiredness) relievers and mood-elevators which act as body-relaxers.

Dr Kanwar is the former Chairman of the Department of Biophysics, Panjab University, Chandigarh.

The way to arsenic hell
By Moslemuddin Ahmed

DHAKA: In the wake of "the world's largest mass chemical poisoning of a population", hundreds of thousands of Bangladeshis and Indians face an agonising choice about their next drink of water.

Do they continue drawing from wells marked red for danger because of arsenic contamination, or do they drink dirty pond-water that may make them sick now?

"What else can we drink?" asks Manwara, standing between one of the problem wells and a polluted pond in the northern Bangladeshi village of Miapur, where the tubewell alarm was first sounded after the death of a housewife from arsenic poisoning. Nine out of 13 other members of her family are also ill.

The crisis is still unfolding. The man who first blew the whistle on the major development disaster, environmental chemist Dr Dipankar Chakraborti, claims the Government "is still sleeping. They do not realise how big is the problem." And many people in India's West Bengal are not even aware of the danger that threatens them.

There are no easy answers, though the organisations responsible for the crisis, including the UN Children's Fund (Unicef), are busy looking for new sources of clean water. "Some people will die," admits. UNICEF head Carol Bellamy. "We have to do something about it. We have to be part of the solution, having been also part of the problem."

Options under scrutiny include small-scale water-treatment plants, collecting and preserving rainwater and sinking tubewells deeper than those which caused the problem in the first place.

The United States of America has promised $267,500 for a feasibility study for cost-effective water treatment. UNICEF, which faces the threat of legal action over its failure to give earlier public warnings about the dangers of arsenic contamination, seems to favour the new wells option, though this will mean drilling 900 feet to get below the arsenic levels.

The tragedy is all the more poignant in that it began 25 years ago with the best of intentions: to bring clean water to all.

In the headlong rush to improve water and sanitation facilities, UNICEF, working with the Bangladesh Government, designed and supplied one million hand-pumped wells to almost all the country's 68,000 villages. Following their lead, people dug another three million wells.

The drive was heralded as a development triumph, and played a part in halving the rate of child deaths in Bangladesh. — Reuters

(To be concluded)

Cutting edge of medicine

Light, sight and workers
LONDON, Aug 17 (DPA) — Flickering computer screens and fluorescent lighting are making millions of office workers ill, according to a new survey in Britain.

Almost one in three persons said they suffered from headaches, eye-strain or stress when using their computers or working under fluorescent light.

Bad lighting was said to contribute to migraine, which lost British businesses 18 million working days a year and cost the economy around 750 million pounds.

The survey was conducted last month and covered more than 1,000 people throughout Britain.

The poll marked the launch of a new kind of spectacle lens designed to filter out the flicker in TVs, video display units and fluorescent lights. Freshlite glasses, developed in conjunction with the British Medical Research Council, are said to help prevent headaches and eye-strain.

Ophthalmic expert Peter Wilkinson, who invented the lenses, said: "Light remains one of the great unknown pollutants in the UK. We are all bombarded daily with bad light from TVs, computers and fluorescent light.

"Freshlite solves this problem by filtering out the harmful elements. It's a real scientific breakthrough that can genuinely help headache sufferers".

Stomach cancer biggest killer
BEIJING, August 17 (PTI) — Stomach cancer has emerged as the biggest killer among all the types of cancers in China, accounting for 23.24 per cent of the deaths, highest in the world, caused by the deadly disease, an official report said.

Statistics from a tumour hospital under the Chinese Academy of Medical Sciences said the death rate due to stomach cancer in the 1990s in China was 30.12 per 1,00,000 for male, and 13.8 per 1,00,000 for female, accounting for 23.24 per cent of the death caused by cancers.

In the past 20 years, the death rate among the male patients with stomach cancer had risen 10.98 per cent while the same among the female patients being 6.32 per cent, Xinhua news agency said.

Doctors found that the rural people were more susceptible to stomach cancer than those living in the urban areas. The figure in urban areas was some 19.44 per 1,00,000, which was 25 per cent lower, while that in the rural areas it was 27.16 per 1,00,000, showing a 25 per cent increase.

Doctors explained that improved living conditions, nutritious diet and healthy life style among the urban residents had been the main causes for the decline in stomach cancers among the urban Chinese. While the intake of pickled food, smoking, psychological factors and stomach ailments had caused an increase in cases of stomach cancer among rural residents.

Ageing had been another major factor. Surveys showed that in the past two decades, the penalty rate among the people between 20 to 59 had dropped, while that for the people above 60 had shown rapid increase.