Acupuncture Analgesia Terence M.
Murphy, MB, ChB, John
J.
Bonica, MD
\s=b\ After the war of liberation, Mao Tse Tung encouraged an integration of Western and traditional Chinese medicine. Several schools of therapeutic acupuncture have defined different points of puncture, originally assumed to be on an empiric basis but now rationalized as areas where nerve endings congregate. Results of therapeutic acupuncture in China cannot be evaluated because of inadequate record keeping. At the University of Washington Pain Clinic, immediate results (two to three days) are good but never lasting, nor do they decrease concomitant medication. For anesthesia, acupuncture acts to produce only hypalgesia in most patients, although some experience total analgesia. Patient selection and mental preparation are careful. Hence, the method is used in much less than 10% of the operations in China, and in these the analgesia is satisfactory by Western standards in only approximately 30%. Concepts as to the mode of action of acupuncture analgesia range from an attitudinal change towards sensory input to the release of a neurohumoral analgesic substances. (Arch Surg 112:896-902, 1977)
his book, The I stated:
Doctors
Dilemma, George Bernard Shaw1
There is no harder scientific fact in the world than the fact that belief can be produced in practically unlimited quantity and intensity without observation or reasoning and even in defiance of both, by the simple desire to believe founded on a strong interest in believing.
He
enlarges
on
this
by reminding
us
that although everybody recognizes the validity of this quotation in the case of amatory infatuations, that it does, however, hold good over the entire field of human activity where doctors are no more proof against illusions than other men.1
Thus, following the initial dramatic reports regarding acupuncture anesthesia in the People's Republic of China by B. Reston (New York Times, Aug 22, 1971, section 4, 13) and Diamond,2 who were among the first Americans to visit that country after a quarter of a century of closed-
door policy, there developed an almost incredible degree of interest in acupuncture therapy and acupuncture anesthe¬ sia. This was accompanied by many misconceptions among the American public and many physicians about the true role of the procedure. The dearth of evidence did not permit reasoned scientific judgment as to the efficacy and mechanisms, but, despite this, widespread false impres¬ sions developed among Americans about the claimed success of acupuncture. This was in part due to these early reports made by Americans, including some highly respected scientists who, though well-meaning, did not Accepted
publication Dec 28, 1976. Department of Anesthesiology and the Pain Clinic, University of Washington School of Medicine, Seattle. Reprint requests to Department of Anesthesiology, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104 (Dr Murphy). From the
for
and Anesthesia
have the expertise to critically evaluate their observa¬ tions. These misconceptions prompted a widespread interest in acupuncture and caused it to be practiced extensively by physicians, other health professionals, and "acupunctur¬ ists" in the United States and other Western countries. Some of these used the method in an ethical, albeit empirical, fashion, and others have done clinical studies and observations. However, some unscrupulous persons have exploited the public's interest by operating their acupuncture "centers" like "mills," treating several hundred patients daily and charging exorbitant fees. Moreover, the interest and curiosity of many physicians has been exploited by the numerous groups who have sponsored many courses and by a large number of acupunc¬ ture equipment companies that sell a variety of charts, needles, and "do-it-yourself kits." Outside of a few wellcarried-out clinical trials, most of the "studies" reported in the recent Western literature are of an anecdotal and uncontrolled nature. Fortunately, further evidence was obtained during visits by official medical missions from several Western coun¬ tries, including the United States,'~:' and subsequently, by the group of anesthesiologists and other scientists who visited China for an in-depth study of the use of acupunc¬ ture for surgical anesthesia." These, together with the results of clinical and other studies, now permit a more realistic appraisal of the phenomenon of acupuncture analgesia and anesthesia. It is the purpose of this article to attempt to clarify the current status of our knowledge of acupuncture and its therapeutic potential. It is important at the outset to emphasize that its use for the therapy of chronic pain (therapeutic acupuncture) and its use to produce surgical anesthesia (acupuncture anesthesia) are different phenom¬ ena in many respects. (Its claimed success in making the deaf hear, the blind see, and the halt walk, or its other nonanalgesic uses, are yet another controversy and will not be considered here.) This account will be presented as follows: an outline of Chinese traditional medicine to provide a background for discussion of the use of acupuncture, an appraisal of therapeutic acupuncture, and an appraisal of acupuncture anesthesia. Possible mechanisms of action will then be discussed. More detailed and comprehensive reviews can be found in national reports'" and the detailed accounts by Bonica.7 s
TRADITIONAL CHINESE MEDICINE
Medicine in China dates back several millennia. The Huang Ti Nei Ching Su Wen, or The Yellow Emperor's Classic of Internal Medicine," is the earliest medical classic in China, written between the eighth and fifth centuries BC. It consists of 18 volumes covering a great variety of
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subjects, including the theory of diseases, their etiology, diagnosis, and treatment. In the book, man is seen as a microcosm of the universe and therefore subject to the same tension disruptions as nature itself. The immutable course of nature, the Tao, is believed to act through two opposing and unifying forces: the Fuz-the feminine, negative, and passive force, and the Yang—the masculine, positive, and active force. In a
normal person, the two opposing forces are in balance and assist the vital energy, called the chi, to circulate to all parts of the body via a network of 14 channels or merid¬ ians, each connected to an important organ. Obstruction (deficiency) and outpouring (excess) in the circulation of the chi causes an imbalance of the two forces and thus results in disease. Diagnosis is made by studying the patient's behavior, coloration, respiration, and complaints, but, most impor¬ tant, by palpating the radial pulse. Six pulses, each repre¬ senting an organ or system, are located at each wrist. Therapy consists primarily of acupuncture, moxibustion, massage, physical exercises, and dietary regimens. Acupuncture therapy at one or more of the 365 specific points located along the meridians corrects the imbalance and thus eliminates the disease. Disease is not regarded as a local process, but affects the entire body and is often influenced by emotional and behavioral factors. During the ensuing two millennia, the book underwent numerous revisions and it remained a standard work in traditional medicine. Moreover, therapeutic acupuncture continued to be refined. A number of books exclusively devoted to the subject were published, and the method spread to Japan and other Asiatic countries, and in the 17th century, it was introduced in Europe. With the introduction of Western medicine in China, traditional medicine in general and acupuncture in partic¬ ular began to fall into disrepute as being nonscientific. In 1822, the Great Imperial Medical Board ordered the virtual abandonment of acupuncture on ethical grounds. Chinese intellectuals came to regard Chinese medicine as oldfashioned and a hindrance to the modernization and devel¬ opment of their country. In 1929, the Kuomintung govern¬ ment banned the practice of traditional Chinese medicine, including acupuncture. Despite this, the populace, particu¬ larly in rural areas, continued to believe in and use acupuncture and traditional medicine. Moreover, before the Chinese communists' victory in 1949, which they call the "War of Liberation," there were only about 20,000 to 30,000 Western-trained physicians, most of whom prac¬ ticed in the large coastal cities and cared only for the foreign and rich Chinese population. Since 80% of the 550,000,000 people in China at the time lived in rural areas, they had virtually no benefit from Western-trained doctors, but relied on the estimated 400,000 traditional practitioners. Before the "War of Liberation," inadequate health care, poverty, frequent famines, chronic malnutri¬ tion, and poor housing were the reasons China had one of the highest mortalities and lowest life expectancies in the world. Soon after "liberation," impressive programs to improve food production, housing, and medicine were initiated. Mao Tse Tung set forth four concepts of health care: (1) to serve
the
workers, peasants, and soldiers; (2) to put prevention first; (3) to unite Western and traditional Chinese medi¬ cine; and (4) to coordinate medical campaigns with mass movements. The integration of traditional and Western medicine was repeatedly stressed by Chairman Mao, who stated, "Chinese medicine and pharmacology are a great treasure house; efforts should be made to explore them and
raise them to higher levels."7 The old-type doctors were urged to abandon conservative prejudices, accept new knowledge, study science, and cooperate with Westernstyle doctors in order to increase their competence. By the same token, Western medicine "must study the popular and widespread spirit of Chinese medicine." One of the most important results of the nationalism and ferment of the great proletarian cultural revolution that took place during the years 1966 to 1969 was the renewed emphasis on traditional medicine. It was given equal status with Western science and medicine, its practitioners were restored to favor, and a vigorous program was mounted to effect the true merger of the two schools. Medical schools, hospitals, and other health care facilities frequently had Western-trained doctors working alongside the traditional
practitioner.
CURRENT STATUS OF THERAPEUTIC ACUPUNCTURE In compliance with the aforementioned health policies and due, in part, to the influence of Western medicine, therapeutic acupuncture has undergone significant changes during the past several years, but especially since the Cultural Revolution. Much effort has been devoted to the improvement of the selection of patients and to techniques by means of clinical trials. Moreover, there has been a significant change in attitude toward traditional concepts in order to make acupuncture acceptable to Western physicians.
Techniques There are now several methods of therapeutic acupunc¬ ture, but that involving insertion of needles in specific acupuncture points is the most commonly used. The needles are made of stainless steel, usually 1 to 10 cm in length, and are of four or five standard sizes, with diameters ranging from 0.4 to 0.28 mm. The selection of acupuncture points varies greatly and depends on the disease being treated and the acupuncture school being followed. The old traditional schools used acupuncture points throughout the body. The number used varied from source to source (although there is some uniformity with regard to certain points) and in its practice could involve the use of as many as 800 of these points distributed around the body surface, or as few as one or two discrete points. The traditional practitioners related these points to organ meridians as dermal repre¬ sentations of internal organs, both real (eg, heart) and unreal (eg, "triple warmer"). More contemporary acupunc¬ ture "science" views these points as aggregations of nerve endings, the stimulation of which produces patterns of activity within the nervous system that is allegedly respon¬ sible for its effects. The practice of acupuncture is difficult to define because
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an incomplete transition of what was originally a philosophy into a scientific practice. However, by and large
of
it appears to involve the insertion of needles into these socalled points following one of three patterns. They may be inserted into specific points along the so-called organ meridians, and these points may bear little anatomical relation to the organ that is being treated, or needles may be inserted only in the ear. This technique, developed by Nogier1" of Lyon, France, maintains that the whole body image is projected on the ear, and therefore needling can be restricted to this organ alone. Finally, there are those who insert needles into the appropriate areas of the body where the pain is felt, eg, for arm pain, the needle would be inserted in the arm, that is, into structures supplied by the same spinal cord segments as the painful area. In many instances, a combination of acupuncture points is used. The needle is inserted and advanced until the te ch'i is experienced by the patient. This is described as a feeling of tingling, distention, heaviness, and numbness. Stimula¬ tion is achieved either manually, through a push-pull and rotatory movement, or by electroacupuncture. Manual stimulation is carried out for 10 to 15 minutes and the needle is either removed or left in place, and after an interval of time the procedure is repeated. In recent years, electroacupuncture has gained widespread use because it produces continuous stimulation over longer periods of time with much less effort on the part of the operator, because the strength of stimulation can be adjusted according to the needs of the patient, and also because a stronger stimulation can be achieved than with manual stimulation. The number of treatments depends on the type of disease and its severity. Acute diseases are treated one to three times daily until the condition improves. In the treatment of chronic disease, acupuncture is done daily or two to three times a week, for a total of 10 to 20 treatments. Other forms of acupuncture include the injection of sterile water, saline, procaine hydrochloride, morphine sulfate, vitamins, or other medication into acupuncture points. "Thread acupuncture" involves the insertion of a surgical needle threaded with catgut through one acupunc¬ ture point and out another. The catgut thread is left in place to produce persistent stimulation for several weeks until it is absorbed. "Pressure acupuncture" or "acupres¬ sure" consists of the application of pressure on the skin overlying the appropriate acupuncture points for a period of several minutes. Cutaneous needle acupuncture involves the application of numerous short (0.5 cm) needles placed either on a roller or on sticks and applied lightly on the skin overlying the acupuncture points. Moxibustion involves the use of a smouldering piece of dried moss (Artemisia vulgaris) that may be applied directly on the skin over the acupuncture points, held at a distance from the skin, or placed on the shaft of an acupuncture needle. It is there¬ fore important when discussing acupuncture therapy to define the specific modes and sites of stimulation, since it varies considerably in use by different practitioners. Clinical Applications Acupuncture has been used extensively in China for centuries for the treatment of various pain states. These
have and continue to include musculoskeletal pain such as chronic back pain, arthritis, and cervical spondylosis; neuralgia, including trigeminal neuralgia and lumbosacral neuralgia (sciatica); headache, especially migraine, head¬ ache due to emotional tension, spasm of neck muscles, hypertension, and that due to disorders of the ear, nose, and throat; and visceral pain, including the primary treat¬ ment of acute appendicitis, cholycestitis, gastritis, cholecystolithiasis, peptic ulcer, and renal colic. Surprisingly, one of us (J. J. B.), during a visit to the People's Republic of China, was consistently told that acupuncture was of no value in the treatment of chronic pain produced by cancer and other neoplastic diseases. Despite its long and very widespread use and the claims for a high degree of efficacy of acupuncture in treating pain and other nonsurgical disease, no hard scientific data are available to support such claims. In fact, in many health stations and even in some hospitals in China, no records are kept either of the patient's medical history or of his or her response to
therapy.
Information with regard to its use in treating pain problems in Western patients is now accumulating. At the University of Washington Pain Clinic, a self-selected series of 100 patients suffering from chronic pain refrac¬ tory to other forms of conventional therapy undertook a trial of acupuncture analgesia at weekly intervals.11 Although the initial results were often spectacularly successful, following the third treatment, long-term benefit from acupuncture analgesia was as disappointing as other forms of therapy for this intractable group of patients. None of the 100 patients showed any continued objective evidence of pain relief, ie, medication intake and functional impairment continued despite claimed subjec¬ tive relief in a small percentage of the patients. Only three out of the hundred patients claimed long-term (upwards of three months) pain relief from a course of acupuncture therapy. A greater number (15%) would maintain subjec¬ tive relief provided they underwent acupuncture at approximately weekly intervals, but they did not, as a result of this claimed relief, decrease analgesic medicines or improve their activity levels. Similar patterns of response to acupuncture therapy for chronic pain states have been noted by other investiga¬ tors.1- In a well-controlled clinical trial, Lee and associates1 demonstrated that it did not matter if the needles were inserted in traditional meridian points or in "control" points. The results were similar: temporary relief. Only 18% of their 261 patients obtained good relief (15%) beyond four weeks after a series of four acupuncture treatments. In self-limiting temporary pain problems such as posttraumatic pain after sporting injuries, acupuncture can be efficacious in relieving pain temporarily and may well be a useful therapeutic maneuver in such short-lived problems,'though whether this is an improvement on conventional therapies remains to be determined. '
ACUPUNCTURE ANESTHESIA Acupuncture anesthesia is not really anesthesia, but more correctly an analgesia, since sensations other than pain are maintained. In contrast to its use for therapy, which goes back several millenia, acupuncture anesthesia is
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new development, first used in 1958. Every report the subject published in China credits "Chairman Mao's Proletarian Medical and Public Health Line" as the impetus for its development. Apparently prompted by the simple question, "If acupuncture relieves pain of medical disorders, why not use it to prevent pain of surgery," it was first employed to relieve posttonsillectomy pain, and subse¬ quently during the changing of wound and burn dressings, for teeth extractions, tonsillectomy, and other simple a
relatively on
operations.
The initial reports created a great deal of excitement and interest among health-care professionals and the Chinese public for two important reasons. First, acupunc¬ ture anesthesia held the promise of helping to solve a serious health care problem—the lack of a sufficient number of trained anesthetic personnel. At this time, anesthesiology, which was started as a discipline a few years earlier, was at a very early stage of development, and virtually all of the small number of trained anesthesiolo¬ gists and nurse anesthetists practiced in large hospitals in urban areas. Consequently, the anesthetics given in rural areas (where 80% of the population lived) were adminis¬ tered by untrained personnel, resulting in a high incidence of complications. A second and equally important reason for the interest that was generated was the fact that acupuncture anesthesia was an exclusively Chinese inven¬ tion unrelated to Western medicine, which still bore the taint of "Western imperialism." Despite the initial favorable impact, acupuncture anes¬ thesia did not become as widely used as had been expected. In fact, during the early 1960s, it was virtually abandoned in many hospitals. One authoritative textbook states that less than 10,000 cases were done in the entire country during the first eight years.13 However, during the Cultural Revolution, there was a great impetus to reintroduce acupuncture anesthesia and expand its clinical use as part of Chairman Mao's movement to fully integrate Western and traditional medicine. Current Status Reports by most early visitors to China gave the lay public and the medical profession of the United States and other Western countries the impression that acupuncture anesthesia was being used widely for many, if not most, operations and was highly effective in most cases. However, Bonica* and others4" found this not to be the case. Bonica computed that it was being used in much less than 10% of the surgical operations done throughout China and, in fact, based on other data, he computed that the figure was more like 1% to 2% of the operations done in China during the seven-year period prior to 1973." Moreover, although a few of these patients undergo the total operation with just acupuncture analgesia, most of the patients require supplement in the form of preanesthetic medication, intravenously administered narcotics, and, in some instances, supplementation with local anes¬ thetic infiltration of the wound and other pain-sensitive structures.
The claim that acupuncture anesthesia is effective in about 90% of the patients-a figure that has been accepted in a report by many other visitors to China-is also
incorrect. This is based on the personal observations of Bonica* and others'" and also is suggested by the data published by the Shanghai group,1' which involved 80,000 patients given acupuncture anesthesia for more than 100 different types of operations. Table 1 lists the criteria used by the Shanghai group and Table 2 contains some of the data on their results.8 The Chinese considered grades 1, 2, and 3 as being effective, and when added they give the overall success rate of 94%. The data, particularly of those operations on the head, neck, and thorax, which are considered the most suitable for acupuncture, show that the pain and reflex responses to noxious stimulation occurred in most of the patients and therefore acupuncture must be considered as unsatisfactory when compared with successful regional or general anesthesia. Their data show that the response in only 30% of their patients really would be considered satisfactory by Western standards.48 The advantages claimed for acupuncture anesthesia include: 1. There is complete safety, because the physiology of the patient is not disturbed. 2. Acupuncture per se has a tonic or regulating effect on the body functions, and since the patient is awake, his brain "is in the most active state" and can regulate body functions and thus overcome the disturbances caused by the surgical disease and the operation. 3. Acupuncture needling is said to have a sedative and antiinflammatory effect, so that patient's conditions "are rarely complicated by postoperative infection." 4. During the operation, the patient is awake and can cooperate with the surgeon, as, for example, in thyroid surgery, where it is important to identify the recurrent laryngeal nerves. Moreover, the patient can take fluids by mouth. 5. Because the technique is simple, convenient, inexpen¬ sive, and requires no elaborate equipment, it can be done by "barefoot doctors" and other paraprofessionals who have not had training in drug anesthesia. This is especially important in view of the shortage of trained anesthesiolo¬ gists in rural areas of China. 6. There is no residual postanesthetic depression or morbidity, nor is there nausea or vomiting, so that the patient can take nutrients by mouth immediately on returning to the ward. Disadvantages of acupuncture anesthesia include: 1. There is a lack of complete analgesia. It is generally acknowledged that, while acupuncture raises the patient's pain threshold, it does not completely eliminate the sensa¬ tion of pain, which in some patients is severe enough to require supplemental anesthesia. 2. Acupuncture does not produce muscle relaxation, so that operations within the abdomen or other procedures requiring relaxation are more difficult. 3. Traction on abdominal viscera often provokes pain, nausea, and vomiting. 4. In intrathoracic operations with lung collapse, the patient can experience dyspnea and other uncomfortable sensations that are at times severe. The selection and preparation of patients are empha¬ sized by the Chinese. Patients are said to always have a choice, and, indeed, many request acupuncture or volunteer
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Table 1.—Criteria for Evaluation of Results of
Acupuncture
Anesthesia*
Gradet
periods of patient calm
Pain
Brief
mild
pain;
Periods of moderate
pain, but operation could still be accomplished
Obvious
Severe
Mild
Moderate
Marked
pain
Changes
Little
Supplementation Meperidine hydrochloride, mg/kg/hr
1.0-1.5
1.0-1.5
1.5-2.0
Necessary
Local anesthetics
None
Small dose
Moderate dose
in blood pressure, heart rate, & respiration
or none
to anesthesia
change
to
drug
Necessary
to
change
to
drug
Necessary
to
change
to
drug
anesthesia
Operating
conditions
Good
Satisfactory
Fair
anesthesia
"From Bonica."
fi indicates excellent; 2, good; 3, moderate, Table 2.—Results of No. of Patients
Operation Craniotomy Thyroid Pulmonary resection Heart
(N
3,457)
and 4, poor
or
failure.
Acupuncture Anesthesia* Grade (% of cases)" ,-·-, 12 3 4
606 670
34 54
35 31
26 10
4 5
Effective Rate (%)t 96 95
656 172
17
26 51
52 16
4
96
24
8
92
763 590
16
45
34
4
96
34
40
11
13
87
30
37
27
6
94
=
Subtotal
gastrectomy Hysterectomy Mean % of total
...
"From Bonica." t1 Indicates excellent; 2, good; 3, moderate; and 4, failure. JGrades 1, 2, and 3 combined.
as 50 used initially to as few as one or two. Although each school differs as to the site and number of acupunc¬ ture points selected, most individuals produce either manual or electrical acupuncture for a period of 15 to 20 minutes as induction, prior to the surgery. During surgery, the patient may receive 75 mg of meperidine hydrochloride or 5 to 8 mg of morphine sulfate intravenously by contin¬ uous infusion. During the operation, the patient is contin¬ uously supported psychologically by every member of the surgical team. Emphasis is made for the surgeon to perform an operation with "steady, sure, light and quick movements." The surgeons are well trained, highly skilled, and use the most modern surgical techniques. In the event the patient experiences discomfort, he is encouraged to breathe as instructed, is continuously supported, and is asked to mobilize positive mental activities.
many
Complications for it. Those patients who manifest anxiety, apprehension or fear, or express any reservations are considered not suitable, because invariably sufficient analgesia does not develop and they often will require drug-induced anesthe¬ sia. Once the decision is made to use acupuncture, the surgical team and the patient carry out "ideologic and material preparation" in advance of the surgery. The patient is often involved in the discussion of the surgical operation and is informed about all of the conditions that may be experienced. Emphasis is placed on the surgical team manifesting confidence in the procedure and being sensitive to the emotional and physical needs of the patient. Most patients receive preanesthetic medication, usually consisting of a moderate dose of a barbituate or other sedative on the night before, and a narcotic (eg, 75 mg of meperidine hydrochloride or 8 to 10 mg of morphine sulfate) one hour before surgery. Patients scheduled for intrathoracic operation receive special preparation for five to seven days prior to surgery, during which time they are given instructions for special diaphragmatic breathing exercises that are said to prevent cardiorespiratory distur¬ bances usually produced by surgical pneumothorax. In regard to the technique used: with experience, the number of needles has been gradually reduced from as
It is
appropriate to say a few words with regard to the complications of this form of therapy. These are actually very few if used responsibly by individuals knowledgable in basic anatomy and pathology. Only one case of death due
acupuncture can be found in the literature.1" This was due apparently to puncture of a pericardial blood vessel, with subsequent tamponade. Obviously, by inappropriately introducing acupuncture needles into the pleura, pneumo¬ thorax would be a very definite risk of this therapy and has been reported.17 The transmission of infection could certainly be a factor if sterility of technique was not. observed. Tissue trauma to such vital structures as the eyes, CNS, etc, would hopefully be avoided by anybody competent in knowledge of anatomy. A very real possible complication of acupuncture therapy is the withholding of more appropriate therapeutic measures; for example, treating, acute appendicitis or perforated ulcer with acupuncture could lead to a deterio¬ ration in the patient's condition by withholding more appropriate surgical therapy. Also, the use of acupuncture therapy for malignancy could permit the neoplastic process to advance beyond the resectable stage, where it might have been more appropriately treated, with a better chance of success at an early stage of the disease, by surgery, to
radiotherapy,
etc.
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MECHANISMS OF ACUPUNCTURE ANALGESIA The traditional explanation of restoration of energy balance is not an acceptable explanation for contemporary understanding of acupuncture. This is somewhat akin to the caloric and phlogiston theories as explanations of inflammatory processes and would invoke the existence of an alternative biological system other than those of conventional physiology and anatomy. It is, perhaps, with neuronal interaction that any mech¬ anisms of acupuncture might be best explained on a physiological basis, and the efficacy of acupuncture anes¬ thesia certainly appears to be dependent on the integrity of an intact nervous system.18 Data suggest that the afferent input generated by acupuncture stimulation can somehow interfere with and suppress the appreciation of pain. The mechanism of acupuncture analgesia may well work within the current framework of some of the recent explanations for the phenomenon of pain extending from the initial concept of the "gate theory" as described by Melzack and Wall.1" The basic principle of this theory involves the concept that one stimulus can be modified, and maybe suppressed, by the input of an alternative stimula¬ tion. This gate theory and its subsequent modification have led to a therapeutic approach to relieving pain by adminis¬ tering an alternative sensory input to the pain via the use of dorsal column stimulators and, more recently, transcuta¬ neous nerve stimulators that apply an electrical current usually to the site of the pain. These therapies with transcutaneous somatic stimulation can relieve pain and often yield therapeutic benefits that outlast their brief duration.-" It is quite conceivable that acupuncture anal¬ gesia might be working via similar mechanisms, especially when the acupuncture needles are stimulated electrically.21 It would also appear that the maximal effect of this electroacupuncture is obtained with stimulation in the same dermatomal distribution as the pain. This has been shown on an experimental basis with dental pain, where there was a substantial analgesic effect obtained from electroacupuncture with regard to experimental dental pain when the acupuncture needles were placed in the same dermatome as the teeth, but there was a trivial analgesic effect if they were used at some remote dermatome, ie, the hand.-2-3 Most theories of the appreciation of pain attest to the fact that the pain experience depends on more than activity in the afferent ascending pathways, and that such factors as the psychological makeup of the individual and his cultural background also play a very important role.24 It is almost certain that the analgesia that follows acupunc¬ ture administration will also be dependent on such factors. Certainly, our interpretation as to whether an afferent impulse is painful or not depends not only on our direct sensory pathways, but also on our "response bias" as to how we interpret this afferent input.24 Clarke and Yang23 have shown, by using a signal detec¬ tion theory in an experimental situation with a radiant heat source on the arm, that acupuncture produced no decrease in the sensory discrimination, but did produce a substantial shift in response bias. The experimental
subjects interpreted the heat stimuli as much less painful following an acupuncture trial, so that acupuncture may not necessarily produce any true analgesia, but can produce an attitudinal change towards sensory input that will result in a diminution of the pain experience. A more recent study by Chapman et al22 has confirmed that intrasegmental stimulation is more efficacious than extrasegmental meridian point stimulation in dental pain. In contrast to the study of Clarke and Yang, the resulting increased analgesia was a relatively pure sensory change
and not due to modifications of response bias. A further possible mechanism of acupuncture anesthesia is that the acupuncture stimulation liberates a neurohu¬ moral analgesic substance.2" An endogenous morphine-like substance that binds to opiate receptors has been reported,27 and the fact that acupuncture analgesia can be reversed by the opiate antagonist naloxone hydrochloride28 supports this thesis. The time sequence characteristics of acupuncture anesthesia, ie, a gradual rise in pain threshold with the onset of needling and a gradual decrease of analgesia after needling is stopped, is compatible with the time course of production and decay of an endogenous pain-relieving substance in response to acupuncture needle stimulation. There is another mechanism whereby acupuncture can be responsible for producing relief of painful symptoms, and that is in those patients whose symptoms are gener¬ ated by their ingestion of excessive and inappropriate medications, producing a dependency that reinforces the pain behavior. Benjamin Franklin said, when considering mesmerism: There is in every great and rich city a number of people who are fond of medicines and taking them, and thereby impair their health and ruin their constitutions, if they can be made to forbear the ingestion of these depressing medicines by the therapist pointing a finger or an iron rod [or maybe an acupuncture needle?] at them, they may feel better, but they mistake the cause.
In the pain clinic of the University of Washington, we many patients whose symptoms are the result of an excessive ingestion of depressant, sedative, and narcotic medications. If they can be persuaded to discontinue this see
medication intake, they are much improved symptomatically and they will attribute their improvement to whatever therapy coincides with this detoxification process. One such woman, referred with an incapacitating tension headache syndrome for which she was taking rectal suppositories of ergotamine tartrate (because the exces¬ sive quantities of codeine that she also consumed made her so nauseated that she was unable to take ergotamine orally), went to the Orient for a trial therapy of acupunc¬ ture, during which time the astute acupuncturist made her abstain from all medications. Her condition improved considerably and she returned much impressed with the efficacy of acupuncture; however, she resumed her previous drug ingestion on returning to the United States and the symptoms gradually returned. A brief period in the hospital with the medicines discontinued, this time without the benefits of acupuncture, proved to the lady and to us
that it was the discontinuance of the medication rather than the acupuncture that was the effective therapy.
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Thus, the mode of action of acupuncture is still yet to be defined. Neurophysiological evidence does suggest that modulation of noxious stimuli may well be involved, and this effect is more to reduce than to necessarily abolish the pain. There are, however, probably other psychological and cultural attitudinal factors at work in the production of acupuncture analgesia.
COMMENT The use of acupuncture analgesia during surgery is associated with a high rate of intraoperative discomfort and would probably be unacceptable to the majority of patients and their doctors in the West. Although there is probably a small percentage of individuals who could successfully undergo surgery with acupuncture analgesia, the identification and preparation of these patients would be so time-consuming and difficult as to preclude any benefits from it. Most of the procedures performed outside of China on patients under acupuncture anesthesia have been limited to minor surgery (dentistry, skin operations, etc) and are frequently associated with supplementation with systemic analgesics and local anesthesia. Acupuncture may well find greater application for the control of chronic pain states, although whether it is any more efficacious than using, for example, transcutaneous stimulators remains to be determined. Certainly, there is evidence that the transcutaneous stimulator and acupunc¬ ture are probably working through similar mechanisms. In a study on low back pain, patients who were treated with both modes experienced similar benefits.21 Therefore, if similar results can be obtained with the use of electrical stimulators, the added investment of time and personnel required by acupuncture may not be worth it. In self-
limiting conditions
that benefit from acupuncture, eg, traumatic musculoskeletal problems, it needs to be shown to be a better means of treating them than conventional therapy, analgesics, etc, to really find a place in their treatment.
Acupuncture analgesia should probably continue to be studied to better delineate what benefits it may accrue for patients treated with this method. This study should ideally be carried out by persons skilled in experimental methods, and practitioners should certainly be knowledgable on matters of anatomy, physiology, pathology, and behavioral sciences. It will require an approach in the experimental laboratory, but clinical trials must also be done to answer questions as to what conditions it is most applicable for and whether it poses a more desirable alternative to conventional medications or more conven¬ tional therapeutic approaches. Acupuncture analgesia for surgery will, we think, have limited success in Western medicine, although there will be a small number of patients who could, perhaps, benefit from it. It is important that practitioners of acupuncture be licensed and that the therapy not be allowed to be used indiscriminately to the exploitation of the general public. This is essential not only to protect the patient, but also for the protection of whatever potential value acupuncture therapy may have. If used indiscriminately, any advan¬ tages it may offer over conventional therapy may be masked. Voltaire claimed that physicians "entertain patients whilst nature cures disease." If used indiscrimi¬ nately, acupuncture could be added to that entertainment program where it may be no better (or no worse) than other nonspecific therapeutic reinforcers of the doctor-patient
relationship.
References 1. Shaw GB: The Doctor's Dilemma. New York, Dodd Mead & Co Inc, 1941. 2. Diamond EG: Acupuncture anesthesia: Western medicine and Chinese traditional medicine. JAMA 218:1558-1563, 1971. 3. Hogness JR (ed): Report of the Medical Delegation to the People's Republic of China. Washington, DC, National Academy of Sciences Institute of Medicine, 1973. 4. Boas RA: The Visit of the New Zealand Medical Delegation to the People's Republic of China. Report to the Director General of Health, Auckland, New Zealand, 1974. 5. McLoud JG, Sainsbury MJ, Joseph D: Acupuncture: A Report to the National Health and Research Council of Australia. Canberra, Australian Government Publishing Services, 1974. 6. American Acupuncture Anesthesia Group. Acupuncture in the People's Republic of China. Washington, DC, National Academy of Sciences, 1976. 7. Bonica JJ: Therapeutic acupuncture in the People's Republic of China. JAMA 228:1544-1551, 1974. 8. Bonica JJ: Acupuncture anesthesia in the People's Republic of China. JAMA 229:1317-1325, 1974. 9. Veith I (trans-ed): The Yellow Emperor's Classic of Internal Medicine. Berkeley, Calif, University of California Press, 1972. 10. Nogier PFM: Treatise of Auruolo Therapy. Moulin-les-Metz, Moulinneuve, 1972. 11. Murphy TM: Subjective and objective follow-up assessment of acupuncture therapy without suggestion in 100 chronic pain patients, in Bonica JJ, Albe-Fessard D (eds): Advances in Pain Research and Therapy. New York, Raven Press, 1976, vol 1, pp 811-815. 12. Levine JD, Gormley J, Fields ML: Observations on analgesic effects of needle puncture (acupuncture). Pain 2:149-159, 1976. 13. Lee PK, Anderson TW, Modell JH, et al: Treatment of chronic pain with acupuncture. JAMA 232:1133-1135, 1975. 14. Shanghai Acupuncture Anaesthesia Coordinating Group: Acupuncture Anaesthesia: An Anaesthetic Method by Combination of Traditional Chinese and Western Medicine. Shanghai, August 1973. 15. Shanghai Acupuncture Research Group (eds): Acupuncture Anesthe-
sia. Shanghai, Jen-min Ch'u-pan She, 1972, pp 1-9, 60, 63. 16. Schiff AF: A fatality due to acupuncture. Med Times 93:630-631, 1965. 17. Lewis-Driver DJ: Pneumothorax associated with Acupuncture. Med J Aust 2:296-297, 1973. 18. Chiang CY, Chang CT, Chiu HL, et al: Analysis of Peripheral Afferent Pathway for Effect of Acupuncture Analgesia. Sci Sinica 16:210, 1973. 19. Melzack R, Wall PD: Pain mechanisms: A new theory. Science 150:971\x=req-\ 979, 1965. 20. Melzack R: Prolonged relief of pain by brief intense transcutaneous somatic stimulation. Pain 1:357-373, 1975. 21. Fox EJ, Melzack R: Transcutaneous stimulation and acupuncture: Comparison of treatment for low back pain. Pain 2:141-148, 1976. 22. Anderson SA, Ericson R, Holmgren E, et al: Electro-acupuncture: Effect on pain threshold measured with electrical stimulation of teeth. Brain Res 63:393-396, 1973. 23. Chapman CR, Chen AC, Bonica JJ: Effects of intra-segmental electrical acupuncture on dental pain: Evaluation by threshold estimation and sensory decision theory. Pain, to be published. 24. Chapman CR: Psychophysical evaluation of acupunctural analgesia. Anesthesiology 43:501-506, 1975. 25. Clarke WC, Yang JC: Acupunctural analgesia? Evaluation by signal detection theory. Science 184:1096-1098, 1974. 26. Research Group of Acupuncture Anesthesia, Peking Medical College: Effect of acupuncture on pain threshold of human skin. Chin Med J 3:151\x=req-\ 157, 1973. 27. Hughes J: Isolation of an endogenous compound from the brain with pharmacological properties similar to morphine. Brain Res 88:295-308, 1975. 28. Mayer DJ, Price DD, Barber J, et al: Acupuncture analgesia: Evidence for activation of a central control system as a mechanism of action, in Bonica JJ, Albe-Fessard D (eds): Advances in Pain Research and Therapy. New York, Raven Press, 1976, pp 751-754.
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Murphy, MB, ChB, John
J.
Bonica, MD
\s=b\ After the war of liberation, Mao Tse Tung encouraged an integration of Western and traditional Chinese medicine. Several schools of therapeutic acupuncture have defined different points of puncture, originally assumed to be on an empiric basis but now rationalized as areas where nerve endings congregate. Results of therapeutic acupuncture in China cannot be evaluated because of inadequate record keeping. At the University of Washington Pain Clinic, immediate results (two to three days) are good but never lasting, nor do they decrease concomitant medication. For anesthesia, acupuncture acts to produce only hypalgesia in most patients, although some experience total analgesia. Patient selection and mental preparation are careful. Hence, the method is used in much less than 10% of the operations in China, and in these the analgesia is satisfactory by Western standards in only approximately 30%. Concepts as to the mode of action of acupuncture analgesia range from an attitudinal change towards sensory input to the release of a neurohumoral analgesic substances. (Arch Surg 112:896-902, 1977)
his book, The I stated:
Doctors
Dilemma, George Bernard Shaw1
There is no harder scientific fact in the world than the fact that belief can be produced in practically unlimited quantity and intensity without observation or reasoning and even in defiance of both, by the simple desire to believe founded on a strong interest in believing.
He
enlarges
on
this
by reminding
us
that although everybody recognizes the validity of this quotation in the case of amatory infatuations, that it does, however, hold good over the entire field of human activity where doctors are no more proof against illusions than other men.1
Thus, following the initial dramatic reports regarding acupuncture anesthesia in the People's Republic of China by B. Reston (New York Times, Aug 22, 1971, section 4, 13) and Diamond,2 who were among the first Americans to visit that country after a quarter of a century of closed-
door policy, there developed an almost incredible degree of interest in acupuncture therapy and acupuncture anesthe¬ sia. This was accompanied by many misconceptions among the American public and many physicians about the true role of the procedure. The dearth of evidence did not permit reasoned scientific judgment as to the efficacy and mechanisms, but, despite this, widespread false impres¬ sions developed among Americans about the claimed success of acupuncture. This was in part due to these early reports made by Americans, including some highly respected scientists who, though well-meaning, did not Accepted
publication Dec 28, 1976. Department of Anesthesiology and the Pain Clinic, University of Washington School of Medicine, Seattle. Reprint requests to Department of Anesthesiology, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104 (Dr Murphy). From the
for
and Anesthesia
have the expertise to critically evaluate their observa¬ tions. These misconceptions prompted a widespread interest in acupuncture and caused it to be practiced extensively by physicians, other health professionals, and "acupunctur¬ ists" in the United States and other Western countries. Some of these used the method in an ethical, albeit empirical, fashion, and others have done clinical studies and observations. However, some unscrupulous persons have exploited the public's interest by operating their acupuncture "centers" like "mills," treating several hundred patients daily and charging exorbitant fees. Moreover, the interest and curiosity of many physicians has been exploited by the numerous groups who have sponsored many courses and by a large number of acupunc¬ ture equipment companies that sell a variety of charts, needles, and "do-it-yourself kits." Outside of a few wellcarried-out clinical trials, most of the "studies" reported in the recent Western literature are of an anecdotal and uncontrolled nature. Fortunately, further evidence was obtained during visits by official medical missions from several Western coun¬ tries, including the United States,'~:' and subsequently, by the group of anesthesiologists and other scientists who visited China for an in-depth study of the use of acupunc¬ ture for surgical anesthesia." These, together with the results of clinical and other studies, now permit a more realistic appraisal of the phenomenon of acupuncture analgesia and anesthesia. It is the purpose of this article to attempt to clarify the current status of our knowledge of acupuncture and its therapeutic potential. It is important at the outset to emphasize that its use for the therapy of chronic pain (therapeutic acupuncture) and its use to produce surgical anesthesia (acupuncture anesthesia) are different phenom¬ ena in many respects. (Its claimed success in making the deaf hear, the blind see, and the halt walk, or its other nonanalgesic uses, are yet another controversy and will not be considered here.) This account will be presented as follows: an outline of Chinese traditional medicine to provide a background for discussion of the use of acupuncture, an appraisal of therapeutic acupuncture, and an appraisal of acupuncture anesthesia. Possible mechanisms of action will then be discussed. More detailed and comprehensive reviews can be found in national reports'" and the detailed accounts by Bonica.7 s
TRADITIONAL CHINESE MEDICINE
Medicine in China dates back several millennia. The Huang Ti Nei Ching Su Wen, or The Yellow Emperor's Classic of Internal Medicine," is the earliest medical classic in China, written between the eighth and fifth centuries BC. It consists of 18 volumes covering a great variety of
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subjects, including the theory of diseases, their etiology, diagnosis, and treatment. In the book, man is seen as a microcosm of the universe and therefore subject to the same tension disruptions as nature itself. The immutable course of nature, the Tao, is believed to act through two opposing and unifying forces: the Fuz-the feminine, negative, and passive force, and the Yang—the masculine, positive, and active force. In a
normal person, the two opposing forces are in balance and assist the vital energy, called the chi, to circulate to all parts of the body via a network of 14 channels or merid¬ ians, each connected to an important organ. Obstruction (deficiency) and outpouring (excess) in the circulation of the chi causes an imbalance of the two forces and thus results in disease. Diagnosis is made by studying the patient's behavior, coloration, respiration, and complaints, but, most impor¬ tant, by palpating the radial pulse. Six pulses, each repre¬ senting an organ or system, are located at each wrist. Therapy consists primarily of acupuncture, moxibustion, massage, physical exercises, and dietary regimens. Acupuncture therapy at one or more of the 365 specific points located along the meridians corrects the imbalance and thus eliminates the disease. Disease is not regarded as a local process, but affects the entire body and is often influenced by emotional and behavioral factors. During the ensuing two millennia, the book underwent numerous revisions and it remained a standard work in traditional medicine. Moreover, therapeutic acupuncture continued to be refined. A number of books exclusively devoted to the subject were published, and the method spread to Japan and other Asiatic countries, and in the 17th century, it was introduced in Europe. With the introduction of Western medicine in China, traditional medicine in general and acupuncture in partic¬ ular began to fall into disrepute as being nonscientific. In 1822, the Great Imperial Medical Board ordered the virtual abandonment of acupuncture on ethical grounds. Chinese intellectuals came to regard Chinese medicine as oldfashioned and a hindrance to the modernization and devel¬ opment of their country. In 1929, the Kuomintung govern¬ ment banned the practice of traditional Chinese medicine, including acupuncture. Despite this, the populace, particu¬ larly in rural areas, continued to believe in and use acupuncture and traditional medicine. Moreover, before the Chinese communists' victory in 1949, which they call the "War of Liberation," there were only about 20,000 to 30,000 Western-trained physicians, most of whom prac¬ ticed in the large coastal cities and cared only for the foreign and rich Chinese population. Since 80% of the 550,000,000 people in China at the time lived in rural areas, they had virtually no benefit from Western-trained doctors, but relied on the estimated 400,000 traditional practitioners. Before the "War of Liberation," inadequate health care, poverty, frequent famines, chronic malnutri¬ tion, and poor housing were the reasons China had one of the highest mortalities and lowest life expectancies in the world. Soon after "liberation," impressive programs to improve food production, housing, and medicine were initiated. Mao Tse Tung set forth four concepts of health care: (1) to serve
the
workers, peasants, and soldiers; (2) to put prevention first; (3) to unite Western and traditional Chinese medi¬ cine; and (4) to coordinate medical campaigns with mass movements. The integration of traditional and Western medicine was repeatedly stressed by Chairman Mao, who stated, "Chinese medicine and pharmacology are a great treasure house; efforts should be made to explore them and
raise them to higher levels."7 The old-type doctors were urged to abandon conservative prejudices, accept new knowledge, study science, and cooperate with Westernstyle doctors in order to increase their competence. By the same token, Western medicine "must study the popular and widespread spirit of Chinese medicine." One of the most important results of the nationalism and ferment of the great proletarian cultural revolution that took place during the years 1966 to 1969 was the renewed emphasis on traditional medicine. It was given equal status with Western science and medicine, its practitioners were restored to favor, and a vigorous program was mounted to effect the true merger of the two schools. Medical schools, hospitals, and other health care facilities frequently had Western-trained doctors working alongside the traditional
practitioner.
CURRENT STATUS OF THERAPEUTIC ACUPUNCTURE In compliance with the aforementioned health policies and due, in part, to the influence of Western medicine, therapeutic acupuncture has undergone significant changes during the past several years, but especially since the Cultural Revolution. Much effort has been devoted to the improvement of the selection of patients and to techniques by means of clinical trials. Moreover, there has been a significant change in attitude toward traditional concepts in order to make acupuncture acceptable to Western physicians.
Techniques There are now several methods of therapeutic acupunc¬ ture, but that involving insertion of needles in specific acupuncture points is the most commonly used. The needles are made of stainless steel, usually 1 to 10 cm in length, and are of four or five standard sizes, with diameters ranging from 0.4 to 0.28 mm. The selection of acupuncture points varies greatly and depends on the disease being treated and the acupuncture school being followed. The old traditional schools used acupuncture points throughout the body. The number used varied from source to source (although there is some uniformity with regard to certain points) and in its practice could involve the use of as many as 800 of these points distributed around the body surface, or as few as one or two discrete points. The traditional practitioners related these points to organ meridians as dermal repre¬ sentations of internal organs, both real (eg, heart) and unreal (eg, "triple warmer"). More contemporary acupunc¬ ture "science" views these points as aggregations of nerve endings, the stimulation of which produces patterns of activity within the nervous system that is allegedly respon¬ sible for its effects. The practice of acupuncture is difficult to define because
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an incomplete transition of what was originally a philosophy into a scientific practice. However, by and large
of
it appears to involve the insertion of needles into these socalled points following one of three patterns. They may be inserted into specific points along the so-called organ meridians, and these points may bear little anatomical relation to the organ that is being treated, or needles may be inserted only in the ear. This technique, developed by Nogier1" of Lyon, France, maintains that the whole body image is projected on the ear, and therefore needling can be restricted to this organ alone. Finally, there are those who insert needles into the appropriate areas of the body where the pain is felt, eg, for arm pain, the needle would be inserted in the arm, that is, into structures supplied by the same spinal cord segments as the painful area. In many instances, a combination of acupuncture points is used. The needle is inserted and advanced until the te ch'i is experienced by the patient. This is described as a feeling of tingling, distention, heaviness, and numbness. Stimula¬ tion is achieved either manually, through a push-pull and rotatory movement, or by electroacupuncture. Manual stimulation is carried out for 10 to 15 minutes and the needle is either removed or left in place, and after an interval of time the procedure is repeated. In recent years, electroacupuncture has gained widespread use because it produces continuous stimulation over longer periods of time with much less effort on the part of the operator, because the strength of stimulation can be adjusted according to the needs of the patient, and also because a stronger stimulation can be achieved than with manual stimulation. The number of treatments depends on the type of disease and its severity. Acute diseases are treated one to three times daily until the condition improves. In the treatment of chronic disease, acupuncture is done daily or two to three times a week, for a total of 10 to 20 treatments. Other forms of acupuncture include the injection of sterile water, saline, procaine hydrochloride, morphine sulfate, vitamins, or other medication into acupuncture points. "Thread acupuncture" involves the insertion of a surgical needle threaded with catgut through one acupunc¬ ture point and out another. The catgut thread is left in place to produce persistent stimulation for several weeks until it is absorbed. "Pressure acupuncture" or "acupres¬ sure" consists of the application of pressure on the skin overlying the appropriate acupuncture points for a period of several minutes. Cutaneous needle acupuncture involves the application of numerous short (0.5 cm) needles placed either on a roller or on sticks and applied lightly on the skin overlying the acupuncture points. Moxibustion involves the use of a smouldering piece of dried moss (Artemisia vulgaris) that may be applied directly on the skin over the acupuncture points, held at a distance from the skin, or placed on the shaft of an acupuncture needle. It is there¬ fore important when discussing acupuncture therapy to define the specific modes and sites of stimulation, since it varies considerably in use by different practitioners. Clinical Applications Acupuncture has been used extensively in China for centuries for the treatment of various pain states. These
have and continue to include musculoskeletal pain such as chronic back pain, arthritis, and cervical spondylosis; neuralgia, including trigeminal neuralgia and lumbosacral neuralgia (sciatica); headache, especially migraine, head¬ ache due to emotional tension, spasm of neck muscles, hypertension, and that due to disorders of the ear, nose, and throat; and visceral pain, including the primary treat¬ ment of acute appendicitis, cholycestitis, gastritis, cholecystolithiasis, peptic ulcer, and renal colic. Surprisingly, one of us (J. J. B.), during a visit to the People's Republic of China, was consistently told that acupuncture was of no value in the treatment of chronic pain produced by cancer and other neoplastic diseases. Despite its long and very widespread use and the claims for a high degree of efficacy of acupuncture in treating pain and other nonsurgical disease, no hard scientific data are available to support such claims. In fact, in many health stations and even in some hospitals in China, no records are kept either of the patient's medical history or of his or her response to
therapy.
Information with regard to its use in treating pain problems in Western patients is now accumulating. At the University of Washington Pain Clinic, a self-selected series of 100 patients suffering from chronic pain refrac¬ tory to other forms of conventional therapy undertook a trial of acupuncture analgesia at weekly intervals.11 Although the initial results were often spectacularly successful, following the third treatment, long-term benefit from acupuncture analgesia was as disappointing as other forms of therapy for this intractable group of patients. None of the 100 patients showed any continued objective evidence of pain relief, ie, medication intake and functional impairment continued despite claimed subjec¬ tive relief in a small percentage of the patients. Only three out of the hundred patients claimed long-term (upwards of three months) pain relief from a course of acupuncture therapy. A greater number (15%) would maintain subjec¬ tive relief provided they underwent acupuncture at approximately weekly intervals, but they did not, as a result of this claimed relief, decrease analgesic medicines or improve their activity levels. Similar patterns of response to acupuncture therapy for chronic pain states have been noted by other investiga¬ tors.1- In a well-controlled clinical trial, Lee and associates1 demonstrated that it did not matter if the needles were inserted in traditional meridian points or in "control" points. The results were similar: temporary relief. Only 18% of their 261 patients obtained good relief (15%) beyond four weeks after a series of four acupuncture treatments. In self-limiting temporary pain problems such as posttraumatic pain after sporting injuries, acupuncture can be efficacious in relieving pain temporarily and may well be a useful therapeutic maneuver in such short-lived problems,'though whether this is an improvement on conventional therapies remains to be determined. '
ACUPUNCTURE ANESTHESIA Acupuncture anesthesia is not really anesthesia, but more correctly an analgesia, since sensations other than pain are maintained. In contrast to its use for therapy, which goes back several millenia, acupuncture anesthesia is
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new development, first used in 1958. Every report the subject published in China credits "Chairman Mao's Proletarian Medical and Public Health Line" as the impetus for its development. Apparently prompted by the simple question, "If acupuncture relieves pain of medical disorders, why not use it to prevent pain of surgery," it was first employed to relieve posttonsillectomy pain, and subse¬ quently during the changing of wound and burn dressings, for teeth extractions, tonsillectomy, and other simple a
relatively on
operations.
The initial reports created a great deal of excitement and interest among health-care professionals and the Chinese public for two important reasons. First, acupunc¬ ture anesthesia held the promise of helping to solve a serious health care problem—the lack of a sufficient number of trained anesthetic personnel. At this time, anesthesiology, which was started as a discipline a few years earlier, was at a very early stage of development, and virtually all of the small number of trained anesthesiolo¬ gists and nurse anesthetists practiced in large hospitals in urban areas. Consequently, the anesthetics given in rural areas (where 80% of the population lived) were adminis¬ tered by untrained personnel, resulting in a high incidence of complications. A second and equally important reason for the interest that was generated was the fact that acupuncture anesthesia was an exclusively Chinese inven¬ tion unrelated to Western medicine, which still bore the taint of "Western imperialism." Despite the initial favorable impact, acupuncture anes¬ thesia did not become as widely used as had been expected. In fact, during the early 1960s, it was virtually abandoned in many hospitals. One authoritative textbook states that less than 10,000 cases were done in the entire country during the first eight years.13 However, during the Cultural Revolution, there was a great impetus to reintroduce acupuncture anesthesia and expand its clinical use as part of Chairman Mao's movement to fully integrate Western and traditional medicine. Current Status Reports by most early visitors to China gave the lay public and the medical profession of the United States and other Western countries the impression that acupuncture anesthesia was being used widely for many, if not most, operations and was highly effective in most cases. However, Bonica* and others4" found this not to be the case. Bonica computed that it was being used in much less than 10% of the surgical operations done throughout China and, in fact, based on other data, he computed that the figure was more like 1% to 2% of the operations done in China during the seven-year period prior to 1973." Moreover, although a few of these patients undergo the total operation with just acupuncture analgesia, most of the patients require supplement in the form of preanesthetic medication, intravenously administered narcotics, and, in some instances, supplementation with local anes¬ thetic infiltration of the wound and other pain-sensitive structures.
The claim that acupuncture anesthesia is effective in about 90% of the patients-a figure that has been accepted in a report by many other visitors to China-is also
incorrect. This is based on the personal observations of Bonica* and others'" and also is suggested by the data published by the Shanghai group,1' which involved 80,000 patients given acupuncture anesthesia for more than 100 different types of operations. Table 1 lists the criteria used by the Shanghai group and Table 2 contains some of the data on their results.8 The Chinese considered grades 1, 2, and 3 as being effective, and when added they give the overall success rate of 94%. The data, particularly of those operations on the head, neck, and thorax, which are considered the most suitable for acupuncture, show that the pain and reflex responses to noxious stimulation occurred in most of the patients and therefore acupuncture must be considered as unsatisfactory when compared with successful regional or general anesthesia. Their data show that the response in only 30% of their patients really would be considered satisfactory by Western standards.48 The advantages claimed for acupuncture anesthesia include: 1. There is complete safety, because the physiology of the patient is not disturbed. 2. Acupuncture per se has a tonic or regulating effect on the body functions, and since the patient is awake, his brain "is in the most active state" and can regulate body functions and thus overcome the disturbances caused by the surgical disease and the operation. 3. Acupuncture needling is said to have a sedative and antiinflammatory effect, so that patient's conditions "are rarely complicated by postoperative infection." 4. During the operation, the patient is awake and can cooperate with the surgeon, as, for example, in thyroid surgery, where it is important to identify the recurrent laryngeal nerves. Moreover, the patient can take fluids by mouth. 5. Because the technique is simple, convenient, inexpen¬ sive, and requires no elaborate equipment, it can be done by "barefoot doctors" and other paraprofessionals who have not had training in drug anesthesia. This is especially important in view of the shortage of trained anesthesiolo¬ gists in rural areas of China. 6. There is no residual postanesthetic depression or morbidity, nor is there nausea or vomiting, so that the patient can take nutrients by mouth immediately on returning to the ward. Disadvantages of acupuncture anesthesia include: 1. There is a lack of complete analgesia. It is generally acknowledged that, while acupuncture raises the patient's pain threshold, it does not completely eliminate the sensa¬ tion of pain, which in some patients is severe enough to require supplemental anesthesia. 2. Acupuncture does not produce muscle relaxation, so that operations within the abdomen or other procedures requiring relaxation are more difficult. 3. Traction on abdominal viscera often provokes pain, nausea, and vomiting. 4. In intrathoracic operations with lung collapse, the patient can experience dyspnea and other uncomfortable sensations that are at times severe. The selection and preparation of patients are empha¬ sized by the Chinese. Patients are said to always have a choice, and, indeed, many request acupuncture or volunteer
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Table 1.—Criteria for Evaluation of Results of
Acupuncture
Anesthesia*
Gradet
periods of patient calm
Pain
Brief
mild
pain;
Periods of moderate
pain, but operation could still be accomplished
Obvious
Severe
Mild
Moderate
Marked
pain
Changes
Little
Supplementation Meperidine hydrochloride, mg/kg/hr
1.0-1.5
1.0-1.5
1.5-2.0
Necessary
Local anesthetics
None
Small dose
Moderate dose
in blood pressure, heart rate, & respiration
or none
to anesthesia
change
to
drug
Necessary
to
change
to
drug
Necessary
to
change
to
drug
anesthesia
Operating
conditions
Good
Satisfactory
Fair
anesthesia
"From Bonica."
fi indicates excellent; 2, good; 3, moderate, Table 2.—Results of No. of Patients
Operation Craniotomy Thyroid Pulmonary resection Heart
(N
3,457)
and 4, poor
or
failure.
Acupuncture Anesthesia* Grade (% of cases)" ,-·-, 12 3 4
606 670
34 54
35 31
26 10
4 5
Effective Rate (%)t 96 95
656 172
17
26 51
52 16
4
96
24
8
92
763 590
16
45
34
4
96
34
40
11
13
87
30
37
27
6
94
=
Subtotal
gastrectomy Hysterectomy Mean % of total
...
"From Bonica." t1 Indicates excellent; 2, good; 3, moderate; and 4, failure. JGrades 1, 2, and 3 combined.
as 50 used initially to as few as one or two. Although each school differs as to the site and number of acupunc¬ ture points selected, most individuals produce either manual or electrical acupuncture for a period of 15 to 20 minutes as induction, prior to the surgery. During surgery, the patient may receive 75 mg of meperidine hydrochloride or 5 to 8 mg of morphine sulfate intravenously by contin¬ uous infusion. During the operation, the patient is contin¬ uously supported psychologically by every member of the surgical team. Emphasis is made for the surgeon to perform an operation with "steady, sure, light and quick movements." The surgeons are well trained, highly skilled, and use the most modern surgical techniques. In the event the patient experiences discomfort, he is encouraged to breathe as instructed, is continuously supported, and is asked to mobilize positive mental activities.
many
Complications for it. Those patients who manifest anxiety, apprehension or fear, or express any reservations are considered not suitable, because invariably sufficient analgesia does not develop and they often will require drug-induced anesthe¬ sia. Once the decision is made to use acupuncture, the surgical team and the patient carry out "ideologic and material preparation" in advance of the surgery. The patient is often involved in the discussion of the surgical operation and is informed about all of the conditions that may be experienced. Emphasis is placed on the surgical team manifesting confidence in the procedure and being sensitive to the emotional and physical needs of the patient. Most patients receive preanesthetic medication, usually consisting of a moderate dose of a barbituate or other sedative on the night before, and a narcotic (eg, 75 mg of meperidine hydrochloride or 8 to 10 mg of morphine sulfate) one hour before surgery. Patients scheduled for intrathoracic operation receive special preparation for five to seven days prior to surgery, during which time they are given instructions for special diaphragmatic breathing exercises that are said to prevent cardiorespiratory distur¬ bances usually produced by surgical pneumothorax. In regard to the technique used: with experience, the number of needles has been gradually reduced from as
It is
appropriate to say a few words with regard to the complications of this form of therapy. These are actually very few if used responsibly by individuals knowledgable in basic anatomy and pathology. Only one case of death due
acupuncture can be found in the literature.1" This was due apparently to puncture of a pericardial blood vessel, with subsequent tamponade. Obviously, by inappropriately introducing acupuncture needles into the pleura, pneumo¬ thorax would be a very definite risk of this therapy and has been reported.17 The transmission of infection could certainly be a factor if sterility of technique was not. observed. Tissue trauma to such vital structures as the eyes, CNS, etc, would hopefully be avoided by anybody competent in knowledge of anatomy. A very real possible complication of acupuncture therapy is the withholding of more appropriate therapeutic measures; for example, treating, acute appendicitis or perforated ulcer with acupuncture could lead to a deterio¬ ration in the patient's condition by withholding more appropriate surgical therapy. Also, the use of acupuncture therapy for malignancy could permit the neoplastic process to advance beyond the resectable stage, where it might have been more appropriately treated, with a better chance of success at an early stage of the disease, by surgery, to
radiotherapy,
etc.
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MECHANISMS OF ACUPUNCTURE ANALGESIA The traditional explanation of restoration of energy balance is not an acceptable explanation for contemporary understanding of acupuncture. This is somewhat akin to the caloric and phlogiston theories as explanations of inflammatory processes and would invoke the existence of an alternative biological system other than those of conventional physiology and anatomy. It is, perhaps, with neuronal interaction that any mech¬ anisms of acupuncture might be best explained on a physiological basis, and the efficacy of acupuncture anes¬ thesia certainly appears to be dependent on the integrity of an intact nervous system.18 Data suggest that the afferent input generated by acupuncture stimulation can somehow interfere with and suppress the appreciation of pain. The mechanism of acupuncture analgesia may well work within the current framework of some of the recent explanations for the phenomenon of pain extending from the initial concept of the "gate theory" as described by Melzack and Wall.1" The basic principle of this theory involves the concept that one stimulus can be modified, and maybe suppressed, by the input of an alternative stimula¬ tion. This gate theory and its subsequent modification have led to a therapeutic approach to relieving pain by adminis¬ tering an alternative sensory input to the pain via the use of dorsal column stimulators and, more recently, transcuta¬ neous nerve stimulators that apply an electrical current usually to the site of the pain. These therapies with transcutaneous somatic stimulation can relieve pain and often yield therapeutic benefits that outlast their brief duration.-" It is quite conceivable that acupuncture anal¬ gesia might be working via similar mechanisms, especially when the acupuncture needles are stimulated electrically.21 It would also appear that the maximal effect of this electroacupuncture is obtained with stimulation in the same dermatomal distribution as the pain. This has been shown on an experimental basis with dental pain, where there was a substantial analgesic effect obtained from electroacupuncture with regard to experimental dental pain when the acupuncture needles were placed in the same dermatome as the teeth, but there was a trivial analgesic effect if they were used at some remote dermatome, ie, the hand.-2-3 Most theories of the appreciation of pain attest to the fact that the pain experience depends on more than activity in the afferent ascending pathways, and that such factors as the psychological makeup of the individual and his cultural background also play a very important role.24 It is almost certain that the analgesia that follows acupunc¬ ture administration will also be dependent on such factors. Certainly, our interpretation as to whether an afferent impulse is painful or not depends not only on our direct sensory pathways, but also on our "response bias" as to how we interpret this afferent input.24 Clarke and Yang23 have shown, by using a signal detec¬ tion theory in an experimental situation with a radiant heat source on the arm, that acupuncture produced no decrease in the sensory discrimination, but did produce a substantial shift in response bias. The experimental
subjects interpreted the heat stimuli as much less painful following an acupuncture trial, so that acupuncture may not necessarily produce any true analgesia, but can produce an attitudinal change towards sensory input that will result in a diminution of the pain experience. A more recent study by Chapman et al22 has confirmed that intrasegmental stimulation is more efficacious than extrasegmental meridian point stimulation in dental pain. In contrast to the study of Clarke and Yang, the resulting increased analgesia was a relatively pure sensory change
and not due to modifications of response bias. A further possible mechanism of acupuncture anesthesia is that the acupuncture stimulation liberates a neurohu¬ moral analgesic substance.2" An endogenous morphine-like substance that binds to opiate receptors has been reported,27 and the fact that acupuncture analgesia can be reversed by the opiate antagonist naloxone hydrochloride28 supports this thesis. The time sequence characteristics of acupuncture anesthesia, ie, a gradual rise in pain threshold with the onset of needling and a gradual decrease of analgesia after needling is stopped, is compatible with the time course of production and decay of an endogenous pain-relieving substance in response to acupuncture needle stimulation. There is another mechanism whereby acupuncture can be responsible for producing relief of painful symptoms, and that is in those patients whose symptoms are gener¬ ated by their ingestion of excessive and inappropriate medications, producing a dependency that reinforces the pain behavior. Benjamin Franklin said, when considering mesmerism: There is in every great and rich city a number of people who are fond of medicines and taking them, and thereby impair their health and ruin their constitutions, if they can be made to forbear the ingestion of these depressing medicines by the therapist pointing a finger or an iron rod [or maybe an acupuncture needle?] at them, they may feel better, but they mistake the cause.
In the pain clinic of the University of Washington, we many patients whose symptoms are the result of an excessive ingestion of depressant, sedative, and narcotic medications. If they can be persuaded to discontinue this see
medication intake, they are much improved symptomatically and they will attribute their improvement to whatever therapy coincides with this detoxification process. One such woman, referred with an incapacitating tension headache syndrome for which she was taking rectal suppositories of ergotamine tartrate (because the exces¬ sive quantities of codeine that she also consumed made her so nauseated that she was unable to take ergotamine orally), went to the Orient for a trial therapy of acupunc¬ ture, during which time the astute acupuncturist made her abstain from all medications. Her condition improved considerably and she returned much impressed with the efficacy of acupuncture; however, she resumed her previous drug ingestion on returning to the United States and the symptoms gradually returned. A brief period in the hospital with the medicines discontinued, this time without the benefits of acupuncture, proved to the lady and to us
that it was the discontinuance of the medication rather than the acupuncture that was the effective therapy.
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Thus, the mode of action of acupuncture is still yet to be defined. Neurophysiological evidence does suggest that modulation of noxious stimuli may well be involved, and this effect is more to reduce than to necessarily abolish the pain. There are, however, probably other psychological and cultural attitudinal factors at work in the production of acupuncture analgesia.
COMMENT The use of acupuncture analgesia during surgery is associated with a high rate of intraoperative discomfort and would probably be unacceptable to the majority of patients and their doctors in the West. Although there is probably a small percentage of individuals who could successfully undergo surgery with acupuncture analgesia, the identification and preparation of these patients would be so time-consuming and difficult as to preclude any benefits from it. Most of the procedures performed outside of China on patients under acupuncture anesthesia have been limited to minor surgery (dentistry, skin operations, etc) and are frequently associated with supplementation with systemic analgesics and local anesthesia. Acupuncture may well find greater application for the control of chronic pain states, although whether it is any more efficacious than using, for example, transcutaneous stimulators remains to be determined. Certainly, there is evidence that the transcutaneous stimulator and acupunc¬ ture are probably working through similar mechanisms. In a study on low back pain, patients who were treated with both modes experienced similar benefits.21 Therefore, if similar results can be obtained with the use of electrical stimulators, the added investment of time and personnel required by acupuncture may not be worth it. In self-
limiting conditions
that benefit from acupuncture, eg, traumatic musculoskeletal problems, it needs to be shown to be a better means of treating them than conventional therapy, analgesics, etc, to really find a place in their treatment.
Acupuncture analgesia should probably continue to be studied to better delineate what benefits it may accrue for patients treated with this method. This study should ideally be carried out by persons skilled in experimental methods, and practitioners should certainly be knowledgable on matters of anatomy, physiology, pathology, and behavioral sciences. It will require an approach in the experimental laboratory, but clinical trials must also be done to answer questions as to what conditions it is most applicable for and whether it poses a more desirable alternative to conventional medications or more conven¬ tional therapeutic approaches. Acupuncture analgesia for surgery will, we think, have limited success in Western medicine, although there will be a small number of patients who could, perhaps, benefit from it. It is important that practitioners of acupuncture be licensed and that the therapy not be allowed to be used indiscriminately to the exploitation of the general public. This is essential not only to protect the patient, but also for the protection of whatever potential value acupuncture therapy may have. If used indiscriminately, any advan¬ tages it may offer over conventional therapy may be masked. Voltaire claimed that physicians "entertain patients whilst nature cures disease." If used indiscrimi¬ nately, acupuncture could be added to that entertainment program where it may be no better (or no worse) than other nonspecific therapeutic reinforcers of the doctor-patient
relationship.
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