508
ANESTHESIAAND ANALGESIA . . . Current Researches VOL.55, No. 4, JULY-AUGUST, 1976
“Acupuncture Anesthesia” - A Clinical Study JEROME H. MODELL, M D * PETER K. Y. LEE, M D t
HAL G. BINGHAM, M D f DONALD M . GREER, JR., MDS MUTAZ B. HABAL, M D / I
Gainesville, Florida* * Forty-two patients who were t o undergo plastic surgical procedures were asked whether they would accept acupuncture as a substitute for local anesthesia. Eight patients agreed t o acupuncture; one of these had 2 operative procedures with acupuncture. Five of t h e 9 procedures were successful; t h e remaining 4 required conversion to local anesthesia. After interviewing t h e patients, we felt t h at
the success of “acupuncture anesthesia” was largely dependent on patient motivation, and t h a t a patient may experience pain during surgical procedures without a ny change in facial expression or vital signs. We concluded t h a t “acupuncture anesthesia” is of little value in our patient population at present. Its results a r e unpredictable; therefore, we anticipate tha t patient acceptance will be small.
1958, in response to Chairman Mao Tse Tung’s suggestion that traditional Chinese medicine is a “great treasure house” and should be combined with Western medicine and elevated to new heights, physicians in the People’s Republic of China began using the traditional technic of acupuncture as anesthesia for surgical procedures. Enthusiasm for the technic, even in the People’s Republic of China, grew slowly until the proletarian cultural revolution in 1966.tt Since that time there has been a concerted effort by physicians and patients in the People’s Republic of China to adopt this combination of traditional and Western medicine whenever possible. Reports of operations performed successfully under “acu-
puncture anesthesia” in the People’s Republic of China are commonplace in the American press.
??Unpublished report of Acupuncture Anesthesia Study Group of the Committee on Scholarly Communication with the People’s Republic of China, May 1-22, 1974.
PATIENT SELECTION AND METHODS Patients were selected who were to have plastic surgical procedures that could be
I
N
One of us (Modell) was privileged to be a member of the Acupuncture Anesthesia Study Group of the Committee on Scholarly Communication with the People’s Republic of China in May 1974. As such, he was the guest of the Chinese Medical Association for 22 days and observed surgical procedures performed under acupuncture. Some details of that visit have been published elsewhere.’ Because of the questions raised in that report relating to whether a combination of acupuncture and surgery could be successful for patients in the United States, we conducted the following study.
”Professor and Chairperson, Department of Anesthesiology. ?Visiting Research Professor, Department of Anesthesiology. XProfessor and Chief, Department of Surgery, Division of Plastic Surgery. $Assistant Professor, Department of Surgery, Division of Plastic Surgery.
11 Associate Professor, Department of Surgery, Division of
Plastic Surgery.
**University of Florida College of Medicine, J. Hillis Miller Health Center, Gainesville, Florida 32610. Paper received: 10/24/75 Accepted for publication: 1/6/76
Acupuncture Anesthesia . . . Modell, et a1
converted easily to local anesthesia should acupuncture fail. Each patient was interviewed before the operation and given the choice of having the procedure performed under “acupuncture anesthesia” or under local anesthesia. All patients were told that if they felt uncomfortable at any time during the surgical procedure while under acupuncture, they could request that the acupuncture be terminated and local anesthetics be used. All questions asked by the patients were answered. None of the patients received any form of premedication. Patients were given acupuncture along traditional meridians appropriate for the site of operation, using needles stimulated electrically with a stimulator capable of producing up to 9 volts at a frequency of 1 to 200 Hz. In general, current intensity and frequency were usually adjusted to the patient’s tolerance. Acupuncture induction time was a minimum of 20 minutes. The surgical field then was prepared and draped and the operative procedure begun. The procedures were considered as either a success or failure, according to whether the patient requested that acupuncture be terminated and whether more than 2 ml of local anesthetic was used. In no case were analgesic drugs given.
RESULTS Of 42 patients interviewed, 8 requested acupuncture. One of these patients had 2 procedures performed under acupuncture. The first patient was a 20-year-old medical student who was to have a granuloma of the scalp excised. Needles were placed bilaterally at Chuan-Liao (SI-18), TsuLin-Chi (GB-41), and Tsan-Chu (BL-2). In this patient, we did not attempt to increase the intensity of the stimulus to the patient’s tolerance. Upon incision of the skin, the patient reported that he was undergoing an experience in “acupain.” The acupuncture was terminated and a local anesthetic was infiltrated. The procedure continued without incident. The second patient was a 45-year-old woman who had contacted one of the authors and requested that a rhinoplasty be performed under acupuncture anesthesia. She said that she had needed a rhinoplasty for a number of years but, because of her fear of both local and general anesthesia, had delayed the procedure. She reported that she was well motivated and wanted to volunteer for the study.
509 Acupuncture needles were placed bilaterally at Ho-Ku (LI-41, Chu-Chih (LI-111, and Tsu-San-Li (St-36). The patient underwent a 21/-hour rhinoplasty, including bilateral fracture of the nasal bones, Epinephrine ( 1:200,000) in saline solution was infiltrated from the beginning of the procedure to help control hemostasis. Throughout the procedure, the patient frequently complained that the electrical stimulus of the acupuncture was too intense. Although she lay quietly on the operating table during much of the surgical procedure, she frequently voiced displeasure, reporting a feeling of intense pressure, particularly when tissues were spread rather than cut. When the nasal bones were to be fractured, the patient reported being quite uncomfortable, and 1 ml of 1% lidocaine with 1:200,000 epinephrine was injected on each side. During the procedure, the patient’s pulse and blood pressure remained reasonably stable, despite discomfort. At the conclusion of the procedure she apologized for any suggestion that she may have been uncomfortable and stated that she had not felt pain, was very pleased with the procedure, and would be happy to undergo a procedure under acupuncture in the future. This procedure, therefore, was considered successful. However, the anesthesiologist and surgeon were more impressed with the patient’s endurance than with the analgesia afforded by the acupuncture. Approximately 3 months later the patient was readmitted for revision of the tip of her nose. This second procedure also was performed under acupuncture but this time without complaint, incident, or changes in vital signs. Patients 3, 4, and 5 were women, aged 26, 31, and 35, who were scheduled for augmentation mammoplasty. Acupuncture needles were placed bilaterally at Ho-Ku, NeiKuan (EH-6), and Tsu-San-Li. When the skin was incised, these patients complained of pain, and soon after the beginning of the procedure requested local anesthesia. Patient 6 was a 28-year-old woman who had her earlobe reconstructed under acupuncture with no discomfort and no observable signs of pain. Needle placement was bilaterally at Ho-Ku and Shya-Chu (St-6) . Patient 7 was a 24-year-old woman who had needles placed bilaterally at Yang-Pai (GB-14) and Ho-Ku. A foreign body was
510
ANESTHESIA A N D ANAI.GESIA . . . Current Researches Vor.. 55, No. 4, JULY-AUGUST. 1976
removed from the upper eyelid below the level of the levator, also with no reported discomfort. or obvious signs of pain.
the pain was far up near my armpit around the area one would put a thermometer. It was hot and burning and a surmise. Several more times from then on I feit it. I don’t The 8th patient was a 35-year-old woman think I could have tolerated a lot of it withwho had an augmentation mammoplasty. out squawking a little. I wanted to tolerate Needles were placed bilaterally a t Ho-Ku, in silence as much as possible because I Nei-Kuan, and Tsu-San-Li. Because she knew you would switch to local if I wanted complained of some discomfort upon inci- and I didn’t want this to happen until I sion through the right nipple, 0.5 ml of 1% could no longer control my reaction. There lidocaine with 1:200,000 epinephrine was in- were periods of time when all I felt were jected into each nipple. No other local anes- pressure and pulling. It seems like those thetic or analgesic agents were used. The points allowed me to face the more painful remainder of the 21h-hour procedure was areas, knowing that the worst would not last without incident and there was no change too long. As time went by I had such a dein vital signs at any time. The patient ap- sire to sleep I would relax and try to alienpeared calm, relaxed, a n d comfortable ate the pain from my mind so as to rest throughout, at times appearing to be dozing. and replenish courage. I was weakening. I The patient did request that the inten- felt and had such a feeling of dismay, not sity of the acupuncture be increased on sev- wanting to relate how I felt any more, just eral occasions but did not report a feeling wanting to get it over, of pain and did not request local anesthesia. “It is now 12:55 a.m. I am not really Vital signs a t these times were stable. At sleepy. I am going to relate, as best I can one point, she asked what was being done. recall at this moment, my feelings mentally, She reported it was as though she were as well as physically, pertaining to all as“being touched with a soldering iron,” al- pects of the operation, as I could see it and though it did not hurt. This coincided with feel it. Having never read about acupuncthe use of cautery deep on the chest wall. ture, I was unaware of how it was done and At the conclusion of the procedure, the pa- didn’t think electric currents were a part of tient reported she was comfortable. The sur- it until Dr. Model1 explained it, and before geon and anesthesiologist considered the going to surgery Dr. Lee demonstrated what procedure an outstanding success. Because to expect. After being hooked up entirely the procedure had gone so well, the patient and the current started, there were a few was given a hand-held tape recorder to dic- minutes of discomfort, ie, a heavy ache and tate her thoughts over the next 24 hours. my hand seemed to contract. After only a few minutes the aching subsided and the Pertinent excerpts from that tape are as electrical current was soothing. I found myfollows: self wanting to relax and sleep but anxiety “These thoughts have come upon me: would not let me do so. I have described 10:25 p.m. What pain I did feel is still already the feeling through the surgery. As vivid a t this moment. As sensitive as my I seemed to feel more pain, I asked for more current. This seemed to help, although I’m breasts-especially the nipple area-are, my greatest anxiety at this moment is fear not sure if it was the distraction of the surge of a complication that would warrant re- of electricity or the lessening of the concuropening or any extra surgical measures a t rent pain. A t any rate it was helpful. At this time. I n effect, if I had not felt any one time I reached a point while asking for pain in surgery, I would not fear going back current that it seemed too much and I asked for a lessening. Towards the end of into it. the surgery it seemed as if my hands and “At first the entire incision really hurt, left leg were getting tired and heavy. Howthen I felt it most a t one central point. I ever, at no time did I experience anything was able to tolerate it and from then on pertaining to the acupuncture itself as painthere were varying degrees of pain-sharp, ful.” short pains which seemed to be snips. I DISCUSSION have skinned turkey legs not wanting to Reports from the People’s Republic of peel the film that keeps in the juice. I felt as if this is what was happening when the China suggest that “acupuncture anesthepockets were being made. It’s hard to say sia” is successful in over 90% of the patients why certain areas hurt more than others. in whom it is used. To interpret these figSomething happened on the left side and ures, it is necessary to understand the
Arupunrture Anesthesia . . . Modell. et a1
Chinese definition of “successful.” The Chinese grade the results of “acupuncture anesthesia” in 4 categories: grades I through I11 are considered successful; grade I is used when the patient has little or no discomfort during the operative procedure and there are minimal changes in vital signs; grade 11, when the patient has slight discomfort that can be controlled with small doses of narcotics and local anesthetics. Also, there may be moderate changes in vital signs. Grade I11 is used when the operation can be successfully completed, but the patient has periods of moderate to severe pain, changes in vital signs, and requires larger doses of parenteral medication and local anesthesia to complete the procedure; and grade IV when acupuncture fails and the operation must be abandoned or the patient given general anesthesia.l The Chinese repeatedly point out that “acupuncture anesthesia” is still an experimental technic and represents an attempt to blend traditional Chinese medicine with Western medicine to improve health care for their people. They acknowledge that some of the present problems with “acupuncture anesthesia” are that many patients suffer incomplete analgesia, that muscle relaxation may be poor, that it does not abolish reflexes, and that patients frequently complain of feeling traction when viscera are manipulated, particularly during operations within the abdominal cavity. The Chinese also stress the need for proper patient selection. “Acupuncture anesthesia” is not recommended for every patient; it is considered only when an accurate preoperative diagnosis has been established, when the surgical procedure promises to be uncomplicated, and when the patient agrees to have acupuncture after the advantages of “acupuncture anesthesia” and the disadvantages of general anesthesia have been explained. It is estimated that only 20% of patients in the People’s Republic of China are operated on with “acupuncture anesthesia.”‘ In some patients, there is considerable preparation; patients who are to undergo thoracotomy must successfully complete a variety of breathing exercises for approximately a week before the operation. The anesthesiologist counsels the patient, and the surgeon and other patients in the hospital ward who have had “acupuncture anesthesia” tell him what they believe its advantages are. Also, each step of the surgical
511 procedure is explained. Patients who are nervous or apprehensive are not considered suitable candidates. It is stressed repeatedly that for “acupuncture anesthesia” to be successful, the surgeon must be precise, rapid, and extremely gentle; tissues must be handled with a minimum of trauma, and retractors are seldom used in the wound. In addition to acupuncture, most patients in the People’s Republic of China received approximately 100 mg of phenobarbital and 50 mg of meperidine preoperatively. Observations in China.-The Acupuncture Anesthesia Study Group had the opportunity to observe, in depth, 48 patients who were preselected to have operations performed under “acupuncture anesthesia.” The operations included such diverse procedures as tooth extractions, craniotomy for tumors, ophthalmologic surgery, tonsillectomy, thyroidectomy, pulmonary lobectomy, mitral commissurotomy, repair of ventricular septa1 defect with extracorporeal circulation, subtotal gastrectomy, ovarian cystectomy, abdominal hysterectomy, inguinal herniorrhaphy, and arthrotomy of the knee. Unfortunately, the Study Group did not observe a sufficient number of procedures in each category to be able to report any statistical significance regarding the success rate in any particular type of surgical procedure. Of the 48 procedures seen, 25 patients 152%) fell into the category of grade I, and 10 patients (21%) into the category of grade 11. The remainder (27%) were classified as grade I11 or 1V.l There is no way to predict whether the same statistics would apply to a group of patients similarly selected and prepared in the United States. However, if one assumes that the American patients’ responses to surgery and discomfort would be similar to those of the patients observed in the People’s Republic of China, grade I results would be applicable to both populations. We also believe that many of our patients would accept a grade I1 result, but that grades I11 and IV would be unacceptable. Of the 9 procedures reported in our study, 4 would fit the grade I category. The rhinoplasty would be grade 11, and 4 procedures would fit grade I11 or IV.
It was extremely difficult to interpret accurately the response of some of the patients observed in the People’s Republic of China because, since none of them spoke English, the Study Group had to work through an interpreter. Many of the patients
512
ANESTHESIA AND ANALGESIA . . . Current Researches Vor.. 55, No. 4. JUI.Y-AUGUST, 1976
reported a feeling of heaviness, pressure, and traction but denied pain. Because we were unable to question the patient directly, it was difficult to say with certainty whether the words “pain,” “pressure,” and “traction” were interpreted in the same way by patients and observers. At least 1 patient who had undergone a thyroidectomy described the feeling during operation as “pressure and traction.” Upon detailed questioning through an interpreter after the operation, the patient admitted that she was unable to differentiate between what she called “pressure and traction” and what we called “discomfort” or “pain.” This difficulty in communication and the suggestion by some members of the Study Group that political motivation, education, conditioning, or some type of ethnic difference could explain the success of acupuncture in the People’s Republic of China led to our current study. Our experience, particularly with patient 2 (rhinoplasty) , certainly emphasized the importance of motivation in the success of the procedure. Our experience with patient 8 (augmentation mammoplasty) places considerable doubt on the ability of an observer to determine if a patient is experiencing pain. From all appearances, this patient was comfortable throughout the procedure. She had no change in blood pressure, pulse, respiratory rate or pattern; did not show any facial signs of discomfort; and did not appear to be peripherally vasoconstricted or to perspire. The 2 anesthesiologists who continually observed the patient were not able to detect any evidence of pain. However, the patient obviously felt pain, as evidenced by her very vivid and detailed report. In spite of extensive research in the People’s Republic of China, no definite physiologic mechanism for “acupuncture anesthesia” has been demonstrated.3 We do not know if it produces anesthesia, analgesia, or hypalgesia. Perhaps hypalgesia is a more accurate description of what the Study Group observed. Another consideration was that needles were placed in traditional meridians and in “new experimental points,” some of which were paraincisional, some segmental, and some appeared to be placed directly over or into a major nerve in an attempt to produce “acupuncture anesthesia.” Seldom were needles placed in the
same location for the same procedure in different patients. One professor in Peking reported, upon questioning, that a Peking surgeon gave the needle to the patient and let him insert and rotate it. He allegedly had a 90% success rate.
CONCLUSIONS We conclude that the success of “acupuncture anesthesia” is largely dependent on patient motivation. It is well known that each patient’s tolerance to pain is different.4 It is entirely possible that a patient with a high threshold for pain and excellent motivation might be sufficiently distracted by the electrical stimulus of the needles from feeling pain during operation. I t also is apparent from our small series that patients may experience pain without producing changes in their vital signs. Thus, it is virtually impossible, by purely clinical observation, to determine if the patient is experiencing pain. Pain appears to be a private experience of the patient which does not always lend itself to objective evaluation by the observer. Our study suggests that “acupuncture anesthesia,” analgesia, or hypalgesia is presently of little value for patients in the United States. Its results are unpredictable and general patient acceptance, therefore, is anticipated to be small. At present, the only clinical application we foresee would be for the patient who is to undergo a superficial procedure in which the risks of general anesthesia are not warranted and who reports a previous true hypersensitivity to a wide variety of local anesthetic agents. If such a patient also is well motivated, has a high pain threshold, and is willing to submit to the procedure, it is possible that he may be successfully operated on under “acupuncture anesthesia.”
REFERENCES 1. Modell JH:
Observations of “acupuncture anesthesia” in the People’s Republic of China (editorial). Arch Surg 109:731-733, 1974 2. Bonica JJ: Anesthesiology in the People’s Republic of China. Anesthesiology 40: 175-186, 1974 3. Modell JH: A perspective of acupuncture. J Fla Med Assoc 63:123-128, 1976
4. Clark WC: Pain sensitivity and the report of pain: an introduction to sensory decision therapy. Anesthesiology 40: 272-287, 1974
ANESTHESIAAND ANALGESIA . . . Current Researches VOL.55, No. 4, JULY-AUGUST, 1976
“Acupuncture Anesthesia” - A Clinical Study JEROME H. MODELL, M D * PETER K. Y. LEE, M D t
HAL G. BINGHAM, M D f DONALD M . GREER, JR., MDS MUTAZ B. HABAL, M D / I
Gainesville, Florida* * Forty-two patients who were t o undergo plastic surgical procedures were asked whether they would accept acupuncture as a substitute for local anesthesia. Eight patients agreed t o acupuncture; one of these had 2 operative procedures with acupuncture. Five of t h e 9 procedures were successful; t h e remaining 4 required conversion to local anesthesia. After interviewing t h e patients, we felt t h at
the success of “acupuncture anesthesia” was largely dependent on patient motivation, and t h a t a patient may experience pain during surgical procedures without a ny change in facial expression or vital signs. We concluded t h a t “acupuncture anesthesia” is of little value in our patient population at present. Its results a r e unpredictable; therefore, we anticipate tha t patient acceptance will be small.
1958, in response to Chairman Mao Tse Tung’s suggestion that traditional Chinese medicine is a “great treasure house” and should be combined with Western medicine and elevated to new heights, physicians in the People’s Republic of China began using the traditional technic of acupuncture as anesthesia for surgical procedures. Enthusiasm for the technic, even in the People’s Republic of China, grew slowly until the proletarian cultural revolution in 1966.tt Since that time there has been a concerted effort by physicians and patients in the People’s Republic of China to adopt this combination of traditional and Western medicine whenever possible. Reports of operations performed successfully under “acu-
puncture anesthesia” in the People’s Republic of China are commonplace in the American press.
??Unpublished report of Acupuncture Anesthesia Study Group of the Committee on Scholarly Communication with the People’s Republic of China, May 1-22, 1974.
PATIENT SELECTION AND METHODS Patients were selected who were to have plastic surgical procedures that could be
I
N
One of us (Modell) was privileged to be a member of the Acupuncture Anesthesia Study Group of the Committee on Scholarly Communication with the People’s Republic of China in May 1974. As such, he was the guest of the Chinese Medical Association for 22 days and observed surgical procedures performed under acupuncture. Some details of that visit have been published elsewhere.’ Because of the questions raised in that report relating to whether a combination of acupuncture and surgery could be successful for patients in the United States, we conducted the following study.
”Professor and Chairperson, Department of Anesthesiology. ?Visiting Research Professor, Department of Anesthesiology. XProfessor and Chief, Department of Surgery, Division of Plastic Surgery. $Assistant Professor, Department of Surgery, Division of Plastic Surgery.
11 Associate Professor, Department of Surgery, Division of
Plastic Surgery.
**University of Florida College of Medicine, J. Hillis Miller Health Center, Gainesville, Florida 32610. Paper received: 10/24/75 Accepted for publication: 1/6/76
Acupuncture Anesthesia . . . Modell, et a1
converted easily to local anesthesia should acupuncture fail. Each patient was interviewed before the operation and given the choice of having the procedure performed under “acupuncture anesthesia” or under local anesthesia. All patients were told that if they felt uncomfortable at any time during the surgical procedure while under acupuncture, they could request that the acupuncture be terminated and local anesthetics be used. All questions asked by the patients were answered. None of the patients received any form of premedication. Patients were given acupuncture along traditional meridians appropriate for the site of operation, using needles stimulated electrically with a stimulator capable of producing up to 9 volts at a frequency of 1 to 200 Hz. In general, current intensity and frequency were usually adjusted to the patient’s tolerance. Acupuncture induction time was a minimum of 20 minutes. The surgical field then was prepared and draped and the operative procedure begun. The procedures were considered as either a success or failure, according to whether the patient requested that acupuncture be terminated and whether more than 2 ml of local anesthetic was used. In no case were analgesic drugs given.
RESULTS Of 42 patients interviewed, 8 requested acupuncture. One of these patients had 2 procedures performed under acupuncture. The first patient was a 20-year-old medical student who was to have a granuloma of the scalp excised. Needles were placed bilaterally at Chuan-Liao (SI-18), TsuLin-Chi (GB-41), and Tsan-Chu (BL-2). In this patient, we did not attempt to increase the intensity of the stimulus to the patient’s tolerance. Upon incision of the skin, the patient reported that he was undergoing an experience in “acupain.” The acupuncture was terminated and a local anesthetic was infiltrated. The procedure continued without incident. The second patient was a 45-year-old woman who had contacted one of the authors and requested that a rhinoplasty be performed under acupuncture anesthesia. She said that she had needed a rhinoplasty for a number of years but, because of her fear of both local and general anesthesia, had delayed the procedure. She reported that she was well motivated and wanted to volunteer for the study.
509 Acupuncture needles were placed bilaterally at Ho-Ku (LI-41, Chu-Chih (LI-111, and Tsu-San-Li (St-36). The patient underwent a 21/-hour rhinoplasty, including bilateral fracture of the nasal bones, Epinephrine ( 1:200,000) in saline solution was infiltrated from the beginning of the procedure to help control hemostasis. Throughout the procedure, the patient frequently complained that the electrical stimulus of the acupuncture was too intense. Although she lay quietly on the operating table during much of the surgical procedure, she frequently voiced displeasure, reporting a feeling of intense pressure, particularly when tissues were spread rather than cut. When the nasal bones were to be fractured, the patient reported being quite uncomfortable, and 1 ml of 1% lidocaine with 1:200,000 epinephrine was injected on each side. During the procedure, the patient’s pulse and blood pressure remained reasonably stable, despite discomfort. At the conclusion of the procedure she apologized for any suggestion that she may have been uncomfortable and stated that she had not felt pain, was very pleased with the procedure, and would be happy to undergo a procedure under acupuncture in the future. This procedure, therefore, was considered successful. However, the anesthesiologist and surgeon were more impressed with the patient’s endurance than with the analgesia afforded by the acupuncture. Approximately 3 months later the patient was readmitted for revision of the tip of her nose. This second procedure also was performed under acupuncture but this time without complaint, incident, or changes in vital signs. Patients 3, 4, and 5 were women, aged 26, 31, and 35, who were scheduled for augmentation mammoplasty. Acupuncture needles were placed bilaterally at Ho-Ku, NeiKuan (EH-6), and Tsu-San-Li. When the skin was incised, these patients complained of pain, and soon after the beginning of the procedure requested local anesthesia. Patient 6 was a 28-year-old woman who had her earlobe reconstructed under acupuncture with no discomfort and no observable signs of pain. Needle placement was bilaterally at Ho-Ku and Shya-Chu (St-6) . Patient 7 was a 24-year-old woman who had needles placed bilaterally at Yang-Pai (GB-14) and Ho-Ku. A foreign body was
510
ANESTHESIA A N D ANAI.GESIA . . . Current Researches Vor.. 55, No. 4, JULY-AUGUST. 1976
removed from the upper eyelid below the level of the levator, also with no reported discomfort. or obvious signs of pain.
the pain was far up near my armpit around the area one would put a thermometer. It was hot and burning and a surmise. Several more times from then on I feit it. I don’t The 8th patient was a 35-year-old woman think I could have tolerated a lot of it withwho had an augmentation mammoplasty. out squawking a little. I wanted to tolerate Needles were placed bilaterally a t Ho-Ku, in silence as much as possible because I Nei-Kuan, and Tsu-San-Li. Because she knew you would switch to local if I wanted complained of some discomfort upon inci- and I didn’t want this to happen until I sion through the right nipple, 0.5 ml of 1% could no longer control my reaction. There lidocaine with 1:200,000 epinephrine was in- were periods of time when all I felt were jected into each nipple. No other local anes- pressure and pulling. It seems like those thetic or analgesic agents were used. The points allowed me to face the more painful remainder of the 21h-hour procedure was areas, knowing that the worst would not last without incident and there was no change too long. As time went by I had such a dein vital signs at any time. The patient ap- sire to sleep I would relax and try to alienpeared calm, relaxed, a n d comfortable ate the pain from my mind so as to rest throughout, at times appearing to be dozing. and replenish courage. I was weakening. I The patient did request that the inten- felt and had such a feeling of dismay, not sity of the acupuncture be increased on sev- wanting to relate how I felt any more, just eral occasions but did not report a feeling wanting to get it over, of pain and did not request local anesthesia. “It is now 12:55 a.m. I am not really Vital signs a t these times were stable. At sleepy. I am going to relate, as best I can one point, she asked what was being done. recall at this moment, my feelings mentally, She reported it was as though she were as well as physically, pertaining to all as“being touched with a soldering iron,” al- pects of the operation, as I could see it and though it did not hurt. This coincided with feel it. Having never read about acupuncthe use of cautery deep on the chest wall. ture, I was unaware of how it was done and At the conclusion of the procedure, the pa- didn’t think electric currents were a part of tient reported she was comfortable. The sur- it until Dr. Model1 explained it, and before geon and anesthesiologist considered the going to surgery Dr. Lee demonstrated what procedure an outstanding success. Because to expect. After being hooked up entirely the procedure had gone so well, the patient and the current started, there were a few was given a hand-held tape recorder to dic- minutes of discomfort, ie, a heavy ache and tate her thoughts over the next 24 hours. my hand seemed to contract. After only a few minutes the aching subsided and the Pertinent excerpts from that tape are as electrical current was soothing. I found myfollows: self wanting to relax and sleep but anxiety “These thoughts have come upon me: would not let me do so. I have described 10:25 p.m. What pain I did feel is still already the feeling through the surgery. As vivid a t this moment. As sensitive as my I seemed to feel more pain, I asked for more current. This seemed to help, although I’m breasts-especially the nipple area-are, my greatest anxiety at this moment is fear not sure if it was the distraction of the surge of a complication that would warrant re- of electricity or the lessening of the concuropening or any extra surgical measures a t rent pain. A t any rate it was helpful. At this time. I n effect, if I had not felt any one time I reached a point while asking for pain in surgery, I would not fear going back current that it seemed too much and I asked for a lessening. Towards the end of into it. the surgery it seemed as if my hands and “At first the entire incision really hurt, left leg were getting tired and heavy. Howthen I felt it most a t one central point. I ever, at no time did I experience anything was able to tolerate it and from then on pertaining to the acupuncture itself as painthere were varying degrees of pain-sharp, ful.” short pains which seemed to be snips. I DISCUSSION have skinned turkey legs not wanting to Reports from the People’s Republic of peel the film that keeps in the juice. I felt as if this is what was happening when the China suggest that “acupuncture anesthepockets were being made. It’s hard to say sia” is successful in over 90% of the patients why certain areas hurt more than others. in whom it is used. To interpret these figSomething happened on the left side and ures, it is necessary to understand the
Arupunrture Anesthesia . . . Modell. et a1
Chinese definition of “successful.” The Chinese grade the results of “acupuncture anesthesia” in 4 categories: grades I through I11 are considered successful; grade I is used when the patient has little or no discomfort during the operative procedure and there are minimal changes in vital signs; grade 11, when the patient has slight discomfort that can be controlled with small doses of narcotics and local anesthetics. Also, there may be moderate changes in vital signs. Grade I11 is used when the operation can be successfully completed, but the patient has periods of moderate to severe pain, changes in vital signs, and requires larger doses of parenteral medication and local anesthesia to complete the procedure; and grade IV when acupuncture fails and the operation must be abandoned or the patient given general anesthesia.l The Chinese repeatedly point out that “acupuncture anesthesia” is still an experimental technic and represents an attempt to blend traditional Chinese medicine with Western medicine to improve health care for their people. They acknowledge that some of the present problems with “acupuncture anesthesia” are that many patients suffer incomplete analgesia, that muscle relaxation may be poor, that it does not abolish reflexes, and that patients frequently complain of feeling traction when viscera are manipulated, particularly during operations within the abdominal cavity. The Chinese also stress the need for proper patient selection. “Acupuncture anesthesia” is not recommended for every patient; it is considered only when an accurate preoperative diagnosis has been established, when the surgical procedure promises to be uncomplicated, and when the patient agrees to have acupuncture after the advantages of “acupuncture anesthesia” and the disadvantages of general anesthesia have been explained. It is estimated that only 20% of patients in the People’s Republic of China are operated on with “acupuncture anesthesia.”‘ In some patients, there is considerable preparation; patients who are to undergo thoracotomy must successfully complete a variety of breathing exercises for approximately a week before the operation. The anesthesiologist counsels the patient, and the surgeon and other patients in the hospital ward who have had “acupuncture anesthesia” tell him what they believe its advantages are. Also, each step of the surgical
511 procedure is explained. Patients who are nervous or apprehensive are not considered suitable candidates. It is stressed repeatedly that for “acupuncture anesthesia” to be successful, the surgeon must be precise, rapid, and extremely gentle; tissues must be handled with a minimum of trauma, and retractors are seldom used in the wound. In addition to acupuncture, most patients in the People’s Republic of China received approximately 100 mg of phenobarbital and 50 mg of meperidine preoperatively. Observations in China.-The Acupuncture Anesthesia Study Group had the opportunity to observe, in depth, 48 patients who were preselected to have operations performed under “acupuncture anesthesia.” The operations included such diverse procedures as tooth extractions, craniotomy for tumors, ophthalmologic surgery, tonsillectomy, thyroidectomy, pulmonary lobectomy, mitral commissurotomy, repair of ventricular septa1 defect with extracorporeal circulation, subtotal gastrectomy, ovarian cystectomy, abdominal hysterectomy, inguinal herniorrhaphy, and arthrotomy of the knee. Unfortunately, the Study Group did not observe a sufficient number of procedures in each category to be able to report any statistical significance regarding the success rate in any particular type of surgical procedure. Of the 48 procedures seen, 25 patients 152%) fell into the category of grade I, and 10 patients (21%) into the category of grade 11. The remainder (27%) were classified as grade I11 or 1V.l There is no way to predict whether the same statistics would apply to a group of patients similarly selected and prepared in the United States. However, if one assumes that the American patients’ responses to surgery and discomfort would be similar to those of the patients observed in the People’s Republic of China, grade I results would be applicable to both populations. We also believe that many of our patients would accept a grade I1 result, but that grades I11 and IV would be unacceptable. Of the 9 procedures reported in our study, 4 would fit the grade I category. The rhinoplasty would be grade 11, and 4 procedures would fit grade I11 or IV.
It was extremely difficult to interpret accurately the response of some of the patients observed in the People’s Republic of China because, since none of them spoke English, the Study Group had to work through an interpreter. Many of the patients
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reported a feeling of heaviness, pressure, and traction but denied pain. Because we were unable to question the patient directly, it was difficult to say with certainty whether the words “pain,” “pressure,” and “traction” were interpreted in the same way by patients and observers. At least 1 patient who had undergone a thyroidectomy described the feeling during operation as “pressure and traction.” Upon detailed questioning through an interpreter after the operation, the patient admitted that she was unable to differentiate between what she called “pressure and traction” and what we called “discomfort” or “pain.” This difficulty in communication and the suggestion by some members of the Study Group that political motivation, education, conditioning, or some type of ethnic difference could explain the success of acupuncture in the People’s Republic of China led to our current study. Our experience, particularly with patient 2 (rhinoplasty) , certainly emphasized the importance of motivation in the success of the procedure. Our experience with patient 8 (augmentation mammoplasty) places considerable doubt on the ability of an observer to determine if a patient is experiencing pain. From all appearances, this patient was comfortable throughout the procedure. She had no change in blood pressure, pulse, respiratory rate or pattern; did not show any facial signs of discomfort; and did not appear to be peripherally vasoconstricted or to perspire. The 2 anesthesiologists who continually observed the patient were not able to detect any evidence of pain. However, the patient obviously felt pain, as evidenced by her very vivid and detailed report. In spite of extensive research in the People’s Republic of China, no definite physiologic mechanism for “acupuncture anesthesia” has been demonstrated.3 We do not know if it produces anesthesia, analgesia, or hypalgesia. Perhaps hypalgesia is a more accurate description of what the Study Group observed. Another consideration was that needles were placed in traditional meridians and in “new experimental points,” some of which were paraincisional, some segmental, and some appeared to be placed directly over or into a major nerve in an attempt to produce “acupuncture anesthesia.” Seldom were needles placed in the
same location for the same procedure in different patients. One professor in Peking reported, upon questioning, that a Peking surgeon gave the needle to the patient and let him insert and rotate it. He allegedly had a 90% success rate.
CONCLUSIONS We conclude that the success of “acupuncture anesthesia” is largely dependent on patient motivation. It is well known that each patient’s tolerance to pain is different.4 It is entirely possible that a patient with a high threshold for pain and excellent motivation might be sufficiently distracted by the electrical stimulus of the needles from feeling pain during operation. I t also is apparent from our small series that patients may experience pain without producing changes in their vital signs. Thus, it is virtually impossible, by purely clinical observation, to determine if the patient is experiencing pain. Pain appears to be a private experience of the patient which does not always lend itself to objective evaluation by the observer. Our study suggests that “acupuncture anesthesia,” analgesia, or hypalgesia is presently of little value for patients in the United States. Its results are unpredictable and general patient acceptance, therefore, is anticipated to be small. At present, the only clinical application we foresee would be for the patient who is to undergo a superficial procedure in which the risks of general anesthesia are not warranted and who reports a previous true hypersensitivity to a wide variety of local anesthetic agents. If such a patient also is well motivated, has a high pain threshold, and is willing to submit to the procedure, it is possible that he may be successfully operated on under “acupuncture anesthesia.”
REFERENCES 1. Modell JH:
Observations of “acupuncture anesthesia” in the People’s Republic of China (editorial). Arch Surg 109:731-733, 1974 2. Bonica JJ: Anesthesiology in the People’s Republic of China. Anesthesiology 40: 175-186, 1974 3. Modell JH: A perspective of acupuncture. J Fla Med Assoc 63:123-128, 1976
4. Clark WC: Pain sensitivity and the report of pain: an introduction to sensory decision therapy. Anesthesiology 40: 272-287, 1974
