An Anesthesiologist’s Perspective
The late John Bonica (1917-1994), one of the great anesthesiologists of the 20th century, has been called “The Founding Father of the Pain Field.” He developed this interest while treating wounded soldiers at Fort Lewis, Washington, during WW II. Shortly thereafter he became a pioneer of epidural analgesia and other forms of safe pain relief for labor and delivery. In 1947 he created the first multidisciplinary pain clinic, at Tacoma General Hospital, and in 1960 brought it to the University of Washington School of Medicine when he became the founder and first chairman of its Department of Anesthesiology. In 1953 he published the first comprehensive textbook on the subject of pain, the 1500 page Management of Pain. In 1973 he founded what is now the largest professional organization devoted to pain relief, the International Association for the Study of Pain (IASP).
Dr. Bonica was born in Italy. He came to New York City with his family when he was 11. His father died four years later and he became the major breadwinner for the family. He competed in wrestling while in high school and won both the New York City and state championships. Later he worked his way through college and medical school by wrestling professionally under the pseudonym ‘Johnny (Bull) Walker’, and according to several sources he was the “Light Heavyweight Wrestling Champion of the World.” He continued to wrestle while in the army but concealed his military identity by becoming, in the ring, the “Masked Marvel.”
At the time of the burgeoning Western interest in acupuncture in the early 1970s, Dr. Bonica became the Chairman of the Ad Hoc Committee on Acupuncture of the National Institutes of Health (NIH). In 1973 he was “selected by the Committee on Scholarly Communication with the People’s Republic of China of the National Academy of Sciences to be a member of the first official American medical delegation to visit the People’s Republic of China, and was given the responsibility of evaluating acupuncture and anesthesia as practiced in that country.”
The delegation spent three weeks in China beginning on June 15, 1973. Dr. Bonica subsequently reported his findings in three articles: “Anesthesiology in the People’s Republic of China” (Anesthesiology. 1974 Feb;40(2):175-86); “Therapeutic acupuncture in the People’s Republic of China; Implications for American medicine” (JAMA. 1974 Jun 17;228(12):1544-51); and “Acupuncture anesthesia in the People’s Republic of China; Implications for American medicine” (JAMA. 1974 Sep 2;229(10):1317-25). Of these, the Anesthesiology article is available online and is well worth reading.
I’ll provide generous excerpts (emphases added). First, more evidence that James Reston had an epidural anesthetic for his appendectomy:
Data provided me suggest that continuous epidural block is used more often than all of the other techniques combined. Virtually all abdominal operations, including gastrectomies and cholecystectomies, are done with segmental (T5-T12) continuous epidural block…
Next:
Acupuncture Anesthesia
In contrast to its use for therapy of disorders, acupuncture anesthesia is a new development, first used in Sian in 1958…The first operations done were tonsillectomies, changing of burn dressings, and other simple procedures. The initial report created a great deal of excitement and interest because this was an exclusively Chinese discovery, unrelated to Western medicine which still had the taint of Western imperialism. Anesthesiologists began to attempt the technique, but it did not become as widely used as expected. In fact, during the early 1960s its use was abandoned in some (many?) hospitals. During the six years preceding the Cultural Revolution, only one article was published in major medical journals. From the guarded comments made by several anesthesiologists, I concluded that this disuse was the result of disappointing failures in a significant proportion of patients. During the Cultural Revolution this “negative” trend of not using acupuncture was considered the work of revisionists, and subsequently greater emphasis was given to the widespread use of acupuncture in all hospitals.
The reports of previous American visitors to The People’s Republic of China have given the American medical community and public the impression that acupuncture anesthesia is being used widely there for many, if not most, operations, but I found this not to be the case. From data given to me by anesthesiologists and surgeons in hospitals we visited, I estimate that acupuncture anesthesia is being used in 5 per cent or less of the operations done in three commune hospitals, 10 per cent or less of the cases in four hospitals, and in 10-15 per cent of the rest [with one exception]. No accurate statistics on the total number of acupuncture anesthesias are available, but according to some newspaper accounts, it has been used for 400,000 to 600,000 operations since it was introduced 15 years ago. Assuming that most of these…were done since the onset of the Cultural Revolution in 1966 (when its use was markedly increased), even the higher figure accounts for a little more than 1 per cent of the operations done during this seven-year period.
Among the physicians with whom I spoke, there was unanimity of opinion regarding the indications, advantages, disadvantages, and limitations of acupuncture anesthesia, which were cited with so much sameness that one is tempted to believe these have been made national policy. Advantages claimed include complete safety with no physiologic disturbance to the patient, [etc.]…However, when I pressed some of these issues, some of the anesthesiologists did admit that in most instances it is better to use chemical anesthesia, especially in intrathoracic operations…
Selection and Preparation of Patients
In response to repeated questions about criteria used for selection of patients for acupuncture anesthesia, the answers were vague and varied…The decision to use this method is usually made by the surgeon, who tells the patient that he or she is a good candidate for acupuncture. Although the patient is said to have a choice, I gained the impression that by the time the surgeon finishes his discussion it is difficult for a patient to refuse acupuncture. The surgeon emphasizes that: 1) this is a new Chinese invention which resulted from the great teachings of Chairman Mao; 2) it does not harm the body, whereas chemical anesthesia has serious toxic effects. All respondents emphasized the importance of avoiding acupuncture in nervous, apprehensive, or anxious patients because these usually fail to achieve good results. It is also important that the patient be in good physical condition, without serious systemic disease and with no adhesions or other complications in the area of operation. Patients who undergo intrathoracic operation are admitted to the hospital several days prior to surgery to practice abdominal breathing under the instruction and supervision of therapists. The Chinese believe this is essential to prevent the usual disturbances of surgical pneumothorax…
The anesthesiologist usually sees the patient the day before the operation and re-emphasizes the advantages of acupuncture anesthesia, as well as the disadvantages and side-effects and complications of chemical anesthesia…The patient is also informed of the sensation he will feel with the surgical incision (“a feeling of coldness across your neck”) and other surgical maneuvers, such as traction on the trachea and neck muscles during thyroidectomy, or feeling of traction or heaviness within the abdomen or chest. Patients who are to undergo thoracotomy are told that they will probably experience shortness of breath, a feeling of heaviness, or inability to breathe—all of which are important signs to breathe with the diaphragm as previously instructed…
Techniques
Initially, acupuncture anesthesia was achieved with numerous needles (as many as 50-90) inserted into traditional acupuncture points in the four extremities, face, and trunk by four to six acupuncturists. With development of this technique, this was gradually reduced to three to five needles; in some cases only one needle is used. Some still use manual twirling, but but most operators us electrical stimulation…In a demonstration I requested of one colleague, the insertion of the needle through the skin of my forearm was painless, but the location of acupuncture point and the needle twirling were uncomfortable. The anesthesiologist locates the acupuncture point by a feeling of “heaviness and vibration.” Induction of analgesia usually consumes 15-20 minutes, but at times it takes longer. After the feeling of local soreness and destention, the patient develops a sense of numbness, but no demonstrable area of analgesia to pin prick or other sensory stimulation… An intravenous narcotic is often given at the beginning of the operation. In addition, surgeons often inject 1-2 per cent procaine into the thoracotomy incision and hilum of the lung and into the parietal peritoneum just prior to laparotomy.
Personal Observations
I personally observed 15 patients undergoing operations with acupuncture anesthesia alone, including four patients undergoing thyroidectomy; three, lobectomy; one, mediastinal tumor; two, partial gastrectomies; one, hysterectomy; one, renal operation; one, operation in the lower limb; two, tooth extraction with acupressure. Of these 15 patients, two showed obvious facial expressions, shivering, and other signs of pain during incision of the skin, but on questioning denied having felt discomfort. About a third of the patients developed significant changes in heart rate and blood pressure, flushing of the face, muscle tension, and other signs of reflex responses to noxious stimulation. All six patients who underwent thoracotomy manifested signs and complained of symptoms of serious ventilatory and circulatory alterations, such as dyspnea, hypoxia, and paradoxical breathing (despite repeated instructions to the patient to breathe abdominally).
In his JAMA article, Bonica was more blunt:
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, such as thinking of Chairman Mao’s teachings. Patients undergoing thoracotomy who develop severe dyspnea (shortness of breath) are often given oxygen under positive pressure with a mask. In some instances, tracheal intubation is done. Patients experiencing severe pain are given additional doses of narcotics and sedatives. General anesthesia is reserved for those situations in which the acupuncture fails and the operation cannot otherwise be continued.
Efficacy
Most reports made by the Chinese claim that acupuncture anesthesia is effective in about 90% of patients—a figure that has been accepted and reported by most other visitors to China. However, my own observation and analysis of data recently published by the Chinese suggest that this figure does not mean that the pain is eliminated and good surgical conditions are achieved…
In that article Dr. Bonica supplied two tables made from data provided to him by the Chinese:
Table 1 shows the criteria used by the Shanghai group, who recently reported that in more than 100 different types of operations done in more than 80,000 patients given acupuncture anesthesia, the overall success rate was between 81% and 96%.
Table 1. Criteria for Evaluation of Results of Acupuncture Anesthesia
Grade
1
Excellent
2
Good
3
Moderate
4
Poor
(Failure)
Pain
Brief periods, mild, patient calm
Periods of moderate pain
Obvious pain, but operation could still be accomplished
Severe pain
Changes in blood pressure, heart rate, and respiration
Little or none
Mild
Moderate
Marked
Supplementation:
Meperidine hydrochloride, mg/kg/2hr
Local anesthetics
1.0-1.5
None
1.0-1.5
Small dose
1.5-2.0
Moderate dose
Necessary to change to drug anesthesia
Operating conditions
Good
Satisfactory
Fair
Necessary to change to drug anesthesia
Table 2 contains their data on results using criteria in Table 1 in a group of patients who had six representative operations.
Table 2. Results of Acupuncture Anesthesia Operation No. of Cases N=3,457 Grade 1 Excellent(%) Grade 2 Good(%) Grade 3 Moderate(%) Effective Rate, % (1,2,3 combined) Grade 4 Failure (In % of cases) Craniotomy 606 34 35 26 96 4 Thyroid Operations 670 54 31 10 95 5 Pulmonary Resection 656 17 26 52 96 4 Heart Operations 172 24 51 16 92 8 Subtotal Gastrectomy 763 16 45 34 96 4 Hysterectomy 590 34 40 11 87 13 Mean % of total … 30 37 27 94 6
Grades 1, 2, and 3 were considered effective, and were combined to 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 pain and reflex responses to noxious stimulation occurred in most of the patients and therefore must be considered as unsatisfactory when compared with successful regional or general anesthesia.
I agree with that assessment. The most generous conclusion is that only those patients in “Grade 1” could be considered ‘successes’. They constituted 30% of an already tiny minority—1% of all surgical patients, according to Dr. Bonica; “a carefully selected group who ‘met very strict criteria’,” according to Dr. DeBakey. Such a conclusion also presumes that the data for “Grade 1” patients were legitimate.
More from Dr. Bonica’s Anesthesiology paper:
There is great variation in the numbers of needles used and the sites of needling…I saw four thyroid operations being done with three different techniques of acupuncture.
…
Although every respondent claimed that the needles were inserted along traditional acupuncture points, in a number of cases I saw the needles were inserted not through classic acupuncture points but parallel or perpendicular to spinal nerves.
…
If acupuncture is in fact harmless, I wonder why it is not taught to surgeons and nurses who work in commune and district hospitals, which usually lack complicated anesthetic machines and trained personnel…
Another paradox relevant to the above is that if the technique is harmless, why not use it in poor-risk patients, e.g., patients with poor pulmonary function…or those in poor physical condition because of complicating disease.
…
Research on Acupuncture Anesthesia
I was disappointed to learn that there has been virtually no clinical research done on patients operated upon under acupuncture anesthesia. This is especially surprising in regard to intrathoracic operations, in view of the fact that anesthesiologists and surgeons are fully appreciative of the problems of surgical pneumothorax and they do have the personnel and equipment capable of making appropriate measurements. I was informed that “a few” studies of blood gases had been done in “a few” patients in Peking and Shanghai, showing a modest rise in PaCO2 and slight decrease in pH, but there are virtually no data on oxygen tension.
In contrast, basic neurophysiologic research is being done to determine the mechanisms of acupuncture analgesia…
An Aside on Basic Research
I am gazing at some reports of this research, which I’ve had for many years. The very first issue of the American Journal of Chinese Medicine , published in January of 1973, included “Four Articles on Acupuncture Anesthesia,” each emanating from a hospital in the PRC. I’ll not review these in detail, but a couple of points are worth mentioning. First, these articles are unanimous in asserting that the technique can be successful only if both acupuncturist and patient experience Teh-Ch’i: the “feeling of ‘heaviness and vibration’ ” by the acupuncturist, and the “feeling[s] of local soreness and destention, [and] a sense of numbness” by the patient—as reported by Dr. Bonica. Thus, according to this article:
It has been mentioned in Chinese medicine that acupuncture therapy stresses Teh-Ch’i. Teh-Ch’i is a principle expressing the function of the meridians and anastomoses. It states that effective results occur only when the patient feels sore, swollen, heavy and numb sensations after needles have been inserted in the correct loci and when at the same time the physician feels that the needle has been lightly attached or sucked in by the flesh. The Nei Ching reports the “Correct insertion can be effective only when it meets the Ch’i.” This explains the importance of the Teh-Ch’i sensation accompanying needle insertion. If the physician does not continuously twirl the needle after its insertion and merely leaves it in situ, then after a certain length of time the feelings of soreness, swelling, heaviness and numbness of Teh-Ch’i will soon gradually weaken in the patient until they disappear.
Similarly, from this article:
The most important technique of acupuncture anesthesia is to make the patient Teh-Ch’i. [sic] If there is no such feeling from the needle, even the application of many needles with prolonged twirling will be of no avail.
Teh-Ch’i is also rendered ‘de Qi‘ and sometimes described as “needle grabbing.” I have experienced the patient’s version of it twice—during episodes of acute, severe back pain when I subjected myself to acupuncture to see if it might pleasantly surprise me (it did not). My take on my own de Qi is straightforward: it was reflex muscle spasm triggered by needling. It seems to me that this is a hypothesis that could be investigated fairly easily, as could de Qi’s effect on the needle itself (perhaps it has been). It might be interesting to compare subjective impressions and measurable effects of needles inserted into muscles, as in my case, to those of needles inserted elsewhere.
The articles in the Am J Chin Med also suggested, contrary to the “meridians and anastomoses” statement quoted above, that nerves have more to do with how acupuncture anesthesia ‘works’ than do traditional notions of acupuncture points and meridians, thus explaining one of Dr. Bonica’s observations. According to this article:
…when comparative study is made between the positions of the loci on the meridians and anastomoses and the distributions of nerves, half of the loci are found to be scattered on the nerve trunks, while the rest lie near the nerve trunks. Thus, we think it to be more precise to use the nervous system in explaining the principles of acupuncture anesthesia and analgesia.
And in this article:
…we observed that the nearer the selected points for stimulation were to the nerves of the operating location, the better the anesthetic effect.
One article, however, asserted that although the nervous system and the “theory of Ching-Lo” (‘meridians and anastomoses’ which “connect the hollow and solid organs of the body and various locations on the surface of the body”) are closely related, they are not entirely so:
…the theory of Ching-Lo can at least partly explain the nerve effect in reflecting rules of control…
However, some of the rules and relationships of the different locations of the human body covered by the theory of Ching-Lo cannot be explained by current knowledge of neural anatomy and physiology. For example, according to the theory of Ching-Lo the locus Kuang-Ming (Bright Light) on the lower leg is a principle [sic] locus for treating eye diseases. We obtained good effects using this locus to produce acupuncture anesthesia for eye operations. But, how can stimulation at Kuang-Ming affect the eye region and what relationship exists between these two locations? It is very difficult to explain these phenomena with our knowledge of modern neuroanatomy and neurophysiology.
One of the articles made another point that is nearly ubiquitous in contemporary discussions of acupuncture anesthesia:
Besides material considerations in acupuncture anesthesia, the emotional situation of the patient also influences the analgesic effect of acupuncture anesthesia. If the patient has an accurate understanding of and confidence in acupuncture anesthesia, the inhibitive action of acupuncture is promoted and its effect is better. If a patient’s state of mind is tense, and if he has a doubtful attitude toward acupuncture anesthesia, the cerebral cortex is strongly excited and hence cannot be inhibited by the action of acupuncture. On the contrary, the patient may easily receive pain impulses from the operating region.
Other investigators, both in China and elsewhere, have performed basic research, including with animals, regarding acupuncture’s apparent analgesic properties. Most reviews make much of endorphins being stimulated by needling, particularly if electrified, but this is not necessarily specific to such needling and is hardly ‘acupuncture’ per se. Some investigators, such as JiSheng Han in China and George Ulett in St. Louis, have been quite convinced that the analgesic properties are real, even if they have nothing to do with pre-scientific Chinese medical ‘theory.’ This is not so different from other techniques, involving electrical stimulation of peripheral nerves, that have been investigated for the treatment of painful syndromes but that have shown modest effectiveness at best.
The topic apparently remains an active area of investigation. A recent review concluded:
After 30 years of acupuncture research, there are still many puzzles left to be solved regarding the mechanism of AA.
Is Acupuncture Anesthesia Real?
My own view differs from even that of rational authors who, I worry, have failed to see the forest for the trees: there is NO acupuncture anesthesia or analgesia—at least not to an extent that is either humane or clinically useful for surgery. Even Dr. Bonica, after offering numerous hints of this truth, was unwilling to dismiss the method altogether. Perhaps this reflected his scrupulous politeness or studied diplomacy, for in the JAMA article he continued to hint at the reality when he concluded:
These comments are intended to place the procedure in perspective and not to distract in any way from this very important Chinese achievement. The fact that acupuncture analgesia permits the completion of surgical operations in some patients is an important gain in a country that has a severe shortage of anesthetic personnel. The Chinese are more successful with the procedure than are others for a variety of reasons, including intense preoperative counseling and preparation, their admirable ability to tolerate moderate to severe pain, the intense motivation provoked in the patient and surgical team by the necessity created by shortage of anesthetic personnel and by political and ideological factors, and the skill, gentleness, and dexterity of Chinese surgeons and their willingness to accept less than optimal operating conditions.
Dr. Bonica knew, obviously, that even a severe shortage of anesthesia personnel could not explain an inadequate technique used in only 1% of cases. I’d be interested to learn of Dr. Bonica’s private views of acupuncture anesthesia, and I imagine that there are, among his surviving colleagues and family, those who can tell us.
I agree with Wally Sampson, Petr Skrabanek and others that apparent analgesic effects of acupuncture are most economically explained by counter-irritation and non-specific ‘placebo’ effects, including expectation and ‘hypnosis’-like states (whatever those may be). I also think that some of the apparent effects in ‘acupuncture anesthesia’ demonstrations had to do with the patients being highly motivated to appear comfortable. I agree with Dr. DeBakey that the addition of sedatives, narcotics, and local anesthetics made ‘acupuncture anesthesia’ irrelevant in many of the operations in which it appeared to be successful.
The 20-minute “induction” periods described in ‘acupuncture anesthesia’ case reports suggest a phenomenon of partial “extinction” (increasing tolerance), over time, to the pain of the needling itself. This may be real, in a biological sense, and could have manifestations in other parts of the body—as would occur with the secretion of endogenous molecules that have opiate-like effects, for example. Nevertheless, even if real I view it as a wash at best: it occurs in response to a stimulus which is sufficiently noxious to elicit it. If it subsequently dulls, to some small extent, the painful shock of a surgical incision, how would that be a net benefit?
The endorphin hypothesis is problematic in other ways, as reviewed by Skrabanek in Examining Holistic Medicine and by Beyerstein and Sampson here. While in Bejing discussing research with the aforementioned Dr. Han, Drs. Beyerstein and Sampson
…wondered if he would agree, as we had read, that a number of other, less invasive stimuli can also raise endorphin levels in the central nervous system. We asked if it were not true, as Dr. Victor Herbert had shown, that any irritative stimulus, such as a pinch, might produce a similar rise in endorphin levels (this is conceded by many acupuncturists who use “acupressure” where the skin points are simply massaged rather than needled). He replied that yes, that is so, but acupuncture does not hurt as much as a pinch.
…
In a personal communication, Herbert presented the following account of a demonstration of animal acupuncture he had observed in China. The experimenter inserted needles into the animal subject and took a blood sample that showed a rise in endorphin levels. Herbert asked if he could try pinching the skin to see if it would have a similar effect on endorphin levels to that of the needles. It did.
When we consider, finally, that patients were selected according to “very strict criteria” and were under extreme pressure, during the Cultural Revolution, to please their physicians and other authority figures, it becomes unnecessary to invoke any special analgesic powers of acupuncture. Skrabanek was particularly cynical:
The Chinese inventors of acupuncture anesthesia used initially more than 50 needles, but the number gradually dropped to one or two. Would the same effect be achieved with no needles whatsoever? Those who dared ask such awkward questions were branded as “counter-revolutionary revisionists.”
Rather than being an important Chinese achievement, was ‘acupuncture anesthesia’ more a form of torture perpetrated by a totalitarian government on its own citizens, with the forced complicity of physicians? It is that issue—the relation of ‘acupuncture anesthesia’ to Chinese politics—that we will consider in Part III.
***
The ‘Acupuncture Anesthesia’ series:
1. “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part I)
2. “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part II)
3. “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part III)
4. “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part IV)
5. ‘Acupuncture Anesthesia’ Redux: another Skeptic and an Unfortunate Misportrayal at the NCCAM