A Neglected Skeptic
Near the end of my series* on ‘Acupuncture Anesthesia’, I wrote this:
Most Westerners—Michael DeBakey and John Bonica being exceptions—who observed ‘acupuncture anesthesia’ in China during the Cultural Revolution seem to have failed to recognize what was going on right under their noses.
I should have added—and I now have—Arthur Taub’s name to that tiny, exceptional group. Taub, a neurologist and neurophysiologist at Yale, was a member of a delegation of Americans sent to China to observe ‘acupuncture anesthesia’ in May of 1974, about a year after Dr. Bonica‘s visit. The delegation included several prominent anesthesiologists. Their report, Acupuncture Anesthesia in the People’s Republic of China: A Trip Report of the American Acupuncture Anesthesia Study Group, was published in 1976 and is available in its entirety here. Excerpts follow (emphasis added):
Pain is a subjective experience. Judging whether an individual is in a state of pain depends on observations of the subject’s behavior, including verbal reports to the observer…When there is no evidence of pain, the observer can adopt one of three positions:
- A judgment about pain cannot be made because of lack of evidence. The corollary of this position is that only the presence—not the absence—of pain is recognized.
- Pain is present in spite of lack of evidence. This position accepts the notion that pain-associated behavior and autonomic responses can be withheld by the subject, but that the presence of pain can be inferred from other factors, such as the presence of extensive tissue damage. This position also implies that the observational measures currently available are too crude to form the sole basis for judgment.
- Since there is no evidence for pain, there is no pain. Although this is the position most often adopted by clinicians and pain researchers, it relies heavily upon the observer’s skill and accepts the notion that a judgment about the presence or absence of pain can be made on the basis of behavioral observations.
The major area of disagreement among members of the group derived from the above issue…The grading system employed indicates acceptance of the last position by most members of the delegation…It was not possible for the group to reach complete accord regarding the degree of hypalgesia under acupuncture, since it could always be argued that, for whatever reason, our observations were inadequate to judge the extent of private pain experience. The realities of life and patient management, however, continually force us to make judgments about pain on the basis of the best evidence available. To the extent that this is possible, then, the group could conclude that the majority of patients were not in pain during surgery.
The delegation was quick to dispense with the term “acupuncture anesthesia”:
It must be clearly understood that acupuncture does not produce conventional surgical anesthesia. In no instance is sensation totally abolished or consciousness disturbed; thus, acupuncture anesthesia is a misnomer. There is considerable evidence, however, that acupuncture affects the pain experience, although our observations suggest that complete analgesia may not occur. Therefore, the term acupuncture analgesia is similarly inappropriate. In view of these limitations, it seems more reasonable to refer to the phenomenon as acupuncture hypalgesia (AH), which may then be graded according to the effectiveness of pain relief.
The group used a grading system similar to that devised by Chinese physicians in Shanghai, previously reported by Dr. Bonica. The 1974 delegation, however, accepted Grades I and II as being satisfactory, whereas Dr. Bonica had implied acceptance of only Grade I (the Chinese considered Grades I-III to be “effective” and “successful,” according to Dr. Bonica). Using that scale, the 1974 delegation found 22 of the 48 observed cases to have been in Grade I and a further 13 in Grade II, for an overall “satisfactory” rate of 73% (compared to 30% reported by Dr. Bonica). They further reckoned–were told, that is, by their hosts–that about 15% of operations in China were being performed under acupuncture anesthesia (also a much higher percentage than Dr. Bonica’s estimate), and thus concluded that acupuncture provided satisfactory anesthesia for 10% of all operations being done in China at that time.
The 1974 delegation barely addressed political issues, but some of their observations seem telling in retrospect:
According to our Chinese colleagues, only good-risk patients, who are not apprehensive and express their willingness to accept AH are selected after a visit by the acupuncturist or the surgeon…To the best of the study group’s knowledge, coercion is not employed…Selection of patients is also determined to a major degree by the type of pathology anticipated. A precise diagnosis is necessary since extensive exploration produces pain during AH. The procedure should offer no untoward problems such as adhesions, infiltrative tumors, or hemorrhagic complications…
(Unlike Dr. Bonica, this delegation did not wonder why, if acupuncture was so safe and effective, it was not used preferentially for high-risk patients or procedures).
Certain other patients are also considered inappropriate candidates for AH. Children under the age of 15 are rarely included because, as we were told, they cannot be relied upon to remain quiet during the procedure…The role of peer acceptance and national pride on the part of patients were believed to be important factors by some of our colleagues, but there was no objective evidence for or against these opinions.The majority of patients received 100 mg of phenobarbital and/or 50 mg to 100 mg of meperidine (Demerol) from 20 to 60 minutes prior to the operation. With the exception of a case of near or actual coma due to a brain tumor, all patients entered the operating room awake and alert.
The delegation observed one veterinary case:
A healthy aging horse was observed during demonstration of an exploratory laparotomy performed with the aid of acupuncture hypalgesia. It seemed less than a dramatically successful performance, as the horse appeared glassy-eyed and frequently struggled.
In their conclusion, the group wrote:
- Acupuncture stimulation can be effectively used for the control of pain in approximately 10 percent of surgical patients in the People’s Republic of China. It is important to recognize that this is an experimental technique at present.
- Acupuncture appears to modify the pain experience at times to a remarkable degree…
- AH is a significant human biological phenomenon of unknown mechanisms. The induction of a hypnotic trance is not necessary. Social factors may be important in some instances but are not, of themselves, sufficient to account for the effects observed. Some psychophysiologic process appears to be important in modifying the experience of pain.
- The effectiveness of acupuncture hypalgesia varies in different procedures, between different patients, and even within the same patient at different times…
Compared to some of the early reports by Westerners, these statements were cautious. Knowing what we now know about ‘acupuncture anesthesia’ in China during the Cultural Revolution, however, the analysis appears to be an example of academics being “overconfident in their ability to understand how things work.” In particular, most of the members of this group failed to distinguish between patients who were free to report pain and those who were not, and failed to recognize that their Chinese hosts were motivated, by threat of exile from job, home, and family, to make the appearance very different from the reality.
Arthur Taub had a different point of view. A footnote to the report is this:
One member of the study group, Arthur Taub, dissents from the conclusions expressed in this report. His views on acupuncture hypalgesia have been published in various scientific journals…
You can read those views here.
An Unfortunate Misportrayal
In contrast to Dr. Taub’s views are those of one of his colleagues, Yale surgeon Sherwin Nuland, who witnessed ‘acupuncture anesthesia’ in China in 1990. He told of this experience at the first “Stephen E. Straus Distinguished Lecture in the Science of Complementary and Alternative Medicine,” given at the NIH on March 10, 2009. Dr. Nuland is an author of some note. I’ve read parts of several of his books and have found him to be a good writer who seems particularly committed to accurate history. This lecture, unfortunately, was an exception.
Dr. Nuland suggested that the recent advent of acupuncture anesthesia in China had entirely to do with the paucity of modern anesthesia practitioners and equipment. He credited Mao Zedong with having encouraged it, but gave no indication of the political complexity of Mao’s decisions or of the coercion involved in executing them.
Dr. Nuland did not mention the reports or opinions of Drs. Bonica, DeBakey, or Taub. He cited the report of the 1974 delegation, implying that it was the first of its kind, but opined that it had been too skeptical:
…Remarkably, they came to the conclusion that the method might be useful in only about 10% of cases…and this was in spite of the fact that if you look into this report, and look at the individual cases, in more than half of those situations, acupuncture went perfectly well; the procedure went well, there was no problem with it, and it’s a little difficult to know why they were hesitant to write in favor of it except that they had no idea how it worked, and maybe that was the reason: Western physicians, Western scientists, are not prone to use technologies whose origins they have no understanding of.
Perhaps Dr. Nuland misunderstood the report: the “10%” figure was derived from the delegation’s view of the success rate, about 70%, multiplied by the 15% of operations that their Chinese hosts had informed them were appropriate for acupuncture anesthesia. Thus the 1974 delegation (with the exception of Dr. Taub) did, in essence, “write in favor” of the method. Whether or not Dr. Nuland understood this, he used the occasion to accuse “Western scientists” of being petty and closed-minded—much to the delight, I’ve no doubt, of his hosts at the National Center for Complementary and Alternative Medicine (NCCAM). Like the late Director for whom the lecture had been named, Dr. Nuland seems to have quickly grasped the power of misleading language in addressing such an audience.
This was a theme throughout his talk. Regarding nature, suggested Nuland, the Chinese philosophy of ‘harmony’ trumps Western notions of ‘subjugation':
Let’s talk about Traditional Chinese Medicine: the basic principle is the concept of harmony, and, in this configuration, man is such an integral part of the natural world that he can only survive, he can only do well, by doing everything he can to fit into the functioning of the natural world, unlike Western science, which analyzes every characteristic of nature, with a view toward influencing or perhaps subjugating it.
The Chinese philosophy seeks an understanding of nature’s world, so that Man may bow to its laws, and remain unhindered as a part of its never-ending cycle. The inter-relatedness of the universe extends to all things and is exemplified by the principles, and here come two very familiar words, of yin and yang…
In studying natural phenomena, holism and mysticism are preferable to small-minded Western reductionism:
One of the most fundamental teachings of Western science is that natural phenomena are best studied by separating them into their component parts, to observe them, uninfluenced by surrounding variables; but it’s fundamental to Chinese medical teaching that attempts to do this are senseless, ’cause you can’t really find out how something functions unless it’s functioning in harmony with the other characteristics that are involved with it. Interdependence, and inter-relatedness, in this philosophy, are at the very basis of why things happen the way they do. Involved in the inter-relatedness of all things is the principle of Qi…an abstract form of influence analogous to what an American might call vital energy or life force. We’re not quite sure what they are, but many of us believe there is such a thing.
Rigid, orthodox, Western scientific dogma points to the need for a new paradigm:
Traditional Chinese Medicine is a vast collection of never-proved, time-honored theories, many of which have also been honored by a considerable degree of success. So far, the basis of that success has never been shown, or explained, to a degree that is completely acceptable to orthodox, Western scientists using orthodox, Western, investigative techniques…what is needed is a new paradigm; a new way of looking at, and interpreting, all of the evidence and observations that we make of the processes of diseases and health…there are phenomena that cannot be fully explained by today’s biomedical science.
Stubborn Western scientists would, it seems, sacrifice the practical for the theoretical, even when faced with overwhelming evidence for the former. Nuland quoted James Reston’s report about Chinese surgeons and acupuncture anesthesia:
…while they cannot agree on the theory of how needle anesthesia works, they are increasingly convinced that it does work, and they’re operating on the pragmatic evidence and they are not waiting for theoretical justification. There is enough objective evidence of practical medical information in the use of acupuncture to justify exploration by somebody more scientific than newspaper reporters.
Dr. Nuland, like so many others, misrepresented James Reston’s personal experience with acupuncture:
…postoperatively, he had a significant amount of pain, pain in the wound, gas pain, this sort of thing, and they treated the wound with acupuncture on each occasion that it occurred, and it worked every single time.
He also offered the standard, exaggerated claim of acupuncture’s antiquity:
The earliest description of acupuncture that has been found was written in about 900 B.C.
Dr. Nuland reported having observed a woman undergoing excision of thyroid cysts under acupuncture anesthesia. She had received phenobarbital, 40 mg, prior to arriving in the operating room.
Just before the surgical drapes were put into place Mrs. Hu had been given an intravenous dose of 40 mg of Demerol, also not an awful lot, and 4 mg of droperidol, which is a tranquilizing agent. Small to moderate amounts, they seemed to have no effect whatsoever on her level of consciousness.
Perhaps not, but the combination of Demerol (a narcotic) and droperidol (a neuroleptic ) would have had a substantial effect on her perception of pain. Such a combination was in vogue in anesthetic practice 2-3 decades ago, and produced a remarkable state of indifference to pain in awake patients. The quoted droperidol dose was not small to moderate, moreover, but substantial. Nevertheless,
I’m convinced that what I saw of surgical acupuncture is exactly what people claim it is: it’s a profound elevation of the pain threshhold and tolerance brought about by a mechanism or mechanisms that have not yet been fully explained in terms that are acceptable to Western science–its paradigm of biomedical science.
Dr. Nuland mentioned nothing of the Cultural Revolution, of the overwhelming political pressures that had occurred at that time, or of the exposés of surgical torture that appeared in its aftermath—although this information had been available for nearly three decades. Even if he believes that there is something to ‘acupuncture anesthesia,’ this information should have been part of a Distinguished Lecture given to the NCCAM in 2009.
*The ‘Acupuncture Anesthesia’ series:
- “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part I)
- “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part II)
- “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part III)
- “Acupuncture Anesthesia”: A Proclamation from Chairman Mao (Part IV)
- ‘Acupuncture Anesthesia’ Redux: another Skeptic and an Unfortunate Misportrayal at the NCCAM