NATIONAL INSTITUTES OF HEALTH
NATIONAL CENTER FOR COMPLEMENTARY AND ALTERNATIVE MEDICINE
First Straus Lecture:
Acupuncture and Medical Paradigms
An illustration of acupuncture points from an early Chinese medical textbook
World Health Organization
The patient, who was conscious and on little medication, groaned loudly—but not because a surgeon was operating on the front of her neck.
She had been immobilized in a half-upright position for quite awhile, and it was getting uncomfortable, she said.
As for having her thyroid resected, "I can tell that I'm being cut, but there isn't any pain. I just feel something is going on."
With the help of four acupuncture needles bolstered by a low electrical current; small doses of several conventional drugs; and coaching in some mind-body techniques, she was conscious during a thyroid operation—without general anesthesia or, later on, postoperative pain drugs.
Her case—at Hunan Medical University, in Changsha, China—helped illustrate the first Stephen E. Straus Distinguished Lecture in the Science of Complementary and Alternative Medicine, given at NIH on March 10, 2009. Sherwin Nuland, M.D., spoke on "Chinese Medicine, Western Science, and Acupuncture."
Dr. Nuland is a clinical professor of surgery at Yale School of Medicine, where he also teaches bioethics and medical history. He has written over one dozen books, including How We Die, which won the National Book Award; The Uncertain Art: Thoughts on a Life in Medicine; and his 2009 book, The Soul of Medicine. His writing has also appeared in Time, The New Yorker, and many other publications.
Sherwin B. Nuland, M.D.
© Lisa Helfert
Dr. Nuland took the NIH audience on a journey to cities, towns, operating rooms, and clinics in China, where, in the late 1980s to mid-1990s, he witnessed a number of procedures and met many practitioners of traditional Chinese medicine as director and chairman of the Yale-China Medical Association.
"Sherwin Nuland is one of the early investigators who observed demonstrations of pain relief from acupuncture, as had been reported by other Western observers-including, famously, columnist James Reston of The New York Times," Jack Killen, M.D., Deputy Director of NCCAM, told Complementary and Alternative Medicine. "Dr. Nuland and others laid the foundation for today's efforts to understand acupuncture in scientific terms and pursue effective and safe applications."
Observing such cases and talking to medical colleagues in China led Dr. Nuland to think about what could explain these effects of acupuncture, and whether the effects could be separated from beliefs underlying the practice of traditional Chinese medicine (for example, in qi, a vital energy or life force, and in yin-yang theory).
In the case described earlier, the 34-year-old factory worker had been diagnosed with thyroid cysts. After her admission for surgery, Dr. Nuland said, she was coached in some techniques for relaxation, abdominal breathing, and "confidence." Shortly before surgery her anesthesiologist chose four acupuncture "points" on her body for needle insertion. The needles were connected to a small battery that provided a low-frequency, low-intensity current.
Throughout the operation, by observing and talking to his patient, he would ascertain how his analgesic measures were working. The medications she received were 40 milligrams (mg) of phenobarbitol, 40 mg of meperidine, and 4 mg of droperidol.
Dr. Nuland was startled at the outset as the surgeon gripped the patient's skin tightly in "the most brutal clamp I know of in surgery"—the Coker clamp—and she did not react. Through the rest of the operation, she appeared relaxed, even bored, with an occasional mild grimace. Besides the sensation of "someone working," she reported two instances of brief, intense heat, when muscles and ligaments were cut; some minor pain, when tissue was cut away; and a few pinprick-like sensations, when stitches were inserted.
Immediately afterward, this patient was smiling and conversing with the staff. When Dr. Nuland saw her 2 days later, she said that the surgery had been "a good experience" and that she felt fine and had not needed any postoperative pain medication (which he verified in her chart).
Dr. Nuland said that her surgeon, who was Western trained, told him, "[Acupuncture] is not really anesthesia… it doesn't really relieve pain [but] increases the patient's ability to tolerate the pain," although not all kinds of pain. Her anesthesiologist said that surgical acupuncture analgesia succeeds about 80 percent of the time; it works better for certain kinds of surgical pain (such as surgery to the head—including the brain—or neck) than others (abdominal surgery, for example).
How does one explain these effects, Dr. Nuland asked? He had carefully considered the possibilities of hoax, autosuggestion, or placebo effect, but was convinced otherwise. Discussions with his colleagues practicing in China yielded many insights and convinced him that acupuncture should be further investigated scientifically.
Since that time, various "Western" explanations have been proposed and investigated, such as the gate control theory of pain—in this case, that electricity or a multitude of small pain stimuli from the needles overloads the nervous system to a degree that the larger bulk of surgical pain cannot get to the brain and thus enter awareness.
More recently, evidence has emerged indicating that acupuncture is effective in raising the threshold of pain because it increases production of endorphins. The effects of endorphins can be blocked by nalaxone, a narcotic-antagonist drug. Endorphins become markedly elevated in the brain and blood in response to acupuncture, according to research carried out in both China and the West.
"All this provides a reasonable explanation for the effectiveness of surgical acupuncture," Dr. Nuland said in closing. "But 'reasonable' does not mean 'proven' or 'well documented' enough to satisfy the rigorous criteria of experimental science.
"Traditional Chinese medicine is a vast collection of time-honored theories, many of which have also been honored by a considerable degree of clinical success," he continued. "Any experienced clinician might tell you that there are phenomena that cannot be fully explained by today's biomedical science…I find myself agreeing with [others] who have said that further study is indeed needed."
An archived copy of Dr. Nuland's lecture may be viewed on the Internet at nccam.nih.gov/news/events/lectures/straus2009mar.htm.
