Br. J. Anaesth.

(1974), 46, 361

ACUPUNCTURE ANALGESIA
Report of 100 Experiments

FELIX MANN

SUMMARY
Acupuncture analgesia was performed on 100 occasions in 35 subjects. In 10% of

Downloaded from https://academic.oup.com/bja/article/46/5/361/259002 by guest on 08 January 2024

cases the resulting analgesia was considered just adequate for surgery, and in 65%
mild analgesia was produced but insufficient for surgery, whilst in the remaining 25 %
there was only minimal analgesia, if any. Some of the subjects with mild analgesia
could have been sufficiently anaesthetized for surgery if the pain of the stimulus had
been increased to an unacceptably high level.

Acupuncture analgesia has caught the imagination
of many Western doctors despite the serious prob-
lems in its application. The author has had experi-
ence of acupuncture therapy and it was decided to
investigate the properties of acupuncture analgesia.
SUBJECTS AND METHODS
One hundred experiments were performed in 35
subjects, including patients, friends and the author.
Acupuncture points used.
Large intestine 4 (Li4), between the 1st and 2nd
metacarpals, produces analgesia of the front of the
face and neck, the teeth and tonsillar areas (Mann,
1966). Stomach 44 (S44), just proximal to the web
between the 2nd and 3rd toes, reinforces the effect
of Li4. Triple warmer 5 (T5), about 2 inches proxi-
mal to the wrist on the dorsal side, induces analgesia
from the base of the neck to about a level of 2
inches below the breast in a woman, both on the
front and on the back of the chest, a distribution
of about C4 to T7. Pericardium 6 (P6), which is on
the anterior surface of the forearm about 2 inches
proximal to the wrist, has an effect similar to T5.
On a few occasions other acupuncture points were
used, including ear points: S36, S40, Sp6, S25,
S27, L l l , L10, endocrine ear point and Cv6.
Type of stimulation.
In therapeutic acupuncture a mild stimulus, con-
tinued for 1-10 sec, is all that is usually required.
The amount of pain produced is similar to that of a
hypodermic injection.
FELIX MANN, M.B., B.CHIR., 15 Devonshire Place, London
WIN 1PB.
In acupuncture analgesia the stimulation must be
continued for about 20 min or even longer to pro-
duce the maximum effect. The amount of pain
produced by the stimulation should be the maximum
that the patient can withstand.
The type of stimulus used for analgesia is
immaterial. If a needle is used it is mosc convenient
if it is of 26 or 28-gauge stainless steel and may be
placed subcutaneously or deep in the muscles. The
needle is then twisted with a to-and-fro motion
between the fingers.
The needle may also be stimulated electrically, in
which case a thinner 30-gauge needle is sufficient.
Initially a Grass Universal Stimulator was used and
later an instrument made for the purpose in China.
Naturally one always tries to use the minimum cur-
rent. The negative pole has a greater effect than the
positive. Whether the positive is used to activate a
second needle or is earthed via an e.c.g. plate elec-
trode at a variable distance from the active needle
is unimportant.
Tests used to determine degree of analgesia.
In most cases the degree of analgesia was deter-
mined by pinpricks. A 23-gauge hypodermic needle
was used, pricking hard enough to draw blood on
most occasions. Light pinprick was found not to be
a good test. It is necessary to do a large number of
pinpricks, so that one is not confused by the normal
variation in response.
In some instances the pain response was deter-
mined by drilling the teeth with a dental drill or by
freezing with ethyl chloride. On other occasions an
accurate electric dental stimulator was used.
It should be noted at this point that when acu-
 362
puncture points are used which have an effect on the
throat, the gag reflex is reduced, but not abolished.
RESULTS
Type of analgesia produced by acupuncture.
Pain is the only sensation affected by acupuncture
analgesia. All other sensations are completely
normal. Hence this method should be called
acupuncture analgesia rather than acupuncture
anaesthesia.
The subject is completely unaware of which area
has become analgesic. The area can only be deter-
mined by pinpricks over the whole body, although
in this instance very light pricks are satisfactory. If
the analgesic area is touched by the patient or doctor
it feels completely normal. Temperature sense and
the appearance of the skin or mucous membrane are
unaffected.
In the initial experiments both subjects and
observer were misled as both expected to find an
area of numbness, similar to that found with local
anaesthesia. It was only later when, more or less
by chance, testing by pinpricks was started it was
realized that the desired result had already been
achieved. The Chinese have never made this point
clear.
It was considered that those patients who felt no
pain response to multiple heavy pinpricks could
have undergone surgery without pain. In these
patients the needle could have been inserted through
the subcutaneous tissue and muscle to the peri-
osteum, which was likewise analgesic.
It should be stressed that these subjects felt the
drilling of teeth, but did not feel pain. This is quite
different from local anaesthesia where only minimal
sensations are felt. It is disconcerting for a subject
to see and feel a needle passing through his tissues
without pain. Sometimes with the drilling of teeth
there was initial onset of pain which did not then
develop as expected. In this group the type of
analgesia was satisfactory and consists of roughly
10% of subjects.
In the next group, constituting 65% of subjects,
the analgesia was either patchy or mild in intensity.
Within the analgesic area, the subject felt pain in
response to pinprick, in a somewhat patchy and
irregular fashion. Alternatively or in addition the
subject felt no pain on mild pinprick stimulation,
but felt pain with heavier pricks. The gag reflex
was diminished to a lesser extent with these
subjects.
Finally there was a group of 25% of failure
BRITISH JOURNAL OF ANAESTHESIA
subjects in whom acupuncture analgesia could not
be produced. Though it should be pointed out that
it was occasionally difficult to decide to which of
the three groups a given subject should be assigned.
Analgesic area.
The area which becomes analgesic is determined
by the choice of acupuncture point or points.
If an acupuncture point on the right arm is
chosen, which has an effect on the right upper
Downloaded from https://academic.oup.com/bja/article/46/5/361/259002 by guest on 08 January 2024
quadrant of the body, then there will also be a mild
and patchy analgesia on the left upper quadrant of
the body. Likewise there may be an even milder
analgesia in the right lower quadrant and no anal-
gesia or nearly so in the left lower quadrant.
If a single acupuncture needle produces analgesia
in the whole of the operative field, there does not
seem to be any advantage in adding extra needles,
provided the single needle is stimulated sufficiently
strongly.
In five patients acupuncture analgesia was per-
formed in the normal manner. The subjects were
told to expect analgesia in a different area of the
body from that in which it was expected by the
observer. In two of the five subjects in whom satis-
factory analgesia was produced, the area corre-
sponded to the area expected and did not occur in
the area the subjects were instructed to expect it.
In several other experiments (with previously un-
tried acupuncture points), patients became analgesic
in the "correct" area and not in the area erroneously
expected by the operator.
Degree of analgesia.
The results reported above are not as impressive
as those described in China, which suggested that
the technique was inadequate. The Chinese, it
should be noted, have made available very little
technical information on the subject.
This impasse was resolved when, due to an intro-
duction by Dr Tim Horder of the Department of
Physiology, Oxford University, and Dr L. K. Ding
(Hong Kong), the author met two Chinese doctors
who between them had, whilst in China, anaes-
thetized several hundred patients by acupuncture.
They performed acupuncture analgesia three times
on the author, twice using mechanical rotation of
the needle and once electrical stimulation. In all
three instances there was a very mild but far from
complete analgesia. The two Chinese doctors
thought that if the stimulus had been increased, the
analgesia would have been adequate. However, the
ACUPUNCTURE ANALGESIA 363

pain was not far from the maximum tolerable. On
several other occasions Western doctors or patients
have been subjected to acupuncture analgesia
administered by Chinese doctors or others who say
they rarely have a failure. In most of these instances
where the subject has not been suitably psycho-
logically prepared, the result has been failure.
DISCUSSION
Patients in whom acupuncture analgesia works well. most it is a distraction.
The 10% of patients in my series, where acu-
The better of the moderate reactors, though, can
only be anaesthetized if the stimulus is increased to
a level which is not really acceptable in the West.
The pain of stimulation is the absolute maximum
the patients can withstand. The pain is so severe
that, even though lying horizontally, the patients
sometimes feel they are almost fainting. Interest-
ingly, despite this severe pain, they can carry on an
animated conversation and even smile—in fact for

Downloaded from https://academic.oup.com/bja/article/46/5/361/259002 by guest on 08 January 2024

puncture analgesia worked well, belong to a group Type of stimulation.
of people who may be called "strong reactors". The optimum pattern of stimulation has not yet
They may be recognized in various ways: been determined in the twenty experiments in which
the frequency, duration of impulse and wave form
(1) They often react strongly to a large number
were varied and the impression gained is that these
of drugs. This is not an allergy which occurs to only
factors are not of particular importance as long as
one or two drugs. These patients usually take half
sufficient pain is produced by the stimulus.
the dose of whatever medicine their doctor pre-
scribes them; if they take the normal dose they feel
ill. Acupuncture points.
Acupuncture points have no special properties.
(2) This same type of patient reacts not only In most instances they correspond with an area of
strongly to drugs, but also to acupuncture. If they nerve distribution coupled sometimes with anatomi-
have an illness which in an average patient would cal and other factors. They are reflexly tender areas
require four acupuncture treatments to cure or s:milar to McBurney's point in appendicitis (Mann,
alleviate, these patients are cured in one treatment.
1973). It is convenient enough to speak of acupunc-
When these patients are treated by acupuncture the
ture points rather than give an elaborate anatomical
needle should only be manipulated gently, as when
description.
treating a child, for if they are given the normal
adult dose, they may temporarily have an adverse Mechanism of acupuncture analgesia.
reaction. (1) Parsons and Goetzl (1945) found that a pain-
(3) If an acupuncture needle is put into, say, the ful counter-irritant raised the threshold of pain for
foot of an average patient, he will feel mild pain for at least 2 hours after the painful stimulus had ceased
a small area around the needle. A strong reactor, being used. In acupuncture analgesia, a partial anal-
though, feels the pain up the whole leg and possibly gesia also remains for ouite a long time after stimu-
also in distant parts of the body. lation has been stopped.
(4) The experienced physician can sometimes (2) The gate control theory of Melzack and Wall
recognize a strong reactor on sight. (1965), could be modified to include several gates.
Some doctors say that acupuncture analgesia The authors themselves are uncertain of this.
works well in strong reactors as they think they are (3) Hypnosis: even if it is unintentional, some-
more easily hypnotized. This is not the case in this thing allied to hypnosis may be taking place. If a
series, for there were two strong reactors in the early patient expects analgesia to work, it will influence
experiments, before the patient or the observer knew the outcome in many cases. In this series of 100
what to expect. experiments in 35 patients this hypnotic factor was
excluded, as the patients were always told the
Achieving acupuncture analgesia in moderate results that had been achieved in others up to that
reactors. date, results which, as you see, are somewhat
Acupuncture analgesia may be achieved in a mediocre.
strong reactor with a fairly severe stimulus. The At the moment one is inclined to think that acu-
degree of stimulation required is extremely un- puncture analgesia is halfway between a physical
pleasant but can be borne without too great diffi- and a mental phenomenon. It is similar, perhaps, to
culty. asthma which can be influenced by both physical
364
and mental means. In support of this, R. Melzack
has shown that dental analgesia may be achieved
when white sound is combined with strong mental
suggestion. White sound by itself, or only sugges-
tion, produces no result (Melzack, Weisz and
Sprague, 1963).
The stimulus required to achieve acupuncture
analgesia is so intense that the resulting pain would
be unacceptable to most Western patients. Possibly
the method could be developed so that a low level
of stimulation would be adequate.
Most patients undergoing major surgery in this
country prefer to be unconscious and unless there
were major advantages in acupuncture analgesia
such as less disturbance of body metabolism and
less postoperative complications, it is unlikely that
this method would succeed chemical anaesthesia
which is one of the best developed aspects of
Western medicine. Perhaps acupuncture analgesia
will have proved to have certain advantages under
special circumstances. Western medicine could to
greater advantage investigate and develop the
properties of therapeutic acupuncture which is of
BRITISH JOURNAL OF ANAESTHESIA
value in many disorders intractable to orthodox
medicine.
ACKNOWLEDGEMENTS
I would like to thank the 35 friends and patients who
took part in these experiments. My thanks are also due to
the Department of Medical Electronics at St Bartholo-
mew's Hospital, who loaned to me a modified Grass
Universal Stimulator, and Dr D. Saltoun from whom I
borrowed the Chinese stimulating instrument. I would
also like to thank Dr E. Isakowitz with whom I performed
some of the early experiments, Dr David Bowsher, and
Dr J. Mumford of Liverpool University, with whom
Downloaded from https://academic.oup.com/bja/article/46/5/361/259002 by guest on 08 January 2024
several of the later experiments, with measurements,
were conducted.
REFERENCES
Mann, F. B. (1966). Atlas of Acupuncture. London:
Heinemann Medical.
(1973). Acupuncture: the Ancient Chinese Art of
Healing, 2nd edn., Chaps. I, XI, XIV. London: Heine-
mann Medical.
Melzack, R., and Wall, P. D. (1965). Pain mechanism: a
new theory. Science, 150, 971.
Weisz, A. Z., and Sprague, L. T. (1963). Strata-
gems for controlling pain: contributions of auditory
stimulation and suggestion. Exp. Neural., 8, 239.
Parsons, C. M., and Goetzl, F. R. (1945). Effect of
induced pain on pain threshold. Exp. Biol., 60, 327.