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In Memoriam: Dr Felix Mann 1931-2014

Felix Mann

The death earlier this month of Dr Felix Mann after a long illness marked the end of an era for me, as it no doubt did for many doctors who learnt acupuncture from him in the 1970s. I first met him when I attended his course in 1977. At that time I was interested in oriental philosophies and that made me want to learn acupuncture, but I had no idea how to go about it. Then I happened to talk to a consultant who was head of the Migraine Clinic and who had recently done Felix's course. She told me it was worth while, so I registered for it.

The course was held in Felix's consulting rooms in the large house he had bought in Devonshire Place, in the West End of London. It lasted five days. There were fourteen of us. We sat in a semicircle on rather hard chairs while Felix stood in the middle and talked to us. From time to time patients would arrive to tell their stories and be treated. This was what I was expecting, but there was an early surprise.

Before starting the course we were supposed to read Felix's books. At that time they were based on traditional Chinese acupuncture and I don't think that any of us made very much of them. But this didn't matter because the first thing that Felix said to us was "I don't believe this stuff any more."

I have to admit that my initial reaction was disappointment, since, as I've said, it was an interest in Eastern ideas that had prompted me to learn acupuncture in the first place. But it was undoubtedly a relief to hear that I didn't need to struggle with all this complicated esoteric stuff, and later I was very grateful to Felix. Probably I should have come to a similar conclusion eventually, but he saved me a great deal of time. After the course I set up an acupuncture service at The Royal London Hospital for Integrated Medicine using the methods I had learnt from Felix. Modern medical acupuncture is still one of the main forms of treatment used there.

From our present standpoint in the second decade of the 21st century it is perhaps difficult to realise just how radical Felix's "acupuncture revolution" was. In the late 1950s people thought of acupuncture — if they thought of it at all — wholly in traditional Chinese terms. To describe it in the way he did required Felix to rethink everything he had been taught about acupuncture by all the 'experts' he had encountered.

Felix's acupuncture career

Acupuncture had been practised by quite a number of British doctors in the 1820s but had later fizzled out. By the twentieth century it was virtually unknown here, although it was still used quite extensively in mainland Europe, especially France and Germany. By this time it had become quite traditional, although that had not been the case in the nineteenth century.

As a young doctor Felix travelled abroad to widen his experience; this was easy for him because he was a good linguist and had plenty of contacts in Europe. He saw acupuncture being used and was impressed by the results, which made him want to learn it himself. He studied at Montpellier in the south of France and at Munich and Vienna. Later, he even studied Chinese with the help of sinologists in Britain so as to be able to read the classic texts. So his subsequent abandonment of the traditional system wasn't due to lack of knowledge. It was based instead on fresh thinking and exact clinical observation.

By the time I met him in 1977 he had rejected practically all the traditional ideas about acupuncture. He now regarded it as a means of altering the activity of the nervous system and as a treatment that could be explained in terms of the modern understanding of anatomy and physiology. There was no need to talk about qi or yin and yang.

According to his new view, neither acupuncture points nor the so-called meridians exist as they are usually understood. Great precision in locating 'points' is unnecessary; instead we should be thinking of areas. In many cases these could be quite large: for example, in some patients needling anywhere below the knee might have the same effect as using the classic point Liver 3 (Felix's favourite site).

He introduced other departures from tradition as well. One was the use of periosteal (bone) needling, both to treat joint pain such as that due to arthritis and also to produce more generalised effects in a wide area. Another was his recognition of a subset of patients who responded particularly strongly to acupuncture, whom he designated strong reactors. Disorders that usually don't respond to acupuncture might do so in a strong reactor. But if a strong reactor were treated too vigorously the result could be a worsening of the symptoms or a feeling of general malaise lasting for some hours or even days.

As time went by Felix came to believe that many traditionalists over-treated their patients. Increasingly he favoured very gentle treatment, with the insertion of few needles — sometime only one — and the duration of needling being brief: seldom more than a minute or two and quite often just a few seconds.

While these ideas usually horrified traditionalists they were certainly easier for doctors trained in modern medicine to understand and accept. This was fortunate because more now wanted to learn. Felix had started teaching acupuncture to doctors in the 1960s although at first few came forward to learn. But in the 1970s the numbers increased, partly because attitudes to unorthodox treatments were beginning to change but also because advances in the scientific understanding of pain were making acupuncture seem more comprehensible in modern terms. Another influence was President Nixon's visit to China in 1972, which aroused interest in acupuncture on the part of a number of prominent British and American doctors.

Felix's former students constituted an informal medical acupuncture society. He used to circulate a yearly newsletter and each year, in November, he held an acupuncture meeting in his rooms for 70 doctors. There would be seven or eight speakers, usually including Peter Nathan, a well-known neurologist, and Felix provided an excellent lunch, with wine. Attendance was free to his former students; others paid a small fee which cannot have come even near to covering Felix's expenditure.

In 1980 matters were made more formal when the British Medical Acupuncture Society, constituted mainly by Felix's former students, was founded; he was its first President. It now has over 2000 members.

Felix's legacy

The fact that the acupuncture practised today by British health professionals is mostly non-traditional is largely thanks to Felix. Outside Britain the change has been more gradual. In much of Europe, apart from Sweden and Portugal, and in North and South America, traditional ideas are still influential. But the journal of the British Medical Acupuncture Society, Acupuncture in Medicine, is now a BMJ publication, so Felix's aim of making acupuncture an accepted form of treatment within mainstream medicine has mostly been accomplished. Perhaps most striking of all is the fact that an increasing number of the papers being submitted to the journal now come from China itself.

Felix wrote several books about his later view of acupuncture. The most important of these was Reinventing Acupuncture: A New Concept of Ancient Medicine. The first edition appeared in 1993 and the second in 2000. Here he described how his understanding of the treatment evolved and gave practical details of his methods. I still dip into it from time to time and continue to be impressed by how much my own experience agrees what he describes. All of us who use acupuncture today in a modern context are deeply indebted to him.

Westerners' misconceptions about Chinese Medicine

When alien ideas are imported into a culture they are pretty well inevitably misunderstood. This happens in religion - how many Christians think of Christianity as a Near-Eastern religion? (There is the probably apocryphal remark by an American congressman: "If English was good enough for Jesus it's good enough for me.")

The same is true of medicine. The current enthusiasm for Chinese medicine is based on a pretty distorted view of what Chinese medicine actually is. One good source for correcting this misconception is Shigehisa Kurihama's book The Expressiveness of the Body and the Divergence of Greek and Chinese Medicine.

Another that I've recently come across is Nigel Wiseman's Westerners' Alternative Health-Care Values Eclipsing a Wealth of Knowledge. available here.

This is a long scholarly discussion of the subject. The topics include:

- Western motives for adopting Chinese medicine
- Influences of spiritual, physical, and philosophical traditions of the Orient
- Inaccurate characterisations eclipsing a body of knowledgge
- Intuition
- The root problem and the solution

The 'solution' proposed is, in outline, more and better translation of the Chinese texts.

From Wiseman's conclusion:

Too often, Chinese medicine is prized for certain qualities judged to be lacking in Western medicine. There is a tendency to assume that any desirable qualities that Western medicine lacks must be present in Chinese medicine, and to project those qualities onto Chinese medicine. In the process of projecting ideas onto Chinese medicine, other features have been obscured. I have argued against the false assumption that clinical experience and intuition are exclusively features of Chinese medicine, while theory and book-learning are characteristics of Western medicine that are of little import to the traditional Chinese physician.

This is an important article for anyone who is seriously interested in Chinese medicine.

New light on acupuncture mechanism

A new paper in Nature Neuroscience has contributed to our understanding of how acupuncture relieves pain (Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture:

We found that adenosine, a neuromodulator with anti-nociceptive properties, was released during acupuncture in mice and that its anti-nociceptive actions required adenosine A1 receptor expression. Direct injection of an adenosine A1 receptor agonist replicated the analgesic effect of acupuncture. Inhibition of enzymes involved in adenosine degradation potentiated the acupuncture-elicited increase in adenosine, as well as its anti-nociceptive effect. These observations indicate that adenosine mediates the effects of acupuncture and that interfering with adenosine metabolism may prolong the clinical benefit of acupuncture.

This work was done in mice so its relevance to human acupuncture remains to be shown. But probably the authors' research does explain part of the analgesic effect of acupuncture. In their discussion they make a couple of interesting points. One, with which I agree, is that the mechanism of action of other kinds of physical treatment, such as chiropractic and osteopathy, may be similar to that of acupuncture. Another is that non-penetrating pressure on the skin, used in some attempts to find a placebo for acupuncture trials, may also cause transient increases in adenosine. Adenosine has anti-inflammatory effects as well as relieving pain, which may explain how acupuncture works for acute injuries such as sprains and tenosynovitis.

Manual stimulation (twisting) of the needles was necessary to produce the effect.

The authors appear to discount the central effects of acupuncture (effects on the spinal cord and brain). But there is a lot of research to support a central mechanism and I think it likely that the adenosine mechanism is part but not all of the explanation for how acupuncture works.

Latest acupuncture trial for back pain

The current issue of Archives of Internal Medicine (17 September 2007) has a report of a German study of acupuncture for chronic low back pain. The findings agree with those of several other German studies published recently, which show that acupuncture does work but it often makes little difference where the needles are inserted. Acupuncture, in other words, does not depend on the traditional theory; whether or not it is just a placebo remains an open question.

This article is reported in today's Independent, and is accompanied by a rather misleading case history. A young student had severe back pain which is responding to twice-weekly acupuncture from a traditional acupunturist. Each session lasts 50 minutes and costs £45, so she is apparently paying £90 a week regularly.

I would regard this as a treatment failure. If acupuncture is successful its effects should last much longer than this; the research article quotes six months. It is also unnecessary to leave the needles in for 50 minutes; quite brief insertion, lasting no more than a few minutes or even seconds, is equally effective and much more practical for use in a NHS setting.