Let us be certain of a fact before being concerned with its cause. It is true that this method is too lengthy for most people who naturally run to the cause and overlook the certitude about facts; but at last we will avoid the ridicule of finding the cause of what does not exist.1
Bernard le Bovier de Fontenelle (1657-1757)
Amidst the plethora of flawed, implausible, and wasteful research on acupuncture and Chinese medicine, a 2002 study on the “Relationship of Acupuncture Points and Meridians to Connective Tissue Planes” stands out as the height of factual neglect. In it, Helene Langevin and Jason Yandow of the University of Vermont’s College of Medicine claim to have matched real anatomical structures with the elusive acupuncture “meridians.” It should be noted that the widely accepted term “meridian” is a metaphor coined by George Soulié de Morant (1878 – 1955), a French delegate to China, and has no semantic relationship with the original Chinese word.2 The original designation is the composite word jing luo (經絡), which literally means “channel-network.” The term has been translated to English as chinglo channels, channels, vessels or more commonly, meridians. Debunking this study is of particular relevance because it is often used by acupuncturists and a wide range of other CAM providers to legitimize the meridian lore. The principle author, Helene Langevin, is a CAM celebrity and a member of the “Scientific Committee” of the International Fascia Research Congress, an organization dedicated to the “emerging field of Fascia Studies.” She is an Associate Professor of Neurology and the Director of the Program in Integrative Health at the University of Vermont; and has conducted multiple NCCAM-funded studies on the role of connective tissue in chronic pain, acupuncture and manual therapies.
In November 2010, the California Department of Consumer Affairs (DCA) finally decided to act responsibly and forbid the prevalent practice of Chinese bloodletting by licensed acupuncturists.
The practice became a concern for the DCA when allegations of unsanitary bloodletting at a California (CA) acupuncture school surfaced.
The incident allegedly occurred during a “doctoral” course for licensed practitioners. The instructor was reportedly demonstrating advanced needling and bloodletting techniques. During the process, he took an arrow-like lancing instrument that is called a “three-edged needle” (三棱针), sharpened it with sandpaper, cleaned it with alcohol, and then asked a student-volunteer to roll a towel around his neck (similar to what is depicted in Image 1). The instructor then cleaned the student’s temporal region with alcohol, and punctured a superficial blood vessel with the arrow-like instrument. The student then held his head over the garbage can, gushing blood for a while.
Images 1 & 2. Chinese bloodletting. Image 1 shows a technique used to bleed the head or the face, where a towel is rolled around the neck to control the arterial pressure. Image 2 shows the practice of “wet cupping.”
The ancient practice of bloodletting, with or without cupping, is still widely used in Chinese medicine to remove “stagnant blood, expel heat, treat high fever, loss of consciousness, convulsion, and pain.”1 The amount of blood let depends on the condition, and the location of the incision. A contemporary book recommends letting a tiny amount from a point adjacent to the thumbnail for a condition described as “wind-heat invasion” of the lung. The symptoms associated with this unscientific nomenclature include chills and fever, sore throat, stuffy or runny nose, and a yellow discharge,2 which could correspond to many respiratory conditions, including the common cold, influenza, pneumonia, etc.
A recent study published in the Archives of Opthalmology compare patching of one eye vs acupuncture in the treatment of amblyopia in older children, and finds positive results from acupuncture. The study, and its press, are a good example of the hazards of studying highly implausible modalities.
First let’s dissect the study itself – from the abstract:
In a single-center randomized controlled trial, 88 eligible children with an amblyopic eye who had a best spectacle-corrected visual acuity (BSCVA) of 0.3 to 0.8 logMAR at baseline were randomly assigned to receive 2 hours of patching of the sound eye daily or 5 sessions of acupuncture weekly. All participants in our study received constant optical correction, plus 1 hour of near-vision activities daily, and were followed up at weeks 5, 10, 15, and 25. The main outcome measure was BSCVA in the amblyopic eye at 15 weeks.
For background, amblyopia occurs when the brain tends to ignore visual information from one eye. This results from a variety of causes, but commonly from the two eyes having different refractive errors (anisometropic) – one eye may be more near-sighted or far-sighted than the other. The brain cannot combine information from both eyes, so it ignores one. This can be corrected in younger children, up to age 7, by correcting the vision for the refractive problems. If visual correction alone is not enough, then patching one eye (the strong eye) to force the brain to use the weak eye can be effective. This is usually done for only 2 hours a day, otherwise amblyopia of the patched eye can occur.
The worst part of flying is the take off and landing. Not that I am nervous about those parts of the trip, it is that I am all electronic. Once I have to turn off my electronic devices, all I am left with is my own thoughts or what is in the seat pocket in front of me. Since there is nothing to be gained from quiet introspection, I am stuck with either the in-flight magazine or SkyMall. I usually choose the latter. SkyMall, for those of you who do not fly, is a collection of catalogs bound in one volume. I have occasionally purchased products found in SkyMall and thumb through it with mild interest.
This time one product caught my eye, the Aculife home acupuncture/acupressure device. I had never noticed the ‘health’-related products in SkyMall before, usually looking for electronic gadgets that I really do not need. I was curious. How many other products besides Aculife are in the catalogue? According to the interwebs, about 100,000,000 Americans fly every year and well over half a billion people world wide. A lot of people can potentially look at SkyMall, including the occasional skeptic.
Make the lie big, make it simple, keep saying it, and eventually they will believe it
– A. Hitler
It seems that just about every article about acupuncture makes some reference to it having been used in China for thousands of years. The obvious reason for such a statement is to make the implication that since it’s been around for so long, it must therefore also be effective. Of course, longevity doesn’t argue for efficacy, otherwise everyone would likely agree that astrology is the way to chart one’s life; astrology has been practiced for many more years than acupuncture.
What’s maddening about the acupuncture longevity myth is that it isn’t true, and demonstrably so. In human medicine, “needling” was illustrated in the 17th century by western observers: no points, no “meridians,” just a big awl-like “needle,” driven in with an ivory-handled circular hammer. In addition, the rationale for hammering these little spikes into various spots (of the practitioner’s choosing) was said to be “exactly the same” as Greek humoral medicine (see, Carruba, RW, Bowers, JZ. The Western World’s First Detailed Treatise on Acupuncture: Willem ten Rhijne’s De Acupunctura. J Hist Med Allied Sci (1974) XXIX (4): 371-398).
A couple of weeks ago, in a review of the Mayo Clinic Book of Home Remedies, Harriet Hall expressed relief that she hadn’t found any “questionable recommendations for complementary & alternative medicine (CAM) treatments” in that book:
Since “quackademic” medicine is infiltrating our best institutions and organizations, I wasn’t sure I could trust even the prestigious Mayo Clinic.
The Home Remedies book may be free of woo, but Dr. Hall was right to wonder if she could trust the Mayo Clinic. About a year ago I was asked to comment on an article in the American Journal of Hematology (AJH), in which investigators from the Mayo Clinic reported that among a cohort of lymphoma patients who were “CAM” users,
There was a general lack of knowledge about forms of CAM, and about potential risks associated with specific types of CAM…
This suggests the need to improve access to evidence-based information regarding CAM to all patients with lymphoma.
No surprise, that, but I couldn’t help calling attention to the paradox of one hand of the Mayo Clinic having issued that report even as the other was contributing to such ignorance:
The Mayo Clinic Book of Alternative Medicine details dozens of natural therapies that have worked safely for many patients in treating 20 top health issues. You may be surprised that Mayo Clinic now urges you and your doctor to consider yoga, garlic, acupuncture, dietary supplements and other natural therapies. Yet the record is clear. Many of these alternative therapies can help you achieve reduced arthritis pain, healthier coronary arteries, improved diabetes management, better memory function and more.
Nor could such a paradox be explained by the right hand not having known what the left was doing: Brent Bauer, MD, the Director of the Mayo Clinic Complementary and Integrative Medicine Program, is both the medical editor of the Book of Alternative Medicine (MCBAM) and a co-author of the article in the AJH.
As chance would have it, I had picked up a copy of the latest (2011) edition of the MCBAM only a couple of days before Dr. Hall’s post. Does it live up to its promises? Do its “straight answers from the world’s leading medical experts” respond to “the need to improve access to evidence-based information regarding CAM?” Let’s find out. In some cases I’ll state the implied questions and provide the straight answers.
Bloodletting, of course, was a major aim of early vessel therapy and is frequently described in the Su wen.1
Paul U Unschuld
“Cargo cult” is a metaphor that describes the act of imitating an activity or a practice without any insight into the underlying principles. In the literal sense, it refers to a magico-religious practice observed in tribal societies, where the members ritually imitate the activities of a technologically-advanced society they had contact with, so that they can magically draw their material wealth. For instance, after WWII, indigenous tribes in New Guinea who had come in close contact with cargo planes, started to build landing strips and populated them with plane-like effigies that were made of straw, bamboo, and coconuts, so that they can magically lure the passing planes.2 The term “cargo cult science” was introduced by Richard Feynman in a speech at Caltech in 1974 to describe pseudoscientific studies in which all the superficial aspects of a scientific inquiry are adhered to, but the underlying principles are not scientific. He classified many educational and psychological studies as such, for having the appearance of academic research but lacking the principles of a scientific inquiry.3
Another example of cargo cult science is the plethora of two-arm acupuncture studies that compare a needling regimen using the traditional concepts, and compare it with a non-interventional placebo. These studies might have the appearance of clinical research, but they are inherently flawed and inconclusive, because they do not rule out the possibility that the observed results are mainly due to the painful stimulus and injury caused by a needle, which can occur regardless of the insertion point. Indeed, an acute noxious stimulus from a prickle, heat, or any other painful stimulus – almost anywhere on the skin – can attenuate the perception of pain in another area of the body through a reflex called “counter-irritation,” also called the “pain-inhibiting-pain effect” or “diffuse noxious inhibitory control” (DNIC).4 DNIC was extensively studied by Fauve et al. in the 1980s, who showed in mice that it has an effect equivalent or superior to that of glucocorticoids.5,6
The bar on this blog is set high. The entries are often complete, with no turn left unstoned. Yet, not every topic needs the full monty with every post. The blog has extensive evaluations on many topics, and new medical literature doesn’t require another complete analysis. Many new articles add incrementally to the literature and their conclusions need to be inserted into the conversation of this blog, like a car sliding into heavy traffic. My eldest son just received his driver’s license, and car metaphors are on my mind. As are crash metaphors and insurance metaphors.
So in response to this need, a need only recognized by me, I give you Short Attention Span SCAM. Occasionally I will summarize a few recent studies and their key points as they relate to prior posts at SBM.
It can be rather frustrating to refute the same old canards about alternative medicine. There’s always been argument as to whether this is even useful. Critics (some verging on “concern troll-ism”) argue that skeptics are convincing no one, others that we are too “dickish”. The first view is overly pessimistic (re: our impact), the second overly optimistic (re: the benign nature of our critics). The truth always bears repeating, even at the risk of becoming the old guy at the end of the bar who always starts his stories off with, “Did I ever tell you…?” The answer is always “yes” but if the story is good, and well-told, it may stand up to re-telling.
We tell many versions of the same story over and over, not just to entertain each other, but to refine our thinking, to convince those who can be convinced, and to point out the weakness in thinking apparent in others. We do this not to be “dicks” but because repeated assaults on reason require repeated defense. Scientific medicine gives us a powerful tool for analyzing new ideas and old ones dressed up in new clothes. It allows us to find ourselves to be wrong in particular facts, if not in our overall approach.
One of the main topics that we’ve covered here on this blog over the last couple of years is the relatively rapid, seemingly relentless infiltration of pseudoscience into what should be bastions of science-based medicine (SBM), namely medical schools and academic medical centers promoted by academics who should, but apparently don’t, know better. From the very beginning, we’ve written numerous posts about this infiltration and how it has been facilitated by a variety of factors, including changes in the culture of medical academia and our own culture in general, not to mention a dedicated cadre of ideologues such as the Bravewell Collaboration, whose purpose is to blur the lines between science and pseudoscience and promote the “integration” of quackery into science-based medicine. Certainly promoters of what Dr. Robert W. Donnell termed “quackademic medicine” wouldn’t put it that way, but I would. Indeed, promoters of quackademic medicine scored a major victory last month, when a credulous piece of tripe about acupuncture passing as a review article managed to find its way into the New England Journal Medicine, a misstep that was promptly skewered by Mark Crislip, Steve Novella, and myself. It’s rare for more than two of us to write about the same topic, but it was earned by a mistake as dire as the editors of the NEJM allowing rank pseudoscience to sully its normally science-based pages.
Today, I want to riff a bit on one aspect of this phenomenon. As a cancer surgeon, I’ve dedicated myself to treating patients with cancer and then subspecialized even further, dedicating myself to the surgical treatment of breast cancer. Consequently, the interface of so-called “complementary and alternative medicine” (CAM) in the treatment of cancer both interests and appalls me. The reason for my horror at the application of CAM to cancer patients, as you might expect, is that cancer is a disease that is highly feared and can be highly deadly, depending upon the specific kind of cancer. Cancer patients deserve nothing less than the best science-based evidence that we have to offer, free of pseudoscience. Yet in even the most highly respected cancer centers, such as M.D. Anderson Cancer Center and Memorial Sloan-Kettering Cancer Center, there are departments or divisions of what is increasingly called “integrative oncology.” The claim behind “integrative oncology” is that it is “integrating the best of science-based and ‘alternative’ medicine,” but in reality all too often it is “integrating” quackery with science-based medicine. I have yet to hear an explanation of how “integrating” pseudoscience or nonscience into science-based oncology benefits cancer patients, but, then, that’s probably just the nasty old reductionist in me. Let’s find out.