Wednesday, March 03, 2010

Orthodox or Complementary Medicine?

I have been asked often for my views on this or that unorthodox - 'complementary' - medical system. There are a lot of them - and the list continues to grow.

The simple reality is that any therapy promptly becomes regular medical practice, if and when it is shown to work. Thus, by definition, 'complementary' medicine comprises theories and therapies which fail critical evaluation.
Nevertheless, unorthodox practitioners flourish and prosper. That is a telling commentary on human nature.

Any physician quickly learns that placebo, suggestion, and faith are wonderfully potent in symptom control - especially if they are exotic and expensive. In itself, an air of authority tempered by patience and kindness is seriously therapeutic, doubly so when backed by impeccable tailoring, and [shhh!] a hefty fee: "He must be good - look at his charges". [As a whole-time health servant I had to do without the vis medicatrix pecuniae.]

What is the placebo effect of surgery? Double-blind controlled trials are difficult or impossible in that specialty. In one famous example a popular procedure for angina pectoris was discredited when operated and sham-operated patients reported approximately equal benefits. No modern ethical committee would sanction such a trial.
As a physician I was often struck how patients are willing, sometimes eager, to submit to surgery.

A frequent problem for the physician is the persistent patient with multiple symptoms but no significant disease. The Germans call it 'Undhier Syndrome". ["O Doctor I have pain here, und hier, und hier, und hier."]
Patients with such problems are often best managed by an unorthodox practitioner. I found I was so advising more often as I grew older.

I confess on many occasions I have prescribed an injection of vitamin B12 as a deliberate placebo. Vitamin B12 is a perfect placebo. A powerful vitamin, essential for life, it is beautifully red, safe and cheap, and must be injected. I instructed nurses to draw up the dose in full view of the patient.
Unfortunately most patients so treated came back for more. Many were grateful and complimentary, which was embarrassing.

Once again in Africa the issues are simpler and starker. Physicians in rural clinics often have a good mutual relationship to the local witch doctors. The witch doctors know a patient losing weight and spitting blood must go to the clinic; the physicians learn the witch doctor is best able to manage hysterical symptoms, such as unexplained paralysis of an arm.

Physicians must admit that reliable medical knowledge and practice is less than two centuries old. Before that we were all 'complementary', to some extent. Evidence-based medicine is the gold smelted by science from a vast accumulation of stories, legends, myths, theories, doctrines and dogmas.
I understand one hundred years ago leeches were still in the British Pharmacopeia, and medical students had to learn materia medica - how to recognize various herbal and other natural products used in practice.

We must also recognise that herbal and folk remedies have on occasion yielded important medical knowledge. 

In the 17th. century Jesuit missionaries in South America learned from Inca herbalists the value of the bark of the "Fever Tree". The tree is now called Cinchona officinalis. Its bark is an important source of quinine, still perhaps the most reliable treatment for malaria.
The English physicians Morton and Sydenham recognized that "Jesuits' bark", as it was called, worked only in intermittent fevers, which are distinctive of malaria.
Pure quinine was isolated from Cinchona in 1820, by Pelletier and Caventou in Paris. A specific chemotherapy for malaria was available 60 years before the parasite was identified.

Digitalis and morphine are valuable drugs originating in folk medicine. Coca yielded cocaine, starting the development of local anesthetics. Chinese herbal practice led to the recent discovery of Artemesia annua,  which yielded Artemesinine, a new potent anti-malarial.

Vaccination is perhaps the greatest contribution of folk medicine to human health. Edward Jenner heard country people in Gloucester say that after cow-pox no-one caught small-pox. He saw local people deliberately infecting their families with cow-pox. In 1796 Jenner inoculated an 8 years old boy, and the rest is history. [The word vaccination is from the Latin vacca, a cow.]

An old farmer once assured me he took 'blue stone of vitriol', a sovereign remedy for rheumatism, " what we give to the 'orses".
Blue stone of vitriol must be copper sulphate, a known toxin. I didn't try it myself. 

Other complementary medicines have added little to the practice of evidence-based medicine. For most of them the theoretical base ranges from unlikely to absurd.
The number and variety of 'complementaries' should further erode faith in them.

It is said that 'complementaries' have no side effects, and do no harm. Well, I have seen an outbreak of Hepatitis B caused by an acupuncturist. I was sent to talk to him. He had beautiful Chinese acupuncture charts, and finely made sets of needles. He assured me he sterilized his needles carefully, every evening. I admired his expensive car.
I have also seen cases of chemical hepatitis traced to a fashionable remedy containing mistletoe.

'Complementaries' would not work with me: I don't believe in magic, I lack the faith. 





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