ACUPUNCTURE AND THE AGE OF UNREASON

1169

operation without difficulty".4

Point of View ACUPUNCTURE AND THE AGE OF UNREASON PETR SKRABANEK Mater Misericordiae

Hospital, Dublin, Ireland

IN a recent article on acupuncture-which, we are told, was subjected to rigorous scrutiny by a panel of medical experts, including a neurosurgeon-it was bluntly stated that a bloodborne substance must be involved in the effect of acupuncture.For experimental evidence the reader was referred to a film on acupuncture produced by the Shanghai Film Studio in 1972. Only those who have seen Soviet propaganda films on "classical experiments" by Academicians Lepeshinskaya or Lysenko, and who have lived in totalitarian systems, will fully grasp the nature of such evidence. The Western reader may get a glimpse of the reality and atmosphere of China in 1972 by reading that

acupuncture anaesthesia was "usually performed by a young girl aged 20-25 who is politically sincere and who spends 2-3 days in advance of the operation encouraging the patient in his mental attitude, especially towards the works and thoughts of Chairman Mao."2 The mystery of acupuncture anaesthesia largely evaporates when we learn2 that it was supplemented by a premedication, local anaesthesia with procaine, and an intravenous drip with pethidine and other drugs, that the patients were carefully selected and perhaps only 10-15% were deemed suitable, and that, despite all this, not all patients obtained adequate analgesia. It is useful to be reminded, in this context, that Harvey Cushing was flabbergasted when he saw Cesar Roux operating on goitres in Lausanne in 1900; the sturdy Valois peasants got no anaesthesia whatsoever.3 Theodor Kocher performed 600 thyroidectomies in Berne between 1895 and 1898, also without general anaesthesia: "An injection ofa1% solution of cocaine is made for the skin incision and intelligent patients, after this has been made painless, bear the remainder of the

perinatal mortality rate as a measure of the efficiency of the maternity services. Hlth Bull (Edin) 1977; 35: 234-42. 2. Chalmers I, Macfarlane A. Interpretation of perinatal statistics. In: Wharton B, ed. 1. Baird D. The

3. 4.

Topics in perinatal medicine. London: Pitman-Medical, 1980: 1-11. Bakketeig LS, Hoffmann H, Sternthal PM. Obstetric service and perinatal mortality in Norway. Acta Obstet Gynecol Scand 1978; suppl 77: 3-19. Lee K, Paneth N, Garter LM, Pearlman M. The very low-birthweight rate: principal predictor of neonatal mortality in industrialized populations. J Pediatr 1980; 97: 759-64.

Prospects for better perinatal health. Lancet 1980; i: 189-92. 6. Knox EG, Marshall T, Kane S, Green A, Mallett R. Social and health care determinants of area variations in perinatal mortality. Commun Med 1980; 2: 282-90. 7. Treffers PE. Regionale perinatale sterfte en regionale hospitalisatie bij de bevalling in Nederland. Ned Tijdschr Geneesk 1978; 122: 291-95. 8. Treffers PE, Breur W. De plaats van de bevalling en de perinatale sterfte. Ned Tijdschr Geneesk 1978, 122: 1856-57. 9. Hoogendoorn D. De relatie tussen de hoogte van de perinatale sterfte en de plaats van bevalling: trims, dan wel in het ziekenhuis. Ned Tijdschr Geneesk 1978; 122: 1171-78. 10. Hoogendoorn D, Citteur CAW. De plaats van de bevalling - de perinatale sterfte. Ned Tijdschr Geneesk 1978; 122: 1857-59. 11 Maathuis JB, De Jonge H. De relatie tussen de hoogte van de perinatale sterfte en de plaats van bevalling: een poging tot correctie. Ned Tijdschr Geneesk 1979, 123: 973-75. 12. Keirse MJNC. Interaction between primary and secondary antenatal care, with particular reference to the Netherlands. In: Enkin M, Chalmers I, eds Effectiveness and satisfaction in antenatal care. London: William Heinemann, 1982: 222-33 13 Spastics Society. Advertisements, 1978. 14. Committee on Child Health Services. Fit for the future. London. HM Stationery Office, 1976. 15. Kerr MG. The influence of information on perinatal practice. In: Chalmers I, McIlwaine G, eds. Perinatal audit and surveillance. London. Royal College of 5. Alberman E.

Quen/

in his historical review of the impact of Oriental acupuncture on Western medicine is puzzled why a large part of the medical and scientific community quickly dissociated itself from the latest revival of interest in the West. One of his

examples of such "premature" rejection by persons who had "no substantial experience with acupuncture technique" is a comment by Lewis Thomas: "These are bad times for reason, all around. Suddenly all of the major ills are being coped with by acupuncture". Quen rightly compares the fate of acupuncture with that of mesmerism and perkinism; and, in his view, the point at issue is not the mechanism or "scientific validity" of acupuncture but rather what determines "the selective inattention to the documented clinical responses and their significance". However, numerous controlled trials have shown that the claims for acupuncture have no scientific validity;6 it is these trials that are systematically ignored by acupuncturists, who themselves are thus guilty of "selective inattention". In my opinion, what is at issue is the complex problem of demarcation between science and quackery, between reason and faith, between honest search for truth and 5 unscrupulous exploitation of human suffering. Quen suggests that "the premature acceptors and the premature rejectors are equally anti-scientific." This is a valid observation only if what is being prematurely accepted or rejected is a testable scientific hypothesis. Quen’s statement leads to the paradox of declaring sceptics no less irrational than the proponents of irrational doctrines. Inventors of perpetual-motion machines cannot reasonably expect that judgment on their claims should be suspended until they are proved false by the non-believers. Outrageous claims are often ignored by sceptics, who may be justified in their sense of the futility of it all. "It is like punching a feather pillow-an indentation is made, but soon refills, and the whole soft, spongy mass continues as before."7 The stoic silence of sceptics is then interpreted by irrationalists as lack of argument; the confused public, always inclined to be deceived, gives the irrationalists the benefit of the doubt. to

The history of the use of acupuncture in East and West is relevant Quen’s charge of "premature" rejection. In Japan, acupuncture

Obstetricians and Gynaecologists, 1980: 319-30. I, Newcombe R, West R, et al. Adjusted perinatal mortality rates in administrative areas of England and Wales. Hlth Trends 1978; 10: 24-28. 17. Mallett R, Knox EG Standardized perinatal mortality ratios: technique, utility and interpretation Commun Med 1979; 1: 6-13. 18. Chalmers I. Perinatal health: the search for indices. Lancet 1979; ii: 1063-65. 19. Wigglesworth JS. Monitoring perinatal mortality. A pathophysiological approach. Lancet 1980; ii: 684-86. 20. Keirse MJNC. A survey of tocolytic drug treatment in preterm labour. Br J Obstet Gynaecol 1984 (in press) 21. Smits F. De doeltreffendheid van het selectiesysteem binnen de verloskundige zorg. Nijmegen: MD thesis, 1981: 66. 22. McCarthy BJ, Terry J, Rochat RW, Quave S, Tyler CW. The underregistration of neonatal deaths: Georgia 1974-77. Am J Publ Hlth 1980; 70: 977-82. 23. Scott MJ, Ritchie JWK, McClure BG, Reid MMcC, Halliday HL. Perinatal death recording: time for a change? Br Med J 1981; 282: 707-10. 24. Pharoah POD International comparison of perinatal and infant mortality rates. Proc Roy Soc Med 1976; 69: 335-38. 25. Keirse MJNC. De Betekenis van Haakjes. Leiden: Universitaire Pers, 1980. 26. Chamberlain G. Background to perinatal health. Lancet 1979, ii: 1061-63. 27. WHO. Recommended definitions, terminology and format for statistical tables related to the perinatal period and use of anew certificate for cause of perinatal deaths Acta Obstet Gynecol Scand 1977, 56: 247-53. 28. FIGO News. Lists of gynecologic and obstetrical terms and definitions. Int J Gynaecol Obstet 1976; 14: 570-76. 29. Mugford M. A comparison of reported differences in definitions of viral events and statistics. WHO Statistics Quarterly 1983; 36: 201-12. 30. British Births 1970, vol I: The first week of life. London: William Heinemann, 1975: 252-53. 31. Keirse MJNC, Kanhai HHH. An obstetrical viewpoint on preterm birth with particular reference to perinatal morbidity and mortality In: Huisjes HJ, ed. Aspects of perinatal morbidity. Groningen: Universitaire Boekhandel Nederland, 1981: 1-35. 16. Chalmers

1170 is known for what it is from centuries of "substantial experience"; it may be still popular among ordinary people but the Japanese medical and scientific community in general does not contribute to published work on the alleged neurochemical basis of acupuncture. In a review on this aspect of acupuncture in Annual Reviews of Pharmacology and Toxicology,8 of 195 references, 102 were from Communist China (most of them in Chinese) and 1 from a Japanese group. In China, acupuncture was rejected by the Emperor in 1822 as a bar to the progress of medicine and was removed from the curriculum of the Imperial Medical College. Surely after 5000 years of acupuncture experience in China (the figure usually given by Chinese acupuncturists9), the rejection cannot be called premature. Its reintroduction by Maoists was a political device to provide cheap medical care for millions in newly "liberated" areas. Neither can the Western rejection of acupuncture be called premature, since the West accepted and rejected acupuncture four times in the past 300 years, before its latest resurgence after Nixon’s visit to China in 1972.10 At the beginning of the 19th century, the acupuncture craze was started in France by Dr L. V. J. Berlioz (father of the composer) who even played with the idea of electroacupuncture.5 If acupuncture is effective beyond its placebo effect, why has it been rejected each time after a period of vogue? The reasons for these repeated rejections, far from being unclear as Quen suggests, were well spelled out in an editorial in the Edinburgh Medical and Surgical journal for 1827:

"Our

reason

[for

not

reporting

acupuncture earlier] has

been, that the first accounts of the virtues of the new remedy were so marvellous, and therefore seemed to savour so much of quackery, that, coming as they did, from persons not of the highest authority, we could not but follow the general example, and decline giving implicit credit to their assertions. But these assertions have been re-echoed from almost every quarter of Europe ... It must be confessed, however, that after all we cannot approach this singular topic without hesitation ... There is in short a total want of every sort of evidence in its favour as a remedy, except that of most treacherous kind, the evidence of success; and

consequently, a philosophical mind, especially considering the diseases in which the greatest success has been obtained, will naturally feel inclined to attribute the cures which have been accomplished to the influence of the imagination, and to sentence acupuncture to banishment from regular

practice." 1]i

How does this modest reticence of the last century compare with the announcement from the National Institutes of Health, USA, ofa "commitment" to study the use of acupuncture in surgical anaesthesia?12 At the time when the Cultural Revolution in China was reaching the acme of absurdity and everything "Western" was being banished, whether Beethoven or beta-blockers, naive American delegations were bringing back happy news of Chinese scientific wonders. In a brochure issued to these delegations, we read "Deep needling oftheyamen point enables deaf-mutes to hear and speak". 13 Did nobody see the joke? "And when the devil was cast out, the dumb spake: and the multitudes marvelled" (Matthew ix,33). Around the same time in France, Dr P. F. M. Nogier announced his great discovery of the inverted homunculus in the human ear, thus laying the foundations for auriculotherapy (now very popular), suitable for both diagnosis and treatment of all diseases. 14 Dr G. T. Lewith, a British acupuncturist, suggested that the folklore belief that the gold ear-ring worn by pirates enabled them to see ships before themselves being seen may not be as fanciful as it appears since it happens that the pirate ear-ring would be most likely placed in the "eye-point" of the ear-lobe (ie, passing s through the eye of the inverted homunculus of Nogier).15 There are now several American acupuncturist journals that started publication in the early 1970s, such as American Journal of

Acupuncture, American Journal of Chinese Medicine, andAcupuncture and Electro- Therapeutics Research, in which holders of MD or PHD degrees from reputable institutions further elaborate the nonsense: "Nonetheless, both auricular diagnosis and ear acupuncture treatment have proved to be of valuable clinical efficacy. Until

further research delineates which aspects of these two systems are more accurate, it may simply be prudent to utilize them both. Certainly both systems maintain the concept of an inverted homunculus." I will refrain from naming the authors. The matter becomes more serious when the editors of Postgraduate Medicine declare that acupuncture has numerous clinical applications-eg, in acute bacillary dysentery. 16 And, when the World Health Organisation lists 44 conditions which "lend themselves to acupuncture treatment", among others, common cold, acute bronchitis, central retinitis, myopia in children, cataract (uncomplicated), gastroptosis, and paralytic ileus,17 one can only agree with Lewis Thomas that these are bad times for reason. The British Medical journal greeted the Mao-Nixon wave of acupuncture with scepticism in 1973;]8 but in 1981, suggestions that acupuncture might not be better than placebo were dismissed: "Can we now assert that acupuncture is more than a placebo? This question seems no longer relevant, since the relief of pain associated with placebos is probably also mediated by release of endogenous opioids". 19 Unfortunately, the question does remain relevant, since placebo effect is, in fact, unlikely to be mediated by endogenous opioids. 20 The editorialist, however, tried to keep a back-door open: "If, however, acupuncture exerts some specific analgesic effect like other physical treatments, this is not amenable to proof by formal clinical trial". And then, to crown it, the editorial concludes: "In any event, if acupuncture provides effective and safe pain relief then its mechanism of action is of secondary importance". 19 Perhaps the less it is investigated, the better for its effectiveness; this would certainly be true of miracle cures. Since the popular demand for acupuncture is great, it is not surprising that medically qualified acupuncturists are afraid of "non-professional" competitors in the lucrative market. They warn against "numerous practitioners of acupuncture who are not doctors, who do not know the basic principles of medicine, who often have not studied acupuncture adequately". 21 Basic principles of what medicine? Oriental and Western combined? I have checked on one important source of Lewith’s claims for what acupuncture can do. 15 In this volume,22 there are 534 experimental papers from various Chinese institutions, confirming the great success (usually 85-90%) of acupuncture in treatment of viral hepatitis, malaria, hereditary ataxia, infantile paralysis, hydrocephalus, mammary hyperplasia (though in Australia acupuncture is used for breast augmentation 23 ), deafness, and many other diseases, some of them unknown in the West. Schizophrenia, of whatever type, is cured or markedly improved in 72% of patients. (This feat has already been emulated by American psychiatrists.24) The great leap forward of acupuncture fantasy knows no bounds: a patient with 96% surface burns, including 90% third-degree burns, was treated with acupuncture and the recovery was—"uneventful". Such publications, often written in Chinese, are cited nowadays in reputable journals by acupuncturists who manage to slip their propaganda past the overworked editor.

Of course, it does not necessarily follow that, because acupuncture is based on irrational principles, it has no therapeutic value. Placebo effect itself is valuable; but then spade should be called spade. As a corollary, it should also be stated that neither does it follow that because acupuncture has been used for 5000 years there must be "something in it". Just think about astrology. Any serious investigation of the effect of skin irritation (or disturbance of subcutaneous structures) by needles, heat, cold, or electricity must start with a testable hypothesis stripped of all mystico-religious elements. The first step would be to stop using Chinese names for various points of stimulation: we are not testing the accuracy of their description in old Chinese manuscripts. Secondly, the term "acupuncture", because of its magic connotation, should be dropped. Many investigators use the neutral term "transcutaneous electric stimulation" for one of the acupuncture equivalents. Similar descriptive terms could be employed for other acupuncture equivalents to avoid obfuscation. There is nothing mystical about claiming pain

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relief by distractive sensory stimuli: for example, the effect of needling in acute pain, particularly in lumbago, has been observed and described by many medical practitioners who did not care for "Oriental" practice-eg, Osler25 who learned the technique from Ringer.26 There are many other earlier accounts in European journals.!],27.3o Teale mentions that a friend wrote to him: "I remember at the Birmingham Hospital it was all the fashion at one time. We used to stick half-a-dozen needles into the deltoid, eg, and leave them for a quarter of an hour, with sometimes ’wonderful’ results"30 Injections of saline into the trigger points were used by Launois.3] These reports are now forgotten, but some of them could be investigated. For example, Frost et al,32 in one such rational study, showed that myofascial pain responds to local injection of saline better than to an injection of local anaesthetic agent. They proposed that the needling itself of the trigger points might have beneficial effects. Traditional Chinese explanations of these effects only help to confuse the issue. By "rediscovering" the five vital principles of Chinese medicine (equivalent to the four humours of the ancient Greeks) and Chinese acupuncture (equivalent to European bloodletting) we degrade medicine to shamanism. If we can now treat obesity or smoking addiction with a "staple" in the ear, why not a copper bracelet or red flannel for rheumatism next? Let us leave quackupuncture to quacks and let us tell the misinformed patient the truth, so that he or she can choose.

Hospital Practice AN END TO ANTENATAL OESTROGEN MONITORING? DEPARTMENT OF OBSTETRICS, ST GEORGE’S HOSPITAL MEDICAL SCHOOL, LONDON

FOR

some

years obstetricians have been uneasy about the

emphasis placed on the results of antenatal monitoring of fetal wellbeing by biochemical tests such as assays of oestrogens in maternal urine or blood. The results have a loose association with the metabolic activity of the fetus or placenta but do little to indicate impairment of transfer across the placenta, the essential feature required of a fetal monitoring test. Furthermore, the normal variation in the metabolism of the products measured is so great that major changes in fetal health may not cause any prompt or significant alteration in the results ofa biochemical test. If we were to rely completely on such monitoring it could be too late to act to help the fetus in many cases.22 This dissatisfaction has been voiced in many obstetric units, but few obstetricians have yet taken the step of stopping oestrogen testing, despite the development of biophysical testing already taking place in most obstetric departments. We now report the effect of the planned abolition of antenatal oestrogen testing in our hospital over a year ago. METHODS AND RESULTS

REFERENCES 1. Steiner RP.

Acupuncture-cultural perspectives.

1. The Western

view.

Postgrad Med

1983; 74: 60-67.

Capperauld I. Acupuncture and acupuncture anaesthesia in China today. J Ir Coll Phys Surg 1974; 4: 15-21. 3. Fulton JF. Harvey Cushing—A biography. Oxford: Blackwell, 1946: 175. 4. Anonymous. 600 more goitre operations. Med Press Dec 14, 1898; p624. 5. Quen JM. Acupuncture and Western medicine. Bull Hist Med 1975; 49: 196-205. 6. Skrabanek P. Acupuncture and endorphins. Lancet 1984; i: 220. 7. Brandon R. The spiritualists. The passion for the occult in the 19th and 20th centuries. 2.

exception of a small number of women in participating a research project, no tests of oestrogen levels in urine of antenatal inpatients were done during 1983. With the

ESTIMATED NUMBER OF TOTAL URINARY OESTROGEN TESTS SAVED IN

1983 BY

ABOLITION OF TESTING

London: Weidenfeld and Nicholson, 1983. 24. 8. Han JS, Terenius L. Neurochemical basis of acupuncture

analgesia. Annu Rev Pharmacol Toxicol 1982; 22: 193-220. 9 Lu G-W. Characteristics of afferent fiber innervation of acupuncture points zusanli. Am J Physiol 1983; 14: R606-R612. 10 Ackerknecht EH. Zur Geschichte der Akupunktur. Anaesthetist 1974; 23: 37-38. 11. Anonymous. On acupuncture. Edinburgh Med Surg J 1827; 27: 190-200. 12. Taub A. Acupuncture. Science 1972; 178: 9. 13. Acupuncture anaesthesia. Peking: Foreign Language Press, 1972: 28. 14 Nogier PFM. Treatise on auriculotherapy. Maisoneuve: Moulins-les-Metz, 1972. 15. Lewith GT. Acupuncture. Its place in Western medical sciences. Wellingborough: Thorsons, 1982: 118. 16. Anonymous. Editorial postscript to ref 1. Postgrad Med 1983; 74: 66. 17. Bannerman RH. Acupuncture: the WHO view World Health December 1979; 24-29. 18. Editorial. When acupuncture came to Britain. Br Med J 1973; iv: 687-88. 19. Editorial How does acupuncture work? Br Med J 1981; 283: 746-48. 20. Gracely RH, Dubner R, Wolskee PJ, Deeter WR. Placebo and naloxone can alter postsurgical pain by separate mechanisms. Nature 1983; 306: 264-65. 21. Mann F. The treatment of disease with acupuncture, 3rd ed. London. Heinemann, 1974: xii. 22. National symposia of acupuncture and moxibustion and acupuncture anaesthesia. Beijing, 1979 23. Tong WT. Breast augmentation by acupuncture. Med J Aust 1981; i: 44. 24. Kane J, Di Scipio WJ. Acupuncture treatment of schizophrenia. Report of three cases. Am J Psychiatry 1979, 136: 297-302. 25. Osier W The principles and practice of medicine, 4th ed. London: H Kimpton, 1901: 407. 26. Ringer S A handbook of therapeutics, 6th ed. New York: Wood, 1878. (quoted by Schnepp KH). British acupuncture. N Engl J Med 1972; 287: 934-35 27. Wansbrough TW. Lumbago treated by acupuncturation. Lancet 1836/37; ii: 25. 28. Belcombe HS. Cases of sciatica and neuralgia successfully treated by acupuncture. Med Times Gazette 1852; 4(ns): 85-86. 29. Anonymous. Employment of acupuncture as a counterirritant. Practitioner 1868; 1; 371-73. 30 Teale TP. On the relief of pain and muscular disability by acupuncture. Lancet 1871, i: 567-68. 31. Launois RPE. The treatment of sciatica and neuralgia by subcutaneous injections of salt water. Med Press 1906; i: 497. 32 Frost FA, Jessen B, Siggaard-Andersen J. A control, double-blind comparison of mepivacaine injection versus saline injection for myofascial pain. Lancer 1980; i: 499-504.

The table shows the numbers of women admitted to the antenatal ward at our hospital with various disorders in 1983 and the average numbers of oestrogen assays carried out for women with those disorders in the previous year. Thus, had we continued biochemical testing we would have carried out an estimated 1344 oestrogen assays in 1983. Instead we relied on antenatal ultrasound measurements of fetal size to determine growth and antenatal cardiotocography done in the ward to determine changes in fetal heart rate in relation to uterine contractions and fetal movements. DISCUSSION

In 1981 and 1982 our department requested 2948 and 2005 urinary oestrogen estimations, respectively. The numbers appeared to be falling but had we continued with the conventional policy of biochemical testing we would have probably allowed the system to atrophy over the next 5-10 years. Costing of all investigative tests is imprecise, since it depends on how much hidden costs, such as heating,