- Email: [email protected]
Searching for alternatives: loser pays
1135
THE LANCET
REFERENCES 1. Pepe PE, Potkin RT, Reus DH, Hudson LD, Carrico CJ. Clinical predictors of the adult respiratory distress syndrome. Am J Surg 1982; 144: 124-30. 2. Bone RC, Fisher CJ Jr, Clemmer TP, et al. Sepsis syndrome: a valid clinical entity. Crit Care Med 1989; 17: 389-93. 3. Kaplan RL, Sahn SA, Petty TL. Incidence and outcome of the respiratory distress syndrome in gram-negative sepsis. Arch Intern Med 1979; 139: 867-69. 4. Fowler AA, Hamman RF, Good JT, et al. Adult respiratory distress syndrome: risk with common predispositions. Ann Intern Med 1983; 98: 593-97. 5. Martin MA, Silverman HJ. Gram-negative sepsis and the adult respiratory distress syndrome. Clin Infect Dis 1992; 14: 1213-28. 6. Niederman MS, Fein AM. Sepsis syndrome, the adult respiratory distress syndrome, and nosocomial pneumonia: a common clinical sequence. Clin Chest Med 1990; 11: 633-56. 7. Montgomery AB, Stager MA, Carrico CJ, Hudson LD. Causes of mortality in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1985; 132: 485-89. 8. Seidenfeld JJ, Pohl DF, Bell RC, Harris GD, Johanson WG Jr. Incidence, site and outcome of infections in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1986; 134: 12-16. 9. van Deventer SJH, Buller HR, ten Cate JW, Sturk A, Pauw W. Endotoxaemia: an early predictor of septicaemia in febrile patients. Lancet 1988; i: 605-09. 10. Parsons PE, Worthen GS, Moore EE, Tate RM, Henson PM. The association of circulating endotoxin with the development of the adult respiratory distress syndrome. Am Rev Respir Dis 1989; 140: 294-301. 11. Miyata T, Yokoyama I, Todo S, Tzakis A, Selby R, Starzl TE. Endotoxaemia, pulmonary complications, and thrombocytopenia in liver transplantation. Lancet 1989; ii: 189-91. 12. Danner RL, Elin RJ, Hosseini JM, Wesley RA, Reilly JM, Parillo JE. Endotoxaemia in human septic shock. Chest 1991; 99: 169-75. 13. Brandtzaeg P, Kierulf P, Gaustad P, et al. Plasma endotoxin as a predictor of multiple organ failure and death in systemic meningococcal disease. J Infect Dis 1989; 159: 195-204. 14. Andersen BM, Solberg O. Endotoxin liberation and invasivity of Neisseria meningitidis. Scand J Infect Dis 1984; 16: 247-54. 15. Bell RC, Coalson JJ, Smith JD, Johanson WG Jr. Multiple organ system failure and infection in adult respiratory distress syndrome. Ann Intern Med 1983; 99: 293-98. 16. Boucek MM, Boerth RC, Artman M, Graham TP Jr, Boucek RJ. Myocardial dysfunction in children with acute meningococcemia. J Pediatr 1984; 105: 538-42. 17. Vandenroucke-Grauls CMJE, Vandenbroucke JP. Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit. Lancet 1991; 338: 859-62. 18. Fein AM, Lippmann M, Holtzman H, Eliraz A, Goldberg SK. The risk factors, incidence, and prognosis of ARDS following septicemia. Chest 1983; 83: 40-42. 19. Ognibene FP, Martin SE, Parker MM, et al. Adult respiratory distress syndrome in patients with severe neutropenia. N Engl J Med 1986; 315: 547-51. 20. Wortel CH, von der Mohlen AM, van Deventer SJH, et al. Effectiveness of a human monoclonal anti-endotoxin antibody (HA-1A) in gramnegative sepsis: relationship to endotoxin and cytokine levels. J Infect Dis 1992; 166: 1367-74. 21. Parsons PE, Moore FA, Moore EE, Ilke DN, Henson PM, Worthen GS. Studies on the role of tumor necrosis factor in adult respiratory distress syndrome. Am Rev Respir Dis 1992; 146: 694-700. 22. Anon. A nasty shock from antibiotics? Lancet 1985; ii: 594. 23. Hurley JC. Antibiotic action and endotoxin [PhD thesis]. Melbourne: University of Melbourne, 1991. 24. Hurley JC. Antibiotic-induced release of endotoxin: a reappraisal. Clin Infect Dis 1992, 15: 840-54. 25. Anon. Endotoxaemia or endotoxinaemia? Lancet 1992; 340: 1323. 26. Brandtzaeg P, Bryn K. Kierulf P, et al. Meningococcal endotoxin in lethal septic shock plasma studied by gas chromatography, massspectrometry, ultracentrifugation, and electron microscopy. J Clin Invest 1992; 89: 816-23. 27. Feingold DS. Biology and pathogenicity of microbial spheroplasts and L-forms. N Engl J Med 1969; 281: 1159-70. 28. Madoff S, ed. The bacterial L-forms. New York: Marcel Dekker, 1986. 29. Yamamoto A, Homma JY. Isolation of unstable L-forms from clinical specimens with Pseudomonas infection during antibiotic therapy. Jpn J Exp Med 1979; 49: 361-64. 30. Gutman LT, Turck M, Petersdorf RG, Wedgwood RJ. Significance of bacterial variants in urine of patients with chronic bacteriuria. J Clin Invest 1965; 44: 1945-52. 31. McKay KA, Abelseth MK, Vandreumel AA. Production of an enzootic-like pneumonia in pigs with "protoplasts" of Haemophilus parainfluenzae. Nature 1966; 212: 359-60.
GH, Waites KB, Crouse DT, et al. Association of Ureaplasma urealyticum infection of the lower respiratory tract with chronic lung disease and death in very-low-birth-weight infants. Lancet 1988; ii:
32. Cassell
240-45. 33. Cassell GH, Waites
KB, Watson HL, Crouse DT, Harasawa R.
Ureaplasma urealyticum intrauterine infection: role of prematurity and disease in newborns. Clin Microbiol Rev 1993; 6: 69-87. Kreger BE, Craven DE, McCabe WR. Gram-negative bacteraemia: IV. Re-evaluation of clinical features and treatment in 612 patients. Am J Med 1980; 68: 344-55. 35. Moore RD, Lietman PS, Smith CR. Clinical response to aminoglycoside therapy: importance of the ratio of peak concentration to minimal inhibitory concentration. J Infect Dis 1987; 155: 93-99. 36. Hurley JC. Bacteremia, endotoxemia and mortality in gram negative sepsis. J Infect Dis (in press). 37. Korvick JA, Peacock JE Jr, Muder RR, Wheeler RR, Yu VL. Addition of rifampicin to combination antibiotic therapy for Pseudomonas aeruginosa bacteraemia: prospective trial using the Zelen protocol. Antimicrob Agents Chemother 1992; 36: 620-25. 38. Tanimoto H. A review of the recent progress in treatment of patients with diffuse panbrochiolitis associated with Pseudomonas aeruginosa infection in Japan. Antibiot Chemother 1991; 44: 94-98. 34.
VIEWPOINT
Searching for alternatives: loser pays
Some conventional doctors have made it their mission to
fight alternative medicine. To them, what is taught in the ivory university tower is the only truth, almost by definition. "Listen", they argue, "you may feel better after seeing your favourite charlatan, but the benefit of his interventions, if any, is ’non-specific’." At best, they say, alternative practitioners can be considered masters of placebo therapy. Few patients, however, care about the scientific classification of their improvement (spontaneous, placebo, or biomedical). They continue to choose the treatment that they expect to give them the best overall benefit. It is always important to optimise placebo effects, in any kind of medicine. But has mainstream medicine something extra to
offer over alternative medicine? The answer to that
question must come mainly from clinical research.
Searching the
literature
The method with the greatest impact for showing clinical efficacy is the controlled trial. To the surprise of people who prefer the debate to study of what has been published, there are many reports of controlled trials of alternative therapies. Sometimes these publications are difficult to trace. Computer databases are biased towards conventional medicine because many established journals are reluctant to print the evidence--especially when it is positive. On the other hand, we also get a biased overview if research initiated by supporters of alternative medicine is not published when the results are disappointing. My experience with alternative researchers is that many are honest people and welcome any effort to dig up the grey literature. Sometimes one finds promising data. The literature on ginseng, for instance, which cannot be found on ADDRESSES- Department of Epidemiology, University of Limburg, PO Box 616, 6200 MD Maastricht, Netherlands
(Prof
P.
Knipschild, MD).
1136
THE LANCET
Medline, shows that it is a helpful tonic for elderly patients who lack vitality.l Ginkgo biloba has been extensively studied in many trials in Germany and France; it seems to work against what the Germans call a TK/eMM.ot’M (cerebral insufficiency).2 But how many in the Angloamerican rampart of science read foreign languages?
Homoeopathy Let me give one illustration of how exhaustive an alternative literature search can be. People from my department rolled up their sleeves to look for research papers on the effectiveness of homoeopathy. The Dutch Ministry of Public Health funded the enterprise. A Medline/Embase search (till 1991) gives 18 published reports of controlled trials on homoeopathy. Stepwise checking the references in these publications yields 28 more. If you stop here, you miss more than half of all studies.3 We continued browsing through many alternative journals, including homoeopathic journals. Our rummage in congress reports and doctoral theses in specialised libraries in Paris, Hamburg, London, and Glasgow was very rewarding. Many homoeopathic companies offered help. We wrote to well-known investigators working on this subject and sometimes paid them a visit. It was important that they felt comfortable discussing homoeopathy with us, so our meetings were often held in good restaurants! We heard details of their studies that were not published and received other reports that were still confidential. Our journey into homoeopathy produced a pile of more than 100 controlled studies. Our subsequent meta-analysis showed, to our astonishment, beneficial effects for homoeopathy in many (but not all) well-performed trials." Lately, we have collected many efficacy studies on all types of alternative treatments. Many of these studies are not very convincing because of faults with the methods. If academia does not help, alternative practitioners may not succeed in doing sound clinical research. Still, many are very research-minded, and would welcome the chance to work with honest, conventional practitioners on new projects.
Betting As long as enough doctors and patients are interested in its results, additional research of high quality makes sense. I believe the burden of proof lies mainly with the alternative practitioners, who make a living out of it. But it is fair to lend them a hand. Who should fund the research? It is too easy to point to government only. To make future research in this field even more fun than it already is, I propose to apply Hofstee’s betting model.’ Prestige will be at stake, but also for a real betting game we need two parties who want the other to pay for a new study. As it is, there are two distinguished camps. Let’s take acupuncture for patients with chronic pain as an example. In one corner is the Union Against Quackery, a noisy organisation of very conventional doctors. They completely despise alternative medicine and look forward to shutting down every acupuncture practice with the help of the police. In the other corner we find the Platform of Classical Acupuncturists. They believe so strongly in what the yellow emperor advocated in the Nei Ching that they believe the non-application of needles is negligence. I would like both parties to get together for a betting game. First we supply them with the existing, clinical evidence.8 If they still want to do a new study to clean out the other, they are invited to design and perform, in full cooperation, the ultimate trial to prove or disprove their claim. After the study, we strike the balance, not only for acupuncture but also financially. The loser pays for the
study. REFERENCES
Knipschild P. Ginseng: pep of nep?. Pharm Wkly 1988; 123: 4-11. Kleijnen J, Knipschild P. Ginkgo biloba for cerebral insufficiency. Br J Clin Pharmacol 1992; 34: 352-58. 3. Kleijnen J, Knipschild P. The comprehensiveness of Medline and Embase computer searches. Pharm Wkly (Sci) 1992; 14: 316-20. 4. Kleijnen J, Knipschild P, Ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302: 316-23. 5. Knipschild P. Looking for gall bladder disease in the patient’s iris. BMJ 1. 2.
1988; 297: 1578-81. 6.
Iridology Our study of iridology is a good example of such cooperation. Medical students challenged me to show that iridology is not a useful diagnostic aid. I began reading about the method and soon found a dozen studies of varying quality, mostly done and published in Germany. The evidence in favour of iridology seemed thin. When I discussed its usefulness with leading Dutch iridologists, many turned out to be very willing to do a new study. We agreed to concentrate on cholecystitis ("Gallstones in your eye") and the iridologists readily accepted my written protocol. Without receiving any payment, five of the best were anxious to stand the test. One even promised me that he would ban iridology from his alternative practice altogether if the new study also showed disappointing results. Unfortunately, iridology was completely useless for discriminating between patients and healthy controls.5 I am told that the iridologist who promised to abandon the method later took up computerised medical astrology as a diagnostic aid instead. A later survey showed the impact of the iridology study. Many doctors who were not sure about the method beforehand could be persuaded of its lack of usefulness when I showed them the empirical evidence.6 Isn’t this what medical research is all about?
Knipschild P. Changing belief in iridology after an empirical study. BMJ
1989; 299: 491-92. 7. Hofstee WKB. De empirische discussie. Meppel: Boom, 1980. 8. Ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol 1990; 43: 1191-99.
From The Lancet Swollen bladders As a general practitioner of 30 years’ standing I am writing through you to those in authority in order to point out a very real physical grievance to which our women motor-drivers are exposed. There have been under my care lately cases of women drivers
from atony of the bladder and cystitis due to overdistension in the performance of their duties. They tell me that very rarely is any provision for their relief afforded, and though they take no fluid all day they frequently suffer badly from distension due to the absence of the smallest forethought on the part of those driven. One lady told me she often had to drive officers from London to a camp and back, a journey of many miles. On her arrival she was always asked to lunch in mess, previously being invited to wash her hands, no provision for a less literal interpretation being provided, with the usual result of all but intolerable distension. The worst offenders are too young to remember that a bladder is an essential part of a woman’s physical equipment. The older officers, fathers of families, are the most considerate.
suffering
(March 30, 1918)
THE LANCET
REFERENCES 1. Pepe PE, Potkin RT, Reus DH, Hudson LD, Carrico CJ. Clinical predictors of the adult respiratory distress syndrome. Am J Surg 1982; 144: 124-30. 2. Bone RC, Fisher CJ Jr, Clemmer TP, et al. Sepsis syndrome: a valid clinical entity. Crit Care Med 1989; 17: 389-93. 3. Kaplan RL, Sahn SA, Petty TL. Incidence and outcome of the respiratory distress syndrome in gram-negative sepsis. Arch Intern Med 1979; 139: 867-69. 4. Fowler AA, Hamman RF, Good JT, et al. Adult respiratory distress syndrome: risk with common predispositions. Ann Intern Med 1983; 98: 593-97. 5. Martin MA, Silverman HJ. Gram-negative sepsis and the adult respiratory distress syndrome. Clin Infect Dis 1992; 14: 1213-28. 6. Niederman MS, Fein AM. Sepsis syndrome, the adult respiratory distress syndrome, and nosocomial pneumonia: a common clinical sequence. Clin Chest Med 1990; 11: 633-56. 7. Montgomery AB, Stager MA, Carrico CJ, Hudson LD. Causes of mortality in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1985; 132: 485-89. 8. Seidenfeld JJ, Pohl DF, Bell RC, Harris GD, Johanson WG Jr. Incidence, site and outcome of infections in patients with the adult respiratory distress syndrome. Am Rev Respir Dis 1986; 134: 12-16. 9. van Deventer SJH, Buller HR, ten Cate JW, Sturk A, Pauw W. Endotoxaemia: an early predictor of septicaemia in febrile patients. Lancet 1988; i: 605-09. 10. Parsons PE, Worthen GS, Moore EE, Tate RM, Henson PM. The association of circulating endotoxin with the development of the adult respiratory distress syndrome. Am Rev Respir Dis 1989; 140: 294-301. 11. Miyata T, Yokoyama I, Todo S, Tzakis A, Selby R, Starzl TE. Endotoxaemia, pulmonary complications, and thrombocytopenia in liver transplantation. Lancet 1989; ii: 189-91. 12. Danner RL, Elin RJ, Hosseini JM, Wesley RA, Reilly JM, Parillo JE. Endotoxaemia in human septic shock. Chest 1991; 99: 169-75. 13. Brandtzaeg P, Kierulf P, Gaustad P, et al. Plasma endotoxin as a predictor of multiple organ failure and death in systemic meningococcal disease. J Infect Dis 1989; 159: 195-204. 14. Andersen BM, Solberg O. Endotoxin liberation and invasivity of Neisseria meningitidis. Scand J Infect Dis 1984; 16: 247-54. 15. Bell RC, Coalson JJ, Smith JD, Johanson WG Jr. Multiple organ system failure and infection in adult respiratory distress syndrome. Ann Intern Med 1983; 99: 293-98. 16. Boucek MM, Boerth RC, Artman M, Graham TP Jr, Boucek RJ. Myocardial dysfunction in children with acute meningococcemia. J Pediatr 1984; 105: 538-42. 17. Vandenroucke-Grauls CMJE, Vandenbroucke JP. Effect of selective decontamination of the digestive tract on respiratory tract infections and mortality in the intensive care unit. Lancet 1991; 338: 859-62. 18. Fein AM, Lippmann M, Holtzman H, Eliraz A, Goldberg SK. The risk factors, incidence, and prognosis of ARDS following septicemia. Chest 1983; 83: 40-42. 19. Ognibene FP, Martin SE, Parker MM, et al. Adult respiratory distress syndrome in patients with severe neutropenia. N Engl J Med 1986; 315: 547-51. 20. Wortel CH, von der Mohlen AM, van Deventer SJH, et al. Effectiveness of a human monoclonal anti-endotoxin antibody (HA-1A) in gramnegative sepsis: relationship to endotoxin and cytokine levels. J Infect Dis 1992; 166: 1367-74. 21. Parsons PE, Moore FA, Moore EE, Ilke DN, Henson PM, Worthen GS. Studies on the role of tumor necrosis factor in adult respiratory distress syndrome. Am Rev Respir Dis 1992; 146: 694-700. 22. Anon. A nasty shock from antibiotics? Lancet 1985; ii: 594. 23. Hurley JC. Antibiotic action and endotoxin [PhD thesis]. Melbourne: University of Melbourne, 1991. 24. Hurley JC. Antibiotic-induced release of endotoxin: a reappraisal. Clin Infect Dis 1992, 15: 840-54. 25. Anon. Endotoxaemia or endotoxinaemia? Lancet 1992; 340: 1323. 26. Brandtzaeg P, Bryn K. Kierulf P, et al. Meningococcal endotoxin in lethal septic shock plasma studied by gas chromatography, massspectrometry, ultracentrifugation, and electron microscopy. J Clin Invest 1992; 89: 816-23. 27. Feingold DS. Biology and pathogenicity of microbial spheroplasts and L-forms. N Engl J Med 1969; 281: 1159-70. 28. Madoff S, ed. The bacterial L-forms. New York: Marcel Dekker, 1986. 29. Yamamoto A, Homma JY. Isolation of unstable L-forms from clinical specimens with Pseudomonas infection during antibiotic therapy. Jpn J Exp Med 1979; 49: 361-64. 30. Gutman LT, Turck M, Petersdorf RG, Wedgwood RJ. Significance of bacterial variants in urine of patients with chronic bacteriuria. J Clin Invest 1965; 44: 1945-52. 31. McKay KA, Abelseth MK, Vandreumel AA. Production of an enzootic-like pneumonia in pigs with "protoplasts" of Haemophilus parainfluenzae. Nature 1966; 212: 359-60.
GH, Waites KB, Crouse DT, et al. Association of Ureaplasma urealyticum infection of the lower respiratory tract with chronic lung disease and death in very-low-birth-weight infants. Lancet 1988; ii:
32. Cassell
240-45. 33. Cassell GH, Waites
KB, Watson HL, Crouse DT, Harasawa R.
Ureaplasma urealyticum intrauterine infection: role of prematurity and disease in newborns. Clin Microbiol Rev 1993; 6: 69-87. Kreger BE, Craven DE, McCabe WR. Gram-negative bacteraemia: IV. Re-evaluation of clinical features and treatment in 612 patients. Am J Med 1980; 68: 344-55. 35. Moore RD, Lietman PS, Smith CR. Clinical response to aminoglycoside therapy: importance of the ratio of peak concentration to minimal inhibitory concentration. J Infect Dis 1987; 155: 93-99. 36. Hurley JC. Bacteremia, endotoxemia and mortality in gram negative sepsis. J Infect Dis (in press). 37. Korvick JA, Peacock JE Jr, Muder RR, Wheeler RR, Yu VL. Addition of rifampicin to combination antibiotic therapy for Pseudomonas aeruginosa bacteraemia: prospective trial using the Zelen protocol. Antimicrob Agents Chemother 1992; 36: 620-25. 38. Tanimoto H. A review of the recent progress in treatment of patients with diffuse panbrochiolitis associated with Pseudomonas aeruginosa infection in Japan. Antibiot Chemother 1991; 44: 94-98. 34.
VIEWPOINT
Searching for alternatives: loser pays
Some conventional doctors have made it their mission to
fight alternative medicine. To them, what is taught in the ivory university tower is the only truth, almost by definition. "Listen", they argue, "you may feel better after seeing your favourite charlatan, but the benefit of his interventions, if any, is ’non-specific’." At best, they say, alternative practitioners can be considered masters of placebo therapy. Few patients, however, care about the scientific classification of their improvement (spontaneous, placebo, or biomedical). They continue to choose the treatment that they expect to give them the best overall benefit. It is always important to optimise placebo effects, in any kind of medicine. But has mainstream medicine something extra to
offer over alternative medicine? The answer to that
question must come mainly from clinical research.
Searching the
literature
The method with the greatest impact for showing clinical efficacy is the controlled trial. To the surprise of people who prefer the debate to study of what has been published, there are many reports of controlled trials of alternative therapies. Sometimes these publications are difficult to trace. Computer databases are biased towards conventional medicine because many established journals are reluctant to print the evidence--especially when it is positive. On the other hand, we also get a biased overview if research initiated by supporters of alternative medicine is not published when the results are disappointing. My experience with alternative researchers is that many are honest people and welcome any effort to dig up the grey literature. Sometimes one finds promising data. The literature on ginseng, for instance, which cannot be found on ADDRESSES- Department of Epidemiology, University of Limburg, PO Box 616, 6200 MD Maastricht, Netherlands
(Prof
P.
Knipschild, MD).
1136
THE LANCET
Medline, shows that it is a helpful tonic for elderly patients who lack vitality.l Ginkgo biloba has been extensively studied in many trials in Germany and France; it seems to work against what the Germans call a TK/eMM.ot’M (cerebral insufficiency).2 But how many in the Angloamerican rampart of science read foreign languages?
Homoeopathy Let me give one illustration of how exhaustive an alternative literature search can be. People from my department rolled up their sleeves to look for research papers on the effectiveness of homoeopathy. The Dutch Ministry of Public Health funded the enterprise. A Medline/Embase search (till 1991) gives 18 published reports of controlled trials on homoeopathy. Stepwise checking the references in these publications yields 28 more. If you stop here, you miss more than half of all studies.3 We continued browsing through many alternative journals, including homoeopathic journals. Our rummage in congress reports and doctoral theses in specialised libraries in Paris, Hamburg, London, and Glasgow was very rewarding. Many homoeopathic companies offered help. We wrote to well-known investigators working on this subject and sometimes paid them a visit. It was important that they felt comfortable discussing homoeopathy with us, so our meetings were often held in good restaurants! We heard details of their studies that were not published and received other reports that were still confidential. Our journey into homoeopathy produced a pile of more than 100 controlled studies. Our subsequent meta-analysis showed, to our astonishment, beneficial effects for homoeopathy in many (but not all) well-performed trials." Lately, we have collected many efficacy studies on all types of alternative treatments. Many of these studies are not very convincing because of faults with the methods. If academia does not help, alternative practitioners may not succeed in doing sound clinical research. Still, many are very research-minded, and would welcome the chance to work with honest, conventional practitioners on new projects.
Betting As long as enough doctors and patients are interested in its results, additional research of high quality makes sense. I believe the burden of proof lies mainly with the alternative practitioners, who make a living out of it. But it is fair to lend them a hand. Who should fund the research? It is too easy to point to government only. To make future research in this field even more fun than it already is, I propose to apply Hofstee’s betting model.’ Prestige will be at stake, but also for a real betting game we need two parties who want the other to pay for a new study. As it is, there are two distinguished camps. Let’s take acupuncture for patients with chronic pain as an example. In one corner is the Union Against Quackery, a noisy organisation of very conventional doctors. They completely despise alternative medicine and look forward to shutting down every acupuncture practice with the help of the police. In the other corner we find the Platform of Classical Acupuncturists. They believe so strongly in what the yellow emperor advocated in the Nei Ching that they believe the non-application of needles is negligence. I would like both parties to get together for a betting game. First we supply them with the existing, clinical evidence.8 If they still want to do a new study to clean out the other, they are invited to design and perform, in full cooperation, the ultimate trial to prove or disprove their claim. After the study, we strike the balance, not only for acupuncture but also financially. The loser pays for the
study. REFERENCES
Knipschild P. Ginseng: pep of nep?. Pharm Wkly 1988; 123: 4-11. Kleijnen J, Knipschild P. Ginkgo biloba for cerebral insufficiency. Br J Clin Pharmacol 1992; 34: 352-58. 3. Kleijnen J, Knipschild P. The comprehensiveness of Medline and Embase computer searches. Pharm Wkly (Sci) 1992; 14: 316-20. 4. Kleijnen J, Knipschild P, Ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302: 316-23. 5. Knipschild P. Looking for gall bladder disease in the patient’s iris. BMJ 1. 2.
1988; 297: 1578-81. 6.
Iridology Our study of iridology is a good example of such cooperation. Medical students challenged me to show that iridology is not a useful diagnostic aid. I began reading about the method and soon found a dozen studies of varying quality, mostly done and published in Germany. The evidence in favour of iridology seemed thin. When I discussed its usefulness with leading Dutch iridologists, many turned out to be very willing to do a new study. We agreed to concentrate on cholecystitis ("Gallstones in your eye") and the iridologists readily accepted my written protocol. Without receiving any payment, five of the best were anxious to stand the test. One even promised me that he would ban iridology from his alternative practice altogether if the new study also showed disappointing results. Unfortunately, iridology was completely useless for discriminating between patients and healthy controls.5 I am told that the iridologist who promised to abandon the method later took up computerised medical astrology as a diagnostic aid instead. A later survey showed the impact of the iridology study. Many doctors who were not sure about the method beforehand could be persuaded of its lack of usefulness when I showed them the empirical evidence.6 Isn’t this what medical research is all about?
Knipschild P. Changing belief in iridology after an empirical study. BMJ
1989; 299: 491-92. 7. Hofstee WKB. De empirische discussie. Meppel: Boom, 1980. 8. Ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: a criteria-based meta-analysis. J Clin Epidemiol 1990; 43: 1191-99.
From The Lancet Swollen bladders As a general practitioner of 30 years’ standing I am writing through you to those in authority in order to point out a very real physical grievance to which our women motor-drivers are exposed. There have been under my care lately cases of women drivers
from atony of the bladder and cystitis due to overdistension in the performance of their duties. They tell me that very rarely is any provision for their relief afforded, and though they take no fluid all day they frequently suffer badly from distension due to the absence of the smallest forethought on the part of those driven. One lady told me she often had to drive officers from London to a camp and back, a journey of many miles. On her arrival she was always asked to lunch in mess, previously being invited to wash her hands, no provision for a less literal interpretation being provided, with the usual result of all but intolerable distension. The worst offenders are too young to remember that a bladder is an essential part of a woman’s physical equipment. The older officers, fathers of families, are the most considerate.
suffering
(March 30, 1918)