Arthritis and Placebos

In Skeptic 30, John Britten outlined the tragic results which can occur when patients fall into the clutches of quacks. In this case, a man with rheumatoid arthritis was not only starved but ended up paying for expensive and useless medications. Most doctors can relate similar examples.

Uncontrolled trials claimed to show dramatic improvements in rheumatoid arthritis patients following laser treatment. However, a placebo-controlled trial showed that sham treatment (placebo) gave just as good results as the laser. (BMJ Vol 307 30 Oct 1993 p1154)

A placebo-controlled trial of diclofenac (an anti-inflammatory drug) for osteoarthritis of the knee, found that half of the patients allocated to placebo stayed on this treatment for two years without any worsening of their symptoms! (BMJ Vol 307 Aug 1993 p394)

Reports of pain relief from subcutaneous injections of water drew a sharp reply from Skrabanek writing in the Lancet (April 3 p905). He pointed out that a historical perspective of such “counter-irritation” methods can help prevent over-enthusiastic adoption of such unlikely treatments. In fact, I seem to remember that water injections were one of the scams exposed in the novel by A.J. Cronin, The Citadel, which should be required reading for any doctor of medicine.

Gulf Gas Mystery

An article in Time magazine (Nov 22 1993) outlines how 8,000 veterans of the Gulf War have claimed that they were exposed to chemical agents producing such symptoms as diarrhoea, aching joints and difficulty in breathing. It is alleged that “multiple chemical sensitivity” may be the cause but nowhere is there any mention of psychological causes such as stress. Many of the claimants have been dismissed as malingerers.

War is hell and it is a terrible experience for some soldiers. Stress-related disorders are common and resulted in shell shock and effort syndrome in WW1, anxiety neurosis after WW2 and alleged Agent Orange poisoning after the Vietnam war. History shows that such claims will continue to occur, as in this case, but I would prefer to see psychological causes included in the differential diagnosis.

Sick Building Syndrome (SBS)

Researchers have finally got around to acknowledging that SBS may be due to “a high level of job stress among individuals with symptoms” (GP Weekly 19 Jan 1994 p15). As would be expected there are now concerns about “sick plane syndrome” (SPS) reported in New Scientist (7 Aug 93 p7). Several cabin attendants reported difficulty breathing, dizziness, fatigue, nausea and headaches during a cross-country flight. “The cause was never determined.”

I wonder if they considered mass hysteria, which is the most likely scenario for both SBS and SPS. Hysteria is not the best word to use — perhaps mass conversion disorder is less pejorative. Essentially, groups of people under stress tend to develop similar symptoms in the face of a common stress. A good example which I have seen myself is mass fainting occuring in military recruits awaiting both blood tests and vaccinations.

Child Abuse

Christian “Scientists” believe that illnesses can be healed with prayer and Bible readings. The religion’s founder, Mary Baker Eddy, was described by Mark Twain as the “queen of hypocrites”. There are numerous examples of people who have died from lethal but eminently treatable conditions. I have no problem with deluded adults who want to be treated in this way but children are entitled to a standard of medical care expected by any reasonable parent.

As would be expected from common sense, there is no evidence that faith has ever produced a cure of any illness. Is it at all likely that faith can produce insulin secretion from a failed diabetic pancreas? In the US, a couple killed their diabetic son by withholding treatment for his diabetes (Lancet Vol 342 Sep 4 1993 p610). Incredibly, the parents were not criminally prosecuted because of “a state law that protects from child neglect statutes, parents who rely on prayer to heal their children”. However, the child’s estranged parent filed a civil suit and the Christian Science church has been ordered to pay US$11.3 million in damages.

The law in the UK seems more rational. A Rastafarian couple refused on religious grounds to allow their diabetic daughter to have insulin and she duly died. As any reasonable person would expect, the parents were charged with manslaughter and convicted (Lancet Vol 342 Nov 13 1993 p1189).

More on Dental Amalgam

As I have previously explained, there is no evidence to implicate mercury in amalgam with significant human illness. An article in the Marlborough Express (24/8/93) outlined an illness which caused weight loss, stomach cramps and nausea in a 34-year-old man. After paying more than $2,000 in medical bills he was no better. As a doctor I know straight away that there is only a slight chance of a significant organic illness (e.g., cancer) either occuring or being overlooked in a 34-year-old.

I have seen this combination of symptoms before in many patients and they all turned out to have depression and were cured with appropriate treatment. However, as I have mentioned many times, psychological causes for illness are seen as somehow inferior to a “physical” cause. To quote the patient: “I was getting worried that it was something psychological. The medical profession was giving me ideas that it was depression, stress, bodily changes.”

In this case, the patient received a diagnosis of “mercury poisoning” following an assessment with a quack “black box” involving electroacupuncture. He then paid $1,000 to have all his amalgam fillings replaced and is reported to be slowly improving. Truly another remarkable example of the placebo effect which is very powerful with any kind of surgical or operative treatment.

Conversion Disorders

These are symptoms or signs produced by notional beliefs (e.g., mass fainting due to a perceived chemical or environmental threat), and are the basis of occupational overuse syndrome, chronic fatigue syndrome, sick building syndrome etc.

“Retractor” is an expatriate Kiwi living in Australia who wrote an interesting article on allergy to local anaesthetic (LA) (NZ Doctor 16 Sep 1993 p7). He found that patients demonstrated their “allergic” reactions even when injected with normal saline solution.

One 12-year-old had fits after dentally administered LA and was investigated with two electroencephalograms (brain-wave recordings), a CT scan and a MRI scan. Following an injection of normal saline (which the patient believed was LA) he had a fit and was incontinent!

“Retractor” was mostly successful in helping patients deal with their subsequent embarrassment but some had trouble and went so far as to dispute the matter. Descartes was certainly completely wrong when he proposed his theory of complete separation between mind and body. Clearly the mind (belief) can have a potent effect on the body.

Pond Scum Scam?

Pro-algal quacks claim that algae harvested from a pond “may be beneficial” for the treatment of AIDS, cancer, heart disease, etc. The product has re-surfaced since the FDA shut down the marketing company, Cell Tech, in 1986.

Note the absurd range of indications of the product, in contrast to the specific use of drugs for particular diseases.

The FDA faces an uphill battle in countering this sort of quackery, as the law is vague on whether such items should be classified as drugs, foods or dietary supplements. A sensible law was passed by Congress in 1990 which prohibited any health claims about such products unless approved by the FDA. The powerful quack lobby has managed to introduce another law which dilutes scientific standards and shifts the burden of proving safety onto the FDA!

C is for Cancer

Linus Pauling’s faith in Vitamin C is undaunted by his cancer (NCAHF Vol 15, No4). Despite it being out of his field (nuclear physics), Pauling has championed the anti-cancer benefits of Vitamin C. Sadly, he has been diagnosed as having prostate cancer but, despite being poorly, his faith in Vitamin C is unshaken. “He credits his high-C regimen with delaying the disease until his present age of 91 yrs.” The physiology of Vitamin C is well described, and excessive amounts are simply excreted in the urine. Prostatic cancer occurs more often with increasing age and if men live long enough there is an almost 100% incidence.

Pauling has helped keep Vitamin C as the number two on the list of the top dietary supplements in the US. Dietary supplements are worth $1.4 billion US annually and are currently 37% of all health food sales.

Oil Strikes Out

The film Lorenzo’s Oil concerns the efforts of a family to save their son from a rare genetic disorder using a highly purified cooking oil of the same name. Thanks to the media there is now a new popular mythology that the oil is effective and that attempts to use it have been obstructed by the unreasonable medical profession.

A French team of scientists have tested the oil and found no evidence of any clinical benefit. Once again, extravagant claims are found wanting when subjected to critical scrutiny.

If You Can’t Beat ’em?

Bernard Howard first drew my attention to worrying trends towards the inclusion of unorthodox therapies into conventional medical practice.

The BMA has acknowledged that acupuncture, osteopathy, homeopathy etc. are “indeed a good thing” provided the practitioners are “properly qualified members of their crafts”. In an article in New Scientist (31 July 1993), Donald Gould comments on this Pauline conversion and accuses the medical profession of a change prompted by concern over the loss of patients to alternative medicine. A “properly qualified homeopath” is still a quack peddling water, and professional registers simply give quackery a spurious respectability.

The NCAHF has already shown how licencing of quackery is soon followed by that body actively lobbying for an expanded scope of practice. In New Mexico, the state Acupuncture Board allows acupuncturists to order tests and procedures such as MRI scans, writing prescriptions and performing bone and muscle manipulations. Chiropractors were predictably indignant and two doctors on the Board resigned in protest. (NCAHF Vol 16, No 5).

I briefly commented on this trend in Skeptic 30 (“Quackery in the US”). The Office of Alternative Medicine has been set up within the US National Institutes of Health at the instigation of a former congressman, Bedell, who claims to have been cured of a “possible recurrence” of prostate cancer by an unconventional “nitrogen enhancement” therapy (unspecified). What Bedell does not say is that he was also receiving conventional treatment for prostatic carcinoma and “possible recurrence” is an example of the meaningless terms and vague language that permeates alternative medicine.

The director of the Office holds establishment credentials and describes himself as a skeptic, yet favours simple outcome studies rather than the proven double-blind, placebo-controlled trial. Outcome studies are weak and will allow for all sorts of extravagant claims. The reason that quacks hate proper clinical trials is that they usually show that quack beliefs are a delusion.

Members of the Office of Alternative Medicine can use their affiliation to advertise their quackery because, as an ad hoc body, they are not subject to normal regulations. One of the members has already claimed to have cured AIDS using herbs. No evidence was offered to support such an extravagant claim.

In New Zealand the ACC will pay for acupuncture, which is an unproven treatment, on the referral of a doctor. I had a patient with a severe neck injury which required (on the advice of a specialist neurosurgeon) an MRI scan but ACC does not pay for this test because it is “not an approved investigation”! This is a good example of politics controlling medicine, instead of science.

Recommended Posts