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In memoriam: Dr Peter Fisher

I 've just received the sad news of the death of Dr Peter Fisher in a cyclinig accident in High Holborn, near The Royal London Hospital for Integrated Medicine, where he had been a leading physician for many years.

Peter was a good friend and colleague in my years at the hospital, where he was consultant physician and Director of Research, as well as Editor of the journal Homeopathy. He was a convinced homeopath but always took an evidence-based approach to the subject. Nevertheless he was largely responsible for changing the name of the hospital from The Royal London Homeopathic Hospital to its present form in 2010. This was a wise move and reflects the fact that the hospital now offers a range of complementary treatments, always in the wider context of modern clinical mediclne.

Peter's death will be an irreplaceable loss to British homeopathy.

Book review: An Introduction to Western Medical Acupuncture (Adrian White, Mike Cummings, Jacqueline Filshie)

This is a book about the modern medical version of acupuncture, often called Western medical acupuncture (WMA) which is widely practised by health professionals today. It is the second edition of the work (the first appeared in 2008) and is described as a companion to Medical Acupuncture: A Western Scientific Approach (Elsevier, Edinburgh, 2016), now also in its second edition. The authors are all among the foremost proponents of WMA in Britain and so are well placed to produce a book of this kind.

Its primary intended audience is health professionals who have recently completed a training programme in modern acupuncture and want to consolidate and extend their knowledge of the subject. But it will also interest more experienced practitioners, because it includes a large amount of up-to-date research evidence for acupuncture that is otherwise not easy to find gathered together in an accessible form. [Continue reading]

Breast screening error: disaster or blessing in disguise?

The NHS computer error that has resulted in some 450,000 women aged around 70 not having received an appointment for a final breast screen is obviously, and understandably, deeply worrying for the women concerned. Predictably, the media have headlined the estimate that up to 270 of them may have developed cancers that are more advanced and difficult to treat than they would have been if diagnosed earlier. But this depends on a number of assumptions. Leaving aside the fact that this is the upper limit of an estimated 135-270 range (compare the "up to" speeds quoted by ISPs - how many customers achieve them?), the situation, as usual, is more complicated than the headlines imply.

New Scientlst has a good discussion of the question (Why breast screening error stories are getting death stats wrong). This article makes the important point that, for some women, the failure to notify them may have done them a favour. The current NHS estimate is that, for every 200 women in the 50-70 age range screened, one will be spared an early death but three will have unnecessary treatment for cancers that would not have been a problem in their lifetime.

... it means that up to 800 women may have been saved from harm by not sending them their final screening appointment letter, as they avoided possible reduction in their life expectancy through unnecessary treatment.

The New Scientist article makes the important point that the women who received unnecessary treatment would never know this and would presumably be forever grateful, believing that their lives had been saved by the 'harrowing treatment process'. So this is an 'invisible' harm that is difficult to quantify.

An interesting paper, possibly relevant to acupuncture

Structure and Distribution of an Unrecognized Interstitium in Human Tissues

This paper is very interesting in its own right and I think may have relevance to acupuncture. Although the focus is mainly on internal organs the findings also relate to the skin and connective tissue generally. The authors describe a previously unknown but widespread system of fluid-carrying channels of potential clinical significance.

"We propose here a revision of the anatomical concepts of the submucosa, dermis, fascia, and vascular adventitia, suggesting that, rather than being densely-packed barrier-like walls of collagen, they are fluid-filled interstitial spaces. The presence of fluid has important implications for tissue function and pathology. Our data comparing rapidly-biopsied and frozen tissue with tissue fixed in a standard fashion suggest that the spaces we describe, supported and organized by a collagen lattice, are compressible and distensible and may thus serve as shock absorbers."

This mechanism is thought to occur in the skin under mechanical compression and in the musculosketal system during activity.

"In sum, while typical descriptions of the interstitium suggest spaces between cells, we describe macroscopically visible spaces within tissues – dynamically compressible and distensible sinuses through which interstitial fluid flows around the body. Our findings necessitate reconsideration of many of the normal functional activities of different organs and of disordered fluid dynamics in the setting of disease, including fibrosis and metastasis."

Whether this discovery will ultimately prove to have relevance for acupuncture remains to be seen, but it's certainly something we need to be aware of. For example, it may be an additional reason for rejecting skin pressure as a valid control in acupuncture trials. So watch this space (literally).

Water companies use dowsing to find leaks

Today's Daily Mirror reports that an engineer working for the Severn Trent water company used dowsing to search for a leak at a property. The property owners' daughter, who is studying for a Ph.D in evolutionary biology at Oxford University, contacted the water company; they confirmed that some of their engineers practise dowsing and they have no objection. She then wrote to other water companies and found that nine of them used dowsing.

Dowsing is generally regarded as pseudo-science. Wikipedia lists a number of scientific studies of the practice that have been conducted since the early twentieth century; they have almost uniformly found the results were no better than chance.

A number of homeopaths use dowsing, usually with a pendulum, to choose their medicines. In the 1980s, when I was a physician at The Royal London Homeopathic Hospital (now The Royal London Hospital for Integrated Medicine), I contacted a dowsers' society to ask if their members were willing to take part in a trial to see if they could distinguish real homeopathic medicines from placebos. They agreed to do this and I started to set up the trial, but unfortunately they then backed out.

Evolutionary aspects of cancer - Mel Greaves

On my book reviews page there is a review of Cancer: The Evolutionary Legacy by Mel Greaves. Anyone who is interested in this important topic should see Greaves's lecture to an audience of biologists published in 2013.

Greaves is Professor of Cell Biology at the Institute of Cell Biology in London. Two important messages emerge from his lecture. One is that the fundamental importance of Darwninian evolution for our understanding of disease in general and cancer in particular is still not fully recognised, and the other - which is a consequence of the first - is that much of the research in cancer treaement at present is missing the real point and is unlikely to provide a lot of benefit. The research effort needs to be directed differently. We also need to do more to achieve early treatment and improve prevention, both of which are achievable right now. The treatment of more advanced cancers is likely always to be difficult.

The history of the RCT

Many of us probably think of the randomised controlled trial (RCT) as a largely British invention dating from shortly after the second world war, but an interesting short paper in the NEJM shows that its antecedents go back much further (The Emergence of the Randomized, Controlled Trial: Laura E. Bothwell, Ph.D., and Scott H. Podolsky, M.D. N Engl J Med 2016; 375:501-504 August 11, 2016 DOI: 10.1056/NEJMp1604635).

RCTs thus represent the most recent outgrowth of a long history of attempts to adjudicate therapeutic efficacy. Their immediate ancestor, alternate-allocation trials, emerged as part of a trend toward empiricism and systematization in medicine and in response to the need for more rigorous assessment of a rapidly expanding array of experimental treatments. Alternate allocation represented a significant advancement for addressing clinical research bias -- but one that had limitations as long as it allowed foreknowledge of treatment allocation. Concealed random allocation merged as the solution to these limitations, and RCTs were soon supported by crucial public funding and scientific regulatory infrastructures.

This open-access paper is well worth reading.

The priesthood of public health

Richard Lehman has a blog about medical research at; extracts from this appear as Research Update each week in the BMJ.

On 16 July 2016 Dr Lehman had a nice comment on a recent JAMA article on "the theology of eating fat", in which he referred to diet pundits as "the priestbood of public health". The occasion was a recently published large-scale study of nurses and doctors in the USA, which concluded that saturated fat is bad for you.and polyunsaturated fat is good. Lehman's comment is that it "doesn't provide the priestbood with very much to preach about in my opinion".

The Greek government is endorsing homeopathy

My wife has provided this item of information from the Greek news.

A medical furore is going on because the government has appointed an eleven-member committee composed of ten doctors and one pharmacist, all of them homoeopaths, to pronounce on whether homoeopathy should be officially recognised as a valid treatment in Greece with requirements set for the qualifications needed to practise.

Dead against this are the majority of the medical community, who point out the unsuitability of the committee and the lack of evidence that homoeopathy is anything other than placebo.

From religious quarters there are also complaints that all complementary medicine is based on mystical and other undesirable ideas, all of which are considered heretical by the Orthodox Church, and as such should not be given
official recognition in an Orthodox country.

Of course, one reason for the government's enthusiasm for this idea may be the fact that homeopathic medicines are relatively cheap.

Book review: Do No Harm, by Henry Marsh

Henry Marsh is a neurosurgeon who has headed his department at a London hospital for many years and has worked in the Ukraine to help set up neurosurgery there. In this book he provides an extraordinarily vivid account of his work and its emotional impact both on himself and on his patients and their relatives. The book consists of a large number of short chapters, each of which tells a story usually linked to a particular kind of brain abnormality. Some chapters are autobiographical and tell us about events in Marsh's own life and how he came to study medicine and become a neurosurgeon.

Patients, Marsh says, invest their doctors with superhuman qualities as a way of overcoming their fears when undergoing surgery.

The reality, of course, is entirely different. Doctors are human like the rest of us. Much of what happens in hospitals is a matter of luck, both good and bad; success and failure are often out of the doctor's control. Knowing when not to operate is just as important as knowing how to operate, and is a more difficult skill to acquire.


In Memoriam: Dr Felix Mann 1931-2014

Felix Mann

The death earlier this month of Dr Felix Mann after a long illness marked the end of an era for me, as it no doubt did for many doctors who learnt acupuncture from him in the 1970s. I first met him when I attended his course in 1977. At that time I was interested in oriental philosophies and that made me want to learn acupuncture, but I had no idea how to go about it. Then I happened to talk to a consultant who was head of the Migraine Clinic and who had recently done Felix's course. She told me it was worth while, so I registered for it.

The course was held in Felix's consulting rooms in the large house he had bought in Devonshire Place, in the West End of London. It lasted five days. There were fourteen of us. We sat in a semicircle on rather hard chairs while Felix stood in the middle and talked to us. From time to time patients would arrive to tell their stories and be treated. This was what I was expecting, but there was an early surprise.

Before starting the course we were supposed to read Felix's books. At that time they were based on traditional Chinese acupuncture and I don't think that any of us made very much of them. But this didn't matter because the first thing that Felix said to us was "I don't believe this stuff any more."

I have to admit that my initial reaction was disappointment, since, as I've said, it was an interest in Eastern ideas that had prompted me to learn acupuncture in the first place. But it was undoubtedly a relief to hear that I didn't need to struggle with all this complicated esoteric stuff, and later I was very grateful to Felix. Probably I should have come to a similar conclusion eventually, but he saved me a great deal of time. After the course I set up an acupuncture service at The Royal London Hospital for Integrated Medicine using the methods I had learnt from Felix. Modern medical acupuncture is still one of the main forms of treatment used there.

From our present standpoint in the second decade of the 21st century it is perhaps difficult to realise just how radical Felix's "acupuncture revolution" was. In the late 1950s people thought of acupuncture—if they thought of it at all—wholly in traditional Chinese terms. To describe it in the way he did required Felix to rethink everything he had been taught about acupuncture by all the 'experts' he had encountered.

Felix's acupuncture career

Acupuncture had been practised by quite a number of British doctors in the 1820s but had later fizzled out. By the twentieth century it was virtually unknown here, although it was still used quite extensively in mainland Europe, especially France and Germany. By this time it had become quite traditional, although that had not been the case in the nineteenth century.

As a young doctor Felix had to travel abroad to learn acupuncture since no one was teaching it here; this was comparatively easy for him because he was a good linguist and had plenty of contacts in Europe. He saw acupuncture being used and was impressed by the results. He studied at Montpellier in the south of France and at Munich and Vienna. Later, he even studied Chinese with the help of sinologists in Britain so as to be able to read the classic texts. So his subsequent abandonment of the traditional system wasn't due to lack of knowledge. It was based instead on fresh thinking and exact clinical observation.

By the time I met him in 1977 he had rejected practically all the traditional ideas about acupuncture. He now regarded it as a means of altering the activity of the nervous system and as a treatment that could be explained in terms of the modern understanding of anatomy and physiology. There was no need to talk about qi or yin and yang.

According to his new view, neither acupuncture points nor the so-called meridians exist as they are usually understood. Great precision in locating 'points' is unnecessary; instead we should be thinking of areas. In many cases these could be quite large: for example, in some patients needling anywhere below the knee might have the same effect as using the classic point Liver 3 (Felix's favourite site).

He introduced other departures from tradition as well. One was the use of periosteal (bone) needling, both to treat joint pain such as that due to arthritis and also to produce more generalised effects in a wide area. Another was his recognition of a subset of patients who responded particularly strongly to acupuncture, whom he designated strong reactors. Disorders that usually don't respond to acupuncture might do so in a strong reactor. But if a strong reactor were treated too vigorously the result could be a worsening of the symptoms or a feeling of general malaise lasting for some hours or even days.

As time went by Felix came to believe that many traditionalists over-treated their patients. Increasingly he favoured very gentle treatment, with the insertion of few needles — sometime only one — and the duration of needling being brief: seldom more than a minute or two and quite often just a few seconds.

While these ideas usually horrified traditionalists they were certainly easier for doctors trained in modern medicine to understand and accept. This was fortunate because more now wanted to learn. Felix had started teaching acupuncture to doctors in the 1960s although at first few came forward to learn. But in the 1970s the numbers increased, partly because attitudes to unorthodox treatments were beginning to change but also because advances in the scientific understanding of pain were making acupuncture seem more comprehensible in modern terms. Another influence was President Nixon's visit to China in 1972, which aroused interest in acupuncture on the part of a number of prominent British and American doctors.

Felix's former students constituted an informal medical acupuncture society. He used to circulate a yearly newsletter and each year, in November, he held an acupuncture meeting in his rooms for 70 doctors. There would be seven or eight speakers, usually including Peter Nathan, a well-known neurologist, and Felix provided an excellent lunch, with wine. Attendance was free to his former students; others paid a small fee which cannot have come even near to covering Felix's expenditure.

In 1980 matters were made more formal when the British Medical Acupuncture Society, constituted mainly by Felix's former students, was founded; he was its first President. It now has over 2000 members.

Felix's legacy

The fact that the acupuncture practised today by British health professionals is mostly non-traditional is largely thanks to Felix. Outside Britain the change has been more gradual. In much of Europe, apart from Sweden and Portugal, and in North and South America, traditional ideas are still influential. But the journal of the British Medical Acupuncture Society, Acupuncture in Medicine, is now a BMJ publication, so Felix's aim of making acupuncture an accepted form of treatment within mainstream medicine has mostly been accomplished. Perhaps most striking of all is the fact that an increasing number of the papers being submitted to the journal now come from China itself.

Felix wrote several books about his later view of acupuncture. The most important of these was Reinventing Acupuncture: A New Concept of Ancient Medicine. The first edition appeared in 1993 and the second in 2000. Here he described how his understanding of the treatment evolved and gave practical details of his methods. I still dip into it from time to time and continue to be impressed by how much my own experience agrees what he describes. All of us who use acupuncture today in a modern context are deeply indebted to him.

Requests for reprints of articles

I just received a request for a reprint of one of ny articles. I get these from time to time; strictly speaking I shouldn't send such reprints since they infringe the copyright of the journal, but I used to do it because the requests usually came from third-world countries where people presumably couldn't easily afford the payment.

But not once did any of these correspondents bother to thank me or even acknowledge receipt, which I take ill; it's a lot less trouble for them to reply than it is for me to find the article in question and attach it to my email. So now I no longer reply to such requests, especially when, as in today's case, the requester is a professor at a university hospital in Paris, who could no doubt easily afford the fee to the journal (which probably wouldn't come out of his own pocket anyway).

Homeopathy - a celebrity's endorsement or not?

The Faculty of Homeopathy is drawing the attention of supporters to "an excellent article" in The Mail Online.

This link takes you to a page where the actress Michelle Collins, who has appeared in East Enders and Coronation Street, describes how she gave up conventional medicine and moved to homeopathy to help her anxiety and depression. This was successful and she now feels much better.

But what is odd about this recommendation by the Faculty is that the article has an inset with a "Expert View" by Dr Ellie Cannon, who says that she does not reommend homeopathy to her patients because more than 150 trials have failed to show that it works.

Homeopathy’s dilution theory – that water ‘remembers’ the active ingredients it comes into contact with – is implausible. If it were true, water would also remember other substances – bacteria, animal waste or the test-tube the remedy was made in.

So how do I explain the positive effects some people experience? Michelle had crucial time and input from a therapist who listened to her worries. It helped her develop a positive mental attitude about coping with her anxiety. I believe it is this that has led to the improvement in her condition.

The placebo effect is real and powerful. So even though the pills are inert, treatment will ease the symptoms of stress. That is why taking a remedy before a show helps to control the panic. But the pill itself could just as well be a sugar lump.

Given the traumatic times Michelle has had, it is so important that she has found something that works for her. But as a general solution for others it would not work.

I think that Dr Collins gets it exactly right here. Homeopathy is best regarded as a form of psychotherapy. Please see my book Homeopathy in Perspective.

Psychotherapy today uses many different theories but it originated with Freud and psychoanalysis. The psychiatrist Anthony Storr was sceptical about much psychoanalytic theory but nevertheless thought that psychoanalysis could have beneficial effects on patients.
. . .
Much or all of homeopathic theory may be mistaken, and the remedies themselves may have little objective efficacy or even none at all, but patients often get better nevertheless. To say that this is due to the placebo effect is to beg the question, because we have only hazy notions about how placebos work anyway. For many patients, especially those whose symptoms really arise from their life situation, merely stating their problems verbally is sometimes enough to put them in a new light and to suggest the direction to look for a solution. In such cases the therapist is merely a sounding board; indeed, even a computer will do as a listener for some people. Many others do need a human individual to interact with, however.

So is the therapist no more than a sympathetic friend? No; this is where the theory comes in. It often doesn’t matter much what a therapist’s theoretical beliefs are (provided they are not actually dangerous, of course); their function in many cases is not to be “right” but to provide a framework to keep the discussion in focus.

Michelle's endorsement illustrates this extremely well.