COMMENTARY

Readers' Responses and Author's Reply to "The Reality of 'Traditional Chinese' Medicines"

Rena C. Gropper, PhD; Bob Flaws, LAc, FNAAOM (USA), FRCHM (UK); William Angelette, MS, MA; Francine Latremouille; Assunta Hunter, BA, ND; Angelique Sabo; Murray Grossan, MD; Darrel Gerard; Z. Lengyel, MD; Wallace Sampson, MD

Disclosures

December 14, 2006

To the Editor,

A few questions for Dr. Sampson:[1]

1. What do you mean by "objectively"/"objective"? Most of us are aware that our science is predicated on a series of assumptions that we have made. Assumptions are necessary to theory building. However, additional research may lead to rejection of a theory and/or some (or all) of its underlying assumptions.

Author's Reply:

The comment that science is based on a series of assumptions reflects the postmodern, deconstructionist view. We assume that there is an external reality that can be described and analyzed by scientific method. Without that assumption, the entire process of science and medicine would be halted, and a rational discussion could not occur.

In direct answer to the question,[1] objectively means repeated observation with measurement preferably by instrument, experiment and replication with mathematical analysis, inductive reasoning, and theory building followed by deductive reasoning for implementing the results and devising further investigations.

The editorial addressed modern physicians and researchers who may lack understanding of the folkway roots of traditional Chinese medicine (TCM). My statement about culturally based systems, such as TCM, addressed the claim of TCM advocates who claim that acupuncture and TCM cannot be evaluated through "Western" criteria. I did not state that acupuncture cannot be so evaluated.

Wallace Sampson, MD
wisampson@aol.com

2. Why do you assume that TCM has been homogeneous throughout time and space when we know that most medical systems existing for centuries, spread through vast territories, and subjected to numerous written commentaries have undergone much alteration? Surely, you took a "History of [conventional Western] Medicine." I wonder whether you are familiar with Payer's[2] documentation of how conventional biomedicine (CB) differs in the United States, England, (Western) Germany, and France.

Author's Reply:

I do not claim that TCM has been homogeneous either in time or geographically. I addressed advocates' claims that TCM methods have been handed down through the centuries as if it were a developed system, and that it must work because it has been used for 2000-3000 years.

The point is that medical science along with other sciences did not develop at the same rate in China as they did in Euro-America because of cultural-political reasons. In addition, some modern forms of TCM were developed not in China, but in Europe and North America. One major organization of acupuncture occurred in France in the 19th and 20th centuries during waves of popularity in Europe. Ear acupuncture was an invention of a French physician in the 1920s-1930s. The last significant formal reorganization occurred in post World War II China, politically influenced by the Marxist state and the Cultural Revolution.

Acupuncture points and indications remain variable and inconsistent throughout the world, and even among various regions of China.

"Conventional Western medicine" is one of several language distortion terms used in PM [postmodern] and the "CAM" [complementary and alternative medicine] movement to establish cultural equivalence. It demeans the significance of science and reason. Modern authors, commentators, researchers, and editors have unfortunately accepted and maintained the term, unaware of their having been semantically trapped into accepting the term's position in language as "normative."

Payer's survey of regional differences in selective practices suggests that medicine has socially determined factors. True, but differences are more than just some mysterious, undefined "cultural" event. Differences occur for other reasons. There may be several equally effective ways of managing conditions, each developed in one region's medical school. There are differences in available technology, economics, funds, insurance coverage, and patient preferences. Payer stepped in and took a snapshot in time of a system in process, with a normal variation in geographically distinct areas. Almost all such changes naturally occur in uneven patterns -- a basic fact of nature, well established by statisticians and scientific observers. One value of medical science is the discovery and development of varieties of effective techniques. Method variations are often distilled over years of experience to more common, universal practices. Additionally, the use of controlled comparative clinical trials that determine the best practice is a recent development -- first formalized in the 1960s-1970s, with refinements still being developed. Practice variations are now resolved in less time than they were 20-30 years ago. Regarding acupuncture and TCM, first, clinical trials, developed in the late 20th century, have been unable to establish efficacy for acupuncture use or for the vast majority of TCM herbal remedies. (Claims for acupuncture efficacy in nausea and pain are not credible.) Second, there has been no demonstration of consistency in diagnosis or treatment recommendation among TCM practitioners to the degree developed by science. Third, there has been no successful attempt to relate TCM diagnoses and treatments to those of modern medicine, so that there can be no claim of therapeutic equivalence. (See Nakeyama and Sivin N. Chinese Science. Explorations of an Ancient Tradition. Cambridge, Mass: MIT Press. 1973:203-272.)

Wallace Sampson, MD
wisampson@aol.com

3. Your research into TCM and acupuncture utilized an odd and biased paucity of sources, considering that as of August 21, 2006, Medline listed 5324 sources for acupuncture.

Author's Reply:

One of the extraordinary features of the CAM phenomenon has been a flood of papers on anomalous methods, including acupuncture, and of over 30 CAM-oriented journals that publish papers extolling sectarian systems that are unacceptable in standard journals. Some journal editors publish sectarian and TCM reports because of their unfamiliarity with the techniques, and the practice of using only experts (proponents, insiders) as reviewers. A colleague and I published a review of 33 systematic reviews of acupuncture for 17 conditions, representing at least 400 clinical trials. We found no firm evidence for efficacy. In 1991 we found that in reports of acupuncture for pain, the worst papers showed the most positive results and the best papers showed no efficacy. The epidemiology group at University of Maastricht, Maastricht, The Netherlands, found the same thing. The positive reports remain listed as positive.

This imbalance of evidence is an example of "alternative medicine's free ride." It is also an indication of the range of systematic error in the "evidence-based medicine" (EBM) system.

Wallace Sampson, MD
wisampson@aol.com

4. When you say "Diseases were not described," do you really mean to say that TCM does not use the International Classification of Diseases (ICD)? You do not seem to have investigated TCM's classification of diseases predicated on its own concepts of physiology, with emphasis on normal functioning rather than pathology, etc. "Tongue and pulse diagnoses" use very detailed descriptions of acceptable norms and aberrations from these normal ranges (Prof. Lobsang Rabgay, personal communication, 1983).[3]

Author's Reply:

The ICD is a creation of the late 19th and 20th centuries. Although current TCM practitioners may use the ICD, classical TCM practitioners could not have done so -- nor could Euro-Americans, for that matter. Diseases and Illnesses were not included in the ICD until 1948. More basically, disorders of TCM diagnostic schemes bear no relationship to modern Euro-American scientific disease classifications. To my knowledge, TCM treatments are still determined by TCM diagnoses and descriptions, not by the ICD. TCM diagnoses are based largely on ideas of systematic correspondence (appearances) and relations to hypothetical cosmic forces, not on classification by cause and pathology. Thus, they are meaningless.

Modern Chinese physicians in modern clinics and hospitals practice medicine as practiced worldwide and use the ICD, not TCM, classifications. As above, TCM is best understood as a folkway medicine, much the same as was prescientific "Western" medicine until the last 100-400 years. In all folkways, diseases were not classified as they are today. Concepts of infectious, genetic, inflammatory, or malignant diseases did not exist, and functions of organs were assigned descriptive terms, often using principles of systematic correspondence -- not functional terms from physiology. Describing a person's problem as excessive heat or wind of the spleen or in terms of deficiency of Ch'i or of yin or yang is meaningless for today.

Finally, there was no TCM system for recognition or elimination of error, for recognition of long-term effects (either beneficial of detrimental), or for differentiating a successful result from spontaneous recovery or chance.

If the writer could relate the tongue appearance to a specific disease or could demonstrate objectively (and record) the existence of 6 or 12 pulses and relate them meaningfully to any illness, condition, or disease, we might have a basis for discussion. In fact, no one can.

Wallace Sampson, MD
wisampson@aol.com

5. On what basis do you contend that "independent thinking and argument were discouraged" when we have documentation of numerous medical conferences convened in East (and South) Asia, often financed by royal patrons to which well-known practitioners from the Middle East, the Chinese Empire, the Tibetan Empire, and the South Asian Empires were invited. The therapists presented papers that they had prepared on the theory and practices that each used, distributed copies of the medical texts of their areas, and participated in lengthy debates on their presentations. In the Tibetan conferences, at least the final session included voting on which presentation (and type of medical system) seemed most persuasive from the perspective of underlying theory and case histories.[4]

Author's Reply:

First, there certainly was an exchange of ideas and techniques. Some scholars have traced techniques as coming from the medicine of ancient Greece and derivatives in Roman and Arabic medicine and from India, with information flowing back as well, via the silk routes and migration of populations. Acupuncture points may have come from astrology (India), and acupuncture itself may have been derived from needling-bloodletting and lancing of boils (from Greece).

TCM advocates often present a different picture from the questioner's description, claiming TCM to be entirely homegrown. However, presentations and exchanges were different from the give-and-take argumentation in the tradition of Europe. Medical information was described in terms of a trinity of cosmic/earth/mankind. Another difference was the Chinese tolerance for holding of contradictory ideas and practices without a need for resolution of differences as occurred in the European tradition. Respect and honor for age and authority also seem to have played a role in China's social stability, but also in what has been described as the stagnation of science in China.

Wallace Sampson, MD
wisampson@aol.com

6. Have you never seen the numerous acupuncture charts indicating the meridians (energy channels) that form the basis for the acupuncture points? Acupuncture has been highly "formalized" for centuries.[5]

Author's Reply:

I have a number of acupuncture and meridian charts. Most common acupoints are diagrammed similarly on the charts, but there are significant variations of location for some. Anatomic variations in humans render any accuracy of less than 10 mm highly unlikely. Actually, some historians attribute formalization of the channels to Europe in the 19th century.

The question uses "energy channel" as though there were a reality to the concepts of energy (Ch'i) and of its coursing through channels (meridians). Neither has been demonstrated to exist. Our official guide in China suggested that I regard Ch'i and channels as symbolic, not real. I do so.

Wallace Sampson, MD
wisampson@aol.com

7. If TCM is "not highly regarded by modern Chinese physicians," why do all of the contemporary Chinese medical schools include a TCM curriculum as well as a CB one?

Author's Reply:

Modern scholars and I are informed that the present government position is to attempt to integrate "Western" science into TCM as a matter of cultural pride, and a multibillion dollar herb industry (perhaps similar to its position on business and economics). The hospitals and schools that we were shown had TCM sections, but the acupuncture/moxa was limited to 1 room, about 5 x 15 m, with room for 8-12 patients in 4- to 7-story hospitals occupying half to 1 city block. The cots and beds were not filled. Most herbal activity took place outside the hospitals.

Wallace Sampson, MD
wisampson@aol.com

I look forward to your response.

Rena C. Gropper, PhD
Medical Anthropologist
Professor Emerita
Department of Anthropology
Hunter College, CUNY
renagropper@yahoo.com

References

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

  2. Payer L. Medicine & Culture: Variations of Treatment in the United States, England, West Germany, and France. New York: Penguin Books; 1999.

  3. Liu Y. The Essential Book of Traditional Chinese Medicine. Vols 1 and 2. New York: Columbia University Press; 1988.

  4. Unschuld P. Medicine in China: A History of Ideas. Berkeley: University of California Press; 1985.

  5. Avedon J, Meyer F, Bolskokheva ND, Gerasimova KM, Bradley TS. The Buddha's Art of Healing: Tibetan Paintings Rediscovered. New York: Rizzoli; 1998.

Author's Reply:

Addendum: The answers to this first questioner's series of 7 questions also require comments. The questioner is a medical anthropologist. Medical anthropology has changed in the past 30 years. It began as a descriptive science of prescientific and culturally based medical systems. However, most contemporary medical anthropologists and medical historians now assume a relativist, "postmodern" (PM) view. They consider medicine to be culturally based, just one of a plurality of systems, with modern scientific medicine having no inherent superiority to other systems of other cultures and other times.

Objective measurement (science) is considered just "another way of knowing." Medical anthropologists assign no hierarchy of intellectual activity or accomplishment, equating rational thinking with intuition, feelings, personal experience, and subjective group consensus.

The PM movement is an outgrowth of literary critique and other fields, including architecture. PM features include (1) a breakdown of standards and consensus for knowledge building out of facts determined by accurate measurement, (2) denial of an objective and knowable external reality, and (3) the derivative assumption that accurate description of reality is not possible. The field's major thrust is "deconstruction" of the status quo.

Some PM philosophers take more radical views. The late Jacques Derrida claimed that "reality" is actually changed by the language that describes it. "Alternative medicine" contains features of postmodernism. Advocates and theoreticians of CAM distort and invent language with the goal of changing perceptions, standards for validity, thus the laws that define them. This is recorded in "alternative medicine" journal articles.

PM has given birth to fields, such as "feminine science," and cultural/nationality-based sciences, such as African science. PM thinking has rationalized traditional Chinese medicine to be nonevaluable by Western scientific standards. PM advocates often describe modern science as "European, white male-dominated." Most PM advocates have been associated with activities of far left and Marxist political beliefs. Thus, medical anthropologists now see modern medicine as a tool for political and economic dominance and sociopolitical hegemony over other cultures. (Advocacy for the supplement industry and certain other methods, such as Laetrile, comes from far right political supporters.)

Medical anthropologists' commentary, often colored by these political orientations, rejects the authority of medicine's scientific status. Modern scientists and physicians are considered "logical positivists." Positivism is considered outmoded and irrelevant. Physicians and scientists are also considered to be "culturally arrogant." Readers may want to keep these matters in mind when reading these questions as well as those that follow.

Wallace Sampson, MD
wisampson@aol.com

To the Editor,

In my opinion, Dr. Sampson's editorial critiquing TCM is one of the most uniformed, reactionary pieces of crap I have read in a very long time.[1] To begin with, let me state my credentials. I am a licensed acupuncturist in Colorado with almost 30 years of clinical experience. I studied Chinese medicine and acupuncture at the Shanghai College of Chinese Medicine. I am author and translator of almost 100 books and thousands of articles on Chinese medicine published around the world, many in peer-reviewed biomedical acupuncture journals. I regularly teach acupuncture and Chinese medicine to MDs around the world. I am widely read in the Chinese medical literature, both premodern and contemporary, and have long experience in the practice of Chinese medicine in China, the United States, Europe, India/Nepal, Australia, and New Zealand. Now let me address each of Dr. Sampson's criticisms one by one.

"Advocates of traditional Chinese medicine (TCM) say that TCM cannot be evaluated through "Western" judgment because TCM differs in tradition and orientation."

This is a naive, romantic, Orientalist, and basically uninformed statement by a single source. Huge resources are spent in China in terms of time, money, and manpower evaluating Chinese medicine from the perspectives of biology and biomedicine. I translate and publish hundreds of pieces of such Chinese research, which is available (some for free and some for a charge) at www.bluepoppy.com.

"TCM developed in a tradition of an authoritarian culture. Independent thinking and argument were discouraged."

There were many contentious and well-known arguments, both theoretical and clinical, in the history of Chinese medicine. Please see Fu Qing-zhu's Gynecology (published by Blue Poppy Press) for just one example of a Chinese doctor debating the practices of his peers. Blue Poppy Press publishes a number of translations of premodern and contemporary Chinese medical texts that either allude to or contain various debates within Chinese medicine. Inability to access this primary source of literature is no excuse for such biased, inflammatory, and uninformed opinions. There is such a thing as journalistic ethics.

"A tradition of objective science did not develop.[2]"

Then Dr. Sampson has never read Wang Qing-ren's Yi Lin Gai Cuo (Correcting the Errors in the Field of Medicine) in which Wang did numerous postmortem dissections in the 19th century in order to correct erroneous anatomic theories and beliefs. This is one of the most widely quoted and most widely reprinted books in Chinese medicine. (Blue Poppy Press is currently preparing its first English language translation.)

"Diseases were not described."

Diseases were most definitely described. In fact, the premodern Chinese classics contain some of the earliest descriptions of diseases in the world literature, descriptions that are still clinically valid today, such as that of diabetes mellitus. However, because Chinese speak Chinese, their disease names are different from our disease names even though they are talking about the same clinical entities. In professional Chinese medicine, there are 200+ specifically named internal medicine diseases, 100+ pediatric diseases, 100+ gynecologic diseases, 100+ dermatologic diseases, 100+ traumatologic conditions, 100+ infectious diseases, etc. For a discussion of the Chinese medical definition and treatment of these diseases, see Sionneau & Lu's The Treatment of Disease in Traditional Chinese Medicine, Vols. 1-7, Blue Poppy Press. This set includes approximately 280 named Chinese medical diseases. It only deals with internal medicine, not gynecology, pediatrics, dermatology, trauma medicine, etc.

"Symptoms and physical characteristics were related only to natural elements and the cosmos. Ideas conformed to those of the emperor and state. TCM contained no concept of physiology, biochemistry, organ function, heredity, or infectious disease."

Just as Western medicine is far different today than 2000 years ago, Chinese medicine has also evolved and continues to evolve. Dr. Sampson is describing pre-Han Chinese medicine, not the Chinese medicine of today. In Chinese medicine, there is a highly developed physiology, pathophysiology (called bing yin and bing ji in Chinese), and a whole literature on infectious diseases (shang han lun, wen bing, and shi bing schools of literature). Yes, Chinese ideas about heredity were simplistic. I will grant you that. However, as for the rest, your statements only show that you really know nothing about Chinese medicine and are simply spouting off in an ignorant and arrogant way.

"Tongue and pulse diagnoses were essentially random."

RCTs [randomized controlled trials] published in China have proven the inter-rater reliability of tongue and pulse examination. Both are taught and practiced in a rigorously logical and methodologic way.

"therapies based on them were useless -- accepted on authority, not proved.[3]"

Again, uniformed foolishness. If Chinese medicine was so useless, why are acupuncture and Chinese medicine growing by leaps and bounds all over the world? As stated above, I and my company have published hundreds of Chinese RCTs and clinical audits proving to any reasonable, unbiased person the therapeutic effects of Chinese medicine.

Further, Dr. Sampson's assertion that the clinical effects of Chinese medicine are unproven is a typical, Western, white boy racist attack on the accumulated intelligence and wisdom of 2000 years of the Chinese people. Dr. Sampson seems to think that only himself and his Western biomedical cronies are intelligent human beings. The "natives," it would seem, are incapable of basic commonsense. However, in the history of Chinese medicine, many, many theories and therapies have been abandoned over time due to the fact that they did not pan out in real-life clinical practice, eg, most of the theories of the Jin-Yuan dynasty doctor, Zhang Zi-he.

"New anthropological findings and China scholars' re-evaluation indicate that acupuncture descended from various informal techniques, not formalized until the 19th and 20th centuries, largely by Europeans[5,6] and in China by the cultural revolution."

What dribble! One can trace a very clear development of acupuncture starting from the Warring States period to today by reading the Chinese language literature. Yes, acupuncture today is different from what it was in the Han dynasty. It has evolved over all that time. Isn't that what it should have done if it was based on real-life clinical experience?

"TCM is not highly regarded by modern Chinese physicians, as 85% or more of medicine there is scientific, and TCM is utilized through self-referral.[7]"

There are 3 healthcare delivery systems in China today: pure Western medicine, integrated Chinese-Western medicine, and pure Chinese medicine. It is true that 85% of medical practitioners in China are Western medical practitioners. However, that in no way negates the clinical efficacy of Chinese medicine and mostly has to do with the rush toward everything "modern" and "Western." When Chinese go to the hospital, they want IV [intravenous] antibiotics for everything because that is what they naively believe is trendy. As more and more Chinese are realizing the limitations and the side effects of biomedicine, more are turning back to Chinese medicine for safe, effective healing. I say this having come back from China last week where I did visit hospitals and talked to both Chinese-Western and Chinese medical practitioners. More important, however, is the growing development of integrated Chinese-Western medicine (zhong xi yi jie he) based on the realization that both systems have their strengths and weaknesses and that they can be used in tandem to get an even better clinical effect. I have published scores of RCTs on integrated Chinese-Western medicine in the following textbooks: Chinese Medical Psychiatry, The Treatment of Cardiovascular Diseases with Chinese Medicine, and The Treatment of Diabetes Mellitus with Chinese Medicine -- all, I would point out, are coauthored by licensed MDs.

OK; I have other fish to fry. This argument is not worth any more of my time or brain cells. I'm sorry that your publication has accepted an opinion editorial by such a 19th-century dinosaur.

Bob Flaws, LAc, FNAAOM (USA), FRCHM (UK)
bob@bluepoppy.com

References

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

  2. Qing-zhu F. Fu Qing-zhu's Gynecology. Shou-zhong Y, Da-wei L, trans. Boulder, Colo: Blue Poppy Press; 1995.

  3. Qing-ren W. Yi Lin Gai Cuo (Correcting the Errors in the Forest of Medicine). Chung Y, Oving H, Becker S, trans. Boulder, Colo: Blue Poppy Press. In press.

  4. Sionneau P, Gang L. The Treatment of Disease in Traditional Chinese Medicine. Vols 1-7. Boulder, Colo: Blue Poppy Press; 1999.

  5. Flaws B, Lake J. Chinese Medical Psychiatry. Boulder, Colo: Blue Poppy Press; 2001.

  6. Becker S, Flaws B, Casanas R. The Treatment of Cardiovascular Diseases with Chinese Medicine. Boulder, Colo: Blue Poppy Press; 2005.

  7. Flaws B, Kuchinski L, Casanas R. The Treatment of Dibetes Mellitus with Chinese Medicine. Boulder, Colo: Blue Poppy Press; 2002.

Author's Reply:

Ignoring the egregious, inflammatory, ad hominem comments, Mr. Flaws' forceful defense and advocacy of acupuncture and TCM are understandable. He is not only a practitioner but an owner or official with a commercial herbal company (www.bluepoppy.com) that also produces education materials and journal article abstracts. He has been affected by the distorted history of Chinese medicine now popularly believed.

Some of his objections are answered in the first answer set above. However, respect within the TCM community does not transfer to the scientific community. His position is similar to defenses and expositions of chiropractic, homeopathy, and others claiming positions in the arena of medicine.

Mr. Flaws' statements and questions confuse and conflate TCM with the recent amalgamation of scientific and Western nomenclature and technology encouraged in the People's Republic of China.

Again, the editorial was directed at TCM advocate claims that TCM, not recent scientific additions to TCM, have validity and can be measured against modern medicine. As stated above, a valid comparison can be made between TCM of prior periods and the traditions of prescientific Euro-American medicine. Scientific experiments that led to the discoveries of cures for scurvy (dietary component) and cholera (water supply contamination) were determined by structured experiment, a factor missing in TCM.

Some successes can be obtained through observation and trial and error, but many more errors than successes are made that way. TCM records no systematic investigation of cause, and no method for determining success or failure, or error. Flaws' arguments suffer from the same deficits. More directly, after 30 years of trials and study, there is still no efficacy attributable to acupuncture or to almost all traditional herbs.

TCM's dependence on ideas of correspondence (appearances and qualities instead of proved activity) is seen in the following description in a recent TCM/Integrative Medicine journal.

The control group for treatment of serous otitis media was treated with the antibiotic cefaclor. Both groups received drainage when indicated:

 

The treatment group received the following: twelve herbs . . . mixed and given in capsules, having the following characteristics: Radix scrofulariae nourishes yin to lessen fire; R. Rehmanniae to clear heat to cool blood; R Salviae Miltorrhizae - promote blood flow to remove blood stasis; R. Achyranthis Bidentatae - eliminates stasis, reduces swelling; R. Angelicae sinensis nourishes and harmonizes blood; Semen Coiesis invigorates Pi and invigorates Fei, clears heat and dispells dampness; Amomum kravanh Pirre ex Gagnep - drive Qi and warm Wei; Stiff silkworm expels endogenous wind to relieve spasm; dissipates phlegm and eliminates stagnation.

The herbs accomplish the above functions while also "removing turbidity and opening orifice, strengthening the essence and driving evil pathogens out of the body."

In this case, the diagnosis (otitis media) was a modern one made with modern equipment. There is no information as to how a diagnosis of otitis media could be made before the use of the otoscope, probably not introduced in China until the 20th century. All a TCM physician could have known about the patient was the presence of an earache. The earache would likely have been described in terms of heat/cold, dry/moist, wind, the elements, yin/yang, and relationships of inner organs to the cosmos. There could not have been a diagnosis of otitis media or of what kind.

Original descriptions of TCM herb effects were made on the basis of 2 methods: (1) systematic correspondence, that is, selecting herbs on the basis of their appearances, colors, tastes, etc, with no relation to the pathogenesis of the illness, and (2) uncontrolled observations with the defects noted above. The concept of reproducibility had not developed. Mr. Flaws would have to produce alternate evidence from TCM documents on how these 12 herbs would have been selected.

The letter states that pulse and tongue diagnoses have interexaminer reliability. Because the 6 or 12 pulses do not exist, I would conclude that experiments demonstrating reliability were probably not adequately blinded. Because tongue appearance only rarely relates directly to diseases, I would allow that descriptions might be reliable, but that they have no significance.

In regard to the usefulness of TCM, the question again conflates TCM with modern attempts at TCM/modern medicine integration -- a type of hybrid or chimera in which both are used concurrently. If used exclusively, TCM efficacy has to be compared with other preliterate culturally based medicines.

The recent growth of TCM accompanies the growth of other sectarian methods, such as chiropractic, naturopathy, and other herbal systems. It is a partially sociologic, political, ideologic, and economic phenomenon. The interest is in Western countries, while interest in modern medicine rises in China.

In regard to the evolution of acupuncture and accompanying changes, apparently Mr. Flaws agrees. His comments on prejudice exemplify the inability of Euro-American TCM advocates to adjust to the reality of TCM inefficacy.

In regard to the practices of medicine in China, the published evidence for TCM efficacy is blemished by the finding that almost 100% of published evidence is positive, unlike published trials in the United Kingdom and the United States, which range from 70% to 80%.

Wallace Sampson, MD
wisampson@aol.com

To the Editor,

Dr. Wallace Sampson, naively, proposes that traditional Chinese medicine (TCM) can be rationally evaluated through "Western" judgment by objectively examining the historical development of the TCM tradition.[1] There is no doubt that careful examination of the history of TCM greatly contributes to our understanding of its current status. However, the arguments put forth by Dr. Sampson in support of his opinion go far beyond historical description and suggest unwarranted confidence in a suspect notion of science. His remarks do not dispel the mystery of Western cultures' evaluation failures. Rather, they put reasons for such failures into strong relief.

Dr. Sampson notes the context of authoritarian culture within which the TCM traditions grew and remarks that such a culture may discourage independent thinking and argument. From this he seems to conclude that "A tradition of objective science did not develop." However, this does not follow. Supposing that there is such a thing as Western science, isn't it the case that the traditions of Western science own a parallel historical marker? For example, think of the fears of Copernicus who delayed publication of his theory for fear of being accused of heresy. If Dr. Sampson reasoned correctly, we would have to dismiss virtually all of science prior to the French Revolution. Or if we think in terms of more recent history, we would have to do away with all of the notions of contemporary physics developed prior to the end of World War II.

Author's Reply:

Mr. Angelette's argument fails for want of logic. I did not state that all TCM information had to be discarded because of dates. I stated what historians of Chinese medicine have found -- that there were cultural reasons for China's not having fully developed a scientific method. Of course, there were inhibitions to European findings in cosmology, but findings were transported across borders and understood in a social milieu that encouraged a specific kind of rational thinking.

Wallace Sampson, MD
wisampson@aol.com

Dr. Sampson provides a brief catalog of theoretical and methodologic notions relied upon by Western medicine, including disease, symptom, physiology, biochemistry, organ function, heredity, diagnosis, therapy, and so on. He notes that those concepts are either differently applied by or absent from traditional Chinese medicine (TCM). Moreover, the TCM counterparts were in necessary conformance with authority. He adds to this "not proved." I will address the question of proof later. However, what conclusions ought we to draw from the happenstance of conformance with authority? How much of Western medicine would count as scientific if we were forced to discount any methods that conformed with government standards. The argument is absurd on its face. What has gone wrong? Obviously, Dr. Sampson wants to say that government authority is now warranted because best practices are driven by prior proofs. So, let's now turn to proofs. Apparently, Dr. Sampson considers patient satisfaction and therapeutic success important hallmarks in proving the success for a scientific practice of medicine, for these are the very markers that he targets in identifying the weaknesses of TCM.

Author's Reply:

Mr. Angelette twists my argument into another, and then proclaims it to be absurd. I did not state that methods in conformity with government standards have to be discounted, only that Chinese cultural forces discouraged innovation and rational thinking and encouraged magical thinking.

Wallace Sampson, MD
wisampson@aol.com

He suggests that in the case of TCM, (1) observational evidence is psychologically flawed, ie, systematically misleading (misdirection, counterirritation); (2) post hoc conclusions were tolerated; and (3) error detection was nil. Dr. Sampson offers an alternative, ostensibly nonscientific explanation for the appearance of TCM success. If patient satisfaction is admitted to be a measure of success for a science, it must be admitted that satisfaction is an equally poor measure of Western successes (even if there are recent attempts to counter the effects of systematic bias). Post hoc conclusions are traditionally looked upon with suspicion by Western science, but it is far from a ban. Note the frequent revision and extension to theory consequent upon post hoc statistical methods or the not infrequent remarks about external sources of error to account for the failure of significance testing. Although not always the best source of inspiration, theory revision does indeed sometimes come through this door. Error detection stands alone as a salient difference between the traditions pointed out by Dr. Sampson. However, this is ambiguous. On the one hand, if no errors are detected by scientists (of whatever description), this does not show that their theories and methods are wrong. This finding would be neutral to the question of efficacy. On the other hand, failure to have the meta-methodologic goal of falsification may be a reason for preferring one set of practices over another. However, a simple falsification may not be enough to make a rational decision about the scientific status of a practice if combinations of competing high-level goals are introduced, such as simplicity or breath of applicability.

Author's Reply:

Perhaps the best way to answer this convoluted question and statement is to point out that uncontrolled human observations really are flawed, and many more erroneous observations are made than accurate ones (Loftus E. Eyewitness Testimony. Boston: Harvard University Press, 1979; Loftus E. Memory. Boston: Addison-Wesley, 1980) and TCM methods have not stood up to tests of efficacy.

Wallace Sampson, MD
wisampson@aol.com

What of the alternative explanation for the appearance of TCM success? "Conditioning and reinforcement, amplified by social pressures, created patient satisfaction and appearance of therapeutic success," according to Dr. Sampson. Even supposing this is true, as we have already noted, the appearance of success does not cause therapeutic failures. In fact, the appearance of success is often a concomitant of real success. For this alternate explanation to be effective in arguing anything about the effects of TCM relative to Western medicine, we need to also have a story about how such conditioning and reinforcement would "cause" patients treated with TCM to have a worse outcome. I look forward to Dr. Sampson's further argument supplying that historical story.

Author's Reply:

The reasons for apparent acupuncture efficacy have to be controlled for in any experimental protocol, but are inadequately controlled in positive acupuncture studies. They are all proven psychological mechanisms that affect experimental outcomes. They explain apparent success of a placebo better than rearrangement of an imaginary Q'i or secretion of endorphins. Conditioning explains how outcomes can appear to be more successful, or equal to placebo controls. There is no reason to explain the absence of a worse outcome.

Wallace Sampson, MD
wisampson@aol.com

William Angelette, MS, MA
Victoria, Australia
angelett22@netscape.net

Reference

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

To the Editor,

It would appear that although TCM developed over thousands of years through keen observation and empirical testing, Dr. Wallace's comments were made with no research into the subject and no real desire to learn anything new.[1]

I believe that he is parroting the comments of those of the scientific community who are afraid to admit that anything that cannot be seen and touched can actually work.

Perhaps the use of positive reinforcement and encouragement with patients does go a long way in helping patients to heal themselves, but I have also seen many patients who are skeptical about TCM show improvement. No; it is not strictly "scientific" in proof, but there is a great deal of empirical proof as to its effectiveness in many areas.

I am pleased that in my relations with Western doctors and medical support people that I do not find Dr. Wallace's prejudices are predominant. In China most Western medically trained doctors are also fully trained in TCM, and the 2 modalities work closely together. In the past few years in North America, the Eastern and Western medical practitioners also have been starting to learn to cooperate for the better treatment of patients. We need to remember that it is the patient who requires our help in whatever way is most effective for them -- not our egos that need to be massaged.

Francine Latremouille
TCM Practitioner
Certified Acupuncturist

Reference

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

Author's Reply:

Ms. Latremouille is more impressed with centuries of uncontrolled observations and with her belief in explanations that include things "that cannot be seen and touched" than she is with rational explanations with proven and reproducible mechanisms. Her thinking illustrates one of the differences between thinking of sectarian medicine advocates and scientific physicians.

I have not seen most elements of the editorial analysis in standard medical literature. That is why I wrote it. Most of the editorial is based on information from reliable translators and historians of Chinese medicine listed in the bibliography. Some is my own synthesis, but based on established principles of physiology and psychology.

Psychologists have demonstrated that one does not have to be a "believer" in an ineffective method to be convinced of its efficacy. The questioner cannot prove through Cochrane collaboration reviews that acupuncture "works" better than a placebo or other methods. All that the reviews show is that some small clinical trials show positive results, and others none. However, that is expected in any analysis of an ineffective method.

The fact that many modern physicians cooperate with cult and sectarian practitioners is truly concerning. Physicians being miseducated and inculcated into believing untrue claims should concern all patients. That is the second reason for the editorial. The egos standing in the way of settling this issue reside in the heads of advocates, not those of objective observers.

Wallace Sampson, MD
wisampson@aol.com

To the Editor,

Dr. Sampson's claim that traditional Chinese medicine is based entirely on nonspecific effects seems to overlook the small, but I would argue significant, number of positive Cochrane Reviews of traditional Chinese medicine practices.[1]

My understanding of evidence-based medicine would suggest that the use of randomized controlled trial methodology and the accumulation of sufficient trials for a systematic review would indicate that there was evidence of efficacy for these treatments over placebo. The fact that the scientific community may be unable at this point to develop a consensus view as to the scientific basis for a mechanism of action of many traditional Chinese medical treatments must be balanced against the conclusion that there is a significant effect over and above the use of placebo.

In my opinion, there is clearly evidence that the efficacy of some traditional Chinese medicine treatments extends beyond nonspecific effects.

Yours sincerely,
Assunta Hunter, BA (hons), ND, Master of Women's Health
a.hunter1@uq.edu.au

Reference

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

Author's Reply:

Ms. Hunter, along with many others (not only naturopaths) is unaware of the limitations of controlled trials and their systematic reviews. Although they are regarded as "gold standard," RCTs [randomized controlled trials] and SRs [systematic reviews] are still being perfected and refined. Unfortunately, because of wide variability in human responses and an at least equal variability in the implementation of trials and of their statistical analyses, the present status can only approximate true efficacy. Unless the results are clear and not conflicting, conclusions about efficacy cannot be drawn. Conflicting results turn out to be typical or diagnostic of inefficacy. The present Cochrane series remains conflicted, with trials showing contradicting results. Reproducibility being one stanchion of scientific method, acupuncture remains unproven. With its implausibility, alternate psychological explanations, and increasing numbers of negative well-done trials, the weight of evidence indicates no effectiveness above that of placebo or suggestion.

The sooner sectarian advocates come to terms with their biases, lack of knowledge, and misinterpretations of reality, the sooner we can cease arguing, learn from their errors, and get on with more productive paths.

Wallace Sampson, MD
wisampson@aol.com

To the Editor,

Reviewing your editorial, it seems clear to me that you have not actually studied TCM [traditional Chinese medicine].[1] Of course, they discussed diseases, symptoms, and organ function in ancient China, just not in terms that you understand. Treatises were published on "cold" diseases, "women's" diseases, etc. Infectious diseases were classified as epidemic or seasonal epidemic diseases. Organ theory in TCM does not correspond clearly to anatomic titles that we assign but rather to complexes of function. For example, kidney function refers to a combination of kidney and adrenal function. The lack of specificity in this language doesn't make the medicine ineffective. Furthermore, you totally overlook the fact that acupuncture is only a small part of TCM, which includes herbs, therapeutic massage, exercise, and diet. (Please don't argue in the same breath that herbs do nothing, yet are dangerous.)

So, much of the medicine that comes down to us through TCM has indeed been empirical. I don't understand why this is a problem for people. To my mind, this means it survived because it worked, not because rats (or the pharmaceutical companies) liked it.

One of the problems in setting up experiments for what we think of as specific illnesses, let's say the common cold, is that a TCM practitioner sees and treats not just a "cold," but the stage it's in and how it affects the individual patient. So clinical trials demand that everyone be treated the same, whether they receive the same TCM diagnosis or not. A good TCM practitioner understands the words: One disease, 100 diagnoses.

WS: It is partly due to reliance on proverbs and sayings that Chinese science and medicine developed so slowly.

I don't turn my nose up to the Western style medicine, and I am repeatedly amazed at what we have accomplished. At the same time, as an acupuncturist who practices TCM (did you guess?), I have been able to successfully treat problems that modern medicine was unable to touch, and I know that TCM has a place in medicine.

Finally, I don't understand why some MDs insist on tearing down alternative therapies. Patients come to me as a last resort when modern medicine is unable to assist and they're often angry and frustrated. Well, I don't tell them that modern medicine doesn't work! I say that it was unable to get to the root of that problem for one reason or another, but don't throw out the MDs phone number. If one thing doesn't work, try another. Is it not okay for a physician to say, "If I'm unable to help you with this, go ahead and try something else?" Must there be only 1 medicine?

Angelique Sabo
angeliqu36@yahoo.com

Reference

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

Author's Reply:

The publishing of treatises does confer validity to their contents. Ms. Sabo did not explain the usefulness of the scores of uses for menstrual blood and the absorbent cloths with same that are clearly enumerated in TCM literature. She did not explain the use of combining kidney and adrenal diseases, none of which has anything to do with the other. More important, she will not be able to describe any kidney or adrenal condition in TCM terms that has any validity in present terms. If lack of language specificity doesn't mean anything, then neither does the language mean anything, and because most TCM methods are ineffective against diseases anyway (even the herbs, which have toxicity but rare efficacy), she really has said nothing.

Ms. Sabo is correct that acupuncture was a small part of TCM therapeutics. However, it is a large part of today's TCM practice.

Modern science has shown that uncontrolled human observation is faulty. Even the courts have come to that conclusion. Scientific method reduces human observational error.

Yes; there is only 1 medicine. There is not a plurality of medicines, nor of astronomies, biochemistries, nor of other biological sciences. Within 1 medicine may be found a plurality of approaches and methods for the same condition. However, their efficacy is determined by the same standards.

Ms. Sabo mistakes observing 2 events in sequence as proof of cause and effect -- perhaps the most common observational error humans make.

Ms. Sabo still has to prove her statements, or at least someone has to. No one has.

Wallace Sampson, MD
wisampson@aol.com

To the Editor,

Enjoyed your article very much.[1]

Actually, If I didn't know how to do surgery and couldn't read ECGs [electrocardiograms] I would set up my practice as "holistic medicine." I see this all the time.

At the height of the acupuncture craze, I invited all of the acupuncturists to do my postoperative tonsil patients -- all declined.

So I had tennis elbow, and as long as I was visiting one of the acupuncture "mavens," I figured, might as well try it. The needle went directly into the ulnar nerve; my hand dropped and I quickly removed the needle.

I was more fortunate than one of my patients who had the seventh nerve needled and didn't recover.

Best wishes,
Murray Grossan, MD
ENTconsult@aol.com
www.grossan.com
http://www.ent-consult.com/irr_bibliog.html

Reference

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

To the Editor,

Thank science and reason for wonderful people like Dr. Sampson.[1] It is hard to believe how wide and deep harmful quackery has spread into medical care in the United States, with acupuncture being one of the foremost wastes of time and money. I have encountered numerous physical therapists and a few physicians who are just dying to believe in the tooth fairy and appear to have no use for the rigors of evidence-based medicine. They convince themselves that things are working that aren't, and I even had an argument with one physician practitioner of acupuncture over whether his treatment was helping my severe chronic pain condition. He got angry with me when after 6 months of treatment I insisted that I had not improved. I have had several physical therapists treating me for this chronic pain condition who believe that tapping on my forehead will somehow help the pain in my lower back and buttocks. I know an otherwise intelligent woman who believed that a so-called animal Reiki practitioner could heal her dog over the telephone! It won't be long before pseudophysicians become "bacteria deniers." It matters not to acupuncturists that their treatment is ineffective nor that their "ancient Chinese miracles" were neither ancient nor miraculous nor even Chinese.

I'm very grateful that there are people like yourself and Dr. Sampson, but how many others in the scientific community are willing to stand up and call quackery and scams what they truly are, and how can we get more truly educated and trained people to speak up?

Darrel Gerard

Reference

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

To the Editor,

I deeply agree with your view of traditional Chinese medicine (TCM).[1]

I find it exceedingly peculiar that in the 21st century, the age of evidence-based-medicine, the age of hyperproliferation of medical science, superstition about medical problems is rampant, even among trained physicians -- who often believe that TCM and other so-called paramedical treatments are suppressed by some secret conspiracy.

Ten centuries ago, the king of Hungary publicly and officially proclaimed that "witches do not exist." If someone tried to do something similar today, he would be running a good chance of being burnt at the stake.

Yours sincerely,
Z. Lengyel, MD
Szent Margit Hospital
Budapest, Hungary

Reference

  1. Sampson W. The reality of "raditional Chinese" medicines. MedGenMed. 2006;8:31. Available at: http://www.medscape.com/viewarticle/541341 Accessed August 7, 2006.

Author's Reply:

I thank Mr. Gerard and Drs. Grossan and Lengyel for their insight and supportive comments. In populations in which a majority believe in ghosts, a majority think that humans and dinosaurs coexisted on the planet, and that evolution is not a fact. Belief in unscientific medical sects does not come as a surprise.

Wallace Sampson, MD
wisampson@aol.com

 

 

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