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Chiropractors are getting very touchy indeed, all over the world. And no wonder, because their claims are being exposed as baseless as never before, in the wake of their attempts to stifle criticism by legal action..

In March, Shaun Holt appeared on Breakfast TV in New Zealand. Holt has done a lot of good work on TV in debunking some of the preposterous claims made by quacks. See him on YouTube.

This time he talked about chiropractic. Here is the video.

One could argue that he was over generous to chiropractic, especially when talking about their effectiveness in treating low back pain. He said, quite rightly, that chiropractors are no better than physiotherapists at treating low back pain.

But a recent trial suggests that neither are much good. “A randomised controlled trial of spinal manipulative therapy in acute low back pain” (Juni et al., 2009 in the BMJ; see also coverage in Pulse). This trial compared standard care with standard care plus spinal manipulative therapy (SMT). The results were negative, despite the fact that this sort of A + B vs B design is inherently biassed in favour of the treatment (see A trial design that generates only ”positive” results, Ernst & Lee 2008, Postgrad Med J.).

"SMT was performed by a specialist in manual medicine, chiropractice and rheumatology (GH), a specialist in physical medicine (DV) or an osteopath (RvB), all proficient in SMT."

"Conclusions: SMT is unlikely to result in relevant early pain reduction in patients with acute low back pain."

Admittedly, the trial was quite small (104 patients, 52 in each group) so it will need to be confirmed. but the result is entirely in line with what we knew already.

It also adds to the evidence that the recommendation by NICE of SMT by chiropractors constitutes their biggest failure ever to assess evidence properly. If NICE don’t amend this advice soon, they are in danger of damaging their hitherto excellent record.

Despite the moderate tone and accuracy of what Holt said on TV, the New Zealand Chiropractors’ Association made a formal complaint. That is what they like to do, as I learned recently, to my cost. It is so much easier than producing evidence.

Quite absurdly the New Zealand Broadcasting Standards Authority (BSA) has upheld some of the complaints. Their judgement can be read here.

The BSA consists of four people, two lawyers and two journalists. So not a trace of scientific expertise among them. Having people like that judging the claims of chiropractors makes as much sense as having them judged by Mr Justice Eady. They seem to be the sort of people who think that if there is a disagreement, the truth must lie half-way between the opposing views.

One of the BSA members, Tapu Misa, has used her newspaper column to quote approvingly the views of the notorious Dr Mercola web site on flu prevention “Your best defence, it says, is to eat right, get lots of sleep, avoid sugar and stress, load up on garlic, Vitamin D and krill oil”. (Snake oil is said to be good too.)    There are some odd attitudes to science in some of her other columns too (e.g. here and here). Not quite the person to be judging the evidence for and against chiropractic, I think.

In fact the TV show in question was more than fair to chiropractors. It adopted the media’s usual interpretation of fair and balanced: equal time for the flat earthers. A Chiropractor was invited to reply to Holt’s piece.  Here he is.

The chiropractor, Doug Blackbourn, started very plausibly, though a tendency to omit every third syllable made transcription hard work. He established that if you cut yourself you get better (without any help). He established that nerves run down the spinal cord. So far, so good. But then he quickly moved on to the usual flights of fancy.

"We have two premises. The body heals itself and the nervous system runs the body. Now the nervous system runs the body, travels down through the spinal cord so chiropractic is not based on the belief that, you know, energy flows, it’s based on the fact that your nervous system runs the body and [inaudible] affects the overall health of the body"

This statement is totally vague. It has nothing whatsoever to do with the main question, can chiropractors do anything useful. It is sheer flannel.

We’re seeing people, heck, diabetes. I had a quadriplegic come in one time for adjustment, we’ve got stroke people, we’ve got all sorts of conditions. We’re not treating the condition, We’re allowing, checking the spine to see if there’s any interference there that will slow the body down"

“Interference”? “slowing the body down”? These are utterly meaningless phrases that simply serve to distract from the only question that matters.

"Chiropractice is the most safest [sic] profession to go to to get your spine adjusted"

Hmm I thought it was the only job that uses the word ‘adjustment’.

Worst of all was his response to a question about asthma.

Presenter: "So chiropractors are not out there claiming they will cure asthma for example?". Chiropractor: "No"

This is simply untrue, both in New Zealand and in the UK. For a start, just look at what Blackbourn’s own web site says about asthma.

"The challenge, of course, with allergy and asthma medication is there is no end-point. There is no cure. Asthma and allergies, for the most part, are lifelong conditions requiring lifelong medication. Might there be a better way, an alternative solution?

“Alternative” is the key word. Medical treatment is designed to combat symptoms, and is successful to a certain extent with allergies and asthma. Underlying causes are not addressed, however, and symptoms continue year after year. What else might be done?

Enter chiropractic care. Chiropractic health care, with its unique comprehensive approach, is able to offer positive benefit to a variety of conditions and ailments. In the case of allergies and asthma, these “hypersensitivity conditions” may respond well to therapy designed to normalize the body’s flow of nerve signals. To use a metaphor, chiropractic treatment removes roadblocks to the body’s natural healing abilities. Restoring these imbalances may help reduce such hypersensitivity reactions."

Blackbourn’s web site describes him thus

"As a Doctor of Chiropractic, Dr. Doug Blackbourn . . ."

But the qualifications of “Dr” Blackbourn are B.App.Sc (Chiro) M.N.Z.C.A , the same as those of “Dr” Brian Kelly.

After a performance like this, perhaps someone should submit a complaint to the New Zealand Broadcasting Standards Authority.

After all, I notice that they have dismissed complaints from one chiropractor, Sean Parker, after a TV programme looked at the business practices of his private chiropractic practice, The Spinal Health Foundation. Perhaps the BSA understands business better than it understands science.

### Follow-up

Is chiropractic crumbling in New Zealand? The New Zealand College of Chiropractic featured in my editorial in the New Zealand Medical Journal, and in the fallout from that article, It’s principle, “Dr” Brian Kelly (B App Sci (Chiro)) seems to be getting desperate. His college is now canvassing for recruits in Canada. They are promised all the woo.

• Subluxation centered techniques – Gonstead, Toggle Recoil, Thompson, Diversified
• Traditional philosophy featuring vitalism and innate healing – congruent curriculum

Perhaps Canada is a good place to recruit, gven the $500 million class action being brought against chiropractors in Canada, after Sandra Nette became tetraplegic immediately after a chiropractor manipulated her neck, Canadian chiropractors must be looking for somewhere to hide. Stuff and Nonsense. jdc described this story at the time the complaint was lodged. Shaun Holt’s own blog follows the action. New Zealand Doctor covers the story. Bay of Plenty TimesBay researcher slams television complaint ruling Jump to follow-up In July 2008 I wrote an editorial in the New Zealand Medical Journal (NZMJ), at the request of its editor. The title was Dr Who? deception by chiropractors. It was not very flattering and it resulted in a letter from lawyers representing the New Zealand Chiropractic Association. Luckily the editor of the NZMJ, Frank Frizelle, is a man of principle, and the legal action was averted. It also resulted in some interesting discussions with disillusioned chiropractors that confirmed one’s worst fears. Not to mention revealing the internecine warfare between one chiropractor and another. This all occurred before the British Chiropractic Association sued Simon Singh for defamation. The strength of the reaction to that foolhardy action now has chiropractors wondering if they can survive at all. The baselessness of most of their claims has been exposed as never before. No wonder they are running scared. The whole basis of their business is imploding. Needless to say chiropractors were very cross indeed. Then in February 2009 I had a polite email from a New Zealand chiropractor, David Owen, asking for help to find one of the references in the editorial. I’d quoted Preston Long as saying "Long (2004)7 said “the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45. And I’d given the reference as 7. Long PH. Stroke and spinal manipulation. J Quality Health Care. 2004;3:8–10 I’d found the quotation, and the reference, in Ernst’s 2005 article, The value of Chiropractic, but at the time I couldn’t find the Journal of Quality Healthcare. I did find the same article on the web. At least the article had the same title, the same author and the same quotation. But after finding, and reading, the article, I neglected to change the reference from J Quality Health Care to http://skepticreport.com/sr/?p=88. I should have done so and for that I apologise. When I asked Ernst about the Journal of Quality Healthcare, he couldn’t find his copy of the Journal either, but he and his secretary embarked on a hunt for it, and eventually it was found.  It turns out that Journal of Quality Healthcare shut down in 2004, without leaving a trace on the web, or even in the British Library. It was replaced by a different journal, Patient Safety and Quality Healthcare (PSQH) A reprint was obtained from them. It is indeed the same as the web version that I’d read, and it highlighted the quotation in question. The reprint of the original article, which proved so hard to find, can be downloaded here. The full quotation is this "Sixty-two clinical neurologists from across Canada, all certified members of the Royal College of Physicians and Surgeons, issued a warning to the Canadian public, which was reported by Brad Stewart, MD. The warning was entitled Canadian Neurologists Warn Against Neck Manipulation. The final conclusion was that endless non-scientific claims are being made as to the uses of neck manipulation(Stewart, 2003). They need to be stopped. The public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45." I have often condemned the practice of citing papers without reading them (it is, of course, distressingly common), so I feel bad about this, though I had in fact read the paper in question in its web version. I’m writing about it because I feel one should be open about mistakes, even small ones. I’m also writing about it because one small section of the magic medicine community seems to think they have nailed me because of it. David Owen, the New Zealand chiropractor, wrote to the editor of the NZMJ, thus.  The quote [in question] is the public should be informed that chiropractic manipulation is the number one reason for people suffering stroke under the age of 45. Long PH. Stroke and Manipulation. J Quality Health Care. 2004:3:8-10 This quote actually comes from the following blog article http://www.skepticreport.com/medicalquackery/strokespinal.htm [DC the URL is now http://skepticreport.com/sr/?p=88] I have attached all my personal communications with Colquhoun. They demonstrate this is not a citation error. Prof Colquhoun believes the origin of the quote doesn’t matter because Long was quoting from a Canadian Neurologists’ report (this is also incorrect). As you can see he fails to provide any evidence at all to support the existance [sic] of the “J Quality Health Care.” This would not be an issue at all if he had admitted it came from a blog site— but I guess the link would have eroded the credibility of the quote. Colquhoun ‘s belief that my forwarding this complaint is me “resorting to threats” is the final nail in the coffin. If he had any leg to stand on where is the threat? This may seem pedantic but it surely reflects a serious ethical breach. Is it acceptable to make up a reference to try and slip any unsupported statement into a “scientific” argument and thereby give it some degree of credibility? Incidentally, at the end of the article, conflicts of interest are listed as none. As Colquhoun is a Professor of Pharmacology and much of his research funding no doubt comes from the pharmaceutical industry how can he have no conflict of interest with therapies that do not advocate the use of drugs and compete directly against the billions spent on pain medications each year? If I may quote Colquhoun himself in his defence of his article (Journal of the New Zealand Medical Association, 05-September-2008, Vol 121 No 1281) I’ll admit, though, that perhaps ‘intellect’ is not what’s deficient in this case, but rather honesty. David Owen ### Financial interests Well, here is a threat: I’m exposed as a shill of Big Pharma. ". . . much of his funding no doubt comes from the pharmaceutical industry". I can’t count how many times this accusation has been thrown at me by advocates of magic medicine. Oddly enough none of them has actually taken the trouble to find out where my research funding has come from. None of them even knows enough about the business to realise the extreme improbability that the Pharmaceutical Industry would be interested in funding basic work on the stochastic properties of single molecules. They fund only clinicians who can help to improve their profits, The matter of funding is already on record, but I’ll repeat it now. The media ‘nutritional therapist’, Patrick Holford, said, in the British Medical Journal “I notice that Professor David Colquhoun has so far not felt it relevant to mention his own competing interests and financial involvements with the pharmaceutical industry “ To which my reply was ” Oh dear, Patrick Holford really should check before saying things like “I notice that Professor David Colquhoun has so far not felt it relevant to mention his own competing interests and financial involvements with the pharmaceutical industry”. Unlike Holford, when I said “no competing interests”, I meant it. My research has never been funded by the drug industry, but always by the Medical Research Council or by the Wellcome Trust. Neither have I accepted hospitality or travel to conferences from them. That is because I would never want to run the risk of judgements being clouded by money. The only time I have ever taken money from industry is in the form of modest fees that I got for giving a series of lectures on the basic mathematical principles of drug-receptor interaction, a few years ago.” I spend a lot of my spare time, and a bit of my own money, in an attempt to bring some sense into the arguments. The alternative medicine gurus make their livings (in some cases large fortunes) out of their wares. So who has the vested interest? ### Does chiropractic actually cause stroke? As in the case of drugs and diet, it is remarkably difficult to be sure about causality. A patient suffers a vertebral artery dissection shortly after visiting a chiropractor, but did the neck manipulation cause the stroke? Or did it precipitate the stroke in somebody predisposed to one? Or is the timing just coincidence and the stroke would have happened anyway? There has been a lot of discussion about this and a forthcoming analysis will tackle the problem of causality head-on, My assessment at the moment, for what it’s worth, is that there are some pretty good reasons to suspect that neck manipulation can be dangerous, but it seems that serious damage is rare. In a sense, it really doesn’t matter much anyway, because it is now apparent that chiropractic is pretty well discredited without having to resort to arguments about rare (though serious) effects. There is real doubt about whether it is even any good for back pain (see Cochrane review), and good reason to think that the very common claims of chiropractors to be able to cure infant colic, asthma and so on are entirely, ahem, bogus. (See also Steven Novella, ebm-first, and innumerable other recent analyses.) Chiropractic is entirely discredited, whether or not it may occasionally kill people. ### Complaint sent to UCL I had an enquiry about this problem also from my old friend George Lewith. I told him what had happened. Soon after this, a complaint was sent to Tim Perry and Jason Clarke, UCL’s Director and Deputy Director of Academic Services. The letter came not from Lewith or Owen, but from Lionel Milgom. Milgrom is well known in the magic medicine community for writing papers about how homeopathy can be “explained” by quantum entanglement. Unfortunately for him, his papers have been read by some real physicists and they are no more than rather pretentious metaphors. See, for example, Danny Chrastina’s analysis, and shpalman, here. Not to mention Lewis, AP Gaylard and Orac.  Dear Mr Perry and Mr Clark, I would like to bring to your attention an editorial (below) that appeared in the most recent issue of the New Zealand Medical Journal. In it, one of your Emeritus Professors, David Colquhoun, is accused of a serious ethical breach, and I quote – “Is it acceptable to make up a reference to try and slip any unsupported statement into a “scientific” argument and thereby give it some degree of credibility?” Professor Colquhoun is well-known for writing extensively and publicly excoriating many forms of complementary and alternative medicine, particularly with regard to the alleged unscientific nature and unethical behaviour of its practitioners. Professor Colquhoun is also a voluble champion for keeping the libel laws out of science. While such activities are doubtlessly in accord with the venerable Benthamite liberal traditions of UCL, I am quite certain hypocrisy is not. And though Professor Colquhoun has owned up to his error, as the NZMJ’s editor implies, it leaves a question mark over his credibility. As custodians of the college’s academic quality therefore, you might care to consider the possible damage to UCL’s reputation of perceived professorial cant; emeritus or otherwise. Yours Sincerely Dr Lionel R Milgrom So, as we have seen, the quotation was correct, the reference was correct, and I’d read the article from which it came I made a mistake in citing the original paper rather than the web version of the same paper.. I leave it to the reader to judge whether this constitutes a "serious ethical breach", whether I’d slipped in an "unsupported statement", and whether it constitutes "hypocrisy" ### Follow-up It so happens that no sooner was this posted than there appeared Part 2 of the devastating refutation of Lionel Milgrom’s attempt to defend homeopathy, written by AP Gaylard. Thanks to Mojo (comment #2) for pointing this out. Shortly after I published my editorial in the New Zealand Medical Journal, Dr Who?, I was delighted to get a letter from someone who had trained in chiropractic and seen it all from the inside. Sadly this wonderful letter had to be removed within a few weeks of posting it because its author was threatened and bullied by chiropractors. Its author is too young and too vulnerable to risk his future career. As a result of this shameful and vindictive treatment, I was asked to remove the letter and did so immediately. Other copies on the web have now vanished too. The experiences described in the letter justified much of what I said in the editorial, and in some ways went further. This letter doubtless contributed to dropping of the threatened legal action by chiropractors against the Journal and against me. The letter was posted originally on 21 August 2008, with the permission of its author. See also the follow-up in Chiropractic wars. Part 3: internecine conflict. Now I have been sent a much more anonymous version, and it is a great pleasure to post this inside information.  David I must begin by stating my background in relation to chiropractic. I am a graduate of a chiropractic college and have practiced for several years. I have elected not to register or practice again and have returned to study to begin a new career. Prior to studying chiropractic, I gained undergraduate and postgraduate qualifications in science. First I would like to address your comment about the validity of a qualification from a private chiropractic college, especially in relation to the difference between studying there and studying at a university. A major difference is the education and experience of faculty. At the time I was there, most of the faculty at my college had only undergraduate qualifications (I would suggest that the American DC degree is of undergraduate level as it is the primary qualifying degree for chiropractic in the US and Canada -it is not the equivalent of a doctorate in a British or Australasian university) and have not published in peer-reviewed journals. This is quite different to my experience of universities where the all of the faculty usually have at least a PhD and are actively involved in research. The content of the chiropractic curriculum was voluminous. It included basic sciences, chiropractic subjects and social sciences. The college I attended did not have any laboratory facilities so the experience of learning science from a textbook was quite different to the way I had been taught at university, where each subject had a significant laboratory program that had to be passed separately to pass the subject. As chiropractic is a clinical discipline, the course contained subjects in common with a medical degree. Sadly, the attitude towards medicine and the medical profession was not always the most constructive. For example, I can recall a noticeboard where newspaper clippings of media reports of medical misadventure and adverse effects of pharmaceuticals were posted regularly. Clinical experience was gained by a 2 year internship in the school health centre concurrent with the last 2 years of academic study; so it was not a full-time internship. The requirements for passing this component of the course were complex but centred around seeing a number of patients, a number of visits, performing a number of various kinds of x-rays and reading a number of x-ray films. Every student was responsible for finding all of their own patients to meet the requirements. The result of this was a clinical experience that was quite narrow for most people. This would seem to be quite different to the hospital internship of a medical degree, the clinical internship of a dental degree or the range of placements in a physiotherapy degree in terms of the breadth of experience of different kinds of patients of different ages and states of health. For people who are not aware, there are a range of ideas within chiropractic about what it is and what it is for. The “wellness”, subluxation-based kind of chiropractic is taught by a minority of schools and is what chiropractors call a “philosophical view”. It advocates that chiropractic care be independent from symptoms or treatment and be a regular part of peoples’ lives. The expectation is that healthy, asymptomatic people will be “adjusted” on a regular basis to keep them free from “vertebral subluxation”. To that end, the training at schools that teach this approach is adequate (and probably even excessive). The issue that you wrote about related to the use of the title “doctor” by chiropractors in New Zealand. In licensing chiropractors and allowing them the use of the title “Dr” in front of their names (provided that the title is qualified by the word “chiropractor”) governments have awarded chiropractors with recognition and prestige that has usually been associated with a level of academic achievement or with a medical qualification. It indicates that the bearer of the title can be trusted to give credible advice within their area of expertise. The issue may seem benign, but in allowing chiropractors to use the title, people who would not normally feel safe to submit to the treatment of an alternative health practitioner, choose to try chiropractic. I make this point because at its core, chiropractic is quite different to medicine, dentistry and physiotherapy. A chiropractic office often looks like a lot like a doctor’s surgery. The layout is similar (with waiting rooms and consultation rooms; there are things like stethoscopes and x-ray machines and there are often informative and education posters and brochures. In many cases, the title “doctor” is used in the office to describe the chiropractor. I have found that some people believe chiropractors are medical doctors. Some even believe that chiropractic is a kind of medical speciality. I have seen patients who choose chiropractic as their primary health care and come to a chiropractic office as their first port of call when they are unwell. I have seen offices where this behaviour is encouraged by the chiropractor. Equally, some of the most “philosophical” chiropractors are adamant that chiropractic does not treat anything. They maintain that it is simply something that everyone should do regularly, at all stages of life, to ensure they stay healthy. These chiropractors sometimes refuse to use the title “doctor” altogether. Two practices are of particular concern in some chiropractic offices and in my view; these alone should be sufficient reason to prevent chiropractors from calling themselves “doctor”. The first is the systematic and deliberate erosion of a person’s confidence in the medical system. Many offices have anti medical literature in their libraries. Chiropractors are sometimes taught practices to subvert medical credibility. See http://chirobase.org/20PB/top7.html for an example. The second is a subset of the first but is particularly damaging. It is active opposition to vaccination. At chiropractic school, I was taught anti-vaccination information in my paediatrics course. I have seen books written by chiropractors opposing vaccination and I have seen many offices with anti vaccination leaflets and books in abundance. Now I am all for informed choice but this type of material is rarely accurate or balanced. People are being encouraged not to vaccinate their children by professionals who they believe to be a reliable and prestigious source of information. Although it may sound paternalistic to people who have not had the privilege of clinical practice (albeit in a profession I no longer agree with), it made me realise several things. The first is that people who are unwell are vulnerable. The second is that there are people who trust “medical” advice unquestioningly. I believe we should be very careful about who we title as a credible source of advice about health care. Legislation treads a fine line between limiting personal freedom and protecting people from harm. Aside from the qualification being inconsistent with the academic level that is usually required to use the title “Doctor”, the greatest danger, in my opinion, is that the legal recognition and permission to use the title has allowed chiropractors to assume the mantle of a doctor. In the guise of this respectability, some chiropractors are deliberately eroding confidence in doctors and denying children (and possibly populations) the protection of vaccination. David, thank you for having the courage to question the use of the title “doctor” by chiropractors. Historically (and in your case), chiropractors fight their battles through litigation so it takes personal courage and integrity to do so. All I can say is, don’t thank me. It doesn’t take much courage at my age. It takes a lot at yours and the world should be grateful to you. ### Replies from chiropractors in the NZMJ The New Zealand Medical Journal, very properly, allowed right of reply to chiropractore. This week’s issue contains three letters, one of which is from Paul Kelly. It is signed “Dr Brian Kelly B App Sci (Chiro), President, New Zealand College of Chiropractic”. This is not quite the same as appears on his College’s web site which shows the president’s welcome. It seems that Kelly has not been quite so careful about use of his title on the web site because (as of 21 August) the signature on his address looks like this. Dr Brian Kelly, President”. That does seem a bit careless, given that his usage of “Dr” was pointed out in my original editorial, published on 25th July. Replies to these letters appeared in the September 5th issue of NZMJ. Jump to follow-up Alfred Joseph Clark FRS held the established chair of Pharmacology at UCL from 1919 to 1926, when he left for Edinburgh. In the 1920s and 30s, Clark was a great pioneer in the application of quantitative physical ideas to pharmacology. As well as his classic scientific works, like The Mode of Action of Drugs on Cells (1933) he wrote, and felt strongly, about the fraud perpetrated on the public by patent medicine salesmen. In 1938 (while in Edinburgh) he published a slim volume called Patent Medicines. The parallels with today are astonishing.  Alfred Joseph Clark FRS (1885 – 1941) I was lucky to be given a copy of this book by David Clark, A.J. Clark’s eldest son, who is now 88. I visited him in Cambridge on 17 September 2008, because he thought that, as holder of the A.J. Clark chair at UCL from 1985 to 2004, I’d be a good person to look after this and several other books from his father’s library. They would have gone to the Department of Pharmacology if we still had one, but that has been swept away by mindless administrators with little understanding of how to get good science. Quotations from the book are in italic, and are interspersed with comments from me. The book starts with a quotation from the House of Commons Select Committee report on Patent Medicines. The report was submitted to the House on 4 August 1914, so there is no need to explain why it had little effect. The report differs from recent ones in that it is not stifled by the sort of political correctness that makes politicians refer to fraudsters as “professions”. ### The problem “2.2 The situation, therefore, as regards the sale and advertisement of proprietary medicines and articles may be summarised as follows: For all practical purposes British law is powerless to prevent any person from procuring any drug, or making any mixture, whether patent or without any therapeutical activity whatever (as long as it does not contain a scheduled poison), advertising it in any decent terms as a cure for any disease or ailment, recommending it by bogus testimonials and the invented opinions and facsimile signatures of fictitious physicians, and selling it under any name he chooses, on payment of a small stamp duty. For any price he can persuade a credulous public to pay.” Select Committee on Patent Medicines. 1914 “The writer has endeavoured in the present article to analyse the reasons for the amazing immunity of patent medicines form all attempts to curb their activity, to estimate the results and to suggest the obvious measures of reform that are needed.”  Clark, writing in 1938, was surprised that so little had changed since 1914. What would he have thought if he had known that now, almost 100 years after the 1914 report, the fraudsters are still getting away with it? Chapter 2 starts thus. ### THE LAW The Select Committee appointed by the House of Commons in 1914 ‘to consider and inquire into the question of the sale of Patent and Proprietary Medicines’ stated its opinion in 28 pages of terse and uncompromising invective. Its general conclusions were as follows: That the trade in secret remedies constituted a grave and widespread public evil. That the existing law was chaotic and had proved inoperative and that consequently the traffic in secret remedies was practically uncontrolled. In particular it concluded ‘”that this is an intolerable state of things and that new legislation to deal with it, rather than merely the amendment of existing laws, is urgently needed in the public interest.” The “widespread public evil”continues almost unabated, and rather than introduce sensible legislation to cope with it, the government has instead given a stamp of approval for quackery by introducing utterly ineffective voluntary “self-regulation”. Another Bill to deal with patent medicines was introduced in 1931, without success, and finally in 1936, a Medical and Surgical Appliances (Advertisement) Bill was introduced. This Bill had a very limited scope. Its purpose was to alleviate some of the worst abuses of the quack medicine trade by prohibiting the advertisement of cures for certain diseases such as blindness, Bright’s disease [nephritis] , cancer, consumption [tuberculosis], epilepsy, fits, locomotor ataxy, fits, lupus or paralysis. The agreement of many interests was secured for this measure. The president of the Advertising Association stated that the proposed Bill would not affect adversely any legitimate trade interest. Opposition to the Bill was, however, whipped up amongst psychic healers, anti-vivisectionists and other opponents of medicine and at the second reading in March 1936, the Bill was opposed and the House was counted out during the ensuing debate. The immediate reason for this fate was that the Bill came up for second reading on the day of the Grand National! This is only one example of the remarkable luck that has attended the patent medicine vendors. (Page 14). The “remarkable luck” of patent medicine vendors continues to this day, Although, in principle, advertisement of cures for venereal diseases was banned in 1917, and for cancer in 1939, it takes only a few minutes with Google to find that these laws are regularly flouted by quacks, In practice quacks get away with selling vitamin pills for AIDS, sugar pills for malaria and homeopathic pills for rabies, polio anthrax and just about anything else you can think of. Most of these advertisements are contrary to the published codes of ethics of the organisations to which the quack in question belongs but nothing ever happens. Self-regulation simply does not work, and there is still no effective enforcement even of existing laws.. “It has already been stated that British law allows the advertiser of a secret remedy to tell any lie or make any claim that he fancies will sell his goods and the completeness of this licence is best illustrated by the consideration of a few specific points. Advertisements for secret remedies very frequently contain a list of testimonials from medical men, which usually are in an anonymous form, stating that ………….. M.D., F.R.C.S., has found the remedy infallible. Occasionally, however, the name and address of a doctor is given and anyone unaware of the vagaries of English law would imagine that such use of a doctor’s name and professional reputation could not be made with impunity without his consent. In 1899, however, the Sallyco Mineral Water Company advertised that ‘Dr. Morgan Dochrill, physician to St. John’s Hospital, London and many of the leading physicians are presenting ‘Sallyco’ as an habitual drink. Dr. Dochrill says nothing has done his gout so much good. Dr. Dochrill, whose name and title were correctly stated above, sued the company but failed in his case. ” “The statement that the law does not prevent the recommending of a secret remedy by the use of bogus testimonials and facsimile signatures of fictitious physicians is obviously an understatement since it is doubtful how far it interferes with the use of bogus testimonials from real physicians.” Dodgy testimonials are still a mainstay of dodgy salesman. One is reminded of the unauthorised citation of testimonials from Dr John Marks and Professor Jonathan Waxman by Patrick Holford to aid his sales of unnecessary vitamin supplements. There is more on this at Holfordwatch. The man in the street knows that the merits of any article are usually exaggerated in advertisements and is in the habit of discounting a large proportion of such claims, but, outside the realm of secret remedies, the law is fairly strict as regards definite misstatements concerning goods offered for sale and hence the everyday experience of the man in the street does not prepare him for dealing with advertisements which are not merely exaggerations but plain straightforward lies from beginning to end. Scientific training is undoubtedly a handicap in estimating popular gullibility as regards nostrums. One imagines that no one today would be willing to spend money on pills guaranteed to prevent earthquakes but yet the claims of many of the remedies offered appear equally absurd to anyone with an elementary knowledge of physiology or even of chemistry. A study of the successes and failures suggests that success depends chiefly on not over-rating the public intelligence. (Page 34) This may have changed a bit since A.J. Clark was writing in 1938. Now the main clients of quacks seem to be the well-off “worried-well”. But it remains as true as ever that “Scientific training is undoubtedly a handicap in estimating popular gullibility as regards nostrums.” In 2008, it is perhaps more a problem of Ben Goldacre’s dictum ““My basic hypothesis is this: the people who run the media are humanities graduates with little understanding of science, who wear their ignorance as a badge of honour.” Clark refers (page 36) to a successful conviction for fraud in the USA in 1917. The subject was a widely advertised ‘get fat quick’ pill that contained lecithin, proteins and sugar. The BMA analysis (in 1912) suggested that the cost of the ingredients in a box of 30 tablets sold for 4/6 was 1 1/4 d. [4/6 meant 4 shillings and six pence, or 22.5 pence since 1971, and 1 1/4 old pence, a penny farthing, is 0.52 new pence]. He comments thus. The trial revealed many interesting facts. The formula was devised after a short consultation with the expert of one of the largest drug manufacturers in the U.S.A. This firm manufactured the tablets and sold them to the proprietary medicine company at about 3/- per 1000, whilst they were retailed to the public at the rate of £7 10s. per 1000. The firm is estimated to have made a profit of about$3,000,000.

These trials in the U.S.A. revealed the fact that in a considerable proportion of cases the ‘private formula’ department of the large and well known drug firm already mentioned had first provided the formula for the nostrum and subsequently had prepared it wholesale.

Nothing much has changed here either. The alternative medicine industry (and it is a very big industry) is fond of denouncing the evils of the pharmaceutical industry, and sadly, occasionally they are right.  One of the less honest practices of the pharmaceutical industry (though one never mentioned by quacks) is buying heavily into alternative medicine. Goldacre points out

“there is little difference between the vitamin and pharmaceutical industries. Key players in both include multinationals such as Roche and Aventis; BioCare, the vitamin pill producer that media nutritionist Patrick Holford works for, is part-owned by Elder Pharmaceuticals.”

And then. of course, there is the deeply dishonest promotion by Boots the Chemists of homeopathic miseducation, of vitamins and of CoQ10 supplements.

The manner in which secret remedies can survive repeated exposure is shown by the following summary of the life history of a vendor of a consumption [tuberculosis] cure.

1904, 1906: Convicted of violating the law in South Africa.

1908:            Exposed in British Medical Association report and also attacked by Truth.

1910:            Sued by a widow. The judge stated: ‘I think this is an intentional and well-considered fraud. It is a scandalous thing that poor people should be imposed upon and led to part with their money, and to hope that those dear to them would be cured by those  processes which were nothing but quack remedies and had not the slightest value of any kind.’

1914:             A libel action against the British Medical Association was lost.

1915              The cure was introduced into the United States.

1919               The cure was sold in Canada.

1924                Articles by men with medical qualifications appeared in the Swiss medical journal boosting
the cure.

Secret remedies have a vitality that resembles that of the more noxious weeds and the examples mentioned suggest that nothing can do them any serious harm.

Most of the time, quacks get away with claims every bit as outrageous today.   But Clark does give one example of a successful prosecution.  It resulted from an exposé in the newspapers -wait for it -in the Daily Mail.

There is, however, one example which proves that a proprietary remedy can be squashed by exposure if this is accompanied by adequate publicity.

The preparation Yadil was introduced as an antiseptic and was at first advertised to the medical profession. The proprietor claimed that the remedy was not secret and that the active principle was ‘tri-methenal allylic carbide’. The drug acquired popularity in the influenza epidemic of 1918 and the proprietor became more and more ambitious in his therapeutic claims. The special virtue claimed for Yadil was that it would kill any harmful organism that had invaded the body. A more specific claim was that consumption in the first stage was cured with two or three pints whilst advanced cases might require a little more.  Other advertisements suggested that it was a cure for most known diseases from cancer downwards.

These claims were supported by an extraordinarily intense advertising campaign.  Most papers, and even magazines circulating amongst the wealthier classes,  carried full page and even double page advertisements. The Daily Mail refused these advertisements and in 1924 published a three column article by Sir William Pope, professor of Chemistry in the University of Cambridge. He stated that
the name ‘tri-methenal allylic carbide’ was meaningless gibberish and was not the chemical definition of any known substance. He concluded that Yadil consisted of :

‘About one per cent of the chemical compound formaldehyde.

About four per cent of glycerine.

About ninety-five per cent of water and, lastly, a smell.

He calculated that the materials contained in a gallon cost about 1/6, whilst the mixture was sold at £4 10s. per gallon.

This exposure was completely successful and the matter is of historic interest in that it is the only example of the career of a proprietary medicine being arrested by the action of the Press.

Clark goes on to talk of the law of libel.

“On the other hand the quack medicine vendor can pursue his advertising campaigns in the happy assurance that, whatever lies he tells, he need fear nothing from the interference of British law. The law does much to protect the quack medicine vendor because the laws of slander and libel are so severe.”

The law of libel to this day remains a serious risk to freedom of speech of both individuals and the media. Its use by rogues to suppress fair comment is routine.  My first encounter was when a couple of herbalists
threatened to sue UCL
because I said that the term ‘blood cleanser’ is gobbledygook.  The fact that the statement was obviously true didn’t deter them for a moment.  The herbalists were bluffing no doubt, but they caused enough nuisance that I was asked to take my pages off UCL’s server.  A week later I was invited back but by then I’d set up a much better blog and the publicity resulted in an enormous increase in readership, so the outcome was good for me (but bad for herbalists).

It was also good in the end for Andy Lewis when his immortal page “The gentle art of homoeopathic killing” (about the great malaria scandal) was suppressed.   The Society of Homeopaths’ lawyers didn’t go for him personally but for his ISP who gave in shamefully and removed the page.  As a result the missing page reappeared in dozens of web sites round the world and shot to the top in a Google search.

Chiropractors are perhaps the group most likely to try to suppress contrary opinions by law not argument.  The only lawyers’ letter that has been sent to me personally, alleged defamation in an editorial that I wrote for the New Zealand Medical Journal.  That was a little scary, but the journal stuck up for its right to speak and the threat went away after  chiropractors were allowed right of reply (but we got the last word).

Simon Singh, one of the best science communicators we have, has not been so lucky. He is going to have to defend in court an action brought by the British Chiropractic Association because of innocent opinions expressed in the Guardian.

Chapter 6 is about “The harm done by patent medicines”. It starts thus.

“The trade in secret remedies obviously represents a ridiculous waste of money but some may argue that, since we are a free country and it pleases people to waste their money in this particular way, there is no call for any legislative interference. The trade in quack medicines cannot, however, be regarded as a harmless one. The Poisons Acts fortunately prevent the sale of a large number of dangerous drugs, but there are numerous other ways in which injury can be produced by these remedies.”

The most serious harm, he thought, resulted from self-medication, and he doesn’t mince his words.

“The most serious objection to quack medicines is however that their advertisements encourage self-medication as a substitute for adequate treatment and they probably do more harm in this than in any other manner.

The nature of the problem can best be illustrated by considering a simple example such as diabetes. In this case no actual cure is known to medicine but, on the other hand, if a patient is treated adequately by insulin combined with appropriate diet, he can be maintained in practically normal health, in spite of his disability, for an indefinite period. The expectation of life of the majority of intelligent diabetics, who make no mistakes in their regime, is not much less than that of normal persons. The regime is both irksome and unpleasant, but anyone who persuades diabetics to abandon it, is committing manslaughter as certainly as if he fired a machine gun into a crowded street.

As regards serious chronic disease the influence of secret remedies may be said to range from murderous to merely harmful.

‘Cures’ for consumption, cancer and diabetes may fairly be classed as murderous, since they are likely to cause the death of anyone who is unfortunate enough to believe in their efficacy and thus delay adequate treatment until too late.

The phrase “‘Cures for consumption, cancer and diabetes may fairly be classed as murderous” made Clark himself the victim of suppression of freedom of speech by lawyers. His son, David Clark, wrote of his father in “Alfred Joseph Clark, A Memoir” (C. & J. Clark Ltd 1985 ISBN 0-9510401-0-3)

“Although tolerant of many human foibles, A. J. had always disapproved fiercely of quacks, particularly the charlatans who sold fraudulent medicines.  During his visits to London he met Raymond Postgate, then a crusading left wing journalist, who persuaded A.J. to write a pamphlet which was published in an ephemeral series called ‘Fact‘ in March 1938. It was a lively polemical piece. . To A.J.’s surprise and dismay he was sued for libel by a notorious
rogue who peddled a quack cure for for tuberculosis. This man said that A.J.’s remarks (such as “‘Cures’ for consumption, cancer and diabetes may fairly be classed as murderous”) were libellous and would damage his business.  A.J. was determined to fight, and he and Trixie decided to put their savings at stake if necessary. The B.M.A. and the Medical Defence Union agreed to support him and they all went to lawyers. He was shocked when they advised him that he would be bound to lose for he had damaged the man’s livelihood!   Finally, after much heart searching, he made an apology, saying that he had not meant that particular man’s nostrum”

On page 68 there is another very familiar story. It could have been written today.

“The fact that the public is acquiring more knowledge of health matters and is becoming more suspicious of the cruder forms of lies is also helping to weed out the worst types of patent medicine advertisements. For example, in 1751 a bottle of oil was advertised as a cure for scurvy, leprosy and consumption but today such claims would not be effective in promoting the sale of a remedy. The modern advertiser would probably claim that the oil was rich in all the vitamins and the elements essential for life and would confine his claims to a statement that it would alleviate all minor forms of physical or mental ill-health.

The average patent medicine advertised today makes plausible rather than absurd claims and in general the advertisements have changed to conform with a change in the level of the public’s knowledge.

It is somewhat misleading, however, to speak of this as an improvement, since the law has not altered and hence the change only means that the public is being swindled in a somewhat more skilful manner.

The ideal method of obtaining an adequate vitamin supply is to select a diet containing an abundant supply of fresh foods, but unfortunately the populace is accustomed to live very largely on preserved or partially purified food stuffs and such processes usually remove most of the vitamins.”

The first part of the passage above is reminiscent of something that A.J Clark wrote in  the BMJ in 1927.  Nowadays it is almost unquotable and I was told by a journal editor that it was unacceptable even with asterisks.  That seems to me a bit silly. Words had different connotations in 1927.

“The less intelligent revert to the oldest form of belief and seek someone who will make strong magic for them and defeat the evil spirits by some potent charm. This is the feeling to which the quack appeals; he claims to be above the laws of science and to possess some charm for defeating disease of any variety.

The nature of the charm changes with the growth of education. A naked n****r howling to the beat of a tom-tom does not impress a European, and most modern Europeans would be either amused or disgusted by the Black mass that was popular in the seventeenth century. Today some travesty of physical science appears to be the most popular form of incantation.”

A.J. Clark (1927) The historical aspect of quackery, BMJ October 1st 1927

Apart from some of the vocabulary, what better description could one have of the tendency of homeopaths to harp on meaninglessly about quantum theory or the “scienciness” and “referenciness” of
modern books on nutritional therapy?

### So has anything changed?

Thus far, the outcome might be thought gloomy. Judging by Clark’s account, remarkably little has changed since 1938, or even since 1914. The libel law in the UK is as bad now as it was then. Recently the United Nations Human Rights Committee said UK laws block matters of public interest and encourage libel tourism (report here, see also here).   It is unfit for a free society and it should be changed.

But there are positive sides too. Firstly the advent of scientific bloggers has begun to have some real influence. People are no longer reliant on journalists to interpret (or, often, misinterpret) results for them. They can now get real experts and links to original sources.  Just one of these, Ben Goldacre’s badscience.net, and his weekly column in the Guardian has worked wonders in educating the public and improving journalism.  Young people can, and do, contribute to the debate because they can blog anonymously if they are frightened that their employer might object.

Perhaps still more important, the law changed this year. Now, at last, it may be possible to prosecute successfully those who make fraudulent health claims. Sad to say, this was not an initiative of the UK government, which remains as devoted as ever to supporting quacks.  Remember that, quite  shamefully, the only reason given by the Medicines and Health Regulatory Authority (MHRA) gave for allowing false labelling of homeopathic pills was to support the “homeopathic industry”. They suggested (falsely) that the EU required them to take this irresponsible step, which was condemned by just about every scientific organisation. But the new unfair trading regulations did come from the EU. After almost 100 years since the 1914 report, we have at last some decent legislation. Let’s hope it’s enforced.

### Postcript

The back cover of the series of ‘Fact‘ books in which A.J. Clark’s article appeared is reproduced below, simply because of the historical portrait of the 1930s that it gives.

### Follow-up

This post got a lot of hits from Ben Goldacre’s miniblog which read

The publication of Gilbey’s paper and my editorial in the New Zealand Medical Journal (NZMJ) led to a threat of legal action by the NZ Chiropractors’ Association Inc for alleged defamation.  After publishing a defiant editorial, the editor of the NZMJ offered chiropractors the chance to put their case.

In the last issue of NZMJ (22 Aug 2008) three letters appeared. One was from Brian Kelly, (President, New Zealand College of Chiropractic) [download letter]. One was from Karl Bale (CEO/Registrar, Chiropractic Board New Zealand) [download letter], and one was from Simon Roughan (Registered Chiropractor and Acting President of the New Zealand Chiropractors’ Association) [download letter].

### The wars within chiropractic

Although the chiropractors seem to be rather upset by the criticisms that have been levelled against them, the most interesting war is not between chiropractors and people who think that medicine should not be based on metaphysics.  It’s the war within chiropractic itself.

The internecine wars within chiropractic have been going almost from the day it was invented.  The (ex-)insider’s view gives us a rare insight into what chiropractic schools actually do.   Now support has come from a rather unexpected quarter.  An article by five chiropractors has just appeared by Murphy et al. (Chiropractic & Osteopathy, 2008, 16:10).

Although the authors declare that they have “a financial interest in the success” of chiropractic, the changes that they propose are so drastic that, if implemented, tthey would leave little left to distinguish chiropractic from, say, physiotherapy. The authors ask the very pertinent question, ‘why is it that podiatry (chiropody in the UK) is well accepted and chiropractic remains on the controversial fringe of medicine?..   Here are some quotations.

“It is also vital that those chiropractors who dogmatically oppose common public health practices, such as immunization [15] and public water fluoridation, cease such unfounded activity.”

“We are concerned that the common perception (which is well supported, in our experience) that chiropractors are only interested in “selling” a lifetime of chiropractic visits may be one of the primary factors behind our low standing in the minds of members of the public [2].”

“One of the problems that we encounter frequently in our interaction with chiropractic  educational institutions is the perpetuation of dogma and unfounded claims. Examples include the concept of spinal subluxation as the cause of a variety of internal diseases and the metaphysical, pseudo-religious idea of “innate intelligence” flowing through spinal nerves, with spinal subluxations impeding this flow. These concepts are lacking in a scientific foundation [27] [28] [29] and should not be permitted to be taught at our chiropractic institutions as part of the standard curriculum. Much of what is passed off as “chiropractic philosophy” is simply dogma [30], or untested (and, in some cases, untestable) theories [27] which have no place in an institution of higher learning, except perhaps in an historical context.”

“The Council on Chiropractic Education requirement of 250 adjustments forces interns to use manipulation on patients whether they need it or not, and the radiographic requirement forces interns to take radiographs on patients whether they need them or not.”

“They [podiatrists] did not invent a “lesion” and a “philosophy” and try to force it on the public. They certainly did not claim that all disease arose from the foot, without any evidence to support this notion. The podiatric medical profession simply did what credible and authoritative professions do [32] – they provided society with services that people actually wanted and needed.”

“In the beginning, DD Palmer invented a lesion, and a theory behind this lesion, and developed a profession of individuals who would become champions of that lesion. This is not what credible professions do.”

“In the interim it [chiropractic] has seen its market share dwindle from 10% of the population [4] to 7.5% [3] [42]. Even amongst patients with back pain, the proportion of patients seeing chiropractors dropped significantly between 1987 and 1997, a period of time in which the proportion seeing both medical doctors and physical therapists increased [43].”

“When an individual consults a member of any of the medical professions, it is reasonably expected that the advice and treatment that he or she receives is based in science, not metaphysics or pseudoscience.”

“The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in our profession than in other healthcare professions [46].”

“Podiatric medicine is a science-based profession dedicated to the diagnosis and treatment of foot disorders. Foot reflexology is a metaphysically-based group consisting of non-physicians who believe that many physical disorders arise from the foot. Podiatrists have rejected foot reflexology as an unproven and unscientific practice, and do not consider it part of mainstream podiatric practice.”

“We must finally come to the painful realization that the chiropractic concept of spinal subluxation as the cause of “dis-ease” within the human body is an untested hypothesis [27]. It is an albatross around our collective necks that impedes progress.”

All this, remember, comes from five chiropractors. That looks like all out war between their view of chiropractic and that taught in New Zealand College of Chiropractic, and, in the UK by the three chiropractic colleges in the UK.

### Follow-up

A report in the New Zealand Herald (18 September 2008) is rather relevant to all this.

Chiropractor to apologise after patient has stroke

A chiropractor has been recommended to apologise to a woman patient who suffered a stroke after he treated her.