Recent eLetters

Ian C. M. Williams' article on the use of comics as a suitable medium for medical narratives is a timely evaluation of the potential of the comicbook form to address several medical issues. For a medium that is roughly over a hundred years old (although some scholar might argue that comics had their roots in the inception of printed cartoons, whereas others trace back their origins as far as the Bayeux Tapestries or even prehistoric cave paintings), comics have surely evolved in content, variety of subject matter and format. As noted, comic studies are relatively new, but a number of books have been published, there are post- graduation courses focusing in comics theory (as the one offered by Opet in Curitiba, Brazil) or literary studies of comics (as the University of Dundee's, Scotland, that began last year), theses, Manchester's University International Comic Conference and even two peer-review periodicals; Studies in Comics and The Journal of Graphic Novels and Comics.

As a practicing neurologist and life-long comics reader I had the opportunity to present last year at the 29th International Epilepsy Congress a poster based on Joshua Hale Fialkov and Noel Tuazon's graphic novel Tumor entitled TUMOR - A GRAPHIC NOVEL REPRESENTATION OF GLIOBLASTOMA MULTIFORME AND MULTIPLE SEIZURES TYPES. This is the story of a private detective who is diagnosed with GB, while solving his last case. A variety of seizure types and other symptoms, such as confusional state and space-time disorientation are presented in graphic form from the standpoint of the main character/patient, providing a layman's interpretation of seizure semiology.

Again, as mentioned in William's article, comics provide a rich source of material for medical studies. Even the so-called mainstream comics have featured characters with multiple medical conditions, such as Barbara Gordon's spinal injury in The Killing Joke, which ultimately led her to become the paraplegic heroine Oracle; David Lapham's Young Liars, where the main female character suffers a bullet wound to the frontal lobe and looses impulse control; or Sue Dibny's death in Identity Crisis as a result of a brainstem stroke caused by the murderous Jean Loring's stepping over her basilar artery in microscopic size.

Also, several characters are Medical Doctors, such as Marvel's Doctor Strange, Gotham City's Dr. Leslie Thompson, the X-Men's Dr. Cecilia Reyes or JSA's Dr. Mid-Nite. There will be more articles on the interaction between comics and Medicine in the coming years for sure.

Conflict of Interest:

None declared

I read with interest Caruncho and Fernandez postulation of Chopin possibly having temporal lobe epilepsy, and resultant complex hallucinations. I was struck by a few other explanations which could account for these bizarre phenomena. He was in a state of poor health, and could have had a few subacute confusional state in clear consciousness. Secondly it is not uncommon for truly gifted people such as Chopin to have synaesthesia, a a process in which one type of stimulus produces a secondary, subjective sensation( for example when some color evokes a specific smell)What could be in favour of this is considering that in some of the accounts these events happened while he was playing music. What isn't in doubt was that these "hallucinations" did not impede him from being one of the greatest musicians of all time.

Conflict of Interest:

Nil

One of the best episodes (and probably most shocking to thousands of people of all ages)of a medical programmes in UK dealt exactly with the need to reassure people about the huge variation in genitalia. Shocking because genitalia are so taboo that a penis still cannot usually even be shown on TV. The programme continues to run a web site so that people can see different genitalia for themselves and also to share experiences and worries . It simply does not work for healthworkers to assume it is reassuring to somebody being examined that they 'have seen hundreds of them, it means nothing...' when there is such a strong taboo about exposing private parts of the body. This programme gave people of all ages the chance to look at real human beings who were at ease with their different bodies including their genitalia. It is to be expected that reactions would be different and they did range from shock, disgust, curiosity, embarrassment to positive acceptance and healthy interest instead of secretive voyeurism or anxiety. It was also the case though that even after seeing how much variation is normal, many youngsters, boys and girls,preferred a cosmetically enhanced version of the stereotypical most ideal bodyshape to variations on that,including a majority preference for certain size and shape genitalia. Some would still choose surgery to conform. Hopefully when the issue is so complex, as many healthworkers as others will access the programme and web site as well as using what are often rather dehumanising descriptions or photographs of parts of bodies. The doctors who ran the programme are to be congratulated for breaking the taboo which causes so much distress.

Conflict of Interest:

None declared

Caruncho and Fernandez interpreted Chopin's hallucinations as temporal lobe epilepsy.(1) Recently, Karhausen examined the 140 causes of death of Mozart that have been proposed in the medical literature.(2) These studies on both composers nicely illustrate how a mechanistic view of death and disease still dominates modern medicine.

Identifying the cause of death can be difficult. Many physicians will share the experience that one is sometimes uncertain about the cause of death. In these instances, cardiac arrest is often written on the death certificate, which almost seems true by definition; the heart stopped beating. Intuitively, physicians realise that the mechanistic view of a single cause and a single effect is not always appropriate. Death certificates and national statistics however demand the identification of a single cause of death.

In a seminal paper, Rothman has argued that death and disease seldom have single causes.(3) His model of causation identifies multiple components. Sufficient causes are subdivided into component causes. This model illuminates important principles as multi-causality, the dependence on the strength of component causes and interaction between component causes. In his view the death from a fall is caused by the combination of e.g. visual problems, a loose rug, osteoporosis and sarcopenia. This has important consequences, since it is therefore recognised that intervention with any of these component causes is important to prevent the formation of a sufficient cause for the fall.

In the next century, people will live longer lives without disabilities.(4) The challenge in the future will be to manage elderly patients with multiple chronic diseases. A mechanistic view of single causes of death and disease is not appropriate for our growing population of elderly patients. A more widespread appreciation of the multi-causal nature of death and disease could be an important step to successful ageing in the next century.

1. Caruncho MV, Fernandez FB. The hallucinations of Frederic Chopin. Med Humanities 2011 doi:10.1136/jmh.2010.005405

2. Karhausen LR, Mozart's 140 causes of death and 27 mental disorders. BMJ 2010; 341:c6789. doi:10.1136/bmj.c6789

3. Rothman KJ, Greenland S, Stat, C. Causation and causal inference in epidemiology. Am J Public Health 2005; 95:s144-s150. doi:10.2105/AJPH.2004.059204

4. Perenboom RJ, Van Herten LM, Boshuizen HC, Van Den Bos GA. Trends in disability-free life expectancy. Disabil Rehabil. 2004 Apr 8;26(7):377- 86.

Conflict of Interest:

None declared

Pekka Louhiala argues that "there is no alternative medicine" because "it escapes a meaningful definition, and 'alternative medicine' cannot be clearly differentiated from conventional medicine" [1]. I do not consider that his arguments are valid.

Louhiala does not mention the proposed definitions for "alternative medicine". For example, Eisenberg defined alternative medical therapies as "interventions neither taught widely in medical schools nor generally available in US hospitals" [2]. Cochrane collaboration defined: "Complementary and alternative medicine (CAM) is a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health system of a particular society or culture in a given historical period. CAM includes all such practices and ideas self-defined by their users as preventing or treating illness or promoting health and well-being. Boundaries within CAM and between the CAM domain and that of the dominant system are not always sharp or fixed" [3]. I do not consider that these definitions are exhaustive, but they capture what I think is the most essential.

These definitions consider that the relevant factor for setting up the boundary around alternative medicine is by the lack of social acceptance within mainstream medicine. Thus, alternative medicine consists of interventions that are outside of the "conventional" or "medical school" medicine. The definitions above do not consider whether a treatment is effective or not. Effectiveness is located on a different dimension and it is not part of a relevant definition for alternative medicine.

Louhiala formulated numerous arguments that do not teach us anything about the usefulness of the concept of "alternative medicine". Although I agree that in many cases "modern medicine is much more varied in its approaches than the propagandists for alternative medicine usually imply", this statement does not imply any conclusions about the concept of "alternative medicine".

I do not agree with Louhiala's statement that "alternative medicine means that the other option is rejected". For example, many of my own patients describe that they also use some forms of alternative therapies, but they do not reject me therefore. Nevertheless, whatever our opinion on this issue is, that has no importance to the question whether "alternative medicine" is a useful concept.

I disagree also with the statement that "if a genuine alternative medicine did exist, it should produce results that are similar to those of ordinary medicine". There is much treatment variation within mainstream medicine, and thus there is no uniform "treatment result" to which the results of alternative therapists might be compared unambiguously. Furthermore, when we accept the rather large treatment variation within mainstream medicine, why should we not accept variation between mainstream medicine and alternative medicine. In any case, this issue does not seem relevant to the question whether the concept of "alternative medicine" is useful.

I agree with the statement that "alternative medicine cannot be clearly differentiated from conventional medicine". There are numerous cases where the border between neighboring concepts is fuzzy. Internal medicine cannot be clearly differentiated from general practice medicine (e.g. both treat hypertension). Children cannot be clearly differentiated from adults (e.g. teenagers are biologically adults but psychologically children). However, the lack of a clear differentiation does not imply that "internal medicine" or "child" are useless concepts.

Louhiala states that "bundling all the so called alternative therapies under one heading is misleading. It is hard to see common features between, say, healing using prayer and healing using megadoses of vitamins." If alternative medicine is defined by the lack of social acceptance as described above, that provides an unambiguous justification to put prayer and megavitamins under the same heading. Furthermore, there is great variation in the approaches within the mainstream medicine from surgery to pharmacology to psychiatry. If Louhiala's argument is valid, we should not bundle such different methods under the one heading of "medical school medicine".

Louhiala states that "alternative medicine" is a buzzword, which may be true in certain contexts. However, in mainstream medicine, there are numerous buzzwords. Laser surgery, computed tomography, broad-spectrum antibiotics, and many others are in certain contexts used to "impress laymen", but that has nothing to do whether those methods are useful, or whether those terms are linguistically sound.

While Louhiala criticizes the vague definition of "alternative medicine", he does not consider the definition options for "homeopathy". When I was young, I studied biochemistry and got a PhD degree. At that stage of my life, I defined homeopathy as "diluting a substance to such an extent that there are no molecules left in a spoonful". Thereafter I studied medicine.

When I started to work as a GP, I realized that there is a fundamentally different second definition for homeopathy: "a person goes to a homeopath and stays there for some time and then leaves". If we ask whether homeopathy is beneficial for a patient, we should first define what we mean by "homeopathy", but this was not done by Louhiala.

In catholic countries, sometimes people go to see a priest for a confession. I believe that the confession often decreases the anxiety of a person, and in that respect it leads to positive health effects. This health benefit has nothing to do whether we think that there is evidence for God. Similarly, homeopathy as an encounter can be beneficial for a patient because visiting a homeopath is much more than biochemistry.

While working as a GP, I have realized that a large part of the positive health effects that I am generating on my patients are caused by listening and speaking. Why should we assume that a priest or a homeopath is incompetent at such an activity? I have seen many physicians who are rather poor in their communication with patients. Compared with them, an average priest or homeopath probably generates greater improvements in health if the major problems of the patient are anxiety and depression.

On average, alternative therapists may have better bedside manners than physicians [4]. Time spent with each patient by an alternative medicine practitioner usually exceeds that spent by the average physician. Alternative medicine practitioners provide patients with understanding, meaning, and self-care methods for managing their conditions. These elements are often lost in the subspecialization, technology and economics of mainstream medicine.

Furthermore, even though it is paradoxical, in some cases homeopathy is better pharmacology than some popular treatment options of physicians. If a patient has a viral respiratory infection and a homeopath treats the patient with a highly diluted solution, the product will not cause harm. If the same patient goes to a physician and gets antibiotics, the benefit is non-existent there too, but the harm is not [5,6]. In such a case, it is the homeopath who follows more closely the guidance "first, do no harm."

I have a long lasting interest in the concept of alternative medicine. My personal interest largely arose from my long term research on vitamin C and the common cold, mainly by carrying out systematic reviews from various points of view. In the latest version of our Cochrane review, we pooled the results of 29 placebo-controlled comparisons measuring the effect of regular >0.2 g/day of vitamin C [7]. We found that vitamin C shortened colds in adults by 8% (P=0.0002) and in children by 13% (P=0.0003). In 5 trials with participants under heavy acute physical stress (3 of them with marathon runners), vitamin C reduced the incidence of colds by 52% (95% CI: 36% to 65%; P=0.0000006), but we found strong evidence with a narrow confidence interval that vitamin C does not prevent colds in the general population.

Given that there is such a strong evidence, mostly from trials published already in the 1970s, that vitamin C differs from the placebo, why does vitamin C fall under the heading "alternative medicine"? Textbooks on medicine, infectious diseases, and nutrition have claimed over decades that vitamin C is useless for the common cold [8-10], and systematic bias against vitamins in general has been documented in the major textbooks of medicine [11,12]. In a Dutch survey, 47% of GPs considered that homeopathy is efficacious in the treatment of the common cold, whereas only 20% of the respondents considered that vitamin C was [13]. In a US survey, 21% pediatricians considered that homeopathy may be effective, and 21% considered that high-dose antioxidant vitamins may be so (e.g. vitamin C for the common cold) [14]. Thus, vitamin C is comparable with homeopathy, and in some cases the credibility of vitamin C is even lower.

While I was wondering the puzzling discrepancy between the positive findings in the placebo-controlled trials on vitamin C and the classification of vitamin C under the heading alternative medicine, I started to think that the most relevant way of defining "alternative medicine" is by the lack of social acceptance. This notion was formulated to explicit definitions by other authors [2,3].

Evidence-based medicine emerged because several physicians realized that many treatments taught at the medical school were useless and started to speak about it loud. Thus, when a treatment falls into the category of "medical school medicine", that will not prove that the treatment is effective. My own observations on vitamin C showed that if a treatment falls into the category of "alternative medicine", that will not prove that the treatment is ineffective. Thus, social acceptability and effectiveness are located on different dimensions, and it is the former that is relevant if we search for a reasonable definition for alternative medicine. I consider that in his paper Louhiala ignores the main characteristic that defines alternative medicine [2,3].

At the end of his paper, Louhiala comments that "demand that alternative medicine be taught in medical schools and/or financed through public funding has no foundation whatsoever". I disagree also with this opinion.

Louhiala does not define what he means by teaching. It is possible 1) to teach the practical methods; how to carry out alternative therapies at one's own office or 2) to teach about the most usual types of alternative therapies in a descriptive way, so that a medical student better understands our surrounding society.

If we follow the definitions described at the beginning of this comment, it is logically impossible to teach medical students how to start using alternative therapies, because including a therapy in the medical school curriculum removes the status "not taught at medical schools". The therapy that was "alternative" is not so any more.

On the other hand, I cannot see any basis to oppose the second kind of teaching. The purpose of education should be to increase understanding why patients use alternative medical treatments, learning how to ask about and discuss alternative treatments in a nonjudgmental manner, learning which therapies can be harmful, and understanding the basic tenets of the most common alternative healing systems [15-17].

Furthermore, Louhiala's final comment is illogical. Given that he states that "there is no alternative medicine", how could "alternative medicine" be used as a criterion for not financing some activity - if there is no alternative medicine.

The purpose of my commentary is not to increase the social acceptability of alternative medicine. I point out that the lack of social acceptability seems to be a reasonable basis for defining alternative medicine [2,3], but this was not considered by Louhiala [1]. I do not hope that the use of homeopathy increases, instead I hope much the contrary. Nevertheless, the question about homeopathy is more complex than whether it is absurd from the biochemical point of view.

A Google search with the term "alternative medicine" finds over 10 million web pages and one survey reported that 40% of Americans had used alternative treatments over the preceding year [2]. I think that it is much more fruitful to contemplate on the nature of alternative medicine [3,4,15-22], instead of trying to argue that such a field does not exist [1].

References

1. Louhiala P.There is no alternative medicine. Med Humanit 2010 [Epub ahead of print]
2. Eisenberg DM, et al.Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA 1998;280:1569-75.
3. Zollman C, Vickers A.What is complementary medicine? BMJ 1999;319:693-6.
4. Ernst E, Resch KL, Hill S.Do complementary practitioners have a better bedside manner than physicians? J R Soc Med 1997;90:118-9.
5. Gonzales R, Sande M.What will it take to stop physicians from prescribing antibiotics in acute bronchitis? Lancet 1995;345:665-6.
6. Mainous AG, Hueston WJ, Clark JR.Antibiotics and upper respiratory infection: do some folks think there is a cure for the common cold? J Fam Pract 1996;42:357-61.
7. Hemila H, Chalker EB, Douglas RM.Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev 2007;(3):CD000980.
8. Hemila H.Vitamin C, the placebo effect, and the common cold: a case study of how preconceptions influence the analysis of results [discussion: 1996;49:1985-87]. J Clin Epidemiol 1996;49:1079-84. .... OtherSOURCE
9. Hemila H.Vitamin C supplementation and common cold symptoms: problems with inaccurate reviews. Nutrition 1996;12:804-9. .... OtherSOURCE
10. Hemila H.Do vitamins C and E affect respiratory infections? [PhD Thesis]. Helsinki, Finland: University of Helsinki; 2006:21-4,36-8,42-5,63-6.
11. Goodwin JS, Goodwin JM.The tomato effect: rejection of highly efficacious therapies. JAMA 1984;251:2387-90.
12. Goodwin JS, Tangum MR.Battling quackery: attitudes about micronutrient supplements in American Academic medicine. Arch Intern Med 1998;158:2187-91.
13. Knipschild P, Kleijnen J, Riet G.Belief in the efficacy of alternative medicine among general practitioners in the Netherlands. Soc Sci Med 1990;31:625-6.
14. Sikand A, Laken M.Pediatricians' experience with and attitudes toward complementary/alternative medicine. Arch Pediatr Adolesc Med 1998;152:1059-64.
15. Eisenberg DM.Advising patients who seek alternative medical therapies. Ann Intern Med 1997;127:61-9.
16. Marcus DM.How should alternative medicine be taught to medical students and physicians? Acad Med 2001;76:224-9.
17. Gaster B, et al.What should students learn about complementary and alternative medicine? Acad Med 2007;82:934-8.
18. Jonas WB.Alternative medicine - learning from the past, examining the present, advancing to the future. JAMA 1998;280:1616-8.
19. Vickers A.Why aromatherapy works (even if it doesn't) and why we need less research. Br J Gen Pract 2000;50:444-5.
20. Tonelli MR, Callahan TC.Why alternative medicine cannot be evidence-based. Acad Med 2001;76:1213-20.
21. Kaptchuk TJ.The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance? Ann Intern Med 2002;136:817-25.
22. Ernst E.Complementary and alternative medicine: between evidence and absurdity. Perspect Biol Med 2009;52:289-303.

Conflict of Interest:

None declared