What’s the harm? Cupping edition

There are so many ridiculous alternative medicine treatments being “integrated” via “integrative” medicine into medicine, no matter how ridiculous they are, that it’s not only hard to believe, but it’s hard to keep track. Homeopathy is, of course, the most ridiculous, although “energy medicine” definitely gives homeopathy a run for its money in the Department of Stupid. The depressing thing is that most physicians, even “integrative medicine” physicians, know that homeopathy is bunk (at least when they even know what homeopathy is—most think it’s just herbal medicine). However, those same physicians don’t mind naturopathy, thinking it nothing more than—you guessed it—herbal medicine, never realizing that you can’t have naturopathy without homeopathy and that homeopathy is an integral part of naturopathic education and practice. In other words, you can’t embrace naturopathy without embracing homeopathy. Apologists for alternative medicine and “integrative medicine” physicians often ask, “What’s the harm?”

Among the silliest of alternative medicine therapies is something called cupping. Cupping is a prescientific, premodern medical practice based in the philosophy of traditional Chinese medicine (TCM) that involves sticking cups on a patient’s skin under suction n order to make them better. Basically, cupping involves heating the air inside of a cup and placing the inverted cup on some part of the body. Thanks to the wonders of physics, as the air in the cup cools, it contracts and produces a vacuum, which produces suction. (Physics geeks, I know that’s a highly simplified explanation. Just go with it.) As is the case with acupuncture, in TCM it is believed that disease is due to blockages or incorrect flow of qi, which is the TCM equivalent of the “vital force” or “life energy.” Acupuncture posits that by sticking needles into specific points in “meridians” through which qi flows the flow of qi can be unblocked. Cupping is much like acupuncture in that it, too, claims that it unblocks and realigns qi, thereby restoring health.

Proving that no woo goes uninvented anywhere, cupping is not unique to TCM. As has been noted elsewhere, Native Americans throughout North America also used wet cupping as a means of blood letting, although it is unknown how long ago they started the practice, using animal horns. In fact, unlike acupuncture, cupping is truly an ancient practice. The ancient Greeks practiced it, and Hippocrates himself used it. There is documentary evidence that cupping was practiced in ancient Egypt as far back as 1,500 BCE. So, using the appeal to antiquity, cupping must be the greatest thing since sliced bread, which it predates by millennia. Obviously.

There are two forms of cupping. “Wet cupping” involves puncturing the skin before applying the suction cup. (Yes, that’s basically what cupping is, applying a suction cup.) The idea is that this will allow the “poisons” or “toxins” to be sucked out of the body by the cup. Dry cupping omits this step. There are also other methods besides relying on the cooling of heated air to produce suction, such as using a pump to to siphon air out of the cup. These days, glass or clear plastic cups are commonly used, in order to allow monitoring of the skin. Given that, you’d think that harm would be very, very difficult. You’d be wrong.

Witness this story from Australia, Popular treatment known as ‘cupping therapy’ leaves man with seven holes in his back:

A MAN has been left with seven holes on his back after undergoing cupping therapy that went horribly wrong.

The man identified as Li Lin, 63, began taking the treatment every day from May to June in the hope of treating his scapulohumeral periarthritis — more commonly referred to as “frozen shoulder”.

He was told the therapy, which has a history of several thousand years in traditional Chinese medicine, would help with the pain and stiffness and allow him to move freely.

The treatment, known in Chinese as “ba guan”, traditionally uses heated glass cups to create local suction on the patient’s skin, causing circular bruising that is believed to be the result of now mobilised and free-flowing blood.

However, instead of having his condition cured, the man from Chengdu, capital of southwestern China’s Sichuan Province, was left with holes on his back that were essentially very serious, deep burn wounds.

This is what the article is talking about:

Cupping burns

I’m a general surgeon. During my residency, I rotated on the burn unit a number o ftimes, during the last of which I was the chief resident there. I know burns. Looking at that picture, I can say that those are some nasty burns, particularly the middle two. They look at least full thickness.

What do I mean by full thickness? Burns, as you might know, are categorized as first, second, and third degree. First degree burns are basically of the sort that just causes redness. Second degree burns are partial thickness, and third degree burns involve the full thickness of the skin. Take a look at that picture again. As a trained general surgeon who has extensive experience with burns, I see burns on Li Lin’s back that can only be described as third degree or full thickness.

How could such burns have come about? Remember, the cups used were almost certainly heated before being placed on Li Lin’s back. However, these wounds probably aren’t thermal burns because the cups usually aren’t heated enough to cause thermal injury, at least if the practitioner is not completely incompetent. A hint of how this could happen is in the story about Li Lin:

Lin said he went for the treatment every day, and his therapist placed the cups in the same position on his back.

After 10 days he reportedly began to notice blisters on his back, but convinced the treatment would cure his aching shoulder, Lin asked his wife to remove the blisters so he could continue the therapy.

Two days before the scheduled end of his treatment, however, Lin started experiencing severe pain on his back and also developed a high fever.

A trip to the doctors then revealed horrifying circular wounds on his back that had started to fester.

The suction from cupping breaks capillaries, which is why not infrequently there are bruises left in the shape of the cups afterward. Think of it as a hickey, which is basically what cupping is: Making hickeys without the fun part. If you repeatedly injure the same area of skin over time, the way the TCM practitioner did to Li Lin by placing the cups in exactly the same place over and over again, the skin there can actually die. In a burn, the skin dies due to fire, but anything that kills the outer layers of skin (the epidermis and dermis) can look and behave like a burn. Lin is not entirely innocent there; he started to get blisters, and a blister is a sign of a second degree burn, now more commonly described as partial thickness burn because it involves the partial thickness of the dermis. In other words, it was an indication that significant injury had occurred, and continuing the cupping the way he did could well have turned a partial thickness burn into a full thickness burn. Given that infection of the burn is the most common (and potentially deadly) complication in patients with major burns, it’s not surprising that Li Lin’s burns got infected. He’s lucky he didn’t become septic.

Oh, wait. He did. His high fever was almost certainly due to sepsis from burn wound infection.

You’re probably thinking: So what? This is just China and maybe a few New Age Gwyneth Paltrow types in the US and Europe. Would that it were just that! Cupping is showing up everywhere, from “integrative” medicine programs in academic medical centers to our very own Department of Defense:

The Army has been using acupuncture to treat post-traumatic stress disorder, despite a lack of evidence that it works. And now it is hiring acupuncturists for its pain clinic at Fort Sam Houston at an annual salary of $68,809 to $89,450. The job description says the candidate will “offer a full array of the most current and emerging evidenced based approaches in integrative medicine for patients with acute and chronic pain who have not responded well to conventional treatment modalities.”

One could argue that acupuncturists have nothing “evidence-based” to offer in the first place, but what is really alarming are the duties listed for the position. They include things acupuncturists are clearly not trained to do, like prescribing orthotics and braces and counseling patients on nutrition. Worse, the duties include providing cupping, moxibustion, and visualization techniques, none of which are effective and two of which directly injure patients. Cupping is the application of glass bulbs filled with heated air to the skin. It creates a vacuum as the air cools, sucking up wads of skin into the bulbs and leaving ugly bruises. Moxibustion involves burning mugwort on or near the skin and can cause burns and permanent scars (and does so deliberately in some forms of moxibustion).

Clearly, our soldiers suffering from PTSD deserve better. They deserve real medicine.

Cupping is nothing more than an ancient medical practice based on a prescientific understanding of the body and disease, much like bloodletting and treatments based on the four humors. As the case of Li Lin shows, it’s all risk for no benefit. It has no place in modern medicine, or at least shouldn’t. After all, we don’t still believe in the four humors that Hippocrates and ancient “Western” medicine invoked for many hundreds of years. TCM is based on much the same concepts, just with different names, substituting, for example, the Five Elements for the Four Humors and attributing disease to imbalances in them, just as ancient Western physicians attributed disease to imbalances in the four humors. Yet “integrative medicine” rejects one and embraces the other when it should be rejecting them both.