It’s the toxins.

Toujours les toxines.

How many times have I read or heard from believers in “alternative” medicine that some disease or other is caused by “toxins”? I honestly can’t remember, but in alt-world, no matter what the disease or condition under discussion is, there’s a good chance that sooner or later it will be linked to “toxins.” It doesn’t matter if it’s cancer, autism, heart disease, diabetes, hypertension, or that general malaise that comes over people who, as British comedians Mitchell and Webb put it, have more money than sense; somehow, some way, someone will invoke “toxins.”

I was reminded of this obsession among believers in unscientific medicine last Friday when I came across an article by Guy Trebay in the New York Times entitled The Age of Purification. The article appeared, appropriately enough, in the Fashion section and was festooned with photos of cupping, surely one of the silliest of the many “detoxification” modalities that alternative medicine practitioners use to claim to draw the “toxins” out of their clients through the application of, well, cups or various other containers in which the air had been heated in order to generate negative pressure when sealed to the skin and presumably thus bring them to a greater level of purification and health. Indeed, the only “detoxification” rituals sillier than cupping that I can think of off the top of my head are detoxifying footpads and “detox foot baths.”

Oh, wait. Scratch that. I forgot about ear candling, which must surely be the undisputed silliest “detox” treatment of all time—until someone thinks of an even sillier one. Or not. There are just so many silly “detox” procedures that it’s hard to select a “winner.”

Be that as it may, Trebay mixes sarcasm with exposition throughout his article in a rather amusing way that’s worth quoting:

My friend, like everyone else around, seemed to believe that mysterious, amorphous sludge had lodged in the anatomical crannies of half the local adult population. Unseen toxins were lurking, like Communists during the Red Scare.

The “toxins” required elimination, somehow, and thus at lunches, at cocktails, at dinner parties, normal conversations turned abruptly from the day’s news to progress reports on juice fasts, energy alignments, radical purging. From painful sessions with traditional healers to toxin-leaching treatments designed, it might seem, to clean out not just body but wallet, a surprising number of New Yorkers (not all of them well-to-do neurotics) are caught up in a new New Age, the Age of Purification.

How had it happened, I wondered, that so many otherwise sensible, urban people found themselves in the grip of a dreadful feeling that systems are down? “I just bought five pounds of carrots, ginger and kale and put it all in my Breville juicer and pounded that all day,” said a corporate adviser of my acquaintance, far from a credulous woo-woo type.

Of course, as we have noted so many times before, hard-nosed skepticism in one area of one’s life does not necessarily translate to other areas. Many are the people who would never ever fall prey to scams in business, for example, but happily fork over money for scams such as “detox footpads”—or fall for anti-vaccine quackery, like J.B. Handley. Whatever the case, why this fascination with “detoxification” in alternative medicine? Why do so many of its treatments, be they dietary, chelation therapy, purges, colon cleanses, or whatever, claim to eliminate “toxins”? Why is it that, if you Google “alternative medicine” and “detoxification,” you find so many references, some of which claim external toxins need to be eliminated, some of which claim that internal toxins need to be purged, and still more of which blame various “parasites” for all manner of health distress? In this post, I’ll try to explain, but first a little history—self-history that is.

“You’re poisoning yourself from within”

My first encounter with the concept of “detoxification” (at least, as it is described in alternative medicine terms) occurred perhaps 10 or 15 years ago, after I had been out of medical school several years and completed my surgery education. Basically, a acquaintance of mine had on her bookshelf on “body cleansing.” Given how much I’ve delved into “alternative” medical practices in the last several years, it’s truly amazing to realize that for the majority of my adult life I had no clue what “detoxification” was or what “colon cleanses” were. My ignorance at the time aside, I don’t remember the title, and I don’t remember the author, but I do remember that, as I leafed through the book, it became rapidly clear to me that “body cleansing” had nothing to do with taking a shower or a bath, at least not in this book. In particular, my attention was riveted to a chapter entitled “Death begins in the colon.”

It turns out that the admonition to beware of your colon trying to kill you came from a chiropractor named Dr. Bernard Jensen, DC, who is apparently known as the “father of colonics.” Personally, that would not be a name or title that I’d be particularly interested in having ascribed to me, but then I’m not a chiropractor. My avoidance of icky titles aside, this was my first ever real encounter with the nitty-gritty (much of the grit within the stool) of colon cleansing. What followed were two chapters, the first telling readers how supposedly up to 20 lbs. of fecal waste lurks in their colons, producing “toxins” that slowly poison them, the symptoms of which manifest themselves as lethargy and a sense of not feeling well, coupled with any or all of a huge number of potential conditions, including diabetes, hypertension, asthma, rheumatoid arthritis, and many others. What’s the solution?

Guess.

Yes, the solution, as I wrote about long ago, is colon cleansing, and this was my first encounter, up close and personal, so to speak, with the concept. What followed were long and rather lovingly limned descriptions of the vast quantities of feces, along with—dare I say it?—almost pornographic-seeming photos of what people fish out of their toilet after colon cleanses. (For examples of the sorts of photos that I encountered, click here, but only if you have a strong stomach.) In the text were passages like this:

It is no longer possible to ignore the importance of alimentary toxemia or autointoxication as a fact in the production of disease. To no other cause is it possible to attribute one-tenth as many various and widely diverse disorders. It may be said that almost every chronic disease known is directly or indirectly due to the influence of bacterial poisons absorbed from the intestine. The colon may be justly looked upon as veritable Pandora’s Box, out of which come more human misery and suffering, mental and moral, as well as physical than from any other known source.

The colon is a sewage system, but by neglect and abuse it becomes a cesspool. When it is clean and normal we are well and happy; let it stagnate, and it will distill the poisons of decay, fermentation and putrefaction into the blood, poisoning the brain and nervous system so that we become mentally depressed and irritable; it will poison the heart so that we are weak and listless; poisons the lungs so the breath is foul; poisons the digestive organs so that we are distressed and bloated; and poisons the blood so that the skin is sallow and unhealthy. In short, every organ of the body is poisoned, and we age prematurely, look and feel old, the joints are stiff and painful, neuritis, dull eyes and a sluggish brain overtake us; the pleasure of living is gone.

Even back then, having recently finished my general surgery residency, I knew this to be utter nonsense. The reason, of course, is that I was still doing abdominal surgery back then, and I had done a lot of colectomies in urgent situations, where there was no time to prep the colon using GoLytely or something similar. Never once had I seen anything resembling the sorts of horrors delineated in this book. While that didn’t rule out that some patients might be as described in the passage above, it certainly indicates that having 20 lbs of fecal waste clogging up one’s insides is not nearly as common as the colon cleansers seem to believe. Similarly, I had done a number of colonoscopies in patients with unprepped colons, and, similarly, had never seen anything like this. None of this means such a thing is not possible, but in reality if a person’s colon has 20+ lbs of impacted fecal matter that person is going to be suffering not from chronic illness or a vague sense of illness. That person is likely to be, to use a scientific term beloved among the surgeons under whom I trained as a resident, sick as snot. In other words, while it is true that the fecal matter in our colons can make us sick, it’s quite uncommon that it does make us sick. Becoming ill from our own fecal waste matter usually only happens when something bad happens to break down the protective barrier of the colon and allow wee beasties that normally reside there to translocate into the bloodstream. For example, common causes of such breakdowns in mucosal barrier function usually involve severe physiological insults resulting in too little blood getting to the colon; i.e., sepsis, shock due to massive bleeding, or acute cardiac failure. These are usually not subtle things.

I told my acquaintance that whoever had written that book was full of…well, never mind. My experience, however, had been, if you’ll excuse the term, indelibly stained. I also came quickly to realize that the concept of autointoxication seems to have a lot more to do with religious concepts than science:

“The body as hotbed of festering sin was first examined by St. Augustine,” said Caroline Weber, a professor of French literature at Barnard College and Columbia University and a writer who often explores the weird byways of shifting cultural mores. “It was adopted later by monastic orders in the form of practices like self-flagellation, the wearing of hair-shirts, ritual fasting and the mortifications of the flesh.”

What is “detoxification” but ritual purification in another guise?

Attack of the toxins

If we are to believe the “detox” cult, our bodies are a pestilent sea of toxins, arising both from internal sources (the colon being but one example) and external sources. That’s why it’s useful to divide our “toxic exposure” from an alt-med perspective into two general kinds: External and internal, the latter of which is often referred to as “autointoxication.” External toxins are easy to understand and consist of pretty much anything that is viewed as toxic that enters the body from the environment. This term thus encompasses diet, pollution, and, of course, the ever-favorite bugaboo, “toxic chemicals.” Don’t get me wrong; there is no doubt that certain chemicals can be toxic. Further, there is no doubt that some environmental exposures can make us sick. Even further still, I do not deny that there have been times when chemical companies have behaved, to put it mildly, less than admirably when it comes to chemical spills and their consequences (Love Canal, anyone?)

That’s why I want to make it absolutely clear that these sorts of demonstrated, defined adverse health events are not what’s meant most of the time when when alt-med believers discuss “toxins.”

As for “internal” toxins, there is the aforementioned belief in “autointoxication” due to massive build up of fecal matter, and then there is—well, let me allow naturopath Robert Groves explain, given how heavily naturopathy emphasizes “detoxification”:

Autointoxication is poisoning by toxic substances generated within the body. In this process the body breaks down the parts that have served their function and attempts to, but fails to fully (or in the proper amount of time) neutralize their poisons and transports them out of the body. When these substances are not properly neutralized and/or eliminated, they damage our other cells causing dysfunction and disease. This continual cycle of destroying and eliminating the old worn out materials and cells happens in a time frame from split seconds to many years depending upon the type of cells and the substances. As an example of this regenerative process, your liver regenerates itself in about 3 weeks. The old cells are now waste to breakdown and move out. The body does this in a number of ways with the help of a few friends such as antioxidants, minerals, vitamins, viruses, bacteria, etc.

Anyone who has a basic understanding of human physiology should immediately recognize how poor an understanding of bodily function the article by Groves represents. Indeed, while the above passage is superficially correct about how the body is continually renewing itself, the conclusions Groves draws from this knowledge are so wrong they’re not even wrong, particularly his answer to the question of why detoxification is necessary:

If you don’t detoxify, you’ll blow up! It sounds like I’m kidding and in some ways I am and other ways I’m not. If there is intake and metabolism, but not elimination of the substances ingested or byproducts produced, an increase in size will occur. This is a matter of physics, the old saying “if you eat more calories than you burn you will gain weight” routine. Without proper elimination of unnecessary substances, obesity will be a problem at the very least. Bacterial and yeast overgrowth will increase bloating and create rotting of the entire digestive system. The cells of your body will no longer have room to take in nutrients and burn them (metabolism) resulting in fatigue. Consequently, the cells will fill with waste within and also in the interstitial space or area surrounding them (toxemia). In this state they will starve, as they are unable to absorb nutrients (malnutrition), and/or be denied oxygen causing cells to suffocate (hypoxia), and finally will die (necrosis). When enough tissues die, your organs die, and when enough organs die, you die.

Again, this is utter nonsense, too. First of all, there is no reason why the amount of waste must necessarily precisely equal the amount of food ingested. After all, what happens to the part of the food that we actually use for energy? How on earth is it that Groves thinks that if we take in too many nutrients we will “run out of room” to use any more, resulting in fatigue? After all, one might well argue part of the problem with our physiology is that it is too efficient in using calories far beyond what our bodies need, happily storing them as fat. Be that as it may, the body has very finely tuned and efficient mechanisms for disposing of waste material or recycling it into other molecules that the body needs, such as proteins, nucleic acids, and lipids. The liver is incredibly adept at getting rid of various waste products, as are the colon, lung, and kidneys. Except when these organs fail, help is rarely necessary; the body can “detoxify” itself just fine, thank you very much. Groves makes an analogy to an automobile in which the owner rarely changes the oil, rarely replaces the filters, and uses bad gasoline. Of course, an automobile is not capable of self-renewal the way that the human body is, which is why, although this analogy may seem attractive, it is too off-base to have even a whiff of a hint of any validity.

In all fairness, it should be noted that the very concept of “autointoxication” was not an alternative medicine concept per se, at least not 100 years ago. True, it is an ancient concept that dates back to the ancient Egyptians, who believed that a putrefactive principle associated with feces was somehow absorbed by the body, where it acted to produce fever and pus, and the ancient Greeks, who extended the idea beyond digestive waste in the colon to include the four humors and incorporate the concept into the humoral theory of medicine. Even so, it was also a concept promulgated by proponents of scientific medicine in the late 1800s and early 1900s. The concept was very much like what I’ve described so far, namely that putrefactive products of digestion remained in the colon, there to leech into the bloodstream and sicken patients due to autointoxication. Indeed, some surgeons, chief among them Sir W. Arbuthnot Lane, advocated total colectomy for the autointoxication that was thought to be the cause of diseases ranging from lassitude to epilepsy. Given that there were no antibiotics effective against colonic flora back then, intestinal surgery was still fraught with peril due to the high rate of sepsis and death, making this approach reckless indeed, even by the standards of the time. Eventually, even Sir Arbuthnot Lane came to the same conclusion and by the 1920s had changed his mind, deciding that diet was the answer. In any case, also by the 1920s, science had shown that the various symptoms observed in patients with chronic constipation were largely due to distension of the bowel and were not due to autointoxication. As is its wont, scientific medicine moved on from a failed hypothesis.

In marked contrast, as is their wont, alternative medicine practitioners clung all the more tightly to this failed hypothesis, an embrace that continues to this day.

What are these “toxin” things, anyway?

The first thing you need to understand when trying to figure out what toxins are is to realize that what an alt-med practitioner means when he or she mentions toxins resemble what a physician, scientist, or toxicologist means when he or she mentions toxins only by coincidence. In science, the formal definition of a “toxin” is actually quite narrow. Basically, a toxin is a poisonous substance produced by living cells or organisms. Man-made substances that are poisonous are not considered, strictly speaking, “toxins” by this definition. Rather, they are called toxicants. In marked contrast, alt-med practitioners do not distinguish between “toxin” and “toxicant,” lumping them all together as “toxins,” be they the products of autointoxication, heavy metals, pesticides, or industrial chemicals. To the alt-med practitioner, they are all “toxins,” which is why at this point I tend to make like Gunnery Sergeant Hartman and proclaim that I do not discriminate based on toxins, toxicants, or heavy metals. To me, in alt-med usage, they are all equally worthless.

Nomenclature aside, however, perhaps the most important differences in how science views toxins versus how alt-med views toxins is in demonstrating an understanding of (1) identity and (2) how the dose makes the poison. When toxicologists speak of toxins or toxicants, they tend to be very specific about the identity of the toxin or toxicant; they do their best to identify the specific compound or chemical that is causing illness, regardless of its source. This is often not an easy task, because there are frequently many confounders. Rarely are we fortunate enough to have a smoking gun like Minamata disease for mercury poisoning or the syndrome associated with Thalidomide dosing. This is particularly true for chronic disease as opposed to acute poisoning. In marked contrast, alt-med aficionados are almost intentionally vague when discussing toxins. To them, it seems, toxins are either all-purpose nasty substances without specific identities or substances whose toxicity appears not to depend upon dose. In the former case, toxins might as well be miasmas. If you’ll recall, the miasma theory of disease stated that infectious diseases were caused by a “miasma”; i.e., “bad air.” This was not an unreasonable concept before the germ theory of disease, because before germ theory the agents through which infectious disease was transmitted were unknown, but it’s not so reasonable now. Alternatively, “toxins” often seem to function like evil humors in the humoral theory of disease. Either way, alt-med toxins do not correspond to anything resembling toxins or toxicants in science.

My favorite example of this comes from the anti-vaccine movement. Remember our old friend Dr. Jay Gordon, pediatrician to the children of the stars and anti-vaccine apologist? A couple of years ago, “Dr. Jay” (as he likes to call himself) asserted that formaldehyde is a horrible toxin in vaccines. Yet, formaldehyde is a normal product of metabolism and ubiquitous in the environment. As I pointed out at the time, Dr. Jay breathes far more formaldehyde sitting in L.A. traffic jams than is in the entire vaccine scheduled, and human infants have many times more formaldehyde circulating in their bloodstream than would be contained in any vaccine. Believe it or not, I personally engaged in a long exchange with Dr. Jay trying to get him to understand why the “formaldehyde” gambit makes no sense from a medical or scientific standpoint. I’m still not sure whether I got through, because periodically he pulls in essence the “toxins” gambit, in which ingredients in vaccines are listed, along with all sorts of scary potential adverse effects, with no mention given as to the dose required to result in those toxic effects.

When it comes right down to it, alt-med “toxins” are as fantastical as the sympathetic magic that is the basis of homeopathy.

But how do you get rid of toxins?

Given that these magical, mystical “toxins” are ubiquitous, the methods proposed to eliminate them are legion. Still, they tend to break down into five main methods. Often two or more of these methods are combined in order to flush out those evil humors toxins:

• Diet. Key to many “detox” regimens is diet. These can range from all juice diets such as the “Master Cleanse” diet, which consists of lemonade, maple syrup, and Cayenne peppers (I kid you not) to raw food diets such as the ones I’ve discussed (cooking food apparently loads it up with toxins) to any number of other bizarre diets.
• Colon cleansing. Discussed in depth by yours truly three years ago and better known as regularity über alles.
• Heavy metals. This is where “chelation” therapy comes in. In essence, the claim is that we are all overloaded with “toxic” heavy metals. The treatment is, of course, chelation therapy. Unfortunately for quacks (and fortunately for us), genuine heavy metal poisoning is increasingly uncommon. Removing lead from paint has made it less and less common for babies to be poisoned when they put paint chips in their mouth, and removing lead from gasoline has decreased the amount of lead people breathe in. Moreover, there are specific criteria for the diagnosis of poisoning due to specific metals, and chelation is only useful for some metals. It’s also important to remember that, for all the claims of anti-vaccine activists that mercury in the thimerosal preservative that used to be in some childhood vaccines causes autism, not only is there no evidence to support this claim, but there is a lot of evidence against it. Worse, often the diagnosis of “heavy metal toxicity” made by alt-med practitioners is based on “provoked” urine levels, a methodology that has no validity.
• Skin detoxification methods. These methods claim to purge the “toxins” by eliminating them through the skin. They include modalities such as “cupping”, pads like the infamous Kinoki footpads whose manufacturers claim they can draw toxins out through the soles of the feet, and the even more infamous “detox foot bath,” where the water turns colors regardless of whether your feet are in there or not.
• Manipulative methods. These tend to break down into methods like massage therapy and “lymphatic drainage,” basically manual methods that claim to “improve lymph flow” and thus “detoxify” the tissues. Examples include rolfing and lymphatic drainage massage (which, while feeling good, doesn’t remove any toxins that anyone can show).

The bottom line is that in medicine, “detoxification” has a specific meaning, and alt-med “detox” believers have appropriated the term for something that has little or nothing to do with its real medical meaning. Basically, in real medicine “detoxification” means removing a real and specific toxin or toxicant (or set of toxins and/or toxicants). In the case of real heavy metal poisoning, chelation therapy is real detoxification. Similarly, using lactulose to decrease the production absorption of ammonia by the gut is an example of detoxification. In contrast, alt-med “detoxification” is far more akin to the exorcism of evil spirits, the removal of evil humors, or the driving away of miasmas.

Fashionable nonsense

It’s not clear to me what’s behind this latest wave of detox faddism, but it’s clear that the concept that we are somehow being “contaminated” or poisoned is nothing new. Perhaps my favorite pop culture example is from a movie that’s nearly 50 years old, Dr. Strangelove or: How I Learned to Stop Worrying and Love the Bomb. In this blackest of black comedies, U.S. Air Force Brigadier General Jack D. Ripper has a paranoid delusion that fluoridation of water is a Communist plot that will lead to the contamination of the “precious bodily fluids” of every American. Acting on this belief, General Ripper initiates an all out first strike nuclear attack on the Soviet Union, and the rest of the movie involves the increasingly darkly funny efforts of the U.S. government to recall the bombers and abort the attack in order to prevent global Armageddon. The idea “contamination” and the need for “purification” goes back much farther than that, though, as Trebay notes:

The idea of toxicity is a constant in Western culture, said Noah Guynn, director of the humanities program at the University of California, Davis, and a researcher into the cultural meanings of ritual cleansing. “We’re obsessed with the idea that our environments have turned against us, that they are poisoning us and we have no choice in the matter,” Dr. Guynn added. “We’ve been contaminated by something that you cannot eradicate, you can only treat.”

Whatever the reason for the resurgence of belief in various “detox” modalities, one thing’s for sure. Unnamed, unknown, undefined “toxins” are the new evil humors and miasmas, and detoxification is the newest fashionable form of ritual purification.

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