Coulter Book Review
by Julian Winston
Divided Legacy: A History of the Schism in
Volume IV; Twentieth Century Medicine: The Bacteriological Era
by Harris L. Coulter
The Center for Empirical Medicine, Washington DC and North
Atlantic Books, Berkeley, CA, 1995
Hardbound, 776 pages, $50.00, ISBN 1-55643-170-8
Reviewed by Julian Winston
This review appeared in the June 1995
issue of Homeopathy Today - the newsletter of the National Center for Homeopathy. I
believe that this book is more important than many people realize. It should be required
reading in ALL medical schools (where, I have been told, they teach little about the
history of medicine) - JW
This volume marks the last in the series that Harris
Coulter began in 1973 as Divided Legacy: a History of the Schism in Medical Thought. The
past volumes (I. The Patterns Emerge: Hippocrates to Paracelcus; II. Progress and Regress:
Von Helmholt to Claude Bernard; III. Science and Ethics in American Medicine 1800-1914)
have provided us with a rich history of the empiric tradition in medicine. If Harris had
stopped there, he would be remembered as one of the most influential authors in the field
of medical thought. But this new book moves him even higher. Like his other books, this
one is not easy going. Heavily annotated (there is a 44-page bibliography), the text is
thick with quotes and references that have to be pondered. But Harris' skill is not only
in the collecting of the information, but in the assembling of it with such clarity, that
the denseness of the subject becomes transparent. I found myself moving through the book
as if it were a fast-reading mystery novel.
In some sense, I am certainly the wrong person to be
reviewing this book. The arguments that Harris sets forth need no proof for me-- I am one
of the converted. I would be curious to see what a conventionally trained physician, who
knows nothing of homeopathy and the empirical tradition, would make of the book. Would the
book be able to convince them of its basic thesis-- that conventional medicine, as it has
developed over the last hundred years, is far from being the "science" it claims
Over the last hundred years we have seen pieces of the
problem. But what we have seen is akin to the story of the blind men trying to describe an
elephant-- one feels the trunk and says, "it's like a snake," another feels the
leg and says, "it's like a tree."It is too big to see the whole, so we each see
only a small part. What Harris has done is to pull all the disparate pieces together and
show us the "whole beast" as it were.
In an interview I did with Harris (which was published in
the 1995 issue of The American Homeopath), he said that upon completing the three other
books in the Divided Legacy series, he put a box next to his desk. Every time he came
across any writing that had a bearing on the history of medicine, the empiric/vitalistic
debate, pharmacology, therapeutics, etc., he would toss it in the box.
"I was afraid of twentieth century medicine," said
Harris. "There's just so much new knowledge in twentieth century medicine that I
couldn't figure out how to maneuver it. I couldn't learn everything there was to learn--
that would be out of the question. And I didn't want to look like a damned fool either. So
I had to figure out a way of dealing with it that would minimize knowledge of the highly
technical areas of medicineI It took me many years to not be afraid to tackle the
"The work that we did on the two vaccination books
(DPT: A Shot in the Dark and Vaccination, Social Violence, and Criminality) clarified my
thinking on immunology. Then the work on the book on the controlled clinical trial (The
Controlled Clinical Trial: An Analysis) showed me something else about the theoretical
structure of allopathic medicine. And what I found out to my very pleasant surprise was
that the approach that I'd adopted from the very first word of these four volumes in the
Divided Legacy series-- which was the division between the empirical and rational way of
looking at things-- was totally applicable to the twentieth century. I shouldn't have been
surprised by that, but I was. I thought that 'I can't have that kind of luck,' but I did,
and I treated the 20th century in the same terms as I treated all the other centuries. And
it doesn't look like a forced argument. I think it develops rather naturally."
(Briefly, the Empirical school was based on the idea that
observation and experience lead to theory, and the body posessed an "engergetic
essence" or "vital force" while the Rationalist School developed practice
from theories, reduced components to parts, and that the body was mechanical in nature. As
used throughout Harris' books, the division between the Empiric school and the Rationalist
school is the division between vitalism and reductionism.)
The first section of the book discusses the developments
that took place in the latter part of the 19th century. The work of Virchow had reduced
all phenomena of life to movement at the cellular level. The work of Claude Bernard
further reduced workings of the body to a series of operations that could be explained in
terms of physics and chemistry. And Pasteur, Behring, Metchnikoff, Ehrlich, and Koch were
all developing their theories that led to the rise of the science of bacteriology. When I
was about ten-years old, one of the most impressive books I read was Microbe Hunters by
Paul DeKruif. Now, years later, after reading Harris' book, it is interesting to come back
at the information from a new viewpoint and to understand the complexities that were not
discussed in the book-- which I now realize was a one-sided look at these
"saviours" of modern medicine: Pasteur with his rabies vaccination, Ehrlich with
Salvarsan-- the "magic bullet" to cure syphilis, and Koch with his vaccine for
Of all those working at the turn of the century, the most
influential seemed to be Ehrlich. He began his work with a dissertation in 1878 on the
theory and practice of Histological Staining. All of Ehrlich's ideas were developed while
he was working with aniline dyes-- and lead to his assertion that medicines act through
physical contact with target organs.
The work that was being done at the turn of the century
reads like a fantasy. Everyone was trying to find "reasons and mechanisms" to
explain the functions of the body, and theories were being proposed with daily regularity.
But as each theory was proposed, the empiricism that was
reflected in homeopathy was in the background. At each turn, when the "model"
began to get overly complex and the thinking began to turn toward a vitalistic
explanation, all parties backed away quickly from even considering explanations which lay
in THAT direction. The doctrines of Contraries as expounded by Ehrlich and Koch, resulted
in a two tier doctrine of diagnosis and therapeutics. The patient's "signs"
revealed the disease "cause" and also the "physiological action" of
the medicine; this was the substance of "general pathology" and seen as
"scientific." The "symptoms," on the other hand, being produced by the
patient's idiosyncrasy, fall under "special pathology" and were not
"A new paradigm was needed, and Ehrlich put it
together based on the ready-to-hand technology of aniline-dye manufacture. Henceforth,
research on the 'physiological action' of medicines fell under traditional pharmacology'--
a 'purely biological' or 'purely theoretical' science 'without any concern for practical
application.' Research on healthy animals (said Ehrlich) may reveal the toxic effects of
medicinal substances, but never their curative powers."
As Harris says, "Ehrlich updated and refurbished
seventieth-century iatrochemistry, reformulating it in the vocabulary and concepts of the
dye-stuff industry. Thenceforth the relationship between the remedy and patient was
patterned on that between dyes and the materials they color."
And "while Twentieth Century Rationalism has dropped
some of his [Erlich's] wilder embellishments, his categories still remain in place...
there is the same attempt to differentiate medicines which act on 'symptoms' from those
which act on 'cause' even though the 'cause' cannot be defined or identified and cannot be
distinguished from the symptoms."
"The doctrine of contraries is the inescapable
corollary of the Rationalist dream that the physician can fashion medicinal substances to
carry out his will and desire; it is so instinctive as rarely to be subject to criticism
or analysis... The doctrine that medicines 'compete' 'antagonistically' for a 'site' on
the wall of the cell of a host organism is the child of Darwinism and of Rationalist
confidence that the action of medicines can be determined otherwise than by testing on
healthy humans. 'Antagonism' or 'contrariety' in its various forms remains to this day the
guiding principle of rationalist-allopathic medicine."
Koch noted in 1890 that medicines that seem to retard the
growth of the tuberculosis bacilli in vitro (in the test tube), often remain without
effect when applied in vivo (in the body). This conceptual stumbling block has been the
thorn in the side of contemporary medicine-- that the medicines work differently in the
BODY than they do upon the bacteria alone.
With all this as a starting point, Harris takes us on a
roller-coaster ride through the major concepts of the standard medical model-- host
resistance and immunity; the disease entity; infectious diseases-- and through quotes from
conventional medicine's own literature which show how their "... boundaries disappear
into the gloaming, like the Cheshire Cat, leaving behind nothing but the smile."
His use of contemporary authors' words makes some of the
points very clearly. For example, on page 208 he quotes Lewis Thomas who said:
"Disease is still a mystery. We don't know how bacterium cause disease. We know, for
instance, that epidemic meningitis is caused by a microorganism called a meningococcus,
but we have no clear idea as to how it works, nor do we know why some people develop
meningitis while others have nothing more than a mild respiratory infection."
After the decline of the major epidemic diseases, medicine
turned to the non-infectious diseases where there were even greater problems defining the
disease "entity." Again, Harris quotes others, and the ideas presented from
these varied sources can be seen as a totality-- probably for the first time.
Writer Alvan Feinstein said, in 1967: "No other branch
of natural science is so imprecise in defining the material exposed to experiment.
Although no uniform standards have been ratified and disseminated, it is commonly believed
that rigorous criteria are invariably present. The clinicians' capacity for intellectual
self-deception is illustrated by the widespread acceptance of this delusion." Dr.
Michael Halberstam is quoted: "Mrs. Ruth LaMotta is a 53-year-old patient of mine
with one husband, one job, three children, and countless pains. One week her throat hurts,
another her back. She is plagued by colds which prevent her from working. She thinks her
sinuses might be infected. She feels tired and is sure she has the 'flu. Her eyes get
'weak all over' at work, and she is afraid she has glaucoma. Mrs. LaMotta is sure her body
is gravely ill. I am sure it isn't."
There is an assumption that the elements of the body
interact with one another by following the laws of physics, chemistry, mechanics, and the
like, and the number of mechanisms is limited. Says Lewis Thomas: "Nature is
inventive, I grant, but not so inventive as to continue elaborating successions of
brand-new impenetrable disease mechanisms. After we have learned enough to be able to
penetrate and control the mechanisms of today's diseases, I believe we will automatically
be well-equipped to deal with whatever new ones turn up."
By halfway through the book, Harris has led us through the
philosophical underpinnings of modern medicine. The next section, 250 pages, is devoted to
a description of the Empiricism and Vitalism in 20th century medicine-- Homeopathy,
Chiropractic, Osteopathy, and Naturopathy. He doesn't tell us, as homeopaths, things we
didn't know about our science. Perhaps to someone unfamiliar with homeopathy something
might be learned from this section, but, to me, it seemed less "together" than
the rest of the book.
Harris then discusses the ways in which vitalism slowly
influenced conventional medicine through immunology and allergy treatments (although
always seen from a rationalist perspective), and the introduction of many homeopathic
drugs into allopathic practice during the late 19th and early 20th centuries. Harris
points out that more than 100 of the 474 medicines listed in a typical textbook of
allopathic practice in 1918 were also found in homeopathic texts.
Conventional medical texts recommended Aconite for 'croup,
quinsy, sore throat, severe colds, asthma due to exposure,' yet by 1953 it was described
as having no therapeutic value. Harris attributes this abandonment of many of the
homeopathic drugs to the closeness of the therapeutic and toxic doses-- which is
problematic if one refuses to use potentized medicines. He presents a case of an American
allopath who, in 1978, treated complicated migraines with the opium based papaverine, and
said that the "basis for therapeutic effectiveness remains obscure." But a look
at the description of Opium in any homeopathic materia medica would show the similarity of
the remedy to the problem.
The second section ends with a discussion of how allopathic
medicine views Hering's Law of Cure. Case after case is presented where a suppression of
the external caused a deeper internal problem.
Patrick Hall-Smith is quoted: "There is a significant
but poorly understood association between [ichthyosis-- a skin disease] and eczema,
asthma, and hay fever." Says Harris: "Allopathic dermatology is aware that
internal conditions are often externalized on the skin, but this information is not put
into a dynamic context."
The third section focuses on the pharmacology of contraries
and its consequences. Harris spends time on the idea of the "receptor site"
where each cell is assumed to have receptor sites on the walls corresponding to the types
of drugs that can be administered. The drug molecule was tailored to fit the specific cell
This leads to the doctrine of contraries-- drugs which are,
for example, calcium antagonists or channel blockers. "That the body's dynamism,
blocked by contrary medicine, may seek some other outlet does not ordinarily occur to the
Rationalist thinker." Referring to the receptor site as an "elegant doctrinal
construction" of which none of the elements can be demonstrated in practice, Harris
says that by "being incoherent, receptor-site theory cannot be described coherently.
When doctrinal difficulties are overcome by adding new assumptions, the resulting
structure cannot be grasped in any logical way-- like pre-Copernican astronomy, where
deviant orbits of planets and comments were incorporated into existing knowledge by
positing new epicycles...
" It is through these arguments that Harris shines.
Saying that the concept of a receptor site is a "doctrinal and economic
necessity," he continues: "The demand that the disease 'cause' and the drug
interact chemically via physical contact placed pharmacology under the dominion of
chemistry, introducing the external explanatory criterion so beloved by rationalist
thinkers. Pharmacology was thereby taken away from physicians-- now deemed incompetent to
negotiate the theological subtleties of receptor-site theory and lacking the material
resources to pursue such research...
"In fact, the 'receptor-site' does not exist. It is a
phantasm, a 'perception of something that has no physical reality,' a mere figment of the
Rationalist imagination." "Most allopathic pharmacology," says Harris,
"is not explicable in terms of the receptor site... in fact, Hahnemann's suggestion
that drugs act by mere contact with the patient's organism is far more scientific and
realistic than the whole phantasmagoria of receptor-site theory. The abortive allopathic
encounter with metal colloids, which were never thought to form a chemical bond with the
tissues but acted by mere contact, momentarily opened the door to this way of looking at
pharmacology but was quickly rejected because it called into question the discipline's
whole doctrinal basis."
The doctrine of Contraries is discussed in terms of adverse
reactions-- "side effects," as we call them (although the expression "side
effect" is a misnomer, since these effects are themselves "direct" effects
of the medicine, even though undesired), rebound effects, and the dangers of overuse of
antibiotics-- all supported with statements from conventional medical literature.
Pointing out that Rationalist theory encourages multiple
prescribing because there could be a different drug for each causal mechanism, Harris
quotes Leighton Cluff, who reported in 1967, that the average patient in a teaching
hospital received from ten to twelve different medicines during their stay-- some got as
many as 50.
Harris then discusses another aspect of the doctrine of
contraries-- drug disease and chronic disease. The examples are numerous and frightening:
Serpasil decreasing sex drive; Aldactone (spitonolactone), a diuretic whose literature
cautions, "unnecessary use of this drug should be avoided," yet it is prescribed
millions of times a year; juvenile onset diabetes which is often generated by the whooping
cough vaccine, hence the "enigmatic" rise in this disease that reflects the
expansion of the use of the DPT vaccine; and many others.
Section four of the book deals with the issue of medical
reform. First, Harris describes the structure that needs to be reformed - the
institutionalization of "medical rationalism" where the United States has set
the pace under the banner of "scientific medicine." Harris suggests that the
stress on disease categories and mechanistic approaches that culminated with the setting
up of the Natiuonal Institutes of Health as the Division of Research Grants has
accentuated the tendency to think in the language of disease entities. This bias has
marked federally supported research projects ever since.
Furthermore, after the Flexner Report in 1910, the
individual states developed legislative "Medical Practice Acts" which limited
those able to be licensed to those who came from the allopathic institutions. "Within
the licensed (allopathic) profession the muscle of the American Medical Association and
its network of state and local medical societies was wielded against internal dissent by
homeopaths and other physicians who disagreed with the narrowly doctrinaire policies
imposed and enforced from above. And as self-appointed keepers of the gates through which
pass all purveyors and suppliers of auxiliary medical services-- nurses, radiologists,
technicians, assistants, and the like-- allopathy has extracted tribute from each."
Underlying this control, however, was a theoretical void.
Medical Rationalism in medicine, says Harris, "... is not well adapted to a
scientific understanding of the living organism." And it is "not a valid
scientific guide to the practice of medicine, the training of physicians, or the
allocation of research funds."
Describing modern medicine as a discipline that has vast
arrays of equipment at its disposal, Ian Stevenson characterizes the field of medicine as
having made the mistake "of thinking that when a phenomenon has been described it has
"Allopaths," says Harris, "maintain that
they seek only 'facts,' ignoring that 'facts' in a science are inseparable from theory,
that there can be no 'facts' without a governing hypothesis. The attempt to assemble
'facts' in the absence of a theory or hypothesis has generated that 'vast hopelessly
fragmentary science of the human body' which today is in crisis."
"But to allopathy, all talk of 'theory' smacks of the
seventeenth or eighteenth centuries, or 'sectarian' medicine. In 1924 the AMA's Judicial
Council demonstrated its dislike of medical theory in branding as 'sectarian' anyone who
followed a 'dogma, tenet, or principle based on the authority of its promulgator.'"
Said writer Lawrence L. Weed in 1974: "Medical
knowledge is passed along like Norwegian songs or in the Middle Ages, doctors singing
ballads to each other in the hospital lobby and in those show-and-tell rounds. They
believe what they want to believe; nowhere else is there more hallucinatory fulfillment
than in medicine." Following this, Harris discusses the search for the
"theoretical structure" (or lack of it) which is seen through the training of
the physicians themselves. Harris says very little through this part-- letting the words
of others issue the judgement:
"The student is fogged in facts... does not see the
patient as a whole. He lacks necessary guiding principles for applying what he has
learned. The student has been working very hard to master subjects, such as the finer
points of gross anatomy and organic chemistry, that in later years he will blissfully
forget." -- Michael Crichton
"We have different doctors for asthma, diabetes,
cancer, and brain tumors, because the knowledge of the specialist in one of these diseases
has no bearing on another. Had we a grasp of underlying principles in medicine, a
physician would feel at ease in any of these conditions. "-- Ian Stevenson
"The GP is only a pimp for the Specialists."--medical
"... the teaching was directed at the recognition
and identification of disease. Therapy was an afterthought, if it was mentioned at
all"-- Lewis Thomas
"The average case notes have become almost verbless
and are often little more than an index of conventionally chosen sets of physicals signs
sought for in every case. How rarely is the eye, as it transverses these deserts of nouns
and of plus and minus signs, refreshed by some flash or originality of observation or
presentation. I suggest that what would revive our clinical nosography is a return for
refreshment to the clinical writings of forty or more years ago."-- F. M. R.
Walshe, in The Lancet, 1956
"We train researchers first, practitioners second.
Those who enter practice are usually our second-rate students... I feel we shouldn't waste
our time on them." --staff physician at a teaching hospital, 1969
"Instead of giving the ill they cannot cure a name,
these physicians give the ill they cannot name a drug."-- Harry F. Dowling 1963
"The chance that the average patient will get the
right drug, in the right amount, at the right time, is on the order of 50 percent."
--Dale Console to Congress in 1969
And to this last, Harris points out that Lawrence
Henderson, in 1910, said "If the average patient visited the average physician, he
would have a fifty-fifty chance of benefitting from the encounter." Have we
progressed in the last 85 years?
The book concludes with a repeat of the theme that carries
through the other books that Coulter wrote-- the conflict between rationalism and
empiricisim-- and the social and economic impact of these modes.
"Empiricism accepts hetereogeneity as an
irreducible fact of medical life, facing up to the fact that patients and 'diseases' come
in a staggering variety."
"Rationalism, on the contrary, seeks to mitigate
this harsh reality by forcing the varieties of disease states into procrustean
pigeon-holes of 'entities' accepted by the given day and age."
Harris suggests that the time consuming nature of
homeopathy (and other branches of empiric medicine) as well as the heavy burden that is
placed on the practitioner to be ultimately responsible for "finding the right
remedy," become a serious drawback of the system. His views are echoed by the grand
homeopath, John Henry Clarke, MD, who said: "If all the allopaths were to be made
into homeopaths, we would not be better off. However much they might believe in the Law of
Similars, they would not be able to practice the art until they have given their heart and
soul to the study of itI It was really with the weakness of human nature that Hahnemann
was confronted, and it is the same problem that confronts us at the present day."
The use of "disease name" suggests knowledge of
the "cause." Says Harris, "Because the explanation is in terms of
'mechanisms' to which only the physician is privy, it elevates the physician's status in
the patient's eyes and alleviates many anxieties. The sociological significance is not to
be underestimated; that their scientific content is minimal is unimportant." Eric
Cassell, in 1986, suggested that "professional coherence is engendered by doctrinal
The general principles of allopathic theory, Harris
maintains, which at first glance seem clear enough, dissolve into thin air when closely
scrutinized. Unfortunately, the therapeutic doctrine enabling the physician to treat the
most patients in the time available will usually command his allegiance.
But the reality, as the The Washington Post pointed out in
1979, was simple: "The most conscientious doctors-- those who rely most heavily on
careful physical examination and take the patient's detailed history, and take the time to
guide and explain, and hear their patients out-- earn the least. The charges for pure time
are always less than the charges for procedures."
Furthermore, the current doctrine holds that no
"disease" is the result of lack of exercise, nutrition, nor the over-consumption
of therapeutic drugs. The existence of one or another "disease" is always and
invariably ascribed to the absence of drugs for that disease. One of the economic
consequences of this thinking is that we are now caught in a rising spiral of medical
In the end, believes Coulter, Empiricism and Rationalism
are contrasting ways of organizing medical services with vastly different economic
consequences. So are there answers? What Harris proposes as a first step is the repeal of
the Medical Practice Acts on which Rationalism's monopoly of power is founded.
"Rationalism cannot be considered a science." Such a recommendation suddenly
brings one back to our shared reality. True, it would shake the very foundations of the
medical system. But to DO IT would require an uprising by the populace on the scale of the
We have to take it one step at a time, and slowly convince
people that their good health is not best served by the medical system that is currently
in place. If we could move rationalism from the place it is now, it would, says Harris,
"make the physician a less tempting target for the producers of drugs. They could do
what they should be trained to do-- tend the sick. And then the public could decide which
type of treatment it prefers."
So there it is. It has been said. In four volumes, over
twenty years, Harris has traced the evolution of medicine as no one else has done. It has
been said that history is written by the "winners." That is certainly true of
all the books you can buy on the history of medicine-- except this one. It is a book
everyone should read and ponder. It certainly describes "the Emperor's clothes."
And, it is full of quotable tidbits. My favorite was on
page 409. George Bernard Shaw called upon Sir Almroth Wright -- a noted allopathic
physician-- to look into homeopathy.Wright expressed complete incredulity. Shaw
remonstrated with him. "Look here," exclaimed Wright, "the thing is absurd
and impossible; let me put it this way. Would you, Shaw, trouble to get out of your chair
if I called from the next room, 'Do come in here and see what I have done-- I have turned
a pint of tea leaves into pure gold.'?"
"Certainly I would,' replied Shaw.
And those of us who use homeopathy, with all it's rational
inconsistencies, would get up also.