Coulter Book Review
by Julian Winston

Divided Legacy: A History of the Schism in Medical Thought
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 to be?

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 subject."

"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 tuberculosis.

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 "scientific."

"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 or organ.

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 been explained."

"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 school dean

"... 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 coherence."

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 costs.

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 American Revolution.

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.