Alternative Medicine, Alternative Science?:
An Historical Perspective (1994)
Steven C. Martin, M.D.This essay briefly explores the relationship between science and alternative medicine over the past 150 years. It is of course impossible to do justice to the history of each individual alternative approach in the confines of a single essay. There are important distinctions among the alternative practitioners as regards their relationship to science. However, although alternative healers differed in many ways, by definition they have shared the characteristic of being different from orthodox medicine. Because a particular conception of science is at the core of orthodox medicine's identity during this era, alternative practitioners needed to confront orthodox science and argue their position in the light of its assumptions. What follows then is an overview of science as defined by alternative practitioners, rather than a comprehensive survey.
"Is it essential that we should now conclude a treaty of peace," asked Abraham Flexner in 1910, "as to recognize dissenters [from orthodox medicine] on an equitable basis?" As Flexner was writing his famous report on the status of American medical education in 1910, a dramatic shift in the relationship between alternative and orthodox medicine was occurring. Throughout most of the 19th century, unorthodox medicine had been widely utilized by Americans. Homeopathy, the largest and most prestigious of medical competitors, accounted for as many as one-quarter to one-third of American health providers, and a rich array of alternative practitioners ranging from snake oil salesmen to sectarians treated patients. Few states required a license to practice medicine and those that did had ineffectual laws .
By 1910, this had begun to change. Enrollment in sectarian medical schools had declined substantially, pure food and drug legislation had been passed to combat patent medicine vendors, and strict licensing statutes were increasingly adopted. One key reason for the ascendancy of orthodox medicine and the parallel decline of alternative practitioners was medicine's claim that it now rejected old doctrines and firmly rested on a scientific basis .
The Flexner Report was the culmination of a half century of efforts to reform medical education using laboratory science as the new defining credo for medicine. When Flexner, who was not a physician but an educator, addressed the issue of alternative medicine, he denied favoritism. If alternative healers accepted the principles of modern science, then they were welcome on equal footing with orthodox medicine. He stated:
Modern medicine has therefore as little sympathy for allopathy as for homeopathy. It simply denies outright the relevancy or value of either doctrine. It wants not dogma but facts. . . . No man is asked in whose name he comes - whether that of Hahnemann, Rush, or of some more recent prophet. But all are required to undergo rigorous cross-examination .
Flexner's standard for evaluation of medical care appears deceptively simple. Few alternative practitioners, in Flexner's time or now, would find fault with his general propositions. Most denied they were dogmatic, accused orthodox medicine of being closed-minded, and insisted that if put to a fair test they would be proven effective. However, the presumed simplicity of using science to provide a fair test assumes there has been a single universally recognized definition of science. The definition of science, however, remained more controversial than Flexner could have ever imagined, both within medicine, and equally importantly, within popular culture. Alternative practitioners have proposed alternative approaches to science, approaches that buttressed their therapeutic practices in a way that sought to remain intellectually acceptable in American society, while distinguishing alternative from orthodox medicine .
Science and Health Care, 1850-1950
Throughout most of the nineteenth century in America, natural history was the dominant approach to the biological sciences. Scientists observed nature and classified their observations in an effort to discern natural laws. Disciplines such as taxonomy and paleontology enjoyed great prestige. Observational rather than experimental science dominated .
This was also true in medicine, where the careful examination of patients and recording of their symptoms and responses to treatment traditionally constituted medical science. Many of the revered names in medical history, from Hippocrates through Sydenham, achieved fame for their exceptional observational skills. In the nineteenth century this was buttressed by the emergence of the Paris School of Medicine, which attracted flocks of American medical students. The Parisians, led by Pierre Louis, pioneered the study of anatomic pathology, which became the most prestigious medical science of its day. Physicians performed thousands of autopsies, correlating pre-mortem and post-mortem findings. Like its predecessors, this form of medical science remained fundamentally observational in character .
The emergence of laboratory science in the mid-nineteenth century—initially with experimental physiology and then with the efflorescence of bacteriology—fundamentally altered the intellectual landscape of medicine. By the last quarter of the nineteenth century, a cadre of elite physicians, most trained in German laboratories, began using laboratory science as the foundation for building a new American medicine .
Since their ascendancy in the beginning of the 20th century, the definition of science in medicine has appeared self evident to elite physicians. Medical science was laboratory science. Using a reductionist philosophy, scientists performed controlled trials where they sought to manipulate a single variable while holding all other relevant variables constant.
These assumptions have been the foundation of American medicine. They are epitomized in a system that values basic science over clinical research and assumes that the route to improved health is through a clearer understanding of the essentials of biology. The process of medical discovery was assumed to be unidirectional—from laboratory bench through animal experimentation to clinical trials to routine practice.
Over the past two decades, however, historians have punctured the myth that this was the sole model of science embraced by physicians. Studies have revealed important distinctions in the definitions of science used by clinicians as compared to laboratory researchers, male and female physicians, and within the nursing profession. Analyses of the roots of major medical discoveries suggest that they are as likely to originate at the bedside as in the laboratory .
Although the new laboratory-based scientific medicine clearly dominated medical thought, it existed in an uneasy parallel with observational science. Clinicians in general, and surgeons in particular, continued to value observation and experiential knowledge and to define these as forms of legitimate science. Perhaps the most celebrated physician of the early 20th century, Sir William Osler, contributed to the medical literature primarily using observational, rather than experimental, science .
The continuing centrality of observational science to popular understanding of science was equally important for alternative healers. The historian Keith Benson argues that it is hardly surprising that natural history remained influential at the turn of the century because it "permeated the fabric of American cultural and scientific endeavors in the nineteenth century." The late nineteenth and early twentieth centuries were the heyday of the great natural history museums, such as New York's American Museum of Natural History and Chicago's Field Museum. Content analysis of popular magazines reveals that between 1910 and 1955, the science they featured most commonly focussed on non-experimental sciences such as paleontology and astronomy. Furthermore, the popularization of laboratory science as the paradigm for science lagged behind its incorporation into academia. John Burnham argues that scientific popularization peaked in the mid-late nineteenth century when natural history remained a dominant model of science. A relative decline in public science education circa 1900 meant that as biomedical scientists retreated into their laboratories, large segments of the public continued to equate science with natural history .
The persistent popularity of natural history, the long tradition of clinical observation within orthodox medicine, and the ascendancy of laboratory science within academic elites created a niche for an alternative conception of science. Alternative practitioners embraced a science that relied on observation and retained intellectual legitimacy and appeal by overlapping with traditional and popular understandings of science. At the same time, this approach to science allowed alternative healers to distinguished themselves from orthodox medicine by challenging the relevancy, philosophy, and moral underpinnings of laboratory science.
Alternative practitioners often turned to the dictionary to support their claims that they practiced legitimate science. In a typical statement, B. J. Palmer, a leading chiropractor, declared that "[Science is] a system of classified systematized knowledge. It consists of the description and formulation of phenomena and their causal relations." Alternative practitioners argued that their science consisted of observing the responses of thousands of patients to their treatment. This not only proved the utility of their treatment, but also allowed them to describe new fundamental laws of nature. Although the different schools of alternative medicine disagreed as to the definitions of these new natural laws, they were all confident that their scientific method constituted. a legitimate intellectual exercise .
Alternative healers considered their science superior to laboratory science. They rejected the assumption that results obtained by studying isolated tissues in the laboratory or from animal experimentation could be extrapolated to human beings. They challenged the conception of disease as an abstract intellectual concept divorced from the experiences of individual patients. Instead, they insisted disease and its treatment can solely be understood as internal disruptions, rather than external invasions .
Many alternative practitioners considered the new scientific medicine fundamentally flawed because it embraced a reductionist approach. Alternative healers were vitalists, arguing that an essential ethereal force was fundamental to all living organisms. Although one might not be able to precisely characterize this force, one could harness its benefits to assist the healing process .
Vitalism was closely tied by alternative healers to assumptions about the moral value of science. Throughout much of the nineteenth century, supporters of natural theology and its descendants asserted that science ennobled the scientist because it demonstrated the magnificence of God. Natural history allowed ordinary citizens to enhance their faith by contributing to scientific knowledge. Alternative practitioners frequently linked vitalism with spirituality, arguing they were the heirs of natural theology while medicine promoted "atheistic materialism." During an era when many were concerned with the growing antagonism between science and religion, alternative practitioners proposed a scientific approach that conceptualized science and religion as mutually reinforcing .
The emphasis on vitalism extended beyond proper scientific methodology or the value of Godliness. Alternative healers argued they obtained better results because they acknowledged the centrality of spiritual and emotional considerations to the development and treatment of disease. Although there was a broad spectrum of alternative practitioners, with some such as Christian Scientists and spiritualists rejecting any materialist influence on disease and others combining in various degrees spiritual and material concerns, virtually all embraced vitalism, with spirituality its most common expression. Vitalism and spirituality made alternative practitioners not only better scientists, but better healers .)
Thus, for most of the 20th century, alternative practitioners presented a coherent vision of science that overlapped with, yet fundamentally differed from, scientific medicine. Emphasizing observation rather than experimentation, a vitalist rather than reductionist philosophy, a mutually supportive relationship between science and religion, and the centrality of the individual, unconventional practitioners created an alternative science that buttressed their alternative approach to healing.
Science and Alternative Medicine after World War II
The decades following World War II constituted a "Golden Age" for scientific medicine. Institutionalized in the National Institutes of Health, the classic model of biomedical science as proceeding from laboratory bench to bedside became deeply entrenched after the war. The dramatic success of penicillin, cortisone, and the development of a polio vaccine underscored the ascendancy of this model for scientific medicine .
During this era, alternative medicine persisted but maintained a very low profile. The American Medical Association vigorously opposed alternative practices. Popular literature rarely discussed alternative medicine, and when it did it was generally negative. Polite society dismissed alternative practices as quackery, even if privately many sought out such practitioners .
Beginning around 1970, this landscape changed dramatically. First, the deference to medical science that characterized most of the 20th century collapsed. Reductionist science was accused of ignoring issues vital to health care. Social scientists and philosophers challenged the assumptions of positivist science, arguing that objectivity was never truly obtained, questioning whether it was desirable, and suggesting that scientific knowledge was socially constructed .
Critics assailed medicine for shifting away from the bedside and into the laboratory. The illusory promise that medicine could defeat all disease left many disappointed. Although life expectancy had dramatically improved, medical advances left many struggling with debilitating chronic diseases. It became commonplace for patients to end their lives in the eerie twilight of hospital intensive care units, kept alive by halfway technologies that extended the quantity but often not the quality of life.(19)
Suddenly alternative medicine was in vogue. Arising partly out of the strength of the counterculture movement, and feeding on dissatisfaction with orthodox medicine, alternative approaches promised to avoid the sterility of modern medicine and offered hope for ailments stubbornly resistant to orthodox therapy. After reestablishment of relations with mainland China, dramatic stories about acupuncture were widely reported in the lay press. A growing fascination with Eastern cultures led to growing interest in traditional Chinese and Indian medicine. A wide spectrum of alternative practices began to flourish, often loosely grouped together under the umbrella of "holistic" health .
Within alternative medicine, the growing strength of the movement spawned different approaches to science. Some continued to emphasize the traditional natural history definitions of science. Some rejected science altogether, denying that it was a useful approach to health care. Others sought to use the tools of orthodox science to establish and explain their effectiveness .
This latter approach among alternative practitioners overlapped with a growing interest among orthodox scientists in the science behind alternative medicine. Beginning with the fascination with acupuncture in the early 1970s, there has been a steady growth in scientific investigations related to unconventional therapeutics. Considerable attention has been refocused on the mind-body interaction among both the general public and professional scientists. The development of such scientific disciplines as psychoneuroimmunology demonstrates that it has become acceptable for basic scientists to investigate areas previously considered on the fringe of medicine .
In addition to applying the techniques of basic science research to alternative medicine, the development of clinical research methodologies has had a dramatic impact on research into alternative medicine. The ascendancy of randomized controlled clinical trials has allowed clinical researchers to develop a research methodology that approached the ideals of the laboratory. More recently, researchers have refined a series of newer approaches, such as meta-analysis, decision analysis and n-of-1 trials, that allow improved assessment of the quality of medical interventions. The result has been clinical research methods that can address the efficacy of therapeutic interventions without making any assumptions about the theory behind the therapy. Articles applying this methodology examining such disparate approaches as laetrile, acupuncture, chronic yeast infection, iridology, homeopathy, and chiropractic have appeared in major medical journals .
As we speak today, the relationship between alternative medicine and science is extremely complex. Among alternative healers there is considerable controversy about the desirability of using orthodox scientific methodologies to evaluate alternative practices. These techniques are intellectually powerful and have wide social acceptance, so that positive results will help legitimate alternative medicine. Certainly trials that have shown positive effects have been widely promoted by alternative practitioners.
Many others, however, see dangers in the use of these scientific methods. Some are cynical about orthodox medicine's intentions and fear that such studies will be used to either discredit or co-opt alternative medicine. The history of intense antagonism towards alternative medicine by organized medicine and the historical trajectory of sectarian movements such as osteopathy and homeopathy buttress these arguments.
Intellectually, some deny the applicability of scientific methods to their practices. One cannot investigate a process that assumes vitalism by using a reductionist model. At the clinical level, orthodox medicine's groupings of patients by disease categories may not match those of alternative practitioners. A central tenet of clinical epidemiology is that one need compare apples with apples, not with oranges. Even the notion of creating groups to investigate is challenged by some. If each patient is unique, then studying groups of patients will miss the essence of an alternative practice.
Evaluating alternative medicine poses a difficult challenge. Is there a single scientific standard to which all practices should be assessed by, or are there several legitimate ways to analyze therapies? If there are more than one legitimate standard, which standard is applied to which therapies? Is orthodox medicine willing to consider vitalism as a useful approach to biological processes?
The political success of alternative medicine reflects the persistence, vitality, and importance of alternative scientific systems within American society. Science is a chameleon, meaning different things to different people, all comfortably claiming the mantle of scientific authority. We have only begun to tease out the implications of the enormous diversity of meanings associated with science. This is especially true of the relationship between science and medicine. For a historian, studying alternative healers and their conception of science provides a useful tool for understanding the complex relationships among science, health care, and society. However, this is a far cry from deciding about the utility of specific alternative approaches. The history of medicine is replete with success and folly of both the orthodox and alternative varieties. Distinguishing between the two has always been difficult, and remains a daunting challenge.
About the Author
Dr. Martin, a medical historian, was an assistant professor Departments of Epidemiology and Social Medicine and Medicine Albert Einstein College of Medicine in New York City.
- Abraham Flexner, Medical Education in the United States (New York:The Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4, 1910) p. 156. For the best introduction to the history of alternative medicine in America, see Norman Gevitz, The D.O.'s: Osteopathic Medicine in America (Baltimore: Johns Hopkins University Press, 1982), which contains an extensive bibliography. Some frequently cited works include: Jane B. Donegan, Hydropathic Highway to Health: Women and Watercure in Antebellum America (Westport: Greenwood Press, 1986); Arthur Wroebel (ed.), Psuedo-science and Society in Nineteenth Century America (Lexington: University Press of Kentucky Press, 1987); R. Laurence Moore, In Search of White Crows: Spiritualism. Parapsychology and American Culture (New York: Oxford University Press, 1977); James Harvey Young's two books, The Toadstool Millionaires: A social history of patent medicines in America before Regulation (Princeton: Princeton University Press, 1961) and The Medical Messiahs: A social history of health quackery in twentieth century America (Princeton: Princeton University Press, 1967); Walter Wardwell, Chiropractic: History and Evolution of a New Profession (St. Louis: Mosby Yearbook, 1992); J. Stuart Moore, Chiropractic in America: The History of a Medical Alternative (Baltimore: Johns Hopkins University Press, 1993); Martin Kaufman, Homeopathy in America: the Rise and Fall of a Medical Heresy (Baltimore: Johns Hopkins Univ. Press, 1971); Phillipp Nicholls, Homeopathy and the Medical Profession (London: Croom Helm, 1988); Norman Gevitz, The D.O.'s: Osteopathic Medicine in America (Baltimore: Johns Hopkins Univ. Press, 1982). on medical licensing, see Joseph F. Kett, The Formation of the American Medical Profession: The Role of Institutions. 1780-1860 (New Haven: Yale University Press, 1967) and Richard Shryock, Medical Licensing in America, 1650-1965 (Baltimore: Johns Hopkins University Press, 1967).
- Flexner (note 1), Kenneth Ludmerer, Learning to Heal: The Development of American Medical Education (New York: Basic Books, 1985), Paul Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982).
- Flexner (note 1)., pp. 156-158.
- Steven C. Martin, "The Only Truly Scientific Method of Healing': Chiropractic and American Science," Isis 1994; 85:207- 227.
- Wayne Hanley, Natural History in America. From Mark Catesby to Rachel Carson (New York: Quadrangle, 1977); Lynn Barber, The Heyday of Natural History (Garden City, NY: Doubleday, 1980); Ernst Mayr, The Growth of Biological Thought (Cambridge, Mass.: Harvard University Press, 1982); William Coleman, Biology in the Nineteenth Century (New York: Wiley and Sons, 1971); Garland Allen, Life Science in the Twentieth Century (New York: Wiley, 1975).
- Erwin H. Ackerknecht, Medicine at the Paris Hospital. 1794-1848 (Baltimore: Johns Hopkins University Press, 1967) and A Short History of Medicine (2nd ed.), (New York: Ronald Press, 1968)
- Thomas N. Bonner, American Doctors and German Universities (Lincoln: University of Nebraska Press, 1963), Ludmerer (note 2).
- The superb historiographic essay by John Harley Warner, "Science in Medicine," in Historical Writing on American Science, Sally G. Kohlstedt and Margaret Rossiter, (eds.) (Johns Hopkins Univ. Press, Baltimore, 1985), pp. 37-58 outlines current scholarship in the field and provides extensive references. on the directionality of scientific discovery, see Judith P. Swazey and Karen Reed, Today's Medicine. Tomorrow's Science (Washington,D.C.: U.S. Dept. of Health, Education, and Welfare).
- Russell Maulitz, "Physician versus Bacteriologist": The Ideology of Science in Clinical Medicine," and Gerald Geison, "Divided We Stand: Physiologists and Clinicians in the American Context," in Morris J. Vogel and Charles E. Rosenberg (eds.), The Therapeutic Revolution (Philadelphia: University of Pennsylvania Press, 1979).
- Keith Benson, "From Museum Research to Laboratory Research: The Transformation of Natural History into Academic Biology," in Ronald Rainger, Keith Benson, and Jane Maienschein (eds.), The American Development of Biology (Philadelphia: Univ. of Pennsylvania Press, 1988); Marcel c. LaFollette, Making Science Our Own: Public Images of Science 1910-1955 (Univ. of Chicago Press, Chicago, 1990); John Burnham, How Superstition Won and Science Lost: Popularizing Science and Health in the United States (Rutgers Univ. Press, New Brunswick, N. J., 1987).
- Bartlett Joshua (B. J.) Palmer, The Science of Chiropractic, (Davenport, IA: Palmer School of Chiropractic, 1917) p. 41.
- Harris L. Coulter, The Divided Legacy: A History of the Schism in Medical Thought (3 vols.) (Washington: Weehawken Book Company, 1973-1977). The internal struggle among homeopaths as they grappled with the new science advocated in medicine is discussed by Naomi Rogers, "The Proper Place of Homeopathy: Hahnemann Medical College and Hospital in an Age of Scientific Medicine," Pennsylvania Magazine of History and Biography 1984, 108:179-202.
- J. Robinson Verner, (The author, Englewood, N.J., 1941).
- E.C. Wilson, "The Idealist-Philosophy-Cycles," The Chiropractor, 1915; 11:28-31. Although the nature of the relationship between science and religion in complex, there is little doubt that many Americans around the turn of the century conceptualized the two as in mortal combat. See, for example, Andrew Dickson White, A History of the Warfare of Science with Theology in Christendom, 2 vols. (New York: Appleton, 1896). The review essay by Ronald Numbers, "Science and Religion," in Sally Kohlstedt and Margaret Rossiter, Eds., Historical Writing on American Science, (Hopkins Univ. Press, Baltimore, 1985), pp. 59- 80 provides an excellent overview of this thorny topic. on the relationship between alternative medicine and religions, see Catherine Albanese, Nature Religion in America (Chicago: University Press of Chicago, 1991), and Robert Fuller, Alternative Medicine and American Religious Life (New York: Oxford University Press, 1988).
- Moore, In Search of White Crows (note 1) is the best source on American spiritualism. There is no adequate book length work on Christian Science; a useful essay is Rennie B. Schoepflin, "Christian Science Healing in America," in Norman Gevitz, Ed. Other Healers: Unorthodox Medicine in America (Hopkins Univ. Press, Baltimore, 1988), pp. 192-214.
- John C. Burnham, "American Medicine's Golden Age: What Happened to it?" Science 1982, 215:1474.
- James Harvey Young, The Medical Messiahs (note 1), Independent Practitioners Under Medicare: A Report to Congress (Dept. of Health, Education, and Welfare, Washington, o.c., 1968), Norman Gevitz, "The Chiropractors and the AMA: Reflections on the History of the Consultation Clause," Perspectives in Biology and Medicine 1989; 32:281-299.
- Michael Mulkay, Science and the Sociology of Knowledge (London: George Allen and Unwin, 1979); Sandra Harding, The Science Question in Feminism (Ithaca: Cornell University Press, 1986.
- John Knowles, Doing Better and Feeling Worse: Health in the United States (New York: Norton, 1977).
- Prior to the 1976, there was no separate listing for holistic medicine in the Index Medicus. Between 1976 and 1984, there are 540 citations listed under holistic health.
- see for example, J.C. Keating, D.J. Lawrence, R.A. Leach, T.F. Bergmann, T.L. Shrader, "Clinical Scholarship in Chiropractic: In Search of Commitment," ACA Journal of Chiropractic (March, 1990) p. 38.
- Douglas Barasch, "The Mainstreaming of Alternative Medicine," The New York Times Magazine (part 2), October 4, 1992, pgs. 6-9; Claudia Wallis, "Why New Age Medicine is Catching On," Time 1991, 138(18):68 -76; Robert Ornstein and Charles Swencionis (eds.), The Healing Brain: A Scientific Reader (New York: Guilford Press, 1990); Norman Cousins, Head First: The Biology of Hope (New York: E. P. Dutton, 1989).
- On the development of the randomized clinical trial, see Harry Marks, "Notes from the Underground: The Social Organization of Therapeutic Research," in Russell Maulitz and Diane Long (eds.), Grand Rounds: One Hundred Years of Internal Medicine (Philadelphia: Univ. of Pennsylvania press, 1988). On the new approaches to clinical research, see David Sackett, R. Brian Haynes, and Peter Tugwell, Clinical Epidemiology: A Basic Science for Clinical Medicine (Boston: Little, Brown and Co., 1985) and C. Mann, "Meta-analysis in the Breach," Science 1990, 249: 476-80. For specific studies, see J. Moertel, et. al., "A Clinical Trial of Amygdalin (Laetrile) in the Treatment of Human Cancer," New England Journal of Medicine 1982 306:201; J. Kleijnen, G. ter Riet, P. Knipschild, "Acupuncture and Asthma: A review of controlled trials," Thorax 1991 46:799; W. E. Dismukes, J. S. Wade, A randomized, double-blind trial of nystatin therapy for the candidiasis hypersensitivity syndrome," New England Journal of Medicine 1990, 323: 1717; P. Knipschild,"Looking for gall bladder disease in the patient's iris," British Medical Journal 1988, 297:1578; T. w. Meade, s. Dyer, W. Browne, J. Townsend, A. O. Frank, "Low back pain of mechanical origin: Randomized comparison of chiropractic and hospital outpatient treatment," British Medical Journal 300, J Kleijnen, P. Knipschild, and G. ter Riet, "Clinical trials of homeopathy" British Medical Journal.;1991 302(6772); P 316-23.
This article was posted on November 5, 2019.