Alan Berkenwald, MD

A court of criminal inquiry against the established religion first appeared in France in the 13th century and attained its full glory in 1484, under Queen Isabella of Spain, with the founding of the Supreme General Inquisition. Serving at the pleasure of the King, known himself as the Grand Inquisitor, his vassals were sent throughout Spain and it's colonies during the Age of Absolutism.

The Inquisitors were an instrument used to maintain absolute rule, to discover and suppress all unorthodox views. Once identified in secret accusation, the heretic was seized by the court's "familiars," and his property was confiscated. Proceeding with imprisonment, secret examination, and torture, these righteous officials brought forth confessions to all manner of criminally impure thoughts and actions. Culmination was often in the public execution, with death by conflagration at the Auto da Fe, on Sundays, the Lord's day of rest.

Today, we have the Quality Assurance Committees. Responding to the public's demand to seek redress for injuries, real or imagined, at the hands of physicians, the established forces of organized medicine have turned inward in an attempt to better police their members. Out of these good intentions came the QA departments, to be found now in every hospital, HMO, and clinic. Their mandate is to weigh accusations, often brought secretly; investigate, often done selectively; deliberate, often done behind closed doors; and sentence, often without chance of appeal. Who says history doesn't repeat itself repeat itself?

The scenario that follows happens every day to practicing physicians. A complaint is made; sometimes it's a letter from a patient, sometimes from a nurse or aid. Sometimes it's generated by a chart review. It is forwarded to the QA committee chairperson, usually an administrator or department head. It is then assigned to a committee member to investigate. Records are then pulled, and often an inquiry is made casually to the physician:

"Dear John, we got this complaint - well, not really a complaint, your understand, sort of a, umm, question - about something you did. It's nothing serious, really, but could you tell us what you remember about this case? No hurry, drop us a note. Sorry to bother you and all that. If you're too busy to get back to us today, don't worry, we'll take care of it..."

A few weeks go by, and nothing more is said. Everyone's all smiles, friendly nods in the hallway - "How’re the kids, John?" or "Lookin' sharp today, John!" then a form letter appears via interoffice mail:

"To: John, MD. The QA committee has reviewed the charges against you in the case of patient Sally Sorrow, MR#123-456-789, assaulted by you on 2/1/10. The committee has voted to change the initial Classification of Care from 3B (serious actual adverse patient outcome that was caused by errors in management), to 3A (serious actual patient outcome that was possibly preventable) under it's Automatic Benevolent Appeals Process. This Committee is organized as a Medical Peer Review Committee under the Medical Malpractice tort Reform Act of 1986. This law provides that the proceedings, reports, and records of a medical record peer review committee shall be confidential and shall not be subject to subpoena or discovery, or introduced into evidence, on any judicial or administrative proceedings, except proceedings held by the Board of Registration in Medicine. Have a nice day.”

In medicine, the last doctor is always the smartest. The QA committee is the academic version of the Monday morning quarterback. QA members make extensive use of the celebrated, mythical “restroscope,” with its spiritually perfected microscopic vision. And, on top of it all, they usually lack humility.

Before the Spanish Inquisition, The Romans asked, "Sed quis custodiet ipsos Custodes?" -- "But who is to guard the Guards themselves?"    

I remember the good old days of "M&M" rounds (Morbidity and Mortality). The accused were forced to present the case before a crowd of peers. Often the accused turned to drugs (usually Inderal - to keep the tremor out of hands and voice) before facing the mob. No cigarettes before a firing squad, but often a buffet lunch. Questions were asked, explanations were given. It was not for the faint of heart. But it was an open, and occasionally brawling, spectacle. It was often personal. Attendance was always high ("John's presenting at M&M today!" "Really - I always hated that arrogant SOB! What time does it start?")

It was open, live, and usually educational. I, personally, would rather have a root canal than face the M&M mob. But you learned from it. You remembered. It was out in the open, unlike the QA committee which is a blunt instrument used to sucker punch its victim. The M&M tradition was one of fine showmanship, where you could cut your own throat and never feel it, being distracted and honored at the same time.

Alan Berkenwald, MD, graduated from BU School of Medicine '78 and is board-certified in Internal Medicine. He is now working as a Hospitalist in a community hospital in Northampton, MA, the medical director of a local Skilled Nursing Facility, and practices addiction medicine part-time. He writes the blog “In the Name of Medicine

Articles

Responding to the public's demand to seek redress for injuries, real or imagined, at the hands of physicians, the established forces of organized medicine have turned inward in an attempt to better police their members. Out of these good intentions came the QA departments, to be found now in every hospital, HMO, and clinic. Their mandate is to weigh accusations, often brought secretly; investigate, often done selectively; deliberate, often done behind closed doors; and sentence, often without chance of appeal.

The Quality Assurance Committee - No One Expects the Spanish Inquisition

	When I was attending New York City’s public schools in the 1960s it was usual, every year, to run out of time before the curriculum ended. In American History, time after time, we never made it past the Spanish-American War. To this day, countless New Yorkers never heard of World War “I.” They assume World War “II” is a typo.

	In medical school, I do not recall any lect-ures on medical history. On the other hand, I don’t recall any lectures on Embryology, either. I was too grossed out by the pictures. Nonetheless, my medical colleagues have no clue about our profession’s past. I am reassured, thus, that I never slept through any such lectures.

	My colleagues assume our profession sprung fully developed from Asclepius, the Greek god of healing. But, he only left us that stick with the snake wrapped around it, and his daughter, Hygieia, the goddess of health. More important were his followers, the Asclepiads. They were a secret, hereditary society of priests, prophets and physicians who would study the ill in their temple, exciting and preparing them to receive healing. They functioned very much like our modern hospitals.

	It is true, that in earliest human society the role of the healer was both religious and magical. Primitive man believed that illness was caused by magic, sent by man or demon to harm him, or visited upon him by a deity for reasons clear or otherwise. This primitive ‘health care system’ functioned with little conflict between the different roles played by the physician-priest-prophet.

	Early Christianity developed a competing, ‘proprietary’ health care system to heal both physically and spiritually. Monks and monasteries preserved and applied the rudimentary surgical skills of the era. By the Middle Ages, in a major policy shift, the Church forbid further practice of medical and surgical techniques. It was deemed not acceptable for a priest to take a life, even while trying to save it, by the knife. (Was this a rudimentary attempt at tort reform?  Scholars and pundits disagree.)   It was thus left to the layman to practice and further develop needed medical skills.

With the Church pulling out of the market (and, with it, a major source of capital funding), medical practice in Europe developed slowly, albeit with a strong and defensive intellectual hierarchy and tradition. Things more or less stayed that way until Colonial America, where anyone could appropriate the title of doctor and practice medicine in any fashion. There field soon exploded. After all, people came to America to start anew. The land was wide open, as was the populace, to new ideas and practices. 

	Before 1800, most American physicians learned their craft under an apprenticeship with an older physician, as there were only three medical schools in this country. Illness was thought to be due to heredity and emotion (which any fool could clearly see). Physical exams were limited to the strength of the patient’s pulse, color of his skin, regularity of his breathing, and the color of his urine and stool.

	The drive for the standards and trappings of a profession, as opposed to an open trade, came from those doctors emigrating from Europe, or returning after studies there. In this country, schools of medicine were slow to start. Who needed the burden of ‘student loans’ when you could just hang a shingle and get to work? 

	Being of a proprietary nature and run on a for-profit basis, American medical schools had minimal entrance requirements. Most did not require a high school diploma and less than 20% of the medical students had some college education. As a degree was still not required to practice medicine, estimates are that only 20% to 70% of the practicing physicians in some parts of the country actually graduated from a medical school. (Think of the money saved on tuition.)

The medical curriculum of that time was presented in lecture classes with  minimum basic sciences, primarily chemistry, being taught. It was rare for a patient to be seen in the setting of these medical schools. Models and preserved anatomical specimens were used instead, no matter how dusty or distressed. Following four sessions of 16 weeks each, over a two-year period, graduates could choose to continue their education by means of apprenticeship, private tutelage, hospital and dispensary courses, as well as further study abroad. Or, they could immediately start practicing their skills upon the public, for better or for worse. 

	With such an open and eclectic approach to medicine, it was natural that various competing disciplines, the “sectarians,” developed. After all, the field was wide open. These were the halcyon days where there were no medical administrators, paper work, or protocols. All you needed to succeed was a quick wit and a sharp knife.

	Philosophically, at this time, thought was divided as to causality of illness. Either it came from within, as evidenced by those with “weak constitutions;” or from without, in environments containing “bad” air, water, or other subtle poisons. Methodologies thus developed that looked both inward, searching the body’s alignment of bones or organs, as well as outward, to the environment, for external influences. Anyone with a strong opinion, and a means to express it, could hypothesize a medical theory, formulate a methodology, and get rich.

	medical sects. There were the “regulars”—the presumed readers of the 

), and the “irregulars” — the Baroussaisians, Sangradoarians, Morrisonians, Bradethians, Beechitareians, Botanics, Regular Botanics,

matical, Emblematical, Electrical, Magnetical, 

Theoretical, Practical, Experimental, Dog

	Herbists, Florists, and “Quacks.” The listing of “Quacks” itself included chronothermalists, mesmerists, Indian doctors, clairvoyants, and spiritualists. 

	The first successful, national, organized, medical society in this country was the 

experiences, teachings, and texts of its founder, Samuel Thompson, a self-taught man who published his 

 in 1822. Thompson felt every man was qualified to practice medicine and saw the trappings of other practitioners as solely for power and mystification. His principles were simple; animal bodies were composed of the basic elements—earth, air, fire, and water; disease was caused by a cold and cured by heat; heat came from the sun and was captured by herbs and other plants; botanicals were thus curative. Non-vegetable remedies were mineral-based, of the earth, and thus “cold” and non-curative.

	It was very popular. It was mail order (a primitive form of e-mail). Rapid acceptance followed.

	Thomsonian medicine was the first organizational attempt at natural medicine, and its proponents strove to expose “quacks” as readily as other physicians. (From “Zell’s Popular Encyclopedia,” 1886; ‘Quack’ - a verb, noun;  “to cry like the common domestic duck; to boast; to talk noisily and ostentatiously; a boastful pretender to medical skill which he does not possess.”)

This organizational effort was due, in part, 

healing class—a popular democratic concept 

as well as the instructions, could be obtained 

to zealous belief in their methods—and in profit. In our profession’s noble history of suppressing competition, this was the opening shot, and fired first by alternative medicine!  The Thomsonian movement empowered the layman who could study those methods and practice with readily available ingredients. People could be freed from the domination of a professional 

in this Jacksonian era. The rights to practice, 

by anyone for $20. Over 100,000 rights were sold by 1840.

	Thompsonian medicine was the first of the successful patented medicines and it soon inspired its own competition. Other successful medical methodologies of the

Dr. Wooster Beach was a “conventionally” trained physician who, in 1827, thought an 

 man could do more to further the interesting ideas of Samuel Thompson.  He opened the first botanical, degree-granting medical school in 1830. (Of note, it was the first medical school, ever, to admit women and blacks.)  The school professed to select the best single remedy from all the sects and schools that existed, be it botanical or mineral in origin. However, in the era of mercury, arsenic and other mineral 

botanicals. They were the first to use chemists to produce concentrated extracts of botanicals.  And, in an astounding paradigmatic shift that brought them financial and popular success, they created botanical prep-

By 1906, there were 10 Eclectic medical schools in the US. After the Flexner report of 1910, exposing the appalling state of medical education in this country, they all closed. Their legacy, however remains both in Mary Poppin’s song, “Just a spoonful of sugar makes the medicine go down...” and in the evolution of laboratory-made drugs.

	Founded by Andrew Taylor Still in the mid 19th-century, Osteopaths believed that the body, in a state of normal musculoskeletal structural relationship and in a favorable environment with good nutrition, is able to make its own remedies and defend itself against disease and other assaulting toxins. They emphasized the importance of manipulative methods in correcting faulty structural relationships and in detecting abnormalities. However, they believed in the “rule of the artery,” in which it was the circulatory system, not the nervous system, that determined health.

	‘Dr’. Stills, son of a preacher man who never had any formal education, discovered the principles of Osteopathy when, at the age of 10, suffering from headaches and stomach aliments, he threw a rope over a tree limb and hung himself by his head on a makeshift swing. After surviving a deep sleep in this position, he awoke cured with new insights into medical pathology. He founded the first Osteopathic Medical School in 1892,  His graduates founded other, for-profit Osteopathic schools to compete with him. This competition encouraged each school to be “early adapters” and open to accepting new breakthroughs, embracing the Germ Theory, blood studies, surgery, and pharmacology, in their effort to attract students and their tuition.

Osteopaths, confronted by 20th century medical progress in laboratory science, embraced, in 1929, “supplementary thera-

	peutics,” to go along with manipulative techniques. Such acceptance made this the only sectarian practice to survive successfully, to this day, without scientific stigma. 

	In 1895 a janitor in Davenport, Iowa, sud-

	denly lost his hearing. A local healer, D.D. Palmer, evaluated him and found a misplaced vertebra in his back exam. With an effective snap of his hands the vertebra was pushed back into place, the janitor’s hearing was restored, and Chiropractic was born.

	Seen as competition to the Osteopaths (who called them “quacks”), they shunned drugs and surgical intervention. Chiropractic was based on the belief that illness is caused by abnormal functioning of the “nerve highway” as it runs through the spinal canal. Thus, by adjustments of the spinal column, all manner of cures can be obtained. 

	D.D. Palmer was not a financial success. He opened his first school, Palmer’s School of Magnetic Cure, in 1899. He had no more than five students a year enroll. His son, B.J. Palmer, bought the school in 1906 and under his guidance, it soon prospered. For $500 and a six-month study, a “Doctor of Chiropractic” degree was received. B.J. was famous for many things, but his marketing skills were revolutionary. He created his own publishing and advertising firm as part of this campaign. His motto: “Early to bed, early to rise, work like hell and advertise,” was promoted in his 1926 book, 

, a how to manual on promoting Chiropractic.

	Benjamin Lust, a German physician, founded the American School of Naturopathy in 1902, advancing a German-based belief system holding that disease came from violations of the natural laws of living—essentially a build up of toxins and waste matter in the body&mdash;that accumulates and causes organ malfunction and disease. It was a drugless form of healing that relied on physical forces such as massage, diet, colonic irrigation, and special “Detox Baths” focusing on the genitals. It has since evolved to focus more on diet and herbal supplements, and less on genitals and high colonics.

	Based on the interesting premise that the body cannot suffer two similar illnesses at the same time (ie, a body cannot have two fevers simultaneously), thus one illness can “drive” out the other. Hence, homeopathic followers thought “like cures like,” and used infinitesimally small doses of preparations that, in higher doses, could create similar symptoms in the patient. With spiritual overtones, the dilutional theory rested on a premise of a “vital force” being present in the medicinals. By 1906, there were 20 homeopathic schools in this country.

Eclectics had the greatest following among the competing sects. Both had established national societies and numerous schools. Historians explain their success as a measure of the popular revolt against the aggressive bloodletting, blistering, purging, and stomach pumping practiced by the “regulars.” 

Equally probable is that the public could not see any difference in outcome between the different approaches and picked practitioners based on availability and reputation. In addition, with an interesting political if not methodological postulate, Homeopaths stated that if someone was first treated by a physician of the “old school,” he would be rendered resistant to later homeopathic techniques. Its founder, Samuel Hahnemann, counseled that once a patient was treated by a “regular” physician his previously existing natural disorder would be irreversibly worsened by the regular’s meddling. Thus, subsequent homeopathic attempts would fail and should not even be attempted.

	Was the public actually following the intersectarian debate? Absolutely. The 19th-century interest in health was no less a subject for the lay press as it is today. Between 1830 and 1890, 85 health magazines were published for the general public in this country. 

	The Regulars politically fought to establish themselves against the activities of the different sects. Lay healers saw the Regulars’ early attempts to limit them as a move to create a professional class system similar to Europe’s and obtain unfair advantage. Physician requests for regulation and licensure (!) were made frequently, but the feelings of state legislators echoed the lay healers. They, too, feared the creation of a titled, undeserving, privileged class, and this outweighed any fears of unregulated practitioners. 

An idiosyncratic romp through the history of organized medicine

Know Your Enemy-A Brief History of Alternative Medicine 

In this, the final installment of my "Follow the Money" review of the competitive beginnings of Alternative Medicine, help for the Regulars comes from an unexpected taxonomic ally and firmly sets organized medicine on its current course.

The Homeopaths and Thomsonian-Eclectics had the greatest following among the competing sects. Both had established national societies and numerous schools. Historians explain their success as a measure of the popular revolt against the aggressive bloodletting, blistering, purging, and stomach pumping practiced by the “Regulars.”

Equally probable is that the public could not see any difference in outcome between the different approaches and picked practitioners based on availability and reputation. In addition, with an interesting political if not methodological postulate, Homeopaths stated that if someone was first treated by a physician of the “old school,” he would be rendered resistant to later homeopathic techniques. Its founder, Samuel Hahnemann, counseled that once a patient was treated by a "regular" physician his previously existing natural disorder would be irreversibly worsened by the regular's meddling. Thus, subsequent homeopathic attempts would fail and should not even be attempted.

Was the public actually following the intersectarian debate? Absolutely. The 19th-century interest in health was no less a subject for the lay press than it is today. Between 1830 and 1890, 85 health magazines were published for the general public in this country.

The Regulars politically fought to establish themselves against the activities of the different sects. Lay healers saw the Regulars’ early attempts to limit them as a move to create a professional class system similar to Europe's and obtain unfair advantage. Physician requests for regulation and licensure (!) were made frequently, but the feelings of state legislators echoed the lay healers. They, too, feared the creation of a titled, undeserving, privileged class, and this outweighed any fears of unregulated practitioners.

This medical free-for-all brought fierce competition between individual practitioners of all types as they strove to develop successful practices among the wealthy and the middle-class. Fees charged were dependent on the class served and might vary by fivefold for the same service. Success in the "carriage trade" (those patients who arrived by carriage and had separate waiting rooms from those who arrived on foot) meant professional stature and economic security. Goals of early medical societies were not directed so much at improving professional ethics but toward standardization of fees and success over competition.

The birth of the American Medical Association (AMA) in 1847 was a direct result of the Regular physicians' efforts to gain control of their runaway profession, as well as to meet the challenge of the Homeopaths, who were also organizing themselves at this time (the American Institute of Homeopathy was founded in 1844). At a physician convention of 1846, a Committee on Ethics was charged to investigate why Regular physicians were not held in similar high esteem as clergy and lawyers (again, "!"), and why they were held to be the same as the other "ignorant pretenders" who employed "crooked devices and low arts."

The primary target of the new AMA was the Homeopaths. Growing rapidly from its core of German immigrants who provided the initial providers and patients, by the end of the 19th-century the Homeopaths were, on average, better off than the Regulars. They had higher incomes as their patients were generally of higher social standing and better able to pay their fees. Public acceptance of Homeopathy was widespread by this time and often led by the clergy who were attracted to the "spiritualized essence" of their drugs and "repelled by the poisoning and surgical butchery of regular practice."  

In perhaps a petulant response to the homeopathic warnings to avoid patients already treated by the Regulars, the AMA strictly forbid any consultation or contact with Homeopaths and others. The bitterness that this financial competition generated reached its lowest point with the regulars’ practice of internecine censure -- expulsion from local medical societies for even consulting with sectarians. Paul Starr points out a particularly ludicrous example in his history of American medicine:

"In 1878 a physician in Norwalk, Connecticut, Dr. Moses Pardee, was expelled from his local medical society under suspicion of having consulted with a homeopath -- his wife, Dr. Emily Pardee.”

State legislators were drawn into the controversy. In Michigan they voted to provide funds for two Homeopaths to join the medical faculty at the University of Michigan, in 1876. In response, the state medical society threatened to sever its connection to any member who ever graduated from that school. In New York State, Homeopaths had enough political power in 1882 to force the state medical society to rewrite its ethical code and reverse the ban on consultations between the two groups. This led to a schism of the New York medical society itself, producing two competing states societies. One had ties to the AMA and the other to the newly formed American Association of Physicians.

The triumph of the Regulars came about with their quick acceptance of the revolutionary "Germ Theory.” Applied to the causality of disease, it was embraced by the leading European physicians, in this country, in the late 19th-century. This reversed the commonly held views of illness as a singular disturbance, with divine overtones, of the patient and his environment. Instead, it became one of a focused, foreign, disturbance in specific organs. We now understood what caused "bad" air, water, and food.

The Sectarians, however, maintained their belief of illness from within, the internal causality of illness. This, in the end, led to their decline as they openly disagreed with what was being discovered without. It was the 1885 demonstration of a vaccine cure for rabies by Pasteur, followed by the work of Koch demonstrating tuberculosis’ causative bacillus, and Lister demonstrating disease vectors being bacterial, that turned the tide for the Regulars. Homeopaths and other sectarians considered germs as merely foreign bodies to be removed, if necessary, like wooden splinters. Vaccines were considered a “dilution” and a vindication of their principles of “similia similibus curantur” (“like cures like”).

The Chiropractics, led by D.D. Davenport in Iowa, responded to the Germ Theory by stating "... why bother so much about the germs that do not affect 99% of the people when it is admitted that there is a condition existing in the other 1% that makes them predisposed to disease and easily affected. Why not find out and correct the cause of this condition or predisposition and so allow nature to use her natural protection against these baleful external influences.”

The long struggle by the Regulars against the Sectarians was ultimately won with the help of microbes, their newly recognized allies in the competitive world of medicine. Our brotherly microbes successfully frightened patients into the Regulars' offices, generations before antibiotics were ever discovered. To this day, they still manage to divert the inward reflections of the Sectarians. Remember when everyone thought stress "caused" ulcers?  Now we have 

In the current, fearful battle against cancer (the latest "evil eye", once again, sent by man, god or demon), the Sectarians still look to diet ("natural foods"), pollutants ("bad" air and water), and "weak constitutions" (stress, life style, and fiber). The Regulars are looking at gene regulation and immunology. They boldly go where Sectarians cannot travel - as they have no bench science back up.

Yet, despite the ascendancy of laboratory science in the service of mankind’s health, many still chose to look inward, seeking solutions and finding legitimacy in existential, mysterious answers to illness and its causality. And, as long as people believe in "magic" -- mysterious medical cures -- Alternative Medicine will always have a place in healthcare.

But we Regulars still have the largest market share and make the big bucks.

In the final installment of this series of blog posts, "the Regulars" receive help from an unexpected taxonomic ally.

A Brief History of Alternative Medicine by Deep Throat, Part III

Philosophically, at this time, thought was divided as to causality of illness. Either it came from within, as evidenced by those with "weak constitutions"; or from without, in environments containing "bad" air, water, or other subtle poisons. Methodologies thus developed that looked both inward, searching the body’s alignment of bones or organs, as well as outward, to the environment, for external influences. Anyone with a strong opinion, and a means to express it, could hypothesize a medical theory, formulate a methodology, and get rich.

 listed the then current and competing medical sects. There were the "regulars"—the presumed readers of the Journal (precursor to 

), and the "irregulars"—the Baroussaisians, Sangradoarians, Morrisonians, Bradethians, Beechitareians, Botanics, Regular Botanics, Thomsonians, Reformed Thomsonians, Theoretical, Practical, Experimental, Dogmatical, Emblematical, Electrical, Magnetical, Diplomatical Homeopathians, Rootists, Herbists, Florists, and “Quacks”. The listing of "Quacks” itself included chronothermalists, mesmerists, Indian doctors, clairvoyants, and spiritualists.

The first successful, national, organized, medical society in this country was the Thomsonians, based on the personal experiences, teachings and texts of its founder, Samuel Thompson, a self-taught man who published his “New Guide to Health” in 1822. Thompson felt every man was qualified to practice medicine and saw the trappings of other practitioners as solely for power and mystification. His principles were simple; animal bodies were composed of the basic elements—earth, air, fire and water; disease was caused by a cold and cured by heat; heat came from the sun and was captured by herbs and other plants; and botanicals were thus curative. Non-vegetable remedies were mineral based, of the earth, and thus "cold" and non-curative.

		It was mail-order (a primitive form of email).

Thomsonian medicine was the first organizational attempt at natural medicine, and its proponents strove to expose "quacks" as readily as other physicians. (From “Zell's Popular Encyclopedia", 1886: ‘quack’ — a verb, noun; "to cry like the common domestic duck; to boast; to talk noisily and ostentatiously; a boastful pretender to medical skill which he does not possess.")

This organizational effort was due, in part, to zealous belief in their methods—and in profit. In our profession's noble history of suppressing economic competition, this was the opening shot, and fired first by organized alternative medicine! The Thomsonian movement empowered the layman who could study those methods and practice with readily available ingredients. People could be freed from the domination of a professional healing class&mdash;a popular democratic concept in this Jacksonian era. The rights to practice, as well as the instructions, could be obtained by anyone for $20. Over 100,000 rights were sold by 1840.

Thompsonian medicine was the first of the successful patented medicines and it soon inspired its own competition. Other successful medical methodologies of the era included the following:

Dr. Wooster Beach was a 'conventionally' trained physician who, in 1827, thought an 

 man could do more to further the interesting ideas of Samuel Thompson. He opened the first botanical, degree granting medical school in 1830. (Of note, it was the first medical school, ever, to admit women and blacks.) They professed to select the best single remedy from all the sects and schools that existed, be it botanical or mineral in origin. However, in the era of mercury, arsenic and other mineral poisons that conventional doctors were using, they advanced knowledge of botanicals. They were the first to use chemists to produce concentrated extracts of botanicals. And, in an astounding paradigmatic shift that brought them financial and popular success, they created botanical preparations that tasted 

, a first in a world where all 'effective' remedies were supposed to taste nasty and bitter.

By 1906, there were 10 Eclectic medical schools in the US. After the Flexner report of 1910, exposing the appalling state of medical education in this country, they all closed. Their legacy, however, remains both in Mary Poppins song, "Just a spoonful of sugar makes the medicine go down," and in the evolution of laboratory-made drugs.

Founded by Andrew Taylor Still in the mid 19th-century, Osteopaths believed that the body, in a state of normal musculoskeletal structural relationship and in a favorable environment with good nutrition, is able to make its own remedies and defend itself against disease and other assaulting toxins. It emphasized the importance of manipulative methods in correcting faulty structural relationships and in detecting abnormalities. However, it believed in the "rule of the artery" where it was the circulatory system—not the nervous system&mdash;that determined health.

'Dr'. Stills, son of a preacher man who never had any formal education, discovered the principles of Osteopathy when, at the age of 10, suffering from headaches and stomach ailments, he threw a rope over a tree limb and hung himself by his head on a makeshift swing. After surviving a deep sleep in this position, he awoke cured with new insights into medical pathology. He founded the first Osteopathic Medical School in 1892; his graduates founded other, for profit, Osteopathic schools to compete with him. This competition encouraged each school to be 'early adapters' and open to accepting new breakthroughs, embracing the Germ Theory, blood studies, surgery, and pharmacology, in their effort to attract students and their tuition.

Osteopaths, confronted by 20th century medical progress in laboratory science, embraced, in 1929, "supplementary therapeutics", to go along with manipulative techniques. Such acceptance made this the only sectarian practice to survive successfully, to this day, without scientific stigma.

In 1895, a janitor in Davenport, IA, suddenly lost his hearing. A local healer, D.D. Palmer, evaluated him and found a misplaced vertebra in his back exam. With an effective snap of his hands the vertebra was pushed back into place, the janitor's hearing was restored, and Chiropracty was born.

Seen as competition to the Osteopaths (who called them "quacks"), they shunned drugs and surgical intervention. Chiropracty was based on the belief that illness is caused by abnormal functioning of the "nerve highway" as it runs through the spinal canal. Thus, by adjustments of the spinal column, all manner of cures can be obtained.

D.D. Palmer was not a financial success. He opened his first school, Palmer's School of Magnetic Cure, in 1899, and had no more than five students a year enrolled. His son, B.J. Palmer, bought the school in 1906, and under his guidance, it quickly prospered. For $500 and a six-month study, a "Doctor of Chiropractic" degree was received. B.J. was famous for many things, but his marketing skills were revolutionary. He created his own publishing and advertising firm as part of this campaign. His motto: "Early to bed, early to rise, work like hell and advertise", was promoted in his 1926 book, "Selling Yourself", a 'how to' manual on promoting Chiropracty.

Benjamin Lust, a German physician, founded the American School of Naturopathy in 1902, advancing a German based belief system holding that disease came from violations of the natural laws of living—essentially a build-up of toxins and waste matter in the body&mdash;that accumulates and causes organ malfunction and disease. It was a drugless form of healing that relied on physical forces such as massage, diet, colonic irrigation, and special "Detox Baths" focusing on the genitals. It has since evolved to focus more on diet and herbal supplements, and less on genitals and high colonics.

Based on the interesting premise that the body cannot suffer two similar illnesses at the same time (i.e. a body cannot have two fevers simultaneously), thus one illness can "drive" out the other. Hence, homeopathic followers thought "like cures like", and used infinitesimally small doses of preparations that, in higher doses, could create similar symptoms in the patient. With spiritual overtones, the dilutional theory rested on a premise of a "vital force" being present in the medicinals. By 1906, there were 20 homeopathic schools in this country.

These were the major players present on the contested medical playing field, vying for patients and the health care dollar, at the turn of the 20th century. Recall that no certification to practice medicine was necessary and attendance to medical school—any medical school&mdash;was voluntary and not required. What happened next ultimately shaped the modern medical world as we know it. It came about with the appearance of a remarkable ally that crossed taxonomic phylum to assist Regular medicine in its efforts to dominate its competition. Part III, "Success At Last", will reveal Regular medicine's ploy to achieve economic and popular success.

The second in a series on alternative medicine, this installment looks at the first organized attempt at natural medicine -- and its many spin-offs.

Alan Berkenwald, MD

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