An idiosyncratic romp through the history of organized medicine
Why Study History?
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.
Clearly, there is more to it than that.
Doctors are Gods
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?
Going to Medical School
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.
“Alternative Medicine” is Identified
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.
Boston Medical and Surgical
In 1836, the
listed the then-current and competing
New England Journal of Medicine
medical sects. There were the “regulars”—the presumed readers of the (precursor to ), and the “irregulars” — the Baroussaisians, Sangradoarians, Morrisonians, Bradethians, Beechitareians, Botanics, Regular Botanics,
Thomsonians, Reformed Thomsonians,
matical, Emblematical, Electrical, Magnetical,
Theoretical, Practical, Experimental, Dog
Diplomatical Homeopathians, Rootists,
Herbists, Florists, and “Quacks.” The listing of “Quacks” itself included chronothermalists, mesmerists, Indian doctors, clairvoyants, and spiritualists.
Meet the Competition
Thomsonians. Based on the personal
New Guide to Health
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.
The Wild, Wild West
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
poisons that conventional
doctors were using, Beach’s school
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 prep-
arations 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 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—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.
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 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.
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 varied widely 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 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 the similar high esteem given clergy and lawyers (!!!) and why they were held to be the same as the other “ignorant
and low arts.”
pretenders” who employed “crooked devices
The primary target of the new AMA was the Homeopaths. Growing rapidly from its core of German immigrants that provided the initial practitioners 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 Homeopaths’ 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 com-
petition 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.
Success at Last
The triumph of the Regulars came about with the general acceptance of the 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 earlier view 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.
similia similibus curantur
None-the-less, the sectarians continued in their belief of illness from within, the internal causality of illness. This, ultimately, led to their decline as they ignored 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 splinters. Vaccines were considered a “dilution” and a vindication of their principles of (“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.”
Our Brothers, Our Microbes
The long struggle by the Regulars against the
Sectarians was ultimately won with the help
of microbes, our newly recognized allies in the competitive world of medicine. Our brotherly microbes successfully frightened patients into our 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 . Thank you, external causality.
In the fearful battle against the latest “evil eye,” cancer (once again, sent by man, god or demon), the sectarians look still to diet (“natural foods”), pollutants (“bad” air and water), and “weak constitutions” (stress, lifestyle, and fiber). The Regulars are looking at gene regulation and immunology, boldly going where Sectarians cannot travel (without 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 legitimacy for an existential, mysterious answer to illness and its causality. And, as long as people believe in magic—mysterious medical cures—alternative medicine will have a niche.
But we still have the largest market share and make the big bucks.
Alan Berkenwald, MD, graduated from BU School of Medicine in 1978 and is board-certified in Internal Medicine. He is now working as a hospitalist in a community hospital in Northampton, MA. He is also the medical director of a local skilled nursing facility, and practices addiction medicine part-time.