10. A Return to Tradition: The Rediscovery of Alternative Medicine
Case 1: A bad day for Western medicine
The year was 1937, and pneumonia season was in full swing. The sick ward at Boston City Hospital—a large, open room with 30 beds neatly arranged around its perimeter—was filling rapidly with patients suffering from its telltale symptoms: chills, fever, bloody cough, and pain in one side of the chest. Yet one patient, a young black musician, stubbornly refused to cooperate. Admitted a few days earlier with chills and fever, he had no cough. And now, as a young intern fresh out of Harvard Medical School made his way through the ward and stopped at the man’s bedside, the patient was unable to produce the sputum sample needed to diagnose pneumonia. The intern, Lewis Thomas, was in just the first month of his service and didn’t think much of it at the time. Drawing the requisite blood sample, he moved on. It was not until later that morning in the upstairs laboratory that Thomas peered through a microscope at the blood sample and made his astonishing discovery.
Thomas immediately notified the hospital’s hematologists, who rushed up to the laboratory to take a look, then charged back down to the ward to collect their own samples. Soon, word spread like wildfire through the hospital, as staff doctors, visiting physicians, and students all raced to the ward and then hurried upstairs to view the evidence with their own eyes. The patient did not have pneumonia, but malaria, a deadly parasitic disease transmitted to humans by infected mosquitoes. Once inside a human, the parasites can invade red blood cells, reproduce, and cause them to rupture. This is what Thomas saw on the microscope slide, and who wouldn’t be transfixed by the sight? Red blood cells literally bursting open, with tiny parasites swarming out and seeking other cells to infect. The hospital-wide sensation was only heightened by an additional mystery: Malaria normally occurs in the tropics and sub-tropics; how could a person in the northern climes of Boston—with no recent travel outside the country—be infected?
Although the mystery was soon solved—the patient was a heroin addict and probably contracted the disease from a used syringe contaminated by someone from out of town—the fascination continued. It continued as doctors visited the ward all afternoon, continued as they drew more blood to look at more slides, continued into the evening as the patient grew weaker, comatose—and suddenly died. In fact, the doctors were so fascinated with the disease, they forgot to treat the patient. As Thomas sadly recalled years later in his book, The Youngest Science, if instead of “animated attention” the patient had been immediately treated with quinine—a malarial drug whose curative powers had been known since the seventeenth century—then “he would perhaps have lived. The opportunity to cure an illness, even save a life, came infrequently enough on the City Hospital wards. This one had come and gone.... It was a bad day for Harvard.”
Case 2: A bad day for Eastern medicine
The year is 2008, and the terror begins just minutes after Yonten sits down to meditate. For Yonten, a 45-year-old Tibetan monk, what haunts him most is not the memory of angry shouting, nor the Chinese authorities torturing his fellow monks with electric shocks, nor even the prison beating he underwent just before his recent escape from Tibet. Rather, it is the image of his monastery going up in flames that burns most vividly in his mind. And despite the decades he has spent mastering Buddhist meditation, none of Yonten’s skills—deep breathing, energy channeling, focused mindfulness—can remove the image of the burning temple that shatters his attempts to meditate. In fact, the harder he tries, the greater his frustration, and instead of inner peace, he is rewarded with feelings of sadness, guilt, and hopelessness.
Although now living safely in the United States, Yonten and many other refugee Tibetan monks continue to be haunted by memories of torture and abuse that disrupt their ability to meditate and practice their religion. The good news is that Tibetan traditional healers have diagnosed their condition as srog-rLung, or “life-wind” imbalance. The idea that balance is essential to health—and that imbalance leads to disease—is hardly unique to Tibetan medicine. Many ancient healing traditions dating back thousands of years teach that the human body is inseparable from the outer world and interconnected by invisible forces. According to these traditions, the secret to good health is maintaining a balance among these inner and outer forces. The bad news for Yonten and his fellow monks is that among the many traditional treatments used to help restore balance, the one they’re using is not working. In fact, it’s failing miserably.
Meditation is an Eastern healing tradition that dates back thousands of years, crosses many cultural boundaries, and today is one of the top three forms of alternative medicine in the United States. For Buddhist Tibetan monks, meditation is the ultimate treatment, a method of attaining Enlightenment, which they view as the cure for all suffering. Yet for Yonten and other refugee monks traumatized by their experiences in Tibet, the meditation skills they have spent a lifetime mastering are not merely failing, but causing numerous symptoms, from guilt and depression to elevated blood pressure and heart palpitations. The problem is the treatment itself: The form of meditation they’re practicing is so “single-minded,” it violates their own principles of balance.
Lessons from the past: East meets West (again)
Two stories of treatment failure from opposite ends of the cultural spectrum: In a world of Western scientific medicine, a young musician dies of malaria when hospital physicians become so fascinated by a disease, they forget to treat the patient. In a world of traditional Eastern medicine, Tibetan monks are so haunted by memories of torture and abuse that the meditation skills they have mastered to prevent suffering are now causing it.
These two stories symbolize how medicine, regardless of its cultural origin, can become a victim of its own methods, even its own success. But more than that, they are a starting point for a much larger story of how two medical traditions, born thousands of years ago from common roots, became divided for centuries, fought an ugly battle over differences in philosophy, and then finally rejoined forces at the brink of the twenty-first century to become one of the top ten breakthroughs in medicine.
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The accidental death of a young black musician from malaria in 1937 may seem an isolated event, but it represented an ominous trend that was beginning to emerge in twentieth-century medicine. Thanks to a growing list of breakthroughs—vaccines, germ theory, anesthesia, X-rays, and many more—scientific medicine was establishing itself as the dominant medical system of the Western world. But with those breakthroughs came a hidden malaise: Enamored by new technologies and an explosion of information, medicine was becoming distracted, forgetting that its primary focus was not disease, but the patient; that while it was not always possible to cure, it was always essential to care.
What caused this shift in priorities? The rise of modern medicine in the twentieth century may seem inevitable, but it did not have to be this way. Barely 100 years earlier, scientific medicine—also sometimes called conventional medicine or biomedicine—was just another alternative medicine, one of many approaches to healthcare up for grabs at the time. In fact, up until the late 1800s, “scientific” medicine was often a barbaric and risky business, with its crude surgery, blood-letting, and use of toxic drugs like mercury as laxatives and emetics. At the time, many other healing systems were competing with scientific medicine for legitimacy if not dominance, including hydrotherapy (use of hot and cold water to prevent and treat disease), Thomsonianism (mix of Native American herbal therapy and medical botanical lore), and magnetic therapy (use of healing touch to transfer “magnetic” or “vital” energy into a patient). For decades, each viewed the other with mistrust and disdain, exchanging cross-charges of quackery and malpractice. It was not until Western scientific medicine began to exert its dominance in the late 1800s that other healthcare models gradually fell from popularity and became, by default, “alternative.”
It’s no mystery why scientific medicine won the initial battle. With its emphasis on experimentation, observation, and reason—the so-called “scientific method” that blossomed in the eighteenth and nineteenth centuries—scientific medicine had found a potent way to explore and explain the world. But perhaps most significant, it led scientists down a rabbit hole of reductionism, of increasingly dividing the body into smaller and smaller parts. With powerful new tools such as microscopes, X-rays, and various laboratory techniques, scientists began delving deeper and deeper into the mysteries of tissues, organs, cells, and beyond, revealing stunning secrets of physiology and disease, each discovery seeming to lead to new treatments.
But as the pace of discoveries accelerated into the twentieth century, the balance of medicine began to shift: Technology and specialization changed the way doctors looked at patients, turning them into a collection of parts and diseases instead of the unique “whole” individuals who had walked into their office seeking healthcare. By the 1980s, the use of managed care to control the burgeoning costs of technology left even less time for physicians and their patients, and further degraded patients by turning them into disease categories. By the final decades of the twentieth century, scientific medicine—despite remarkable successes ranging from organ transplants to heart surgery and cancer treatment—had lost its balance, unleashing a backlash of frustration so strong that more and more patients were demanding an alternative.
As it turned out, the alternative had never gone away.
Despite the dominance of scientific medicine in the twentieth century, many alternative therapies born in the previous century—including chiropractic, osteopathic, and homeopathic medicine—continued to survive and evolve. As many patients turned to these options in the 1970s and 1980s, others looked to ancient alternatives, including traditional Chinese medicine and Indian Ayurvedic medicine, which not only offered entire medical systems, but specific treatments such as meditation, massage, and acupuncture. In the end, the bottom line was simple. Alternative medicine offered something Western medicine had too often abandoned: the view that every patient was an individual; that natural treatments were sometimes better than dramatic surgery and dangerous drugs; and that the essence of medicine begins with a caring relationship between healer and patient.
The reaction by modern medicine to this trend was predictable: the same denial and derision with which it had regarded alternative medicine for the previous 150 years. But in the late 1990s, the milestone moment finally arrived in a form that scientific medicine could not afford to ignore: Two of its most prestigious medical journals—the New England Journal of Medicine and the Journal of the American Medical Association—reported that not only had alternative medicine use been increasing “dramatically,” but that by 1998, Americans were actually seeking alternative care practitioners more often than their own primary care physicians.
The wake-up call had been sounded, and one of the top ten breakthroughs in medicine had arrived: the rediscovery of alternative medicine. But the full story of this breakthrough reached much further back in time than the past few decades or even centuries. In fact, its roots can be traced back through almost every stage of medical history—from the rise of traditional medicine at the dawn of civilization, to a revolutionary change during the Renaissance; from the birth of “alternative” medicine in the 1800s, to the twentieth century battles that led to the rediscovery of alternative medicine—and something more.
Milestone #1 The birth of traditional medicine: when caring was curing
They emerged from the misty origins of civilization thousands of years ago and at first glance seemed to have almost nothing in common. Yet despite vast differences in geography, culture, and language, three of the first major systems of ancient medicine—traditional Chinese medicine, Indian Ayurvedic medicine, and Greek Hippocratic medicine—shared some remarkable similarities. It’s not just that they all arose out of legend and magical/religious practices several thousand years ago and developed into their classical forms around 600 to 300 BC. Rather, it is that all three discovered some of the most important principles medicine would ever know—and one day, forget.
Traditional Chinese medicine
Born about 5,000 years ago in ancient China, Huang-Di must have been a very busy man during his reputed 100 years of life: In addition to founding the Chinese civilization, he is said to have: taught the Chinese how to build houses, boats, and carts; invented the bow and arrow, chopsticks, ceramics, writing, and money; and still somehow found time to father no less than 25 children. But Huang-Di, also known as the Yellow Emperor, is also famous for one other major milestone in Chinese history: discovering the principles of traditional Chinese medicine. Although his text, Huang Di Nei Jing (Inner Canon of the Yellow Emperor), was probably not compiled until thousands of years after his death (around 300 BC), today it remains a classic in traditional Chinese medicine, from its early descriptions of acupuncture to its ancient theories of physiology, pathology, diagnosis, and treatment.
But perhaps even more important, the Inner Canon introduced to traditional Chinese medicine (TCM) the philosophy of Taoism, with its two major teachings: First, that the human body is a microcosm of the universe and, thus, interconnected with nature and its forces; and second, that health and disease are determined by the balance of forces within the body and its connection to the outer world. The Inner Canon also describes many other key concepts in TCM, such as the theories of yin-yang (the world is shaped by two opposing yet complementary forces); qi (a vital energy or life force that circulates through the body in a system of pathways called meridians); the five elements (the relation of fire, earth, metal, water, and wood to specific organs in the body and their functions); and the “eight principles” used to analyze symptoms and categorize disease (cold/heat, interior/exterior, excess/deficiency, and yin/yang).
Yet despite the many forms of treatment provided by TCM—including herbs, acupuncture, massage, and movement therapies such as tai chi and qi gong—two underlying principles stand out:
- Treatment is designed to help patients restore the balance of their qi, or vital energy.
- Treatment is individualized based on the healer’s careful evaluation of the patient, using such traditional methods as detailed observation, questioning, hearing/smelling, and touching/palpating.
Indian Ayurvedic medicine
Ayurvedic medicine can also be traced back to busy times around 5,000 years ago when, according to one legend, a group of sages gathered in the Himalayas to stop an ongoing epidemic of disease and death. In this lofty setting, the god Brahma taught the art of healing to Daksha, who taught it to Indra, who taught it to Bharadvaja, who taught it to Atreya, who taught it to six disciples, who—finally—compiled the knowledge into the Ayurveda. No word on what happened in the meantime with the epidemic. Legends aside, modern scholars generally trace Ayurvedic medicine back to at least 1,000 BC, when an early form known as Atharavaveda was dominated by magical/religious practices. However, similar to TCM, around 500 to 300 BC, a new classical form arose that combined past knowledge with new ideas. It was called Ayurveda, or “science of life,” from the Sanskrit words ayur (life) and veda (science).
Despite some obvious differences, Ayurvedic medicine is remarkably similar to traditional Chinese medicine in its basic philosophy, including the view that all living and nonliving things in the universe are interconnected and that disease arises when a person is out of balance with the universe. At the same time, Ayurvedic medicine has its own unique terminology and ideas, including the idea that each person has a unique prakriti, or constitution, which in turn, is influenced by three doshas (life energies). While the system is complex, one underlying message, similar to TCM, is that disease can arise if there is an imbalance in a particular dosha. Ayurvedic medicine also shares the same patient-focused approach seen with other traditional medicines, including a detailed and sophisticated system for examining patients. Once the nature of the illness is determined, treatment is based on a variety of individualized therapies, such as herbs, massage, breathing exercises, meditation, and dietary changes. And while some treatment goals are unique to Ayurvedic medicine, the ultimate goal is unmistakably familiar: to restore health by improving balance in the patient’s body, mind, and spirit.
Greek Hippocratic medicine
When we last visited with Hippocrates for any length of time, he had just achieved one of the top ten breakthroughs in the history of medicine: the discovery of medicine itself (Chapter 1). Indeed, even as classical traditional medicine was evolving in China and India, the milestone achievements by Hippocrates and his followers were defining the profession of medicine itself. Yet Hippocratic medicine was also a traditional medicine, with many similarities to early Chinese and Indian medicine. For example, the roots of Hippocratic medicine can also be traced to 1,000 BC or earlier, when medicine was practiced in the Asklepieion healing temple on the island of Kos (see Chapter 1).
But by the time ancient Greek medicine developed into its classical form in the fifth century, Hippocrates was teaching many concepts similar to the classical Chinese and Ayurvedic medicine emerging at the time, including the view that health was influenced by interactions among the body, mind, and environment. Of course, Hippocratic medicine had its own unique system, including the belief that the body produced four circulating fluids, or humors—blood, phlegm, yellow bile, and black bile. Nevertheless, similar to the other traditions, Hippocrates taught that disease arose from some imbalance—either among the patients’ humors or in their relation to the outer world—and that the goal of treatment was to restore a healthy balance. Hippocratic medicine also shared a similar approach to treatment seen in other ancient traditions, including the use of remedies such as dietary restrictions, exercise, and herbs. In addition, Hippocrates strongly emphasized the physician-patient relationship, teaching that the best way to diagnose and predict the course of disease was through lengthy interviews, careful observation, and detailed examinations. This emphasis was documented in excruciating detail in the text Epidemics 1, which teaches that physicians should not only study “the common nature of all things” but also the patient’s “customs, way of life, age, talk, manner, silence, thoughts, sleeping, dreams, plucking/scratching/tearing, stools, urine, sputa, vomit, sweat, chill, coughs, sneezes, hiccups, flatulence, hemorrhoids, and bleeding.”
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Despite some obvious differences, the earliest medical traditions uncovered the same secrets of health and disease, from the interconnectedness of the body, mind, spirit, and universe to the importance of balance and natural treatments. What’s more, all emphasized the patient-healer relationship and patient care. With such principles, it’s no surprise that traditional Chinese medicine and Ayurvedic medicine would thrive for the next 2,500 years. But though Hippocratic medicine would remain influential for more than a millennium, beginning around the sixteenth century, a revolutionary change would send it down a different path and an entirely new way of looking at the world.
Milestone #2 Enlightenment: 1,200 years of tradition overturned and a new course for medicine
It is perhaps the greatest irony in the history of medicine: A Greek physician whose brilliance was second only to Hippocrates and whose discoveries and writings were influential for more than 1,000 years is more often remembered today for his biggest mistakes. Yet when two individuals discovered during the Renaissance that Galen had made a number of critical errors, they not only overturned a long tradition of misinformation—they also gave birth to a new world of modern scientific medicine.
Born in Pergamum (now modern-day Turkey) in 129 AD, Galen’s skills as a physician were so admired that he was made physician to the son of the famous Roman emperor Marcus Aurelius. However, it was his numerous discoveries in anatomy and physiology, along with tracts on medicine and ethics, which earned him fame and influence for more than a millennium. With a passion for truth that bordered on arrogance—he once wrote, “My father taught me to despise the opinion and esteem of others and to seek only the truth”—Galen investigated every branch of medicine possible at the time and became famous for his skills as a physician, his animal dissections, and lectures. Among his many great discoveries was the finding that arteries carry blood rather than air and that muscles are controlled by nerves coming from the brain. Unfortunately, Galen also held many false beliefs, particularly his view that the liver—and not the heart—was the central organ of the circulatory system. And so, just as Galen’s brilliant insights were passed on for 1,200 years, so were many of his misconceptions.
It was not until the Renaissance that people began to question ancient writings long-assumed to be true. During this time, many great thinkers were beginning to change how the world was viewed, such as Nicolaus Copernicus’ theory in the 1500s that the earth revolved around the sun, rather than vice versa. However, the greatest transformation in medicine began with the work of two physicians—Andreas Vesalius and William Harvey—whose groundbreaking study of the human body overturned tradition and set medicine on a revolutionary new course.
Andreas Vesalius was a Belgian physician and anatomist who was born in 1514 and who, as a child, not only enjoyed dissecting small animals, but also the bodies of executed criminals left out in the open on some land near his family home. It was just the kind of hands-on experience he needed to realize, by the time he had finished his medical training and had been appointed professor of surgery and anatomy in Padua, Italy, that what he had been taught as a student did not match what he’d personally seen in his own dissections. And so after his medical training, Vesalius continued dissecting cadavers and was soon admired not only for his careful and detailed dissections, but his lectures and demonstrations. Although Vesalius initially performed his dissections in an attempt to account for the differences with the writings of Galen, he eventually began to lose faith: He uncovered more than 200 errors in Galen’s work, including Galen’s belief that the human jawbone has two sections (it only has one) and that there is a coil of blood vessels at the base of the human brain (there isn’t). While many of the mistakes were understandable—Galen had dissected animals, while Vesalius worked on human cadavers—it did not stop Vesalius from setting the record straight.
And so in 1543, at the age of 29, Vesalius published a seven-volume work, De Humani Corporis Fabrica, capturing his years of masterful dissection work. Comprised of more than 300 finely detailed illustrations of human anatomy, it was the first book of its kind and immediately recognized as a masterpiece. While some resisted the idea that Vesalius’ work contradicted the long-revered texts of Galen, the unprecedented detail and proof of Vesalius’ work spoke for itself. In exposing the errors of Galen, the Fabrica set a new standard that subsequent generations would not forget: Detailed observation and recorded facts must take precedence over unexamined assumptions.
While Vesalius had exposed Galen’s mistakes in anatomy, just a few decades later English physician William Harvey pursued his own trail of truth to uncover equally shocking mistakes in physiology. Until that time, scientists had not questioned Galen’s explanation of how blood flowed through the body. For example, Galen had taught that blood, rather than circulating continuously through the body by the pumping heart, was continuously created in the liver, pushed through the body by an “ebb and flow” of the heart, and sent to the tissues where it was “consumed.” Galen also thought that once in the heart, blood passed through pores in the wall between its lower chambers (ventricles). But Harvey, who was born in 1578 and raised in a time when his idols, including Vesalius, promoted experimentation, decided to take a closer look.
And in 1616, after numerous experiments on a variety of animals, Harvey announced his stunning discovery to the world: “The blood moves as in a circle. The arteries are the vessels carrying blood from the heart to the body and the veins returning blood from the body to the heart.” It was a completely different concept than that described by Galen and, although Harvey faced some criticism and doubters, he eventually published his findings in 1628 in the small book, De Motu Cordis. In addition to accurate descriptions of how the heart receives and pumps blood to the body, he correctly described the different functions of veins and arteries, and in one famous contradiction to Galen’s work, concluded that blood does not flow through the wall in the heart “because there are no openings.”
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It may sound simple today, but some call Harvey’s explanation of circulation the greatest discovery in physiology and medicine. What’s more, like Vesalius’ milestone revelations in human anatomy, Harvey’s discovery transcended the mere embarrassment of a biological boo-boo. Coming after more than 1,200 years of unquestioned authority, Vesalius and Harvey dared look at the human body in a way no one had before. Overturning tradition, they threw open doors to a new way of seeing the world. It was the start of a slow transformation that medicine—scientific medicine—would undergo over the next five centuries.
Milestone #3 The birth of scientific medicine: when curing began to overshadow caring
While the revolutionary work of Vesalius and Harvey spanned just a few decades, the subsequent birth of scientific medicine was a long process, during which tradition remained alive and well. For example, up until the 1800s, many doctors still practiced Hippocratic medicine, including the use of laxatives, bleedings, and emetics to balance the humors. Nevertheless, two key figures stand out in the birth of modern scientific medicine: Ambroise Paré, whose pioneering work bridged the worlds of tradition and innovation; and René Laennec, who in 1816 invented a simple device that has been hailed one of the great discoveries in medicine—and a dark omen for the terrible turn Western medicine was about to take.
Ambroise Paré was a French military surgeon whose break with tradition in the mid-1500s has led many to call him the father of modern surgery. The title is justified given that Paré helped transform surgery—traditionally viewed as equivalent to butchery and reserved for barber surgeons with little training—into a professional art. But a closer look at his accomplishments shows that Paré had a healthy respect for innovation and tradition. Paré’s best known discovery came in 1537 when he was working in the battlefields as a military surgeon and ran out of the oil that was traditionally used to treat gunshot wounds. At the time, gunshot wounds were thought to be poisonous and so were treated like snakebites, with boiling oil. With no oil at hand, Paré was forced to improvise and instead created an odd concoction of egg yolks, oil of roses, and turpentine. To his delight, the new formula was not only less painful for the soldiers, but also more effective. As he later wrote, “I resolved with myself never to so cruelly burn poor men wounded with gunshot.” But along with such innovations, Paré had a healthy respect for tradition. In another milestone achievement, he revived the ancient art of ligature—tying off blood vessels to stop bleeding—in soldiers who required amputations, rather than cauterizing the wounds with red-hot irons. This, too, turned out to be a gentler and better way to stop bleeding and improve healing.
Paré’s kinder approach to medicine—which also included making simple wooden legs for amputees who could not afford better devices—blended tradition and innovation, and eventually earned him the title, “The Gentle Surgeon.” And in one final nod to tradition, Paré is famous for a humble comment he once made, echoing a similar point made by Hippocrates 2,000 years earlier: “I treated him, but God healed him.”
If Paré’s achievements in the 1500s represented a transitional phase when Western medicine overlapped two worlds, no milestone better symbolizes its shift into modernity than French physician René Laennec’s milestone invention two centuries later: the stethoscope. At the time Laennec was practicing medicine, in the early 1800s, physicians typically listened to a patient’s lungs and heart for signs of disease by placing their ears directly on the patient’s chest or on a handkerchief laid on the chest. However, one day in 1816, Laennec was struggling with this method as he attempted to examine a young obese woman suffering from advanced heart disease. Frustrated by her size, modesty, or both, he was unable to place his ear on her chest to listen to her heart.
That’s when inspiration struck. Laennec suddenly remembered a recent memory of two children he had seen playing in a park. At one point, they had picked up a long stick and, placing an end in their ears, began lightly tapping signals to each other. Recalling how the stick had amplified and transmitted the sounds, Laennec was suddenly struck by an idea. He quickly found a “quire” of paper (24 sheets) and rolled it into a cylinder. Then he placed one end in his ear, the other end on the woman’s chest, and began to listen. Laennec later wrote that he “was not a little surprised and pleased to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of my ear.”
Laennec went on to build sturdier versions of his stethoscope and used them to make many important discoveries, not only about how the new device could be used to amplify heart sounds, but how those sounds provided important clues about normal heart function and heart disease. Three years later, he published his findings in a landmark work, On Mediate Auscultation or Treatise on the Diagnosis of the Diseases of the Lungs and Heart, with the term “mediate auscultation” referring to “indirect listening.” But despite his discovery and clinical observations, Laennec’s stethoscope was met with criticism and skepticism for decades. As late as 1885, one professor of medicine was famously quoted as stating, “He that has ears to hear, let him use his ears and not a stethoscope.” Even Lewis A. Conner, founder of the American Heart Association, opted for placing his ear on a handkerchief over the chest, rather than Laennec’s stethoscope.
But despite this resistance, the stethoscope was welcomed by many physicians and today is seen as a defining symbol in the birth of modern medicine, for good and bad. On the plus side, the stethoscope was one of the first effective technologies to advance the science of medicine. Indeed, it is still used today to gather diagnostically valuable information. On the other hand, the stethoscope represented a giant step away from tradition, from when physicians placed their ears over the hearts of their patients in an act that couldn’t help convey a sense of intimacy and caring. Like no other innovation before or after, the stethoscope put a small, chilly barrier between physician and patient.
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Beyond the invention of the stethoscope, the birth of modern medicine arose from many other advances over the next 150 years, as documented earlier in this book. But the advent of the stethoscope signaled a turning point in the physician-patient relationship, a shift in how physicians would care for their patients. When patients finally began to rebel against that shift, a range of traditional alternatives were available, not only those from ancient times, but some born only a century or two before.
Milestone #4 The birth of alternative medicine: a healing touch and a disdain for “heroic” medicine
One shouldn’t feel too badly about the long history of scorn and disdain scientific medicine has heaped upon alternative medicine. Alternative medicine itself was born in part from the scorn and disdain it held for scientific medicine. The attitude was understandable given the state of scientific medicine in the early 1800s. As described earlier, scientific medicine was just one of many competing healthcare systems at the time, with few successes and little to offer. In fact, to practitioners of other healing systems, scientific medicine had much to offer against it. With its harsh attempts to “save” patients with bleedings, toxic purgatives, and surgery that often ended in death from infection, scientific medicine was often sarcastically called “heroic” medicine. This contempt was perhaps best summarized by Samuel Hahnemann, the founder of homeopathy, who called “heroic” medicine a “non-healing art...that shortened the lives of ten times as many human beings as the most destructive wars and rendered millions of patients more diseased and wretched than they were originally.”
Hahnemann’s use of the term “non-healing” was telling because, like the ancient forms of traditional medicine, many alternative therapies that arose in the 1800s shared a belief in the mysterious forces of healing, as well as the value of natural treatments and the healer-patient relationship. This was at odds with scientific medicine’s tendency to aggressively “attack” diseases with surgery and drugs. But among the many healing systems born in the nineteenth century, two in particular—homeopathy and chiropractic—illustrate how widely diverse they can be in treatment approach, while retaining some crucial similarities in their underlying philosophies.
Homeopathy
For many people, modern alternative medicine began in the late 1700s when Samuel Hahnemann discovered a new and almost completely counterintuitive theory of medicine. Hahnemann was a German physician and was translating a text on herbal medicine when he came upon a statement that struck him as odd: The author claimed that quinine, which is derived from Cinchona bark, was able to cure malaria because of its “bitterness.” This made no sense to Hahnemann. So, taking the matter into his own hands, he began ingesting repeated doses of Cinchona to personally experience its effects. When he found the bark actually caused malaria-like symptoms, he had his milestone insight: Perhaps quinine’s curative powers against malaria came not from its bitterness, but its ability to cause symptoms similar to the disease it was being used to treat. And if that was true, perhaps other medicines could be developed based on how closely they mimicked the symptoms of a given disease. After testing his theory with numerous substances in many volunteers, Hahnemann concluded his hypothesis was correct. He called it the “principle of similars,” or “like cures like.”
As Hahnemann continued his experiments and developed his theory of homeopathy—from the Greek omoios (similar) and pathos (feeling)—he incorporated two other central ideas. The first and most counterintuitive idea was that while homeopathic remedies, by definition, caused unwanted symptoms, their toxicity could be reduced by diluting them over and over until they caused no symptoms. And though the amount of substance that remained after so many dilutions was vanishingly small, their therapeutic power could be increased by a process he called “potenization”—shaking the solution between dilutions to extract the “vital” or “spirit-like” nature of the substance. Hahnemann’s second major idea was that selection of a particular homeopathic therapy must be based on the total character of a person’s symptoms, which therefore required a detailed understanding of the patient’s history and personal traits.
From these concepts, one can see how homeopathic medicine shares some underlying values seen in ancient traditional medicines. First, the “vital” energy of the medicinal substances echoes the ancient view of vital energies in the human body and their interconnections with the outer world. Second, Hahnemann’s emphasis on understanding the entire “character” of a patient’s symptoms reflects the importance of the healer-patient relationship. For example, to determine a patient’s symptom “picture,” practitioners must spend considerable time interviewing patients to learn not only their symptoms, but how symptoms are affected by such factors as time of day, weather, season, mood, and behavior. Once this information is gathered, practitioners can select one or more homeopathic medicines, which today include more than 2,000 remedies. Finally, homeopathy is similar to traditional medicine because its treatments are derived from natural products (for example, plants, animals, and minerals) and involve tiny amounts.
Not surprisingly, scientific medicine opposed the theory of homeopathy from the start, dismissing the notion that such highly diluted substances could have any therapeutic effect and attributing any apparent benefits to the placebo effect. Nevertheless, despite a large body of contradictory evidence, in recent years a number of well-designed studies have suggested that homeopathic treatments may be effective for some conditions, including influenza, allergies, and childhood diarrhea. What’s more, today, scientists continue to investigate molecular mechanisms that could explain how homeopathic remedies might work, including the idea that complex interactions between the substance and diluting solvent may create a molecular “memory” that gives the final solution its therapeutic effects. In any case, despite many battles with scientific medicine throughout the nineteenth century, homeopathy has survived more than 200 years, and in 2007 was one of the top ten alternative medicine therapies in the United States.
Chiropractic
Chiropractic medicine—the manipulation of misaligned joints to treat a variety of ailments—has a colorful history dating back to Hippocrates, whose treatments for curvature of the spine included tying patients to a ladder and dropping them from roof-height. While modern chiropractic medicine is considerably more sophisticated, it is certainly no less colorful: It was developed in the late 1890s by Daniel David (D. D.) Palmer, a former magnetic healer who had a sixth-grade education and who claimed that “ninety-five percent of all diseases are caused by displaced vertebrae.”
Although Palmer had worked as a magnetic healer long before discovering chiropractic medicine in 1895, he eventually combined his gift for healing with a modern biological twist: He believed that the essential feature of all disease was inflammation and that he could heal patients by channeling his “vital” magnetic energy through his hands and into the site of inflammation. According to one homeopathic physician who had witnessed Palmer in action, “He heals the sick, the lame, and those paralyzed through the medium of his potent magnetic fingers placed upon the organ or organs diseased.... Dr. Palmer seeks out the diseased organ upon which the disease depends, and treats that organ.” It was not until 1895 that Palmer adopted a new concept that would eventually lead to his discovery of chiropractic: He theorized that diseases arose when organs and tissues became displaced and rubbed against each other, with the resulting friction causing inflammation. From this theory, he developed the idea that by manually repositioning, or manipulating, displaced body structures back into their normal position, he could stop the friction, which “cooled down” the inflammation and cured the disease.
Palmer’s milestone moment came on September 18, 1895, when he tried his new technique on a janitor in his building. Harvey Lillard had lost his hearing after twisting his back, and during the examination, Palmer noticed that one of Lillard’s vertebrae was out of position. Palmer manipulated the bone to realign it, and both patient and physician were astonished by the result. “I was deaf for 17 years,” Lillard wrote later, “and I expected to always remain so, for I had doctored a great deal without any benefit.... Dr. Palmer treated me on the spine [and] in two treatments I could hear quite well. That was eight months ago. My hearing remains good.” Palmer became further convinced when, a short time later, he successfully treated a patient with heart trouble. After more experiments and refinement, Palmer called his new treatment “chiropractic” (from the Greek word for “done by hand”), and within a year he had opened a training school.
Although Palmer’s original technique applied to any displaced tissues in the body, by 1903 he was focusing only on joints—particularly the spine—based on the so-called “foot on the hose” theory. According to that theory, if vertebrae became misaligned, they could pinch the roots of nerves exiting the spine, interrupt the transmission of nerve impulses to various organs, and thereby cause inflammation and disease. Thus spinal manipulation, realigning misplaced vertebrae and removing the pressure they put on nerves, could theoretically relieve inflammation and disease anywhere in the body depending on which body tissue the nerve supplied.
While many chiropractors today have evolved beyond Palmer’s original “one-cause, one-cure” thesis, this view has long been a key tenet of chiropractic theory and a major reason why scientific medicine has opposed the profession. But although there is no scientific proof to the broad theory that impingement on nerves by misaligned vertebrae causes disease, in 1994 an evidence-based consensus panel convened by the U.S. Agency for Health Care Policy and Research did find that spinal manipulation is an effective treatment for back pain. With other studies showing benefits in other specific conditions, chiropractic has been increasingly accepted by mainstream medicine, and by 2007 it was the fourth most commonly used alternative therapy in the United States. This popularity undoubtedly stems not only from its effectiveness, but from its roots in tradition—from Palmer’s belief that he was tapping into the body’s “innate healing intelligence,” to its realization of the ultimate in physician-patient care: hands-on healing.
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Apart from homeopathy and chiropractic, many other forms of alternative medicine born in the 1800s are alive and well today, including naturopathic medicine (which focuses on the healing power of nature and natural treatments) and osteopathic medicine (which emphasizes natural treatments and manipulation of the musculoskeletal system and today is a conventional system equivalent to scientific medicine). Despite differences in technique, all shared traditional values that would never completely disappear or lose their appeal. Unfortunately, they also shared something else: a long and bitter battle with scientific medicine.
Milestone #5 Battle for the body: scientific medicine’s blinding quest to conquer “quackery”
Scientific medicine has never been shy to dismiss if not denigrate any perceived threat to its values or power. This was never better illustrated than in 1842—decades before scientific medicine had achieved most of its greatest milestones—when Harvard Medical School’s Oliver Wendell Holmes threw down the gauntlet in the looming battle with alternative medicine. Responding to Hahnemann’s earlier criticism of scientific medicine, Holmes thundered that homeopathy was a “mingled mass of perverse ingenuity, of tinsel erudition, of imbecilic credulity, and artful misrepresentation.” Despite the ironies of ignorance—scientific medicine would soon be similarly vicious in dismissing John Snow and Ignaz Semmelweis’ evidence of germ theory (Chapters 2 and 3)—Holmes’ concern was understandable: Among the hodge-podge of medical systems brewing at the time, scientific medicine was, as much as any other, fearing for its own survival.
The rise of modern medicine over the next two centuries is impressive, given that in 1800 there were only about 200 educated physicians in the entire United States. And though this number would increase to several thousand by 1830, most patients were still getting their healthcare from such “specialists” as botanical healers, inoculaters, midwives, bone-setters, and various shady purveyors of ill-defined tonics and nostrums. To bring some order to this medical mish-mash, practitioners were often grouped into one of three general categories. The “regulars” included scientific, or conventional, physicians who practiced orthodox medicine; “irregulars” included practitioners of unconventional or unorthodox medicine such as homeopathy; and the remaining jumble of swindlers and dreamers fell into the category of “quacks and charlatans.” But such labels could not hide the disturbing fact that as late as the 1840s, essentially anyone could call himself a doctor. It was this alarming reality that finally prompted the “regulars” to marshal their forces in 1846 and achieve a milestone that would have an historic and long-lasting impact: At a national gathering of state medical societies in Philadelphia, they formed the National Medical Association—soon to be renamed the American Medical Association (AMA).
From its inception, the AMA had many noble goals, including raising the standards of medical education, eliminating poorly trained conventional physicians, and advancing medical knowledge. In addition, by the end of the 1800s, the AMA’s legislative influence had led to all states requiring a license to practice medicine. And when in the early 1900s the AMA was concerned about medical education standards and quality, it commissioned an investigation. The resulting 1910 Flexnor report was so critical of medical education that the subsequent changes transformed medical schools and led to the standards that still apply today, including the requirement that students receive two years of basic science followed by two years of clinical training.
But beyond raising its own standards, the AMA was continually engaged in a battle against the irregulars, those practitioners of “alternative” medicine whose unscientific methods and philosophies jarred with their own. But though AMA efforts were largely successful—many fringe alternative systems were in decline by the late 1800s—it discovered to its dismay that one particularly grating system, homeopathy, was actually gaining followers. And so in 1876, the AMA initiated a strategy it would often use to squeeze out those whose values did not align with its own: It passed a resolution making it unethical to associate with homeopathic practitioners.
The AMA’s battle and shunning strategies would only escalate in the twentieth century. As late as the 1950s, it still considered osteopathy to be quackery, and in the 1960s it created a “Committee on Quackery” against chiropractors, whose goals included “first the containment” and ultimately “the elimination” of chiropractic. But the AMA’s cleansing tactics reached an all-time low in the 1960s, when it stooped to suppressing research favorable to chiropractic and initiated a campaign of misinformation that portrayed chiropractors as “unscientific, cultist, and having philosophy incompatible with western scientific medicine.” Despite such tactics, by 1974 chiropractors had gained legal recognition in all states, and in 1987 the U.S. Supreme Court upheld a lower-court decision that found the AMA guilty of antitrust violations in its attempt to eliminate the chiropractic profession. Nevertheless, in a statement that summarized scientific medicine’s bruising impact on many forms of conventional medicine, one federal judge concluded that “the injury to chiropractors’ reputations... has not been repaired.”
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Despite the battles and the damage done, it would be foolish to underestimate the importance that rigorous standards of scientific medicine played in the breakthroughs that saved millions of lives throughout the nineteenth and twentieth centuries. What’s more, these advances did not always come at the expense of patient caring. Up until the 1920s and 1930s, many conventional physicians still put patient care at the center of their practices. But by the 1930s and 1940s, a shift in priorities was clearly underway. Scientific medicine was becoming progressively removed from patients, just as it progressively removed patients from control over their own care. By the final decades of the twentieth century, patients sought to regain that control by reaching for new alternatives.
Milestone #6 Prescription for an epidemic (of frustration): the rediscovery of alternative medicine
The wake-up call finally arrived in a double-punch from the two most respected voices in scientific medicine. The first blow landed in 1993 when a study by David M. Eisenberg and associates in the New England Journal of Medicine found that, based on a 1990 national survey, 34%—more than a third—of respondents had used at least one “unconventional” therapy in the past year. Even more stunning: Projected to a national level, the study found that there were more visits to alternative practitioners than to all primary care physicians. The second punch arrived five years later in a 1998 follow-up study in the Journal of the American Medical Association: Since the first study, alternative medicine use had increased “substantially,” with more than 42% of respondents reporting they had used at least one form of alternative therapy in 1997.
The turning point had arrived. With the evidence-based writing on its own wall, there was no turning back. The authors of the 1998 study, noting that “our survey confirms that alternative medicine use and expenditures have increased dramatically,” concluded with a call for a “more proactive posture,” more research, and the development of better educational curricula, credentialing, and referral guidelines. Scientific medicine had finally accepted a long-denied reality and was now actually inviting its black sheep relation into the family—providing it cleaned up its act.
As it turned out, the cleaning was already underway. In that same year (1998), Congress formally established the National Center for Complementary and Alternative Medicine (NCCAM), a landmark agency that bridged two long-separated worlds of medicine. As one of 27 institutes and centers within the National Institutes of Health (NIH), NCCAM’s mission included exploring complementary and alternative medicine (CAM) “in the context of rigorous science.” By 2009, it had an annual budget of $125.5 million—up from $19.5 million in 1998—and had funded more than 1,200 research projects throughout the world.
Since its inception, the NCCAM has gone a long way to help define, explain, legitimize, and sometimes debunk the many therapies found in the world of alternative medicine. For example, NCCAM broadly defines CAM as “a group of diverse medical and healthcare systems, practices, and products that are not generally considered to be part of conventional medicine.” It also distinguishes between complementary medicine, treatments used with conventional medicine (such as aromatherapy to lesson discomfort after surgery); and alternative medicine, treatments used instead of conventional medicine (such as a special diet to treat cancer instead of radiation or chemotherapy).
And while it’s difficult to classify and sort out the many different types of alternative medicine, the NCAAM groups CAM into four major categories: mind-body, biologically-based, manipulative/body-based, and energy. In addition, the broad category of “whole medical systems” includes those from both Western cultures (homeopathy and naturopathic medicine) and non-Western cultures (traditional Chinese medicine and Ayurvedic medicine). The NCCAM also provides information on specific therapies and recent findings. For example, in 2008, it released results from the National Health Interview Survey (NHIS), which showed that in 2007, half of all Americans—38% of adults and 12% of children—used some form of CAM. As shown in the accompanying figure, the study also found that the most five common CAM therapies were natural products, deep breathing, meditation, chiropractic and osteopathic treatment, and massage.
Figure 10.1. Top 10 alternative medicine therapies in 2007
The NHIS survey also revealed which CAM practitioners patients visit most. As shown in Table 10.1, the top two were chiropractic or osteopathic practitioners and massage therapists, accounting for more than 36 million visits.
Table 10.1. Top 15 CAM Practitioner Visits in 2007
But perhaps the most revealing findings from the 2007 NHIS study were the most common reasons why patients seek CAM practitioners. Among the top five reasons, all were chronic conditions: back pain (17.1%), neck pain (5.9%), joint pain (5.2%), arthritis (3.5%), and anxiety (2.8%). This underscores why the rediscovery of alternative medicine has emerged as one of the top ten breakthroughs in medicine. With Western medicine’s focus on subspecialization and dividing the body into smaller and smaller pieces, it has often failed to successfully treat patients suffering from chronic conditions and pain affecting the entire body. For many patients, that need is often better met by alternative medicine whether because of its focus on holistic balance, more natural treatments, or a more traditional healer-patient relationship.
Listening: the unexpected phenomenon that triggered a transformation
Since the early 1800s, alternative and scientific medicine have struggled in a tug of war over philosophy, values, and methods—one side pulling patients in the direction of tradition, natural treatments, and a closer physician-patient relationship; the other tugging back with the allure of technology, tests, and harsh but effective treatments. But in the final decades of the twentieth century, just when the shouting seemed to be loudest, an unexpected phenomenon triggered a transformation: Each side began listening to the other. Many in the world of alternative medicine began to realize—as the AMA had understood 150 years earlier—that their credibility and success would depend on better research and higher educational and practice standards. For example, chiropractic now requires four years of training and has standardized examinations and licensing in every state, and a recent surge of research is looking more closely than ever before at its methods.
At the same time, scientific medicine has opened its ears and mind to the shift in patient attitudes and a new consumer-oriented healthcare system. Physicians have begun to accept that patients are demanding more power over their own healthcare decisions, including the use of alternative medicine when conventional treatments fail. Other factors underlying the transformation range from society’s increasing acceptance of cultural, ethnic, and religious diversity to physicians’ own frustration with how technology and other trends have diminished their relationships with patients.
And so, in a surprisingly short time, the practice of medicine has undergone a remarkable change impacting patients, physicians, and institutions. And, perhaps most important, many would argue that this transformation was not simply additive.
Greater than the sum of its parts: a new integrative medicine
The rediscovery of alternative medicine was more than a handshake extended through a barb-wired fence. From the start, many healthcare practitioners recognized an opportunity to create a new kind of medicine—an integrative medicine—that would unite the best of both worlds and thus transcend the shortcomings of each. Integrative medicine has been defined as a “healing oriented medicine that takes account of the whole person (body, mind, and spirit), including all aspects of lifestyle. It emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and alternative.” This definition was provided by the pioneering Program in Integrative Medicine at the University of Arizona, which was started in 1997 by physician Andrew Weil. As the country’s first fellowship program in integrated medicine, its goals include teaching physicians about “the science of health and healing” and “therapies that are not part of Western medical practice.” Since that time, it has been joined by a number of other fellowship programs and a Consortium of Academic Health Centers for Integrative Medicine that includes more than 30 medical schools.
Despite its promise, integrative medicine faces many challenges, including holding alternative treatments to the same standards as those held by scientific medicine. While the answer may seem to lay in the mantra of evidence-based medicine—randomized placebo-controlled clinical trials that objectively study whether or not treatments work—conducting such studies can be problematic. For example, the nature of many alternative therapies—with individualized or experiential treatments whose benefits are difficult to measure—can make such testing difficult if not impossible. Still, many alternative therapies are now undergoing rigorous scientific testing through the funding efforts of the NCCAM and others. In the meantime, advocates of integrative medicine stress that their goal is to make use of all appropriate therapies in both scientific and alternative medicine, while addressing the shortcomings of each.
Successful partnerships between alternative and scientific medicine have already formed. For example, a 2008 article in Current Oncology described “integrative oncology” as the next step in the evolution of cancer care, noting that the goals include supporting cancer patients and their families by improving quality of life, relieving the symptoms caused by conventional treatments, and in some cases enhancing conventional treatment. As one example, the authors wrote that “after a careful review of the available evidence,” the Society for Integrative Oncology now supports acupuncture as a complementary therapy when cancer-related pain is poorly controlled.
While the jury is still out on whether many alternative therapies can safely and effectively be used as alternatives or complements to scientific medicine, the textbook Integrative Medicine notes that an integrative approach offers many benefits, including removing barriers to the body’s natural healing response; using less invasive interventions before costly invasive procedures; facilitating healing by engaging mind, body, spirit, and community; providing care based on “continuous healing relationships” rather than “visits”; and giving patients more control over their own treatments. As a 2001 editorial in the British Medical Journal (BMJ) concluded, “... integrated medicine is not just about teaching doctors to use herbs instead of drugs. It is about restoring core values that have been eroded by social and economic forces. Integrated medicine is good medicine... and its success will be signaled by dropping the adjective.”
A better day for Eastern medicine: balance regained
“It is much more important to know what sort of patient has a disease, than what sort of disease a patient has.”
—Sir William Osler (1849–1919); Canadian physician, father of modern medicine
You’ll recall that shortly after Yonten and his fellow Buddhist monks arrived in the United States, the memories of their traumatic experiences in Tibet were causing various symptoms and interfering with their ability to meditate. Although traditional Tibetan healers had diagnosed the problem as a life-wind imbalance, once in the U.S., the monks were referred to the Boston Center for Refugee Health and Human Rights for additional help. Psychiatrists at the Center had no objection to the Tibetan healers’ diagnosis of srog-rLung but added a diagnosis of their own: post-traumatic stress disorder (PTSD). Then, using the principles of integrative medicine, clinicians worked with the monks to develop a treatment that combined both traditional and conventional medicine. The monks are now doing better thanks to an integrative—and more balanced—approach that includes not only breathing exercises, herbs, mantras, and singing bowls, but also a Western regimen of psychotherapy and antidepressant drugs.
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The breakthrough rediscovery of alternative medicine and the emergence of integrative medicine is intuitively appealing because it embodies the best of what medicine has learned over thousands of years, from its culturally diverse origins in China, India, and Greece, to its revolutionary break with tradition during the Renaissance; from the rolled up paper in 1816 that led to the first stethoscope, to nearly two centuries of animosity between scientific and alternative medicine. Today, many believe that medicine can best achieve its potential through life-saving technologies and drugs, and traditional values that respect mind, body, spirit, and the physician-patient relationship. Since the time of Hippocrates and a millennium before, healers have known that curing isn’t always possible. But caring—and therefore, healing—is.