PEER GYNT'S ONION by ANTHONY CAMPBELL Posted to Wiretap 10/13/94. (C) Copyright 1994 Antho

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PEER GYNT'S ONION by ANTHONY CAMPBELL Posted to Wiretap 10/13/94. (C) Copyright 1994 Anthony Campbell This text is COPYRIGHTED, but freely distributable. COPYRIGHT NOTICE This book is copyright. I am distributing it electronically as an experiment. Permission is granted to make and distribute verbatim copies of this book provided the copyright notice and this permission notice are preserved on all copies. Comments, questions etc. should be sent to the author at Anthony Campbell Consultant Physician, Royal London Homoeopathic Hospital, London, UK. --------------------------------------------------------------------- PEER GYNT'S ONION An Alternative Alternative Medicine Book Anthony Campbell [Peer Gynt addresses the onion] I'm going to peel you now, my good Peer! You won't escape either by begging or howling. [Takes an onion and pulls off layer after layer.] ... What an enormous number of sheaths! Isn't the kernel soon coming to light? I'm blessed if it is! To the innermost centre, It's nothing but sheaths - each smaller and smaller - Nature is witty! [Henrik Ibsen, PEER GYNT, Act V, Sc.5] (C) Anthony Campbell 1992, 1994 For Marie-Christine CONTENTS ________________ INTRODUCTION 1. THE CHANGING FACE OF MEDICINE 2. WHAT IS ALTERNATIVE MEDICINE? 3. COMPLEMENTARY OR ALTERNATIVE? 4. IDENTIFYING FEATURES 5. ALTERNATIVE CAUSES OF DISEASE 6. IS IT SAFE AND DOES IT WORK? 7. PLACEBOS AND PSYCHOTHERAPY 8. THE NEW AGE 9. TRYING TO MAKE SENSE OF IT ALL INTRODUCTION Like Peer Gynt's onion, alternative medicine has many layers: practical, sociological, philosophical, even mystical. In this book I have sought to peel my own version of it, discovering in the process a variety of opinions both in others and in myself. And if in the end I find, like Peer, no centre to my onion, no one fixed viewpoint I can confidently label as right to the exclusion of all the rest, perhaps that is no bad thing; the world seems over-supplied just now with people convinced of their own rightness. I have been practising a combination of unorthodox and orthodox medicine for nearly twenty years, and this seemed a good time to put down the conclusions I have arrived at up to now, although without claiming that they are final (the only final conclusions should be those we hold when we die). Their merit, such as it is, comes from the fact that I am not a journalist or other armchair critic but a labourer at the coal face. (Not that I have anything against journalists; indeed, I was a medical journalist myself for a number of years.) Patients quite often ask me how an orthodoxly trained doctor like me came to practise homoeopathy and acupuncture. I think they often expect to hear about a 'road to Damascus' conversion experience, but really it wasn't at all like that. It happened more or less by chance, as these things so often do. As a medical student in the late 1950s I learnt nothing whatever about any form of alternative medicine. I can only remember homoeopathy, for example, being mentioned on one occasion, and I assumed, without thinking about it very much, that homoeopathy had probably ceased to exist as a medical system in the nineteenth century. As for acupuncture, I knew, of course, that it was still practised in China, and at some time in the 1960s I happened to read a letter in the British Medical Journal from a doctor who described with amusement his experience of being treated with acupuncture for a sprained ankle in France. This was pretty much the total of my knowledge of alternative medicine until the 1970s. At that time I was working for a journal called ABSTRACTS OF WORLD MEDICINE, which was published by the British Medical Association. Sometimes as I walked about the streets in the neighbourhood of BMA House I would chance to pass by a building that bore the legend "Royal London Homoeopathic Hospital". I used to wonder about this a little; I supposed that the name was probably a quaint survival from the nineteenth century, but it seemed unlikely that homoeopathy was still practised there today. I found out my error thanks to some friends who were ardent homoeopathic patients. They told me that homoeopathy, far from being extinct, was still alive and flourishing and was practised by doctors as well as by people without a formal medical training; the homoeopathic hospital I had noticed was in fact the foremost institution for the study and practice of medical homoeopathy in Britain and perhaps the world. By this time I had for various reasons (including the demise of the journal for which I worked) left medical journalism and returned to clinical medicine. I had just obtained the membership of the Royal College of Physicians, which is the essential higher qualification needed by anyone who wants to become a consultant in medicine in the National Health Service, and I was looking for a new career direction. Owing in part, perhaps, to a certain contrariness of character, I was also interested in exploring unorthodox medicine. What attracted me most was acupuncture, but I did not know of any way to take this interest further, while homoeopathy was evidently a practical possibility. I therefore made enquiries at the hospital. As it happened, British homoeopathy was in crisis at that time. A short while previously a British Airways Trident had crashed just after taking off from Heathrow, killing all aboard. Among the passengers were several of the most prominent homoeopathic doctors of the day, who had been on their way to an international congress in Belgium. There was accordingly an urgent need to find new recruits for homoeopathy in Britain and to secure the future staffing of the Royal London Homoeopathic Hospital, and I was one of the doctors who eventually filled this gap. The Hospital is within the National Health Service, and sees a large number of patients annually (over 20,000 consultations in a year). It offers not only homoeopathy and orthodox medicine (all the doctors who work there are qualifed in both areas) but also a range of other complementary therapies, including acupuncture, osteopathy, and autogenic training. Some patients are admitted for more intensive treatment or for investigation, but the majority are outpatients. Most have long-term disease; we see few acute problems, partly owing to the length of our waiting lists. In the time that I have been at the hospital public attitudes, and doctors' attitudes, have changed considerably. I have noticed this in connection with the acupuncture courses for doctors which I hold. Ten years or so ago I had to spend a certain amount of time on courses answering questions from doctors who were sceptical. Nowadays this very seldom happens; they nearly all assume unquestioningly that acupuncture works and simply want to get on with learning it. As might be expected, however, the enormous outpouring of popular interest in alternative medicine has not gone unchallenged. There has been a reaction. Books and articles criticizing various aspects of alternative medicine have begun to appear, and the British Medical Association carried out an investigation whose findings were largely unfavourable to unorthodox treatments. However, the mistake of the 'anti' lobby is usually to pick off the easy, obvious targets without really going into the subject in any depth. Of course there is a large element of nonsense in alternative medicine, and it is tempting, and sometimes legitimate, to make fun of it. But some of the treatment that is included under the rubric 'alternative' does actually work, and has been shown to do so in proper scientific studies, so it is wrong to dismiss the whole lot as mumbo-jumbo. Reading some of these books, I seem to hear the despairing gurgles of some quite presentable babies as they disappear down the plug hole. Moreover, the critics of alternative medicine usually fail to see that, even if a lot of what they attack so vehemently is foolish and misguided, there must be a reason why it has become so popular. There must be something wrong with orthodox medicine, there must be a need that it is not responding to. It can be difficult and uncomfortable for people trained in Western mainstream medicine to come to terms with unorthodox practices. I have noticed, for example, that many of the doctors who come on my acupuncture courses seem quite happy to use the technique for treating painful disorders of muscles and joints, but relatively few go on to apply it to the treatment of other things like allergies, gynaecological problems, or colitis, to mention just a few which often respond well. Yet treating these disorders is no more difficult than treating muscles and joints; in fact, in some ways it is easier. What prevents them is probably a psychological block; they can just about imagine that acupuncture might work for a painful back, but they cannot see any reason why it should work for, say, ulcerative colitis. For that matter, nor can I; but it certainly appears to. At the other extreme a few doctors switch allegiance almost completely after they qualify and become, in effect, alternative practitioners, using almost no conventional treatment at all. However, these are very much the exception, and the vast majority continue to use the two approaches together. In so doing they attract the scorn of many non- medical therapists, who regard them as dabblers. However, I am quite unrepentant about mixing methods in this way. I am thoroughly convinced of the value of sustaining creative tensions within oneself. It is no doubt more comfortable to be a whole-hearted believer or a whole-hearted disbeliever in anything, but either of these attitudes tends to cut one off from many possibilities. I am reluctant to do this; I like to keep my options open. This book should be seen as an exploration of the (I hope creative) tension that results from trying to keep both the orthodox and the alternative perspectives in view simultaneously. 1: THE CHANGING FACE OF MEDICINE To begin with, a thought experiment, which will help you to define your own attitude to the ideas I want to examine in this book. Suppose that an old friend whom you have not seen for several years telephones you unexpectedly and says she would like to talk to you. When you meet, she tells you that she is seriously ill and has not long to live. She has no close relatives, so she wants to leave her considerable fortune to a medical charity of some kind. She has two ideas, and finds it difficult to choose between them. The first idea is to leave the money to buy a scanner for her local hospital, where she has been well treated. She knows that there is a need for such a machine in the district, and it would undoubtedly benefit many patients. The other idea is more unorthodox. She has received a lot of help from a practitioner of alternative medicine, who is keen to set up an institute for the study and practice of various kinds of therapy. This person has plenty of enthusiasm and many plans and your friend is convinced of the value of what he is trying to do. Although your friend is well off, her legacy would not be enough to fund both of these projects fully. She wants your advice about what she should do. How do you advise her? 1. She should leave all her money to fund the scanner. 2. She should leave it all to fund the institute for alternative medicine. 3. She should divide it between them in the hope that the balance will be made up from elsewhere. If so, what proportion would you suggest she ought to leave to each? (Give your reasons.) It is a fairly safe prediction that this imaginary situation has at least made you pause for a moment to wonder about your attitude to alternative medicine. Fifteen or twenty years ago, unless you happened to belong to the then tiny band of stalwart supporters of homoeopathy and other unconventional forms of therapy, you probably would not have hesitated for a moment in dismissing it all as quackery. As we know, things are very different today. Recently I was in the Casualty Department of my local general hospital. The notice board contained advertisements for local services of various kinds; nothing very remarkable in that, except that included among them were a group of local osteopaths and a hypnotherapist. Only a very short time ago such a thing would have been inconceivable. Indeed, it is not very long since an orthodox doctor would have been liable to erasure from the Register if he 'associated' with an alternative practitioner. Things are certainly changing fast. Nowadays we hear more and more about osteopathy, homoeopathy, acupuncture and other kinds of unconventional treatment. Once they were a minority interest, pursued by just a few cranks. Now they are constantly in the news, on television, in articles in popular magazines. But there is a correspondingly large amount of confusion in the minds of both patients and doctors. What are these things? Do some of them work? All of them? None of them? Is it all a media hype? And it is difficult to find definite answers to questions such as these. There are so many different alternative treatments available, and the number seems to grow all the time. It is not even clear what we should call the phenomenon. Once it was 'fringe medicine', then 'alternative medicine', and now often 'complementary medicine'. (The progressive change reflects the increasing respectability of the thing in question.) Nor can one easily define alternative medicine. At one time it would have been safe to say that it was any kind of treatment that is not taught to medical students or practised in National Health Service Hospitals, but that definition is no longer valid; many hospitals now use acupuncture, and other forms of alternative treatment, such as osteopathy or reflexology, can be found in some. So far no form of alternative medicine is officially part of an orthodox medical course in this country, but a number of medical schools have included occasional lectures on homoeopathy or acupuncture, and a University Chair of alternative medicine is now about to be established. At a postgraduate level these subjects are already well accepted; many doctors have attended courses in them. So why are these forms of 'rejected knowledge' suddenly so acceptable? An important part of their appeal must surely be that they provide answers to questions that orthodox medicine fails to address or answers unsatisfactorily. Sometimes these questions and answers are quite down-to-earth and practical (What can I do to relieve my migraine? Take feverfew), but sometimes they are psychological or spiritual (Why have I got cancer? Because you failed to resolve your deepest psychological and emotional problems). Philosophical ideas are seldom far from the surface in alternative medicine. Partly, too, it is simply a question of time and attention. When patients visit their family doctor they usually expect a prescription, certainly, but they also want (but probably seldom really expect) something less tangible: to be listened to, to be given sympathy and reassurance, and especially to be allowed time to talk about themselves. This tends not to happen in consultations under the National Health Service, simply because there are too many patients. But in any case doctors are not always well equipped to provide this kind of service. Their education does not necessarily prepare them to cope with the social and emotional problems they encounter, especially in general practice. A modern medical training is largely concerned with the diagnosis and treatment of identifiable physical disease, and even the psychiatry that a medical student learns is likely to be based on physical models. Orthodox medicine has fallen into difficulties that in large part have been created by its own successes. The roots of this lie in the late nineteenth century, when medical scientists such as Pasteur, Koch, and Virchow were making discoveries that, for the first time, gave doctors an insight into the way the body works and what happens to it in disease. This was a most exciting time for young medical men, as we can see in George Eliot's portrait of Lydgate in Middlemarch. And the excitement continued into the twentieth century, with the discovery of insulin and other hormones, vitamins, and the sulphonamides and penicillin. Later, effective treatment was introduced for tuberculosis, and vaccination against poliomyelitis more or less eliminated this disease from the rich countries. Smallpox was finally eliminated world-wide, the first (and so far the only) time that a major infective disease has succumbed to the advance of science. In Britain, the setting up of the National Health Service made all these medical advances freely available to the whole population. Aneurin Bevan, who introduced the scheme, apparently believed that it would eventually result in many fewer people going to their doctor. Possibly this thought was suggested to him by his Socialist ideals; it sounds a little like the withering away of the State which was supposed to occur in Communism, and it proved as delusive. Instead of diminishing, the numbers of patients coming for treatment increased steadily, as people came to think of health as their right. Gradually, however, medical optimism began to receive set-backs. Perhaps the first major disappointment was the discovery that cortisone, which at first had been greeted enthusiastically as the scientific answer to arthritis, proved to have serious unwanted effects. Since then the same story, with variations, has been repeated again and again, most notably in the thalidomide disaster in 1962. A certain degree of naive optimism about medicine does still exist, especially in the popular press, which continues to trumpet the arrival of new miracle cures for various ailments, as it has done for many years; and we feel aggrieved if we learn from our doctor that there is still no effective treatment for many people suffering from quite common diseases - asthma, for example, or migraine. A lot of these patients can be helped to a greater or lesser extent, of course, but they cannot be cured, and a sizable minority still cannot be helped at all. Along with our expectations of modern medicine, however, many of us have also grown suspicious of it. There have been too many cases in which people have been harmed or even killed by treatment, and some of us therefore reject scientific medicine - 'drugs' - partially or even wholly. There is a paradox here - modern medicine is perceived as both good and bad - and there is another paradox in the way we think about doctors. The old paternalistic image of the doctor as a benign bespectacled figure in a white coat dispensing wisdom as well as medicines still persists in many people's subconscious, but it is beginning to coexist uneasily with another image, that of the coldly dispassionate scientist, who is more interested in research or diagnosis than in actually treating patients. Nevertheless, surveys continue to show that people rate doctors very highly in terms of trustworthiness. And the persistence of the avuncular image leads us to bring to the doctor many problems that in other times might have seemed more appropriate for a clergyman to deal with - unhappiness, loneliness, guilt. Many people become deeply emotionally dependent on doctors because, in a secular age, they have no one else to turn to. Doctor-dependency is quite a new phenomenon, and so is the degree of respect commonly accorded to doctors and medicine today. In former times doctors were often considered as little better than tradesmen. (Within living memory physicians were excluded from the Turf Club at York because they sent in bills.) As for surgeons, their original associations were, we remember, not with the consulting room or the operating theatre but with the barber's shop. Nous avons chang‚ tout cela. But doctors today find it difficult to live up to their reputation; most of them know they do not have all the answers, and, increasingly, so do their patients. A large part of the appeal of alternative medicine stems from patients' rejection of the god that has failed them. "Much of today's revolt against orthodox medicine is not so much kicking the habit completely as seeking an alternative guru, a drug that is more satisfying... Faced with life's problems, more and more people become doctor-dependent or medicine-dependent." (Roy Porter, Senior Lecturer in the History of Medicine at the Wellcome Institute, writing in The Listener in 1985). But there is an additional reason for the rejection of orthodox medicine by many people today. This has to do with the popular image of the doctor as a scientist - a picture of themselves which many doctors share. Modern medicine, in keeping with the rest of our lives, becomes ever more dominated by technology. This makes it more expensive, but also widens the range of problems it can tackle. In one way this is perceived as good, but it can also appear soulless and impersonal. And it is easy to understand this idea. There is undoubtedly something intimidating - terrifying to some people - about a large modern hospital; it is not hard to imagine oneself being swallowed up in it for ever more, like a Kafka protagonist (hero does not seem quite the word here), or like Russell Hoban's Kleinzeit. (Not that there is much new about this. The hospitals of former times were also perceived as frightening, though for different reasons; admission to hospital was often regarded as little better than a death sentence, which in view of the lack of sterility, anaesthetics, and effective treatment of almost any kind it often was.) Why is this image of the doctor as scientist so off- putting for many of us? Partly because we fear - with some justification - that care for the individual patient may sometimes conflict with the demands of research, and it may not always be the interests of the patient that come out ahead. But it goes deeper than that. When I was a boy in the 1940s I had a series of books called the Wonder Books. There was, I remember, The Wonder Book of Why and What, The Wonder Book of How and Why, and various others whose titles I have forgotten. The general theme (still based on pre-war euphoria) was the conquest of the natural world by human science and technology. If I had those books today they would seem impossibly dated, and not only because the information they contained has long been superseded by later discoveries. An even more significant change has been the abandonment of our triumphalist convictions about the very notion of 'conquering nature'. Our self-praise is more muted than it used to be; we are a good deal less sure of ourselves. At the same time as we have begun seriously to question the attitude to nature that almost everyone took for granted in my youth (along with a pride in, and conviction of, the durability of the British Empire), there has been a subtle but important shift in the kind of thought and sensibility that many of us value. One way of representing this shift is to construct a table containing opposed pairs of ideas, which could conveniently be labelled 'head' and 'heart'. If you prefer a more up-to-date way of saying the same thing, they could also be called left-hemisphere and right-hemisphere thinking. HEAD HEART left brain right brain reductionism holism tough-minded tender-minded rational intuitive scientific artistic materialistic spiritual mechanism vitalism astronomy astrology chemistry alchemy artificial natural yang yin male female complementary alternative The psychologist and philosopher William James identified a quite similar polarity when he divided people up into two groups, which he called tough-minded and tender-minded. TOUGH-MINDED TENDER-MINDED empiricist rationalistic sensationalistic intellectualistic materialistic idealistic pessimistic optimistic irreligious religious fatalistic free-willist pluralistic monistic sceptical dogmatic For the last several hundred years, Western thought has been dominated by left-column attitudes, but now there seems to be a movement towards the right column, at least at a popular level. For many people - certainly for nearly all who are involved in alternative medicine - the left-hand column represents BAD and the right-hand column GOOD. I have arranged the columns in this way because the right side of the brain, which controls mainly the left side of the body, is supposed to be artistic, creative, and so on, therefore 'good', while the left side of the brain, controlling mainly the right side of the body, is analytical and language-dominated, and therefore, if not actually 'bad', at least not entirely approved of. (It would be possible to tease this distinction out further. For example, left-handedness, because of its association - sometimes - with a dominant right hemisphere, has a certain aura of virtue and value in alternative circles. Again, there are political overtones in the idea of the right hemisphere as somehow occupying the place of a repressed, non-vocal, minority vis … vis the dominant left hemisphere.) You may have noticed something odd about the first table. I have listed 'alternative' and 'complementary' as polar opposites, yet a little earlier I used these terms more or less interchangeably. In fact, the difference between them is, in a way, what this book is about. 'Complementary' implies a fairly amicable relationship between orthodox and unorthodox medicine. The recently founded Research Council for Complementary Medicine includes both orthodox and unorthodox practitioners among its trustees. 'Alternative', on the other hand, implies a rejection of the conventional approach and the substitution of something different. For the most part, my focus in this book is on the philosophical and emotional rejection of conventional medicine, which is why I have generally used the term 'alternative'. I realize that many people practising various forms of unconventional medicine would claim that their methods are complementary, not alternative, and that they have no hostility to orthodox medicine. I fully accept this, and in so far as anyone does maintain this position, what I say about alternative medicine may not be applicable to him or her. However, there are undoubtedly many others who are hostile to conventional medicine at least to some degree, and it is their attitude that I have in mind in much of what follows. Believers in alternative medicine tend to act in one of two ways. Either they try to build bridges between the orthodox and the unconventional methods as much as they can, or they think of them as mutually antagonistic and not only do not build bridges but often devote a good deal of energy to trying to blow up those that may already exist. When one listens to some of the more radical advocates of alternative medicine one often gets the feeling that they are saying medicine is too important to be left to the doctors. And doctors who use alternative medicine themselves often seem to be regarded as the worst of the lot; it is as if they have committed a kind of trahison des clercs in reverse. Hahnemann spoke contemptuously of 'half-homoeopaths', meaning doctors who used orthodox medicine together with homoeopathy; nearly 200 years later this practice attracts the same scorn from the ultra- committed. Inglis and West, for example, are dismissive of most doctors who claim to practise alternative medicine: 'Medical qualifications do not in themselves make anybody a better therapist than somebody who has not done the standard medical training. Rather the reverse, in fact, as the standard training is only too likely to condition medical students into accepting ideas and attitudes inimical to the practice of natural medicine' [295] It is clear what they have in mind; in terms of the table on p.000, the standard medical training is supposed to condition you to think in the left-hand column (assuming, that is, that you were not initially selected for medical school precisely because you thought like that, which you probably were). What comments like that of Inglis and West tell us is that there are important differences between the underlying assumptions of nearly all non-medical alternative practitioners on the one hand and most, though certainly not all, medically qualified ones on the other. (But I must emphasize once more that I am, inevitably, generalizing, and exceptions on both sides can always be found.) A remarkably clear statement of the alternative position appeared quite recently in The Homoeopath [1990, 10, 110 - 113]. Its author, Dr Denis MacEoin, is an academic who is not professionally involved in homoeopathy; however, he feels strongly on the subject, as he indicated in his response to a talk given by a senior homoeopathic doctor at a seminar on the relations between medical and non-medical homoeopaths. Most of the audience, one gathers, approved of the sentiments expressed; not so Dr MacEoin. He is entirely hostile to any attempt to integrate the two brands of homoeopathy. Orthodox doctors, and this often includes those with a smattering of homoeopathic training, are not competent to lay down the parameters for the management of a homoeopathic case. It is axiomatic that homoeopathy represents, in the broadest sense, a philosophical and clinical contradiction of allopathy and a system of medicine in its own right. MacEoin correctly identifies the dilemma that has always faced homoeopathy. Either it tries to go it alone, and risks isolation, or it tries to integrate itself with orthodox medicine, in which case it risks being taken over. MacEoin has no doubt that independence is the right course, and he believes that this will eventually lead to a situation in which homoeopathy will become 'a distinctive, broadly-based medical system capable in the fullness of time of usurping the current role of allopathy...'. There must, he insists, be no compromise on essentials: 'to seek for anything less than freedom to pursue the goal of raising homoeopathy to the status of a primary system of medical treatment to which surgery and drug treatment will be complementary would be to betray the vision of generations of homoeopaths and the hopes of thousands of patients like myself.' There is evidently an almost unbridgeable gulf between alternative views of this kind and the more moderate 'complementary' version of unorthodox medicine. I shall look at this in more detail in Chapter 3. First, however, we need to try to establish what it is we are talking about. 2: WHAT IS ALTERNATIVE MEDICINE? About the only way one can define alternative medicine is negatively, by saying that it is all those forms of treatment that are not taught in conventional medical schools. It would be impossible to list all the different kinds of alternative medicine, partly because new ones keep appearing, and partly because in some cases it is a matter of opinion whether or not a particular method is 'medical' at all. Homoeopathy and osteopathy, for example, obviously do qualify as therapies, but what about yoga, 'sacred Native American exercises', and 'techniques for releasing Karmic patterns that may be inhibiting your growth and well-being', all of which were on offer at a recent exhibition of alternative medicine and complementary therapies in London? It is hard to classify these as treatments, but they are certainly intended to be methods of improving your physical and mental well-being. But methods of treatment as such were on offer at the exhibition too, of course. They included reflexology, therapeutic massage, kinesiology, Feldenkrais, the Alexander technique, Touch for Health, biofeedback. Aroma therapy, shiatsu, and polarity therapy, as well as other methods, some of which I had not heard of previously. Prevention was not forgotten either: there were lectures about the technological dangers that surround us. 'An academic teacher and scientist' looked at 'how computers, microwave ovens, electronic watches, and geopathic stress can make you ill and what you can do about them,' and another lecturer gave a timely warning about 'how the misuse of Kundalini energy can cause mental, physical, and emotional problems.' There was a good range of alternative treatments on offer at this exhibition, but even so only a fairly small proportion of those that exist were represented. A survey carried out in New Zealand found that among 270 people advertising some kind of alternative medicine a total of 94 distinct therapies were mentioned and 81 practitioner qualifications were listed. We need some kind of scheme to make sense of this plethora of treatments, to fit them into categories of some kind. But it is not easy. In their book THE ALTERNATIVE HEALTH GUIDE, Brian Inglis and Ruth West use four main groups, with subdivisions. Their main groups are Physical Therapies, Psychological Therapies, Paranormal Therapies, and Paranormal Diagnosis. But, as they point out, the boundaries between the various therapies are tending to break down, which makes categorization difficult. Even so, their scheme contains some curious illogicalities: it is not obvious, for instance, why Iridology, which purports to be a scientific method of diagnosing disease, should be classed as paranormal, or why art therapy and music therapy should be included as Physical Therapies instead of as Psychological Therapies. My task, fortunately, is easier than theirs, since I am not trying to survey the whole field of alternative medicine but only to pick out certain items to look at in more detail. For my purpose it will be sufficient to use the following scheme. A. Medical therapies: that is, therapies which use pharmacopoeias of some kind (herbalism, homoeopathy). Anti-allergy treatments such as dietary manipulation and clinical ecology (Chapter 5) form a sub-group. B. Physical therapies: osteopathy, chiropractic, acupuncture; also polarity therapy, metamorphic technique, and Rolfing, which have additional psychotherapeutic aspects. C. Psychological therapies: psychotherapy, hypnotherapy, biofeedback, the humanistic psychotherapies, autogenic training, meditation, Silva Mind Control, psychosynthesis. D. Miscellaneous, including so-called paranormal therapies (spiritual healing, radionics and radiaesthesia, 'psychic surgery'.) I include this category for the sake of completeness, but I don't want to say very much about it. E. Diagnostic methods (Kirlian photography, Iridology, astrological medicine). Many of the categories overlap to some extent. Although I have included psychological therapies as one of the categories in its own right, there is an element of psychology in all the treatments, as of course there is in orthodox medicine too; but in some of them it is much more prominent than in others. On the other hand, there are some therapies that are mainly intended to produce psychological effects but which use physical methods such as massage and posture to do so. There is another way of classifying alternative treatments which is more contentious. This is to divide them into those that are semi-respectable from the point of view of orthodox medicine and those that are not. Obviously this cannot be a rigid distinction, if only because the tolerance of individual doctors for the unorthodox varies from doctor to doctor. However, it is fair to say that homoeopathy, acupuncture, manipulative medicine (a deliberately vague term to include both osteopathy and chiropractic), and hypnotherapy are semi-respectable, in the sense that there are appreciable numbers of orthodox doctors who have studied these methods and use them at least part of the time, whereas the remainder of the therapies are used hardly at all by doctors, although even here there are a few exceptions (some doctors, for example, use radionics and radiaesthesia). A third classification has been used by some people. This has three main categories: (1) well-established treatments (acupuncture, osteopathy, homoeopathy, naturopathy, herbal medicine, hypnotherapy); (2) 'core' treatments, used by a wide range of alternative 'specialists' as an adjunct to their own methods (advice, diet, vitamins, relaxation, stress management, massage, exercise); (3) fringe treatments and diagnostic methods (colour therapy, music therapy, radionics, aromatic oils, gem therapy, biofeedback, iridology, Kirlian aura diagnosis, hair analysis). Although the vast majority of alternative practitioners lack conventional medical qualifications, some alternative techniques are used by doctors. In Britain there are very few legal restrictions on the techniques that a doctor can use, even within the National Health Service. Provided the doctor is either a principle in general practice or a consultant, he is remarkably free to do what he thinks best for his patient. If he wants to attend a course in homoeopathy or acupuncture, for example, he can do so, even if it is given by people without orthodox medical qualifications, and he can use the techniques he learns to treat his patients, provided they agree. Under the new provisions of the National Health Service general practitioners can employ alternative practitioners to work under their supervision in their practices. Non-medical practice is also very free in Britain. A few diseases, such as venereal infections, may only be treated by doctors, but otherwise anybody may call himself or herself a therapist of any kind, with or without having received any kind of training. The situation is different in many other countries, where often it is only doctors who are allowed to treat patients. One tends to think that interest in alternative therapy on the part of doctors is quite new. But this is due to our historical parochialism. The Scottish surgeon James Braid used hypnosis in the 1840s to relieve pain during surgery. He coined the term hypnosis to dissociate the phenomenon from Mesmerism and he tried to get the method generally accepted, but shortly afterwards anaesthetics were introduced and hypnotism was abandoned. However, a French country doctor named A.A.Li‚bault took up hypnotism as a method of relieving symptoms by suggestion, and later it was used in Paris at the SalpetriŠre hospital by the celebrated neurologist Charcot. Hypnotism is still used today by some doctors in Britain and elsewhere, and it has now largely completed the journey from quackery to orthodoxy. There has been a Society of Medical and Dental Hypnosis in this country for many years. Acupuncture has likewise been known in the West for a surprisingly long time; as early as the seventeenth century, in fact, although it only became widely known in the nineteenth. At that time it was practised quite extensively in France and in England, where the Leeds Infirmary became a major acupuncture centre in the 1840s. Shortly afterwards, however, it fell into disuse, and only revived after President Nixon's visit to China in 1972. Today the British Medical Acupuncture Society has over 1200 members and the number is constantly rising. The position of homoeopathy is more curious. For a variety of reasons it has attracted more hostility from orthodox doctors than either acupuncture or hypnotherapy, yet there has always been a small but resolute body of medically qualified homoeopathic doctors. When the National Health Service was set up after the war the homoeopathic hospitals were included, perhaps because there were influential people who habitually received homoeopathic treatment, and later the Faculty of Homoeopathy, the official teaching body for medical homoeopathy in Britain, was incorporated by Act of Parliament. This gives homoeopathy a greater degree of official recognition than it enjoys in any other country except, perhaps, India, yet British medical students learn nothing whatever about the subject and indeed are (or were until very recently) not likely even to have heard of it except in the dismissive phrase 'a homoeopathic dose', meaning an absurdly small dose. In the next chapter I return to some of these issues and look at them in a little more detail. 3: COMPLEMENTARY OR ALTERNATIVE? In her recent book on alternative medicine, Rosalind Coward made an important point. The alternative health movement has given voice to a fundamental philosophical opposition to past ways of viewing health... For many, the notion of being alternative is considerably more than just doing it differently from orthodox medicine. It is also a symbolic activity. It is a profound expression of a new consciousness which individuals have about health and the body. [THE WHOLE TRUTH, 11] This is exactly right. Another way of putting the same thing would be to use William James's term "over-belief". For many alternative medicine enthusiasts the over-beliefs are far from being incidental additions to practical methods of treatment; one could almost say that the practical therapies emerge from the philosophical presuppositions than the other way round. All the same, an important qualification is needed here. There are certain "major" forms of alternative medicine - acupuncture, homoeopathy, osteopathy and hypnotherapy - that are practised by quite large numbers of doctors as well as non- medical practitioners. The British Medical Acupuncture Society, for example, has over a thousand members at present and the number is rising all the time. A few doctors who take up alternative medicine become "renegades" and abandon conventional medicine altogether, but this is exceptional; most remain more or less orthodox but modify their practice by adding one or more of the alternative therapies, which they generally practise part- time. These "major" alternative therapies therefore tend to exist in two forms. To use the terminology of politics and religion - not wholly inappropriately - one could speak of moderates and extremists. The problem here, however, is that opinions about these things are not sharply polarized but lie along a spectrum; it would be an over-simplification to represent all medical practitioners of alternative medicine as moderates and all non- medical practitioners as extremists. In the case of osteopathy, in fact, the distinction is not very relevant. The osteopaths have decided, for better or worse, to cast their lot with "the medical establishment", and it seems likely that within a few years osteopathy will be as "orthodox" and uncontentious as, say, physiotherapy. But some of the early osteopaths' theories and beliefs will have been jettisoned along the way. The distinction is however very relevant for acupuncture, homoeopathy, and hypnotherapy, and I should like to bring this out by looking briefly at the way these two forms of medicine have developed. ACUPUNCTURE In traditional Chinese medicine acupuncture has an elaborate theoretical basis. The most basic idea is yin-yang polarity, which underlies every phenomenon in nature. There is also said to be a universal subtle fluid or energy called chi which is responsible for the processes of life. Chi flows through the body in the blood vessels and also in special channels, usually misleadingly called meridians in English. The so-called meridians connect the various internal organs (liver, spleen, kidney and so on). Disease is held to result from imbalances in the flow of chi and hence in the proportions of yin and yang, and the task of the acupuncturist is supposed to be to restore the balance by judiciously adjusting the flow. This is essentially a hydraulic concept, and the acupuncturist is pictured as a kind of engineer. The theory of acupuncture is elaborate and complicated. It is said to be very ancient and may indeed be so, although most of the texts on which the modern practice is based are mediaeval. It is certainly very complicated, and it employs concepts and terminology that are exotic and strange for Westerners. This seems to be a considerable part of its appeal for Western enthusiasts, especially for those (the majority) who are not medically qualified. To learn it, you must put aside your Western concepts of pathology, physiology, and even anatomy; such a willing suspension of disbelief is obviously easier if you have not acquired them in the first place to any great extent. Moreover, acupuncture is part of Eastern wisdom, hence profound, and in studying it you distance yourself decisively from dull, mechanistic, materialistic Western science. In part the notion that acupuncture is vaguely mystical is illusory, for the ancient Chinese were remarkably pragmatic and mechanistic thinkers themselves, and there is nothing mystical about their view of acupuncture. Many Western enthusiasts for acupuncture, however, do think of it as an esoteric, mystical branch of knowledge. This is merely one example of the difficulty of making cross-cultural leaps of this kind. But there is another view of acupuncture. In the last fifteen year or so there has grown up a different version, which might be called modern or non-traditional. This is based, not on the ancient Chinese theory of chi, yin and yang, 'meridians' and so on, but on modern Western concepts of anatomy and physiology. It ignores the Chinese system of pulse diagnosis and assumes that the effects of acupuncture - many of which, obviously, it accepts as real - are produced via the nervous system as generally understood by modern science. And it assumes that there must be changes in blood flow in various organs, alterations in hormone levels, and other physiological effects to account for the effects. I originally learned acupuncture from a Western doctor who had written a number of books on the subject; these we were required to read before attending the course, which lasted a week, from Monday to Friday. When we arrived on the course we were told by our tutor that he no longer accepted the Chinese theories which his own books were about, though he still thought it was important to have a grasp of the traditional ideas so as to understand the subject. He said he had come to this iconoclastic position as a result of his own experience, which showed that you got the same kind of results even if you didn't practise according to the classic Chinese principles. I admired his honesty in reversing his thinking in this way. Nearly all non-medical acupuncturists in the West base their practice on the traditional system, though sometimes in a somewhat modified form. (I think it is in fact questionable how far it is possible for a Westerner to adopt traditional Chinese ideas and make them thoroughly his own, at least without learning to read Chinese and spending a considerable time in China.) In China itself, it seems, things are changing. According to Nathan Sivin, a sinologist who has studied the question at first hand, modern Chinese doctors do not use or understand the ancient system. They are unable to read the classical literature, which has to be translated into modern Chinese. Although acupuncture is still used, the diagnostic methods are modern. Patients, likewise, are no longer familiar with the yin - yang and five-element concepts. Sivin concludes regretfully that there can be no return to traditional Chinese medicine in its original form. (American Journal of Acupuncture 1990, vol. 18, 325, 341). The majority of Western doctors who take up acupuncture use the non-traditional version, although this is not universally true; adherents of both views can be found in the British Medical Acupuncture Society, whose members are all medically or dentally qualified. For a Western doctor, the non-traditional version has several advantages. There is no need to try to come to terms with obscure medical concepts, which are likely to seem incomprehensible or incredible, or both, to someone with a modern scientific training. Moreover, since the 'new' version is based on the orthodox medical ideas that the doctor is already familiar with, he or she can absorb the basic skills in quite a short time and start to practise them without a long delay. The traditionalists, not surprisingly, look on all this with horror. They say that doctors are looking on acupuncture simply as a medical technique, and neglecting the real treasures that the 'proper' version contains. They speak disparagingly of doctors who attend one or two weekend courses in acupuncture and then start to treat their patients. In reply, doctors point out that all their conventional medical knowledge is relevant to modern acupuncture and therefore they have in effect been studying for years. Who is right? There is no doubt that doctors can learn the basics of practical acupuncture in a short time, and by applying these principles in the light of their knowledge of medicine they get good results in many disorders. Naturally it takes time and experience to become thoroughly skilled in the techniques, but the contention of the modernists is that techniques is what they are; the ancient theory is irrelevant. And clearly if someone is not convinced that the traditional Chinese ideas are valid, he or she has little motive to spend years learning them. The traditionalists, of course, claim that acupuncture done according to the ancient theories gives better results. The modernists claim the contrary, and moreover point out that the Chinese themselves have in recent years been quite prepared to update the traditional practice in various ways. In the absence of any proper scientific studies of the question it is impossible to say whether the classical or the modernistic approach gives the better results, or whether there is no real difference between them. The practical details of the treatment are in any case often quite similar in the two versions, though there is a tendency for the traditionalists to use more needles per patient and to leave them in for longer. (For what it is worth, the ancient texts seem to imply that the most skilled acupuncturists use very few needles - ideally only one - so in this respect the modernists seem to be the more 'traditional'!) HOMOEOPATHY In the case of homoeopathy we again find at least two views of how it should be approached. There is a purist school of so- called 'classical' homoeopathy, and there is also a more pragmatic version which takes more notice of recent developments in orthodox medicine and tries to relate homoeopathic practice to these. Nearly all non-medically qualified homoeopaths are purists in this sense, but the position of medical homoeopaths is more complicated; there are wide variations from country to country and changes are occurring all the time. One important way in which homoeopathy differs from acupuncture and indeed from most other forms of alternative medicine is that it was invented or discovered by a doctor and at first was practised almost exclusively by doctors. (There were in fact some eminent early non-medical practitioners, such as Hahnemann's widow Melanie and Von Boenninghausen, a lawyer; but these were exceptions and they had to get special permission from the authorities to practise.) The story of homoeopathy begins with Samuel Christian Hahnemann (1755 - 1843). He was an orthodoxly qualified German doctor who became disillusioned, understandably, with the medicine of his day, and therefore abandoned medical practice for a number of years, working instead as a translator and chemist. In 1790 he carried out an experiment on himself which planted the seed of homoeopathy in his mind and ultimately was to change his life. The idea was suggested to him by a book he was translating from English, Cullen's Materia Medica. In this he found a description of the Peruvian bark cinchona, from which quinine is derived. He disagreed with Cullen's explanation of how cinchona acted, and decided to take some himself to see what happened. He experienced the symptoms of an attack of 'intermittent fever', and this eventually gave him the central idea of homoeopathy: to choose medicines on the basis of similarity between their effects and the symptoms of the disease. The medicines Hahnemann used at this time were almost all taken from the ordinary pharmacopoeia of his day. Most were herbal, although he also used a few minerals. Thus they can in a sense be called 'natural', an important consideration for modern homoeopaths although probably less so in Hahnemann's day. In 1821 Hahnemann was forced to leave Leipzig owing to the hostility of the apothecaries. He moved to Anhalt Kothen, a small principality some 36 miles away where the Duke was an ardent admirer of his system. Here he remained in virtual seclusion (for travel in those days was very arduous), cut off both from his followers and from contact with mainstream medicine. His patients were now nearly all sufferers from chronic disease, and this, together with his virtual isolation, led to changes in his ideas. While in Kothen he published a controversial theory of chronic disease, the miasm theory (see p. 000), together with a series of new and unfamiliar medicines for treating such disease according to his theory. And he propounded the 'dynamization' idea, which was to grip the public imagination almost to the exclusion of everything else. 'Dynamization' is the term Hahnemann applied to the process of trituration (for solids) or hard shaking (for liquids) which he used in preparing his medicines. As well as this, he also diluted them in successive steps, to levels that seemed improbable to his contemporary critics and even more so today, when according to modern molecular theory there should be none of the original substance left at all in many of the medicines and very little indeed in the rest. He explained the claim that these extraordinarily dilute substances nevertheless could be used as medicines by saying that the process of dynamization made them much more active than before. During his lifetime Hahnemann was a very contentious individual who managed to sow discord wherever he went, not least among his followers. He was unwilling to accept any deviation from his precepts, and as these changed quite considerably over the years adherence to them was not always easy. He disapproved violently of any attempt to compromise with orthodox medicine, an attitude which resulted in the premature closure of a homoeopathic hospital founded in Leipzig after his departure. Fierce disputes continued to be a feature of homoeopathy even after Hahnemann's death. To see why, we need to understand that there were two distinct sides to Hahnemann's thought. In some ways he was a scientist, carrying out pharmacological and clinical research. In other ways, however, he was prone to build speculative theories that were closer to metaphysics; in this he resembles Anton Mesmer. Thus, in later editions of his main theoretical work The Organon he included a considerable amount of speculation about vitalism that some of his disciples, especially in England, found unacceptable. He also became progressively more extreme in his teaching about potency. At Hahnemann's death his ideas had become widely diffused throughout Europe. They had also crossed the Atlantic to both Americas, and at some point they reached India, still the country where homoeopathy is most widely practised. In the late nineteenth century, however, it was the USA rather than India which was most deeply committed to homoeopathy. The new doctrine reached a peak of success in the decades 1865 - 85, when an astonishing number of homoeopathic hospitals and colleges were constructed. In 1900 there were 22 colleges, and before the First World War there were 56 purely homoeopathic general hospitals, some with up to 1400 beds, 13 mental asylums with up to 2000 beds, 9 children's hospitals, and 21 sanatoriums. Soon after this homoeopathy went into decline in America. The main reason for this was quarrelling among the homoeopaths themselves. They were divided into two factions. The more numerous was composed of doctors who did not distinguish sharply between homoeopathy and orthodox medicine and were prepared to compromise with orthodoxy. The other group, who regarded themselves as strict Hahnemannian purists, distanced themselves as much as possible from orthodox medicine and took Hahnemann's later ideas even further than Hahnemann himself had done. In particular they were extremists in the matter of potency, taking the dilution method to extraordinary lengths. For this purpose they invented various machines, since to make these ultra-high dilutions by hand would have taken far too long. This 'purist' group, the best known of whom was Constantine Hering, were strongly influenced by the teachings of the Swedish mystic Emanuel Swedenborg, which by this time had become established in America. The Swedenborgians found in homoeopathy just the medical system they were looking for, while the homoeopaths thought that Swedenborg's ideas complemented Hahnemann's perfectly and gave them a new philosophical profundity. They were particularly attracted by the Swedenborgian emphasis on the mental and spiritual characteristics of patients, and also by the idea that chronic disease has deep roots in the personality. The last, and probably the most influential, of these Swedenborgian homoeopaths was James Tyler Kent (1849 - 1916). He compiled a Repertory - a kind of large index of symptoms and medicines - which is very widely used today; he also wrote extensively on methods of prescribing and on the medicines themselves. In England, meanwhile, homoeopathy was pursuing quite a different course. The English homoeopaths, of whom the best known today are Robert Dudgeon and Richard Hughes, were enthusiastic about the new medical teaching but nevertheless were prepared to be critical. They rejected some of Hahnemann's more extreme ideas, and instead of ignoring orthodox medical knowledge they did their best to build bridges between it and homoeopathy. For example, they took account of the results of animal experiments, and in choosing medicines they took note of the pathological changes of disease as well as the symptoms. This could be called Hughesian homoeopathy. If the empirical school of British homoeopathy that existed in the late nineteenth century had continued it is possible that homoeopathy today would be much more accepted by orthodox medicine than it actually is. But change was on the way. In the early years of the twentieth century an English homoeopathic doctor, Margaret Tyler, went to America to study under Kent. She returned full of enthusiasm for Kent's ideas, and began to proselytize for them with considerable success. Other doctors took them up, notably Dr (later Sir) John Weir. Probably Tyler did not convert many of the old guard, but as they retired or died they were replaced by her sympathizers. As a result, British homoeopathy changed its character radically in the first two decades of the twentieth century and became predominantly Kentian. In this form it was taken up by a number of lay homoeopaths. As we have already seen, there had been non-medical homoeopaths right from the beginning, but they had been exceptional. In Britain, however, there were few or no legal restrictions on lay practice, and it flourished. In part this was because Tyler's writings were so distant from orthodox medicine that they were immediately accessible to non-medical readers. Margaret Tyler remained active in homoeopathy for many years and wrote a number of books on it. Her principle contribution was to establish the idea of constitution in homoeopathy, which is often what appeals to people today. Previously homoeopathy had been fairly firmly based on Hahnemann's pharmacological experiments. The idea was to find a medicine whose effects, as verified by experiments on healthy people, were as similar as possible to those from which the patient was suffering. For example, white arsenic causes severe diarrhoea, vomiting, and thirst for small quantities of water. These symptoms are similar to those of acute gastroenteritis, so white arsenic would be the similimum in such a case and could be used to treat a patient who showed these symptoms. Under Tyler and her associates this way of prescribing was not abandoned but it was complemented, and partly overshadowed, by a new theory that seems to have originated in America with Hering. This was that there are certain personality types, each of whom is supposed to have a suitable kind of medicine. For example, the 'white arsenic' patient is fearful, chilly, tidy and fussy; he dresses neatly, can't bear anything out of place, and is therefore known as the 'gold-topped cane' patient. The sulphur patient is in many ways the opposite: intolerant of heat, untidy, careless, given to abstract thought, he is called the 'ragged philosopher'. Or there is the Sepia patient (usually a woman); she is pictured as a sallow tired mother of a large family, with whom she is totally fed up. Tyler says that she longs to escape from the house, and feels exhausted. Her six-year-old son starts drumming with a spoon on a tin pot; she snatches the pot away and smacks her son, who starts to howl. The whole kitchen is in uproar, and she doesn't care. Obviously these constitutional indications are not directly derived from experimental testing of drugs - which homoeopaths call "proving". It is hardly likely that taking sulphur, say, would make someone untidy who was not so already. The idea of constitution must therefore come from homoeopaths' theorizing or observation, although there is unfortunately no way of verifying this from the homoeopathic literature. There are a few hints of this way of looking at medicines in Hahnemann's writings but nothing more than hints; mainly it seems to come from Hering and Kent but especially from Tyler. So-called classical homoeopathy today is really Kentian/Tyler homoeopathy and is certainly not identical with what Hahnemann taught and practised - a fact that is unknown to many modern enthusiasts. A consultation with a modern homoeopath who adheres to this "classical" system is thus likely to involve a great deal of questioning about the patient's moods, fears, reactions to weather, food likes and dislikes, and so on. These are deliberately not directly related to the main complaint that has brought the patient to the homoeopath, because for the purist this complaint, if not exactly irrelevant, is simply the end point of a deep-seated disorder affecting the patient's whole physical, mental and spiritual being. For homoeopaths of this persuasion the "pathological" (disease-based) prescribing of Hughes and his disciples is a very inferior method. Ostensibly for this reason, Hughes and his ideas were displaced from their former pre-eminence shortly after Hughes' death in 1902. I think it likely, however, that another and probably more important reason for Hughes's posthumous fall from favour was his enthusiasm for reconciling homoeopathy with the orthodox medicine of his day. The Kentians who came to dominate British homoeopathy throughout most of the twentieth century were isolationist and rather hostile to orthodox medicine, a trait they inherited from their mentor, Kent, himself. Anton Mesmer and hypnotherapy Many people think of Mesmerism and hypnosis as simply different names for the same thing. There is however rather more to it than that, and the story of Mesmerism is worth looking at in its own right, since it exemplifies many of the difficulties that attend the attempt to introduce an unconventional form of treatment into orthodox medical practice. There are also some curious and interesting resemblances between the careers of Mesmer and Hahnemann which do not generally seem to have been noticed. Franz Anton Mesmer (1734 - 1815) was almost an exact contemporary of Hahnemann (1755 - 1843). He grew up on the shores of Lake Constance, on the border between Germany and Switzerland, in a Swabian town called Iznang. His father was gamekeeper to the Bishop of Constance and Mesmer was brought up as a Catholic; indeed, as a youth he contemplated entering the priesthood, but he soon realized that he lacked a vocation. For a year he studied law, but in 1760 he became a medical student in Vienna, where he qualified MD and PhD in 1767 at the fairly advanced age of 32. Mesmer was thus, like Hahnemann, well grounded in the science of his day, and he showed no leaning towards occultism or mysticism. It is therefore somewhat ironic that his name should have become linked with these qualities. His early career after qualifying was, in fact, conventional enough. He married a rich aristocratic widow, ten years older than himself, and thanks to his wife's connections soon established a prosperous practice in Vienna, where he met and became friendly with the young Mozart and his father. Not until the 1770s did he begin to move in the direction that was later to bring him such renown and notoriety. A young girl called Franzl Oesterlin, a relative of Frau Mesmer, became Mesmer's patient. She was suffering from symptoms that would now be regarded as psychological, possibly associated with hyperventilation. In order to make herself more easily available for treatment she came to stay with the Mesmers, and as he studied her case Mesmer was led to formulate remarkable theory. Mesmer's doctoral thesis had been concerned with the influence of gravitation on human physiology. He had suggested that gravitation depends on a subtle universal fluid which he imagined to pervade the whole cosmos, including living organisms, and to set up 'tides' in the bloodstream and nerves of human beings. This thesis, which in later years he referred to as The Influence of the Planets on the Human Body, sounds as if it should be concerned with astrology, but Mesmer intended it to be fully scientific. Ideas of this kind were acceptable scientific currency in the eighteenth century, and indeed Mesmer had lifted whole sections of his theory from the writings of the respected English physician Richard Mead. Contemplating Franzl's symptoms, he made the 'obvious' connection. He now understood what was causing the ebb and flow of her attacks: nothing else than the gravitational tides he had described in his dissertation. How to use this discovery to effect a cure? Why, by magnetism. Magnets were already in use by at least some doctors, though admittedly this was a contentious subject; and of course magnets, with their polar attraction and repulsion, could be plausibly supposed to act in the same general way as gravitation. Mesmer's friend Maximilien Hell, professor of astronomy at the University, had a number of magnets made for him in the astronomy department, with different shapes according to the part of the body they were intended to treat. The effects were gratifying. As soon as the magnets were applied to Franzl she had an immediate strong reaction followed by a dramatic improvement, and after further experiments Mesmer convinced himself that he had succeeded in controlling the ebb and flow of the universal gravitational fluid. Almost immediately after this, Mesmer quarrelled with Hell about who should have credit for the discovery. Hell claimed that it was the magnets themselves that had effected the cure, but Mesmer insisted that their only role was to channel the cosmic flow through the patient. It was in fact unnecessary to use magnets, he discovered; objects made of cloth or wood worked just as well. The explanation, he concluded, was that he himself was touching them; he was an 'animal magnet' who acted on objects and people in an analogous way to a mineral magnet acting on metal. Mesmer now tried to persuade the medical Establishment in Vienna of the validity of his discovery. In this he was unsuccessful, but Franzl made a complete recovery and eventually married Mesmer's stepson. (Mozart, in a letter, records a meeting with this lady, now grown stout and the mother of three children.) Mesmer's fame increased, and so did his practice; in 1755 and 1776 he travelled in Swabia, Bavaria, Switzerland, and Hungary, treating the famous. He was less successful in the case of Maria Theresa Paradies, a girl suffering from psychologically caused blindness since the age of three who was nevertheless a professional pianist. She had been treated with the conventional drastic methods of the time - bleeding, purging, blistering - and also with some experimental techniques, including the application of a tight plaster helmet and painful electrotherapy. At first Mesmer was successful; Maria Theresa recovered her sight, at least temporarily. But the ophthalmologist who had failed to cure her was, not unnaturally, jealous of Mesmer, and claimed the cure was not genuine. Eventually, for reasons that are unclear, the patient's father reacted violently against Mesmer, finally appearing at his house, sword in hand and demanding that the treatment of his daughter be stopped. Partly, at any rate, the explanation for the fiasco is that as the girl's sight improved her piano-playing deteriorated; she ceased to be so much of a public curiosity and was in danger of losing a pension that she was in receipt of from the Empress. Perhaps, too, there were other causes connected with the Paradies' family life (child sexual abuse?) which may have been responsible for the girl's initial blindness. At any rate she relapsed; eventually she achieved a reasonably successful career as pianist and composer, but she never again recovered her sight. Mesmer, meanwhile, was the centre of a scandal. Many people suspected him - almost certainly unjustly - of having had improper relations with Maria Theresa, and the hostility of the Viennese doctors increased. In 1778 Mesmer, by now informally separated from his wife, left Vienna for Paris. Once established in Paris, Mesmer began a long series of feuds with the French medical Establishment. The Academy of Sciences, in spite of attending demonstrations, were unconvinced by the animal magnetism theory. Mesmer therefore approached the newly founded Royal Society of Medicine, which he hoped would be more amenable than the long-established Paris Faculty of Medicine. His initial demonstration at his suite in the Place Vend“me was not well received. In 1778, therefore, he moved out of Paris and set up a clinic at a nearby town, Cr‚teil, where he had more room to treat the large number of patients who flocked to him. Some received individual therapy, while the less seriously ill or the convalescent were treated in groups. For this purpose Mesmer invented the baquet, a large wooden tub containing bottles of magnetic metal, stone, glass and so forth. Mesmer had magnetized all these items himself, by touching or pointing at them. The baquet had iron rods projecting from it; the patients pressed these against the affected parts of their bodies, and they also held hands to allow the animal magnetism to flow through the group. Many grateful patients wrote testimonials to the efficacy of the treatment, but the Royal Society was unimpressed and refused to attend the demonstrations. However, Mesmer was more successful with the Paris Faculty of Medicine, a prominent member of which, Charles Deslon, became a convinced believer in animal magnetism. He had himself magnetized, served as Mesmer's assistant, and eventually established his own clinic. Having moved back again to Paris, Mesmer now accepted Deslon's suggestion that they should try to gain the endorsement of the Paris Faculty. Three prominent members of the Faculty agreed to watch Mesmer at work. They were shown a number of remarkable cures, but remained obstinately unconvinced. Mesmer now gave up hope of obtaining the Establishment's approval, and concentrated on his clinical work. It is important to notice that he distinguished between what we would now call psychological and physical disorders, and refused to treat the physical. His patients ranged from the rich and aristocratic to the poor; everyone received an equal amount of attention and those who could not afford to pay were treated free. One feature of Mesmer's methods which attracted a good deal of unfavourable comment was the 'Mesmeric crisis'. Some patients, especially those suffering from more serious symptoms, experienced nervous trembling, nausea, occasionally delirium or convulsions. Mesmer regarded these as an inevitable accompaniment of the process of normalization of the flow of animal magnetism, and he had special padded 'crisis rooms' in which patients could throw themselves about without hurting themselves, while Mesmer or his assistants gave them individual attention. The depth of the crisis naturally varied from case to case, but Mesmer insisted that some degree of crisis, no matter how slight or transient, would always be found if it was looked for carefully enough. Even more dramatic than the crisis, however, was the Mesmeric trance. Mesmer discovered this phenomenon only after he had been practising his method for some considerable time; the trance then became for him a method of inducing the crisis. Another of his followers, the Marquis de Puys‚gur, discovered that it was possible to communicate with people in trance, getting them to answer questions, remember long-forgotten childhood events, and so on. The Marquis came to believe that it was possible to produce cures without a crisis, but Mesmer, constrained by the demands of his theory, did not agree. It is generally held that Mesmer was practising hypnotherapy, but it is probably more accurate to say that he was a shamanistic healer whose methods certainly included hypnotherapy but were not identical with it. Mesmer's conduct during therapy sessions was highly impressive, being intended to augment the drama of the situation as much as possible. His clinic was meticulously furnished to maximize suggestion: the light was dim, everyone conversed in whispers, and music was used to alter the patients' mood according to what was required at each stage of the process. There were four baquets in the room, three for paying patients and the fourth for those being treated free. Mesmer, as Master of Ceremonies, was elaborately dressed and carried a wand, which he pointed at patients or used to touch or stroke them. The patients gasped, twitched, went into trance, or experienced convulsions or catalepsy. Mesmer's assistants ministered to the more severely afflicted and if necessary brought them into one of the padded crisis rooms. Although Mesmer made some influential converts, especially Deslon, he was eventually to break with almost all of them. He was autocratic and dictatorial (like Hahnemann) and would brook no opposition. A lawyer called Nicolas Bergasse became converted to Mesmerism and suggested to Mesmer the establishment of a private academy to propagate his ideas. The result was the grotesquely misnamed Societ‚ de l'Harmonie. The Society was secret. All the members had agreed to sign an undertaking that they would not pass on any part of Mesmer's teaching without his written permission, nor would they establish a clinic without such permission; they were permitted to treat only individual patients. It was this last condition that destroyed the Society within two years of its foundation in 1783. The Society combined the roles of institute, medical school, and clinic. Students learnt the theory of Mesmerism and how to apply it in practice to patients. Schools were set up in Paris and also in several other cities in France, and thousands of pupils attended the courses. Bergasse took on much of the administration and became correspondingly powerful within the organization. Meanwhile Mesmer's erstwhile assistant Deslon had set up on his own account, and in 1784 he was investigated by a royal commission. The committee was convinced by his cures but denied, once again, the reality of animal magnetism. Another commission, set up by the Faculty of Medicine, reached the same conclusion. Mesmer objected that it was he, rather than Deslon, who should have been investigated, but there was nothing he could do about it. Bergasse, Puys‚gur, and other disciples of Mesmer now began to make public the knowledge of animal magnetism. Mesmer was furious, and the Society dissolved amid scenes of rancour and confusion. In any case the Revolution was coming and Mesmerism began to be overtaken by politics; Bergasse was later to adapt the doctrine of animal magnetism to support his views on revolutionary politics. Mesmer kept aloof from politics. He travelled about in Europe for a number of years, though he was back in France from 1798 to 1802; he sued for his losses under the Revolution and was awarded enough to keep him in reasonable comfort for the rest of his life. He now recommenced his wanderings, and began to develop more outlandish ideas than he had entertained hitherto, starting to speculate on what we today would call paranormal phenomena and extrasensory perception. During the trance, he said, the mind comes into contact not only with other minds but also with the cosmos, and so in principle is capable of acquiring universal knowledge. In this way it is possible for seers and fortune- tellers to foretell the future. He published these ideas in a book in 1799, and as a result gained the reputation of an occultist. Mesmer died in Switzerland in 1815. He was in his eighty- first year; a gypsy in Paris had foretold long ago that he would die at this age, and he believed her, so he was prepared for the end when it came. In his own terms, Mesmer must be judged to have failed. His dominating ambition was to achieve scientific recognition for his theory of animal magnetism and this did not occur. His methods of treatment, however, were reinterpreted as suggestion and were rechristened hypnosis or hypnotherapy, and in this form they were taken up by, among others, Jean Martin Charcot, Pierre Janet, and Sigmund Freud (although Freud later abandoned hypnosis). Although a faint aura of the disreputable has clung to hypnosis, there has always been a minority of doctors and psychiatrists who have valued and practised it. There is still a Society of Medical and Dental Hypnosis in Britain. Like Mesmer himself, some people have been attracted by the idea that hypnosis facilitates telepathy and clairvoyance. Numerous books, some by doctors, appeared in the mid-nineteenth century describing remarkable cases of thought transmission and other marvels during trance. It is interesting, however, that Mesmer's name is not mentioned at all in some of these books; the aura of charlatanry could not be dissipated. Matters were not helped by the development of hypnosis as a stage entertainment. There was also the fear that hypnotists might be able to manipulate their subjects for their own purposes; Svengali might be fictional, but could there not be real-life Svengalis? Mesmer regarded his ideas as thoroughly scientific, although admittedly he did later flirt with the occult. In the nineteenth century hypnosis was part of the stock-in-trade of occultists such as Helena P. Blavatsky, the founder of Theosophy, and there is still a widespread belief that the hypnotic trance affords a way into hidden depths of the mind. And although the term animal magnetism is little used today, very similar ideas keep surfacing under other names: for example, Wilhelm Reich's "orgone energy". MESMER AND HAHNEMANN The sixth edition of Hahnemann's textbook THE ORGANON contains a number of approving references to the then topical subject of Mesmerism. Hahnemann apparently used Mesmeric techniques himself, and he made a connection in his mind between the 'vital force' which, he believed, brought about healing, and Mesmer's 'animal magnetism'. Subsequent generations of homoeopaths have made little of the connection, however, probably because of the reputation for charlatanry that later became attached to Mesmer's name. The similarities between Mesmer and Hahnemann, both in career and in character, are in fact striking. It is worth listing them. 1. They were almost exact contemporaries. 2. Both came from fairly humble backgrounds (Hahnemann was the son of a worker in the Meissen pottery trade.) Neither had very much to say about his childhood, which may have been because neither was particularly happy. 3. Both qualified, rather late in life, as orthodox physicians and both adopted heterodox ideas that brought them into conflict with the medical Establishments of their day and came to dominate their lives and thought completely. 4. Both spent a considerable time in Paris. 5. Both had lawyers as prominent followers. 6. Both started as scientists and then moved gradually towards more occult or metaphysical ideas. 7. Both were characterized by feelings of injustice and persecution. 8. Both were intolerant of any deviation on the part of their followers, with whom they became involved in acrimonious and destructive disputes, which led to the closure of establishments set up to propagate their ideas (Mesmer's Society of Harmony, the Homoeopathic Hospital in Leipzig). 9. Both insisted that cure must always be preceded by an aggravation or crisis, no matter how brief and slight. 10. There are close resemblances between Hahnemann's vital force and Mesmer's animal magnetism. It is significant that some American homoeopaths actually suggested the existence of a homoeopathic force, which they called Hahnemannism by analogy with galvanism. CONCLUSION It seems that there is an inevitable contradiction inherent in the attempt to get alternative medicine accepted "officially" as valid. It can be done if its practitioners are prepared to compromise with the "establishment", but in the process they to may have to give up some of their cherished ideas and theories. It is usually this, quite as much as the difficulty of providing hard evidence for the efficacy of the alternative system in question, that causes so much heart- searching and agonizing. There will probably always be some people who feel that the sacrifice is simply not worth while, and who prefer to remain aloof from mainstream medicine altogether. The converse of this, however, is also true: increasing contact with the alternative forms of medicine is likely to alter doctors' thinking in ways that are not easy to foresee in detail; indeed it is already beginning to do so. 4: IDENTIFYING FEATURES People who subscribe to the view that unorthodox medicine should be alternative rather than merely complementary nearly always base this opinion on a number of characteristics which they think distinguish the kind of medicine they favour. These apply to most forms of alternative medicine but especially to the medical and physical therapies (Groups A and B, Chapter 2, p.00). Alternative medicine, we could say, is supposed to be: 1. natural. 2. traditional. 3. holistic. 4. vitalistic. 5. supported by modern physics. 6. more truly scientific than orthodox medicine. 7. optimistic 8. ecological 9. anti-authoritarian 10. capable of dealing with the real causes of disease But what do these claims really amount to? ALTERNATIVE MEDICINE IS NATURAL This is probably the single most important claim made on behalf of alternative medicine; no form of therapy is complete without it. It stems from a nostalgic yearning to return to Nature, to our Source. In its extreme form, this is a quest for what Marghanita Laski called the Adamic state. The designers of travel advertisements and brochures draw on this longing when they try to seduce us with their specious images of blue skies, empty beaches, and laughing figures redolent of eternal youth. 'For ever wilt thou love, and she be fair!' All the same, Mr Squeers was right: Nature is a curious concept. How we think of it at any given moment depends a great deal on social and economic circumstances. In Victorian times, Nature (the capital N was almost invariable then) was thought of as an arena of battle: 'Nature red in tooth and claw.' This interpretation of Darwinism derived, not from Darwin himself, but from philosophers such as Herbert Spencer who based themselves on Darwin, and it reflects the competitive entrepreneurial spirit of Victorian England. Survival of the fittest could be seen to be part of the 'natural law'; a satisfying idea for those who happened to have reached, or been born into, a superior economic and social position. For us, the ecology-minded descendents of those Victorians, the natural world has become a cooperative effort rather than a battlefield. We know, of course, that animals eat one another and members of the same species fight one another for territory or mates, but they do so only within certain limits. Predator and prey are not deadly enemies; the lion wants to eat the individual antelope but it doesn't want to destroy the whole herd - if it did it would have nothing left to eat. Predator and prey depend on each other in a delicate symbiosis, so that their relationship is more like a partnership than a struggle for survival. As for battles between members of the same species, these seldom lead to death for the defeated individuals, and in any case the conflict results in greater health and fitness for the species as a whole. Today we are taught to think of nature as forming a vast ecosystem, which would persist indefinitely in harmony with itself were it not for us. We are the wild card, the unnatural joker in the pack, who has entered the ecosystem and disturbed it, perhaps irreversibly. The evidence of our meddling is continually brought home to us in television programmes, books, and newspaper articles. We are made to feel guilty because we are destroying our planet by pollution, by upsetting its temperature control mechanism with carbon dioxide, by deforestation. Alternative medicine sees our orthodox medical treatments as one aspect of the ecological catastrophe we are in the process of bringing about. Our medicine, it could be said, is flawed in the same way as our management of the planet is flawed, and for the same reason: because we have moved too far from our roots in nature. Just as we insensitively try to 'conquer nature' on the outer level, so too on the inner, physiological, level we try to bulldoze our way to health. Antibiotics, corticosteroids, antidepressants, and the rest of the conventional therapeutic armamentarium may 'work' in a sense, the alternative purists admit, but they are 'against nature' and so can only lead in the end to worse catastrophes than those they are designed to cure. Notice that word 'armamentarium'. As Susan Sontag has pointed out, a lot of the vocabulary we tend to use (the 'fight against cancer') implies a military model for treatment, in which disease is the enemy, to be conquered by the doctor; an idea that is unappealing for alternative medicine, which more often sees your symptoms as your body's attempt to heal itself, and therefore not to be suppressed as in 'allopathy'. 'Primitive' peoples who live or lived close to nature - the Australian aborigines, the North American Indians, the forest dwellers of the Amazon - are said to preserve valuable information about the uses of plants and to possess sophisticated rituals of healing and psychotherapy that we have arrogantly spurned or even tried to suppress. Our own pharmacology, in contrast, is seen as crude, dangerous, and, inevitably, 'unnatural'. Some forms of alternative medicine make less claim to be natural than others. Patients who ask for homoeopathy often explicitly say that they want it because it is natural, but naturalness was not a selling point for homoeopathy originally - the quality was not so highly prized in the early nineteenth century - and even today more emphasis is placed on the safety and effectiveness of homoeopathy, and its 'holistic' character, than on its naturalness. However, homoeopathy is supposed to stimulate the natural healing properties of the body, instead of suppressing them as orthodox treatment is held to do, and the starting point of practically all the traditional homoeopathic medicines is a natural vegetable, mineral, or animal extract; often the plant or animal is used whole. In this respect homoeopathy is rather similar to herbalism, in which the medicines are typically prepared from the whole plant. This is said to be natural, in contrast to the products of the modern pharmaceutical industry, which are isolates of the 'active principle'. Using the whole plant is said to prevent adverse effects, because the various components balance one another instead of acting unopposed, as in 'allopathy'. Even within orthodox medicine, the use of whole plant extracts died out only quite recently. As late as the 1960s, when I was a medical student, some of the older physicians were still using digitalis (foxglove) leaf tablets to treat heart failure, in preference to the active principle, digoxin. There is a deep-seated belief in alternative medicine circles that herbal medicines - and by extension, 'natural' methods of treatment in general - are safe and somehow intrinsically virtuous, whereas 'drugs' are nasty and even vaguely immoral; a belief that slides rather easily into sentimentality. "Clear your mind of cant, sir," as Dr Johnson used to say. The natural world abounds with toxins - the deathcap mushroom, snake venom, puffer fish toxin; and of course bacteria and viruses, are all natural too. Comfrey, which has been widely recommended as a cure for migraine, and indeed does seem to work for this purpose, has been suspected of causing liver damage. The idea that nature is inevitably benevolent is extraordinarily sentimental. Mother Nature is not only Mother Divine, taking care of her children; she is also Kali, dancing naked on the bodies of her victims and wearing a necklace of human skulls. She cares nothing for the survival of the individual, only for the species. The corollary of the view that natural = good is, inevitably, the corresponding equation: artificial = bad. I think it is this notion that underlies the belief, taken seriously by some people, that the Aids virus was manufactured deliberately by bacteriological warfare laboratories in the USA or the USSR (take your pick according to your political attitude) and then either escaped or was disseminated deliberately. The psychological basis for this belief seems to be the feeling that a benign nature would not have produced such a terrible plague; it must have been due to human malevolence. But even if it were true - even if Aids had really been produced artificially, by genetic engineering (a telling expression), would that make it 'unnatural'? An important question, surely. Can anything that happens, no matter how technological, really be outside nature? After all, we ourselves are part of nature, not separate from it. In fact, it's the delusion that we can escape from the natural consequences of our actions that has led to the seemingly disastrous situation we find ourselves in today. The physicists who made the first nuclear explosion depended after all, on the cooperation of the laws of nature. Usually, however, we do tend to think of ourselves as in some sense having lost contact with nature, and this is perceived as a Fall from Grace. There is a clear moral implication in this perception, which emerges in the kinds of things patients say. They announce: "I eat all the right things," with the unspoken implication that they deserve praise for this. And if, in spite of eating all the right foods, doing all the right things, and thinking all the right thoughts they nevertheless become ill, they feel aggrieved. It wasn't fair, they complain. When we set the word 'fair' down on paper we at once see the absurdity of applying it to nature; we don't, rationally and consciously, expect nature to be fair. But emotionally and unconsciously we do, thanks to an enormous amount of propaganda on its behalf in recent years in books, magazine articles, and on television. Part of the reason we expect this is probably the decline of formal religious belief. In other times people looked to God to hand out appropriate rewards and punishments, either in this life or the life to come. Now that many of us no longer believe in a future life or, except vaguely, a God, we transfer our longings for justice to a semi-personalized Nature. (The Victorians spoke of Providence in this way, and I remember, as a child, puzzling over the question whether Providence was or was not the same as God, and, if not, what the difference was.) "When people stop believing in God, they don't believe in nothing, they believe in anything." (G.K.Chesterton) The problem with casting Nature in the role of God is that she inherits the metaphysical uncertainties that used to attend Divinity. 'If God is all-powerful and all-good, why does He permit evil to exist in the world?' we used ask. Now it's Nature who has to answer this question. In fact, however, we don't expect quite so much from Nature as we used to expect from God, if only because most enthusiasts for purist alternative medicine are not much given to metaphysical speculation and don't ask the really awkward questions. Nature can get away with more than God used to do. ALTERNATIVE MEDICINE IS TRADITIONAL Nature and tradition are closely allied concepts in alternative medicine. The underlying assumption is that our hunter - gatherer ancestors lived happy lives in total harmony with nature, free from environmental poisons and pollutants, successfully treating such few illnesses as they might acquire with plants gathered from the forest. Those happy days are long gone, but we can, via our television screens, glimpse people still leading a version of this idyllic existence in what remains of the Amazon or African rain forests. Several overlapping myths seem to be present in this idea, or perhaps it is the same myth that has reappeared more than once in history in different guises. There is the myth of the Garden of Eden. There is the myth of Arcadia, the idyllic rural setting where every prospect pleases. And there is the nineteenth-century myth of Rousseau's Noble Savage, uncontaminated by civilization. The combination of these fantasies is extraordinarily powerful, and not necessarily wholly delusive. The forest dwellers do still exist, just, and there are important lessons that we could learn from them before it is too late. But they are not 'primitive'; their societies are complicated and sophisticated, even if not in the way that ours is, and it is patronizing of us to say otherwise. Probably the nearest we can get to the primitive origins of our species is to study the way of life of our closest living relatives, the chimpanzees. Thanks to Jane Goodall's work at Gombe we now have a much better idea about this, but the implications are not wholly reassuring. True, chimpanzees have the beginnings of a 'culture', and they also take 'plant medicines' when ill: evidence, if you like, that these things are 'natural'. But in that case, murder, infanticide, and warfare are also 'natural' since chimpanzees seem to indulge in these activities too. But we don't have to go so far back as that, you say. Are there not more recent societies or civilizations from whom we could learn: the Indians of North America, for example? We read moving statements by American Indian shamans and chiefs, lamenting the destructiveness of the white man. (It is remarkable, incidentally, how radically the popular image of the 'Redskin' has been transformed in the last twenty or thirty years, from tomahawk-wielding savage, fit only to be mowed down by the superior courage and technology of the white man, to sage guardian of truths we are in peril of losing for ever.) Indeed it is probable that a considerable number of herbal medicines were borrowed from the Indians by nineteenth-century American settlers. The idea of looking to the New World for traditional knowledge is a fairly new development, however. The favourite region in which to seek wisdom remains the East, as it has been since Roman times. Acupuncture has been with us for a long time, but there have been fresh imports recently: Japanese, Indian (Ayurvedic), and even Tibetan traditional medicines are beginning to arrive in the West. It is not every alternative therapy that can claim an antiquity as impressive as that of acupuncture or Ayurvedic medicine. Even so, practically all the therapies make at least some claim to have roots in tradition; certainly it is very difficult to think of any system that makes a virtue of being completely new and original. Those therapies that are not obviously ancient, such as osteopathy and chiropractic, homoeopathy, Anthroposophical medicine, and the Alexander technique, do the best they can by pointing to a Founding Father (or sometimes Founding Mother). This may seem like a trivial comment, since it is clear that if a system did not originate in the mists of antiquity or even prehistory, as did acupuncture, for example, there must have been someone who invented or discovered it in the first place; but the important thing is that this person almost invariably becomes invested by practitioners of the system with an aura of near- infallibility. As Jung (who is himself an illustration of the process) would say, this is an activation (or 'constellation') of the archetype of the Wise Old Man. Even if a therapy is relatively recent, there is often a tendency for its advocates to try to trace the underlying concepts as far back as possible, as if proving their antiquity would somehow validate them. Claims are often made that the treatment in question was anticipated by Hippocrates, always a favourite ultimate progenitor. This is true of homoeopathy, which seems to be exceptionally richly endowed with authority figures, starting, of course, with Hahnemann himself. ALTERNATIVE MEDICINE IS HOLISTIC This is another pretty well universal claim of alternative medical systems; indeed, the description of a treatment as natural and holistic could be said to identify it as alternative. But it can sometimes be difficult to ascribe any definite meaning to the term except as an indication of approval. What does being holistic actually amount to? Indeed, is it really much more than a card of identity, a label that people attach to themselves or their method to indicate their allegiance to a cause? One might expect that a truly holistic practitioner would be one who had a practical grasp of several methods of treatment, or was at least sufficiently familiar with a large range of alternative (and, ideally, orthodox) treatments to be able to advise patients about which would be most likely to help them. But this seldom seems to be the case; more often therapists seem to be firm adherents of one or two kinds of treatment, and indeed there seems to be a certain amount of suspicion of a more eclectic approach, people who use it being regarded as dabblers. Each therapy tends to have its own view of what holism means. For some it is a good deal more elaborate than for others. The Western manipulative methods, osteopathy and chiropractic, are probably the least concerned with constructing comprehensive theoretical frameworks. The oriental therapies, on the other hand, arrive equipped with ready-made and very detailed schemes. Homoeopathy, in this as in some other respects, is somewhere in the middle. Homoeopathy does have a tendency to take on philosophical or metaphysical characteristics. This has happened a number of times in the past, most notably in the USA in the late nineteenth century, when it became interwoven with Swedenborgianism. In Britain, homoeopathy has on the whole been more down-to-earth, and the claim that it is holistic is usually based not so much on philosophical ideas as on the fact that it takes the patient's personality and individual reactions into account. The main weakness of this claim is that the commonly used homoeopathic history-taking, although elaborate, is somewhat stereotyped, and usually ends in the selection of one of a fairly small group of medicines. (A number of computer programmes for selecting medicines have been introduced in the last few years, and it is hoped that these will improve the accuracy and scope of the process.) Another way in which alternative medicine is often said to be holistic is that it is not supposed to deal in disease categories; these are said to be a feature of conventional medicine, and derive from its insensitive lack of concern for the individual. 'There are no such thing as diseases, only sick people.' Taken to an extreme, this would mean that an alternative practitioner would have no interest at all in making a conventional diagnosis, and some practitioners do indeed adopt this viewpoint. Rejection of diagnostic labels is an ancient idea that surfaces a number of times in the history of alternative medicine. It was held, for example, by Paracelsus, that maverick among physicians and forerunner of many alternative practitioners down to our own day. Hahnemann held the same view, which he had probably arrived at independently. Modern non-medical practitioners also advocate it at times and it is easy to understand why: it exempts them from the need to bother about orthodox medicine. Even within orthodox medicine the concept of disease categories is challenged seriously from time to time, especially by psychiatrists. There are for example considerable differences in the ways that British and American psychiatrists diagnose schizophrenia. Indeed, it is in psychiatry that the conventional medical model seems most open to question, as Thomas Szaz has pointed out in The Myth of Mental Illness, and since alternative medicine has much in common with psychotherapy it is not surprising that we find alternative practitioners expressing reservations about the value of diagnosis. Probably the truth lies somewhere in the middle. It is undeniably often convenient, in fact pretty well unavoidable, to use disease categories. (Could you go through life without using the concept of the common cold?) Problems arise, however, if we adhere to them too rigidly, or fail to recognize that there can be many individual variations among people who have been affixed with the same disease label. But awareness of this truth is not confined to alternative medicine; it is characteristic of good conventional medicine too. The commonest problem with conventional diagnosis is not that diagnostic labels are used, but that they are used inappropriately, as a cover for ignorance. All of us (not just doctors) feel more secure if we think we have identified something and given it a name. Patients, too, feel this; they constantly ask: 'Is it arthritis?' (or ME, or allergy, or whatever is fashionable at the moment). Having a label does not necessarily help in treatment, but it gives a (usually spurious) sense of control. However, labels can also inhibit further thought and action, and this is my real objection to them. Many patients, for example, have pain in their neck radiating down into their arms or shoulders. On the basis of an x ray which has shown the kinds of changes that almost everyone acquires as they age they have been told that they have arthritis and nothing can be done about it. But this is doubly misleading. First, the x ray changes may have little or nothing to do with the symptoms patients experience; there are plenty of people with severely abnormal x ray findings and few or no symptoms, and conversely others who have a great deal of pain and hardly any x ray abnormalities. Very often neck pain arises from the muscles and other soft tissues rather than from the bones and joints. Secondly, quite a number of these people can be helped a good deal by physical methods: I use acupuncture for this, but manipulation or other forms of treatment (all of which, probably, act in much the same way) can work well too. To label such people as arthritic is both inaccurate and unhelpful, since it tends to paralyse further thought. This is one of the ways in which the use of excessively materialistic ways of thinking can be damaging. As Dr R.S. Macdonald, an osteopathic physician, has put it: Orthodox doctors are used to seeing such abnormalities as tight muscles, restricted joints, and tenderness, around areas like a fractured bone, inflamed joint, abscess, or cancer. Therefore, whenever these abnormalities are found, it is not surprising that the orthodox doctor presumes there is some pathological cause. In similar circumstances, the osteopath will always consider the possibility of pathology but, when no evidence for it can be found, the osteopath will diagnose only the dysfunction observed. [Natural Health Handbook, 128]. This is an important principle that ought to be applied much more widely in medicine, not just in osteopathy. Doctors are trained to look for pathology: that is, for definite abnormalities which can be detected by x rays, blood tests and so on, and they are taught to regard it as a failure if they miss such an abnormality. And this is how it should be; the doctor should make every effort to reach an accurate diagnosis if possible. But the concept of 'accurate diagnosis' needs to be expanded to include the idea that there are many medical problems which must, indeed, have a 'cause' in the widest sense of the word, but not necessarily a cause that can be detected by conventional tests. The abnormalities exist but they are subtle and sometimes transient. A good example is the muscle trigger point, or trigger zone. These are tender areas in muscles which hurt when pressed and can give rise to 'referred' pain and sometimes other symptoms in areas of the body some distance away. Trigger points in the back of the neck, for example, can give rise to headache often localized in the forehead or around the eyes, and this is often labelled incorrectly as 'sinus headaches'. No one knows what muscle trigger points are, though there are several theories. Nearly everyone has a few, which are usually latent, not causing any problems; but unaccustomed over- use of a muscle, psychological tension, and probably many other things can cause them to become active and give rise to symptoms. It is very easy for any doctor to convince himself that trigger points exist - he need only examine a few patients and look for them - so why are they not generally recognized? Because they are not taught in medical school. This in turn is presumably because they cannot, so far, be detected by laboratory or other tests; they are outside the scope of present-day medicine. Describing a patient as suffering from a muscle trigger point disorder is still attaching a label, making a diagnosis, even if an unconventional one. For that matter, it is attaching a label to say, as many homoeopaths do, that a patient is a 'sulphur type', an 'arsenicum type', or whatever. We cannot speak or think about anything without using categories. Instead of deluding ourselves that we can we ought to be more relaxed and undogmatic about the labels we do apply. As a rule, the label 'holistic' is used so loosely as to be nearly meaningless. It is almost invariably attached to any kind of alternative medicine you care to think of, but often all it seems to mean is that the practitioner is applying the principles of his own particular form of therapy. These are different, certainly, from those of orthodox science, but they are often just as rigid, just as stereotyped, in their own way. The real problem is that we as a society have no definite agreement about what constitutes a human being. The dominant scientific model is a mechanistic and materialistic one, in which human beings are thought of as flesh and blood computers transported about in bodies. To this view the alternative medicine movement opposes its body, mind, spirit model, but this is simply a set of words and is so vague as to be able to accommodate pretty well any theory you want to think up. It seems preferable to avoid both these models. If holism means anything in this context, it should indicate an ability on the part of the practitioner to assess the patient's needs in relation to a wide range of possible therapies, some orthodox, some alternative, without necessarily distinguishing rigidly among them. It should also include the ability to know when it is more appropriate not to give any treatment at all. Holistic treatment in this sense is undogmatic, not tied rigidly to any view of human nature, able to select from a wide range of therapeutic possibilities. ALTERNATIVE MEDICINE IS VITALISTIC The debate between vitalists and mechanists is an ancient one, indeed it goes back to the dawn of philosophy. Until relatively recently the vitalists appeared to be winning, which is hardly surprising. After all, living creatures are 'obviously' different from non-living matter, and it seems a matter of mere common sense to classify the world into two broad categories, living and non-living. We can then subdivide the living in various ways: plants and animals, fish, birds, beasts, and so on. But the gulf between living and non-living systems is apparently the widest of all and is fundamental, underlying all the others. In earlier times it was generally held that there is some kind of subtle substance or force that is responsible for life. In the case of animals and human beings, at least, this principle of life was often identified with the breath, doubtless because we only stop breathing when we are dead. This might be conceived of in a fairly literal way, so that the soul was thought of as escaping from the dying body in the last breath. In Greek, pneuma refers both to breath and to spirit, and the same idea is found in the Sanskrit prana; yogic breathing exercises are called pranayama, but prana is also the universal breath of life. We tend to interpret such statements poetically or figuratively, but for the ancients they were literal equivalents. The corresponding Chinese concept is chi. In keeping with the rather materialistic character of much Chinese thought, chi is supposed to have a number of specific functions in the body, which are worked out in considerable detail, and it circulates in well-defined channels, the so-called meridians. But an individual's chi is not self-contained in the way that Western science thinks of each person's blood volume as an isolated entity; rather, chi is constantly flowing in and out of the body, which is therefore in communication with cosmic chi. The actual nature of chi is difficult to specify in Western terms; it is neither energy nor matter but has characteristics of both of these, and so lies on the border between them. Even in ancient times, however, in India and elsewhere there were materialists who did not accept that there is anything like a soul in living creatures. This minority view gradually gained increasing acceptance in Western thought after the Middle Ages, as the mechanistic outlook came to predominate; William Blake's hostility to Newton reflects an awareness of the coming change in our perception of the world. Descartes took matters further by claiming that animals were automata, though for religious reasons he stopped short of applying the same idea to human beings. Ideas that were surprisingly similar to those of ancient China and India continued to be current in Western medicine until as late as the nineteenth century. Vitalism was taught in France at the respected University of Montpellier, where it was held that the vital force had its seat in the brain, whence it travelled via the nerves (thought of as hollow) to reach the different parts of the body. But major changes were on the way. Hitherto it had been supposed that there is something uniquely special about the chemical processes that occur in living creatures, a belief that is enshrined in the name 'organic chemistry'. Then a chemist synthesized urea. This may not seem a world-shaking event, but in fact it was, because hitherto urea had been thought to be produced only by animals. And urea was only the first of numerous other organic compounds to yield to chemical synthesis, until it was finally realized that organic chemistry was simply the chemistry of carbon. The reason that carbon is so special and is capable of being the essential building block of life is that it has four valencies or 'hooks' by which it can link up to other atoms, including other carbon atoms, to make long chains or rings; but otherwise there is nothing mysterious or 'living' about it. Vitalism was not immediately discredited by this discovery. But it was now definitely on the defensive, and as time went by it began to look less and less convincing. The last major philosopher to base his thinking on vitalism was Henri Bergson. In modern science vitalism is no longer discussed at all; it has gone the way of the phlogiston theory as an explanation of combustion and of the cosmic ether as a conductor of electromagnetism in space. It is doubtful how far such thinking has penetrated the thinking of non-scientists even today, however, and this may help to explain some of the popularity of alternative medicine, which is firmly vitalistic in outlook. Hahnemann, after an initial hostility to vitalism, adopted it as a principle of homoeopathy; healing, he said, depended on the operation of the vital force or dynamis, and so did the process of 'dynamization' which he used to make his medicines. Homoeopathic medicines, as conceived of by Hahnemann, could thought of as the vital force caught in a bottle. Pragmatic British homoeopaths, such as Richard Hughes and Robert Dudgeon, rejected both vitalism and dynamization. The concept of vital force is closely intertwined with that of energy; indeed, the two are often almost synonymous. 'Energy' is a precise term in physics, but in alternative medicine it is used far more loosely, and generally amounts to a little more than a metaphor. In spite of or because of this vagueness, energy is a near-universal item of conceptual currency for people in alternative medicine circles. There is much talk of healing energies and of energy centres in the body (these usually derive from the chakras of yogic physiology), and patients sometimes talk of feeling that their energy is blocked. This borrowing of 'energy' from physics (together with certain related terms, such as 'vibration') is symptomatic of a curious symbiosis that exists between alternative medicine and physics. ALTERNATIVE MEDICINE IS SUPPORTED BY MODERN PHYSICS Mainstream physics and cosmology today are so strange, so contrary to common sense expectations, that it is hardly surprising if those of us who are not physicists begin to get the impression that almost anything goes - that there is hardly any conceivable possibility that is too strange not to have at least the chance of being true; we remember J.B.S. Haldane's celebrated remark that reality is not only queerer than we suppose, it is queerer than we can suppose. Numerous books by physicists have appeared, popularizing quantum physics and cosmology. What is more, some physicists have espoused the kinds of thinking that appeal to people interested in alternative medicine and the paranormal. The connection between physics and the occult is hardly new, for no less a scientist than Isaac Newton spent many years working on practical alchemy, but more physicists seem to be willing to look at such matters today. To name just a few, Wolfgang Pauli collaborated with Jung in formulating a theory of psychologically meaningful coincidences, Henry Margenau has written a good deal about the paranormal, and Fritjhof Capra has written best-sellers about the apparent similarities between mystical and scientific world views and about New Age thinking, including alternative medicine. And if some physicists have expressed interest in unorthodox ideas such as alternative medicine, alternative practitioners have not been slow to return the compliment. There have been attempts by homoeopaths to construct physical theories to explain the apparently paradoxical claim that medicines which are so dilute that none of the original substance is left can nevertheless have a beneficial effect. These theories have usually been based on somewhat esoteric physics concerning the properties of water. Other alternative medicine enthusiasts have written at length about electromagnetic fields that are supposed to surround living organisms, including trees as well as human beings. Sometimes speculations of this kind remain at a fairly theoretical level, being designed to provide scientific support for pre-existing systems of ideas derived from other sources, but often they merge insensibly with practical techniques of diagnosis and treatment. These techniques can rely simply on the operator's hands, but more often they use apparatus, which may be as simple as a pendulum or as complicated as an electrical machine costing hundreds or even thousands of pounds. The starting point of much of this is radionics and radiaesthesia. A number of lay practitioners of various therapies, and some doctors also, use a pendulum to diagnose allergies and other problems and to decide which medicine to prescribe. This can go to extreme lengths; it is somewhat alarming to see an otherwise intelligent person who is so convinced of the validity of these methods that before she eats or drinks anything she has to test it with her pendulum to see whether it is suitable for her. Numerous machines have been manufactured to do the same sort of thing in a more complicated way. In some, the patient merely holds a metal contact to connect her to the machine, while the therapist adjusts the settings to obtain a reading. This may indicate the homoeopathic or other medicine that is required or may give an indication of what sort of acupuncture treatment should be given. More elaborate and expensive machines take readings from the whole of the patient's body as she lies on a special couch. As a variant on this, machines exist that purportedly make homoeopathic medicines by radionic means without the need to go through the steps of manufacture traditionally used. There are other diagnostic methods allegedly based on physics. One of these is Kirlian photography, which is sometimes claimed to produce a picture of the human aura. It does this by placing the object (usually a human hand) in a strong electrical field and photographing the consequence emission of electrons. In spite of the apparent technological sophistication of some of the devices used, there is almost no independent objective evidence that any of them produce any meaningful information at all. Most of the machines now in use appear to depend heavily on self-deception. There has, however, been one curious apparent exception to this generalization, in the investigations carried out many years ago by Dr William Boyd, a homoeopathic doctor in Glasgow. Boyd was a careful scientist, who made a number of pioneering studies of homoeopathy between the wars. One series of these concerned a machine he invented called the Emanometer, with which he claimed he was able to detect an 'energy' of some kind, which he thought was similar, though not necessarily identical, to radio waves (radio was at the time a fairly new invention, still, literally, very much 'in the air'). He was apparently able to detect various abnormalities in patients, sometimes before they themselves were aware that anything was wrong, and he could also distinguish various homoeopathic medicines from one another. In 1924 a committee under an eminent physician, the future Lord Horder, investigated the Emanometer; later the committee was joined by E.J. Dingwall, research officer of the Society for Psychical Research and an authority on fraud. The committee concluded that Boyd was certainly able to detect something with the Emanometer, but they had no idea what it was or what it meant. They were also careful to say that there was as yet no good evidence that the Emanometer could be used in diagnosis or treatment - a cautious attitude that Boyd himself fully shared. The Emanometer was difficult to use in practice, and after Boyd died work on it was abandoned. It is impossible now to say whether some form of 'energy' was detected in the experiments or whether there was, after all, some subtle error in the set-up which no one noticed (that Boyd produced his results in good faith seems beyond doubt). This unsatisfactory result is rather similar to the uncertainty that afflicts scientific research into the paranormal, which often seems to be on the verge of yielding definite proof but somehow always fails to do so at the last moment. The resemblance may not be accidental; it is conceivable that, if paranormal abilities do exist, these are what Boyd possessed. All this work was carried out a considerable time ago, and is remote from the main direction of research in homoeopathy today. I will return to this later, but for the moment I want to look at the question of science and alternative medicine from a different angle. Alternative medicine is the only truly scientific form of medicine. This claim keeps being made, especially by the more philosophically-minded non-medical homoeopaths. Harris L. Coulter, for example, writes that: The principal difference [between homoeopathy and allopathy] is that homoeopathy is a precisely structured doctrine. Even though most of its ideas find their parallel in allopathy, it differs from the latter in that the homoeopathic ideas are mutually consistent and coherent... Allopathy, in contrast, lacks a precisely defined and delineated set of ideas. It accepts concepts, principles, and procedures from any number of sources, with the result that the various parts of allopathic doctrine are at times inconsistent, and even incompatible, with one another... [Homoeopathic Science and Modern Medicine, 93 - 94] This is a fascinating passage, for it beautifully encapsulates the difference between a scientific and a dogmatic approach, although not quite in the way Coulter intends. Everything depends on what we understand by the scientific method. Coulter evidently believes in the Baconian model, which is based on the principle of induction. According to this model, what we have to do is to keep accumulating facts until at last we discern the theory that fits them; the more facts we can find to support the theory the better. There is a fallacy in the idea of induction, which was pointed out long ago by David Hume and has continued to perplex philosophers ever since. It would take too long to discuss it in detail here, but we can get at the essence of the matter by considering the question of apotropaic magic. For many traditional societies, an eclipse of the sun or moon was, understandably, an awe-inspiring and alarming event. Often it was thought that a dragon was eating the sun or moon; in order to frighten it away the people would beat drums and perform magical rites. Fortunately these always worked. The success of the method proved, naturally, that it was the right one, and no one would be rash enough to try the experiment of doing nothing to see what happened. In this case, clearly, the theory was fully confirmed by the facts. It was nevertheless mistaken. The extraordinary scientific advances that have occurred in the last three hundred years or so have come about because this way of confirming theories gave way to another approach, which might be called the iconoclastic method. The iconoclastic method consists, essentially, not in looking for facts that support our theory, but in trying to find facts that contradict it. To put the matter less paradoxically, we ask what things the theory predicts should happen or should not happen, and then see if they do (or don't). The critical word here is 'predicts'; a genuine scientific theory has to be ready to risk its reputation by making predictions which, if falsified, disprove the theory or at least demand that it be modified. On this view of science (which I have, of course, taken from Karl Popper, currently regarded as the foremost modern philosopher of science), any theory which is truly scientific has to have a provisional character. There are no absolute truths in science. We can never know for sure whether any scientific theory is really true; all we can say is that it has not been found wanting so far. No matter how many facts you find to support your pet idea, this will still not make it into a law of nature. In fact, there are no natural 'laws' in this sense; all are in the last resort provisional and open to challenge. And this sometimes happens in practice: for example, Newton's gravitational law, for so long regarded as the ultimate example of an immutable scientific principle, has in our own day had to be modified in the light of Einstein's Special Theory of Relativity. The reason I have laboured this question is that the modern view of science stands Coulter's argument on its head. He may well be right in claiming that homoeopathy is a 'precisely structured doctrine', based on 'mutually consistent and coherent' ideas (although it would be possible to argue that they are not quite so consistent and coherent as he says they are), but in so far as it is so based, it is not scientific. The more you make homoeopathy or any other set of ideas immune to challenge and criticism the less truly scientific they become. Conversely, of course, the more you try to make homoeopathy scientific by carrying out clinical trials and subjecting its basic concepts to the kind of criticism that other scientific theories have to withstand, the less of a 'doctrine' it will be. This is the dilemma that confronts all would-be homoeopathic purists who want to represent themselves as scientific. Similar difficulties are faced by purist supporters of other kinds of alternative treatment. It may indeed be possible to make some of these methods more scientific, but there will be a price to pay in terms of the 'purity' of the system. ALTERNATIVE MEDICINE IS OPTIMISTIC If there is one feature of alternative medicine which, more than any other, distinguishes it from orthodox medicine, it is the extent of its optimism. From an advertisement for a homoeopathic clinic: Most certainly, the alarming rise in all killer diseases, such as asthma, epilepsy, and heart-related chronic disorders, claim hundreds of thousands of precious lives each year. Yet there is hope, for at ..... we are helping all types of people suffering from a vast array of chronic life-threatening diseases, termed incurable by conventional medicine... This a particularly naive example of the genre, no doubt, and the implied claim of a universal panacea is certainly unusually blatant. But the confidence that alternative medicine has a cure for practically everything that orthodox medicine can't help is not unusual. Anything that the body can regenerate, homoeopathy can encourage happening. Uterine fibroids can dissolve, brittle nails can go away. All kinds of viral problems can abate. Aids. Obesity. Anything that the body can throw off, we have mechanisms against. The idea is just to stimulate the body and get those mechanisms working. [Quoted by Coward, 47-48, from Homoeopathy Today, 1986] Although some non-medical alternative practitioners are commendably cautious about what kinds of problems they will take on, others are not; and the result is that many patients acquire quite unrealistic expectations of what can be achieved. It is quite common, for example, to find patients whose blood pressure is dangerous raised, to a point at which they are at considerably increased risk of a stroke, asking for alternative treatment in place of conventional medicines, or patients with troublesome gallstones who expect them to be 'made to dissolve' homoeopathically. Sometimes it can be quite difficult to convince such people that what they are asking for cannot be done. I sometimes get the impression that one reason for the existence of this over-optimism among patients is their belief in a conspiracy theory. Conventional doctors are seen as deliberately blackening the reputation of alternative medicine out of a misplaced sense of professional pride. But this is by no means the whole of the story. There is a deeply held belief in alternative medicine that the body has its own wisdom and, left to itself, will heal itself. Indeed, our 'natural' state is said to be health; disease is unnatural. In a sense, disease (often rendered as dis-ease, to emphasize the point) is almost an irrelevance, a distraction from the real business of staying healthy. In this respect, as in some others, there is an increasing amount of common ground between orthodox and alternative medicine. The government - responding, no doubt, to popular pressure - is placing more emphasis now on the prevention of disease; general practitioners are being encouraged, in fact almost compelled, to practise 'preventative medicine', to such an extent that we read of doctors who strike patients off their lists because they refuse to attend for 'health checks'. Many doctors are sceptical, probably rightly, about the value of much of this screening, but it is difficult for them to resist the demand. ALTERNATIVE MEDICINE IS ECOLOGICAL Interest in alternative medicine often shades off imperceptibly into wider concerns, for example with the state of the environment. The word 'ecology', which ten or fifteen years ago would probably have been unknown to many people, now turns up all over the place, and we are all being reminded constantly of our responsibility for the condition of the world. Although I have no figures to prove it, most of the people who feel strongly about environmental matters would probably also be sympathetic to alternative medicine, and the reverse is likely to be true as well. Probably the equation is not always fully worked out consciously, but there is a sense in which avoiding causing pollution in the world can be related to not taking harmful 'drugs' into our inner environment, while a concern for preserving the balance in nature outwardly can be correlated with allowing the body to heal itself instead of disturbing its equilibrium as conventional medicine is said to do. (I return to the 'public health' implications of alternative medicine in Chapter 12.) ALTERNATIVE MEDICINE IS ANTI-AUTHORITARIAN The expression 'doctor's orders', which used to be heard a lot forty or fifty years ago, may not have disappeared completely, but it is certainly much less common today. The notion of the doctor as the expert who must be deferred to is becoming unfashionable, and instead we are encouraged to take responsibility for our own health, and to view the doctor as a co-worker in the enterprise rather than an authority figure. In some ways this change is more apparent than real. People may say they want to have more responsibility for their health, but when it really matters they are often quite happy to leave decisions to the doctor. Partly this is because the complexity of modern medicine means that patients can't easily assimilate information when they are given it, but partly, also, it is because people who are seriously ill don't necessarily want all the information which, in health, they might have thought they would. A personal account written by a doctor a few years ago illustrates this. He was a retired physician who had to go into hospital for a major operation. As he was a colleague, the surgeon started to explain all the technical details of the treatment he proposed to carry out, but the physician did not want to know, and simply asked the surgeon to get on with things as he thought best and spare him the details. If this is how a medical patient felt, many who are not medically qualified would surely react in the same way. But some people do want to know what is being done to them and some want to be actively involved in their treatment. In theory, alternative medicine is supposed to encourage patient participation, but there often seems to be a tendency for the alternative therapist to take on the role of the expert which the doctor is supposed to have abandoned. And patients usually go along with this, which is hardly surprising; for unless you regard a therapist as an expert in his field, what is the point of asking his opinion? A recent survey of complementary practitioners in the Midlands, which was carried out by Ursula M. Sharma of the Centre for Medical Social Anthropology at the University of Keele investigated this question among others. Dr Sharma found that although the therapists she interviewed generally believed in treating the patient as an individual and expected her to be an active partner in treatment, they were also pulled in the other direction by their wish to be more 'professional' and to lay claim to genuine forms of specialized knowledge. As Dr Sharma remarks, 'The practice of non-orthodox medicine abounds in contradictions, some internal and others imposed from outside.' [Complementary Medical Research, 1991, 5, 12 - 16] The Founding Fathers and Mothers of alternative medical systems are often, indeed nearly always, strongly authoritarian. Hahnemann, for example, would tolerate no deviation on the part of his disciples. He referred contemptuously to those who combined homoeopathy with allopathy as "half-homoeopaths". When one of his closest disciples, called Gross, who had had the misfortune to lose a child, remarked that the experience had taught him that homoeopathy was not the answer to everything, Hahnemann was furious and never fully restored him to favour. And when a Homoeopathic Hospital was established in Leipzig Hahnemann, by now living at Kothen, took exception to the Medical Director on the grounds that he was not sufficiently committed to homoeopathy and had him replaced; unfortunately the new Director soon left and his successor, who bore the appropriate name of Fickel, took the job with the undeclared aim of discrediting homoeopathy, and the ensuing debacle led to the closure of the hospital. We have already noted the similarities between Hahnemann and Mesmer (p.000); Mesmer, like Hahnemann (and Kent) was an extreme authoritarian. (The same, incidentally, is true of Freud; and psychoanalysis has many of the features characteristic of an alternative medical system.) The trend towards authoritarianism in alternative medicine persists undiminished today. It is not difficult to think of practitioners who have built up considerable followings of patients and pupils who accept their gurus' ideas unquestioningly and proselytize for them enthusiastically. Alternative medicine deals with causes Many patients say: "I don't just want to take a drug to suppress my symptoms, I want to find the cause." This idea is very prevalent in alternative medicine; we constantly see claims that conventional medicine merely deals with the manifestations of disease instead of eradicating it at the root. On the face of it this is rather strange, for if you asked most orthodox doctors what they think of alternative medicine their main criticism of it would be that it is merely a placebo which may help on a symptomatic level but does not tackle the causes of disease. We are therefore confronted with the curious paradox that both sets of practitioners believe that they are treating the causes of disease while their opponents are merely offering palliatives. The explanation is that the two groups have different ideas about what counts as a cause. Medical students are sometimes taught a little mnemonic for the possible causes of disease: Tumour, Trauma, Toxin, Degenerative, Deficiency. This scheme does not cover all the recognized possibilities and is old-fashioned in certain ways, but it does help to prevent one forgetting the major causes. Tumour and trauma are fairly self-explanatory. Toxin includes not only poisons of various kinds but also two very large subdivisions, bacterial and viral infection. Degenerative includes the inevitable accompaniments of aging and also the 'autoimmune' disorders, such as rheumatoid and certain other kinds of arthritis. Deficiency includes food, mineral, and vitamin deficiencies and also internal failures of glandular secretion such as thyroid deficiency and sugar diabetes. To these groups of causes we must add one large and important category, Unknown. Very gradually, diseases move out of the Unknown into one of the other groups. There is also movement among the (more or less) Known groups, so that, for example, Alzheimer's disease, which twenty or thirty years ago was thought of as more or less an inevitable accompaniment of aging, and therefore Degenerative, is increasingly suspected of being a Toxic disease, in some way related to aluminium accumulation in the brain. Parkinson's disease, which similarly used to be classed as Degenerative, is likewise now thought to be perhaps caused by an environmental toxin or possibly by a dietary deficiency of some kind. There is another way of thinking about causation of disease, which is to look at what happens pathologically. A good deal of the space in medical textbooks is concerned with this aspect. In the second half of the nineteenth century it came to be recognized that the organs and tissues are made up of cells, and techniques were developed by Virchow, Ramon y Cajal, and others to allow these microscopic structures to be investigated in health and disease. In this way it came to be seen that disease processes could be understood at the cellular level. At much the same time, other workers were exploring the chemical constitution of the body, and finding that alterations in what came to be called biochemistry underlay many manifestations of disease. In our own day these trends have been taken much further. We no longer are confined merely to studying cells; now it is possible to analyse the molecular processes that occur inside the cells. As well as chemistry, we have a whole new science, immunology, with its own concepts and vocabulary. Viruses, which previously were too small to be analysed, can now be taken to pieces to allow their method of working to be understood. It is even becoming possible to replace individual faulty genes with good ones. And it is not just at the microscopic level that so much has been achieved; now it is possible literally to see into the living body without damaging it. Until quite recently almost the only tool available for doing this was the X ray. This merely provided pictures of 'shadows from shadowland', as the actor representing a radiologist in an American film once absurdly expressed it. Now radiology is simply one part of the much grander subject of 'medical imaging'. There are ultrasound echo techniques, which can be used to show the working of the heart or the condition of the fetus before birth. We have computer- assisted tomography, magnetic resonance imagery, and positron emission tomography, all of which are capable of giving the most astonishing three-dimensional pictures of the interior of the body. And it is possible to insert fibre-optic devices into all kinds of body cavities to allow the surgeon to see what is going on there. It is hardly surprising that, with all this in mind, modern doctors feel that they are able to say a good deal about the causes of disease. For alternative medicine, however, much of this is beside the point. No matter how much you understand about the mechanisms of disease, the argument goes, you still are not really dealing with The Cause. Bacteria and viruses may be proximately responsible for disease (that much is generally admitted by even the most radical enthusiasts for alternative medicine), but these organisms couldn't gain a purchase on us if we were not already weakened by other things. Alternative medicine makes a great virtue out of the fact that it distinguishes between the 'seed' and the 'soil'. It is only by understanding what alternative medicine means by 'causes' that we can explain the otherwise puzzling paradox that, according to alternative medicine, we are supposed to be naturally healthy, yet we continue to suffer from disease. 5: ALTERNATIVE CAUSES OF DISEASE It's worth looking at this concept of causation in alternative medicine in a little more detail. The main causes of disease according to alternative medicine are: 1. diet 2. stress 3. faulty ways of thinking and feeling 4. allergy 5. orthodox medicine (allopathy) 6. miasms The role of diet. Since the natural is generally equated with health and virtue, it logically follows that living unnaturally is likely to be harmful. There are of course many respects in which our present way of life can be seen to be unnatural. Pollution in all its forms is widely regarded as a cause of disease. There is not much we can do individually about environmental pollution, but we can limit the amount of pollution we ingest by not eating things that will harm us. Diet, in fact, is a central cause of disease for nearly all alternative practitioners, and this idea has taken firm root in the population as a whole; about half the patients who come to see me raise the question at some stage, and nearly all are interested in discussing what they eat. This is hardly surprising, for orthodox medicine, too, attaches a lot of importance to a healthy diet in the prevention of coronary heart disease. Alternative and orthodox medicine agree on the desirability of reducing animal fats, sugar, and salt, and increasing the intake of vitamins and minerals; but for alternative medicine this is just the beginning. Diets exist to help control eczema, sinusitis, arthritis, colitis, multiple sclerosis - almost any disease or symptom you like to think of, in fact. Hardly any of these diets is based on proper scientific assessments, and many seem to have been composed at the whim of the author; few have any discernible scientific basis. But this is not why people follow them. And follow them they do, in considerable numbers and often with extraordinary tenacity, sometimes in spite of the unpalatability of the diet, its practical inconvenience, and even its manifest nutritional inadequacy. It is difficult to understand why this should be so, but possibly it is partly because we feel that changing our diet is something that lies wholly within our own control; it is something we can do. But it is not only that. Food and cooking customs have stronger emotional and cultural roots than almost any other human activity, perhaps stronger even than sex. We mostly acquire our eating habits literally at our mother's knee, and many of us never change them much for the rest of our lives. The anthropologist Claude L‚vi-Strauss sees the cooking of food as a central theme in the development of human culture. Because cooking can be thought of as a form of technological processing, the back-to-nature movement prefers to eat raw food as much as possible - vegetarian, naturally, because vegetarianism, though not obligatory for a healthy diet, is preferable for a number of reasons, moral, aesthetic, and nutritional. If people must eat meat, they should eat white meat such as chicken rather than red meat, and fish is better than chicken. Partly, no doubt, this is because even orthodox medical authorities say that too much red meat is undesirable, but Coward may be right [141-143] in believing that red meat, because it contains blood, is thought of as 'too strong'. Coward also remarks on what she calls 'magical foods' such as ginseng and royal jelly, to which I would add vitamins, which are sometimes taken in such large doses ('megavitamins') that they cease to be a mere supplement and become a food in their own right. Many people invest much time, energy, and money in their diet, because they regard errors in this matter as a potent cause of ill-health. 'You are what you eat,' the saying runs, and this has been taken profoundly to heart by alternative medicine enthusiasts. My objection is not that diet is unimportant, for I am sure it does matter a great deal, but many alternative therapists have no idea of the standards of evidence, the quality of the research, that would be needed to establish the facts and to sort out the real from the imaginary. STRESS This rivals incorrect diet as a putative cause of illness and many of the same criticisms apply. It is almost invariably held that we are more subject to stress than previous generations, although the reasons for saying this are not spelled out in any detail and the statement often seems to betray a lack of historical awareness. There seem to have been plenty of causes for 'stress' in earlier times. A hundred years or so ago, for example, you could routinely expect to lose several of your children in infancy, and giving birth to the children in the first place was a risky undertaking for a woman. Throughout most of history, if you had to undergo an operation it would be without anaesthesia. These, one would think, were ample causes for worry and stress, quite apart from noisy or otherwise objectionable neighbours, poverty, bad housing, and all the thousand and one causes of unhappiness that people have always had to endure. Stress is not always regarded as bad for you; a great deal depends on how much there is, and of what kind, and on how you respond. What one person would call stress, another might call challenge. The problem is that 'stress' is never clearly defined. Often it seems to amount merely to any experience you don't wish to have, which is so wide as to be almost meaningless. And why is stress so bad for you, anyway? The usual explanation is that repeated exposure to challenging situations stimulates us to produce a primitive 'fight or flight' reaction. Our blood pressure rises, our heart rate increases, the blood flow to our muscles increases while that to our intestines decreases: in short, we are prepared for action. But as a rule, in a modern urban society, no physical action is needed. If we are cut up by another driver while in our car, or if we are reprimanded by our boss at work, we can't resort to physical violence, much though we might like to. The result is that the aggression is internalized; our blood pressure remains up for a long time, we may develop a gastric or duodenal ulcer, and so on. It is a persuasive theory, and may even be true. But it is difficult to prove, and possibly is misleading. The medical writer Richard Asher once played a trick on his readers to illustrate this point. He quoted a description from a medical text written in 1871, in which the eminent author explained how the stress of modern life was causing people to suffer from peptic ulcers. It all sounds rather convincing, and, reading it, one is mildly amused, and rather impressed, to find that someone was saying this kind of thing as early as that. If that's what life was like in 1871, you think, how much worse must things be today. Then Asher pulls the carpet from under our feet. He admits to having practised a deception; the article he was quoting wasn't really about duodenal ulcer at all, it was about general paresis - syphilitic dementia, the true cause of which was unknown when the article was written. So much for the stress theory in this case. (In fact, even the hitherto accepted wisdom that duodenal ulcers are due to stress may have to be revised. Modern research suggests that ulcers may be caused by infection with a bacterium called Helicobacter pylori.) Anyone who practises medicine is bound to see patients who have been through appalling experiences, some of whom (though by no means all) then suffer various physical and mental disorders which it is very difficult to avoid linking with the stress that they have undoubtedly suffered. At the other end of the scale, people come with symptoms they attribute to stress, but the experiences they relate seem to be nothing more than the ordinary troubles inseparable from living. In these latter cases it is questionable whether the concept of stress really has any useful contribution to make. Stress, like diet, is invoked too easily by many alternative therapists as an explanation for patients' symptoms. It is essential not to be simplistic about it; during the Second World War, we are told, the incidence of anxiety neurosis and similar relatively minor psychiatric disorders fell considerably, presumably because people had more important things to worry about than their own symptoms. And yet it would be going too far to dismiss stress as a cause for disease. Very many of the symptoms that patients complain of are transparently related to painful psychological experiences that they are undergoing: financial worry, family problems, housing difficulties. Either these things cause the symptoms directly or they make existing fairly trivial symptoms appear intolerable. Naturally there are wide individual variations in susceptibility to stress and the kinds of effects it produces. Perhaps as a result of behaviour patterns learnt in childhood, some people seem to be incapable of recognizing mental suffering for what it is and so they express their unhappiness in a physical way, as stomach pain, chest pain, nausea and so on. This is the phenomenon the Americans call somatization, and most doctors groan inwardly when they recognise it in a patient. Other people seem actively to seek and increase stress, almost as if it were a drug; this is the so-called Type A personality, who is supposed to be vulnerable to coronary heart disease. Such people are described as ambitious, perfectionist, and governed by time, unable to delegate, constantly driving themselves to try to achieve more and finally cracking under the strain. Lately there seems to have been less emphasis on this aspect of heart disease, and the question whether there is a particular kind of individual who is especially liable to it still is not decided. There have been many claims that modifying people's reactions to stress and teaching them to relax can reduce their blood pressure and hence their liability to strokes and heart attacks. Falls in blood pressure with meditation have indeed been demonstrated fairly convincingly, but whether the hoped-for reduction in disease will follow is still uncertain. Some studies seem to show that there is such an effect, but the numbers of patients involved have been small. A recent study reported in THE BRITISH MEDICAL JOURNAL (10 April 1993), which used larger numbers, puts this in doubt. Patients with mildly raised blood pressure were recruited for the study and were taught to take their own blood pressures over a 12-week period. They were then randomly allocated either to a stress management programme (passive relaxation, meditation, and the use of relaxation in daily life) or to a programme of simple stretching exercises that would not be expected to reduce blood pressure. The effects of these two programmes were assessed by subjecting the patients to a mildly stressful interview designed to elicit Type A behaviour. Ninety-six patients were studied; 48 were allocated to stress management and 48 to gentle exercise. Neither stress management nor gentle exercise had any detectable effect on the patients' blood pressure. This is in contrast to previous studies that have shown an effect, so why the difference? The researchers think the answer is that they allowed a long (12-week) "run-in" period for the patients to get used to recording their own blood pressures. It is known that if patients have their blood pressure measured repeatedly it often tends to fall progressively towards normal, and these researchers think that this effect was not allowed for sufficiently in previous studies. Notice that this research does not necessarily prove that stress reduction has no effect in reducing the incidence of heart attacks over a period of several years. At least one study suggests that it does, but if so it probably works in other ways than simply by reducing blood pressure. All of which goes to show how difficult it is to get definitive answers to questions of this kind. Faulty habits of thinking and feeling Attempts have been made to try to link personality patterns with susceptibility to cancer. These apparently show that the chances of surviving cancer are better for some kinds of people than for others; patients who simply accept the diagnosis fatalistically seem to do worse than those who 'fight' the disease energetically, and also (which is perhaps more surprising) worse than those who deny that they are ill at all. The validity of these conclusions has been questioned, however, and even if they are correct one could still interpret them differently. It is possible that patients who simply accept the diagnosis without resistance do so because they already know, at some subconscious level, that they won't recover. It is also been claimed that it is possible to detect which kinds of people are most at risk of cancer many years before they actually acquire the disease. Cancer patients are supposed to be self-sacrificing individuals who for much of their lives have done what other people wanted rather than what they themselves wanted. They are therefore repressed and suppressed, full of unacknowledged anger. The studies I refer to have been made by orthodox researchers, some of whom are eminent, so it is not surprising that they have been welcomed by many alternative practitioners, who have adopted them unquestioningly, even though they are by no means full accepted as valid within orthodox medicine. Rather similar pen portraits have been drawn of the kinds of people most liable to suffer from other serious chronic diseases such as rheumatoid arthritis and multiple sclerosis. I must admit to finding this linking of personality with disease one of the least attractive ideas in alternative medicine. Firstly, it may not be true; the evidence is still unclear, and if the history of medicine in general, and psychiatry in particular, is anything to go by it is likely to remain so for some time. Secondly, as Susan Sontag writes in ILLNESS AS METAPHOR, although these portraits are presented sympathetically the kind of personality depicted is not the one most valued in the twentieth century. We may pity such people but we regard them as social failures. Miss Beal and Miss Buss Cupid's darts do not feel. How different from us, Miss Buss and Miss Beal. And, because they are different, we are enabled to feel comfortably superior to them. We are not repressed and frustrated, so we are not at risk of getting cancer. It is bad enough to know you have got cancer (or cancer has got you) without having to feel that it is happened because you are psychologically and emotionally inadequate. Even if it is true, but especially if it is not true. Allergy in alternative medicine Allergy: a difficult word, because it is used so widely and loosely, sometimes even figuratively ('I am allergic to him'). In orthodox medicine, 'allergy' has a fairly precise meaning. It refers to a particular type of antigen - antibody reaction. The commonest form of this is hayfever, in which the antigen is pollen; antibodies of a particular kind (IgE) are present on the linings of the nose and elsewhere and react with the pollen to give the familiar symptoms of sneezing, running nose, and itching eyes. But although alternative medicine certainly recognizes hayfever as allergic, when alternative medicine practitioners speak of allergies it is usually food they have in mind. Orthodox medicine also recognizes the existence of food allergies. Some people have an immediate reaction to food which is usually easy to spot. Their lips swell, their mouth and tongue tingle, and blister-like swellings develop inside the cheeks; there may also be asthma and nettle rash. All these symptoms develop within ten minutes of eating the offending food and are certainly due to allergy. About 60 per cent of children with eczema develop symptoms in their skin and elsewhere in response to certain foods; many different foods are responsible in such cases, but eggs, citrus fruit, wheat, and milk are among the commonest offenders. There are also reactions caused by food that are not due to allergy but are produced in other ways. In a certain number of patients with migraine the attacks are brought on by food, especially chocolate, cheese, and red wine, though this is less common than many people think. Some patients have enzyme deficiencies that interfere with digestion and can cause intolerance to certain foods; for example, 80 per cent of Africans and Asians lack the enzyme needed to digest milk sugar. If they drink milk they experience bloating and diarrhoea. Some patients with the irritable bowel syndrome react adversely to certain foods, but this is not a true allergy; the bloating and discomfort experienced by such patients is probably due to the action of bacteria in the intestine, which ferment the food and produce gas and acid. Skin tests for allergy, though fairly satisfactory for hay fever, don't work well for food allergy, and there are no really satisfactory laboratory tests either. The RAST (radioallergoabsorbent test) is only moderately helpful, and optimistic attempts to detect food allergies by mixing samples of the patient's blood with various foods (cytotoxic testing), by hair analysis, or 'iridology' are hopeless. There is no satisfactory method of confirming the diagnosis except to get the patient to take a strictly controlled diet (elemental diet) for two to four weeks and see whether the symptoms improve, but this is not something to do lightly; it is easy to mistake a psychological improvement due to suggestion for an improvement due to the diet, and diets of this degree of severity are not safe to maintain for any length of time and are not safe at all for children. It is of course the suggestion factor that bedevils the whole question of food allergy. Thanks to an enormous amount of publicity, many people, including many alternative practitioners, are firmly convinced that their miseries are caused by food, especially the dreaded 'E numbers'. Some unfortunates have dedicated their lives to this idea and have become victims of the so-called 'total allergy syndrome'. They are said to be 'allergic to the twentieth century'. Some have lost their families, their jobs, and their money in consequence and a few have committed suicide. Such extremes are luckily rare, but many patients are victims of this delusion in a less catastrophic form. We are told on dubious evidence that food sensitivity is a common cause of headache, insomnia, tinnitus, palpitations, breathlessness, ankle swelling, abdominal bloating, and fatigue; in children it is supposed to cause hyperactivity, bed-wetting, and poor school performance. The delusive nature of much of the food allergy idea has emerged clearly from several recent studies. In a recent survey in Buckinghamshire, in which over 18,000 people took part, over 4,000 claimed to have adverse reactions of kind or another to foods, food additives, or aspirin. Reactions to food additives were reported by 7.4 per cent of the responders, but when they were tested objectively only three people were found to be affected. Another investigation was carried out in Manchester a few years ago. Twenty-two patients attending an allergy clinic for suspected food intolerance were assessed by a psychiatrist, after which they were tested for food intolerance with exclusion diets and by being given the suspected foods 'double-blind'; that is, with neither the patient nor the tester knowing whether they were receiving the food or a placebo. Only four of the patients had definite evidence of food intolerance and all four were psychologically normal. Of the 18 in whom food intolerance was not confirmed, only one was found to be normal psychiatrically; ten of the remainder were depressed, and the others were thought to suffer from other kinds of psychiatric disorder. The group in whom food allergy was not confirmed was then compared with another group of patients who did not complain of food allergy but who had been referred to a general psychiatric clinic. The two groups turned out to be exactly the same in respect of their symptoms and psychiatric abnormalities. However, there was one significant way in which they differed: social class. The psychiatrically abnormal group whose members believed that they were allergic to food was composed predominantly of professional people. In the United States, and to some extent in Britain and other countries too, interest in the question of food allergies has led to the development of a form of treatment often called clinical ecology. Extracts of what are thought to be the offending foods are injected into or under the skin; if the patient is indeed sensitive to the food, the relevant symptom (wheezing, headache, or tinnitus, for example) occurs within a few minutes. The clinical ecologist can then stop the reaction by giving a different, 'neutralizing', dose of the same substance. Clinical ecology is practised both by doctors and by therapists who are not medically qualified. It has attracted a great deal of criticism from within mainstream medicine, but until recently there was little objective evidence available to help one to make up one's mind. A short while ago, however, a study was carried out at the University of California which sheds a lot of light on the subject. Several experienced clinical ecologists took part. They selected a total of 18 patients who they believed were undoubtedly sensitive to foods, on the basis of repeated injections with a variety of food extracts. The patients had known what they were receiving on these occasions; none of them had reacted when given control injections of what they knew to be just the diluent, without the food extract. In the study they were retested with the same substances in the same office, with the same technician giving the injections as before; the only difference was that now they did not know when they were receiving the active injection and when they were receiving the control. The technician and the observer who was assessing the result were also ignorant of what was being injected on each occasion. The results were clear-cut. Various symptoms were indeed produced by the injections, but the patients correctly identified only 16 out of 60 active injections (27 per cent) as having provoked symptoms. They also thought that 44 out of 180 control injections (24 per cent) were active. There was no difference in the symptoms produced by active and control injections. Seven patients who had produced symptoms were given neutralizing injections. In most of these cases, as it later turned out, the initial injection which had produced the symptoms had been a control one; but the neutralizing injections relieved these symptoms just as effectively as they did the 'real' symptoms provoked by active injections. The conclusion of this study seems to be inescapable: although (or because) these clinical ecologists genuinely believed in the technique they were using, on the basis of their experience, the effects they were seeing were due to suggestion and not to the substances they were injecting. The moral of this, as pointed out by Dr Anne Ferguson in a leading article on the subject in the same issue of the New England Journal of Medicine [1990,323:429-33; 476-478] is that 'Self-deception affects doctors as well as patients, and through kindness and enthusiasm many of us may be doing a great disservice to ill persons anxiously seeking a non-psychiatric diagnosis. If we apply the wrong label with conviction, and then treat the symptoms with suggestion and placebo, relief is likely to be transient, and psychopathology will probably emerge.' As a footnote to this story, it is worth mentioning a recent study of another alternative diagnostic technique, Iridology (Chapter 2, p.00). It depends on the theory that diseases can be diagnosed from the appearance of the iris (the coloured part of the eye), which is divided into segments like a clock face; if a segment is flecked or coloured unusually it is supposed to point to a disorder of a particular organ. Iridology is used not only by clinical ecologists but also by osteopaths, acupuncturists, herbalists, homoeopaths and others. Often they inspect the iris simply with the help of a torch and a magnifying glass, but professional iridologists have special equipment with which to photograph the iris and make slides which can be projected on a screen. The method has obvious attractions. It appears to be scientific; after all, orthodox doctors pay a great deal of attention to the appearance of the back of the eye (the fundus), so why not the iris? It is also safe and painless, and its practitioners claim that it can provide information that is not otherwise available, not only about past health but even about what is to come. 'The beauty of the iris diagnosis is that it reveals tendencies that may not yet have begun to express themselves as actual symptoms. This makes it possible to plan our lifestyle, including appropriate treatment, according to our natural strengths and weaknesses, likes and dislikes.' [quoted by Inglis and West, 279]. Unfortunately, however, it seems that it does not work. In a careful study [BMJ (1988) 297, 1578 - 81], a Dutch researcher, Paul Knipschild, tested the ability of experienced iridologists to diagnose the presence or absence of chronic cholecystitis. All the iridologists agreed that his study design was fair, and they were confident of their ability to make the diagnosis. However, the outcome was no better than chance. In spite of analysing the results with a variety of sophisticated statistical methods in an attempt to detect some pattern that was not immediately obvious, Knispschild was forced to conclude that the iridologists had completely failed the test. When shown these results they were puzzled and couldn't explain them. In an interesting sequel to this study Knipschild went on to investigate the effects that research of this kind has on doctors' belief systems. Three weeks before his paper on iridology appeared in the British Medical Journal he sent a questionnaire to 200 doctors, including some who had written articles in journals of alternative medicine, asking them whether they believed in iridology as a useful diagnostic aid for certain diseases. Later, he sent them copies of his paper and asked them to say whether their opinion had changed. Knipschild obtained replies from 78 doctors. Fifteen who did not believe in iridology before reading the report continued not to believe in it afterwards. Most were initially uncertain, and two-thirds of these became disbelievers as a result of the report. However, four who were strong believers initially continued to believe in it afterwards. [BMJ, 299, 491-2. 1989]. It would be interesting to know what effects reading this report would have on non-medical practitioners' attitudes. THE CANDIDA THEORY AND ME This is an example of how ideas gleaned from orthodox medicine can be combined with long-standing alternative beliefs to produce a theory of disease that can be applied to almost any set of symptoms. Candida albicans is a fungus that gives rise to thrush, a superficial infection of moist surfaces such as the vagina and, in babies, the mouth. It is in fact often present in the vagina without causing symptoms, but sometimes, for unknown reasons, it gives rise to discharge and itching; some women seem to be particularly susceptible to it. It is also found in the lower part of the bowel, where again it usually causes no problems. As a rule it is a nuisance rather than a threat to life, but in people whose immune system is damaged, perhaps by drugs given to suppress tumours, candida may spread inside the body, affecting many internal organs and leading eventually to death. This much is well recognized in orthodox medicine. In alternative medicine, however, there has grown up a wide-spread belief that there is another set of symptoms due to candida overgrowth in the intestines. These include almost anything you like to name: fatigue, headache, listlessness, spots before the eyes, abdominal bloating, looseness of the bowels... the list goes on and on. It is, in fact rather reminiscent of Hahnemann's list of symptoms due to the psora 'miasm' (see p.000), and there is another indirect link with Hahnemann's ideas as well. Hahnemann believed that orthodox treatment was responsible for many of the ills suffered by his patients. This idea comes into the candida story too, for the reason for the overgrowth of candida is supposed to be the use of antibiotics. A recognized unwanted effect of some antibiotics (the so-called broad-spectrum group) is that they tend to alter the proportions of the bacteria that normally live in the lower part of the intestines, and in rare cases this can have serious or even fatal consequences. The candida theory builds on this fact; if you have had a course of antibiotics in the past, especially a long one or a repeated series of courses, this is said to make you vulnerable to candida. The trouble with the candida theory, as with most theories of this kind, is that it is very hard to assess objectively. Candida certainly does exist in the gut, but it is difficult to say at what point it becomes abnormal in quantity. It is still more difficult to explain how candida could give rise to the remarkable range of symptoms that it is blamed for. But this comprehensiveness is of course just what recommends it to many patients and alternative therapists. The Candida theory has, not surprisingly, been proposed as a main cause for what has come to be the very model of an 'alternative disease', myalgic encephalomyelitis (ME). The Myalgic Encephalomyelitis Association estimates that there are currently 150,000 sufferers in Britain. The first description of what may or may not have been the same disorder was given in the 1950s, following an outbreak of a mysterious disease at the Royal Free Hospital in London; it was therefore called Royal Free Disease. The term Postviral Fatigue Syndrome has also been applied to more or less the same clinical picture. This confusion about what to call the condition reflects the considerable uncertainty that exists about ME. None of the names that have been suggested is satisfactory. "Myalgic encephalomyelitis" means inflammation of the brain and spinal cord accompanied by aching muscles, but neither of these is necessarily present in ME. "Postviral Fatigue Syndrome" is likewise unsatisfactory, since the condition is not necessarily preceded by an identifiable viral infection. 'Chronic Fatigue Syndrome' would be a suitably non-committal expression, conveying our ignorance of its cause, or causes, but ME seems to be the name that has established itself. (It is also been called 'yuppie flu', probably reflecting a tendency for it to afflict people in the professional classes; a feature that recalls food allergy.) A typical way for ME to begin is with a sore throat, running nose, and enlarged nodes ("glands") in the neck. This is of course what most people would describe as "flu". In addition, there may be diarrhoea and vomiting, or sometimes giddiness and a fast pulse rate. Some patients at this stage suffer from headaches, blurring of vision, and double vision. However, the worst complaint is usually severe muscular weakness, together with a feeling of intense physical and mental misery. As time passes the physical and mental debility persist, though they may vary in intensity from day to day or even within the same day. Some patients are so badly affected that they have to stay in bed all the time, and if they do get up they may find that the smallest household task is too much for them; going to work is out of the question. The muscles may be tender to the touch. Memory is often affected. The ability to concentrate is impaired or lost, and patients may be more emotional than normal, being liable to outbursts of tears or anger at things that would normally seem trivial. Sleep patterns may be disrupted. Other symptoms include cold hands and feet, extreme sensitivity to changes in temperature and weather, bouts of sweating, and palpitations. The patient may have to pass urine more frequently than normal. As the months go by, these symptoms may diminish in intensity although without going away completely; the patient can go back to work, but finds that he is exhausted at the end of the day and has no energy for anything else. This may persist for months or even years. A few more severely affected patients do not recover even to this limited extent, and have to spend most of their time in bed. There is no agreement about what causes ME. At one extreme some doctors regard it as a wholly psychological disorder, while others are convinced that it is due to a preceding viral infection. It is also been thought to be due to hyperventilation. This is an interesting disorder, thought to be fairly widespread, in which people tend to breathe just a little too deeply for long periods. As a result the chemical balance of the blood is altered, with a shift towards the alkaline pole, and numerous symptoms such as tingling, palpitations, and anxiety can result. Hyperventilation is almost certainly part of the picture in a number of cases of ME but the two disorders are probably not identical. ME is probably not a new disease. It is very similar to 'neurasthenia,' which was first described in 1867 by an American neurologist, George Beard. The symptoms he gives are almost identical with those of ME; he attributed it to an organic cause (depletion of the stored nutriment of nerve cells). It chiefly affected the middle classes, like ME, and the treatment he advocated (complete rest) was again similar to that now advised for ME. Chronic fatigue without a diagnosis of ME is extremely common. In the USA a survey in 1988 found that chronic fatigue was a major problem for 24 per cent of all adults attending primary care centres, and in this country the findings are similar; a community survey in 1987 showed that 25 per cent of women and 20 per cent of men 'always feel tired'. There is no way of diagnosing ME by means of laboratory tests. The commonly used tests give normal results as a rule, although thyroid function may be at the lower end of the normal scale and certain enzymes in the blood may be a little raised. A test for infection with a particular group of viruses (enteroviruses) has recently been developed at St Mary's Hospital, Paddington, and gives positive results in a number of patients with ME. Many patients think that this a specific test for ME, but in fact all it shows is whether or not a patient has at some time been infected with the virus in question; it cannot show that this virus is the cause of the present symptoms. For the moment, therefore, ME is a purely clinical diagnosis. Tests may be used to eliminate other possible causes of the patient's symptoms, but once this has been done ME can be said to be the diagnosis if the symptoms correspond with the description of the condition. Patients often ask: 'Is it ME, doctor?' The answer is that if you have the symptoms, you have ME by definition, because ME is, at present, simply a collection of symptoms. What underlies the question, however, is a request for reassurance that it is not 'all in the mind'; patients who believe that they have ME usually resist any suggestion that they might be depressed. But in fact there are many resemblances between ME and depression. Depressed patients typically do complain of severe tiredness after even minimal effort. (Manic patients, in contrast, have boundless energy.) In fact, loss of energy is a common way for depression to appear, and depression often comes on suddenly, just as ME does. Both depression and ME are twice as common in women as men, and rare in children. When patients suffering from chronic fatigue are assessed psychiatrically in standard ways, between 50 and 80 per cent fulfil the criteria for diagnosis of a psychiatric disorder. Mental as well as physical fatigue is common in ME, but in neuromuscular disorders such as myasthenia gravis there is little mental fatigue. Patients' resistance to the idea that their ME symptoms may be due to depression is understandable, but if we accept the view that depression itself is an organic disorder, due to some impairment of brain function, much of the ground for argument disappears. A diagnosis of depression says nothing about the cause of the depression; it may come on after a viral infection, and conversely depressed people may be more liable to viral infections through an effect on their immune systems. But a diagnosis of depression carries a certain undesirable connotation for many people, hence their reluctance to accept it. At present treatment of ME is inevitably unsatisfactory, in view of the uncertainty about what causes it or even whether it exists. This frustrates many doctors and can breed resentment in the patients, who feel that no one has adequately recognized the serious nature of their condition. Almost every form of alternative medicine has been tried for ME. Candida overgrowth, as I have said, is a popular theory about its cause, and therapists who believe in this, and who are also doctors, may give patients courses of antifungal drugs. Non- medical practitioners often try a dietary approach to reduce candida. Undue sensitivity to carbohydrates (reactive hypoglycaemia) and allergies to foods are also popular as explanations. Some patients do seem to improve if refined carbohydrates are eliminated from their diet, and others can be helped by elimination diets to try to find the offending item or items, but both of these measures, especially elimination diets, are difficult to put into practice and should never be undertaken lightly or without skilled supervision. As always, the role of suggestion is hard to exclude. Homoeopathy helps some patients, and so does acupuncture, but neither of these can offer a sure cure. It seems likely that ME is not just one thing. There are some patients in whom it is the result of a persisting viral infection, but these are a probably a minority. In most cases psychological factors appear to be playing a large part, but it could certainly be objected that these are the result of the disease rather than its cause, and this is usually hard to disprove. Perhaps in the end it is a meaningless question. As a rule the best plan of treatment is to encourage patients to find out how much activity they can sustain without making themselves worse. "Overdoing things" can easily bring on a relapse and is to be avoided, but on the other hand complete inactivity is also undesirable, partly because it is likely to increase the patient's depression and partly because the muscles, if not used, will deteriorate further and become still weaker, and this weakness due to disuse will then be superimposed on that due to the illness. A gradual increase in activity as the condition begins to improve is the thing to aim at. What happens instead in too many cases is that the unfortunate patient goes from therapist to therapist, seeking a cure and never finding it, trying endless methods, swallowing innumerable medicines, vitamins and minerals; some people take thirty or more medications daily. To persuade such patients to give up the quest is nearly hopeless. Orthodox medicine (allopathy) Running through much of alternative medicine like the wire thread in a banknote is the notion that orthodox medicine is bad for you. Like many of these ideas, this one goes back to Hahnemann, who believed in it strongly. Indeed, it was so entrenched in homoeopathy in the early days that when The London Homoeopathic Hospital was founded in the nineteenth century the rule was laid down that no 'allopathic' medicine was to be kept in the pharmacy, and even the use of homoeopathic medicines in an undiluted form was discouraged. (However, it appears that on Hahnemann's death a bottle of Bryonia tincture [the undiluted plant extract] was found in his medicine set.) Certain kinds of orthodox drugs are held to be particularly harmful; these include corticosteroids and antibiotics. There is of course a good deal of support for this idea in orthodox medicine itself. Every drug has potential undesirable effects and some have a great deal of them. Every prescription is a balancing act; the doctor has to weigh up the possible benefits of his medicine against the possible dangers. But alternative practitioners seldom base their criticisms on detailed lists of the unwanted effects of drugs, and their objection is as much emotional as rational. It sometimes happens that patients are advised by their alternative practitioner to stop their orthodox treatment; they may be told that they cannot have alternative treatment until they have done this. The results of this can be unpleasant or even catastrophic. If the orthodox medication is doing no good, as may be the case, no harm will result, of course, but it may be affording a lot of symptomatic relief, for example by dulling pain or suppressing a rash, and stopping it will then make the patient much worse. In some cases stopping a medicine could have serious or even fatal consequences. The evidence that orthodox medicines really do interfere with the action of homoeopathic medicines or acupuncture is flimsy, being based mainly on prejudice or hearsay. On principle it is always a good thing to reduce medication if this can be done safely, since many patients, especially the elderly, are over-medicated; but the important word is 'safely'. Belief in the adverse effects of allopathic drugs, especially antibiotics, has given rise to the idea, held by some alternative practitioners, that the cause of Aids is not the HIV virus, which is supposed to be merely a harmless 'passenger'. The alternative theory has it that Aids is really a form of 'suppressed syphilis' (a miasm, in fact), which has taken on this aggressive form because people's immune systems have been weakened by antibiotics. The appeal of this theory seems to be mainly that it provides yet another reason to condemn the use of antibiotics. THE MIASM THEORY. This discussion of the causes of disease according to alternative medicine would not be complete without mention of the miasm theory proposed by Hahnemann, which is still taken seriously by some homoeopaths, especially in South America. Although its main relevance is to homoeopathy, somewhat similar ideas crop up from time to time in other contexts too. In outline, Hahnemann postulated that the vast majority of chronic disease is due one of three pollutions or 'miasms'. These are supposed to operate very much like infections; two are venereal (syphilis and sycosis), while the third, called psora, which is much the most important, is non-venereal and extremely widespread; so widespread, indeed, that the only person not to have been infected appears to have been Hahnemann himself. Psora enters via the skin, where it gives rise to an itchy rash, which may however be localized and transient and so not be noticed. Nevertheless it becomes generalized throughout the body immediately, and lies in wait, possibly for many years, until at some later stage it bursts forth in a terrifying explosion of manifestations of chronic disease. In his book on chronic disease Hahnemann devotes over thirty pages to the chronic results of infection with this Hydra-headed monster. He names almost every ill known to man, so that it is almost impossible to think of any disease or symptom (he does not distinguish clearly between these) that would not be due to psora. As a result, the psora theory becomes so universally explanatory as to be practically useless; by explaining everything it explains nothing. This has not prevented numbers of later homoeopaths from trying to adapt the theory to fit subsequent discoveries. Psora has been equated at various times with, among other things, chronic infection, autoimmune disease, viral disease, and hereditary disease. The most dramatic development was in nineteenth century America, where psora acquired a strongly moralistic flavour and was regarded as a moral as well as a physical contagion. Moreover, it was now held to be passed on from generation to generation. In the words of James Tyler Kent, one of the best known American homoeopaths of the late 19th century: 'The human race walking the face of the earth is little better than a moral leper. Such is the state of the human mind at the present day. To put it another way, everyone is psoric... A new contagion comes with every child.' As critics remarked, psora took on many of the characteristics of Original Sin. This perhaps rather unlikely development was due to the influence of the ideas of the Swedish philosopher and mystic Emanuel Swedenborg, which profoundly affected the course of homoeopathy in America and, later, in England as well. (Many of the more extreme features of modern homoeopathy are due to Swedenborgianism, a fact that has not always been given the attention it deserves. See Appendix I.) We seldom read quite such blatant equations of disease with morality today, but the implication that healthy living is virtuous living often lies just below the surface. The expression 'I try to eat the right things' is heard very frequently, and there is usually the unspoken implication that the patient has earned merit by this. 6: IS IT SAFE AND DOES IT WORK?- Why have doctors usually been so resistant to these 'unorthodox' forms of treatment? There does not seem to have been any one reason for their hostility, and it probably varied from therapy to therapy. It certainly was not on the grounds of safety, for in many cases the unorthodox treatment was a lot safer than the orthodox treatment of the day. Homoeopathy, for example, was at least harmless, if nothing else, whereas the orthodox doctors in the early nineteenth century were happily giving their patients enormous doses of highly toxic substances such as mercurous chloride and extracting large quantities of their blood, sometimes to the point of literally bleeding them to death. (To be fair, we must also remember that the patients demanded this treatment and felt aggrieved if they did not get it.) It seems likely that some of the hostility felt by the orthodox was simply the customary human dislike of anything unfamiliar, coupled with financial interest; the new homoeopathic treatment tended to attract patients. But naturally the orthodox tried to rationalize their objections in various ways. In our own time the usual reason given for rejecting alternative treatment is that it has not been tested scientifically. 'Carry out proper clinical trials,' orthodox doctors say, 'and we'll listen to you; until then, don't waste our time.' The background to this is the change that came over orthodox medicine just after the Second World War. Up to then medicine had been largely 'anecdotal' (a term applied today in a derogatory sense); doctors published accounts of their experiences but did not make a serious attempt to validate them objectively. Now it has become increasingly recognized that it is very easy to fool oneself. There is a natural human tendency to remember one's successes and forget one's failures, so that in retrospect one's results are surrounded by a comforting rosy glow. A closely allied source of error arises from the almost universal belief that if someone recovers after receiving a particular treatment it must be because of that treatment. The history of medicine affords many curious instances of this. For example, in the FOUR BOOKS OF THAT LEARNED AND RENOWNED DOCTOR LAZARUS RIVERIUS, published in 1678, we read of the remarkable cures effected by 'Powder of Woolfs Guts': one case concerned a woman suffering from abdominal pain, and another was a woman with a 'Hysterical Epilepsie'. A cancer of the upper lip was cured by Oyntment of Green Frogs. To make this, 'Take Green Frogs that live among trees, or in pure waters, and put them in an Earthen Pot full of small holes in the bottom, and fill their mouths with butter, cover the Pot close, and daub the juncture with clay, and set over it another empty pot which must be set in the ground up to the brim; then make a fire around fit for distillation, and gather the Oyl that drops into the pot in the ground, and mix the powder of frogs into a Liniment.' [The Lancet, (1990) Burton, J.L., 'Herbal remedies - an alternative.' 336, 1565 - 66] 'Oyl of scorpions' was regarded by Dr Riverius as an 'ordinary remedy'; applied externally, it could be useful in treating cough and fever. This recalls rat oil, still apparently much in demand in the monasteries of Mount Athos, where it is used as an external application in all kinds of disorders. To make it, you catch a baby rat, immerse it in a bottle of olive oil, and expose it to the sun. Gradually it dissolves in the oil, which can then be used medicinally: rubbed on the head for headache, instilled in the ear for earache and so forth. [De Loverdo, C. (1956), J'ai ete moine au Mont Athos. La Colombe, Paris.] All these remedies have been found to 'work'. Nevertheless, the unprejudiced observer is left with the feeling that there is something rather improbable about them, and it was in an endeavour to weed out the modern equivalents of Oyntment of Green Frogs that doctors began, after the Second World War, to carry out 'clinical trials'. The practical details of these vary, but the general principle is quite simple. It is to make a comparison. One can, for example, compare two different treatments with each other, or one can compare the effect of giving a particular treatment with that of not giving it. Two things to notice about this idea. Firstly, clinical trials nearly always compare groups of patients, and the results are analysed statistically by means of mathematical techniques that are often complex. They therefore don't tell you much about the reactions of individual patients, a failing that bothers many advocates of alternative medicine. Secondly, clinical trials usually include the use of a 'placebo control', which in the case of a medicine is a tablet or capsule that is supposed to be indistinguishable from the 'active' substance. This is to try to eliminate the effects of suggestion. If the doctor knows what the different patient groups are taking but the patients don't the trial is said to be 'single blind', but whenever possible the doctor is kept in ignorance as well, in which case the trial is 'double blind'. Alternative practitioners, especially those who were not medically qualified, were at first not very interested in the idea of carrying out clinical trials. Moreover, they tended to object to the methods used in these trials, saying that treating patients as groups, with standardized treatments, was contrary to the spirit of alternative medicine, which regarded everyone as an individual. And even those practitioners who were willing to participate in trials generally lacked the necessary resources and expertise. Some clinical trials were carried out by doctors practising alternative medicine, however, mainly in homoeopathy. Probably the earliest of these was the mustard gas experiments during the war, in which homoeopathy was shown to be effective in preventing the effects of skin burns with the gas. Placebo controls were used in this study. There was then a long gap until the late 1970s, when a group of homoeopathic doctors in Glasgow carried out trials of homoeopathy in the treatment of rheumatoid arthritis. Since then further studies of the homoeopathic treatment of other disorders, notably hay fever, have appeared, and some of these have been published in well-known medical journals such as The Lancet. There have also been trials of homoeopathic medicines in veterinary practice. In France, as well as in other countries on the continent of Europe, there have been many elaborate scientific laboratory studies of homoeopathic medicines. It is therefore no longer correct to say that there is no scientific evidence for the efficacy of any alternative medicine; for some kinds, at least, there is quite a lot. (I will return to this question later.) Another development in the 1980s was the setting up of the Research Council for Complementary Medicine. This is a group consisting of both doctors and non-medical practitioners; its main task is to foster research in all kinds of alternative therapy. It gives advice to would-be researchers, helps them to design their projects, and tries to obtain funding for these schemes from Government and other sources. This all sounds very optimistic. But difficulties still exist, and most of these stem from a deep division in attitude which often separates doctors, including those sympathetic to alternative medicine, from non-medical practitioners. Ardent supporters of alternative medicine often do not acknowledge the need to offer objective evidence for their claims even today. Inglis and West provide an illustration of this, for in their book THE ALTERNATIVE HEALTH GUIDE neither 'placebo' nor 'suggestion' are mentioned in the index. Reservations of orthodox doctors. An anxiety often voiced by orthodox doctors is that those alternative practitioners who lack an orthodox medical training may fail to realize when their patients are seriously ill and need ordinary medical attention. Alternative practitioners say that this worry is exaggerated, although many of them would like to have some training in diagnosis if it were available. They also suspect that doctors are tempted to use the danger of missed diagnosis as a weapon against the alternative competition. There is no doubt that diagnoses are missed by alternative practitioners. They are also missed by orthodox doctors, of course, but at least one can say that they should not be. Alternative practitioners, on the other hand, are not expected to make pathological diagnoses. The important, but at present unanswerable, question is how frequently these disasters occur. I doubt in fact whether missed diagnoses by alternative practitioners are all that common, though there are no statistics. Still, the possibility is alarming, and instances of it certainly do occur. It is particularly worrying in the case of acupuncture, because this sometimes relieves pain effectively even though there is a serious cause for it. In a study reported a few years ago from the National Hospital for Nervous Diseases it was found that acupuncture was capable of temporarily relieving headache due to brain tumours. It certainly is possible to imagine that this kind of treatment might lull both patient and therapist into a false sense of security, and the risk probably is not confined to brain tumours; disease in other parts of the body might be similarly masked. It is sometimes said that non-medical practitioners should receive at least a brief training in diagnosis, so that they could detect problems that needed referral to a doctor. It sounds like a good idea, but given that an orthodox doctor has six years' training and even after that is not regarded as safe to practise unsupervised until he has had a further period of post- graduate supervision, it seems unlikely that much could be achieved for non-medical trainees in a few weeks or even months. A much worse problem that I have occasionally encountered is, in a way, the reverse of this. There are a few alternative practitioners who use various unorthodox diagnostic methods, on the basis of which they claim to detect that the people who consult them are at risk of developing serious diseases such as cancer, multiple sclerosis, or even Huntington's chorea, one of the most unpleasant disorders it is possible to suffer from. There is no reason whatever to believe that these prognoses means anything at all, but it can place any unfortunate recipient in the most horrible dilemma. Some of the people who have been given such a diagnosis (the son of a personal friend, in one instance) have not believed my reassurance and have continued to worry, eventually embarking on a long and costly regimen of treatment to prevent the onset of a non-existent disease. Out-and-out charlatanry of this kind is fortunately rare. But even when practised in good faith, some treatments, such as acupuncture, are potentially dangerous. They may nevertheless be used by people who have no anatomical knowledge or training whatever. There certainly is a good case to be made out for requiring anyone who practises these techniques to have undergone at least a minimum period of instruction, but a proposal of this kind raises the whole question of accreditation and this will not be easy to resolve. Leaving aside the thorny question of safety, I pass on to look at some of the evidence regarding efficacy. THE QUESTION OF EFFICACY. You may remember the epithets used by the authors of 1066 AND ALL THAT to describe the two sides in the Civil War. The Republicans were Right but Repulsive, the Royalists were Wrong but Wromantic. Not so long ago a sympathetic but uncommitted observer of the medical scene might have been tempted to categorize orthodox and alternative treatments in more or less these terms. On the one hand there was mainstream medicine, with its surgery and its drugs, able to cure or relieve many disorders but doing so in an impersonal, soulless, mechanistic way, and on the other hand there was alternative medicine of various kinds, caring for individuals but able to offer nothing more than placebo therapy. Today the difference between the two is no longer so clear- cut, because for some forms of alternative treatment, at least, there is a certain amount of scientific evidence to show that they work. In the case of the alternative physical therapies (osteopathy, chiropractic, acupuncture), for example, a fair amount of research has been carried out. Admittedly the quality of some of this work is rather variable. Two recent reviews of acupuncture, one of which listed 32 papers and the other 40, found serious shortcomings in most of them. Making allowances for this, however, it appears that there is good evidence that acupuncture can relieve quite a number of kinds of pain, at least temporarily, although treatment may need to be repeated at intervals. At one time there was a great deal of interest among acupuncturists in the naturally occurring substances known as opioids. These are found in many tissues, but particularly in the brain, where some of them are apparently involved in the mechanism that underlies pain perception. At first it was thought that the discovery of these substances explained the relief of pain by acupuncture, but this now looks unlikely. There are probably two separate processes at work here. When an acupuncture needle is inserted there is a short (90 minute) diminution in sensitivity to pain; this effect is produced by the release of substances within the nervous system. The use of acupuncture as an alternative to anaesthesia in surgery depends on this, although acupuncture is now little used for surgery even in China. The other effect is a local reduction in pain, lasting for several days or even longer, in an area of the body which was previously painful. This is the effect which comes into play when acupuncture is used as a treatment for disease, but unfortunately very little is known about how it occurs. Partly this ignorance exists because we also know very little about the mechanisms of pain itself in many chronic disorders. It seems quite likely that acupuncture and manipulation work in rather similar ways. Certainly a good many of the disorders that respond to acupuncture will also respond to manipulation and vice versa. One way in which acupuncture and other physical treatments differ from medical treatments like homoeopathy is that they are less amenable to placebo-controlled trials of the kind that orthodox doctors expect. It is certainly possible to needle patients in the 'wrong' places and to compare the effects of this with needling them in the 'right' places, but for several reasons this is not a satisfactory comparison, especially when it is non- traditional acupuncture that is under consideration. (The acupuncturist inevitably knows whether or not he is needling the 'correct' point and so may unconsciously influence the outcome, the sensations excited at the two sites may well be different, the depth of needle insertion at the 'real' and 'placebo' points is often different, and so on. Moreover, it seems fairly certain that there is some response to inserting a needle no matter where it is done, so the question is whether one can improve on this 'baseline' effect by specific means.) Practitioners of both herbal medicine and homoeopathy are under pressure to justify their treatments through clinical research, and both have encountered difficulties in carrying it out. There is, however, one outstanding difference between the two methods: herbalism is not faced with the difficulty of proving that very highly diluted substances can have a measurable pharmacological effect. If anything, in fact, it suffers from the opposite problem: because it uses extracts of the whole plant, often containing a large number of substances some of which may not yet even be chemically identified, there can be a question about the safety of some of the medicines as well as about their efficacy. As Simon Mills, himself a herbalist and Co-director of the Centre for Complementary Health Studies at the University of Exeter, has pointed out, although herbal medicines have been used as far back as historical records go and no doubt long before that, interest on the part of herbalists in research is quite recent, partly because there has hitherto been little organization to encourage this kind of work. Mills himself is emphatic that research is needed: 'if what you say is so valuable and powerful then it should be able to stand up for itself in any forum.' [Complementary Medical Research, 1991, 5, 29 - 35] As he also acknowledges, however, research in herbalism faces special problems: one, which I have already mentioned, is the complexity of the substances used, and another is the belief that herbs are usually supposed to act on the body differently from orthodox medicines. Like homoeopaths, herbalists set much store by contact with the patient; they see their work as 'healing', not just prescribing a medicine. In spite of all this, Mills insists, research in herbal medicine is possible, even by conventional double-blind comparisons in some cases, but in general he favours the use of different trial designs to take account of the special characteristics of herbal prescribing. Laboratory research, and even animal research if conducted without causing harm or suffering to the animals, also have a place, he believes. A most comprehensive review of clinical trials in homoeopathy was carried out recently by three researchers at the University of Limburg, in Holland; one of the three was Paul Knipschild, the professor of epidemiology, whose work on iridology I have referred to elsewhere. [Kleijnen, J., Knipschild, P., ter Riet, G. (1991). British Medical Journal, 302, 316 - 23] This review looked at 107 controlled trials in 96 reports published throughout the world. Most of the trials were found to be poor in quality, but there were many exceptions. As a whole, of 105 trials in which it was possible to make some kind of assessment of the results, 81 had a positive outcome and 24 a negative one. Positive results were obtained with all kinds of homoeopathy, whether 'classical' or 'modern'. (The authors rightly comment on the 'innumerable ways' in which Hahnemann's principles have been applied in practice.) The reviewers were surprised by the large amount of positive evidence they found. 'Based on this evidence we would be ready to accept that homoeopathy can be efficacious, if only the mechanism of action were more plausible... The evidence presented in this review would probably be sufficient for establishing homoeopathy as a regular treatment for certain indications.' Although there were shortcomings, these were no worse than those found in comparable studies of conventional therapy. The authors conclude that there is a great need for further research, in the form of 'a few well-performed controlled trials in humans with large numbers of participants under rigorous double blind conditions.' The mechanism of action is indeed the crucial issue; if this were not such a problem homoeopathy would have been generally accepted long ago. It is difficult for the unprejudiced observer not to feel that there must be something odd about a treatment that consists in nothing more than throwing a few drops of medicine into a cattle drinking-trough, especially when the medicine itself, on ordinary chemical analysis, would be shown to contain nothing but water. For most scientifically trained people this strains credulity to breaking point or beyond it. SCIENTIFIC CONTROVERSY: THE BENVENISTE AFFAIR. The extraordinary passions that this question can raise were dramatically illustrated a few years ago by the feud between Jacques Benveniste, a highly respected researcher in immunology, and the journal NATURE. On 30th June 1988, the journal published an article by Benveniste and his colleagues at the Unit for Immunopharmacology and Allergy of INSERM at Clamart, in the outskirts of Paris. The article appeared to provide support for homoeopathy. When a certain type of human white blood cell, the polymorphonuclear basophil, is exposed to antibodies against IgE (the protein concerned in allergic reactions), certain changes occur. Histamine (the chemical that causes many of the clinical symptoms of allergy) is released from the cell, and the cell itself changes its appearance. What Benveniste and his team claimed was that these changes could occur even though the liquid containing the anti-IgE antibodies was diluted to fantastically high levels (1 x 10-120); that is, far beyond the point at which any molecules of the starting substance could be expected to be present. As Benveniste put it, perhaps rather over-dramatically, in an interview in LE MONDE, it is as if one shook a car key in the Seine at the level of the Pont Neuf in Paris and then collected a few drops of water at Le Havre that would start that very car and not another. Benveniste also found that in order to produce these effects it was not enough just to carry out a plain dilution; vigorous shaking, of the kind used in making homoeopathic medicines, was required. Another interesting finding was that there were successive peaks and troughs in the effect as the dilution process was continued. (This feature has appeared repeatedly in homoeopathic research as far back as the early 1900s, and presumably must mean something; it suggests a kind of 'resonance' phenomenon.) As an established scientist with a sound reputation, Benveniste was under no illusion about the storm of controversy that his paper was likely to provoke. However, he can hardly have been prepared for the scandal that broke over his head soon after his paper appeared. The editor of NATURE, John Maddox, had accompanied publication of the paper with an editorial expressing considerable reservations: 'Benveniste's observations are startling not merely because they point to a novel phenomenon, but because they strike at the roots of two centuries of observation and rationalization of physical phenomena. The principle of restraint which NATURE applies in its editorial is simply that, when an unexpected observation requires that a substantial part of our intellectual heritage should be thrown away, it is prudent to ask more carefully than usual whether the observation may be incorrect.' Benveniste was in full agreement that his results ought to corroborated by other scientists - indeed, this had already happened at five other institutions. (However, in a later television discussion he also made the valid point that there was no need to be quite so apocalyptic as Maddox had been in saying that two centuries of science would have to be thrown away. Benveniste's results, if correct, were certainly very interesting and important, but they were not quite as world-shaking as that. They were, he thought, in principle capable of being explained by the electromagnetic properties of water.) On 28th July NATURE published what was in effect a recantation of its initial decision to endorse Benveniste's paper at least to the extent of agreeing to publish it. An investigative team, composed of John Maddox, the editor, James Randi, a professional magician and debunker of claims for the paranormal, and Walter W. Stewart, a specialist in errors and inconsistencies in the scientific literature and scientific fraud, had spent five days at Benveniste's Unit at Clamart. Their report, entitled '"High dilution" experiments a delusion', was dismissive of his results. It concluded that 'the care with which the experiments reported have been carried out did not match the extraordinary character of the claims made in the interpretation; the phenomena described are not reproducible, but there has been no serious investigation of the reason; the data lack errors of the magnitude that would be expected and which are unavoidable; no serious attempt has been made to eliminate systematic errors, including observer bias; the climate of the laboratory is inimical to an objective evaluation of the exceptional data.' In other words, Benveniste, in the view of the investigative team, had been guilty of extreme gullibility and self-deception. Benveniste, understandably, reacted with great anger - not to the fact that an inquiry had been conducted, for he had been quite willing for this to be done - but to the way in which it had been conducted and to the implication that his team's honesty or scientific competence were dubious. 'The only way definitively to establish conflicting results,' he said, 'is to reproduce them. It may be that we are all wrong in good faith. This is no crime, but science.' Several things occur to me about this sorry tale. One is that it seems extraordinary that a scientific journal like NATURE did not conduct its investigations before publishing Benveniste's paper rather than afterwards. Another is that the composition of the team, which did not include anyone competent to assess Benveniste's work scientifically, must surely indicate the kind of conclusion it was expected to reach. (Like the Latin num, it expected the answer 'no'.) A third is that surely it was naive of Benveniste not to anticipate this outcome when he was informed of the composition of the team; it was then that he should have objected. Probably most people who knew little or nothing about the subject before the occurrence of the NATURE controversy gained the impression that Benveniste's research was unique in modern times. This is very far from the case; a great deal of laboratory work has been carried out, and is still continuing, in a number of countries. France and Germany have been particularly prominent in this, but centres elsewhere (in Italy, Israel, and Canada, for example) have also contributed. A few years ago an international society known as GIRI was established thanks to the efforts of Professor Madeleine Bastide, of the University of Montpellier in France, in order to coordinate and encourage this work. I was one of the founding members of this group in 1987, and since then we have seen it grow and develop rapidly. Researchers who are members of GIRI have published their results in various mainstream journals, but for some reason this work has so far not given rise to anything like the furore that greeted the NATURE publication. One would like to believe that questions about the reality of the high dilution effect and its possible mechanism of action would soon be settled by further scientific studies. Unfortunately this appears rather unlikely. What leads me to this rather depressing conclusion is the fate that seems to have befallen another recent scientific controversy that has excited even fiercer argument: the cold fusion affair. On 23rd March 1989, less than a year after the Benveniste furore, Stanley Pons and Martin Fleischmann, two chemists working at the University of Utah, announced to the world that they had achieved nuclear fusion - the process that powers the Sun - not in a huge apparatus costing many millions of dollars and operating at thousands of degrees centigrade, but in a test tube of water, at a cost of about 100 dollars, at room temperature. This claim, if correct, would make the alchemist's hope of making gold look trivial in comparison. Cold fusion would provide the world with limitless supplies of energy, without causing pollution or radiation. (It might also provide dictators of small countries with an easy way of making nuclear weapons, but that is another story.) It sounded too good to be true; but was it? Pons and Fleischmann chose to announce their discovery, not in the normal scientific way by publication in a journal (such as NATURE), but directly to the press. Few details emerged at first, although it appeared that their technique depended on passing an electric current through heavy water (water containing deuterium, a heavy isotope of hydrogen) between palladium electrodes. This process, they said, produced a huge amount of heat, which could not have come from any electrochemical reaction but must be due to the fusion of deuterium nuclei. Immediately governments and scientists throughout the world began to try to reproduce the phenomenon. Meanwhile the State of Utah voted five million dollars for further research into cold fusion and a National Cold Fusion Institute was established in Salt Lake City. Many scientists were sceptical, however, and bitter controversy ensued, with claims and counterclaims; there were allegations of fraud and of suppression of scientific evidence. The scientific paper that Pons and Fleischmann eventually published did not answer all the questions people were asking, and scientists who tried to reach them by telephone were generally unsuccessful. Most mainstream scientists, having failed to confirm the existence of cold fusion, gave up and returned to their regular work. This side of the story has been presented recently by Frank Close, a nuclear physicist, writing in NEW SCIENTIST (19th January 1991). However, the same issue of the magazine contains another article, by John Bockris, who is a distinguished professor of chemistry at Texas A & M University. Unlike Close, Bockris believes that Pons and Fleischmann had discovered something important. 'There is already enough evidence... to dismiss the widely held view that the original claims had no value. [A remarkable use of double negatives to express a contentious idea with the maximum of scientific caution!] It seems now established that nuclear particles are, under some circumstances, produced in bursts at electrodes in the cold. As to the heat, there is no proof that it originates in a nuclear process, though when it coincides with nuclear emissions it is difficult to think that it does not.' This conclusion is not based merely on an examination of the claims of Pons and Fleischmann. Confirmation has been reported at a number of centres, including Bockris's own laboratories. It seems, therefore, that the matter still is not finally settled. There are distinct similarities between this extraordinary affair and the Benveniste controversy. Like the high dilution effect, cold fusion poses a challenge to accepted ideas of what is and is not possible according to established scientific principles. In both cases there has been what NEW SCIENTIST rightly calls a lack of mutual respect between scientists working in different disciplines. 'The chemists failed to consult nuclear physicists before making their claims, treating the nuclear evidence for fusion with extraordinary carelessness. Physicists adopted a dismissive, arrogant attitude to those some described as "mere chemists", without appraising the possible significance of the electrochemistry behind the reaction. The sneers that have accompanied claims and counterclaims in both camps are a poignant reminder of the fragmented specialism and tunnel vision that dogs much research today.' In spite of the enormous importance that cold fusion, if it exists, would have for the world, there is still no agreement about whether it is a mare's nest or not. Millions of dollars have already been devoted to research, it has attracted some of the best scientific minds in the world, and still we don't know what to believe. If this is the case with cold fusion, what likelihood is there that early clarification will be forthcoming in the question of high dilution, whose potential importance is comparatively so minor? There is a widespread belief that scientists are objective observers, who weigh up the evidence for and against hypotheses dispassionately and then come to conclusions that are based on facts and facts alone. Even a limited personal acquaintance with real live scientists, however, or an exploration of the history of scientific ideas, will show that this idea does not correspond very closely with what is found in practice. One may have reservations about some of the arguments put forward by Thomas Kuhn in THE STRUCTURE OF SCIENTIFIC REVOLUTIONS, but it is difficult not to agree that there is a fair amount of truth his central thesis, which is that scientists, on the whole, don't change their minds; changes in science occur as old men die off and are replaced by younger ones with different outlooks. There is, Kuhn seems to imply, a considerable element of fashion in science, although Kuhn prefers to speak, more formally, of paradigm shifts. If Kuhn's view of how science develops is even approximately right, it is still more true of medicine. Medicine is based on science but can never be wholly scientific, for much the same reason that politics cannot be scientific: medicine and politics both deal with people, and people's behaviour cannot be analysed with the rigour demanded by science. Doctors, whether they like it or not, are constantly having to make up their minds about diagnosis, prognosis, and treatment on the basis of inadequate evidence. The results of investigations in individual cases, no matter how sophisticated, are often inconclusive; it is notorious that when postmortems to establish the cause of death are carried out (this happens much less frequently now than twenty or thirty years ago) there are liable to be some red faces among the doctors looking on, even at the most renowned medical centres. It is probably because of this inevitable degree of uncertainty in medicine that doctors who come on training courses to learn acupuncture or homoeopathy often seem less interested than might be expected in research in these subjects. It may well be that we are currently experiencing a paradigm shift in medicine, as younger doctors, especially younger general practitioners (hospital doctors seem more resistant), increasingly accept the validity of using alternative methods such as homoeopathy, acupuncture, and manipulation. (As I write this, membership of the British Medical Acupuncture Society, which was founded only a few years ago, has passed the 1,000 mark and is still rising fast.) Not long ago the British Medical Association set up a working party to study alternative medicine. Its conclusions, as might have been predicted, were largely negative and hostile; but, as also might have been predicted, the BMA is already beginning to look like King Canute and there are signs that it will shortly modify its stance. 7: PLACEBOS AND PSYCHOTHERAPY Whenever a television programme about alternative medicine is broadcast the result is a sudden, sometimes overwhelming, influx of would-be patients at the homoeopathic hospitals. By no means all of these people, unfortunately, are suitable for treatment, and this can create difficult problems. Many alternative practitioners might say that there are no patients who are unsuitable for treatment. And in a way this is true, at least as regards medical treatments such as homoeopathy. (Acupuncture is rather different, for even in ancient China it was never regarded as the only or even the main form of treatment; many more texts deal with herbal medicine than with acupuncture.) However, suitability for treatment is one thing and prospects for success are another. Here, for example, is a list of some of the kinds of problems brought to the hospital in a month: spondylosis, trigeminal neuralgia, rheumatoid arthritis, motor neurone disease, osteoarthritis, migraine, irritable bowel syndrome, hypertension, frozen shoulder, Parkinson's disease, intermittent claudication, sinusitis, peripheral neuritis, peptic ulcer, depression, tinnitus, rhinitis, epilepsy, unstable bladder, rosacea, eczema, psoriasis, otitis externa, asthma, multiple sclerosis, ulcerative colitis, piles, carpal tunnel syndrome, recurrent urticaria, psychosexual problems... and, of course, undiagnosed aches and pains and other obscure symptoms that no one has managed to explain. How many of these are suitable for alternative, or complementary, treatment? Homoeopathic prescribing is based mainly on the symptoms that patients describe, and in theory at least takes little or no account of the orthodox medical diagnosis. It should therefore in principle be possible to match a patient's symptoms to those of some homoeopathic medicine or other and so find something to prescribe. And so it is, as a rule; but unfortunately this does not necessarily produce an improvement. Of course, it may do so, and every experienced homoeopathic prescriber can point to instances in which a seemingly hopeless illness has improved dramatically following a homoeopathic prescription. But what about the cases where it does not? For the dyed-in-the wool enthusiast there is no real problem here. He has immersed himself completely in a belief system, and can always explain failures away in one way or another. If the treatment has not worked in any individual case it must be because it has not been applied properly. This was Hahnemann's position. Those who are less firmly committed to a principle have to find another approach. There are several groups of patients for whom this may be necessary. Some people who come are suffering from serious, perhaps fatal, diseases: not cancer, necessarily, though that is probably what comes first to mind; there are plenty of other equally unpleasant possibilities. There are other patients with long-standing disorders that are not fatal but for which there is no effective orthodox treatment (tinnitus, Parkinson's disease). Or perhaps there is reasonably effective orthodox treatment (asthma, high blood pressure) but the patient wants a total cure, a complete freedom from the need to take any kind of medication. And then there are those who arrive saying: "Doctor, you're my last hope." Many of these 'last hopers' have complex psychological problems, which they insist are physical, and which have taken them from specialist to specialist over months or years. Commonly they arrive accompanied by a long-suffering, over-solicitous spouse, who interjects remarks into what is clearly by now a well-rehearsed descriptive routine. In extreme cases such people may become therapeutic black holes, insatiably sucking in therapists, investigations, and treatments. Like black holes they can be destructive and dangerous; it is not uncommon to find that they have already become involved in sagas of complaint or even litigation against former 'last hopes'. Any doctor will see a number of such patients like this in the course of a year. Orthodox critics of alternative medicine tend to think that the whole clientele of alternative practitioners is made up of such patients, but fortunately that is not the case; however, it is true that patients of this kind tend to gravitate towards alternative medicine. To say that none of the patients in these 'difficult' categories can be helped by alternative, or complementary, methods would be too sweepingly pessimistic. Some can; there are many surprises. And even if nothing can be done, at least it is possible to offer a little kindness and attention. Inevitably, however, any doctor who is self-critical about what he is doing is bound to recognize that in many of these cases any treatment he gives is likely to have a placebo effect only. For the critic of alternative medicine, of course, it is all placebo. The clinical trials I discussed earlier have been conducted to try to defuse this criticism, but there is another way of responding to it which is favoured by some of the younger and more self-confident medical practitioners of complementary medicine. Instead of desperately trying to prove that none of their cures are due to placebo, they want to turn the tables on their critics by invoking what they have called an 'enhanced placebo effect'. I find this an interesting concept, and up to a point a persuasive one. THE ENHANCED PLACEBO RESPONSE. The placebo effect is a great deal more important and more interesting than many people realize. It is generally said that, in clinical research, one should expect a response to placebo in about 30 per cent of the patients. Such responses are believed to be fairly brief - about six weeks as a rule. However, it seems that if you attempt to increase the placebo effect as much as possible, by using the strongest possible suggestion, the response rate can be much greater - as high as 80 per cent in some studies. Richard Asher reports an experiment he carried out in which more than 90 per cent of the group got some relief of pain from a dummy pill and more than 50 per cent had complete relief. The duration of relief from placebo may also be much greater than is usually believed: several months in some studies. There are other surprises in store as well. 'Organic' symptoms respond to placebo just as well as psychological ones, perhaps even better. Most doctors tend to assume, rather patronizingly, that placebo responders are likely to be somewhat inadequate, uncritical, 'suggestible', individuals. But not so. There seems to be nothing that distinguishes the placebo responder from you and me. In fact, there probably is no such person as a 'placebo responder' at all, for if you repeat your study later with the same group of subjects, you find that the people who show a response to placebo the second time round are not necessarily the same as those who responded the first time. Perhaps the most surprising thing of all is that even belief in the placebo may not be necessary. In one study in America the patients were told that they were being given sugar pills, without any medication, which would have no effect on their illness at all. In spite of this, quite a number of them had a good response to the 'treatment'. Admittedly, this is only one study, which has not been repeated; but it prompts some interesting reflections. Not long ago a study of the effectiveness of suggestion in general practice was carried out in Southampton. Patients suffering from not very serious illnesses that would be expected to clear up spontaneously in a few days were interviewed in one of two ways. For one group the doctor was non-committal and simply asked the patient to return in a few days to report progress; in the other group the patients were told firmly that they would soon be better and there was nothing to worry about. It was found that those who were given reassurance about their condition recovered, on average, significantly faster than those who were treated neutrally. To use positive suggestion in this way is surely legitimate and acceptable. But is it right to go considerably further? It is often said, with some justification, that the methods of alternative medicine are such as to maximize the effects of suggestion. For the most part alternative medicine is private medicine, and there is some evidence that patients who pay for their treatment fare better than those who don't. The patients get individual attention from the therapist, with whom they are able to build up a personal relationship. The techniques used are often impressive, nearly always involving elaborate diagnostic rituals which are sometimes supplemented by impressive-looking pieces of apparatus. Above all, the patient (often) and the therapist (nearly always) believe strongly in the efficacy of the therapy being used. Advocates of the enhanced placebo response hold that it is right to seek to increase the placebo element deliberately as much as possible - and probably give it a different name, so as to avoid the adverse association that 'placebo' carries with it. In this way, they say, one augments whatever direct benefit may be produced by the therapy itself in its own right. And they see this as perfectly legitimate; after all, the aim is to help the patient, and if suggestion can play a part in this, why not? I can certainly see the logic of this argument, but there are two aspects of it that bother me. The first is that, if you deliberately set out to convey more belief and confidence than you feel, you are deceiving the patient and, possibly, yourself. There may well be occasions when this is justifiable, but to make it into a general rule seems to be a rather dubious policy. For some therapists, in fact, it may be psychologically difficult or impossible. Probably the most dramatic example of the use of therapeutic suggestion on a large scale in the history of Western medicine is that of Anton Mesmer. Mesmer used every device imaginable to maximize suggestion and produce his cures. But he did not himself think that his cures were merely the result of suggestion; on the contrary, he believed strongly in his theory of 'animal magnetism' as the explanation. Indeed, much of his life's work was devoted to trying to get this idea accepted by the orthodox medical authorities of his day. The moral of this is that you are unlikely to have much success with your enhanced placebo effect unless you believe strongly in your treatment yourself. Of course there are examples to the contrary - charlatans who have successfully duped the public without having any belief in what they were doing - but they are the exception rather than the rule. A second difficulty with the enhanced placebo idea is that it is condescending and 'paternalistic', in the pejorative sense of the word. It puts the therapist, by implication, on a different level from the patient. This is, or should be, contrary to the spirit of complementary medicine, which usually claims to think of patient and therapist as involved in a joint venture together. My own feeling is that whenever possible it is best for the doctor or therapist to tell the patient the truth as he sees it. I certainly accept that there will be many cases in which this is impracticable or undesirable. 'Humankind cannot bear very much reality.' However, not to be truthful in cases where it is possible to be so is somewhat condescending. Certainly it is always right to be as optimistic as possible in every case. After all, none of us knows the future, and we all see instances in which even the most hopeless-seeming problem turns out very well. Nevertheless it is right to be as honest with patients as circumstances allow, and to give them, in general, a frank account at the outset of what one expects that treatment can, and cannot, achieve for them. There is another aspect of the placebo response that needs to be kept in mind. Neutral treatments such as inert tablets can do harm as well as good. (This is sometimes called the 'nocebo' effect.) A remarkable example of this occurred in the course of a modern homoeopathic 'proving' carried out a few years ago in the north of England. A proving is an experiment made to ascertain the effects of a homoeopathic medicine on healthy people, according to the principle enunciated by Hahnemann. In this case the medicine in question was one commonly used in homoeopathy, called Pulsatilla. It was given in the '3x potency', which meant that there was a certain amount of the medicine present in the tablets, although not very much. (This was the lowest dilution which could be used without giving the game away by differences in appearance and taste between medicine and placebo.) The study was carried out on volunteers in the north-west of England; most were members of a large philosophical society. It was planned to last for three months, with the volunteers taking one tablet twice daily and recording their symptoms in a diary. During the first month all the 'provers' received a dummy tablet; they did not know this, although the doctor who was conducting the trial did. In the second month half the provers received Pulsatilla and half dummy tablets, and in the third month those who had received Pulsatilla previously now received the dummy tablet and vice versa. In the second and third months neither the doctor nor the provers knew which group was receiving Pulsatilla, and indeed at this time the provers did not even know that it was Pulsatilla that had been chosen for the trial. The results were very interesting. Thirty of the 52 participants returned their diary sheets filled in to some extent, although only 18 completed the whole three months. When the diaries were analysed no evidence emerged to show that Pulsatilla had produced any more symptoms than the dummy tablet. What was very striking, however, was the fact that much the largest number of symptoms occurred during the first month; that is, at the time when all the volunteers were taking dummy tablets. The incidence of symptoms declined progressively over the whole three-month period, regardless of whether the participants were taking Pulsatilla or dummy tablets. Several of the provers experienced such severe symptoms while taking the dummy tablets that they had to withdraw from the trial. This experiment does not necessarily show that Pulsatilla is incapable of causing any symptoms, but it does indicate that, at least in these circumstances, any symptoms it did provoke were completely swamped by those due to self-suggestion. It also confirms the remarkable efficacy of self-suggestion as a cause of severe symptoms. Many years ago I had an experience which reflects this. A patient holding an academic appointment came to see me at the hospital. I had the impression that she might easily produce symptoms through self-suggestion, so I cautiously gave her an inert sugar tablet to start with. Sure enough, a few days later I received an outraged letter from her, demanding to know what this highly dangerous substance was which I had given her; she said it had caused an acute psychotic reaction and her professor was very worried about her. I wrote back saying that I was sorry to hear this but did not think there was any way that the tablet could have caused her symptoms, since it was only milk sugar. No further correspondence ensued between us. Many homoeopaths believe, following Hahnemann's dictum, that homoeopathic medicines frequently give rise to 'aggravations'; that is, to temporary worsening of the patient's symptoms. One of the best-known of the nineteenth-century English homoeopaths, Robert Dudgeon, was sceptical about this, saying that aggravations are much rarer than Hahnemann supposed, and I entirely agree with this. If you tell patients firmly that there will be no adverse effects from their medicine you hardly ever see 'aggravations'. If, on the other hand, you tell patients that aggravations are likely you will certainly see plenty. Alternative medicine as psychotherapy. Although I have reservations about the idea of the enhanced placebo, I certainly do accept that much of what any alternative therapist does is, in the broadest sense of the word, psychotherapy. Many practitioners of alternative medicine resist the notion that psychotherapy plays any part in what they practise. Up to a point this is understandable, since the notion that alternative medicine is partly psychotherapy can too easily be used by critics as an excuse to dismiss the whole thing; but as there is now a fair amount of evidence to show that at least some of the alternative therapies do have effects over and above what is attributable to psychological factors there is no real need to be so defensive. In everyday clinical practice, as opposed to the rather artificial setting of a scientific clinical trial, the alternative therapist is constantly dealing with psychological problems, either on their own or as part of a more comprehensive clinical picture. Whether he likes it or not, therefore, and whether he calls it that or not, a great deal of his work is psychotherapy. Very many patients suffer from symptoms that are due wholly or partly to psychological factors. One example of this among scores of others remains in my memory. A middle-aged woman was thought to be suffering from multiple sclerosis. Her symptoms were typical of this disease, although there was always a little residue of doubt about the diagnosis, partly because she had had a test by a neurologist which had not confirmed it. (This test, known as the visual evoked response, is not conclusive proof either way, but a negative outcome does make the diagnosis less likely.) After some time it emerged that there was a definite psychological factor in this patient's case; she was unhappily married, and although she was separated from her husband he still used to beat her on occasion. Some years went by, during which she continued to attend the hospital without any great change in her condition. Then she divorced her husband and made a second marriage, which was happy. As soon as she did this all the symptoms of her multiple sclerosis disappeared. Less clear-cut examples of psychologically caused illness are extremely common. This, of course, is fully recognized by orthodox medicine, and almost every doctor in clinical practice - every general practitioner, certainly - sees numerous examples. In some cases it is possible to put a formal psychiatric label on the patients in question but often it is not. Although orthodox doctors vary in their attitudes much more than most alternative therapists would allow, it is fair to say, as a generalization, that they tend to look for a pharmacological solution for mild or moderately severe psychological symptoms. In a busy general practice there simply is no time to practise very much psychotherapy even if the doctor's interests lie in that direction, and although psychotherapy is available in National Health Service psychiatric hospitals there are far more patients than these units can cope with. In consequence, doctors often take what seems the easiest way out, which is to prescribe a so- called minor tranquillizer or a 'sleeping tablet'. Although this practice has been discouraged in recent years there still are many thousands of patients who have become dependent on these drugs. Alternative therapists, naturally, are critical of the orthodox approach to psychological problems, and not simply because it relies predominantly on drugs. They object to the whole series of assumptions on which this treatment is based. We touch here on what is probably the core of the difference between the alternative and orthodox approaches. The assumption that underlies much of mainstream psychiatry today is that psychiatry should, ideally, be reducible to neurology. Admittedly we are not at that stage yet, and perhaps never will be, but many psychiatrists write and talk as if this is what they believe; sometimes it is explicitly stated. Much modern theorizing about depression, mania, and schizophrenia, for example, proceeds on the assumption that an explanation in terms of brain chemistry or structure will eventually be found. Biochemical hypotheses are put forward to account for the ways in which the drugs used to treat these mental disorders are supposed to work. The resulting picture is of the human being as a mechanism - enormously complicated, it is true, but a mechanism none the less. The model that is assumed in much of this discussion is that of the computer. Mostly it is the hardware - the nerve cells or the chemical composition of the fluids in which they live - that is supposed to be at fault; and even when more 'psychological' factors are admitted to be part of the equation they often seem to be thought of as faults in the programme, the software. The view of the alternative therapists, I need hardly say, is diametrically opposed to these ideas in almost every respect. The central claim of pretty well all the various alternative therapies is that they reject the materialistic outlook. We quite often find it stated that human beings are composed of body, mind, and spirit. Alternative treatments are supposed to act on all these levels simultaneously, whereas orthodox medicine, in contrast, only recognizes the first level, the physical, and even then its outlook is thought to be pretty blinkered. This is partly true of even the more physical forms of treatment, but it becomes increasingly evident as we move towards the more overtly psychotherapeutic end of the spectrum (Chapter 2, p.00). If you ask for a clearer statement of what is meant by mind and spirit in this context and how they differ from each other you are unlikely to get a definite answer, except in the case of those few systems, such as Anthroposophical medicine, which are explicitly based on an elaborate philosophical theory. This is hardly surprising, since few alternative therapists, after all, are philosophers, but it does result in a certain haziness of thought and language. Nevertheless the concept of a 'spiritual dimension' underlies a great deal of the discussion of alternative medicine. In a recent review of some aspects of complementary medicine, Lorraine Nanke and David Canter quote an earlier finding that 'nearly half of the holistic practitioners replied that religious and spiritual experiences were important in shaping their views about health, illness and healing, in contrast to 13 per cent of family practitioners.' [Complementary Medical Research, 1991, 5, 1 - 6] It is of course perfectly true that many, perhaps most, patients who seek alternative treatment have no definite theoretical stance on the question. Nevertheless many forms of alternative medicine do have these 'spiritual' aspects if one looks for them. This emerges most clearly in the case of homoeopathy. Samuel Hahnemann, the founder of homoeopathy, was not a mystic, but in his later years he did incorporate certain ideas into homoeopathy (especially the potency theory and the notion of the vital force) that verged on the metaphysical, and were so regarded by his contemporaries. In the second half of the nineteenth century a number of North American homoeopaths, including some of the most respected and influential among them, became ardent disciples of the seventeenth century philosopher and mystic Emanuel Swedenborg. Swedenborg's teachings, which derived from his accounts of contacts with spirits, gave a new and distinct character to American homoeopathy, and in the early twentieth century these ideas crossed the Atlantic to Britain, where they took root strongly and largely transformed the native school of homeopathy. (I have related this story in my book THE TWO FACES OF HOMOEOPATHY.) Homoeopathy is certainly not unique among alternative medical systems in possessing this semi-mystical element. Anthroposophical medicine, for example, was invented in the early twentieth century by the Austrian philosopher and mystic Rudolf Steiner, and incorporates numerous mystical ideas derived in part from Paracelsus and Goethe. (Anthroposophical medicine has something in common with homoeopathy but uses different medicines prescribed in different ways.) Traditional Chinese acupuncture, although not a mystical form of treatment in China itself, often seems to appeal to Westerners sympathetic to ideas of that kind. Then there is a large number of alternative psychotherapies that possess a 'spiritual' dimension. Some, such as Silva Mind Control, are frankly concerned with the attempt to enhance people's paranormal abilities. Others make use of astrology or of memories supposed to be derived from previous lives. Nor is it only the 'far out' therapies that show these characteristics. Even Freud, who was in many ways the perfect example of a 'left- column' thinker, toyed with the paranormal, and his pupil Jung was still more receptive to these ideas. At the furthest edge, so to speak, alternative therapies shade imperceptibly into other things such as meditation, methods of self-development, paranormal healing and forms of prayer. At this point alternative medicine begins to blend with New Age thought. Although not everyone who uses alternative medicine is necessarily much concerned with ideas of a New Age, many are, and the converse is certainly true; there can hardly be anyone who believes in New Age concepts who is not also firmly committed to alternative medicine, as either a patient or a practitioner. In a recent television programme on the New Age at least half the members of the invited audience who spoke identified themselves as therapists of one kind or another. In appearance, the New Age movement originated with the hippie movement in the 1960s, but it can be traced much further back than that; William James describes what is essentially the same phenomenon at the end of the nineteenth century in America, while Norman Cohn has given us a brilliant analysis of similar ways of thinking in the millenarian movements of the Middle Ages. There is indeed something strongly archetypal about it, so that it keeps on cropping up again and again in history. It was, for example, particularly evident among the American homoeopaths in the nineteenth century. They believed that homoeopathy would eradicate the deeply rooted 'miasms' that were poisoning human existence and were being transmitted from one generation to the next; and this happy development, they supposed, would not merely eliminate chronic disease but would bring about a complete transformation in social conditions. Similar ideas are still held today by some influential lay homoeopaths. 8: THE NEW AGE To discuss in detail all the causes for the rise of New Age thought would take me too far from my theme. Several obvious ones present themselves. War, famine, pollution, over-population, and disease seem to crowd in upon us more and more as the twentieth century draws to its close, and one would have to be stoical indeed not to feel at least apprehensive about the future. Then there is the dissatisfaction with science that I noted at the beginning of this book. Even as recently as fifty years ago, science seemed to most people to be benevolent; far fewer of us would assert that so confidently today. There is a feeling abroad that we have been too hubristic, too clever for our own good, and are beginning to reap the consequences. In addition to these causes for anxiety a growing number of people, especially among those sympathetic to alternative medicine, are taking seriously ideas that would thirty or forty years ago have seemed like the rankest superstition. The prophecies of Nostradamus are wheeled out and apparent fulfilments of them are discerned. Biblical fundamentalists, especially in America, see prophecies of doom in various parts of Scripture: in the Apocalypse (Book of Revelation) ascribed to St John, naturally, but also in a number of books of the Old Testament. Astrology, though often declared dead, refuses to die; and astrologers are convinced that the end of the second millennium, coinciding as it does with the transition from the Age of Pisces to the Age of Aquarius, must be accompanied by dramatic changes in human fortunes. So much is more or less self-evident. But why the close connection with alternative therapy? So far we have been looking at alternative medicine almost entirely as something that affects just the individual. It does, however, also have what might be called its public health persona. For rather in the way that conventional medicine can be thought of as linked with social measures to improve people's lives (better housing, clean water, healthier food), alternative medicine could be thought of as being concerned with the spiritual as well as the material health of society and the planet itself. And rather as on the individual level our symptoms are said to be a sign that the body is seeking to heal itself and are thus in some sense to be welcomed, so too on the planetary level all is going to be well. Yes, we are in for a period of tremendous turmoil and upheaval, but at the end of our journey through the valley of despair we can expect to emerge into the broad sunny uplands of a new Eden. The close connection between New Age thinking and alternative medicine is well exemplified by Transcendental Meditation (TM). This technique was brought to the West in the 1950s by an Indian teacher, the Maharishi Mahesh Yogi. The special features of TM, according to its founder, were that it was easy to learn and did not require any commitment to strange dress or postures or the adoption of a new way of life. It was simply a technique, and could be learned by anyone without the need to take on a belief system. At the same time - and this was part of its appeal for many people - it did stem from an ancient Indian tradition; it had an authentic background. Maharishi was said to have been the closest disciple of a renowned Indian teacher, Swami Brahmananda Saraswati, the Shankaracharya of Jyotir Math in the foothills of the Himalayas. (Shankaracharya is a title; four maths, or monastic seats of learning, were founded in different parts of India, probably about 800 AD, by the original Shankaracharya, the most renowned philosopher of the Advaita Vedanta school of Indian philosophy.) It was from his master that Maharishi obtained the system of meditation he later taught. After his master's death in 1953 Maharishi remained for some time in seclusion but then begun to teach; at first only in India, but later in countries throughout the world, including the USA and Britain. Initially his success was reasonable but not dramatic. In 1967, however, TM was taken up by the Beatles, and this certainly brought it decisively to public attention. Maharishi was interviewed on television by Malcolm Muggeridge and David Frost, and articles appeared in almost every newspaper and in numerous magazines. The Beatles went to India with Maharishi, and although their involvement with TM was fairly short-lived the impetus they gave to his movement was great enough to keep it in the public eye long after their departure. TRANSCENDENTAL MEDITATION AS A MEANS TO HEALTH Transcendental meditation (TM) is at bottom a spiritual technique, but it has always been described as having many beneficial effects not only on psychological functioning but also on physical and mental health. Among the benefits listed in a current TM brochure we find: - Increased mental clarity, alertness and creativity. - Increased self-esteem, well-being, and vitality. - Reductions in stress, anxiety and depression. - Improved immunity and resistance to disease. - Improved sleep patterns. - Better relationships at home and work. The basis for these effects is the state of deep rest provided by TM. 'During TM, the mind experiences its quietest, most settled state, while alertness is fully maintained: a state best described as "restful alertness" or "pure consciousness". Research has shown that TM gives rise to a unique state of deep rest, accompanied by a high degree of integration in brain functioning. This profound state of rest allows the body to throw off deeply rooted stresses that are not removed by ordinary relaxation or sleep.' [TM brochure] These claims are supported by a large number of scientific studies - more than 350, we are told. In one of these, a group of more than 2,000 TM practitioners followed up for five years was found to need only half the number of doctors' visits and hospital admissions recorded for a comparable control group; heart disease and nervous system disorders were particularly infrequent, and so were tumours. TM is said to help in a wide range of physical illnesses, including asthma, hypertension, angina, multiple sclerosis, and ME. It also has an important part to play in prevention: it reduces all the major risk factors for heart disease, increases resistance to stress and 'promotes positive health habits'. A three-year survey of psychiatric hospital admissions in Sweden showed that there was much less need for psychiatric care among people practising TM. One of the chief attractions of TM has always been the ease with which it is learnt and practised. It is described as 'a simple, natural and effortless technique practised for 15 - 20 minutes each morning and evening, sitting comfortably with eyes closed. This technique can be easily learned by anyone, regardless of age, educational background, culture or religious belief, and requires no change of life-style or diet.' While this is perfectly true, it is also the case that TM is not just a technique. Like its founder, it is rooted in the Indian tradition, and has an elaborate philosophical basis. However, it is quite possible to meditate for years without troubling oneself about this aspect. In 1985 Maharishi set up a centre in New Delhi to study Ayurveda, the ancient traditional form of Indian medicine. This led to the development of 'Maharishi Ayurveda', which is Maharishi's version of the ancient system, incorporating TM. The basis of Maharishi Ayurveda is said to be the establishment of balance within a person's mind and body, which will then relieve stress and tension. TM is the main technique for achieving this, but now it is supplemented by a variety of means, including diet, exercises, breathing methods, and herbal preparations. Claims are made for the alleviation of many diseases, including Aids, and there is even a report that this treatment can reverse some of the effects of normal ageing. Public health is not neglected either. It has long been a TM claim that there are beneficial effects on society at large - the 'Maharishi effect' - including decreases in the incidence of diseases, hospital admissions, suicides, accidents, crime, and even reductions in national and international conflicts. Once again, these claims are supported by numerous sociological studies. I first came into contact with TM shortly before the Beatles arrived on the scene, and I used the technique for many years. I thought then, and I still think, that it is a Good Thing. Whether or not all the claims made for it can be substantiated is another question and I have no first-hand experience of the recent Ayurvedic aspect. But that the practice of TM does reduce one's vulnerability to stress I have no doubt. The main effect seems to be that after a year or two of meditation strong outside stimuli, whether pleasant or unpleasant, tend to 'damp out' more quickly than before; they push one off balance less than they used to do. This may seem a fairly modest claim, but I think it is a genuine and valuable effect which is not the result of suggestion. In the late 1960s and early 1970s I attended a number of the large international TM gatherings, or 'courses', as they were known, which were held in various parts of the world. Numerous young Americans used to attend these courses, and most of them had absorbed the hippie values of the Sixties, which seemed to blend easily with TM. There was a good deal of talk of 'negativity' and 'positivity'. To have serious doubts about TM would certainly be 'negative', but it was also 'negative' to think or talk much about illness, death, war, famine, over-population, or any of the other individual or collective threats we might feel exposed to. Instead we were supposed to concentrate on the beneficial effects of TM. If the meditation were only practised widely enough all these problems would be solved. There was no need to go into the details of how this would come about, but everything would be taken care of automatically, thanks to the increased creativity of meditators on the one hand and the beneficial effects of TM on society at large on the other. Maharishi himself appeared to believe this, at least in public. He gave talks to large audiences in which he announced the arrival of a Golden Age of Enlightenment - literally golden, for all the literature of the TM movement was now embellished by having the titles picked out in gold lettering. In private, too, he was generally up-beat, although he continued to emphasize the need to hurry to get people to start meditating in order to counteract the harmful stresses of modern life, which he blamed for such things as civil disorder and war. This insistence on positivity and optimism, and on the dawning of an Age of Enlightenment, fitted in very well with the ideas of the alternative health movement, which was just beginning to take off at the end of the 1970s. The problem which quite a few of us found with all this hyperbole was that it overstated what was actually quite a good case to be made out for TM. Meditation done in the TM way really did help many people to cope with the effects of psychological tension and there were few serious adverse effects. Severely disturbed individuals could certainly react badly to TM, but the initial screening procedure was reasonably successful in detecting such vulnerable people, who were regarded as unsuitable for TM. (Some of them could however be given a different, less far-reaching, practice to help them.) The main weakness of TM was the fact that it was stereotyped. This is a relative criticism only, for if you are going to offer a form of meditation to many thousands or even, ideally, millions of people, which is what Maharishi intended, it clearly has to be done in a standarized manner. But this did inevitably mean that meditators who came across difficulties of various kinds had no easy way of resolving them within the TM framework. Some people, for example, experienced personal disasters of various kinds which they had been led to believe should not have happened to them. (Not that it was ever stated that meditators should not expect to have accidents or become ill, but the implication that such things ought to become less likely was there.) Others were sufferers from mild or moderate anxiety, depression, or other psychological symptoms which were not severe enough to exclude them from TM but were nevertheless distressing. Meditators who encountered problems of this kind naturally tended to approach their teacher of meditation or one of the other meditation guides specially trained to monitor the progress of TM, but all these people were supposed to confine themselves to the meditation itself, not to offer advice on meditators' lifestyles or to diagnose their physical and mental ills. This was a perfectly reasonable rule, given that few of the meditation teachers or their assistants were professionally qualified to give advice of that kind. Nevertheless there were inevitably a considerable number of meditators who had need of something of the sort in addition to the meditation itself. Another kind of difficulty arose when people reported strange, sometimes very powerful, experiences during meditation. The policy was to play these down and not to attach much importance to them, which again was sensible, given the large numbers of meditators. But not everyone found this satisfactory; some wanted to know what the experiences meant, and these people required individual attention; it wasn't enough to give them stock answers. In the end I found the grandiose claims increasingly being made on behalf of TM impossible to go along with. This tended to induce a mood of disillusionment; Louis Macneice's line often ran through my mind: "It's no go the yogi man, it's no go Blavatsky." Yet it was necessary to remember that TM did, in a sense, appear to work; it was not all a waste of time, and I still felt I had gained a great deal from it, if not perhaps as much as I had been promised. Which brings us back to the theme I hinted at in the Introduction: the difficulty of keeping a balance between credulousness and cynicism. TM is not without parallels; there have been a number of rather similar movements over the last 20 years, but I have singled out TM partly because of my first-hand experience of it but also because it includes pretty well all the components of the New Age: the quest for individual spirituality, alternative medicine, and the promise of collective transformation leading to the dawning of an Age of Enlightenment. It exemplifies rather well both the attractions and the drawbacks that characterize New Age movements in general. 9: TRYING TO MAKE SENSE OF IT ALL At the beginning of this book I posited an imaginary situation to help you to define your own attitude to alternative medicine. From what followed it should be apparent that I don't myself believe that there is any one 'right' answer to questions about the value or otherwise of these therapies. Much depends on your initial assumptions and the belief system you bring with you, as well as on the exact nature of the therapy being considered. A few general conclusions do, however, seem possible. Clinical research provides a fair amount of evidence to show that the better-established therapies (acupuncture, manipulation, homoeopathy, hypnotherapy) do work part of the time and for certain kinds of disorders. Indeed, all those I have mentioned have already made a greater or lesser amount of progress from the 'fringe' towards medical respectability, and in so doing have begun to lose something of their alternative character. Whether you find this a matter for rejoicing or regret is a matter of individual reaction. We have also seen, however, that part of the appeal of alternative medicine for many people is precisely that it is perceived as being anti-mechanistic, non-reductionist - that is, a right-brain phenomenon. This version of therapy is inevitably more or less at odds with the prevailing medical orthodoxy, which is mechanistic, reductionist, left-brain. Here your choice of attitude is largely determined by where on the left-brain/right- brain spectrum you happen to find yourself. (You probably can't do much to alter your positioning on this spectrum; it seems to be determined largely by factors outside your control.) What follows, therefore, is determined by my own position (somewhere in the middle, I think, but more towards the left in respect of many topics). In reading what I write you should make appropriate allowances, but don't overdo these because I have done my best to allow for my own biases and to be as fair to both views as I can. A FRANKLY PERSONAL APPRAISAL The principal failing of the philosophical alternative medicine enthusiasts, it seems to me, is their facile over- optimism. From some popular books about alternative medicine you would infer that there is almost nothing that can't be cured. And quite a number of patients do indeed draw just this conclusion, and are bitterly disappointed by the outcome. As for the therapists, they sometimes seem to believe that, if their treatment fails to cure a patient, this must be because they haven't yet found the right combination of medicines, acupuncture points or whatever that would do the trick; they are usually strongly resistant to the idea that their treatment might simply not provide the answer in every case. Of all the uncomfortable facts that need to be faced, the starkest and most uncomfortable of all is of course death. It is often said, with a fair amount of justification, that conventional medicine is inadequate when it comes to coping with the dying. Hence the hospice movement. This inadequacy is probably at least in part due to the difficulty that doctors, like other people, experience in coming to terms with their own mortality. But what about the alternative movements? Do they do any better? It hardly seems likely. Few of them, after all, have much to do with the dying; most patients these days die in hospital. The difficulty that many doctors experience in confronting the fact of death is not wholly their fault. Patients, too, often collaborate in the conspiracy of denial. We seldom talk much to our patients about death; perhaps we should do so more. But there is a strong cultural resistance against it; as many people have noted, death has become the ultimate unmentionable. Patients are usually quite happy to discuss intimate details of their sex lives, but they are nearly always much more reticent about death. And naturally doctors, too, experience the same reluctance. 'For those who live neither with religious consolations about death nor with a sense of death (or anything else) as natural, death is the obscene mystery, the ultimate affront, the thing that cannot be controlled. It can only be denied.' (Susan Sontag, ILLNESS AS METAPHOR, p. 55.) Denial is certainly the rule, although one can sometimes discern a different note. The middle-aged and elderly may voice their anxieties indirectly, often making a little joke of it, as we tend to do when we are afraid of something: 'it's anno domini, I suppose,' or, more sombrely, 'don't grow old, Doctor, it's a mistake, I can tell you.' Denial can take very odd forms indeed. Now we are offered the prospect of technological immortality. Certain entrepreneurs invite us to pay them huge sums of money for the privilege of being frozen in liquid nitrogen (head down to preserve the brain in case the refrigeration fails temporarily), in sure and certain hope of resurrection when at some future time it has been discovered (a) how to revive us and (b) how to cure whatever it was we died of. For people who cannot afford to have their whole body frozen there is a cut-price alternative which consists in freezing just the head. There is an interesting resemblance here to the Egyptian practice of embalming the dead in order to ensure their immortality. Like our modern 'cryonics', embalming was a very costly affair; only a small minority of the population could afford the full treatment, although, as in our case, a cheaper alternative version was also available. The modern transformation of a 'spiritual' conception of immortality, as held by the Egyptians and other peoples of the ancient world, into a materialistic and technological one is surely very significant. What is astonishing about the whole cryonics idea is not so much the implausibility of the 'science' involved as the extraordinary and probably unwarranted optimism it implies about the future stability of our sophisticated technological civilization. There is also a remarkable degree of egotism in the assumption that a future society would actually want to revive large numbers of unknown people. It is certainly not for the doctor to try to make patients confront things they don't wish to confront. We all have the right to our reticence and our escapes from reality. On the other hand, probably no therapist can achieve very much for many of his patients unless he has at least begun come to terms in one way or another with his own mortality. No choice is uninfluenced by the way in which the personality regards its destiny, and the body its death. In the last analysis, it is our conception of death which decides our answers to all the questions that life puts to us. [Dag Hammerskjold, United Nations Secretary General: 1966 Markings, tr. W.H.Auden and Leif Sjoberg, Faber and Faber, p.136] This coming to terms with mortality may have been an easier task in more religious ages; certainly the Victorians had no false shame about discussing death. When I was a boy in a Roman Catholic school we were frequently exhorted to remember, on going to bed, the Four Last things: Death, Judgement, Hell and Heaven. It is, or at least was, one of the great strengths of Catholicism that it did not shrink from acknowledging the reality of death. Our headmaster used to boast that, when he attended the annual Headmasters' Conference and was asked what he thought he was preparing his pupils for, he used to reply: "For death." That reply would probably be considered morbid today; I have no idea if his modern successor would say the same thing. Of all the great world religions it is, I think, Buddhism that faces the fact of death with the greatest degree of honesty. In the Theravada Buddhist tradition, for example, the monks and nuns regularly chant: "I have not gone beyond sickness, I have not gone beyond aging, I have not gone beyond death." Morbid? No: wholly admirable. The onset of a serious or fatal illness is one way in which our inevitable mortality may be brought home to us. The slow breakdown of our physical or mental faculties is another. Like Peer Gynt, we find ourselves gradually peeling away the layers that went to make up our physical and mental selves, until at last we reach the end and nothing is left at all. It can seem like a bad cosmic joke: "Nature is witty." Of course, I am deliberately putting the matter in its starkest terms. In many instances a certain amount of compromise is possible. Useful treatments, conventional or alternative, do after all exist for many diseases, and some at least of the disabilities of aging can be mitigated in various ways. There is also a lot we can do to help ourselves, especially by prevention: we can avoid tobacco and excessive amounts of alcohol, we can take exercise and prevent putting on weight by eating sensibly, we can keep our minds active. Not to do these things is doubtless foolish. But we ought also to recognize that we may do all this and still become ill, and our illness may be of a kind that no presently available treatment can help. We ought also to recognize that there can be no guarantees of immunity from the attrition of time. Sometimes patients say: 'Why should this have happened to me?' To which there can be only one honest, if brutal, answer: 'Why not you?' The implied message of technology and of the Welfare State is that pain and suffering should not be part of life and we have a right to be relieved from them. It is not a message that would have made much sense to earlier generations, who seem to have accepted these things as inevitable. And alternative medicine, although it rejects technology as such, generally colludes in fostering the delusion that we should be perpetually healthy. There is therefore nothing surprising if many patients with incurable disorders believe that a cure must exist somewhere. But for many such people there will be nothing but an incessant progression from one specialist to another, from one form of alternative therapy to another. It is never right to deny a patient hope. At the same time, however, it is equally wrong to buoy people up with false promises. A fine balance is to be struck. ALTERNATIVE MEDICINE AND THE SPIRITUAL DIMENSION We saw a little earlier (p.000) that nearly half of a group of alternative practitioners who were questioned said that religious and spiritual experiences played an important part in forming their clinical practice, whereas only 13 per cent of orthodox general practitioners thought in this way. This is surely a most important difference. It points to the fact that many alternative practitioners don't hesitate to assume the role of guide, guru, shaman or what you will. In other words, they are not content to confine their activity to giving fairly mundane advice about diet, exercise, and the avoidance of stress, but believe that they can communicate to their patients a wider vision of human nature and its relation to spiritual forces. In this respect the alternative practitioners are reverting to an older view of the place of the healer. In many traditional societies, healing and religion were closely connected; in fact, healer and priest were often one. The shaman was a man or woman who had undergone certain initiations, often of a very exacting kind, that enabled him or her to communicate with the spiritual world and to mediate between that world and ours. Practices of this kind were not confined to so-called 'primitive' peoples such as the tribes of Central Asia or the North American Indians; they persisted in one form or another into Classical times and even later. The use of dreams as an aid to diagnosis, for example, was widespread in antiquity, and patients would visit well-known shrines in order to sleep there and have dreams which would be interpreted by the resident priest, who would then prescribe the necessary treatment. And even the medicine of the ancient world (for example, that corpus of knowledge ascribed to Hippocrates) preserves a good deal of its religious origins. Gradually, however, conventional doctors abandoned this connection with religion and the spiritual. We find little evidence of it, for example, in Galen's writings, and by the time we reach the rational eighteenth century the physicians of the day are eager to distance themselves as much as possible from any such cultic connections. In our own time this separation has become pretty well complete. For example, the phrase 'a good bedside manner', which some thirty or forty years ago could still be applied to a physician as a term of praise, today has connotations of the slightly bogus if not of outright charlatanry; it is taken to imply the use of positive suggestion beyond the limit of reputable practice. Modern doctors insist on their scientific credentials and on objectivity. Alternative practitioners are seldom sufficiently detached from the prevailing climate of opinion to ignore science totally, but they reinterpret it in their own terms. And this is an important part of the appeal of the alternative therapies for many people. Even the most way-out practices usually have at least a veneer of science, but they are also perceived as partaking of the spiritual dimension. Hence their practitioners and their patients can claim the best of both worlds. The wish to link the spiritual and the mundane in this way is surely valid in principle. Given that many patients do come to therapists (of all kinds) with problems that are not amenable to treatment in the ordinary sense of the word, there really is no choice. Either the therapist has to do the best that he or she can, or the patient must be sent elsewhere. But to whom? To a psychiatrist? Sometimes that is the right solution, but not very often. To a priest? Yes, sometimes; but not many patients these days want an overtly religious solution, and in any case, many clerics, at least in the West, appear to be quite as much at sea about what they believe as the rest of the population - sometimes, one suspects, even more so. The therapist must often, therefore, fall back on his or her own inner resources. This presupposes that he or she has some kind of metaphysical framework to rely on, or has at least given the matter sufficient reflection and attention to have something to offer. A conventional medical education today clearly does not supply anything of the kind. The strength of many alternative practitioners is that they have found some kind of Answer that at least satisfies themselves and may appeal to other people as well. Admittedly some of these Answers may well appear bizarre to many uncommitted outsiders, but there are likely to be some who will find them to be what they have been looking for. Probably the person who has understood this need most clearly in modern times was C.G.Jung. His form of psychotherapy, which he called analytical psychology, is professedly scientific; he himself always insisted that he was a scientist and based his ideas on practical observation. But however this may be, there is no denying the fact that Jung's ideas and methods have many of the features of alternative psychotherapy, especially the use of dreams as the gateway to the unconscious. As is well known, Jung paid an enormous amount of attention to religion. Indeed, he is on record as saying that all those middle-aged patients with whom he worked who achieved a substantial degree of self-integration (which he called individuation) did so because they succeeded in resolving a religious dilemma, in the widest sense of the term. But although Jungian analysis might be described as alternative psychotherapy, at least in the sense that it is not fully accepted as valid by mainstream psychiatry, it emphatically could not be accused of sentimentality or refusal to face facts. Many of Jung's own patients were middle-aged, and this is still true of many people who undergo Jungian analysis today. (The term 'midlife crisis' originates with Jung.) A Jungian analysis is therefore very likely to lead, at some stage, to an encounter with the idea of death, and facing this and other unwelcome thoughts is a central part of the process of 'individuation'. What follows from all this is the perhaps rather uncomfortable conclusion that the only therapists who can help people to encounter the deep problems - incurable illness, awareness of death - are likely to be those who have at least begun to resolve these questions for themselves. It probably doesn't matter so much exactly how they have done so, although certain paths are intrinsically more promising than others; but what does matter is the personal qualities of the woman or the man who is conducting the therapy. I should not wish to imply that this is necessarily a matter of arriving at a formal set of metaphysical or religious beliefs. Indeed, it may be that what some people need is the ability to transcend belief systems that have become too constricting. This often seems to be true of patients whose suffering stems in part from the fact that they are perceiving their life situation too exclusively from one narrow point of view. Yet still we are not at the core of the matter. Maybe it is really the word 'therapy' that we keep stumbling over, for it implies that there is something 'wrong' that needs to be 'fixed' by the expert. But perhaps we should do better to stop thinking so much in terms of health versus disease. Many patients come to alternative therapists with a request for a 'natural' form of treatment. As we have seen (p.000), the word begs many important questions. But even beyond this, perhaps the whole idea of 'treatment' - the implied model on which it is based - is inappropriate for some people. Perhaps some of us need to abandon the notion of an expert therapist 'treating' a 'patient' and instead to think more in terms of a dialogue between two people caught in the same situation. A dialogue of this kind naturally demands a fair degree of maturity in both participants, and it is by no means what is needed in every case. But there are times when the so-called therapist will be best advised, not to prescribe a medicine, whether natural or not; not to stick needles into the 'patient'; indeed, not do anything at all, even to give advice about life style or anything else, but simply to listen and to reflect back the situation to the sufferer without making a judgement or a recommendation about what to do or not to do. The result of this can be an increased willingness to accept things as they are, and to recognize that ill health, aging and death lie in wait for all of us in one form or another. If we can do this, without making up metaphysical theories to account for our situation and without trying to explain it away, there may be a way forward. It isn't an easy one, for it requires the development of an ability to tolerate physical and mental discomfort and uncertainty. Our minds dislike uncertainty and much prefer the apparent security of fixed views. But we have it on good authority that it is by facing uncertainty that ultimate freedom from suffering can be attained. Speaking of his own experience on the way, the Buddha said: "If I stood still, I sank; if I struggled, I was carried away. Thus by neither standing still nor struggling, I crossed the flood." BIBLIOGRAPHY Buranelli, V. (1976). The Wizard from Vienna. Peter Owen, London. --------- (1984a). The Two Faces of Homoeopathy. Robert Hale, London. --------- (ed.) (1984b) Natural Health Handbook. QED Publishing, London. Capra, F. (0000) The Tao of Physics. Cohn, N. (1970). The Pursuit of the Millennium. Paladin, London. De Loverdo, C. (1956). J'ai Et‚ Moine au Mont Athos. La Colombe, Paris. Coward, R. (1990) The Whole Truth: The Myth of Alternative Health. Faber and Faber, London and Boston. Goodall, J. (0000) In the Shadow of Man. Weidenfeld and Nicolson, London. --------- (1990) Through a Window: Thirty Years with the Chimpanzees of Gombe. Weidenfeld and Nicolson, London. Inglis, B. (1964). Fringe Medicine. Faber & Faber, London. --------- (1981). The Diseases of Civilisation. Hodder and Stoughton, London. --------- and West, R. (1983) The Alternative Health Guide. Michael Joseph, London. Jones, F.A. (ed.) (1972) Richard Asher Talking Sense. Pitman, London. Kuhn, T. (0000) The Structure of Scientific Revolutions. Lovelock, J.E. (1979). Gaia: A New Look of Life on Earth. Oxford University Press, New York. Popper, K. (1963). Conjectures and Refutations. Routledge and Kegan Paul, London. Russell, B. (1946) History of Western Philosophy. Allen and Unwin, London. Schrodinger, E. (0000). What is Life? and Mind and Matter. Cambridge University Press, Cambridge. Sontag, S. (1979) Illness as Metaphor. Allen Lane, London. Szaz, T.S. (1972) The Myth of Mental Illness. Granada, London. [End.]


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