Divided Legacy. 
A history of the schism in medical thought. 
Volume IV: Twentieth century medicine: the bacteriological era. 
Harris L Coulter. 
North Atlantic Books, Berkeley, California. 
$50. 

Throughout its history homoeopathy has been characterized by two divergent trends. Some homoeopaths, such as Richard Hughes, were concerned to build bridges to orthodox medicine and were reluctant to accept the more 'extreme' homoeopathic doctrines of vitalism, miasms, and ultra-high potencies: and others, such as Constantine Hering and James Tyler Kent, accepted these ideas enthusiastically and ignored conventional medicine or rejected it outright.

Hahnemann's own career exhibits this ambivalence. He did not publish any systematic description of homoeopathy until The Medicine of Experience in 1806, when he was 51. Soon after this he moved to Leipzig, where he remained until 1821, and during these 15 years, which saw the publication of the early editions of The Organon and the Materia Medica Pura, his approach was more or less that of a medical scientist, albeit an eccentric one. He was lecturing at the university and was thus exposed to the medical ideas of the day, even if he rejected them, and he was treating patients with acute as well as with chronic diseases.

In 1821, however, he was driven by the hostility of the Leipzig apothecaries to move to the little principality of Koethen, where he was pretty well cut off, not only from mainstream medicine, but even from most of his own disciples, while his practice became largely confined to the treatment of chronic diseases. It is to this period that the announcements of his potency and miasm theories belong. Thus those of his ideas that have proved most contentious in later years were produced after the age of 66 and at a time when he was relatively isolated. This does not of course invalidate them but the setting in which they were arrived at does need to be kept in mind in trying to evaluate them.

Not all homoeopaths regarded these developments as improvement either at the time or subsequently. Certainly they tended to give rise to inconsistencies, apparently unnoticed by Hahnemann. Take, for instance, the miasm theory. Hahnemann had always maintained that the mechanisms of disease production are unknowable. Yet the miasm idea is essentially a pathological theory. It postulates that the vast majority of chronic diseases is caused by one of three miasms, and especially by one of these, psora. Hahnemann did not offer any suggestions about what the miasms might be in themselves, but to a modern reader his description inevitably calls to mind the concept of infection. And indeed, although Hahnemann did not explicitly state that the chronic miasms might be caused by microorganisms he did make this suggestion in connection with cholera.

The miasms are supposed to enter the body-through the skin, in the case of psora-and there remain latent for months or years before giving rise, later in life, to innumerable forms of chronic disease. What can this be but a theory of disease mechanism?

Because Hahnemann's writings exhibit such inconsistencies it has been open to his successors to emphasize different aspects of homoeopathy while claiming to be authentic homoeopaths. But there have often been bitter disputes among the faithful, and it was this that led to the downfall of homoeopathy in the USA in the nineteenth century. At that time American homoeopathy was divided into a large number of 'low-potency' prescribers on the one hand and a smaller but vocal body of 'high-potency' homoeopaths on the other. The high-potency group held out for what they regarded as the pure doctrine of homoeopathy, while the low-potency majority were prepared to mix their homoeopathic medicines, to use allopathy at times, and generally to make compromises with the conventional medicine of the day. Eventually there ceased to be any real difference between low-potency homoeopathy and allopathy, and the great majority of American homoeopaths quietly ceased to identify themselves as such. The high-potency enthusiasts held on for a time but eventually they died out and were not replaced. In the end all the homoeopathic hospitals and colleges were closed by the Government as being 'not up to standard', and homoeopathy pretty well ceased to exist in the USA; until, that is, it was revived in recent years.

In his lengthy historical survey of medical history, of which this is the fourth and final volume, Coulter has been concerned to defend one side in this dispute. He is a passionate advocate of the way of thinking that inspired the 'high-potency' school in America in the nineteenth century and in the twentieth came to dominate British homoeopathy under the influence of Margaret Tyler, John Weir, and others.

Coulter labels the 2 approaches 'rationalism' and 'empiricism'. This is a rather confusing terminology, somewhat reminiscent of the mediaeval philosophical schools of nominalism and realism. Probably many readers will identify empiricism with holism, and rationalism with reductionism, although this is not the terminology that Coulter uses himself.

For Coulter, empiricism is good and rationalism is bad. Rationalism, we are told, explains the functioning of the body by the laws of chemistry, physics and mechanics, whereas empiricism does not attempt to explain it or to generalize but deals with the individual. Homoeopathy is of course empirical, allopathy rational.

Coulter's book looks at the fairly recent history of medicine from this point of view. The first few chapters consider the work of nineteenth-century medical scientists such as Pasteur, Koch, Erlich and Metchnikoff. There follows a long chapter explicitly on homoeopathy, and indeed the underlying theme of the book is that homoeopathy is the one true embodiment of empiricism. But even within homoeopathy itself Coulter identifies heroes and villains. The chief homoeopathic villain is, predictably, Richard Hughes, identified as the world leader of the low-potency school of homoeopathy in the later decades of the nineteenth century. The heroes include, again predictably, Constantine Hering, Kent and Margaret Tyler; G. Vithoulkas is cited as a latter-day inheritor of this 'correct' understanding of homoeopathy. Other twentieth- century figures who receive Coulter's seal of approval include Sir John Weir and the late Dr Margery Blackie, whom Coulter oddly describes as Lady [sic] Margery Blackie.

There is no doubt that Coulter's study is based on a prodigious amount of research. The numerous quotations are fully referenced and the bibliography takes up 42 pages. All this scholarship might lead the unwary reader to suppose that he or she was being offered a reasonably objective view of the subject. But this is not the case.

It is of course undeniable that every writer, no matter how much he tries to be objective, will inevitably introduce his own bias into what he writes, but Coulter's approach is frankly tendentious. Kent and his supporters and followers are represented as exponents of something called 'classical' homoeopathy.

In the twentieth century the spirit of strict Hahnemannian homeopathy has been represented by [Kent's] Repertory, and the degree to which practitioners in any country abide by Hahnemann's empirical legacy is defined by how closely they follow the Kentian method.

This claim is quite unequivocal: Kent is the one true interpreter of homoeopathy for the twentieth century. But this is a serious and misleading over-simplification. It neglects or even wilfully ignores two important strands in the Kentian system that have no connection with homoeopathy.

We know that Kent, in common with Hering, Boericke, and most if not all of the other high-potency homoeopaths in America in the nineteenth century, was a deeply committed Swedenborgian; indeed Kent himself states this explicitly. Swedenborgian ideas appeared to these people to offer an ideal philosophical and mystical complement to homoeopathy; conversely, homoeopathy was seen by the numerous Swedenborgians of the day as the ideal system of medicine for them. Much of the structure of Kent's Repertory - in particular the great emphasis it places on the 'Mentals'-derives from Swedenborgianism. One would therefore naturally expect that Coulter would at least discuss the influence of Swedenborg on nineteenth-century American homoeopathy, even if only to discount it. But not so; Swedenborg does not even appear in the index, and Swedenborgianism receives only a glancing and dismissive reference in the text.

It is inconceivable that Coulter did not know about Swedenborg's impact on nineteenth-century American homoeopathy, so why does he so carefully avoid discussing it? It is difficult to avoid the suspicion that be does so because it does not fit neatly into the picture he wants to paint. To have introduced Swedenborg at this point would have required a long digression, since few modern readers know anything about him; and it would have introduced a frankly mystical element into Coulter's semi-scientific treatment of his material. Nevertheless, in omitting any discussion of Swedenborg he has left out one of the chief formative influences on Kentian homoeopathy.

Another important influence on Kent came from his early training in the medical system known as 'eclecticism'. This has been emphasized recently by Matthew Wood (The Magical Staff- the Vitalist Tradition in Western Medicine [1994]). It was a tenet of John M. Scudder, Kent's teacher, that the life force of the physician played an important part in the therapeutic process; Kent imported this idea into homoeopathy, but it was, Wood says, a homoeopathic heresy. Coulter has a poor opinion of eclecticism and consequently downplays its influence on Kent.

There are numerous other instances where Coulter's enthusiasm for a particular interpretation has led him to present a one-sided view of his material. He states (p. 256) that Hahnemann's miasmatic doctrine was 'in due course accepted by all [sic] homoeopathic physicians...'. This is manifestly not the case; it was not accepted, for example, by Richard Hughes or Robert Dudgeon (but possibly Coulter would not admit that Hughes was a truly homoeopathic physician).

Some of Coulter's criticisms of 'allopathic' medicine are well taken if perhaps a little hackneyed (thalidomide, chloramphenicol, streptomycin). In fact, nearly all his references to conventional medicine are 20 or more years old. This leads him into some dubious arguments.

His dismissal of the 'allopathic' treatment of hypertension is a good example. The rauwolfia alkaloids are obsolescent if not frankly obsolete as a treatment for hypertension; there is therefore little point in devoting a page to detailing their unwanted effects. And, like many critics of 'allopathy', he entirely fails to suggest a plausible alternative to the treatments he pillories. It is true that there is no drug treatment of hypertension that is wholly satisfactory or without unwanted effects. But what follows from this, given that numerous trials have shown the efficacy of the available drugs in reducing the incidence of strokes and heart attacks? Are we supposed to give up using -them? Coulter seems to imply this, although he does not say so in so many words; nor does he offer any alternative.

His remarks on diabetes are even more unsatisfactory. Here we are offered the surprising statement that 'Juvenile diabetes, an autoimmune disorder, is often generated by the whooping cough vaccine...'. The rubella vaccine is also alleged to have this effect; the reference produced in support of this alarming statement is an article by one R. M. Henig in The New York Times Magazine of 20 March 1988. We are then told that insulin and hypoglycaemic drugs are practically useless and that 'The best treatment for diabetes today remains proper adjustment of the diet.' This ignores the modern studies which make it clear that good diabetic control undoubtedly reduces the incidence of diabetic complications. Claims such as these are potentially dangerous because the book will doubtless be read mainly by non-medical people, who will probably take its pronouncements at face value. Conceivably, if you suffered from hypertension or diabetes and were already unhappy about taking 'allopathic' medication, reading Coulter might just persuade you that it was all right to stop your treatment. Non-medically-qualified homoeopaths may well also draw the same conclusion and advise their patients accordingly.

But the book is also misleading in another way: it seems to me that it does a disservice to the cause it purports to defend. Coulter has done an enormous amount of bibliographical research and he has a valid point to make: namely, that there has been a strong tendency for doctors to concentrate on technology while neglecting the personal and individual aspects of patients. A lot of the popular enthusiasm today for homoeopathy and other kinds of complementary medicine arises from dissatisfaction with this impersonality. But Coulter protests too much; he overstates his case to such an extent that it is difficult to take it seriously. For him, those whom he places on the side of the empiricists can do no wrong, while the blinkered and bigoted 'rationalists' are totally misguided. This rigid separation of people into sheep and goats is something that has characterized many homoeopathic writers, starting with Hahnemann himself; Coulter's mentor Kent was another such. On the other hand, Richard Hughes, the execrated 'rationalist traitor' within the homoeopathic camp, was a model of tolerance. Perhaps there is a message there somewhere?

It would be going too far to dismiss this book as valueless. It brings together a lot of historical information that most people would probably not find easy to track down without the resources of a large library, and, if read selectively, it could provide a useful overview of the way in which medicine developed between about 1850 and 1950. But its view of modern therapeutics is so distorted and one-sided as to be misleading and even dangerous to readers who come to it without a prior knowledge of the subject.

ANTHONY CAMPBELL

British Homoeopathic Journal
Volume 84, Number 2, April 1995