INTRODUCTION: MODELS OF MEDICINE AND HEALING Wayne B. Jonas Jef f rey S. Levin PHYSICIANS ARE FACED DAILY WITH DISEASE, ILLNESS, SUFFERING, AND DEATH. THE MEDICAL PROFESSION AIMS TO HELP CURE, TREAT, COMFORT, AND SAVE THE LIVES OF THOSE WHO SEEK HELP. MOST PHYSICIANS MUST ALSO PERSONALLY FACE ILLNESS AT SOME TIME IN THEIR LIVES OR CARE FOR A LOVED ONE WHO IS ILL. WHETHER PROFESSIONALLY, PERSONALLY, OR WITH FAMILY, WHEN ILLNESS COMES ALL PRACTITIONERS WANT BASICALLY THE SAME THINGRAPID, GENTLE TREATMENT THAT CAN CURE US OR AT LEAST ALLAY OUR FEARS AND ALLEVIATE OUR SUFFERING. IN 1996, AN INTERNATIONAL GROUP OF HEALTH SCHOLARS AND PRACTITIONERS RECLARIFIED THE TRADITIONAL GOALS OF ALL MEDICINE (1) . THESE GOALS ARE:

THE PREVENTION OF DISEASE AND INJURY AND PROMOTION AND MAINTENANCE OF HEALTH. THE RELIEF OF PAIN AND SUFFERING CAUSED BY MALADIES. THE CARE AND CURE OF THOSE WITH A MALADY, AND THE CARE OF THOSE WHO CANNOT BE CURED. THE AVOIDANCE OF PREMATURE DEATH AND THE PURSUIT OF A PEACEFUL DEATH.

IT IS TOWARD THESE GOALS, THEY URGED, THAT ALL MEDICAL EDUCATION, RESEARCH, PRACTICE AND HEALTH CARE DELIVERY SHOULD BE AIMED. Desp i te these common goa ls , prac t i t ioners ' responses to d isease and i l lness are remarkab ly var ied, and op in ions about these d i f ferences in approach are o f ten s t rong ly he ld . Who we t rus t to our care , what we dec ide is the best t reatment , how we eva luate success, and when we look for a l ternat ives depend on many fac tors . These fac tors inc lude how one unders tands the nature o f hea l th and d isease, what is be l ieved to have gone wrong and why, the type and s t rength o f the ev idence suppor t ing var ious t reatments , and who is consu l ted when obta in ing he lp . In shor t , our cho ice o f medica l modal i t ies depends on our models and percept ions o f the wor ld , the pre ferences and va lues we share, and the be l ieved benef i t that may come f rom a cer ta in t reatment , sys tem of prac t ice , or ind iv idua l . Even in an age o f modern sc ience when medica l dec is ions can be made on a more ob jec t ive bas is than ever before, these dec is ions are a complex soc ia l p rocess. To unders tand what shapes our behav ior toward hea l th care , we must care fu l ly examine these socia l fo rces. The r ise in in teres t and use o f complementary and a l te rnat ive medic ine (CAM) re f lec ts soc ia l changes in our models , va lues, and perce ived benef i t f rom modern hea l th care prac t ices in the last severa l decades. THE RISING INTEREST IN COMPLEMENTARY AND ALTERNATIVE MEDICINE Publ ic and Professional Adopt ion of CAM Two ident ica l surveys o f unconvent ional medic ine use in the Uni ted Sta tes , one done in 1990 and the o ther in 1997, showed that dur ing that t ime f rame CAM use had increased f rom 34% to 42%. V is i ts to CAM pract i t ioners went f rom 400 mi l l ion to more than 600 mi l l ion v is i ts per year , and the amount spent on these pract ices rose f rom $14 b i l l ion to $27 b i l l ionmost o f i t no t re imbursed (2) . As increased use o f the phrase o f in tegra ted medic ine fo r the CAM f ie ld suggests , these prac t ices are now be ing in tegra ted in to mains t ream medic ine. Over seventy- f ive medica l schoo ls have courses on CAM (3) , hosp i ta ls are deve lop ing complementary and in tegra ted medic ine programs, hea l th insurers are o f fer ing expanded benef i ts packages that inc lude a l te rnat ive medic ine serv ices (4) , and b iomedica l research organ izat ions are invest ing more in to the invest igat ion o f these pract ices (5) . The Amer ican Medica l Assoc ia t ion recent ly devoted an ent i re issue o f each o f the i r journa ls to CAM. Th is r is ing in teres t in CAM re f lec ts not on ly changing behav iors , but a lso changing needs and va lues in modern soc ie ty . Th is inc ludes changes in the psychosoc ia l determinants o f CAM use; the normal iza t ion o f users over t ime; concepts o f the body; the re la t ionsh ip among the growing f i tness movement , ag ing baby boomers , and CAM; and the nature o f both the therapeut ic re la t ionsh ip and the hea l th care pre ferences. Many complementary hea l th care prac t ices d i f fuse throughout soc ie ty th rough hea l th networks that increas ing ly determine therapeut ic cho ices (5a) . Of note is that CAM pract ices , l i ke most convent iona l prac t ices , are adopted and normal ized long before sc ient i f i c ev idence has estab l ished thei r sa fe ty and e f f icacy. A key d i f fe rence in how th is occurs , however , is that in convent iona l prac t ice , procedures are usua l ly in t roduced by pro fess iona l ized bod ies or indust r ies ra ther than by the pub l ic (6) . Adopt ion in complementary medic ine has occur red in the oppos i te d i rec t ion: the pub l ic adopts and seeks out these pract ices f i rs t , and hea l th care pro fess ions and indust r ies fo l low. Th is says someth ing about the changing nature of pub l ic preferences and pro fess iona l respons iveness to those pre ferences. I t a lso pred ic ts that new unconvent iona l prac t ices wi l l a r ise in the fu ture as cur rent CAM groups become more pro fess ional ized themselves and are adopted in to the mains t ream. Thus, we wi l l a lways need ways o f address ing a l te rnat ive prac t ices respons ib ly . Responding to CAM The prominence and def in i t ion o f unor thodox prac t ices var ies f rom generat ion to generat ion. Wi th the deve lopment o f sc ient i f i c medic ine and advances in t reatment of acute and in fec t ious d isease in th is century , in teres t in a l te rnat ives large ly subs ided. As the l imi ta t ions o f convent iona l medic ine have become more obv ious, in teres t in a l te rnat ives has r isen. The medica l and sc ient i f i c response to c la ims o f e f f icacy outs ide o f f ic ia l medic ine has a d is t inc t pat tern (7) . In i t ia l l y , o r thodox groups e i ther ignore these prac t ices or a t tempt to

2undermine and suppress them by mak ing them hard to access, by labe l ing them as quackery or pseudo-sc ient i f i c , and by d isc ip l in ing those that use them (8, 9 and 10) . Later , i f the in f luence o f these prac t ices grows, the mains t ream communi ty beg ins to examine them, f ind s imi la r i t ies w i th what they a l ready do, and se lec t ive ly adopt prac t ices in to convent iona l medic ine that eas i ly f i t (8 , 9 ) (see a lso Chapter 1) . Once these concepts are in tegra ted, the groups that or ig ina l ly he ld them are then cons idered mains t ream, and those le f t on the f r inges are aga in ignored and persecuted unt i l the i r in f luence r ises . Th is pat tern o f wholesa le marg ina l iza t ion, fo l lowed by rap id but se lec t ive adopt ion, resu l ts in a lmost cont inua l conf l ic t between d i f fe r ing camps and wide f luc tuat ions in resources and a t tent ion devoted to these areasproduc ing what Thomas Kuhn ca l led revo lu t ions in sc ience and medic ine (10) . How can the mains t ream sc ient i f i c and medica l communi ty respons ib ly address the unof f ic ia l , unor thodox, f r inge, and a l ternat ive on a less er ra t ic , more regu lar , and more ra t iona l bas is? Any approach must not comple te ly ignore or at tempt to e l iminate impor tant va lues, concepts , and ac t iv i t ies that a l te rnat ives have to o f fer . A t the same t ime i t must not th row open medic ine to dangerous prac t ices that compromise the des i rab le qua l i ty and eth ica l and sc ient i f i c s tandards in the convent iona l wor ld. Any such process must c reate a space and prov ide resources whereby unconvent iona l concepts and c la ims can o f f ic ia l ly be exp lored, deve loped, and accommodated. Given the d ivers i ty o f concepts , languages, and percept ions about rea l i ty that these var ious sys tems ho ld , th is process must in tent iona l ly incorporate methods for conf l i c t reso lu t ion, knowledge management , and t ransparency (11, 12) . Such a process must f i rs t sys temat ica l ly exp lore the reasons for a l te rnat ive prac t ices . I t must then seek out the common, under ly ing concepts upon which change in both a l te rnat ive and convent iona l prac t ices can be based. WHY IS THERE INCREASING INTEREST IN CAM? The Potent ial Benef i ts of CAM Many CAM pract ices have va lue for the way the i r pract i t ioners manage hea l th and d isease. However , most o f what is known about these prac t ices comes f rom smal l c l in ica l t r ia ls . For example , there is research showing the benef i t o f herba l products such as ginkgo b i loba fo r improv ing dement ia due to c i rcu la t ion prob lems (13) and poss ib ly A lzhe imer 's (14) ; saw pa lmet to and o ther herba l preparat ions for t reat ing ben ign pros ta t ic hyper t rophy (15, 16) ; and gar l i c for prevent ing hear t d isease (17) . Over 24 p lacebo-contro l led t r ia ls have been done wi th hyper icum (St . John 's wor t ) and have shown that i t e f fec t ive ly t reats depress ion. For mi ld to moderate depress ion, hyper icum appears to be equa l ly e f fec t ive as convent iona l ant idepressants , yet produces fewer s ide e f fec ts and costs less (18) . The sc ient i f i c qua l i ty o f many t r ia ls , however , is poor . As cred ib le research cont inues on CAM, expanded opt ions for managing c l in ica l cond i t ions wi l l a r ise . In ar thr i t i s , for example , there are contro l led t r ia ls repor t ing improvement w i th homeopathy (19) , acupuncture (20) , v i tamin and nut r i t iona l supp lements (21) , botan ica l products (22, 23) , d ie t therap ies (24) , mindbody approaches (25) , and manipu la t ion (26) . Co l lec t ions o f (most ly smal l ) s tud ies ex is t fo r many o ther cond i t ions, such as hear t d isease, depress ion, as thma, and add ic t ions. The Cochrane Col laborat ion (w i th ass is tance f rom the Research Counc i l for Complementary Medic ine in the Uni ted K ingdom) prov ides a cont inua l ly updated l i s t o f randomized cont ro l led t r ia ls in CAM. A summary o f the number of cont ro l led t r ia ls cur rent ly in that database by cond i t ion and modal i ty is in Appendix (B) o f th is book. The database in ava i lab le on l ine through the NCCAM webpage and through the Cochrane Col labora t ion (see Chapter 5) . Wi th increas ing ly bet ter research, more opt ions and more ra t iona l and opt imal CAM t reatments can be deve loped. A d ivers i ty o f cred ib le approaches to d isease is someth ing that the pub l ic increas ing ly seeks (5a, 7) . The Potent ial Risks of CAM Safety concerns o f unregula ted products and pract ices are a lso an impor tant area for concern. Desp i te the presence of potent ia l benef i ts , the amount o f research on CAM systems and pract ices is nonethe less qu i te smal l when compared wi th convent iona l medic ine. For example , there are more than 20,000 randomized cont ro l led t r ia ls c i ted in the Nat iona l L ibrary o f Medic ine 's b ib l iograph ic database, MEDLINE, on convent iona l cancer t reatments , but on ly about 50 on a l ternat ive cancer t reatments . As pub l ic use o f CAM increases, l im i ted in format ion on the safe ty and e f f icacy o f most CAM t reatments creates a potent ia l ly dangerous s i tuat ion. A l though pract ices such as acupuncture , homeopathy, and medi ta t ion are low-r isk , they must be used by fu l ly competent and l i censed pract i t ioners to avo id inappropr ia te app l ica t ion (27) . Herbs, however , can conta in power fu l pharmacolog ica l substances that can be tox ic and produce herbdrug in terac t ions (28) . Some of these products may be contaminated and made wi th poor qua l i ty cont ro l , espec ia l ly i f sh ipped f rom As ia and Ind ia (29) . Reasons for Supplementary Role of CAM Pat ients use CAM pract ices for a var ie ty o f reasons. For example, use o f a l ternat ive therapies may be normat ive behav ior in the i r soc ia l networks ; they may be d issat is f ied wi th convent iona l care ; and they may be a t t rac ted to CAM ph i losoph ies and hea l th be l ie fs (5a, 30, 31) . The overwhelming major i ty o f those who use unconvent iona l prac t ices do so a long wi th convent iona l medic ine (32) , thus cor responding to the impl ic i t idea l o f the phrase complementary medic ine. CAM is t ru ly a l ternat ive that is , used exc lus ive lyfor less than 5% of the popu la t ion (31) . Fur ther , cont rary to some op in ions wi th in convent iona l medic ine, s tud ies have found that pat ients who use CAM do not genera l ly do so because o f ant isc ience or ant iconvent iona l -medic ine sent iment ,

3nor because they are d ispropor t ionate ly uneducated, poor , se r ious ly i l l , o r neurot ic (30, 31, 33, 34) . Ins tead, severa l sa l ien t be l ie fs and a t t i tudes mot iva t ing CAM and character iz ing CAM users can be ident i f ied . PRAGMATISM For the major i ty o f pat ien ts , the cho ice to use unor thodox methods is la rge ly pragmat ic . They have a chron ic d isease for wh ich or thodox medic ine has been incomple te or unsat is fac tory . Thus, we see many pat ients w i th chron ic pa in syndromes ( low back pa in, f ib romyalg ia , ar thr i t i s) or chron ic and f requent ly fa ta l d iseases (cancer , A IDS) seek ing out CAM for suppor t ive care (2 , 30, 30a) . An under ly ing character is t ic o f a l l o f these cond i t ions is that a spec i f ic cause o f the d isease e i ther is unknown or cannot be s topped. Medica l approaches d id not work wel l w i th these cond i t ions. Many CAM systems of fer suppor t ive care under these c i rcumstances ra ther than address ing spec i f ic causes. HOLISM CAM users are a t t rac ted to cer ta in ph i losoph ies and hea l th be l ie fs (31) . In medic ine, th is ph i losophy is re f lec ted in the des i re for a ho l is t ic approach to the pat ient . In rea l i ty , a l l therapy, whether convent iona l or a l te rnat ive , is ho l is t ic in the sense that the whole person a lways responds. Any in tervent iondrugs, surgery , psychotherapy, acupuncture , or herba l t reatmentsaf fec ts the ent i re body and mind. For pat ients , ho l ism of ten means at tend ing to the psychosoc ia l aspects o f i l lness. CAM pract i t ioners spend more t ime address ing psychosoc ia l issues, leav ing pat ients more sat is f ied than wi th the i r v is i ts to convent iona l prac t i t ioners (35) . Th is perspect ive a lso emphas izes us ing hea l th enhancement in the t reatment o f the d isease, and being proact ive in address ing ear ly warn ing and l i fe s ty le fac tors that put pat ients a t r isk (36, 36a) . LIFE STYLE The emphas is on hea l th promot ion as an in tegra l par t o f d isease t reatment is par t o f a lmost a l l CAM systems. Most o f these sys tems use s imi lar heal th enhancement approaches that cover f i ve bas ic areas. These f ive areas are : a) s t ress management ; b) sp i r i tua l i ty and meaning issues (37) ; c ) d ie tary and nutr i t iona l counse l ing; d) exerc ise and f i tness; and e) add ic t ion or hab i t management (espec ia l ly tobacco and a lcoho l use) (38, 38a) . A l l major CAM systems (and increas ing ly convent iona l approaches) make these areas pr imary in d isease t reatment (see chapters in PART I I I ) . Many pat ients f ind that the more they incorporate these act iv i t ies in to the i r l i ves , the less d i f f i cu l ty they have in managing chron ic d isease no mat ter what the cu l tura l o r ien tat ion (38, 38a and 39) . SPIRITUALITY There is a surge o f in terest in the ro le o f re l ig ion and sp i r i tua l i ty in medica l prac t ice , research, and educat ion (39a) . The concept o f ho l ism o f ten takes on the language o f sp i r i tua l i ty , in which pat ients seek a greater meaning in the i r su f fer ing than is o f fered in convent iona l medic ine (39b) . Most CAM systems address sp i r i tua l i ty and the meaning o f su f fer ing d i rec t ly . Of ten they have the i r own spec ia l concepts and terms for how hea l ing re la tes to the inner and outer forces o f the sp i r i t . T ibetan medic ine (Chapter 14) and Nat ive Amer ican medic ine (Chapter 13) i l lus t ra te th is most c lear ly . In anthroposophica l ly -ex tended medic ine, phys ic ians rece ive convent iona l t ra in ing and then get spec ia l ins t ruc t ion a imed a t deve lop ing in tu i t i ve and sp i r i tua l sens i t iv i ty . HEALING When a spec i f ic cause is the dominant fac tor in an i l lness, i t makes sense to d i rec t a therapy toward that fac tor and then a t tempt to min imize the s ide ef fec ts o f therapy. I f a pat ient has an upper resp i ra tory t rac t in fec t ion (URI) that deve lops in to bacter ia l mening i t is , fo r example , the hea l ing ac t ion o f the body has been overwhelmed by the cause, and the on ly hope o f recovery is to e l iminate the bacter ia w i th h igh-dose ant ib io t ics . However , i f the URI becomes a chron ic s inus prob lem, in which the e f for ts o f the body are the dominant fac tor in the i l lness complex , a drug must ac t on the person to enhance (by s t imula t ion or suppor t ) those se l f -hea l ing e f for ts . Approaches for s t imula t ing the immune system (e .g . , acupuncture or herbs) or suppor t ing auto- regu la tory mechanisms (e .g . , res t , f lu ids , d ie tary changes, re laxat ion and imagery) may be pre fer red. Most CAM systems a im to enhance the body 's hea l ing e f for ts but may not address a known cause. Th is character is t ic o f CAM is a t t rac t ive to pat ients (40) . ADVERSE EFFECTS OF CONVENTIONAL THERAPIES Pat ients are a lso concerned about the s ide e f fec ts o f convent iona l medic ine. Approx imate ly 10% of hosp i ta l iza t ions are due to ia t rogen ic fac tors (41) , and proper ly de l ivered convent iona l t reatments are the s ix th lead ing cause o f death in the West (42) . There is a percept ion among pat ients that or thodox t reatments are too harsh, espec ia l ly when used over long per iods for chron ic d isease (43) and that CAM t reatments are safer . Some in terest in CAM is based on the myth that natura l i s somehow inherent ly sa fer than convent iona l medic inean idea that is cer ta in ly not t rue (44, 45) . Another misconcept ion is that avo id ing harsh or thodox t reatments wi l l resu l t in bet ter qua l i ty o f l i fe . Th is is a lso not necessar i ly t rue. For example , Cass i le th showed that pat ients who underwent chemotherapy compared wi th those who underwent a d ie tary and l i fe s ty le t reatment fo r cancer ac tua l ly had s l igh t ly bet ter qual i ty o f l i fe scores (46) . COSTS Concern over the esca la t ing costs o f convent iona l hea l th care is another reason for the in teres t in CAM. Contro l o f hea l th care costs by improv ing e f f ic iency in de l ivery and management o f hea l th care serv ices has reached a max imum, and costs are expected to doub le in the next 10 years (47) . Many deve lop ing count r ies are rea l iz ing that access to and a f fordab i l i ty o f convent iona l medic ine are imposs ib le for the i r popu lat ion and that lower-cost ,

4 t rad i t iona l medica l approaches need to be deve loped (47a) . Approaches that a t tempt to induce auto- regu la t ion and se l f -hea l ing and that re ly on l i fe s ty le and se l f -care approaches may reduce such costs (39, 48) . THE DEMOCRATIZATION OF MEDICINE Severa l o ther soc ia l fac tors a lso in f luence the increas ing in teres t in CAM. These inc lude the r is ing preva lence o f chron ic d isease wi th ag ing; increased access to hea l th in format ion in the media and over the In ternet ; and a dec l in ing fa i th that sc ient i f i c breakthroughs wi l l have re levant benef i ts for personal hea l th ; (49) . An espec ia l ly sa l ien t fac tor has been the democrat iza t ion and consumer iza t ion o f medica l dec is ion mak ing (12, 50) . The exp los ion o f read i ly ava i lab le in format ion for the consumer and the ab i l i ty to exper ience d iverse cu l tures around the wor ld have acce lera ted th is process. Increas ingly , pat ients w ish to be ac t ive par t ic ipants in the i r hea l th care dec is ions. This par t ic ipat ion inc ludes eva luat ing in format ion about t reatment opt ions, access ing products and prac t ices that enab le them to exp lore those opt ions, and engaging in ac t iv i t ies that may he lp them remain hea l thy (5a) . CAM AND STANDARDS OF EVIDENCE New s tandards may be needed for the examinat ion o f both unconvent iona l and convent iona l medic ine (51, 54) . H is tor ica l ly , medica l sc ience has benef i ted f rom the deve lopment o f new methodolog ies , such as b l ind ing and randomizat ion which are f i rs t app l ied to unor thodox prac t ices before be ing adopted as s tandards for a l l medic ine (51, 52 and 53) . Humans seem to have an in f in i te capac i ty to foo l themselves and are constant ly mak ing spur ious c la ims o f t ru th , postu la t ing unfounded explanat ions, and ignor ing or deny ing the rea l i ty o f observat ions they cannot exp la in or do not l i ke . Sc ience is one o f the most power fu l too ls fo r mi t iga t ing th is se l f -de lus ionary capac i ty . However , the complex i ty o f d isease and the power fu l hea l ing capac i ty o f the body o f ten make i t d i f f i cu l t to app ly sc ience to c l in ica l medic ine, espec ia l ly when eva luat ing chron ic d isease (55, 56) . K . B. Thomas demonst ra ted that near ly 80% of those who seek out medica l care get bet ter no mat ter what hand-wav ing or p i l l -popp ing is prov ided (57) . Th is is ca l led the 80 Percent Ru le , meaning that data co l lec ted on nove l therap ies de l ivered in an enthus ias t ic c l in ica l env i ronment typ ica l ly y ie ld pos i t ive outcomes in 70 to 80% of pat ients (58) . NONSPECIFIC EFFECTS Oftent imes our most accepted t reatments are shown to be nonspec i f ic in nature (59, 60 and 60a) or even harmfu l (61) when f ina l ly s tud ied r igorous ly . The ir apparent e f fec t iveness in prac t ice is due to a var ie ty o f fac tors unre la ted to the t reatment , such as the ab i l i t y o f the body to hea l (o f ten enhanced by expecta t ion) , s ta t is t ica l regress ion to the mean (a measurement prob lem) , and se l f -de lus ion (somet imes ca l led b ias) (58) . I t i s not surpr is ing that for the major i ty of phys ic ians and pat ients , many therapies , both or thodox and unor thodox, seem to work. The methods o f c l in ica l researchespec ia l ly b l ind ing and the randomized cont ro l led t r ia lhave emerged as power fu l approaches for bet ter ident i fy ing to what extent the outcome can be at t r ibu ted to the t reatment . These methods must be used r igorous ly , however , i f we wish to examine both the soc ia l and s ta t is t ica l fo rces that shape our percept ion o f rea l i ty . As soph is t ica t ion in c l in ica l t r ia ls methods improves in order to bet ter contro l for these nonspec i f ic e f fec ts , however , the r igorous eva luat ion o f chron ic d isease prevent ion and t reatment approaches become more d i f f i cu l t and expens ive (62) . METHODS FOR EXAMINING CHRONIC DISEASE TREATMENTS For these and a var ie ty o f o ther e th ica l , economic , and sc ient i f i c reasons, i t i s very un l ike ly that a l l CAM (or convent iona l ) therap ies can be examined us ing la rge, r igorous, randomized t r ia ls (see Chapter 4) . There are now soph is t ica ted sc ient i f i c methods for app ly ing bas ic -sc ience in format ion to c l in ica l p rac t ice and h ighly e f fec t ive approaches for the management o f t rauma and acute and in fec t ious d iseases. Current methods for examin ing chron ic d isease or prac t ices that have no exp lanatory model in Western terms, however , are not adequate ly in formed by sc ience. CAM of fers the oppor tun i ty to tes t new approaches for examin ing these areas as the i r presence in medic ine increases. For example , the deve lopment of observat iona l and outcome research methods is be ing exp lored in CAM as a new approach for obta in ing acceptab le ev idence for the use o f low-r isk therap ies for t reatment of chron ic d isease (63, 64 and 65) . SYNERGISTIC EFFECTS Most research on p lant products is done to ident i fy s ing le ac t ive chemica ls for drug deve lopment . Many herba l products , however , conta in mul t ip le chemica l agents that may operate synerg is t ica l ly , p roduc ing e f fects w i th low amounts o f mul t ip le agents and lower r isk for adverse e f fec ts . Standard izat ion and qua l i ty product ion of herba ls (necessary for produc ing safe and re l iab le products) may a l low us to deve lop low-cost therap ies wi th reduced r isk over pharmaceut ica ls (16, 18) . CONSCIOUSNESS Another f ront ie r area wi th potent ia l ly pro found impl ica t ions for sc ience and medic ine is the area of consc iousness and i ts re la t ionsh ip to s ta t is t ica l events and b io logica l outcomes. For example , ex tens ive research has documented that in tent ion can have an in f luence on chance events (75a, 76 and 76a) and l iv ing sys tems (77, 78) . Trad i t iona l and ind igenous hea l ing pract ices f rom around the wor ld un iversa l ly assume that th is is t rue and c la im to use these forces in pract ices such as shamanism, sp i r i tua l hea l ing, and prayer . Sc ience now has the exper imenta l methodology, soph is t ica ted techno logy, and s ta t is t ica l exper t ise to examine th is quest ion prec ise ly . I f changes in consc iousness do have s igni f icant e f fec ts , what potent ia l might th is have for d iagnos is and t reatment (79, 80)? What impl icat ions would th is have for our methods o f exper imenta t ion and

5the not ion o f ob jec t iv i ty? Research on unor thodox medica l prac t ices a l lows us to beg in ser ious sc ient i f i c invest igat ion o f such areas. ANOMALOUS FINDINGS The unconvent iona l bas ic -sc ience assumpt ions that under l ie some CAM pract ices prov ide oppor tun i t ies to exp lore some of the deepest and most d i f f i cu l t en igmas o f modern b io logy and medic ine. Acupuncture, fo r example , was la rge ly ignored in the Uni ted Sta tes unt i l b rought to nat iona l a t ten t ion by a prominent repor ter t rave l ing wi th Pres ident N ixon in 1972. Th is led to bas ic sc ience research and the d iscovery o f i ts pa in- re l iev ing mechanisms (66) . Another cur rent en igma is whether b io log ica l ly ac t ive nonmolecu lar in format ion can be s tored and t ransmi t ted through water or over w i res , as c la imed in homeopathy and e lec t rodermal d iagnos is (40, 67, 68, 69, 70, 71 and 72) . Most sc ient is ts are unaware of the research in th is area and c la im that the concept is imposs ib le . I f some vers ion o f th is c la im were t rue, however , i ts potent ia l impl ica t ions for b io logy, pharmacology, and medica l care are enormous. Data f rom c l in ica l research on homeopathy do not suppor t the expected assumpt ion that homeopathy operates ent i re ly l i ke p lacebo (73, 74 and 75) . Bas ic research on homeopathy can he lp examine the accumula t ing anomalous observat ions and exper iments in th is area (40) . CENTRAL MODELS OF ETIOLOGY AND TREATMENT IN MEDICINE What can we make o f the d ivers i ty o f CAM approaches? Are they an unre la ted, soc ia l ly def ined, and sh i f t ing group o f d ispara te prac t ices , or do they have common concepts and centra l themes that t ie them together and to convent iona l medic ine? I f so , how are these approaches s imi la r to and d i f ferent f rom modern Western medic ine? His tor ica l ly and cross-cu l tura l ly , d i f ferent medica l sys tems have exh ib i ted d i f ferent unders tand ings o f d isease causat ion and o f fac tors re levant to e t io logy. A longs ide th is d ivers i ty are d i f ferent approaches to ident i fy ing e t io log ica l fac tors and to address ing them in c l in ica l prac t ice . These d iverse perspect ives can be c lass i f ied in to (a) those that focus on a spec i f ic cause, and (b) those that emphas ize complex systems of causat ive or antecedent fac tors . A longs ide these two cent ra l perspect ives on d isease e t io logy, most major medica l sys tems emphas ize one o f three approaches in the t reatment o f d isease. These are (a) a hyg iene-or iented or hea l th-promot ion approach, (b) approaches that induce or s t imula te endogenous hea l ing responses, and (c) approaches that oppose, in ter fere wi th , or e l iminate d isease causes and b io logica l responses to those causes. F igure 1 i l lust ra tes these d i f fe rent models o f e t io logy and approaches to t reatment . The spec i f ic cause model (1 , F igure 1) a t tempts to ident i fy the most prominent l inear et io log ica l pathway o f the headache. Th is usua l ly leads to a therapy that in ter feres wi th that pathway d i rec t ly (oppos i t ion approacha, F igure 1) . Thus, in a pat ient who presents w i th a headache, an unders tand ing o f the pathophys io logy o f the headache is t raced to vasospasm, and medicat ion or b io feedback is prov ided to in ter fere wi th that pathway. Treatment is o f fered for on ly those aspects o f the i l lness that c ross a predef ined d iagnost ic th resho ld . The sys tems model (2 , F igure 1) a t tempts to ident i fy the web o f e t io log ica l in f luences that contr ibu te to the headache and the i r re la t ionsh ips to o ther cover t prob lems or r isks . In terven t ion targets the most prominent o f these fac tors on mul t ip le leve ls . Thus, a chron ic headache pat ient who has o ther less prominent prob lems ( fa t igue, border l ine b lood pressure, insomnia , e tc. ) i s t reated wi th l i fes ty le changes and behav iora l therapy address ing d ie t , exerc ise , re laxat ion sk i l l s , and drug or medicat ion abuse (hyg iene approachb, F igure 1) . The whol is t ic model (3 , F igure 1)

examines the pat ient 's react ions to e t io log ica l agents and in f luences. Treatment approaches focus on improv ing res is tance, res tor ing homeosta t ic ba lance, or s t imula t ing se l f -hea l ing processes in the pat ient ( induct ion approachc, F igure 1) . Thus, the headache pat ient may be g iven acupuncture to res tore the ba lance o f ch i , a vasospast ic agent (e .g . , ca f fe ine or be l ladonna a lka lo ids) to ad jus t autonomic react iv i ty , o r a spec i f ica l ly se lec ted homeopath ic drug to res tore auto- regu la tory processes. F igure 1 . Models o f d isease t reatment . The Use and Specia l izat ion of Centra l Models in Medic ine The spec i f ic cause model , the sys tems model , and the whol is t ic models of e t io logy (and the i r f requent ly cor responding t reatment

approaches) a l low us to bet ter unders tand the re la t ionsh ip between var ious medica l t rad i t ions . They help exp la in how qu i te var ied in tervent ions can produce res tora t ive e f fec ts on s imi lar d iseases and how s ing le in tervent ions may a f fec t a var ie ty o f cond i t ions. In add i t ion , they a l low us to examine how d i f fe rent medica l t rad i t ions have spec ia l ized in deve lop ing theor ies and in tervent ions based around one or more aspects o f agent /host in terac t ions. A l l major medica l sys tems use a l l th ree o f these approaches when needed. F igure 1 i l lus t ra tes how these common concepts o f e t io logy and t reatment can be used to map a par t icu lar medica l sys tem's emphas is . Convent iona l medic ine f requent ly wa i ts unt i l a d isease has crossed a cer ta in d iagnost ic

6thresho ld before in tervent ion is a t tempted. The t reatment usua l ly assumes a l inear causeef fec t pathway and uses a t reatment des igned to in ter fere wi th that spec i f ic pathway (combinat ion 1 .a in F igure 1) . Many CAM (and some convent iona l ) sys tems use the hyg iene approach which in tervenes pr ior to the d iagnost ic thresho ld and assumes that genera l mul t i - leve l suppor t across sys tems is needed (combinat ion 2 .b in F igure 1) . Many CAM systems assume complex e t io log ies may or may not wa i t unt i l the d iagnost ic thresho ld is crossed. F ina l ly , in tervent ions may be a imed a t a l ter ing the host response to mul t ip le e t io log ies in a way that reestab l ishes homeostas is (combinat ion 3 .c in F igure 1) . Whi le most major medica l sys tems use a l l these e t io log ica l models and t reatment approaches, some medica l sys tems have deve loped approaches that emphas ize par t i cu lar leve ls as pr imary and have deve loped them extens ive ly . In Nat ive Amer ican and many ind igenous medica l sys tems, for example , the sp i r i tua l nature o f the d isease/hea l ing complex is o f ten emphas ized. In these cu l tures , access to and in terac t ion wi th pat terns and forces in the sp i r i t rea lms is cons idered a cent ra l focus for hea l ing prac t ices . Sp i r i ts are removed or opposed to s top a patho log ica l p rocess. In acupuncture and homeopathy, the energet ic nature o f d isease/hea l ing sys tems is emphas ized. Pat terns of energy assessed through h is tory and phys ica l examinat ion are s t imula ted and ba lanced to induce a res tora t ive response. In Ayurved ic medic ine, the emphas is is on approach ing i l lness through consc iousness, and entry in to pure consc iousness is the core o f medi ta t ive and c leans ing pract ices that suppor t hea l ing . Naturopathy , nut r i t iona l b io therapy, and or thomolecu lar medic ine a l l conta in e lements that have the i r roots in the Greek hyg iene approach, wh ich used d ie t , p lant remedies , baths , ton ics , and o ther supp lements as the cent ra l focus o f in tervent ion. Modern Western medic ine addresses i l lness on the natura l is t ic leve l typ ica l ly uses approaches that b lock a path in the d isease/hea l ing process or by removing a spec i f ic causa l agent . These centra l approaches are a lso used in convent iona l medic ine today as s ince ant iqu i ty . I f a person has an in fec t ion one is g iven an ant i -b io t ic , a drug des igned to k i l l the in fec t ing agent . I f one has in f lammat ion and pa in in the jo in ts one is g iven an ant i - in f lammatory or ana lges ic ( l i te ra l ly aga ins t sensat ion ) . These are examples o f the in ter ference/oppos i t ion approach as used in modern medic ine. Th is approach has evolved t remendous ly over the las t 50 years and is a very soph is t ica ted component o f modern medica l t reatment . Th is approach works wel l when a cause is s imple , eas i ly ident i f ied and dominates the d isease/hea l ing complex. Vacc inat ion and a l le rgy desens i t iza t ion shots are examples o f the induct ion/s t imula t ion approach in modern medic ine. Some drug t reatments use the induct ion pr inc ip le , too , such as Ri ta l in (a s t imulant ) for hyperact ive (overs t imula ted) ch i ld ren and vacc ines to induce res is tance to d isease. For the most par t , modern drug therapy looks for chemica ls that w i l l s top or in ter fere wi th phys io log ica l processes invo lved in an i l lness and then t ry to manage the s ide e f fec ts separate ly . I t i s much eas ier to use the in ter ference approach when a speci f ic cause is known, wh ich is one reason i t i s cur rent ly the dominant method. F ina l ly , l i fe s ty le , d ie t , exerc ise , and o ther hea l th promot ion and suppor t approaches were cons idered outs ide o f mains t ream medic ine unt i l the las t 20 years or so , but have now become more accepted and wide ly used in modern medic ine. These are examples o f the hyg iene approach that over lap convent iona l and complementary medic ine. THE INTEGRATION OF CAM AND CONVENTIONAL MEDICINE I f we, as heal th care prac t i t ioners , sc ient is ts , and educators , do not beg in to examine more c lose ly the soc ia l and sc ient i f i c fo rces that shape medic ine, then we are dest ined to re l ive much o f the d iv is iveness that has character ized the past and cur rent re la t ionsh ip between mains t ream and nonmainst ream medica l care (81) . To adopt CAM wi thout deve lop ing qua l i ty s tandards for i ts prac t ices , products , and research threatens to return us to a t ime in medic ine when therapeut ic confus ion preva i led. Modern convent iona l medic ine exce ls spec i f ica l ly in the prov is ion o f qua l i ty -cont ro l led hea l th care and the use o f cu t t ing-edge sc ient i f i c f ind ings. CAM must adopt s imi la r s tandards. Convent iona l medic ine is a lso the wor ld 's leader in the management o f in fec t ious, t raumat ic , and surg ica l d iseases; in the s tudy o f patho logy; and in b io technology and drug deve lopment . A l l medica l prac t ices , convent iona l and unconvent iona l a l ike , have the e th ica l ob l iga t ion to re ta in these s t rengths for the benef i t o f pat ients (82) . A t the same t ime, impor tant character is t ics o f CAM are a t r isk o f be ing los t in i ts in tegra t ion w i th convent iona l care . The most impor tant o f these is an emphas is on se l f -hea l ing as the lead approach for both improv ing wel lness and t reat ing d isease. A l l o f the major CAM systems approach i l lness by f i rs t t ry ing to suppor t and induce the sel f -hea l ing processes o f the pat ient . I f th is can s t imula te recovery , then the l i ke l ihood o f adverse e f fec ts and the need for h igh- impact /h igh-cost in tervent ions are reduced. I t i s prec ise ly th is or ienta t ion toward se l f -hea l ing and hea l th promot ionwhat Antonovsky has te rmed sa lu togenes is as opposed to pathogenes is (84)that makes CAM approaches to chron ic d isease espec ia l ly a t t ract ive . The rush to embrace a new in tegra t ion o f a l ternat ive and convent iona l medic ine shou ld be approached wi th great caut ion. A l ternat ive medic ine, l i ke convent iona l medic ine, has pros and cons, promotes bad ideas and good ones, and o f fers both benef i ts and r isks . Wi thout c r i t i ca l assessment o f what shou ld be in tegrated and what shou ld not , we r isk deve lop ing a hea l th care sys tem that costs more, is less safe , and fa i ls to address the management o f chron ic d isease in a pub l ic ly respons ib le manner . We must examine carefu l ly the potent ia l r isks and benef i ts o f CAM before we head in to a new, but not necessar i ly bet ter , heal th care wor ld . The Potent ial Risks of Integrat ion

7The potent ia l r isks o f in tegra t ion are eas i ly ident i f iab le , ye t much res is tance to the i r amel io ra t ion remains among CAM pract i t ioners . These r isks inc lude issues re la ted to qua l i ty o f care , qua l i ty o f products used in t reatment , and qua l i ty o f sc ient i f i c research under ly ing CAM therap ies . QUALITY OF CARE The formal components o f medica l doctor l i censure are usua l ly not requ i red of var ious CAM prov iders . These requ i rements inc lude the content and length o f t ime o f t ra in ing, tes t ing , and cer t i f i ca t ion ; a def ined scope o f prac t ice ; rev iew and aud i t ; and pro fess iona l l iab i l i t y w i th regu la tory pro tec t ion and s ta tu tory author iza t ion comple te wi th cod i f ied d isc ip l inary ac t ion (85) . A l l 50 s ta tes provide l i censure requ irements for ch i ropract ic , but on ly about ha l f do so for acupuncture and massage therapy, and much fewer do for homeopathy and naturopathy . Many o f these prac t i t ioners operate la rge ly unmoni tored (27) (see Chapter 2) . QUALITY OF PRODUCTS The natura l p roducts used by CAM pract i t ioners are la rge ly unmoni tored and the i r qua l i ty uncont ro l led . These products are ava i lab le on the market as d ie tary supp lements and may be contaminated or vary t remendous ly in content , qua l i ty , and safe ty (86, 87) . Gar l ic , for example , demonst ra ted to have cho les tero l lower ing e f fec ts fo r many years (17) , may not produce such e f fec ts i f processed in cer ta in ways (88) . Thus, even i f one product is proven safe and e f fec t ive , o ther s imi la r products on the market may have qu i te d i f fe rent e f fec ts that prec lude cons is tent dos ing. F i f teen mi l l ion Amer icans are tak ing h igh-dose v i tamins or herbs a long wi th prescr ip t ion drugs, thus r isk ing adverse e f fec ts f rom unknown in terac t ions (2) (see Par t I I , Chapter 6, Chapter 7 , and Chapter 8) . QUALITY OF SCIENCE There is o f ten no sc ient i f ic foundat ion for a par t icu lar CAM pract icewhether accord ing to Western b iomedic ine or even to an a l te rnat ive sc ient i f i c wor ld v iew (e .g . , Ayurveda, t rad i t iona l Ch inese medic ine) . Most CAM systems have been around la rge ly unchanged for hundreds or thousands of years . Many o f these tenets or ig inated f rom the teach ings o f a char ismat ic leadertenets that have not been advanced wi th new observat ions, hypothes is -dr iven tes t ing , innovat ion, and peer - rev iew. C la iming that the i r prac t ices are too ind iv idual or ho l is t ic to s tudy sc ient i f i ca l ly , many CAM pract i t ioners h ide beh ind anecdota l , case-ser ies , or outcomes research (89) . To accept such v iews is to fa lse ly labe l convent iona l medic ine as nonhol is t ic and to re jec t the hard fought ga ins made in the use o f bas ic b io log ica l knowledge, randomized contro l led c l in ica l t r ia ls , and ev idence-based medic ine for hea l th care dec is ion mak ing (90) (see Chapter 4 and Chapter 5) . The Potent ial Benef i ts of Integrat ion Among the potent ia l benef i ts o f in tegrat ion, severa l in par t icu lar are espec ia l ly va luab le . The emergence o f a t ru ly in tegra ted medic ine promises to sh i f t medic ine 's emphas is to the to ta l hea l ing process, to reduce unnecessary s ide e f fec ts , and to reduce the costs of care . EMPHASIS ON HEALING Most CAM systems care fu l ly a t tend to the i l lness and suf fer ing that accompanies a l l d isease. Pat ients are o f ten more sat is f ied wi th the i r in terac t ions wi th unor thodox than or thodox medica l prac t i t ioners (35) . Pat ients requ i re unders tand ing, meaning, and se l f -care methods for managing thei r cond i t ion . Empowerment , par t ic ipat ion in the hea l ing process, t ime, and persona l a t tent ion are essent ia l e lements o f a l l medica l care , ye t these e lements are eas i ly los t in the subspec ia l iza t ion, techno logy, and economics of modern medic ine. By increas ing ly being in tegra ted in to mains t ream medica l prac t ice , CAM promises to res tore to medic ine a more focused emphas is on the hea l ing process. REDUCTION IN SIDE EFFECTS In the e ighteenth century , unconvent iona l medica l prac t ices increased in popu lar i ty in par t because they eschewed the use o f severe t reatments such as b lood le t t ing , purg ing, and use o f tox ic meta lsa l l s tap les o f convent iona l medic ine a t one t ime (91) . The popu lar i ty o f CAM in th is century is a lso dr iven by the percept ion that convent iona l t reatments are too harsh to use fo r chron ic and non- l i fe- threaten ing d iseases (30, 31) . Ia t rogen ic d isease f rom convent iona l medic ine is a major cause o f death and hosp i ta l iza t ion in the Uni ted Sta tes (43) . A l though some CAM pract ices may in t roduce tox ic i ty , many o f them of fer reduced potent ia l fo r adverse e f fec ts when proper ly de l ivered (45) . Unconvent iona l medic ine may he lp us gent le our approach by focus ing on the pat ient 's inherent capac i ty fo r se l f -hea l ing (84) . REDUCTION IN COSTS The skyrocket ing costs o f convent iona l medic ine a lso dr ive the search for medica l a l te rnat ives. Sav ings f rom managed care are now maximized, and hea l th care costs are predic ted to double wi th in the next 10 years (47) . I f low-cost in tervent ions, such as l i fe s ty le changes, d ie t and supp lement therapy, and behav iora l medic ine, can be de l ivered as subst i tu tes for h igh-cost drugs and techno log ica l in tervent ions, t rue cost reduct ions and reduct ions in morb id i ty may be ach ieved (48) . Science and Heal ing Today we have d iscovered more sc ient i f i c ways o f dec id ing how to counter and oppose d isease causes, but very l i t t le research has been done on the suppor t and induct ion o f hea l ing processes. Th is has made the in ter ference/oppos i t ion approach (see F igure 1) much more usefu l than in the past , and is one o f the reasons for the t remendous r ise in the use o f these k inds o f therap ies around the wor ld . Techno logy has prov ided another impetus for th is growth. B io techno logy a l lows for f iner d issect ion o f d isease causes and for

8deve lopment o f sc ient i f i c methods to manipu la te these causes. The usefu lness o f th is approach, however , is l im i ted to those d iseases in which there are on ly a few causes and they have been c lear ly ident i f ied . For i l lnesses o f mul t i fac tor ia l o r unknown causat ion (as in most chron ic d iseases) , th is approach is not very usefu l fo r produc ing long- term hea l ing . Unfor tunate ly , app l ica t ion o f the sc ient i f i c method to the s tudy o f the induct ion and hyg iene approaches is s t i l l in i ts ear ly s tages. As invest igat ion o f convent iona l prac t ices (e .g . , phys ica l therapy, d ie tary therapy, and immunizat ion) and o f CAM systems (e .g . , acupuncture , homeopathy, and manipu la t ion) increases, a sc ience o f hea l ing may emerge. WHAT PHYSICIANS NEED TO KNOW ABOUT CAM For phys ic ians to be ab le to he lp the i r pat ients choose the most rap id , sa fes t , and most e f fec t ive long- term so lu t ions for t reat ing d isease and a l lev ia t ing suf fer ing, cer ta in bas ic knowledge and sk i l l s are needed. Unders tand ing the fundamenta l assumpt ions o f e t io logy and t reatment o f medica l sys temsboth convent iona l and unconvent iona l is c ruc ia l . When spec i f ic causes are known and e f fec t ive methods for in tervent ion ex is t , approaches that can in ter fere w i th those causes are key to successfu l t reatment . When spec i f ic causes are unknown or complex contr ibu tory in f luences are dominant in a d isease, approaches that suppor t hea l th and induce hea l ing become pr imary . Somet imes a combinat ion o f approaches is needed, whereby causes are b locked and hea l ing mechanisms are s t imula ted and suppor ted. An opt imal pract ice makes f lex ib le use o f what best f i ts the c l in ica l s i tuat ion. To respond appropr ia te ly , phys ic ians and o ther hea l th care prac t i t ioners must be ab le to obta in in format ion about the h is tory o f se l f - t reatment by the i r pat ients and must communicate to them the resu l ts o f the best cur rent research ev idence. Pract i t ioners need a var ie ty o f sk i l l s : communicat ing wi th pat ients , document ing pat ient encounters w i th a l te rnat ive therap ies , eva luat ing and app ly ing modern pr inc ip les o f sc ient i f i c ev idence and medica l e th ics , and unders tand ing the cur rent qua l i t y and l iab i l i t y s ta tus o f CAM medica l t reatments . F ina l ly , prac t i t ioners shou ld become fami l ia r w i th the bas ic pr inc ip les o f t reatment for spec i f ic CAM systems as wel l as the cur rent ev idence o f benef i t o r harm f rom these systems. Th is in format ion is requ i red for the care fu l and thought fu l management o f pat ients, many o f whom have a l ready v is i ted a l te rnat ive pract i t ioners . This bas ic knowledge of common CAM pract ices wi l l be an ind ispensable component o f medica l in format ion in the twenty-f i rs t century . CHAPTER REFERENCES 1. Hast ings Center Repor t . The goa ls o f medic ine: se t t ing new pr ior i t ies . Br iarc l i f f Manor , NY: The Hast ings Center , 1996. 2 . E isenberg DM, Dav is RB, Et tner S, e t a l . Trends in a l te rnat ive medic ine use in the Uni ted Sta tes 19901997: resu l ts o f a fo l low-up nat iona l survey. JAMA 1998;280:15691575. 3 . Wetze l MS, E isenberg DM, Kaptchuk TJ. A survey o f courses invo lv ing complementary and a l ternat ive medic ine a t Un i ted Sta tes medica l schoo ls . JAMA 1998;280:784787. 4 . Pe l le t ie r KR, Mar ie A, Krasner M, Haske l l WL. 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1047a. Panel on Trad i t iona l Medic ine. Deve lop ing a research agenda for t rad i t iona l medic ine. Bodeker J , ed. Bethesda, MD: Nat iona l Ins t i tu tes o f Heal th , 1997. 48. Sobel DS. Reth ink ing medic ine: improv ing hea l th outcomes wi th cost -e f fec t ive psychosoc ia l in tervent ions. Psychosom Med 1995;57:23444. 49. Fox E. Predominance o f the cura t ive model o f medica l care : a res idua l prob lem. JAMA 1997;278:761763. 50. Star r P. The soc ia l t ransformat ion o f Amer ican medic ine. San Franc isco: Bas ic Books (a d iv is ion o f Harper Col l ins Publ ishers) , 1982:514. 51. Eddy DM. Should we change the ru les for eva luat ing medica l technolog ies . In : Gel i jns AC, ed. Modern methods o f c l in ica l invest igat ion. Washington, DC: Nat iona l Academy Press, 1990:117134. 52. Hor ton R. The rhetor ic o f research. BMJ 1995; 310:985987. 53. Kaptchuk TJ. In tent iona l ignorance: the h is tory of b l ind assessment and p lacebo contro ls in medic ine. 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L is ten ing to Prozac but hear ing p lacebo: a meta-ana lys is o f ant idepressant medicat ion. Prevent ion Treatment 1998;1 :0002a. 61. Pra t t CM. The card iac ar rhy thmia suppress ion t r ia l . In t roduct ion: the af termath o f the CASTa recons idera t ion o f t rad i t iona l concepts . Am J Card io l 1990;65:1b2b. 62. Co ld i tz GA, Mi l le r JN, Moste l le r F . How s tudy des ign af fec ts outcomes in compar isons o f therapy. I : Medica l . S ta t Med 1989;8 :441454. 63. Melchar t D, L inde K, L iao JZ, e t a l . Systemat ic c l in ica l aud i t ing in complementary medic ine: rat iona le , concept , and a p i lo t s tudy. A l t Therap Heal th Med 1997;3 :3339. 64. Stand ish LJ , Ca labrese C, Reeves C, e t a l . A sc ient i f i c p lan for the eva luat ion o f a l ternat ive medic ine in the t reatment of HIV/AIDS. A l t Therap Heal th Med 1997;3 :5867. 65. P incus T. Ana lyz ing long- term outcomes o f c l in ica l care wi thout randomized cont ro l led c l in ica l t r ia ls : the consecut ive pat ient quest ionna i re database. Advances 1997;13:331. 66. Pomeranz B. Acupuncture research re la ted to pain , drug add ic t ion and nerve regenerat ion . In : Pomeranz B, Stux G, eds. Sc ient i f i c bases o f acupuncture . Ber l in , He ide lberg: Spr inger -Ver lag, 1989:3552. 67. Scof ie ld AM. Exper imenta l research in homoeopathy. Br Hom J 1984;73:161181, 211225. 68. Davenas E, Beauva is J , Oberbaum M, e t a l . Human basophi l degranu lat ion t r iggered by very d i lu te ant iserum aga ins t IgE. Nature 1988;333: 816818. 69. Ove lgonne JH, Bo l AW, Hop WC, van Wi jk R. Mechanica l ag i ta t ion o f very d i lu te ant iserum aga ins t IgE has no e f fec t on basophi l s ta in ing proper t ies . Exper ient ia 1992;48:504508. 70. L inde K, Jonas WB, Melchar t D, e t a l . Cr i t i ca l rev iew and meta-ana lys is o f ser ia l ag i ta ted d i lu t ions in exper imenta l tox ico logy. Hum Exp Toxico l 1994;13:481492. 71. Be l lav i te P, S ignor in i A . Homeopathya f ront ie r in medica l sc ience. Berke ley , CA: Nor th At lant ic Books, 1995:335. 72. van Wi jk R, Wiegant FAC. The s imi l ia pr inc ip le as a therapeut ic s t ra tegy: a research program on s t imula t ion o f se l f -defense in d isordered mammal ian ce l ls . A l t Therap Heal th Med 1997;3 :3338. 73. K le i jnen J , Kn ipsch i ld P, R ie t te r G. C l in ica l t r ia ls o f homoeopathy. Br Med J 1991;302:316323. 74. L inde K, C laus ius N, Ramirez G, et a l . Are the c l in ica l e f fec ts o f homeopathy a l l p lacebo e f fec ts? A meta-ana lys is o f randomized, p lacebo cont ro l led t r ia ls . Lancet 1997;350:834843. 75. Bo isse l JP, Cucherat M, Haugh M, Gauth ier E. Cr i t i ca l l i terature rev iew on the e f fec t iveness o f homoeopathy: overv iew of data f rom homoeopath ic medic ine t r ia ls . Brusse ls : Homoeopath ic Medic ine Research Group. Repor t to the European Commiss ion, 1996. 75a. Jahn RG, Dunne BJ. Marg ins o f rea l i ty . The ro le o f consc iousness in the phys ica l wor ld . New York : Harcour t Brace Jovanov ick , 1987. 76. Radin DI , Ne lson RD. Ev idence for consc iousness- re la ted anomal ies in random phys ica l sys tems. Foundat ions o f Phys ics 1989;19:14991514. 76a. Radin DI . The consc ious un iverse: the sc ient i f ic t ru th beh ind psych ic phenomena. San Franc isco: HarperEdge, 1997. 77. Braud WG, Sch l i tz MJ. Consc iousness in terac t ions wi th remote b io log ica l sys tems: anomalous in tent iona l i ty e f fec ts . Subt le Energ ies 1992;2 :146. 78. Sch l i tz M, Braund W. Dis tant in tent iona l i ty and hea l ing: assess ing the ev idence. A l t Therap Heal th Med 1997;3 :6273.

1179. Bem DJ, Honor ton C. Does ps i ex is t? Repl icab le ev idence for and anomalous in format ion t ransfer . Psychol Bu l l 1994;115:418. 80. Benor DJ. In tu i t i ve d iagnos is . Subt le Energ ies 1992;3 :4164. 81. Jonas WB. A l ternat ive medic ine learn ing f rom the past , examin ing the present , advanc ing the fu ture . JAMA 1998;280:16161618. 82. Chez RA, Jonas WB. The cha l lenge o f complementary and a l ternat ive medic ine. Am J Obste t Gynecol 1997;177:11561161. 83. De le ted. 84. Antonovsky A. Unrave l ing the mystery o f hea l th : how people manage s t ress and s tay wel l . San Franc isco: Jossey-Bass, 1987. 85. Fund MM. Enhanc ing the accountabi l i ty o f a l te rnat ive medic ine. New York : Mi lbank Memor ia l Fund, 1998. 86. Ernst E. Harmless herbs? A rev iew of recent l i tera ture . Am J Med 1998;104:170178. 87. Angel l M, Kass i rer JP. A l ternat ive medic inethe r isks o f untes ted and unregu la ted remedies. N Engl J Med 1998;339:839841. 88. Ber tho ld HK, Sudhop MD, von Bergmann K. Ef fec t o f a gar l ic o i l p reparat ion on serum l ipopro te ins and cho les tero l metabo l ism. JAMA 1998; 279:19001902. 89. Coul ter HL. The contro l led c l in ica l t r ia l : an ana lys is . Washington, DC: Center for Empi r ica l Medic ine, 1991. 90. Jonas WB. Cl in ica l t r ia ls fo r chron ic d isease: randomized, cont ro l led c l in ica l t r ia ls are essent ia l . J NIH Res 1997;9 :3339. 91. Wor ton JC. The h is tory o f complementary and a l te rnat ive medic ine. In : Jonas WB, Lev in JS, eds. Essent ia ls o f complementary and a l ternat ive medic ine. Ph i lade lph ia : L ipp incot t Wi l l iams & Wi lk ins , 1999. CHAPTER 1 THE HISTORY OF COMPLEMENTARY AND ALTERNATIVE MEDICINE James C. Whorton GENERAL CONSIDERATIONS The not ion o f complementary medic inethe poss ib i l i t y that t reatments not commonly employed or recognized by the a l lopath ic medica l profess ion might be combined wi th the convent iona l therapeut ic armamentar ium to ba lance and comple te i thas appeared on ly recent ly . Before the 1990s, unconvent iona l therap ies were la rge ly d ismissed by the Amer ican medica l pro fess ion as opposed to and incompat ib le w i th sc ient i f i c medica l prac t ice . Even the term al ternat ive , wh ich has been used s ince the 1970s, would not have been acceptab le to the a l lopath ic prac t i t ioners o f prev ious generat ions; i t wou ld have confer red too much respectab i l i ty , imply ing that non-a l lopath ic remedies might be an equa l , i f separate , opt ion. H is tor ica l ly , the phrases pre fer red by mainst ream phys ic ians have been i r regu lar medic ine, f r inge medic ine, sectar ian medic ine, medica l cu l t i sm, and quackeryal l pe jora t ive terms. To avo id such d ismiss ive language as wel l as to main ta in cons is tency, the term al ternat ive medic ine i s used throughout th is chapter . However , i f our present w i l l ingness to th ink o f a l ternat ive medic ine as complementary s ign i f ies the opening o f a new era , we can hard ly expect to make a c lean break wi th the past . The s tory o f complementary medic ine 's years as desp ised a l te rnat ive medic ine is one o f unceas ing conf l i c t w i th the medica l es tab l ishment , dur ing which an unto ld amount of bad fee l ing accumula ted on both s ides. I f a l ternat ive medic ine is to be enf ranch ised sc ient i f i ca l ly and pro fess iona l ly , i f i t i s to become complementary in fac t and not jus t in asp i ra t ion, th is h is tor ica l legacy o f mutua l i l l w i l l must be addressed and overcome. An awareness o f the h is tor ica l deve lopment o f complementary medic ine is essent ia l fo r unders tand ing the ph i losoph ica l or ientat ion that b inds together many a l te rnat ive systems of prac t ice . Whether an a l te rnat ive sys tem proc la ims i tse l f to be natura l hea l ing ( the favored descr ip t ion in n ineteenth-century par lance) , drug less hea l ing ( the term popu lar dur ing the ear ly twent ie th century) , or ho l is t ic hea l ing ( the labe l s ince the 1970s) , a l te rnat ive medic ine has cons is tent ly , f rom i ts beg inn ings in the la te 1700s, seen i tse l f as o f fer ing a d is t inc t ive approach to therapy and to phys ic ianpat ient in terac t ions. That d is t inc t ive out look is drawn, i ron ica l ly , f rom the work o f the very same phys ic ian whom or thodox prac t i t ioners revere as the fa ther o f the i r medic ineHippocrates . Complementary medica l ph i losophy might thus be thought o f as the Hippocra t ic heresy. ORIGINS OF ALTERNATIVE MEDICINE I am s ta t ing on ly what everybody knows to be t rue, when I say that the genera l conf idence which has here tofore ex is ted in the sc ience and ar t o f medic ine has wi th in the las t few years been v io lent ly shaken and d is turbed, and is now great ly lessened and impaired. The ho ld which medic ine has so long had upon the popu lar mind is loosened; there is a w idespread skept ic ism as to i ts power o f cur ing d iseases, and men are everywhere to be found who deny i ts pre tens ions as a sc ience, and re jec t the benef i ts and b lessings which i t p ro f fers them as an ar t (1 ) . Th is compla in t sounds modern enough, someth ing that might have appeared in las t week 's JAMA . In fac t , i t was issued in 1848. At that t ime (as wi th today) , the c learest s ign of eros ion o f pub l ic conf idence in a l lopath ic medic ine was the rap id growth over the preced ing two decades o f r iva l hea l ing sys tems that c la imed to be safer and more e f fec t ive than convent iona l medic ine. Those systems began to appear a t the turn o f the century ,

12large ly as pro tes ts aga inst the b leed ing, purg ing, and o ther hero ic measures prac t iced by phys ic ians o f the day; however , there were more reasons for revo l t than d issat is fac t ion wi th s tandard therap ies . There had been a l te rnat ives to convent iona l methods of cure before the 1800s: both fo lk medic ine and quackery had been opt ions for centur ies . But the d i f ferent vers ions o f a l ternat ive medic ine, as they were der is ive ly labe l led even through the ear ly decades o f the twent ie th century , were a d is t inc t depar ture . They were actua l systems o f care , the prac t i t ioners o f each be ing bound together not jus t by the i r oppos i t ion to the medica l es tab l ishment , but a lso by shared theoret ica l precepts and therapeut ic regimens: by membersh ip in loca l , s ta te , even nat iona l soc ie t ies and by pub l ica t ion o f the i r own journa ls and operat ion o f the i r own schoo ls . Essent ia l ly , they were pro fess iona l ized. And by the end o f the 1840s, th is medica l countercu l ture had cornered rough ly 10% of the hea l th care market (2 , 3 , 4 , 5 and 6) . Thomsonianism, Homeopathy, Hydropathy, and Mesmerism Thomsonian ism was the f i rs t a l te rnat ive sys tem to be deve loped in Amer ica. I t invo lved a program of botan ica l hea l ing formula ted in the 1790s by Samuel Thomson, a New Hampshi re farmer . H is combinat ions o f p lant drugs that e i ther evacuated or heated the body (e .g . , the emet ic lobe l ia , cayenne pepper enemas) were warmly rece ived by the pub l ic o f the 1820s and 1830s. However , the sys tem qu ick ly foundered a f ter Thomson 's death in 1843 (7) . Homeopathy, the sys tem formula ted by the German phys ic ian Samuel Hahnemann in the 1790s, es tab l ished a footho ld in the Uni ted Sta tes in the 1830s. Der ived f rom Greek roots meaning l i ke the d isease, homeopathy t reated conste l la t ions o f symptoms wi th drugs that had been found to produce the very same symptoms in hea l thy peop lei .e . , l i ke cured l i ke . Homeopath ic remedies were c la imed to work most e f fec t ive ly a f ter be ing car r ied through a ser ies of d i lu t ions that essent ia l ly removed a l l the mat ter o f the or ig ina l drug before the preparat ion was g iven to the pat ient ; molecu lar ly speak ing, homeopath ic remedies were in f in i tes imals . Hahnemann a lso co ined the term al lopathyother than the d iseaseto s ign i fy the or thodox ph i losophy o f neut ra l iz ing compla in ts w i th therap ies oppos i te to the symptoms. By the mid-1800s, a l l a l te rnat ive medica l groups had embraced al lopath ic as the s tandard term for or thodox medic ine; on ly in recent years has the word shed i ts negat ive connota t ions. Homeopathy was eas i ly the most popular a l ternat ive sys tem by midcentury , and would remain so in to the ear ly 1900s (8 , 9) . The next most popu lar medica l a l te rnat ive a t midcentury was hydropathy , an Aust r ian creat ion o f the 1820s impor ted in to the Uni ted Sta tes in the ear ly 1840s. The water -cure , as Amer icans l i ked to ca l l i t , s t imulated the body to r id i tse l f o f d isease through a var ie ty o f baths (usua l ly co ld) , supp lemented wi th care fu l regu la t ion o f l i fes ty le (e .g . , d ie t , exerc ise , s leep, dress) . Hydropathy main ta ined a s izeab le fo l lowing in to the 1860s, but s tead i ly faded a f ter the Civ i l War (10, 11 and 12) . Dur ing th is t ime in Amer ica , the r ise and fa l l o f Mesmer ism, or magnet ic hea l ing , occur red. The invent ion o f e igh teenth-century Austr ian phys ic ian Franz Mesmer , magnet ic therapy re l ied on hypnot ism and the power o f suggest ion to re l ieve pat ients ; Mary Baker Eddy, the founder o f Chr is t ian Sc ience in the 1870s, was h igh ly in f luenced by th is therapy (13) . F ina l ly , ec lec t ic ism, as i ts name impl ies , was an assor tment o f therap ies se lec ted f rom a l l schoo ls o f prac t ice , a l lopath ic and a l te rnat ive , on the bas is o f c l in ica l exper ience. Or ig inated by New York prac t i t ioner Wooster Beach in the la te 1820s, ec lect ic medic ine las ted in to the 1930s (14) . THE SECOND GENERATION OF ALTERNATIVE MEDICAL SYSTEMS Less successfu l cha l lengers o f a l lopath ic medic ineBaunscheid t ism, chronothermal ism, phys iomedica l ism, and o ther medical i smsmight a lso be ment ioned to comple te the antebe l lum generat ion o f a l te rnat ive systems. A second wave appeared in the la ter n ineteenth century , beg inn ing wi th os teopathy, a techn ique o f muscu loske le ta l manipu la t ion or ig inated by Andrew Tay lor St i l l in the 1870s. However , the f i rs t os teopath ic schoo l would not beg in operat ion unt i l 1892 (15) . The f i rs t schoo l o f ch i ropract ic opened i ts doors in 1895, the same year that the manipu la t ion method was d iscovered by Danie l Dav id Pa lmer in Davenpor t , Iowa (16) . Dur ing the las t few years o f the century , German emigre Benedic t Lust b lended the new manipu la t ion procedures wi th hydropath ic ph i losophy and t reatments , herba l t rad i t ion , and o ther natura l remedies to create naturopathy (17) . By then, near ly 20% of a l l p rac t i t ioners o f medic ine were a l ternat ive phys ic ians, up f rom the es t imated 10% of the 1850s; in 1900 in Amer ica , there were approx imate ly 110,000 a l lopaths , 10,000 homeopaths, 5000 ec lec t ics , and another 5000 pract i t ioners o f o ther a l te rnat ive sys tems (18, 19) . Acupuncture has more recent ly been red iscovered; there was some exper imenta t ion wi th acupuncture in Europe and Amer ica in the n ineteenth century . Repor ts o f i ts e f f icacy by t rave lers to China in 1970 t r iggered an explos ion o f in teres t not on ly in acupuncture , but a lso in a l l aspects o f t rad i t iona l Ch inese medic ine and in Ayurveda, the anc ient hea l ing sys tem of Ind ia (20) . ALTERNATIVE MEDICINE'S CRITIQUE OF ALLOPATHIC MEDICINE Despi te the d i f fe rences between Hahnemann 's and Thomson 's drug, or between Palmer 's and St i l l ' s theor ies , the ph i losophy o f hea l ing and i ts impl ic i t c r i t ique o f a l lopathy was (and remains) the same for a l l a l te rnat ive sys tems. That ph i losophy was presented in a car toon pub l ished in 1834, in the f i rs t i ssue o f The Thomsonian Botan ic Watchman , a t the very beg inn ing o f the c lash between or thodoxy and the new medica l here t ics (F ig . 1 .1) . Th is Thomsonian car toon is t shows a man mired in the s lough o f d isease, desp i teactua l ly , because o fthe min is t ra t ions o f an a l lopath ic doctor . The phys ic ian is a t tempt ing to b ludgeon the d isease in to submiss ion wi th a c lub labe l led ca lomel . Ca lomel (mercurous chlor ide) was the most popular purgat ive in n ineteenth century medica l prac t ice ; in fac t , w i th the poss ib le except ion o f op ium, i t was the most f requent ly prescr ibed drug. As a

13mercur ia l , i t cou ld (and o f ten d id) produce severe s ide e f fec ts : u lcera t ion of the mouth , loss o f teeth, necros is o f the jawbone, and, most typ ica l ly , a pro fuse, th ick , fe t id sa l iva t ion. In the car toon, the MD is assur ing h is pat ient that , You must be reduced, S i r ! , in tend ing that the d isease wi l l be reduced by ca lomel 's c leans ing o f the in tes t ina l t rac t . The pat ient , however , fears that he is be ing reduced to the grave: The Doctor knows best , he moans facet ious ly , but send for the Parson. In the midd le o f the p ic ture , an ob jec t ive observer a t tempts to get the doctor 's a t tent ion , to show h im there is a bet ter way, the way o f the Thomsonian hea ler to the r ight , who rescues the pat ient by pul l ing h im up the s teps o f common sense (21) .

By dep ic t ing the a l lopath ic phys ic ian as seeming ly ho ld ing h is pat ient down, dep ic t ing ca lomel as a c lub, and hav ing the pat ient ca l l fo r the parson, the Thomsonian car toon is t is suggest ing that a l lopathy a t tacks d isease so brash ly as to ind iscr iminate ly overwhelm the pat ient , too ; i ts therap ies are , in the language o f a la ter day, invas ive. However , Thomsonian remedies are ind icated to be gent le and natura l , and to suppor t and enhance the body 's own innate recuperat ive powers : I w i l l he lp you out , the Thomsonian doctor te l ls the pat ient , w i th the b less ing o f God. He might as wel l say , w i th the b less ing o f nature because, in n ineteenth century thought , God and nature were impl ic i t l y one. Thomsonians o f ten s ta ted the mat ter exp l ic i t l y though, Thomson h imsel f dec lar ing that nature ought to be a ided in i ts cause, and t reated as a f r iend; and not as an enemy, as is the prac t ice o f the phys ic ians. H is approach had a lways been to learn the course po in ted out by nature, then to admin is ter those th ings best

ca lcu la ted to a id her in res tor ing hea l th (22) . He hard ly s tood a lone. Most a l te rnat ive pract i t ioners , in h is day and the present , pro fessed to consu l t and cooperate w i th the v is medicat r ix naturae , the hea l ing power o f nature f i rs t descr ibed and pra ised by Hippocrates :

F IGURE 1.1. The Cont ras t ; o r an i l lus t ra t ion o f the d i f fe rence between the regu lar and Thomsonian systems of pract ice in res tor ing the s ick to hea l th .

A l l hea l ing power is inherent in the l i v ing sys tem. (Russe l l Tra l l , hydropath , 1864) (23) Naturopathy, w i th a l l i t s var ious methods o f t reatments , has a lways one end in v iew and one on ly : to increase the v i ta l fo rce. (Benedic t Lust , naturopath , 1903) (24) Osteopath ic manipu la t ion removes obstac les to the f ree f low of the b lood and wi th the l i f t ing o f th is embargo nature i tse l f does the necessary work to res tore the body to i ts normal s ta te and even beyond i t. Osteopathy f igh ts on the s ide o f nature . (M. A. Lane, os teopath, 1925) (25)

In F igure 1.1, the d ip loma hanging f rom the phys ic ian 's coat pocket is as prominent as h is ca lomel c lub. Emblazoned wi th the MD, the d ip loma is emblemat ic to Thomsonians o f the abst ruse theoret ica l t ra in ing the a l lopath has rece ived and that d ic ta tes h is prac t ice . As the person in the middle o f the f igure observes, the a l lopath ic phys ic ian is sc ient i f i c w i th a vengeance, he l lbent on do ing what theory te l ls h im ought to work , ob l iv ious to the common sense that would show h im he is po ison ing h is pat ient . But the er ror o f h is a l lopath ic way is not jus t that he makes the s ick even s icker w i th misgu ided therap ies ; h is devot ion to theory , the car toon is t suggests , prevents h im f rom even a t tempt ing a fa i r eva luat ion o f a l te rnate remedies , remedies that cannot be ra t iona l ized by , or that seem to conf l i c t w i th , h is sc ience. Hence, f rom the onset , homeopath ic drugs were laughed a t by a l lopaths because o f what seemed the theoret ica l s imple-mindedness o f the l i ke cures l ike pr inc ip le and the imposs ib i l i t y o f in f in i tes imals exer t ing any mater ia l ac t ion. St i l l ' s muscu loske le ta l manipu la t ions were d ismissed because o f the perce ived na ivete o f h is ru le o f the ar tery theory ; Pa lmer 's ch i ropract ic ad jus tments were d ismissed because o f the apparent s i l l iness o f the ver tebra l subluxat ion model ; and acupuncture in the ear ly 1970s was d ismissed because o f the a l ien concepts o f qi and energy mer id ians. The recent response o f a un ivers i ty medica l sc ient is t to repor ts o f c l in ica l t r ia ls showing that pat ien ts who are prayed for recover bet ter than those who do not rece ive prayers is a wonder fu l ly d i rec t summary o f th is h is tor ica l a t t i tude: That 's the k ind o f c rap I wou ldn ' t be l ieve, th is sc ient is t i s repor ted to

14have sa id , even i f i t were t rue. (L . Dossey, unpubl ished) . Complementary phys ic ians contend that the sc ient i f i c medica l es tab l ishment has a lways had a negat ive at t i tude about complementary methodsmost a l lopaths re fuse to be l ieve them even i f they are t rue because they make no sense in terms of convent ional sc ience. L ike the doctor in the car toon, MDs as a group are seen by a l te rnat ive pract i t ioners to be sc ient i f i c w i th a vengeance. Alternat ive Medicine's Emphasis on Empir ic ism Al ternat ive prac t i t ioners have never re l ied on pure ly theoret ica l determinants o f prac t ice , main ta in ing the i r methods have been der ived la rge ly f rom empir ica l bases. Wi th the except ion of Mesmer ism, a l te rnat ive medica l sys tems or ig inated f rom the founder 's therapeut ic exper iences, in i t ia l ly unta in ted by the in f luence o f specu la t ive hypothes is . Hahnemann c la imed for h is mater ia medica tha t i t was f ree f rom a l l con jec ture , f i c t ion, or gra tu i tous asser t ioni t sha l l conta in noth ing but the pure language o f nature, the resu l ts o f a care fu l and fa i th fu l research (26) . L ikewise, Thomson had noth ing to gu ide h im but h is own exper ience. His mind was unshack led by the v is ionary theor ies of o thers ; h is whole s tud ies have been in the great book o f nature (27) . The power o f muscu loske le ta l manipu lat ion was d iscovered by St i l l th rough pract ica l t r ia ls on h is ne ighbors and by Pa lmer dur ing an exper iment on h is jan i tor . A l ternat ive systems have cons is tent ly s tar ted through what today would be descr ibed as observat iona l , o r outcome, s tud ies . Once a therapeut ic method was determined to have pos i t ive outcomes, however , the temptat ion to exp la in i t was a lmost never res is ted, and theoret ica l ra t iona l iza t ions were soon for thcoming. Ec lec t ic ism a lone was able to s tand f i rm wi th an i t works , who cares how a t t i tude; a l l o ther sys tems qu ick ly sur rendered to the lu re o f con jec ture and v is ionary theor ies . Hahnemann con jec tu red h is in f in i tes imals operated through dynamici .e . , sp i r i tua lact ion. Thomson theor ized h is empi r ica l ly demonstra ted herbs worked by promot ing the d is t r ibu t ion o f l i fe -susta in ing heat through the system. St i l l hypothes ized a ru le o f the ar tery that res tored the body to hea l th as soon as ske le ta l p ressures on b lood vesse ls were re l ieved by manipu la t ion. Pa lmer imagined that ver tebra l sub luxat ions const r ic ted nerves and impeded the f low o f Innate In te l l igence, a d iv ine l i fe force, through the body. A l ternat ive prac t i t ioners , in other words, genera l ly reversed the process a t t r ibu ted to a l lopath ic phys ic ians. Ins tead o f fo rmula t ing a theory , then deduc ing therapy f rom i tthe a l lopath ic modelthey d iscovered a therapy, then deduced a theory . And invar iab ly , the theoret ica l p r inc ip le that fo l lowed was that the therapy in quest ion worked by e l iminat ing some obsta