A certain amount of resistance to new ideas is normal and functional in science providing the innovations have a means of being tested. A number of differences between medicine and pure science are noted which can result in some medical innovations being ignored or rejected without an adequate assessment. Historical and current instances of resistance to innovation are given. Social-organizational factors in medicine appear to favor the acceptance of theoretically glamorous, pharmaceutical, and high technology innovations over simpler and less profitable ones.
Science is committed to the exploration of new ideas, so that excessive resistance to innovations in science would seem to be contrary to scientific canons and consequently very rare. Barber called attention to a number of historical instances of resistance to new scientific ideas.
(1) Philosophers (12, 17) and sociologists (8, 25) of science agree in defending the practice of resistance to innovation and even argue that resistance is necessary, that a new idea should have to prove itself before it deserves being adopted by the scientific community. Kuhn states that as a new paradigm Is seldom perfect, its superiority over the existing one is not always overwhelming, so that in such cases, one may do as well by sticking with the existing paradigm. (12, p. 76)
Cole and Cole, both sociologists, go so far as to advance the opinion that today there is little “delayed recognition” of scientific ideas as there was with Mendel because “the evaluation system of science operates so efficiently that most Mendels would be in top university departments.” (6, p. 213) Their conclusions, however, are based primarily on the study of the “hard” sciences, as is most research on and theorizing about science. They concede there is some resistance to innovation, though, pointing out that both resisters and innovators base their arguments on scientific tradition. “The scientist who produced the contrary ideas invokes the memories of Pasteur, Lister, and others, whose ideas were initially resisted.” (6, p. 87) It may be more than coincidental that the examples of resistance referred to are from the medical field. In an earlier work, Stern devotes a whole chapter to a discussion of resistance to medical change. (23)
The belief in the legitimacy of resistance to innovation noted above, however, is based on the assumption that a new idea will have a chance to be presented and will receive a fair hearing and adequate test when it is introduced. These assumptions seem to be generally met in the fields studied by those in the philosophy and sociology of science. But these “pure” sciences differ in a number of ways from the practice of medicine so that conclusions derived from the study of “science” may not be applicable to medicine.
Although medicine is rooted in science, it has a number of extra-scientific characteristics that could have an effect on the reception given to new ideas as compared to pure science. Whereas the pure science researcher deals either with inanimate objects or with living things he is free to manipulate at will (subject to some concerns about humane treatment of mammals) the physician confronts patients having legal, moral, and ethical rights. Experimentation and mistakes have much more drastic consequences for the physician than for the pure scientists. As a result of this, the physician has many more limitations, actual or potential, placed on his freedom of action. Laws at various governmental levels restrict methods of diagnosis and treatment including types of medications that may be prescribed. Sanctions can include loss of the medical license, refusal of hospital privileges, failure to refer patients to a physician, social and professional ostracism, and suits for malpractice.
Medical practice is subject to more uncontrolled variables. Whereas the scientist can follow his project through to the end the physician must frequently depend on the cooperation of the patient to take the medication, follow the diet, do the exercises, etc. Also, the physician regularly encounters combinations of conditions and atypical cases that call for the art, rather than the science, of medicine in making judgments.
The goal of pure science research is that the phenomena being investigated be understood and explained theoretically. In contrast, the goal of medicine is the successful treatment of illness. While theoretical understanding is desirable in medicine, it is not essential, there having been many treatments over the years that worked empirically despite the lack of a full understanding of them.
Puerperal Fever and Semmelweis
This has become a classic case of resistance but will be reviewed briefly here. Puerperal fever only became a serious problem when large hospitals providing lying-in facilities were built in cities during the 19th century. Maternal mortality rates from this illness frequently ranged from 20% to 30% and in at least one instance reached 96% for one hospital during one month in 1846. (3, pp. 107, 92)
Ignaz Semmelweis, in a position equivalent to that of head resident in one of two obstetrical wards of Vienna General Hospital in the 1840’s concluded that “cadaveric particles” caused the disease and were spread by the doctors’ hands as they went directly from doing autopsies to examining women in labor without washing their hands or changing clothes (3, p. 121) Associating the “particles” with the odor of the disease, he tried to eliminate the odor with a chlorine solution, requiring all medical students to wash their hands in it before touching patients. In the following month, the mortality rate fell to 0.23%. (3, pp. 123—4) But physicians ridiculed the idea and medical students rebelled at the practice. Dismissed from his position, Senmielweis returned to his native Budapest where he eventually was given a part—time post in an obstetrical hospital on the condition that he would say nothing to medical students about washing their hands.
A few Vienna physicians accepted Semmelweis’ ideas and wrote to others in various European cities. One went to England and made a presentation on the subject to the Medical Society of London; another spoke to the Academy of Medicine in Paris. But his method was, either denounced or ignored. Unable to bear the burden of recognizing all the needless deaths, his mind gave way and .he deliberately infected himself with puerperal fever and died in an insane asylum in 1865. Two years later Lister announced his discoveries about antisepsis, which with the work of Pasteur, paved the way for aseptic surgery and childbirth. Semmelweis’ ideas as such never were accepted except through historical recognition.
Polio and Sister Kenny
Working as an independent “bush nurse” in Australia, Sister Elizabeth Kenny was called upon in 1911 to treat six cases of polio. (5) She improvised a system of using hot packs to relieve apparent muscle spasm followed by manipulation of the affected limbs so they would not get “alienated” from the brain. All six cases recovered successfully. Both her theory and method were diametrically opposed to medical authorities, who viewed the illness as one of the nerves which pulled the muscles out of position, contorting parts of the body. Orthodox treatment was to hold the body in a normal position with splints or casts during the acute phase and eventually to fit the patient with braces.
Kenny worked as a military nurse during World War I and did general nursing during the 1920’s, not getting drawn back into polio nursing until 1931 when she enabled a young women to walk who had been paralyzed from a polio attack eight years earlier. In 1933, she wrote to Queensland officials saying she was rehabilitating cripples and asked for governmental aid. Three physicians supported her application, one of them calling her work “revolutionary.” (5, p. 85)
While she did receive governmental assistance in establishing clinics, they were only for post—acute cases. With only a few exceptions, physicians ignored or rejected her. In London, in 1937, she was given space in a hospital for a treatment unit, but again not for acute cases. Various reports and evaluations of her method were generally critical. Most important of these was a report of the Queensland Royal Commission, which “damned her.” (5, p. 107) Although some physicians called for a scientific comparison of her method with the conventional treatment such a study was never done.
In 1939, aided by Australian governmental funds, she came to America carrying supporting letters by five Australian physicians. Meetings with the National Foundation for Infantile Paralysis, a polio expert from a leading eastern medical college, and officers of the American Medical Association proved unproductive. The Mayo Clinic referred her to orthopedic specialists in Minneapolis and St. Paul, including the chief of orthopedics at the University of Minnesota Medical School. The Twin City physicians listened to her and observed her work with patients. Becoming convinced of the value of her approach they started trying to win wider acceptance of it, their efforts culminating in a highly favorable editorial in the 6 December 1941 issue of the JAMA. But even this was preceded by “violent disagreement” within the AMA Committee on After Effects which led to the resignations of some of its members. (5, p. 147)
The success of her method is indicated by the decline in the number of immobilizing splints used during the polio season — from 14,000 in 1941 to three in 1943. (5, p. 150) But it had taken thirty years from the time in 1912 when she first demonstrated her method to a physician, and one who was both a hospital senior surgeon and a member of the Queensland (state) Medical Board.
The preceding instances are from the past. Is there still resistance to innovation today? A difficulty in dealing with current situations is that the innovations being resisted are automatically ones that have not proven themselves. The resister can argue that the opposition is justified. But if that be so, the resistance should prove upon examination to be based on reasonable evidence and sound scientific principles. We will inquire whether that is the case.
Allergy, Food Sensitivity, and Clinical Ecology
Conventional medicine views allergy as a malfunctioning of the immune system, which over—reacts to otherwise harmless proteins, identifiable by means of skin tests. In the 1930’s Coca observed that the consumption of foods to which a person was sensitive could cause an acceleration in the pulse rate. In the course of using the “pulse test” he found that many more medical conditions were caused by food sensitivity than had been recognized up to that time. In the second edition of his book describing the method and detailing his findings, he reported that the first edition led to his being criticized by colleagues for trying to expand the field of allergy. (4, p. 68) He also commented upon his ideas meeting “a skepticism so uncompromising that I have not even been invited to demonstrate the new method described herein.” (4, p. vii) Thus, his ideas were not disproven, but simply ignored. Some doctors do use the pulse test and have concluded that it works quite well. (9, p. 29)
Also during the 1930’s Rinkel made the discoveries and developed the basic concepts that now underlie the field known as clinical ecology.
When he submitted an article to the Journal of Allergy in 1936 describing the mechanisms and effects of food allergy, it was refused publication. (19, p. 20) In 1951, with Randolph and Zeller, Rinkel published Food Allergy (20) which described a system for detecting food sensitivities in which patients’ observable or reported reactions to specific foods could be verified objectively through leukocyte counts of blood samples. As did Coca, these workers found many more symptoms and illnesses caused by food sensitivities than were conventionally recognized. The typical food reactor is polysymptomatic, “with a long history of many problems, physical and mental ,” (19, p. 16) the type of person conventional medicine is least successful in dealing with. Clinical ecologists have increasingly emphasized reactions to chemicals as a cause of illness. (18)
They have not been denied publication and, Randolph especially, have published numerous articles in medical journals over the past four decades.
Nevertheless, clinical ecology remains controversial,“ and is either unknown or rejected by most allergists, with food sensitivity being regarded as quite rare. A major problem is that while the immunological basis of allergy as conventionally viewed is well developed theoretically ‘‘much of the study of food allergy is empirical practice with no relation to basic science and no knowledge of the pathogenic mechanism involved.” (22, p. 155)
Here we encounter a conflict between the intellectual needs of the physician-researcher and the practical needs of the patient. If the patient can be relieved by empirically-based treatment why should he have to wait until the physician can gain a theoretical understanding? Because medical education is dominated by theoretically oriented researchers, clinical ecology is generally not taught in medical schools, even to allergists. (9, p. 37) Physicians are warned against making diagnoses of allergy; one conventional textbook warns that “the allergist should avoid the pitfalls of over—diagnosing allergy,” (21, p. 200) while a recent editorial in The Lancet states that “the diagnosis has been overworked to explain a great array of poorly understood symptoms.” (10) The charge that allergy is diagnosed too frequently is based on the conventional view, which is thus used to discourage further examination of an alternative.
Despite the continued ignoring of clinical ecology, the existential basis behind it cannot be made to go away. Thus, three researchers in a recent report on the use of sodium cromoglycate (cromolyn, D.C.G.) in cases of food intolerance stated they “were surprised to note that symptoms not usually ascribed to allergy, such as lassitude, irritability, rheumatism (aching limbs and joints) and headache were ... produced by the ingestion of foods.” (27) Every one of these symptoms, and many others as well, were ascribed (in at least some cases) to food sensitivity by Rinkel, Randolph, and Zeller in 1951. (20) That knowledgeable physicians should find them “surprising” almost thirty years later is eloquent evidence of resistance. Increased use of newer conventional testing methods (e.g., RAST) are sure to increase the awareness of food sensitivities.
There are indications that clinical ecology is starting to get increased recognition. The Society for Environmental Therapy organized in 1980 in England encompasses the field. In the U.S. the Society for Clinical Ecology grew from five members in 1965 to some 350 in 1980. Both popular and technical publications have increased markedly. Were it not for resistance, this all could have happened decades earlier.
While the United States National Research Council recommends 60 mg. of vitamin C per day for humans, it stipulates on an equivalent body weight basis 3,830 mg. per monkeys and from 2.920 to 11,650 mg. for guinea pigs. (24, p. 53) This, plus evidence that animals who do produce their own vitamin C make amounts equivalent for humans of thousands of mg. per day has led some workers to believe it would be advantageous for humans to have more than just the amount needed to prevent scurvy. A number of studies indicate that both humans and animals can benefit from large amounts of vitamin C. (14, 24) Pauling complains that the medical community requires rigorous evidence supporting vitamin C but accepts flimsy evidence against it. (14, p. 130)
Reasoning that vitamin C might better enable the body to resist the invasiveness of cancer, Cameron started giving terminal cancer patients in a Scottish hospital high doses of the vitamin in 1971. Results were striking, with 16 percent of the experimental patients still surviving after practically all of the controls had died. Five of the experimental patients were still alive and apparently free of the disease some three years after the last control patient died. (2, pp. 134-5)
Convinced of the value of vitamin C, Cameron could no longer ethically withhold it from patients for research purposes, so in 1973 Pauling requested the National Cancer Institute to replicate Cameron’s work. Only after a four-year delay did the Institute respond, but the resulting study, done at the Mayo Clinic, deviated from Cameron’s in an important way. While only four percent of Cameron’s patients had had prior chemotherapy, 87 percent of the Mayo patients had received prior chemotherapy, which, according to Pauling, could have destroyed the body’s ability to benefit from vitamin C. (15) Pauling states that he called attention to the importance of chemotherapy while the Mayo study was being planned and was assured the report would take this into account. (15) When the report of the Mayo study was published, it stated that vitamin C was not effective and misrepresented Cameron’s sample as having had 50 percent chemotherapy patients. (7) Now, ten years after the original research began, another trial is being planned. (13)
In recent years, Dr. William Cathcart has been using extremely high doses of vitamin C in the treatment of viral diseases, for which antibiotics are unsuccessful. He has found that whereas a healthy person can only take from 10 to 15 grams in a day without getting diarrhea, a person who is sick with a viral disease (including colds, pneumonia, and mononucleosis) can tolerate as much as two hundred grams. (16) He uses his concept of “bowel tolerance” to determine how much vitamin C the patient should have. Cathcart states that while the vitamin does not shorten the course of the disease it suppresses symptoms so that the person is able to live normally. As the disease lessens, the patient’s tolerance for vitamin C decreases back to normal. The methods and results would be easily verifiable by others and the potential therapeutic benefits are great. Yet, Cathcart states that when he tried to publish his findings his articles were refused “flat out” by medical journals without explanation. (16)
I doubt that these are the only instances of resistance to innovation in medicine. A number of other current controversies come readily to mind
-- DMSO, orthomolecular (megavitamin) treatment for schizophrenia, laetrile, and chelation therapy, to name at least some others. Resistance would be more understandable if the new approach were only marginally superior to the old, but that is not the case in the examples given here. A change in obstetrical care which reduces the maternal mortality rate from as high as 96% to less than 1% is hardly marginal. The almost instantaneous change in polio treatment when the Kenny method was finally seriously examined is testimony to its superiority. The promise that clinical ecology seems to offer of alleviating major chronic illnesses is far from insignificant, and the potential value of vitamin C in areas where conventional medicine has,little to offer calls out for serious consideration.
The professional status of the innovator might seem to be a factor. Semmelweis had only recently obtained his degree and was a foreigner; Kenny was a female bush nurse. Yet, in both cases, more highly placed physicians tried to win over others and failed. More recent innovators are not lacking in status. Coca was founder and first editor of the Journal of Immunology. Both Rinkel and Randolph had backgrounds including publication and medical school teaching when they published Food Allergy. Rinkel’s death was noted in the Archives of Otolaryngology with a two-page obituary which included his picture and described him as an “internationally known ... foremost authority on allergy.” (26) Cathcart developed a hip joint prosthesis which is widely used. Pauling is a Nobel Prize winner. Lack of professional stature does not seem to be an adequate explanation.
I am not maintaining that all innovation in medicine is resisted. Indeed, there is a long list of medications and treatment approaches that were adopted very rapidly, such as insulin for diabetes, open heart surgery, tranquilizers, CAT scanners, and fetal distress monitoring (even though “it is still difficult to decide whether fetuses are distressed.”) (11)
Treatment methods follow the leads of research, especially prestigious research which involves theoretical breakthroughs, the development of new medical techniques (generally surgical), and/or the use of elaborate technology. The combination of prestige for the doctor and profits for the suppliers of the technology ensure that innovations of these types will not be overlooked. Similarly, the development of new medications by pharmaceutical companies is certain to be brought to the attention of physicians.
Treatment modalities that are not interesting theoretically or that do not offer promise of prestige for the physician-researcher or profits to corporations are not likely to be extensively promoted in the medical world. Both contemporary instances of resistance discussed here have these characteristics. Food sensitivity is poorly understood theoretically and its diagnosis and treatment involve only the use of simple extracts and control of the diet. Ascorbic acid is a standard chemical that cannot be patented and promoted for substantial profits.
One wonders how many potentially valuable medical discoveries are being overlooked because they are too simple and not profitable enough.
From Medical Hypotheses, Volume 7, Number 8, 1981, pp. 1009-1017
20 November, 2013.
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