Abraham Flexner's View of Homeopathic Schools:
An Excerpt from the Flexner Report (1910)
In 1908, the Carnegie Foundation for the Advancement of Teaching commissioned Abraham Flexner to study and report on the schools of medicine in the United States. His landmark report—Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching—was published in 1910. Commonly referred to as the "Flexner Report," it concluded that there had been an "enormous overproduction of uneducated and ill-trained medical practitioners . . . . in absolute disregard of the public welfare." The report, plus Flexner's vigorous personal efforts for reform, resulted in the closing of about 80% of the then-existent medical schools and the development of high standards for medical training.
Chapter X of the report dealt with schools whose teachings were fundamentally irrational and based on dogma. This page contains the passagesin which Flexner explained why he believed that homeopathic schools could not survive the advance of science. The full report can be downloaded as a 29MB PDF file from the Carnegie Foundation Web site.
The proposition raises at once the question as to whether in this era of scientific medicine, sectarian medicine is logically defensible; as to whether, while it exists, separate standards, fixed by the conditions under which it can survive, are justifiable. Prior to the placing of medicine on a scientific basis, sectarianism was, of course, inevitable. Every one started with some sort of preconceived notion; and from a logical point of view, one preconception is as good as another. Allopathy was just as sectarian as homeopathy. Indeed, homeopathy was the inevitable retort to allopathy. If one man "believes” in dissimilars, contrary suggestion is certain to provide another who will stake his life on similars; the champion of big doses will be confronted by the champion of little ones. But now that allopathy has surrendered to modern medicine, is not homeopathy borne on the same current into the same harbor?
The modern point of view may be restated as follows: medicine is a discipline, in which the effort is made to use knowledge procured in various ways in order to effect certain practical ends. With abstract general propositions it has nothing to do. It harbors no preconceptions as to diseases or their cure. Instead of starting with a finished and supposedly adequate dogma or principle, it has progressively become less cocksure and more modest. It distrusts general propositions, a priori explanations, grandiose and comforting generalizations. It needs theories only as convenient summaries in which a number of ascertained facts may be used tentatively to define a course of action. It makes no effort to use its discoveries to substantiate a principle formulated before the facts were even suspected. For it has learned from the previous history of human thought that men possessed of vague preconceived ideas are strongly disposed to force facts to fit, defend, or explain them. And this tendency both interferes with the free search for truth and limits the good which can be extracted from such truth as is in its despite attained.
Modern medicine has therefore as little sympathy for allopathy as for homeopathy. It simply denies outright the relevancy or value of either doctrine. It wants not dogma, but facts. It countenances no presupposition that is not common to it with all the natural sciences, with all logical thinking.
The sectarian, on the other hand, begins with his mind made up. He possesses in advance a general formula, which the particular instance is going to illustrate, verify, reaffirm, even though he may not know just how. One may be sure that facts so read will make good what is expected of them; that only that will be seen which will sustain its expected function; that every aspect noted will be dutifully loyal to the revelation in whose favor the observer is predisposed: the human mind is so constituted.
It is precisely the function of scientific method—in social life, politics, engineering, medicine—to get rid of such hindrances to clear thought and effective action. For it, comprehensive summaries are situate in the future, not in the past; we shall attain them, if at all, at the end of great travail; they are not lightly to be assumed prior to the beginning. Science believes slowly; in the absence of crucial demonstration its mien is humble, its hold is light. "One should not teach dogmas; on the contrary, every utterance must be put to the proof. One should not train disciples but form observers: one must teach and work in the spirit of natural science." [Johannes Orth: BerZiwr Kimiscfus Wochenschrift, vol. xliii. p. 818]
Scientific medicine therefore brushes aside all historic dogma. It gets down to details immediately. No man is asked in whose name he comes—whether that of Hahnemann, Rush, or of some more recent prophet. But all are required to undergo rigorous cross-examination. Whatsoever makes good is accepted, becomes in so far part, and organic part, of the permanent structure. To plead in advance a principle couched in pseudo-scientific language or of extra-scientific character is to violate scientific quality. There is no need, just as there is no logical justification, for the invocation of names or creeds, for the segregation from the larger body of established truth of any particular set of truths or supposed truths as especially precious. Such segregation may easily invest error with the sanctity of truth; it will certainly result in conferring disproportionate importance upon the fact or procedure marked out as of pivotal significance. The tendency to build a system out of a few partially apprehended facts, deductive inference filling in the rest, has not indeed been limited to medicine, but it has nowhere had more calamitous consequences.
The logical position of medical sectarians today is self-contradictory. They have practically accepted the curriculum as it has been worked out on the scientific basis. They teach pathology, bacteriology, clinical microscopy. They are thereby committed to the scientific method; for they aim to train the student to ascertain and interpret facts in the accepted scientific manner. He may even learn his sciences in the same laboratory as the non-sectarian. But scientific method cannot be limited to the first half of medical education. The same method, the same attitude of mind, must consistently permeate the entire process. The sectarian therefore in effect contradicts himself when, having pursued or having agreed to pursue the normal scientific curriculum with his student for two years, he at the beginning of the third year produces a novel principle and requires that thenceforth the student effect a compromise between science and revelation.
Once granted the possibility of medical dogma, there can be no limit to the number of dissenting sects. As a matter of fact, only three or four are entitled to serious notice in an educational discussion. The chiropractics, the mechano-therapists, and several others are not medical sectarians, though exceedingly desirous of masquerading as such; they are unconscionable quacks, whose printed advertisements are tissues of exaggeration, pretense, and misrepresentation of the most unqualifiedly mercenary character. The public prosecutor and the grand jury are the proper agencies for dealing with them.
Sectarians, in the logical sense above discussed, are (1) the homeopathists, (2) the eclectics, (3) the physiomedicals, (4) the osteopaths. All of them accept in theory, at least, the same fundamental basis. They admit that anatomy, pathology, bacteriology, physiology, must form the foundation of a medical education, to use the words broadly so as to include all varieties of therapeutic procedure. They offer no alternative to pathology or physiology; there is, they concede, only one proper science of the structure of the human body, of the abnormal growths that afflict it. So far, they make no issue as against scientific medicine. Much is involved in agreement up to this point. The standards of admission to the medical school, the facilities which the schools must furnish in order effectively to teach the fundamental branches, are the same for all alike. A student of homeopathy or of osteopathy needs to be just as intelligent and mature as a student of scientific medicine; and he is no easier to teach; for during the first and second years, at least, he is supposed to be doing precisely the same things.
At the beginning of the clinical years, the sectarian interposes his special principle. But educationally, the conditions he needs thenceforth do not materially differ from those needed by consistently scientific medicine. Once more, whatever the arbitrary peculiarity of the treatment to be followed, the student cannot be trained to recognize clinical conditions, to distinguish between different clinical conditions, or to follow out a line of treatment, except in the ways previously described in dealing with scientific medicine. He must see patients and must follow their progress, so as to discover what results take place in consequence of the specific measures employed. A sectarian institution, being a school in which students are trained to do particular things, needs the same resources and facilities on the clinical side as a school of scientific medicine.
Sectarian institutions do not exist in Canada; in the United States there are 32 of them, of which 15 are homeopathic, 8 eclectic, 1 physiomedical, and 8 osteopathic. Without attempting to indicate the peculiar tenets of each, we shall briefly review them as schools, seeking to ascertain how far they are in position effectively to teach, quite regardless of the individual doctrine each sect may desire to promote. None of the fifteen homeopathic schools [Hahnemann (San Francisco), Hahnemann and Hering (Chicago), state universities of Iowa and Michigan, Southwestern Homeopathic (Louisville), Boston University, Detroit Homeopathic, Kansas City (Kansas) Hahnemann, New York Medical College for Women, New York Homeopathic, Pulte (Cincinnati),Cleveland Homeopathic, Hahnemann (Philadelphia), Atlantic Medical (Baltimore)] requires more than a high school education for entrance; only five require so much. [State universities of Iowa and Michigan, Detroit Homeopathic, and the two New York schools.] The remaining eleven get less,—how much less depending on their geographical locations rather than on the school's own definition. The Louisville, Kansas City, and Baltimore schools cannot be said to have admission standards in any strict sense at all; Pulte at Cincinnati is bound to be careful in dealing with Ohio candidates: outsiders are responsible for themselves. The minimum at Boston University, to judge from the examinations which, in default of acceptable credentials, the candidate must pass, covers less than two years of a good high school course.
On the laboratory side, though the homeopaths admit the soundness of the scientific position, they have taken no active part in its development. Nowhere in homeopathic institutions, with the exception of one or two departments at Boston University, is there any evidence of progressive scientific work. Even "drug proving" is rarely witnessed. The fundamental assumption of the sect is sacred; and scientific activity cannot proceed where any such interdict is responsible for the spirit of the institution. The homeopathic departments at Iowa and Michigan are in this respect only half-schools,—clinical halves. For their students get their scientific instruction in pathology, anatomy, etc., in the only laboratories which the university devotes to those subjects, under men none of whom sympathizes with homeopathy. Their disadvantage is increased by the fact that the instruction is adapted to students who have had one or two years of college work. The general argument in favor of higher standards is here reinforced by the consideration that the homeopathic students should certainly qualify themselves for the only grade of scientific instruction that the two universities offer.
Of complete homeopathic schools, Boston University, the New York Homeopathic College, and the Hahnemann of Philadelphia alone possess the equipment necessary for the effective routine teaching of the fundamental branches. None of them can employ full-time teachers to any considerable extent. But they possess fairly well-equipped laboratories in anatomy, pathology, bacteriology, and physiology [The Philadelphia Hahnemann is defective in experimental physiology.], a museum showing care and intelligence, and a decent library. Boston University deserves especial commendation for what it has accomplished With its small annual income.
Of the remaining homeopathic schools, four are weak and uneven: the Hahnemann of San Francisco and the Hahnemann of Chicago have small, but not altogether inadequate, equipment for the teaching of chemistry, elementary pathology and bacteriology ;the Cleveland school offers an active course in experimental physiology. Beyond ordinary dissection and elementary chemistry, they offer little else. There is, for example, no experimental physiology in the San Francisco Hahnemann: "the instructor doesn't believe in it;" the Chicago Hahnemann contains a small outfit and a few animals for that subject; the Cleveland equipment for pathology and bacteriology is meager. The New York Homeopathic College for Women is well intentioned, but its means have permitted it to do but little in any direction.
Six schools remain—all utterly hopeless: Hering (Chicago), because it is without plant or resources; the other five [Southwestern (Louisville), Pulte (Cincinnati), Atlantic (Baltimore), and the Detroit and Kansas City schools], because in addition to having nothing, their condition indicates the total unfitness of their managers for any sort of educational responsibility. The buildings are filthy and neglected. At Louisville no branch is properly equipped; in one room, the outfit is limited to a dirty and tattered manikin; in another, a single guinea pig awaits his fate in a cage. At Detroit the dean and secretary "have their offices downtown;" the so-called laboratories are in utter confusion. At Kansas City similar disorder prevails. At the Atlantic Medical appearances are equally bad; to make matters worse, the school has lately omitted the word "homeopathic" from its title so as to gather in students dropped from other Baltimore schools.
In respect to hospital facilities, the University of Michigan, Boston University, and the New York Homeopathic alone command an adequate supply of material, under proper control, though modern teaching methods are not thoroughly utilized even by them. The Iowa school controls a small, but inadequate, hospital. All the others are seriously handicapped by either lack of material or lack of control and in most instances by both. The Hahnemann of San Francisco relies mainly on 30 beds supported by the city and county in a private hospital; the Detroit school is cordially welcome at the Grace Hospital, but less than 60 beds are available, and they are mostly surgical; the Woman's Homeopathic of New York controls a hospital of 35 available beds, mostly surgical [This school has scattered supplementary facilities, as is the way of New York schools.]; the Southwestern (Louisville) and the Cleveland school get one-fifth of the patients that enter the city hospitals of their respective towns, but these hospitals are not equipped or organized with a view to teaching. The Kansas City school holds clinics one day a week at the City Hospital; Pulte (Cincinnati) and the Atlantic (Baltimore) have, as nearly as one can gather, nothing definite at all. Several of the schools appear to be unnecessarily handicapped. The Chicago Hahnemann adjoins a hospital with 60 ward beds. But as the superintendent "doesn't believe in admitting students to wards," there is little or nothing beyond amphitheater teaching. A bridge connects Hering (Chicago) with a homeopathic hospital, but "students are not admitted." The Cleveland school is next door to a hospital with which it was once intimate; their relations have been ruptured. An excellent hospital is connected with the building occupied by the Philadelphia Hahnemann, but there is no ward work.
The dispensary situation is rather worse. Iowa and Ann Arbor have little opportunity. Of the others, Boston University alone has a really model dispensary, comparing favorably in equipment, organization, and conduct with the best institutions of the kind in the country. The New York Homeopathic, the Chicago Hahnemann, and the Philadelphia Hahnemann command material enough. The others lack material, equipment, or care; in some instances,—Atlantic Medical, Pulte, Detroit, Kansas City,—they lack everything that a dispensary should possess.
Financially, the two state university departments and the New York Homeopathic school are the only homeopathic schools whose strength is greater than their fee income. All the others are dependent on tuition. Their outlook for higher entrance standards or improved teaching is, therefore, distinctly unpromising. Only a few of them command tuition fees enough to do anything at all: the Chicago Hahnemann, Boston University, and the Philadelphia Hahnemann, with annual fees ranging between $12,000 and $18,000. Nine of them are hopelessly poor: the San Francisco Hahnemann, Hering (Chicago), the Detroit Homeopathic, and the Atlantic Medical operate on less than $4000' a year; the Southwestern (Louisville) and Pulte (Cincinnati) on less than $1500. [Estimated]
In the year 1900 there were twenty-two homeopathic colleges in the United States; to-day there are fifteen; the total student enrolment has within the same period been cut almost in half, decreasing from 1909 to 1009; the graduating classes have fallen from 418 to 249. [Journal of the American Institute of Homeopathy, vol. i , no. 11, p. 537. The Journal of the American Medical Association, Aug. 14. 1909 (p. 556,557), somewhat lower: 889 instead of 1009; 209 instead of 246. The discrepancy does not alter our interpretation.]
As the country is still poorly supplied with homeopathic physicians, these figures are ominous; for the rise of legal standard must inevitably affect homeopathic practitioners. In the financial weakness of their schools, the further shrinkage of the student body will inhibit first the expansion, then the keeping up, of the sect.
Logically, no other outcome is possible. The ebbing vitality of homeopathic schools is a striking demonstration of the incompatibility of science and dogma. One may begin with science and work through the entire medical curriculum consistently, exposing everything to the same sort of test; or one may begin with a dogmatic assertion and resolutely refuse to entertain anything at variance with it. But one cannot do both. One cannot simultaneously assert science and dogma; one cannot travel half the road under the former banner, in the hope of taking up the latter, too, at the middle of the march. Science, once embraced, will conquer the whole. Homeopathy has two options: one to withdraw into the isolation in which alone any peculiar tenet can maintain itself; the other to put that tenet into the melting-pot. Historically it undoubtedly played an important part in discrediting empirical allopathy. But laboratories of physiology and pharmacology are now doing that work far more effectively than homeopathy; and they are at the same time performing a constructive task for which homeopathy, as such, is unfitted. It will be clear, then, why, when outlining a system of schools for the training of physicians on scientific lines, no specific provision is made for homeopathy. For everything of proved value in homeopathy belongs of right to scientific medicine and is at this moment incorporate in it; nothing else has any footing at all, whether it be of allopathic or homeopathic lineage. "A new school of practitioners has arisen,'" says Dr. Osler, "which cares nothing for homeopathy and less for so-called allopathy. It seeks to study, rationally and scientifically, the action of drugs, old and new.” [Loc. cit ., p. 268]
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In dealing with the medical sectary, society can employ no special device. Certain profound characteristics in one way or another support the medical dissenter: now, the primitive belief in magic crops up in his credulous respect for an impotent drug; again, all other procedure having failed, what is there to lose by flinging one's self upon the mercy of chance? Instincts so profound cannot be abolished by statute. But the limits within which they can play may be so regulated as to forbid alike their commercial and their crudely ignorant exploitation. The law may require that all practitioners of the healing art comply with a rigidly enforced preliminary educational standard; that every school possess the requisite facilities; that every licensed physician demonstrate a practical knowledge of the body and its affections. To these terms no reasonable person can object; the good sense of society can enforce them upon reasonable and unreasonable alike. From medical sects that can live on these conditions, the public will suffer little more harm than it is destined to suffer anyhow from the necessary incompleteness of human knowledge and the necessary defects of human skill.
This article was posted on January 22, 2005.