Importance of Therapeutic Strategies in Homeopathic Management

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Abstract:

A Therapeutic Strategy can be defined as a plan of action, a methodology within a philosophical conceptualization and structure, based on clear principles to guide decision and action. Homeopathic symptoms are observed as a picture of disease that can be formulated into a Totality of symptoms, based on the presentation of characteristic symptoms. This presentation of symptoms is individual to every case. The perception of the totality so formed forms the basic building block indicating an appropriate remedy, plan of action and long term management. This forms the Therapeutic Strategy, the construction of appropriate homeopathic methodology as a general yet replicable action plan for case management and cure.

Two established homeopathic therapeutic strategies are examined for their reliability:

Von Boenninghausen in 1846, supported by Hahnemann, constructed his Therapeutic Strategy compiled into his Therapeutic Pocket Book that contained all necessary instructions for a homeopath to succeed in this endeavor.

Dr. CM Boger, MD, in 1915 constructed his Therapeutic Strategy of Pathogenesis in remedy and disease, compiled into his book, A Synoptic Key of the Materia Medica. It also contains a detailed understanding and instruction on his methodology.

The author investigates the philosophy behind these methodologies, for their completeness, in contrast to newer incomplete or almost fanciful methods, that fall short of criteria necessary for a reliable therapeutic strategy.

Both the methodologies discussed could also foray confidently into the realms of homeopathic research (Dean, 2007) and homeopathic hospital protocol as they are strategies that are foundational to evolutionary development, without watering down the basic homeopathic principles and components on which they are based.

Introduction:

This work identifies areas of inadequate development in homeopathic practice and suggests key therapeutic strategies that overcome these inadequacies for successful homeopathic practice. A reliable therapeutic strategy is a methodology providing a clear structure and direction for case analysis and management of a patient at every stage of disease.

Well established strategies are investigated for authenticity in satisfying homeopathic principles (Kent,1905: 292) established by Hahnemann in his key texts [Organon (1921), The Chronic Diseases (1896)]. The relevance of these strategies in the present dominant scientific (medical) paradigm, allowing for both scientific study and the flexibility of the art, is investigated.

Homeopathy lends itself to a variety of perceptions, both scientific (Oberbaum et al, 2003) and esoteric (Walach, 1999), which has lead to a global confusion and misrepresentation of what is fundamentally homeopathic. Many homeopaths remain either confused or misguided in therapeutic strategy. Science in general and the medical profession in particular still remain unconvinced about the reliability and effectiveness of homeopathy. Without ‘evidence’ (Goldenberg, 2005) the inclusion of homeopathy into health care systems is uncertain (Dobrow et al, 2004). The need today is to present its principles through accepted ontological, epistemological and research criteria (Oberbaum et al, 2003).

Inadequacies in Homeopathic Therapeutic Strategy

A clear therapeutic strategy is the backbone to homeopathic practice. Students, after graduation, are often unsupported in finding their way through a maze of disease diagnosis, symptom pictures, changing clinical expressions and pathology. They are unaware of the direction to take following a case to cure, or to critically evaluate whether their therapeutic application has been truly homeopathic or merely symptomatic or antipathic (Hahnemann, 1921: $71, p.). Various recent developments and methods in vogue seem to obsessively driven towards finding a simillimum remedy solely for chronic conditions. The question, “What happens next?” is often answered in a cursory manner: “The patient said s/he felt better” or “we get results”, neither of which imply that relief is in a curative direction. Homeopathic remedy analysis does not stop with the choice of the first simillimum. Often the first remedy may be inaccurate or else move the process of cure through one phase only. Again, the question arises, “what happens next?”. Here a majority of homeopaths falter when their perception is either limited to finding that single most important simillimum, the cure for all conditions (Sankaran, 1991) or else frequently changing synthetic similimums (Scholten, 1996) that do not seem to get a curative hold of the case. Miasmatic diseases or complex chronic problems or acute changing clinical conditions have not been adequately managed with these approaches, as there is no strategy in place to guide the next course of action in management and remedy choice. Hahnemann’s theory of Chronic Diseases (1896) was actually a solution to this very same homeopathic problem that he perceived as early as 1819 and worked on for 12 years. (Hahnemann, 1920: Aph 80 footnote)

Totality: Hahnemann, after 60 years of successful clinical work in homeopathy, continued to maintain in the Organon (1921, $7) the importance of perceiving the totality as the corner stone of homeopathic management. He described it as the picture of characteristic symptoms indicating the curative remedy that the ‘vital force’ ($9), the animating power in living beings, makes available to our trained senses, for the purpose of cure. He states: “Now, as in a disease ……………. and, moreover, the totality of these its symptoms, of this outwardly reflected picture of the internal essence of the disease, that is, of the affection of the vital force,…. the totality2 of the symptoms must be the principal, indeed the only thing the physician has to take note of in every case of disease and to remove by means of his art (emphasis added), in order that it shall be cured and transformed into health.” Samuel Hahnemann, 1921, $7:95-96

Roberts (1935) understood that:

“The Totality, in homeopathic practice, is the true diagnosis of disease and at the same time the diagnosis of the remedy.”HA Roberts, 1935: 16

“… the Totality is an abstract form … of artificial disease so arranged as to have an individuality of its own.” HA Roberts, 1935: 14

Roberts clarified that the conceptual totality formed by the homeopath remains flexible, depending on the individual presentation and balance of characteristics in the patient at different points of time.

This paper proposes that a reliable therapeutic strategy follows a perception of “Totality” as a foundational building block where:

• Remedy perception and analysis is visualized through that totality structure. • Defines clear clinical areas of remedy application for various disease presentations • Supports long term clinical management and ongoing remedy selection including antimiasmatic remedies, perceived through various totality presentations. • Demonstrates a direction of CURE (Organon 1921, $1,$2, $71)

A case of Prolapse Intervertebral Disc (PID) or Slip Disc requires both chronic case analysis of general mental and physical characteristics for a constitutional remedy, as well as acute symptom picture indicating a superficial pain relieving remedy. E.g. Lycopodium as constitutional; Rhus Tox as acutely indicated remedy. Two different totalities (acute and chronic) are perceived, for two remedies at different levels of similarity (Clarke, 2006). One without the other is an incomplete therapeutic strategy for the clinical management.

The acute pain resolves to some extent with the acute remedy, and is followed or supported by the constitutional remedy (Lyco) indicated which prevents the recurrence of the PID, while at the same time brings up past suppressed conditions for appropriate cure (REF). Old sore throats, gastric disturbances, joint pains, etc may recur. How do we evaluate cure in this maze of symptom expression unless we have a clear concept of why these symptoms are recurring? A strategically un-indicated, suppressive prescription (usually palliative) here would bring back the PID in full force.

Based on Hering’s Laws (Vijaykar, 2003) or levels (Vithoulas, 1980) of disease progression and miasmatic progression (D’souza, 2006), we can know whether the intercurrent remedies chosen are truly curing or suppressing/palliating the expression of symptoms while internal disturbance continues to progress unabated (Hahnemann, 1896) to erupt later in deeper disease manifestation like cancer or destructive disease in vital organs (heart, brain, liver).

This evaluation includes perceiving drug disease and miasmatic inherited diathesis when their totalities present themselves, as blocks to the simple direction of cure, and must be prescribed for accurately. These may lead to a longer timeframe than expected needing intercurrent remedies, related to the curative remedies prescribed, as complementary. These relationships were first observed by Boennighausen (1846).

Therapeutic Strategy or Methodology:

Basic to the methodology used for remedy choice and clinical management is the totality perception. Some well known approaches are in Table 1 below.

(DEAR EDITOR, THIS SHOULD BE A TABLE FORMAT) Totality perception Originator, Year Therapeutic Strategy One grand symptom of LSMC Boenninghausen, 1846 Complete but limited application in chronic psychological conditions Hierarchy of Mental, Physical General, Particular Kent, 1900 Complete but limited to complete case presentations Miasmatic Totality JF Allen, 1908 Complete as a complement to therapeutic strategies Pathogenetic Symptom Complex Boger, 1915 Complete application in most conditions Core Delusion Sankaran, 1991 Incomplete ie limited to first prescription and psychosomatic diseases Essence and Layers/Levels of Disease Vithoulkas, 1995-97 Complete in most conditions Synthetic Totality with Periodic Table Scholten, 1996 Incomplete I.e. direction of cure undefined Vital sensation and levels Sankaran, 2004 Incomplete ie direction of cure undefined Genetic Chronic Similimum/ Acute totality Vijayakar, 2003 Complete in most conditions

Table 1: Analysis of some therapeutic strategies

An incomplete therapeutic strategy does not address the myriad of disease progress, deviation and suppression. Treatment remains incomplete over a period of years, and the answer to “what next?” is not formulated. Incomplete treatment methods have various fall-outs. The impression both practitioner and patient have is that homeopathy is not capable of handling certain pathologies so alternative therapies need to be considered, or else exotic remedies are needed. These methods may also give a false impression that one single remedy is adequate to cure all disease a person suffers from. They fail to account for partial actions of a remedy.

Diseases curable with clear strategy over time, may be instead considered incurable if the ‘ultimate’ simillimum is not found, a misconception. Homeopathic management is more than finding a single similimum. Partial simillimums can lead to cure if management accurately observes change in symptom pictures indicating a succession of remedies and progress is observed in a curative direction. The basic constitutional simillimum remedy ultimately becomes clearly apparent.

For example: A psychosomatic case followed up over the last 6 years is a lady, 45 yrs of age, with complicated chronically suppressed emotional expression in a deeply sycotic miasmatic expression was first given Calc Sulph based on the initial totality, for about 6 months. Soon the miasmatic totality of Thuja developed emotionally and physically, and was needed for 8 months. Following this, a totality of Natrum Mur became apparent for another year. The next totality that came up was Germanium that helped clear chronic emotional issues over 1 year. It then made the patient feel very emotionally friable and vulnerable and she refused to repeat another dose. She next developed hemorrhoids with fissures, she had first had in her teens. Lycopodium helped her out for 6 months. Following this, a totality of constipation she had suffered from as a child of 5, reared its head in the direction of cure. She began to describe the emotional trauma she suffered as a child being given enema’s in public view – shame, fear. The remedy given for this phase was Opium which she is on now. We await the totality her basic constitutional state, which can be expected next.

The clearly changing symptom picture/totality indicated remedy change. The time line unfolding itself in the direction of cure, moves from advanced sycotic miasm into psoric expression. We reach the point of severely suppressed childhood emotional trauma which pushed the child into an Opium state, and then onwards to fractured personality development. Once the Opium state is healed we await the basic constitutional remedy state.

Homeopathic instruction at the graduate level could reinforce homeopaths for clinical practice through complete therapeutic strategies based on established and reliable methodology allowing them to manage a variety of clinical situations confidently. Most modern methods mentioned earlier though incomplete in methodology could complement established strategies for greater accuracy. But the fact remains that they require further development on clear homeopathic principles, whatever their “modern approach”, which should be the future endeavor of their originators.

Boennighausen’s Methodology

Roberts (1935: 20) stated that the structure of the Boenninghausen totality is one grand symptom - the complete symptom of the patient from whom four components (LSMC) must be accurately obtained for scientific classification: • Location: part, organ, tissues involved. • Sensation: pain or description of feeling in functional or organic change. • Modality: which includes causative factors – emotional and physical • Concomitant: the “attending circumstance” occurring at the same time with no rational explanation; includes an analysis of the Mental State.

Boenninghausen constructed his repertory, The Therapeutic Pocket Book (TPB) in 1846, to support this analysis, founded on 2 doctrines: The doctrine of concomitants: The concomitant symptom is often crucial to remedy choice. The doctrine of analogy: Boenninghausen found “numerous gaps” (1846: vi) with “incompleteness of symptoms” from provings and from patients. Wanting to overcome these two problems, he suggested the concept of analogy, confirmed by experience, that whenever observations were missing in a particular area, they could validly be inferred from the characteristic expression of sensation and/or modalities in another area of the body. This opened his understanding to a "wide field of (symptom) combinations which hitherto had never been trodden" (1846: vi). This allows for great flexibility in totality perception that focuses on individual expression matched with remedy characteristics, without preconceived notions about remedies and personalities. Boenninghausen explained the concept of “secondary or alternating effects” (1846: v, ix), where the same modality would aggravate as well as ameliorate, in different degrees, in the same remedy. eg: < motion, > motion. Alternating effects were secondary symptoms of inferior worth, also termed contradictory modalities (1846: i, ix). These assist in confirming/rejecting remedies. The grade of the modality when matched with its intensity in the patient should coincide or else the remedy is contraindicated.

Boenninghausen’s Therapeutic Strategy

The TPB construction supports a 5 component Totality for a remedy choice. The grading of symptoms in the TPB gives a value to each remedy in a rubric based on provings and clinical confirmation. This supports remedy choice. Relief in symptoms, wellbeing is then followed by re-analysis of left over symptoms. A remedy complementary to the previous one is chosen, based on the Concordance in the TPB. A sequence of simillimum remedies are prescribed in chronic cases (Boenninghausen, 1846: x). He (1861) also made use of antimiasmatic remedied when indicated. With this totality perception an acute prescription takes under 5 minutes, a chronic prescription – 15 minutes. Boenninghausen’s purpose that the TPB helps beginners easily find a simillimum at the bedside (Boenninghausen, 1846: x) was served. Obscure chronic cases with a paucity of symptoms; lack of mental symptoms; those with peculiar symptoms or characteristic modalities can be taken towards complete cure using this methodology.

Boenninghausen has his fair share of criticism. One of these was that the Doctrine of Analogy distorted proving symptoms to make them unrecognizable. Boenninghausen responded that generalization completed symptoms following which reliable CLINICAL symptoms were obtained in documented cases. It resulted in a “wide field of combinations” (Benninghausen, 1846: vi) within the scope of a remedy. Another valid criticism was that mental symptoms were not emphasized as expected by the Organon while the Kentian approach relied heavily on understanding the mental state. Boenninghausen chose this lack of emphasis for the benefit of beginners who may not accurately perceive the subjective mental state. In holistic medicine, he felt, the mental state and somatic state equally express the central disease (Boenninghausen, 1846: viii).

In terms of therapeutic strategy, the inadequacy is in the unclear direction of cure. Boenninghausen did not stress on perception of cure or miasmatic progression or evolution, but it is apparent that these later developments of theory, moving onward to hospital protocol, emergency and research sit easily on a strong fundamental base of Boenninghausen’s totality perception. Also the Boenninghausen totality can be supported and confirmed by various newer remedy perceptions like core delusions (Sanakran, 1991), emphasized mental state (Kent, 1900) or synthetic totality based on themes (Scholten, 1996) for an accurate simillimum.

The reliability and flexibility of Boenninghausen’s therapeutic strategy is evident. It requires the presenting totality to be complete with characteristics, by analogy if necessary, reflecting the internal disease state, with or without emphasis on the mental state. This choice is supported by the concordances of remedies with a natural affinity towards each other. Eye-witnesses accounts (Dunham, 1877) confirm Boenninghausen’s extremely successful practice in managing all including serious diseases.

Boger’s Methodology

Dr. CM Boger, a master clinician, was considered “the dean of the homeopathic profession” (1964, Preface to 1st Ed). He treated complicated cases with advanced pathology for over 25 years before he articulated his PATHOGENETIC TOTALITY in his Synoptic Key (1915).

Boger articulated the pathogenetic expression of the remedy .By pathogenetic, he meant the pathological scope of action a remedy had on various tissues of the body, some with a scope on particular physiological systems (genital system, digestive system, nervous system, etc) others on particular types of tissue (endocrine, nerves, mucous membrane, etc).

“One perceives remedies by their general expression or genius. We learn our remedies by their air or personality; an every changing composite effect, but always reflecting the same motive.” C.M. Boger, 1915

There is a strain, a pattern that runs through every pathogenetic symptom complex. This he termed the "GENIUS" of the remedy. The arrangement of symptoms in every remedy in his Synoptic Key brings this idea into greater emphasis. After the patient tells his story, the pathogenetic symptom complex can be “amplified and more accurately determined” (Boger, 1915) by structuring the totality with various characteristic expressions in a predetermined format that could be easily compared to the pathogenetic totality in a remedy.

On the basis of his vast experience, he decided on 5 components with sub-components of this totality: A. Modalities: 1. Causation 2. time 3. temperature 4. weather/Open Air 5. posture 6. Motion 7. eating and drinking 8. Sleep 9. If alone 10. pressure/touch 11. Discharges

B. Mental State: especially: 1. Irritability 2. Sadness 3. Fear 4. Placidity

C. Sensations:

Listen to the patients’ own description of sensations
1. Burning 2. Cramping 3. Cutting 4. Bursting  5. Soreness 6. Throbbing 7. Thirst

D. Objective Observations: The distressed vital force uses the oldest and most universal language in the world, the Sign Language. (Boger, 1964a: 21) 1. Demeanour: (behaviour, conduct); manner - a way of acting 2. Restlessness/ Torpor: A state of mental or physical insensibility 3. Nervous Excitability/ Sensibility: mental or emotional responsiveness; receptiveness to impressions 4. Facial Expression 5. Secretions: description/appearance 6. Colour 7. Odour E. Location: Part Affected: Organs, right/left side Linking this totality with clinical diagnosis and investigations, determines remedy choice and management.

Boger’s Therapeutic Strategy:

Boger describes in the foreword of his Synoptic Key (1915) the pathogenetic totality required from the patient. Appropriate rubrics are found to contour the disease picture and match it with a remedy. The differentiating factor for remedy choice may belong to any rubric. Cure may be hampered by laying too much stress on some particular (mental or physical or diagnosis) factor at the expense of the disease picture as a whole, thus destroying its SYMMETRY and forming a distorted conception of the natural image of the sickness.

After the simillimum, if there is little or no reaction to a remedy, the analysis is: a) Selection faulty b) Miasmatic block requiring Psorinum, Sulph, Medorrhinum or Syphilinum (Boger, 1964b: 42). Advising regarding the group of Inveterate Diseases (Boger, 1964b: 40-42), he stressed that when beneficial response is seen, do not change the remedy if new symptoms come up. Repeat it in a higher potency or change the potency scale first. Wait for a fairly definite new symptom totality to choose the remedy successor. He reminds us that the possibilities following the contact of the simillimum with the disordered vital force can never be foreknown, hence utmost care is needed in selecting the simillimum. An acute remedy is almost always followed by the constitutional remedy. (Boger, 1964b: 38) Disease cure follows Hering’s Law of Cure (Boger, 1964c: 69) and Miasmatic Cure (Boger, 1964c: 62)

Hence we see that Boger discussed most of the clinical possibilities that one encountered in practice, and suggested adequate strategy explanations that are in line with Hahnemann’s instructions in the Organon (1920) and Chronic Diseases (1896). He even suggested that studying this methodology allows one to prescribe in medical emergencies and for infants (Boger, 1964d: 76) The Dhawle Symposium (Kasad, 2003:D2) perceived a further development of his methodology. Here, disease progress is assessed at 3 levels: 1. State of the individual: Health à Diathesis à Disease 2. Phase of disease expression: Prodrome à Functional à Structural 3. Miasmatic evolution: Psora à Sycosis à Syphilis Analysis of the totality includes observing the pathogenesis of disease in an individual at a particular point of time, in FORM (disease symptoms), FUNCTION (affected physiological function) and STRUCTURE (extent of tissue change) over TIME. This must match the pathogenetic symptom complex of the remedy chosen to ensure the closest curative simillimum. Barvalia (2006) while describing this analysis in the case of pancreatitis (Cases 2006c:2) explains how it can be integrated easily and wisely with complementary support from Modern Medicine.

Homeopathic Hospital Protocol and Research Strategy (LINK HERE)

Conclusion:

Both Boenninghausen and Boger established systems of therapeutic strategies developed on clear homeopathic principles and understanding of health and disease. Their development was modified on constructive criticism from peers. This helped achieve a high standard of methodology based on repeated clinical experience.

Their future is in further application in the developing sphere of homeopathic research with support from established research methodology in other fields, modified for homeopathic purposes.

Besides, these two methodologies have stood the test of time (over 100 years) in their reliability and clinical application, even alongside developments in Modern Medicine. This is documented in clinics and hospitals of the Dhawle’s ICR (Pavaskar, 2006). Hospital Protocol requires a healthy and wise collaboration of supportive advances in modern medicine and health care that is complementary (Barvalia, 2006:1), without compromising on homeopathic principles.

Homeopathy is on the threshold of developing, in the New Millennium, as a serious alternative to Modern Medicine.

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