| IN MY FIRST COLUMN we started to explore some aspects of the central tradition of homeopathy, the approach often referred to as "classical" homeopathy. We looked at two fundamental principles which derive from The Organon, the use of the single dose and the use of the single medicine. We found that Hahnemann's understanding of the concept of the single dose changed in the last three editions of The Organon, and that he moved from advocating long intervals between dry doses (i.e., pillules) to advocating more frequent doses using the "plussing" method, whereby the potency of each dose is raised by one, and pillules are diluted in liquid. But since the Sixth Edition of The Organon was not known until well into the twentieth century, the technique of plussing was passed over, and never became part of the mainstream. The Kentian approach, which was based on the fourth edition of The Organon, became standard. The use of the LM potencies suffered a fate similar to that of plussing, but that's another story.
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We also reviewed the origins of the principle of the single medicine, and the prohibition on the use of more than one medicine at a time in Aphorism 272 of the Sixth Edition. We found that Hahnemann disobeyed his own commandment and often prescribed two medicines at a time in his later years. However, although he revised the parts of The Organon relating to the single dose, he kept the prohibition on the use of more than one medicine at a time right into the Sixth Edition.
Hahnemann's hatred of "polypharmacy" was one of the most fundamental defining characteristics of his thinking. His rejection of the common practices of his time, in which apothecaries mixed together cocktails of many different herbs, lies at the very origins of homeopathy. And yet the use of combinations of homeopathic medicines, and the prescription of several medicines at one time, crept back into homeopathy itself and refuses to go away. One important point of clarification we need to make before proceeding any further is that there are really two issues here, not one. There is a great difference between taking the case and choosing two medicines for an individual patient, based on the totality of symptoms (let us call this dual prescribing) on the one hand, and prescribing a medicine into which a number of single homeopathic medicines have been combined and mixed together by a manufacturer (use of complexes) on the other. In my first column I presented some arguments against dual prescribing, but it is possible to present credible arguments in its favor. Now I want to consider the use of complexes, and here there are fewer convincing defenses. Some Arguments for Prescribing Complexes So what are the arguments in favor of using complexes? In point of fact, these are difficult to come by. Many practitioners have used complexes, but few of the homeopathic masters have had any time for them. The homeopathic literature is almost entirely dominated by "unicists." It is suggestive that nearly all those who have attained the deepest understanding of homeopathy have found themselves drawn down this path. On July 7, 1992, a formal debate took place at the Royal London Homoeopathic Hospital on the motion: "This house believes that the single remedy is the medicine of experience." The debate is an interesting source for understanding some of the important issues, and a transcript was published in the British Homeopathic Journal (RLH, 1993). If we bear in mind the distinction made above, it is evident that most participants were contrasting the use of simplexes as opposed to complexes, and dual prescribing was not really considered, although this is nowhere made explicit. Dr. George Lewith, opposing the motion, argued that there was a place for singles and a place for complexes too: "horses for courses." The use of complexes was common in continental Europe. Modern practitioners faced different problems from those faced by their predecessors: "physiologically and biochemically our problems are different from those which confronted us 200 years ago" (RLH, 1993, page 40). Here it becomes evident that proponents of complexes are focused on the particular form of pathology from which their patients are suffering. A particular pathology, they feel, must require a particular remedy. This is in opposition to one of the central insights of the homeopathic tradition, which is that the nature of the pathology is less important than the nature of the patient. This divergence from homeopathic thinking becomes even clearer as Dr. Lewith goes on to discuss "functional medicine" (RLH, 1993, page 41):
In many ways functional medicine, and that is how I see complex homoeopathy being used, has a great deal in common with conventional medicine. It learns from pathology and microbiology, it learns from organ function. For instance, let us take a case of rheumatoid arthritis in a person who has had a series of recurrent tonsillitis infections in their youth. You will look at this patient and you will say to yourself, `Well, this patient has a malar flush and they've got chronically enlarged tonsils. Somebody forgot to take the tonsils out . . . and I actually think they've probably got a streptococcal toxicity. That is probably what is wrong.' Now a conventional doctor may well be able to make that link, make that diagnosis, but complexes actually give you a treatment handle. Complexes: Curative, Palliative, or even Ineffectual? One can only agree with Dr. Lewith that functional medicine and the use of complexes has a great deal in common with conventional medicine! The poor patient may well have been suffering from a streptococcal toxicity, but by focusing solely on that infection we entirely miss the wider picture. Is it not significant that this particular patient is prone to recurring problems of this kind? What is it about the internal environment of this particular patient that allows these infections to take root, and that prevents the normal immunological processes from dealing with them? (It is somewhat disconcerting to find someone in a homeopathic journal regarding amputation of part of the immune system as a normal treatment for recurring infection.) All of these questions, which are fundamental to understanding the case, are begged by the conventional approach. When homeopathy has opened out to us a wider perspective, why close down again to a narrower one? The living, breathing patient is nowhere to be found in this sort of analysis – he or she is merely the site for an interesting case of streptococcal toxicity. There are other methodological deficiencies of treatment by complexes. While the medicines chosen by a particular company may be correlated to a certain extent with a particular clinical condition, the correlation will usually be a loose one. Perhaps 30% or 40% of patients may respond to one of the ingredients. But what then of the other 60% or 70%? They may end up by getting little or nothing out of the treatment. This is the problem with the shotgun approach. And will the response be curative or palliative? Even if 60% to 70% of patients respond in some way to the complex, then 30% to 40% are still left out, whereas 100% of patients will respond to their indicated single remedy, and furthermore they will be cured. A further problem is that the combinations will come in fixed potencies. As we discussed last issue, there have been different recommendations within classical homeopathy about how to vary potencies, but all authorities have agreed that it is necessary to vary them in some fashion, in order to keep the cure progressing. As the human system seems to desensitize very quickly to a given medicine in a given potency, repeated use of combinations will most probably lead to stagnation of the case even if one or more of the medicines in the combination is acting. Let us look at some actual examples of proprietary complexes. Details are drawn from the Practitioner Handbook, published by the Australian manufacturer and distributor, Brauer Biotherapies (Brauer Biotherapies, n.d.).
Reckeweg formula No. 3 is called Corvosan and is described as "heart drops." The active ingredients are: Arsenicum album 3x,
The indications given are:
The first-listed medicine is one of our greatest polychrests, described (Vermeulen, 1994) as "A profoundly acting remedy on every organ and tissue." Yet here it is being prescribed solely for its actions on the heart. By using it in this way we are moving back into an approach where some of the effects of a prescription are intended and some are unintended, as in conventional medicine. Some of the effects are targeted at the problems the patient is suffering from, and some are targeted at problems the patient does not have, and which are not characteristic of the patient's constitution. This is common in allopathic medicine, but hardly desirable. While some of the ingredients, such as Cactus grandiflorus, Crataegus, Spigelia, are rich in heart-related symptoms, Arsenicum is not. Why include a polychrest that is not particularly well known for the conditions the complex is designed to treat? Why, on the other hand, leave out a medicine such as Ammonium carbonicum, with its well-known tendency to produce weakness of the heart and slowness of circulation? And is it wise to include both Kalmia and Spigelia, which are antidotal to each other? An equivalent in the French Pharmaceutical Codex range is 126 Stropanthus F.P.C., which (again according to Brauer Biotherapies, n.d.) includes: Aurum muriaticum natronatum 4x,
The indications given are:
There is considerable overlap in the choice of ingredients in the two formulas, yet the indications are very different. One attempts to treat cardiac weakness, one attempts to sedate the heart. And Cactus and Valeriana are antidoted by Camphor. Is Precision Possible in Prescribing Complexes? Who decides what shall go into these complexes, and on what basis? All knowledge of the properties of our medicines is based on knowledge of the symptoms produced in the provings of simplexes, and symptoms observed by the masters of the past in their clinical use of simplexes. To make up a complex, it is necessary to translate from this classical homeopathic language, which focuses on patterns of symptoms, to another language, which focuses on pathology or malfunctions of organs. The result can easily be a dog's breakfast (or, in certain parts of the world, a pig's breakfast). But one thing is sure: There is no credible set of precise principles for selecting medicines to go into a complex. As prescribers, how would we distinguish between the indications for the Reckeweg formula and those for the French formula? Or would we use either indifferently for any type of heart complaints? The indications lack the precision of either conventional diagnosis or homeopathic symptoms. They are simply vague. To use complexes, we must resort to classifying our patients according to pseudo-conventional categories such as these. But there is no certain basis for drawing links between homeopathic information and such categories. My view is that if we are going to use homeopathic medicines, we should be using homeopathic categories: situating our patients in relation to the patterns of symptoms that are known to be related to individual medicines. This opens the way to matching the deep nature of the patient with the deep nature of a medicine. This is the approach that can lead to radical cures. The proponents of complexes in the London debate, by contrast, seem content to achieve symptomatic relief, like their allopathic colleagues. Now one can argue that symptomatic relief, or relief of pain, is better than nothing. There may indeed be occasions where action has to be taken quickly, and there is no time to consider all the multiple points of reference which are necessary in order to match a constitutional remedy to the totality of the patient. So there is perhaps room for a little flexibility, and acknowledgment of the exigencies of daily practice. On the other hand, this should not lead into a readiness to take shortcuts, when the opportunity was in fact there to make a much more searching analysis of the case and an accurate choice of a constitutional medicine. Let us not take the pressure off ourselves, and let us keep trying to achieve the optimal result wherever possible. To quote Hahnemann, in Aphorism 2 (Hahnemann, 1988):
The highest ideal of cure is rapid, gentle and permanent restoration of the health, or removal and annihilation of the disease in its whole extent, in the shortest, most reliable, and most harmless way, on easily comprehensible principles. A Critique of Some Published Arguments for Using Complexes One of the few eminent homeopaths to have publicly advocated the use of complexes is Dana Ullman. It is worthwhile pausing for a moment to consider some of his arguments, as he has mounted a serious case. Some months ago, controversy broke out on the homeopathy mailing list on the subject of complexes, and Ullman intervened with some reflections and an excerpt from his latest book, The Consumer's Guide to Homeopathy, The Definitive Resource for Understanding Homeopathic Medicine and Making It Work for You (Ullman, 1995). (Editor's note: The Consumer's Guide to Homeopathy is reviewed in this issue of Homeopathy Online on the Reviews page.) One of the most common arguments against complexes is that their effects are essentially unknown, as, although the individual remedies contained in the complex may have been proved, the complex itself has not been proved. Ullman countered by arguing that a fresh proving would only be necessary if the manufacturers mixed several medicines together before potentization, thus creating a new remedy. If several remedies are mixed together after potentization then the resulting complex is merely the sum of its individual parts, and not a new medicine as such. This is a reasonable argument, but it is directly contradictory to a passage which follows, quoted from Ullman's book, which argues that in herbal traditions, including Chinese medicine, use is commonly made of formulas of several ingredients: "The use of these mixtures has consistently shown that there is a synergistic action when certain ingredients are mixed together which creates greater benefit than the use of single herbs." This would seem to imply that a complex is, in fact, a new medicine, and is more than the sum of its parts. Leaving aside the contradiction, what are we to make of this argument? I have two problems with it. First, herbal medicine and homeopathy are two entirely different paradigms of health and disease, and pharmacology. Second, the existence of such synergies is entirely speculative in the case of homeopathy, even if it could be demonstrated for herbalism. Ullman goes on to point out that several controlled trials have shown the efficacy of homeopathic complexes for a number of conditions. Here he is on safer ground, and it is certainly true that there have been a number of positive trials of complexes. Only limited conclusions can be drawn from controlled trials, however, as I have argued elsewhere (Tomlinson, 1995, pages 8-11). Trials ask very limited questions, about the effect of a particular treatment on a restricted number of clinical parameters, and hence can only give limited answers. They cannot tell us whether the patient benefited overall from a given treatment, and this is the most important question of all. Ullman goes on again to give examples of the successful use of combinations of Arnica montana, Hypericum perforatum, Symphytum officianale and Ruta graveolens in treatment of injuries. He maintains that the use of such multiple prescriptions, and even complexes, in the treatment of injuries can be more successful than using only one medicine. This seems quite reasonable. It is not hard to imagine that a severe knee injury, say, from a bashing, might need both Arnica, to help repair of the soft tissues, and Symphytum to help bone repair, and that these might be given together. Ullman makes a plea for tolerance in the homeopathic community and asks us to refrain from hostile attacks on anyone who deviates from homeopathic orthodoxy. Here I agree with him completely. I think we can only lose from defensive thinking and rejection of dissident opinions. On the other hand we are also bound to keep evaluating rigorously everyone's contributions to the continuing homeopathic debate (including mine, of course), and trying to reach a clearer picture of what is best practice. I would agree that there is a place for off-the-shelf complexes for members of the public to self-treat common conditions. Many people may become familiar with homeopathy in the first instance through such products, and go on to consult homeopaths and receive first-class classical treatment. I am happy to accept, too, that dual prescriptions and maybe even complexes might have a role to play in cases of injuries, where the influence of an external violent influence has been paramount. However, I believe that the great majority of patients who come to practitioners for treatment are laboring under chronic problems which have their origins at a fundamental level. Only holistic assessment of the case and treatment with a fundamental medicine will lead to optimal results in these cases.
While symptomatic relief may be better than nothing, we should always aspire to do better. We should always aspire to achieve that highest level of cure which the founder of our science set out to achieve two centuries ago. References
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