CHAPTER 24 HOMEOPATHY
Homeopathy is a highly systematized method of healing that follows the principle “use likes to treat likes” and is practiced by licensed physicians and other health care professionals throughout the world. In the United States, homeopathic medicines are protected by federal law, and most are available over the counter. Among the many challenges that homeopathy poses to conventional medicine and science, the greatest may be the common use of extremely diluted medicinal substances.
HISTORY
The homeopathic method was developed by Samuel Hahnemann, MD (1755-1843), a German physician, chemist, and author of a well-known textbook on the preparation and use of contemporary medicines (Figure 24-1). In a series of experiments conducted from 1790 to 1810, Hahnemann demonstrated that (1) medicinal substances each elicit a pattern of signs and symptoms in healthy people, and (2) the medicine whose symptom pattern most closely resembles that of the illness being treated is the one most likely to initiate a curative response for that patient (Hahnemann, 1833).
Figure 24-1 Samuel Hahnemann’s remedy box. Many homeopaths kept their remedies in a similar box, but few had one that was so splendid.
(From Richardson S: Homeopathy: the illustrated guide.)
Hahnemann understood these experiments to mean that the outward manifestations of illness represent the concerted attempt of an organism to heal itself and that the corresponding remedy reinforces that attempt in some way. He coined the term homeopathy to describe his method of using remedies with the power to resonate with the illness as a whole, in contrast to the more conventional method of opposing symptoms with superior force.
The word homeopathy is derived from the Greek roots omoios, meaning “similar,” and pathos, meaning “feeling.” Hahnemann also began using allopathy, from the Greek alloios, meaning “other,” to denote the standard practice of using medicines either to counteract symptoms or to produce an action unrelated to symptoms, such as purging, bloodletting, or blistering of the skin.
Hippocrates, Celsus, Paracelsus, and others advocated treatment with “similars” for some patients. Hahnemann credited his teacher, Quarin, as the source of his own medical capabilities. Quarin’s teacher, Stoerck, advocated testing drugs for their “like” effects: “If stramonium makes the healthy mentally sick through a confusion of the mind, why should one not determine whether it gives mental health in that it disturbs and alters the thoughts and sense in mental disease, and that if it gives health to those with spasms, to try and see if, on the other hand, they get spasms” (Stoerck, 1762).
Hahnemann was the first to base an entire therapeutic approach on the “likes cure likes” methodology. He believed that the detailed correspondence between the clinical symptoms of patients and the experimental pathogenesis of remedies reflected a universal law of healing with medicinal substances. His development of such a rigorous system integrating a medical philosophy, formalized drug testing, and protocols for clinical application is a unique achievement in medical history.
The Hahnemannian law of similars—similia similibus curaentur, or “Let likes be cured by likes”—never gained general acceptance in medicine and is considered implausible to most physicians. Even committed homeopaths regard it as a mystery not yet explained or proved. This tolerance of uncertainty is consistent with Hahnemann’s commitment to the belief that theory must always be secondary to the patient’s clinical benefit.
THEORETICAL BASIS
The physician’s highest calling, his only calling, is to make sick people healthy—to heal, as it is termed.
In the opening line of the founding document of homeopathy Hahnemann forcefully establishes that the practical impact of any therapy on the patient’s well-being is its sole importance. Although he goes on to elaborate the lesser significance of developing of theoretical systems, ironically many physicians and patients have been drawn to homeopathy precisely because of their attraction to the distinctive and internally consistent theoretical constructs of homeopathic medicine (Astin, 1998; Clark et al, 2008). The homeopathic view of the primacy of an inner world paralleling the common one is a familiar and appealing concept stretching across many religious and spiritual traditions, as well as more recent conceptualizations of an “energy” basis to biological organisms. Homeopathy’s foundation is a radical innovation in the experimental investigation of medicinal substances. Its cardinal principles follow logically from the law of similars and the conceptual transformations required to accommodate this law.
The theory of like cures like is supported by the concept that a symptom represents the body’s physiological response to an illness or disease in the effort to maintain homeostasis and to help heal or cure that illness or disease. For example, a fever is the physiological response to infection with pyrogenic bacteria. Elevated body temperature slows the rate of reproduction of bacteria (see Figure 1-1). Therefore, a fever is literally bacteriostatic. It was the bacteriostatic properties of early antibiotics that provided an elegant mechanism for treating infection, which resulted in the “miracle drugs” of the twentieth century.
With either fever or antibiotics, the immune system must still overcome the infection. These agents just give the body a chance to catch up by generating white blood cells faster than the bacteria can generate more bacterial cells. Thus a fever can be seen as nature’s antibiotic. In the natural history of an infection, when a fever “breaks” it is a sign that the infection is being overcome. In a “healing crisis” the potentiation of a symptom like fever by a homeopathic remedy may be a means to cure.
Provings
In 1790, while experimenting with cinchona (Peruvian bark), Hahnemann decided to ingest a therapeutic dose because he was frustrated by the conventional explanation of its medicinal action. Cinchona bark, also known as “Spanish bark” or “Jesuit bark,” was brought back to Europe from South America, where it was used indigenously to treat remittent fevers.
It later became the source of quinine to treat malaria and quinidine to treat heart conditions. As a natural remedy with synergistic properties it remains effective against chloroquine-resistant malaria today (see Chapter 38).In Hahnemann’s early experiments with cinchona, he soon experienced feelings of cold, numbness, drowsiness, thirst, and anxiety, as well as palpitations, prostration, and aching bones. He recognized these as the exact symptoms of ague, or intermittent fever, the syndrome that was then being treated with cinchona (Bradford, 1895). He allowed the effects of the dose to wear off before taking a second and a third dose, which confirmed his original observation that a natural substance that treated the disease also produced the same symptoms as the disease—or like cures like. The prevailing treatment of ague, familiar to modern readers as malaria, continued to be an extract of the cinchona tree (quinine) until recent times.
Hahnemann recognized this response as a confirmation of principles taught in Hippocratic writings and by Paracelsus. Excited by the possibilities of a fuller application of the approach, Hahnemann devoted the rest of his life to ascertaining the therapeutic properties of medicinal substances by administering them to healthy people: himself, his colleagues, and his students. His Materia Medica Pura records the detailed symptoms of more than 90 medicines, a monumental achievement that represents 20 years of painstaking labor (Hahnemann, 1833, 1880).
In these provings, as he called them, Hahnemann administered the substance in question to a group of reasonably healthy people in doses sufficient to elicit symptoms without provoking irreversible toxicity, anatomical changes, or organic damage. These experiments developed a unique composite portrait, or “symptom picture,” for each substance. Therefore the homeopathic understanding of a medicinal substance, or “remedy,” is a shorthand sum of the responses of all people who have taken that substance, a distinctive totality that must be studied as a whole and for its own sake, rather than simply as a weapon against a particular disease or a group of symptoms.
The Vital Force
Like acupuncture, herbalism, and other natural methods, homeopathy belongs to the vitalist tradition in medicine, based on the old vis medicatrix naturae, the natural healing capacity, and summarized in the aphorisms of Paracelsus, as follows:
The art of healing comes from Nature, not the physician. . . . Every illness has its own remedy within itself. . . . A man could not be born alive and healthy were there not already a Physician hidden in him. (Jacobi, 1958)
Underlying these approaches is a coherent philosophy of ancient lineage (traced elsewhere in this book), the precepts of which still ring true despite modern efforts to ignore or surpass them (Box 24-1).
Within homeopathy, curative remedies imitate and therefore resonate with manifested signs and symptoms. Illness is viewed as the organism’s attempt to heal itself. Hahnemann identified the life energy itself (the vital force) as the ultimate source of health and illness alike, ending only with the death of the organism. Hahnemann described his process of preparing remedies by sequentially diluting and shaking them (see later) as liberating the essence of the remedy from its material aspects and thereby increasing its potency. Whatever we choose to call it, some version of the vital force is required to refer to the bioenergetic integrity of living beings.
THE HOMEOPATHIC MATERIA MEDICA
The Hahnemannian concept of medicinal action remains the most distinctive contribution of homeopathy to medical science, with implications for pharmacology, ethnobotany, and industrial medicine and toxicology. Without recourse to pathological models or unconsenting animal subjects, provings offer a purely experimental technique for investigating the medicinal action of any substance.
The homeopathic pharmacopeia currently recognizes more than 2000 remedies, with more added all the time. Most are of plant origin, including flowers, leaves, roots, barks, fruits, and resins. Although many are poisonous in their crude state (e.g., aconite, belladonna, digitalis, ergot, hellebore, nux vomica), others are common medicinal herbs (comfrey, eyebright, mullein, yellow dock); foods and spices (cayenne, garlic, mustard, onion); fragrances, resins, and residues (amber, petroleum, charcoal, creosote); and mushrooms, lichens, and mosses.
Mineral remedies include metals (copper, gold, lead, tin, zinc), metalloids (antimony, arsenic, selenium), salts (calcium sulfate, potassium carbonate, sodium chloride), alkalis, acids (hydrochloric, nitric, phosphoric, sulfuric), elemental substances (carbon, hydrogen, iodine, phosphorus, sulfur), and constituents of the earth’s crust (silica, aluminum oxide, ores, rocks, lavas, mineral waters).
Remedies from the animal kingdom include venoms (from jellyfish, insects, spiders, molluscs, crustaceans, fish, amphibians, snakes); secretions (ambergris, cuttlefish ink, musk); milks, hormones, and glandular or tissue extracts (sarcodes); entire creatures (Apis mellifera, or honeybee; tarantula); and nosodes, or products of diseases (tuberculosis, gonorrhea, syphilis, abscesses) and vaccines.
The investigative method of provings is equally applicable to the study of conventional drugs, unproven folk remedies, toxic or laboratory chemicals, pollutants, and commercial or industrial products (dyes, insecticides, paints, solvents). Some homeopaths have extended the method to create and test remedies made from such surprising sources as the poles of the magnet and Coca-Cola (although today’s formula is a secret, the original 1885 recipe created by Dr. John Pemberton, a physician in Atlanta, included extracts of coca leaf –including cocaine—and caffeine-rich kola nut [see Chapter 1]). The homeopathic materia medica is as boundless as the creation of the earth and as inexhaustible as its transformation by human or environmental forces.
Finally, the richness and diversity of the materia medica database increases the likelihood that some degree of medicinal help can be found for most people. At the same time, its basic principles are simple enough that even a novice can achieve some results with a small number of remedies. As long as a few commonsense guidelines are observed, the method is perfectly safe for laypeople of average intelligence to learn at their own pace and to use for first aid and for the treatment of common domestic ailments. Considerable study and experience are required, however, to take full advantage of the enormous body of homeopathic information collected over the past two centuries.
The Totality of Symptoms
Just as provings include the full range of symptoms elicited by each remedy, homeopathy teaches that illness is primarily a disturbance of the vital force and manifests itself as a totality of physical, mental, and emotional responses that is unique to each patient and cannot be adequately understood as a mere specimen of any disease process. The Hahnemannian totality of symptoms describes the entire complex of signs and symptoms as they appear in the patient.
To the practicing homeopath, this composite totality or psychophysical style—much more than any abstract disease category or printout of laboratory abnormalities—furnishes the truest picture of the health and illness of the individual patient as a whole.
In practice, determining the totality of the symptoms demands that the homeopathic prescriber take into account the living experience of the patient, including the full range of thoughts and feelings. This approach by no means rejects or ignores the technical expertise of the physician and does not hesitate to make use of pathological diagnosis or of conventional drugs or surgery. Homeopathy uses the technical language of abnormalities to educate the patient, allowing the patient to retain control and to participate at every step. The conventional diagnosis, particularly the disease severity and degree of tissue damage, can also be important in predicting patient response to homeopathic treatment.
The homeopathic principle of symptom totality also explains why mental and emotional symptoms that would sometimes seem irrelevant to a conventional physician on occasion weigh heavily in choosing the remedy. Whereas most physical symptoms relate to a certain part of the body (e.g., arm, nose, back, stomach), psychological states involve how patients feel as a whole (e.g., afraid, depressed, happy, confused). The totality of symptoms gives special importance to describing the condition of the patient as a whole. Thus, homeopathy stands with all other therapeutic modalities labeled as complementary and alternative medicine (CAM) in that it is also a form of mind-body medicine.
Achieving a clear understanding of each individual’s health is vital to a successful homeopathic prescription. Consequently, other approaches to analyzing the case may be necessary. Symptoms that are strange, rare, or peculiar help the homeopath understand the given patient’s unique response to the illness. Symptoms affecting the person’s emotions and mental abilities are more important, because they most deeply impact the person’s well-being. Similarly, symptoms reflecting more serious disease must be given more attention, because a remedy without power to influence these problems cannot be the correct choice for a patient with such a condition. In some cases, modalities—factors that increase or diminish symptom severity—can help lead the homeopath to the correct remedy more than a specific symptom, because the modalities are more uniquely individual. Paying such close and careful attention to symptomatology requires listening intensively to the patient, as well as talking to the patient, to elicit responses. Listening and talking to the patient in itself is a powerful means of therapy, which in CAM modalities is not limited to the “talk therapies” of psychiatry, psychotherapy, and psychology in mainstream medicine today.
The Single Remedy
Based on the materia medica, the Hahnemannian method uses one remedy at a time for the whole patient, comparing the symptoms of the individual with those associated with various remedies until the best possible match is found. The reason is that the homeopathic materia medica has been compiled by testing individual substances, and the effects of combining them are unpredictable. Although almost all homeopathic remedies are made from a complex mix of substances (e.g., plants, insects), they have been tested in toto, and the homeopathic materia medica establishes that even slight differences (e.g., the mineral calcarea phosphorica vs. calcarea carbonica) produce distinctly different symptom patterns.
The encyclopedic scale of the homeopathic materia medica ensures that it can never be grasped in its entirety. As a result, some have tried to abbreviate and simplify clinical use of homeopathic remedies. Over-the-counter combination remedies also are available in many pharmacies and health food stores and are safe and effective if used properly. Although the practice is controversial in some quarters, some respected physicians use two, three, or more remedies simultaneously.
Administering different remedies to affect each part of a patient makes it difficult to know which remedy has acted and, in the view of many homeopathic practitioners, is contrary to homeopathic tradition. For this reason, remedies would have to be selected according to the rough indications of folk medicine or the technical language of abnormalities, much as in conventional drug treatment. Although it is often disparaged as a general approach, even the staunchest supporters of classical homeopathic methods recognize that there are situations in which the best homeopathic remedy for a certain patient at a certain time can be indicated by a single very important symptom. This is most likely when the patient is extremely ill.
Studying the totality of symptoms enables the serious student to accumulate detailed personal experience with remedies and generates much of the excitement about learning how to use them. The revival of American homeopathy in recent years has been achieved largely on the strength of the single-remedy concept. Only the totality of symptoms can illuminate remedies, and patients are unique individuals worthy of study for their own sake.
The Minimum Dose
Because homeopathic remedies stimulate an ailing self-healing mechanism rather than correct a specific abnormality, large or prolonged doses are seldom required and might even have harmful effects. Homeopaths use the smallest possible doses and repeat them only as necessary, allowing remedies to complete their action without further interference. The remedy will not work unless it fits the illness so closely that it renders the patient uniquely susceptible to its action. The minuteness of the dose minimizes the likelihood of untoward or dangerous adverse effects.
Hahnemann’s advocacy of infinitesimal doses remains one of the most controversial aspects of his work. No one has explained satisfactorily how medicines diluted beyond the molecular threshold of Avogadro’s number could possibly have any effect, let alone a curative one. However, the standard argument that “the remedies are simply placebos” cuts both ways. People do heal themselves of serious illnesses without drugs or surgery. For 200 years, homeopathic patients have been spared the adverse effects of conventional treatments later derided by conventional practitioners. With a variety of basic scientific investigations ongoing and many showing evidence of physical change in homeopathic dilutions, homeopathy envisions a new bioenergetic science that is still in its infancy.
In the study of modern environmental sciences and toxicology the concept of hormesis has developed based on the observation that the behavior of biologically active substances at very low concentrations is very different from their activity at higher concentrations and that they do not demonstrate a simple dose-response curve across all concentrations. Highly dilute substances that are toxic at higher doses may demonstrate a trophic effect by stimulating physiological and metabolic processes. These observations from mainstream science may be useful in understanding the observed clinical benefits of homeopathy.
The Laws of Cure
Consideration of the whole patient makes clear why drugs that successfully lower the blood pressure or kill bacteria may leave the patient feeling as bad or worse than before. Judgments about improvement, worsening, and the effectiveness of treatment are difficult to interpret apart from a more global perspective on how patients feel as a whole, and how they function according to their own individual standards. Perhaps the greatest shortcoming of the biomedical model is its failure to comprehend patients as integrated energy systems and to follow them throughout their lifetime.
Since the era of Hahnemann, classical homeopathy has addressed this critical issue by attempting to track the order in which symptoms and illnesses appear, the grouping of symptoms that appear and disappear together, and the relation of each group to the overall health and functioning of the patient. Constantine Hering (1865, 1875) proposed four general principles by which to evaluate the changes experienced by the patient during the recovery process (Box 24-2).
Like most attempts to succinctly define general principles, Hering’s laws of cure can both confuse and elucidate. The fourth principle has proved most reliable for long-term case management. Although some health changes are obviously better or worse, more literal interpretations of Hering’s law, particularly subtle distinctions about the relative importance of internal organs, are difficult and subjective. Some approximation of the totality of symptoms over time remains indispensable to the general assessment of the patient as a whole, for clinician and researcher alike.
These “laws of cure” provide clear standards by which to evaluate the actions of all therapies, including homeopathic medicine. When the intervention is followed by a lasting decline in the patient’s condition as defined in this manner, the intervention was a poor choice. This pertains to homeopathy as well as to conventional medicine or other healing approaches.
METHODOLOGY
Pharmacy
The Homeopathic Pharmacopoeia of the United States (American Institute of Homeopathy, 1989) is the official standard for the preparation of homeopathic medicines. Crude medicinal substances are transformed into remedies by serial dilution and succussion in a liquid or solid medium. First crushed and dissolved in a specified volume of 95% grain alcohol, crude plant materials are shaken and stored, and the supernatant liquid is kept as the “mother tincture.” The same procedure is used for animal products, nosodes, and any other substances that are soluble in alcohol. Metals, ores, and other insoluble remedies are pulverized with mortar and pestle and diluted with lactose, undergoing succussion until they become soluble.
Tinctures are further diluted with alcohol or lactose, either 1:10 (the decimal scale, written “X”) or 1:100 (the centesimal, written “C”) and succussed vigorously, which yields the 1X or 1C dilution. The process is repeated for the 2X, 3X, 4X (or 2C, 3C, 4C) dilutions, and on up as desired.
In clinical practice any dilution may be used, but the most popular for self-care are the 6th, 12th, and 30th (X or C). Higher dilutions for professional work are in the centesimal scale, namely, the 200th, 1000th, 10,000th, and 50,000th, written 200C, 1M, 10M, and 50M, and representing dilutions of 10–400, 10–2000, 10–20,000, and 10–100,000, respectively.
The general skepticism about diluted remedies, as expressed by Oliver Wendell Holmes and modern critics, is readily understandable, because even the 12C and 30C remedies are well beyond the apparent limits imposed by Avogadro’s number and therefore out of the realm of conventional chemistry entirely (Holmes, 1842). Because there is essentially no likelihood that any of the original substance remains in many homeopathic preparations, for 40 years researchers have been investigating changes in the solvents used in the transformation of a medicinal substance into a homeopathic remedy. (Holmes also expressed skepticism about regular medicine; for example, in an address to the Massachusetts Medical Society, publisher of the New England Journal of Medicine, in 1860 he stated, “If the entire materia medica as currently practiced could be sunk to the bottom of the sea, it would be all the better for mankind and all the worse for the fishes.”)
Case Taking
As in general medicine, in homeopathy the evaluation requires more than simply taking down information or selecting remedies. Encouraging patients to tell their stories, in their entirety, relieves their burden of pain and suffering, which makes the homeopathic interview a powerful healing experience in its own right. It even might suggest a path of recovery, allowing remedies to continue the process.
Traditionally, patients are invited to speak and allowed to continue for as long as possible without interruption, while the homeopath asks, “What else?” as often as necessary to elicit more symptoms and to remind the patient that no one disease is being sought but rather the totality of symptoms. Symptoms are written down verbatim whenever possible, supplemented by the homeopath’s own observations about the patient’s temperament, behavioral patterns, and personality style.
After the patient finishes his or her story and the principal symptoms have been noted, the homeopath must investigate further to characterize symptoms in detail. Conventional diagnosis is based on common symptoms such as fever, pain, cough, and bleeding, whereas homeopaths look for unusual or idiosyncratic features that tend to be ignored or discarded by conventional physicians (Box 24-3).
BOX 24-3 Fully Characterized Symptoms Described in a Homeopathic Interview
Medical school faculty who learn about the process of homeopathic interviewing often comment that the careful attention to the patient’s descriptions and nonjudgmental respect for the patient’s experience would be useful skills for all medical students to learn.
The interview also includes physical examination and laboratory work as needed to establish a diagnosis, both homeopathic and conventional.
Selection of the Remedy
Remedy selection, homeopathic “diagnosis” in a sense, is the product of the homeopath’s understanding of the patient. Homeopathic prescribing is the clinical implementation of the correspondence between the database of the materia medica and the details of each patient’s case record.
Because of the mass of information contained in the homeopathic materia medica, an encyclopedic memory or a computer with a similar capacity would be required to fully grasp the treatment options for each patient. Even experienced homeopathic specialists often use reference materials.
For professional homeopaths to consider as many remedies as possible, they need help in proceeding from the clinical totality to a menu of possible remedies that they can study and from which they can choose. This is the purpose of the repertory. Patients complain of problems and symptoms, but homeopathic materiae medicae are organized by the name of the medicinal substance. The repertory overcomes this problem by indexing the symptoms correlated with the remedies that have either elicited them in provings or cured them clinically. By finding the remedies that match the leading symptoms in a case, the search for a cure can be narrowed, and the homeopathic specialist can study most effectively.
Whether in the form of a book or computer software, the largest, most comprehensive repertories (Archibel, 2004; Kent Homeopathic Associates, 2008; Murphy, 2005; Schroyens, 2004; van Zandvoort, 2004) include all types of symptoms from every anatomical region and physiological system, as well as mental and emotional symptoms, “generalities” (physical symptoms or modalities attributable to the patient as a whole), and rare symptoms, the oddity of which may point directly to the remedy. The repertory is only a tool for locating remedies; these remedies must then be studied in the materia medica. The final selection is based more often on a total or qualitative fit than on any narrow, technical calculation.
Regimen and Precautions
Although they remain stable in the cold and across a wide range of temperatures, dilute remedies are inactivated by direct sunlight and should be stored in a dark, dry place, shielded from heat and radiation. Patients are instructed to put nothing in the mouth for at least 30 minutes before and after each dose, because competing tastes can interfere with the action of the remedy. Coffee and camphorated products might reverse the effects of the remedy, so patients should avoid them throughout the treatment period, even when no remedies are actually being taken. The use of medicinal herbs and exposure to mothballs and other aromatic substances also should be curtailed. Homeopaths may differ on how compulsive patients need to be about avoiding possible interferences.
Although conventional drugs often interfere and should be avoided when possible, severely ill patients should not stop taking medications. Because of their potentially synergistic effect, some homeopaths believe that acupuncture and chiropractic should not be started concurrently with homeopathic remedies. Relapse might also follow dental work that includes drilling and local anesthesia.
Administration and Dosage
Remedies are dispensed in the form of tablets or pellets of sucrose or lactose that are taken dry on the tongue or dissolved in water. Lower dilutions are preferred in acute situations because they can be repeated as often as necessary and will be somewhat effective even if only broadly similar to the totality of the case. Higher dilutions are used mainly by professionals for long-term treatment. More care must be taken in the selection of higher dilutions, and administration should not be repeated while the remedy’s action is in progress.
In homeopathy the term dosage refers primarily to the number and frequency of repetitions, which must be tailored to fit the patient, as with the choice of the remedy. In both acute and chronic cases, the rule is to stop the remedy once the reaction is apparent, repeating only when the reaction has subsided.
Pros and Cons
There are few, if any, absolute contraindications to homeopathic treatment. Although patients with severely disabling illnesses or chronic drug dependence are difficult to help—by any method—homeopathy at least might be considered before resorting to more drastic measures or after conventional methods have failed. Homeopathic remedies are relatively safe, economical, simple to administer, and gentle in their action, with very few serious or prolonged adverse effects. Although subtle at first, the effects of treatment are prompt, thorough, and long lasting. Simple acute illnesses and injuries are easy for even untrained laypeople to treat homeopathically, because the amount of information required is minimal.
On the other hand, homeopathy is far from a panacea. It is a difficult and exacting art. Even after years of study and practice, a skilled prescriber might need to try several remedies before any benefit is obtained. Some patients might show little or no improvement, despite the most conscientious efforts. Remedies are rather delicate and easily inactivated, so certain precautions must be observed. Finally, how dilute remedies act is not understood, and how a patient will respond or which symptoms will change and in what order cannot be predicted with absolute certainty. As with all medicine, homeopathy is an art dependent on the living energy and variability of individual humans.
HISTORICAL DEVELOPMENT
Early Controversies
Hahnemann’s successful treatment and prophylaxis of scarlet fever during an epidemic brought wide fame to homeopathy throughout Europe. In America, successive waves of epidemics of yellow fever, cholera, influenza, typhus, and typhoid fever were successfully treated by homeopathy throughout the 1800s. With epidemics came converts—both physicians and patients—from regular medicine to homeopathy, discouraged at the failure of regular medicine and the poisoning that accompanied use of the materia medica as then practiced. One of the converts to homeopathy was Abraham Lincoln, who often resorted to “frontier medicine” where there was no physician; he referred to homeopathic remedies as a “soup made from the shadow of a pigeon’s wing.”
Nevertheless, Hahnemann was ridiculed and persecuted for his heresies until 1822, when he was awarded a stipend to publish his writings (Bradford, 1895). He fueled the controversy by his unflagging convictions and determination to speak out. Famously, he upset the local medical community when he published a letter in the paper decrying the care other physicians provided to the newly deceased emperor of Austria, claiming that instead of helping the patient, they hastened his demise. Similar claims were made that not only did the physicians hasten the demise of their patients but tortured them before death in the case of Charles II (1680s) and George III (1820s), as well as George Washington (December 1799).
In addition to his Organon of Medicine and Materia Medica Pura, Hahnemann wrote many technical and expository works, maintained a busy correspondence, and continued to practice and conduct experimental research. Hahnemann died secure in the knowledge that his students were practicing homeopathy throughout Europe and America. Fired by ambition and gifted with intellect, Hahnemann left a body of work and a method that have stood the test of time.
Homeopathy in America
In the latter half of the nineteenth century, the United States became the center of the homeopathy movement and produced some of its greatest masters, whose works still enjoy international use. Three major factors contributed to the rapid growth and development of American homeopathy.
The first was the absence of laws or bureaucracy to license the practice of medicine, a tolerant attitude born of the hope to break free from the oppressive social and economic constraints of Europe. When the first school of homeopathy opened in Pennsylvania during the 1830s, American physicians were organized on a voluntary basis, and state legislatures were reluctant to prevent uneducated or lay healers from helping anyone who wanted to use their services (Starr, 1982).
The second factor was the great migration of those seeking land and fortune in the West. The westward expansion of America into the wilderness stretched beyond the reach of established society, including medical care. Frontier mothers had to develop essential medical skills to enable the survival of their families. Hering’s Domestic Physician, published in 1835, provided instructions in the lay use of homeopathic medicines. The book was so popular that the first homeopathic book to break its sales record was not published until 150 years had passed.
Third, the concept of the materia medica itself was easily adapted to Native American medicine. Introducing dozens of Native American herbs into the pharmacopeia, American homeopathy was enriched by the botanical lore of midwives, medicine men, eclectics, and other herbalists whose recipes are still in use today (Hale, 1867).
Under these conditions, homeopathy flourished in the United States, inspiring the creation of hospitals, medical schools, and “insane asylums” that scored notable triumphs and attracted public attention (Coulter, 1973). Hahnemann was among the first European or American physicians to speak out against the violent treatment administered to mentally ill patients. Consequently, homeopathic asylums provided quite enlightened treatment compared with the prevailing standard of care (Gamwell, 1995). Published accounts indicate that, during epidemics of cholera, typhus, and scarlet fever, homeopathy proved its superiority over the often toxic conventional treatments then in vogue (Bradford, 1900).
Physicians practicing this new method quickly rose to social prominence, treating such rich and famous patients as members of President Lincoln’s cabinet (Coulter, 1973). By the turn of the nineteenth century, 10% of all physicians used homeopathy in their practices (Ullman, 1991a, 1991b).
During and after the Civil War, however, the tremendous expansion of American industry transformed the nature of medicine. American homeopathy—with its use of minimal doses at rare intervals—never created a large or profitable industrial base capable of financing large educational or research institutions. Experimental medicine, based on rigorous physicochemical causality, generated such unprecedented technical achievements as anesthesia, antisepsis, surgery, microbiology, vaccines, and antibiotics (Bernard, 1957).
The American Medical Association (AMA) and its state societies forbade their members to consult or fraternize with homeopaths (Coulter, 1973). Such persecution had little effect until state legislatures began to license physicians and accredit medical schools, and the pharmaceutical industry won control of the process (Starr, 1982). Thereafter the AMA invited homeopaths and physicians of all schools to become members in exchange for licensing, creating a monopoly against lay healers, midwives, and herbalists. The Flexner Report, published in 1914, proposed a uniform standard of medical education for all physicians and used the power of accreditation to phase out homeopathic colleges that fell short of these standards (Starr, 1982). Philosophical disputes within the homeopathic community precluded unified action to maintain homeopathy’s foothold in American medicine (Coulter, 1973).
The AMA strategy succeeded. By the 1920s, the homeopathic schools had closed or conformed to the new model, and homeopathy was reduced to a postgraduate specialty for the few physicians who were prepared to swim against the tide. Although some fine homeopathic physicians continued to practice, the movement declined rapidly over the next 40 years. By 1970, homeopathy appeared to be moribund, its teachers aged or dead (Kaufman, 1971).
American homeopathy has begun to flourish once more, largely because of the rebirth of the self-care movement, the health care crisis, and the overemphasis on technology that provoked these events (Illich, 1976; Lown, 1996; Ray, 2001). By eliminating lay healers and aspiring to control every abnormality by purely technical means, American medicine has become a colossus that thrives on great cost and great risk (Moskowitz, 1988), generating more iatrogenic illness (Steel, 1981), and consuming a greater share of the gross national product than anywhere else in the world. Facing crises in health insurance, malpractice litigation, and the physician-patient relationship (Moskowitz, 1988), the public—and now the medical profession itself—has turned to alternatives such as those described in this text.
Safe, effective, and inexpensive enough to sustain busy practices even without third-party reimbursement, homeopathy has become increasingly popular with young family physicians. As in frontier days, the renaissance of American homeopathy would not be occurring were it not for the devotion of laypeople—not only in performing self-care, but also in organizing study groups in their communities and teaching these methods to their friends and neighbors.
RESEARCH
Hahnemann’s system of provings—using individuals to determine the symptoms that a medicine could produce—was the first research in homeopathy and some of the first systematic clinical research in medical history. Indeed, the whole field is based on this experimental work, which was unprecedented both in method and in scope. Provings are still conducted on many herbal medicines that have been used by traditional healers for centuries, particularly in Asia and in South America. The proving method also is being modernized; statistical methods are used to determine the significance of various symptoms. Some historians of medicine consider Hahnemann’s system of provings to be the first phase 1 drug trials (Kaptchuk, 1998). Following Hahnemann’s scientific bent, homeopaths have been conducting all types of research investigating the method since its inception. The proving methodology itself has been investigated as a means of demonstrating the effects of homeopathic dilutions with and without success (Brien et al, 2003; Dantas et al, 2007; Walach et al, 2001). The Samueli Institute for Information Biology published a very good overview of the field of homeopathic research as it stood in 2002 (Walach et al, 2002).
Basic Science Research
Basic scientific research in homeopathy primarily has investigated the chemical and biological activity of highly diluted substances. As discussed previously, Hahnemann found that if the homeopathic remedies were highly diluted to concentrations as low as 10–30 to 10–20,000, medicinal effect could be preserved while simultaneously minimizing adverse effects. Most scientists reject homeopathic theory because of the common usage of dilutions exceeding Avogadro’s constant (1 × 10–23), beyond which point no molecules of the original material should remain. Although some believe that conventional scientific knowledge already encompasses the most unlikely homeopathic principles (Eskinazi, 1999), that is a minority opinion. The general belief is that the purest scientific research is necessary to overcome entrenched intellectual resistance to this theory.
Toxicology
The model most often used for investigating biological effects of homeopathic dilutions is toxicological research. Generally these studies have used rats subjected to lethal doses of toxic metals (arsenic, mercury, lead). In a meta-analysis and critical review of published and unpublished work on this topic (Linde et al, 1994), the quality of the studies overall was found to be poor. Although this problem significantly impaired the ability to draw definitive conclusions, interestingly the best studies used dilutions exceeding Avogadro’s number, and more than 70% of these studies reached findings in support of biological effects of the homeopathic dilutions.
Immunology
A number of studies on the effects of high dilutions have been conducted in the field of immunology (Bastide, 1994; Belon, 1987), including a study that prompted one of the most notorious controversies in recent scientific literature. This study of the effects of high dilutions showed degranulation of human basophils in response to immunoglobulin E antibodies diluted as much as 10–120 (Davenas et al, 1988). This article was highly criticized not only because the findings challenged the basic tenets of biomedicine, but also because of its handling by the Nature editors (Anderson, 1991; Benveniste, 1988; Coles, 1989; “When to believe the unbelievable,” 1988), who published it conditional upon a subsequent investigation by a team that included a professional magician but no immunologist (Maddox et al, 1988). The controversy over this study continues, with attempts to repeat the experiment reporting both success and failure (Belon et al, 2004; Benveniste et al, 1991; Hirst et al, 1993).
Miscellaneous Life Sciences
A large number of research studies using animal, organ, tissue, plant, and cellular materials to evaluate aspects of homeopathic principles have been published in scientific journals. In fact, this line of inquiry has been followed for over 80 years; in 1927, researchers first published a study investigating the effects of a homeopathic dilution on developing tadpoles (Konig, 1927). To explore the foundations of these areas of homeopathic research further, refer to Bellavite and Signorini (1995, 2002) and Endler and Schulte (1994).
Fundamental Science
The two crucial aspects of homeopathic theory have frequently been investigated independently of each other. The similia principle (“likes cure likes”) is often linked to well-established paradoxical effects of nearly all conventional medicines. Systematic study of the similia principle has mostly appeared under the guise of “hormesis” research (Calabrese et al, 2001; Jonas et al, 2008). However, others have performed investigations of this concept as a general physiological principle (van Vijk et al, 1994).
Investigations searching for evidence of physical changes created by the potentization process have a long and creative history. In the 1960s, researchers first assayed homeopathic dilutions using nuclear magnetic resonance imaging (Smith et al, 1966, 1968). As might be expected when attempts are made to apply new technology to an unconventional subject, these studies have generally been of very poor quality, and both cautious interpretation and excellent data are required (Aabel et al, 2001; Demangeat et al, 2001). More recently, as technology has advanced with finer instruments capable of measuring more subtle phenomena, scientists have begun to apply these tools to study homeopathic principles (Becker-Witt et al, 2003; Bellavite et al, 2002; Berezin, 1994; Lo et al, 1998; Poitevin et al, 2000).
Clinical Research
Before the mid-1980s, few reports of clinical research in homeopathy were published outside of homeopathic journals. The first double-blind experiment reported in a peer-reviewed medical journal showed statistically significant results in treating rheumatoid arthritis with individualized prescribing of remedies (Gibson et al, 1980). A later study on arthritis comparing response to a single homeopathic remedy with that to a conventional drug showed the homeopathic treatment to be inferior on almost every outcome measure (Shipley et al, 1983). This study provides an excellent example of the difficulties in adapting classical homeopathic practice to double-blind, randomized controlled trial protocols. Standard homeopathic practice calls for an individualized remedy selection and dosing scheme, as well as a long time frame for treatment of chronic conditions, but the Shipley study design violated all these essential components and led one of the experimenters later to recant the negative finding, as follows:
One cannot logically extrapolate from this any conclusions about other potencies of Rhus tox., other homeopathic remedies, or homeopathic medicine in general. The most important lesson that we have learned from this study is that a double-blind crossover trial of short duration using a single potency of a remedy prescribed on local features is unlikely to be a fruitful method of seriously studying homeopathic medicine. (Lancet, 1983).
A study of recurrent respiratory illnesses in a pediatric population (de Lange de Klerk et al, 1995) recalls the Shipley study because of the problems in interpreting the data. Superficially, the pediatric study found no significant benefits of homeopathic medicine. However, good reasons exist to contest this conclusion. As one of the confounding factors, the “placebo” intervention included all the components typical of homeopathic clinical consultations (homeopathic interview, dietary and lifestyle advice, clinical management avoiding overuse of medication). Other studies have shown that these interventions appear to be effective in themselves, and the investigators found that both groups improved dramatically. Although the group who received the remedy improved even more, the difference between the groups was not statistically significant. Was the placebo group improvement in this case simply the course of natural history, or was it the effect of the homeopathic approach minus the remedy?
Other notable studies include work on pediatric diarrheal disease (Jacobs et al, 1993, 1994, 2000, 2003), fibrositis and fibromyalgia (Bell et al, 2004; Fisher et al, 1989), hay fever and pollinosis (Lüdtke et al, 1997), vertigo (Weiser et al, 1998), and otitis media (Jacobs et al, 2001), as well as use of the homeopathic standard arnica in surgery, trauma, and physical overexertion (Campbell, 1976; Hart et al, 1997; Ramelet et al, 2000; Stevinson et al, 2003; Tveiten et al, 1991, 1998, 2003; Vickers et al, 1998; Wolf et al, 2003).
Ferley et al’s early positive findings (1989) for a homeopathic treatment for influenza have received equivocal support, best summarized in a recent meta-analysis (Vickers et al, 2004).
Probably the most impressive series of trials was conducted by Reilly’s group investigating allergic rhinitis and asthma (Reilly et al, 1986, 1994; Taylor et al, 2000). For 15 years this group conducted research into these allergic diseases using homeopathically prepared allergens as an intervention in sensitive patients. They repeatedly achieved positive findings of such a degree that the pooled patient subjective data (visual analogue scale) resulted in a P value of .0007. This highly impressive finding was tarnished by a failed but admittedly imperfect attempt at replication (Lewith et al, 2002). A Cochrane review of trials of homeopathic treatment of asthma concluded that there was insufficient evidence to reach a determination of whether homeopathy was or was not effective (McCarney et al, 2004).
Systematic Reviews
In homeopathy, as in all areas of medicine, systematic reviews and meta-analyses have been in vogue as a means of refining our understanding of the research data. Some reviews were disease specific. Others were meta-analyses of general research, a few studies specifically considered quality issues, and one super meta-analysis even looked at the quality of the meta-analyses (Cucherat et al, 2000; Ernst, 2002; Jonas et al, 2001; Linde et al, 1997, 1998, 1999). Among the conclusions were comments in every review regarding the poor quality of most of the studies. Each found results favoring homeopathy, which became more ambiguous as the quality of the studies improved. Unfortunately the quality of some of the meta-analyses themselves has become an issue, most notably that of Shang et al (2005). The strength of Shang et al’s conclusions were at odds with important deficiencies in their design, which led to a volume of criticism that continues to this day (Lüdtke et al, 2008).
The British Medical Journal published the first meta-analysis of homeopathic clinical trials (Kleijnen et al, 1991). The authors’ comments remain an interesting reflection on the intellectual and emotional milieu of the discussion as well as on homeopathic research:
The amount of published evidence even among the best trials came as a surprise to us. Based on this evidence we would be ready to accept that homeopathy can be efficacious, if only the mechanism of action were more plausible. . . . The evidence presented in this review would probably be sufficient for establishing homeopathy as a regular treatment for certain indications. There is no reason to believe that the influence of publication bias, data massage, bad methodology, and so on is much less in conventional medicine and the financial interests for regular pharmaceutical companies are many times greater. Are the results of randomized double-blind trials convincing only if there is a plausible explanation? Are review articles of the clinical evidence only convincing if there is a plausible mechanism of action? Or is this a special case because the mechanisms are unknown or implausible?
Global Measures of Homeopathy: Cost Effectiveness and Outcomes
Another relevant area of research in homeopathy is cost effectiveness and outcomes. Many believe that outcomes research will prove to be the most important area of homeopathic research (Carlston, 2003; Jacobs et al, 1994). Like several other forms of CAM, homeopathic treatment is directed toward the patient’s global well-being, not toward specific disease features. Therefore, general outcome measures such as overall health status (assessed using widely accepted scales), patient satisfaction, days missed from school or work, and the cost of treatment are most suitable for evaluating homeopathic treatment. Also, patients do not care if their treatment is merely statistically superior to placebo. They only want to get better, and thus many conventional medical researchers argue that measuring patient satisfaction is crucial. As Ian Chalmers, the founder of the Cochrane Collaboration, states, “The patient’s opinion is the ultimate outcome measure.”
A German study in which nearly 500 patients received either conventional or homeopathic care found that, although costs were similar, patients’ clinical response to homeopathic treatment was significantly better as determined by both patient and physician ratings (Witt, Keil et al, 2005). Another study of patient outcomes found a highly significant improvement in disease severity and quality of life among 3981 German and Swiss patients (Witt, Lüdtke et al, 2005). In France the annual cost to the social security system for a homeopathic physician is 15% less than that for a conventional physician, and the price of the average homeopathic medicine is one third that of standard drugs (Caisse Nationale des Assurances Maladie, 1991). Fisher found that expenditures for patients of the London Homeopathic Hospital were significantly lower than those for matched, conventionally treated patients. The reduction in expensive services documented in other studies also suggests a potential for cost effectiveness (Jacobs et al, 1998; Swayne, 1992; Van Wassenhoven et al, 2004).
HOMEOPATHY TODAY
The use of homeopathy is increasing rapidly throughout the world, particularly in Europe, Latin America, and Asia. In many European countries, homeopathy is the most popular form of alternative and integrative medicine. Developing countries have turned to homeopathy as the cost of conventional, Western medicine becomes too costly to afford. In both Argentina and Brazil, several thousand physicians use homeopathy, and Mexico has five medical colleges that provide homeopathic training. South Africa has homeopathic medical colleges in several major cities, and the health ministry in Israel has approved the importation of homeopathic preparations for sale in pharmacies (Kayne, 2003).
The use of homeopathy in the United States has increased tremendously in the last 20 years. A survey showed that 1% of the American population used homeopathy in 1989 (Eisenberg et al, 1993). Sales of homeopathic remedies increased by 1000% during the 1980s (U.S. Food and Drug Administration, 1985) and were reported to be $200 million in 1992, climbing at the rate of 25% per year (Swander, 1994). A 1999 survey found that 17% of Americans were using homeopathy for self-care (Roper Starch Worldwide, 1999).
Physician interest parallels patient enthusiasm. In Germany, 25% of all physicians use homeopathy (Ullman, 1991a, 1991b); in France, 32% of general practice physicians use it (Bouchayer, 1990); and in Great Britain, 42% of physicians refer patients to homeopaths (Wharton et al, 1986). In India, homeopathy is practiced in the national health service, at several hundred homeopathic medical schools, and by more than 100,000 homeopaths (Kishore, 1983). In 1995, about 10% of conventional U.S. medical schools offered elective instruction about homeopathy (Carlston et al, 1997). By 1998, almost 15% of U.S. medical schools required that students study homeopathy (Barzansky et al, 1998).
Because education in CAM has expanded dramatically, more recent numbers for homeopathy would likely be much higher. Data published in 2004 showed that almost 50% of American schools of osteopathic medicine include homeopathy in the required coursework (Saxon et al, 2004).
Appropriate Use
Homeopathic remedies are most likely to be successful and to optimize overall health for the types of conditions listed in Box 24-4.
BOX 24-4 Uses of Homeopathic Remedies
Homeopathy is less useful (1) for the treatment of chronic diseases involving advanced tissue damage, such as cirrhosis of the liver or severe cardiovascular disease; (2) for people with prolonged dependence on conventional medications such as corticosteroids, anticonvulsants, and antipsychotics; or (3) as a substitute for appropriate conventional treatments such as emergency surgery or reduction of fractures. Homeopathy is often used by homeopathic specialists as a treatment complementing conventional medicine in these circumstance or as a palliative measure when no other effective treatment exists.
Practice Patterns
Surveys of American physicians document interesting differences between those using homeopathic medicines in their practices and those using more conventional remedies ( Jacobs et al, 1998; Schappert, 1992). Physicians using homeopathy saw fewer patients and spent more than twice as much time with each patient than did conventional physicians, averaging 30 minutes per visit versus 12.5 minutes. In addition, homeopathic physicians ordered half as many diagnostic procedures and laboratory tests as conventional physicians and prescribed fewer standard medications.
Asthma, headaches, depression, allergies, psychological problems, and skin problems were among the top 10 conditions treated most frequently by homeopathic physicians (Jacobs et al, 1998). Schappert’s contemporaneous survey (1992) found that conventional physicians, on the other hand, saw more patients with hypertension, upper respiratory tract infections, diabetes, sore throats, bronchitis, back disorders, and acute sprains and strains. These practice patterns suggest that patients were seeking homeopathic care mostly for chronic conditions not managed adequately by conventional medicine. The low number of acute problems treated by homeopaths may be the result of patients’ treating these conditions on their own.
SUMMARY
Homeopathic medicine has persisted both in spite of and because of its dissident voice. Its theories usually contradict those of conventional medicine, and the intensive clinical interaction between patient and practitioner stands in opposition to the time pressures of managed care. Although its controversial aspects would seem to weaken homeopathic practice severely, in fact this distinction attracts interest, and in many ways this controversy serves to invigorate both conventional and homeopathic thought.
Chapter References can be found on the Evolve website at http://evolve.elsevier.com/Micozzi/complementary/