A quest for consensus of speech – Say what you mean!

An exploration and critical analysis of the terminology used to describe ultra high dilution, the position of homeopathy in medicine and its relation to science – a demand for agreement on inter- and cross- disciplinary definition and vocabulary.

Abstract

In homeopathy there is a lack of consensus on the terminology used to describe it. The meaning of nomenclature is frequently not what we are expressing in words, because the terms we are using are not universal to the discipline of homeopathy. This fosters criticism, misinterpretation and confusion. The words describing `ultra high dilution´, serve as an example to illustrate this requirement for agreement on semantics.

Even outside the realms of homeopathy there is no agreement on a joint language. Medicine as a generic term, repositions homeopathy, and raises questions of the place of homeopathy as a science.

The dominant paradigm of science is ignorant of immaterial notions; therefore the question of a shift of paradigm to match the development of knowledge and science over time is discussed. Consequently it becomes evident that with a consensus of speech and an amendment to the existent paradigm, the position of homeopathy in medicine and science could be clarified. A universal language, will unite the knowledge, and avoid the misunderstanding of homeopathy.

Keywords: terminology, semantics, homeopathy, ultra high dilution, criticism, science, paradigm, medicine.

Introduction

With Homeopathy we have at our disposal a health care system that meets the demand for a scientific methodology strictly researched on human subjects. Homeopathy has been objectively and subjectively documented in sensitive detail for over 200 years. No other medical system is subject to such intense investigative, case-descriptive and experiential verification as is homeopathy [14]. Despite such extensive clinical evidence, the foundational pillars of this alternative medical approach are stumbling blocks to acceptance and acknowledgement of the efficacy of this treatment approach. The prime criticism against homeopathy relates to the law of Similars, the law of Infinitesimal and the law of Chronic Disease [10].

In my practice as a homeopath I have had the most queries concerning homeopathy, questioning the plausibility of the law of infinitesimal. A lot of controversy, criticism and misunderstanding surrounds this homeopathic principle. But not alone due to the persistent doubt of its efficacy, the inexplicability of the underlying mechanism, or its  position in the realms of medicine and science are practicing homeopaths constantly in need to defend their therapeutic approach. The terminology too, is often causing confusion.  I have therefore chosen to critically evaluate and analyze the fundamental concept of ultra high dilution from the point of view of its terminology. By way of terminology, I have also sought to identify the position homeopathy holds in medicine and science and am aiming at deconstructing conjectural beliefs and fundamental claims.

Relevant literature for this essay comes from books, and articles and studies that were taken from electronic databases such as Sciencedirect and Elsevier available via the UCLan subscription.

I have chosen to take definitions from “the pocket oxford dictionary” [19], a `house-hold´ dictionary, devoid of having a specialty focus in the contained vocabulary.  This is relevant for the argumentation concerning the confusion surrounding the semantics of homeopathy.

Personal experience from the patient-practitioner interaction and discussions with opponents to this treatment methodology, founds the basis for argumentation and investigation undertaken in this essay.

The importance of semantics

In my practice with patients it has not gone unnoticed that, although homeopathy is understood as an ‘other, gentle´ treatment approach, the comprehension of principles and specialized vocabulary is cause of confusion and misunderstanding. This is not surprising, considering the falsified semantics we homeopaths have been employing. When addressing ultra high dilution for example, by use of the wording, we are describing a solution that in reality is far from what we actually utilize as a homeopathic remedy.

Ultra molecular dilutions, ultra high dilutions, infinitesimal dilutions, are names given to the medicinal substances of homeopathic prescribing. Yet, they are false as they do not describe what is actually meant and are not precise in the dimensions they are sought to be descriptive of.

By the definition of the prefix ´ultra` as “extremely, excessively, beyond” [19] (p.817), one decisive explanatory factor is omitted. The use of the word `high´, is equally controversial. The most matching definition, for the description of the term ` high´, is “extreme, intense, above the normal” [19] (p. 346).

These quantitative terms that we utilize in the description of homeopathy, are relative and stand widely in connection to individual parameters. What is `ultra´ or `high´ is therefore dependent on who uses the term and in what context. `Infinitesimal´ likewise is best understood within context, but comes closer to what we mean it to describe in homeopathic terms. It is descriptive of something that is “infinitely or very small”, with `infinite´ meaning “boundless, endless; very great or many” [19] (p. 377).

Molecular has the meaning “of or relating to or consisting of molecules” [19] (p. 473). `Dilution´ is derived from the stem verb `to dilute´ which is to “reduce strength of (fluid) by adding water or other solvent; weaken or reduce forcefulness of” [19] (p.204).

When using the term `ultra molecular´ for a dilution, we describe a solution `beyond´ the consistence of molecules, if we employ the above definitions. But in relation to `dilution´, this lacks the correct description of the element that makes the remedial substance homeopathic. An ultra molecular substance as we comprehend it in homeopathy is not one that has merely been reduced in concentration [12], but one that has been serially diluted and rendered dynamic. Hahnemann [15] described this in Aphorism 269 of the Organon. This process is known as dynamization or potentization. Crude substances lose their toxicity or their respective state of `being without healing´, by dilution, and increase their medicinal power by succussion or trituration [6]. Therefore a homeopathic remedy has to be serially diluted and vigorously shaken at each stage of potentization, in order to attain its healing modalities [7], [30]. A more correct term descriptive of a homeopathic remedy, is therefore an `ultra molecular potentization´.

To be descriptive of what we mean when we speak our homeopathic language, the definition of the wording we use has to be known and understood.

Complemented by a definition given according to www.britannica.com, `infinitesimal´ is of a “quantity less than any finite quantity, yet not zero.” This description of the word could meet the demand for a more precise definition, when used in a homeopathic context, as it incorporates a descriptive component of the dimension of the infinitesimal potentization. But this requirement for extension to the meaning may be unclear to the lay person or to potential patients as it makes use of a definition that is taken from another source. This raises the question of which definition comes closest to the correct meaning of the term and underlies an expression, or which dictionary or lexicon carries the most precise definition. We homeopaths need to utilize the same definitions and words if we and our therapeutic approach are to be clearly and correctly understood.

This is essential! Different sources produce different meanings to one and the same term and there from, at the very root, foster differentiation in meaning and consequently fallacy and disagreement in speech.

In my discussion with my patients, it has become evident that the difficulty of acceptance of and the criticism towards homeopathy lies mainly within the realms of the principle of `ultra high dilution´, or actually within the false terminology that describes it. A mere dilution is not what patients can see as an effective agent for the treatment of ailing symptoms. How controversial the mechanism of potentization is, the application of a mechanic motion to the remedial substance receives more acceptance of plausibility than just dilution. In practice therefore, this is not subject to quite as much scrutiny as is experienced from the realms of science or other medicinal methodologies. Patients frequently believe in `things between heaven and earth that cannot be explained´ and if these are able to make them feel improved, the `how´ this happens is not that relevant [16].

Alternative or discipline of medicine

Having no clear one language and precision in what we, within the discipline, mean causes confusion in the dialogue with lay persons and as previously illustrated, with our own patients. The above example of a re-definition, may have little implication on the overall comprehension of homeopathy, but does in the discourse with persons who only engage with homeopathy in the broadest sense, foster misunderstanding and consequently uninformed criticism. We are postulating in our practice an ethical treatment approach where patients are able to make an informed choice for their treatment [25] and therefore require provision of enough information for them to found their decisions. With an inappropriate terminology this is difficult. Consequently what can be identified as homeopathic terminology may, require slight correction [12].

Semantics also plays a crucial role when it comes to the communication amongst us practicing or engaged with homeopathy, and with those outside the homeopathic field of practice, with science and other medical disciplines [11], [12].

Our unorthodox use of the term `homeopathy´, already bares proof of the need to speak with one voice when representing a homeopathic stance. `Homeopathy´ in its usage, even amongst homeopaths, has different meanings [22]. In discourse with practitioners and lay persons alike, I have heard this terminology in use for the description of the consultation, the remedy, the philosophy and the principles; much like is mentioned in Relton et al. [20]. And I follow with Relton et al. for `homeopathy´ to describe a “system of therapeutics” (p.153) and all other terms to provide a distinguishable prefix, suffix or additional term highlighting their difference.

As much as the term `homeopathy´ is unclear in its application, the position of this treatment approach is not certain in its comparison and relation to what we normally describe as general medicine.

Homeopathy is described as a discipline unconventional or alternative; as opposed to what? To allopathy or allopathic medicine? Is homeopathy really that `other´? Is it not a therapeutic approach aimed at treating illness, just as is what we know as general medicine? Guajardo, Searcy, and Reyes, [13] have aimed at specifying semantics that may permit a better understanding of the position that homeopathy holds in the realms of medicine.

They point out that `allopathic medicine´ as such is not existent, but that `allopathy´ itself is descriptive of a treatment approach and not of medicine in general. The word `medicine´ is not equivalent to allopathy, although in practice it is frequently used interchangeably. From this it already becomes evident that outside homeopathy there is also little consensus of terminology or definition.

With respect to homeopathy, Guajardo et al. [13] state that we, homeopaths, “maintain the habit of labeling ourselves as a dissident medicine” (p.35), so to speak as `alternative´ or `unconventional´, “when in truth homeopathy is but a method” (p.35). Why is homeopathy described as a ‘other´ medicine, when in reality homeopathy just like many other therapeutic methods, is but a treatment approach to illness [12], a discipline, a methodology or a specialty? Homeopathy is not alternative or unconventional compared to medicine, but complementary to the different treatment disciplines that make up health care and make up what is described as `medicine´. The term `medicine´, is therefore the generic expression for many different treatment approaches aimed at treating disease.

Science or paradigm

Homeopathy, being one treatment approach of many that are together comprised in the term `medicine´, raises fundamental questions. If homeopathy belongs to the group `medicine´, and medicine is described as scientific, then homeopathy as a medicinal discipline should also be scientific. Yet critics find it hard to permit homeopathy this sort of labeling [4]. The argumentation is that the principles underlying homeopathic practice are “not explainable on the basis of established science” [10](np). Bellavite [3], states that “the homeopathic and scientific medical worlds have developed separately” (p.203). But this again places homeopathy aside of medicine when semantics above has shown that it is in fact a therapeutic discipline of medicine. So where does homeopathy stand?

Campbell [4] argues that what is described as conventional medicine frequently does not live up to the attempt to be scientific, and homeopathy, on the other hand, is the “only true scientific form of medicine” (p.79). Science, according to a dictionary definition is a: “branch of knowledge involving systematized observation of and experimentation with phenomena; systematic and formulated knowledge” [19] (p. 667). Does this not apply to both the generic term `medicine´ and specifically to homeopathy? With its underlying principles that are fundamental to homeopathy, and the confirmation of its efficacy in practice [4] homeopathy should be acknowledged the requirements defined for a science. Why then is it viewed with criticism and not acknowledged as scientific?

The question of the efficacy of ultra molecular potentization is one that critics describe as obstacle to homeopathy’s acknowledgement as a science. The efficacy of a homeopathic remedy potentized beyond Avogadro´s number, that is, beyond the stage where an molecular entity is traceable in the attenuation [28], [32], is in its mechanism not explainable by the laws of the mechanistic [1] or materialism [23] paradigm of science that scientists generally apply to the realms of medicine [1], [23]. What a paradigm represents is according to a dictionary definition, simply an “example or pattern” [19] (p.531). A better description is given by Swayne [27]: “a mindset that determines, and restricts, the direction in which scientific thinking and investigation are allowed to progress” (p. 90).

And again, here it becomes evident that there are differing terminologies in use. Is there the mechanistic paradigm as Bastide [1] calls it, or the materialism paradigm, so named by Scholten [23] in his article, in application of mainstream science? Are they the same or different? Why do we use different terminologies? `Mechanistic´ relates to `mechanism´, “structure or parts of machine or other set of mutually adapted parts” [19] (p.456), and `materialism´ means “nothing exists but matter and its movements and modifications” [19] (p.453). Both definitions have in common what Scholten [23] points out for the materialism paradigm that denies “the existence of emotions and thought” (np), and claims that “only the material world can be object of scientific research” [23] (np). Consequently homeopathy is declared as incompatible with the dominant scientific paradigm, and is denied recognition as a science.

In homeopathy, we speak of vitality and potentization and include criteria that are immaterial such as emotions and consciousness [23]. Therefore, does this not call for a new framework or paradigm as the, to date, dominating one “is in contradiction with the experience of all people” [23]?

We are in need of a shift in paradigm! A shift that permits the comprehension of “living structures” as Bastide [1] put it.

The paradigm of signifiers identified by Bastide and Lagache in 1992 is one that could be used to understand the impact of ultra molecular potentization [2] (nd). It states that “life forms communicate with their world in a non-verbal way, both on a somatic and a psychological level” [1] (p.129). In terms of ultra high potentization, this implies that homeopathy is related to a form of information transference. This implies that the remedy incites a transference of information from the remedy into the patients system, that is there recognized as a potential source of harm and consequently the immune system reacts by fighting this and the similar, existent disease information [1]. The result is a return to health of the patient.

Potentization can therefore be seen as the process that extracts information from the solvent [2] and thus a homeopathic remedy “contains only information but no molecules” [29] (p.109).

The problem that remains is that “as long as the materialism paradigm prevails, proof in favor of homeopathy will be denied, ridiculed or put away as irrelevant or unreliable” [23]. And this explains why recent research that undeniably provides evidence for the efficacy of ultra molecular potentization is rejected, although “information specific to the original dissolved substance remains and can be detected” [29] (p.109).

Experience or research

The recent research conducted by Montagnier et al. [17] has been revolutionary in that it demonstrated that there exists the “capacity of some bacterial DNA sequences to induce electromagnetic waves at high aqueous dilutions” (p.81). Chikramane et al. [8] have been successful in providing evidence for the retention of “starting materials and their aggregates even at extremely high dilutions” (p.242). The latter is, like the former, for homeopathy, of radical and outstanding value. This has major implications for future research, focusing on the comprehension of the processes underlying potentization and remedy activity [8], and consequently, may, at the scientific foundations, foster the necessity to re-consider the paradigmatic orientation.

Scientific research is necessary where the results reduce insecurity and deliver a better basis for decision making [31]. But according to Rubik [21] “major changes in science have never been brought about by isolated experimental findings but by collective evidence” (p.165). This gives rise to the question of why the numerous homeopathic provings that have been undertaken, with ultra molecular potentized remedies, leaving healthy individuals experiencing symptoms that have distinct parallels to the symptoms created in the testing of crude substances [18], are given little notice. Likewise the many successful treatments reported by patients, providing proof of efficacy of homeopathic remedies, are consistently ignored by those external to the discipline.

Experience in practice has justified our treatment approach and yet not all rules of homeopathy behave strictly as Hahnemann had described it. The circumstances out of which Hahnemanns´ postulations developed, have to be viewed critically and comparatively to the development of us and our environment in the time since Hahnemann wrote the Organon [22]. For example, we have to acknowledge that in ultra molecular potency prescribing “the old axiom of high potency for mentals and low for physicals is irrelevant” (p.83) as Sherr [24] put it. This shows that our practice in over 200 years is constantly put to the test in order to improve and prove our claims.

Likewise I believe that Science and its´ paradigm should be re-viewed critically and comparatively to its development through time and should experience a re-evaluation.

We humans are undeniably emotional and have a conscious functioning. Therefore, the dominant paradigm excluding the immaterial is outdated and should undergo a shift.

Conclusion

In the over 200 years of its existence, homeopathy has experienced highs and lows, great acceptance and large opposition. It is undisputable for those convinced by its efficacy that ultra molecular potentization contains an active property. Critics undoubtedly will oppose even the above mentioned study results.

What happens during the process of dynamization of an ultra molecular potentization, is still without comprehension even for us homeopaths, and is, for those from outside homeopathic prescribing, an even greater prohibition to acceptance of homeopathy as a rational healing discipline [26]. Yet research has provided us with the proof that something remains in our potentized remedies.

Therefore, in my communication with patients and in discussions with interested persons, when asked to theorize on a possible mechanism of action of the ultra molecular potentization, I describe a model quite similar to that fundamental to the paradigm of signifiers. The terminology of `ultra molecular potentization´ allows, for me, little other speculation of a possible mechanism of action. The transfer of information and a subsequent immune response against the intruder that carries a very similar imprint of information to that of the disease, present in the patient, cannot be denied plausibility. Given this explanation, the criticism against homeopathy is not silenced, but its plausibility thoughtfully weighed as possibly inherent of a mechanism following this explanation [16].

Future research will hopefully bring us closer to knowing how exactly this mechanism works.

It cannot be renounced that we have to be more careful with the choice of our wording. We homeopaths, have to reach an agreement on our language, such that this will be copied and borrowed correctly by others engaged with homeopathy, and by those external to our discipline, scientists and lay persons alike.

It is false to postulate `ultra high dilution´ as a fundamental concept of homeopathy. The definition of terminology used, requires specification and consensus of meaning. What we seek to express, needs to be just.

A universal consensus will globally inform and subsequently reduce criticism that is founded on wrong semantics.

Guajardo et al. [13] state that, “we should nurture the dignity of our specialty” (p.36). We can do this by assuring a high level of education of future practitioners [5], [13], by committing to unbiased research and by sharing a joint terminology, globally, of those practising the homeopathic healing art.

[Many thanks to Hazel Partington and Jean Duckworth, University of Central Lancashire, U.K., for their assistance with this assignment]

© U.M. at Clever Homeopathy

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The challenges of IBS – A critical analysis of research in CAM and a critical examination of methodological modifications suitable for future investigations on IBS and for research in CAM in general

Introduction

Irritable bowel syndrome, IBS, is a diagnosis that is difficult to understand and difficult to treat [8]; [30]. Its definition is vague: IBS is a syndrome that incorporates symptoms of several functional gastro-intestinal disorders [8] that should have been experienced by patients´ for at least 3 months [3]. As a description, this is non-inclusive of the vast array of symptoms that have been identified as characteristic of IBS [16]; [21]; [24] [See Table 2]. Further complication arises with the fact that “the nature of symptoms [also] can vary amongst patients with IBS and within the same patient over time” [8] (p.1697).

Doctors and therapists therefore, find themselves confronted with variable aspects that make it difficult to diagnose the syndrome and complicate the process of identifying a curative treatment [8]. A precise etiology of IBS does not exist [4]; [24]; [26]; [30] and the diagnosis of IBS is largely achieved by exclusion of other more serious ailments [3]; [8]; [23]. IBS is associated with numerous burdens for the patient, ranging from physical and emotional impact to increased medical costs and decreased quality of life [8]; [13] [20].

In conventional medicine the treatment of IBS is “notoriously unsatisfactory”, [18]; [1] no curative agent is known [4]; [18]; [19]; [20]; [1] and no conventional treatment has educed efficacy in research [8]; [24]; [23]. As a consequence, “therapy for IBS is palliative and supportive, targeting specific symptoms” [18] (p. 2650) only.

Management of symptoms is in CAM, likewise, the main focus in the quest for improvement. CAM too, has to date not produced an effective treatment for the expressions of IBS [4]; [15], albeit offering aspects of treatment such as patient centeredness and individualisation that have been identified as prospective influential components of patient improvement and compliance [12]; [22].

The initial aim of this essay had been to identify evidence of efficacy of homeopathy for IBS. Unfortunately, respective studies and trials were scarce and available as abstracts only, such that the field of investigation had to be broadened to allow a critically examination of research in complementary and alternative medicine (CAM). Yet, focus had to be diverted again, due to the lack of evidence of efficacy of CAM treatments. Consequently this essay seeks to critically analyse research in CAM using the example of IBS. The aim is to identify improvements to research models employed for CAM that acknowledge the philosophical principles underlying holistic, complementary health care, whilst meeting the demand for evidence based proof of efficacy that is fundamental to research in conventional medicine. It is sought to extrapolate from these findings implications for future investigations into the efficacy of homeopathy, for IBS and in general.

Identification of existing literature on IBS

Studies, trials, systematic reviews and meta-analyses were included in this critical analysis. A search for relevant publications was performed on several databases namely, on Sciencedirect, Ebscohost, Pubmed, the Archives of Internal Medicine, the National Institute of Mental Health, Sage publications, the British Medical Journal and the Cochrane collaboration, as well as Google and Google-scholar. The search was performed in the English, German and French language. The initial search terms were: Irritable bowel, irritable bowel syndrome, IBS, complementary and alternative medicine, CAM, alternative therapies, and respective terminology in French and German. These terms were used separately or in differing conjunctions.

Most studies and publications were found via Science-direct, Wiley Online Library, and BMJ. Results in German and French were mainly pay on demand and were only available as abstracts, and were therefore excluded.

The search for articles on research methodology in general, in conventional medicine, CAM and homeopathy was conducted principally via Sciencedirect and Ebscohost. Keywords were: Study design, qualitative research method, methodology of trials, challenges to RCT, random controlled trial, research in CAM, research in homeopathy, whole system research.

Via the references of studies and reviews, the selection of the search-option `similar articles´ on Sciencedirect, and citations of articles, further publications and information were obtained. The selection of articles was restricted to the years 1978 until 2011. The final update of references for this essay was in April 2011.

With respect to the publications included in this analysis, what was considered as CAM were disciplines conform with Chang and Lu´s [4] definition of CAM, as:  “medical practices that are not currently considered a part of conventional medicine” (p.295).

Critical examination of selected studies on IBS

Table 1 – Selected Studies

What becomes evident from the analysis of sourced publications is that there exists a fundamental problem with research on IBS. The absence of consensus of definition of what irritable bowel syndrome precisely describes, flaws trials and studies from the very beginning.

Bommelaer et al. [2] have clearly demonstrated this with the outcomes of their study. Whether IBS is identified by use of the Manning, or evaluated by the ROME I, II or III criteria has impact on the prevalence measure of IBS (See table 2 for criteria describing IBS). Cabré [3] and Pavan et al. [19] also voice this criticism.

Bommelaer et al. [2] further point out that the inclusion of a factor descriptive of “frequency and duration of disorder is highly discriminating” (p.559), as prevalence is influenced by such data and consequently cannot be judged as precise. Biased outcome may also result if participants of the trial or study are expressing symptomatology of IBS at different stages [7]; [9]. Furthermore, in multi-national trials, prevalence, as is noted by Quigley et al. [20] may be flawed due to differing patient and practitioner awareness of the syndrome from one country to another.

Table 2 – Criteria defining IBS

Complementing the above, Whitehead [30] points out in his review of studies on the evidence of efficacy of hypnosis for IBS, what is critical for all studies, equally, if not more so for meta-analyses and systematic reviews in CAM, on IBS and in general. When comparing the efficacy of numerous studies, it “requires basic comparability in outcome measures” (p.17). This is not only of relevance concerning the definition of IBS, but likewise when investigating other measures, such as quality of life or emotional impact, especially when comparing studies from different disciplines.

The meta-analysis of Dorn et al. [6] abstracted the diagnostic criteria in their analysis. Their analysis was indifferent of the bias underlying the employment of differing definitions of IBS, and therefore of prevalence, as their focus was on “placebo response in CAM trials of IBS” (p.630). For identification of their outcome, the authors used 10 trials on herbal remedies, 1 on the use of melatonin and 1 on psychotherapy. Their results can hardly be generalized for all of CAM, and due to the superiority in number of studies on herbal therapy are at best representative of an evaluation in herbal treatment. Further, as the authors themselves point out, the inclusion of a study from the field of psychotherapy is critical, as this treatment approach is one considered to belong into the realms of conventional medicine.

Dorn et al. [6] contradict themselves in discussion and conclusion, when they point out in one that some consideration has to be given the nature of CAM treatments, with a possibly enhanced placebo response in CAM due to the therapeutic relationship, yet exclaim in the other that in CAM and conventional medicine placebo response rates are similar and therefore “independent of the type of therapy used” (p.634). Dorn et al. [6] take the evidence for these statements from different sources, showing clearly that research in this field is still inconclusive. This raises the question whether it is appropriate, in investigations into CAM, to employ research models that fall short of identifying and considering non-specific, but influential factors such as the therapeutic relationship in a treatment. RCTs deliver only one answer to a question and are non-multi-factorial in design [28] and therefore seem insufficient for investigations into CAM.

Shi et al. [21] have restricted focus, in their review, on the “effectiveness and safety of herbal medicine” (p.454) for IBS. They too have noted that prevalence differs depending on criteria employed and mention yet another evaluation criteria employed in China. They have evaluated RCT´s only, but have not insisted on blinding of the trials and studies selected. Shi et al. [21] concluded that 82% of studies reviewed were of poor methodological quality and consequently herbal treatment should “not be reliably recommended” (p.461). They further criticize that duration of study and respective treatment and follow-up were too short in most studies to be able to identify efficacy of herbal treatment. They make the point that in practice too, with short treatment duration, “it is hard to reach the therapeutic goal in IBS” (p.460). Although they did not focus on the placebo-response rate Shi et al. [21] further remind of the therapeutic relationship as possible causative factor of a high rate.

The importance of a longer duration of a study is also an aspect implied from the McFarland and Dublin [18] meta-analysis on the use of probiotics for IBS.  They too point out that current research suffers many methodological flaws and future trials should be designed for longer duration, and should be conducted with more rigor.

Hussain and Quigley [11] stress that in CAM few studies have been subject to RCT´s, and if investigated employing the `gold standard´ of conventional scientific research, the quality of trials has been low. They point out that in as many as 5000 trials, as little as 10% were actually properly blinded and randomized. They conclude that studies in CAM are complicated by higher placebo response rates and consequently little progress has been made in CAM research in general and for IBS.

An RCT, performed on the efficacy of acupuncture on IBS, by Kaptchuk et al. [12] demonstrates the difficulty in association to blinding in some treatment approaches of CAM. Kaptchuk et al. [12] have blinded their trial by using sham acupuncture and although Kaptchuk et al. [12] claim that their blinding has been successful, Mason et al. [17] state that such blinding in CAM “should be treated with caution” (p.833). They point out that the patient experience of a sham treatment does differ to that in regular practice.

In conclusion to their study Kaptchuk et al. [12] emphasize “that an enhanced relationship with a practitioner, together with the placebo treatment” studied in one of their 3 groups, provided “the most robust effect” (p.6). The therapeutic relationship therefore could be rated as the strongest of non-specific effects of the study. Its dominance is markedly and proves of clinical significance in the management of IBS. Kaptchuk et al. [12] in fact stress person-centred modalities as elemental to the patient-practitioner interaction, and consequently acknowledge these as significant to the clinical outcome, although they recommend further research to verify this. They further point out that they suspected in a trial on IBS, with a markedly subjective symptomatology, to be able to best demonstrate the relevance of such non-specific effects as the therapeutic relationship. They acknowledge as a limit to their trial, that it could not be identified whether the placebo outcomes originated from true pathological improvement or were due to a mere shift in patient focus away from their symptoms of IBS, and further admit that they experienced difficulty separating observation and assessment effects.

None of the above publications provided generalisable, conclusive evidence of efficacy of the therapeutic approaches for the treatment of IBS.

The potential contribution of other research designs on understanding IBS

What can be extrapolated from the above its that, beyond consensus in criteria used to identify IBS, it is essential, that in order to provide evidence for the efficacy of CAM for IBS, research models are adopted that are not ignorant of non-specific effects, and in fact identify such influential factors.  The gold-standard RCT cannot provide this. The above has shown that the possibility exists that “the non-specific components of treatment may be vehicles for the delivery of clinical benefits” [29] (p.187). RCTs are designed to investigate into one single quantitative effect [5]; [27], an aspect that entirely ignores the qualitative idiosyncratic approach of CAM [17]; [27]. A research methodology investigating into CAM must meet the demand of high scientific rigor and must be able to merge this with the holistic principles underlying the practices of CAM disciplines [17]; [29].

The identification of a blind-able placebo is another aspect complicating RCT approaches to research in CAM [17]; [27]; as could be extrapolated above in the study by Kaptchuk et al. [12].  Randomization may also be difficult, the patients prepared to participate in this type of trial, may be influenced in their decision by their own preference and belief [17]; [27]; [28].

It has been attempted to modify RCTs to adopt a more qualitative assessment. In what is termed `pragmatic RCT´, it was sought to create a model that investigates the entire system of a discipline within its individualised context [27]. Unfortunately, this format is restrictive and only partially meets the demand for a trial assessing multiple aspects of a holistic treatment approach [27]. Randomization, a blind-able placebo, as mentioned above, and the exclusion of influence of the therapeutic relationship with the practitioner are only marginally achievable [27]. Other variations of RCT´s, such as `preference trials´ [27] and `n-of-1 trials´ [28], have been identified to be likewise restrictive.

The `formal case study´ is a model for investigation that seeks to combine the conventional RCT design with the homeopathic patho-genetic trial, the homeopathic proving [25]. RCTs on homeopathy are flawed as the control with placebo is identifiable at follow-up level and the patient-practitioner relationship may be influential on the outcome [25], as is shown in the above analysis of studies in CAM. The formal case study delivers information on the contextual effects of the researched intervention and is adaptable to other alternative treatment approaches, nonetheless it is also criticised as being inconclusive [25]. A still unmet requirement for the `FCS´, is to master the divergence of the interpretative outcomes established by the different researchers analysing the same data [25].

In opposition to Thompson [25], Weatherley-Jones et al. [29] understand homeopathy as a discipline of CAM that “appears to lend itself well to placebo-controlled trials of efficacy”. They do not acknowledge the identification of the placebo upon progression into follow-up. Nonetheless they consent that the effect of the multiple components belonging to therapeutic interventions of CAM cannot be identified using the RCT, and as such outcomes in homeopathy cannot be generalised [29].

The ANOVA model is a research design that permits identification of two therapeutic aspects, yet Weatherley-Jones et al. [29] have identified its restriction. This model is flawed by the inaptitude of creating a study arm that can provide a group with an individualised treatment, devoid of a consultation [29]. Weatherley-Jones et al. [29] make the suggestion that focus of research on individualised therapies, such as homeopathy, should be diverted to the question of usefulness to health care in general. The relevance of an intervention to patients and practitioners may be valuable in the analysis of effectiveness of a whole system [29]. They suggest pragmatic trials for this purpose, yet these have limits as was noted by Verhoef et al. [27] and described above.

Most investigations have their focus on identification of efficacy or effectiveness of a treatment approach, the principles according to which CAM treatments work are in conventional research neglected [28]. Restoration to health in a holistic CAM treatment is influenced by multiple, individualised factors that are interconnected [5]; [17]; [28] and cannot be separated. Like Weatherley-Jones et al. [29] above, Verhoef et al. [28] postulate the adaptation of research models that take a whole system approach. This form of research must value to equal terms qualitative and quantitative methodologies in order to do justice to both, the nature and the holistic principles of the CAM approach and at the same time the demand for scientific rigor. A mixed-method-research model, therefore, “has most potential to effectively evaluate whole systems of health care” [28] (p.209). Such a model would incorporate patient experience and value attributed to the context within which a treatment is delivered, and would merge this with the evaluation of effectiveness gained through statistical appraisal of RCTs. Not only for disciplines of CAM, such as homeopathy, with its individualised case-taking and prescribing, but indeed also for “complex interventions in conventional health care” [28] (p.211), is a whole system research approach increasingly valuable.

Conclusion

In conventional medicine the striving is for `evidence-based´ approaches to treatment, yet with IBS, according to Thompson et al. [26] it should be stressed to make patient-centred, individualised decisions, an aspect belonging much more into the realms of CAM. The patient-practitioner relationship has been augmented as a factor important to the management of IBS [10]; [11] and research has delivered evidence of the therapeutic relationship as a non-specific effect of RCT´s undertaken in CAM [12]. The quest of finding an effective treatment for IBS requires understanding of patient experiences [1]; [24]. In the disciplines of CAM employing a holistic view of patient condition [22], practicing an idiosyncratic treatment approach [1] promoting a therapeutic relationship [23], and allowing patient empowerment [11]; [14]; [15], have been recognized as influential in a successful treatment of IBS.

Research in CAM needs to be as rigorous as that of conventional medicine, but failure to take into account the impact of the holistic nature of CAM produces, with RCTs, flawed results [17]. Consequentially a new model of research needs to be adapted for investigations into CAM. Future research into CAM should be sensitive to such elements that are increasingly being recognized as influential to patient treatment. Whole system research is an approach aiming to incorporate scientific rigor and qualitative experience [28]. Verhoef et al. [28], state that investigations into such models are currently being undertaken. Therefore, as IBS is considered a disorder that affects patients all their life [1], for the sake of the suffering patients, a consensus on a research model considering implications of whole systems should, preferably, be found soon.

Consequentially, future studies and trials investigating into the efficacy of CAM therapies for IBS could then possibly, with the utility of a modified research methodology, eventually elicit a successful treatment for IBS.

[Thanks to Kate Chatfield, University of Central Lancashire, for the assistance with this assignment.]

© U.M. at Clever Homeopathy

References:

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A Critical Analysis of Organopathy in Diagnosis and Practice

Introduction

There are many different ideas in homeopathy today and many angles from which case-taking, analysis and prescribing is approached. The more recent theories come from homeopaths such as Scholten, Mangialavori and Sankaran, to name a few, who seek to enhance the comprehension of homeopathy, the familial connections of remedies and the methodological aspects of case-taking and case-analysis1.

We have already seen the development of approaches which differ from Hahnemann’s classical approach. These approaches have gained a valued place in the treatment of disease.

This essay investigates one of the `older´ approaches, that is different from the classical concept, but nonetheless homeopathic in its foundation2.The focus of this critical analysis is ‘Organopathy’, which describes a treatment practice where case-taking focuses on locality, and remedy selection on the symptoms of organs or organ-systems3. This approach implies that the vital force creates disease in the organs and that organs and organ-systems are interactive parts of the whole4.

Historical evolution

The organopathic treatment approach is much older than classical homeopathic prescribing5. Beginning in folk medicine, prescribing by interpreting similitude of a healing agent to indications of internal organs was common practice. What found its origin in Paracelsian medicine and was regarded much as an earlier notion of the Hahnemannian understanding of similar, was further developed by Rademacher as an independent pragmatic medical art. It was refined and defined by Burnett in the 1900´s as organopathy5.

Paracelsus (1493-1541), 200 years prior to Hahnemann (1755-1843), pointed out that “similar must be compared to similar”6. He referred to plants as ‘external’ organs, and was the initiator of the idea that a “disease is cured with a substance which has the same essence”5. It was Paracelsus who first spoke of the idea of Similars7. But his understanding was not the same as what Hahnemann later incorporated into his Law of Similars. The difference between the Paracelsian view and the Law of Similars is of a pharmacological nature. To Paracelsus, ´similar` meant that the internal organs of an organism had an herbal counterpart in nature that was similar to the organ’s specific disturbance8. For Hahnemann, ‘Similar’ meant that the symptom picture expressed in an ill individual had to be similar to the symptoms experienced by a healthy person upon ingestion of a substance, in order to cure5.

Hahnemann (1974), as described in Aphorism 18, saw only the totality of symptoms expressing the ill state, and cure therefore should only be possible matching a remedy to the given totality.

Rademacher (1772-1850), who was a contemporary to Hahnemann, introduced the identification of the pathologic organ as origin of an illness9. Paracelsus and Rademacher alike understood an organ to express the state of the whole individual, and the curative action of a remedy on the diseased organ should heal the entire individual. Hahnemann refined this by taking into consideration specifics about the character of the indisposition and by seeking a comparative system of mapping remedial action identified in a healthy individual, with the symptom pattern of a disease7.

It was in the late nineteenth century that Burnett (1840-1901) sought to combine the Paracelsian view of the curative effect of remedies in nature, with the physical aspects of diseases that Rademacher had identified, and aimed at unifying this with the philosophy of the homeopathic treatment approach10. He thereby introduced a new joint approach to healing described as organopathy.

Burnett was member of the legendary Cooper club, where Skinner (1825-1906), Cooper (1844-1903), Burnett and Clarke (1853-1931) critically investigated the old and new theories of homeopathy. Whilst Skinner and Clarke were advocates of high potency prescribing, Burnett and Cooper were users of un-potentized tinctures and low potencies. During the time of the Cooper-club, these four investigated treatment approaches and remedies, and expanded the use and diversity of nosodes10, (preparations derived from pathological cultures or secretions11). Burnett made use of organopathy and the miasm theory, with the prescription of nosodes, especially in his treatment of cancer10.

Philosophical underpinnings

Rademacher challenged the theories postulated by Paracelsus and researched the principles the latter had formulated. Rademacher had to acknowledge that organs could be seen as individual entities and as connected to the bigger whole2,8. He also had to confirm that in nature there existed sources of remedies that reflected organs in the body, and that the expressions of a disease were also influenced by the patient’s environment. In conclusion, he had to affirm that the “energetic principle of the remedy is curative of the disease” 8 (p. 540).

He identified and described ‘Universal remedies’ that reflected the theory that Hahnemann had found in his miasms. These were three basic ailment patterns he recognized inherent in patients, much like Psora, Sycosis and Syphilis8. To him the reaction of a remedy on the whole person was universal, and that affecting only an organ, of organopathic utility12. Rademacher therefore declared that a patient, whose pathology could not be helped by the use of organ remedies, would be subject to amelioration by a universal remedy related to one of the three principal patterns8.

Rademacher identified a disease as organopathic if the primary seat of the disease was the localization of pain in that particular organ. This ‘specificity of seat’ was recognizable if in the acute flare-up, pain was felt longest in the organ of primary affection9. This did not mean however, that the symptom manifestation in an organ, necessarily identified the disease as confined to this one particular organ12.

Underlying this, according to Burnett, was the idea of a pathological perspective of homeopathy, where the simillimum selected is that of the disease and not just that of the symptoms. He believed that behind the holistic symptom expression is a more distinctive, a more precise symptomatology that identifies the “true pathologic simile” 2(p.95). To Burnett there existed different types of simillimum, namely the ‘pathologic simile’ reflecting the development of disease, the ‘simple symptomatic simillimum’ taking into account the totality as proclaimed by Hahnemann, and a ‘simple simillimum’ that has a superficial correspondence to symptoms expressed2(p.95).5

Comparison with Hahnemannian teachings

In order to compare Hahnemann’s and Burnett’s homeopathic approach, their two descriptive terms of homeopathic treatment have to be differentiated. Classical homeopathy is the Hahnemannian approach, where the prescribed remedy is selected in order to most closely match the totality of the individual symptoms in a particular patient.13,3 Clinical homeopathy comes closer to the fundamental principle of organopathy. In this, homeopathic remedies are selected according to a “disease name”14, that is, according to a clinical diagnosis and the symptom-similarity to the diseased organ13. Organopathy is therefore seen as quite close to allopathic, diagnostic treatment15.

Hahnemann’s and Burnett’s aspects differ fundamentally in terms of idiosyncrasy. Individualization is that fundamental key to Hahnemannian case-taking. Hahnemannian focus is on the individual, externally expressed signs created by the impaired state of health. Hahnemann sought to compile subjective, patient specific symptoms16 which could be descriptive of a defined anatomical area of the body, but not so refined as to be specific of an organ-pathology. This meant that with Hahnemannian case-taking, organ specific descriptions could be missed2. Burnett represented the belief that the pathologic aspect, the ailment inside the organism, needed also to be taken into consideration, and that “a case had to be homeopathic from the pathological perspective too”2 (p.95).

The detail of anatomical expression, specifically of physiological activity, to Burnett, described the organ that was pathologically impaired and reflected indicators to the remedy that had an affinity to that particular organ2. Yet Burnett believed that the simillimum to a patient’s diseased state could be found by application of either technique, Hahnemann’s symptomatic, taking into account the totality of symptoms, or his pathologic, disease-specific, simillimum approach2.

There are diseases that have no totality encompassing symptomatology, where the pathology is organ specific, organ symptomatic and confined to the locality of a specific organ17. Burnett was constantly aware and deliberate of retrieving the most ‘similar’ remedy for a disease, but recognized that organ diseases frequently required only organ specific healing18. This is much in opposition to what Hahnemann indicated in Aphorism 7 of the Organon, that the only form of healing is that which incorporates the totality of the patient, even if there is only a localized, organ-specific symptomatology19.

In prescribing, Burnett’s method was also in opposition to Hahnemann’s idea. Burnett could not confirm Hahnemann’s postulation that each case of illness of every individual required only one single prescription. Burnett’s emphasis was, that there was a requirement for well-reasoned multiple prescribing and administering of remedies2,20. But Burnett had to acknowledge limitations to organopathic prescribing. A health impairment on a constitutional level lies beyond the range of activity of organ remedies. Burnett saw this as the “inherent defect of organopathy”5 (p.18).The holistic organism is left unaffected by organopathic prescribing, only the interaction of organ and organism may be influenced positively2.

Particular indications for the use of this method included specialized areas of practice According to a survey done by Monk-Schenk in 2002 the main characteristics demanding the use of organ supporting remedies today, are indicated by chronic suffering where the central focus of symptom expression is on a particular organ. Organopathy is also indicated where expressed symptoms are localized and of a physical nature, and where the patient claims to never have been improved since the organ was affected2.

Whilst it has been repressed in classical homeopathy, locality is one main indicator for an organopathic treatment. Locality is of major importance, as Burnett points out that the pathology of symptom expressions needs to be encompassed by the chosen simillimum9. According to Blair’s (2009) article, Burnett found Hahnemannian homeopathy too limiting, as the Law of Similars only permits one interpretation of a simillimum and is therefore restrictive in finding the specifically matching prescription. Burnett pointed out that organs are individual systems within the organism, the bigger system, which have individuality in terms of their functions and their diseases. He indicated that if an organ autonomously suffers from disease it can be cured by treating organopathically. If on the other hand the organ is impaired due to the whole organism’s suffering of a chronic, miasmatic impairment, the organopathic remedies will act solely as palliatives and the great anti-miasmatic remedies have to be prescribed20. This becomes evident in Burnett’s treatment of Tumors in Cancer.

Burnett was described as a “great cancer doctor” in his time20. He insisted that in advanced physical pathology, the treatment with low potencies and tinctures is of greatest benefit to the patient10. It is with the combination of the high potency prescribing of classical homeopathy, the administration of Nosodes and organ-specific treatment that great success is seen in the treatment of cancer2,5,21. This combined treatment of local affinity and miasmatic trait is aimed at achieving a complete and permanent recovery4.

Burnett successfully treated the local affection and the effective disposition. The local destruction of the cancerous growth alone could never have been declared a healing, as long as the disposition was not eliminated4. “The chemical destruction of a tumor is pointless, because it is a sanguine growth that has to be cured vitally”4 (p. 5).

Burnett saw cancer as “the final stage of a chain of causal occurrences”4(p. 5). Whilst his belief remained strictly classical homeopathy in that the aim was to heal the vital force that had created the cancerous growth, he was convinced that only a series of remedies could cure a case. He believed that each individual remedy working in the direction of cure could, combined together, lead to cure of the cancer4. In his prescriptions for the treatment of cancer, he alternated between anti-miasmatic remedies in high potencies and organ-specific medicines in low potency. His repeated administration of remedies in high potencies did not follow Kentian specifications4, where a single dose of a single remedy was administered and a repeat or subsequent prescription would not be given until the prior remedy had completed its action22. Burnett would administer high potencies in a few weeks of one another and low potencies several times daily4.

This methodology has regained its importance and has been applied by Coulter and Ramakrishnan (2001). They have recognized that the affinities of organ remedies to an organ are thus also specific to the site of cancer development if it is located in that organ. Their treatment of cancer incorporates the alternation of an organ support remedy with one identified as constitutional.

Another indication for the use of an organopathic treatment approach is found in the methodology that is described as drainage. Here the aim is to select remedies that lead to a detoxification of the body23. Maury (1965) ascribes a dual role to drainage; that of organ stimulation and of excretion of toxic products that have been bound in the diseased organism. He postulates a three-fold benefit to the methodology. There is a benefit to the patient in that the detoxification of the organism will avoid an interaction of toxins with the remedies that are subsequently administered. The treatment of the excretory organs prior to remedy prescription may result in a more rapid onset of the effects of the remedy that is to follow detoxification. As a consequence, the homeopathic treatment will be experienced as a rapidly acting methodology without any aggravation24. A further indication for the use of organopathy in organ support, as Runcie (1972) points out, is to eliminate possible aggravations for patients who are sensitive25.

Implications for case-taking method

The organism is an entity, a co-existence of inside and outside that is monitored and operated by a dynamic life-force20. Therefore, prescriptions in homeopathy are sought to be individualized. Hahnemann (1974) in Aphorism 5 of the Organon points out that only the idiosyncratic totality of symptoms perceived in the state of illness can point the practitioner to the selection of an appropriate remedy. In Aphorism 185 he discusses the implications of a locally circumscribed disease that does not create symptoms other than those at the specific location. Yet Hahnemann never omits the aspect of individuality and totality of symptoms in his case-taking, much in opposition of the information that is needed in application of organopathic principles.

Case-taking with an organopathic focus is considered much more superficial than that of classical homeopathy, as only local symptomatology is considered26. Organopathic case-taking requires the practitioner to have vast knowledge of disease symptomatology and organ function2. To Hahnemann of course, this was the much rejected alliance of allopathy and homeopathy that he wanted to avoid and that opposed the acquisition of the symptom totality that he taught2.

The allopathic diagnostic techniques utilized by Rademacher, such as palpating the organ, were later adapted by Burnett5,8. Burnett had sought a system to utilize for prescribing, when with the classical Hahnemannian case-taking, the identification of a simillimum was not possible5. For an appropriate prescription, he considered three fundamental foci of action of an organ remedy. There had to be the considered the relation of a remedy to a particular organ, the character of action it was able to produce and its range of impact2. He also indicated that there was a posological and dosological aspect to organopathy. He pointed out that organ remedies had a stronger impact on disease in material dosage and in repetitive prescription, whilst the higher potencies were considered more appropriate for constitutional prescribing and less frequent administrations2. Here Burnett conformed to the principles laid out by Hahnemann. The dosage and potency that Burnett expressed, he justified as due to the reduced similitude that organopathic prescriptions have, whilst the remedies given constitutionally, in increased potency had a larger spectrum of similitude and therefore the dosage could be lessened18. The organopathic treatment was generally a single or compound prescription administered in low potency that was frequently repeated. The dosage was adjusted according to the patients´ reaction to the prescription. Rademacher pointed out that seldom is one single remedy sufficient to cure a case5.

Implications for conceptual analysis of materia medica

Organopathy has given a new approach to remedies and their prescribing. The organopathic remedies are selected by knowledge of their pharmacological activity on the local expression and their linkage to an organ and its pathology. There is a ‘doctrine of signature’ perspective in organopathic prescribing; where characteristics and structure of plants resemble organs of the body and have a therapeutic effect on the disease expressions in an organ27. “The healthy force from the plant can be utilized against the unhealthy force in the diseased person”10. This reflects the parallel to what was understood as the Paracelsian law of Similars, and is difficult to combine with the philosophy of Hahnemannian homeopathy10. Paracelsus was a firm believer that in nature there existed an herb for every ailment.7,8.

Being largely derived from plants and administered mainly in un-potentized form, the organopathic remedies are more commonly described in the herbal materia medica than in material medica of homeopathy28. Whether herbal or homeopathic, is therefore determined by a pharmaceutical and a clinical perspective. The pharmaceutical domain requires congruence in the production of remedies as outlined in existent homeopathic pharmacopeias. The manufacturing of homeopathic mother tinctures does not differ to that of phytotherapeutic fabrication. Whether a remedy is homeopathic is therefore determined by the clinical rationale behind the administration of a remedy, by the reference to signs and symptoms valued in the homeopathic case-taking29.

Burnett also began introducing Nosodes to his organopathic treatment2,5. Especially in cancer this is today common practice as can be noted in the treatment approach to cancer taken by Coulter and Ramakrishnan (2001).

More recently Ian Watson introduced and enriched the organ therapy by the use of Sarcodes30, remedies made from healthy organ tissue11.

Conclusion
Organopathy implies that a defect in an organ should be corrected, by removing the impairing influence. The appropriate remedy is the agent employed to stimulate repair within that organ28. Burnett’s methodology is one that complements Hahnemannian philosophy2. What initially was postulated a relic of ancient folk medicine, was refined and developed through time, mainly, by Paracelsus, Rademacher and Burnett, to become a vital method of homeopathy.

Organopathic treatment stands largely isolated and much in opposition to that of today’s contemporary homeopaths, such as Scholten, with his concept of series and stages31 or Sankaran with his designation of different potencies to different levels of sensation32. Their new ideas and approaches seek to find the simillimum in the spheres of remedy affiliations to groups or families1, and are more compliant with the single remedy prescribing of classical Hahnemannian homeopathy.

Another method that has complemented the diversity of homeopathic treatment approaches, is Schüssler’s biochemic remedies12. Schüssler’s focus of prescribing also lay in the realms of low potencies10 and was aimed at promoting the regulation of imbalance33.

Whether the homeopathic practitioner relates the disharmony of a specific organ within the Hahnemannian totality to the mental and emotional traits of the individual34 or associates symptomatology to a specific organ, as in organopathy, the only aim of the practitioner should be relief the patient as described in Aphorism 1 of the Organon19.

Keller16 (p.151) stressed one point about organopathy: “However great the differences may have been in the medical thinking of Hahnemann and Rademacher, in practice we are heirs of both”!

References:

1Makewell, S. (2006) Secret Lanthanides: Commentary, Reflection, and Book Review. Interhomeopathy – International Homeopathy Internet Journal [online] last accessed 15.03.10 at URL http://www.interhomeopathy.org/index.php/journal/entry/secret_lanthanides/

2Blair, J. (2009) Organopathy – a relevant approach? The Homeopath Vol.28, No.3, pp.92-99.

3Witt, P. (2007) Organotropie : Was versteht man in der Homoeopathie unter Organotropie? [online] last accessed 13.03.10 at URL http://www.homoeopathie-heilpraktiker.de/lexikon/organotropie.htm

4Schuller, M. (unknown) Analyse der Krebsbehandlung von J. Compton Burnett, John Henry Allen, Emil Schlegel und Eli Jones [online] last accessed 13.03.10 at URL

5Monk-Schenk, M. (2002) Organ Remedies; Our Gift from Paracelsus and Rademacher, with Special Focus on the Liver and Spleen The Homeopath No.87, pp.14-19.

6Clarke, J.H. (1999) Hahnemann and Paracelsus [online] last accessed 13.03.10 at URL http://homeoint.org/morrell/clarke/prefacemorrell.htm

7Dudgeon, R.E. (2000) Similarities between Hahnemann and Paracelsus [online] last accessed 13.03.10 at URL http://www.homeoint.org/morrell/clarke/dudgeon.htm

8Whitney, J. (1996) The Legacy of Rademacher The Homoeopath No.61, pp.540-542.

9Wholehealthnow (2008) Specificity of Seat – James Compton Burnett and the Generalization of Locality [online] last accessed 13.02.10 at URL http://www.wholehealthnow.com

10Morrell, P. (1995) From Cooper Club to Flower essences: A Portrait of British Homeopathy 1870-1930 [online] last accessed 13.03.10 at URL http://homeoint.org/morrell/articles/pm_coope.htm

11Ali, M. (unknown) A study of Nosodes and Sarcodes [online] last accessed 15.03.10 at URL similima .com

12Runcie, J. (1972) Rademacher and his remedies The British Homeopathic Journal April, pp.32-34.

13 Garbers, U. (unknown) Abgrenzung des Begriffes „Klassische Homoeopathie” [online] last accessed 13.03.10 at URL http://www.praxisgarbers.de/

14Sujis, M. (2007) Potencies and chakras [online] last accessed 13.03.10 at URL http://www.interhomeopathy.org/potencies_and_chakras

15 Netdoktor.de (2010) Klassische Homoeopathie [online] last accessed 13.03.10 at URL

16Keller,von G. (1981) Chelidonium and organ therapy The British Homeopathic Journal July Vol.70, No.3, pp.143-151.

17Twentyman, L.R. (1980) The liver and depression. The British Homeopathic Journal January Vol.69, No.1, pp.12-14.

18Hofmann, R. (2000) James Compton Burnett (1840 -1901) [online] last accessed 13.03.10 at URL http://homeoint.org/biograph/burnettde.htm

19Hahnemann, S. (1974) Organon der Heilkunst (2.Auflage) Heidelberg: Karl F. Haug Verlag.

20Lohmann, W. (2008) Hereditäre chronische Krankheiten [online] last accessed 07.02.10 at URL http://www.doktor-lohmann.de/hereditäre-chronische-krankheiten.html

21Coulter, C. and Ramakrishnan, A. (2001) A homeopathic approach to cancer St.Louis: Quality Medical Publishing, Inc.

22Dayraud, V. (2000) James Tyler Kent [online] last accessed at URL http://www.homeoint.org/biograph/kenten.htm

23Voegeli, A. (1979) Das ABC der Gesundheit Heidelberg: Karl F. Haug Verlag.

24Maury, E.A. (1965) Drainage in Homoeopathy (Detoxification) Essex: The C. W. Daniel Company Ltd.

25King, S. (2005) Organ remedies Home page [online] last accessed 27.12.09 at URL

26Ärzte Zeitung (2008) Organotrope Homoeopathie ist leicht und schnell zu erlernen [online] last accessed 27.12.09 at URL

27Rafeeque, M. (unknown) Doctrine of Signature in Homeopathy [online] last accessed 15.03.10 at URL http://www.similima.com

28Rozencwajg, J. (2008) When the Perfect Simillimum is not Working [online] last accessed 13.02.10 at URL https://hpathy.com

29Jütte, R. and Riley, D. (2005) A review of the use and role of low potencies in homeopathy [online] last accessed 13.02.10 at URL http://www.elsevierhealth.com

30Watson, I. (1997) Organ-remedies – recording of a seminar in San Anselmo, California.

31Homoeopathyclinic (unknown) Prescribing on the basis of Jan Scholtens´ Method [online] last accessed 17.03.10 at URL http://www.homoeopathyclinic.com

32Olenev, D. (2010) Sankarans´ seven levels and selecting the potency in Homeopathy [online] last accessed 17.03.10 at URL http://www.homeopathyforhealth.net

33DHU (unknown) Biochemic remedies according to Dr. Schüssler [online] last accessed 17.03.10 at URL http://www.dhu.com

34Ledermann, E. (unknown) The homeopathic treatment of common liver and gall-bladder disorders [online] last accessed 13.03.10 at URL

first published at hpathy 2010

In a nutshell…evidence based medicine

What is evidence based medicine (EBM)?

Handoll and Smith [1] define EBM as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (p.251). Rosenberg and Donald [2] imply that this must be a systematic “finding, appraising, and using” of studies and trials (n.p.). Sackett et al. [3] state that the focus of EBM is to integrate “individual clinical expertise” with “the best external evidence” (n.p.) available from systematic research [4]. This means not to say that the traditional practice medicine is unreliable, because it lacks evidence or relies only on bad quality evidence, no, it is the thorough and rigid evidence that EBM demands that makes the difference. EBM looks at “evidence that matters” as White [4], (p.52) states.

Why do we need evidence based information?

Practitioners in the care of their patients will come across issues that exceed their present or most up-to-date knowledge of best practice or appropriate therapeutic handling. For clarification therefore, they may require to consult latest knowledge and research on a topic or issue to inform their practice [2]. The studying of information is a time consuming task, as it requires the consultation of vast amounts of literature, from which the qualitatively best papers and reports that have been rigidly conducted with minimal bias, have to be identified before they can be taken into consideration. This is a complicated process and is too time consuming for the busy practitioner running his surgery. For the patient too, who wishes to be well informed, about his condition or therapeutic approaches, qualitatively good information needs to be available and accessible [4].

What makes evidence-based medicine different?

EBM has sought to provide tools that summarize the information available from the vast amount of studies and trials on a specific topic. As such EBM stresses to identify those investigations that are of best quality, of rigid and thorough conduction, with the least possible of bias. These studies are then critically analyzed, and structurally summarized. This quality information is then made accessible for individuals that have no time to conduct investigations themselves, and may also, at times, not have the expertise to separate good research from bad [4].

How is evidence-based medicine presented?

Systematic reviews:

A systematic review is a structured summary of relevant evidence from research. It has a precise question that the data retrieved seeks to answer, and follows a systematic method in the process of searching for papers, selecting those of relevance and critically appraising the data from these studies. From the data that has been extracted then, a conclusive statement can be made concerning the review question [1].

Therefore a systematic review is structured as follows [1], [5]:

– There is a replicable protocol that describes and outlines the procedure to be undertaken in the process of the conduction of the review, and a predefined question that the systematic review seeks to answer and inform on.

– Step 1: It then follows a structured method of identifying studies that provide evidence for the issue investigated. Online databases provide access to published studies and trials.

– Step 2: It applies criteria for the inclusion and exclusion of trials and studies that are select for use in the review.

– Step 3: The quality of studies is then assessed using a predefined framework for the type of studies that are included. It is sought to identify bias in the individual studies. For the quality analysis of random-controlled trials the CONSORT statement may provide guidelines [9].

– Step 4: Data is then extracted and the results are combined.

– Step 5: Following the synthesis of data, a discussion and conclusion serve then to answer the review question.

Meta-analysis:

When the result from a systematic review requires statistical appraisal to synthesize the data from the included trials, a systematic review becomes a meta-analysis [1].

Where can we find EBM?

The conduction of any review presupposes that good quality trials and studies are accessible. Unfortunately the majority of research is published in journals that are available on databases that have subscription access only, or offer articles, studies and trials only pay per view. Unless therefore, the individual practitioner or patient is affiliated to an institution that has a subscription to electronic databases, he has to dispense the costly fees for publications privately. Google, with the Googlescholar search engine, provides a search option for research that can be found published on websites roaming the www. Yet, these are few, and rarely have a peer-reviewed status. There are however some open access databases, that make research available to the general public at no cost. The following are online open access databases:

Biomed Central – http://www.biomedcentral.com/

Directory of open access journals – http://www.doaj.org/

Medline via Pubmed – http://www.ncbi.nlm.nih.gov/pubmed?otool=wiuwiblib (some articles are available as open access)

Free medical journals – http://freemedicaljournals.com/

Oxford journals – http://database.oxfordjournals.org/ (some articles are available as open access)

None-the-less there is no guarantee that published studies on open access databases have been subject to peer-review verification. This can be checked by contacting the journal directly in which the study or trial has been published.

Peer-review in EBM

Peer review is a status and a criterion that EBM and consequently many of the electronic databases have for research they intend to publish. It is a quality verification whereby prior to publication, research is reviewed by experts to the topic or intervention investigated. The peer-reviewers evaluate methodology and study-design of trials, studies, reviews and analyses [6].

Why do we need EBM?

Evidence based medicine helps not only to inform practitioners and patients alike, improving care and practice, but, it may in its execution offer a means of evaluating the effectiveness of treatment approaches, and may consequently inform further research  [2],[6].

The problem with EBM in CAM

There are two aspects where EBM and CAM clash. The first is the opposition of standardization that is genuine to the conventional medical approach, and individualization that is fundamental to the philosophies of CAM practices. The second conflict is that of the tools used in the conduction of research. Whilst the RCT, the random-controlled trial, is the gold standard of conventional medicine; it is a tool that is inappropriate for investigations into the alternative, holistic treatment approaches. RCT´s fail to inform of the non-specific effects, the patients´ experience of the treatment approach [7].

There is much opposition from conventional practice concerning the question of the evidence base of CAM treatments, the notion to believe that the orthodox treatment approach is, and alternative treatment is not evidence-based, is incorrect [8]. The questions at hand are, what evidence is, who says what evidence is, and under what circumstances outcomes are considered as evidence [8]. This is and remains a controversial issue and is repeatedly subject of discussions.

References:

[1] Handoll, H. and Smith, A. (2003) How to perform a systematic review, article from Current Anaesthesia and Critical care last accessed December 2012 at URL http://www.sciencedirect.com

[2] Rosenberg, W. and Donald, A. (1995) Evidence based medicine: an approach to clinical problem-solving, article from BMJ last accessed December 2012 at URL http://www.bmj.com

[3] Sackett, D., Rosenberg, W., Gray, J., Haynes, R., and Richardson, W. (1996) Evidence based medicine: what it is and what it isn`t, article from BMJ last accessed December 2012 at URL http://www.bmj.com

[4] White, B. (2004) Making evidence-based medicine doable in everyday practice, article from Family practice management last accessed December 2012 at URL http://www.aafp.com/fpm

[5] Hemingway, P. and Brereton, N. (2009) What is a systematic review?, article from Hayward Medical Communications  last accessed December 2012 at URL http://www.whatisseries.co.uk

[6] Manheimer, A. and Berman, B. (2005) Exploring, evaluating, and applying the results of systematic reviews to CAM therapies, article from EXPLORE last accessed December 2012 at URL http://www.biomedsearch.com

[7] Yamey, G. (2000) Can complementary medicine be evidence-based?, article from West J Med last accessed December 2012 at URL http://www.ncbi.nlm.nih.gov

[8] Walach, H. (2009) The campaign against CAM and the notion of “evidence-based”, article from The Journal of Alternative and complementary medicine last accessed December 2012 at URL http://www.ehis.ebscohost.com

[9] Schulz KF, Altman DG, Moher D, for the CONSORT Group. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomised trials. Trials 2010, 11:32. (24 March 2010)