Review of the Course Resolving Difficult Cases (2)

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André Saine at Breitenbush: “Nature is Generous”
Peter Wright N.D., D.H.A.N.P.

André Saine presented a brilliant seminar on solving difficult cases at Brietenbush Hot Springs, March 31 through April 2. The weather was sunny, despite patches of snow on the ground, the setting in the Cascade range of central Oregon was sublime, and those in attendance were attentive. I would like to share a number of points here from his lively and passionate presentation, focusing mostly on his more general remarks.

Dr. Saine opened his talk with the comment that “Nature is generous:” while we always strive to find the simillimum, we are often able to help and even cure our patients with similes, imperfectly matched but close enough to their state to evoke a healing response.

Causes of failed cases
The causes of failure in homeopathic treatment, according to André, are related to deficiencies on the part of the prescriber about 70 percent of the time.

Fully 40 percent of treatment failures are due to inadequate casetaking. Dr. Saine stated flatly that if the case was taken in less than two hours, the information from the intake visit is probably insufficient. He spends an average of three hours on the initial visit, including physical examination. He will persist in gathering symptoms and sorting through possibilities until he is satisfied that he has arrived at the correct prescription, even if six or seven hours are required to do so. The right remedy is not so hard to find if enough information has been elicited. Pierre Schmidt used to routinely spend an entire day with each new patient!

Defective case analysis is responsible for about 15 percent of failed cases. Most commonly, Dr. Saine finds that symptoms common to a disease are emphasized by the prescriber. With a background of treating more than 200 patients with multiple sclerosis, for example, he noted that nearly all of his MS patients who had previously seen other homeopaths had been given Causticum, Phosphorus, Alumina, or Argentum nitricum, as was commonly taught 20 years ago or so. These four remedies, with many symptoms similar to the common symptoms of the condition, are listed in many books as the major medicines required by people with MS. Symptoms common to a disease, however, are unlikely to be useful in identifying the required remedy.

10 percent of the time, the case has been taken adequately, but the wrong remedy is chosen.

Five percent of cases are spoiled when the correct remedy has been given, but on follow-up, the prescriber fails to note, or misinterprets, a positive response to the medicine.

Defective tools are responsible for failures in about 10 percent of unsuccessful cases. The tools potentially at fault include problems with intake forms, poor notetaking (especially a lack of emphasis to guide prioritization of symptoms), and unreliable or inadequate materia medica and repertory data. Most of our books of materia medica have been compiled from successive previous compilations, with many mistakes and unverified symptoms added into the data base along the way. To avoid this obstacle, André emphasized returning as much as possible to the original sources. The greatest prescribers in the history of the art, such as Boenninghausen and Lippe, used only the original proving data as the basis of their work. On the other hand, he noted, although some homeopaths today remain attached to Kent’s 1912 repertory, it is an artifact of his era, outdated by progress since that time. Contemporary prescribers should use up-to-date tools, while remaining wary of possible inaccuracies in the updated versions.

Failure can be attributed to defective patients in about 10 percent of failed cases. Many people who come to us lack the verbal tools to properly convey the essential aspects of their symptoms and life experiences. Others are unable to share the information we need for accurate prescribing due to being out of touch with themselves. We may need to train some of our patients to better observe and report their condition and inner state in order to be able to help them.

Defective diseases, as described by Hahnemann, are the obstacle to successful treatment in something less than five percent of treatment failures. A disease which is not accompanied by perceptible symptoms, and is detected only by physical changes or abnormal laboratory values, may not be treatable with homeopathy. Some patients will reach a point where their condition cannot be reversed by nature. These are definitely incurable, since homeopathy can only work by stimulating a natural curative response from the organism. Homeopathy’s range of action is limited to dynamic disease. Anatomical defects which the organism cannot reverse on its own remain outside of that range. (For instance, higher animals are incapable of regrowing amputated limbs.)

Certain neurotic conditions, provoked entirely by powerful thoughts or ideas, likewise are in a sense not dynamic in their origin, and must be therefore be treated by other thoughts or ideas, rather than with medicines. (See paragraphs 16-17 of the Organon.) An extreme example of such a condition is seen in the well-documented phenomenon of voodoo death, where an individual’s belief in a threat of magical assassination is enough to cause his demise at the specified hour.

Homeopathy is dynamic medicine, and can cure dynamic disease. Not all disease is dynamic; where it results from a persistent thought, a nutritional deficiency, or a stressful or unhealthy situation, or other causa occasionalis, it can only palliate, at best.

The question of curability
Dr. Saine described himself as “a homeopathic archeologist.” He has spent countless hours digging through the homeopathic literature, in the classic books and in the stacks of old journals in special collections at the libraries of previously homeopathic medical schools in Michigan, San Francisco and elsewhere. (These excavations are actually his preferred activity on vacations!) His quest there has been largely to determine who were the best prescribers, what were their methods, and which conditions did they find to be either curable by, or unresponsive to, homeopathic treatment. When we are wondering about whether a particular disease may respond to homeopathy, the case records and comments of master prescribers can offer helpful guidance.

Hahnemann’s immediate successors, particularly Lippe and Boenninghausen, “found the Promised Land” of effective homeopathic practice, right where the Founder pointed it out to them. This “Old Guard” of first-generation homeopaths heeded his admonitions closely and tried to prevent allopathic encroachment on his teachings. The results which they obtained, despite the limited range of remedies available at the time, have not been surpassed by the generations of prescribers since that era.

P.P. Wells, Hering and Nash followed the master’s words very closely, and were nearly as successful in their work. Jahr was an accurate observer, and his book, 40 Years in Practice, is a useful resource when we are wondering about the curability of an illness. Burnett, a maverick English homeopath of the early 20th century, pushed the limits of the art in successfully treating cancer, which others, including Kent, had described as incurable.

While the curability of a disease is important to assess, the prognosis of each case, like every other aspect of homeopathy, must be strictly individualized. Diagnosis is crucial for proper case management, as well as for remedy choice and prognosis. The name of the disease is not so important, but we must understand the nature of the process at work. Of course, we have no basis for distinguishing the homeopathically useless common symptoms of the illness from the valuable distinctive ones unless we know the nature of the patient’s condition.

Dr. Saine uses laboratory testing frequently, nearly always when decisive in monitoring the course of the patient’s condition. Subjective improvement, when it is accompanied by objective markers indicating a deterioration of the condition, is often a bad prognostic sign in terms of the degree of similarity of the remedy.

In cases of defective disease, lacking in associated symptoms, two strategies André relies on heavily are looking at clues from the childhood history, and using the symptoms which arise in acute conditions. In some instances he must actually wait for such conditions to develop in order to find the curative remedy. He is encouraged when a cancer patient develops pneumonia, for example, since the characteristics of the untreated pneumonia may lead to the remedy needed to address the cancer. Pneumonia symptoms will call for the same remedy needed for the chronic disease in as many as 50 percent of the patients who contract it. Half of cancer cases are defective at present, although this number is greatly increased by palliative interventions. Homeopathy is not very effective for patients who are currently receiving radiation or chemotherapy; often effective for those who have had such treatment in the past, but discontinued it; and offers the best results in patients who have avoided it altogether. The latter category is now the only one which Dr. Saine takes into his practice. Even coffee enemas and high-dose nutritional supplements can interfere significantly with the clarity of the picture. Basically, anything which changes symptoms without changing the causes (palliative) is not welcome.

For homeopaths who have not yet gained much clinical experience, insight into treating an illness maybe gained by reading many cured cases with a similar condition. Through this research, the perception of distinctive symptoms which have led others to successful prescriptions will become evident. Talking to other homeopaths with more experience treating patients with a similar illness can also be very helpful.

Simple remedy, complex disease
Complex disease, where patients may exhibit shifting complexes of symptoms, each constellation calling for a different medicine, represent another kind of difficult case. These cases are not necessarily incurable but call for skilled and attentive prescribing. The correct remedy for each state must be given as it appears, a process which André compared to patiently untangling a rope, undoing each knot in turn.

In the majority of cases, one remedy will cover most or all of the chronic symptoms which an individual develops over the course of a lifetime. When acute illnesses present, the correct remedy for the acute illness will usually improve the patient’s overall state. If the chronic illness worsens after acute treatment, the symptoms pointing to the right remedy are usually clarified by the response to well-indicated remedies.

How do we know when to stop waiting and give a remedy? This is a matter of discrimination, which must be learned through experience. When we see clear indications for prescribing, we must give the medicine. “Homeopathy is simple; we make it complicated because we are complicated.”

On provings
Much of the materia medica data which has been added since Hahnemann’s time is questionable or dubious, according to Dr. Saine. “Many symptoms in our literature have been invented.” Many remedies included in the books have not been proven at all, or have been inadequately proven at best. “If you knew the history of Carcinosin, you’d never prescribe it!” Proving symptoms have been elaborated, mistranslated and distorted over the years, and mixed with clinical symptoms of questionable accuracy.

Hahnemann sought and found sensitive individuals for his provings, and instructed them carefully in order to elicit clear and reliable symptoms. André believes that provers should be given no more than three doses of the remedy, repeating only when the symptoms from the previous dose have subsided. Symptoms added to the repertory on the basis of dubious proving techniques represent a real threat to the integrity of the art.

On posology
André noted that Hahnemann in fact often gave repeated doses of the same potency. When symptoms relapse after a somewhat favorable response to a remedy, Dr. Saine will usually repeat the same dose. If the second response is less marked than the first, he assesses the medicine as less than optimally similar, and looks for a better prescription. When he is confident of a remedy choice, he may give a high potency in three doses over a 24-hour period, cautioning the patient to repeat the dose only if no change has been noted following the previous one. While we must be careful about too-frequent repetition, especially with higher potencies, many patients do very well and heal faster on more aggressive dosage schedules. Many cases recorded in the literature describe successful treatment, without accidental provings, in which the remedy was given daily in high potencies over periods of weeks or months. The key factor to assess is the individual’s sensitivity.

Certain patients seem to respond best to a remedy in a particular potency. He finds that the 50M potency produces marked and lasting benefits in many cases.

For extremely sensitive patients, an adequate dose may be administered by simply briefly opening and then immediately closing a vial of the remedy in a low potency, without bringing it into close proximity to the person. Later they may tolerate sniffing the open vial with one nostril, then with both nostrils.

With each dose of the correct medicine, the aggravation phase should become shorter, followed by a lengthening phase of improvement. While some patients may be treated successfully without noticing any aggravation, it is always better to see some aggravation. Improvement without any aggravation is often associated with a prescription whose similarity to the patient’s state is less than optimal. The ideal point in the cycle for repeating the dose is just prior to, or at the very first sign of, a relapse. In treating acute febrile illness, he often monitors the response to a dose by changes in the pulse, a more sensitive indicator than the body temperature.

André is critical of LM remedies, stating that Hahnemann only used them from 1841 to 1843 over a period of about 18 months, at a time when he was not seeing many patients, a phase too brief to provide definitive long-term follow-up. His evaluation of those cases from Hahnemann’s records has convinced him that the master’s last experiments with posology were not particularly successful. The potency of LM medicines is not very high, and the fine-tuning of the dosage is too complicated to work out with patients. Since the publication of the sixth edition of the Organon, a number of excellent 20th century prescribers, including Pierre Schmidt, Kunzli, and P. Sankaran (Rajan’s father), have tried and rejected it. Giving doses in water, however, is often a useful method and can be employed with any potency.

Many patients are sensitive to the nosodes, and André feels the response they elicit is “non-specific.” The materia medica indications “invented” from these clinical responses have entered the literature, and now lead homeopaths to prescribe these remedies, still poorly-proven or unproven, quite frequently. Swann’s development of the nosodes was a cause of considerable controversy in his era, raising objections from other homeopaths, especially Lippe, Boger and Wells. André does not make much use of them, and doesn’t miss them.

Lippe and the lessons of history

On Saturday evening, Dr. Saine showed slides and lectured on Dr. Adolphus Lippe. He asserted that Lippe was the most accomplished homeopathic prescriber ever, and therefore quite probably the most successful physician in history. He had a practice which was known as one of the largest in the country, and he recorded incredible results, especially in treating the epidemic diseases which ended so many lives in that period. His published cases are models of inductive reasoning. However, Lippe’s writings are poorly represented by his books currently in print, and he is not well-known among many modern students of homeopathy. André has collected more than 700 of his journal articles, and has been working since 1986 on editing a book of Lippe’s writing, which he plans to publish this fall.

Homeopathy gained wide acceptance and recognition because the early homeopaths relied strictly on Hahnemann’s methods and the accurate provings he recorded, and demonstrated consistently excellent clinical outcomes. It was very nearly destroyed when these fundamentals were neglected: physicians often graduated from “homeopathic” medical schools without knowing of the Organon’s existence! Routine methods, prescribing on pathology, and dilution of the materia medica with inaccurate data led to poor results. Poor results with a hybridized, semi-allopathic medicine miscalled “homeopathy” led to a loss of public respect for the art, and to its abandonment by many nominally homeopathic doctors.

In fact, André argued that it was only the vital transmission of true homeopathic principles through the International Hahnemannian Association which has made its current rebirth possible. The IHA, which Lippe cofounded after Hering’s death in 1880, carried the torch for genuine homeopathy, in a time when the much larger American Institute of Homeopathy had ceased to stand for Hahnemann’s art. The final meeting of the IHA took place in 1959. One of its prominent members was J. T. Kent, who in turn taught Pierre Schmidt, the Swiss physician who kept the Kentian flame burning into the era of George Vithoulkas and our contemporary teachers. Unfortunately the pure Hahnemannian homeopathy was no longer transmitted after the disappearance of the old guard.

The lessons of homeopathy’s last period of decline may be ignored at our peril. André was very persuasive regarding the critical importance of sticking to the well-established procedures of homeopathic prescribing, and the most reliable information. He pointed to Hahnemann’s and Lippe’s works as the indispensable, core material for homeopaths to study: “It’s all right there.”

Clinical pearls
While I will not go into a full discussion of the cases in the seminar, many aspects of Dr. Saine’s approach to them were instructive. In analyzing the cases, he made deft use of MacRepertory and Referenceworks, combining many incomplete rubrics into more inclusive “superrubrics,” searching swiftly through the library for symptoms, and graphing the analysis of dozens of symptoms in the preliminary phases of the process, prior to narrowing the case down to a much smaller number of truly distinctive rubrics.

In one case, a picture which suggested Baryta carbonica included a symptom, making plans for a journey which is somehow never really carried out. This characteristic is listed in the materia medica as a Baryta carbonica symptom. From his deep and thorough study of the materia medica, André knew that it was actually derived from a proving of Baryta acetica which was later combined with the Baryta carbonica symptoms. Baryta acetica cured the case, in a striking example of the power of an inexhaustible appetite for detail.

The specific foods which produce symptoms are seldom useful in the analysis of cases of people who suffer from food allergies. Cold sores and back pain, however, are two conditions whose specific symptoms quite often point to the remedy needed by the patient, and the seemingly nondescript details of the live patient’s back pain were important in arriving at a prescription for her.

I have never seen a live homeopathic case taken in front of a seminar group where more attention was paid to making the patient feel that nothing else mattered except finding the key to her healing process. André’s compassion was abundantly evident in every word and expression. By the same token, I have never seen a homeopath pursue completeness and accuracy in casetaking so singlemindedly, never worried about appearing tedious or pushy in gathering information, taking nothing for granted. He advised the patient to expect the return of the old symptoms which had been treated allopathically, and firmly instructed her to consult with her homeopath, and not to seek additional treatment for them, when they resurfaced.

Two of the paper cases were cured with Aloe socotrina. This remedy is well-known for its value in treating certain types of acute diarrhea, but it is generally overlooked as an important remedy for patients whose gastrointestinal illness originated with a suppressive treatment, often (though not necessarily) for a skin condition. While the diarrhea symptoms of Aloe are reasonably distinctive in many instances, two of the Aloe patients Dr. Saine discussed shared the notable symptom of wanting to eat only one food at a time, every day for every meal, for extended periods of time. This tendency toward behavioral fixations is not evident from provings of the medicine, but has been repeatedly confirmed in Aloe patients, who were freed from it after taking the remedy.

Many of the points I have touched upon in this review are covered in greater detail in the articles posted at the website of the Canadian Academy of Homeopathy, www.homeopathy.ca.

Concluding remarks
In closing, André emphasized a few major concepts which bear repeating here.

First and last, beware of palliation: if a disease is curable, the homeopath must avoid blunting the signals which can lead to a curative medicine. If the law of similars is indeed the fundamental law of healing, we do not have the freedom not to follow the law.

The doctrine of signatures is a concept which Hahnemann specifically criticized in his essay “The Genius of the Homeopathic Art.” The more we indulge in speculation about our medicines, the farther we depart from strict reliance on solid provings, the deeper we go into error. The title of a French book on the history of science phrases it perfectly: “I Think, Therefore I Am Wrong.”

Challenged on the previous point, with reference to allegedly effective traditional healing systems based on the doctrine of signatures, Dr. Saine stated that his critical scrutiny of botanical medicine around the world has convinced him that none of it can compare favorably with homeopathy. It is all allopathic, using crude doses, and resulting at best in palliation only. When contagious infections raged around the world in the 19th century, the Eclectic physicians prescribing herbal medicines were no more effective at saving lives than their orthodox contemporaries, while homeopathic physicians met with impressive success.

Homeopathic healing is a process which impacts everyone around it. Think of the scene with the angel in the movie “It’s a Wonderful Life,” where the Jimmy Stewart character is shown how the fate of his little hometown would have been disastrously different, had he not been present, living his humble life, doing the right thing. The effects of correct prescribing move outwards through the world in expanding circles, far beyond our ability to know the good we do.

Your weaknesses and strengths are inevitably reflected in how you practice homeopathy. If you follow Nature, and you attend to the lessons which arise from that effort, you will be changed.

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