Open Forum.
NATIONAL JOURNAL OF HOMOEOPATHY 1994 Jan / Feb Vol III No 1.
Vishpala Parthasarathy.
Polypharmacy Versus Monopharmacy
Editors Note: With a view to promote a healthy debate and discussion and thereby enhance the quality of homoeopathic prescribing, the NJH introduces, beginning from this issue, the Open Forum, which shall deal with burning topics of vital importance where there are a plethora of conflicting views and opinions. To begin with, the present issue deals with Polypharmacy versus Monopharmacy. Readers are requested to send in their rejoinders which will be published in future issues.
This topic will be collumned with in three issues. So, please send your rejoinders promptly.
A combination of homoeopathic medicines is the field of the practitioner, academicians, puritans and the traditional homoeopaths will scoff and scorn at us. My sincere apologies to them.
In the times of Hahnemann and latter his followers. Homoeopathy was in its infancy. Drug proving was still on. The characteristic of a drug substance, the classification and verification of symptoms were in the process of documentation for the benefit of future generations to establish the curative powers of the Homoeopathic system of medicine. Hahnemann advocated single remedy selection so as to make sure that the action of the infinitesimal doses was not interrupted by anything whatsoever. He merely followed the Law of Similars, and after years of provings, gave a thought to alternation of medicines when the similia was elusive.
Homoeopathy is a therapeutic method which applies clinically the law of similars using medicinal substances in small or infinitesimal doses. This presupposes, first a thorough knowledge of the case and secondly a thorough knowledge of Materia Medica.
It is not the aggregate symptoms of a case that gives us the totality. Totality does not mean all the symptoms but the completed symptomatic complex including location, sensation, modalities and concomitants. The most difficult part of our duty is taking the case. Some patients talk too much while others think that the doctor must merely look at them and prescribe, giving their symptoms reluctantly, especially the peculiar and uncommon ones. The efficacy of the remedy is then illustrated when applied in strict compliance with the Law of Similars.
However, after practising for so many years and after seeing a wide variety of cases and prescriptions of all and sundry, we find that the concept of characteristic symptom totality is not so simple and solid. It seems that even within the totality of symptoms some characteristic symptoms can safely be omitted.
The patient with acute symptoms presents a completely different picture. The control of mind and emotions is far more important than what the average physician realizes. Many a fine prescription has had its curative action stopped by a sudden violent, emotional outburst, shock, grief, anger and fright.
No mind could contain all the symptoms and no practitioner has the time to examine a large part of the Materia Medica to find out the remedy. The practical physician has neither the inclination nor the time to draw such fine distinctions between similar diseases and assign to each its appropriate remedy. The most difficult thing to understand about homoeopathic remedies is that they do not work in the same way in each individual.
Remedies are known to have relationships with each other; either inimical or antidotal, or similar, collateral mode of action. Often they are complementary in nature and carry the beneficial effect in follow through. Also, medicines have their scope and period of action. Some are short acting, superficial and have a temporary effect, while others have medium duration of action. Some are deep acting and have a long lasting effect. There are Organ remedies having a specific action on the functional aspect of certain organs. Then, there are miasmatic drugs capable of causing a pathological change. The constitutional medicine is individualistic in nature, while the nosode and the sarcodes have a deep seated effect. All these medicines in their potentised state seem to act in an entirely different plane. It must be borne in mind that due to their serial dilutions, homoeopathic treatment is always non-toxic.
It would be absurd to try and deny the placebo effect which exists in all therapies. From the moment a patient consults a doctor, a relationship is established between the two which may be more or less helpful for the patient. One must simply be careful in interpreting the therapeutic results. A treatment can be helpful as much for its psychological effects as far its physiological action.
Similia Similibus Curentur is indeed a rule of healing most difficult to understand for a person not familiar with Homoeopathy. A principle, a rule, a schedule or the application of an intended method, according to which the therapy is to be applied is most certainly not an axiom but rather a working hypothesis only. In medical emergencies or miscalculation of totality of symptoms due to lack of information or when a patient suffers from double or triple complex diseases (when two or more miasmatic diseases combine to affect a person), there comes the role of combination of two or more remedies having a similar action and to work more effectively on organs in comparison to single remedy. A single remedy in some cases has the same point of attack and a different pharmacological target, but a complex intervenes at several points. The secret of efficacy of combinations lies in carefully selected composition in accordance with the principles of homoeopathy. They exert their influence by animating the healing force inherent in the organism. In the precise framework of the Law of Similars there exist substances whose pathogeneses have a selective and a limited tropism for the same function of the same organ. At this level they may have similar physiological actions. Pairing of ingredients with similar complementing effects are taken together. In this way the field of efficacy has been enlarged, their aggressiveness increased and therapeutic effects assured. The different formulas are thus perfectly justified and useful. They have no other claim than that of providing the patient with quick relief from their functional disorders. Hence, the combination of medicines not only gives symptomatic relief to the patient upto a certain stage but also paves the way for the remedy to effect cure.
To quote Eric F. W. Powell, "nature produces its own combinations and all animal life feeds on combination of foods of various classes. What is medicine, but specialised feeding. The body is starved for certain elements, there is a cell hunger. A group of cells and the regulating chemistry of the body mechanisms will be attracted and utilised under the direct intelligence which governs the entire body."
A correct interpretation of the auto-curative effort of the organism permits a Doctor, a Homoeopath, to observe and guide this restorative attempt in quite a new and unique manner. Hence to dismiss the practitioners of combinations medicines as unhomoeopathic by citing the Master is grossly unfair. With changing times when medicinal sciences have been developing at a fast pace the newer aspect of homoeopathy too awaits to be discovered.
We all differ in some way and yet have success. We should not in an egotism demand or expect that all others proceed as we do and adopt our way. Men differ, therefore they must proceed differently to become successful prescribers. The successful mode in one would be near failure with another just as competent. Live and let live with due allowance for the procedure of the other men. Individuality must be recognised both in the individual prescriber as well as in taking the case and prescribing for it.
Polypharmacy-To Save Time and Earn A Living!
It is a widely known fact that most Homoeopaths resort to polypharmacy as a routine though some are timid to admit it. This timidity is purely a psychological aberration; even when they are starkly convinced that they are doing nothing wrong (anti-homoeopathic) in the given circumstances of today.
The South Delhi Homoeopathic Association in one of its monthly meetings held recently asked its members to give a frank expression to their justification for taking recourse to polypharmacy even though they know well that it is at variance with the scientific homoeopathy promulgated by its master. The common denominator was the bare truth "Where is the time with patients and with the doctors?" So, to save time of patients not only do they prescribe more than one Homoeopathic remedy but along with also give some combinations and biochemics. What else should they do? Should they not earn two square meals a day? Should they not have to keep the confidence of their clients and their faith in Homoeopathy?
Anyone questioning this outright is not candid in his thoughts as they reflect the ground reality. But closing our eyes completely on this aspect of Homoeopathy will do a great disservice to the science of Homoeopathy. At the level of ideals, there is no scope for polypharmacy in Homoeopathy. The masters and the great exponents of this system neither in the past nor now have found it incumbent. At best in rare and very complicated cases of abnormal nature, they used two medicines in alternation for some period.
Then why this contrast?
Ask any homoeopath the prescription for the following case One winter morning, after a walk, Mr. X developed cough, cold, headache and fever. Without a pause they will cry Aconite. They will not tell you two or three medicines or combinations. Why?
Because the case is crystal clear.
So, the inference drawn is that the biggest single factor behind a polypharmacy prescription is insufficiency of the art in the artist of Homoeopathy learned physician.
But for improving proficiency, they have to work hard on their study table, spend more time with each patient in case taking, should have sufficient number of patients and would be prepared to lose some.
This is a vicious circle. I do not think that anybody has a ready solution out of this tangle. But then, Homoeopathy is a rational system of medicine and hence every Homoeopath has some rationale within him which should give him the authority as to-
- When can he avoid polypharmacy?
- When can he use two (or even three) remedies?
- When does he have to resort to polypharmacy alone?
1. Take for example, a chronic disease and its chronic phase, where the patient does not have much discomfort (e.g. hypertension, diabetes etc.). Where is the need to hurry up and gag scientific Homoeopathy.
2. When some acute cases and acute phases of chronic diseases are clear in their origin and symptoms and the physician can rely on a single remedy even without spending a minute on a single case. Then, why develop the habit of polypharmacy blindly? A case of Aconite as cited above. There are hundreds of cases that are as clear as that.
3. What about cases of severe aches and pains (including injuries)? Should the homoeopath try to test his skill of classical practice at the cost of patients discomfort? No! No system is worth its name if it does not develop the confidence at the right time and in the right proportion. Is it a priority here to analyse if the pain is muscular, nervous or deep in cartilage, ligament, or bone or is the priority to use what is in the armament to relieve the suffering.
4. All said and done, most homoeopaths are allergic to take the advantage of modern diagnostic aids. Every day one comes up with more and more complexities. Many a ailment are asymptomatic or with inadequate symptoms where the pathology is quite advanced. Then, on what basis is the treatment prescribed? Surely a lot of safeguard and guess is in action and it perforce means polypharmacy. To support this argument, we quote the most prevalent of all diseases namely, cardiac and circulatory. (a widely used Crataegus MT is considered only a base remedy).
5. Cases of emergencies, accidents, coma, semiconsciousness (homoeopaths should be lucky to get such cases) call for quick and efficient management single remedy vs polypharmacy should be a non issue.
6. Lastly, where polypharmacy is really necessary, it should be played rationally with some ground rule-
- Do not mix indiscreetly deep acting remedies.
- Do not repeat unduly the deep acting remedies. Remember the iatrogenic symptoms / disease they may cause.
- Do not mix remedies known to be inimical to each other.
Surprisingly. this issue is hotly contested. Some believes that there is no such hurdle. All remedies can be used freely. I have a very conservative opinion on this and that this method will do no good, neither to the doctor nor to the patient. I have not experimented on polypharmatic use of say Silicea and Mercurius or Apis and Rhus-tox and hence am unable to elucidate. I suggest that they should be used rationally as per norms.
To conclude, I say that excellence is the goal of life for every human being. There is no reason why Homoeopaths should not gradually proceed to the true scientific Homoeopathy and use polypharmacy rationally rather than make it a blind habit for each and every case and deprive their sense of achievement.
