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THERAPEUTIC STRATEGIES
Leela DSouza-francisco, Christine Lauterbach, Matthias Strelow

Key Points:
The challenge for all of us clinically is to identify appropriate therapeutic strategies in individual cases. Where do we meet the patient? What does the patient offer us? Leela suggested that the patient offered us a TOTALITY and the type of totality that we perceive, is what defines the therapeutic strategy. In addition we feel, the Therapeutic Strategy should address 1. Case analysis 2. Remedy response 3. Long term case management Each of us investigated strategies of our choice to find out how well they addressed these issues, with their advantages and limitations. LEELA DSOUZA FRANCISO I have always been a clinically oriented homeopath, hence it was most interesting to thoroughly investigate Therapeutic Strategies that addressed all areas of clinical practice. Two of these, much neglected in the recent past, are von Boennighausens and Bogers TOTALITY and subsequent case management. Their importance is more relevant today for theyre reliability in the construction of Research Strategy and Protocol.

BOENNINGHAUSANS TOTALITY and his construction of the Therapeutic Pocket Book, are based on the doctrine of Concomitants and of Analogy.1 Boenninghausen suggested that TOTALITY was ONE complete, GRAND symptom of the patient (Roberts, 1935) obtained in case taking categorized into Location, Sensation, Modality, Concomittant (LSMC) of presenting symptoms. The concomitant includes the MENTAL STATE of the patient. Boenninghausen (1843) constructed his Therapeutic Pocket Book1 (TPB) to aid the analysis of the TOTALITY with this structure. Grading of remedies and its Concordance is supportive in therapeutic strategy. Concomitance 1 is to the totality, what the modality is to the single symptom. Analogy 1 by logic allows valid inferences of characteristic sensation and/or modalities in one area, to be used to complete a missing part of grand symptom in another area of disease. Limitations/Criticisms: 1) Mental State not well represented. Proving symptoms fragmented. 2) Overgeneralization with loss of individuality, when characteristics are not carefully obtained.5 3) Originally had only 129 remedies1 (TF Allen added 229 more).

BOGERS TOTALITY and hence his Synoptic Key3 (1915) are based on perceiving the pathogenesis of symptoms over time as the genius of the remedy as well as the patients disease. Pathogenesis means the pathological changes that occur as disease progresses, in changing signs and symptoms. Boger (1915) gave very clear instructions on the areas that were needed for a pathogenetic totality. His Synoptic Key describes the genius of remedies in a similar format. A) Modalites B) Mental state C) Sensations D) Objective Observations E) Location Limitations: 1) Medical knowledge or paramedical training required 2) Detailed study of Theory of Miasms necessary

Clinical Advantages: These two therapeutic strategies are complete. Successful homeopathic hospitals and clinical in India are based on these methodologies 2, 4,5. The principles of homeopathy are not compromised. They can both be utilized for research strategy and protocol. Boenninghausens methodology follows inductive logic, is very reliable, resulting in an effective remedy within 15 minutes. The Concordance helps in prescribing the next related remedy for cure. Bogers methodology allows treatment of medical emergencies 6 on par with allopathic emergency treatment, yet more effective. It is a backbone in advancement of hospital protocol. CHRISTINE LAUTERBACH I would like to find out where the terms Essence and Keynotes come from, what they mean and where their strong sides or limitations. As I could not find any definition of Vithoulkas about what an Essence. I emailed him. He answered that there was a lot of confusion about Essence, he taught it in his 4-year course 1. Roger Morrison (1989)2 gives some explanation. He differentiates case analysis in three categories: 1. Totality 2. Keynotes and 3. Essence In his eyes Essence means a very deep understanding of a remedy and reflects its taste. Jonathan Shore 3 has an interesting and more refined definition pointing out that it cannot be experienced directly. He underlines what Stuart Close 3 formulates when speaking about Totality. Essence is the connection and relation between the symptoms that give a common sense or meaning to the wholeness. Strong sides of Essence prescribing and its clinical application:

3 1. 2. 3. 4. In cases when the patient offers her/ his symptoms in a more discriptive way In cases where clear pathologic symptoms in the body level are missing It reinforces a deep understanding of the patient and a wide and deep case-taking For students: Easier to learn a whole contextual remedy picture

Limitations: 1. Patient offers no Essence or discriptive symptoms/ one-sided pathology on the body-level 2. In emergency cases/ acute illness 3. Beginners could cling to the Essence picture and not recognize it when it appears differently in the patient 4. No Essence is formulated in small remedies. The question arises whether only one Essence exits for every remedy 5 and if it can be transferred to other countries with different social, cultural, religious, gender, etc. context. Question: Who determines what an Essence is? Does it change through the decades? The term Keynotes was introduced by Guernsey (1868) 4 who underlines the term as suggestive and merely provisorial. It suggests a remedy that has to be confirmed by totality. Keynote is the fundamental note or tone to which the whole piece is accomodated; the key-note of music finds, by analogy through which things most remote and unlike superficially are connected in the closest relationship its likeness everywhere. The strong sides of the Keynote strategy and its clinical application: 1. Cases with striking symptoms 2. Genius epidemicus 3. acute cases / emergency cases 4. In learning or teaching it offers a good and logic structure The limitations: 1. Cases without outstanding symptoms 2. When keynote and totality point out different remedies 3. It is easily misunderstood as a shortcut (Kent) 6

MATTHIAS STRELOW

Flexibility versus clear rules:

A comparison of Jan Scholten and Prafull Vijayakar. In this work the different ideas of totality and its implications for the case management shall be discussed. Two contemporary homeopaths, representing two poles in modern homeopathy link homeopathy to modern science, but in different ways. Jan Scholten is known for his work on the Periodic Table of the Elements 1,2 deriving themes of elements. He introduced many new remedies into homeopathy. His discussion on case management is controversial, which led to criticism internationally 5,6. His philosophical background seems to be buddhist 8.

4 Praful Vijayakar is known for combining homeopathy with embryology and cell defence mechanisms 3,4. His work is based on Kent, J.H. Allen and Boenninghausen. In his Theory of suppression 3 he describes suppressive effects of inadequate homeopathic treatment. His foundation is indian philosophy 7 . Case Analysis: Scholten: 1a) Several themes form the TOTALITY 2) A STRUCTURAL analysis of the created disease based on PERIODIC TABLE 3) Preference for the MENTAL STATE 4) MIASM CLASSIFICATION only partially on remedy selection Vijayakar: 1) The Genetic Similimum is the TOTALITY of genetic disposition 2) CHARACTER Analysis of life long symptoms 3) Balance of MIND and BODY with the help of physical generalities 4) MIASM CLASSIFICATION essential for prognosis, management of case

Remedy response: Scholten Strategy 1) AMELIORATION in mind is evaluated according to the theme(s) analysed 2) Hering`s law is mainly used in the sense of REVERSAL of symptoms 3) GENERAL AMELIORATION is evaluated in % 4) DISAPPEARANCE of part of symptoms without complete healing is not suppression Vijayakar Strategy 1) Herings law is guided by 3 GERMINAL TISSUE- DEVELOPMENT for the direction of cure 2) If the disease progresses UPWARDS in Vijayakar 7 layer hierarchy, the remedy is suppressive 3) MIASMATIC evaluation 4) MENTAL amelioration may indicate suppression in advanced cases

Case Management: Scholten Vijayakar

5 1) REPETITION of the remedy quite frequent if indicated 2) REMAINING state of symptom picture indicates new remedy 3) Hardly any PLACEBO 1) REPETITION very occasional, except in sycotic miasm 2) CHANGE of remedy indicated if not in the direction of Hering and miasm 3) Daily PLACEBO

Critique: These two strategies symbolize the 2 poles we are caught up in daily practice: Scholten is too flexible, the expectations on the follow-up are unclear, signs of cure underdetermined. Remedies are changed or repeated often. Vijayakar is too idealistic with strict guidelines. Exceptional or individual ways of cure may not fit in. Staying with one remedy without change might result.

Conclusion:
The various therapeutic strategies we researched had strengths and limitations. Their clinical applications are: Boenninghausen: Obscure cases; When TIME LIMITED for patient; Totality with more physical characteristics; Acute disease; Genus Epidemicus Boger: Emergency cases; Pathological cases; Cases where Subjective history impossible Essences: Functional or psychological cases that need a deep understanding of the patient and his suffering. Keynotes: Genius Epidemicus; Acute Disease; Chronic cases with PQRS Scholten: Mental State predominant; Supportive Analysis to all other Totality Methods Vijaykar: All types of Cases; Homeopathic Rules for Research Methodology Analysis

References:
Key references: (Leela DSouza Francisco) 1. Boenninghausan's Therapeutic Pocket Book: 5th American Edition by Dr. T. F Allen Part 1: Introduction by HA Roberts; Preface by von Boenninghausen Part 2: TPB 2. Boenninghausan's Philosophical Approach: Chapter D1, Dr. Jugal Kishore MD (Hom) Dhawle's ICR Symposium Council's Standardization Part II. 3. A Synoptic Key of the Materia Medica: Dr. CM Boger, MD, Reprint Edition 2006 4. Boger's Concept of Totality: Chapter D2, dr. KN Kasad MBBS, MF (Hom), ML Dhawle's ICR Symposium Council Standardization Part II 5. Kents Lesser Writings; Kent JT, 1926; Reprint Edition 1927

6 6. Neonatal Convulsions: Pavaskar, Naveen; www.hpathy.com 2006 http://www.hpathy.com/casesnew/pavaskar-cicuta.asp References: (Christine Lauterbach)
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Vithoulkas (2007) personal information by email of February 17th 2007. Roger Morrison (1989), Methoden homopathischer Fallanalyse, Kai Krger Verlag 3 Stuart Close, The Genius of Homeopathy, The totality must express an idea. It is the numerical aggregate
plus the idea or plan which unites them in a special manner to give them its characteristic form.

cited in: Shore J., The salt of the essence: an exploration of the relationship between totality, essence, and central delusion. The American Homeopath: the journal of the North American Society of Homeopaths, 1999; 5: 84-87
J. Shore: The forces which hold together the pattern or shape of the thing, those forces which make it what it is may be called essence. and ...the central thread that brings unity to the diversity of manifestations but we cannot ... experience the essence of a thing directly. We cannot become one with it.
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H.N. Guernsey, THE KEY-NOTE SYSTEM, The Hahnemannian Monthly, Vol. III (1868), No.12, pp. 561-569 cited in Stefan Reis
... these invariable points of peculiar difference are the keynotes; they help to suggest a remedy by a symptom that isolates one remedy from all others. ... the totality afterwards confirms or disapproves the choice..
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Vithoulkas solved this problem by developing different phases of a remedy (for example see Sepia in: Vithoulkas, G. Essence of Materia Medica, 2005, 2. edition) 6 see: Kent J.T., Lesser Writings, B. Jain Publishers, reprint edition 2001; page 327 There is another ism that destroys Hahnemanns teaching, viz., the misunderstood keynote system. This system appeals to the memory only. It does not train the mind to know the character of the remedies. It makes the memory hold only a few fragments of the remedy. It omits the nature of the remedy or the image of the patient, which was the soul of Hahnemanns teaching. If we omit from our thoughts this soul, this image, we omit all upon which a homoeopathic prescirption rests, viz., the totality.(italics in original) Key References: (Matthias Strelow) 1. Jan Scholten(1993), Homeopathy and Minerals, Stichting Alonnissos 2. Jan Scholten (1997), Homopathie und die Elemente, Stichting Alonnissos 3. Dr. Praful Vijayakar (2004), Die Theorie der Unterdrckung, Hmopathie Fachverlag und Vertrieb Peter Irl 4. Dr. Praful Vijayakar(2004), Die Gesetzmigkeit der Miasmen, Hmopathie Fachverlag und Vertrieb Peter Irl 5. G. Vithoulkas Interview, Homeopathic Links (4/1999) 6. Andre Saine, article Drawing a line in the sand, Journal of the American Institute of Homeopathy (6/2002) 7. Seminar Mahabaleshwar (2007) 8. Web- site Jan Scholten, www.janscholten.com/page 4 (philosophy)