Placebo and its Clinical Utility in Homoeopathic Practice

Abstract

Placebo is mentioned as an invaluable gift of God by master Samuel Hahnemann in his book The chronic diseases. It has been considered as second best remedy in homoeopathic practice. Hahnemann has described its usage in different aspects of clinical practice e.g., in cases of indispositions, pseudo chronic diseases, emotional illnesses, hypochondriacs & other sensitive patients, etc. Placebo is usually given during the treatment or after giving the indicated medicine to fill up the many days in between so that the indicated medicine may act undisturbed for long. Placebo has a crucial role in homoeopathic practice from first prescription, second prescription, and until the patient has been cured. The primary reason for giving placebo is to satisfy the desire of the patient who is habitual of taking medicine frequently.

Introduction

Placebo is derived from the Latin word placere, which means ‘to please’. ⁽¹⁾ Numerous definitions have been proposed for the term placebo but none of them cover every aspect of it and are not fully satisfactory. Placebo can be defined as an inert treatment given as if it was a real treatment. ⁽²⁾ Another definition describes placebo as an intervention design to simulate medical therapy which at the time of use is believed not to be a specific therapy for the condition for which it is offered. ⁽³⁾ 

Placebo is also used in various clinical trials or experimental studies as a control in order to signify the action of specific medicine or intervention.

In homoeopathy, placebo is used in order to satisfy or please the patient, without injuring, who is habitual of taking medicine regularly. As homoeopathy advocates the use of single, simple medicine to be given singly at a time, so it is advisable to prescribe something of unmedicinal nature so that it does not disturb the action of indicated medicine.

History of placebo

In 1772, William Cullen (1710-1790) demonstrably used the term placebo for the first time in his Clinical Lectures in connection with the patient to whom he gave mustard powder for external application, although he was not convinced of its specific effect. He tends to use low doses of drug which is thought to be ineffective given the severity of disease. ⁽⁴⁾ Before Cullen, Alexander Sutherland, an English physician, also used this expression for certain type of fashionable physician whom he called placebo. ⁽⁵⁾ Another English physician, John Coakley Lettsom (1744-1815) used the term placebo in similar manner. ⁽⁶⁾

Earlier the physician used to prescribe impure placebo (substance with pharmacological effect but on the condition been treated) but some physician used inert substances as placebo (pure placebo i.e., substances with no pharmacological effect). ⁽⁷⁾

Hahnemann’s view on placebo

Samuel Hahnemann in his practice clearly discriminates between medicated substance as similimum for the purpose of treatment, and unmedicinal substance as placebo to satisfy the patient’s desire of having medicine.

In his earlier practice, he significantly used placebo in his prescriptions. In his case journal 22 from 1821, 85% of the medications were placebo. While in 1833-1835, about 54% of Hahnemann prescriptions were placebo. ⁽⁸⁾ Hahnemann usually marked placebo with paragraph symbol (§) in his case journals (1801-1843). Another sign he used for placebo was a small zero (о) below the line indicating non-medicinal globules. ⁽⁸⁾ 

Hahnemann used to prescribe conchae (oyster shells) as placebo in his earlier practice, but later he exclusively gave lactose (sugar of milk/ saccharum lactis) as placebo. He has mentioned about placebo and its utility in homoeopathic practice at various places in his literature. Some of which are mentioned here: –

1. The chronic diseases, their peculiar nature & their homoeopathic cure (1828)

Hahnemann in his chronic disease remarked the sugar of milk as an invaluable gift of God. ⁽⁹⁾ He advised to give a dose of sugar of milk at the usual time of medicine which shall be marked as usual with continuous numbers, so that the indicated medicine may continue its action undisturbed. Hahnemann is convinced about the indifferent & unmedicinal nature of sugar of milk by experiments on very sensitive person. ⁽⁹⁾ 

Hahnemann used placebo to satisfy the patient who everyday ask for medicine, without injuring him. During the intake of placebo, the patient expects no ill effects and will then quietly note the changes in his state which are actually present and therefore can only report the truth to his physician.

2. The lesser writings of Samuel Hahnemann

In chapter “Treatment of typhus or hospital fever at present prevailing (1814)” Hahnemann stated that after giving indicated medicine (here, Bryonia alba) in the first period of fever, improvement takes place in the course of four and twenty hours. As long as improvement goes on, he gave patient neither any other medicine, nor repeat the same one. In this interval until it is time for giving the second medicine, we may in order to satisfy the desire of the patient for medicine and to quite his mind give him something innocuous e.g., a few teaspoonfuls of raspberry juice in the course of day or a few powders of milk sugar. ⁽¹⁰⁾

In the chapter “On the preparation & dispensing of medicine by homoeopathic physician (1825)” Hahnemann in defence to use sugar of milk as a vehicle describe the inertness of it. He stated that sugar of milk is not a medicinal ingredient, it is mere a vehicle and recipient for the simple medicinal substance of the homoeopathic practitioner. ⁽¹⁰⁾

      (c) Organon of medicine 5^th and 6^th edition combined –

 In §91, §96 and § 281 Hahnemann advised to give sugar of milk or something of unmedicinal nature in certain cases: – 

•  §91 (5^th edition of organon of medicine) –  

“When the disease is of a chronic character, and the patient has been taking medicine up to the time he is seen, the physician may with advantage leave him some days quite without medicine, or in the meantime administer something of an unmedicinal nature”

• § 96 (5^th edition of organon of medicine) –  

“A pure fabrication of symptoms and suffering will never be met with in hypochondriacs, even in the most impatient of them; a comparison of the sufferings they complain of at various times when the physician gives them nothing at all, or something quite unmedicinal, proves this plainly”.

• §281 (6^th edition of organon of medicine) –  

“In order to be convinced of this, the patient is left without medicine for eight, ten or fifteen days, meanwhile giving him only some powders of sugar of milk.” 

In § 17 FN/1 (moral remedy), § 77 (pseudo chronic disease), §150 (indisposition), and in §226 (emotional disease) Hahnemann advised that no medicine should be given in these cases. Only improved diet, regimen or friendly exhortations, sensible advice is sufficient to dispel the disease. ⁽¹¹⁾

Stuart close’s view on placebo 

In his book “The genius of homoeopathy” Stuart Close consider sac lac as second best remedy without which no good homoeopathist could practice medicine. He mentioned few of the practical uses of placebo. 

First, when the case is difficult and you are not able to decide what remedy is indicated. You must have time and opportunity to study it up. The patient and friends want something at once. This is where your knowledge of second best remedy comes into use. Calmly and confidently, you prepare and administer a generous sac lac powder leave explicit direction for the use of many subsequent doses. ⁽¹⁴⁾  Then you can proceed to apply your knowledge of how to study the case and find the remedy according to the principle of the Organon.

Another use of second best remedy is as a supplement to the indicated remedy. When after giving the indicated medicine, improvement begins and you desire to cease medication, you will simply substitute sac lac for the remedy and watch your case. ⁽¹⁾ 

In this chapter Stuart Close also dealt with the ethical consideration of giving placebo. He mentioned that, any harmless measure when tends to arouse the curative reaction of organism through the awakening of faith and confident expectation, is not only right but legitimate and sometime indispensable. ⁽¹⁾

Kent’s view on placebo 

In the lesser writing of J. T. Kent in chapter 31 “How symptoms change” Kent advised to note the changes in the symptom after giving the indicated medicine. He said, “When a patient returns and report symptoms worse or changed, it is proper to look to see if the new symptoms are found under the medicine taken. If they are found, their prescription is a good one and the physician may say to himself, sac lac. ⁽¹²⁾

In the chapter 37 “Management of displacements without mechanical support” in such cases when the mechanical support is removed at once by the physician or the patient, if she be so instructed. She must be immediately placed upon sac lac and at least a week permitted to pass before a full symptoms image will be found. ⁽¹²⁾

In the chapter 55 “the second prescription” he advised to give proper time before changing the remedy, avoid haste, to wait and observe and in the meantime resort to sac lac. ⁽¹²⁾

Modern view on placebo

Two theories that explain of placebo effect are unconscious conditioning and conscious expectation. According to conditioning theory, patient learn to experience improvement after medical treatment because in the past, they benefited from consulting the physician. While the expectancy theory suggests that the expectations of patient are raised through the ritual of administering a medical treatment. Neurobiological mechanism such as release of dopamine and endorphins are also considered to be important mediators of placebo effect. ⁽¹³⁾

In the study published in 2015 conducted by Girija Sharma Shukla et.al conducted in district Sagar, MP (India) May 2007 – January 2008 and thereafter in Allahabad, UP (India) February 2008 -2012 has concluded that the patient suffering from depression receiving a placebo medicine were significantly benefited. ⁽¹⁴⁾

A ground breaking study in late 70s showed for the first time that placebo could trigger the release of endorphins (the body’s natural painkiller), just as certain active drug does. In this study, Jon Levine, M.D., Ph.D., of the University of California, San. Francisco, gave placebos instead of pain medication, to 40 dental patients who had just had their wisdom teeth removed. Not surprisingly, because the patients thought they were getting medicine that would indeed relieve their pain, most reported relief. ⁽¹⁵⁾

Conclusion

Different authors and stalwarts of homoeopathy have mentioned about the utility of placebo during homoeopathic practice, and they have confirmed its usage by experimenting themselves in different situation and found its extensive clinical applications. Different clinical trials and experimental studies conducted in modern era have also substantiated the utility of placebo. Different physiological mechanisms have also been suggested to confirm the action of placebo in patient which helps in the treatment of various diseases. Nowadays, placebo is not only used in homoeopathic practice but it has also been accepted as an indispensable tool in other systems of medicine.

References

1. Close S. The genius of homoeopathy: lectures and essays on homoeopathic philosophy. New Delhi: Indian Books & Periodicals Publishers; 2005
2. Moore, A. and McQuay, H. Bandolier’s Little Book of Making Sense of the Medical Evidence. Oxford University Press; 2006
3. Brody, H. Placebos and the Philosophy of Medicine. Clinical, Conceptual and Ethical Issues. University of Chicago Press, 1980
4. Cullen W. Clinical lectures 1772-3 RCPE Manuscript Cullen 4/2 299-300.
5. Sutherland A. Attempts to revive ancient medical doctrines: I. Of waters in general. London: A. Millar; 1763
6. Lettsom JC. Reflections on the general treatment and cure of fevers. London: J.D. Cornish; 1772. p. 44ff
7. Jütte R. The early history of the placebo. Complementary therapies in medicine. 2013;21(2):94–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23497809
8. Jütte R. Hahnemann and placebo. Homeopathy. 2014 Jul;103(3):208–12
9. Hahnemann S. Nature of chronic diseases- Psora. The chronic diseases, their peculiar Nature and Their Homoeopathic Philosophy, Reprint ed. Vol. 1. New Delhi: B. Jain Publishers (p) Ltd; 1999. 
10. Hahnemann S. The Lesser Writings of S. H. Collected and Translated by R. E. Dudgeon. 1851
11. Hahnemann S, Dudgeon RE, Boericke W, Organon of Medicine, fifth & sixth edition combined, B. Jain Publishers, 2010.
12. Kent J T, Lesser writings clinical cases, new remedies, aphorisms and precepts. Second prescription,14^th impression:2019, B Jain Publishers.
13. ERNST E. Placebo: new insights into an old enigma. Drug Discovery Today. 2007 May;12(9-10):413–8
14. Shukla GS, Rai PK. Effect of placebo on depression. International Journal of Pharmaceutical Sciences and Research. 2015 Feb 1;6(2):903.
15. Dispenza J. You Are the Placebo Meditation 1 — Revised Edition. Hay House, Inc; 2016

About Authors: –

1. Dr. Suman Mahawar, PG Scholar, Department of Organon of Medicine & Homoeopathic philosophy, Government Homoeopathic Medical College, Bhopal, M.P., 462003
2. Dr. Abdul Rahmaan Siddiqui, PG Scholar, Department of Organon of Medicine & Homoeopathic philosophy, Government Homoeopathic Medical College, Bhopal, M.P., 462003