Originalia | W i l k e n s • Lüdtke • Stein • Schuwirth • Karenovic | Comparative Studies 22
Johannes Wilkens, Rainer Lüdtke, Frank Stein,
Wolfgang Schuwirth, Angela Karenovic
* By kind permission of Erfahrungsheilkunde, where it first appeared in the 6/2002 issue.
In a retrospective pilot study with 172 patients, two complementary treatment approaches?one homeopathic, the other following a WALA anthroposophic treatment were compared as to their possible efficacy in treating the sequelae of stroke. In both groups, the treatment consisted chiefly in the use of snake poisons and arnica in homeopathic doses. A slightly better result was found with the homeopathic approach. This practical experience made it possible to take the further step of designing a therapeutic schema that proves effective in practice while respecting both approaches?the need of anthroposophical medicine for a pathophysiological rationale and the need of homeopathy for an individualized treatment.
Stroke: epidemiology and therapy
The incidence of stroke in Germany is approx. 150 – 260 per 100,000 population. Its prevalence is estimated at 600/100,000 population. Around 75 – 85% of all strokes are ischemic insults, about 20% are vascular cerebral hemorrhages, and 5% venous circulatory dysfunctions. In the mortality statistics of Western countries, stroke occupies third place behind cardiovascular and tumorous diseases. The peak age is around the 70th year of life; men are more frequently affected than women. The greatest risk factor is considered hypertension. Nicotine abuse raises the risk by a factor of three. Other factors are coronary heart disease (CHD) and diabetes mellitus.
While the institution of the stroke unit has improved the therapy of stroke, fundamental progress remains insignificant. As Fintelmann rightly judges, “we are faced with the incredible phenomenon that to this day modern medicine has been unable to develop any really effective and reliable therapy for stroke, so that what we observe is almost always the spontaneous course” (3) (V. Fintelmann).
Unfortunately much the same statement could be applied to anthroposophical medicine. The standard treatment, based on Rudolf Steiner’s indications, appears to consist solely of arnica. There are two known treatment cases from him that apply to therapy of stroke: In two cases mentioned by Hilmar Walter, Arnica (D 4 and D 15) was recommended.
From the homeopathic side, only two studies are known on apoplexy (stroke). The two studies, both from England, entailed sole administration of arnica in high potency; each produced a negative result. In anthroposophical medicine no study on stroke has yet been published.
Towards a broader therapeutic concept
Stroke is essentially a blood clotting/vascular system disease that secondarily damages the brain tissue. Due to deficient or excessive (hemorrhagic infarction) blood supply, the blood-nerve barrier is breeched, resulting in the death of nerve tissue. Nerve and blood have become dissociated, alienated from one another. Thus it is a weakness in the integrative function of the circulatory system that is ultimately responsible. There is a failure in keeping the mean?the condition of balance between too solid (embolism) and too fluid (hemorrhage). Secondarily, the nerve tissue is damaged (and here too the “mean” is not kept: the A. cerebri “media”) and voluntary movement of the limbs is paralyzed. In this light, stroke can be seen as a primary failure of the circulatory system that secondarily damages the nervous system.
Seen in another light, stroke is also the most striking disease of the symmetry plane of the body. A brief characterization of this plane is given by the anatomist Rohen: “The medial/saggital plane divides the organism into two mirror-image or at least similar halves. The formative principle here is that of bilateral symmetry, a formative principle whose nature is not easily grasped. Essentially, we find repeated on one side what is already present on the other?it is mirrored, without anything new or different being formed. The condition for faithful mirroring is that the reflecting surface must remain quiet and unchanged: A lake can reflect the face of the person bending over it only as long as the surface is unmoving and smooth. (...) Image-forming of the external world by the sense organs and nervous system is essentially based on a reflection process. (...) In this sense, the right-left dimension could be assigned to reflective representation in the soul-spiritual domain.”(7)
In stroke the two almost identical “twins” of right and left become alienated, each unable to be reflected in the other. The mirror has been obscured, the reflecting process disturbed. A part or even a whole side of the patient is lost from his “representation” and becomes part of the “outer world.” One side or one part of a side can no longer be inwardly grasped (flaccid paralysis), or is too firmly grasped (spastic paralysis). The patient has lost inner access to himself.
Accordingly, the first aim of a causal therapy will be to regulate blood coagulation; “repairing” the nerve tissue, i.e. restoring the reflective function of the body, will be a secondary task. In the choice of remedies, attention will be given to those that have an integrative strengthening effect on the vascular system as a whole, are effective for thrombosis/embolism and bear a relation to the “asymmetry” characteristic of the disease.
Anthroposophical medicine will seek in nature for mineral, plant and animal substances that functionally imitate the disease of stroke. The homeopathic approach will seek after substances which, when “proved” on a healthy individual, display a relationship to a single side of the body and to paralytic symptoms.
Both from the homeopathic approach as well as that of anthroposophical medicine, one arrives at direct indications that snake poisons should occupy a special position in the treatment of stroke. Some of the underlying considerations are described below.
Phenomenology of snakes
Friedrich Husemann gives the following description of snakes: “The snakes, along with the turtles and crocodiles, make up the class of reptiles. Like the amphibians, they are still poikilothermic (of variable body temperature), but like the birds they possess an amnion and reproduce through eggs that are no longer dependant on an external watery environment but are covered with calciferous shell. (...) Snakes might be called the purest reptiles: Their four limbs having regressed, they slither over the earth and up trees, burrow into sand or even swim in the water?all leglessly. (...) Serpentine nature has accommodated itself to a tubular body that has lost its limbs. (...) On the other hand, the snakes are deaf, lacking a middle ear.” (4)
Snakes are most closely bound to the earth. In the structure of their body there is also a pronounced asymmetry. The higher snakes have only a right lung, the left one being absent. Other organs, such as the ovaries, are arranged asymmetrically, the left or right ovary being situated higher than the other. It is similar with the other organs. (For details, see Husemann (4).) Snakes have a “swallowing disorder”, a pronounced dysphagia. The linguistic relationship between schlingen (“to gulp down”) and Schlange (“snake”) is not accidental. Considering their darting tongue and hissing, one might also say they are characterized by “dysarthria.”
Of the 300 – 400 different venomous snakes in existence, only a good dozen have been put to medical use. Terrestrial venomous snakes can be divided into three large groups:
• true vipers (Viperidae),
• pit vipers incl. rattlesnakes (Crotalidae),
• cobras, coral snakes, mambas, etc. (Elapidae).
The cobras, coral snakes etc. are chiefly neurotoxic (Naja naja, Elaps corallinus etc.); pit vipers (Crotalus and Lachesis) are preponderantly hemotoxic; and the vipers (Vipera), cytotoxic. In other words, the vipers lead essentially to an isolated necrosis (a metabolic disorder), the pit vipers to a clotting disorder, and the cobras and coral snakes with their curara-like neurotoxins, to paralyses (disorders in the nervous system) (cf. Spielberger for details (8)).
Snake venoms in homeopathy
Snake venoms were introduced by Constantin Hering in 1837 and have become an integral part of the homeopathic pharmacopeia. His very first remedy proving already provided a comprehensive portrayal of the essential characteristics of Lachesis muta. For the most part, 8 snake venoms are now commonly employed: Lachesis, Crotalus horridus, Crotalus terrificus, Naja tripudians, Vipera berus, Bothrops, Cenchris contortrix, and Elaps corrallinus.
In remedy provings almost all snakes display an emphasis on one side of the body, i.e. their effects are felt more strongly on the left or the right side. This is particularly true of Lachesis muta (left) and Crotalus horridus (right). Clotting disorders (tendency to black and blue marks), swallowing disorders and sensations of constriction in the throat region are also very common. On the soul (“mind”) level, there are indications for “loquacity” (Lachesis) as well as for a quiet, withdrawn state and aphasia (Crotalus, Bothrops) (cf. Mezger for more details (6)). With these (and many other) symptoms, snake venoms produce an “ideal image” of stroke.
Retrospective evaluation of therapy
It remains to be proved whether in fact these considerations can result in a viable therapeutic concept. Before putting this question to the test in a prospective study, a systematic evaluation of collected past experiences with a homeopathic and an anthroposophical concept was conducted at the Alexander von Humboldt-Klinik in Bad Steben. To this end all patient data from the period of 9/00 – 8/01 were gathered. (Since 9/00 the computer system Geridoc of the AFGiB has been in use at the clinic, which has considerably facilitated data gathering.)
Alongside of the essential therapies provided by the department for physio- and ergotherapy, the clinic’s integrative therapy concept embraces treatment according to the principles of classical homeopathy and to a lesser extent, those of anthroposophical medicine and phytotherapy.
Between 9/00 and 8/01, the pilot study accepted all patients who had suffered a stroke (even if it had occurred years or decades earlier) and were still suffering from its consequences. The treatment phase lasted from a minimum of 3 weeks to however long the patient remained in the clinic.
The basic therapy consists of treatment within the framework of conventional medicine (e.g. administration of ASA (aspirin) or Marcumar if the patient was already accustomed to these). When the cause was ascertained as cerebral hemorrhage, no specific therapy was given. In particular, the following measures were provided to each patient: ergotherapy, speech therapy and physiotherapy, individually tailored to patients' condition. Adequate supply of accessories (wheelchairs, rollators, walkers, canes) was provided for. The help of an in-house neurologist and/or associated urologist and/or orthopedist was called in as needed. All types of medically necessary accompanying therapy were permitted, in particular:
- all drugs, remedies or therapies needed by the patient for illnesses other than the stroke,
- all drugs or remedies for treatment of the stroke to which the patient was accustomed and which in the judgment of the supervising physician should be continued,
- all new medications deemed necessary for treatment of the stroke by the supervising physician,
- all diagnostic procedures and tests,
- the standard therapy with Aspirin 100 or in rare cases Marcumar.
Homeopathic therapy was conducted most frequently with snake venoms. The majority of patients received either Lachesis (left-sided) or Crotalus (right-sided), generally in D 30. The plant remedies most used were Arnica and the nightshades (Belladonna, Nicotiana, Stramonium, Hyoscyamus) as well as the Logoniaceae (Nux vomica, Ignatia and Gelsemium). Preference among the metals fell on silver (Argentum metallicum) and lead (Plumbum mellitum). In cases of extreme vertigo, additional use of Vertigoheel® (Heel GmbH, Baden-Baden) proved highly effective; CHD patients frequently received additional treatment with Crataegus comp.® (Weleda Heilmittelbetriebe AG, Schwäbisch-Gmünd). Cancer patients were given courses of mistletoe therapy (Abnoba viscum, Iscucin and Iscador).
In all, the homeopathic treatment adhered only partially to the rules of classical homeopathy, admitting the use of complex remedies and simultaneous administration of 2 or 3 remedies?but these were individually tailored. Also, the frequency of administration was too high for advocates of classical homeopathy. However, since in our judgment stroke must be treated as an acute illness, even from the homeopathic point of view we saw no error in the use of frequent doses. The potencies generally used were D 6 and D 30.
In most cases therapy was carried out with Lachesis (44 x), Arnica (43 x), Crotalus horridus (18 x), Nicotiana tabacum (12 x), Phosphor (7 x), Ledum (5 x), Gelsemium (5 x), Digitalis (5 x), or Lathyrus sativus (7 x). Of the complex complementary remedies employed, Crataegus comp. (27 x for severe CHD) and Vertigoheel (17 x for severe vertigo) were frequent.
The anthroposophical concept
No real concept had been available in the field of anthroposophical therapy, so we turned to the research division of WALA Heilmittel GmbH, Bad Boll. They graciously told us of a therapeutic concept that was to prove effective in practice, one essentially based on a combination of two important remedies in stroke (Arnica and Lachesis) along with organ preparations of the affected region. Indirectly, this provided a test of the efficacy of organ preparations and the efficacy of injections. The anthroposophical WALA study concept is quite comprehensive, providing for:
• taking of complex or single homeopathic remedies, as well as
• phytotherapeutic measures,
• embrocations and baths, and
• movement exercises from the field of curative eurythmy.
The total treatment concept includes injections, embrocations and baths. In practice, only the medicinal applications could be implemented in the pilot study, since the oil dispersion baths were not yet at our disposal and?for financial reasons?the artistic therapies could not be generally implemented.
Patients were not assigned to the therapies randomly, but according to the station at which they were admitted. The patients at stations 1 and 2 always (almost always) received homeopathic treatment. The treatment received by patients at station 4 followed the anthroposophical therapy concept. The assignment of the patients to stations was dictated by the capacities of the stations. Thus it can be assumed that the assignment followed solely from capacity considerations (only in rare cases following patients’ requests) and was not guided by the severity of illness or considerations of possible therapeutic success.
In all, the data of 172 patients were documented and evaluated. Of these, 24 were treated anthroposophically, 143 homeopathically and 5 according to neither of the two concepts. More than two thirds of the patients were female. There was little age difference between the two groups and the average age of 79 was relatively high in comparison to other studies. The mean pre-admission waiting period was quite short: 19 days = under 3 weeks (table 1).
Figure 1: Functional impairments at admission according to the
Table 1: Basic patient data (absolute frequency or median (ranges))
|79 (65 - 88)
|79 (58 - 92)
|Referred by: Emergency clinic/family doctor
|23 / 1
|130 / 13|
|Pre-admission waiting period (days)
|18 (11 - 41)
|20 (5 - 1,594)|
Severity of illness
The average Barthel Index at admission was approx. 33 (anthrop. group) and 35 points (homeopathic group)?a rather low score in both groups (table 2). The average values of 21.1 (anthrop. group) and 22.5 points (hom. group) on the Mini-Mental Status Exam (MMSE) correspond to the age and illness and as a rule point towards incipient dementia. Averages of 4.7 (anthrop. group) and 4.1 (hom. group) on the Geriatric Depression Scale (GDS) can be taken as evidence of the common depressive tendency following stroke. It should be noted that approx. 25% of the patients in each group were unable to take the MMSE and the GDS; in most cases this correlated with the severity of their illness.
The GDS correlates with the depression data gathered on the 4D+S questionnaire (Fig.1): Severe depressions are found in almost 3% of cases, moderate in almost 12% and mild in 34%. Thus one may speak of manifest depression in more than half of the patients (table 3). The 4D+S shows severe dysphagia in 4%, moderate in 9% and mild in 12%; thus, swallowing disorders can be assumed in (••???••) of the patients. A similar situation is found with dysphasia: 37 % display dysarthria, with severe aphasia in 9%. Social problems are found in 3 patients of the anthroposopical group and 47 of the homeopathic group.
Fig. 2: Weekly Change in Average Barthel Index
values (last observations carried forward)
The severity of a disease is also documented with the LACHS. On a 14-point scale, the average values of 8.3 (anthrop. group) and 8.points (hom. group) puts the overall degree of illness in the moderately severe range (table 2). Another, more specific way of documenting the severity of paralytic conditions of stroke patients is with the Rankin Scale. The higher the value (at a 4 point maximum), the more pronounced the paralysis. The averages of 3.2 (anthrop. group) and 2.3 (hom. group) point to severe/moderately severe impairments.
On the Scandinavian Stroke Scale (SSS), the reverse is the case: a low point score indicates severe condition and a high point score a normal finding. Here again, the patients receiving anthroposophical treatment showed more severe conditions, with a markedly lower initial score (2.7) than the homeopathic patients (4.3).
The totality of these data show that the study population was not subject to any positive selection, but rather that the patients must be ranked among the severely ill. The illness of the patients of the WALA group is markedly more severe, as is showed particularly by the SSS and Rankin Scale.
Table 2: Median (range) of various scales on severity of illness
|25 (0 - 95)
|35 (0 - 95)
|Mini-Mental Status Test
|23 (13 - 30)
|25 (6 - 29)
|Geriatric Depression Scale
|3 (0 - 14)
|4 (0 - 13)|
|9 (0 - 13)
|8 (0 - 14)|
|Scandinavian Stroke Scale
|3 (2 - 6)
|4 (2 - 6)|
|5 (1 - 5)
|2 (1 - 5)|
There was a significant difference in length of treatment between the two therapy groups: The treatment of the patients in the WALA group lasted on average 35.3 days (median: 40 days), while the homeopathically treated patients were released after only 29.6 days (median, 21 days). At the same time, a good to very good result is documented in almost 60% of the homeopathic group but only 33% of the WALA group. This was true despite the fact that 10 patients in the homeopathic group died (7.0%, registering statistically as a Barthel 0 at discharge), while in the anthroposophical group there were no deaths.
Table 2: Median changes (for ranges) on various severity of
|+15 (-20 - +60)
|+30 (-5 - +70)
|Scandinavian Stroke Scale
|0 (0 to +3)
|+1 (-4 to +4)|
|-1 (-2 - 0)
|-1 (-3 - +2)|
Similarly, good to very good improvement in avoidance of dependency was achieved in almost 60% of the homeopathic group, but in only just under 37% of the group treated according to the WALA schema. In correlation with this, the Barthel Index in the homeopathic group improved by an average of 29.5 points, but by only 17.6 points in the WALA group (table 3). Figure 2 shows the course of the Barthel Index as registered weekly. On the Rankin Scale, the average improvement was 1.0 points in both groups. On the SSS, the homeopathic group rose by 1.0 points, the WALA group by 0.4 (table 3).
The results of the pilot study show that both homeopathic as well as anthroposophical treatment of stroke can produce good to very good results: After an average of 4 weeks of inpatient treatment, almost no patients were left with a Barthel Index under 20, and the Barthel Index as a whole displayed quite a respectable rise?a rise of a kind very seldom met with, to judge by comparable Bavarian data in our possession.
This increase in the Barthel Index, averaging 27.7 points, is remarkable when compared to the prospective study of Meier-Baumgartner, which showed an average rise of 24 Barthel points?from 42 to 66?at an average treatment period of 55.7 days and an average age of 75 years ). It should also be considered that the Barthel Index in our study actually reflects a lowering effect caused by inclusion of all patients, without selection for those with “better prognoses.”
On a critical note, it should be pointed out that it is standard clinical practice to record the initial Barthel Index from the application form for geriatric rehabilitation. As a rule, this form had already been filled out at the interim clinic several days before admission. The Barthel score was frequently lower (though in some cases better) than the one ascertained by us. We must assume a systematic error here, the extent of which is difficult to judge.
The differences between the remedy concept derived from anthroposophical medicine and the homeopathic concept are satisfactorily explained by the greater severity of the condition of the stroke patients in the WALA part of the study?an aspect that is poorly reflected by the Barthel Index. Hence in this respect great caution is necessary in interpreting the results. An indication of similar efficacy is in fact found in the almost identical change in the Rankin Scale in both groups.
The best results were obtained with use of a snake venom and (parallel) use of Tabacum and/or Arnica. In cases of weakness involving the arm (left-sided) and BAA Syndrome, Digitalis proved effective. Cases of contracture (esp. in alcoholics) frequently show significant improvement with Ledum D6; with smokers and multi-infarction syndromes, very good improvement is very regularly noted using Nicotiana tabacum D6–30. Mistletoe therapy too appears to have a favorable influence on healing.
Parallel to therapy with snake venoms, a therapy of the risk factors should always take place: Nicotiana tabacum for nicotine abuse, Crataegus comp. or the like for CHD (proven results!), and so on. In addition, it is expected that the accompanying therapy with oil dispersion baths and curative eurythmy, which could not yet be implemented for this study, will make it possible to achieve further improvement.
Initial empirical confirmation now exists that an approach based on complementary medicine can treat stroke with good to very good results. Following this first evaluation, our intention has been to explore whether, on the basis of the experiences described here, the stroke treatment provided might not be still further optimized using therapeutic remedies.
This in fact appears to be the case. In the months after conclusion of the pilot study, it was possible to achieve marked improvements in very severe cases?aphasia in particular? using the snake venom mixture Naja comp. (Weleda Heilmittel GmbH, Schwäbisch Gmünd) (2–3 x week s.c.). The improvement was also seen in old cases. With Naja comp., the rise in the Bartel Index averaged 30 points (after 15 cases)! If the physician has no experience with homeopathy, for routine practice Naja comp. is recommended (2–3 x week).
The remedy Naja comp. consists of Lachesis, Naja, Crotalus and Vipera in various potencies, thus covering all three venom types (hemotoxic, neurotoxic and cytotoxic). In this way, it represents a kind of “archetypal” snake venom. Inasmuch as stroke too represents a disorder on all three planes (circumscribed cytolysis in the area of infarction; the coagulation disorder that is nearly always present; and the neurological losses), the surest treatment for it will employ all three types of snake venom.
Based on our current level of knowledge, we believe that the optimal medical treatment will combine a complex remedy specifically matched to the pathophysiology of the disease (Naja comp.)?in accordance with the intentions of anthroposophical medicine?and a carefully chosen single homeopathic remedy (in most cases Arnica, Digitalis, Ledum, Phosphorus, or Tabacum)?following the intentions of classical homeopathy. In this way, anthroposophical breadth is ideally complemented by the individualized precision of homeopathy.
It is astonishing that Naja comp. has scarcely been known in the anthroposophical treatment of stroke. Much the same is true of Nicotiana tabacum in homeopathy. In order to verify or possibly falsify the results presented here, as well as to render them more precise, a multicenter prospective study would be called for. Our clinic envisions initiating such a study in 4/02.
First and foremost, I am indebted to the Karl- und Veronica-Carstens-Stiftung for its financial and logistical support in conducting this study. The research division of WALA Heilmittel GmbH gave freely of its good will and un-bureaucratic support to our endeavor, accompanying us in friendly collaboration. Thanks also to Mr. Tümena for his steady and attentive work on the GERIDOC-Programm, which considerably eased the implementation and assessment of the study.
Dr. med. Johannes Wilkens
D-95138 Bad Steben
Literature and Notes
- Ärztliche Arbeitsgemeinschaft zu Förderung der Geriatrie in Bayern (AFGIB e.V.): GIB-DAT (Geriatrie in Bayern Datenbank) -Projekt
- Bundesarbeitsgemeinschaft der klinisch-geriatrischen Einrichtungen: Geriatrisches Minimum Data Set (Gemidat), Berlin 1997
- Fintelmann V. Alterssprechstunde, Urachhaus Stuttgart 1991, p. 219
- Husemann F. Das Schlangengift; in Beiträge zu einer Erweiterung der Heilkunst, Heft 2, 1998
- Meier-Baumgartner H.-P. Determinanten der Schlaganfall-Rehabilitation,Thieme-Verlag Stuttgart 2000
- Mezger J. Gesichtete homöopathische Arzneimittellehre, Haug-Verlag Heidelberg 1987
- Rohen JW. Morphologie des menschlichen Organismus, Verlag freies Geistesleben, Stuttgart 2000
- Spielberger F. Schlangengifte als Heilmittel; der Merkurstab, Heft 3 Mai/Juni Stuttgart 1993