Within these social and ecclesiastical parameters, and due mainly to the woeful inadequacies of orthodox medical services during the middle ages, most people resorted to folk medicine, based on the accumulated experiences of inherited lore from times bygone. At the same time practitioners of these 'arts' would also include certain rituals in which prayers, spells or charms were recited to accompany their herbal knowledge. This form of magical healing would commonly be the sole form of treatment and firmly reflected the old belief in the curative powers of the Church. An example of such a practitioner was Margaret Hunt, who in 1528 described her methods to a court. First she ascertained the names of the sick people, then she knelt and prayed to the Trinity, then she told them to pray for nine consecutive nights five Our Fathers, five Aves, the Creed, followed by three more Our Fathers, three Aves and three Creeds. After that she might prescribe some herbs, to be taken with holy water and some more prayers.(3) Catholic prayers said in Latin remained a common ingredient in magical treatment of illness. The scope that this form of healing took, encompassed incantations and meaningless formulas imbued with ancient tradition, healing by Royal touch, to a whole series of practises that ranged from the absurd to the dangerous.

Nevertheless such a social fabric imbued with a certain quality of numinosity, must have reinforced strongly the healing abilities of most pre- seventeenth century healers who worked only with charms and spells. Two ingredients were necessary then to affect a healing process, faith and imagination. Contemporaries were well aware of the therapeutic powers of both such ingredients. Francis Bacon, who was a founding member of the scientific revolution, still accepted the healing powers of miracle-working faith. "Even Dr. Edward Jorden in 1640, one of the most perceptive writers on witchcraft, observed when discussing the medical value of such remedies as charms, amulets and holy water, that any success they might have was attributed, not to the inherent supernatural virtue, but to the confident persuasion which melancholic and passionate people may have in them". (4)

It could be argued that this state of magical healing, which was so prevalent prior to the scientific revolution, was in the light of modern medicine, only due to the "Placebo Effect". Nevertheless, however disparaging such a notion might be, the scientific study of the role of suggestion in healing has recently begun, and remains so startling in its results, that one is unable to discount the genuine potency of pre-seventeenth century healers. It could equally be argued that the social and religious fabric of the medieval ages tended to foster such faith in divine intervention that it acted a powerful source of healing in its own right. The Church as an authority imbued with divine power acted as a repository for the great power of the imagination, from which the healer could draw immense resources. Such an example is found told by Denis Granville in 1648 in which a French doctor had a patient possessed by the devil. The doctor called in a priest, surgeon, meanwhile equipping himself with a live bat in a bag. The patient was told that it would take a small operation to cure him, consisting of a slight incision. Just as the cut was done, the doctor let the bat out of the bag crying" Behold there the devil is gone!". The man believed it and was cured.

However we wish to approach this topic of Placebo, it must be realised that it only became an area of contention from the inception of the scientific revolution, with the introduction of a model based on clockwork precision, which considered the human as a machine and likened the human body to a well-made clock. Such an attitude not only led to a mechanistic view but also removed God from the very centre of the medieval world to a place where he was only responsible for setting in motion existence. In such an atmosphere, the entire healing process became devoid of any rational credibility, overtaken by the overweening rationalism of the scientific model of medicine.

The word 'Placebo' comes from the Latin "I shall please" and was introduced into ecclesiastical English in the 12 century in the first verse of the Vulgate. From the time of Chaucer onwards the term was used to denote the practise of singing vespers on behalf of strangers for money and came to mean servile flatterer. It had already begun to acquire negative associations by this time. (M. Sullivan). The earliest instance of an explanation of the placebo effect, comes from a medical dictionary in 1785, where it is defined as "common place medicine or method" which is further elaborated on in the fourth edition, "placebos are calculated to amuse for a time rather than for any purpose" ( the word amuse at that time meant deceive).(5) In 1823 T. Jefferson, an English doctor, defined placebo as a "pious fraud meant to please the innocent patient and the cunning doctor". Another shrewd observer of the human condition was Nicolas Restif, 1734-1806, a French novelist and reporter admired in his heyday by Baudelaire and Goethe. This individual not only wrote over 200 novels, some which he composed within days of each other but also wrote many tracts on the social morality of his day. In one such encyclopaedic work, he is quoted as saying on the Placebo effect " Of all the prejudices this is the most useful. Like anybody else, I know that the physician does not cure, that he can only give advice as to the general measures, which an experienced nurse could give just as well. I know that the would-be remedies have little effect--- but here in confidence is the best medicine of all. All that matters is having confidence, ample, profound, ardent confidence in the doctor and in the remedy. As to the internal disease, the belief in the doctor is even more efficacious as he refreshes the patient’s blood as he is convinced of the prescription. What prejudice is as useful as one that consoles a man in his most critical situation, revives him through hope that balm of life and lets him obtain what he so ardently desires by being assured that he will obtain it ". (6)

As orthodox medicine advanced, the pursuit of rational explanations for therapeutic successes together with a growing stridency towards professionalism, led to a denigration of the placebo effect. Moreover Pasteur's germ theory in the late 1800's provided a secure foundation for the identification of a causative factor, which in turn led to an ever-increasing belief in the omnipotence of medical science. The technical superiority together with its undeniable knowledge of disease based on physiology, created a profession, which became increasingly powerful. In time this formidable association came to gain political power, in the guise of the Flexnor report in the 1900's, which allowed the medical establishment to implement and enforce higher standards, thereby bringing about the demise of alternative models of medicine. " The cultural authority of the scientific method allowed medicine to go beyond the claim to be the most successful medicine to the claim of being the only valid medicine.

From this time onwards, a fierce struggle ensued for the exclusive right to prescribe medicines, and out of a wish to monitor the efficacy of drugs, placebo controls were instigated.

Notwithstanding the ambivalent attitudes towards placebo in orthodox medicine, there is a vast literature on the subject, which tries to come to terms with this epistemological dichotomy at the very heart of modem medicine. Having rendered it illegitimate it is still impossible to deny its pervasive influence, and so with changing attitudes, medicine now accepts the complexity of the placebo effect and the possible interactions of the mind on the body.

The classic trials on placebo effects were conducted by Beecher in 1955 (10) in which he concluded from his analysis of 15 studies involving over 1000 patients, that the placebo effect has an average effectiveness of over 35 per cent. Later studies showed an even wider scope as reviewed by Roberts et al, and others ranging from anywhere between 0- 100 percent in effectiveness. Even sham treatments produced excellent results, for example 64 per cent of patients who underwent a sham tooth grinding operation for myo-facial pain reported total or near total symptom remission. (12) Beecher in another trial emphasized that surgery could evoke a placebo effect and urged caution in interpreting the benefit of new operations (13). It was noted in another study that initial reports in the enthusiastic phase of a new drug/ doctor relationship yielded 70-90 percent results whereas as enthusiasm waned the effectiveness of the drug fell to 40 percent. (14) Another report found that nurses sceptical about placebo injections when communicated to the patient reduced effectiveness from 72 to 25 percent.' (15) In an evaluation of the effects of psychiatric drugs on patients it was found that studies on the use of antidepressants in general practice show---that only about one third of patients are treated for at least 4 weeks, that more than two thirds receive less than 150 mg daily (regarded as a therapeutically useful dose), that most receive doses which are below the effective dose recommended for the treatment of depressive disorders, and that almost half the prescriptions are repeat prescriptions without consultation. "It was also noted in this study that the apparent effectiveness of a drug is partly determined by the size of the placebo response. (16) On the negative side placebos have been associated with many adverse reactions, from drowsiness, headaches, nervousness, insomnia and constipation, and can mimic virtually any condition. Placebo effects have been documented to produce toxic effects, withdrawal effects, complete cures, apparent drug addictions, and even seemed to work in one trial in which patients were told they were on placebo. (17) Shapiro goes so far as to say that the placebo effect is so omnipresent that if not reported then the trials will be accepted as unreliable. He then speculates that the placebo effect is so overwhelming that the major medical achievements of the last few decades may well be recorded by future historians as only the development of methodology and controlled drug trials. (18)

One is therefore led to the inescapable conclusion, that the placebo effect is not only a pervasive force but that every healing intervention will not only have a physiological effect but also has a symbolic function. Moreover it not only questions the entire rationale behind drug therapeutics but actively calls into question the very ethics of modem medicine since denying the placebo effect denies its crucial role in the healing process.

The homoeopathic community has spent many years applying the medical paradigms to its own form of empiricism, trying to carry out double blind tests to validate our own form of medicine. Placebo trials now represent a crucial function in demarcating illegitimate from legitimate medicine. They allow clear guidelines for delineating the action of pharmacological effects to produce clear effects. But such a policy represents a yearning for respectability and a mockery of the entire healing process, since the homoeopathic model is constantly rejected on the grounds of being pure placebo. Can such trials have any genuine value?

From a recent overview of 107 trials in the effectiveness of homeopathy, some of the best-designed studies showed no difference between homeopathy and placebo. Of those that show homeopathy to be effective only three stand up to scrutiny. One British trial was in rheumatoid arthritis, an Italian trial in migraine and a Scottish trial in hay fever. All were well-conducted and showed patients doing better on homoeopathy than placebo. But on replicating them only one, that of Dr. D.Taylor Reilly's study of hayfever at Glasgow University was shown to be flawless. Moreover Dr. Reilly produced recently another flawless study that was published in the Lancet in November, and one criticism was that steroids seemed to be so much more effective!! Whatever the outcome of this power struggle between these two models, using and designing trials which are fundamentally flawed, the lay contingency should be equally aware of the dangers of turning homeopathy into a technology. Since the pristine precision of classical homeopathy with its need to find the simillimum, is in danger of denying the healing process and thereby invalidating the placebic interaction. Both models of medicine need to re-evaluate the epistemological foundations of the entire healing process, and though homeopathy might claim its holistic approach as sufficient basis to activate the placebo effect 1 feel very little emphasis is ultimately placed on this function.

J. Boulderstone in a small article (19) states his own experience in using placebo and argues that it is neither the simillimum nor the placebo that initiate healing but the very process of 'understanding' that remains the most vital part of the entire healing process. In an experiment he gave sac lac for six months imbued with his own idea of the needed remedy, and found his results to be similar to the previous 6 months when he had prescribed Helios remedies. Though anecdotal it is an experience that I am sure many homoeopaths will appreciate. We as homoeopaths seem to have insisted on our own precise technology orientated as it is, towards a specious form of classicism that savours precision and denies the individual, for the sake of an overriding obsession with medical objectivity. Yet our model of healing at times mimics the very model that we consistently reject obsessed as we are with detail and not the qualitative experience of the healing process.

Medicine is replete with explanations for the placebo effect from the psychological to the chemically mediated. Levine in 1978 published a paper demonstrating that endorphins increased in patients receiving placebo which could be a possible mechanism for the action of placebo analgesia. But a year later, this theory was discredited and psychological mechanisms once again replaced it.(20)

But despite the allopathic model maintaining some schism between psyche and soma, and excluding such an anomaly as illegitimate, the placebo effect nevertheless still appears to operate. One can only assume that healing power of the placebo arises out of an encounter, which alters the physiology of the body according to a certain indefinable quality in that encounter. It is unlikely that this power has any biochemical basis but is fundamentally symbolic on an archetypal level. The encounter is a moment in time replete with possibility, in which the integrity of the patient "in his entirety" is examined and constellated into a state of imagined wholeness. This process might remain unconscious, in which case the dynamic might not completely captivate that moment or conscious in which case the healing process becomes saturated with its own numinous quality.

Whatever the outcome of this mysterious process, there is no doubt that at its deepest level, it is surely an aesthetic meditation on the mysteries of soul interaction. It is a process of potentized potential whose quality must not be lost to mere analysis but must be elevated to a state of saturated wholeness where quality become identified with empathy. It is at this point in time when whatever becomes constellated must "seek out images that give rise to meaning and value " and strive for depth, resonance and texture in all that it considers. (21) In this context drugs, or remedies merely become emissaries which can satiate an encounter replete with an imagined state of wholeness. "When the imagination works, everything works, -The entire psyche regains courage; life regains its goals; passion rediscovers hope. A sick, weak hesitating, and blocked imagination can be returned to a state of healthy effectiveness by means of a well-directed image ". So writes Gaston Bachelard, a philosopher and one of France's foremost thinkers, an iconoclast that devoted his time to outlining the power of the poetic imagination. Within this context his whole work is orientated towards sensitising us to the activity of the imagination and demonstrating its extraordinary power over our existential state, to the point that the imagination ought to be capable of revitalizising the inner image, hidden in words and relationships and unleash its hidden content and thereby elicit a healing crisis.

It is important to realize that the Imagination for G. Bachelard, and his fellow travellers. C.J.Jung, James Hillman, and most recently Thomas Moore (with his current best seller in America: with "Care of the Soul" ) acts as a source of infinite healing potential since it is within the confines of its own poetic dimensions that life soars into creative freedom. After all one of the best definitions of health is the ability to create freedom without constraint, and an ability to transpose one note of discordance into a major symphony of unbounded plenitude. It is only through using the imagination that patient and practitioner can empathize into wholeness and thereby enact a crisis of mythic proportions. The words of another extraordinary individual Marsilio Ficino come to mind, whose role in setting up a Florentine academy was crucial in the rebirth of Renaissance thought, and was also responsible for the most radical book on health to surface in over a thousand years. This long neglected work published in 1489, called the Book of Life, was a masterful text of archetypical medicine in which he imagined the planetary gods as presiding over foods, flowers, minerals, animals and modes of behaviour. In this process Ficino lifts the world and its humanity to a state of soulful imagination in which each part plays a crucial role to every other part. He lifts existence to a state of "imaginal wholeness" in which everything comes alive with a numinous meaning larger than man. In his own words

"The intention of the imagination has its force not so much in images or medicines as in the act of applying them and using them. It is as if someone wearing an image correctly made, or using a medicine, strongly created a power from this, unhesitatingly and firmly believing and hoping that this and even a whole multitude of things, came about through this aid. For where the power of the image, if it has one, is warmed up and penetrates the flesh of someone touching it, at least the natural power in its material or the vigour of the medicine one swallows slips into the veins and the innards, carrying with it a Jovial property. The spirit of man is then transformed into a Jovial spirit with this affect, that is, with love." (22)

Moreover this encounter between patient and practitioner being also a function of the current social paradigm can be enhanced by the quality of the society, as I tried to demonstrate in the case of medieval society. Since our present social fabric is in a state of tremendous upheaval it becomes even more important to try and enhance this encounter in every possible interaction between patient and practitioner. Such a qualitative encounter between patient and practitioner becomes a moral necessity and must be taken into account in any process of cure since it is an aspect which is even more important than any medicine we can find.

Larry Dossey in a fine work called Healing Words: The Power of Prayer and the Practise of Medicine, reviews an enormous range of evidence which demonstrates the potency of prayer and encapsulates this quality of numinosity residing in the very process of a healing interaction. He points out the shifting paradigms occurring in medicine, its state of crisis arising out of an iatrogenic apocalypse and a technology that engineers the dreams of reason. Such a consequence leads to favour non-linear and non-local methods of healing which he describes as a new era of transpersonal medicine (23). In the process of prayer and its documented effects he states that everybody must agree in some degree or other to engage a part of the mind which is at times not conscious, and in so doing surrendering to that state of "imagined wholeness" which we are at times totally unaware of. Nevertheless his whole thesis rests on an aspect of the transpersonal which was similar to those forces articulated and constrained by the power of the Church in medieval society. Ironically empirical evidence and efficacy forces us back to those states of ‘soulful healing’ though attempts are constantly made by orthodox medicine to undermine this state of ‘unknowing’.

REFERENCES

1. Religion and the Decline of Magic Keith Thomas Penguin Books 197 1.

2. Ibid 1 3. Ibid 1 4. Ibid 1 5. An Eighteenth Century view of the placebo effect- Francis Schiller- Clio Medica 1984

6. Ibid 5

7. Placebo Controls and Episten-tic Control in Orthodox medicine by Mark D Sullivan. Journal of Medicine and Philosophy Vol 18 N2 1993

8. Placebo Reactor by Parkhouse Nature 1963 No 199 9. Placebos and Philosophy of Medicine by Howard Brody Chicago Press 1980

10. Beecher H.K. The powerful placebo JAMA 1955159

11. The Importance of the Placebo Effects in Pain Treatment and Research by LA. Turner, R.A.Deyo, J.D.Loesser, Micheal Von Korff, W.E. Fordyce JAMA 1994 -271

12. Ibid 11