Videos, stills and nagging – dosing in homoeopathy

Jerusalem Homeopathy Clinic

I’m writing this because lately I have been asked, on the one hand, why I prescribe so many remedies – and on the other hand, why I prescribe so few doses.  It all boils down to videos, stills and nagging…

Do people essentially remain the same, or do they change the whole time? And when someone gets sick, does that mean they’re in a different place, a different state to when they are healthy – or are they still basically in the same state and just need a little tweaking?

In essence – is the human being a dynamic video, constantly shifting and changing, or are human beings just a series of stills photographs with occasional retouching?

Samuel Hahnemann, the founder of homoeopathy, saw the human organism as highly dynamic, constantly shifting and changing.  The job of the homoeopath, as defined by Hahnemann in his Organon of Medicine (first version…

View original post 817 more words

Cases – a puzzle or a mystery?

I was recently reading about the distinction between a puzzle and a mystery in a piece written by Malcolm Gladwell about Enron. He states that “a puzzle is a situation where you don’t have enough information.  If things go wrong with a puzzle, identifying the culprit is easy: it’s the person who withheld information. Mysteries, though, are a lot murkier: sometimes the information we’ve been given is inadequate, and sometimes we aren’t very smart about making sense of what we’ve been given, and sometimes the question itself cannot be answered. Puzzles come to satisfying conclusions. Mysteries often don’t.”

So let’s take all that and think about case taking and prescribing.  The parallel isn’t precise but I think it can be useful.  So puzzle or mystery?  I think it’s important to understand the distinction in each case before us.  If a case is a puzzle, if we think hard, we often realize that we’re missing a vital piece of information.  Either the patient didn’t volunteer it, or we didn’t ask it.  Whether it’s modalities or particulars – is it better to lie on the painful side or on the painless side, where exactly is the sweating on the body, which comes first – the chill or the perspiration – when these pieces of information are missing, we are faced with a puzzle.  And when we sense that something is missing from our case-taking, we’re faced with an even more complex puzzle, because we need to go over all our case-notes and find what we neglected to ask the patient, what information is missing.

But if the case is a mystery – we’re in a whole other ball park.  We know we asked all the questions.  We know we have all the information.  But the patient isn’t responding to the remedies we’re giving.  Often in such cases we retake the case, over and over again, but no new, dazzling piece of information comes up.  Here it is not the information, it’s how we’re connecting the dots.  What patterns we’re forming in how we view the information we’ve been given.  Maybe we’re putting more stress on recent developments when we’re really facing an old symptom that has morphed into different versions of itself over the years.  Maybe we’re putting more emphasis on physicals and we will only be able to resolve the case using mentals – or vice versa.  Maybe we’re getting bogged down in ancient history, when we should be looking much more closely at current presenting symptoms.

The reason I found this distinction so interesting in its possible application to case-taking and analysis is this: there is a tendency among homeopaths to take down much more information than needed during a case.  I remember during my training that you could always tell students who were finishing first year – they were suffering from constant chronic hand pain from writing down every word in live cases.  (yes, in the olden days not everyone brought a laptop to class, our caves didn’t have electricity sockets… ).  And then our case-taking and analysis is flooded with a tsunami of information – which is just too much.  From looking for a missing piece of information to solve a puzzle, we essentially create a mystery of finding a path through the deluge that is now our case, and trying to keep our heads above water in a sea of case-taking disorder.

I believe that when we begin working with each patient, the case should be viewed as a puzzle.  We want to make sure we have all the information we need to fill the boxes – if a patient perspires we need to know where, when, hot, cold, mental state etc.; we need to know actual facts, where, how much, hard or soft, internal or external, colours, textures.  We need to know presenting symptoms and background.  Prescribing is a function of viewing the relevant facts, examining the provings and literature on a small group of remedies, coming to conclusions.

But if we’re sure of a remedy and it’s not helping, we’re now faced with a mystery.  And as any avid watcher of thrillers knows, often the criminal is found when someone looks at the event board and arranges the facts in a different pattern.

 

When you can’t find a proving (or can’t find it in English)…

Why view remedies through the P&W repertory?

I have written on the importance of source material, especially of provings, in working to principle. As Hahnemann specified in Aphorism 3, in order to do homoeopathy we need to know what’s wrong with the patient, what the remedies can do and how to match a remedy to a complaint – with the proviso regarding appropriate potency and dosing.

How do we know what remedies can do? Through provings, first and foremost – the symptoms can a substance cause in a healthy person.

Hahnemann’s lesser writings include an essential article published in 1796, among his writings leading up to the Organon published in 1810. It is entitled “Essay on a New Principle for Ascertaining the Curative Powers of Drugs.” In this article, Hahnemann tackles existing methods one by one, and demonstrates their problematic nature. One after the other, with reasoned arguments and logical discussion, he knocks over chemistry as partial, nixes mixing unknown drugs with newly drawn blood, and more. He counsels against the doctrine of signatures, botanical affinity and families, stating categorically that the hints of the natural system “can only help to confirm and serve as a commentary to facts already known… or in the case of untried plants they may give rise to hypothetical conjectures which are, however, far from approaching even to probability.” He discusses experiments on the sick and how many discoveries were made by chance – and then laments “how humiliating for proud humanity did his very preservation depend on chance alone…”

Through step-by-step argument, Hahnemann comes to the conclusion that “nothing then remains but to test the medicines we wish to investigate on the human body itself,” which he states has so far been done “empirically and capriciously in diseases.” A standard human response to medicines, “some natural normal standard,” he states “can only be derived from the effects that a given medicinal substance has, by itself in this and that dose developed in the healthy human body.”

The body of provings which is easiest for us to access nowadays is in the Materia Medica Pura and Chronic Diseases. All the symptoms were carefully sifted through by Hahnemann, so if we see Hahnemann as a reliable source of information, that reliability extends to the provings he collated – and to his decisions to include some symptoms not taken from provings, rather from clinical work. We have less knowledge regarding the provings of other remedies noted in Boenninghausen’s Therapeutic Pocket Book, although here again, if we see Boenninghausen as a reliable source, information about these remedies will be important in our work. There is information in Hughes Cyclopaedia, and many other materia medica refer to provings, but all too often provings information is intermixed with symptoms derived from therapeutic clinical work and poisonings, or separate as in Hughes, but not organized.

But we have another source of information for those remedies whose provings were not collated or overseen by Hahnemann – the Therapeutic Pocketbook itself. Boenninghausen examined and brought together all the remedies in use in his time. Some were proven by Hahnemann but not published by him. Some were proven by Hartlaub and Trinks and others. Furthermore, Boenninghausen was kind enough to give us a grading system, indicating where a symptom derives from a proving of a remedy with grades 1 and 2, and strengthening the relevance of that symptom for that remedy from his clinical work with grades 3 and 4.

This means that if we take a remedy through the Reversed Materia Medica in the P&W software, we can actually gain a picture of the proving through grades 1 and 2, together with reliable clinical expansion on that remedy through grades 3 and 4. This in itself is information from early and primary sources, with Boenninghausen and Hahnemann’s stamp of approval. Furthermore, thanks to P&W, this information is available in English, Spanish, and Hebrew in addition to the original German. And there are other languages on the way. This means that those who have difficulty accessing the Materia Medica Pura in their own languages and use the P&W reversed to shed more light on these primary sources.

How can we begin to analyze this mass of information? The TPB was developed to help repertorize, guide the practitioner towards remedies to read up on more intensively. But the computerized version has given us the ability to access the material in different ways, including using the Reversed Materia Medica as a “back door” into gaining reliable knowledge of remedies where the provings are not accessible.

For example, on a very basic level, we can see a remedy’s position in any rubric. We can see if it’s there because it’s in the proving, graded 1 or 2, or because Boenninghausen emphasized its clinical use with grades 3 and 4. A remedy may appear in a symptom with very few other remedies, giving it additional importance in that symptom regardless of its grade. A remedy may appear in a large rubric, with over a hundred remedies, and there we may want to see if it’s in a higher grade than other remedies, if that symptom is very strongly connected to the remedy we’re examining. The relationship between remedy grade and rubric size may have relevance in the case we’re working on. All this while keeping in mind that the appearance of a remedy in proving is the basis for prescribing, and Boenninghausen’s clinical use of that remedy is an added bonus.

For those interested in working to principle, which means using provings-based materia medica, the reversed MM offers a treasure trove of information about provings which are harder to access, which is definitely worth while exploring.

The aggravating question of aggravations

I recently posted a small case quiz on the IHM facebook group.  This is what I posted:

A short case management quiz…
A woman had been suffering from a bad dose of poison ivy. She had taken steroids, and some of the rash still persisted. She felt something still needed to heal and asked for treatment.

I gave Mercury LM1, which helped the rash immediately, but then within a day or so the patient started coughing. The next day, the cough went to the chest, productive cough with thick yellow mucus. The patient said this is chronic, and was very worried that the cough would get much worse and remain for months, as that is what usually happened.

What questions would you ask the patient at this stage? What’s the next step? Why?

This is a situation which we all deal with, in many if not most cases.  We have given a remedy which is doing well on the chief complaint but within several days, an old symptom emerges.  The patient may be extremely distressed, insisting that he or she be given a medicine to deal with the chronic, as now it will only get worse as it usually does.

And now we must understand what is going on, what’s the trail of activity and response here, in order to determine the next step.

Is the old symptom an aggravation from the remedy?  Or has the patient simply moved into a familiar chronic state as they suspect? and fear?

As people in the facebook discussion correctly responded, we want to look into the nature of the old symptom, and especially to see if the symptom is now presenting in the same way as always, or if there is something different about it.  We also want to see whether the old symptom is covered by the remedy we gave.

In this particular case, the old symptom was presenting slightly differently, and it was indeed covered by the remedy given.  I told the patient to wait.  It wasn’t what she wanted to hear.  Yes, we can always prescribe sac lac in these cases, but then the patient learns nothing.

As I and others have noted in the use of LMs, an aggravation of an old symptom often passes within hours, usually passes within one or two days, and occasionally drags on a little longer.  In these situations, usually after a day the patient will say the symptom is still there, but less.  In C potencies, the aggravation may take longer.

What we must be aware of is that when there is an aggravation triggered by the remedy, it is a substance symptom which is sitting on susceptible areas in the organism – treading on its corns, so to speak – and not a disease symptom.  And the symptom is challenging the immune system to address it.  It’s an opportunity to allow the immune system to finally recognize a symptom it has not been dealing with properly (resulting in chronic illness), and to deal with it as needed.  If we rush in with a remedy or even antidote, we are passing up on a vital opportunity for the organism to become stronger and more effective.

Obviously, if  the symptom persists, becoming more and more identical to the old chronic, it must be addressed – the case must be reviewed, symptoms chosen again, and the best remedy prescribed for the situation.

However – a word of warning.  Sometimes it is possible, especially when the dose given was too high, for the patient’s situation to slide into an acute flare-up of the chronic, something too intense for the organism to handle, especially when weakened by the heavy-duty symptoms it is experiencing.  For this reason, I believe it is essential to keep tabs on what is happening, to ask the patient to check in after 24 hours, to understand exactly what process we are looking at.

In this particular case, the old chronic symptom passed within two days, all in all around five days after one dose of the remedy was given.  It was already easing after 24 hours.  The patient expressed amazement at the strength and duration of the remedy.

One of the most important elements of this kind of situation is that when we prescribe, we must have a clear path in mind of what we want to see, of why we’re seeing what we’re seeing, and of the options available to us.  Most importantly, patients will insist on new prescriptions, different remedies, etc., but if we are to help them we must understand whether their insistence is based on deeper understanding of what’s happening, which can happen but is rare, or simply on their lack of knowledge about how homoeopathy works, mixed in with real fear of getting sicker.

The case of Lady Ponsonby-Blythe

The case of (the fictitious) Lady Gwendolyn Ponsonby-Blythe

There are certain attributes to this case (details given again at the end of this post), some reflect prescribing symptoms, and some must be noted with care….

• the patient is haughty
• chief complaint – pain on turning the head to the left and to the right
• aggravation from drafts
• coughing and sneezing
• susceptibility to neck pain since childhood
• hot bath amel
• brandy amel
• lachrymation
• agg mortification

The mortification this patient felt in not getting an invitation to the wedding does seem to be part of the trigger for the flare-up and I would include it in repertorization.  So too aggravation from drafts and turning the head, the amelioration from brandy and from a hot bath, and even the weeping.  But although I would not include haughtiness in my repertorization as it is part of her personality, not part of her pathology (although some would say it is the inbred pathology of many aristocrats…), I wouldn’t be surprised if haughtiness was found in the chosen remedy’s proving.  The spring allergies will probably show up in the proving as well.

Possible remedies are easy to see here.  But I didn’t post this small fictitious case as an exercise in choice of remedy.  It’s not particularly complex, and there aren’t even any interesting a-ha moments in it.

The important thing to note is that this case is an acute flare-up of a chronic condition.  This kind of case can be very muddied by dosing as if it is a completely new acute.  Often, less doses are needed, and greater care must be taken that the patient won’t aggravate.

Very often patients come with an acute complaint which turns out to be a flare-up of a chronic condition.  In such cases I have found patients to be more susceptible to remedies and more likely to aggravate on frequent dosing.  This is also a logical expectation.  For example, if someone is chronically susceptible to insults, and usually gets sick after any mortification, any remedy which can cause a feeling of offense in a person will be treading directly on the thin ice of a large frozen lake of existing sensitivity to this.  Sensitivity is increased, and so dosing must be carefully monitored.

In addition, because this is really a chronic, not an acute, there is more likelihood that changes in the symptom picture during treatment, both in resolution of the acute flare-up and subsequently, will make it necessary to switch remedies.

In these cases, the patients can be difficult to work with.  They often find it hard to believe that they aren’t being told to take a remedy three times a day for a week, and some will even be convinced that the instructions for minimal dosing were wrong, and will take more of the remedy “just in case”.  In these situations, a slew of old and new symptoms may appear, and case management becomes far more complex than it should be.

More on case management in a future post.

***************************************************************************

another british aristocrat…

Lady Gwendolyn Ponsonby-Blythe sat condescendingly in my consulting room. I have never seen anyone sit condescendingly before, but Lady Ponsonby-Blythe’s sitting had an expression all of its own. She looked around and sniffed, clearly unimpressed by my simple chairs, desk and unadorned walls.

I asked how I could help.

“It was the royal wedding, you know,” she confided. I must admit, I was impressed.
“You were invited?” I asked.
“One’s television screen in the main hall of one’s castle is set at the most inconvenient angle,” she continued, ignoring my question as an expression of plebeian ignorance. “Since the royal wedding, one’s neck hurts, every time one turns it, so,” and she turned her head to the left and to the right, wincing with the utmost gentility. I thought for a moment that she was about to wave to imaginary courtiers.
“It’s dreadfully cold in the big hall, impossible to heat, you know, and one cannot stand drafts.”

I asked about other complaints.
“Spring allergies, you know, most people have ‘em,” was the response. “One still suffers from the occasional cough and sneeze,” and she withdrew a small square of cambric and patted her nose.

“And does one – er, do you get neck pain often?”
“Oh yes,” she responded. “Since one was a child, always the drafts, one just can’t abide ’em . One asks Tompkins to draw one a hot bath, that and a small brandy, for medicinal purposes, you know.”
“Does that help?” I asked.
“Of course,” the lady snapped, clearly impatient with so many impertinent questions.

And suddenly, the small square of cambric emerged again as the lofty Lady Gwendolyn Ponsonby-Blythe dissolved into tears. I don’t know which one of us, whether it was “one” or myself, was the most surprised.

I handed her a glass of water and waited.

She sipped the water with a grimace, as if it was not sufficiently well-bred. When she spoke next, her voice was uneven but controlled.
“It was that damned wedding,” she explained. “Obviously Cedric and oneself must have been invited, but without the invitation there would have been a fuss, don’t you know, and one does not like fuss. So common, you know.  So one watched the event on the television – and now this!” she ended, turning her head gently but painfully from side to side.
“It’s just all too much!” The tears threatened again, but were subdued into silence by “one’s” iron will.

I asked some more questions, gave a remedy and instructions, and Lady Ponsonby-Blythe sailed, galleon-like, out of my consultation room into the masses of the great unwashed, cambric handkerchief held gently to her nose for protection.

As others greater and wiser than myself have said of this kind of story – it didn’t happen but it could have done… in a parallel universe or somewhere equally exotic…

What remedy would you give – and why?
How would you dose? And why?
What results would you expect?

The Lady and the Homoeopath

Queen Victoria – not Lady Ponsonby Blythe…

Lady Gwendolyn Ponsonby-Blythe sat condescendingly in my consulting room. I have never seen anyone sit condescendingly before, but Lady Ponsonby-Blythe’s sitting had an expression all of its own. She looked around and sniffed, clearly unimpressed by my simple chairs, desk and unadorned walls.

I asked how I could help.

“It was the royal wedding, you know,” she confided. I must admit, I was impressed.
“You were invited?” I asked.
“One’s television screen in the main hall of one’s castle is set at the most inconvenient angle,” she continued, ignoring my question as an expression of plebeian ignorance. “Since the royal wedding, one’s neck hurts, every time one turns it, so,” and she turned her head to the left and to the right, wincing with the utmost gentility. I thought for a moment that she was about to wave to imaginary courtiers.
“It’s dreadfully cold in the big hall, impossible to heat, you know, and one cannot stand drafts.”

I asked about other complaints.
“Spring allergies, you know, most people have ‘em,” was the response. “One still suffers from the occasional cough and sneeze,” and she withdrew a small square of cambric and patted her nose.

“And does one – er, do you get neck pain often?”
“Oh yes,” she responded. “Since one was a child, always the drafts, one just can’t abide ’em . One asks Tompkins to draw one a hot bath, that and a small brandy, for medicinal purposes, you know.”
“Does that help?” I asked.
“Of course,” the lady snapped, clearly impatient with so many impertinent questions.

And suddenly, the small square of cambric emerged again as the lofty Lady Gwendolyn Ponsonby-Blythe dissolved into tears. I don’t know which one of us, whether it was “one” or myself, was the most surprised.

I handed her a glass of water and waited.

She sipped the water with a grimace, as if it was not sufficiently well-bred. When she spoke next, her voice was uneven but controlled.
“It was that damned wedding,” she explained. “Obviously Cedric and oneself must have been invited, but without the invitation there would have been a fuss, don’t you know, and one does not like fuss. So common, you know.  So one watched the event on the television – and now this!” she ended, turning her head gently but painfully from side to side.
“It’s just all too much!” The tears threatened again, but were subdued into silence by “one’s” iron will.

I asked some more questions, gave a remedy and instructions, and Lady Ponsonby-Blythe sailed, galleon-like, out of my consultation room into the masses of the great unwashed, cambric handkerchief held gently to her nose for protection.

As others greater and wiser than myself have said of this kind of story – it didn’t happen but it could have done… in a parallel universe or somewhere equally exotic…

What remedy would you give – and why?
How would you dose? And why?
What results would you expect?

Hepar Sulph, provings, and a rant in a teacup…

winking? or dry eye…

I was recently working with a patient suffering from dry eyes. The patient would wake at night unable to open his eyes, and said the condition was ameliorated by cupping his hands gently over his eyes. Among the symptoms – worse during sleep, worse in artificial light, sensation of dryness and burning in the eye, unable to open the eye at night. I had given Rhus Tox which had helped somewhat but it was stalling. And we homeopaths expect more from our remedies – don’t we now…

I used the rubric worse for uncovering as an expression of the hand-cupping amelioration but based the center of the case on all the other symptoms and modalities where the rubrics were more precise. I reviewed everything again and saw that only two remedies covered all the symptoms – Rhus Tox and Hepar Sulph. I looked closely at the provings of the two remedies, thinking that if Hepar Sulph didn’t look like a better match I’d go up in potency on the Rhus-Tox. The eye symptoms were very well represented in the Hepar proving, but I could not find clear mention of hand-cupping ameliorates.

So I went on an obsessive hunt for the symptom – even though I knew I didn’t really need it. I found it in Kent’s repertory – but no Hepar. The only remedies there were Aur-Mur and Thuja. I went through the books I used many years ago, in the olden pre-TPB days – Phatak, Kent, Clarke, Boger Synoptic and others, and finally tracked down the symptom in Vermeullen’s Prisma given as Eye, pain, better for lightly covering eyes with hand.  But where did it come from?

I looked in Schroyen’s Synthesis, and there I found Eye Pain, covering eyes, hand with, amel with the previous suspects from Kent – Aur mur and Thuj. And then – Eye pain, covering eyes, lightly, amel – Hepar.

Various materia medicas do report that some light covering amel with Hepar. Vermeullen is the only one I found in my search who specifically states the symptom, and the source is unclear. It appears in the Rubrics section of his Prisma, which he writes gives symptoms taken from the Synthesis, and further states that he made corrections and additions in this section where he felt symptoms had been misinterpreted or overlooked. So no certainty there…

And as I was on this hunt which was unnecessary  as I could already see that Hepar was indicated but by this time I couldn’t stop – I realized that this was a kind of reversed engineering of  the way I used to work, a way that has become completely unnatural for me.

I started out on my homoeopathy studies with an impressive (and heavy) hardcopy of Schroyen’s Synthesis, in a scholarly dark red binding with gold lettering. I studied out of town, and this huge book, together with other weighty tomes, were my constant companions and back-straighteners (in a reinforced  backpack for hikers). I would take symptoms, rummage around in the Synthesis to repertorize the case, and hunt through Kent, Phatak, Tyler, Boger, Vermeullen, Sankaran et al to see if I could make a case for a remedy. The work was imprecise and frustrating. There was no certainty, no clear path through all this literature – even though eventual purchases of a laptop and software eased the back pain somewhat but little else…

Which brings me to a conversation I had recently with a colleague (this is the “rant-in-a-teacup” part). I had mentioned that I was thinking of putting together an online course for the study of provings. Wake up, he said, don’t you get it? No-one is interested in provings. And I had to admit he was right. I can see from the interest in various posts on the IHM sites. Readers of our sites really like the articles on vaccinations, and damning materials quoted from other sources.  Scandals in the conventional medical world are a particular favourite. Readers, hopefully many of them homoeopaths, like case presentation and analysis, methodology, posology, repertorization, and even discussion of materia medica, and this is good. IHM rants are quite popular as we can on occasion be quite amusing… But while articles on provings have their devotees (thank you, you know who you are), they garner much less interest in the world of modern homoeopathy.

But then I thought further. If the mass of people in this field are not interested in provings, then they are also not interested in doing homoeopathy properly. Because the principle of like cures like rests on provings, without provings homoeopathy as a scientific medical method would not exist.

Until you’ve read a remedy proving you really know very little about it, about its diversity, potential for healing. You will be forever mired in the prejudices passed from teacher to student, prescribing Pulsatilla for needy, weepy blonde women with blue eyes, and Hepar only where the patient is extremely chilly. Men and children would never be given Sepia. Everything would rest on what was learned from teachers rather than primary sources. And so much would be lost.

And if you start with software, speculative materia medica, and the mass of material from the older homoeopaths which has simply been copied from work to work as can be seen from the exact repeats in wording – it’s a mess. You don’t know what symptoms come from provings, clinical or poisoning. What is central and certain and what is at best confirmatory. You don’t know where to start and where to finish. And in my obsessive sleuthing, when I started with the proving and ended with the synthesis, I realized just how little these materia medica reflect the proving, how disconnected the investigation became.

Since I had started out on this rather senseless quest with Hahnemann’s provings on Hepar and Rhus Tox, and with Boenninghausen’s therapeutic pocketbook which is based on primary sources and not on a cacophonous centuries-long game of Chinese Whispers and creative writing, I recognized that my sleuthing was, for the most part, a waste of time. I was confident that Hepar would help my patient. My process today, for which I am totally grateful to P&W and the IHM, is much easier, and more sure-footed. But it also reminded me of those early days, how literally back-breaking it was to rely on these hefty tomes which just didn’t seem to add wisdom, only to dilute it, to shatter what little knowledge they contained into tiny unrecognizable fragments.

Homoeopaths should be interested in provings. Homoeopaths should want to go to original sources, and to have the ability to do so. But I have come to the point where I feel I have to recognize and accept the reality. Very few (undeniably intelligent) homoeopaths are interested in provings.

Unless I’m wrong? Whether I do an online course on the study of provings or not – I would be delighted to be proven wrong.