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 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.

LMs – what are the odds (or the evens)…

hardworking horses…

I have recently been asked about changing potencies in LMs, with people mentioning using odd numbers, even numbers, going up in steps of 2 potencies (LM1 – LM3 – LM5) etc.

I came across this issue before I started studying with David Little, from a post he wrote on the Minutus list, sometime around 2005.  He mentioned that while most people do just
fine on a series of ascending potencies (LM1 – LM2 – LM3 etc.)  he had noticed that some seem to do better on odd or even numbers of dilutions or succussions.  He also noted that Hahnemann didn’t always start with LM 1.

There are two issues in play here, in my view.

The first is the risk of putting theory before experience.  The beauty of homoeopathy is that Hahnemann first observed, then developed a way of harnessing the power of the similar stronger artificial disease without harming the patient, and  what he thought was the most probable explanation for what he was observing.  In Aphorism 28 (and elsewhere), Hahnemann sets out the basis for his thinking on experience versus explanations of how something happens:

“As this natural law of cure manifests itself in every pure experiment and every true observation in the world, the fact is consequently established; it matters little what may be the scientific explanation of how it takes place; and I do not attach much importance to the attempts made to explain it.  But the following view seems to commend itself as the most probable one, as it is founded on premises derived from experience.”

The second issue is the sensitivity of the patient, something that is difficult to assess ahead of time.  In Aphorism 278 Hahnemann explains that individual sensitivity can’t be deduced through “fine-spun reasoning” or “specious sophistry.”  In order to learn the appropriate dose, “pure experiment, careful observation of the sensitiveness of each patient and accurate experience can alone determine this in each individual case…”

To my mind it comes down to “specious sophistry” if we adopt a theory of odds and evens, where there is no solid backing for the theory, or to apply it and then say it worked – especially when there is a body of material showing that many patients do well just going up through the potency scale.  On the other hand, some patients do especially well on a particular potency, but we cannot know if it was the potency itself or if the improvement was built up by the work of the previous potencies and only manifested itself with the current one.

And furthermore – although it is natural to look for protocols, for theories which provide rules for action which can be employed in every case, we will then have moved away from the individualization of the patient, and of the patient’s sensitivity.

In my own experience, many patients do very well going up the scale, some seem to advance more with specific potencies in the scale, and if the remedy is going to help it is usually already visible in the patient’s response to LM1.

However, looking for a pattern in the sensitivity of individual patients and developing theories to govern posology rather than drawing on pure experiment, careful observation and accurate experience on an individual case-by-case basis seems to be a case of putting the dazzling cart of theory in front of the plodding hardworking horse of experience.  Specious to say the least.

 

 

Pimples, Pustules and Boenninghausen’s Questions

Pimples Pustules and Boenninghausen’s Questions

I was recently asked about Phosphorous in eruptions. Specifically I was asked why Phosphorous doesn’t appear in the TPB symptom Eruption, pustules (symptom no. 1426 in P&W Synopsis), when the word “pustule” appears twice in Hahnemann’s proving.

In the proving “Pustules” appears in the following contexts:

Preparation of medicinal solutions

I’m often asked about preparation of remedies for dosing, especially in connection with use of LM potencies.  I’ve quoted David Little’s article on Solutions Large and Small below in full.  You can read the original here.  David also describes the experiments he carried out.

 

Solutions Large and Small
Preparation of the Medicinal Solution

The question of how to make a medicinal solution has been raised. Our research group uses the Hahnemannian Standard as discussed in The Chronic Diseases and The 6th Organon of the Healing Arts. The reason for this is twofold.

Birth control pills and IUDs – cause and maintaining cause

Sometimes it’s a question of finding reasons, not giving remedies.

 

A patient came to me recently suffering from anal fissure, hemorrhoids and constipation.  In that order – the fissure began several years previously, then the hemorrhoids appeared, and in recent months she began suffering from constipation.  In itself this progression looks odd, as usually we’d expect the constipation to come first.  But then the patient reported that she was completely clear from symptoms during pregnancy and immediately after giving birth. And then the nightmare began again.  Curiouser and curiouser, to borrow an expression.

Aphorism 224 – mental disease

These days so many situations are classified as mental disorders, from defiance in children to reasonable depression (where it is normal to be unhappy, due to  temporary or changeable situations of loss, firing etc.) in adults.  So many people are on anti-depressants these days, and the age of those taking the drugs is constantly dropping.

But where will these mental states fit into our prescribing?  Are we looking at early stages of a mental disease, which is part of a systemic problem, or at a reasonable mood change resulting from events and lifestyle where what is really needed is encouragement and advice from friends or professionals?  I am of necessity simplifying a complex differential for this article, as when a reasonable mood change becomes prolonged and entrenched, encouragement and advice may no longer be of use.