The nuts and bolts of homeopathy

It is a while ago that I became the proud owner of a copy of Clarke's Encyclopaedia of Homeopathic Materia Medica. I remember the first time I studied the long lists of miracles that could be wrought with homeopathic remedies. Sulphur seemed the most impressive substance. And my excitement increased manifold when I found myopia in the list of clinical indications for Sulphur. Could that miraculous remedy help me get rid of my glasses? For some reason, 25 years on, I don’t expect Sulphur to cure myopia. I am still wearing my glasses. And although I have seen many great cures and improvements by homeopathic remedies, my expectations have changed. I was a student, now I am an experienced homeopathic practitioner. Perhaps an expert, although I realise that more than a few colleagues, and definitely some of my patient's will express their doubts here.

The educational sciences have redefined what it means to be an expert. Compared to a novice, an expert is not just better equipped to solve certain problems. In fact, novices and experts don’t see the same problem. When looking at Clarke's Materia Medica, a novice to homeopathy and an expert don’t see the same book. The expert sees certain information that he knows is essential, and other information that he has learnt to discard. Things are different for the novice. The novice must learn from practice, and learn from experts, until he becomes an expert himself. ‘Macht's nach, aber macht es genau nach’, Hering said: Copy, but copy exactly. Homeopathy has leaned on this tradition for a long time: learn from the masters, do as they do. The method is perfect, but we are fallible. Some of our brightest young colleagues refuse to copy. They look under the hood, at the nuts and bolts of our machinery, then they think and criticise. For me, that's where the fun starts. ‘I’ve yet to meet the first homeopath who refutes information from the repertory’, one young colleague said. Bull's eye, as far as I am concerned. Why should Sulphur be mentioned for myopia if nobody I know has seen myopia disappear? How often does it really happen? What can I promise my patient?

In a remarkable series of papers in this journal, Rutten et al. make their case for improving our repertories. ‘Is it possible to make the perfect repertory ... and repertorisations that always put the effective medicine in first place?’ It sounds like a rhetorical question, but one wonders how we can manage without such tools. ‘Entries should be based on systematic analysis of materia medica, instead of casual observations’. The bare fact that this needs to be said should make us happy that our opponents are still aiming their arrows at our dilutions, and seem oblivious to the lack of transparency of our prescribing criteria.

Rutten et al. call for structural changes in the repertory, and the likelihood ratio (LR+) of symptoms is their instrument of choice.[ ¹ ] Van Wassenhoven gives us examples of how LR+ can be used to quantify the relevance of symptoms for a remedy.[ ² ] After 16 years of meticulous registration in his practice, he gives us his results for Veratrum album (Verat-a). According to his data, worse from warmth has an LR+ of 23.9 for Verat-a. If we don’t know how a patient reacts to warmth, he may yet need Verat-a. But as soon as we know the patient gets worse from warmth, then the probability that he or she will improve from Verat-a increases almost 24 times. In their article in this issue, Rutten et al. show how the reliability of our prescriptions may increase by using symptoms with known likelihood ratios. A combination of several symptoms with high LR+'s for a certain remedy may lead us straight home. According to Van Wassenhoven's data, other symptoms with a high LR+ for Verat-a are: Courageous (LR+=66), Fear (of) death (LR+=32), Sexual desire increased in women (LR+=86), viscid saliva (LR+=4.4) and: Cough in spring (LR+=520 !). With an LR+ of 0.99, the rubric ‘conscientious about trifles’ is useless for Verat-a: People who need Verat-a are not more or less conscientious than the general population, at least according to van Wassenhoven's data. Is there a prize for the first author who dares pull the trigger, and take Verat-a out of the rubric ‘conscientious about trifles’?

Interestingly, the symptom ‘lassitude’, with an LR of 0.29, is useful information for Verat-a. In the general population, lassitude is more than three times as common as in the people who need Verat-a.

With a multitude of articles on the application of clinical epidemiology to homeopathy, these are times of progress for homeopathy as a clinical science. Rutten et al. show that well-known tools, such as likelihood ratios, are highly applicable to the improvement of the homeopathic knowledge base. Van Wassenhoven shows that conscientious registration actually will give us data that are relevant for daily practice. But there are challenges yet. From the Delphi Project, we know that clinical case research in homeopathy becomes complicated once it involves more than a small group of people, and we will need a coherent scientific community to move things forward.[ ³ ] The biggest cloud on the horizon was identified in an article in the R&D Newsletter of the Homint pharmaceutical group.[ ⁴ ] An international survey shows some worrying correlations: In countries where homeopathy is well established, prescribers had more years of experience in homeopathy, they had more confidence in their prescribing, and they were less willing to collect data in a systematic way, and much less likely to respond to the survey.

Asking critical questions about our results and prescriptions is not popular with everybody. But in medicine, being sure has often been a major obstacle to progress. If homeopathy is a science, and thus part of medicine, then basing homeopathic prescriptions on validated information should certainly help to improve results.

• References

• 1 Rutten A, Stolper C, Lugten R, Barthels R. Repertory and likelihood ratio: time for structural changes. Homp 2004; 93: 120–124.
• 2 Van Wassenhoven M. Towards an evidence based repertory: clinical evaluation of Veratrum album. Homp 2004; 93: 71–77.
• 3 Baas C. The pitfalls of clinical case research: lessons from the Delphi Project. Homeopathy 2004; 93: 21–26.
• 4 Golovatiouk A, Seith B, et al. Science and homeopathic practice: opportunities for dialogue? Homint R&D Newsletter 2001; 6: 7–19.