Book review: Praxis by Massimo Mangialavori

Massimo Mangialavori's latest work is valuable medicine for all homeopaths. Simply reviewing it has already enriched and sharpened my practice. It is written perceptively, with careful attention to detail, and requires a comparable intelligence on the part of the reader. Most of all, it is a philosophy, beginning with the basics and reshaping them for the needs of our time, in a way that makes logical and practical sense. To me this is no small achievement, since I've been practicing and making the same mistakes for so long that getting me to change in any way is bound to provoke serious resistance. 

So, maybe the phrase "a pleasure to read" needs further clarification. How pleasant can it be to have to re-examine every step of what we do and every rationale for how we think? Or to have our noses rubbed in the inadequacies of our early training and the bad habits that we didn't even know we had? Fortunately, it's the kind of medicine we all need, since it teaches what we already know and profess to be true, but haven't yet figured out how to accomplish, or have simply become too lazy or complacent to make the effort. Even what is most innovative and controversial about it is firmly rooted in the homeopathic philosophy that we all share, devoutly respectful of that history, and also fully conversant with the best that both hard science and holistic thought have to offer. So once you've made up your mind to take the medicine, I can assure you that it tastes good and won't upset your stomach.

Massimo is of course already well-known and esteemed by homeopaths everywhere, for his ongoing courses in Italy, his seminars on materia medica, and a growing library of books based on them. The present work is his major theoretical statement, beginning with methodology, followed by an overview of the "Drug" family and its principal themes, and concluding with illustrative cases involving six drug remedies, mostly lesser-known ones.  

Its subtitle, "The Search for Coherence in Clinical Phenomena," announces its guiding purpose: to find a deeper, more meaningful similitude between remedy and patient than any list of unrelated symptoms in a Repertory, such that the various symptom-elements all fit into and indeed are derived from an integrated whole, much like the "essence" that Kent, Vithoulkas, Scholten, and Sankaran have also sought, and are still seeking. It is Massimo's way of discovering that unity, and of describing and understanding it once found, that is uniquely his own.

Because of limited time and space, I will simply highlight a few of the items that caught my fancy along the way. I love the fact that he begins with the Doctrine of Signatures and even seems to agree with the fundamentalists that such trivial resemblances as the yellow color of Chelidonium and that of the bile, for example, fall short of a genuine affinity. But that is only because he is interested in the deepest levels of meaning, precisely what the old school insists on steering clear of, arising from the core of each remedy as a unique system of adaptation to its natural habitat, and including both physicochemical and mythic realms, as indicated by their time-honored uses in folklore and medicine. 

At times these multi-layered resonances can seem almost spooky. Ever since my first course in homeopathy, for example, I've often reflected on the fact that our greatest snake remedy was named for Lachesis, one of the three Greek goddesses who fix the span of life, and the unlikely circumstance that Hering, who first proved the venom in 1828, died on the fifty-second anniversary of that event, almost to the day. Signatures of this sort are heavy with meaning, because they probe deeply into the history of our culture, and weave what first seem like unrelated details into a tapestry that becomes cogent and persuasive. 

Massimo's "Method of Complexity" is so named because it encompasses fields as diverse as anthropology, folk medicine, physiology, biochemistry, toxicology, classical homeopathy, and the art of clinical medicine, which ties them all together and arises from acquaintance with human nature more than book learning. He differs from other teachers chiefly in this multi-systems approach, his quest for resonance and corroboration on so many levels, and his insistence that no one method of case-taking or remedy study will work every time, that homeopathy is an art to be experienced anew with every case, and is never complete. 

Contrary to sacred truths we've all been taught, his first great heresy is that provings are not the best source for materia medica study, because they yield long lists of detailed symptom-information, whereas the student mainly needs to know how important each symptom is for prescribing the remedy. Reliable remedy information adequate for prescribing on thus requires some system for organizing and prioritizing the data. More than any other leading teacher today, Massimo prefers cured cases for this purpose, because they alone provide sufficient richness and context to display the whole of the remedy in the whole of the patient, to connect the threads that led him to prescribe it, and to grasp the analogy with other patients needing the same remedy. These connections he calls "themes," and from them he builds his materia medica.  

Arising from the clinical experience of every homeopath, but rarely spoken out loud, this little iconoclasm reminds me of my home birth years, when I often wracked my brains over Cimicifuga and its disembodied rubric "Fear of insanity," which never seemed to fit my cases. But when one of my patients carried to 42 weeks without going into labor, the threat of hospitalization prompted her to tell me about her previous miscarriage and D&C, the most traumatic experience of her life, and the frightful premonition that the more intense pain of labor would "unhinge" her wits, and push her "over the edge" into a state of disintegration from which she would never return. A few days later, she appeared at my office already well along in labor, looking wild-eyed and out of control, just as she had foreseen: her speech was fragmented, her movements abrupt and unpredictable, and her mood pitiable. In that instant I understood not only the rubric, and why she'd been so reluctant to confide in me, but also many physical symptoms of the remedy in relation to it, so that I too was alarmed for her sanity. Although remaining clinically psychotic throughout the labor, she progressed rapidly on two or three doses of Cimicifuga 200, gave birth normally, and made a full recovery, on the strength of which I learned to prescribe the remedy to a variety of patients and with splendid results. 

Massimo's criteria for a "cured" case are so strict that many of the successes we love to report at conferences would fall far short of satisfying them.  For chronic conditions, he accepts a remedy as simillimum only after a follow-up of at least two years, and preferably longer, during which the remedy has continued to act in a curative manner, and has been effective in overcoming seemingly unrelated acute conditions developing in the interim, even injuries and other common domestic ailments, in lieu of the usual first-aid remedies.  

Themes emerging from cured cases also provide the ideal framework for organizing the proving data, which can then be used to confirm, refute, or modify the themes. Materia medica study is thus an ongoing process of integration, not a rôte memory exercise. The end result is rewriting and re-organizing the Repertory itself on thematic grounds, a monumental task that will require the collaborative efforts of at least a whole generation of dedicated homeopaths. 

I especially loved his case of the patient with a passion for toy trains, cured with the help of Allium sativum, whom he uses to illustrate how to clarify a symptom, that is, to give it meaning by deriving it from or redefining it as a theme. To render this patient's hobby in symptom-language, rubrics like "Passion for model making" or "Plays with toy trains before supper" at first seemed likely candidates, since they disappeared after the remedy, along with his other disabling pathologies, and were precisely the kind of quasi-objective, "value-neutral" observations that our Repertories are filled with.  Yet in the end he found them misleading by giving too much detail, and thus obscuring the deeper meanings that could suggest useful analogies for similar cases, a consideration that persuaded him to add the remedy to the rubric "Childish," in effect upgrading it to a theme, and to identify and cure several other patients with equally consuming hobbies.            

For me another fascinating highlight was how he defined and distinguished the themes themselves. What he calls "characteristic" themes are distinctive of the remedy and often present, but not always, because they are limited either to certain stages, such as acute inflammation for Belladonna, which is typical of childhood, or to polar opposites, depending on whether the patient is in a compensated or decompensated state. "Fundamental" themes, on the other hand, are essential structural components that must be present, although not always easy to spot, and provide the core or ultimate basis of similitude. Thus the theme of "Isolation" in Camphora turns out to be fundamental to all the "Drug" remedies, whereas "Sensitivity to cold," its most famous keynote, is only characteristic of its most extreme or decompensated cases, so that a more typical, compensated patient would be more likely to defy the cold.  

This kind of nitty-gritty scholarship is to be found in every chapter, and it is a thing of beauty. His elucidation of themes is likewise masterful and easy to grasp, although he makes their actual discovery look a lot easier than it is for someone trying out the idea for the first time. In any case, it is obvious that the Repertory extractions on which they were based were made possible by MacRepertory and Reference Works, the computer software he uses, and to which he pays frequent and well-deserved tribute.

The method culminates in his concept of the Homeopathic Family, which is precisely the point where his method comes closest to that of Sankaran and Scholten, and where he also most clearly diverges from them. Whereas Sankaran and Scholten identify homeopathic remedy "families" taxonomically, according to their place in Nature, Massimo insists on a classification based solely on the homeopathic characteristics of the remedies themselves. Often he begins taxonomically, based on a suspicion, such as might arise from a treatment failure involving the best-known representative of a natural biological or chemical grouping, usually a polycrest, like Lachesis for the snakes. But the next step, extending the analysis to a few others taxonomically related to it, like Crotalus, Naja, and Bothrops, insists on a purely homeopathic definition, based on the fundamental themes that all of them have in common. Eventually, identifying them makes it possible to add other remedies that are taxonomically unrelated, often "small" or at least unfamiliar and underrepresented in the literature.         

The same idea has fruitful applications for the "second prescription," where one remedy has acted curatively for a period of years, but then stops working, and therefore needs to be changed. In my earlier training, based on the work of Kent and his successors, this was a clear signal for retaking the case and prescribing a new remedy, perhaps but not necessarily complementary to it. But if the major themes are still at work in the patient, as one would expect them to be from the length and strength of the curative reaction, Massimo's family concept argues strongly for choosing a different remedy from the same family, a strategy he has evidently employed with great success. 

In Volume II, I marvel at how he gets his patients to confide in him as they do, to blurt out their deep inner truths, in the absence of which we often substitute a Review of Systems for no better reason than that's all we can think of to fill up the time. This is the mystery of case-taking, which is what distinguishes great homeopaths from merely competent ones, and ultimately it can't really be taught in a discursive fashion, because it involves the subjective experience of the homeopath as a human being, not just a doctor, scientist, or healer. 

The Method of Complexity aims to identify the patient's adaptive strategies, and finds them in physical symptoms no less than mental, so that even the distinction between them tends to disappear. The idea is to encourage a free-flowing narrative, by tolerating the silences, trusting patients to tell what they have to tell without trying to force them in a certain direction, and finding the themes and thus the whole story wherever the patient leads us, rather than by our default setting of simply amassing as much data as possible. 

The cases in Volume II are beautifully presented, and a pleasure to read. Each remedy is introduced with a brief but scholarly essay on its natural history, its uses in folk medicine, and its pharmacological, toxicological, and homeopathic characteristics, such that the cases  seem to materialize out of this background. These little gems are materia medica writing at its finest. The cases are sensitively taken and full of deep confidences from real people that bring to life the method that Massimo has outlined and elaborated. Many are followed by commentary by Dr. Giovanni Marotta, Massimo's long-time collaborator, mentor, and friend, almost an alter ego, whose more reflective style is nevertheless perfectly attuned to the method that they both created and developed, and thus adds a further richness to the work that in no way detracts or distracts from its mission.

I wish I could say the same for some of the contributions of other authors. The concluding section of Volume I, Chapter 1, for example, is a learned essay by Professor Alberto Panza, an academic colleague of Massimo's who sought to identify themes in modern European philosophy, science, and culture that are congruent with homeopathic teachings, an eminently worthy project. I couldn't help feeling a bit disappointed and let down that the writing, the translation, and even some of the sources cited revolved around highly technical terminology that are difficult to translate, unfamiliar to most readers, and too abstruse for them to understand. 

Another example was the last chapter of Volume I, the longest in the book, which was a summary of the main teachings of modern psychology for homeopaths. For the English edition, this important task was undertaken by John Sobraske, the General Editor, and carried out with thoroughness; but in comparison with Massimo's engaged, incisive, and goal-oriented style, it often seemed an overlong and tedious digression that lacked sufficient relevance to the work as a whole. On the other hand, Sobraske's Introduction to Volume II, a brief summary of Volume I, is excellent, thoroughly competent, and easy to read. My only question was, why do a shortcut for people choosing to omit Volume I, which contains some of the finest writing on homeopathy that I have ever read and would thus be a great pity and a huge mistake to skip over? 

In addition, there were a sizeable number of translators and editors, including such dedicated homeopaths as Betty Wood, Krista Heron, Bill Gray, and Maria Kingdon in North America, and several others in the UK and Europe; and their work certainly deserves hearty commendation. But their task was made almost superfluous by Massimo's own excellent command of English, on the one hand, and almost impossibly difficult by Prof. Panza's much greater need and unfamiliar subject matter, on the other. 

All of these, of course, are but minor quibbles. My main reason for recommending these volumes is my belief that they will change and ultimately improve how homeopathy is taught and practiced, both now and for years to come. 

Praxis Vol.1&2 by Mangialavori Massimo
Press, Modena, Italy
284, 298 pages, € 90/ $120