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.

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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?

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.

Case quiz: eruptions on the tongue – ANSWERS

SCROLL DOWN FOR REMEDY NAMES

Case quiz: eruptions on the tongue

just for illustration, not a pic of the patient!

The patient presented with an eruption on the left side of the tongue.   There was a small spot just under the tip of the tongue, and what looked like small flat red circles on the tongue itself. The area under the tongue on the right side was very dark red. The tongue itself was slightly white coated, but the patient said she had not yet eaten and that may be why.

The patient said the tongue felt like it was burning, and was especially aggravated by hot drinks, and eating in general. She said when anything touched the spot on the tongue the pain was excruciating.  She said her tongue felt very rough against her teeth, giving a sensation that the teeth were not clean, when they had just been cleaned.

Several remedies were prescribed, which all helped slightly but did not hold. The patient then reported a change in symptoms. There were now two spots on the tongue, one under the tip and one on the edge of the right side of the tongue, both extremely painful and white-ish in colour, and the tongue had become mapped.

Remedy 1 was prescribed and the condition improved significantly. The pain diminished by around 50% after the first dose, even though the spots were still present on the tongue. By the following morning, after three doses of Remedy 1, the tongue was clear, the discolouration had disappeared, and the patient was pain free.

At this point a further symptom appeared, which was not helped by Remedy 1. The patient reported a sensation of mouth ulcers inside the lower lip and then the upper lip on the left hand side. A further ulcer was reported the following day on the inside of the upper lip on the right hand side. The ulcers were hardly visible, and the lips were slightly swollen on the inside. The swelling in the lips felt firm but not hard. The patient reported that the ulcerated areas felt dry and reported discomfort when the areas touched the teeth and on pursing the lips. There may have been a slight discolouration on the ulcerated areas but the patient was not sure. The area was completely flat, not raised at all.

In addition, the patient reported a deep crack on her tongue, along the centre towards the tip.

Remedy 2 was given and the ulcers cleared significantly within a day, and completely within two days, after two doses.

What were the two remedies?

AND NOW FOR THE REST OF THE STORY…

Thanks to all those who actively contributed to this discussion, and to those who worked on the case even if you didn’t chose to comment online.

Arsenicum seemed so certain for this case, that it briefly shook my confidence in homoeopathy, Hahnemann, Boeninghausen, the prescribing pharmacy and myself when  it didn’t hold… Carbo-v also looked good, but did not help. Phosphorous came up, but on checking the materia medica did not look right.

The white spots (P&W’s TPB no. 1579) narrowed the choice down to 8 remedies: Alum, Am-c, ARS, Carb-an, Phos, Sep, SIL, Sulph

I checked the other remedies in the materia medica, and since Arsenicum clearly was not working, Sepia looked like the next best candidate. I have also seen Sepia working very well in previous cases where a central presenting symptom was white apthae in the mouth.

The patient wrote after receiving the Sepia: “I had felt as if my tongue was held in pincers, almost as if there was a crab latched on to my tongue! With the first dose of the Sepia it was if it had loosened its grip, the pain eased a lot, and gradually disappeared.”

I must admit I was glad she didn’t say anything about crabs and pincers during the intake or following phone calls – it was so much easier just to look for white spots…

Remedy 2 was indeed Mercury. I used:

Face, sensations lips (247)
Ulcers, flat (26)
Aggravation, motion of affected part (2227)

Belladonna did show up in grades 4, 2, and 3. Mercury however presented here in even grades of 3 and checking in Materia Medica confirmed the prescription.

Case of pain in the hip joint

The following is a case of pain in the hip joint presented by Gary Weaver on the main Institute for Homoeopathic Medicine site blog.  I have presented both Gary’s initial case presentation and the follow-up published by Gary the next day.

Desires Refreshing Foods – What do you mean by that?

A refreshing cuppa char!

Yesterday I was working on a case of a 17-year-old girl who has an eating problem . She does not seem to be anorexic, but has difficulty with eating.

–   She does not get hungry – she gets stomach cramps which is how she knows she must eat. She also gets a “mouth” sensation that she wants something “with a lot of taste”, but when questioned it turned out that some of the foods she likes that fall into this category include pasta with olive oil and mild flavouring, cheese Danish, and similar. Her concept of “a lot of taste” did not mean highly spiced or strongly flavoured.

Boenninghausen and Treatment of Composite Fevers

Composite fevers are situations where there are all kinds of combinations of heat, cold, shivering, shuddering, perspiration – with each remedy ringing its own characteristic changes on what pattern it will produce.  Each pattern is so individual in each case of sickness, or where epidemic looms, that these composite fever patterns can often unlock cases, point directly to the best prescription and achieve cure.  It is essential in such cases to get very specific information about what comes first and what comes after – is it heat first then chill? Chill, then heat, then perspiration?

Here are some of the composite fever rubrics that appear in the Therapeutic Pocketbook.  Click on the image to see the rubrics more clearly.  The first number appearing after each rubric is the symptom number in the P&W, and the second number is the number of remedies in that rubric.

Changed and unchanged mental symptoms in prescribing

8. Are you sure the symptoms you took are symptoms of the disease?  If the patient is generally angry, this is a point you can use in differential diagnosis, but if that is not something that has changed, it is not part of the disease totality – don’t use it in your initial set of prescribing symptoms.  (vide Aphorism 6).

Dr. Marco Colla asked me to explain this point from my previous post in greater depth.

Before I begin, please make sure you’re sitting comfortably with a copy of the Organon on your lap, laptop, tablet (wax or digital) – and READ APHORISM 6! 

Viewed through proving: Bryonia – expect the unexpected

Viewed through proving: Bryonia – expect the unexpected

In a recent facebook post I asked readers where they would least expect to see the following symptom:

“It is intolerable to him to keep the affected part still, he moves it up and down.”

Understandably, most opted for Bryonia.  Of course.  We know of Bryonia as the remedy for those who have to keep completely still.  For those who are so sensitive that even if you jar their beds slightly they go into paroxysms of whatever they are suffering from at the time.

It is true that when symptoms agree, Bryonia will be relevant in this need to keep still.  Rhus Tox will be relevant in the need to move.  However, to quote from Porgy and Bess – it ain’t necessarily so.  The above symptom appears as symptom 593 in the proving of Bryonia.