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.

 

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?

בונינגהאוזן ושיטת ה-LM – חלק 2: ניתוח ניהול מקרה של הנמן

Hahnemann Sends LM Cases to Boenninghausen

Hahnemann sent Baron von Boenninghausen two LM case histories in 1843, shortly before he left for his Heavenly Abode.  The Baron shared these cases with his colleagues in the Neus Archive f. hom, Heilkunst (Stapf’s Archives) Volume 1 number 1 1844, page 69. These cases can be found in Boenninghausen’s Lesser Writings in an article called, Three Precautionary Rules of Hahnemann, in the section called, 1. Warning, the Smallness of the Dose. These cases were very instructive as they show how the Founder administered olfaction as well as the oral medicinal solution of the C and LM potency.

The following case history has been checked with the original case found in the Paris Casebooks. This information was presented in an article by Hanspeter Sailer called Di Entwicklung von Samuel Hahnemann’s aertzukcger Praxis, Verlag, Haug, 1988. The Baron noted that Hahnemann dictated the example cases to a secretary and dated and signed the letter in his own hand. This was the last letter he received from his honored teacher.

On January 14, 1843 a patient referred to as O-T came complaining of sore throat alternating with an anal fissure. Sailer noted that the patient’s name was Varlet. For several years the patient had a sore throat but the present attack had lasted for one month. The last time he had a sore throat it lasted for six weeks. The patient reported that when he swallowed saliva he feel a pricking sensation with constriction and soreness. When he was not suffering from the sore throat he experienced a fissure of the anus with violent pains as from a chap. At this time, the anus was inflamed, swollen and constricted. The patient could only discharge his stool with great exertion with swollen, extruding hemorrhoidal veins.

1. January 15, 1843 – Belladonna in a 7 tablespoon solution.

Hahnemann prescribed Belladonna for sore throat on the 14th but told the patient to take the remedy the next morning on an empty stomach before breakfast. The potency was not noted in his letter to Boenninghausen but Sailer confirmed that it was the LM 0/3 from the original casebook. The patient was instructed to put one tablespoon of the medicinal solution into a glass of water, stir it well and take one coffeespoon as a dose.

2. January 16 – Merc. 0/1 in a 7 tablespoon solution.

The throat ache was gone but the fissure returned immediately! This shows that these conditions were related. The patient then revealed that eight years earlier he had a syphilitic chancre that was destroyed by corrosives. All his problems started after the suppression of the syphilitic miasm. Hahnemann immediately prescribed Mercury 0/1, his cardinal anti-syphilitic remedy. The fissure and the chap were very painful. How often he gave the dose is not noted. This may be a daily dose as the symptoms were in an acute-like crisis. The Mercury 0/1 was to be prepared and taken in the same way as the Belladonna.

3. January 20 – Merc. 0/2 in 7 tablespoons.

The patient returned for his check up 4 days later. This example shows how closely Hahnemann was following this rather serious case at the start. There are no “take this daily for one month” prescriptions in his casebooks. The patient’s throat pain returned slightly and the anus was better although there was still soreness during stool. At this time, Hahnemann raised the potency! The journal says: “One pellet of the Mercurius viv., 2 dynamization, prepared and taken in the same manner in the morning”. If the patient took the Mercury 0/1 in the “same manner in the morning” the 7 tablespoon medicinal solution would not be finished yet. Nevertheless, Hahnemann immediately raised the potency to 0/2.  This shows that the Founder raised the potency when he considered it necessary and did not always wait for the bottle to be finished.

4. January 25 – Sailer says Hahnemann gave 2 placebos. This is not in Boenninghausen’s text.

The 0/2 continued to improve the throat but there was severe lancination in the anus. This may have been a similar aggravation caused by the remedy. The patient was then given 2 placebos. It seems these two placebos were alternated with the remedy so he was now taking the alternate day dose.  This can be deduced because Hahnemann wrote on Jan. 30th that the patient had taken the last dose of medicine that afternoon. He only had 7 doses and this was 10 days later so he could not be taking the remedy daily. The Mercury 0/2 was taken daily for 4 days and then slowed down to alternate days interspersed with placebo. This shows Hahnemann slowing down the remedy, which is an important method used to prevent overmedication. The daily dose of Mercury was not continued.

4. January 30 th – 7 days of placebo in medicinal solution.

The anus was now better but the throat was worse. This shows the alternation of the symptoms still continuing although the symptoms are a little better in general. There was no particular aggravation yet Hahnemann decided to give placebos for 1 week and wait and watch. He must have observed enough medicinal action so he stopped the remedy. This prescription demonstrates how the Founder alternated periods of active doses with periods of placebo and waiting and watching.

5. February. 7 – Sulphur 0/2 in 7 tablespoon solution.

The anus was still well but there was severe pain as if an ulceration in the throat. Hahnemann wrote in The Chronic Diseases that the suppression of syphilis could cause a flare up of psora that obstructs the cure. On this basis, Hahnemann gave Sulphur 0/2 as a chronic intercurrent remedy. It was his hope that this anti-psoric remedy would assist the action of his anti-syphilitic remedy in removing the complex miasmic disorder. Exactly how often the remedy was administered is not noted. Just because the patient returned in one week one cannot assume it was a daily dose but it may have been.

6. February 13  – Mercury olfaction.

The Sulphur brought out clear Mercury symptoms on the 11th and 12th. The throat felt ulcerated and the saliva was increased and now was in great quantities! This was a sign that the anti-psoric intercurrent had an effect on the overall symptom pattern. There was also some constriction in the anus from yesterday. Rather than alternating, the symptoms were both present at the same time. At this time, the patient was given a single olfaction of Mercury, potency not noted.

7. February 14 – Merc 0/2 in 7 tablespoon medicinal solution.

Hahnemann now gave the patient a medicinal solution of Merc. 0/2. This was to be taken “as before”. Hahnemann kept the patient on the same potency as given on January 20th, around 25 days previously. In this case he did not raise the potency every 7 or 14 days as suggested by the example in aphorism 248 of the 6th Organon . This shows that the paragraph is only offering a baseline example, not a rigid predetermined schedule. Hahnemann individualized all these procedures. In one prescription he raised the potency before the bottle was finished and in others he kept the patient on the same potency for longer periods.

8. February 20 – Placebo in 7 tablespoon medicinal solution.

The throat was better since the 18th but there was much suffering at the anus. There seemed to be strong aggravation so Hahnemann waited and watched for around 11 days.

9. March 3 – Single Dose Olfaction of Nitric Acid.

After the aggravation passed the symptoms of the patient improved. The sore throat was now ameliorated. On going to stool a hemorrhoidal vein still extrudes although it did not cause as much pain as before. Now there is only a bit of itching in that spot. Hahnemann wrote, “I let him smell of Ac. Nitr.” Sailer confirms that this prescription was a single inhalation of the remedy. In this example, Hahnemann is using this method to give a gentle but deep dose toward the end of the treatment in an effort to complete the cure without aggravation.

10. March 20 – Single Dose Olfaction of Nitric Acid. (Patient cured)

Now there was hardly any pain after stool, throat well, although he feels some sensation on drinking cold water. Hahnemann wrote, “Now he is allowed to smell of Ac. nitr.” This means that before this and since March 3rd the patient was not allowed to smell Nitric acid! This dose was allowed to act over a period of 17 days. How long the second olfaction acted one cannot tell from the record because Hahnemann only wrote, “His health was permanently restored”. The prescriptions in this case show the following pattern.

1. Jan. 14, 1843. Belladonna in LM 0/3 in a 7 tablespoon solution.

2. Jan 16. Merc. 0/1 in 7 tablespoons medicinal solution.

3. Jan. 20. Merc. 0/2 in 7 tablespoons medicinal solution.

4. Jan. 25. 2 placebos to be alternated with final doses of the Mercury.

4. Jan. 30. 7 days of placebo in medicinal solution.

5. Feb. 7. Sulphur 0/2 in a 7 tablespoon medicinal solution.

6. Feb 13.  Merc. olfaction.

7. Feb 14. Merc 0/2 in a 7 tablespoon medicinal solution.

8. Feb 20. Placebo in a 7 tablespoon medicinal solution.

9. March 3. Single dose olfaction of Nitric Acid (17 days on an olfaction).

10. March 20. Second single dose olfaction of Nitric Acid (Patient cured).

What does this case tell us? First of all, Hahnemann’s prescriptions were individualized according to the cause, symptoms, miasms and attending circumstances. He did not use preconceived schedules over long periods of time. He responded to each change in the symptoms and customized his case management methods according to the time and circumstances. Secondly, this case shows how the Founder often interpolated and followed his medicinal doses with a series of placebos. In this example the patient spent around 37 days on placebos over a period of 64 days! The idea that Hahnemann gave the daily dose for weeks, months and years on end is a complete myth!

Hahnemann’s case examples offer a true picture of how Samuel Hahnemann actually practiced in Paris in the 1840s. Over the last 8 or so years I have reviewed scores of LM cases that show a similar pattern. Hahnemann used single doses (usually by olfaction) followed by placebos as well as a series of oral doses interpolated with and/or followed by placebos. Hahnemann did not speak about his liberal use of placebos in the 6th Organon. This may have been because he did not want to state this in a public work, as the placebo was his “secret simillimum”.  If the public found out it could have caused problems.

Hahnemann never gave the daily dose or alternate day dose for long periods without stopping the medicine, giving placebos and waiting and watching. Some patients remained on placebo for 7, 14 , 21 or even more days at times. This “on again – off again” technique was used with all of his patients. I have not seen a single case in the microfiches of the Paris casebooks between 1840 to 1843 where Hahnemann gave the daily or alternate day dose of the LM potency for months without stopping the remedy and giving placebos. This is true in the Casebooks DF-10, 11, 12, 13, 14, etc., which are replete with LM prescriptions

Any time there is a noticeably progressive and strikingly increasing amelioration the LM potency should not be repeated as long as this state lasts. These cases may be cured by a single dose or infrequent repetitions of the remedy. If the patient is only slowly improving, the remedy should be repeated at suitable intervals to speed the cure. Any time during the treatment that there is a sudden strikingly increasing amelioration, or an aggravation or strong accessory symptoms, the dose should be stopped as long as the state lasts. In the case of light to moderate similar aggravation it is usually best to wait and watch for the expected amelioration. In the case of strong aggravations, obstructive accessory symptoms, and the appearance of new troublesome symptoms, the situation should be rectified by skilful intervention to regularize the symptoms.

As long as the patient is improving at a reasonable rate the remedy should be repeated at suitable intervals to speed the cure. In “protracted diseases” the remedy may be repeated daily or on alternate days, if necessary, to speed the cure in otherwise long drawn out cases. The more frequent repetition may be used as long as the patient is improving and there are no aggravations or new symptoms. As the patient improves over time it is best to slow down the repetition of the remedy as the potencies are increased to prevent aggravations.

If there is an aggravation toward the end of treatment when the patient is well in most respects this is a sign of that the cure is reaching completion. To test this scenario one stops the medicine, gives placebo if necessary, and waits and watches. If the aggravation is followed by a period of amelioration and then a relapse of symptoms, the remedy should be again administered but at longer durations until the cure is complete. If the aggravation is followed by the complete restoration of health the remedy is no longer needed. This is the case management method of the 6 th Organon in a nutshell.