I’ve decided to share a case that was complicated for me and from which I learned a lot. I am publishing this particular case to demonstrate the consequences of getting lost in the patient’s stories. To further complicate the case the story includes multiple homeopathic care givers, long term remedy use, and treatments that ostensibly are congruent with the indications presented.
I am presenting this in two formats: interview style and narrative. Interview style presents an overview of proper case taking. The point narrative gives a small glimpse of the amount of information collected in the case. The College I attended taught me to take a lengthy initial consultation with complete history, and consults are 2 hours or longer. You can imagine that in 2 hours there is a lot to talk about and I know that I can only hold your interest, my dear readers, for a limited amount of time and editorial space.
Let’s us begin:
Gentleman, 60 years old. He is robust, average height with dark hair. He is very jovial and VERY talkative.
He has brought me back the completed intake form which I emailed him at the time of booking. I ask him if he read through the homeopathic information brochure which was attached to that email and if he had any questions about it. He said that he had read it. He tells me that he is very familiar with homeopathy, having gone to a homeopath since childhood who prescribed Nux-v and he has taken it periodically since then and it has helped him.
He tells me, “You will give me Nux vomica because it’s a good remedy for me and has worked so well in the past.”
I offer him a cup of tea, and we both have some, while I review the intake form with him.
The patient wrote this on the intake form:
Major Complaint, and in order of importance for you:
- very poor blood circulation since 1 year
- stiffness in legs since 1 year
- very painful leg cramps since 1 – 5 years
- gas in stomach/ headaches since 2 years
- very low energy levels since 3 – 5 years
- APO Ramipril
He has been diagnosed with:
- High blood pressure
- High cholesterol
- Colitis / Crohn’s disease. ( He uses these words interchangeably)
He had typhoid when he was a small child.
History of stroke and heart failure in the family.
I had asked the patient to bring in any blood test results that he had taken when we had spoken on the phone. I asked him if he had brought them in with him. He told me that he did not get a chance to ask the doctor for them. Throughout treatment the patient never did give me test results.
Homeopath: Out of all this that you have made note of on the intake form, tell me what bothers you the most?
Patient: Apathy. I feel that I have lost incentive in life. I have a lack of energy. I’ve got joint pains and muscular cramps. I’ve got a poor memory. I suffer from diarrhea. I think for sure I suffer from depression. I’m also very excitable.
Homeopath: From these issues what troubles you the most?
Patient: What bothers me the most? My leg on the left side is very painful, like cement. Getting up in the morning I usually have a huge cramp which is very painful.
Homeopath: Since when?
Patient: Since 6 or 8 months
Homeopath: What makes it worse?
Patient: Don’t know.
Homeopath: What makes it better?
Patient: Lying down on my back, with no pressure. My calf is like cement. I have a pain on top of the foot, on the back over then ankle. See, here the swelling on top of the ankle?
Physical exam: I ask the patient if I can perform a physical exam by touching his legs. He said yes. I ask him if he feels pain in his leg now. He said, “No, not now”. I observe that there is indeed minimal swelling on the top of the left ankle, no swelling on the right leg. Palpation confirms the visual. I palpate both left and right extremities, starting from the toes up to the thighs, asking if he felt pain. He did not. His feet felt neither extremely warm, nor extremely cold.
The patient then proceeds to tell me about his troubles with pain in the shoulder while on a motivational seminar cruise. He tells me about the celebrities in the seminar run by a famous self help guru type, how much he learned, and how much he enjoyed it. He talked about being hospitalized with Crohn’s a couple of times.
He tells me that his sexual organ is not as hard as it used to be, and his sex drive has gone down.
We stop so that he can pour another cup of tea.
Homeopath: Tell me more.
The patient then proceeded to tell me about his life:
It was full of love and disappointment.
Flash and opulence.
His young child, his wife, and his mother, all died within months of each other.
His second wife took him to the cleaners. (He is talking about the money cleaners.)
This man knew how to tell a story, and he effortlessly went from one to another.
He told me that he came from a political family and that he was involved with many political figures and could walk into high official offices whenever he wanted. He had lost a lot of money in a business venture from which he never recovered. He lives with a girlfriend now.
Patient: I’m a people person, not shy. I can walk into a room and talk to anybody. There were people in our house all the time…….I used to be a good singer. I don’t sing anymore. I choke up and start crying if I read something, even if it’s very nice I cry. For instance if I read poetry where the words are significant. I can’t watch movies in public anymore, if anything nice happens I cry. It’s embarrassing…..I have lost that mental strength, of being positive, of being 100% right. I was very arrogant. I can drop the arrogance now.
Homeopath: How is your digestion?
Patient: I’m good. No heartburn. No indigestion.
I asked him what he ate on a daily basis. He told me he likes spare ribs, steak, pasta, garlic bread, Indian food, Italian food. (You know, all the right kind of foods to feed his condition.) Does not care for vegetables. He eats out at restaurants frequently with clients.
I asked him again, “How is it possible that you suffer from this colitis condition and yet you don’t ever have heartburn or indigestion?” He said to me, a little sheepishly, “Well, I don’t anymore since I take antacids right away.
Homeopath: Any sensitivities?
Patient: Light and noise affect me very badly. I pass a lot of wind. I get diarrhea if you or anyone else upsets me. I get diarrhea with a lot of milk or cakes. Milkshakes and pizza.
The patient’s narratives presented certain roadblocks that had to be overcome. The basic road block was that there was too much information The other roadblock for me was that the patient wanted Nux-v and, on the surface, it seemed to be the right remedy for him. Yet, if it was the right remedy I couldn’t understand why he was still suffering with the same things and taking the same remedy for so many years. I wanted to make sure to do a thorough and proper job. It was a case that needed extensive evaluation, and research, and with that, time.
Since there was a history of typhoid I made a note for myself that I would look at the remedies that were under the Typhoid miasm, identified and classified by Dr. Rajan Sankaran to see if any fit.
I thought of causa occasionalis (footnote 7a, aphorism 7 *). I view the patient’s eating habits to be the exciting cause, as well as the maintaining cause. Based on the type of food he likes to eat, some of the symptoms this patient is experiencing might be alleviated by a change in diet.
As I needed the time to do some research I started the patient off with Gemmotherapy, Oligotherapy and Tissue Salts. These remedies were to address the skeletal, mental and generalized energy levels, giving me time to come up with a homeopathic remedy and help him feel better right away. I gave Pinus Montana, Manganese Copper, Lithium, and 5 Phos Tissue Salts.
Recommended dietary and lifestyle changes:
I had asked the patient if he had ever had diet counseling and he said no. I asked him if he was amenable to change his diet in order to help himself alleviate the problems he was having with gas and diarrhea. “NO WAY!” He exclaimed, while throwing his arms in the air as he leaned back on his chair. Just like that. I explained that if he does not want to change his diet to help himself that he would suffer like this for the rest of his life, and so on, until his face softened and I could see that he was at least listening to me. I asked him to avoid eating beef, and rich foods and to add vegetables to his diet. He reluctantly agreed to try.
Follow up 6 weeks later:
Homeopath: Have you noticed any changes since taking the remedies I gave you?
Patient: Mentally I feel much better. I feel happier, more upbeat. Within the first week it was at its highest peak. I stopped getting up in the middle of the night to go to the bathroom. My stool was formed. My stomach though is unsettled. Some days there was gas, some days not. My scalp felt very sensitive, tiny little, little, not classified as pimples, not dandruff, like a grain of sand. Now I have other things on my forehead and chest. I am using Head and Shoulders shampoo.
Homeopath: What about the cramps in your leg?
Patient: I had muscular cramps for 2 days and then it was gone. Recently it came back, occasionally in the arms. I have cramps every 3 days or something in the soles of the feet.
Homeopath: What about your energy level? On a scale from 0 to 10, 0 being no energy and 10 being the most energy, where do you think you are now?
Patient: No change, 3-4. I also have stiffness in the left shoulder and in my legs. By the way, I sleep with a sleep apnea machine. In the morning I have to blow my nose. There was always blood in it. Now after the remedies there is no blood, but sniffling.
Homeopath: How is your libido?
Patient: Libido a little bit better.
Homeopath: Anything else you want to tell me about?
Patient: No. I think I’m good.
I am confused. The patient says he feels much better mentally, happier and upbeat. Yet, no change in energy level. So I will be optimistic and listen to what he said the first time round. Since the patient was feeling so much better and symptoms were ameliorated I felt that I should leave the prescriptions in place for now and wait and see if a homeopathic prescription would be made clearer for me in the future.
I prescribed more Gemmotherapy, adding Tilia for its calming effects. Repeat the Oligotherapy and the Tissue Salts.
Recommended dietary and lifestyle changes:
I advised the patient to stop using the Head and Shoulders as it is full of chemicals and since the scalp sensitivity and rash of sorts spread during its use it would be good to discontinue it and see if the sensitivity and rash would resolve on its own.
Follow up 4 weeks later:
Homeopath: How are you feeling now?
Patient: Stool is bits and pieces, waterish. Like the diarrhea, but not as liquidy. I have to go right way. Several times a day doing that. From my childhood I had a weak tummy. I had to watch what I ate, little stale, wrong oil, would upset my stomach. I took a job overseas and the first thing they taught me was how to make your own wine. I started having wine. I developed a type of dysentery, bleeding after 6 months. He proceeded to tell me the story of the progression towards Chrohn’s disease.
Homeopath: how about the sensitivity and rash on your head?
Patient: nothing is there now.
I would like to say that I had a few remedies in mind, but I didn’t. I still felt that there were too many symptoms to contend with and that the method of treatment would probably be a zig zag.
I had researched the typhoid miasm. The Typhoid miasm is classified by Rajan Sankaran in his book, Sankaran’s Schema , 2005 Ed., Homeopathic Medical Publishers, India. From the remedies listed under that miasm Nux vomica seemed to be the best simillimum. I felt that it fit the mentals, sudden loss or business failure, the patient’s description of his high living, the sub-acute nature of the patient’s complaints, the digestive problems. Also, confirmatory for me was that he has been on it for almost a lifetime and it worked for him.
According to Boericke: “seeks stimulants, coffee, wine, possibly in excess; or, again, he hopes to quiet his excitement, by indulging in the sedative effects of tobacco, if not really a victim, to the seductive drugs, like opium, etc. These things are associated with other indulgences; at table, he takes preferably rich and stimulating food; wine and women play their part to make him forget the close application of the day. Late hours are a consequence; a thick head, dyspepsia, and irritable temper are the next day’s inheritance. Now he takes some cathartic, liver pills, or mineral water, and soon gets into the habit of taking these things, which still further complicate matters. Since these frailties are more yielded to by men than women. Nux is pre-eminently a male remedy. These conditions, produce an irritable, nervous system, hypersensitive and over-impressionable, which Nux will do much to soothe and calm. Especially adapted to digestive disturbances, portal congestion, and hypochondrical states depending thereon.”
Nux vomica LM1.
Follow up 6 weeks later:
Patient: Libido cleared completely. With my weight, I started losing some. My diet has changed. My energy has gone up except with the diarrhea.
Nux vomica LM1
One day, about 3 years later, the doorbell rang and when I opened the door, there he was. My patient had come to see me, to have a cup of tea and visit, if I had the time. We had a visit and he updated me on what had gone on in his life in the 3 years he had been out of touch. I did not take notes. It wasn’t a consultation. He did come for a consultation a year later and the updates on what happened in his life are detailed there.
Follow up 4 years later:
The patient lost his business and lost money on it.
He got very ill. He had an intestinal blockage.
He was in intensive care and underwent 2 surgeries.
He finished the relationship with the girlfriend a couple of years ago.
Homeopath: what would you like me to help you with today?
Patient: I want you to give me Nux vomica 30ch.
Homeopath: tell me what’s going on.
The patient proceeds to tell me about muscle pains that radiate from the heel upwards. It hurts 24/7. Both his legs are cold, tingling in his finger toes. His circulation is bad. “nobody has been able to diagnose it”.
He then pulls out a remedy bottle and says, “I got this from a homeopath just before I came to see you”. I look at the remedy. It is Natrum Sulphuricum 30ch, prescribed by a well known Toronto homeopath.
I see in Boericke, under Abdomen: “flatulency, worse, before breakfast…diarrhea yellow, water stools. Loose morning stools…stools involuntary when passing flatus.” I ask him if it helped him. He said no.
Then, out of the blue he says, “I easily cry, very easily, reading something, listening to a song, poetry, if it’s good it makes me cry. Reading a book about God, Swamis, I would cry.
Homeopath: Why are you crying?
Patient: I always cried. Just that I’m getting older and I cry more.
Homeopath: Help me understand this. What emotion do you experience mostly?
This is the second time that the patient has told me that he cries. I did not take it into account during the initial consult because I had gotten lost in his story. The picture became much clearer for me. He had anxiety with diarrhea as the concommitant. He had also said that he had diarrhea if someone upset him. There were too many symptoms to take into account and this, too, was very peculiar to me.
I thought of Pulsatilla. Pulsatilla is a crier. She cries in the consultation. I remember reading somewhere that Argentum nitricum is the man’s Pulsatilla. I decided to look at Arg-nit.
Research on Arg-nit:
Essence of Materia Medica by Vithoulkas : “the anxiety so overwhelms him….possibly diarrhea occurs”.
Boericke: “an irritant in mucus membranes, producing violent inflammation…..and a marked gastro-enteritis”.
Nash: “Like gold it is one of the best remedies for hypochondriasis. The symptoms are so many in this trouble that we can only call attention to them as found in Guiding Symptoms.”
Arg. nit. 30ch, liquid dose, one dose in office
Follow up 4 weeks later:
Just listen to his voice – the dramatic change that has occurred in this short period:
Patient: Now let me tell you what’s happened. I have formed bowel movements, usually mid day, instead of the morning. Before I had to get up and go immediately and stool was loose. I only have a few bowel movements, maybe 1 or 2 max, not 5 or 6 like before. I have better digestion. When I go out and eat my stomach is happy. Before it could bother me right away, ten minutes or 1/2 hour. My tolerance level has increased for different foods dramatically. One day I took ice cream, no problem. My sleep is good and I’m waking up earlier. THE FEELING OF HAPPINESS, HOPE, JOY, FOCUS, WAS SO GREAT. I HAVE ENERGY. Stuff I haven’t experienced in a long time.