Cryptogenic Fibrosing Alveolitis is a condition of unknown aetiology, pathologically characterised by migration of large mononuclear cells into alveolar spaces, with later thickening of alveolar walls with fibrosis. It is typically a disease of late middle age, affecting males twice as frequently as females. The acute variant may present with rapidly progressive dyspnoea and cough, widespread crackles and progressive respiratory failure within a few months.
Occupation – retired, biology teacher
In Spring 1998 he developed a persistent dry, tickling cough, which was difficult to shift. He had several courses of antibiotics, and then was referred to a chest physician. He had a major work-up with blood tests, respiratory function tests and a CT scan. In June 1998 he was diagnosed with Cryptogenic Fibrosing Alveolitis (CFA).
He was then referred from his district general hospital to another chest physician at a major University teaching hospital, where he was put on steroids. After a couple of months he saw a third chest physician in another major centre for a further opinion. He confirmed the diagnosis in 1999 and prescribed Azathioprine, prednisolone and Didronel. He was then returned to the care of the original chest physician.
In 2000 his condition deteriorated and he had the prednisolone increased to 50mg daily. The Azathioprine was stopped. Since then he had been on variable doses of steroids depending upon his clinical state.
In January 2001 he was referred to yet another major university hospital about a possible heart-lung transplant. He was taken on the assessment program for 4 days of tests, and then a case conference was held. He was told that he was too well, but also that was also too old for a heart-lung transplant.
He was told candidly that his ultimate prognosis was not good, that his chance of living two years was not high, and that an operation would make him worse than he currently was for several months, yet with no promise that he would survive for any longer. He was content with that decision. He discussed all this with his chest physician, who advised trying homoeopathy.
Family History
Father died aet 70 with Ca prostate
Mother died at 78 – had a CABG
Maternal Grandmother died from a CVA
Paternal Grandfather died from a brain tumour
Past Medical History
Tonsillectomy aet 10 years
Perianal abscess 50 years
Cyst of scrotum at 53 years
Social history
Married
General Symptoms
Cough – dry + tickling
SOB – < effort (able to walk 200 yards)
< sitting up
< lying
sometimes wakes gasping, also in day
only uses 1 pillow – 2 at most – best position is semi-recumbent
Water gurgles when swallows
Sleep – dreams of fire and suffocating
– always sleepy
Chilly
On Examination
Pleasant demeanour. He was very calm and not at all anxious. He seemed accepting of his condition, although he was fully aware of the grave prognosis. He did seem to be quietly and logically seeking to do whatever was necessary to maintain his health.
Cyanosed
Cushingoid from steroids
Thready pulse
Finger Clubbing
Bilateral crepitations
Assessment
July 2001
This man was strikingly cheerful, despite a terrible prognosis and with very marked symptoms. I felt that at the very start there were two important questions to answer. Firstly, does homoeopathy have a role? Secondly, what is the aim of treatment?
The patient considered himself to have gone as far as he could with conventional treatment and was willing to try homoeopathy in order to gain some symptom improvement. I believe that answered the first question – so yes, it does have a role.
Answering the second question was not so simple. This is a complex case, with a patient in a fragile state. Great care needs to be taken. I believed that a modified layers approach would be helpful.
Layers – I use this in cases where a time-line can be drawn up. It is used mainly in chronic illnesses where separate prescriptions are given for the different layers in sequential order. The method was pioneered by Eizayaga and looks at miasmatic, constitutional, fundamental and lesional layers.
The first thing being to help boost his system, so starting with a classical remedy seemed a good starting point. I often will do this as an opening remedy. I felt that lesional or local layers would need dealing with and possibly miasmatic layers at some point. Miasmatically, the sycotic miasm seemed to be active, in that CFA is an overgrowth of tissue within the lungs.
I did a repertorisation on totality, choosing the following symptoms:
Mind, cheerful
Cough, dry
Generalities, cyanosis
Sleep, sleepiness
Generalities, lack of heat
Gurgling, when drinking
Respiratory, gasping
Cough, tickling
Finger Clubbing
Results: Ars 17/8 Thuj 14/9 Laur 13/9 Phos 16/7 Carbo veg 13/6 Lyc 15/7 Cup 12/7 Lach 17/6 Nux vom 15/6
On this first treatment, I considered cyanosis an eliminating symptom.
Lachesis seemed particularly well suited. We tend to think of Lachesis as being a negative type of remedy[1], associated with irritability. This can be the case when it is very active, but people in need of Lachesis are often quite calm and very efficient. The ‘blueness’ of the remedy, especially considering this man’s cyanosis and Cushingoid bloated appearance made this seem appropriate. I discounted Arsenicum album, which also scored highly, because he seemed to be very accepting of his condition. He sat quietly and was not at all restless. Arsenicum did not seem right at all.
Rx Lachesis 30c bd for 2 days
August 2001
No improvement whatever. I therefore considered whether the steroids could be an obstacle to cure. This necessitated consideration of a tautopathic remedy. I decided against this, because the steroids had obviously been of great value.
A tautopathic remedy based on Prednisolone could have been counterproductive and may even have worsened his condition, so I decided against this. I tend to use tautopathic remedies when there have been side effects from a drug, or when a condition has worsened after the use of a particular type of drug. This did not seem to be the case here.
Miasmatically, the sycotic miasm seemed to be active, so a remedy which is an anti-sycotic remedy would be apt. Thuja and Ars alb had both repertorised well, but Thuja does not have great association with cyanosis, which I considered to be a very marked feature.
He does not have the restlessness characteristic of Ars alb and is not obsessionally neat,[2] so I then considered Carbo veg, which would also seem reasonable. But his clubbing is marked, as is his cheerfulness, and the sleepiness is complained of quite markedly.
These features are very much in keeping with Laurocerasus, although I would not always think of it in this ‘walking’ seriously ill chronic type of case. It does repertorise well, and it does have anti-sycotic features.
Rx Laurocerasus 30c bd for two days
The patient also asked if there was something that he could take regularly. I had in fact intended treating him intercurrently (at a later stage) with an organo-remedy, since I find these very helpful in chronic conditions. (See discussion).
I therefore also prescribed Lung 4c on alternate days.
September 2001
The patient reported a dramatic improvement after having two of the best nights sleep since the diagnosis. He felt more refreshed and had three days when he felt as if he could almost ‘stride out.’
He also felt that the Lung 4c helped immensely, whenever he took it. He did feel, however, as if the improvement he gained from the Laurocerasus was wearing off in the last week before the consultation.
I felt that there was no indication for a potency change in the Laurocerasus. I also continued the Lung 4c on alternate days
Rx Laurocerasus 30c bd for 2 days
October 2001
The patient was delighted to report that he had lost the dreams of fire and suffocation. I had previously noted these but had not included them in the repertorisation. On checking Kent, however, I noted that Laurocerasus is a high rank remedy under dreams of fire.
He reported that his walking was improved, and that he was able to walk further – up to 300 yards at a time now.
The pattern of his remedy response was the same as before. The main effect lasting about three weeks before tailing off, although he still maintained that he felt better whenever he took the Lung 4c.
Rx Laurocerasus 30c bd for two days, continuing the Lung 4c on alternate days.
Plan
To continue until Laurocerasus 30c ceased to have effect or until the effect was reduced. We had achieved subjective improvement as well as objective improvement. The patient felt better and noted that his walking distance has improved. Initially, he felt that 200 yards was his limit, whereas this distance increased to 300 yards. And in addition, he felt that at times he could almost ‘stride out.’
I continued to see him on a regular basis over the next two years until his condition deteriorated so that he could no longer attend. He died peacefully in his sleep.
DISCUSSION
This patient’s attitude to his condition was very positive. He was an intelligent man who accepted that he had a progressive condition with a poor prognosis. Because of the nature of his condition it was very important not to risk giving him any treatment which could aggravate his state.
Accordingly, I felt that a classical homoeopathic remedy should be used in the first instance, based on the totality of his symptoms. Lachesis seemed to be the indicated remedy, but it produced no effect at all.
Laurocerasus also repertorised well, and since it is an anti-sycotic remedy (and miasmatically, a sycotic miasm seemed to be active) there was an additional reason for using it. As I mentioned earlier, however, I do not think of it as a ‘walking’ type of remedy. It is more indicated in the energy-depleted, even bedridden case. Its effect, however, had been remarkable in his case.
Laurocerasus comes from the plant Prunus laurocerasus, a member of the Order Rosaceae. Homoeopathically, it influences the lungs, heart, blood and circulation as is typical of Rosaceae. Its leaves contain hydrocyanic acid, which is corrosive to the lungs. The sleepiness is characteristic of this remedy, as is feeling better in a semi-recumbent position. Often, it will allow the patient a good long refreshing sleep.
The organo-remedies are often very useful in my experience as intercurrent remedies. They are not widely used in British homoeopathy, but they have wide usage on the continent, especially in France. They are homoeopathic remedies or sarcodes prepared from the organs, glands or tissues of healthy cattle, sheep or pigs.
The basic principle is that the organs have a sort of ‘tissue memory’, which is capable of recognising homologous organ remedies. Thus, a specific organ remedy or sarcode will act upon that type of organ in the body.
There is a triphasic action of the remedies, which are all used in low potency. Basically, low potencies (3c, 4c or 5c) have a stimulatory effect on the organ; medium potencies (6c, 7c and 8c – in fact, usually 7c) are regulatory; and higher potencies (9c, 12c and 30c) depress the organ.
Generally, I use the organo-remedies in this sort of situation. The Lung in this patient’s case needed stimulation, so a 4c was indicated. Since I want this to be an ongoing stimulation in a chronic condition, which would lead to progressive lung hypofunction, I use it on frequent repetition. Thus Lung 4c alternate days.
The ongoing management of this case needed careful monitoring. The aim was to keep him as free from infections as possible. He understood the need to nurture himself and be wary of putting himself at risk of picking up any infections. The approach of using intermittent Laurocerasus and alternate day organo-remedy Lung 4c seemed to serve him very well.
[1] By negative, I refer to the unconscious use that we make of the ‘affect heuristic’, which is the way in which we tag characteristics in a sort of good or bad, positive or negative manner.
[2] In my consultations I usually ask the patient whether they could cope with my desk or with my bookcase. It seems to be a reasonable test of neatness, in that some patients will go to into great detail about how best to categorise my bookcase and tidy it up, while others feel it is OK. The patient felt that my office was OK, so I concluded that he was not excessively neat!
A nice example of how a serious progressive case should be managed. Well done.