A most disturbing situation is encountered when a case seems to present clear-cut symptoms, definitely suggestive of a certain remedy, yet the patient fails to show a satisfactory therapeutic response when that medicine is given. To the extent that incomplete casetaking might have been at the root of the trouble, we may except to find new leads by retaking the case. Not infrequently, however, our difficulty is accounted for by the extensive overlapping of symptoms (not only of particulars, but of mentals and generals as well), which is so typical for our materia medica. The art of selecting the similimum from among several medicines, which share the main symptoms of a case, depends upon finding features which are characteristic of only one of those drugs.
This detailed differentiation is difficult or impossible when our case has but few prescribing symptoms or when the remedies in question are but poorly proven. Thus, really precise symptomatological differentiation is limited, among remedies, to the polychrests and among, patients, to those cases which furnish a certain minimum of modalities. Unfortunately, it seems that, on the average, one of every 4-5 patients, if we desire optimal improvement, requires a medicine which is not one of our well proven polychrests.In dealing with these cases, we have to fill in the gaps of our exact knowledge with hunches, intuition, guesswork or good luck.
It may be added that in such an impasse the various objective methods of remedy selection may be quite helpful. They can greatly enhance the accuracy of prescribing, provided they are considered as auxiliary approaches, complementary and subordinated to the symptomatic method, and not as attempts to replace it.
When our first remedy failed and the most careful restudying of the case fails to produce a better alternative, two possible courses are open to us. We may admit defeat and try intuition or a good guess. This course of action may lead us to a brilliant hit but also to a hopelessly confused, mixed up case. The second possible approach, when we are sure that our first prescription was really the correct one on the basis of the available evidence, is to classify our case as an insurance of failure to respond to the properly chosen drug.
Our subsequent task will now be to search for possible obstacles to recovery, such as living habits, drugs, irreversible or mechanical pathology, psychological factors and the miasmatic background. An identification of the miasmatic factor introduces new evidence which often may break the deadlock in our prescribing.
However, it would appear that, particularly in respect to psora, our understanding of the underlying constitutional factors and remedies is still rather fragmentary. The following antipsoric prescriptions have been selected for presentation because they demonstrate the vastness of the still unexplored territory:.
CASE 1-Mrs. A.S., aged 28. Rectal fistula of several years standing. In cycles of 1-3 weeks there occurs engorgement with painful swelling which is followed by drainage of purulent matter. Frequent headaches, general tendency to acne and boils. Itching eruptions around the arms and the genitals. Tendency to diarrhea, offensive discharge from the navel. The patient is of heavy build, obese, sensitive to heat, worse warm wraps, uncovers her feet, has a tendency to catch colds, is irritable, desires sweets and meat, perspires freely and has a very marked, offensive body odor. Sulphur gave a good response but stopped acting after a few months.
The general symptoms do not present a rational basis for any other remedy. Therefore, still considering Sulphur the legitimate medicine and classifying the case as one of failure to respond to the obviously indicated remedy, an anti- psoric nosode seemed required. Psorinum helped for a while. After it failed to hold longer, sulphur was again tried and worked longer and better, but still, even in the CM, failed to bring about a permanent constitutional change. At that time experience with other cases had taught me that the antipsoric nosode par excellence which has the broadest field of action seems to be not Psorinum but a Tuberculin.
Bacillinum 200. in infrequent doses is now accomplishing a cure. During the course of a year there has been no need to change the potency which still remains 200. This detail is in conformity with a gradually growing impression that whenever a frequent change of potency is necessary the medicine is likely to be the simile, rather than the similimum.
A few noteworthy features are brought out by this case. Obesity does not contradict Tuberculin. Rather, from repeated experience, obesity as well as a fair, flabby complexion, similar to Calc. carb., should be listed as symptoms positively suggestive of Tuberculin.
Tuberculin is the closest complementary remedy to Sulphur, Calcarea and Phosphorus, being a synthesis of their symptom pictures with Sulphur having the lions share. Its similarity to Sulphur is so great that any Sulphur case which fails to respond to Sulphur may be tentatively considered a Tuberculin case on the strength of its Sulphur symptoms.
CASE 2-Mrs. M.R., aged 42. Recurring paronychia affecting the bases of all of her fingernails with tenderness, swelling and seropurulent discharge, always aggravated by hard use of her hands (housework, dishwashing, etc.). Chronic constipation with enema habit for years in spite of correct eating. Tendency to what she calls “bilious spells” consisting of nausea, vomiting, griping pains in the abdomen and violent headaches. Several times she found pinworms in her rectum. Recurrent violent attacks of trifacial neuralgia.
She gives a history of having been a sickly child of thin build with swollen lymph glands, had several attacks of pleurisy, recurring cystitis and an outbreak of boils and carbuncles over the face and upper arm. She is of small spare stature, easily exhausted, very sensitive and emotional, impatient and irritable, easily worried, feels worse in wet, cold weather and suffers from lack of vital heat; her menses are scanty and she feels worse before them. Easy perspiration and damp feet. The skin is dry, chafes and cracks easily. She craves sweets, starches and fruit. The neuralgia is worse on the right side and worse at night. The first prescription, Silica, did not touch her at all, nor did Tuberculin. Phosphorus initiated good progress for 5 months, then ceased to act.
The next two years saw attempts with Psorinum, Arsenicum, Sulphur, Lycopodium Nitric ac., Hydrastis, etc., with absolutely no success. A reconsideration of the case started from the premise that, Phosphorus having been the nearest medicine which failed to hold, a fitting antipsoric nosode must be found. The tendency to pus formation led to the consideration of Streptococcus viridans cardiacus (Stearns) 200.
The ensuing response was a true homoeopathic aggravation which, prior to the improvement, singled out each group of symptoms, rather than the purulent state alone, thus marking them as belonging apparently to the pathogenesis of this drug. The first response came from the gastrointestinal tract, then came the trifacial neuralgia and lastly the inflammation of nails and skin.
From the limited experience of prescribing this nosode in other cases it would appear that the viridans strain from the cardiac lesion is the most active and therapeutically most frequently indicated one among the streptococcic strains, at least in general constitutional states. In none of the limited number of cases in which its prescription proved therapeutically effective was there any clinical evidence of rheumatic or cardiac pathology.
The symptoms common to those Strept. vir. card. cases, which tentatively may be considered prescribing indications for the medicine, are the following: the patients are of fair complexion, rather slender build, oversensitive, emotional, active types, have a low resistance to colds and infections, a tendency to swelling of the lymphoid tissues, an unhealthy skin with a dry type of eruption. The drug is a constitutionally deep acting antipsoric, apparently, holding a midway position between Phosphorus and Psorinum. It may have to be considered when either Phosphorus or Psorinum seems indicated yet fails to work.
CASE 3-Mrs. J.C., aged 57. Her complaints is rapid heart action (pulse rate about 100). This state is punctuated by more acute spells of tachycardia attended by shaking of hands and feet. She also suffers from intense headaches localized on top of the head, pressing or penetrating pains. She is very apprehensive, nervous and impatient and very sensitive emotionally. There is a fine tremor of hands and fingers, globus sensation in throat, easy perspiration. Her basal metabolism rate was above +15 when taken several times in the past. Tendency to constipation and flatulent distension from sweets and fats.
Clinically, this is a definite case of hyperthyroidism (in the past she had had treatments with Lugols solution without any effect). Generals: lack of vital heat, better from warmth but worse in closed rooms, worse night, after eating, in damp weather, approaching storm; she is of fine, thinly built, narrow- chested, phthisical habitus. The obvious prescription was Sulphur, which over 2 years improved her condition but never succeeded in bringing about a really decisive change.
