THE MANAGEMENT OF THE CHRONIC CASE AND THE REMOVAL OF OBSTACLES TO RECOVERY


What does chronic mean to us as Hahnemannians? Does it mean a long case?–it means that to the “successful” physician of whatever school or system of therapy. Does it mean incurability?–if it does there is something radically wrong and we have been boasting of powers we are either failing to use or do not possess.


“Why doctor you dont think my case is chronic do you?” Casually, perhaps thoughtlessly, we let slip the fatal word and it has struck deep, carrying terror and a feeling of utter hopelessness to the very centers of conscious existence. Doubtless we have all had this experience; we have spoken the word, have seen the look, have heard the question and have tried to comfort as best we could. Can one doubt the power of the spoken word?.

Chronos means time, but chronic means incurability as far as the average patient is concerned, and it must be admitted that the medical fraternity in defining chronic disease includes, as part of the definition, the same idea of incurability and fatal outcome.

What does chronic mean to us as Hahnemannians? Does it mean a long case?–it means that to the “successful” physician of whatever school or system of therapy. Does it mean incurability?–if it does there is something radically wrong and we have been boasting of powers we are either failing to use or do not possess.

Let us pin down this word incurability in the hope that it may no longer, inevitably like a shadow, or a nemesis, dog the footsteps of our chronic patients.

It has been pretty definitely determined that all chronic diseases of whatever nature begin on the functional plane and gradually progress toward altered structure and organic change. Properly handled no case should be considered incurable so long as the disease manifestations are chiefly those of functional disturbance.

Does the death of the patient prove that his case was incurable? Not necessarily by any means. Was the real similimum given in proper potency and repeated, or the potency changed at the proper time? Were all the obstacles to cure removed? Was the diet intelligently managed? Did the patient really co-operate with his physician? Did the environment and routine of life receive due consideration?.

Unless all these questions can be honestly answered in the affirmative we have no right to call the case incurable.

In section four of the Organon Hahnemann says: “He (the physician) is at the same time a preserver of health when he knows the causes that disturb health, that produce and maintain disease and when he knows how to remove them from healthy persons.”.

This lead us to consider in general and very broadly the cause of chronic disease. For this consideration we must not allow ourselves to worry too much about the three chronic miasms of Hahnemann or the transcendental speculations of modern medical science.

The causes of chronic disease are:.

1. The inherent, individual constitutional bias and susceptibility. This may or may not follow the general family trend. It is highly probable that this “constitutional bias”– call it psora if you wish–determines in large measure the type, direction and ultimate localization of chronic disease.

Every human being is born with certain mental tendencies and with corresponding and correlated physical tendencies. There are in everyone some inherent defects in character, mind and body. Balanced, more or less, against these are certain strong points of character, mind and body.

The homoeopathic physician would be the last to call in question the correlation and reciprocity of reaction between the spiritual, mental and physical planes of life.

2. The environment. This is to be considered in its broadest sense–namely, the totality of all the conditions of existence,.

Philosophers have taught that back of will stands desire. Accepting this statement as axiomatic we are forced to conclude that in so far as possible man will harmonize his environment– consciously, but more often unconsciously–with his inherent constitutional bent or tendencies. Almost automatically his environment will, as the years go by, tend to gradually increase and augment the original bias. Chronic disease, therefore, has its roots in the very core or essence of existence. It is a part and parcel of the defects and faults in mans own nature. The environment merely furnishes the conditions and culture necessary to work those defects out to their ultimate manifestations. Intelligent intervention on the part of the physician is absolutely necessary in order to stop or retard the progress of chronic disease.

In order to intelligently intervene the physician must know the essential generals in respect to the patients environment and routine of life. He must comprehend in some measure the loves and hates, the unsatisfied longings, the griefs and disappointments, the shame and remorse, the fears and forebodings, the jealousy, the avarice, the ambition, the lust for name, fame and fortune. Clearly perceive the dominant qualities, perversions of the mind and heart, and the relation existing between the patient and his environment, and his chronic sufferings will be made plain and understandable. Moreover the similimum for the case in hand must, in the provings, have shown essentially similar mental and moral characteristics.

The remedy must fit the mind, the internal man. Recovery must be from within out, from mind to body, from cause to effect and not from effect to cause. “That physician is also the preserver of health and the promoter of happiness” who not only gives the similimum but who also counsels his patients to think less of themselves and more of others, to be less introspective and more altruistic. By careful suggestion and correction of the attitude of mind some of the serious obstacles to recovery can be removed.

Coming now to the more external or physical elements of environment we must consider the matter of intake–food, drink, drugs, anything and everything taken into or consumed by the body, including even the very air the patient breathes.

The intake is apt to be more or less habitual and, therefore, directional. We have only too often to contend with the alcoholic habit, various drug habits, the candy habit, the soft drink habit, the tea, coffee, pastry and tobacco habits– perversions of appetite, wrong food combinations, over-eating, over-seasoning, vitamin deficiencies, radical reducing diets, over-indulgence in canned, bottled and preserved foods, delicatessen products, manipulated, processed, adulterated and medicated foods. Less time in the kitchen and more than time at the club, the card parties and the movies. The modern tempo is a fast one but everything has its price. The relation of diet to chronic disease cannot be ignored.

The physician who fails to correct and simplify the diet in harmony with good, common sense is unintentionally leaving serious obstacles to recovery unremoved and to that extent he is falling short of “the physicians highest and only calling (which) is to restore health to the sick”.

The intake of laxatives, tonics, sedatives, serums, vaccines, antitoxins, external medicaments, antiseptic douches, cold tablets, headaches remedies, nostrums, poisons of all kinds and description must be absolutely and finally discontinued. There can be no temporizing in the handling of the chronic case. Patients exposed by occupation or otherwise to noxious or deleterious gases may require the removal of these obstacles before the remedy can do really curative work.

Next we will briefly consider the question of elimination of waste from the body.

Retention is a word that fits many a chronic case–a damming up process that may have been going on for years. Too much going in, not enough going out. A chronic toxic state is the inevitable result.

Normally the elimination of waste is accomplished through the kidney, the bowel, the skin, the expired air and to a greater or less extent through all the mucous membranes, especially those of the nose and throat. Abnormally or pathologically other means of elimination are devised by nature–eruptions, fistulas, sores and discharges of all kinds. The excretory organs function on a selective basis and only to a partial and limited extent is one able to do the work of another. Stimulation of the excretory mechanism is often but temporary and palliative in effect. Moreover, in many cases artificially increased elimination through certain of these organs is more than offset by reactive suppression through other channels and this to the detriment of the patient.

The relation between intake and output is direct and obvious,, yet many physicians pay scant if any attention to the matter. Others concentrate on laxatives, purgatives, bowel lubricants, enemas, irrigations and whatnot, meanwhile permitting their patients unrestricted license in the management or mismanagement of their diet and habits of eating.

The next factor in environment is the daily routine–the more or less habitual schedule followed and only occasionally interrupted day after day, year in and year out. No matter how large a variety there is in ones daily life, it is more or less the same old grind after all, until finally a rut or groove is formed–in other words it becomes habitual, and therefore, directional in respect to chronic disease.

For how many is breakfast a quiet, restful meal? How many find time for a little repose of mind and body other than perhaps occasionally on Sunday? How many take any worthwhile exercise in the open air or enjoy the priceless benefits of the great outdoors and the free and glorious sunshine? How many retire at a reasonable hour and get really sufficient sleep?.

Repose of mind and body, adequate sleep, suitable sensible and sufficient exercise in the open air, away from the noise and fumes of industry and traffic, in short a sane, intelligent daily routine of life is to be prescribed and insisted upon in the management of the chronic case. Optimum conditions can rarely be had but this is no excuse for failing to ameliorate circumstances in so far as possible for each and every patient.

When the apparently well indicated remedy fails to act or permanently relieve it may be that we havent given it a chance. If the conditions that brought about the disorder still obtain the best selected remedy–the similimum itself–may not bring about a complete and permanent cure. Causes are continuous into effects. It is our duty to break the chain of cause and to destroy as many links as we can or it will drag the patient down to the grave sooner or later. We have performed only part of our duty when we have given the homoeopathic remedy. Let us do our full duty and then watch results. If the patient will not co- operate the responsibility is his. If we do not prescribe some thing more than the remedy when that something more is needed the responsibility is ours and the failure to cure will also be ours.

At the risk of repetition permit me to briefly outline the essential factors to be considered in the management of the chronic case.

1. The inherent, individual constitutional bias and the ruling qualities, and aspects of the mind.

2. The totality of the environment.

(a) The psychological environment, personal contacts, etc., not only at home, but also in business and social life, with especial reference to any pronounced emotional complex.

(b) Intake of all kinds.

(c) Elimination of waste.

(d) Rest and sleep.

(e) Outdoor recreation and exercise.

(f) Habitual drains and depletions especially those of sex vice and excesses–if such were large factors in a given case how much curing can the remedy accomplish if the depletion continues unabated? Perhaps the remedy will check and correct the habitual tendency , perhaps it will not.

(g) Venereal, malarial and other infections. These we will pass over without comment save to state that the constitutional bias and the totality of the environment doubtless determine both the susceptibility to these infections and the virulence of the disease when once acquired.

PRACTICAL CONSIDERATIONS.

The urge to get busy and do something right away is almost overpowering to many physicians. In the average chronic case such haste is generally to be condemned. Let haste give way to sober judgment and thoughtful deliberation.

It is only exceptionally that it is either necessary or desirable, in chronic work, to prescribe at the first interview.

The old routine of at once giving Nux vomica or other antidotal medicine to a patient fresh from old school hands is generally unwise. In the first place over-drugging is only one indication and in the second place supposing Nux to be symptomatically called for we have not had the opportunity to find out and remove the obstacles to recovery and thus get the full curative effect of the homoeopathic remedy. The obstacles, in so far as possible, should be removed before, certainly no later than at the time of giving the remedy if the best results are to be obtained.

If the patients life is first untangled and intelligently simplified and harmonized with his individual needs the remedy at first apparently or only superficially indicated may be found to be unrelated to the essential symptom ensemble and valuable time may be lost in waiting weeks or months following the administration of an inadequate or unhomoeopathic remedy.

It is at times surprising how much a patient will improve and how much the symptoms will clarify in even a few weeks or a months time, when the contributory and perpetuating causative factors have been corrected or eliminated.

In addition to his medical knowledge what special sagacity and technique are required of the physician if he would undertake the removal of the obstacles to cure?.

Three things are absolutely necessary—.

First–A broad knowledge of human nature coupled with an understanding heart.

Second–A clear perception of the condition, environment and needs of the individual patient.

Third–An unlimited store of good common sense.

The patient must be pointed and guided away from the artificial and the complex toward the simple and the natural. The ideal, of course, can not be reached but we must nevertheless aim for it, travel toward it.

Now what shall we do at the first interview?.

The doctor or his secretary should first of all obtain complete and accurate data as to the patients name, address, telephone number, age, occupation, marital status, etc.

Method and painstaking accuracy in all these preliminary details are important psychologically as well as practically.

Next inquire very carefully as to the chief complaints giving the patient freedom to tell all he will (if not too rambling) before questioning him more closely.

We thus come quickly to understand in some measure the patients viewpoint in respect to his own case. The family history and previous medical history can be more understandingly investigated if the salient factors of the case as it stands at present are before the mind of the physician.

It is not necessary in this paper to go further into the important subject of the taking of the case.

One suggestion, however, may be well to leave with you.

Some patients can write out their case and their symptoms better than they can tell them, in others the reverse is true.

It can do no harm to request the patient or a member of the family to write out the symptoms and describe their case in detail.

No matter how well and how completely we may have taken the case every now and then peculiar and characteristic symptoms, veritable gold nuggets for purposes of remedy selection, can be picked up from such written statements.

Both men and women can be made to co-operative in this way and a little “home work” in behalf of their health or the health of a loved one will do them no harm.

Patients in general can be made to do almost anything within reason. If the physician cannot make his patients work and co- operate in their own behalf the fault is his, not theirs.

While we are on the subject of “home work” let each patient write out and bring in a complete list of all foods and drink taken for say two days time–breakfast, luncheon, dinner and anything taken between meals or upon retiring. Make no modification of the diet until after this list is turned in. When requesting the complete two day menu tell the patient you will make whatever corrections may be necessary in his present diet without disturbing him any more than necessary.

Often you will have a treat in store for you.

Let each member of the Association make this request of each new patient or old patient for that matter and the importance of diet in the management of the chronic case will soon be brought forcibly to mind, and furthermore we will all hear about it at the next meeting of the I.H.A.

Correct the diet as promised. Usually it will be necessary to add more raw fruits which can be taken between meals or upon retiring in place of the candy, cookies, soft drinks, ice cream, pastries, jellies, etc.–raw fruit between meals will not disturb the digestion.

Add more fresh raw vegetables to the diet and a larger variety of fresh non-starchy cooked vegetables.

Observing how restricted and habitual the patients diet has been you will advise a small variety of foods at any one meal, of course, but a very large variety over a week or a months time.

You will often find it necessary to restrict meats–using your judgment according to the needs of the individual patient and not being influenced by your own desires, prejudices, or aversions in respect to meat or any other food.

Often you will find patients overloading themselves with carbo-hydrates–some with starches, others with sweets, some with both. Sensible corrections in such cases are in order.

Right food combinations should take the place of wrong ones, but time will not permit any detailed consideration of these matters at present.

Habits of over-eating and fast eating must be corrected.

Excesses, deficiencies and perversions in respect to food and drink constitute some of the major obstacles to recovery. There are all kinds of diet fads and fadists and all kinds of diet insanities brought to the attention of the physician and the public, many of them bearing the scientific label. But there is sanity as well as insanity and the intelligent and discriminating physician will be able to choose that which is good for both himself and his patients.

Proper attention to diet alone has cured many patients of chronic constipation.

Suitable exercises persistently carried out have cured many cases.

The homoeopathic remedy alone and unaided has cured obstinate constipation of years standing.

1. Correction of the diet.

2.Suitable exercise.

There is little excuse for failure.

Find out what drugs and chemicals the patients has been taking and using externally and internally. Stop medicines and drugs of all kinds once and for all before giving the homoeopathically indicated remedy. Chemical interference with the action of the remedy may or may not be a very real obstacle to recovery. As long as there is any doubt best eliminate whatever may possibly be a factor in perpetuating the constitutional disorder or that may perhaps more or less antidote or divert the remedy.

Having removed all the probable obstacles to recovery and having found what we consider to be the actual similimum we prescribe the remedy and hopefully, in fact confidently, await results.

Just here is a point I wish to stress and that is the kind of improvement that is to be looked for under the action of the homoeopathic remedy. No matter what particular symptoms may persist, if the patient looks better, steps firmer and quicker, says he feels stronger, has more ambition, more interest in things and the world looks brighter it is practically certain that the remedy is acting in an orderly and curative manner.

Now suppose after a time improvement lags or comes to a standstill or the patient gets worse. Relapses are all too common in chronic patients. Just at this point many a case is confused or spoiled by stepping in with another remedy or an untimely repetition of the same remedy. Careful and thoughtful deliberation on the part of the physician is most essential to the ultimate welfare of the patient.

What are the possibilities?.

First, a temporary aggravation or reaction–a mere passing phase in the recovery process. Often a number of such reactions will occur and still the remedy continue to act.

Second, failure of the patient to continue his whole hearted co-operation–he may have grown weary in well doing.

Finally, the remedy may really have ceased to act.

The discriminating physician will determine which is the case and govern himself accordingly.

To the average patient and to many physicians the word chronic does indeed convey a threat of incurability, but correct homoeopathy supplemented in the way indicated will often accomplish the apparently impossible.

Therapeutics will take on a keener edge and cut through and cut away the barnacles of time and the chronically sick will become actually and permanently well.

PHILADELPHIA,.

DISCUSSION.

DR. C. L. OLDS: I want to commend this very valuable paper of Dr. Underhills. I think we are rather up against it when it comes to food. This is one of the great obstructions that needs attention in a chronic case. It is very difficult to tell your patient just what to take, particularly of manufactured products. Of course, when it comes to fresh fruits and fresh vegetables, in general, that is easy, although some of those things have been doctored.

They have been sprayed or ammoniated or something of that sort, so that it is very difficult to know whether your patient is getting pure food when it comes to the manufactured products. Very likely the flour your patient is using has been bleached. You know what that means. The prunes have probably been shrunken down by the use of some preservative. The raisins have been sulphured. Almost every variety of adulteration is used in preparing commercial food stuffs. That is what we are up against.

Eugene Underhill