The Darnell prize is a small reward offered each year at Hahnemann College, Philadelphia, Pa., for the purpose of stimulating interest in homoeopathic materia medica and therapeutics. The prize this year was won by Frederick A. Riemann, Jr. and the following case analysis forms part of this thesis. The first part of this thesis gives an excellent analysis of the interpretation of symptoms, a description of the books referred to, and a short description of repertory analysis.
We are giving the first of three cases exactly as analyzed in he thesis. this is followed by criticism and analysis by Dr. H.A. Roberts according to the boenninghausen method, and by Dr. Elizabeth Wright-Hubbard according to the Kent method. The other two cases in this series will be presented in the next two issue of The Recorder. This thesis is an excellent piece of work. We congratulate Dr. Frederick A. Riemann, Jr. and with him success in his homoeopathic endeavors. ED.
Mr. E.W., aged 60, complains of a burning heat in the right thigh, which seems to be located in the skin, and which, during the past 15 years, has spread to the right arm and hand and foot. It is present during sleep as well as in the daytime. There is an almost complete paralysis of his entire right side. He is slow and deliberate in his speech, of good intellect and in good spirits although not a little suspicious, especially so of all doctors.
Some 15 years ago he developed a series of ulcers on the groin, from one of which a sequestrum of bone discharged. He treated himself by a home remedy of chewed lead and this he prepared himself. Eighteen years ago he had typhoid but remembers no other disease. He denies venereal infection. He has no children and has been separated from his wife for more than ten years. He has a lack of facial expression but no Argyrl Pupil or Rhomberg, although the reflexes in the right extremities are lacking. He cannot repeat the words “Methodist Episcopal,” etc. There is very little atrophy of the muscles although his strength on this side is gone. He has to eat with his left hand, and has a shuffling gait.
To discuss a given case from the standpoint of homoeopathic philosophy means to attempt to correlate the medical aspect of the patient with the philosophical interpretation of the disease process, its origin, causation, and development, and in this manner attempt to explain the present picture. The value of this work lies in the more complete understanding of the disease as it relates to distortions of the vital force in the human organism and, as a result of this improved viewpoint, a more effective therapy follows since it is based upon a more thoroughly understood disturbance which the physician is attempting to subdue.
We must first attempt to formulate a theory which will explain the beginning of this patients condition. Until eighteen years ago this patient states he had suffered from no illnesses. Further, he denies venereal infection, a statement which the physician must regard with skepticism until confirmed.
There is the most remote possibility that this patient was an example of the perfect organism, devoid of all acquired and inherited taint until the onset of the typhoid fever. We are more inclined to consider the patient as one of the vast majority who harbor within themselves one of the three universal miasms, termed by Hahnemann psora, sycosis and syphilis. Although we are unable to name the miasmatic process underlying the beginning of the disturbance, we are, at the same time, able to trace its progress and the path traversed in the organism.
Hahnemann, in his work The Chronic Diseases, emphasizes the fact that the miasm may exist in a latent state unknown to the patient, partially bound down to the organism by the robust constitution of the individual, his mode of living and his habits (moral and physical). The ability of the organism to counter- balance the abnormal process does not, however, permit of its overcoming it to the extent that it is able to cast it off. Instead for years of a lifetime, this balancing of vital force and morbific process may continue until the balance is upset by proper medication in favor of the life force to the exclusion of the miasm, or, on the other hand, upset by the invasion of a more active disease process to the detriment of the vital resistance.
It is this condition of balanced serenity that we believe existed in this patient. the onset of the acute attack of typhoid taxed the resistance of the organism to the extent that its control over the miasm was weakened. With the subsidence of the acute invasion, the released latent process gradually became accelerated, and working from within outward eventually became accelerated, and working from within outward eventually manifested itself upon the skin in the form of ulcers.
The long delay in the appearance of the ulcers is not unusual when we consider that this patient has been able to boast to this time of what he states has been perfect health. The morbid process released within him him had to bore its way to the surface, figuratively speaking. The sequestrum of bone discharged might be taken as indicative of the depth of the disease. All this is in harmony with Herings law of the centrifugal action of disease which is so important yet so little understood.
When the condition appeared upon the skin it showed itself in its simplest and least complicated form so that active homoeopathic treatment at this point would have quickly and efficiently released the organism from its hold (Hahnemann). Instead, local suppression was resorted to, and the disease process, no longer subject to modification by the vital forces, is hurled back into the organism where it continues its never- ending destruction in its efforts to relieve its intrinsic tension by symptom manifestation and discharge.
Its course from this point might be taken as a confirmation of the reasoning of James Tyler Kent as brought out in his discussion of the correspondence of organs and the direction of cure, all of which is based upon Herings Law of Symptoms. A complete understanding of this philosophy is necessary for an accurate estimation of the progress of a case under homoeopathic therapy.
The subject in its entirety is worthy of a thesis of itself and we must confine ourselves to a mere scratching of the surface as fits the needs of this case. Briefly it has to do with the course taken by morbific processes within the body, the course under proper treatment being shown by the appearance of characteristic symptoms in specific organs (this being the path of cure); conversely, the path under improper medication, homoeopathic et al, or the path that the process if forced to assume from other causes may be traced in the opposite direction.
In this case the gastro-enteric tract is the fulcrum. We may assume that the miasmatic process released here in conjunction with the typhoid attack, of its own accord and by natures law worked itself in the proper direction, to the skin. The suppression of the condition at this point caused a pronounced reversal so that its path is inward and eventually it strikes at the innermost part of the organism, the brain and central nervous system.
It may go still further, destroying eventually the innermost factor in this, the innermost organ in man, namely, the intellectual faculties with the appearance of an insidious insanity. In this case the path taken by the morbid process is well marked and unmistakable. Gradually burrowing inward, it manifests itself by prodromal signs of distorted sensation. unmolested it continued until we are confronted with frank paralytic weakness and now we find our patient is suspicious, and early manifestation of impending intellectual impairment.
With the commencement of active homoeopathic treatment two results may be obtained. Under improper prescribing this case will be precipitated into a frank mental case; if the remedy chosen is correct we may expect to see disappear first, all the mental symptoms; this will be followed by a decline of the paralytic manifestations (or there may be at the beginning a slight intensification followed immediately by the decline) with the appearance of marked intestinal symptoms, as spasms, diarrhoea, etc. Finally the skin may be resorted to as the final outlet for the miasmatic process if necessary. One other possibility, the process may taken a more rapid exit, going directly from the cerebro-spinal tract to the skin.
The extent of recovery, naturally, is modified by the extent of the organic destruction of the nervous tissue, if any be present.
CHOICE OF SYMPTOMS FOR ANALYSIS.
Before selecting our symptoms let us consider the task before us. We are about to review the various complaints and evidences of a disease process in our patient. From the symptoms we receive we will attempt to construct, logical, a picture of his condition which will identify and simulate a similar drug group picture. Our symptoms, when chosen and logically arranged, will give us our totality, the integrity of which will be reflected in the integrity of the remedy chosen.
As a guiding light we take a statement by Stuart Close: “It has come to be a maxim among experienced provers that the last appearing symptoms are the most valuable and characteristic. In the same way the last appearing symptoms in a disease,especially chronic diseases, are of the highest rank in selecting the remedy”. We will, therefore, in this case and those to follow heed his advice, at the same time keeping in mind the value of the symptoms as brought out in he general discussion of the interpretation of symptoms.
Considering each symptoms separately we find only a few that are positive and distinct. These we will take and set the others aside for consideration when we have completed our repertorizing, their chief value being confirmatory. Two mental symptoms present themselves at the start. Since mental symptoms are of the highest order we them first place in our analysis. Here they serve also as eliminative symptoms. The general attitude of the patient, being a manifestation of his will, is ranked first and cheerfulness is taken as symptom number one.
The other mental, his suspicious attitude, being a perversion of understanding is chosen as the second symptom. Because there is the possibility that his slowness of speech is due to cerebral complications this was chosen as the third symptom. In this symptom we have our first particular. We next consider the terminal organic manifestation and the patients complaint, his paralysis. We find this to be right-sided, that is confined to one side of the body so we take this general rubric of one-sided paralysis as symptom number four.
Since many of the patients complaints are traceable to weakness of the affected parts (for example, the difficulty in walking and the inability to use his right hand while eating) we chose as our fifth symptom paralytic weakness. Lastly, we chose the general rubric ulcerations of the skin not because of any intrinsic value but because we feel that in the course of the disease this symptoms played a prominent part, therefore we would like to have as our final group of drugs, those in which ulcers made up a part of the picture.
while considering the rubric” Paralysis” in Kents Repertory we came across the statement “heat in the paralyzed parts”. This fits in with our picture, but because of the peculiarity of the symptom we are more inclined to keep this in mind and use it after our drugs have been definitely limited to a few.
the symptom of “burning heat in the skin”, while it is the patients chief complaint, is not to be taken as our chief symptom. We prefer to place it as symptom number seven giving it a place in our analysis but not too prominent a one. In value it is equal or perhaps a little above “Ulcers.”.
As stated in the general discussion of the repertories to be used, James Tyler Kents Repertory of the Materia Medica is our choice. Its scope is the widest and our symptoms were easily found therein. Boenninghausen;s Hand Book was given considerable thought and scrutiny. On the whole the case seemed applicable to this book but investigation brought to light the fact that in order to use our chosen symptoms it would be necessary to distort the terminology and to some extent the meaning of them.
It was feared that the real significance and value of the individual symptom would be lost in the effort. Examples of this distortion are, mistrustful for suspicious, and, in the absence of a speech rubric “tongue affected” for “slow speech”. This last example shows clearly what might happen. We cannot point to any definite lesion of the tongue which is responsible for the slow speech nor can we emphatically say that this symptoms is purely a disorder of this organ. Rather than invite error and increase our chance of failure we are content to rely upon the more accurate and better understood repertory, Kents.
As a result of the procedure already outlined using the previously discussed symptoms, three remedies stand out. They are Lachesis, Phosphorus and Causticum.
This case is certainly deep seated. It might be well to consider whether or not one of the nosodes might be needed to uproot the condition. After reading kents opinion regarding the use of nosodes we are inclined to be less hasty in prescribing them unless we can satisfy ourselves that they are really indicated. He says:.
The nosode tendency is becoming altogether too extravagant. I have known Medorrhinum to be given and fail where Thuja would have promptly, because the symptoms were predominantly Thuja and not Medorrhinum. I have known Psorinum to be given because a case was supposed to be due to psora, where Sulphur was well given indicated. It is a great error to prescribe for the miasm instead of the totality of the symptoms.
Nosodes may be of use when the symptoms are scanty or distorted or where the picture of the condition has been smothered beneath a series of complications thus rendering definite selection of the indicated remedy impossible. If these conditions are present and we have a definite history of one of the miasmatic disorders, Kent states that is a good “experiment” to resort to a nosode.
In this case the symptoms are not distorted. Those given are not hazy nor has the condition as a whole been subjected to frequent or radical distortion as evidenced by the fact that his present complaint is off fifteen years standing. In other words we do not feel that we would be justified in prescribing a nosode in this case when we are able to derive the truly indicated remedy from the totality of the symptoms given.
As has been previously stated, Lachesis, Phosphorus and Causticum seem to be the remedies from which we are to make our choice.
First let us consider the general modality of right or left- sidedness in these remedies. Lachesis is predominantly a left- sided remedy. Dr. Garth W. Boericke in speaking of Lachesis stated that it is exclusively left-side or at least the initial symptoms must make their appearance on the left side. This point is also emphasized by Willard Ide Pierce. Phosphorus, although also frequently mentioned as a left-sided remedy (especially in the respiratory field0 when paralytic symptoms are concerned seems to be less pronounced on this point. It will be noted that in Gross Comparative Materia Medica mention is made of the fact that paralysis of Phosphorus (especially of the lower extremities0 is frequently right-sided. Of the third remedy, Causticum is prominent right-sided drug.
The pronounced left-sidedness is a strong point against Lachesis. While one of its main actions is upon the brain and the cerebro-spinal nerves, its principal action seems to be upon those nerves which take origin at the base of the brain or in the medulla, especially the pneumogastric. The after effects of this involvement is more congestion, coma, convulsions or sudden prostration rather than paralysis as is found in this case. What is more, long and chronic as this case, is there is not mention of two very prominent features of this drug, namely, the extreme sensitiveness of the affected part to touch or light pressure and the almost universal distress that comes on during and congestion and disintegration are not prominent in this case.
Of phosphorus, we recently found (in the handwriting of Dr. Clarence Bartlett) on the margin in Farringtons Clinical Materia Medica the following notation: “Paralyses are characterized by itching and formication, numbness, trembling, muscular contractions and increased heat in the affected parts. Phosphorus is useful in mental decay especially if premature old age occurs.
The paralytic symptoms and mental weakness of cerebral softening disappear under its use”. Further, we find in Clarkes Dictionary of the Materia Medica these statements: “Phosphorus: walk less strong; often stumbles on a smooth road. As a leading constituent of nervous tissue Phosphorus has a deep action on the organ of mind and sensation”. All this nicely fits in with our repertorizing and when we find that the peculiar symptom “heat in the affected parts” in Kents Repertory applies to phosphorus and alumina) we might be tempted to rest our oars and consider the work completed.
We are given an incentive to look further when we find that Causticum, the lowest numerically of the drugs brought out by the repertory analysis, is recognized universally as the right-sided Phosphorus. Farrington states that although the two remedies (phosphorus and Causticum) do not follow each other well, they are, nevertheless, indicated in the same class of disease. Further, he points out that the main power of this drug pies in the paralytic weakness which the drug exhibits.
This paralytic tendency is a genuine potash weakness. We are amazed that slowness of speech did not bring out this remedy in our repertory study when we consider that its paralytic effects are very pronounced upon the organs of deglutition and speech, upon the tongue, upon the lips and in glosso-pharyngeal paralysis. These paralyses, states Farrington (among other causes) may be the result of a deep seated nervous disease. In the end, this point is valuable in that it very clearly demonstrates the fallibility of our efforts and the dangers from misinterpretation of symptoms.
Burts physiological Materia Medica classes the action of Causticum as first through the cerebro-spinal nervous system and principally the motor tracts of the cord with resultant paralysis. Farrington, in addition to naming paralysis as the predominant action of this drug, further outlines its sphere of action upon bone by Causticum, it being confined mostly to the epiphysis of the long bones as compared with the action of Phosphorus which is more pronounced upon the diaphysis of the bones. Burt also points out that the action of Phosphorus is principally through the vegetative nervous system and is spread over thirteen fields of which the cerebro-spinal is the ninth of Phosphorus upon bone is almost exclusively confined to the inferior maxilla and the tibia, the destructive process of the former being the more common.
ulcers, in general, are featured in both drugs. This fact is borne out both in the repertory analysis and the study of the materia medica, the ulcers of Causticum being fistulous, or following burns with throbbing and burning pain and watery pus, as compared with the ulcers of phosphorus which may be either painless or with piercing, festering pain, with viscous pus (Gross).
Finally a few words from Jahr. He states that, in general as well as in partial paralysis one of the most important remedies is Causticum and he admits that while Causticum is not sufficient to cure paralysis he has never yet treated a case of long standing where this drug did not materially contribute towards a cure. He recommends this drug highly after suppressed eruptions or ulcers; for semilateral paralysis, right or left-sided; for paralysis of the facial nerves; for paralysis of the tongue and organ of speech.
William Boericke recommends Causticum as an antidote for paralysis resulting from lead poisoning. Gross also expresses this thought when he mentions Causticum in ailments from abuse of Lead of Cinchona, etc., as compared with Phosphorus where the ailments are more frequently the result of abuse of Iodine or Natrum muriaticum. How much we can incorporate this idea into this discussion is problematical yet it may be mentioned here as food for thought.
We consider it almost unnecessary to make the statement that for this case Causticum is our choice.