Difficult Cases: Frustrating Ordeals or Learning Experiences?
The New England Journal of Homeopathy
Fall/Winter 1999, Vol. 8 – No. 2
by Frank Gruber MD
In homeopathy, often the most interesting cases are not the ones you find the remedy for quickly. The cases that you don’t solve with the first remedy often provide the most opportunity for learning.
Let’s talk about this first in a general way and then I’ll present a case that took me a while to get to the remedy. The first thing you have to understand for any case is what needs to be cured. This is not always as easy or as obvious as it seems. For example, a woman in her seventies presented with pain due to stiffness in her ankles. That was pretty much all that bothered her, she said. She seemed straight-forward, confrontive, a bit jarring in her personality, but there were no other symptoms that I could find that seemed too strong or needed to be dealt with. She did talk about fear of her husband dying and her being left alone but that seemed reasonable since he was older as well and not in particularly good health.
I gave her a remedy and she did very well for 4 months, when the pains began to recur. I repeated the remedy and she came back in a month very depressed. It seems that her husband wouldn’t talk to her much. He was the “silent type” and she found herself being more or less his caretaker. She was resentful of that. It just wasn’t the way she had pictured her retirement. When did she get to retire? He had stopped working but she never could. She had to take care of him. She was grieving about that. Yet she wouldn’t stop since she was more afraid of the grief of him dying. She also felt guilty because she was letting them both down. That would make her work harder to take care of him.
Ignatia cured both the depression and the stiffness of the ankles. It was not the stiffness that needed to be cured. It was her whole cycle that needed to be looked at and helped. This is one of the beauties of using the Cycle and Segment method of analysis of the case developed by Dr. Paul Herscu. But sometimes the whole case is not present when you initially take it. However, you can count on the vital force to deliver the rest of the case to you. As you give a remedy, symptoms will come up that reveal what needs to be cured. Just following the vital force and thinking about what needs to be cured will eventually lead you to the right remedy.
The second point I would like to touch on in these more complicated cases is your own beliefs. In a conversation I had with Dr. Herscu about how he approaches the patient, he mentioned that he has a belief that the patient is going to tell him exactly what he needs to find the correct remedy. I thought this was a tremendously powerful belief. So I adopted it for myself as well, adapting it a bit for my own skill level. I began to believe that the patient would tell me exactly what I needed to know to find the right remedy eventually, and if the patient stuck with me I would find their remedy. What that does is keep you focused on the case, keeps you looking at the case in deeper and deeper ways. Instead of beginning to despair about whether you are ever going to understand this person enough to find the right remedy, you keep focused on what the patient is telling you.
But even more than that, the key to the case may not at all be in what the patient is saying but rather what they are showing you with their non-verbal behavior, or the way they are responding. Are they haughty? Do they cut you off and not let you speak? Are they giving you one-word answers? Are they exaggerating? Are they telling you such a fantastic story that you realize they are actually paranoid, and it is likely that they are telling you their suspicions and not what is really happening.
And what are you feeling about the patient? This counts as part of what the patient is telling you. Are they intimidating you? Are you finding yourself anxious? Are you angry with them? Are you sympathetic toward them? Are you confused? All of these feelings are likely coming to you from the patient. Be aware of what you are feeling. It is a tremendous clue that the patient is giving you. However, you have to be conscious that the information is not just your own reaction, but is coming from the patient. You have to become aware of your feelings in order to figure out whether the patient is causing them or not. More than likely, they are. So be aware. Patients “speak” to us in many ways.
The third point I’d like to mention is that the patient gives us clues to their remedy over time. Each time the patient gets sick, they give us another piece of their puzzle. The patient can only get sick in two ways: one way is in the basic pattern of their pathology which gives us more information for their chronic remedy. The other is in an acute pathology. The further I go in studying and practicing homeopathy, the more I realize that illnesses, which seem to be acutes often are not. They are other examples of the chronic pathology, which seem to be acute.
For example, in the patient above who needed Ignatia for her ankle pain: as I went back through her previous illnesses, I found a history of irritable bowel, shortness of breath from chest constriction, and a history of menstrual cramps when she was younger. She currently had the stiffness of the ankles, which is a type of constriction, but Ignatia often has severe cramping which I didn’t see much example of in the case I was taking. In looking back through previous illnesses though, there was enough to make a case for cramps, but all from different parts of her life. All of that taken together filled out the cramp segment of the cycle. That, with the other symptoms she had, made up the cycle of Ignatia. She undoubtedly had needed the remedy for years. However, if I looked at each as a local, isolated, acute illness, I never would have given Ignatia.
Now let’s get to the main case: I am going to fully describe the patient because the remedy is not well known.
This is a 28 year old female complaining of no motivation (3). She can’t really seem to change her life even though she wants to because she can’t get started. Most of that revolves around a difficulty focusing (3). She doesn’t really know what she wants. She has difficulty on a day to day basis in keeping focused and getting things done.
She has a profound depression (3), which dates from her teenage years. It occurs every couple of months. At these times she has intense weeping (3) and can be suicidal (3). But even during the rest of the month there is a feeling of hopelessness (3), that nothing will ever work out and that something terrible is going to happen in her life (3). It makes her quite fearful for her day to day survival with a lot of the fears being based around money and the lack of it. Each day she is very anxious about her health and about whether she will survive due to the crises which constantly occur and drain her financially. She never seems to be able to get ahead since something happens each time she gets ahead to wipe her out financially.
“I’m a pessimist. You have to expect the worst. Something will come and take it away from me. I’m very vigilant. I go to bed with my clothes on. I’m afraid something will happen to me. I’m sad. There is nothing to live for; nothing to look forward to.”
She has extremely low self-confidence (3). Even though she is quite attractive she sees herself as unattractive, unable to compete with other women.
“I feel like I let my family down. I just couldn’t be the way they wanted me to be. I need a lot of recognition. I want people to like me but I don’t make the effort to initiate it.” She is very critical of herself (3), of how she walks, talks and looks.
She finds that she is bossy (3), like her mom. She is irritable and “bitchy” (3) and can get into arguments with her husband that can lead to out and out physical battles, with verbal aggression and can even lead to striking and hitting (3). She’s aggravated she can’t fix things on her own. She can be vindictive and spiteful (3). She can also be extremely weepy over nothing.
“If someone says something to me, I’ll cry. I feel ready to explode.”
She didn’t get along well with her husband who was very passive and let her do all the work and planning. She wouldn’t leave him because she has an intense fear of being alone (3).
“I’ve been hurt a lot and just can’t think about being alone and on my own.” She eventually did leave, had a series of quick relationships, and then got into a relationship with a man who is physically abusive to her.
“It is important for me to feel needed. I took care of my mom who died of cirrhosis. I’m afraid I am so nitpicky that my husband will leave me or I’ll push him too far and he’ll leave. I like to look different so I’m the center of attention. I’m fussy and mothering but carefully push people away.”
“People say I’m too confident, that I’m stuck-up and snotty. I stand back with crossed arms and look around the room and watch people. I’m nosy. I see who’s looking at me.”
“Basically, I just don’t trust people (3). My parents were alcoholic and I couldn’t trust my dad who would abuse me when drunk. I am extremely jealous (3); not of them looking at other women, but more of being left out, of people talking about me. What are they saying about me?”
Physically she has palpitations (3). They can occur any time. It makes her very afraid that she has some horrible disease. They are worse when she lies down to go to bed. At one point she was on Inderal for them.
“They give me a sharp pain like someone sticking a knife in my chest and they take my breath away. I have them daily and they last for about 5 minutes. I can’t control them. I’m wondering if I’ll die from them.”
“I have a low sex drive (2). I’m a disappointment to my husband. He might leave.”
“I used to get hives (2) from age 9 – 14. They’d come on the back of my neck, back and chest. I’d scratch them a lot, since they were so itchy. They made me feel so ugly. They were humiliating. They made me less self-confident. I couldn’t control them or make them go away.”
“I have severe arthritis of the knees and back (2). The knees swell above the kneecaps. It is a sharp pain when going up stairs. There is a stiffness of the knees. I have spinal bifida and scoliosis. I can get spasms of the back (3) and sciatica, which is a prickling pain down both legs. I get an ache and a pressure in my back, like an elephant standing on it. There is also some twitching of the muscles of the back. The arthritis bothers me every day. My muscles feel tight (3). There is also tightness of chest (2). I get another type of pain in my knees which makes them feel like they are going to explode (3).”
“I have severe headaches (3) in back of my neck and head. The head feels like it is in a vice grip. I have to go lie down and rest in a dark room with no noises.” These are worse with motion of her head. They occur mainly around menses (3). The headaches are of two types. The first is a constricting type mentioned above. The second is a feeling like the head is going to explode (3).
She has severe menstrual cramps (3). They are debilitating. She has to go lie down (3). They occur on the second day of the bleeding. There are lots of clots with dark red blood, associated with nausea.
“My sleep is poor. My mind is racing. Did I do this right? Is my husband cheating on me?”
She is chilly, has low energy of three to four on a scale of one to ten, and craves cheese and milk, which upset her stomach. She has aversion and aggravation from eggs.
Remedies given: Arsenicum album, Lachesis, Ignataia, Platina, Hyoscyamus, and Anacardium.
Most relief was with Lachesis. The emotional states were ameliorated by 50-60% with some symptoms even going away, but the physical complaints got worse. Then she began to develop a series of bronchitis-like symptoms with sneezing, fevers, cough, and muscle aches all the time. She felt completely fatigued and burned out. The joint pains got so severe that she was crying from the pain. I was constantly giving her prescriptions for Tylenol (3).
Let’s look at the analysis of the case.
The segments broke down like this:
1. Difficulty focusing
2. Hopeless/fear something bad will happen
3. Fear of being alone
4. Holding on / constrictive pains
5. Jealous and suspicious
6. Abusive, violent/explosive pains
I chose the following rubrics, which I combined to give the fullest repertorization possible. Each of the combined rubrics represents the segment listed above.
1. Mind, concentration difficult; Mind concentration difficult, studying.
2. Mind, fear something will happen; Mind, ailments from anticipation; mind, despair of recovery.
3. Mind, fear, alone; Mind , forsaken feeling; Mind , delusions of being alone in the world; Mind delusions, she is always alone in the world.
4. Head, constriction, band or hoop; Back, spasmodic drawing, cervical region; Female genitalia, sex, menses, painful; Head, constriction; mind, company desire for.
5. Mind, suspicious; Mind, jealousy.
6. Mind, abusive; Mind, censorious; Mind, striking; Mind, violent; head, pain, bursting.
When I repertorized these segments, 22 remedies came up in all 6 segments. 11 small remedies or nosodes came up in 5 segments. When you are looking for smaller remedies, which are likely to be under-represented in the repertory, you should look at the small remedies and nosodes, which come up in all but one of the segments. This gives them more of a chance to show up in your repertorization.
So in September 1998 I gave her Cenchris 200C, based on the above repertorization and everything got better. All the emotional problems went away. The headaches and menstrual cramps stopped. The arthritis went away. The palpitations had gone away with the Lachesis. The muscle aches all went away. I repeated the Cenchris 200C once in June Â99. She was asymptomatic after that except for mild occasional headaches and occasional mild menstrual cramps, but nothing like the debilitating headaches and menstrual cramps of the past.
Let’s talk about Cenchris for a moment. Cenchris is prepared from the venom of the Copperhead snake.
The cycle of Cenchris:
1. Suspicious/jealous; They are extremely suspicious and jealous
2. Arguing/irritability/nastiness; (If person explodes quickly it is more likely Cenchris rather than Lachesis who tries to control themselves.) Intense irritability from jealousy and suspiciousness. This, of course, tends to drive the loved one away.
3. Dullness; All the arguing and nastiness leads to a weak, dull, confused state, with a poor memory.
4. Fear of death, of night, of exposure; Something bad is going to happen. From the dullness and weakness, they feel that something bad is going to happen. It makes them feel like they are going to die. In Lachesis it happens as they are falling asleep. For Cenchris, there is just a feeling that something is going to happen to them. Fear of death at night.
5. Alone, Forsaken; They feel alone and abandoned in the world. They have driven their loved one away. Their worst fear has happened. Something bad has occurred.
6. Desires company; Don’t want to lose company. They are alone and think they are going to die. They want someone there to protect them. They will do anything to hold on to their selected loved ones. They go after them and are nice to them to win them back. But soon enough the loved one messes up in some way and they start again with jealousy and suspiciousness.
Cenchris is a remedy in between Lachesis and Hyosyamus. It is as though Cenchris is stuck in a constant PMS state and has a lack of logic. The suspiciousness makes them angry. The mate did the wrong thing, they drove him away and then they are alone. In a woman who has fear of being alone and treats her husband badly, consider Cenchris.
Difficult cases
So let’s look at what happened here. I was stuck with a case that I had prescribed multiple remedies for. Instead of groaning each time she came in, I tried to stay open to the case and see where it was leading me and what I could learn from it. If you stay open to the case and realize the vital force is trying to teach you, you will learn the lessons. Often, as the patient is in front of me I ask myself, what is the patient trying to tell me that I am not getting; what is the patient showing me by his/her actions that I haven’t seen; what is the feeling that I’m getting from this patient that I haven’t felt yet; how is the patient saying things that might give me a clue to what I need to understand? Often this will open up other senses that I’ve somehow closed off for the moment that will lead to new understanding of the case.
What I gradually became aware of is that the mental and emotional symptoms were responding to the remedies that I was using but not the physicals. So I tried to pay more attention to the physicals, combining them with the mental/emotional symptoms that I already had. When new symptoms arise or other symptoms become more prominent in a case, it is the vital force trying to get you to pay attention to the new symptoms and add them to the symptoms you already have, to come to a new remedy.
Then you have to use your common sense as well. Lachesis, a snake remedy seemed to give the most improvement. Maybe another snake remedy would be called for. I have my materia medica listed in different ways on my computer. Lectures that I’ve had on various remedies have been categorized in multiple ways. One listing that I have is for snake remedies, with the cycle for each one on a one page sheet. This way I have rapid access to a brief summary of the heart of each snake remedy.
So besides coming up in the repertorization, Cenchris was a snake remedy which I saw from my snake remedy Âcheat sheet” covered fear of being alone, jealousy and suspiciousness leading to abusive treatment leading to the person being alone. From all perspectives it seemed like the right remedy. So by forcing myself to reason things out, by staying focused on the case and on what needed to be cured instead of on my feelings about not being able to find the remedy; by realizing that if I simply focus on the case and what the vital force is telling me, and by looking at all the various visits and symptoms as part of the case sequentially revealed, I was able to realize my belief is true. If I stick with it, I will come to the remedy.
Difficult patients are our stimuli to let go of our need to stick patients into our previous experience. If we discover first who the patient is and what the cycle of their pathology is, we will continue to learn about homeopathy and about remedies we have little experience with by allowing our patients to become our teachers. For me, that is both fun and rewarding.
To Read More About Cycles & Segments, click here
Frank Gruber, M.D. practices homeopathy in Norfolk, Virginia. He has studied with Dr. Herscu for the last seven years and greatly appreciates that all the ideas in the above article which came from Dr. Herscu have percolated through him for the benefit of his patients and perhaps, through this article, for the benefit of yours.
Dr. Herscu responds to that biographical note: Dr. Gruber is the kind of student every teacher dreams of. He has asked many of the right questions at the right time. And by so doing, has elucidated for me much of what I do. Above all, I have received friendship and support from Dr. Gruber, and for this I am deeply grateful.
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