The case of case analysis (A. Bickley RSHom)
 The purpose of presenting this case is to show that there is more than one acceptable or accurate method of case analysis, to give some examples of consideration of specific elements within a case, and to explain and justify potency and dose choices in such a way as readers can emulate the methods should they choose to do so.
 Zara age 29 
 Presenting symptoms: 

 Asthma since the birth of second child (children are aged 2  and 4.) There was no problem with the birth of either child and no medication was required other than gas and air mixture during delivery.
 Zara has a craving for air when under any emotional pressure or in any anxious state.
 The following are extracts from her actual words:
 “If the children are being a nuisance I find difficulty in breathing and I want to take a really deep breath to shout at them but I can’t. My chest gets tight and I panic. As soon as I realise that I have got into a state again it seems to take me over and I can’t think of anything else. Just realising I am ill seems to make the whole thing worse-harder to bear somehow. I’m all right until I think about the breathing difficulty but as soon as I think about my breathing then something is wrong with it. In my worst moments I am convinced that I will die from suffocation. I am awfully afraid of lack of air. My mother told me that I nearly smothered myself in a pillowcase once when I was very small-I suppose that’s where it comes from. I am petrified of dying, and of the pain that would be involved. I keep imagining that I have all these awful diseases, you know, cancer and such like, but I am just afraid of death I suppose.
 Apart from this I don’t really get worked up very much about life and all its problems. I can get worked up about being late for a coffee morning, but I can cope with the knife edge our business has been on for the last two years. (The family has a home heating and plumbing business which has been suffering from a lack of work and poor cash flow.) I don’t worry about the big things-they will come right eventually.”
 Q. Are you sure that nothing else worries you? 
 “Only smoking! Other people’s! The fumes give me a headache and make it difficult for me to breathe. I get pains in the left cheek and spasms across the throat if I inhale the smoke. I can feel as if there is a lump in my throat for days after being poisoned with smoke. It makes me sick just thinking about it-and angry too!”
 Q. Anything else? 
 “Nausea if I don’t eat at regular intervals. Eating makes it better again. So does drinking usually, although I do have a tendency to drink too much in the way of booze at the slightest opportunity. If I can’t eat or drink then the nausea just sits there and I feel sick although I never am, even when I get the hiccups which happens quite often, for no obvious reason.”
 There follows a selection of other symptoms from the case:
 A thin, but sticky discharge either from the anus or vagina (she was not sure) which seems unconnected with the menstrual cycle, but which stains the underwear slightly. It occurs randomly for a few days and then goes away for weeks on end.
 Zara finds difficulty in speaking when she is angry or tired-the words seem to get stuck in her throat and just won’t move. She is prone to profuse perspiration at night whether or not she feels hot in herself and whether or not the weather is warm or chilly. It is rare for her to feel cold and sweaty but not impossible.
 All symptoms greatly aggravated by consuming alcohol or paracetomol. Several years ago used to eat several paracetomol as a prophylactic against headaches if she wanted to go out. She found that taking this analgesic meant she got a headache the next day and she does not do this now, and has not done so on a regular basis for a couple of years.
 The patient: 
 Zara has a slightly embarrassed look about her, but seems eager to answer questions. She seemed to have no difficulty in breathing or talking during the consultation. She becomes vehement when talking about the children but exhibited no signs of dislike of them, only of what happens to her when they are being difficult. Her medical history is innocuous except that she had a severe fall two weeks after the second child was born when she slipped down some steps, cracked her coccyx and was impaled in the buttock by a garden fork. She needed antibiotic treatment for some weeks to deal with the infection.
 Apart from considering the ‘whole’ of the case we must look at possible precipitating factors before deciding on a strategy.
 Firstly, the complaint seems to have come on since the birth of the second child, but is there any evidence from the symptoms that there is a causal connection between the two? There does not seem to be any. Some might consider that the need for gas and air during the delivery process is relevant to her craving for air now, but whilst it seems possible, it is difficult to perceive a causal connection or to identify any rubric which would specifically address this point should it be true. There is also no evidence that her second birth was any different to the first and so, on balance it seems that we will bear the possible connection in mind for consideration when we look at our remedy differential but ignore it in the initial consideration process.
 What about the trauma as a child when she nearly suffocated in a pillowcase? Well, we won’t find a rubric for it of course, and the same point also applies as to the previous point, that we cannot be certain that the possible air trauma has any relationship to the case at this moment. Apart from which all we could really take would be an ‘ailments from….’ rubric, whereas the Vital Force is giving us good quality symptoms which are more easily repertorisable. So even if the ‘ailments from…’ state were definite and repertorisable it would still not be as useful as the good quality symptoms the state has produced which show the way the Vital Force is reacting NOW to the dis-ease. So again we will leave this point for further consideration in our remedy differential process later.
 What about the paracetomol analgesia? Could this have had a cumulative effect over the years when she was using it prophylactically? The answer is, of course, yes-but what effect, and again, can we be certain? Well, we don’t know what effect it had, if it did have one, but we can be certain that the Vital Force is still telling us the answer, whatever the cause. Now, I know some practitioners in circumstances like this who would be prescribing potentised paracetomol ‘to clear the layer.’ In my view this is unnecessary. It may change the presenting condition or symptoms but since we already have good quality prescribable symptoms then it is not necessary to force the Vital Force into a change when it is already giving us the necessary information. Should the indicated remedy not have the desired effect, then of course one would consider all possible hindrances to cure-of which paracetomol poisoning might be one. Until that time my view is that no action is necessary at this stage on the possible effects of paracetomol overuse.
 Now what about the twin traumas just after the birth of the second child-the fall and the course of antibiotic treatment? Well again it is difficult to be certain about the fall. Certainly the time factor is close and relevant but to quantify the fall as causative seems to me to be a speculation. In this circumstance we might consider giving added weight in our differential diagnosis to any remedy which has post trauma effects as part of its symptom picture, but not colouring our case at this stage with the assumption that the trauma was causative.
 The antibiotic treatment which resulted from the fall could also be relevant. I have many cases in my files where antibiotic treatment has prevented the resolution of a problem satisfactorily and where the patient has not managed a complete recovery until we have dealt with the damage and suppression which the antibiotics seem to have caused. Usually, however, those cases show a confusion of symptoms and a lack of clarity in the presentation. In this case, as previously mentioned, there are clear symptoms and so we will only consider using a remedy to deal with the antibiotics (Gaertner, perhaps) if the indicated remedy does not have the effect we expect.
 So let us move on to creating a methodology for solving the case. Using a Kentian hierarchy as it is often taught will lead to the taking of rubrics to represent all areas of the patient from mentals through to particulars. You might use a sycotic Kentian repertorisation where all reasonable symptoms are taken, which might give the following rubrics
 Mind, thinking of complaints
 Mind, fear, cancer
 Mind, fear of suffocation
 Mind, anxiety, trifles
 Gen. desire to breathe deeply
 Gen. alcohol agg.
 Gen. tobacco agg.
 Head pain from smoking tobacco
 Stomach, hiccups
 Stomach, nausea, eating amel.
 Stomach, nausea, drinking amel.
 Female, leucorrhea, thin
 This indicated the following likely remedies from repertorisation:
 Arsenicum album
 We might, however, take a set of rubrics on a more individualised basis to the case, still using a Kentian model. This would eliminate those rubrics which are based on less striking or individualised symptoms and gives us a much more manageable repertorisation from the following rubrics:
 Mind, Fear, cancer/death
 Mind, fear of suffocation
 Gen. alcohol agg.
 Gen. tobacco agg.
 Head pain from smoking tobacco
 Stomach, nausea, eating amel.
 Stomach, nausea, drinking amel.
 This gives the following main remedies for study:
 Arsenicum album
 Another possible route into the case is to simply use the generals and strange symptoms. They do not exist in all cases but where they do they can give you a lot of help and make the repertorisation process much quicker. In this case we might use:
 Stomach, nausea, eating amel.
 Stomach, nausea, drinking amel.
 Gen. alcohol agg.
 Gen. tobacco agg.
 This gives us the remedies to study:
 I also have my own method of analysis of cases which I could apply to this case as follows:
 What is most affecting this patient’s life?
 (Because that is the greatest sign of deviation from normality of the Vital Force.)
 Her fear of suffocation and the difficulty in breathing when she gets angry.
 What is the greatest change that has taken place in this patient?
 (Because that shows where the Vital Force has given in most.)
 In this case it would be in the respiration-she now has difficulty in breathing under certain conditions. We could take ‘respiration asthmatic’ though this is diagnostic and not individual to the patient, and anyway is better covered by the specific symptom in the section above so I would not take any additional rubric here. Too many rubrics always makes cases more likely only to show polychrests and to skew cases towards certain sections of the patient’s symptomatology.
 Are there any specifically individual or strange symptoms in this case?
 (Because those indicate the individuality of response of the Vital Force.)
 Well certainly we have:
 Nausea which is better for eating and drinking
 Are there any strong symptoms which are characteristic of the patient, although not necessarily changed reactions of the Vital Force? 
 I take these because they are indicative of the normal behaviour of the Vital Force. They are not expected to change as a result of the treatment but are capable of being considered as symptoms in an otherwise healthy person when shown as a change from normal behaviour. One might consider therefore that they were signs of an underlying weakness in the Vital Force rather than a recent sign of dis-ease. You might also include in this section symptoms which are strongly indicative of a miasmatic tendency.
 Are there any complete symptoms-ones with sensation, location, extension and modality?
 These of course are excellent indicators of total Vital Force reaction, but sadly are less common than homoeopaths would like. In this case the nearest to a complete symptom would be the effects from tobacco and it would be possible to do a mini-repertorisation of those effects and include it here, but in this case the other rubrics are so clear that it is not necessary to do this.
 Using my own technique gives the following remedies for study:
 So if we look at all remedies thrown up by each of the various methodologies they are:
 Arsenicum album
 Calcarea carbonica
 Of these remedies, Phosphorous and Lobelia occur in each repertorisation as meaningful possibilities and these would be our first study.
 Phosphorous is a fair match for Zara’s symptoms as can be seen from the study of Materia Medica, but Lobelia fits as follows in addition to the rubrics taken:
 profuse perspiration
 discharges from the anus and vagina concurrently lump or foreign body in the pit of the throat craving for air
 feeling as if would die from oppression of the chest
 worse cold, tobacco
 despondency and depression
 presentiment of death
 This is an extremely good match from a fairly small remedy and is ample justification for my choice of Lobelia as the remedy for Zara.
 It seems likely from the differential study of Phos., Bryonia and Ars. alb. that all three would be close enough analogues to the patient to give some benefit, and Ars. alb. would probably be my reserve choice (Kent always suggested it is wise to have a second arrow ready in your hand in case the first should miss the target.) It is also certain that in many cases Lobelia is indicated in cases where Ars. alb. should work but fails, and I assert to you that the reverse is also true-that Ars. alb. may be useful to complete work half done by Lobelia inflata.
 Potentcy and Dose: 
 Now we come to the question of potency and dose. In order to decide on the potency, we need to individualise the patient in the same way as we do in case analysis. Let us consider the questions we must ask:
 How serious is the condition of the patient? How deeply has the disease process penetrated into the vital economy? 
 The deeper the penetration of the disease, the higher the potency will be required. In this case the patient’s health has been diminished not only in her physical body, but also in her mental and emotional interactions. Thus we may assume that the disease has penetrated quite deeply into her vital economy and a higher potency is required.
 How quickly is the Vital Force being compromised? What is the speed of deterioration in the case?
 The quicker the deterioration, the higher the potency required. In this case the condition became serious quite quickly after the initial onset-although we are not certain of the actual causation. It has not improved since then and there are no periods of great remission. Thus, we can see that the Vital Force retreated quickly and although it has no periods of success in fighting off the disease, it has managed to prevent serious further development since the initial failure of resistance. This implies that some strength still exists in the Vital Force, although not sufficient for improvement. This indicates that a medium potency is required.
 What is the direction of the progression of symptoms?
 Where the complaints of the patient are progressively becoming more serious and relating more to the mental and emotional sphere, higher potencies are needed. If complaints are remaining at the same level of penetration into the vital economy, then lower or medium potencies are required. In this case the patient’s symptoms have encroached deeply into the vital economy but are now at a relatively stable, albeit serious, level. This indicates that a medium potency is required.
 Are there any maintaining causes? 
 Where there is a maintaining cause for the complaints that a patient presents with, there may be a requirement for a different level of potency than that which would be indicated by the original complaint. In this case the maintaining cause could be seen to be the children who do seem to stimulate the problem in Zara so this must be taken into account in the potency choice. Because the children stimulate the disease response and the stimulus is non-removable, we do not want the Vital Force to be presented with an impossibly strong stimulus, expecting a reaction which might be compromised by the maintaining cause. The maintaining cause will reduce the Vital Force’s ability to respond to the remedy so we will choose a slightly lower potency than might otherwise be indicated by the condition to allow the remedy to connect with the more physical effects of the dis-ease.
 Is there any suppression in the case? 
 Where there are suppressive elements in the case such as drug therapy, social drug use or special diets or lifestyle, there may be a need to modify the potency to take into account the effects of the suppression on the Vital Force which might change its ability to react. There is no sign of any suppressive element in this case which would modify the potency requirement.
 The miasm which is relevant to the patient may give some indication as to the potency required.
 Those patients whose complaints clearly fall into the sphere of one of the miasms will need remedies based on the level of function indicated by the miasm, i.e. , Psoric patients will generally need higher potencies as they need a big push to get them moving. Sycotic patients will tend to need lower potencies as they are very easy to get a reaction from. Syphilitic patients will often need frequent changes of potency as different levels of the organism are affected during the curative process.
 In this case the indicated remedy, Lobelia, tends to be psoric. Psoric patients tend to need a bigger kick within their actual assessed potency to achieve the desired effect. As an example, if a 30c potency were to be indicated for a Phosphorous patient with a particular level of disturbance, then a 200c might be needed for a Calc. carb. patient with the same level of disturbance. In this psoric case we will need a medium potency for the disturbance, but will need to increase the potency a little to account for the psoric nature of the remedy.
 Remedy sensitivity: 
 This follows from the above in that remedies themselves have levels of reaction even within a miasm. Thus, Baryta carb. and Calc. carb. are both psoric remedies but Baryta carb. will need a higher potency generally to achieve the equivalent reaction than Calc. carb., as its level of functional activity is less. Thus when you have decided on a remedy for an individual patient you need to look at the nature of the remedy itself, which will give you some indication as to the level of potency required. In this case the indicated remedy, Lobelia, is at the high end of the psoric scale and so, within the confines of the psoric remedy scale we will need a medium potency to achieve the required effect.
 Patient sensitivity: 
 As a general rule, patients who react easily to stimuli and may be classed as ‘sensitive’ require a lower stimulus to achieve the right response from the Vital Force. If a patient has insufficient energy to respond to mild stimuli then it is reasonable to expect that a bigger kick to the system will be needed than if the patient were to have easy response. This case shows excessive response in only one area and therefore we shall be using a medium potency.
 If we look at all of the above it will be clear that the overall assessment is that we will need a medium potency, the single higher indication being counteracted by the single lower indication.
 At this point you will have realised that I have given no indication as to which potency scale should be used, whether to use the centesimal or the fifty-millesimal. That is because I do not usually make such a choice until this point in the analysis. The most important decision for me is the degree of potency. In this case I have decided that a medium potency is required and I now make my choice between a medium ‘C’ potency, or a medium ‘LM.’ You will infer, rightly, from this that I do not necessarily start my ‘LM’ prescriptions with LM1. If I decide to use a medium potency of an LM then I am likely to start with LM3 or 4 depending on the remedy. If I were to be using Calc. carb. then I might be starting with LM5 if I were choosing a medium potency whereas if I were using Mercurius it might be LM4 and Phosphorus perhaps LM2-all relating to the basic sensitivity and activity levels of the Vital Force within these remedies.
 The sensitivity of the patient and the level of activity of a remedy also influence my choice of remedy scale. In cases where both the patient and the remedy I have chosen have strong levels of reactivity, the more sensitive LM scale is most appropriate. Where the patient has a relatively lesser sensitivity, as in this case, I am likely to prescribe a centesimal potency, as the patients often lack the ability to respond at the degree of sensitivity needed for LM potencies. In this case, with the patient responding with sensitivity in only one area I will stay with a medium centesimal potency. Since Lobelia is mainly psoric and thus not excessively sensitive in itself, I will choose a medium potency taking into account the psoric nature of the remedy. Thus, in Lobelia a low potency might be 18c, a medium would be 100c/200c and a high might start at 1m. In this case since a medium potency is indicated I will prescribe Lobelia 100c.
 Now to consider the dose. In homoeopathy we need to give the smallest dose capable of generating the appropriate curative response in the Vital Force. In cases where there is little in the way of suppression and maintaining causes, that usually means a single dose, and that will be so in this case.
 Parenthetically it has always been surprising to me to see that practitioners claim to get results with multiple doses and yet I know that single doses, when appropriate, work on their own. I have to believe in the honesty of both sets of practitioners, so how can this be true? Perhaps if we model the ‘sick’ patient as a sphere with a hole of a particular shape in their Vital Energies, then the prescription needs to fill that hole-the shape is the remedy and the volume the potency perhaps. If we give the appropriate remedy and potency then it fills the hole and the Vital Energies are complete. Certainly it may be some while before the newly regenerated Vital Force can complete the recovery, but the process is underway. What then if a second prescription is given? In that case there is simply no ‘hole’ in the Vital Energies for the prescription to fill, so it ‘bounces off ‘ causing no effect, beneficial or deleterious. Indeed repeated doses of the same prescription can only do the same as long as the Vital Energies remain whole. If, of course, the prescription is repeated frequently, then it will have the same effect as a hammer on the sphere-it will create its own hole! Thus we get a proving effect and the patient begins to recreate the symptoms s/he was being treated for. If this model were to be an accurate representation as to why single prescriptions and multiple prescriptions can both have effects it would explain why both types of prescribers get results-although it probably also means that multiple dose prescribers actually only need one if the prescription is right!
 Anthony Bickley has been practicing homoeopathy since 1980, has founded several schools of homoeopathy in England, and has served both as Director and Chairman of The Society of Homoeopaths. He has a special interest in helping to develop graduate homoeopaths who understand the simplicity of homoeopathy and who can relate those principles to each case in their daily practice. 

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