Mr. Archambeault's aggravation:

“For instance, Dr. Somerville, consider the eyeglasses you are wearing. You got them on prescription, I assume.”

Leigh Somerville obligingly took off her reading glasses and handed them to her patient. “Yes, from an optometrist.”

Nicholas Archambeault turned the spectacles around in his hands a few times. “The length and curve of the arms, the setting and span of the nose-piece, the style of the glasses and, of course, the prescription for the lenses — all tailored to your own personal needs.”

Leigh always scheduled Mr. Archambeault as her last appointment of the day. His spastic, scanning speech with its unrealistically cheerful tone, his intention tremor, the cane at his side, his MRI results — all legitimized him as a classic case of multiple sclerosis, a patient worthy of a family practitioner's unhurried care. And he was bright and witty. As he adjusted himself in his chair, every successful placing of his left hand was preceded by a series of oscillations that usually grew wider and more vigorous as he approached the target. Intention tremor, the opposite of Parkinson's tremor, which abates with motion, as a hard-headed neurologist had once demonstrated on ward rounds in consecutive patients.

“I live with MS, but I certainly did not o-pen the door for it,” he said, noting her appraising eyes on him. Leigh knew what he meant. Multiple sclerosis would be a tragic burden for anyone, but for someone who fervently believed in healthful living, natural foods, and alternative medicine it must be beyond comprehension. Nicholas Archambeault fought his uninvited guest with his head and his heart. He always prepared himself for his monthly checkups with new information, new questions. Today his theme was “tailoring,” the careful adjustment of treatments to the individual patient's needs, complaints and tolerance.

“Would you say, Dr. Som-er-ville, that I am a typical La-chesis pa-tient?”

“Well, no, according to the classical descriptions you don't have all the characteristics of the proving — your skin isn't mottled, and you don't bleed easily, do you?”

“No, I don't think so, but my symptoms did start on the left side, and the headaches, the awkward tongue …”

“Yes, those were some of the reasons I started you on Lachesis. The venom of the bushmaster.”

“I know. A nasty character. I always carry a forked stick.” Archambeault choked as he laughed and gave a shallow cough as he tried to clear his throat.

“Sit up on the table, will you? Let's see how you are doing.”

It was the first time Leigh could remember that Mr. Archambeault needed help to get up on the examining table. She took hold of his wrists and spread his arms out to either side. “Now touch your right index finger to your nose.” She released his right hand; his finger pursued a jerky course to his nose, landing a little hard on the right nostril. “The left?” The oscillations were so severe that he completely lost confidence in the motion, twisting his hand so the back of it touched his face. Strangely, the tremor he felt when he attempted to run his heel down the shin of the opposite leg was equally bad on both sides. Two legs and one arm cock-eyed. They might improve, but …

“It's an agg-ravation, isn't it? Didn't you say the medicine might make the symptoms worse before it started working?”

Leigh took a deep breath. “It may be another exacerbation, where the MS gets worse for a while. You've had them before.”

“It's still an agg-ra-vation, no matter what you call it.”

“Let me see into your eyes, okay?” She riffled through the setttings on her ophthalmoscope. This instrument would give her the only glimpse she would ever have of a living person's nervous system, and her only direct view of arteries and vein walls. Even though you were breathing almost nostril to nostril with the patient, the inquisitive little light and the clever lens painlessly unpeeled the patient's skin, producing an almost embarrassing intimacy, even more than in a pelvic exam, where the patient generally could be made to understand you were just checking “equipment.” Right eye to right eye, left eye to left eye, a minimalist tango: grip the cool metal of the scope, click on the light, spin the knurled disk to find the best lens, and seek into the dark spot that conceals the soul. Look for revelation, shiny red, streaked with deeper red arteries, the retina rolling beneath your gaze.

“Look right at my ear.”

The optic disk swam into view, escaping, captured, lost. His disk looks really pale. Maybe smaller than last time. Optic atrophy? How can I tell? Maybe he needs a referral to neuro-ophthalmology. No, what's the use? Their micro details won't help him, or me. Maybe just visual fields.

“How's your vision, Mr. Archambeault?”

“Sometimes it in-terferes with my reading. A black spot comes and goes. Can't you give me some more of those homeopathic pills?”

“To add to the Lachesis?”

“Yes, something. It got better for a while, but now it's worse.” The patient's forced cheerfulness vanished. A short, crying waver mingled into the staccato of his voice. Leigh put away the ophthalmoscope. His soul was crying for help she could not offer. She would see tears if she looked into his eyes again.

“Classical homeopathy requires that only one remedy be given at a time. But we could try another one.”

“Yes, please do.”

Leigh's mind went blank for a minute. She could not remember the name of the remedy she had at the edge of her mind. I really should take another course before I get this deep into it. It was Sharon Bridges, wasn't it? Gentle, sympathetic, sentimental. A vegetarian. She said the Pulsatilla strengthened her. Her colour improved. Is this patient soft and dependent, like Sharon? Well, anyone with MS would tend to become dependent over time.

“Pulsatilla, let's try that. It's a versatile remedy. But you'll have to stop the Lachesis.”

“It's harmless, right?”

“Certainly. Today is July second. What about August for your next appointment?”

Mr. Archambeault grimaced. “My grandson is coming to visit. He only tolerates me because I take him fishing.”

“The fish in Lake McPhee never bite before noon. What about 9:30?”

Mr. Archambeault choked out a staccato laugh. “Okay, but you won't get any of the day's catch from me.”

Leigh rose instinctively to help her patient, then held back. Mr. Archambeault made his way carefully to the open door.

He turned in the doorway, as he always did, and said what he always said, but in many different ways. “You are giving me this homeopathy because you can't help me, aren't you?”

Peter Morgan Lanark, Ont.

Dr. Morgan is a former scientific editor of CMAJ.