Learn Finnish: Kaksi potilasta kieltäytyi lääkkeestä, saati sitten neulasta. - Two patients refused the medicine, let alone the needle.

When using saati sitten (let alone), the noun that follows it must match the grammatical case of the noun it is being compared to. Because the patients refused the medicine (lääkkeestä), and the verb kieltäytyä (to refuse) requires the elative case, the needle (neulasta) must also be in the elative.

Why does kieltäytyä (to refuse) require the elative case (lääkkeestä) instead of the partitive or illative?

In Finnish, verbs expressing separation, avoiding, or moving away from something often require the elative (-sta/-stä) or ablative (-lta/-ltä) case. When you refuse something, you are figuratively backing away or detaching yourself from it, which triggers the elative.

Could I use puhumattakaan in this sentence instead?

Yes! You could say ..., puhumattakaan neulasta (not to mention the needle). Just like saati sitten, it usually shares the same case ending as the thing you are comparing it to. Both phrases are used in negative or limiting contexts to add an even stronger point.

I'm confused by the spelling of lääkkeestä. Doesn't the basic word lääke only have one 'k'?