Dr. Sneha Vyas, M.D. (Hom), Resident Doctor, the other song
Dr. Devang Shah, M.D. (Hom), In-house Consultant, the other song.
Dr. Ruchita Shah, B.H.M.S.
Dr. William Osler once shocked his students by disclosing that medicine is not an exact science. The apparatus of a doctor, he added, consists of an array of instruments some of which are very subjective. Observation and study are much more important in therapy than the canons coded in the textbooks.
Homoeopaths often face difficulties in solving complex pathological cases and managing acutes. Even experienced homoeopaths seek guidance in such cases as regards the techniques of approaching the case, the remedy to be prescribed and the posology. Every homoeopath aspires for successful, reproducible results in these cases. To help homoeopaths seek a solution to problems faced in difficult cases, ‘the other song – International academy of Advanced Homoeopathy’ had organized a two-day seminar with Dr. Ashok Borkar and Dr. Gajanan Dhanipkar, as the expert speakers, to share their cases with the homoeopathic fraternity on the 29th and 30th March, 2014, on its premises.
Dr. Borkar is a very experienced homoeopath practicing in Goa for the past 24 years. He is also the author of ‘The Pathological Factor in Homoeopathy’ wherein he has presented a roaster of successfully cured pathological cases using various approaches, incorporating them with the Sensation Approach. Given below are snippets from a few cases presented by Dr. Borkar.
One of the cases was that of an elderly man admitted in the ICU (Intensive Care Unit). He was a known case of Ischemic Heart Disease (IHD) and Diabetes mellitus (DM). He complained of oliguria, pyelonephritis with post-septicemic acute renal failure, uremic encephalopathy and an infected ulcer on the foot. When he approached Dr. Borkar, his toes had already been already amputed. Dialysis was inadvisable owing to his poor vitality. The physicians had given up on his case. As the patient was disoriented, Dr. Borkar resorted to the patient’s relatives for the account of case details.
At that moment the patient had difficulty in breathing over 3 days and hiccups for over 3 months. There was a lot of burning sensation in the retrosternal region which was worse on eating and the burning felt as if fire. Even drinking water caused a burning sensation. He felt cold all the time and hence desired covering except for the head which was warm. He had not passed stools for the past 8 days. His sleep was restless and he felt a constant sense of uneasiness especially in his chest.
The physical examination findings were: Flapping tremors ++ , feet and toes – cold to touch, tongue flabby, pulse – irregular, intermittent, weak and slow, dry lips. Investigation findings were: shrunk kidneys, hydronephrosis, perinephritic fluid around the lower pole of left kidney, right renal calculus, left pyelonephritis, debris in urinary bladder and prostatomegaly. Diagnosis: Prerenal parenchymatic obstructive renal failure.
Dr. Borkar explained that the central issue of the case was the failure of vital organs like brain, kidney, liver and heart. Hence, the remedy selected should have an affinity for these organs. The rubric ‘contraction, kidney’ and uremia was selected which has Digitalis, Plumbum met and Nitric acid. The entire focus was based on the pathology as this was the most prominent feature of the case. Once the pathology of the case was taken into consideration, then the local symptoms were considered to finalize the remedy. The weak and intermittent nature of pulse, dryness of lips, constipation, and flabby tongue seemed to match the picture of Digitalis. He was prescribed Digitalis 6C in water, 4 drops to be taken every 2 hourly.
Dr. Borkar validated his approach by invoking two excerpts each from Dr. Burnett and Dr. Hahnemann. Dr Burnett quoted, ‘It is not enough to cover the totality of the symptoms; for when this has been done we are only half way. We have then asked these questions: what is the real nature, the natural history, the pathology of the malady under consideration? Is the drug chosen capable like the one before us? In fact: is it really homeopathic to the morbid process. Thus the pathological (morbid) process going on in the body has to be covered by the remedy.’
Also, Hahnemann in aphorism 6 points out the significance of pathology where he says ‘The unprejudiced observer….Takes note of nothing in every individual disease, except the changes in the health of the body and of the mind (morbid phenomena , accidents, symptoms).’ All of the above, emphasize the point that every patient and drug will have a nature of pathology which is unique and that should not be neglected.
Two days after dispensing the medicine the patient was well oriented, the wound (infected ulcer) was better. A reduction in flapping tremors indicated that uremic encephalopathy was better. His blood pressure was stable and his urine output was 70ml/ hour. The creatinine reduced from 8.7 to 7.8.
Dr. Borkar stressed the aspect of physical examination and emphasized on the need to check the pulse in cases of cardiac and renal pathologies which can come in handy while forming a totality demonstrating this by giving some key notes about pulse of different remedies:
- Carbo veg – small, weak, imperceptible, uneven, intermitting pulse.
- Veratrum viride – slow, soft, weak, irregular and intermittent.
Phatak – full large soft or slow with strong or violent heart beats. Suddenly increases and gradually decreases below normal.
- Crataegus – rapid, irregular, small, feeble, intermittent or strong and forcible in angina pectoris.
Boericke – extreme dyspnoea on least exertion without much increase of pulse.
- Digitalis – small, weak, irregular and intermittent pulse and excessively slow especially when at rest but accelerated by the slightest movement.
Another case that Dr. Borkar presented was of a 32-year-old lady suffering from polyarthritis who came to see Dr. Borkar on 19th April, 2013, with pain and stiffness in knees over 1 month. She was prone to frequent colds and had already taken 5 courses of antibiotics before Dr. Borkar saw her. She presents with dullness, throat pain, coryza, severe knee pain and cracking, cracking in neck, wrist pains. She became stiff with the pains. When asked to describe stiffness, she said it was hard, tight, not free, as if pulled from inside. The patient had a lot of fear of injections, she became very stiff and hard, tight. She had to move, wanted to be free. She had this experience when her grandmother passed away. In all the situations, her experience was the same. She had fear of exams, where again she would become stiff and tight, could not be free, wanted to move. The remedy that comes to our mind is Rhus tox.
Dr. Borkar asked her to get ASO titre, as she had already taken 5 courses of antibiotics for throat infection and cold. So mostly, this was post streptococcal arthritis. ASO titre was high – 226 IU. Now we see that there are two states coming up. One with a clear cause in past, from streptococcus infection and one of Rhus tox, where she becomes stiff and tight, in all her experiences and also experiences the same with the pain. So she was given Streptococcin 200, 1 dose, followed by a dose of Rhus tox 30 after 4 days. He explained that this was the method he followed recently, when there were 2 apparent states appearing in a patient, he would give the medicine, indicating the immediate cause first.
After 5 days, right knee pain was almost the same, the stiffness of head was better, cold and sneezing in morning was better. There was no swelling of fingers now. So, 4 doses of Rhus tox 30 were repeated. She was fine for the next 3 months and was very happy, as she could move freely. After 3 months, the patient again came with cold, nose block, thick yellow discharge, itching in throat and headache. She felt very tired and dizzy and but knee pain was better. On repeating a dose of Rhus tox, there was no change. So she was given Streptococcus 200, 1 dose, as what she presented the second time was Streptoccocus infection actually that she was prone to.
This is a case where 2 states existed side-by-side along each other. After this she is absolutely fine till now. We are using the substance causing the disease to cure that disease, that is how nosodes are used. If we can find the substance that causes the disease to cure it, there is excellent cure. This is the principle on which nosodes are prescribed. Dr Borkar has given some rules to prescribe a nosode: when the patient is never well since the past disease, when the patient does not respond to a well selected remedy and there is a dominant nosode state present, when an individual remedy has been given and you have history of a specific disease and when there is a toxic effect of a substance.
Thus causation is a very important part of any totality. The three aspects that Dr. Borkar considers important for his prescription in pathological cases is CPS, namely the cause, the pathology and the symptoms. For most of the cases, he forms the totality along the CPS timeline, so that he has a clear idea of what exactly is to be treated in a patient. If any case, there are different causes and they aggravate the same state, then there is only one state to be treated and only one remedy is required. However, if a certain cause creates a new state then a different remedy is required to cure the pathology and the symptoms produced by that cause.
To understand the pathology, Dr. Borkar advised to go through all the investigations thoroughly and get more investigations done if required. We have to be sure of the diagnosis and should not hesitate to take a specialist opinion if required. Every homoeopath should thoroughly understand what is happening in the patient’s system, the pathological processes going in the body, which can be well understood by symptoms and signs through examination.
He said that there are 3 types of prescriptions, namely, cases where only the individuality is to be taken into account, cases where a ‘specific remedy covering the pathology’ is also required without taking individuality into account and cases where we first ‘consider specific remedies for the pathology and then give the one which covers the patient’s individuality’.
Dr. Gajanan Dhanipkar took the podium on the second day. A homoeopath with 15 years of experience under his belt, Dr. Gajanan Dhanipkar has a number of achievements to his credit. He has presented research papers on innovative methods in applied Homoeopathy. He has been a guest lecturer in numerous colleges. He is driven by the passion to expand the homoeopathic therapy into newer and broader perspectives.
Homoeopaths often treat the symptoms without knowing the pathology, so the prognosis is not known. They often hit the target in the dark if luck favours, or else we fail to treat the patient. Knowledge of clinical medicine is important in the management of acute conditions, where the course of the disease, its symptomatology, its pathology and the prognosis form an important base for the prescription. In acute conditions, the physiological and the pathological symptoms have to be stressed upon.
Acute conditions allow a very short time to absorb the symptoms and determine the prescription. One has to be proactive in perceiving rapidly unfolding physiological changes, which can be a key to the prescription. The pathological changes if occurring are very late to follow. Various homoeopathic pioneers like Burnett, Boericke, Phatak have described in detail the physiological changes caused by the remedy in its drug picture.
Going on further, Dr. Gajanan said that it is vital to focus on the cause for these physiological changes. A homoeopath should learn everything he can about the existing state of the patient through the patient, his relatives’ and friends’ observation and the homoeopath’s own subjective observation. The onset of the disease is very important. The exact onset and the progression of the complaints, often is a crucial key to correctly understanding the disease totality. He gave a case example to demonstrate this.
A child came down to Dr. Gajanan’s practice with recurrent episodes of fever every month, for which he was given his constitutional remedy, yet the fever recurred. What was of primary importance in this case was the pattern of recurrent fever. When enquired carefully, it was found that the child developed cough each time before the fever set in. His chest would be clear with the cough. This precise data, greatly helped prescribed a medicine for him. Sambucus was the only remedy covering dry cough before fever. After a single dose of medicine, there was no recurrence of fever again.
(Roger van Zandvoort, Complete Repertory, MacRepertory 8.2.01, Professional, Kent Homoeopathic Associates)
Sharing his experiences, Dr. Gajanan further elaborated that when approaching an acute state, one must be alert, as there may be a symptom which the patient states just once, but may be very important to form a totality. All symptoms must be paid heed to and evaluated accordingly.
He then presented a case of a 4 month old child. She had coryza since 15 days and was better with medicine for a few days, but came to Dr. Gajanan one day with fever over two days. As soon as she was fed she coughed and vomited. With fever she is irritated and started crying. She was better only when she was hugged tightly and she cried as soon as she was put down. She generally liked watching television and was fond of wearing colorful clothes. Her head was warm and her palms and soles were always moist. She was comfortable when she was covered. With fever, there was loss of appetite.
In such cases, we have to be sure of the physical signs and the objective symptoms that the patient has. These symptoms carefully confirmed will be the anchor in such cases. Mother’s narration should be taken with a pinch of salt, as the mother too portrays her anxious state, so everything that she states should be confirmed before considering it into totality.
In this case, the mother says that the child feels chilly during fever and she starts to shiver when she is wiped or when her clothes are changed. On asking, she said that she did not shiver otherwise when afebrile. This confirmed that she was chilly with fever. The mother also remarked that she would always wet the pillow she was sleeping on with sweat. Her careful observation also revealed that she stared at lights around her.
On examining the child, it was found that her head was warm and her feet cold. Thus examination of the patient from top to bottom is very important. After examining all aspects of her behaviour, her generals, observation, the totality formed consisted of the following symptoms: coldness of feet, warmth of head, moist palms and soles, magnetism, desire to be carried. She was given Silicea 1M, repeatedly.
(Roger van Zandvoort, Complete Repertory, MacRepertory 8.2.01, Professional, Kent Homoeopathic Associates)
When followed up 2 days later, her coryza and cough were better, she had no fever and her irritability was less. The first change observed on administering the medicine was that the heat of the head had reduced. She followed up with Dr. Gajanan and had no recurrence of the complaints for a long time later. The right remedy administered after a careful case-taking, not only takes care of that acute condition, but breaks the tendency for the complaint, preventing recurrence.
Another case presented was of a middle aged man, who complained of fever with chills after having cold drinks and cold fruits. He said that he had a lot of burning sensation and congestion in the chest. His ears and nose were blocked and he had severe headache. His appetite was completely lost and he also complained of intense throat pain. The intense ear ache was aggravated by the least draft of air. The patient had covered his face and appeared dull and weak, hardly able to speak.
What the patient does with the problem is unique to him and is often the entry point in the case; it can be an observation or an examination finding. That one small thing which the person does as his adaptive mechanism to the situation is very peculiar. If we have the physical generals to confirm the remedy and if you can find a peculiar rubric for that symptom, you solidify your finding. If we cannot do so, we have to go ahead and find something more important.
On taking the case ahead, Dr. Gajanan found that the patient had moderate perspiration and reduced thirst. He had throat pain for a day which was aggravated by coughing and eating. There was profuse coryza and accompanying lachrymation. The patient felt like sleeping but could not sleep due to blocked nose. He said he did not feel cold but had a habit of wearing a cap throughout. He repeatedly mentioned that he had burning sensation in face. Dulcamara is a drug which has burning of face during fever and it also covered the other totality.
In the follow up we see that the fever went away completely, no burning of face but he came with congestive headache. He also said that his appetite had improved, but he felt full in one morsel only. He got eructations and bloating after eating bread. He needed fanning but could also do without it. He had severe headache and reduced thirst and unsatisfactory stools. Repeating the remedy did not work. The thing missed was his gastrointestinal symptom. He did not have indigestion the first time which he said in the follow up. China was given based on catarrhal stage, appetite eating with inability to, eructations after eating bread and cold feeling.
(Roger van Zandvoort, Complete Repertory, MacRepertory 8.2.01, Professional, Kent Homoeopathic Associates)
From this case, Dr. Gajanan summarized that it is important to look at physiological signs as they convey more than the symptoms do. When an indicated remedy works very well but a part of the symptoms still remains, the totality should be considered again in relation to the earlier totality and the remedy indicated then will help bring about a complete cure.
What helps during acute cases is also eliciting the exact symptom which is confirmed and finding a specific rubric for it through repertories which are known for that type of rubrics, e.g. clinical and diagnostic rubrics from Phatak’s repertory, fever rubrics from Boger- Boenninghausen’s repertory, general rubrics in the Complete repertory, mind rubrics from Kent’s Repertory.
To shed more light on his approach during acute conditions, he gave example of a young girl suffering from fever for a week who had been given Gelsemium by her mother who is a homoeopath. The medicine did not help her much, so Pulsatilla which was her constitutional medicine was given, but without much success. The mother then approached Dr. Dhanipkar. She described that the temperature increased quickly. The patient was restless even when lying down during fever. During fever, her body was warm, but her soles were cold. She was extremely sleepy at the beginning of heat stage and was very restless. Her sleepiness and chills would diminish with the given medicine.
She had continuous headache during fever with a sensation of heaviness in head and giddiness. She complained of pain in the right hypochondrium for a few months which was aggravated when she was stressed. She was thirstless. On enquiring about the onset of fever, the patient said that it started with headache and she could not read or write, just wanted to lie down. This had started after she had cold drinks. She then started with fever with chills which lasted for 6 hours. During chills, she kept moving her legs; she lay down on bed and rubbed her feet against the bed. She wanted to be covered by a blanket, however she also wanted fan during fever.
Dr. Gajanan said that one should always look at every system, the external signs, in case of fever to judge the pathology and find the peculiarity thereby. Here, it is seen that there are only inflammatory changes at the level of physiology. On auscultation of respiratory system, it was found that there was decreased air entry in the right lung base. Based on the careful examination as described above, the totality was formed consisting of symptoms: ailments from taking cold, heat with chill, headache concomitant to fever, thirstlessness, fever, chill covering and warmth ameliorates, restlessness of lower limbs.
She was given Belladona 1M as the totality matched the drug picture quite well and the process was mainly inflammatory. Her fever subsided after the medicine, but recurred in a few days time. The fever was accompanied by difficulty in breathing. On investigating, X-ray chest showed right sided pleural effusion. Here, the pathology, which was earlier indicative of only inflammatory process through external signs, now is evident as effusion. Hence, the remedy selected should cover the pathology of inflammation leading to serous effusion.
If we are to consider the above totality keeping in mind the pathology now, we get:
The remedy selected was Lycopodium. On reading Lycopodium from Phatak, we see that
– Respiratory organs – Lycopodium (Phatak’s Materia Medica, ReferenceWorks Pro 184.108.40.206 Michael Hourigan and David Kent Warkentin)
Craves air but is chilled by it. Unresolved pneumonia. Difficult respiration due to hydrothorax and / or hydropericardium, with flapping of alae nasi. Feeling of tightness in chest with burning.
So we see a tendency to inflammation going into abscess and fluid accumulation. The patient was given Lycopodium 1M, followed by Lycopodium 10M, in infrequent doses, after careful follow ups and monitoring. After 2 days she settled down. She had no fever. Appetite and thirst gradually improved. She had occasional pain in chest only during inspiration. Her weakness gradually improved to completely disappear in a few days. The improvement in the symptoms – on observations and signs on examination with the improvement in general state indicated that the underlying pathology was treated. She was completely fine, with no symptoms after a fortnight of starting with Lycopodium. The patient was carefully observed for a month thereafter. She had no recurrence of any of the symptoms.
From this case, we learn that in cases where the physiological and pathological symptoms both exist, the physiological symptoms must be considered in the light of pathological changes. The physiological changes indicate the individuality of the patient. However, it is only when they are seen in totality with the pathology, that a complete cure is possible. The pathology has to be resolved for a complete cure to take place and the physiological symptoms help to individualize the patient with a particular pathology. In such cases, when we are sure of the remedy, it should be administered in a higher potency for an effective treatment.
While treating fevers, it is very important to make a few observations. The changes in the general state of the patient, his activity levels: whether the patient is dull, active, indifferent, playful; his state – physically and mentally, heat, coldness or redness of the body parts; the patient’s behaviour; the quantity and the nature of secretions are points to be carefully considered when taking a fever case. Taking a note of the peculiarities observed and combining them with the physical general state of the patient, gives us a group of remedies. Then one should carefully consider every remedy from amongst those to see which matches the pathology/ physiological action with that seen in the patient.
The causative factor plays a very important role in the totality of fever, especially if it is fever since a short duration. The causation is the most important factor and is placed highest in evaluation of symptoms for any acute condition. Hence in every case of fever for a few days, the patient or his relatives should be asked for the cause or a probable exciting factor like ailments from getting wet, change of weather, taking cold food, after emotions, vaccination etc.
In case of a long standing and chronic fever, it is very important to elicit a careful history including the causation and the pattern including an onset, duration, progress and recurrence. Most acute cases, have physiological changes at first. The signs and symptoms are an indication of the physiological and pathological changes occurring in the body. We have to look beyond the symptoms to understand the underlying process to match our remedy accordingly. Hence, one should carefully ask about symptoms which indicate an underlying process, e.g. dryness of mucous membranes, increased secretions, articular inflammation, myalgia, tenderness or other signs of involved organs etc.
Dr. Gajanan then quoted a reference, from Dr. Burt’s works which read, ‘A special study of the physiological action of each drug has to be made; for drug pathology is quite as necessary to the scientific physician as disease pathology, and a physician who cannot diagnose the pathology of a drug need not expect to be successful in the treatment of disease….We are fully persuaded that to endure the crucial test of science the materia medica of the future must stand upon physiological basis.’
Above all, to individualize any case of fever, it is essential to study the peculiarity of each stage of fever – prodrome, chill, heat, sweat and also to study the associated symptoms with each stage. Dr.H.C.Allen writes “the symptoms occurring before and during the chill, heat and apyrexia; the time of occurrence of the paroxysm; the parts of the body in which the chill first makes its appearance; the regularity of its stages; the degree or absence of thirst, and time of its appearance; as well as the constitutional ailments aroused by the fever are all to be carefully noted.”
One lady suffering from rheumatoid arthritis came to Dr. Dhanipkar with inflammation of almost all finger joints and had disfigured fingers. On asking about the onset, she said she first had fever with chills and then the joint pains began. The chills always started with lips, which started shivering and then there was shivering throughout her body. This was the most peculiar feature of her case. When we look up the symptom, we get only one remedy, Bryonia.
Bryonia also covered the totality of joint pains. When we are investigating any stage of fever, it is essential to go into the microscopic details, which will surely hint the remedy. However, the hint has to be concrete, it cannot be an assumption, and has to be very clear, expressed subjectively and confirmed objectively.
Concomitants during fever also form an important part of the totality. For this purpose, Boenninghausen’s repertory comes in very handy. Finely confirmed modalities also are an important guide in any totality. Clinical examination should be given a lot of importance, as it helps us understand the underlying process through signs observed. After administering any remedy in a fever or any acute case, the follow-up should be studied thoroughly for the next 24-48 hours.