Gyandas G. Wadhwani MD(Hom)

Chief Medical Officer (Homoeopathy), Directorate of AYUSH,

Government of National Capital Territory of Delhi. India.

Email: homoeopathygyan@gmail.com

MANAGING HEALTH OUTCOMES OF PATIENTS-CHANGE OF THERAPEUTIC APPROACH WHEN DISEASE

PICTURES CHANGE

PRESENTED AT THE BIANNUAL CONGRESS OF HOMOEOPATHIC ASSOCIATION OF SOUTH

AFRICA AT DURBAN ON 26-9-14

Sun Tzu

The Art of War

GREAT RESULTS CAN THUS BE ACHIEVED WITH SMALL FORCES.

Three Precautionary Rules of Hahnemann

•The improper selection of a drug

•To suppose that the doses which he hadrecommended for every anti-psoric (read anti-miasmatic) remedy, and which experience had taughthim to be the proper doses, are too small

•The too great haste in administering a new dose

•Every good mechanic knows the importance of timing in your car’s engine. If the cylinders do not synchronize there is severe loss of power.

• In diplomacy too, timing is of the most vital importance.

•To musicians, as well as to athletes, rhythm, which is really timing, is paramount.

•To understand the importance of timing, you have to imbibe the entire sequence.

•Curing in medicine is like the peeling of an onion; you must start at the topmost layer, and then move slowly deeper and deeper.

•The homoeopathic cure too is like that but even more appropriately it is like the result of a ‘relay race’;

•If we do not time the remedies/ potencies well, then we stand no chance of winning.

The most perilousmoment underhomoeopathic treatmentis the moment of secondprescription.

•If the doctor is over zealous or panicky, he shall prescribe before the indicated medicine has finished its action in entirety, and shall loose the chance of providing a cure.

•On the other hand, if over cautious or unfocused, the prescriber may lose valuable time or estrange the patient.

•Many physicians fail because of not waiting, and yet the waiting must be governed by knowledge.

•To know that this waiting is quite different from waiting without a fixed purpose.

•When the first prescription has been made and the remedy has been similar enough to change the existing image, we have but to wait for results.

•The manner of change taking place in the totality of symptoms signifies everything, yet the manner of the return of the image, provided it has disappeared, signifies more.

Where to find the knowledge

•Hering’s direction of cure

•Kent’s 12 observations

•An understanding of aggravation and amelioration

•A thorough grasp of teachings of Organon & Homoeopathic philosophy

Ideal Time To Wake Up And Focus

•When no change of any kind follows the first prescription

•Symptoms improved, but the patient did not

Ideal Time To Wake Up And Focus

•The mental state shows an embarrassed, helpless state instead of the tranquility of improvement.

•When new and important symptoms and old modalities, especially aggravations that persist, characterize the case

•When a completely new set of symptoms appear, having no relation to past history

Ideal Time to change the remedy

•When the demonstration is clear that the prior remedy has done all it is capable of doing and the patient isn’t cured

•The patient is feeling better but some symptoms remain/ appear, that are not covered by the prior prescribed remedy

•When the new symptomatology appears, reflecting past/ family history, which is not covered by prior remedy prescribed

The last appearing symptom shalldecidedly govern the selection of thenext remedy.

My Clinical Experience

A 34 years old male, having Stage IISarcoidosis, consulted on 25th Aug 2008.On observation, he was of average height, hadpot belly (due to sedentary lifestyle), recedinghairline, dark brown eyes & hair, scantyeyebrows, sharp nose and tapering fingers.He had been advised to take steroids, whichhe wanted to avoid.

CT Chest dated 148-08

He complained of shortness of breath, poorappetite, low energy levels and constipation.

He was also having intense heaviness/ fullnessaround ankles, b/l pedal edema (+) and feltmost comfortable with his feet elevated.

He also had a tendency for recurrent tonsillitiswith delayed recovery since childhood < coldexposure.

Past history:- Measles in childhood- Ascariasis about 2 years back- Tinea cruris few years back, treated with Itch guard/ quadriderm

Family history:Mother: D.M., HTFather: CABGPaternal uncle(s): T.B. COPD Alcoholism

Personal history:Diet: Non vegAddictions: Alcohol 360 ml + daily

Generals

Desire: Eggs ++ (+++ in childhood, now less intake though still loved them); Sweets ++Aversion: Milk ++

Life and circumstances

He was brought up in a middle class family and was average in studies. After graduation he started his own business, worked very hard and took it to great heights in a short span of time. Though his work requires him to travel constantly, he now leads a comfortable married life.

Mind & disposition

Since college time, he consumed alcohol regularly. He was highly ambitious by nature and at the same time easy going and friendly by nature. The only thing he was averse to was physical activity. One of his favourite past times was watching movies.

Analysis- craving for alcohol- social, friendly- sedentary, averse to physical labor- sensitivity to cold - recurrent tendency for tonsillitis- craving for eggs ++, sweets ++- aversion to milk++- heaviness/ fullness around ankles > elevation of feet

J. H. Clarke

•A keynote for Vip. in cases of phlebitis andvaricosis is "< on letting the limb affected hangdown"; as if it would burst with fulness.

•A case (quoted from Med. Adv. in Med. Cent., ii. 79)of varicose vein of the popliteal space, with thesensation as though the leg would burst, and anervous, fidgety condition of the feet which keptthem in constant motion, was cured with Vip.torva 30.

J. H. Clarke

•The bursting feeling appears to be at theroot of this characteristic.

•< Letting limb or part hang down.

•Patients resist the cold badly.

•Vip. has a chronic and periodic action; thesymptoms return annually for years.

J. H. Clarke

•Generalities: Persistent edema, faintness,prostration

•Appetite lost

•Suffocation & dyspnoea

•Etc.

RxVipera 6 t.i.d. for 3 days

Follow upAll his physical symptoms disappeared and he felt better.

He received placebo for the next few months.

CT Chest dated 5-3-09

In his subsequent review, he informed that in last few weeks he had noticed that his craving for Eggs had become as strong as in childhood!

DURING EITHER SICKNESS OR CONVALESCENCE, GREAT LONGING FOR EGGS;

Henry Clay AllenKeynotes And Characteristics With

Comparisonsof some of the Leading Remedies

of the Materia Medica

Chronic Diseases- 579 Much appetite for wine, which she did not else care for.- 582 Milk does not agree with him, causes qualmishness and nausea.- 583 – Milk tastes sour, and is repugnant to him.- Throat 511-515, 528- Sens to cold Hahnemann’s prominent symptoms & 1446-1449

RxCalacarea carb 0/1 OD

Follow up

While he was on Calcarea carb in LM potencies, he developed numerous acneiformeruptions on forehead and dorsal region as well as tinea cruris, which also disappeared during the course of treatment.

There was also a slight reduction in his intake of alcohol, as reported by his family.

CT Chest dated 4-2-10

The changed therapeutic approachComplementary remedy

• A remedy that completes, most successfully, the action of a prior prescribed drug

• Numerous authorities have compiled them viz. Boenninghausen, Hering, Adolph Lippe, T F Allen, H C Allen, A Teste, Guernsey, Kent, R Gibson Miller and J H Clarke.

The changed therapeutic approach

Complementary remedy

•Identified by their occurrence together:

•Arsenic album – Phosphorus

•Pulsatilla – Silica

•Natrum mur – Sepia off

•Etc.

The changed therapeutic approachComplementary remedy

• Identified by their similar symptomatology:• Antim tart – Ipecac

• Chamomilla – Magnesia carb

• China – Ferrum

• Natrum sulph – Thuja occ

• Bryonia – Rhus tox

• Rhus tox – Calcarea carb

• Sulphur – Psorinum

• Colocynth - Staphysagria

• Etc.

My Clinical Experience

A 38 years old male, consulted on 4-7-14 withacute ureteric colic for last 18 hours. Thesonography report revealed his havingbilateral renal calculi and a right ureteric

calculus.

On observation, he was short statured, potbellied and dark complexioned. He waspressing the right lower abdomen with thepoint of his elbow all through.

Analgesics and injections had failed to relievehim.

RxColocynth LM1, hourly; interval to be increasedas pain improved.

He reported on 7-7-14 that he was relieved ofpain within 3 hours of colocynth LM1.

He continued with colocynth in ascendingpotencies and reported passing on few calculi.

On 11-7-14 he reported of intense burning inurethral region, not relieved by micturitiontoo. The burning was a constantly presentsince last morning and didn’t improve after hepassed some gravel. The burning made himintensely restless.

Slight pain in iliac fossae was better bypressing with point of elbow.

RxStaphysagria LM1, hourly; interval to beincreased as pain improved.

The remedy provided instant relief and he didnot face any problem thereafter.

The X-ray KUB done on 22-7-14 confirmedpassing out of calculi.

The changed therapeutic approachComplementary remedy

• Identified by their chemical constituents:

• Colocynthis – Magnesia phos

• Iodum – Badiaga

• Iodum – Spongia tosta

• Pulsatilla – Kali sulph

• Allium cepa – Sulphur

• Etc.

The changed therapeutic approachComplementary remedy

• Identified by similar symptomatology but different kingdoms:

• Phytolacca & Mezerium are known as ‘vegetable Mercury’

• Kali mur is the chemical analogue of Pulsatilla

The changed therapeutic approachComplementary remedy

• Identified by their phase/ depth/ pace of action:

• Chronic complements of an acute remedy

• Belladonna – Calcarea carb

• Arsenicum album - Thuja

• Aconite – Sulphur

• Ignatia amara – Natrum mur (only in mind)

• Bryonia - Natrum mur, Alumina

• Nux vomica – Sepia off

• Hepar sulph – Silica

• Colocynth – Kali carb

• Etc.

The changed therapeutic approach

Complementary remedy

• Identified by their phase/ depth/ pace of action:

•Acute complements of an chronic remedy

• Natrum mur - Bryonia, Apis, Ignatia

• Lycopodium – Rhus tox, Chelidonium**, Pulsatilla, (Iodum)

• Etc.

The changed therapeutic approachCognates

• Prescribed in series as their symptoms often follow each other or lead to one another:

• Sulphur – Calcarea carb – Lycopodium**

• Aconite – Spongia – Hepar sulph

• Sulphur – Sarsaparilla – Sepia

• Pulsatilla – Silica – Fluoric acid

• Arsenicum – Thuja occ - Tarentula

• Allium cepa – Phosphorus – Sulphur

• Arnica – Rhus tox – Calcarea carb

• Merc sol - Hepar sulph – Silica

• Ignatia – Natrum mur – Sepia off

• Etc.

The changed therapeutic approach

The miasmatic shift

• It shall be wise to remember that just because we notice a shift in the pattern of miasmatic symptomatology, we need not always change our remedy.

• For example, a few lines from the remedy Thuja occidentalis, as mentioned under Allen’s keynotes:

• Headache: as if a nail had been driven into parietal bone (Coff., Ign.); or as if a convex button were pressed on the part; < from sexual excesses; overheating from tea (Sel.); chronic, or sycotic or syphilitic origin.

The changed therapeutic

approach

The paradigm shift in

prescribing

The Paradigm shift in Prescribing‘Intercurrent remedy’

• The usage of Intercurrent remedies in homoeopathy should be restricted for only those cases, wherein the patient returned with indications of the previous remedy, which however may not happen in every case.

• It shall be un-wise to repeat the previous remedy, without the review of symptomatology carefully.

• In my short experience, I have seldom seen the return of same symptomatology, or same remedy. It does happen, however, occasionally.

On the other hand….‘Inter-current prescribing’

• In many of diabetic patients, who are on insulin, infrequent usage of Insulinum 30C, especially if they are subject to diarrhoea or painless suppuration, improved the response of indicated constitutional remedy.

•Also in patients who are on cortico-steroids, infrequent interpolation of adrenal cortex 30, also helps improve the response of indicated constitutional remedy.

BOENNINGHAUSEN’S

THERAPEUTIC POCKET BOOK

FOR

HOMOEOPATHIC PHYSICIANSTO USE

AT THE BEDSIDE AND IN THE STUDYOF THE

MATERIA MEDICA

James Tyler Kent

The Second Prescription

International Hahnemannian Association at Niagara Falls in 1888

Concordances in boenninghausen must not be ignored. The new remedy should sustain a complementary to the former.

Relationship of remedies

• In 1836, Boenninghausen published his first work on relationship of remedies, which he later discarded.

•However, in 1846, in his work on TPB, he named it Concordance of Remedies.

•Farrington defines ‘Concordant’ as Relationship of remedies with similar action but dissimilar in origin.

•T. F. Allen renamed it as Relationship of Remedies.

Relationship of remedies(H A Roberts and A C Wilson)

•To the majority of homoeopathic physicians the last chapter in the Pocket Book, Relationships, has been a complete mystery.

•He could weigh the comparative value of remedies in relation to particular symptom groups.

•He tells how he kept notes for years on various symptoms, their relationship to each other, and the relationship of remedies to symptom groups.

• It was the accumulation of practical knowledge of many years' experience.

Boenninghausen says..

• I therefore hope that no one will consider this section useless and superfluous in this improved, and, as far as possible, corrected form.

• For myself, who for the past fifteen years have made the Materia Medica Pura my chief study as one of the most indispensable works of homoeopathy, this concordance has been of extreme importance,

• not only for the recognition of the genius of the remedy,

• but also for testing and making sure of its choice, and

• for judging of the sequence of the various remedies, especially in chronic diseases.

Cyrus Maxwel Boger

BOENNINGHAUSEN’SCHARACTERISTICS

AND REPERTORY

Concordances• The concordances (named by Boger, as per

Boenninghausen) is similar to the section in TPB with same headings

• It contains 125 remedies

•Angustura and 3 Magnet remedies make a come back in BBCR

• Few remedies that are found in this chapter of TPB, but not in BBCR are: Aesculus, Allium cepa, Aloes, Apis, Argentum nit, Arum triph, Baptisia, Berberis, Cactus etc.

My Clinical Experience

•Ms SB, 28 years old, consulted us first on 6th June 2011 for ITP.

•O/E: Short, heavier built, black eyes, (streaked/ coloured) brown hair, sunken eyes, thin upper limbs, mrked DNS with flattened nose. Her nose, hands and feet were cold and forehead was warm.

•Since 2008, there was seen a tendency for bruising.

• Investigations revealed a platelet count of 40,000. Bone marrow biopsy was also undertaken.

•Diagnosed as a case of ITP by haematologist.

•Ever since has been on steroidal drug therapy. Had needed platelet fractions twice .

PRESENTING COMPLAINTS

•She also suffered with recurrent episodes of sore throat since last 8-9 months, for which she was treated with antibiotics and anti-allergics.

•She had also noticed corns in feet in last 2 months.

•She also felt lethargic and drained out.

PRESENTING COMPLAINTS

• When 3 years old fell from roof.

• Rolled down-stairs few times as a child-stitched up

• 1996- fell from school bus- stitches right knee.

• 2003-Appendicectomy in Rajasthan.

PAST ILLNESSES

•Since 2000 suffered from episodes of cramps in abdomen with vomiting and severe constipation. Pains gradually came on and off until was diagnosed with Intestinal T.B. in 2005; taken 12 months ATT

•Underwent abdominal surgery-exploratory laporotomy-adhesiolysis and resection of ileal loop- 2006

PAST ILLNESSES

•Father-DM, HT

•Mother-DM, HT

•Paternal Grandmother-Asthma

•Paternal Uncle-DM, asthma

•Paternal Aunt- DM, asthma, skin.

FAMILY HISTORY

•Maternal Grandfather-DM

•Maternal Grandmother-Kidney.

•Maternal Uncle-HT

•Maternal Aunt-HT

•Sister-PCOS.

FAMILY HISTORY

•Fashion designer

•Single girl with a steady partner for last 7-8 years

•Diet: Non vegetarian; no addictions

•Menses: 7 -4 days??/30+ 1days; Flow was less since she was on steroids.

PERSONAL HISTORY

•Appetite-Since 2005 controlled diet, regular timings.

•Thirst-mostly poor; up to 1 litre.

•Desire-spicy, red chili, hot food/hot tea(+++)

•Bowels- regular.

•Urine –regular.

GENERALS

•Sleep-Since on steroids sleepless has to wait long; restless too; on side ; in dark; no salivation.

•Dreams- of business.

•Perspiration-More when on steroids; poor otherwise.

•Thermal Reaction-likes winters.

GENERALS

•Belongs to a well-off business family

•Youngest of 3 sisters, pampered and loved

•Steady boyfriend for last 8-9 years

•Both families have consented for their relationship

•Runs her own boutiques, works hard and enjoys fashion designing/ ethnic Indian wear

LIFE & CIRCUMSTANCES

•Not aggressive by nature

•Anxious about business/ work/ deadlines

•Conscious about weight gain/ appearance

MIND & DISPOSITION

- bruising tendency- anxiety prone - fatigue- tendency for cold hands/ feet/ nose and warm forehead- desire for hot food/ hot tea- recurrent tendency for sore throat- family history of DM, HT, Asthma- past history of falls/ injuries- past history of intestinal TB

ANALYSIS

A REMEDY FOR ANXIETY DISORDERS

• 600. Slight repeated attacks of anxiety with flying heat all over the body.

• 607. Attacks of anxieties. [DE LA MARCHE, DE MEZA , COLLIN, l. c. , Hbg.]

• 608. Severe attacks of anxieties. [VICAT . l. c.]

• 609. Anxious concern about the present and the future. (3 rd d.) [Lr.]

• 611. Fright and starting at unexpected trifles (aft. 1.1/2h.). [Kr.]

• 617. Hypochondriacal anxiety.

• 618. Hypochondriacal peevishness; he is indisposed for everything.

• 635. Easily startled.

• 637. Fears; anxious dread of coming evil.

• 547. Anxious heavy dreams from the beginning of the evening all through the night , which fatigue him greatly.

A REMEDY FOR FATIGUE• 523. Exhaustion fatigue, bruised feeling, that compels him to lie down.

[Stf. Gss.]

• 524. Trembling restlessness and exhaustion. [Stf. Gss.]

• 525. When walking he becomes faint, but on standing still he recovers. After a walk in the open air, weak in the legs; the knees bent under her; as soon as the weakness came in her legs she immediately grew drowsy, fell asleep at once, and dreamed immediately.

• 527. Heaviness in all the limbs, as from great fatigue. [Hbg.]

• 528. In all the muscles under the joints of the upper and lower extremities, when walking in the open air, sensation of weight and pressure (aft. 8 h.) [Fz.]

• 532. Relaxed state of the limbs, as if they were all over-stretched. [Fz.]

• 533. Lassitude and laziness of the whole body, the legs can scarcely stand. [Hbg.]

• 535. General sinking of the strength; he imagines he can scarcely move a limb. [Hbg.]

Montana Sign• 19. Heat in the head; the rest of the body being cool,

at least not hot.

•65. Dry heat in the face towards evening to behind the ears, without thirst, with very cold nose (aft. 24 h.). [Hbg.]

• 103. Red swelling of the right cheek, with throbbing nipping pain, swollen lips and great heat in the head and cold body; only the feet were sometimes hot.

• 115. Hot feeling in the nose, and yet it is cold to the touch. [Hbg.]

•She improved readily on Arnica montanain LM potencies

•While with cortico-steroids, her platelet count used to stay between 1-1.5 lacs; after starting Arnica, her count went up to 2-3 lacs

•Hence hematologist tapered off steroids within 6 months

•Only under Arnica her counts were stable between 1-2 lacs

PRESCRIPTION & FOLLOW UP

•In January 2014, she reported with dipping platelet counts between 35000-50000

•Revaluation of the case did not reveal any change in symptomatology

•Prescribing Arnica 1M/ 10M also did not prove to be of any help.

TIME FOR CHANGE

•It was required to select a remedy that shall carry further the action of Arnica.

•We referred to the rubric, ‘Blood, circulation and fever’, under the drug Arnica in section on Concordances in TPB and BBCR, for next remedy.

•Chelidonium, suggested by the rubric, also seemed to agree with the generalities of the patient (desire for very hot food/ drink).

CONCORDANCES OF TPB/ BBCR

•In February 2014, she was prescribed Chelidonium 200, 9 doses, tid for 3 days

•Ever since again her counts have maintained steady between 1-2 lacs

•SHE IS STILL BEING FOLLOWED

CONCORDANCES OF TPB/ BBCR

We need to reprise the spirits ofHahnemann, Boenninghausen,Hering, Lippe, Guernsey, Allen, etc.and devote ourselves at the altar ofthis truthful way of prescribing!