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MANAGEMENT OF ACUTE LOWER RESPIRATORY DISEASES
A synopsis of the presentation done at the HMAI seminar at Belgaum- 21st April 08

Management of acute case requires certain precautions to be taken when compared to `cold' or chronic cases. The pitfalls of handling such cases homeopathically must hence be known to every practicing Homoeopath. The duty of the doctor is to set the patient on the road to recovery as soon as possible with the least time lost in philosophical reverie.

The following guidelines may be observed which by far are neither exhaustive nor complete, but may be adhered to as the bare minimum.

  1. Ensure your medical diagnosis is right with appropriate investigations.
  2. Assess the patient's clinical condition well vis a vis his general condition.
  3. Assess your own ability to treat the case i.e. your previous experience with such cases, confidence level, your knowledge and familiarity of the Homoeopathic doctrines & Materia medica applicable to the case.
  4. Explain the seriousness of the patient's condition and take the relative's informed consent before treating the patient.

Having passed the first four check points, it is now down to Homoeopathic management.

Get a good case history. First, note down the disease symptoms to justify the medical diagnosis. Below each symptom that is elicited note down the concomitants and below each such concomitant, note down the modalities. Do not be discouraged by the absence of modalities especially the thermals. In infants thermals are difficult to elicit and the mothers narration may not be accurate - exercise care while attaching importance to these. In pediatrics, the child may narrate modalities but may only reflect the mothers imposition of her opinions e.g. preference for warm drinks/clothes etc.

It is important to note down the sequential order of appearance of the symptoms and their concomitants. In infants, mentally challenged individuals and in unconscious patients, it may be difficult to elicit accurate modalities and concomitants. Here, observation of the patient's particulars (objective symptoms) noticed by you and few symptoms as told to you by the relatives will have to do. Do not justify any symptom, concomitant or modality as the fait acompli of the disease.

Exercise caution in assigning importance to any symptom stressed upon by the relatives. In their anxiety, truth may be the first casualty; they may exaggerate or attempt to focus your attention on to symptoms they regard as important or serious, especially during follow-up. Take an unbiased and unprejudiced case history. Symptoms will be evaluated only after the complete history is noted. Train yourself to note the finer points of objective symptoms and modalities since infants, mentally challenged and unconscious patients will not contribute any symptoms. OBSERVATION is the watch word.

Do not delve too deep into the past history. It may be irrelevant. Past history is useful when a paucity of symptoms creates the need to know the miasmatic background or suppression (probable cause). Take care not to assign too much importance to the causative factor as told to you by the relatives - make your own evaluation of this aspect. Many ailments especially pneumonias are known to be seasonal i.e. < winter, monsoons.

Some of the symptoms expressed by the patient/relatives may be iatrogenic. Rule these out of the therapeutic totality.

TOTALITY is not in the number of symptoms you have collected. Anybody claiming to take a case history over several hours or even days appears not to have understood Homoeopathy and Hahnemann's teachings. Hahnemann clearly said `The physicians sole mission is to cure the sick'; not `take the case history'. Read Lesser Writings - Kent and Boenninghausen for appropriate case taking.

The PQRS symptoms are nothing but the concomitants and their modalities and never the disease symptoms. (Read Guernsey, Kent's lectures on the use of Guiding symptoms)

While repertorizing the case, involve as many general symptoms as possible. Do not go too deep into the particulars where you will get lost in rubrics having drugs with one mark. E.g. (In complete repertory) EXTREMITIES PAIN: Lower limbs: Sciatica: morning < rising after: colo; This rubric has only one drug with 1 mark. Go back to the rubric `Sciatica'.

MIND: absent minded: morning: shows 5 drugs all with 1 mark. Go back to `absent minded'. Avoid all rubrics with drugs carrying 1 mark. Rubrics having few drugs with 1 mark are best avoided unless the patient very strongly stresses on that symptom and modality. Attempts to involve such rubrics will end up in a disjointed repertorial totality where no single drug is indicated with any certainty.

PRESCRIPTION: The indicated drug is the simillimum and vice versa. The simillimum is the only drug which can cure, hence it is given in the appropriate potency irrespective of whether it is `deep acting', `long acting', Psoric, syphilitic or sycotic. The miasmatic theory is applicable chiefly in chronic cases. Its applicability in acute cases is limited.

POTENCY: The indicated drug (simillimum) in any potency, will invariably act, (note confusion created by Stuart Close, Hahnemann, Boericke) but quicker results may be achieved if susceptibility is taken into account. The chief indicators of susceptibility are:

  1. Age of the patient
  2. Organ affected.
  3. Acuteness of onset of the disease (time taken for the disease to establish or overwhelm the patient).
  4. Duration of disease
  5. Previous treatment taken
  6. Mental symptoms - more the mentals, higher the potency
For further details read Dudgeons lectures and B.K.Sarkars commentary on the Organon. Constitution does not help much in acute diseases; can be relied upon only as a last resort with paucity of symptoms. Read also Boenninghausens Lesser writings (case histories) regarding use of high potencies and drugs in alternation as well as complementary drugs.

REPETITION: In acute cases frequent repetition is permissible. Read Organon aph: 247, foot note to 247; aph.248 (compare with Vth edn.). Read also Dudgeons lectures, Stuart Close, Kent's lectures, Boenninghausens Lesser writings, Borland's Pneumonias. Remember, the stalwarts practice was based on the 5th edition of the Organon, where-in Hahnemann left repetition largely to the discretion of the physician. This method was used with great success and no untoward incidents. Opinions may vary, but practice shows, repetition in diluted form (in water) succussed before every administered dose, does not harm the patient.

HOMOEOPATHIC AGGRAVATION: A case of more smoke than fire. Read Dudgeons and Andre Saine's views on the same. This topic in Homoeopathy has more confusion, contradictory opinions and theories after posology. In fact, a rarely seen phenomenon, my opinion (in both acute and chronic cases) is that it depends upon:

  1. The preconceived notions of the doctor
  2. False indoctrination of the patient
  3. The physicians lack of knowledge of the disease and its progression.
  4. Sudden cessation of previous treatment (allopathic) causing exacerbation of disease symptoms.
  5. Imperfect case taking; omitting disease symptoms in search of PQRS.
  6. Reliance upon symptoms related by the mother or relatives; ignoring your own observation. The patient must be brought to the clinic for every follow-up and examined thoroughly to ascertain improvement or deterioration. Run through all general symptoms narrated by the patient during the first consultation. Note decrease or increase in intensity of each sign (objective symptom).

Note aph.160. ". a dose of the appropriate Homoeopathic medicine, .. does always, during the first hour after its ingestion, produce perceptible homoeopathic aggravation of this kind." In acute cases, is such immediate action of Homoeopathic medicine without an interlude (while the disease is checked) possible, or is there a brief progress of the disease before the Homoeopathic medicine overpowers the disease?

RECOVERY: The concomitants subside first. The concomitants disappear in the reverse order of their appearance, hence the previously expressed requirement of sequential recording of the symptoms. The disease symptoms of cough, fever go last, also in reverse order of their appearance. However, adventitious sounds which are due to pathology may not obey this rule. Indication of the drug being the simillimum and the potency being right is better assessed by the following phenomena as observed in a serial study of Pneumonia & Chikungunya.

  1. Deterioration of condition is arrested in 2-3hrs after giving the simillimum.
  2. Patient shows less irritability/restlessness and calms down some what.- 24hrs
  3. In lower respiratory ailments: Cyanosis decreases - 24-36hrs
  4. Air entry improves on auscultation - 36-48 hrs
  5. General condition visibly improves. Patient becomes aware of surroundings and people other than the mother (in children) - 24 -72 hrs.
  6. Patient asks for food or milk - 48-72 hrs.
  7. Fever starts declining. 48 - 96 hrs. Will touch normal after 3-4 days.
  8. Cough decreases last after 8-10 days. (in pneumonia)
  9. Occasional patient may have mild diarrhea or a nasal discharge at the end. This condition often needs to be treated as a separate entity, hence not a natural accompaniment of the curative action of the drug.

Here I have found that Hering's law does not seem to apply. Hering is being ambiguous when he states from more important organs to less important organs. He stresses on the skin being a less important organ than say the heart or the lungs. Does this hold true? One can survive and lead an almost normal life with one lung, kidney or a lobe of the liver removed or destroyed by disease. The clinical onset of Cirrhosis begins only after almost 90% of the liver is destroyed. The heart with only 50% of its ejection fraction (in LVF) can still pump enough blood through the body. Can one survive with 50% burns of the skin? With today's knowledge of medical science and a little common sense, Herings law seems specious, ill thought of and rather improbable. Have you seen Herings law demonstrated in the cure of mental diseases or one sided diseases? We no longer see syphilis as it was seen before. Has any one seen a primary chancre in the last 8 - 10yrs? Hence in so many diseases, is it reasonable to expect any primary symptoms of the miasm to present themselves? The term `reverse order of symptoms' must hence be interpreted in a different manner today - it may at best be limited to where the symptomatology began in that particular patient and confined to his history alone. My findings in the above study of pneumonias, shows the best meter to be the early disappearance of the concomitants. As for reverse order of appearance, the onset is so acute and the concomitants and symptoms often modified by allopathic treatment that the patient is often confused as to the order of their appearance. If you go back into past history of an infant, where did the disease process commence? Can this be determined in all cases? Today it is often impossible to do this even in adults.

AUDE SAPERE
Lastly we are scientists and doctors who should not feel comfortable in blindly emulating our seniors, but to interpret honestly accumulated facts in the light of modern science. The millstone of Homoeopathy is its philosophy, which allows the science to veer away from facts into the realms of delusion and opinions almost never backed by statistics (a tragedy perpetrated by Hahnemann himself). Many aspects of the phenomena of life are explained by science beyond doubt today. Many phenomena explained by Hahnemann and his peers as per their understanding of science (mixed largely with religious philosophy), are untenable today. If Hahnemann were reborn, I am sure his outlook and explanations would see a radical change. After all, in just 32 years he took to write the Organon, he changed his opinions six times on various issues. Hence he was open to re-interpretation in the light of new knowledge based on his experiences, when there was no other scientific light to guide him. The title of this paragraph, borrowed from the master himself, sums up whatever I have said. It is the only altruism after `SIMILIA SIMILIBUS CURENTER'.

 
 

STUDY OF AN EPIDEMIC- CHIKUNGUNYA
Published in the Homeopathic Heritage by Jain Publications - New Delhi - Sept.06

Chikungunya is an African word meaning `Bent double with pain'. The disease is caused by a virus, spread by the Aedes Egypti species of mosquito. The mosquito breeds in clean water and is a day-time biter. The vector is identified by its white and black, striped abdomen whence it gets its common name `tiger mosquito'.

The disease is generally restricted to coastal regions during or after the monsoons, the infected mosquitoes or humans arriving from the coast of Africa on cross country cargo ships. This year due to unknown reasons the disease spread rapidly across almost the entire length and breadth of India. In Karnataka, especially in the northern districts, the disease spread like wild fire, affecting almost one of three families in Belgaum district. In some house-holds, all family members were affected by this crippling disease, restricting them to bed, having to rely on kindly neighbors to fetch medical help and even food!

The common symptoms of the disease are chills with fever lasting 48 to 72 hours, followed by severe headache, joint pains and backache lasting from a few weeks to several months. Many patients described the onset as so fast that, in seconds they were immobilized by the pain, even as they attempted to get up from the toilet. The most commonly affected joints were the large joints (knees, elbows, shoulders) and to some extent the smaller joints (Meta-carpal, carpal, meta-tarsal and tarsal). Swelling of the joints with intense pain and heaviness was noticed, which in some patients lasted as long as four to six months. A few patients demonstrated a red eruption all over the body, very similar to measles. A few respiratory complaints like dry cough and pain in chest were noticed. However examination and investigations revealed no involvement of the lower respiratory tract. Patients who had taken allopathic treatment showed almost no improvement of their condition even after several weeks or months of therapy. In contrast, Homoeopathic treatment as best described by my patients was `sheer magic'.

The peculiar or individual rubrics used to arrive at the similimum were as follows:

  1. MIND : Restlessness, tendency: anxious
  2. " "       : Impatience
  3. " "       : Despair pain due to
  4. " "       : Weeping pain due to
  5. GENERALITIES: Midnight after<
  6. " "                         : Change of position<
  7. " "                         : Touch < Pressure>
  8. " "                         : Warmth > Cold air<
  9. " "                         : Rubbing>
  10. " "                         : Food & Drinks: cold drinks desires
  11. EXTREMITIES : Pain lower ext: Knee: Motion beginning<
  12. " "                       : Motion contd.>
  13. " "                       : Rising from seat<
  14. STOMACH : Thirst : large quantities often
  15. SKIN : Eruptions: red
  16. FEVER (Heat): Succession of stages: Chill followed by heat: thirst with

Through a maze of symptoms a pattern emerged. With careful elicitation and evaluation of each patient's PQRS, a similimum was chosen by the process of elimination. The miasmatic evaluation was not necessary as all epidemics are considered an exacerbation of an inherent Psoric trait. The drug most often administered was RHUS TOXICODENDRON. The potency chosen was 10M in the acute cases and the same was given as a prophylactic in the 200th as it was noticed in the early patients that, the lower potencies did not produce very remarkable results. Other drugs used were BRYONIA ALBA, NUX VOMICA, LYCOPODIUM CLAVATUM, PULSATILLA, EUPATORIUM PERF, LEDUM PAL, ACONITE & SULPHUR. Rhus tox when given in 10M potency was given as 2 doses to be taken at 1 hour interval, followed by placebo. Second prescription was also given in 10M potency as single dose.

A total of 147 cases were treated with the following outcome:
TOTAL RELIEF WITHIN 4 DAYS WITH FIRST PRESCRIPTION: 106 cases
TOTAL RELIEF WITHIN 8 DAYS: 25 cases
TOTAL RELIEF AFTER SECOND PRESRIPTION: 9 cases (change of simillimum after 6days observation)
PARTIAL RELIEF DESPITE SECOND PRESCRIPTION: 3 cases
NO RELIEF DESPITE THIRD PRESCRIPTION: 4 cases

This study shows 95.2% of treated cases recovered with no remaining symptoms after 8 days therapy. Another remarkable observation was that, no complications of bleeding tendency were observed in any of the cases treated with Homoeopathy as compared to the incidence of hemarthrosis, G.I. bleeding and even death in several cases treated by allopaths. However it may be mentioned that one case in this study did present with hematemesis, which was quickly controlled with the help of ARSENIC ALB 1M 4 doses given repeatedly over 8 hours. The crisis was precipitated, because the patient was advised by his brother an allopath, to take Nimesulide on the same night that he consulted me. This man's wife too was afflicted, but did not take any allopathic medication and recovered uneventfully within 48 hours. Other observations I may mention are: most of my patients being farmers involved in heavy field work, the time taken to return to their field duty was as short as 48 - 72 hours as compared to several weeks or months with low potency homoeopathic or allopathic treatment.

The pattern of drug usage was as follows:

  1. RHUS TOX 124 cases
  2. BRYONIA ALB 11 cases
  3. NUX VOMICA 5 cases
  4. LYCOPODIUM C. 1 case
  5. PULSATILLA N. 1 case
  6. EUPATORIUM PERF. 1 case
  7. LEDUM PAL 2 cases
  8. SULPHUR 1 case
  9. ACONITE NAP 1case

Rhus tox was the preferred drug in most cases due to the prevalence of the following symptoms:

  1. Pains < motion beginning of
  2. Pains > continued motion, warmth, rubbing
  3. Fever chills followed by heat with thirst
  4. Pain in knees < rising from seat
  5. Restlessness with anxiety
  6. Midnight about <
  7. Mental symptoms of anxiety and restlessness driving him/her out of bed despite the pain.

Most of the patients presented as acute cases and within 15 days of onset of symptoms (108 cases). The remaining cases came after varying periods ranging from a few weeks to as long as 6 months in one case. It was noted that in the older cases the recovery time was also longer; these patients were given the similimum as single dose in 10M potency, followed by placebo for 6 days.

Ledum Palustre was not preferred despite many symptoms being similar, because all the patients complained chiefly of knee, shoulder and wrist joint involvement. Only two cases complained of exclusive involvement of small joints and were hence given Ledum Pal. The marked relief with continued motion and warmth favored Rhus tox. In few cases the excessive thirst, measles like rash and marked aggravation on movement favored Bryonia Alba. Many of these patients suffered early morning aggravation but the relief from continued motion or aggravation was the deciding factor. (It is interesting to note that Bryonia also has relief from motion but in 1 mark).

The conclusions drawn were as follows:

  1. Use of high potency in acute and especially epidemic cases is safe and to be recommended as there is very little fear of Homoeopathic aggravation. This happens because the Psoric ingredient of the disease influence is so over whelming that the lower potencies do not act sufficiently to overturn the disease influence.
  2. While repeating the drug in an acute case i.e. when the symptoms subside and reappear in lower intensity after a period of time; a shift to higher potency is not to be hurried into as the susceptibility to the particular potency has already been demonstrated, hence the drug may be repeated in the same potency with great benefit.
  3. Prophylactic treatment based on the same set of symptoms but given in a lower potency (200) and repeated after 20 days was equally effective as none of my two thousand odd patients suffered the disease over 6 months until the epidemic subsided. The concept of GENUS EPIDEMICUS is hence established.
  4. Homoeopathy is highly effective and can play an important role in community medicine, saving millions of hours of lost man-hours.
Economic gains from using Homoeopathy in community medicine are huge as compared to other systems

 
 

CASE SELECTION AND MANAGEMENT OF MEDICAL & SURGICAL EMERGENCIES
SEMINAR FOR FINAL YEAR AND PG STUDENTS OF UNAIDED HOMEOPATHIC COLLEGES OF KARNATAKA & GOA AT THE GINDE JIRGE AUDITORIUM - J.N.MEDICAL COLLEGE, BELGAUM. 30TH APRIL 2010

It is a well known fact that certain persons are pushing forward unsubstantiated, undocumented and at times preposterous personal theories in the guise of homeopathic philosophy. Couched in smart presentations and backed by good oratorical skills, the impossible and fantastic is marketed as homeopathic gospel.

Let us differentiate between philosophy and fantasy. Philosophy is the study of problems utilizing a critical (scientific), systematic (factual) approach, relying on rational (having reason) argument. Rational argument is a conclusion based on assumptions leading to explanations of cause (homeopathic medicine) & effects i.e. cure. Fantasy is the use of unexplained or inadequately understood phenomena (genetics) as a primary element of a theme. It may use imagination in a self explaining setting by including some elements (patients) which are a part of the real world to connect to a phenomenon i.e. cure. It does not provide a logical explanation for the unscientific events that occur. E.g. A speaker at a seminar reportedly claimed to cure a child of his ailment, basing his prescription on the dreams his mother saw when she was pregnant!!!

The need for this talk arises from the tendency of certain persons as aforesaid, who tend to present chronic cases in seminars, substituting glaring facts with fantasy. This results in bad case selection and handling by novices, leading to failure and disillusionment about the system. The need to address the acute cases is that it hones the diagnostic skills of the practitioner (an integral part of medical practice), so that he knows what he is treating and he addresses the case with the responsibility befitting that of a homeopathic physician. The acute cases necessarily resolve in a short time, hence the truth of many of the doctrines of homeopathy are made apparent to the novice, building his confidence in the system. Cures in acute infectious diseases cannot be dismissed as placebo effect. The need to peruse the materia medica while treating the acute cases familiarizes the student of homeopathy with many drugs which he will find invaluable even while treating chronic cases. Treating acute cases helps you observe objective symptoms which the patient may not express, paving the way for creation of a more alert and observant physician.

Medical and Legal issues must be attended to and precautions taken while treating acute cases. A wrong diagnosis can affect both your assessment of recovery and appropriateness of treatment and lead to legal complications. Diagnosis helps to ascertain curability of the disease, selection of similimum, tracking the follow-up and interpretation of new or changed symptoms. It also helps in sorting disease symptoms from totality, helps to point out the concomitants and helps anticipate complications while differentiating them from the homeopathic aggravation if any.

ASSEMBLING A TOTALITY:
Besides writing down the history which is often very brief in acute cases, observation is the key to most cures. Physical examination- distant observation (gait, flushing of face, perspiration on single parts, position in which patient sits or lies down etc.) as well as by traditional means of palpation, auscultation and thorough systemic examination are essential to gather leads especially when the patient is unconscious or a child or when the onset is sudden with no relatives or friends to contribute their own observations. NOTE THE CHIEF COMPLAINT - each with its Concomitant symptoms.

  • onset
  • duration,
  • cause,
  • sensations,
  • modalities,
  • Symptoms noted in sequential order of their appearance, time and date.

A causal factor may emerge such as exposure to weather conditions; emotions such as grief, anger etc; fall or injury even if remote and so on. Distant causes need to be assessed objectively before inclusion into the totality. Concomitants are the secret to a good totality- always ask "What else troubles you?" Study the manifestations of the acute miasm. After studying the totality, arrive at the prescription either by repertorization or through your knowledge of the materia medica. Often in acute cases the first prescription may not complete the cure and a second or third remedy may need to be given.

Recognition of improvement is the most important part of treating the emergency since time will be short and an instant decision to refer the patient to a hospital may be necessary to save life. At every follow-up the patient must undergo a brief review of totality by recounting every symptom and a thorough systemic examination to detect changes in the patient's condition as relatives often deny improvement until confronted with physical findings of improvement.

2 Video cases of Acute broncho-pneumonia and 1 video case of Acute appendicitis were presented with case analysis, repertorization and documentation of improvement.

The selection of the simillimum along with dosage and repetition were discussed along with justification by quoting several homeopathic gurus was done. Homeopathic aggravation the myths and its pitfalls were discussed.

 
 
 
Dr. Profile
Dr. Dinesh Anand Kowshik: Born and brought up in the megapolis of Bombay (now Mumbai), in India. A student of the CMP Homeopathic Medical College – Irla, Vile Parle, Mumbai, he passed his LCEH in 1981. Later he completed his MD(Hom).
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how it works
Homeopathy is a much maligned system of medicine only because it is not understood in its entirety. Modern medicine or `allopathy’ (nomenclature used by Dr.Hahnemann) leans heavily on today’s science to explain its methodology.
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doctor kowshik's case studies
Patient was operated for being enlargement of the prostate and Lithotripsy for (L) Kidney stone 6 months ago. Subsequently developed urgency and frequency of urination, needed to pass small quantities of urine every 10-15 minutes;
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doctor kowshik's health tips
`How to stay healthy and disease free'. A large number of health problems today arise from our present lifestyle. Some are due to increased longevity or increased life span due to which many old-age diseases, rarely seen in the past, are now fairly common.
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“Management of ACUTE LOWER RESPIRATORY DISEASES”

Management of acute case requires certain precautions to be taken when compared to `cold’ or chronic cases.
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STUDENTS CORNER

How to remember the materia medica
COLCHICUM AUTUMNALE - pain remedy
RHUS TOXICODENDRON - pain remedy
ARNICA MONTANA - pain remedy
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