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.
- Ensure your medical diagnosis is right with appropriate investigations.
- Assess the patient's clinical condition well vis a vis his general condition.
- 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.
- 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:
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.
- Age of the patient
- Organ affected.
- Acuteness of onset of the disease (time taken for the disease to establish or overwhelm the patient).
- Duration of disease
- Previous treatment taken
- Mental symptoms - more the mentals, higher the potency
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:
- The preconceived notions of the doctor
- False indoctrination of the patient
- The physicians lack of knowledge of the disease and its progression.
- Sudden cessation of previous treatment (allopathic) causing exacerbation of disease symptoms.
- Imperfect case taking; omitting disease symptoms in search of PQRS.
- 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.
- Deterioration of condition is arrested in 2-3hrs after giving the simillimum.
- Patient shows less irritability/restlessness and calms down some what.- 24hrs
- In lower respiratory ailments: Cyanosis decreases - 24-36hrs
- Air entry improves on auscultation - 36-48 hrs
- General condition visibly improves. Patient becomes aware of surroundings and people other than the mother (in children) - 24 -72 hrs.
- Patient asks for food or milk - 48-72 hrs.
- Fever starts declining. 48 - 96 hrs. Will touch normal after 3-4 days.
- Cough decreases last after 8-10 days. (in pneumonia)
- 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.
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'.