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Case Study

And I Ache all over
Dr Kershasp N Kasad

Female, aged 31, M D in Community Medicine. Works in a hospital as a Marketing Manager, Quality control from 1993 onwards till date. She came to me on 18-2-95. 

Menarche: 11 yrs. Menses 7/28 heavy. Married on 21-11-91. Conceived in June 1992, took ciprofloxacin for the ear infection in the first 15 days of pregnancy. Therefore MTP had to be carried out on 30-7-92. 
6-8-92 - Erratic, heavy bleeding
30-9-92 - second D and C with hysteroscopy. Bleeding profuse from 3rd day following D and C not amel by progesterone.
Treated by Dr Indira Hinduja - an infertility specialist for many months with LH-RH nasal spray, natural oestrogens and injectable progesterone, resulting in a normal cycle on June '93.
Conceived in Sept 1993 but learnt foetus was dead on 10-11-93. D and C done on 22-11-93. Normal periods from Dec 1993 - Aug 1994. The present illness started fro 24-11-93 after the D and C. 

Chief Complaints
Excruciating pain all over with aching, amel Hard Pressure, Hot Shower - feels as if someone is wringing her body. Aggr Night, not amel Brufen -600. Cannot sit up. Muscle fatigue3***. Cramps3***. Restless with pains. Spasm - neck, Lt head, ear, Lt shoulder around, Lt trapezius, pectorals, triceps, brachioradialis, hands, fingers. Stiffness, spasms-knotted-cannot lift a glass of water. Aggr Fan, cold climate, Hot humid weather, cannot lie in one position - Restless.
Amel, in Pune [dry weather], hot fomentation, lying down. AM, support, sudden onset. Limping while walking with a tilt to the Lt and torticollis to the Lt side. Amel acupressure, no amel with acupuncture. No response to hosts of pain killers, anti-inflammatory agents, tranquillizers, Mag-phos, mixture, Mag-phos-CM, Bry amel little. Muscle-6 and Laser treatment > trapezious spasm. 

Blood: CBC L-40-50 M-10-11 ESR - N WBC 3000 Plasma Fibrogen - N, A.N negative CMV +ve.
EMG: N. MRI - Cervical Dorsal Spine: N. [Cytomegalos virus]
IgG elevated: 1.2, IgM Negative R A Test: -ve. DNA: -ve. L E -ve. T cells: reduced.
Na-reduced K - N. Mg-N
Several Consultations with several specialists. No one wanted to hazard the diagnosis. All advised steroids, one advised Endoxan. Patient declined both and sought out Homeopathy.
O/E: BP 110/75. No organomegaly. No Iymphadenaopahty. No neurologic deficit. Nil haematologically. Baggy lower eyelids. Cold hands and feet RS/CVS/PA - Normal. Neck torticollis to the Lt Tenderness all over. Pathetic look, scars of suffering obvious as she limped to my clinic. THROAT: N. Stiffness and spasms all over, especially nape of neck and flexors. Muscle Biopsy advised; the patient declined lest she develops paralysis. 

Family History: Fa: 84, supra-ventricular tachycardia. Mo: 67 Pulmonary T B, Diabetes Mellitus, obesity, Hypertensive Encephalopathy and 7 absorptions [3rd-4th months]. The patient was the only living child, the last survivor - born on 6-8-83; 7 ½ pounds, a big baby, FTCS. Diabetes Mellitus and hypertension on the maternal side. 

P/H/O: Jaundice at 4; Rheumatic fever at 10 - amel. With Sulphas she was allergic to Penicilin; chicken pox at 16. Liver affection in 1985 (Gynaec). Exploratory Laparotomy - A calcified, necrotic infection of the liver found-parasitic, with enlarged mesenteric lymph nodes; the appendix was removed. She had low grade fever, while stools and highly colored urine. The laparatomy scar hypertrophied, was treated with local Hydrocortisone; this resulted in Polymenorrhagia for 15 days, followed by Amenorrhoea for 3-4 months. Right otitis media in 1990 - throbbing pain with fever -100-101, amel Ciprofloxin molars, under GA. She came to me on 18-2-95 

Appearance: Thin, 64 kg. Tall, 5ft 10". Appetite++ craves: sour, but aggr, bile; dals, sweet, potatoes, and spicy (but aggr = acidity), indigestion, diarrhoea. Pulses oily aggr. Very hot weather aggr; lethargic, miserable, irritable. Sun aggr = headache. Draft, fan aggr = headache, nose block. AC aggr. Very Hot bath all the year round; cannot tolerate cold weather -fingers, nose and limbs cold. C4H. Recurrent tendency to colds - larynx. Sleep normal, except with pains. Must have long sleep, short sleep aggr. Loss of sleep aggr = acidity, irritable, tired, sea-sick. 

Life History: 20-2-95
Age 31, Dt of Birth: 6-8-63. Husband 37.
Emotional description of Self: Short tempered, but at times very unsure of self, and hence subdued. Tends to be very shy in crowds. Extremely sensitive nature. Very fond of animals. Likes to make friends, but very selective. Enjoys intellectual stimulation in conversation. Easily bored. Fond of learning new things. Quick grasping power, but very short spells of intense concentration. Tends to think and worry too much. Great fear of future. Detests dishonesty, hypocrisy, conventionalism, sweet talking, very orderly and neat in habits. Very jittery in untidy and dirty surroundings Loves music. Very loving and understanding relationship with husband. Very attached to parents, but thinks diametrically opposite to them in many issues. Respectful with MIL and BIL but find them very narrow minded and orthodox, hence not very close to them mentally and emotionally. Enjoyed working - was well respected in the hospital by all. She is missed by all. She does not like over-possessiveness in friends and likes to keep to herself at times. However, ready to help anyone at any time. She has close friends. 

Responsibilities in life: 'my work, my parent's health which is not the best, my husband's career and future, health of husband's family, all household responsibilities, both in and out of the house. I feel often that too much is expected out of me except for my husband who expects nothing and I wish I had more physical energy to cope with everything. I like to do things and hate sitting steady in one place for long. I love to travel and move around, but I feel I take up more than I can manage; and tend to get irritable when I fall short of my own expectations, or when delays keep hindering my work. I am Impulsive and extremely Emotional and Sentimental, and I want to slow my pace and spend some time for myself. Easily upset by other suffering; now irritated at my own illness. 
Foods: Non-veg, but prefers veg diet. Detests bitter things. Milk, curds, oily, fatty, pulses, spicy, bulk foods do not suit.
Like moderately cool, non-windy environment. Extremities usually cold. Nose turns cold as the first sign of the weather becoming cold. Uncomfortable in cold, damp weather, and during rains. Prefers socks at night. Likes heat and dry weather. Fan aggr = blocked sinuses and headache, or in a breeze, warm minimal, only in axillae and lips; no smell, no stains. I do not drink lots of water, since if I do, I tend to pass it out by way of urine within 20-30 minutes. Likes swimming and outdoor activities, but cannot do them, because they do not suit her constitution; tend to feel tired soon and catch colds easily. Likes music, dancing, piano, reading, seeing places, talking to people intelligently-not idle, boring talk. Sleep is disturbed if something is bothering her. Get vivid dreams at times. Lack of sleep if her greatest enemy. Early waking up or interrupted sleep causes terrible acidity and gastritis. Tend to be constipated since childhood, increased considerably in the past 10 yrs.

In Sept 1994, MC delayed for 15 days. Once started, it did not stop till Nov 1994, when once again she started LH/RH spray and Progesterone under Dr Hinduja's advice. In Jan '95, LH/RH+ Oestrogen+ Progesterone given and normal withdrawal bleeding took place on 28-1-95. Once again bleeding persisted for 6 days without any sign of stoppage, amel. Only with Hamamelis and Bursa- pastoris, in 2 days. Since then all hormonal therapy stopped. Now she was awaiting her next period on 25-2-95. Menses are profuse, odourless, bright red or maroon, no clots, at times stains delible. Menses before aggr = generalized water retention, backache and abdominal pain radiating to thighs, Ecchymoses, chilliness and coldness; pains spasmodic, crampy -amel with flow in 24 hours. LMP 28-1-95 

Low grade fever on and off treated with mycins. Her quality of life has gone very low and she appealed to me to help her.
After hearing her, the remedy loomed clearly on my mind's horizon, but abstained from administering it, for the interpersonal relationships were lacking and I wanted to probe further. 

On 21-2-95, I conducted The Second Interview
Father : Lawyer, hot tempered, sarcastic, not conventional. His thinking is different.
Mother : Conventional, religious, dictatorial, did not allow her o go with friends, very possessive. Wanted her to be best in everything, even piano. She was scared of her mother, even now is. Mother is sweet, but yet feels resentment, inward agitation, feeling none in the world to look after her. Often the impulse to run away, especially in the last 2 yrs, because of ill-health. Mother would bang her head against the wall, before marriage. Father too used to beat her till 13-14 years of age. The patient felt bitter, angry and frustrated. Her marriage was arranged (2) through mutual friends with parental approval; their ideas matches, very happy relation. Sex no problem, husband - a friend. Mother feared: "my daughter is not with me" and behaved very badly. On the wedding day she refused her embrace. And patient felt bitter, bad, hurt and frustrated. She made up after sometime - Feb 1992. 

She was shy in her childhood, and mother never allowed her to mix freely with friends. Basically friendly, now she can mix up well, meet people freely, yet she likes to be alone. No specific tears. Loves animals- more faithful than humans. Parental disharmony and quarrels constant to which she was a witness. She was a buffer between her parents. Mother was scared of her husband, but she still fires and beats her. Her maternal grandma was a first class MA in Economics, a gold medalist and a Prof, she was harsh and would beat her mother, and had an unhappy childhood. She died of paralysis when her mother was 12 yrs old. Father was fairly stable, since childhood. (3) Maternal uncle- also a lawyer, gold medalist, with unfulfilled desire and frustrated, he too expired. Father not expressive of love. Mother - wants love, appreciation, has not received it, hence frustrated. The patient is averse to fights, she gets upset. Depressed, brooding, feels low, have palpitations, gnawing heavy feeling in the heart, unhappy, bogged down. 

Fear of Ghosts, mother and husband. Frightened from sudden noises.
Examination funk always, yet always first. Anticipation anxiety - before reading a paper at Medical conferences, catching a train etc = hands tremble, nausea, cold hands and feet, sweating, urge to stool, poor appetite and a butterfly sensation in the epigastrium.
Apprehensive, subdued by the mothers behaviour and easily tearful. Feels better when alone. Fearful, anxious since childhood: scared of violent movies, blood, anybody being beaten, something will happen to parents3 - are they breathing? When they go out, that they will die3 eg mother fell down and sustained a Colle's fracture, and when her husband comes home late when usually he is punctual, she worries I hope he is ok. Thousand thoughts assail my mind. But, all this - not for myself." 

Recurrent headaches - Migraine, aggr sun, fasting, indigestion and Fan = also blocked nose. After this interview was over, whilst leaving the residence, she disclosed to me quietly in a hushed whisper "Dr, these are not my true parents, I am a adopted child, right from birth. This was disclosed by my mother just before marriage at 28 - first to my husband and later to me. The news rattled both of us, but we accepted the situation, and the marriage went through without any mishap. "The physician too was stunned, kept his cool, did not react and quietly asked the patient how she felt about this sudden disclosure. She too was stunned and flabbergasted; the true parents are still alive somewhere in the city. When asked if she would like to make enquiries about the same and find them out, she categorically declined lest it produce an intense psychological trauma which she would not be able to digest, especially in her present incapacitating condition. The husband and his parents accepted the situation, and held a similar opinion. The husband was on board Merchant Navy and was not available during the interviews.
After this, I quietly left her residence. The drug was released on 23-2-95. 

The Third Interview at the Clinic on 3-3-95
Pains amel 50% - Lt neck, nape, sternomastoid, shoulders, legs - including cramps, knotted muscles, and generalized bodyache. Muscle fatigue less. Weakness less. Quivering muscles. Sleep better, on the whole better. "I am not happy her at all. Mother is RUDE to me, as I lie down the whole day due to pains. This HURTS me. I want to join my husband in the Merchant Navy," and she broke into tears. I never had a heart to heart talk with them at all. I am rebuked, and so I cannot stay with them. I feel GUILTY, therefore, I stay with them; they have none others to help them. My husband agrees with this. But, I have no rest here. He too feels guilty. No pains hands, joints. Mother tells me that I am rude."

This case has been referred to me after filtration through several experts. It has a wide belt of mental and psychological aspects running parallel to and in temporal correlations with a number of diseases. From the age of 4 onwards, she is under various environmental stressors - physical, chemical and biological - in an uncongenial and unfavourable psycho-cultural milieu in the family. The case demonstrates how the environment shapes the disposition of the individual which, through interactions with the continuous adverse inputs from life events, ultimately culminates in the psychosomatic disease in the field of Rheumatology, which crippled her life functionally and qualitatively, with continuous emotional upheavals.

The main sphere of affection in this patient was the Fibro-musculoskeletal System, especially the muscles of the shoulder girdle. The classical modalities of this chief complaint in a thin, tall, chilly, lady with craving for sour which aggr and the preceding uterine haemorrhage gives to the Schuesslerian mind the impression of Mag-phos, which was given earlier in CM potency with no benefit. Bry, amel a little, the fundamental Tubercular miasm further strengthened the prescription, which was withheld. The clinical, biochemical and immunological parameters [lymphocytosis, monocytosis, decreased T cells and increased IgG level] suggested RES involvement, probably Autoimmune process in the case. The diagnosis of Viral Myositis was first advanced, the Cytomegalo virus being present. Polymyalgia Rheumatica was the most probable diagnosis, Polymyopahty being close on the heels. The slow evolution of the disease from 24-11-93 till the moment of observation on 18-2-95 and functional level of muscular derangement with no structural damage [muscle biopsy being declined by the patient] with aggr From HOT, HUMID, WEATHER, amel In DRY WEATHER, suggested the dominant miasm being Sycotic, with characteristic cramps and spasms, torticollis with a tilt to the Lt while limping.

The associated complaints were Migraine and tendency to catch colds with hoarseness, suggestive of tubercular miasm. The life story of the patient submitted by her as well as assessed by me, demands careful study and apprehension of the patient as a person. Born into a family after 7 abortions, a lone survivor, she would expect a normal child-parent relationship. Instead she has been 'an ear and eye' witness to parental discord, fights, quarrels, and experienced constant bad, aggressive, violent behaviour from both the parents during her childhood and adolescence, nay, right upto the time of marriage at the age of 28. Child's response to the parental domination and aggression was mute, and subdued, being basically a shy, passive and submissive girl, feeling better when alone and weeping. This behaviour evoked bad feelings of HURT, ANGER, RESENTMENT, AND FRUSTRATION, not expressed, bottled up. Father's statement 'You are not my daughter' evoked the feeling of MORTIFICATION/ AND REJECTION which ran through her life. Under continuously adverse home environment of parental conflicts and their consequent behaviour towards her, she was under constant tension with ANXIETY, FEAR, FRIGHT AND APPREHENSION. By nature she could not retaliate, no action under extreme provocation, no feelings of hatred, malice, vindictiveness, hostility - at all. She absorbed the shocking inputs with inward agitation, vexation and mounting RESENTMENT and BOTTLED UP EMOTIONS - REPRESSIONS. Her attitude towards her parents could be termed 'ambivalent'. The climax came just before her marriage at 28 yrs by the sudden disclosure of her being adopted by her foster parents on the 10th day of birth, her real parents being still alive. 

This was a Shocker; she felt stunned, bad bitter, hurt, rattled with mounting resentment, suppressed anger, mortification all re-inforced, especially at the wedding. She felt FRUSTRATED. Add to this the fact that her husband was told first, and she later. Subsequently the two pregnancies not carried to terms [July '92 - Nov '93] added to her cup of misery with extreme grief and depression, HOPELESS AND HELPLESS DESPAIR. 'There is no one to look after me.' Despite the emotional strains and stresses through her life, she exhibited a degree of resilience in functioning as a 'buffer' between her parents. 

Despite the emotional turmoil throughout her life, her intellectual repertoire remained intact, going by her academic performance and rating in the hospitals. Her relationship with people were extremely cordial. This 'Channelization of disturbed emotions' into the creative fields of education, work areas and art prevents her from sinking further into the miasma of base emotions with their inevitable negative repercussions on the mind and the body, at the structural level. At present they remain at the functional level, despite RES involvement, probably the AID [Auto Immune Disease]. Her quick grasp, sharp memory, heightened imagination, creative and innovative nature, pure motivation, fast decision making, a strong determination, drive and will to execute action speak volumes of her level of intelligence, despite tremendous emotional load and drag. As also an awakened conscience with a strong sense of moral responsibility towards those whom she perceived as having rejected her. Repression and Rejection form the core of this case. With the whole gamut of emotions emerging there from as the continuous underlying stream of emotional state, which undermines immunity and makes the organism susceptible /vulnerable to various environs, as follows.
4 yrs-liver, jaundice-virus
10 yrs-Rheumatic fever-RES, joints
16 yrs-Chicken pox-virus
22 yrs-Liver, with inflammation necrosis, granuloma, calcification and eosinophilic-lymphocytic infiltration parasite
27 yrs-Rt ear infection-Coccus treated with Ciprofloxin [ tertogenic in animals] 29 yrs-impacted molars, extracted
-URTI with Sinusitis Larynx - Allergy
-Conception and Rt Ear Infection - MTP uterine bleedings-hormonal treatment
30 yrs-Conception, Intrauterine foetal death, uterine bleedings
-URTI, Migraine
31 yrs-Muscular systems RES and AID. 

Two streams run parallel to each other in the life of this patient: the Emotional and Immune System, the former undermining the latter. REPRESSION AND REJECTION form the core at the mental level, and the depressed Immunity form the age of 4 onwards - at the physical level. The fundamental miasm is Tubercular mainly [viral, parasite, coccus, sinusitis]; sycotic miasm [nasal allergy, rheumatic fever] and syphilitic miasm [lever necrosis, impacted molars and IUFD] in the lower key. This in conjunction with tendency to constipation from childhood and multiple food allergies form the nucleus of Magnesium, with strong Motivation, Will and Drive. These two streams do not have precise cause-effect relationship, but do have temporal correlations - the Concomitant Axis.

Considering the chief complaint alone as the Complete symptom of 4 elements [Boenninghausen], Mag-phos, strikes the eye. But is has failed to deliver the goods, despite the collaboration of the classical modalities form Boger's Synoptic Key and Boger-Boenninghausen's Characteristics and Repertory. This needed agonizing reappraisal of concepts in the differential diagnosis of the Mag slats, as the nucleus of Mag remains in the case. A lot of work has been done at the ICR on the Magnesium group, reflected in the ICR Symposium Volume, area F, recently reprinted with modifications. The attention of the intracellular Mg ion to the mitochondria with cell respiration and energy-producing mechanism, and its presence in the muscle and thymus gland speaks of its depth in the maintenance of homeostasis and immune status, deeper than the extracellular Na ion, with which it bears close relationship though being physiological antagonists. Although the patient is chilly, the muscular pains are aggr by HOT, HUMID WEATHER amel. In DRY WEATHER and aggr In TOO HOT WEATHERS. Referring to Kent's Repertory warm wet weather aggr, Nat-s3. Referring to BSK on Mag-s drug, the related remedy is Nat-s. 

The totality of Mag-s was built up as follows
Fibro-muscular structures
Dominant Sycotic miasm
Hot, humid weather aggr Cramps, spasm.....> Nat-s.......Mag-s [BSK]; Related remedy.
The travel from the patient to the drug was as follows:
Mag-p........> Nat-s.......Mag-s. 

Assessment Of Susceptibility
Sensitivity very high emotional levels, noise, environmental stressors - thermal, biological, foods, drugs etc.
Vitality: very low: functional nerves - agonizing pains. Incapacitation, diminished mobility
Immunity: moderate to low
Reactivity: Tissue level - still functional, not yet structural.
Dominant Miasm: Sycotic
Suppression: At the mental emotional level and the immune one.
Overall Susceptibility: Moderate
The intercurrent remedy selected was Thuja-chilly antisycotic. 

23-2-95: Mag-s 1 M HS SOS [to the point of reaction]
3-3-95: Record enclosed Interview III Mag-s 1 M [3] H.S. - weekly
7-3-95: Thuja 1M [1] HS Mag-s 1M qds
17-3-95 Pains and Spasms returned. Constipation better. No low grade fever. LMP 2-3-95
26-3-95: Pains and spasms amel. With 3 doses of Thuja 1M again returned with less agony. No fever, went on the merchant navy ship with her husband. Gave the stock of medicines: Thuja 1M and 10M, Mag-s 1M and 10M, with instructions to take Thuja H S and Mag-s tds to the point of reaction. If better to stop and take placebo [she was supplied] if not, amel, to progressively raise the frequency of Mag-s, To contact on phone or by fax.
8-5-95: Telephoned on board the ship to Tehran at 9 am. Pains amel. Cannot get through calls/fax Thuja 10M HS Mag-s 10M SOS.
8-7-95: Returned from Iran, much better in every way. At the clinic LMP 27-3-95. Pregnancy 3 ½ months Placebo
4-9-95: On the whole amel. Pains aggr last week Mag-s 10M SOS
Nov 1995 telephoned to say to say that was amel Pains fluctuate mildly. Placebo.
5-12-95: Delivered a baby girl FTND Episiotomy
14-8-96: At the clinic: pains recur, 2 mths, aggr shoulders. Torrential rain in Bombay.....Dulc 2003 hrly.
Home situation as bad as ever. In between visit, baby had diarrhoea; insufficient milk in breast. Lac-d 1M 4 hrly.
15-4-95 again on board the Merchant navy with husband and child. No communication till date. 

Result : Remarkable palliation. Cure remote as the maintaining cause remains in the immediate environment at home. Irregular and erratic reporting a problem for the physician. Suggestion: Counselling. Gratifying response to treatment, with the delivery of a healthy baby girl. I await communication from her.