A Case of Ischaemia
NATIONAL JOURNAL OF HOMOEOPATHY 2003 Sep / Oct VOL V NO 5.
Dr S S Vithal

Importance of Causative Factor
There are many approaches to a case, but whatever approach we take to solve a case if we are able to find the causative factor then our job becomes very easy. Prime and utmost important is given to the causation. There are 2 types of causative factors as mentioned in aphorism # 5 of the organon.

1. Exciting cause
2. Fundamental cause

Now we all know that the exciting cause is very important in acute diseases but seldom have we given importance to it in the chronic diseases. It is very difficult to elicit the cause in chronic diseases because of the chronicity of the complaints and patients having short memory, but if and when the cause is elicited, arriving at the remedy becomes very easy. What we mean by cause is not superficial causes like injury or eating something cold or spoiled food etc. These can be only exciting cause but the main emotional cause such as strong grief or fear or some mortification. These causes can cause changes in the level of the neuro-transmitters which arises from the limbic system which in turn disturbs the homeostasis of a patient and causes illness. Many remedies can have the same cause, so how do we differentiate them? By ascertaining the reaction of the constitution to that cause. Every remedy reacts in a different way and that reaction is what differentiates one remedy from the other having the same cause.

The fundamental cause in every case is the miasm. The importance of miasm cannot be stressed enough. Without this the right constitutional cannot be arrived at. Considering the cause and then combining with the below mentioned approaches makes arriving at the remedy very easy. This case in this chapter is a demonstration of how a cause such as long standing prolonged grief can cause a profound, serious life threatening disease such as Ischaemic heart disease and how homoeopathy can tackle problems of this sort with comparative ease and in a very gentle manner without the harsh invasive treatment which is even rising. If he is lucky he ends up being under medication lifelong.

The Case
A 71 yr old male came with right-sided chest pain, worse eating, bathing, even walking few steps. The pain radiates to right arm up to wrist and is relieved by resting a few minutes. It started in 1996, after the death of his young son due to Leukemia, which was a great shock for him. The problem worsened since last 3 months. Allopathic medication were not giving him any relief. He was investigated thoroughly including. Coronary Angiography, which showed block in three major coronary vessels. Advised Angioplasty. When in hospital, he met many patients who had undergone angioplasty in the past and had now come back with recurrence and had to undergo bypass surgery. This scared him and he was not ready to undergo any interventional procedures.

When he came for homoepathic treatment he was on the following drugs

1. Betaloc 50 mgs 1-1 daily
2. Ismo 20 mgs 1-1
3. Ecosprin 150 mgs 1-1

Physical Constitution: Lean, thin, emaciated weighing only 50 kgs. Earlier normal wt was 62 kgs.

Generals:
Appetite: Normal. Likes and prefers warm food.
Thirst:7-8 glasses/day
Stools: 2 times a day, normal
Urine: Increased frequency at night, every 1 hourly
Desires: warm food, lemonade, fruits, milk, sweets++, ghee, tea
Aversion: Pickles, Chilies
Perspiration: Less, slightly on the face and axilla, no odour, no stains
Sleep: Disturbed when tense, otherwise normal
Dreams: Rarely, occasionally of him fighting with animals like tiger, jumping from height.
Past History: Pneumonia in childhood, appendectomy in 1962, renal calculi 20 yrs back.
Family History: Father-died during prostatectomy 30 yrs back. Mother- died of Stroke 20 yrs back

Thermals: Chilly
Tolerance - Can tolerate heat
Fan - Can do without fan
A/c - Feels chilly in A/c

Life Situation and Mentals:
Patient is a well-educated man working in a reputed company for more than 30 yrs and retired as a manager. He is B.Com, L.L.B. and later he did DTM simultaneously with his job. He was a systematic worker, and progressed well in his career. Even at this age he was running a Public phone booth and working about 11-/12 hours daily. In spite of his severe, serious, debilitating disease, he still works and wanted to continue working despite of his illness. He cannot sit idle.

He was very anxious about his own health and that of other members of his family; he cannot eat or sleep when family is sick. He is apprehensive and plans everything in advance. He is impatient. He is very punctual and expects the same from others. He is very particular and fastidious about his work. He is a strict disciplinarian as well as obstinate. All his problems started after his son died of leukaemia. After this, he became silent, did not talk to anybody and used to think constantly. He felt like his right hand was cut off and he became depressed.

He was a very serious person. He did not like spending money unless and until it was absolutely necessary. Before buying anything he would ensure he was getting his money’s worth and prices were proper.

Investigations:
Stress test: 21/11/01 was positive for Ischaemic Heart Disease. His ECG showed marked ST-T depression in inferior and septo lateral leads.
Coronary Angiography: showed that the following of his coronary vessels were blocked.
LAD-proximal - 100%, LA-distal-90%, Circumflex-distal 80%,
DM2 - 80%, RCA - Distal plaque, Left ventricle showed apical aneurysm.

For prescribing the basic (innate) qualities or characteristics of a patient are taken into consideration, beginning with his will, desire and need to work. Every cell in every individual is supposed to work and hence in turn, every human being is supposed to work. Every individual works in a different way. We can select remedies on the basis of whether a cellà individual is functioning in the way he/she is supposed to work. Every cell has a nucleus and this nucleus has genes. Every gene is supposed to express and work. This individual expression in terms of work is called Diligence or Conscientious. So we have to find out whether a patient is Diligent or Non- diligent and to what extent?

But, remember is that the quality chosen to select the similimum has to be a very prominent characteristic of that person. Only if prominent and innate, only then it can be taken as a eliminating rubric. Innate means the quality with which he is either born or present in him for a long time. We at predictive homeopathy, always advocates ruling out remedies rather than ruling in. While ruling in remedies, we tend to forcefully fit in remedies according to our bias and we can go wrong. In ruling out remedies we make sure that the remedy which we want has to have certain characters and as a result all remedies not having that basic character are ruled out.
So to arrive at a similimum in any case we need to have:

1. Mental make-up
2. Physical make- up
3. General make- up.

Mental Make-up
Will Timid (Negative, weak)
Moral (Conscience) Diligent
Intellect Good

But the biggest confusion is to find out whether the patient is Diligent or Non-Diligent. Not all remedies are truly diligent. Diligence of every remedy differs.
Dictionary meaning of Diligent is -"steady, earnest, energetic effort"
The other word for diligent is painstaking
Dr. Vijaykar’s meaning is "to gain knowledge and achieve the higher purpose of life" (Organon Aphorism 9)
In the repertory, diligence is given under the rubric Conscientious, about trifles.
This rubric is made up of remedies that are Scrupulous and Diligent (conscientious)
The other word for Conscientious is scrupulous. The dictionary meaning of conscientious is
"guided by one’s own sense of right and wrong" hence diligent is more than just being conscientious.

Why so much importance to diligence?
Diligence is expressed by the genes since the basic function of every person/cell is to work and express them. Expression of every person differs because of difference of his genetic code. The way in which a person works makes him different from others.

The person works because it his duty to work and not because he has too.
The diligence of a person is judged by his desire to work without expecting more in return. The work he does is not out of some compulsion or out of some fear. A diligent person will want to work in spite of his sickness

How to judge the Diligence of a person?
The work he does is not done out of some attachment to family members.
It is not done solely for financial gains or for personal gains of fame or name.
The work is done in a systematic manner, earnestly, surely and steadily in a scrupulous manner. Work is done with full honesty and should not be detrimental to others or or to society. If so, then the person is considered to be diligent.

The definition of work is that duty expected of a person at that time of her life period. For e.g. in an adult it is expected of him to work for his family and earn a living to the best of his capacity. In a child it is to study without being told to and not out of fear of punishment. For a house wife it is to take care of the house and children to the best of her abilities without any compulsions.

Mental Makeup
So the mental make-up in this patient is strongly diligent. He wanted to work even when he was seriously ill and this rules out all the non-diligent remedies. The ailment from in this case is prolonged grief death of son and the reaction to this is shock. The other characteristics are:
Avarice
Timidity
Anxiety of health

Physical Make up
Patient has lost about 10-/12 kgs of weight so considering that as Emaciation in people who were initially fat. Patient had extreme Wweakness and excessive debility. Thermal- Chilly.
Craving for warm food and refreshing things
Cravings - sweets, refreshing things
Weakness- after emaciation
Chilly

General Make up
Speed is a very important characteristic to be considered in the general make-up. The speed of the patient is slow and the disease is insidious, slow in onset and progress. The sphere of action, organ involved and the pathology is very important and the remedy considered on the basis of mental’s and physicals should also cover the above factors to.
Speed - slow and insidious onset
Organ involved - Heart
Pathology - Lack of Blood circulation due to spasm along with Atherosclerosis and above all the miasm which in this case according to the pathology is:

Miasm - Psoro- sycotic
The remedy has to be one out of these. Here, remedy given was Acid-Phos 200 1 Dose

Repertorisation
According to Dr. Vijayakar the following remedies are the most diligent remedies:
Arsenic, Aurum-met, Aurum-ars, Aurum-iod, Carcinocin, Ignatia, Ferrum-met, Ferrum-Ars, Ferrum-iod, Lycopodium, Natrum-ars, Natrum-carb, Natrum-sil, Silicea, Staphysagaria, Iodum, Acid-phos, Magnetus-polus-articus, Thuja.

Follow-up:

1. I. After 15 days: The patient who could not even walk for a few meters without chest, pain started walking more and more distance without getting pain in chest. His dependence on drugs like Sorbitrate which he took 5/6 times in a day became much less. 
   He kept on improving; all his allopathic medicines were tapered and eventually stopped. His capacity to walk increased and eventually he could walk a distance of about 2 kms without any chest pain.
2. II. After 6 months: Could walk a distance of about 2 kms without any chest pain. His need for sorbitrates became minimal. His nervousness and anxiety became much less. He had 3 incidences of very serious illness and death in the family, of his sister and other relatives but he could handle them, without getting much affected by that grief.

Group symptoms of Acid remedies - Mentals

·         All acid remedies are Non-conscientious (except Acid-phos)

·         Absent mindedness

·         Ailments from-Anger, vexation with indignation, Shock

·         Amativeness

·         Poor concentration

·         All kinds of Anxieties with fear

·         Anticipation

Group symptoms of Acid remedies - Physicals

·         Weakness, Prostration, enervation after being overexerted

·         Acid-phos, Muriatic-acid, Sulphuric-acid are Chilly remedies while Flouric-acid, Picric-acid are hot remedies

·         Evening aggravation

·         Aggravated in the open Air (except Acid-Flour).

Diligence of every diligent remedy: differentiation.
The drug picture of some of the diligent remedies is as follows.

Acid-phos

·         Associated with Indifference and apathy

·         A/F-grief

·         Anticipation

·         Homesickness

·         Prostration

·         Emaciation

·         Craving for- Refreshing things, Fruits

·         Chilly

Carcinocin

·         The Diligence of Carcinocin is with Responsibility.

·         Precocity

·         Artistic Aptitude

·         Fastidiousness

·         Love for music & animals

·         Strict parentage

·         Can be Chilly or hot

Silicea

·         The Diligence of Silicea is with hard working and obedience.

·         Good boy-girl image

·         Obstinate yet yielding

·         Lack of grit, Mildness

·         Cold sweaty palms

·         Aversion to warm food

·         Tendency for easy suppuration and delayed healing.
Chilly

Arsenic alb

·         The diligence of Arsenic is more of a scrupulous kind.

·         Fear and insecurity

·         Avarice

·         Fastidious

·         Scrupulous

·         Graceful

·         Weakness out of proportion to illness

·         Chilly

·         Thirsty for small sips often, or for large quantity.

Aurum-met

·         The diligence of Aurum-met. is due to his moral character, Conscience and Honesty. He is Duty-conscious.

·         Sacrificing

·         Serious

·         Dictatorial

·         Not so emotional

·         Chilly and

·         Depressed bridge of nose.

Natrum-carb

·         The Diligence of Natrum-carb is with sensitivity.

·         Introvert,

·         Seriousness,

·         Aggravated by Noise and Music,

·         Chilly yet sun aggravates and

·         Thirst less

 

Ignatia

The Diligence of Ignatia is with courage and conviction.

·         Silent grief	·         Emotional
·         Courageous	·         Hysterical
·         A/f long standing grief	·         Chilly and
·         Thirst less

 

Aphorism # 83 states and I quote "This individualizing examination of a case of disease, for which I shall only give in this place general directions, of which the practitioner will bear in mind only what is applicable for each individual case, demand of the physician nothing but freedom from prejudice and sound senses, attention in observing and fidelity in tracing the picture of the disease". This is absolutely necessary for being a good homeopath and the difference between a successful and not so successful homeopath. The ailments from and its reaction to the ailment from is of prime importance along with the basic innate characteristics will help us in arriving at the remedy very easily.