Approach to Rehumatic Cases
NATIONAL JOURNAL OF HOMOEOPATHY 1997 Sep / Oct VOL 5 NO 5.
Dr D B Dikshit
'Thuja / Mag-ph / Kali-c

Case 1: Case Summary.
27 yr old, female, married 
C/o joint pains, swelling & stiffness since 1 yr. She had done BCom and ICWA but quit her job after marriage as her husband desired. 

History Written By Patient:
Name: Mrs MGD
DOB: 24.04.70
Marital Status: married in 1992
Hindu, Brahmin, Vegetarian (however had consumed eggs in pregnancy & even now occ does) Non-smoker, Non-alcoholic. 2-3 cups of tea daily. Tried to have coffee but has stopped since the last 6 mths.
Education - BCom, ICWA(inter completed).Had worked as an Accounts Assistant at SC, Madras for 1 yr prior to marriage. Quit her job after the marriage as desired by the Husband. Her job involved handling of accounts and auditing, She was also responsible for cash transactions & was fully satisfied with her job.

Family:
Father-retired. Mother -housewife, both residing at Madras. She misses them a lot. One brother, his wife and a daughter residing with parents. Brother's career was a grave concern but he has recently changed his job and joined a new company. His future and his activities are still a cause for concern and trouble me a lot whenever I think about it. Ours was a joint family. 
Two of my paternal uncles are very close to me. I have 1 cousin brother & 3 cousin sisters and I like them very much.
I also have my paternal grand mother living with my parents/uncles intermittently. A typical old lady, whimsical at times, irritating sometimes but generally lovable. She is becoming senile and honestly her days are numbered.

I live here in Bombay since 1992 with my husband. We have a daughter born in 1993. Normal delivery. Our marriage was a mutually agreed one with the consent of our parents. We knew each other since childhood and may be for 7 yr before the wedding with the idea of becoming life partners. Though there were many issues over which we do not agree, discuss and argue, I still get along well with him and I can fairly confidently say that we love each other. We wanted a second issue this year but due to this health problem, I am a bit worried and we have decided to postpone the ideas about the second child for the time being. We have decided to have our second child in the second half of 1998.

My husband has 2 elder brothers, married, 2 nephews & 1 niece. My in-laws are alive. I personally like my husband's eldest brother. Same with SIL, eldest one is OK, elder one is not very compatible. My in-laws were nice too. The first year after the marriage they came to Bombay and were very impressed with me. However when they returned the next year, I was busy with my young baby, and they went back with an impression that I do not respect them and I do not take care of my husband also. They have not changed their opinion after that. Our relationship is very luke-warm after this. This will not change. My FIL is my father's uncle, my grand mother's brother. My father and him were very close upto our wedding. Ever since their disappointment with me my in-laws have distanced themselves from my family too. This is a great trauma for me. My parents often complain about this. Whenever I open this topic my husband closes it. He remains indifferent and is apparently not affected by any emotion but I cannot be so and this is also very disturbing. I often complain to him but he is not an overt type. He does not express his affection physically like a hug or a kiss. This also troubles me sometimes.

Diet And Daily Routine:
7.30-8.00 a.m. Sleep
8.00-8.30 a.m. Breakfast for husband and send him off. Make things meet their ends
In 1992-1993. Salary of my husband was not sufficient and had to forego many pleasures. But the financial condition improved from end1993 and today is quite comfortable. However a sense of saving less and not having invested in fixed property like a home of our own is still troubling me. I am after my husband to commit himself to buying a house. Nothing has materialized so far. Hoping to buy a house soon. Living in the company quarters. Having a good social life. Lot of gossip mongers particularly my neighbor but generally a very welcome lovable group of friends.

Chief Complaints:
Started having swelling near [L] index finger and [L] foot from Jan'97. Suspected this to be an after effect of either grafting done on right thumb (after I got my finger cut in a mixer) or urinary infection subsequent to a picnic to a beach in Dec'96.

Consulted Dr. KA and took medicine. Strong antibiotics did not suit me long. Ended up with nausea and vomiting. Finally Dr. KA diagnosed it as Autoimmune disorder. Initially he thought it was a torn ligament. Not satisfied with Dr. KA I went to Dr. S .Dr. P treated for urinary infection and started a course of Physiotherapy. Not satisfactory either. Went to KJ for a comprehensive medical check-up in May-97. After the check-up every thing was reported to be normal. Dr. ED suggested Microcid, the only tablet that gave me immediate relief without any side effects. I am still continuing Microcid¹ whenever I have indications of the problem. A permanent solution to the problem is what I am looking forward to and the absence of this is causing me great concern. Continuos medication does not appeal to me.
After an afternoon's sleep sometimes the joint stiffness and pain surface. If I work continuously then the pains do not surface at all.

Personal Data: Physical Generals: Tall, fair & lean
Highly emotional. 
Having done my costing I wanted to become a full fledged Cost Accountant and wanted to continue service in a good concern and hold a high position. I have to discontinue my service, as there is no one to take care of my child. I am not interested in spoiling my child at the hands of my maidservant. This disturbs me to some extent. The thing bothers me a lot only if there is some financial strain in the family. I do not have any additional responsibility except bringing up my family

Reactions To Surroundings - We have a social set up and have few close friends who won't let me down at any cost. Sometimes when their behaviour is not upto my expectations, I get worried but mostly I am happy.
Food - Like all food and don't like anything spicy. I like sweets more. All foods suit me.
Skin - My skin is a little dry. I always like the rainy season or weather that does not dry your skin. I have bath twice a day in all seasons Have get together with my friend circle in the colony.
(c)Always have good sleep and dreams are a rare event.
(d)Sex-Does have sex at regular intervals.But have proper sex only on the safer days.The menstrual cycle is regular and had normal delivery.

Additional Infor Mation Obtained From Life Space And Case Taking:
Since childhood patient was extremely attached to her family,especially so with her parents sister and her grand mother & uncles.She was very sensitive and caring person.Hers was partially a love marriage & parents agreed to it half-heartedly.She also felt bad at having caused her parents the mental trauma.Inspite of the fact that the families knew each other so well yet certain tensions prevailed in them.In the in -laws family patient did not find much difficulties however she took nearly 6-7 months to adjust to the household.Patient was married in 1992 and in the same year itself they came to B as her husband got a good job here ,in the mean time husband insisted her to leave the job she was doing and inspite of having an extreme desire to come up in life she gave up her job ,which was another agony for her .but slowly she adjusted to the domestic life and supressed her desire to occupy an authoritative position in a job.

Her daughter was born in 1993.In between 1992-93 they were under great financial stress.When daughter was born there was an addded responsibility.During the same period in-laws came to stay with them and she could not manage to look after them well as there was also the baby to look after.Her in-laws interpreted this as that she was disrespecting them and went and told her parents also of the same.Patient was shocked regarding this and was also very angry of them for spreadine this news.During all this her husband consoled her a lot and she has high regards for him.She describes her husband as a carefree and happy go lucky person.Due to this relations with the inlaws have soured and though she talks to them they are very formal.This also affects her a lot and she constantly worries about the same.Whenever she tries to tell this to her husband he changes the topic so she feels frustrated.Now she visits her parents once a year and husband also accompanies her.There is a lot of fear and apprehension in her about her health and due to this they have postponed the second issue.Sometimes inspite having a group of friends she feels all alone here and that there is nobody along.Now she sits idle at home worrrying about her health most of the time.When asked she said she had a great desire do do accounts work and feels she can take up some work,but giving it a serious thought she is not that keen on it as she feels her daughter will be neglected then.Thus she is in a dilemna.

S.C.R Recording:
Chief Complaints

No other associated complaints.

Pt.As A Person:
Ht.- 5.5 ft.
Wt.- 55kgs
Skin - Wheatish,Dry,cracks in winter3.
Wound healing - normal,healthy.
Perspiration - moderate - scanty, Face3 Back3, Odour 3 on much sweating.

Apetite - normal
craving - sweets3 . salt-normal.
Thirst - normal

Obestetric history - FTND in march1993-(1'st issue,girl)
Menstrual history - Cycle-28d, Duration-4-5d.Dark Red, occ.clots. FMP - 15y of age.
Before menses - Coryza and perspiration.
During menses - Pain in abdomen from 2'nd day onwards,if severe then vomiting.
THERMAL STATE - C3H2,No sun <. 

Mental State:
Sleep - good,sound
Dreams - Sometimes she dreams that she cannot walk suddenly and gets frightened.No other specific dreams.
Anxiety3 - health,routine etc.
Sensitive2 - gets hurt but does not bear a grudge against any one,generally social and mixing.
Worry3 - health about ,personal matters etc.,daughter also cause for worry.
Dissappoimtment - personal IPR, about giving up career3.
A/F vexations3,Dissappointment,worry - long continued.
Dejected feeling-due to tensions of in - laws.
Anger3 - supressed2
Attachments3 - to family,worries about her brothers future.
Dissappointed as expectations not fulfilled-Oppurtunity Block2
> company of people,free atmosphere and happiness
< financial insecurity2

Investigations - RA - Negative
Uric acid - 6.2

Diagnosis - SERONEGATIVE ARTHRITIS

Case Management -
* The case was started with Colchicum as acute prescription which took care of the acute presentation .

·         Calc Fl 30 single dose was given later on but without any significant relief.

·         Since then the case has been on Thuja 200 weekly single doses & pt has improved substantially .

·         Kali Carb was considered to the constitutional remedy but has not been introduced up till now.

The case is a demonstration of What Homoeopathic Treatment in hospital setting can do in acute volatile clinical conditions and its reflection in the Laboratory Finding like R.A. etc.

Case 2:
Baby P.S. 10 yr 6 mts old ,female girl comes from a Bengali Family in OPD on 27/10/97. Family comprises of parents & one elder sister 16yrs old.
Clinical Presentation
C/O Fever off & on from 4/10/97 ranging from 102-103 'F and lasting for a day or two & subsiding with Allopathic Rx. Thrice uptill now- ( 4/10 - 1 day; 10/10 - 2 days; 13/10 - 1 day )
On 16/10 started with Inj. Imferon (2) , Inj Vitcofol & cap Zint.
From 22/10 started complaining of bodyache3 , Jt pains3 & vague multiple muscular aches3 & pains esp extremities, neck,trapezius etc > tight bandages2 ; > rubbing3 < exertion2
Patient could not walk. Required mother's support.
No fever since 3-4 days.
No H/O palpitations, breathlessness on exertion
No H/O fliting joint pains


Associated complaints -
1. LL pains,aches since 6-7 yrs once/twice a month
2. Headaches- frontal & occipital since 3-4 yrs with nausea & vomiting, A/F Change of weather < afternoon , > vomiting
3. Sinusitis watery ---> thick greenish yellow discharge with mild cough,frontal headache A/F Ice Cream, cold drinks, < rainy weather, fan

O/E - Afebrile
Sclera -/Tinge icterus
Chest - Clear
CVS - No murmur
P/A - L /S - Not Palpable
No obvious jt swelling
Pain in extremities on moving

Investigations - Hb 9.2
13/10/97 RBC - 3.1 
WBC - 16,800 L13 M 1
Hypochromia++,Anisocytosis++, Poikilocytosis+
ESR - 75 mm/hr
MT - Negative (15/10/97)


Adv - CBC with MP
ESR
Urine
Widal
RA
Pt admitted in the hospital
27/10/97 evening Hb 8.4
WBC 24,000
ESR 83 mm/min
MP Not detected
Widal Positive
O 1: 160
H 1 : 160
RA Positive 1: 64
Urine WNL

28/10/97 Case Defined-
Physicals - Perspiration Mod Neck + No odor/stains
Cravings - Pickles3, sour2
Aversion - Fish2, Milk2, Vegetables2
Wound healing - pus formation Scars++ hypertrophied+
Motionsickness + bus
Thermal - Chilly pt
Sleep -G
Dreams - Ghosts 2 ;Exam failure
Urine, Stool - N
P/H - Chickenpox, H/O LM in childhood-6 mts of age
F/H - Fa - H.T., O..A.
MGMo - O.A.
Mo & Sis - Rec. URTI
MGFa - Asthma
Developmental landmarks - FTND
Antenatal - No complaints
Milestones - Teething 8 mts > LM
Walking 1yr with support
Talking - Words b.1 yr
Sentences 2-2& half yrs

Mentals - Fearful - Ghosts, insects -- Screams
Gets angry easily- If mo takes sister's side, sister teasing her, if things are not given
Cools down afterwards.Occ back answers
Hobbies - drawing, stitching++
Active in sports
Obstinate
Likes to play with kids or children of her age.No shyness in front of new people
Inquisitive +
28/10/97 Morn Adv -CRP
ASO Titre CXR Evening - CXR -NAD
ASO Titre positive 1: 128 & Rising
CRP Positive 1 : 128

S/B Dr. Rajiv Karnik M.D., D.M. (Cardio)
ECG - NAD
Echo - NAD
Opinion- RHD & Valvular Affections ruled out.To do acute phase reactants & LE (sos)

Fu Summary -
DOA - 27/10/97
DOD - 30/10/97
Rx given --27/10 Tuberculinum 1M (1P)
28/10 Mag Phos 6X 4 Hrly from 8 p.m.
29/10 ct all Generals >+ Myalgias >2
30/10 ct all Generals >3 Pains >++
Pt discharged
2/11 > 3 occ pains Intensity much less ct Mag Phos 6X 4 hrly
Adv repeat CBC with ESR,ASO,CRP,RA

4/11 Overall much better
Hb 11.6
WBC 6400 N38 L56 M4
ESR 70 mm
RA positive 1: 32
ASO positive 1: 128
CRP Negative Mag phos 6X 4 Hrly

7/11 S/B Dr. Pispati (Consulting Rheumatologist for Arthritis & Rheumatism) M.D.M.Sc (Med) B.Sc (Hons) F.R.S.M. (Lon )

Impression - Reactive Arthritis following Pyrexia
Tub 1M (1p) HS
Mag phos 6X 4 hrly
10/11 generals >3 weakness = 0 App = G headaches 0
Pains >++ occ
Tub 1M 1P on 14/11
1p on 21/11
Pt wants to go to native - urgent work.Mag Phos 6X 4 hrly X 10 days
Tried to convince but not convinced

Integration of clinical understanding & Homoeopathic concepts -
* Definite precipitating factors are evident in the case -- Some viral febrile illness 8-10 days prior
-- H/o Inj imferon - known to produce symptoms like the serum sickness due to hypersensitivity
* D.D. -Rheumatic fever -- No other concomitants are present - Influenza - The duration of the fever & no involvement of the mucus membranes goes against it.
Dermatomyositis- Widal - could be false +ve due to 
* Hypersensitivity reaction thrown by the body to a viral antigen or to Imferon particles because of the basic Rheumatic diathesis , affecting the Musculoskeletal System giving rise to typical presentations of myalgias with peculiar modalities.
The overall understanding goes as a non-infective inflammatory complement hypersensitivity type 3 reaction.
* From the above understanding we need to use a deep acting force & also need to define the case in detail. Role of the Intercurrent Tubrculinum in view of Hypersensitivity reactions & Ancillary measures as required (Hot fomentation)
* The characteristic modalities along with the clinical & pathological understanding suggests Mag Phos... Initially it was selected as the acute prescription but the spectacular response prompted us to consider it as a deeper acting force.

Case 3:
Name: ssk D.O.B. 14-5-1959 Male Hindu Brahmin
Education: B. Sc. Occup: Typist Veg.
Family- Parents stay in the Native place
Himself stays with wife in distant Central Suburbs
Chief complaint: 5-6 months knees Pain3 & swelling
G.I. Hyperacidity,Heartburn feel as if mucus in rt side chest. Weakness
1987 Hearing Loss A.F. Injury car Accident Ear
Height 5'2" Weight 43kgs. Lean thin Anxious, Intense, Sharp Features

Nature : Mild , Gentle and Mixing. Has cordial relations with every one. F/H Mother had sever arthritis after his birth. Bed ridden for six months. Mother - Operated for Mitral Valve Stenosis in 1968. Now O.K. P/H 1987 Jaundice sick for 2 months, occ. Flue/cold/headache. 
Food: No aversions/cravings 
Bath Warm
Thermals C3 H1
Path: CBC Hb 14.2 Total 5300 N:66, E:4, L 29, M:1 ESR-20mm
14-5-96 R.A. Test POSITIVE

Follow Up