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Case Study

All Play And No Work...
Dr D J Karat
'Tub-b / Nat-sul

Mast M W, 8yrs, Roman Catholic, Student of III Std, was brought by his mother to one of the free medical camps conducted at Vamadapadavu, a remote village 100 Km from Mangalore on 28/07/2002.
A preliminary enquiry into the case amidst the hustle and bustle, revealed the following details:

Past history of febrile convulsions till the age of 4 years.
At the age of 5 years, he was diagnosed to have Pulmonary Tuberculosis and put under anti-tubercular drugs. Treatment however was stopped after 8 months (before full 9-month course was complete) against medical advice, as mother felt that the child was becoming too weak. Another Paediatrician was consulted and after a chest X-ray, he opined that treatment was successful and chest X-ray was normal.
Since the age of 4½ years, the child has been developing recurrent cold, cough and attacks of breathlessness and has been given multiple courses of antibiotics.
Since 1 year, recurrent blocked sensation and mild ear pain and with cold. But no otorrhoea.
The complaint of cold and ear pain and block has recurred since the previous day. Child was uneasy and had disturbed sleep that night. Nasal discharge was watery, but today is thicker and white.

The child is very weak, lean, and ill tempered, constantly fighting with younger sister. Not very interested in studies. Talented in singing.
His mother is very anxious about him, since he has developed one complaint after another since childhood. She was more worried about him than 3 yr old daughter. O/E-Afebrile. The child was breathing through his mouth.Nasal Mucosa congested, discharge +.
Pharyngeal congestion +
Cervical Lymph-nodes-bilaterally++, firm, non-tender.
R S-Vesicular breath sounds. No added breath sounds heard.
Ear-No discharge at external auditory meatus.
Otoscopy-Not done.
Acute Rhinopharyngitis with Acute Eustachian Tube Catarrh
The P/H/O Pulmonary Tuberculosis, the child’s tendency to easily take cold and the quick progress to involve the Bronchi and Eustachian Tubes indicated a strong Tubercular miasm.
The present complaints of cold with nose-block, thick, white nasal discharge accompanied by ear pain and blocked sensation indicated Kali-mur at sector level.
The patient’s mother was told that the child would require follow up treatment and it would be best if the child could be brought for a more detailed case taking and follow up treatment to the OPD at Mangalore. Even so, it was not really expected that the patient would report because of the distance, the poor transportation facilities and their financial status.

1) Kali-mur 6x TDS for 2-3 days and then SOS.
2) Tub-bov 200 (1P) after present complaints subside.
Advised-To avoid blowing the nose forcefully.
The patient was promptly brought to the OPD at Mangalore on 17/8/2002 by his mother within 2 weeks the medical camp. Such was the improvement that she did not want to stop the treatment. She had never evidenced such a positive response after any treatment schedules her son had undergone. All these treatment schedules had only made her son progressively weaker.
A more detailed case taking was done on 17/08/2002 and the following details emerged.

COMPLAINTS: Recurrent attacks of cold and cough since 3 years. The frequency has increased in the past year and now it is almost every week. The episode starts with sneezing3 worse in the mornings3. This is followed by nose block and coryza, first watery, then thicker, white and soon turning into thick and yellowish discharge. Within the next day or so, he develops cough, usually with white expectoration and breathlessness especially at night. Attacks more in cold weather and rainy season3. Sometimes they are brought on by cold drinks2, but mostly no causative factor is apparent. He becomes quite weak. In the past 1 year he also complains of a blocked sensation in both the ears during cold and slight pain in the left ear. No H/O discharge from the ear. He also develops fever with these complaints with shivering and severe weakness. During fever, he talks gibberish in his sleep. Even when attempting to shake him awake, he does not awaken but continues his unintelligible talk.
1) Every morning, he seems to be breathing with an effort. He does not complain, but his mother has observed and reported this.
2) Also has of peri-anal itching worse at night. Small white worms come out of the anus.

Past History:
- Febrile convulsions till the age of 4 yrs
- Pulmonary Tuberculosis at the age of 5 yrs
Family History:
Mother - Bronchial Asthma
Father - Respiratory Allergy
Grandfather - Pulmonary Tuberculosis. Expired due to Brain Tumor
Patient As A Person:

Appearance - Lean, small face with large upper central incisors. Perspiration - face
Appetite - Poor, claims to be full after taking a very small quantity of food.
Desires - Sweets3 Aversion - Pickles2
Neonatal History - FTND, 3 Kg birth weight. Was Rh incompatible with mother’s blood.
Used to vomit milk after breastfeeding during the first 3 months of life. Had to be bottlefed.
Milestones - Normal. Thermal State - hot

Additional Details:
The patient is described as quite disobedient and willful. He is particularly averse to studying or going to school. He does not listen to his parents specially when asked to study or do schoolwork and does whatever he likes. Quite often, he needs to be beaten to make him study. Even so, he does it just for the sake of it and then cannot remember what he has studied.
Otherwise, a bright child, he has special interest in singing and dancing. He can learn a tune and remember the words of the songs, just on hearing the song once or twice. All day long he is either humming or singing. He is quite active and can’t stay in one room. He is always running around. Even when not well, he still moves around from room to room, even if asked to rest.

Things have worsened after his younger sister was born. He is openly jealous as more attention is given to her. He is constantly fighting with her, yet misses her badly when she occasionally goes out or visits her grandmother’s house.
He gets angry when scolded; throws things and runs away weeping. He gets upset when reprimanded (even as a joke). He immediately believes what is told to him and without even trying to confirm the truth, gets upset and cries. His mother related a small incident which occurred that morning. She had prepared his favorite breakfast. When he got up, she jokingly told him that his father had eaten it all and none was left for him. He immediately started crying without even going to the kitchen to check. Crying was also a means for him to get what he wanted. If he asks for anything, it has to be given to him. Otherwise he cries loudly and will not capitulate to any amount of reasoning or manipulation and will be satisfied only when the object in question is given to him.
He is quite loyal to his family and is protective of his sister when they go out. During the interview when asked, if his parents beat him, he said that they never beat him, despite the mother having admitted the same.

CASE ANALYSIS: Miasmatic Evolution:
The child initially manifested features of Sycotic miasm, with the recurrent febrile convulsions and the delayed developmental landmarks. Later the progress to the Tubercular miasm is evident with the onset of recurrent upper respiratory tract infection, and the onset of Pulmonary Tuberculosis. As time progressed, the child developed more frequent attacks of URTI with yellowish mucopurulent discharge, sometimes with a clear causation but mostly without. The infection from upper respiratory tract showed a rapid progression to the pharynx. Bronchioles and lately the mucosa of the eustachian Tubes, associated with chronic enlargement of the cervical lymph nodes, demonstrating the inherent weakness in the defence and immune systems. These complaints are accompanied by weakness-another important feature of the Tubercular miasm.
The Tubercular miasm is also manifested in some of the personality traits of this child: Aversion to work and study with desire to play constantly. The marked restlessness making him a hyperactive child coupled with a sharp mind and his ability to pick up things fast and retain it is a definite pointer to the Tubercular miasm.

At the sector level, Ars-alb would come up in the early phases of the infective process with the manifestation of watery coryza, cough and breathlessness worse at night with associated weakness and restlessness. Later as the infective process progressed, with yellow discharges, specially when rainy weather is the causative factor, Natrum-sulph would be the simillimum at the sector level.

So far not used, but the constitutional drug selected was Calc-iod as a hot Calcarea, considering the obstinate and weepy nature coupled with deep affection for his family, delayed developmental landmarks, tendency to easily take cold and enlarged and firm cervical glands.

The child was maintained on Tub-bov 200 once in 15 days. He was once given Nat-Sulph 30 SOS and on another occasion Cina 30 O.D. and Teucrium Q 10 drops in 1 Oz of water BD for 4 days when Pin worm infestation became troublesome.

The child showed significant improvement. He now develops occasional colds but only slight watery discharge with sneezing. There is no cough/ breathlessness/ fever/ ear complaints. Breathing with an effort has completely ceased. But Pin worm infestation did not show much improvement even after Cina and Teucriumand an Allopathic physician was consulted  for deworming the child.
Another welcome development that her son who was so averse to studies has now occasionally started studying by himself without any force on the parents’ side. The child is still on treatment and visits the OPD, monthly with his mother.