h1 PDF

STANDARD
TREATMENT
GUIDELINES IN
HOMOEOPATHY
Central Council for Research in Homoeopathy,

Ministry of AYUSH, Govt. of India
2016
©Central Council for Research in Homoeopathy, 2016
ISBN:
Publisher: Central Council for Research in Homoeopathy

Updated: 10th July 2016
Disclaimer
While it is hoped that the book may prove to be a concise and ready reference, it makes no
pretension to being anything more than an introduction to the important conditions; in no
sense it is put forward as complete treatise. Readers are advised to check the most current
information. It is the responsibility of the practitioners, relying on his/her clinical experience
and knowledge of the patient, to make diagnosis, to determine dosages and the best
treatment for each individual patient and to take all appropriate safety precautions.
Central Council for Research in Homoeopathy
STANDARD TREATMENT GUIDELINES IN HOMOEOPATHY
Contents
S.no Topics
I. Foreword
II. Preface
III. Acknowledgement
IV. Introduction and how to use the book
V. Homoeopathic management of diseases
1. Acute otitis media
2. Alcohol dependence
3. Attention deficit hyperactivity disorder
4. Benign prostatic hyperplasia
5. Cancer
6. Depression
7. Diabetes mellitus
8. Diarrhoea
9. Hypertension
10. Irritable bowel syndrome
11. Menopause
12. Polycystic ovarian syndrome
13. Psoriasis
14. Rhinitis
15. Sinusitis
16. Urolithiasis
17. Uterine fibroids
18. Vitiligo
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AJIT M. SHARAN SECRETARY
GOVERNMENT OF INDIA
MINISTRY OF AYURVEDA, YOGA & NATUROPATHY
uNANt, SIDDHA AND HOMOEOPATHY (AYUSH)
INA, NEW DELHI. 110023
Tel. :01 1-246519S0, Fax : 01 1-24651997
E-mail : [email protected]
Foreword
Globally' health service delivery institutions

shrinking resources, competing are engaged in addressing problems of
;",";;;.,';ffi;l*ij'lt
Standard treatment guioeiineslsrCsl p".,u,ions for quarity services.
outrine the p."r..?J treatment for health
They can be the channel to intpi.tnofe problems.
and contriurt. to 1,*lth ard well-being
the best care to every patient dv by providing
u.,r,glrg together integrated clinical practice,
research' A src offers advantages education and
to'leatttr .u." p.orIa"., (by giving an expert
quality o.f care standard. and bisis consensus,
for moninring), supply manager s (by making demand
more predictable and ailowingfor
pre-pa.ckagirsi'i"i,;;r:.J
and treatment fficacv) ano"heattrr poti"y @y provrding more consistency
integration of speciar programs and pimoting
;;!;t rii'"'prgviding focus for therape,ic
fficient use offunds).
2' The central council for Research,in
HomoegRathv (ccRH) is an autonomous body
under Ministry of AYUSH which undertakes
..r"u..h i, irnau."ntal and applied aspects of
Homoeopathy' clinical research studies
explore the effectiv.n.s. orrromoeopathy in
disease conditions' A considerable specific
number of observatiorui- rtuai., as well as randomized
control trials have been conducted in
specific disease conditions. There is a need to
consolidate these research findings for
the benefit ortrre p.oression and patient both.
3' Based upon the information available

in the authoritative texts, outcome of
research studies conducted globally the
and the expert guidance, ccRH has prepared these STGs
which could be considered as a noiable
u"ginrirg ii'thisu."u ro. the benefiiof homoeopathic
practitioners' both in govemment
and private slctors. These shall aid in development
standardised therapeutic approach for patients of a
una gir. ffitus to evidence based clinical
practice in homoeopathy.
4' I am pleased to support this initiative undertaken

by ccRH. I hope this document will
be updated with passing iir" on the uurrc or emerging scientific evidence and
additions of
other diseases as well.
New Delhi (Ajit M. Sharan)

23'd May,2016
Preface
It was often said that “Homoeopathy treats the patient and not the disease” but the
relevance of the statement was only limited to olden days when disease diagnosis was
not much developed. The statement only highlighted the fact that a homoeopathic
practitioner could treat/ provide relief to a patient based on the available
symptomatology barring the nosological labelling which wasn’t that well developed.
Knowledge about diagnosis in earlier times was limited and was primarily done for
prognosis of the case. With advances in sophisticated techniques, medical diagnosis
has come a long way, from empirical diagnosis to clinical and laboratory diagnosis
which has widened its scope in management of the patient.
This advancement in medical field has been of paramount importance for a

homoeopathic practitioner as well who is faced with the challenge of treating various
diseases. A homoeopathic physician has a dual task of establishing a disease diagnosis
as well as a patient diagnosis as per the individualistic holistic approach of the system
of medicine. Both are vital in identification of the indicated remedy for the
management/treatment of the patient. Casual observation, as well as more systematic
study of prescribing practices, frequently reveals a pattern of tremendous diversity
among prescribers in the treatment of even the most common conditions. A Standard
Treatment Guideline (STG) which provides standardized guidance of diagnosis and
therapeutic management of a diseased condition can be a solution to this therapeutic
anarchy. Also, a simplification of treatment can facilitate the objective appraisal of
value of homoeopathic system of medicine.
Over the years, RCTs/ Observational studies, experiences of homeopathic

practitioners have tried to identify remedies suitable for various disease conditions
per se. The Council with the aim of conducting research on scientific lines in
Homoeopathy has completed 119 clinical studies and has collected data of most useful
medicines in various diseases.
Council has made an attempt to develop a standardised guideline for management of

diseases, based on expert consensus, review of current published scientific evidence
of acceptable approaches to diagnosis, management and/or prevention of specific
diseases; data from research studies. Such a systematically developed statement can
assist practitioners in rational decision making about appropriate health care for
specific clinical circumstances, help maintain quality standards and also represent one
approach in promoting therapeutic effective and economically efficient prescribing.
In the beginning of this initiative, eighteen diseases have been identified. Each
condition gives clear presentation of definition, symptoms, epidemiology, diagnosis,
differential diagnosis and its general management. Apart from this the STGs also
include information about various outcome measurable questionnaires which can be
used by the homoeopathic practitioner for disease assessment, treatment evaluation
(follow up) and research. An algorithm of the treatment process given at the end of
each disease condition helps in having bird’s eye view of disease and also indicate
appropriate time of referral.
The book puts forward a group of medicines found most commonly indicated in each
disease as identified from published research papers, MateriaMedica and inputs of
experienced homoeopathic practitioners. These STGs are prepared for wider
dissemination and implementation by the practitioners at large. The Council welcomes
inputs and experiences of practitioners for betterment of these guidelines and looks
forward to continuous updating.
While it is hoped that the book may prove to be a concise and ready reference, it
makes no pretension to being anything more than an introduction to the important
conditions; in no sense is it put forward as a complete treatise. Readers are advised to
check the most current information. It is the responsibility of the practitioner, relying
on his/her own experience and knowledge of the patient, to make diagnosis, to
determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.
Dr Raj. K. Manchanda
Director General
Central Council for Research in Homoeopathy
ACKNOWLEDGEMENT
Facilitation and guidance
Dr Raj K. Manchanda, Director General, Central Council for Research in Homoeopathy
(CCRH), New Delhi
Content planning and technical expertise
Dr. Anil Khurana, Deputy Director General, Dr Praveen Oberai, Scientist -4, and Dr. Varanasi
Roja, Research officer (H)/Scientist -2, CCRH
Review and critical appraisal
Dr. Manjit Singh, Neurologist, Former Addl. Cum Medical Superintendent, Safdarjung
Hospital, New Delhi, Dr. S.K. Nanda, Director, National Institute of Homoeopathy, Kolkata,
West Bengal, Dr. Lalit Verma, Secretary, Central Council of Homoeopathy, New Delhi, Dr.
V.K.Gupta, Former principal , Nehru Homoeopathic Medical College and Hospital, New
Delhi, Chairman, Scientific Advisory Committee (SAC), Dr. C. Nayak, Former Director
General, CCRH, Chairman, Special Committee for Fundamental and Collaborative research,
CCRH, Dr.L.K.Nanda, Former Principal cum Superintendent, Dr. A.C. Homoeopathic Medical
College and Hospital, Bhubaneswar, Odisha, Member , SAC, CCRH, Dr. Kusum Chand,
Medicine Specialist, Visiting Consultant, CrossLay Hospital, New Delhi, Dr. Mohit Mathur,
Professor, Nehru Homoeopathic Medical College and Hospital, New Delhi,
Dr.SandhyaRastogi, Reader, BR Sur Homoeopathic Medical College and Hospital, New Delhi,
Dr. Pankaj Bhatnagar, Homoeopathic consultant, Member Governing body, Central Council
for Research in Homeopathy, New Delhi, Dr.Nandini Sharma, Homoeopathic consultant,
Member Governing body, CCRH, Dr.K.M. Dhawale, Director, Dr.Dhawale Memorial trust,
Mumbai (DMT), Chairman, Special Committee Clinical Research, CCRH, Dr. Bipin Jain,
Dr.SunitaNikumbh,Dr. Sachin Junagade, Dr.TruptiSwain,Dr. Swapnil Naik,Dr.AnandKapse,
Dr. Dinesh Rao, Dr. NikunjJani,Dr.Bhavik Parekh,Dr. Sunil Bhalinge,Dr.ShamaNayak, DMT,
Dr. VeenuKrishnan,
Content drafting and editing
Dr. Varanasi Roja, Research officer (H)/Scientist -2, Dr. Anupriya, Research Associate (H),
CCRH.
Contributors for document development
Dr. Anil Khurana, Deputy Director General, Dr Praveen Oberai, Scientist -4, Dr. Varanasi
Roja, Research officer (H)/Scientist -2, Dr. Chetna Deep Lamba, Research officer
(H)/Scientist -2, Dr. Divya Taneja, Research officer (H)/Scientist -1, Dr.Anupriya, Research
Associate (H), Dr. Rupali Dixit, Research Associate (H), Dr. SwapnilKamble, Research
Associate(H), Dr. Deepti Dewan, Consultant(H), Dr. Kalpana Gautum, Senior Research
Fellow(H), Dr. Ashish Dixit, Senior Research Fellow(H), CCRH, Dr. Sandhya Kashyap, Senior
Research Fellow(H)
Secretarial assistance: Hem Chaudhary &Vandana Sharma.
INTRODUCTION
The Quality and standard health care delivery is very important for the people of a
country. To have quality control and assurance set standards are required to reach the
target harmonized health care delivery. Standard Treatment Guidelines (STGs),
systematically developed statement designed to assist practitioners and patients in
making decisions about appropriate health care for specific clinical circumstances are
one such document.
Standard Treatment Guidelines (STGs) have been in vogue in India only since
recent times and is gaining popularity among practitioners, with its uniform guidelines
have advantage in bringing together the patients, healthcare providers, drug
manufacturers and marketing agencies, and above all, the policy makers and the
legislative system of the country. The drawback in STGs lies in the difficulties in
implementation on a large scale.
Homoeopathy is a holistic system of medicine wherein patients are treated with
an individualistic approach. Here the treatment is given tailored to each patient. Quality
control and assurance can be achieved by following uniform guidelines which is in
consonance with the available homoeopathic literature, modern medicine, research and
day to day practice. In pursuance to Ministry of AYUSH, Government of India, Central
Council for Research in Homoeopathy has taken a lead and developed standard treatment
guidelines for both acute and chronic diseases.
The set of conditions included is not exhaustive, but rather is based on the
conditions recommended for management and treatment in day to day practice. It is
emphasised that the choices described here have the weight of scientific evidence to
support them, together with the collective opinion of a wide group of recognised experts.
Recommended treatments are primarily limited to the medicines which were published
in research papers, opinion of experts, experience in homoeopathic practice. It also
covers medicines enlisted in essential drug list (2012).
This standard treatment guidelines (STGs) is designed for use by a homoeopath at all the
levels delivering the Health Services. The guidelines can also be used by general
practitioners in their private practice. The STGs are designed to be used as a guide to
treatment choices and as a reference book to help in the overall management of patients,
such as when to refer.
1
The research recommendations used have been rated on the following WHO ratings:
Evidence rating A − requires at least one randomised control trial as part of a body of
scientific literature of overall good quality and consistency addressing the specific
recommendation.
Evidence rating B − requires the availability of well−conducted clinical studies but no

randomised clinical trials on the topic of recommendation.
Evidence rating C − requires evidence obtained from expert committee reports or

opinions and/or clinical experience of respected authorities. This indicates an absence of
directly applicable clinical studies of good quality.
The content of these treatment guidelines will undergo a process of continuous review.
Comments or suggestions for improvement are welcome. Those comments or
suggestions for addition of diseases should include evidence of prevalence as well as a
draft treatment guideline using the format set out in this book.
HOW TO USE THIS BOOK?
To use these guidelines effectively, it is important that you become familiar with the
contents. Take time to read the book and understand the content and layout.
The contents of this book have been arranged in alphabetical order/acute/chronic.

Within each section, the disease which are significant with research outcome both
nationally and internationally have been identified. For each of these disease states the
structuring of the information and guidance has been standardised to include a brief
description of the condition or disease, more common signs and symptoms, general
management followed homoeopathic treatment choices and flow chart of entire
condition.
The book also incorporates the assessment scales used by across the globe by researchers
and to some extent by physicians can also be used for making homoeopathy evidence
based system of medicine.
Homoeopathic therapeutics have been suggested, which includes the characteristic

physical and mental generals and particular symptoms related to the disease. The pattern
2
has been adopted to emphasize on holistic approach of homoeopathic treatment which
forms the fundamental basis of prescription.
REFERRAL
These guidelines also make provision for referral of patients to other health facilities.
Patients should be referred when the prescriber is not able to manage the patient either
through lack of personal experience or the availability of appropriate facilities. Patients
should be referred, in accordance with agreed arrangements, where the necessary,
diagnosis and support facilities exist. The patient should be given a letter or note
indicating the problem and what has been done so far, including laboratory tests and
treatment. When indicated for referral minimal treatment must be given before the
patient reaches to a physician/hospital of referral.
3
HOMOEOPATHIC MANAGEMENT OF DISEASES
Introduction
Homoeopathy, a therapeutic system of medicine discovered by a German physician, Dr.

Christian Friedrich Samuel Hahnemann (1755-1843), in the late eighteenth century based
on fundamental idea of similarity (or similia) principle: Similia similibus curentur: “let likes
be treated by likes”. This implies that substances capable of causing disorder in healthy
subjects are used as medicines to treat similar patterns of disorder experienced by ill
people.1 These substances in diluted form are believed to stimulate the body’s self-
regulatory mechanism and a healing response in the body. The other important principles
of the system include: Law of Simplex, Law of Minimum Dose, Doctrine of Drug Proving,
Theory of Chronic Diseases, Theory of Vital Force, and Doctrine of Drug Dynamization.
Holistic concept of Health and Disease
A holistic model of health in Homoeopathy, taking an overview of the patient, including

their individual mind, body and spirit, life situation and other circumstances, is central in
evolving a curative approach to chronic and complex diseases. The holistic view uses the
totality and the constitution of each patient to find a remedy that suits him/her, rather than
just the disease. This is a paradigm shift from the conventional model of treatment
approach, i.e. how illness is viewed.2, 3,
Selection of Medicine
The medicine selected for each patient is tailored to person specific, taking into
consideration4, 5 his/her mental make-up, physical symptoms, and characteristic particulars
etc. In case of long term illness besides the above mentioned factors, age, occupation,
previous illnesses and life circumstance unique to that individual irrespective of the
disease which he/she is suffering from, are taken into consideration; thus the dictum
“Homoeopathy treats the patient and not the disease”.
1WHO. Homoeopathy: Overview and analysis of clinical research. December 2006 [unpublished]
2FritjofCapra, The Web of Life: A New Scientific Understanding of Living Systems -1996
3 David Owen. Principles and Practice of Homeopathy. Elsevier Ltd. Churchill Livingstone.2007
4Carlston C. Classical Homoeopathy. Philadelphia, Pennsylvania; Elsevier sciences: 2003
5 Hahnemann Samuel. Hahnemann, S. Organon of Medicine, 5 & 6 Ed. Delhi: Birla Publications, 2003
4
Selection of potency
After the appropriate medicine is selected, it is essential to decide the requisite potency, dose
and repetition which is imperative for optimum response and faster recovery in each case.
Different types of potencies such as centesimal/ decimal/ 50 millesimal potencies can be
employed for treatment of both acute and chronic diseases. However, selection of potency
of the remedy is dependent on various factors like susceptibility of the patient (high or
low), type of disease (acute/chronic), seat/ nature and intensity of the disease, stage and
duration of the disease and also the previous treatment of the disease.6 In this context,
given below are the basic rules as evolved through experience:
 The closer the similarity a remedy bears to the picture presented by the patient, the
higher is the potency, provided no specific contra-indications to the use of high
potencies exist in the case.
 A prescription that is predominantly determined by the mental symptoms in a case,
gives best results when higher potencies are employed.
 When a prescribing for advanced pathological conditions it is advised to begin the
treatment of the case with a remedy in lower potency.
Repetition of the remedy

The repetition of the remedy in regard to potency and dosage is almost as important as the
selection of the remedy itself. The selection of the remedy can hardly be said to be finished until
the potency and dosage have been decided upon. 5, 7,8:
Centesimal scale
 Low potencies may be repeated frequently whereas high potencies are not to be
frequently repeated.
 In acute diseases, the medicine may be repeated at very short intervals of every
24, 12, 8, 4 hours or even every 5 minutes.
 In chronic cases, the medicine may be repeated at the interval of 14, 12, 10, 8 or 7
days.
 In chronic diseases resembling acute diseases, the repetition may be made at still
shorter intervals. In these cases, either repeated doses of a low potency of the
remedy are given till the patient is cured or a single dose of high potency is
administered followed by placebo till recovery ensues.
6Close S. The Genius of Homeopathy: Lectures and Essays on Homeopathic Philosophy. New Delhi; B Jain
Publishers : 183-211
7 Kent JT Lectures on Homoeopathic Philosophy. North Atlantic Books, 1992: chapter 35
8CCRH. Handbook on Case taking to prescribing; New Delhi; 2011
5
LM scale
 In acute diseases- every 2,3,4,6 hours
 In very urgent cases- every hour or oftener
 In long lasting diseases the medicine may be repeated daily or every second
day
Remedy response
After the administration of the similimum, some results are expected. Further prescription
largely depends on the response of the patient to the remedy and proper interpretation of
the remedy response. The remedy response can be understood in respect to: aggravation,
amelioration, disappearance, no change/status quo and change in the order of the
symptoms.
1. Aggravation
There are two types of aggravation, either of which may manifest. The first relates to an
aggravation of the disease condition, in which the patient becomes worse. Another type of
aggravation is where the symptoms of the patient are worse, but the patient feels better.
Aggravation of symptoms may manifest in the following manner after the administration of
a medicine:
1.1. The aggravation is quick, short and strong with rapid improvement of the
patient.
Interpretation: The response of the patient is satisfactory. There is no much tissue
change, or very superficial, if any. The potency was a bit higher. The medicine was
most similar one. An aggravation of this kind is very much reassuring
Prognosis: Very good
Follow-up action: Wait and watch
1.2. Long aggravation but final and slow improvement.

Interpretation: After a prolonged aggravation, the patient improves slowly. This
indicates the beginning of definite structural change in some organs but the disease
has not progressed quite so far. The medicine was right but the potency was high.
Though there have been enough tissue changes but the medicine would act for a
very long time. The patient was on the borderline and had the disease condition
gone further, cure would have been impossible.
Prognosis: Favorable
Follow- up action: Not to disturb till the action of the medicine has exhausted.
6
1.3. A prolonged aggravation and final decline of the patient.
Interpretation: The case is incurable since there has been enough irreversible tissue
changes in the patient. The medicine prescribed may or may not have been a correct
one but the potency was very high. The medicine was deep acting in nature,
therefore, instead of helping it has established destruction.
Prognosis: Bad
Follow up action: It necessitates immediate anti-doting. After re-case taking a more
similar medicine in low potency is to be given. Deep acting medicine and high
potency should not be used in chronic and doubtful cases especially where tissue-
change may have occurred.
1.4. Some patients prove every remedy they get.

Interpretation: Some patients are hypersensitive and have a tendency to be affected
by everything, i.e they are idiosyncratic. These patients go on to prove every
medicine they take and while under the influence of that medicine they are not
under the influence of anything else. The medicine has its prodromal period, its
period of progress and its period of decline. Such patients are good provers and are
often incurable.
Prognosis: They are useful for the purpose of homoeopathic drug proving.
Follow up action: These hypersensitive patients should be given medicine in the
lower potencies preferably 30th and 200th both in acute and chronic conditions.
2. Amelioration
When the symptoms are ameliorated, the physician has to observe the pattern in greater
detail and note especially the sequence of events, the duration, etc. which will enable the
physician to judge whether the amelioration is long lasting or due to the palliation.
2.1 Disappearance of symptoms/no aggravation with recovery of the patient.

Interpretation: The medicine was the most similar one and the potency exactly
fitted the case. There was no organic disease or any tendency towards organic
change. The trouble was only a functional disorder. This is an example of highest
order of cure, mostly in acute disease conditions.
Prognosis: Very good
Follow up action: Wait and watch. Assessment to be done as per the nature of the
disease. This case may not require further repetition of medicine.
2.2 The amelioration comes first and the aggravation comes afterwards.
7
Interpretation: The medicine was palliative in nature, or it was only
partially/superficially similar or the patient was incurable and the remedy was
somewhat suitable. In depth assessment may show that in majority of the cases
the remedy was only similar to the most grievous symptoms and did not cover the
whole case.
Prognosis: Bad
Follow up action: A more similar medicine is to be given after re-casetaking.
2.2 Too short relief of the symptoms.
Interpretation:
A) In acute diseases:
1. High grade inflammatory action is present that organs are threatened by
the rapid processes going on. The infection is violent/virulent in nature.
B) In chronic disease:
1. The medicine was partially similar, or
2. There is a condition which interferes with the action of the remedy, or
3. Structural changes have occurred, or organs are destroyed or are in very
precarious condition.
Prognosis: Very bad (especially in chronic diseases)
Follow up action: Medicine complementary to the first prescription should be
prescribed in acute conditions.
A more similar medicine is to be found out and given in a chronic condition or if
the patient is incurable and the subsequent medicine should be of palliative
nature.
2.3. A full time amelioration of the symptoms, yet no special relief of the patient.
Interpretation: There are latent conditions (existing organic conditions) in a few

patients that prevent improvement beyond a certain limit. For example, a patient
with one kidney or bigger part of the lungs having been calcified / fibrosis. Hence
the patient is curable only to a certain limit. Suitable palliation has been brought
about by the homoeopathic remedies.
Prognosis: Bad
Follow up action: Palliative medicine should be prescribed.
3. No Change / Status Quo
Interpretation: when no change is observable in the symptomatology in a patient, even

after waiting for an adequate period of time and a careful re-evaluation reveals no error in
the previously administered remedy, the inference may be drawn that the susceptibility of
8
the patient was not such as to be favourably affected by either the number of doses
administered or the potency selected.
Prognosis: Cannot be predicted definitely unless right remedy with proper dosage is
administered
Follow up action: Intercurrent medicine may be prescribed.
4. Change of Symptoms
5.1. New symptoms appearing after the remedy.

Interpretation: The medicine was wrong. Greater number of such symptoms
indicates towards a dissimilar selection of medicine.
Prognosis: Bad
Follow up action: If the symptoms are not of serious nature we should wait till the
new symptoms pass off and the patient settles down to original state. After re-case
taking a more similar medicine is to be given. If the symptoms are of serious nature
and threatening it has to be antidoted.
5.2 Old symptoms are observed to reappear.

Interpretation: The medicine has been very right. Appearance of old symptoms
indicates that the patient is curable.
Prognosis: Good.
Follow up action: The action of the medicine should not be disturbed. Only if the
reestablished symptom/discharge/eruption stays for pretty long time, the medicine
may be repeated. Here old symptom/diseases may come and go in the reverse
order of their appearance. (Following Hering’s Law of Cure)
5.3 Symptoms take the wrong direction.

Interpretation: When the symptoms go from periphery to the centre, the remedy
administered was a wrong one.
Prognosis: Very bad.
Follow up action: It has to be antidoted at once. A more similar remedy has to be
found out and given.
Inspite of best efforts in any disease condition, if a favorable response to the treatment is
not achieved, it is advised to refer the case as per the guidelines given in STGs for individual
disease.
Advantages of Homoeopathy
 Treatment with homoeopathic medicines is safe, effective and based upon natural
substances. With the use of single simple substance in micro-doses, medicines are not
9
associated with any toxicological effect and can be safely used for pregnant women and
lactating mothers, infants and children and in the geriatric population.
 Medicines, instead of having a direct action on the micro-organisms, act on the human
system (self-protective) to fight disease process. As such, no microbial resistance is
known to develop against homoeopathic drugs.
 The mode of administration of medicines is easy. There are no invasive methods and
medicines are highly palatable, thereby enhancing treatment compliance.
 Lack of diagnosis is not a hindrance for initiating treatment with homoeopathic
medicines.
 Individualized approach for treatment which is the mainstay in Homoeopathy is in
consonance with increasing need for customized treatment, being realized in the
modern era.
 Homoeopathic remedies are non-addictive and once relief occurs, the patient can easily
stop taking them.
 Treatment is cost-effective.
10
ACUTE OTITIS MEDIA
CASE DEFINITION
Acute otitis media (AOM) is defined as the presence of inflammation in the middle ear
accompanied by the rapid onset of signs and symptoms of an ear infection.1
INCIDENCE
 The clinic-prevalence of AOM is 35% annually with peaks reported in July and
December.2
 By the age of 5 years, 80% of all children would have suffered from at least one
episode of AOM.
 Otitis media is the cause of nearly 20% of all hearing loss3.
AETIOLOGY
Typically the disease follows the viral infection of the upper respiratory tract but soon the
pyogenic organisms invade the middle ear. Most common organisms responsible for the
disease in infants and young children are Streptococcus pneumoniae (30%), Haemophilus
influenzae (20%) and Moraxella catarrhalis (12%). Other organisms include Streptococcus
pyogenes, Staphylococcus aureus and sometimes Pseudomonas aeruginosa.4
ROUTE OF INFECTION4
1. Via Eustachian tube: most common route, infection travels via the lumen of the tube.
Eustachian tube in infants and younger children is shorter, wider and more
horizontal so may account for higher incidence of infection.
2. Via External ear: perforation of tympanic membrane due to any cause open a route
to middle ear infection.
3. Blood-borne: uncommon route.
1
British Columbia Medical Association. Otitis Media: Acute Otitis Media (AOM) & Otitis Media Effusion
(OME). Guidelines & Protocols Advisory Committee. [cited April 05, 2015]. Available at
http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/bc-guidelines/otitis-
media
2 D'silva L, Parikh R, Nanivadekar A, Joglekar S. Survey of Indian pediatricians: Clinic-prevalence, diagnostic
and management strategies for acute otitis media. Pediatric Infectious Disease 2013;5 (4): 165 - 171
3 Deshmukh C; Acute otitis media in children--treatment options. Journal of Post Graduate Medicine
1998:44(3): 81-4.
4 Dhingra PL & S; Diseases of Ear, Nose and Throat; 5th Edition; Elsevier, A division of Reed Elsevier India
Private Limited; New Delhi; 2010: 69.
CCRH 1 Updated on 10th Jul, 16

RISK FACTORS 2,5,6
The following are proven risk factors for otitis media:
 Frequent upper respiratory tract infection
 Prolonged bottle use
 Nasal allergy
 Recurrent ear infection in siblings
 Day care attendance outside home
 Genetic predisposition
 Cleft palate
 Prone sleeping position
 Improper way of breast-feeding
DIAGNOSIS1, 2,3, 7
Clinical presentation
 Ear pain (otalgia)
 Irritability/excessive crying
 Fever
 Cough
 Nasal discharge/stuffiness
 Vomiting
 Loss of hearing
 Rubbing or holding of the ears with crying
 Other complaints: increased pulse rate, malaise, disturbed sleep, loss of appetite,
cold symptoms, child become less playful or active and occasional balance problems.
Otoscopy findings1
 Opaque, bulging of ear drum,
 Inflamed tympanic membrane/redness of tympanic membrane
 Reduced or absent mobility of tympanic membrane
 loss of landmarks
Although pneumatic otoscopy is helpful in the diagnosis of AOM, it is not routinely

performed as it may elicit severe pain.
5 Donaldson JD. Acute Otitis Media; [cited 2014 Dec. 15,]. [Updated 2015 23 Feb.] Available at
http://emedicine.medscape.com/article/859316-overview
6 Uhari M, Mäntysaari K, Niemelä M.A Meta-analytic review of the risk factors for acute otitis media. Clin
Infect Dis. 1996; 22(6):1079-83
7 Kliegman RM, Behrman RE, Jenson HB, Stanton BF; Nelson Textbook of Pediatrics;Vol.2;18 th edition.New
Delhi ; Elsevier India Private Limited; 2010: 2633-34

Natural history and stages of AOM 4,8
Spontaneous recovery from recurrent acute otitis media is common with increasing age9.
AOM symptoms improve within 24 hours without antibiotics in 61% of children, rising to
80% by 2 to 3 days10. However, the disease runs through following stages:
(I) Stage of tubal occlusion: This is due to inflammatory occlusion of the eustachian tube.
Patient has a feeling of ear blockage, pain, hearing loss and associated symptoms. Pain may
also be referred to the throat or teeth. There is generally no fever.
O/E: The tympanic membrane is congested and retracted. A pneumatic otoscopy can
induce an aggravation of the pain. Tuning fork tests demonstrate a mild-moderate
conductive hearing loss.
(II) Stage of pre-suppuration: This stage occurs following exudation into the middle ear
cleft and gradually starts pushing the tympanic membrane outwards. The intensity of pain
increases as does hearing loss which may disturb sleep and pain is of throbbing in nature.
Usually, child runs high degree of fever and is restless.
O/E: The tympanic membrane is seen grossly congested with loss of landmarks.
(III) Stage of suppuration: As the inflammatory process proceeds, the exudative fluid
becomes purulent in nature with polymorphs. The pain at this stage is excruciating.
Deafness increases, child may run fever of 102-103oF. This may be accompanied by
vomiting and convulsion.
O/E: Otoscopy shows a bulging tympanic membrane and often a pointing may be
appreciated. Sometimes a fluid level behind the membrane may be seen.
(IV) Stage of resolution: At this stage, if the inflammation persists, the tympanic
membrane rupture at its weakest part and the purulent discharge comes out from this
perforation into the external auditory canal. The patient would now present with muco-
purulent ear discharge which may be initially blood stained. The otalgia reduces and
resolution of symptoms may occur.
(V) Stage of complication: If tympanic membrane does not rupture and the inflammation
continues, stage of complication occurs. The importance of the first attack of AOM in young
children lie in the fact that subsequent long lasting dysfunction of the Eustachian tube may
8 AFMC; Standard Treatment Guidelines Medical Management & Costing of Select Conditions; In
Collaboration with Ministry of Health & Family Welfare Government of India & WHO Country Office, India;
Armed Forces Medical College, Pune: 2007: 103-104
9 Alho OP, Laara E, Oja H; What is the natural history of recurrent acute otitis media in infancy? The Journal
of Family Practice (1996), 43(3):258-264
10 Rosenfeld RM and Kay D. Natural history of untreated otitis media. The Laryngoscope 2003; 113(10):
1645–57.

lead to chronic serous otitis media (Glue ear)11. These complications may be range from
intra-temporal like mastoid abscess, facial nerve palsy, and labyrinthitis to intra-cranial
complications like extra-dural abscess, meningitis, sub-dural abscess, brain abscess etc. The
patient’s general condition worsens and increasing fever and otalgia are indicative of
emergence of complications. In this stage imaging modalities are required to further
diagnose and treat. These are also known to progress to chronic phase and can affect the
bones of the middle ear and hence cause hearing deficit.
Investigations
The diagnosis is essentially clinical and no investigations are required.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis includes any condition having otalgia. Common ones include: -
 Otitis externa
 Furunculosis
 Impacted wax
 Foreign body in the external ear canal
 Conditions causing referred otalgia i.e. oropharyngeal and dental infections.
PREVENTION3
 Washing hands frequently is the single most important thing that can prevent AOM.
 Prolonged and proper breast feeding protects the infant from chronic otitis media
and is known to reduce H. Influenzae infections.
 If the child is bottle-fed then he should be fed in upright position.
 Avoiding exposure to tobacco smoke (passive smoking).
RED FLAG
 No change or progressing Otalgia
 Worsening of general condition
 Evidence of complications like headache, vomiting, vertigo, mastoid abscess etc.
MANAGEMENT
Clinical research in homoeopathy suggests that over the-counter homeopathic medicines
offer pragmatic treatment alternatives to conventional drugs for symptom relief in children
suffering with uncomplicated AOM 11 . Numerous clinical studies demonstrate that
homeopathy accelerates early symptom relief in acute illnesses at much lower risk than
11Bell
IR. Homeopathic Medications as Clinical Alternatives for Symptomatic Care of Acute Otitis Media and
Upper Respiratory Infections in Children. Global Advances in Health and Medicine 2013;2(1):32-43

conventional drug approaches. Evidence-based12,13,14,15advantages for homeopathy include
lower antibiotic fill rates during watchful waiting in otitis media, fewer and less serious
side effects, absence of drug-drug interactions, and reduced parental sick leave from work.
General management has its role to play along with medicinal treatment. Counseling
should be given to the parents of the patients by giving information regarding avoidable risk
factors and also about advice about the correct method of breast- feeding and burping after
meals. Further the following advices are also necessary:
 Avoid putting baby down for a nap
 Avoid exposing baby to passive cigarette smoke
 Don’t allow sick children to spend time together
 The ear should be kept dry and nothing should be instilled into the ear
 The patient should be advised not to blow the nose and wash hands frequently
 Steam inhalation may be advised.
In homoeopathic texts approximately 67 medicines have been given16. Given below are few
commonly prescribed medicines with their indications, enlisted from experiences, research
papers and text books.
S.No. Medicines Indications

1. Belladonna Child suffers from otitis media which may cause delirium and
he often cries out in sleep; throbbing and beating pain deep in
ear, synchronous with heart beat. Inflamed red ear drum,
often combined with reddened throat, cold extremities, high
fever, throbbing pains in the ears. Other symptoms may be
sudden, violent effects, dryness, bright redness, burning heat,
throbbing pains, appear and disappear suddenly. Worse:
afternoon (3 p.m.), drafts, washing head, after taking cold.
Better: light covering, rest in bed.
12Jacobs J, Springer D A, Crothers D; Homoeopathic treatment of acute otitis media in children: a preliminary
randomised placebo controlled trial. Pediatric Infect Dis. J., 2001;20: 177-83.
13 Friese KH, Kruse S, Lüdtke R, Moeller H.The homoeopathic treatment of otitis media in children--
comparisons with conventional therapy. Int J Clin Pharmacol Ther. 1997;35(7):296-301

14 Frei H, Thurneysen A. Homeopathy in acute otitis media in children: treatment effect or spontaneous
resolution? Br Homeopath J. 2001;90(4):180-2.

15 Fixsen A. Should homeopathy be considered as part of a treatment strategy for otitis media with effusion in
children? Homeopathy. 2013 Apr;102(2):145-50.

16Schroyens F. Synthesis Repertory. RADAR Repertory Program. Treasure edition. CD ROM. Archibel:2007

2. Chamomilla Otalgia with soreness, swelling and heat, unbearable pain
driving the child frantic. Ears feels stopped. Ringing in
ears. Worse: heat, anger, open air, wind and night. Better:
being carried, warm wet weather.
Child is in state of whining restlessness, can only be quieted
when carried about and petted constantly. Irritable,
quarrelsome, nothing pleases. Asks for something then rejects
it. Oversensitive to all external impressions. One cheek red,
other pale, hot, thirsty for cold drinks.
3. Pulsatilla Indicated when earache comes on in the middle of the night.
nigricans External ear and meatus is red, decreased hearing as if the ear
were stuffed. Earache following a cold. Worse, at night, warm
room, lying on painless side. Better: open air, motion, cold
applications.
Child is mild, gentle, affectionate, yielding with weeping
disposition. Children like fuss and caresses. Hot patient,
thirstless with great dryness of mouth.
It is also indicated in the chronic phase when there are thick,
profuse, yellow or yellowish-green, bland discharges worse in
evening and warm room, better from open air.
4. Sulphur Child comes with much itching in ears, changing to pain when
attempting to scratch them; dirty offensive, sometimes sour
smelling pus flowing from ears; children averse to having
them washed. Bad effects from the suppression of an
otorrhœa. Sharp pain, worse on left side. Earache with painful
ringing in the ears. Worse: from heat, atmospheric changes.
Better: by open air.
Child is nervous, quick tempered, emotionally irritable and
sluggish, Hot patient, restless sleep, thirsty for cold drinks,
worse 5 A.M. It is also indicated in the chronic phases.
5. Calcarea Child comes with throbbing, ear pain with decreased hearing
Carbonica and heat in the ears with or without enlarged cervical lymph
nodes. Purulent discharge from the ears. Profuse, often sour
discharges.
Child is timid, obstinate, and fearful, shy, slow and sluggish.
Chilly patient, takes cold easily. Fat, fair, flabby; large head,
distended abdomen; pale, weak, easily tired; head sweats
profusely while sleeping; tendency to lymphatic glandular
enlargement; sour smelling discharges; longing for fresh air;
desires for eggs and indigestible things; aversion to meat and
milk. Worse: from cold in every form, getting wet, wet
weather. Better: dry climate, lying on painful side. It is also

indicated in the chronic phase.
6. Lycopodium Pain in ear starts on the right side first, then on the left. Worse:
clavatum warm room, from heat, hot air, hot bed, wind, warm
applications, 4-8 p.m. Better: on getting cold, by motion, from
being uncovered.
Child is dominant, cranky, lacks self-confidence, precocious.
7. Mercurius Shooting pains in ears, which feels stopped and swollen.

solubilis Stiches deep in the ears with burning. Ringing and roaring in
the ears. Worse: warmth of bed; at night, wet, damp weather,
lying on right side, during perspiration.
Child has weak memory, fearful, shy, hurried, violent,
impulsive, nervous, irresolute. Tongue flabby with imprint of
teeth, profuse offensive perspiration, increased salivation.
It is also indicated in the chronic phase.
8. Silicea Otorrhœa with great sensitiveness to cold air. If progress is
terra protracted, purulent otorrhoea occurs with mild pain in the
ear(s), generally having no fever. Discharges are foetid and
thin. May be associated with caries of mastoid. Worse: cold
changes: air, drafts, uncovering, bathing, when the moon is at
the full. Better: warm wraps to head.
Child is obstinate, nervous, oversensitive, irritable and fearful.
Extremely chilly, profuse offensive discharges. Sweat profuse
especially on feet, easy suppuration, and glandular affinity.
9. Hepar Child has darting and shootings pain in the ears. Deafness,
sulphuris hearing returns with a loud report or on blowing the nose.
calcareum Worse: from cold, dry air in winter, on least uncovering, touch
and noise, lying on painful side, night. Better: from heat, warm
wraps to head and in damp weather, exposure to cold.
Discharge of pus from the ears, which is sometimes fetid.
Secretions are Profuse; foul; like old cheese and sour. Patient
in general chilly and oversensitive; to cold, pain and touch;
easily faints due to pain. Patient is excessively irritable,
touchy, mentally and physically to pain and cold.

ALGORITHM OF TREATMENT PROCESS
Diagnosis through clinical signs and symptoms
 Ear pain
 Tugging/rubbing of ear
Algorithm
 Lossof
of treatment
hearing process
 Fever with irritability and excessive crying
On Examination
 Opaque, bulging of ear drum,
 Inflamed tympanic membrane/redness of tympanic membrane
 Reduced or absent mobility of tympanic membrane
 Loss of landmarks
 Perforation with ear discharge
General management
Start homoeopathic
treatment and  Avoid putting baby down for a
Advice for general nap.
management  Avoid exposing baby to cigarette
smoke.
 Wash hands frequently.
 Don’t allow sick children to spend
Follow up time together.
 Keep the ear dry and don’t instill
anything into the ear.
 Advise the patient not to blow the
Improvement nose.
NO YES
 Advise steam inhalation.
Others
 In case of high grade fever

Refer for standard care Continue Homoeopathic (>103oF) cold sponging may be
Treatment given.
Referral criteria Check for complete

 No change in or resolution
worsening otalgia
 Worsening of
general condition
 Evidence of
complications like If resolution is incomplete If resolution is complete
seizures,
headache,
vomiting, vertigo, Reassess the case and give Stop treatment
facial palsy, appropriate
mastoid homoeopathic medicine
abscess.etc.

ALCOHOL DEPENDENCE
CASE DEFINITION
A disorder characterized by a pathological pattern of alcohol use that causes a serious

impairment in social or occupational functioning. In this condition, the person craves
drinks that contain alcohol and is unable to control his or her drinking. He also needs to
drink greater amounts to get the same effect and has withdrawal symptoms after stopping
alcohol use. 1,2
INCIDENCE
 Worldwide, 3.3 million deaths every year result from harmful use of alcohol, which
represents 5.9 % of all deaths.
 The harmful use of alcohol is a causal factor in more than 200 diseases and injury
conditions.
 Overall 5.1 % of the global burden of disease and injury is attributable to alcohol, as
measured in disability- adjusted life years (DALYs).3
 Prevalence of alcohol use in India is reported to be 21.4% and there is increasing
alcohol intake among the young people. 4.5% males and 0.6 % females in age group
of 15 years and above are suffering from alcohol use disorders and 3.8% of males
and 0.4% of females are suffering from Alcohol dependence.
 Deaths attributed to alcohol consumption in males and females are 62.9% and
33.2% respectively of total deaths in the country.4
PATHOPHYSIOLOGY
Alcohol affects virtually every organ system in the body and, in high doses, can cause coma
and death. It affects several neurotransmitter systems in the brain, including opiates,
gamma-Aminobutyric acid (GABA), glutamate, serotonin, and dopamine. Increased opiate
levels help explain the euphoric effect of alcohol, while its effects on GABA cause anxiolytic
and sedative effects. Alcohol inhibits the receptor for glutamate. Long-term ingestion
results in the synthesis of more glutamate receptors. When alcohol is withdrawn, the
central nervous system experiences increased excitability. Persons who abuse alcohol over
the long term are more prone to alcohol withdrawal syndrome than persons who have
been drinking for only short periods. Brain excitability caused by long-term alcohol
ingestion can lead to cell death and cerebellar degeneration, Wernicke-Korsakoff
syndrome, tremors, alcoholic hallucinosis, delirium tremens, and withdrawal seizures.
1ICD-10-CM Diagnosis. CDC/National Center for Health Statistics [Internet] [cited 2016 Mar 23] Available at
http://www.icd10data.com/ICD10CM/Codes/F01-F99/F10-F19/F10-/F10.2
2Management of substance abuse. World health organisation. [Cited 2014 Sep 18]. Available from:
http://www.who.int/substance_abuse/terminology/definition1/en/
3World Health Organization. Alcohol –fact sheet. [Cited 2015 March 18] Available from:
http://www.who.int/mediacentre/factsheets/fs349/en/
4World Health Organization. Country Profile India. 2014; 252. (Cited 2014 Sep 18).Available
from:http://www.who.int/substance_abuse/publications/global_alcohol_report/msb_gsr_2014_2.pdf?ua=1.

Opiate receptors are increased in the brains of recently abstinent alcoholic patients, and
the number of receptors correlates with cravings for alcohol.5
RISK FACTORS6:
 Genetics: Anybody who has a close relative with an addiction problem has a higher
risk of eventually having one themselves.
 Gender - Significantly higher percentage of people addicted to a substance are
males.
 Mental illness
 Peer pressure
 Family behavior
 Loneliness
 Age when substance was first consumed: People who start consuming a drug
earlier in life have a higher risk of eventually becoming addicted, than those who
started later.
 Stress: If a person’s stress levels are high there is a greater chance a substance, such
as alcohol may be used in an attempt to blank out the upheaval.
Conceptual causal model of alcohol consumption and health outcomes3:
5Warren T. Alcoholism. [Cited 2014 Sep 18].Available from: http://emedicine.medscape.com/article/285913-

overview
6Medical News today. Addiction. [Cited 2014 Sep 18].Available from:
http://www.medicalnewstoday.com/info/addiction/risks-of-addiction.php

DIAGNOSIS2:
Clinical Presentation
The Tenth Revision of the International Classification of Diseases and Health Problems
(ICD-10) diagnoses alcohol dependence when three or more of the following
manifestations should have occurred together for at least 1 month or, if persisting for
periods of less than 1 month, should have occurred together repeatedly within a 12-month
period:
ICD-10 criteria for Alcohol dependence clustering:

(A) Three or more of the following: occurring together for at least 1 month, or if less than
1 month, occurring together repeatedly within a 12-month period:
 A strong desire or sense of compulsion to drink
 Need for significantly increased amounts of alcohol to achieve intoxication or
desired effects; or markedly diminished effect with continued use of the same
amount of alcohol.
 Physiological symptoms characteristic of the withdrawal syndrome for alcohol; or
use of alcohol (or closely related substances) to relieve or avoid withdrawal
symptoms.
 Difficulties in controlling drinking in terms of onset, termination, or levels of use;
drinking in larger amounts or over a longer period than intended; or a persistent
desire or unsuccessful efforts to reduce or control drinking
 Important alternative pleasures or interests given up or reduced because of
drinking OR
 A great deal of time spent in activities necessary to obtain, to use, or to recover
from the effects of drinking
 Persisting with drinking despite clear evidence and knowledge of harmful
physical or psychological consequences
Duration criteria
(B) Three or more of dependence criteria occurring for at least 1 month, or if less than
1month, occurring together repeatedly within a 12-month period.
Signs and symptoms of alcohol withdrawal syndrome5:

Signs Symptoms
 Elevated blood pressure  Anxiety
 Tachycardia  Insomnia
 Elevated body temperature  Illusions
 Sweating  Hallucinations
 Tremulousness of body/increased hand tremor  Paranoid ideas
 Dilated pupils  Nausea
 Disorientation  Irritability
 Hyper arousal

 Grand mal seizure
Signs of chronic alcoholism:

 Gynecomastia
 Spider angiomata
 Dupuytren’s contractures (also may be congenital)
 Testicular atrophy
 Enlarged or shrunken liver
 Enlarged spleen
Biomarkers
Alcohol biomarkers are physiologic indicators of alcohol exposure or ingestion and may
reflect the presence of an alcohol use disorder. These biomarkers are not meant to be a
substitute for a comprehensive history and physical examination. Indirect alcohol
biomarkers, which suggest heavy alcohol use are as follows7:
 Aspartate aminotransferase (AST)
 Alanine aminotransferase (ALT)
 Gamma glutamyltransferase (GGT)
 Mean corpuscular volume (MCV)
 Carbohydrate-deficient transferrin (CDT)
Direct alcohol biomarkers include alcohol itself and ethyl glucuronide. A blood alcohol level
detects alcohol intake in the previous few hours and thus is not necessarily a good
indicator of chronic excessive drinking. Blood alcohol levels that indicate alcoholism with a
high degree of reliability are as follows5:
 >300 mg/dL in a patient who appears intoxicated but denies alcohol abuse
 >150 mg/dL without gross evidence of intoxication
 >100 mg/dL upon routine examination
Investigations8
Laboratory investigations given below can further help in prognosis of the case:
Liver function tests o AST:ALT ratio – >2 suggests alcoholic etiology

o May not be elevated – not highly sensitive or
Aspartate transaminase (AST) specific
and alanine transaminase (ALT)
7Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. The
Role of Biomarkers in the Treatment of Alcohol Use Disorders. US Department of Health and Human Services.
September 2006. [cited 2016 Mar 28]. Available at http://store.samhsa.gov/shin/content/SMA12-
4686/SMA12-4686.pdf
8Physicians guide to laboratory tests-Alcohol abuse.[cited 2015 Oct 13] Available at
http://www.arupconsult.com/Topics/AlcoholAbuse.html

 Gamma o Sensitive and inexpensive indirect marker of
glutamyltransferase alcohol consumption
(GGT) o May be a less-sensitive marker in young drinkers
o Age dependent – levels increase with age, even in
abstinent patients
o Normalization requires 2-3 weeks of abstinence
COMPLICATIONS OF ALCOHOLISM9
 Seizures: Withdrawal seizures usually consist of generalized convulsions
alternating with spasmodic muscular contractions (i.e., tonic-clonic seizures).
 Delirium Tremens: DT’s are a serious manifestation of alcohol dependence that
develops 1 to 4 days after the onset of acute alcohol withdrawal in persons who
have been drinking excessively for years. Signs of DT’s include extreme
hyperactivity of the autonomic nervous system, along with hallucinations. Women
experiencing DT’s appear to exhibit autonomic symptoms less frequently than men.
 Wernicke-Korsakoff Syndrome: The combination of Wernicke’s and Korsakoff’s
syndromes is not a complication of Acute Withdrawal (AW) but rather of a
nutritional deficiency. The syndrome is characterized by severe cognitive
impairment and delirium, abnormal gait (i.e., ataxia), and paralysis of certain eye
muscles
 Disturbances of Mood, Thought, and Perception: Withdrawing alcoholics exhibit
psychiatric difficulties that may be related to the process of withdrawal itself or to
co-occurring conditions.
DIFFERENTIAL DIAGNOSIS5
The relationship between alcohol and bipolar disorder is an important dual diagnosis. In
fact, a substance abuse disorder is seen in nearly 60% of individuals with bipolar disorder.
Any individual who presents with significant mood fluctuations must be screened for an
alcohol use disorder. Panic disorder, generalized anxiety disorder, social phobia,
dysthymic disorder, major depression, bipolar mania, or primary (idiopathic) insomnia.
Alcohol abuse or dependence might reflect self-treatment for these conditions:
 Anxiety disorders
 Bipolar Affective disorder
 Depression
 Dysthymic disorder
 Insomnia
 Panic disorder
 Social phobia
9LouisA. Trevisan. Nashaat Boutros. Ismene L. Petrakis and John H. Krystal. Complications of Alcohol
Withdrawal. Alcohol Health & Research World. 1998; 2 (1): 61-66.

ASSESSMENT AND EVALUATION
A. Scales for screening:

i. CAGE (cute down, annoyed, guilty, eye opener
http://pubs.niaaa.nih.gov/publications/inscage.htm
ii. AUDIT: The Alcohol Use Disorders Identification Test
(AUDIT).http://www.ncbi.nlm.nih.gov/books/NBK64829/
iii. MAST-R for screening:Michigan Alcohol Screening Test (MAST), Revised
http://www.ncbi.nlm.nih.gov/books/NBK64829/
B. Scales for assessment:

i. SADQ (Severity of Alcohol Dependence
Questionnaire)http://www.alcohollearningcentre.org.uk/_library/Resources
/ALC/severity_of_alcohol_dependence_questionnaire.pdf
ii. ADS(Alcohol Dependence Scale)
www.emcdda.europa.eu/attachements.cfm/att_4075_EN_tads.pdf
iii. CIWA-Ar (Clinical institute Withdrawal Assessment for
Alcohol)http://www.ncbi.nlm.nih.gov/books/NBK64829/#A46038
MANAGEMENT
Homoeopathy is one of the most popular complementary and alternative medicine

therapies and has strong focus on mental health disorders and has a role to play in
managing alcohol dependents and in the withdrawal episodes as standalone or add on to
conventional treatment. Often the first stage of alcohol management is detoxification and
the attendant withdrawal syndrome which are usually seen within 24-72 hours of ceasing
alcohol consumption. Patients need admission and close supervision to prevent infections
and secondary complications. Research studies10,11,12,13,14,15 on alcohol withdrawal and
alcohol dependence with homeopathic medicines has shown to be useful.
Apart from medicinal management, counseling16 and coping of patients play a vital role in
the management. Counseling during the withdrawal episode/detoxification should be
10Bakshi, JPS. Homoeopathy – A New Approach to Detoxification. Proceedings of the National Congress on
Homoeopathy and Drug Abuse. March 16-18, 1990; 20-28. New Delhi. Available from http://www.cam-
quest.org/nl/search/therapies/?l1=403&show . (cited on 2014 Oct 15 )
11Garcia-SS, A Double-Blind, Placebo- Controlled Trial Applying Homeopathy to Chemical Dependency.
Hahnemann College of Homeopathy, Albany, California. (1993) Available from http://www.the-alcoholism-

guide.org/homeopathic-remedies-for-alcohol-withdrawal.html
12Nayak D, Arora S, Singh U, Borah N, Thakur JN and Khurana A. Managing acute alcohol withdrawal with
Homoeopathy: A prospective, observational, multicentre exploratory study. Indian Journal of Research in

Homoeopathy Oct-Dec 2014; 8 (4): 224-230.
13Rogers J. Homoeopathy and the treatment of alcohol related problems. Complement Ther Nurs Midwifery
1997 Feb; 3 (1): 21-8.

14Milewska G, Olga TT. Homoeopathic treatment of alcohol withdrawal, British Homoeopathic Journal
October 1993; 82: 249-251.

15Gopinadhan S, Balachandran VA. A pilot study on the effect of Arsenicum Album in Alcohol dependents,
CCRH Quarterly Bulletin 1994; 16 (1&2) : 10-15

16Alcohol withdrawal Management: Signs and symptoms of alcohol withdrawal. [cited 2015 Sept.15]
Available at www.health.gov.au/internet

aimed specifically to supporting the patient through withdrawal symptoms, maintaining
motivation, and facilitating post withdrawal treatment. Handling of mental crisis may be
needed during a withdrawal period as many patients will desire to address a range of
personal, emotional or relationship problems at the start of treatment; however, these
should be deferred until after withdrawal as attempting to work through such issues will
almost certainly be anxiety provoking, which merely intensifies craving and jeopardizes
withdrawal completion. Assure the patients that you understand that they have important
issues they want to work through, explain why they are being deferred, and that there will
be opportunities to address them as part of ongoing treatment after withdrawal.
Management of withdrawal symptoms as mentioned above should be treated
symptomatically depending on the intensity of symptoms. If required in hospital set up for
severe cases to avoid undue complications.
The chronic phase needs a careful appraisal of the mind and the body. Should there be any
indication of liver involvement, (See investigations above) appropriate remedial support
may be needed. The underlying mental state gives a good glimpse of the extent to which
constitutional forces would be useful. Also, the treatment of the mental state sometimes is
crucial for a good and lasting recovery. There are total 182 medicines in repertory for
alcoholism. Homoeopathy medicine helps the patient in reduction of craving for alcohol as
well as controlling withdrawal symptoms. Medicines like Quercus takes away craving for
alcohol drinks. Avena sativa: Alcoholism; sleeplessness; verge of delirium tremes especially
of alcoholics. Similarly, Angelica atropurpurea produced disgust for alcohol. Asarum used
when there is desire for alcohol with nervousness and erethism. Zincum sulphuricum:
Abuse of alcohol with chronic diarrhea. Indications of some of the commonly indicated
homoeopathic medicines for Alcohol dependence17
S.no Medicines Indications

1. Arsenicum Morning vomiting of habitual drunkards; chronic gastric
album irritability; heartburn, as if epigastrium and stomach were
being made raw by an acrid corroding substance; fruitless
retching, or retching and vomiting; indescribable nausea,
loathing and weakness satiety of life and still fear of death,
will not be alone; fear of ghosts, thieves, with desire to hide
one’s self, trembling of limbs. Is morally perfectly upset,
with cravings for acids and coffee, which relieve.
2. Lycopodium Patients with chronic alcoholism suffer from dropsy, ascites
clavatum in liver disease; Failing brain-power and constant fear of
breaking down under stress. There is great weakness of
digestion, eating ever so little creates fullness. These
patients are intellectually keen but physically weak, their
ailments gradually developing, functional power
weakening, symptoms worse from 4-8pm, usually right
sided complaints or symptoms go from right to left with
desire warm food, drinks, and sweets.
17Boericke W. Boericke’s new manual of Homoeopathic Materia Medica. 3rd revised and augmented edition. B.
Jain Publishers. New Delhi.

3. Lachesis Delirium tremens with visions of snakes and other hideous
mutus objects, believes he is not at home, fears robbers in the
house, undertakes many things and perseveres in nothing,
sensation in throat as if choking, and springing out of sleep
suddenly as if from a dream; cannot bear pressure around
throat or waist; loquacious with mocking jealousy.
Inclination to vomit, with sensation of illness arousing him
from a sound sleep, vomits ingesta, bile, mucus, especially
mornings. Diarrhea of drunkards, with languor and
exhaustion, very excessive in hot weather, and with large
haemorrhoids which protrude aft each pappy, offensive
stool, with constriction of sphincter and continued desire to
evacuate, or alternate constipation with ineffectual desire
for stool and pulsating headache. Enlarged liver with
tendency to formation of hepatic abscess; spleen diseased.
Ascites, urine blackish, oedematous parts dark, bluish-
black; craves brandy and > by coffee.
Hot patient; thin and emaciated; hemorrhagic diathesis;
greatsensitiveness to touch; hot flushes and perspiration;
all complaints worse after sleep; loquacious, jumps from
one idea to another, jealous, suspicious, indolent.
4. Nux Delirium tremens, with over sensitiveness; nervous
vomica excitability and malicious vehemence; every little noise
frightens; anxious and beside himself; stupefaction as from
nightly reveling; intoxication from funkiness of the
previous day, with vanishing of sight and hearing; worse
after dinner and in the sun; hemicrania after intoxication,
with sensation as if a nail had been driven into the brain;
gastric derangement; constipation or diarrhea; tremor of
the limbs; debility ; convulsions from indigestion; at night
spring up delirious; has frightful visons. Especially adapted
to chilly patient; thin, dark complexion; spare, quick,
active; prone to indigestion and hemorrhoids; sedentary
lifestyle; tongue coated yellowish in the posterior part;
desire for stimulants; nervous disposition; oversensitive to
external impressions, to noise, odors, light or music etc.;
zealous and irritable, impatient, spiteful with violent
action; ardent nature.

5. Sulphur Dropsy and other affections of drunkards, especially when
they indulge in the abuse of coffee; longing for alcoholic
drinks; fullness in stomach after eating or drinking ever so
little; cannot digest milk and vomits it up immediately,
mixed with half-digested, sour food.
Hot patient; kicks off the cloth at night; dirty, filthy, does
not want to be washed; lean, thin, stoop-shouldered
children who walk and sit stooping; red orifices; desires
sweets; when the best selected remedy fails to improve;
restless, quick tempered.
6. Syphilinum This medicine is of value in patients with history of
alcoholism in family. There is hereditary craving for
alcohol. Tendency to heavy drinking; alcoholism. Utter
prostration and debility in morning. Terrible dread of night
on account of mental and physical exhaustion on
awakening; it is intolerable, death is preferable. Loses
remembrance of passing occurrences, names, dates, etc.,
while all occurrences previous to inception of disease are
remembered as distinctly as ever. Hopeless; despairs of
recovery. All symptoms are worse at night. Absolute
sleeplessness. Serrated and irregular teeth; scanty hair;
successive abscesses, easy prostration, night terror,
destructive tendency.
7. Sulphuricum Pyrosis, morning vomiting, inappetency, trembling,
acidum especially mornings. Drunkard on his last legs looks pale,
shriveled and cold, stomach will not tolerate any food, he
cannot even take a sip of water unless it contains whisky;
liver enlarged, with dry stomach-cough; hemorrhoids;
offensive watery diarrhea; cross and irritable.
8. Ranunculus One of our most effective agents for the removal of bad
bulbosus effects from the abuse of alcoholic beverages; at the
beginning of delirium tremens, with talkative mania;
unusual exertion and powerful efforts to escape from the
bed; convulsions of the facial and cervical muscles; risus
sardonicus; stitches in the liver; long-lasting gastralgia;
burning, changing to dull pressure, with nausea; vertigo,
with danger of falling when going from warm room into the
open air; confusion of the head as if intoxicated.

Screening
Diagnosis as per ICD 10 classification.
Symptomatic assessment, Clinical examination, Counseling:

laboratory investigations
A. Counseling during detoxification:
 Supporting the patient through
withdrawal symptoms
 Maintaining motivation
 Facilitating post withdrawal treatment.
Start Individualized B. Coping with cravings:
Homoeopathic Treatment  Delay the decision as to whether you
and advice for abstinence will drink for one hour.
with life style  Distract yourself with an activity during
modifications this hour that will take your mind off
whether you will drink or not.
 Desist After the hour; say to yourself:
“Why I don’t want to drink” and “What
Follow up regularly have I got to lose” By this stage the
craving should have settled down-
although probably not gone away.
Look for: Assessment by SADQ

 Reduction of SADQ score & CIWA-Ar for
score. withdrawal symptoms.
 Maintaining
abstinence.
 Improvement in
Homoeopathy
quality of life.
treatment with
 Improvement of
associated physical periodical counselling,
symptoms. assessment & home
visits
Yes No Refer for appropriate

Improvement
treatment

ATTENTION DEFICIT HYPERACTIVITY DISORDER
CASE DEFINITION1
Attention Deficit Hyperactivity Disorder (ADHD) is a chronic condition usually starting from
childhood (first five years of life). It is characterized by inattention, poor concentration and
hyperactivity or impulsivity that interferes with functioning at home, school and social
relationships. The symptoms of ADHD must be present most of the time and in at least 2
different settings, for example, at home and school. The child must have these symptoms for
at least 6 months and they must be more prominent than others of their age for a doctor to
consider the diagnosis.
INCIDENCE
 The prevalence of ADHD in India has increased from 5.2% (2003)2to 11.32%(2011)3.
 In approximately 80% of children with ADHD, symptoms persist into adolescence and
may even continue into adulthood4.
 Children and adolescents in the age group of 4-18 years are the sufferers of the
condition. It is more common in males than females.
AETIOLOGY5
The etiology is unknown, however following causes may play a role in development of the
disorder.
 Genetic Certain genes and neurotransmitters are responsible for its occurrence and
plays a major role in the development of ADHD and may run in family.
 Environmental factors: substance use and abuse (cigarettes, alcohol etc.) during
pregnancy, exposure to high levels of lead.
 Brain injuries in children, during pregnancy, delivery or immediately after birth
 Others: Premature delivery and Low birth weight, consumption of certain food
additives like artificial colors or preservatives, and sugar.
1W.H.O., ICD-10, International statistical classification of Diseases and Health related problems, 10th revised ed.
2004.
2CONNOR D.F Preschool Attention Deficit Hyperactivity Disorder: A Review of Prevalence, Diagnosis,
Neurobiology, and Stimulant Treatment. JDBP. 2002 February, 23 (1S). S1-S9.

3Venkata J. A, Panicker A. S. Prevalence of Attention Deficit Hyperactivity Disorder in primary school children.
Indian J Psychiatry. 2013 Oct-Dec; 55(4): 338–342.

4Faraone SV, Sergeant J, Gillberg C, and Biederman J. The worldwide prevalence of ADHD: is it an American
condition? World Psychiatry. Jun 2003; 2(2): 104–113.

5The National Institute of Mental Health (NIMH). Attention Deficit Hyperactivity Disorder (ADHD). NIMH. 2015.
[cited 11 July 2015]. Available at : http://www.nimh.nih.gov/health/topics/attention-deficit-hyperactivity-

disorder-adhd/index.shtml
DIAGNOSIS
ADHD can be identified on the following symptoms.

 Easily distracted
 May not follow instructions or listen when spoken to
 Leaves tasks unfinished
 Makes careless mistakes
 Have trouble sitting still and run around at inappropriate times
 Tend to be clumsy and occasionally destructive
Diagnosis of ADHD as per Diagnostic Statistical Manual of Mental Disorders V (DSM V)

criteria covers the following6,7:
1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more
for adolescents 17 and older and adults; symptoms of inattention have been present for at
least 6 months, and they are inappropriate for developmental level:
1. Often fails to give close attention to details or makes careless mistakes in

schoolwork, at work, or with other activities.
2. Often has trouble holding attention on tasks or play activities.
3. Often does not seem to listen when spoken to directly.
4. Often does not follow through on instructions and fails to finish schoolwork,
chores, or duties in the workplace (e.g., loses focus, side-tracked).
5. Often has trouble organizing tasks and activities.
6. Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a
long period of time (such as schoolwork or homework).
7. Often loses things necessary for tasks and activities (e.g. school materials, pencils,
books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
8. Is often easily distracted
9. Is often forgetful in daily activities.
2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for
children up to age 16, or five or more for adolescents 17 and older and adults; symptoms
of hyperactivity-impulsivity have been present for at least 6 months to an extent that is
disruptive and inappropriate for the person’s developmental level:
1. Often fidgets with or taps hands or feet, or squirms in seat.

2. Often leaves seat in situations when remaining seated is expected.
3. Often runs about or climbs in situations where it is not appropriate (adolescents or
adults may be limited to feeling restless).
4. Often unable to play or take part in leisure activities quietly.
6American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington (DC):
American Psychiatric Association; 2000. [cited 11 July 2015] Available at:
http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf.
7Centers for Disease Control and Prevention. American Psychiatric Association: Diagnostic and Statistical Manual
of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013. [cited31 Mar 2016].
Available at: http://www.cdc.gov/ncbddd/adhd/diagnosis.html
5. Is often "on the go" acting as if "driven by a motor".
6. Often talks excessively.
7. Often blurts out an answer before a question has been completed.
8. Often has trouble waiting his/her turn.
9. Often interrupts or intrudes on others (e.g., butts into conversations or games)
Subtypes of ADHD7
1. Predominantly hyperactive-impulsive:if enough symptoms of both criteria
inattention and hyperactivity-impulsivity were present for the past 6 months.
2. Predominantly inattentive: if enough symptoms of inattention, but not

hyperactivity-impulsivity, were present for the past six months.
3. Combined hyperactive-impulsive and inattentive: if enough symptoms of both

criteria inattention and hyperactivity-impulsivity were present for the past 6 months
COMORBIDITIES OF ADHD5, 8
About 50 % of children with ADHD have associated behavioral disorders and chances of
comorbidity increases with age. The comorbidities are as follows:
1. Learning disability. Children with specific learning disorder may appear inattentive
because of many factors like inability to read,write certain things and find it difficult
to comprehend.
2. Oppositional defiant disorder. Children will not obey any command that comes
from authority and they will have strong negativity, hostility and defiant behavior.
3. Conduct disorder. Child often harbors resentment towards family members and
goes on reacting for every action. This condition includes behaviors in which the child
may lie, steal, fight, or bully others.These children or teens are also at a higher risk of
using illegal substances.
4. Anxiety and depression. Inability to perform in the expected way produces lot of
emotional responses or expressions in the individual ranging from anxiety to
depression. He may exhibit this with certain emotional/ physical responses and goes
in to vicious cycle of unproductive activity.
5. Bipolar disorder. Some children with ADHD may also have this condition in which
extreme mood swings go from mania (an extremely high elevated mood) to
depression in short periods of time.
6. Tourette syndrome. Very few children have this brain disorder, but among those
who do, many also have ADHD. Some people with Tourette syndrome have nervous
tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing, clear
their throats, snort, or sniff frequently, or bark out words inappropriately.
8 V A Harpin. The effect of ADHD on the life of an individual, their family, and community from preschool to adult
life. Arch Dis Child 2005;90(Suppl I):i2–i7. doi: 10.1136/adc.2004.059006.
DIFFERENTIAL DIAGNOSIS9,10
Disorder Differentiating Features from ADHD

Oppositional  Defies initial direction, but once engaged in a task is able to
Defiant and persist (sustain attention).
Conduct Disorders  Lacks hyperactive/impulsive behaviors.
 Behavioral problems most acute in the home (defiance often
directed primarily toward parents).
Learning  Symptoms are specific to academic setting and/or subjects (e.g.,
Disorders reading groups).
 Lacks early history of hyperactivity and problems associated
with impulsivity (e.g., no aggression and/or disruption).
Anxiety and Mood  Problems with focused (not sustained) attention.
Disorders  Over inhibited (not impulsive). School adjustment typically
does not include disruptive behavior or teacher concerns
regarding hyperactivity, impulsivity or inattention.
Thought Disorders  Early school adjustment typically does not include disruptive
behavior or teacher concerns regarding hyperactivity,
impulsivity or inattention.
 Poor reality contact
Bipolar Disorder  Severe and persistent irritability and/or elated mood
 Temper outbursts that can become severe (e.g., destructive or
violent)
 Grandiosity
Pervasive  Distractible inattention related to internal (not external)
Developmental stimuli.
Disorder (autism)  Deterioration in attention and vigilance over time not as
pronounced.
Mental  Relative to developmental level, attention span not severely
Retardation impaired.
 Relative to developmental level, activity level considered
appropriate.
Substance-Related  Acute symptom on-set after 7 years of age.
Disorder
Other Substance-  Symptoms related to the use of medication (e.g.,
Related Disorder bronchodilators, isoniazid, akathisa from neuroleptics).
9Canadian ADHD Resource Alliance. Differential Diagnosis and Comorbid Disorders. Ontario. Canada. Canadian
ADHD Resource Alliance. 2013. [Cited 11 July 2015] Available at:
http://www.caddra.ca/pdfs/caddraGuidelines2011Chapter02.pdf.
10Stephen E Brock, Shane R. Jimerson, Robin L. Hansen. Developmental Psychopathology at School. Identifying,
Assessing and Treating ADHD at School. [Internet]. Springer Dordrecht Heidelberg London New York. 2009.
[Cited 11 July 2015] Available at: https://books.google.co.in/books?isbn=1441905014.
PREVENTION11
These initiatives will not eradicate ADHD, but they may lower incidence rates.
Primary preventive measures:
1. Initiatives to reduce or avoid exposure to environmental toxins, such as lead and
mercury.
2. Promote maternal health during pregnancy, such as warnings against alcohol and
cigarette use.
3. Reduce or avoid exposure to head injury during pregnancy and in infants, toddlers
and children.
4. Consumption of certain food additives like artificial colors or preservatives, and sugar
can be avoided.
Secondary preventive measures:

1. Identify hyperactivity and impulsivity in children which are evident during the
preschool years who go on to develop the disorder.
2. Engage children in challenging and cognitively stimulating games that are growth-
promoting.
Tertiary preventive measures:

1. Manage or limit consequences after the disorder has manifested by advising behavior
therapy and brain stimulating activities and learning.
RED FLAG / CONSEQUENCES12
1. Increased risk for school failure and dropout in both high school and college.
2. Social difficulties and family strife.
3. Depression, anxiety and other mental health disorders.
4. Accidental injury, Alcohol and drug abuse.
PATIENT EVALUATION13, ASSESSMENT & FOLLOW-UP14

1. Clinical interviews with the parent and patient, obtain information about the patient’s
school or day care functioning, evaluation for comorbid psychiatric disorders, and
review of the patient’s medical, social, and family histories.
2. If the patient’s medical history is unremarkable, laboratory or neurological testing is
not indicated.
11Jeffrey M. Halperin& Anne-Claude V. Bédard& Jocelyn T. Curchack-Lichtin. Preventive Interventions for

ADHD:A Neurodevelopmental Perspective. Neurotherapeutics (2012) 9:531–541. DOI 10.1007/s13311-012-
0123.
12 American Academy of Child & Adolescent Psychiatry and American Psychiatric Association .ADHD. Parents
Medication Guide. Revised July 2013.1-45.

13Steven Pliszka, et.al. Practice Parameter for the Assessment and Treatment of Children and Adolescents With
Attention-Deficit/ Hyperactivity Disorder. J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:7, JULY 2007. 894-
921.
14 Practice Parameter for the Assessment and Treatment of Children and Adolescents With Attention-Deficit/
Hyperactivity Disorder. J . AM. ACAD. CHILD ADOLESC. PSYCHIATRY, JULY 200746:7.

3. Psychological and neuropsychological tests are not mandatory for the diagnosis of
ADHD, but should be performed if the patient’s history suggests low general cognitive
ability or low achievement in language or mathematics relative to the patient’s
intellectual ability.
4. Evaluate the presence of comorbid psychiatric disorders.
5. For quantitative assessment of the patient at interactive follow-up any of the
following scales mentioned below can be used. However these are not mandatory.
 ADHD Rating Scale-
IV15(http://www.fmpe.org/en/documents/appendix/appendix%201%20-
%20adhd%20rating%20scale.pdf)
 Swanson, Nolan, and Pelham (SNAP-IV)16(http://www.myadhd.com/snap-iv-
6160-18sampl.html)
 Conners Parent Rating Scale Revised (CPRS-R) (Conners, 1997)17
(http://www.doctorrudy.com/files/add_adhd_parent_long.pdf)
 Conners Teacher Rating Scale Y Revised (CTRS-R) (Conners, 1997)
(http://www.doctorrudy.com/files/teacher_add_adhd_short.pdf)
 Conners Wells Adolescent Self-Report Scale (Conners and Wells, 1997)
 Vanderbilt ADHD Diagnostic Teacher Rating
Scale(vanderbilt.edu/VCHWEB_1/rating~1.html)
 VANDERBILT ADHD DIAGNOSTIC PARENT RATING
SCALE(http://www.ncfahp.org/Data/Sites/1/media/images/pdf/CHIP-
Vanderbilt-parent.pdf)
REFERRAL
Since homeopathy has a great role in mental diseases, referral of the cases can be avoided to
a great extent. However assistance of other homeopathic physician or a pediatric specialist
(eg, a psychologist, psychiatrist, neurologist, educational specialist, or developmental-
behavioral pediatrician) can be taken in the following conditions:
1. Intellectual disability (mental retardation)
2. Developmental disorder (eg, speech or motor delay)
3. Visual or hearing impairment
4. History of abuse
5. Severe aggression
6. Seizure disorder
7. Children who continue to have problems in functioning despite treatment.
15David Goodman. Interpreting ADHD Rating Scale Scores: Linking ADHD Rating Scale Scores and CGI Levels in
Two Randomized Controlled Trials of LisdexamfetamineDimesylate in ADHD. Primary Psychiatry.
2010;17(3):44-52.
16 Atkins MS, Pelham WE, Licht MH. A comparison of objective classroom measures and teacher ratings of
Attention Deficit Disorder. J Abnorm Child Psychol. 1985 Mar;13(1):155-67.[Cited 11 July 2015] Available at:
http://www.crfht.ca/files/8913/7597/8069/SNAPIV_000.pdf
17Conners CK, Sitarenios G, Parker JD, Epstein JN. The revised Conners' Parent Rating Scale (CPRS-R): factor
structure, reliability, and criterion validity. J Abnorm Child Psychol. 1998 Aug;26(4):257-68. [Cited 2015July
11] Available at: http://www.ncbi.nlm.nih.gov/pubmed/9700518.
MANAGEMENT18
In paediatric practice, attention deficit disorders (ADHD/ADD) are the most common serious
psychosocial problems prompting parents to seek help for their children. Since the ability to
pay attention and concentrate is a basis prerequisite of child development, forming the
foundation of all learning and thinking as well as of emotional and social interaction, the
suffering of these children as well as their siblings, parents, teachers, and fellow pupils is
often considerable. Whether ADHD/ADD is expressed as mild disturbance or severe
disability depends on the child’s personality, temperament, talents and abilities.Even today
the usual testament approach consists of educational and psychotherapy measures,
increasingly combined with stimulants. Unsure which way to turn for help, parents often
seek assistance from homoeopathy, which claims to offer an important contribution in
addressing this issue19. Several researches20, 21, 22,23, 24, 25,26 has been done which reflects
positivity of homoeopathy in managing ADHD. However, together with calmness, patience,
equanimity, and consistency, the following points deserve special attention19:
1. Avoid a reproachful tone; more can be achieved with decisiveness and humour.
2. Do not apply pressure to perform – the result is better achievement
3. Lighten work and tasks with plenty of breaks.
4. Prevent arguments by setting clear rules and boundaries
5. Both parties should honour common agreements.
6. Promote self-responsibility and accountability in a spirit of freedom since telling
others mutual what to do generates much resistance.
7. Foster mutual respect to achieve long-term improvement.
8. Offer recognition and praise at every opportunity
9. Set a good example with positive behavior.
10. ADHD/ADD children should be able to spend at least one hour a day exercising
outside in the fresh air. Preoccupation with electronic media such as laptops, TV,
smartphones, gaming devices and so on should be kept to a minimum.
18Wolraich M., BrownL, Brown RT, DuPaul G, Earls M, Feldman HMet.al. ADHD: Clinical Practice Guideline for
the Diagnosis, Evaluation, and Treatment of Attention-Deficit/ Hyperactivity Disorder in Children and
Adolescents.PEDIATRICS 2011; 128(5):1007-22.
19Frei H. Homoeopathy and ADHD: A New Treatment concept with polarity analysis. Germany. Narayana Verlag.
2009
20 Oberai, et al. Homoeopathic management of attention deficit hyperactivity disorder: A randomised placebo-
controlled pilot trial. IJRH. Oct-Dec 2013. 7 (4). 158-167.

21 Lamont J., Homoeopathic Treatment of Attention Deficit Hyperactivity Disorder (ADHD). British
Homoeopathic Journal, 1997: 86:196-200.

22Frei H., Thurneysen A. Treatment for hyperactive children: Homeopathy and methylphenidate compared in a
family setting. British Homeopathic Journal 2001 (90): 183-188, Revised 2013.
23Frei H et.al.Homeopathic treatment of children with attention deficit hyperactivity disorder: a randomised,
double blind, placebo controlled crossover trial. Eur J Pediatr (2005) 164: 758–767.
24Frei H.Attention Deficit / Hyperactivity Disorder and Polarity Analysis: Features, Cases, Results. Simillimum
Journal 2014.1-24.
25 Jacobs J, Williams A, Girard C, Njike VY, Katz D. Homeopathy for attention-deficit/hyperactivity disorder:
apilot randomized controlled trial. Journal of Alternative and Complementary Medicine 2005;11(5):799–806.
26BruléD.An Open-Label Pilot Study of Homeopathic Treatment of Attention Deficit Hyperactivity Disorder in
children and Youth. ForschKomplementmed 2014;21:302–309.

11. Judo, karate, aikido and other Asian martial arts encourage the development of
optimal self-control, body control and body perception. They are especially
recommended for patients with ADHD/ADD.
12. Profession Help:Parenting of these children can often only be accomplished with
professional help. The first and very significant treatment option for young children
should therefore be counselling of the parents in parenting. This can be obtained from
parental counselling centers, child psychologists, child psychiatrists or pediatricians
with the necessary training. Remedial teachers can also provide important support
for the child and parents.
Homoeopathic armamentarium has large number of medicines referred for the

symptomatology of ADHD such as “inattention” (mind, concentration, difficult) 384
medicines, for “Hyperactivity” (mind, activity, in general, hyperactive) 40 medicines, and for
“Impulsivity” (mind, impulsive) 44medicines are available. Given below list of medicines with
indications, however, only these symptoms should not be used for finding the most
similimum, constitutional or totality of symptoms including mental generals and physical
generals must be base of prescription. Given below are the list of medicines with their
indications collated from research papers and text books which can be used in prescribing
ADHD patients:

1. Hyoscyamus Complaints of ADHD from bad effects of fright, jealousy or rage.
niger Patient of sanguine temperament; who are irritable, nervous,
and hysterical, malicious, jealous, irritable, aggressive with
many bewildering aberrations (deviations).The child may have
poor control over his impulses, talking, joking, throwing
tantrums at the most inappropriate times. Mania, erotic, exposes
genitals, singing, silly with comical acts, plays with fingers,
talking, babbling, and inclined to laugh at everything. Active
mania alternating with, or ending with depressive narcosis. There
are often tremendous difficulties with other siblings; jealousy,
provoking of fights and abuse. Quarreling Suspicious, fears
being alone, being pursued etc. Child has tendency to hurt self
when irritated. Speaks each word louder. In most, not all cases,
there is precocious sexual behavior; masturbation, secretive
sexual play with other children, exhibitionism, touches genitals.
Child starts up frightened from sleep, sobs and cries without
waking.
Symptoms <from touch, mental affections, jealousy.
2. Stramonium Adapted to plethoric children whose face is hot, red,
circumscribed redness of cheeks, distorted, having stammering,
has to exert before can utter a word, after a strong fright such as
car accident, a sexual abuse, witnessing of act of violence in the
environment. The precipitating events is often followed by
nightmare and eventually development of rage. The rage is
uncontrollable and impulsive, without malicious forethought.
Distorts face, pupils dilate when child is reprimanded (scolded)
with expression of terror. Child is fearful, dreads darkness, clings

to mother due to fear, desires light and company; worse in dark
and solitude. Mood of child rapidly changes from joy to sadness,
raving mania with cursing and praying.
Child is sleepy but can’t sleep. He weeps in dreams and awakes
in fear or screaming. Painlessness of general condition is
characteristics of the stramonium child.
Symptoms < from fright, dark, bright shiny objects, after sleep,
>in company, from bright light.
3. Tarentula Adapted to fiery red, terror expression face children who are
hispanica hurried, restless, could not keep quiet in any position; impulse
to walk, must keep in motion, though walking <all complaints.
Festination, fidgety, constant movement of legs, arms in child
with incessant motion and inability of do anything, keeps hands
busy, picks fingers. Child gets irritated from least excitement
which is followed by languid sadness. Child lacks control, erratic
and moods suddenly changes, from nervous laughter to scream,
fancies or strength. Hysteria, hateful, clever, crafty, and
destructive, moral relaxation, kleptomania. Averse to company,
but wants someone present. Child is ungrateful and
discontented, angry despair. There is marked love for music,
which excites and calms him, and dancing, even wild dancing.
This child has destructive nature, breaks, tears, throws things.
Complaint <from motion, seeing others in trouble, noise, >
music.
4. Tuberculinum Adapted to children who are very sensitive physically and
mentally, active and intelligent, with irritable, fretful, peevish,
taciturn, sulky, naturally of sweet disposition, now on
borderline of insanity. The child is unable to remain long in one
place, is loud and very demanding and capricious. Sensitive,
every trifles irritates, <awaking. Parents tell that the child is
coldly and deliberately destructive and malicious, obstinate and
disobedient. Fits of temper, and breaks his mother’s favorite
vase right in front of her if contraindicated. desire to use foul
language, curse and swear, great anger, even violence and
tendency to strike others. He seems completely indifferent to
punishment or reprimand. Child is confused, dissatisfied, always
wants a change, symptoms constantly changing, reckless. Fear of
dogs, animal especially.
Tuberculinum child has contradictory characteristics of mania
and melancholia, insomnia and spoor with rapid and
pronounced emaciation and takes cold easily. Child craves cold
milk and bed wetting is common problem of the child.
Complaint <close room, motion, music, mental excitement,
thinking, after sleep> open air.
5. Veratrum A Veratrumlbum child is curious and almost adult level in
album conceptual ability who is nervous sanguine temperament,
cannot bear to be alone, yet persistently refuse talking and

brood indifference. The inner frustration leads to disobedience
and behavior problems. There is great restlessness in the child
which is expressed by senseless, repetitive behavior such as
stacking things, cutting paper into ever smaller bits. He is so
restless he cannot sit down to eat but instead must be moving
constantly. Acute violent mania alternated with silence and
refusal to talk, desire to cut and tear, insanity, shrieks, curses,
howling all night, remorse (regret),Coprophagia. Aimless
wandering from home.
Child craves acid or refreshing things, icy water, and sour things.
Awakes at night trembling from fright. There is cold
perspiration on forehead with nearly all complaints. This child
may be extremely disconnected, or also hard and tough.
Symptoms <from fright, least motion, night,>walking about.
6. Lycopodium Many of the children are angry, bossy and rude to patients who
clavatum are too “permissive” as a result of fright, anger, mortification, or
vexation with reserved displeasure. The parents are often
perplexed to find that at school the child gets good conduct
sores because this bullying attitude is not tolerated. He has
bullying, domineering, arrogant behavior to family and those
with less authority, obsequious to superiors. A Lycopodium
child is thin, withered, and unhealthy, looks older than age, head
is overly large for his body, dreads of men, solitude, fear of being
alone, headstrong and haughty when sick. Child is peevish and
cross on waking; kick and scream; easily angered; cannot
endure opposition or contradiction, little things annoy; seeks
disputes; disobedience. Child is hateful, cranky, reserved and
despair. He has weak memory, confused thoughts, and averse to
understand new things, difficult to study new lessons or do new
assignment, cannot bear to see anything new. Makes mistake in
writing especially letters as of a mirror image, misplacing words,
can’t think, miscalls or omit words and, cannot read what he
writes.
Child has constant satiety, good appetite but few mouthfuls fill
up to the throat but wakes at night feeling hungry. Mouth is dry
without thirst. Mentally active but grows weaker.
Complaints <4- 8 Pm, >motion.
7. Medorrhinum Adapted to children who are dwarf and stunted, fears dark,
having weak memory, excessive aggressive withintense
restlessness and fidelity of legs and feet. Child is in a great hurry,
when doing anything is in such a hurry she gets fatigued. He
may have violent temper tantrums, kick or strike parents, and
fights with other children. Like adult child often has extremely
passionate nature. Child is sensitive and may withdraw from
parents and family because of emotional shocks. There is often
excessive attachment to animals and also cruel behavior
towards animals. Difficult concentration, nervous. Weakness of

memory; cannot remember names, words or initial letters; has
to ask name of most intimate friend; even forgets his own name.
Cannot spell correctly; wonders how a well-known name is
spelled. Constantly loses the thread of conversation. Child is
extremely sensitive; starts at the least sound, impatient;
peevish, irritated at trifles; cross during the day, exhilarated at
night. Child is always sleepy, wants burning hands and feet
covered and fanned. Symptoms<when thinking of them, touch,
close room, >fresh air.
8. Cina Adapted to children with dark hair, Ill-humored, cannot be
maritima quiet, very capricious, cross, wants to be carried, but carrying
gives no relief. The typical child is irritable in the extreme,
perhaps more so than Chamomilla. He may even strike or often
pinch or scratch parents when frustrated. Child may be
precocious and hard; he cannot be reprimanded and will not
tolerate parental authority. Patient is ugly, moody and
dissatisfied. Child does not want to be touched or bear to come
near anyone and averse to caress; child desires many things; but
rejects everything when offered.
Patient is restless in sleep; Starts and screams during sleep.
Complaints < from vexation (annoyance), when angry, looked at,
>by motion.
9. Chamomilla Whenever a case is accompanied by great irritability and anger
(or if the complaint is initiated by anger), must consider
Chamomilla. Complaints of ADHD in children from anger and
vexation with one cheek red and hot, other pale and cold,
nervous, oversensitive to pain and angry, accusatory ,excitable
temperament. Child Peevish,irritable ,even strike or kick at
parent (or doctor), snappish, cross, spiteful, quarrelsome,
exceedingly fretful, answers peevishly, uncivil, cannot return a
civil answer, quiet only when carried, cries angrily if put down
and parents must walk up and down to quiet him. Child is
inconsolable, impatient, whining restless, piteous moaning
because he cannot have what he wants many things, capricious;
demands then throws it away (often at someone) and becomes
angry when refused, or when offered, “too ugly to love”. Cannot
endure anyone near him; cannot bear to be spoken to; shies
angrily away from being touched. Averse to touch or talk, always
complaining.
A child without mental calmness contraindicates Chamomilla.
Child weeps during sleep and frightened from dreams.
Complaints < from anger, at night, >from being carried.

ALGORITHM for TREATMENT PROCESS
≥4 year-old patient identified with signs or symptoms suggesting ADHD.
Inattention(≥Six or more symptomsup to age 16or ≥ five Hyperactivity and Impulsivity(≥Six or more symptomsupto
for adolescents 17 and older and adults; for at least 6 age 16or ≥ five for adolescents 17 and older and adults; for at
months): least 6 months):
1. inability to pay attention to details or a tendency to 1. fidgeting or squirming
make carelesserrors in schoolwork or other activities 2. difficulty in remaining seated
2. difficulty with sustained attention in tasks or play 3. excessive running or climbing
activities 4. difficulty in playing quietly
3. apparent listening problems 5. always seeming to be “on the go”
4. difficulty following instructions 6. excessive talking
5. problems with organization 7. blurting out answers before hearing the full question
6. avoidance or dislike of tasks that require mental 8. difficulty waiting for turn or in line
effort 9. problems with interrupting or intruding
7. tendency to lose things like toys, notebooks, or
homework
8. distractibility
9. forgetfulness in daily activities
Status of Patient’s condition using scales or
input from multiple informants (e.g.
parents/caregivers, teachers)
Mild: If any symptom(s) result Moderate: Symptoms of Severe: Many symptoms in excess, or
in no more than minor functional impairment between several symptoms that are particularly
impairments in social or “mild” and “severe “are severe, are present, or the symptoms result
occupational functioning. present. in marked impairment in social or
occupational functioning
StartHOMOEOPATHIC TREATMENT
(Constitutional medicine)
Supplementary
therapies:
1. Educate family and 1. Assess for any
child maintaining or
2. advice/provide exciting cause and
behavior Improvement? remove the same if
management present. &/or
strategies or 2. Provide education to
school‐based NO improve adherence
strategies (Cognitive
YES to treatment.
Behavior Therapy)
3. speech therapy, if
required No
improvement
 Review regularly (at least 6-monthly)
 Follow- up for chronic care management at least 2 Reconsider treatment plan
years for ADHD symptoms using scales and including changing of the dose,
monitor improvement in at least 2 settings potency or, medicine, if
(home, school or social performance) required.

BENIGN PROSTATIC HYPERPLASIA
CASE DEFINITION
Benign prostatic hyperplasia (BPH), also called benign enlargement of the prostate (BEP),
or benign prostatic hypertrophy, is a noncancerous enlargement of the prostate gland.The
enlarged prostate may compress the urinary tube (urethra), which courses through the
center of the prostate, impeding the flow of urine from the bladder through the urethra to
the outside.It is a histological diagnosis associated with unregulated proliferation of
connective tissue, smooth muscle and glandular epithelium within the prostatic transition
zone.1It is a common cause of significant lower urinary tract symptoms in men and is the
most common cause of bladder outflow obstruction (BOO) in men > 70 years of age.2
INCIDENCE
BPH is a common problem that affects the quality of life in approximately one third of men
older than 50 years. BPH is histologically evident in up to 90% of men by age 85 years.
Worldwide, approximately 30 million men have symptoms related to BPH.
It tends to be more severe and progressive in African-American men because of the higher
testosterone levels, 5-alpha-reductase activity, androgen receptor expression, and growth
factor activity in this population.3
Few epidemiological studies conducted on BPH patients from India suggest it as the most
common pathological condition with an incidence of about 93.3%.4,5
AETIOLOGY/ RISK FACTORS

Two broad categories of risk factors associated with BPH are identified6:
Non-modifiable factors
 Age: prevalence of BPH rises markedly with age
 Geography: Lower prostate volumes have been observed in men from Southeast
Asia compared to western populations
 Genetics: An autosomal dominant pattern of inheritance is suggested.
1
Auffenberg GB, Helfand BT, McVary KT. Established medical therapy for benign prostatic
hyperplasia. UrolClin North Am.2009; 36:443–59.
2Love’s& Bailey Short Practice of Surgery 25 th edition(International students edition) Edward Arnold
Publishers Ltd.; 2008

3 Deters L A, Kim ED Benign Prostatic Hypertrophy [cited 2014Dec 31] Available at:
4 Mittal BV, Amin MB, Kinare SG. Spectrum of histological lesions in 185 consecutive prostatic specimens. J
Postgrad Med 1989; 35:157-61.

5Mathur SK, Gupta S, Marwah N, Narula A, Singh S, Arora B. Significance of mucin stain in differentiating
benign and malignant lesions of prostate. Indian J PatholMicrobiol 2003; 46:593-5.

6 Patel ND, Parsons JK. Epidemiology and etiology of benign prostatic hyperplasia and bladder outlet
obstruction Indian J Urol. 2014 Apr-Jun; 30(2): 170–176. doi: 10.4103/0970-1591.126900

Modifiable factors
 Sex steroid hormones: Androgens (testosterone; especially dihydrotestosterone
(DHT) and estrogen are known to result in prostate enlargement
 Obesity and physical activity: Increased adiposity and decreased physical activity
is associated with increased prostatic volume.
 Presence of metabolic syndrome and diabetes
 Other factors like smoking, diet and socio economic status7
DIAGNOSIS
Clinical presentation
Initial symptoms of BPH include difficulty in starting to urinate and a feeling of incomplete
urination. The symptoms can be understood as irritative and obstructive.2,7
Irritative:
 Increased frequency
 Nocturnal urgency
 Urge incontinence
Obstructive:
 Hesitancy
 Decreased flow of urine
 Dribbling
 Straining
 Feeling of incomplete emptying of bladder
 Prolonged urination
 Urinary retention
Natural history of disease

BPH can be a progressive disease, especially if left untreated. Clinical endpoints of
progression for BPH include the development of more severe symptoms like recurrent UTI,
bladder stones, more severe bladder outlet obstruction, acute/ chronic urinary retention,
bladder dysfunction manifested by incomplete emptying or detrusor instability, urosepsis,
incontinence, chronic renal insufficiency and hematuria.8
Investigations2, 3, 7
1. Digital rectal examination: to assess the prostate size and contour; presence of
nodules and areas suggestive of malignancy.
7Praveen R. Benign prostatic hyperplasia: updated review. Int.Res.J.Pharm.2013;4(8):45-51

8Lepor H. Pathophysiology, Epidemiology, and Natural History of Benign Prostatic Hyperplasia. Rev Urol.
2004; 6(suppl 9):S3-S10

2. Ultrasonography: Ultrasonography (abdominal, renal, transrectal) and intravenous
urography are useful for helping to determine bladder and prostate size and the degree
of hydronephrosis (if any) in patients with urinary retention or signs of renal
insufficiency.
3. Total Prostate-specific antigen (PSA): The normal values should be less than 4
nanogram /ml depending on age(if PSA concentration >10.0 ng/mL, the probability of
cancer is high)
4. Intravenous pyelogram with post voiding film
5. Uro-flowmetry: is done electronically to determine bladder obstruction and speed of
the urine flow.The values more than 15ml per second and voiding volume of 150 ml or
more is considered to be normal.
6. PVR urine volume –One of the important tests for urinary incontinence. Normally,
about 50 ml or less of urine is left after urination; more than 200ml is a definite sign of
abnormalities.
7. Other extended tests include:Urethrocystoscopy, Urine analysis, Urine culture, Blood
analysis for electrolytes, blood urea nitrogen (BUN), and creatinine , Renal function Test
COMPLICATIONS2, 7
In general, BPH progresses slowly. However, condition might be complicate due to:
 Bladder outlet obstruction resulting in: Acute retention;Inability to pass urine;Supra-
pubic constant, dull aching pain;Increased voiding pressure
 Chronic retention resulting in: Overflow incontinence; enuresis and renal
insufficiency
 Impaired Bladder emptying resulting in: Urinary infection and calculi
 Features of uremia resulting in: Headache;fits; drowsiness
DIFFERNTIAL DIAGNOSIS
 Neurogenic bladder
 Prostatitis
 Bladder cancer
 Prostate cancer
 Cystitis
 Urinary tract infection
RED FLAG
 Acute retention: inability to pass urine
 Chronic retention
 Overflow incontinence
 Hematuria
 Uremia

 International Prostate Symptom Score (IPSS)9

 American Urological Association Symptom Index (AUA-SI)10
 BPH Impact Index10
MANAGEMENT
BPH management has been broadly categorized into three types.11 They are watchful
waiting, medicinal management and ultimate is surgery when the patient fails to respond
medical treatment.
Watchful waiting: As long as the symptoms are mild and are not causing any change in the
day to day activities, wait and watch approach with regular checkup is recommended. It is
appropriate in patients with mild to moderate IPSS symptom score.Lifestyle alterations to
manage the symptoms of BPH include7
 decreasing fluid intake before bedtime,
 moderating the consumption of alcohol and caffeine-containing products, and
 Following a timed voiding schedule.
 practicing muscle strengthening exercise: Kegel exercises (pelvic exercises)
Medicinal management: If the symptoms are troublesome medicinal aid is required. The
aim of treatment of BPH is to improve symptoms, relieve obstruction, improve bladder
emptying, prevent UTI’s and avoid renal insult.
In homoeopathy, observational studies12,13, case series14 and reports15,16in the past throw
light on its usefulness in BPH. Experiences of many physicians have also shown that
9 Royal United Hospital bath. NHS. International Prostate Symptom Score (IPSS) [Internet] [cited 2016 Mar
23]. Available at http://www.ruh.nhs.uk/patients/Urology/documents/patient_leaflets/Form_IPSS.pdf
10 AUA Guideline on the Management of Benign Prostatic Hyperplasia: Diagnosis and Treatment
Recommendations.[internet][cited 2016 Mar 23].Available at:

https://www.auanet.org/common/pdf/education/clinical-guidance/Benign-Prostatic-Hyperplasia.pdf
11Dhingra N, Bhagwat D. Benign prostatic hyperplasia: An overview of existing treatment Indian J Pharmacol.
Feb 2011; 43(1): 6–12

12Gupta G, Singh J P, Tandon S, Singh S, Nayak C, Singh Het al. Evidence Based clinical study to assess the
usefulness of homeopathic medicines in patients of Benign Prostatic Hyperplasia. Indian Journal of Research
in Homeopathy 2010; 4(4):49-56.
13Oberai P, Varanasi R, Ramesh D, Arya DD, Reddy GRC, SharmaSK etal. Homoeopathic medicines in the
management of benign prostatic hyperplasia: A multicentric prospective observational study. Indian Journal
of Research in Homeopathy 2012; 6(3): 16-25
14Reddy G R C, Oberai P, Singh V, Nayak C. Treating Prostatic Hyperplasia in Elderly Men with Homeopathy- A
series of 11 cases. Indian Journal of Research in Homeopathy 2009; 3(4):37-43

15 Gupta G. Ultrasonographic assessment of Benign Prostate Hypertrophy cases in response to Homeopathic
drugs. Asian Homeopathic Journal 1994; 4(3):10-17.

16Gupta G, Gupta N, Singh V, Chaudhary M, Singh M. Evidence based study on cases of Benign Prostatic Hyperplasia
in response to homeopathic drugs. The Homeopathic Heritage 2006; 31(7): 31-41

homoeopathic medicines can improve distressing symptoms of BPH: relieve obstruction, as
well as improve bladder emptying to the relief of the patient.
Homoeopathic literature17,18,19,20,21,22,23,24 contains references to many medicines for

BPH. These include our well known polychrest remedies, some organopathic remedies and
other remedies with their specific indications which, when found well indicated in a case
possess no less power to cure the patient as our more commonly prescribed polychrests.
Organopathic remedies may find their use in cases with symptoms not pointing to any
other medicine clearly. Few examples with their indications are:Hydrangea arborescens:
enlarged prostate with great thirst; white amorphous salts in the urine; enlarged prostate
with residual urine and renal stone;Triticumrepens: enlarged prostate;strangury, pyelitis;
Acid picricum: prostatic hypertrophy, in cases not too far advanced; Digitalis: senile
hypertrophy of prostate with marked cardiac symptoms; Populustremuloides: Enlarged
prostate with residual urine; severe tenesmus, dysuria scalding, urine contains mucus and
pus, pain behind the pubis at the end of micturition.
The indications of few important remedies are given below.However, the presenting
totality of symptoms indicative of any medicine in the homoeopathic Materiamedica shall
always be the sole guide for every individual case.
S no. Medicine Indications

1. Pulsatilla Indicated in cases of prostate enlargement with pain and
nigricans tenesmus in urinating, worse lying on back.Useful in acute
prostatitis. After micturition, spasmodic pains in the neck of
the bladder, extending to pelvis and thighs. Involuntary
micturition at night, while coughing or passing flatus.
Prostatic troubles with small and flattened feces.
Hot patient; marked changeability; thirstlessness with great
dryness of mouth. Desire for cheese, pungent things, highly
seasoned food; aversion to fat,warm foods and drinks;
tongue coated yellow or whitish; worse towards evening
17
Zandvoort RV Complete Repertory 3.0.(English) 5.1 Repertory by, MacRepertory for Windows, Kent
Homoeopathic Associates, USA.
18
Murphy R. Homoeopathic Medical Repertory.Third Edition. Lotus Health Publishers; 2005
19
Boerick W. Boericke’s New Manual of Homoeopathic MateriaMedica with Repertory: Third Revised &
Augmented Edition based on Ninth Edition. B. Jain Publishers,New Delhi; 2010
20
Allen HC. Allen’s Keynotes- Rearranged and classified with leading remedies of the material medica and
bowel nosodes. 10th Reprint edition. Jan 2006
21
Clarke JH. A dictionary of Practical Material Medica . Reprint edition 2007.B Jain Publishers Pvt. Ltd.
22
Pulford. Key to the Homeopathic MateriaMedica. Second Edition. B Jain Publishers, N Delhi
23
Boger CM. A synoptic key of the MateriaMedica. Reprint edition 2008, B. Jain Publishers Pvt. Ltd.
24
Allen T.F. Handbook of MateriaMedica and Homeopathic Therapuetics First edition 1889. Philadelphia: F E
Boericke

and in the warm room,always better in open air, by slow,
gentle motionand cold applications. Desire company, mild,
gentle, affectionate, yielding, weeping disposition.
2. Conium Useful in enlargement and induration of prostate which

maculatum causes intermittent urination in old people and much
difficulty in voiding urine. Urine flows and stops; pressure
on the bladder,flow of urine attended with violent stitches;
worse when walking, better when sitting,
standing.Frequent, and sometimesinvoluntary emission of
urine at night.
Progressive debility, weakness of body and mind, Indolent,
indifferent, easily overstrained, shy and fear being alone.
There is early senility,hasty, clumsy movements and
trembling.Cancerous and scrofulous persons with enlarged
glands; rigid muscular fiber.Chilly; perspire during sleep
and desire salt.
3. Sabal Of unquestioned value in prostatic enlargement and urinary
serrulata difficulties. Cystitis with prostatic hypertrophy. Discharge of
prostatic fluid with enlargement of the gland. Difficult
urination and smarting and burning in urethra.
Patient is despondent, irritable, sympathy seems to anger
him, apathy and indifference, general and sexual debility,
atrophy of testes and loss of sexual power,; fear of going to
sleep.
4. Calcarea Useful in cases where symptoms of irritable bladder
carbonica predominate. Stitching cutting pain in urethra with
ineffectual desire to urinate. Painful urination, urine with
peculiar fetidodor but usually clear with white sediment,
bloody.
Indicated in torpid, fair, flabby, anaemic persons with large
head, distended abdomen and tendency to lymphatic
glandular enlargement; fearful, shy, timid, slow and
sluggish; who are chilly andtake cold easily; sweat profusely
on headwhile sleeping or mostly on back of head and neck,
or chest and upper part of body;have sour smelling
discharges; longing for fresh air, cold sweaty extremities,
desire for eggs, sweetsand aversion to meatand milk. Feel
better in every way when constipated.
5. Baryta Suitable in diseases of old men, with enlarged prostate and
carbonica indurated testes. Urgent inclination to pass urine; which can
hardly be retained.Renewed desire after urinating, followed
by dribbling when walking.Every time patient urinates, his
piles come down.Burning in urethra while urinating.

Well indicated in people who are mentally and physically
dwarfish; timid, weary and lack self-confidence. These
people avoid strangers andthinking of their own complaints
makes them worse. They are greatly sensitive to cold, have
offensive foot-sweat and are better in open air.
6. Chimaphila Owing to its property of increasing the renal
umbellata secretion,indicated in prostate enlargement showing
symptoms of acute prostatitis, with retention of urine and a
feeling of a ball in perineum when sitting; from sitting on
cold stones or pavements. Scanty urine, loaded with ropy
or muco-purulent, sediment. Burning and scalding during
micturition, and straining afterwards. Unable to urinate
without standing with feet wide apart and body inclined
forward.
Suitable for persons who are nervous, cannot bear anything,
hot, irritable, restless, melancholic; have a faint feeling and
are weak.
8. Thuja The remedy acts vigorously on the genito-urinary tract.
occidentalis Indicated in prostatic enlargement with pain and burning
felt near neck of bladder, with frequent and urgent desire to
urinate. Must urinate many a times before the bladder is
emptied. Sensation as of urine trickling in urethra after
urinating; severe cutting after urination.
Chilly patient;with illusions &fixed ideas. These persons
suffer from ill-effects of vaccination;predominantly left
sided complaints; unhealthy skin with tendency for warty
growths; sycotic pains, worse at rest, warmth & damp
humid atmosphere and better in dry weather; oily/ greasy
sweat, face & stool; perspiration on uncovered parts.
09. Ferrum Indicated in hypertrophy of the prostate; frequent
picricum micturition at night, with full feeling and pressure in
rectum. Smarting at neck of bladder and penis. Retention of
urine.
It is considered to complete the action of other medicines.
Acts best in dark-haired patients, bilious looking, plethoric,
with sensitive livers; warts and epithelial growths.
Aggravation from fatigue is a leading indication:
overpowering effects of fatigue.
10. Sulphur The remedy is indicated in painful ineffectual efforts to
urinate, with retention. Frequent micturition, especially at
night. Burning in urethra during micturition, lasts long
after. Mucus and pus in urine; parts sore over which it
passes.
Hot patient; kicks off the cloth at night; dirty, filthy, does not

want to be washed; lean, thin, stoop-shouldered patient
who walk and sit stooping; prone to skin affections, venous
congestions; especially of portal system; have a very weak
and faint feeling about 11 a.m. and must have something to
eat; desires sweets; have burning heat of palms and soles
especially at night; aversion to being washed; worse from
standing, at night; when the best selected remedy fails to
improve; restless, quick tempered.
13. Lycopodium The remedy finds its usefulness in hypertrophy of the
clavatum prostate when there is pain in back before urinating which
ceases after flow; flow of urine slow, must strain. Polyuria
during the night.Heavy red sediment in urine.
Adapted to persons suffering from deep-seated,
progressive, chronic diseases who are intellectually keen
but physically weak, dominating, avaricious, greedy, miserly
and lack self-confidence. They have mostly right sided
complaints (or symptoms shift from right to left);
emaciation of the upper part of the body & semi-dropsical
lower part; pale complexion, dirty, sallow with deep
furrows; look prematurely old and are predisposed to lung
and hepatic affections. They have a tendency for flatulent
dyspepsia;worse from 4 to 8 pm, lack of vital heat and
desire warm food,drinks & sweets.

Diagnosis through clinical signs and symptoms:
 Increased frequency
 Nocturnal urgency
 Urge incontinence
 Hesitancy
 Decreased flow of urine
 Dribbling
 Straining
 Feeling of incomplete emptying of bladder
 Prolonged urination BHP with obstructive
 Urinary retention symptoms causing:
Examination:  Kidney damage
 USG  Bladder stone
 Digital rectal examination  Haematuria
 Laboratory tests: urine analysis etc.  Urinary retention
 PSA> 4 ng/ml
Evaluation:
 IPSS/AUASI
AUA/ IPSS symptom

score
Mild Moderate Refer for standard care

to severe
Symptoms don’t Symptoms

interfere with interfere with
daily life daily life
Watchful waiting Start homoeopathic treatment and

Advice for general management
Follow up assessment
clinically and investigations
No clinical Incomplete improvement Complete improvement

improvement/worsening general
condition
Acute retention; Inability to pass
urine; Supra-pubic constant, dull
aching pain; chronic retention; Reassess the case and give Stop treatment
overflow incontinence, uremia. appropriate homoeopathic
medicine
Refer for Standard care
CANCER
CASE DEFINITION
Cancer may be regarded as a group of diseases characterized by an abnormal growth of

cells, ability to invade adjacent tissues and even distant organs and eventual death of the
affected patient if the tumor has progressed beyond that stage when it can be successfully
removed. Cancer can occur at any site of the body and may involve any type of cells. 1
INCIDENCE2
Cancer is a leading cause of death worldwide, accounting for 8.2 million deaths in 2012.
The incidence of cancer cases is estimated to increase from 6.1 million in 2008 to 10.6
million in 2030, due to ageing and growing populations, lifestyle and socioeconomic
changes. As per Globocan 2012 report, on the Indian scene, 1.1 million new cancer cases
were estimated, indicating India as a single country contributing to 7.8% of the global
cancer burden; mortality figures were 682830, contributing to 8.33% of global cancer
deaths; and the five year prevalence was 1.8 million individuals with cancer
corresponding to 5.52% of global prevalence.
AETIOPATHOGENESIS 1, 3
As with other chronic diseases, cancer has multifactorial etiology.

1. Environmental Factors
a) Tobacco in various forms of its usage (e.g. smoking, chewing) is the major
environmental cause of cancers of the lung, larynx, mouth, pharynx, esophagus,
bladder, and pancreas.
b) Alcohol-Excessive intake of alcoholic beverages is associated with esophageal and
liver cancer.
c) Dietary Factors: Smoked fish is related to stomach cancer, beef consumption to
bowel cancer, and a high fat to breast cancer. A variety of other factors such as
food additives and contaminants have fallen under suspicion as causative agents.
d) Occupational exposure- These include exposure to benzene, arsenic, cadmium,
chromium, vinyl chloride, asbestos, polycyclic hydrocarbons. The risk of
occupational exposure is considerably increased if the individuals also smoke
cigarettes.
e) Viruses- Following viruses are causally related to cancers
Virus Cancer
Hepatitis B and C virus Hepatocellular carcinoma
1 Park K. Park’s Textbook of Preventive and Social Medicine. 19th edition. Jabalpur: Banarsidas Bhanot
Publisher; 2007. Chapter 6; p.318-327
2 Saranath D, Khanna A. Current Status of Cancer Burden: Global and Indian Scenario. Biomed Res J
2014;1(1):1-5 accessed from http://www.nmims.edu/docs/science/journal/01-editorial.pdf

3 Andreeff M,Goodrich D W,. Pardee B Arthur. Cell Proliferation and Differentiation. In: Kufe DW, Pollock
RE, Weichselbaum RR, et al., editors. Holland-Frei Cancer Medicine. 6th edition. Hamilton (ON): BC Decker;
2003.

Epstein Barr Virus (EBV) Burkitt’s Lymphoma and
nasopharyngeal carcinoma
Human Papilloma Virus (HPV) Cancer Cervix
f) Parasites-Schitosomiasis produces carcinoma of bladder.

g) Others- There are numerous other environmental factors such as sunlight,
radiation, air and water pollution, medications (e.g. estrogen) and pesticides
which are related to cancer.
h) Customs habits and lifestyles: To the above causes must be added customs habits
and life styles of people which may be associated with an increased risk for
cancers. The familiar examples are demonstrated, association between smoking
and lung cancer, tobacco and betel chewing and oral cancer, etc.
2. Genetic Factors
a) Retinoblastoma occurs in children of the same parent.
b) Mongols are likely to develop cancer (leukemia) than normal children.
There is a probability of a complex interrelationship between hereditary
susceptibility and environmental carcinogenic stimuli in the causation of a
number of cancers.
DIAGNOSIS
Clinical Presentation4, 5
A standard workup including a medical history; physical examination; and laboratory

studies, including liver and renal function tests, haemogram and chest x-ray are essential
for diagnosis of Cancer.
The first step in diagnosis includes a medical history giving the signs and symptoms.
When patients cope with cancer, fear, worry, and sadness are expected and normal. The
most common form of distress in patients with cancer is anxiety and depression.
The signs and symptoms can be elucidated in following manner:

a) Signs and symptoms pertaining to individual cancer sites:
Although the general signs of early cancer may be very subtle but that of advanced cancer
include asthenia, cachexia and a general appearance of fatigue and ill health. Site-specific
signs include the following:
1. Lung malignancy
4
Ploman P.N. People with cancer. In: Swash Michael, G lynn Michael, Hutchinson Clinical Methods: An
Integrated Approach to Clinical Practice. 22nd Edition,: Elsevier Ltd;2007: 456-458.
5
Longmore Murray, Wilkinson Ian B., Davidson Edward H., Foulkes, Mafi Ahamd R. Oncology and Palliative
care: Oxford Handbook of Clinical Medicine. 8th edition. United States: Oxford University Press. Inc.: 526.

Symptom Sign
Cough Clubbing
Breathlessness Nicotine staining
Hemoptysis Cyanosis
Pain in chest Lower brachial root signs, Horner’s
syndrome
1. Breast malignancy
Symptom Signs
Mass Skin discoloration
Nipple discharge Inflammation
Ulceration Lymphadenopathy
2. Gastrointestinal malignancy
Symptom Signs
Dysphagia Glossitis
Indigestion Anemia
Abdominal Pain Gaurding
Nausea and vomiting Jaundice and ascites
Haematemesis Epigastric mass and tenderness
Malaena Palpable colonic mass
Rectal bleeding Hepatomegaly and hepatic failure
3. Urological Malignancy
Symptoms Signs
Dysuria Abdominal and pelvic mass
Frequency Rectal prostatic mass
Incontinence Penile or vulval ulceration
Hematuria Testicular mass
Prostatism Hard Prostatic mass
4. Gynaecological Malignancy
Symptoms Signs
Vulval pruritus Vulval ulceration
Vaginal discharge Cervical Mass
Vaginal bleeding Pelvic mass
Pelvic pain Mass, discharge
Bleeding
5. Head and Neck Malignancy
Symptoms Signs
Taste and swallow disturbed Ulceration
Hearing and voice abnormal Discharge
Bleeding Cranial nerve palsies
Persistent Cough Lymphadenopathy
Sinusitis
6. Ear / Nose / Throat malignancy
Symptoms Signs
Odynophagia Lump or ulcer
Deafness
Hoarse voice/dysphonia

Blocked nose, nasal discharge
(?bloody), sputum (?bloody)
7. CNS Malignancy
Symptoms Signs
Headache and vomiting Mental function
Convulsions Focal neurological signs
Loss of function
8. Primary Endocrine Malignancy
Symptom Signs
Hoarseness Thyroid mass
Headache, sweats Hypertension, oedema
Palpitations, nausea Adrenal mass, pallor
Hypoglycemic coma Pancreatic mass
Polyuria, polydipsia Pituitary mass
Visual field loss Hypopuititarism
Fatigue Buccal pigmentation of hypoadrenalism
b) Signs and symptoms pertaining to oncological emergencies:
 Febrile neutropenia -when neutrophil count ≤ 1.0×109/L

 Spinal cord compression-Back pain with a root distribution, weakness and
sensory loss (a level may be found), bowel and bladder dysfunction.
 Superior vena cava (SVC) obstruction with airway compromise- Dyspnoea;
orthopnoea; swollen face & arm; cough; plethora/cyanosis; headache; engorged
veins.
 Hypercalcaemia: Lethargy, anorexia, nausea, polydipsia, polyuria, constipation,
dehydration, confusion, weakness. Most obvious with serum Ca2+ >3mmol/L.
 Raised intracranial pressure: Headache (often worse in the morning), nausea,
vomiting, papilloedema, fits, and focal neurological signs.
 Tumour lysis syndrome-Rapid cell death on starting chemotherapy for rapidly
proliferating leukaemia, lymphoma, myeloma, and some germ cell tumors can
result in a rise in serum urate, K+, and phosphate, precipitating renal failure.
Investigations 4,5,6
Diagnostic imaging at various cancer sites is given below. The confirmed diagnosis of
cancer almost relies on the histological examination of the tumor either biopsy or
resection specimen; this is called the tissue diagnosis.
Diagnostic Imaging at various cancer sites
Lung
6
Seymour Gregory, Wang Michael, Pei Lin, Weber Donna. Lyphoma and Myeloma. In: Kantarjian Hagop M.,
Wolff Robert A., Koller Charlesa. The M D Anderson Manual of Medical Oncology. 2nd edition Part II Tata Mc
Graw-Hill Publishing Company Ltd; 2007

 Bronchoscopy
 Chest X-ray and CT scan staging
 Gastro-esophageal
 Endoscopy
Breast
 Mammography
 Ultrasound
 MRI scan , CT body and bone scan
Colorectal
 CT scan diagnosis and staging
 Colonoscopy
 Barium enema
Pancreatic and biliary
 Endoscopic ultrasound
 CT scan staging
 Endoscopic and MR cholangiography
Endoscopic ultrasound
 CT staging
 Barium Swallow
Urological
 IVU
 Cystoscopy
 Trans rectal ultrasound
 MRI and CT staging
Gynecological
 Abdominal transvaginal ultrasound
 Colposcopy and hysteroscopy
 MRI and CT scan staging
Head and Neck
 Nasal endoscopy
 MRI or CT scan staging
 PET scan
Ear/Nose/Throat
 Endoscopy (direct or indirect via mirror/endoscope)
CNS
 MRI scanning
Endocrine
 MRI and CT staging
Bone, thyroid and carcinoid
 Radionuclide scan
Tumor Markers
Tumors markers are rarely sufficiently specific to be of diagnostic value. Their main value
is in monitoring the course of an illness and the effectiveness of treatment.

 Alfa-fetoprotein (AFP): Increased in hepatocellular carcinoma, germ cell tumors
(not pure seminoma). Also: hepatitis, cirrhosis, pregnancy, open neural-tube
defects.
 CA 125: Raised in carcinoma of the ovary, uterus, breast, and hepatocellular
carcinoma. Also: pregnancy, cirrhosis, and peritonitis.
 CA 15-3: Raised in carcinoma of the breast and benign breast disease.
 CA 19-9: Raised in colorectal and pancreatic carcinoma, and cholestasis.
 CA 27-29: Raised in breast carcinoma, with better sensitivity and specificity than
CA 15-3, being raised in 1/3 women with early breast cancer.
 Carcino-embroyonic antigen (CEA): Raised in gastric neoplasms, especially
colorectal CA. Also cirrhosis, pancreatitis, and smoking.
 Human epidermal growth factor receptor 2 (HER-2/ NEU): Over –expression of
the HER-2 gene in breast cancer carries a worse prognosis, but may be targeted
with the monoclonal antibody trastuzumab (Herceptin). Also: ovarian, stomach &
uterine ca.
 Human chorionic gonadotrophin (β-HCG): Raised in pregnancy and germ cell
tumors. For hydatidiform moles and choriocarcinoma.
 Neuron-specific enolse (NSE): Increased in small-cell lung cancer and
neuroblastoma.
 Monoclonal immunoglobulins: In multiple myeloma one class of immunoglobulins
is produced in excess, whereas the other immunoglobulins (Ig) are depressed.
 Placental alkaline phosphatase (PLAP): Increased in pregnancy, seminoma,
smoking.
 Prostate Specific Antigen: As well as being a marker of prostate cancer, PSA is
(unfortunately) raised in benign prostate hyperplasia.
STAGING OF CANCER7
Staging of cancers is based on the size of the primary lesion, its extent of spread to
regional lymph nodes, and the presence or absence of metastases. This assessment is
usually based on clinical and radiographic examination (computed tomography and
magnetic resonance imaging) and in some cases surgical exploration. Two methods of
staging are currently in use: the TNM system (T, primary tumor; N, regional lymph node
involvement; M, metastases) and the AJC (American Joint Committee) system. In the
TNM system, T1, T2, T3, and T4 describe the increasing size of the primary lesion; N0,
N1, N2, and N3 indicate progressively advancing node involvement; and M0 and M1
reflect the absence or presence of distant metastases. In the AJC method, the cancers are
divided into stages 0 to IV, incorporating the size of primary lesions and the presence of
nodal spread and of distant metastases.
RED FLAG1
a. A lump or hard area in breast
7
Kumar, Abbas, Fausto, Mitchell. Robbins Basic Pathology 8th edition. Elsevier Ltd. Chapter 6: Neoplasia: p.
219.

b. A change in a wart or mole
c. A persistent change in digestive and bowel habits
d. A persistent cough or hoarseness
e. Excessive loss of blood at the monthly period or loss of blood outside the usual
dates
f. Blood loss from any natural orifice
g. A swelling or sore that doesn’t get better
h. Unexplained loss of weight
ASSESMENT AND EVALUATION
a) EDMONTON SYMPTOM ASSESSMENT SYSTEM8

b) EORTC Quality of Life Questionnaire 9
MANAGEMENT
Management of cancer is a challenging issue in all the systems of medicine. 1,3, 5 Vast
majority of people tend to bear some mark of cancer and/ or its treatment and a large
number of people experience long term consequences that include medical problems,
psychosocial dysfunction, economic hardships, sexual dysfunction, difficulty in
employment etc. 10 The goal of cancer management should be to take care of all such
aspects and improve quality of life of cancer survivors.
Communication forms the first step in understanding, treating, or coming to terms with
cancer. A range of overwhelming feelings can surface on receiving this diagnosis,
including shock, numbness, denial, panic, anger and resignation (“I knew all along…”). A
more positive approach is required to benefit and motivate patient through listening to,
and addressing, their worst fears. Counseling for anxiety and depression along with
treatment is important.
Guidelines on Nutrition and Physical Activity11 along with nutritional assessment for
survivors should begin soon after diagnosis and should take into consideration treatment
goals (curative, control, or palliation) while focusing on both the current nutritional
status and anticipated nutrition-related symptoms. For many long-term cancer survivors,
healthy weight management, a healthful diet, and a physically active lifestyle should be
aimed to preventing recurrence, second primary cancers, and other chronic diseases. The
goal is to achieve and maintain healthy weight. The patient should be encouraged to
engage in regular physical activity, exercise at least 150 minutes per week should be the
aim.
8 Caritas health group: Regional Palliative Care Program. Guidelines for using the Edmonton Symptom
Assessment System (ESAS). [Internet] [ cited 2016 May 31] Available at
http://www.npcrc.org/files/news/edmonton_symptom_assessment_scale.pdf
9 EORTC Quality of Life. [Internet] [ cited 2016 May 31] Available at http://groups.eortc.be/qol/
10 Freter Carl E, Longo Dan L. Late consequences if cancer and its treatment. In : Fauci AS, Braunwald E,
Kasper DL, Hauser SL, Longo DL, Jameson JL, et al., editors. Harrison’s principles of internal medicine. 18th
ed. New York: McGraw Hill; 2012: p 838-843
11 Simone Charles B. Cancer & Nutrition. Revised and Expanded edition. Avery Publishers; 1991

Integrative approach with benefits of all systems of medicine seems as the best approach
to such patients.
Clinical studies indicate that homeopathy either standalone or in combination with
conventional care can improve quality of life, reduce symptom burden, and possibly
improve survival in patients with cancer and thus can be used as integrative management
therapy. Few pre-clinical research studies with homoeopathic medicines have identified
the anticancer role and delineated the detailed molecular mechanism(s) underlying their
apoptogenic effect.12, 13,14 The findings from several research studies 15,16 ,17,18, 19, 20, 21, 22,
23and homoeopathic literature24,25,26,27,28,29 suggest the beneficial effect of homeopathy
12 Saha S, Bhattacharjee P, Guha D, Kajal K, Khan P, Chakraborty S, Mukherjee S, Paul S, Manchanda R,

Khurana A, Nayak D, Chakrabarty R, Sa G, Das T. Sulphur alters NFκB-p300 cross-talk in favour of p53-p300
to induce apoptosis in non-small cell lung carcinoma. Int J Oncol. 2015 Aug;47 (2):573-82. doi:
10.3892/ijo.2015.3061. Epub 2015 Jun 22.
13 Saha S, Bhattacharjee P, Mukherjee S, Mazumdar M, Chakraborty S, Khurana A. et.al. Contribution of the
ROS-p53 feedback loop in thuja-induced apoptosis of mammary epithelial carcinoma cells. Oncology
reports.
14 Saha S, Sakib Hossain D.M, Mukherjee S, Mohanty S, Mazumdar M, Mukherjee S. et al. Calcarea carbonica
induces apoptosis in cancer cells in p53-dependent manner via an immuno-modulatory circuit. BMC
Complementary and Alternative Medicine 2013, 13:230.
15 Rajendran ES. Homoeopathy as a supportive therapy in cancer. Homeopathy (2004) 93: 99-102.
16 Schlappack O. Homeopathic treatment of radiation-induced itching in breast cancer patients. A
prospective observational study. Homeopathy 2004 ; 93 (4): 210-215

17 Thompson EA, Reilly D. The homeopathic approach to the treatment of symptoms of oestrogen
withdrawal in breast cancer patients: a Prospective observational study. Homeopathy, 2003 Jul; 92(3):131-
4
18 Rostock M, Naumann J, Guethlin C, Guenther L, Bartsch HH and Walach H. Classical homeopathy in the
treatment of cancer patients - a prospective observational study of two independent cohorts. BMC Cancer
2011; 11:19
19 Kulkarni A, Nagarkar BM, and Burde GS. Radiation protection by use of homoeopathic medicines.
Hahnemann Homoeopath Sandesh 1988; 12(1): 20-3.

20 CCRH Clinical evaluation of homoeopathic medicines along with Iscador therapy in managing malignant
diseases. Clinical Research Studies -Series III. New Delhi: CCRH; 2010: 24-35.
21 Gaertner K, Müllner M, Friehs H, Schuster E, Marosi C, Muchitsch I, Frass M, Kaye AD. Additive
homeopathy in cancer patients: Retrospective survival data from a homeopathic outpatient unit at the
Medical University of Vienna. Complement Ther Med. 2014 Apr; 22(2):320-32. doi:
10.1016/j.ctim.2013.12.014. Epub 2014 Jan 8.
22 Frass M, etal. Influence of adjunctive classical homeopathy on global health status and subjective
wellbeing in cancer patients - A pragmatic randomized controlled trial. Complement Ther Med. 2015 Jun;
23 (3):309-17. doi: 10.1016/j.ctim.2015.03.004. Epub 2015 Mar 23
23 Moshe Frenkel. Is There a Role for Homeopathy in Cancer Care? Questions and Challenges. Curr Oncol
Rep (2015) 17:43 DOI 10.1007/s11912-015-0467-8.

24 Clarke J. H. A Dictionary of Practical Materia Medica. Reprinted edition. New Delhi: B. Jain Publishers (P).
Ltd.; 2006.
25 Allen H.C. Keynotes and characteristics with Comparisons of some of the leading remedies of the Materia
Medica with Bowel nosodes. Eighth edition. B.Jain Publisher’s (P) Ltd.
26 Boericke William. New manual of Homoeopathic Materia Medica with Repertory. New Delhi B.Jain
Publisher’s (P) Ltd.

27 Dewey, Willis A. Practical Homeopathic Therapeutics. India. Reprint edition 2005. B Jain Publishers Ltd.
Chapter Tumors: p 384-388

28 Lilienthal Samuel. Homoeopathic Therapeutics. New Delhi. B Jain Publishers Ltd.; Chapter Carcinoma:
p113-118.
29 Kent J.T. Lectures on Homoeopathic Materia Medica. New Delhi. B.Jain Publisher’s (P) Ltd.

in cancer care as an adjunctive treatment and to some extent as standalone treatment in
pre-cancerous or early stages. There are about 168 remedies mentioned in Synthesis
Repertory for cancerous affections.
Broadly cancer patients seek homoeopathic treatment either as a primary treatment

modality or as an integrative approach where the patient takes both the conventional and
homoeopathic treatment for better management of their illness. It is the duty of the
physician to provide the information to the patient about the disease prognosis in both
the conditions.
Cell type, location and size of tumor, extent of disease, physiologic and psychological
status and other accessory symptoms of the patient are the main factors that would
determine treatment strategy and modality of treatment adopted for a particular
individual suffering from cancer. Physician should inform the patient of the scope and
limitations of both the conventional and homoeopathic system and allow the
independent decision of the patient regarding treatment.
The treatment strategy must be formulated according to the therapeutic goal mentioned
below:
1. In precancerous conditions- to cure

2. In early stages of cancer
 Treatment to delay or prevent metastasis
 Increase life span
 Symptomatic relief
 Improve quality of life
3. In terminal cases of cancer
 Symptomatic relief
 Control metastasis
 Improve quality of life
 Pain management
 Painless death
Constitutional remedies, nosodes, Indian drugs and organ-specific remedies may be

indicated as per prescribing totality.
Few remedies are enlisted below are known for their beneficial role in specific cancers
which can be prescribed when indicated:
Nitric acid: Cancer of cervix; Lapis albus: Cancer of uterus; Ornithogalum umbellatum:
Cancer of intestinal tract, especially of the stomach and Caecum; Cadmium sulphuratum:
carcinoma ventriculi with persistent coffee ground vomiting; Asterias rubens: Cancer of
breast; Euphorbinum officinarum: Pains of cancer and metastasis; ulcerating carcinoma
and epithelioma of the skin and Hekla lava: Tumors in general; osteosarcoma.

Indications of few commonly prescribed homoeopathic medicines for cancer are
given below:
S.no Medicine Indications

1. Arsenicum Arsenic album is palliative in cancerous affections of
album uterus, mammae, and lips. Burning and stinging pains.
Debility, exhaustion, restlessness.
Anxiety, sadness and fear of death. Symptoms are
aggravated at midnight, from cold and are better from heat
and warm drinks. Predominantly left sided affections and
thermally patient is chilly.
2. Calcarea Calcarea can be given in cancerous affections of lymphatic,
carbonicum parotid, sublingual, submaxillary glands. Burning and
stinging pains where the growth has invaded and
appropriated the surrounding tissues, so that there are
adhesions. Cold sweat on face; face sallow, pale and
cachectic in advanced stages of disease.
Generally patients are worse from exertion, mental or
physical; wet weather and better lying on painful side.
Predominantly a right sided remedy and thermally patient
is chilly.
3. Condurango The remedy can be used in cancers originating in epithelial
structures especially epithelioma, and scirrhus. Rhagades
at muco-cutaneous orifices. Pains are cutting, stinging,
burning, tingling, constrictive and piercing.
In cancer of tongue, “a painful crack in the right corner of
the mouth" is key note symptom. Slight pain in left half of
tongue. Small painful pustule on right side of tip of tongue,
on upper surface towards edge.
Flat epithelioma left side of nose. Much glairy mucus from
nose alternating with unusual dryness. Nasal intonation of
voice. Stiffness in nose. Pressive full feeling in bridge.
Allays the pain in gastralgia accompanying cancer of
stomach. Cancer of stomach, severe pains, vomiting of
coffee ground masses; hard knobby, large swelling in
pylorus, complete loss of appetite, emaciation, cachectic
look, constipation. Anorexia.
Schirrhus mammae; tumor hard immovable with severe
lancinating pains, nipple retracted; skin purple in spots and
wrinkled; ulceration with foetid sanious discharge and
much sloughing.
Most efficacious in open cancer or cancerous ulcers, where
it effectually moderates the severity of pain.
Patient generally feels miserable.

4. Conium The remedy is found useful in Carcinoma Breast. It acts on
maculatum the glandular system, engorging and indurating it, altering
its structure. Breasts are sore, hard and painful before and
during menstruation. Tumors, piercing pains; worse, at
night. There is a general feeling as if bruised by blows. Great
debility in the morning in bed.
The patient is generally worse, lying down, turning or rising
in bed; before and during menses, from taking cold, bodily
or mental exertion and better while fasting, in the dark,
from letting limbs hang down, motion and pressure.
Predominantly right sided affections and thermally the
patient is chilly.
5. Hydrastis Hydrastis is found useful in cancer breast and stomach. In
canadensis cancer of stomach there is bitter taste and pain as if from a
hard cornered substance, all gone sensation, cannot eat
bread and vegetables, vomits everything except milk and
water mixed; pain in the pit of stomach, emaciation,
cancerous cachexia. In Cancer of breast, tumor is hard,
adherent, skin mottled, puckered; cutting like knives in
mammæ.
Mentally the patient is irritable; disposed to be spiteful;
gloomy, taciturn, disagreeable. Moaning with occasional
outcries from pain. Depression; sure of death and desires it.
Generally worse in cold, dry winds.
6. Lachesis Indicated in melanotic, colloid and encephalitic cancer;
mutus ulcers are sensitive to touch with ichorous offensive
discharge, blood dark, non-coagulable; violent burning
gangrenous spots; cancer of lower lip, dry bleeding.
Cancer of stomach, the pit very sensitive to touch, with a
gnawing pressure, amelioration by eating, but coming on
again in a few hours, and the more violent the emptier the
stomach.
Cancer of breast with lancinating pains and a constant
painful feeling of weakness and lameness in left shoulder
and arm; open cancer has a dark, bluish-red appearance,
with blackish streaks of decomposed blood.
Uterine cancer developing itself at climaxis, pains increase
rapidly until relieved by profuse discharge of blood.
Patient is loquacious; thin and emaciated, sleeps into an
aggravation; complaints usually left sided & are thermally
he is hot. Blueness of affected parts; weakness of whole
body on rising in the morning.
7. Lycopodium Useful in Cancer of Breast: Right breast eaten away by
clavatum cancer. Swelling of the breasts with nodosities. Excoriation
and moist scabs on nipples. Stinging in nipples. Pains:

aching-pressure, drawing; chiefly right sided, < four to
eight P.M. Affects right side, or pain goes from right to left;
throat, chest, abdomen, liver, ovaries. Gastric
affections; excessive accumulation of flatulence;
constant sensation of satiety; good appetite, but a few
mouthfuls fill up to the throat, and he feels bloated;
fermentation in abdomen, with loud grumbling, croaking,
especially lower abdomen ; fullness not relieved by
belching. Debility in morning. Emaciation.
Indicated in prematurely old persons who are mentally
keen but physically weak persons. Generally worse, warm
applications, except throat and stomach which are better
from warm drinks and better, by motion, after midnight,
from warm food and drink, on getting cold, from being
uncovered. Thermally a hot person.
8. Phytolacca Pre-eminently a glandular remedy. Glandular swellings
decandra with heat and inflammation. Indicated in cancerous
affections of nose with total obstruction of the nose: when
riding, must breathe through the mouth. Cancer of lips:
Lower lip drawn down, lips everted. Cancer of breast when
the tumor is hard, painful and purple.
It is suited to individuals sensitive to damp weather.
Aching, soreness which cause the patient to groan,
restlessness and prostration are general symptoms guiding
to the selection of Phytolacca. Generally worse raising up,
motion, swallowing, hot drinks. heat, cold damp
weather, night, change of weather and better lying on
abdomen and by taking cold drinks.
9. Thuja Thuja can be given in spongy tumors and bleeding fungous
occidentalis growths. Hydrogenoid constitutions, cancerous cachexia,
weakly cachectic, yellowish and pallid. Rapid exhaustion
and emaciation.
Fixed ideas, as if a strange person were at his side; as if
soul and body were separated; as if something alive in
abdomen. Emotional sensitiveness, music causes weeping
and trembling. Indicated for Ill effects of vaccination.
Sycotic pains, i.e, tearing in muscles and joints, worse at
rest, better in dry weather, worse damp humid
atmosphere; lameness. Generally worse at night, from heat,
at 3 am and 3 pm ; from cold , damp air and better left side
, while drawing up a limb. Affections are generally left sided
and patients are predominantly chilly.

DEPRESSION
CASE DEFINITION1
Depression is a common mental disorder that presents with a low or depressed mood, loss
of interest or pleasure, decreased energy, feelings of guilt or low self-worth, disturbed sleep
or appetite, and poor concentration. Moreover, depression often comes with symptoms of
anxiety.
INCIDENCE:2
 Depression is a common mental disease & about 350 million people are affected
worldwide.
 In south East Asia around 40.8 million populations suffer from unipolar depression &
7.2 million suffer from bipolar depression. The World Health Organization estimates
that nearly 1 million people worldwide commit suicide every year, including 170,000
in India and 140,000 in high-income countries.3
 Women are 50% more affected than men (according WHO ,2008)3
AETIOLOGY & RISK FACTORS4,5
 History of depression in close relatives

 History of abuse (any sexual , physical , emotional)/trauma
 Marital or relationship problems
 Major events; Death or loss of loved one, losing a job, getting divorced, retiring etc.
 Loneliness
 Chronic anxiety
 Persistent anger & irritability
 High stress levels
 Substance abuse -Alcohol & tobacco use
1Marcus M, Yasamy MT, Ommeren M, and Dan Chisholm, Shekhar Saxena. Depression, A Global Public Health
Concern, WHO Department of Mental Health and Substance Abuse. [cited 2015 July 13]. Available at
http://www.who.int/mental_health/management/depression/who_paper_depression_wfmh_2012.pdf
2 World Health Organization- Depression Fact sheet 2015; Geneva, Switzerland : 2015 [ cited on 2015 march
19] Available at http://www.who.int/mediacentre/factsheets/fs369/en/

3 World Health Organization, The Global Burden of Disease: 2004 Update World Health Organization, Geneva,
Switzerland (2008). [ cited on 2015 march 20] Available at

http://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf
4Depression in Adults: Diagnosis & Treatment Guideline [cited 2015 Jan 8]. Available at
http://healthteamworksmedia.precis5.com/769675d7c11f336ae6573e7e533570ec
5 Depression Health Center. Causes of Depression [cited 2015 Mar 20] Available at
http://www.webmd.com/depression/guide/causes-depression
 Multiple somatic complaints
 Postpartum/ during pregnancy/during menopause
 Geriatric age group especially with loneliness and chronic debilitating illnesses
 Certain medications- Drugs, such as Accutane (used to treat acne), the antiviral drug
interferon-alpha, and corticosteroids can increase risk of depression.
 Chronic& serious illnesses-like Cancer, Parkinsons disease, heart disease, diabetes
and its complications, etc.
 Other psychiatric disorders- like Schizophrenia, anxiety disorder etc.
 Personalities with fastidious, perfectionist, self-critical traits; melancholic outlook or
general pessimistic tendencies.
Types of Depression:
1. Unipolar depression: - Involves symptoms such as depressed mood, loss of interest
& enjoyment and increased fatigability. Depending upon number & severity of
symptoms it further divided into mild, moderate & severe depression.
2. Bipolar depression:-It consists of both depressive & manic episodes separated by a
period of normal mood. Manic episodes involve elevated mood & increased energy.
3. Dysthymia: -A chronic depression of mood, lasting at least several years, which is not
sufficiently severe, or in which individual episodes are not sufficiently prolonged, to
justify a diagnosis of severe, moderate, or mild recurrent depressive disorder .
4. Cyclothymia:-A persistent instability of mood involving numerous periods of
depression and mild elation, none of which is sufficiently severe or prolonged to
justify a diagnosis of bipolar affective disorder or recurrent depressive disorder.
DIAGNOSIS
Screening & assessment6
The patients who present with symptom for depression should be screened using two
quick questions as follows:
In the past 2 weeks
1. Have you lost interest or pleasure which usually you like to do?
2. Have you felt sad, low, down, depressed or hopeless?
If “yes” on either question, then further assessment should be done using scales developed
for assessing it, for ex. PHQ-9 score
6Depression in Adults: Diagnosis & Treatment Guideline.[cited 2015 march 19].

Available at http://healthteamworksmedia.precis5.com/769675d7c11f336ae6573e7e533570ec
ICD-10criteria for diagnosis7
a) First set of symptom are usual which include
 Depressed mood
 Loss of interest
 Reduced energy leading to increased fatigability and diminished activity
b) Second set of common symptoms which include
 Reduced self- esteem and self -confidence
 Reduced concentration and attention
 Ideas of guilt and worthlessness
 Bleak & pessimistic views of future
 Disturbed sleep
 Diminished appetite
 Ideas or acts of self- harm or suicide
c) At least two of the symptoms of first set and two from the second set for a 2 week period
would make a mild depressive episode
d) At least two of the symptom of first set and three from the second set for a 2 week period
would make a Moderate depressive episode
e) All three symptoms of first set and at least four from the second set for a 2week period
would make a severe depressive episode
f) All three symptoms of first set and at least four from the second set including delusions,
hallucinations and depressive stupor for a 2 weeks’ period would make a severe depressive
episode with psychotic symptoms
g) Depressive symptoms of mild and moderate levels persisting for a very long duration (two
years as per DSM- IV) constitute the criteria for Dysthymic disorder.
 Anxiety disorder
 Personality disorder
 Substance abuse disorder
 Dementia
 Hypothyroidism
 Nutritional deficiency
7AFMC; Standard Treatment Guidelines Medical Management & Costing of Select Conditions; In Collaboration
with Ministry of Health & Family Welfare Government of India & WHO Country Office, India; Armed Forces
Medical College, Pune: 2007:122-128
RED FLAG/ REFERRAL CASES8
 All types of depression with high suicidal risk
 Depression with psychotic feature.
 Bipolar depression - The patient is currently depressed, as in a depressive episode
of either mild or moderate severity and has had at least one authenticated
hypomanic, manic, or mixed affective episode in the past9.
 Co- occurring Substances abuse
 Cases which are unresponsive to the treatment.
ASSESSMENT AND EVALUATION 7

There are different depressive scales and screening tests for diagnosis of the case. These
are as follows
 PHQ9 Scale [http://www.phqscreeners.com/pdfs/02_PHQ-9/English.pdf]
 Beck’s Depressive Index(BDI)
http://www.ibogaine.desk.nl/graphics/3639b1c_23.pdf]
 Hamilton Scale for depression (HDRS)[
http://healthnet.umassmed.edu/mhealth/HAMD.pdf]
PREVENTION10
For prevention of depression following community approaches should be included:
 Life Skills Programmes addressing concerns of children and adolescents to enhance

cognitive, problem-solving and social coping skills.
 School-based awareness programmes for the prevention of child abuse and substance
abuse.
 Interventions for parents of children with behavioural problems may reduce parental
depressive symptoms and improve outcomes for their children.
 Exercise programmes for the elderly are also effective in depression prevention.
MANAGEMENT
Mental symptoms such as depression, anxiety and insomnia are amongst the common
reasons for individuals to seek treatment with complementary therapies in general and
8Depression in Adults: Diagnosis & Treatment Guideline. [cited on 19 th march2015] Available at

9 ICD -10, version 2015 (cited 20th march 2015).Available at
http://apps.who.int/classifications/icd10/browse/2015/en#/F31.3
10 World Health Organization- Depression Fact sheet 2015; Geneva, Switzerland : 2015 [ cited 19th march 2015]
Available at http://www.who.int/mediacentre/factsheets/fs369/en/
homoeopathy in particular. There are few researches11, 12, 13, 14,15, 16 done in depression using
homoeopathic intervention which directs to its positive effect. Nonetheless the vast
literature and traditional homoeopathic text books have plenty of symptoms pertaining to
this condition. Homoeopathic medicine along with counseling, psychotherapies shall be in
help for recovery of the patient.
The patient should be informed regarding avoidable risk factor of the disease & motivate to
take steps for improving their health and wellbeing17. Motivational interviewing & empathy
help the patient in changing their behavior regarding disease and to do the following things
 Advice for regular exercise.
 Avoid alcohol, tobacco & illicit drugs
 Healthy diet should be taken
 Healthy sleep pattern should be maintained
 Engage in positive activities
 Stress management (Yoga, meditation, Breathing exercise)
 Social support should be given by family.
A variety of psychotherapeutic approaches18 are available for the relief of symptoms or the
management of depression. All of these need the services of a specially trained
counselor/psychotherapist to assess the needs of the patients and plan the nature of the
intervention. Generally, these interventions are combined with medication to hasten the
process of recovery. They are Cognitive/behavioral therapy (CBT), Interpersonal
psychotherapy (IPT) -, Problem-solving therapy (PST), Psychodynamic therapy and Light
therapy
11 Oberai P, Balachandran I, Janardhanan Nair KR, Sharma A, Singh V P, Singh V, Nayak C . Homoeopathic
management in depressive episodes: A prospective, unicentric, non‑comparative, open‑label observational
Study. Indian Journal of Research in Homoeopathy 2013;7(3):116-125
12 Katz T, Fisher P, Katz A, Davidson J, Feder G. The feasibility of a randomised, placebo-controlled clinical trial
of homoeopathic treatment of depression in general practice. Homeopathy 2005; 94.

13 Thompson EA, Reilly D. The homeopathic approach to symptom control in the cancer patient: a prospective
observational study. Palliat Med 2002; 16(3): 227–233.

14 Nayak C, Singh V, Singh K, Singh H, Gupta J, Lamba CD, et al. Management of distress during climacteric years
by homeopathic therapy. J Altern Complement Med. 2011 Nov;17(11):1037-42.

15 24 Thompson EA, Reilly D. The homeopathic approach to the treatment of symptoms of oestrogen
withdrawal in breast cancer patients. A prospective observational study. Homeopathy 2003; 92(3): 131–134.
16 Adler UC, Paiva NMP, Cesar A T, Adler M, Molina A, Padula A E, et al. Homeopathic Individualized Q-Potencies
versus Fluoxetine forModerate to Severe Depression: Double-Blind, Randomized Non-Inferiority Trial. Evid
Based Complement Alternat Med. 2011;2011:520182.
17Depression: A Global Crisis, World Mental Health Day, October 10 2012. World Federation for Mental Health.
[cited on 2015 Mar. 19]. Available at

http://www.who.int/mental_health/management/depression/wfmh_paper_depression_wmhd_2012.pdf?ua
=1
18Depression in Adults: Diagnosis & Treatment Guideline. [cited 2015 Mar. 19]. Available at
There are a number of homeopathic medicines available in homeopathic literatures19, 20,
21,22,23 for the treatment of depression Hahnemann also describes mental disease and its
management in Organon of medicine from aphorism 210 to 230. In synthesis repertory

around 764 remedies given under rubric sadness (depression). Medicines like Sepia &
Lachesis mostly used in depression during menopausal age. Pulsatilla is indicated in
depression around the time of hormonal changes (puberty, menstrual periods, or
menopause). Natrum muriaticum and Carcinosin are often employed to treat chronic and
serious forms of depression. Caladium indicated in depression due to impotence. Coffea
cruda or Kali phosphoricum can be used to treat insomnia in depression. Arsenicum album
can be given when prolonged anxiety leads to depression. Aconite can be given in acute panic
attack. Here indications of some important medicines for depression are given below. The
list is by no means exhaustive and as explained above, the correct appreciation of the totality
is the key to the correct remedy.
S.No Medicines Indications

1. Aurum Indicated in depression which results from fright, anger,
metallicum contradiction, mortification, vexation, dreads and reserved
displeasure. Person become low spirited & lifeless with
feeling of self-condemnation and utter
worthlessness. Suited in extreme cases of depression where
patients seek different methods to commit suicide. Least
contradiction excites anger in them. Feel hateful &
quarrelsome. Sleepless. Complaint <in winter >in summer
having weak memories. Sad, feels that all is against her and
life is not desirable, and the thought of death alone gives
pleasure
2. Ignatia Suited to sensitive, easily excited nature women having mild
amara disposition, quick to perceive, rapid in execution. Person
become depressed aftershocks, grief, disappointment & also
result from bad effect of bad news, from vexation with
reserved displeasure, from suppressed mental suffering, of
shame &mortification. Patient is introspective, sad, and
tearful; brood silently, mood swings. sighing and sobbing.
Worse, in the morning, from smoking,
19Boericke W., Boericke’s New Manual of Homoeopathic Materia Medica with Repertory: Third Revised &
Augmented Edition based on Ninth Edition. New Delhi: B. Jain Publishers; 2010.
20Allen HC. Allen’s Keynotes- Rearranged and classified with leading remedies of the materia medica and bowel
nosodes. 10th Reprint edition. B. Jain Publishers (P) Ltd.; Jan 2006.
21 Clarke JH. A Dictionary of Practical Materia Medica, New issue with additions in three volumes. New Delhi:
B. Jain Publishers, 2006.

22 Murphy R .Homeopathic medical repertory,2nd revised edition, B. Jain Publishers ,Page 1307
23 Oberai P, Balachandran I, Janardhanan Nair KR, Sharma A, Singh V P, Singh V, Nayak C . Homoeopathic
management in depressive episodes: A prospective, unicentric, non‑comparative, open‑label observational

Study. ,Indian Journal of Research in Homoeopathy 2013;7(3):116-125
3. Kali Suited to anxious, nervous & irritable person. Indicated in
phosphorium extreme lassitude and depression. Slightest labor seems a
heavy task for them. Exhaustion after moderate mental
effort. Person is indifferent and captious. Loss of memory.
Easy perspiration, sensitivity to cold, anemia, insomnia, and
indigestion are often seen when this remedy is needed.
4. Natrum Suited to reserved, sensitive and emotional persons. Bad
muriaticum effect of grief, disappointment, anger, fright, vexation &
suppression of inner feelings. Becomes angry if someone
tries to console them. Wants to be alone to cry. Anxiety,
brooding about past grievances, migraines, back pain, and
insomnia can also be experienced when the person is
depressed. Person is awkward & hasty. Craves for salt and
tiredness from sun exposure are other indications for this
remedy.
5. Sepia It is a remedy indicated especially to women and in
officinalis depression occurring during & after pregnancy. Weary,
irritable & indifferent to loved ones or family members.
Persons worn out by the demands of everyday life, easily
offended, very sad. Having weeping disposition. Dreads to be
alone. Anxious toward evening Indolent & sensitive to cold
air. Menstrual problems, bearing feeling in internal organs,
sluggish digestion, and improvement from vigorous exercise
are other indications for this remedy.
6. Acid Indicated for depression caused by chagrin, grief, from
phosphoricum excessive care, sorrow, from long succession of moral
emotion, from disappointed affection. Person become
listless, apathetic & indifferent to the affairs of life. They feel
prostrated and stupefied with grief.
7. Conium Suited to old age people & bachelors. Depression from any
maculatum kind of excitements. Patient is timid & morose. No inclination
for business or study; takes no interest in anything. Afraid of
being alone yet avoids society. Memory weak; unable to
sustain any mental effort. Cannot bear contradiction. Bad
effect of suppression of sexual desire. Debility, vertigo,
cancerous tendencies are other indicators of this drug.

8. Staphysagria Suited to quiet, sensitive, emotional people. Humiliating
experiences, insult or loss of pride and suppressed emotions
or anger can lead them to depression. Bad effect of onanism,
sexual excess, mortification, chagrin & reserved displeasure.
Person become indifferent, apathetic & low spirited. Memory
weak. People are sad & fear about his future. Headaches,
toothache and stomachache are pointers to the use of this
remedy.

ICD -10 criteria for diagnosis
a) Set1- depressive mood, loss of interest, reduced energy
b) Set 2-Reduce self- esteem, reduce concentration, ideas of guilt, pessimistic future,
ideas of suicide, disturb sleep, decrease appetite.
c)At least 2 symptoms 1st set & 2 symptom 2nd set for 2 week- Mild depressive episode
d)At least 2 symptoms 1st set & 3symptom 2nd set for 2 week- Moderate depressive
episode
e) All 3 symptoms 1st set & 4 symptom 2nd set for 2 weeks -Severe depressive episode
f) All 3 symptoms 1st set & 4 symptom 2ndincluding delusions, hallucination &
depressive stupor for 2 weeks -Severe depressive episode with psychotic symptoms
g) Depressive symptoms of mild& moderate levels persisting for long duration (2year
as per DSM)- Dysthemia
Evaluation test
Beck’s Depressive Index(BDI)
Hamilton Scale for depression (HDRS)
Bender Gestalt Test(BGT)
PHQ- 9 score
Mild depression Moderate Severe depression

depression
Begin homeopathic Begin multi-modular treatment

treatment & advice for  Homeopathic treatment
general management  Psychotherapies like
o Cognitive/behavioral therapy
General Management o Interpersonal psychotherapy
o Problem-solving therapy
Advice for regular exercise.
o Psychodynamic therapy
Follow up – Avoid alcohol, tobacco & illicit
intermittently at drugs
different visits to Healthy diet should be taken
Healthy sleep pattern should Referral criteria
assess the changes
be maintained  Depression include high
Engage in positive activities suicidal risk
Stress management (Yoga ,  Major depressive
meditation) disorder
Social support should be given  Depression along with
by family psychotic feature.
 Bipolar depression

DIABETES MELLITUS
CASE DEFINITION
Diabetes mellitus (DM) refers to a group of common metabolic disorders that share the
phenotype of hyperglycemia. Several distinct types of DM exist and are caused by complex
interaction of genetics and environmental factors. Depending upon the etiology of DM,
factors contributing to hyperglycemia include reduced insulin secretion, decreased glucose
utilization, and increased glucose production.1
INCIDENCE
According to World Health Organization, the number of people with diabetes has risen
from 108 million in 1980 to 422 million in 2014. The global prevalence of diabetes among
adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014.2
India leads the world with largest number of diabetic subjects earning the dubious
distinction of being termed the “diabetes capital of the world”. According to the Diabetes
Atlas 2006 published by the International Diabetes Federation, the number of people with
diabetes in India currently around 40.9 million is expected to rise to 69.9 million by 2025
unless urgent preventive steps are taken.3
AETIOLOGY/ RISK FACTORS
Various etiologies can result in Diabetes 5, 4
1. Immune-destruction of β-cells of pancreas leading to absolute insulin deficiency:Type 1

diabetes
2. Relative insulin deficiency to predominantly an insulin secretory defect with insulin
resistanceleading to Type 2 diabetes orNon-insulin dependent diabetes or adult-
onset diabetes.
Risk Factors for Type-2 DM8
 Overweight and obesity

 Abdominal obesity
 Physical inactivity
 Maternal diabetes
 Stress
1
Powers C. A. Diabetes Mellitus. In : Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL,Jameson JL, et al.,
editors. Harrison’s principles of internal medicine. 17th ed. New York: McGraw Hill; 2008: p 2275-2310
2
World Health Organization - Diabetes Factsheet; Geneva, Switzerland: 2015[cited 13th July 2015] Available at
http://www.who.int/mediacentre/factsheets/fs312/en/
3Mohan etal. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res. 2007 March ;125; 217-230
4 Diagnosis and Classification of Diabetes Mellitus; American Diabetes Association; Diabetes Care. 2005; 28:
38-39.
 Excess alcohol
 Excess smoking
 High blood pressure
3. Glucose intolerance during pregnancy

4. Other factors like:
• Genetic defects of the β-cell
• Genetic defects in insulin action
• Diseases of the exocrine pancreas
• Endocrinopathies
• Drug- or chemical-induced diabetes
• Infections
TYPES
DM is classified on the basis of pathogenic process that leads to hyperglycemia, as opposed
to earlier criteria such as age of onset or type of therapy. The two broad categories of DM
are Type I and Type II. Other than these Pre- Diabetes or Impaired fasting
glucose/Impaired Glucose Tolerance is a commonly identified state in which the blood
glucose levels are higher than normal but not high enough to be classified as full-blown
diabetes. Patients with these states usually have no symptoms and are diagnosed because a
test is done upon patient request or because he/she falls into a high risk category. 1
DIAGNOSIS
Symptoms5
 The early symptoms of untreated diabetes are related to elevated blood sugar levels,
and loss of glucose in the urine. High amounts of glucose in the urine can cause
increased urine output (polyuria) and lead to dehydration. Dehydration causes
increased thirst (polydipsia) and water consumption.
 The inability of insulin to perform normally has effects on protein, fat and
carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that
encourages storage of fat and protein. A relative or absolute insulin deficiency
eventually leads to weight loss despite an increase in appetite (polyphagia).
 Some untreated diabetes patients also complain of fatigue, nausea and vomiting.
Patients with diabetes are prone to developing infections of the bladder, skin, and
vaginal areas.
 Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated
glucose levels can lead to lethargy and coma.
5 Stoppler MC. Diabetes Mellitus; [cited 2015 April 13]. Available at

http://www.medicinenet.com/diabetes_mellitus/page3.htm#what_causes_diabetes last retrieved on date
11/02/2014.
Symptoms may develop rapidly (weeks or months) in type 1 diabetes, while they usually
develop much more slowly and may be subtle or absent in type 2 diabetes. The clinical
presentation of the two types vary as:
Type 1 diabetes (T1DM/ Juvenile onset diabetes)

The diagnosis of T1DM can be made throughout childhood but it is more likely below 15
yrs of age. The onset is usually acute and severe and insulin is required for survival Type 1
diabetes results from autoimmune destruction of the beta cells in the pancreatic islets.
Family history of diabetes is rare. Presence of features of associated autoimmunity
(autoimmune disorders, vitiligo) and absence of obesity and acanthosis nigricans are
characteristics of T1DM. In addition, urine of T1DM patients with uncontrolled
hyperglycemia is positive for ketone bodies.
Type 2 diabetes (T2DM/ Non-insulin dependent diabetes or adult-onset diabetes)

It usually occurs after the age of forty years but occurs frequently even at lower age among
Indians. T2DM was previously known as non-insulin dependent diabetes mellitus. The
onset is usually insidious and may be mild to severe. The family history is usually positive
and strong. Obesity, metabolic syndrome and acanthosis nigricans are usually seen in these
patients while there is no evidence of autoimmunity. Further, there is no insulin
dependence till late in the course of illness.
Table 1: Important differentiating features between T1DM and T2DM
Age Bimodal peak 4th decade
i. 5-7 yrs
ii. 14yrs
Onset Explosive Less explosive
oftenincidental detection
Phenotype Lean Obese
Signs of Insulin Absent Usually present
resistance
i. Acanthosis nigrica
ii. Skin tags
Diabetic ketoacidosis Common Rare
Auto –immune disorder Commonly associated Not associated
Insulin and C-peptide Low Normal to low
Drugs Insulin Oral drugs and Insulin if
required

Investigations 1,6
1. Fasting or random blood glucose

2. Oral glucose tolerance test with 75 g glucose load (adults) or 1.75 g/kg body weight
in children (if required to confirm diagnosis)
Diagnosis of Diabetes Mellitus

1. Symptoms of diabetes plus NOTE:
casual plasma glucose
Three ways to diagnose diabetes are possible, and each, in the
concentration ≥200 mg/dl
absence of unequivocal hyperglycemia, must be confirmed, on a
(11.1 mmol/l) €
subsequent day, by any one of the three methods. The use of the
Or hemoglobin A1c (A1C) for the diagnosis of diabetes is not
recommended at this time.
2. FPG ≥126 mg/dl (7.0
mmol/l) Fasting is defined as €Casualis defined as any time of day without regard to time since last
no caloric intake for at least 8 meal. The classic symptoms of diabetes include polyuria, polydipsia,
h. and unexplained weight loss.
Or *The test should be performed as described by WHO, using a glucose
3. 2-h post load glucose≥ 200 load containing the equivalent of 75 g anhydrous glucose dissolved
mg/dl (11.1 mmol/l) during in water. In the absence of unequivocal hyperglycemia, these criteria
an OGTT*. should be confirmed by repeat testing on a different day. The third
measure (OGTT) is not recommended for routine clinical use.
Or
HBAIC (Glycosylated Gestational diabetes (GDM): Standard OGTT is done at 24-28 weeks
Haemoglobin) ˃ 6.5% after an overnight fast (fasting plasma glucose and a plasma glucose
2 hours after 75g glucose drink is done). A 2-hour level >=7.8
mmol/L (or 140 mg/dL) is diagnostic of gestational diabetes. If
According to WHO, fasting and postprandial blood sugars are elevated in the first
Intermediate hyperglycemia trimester, this may indicate preexisting diabetes mellitus (which is
or Pre-diabetes is : considered a different condition, with different implications).
Impaired fasting glucose(IFG)
Pre- Diabetes or Impaired fasting glucose/Impaired Glucose
/Fasting Plasma Glucose
Tolerance is a commonly identified state in which the blood glucose
levels of 100 mg/dl to 125
levels are higher than normal but not high enough to be classified as
mg/dl and impaired glucose
full-blown diabetes. Patients with these states usually have no
tolerance(IGT) as 2-h OGTT
symptoms and are diagnosed because a test is done upon patient
values of 140 mg/dl to 199
request or because he/she falls into a high risk category.
mg/dl.
3. Urine ketones
4. Urine protein
5. Blood urea, electrolytes and creatinine
6. Fasting blood lipid profile (adults)
7. Glycatedhaemoglobin (HbA1c)
8. CBC
9. Serum fasting Insulin
10. ECG (adults)
6Diagnosis and Classification of Diabetes Mellitus; American Diabetes Association; Diabetes Care, Volume 28
(1); 2005: pp. 41.
Subsequent monitoring
 Blood glucose
 Recorded results of regular self-monitoring of fasting and randomtests at
home by the patient using a glucometer.
 Periodic fasting or random tests during clinic reviews
 Glycatedhaemoglobin (HbA1c)
 at least three times a year, if available
 Blood lipid tests
 annually, but more frequently if levels abnormal or on lipid lowering
medication
 Blood urea, electrolytes and creatinine
 annually, but more frequently if levels abnormal
 Urine protein
 annually
COMPLICATIONS
Diabetes complications are divided into micro vascular (due to damage to small blood
vessels) and macro vascular (due to damage to larger blood vessels). Micro vascular
complications include damage to eyes (retinopathy) leading to blindness, to kidneys
(nephropathy) leading to renal failure and to nerves (neuropathy) leading to impotence
and diabetic foot disorders (which include severe infections leading to amputation).Macro
vascular complications include cardiovascular diseases such as heart attacks, strokes and
insufficiency in blood flow to legs.7
Micro vascular complications

Diabetic Diabetic retinopathy is a leading cause of blindness and visual
retinopathy disability. It is caused by small blood vessel damage to the
back layer of the eye, the retina, leading to progressive loss of
vision, even blindness. Usually the patient complains of
blurred vision, although other visual symptoms may also be
present.
Nephropathy Diabetic kidney disease is also caused by damage to small
blood vessels in the kidneys. This can cause kidney failure, and
eventually lead to death. In developed countries, this is a
leading cause of dialysis and kidney transplant. Patients
usually have no symptoms early on, but as the disease
progresses, they may feel tired, become anaemic, may not be
able think clearly and even develop dangerous electrolyte
imbalances.
Neuropathy It is the most common complication of diabetes. Diabetes
causes nerve damage through different mechanisms, including
7
World Health Organization[Internet]. Geneva, Switzerland: Diabetes Programme; 2006[cited 2015 Apr 24]. Available at:
http://www.who.int/diabetes/action_online/basics/en/index3.html
direct damage by hyperglycaemia and decreased blood flow to
nerves by damaging small blood vessels. Sensorimotor
neuropathy is characterized by symptoms such as burning,
shooting, and tingling sensations, and allodynia (super-
sensitivity or pain from normal stimuli). Impaired sensation in
the feet is a strong risk factor for foot ulcer and other foot
problems. Carpal tunnel syndrome is also common in diabetic
subjects. Autonomic neuropathy can cause gastroparesis,
sexual dysfunction, bladder incontinence, and cardiovascular
damage.
Macro vascular complications
Cardiovascular People with diabetes are 2 to 4 times more likely to develop
disease cardiovascular disease (CVD) than those without diabetes. The
risk of coronary artery disease is increased in patients with
poor glycemic control.Hyperglycaemia damages blood vessels
through a process called “atherosclerosis”, or clogging of
arteries. This narrowing of arteries can lead to decreased
blood flow to heart muscle (causing a heart attack), or to brain
(leading to stroke), or to extremities (leading to pain and
decreased healing of infections). The symptoms of these
different conditions are varied: ranging from chest pain to leg
pain, to confusion and paralysis.
Cerebrovascular disease is a term encompassing many

disorders that affect the blood vessels of the central nervous
Cerebrovascular
system. These disorders result from either inadequate blood
disease
flow to the brain (i.e., cerebral ischemia) or from hemorrhages
into the parenchyma or subarachnoid space of the central
nervous system (CNS). Various terms have been used to
describe cerebrovascular events, these include: Transient
Ischaemic Attack, Cerebral infarction, Cerebral haemorrhage.
Sudden confusion, loss of coordination, unilateral weakness,
and numbness are warning signs of a cerebrovascular event.
Peripheral Arterial Peripheral arterial disease (PAD) is an atherosclerotic

Disease occlusive disease. It is the major risk factor for lower extremity
amputations. The abnormal metabolic state accompanying
diabetes results in changes in the state of arterial structure
and function predisposing people to PAD. The risk of
development of PAD increases threefold to fourfold in patients
with diabetes mellitus. The 2 cardinal symptoms of PAD are
intermittent claudication and pain at rest.

 Endocrine disorders - Endocrine tumor causing increased production of growth

hormone, glucocorticoids, catecholamines, glucagon, and somatostatin; Addison
disease; Grave’s disease; Hashimoto thyroiditis; Acanthosis nigricans (genetic disorders
with insulin resistance)
 Chronic pancreatitis
 Cystic fibrosis
 Non-diabetic glycosuria
 Renal glycosuria
 Peripheral neuropathy from alcohol abuse or vitamin B-12 deficiency
MANAGEMENT
Diabetes is a chronic metabolic disorder which demands careful medical management with
life style modifications. The following therapeutic goals need to be achieved for efficient
management of diabetes:
 Relief from symptoms and improvement in quality of life

 Maintenance of appropriate glycemic targets: FBG: 4 - 6 mmol/L (70-110 mg/dl), 2-
hour post-meal blood glucose: 4 –7.8mmol/L (70-140 mg/dl) and Glycated
hemoglobin 6.5 % or less
 Prevention of acute hyperglycemic complications and treatment-related
hypoglycemia
 Weight reduction in overweight and obese individuals
 Maintenance of BP less than 130/80 mmHg
 Maintenance of LDL-cholesterol less than 2.5 mmol/L (45 mg/dl)
The great diabetologist Joslin has mentioned that “the person who knows his /her diabetes
will live longer.” He/ She should be oriented and motivated about consumption of heathy
diet, importance of regular physical activity, maintenance of complications of DM,
relevance of timely investigations. Few important points pertaining to this include:
 Diet
 Avoid refined sugars as in soft drinks, or adding sugar to their beverages.
Artificial sweeteners and 'diet' soft drinks, which do not contain glucose, may
however be used.
 Carbohydrates (60%), protein (15%) and fat (25%) mostly of plant-origin and
low in animal fat.
 A reduced total caloric content (portions) and an increase in the amount of fibre
e.g. vegetables, fruits and cereals.

 Exercise
 Regular, simple exercise e.g. 30 minutes brisk walking at least 3 days a week in
ambulant patients.(All advice on exercise must give consideration to the patient's
age and the presence of complications and other medical conditions.)
Therapeutic intervention in the form of lifestyle modification or medicine at an early stage

can be beneficial in relieving symptoms and halting the progress of the disease. Many
research studies in the past on pre diabetic states, established disease and even its
complications 8, 9, 10, 11, 12, 13, 14, 15, 16 have shown favorable outcome with homoeopathic
treatment. Homeopathic medicines can be given as a standalone medicine along with life
style modification as soon as the disease is detected or as an adjuvant to conventional
treatment when the disease has progressed. This kind of treatment can be helpful to relieve
symptoms, improve quality of life and taper the dosage of conventional medicine as and
when required.
Homoeopathic literature/armamentarium enlists many medicines to deal with this

condition per se, however, the presenting totality of symptoms indicative of any medicine
in the homoeopathic materiamedica shall always be the sole guide for every individual
case.
A constitutional medicine is required to be prescribed covering the entire symptomology of

the patient. Polychrests in homoeopathic system of medicine are often found to be
constitutional remedies and are found indicated. Constitutional remedies like Arsenicum
album, Arsenicumbromatum, Calcareacarbonicum, Phosphorus, NatrumMuriaticum,
Lycopodium, Silicea, Kali bromatum, Sulphur etc. are found to frequently correspond to the
condition. Few commonly indicated medicines include the acid group of medicines (Lactic
acid, Phosphoric acid, Sulphuric acid, Oxalic acid, Picric acid and Uranium nitricum) which
are known to possess therapeutic value to arrest or stop the progress of diabetes. However,
8Sampath S, Narasimhan A, Chinta R, Nair KR, Khurana A, Nayak D, et al. Effect of homeopathic preparations of
Syzygiumjambolanum and Cephalandraindica on gastrocnemius muscle of high fat and high fructose-induced
type-2 diabetic rats: Homeopathy. 2013 Jul;102(3):160-71
9Pal A, Misra BB, Das SS, GauriSS,Patra M, Dey S. Antidiabetic effect of Cephalandraindica Q indiabetic rats.
Indian J Res Homoeopathy 2013;7(2):81-90

10 Maiti S, Bera TK, Chatterjee K, Ghosh D.A study of the effect of mother tincture of Syzygiumjambolanum on
metabolic disorders of Streptozotocin induced diabetic male albino rat. Indian J Res Homoeopathy
2014;8:129-35
11 Rastogi DP., Saxena AC., Kumar S.Pancreatic beta-cell regeneration: a novel anti-diabetic action of
Cephalendraindica mother tincture.British Homoeopathic journal 1988; 77(3): 147-151

12Nayak C, Oberai P, Varanasi R, Baig H, Ch R, Reddy GR, Devi P et al. A prospective multi-centric open clinical
trial of homeopathy in diabetic distal symmetric polyneuropathy. Homeopathy 2013; 102(2):130-8.

13 Tiwari ML. Diabetes mellitus - defining scope and clinical approach for homeopathic management. Indian
Journal of Research in Homœopathy 2008;2(3):28-36.

14Nayak C, Singh V, Singh K, Singh H, Gupta J, Ali Mohd.S, et al. A prospective observational study to ascertain
the role of homœopathic therapy in the management of diabetic foot ulcer. American Journal of Homeopathic
Medicine 2011; 104(4):166-76.
15Baig H, Singh K, Sharma A, Kaushik S, Mishra A, and Chug S. Rhusaromaticus in management of Diabetes
mellitus. Clinical Research Studies-Series II. New Delhi: CCRH; 2009:21-7

16Baig H, Singh K, Sharma A, Oberai P, Kaushik S, Nayak D, et al. Role of Cephalandraindica Q in the
management of Diabetes mellitus as an add on medicine along with conventional anti-diabetics. Indian
Journal of Research in Homœopathy 2008; 2(3):22-7
various remedies like our nosodes (Bacillinum, Medorrihnum, Lyssin etc.), sarcodes
(Adrenalin, Insulinum, Lac vaccinumdefloratum, Lac vaccinum, Lac
defloratum,Thyroidinum etc.), bowel nosodes (B. gaertner, B.morgan, Proteus etc.) and
other remedies with their specific indications which, when found well indicated in a case
possess no less power to cure the patient as our more commonly prescribed polychrests.
Some organ remedies and indian medicines like Abromaaugusta (Diabetes mellitus, fishy
odor in urine), Cephalendraindica(Diabetes with polynueropathy), Syzigiumjambolanum
(Diabetes with pruritis), Gymnemasylvestre(Diabetic carbuncles, burning all over the
body) etc. may also be given especially in some long standing cases who present with very
few constitutional symptoms or in whom pathological changes or complications are quite
apparent and susceptibility to react to constitutional medicines is low or may produce a
severe disease aggravation. In such cases once the acute pathological insult has been
controlled with the organ remedy or if the symptoms became clearer, it may be possible to
later follow up with indicated constitutional medicine.
For treatment of adverse effects/complication of diabetes/ diabetes with some associated

diseases there is further list of medicines in the repertory which is indicated through their
peculiar symptomatology. Few examples other rare remedies with their indications are:
Diabetes Mellitus with gouty symptoms -Lac acid, Nat. sulph. , Diabetes with albuminuria-
Helonia), Diabetes with debility- Acetic Acid, Opium;Diabetes with gangrene, boils, carbuncles,
diarrhoea- Arsenicum album;Diabetes with impotency- Coca, Moschus;Diabetes with
melancholia, emaciation, thirst, restlessness- Helonias;Diabetes with motor paralysis-
Curare;Diabetes with rapid course- Cur., Morph.;Diabetes with ulceration- Syzygium;Great
emaciation, debility, and a tendency to ascitis with general dropsy- Uranium nitricum.
Apart from the above medicines, given below the indications of commonly
prescribed constitutional medicines excerpted from research and experience are given
below:

1. Arsenic Suitable for persons with rapid weakness and emaciation.
album Polyuria with bulimy and increased thirst for small quantity
of water at short intervals. Burning all over the body due to
acute or chronic pathology of nerves and blood vessels > by
warm application;Great exhaustion after slight exertion.
Paleness of skin; disposition to gangrene and skin affections.
Anxiety with fear of death; Restlessness with tossing about in
agony. Fastidious and oversensitive patients. Chilly patient
but wants head uncovered. Mid-day and mid-nightand
periodical aggravation. Worse cold: food, drinks, air, damp
weather. Better: hot applications, warm drinks, wrapping up,
in company and while sweating.

2. Natrum Indicated in patients who have polyuria, unquenchable thirst;
muriaticum emaciation especially marked about the neck though eating
well; loss of appetite and scanty sweat. Dryness of all mucous
membrane and skin; great weakness and weariness.
Involuntary escape of urine while walking, coughing, or
sneezing.
Patient is very sensitive, emotional and strong willed
personality. Broods over past undesirable events and suffers
from silent grief.Contradiction and consolation
aggravate.Anemia and cachexia from loss of vital fluids,
menses and after mental affection.Earthy complexion and
oily greasy skin especially of face. Mapped or geographical
tongue. Craving for salt, bitter things, oysters, fish and milk.
Aversion to bread, fats and coffee. Aggravation in morning
and forenoon; 10 to 11 AM, heat Better: Open air, cool
bathing, sweating, rest, before breakfast.
3. Lycopodium Suitable in persons who suffer from burning in general and
clavatum urine in particular; constant hunger and thirst worse at night;
flatulence; diminished sexual power and desire (impotency);
great emaciation; mental and bodily exhaustion; tendency for
lithic acid gravel and tardy wound healing.
Sensitive, intelligent, dominating, dictating and headstrong.
Peevish and depressed in mind. Miserly and coward.
Irritable, contradiction aggravates. Adapted to old persons
or children who age prematurely and have a weak body but
sharp mind (intellectually keen but bodily weak). Earthly
complexion and yellowish spots on skin with or without
vertical furrows on forehead. Desire sweets, warm drinks.
Aversion to breads. All complaints < 4-8 pm Better: warm
drinks, food, cold applications, eructation, urinating.
4. Phosphorous Glycosuria; urine pale, watery or turbid, whitish like curdled
milk, with brick dust sediment etc.; ravenous appetite
(Hungry soon after eating); sudden emaciation and gradual
weakness and prostration;trembling, numbness and
paralysis of lower limbs; increased perspiration and thirst for
cold water.
Patient is lively, cheerful, and communicative. Affectionate
and reciprocating; desires to be magnetized. Sensitive to all
the impressions. Nervous fidgety cannot remain still in one
place. Tall, stooped shoulder slender, sickly face, earthy,
sunken and pale, Fair skin, delicate eye lashes, fine blond or
red hair. Bleeding tendency. Desires for salt, refreshing spicy
things, wine and sour things. Aversion to sweet, milk, boiled
meat, salted fish, beer, puddings, tea and coffee. Aggravation
from lying on left side, evening, by thunderstorm, change of
weather slight causes: emotions; talking, touch, odors.
5. Calcarea Frequent and copious urination; sour or pungent; trickling of
carbonica urine after micturition; tendency for unhealthy and flaccid
wounds which donot heal easily; recurrent infections with
suppurative tendency; tendency for obesity.
Adapted to apprehensive fearful (fear of night, dark, alone
strangers), sluggish, obstinate, mischievous and irritable
persons having anxiety with palpitation. Sensitive to noise,
and averse to work or exertion. Fat, flabby persons with easy
and profuse perspiration, which is cold, damp and sour.
Suited to persons with blond hair, light complexion, blue
eyes, fair skin,and distended abdomen with thin
extremities.Chilliness with internal coldness who get cold
easily. Desire for undigested food like chalk, coal, pencil,
sweets, eggs and aversion to boiled food and meatwith
intolerance to milk. Character of discharges are yellowish,
greenish thick or thin < from physical and mental exertion.
Worse from cold, bathing, morning; during full moon. Better
in dry weather; lying on painful side.
6. Mercurius Indicated in persons with excessive hunger, emaciation and
profuse perspirationwhich does not relieve and may even
increase the suffering. Profuse urination where the quantity
of urine voided is larger than amount of water drunk,
frequent urging to urinate.Intense thirst, although the tongue
looks moist and the saliva is profuse. Great weakness and
trembling from least exertion. Itching and burning in the
vulvae.
Hasty, impulsive and restless persons with light hair, skin
and lax muscles. These persons are often hurried and talk
rapidly. He has earthy dirty looking puffy face. Intense
craving for cold drinks Aversion to meat, wine, brandy,
coffee, greasy food, and buttermilk. Milk and sweets disagree.
Profuse discharges which are offensive and do not
ameliorate. Aggravation of complaints at night, wet damp
weather; in autumn, warm days and cold, damp nights; lying
on right side; perspiring.
7. Sulphur Excessive hunger,thin and weak, even with good

appetite.Weak, empty, gone or faint feeling in the stomach
about 11 a. m. (10 or 11 a. m. > by eating, Nat. c.); cannot wait
for lunch; frequent weak, faint spells during the day. Profuse
thirst drinks much eats less. Frequency of urination, must
hurry to urinate large quantity of colorless urine. Burning all
over the body. Dry filthy dirty suppurating skin; with profuse
acrid discharges excoriating the parts.
Suitable to quick motioned, quick tempered,irritable persons
who are mentally egoistic, dwell on philosophical and
religious speculations(ragged philosopher). Hot patientswho
desire sweets and in whom milk disagrees. Aggravation from
rest, warmth of the bed, washing, 11am, night, early morning,
standing. Amelioration dry warm weather lying on right side,
drawing limbs. Burning all over the body especially in all the
orifices e.g. nose, ear, rectum vagina, urethra etc.; flushes of
heat on face.

Algorithm for Type II DM
Obtain case history and clinical
assessment of diabetes
Diagnostic investigations Initial Investigations

Repeat testingon
Random blood glucose˃200mg/dl different occasions CBC, Urine routine/ microscopic, micro
Fasting plasma glucose˃126mg/dl for confirming the albuminuria, lipid profile, blood urea,
Two hour prandial glucose˃200mg/dl diagnosis
creatinine, ECG, chest X-ray PA view
HBA1C, Urine routine/ microscopic
Pre-Diabetic Initial blood glucose fasting˃126mg/dl- Initial blood glucose fasting˃ 200-
FPG 100–125 mg/dl
180mg/dl 300mg/dl
2-h Postload glucose 140–199
mg/d Post prandial plasma glucose ˃200-250 Post prandial plasma glucose˃250-
mg/dl 300 mg/dl
Educate patients about lifestyle

changes, disease progression and
Start homoeopathic Standard care+ add on
complication, foot care homoeopathic treatment +Life
treatment +Life style
Nutritional diet (Carbohydrate 55- style changes
changes
65%, Protein 15-20%, Fat ˂25%)
Encourage physical exercise (at least
30-60 mins/daily)
Mild symptoms: re-assess the case
and restart homoeopathic
treatment
Worsening of symptoms /
Improvement NO blood values
YES Improvement
Continue same Continue Homoeopathic YES NO

treatment treatment & Life style changes
Refer for standard care

DIARRHOEA
CASE DEFINITION
Acute diarrhea is defined as the passage of three or more loose or abnormally liquid stools
per day (within 24 h).The attack usually lasts for about 3 to 7 days but it may last for 10-14
day.1It is often accompanied by vomiting.
INCIDENCE 1
Because of poor sanitation and more limited access to health care, it remains one
of the most common causes of mortality due to fluid loss thereby leading to
dehydration particularly among children in developing countries.
 Worldwide, nearly 1.7 billion cases of diarrhoeal disease emerge every year.
 Diarrhoeal disease is the second biggest killer of children under five years old &
responsible for about one in five deaths next to malnutrition. Each year diarrhoea
kills around 7, 60, 000 children under five.
 In India, at least 1.5 million children under the age of 5 yrs. die every year due to
acute diarrhea. 2 It accounts for 20% of all pediatric deaths.2
AETIOLOGY
Diarrhoea is usually caused by the infection of intestinal tract which may be bacterial, viral
or parasitic. 3
 Viral agents –Rotavirus (15-25%), norovirus, cytomegalovirus, herpes simplex
virus, and viral hepatitis.
 Bacterial agents -E. Coli (10-20%), Campylobacter (10-15%), Shigella species (5-
15%), Vibrio cholera(5-10%), Salmonella (1-5%).
 Parasitic agents-Giardia intestinalis, Cryptosporidium parvum (5-15%),
Entamoeba histolytica
Other causes: malaria, urinary infection, meningitis, respiratory infection, ENT infection,
Simple teething in children.
1World health organization- Diarrheal disease; Geneva, Switzerland: 2015 [cited 2015Mar19] Available at
http://www.who.int/mediacentre/factsheets/fs330/en
2Pathak et al, Adherence to treatment guidelines for acute diarrhoea in children up to 12 years in Ujjain
,India - a cross-sectional prescription analysis ,BMC Infectious Diseases, 2011;11:32
3Park K. Park’s textbook of Preventive and social medicine, 19 thedition. Jabalpur: Banarsidas Bhanot
Publisher:2007

ROUTE OF INFECTION
Infectious diarrhea is usually acquired by oro-fecal route, especially through contaminated

food or drinking-water. It may also spread from person-to-person as a result of poor
hygiene.
RISK FACTORS1, 4, 5
 Malnourished children
 People having impaired immunity or suffering from HIV
 Prolonged intake of antibiotics
 Children born to undernourished mothers 7
 Zinc deficiency which suppresses immune function
 Incorrect feeding practices in babies
 Lack of personal hygiene
CLASSIFICATION
Episodes of diarrhoea can be classified into 3 categories:

 Acute diarrhea – Presence of 3 or more loose watery stool in the preceding 24 h.
 Dysentery – Presence of visible blood in the stool.
 Persistent diarrhea- Acutely starting episodic diarrhoea lasting more than 14 days.
DIAGNOSIS6, 7
 Frequent passing of abnormal watery stool

 Abdominal pain/ cramp
 Nausea
 Vomiting
 Fever
 Dehydration
4World Gastroenterology Organisation: Practice guideline: Acute diarrhea March 2008. [cited 19th March
2015] Available at
http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/01_acute_diarrhea.pdf
5BorooahVani K et al, On the incidence of diarrhoea among young Indian children, Economics and Human
Biology, 2004; 2:119–138.

6Lotte Dinesen, Marcus Harbord, Acute Diarrhoea , Medicine, 2013; 41(2) : 104-107
7World Gastroenterology Organisation Global Guidelines ;Acute diarrhea in adults and children: a global
perspective, February 2012

 Weight loss
 Loss appetite
Additional symptoms may include:

Tachycardia, hypotension, abdominal tenderness, cold, sneezing, cough, irritability and
lethargy
Diarrhea presentation in different infections:

 Diarrhoea present WITH vomiting, low grade fever with no mucus in stools: indicates
viral infection
 Diarrhoea present WITH vomiting, abdominal cramps, blood and mucus in stools WITH
fever: indicates bacterial infection
 Diarrhoea present WITH blood and mucus in stool WITH no fever: indicate amoebiasis
 Profuse diarrhoea present (rice water stools) WITH vomiting: indicate cholera
 Diarrhoea present WITH excessive vomiting (especially if in more than one member of
the household or group) :indicate food poisoning
Signs of dehydration:
• Pulse rate > 90/min
• Postural hypotension
• Supine hypotension and absence of palpable pulse
• Dry tongue
• Sunken eyeballs
• Skin turgor
 sunken fontanelle (in infants)
 Breathing abnormally rapid
Evaluation of diarrheal cases 6,8
Clinical evaluation is done on the basis of patient history, physical examination & level of
dehydration during diarrhea.
History-
1. History of travel(suggest source of diarrhea)

2. Attack of crying with pallor
3. Onset, frequency & quantity of stool
4. Character of stool (bile ,bloody, mucous etc.)
8Baldi F,Bianco MA, Nardone G, Pilotto A, and Zamparo E.Focus on acute diarrhoeal disease, World J
Gastroenterol2009 ; 15(27): 3341-48

5. Past medical history
6. Abdominal pain, nausea, vomiting& fever (suggests effect of toxins:Organophosphate
insecticides, Arsenic or small intestinal pathogens)
7. Epidemiological clue
8. Consumption of certain food items
9. Any systemic manifestation like Arthritis, Reiter’s syndrome
10. Any anxiety/acute emotional stress
11. Over consumption of alcohol
Physical examination-
1. General status
2. Temperature
3. Body weight
4. Blood pressure
5. Respiratory rate
Levels of Dehydration 1
Mild Moderate Severe

Finding
Pulse Full, normal rate Rapid Rapid and weak
Systolic pressure Normal Normal to low Very low
Deep, rate may be
Respirations Normal Deep, rapid rate
increased
Oral tissues Tacky or slightly dry Dry Parched
Infant fontanel
Normal Sunken Markedly sunken
(soft spot in skull)
Eyes Normal Sunken Markedly sunken
Cool, mottled, blue-
Skin Normal Cool
tinged hands/feet
Urine output Mildly reduced Markedly reduced Absent
Listlessness, Grunting, lethargy,
Systemic signs Increased thirst
irritability coma
Treatment Prevent dehydration Rehydrate with ORS Rehydrate with I.V.
solution fluid & ORS
Investigations
 Complete blood count

 Stool routine examination
 Stool for culture and sensitivity

 Blood urea and creatinine
DIFFERENTIAL DIAGNOSIS 1
 Food poisoning
 Hepatitis
 Volvulus & Intussusception
 Irritable bowel syndrome
 Pancreatitis
 Lactose intolerance
 Appendicitis
RED FLAG9
 Evidence of severe dehydration & malnutrition
 Severe abdominal pain & excessive bloody diarrhea
(more than 5 bloody motions/day)
 Severe weight loss (>10% body weight in previous 2 wk.)
 Fever >38.5◦C
 Persistent vomiting
 Suboptimal response to ORT(Oral rehydration therapy)
 No urine in previous 12 hours
ASSESSMENT AND EVALATION
Diarrhea index score (Developed by Central Council for Research in Homoeopathy)

Symptom/signs Score
0 1 2 3 4
No. of Stools / day Normal 4 6 8 12
Diarrhea Normal Loose Watery Slimy Mucus
(consistency)
Fever Absent Low grade High grade
Vomiting/ day Absent Only once 2–3 3–5
Gross/Occult blood in Absent Fresh Black
stool blood
Weakness Absent Mild More Profound has
torest
9Dinesen L, Harbord M, Acute Diarrhoea , Medicine, Volume 41, Issue 2, February 2013, Pages 104-107

Muscular cramps Absent Mild Moderate Severe
Weight loss None < 5% Mild (5-6%)
PREVENTION1,6
 Access to safe drinking-water

 Use improved sanitation
 Wash hand with soap
 Food preparation & preservation should be clean
 Child exclusively on breastfed for initial six months of life
 Maintain personal hygiene
 Educate the people about its infection, spread, nutrition & prevention
 Vaccinate the child from rotavirus vaccination, salmonella typhi vaccination 6
 Measles immunization can significantly lessen the incidence and severity of
 Diarrheal diseases 6
 Breeding of flies should be controlled
 Improving nutrition of mother and child
 Prevention of diarrhoeal epidemics
MANAGEMENT
The main objectives of acute diarrheal management are10, 11, 12:

 To prevent dehydration: this is very important since so much of the child's body fluid is
being lost through the stools and vomiting
 To replace lost fluid: as much fluid as goes into the stools should be given to the child to
drink for replacement
 To maintain nutrition: mothers tend not to give a child who has diarrhoea anything or
very little to eat, at a time when he needs all the food he can get. Continue to feed as
much as can be tolerated.
 Reduce severity of disease
10 World Health Organization -The Treatment of Diarrhoea: A manual for physicians and other senior health
workers; Geneva, Switzerland: 2014. (cited Jan 2015) Available at
http://whqlibdoc.who.int/publications/2005/9241593180.pdf?ua=1
11 Homeopathy for mother and child care (paediatric),Training manual volume-2,Central council for research
in homeopathy in collaboration with country office WHO , India

12World Health Organization - Oral Rehydration Salts: Production of the new ORS, Geneva, Switzerland 2006
available at http://apps.who.int/iris/bitstream/10665/69227/1/WHO_FCH_CAH_06.1.pdf

 To maintain personal hygiene: or else you end up taking the germs from the stools, back
into the mouth, continuing the diarrhoea you are trying to stop.
Regular assessment for dehydration during diarrhea guides for further treatment plan
which is given below:
Treatment Plan A- mild or no dehydration

 Child can be treated safely at home
 Instruct mother to give home-based fluids like rice water, soup, water, and Orally
child should continue to feed.
 Ask the mother to return to the health facility if the child gets worse, passes more
watery stools, vomits repeatedly, becomes very thirsty, eats or drinks poorly or is not
better in 2 days.
 Instruct mother on how to prevent diarrhoea.
Treatment Plan B – mild to moderate dehydration

 Child to be treated in the health facility.
 Give Oral Rehydration Salt (ORS)during first 4 hours.
 If child vomits, wait 10 minutes and start again.
 Continue with other fluids the child will accept
 Reassess the child & classify the child for dehydration
If no dehydration seen- switch to plan A & send child home
If mild to moderate dehydration continue- Continue plan B
If severe dehydration seen- follow plan C
Treatment Plan C- Severe dehydration
 A child with severe dehydration requires treatment with Intravenous fluid (IV)
fluids in hospital.
 Start IV fluids immediately. Give 100 ml/kg Ringer's lactate solution
 Reassess the child every 1- 2 hours. Also give ORS as soon as child can drink.
However, nasogastric administration of ORS solution is potentially lifesaving when

intravenous rehydration is not possible and the patient is being transported to a facility
where such therapy can be administered.
Acute diarrhea can be effectively managed with homoeopathic medicines along with
general management detailed above. The main aim of treatment is to provide symptomatic
improvement, minimize complications and promote early recovery. Regular evaluation and
assessment of the person directs further treatment, response of remedy, need for referral
(if any) and course of action.

Observational studies13, Randomized controlled trials14,15,16 and meta-analysis17 of
evaluation of individualized homeopathic treatment in acute diarrhea bring forth that
homeopathic treatment decreases the duration of acute childhood diarrhea. There are a
number of medicines in homoeopathic literature18,19,20 for the treatment / management of
acute diarrheal condition. Around 584 homeopathic medicines are given in synthesis
repertory under the rubric diarrhea. Commonly prescribed medicines include Aloe soc. , Ars
alb, Calc carb, Camphor, Cham, Croton tig, China, Dulcamara (Diarrhoea from damp cold
weather), Ferrum, Gambogia, Ipecac (Diarrhoea with persistent nausea & vomiting), Mag
mur, Nat carb, Nat sulph( Diarrhea in damp weather), Podo, Rheum(Use in children with
sour diarrhoea during dentition), Sepia, Silicea, Verat –alb, Zingiber etc. Medicines which
are usually prescribed for diarrhea during dentition are Calc carb, Cham, Dulcamara,
Ferrum, Rheum and Silicea. Most useful medicines in anticipatory diarrhea include Arg. nit.,
Gels & Acid phos. Medicines prescribed for diarrhea from milk are Calc., mag mur, Nat carb,
sepia. Medicine frequently used for diarrhea during hot weather are Bry, Camph, Crot t , Nux
–m, Podo .
Indications of few commonly prescribed medicines for diarrhea are given below:
S.No. Medicine Indications

1. Aloe Indicated in diseases of mucous membranes; causes the
Socotrina production of mucus in jelly-like lumps from rectum. Diarrhoea:
has to hurry to closet immediately after eating and drinking with
want of confidence in sphincter ani; driving out of bed early in the
morning .When passing flatus, sensation as if stool would pass
with it. Colic: cutting, griping pain in right lower portion of
13Nayak C, Singh V, Singh K, Singh H, Sharma A, Oberai P, etal. A Prospective Multicentric Observational Study
To Evolve The Usefulness Of The Predefined Homoeopathic Medicines In The Management Of Acute
Diarrheal Disease In Children. American Journal American Journal of Homeopathic Medicine 2009; 102
(3):122-9.
14 Jacobs J, JiminezLM, Gloyd S, Carares F E, Gaitan MP,Crothers D. Homœopathic treatment of acute childhood
diarrhoea: A randomized clinical trial in Nicaragua. British Homoeopathic journal 1993; 82(2): 83-86
15 Jacobs J, Jiménez LM, Malthouse S, Chapman E, Crothers D, Masuk M, et. al. Homeopathic treatment of acute
childhood diarrhea: results from a clinical trial in Nepal.J Altern Complement Med. 2000 Apr;6(2):131-9.
16 Jacobs J, Jiménez LM, Gloyd SS, Gale JL, Crothers D . Treatment of acute childhood diarrhea with
homeopathic medicine: a randomized clinical trial in Nicaragua.Pediatrics. 1994 May;93(5):719-25.

17 Jacobs J, Jonas WB, Jiménez-Pérez M, Crothers D. Homeopathy for childhood diarrhea: combined results
and meta-analysis from three randomized, controlled clinical trials.Pediatr Infect Dis J. 2003 Mar;22(3):229-
34.
18Boericke W. Boericke’s New Manual of Homoeopathic Materia Medica with Repertory: Third Revised &
Augmented Edition based on Ninth Edition. New Delhi: B. Jain Publishers; 2010
19 Clarke J. H, A Dictionary of Practical Materia Medica, 3 –volume, New Delhi: B. Jain Publishers.
20Allen HC; Keynotes And Characteristics With Comparisons of some of the Leading Remedies of the Materia
Medica

abdomen; excruciating, before and during stool; all pains cease
after stool, leaving profuse sweating and extreme
weakness; attacks preceded by obstinate constipation. Flatus
offensive, burning copious; much flatus with small stool; burning
in anus after passage of flatus. Solid stool and masses of mucus
pass involuntarily; hungry during diarrhoea. Before stool:
rumbling, violent sudden urging; heaviness in rectum; during
stool, tenesmus and much flatus; after stool faintness.
Adapted to indolent, "weary" persons; averse to either mental or
physical labor; mental labor fatigues. Dissatisfied and angry
about himself or his complaints. Old people; especially women of
relaxed, phelgmatic habit. Extreme prostration, with
perspiration. Worse early morning; sedentary life; hot dry
weather; after eating or drinking; standing or walking. Better:
cold water; cold weather; discharge of flatus and stool.
2. Arsenicum Indicated in gastric derangements; after cold fruits; ice cream;
album ice water; bad sausage; alcoholic drinks; strong cheese; decayed
food or animal matter. Diarrhoea, after eating or drinking; stool
scanty, dark-colored, offensive, and whether small or large,
followed by great prostration. Dysentery dark, bloody, very
offensive. Cholera, with intense agony, prostration, and burning
thirst. Body cold as ice. Nausea, retching, vomiting, after eating
or drinking. Cannot bear the sight or smell of food. Anxiety in pit
of stomach. Great thirst; drinks much, but little at a time.
Suited to restless, anxious and irritable persons with burning
pains which are better from heat. There is debility, exhaustion,
and restlessness after the slightest exertion. Worse after
midnight (1 to 2 a. m. or p. m.); from cold; cold drinks or food;
when lying on affected side or with the head low. Better from
heat in general.
3. Chamomilla Commonly indicated in infants and children for diarrhea during
dentition. Diarrhoea: from cold, anger or chagrin; after tobacco;
in child-bed; from downward motion Stool green, watery,
corroding, like chopped eggs and spinach; hot, very offensive,
like rotten eggs.
Suitable for peevish, irritable, cross, snappish, uncivil persons
who are oversensitive to pain, driven to despair. Child is quiet
only when carried; impatient, wants this or that and becomes

angry when refused, or when offered, petulantly rejects it.
Mental calmness contraindicates Chamomila. Worse by heat; <
evening before midnight; with heat, thirst and fainting;
with numbness of affected part. One cheek red and hot, the
other pale and cold.
4. Croton A valuable remedy in diarrhœa and summer complaint. Copious
Tiglium watery stools, with much urging; always forcibly shot out, with
gurgling in intestines; worse, drinking the least quantity, or even
while eating. Constant urging to stool followed by sudden
evacuation, which is shot out of the rectum. Swashing sensation
in intestines. Yellow, watery stool. Diarrhea associated with skin
affections. Diarrhoea is worse every motion; after drinking;
while eating or nursing; during summer; from fruit and
sweetmeats; the least food or drink.
5. Cinchona Indicated in painless diarrhea with great bloating, indigestion,
officinalis and general weakness. Sensation as if abdomen is full of gas
which is not relieved by eructations. Undigested, frothy, yellow;
painless; worse at night, after meals, during hot weather, from
fruit, milk.
For stout, swarthy persons; for systems, once robust, which have
become debilitated, "broken down" from exhausting discharges.
Periodicity of complaints; liking for sour things. Sensitive to
draughts of air yet wants to be fanned; face pale, eyes sunken
and surrounded by blue margins. Worse: slightest touch.
draught of air; every other day; loss of vital fluids; at night; after
eating; bending over. Better: bending double; hard pressure;
open air; warmth.
6. Gambogia Indicated in profuse watery with sudden & forcible ejection of
bilious stools which usually occur in hot weather. Tenesmus
after, with burning at anus Great rumbling and rolling in
abdomen with frequent emission of flatulence. Profuse, watery
diarrhœa in hot weather, particularly old people. Symptoms
aggravate toward evening & at night.

7. Podophyllum Diarrhœa of long standing; early in morning; during teething,
with hot, glowing cheeks while being bathed or washed; in hot
weather after acid fruits. Morning, painless diarrhœa when not
due to venous stasis or intestinal ulceration. Green, watery, fetid,
profuse, gushing. Stool profuse, painless, polychromatic, putrid
with prolapse of rectum. Stools watery in the morning continues
through forenoon, followed by natural stool in the evening with
sensation of weakness or sinking in abdomen or rectum.
Painless cholera morbus; cholera infantum. Violent cramps in
feet, calves, thighswith watery, painless stools. Diarrhoea of
children: during teething; after eating; while being bathed or
washed; of dirty water soaking napkin through with gagging.
Patient is constantly rubbing and shaking the region of liver with
his hand. Great thirst for large quantity of cold water. Diarrhea
aggravated by eating, drinking, moving around and early in
morning.
9. Veratrum Diarrhœa: very painful, watery, copious, and forcibly evacuated,
album followed by great prostration. Evacuations of cholera morbus
and true cholera when vomiting accompanies the purging.
Bloated abdomen with cramps commencing in hands and feet
and spreading all over. Cold sweat on forehead during diarrhea.
Diarrhea < at least movement. Diarrhoea with great vomiting
and purging.
Indicated in a condition of collapse, with extreme coldness,
blueness, and weakness. Chilly and weak yet craves cold drinks.

 Frequent passing of abnormal watery stool
 Abdominal pain/ cramp
 Nausea ,Vomiting
 Fever
 Dehydration (skin turgor, thirst increase, hypotension, lethargy, mentally restlessness)
 Weight loss
 Loss appetite
General Management
Start homoeopathic treatment and  Correct electrolyte & fluid losses with the
Advice for general management help of ORS.
 Nutritious rich diet advice during
diarrheal episode.
Follow up every hour in emergency case  Should take more Bland & fluid food
& every day in mild and moderate cases  Breast feed frequently & for longer
period in children.
 Access safe drinking-water;
 Improve sanitation;
Assess the case for dehydration &  Wash hand with soap
 Clean food preparation & preservation.
symptomatic improvement
 maintain personal hygiene
NO YES
Improvement in Formulate treatment plan
symptoms & According to level of dehydration
dehydration
No dehydration/mild dehydration
– Plan A + Homeopathic treatment
Refer for appropriate Continue Homoeopathic
treatment treatment with general Moderate dehydration- Plan B +
management till the patient Homeopathic treatment
restores normal bowel Severe dehydration –Plan C
Referral criteria function and general health (see text)
 Evidence of severe
dehydration & malnutrition.
 Severe abdominal pain &
excessive bloody diarrhea
(more than 5 bloody If restoration is If restoration is Complete
motion/day). incomplete
 Severe weight loss(>10%
body weight in previous 2 Reassess the case and give Stop treatment
week) appropriate
 Fever >38.5◦C homoeopathic medicine
 Persistent vomiting
 Suboptimal response to
REFERENCES
ORT
 No urine in pervious 12 h


HYPERTENSION
CASE DEFINITION
Hypertension also known as high or raised blood pressure, is a condition in which the
blood vessels have persistently raised pressure, putting them under increased stress.
The condition is said to arise when the systolic blood pressure is equal to or above 140
mm Hg and/or a diastolic blood pressure equal to or above 90 mm Hg. 1
INCIDENCE
Hypertension exerts a substantial public health burden on cardiovascular health status

and healthcare systems in India. 2,3 HTN is directly responsible for 57% of all stroke
deaths and 24% of all coronary heart disease (CHD) deaths in India.4
In an analysis of worldwide data for the global burden of Hypertension, 20.6% of Indian
men and 20.9% of Indian women were suffering from the disease in 2005.5
A region-specific (urban and rural parts of north, east, west, and south India) systematic
review and meta-analysis of the prevalence, awareness, and control of hypertension
among Indian patients conducted from studies between 1950 to 30 April 2013 reveal
overall prevalence for hypertension in India as 29.8%. Significant differences in
hypertension prevalence were noted between rural and urban parts as 27.6% and
33.8% respectively. Regional estimates for the prevalence of hypertension were: 14.5%,
31.7%, 18.1% and 21.1% for rural north, east, west, and south India; and 28.8%, 34.5%,
35.8% and 31.8% for urban north, east, west, and south India, respectively.
CLASSIFICATION
Depending on the methods of patient ascertainment ~ 80-95% of hypertensive patients

are diagnosed with Essential (Primary or idiopathic) hypertension
in which no obvious medical cause is identified. In the remaining 5-20% of
hypertensive patients, a specific underlying disorder causing elevation of blood
pressure can be identified with its specific mechanism can be identified and these
individuals are known to suffer from Secondary Hypertension.6
1 World Health Organization - Q&As on hypertension; Geneva, Switzerland: 2015[cited 30 th May 2016.
Updated September 2015 ] Available at http://www.who.int/features/qa/82/en/
2 Leeder S, Raymond S, Greenberg H, Liu H. A race against time. The challenge of cardiovascular disease in
developing economies. New York:Columbia University; 2004

3 Srinath Reddy K, Shah B, Varghese C, Ramadoss A. Responding to the threat of chronic diseases in
India. Lancet 2005; 366:1744–174

4 Gupta R. Trends in hypertension epidemiology in India. J Hum Hypertens 2004; 18:73–78
5 Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension:
analysis of worldwide data. Lancet 2005; 365:217–223

6 Kotchen T. A. Hypertensive vascular disease. In : Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo
DL, Jameson JL, et al., editors. Harrison’s principles of internal medicine. 18th ed. New York: McGraw Hill;
2012: p 2042-2059

According to Joint National committee (JNC-VII) blood pressure is classified as:7
Category Systolic BP(mmHg) Diastolic BP(mmHg)

Normal BP <120 <80
Pre hypertension 120-139 80-89
Hypertension
Grade 1 140-159 90-99
Grade 2 ≥160 ≥100
Malignant or accelerated hypertension –It is a severe form of hypertension in which

BP above 220/ 120 mmHg. This lead acute headache, visual disturbances, haematuria,
rapid development of cardiac and renal failure, high urea, NPN, and creatinine levels of
blood etc.
AETIOLOGY
 Causes /Risk factors of primary hypertension
Non- modifiable factors

• Age
• Positive family history
Modifiable factors
• Obesity
• Increase intake of saturated fat
• Low level of physical activity
• High salt intake
• Smoking
• Psychological stress
• Alcohol consumption
 Causes of secondary hypertension 6
Renal disease
• Renal vascular disease- arteriosclerosis, fibromyalgia
• Renal parenchymal disease (glomerulonephritis), renal cyst (polycystic
renal disease), renal tumor ( rennin secreting tumor), obstructive uropathy
Endocrine disease
• Adrenal – primary aldosteronism, Cushing syndrome, pheochromocytoma,
Congenital adrenal hyperplasia due to 11-β hydroxylase or 17 α-
hydroxylase deficiency
• Thyroid, parathyroid – Hypothyroidism, thyrotoxicosis,
hyperparathyroidism
7Martin J. Hypertension guidelines: Revisiting the JNC recommendations, The journal of Lancaster general
hospital, 2008; volume 3(3):91-97.

 Other- Liddle syndrome, Acromegaly
Neurogenic
 Psychogenic, Acute increased intracranial pressure, acute spinal cord
section
Drugs
• Oral contraceptives, anabolic steroids, corticosteroids, NSAIDs,
sympathomimetic agents, tri cyclic anti-depressants, cocaine etc.
Pregnancy
• Eclampsia/ pre-eclampsia
Co-arctation of aorta
Obstructive sleep apnea
DIAGNOSIS
Clinical Presentation 6
Most people with hypertension have no symptoms at all; this is why it is known as the
“silent killer”.
However, the patient needs to be assessed for a clinical history, sign & symptoms, BP
reading, physical examination, basic investigations to confirm the diagnosis, other
cardiovascular disease risk factors, and secondary causes of hypertension or
involvement of target organs.
 HISTORY should include

 Duration of hypertension
 Previous therapy: its response & side effects
 Family history of hypertension & cardiovascular diseases
 Dietary & psychosocial history
 Daily routine and lifestyle
 Other risk factors: weight change, Dyslipidemia, smoking, diabetes, physical
inactivity.
 Evidence of secondary hypertension: like history of renal disease, symptom of
hypo or hyperthyroidism, change in appearance, muscle weakness, snoring,
sweating, palpitation, tremor, use of agents that increase blood pressure.
 Evidence of target organ damage: history of transient ischemic attack, stroke,
transient blindness, angina, myocardial infarction.
 SIGNS & SYMPTOMS may present as
No symptoms or common symptoms like

 Headache
 Dizziness
 Insomnia
 Lack of concentration
 Loss of memory

 Palpitation of heart
 Nosebleed
Symptoms of hypertensive encephalopathy like7,8

 Acute severe headache
 Nausea & vomiting
 Visual disturbance
 Transient disturbance in speech
 Paraesthesiae
 Fits & loss of consciousness
 PHYSICAL EXAMINATION
• Weight, height
• Pulse rate, rhythm & character
 Jugular venous pulse
 Evidence of cardiac enlargement (displaced apex , extra heart sound) or evidence
of decompensation (crackle or wheeze on lung auscultation, peripheral oedema)
 Evidence of arterial disease (carotid, renal or abdominal bruit, radio femoral
delay, abdominal aortic aneurysm)
 Evidence of kidney disease (palpable kidney)
 Evidence of abnormality of endocrine system(enlargement of thyroid gland, )
 Optic examination of fundi
 Blood Pressure measurement 8,9
Steps for ensuring accurate Blood Pressure Measurement

- In ideal situations, instruct the patient to avoid smoking or drinking or drinking
caffeinated beverages for 30 minutes before the blood pressure is measured.
- Ask the patient to sit quietly for at least 5 minutes in a chair with feet on the
floor, rather than on the examining table.
- Make sure the arm selected is free of clothing. There should be no arteriovenous
fistulas for dialysis, scarring from prior brachial artery cut downs, or signs of
lymphedema (seen after axillary node dissection or radiation therapy).
- Palpate the brachial artery to confirm that it has a viable pulse.
- Position the arm so that the brachial artery, at the antecubital crease, is at heart
level – roughly level with the 4th interspace at its junction with the sternum.
- If the patient is seated, rest the arm on a table a little above the patient’s waist; if
standing, try to support the patient’s arm at the mid chest level.
8Colledge NR, Walker BR, Ralston SH editors. Davidson’s principle & practice of medicine, 21st ed, 2010, p
606- 612
9
Lynn B. Bates' Guide to Physical Examination and History-Taking. Eleventh, North American Edition.
Lipincott Williams and Wilkins.

Steps for blood pressure measurement
- With the arm at heart level, center the inflatable bladder over the brachial artery.
The lower border of the cuff should be about 2.5 cm above the antecubital crease.
Secure the cuff tightly. Position the patient’s arm so that it is slightly flexed at the
elbow.
- To determine how high to raise the cuff pressure, first estimate the systolic
pressure by palpation. Feel the radial artery with the fingers of one hand, rapidly
inflate the cuff until the radial pulse disappears. Read this pressure on the
manometer and add 30 mm Hg to it. It prevents discomfort from unnecessarily
high cuff pressures. It also avoids the occasional error caused by an auscultatory
gap- a silent interval that may be present between the systolic and the diastolic
pressures.
- Deflate the cuff promptly and completely and wait 15 to 30 seconds.
- Now place the bell of a stethoscope lightly over the brachial artery, taking care to
make an air seal with its full rim. Because the sounds to be heard, the Korotkoff
sounds, are relatively low in pitch, they are generally better heard with the bell.
- Inflate the cuff rapidly again to the level just determined, and then deflate it
slowly at a rate of about 2 to 3 mm Hg per second. Note the level at which you
hear the sounds of at least two consecutive beats. This is the systolic pressure.
- Continue to lower the pressure slowly until the sounds become muffled and then
disappear. To confirm the disappearance of sounds, listen as the pressure falls
another 10 to 20 mm Hg. Then deflate the cuff rapidly to zero. The disappearance
point, which is usually only a few mm Hg below the muffling point, provides the
best estimate of true diastolic pressure in adults.
- Read both the systolic and the diastolic levels. Then wait 2 or more minutes and
repeat. Average the readings. If the first two readings differ by more than 5 mm
Hg, take additional readings.
- When using an aneroid instrument, hold the dial so that it faces you directly.
Avoid slow or repetitive inflations of the cuff, because the resulting venous
congestion can cause false readings.
- Blood pressure should be taken in both arms at least once. Normally, there may
be a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg.
Subsequent readings should be made on the arm with the higher pressure.
Ambulatory BP measurement & patient self-check BP measurement is

recommended in selected circumstances which include:
- Suspected case of white coat hypertension
-Masked hypertension
- When finding the response of therapy

Investigations
Investigations should be carried out to assess associated clinical disease and end organ
damage6:
• Urinalysis for blood, protein and glucose
• Blood urea, electrolytes and creatinine
• Serum sodium, potassium, calcium
• Fasting blood glucose
• Serum total and HDL cholesterol, triglycerides
• 12 Lead ECG
• Haematocrit
Further investigation should be carried on the basis of clinical suspicion:

• Chest X ray (to detect cardiomegaly, heart failure, coarctation of aorta)
• Echocardiogram( to detect left ventricular hypertrophy)
• Renal Ultrasound( to detect renal disease)
• Renal angiography( to detect renal artery stenosis)
• Urinary catecholamine( to detect possible pheochromocytoma)
• Urinary cortisol & dexamethasone suppression test(to detect possible Cushing’s
syndrome)
• Plasma rennin activity and aldosterone (to detect primary aldosteronism)
• Fundoscopy ( to detect retinopathy)
COMPLICATIONS10
Organ Disease History Examination Investigation

condition Evaluation
Heart Heart failure Exertional Pedal oedema, Chest X-ray, ECG,
breathlessness, JVP, Chest Echocardiography
Orthopnea, examination for
edema pulmonary
edema
Coronary History of angina, Coronary
artery disease prior myocardial angiography
infarction
Left ventricular Forceful apical ECG,
hypertrophy impulse Echocardiography
CNS Stroke due to Neurological CT scan,MRI
cerebral examination angiography
haemorrhage
or infarction
Kidney Progressive Uremic Pallor, oedema, Urine analysis,
renal failure complaints, peripheral BUN, Creatinine,
dyspnoea neuropathy renal ultrasound
10Standard treatment guidelines. National health mission. ,p 54- 60 [Internet] [cited on 2015 Mar. 12]
Available at http://nhm.gov.in/images/pdf/guidelines/nrhm-guidelines/stg/hypertension.pdf

,asterixis,
uremic odour
Retina Hypertensive Fundoscopy
Retinopathy Grade 1-Arteriolar
thickening (silver
wiring)
Grade 2-
Arterivenous
nipping + Grade1
Grade 3- Retinal
ischemia (flame
shaped or blot
haemorrhage &
cotton wool
exudates) +grade 2
Grade 4-
Papilloedema +
grade 3
Peripheral Atherosclerosis History of Assess Doppler studies
Blood claudication peripheral
vessel pulse, look
arterial pulse
• Anxiety disorder
• Hyperthyroidism
• Myocardial infarction
• Hyperaldosteronism (primary)
• Stroke (haemorrhagic or Ischemic)
• Cardiomyopathy
• Toxicity (amphetamine & phencyclidine)
RED FLAG SYMPTOMS12

• Papilloedema
• Pre- eclampsia
• Convulsions or coma
• Signs of end organ damage
• Heart failure
• Severe headache with high blood pressure
11 Hypertension: Practice essentials. Internet [cited 2015 March] Available at

http://emedicine.medscape.com/article/241381
12 Jacobi T. Red flag symptoms: Hypertension 2010. [Updated 2010Jan 29], [cited on 2015 Mar. 18]
Available at http://www.gponline.com/red-flag-symptoms- hypertension/cardiovascular-

system/article/978521

MANAGEMENT
High blood pressure generally develops over many years, and requires stringent
therapeutic lifestyle changes (TLC) for its effective control. Few recommendations are
given below 6,7
MODIFICATION RECOMMENDATION APPROX. SBP

REDUCTION
RANGE
Weight reduction Maintain normal body mass index (Normal 5- 20 mm Hg/ 10 Kg
range - 18.5 – 24.9 Kg/m2 or <25 Kg/m2) loss of weight
Alcohol consumption Men: consumption limit<2 drink /day 2-4 mmHg
(1 drink =30 ml) Women or light weight person < 1 drink / day
Adopt DASH diet Diet rich in fruit, vegetable, low fat dairy 8-14 mmHg
product with reduce of saturated & total fat.
Dietary sodium intake Reduce dietary sodium intake <100 mmol/ 2-8 mmHg
reduction day (normal- 2.4g sodium or 6g sodium
chloride)
Physical activity Do regular aerobic activity like brisk walking 4- 9 mmHg
at least 30 min /day most days of the week
Tobacco cessation Smoking cessation may not directly involve in
BP reduction but it markedly reduces
cardiovascular risk.
Management of hypertension should be done with caution keeping in mind its natural
history and complications. TLC when given along with homoeopathic treatment can
help in managing the condition and prevent progression of disease. There are number
of medicines available in homeopathic literature13,14,15 for management & treatment of
hypertension. Around 140 remedies are given in Synthesis repertory under the rubric
hypertension. Our well known polychrest medicines especially are useful as a
constitutional remedy to bring about a cure in these cases. Nevertheless, nosodes,
uncommon medicines or other organ remedies with their specific indications which,
when found well indicated in a case possess no less power to cure the patient as our
more commonly prescribed polychrests.
Sudden increase in blood pressure requires urgent attention and prescription of the
indicated remedy. Acute attack of hypertension can be controlled by acute medicines
like Adonis, Allium sativa (Useful in hypertension along with history of raised
cholesterol), Amyl nitrosum (Useful in hypertension associated with angina; can dilate
the blood vessel), Glonoine (High blood pressure from bad effects of sunstroke),
Rauwolfia serpentina (high blood pressure without marked atheromatous changes in
the vessels), Viscum album, Spartium scoparium (useful in renal hypertension),
13Clarke. J.H, A Dictionary of Practical Materia Medica, 3 –volume, New Delhi: B. Jain Publishers
14AllenHC. Allen’s Keynotes- Rearranged and classified with leading remedies of the materia medica and
15Boericke W. Boericke’s New Manual of Homoeopathic MateriaMedica with Repertory: Third Revised &

Passiflora incarcinata, Crategus (heart tonic: lowers down the blood pressure; Good for
arteriosclerosis and angina pectoris; Said to have a solvent power upon the crustaceous
and calcareous deposits in arteries) etc. These medicines may cure the case if symptom
similarity is found but mostly these medicines are used for providing palliative relief to
the patient.
Research in homoeopathy16,17,18,19,20,21,22,23,24 on hypertension shows benefits from

medication however long term benefits require to be studied.
Indications of few important medicines for the management of hypertension are given
below:
S. No. Medicine Indications

1. Aurum Indicated in hypertension due to valvular lesions and
metallicum arteriosclerosis. Prolonged depression, anger, stress &
worry may cause high blood pressure. Pulse small, feeble,
rapid and irregular with visible beating. Violent
palpitation with congestion of blood in head & chest after
exertion which compels the patient to stop walking or
motion. Sensation as if heart stopped beating for two or
three seconds which immediately followed by a
tumultuous rebound.
Indicated in oversensitive, conscientious persons who are
low spirited, lifeless with weak memory, despondent,
depressed with suicidal tendency and have a tendency for
self-reproach. Worse from emotions, mental exertion, cold
weather, sunset to sunrise.
2. Baryta Indicated in hypertension due to vascular degeneration
Muriaticum when systolic pressure is high with comparatively low
diastolic pressure which is attended by cerebral & cardiac
16MehraP. Usefulness of homeopathy in essential hypertension: an exploratory interventional trial.

Homeopathy,Jan2014 ;103(1): 88
17Poruthukaren KJ, Palatty PL, Baliga MS, Suresh S.Clinical evaluation of Viscum album mother tincture as
an antihypertensive: a pilot study,Eur J Heart Fail. 2003 Jun;5(3):319-26
18 SchröderD, WeiserM, KleinP.Efficacy ofa homeopathic Crataegus preparation compared with usual ther
apy for mild (NYHA II) cardiac insufficiency: results of an observational cohort study.JEvid Based
Complementary Altern Med. 2014 Jan;19(1):31-5
19Saha S. Koley M , Hossain S I , Mundle M , Ghosh S , Nag G , Datta AK, et al. Individualized homoeopathy
versus placebo in essential hypertension: A double-blind randomized controlled trial,Indian Journalof

Research in Homoeopathy 2013:7(2):62-71.
20Baig H, Singh K, Sharma A, Kaushik S, Mishra A, and Chugh S. Essential Hypertension. Clinical Research
Studies - Series II,CCRH. 2009:29-41

21Lakhera BC, Dhawan IM, Manjushree, Kaushik S, Mishra A, and Chugh S. Essential Hypertension (Drug
related study) Clinical Research Studies-Series II. :CCRH.2009:43-9

22Rastogi D.P. , Baig H. Rauwolfia serpentina (Aqua): A New Approach in the Treatment of Hypertension
in Homoeopathy:CCRH.1996: 18(1&2):22-24
23A. Mahmoudian. Homeopathy effect on high blood pressure, Journal of Research in Medical Sciences.
2004: Vol 6:315-316

24Singh R. K., Kasliwal R.R. Efficacy of homoeopathic drugs in the treatment of essential hypertension: A
study in a specialized cardiac hospital; Focus on Alternative and Complementary Therapies. 2003:8(4)

S. No. Medicine Indications
symptoms. Useful in arteriosclerosis & in aneurysm of
aorta. Headache, but without acute crisis, occurring in old
people; heaviness rather than pain.
Useful for organic lesions of the aged who are physically
and mentally dwarfish.
3. Natrum Indicated in persons with tachycardia. Heart and chest feel
muriaticum constricted. Sensation of coldness in the heart when
exerting the mind or from mental overexertion. Fluttering
of the heart, & weak faint feeling <lying down. Weak,
palpating, intermittent pulse. Pulsation of heart shakes the
body. Headache with blindness; > perspiration.
Bursting headache over eyes; < sunrise to sunset.
Nosebleed, on stooping or when coughing; at night; clotted
blood.
Patient is reserved, sensitive and emotional. Suffers from
bad effect of grief, disappointment, anger, fright, vexation
& suppression of inner feelings. He is thin, thirsty, poorly
nourished on account of digestive disturbances with great
weakness and weariness. Craving for salt, bitter things,
sour and farinaceous food. Mapped tongue. Aggravation
from consolation, being in the sun, around mid-morning
and better from being alone in a quiet place.
4. Veratrum It induces fall of both systolic and diastolic blood pressure.
viride Pulse: suddenly increases and gradually decreases below
normal. Pulse slow, soft, weak; irregular, intermittent.
Rapid pulse with low tension. Beating of pulse throughout
body, especially in right thigh. Useful in violent congestive
conditions. Severe frontal headache and vomiting. Bad
effect of sunstroke: head full with throbbing arteries.
Pupil dilated with double vision.
Indicated in full blooded, plethoric persons. They have
thick speech, coated tongue with red streak in middle.
Worse rising, motion, cold, lying on back. Better rubbing,
lying with head low.
5. Viscum Indicated in hypertension with valvular insufficiency and
album hypertrophy of heart. Weight & oppression; feeling in
heart as if squeezed with hand.Pulse small, quick, and very
irregular. Feeling of suffocation when lying on the left side.
Unable to rest in reclining position. Useful in hypertensive
albuminuria.
These persons may have frightful thoughts on waking at
night and abstraction of mind. Worse in winters, cold
stormy weather; lying on left side.


Asymptomatic or may have:
• Headache (non-specific)
• Nausea & vomiting
• Visual disturbance
• Somnolence
• Dizziness
• Insomnia
• Lack of concentration
• Loss of memory
• Breathlessness
• Palpitation of heart
• Nosebleed
Check –For BP. BP should be measured at least 2 times at the interval of 15mins before diagnosing
hypertension.
Further examination & investigations

should be advised to confirm the diagnosis
of Hypertension and identify any cause
Advice: Life style modification
Start Individualized • Weight reduction

Homoeopathic • Reduce alcohol intake
Treatment and advice • Adopt DASH diet- Increase
for life style consumption of vegetable, fruits &
modifications low fat dairy product.
• Stop tobacco
• Reduce sodium intake
• Include daily physical activity
Regular follow up:
Symptomatic assessment,
Clinical examination& BP
measurement
Improvement in
signs/symptoms &
BP reading
YES NO
Continue homeopathic Refer for standard care

Referral
medicine with general criteria
management Papilledema
Pre -eclampsia
Fits or coma
Sign of end
Periodically assess the organ damage
case for sustaining the Worsening of
Heart failure
normal range of BP symptoms /
High BP with
BP reading
severe
headache

IRRITABLE BOWEL SYNDROME
CASE DEFINITION
Irritable bowel syndrome (IBS) is a chronic functional bowel disorder in which abdominal
pain or discomfort is associated with defecation or change in bowel habits often in the
absence of detectable structural abnormalities. Bloating, distension and disordered defecation
are the commonly associated feature. 1
INCIDENCE
 Depending on the diagnostic criteria employed, IBS affects around 11% of the
population globally. Around 30% of people who experience the symptoms of IBS
will consult physicians for their IBS symptoms.2
 IBS affect 10-20% population of western country with female predominance
whereas in India 4.2 -7.9% population affected from IBS with male predominance2.
IBS is more common in younger age group.3
AETIOLOGY3
Etiology of IBS is uncertain and likely multifactorial.There are number of mechanisms
which are responsible for IBS:
 Visceral Hypersensitivity:Visceral hypersensitivity responsible for pain in abdomen
in IBS which occurs due to hypersensitivity of peripheral and CNS due to inflammatory
or non-inflammatory agents.
 Abnormal gut motility:Gut motility regulated by sympathetic & parasympathetic
nerve through serotonin mediator.Mental stress, anxiety or other psychiatric illnesses
(panic disorder, depression etc.) affect sympathetic system &serotonin level which
leads to abnormality in gut motility.
 Small intestinal bacterial overgrowth (SIBO): About 84% patient with IBS are found
to have small intestinal bacterial overgrowth.In India SIBO is a common cause of IBS.
 Psychosocial factor: Patient with history of physical or sexual abuse, loss or
separation during childhood & conflicts in interpersonal relationships are at increased
risk of IBS.
1 World Gastroenterology Organization Global guideline. Irritable bowel syndrome: a global perspective
[Internet]. 2009 [cited 2015 Mar. 12]. Available at
http://www.worldgastroenterology.org/assets/downloads/en/pdf/guidelines/20_irritable_bowel_syndrom
e.pdf
2 Canavan Caroline, West Joe, Card Timothy. The epidemiology of irritable bowel syndrome Clin Epidemiol.
2014; 6: 71–80. Published online 2014 Feb 4. doi: 10.2147/CLEP.S40245

3Upadhyay R, Singh A, Irritable bowel syndrome: The Indian scenario [Internet] [cited 2015 Mar. 12]
Available at: http://www.apiindia.org/medicine_update_2013/chap56.pdf

 Genetic factor: Studies suggest that 33% patient with IBS have a positive family
history.
 Food allergy or intolerance: Certain foods (like chocolate, spice, fat, milk, alcohol,
cabbage, beans etc.) which lead to hypersensitivity reaction in the body & mast cell
degranulation and thus trigger IBS.
CLASSIFICATION
Rome III criteria divide Irritable Bowel Syndrome (IBS) based on predominant stool
pattern as 1,4,5
1. Diarrhea predominate IBS. (IBS- D)- Loose stool >25% of the time and hard
stool<25% of the time. One third cases have this type of IBS. This condition is more
common in males.
2. Constipation predominate IBS(IBS-C)-Hard stools >25% of the time and loose stool
<25% of the time.One third cases have this type of IBS. This condition more common
in female.
3. Mixed IBS (IBS-M): hard or lumpy stool with at least 25%, and loose or watery stoo†
with at least 25%, of bowel movements.
4. Unsubtyped IBS: insufficient abnormality of stool consistency to meet criteria for
IBS-C, -D, or -M
DIAGNOSIS
Diagnosis of IBS is mostly done on the basis of clinical history. 1
 Common symptoms of IBS which help in diagnosis are:

 Abdominal pain or discomfort
 Bloating
 Abnormal stool form(hard or loose stool)
 Abnormal stool frequency(less than 3 time /week or more than 3 time /day)
 Straining for defecation
 Feeling of incomplete evacuation
 Passage of mucus per rectum
 Urgency
4 David Q. Shih, MD and Lola Y. All Roads Lead to Rome: Update on Rome III Criteria and New Treatment
Options Kwan Gastroenterol Rep. 2007 WINTER; 1(2): 56–65.
5Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders.
Gastroenterology. 2006;130:1480–1491

 Duration, modalities and associated features helpful in diagnosis are:
 Symptom present more than 6 month
 Stress aggravate the symptom
 Aggravation after meal
 Associated with anxiety, depression or other psychological conditions
 Other symptoms which may be associated with the disease are:
 Dyspepsia
 Heartburn
 Nauseaand vomiting
 Lethargy
 Backache
 Urinary frequency
 Dyspareunia (in women)
 Insomnia
The widely accepted Rome III diagnostic criteria in clinical practice is:
 Onset of symptoms at least 6 months before diagnosis.

 Recurrent abdominal pain or discomfort for > 3 days per month during past 3
month
 At least 2 or more of the following features:
- Improvement with defecation
- Onset associated with a change in frequency in stool
- Onset associated with change in stool form
Diagnostic cascade and Investigations
History Ask for abdominal pain, disordered bowel habit.

History of dyspepsia, heartburn, nausea, vomiting along
with use of laxatives and antacids may give idea about
constipation and upper GI symptoms.
Psychological factor Ask for some kind of psychological distress, feeling of
reluctant, anxiety, depression and unexplained
symptoms.
Family history Inquire about family history for inflammatory bowel
disease, colon cancer
Exclusion alarming symptom See red flag
Physical examination General examination should be done alongwith
searching for signs of systemic examination.
-Abdominal examination
-Examination in perianal region
- Digital rectal examination

Investigations - Full blood count, ESR, C - reactive protein
-Stool test for occult blood, ova & parasite
-Serum biochemistry, Thyroid function test
-Colonoscopy, biopsy
-LFT
-Abdominal ultrasound,
-Endoscopy
-Fecal inflammation marker
Note: Investigations or tests are less recommended in clear cases of IBS but when warning
signs or symptoms are present then tests are advised to exclude other conditions to make
the diagnosis.
S. No. Suspected Disease Symptoms & diagnostic test for confirmation

1. Coelic sprue/ gastric -Chronic diarrhoea
enteropathy Diagnostic test- small bowel biopsy
2. Lactose intolerance -Bloating, flatulence, diarrhea from consumption of
dairy products
Diagnostic test- Hydrogen breath test
3. Inflammatory bowel Diarrhoea>2week
disease Rectal bleeding
Inflammatory masses, weight loss
Diagnostic test- Small bowel barium radiograph,
Sigmoidoscopy
4. Colorectal carcinoma Affect older age initial IBS like symptom.
Passage of blood in feces.
Unintended weight loss.
Diagnostic test- Colonoscopy, Biopsy
5. Acute diarrhea due to Acute onset of diarrhoea
bacteria or protozoa Diagnostic test- Stool examination
6. Diverticulitis Left side abdominal pain
Fever
Diagnostic test- Ultrasonography
7. Pelvic inflammatory Lower abdominal pain
disease Fever
Cervical motion tenderness
Diagnostic test- Ultrasonography
8. Ovarian cancer Bloating, increase abdominal size, pain in pelvic
region.
Diagnostic test- Ultrasonography, Tumor markers

RED FLAG1,6
 Onset of symptom after 50 years of age
 Short history of symptom
 Unintended weight loss
 Family history of rectalcancer, inflammatory bowel disease, coeliac disease,
 Persistent or progressive pain
 Rectal bleeding
 Fever
 Abdominal /rectal masses
 Raised inflammatory markers
 Anemia
 Recent antibiotic used
 Nocturnal or large volume(>300ml/day) diarrhea
Evaluation/Assessment of IBS severity7
 Functional bowel disorder severity index

 IBS-QOL questionnaire [http://depts.washington.edu/seaqol/docs/IBS-
QOL_Info.pdf]
PREVENTION
 Regular relaxing exercise, yoga & meditation help to reduce the mental stress
 Different therapies can be used to reduce stress like cognitive Behavioral therapy,
relaxation therapy , hypnotherapy , psychotherapy
 Maintain sleep pattern
 Eat healthy balanced diet including fiber in food
MANAGEMENT
Patients with IBS have a poor quality of life with severe impact on their social and
economic burdens. Its pathogenesis remains evolutional, involving biological, psychiatric
and social factors. The biopsychosocial dysfunctional model has thus attempted to
integrate all the above mentioned mechanisms in order to understand how IBS can develop
6Black T.P. et al , “Red flag” Evaluation yield in irritable bowel syndrome, Division of gastroenterology ,
University of south albama college of medicine [Internet][ cited 19 march2015] Available at
http://www.jgld.ro/2012/2/9.pdf
7IBS patient: their illness experience and unmet need, IFFGD and the UNC Center for Functional GI and
Motility Disorders.[Internet] [ cited 12 march2015] Available at www.aboutibs.org/pdfs/IBSpatients.pdf

under such complex interactions8. Management of this condition should thus address all
the above factors in a holistic approach. An integrative approach to treatment can thus play
the desired role in this condition.
IBS is affected by lifestyle, nutrition, stress and emotions. Initial IBS management includes
education, reassurance, and investigation of psychosocial issues. Information to the patient
regarding the triggering factors of IBS along with advice regarding diet etc. as given below
is essential:
Dietary management9,10
 Consumption of a balanced diet

 Avoid foods which trigger the disease condition like fat diet, cabbage, beans and
legumes.
 Maintain regular meal timings
 Include fiber rich diet & bulking agents like psyllium fiber as it relieves constipation.
Fiber content must be increased slowly to reduce the bloating & flatulence.
 Exclusion of milk products from diet if lactose & fructose intolerance is elicited
 Intake of sufficient fluid daily
Lifestyle and Psychological management 8,9
 Inquiry into stressful factors & their resolution

 Advice about regular exercise, yoga and meditation practices on daily basis. Advice
to the patient about cognitive behavior therapy, psychodynamic interpersonal
therapy, relaxation training to reduce stress if required
 Regularity in sleep pattern and meal timings
Homoeopathy is truly a holistic form of treatment, addressing not only the bowel
symptoms, but also the psyche and the other extra-bowel symptoms that may be present in
each individual and can play a beneficial role. Homoeopathic research studies11,12,13,14 in IBS
8Chang F Y. Irritable bowel syndrome: The evolution of multi-dimensional looking and multidisciplinary
treatments. World J Gastroenterol. 2014 Mar 14; 20(10): 2499–2514.
9Irritable Bowel Syndrome (IBS): Introduction. [Internet][cited 19 march2015] Available at
http://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/small_large_intestine/irritable_bowel
_byndrome_IBS.pdf[ cited on 19 march2015]
10Talley NJ. Functional Gastro intestinal disorders: Irritable Bowel Syndrome, Dyspepsia and Non cardiac
chest pain. In Goldman L, Ausiello D. Cecil Medicine, 23rdedition,volume I, New Delhi; Elsevier:pg 990-94
11Gray J. How I treat irritable bowel disease: A survey of 25 consecutive patients, British homeopathic journal,
Oct 1998; 87:195-202.

12Lewith GT, Irritable bowel syndrome the complementary approaches considered, Complementary therapies
in Medicine, 1995; 3:220-223.

have shown positive treatment implications. There are many medicines15,16,17 available in
the homoeopathic literature which can be selected on the basis of the presenting totality of
each case for treatment of this syndrome. Synthesis repertory enlists around 584
medicines under the rubric – “diarrhoea”, 434 medicines under the rubric “constipation”,
121 remedies for “alternate constipation & diarrhea” and around 7 medicines for “stool
ameliorate the pain”. Few important remedies which can be used in treatment of IBS
include Antimonium crudum: indigestion after a huge meal along with alternate
constipation and diarrhoea; Staphysagria: IBS caused by suppressed anger; Arsenicum
album : intolerable abdominal pain with diarrhoea, restlessness & excessive thirst in sips;
Aloes socotrina : IBS with abdominal pain, gas formation, diarrhea and want of confidence
in sphincter ani; Carbo vegetalis : flatulent colic, distended abdomen, when simplest food
disagrees & eructations give temporary relief.
Other than these indications of few important homeopathic medicines for Irritable bowel
syndrome are given below:

1. Argentum Indicated in gastrointestinal conditions accompanied by
nitricum nervousness & anxiety. Upper abdominal affections brought on
by undue mental exertion. Belching accompanies most gastric
ailments. Flatulence; painful swelling of pit with colic. Painful
spot in the stomach that radiates to all parts of the abdomen; <
slightest pressure. Stool is watery, noisy, flatulent; green like
chopped spinach, and shreddy mucus with enormous distension
of abdomen. Diarrhoea immediately after drinking water and
eating too much sweet or salty food.
Impulsive, anxious and nervous persons. Withered up, old
looking people with marked emaciation especially in the lower
extremities. Craving for sweets and desire for salty food.
Intolerance of heat. Desire for open air.
Worse fear, fright, mental strain, cod food, ice cream etc. Better
cold open air; hard pressure etc.
2. Cinchona Indicated in persons who suffer from painless watery diarrhea
13Oberai P, Dissertation Scope of homeopathic medicines in the cases of irritable bowel syndrome with
reportorial analysis [M.D. Thesis]Unpublished ;2009
14Peckham EJ, Relton C, Raw J, Walters C, Thomas K, Smith C, et. al. Interim results of a randomized controlled
trial of homeopathic treatment for irritable bowel syndrome. Homeopathy. 2014 Jul; 103 (3):172-7. doi:
10.1016/j.homp.2014.05.001. Epub 2014 May 29 available at
http://www.ncbi.nlm.nih.gov/pubmed/24931748
15J. H. Clarke, A Dictionary of Practical MateriaMedica, 3 –volume, New Delhi: B. Jain Publishers
16Allen HC. Allen’s Keynotes- Rearranged and classified with leading remedies of the materiamedica and

17Boericke W. Boericke’s New Manual of Homoeopathic MateriaMedica with Repertory: Third Revised &

officinalis with great bloating, indigestion, and general weakness.
Sensation as if abdomen is full of gas which is not relieved by
eructation. Slow digestion. Weight after eating. Hungry without
appetite. Hungry, longing for food which lies undigested.
Flatulence; belching of bitter fluid or regurgitation of food gives
no relief; worse eating fruit. Bloatedness better by movement.
Undigested, frothy, yellow, painless stool; worse at night, after
meals, during hot weather, from milk.
Suited to apathetic, indifferent, despondent & gloomy persons
in which there is debility from exhausting diseases; from loss of
vital fluids and nervous erethism. Periodicity of complaints.
Weak and oversensitive persons. Sensitiveness to draughts.
Chilly person, sensitive to draughts of air yet wants to be
fanned; face pale with sunken features.
3. Lycopodium Indicated in dyspepsia with great flatulence and fermentation.
clavatum Much noisy flatulence< lower abdomen, gurgling and rumbling
esp. in the region of transverse colon. Fullness not relieved by
belching. Constant sensation of satiety; good appetite but a few
mouthfuls fill up to the throat. Inactivity of bowels. Ineffectual
urging to stool. Constipation since puberty, last confinement,
when away from home. Small stool, with the sensation as if
much remained behind, followed by excessive and painful
accumulations of flatulence. Everything tastes sour, eructation,
heartburn, waterbrash, sour vomiting.

Peevish and depressed in mind. Miserly and coward. Irritable,
contradiction aggravates. Adapted to old persons or children
who age prematurely and have a weak body but sharp mind
(intellectually keen but bodily weak). Earthly complexion and
yellowish spots on skin with or without vertical furrows on
forehead. Desire sweets, warm drinks. Aversion to breads. All
complaints < 4-8 pm Better: warm drinks, food, cold
applications, eructation
4. Natrum Indicated in persons with very weak digestion, caused by
Carbonicum slightest error in diet. Gastrointestinal trouble from various
types of foods esp. dairy products which lead to gas formation
and spluttering diarrhoea with an empty feeling in the stomach.
Intolerance of milk, and dairy products. Old dyspeptics, always
belching, have a sour stomach and rheumatism. Ill effects of
drinking cold water when overheated. Bitter taste.
Inabilty to think or perform any mental labor. Melancholic and
apprehensive. Great debility caused by summer heat; chronic
effects of sunstroke. Thin emaciated persons with milky, watery

skin and very weak ankles. Worse from music, in the sun,
mental exertion, thunderstorm.
5. Nux Flatulent distension with spasmodic colic. Constant nausea after
Vomica eating. Pressure in stomach an hour or two after eating as from
stone. Cannot use mind for 2-3 hours after meal. Constipation
with frequent ineffectual desire, passing small quantities of
faeces, sensation as if not finished. Constant feeling of
uneasiness in the rectum. Diarrhoea after debauch<in morning.
Constipation & diarrhea alternate in persons who have taken
purgatives all their life.
Suited to excitable, hypochondriacal, zealous, ambitious and
workaholics who become are prone to anger, spite and
deception. Debauchers prone to indigestion and haemorrhoids.
Craving for spicy foods, alcohol, tobacco and other stimulants &
worse from having them, oversensitive to external impressions
are other indications of this remedy. Worse in morning, from
mental exertion, after eating, touch. Better at rest, damp wet
weather.
6. Pulsatilla Dyspepsia with great tightness, all gone sensation in stomach
&waterbrash with foul taste in mouth. Bitter belching,
indigestion and heartburn worse at night. Excessive flatulence
with great rumbling, difficult to expel. Colic with chilliness in
evening .Stool changes from constipation to diarrhea during the
course of a day. Diarrhoea: only at night or usually at night;
watery, greenish yellow, changeable, as soon as they eat, from
fruit, cold food and drinks, ice cream...
Persons who desire company, mild, gentle, affectionate,
yielding, weeping disposition. Hot patient; marked
changeability; thirstlessness with great dryness of mouth.
Desire for cheese, pungent things, highly seasoned food;
aversion to fat, warm foods and drinks; tongue coated yellow or
whitish; worse towards evening and in the warm room, always
better in open air, by slow, gentle motion and cold applications.
7. Sulphur Indicated in complete loss of or excessive appetite. Drinks a lot,
eats little. Great acidity, sour eructation. Burning, painful weight
pressure. Abdomen very sensitive to pressure. Weak empty all
gone sensation in the stomach around11A.M. Early morning
diarrhea, which drives out of bed. Diarrhea frequent, painless.
At the other time, person may suffer from constipation where
stool large, hard as if burnt, painful and suffer from gas with an
offensive smell.Redness around the rectum, with itching and
burning.
Suitable to quick motioned, quick tempered, irritable persons
who are mentally egoistic, dwell on philosophical and religious

speculations (ragged philosopher). Hot patients who desire
sweets and in whom milk disagrees. Aggravation from rest,
warmth of the bed, washing, 11am, night, early morning,
standing. Amelioration dry warm weather lying on right side,
drawing limbs. Burning all over the body especially in all the
orifices e.g. nose, ear, rectum vagina, urethra etc.; flushes of heat
on face.

Diagnosis through sign & symptoms
 Chronic or recurrent abdominal pain
 Bloating
 Abnormal stool form (hard or loose stool)
 Abnormal stool frequency (less than 3 time /week or more than 3 time /day)
 Straining for defecation
 Feeling of incomplete evacuation
 Passage of mucus per rectum
 Urgency
Diagnosis through Rome III criteria
 Onset of symptom at least 6 month before diagnosis.
 Recurrent abdominal pain or discomfort for > 3 days per month during past 3
month
 At least 2 or more of the following features.
- Improvement with defecation
- Associated with a change in frequency in stool
- Associated with change in stool form
General Management
Start homeopathic treatment& advice
for general management Counseling-Inform the patient regarding the
triggering factors & avoidable risk factor of
IBS. And reassure the patient.
Dietary management-
Improvement  Advice for balanced diet food
on the basis
of clinical  Avoid the food which trigger the
NO YES
assessment disease condition
 Maintain regular meal time
 Fiber rich diet & bulking agent like
Reassess the case and Continue psyllium fiber advice as it relieves
remove any Homoeopathic constipation. Fiber content must be
Assess for
maintaining factors Medicine with increased slowly to reduce the
Red flag
for the diseased general bloating & flatulence.
signs
condition management  If found lactose & fructose intolerant
then advice to exclude dairy products
from diet
No improvement/
 Take sufficient fluid.
Red flag signs
Periodically assess the Lifestyle management
case for improvement  Relieve stress factor
Red Flag  Practice yoga and take regular
 Unintended weight loss exercise
 Family history of rectal  Take meals on regular time
cancer, inflammatory
bowel disease, coeliac
disease.
 Persistent or progressive
pain
 Rectal bleeding
 Fever
 Abdominal/rectal masses
 Raised inflammatory
markers
 Nocturnal or large
CCRH volume(>300ml/day)
11 Updated on 10th Jul, 16
diarrhea
MENOPAUSE
CASE DEFINITION
The term natural menopause is defined as the permanent cessation of menstruation
resulting from the loss of ovarian follicular activity. Natural menopause is recognized to
have occurred after 12 consecutive months of amenorrhea, for which there is no other
obvious pathological or physiological cause. Menopause occurs with the final menstrual
period (FMP) which is known with certainty only in retrospect a year or more after the
event.1 The terms menopause, climacteric and pre, peri and post menopause are often used
loosely and interchangeably but strictly apply to different periods at the end of the
reproductive period in a woman’s life.
INCIDENCE
The time of menopause is remarkably stable down the generation and throughout the
world. At present in India, most people refer 47.5 years as the average age of menopause
which is slightly lower than the standard North American benchmark of age 51. In present
day management of menopause, the ages of 45 to 55 years are taken as the limits of
normality and those menstruating after 55 years’ merit investigation to exclude pathology.
CLASSIFICATION
There are three types of menopause.
1. Natural
2. Premature menopause, if the menopause occurs before the age of 40 years.
3. Iatrogenic, due to surgical removal of the ovaries or chemotherapy and radiation to
the ovaries.
PATHOPHYSIOLOGY
With aging, there is depletion of oocytes and decline in oestradiol which falls below critical
level with atrophy of endometrium leading to amenorrhea and menopause. Both FSH and
LH are elevated. Post menopausal ovary produces androstenidione and testosterone and
there is excess of androgen. Adrenal glands contribute to the same. Androstenidione is
converted to estrone in adipose tissue so that E1 and E2 ratio is reversed. Estrone is less
active biologically explaining the symptoms due to hormonal deficiencies.
1
CCRH. Menopause – Disease Monograph series1. New Delhi, CCRH:2011

DIAGNOSIS
In most cases, the diagnosis is made based on symptoms given below. Checking an FSH
level or serum oestradiol and progesterone are totally unnecessary tests in diagnosing
menopause and doing an androgen profile as a routine on all peri-menopausal women is
unnecessary and costly. Respond to the symptoms, not the biochemistry2.
Symptoms
 Menstrual irregularity: the intervals between periods may be longer or shorter,
flow may be scanty to profuse, and some periods may be skipped.
 Hot flushes and sleep problems: During late peri-menopause sudden feelings of
heat all over or in the upper part of body, flushing of face & neck, red blotches on
chest, back, & arms, heavy profuse sweating and cold shivering.
Sleep problems are often due to hot flushes or night sweats, but sometimes sleep
becomes erratic even without them.
 Mood changes: Some women experience mood swings, irritability or increased risk
of depression during peri-menopause.
 Vaginal and bladder problems: Due to loss of lubrication and elasticity in vaginal
tissues intercourse becomes painful, vulnerability to urinary or vaginal infections
and urinary incontinence.
 Decreasing fertility: As ovulation becomes irregular, ability to conceive decreases.

However, pregnancy remains a possibility until no periods for 12 months.
 Changes in sexual function: During peri-menopause, sexual arousal and desire

may change. But for most women who had satisfactory sexual intimacy before
menopause, this will continue through peri-menopause and beyond.
 Loss of bone: With declining estrogen levels, one starts to lose bone more quickly
than one can replace it, increasing risk of osteoporosis.
 Changing cholesterol levels: Declining estrogen levels may lead to unfavorable

changes in blood cholesterol levels, including an increase in low-density lipoprotein
(LDL) cholesterol — the "bad" cholesterol — which contributes to an increased risk
of heart disease. At the same time, high-density lipoprotein (HDL) cholesterol — the
2 Australasian Menopause Society. Menopause [internet][cited 2015 April 13] Available at:
http://www.menopause.org.au/consumers/information-sheets/420-diagnosing-menopause

"good" cholesterol — decreases in many women as they age, which also increases
the risk of heart disease.
 Urethral Caruncle: Urethral caruncle is predominantly found in post menopausal

female and most likely represents ectropion of the urethral wall due to post
menopausal regression of the vaginal mucosa. Symptoms may range from mild
bleeding to extreme urinary discomfort.
 Lower genital tract atrophy: Exact incidence of this condition may not be known
but most of the post menopausal females as well as clinicians have dealt with this.
The long-term complications of ageing and oestrogen deficiency may have greater
bearing on a woman’s quality and even quantity of life than the acute short-term
symptoms at the time of the menopause. Although they remain clinically silent for many
years, it may present a far greater problem in terms of morbidity, mortality and
economic burden.
Physical examination
A thorough general physical examination is necessary to document changes associated

with menopause and to institute effective therapy.
 Nutritional status
 Height: height loss is associated with osteoporosis and spinal compression
fractures. Therefore, height should be measured yearly.
 Weight: to counsel the woman about physical exercise
 Body mass index
 Waist circumference: to identify truncal obesity
 Pulse
 Blood pressure
 Auscultation of heart and lungs
 Examination of oral cavity: atrophy of oral mucosa, tooth decay and tooth loss are
common.
 Cognitive: cognitive decline is unusual, but complaints of forgetfulness are common.
The patients who are very much concerned about cognitive decline should be
referred to a neurologist.
 Psychosocial: evaluation of psychosocial wellbeing should be a part of clinical
evaluation. Clinicians may directly ask about depression, anxiety and sexual
functioning or use a simple questionnaire to assess psychosocial issue.

 Dermatologic: skin changes associated with estrogen deficiency are skin thinning
and wrinkling. In addition, other skin lesions are common with ageing and photo
ageing. Abnormal nevi or excessive sun exposure require prompt referral to
dermatologist for further skin cancer evaluation.
 Breast examination: breast tissue and axilla are carefully inspected and palpated.
Nipple discharge, nipple inversion, masses should be documented and evaluated.
 Pelvic examination: examination of vulva may demonstrate shrinkage of labia
majora, labia minora may shorten or disappear completely and there is narrowing
of introitus. The vulva should be examined for redness, atrophy or scarring. In those
with pain, point of pain and any scar tissue should be noted.
 Vaginal examination will reveal loss of rugae, pale, dry vaginal mucosa. Epithelial
tissues are friable and submucosal petechial haemorrhages are seen. Vaginal PH is
more than 5 and maturation index shows basal cell predominance. Culture of vagina
may reveal pathologic bacteria not normally found in vagina. Cervix is inspected and
Pap smear is taken.
Investigations
Routine laboratory tests which should be done routinely for screening are-
 Complete blood count
 Urine examination: routine and culture
 Fasting blood glucose level
 Lipid profile
 Stool for occult blood
 Pap smear
 Ultrasonography including TVS
 Mammogram
Whenever there is abnormality in screening test or there is specific indication following
investigations are to be done.
1. Thyroid profile.
2. Follicle Stimulating hormone
3. Oestradiol
4. Tests to assess increased risk of thrombosis
5. Endometrial biopsy
6. Coloscopy and cervical biopsy
7. Bone mass measurement

ASSOCIATED CO-MORBITIES
There are major chronic diseases associated with menopause as risk factor which should
be interrogated with respect to family history, life style which includes diet, physical
activity, addiction and medication such as psychotropic drugs, anti-hypertensives, anti-
histaminics and oral contraceptive pills being taken. The risk factors are as follows:
1. Osteoporosis
2. Coronary heart disease
3. Deep vein thrombosis
4. Diabetes mellitus
5. Alzheimer’s disease
6. Gynecological cancers, breast cancers, lung cancer, oral cancer and colorectal cancer
DIFFERENTIAL DIAGNOSIS
 Abnormal uterine bleeding: anovulation, endometrial hyperplasia, endometrial

polyp, cervical cancer, uterine leiomyoma, atrophic endometritis, hormone
treatment
 Vasomotor instability: psychosomatic, stress, anxiety, febrile illness,
hyperthyroidism, pheochromocytoma, carcinoid syndrome, leukemia and cancers
 Urogenital atrophy: bacterial vaginosis, candidiasis, pelvic pathology, marital
disharmony, urinary tract infection
There are various valuation scales used for assessing severity of disease and prognosis
during treatment. These are as follows:
1. Menopause Rating Scale (MRS)3
2. Utian Quality of Life Scale4
3. Greene Climacteric scale5
MANAGEMENT
The Goal and purpose of menopause management is Health promotion, disease prevention
and disability postponement as there are several risk factors for other diseases associated
3 Menopause rating scale. Available at: http://www.biomedcentral.com/content/supplementary/1477-

7525-1-28-s3.pdf
4 Utian Quality of Life Scale. Available at: http://www.menopause.org/docs/default-document-
library/uqol.pdf?sfvrsn=2
5 Greene, J, A factor analytic study of climacteric symptoms Journal of Psychosomatic Research (1976), 20,
425—430.

with menopause. Multifactorial approach is required for leading a healthy life. For
physical fitness a post-menopausal woman must consume fat free milk, green vegetables,
fruits for Vit E; dark green leafy vegetables for beta carotene; yellow orange colored
vegetables for Vit C; amla, citrus fruits for protein and omega 3 fatty acids ragi, fish,
legumes and soya beans in proper proportion. Participation in regular physical activity
(both aerobic and strength exercises) from adolescence itself elicits a number of favorable
responses that contribute to healthy aging and healthy menopause.
The therapeutic aim is to alleviate the distressing menopausal symptoms. In homoeopathy
research has been done on menopause and other disease such as cancer during
menopause. These studies 6,7,8,9,10,11,12,13 indicate a positive role of homoeopathy in
managing the menopausal symptoms.
There are 109 medicines mentioned in Synthesis repertory for the treatment of
menopause. The climacteric period per se is not a disease. It is a physiological epoch, a
period of transition just like childhood to adolescence and then adolescence to child-
bearing. The changes in the hormonal levels at this time lead to subsequent changes in
different parts of the body. Some women are very sensitive to these changes and will
exhibit ‘symptoms’ of menopause like flushes, sweating, emotional upheavals, etc. All these
symptoms can be easily treated with the constitutional medicines or related deep acting
chronic medicines. Along with the constitutional medicines, the physician has to reassure
the patient and give emotional support. When the polycrest or constitutional remedies are
not indicated or fail to relieve in the case, then the indigenous, rare, organ remedies and
other medicines could be thought of as required in the case. Few such remedies include:
Amyl nitrosum: Climateric headaches and flushes of heat, with anxiety and palpitations,
Ustaligo: Congestion of various parts at climacteric, menorrhagia at climaxis and
Mancinella: Mentally depressed states at climacteric.
6 Clover A, Ratsey D. Homeopathic treatment of hot flushes: a pilot study. Homeopathy. 2002 Apr; 91(2):75-9.
7 Thompson EA. Homeopathy and the menopause. J Br Menopause Soc. 2002 Dec; 8(4):151-4.
8 Cortés E M, González L, Faisal A, Bojalil A-. Individualized homeopathic treatment and fluoxetine for
moderate to severe depression in peri- and postmenopausal women (HOMDEP-MENOP study): a randomized,
double-dummy, double-blind, placebo-controlled trial.PLoS One. 2015 Mar 13; 10(3):e0118440.
9 Thompson, E.A., Reilly, D. The homeopathic approach to the treatment of symptoms of oestrogen
withdrawal in breast cancer patients: A prospective observational study. Homeopathy. 2003; 92:131-134.
10 Bordet MF, Colas A., Marijnen P, Masson JL, and Trichard M. Treating hot flushes in menopausal women
with homoeopathic treatment-Results of an observational study. Homeopathy. 2008; 97:10-15.

11 Relton C, Weatherley-Jones, E. Homeopathy service in a NHS community menopause clinic: audit of clinical
outcomes. Journal of the British Menopause society. 2005 ; 11 (2):723.

12 Nayak C, Singh V, Singh K, Singh H, Gupta J, Lamba CD, et al. Management of Distress during Climacteric
Years by Homeopathic Therapy. J Altern Complement Med 2011 Nov;17(11):1037-42

13 Jacobs, J., Herman P., Herron, K. et al. Homeopathy for menopausal symptoms in breast cancer survivors: a
preliminary randomized controlled trial. Journal of Alternative & Complementary Medicine.2005; 11(1): 21-
27.

Indications of Common homoeopathic medicines are as follows:

1. Sepia Medicine is suitable to patients having climacteric flushes
officinalis ascending from pelvis with least motion, anxiety, an oppressed
feeling ending in perspiration. Dyspareunia from dryness of vagina
and bleeding. Decreased sexual desire. There is history of repeated
pregnancies in patient. Weakness, yellow complexion, bearing-
down sensation, especially in women, upon whose organism it has
most pronounced effect. Pains extend down to back, chills easily.
Prolapsus uteri, with congestion, with yellow leucorrhœa.
Irritable; easily offended.
Persons who are sad, indifferent even to loved ones, irritable,
indolent and quarrelsome. Chilly patient; predisposed to take cold
at the change of weather; thin built with narrow pelvis; sudden
prostration with sinking faintness with all complaints; offensive
sweat; desire for vinegar, acids, pickles and sour, but sour food
aggravates. Aggravated after laundry work and better by warmth
of bed, after violent exercise.
2. Lachesis This drug is of value in females who have never felt well since
mutus change of life-"have never felt well since that time". During change
of life, she has flushes of heat all day, and cold flushes on retiring
at night. Burning in vertex with headache, especially at or after the
menopause. Lachesis is a valuable remedy at the climaxis, esp. in
the woman who has exhausted herself by frequent pregnancies
and hard work. In this worn out condition, there occurs a sudden
cessation of menses. Suppression or non-appearance of discharges
always makes the Lachesis patient worse.
Suspicious, jealous, loquacious. Thinks she is someone else; in the
hands of a stronger power; that she is dead and preparations are
being made for her funeral; that she is nearly dead and wishes
someone would help her off. Left-sided complaints or moving from
left to right.
3. Graphites What Pulsatilla is during puberty, Graphites is at the climateric.
Flushes of heat with numbness felt in whole head. Menses: late,
irregular, scanty, pale mixed with small clots and of short duration.
Great aversion to coitus. Suited to patients who are who are rather
stout, of fair complexion, with tendency to skin affections and
constipation, fat, chilly and costive, with delayed menstrual
history.

Suited to women inclined to obesity, who suffer from habitual
constipation, with a history of delayed menstruation.
. Large, knotty, difficult, stringy, slimy coated stools. Takes cold
easily.
4. Sulphur Sulphur is useful in flushes of heat to the face and head at
climacteric period. Burning palms and soles with tendency to
uncover. The flushes begin somewhere in the heart region, in the
chest and feels as if a glow of heat is rising to the face. Irregularity
in the menstrual flow, suppressed from the slightest disturbances.
Prolonged uterine hemorrhages. Hot patient, dirty filthy, lean thin,
stoop shoulder who walk and sit stooping. Nervous, quick
tempered. Emotionally irritable and sluggish. Doesn’t want to
wash or bathe. Thirsty for cold drinks, little appetite, worse 5 A.M.
5. Argentum This medicine is indicated in metrorrhagia at climaxis, (also of
nitricum young widows and childless women). Nervous erythrism at
change of life. Palpitation, trembling, coldness of the surface,
desire for open air, blueness, coldness of lower extremities.
Menses irregular, too soon or too late or last for a day only. Menses
scanty with dyspnoea. Patients are old, dried up, tremulous and
weak. Coition painful, followed by bleeding from the vagina.
Craves sugar, which <. Impulse to do everything in a hurry, time
passes too slowly. Fear at high places. Impulse to jump while
crossing a bridge.
6. Calcarea Medicine is suitable for women with history of too early & profuse
carbonica menstruation. Congestive headache. The menstrual flow is
provoked by over-exertion or by emotion. Voluptuous sensation in
the genital parts, with emission. Leucorrhea, with burning itching,
or else like milk, flowing by fits, and during the emission of urine.
Depressed melancholic or doubting mood; fears disease, misery,
disaster, being observed. The patient fears she will lose her reason,
or that people will notice her mental confusion. Fears she has
some fatal disease, especially heart disease. Pain as if the parts
would burst, were pressed as under, were pushed as under; as if
cold, damp stockings were on the feet. Chilly patient, takes cold
easily, fat flair, flabby. Sour odor of sweat, stools, breath. Desire for
eggs and indigestible things, aversion to meat and milk.
7. Sanguinaria In Sanguinaria patient’s headaches return at climacteric; every

canadensis seventh day. There is flushing with headache, > open air and

sleep. Climacteric disorders, esp. flushes of heat and corrosive,
fetid leucorrhea. Burning of palms and soles at climaxis;
compelling her to throw off her clothes. Painful enlargement of
breasts at climaxis. Sharp, piercing pain in right breast, just
beneath nipple; < deep breath, some dyspnœa. Pain in right breast
extends to shoulder, can hardly place hand on head. Anxiety and
feeling of dread. Anxiety precedes vomiting and delirium.
Moroseness, with nausea; cannot bear a person to walk in room.
8. Phosphorus Menorrhagia at climacteric period. Vicarious menses. Flushes of
heat beginning in back or stomach. Violent palpitation. < from
motion; lying on left side, evening; at night or waking. Copious
hemorrhages from uterus at the climacteric period; menses too
early, flow bright red.
Nervous persons, oversensitive to external impressions – light,
noise, touch, odour, etc; desire to be magnetized and those who
have anxiety especially during thunderstorm. Melancholy sadness,
sometimes with violent weeping, or interrupted by fits of
involuntary laughter. Nymphomania Chilly patients; tall, slender,
narrow chested; have a craving for salt and cold water. Aversion to
sweets.

ALGORITHM OF TREATMENT PROCESS:
In most cases, recording a symptom Assessment of risk factors for Screening and diagnostic tests
score helps to make the diagnosis and at major chronic diseases associated  Complete blood count
the same time educates the women. with menopause including  Urine examination: routine and
Clinical diagnosis:  Osteoporosis culture
Females in the age group of 45 to 55  Coronary heart disease  Fasting blood glucose level
years experiencing  Deep vein thrombosis  Lipid profile
 Menstrual irregularity  Diabetes mellitus  Stool for occult blood
 Hot flushes and sleep problems  Alzheimer’s disease  Pap smear
 Mood changes  Gynaecological cancers, breast  Ultrasonography including TVS
 Vaginal and bladder problems cancers, lung cancer, oral cancer  Mammogram
 Changes in sexual function and colorectal cancer are to be In case of abnormality in screening tests or
 Loss of bone assessed. specific indication following investigations
 Changing cholesterol levels are to be done-
 Recurrent urinary tract Physical examination (including  TSH, FSH, Oestradiol
infections pelvic and breast examination)  Tests to assess increased risk of
 Urinary incontinence thrombosis
 Urethral caruncle  Coloscopy, Endometrial and cervical
 Lower genital tract atrophy biopsy.
 Bone mass measurement
General management
Start homoeopathic treatment and Exercise prescription:
Advice for general management  Moderate to severe aerobic activity or brisk walking
for 150 min per week or 30 min /day for 5days in a
week
Follow up regularly till  Strength and stamina building exercises should be
the symptoms persists. added for 2 or 3 times in a week of 20 min per
session.
NO  Meditation and stretching exercises like Yoga should
also be included and can be done as a warm up
Improvement YES exercise.
after adequate Diet & nutrition:
follow up  Calcium and Vit D
 Encourage to take fat free milk, green vegetables,
fruits for Vit E; dark green leafy vegetables for beta
Refer for appropriate Continue Homoeopathic carotene; yellow orange colored vegetables for Vit C;
Treatment/ follow up for 6 amla, citrus fruits, for protein and omega 3 fatty
treatment
months with reduced acids ragi, fish, legumes and soyabeans in proper
repetition proportion.
Referral criteria
 Worsening general Check for complete
Condition resolution of symptoms
 Evidence of complication of
chronic diseases associated
with menopause
If resolution is incomplete If resolution is complete
Stop treatment
Reassess the case and give
appropriate homoeopathic medicine

Polycystic Ovarian Syndrome (PCOS)
CASE DEFINITION
It is defined as a Heterogeneous syndrome complex characterized by persistent hyper

androgenic chronic anovulation in the absence of any other cause and frequently associated
with hyperinsulinemia and insulin resistance, resulting into menstrual irregularity,
infertility & hirsutism. PCOS is the most common endocrinopathy in women of the
reproductive age group.
INCIDENCE
 Polycystic Ovarian Syndrome (PCOS) is a complex metabolic, endocrine and
reproductive disorder affecting approximately 5-10% of the female population in
developed countries.1
 Prevalence of PCOS in Indian adolescents is 9.13%.2
PATHOGENESIS3
The pathogenesis of polycystic ovaries and PCOS is still being elucidated, but the
heterogeneity of presentation of PCOS suggests that a single cause is unlikely. Some genetic
studies have identified a link between PCOS and disordered insulin metabolism, and indicate
that PCOS may be the presentation of a complex genetic trait disorder.
The central issue in the pathogenesis seems to be the inability or insensitivity of the ovaries
to respond to the stimulation from the Pituitary gland and Hypothalamus which go on
secreting LH and FSH in an inappropriate, insufficient and untimely manner. This results in
increased LH secretion, which is a prominent feature. The other being ovarian
Hyperandrogenism. The features of obesity and hyperinsulinaemia, which are commonly
seen in PCOS, accentuate the pathogenesis.
1Heidi A. Polycystic ovary syndrome (PCOS) in urban India. Manlove University of Nevada, Las Vegas.5-1-2011
accessedfrom
http://digitalscholarship.unlv.edu/cgi/viewcontent.cgi?article=1937&context=thesesdissertations
2Nidhi R, Padmalatha V, Nagarathna R, Amritanshu R. Prevalence of polycystic ovarian syndrome in Indian
adolescents. Journal of Pediatric and Adolescent Gynecology - August 2011 (Vol. 24, Issue 4, Pages 223-227,
DOI: 10.1016/j.jpag.2011.03.002)
3Adam Balen. Polycystic ovary syndrome. Text book of gynecology by R. Shaw; fourth edition. Churchill
Livingstone Elsevier publication. 251-264.

CLINICAL FEATURES4:
 Oligomenorrhoea, amenorrhea, abnormal uterine bleeding (All types of menstrual
irregularities are more common in obese patients than in lean patients), normal
menstrual pattern
 Infertility
 Obesity
 Hirsutism
 Acne
 Virilisation
 Polycystic Ovary in ultrasonography
Other clinical features include:

 Decreased breast size
 Decreased sexual desire
 Achordonosis (skin tags) – tiny flaps of skin seen on eyelids, neck, armpits and groins
 High blood pressure
 Mood swings
 Depression and anxiety
 Acanthosis nigricans
 Male pattern alopecia
 Revised 2003 Diagnostic criteria for PCOS-presence of 2 out of 3 of following symptoms

(Rotterdam criteria)
1. Oligoovulation or anoulation.
2. Clinical and/or biochemical signs of hyperandrogenism.
3. Polycystic ovaries and exclusion of other etiologies.
It is recognized that women with regular cycles, hyperandrogenism, and PCO morphology may be
part of the syndrome.
 Androgen Excess Society criteria for diagnosis of PCOS: (AES-1990) Diagnostic criteria for
PCOS. The Androgen Excess Society (AES) is an international organization dedicated to
promoting knowledge, and original clinical and basic research in every aspect of androgen
excess disorders.
1. Hyperandrogenism: Hirsutism and /or hyperandrogenaemia
And
2. Ovarian dysfunction: Oligo-anovulation and / or polycystic ovaries
And
3. Exclusion of other androgen excess or related disorders.
4 Michael T. Sheehan. Review. Polycystic Ovarian Syndrome: Diagnosis and Management. Clinical Medicine &
Research. 2004. Volume 2, Number 1: 13-27

HEALTH CONSEQUENCES3:
 Ischaemic heart disease
 Insulin resistance
 Homocysteine
 Endometrial cancer
 Endometrial hyperplasia
 Breast cancer
 Ovarian cancer
INVESTIGATIONS5:
There is no single test diagnostic for PCOS & number of investigations in unison is useful to
confirm the diagnosis
TEST DIAGNOSTIC FEATURE
Day 2 serum FSH /LH Raised LH, decreased or normal FSH

LH:FSH > 2-3 : 1
S. Testosterone Raised
S. DHEA Raised
S. Free Estradiol Increased
S. Prolactin Increased
S. Fasting Insulin Increased
GTT Impaired
S. Fasting glucose: Insulin ratio < 4.5
USG “Necklace” / “string of pearls” appearance
Laparoscopy “Oyster” ovaries
 Clinical Laboratory Evaluations – Explanation of the Table

 Endocrine profile for PCOS
1. LH/FSH ratio5:- A ratio >2.0 is suggestive of PCOS but is not highly
sensitive or specific.
5 Central Council for Research in Homoeopathy. Homoeopathy in polycystic ovarian syndrome: A randomized
placebo-controlled pilot study. IJRH.2014;8(1), 3-8.

2. Dehydroepiandrosterone-sulfate (DHEAS) 5: DHEA-S values may be normal or
slightly elevated in PCOS. DHEA-S values >800 µg/dL (21.7 µmol/L) warrant
consideration of an adrenal tumor.
3. Serum insulin: Increased
4. Glucose insulin ratio5:<4.5 in obese, euglycemic, non-Hispanic white adult
polycystic ovariansyndrome patients14 (<7.0 in adolescents) consistent with
insulin resistance
5. Triglycerides
6. HDL-cholesterol
 Investigations to rule out disorders which mimic the PCOS phenotype-

1. Urine Pregnancy Test in case of married women with amenorrhea
2. Complete Blood Count with ESR
3. Fasting glucose (If >150 mg/dL)
4. Thyroid Function Test – TSH, Free T3, Free T4
5. Serum Prolactin5: Mild hyperprolactinemia has been reported in 5% to 30%
of patients with PCOS. Prolactin is generally only 50% above the upper limit of
normal. Furthermore, hyperprolactinemia is most often transient, with
perhaps only 3% to 7% of hyperprolactinemic PCOS patients having
persistently elevated prolactin levels.
6. Basal morning 17-OHP
7. Complete Urine Examination
 Pelvic Ultrasonography
To be done to confirm the diagnosis of PCOS. The PCO should have at least one of the
following: either 12 or more follicles measuring 2±9 mm in diameter or increased ovarian
volume (>10 cm3). If there is evidence of a dominant follicle (>10 mm) or a corpus
luteum, the scan should be repeated during the next cycle.
Only one ovary fitting this definition or a single occurrence of one of the above criteria is
sufficient to define the PCO.
DIFFERENTIAL DIAGNOSIS AND LABORATORY TEST5
Diagnosis Laboratory test

Pregnancy Pregnancy test
Hypothyroidism Thyroid stimulating hormone (TSH)
Hyperprolactinemia Prolactin
Late-onset congenital adrenal hyperplasia 17-Hydroxyprogesterone
(CAH)

Ovarian tumor Total testosterone
Hyperthecosis Total testosterone
Adrenal tumor Dehydroepiandrosterone-sulfate (DHEA)-S
Cushing’s syndrome 24-hour urine free cortisol
RED FLAG
 Amenorrhea of more than three months/irregular menses
 Exclude the pregnancy in case of amenorrhea
 Hirsutism/unwanted hair growth
 Weight gain during puberty
Different scales are used for assessment of different features of PCOS. Some of scales require
permission for use and some are free for use.
 Polycystic Ovary Syndrome Questionnaire (PCOSQ)6: The PCOSQ is a reliable

instrument for measuring the health-related quality of life (HRQoL) of women with
polycystic ovary syndrome.
 Acne Global Severity Scale7: It is an acceptable global assessment scale.
 Hirsutism8: Quantifying the extent of male-pattern terminal hair growth is then critical
for the thorough evaluation of women with potential androgen excess. The use of the
modified Ferriman-Gallwey visual scoring method has been used extensively for this
purpose.
MANAGEMENT
PCOS is a complex metabolic, endocrine and reproductive disorder. The therapeutic goal is
to establish the normal ovulatory cycles/ menstrual regularity with ultrasonological
improvement of polycystic ovaries and control hyperandrogenism. There is no single rubric
covering this disorder in the homoeopathic repertory. As per the principles of Homoeopathy
well indicated constitutional remedy on the basis of totality of symptoms can work well.
However, when the polycrest or constitutional remedies are not indicated or fail to relieve
6 L. Cronin, G. Guyatt, L. Griffith, E. Wong, R. Azziz, W. Futterweit, D. Cook, and A. Dunaif Development of a
Health-Related Quality-of-Life Questionnaire (PCOSQ) for Women with Polycystic Ovary Syndrome
(PCOS)JCEM 1998 83: 1976-1987; doi:10.1210/jc.83.6.1976
7 Acne global severity scale.
http://www.fda.gov/ohrms/dockets/ac/02/briefing/3904B1_03_%20Acne%20Global%20Severity%20Sca
le.pdf
8 Androgen Excess and PCOS society. http://www.ae-society.org/tools accessed on 4-07-2012.

in the case, then the indigenous, rare, and other medicines could be considered. For example,
emmenagogues like Pulsatiilla, Gossypium, Ashoka etc. may be required at times in cases of
prolonged amenorrhoea. Homeopathic literature9,10,11,12 and research13,14 could identify
medicines which are prescribed and effective in this condition or with symptom similarity.
Counseling to Patients and Family

Information regarding avoidable risk factors needs to be told to the patients and their
families along with guidance regarding lifestyle modifications i.e. diet and physical activity.
Lifestyle modification should be the first treatment and is effective in reducing the signs and
symptoms of PCOS.
 Regular brisk walking for 45 min daily for minimum five days in week.
 Nutritionally adequate, low-fat (approximately 30% of energy, saturated fat
approximately 10%), moderate-protein (approximately 15%) and high-carbohydrate
dietary intake (approximately 55%), with increased fiber-rich wholegrain breads,
cereals, fruits and vegetables.
 Avoid junk food.
 Weight loss exercise is advisable in obese patients.
Management of Depression and Anxiety
As said in the section of Signs and Symptoms, Depression, Mood swings and Anxiety are
commonly found in pts of PCOS. In our country there are many socio-religious-cultural and
economic factors that influence the individual response to the disease and how society at
large accepts these patients. A physician needs to keep all these in mind when he interacts
with these patients in whom low mood and anxiety is commonly found.
The indications of commonly used medicines are given below:
Sl. No. Medicines Indications

1. Apis This medicine is indicated in amenorrhea or menorrhagia of
mellifica females. There is an inflammation, induration, swelling, and
dropsy of the ovaries (right). Weight and pain in either ovarian
9
Schroyens F, Synthesis 9.1. Ovaries tumours, Female genitalia. Radar 10
10Boericke W. Boericke’s new manual of Homoeopathic Materia Medica. 3 rd revised and augmented edition. B.
Jain Publishers. New Delhi.
11Gimeno ML Q. Homœopathic treatment of ovarian cysts: A series of 40 cases. British Homoeopathic journal
1991;80(3): 143-148
12 Cardigno P. Homeopathy for the treatment of menstrual irregularities: a case series. Homeopathy 2009;
98(2): 97-106
13Sanchez-Resendiz J., Guzman-Gomez F., Polycystic Ovary Syndrome. Boletin Mexicano de Homeopatica 1997;
30: 11-15.
14 Gupta G. Polycystic Ovarian Disease (PCOD). The Homoeopathic Heritage. May 2009.

region, predominantly right side. The ovaries feel better by
lying on right side. Enlargement of the right ovary with pain
which is sharp, cutting, stinging worse during menstruation.
Ovarian tumours, with stinging pains like bee-stings. Sudden;
shrill cries or pains that extort cries. Ovaries numb with cystic
tumor. Menses suppressed, with cerebral and head symptoms,
especially in young girls. Dysmenorrhoea, with severe ovarian
pains. Useful for amenorrhea of puberty. Apis is more a right-
side medicine; symptoms proceed from right to left and from
above downwards. Patient is Irritable, excitable, jealous, fussy
and fidgety or apathetic in nature.
2. Natrum Suitable to patients having shining face, as if greasy. Itching
muriaticum and eruption of pimples on face and forehead. Affects hair
follicles. Alopecia. Difficulty in appearance of first menses.
Menses premature and profuse; or retarded and scanty.
Headache before, during, and after Menses. Before menses,
moroseness and irritability. At commencement of menses,
sadness. During menses, cramps in abdomen. Spitting blood at
menstrual nisus; bloody saliva. Averse to bread. Nat. m. is one
of the first remedies for headaches of schoolgirls. Headache
with partial blindness. Melancholy sadness, which induces a
constant recurrence to unpleasant recollections, and much
weeping; all attempts at consolation <. Psychic causes of
disease; ill effects of grief, fright, anger, etc. Depressed,
particularly in chronic diseases. Oversensitive to all sorts of
influences.
3. Pulsatilla Remedy is suited in affections in general of the female genital
nigricans organs; of the uterus. Catamenia irregular, tardy, or
premature, of too short or too long duration, or entirely
suppressed (esp. if produced by getting the feet wet), with
colic, hysterical spasms in abdomen. Delay of first menses in
mild, gentle girls, low-spirited, diarrhea during menses.
Suppression of menses (esp. in elderly women in whom they
usually occur at full moon). Symptoms are changeful &
shifting. Patients are chilly, yet averse to heat; in a warm
room; with the pain; on lying down at night. Aversion to fatty
foods, thirstless with great dryness of mouth, discharges thick,
bland, and yellowish-green, worse in evening and warm room,
better from fresh air.
4. Calcarea In Calcarea carbonica patient, there is headache, colic,
carbonica chilliness and leucorrhoea before menses. Cutting pains in
uterus during menstruation. Menses too early, too profuse, too
long, with vertigo, toothache and cold, damp feet; the least
excitement causes their return. Burning and itching of parts

before and after menstruation; in little girls. Face pale and
hollow, with eyes sunk and surrounded by a livid circle.
Patient is forgetful, confused, and low-spirited. Has anxiety
with palpitation. Obstinacy; slight mental effort produces hot
head. Averse to work or exertion. Calcarea patient is fat, fair,
flabby and perspiring.
5. Sulphur Sulphur patient is stooped, lank, uncured, untidy and
unwashed. Suffers from menses too late; too short. Delay of
first menses. Amenorrhœa, dreadful depression and
apprehension, head feels full and heavy, followed by violent
headache, numbness of arms and legs, cramp and sick feeling
at during menstrual period. Menstrual blood thick, acrid,
corroding thighs; scanty, dark; dark, putrid, clotted. Before
menses: headache, itching in the parts; spasmodic colic;
inquietude; cough; toothache; pyrosis; epistaxis; leucorrhœa,
and asthmatic sufferings. Patient’s drinks much, eat little.
Great indolence and repugnance to all exertion, both mental
and bodily. Burning in feet wants to find a cool place for them;
puts them out of bed to cool them off.
6. Ignatia Ignatia is especially adapted to the nervous temperament-

amara women of sensitive, easily excited nature, dark, mild
disposition, quick to perceive, rapid in execution. Menstrual
flow is black, too early, too profuse, or scanty.
During menses great languor, with spasmodic pains in
stomach and abdomen. Feminine sexual frigidity. Suppression
from grief. The dysmenorrhœa in which Ign. is indicated has
labour-like bearing-down in hypogastrium, >by pressure; by
lying down; by change of position. The flow is black, putrid; if
profuse, clotted. The superficial and erratic character of its
symptoms is most characteristic. Effects of grief and worry.
Rapid change of mental and physical condition, opposite to
each other. Great contradictions.
7. Sepia Sepia patient is usually having saddle-like brownish
officinalis distribution on nose and cheeks. Sepia acts best on brunettes.
Menses too late and scanty, irregular; early and profuse; sharp
clutching pains. Violent stitches upward in the vagina, from
uterus to umbilicus. When menses fail to appear in mothers
who do not nurse, with inflation of abdomen. Colic before
menses. During menses: irritability, melancholy, toothache,
headache, nose-bleed, and painful weariness in limbs, or
spasmodic colic and pressure towards the parts. Must cross
her limbs to prevent protrusion of the parts. Dull, heavy pain

in ovaries; Adapted to persons of dark hair and rigid fibre;
with venous stasis, ptosis, moth spots, drooping eyelids.
Indifferent to those loved best. Averse to occupation, to family.
8. Kalium This drug is of value in ovarian neuralgia with great nervous

bromatum uneasiness. Cystic tumors of ovaries. Pruritus Exaggerated
sexual desire. Acne; on face in young fleshy people of gross
habit. Ovarian neuralgia from ungratified sexual desire;
nervous unrest. Neuralgia of ovaries; pain, swelling,
tenderness of left ovary, diminution of sexual desire. Before
menses: headache. During menses: epileptic spasms,
nymphomania, itching, burning, and excitement in vulva,
pudenda, and clitoris. After menses: headache, insomnia, and
heat in genitals. Epileptic attacks at or near menstrual periods.
Scanty menstruation in fleshy women. Profound, melancholic
delusion; feeling of moral deficiency; religious depression;
delusions of conspiracies against her.


• Oligomenorrhoea/ amenorrhea
• Infertility / first trimester miscarriage
• Obesity
• Hirsutism
• Acne
• Acanthosisnigricans
• Male pattern alopecia
Symptomatic assessment, Clinical Advice:

examination, laboratory investigations
for confirmation of diagnosis of PCOS.  Regular brisk walking for
45min daily for minimum five
days in week.
 Nutritionally adequate, low-fat
(approximately 30% of energy,
saturated fat approximately
Start Individualized 10%), moderate-protein
Homoeopathic Treatment (approximately 15%) and high-
and advice for life style carbohydrate dietary intake
modifications (approximately 55%), with
increased fiber-rich wholegrain
breads, cereals, fruits and
vegetables.
 Avoid junk food.
Look for: Follow up regularly  Weight loss exercise is
Establishing the advisable in obese patients.
menstrual
regularity with Each follow up-
either Symptomatic assessment,
ultrasonological Clinical examination
improvement of
PCO or
If no improvement
improvement in
hirsutism/ acne.
6th month –Symptomatic
assessment, Clinical Refer for appropriate
examination, Pelvic Usg., treatment

PSORIASIS
CASE DEFINITION
Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin
and joint manifestations. 1 It is characterized by well defined erythematous scaly plaques
which become silvery on attempt to scrape. 2
INCIDENCE 3
In India the prevalence of psoriasis varies from 0.44 to 2.8%, it is twice more common in
males compared to females, and most of the patients are in their third or fourth decade at the
time of presentation.
AETIOLOGY
Exact cause is not known. It is considered to be inherited as an autosomal dominant
condition with irregular penetrance. In psoriasis, the time taken for transfer of epidermal
cells from basal cell layer to outer surface of skin is drastically reduced from the normal one
month to 3-5 days. This results in the formation of immature epidermal cells which are shed
as scales.
It is known to be an autoimmune process with genetic predisposition. It is also known to be
associated with other autoimmune illnesses like sero-negative arthropathies.
Emotional stresses are known to be associated with triggering of or aggravating the
psoriasis, however their exact mechanisms are still not established.
TYPES 1
Classification is based on phenotyping. However, clinical findings in individual patients
frequently overlap in more than one category.
1. Plaque type psoriasis

Plaque psoriasis is the most common form, affecting approximately 80% to 90% of patients.
It manifests as well-defined, sharply demarcated, erythematous plaques varying in size from
1 cm to several centimeters
Patients may have involvement ranging from only a few plaques to numerous lesions
covering almost the entire body surface. The plaques are irregular, round to oval in shape,
and most often located on the scalp, trunk, buttocks, and limbs, with a predilection for
extensor surfaces such as the elbows and knees. Smaller plaques or papules may coalesce
1 Menter A, Gottlieb CA, Feldman SR., Voorhees ASV, Leonardi CL, Gordon KB, et al. Guidelines of care for the
management of psoriasis and psoriatic arthritis . J Am Acad Dermatol Volume 58(5): 826-850
2 Gupta R. Manchanda RK. Textbook of Dermatology for Homoeopaths. 3rd Edition. 2009. B Jain Publishers.
New Delhi. Pg 186- 190

3 Dogra S, Yadav S. Psoriasis in India: Prevalence and pattern. Indian J Dermatol Venereol Leprol [serial online]
2010 [cited 2015 Mar 20];76: 595-601. Available from:

http://www.ijdvl.com/text.asp?2010/76/6/595/72443
CCRH 1 Updated 10th Jul, 16

into larger lesions, especially on the legs and trunk. Painful fissuring within plaques can
occur when lesions are present over joint lines or on the palms and soles.
2. Inverse
Inverse psoriasis is characterized by lesions in the skin folds. Because of the moist nature of
these areas, the lesions tend to be erythematous plaques with minimal scale. Common
locations include the axillary, genital, perineal, inter gluteal, and inframammary areas.
3. Erythrodermic
Erythrodermic psoriasis can develop gradually from chronic plaque disease or acutely with
little preceding psoriasis. Generalized erythema covering nearly the entire body surface
with varying degrees of scaling is seen. Altered thermoregulatory properties of
erythrodermic skin may lead to chills and hypothermia, and fluid loss may lead to
dehydration. Fever and malaise are common.
4. Pustular
Pustular psoriasis maybe generalized or localized. The acute generalized variety (termed the
‘‘von Zumbusch variant’’) is an uncommon, severe form of psoriasis accompanied by fever
and toxicity and consists of widespread pustules on an erythematous background. Cutaneous
lesions characteristic of psoriasis vulgaris may be present before, during, or after an acute
pustular episode. There is also a localized pustular variant of psoriasis involving thepalms
and soles, with or without evidence of classic plaque-type disease.
4. Guttate
Guttate psoriasis is characterized by dew-drop like, 1- to 10-mm, salmon-pink papules,
usually with a fine scale. There is history of upper respiratory infection with group A beta-
hemolytic streptococci often preceding guttate psoriasis, especially in younger patients, by 2
to 3 weeks. This sudden appearance of papular lesions may be either the first manifestation
of psoriasis in a previously unaffected individual or an acute exacerbation of long-standing
plaque psoriasis
Based on area of affection psoriasis is reflected as:
Scalp psoriasis 4
Psoriatic lesions present on scalp, margin of scalp, occasionally extending to back of
neck or behind the ears. It may present as:
 Reddish patches on the scalp varying from barely noticeable to very noticeable, thick,
and inflamed patches.
 Dandruff-like flaking and silvery-white scale
 Dry scalp, which may be so dry that the skin cracks and bleeds.
 Itching is one of the most common symptoms.
 Bleeding, because lesions can be very itchy.
 Burning sensation or soreness in the scalp
4
American Academy of Dermatology- Psoriasis: Signs and symptoms 2015; US cited 13th Sept 2015] Available
at https://www.aad.org/dermatology-a-to-z/diseases-and-treatments/q---t/scalp-psoriasis/signs-symptoms
 Temporary hair loss - Scratching the scalp or using force to remove the scale can
cause hair loss. Once the scalp psoriasis clears, hair usually regrows.
Nail Disease (Psoriatic Onychodystrophy)

Nail psoriasis can occur in all psoriasis subtypes. Fingernails are involved in approximately
50% of all patients who are psoriatic and toenails in 35% of patients. 1 Characteristic
changes in the nail include multiple pin point pits on nail plates, separation of nail plate from
nail bed (called onycholysis, presenting as an area of yellowish discolouration), brownish
discolouration, thickening and irregularity of nail plate called onychodystrophy. 2
Psoriatic Arthritis
About 5% of people with psoriasis will develop arthritis, which is seronegative
oligoarthritis 5 commonly involving distal interphalangeal joints.2 In most cases, psoriasis
comes before the arthritis. Most of the time, people with psoriatic arthritis have the skin
and nail changes of psoriasis. Often, the skin gets worse at the same time as the arthritis.
In some people the disease may be severe and affect many joints, including the spine.
Symptoms in the spine include stiffness, burning, and pain. They most often occur in the
lower spine and sacrum. 6
DIAGNOSIS
The major manifestation of psoriasis is chronic inflammation of the skin. It is characterized
by disfiguring, scaling, and erythematous plaques that may be painful or often severely
pruritic and may cause significant quality of life issues. 1 Psoriatic plaques typically have a
dry, thin, silvery white scales, often modified by regional anatomic differences, and tend to
be symmetrically distributed over the body. 1
The patient may be asymptomatic, however, some patients may have lesions with severe
itching. They may tend to worsen during winters and improve or even clear in summers.
Spontaneous remission & relapses at variable intervals is frequent. 2
Clinical evaluation 7
For people with any type of psoriasis assess:
 disease severity
 the impact of disease on physical, psychological and social wellbeing
 whether they have psoriatic arthritis
 presence of comorbidities.
Assess the severity and impact of any type of psoriasis:

 at first presentation
5
Psoriatic Arthritis : Practice essentials 2014; New York: 2014 [cited 25th September 2015] Available at
6 Medical encyclopedia on Psoriatic arthritis ; U.S. National library of medicine [Updated 4/18/2014 , cited
25th September 2015] Available at http://www.nlm.nih.gov/medlineplus/ency/article/000413.htm

7 NHS. Psoriasis: The assessment and management of psoriasis. NICE clinical guideline 153. Issued: October
2012
 before referral for specialist advice and at each referral point in the treatment
pathway to evaluate the usefulness of interventions.
When assessing the disease severity, record:

 physician's Global Assessment
 patient's assessment of current disease severity
 body surface area (BSA) affected
 any involvement of nails, high-impact and difficult-to-treat sites (for example, the
face, scalp, palms, soles, flexures and genitals)
 any systemic upset such as fever and malaise
Physical examination 2
Grattage test: when an attempt is made to scrap the psoriasis plaque, it becomes
silvery. On further scraping a thin membrane of skin comes out resulting into
multiple pin point bleeding spots. This is known as Auspitz sign and the whole
process is called grattage test.
Investigations
In case where there is diagnostic uncertainty, skin biopsy is conducted to confirm the
diagnosis of psoriasis.
Co-morbidities 8
• Psoriasis may be an independent risk factor for myocardial infarction with the
greatest relative risk for young patients with severe disease.
• Several studies have shown an association between severity of psoriasis and
obesity
• Patients with psoriasis have an increased risk of metabolic syndrome and its
individual components.
• Psoriasis and psoriatic arthritis affect all aspects of quality of life with
potentially profound psychosocial implications. Long term psychological
distress can lead to depression and anxiety. Psoriasis may be associated with
increased smoking and alcohol consumption.
RED FLAG
• People with generalized pustular psoriasis or erythroderma should be referred
immediately
• Psoriasis is severe or extensive.
• Psoriasis is having a major impact on a person's physical, psychological or social
wellbeing.
8Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of psoriasis and psoriatic
arthritis in adults. Edinburgh: SIGN; 2010. (SIGN publication no. 121). [cited 20 March 2015].Available from
URL: http://www.sign.ac.uk
 Psoriasis Area and Severity Index9
 Nail Psoriasis Severity Index 10
 Dermatology Life Quality Index (DLQI)11 for adults or Children's Dermatology Life
Quality Index (CDLQI) 12 for children and young people
MANAGEMENT
Patient should be encouraged to expose to sunlight and avoid trauma during active
phase2. Discuss the condition and its treatment with the patient in detail. Information
giving is an integral part of any consultation.7
 Explain to patients what psoriasis is and how it is diagnosed
 Explain that psoriasis is not infectious and discuss the patient’s family history
 Explain the unpredictable but recurring nature of psoriasis and that flare-ups
can occur
 Emphasize to patients that psoriasis is a long term, relapsing condition but can
be managed with appropriate treatments
 Advise patients that referral to dermatology may be necessary when the
diagnosis is unclear or the disease is extensive.
 Emphasize the importance of reporting joint pain, swelling or stiffness for
further investigation
 If joint pain is present, explain to patients what psoriatic arthritis is
 Discuss the following quality of life issues whilst reassuring patients that these
issues may not be pertinent in every case
 skin pain and itch
 employment issues and managing treatments while at work
 possible stigma and impact on daily activities
 family life and relationships (including sexual relationships)
 emotional issues such as depression, anxiety and stress
 Make patients aware of the increased risk of co-morbidities, e.g.,
cardiovascular disease and the importance of regular check ups
 Discuss the following lifestyle factors in relation to co-morbidities of psoriasis
• smoking and how to stop smoking
• blood pressure control
• weight control
• alcohol advice
 Emphasize to patients that the aim of treatment is to reduce plaque size,
thickness and extent of scaling and thereby improve quality of life.
9 Psoriasis area and severity Index (PASI) Worksheet. British association of Dermatologists. Available at
http://www.bad.org.uk/shared/get-file.ashx?id=1654&itemtype=document
10 Rich P, Scher RK (2003) Nail Psoriasis Severity Index: a useful tool for evaluation of nail psoriasis. Journal of
the American Academy of Dermatology 49: 206–12.

11 Dermatology Quality of Life Index (DLQI). Department of Dermatology U.K. [cited 23 rd September 2015]
Available at http://www.dermatology.org.uk/quality/dlqi/quality-dlqi.html
12 Children’s Dermatology Life Quality Index (CDLQI). Department of Dermatology U.K. [cited 23 rd September
2015] Available at http://www.dermatology.org.uk/quality/cdlqi/quality-cdlqi.html

 Discuss the various treatment choices and ensure the patient is involved in the
decision making process. Explain the risks, side effects and benefits of
treatments to help patients make an informed choice.
 Discuss requirements for monitoring and assessment of ongoing disease
activity.
 Encourage patients to identify trigger factors if possible and develop coping
strategies for flare-ups.
Role of complementary and alternative therapies (CAM) in treatment of skin

conditions like Psoriasis is increasing amongst the masses. 13,14 Research studies and
case reports in the past throw light upon the beneficial role of Homoeopathy in these
cases.15 Psoriasis is a multi-systemic illness with varying locations, varying
expressions, varying state and stage of pathology with different rates of progress
either showing predominant skin symptoms or symptoms pertaining to nails, joints
or other systems. Apart from prescribing constitutional based on totality of
symptoms, certain specific remedies which are commonly prescribed are as follows:
Arsenicum iod ( Skin is dry, scaly, itching. marked exfoliation, in large scales with
debilitating night sweats), Kali ars.(Intolerable itching, worse on undressing, warmth,
change of weather. Dry scaly eruptions), Kali br.(, Natrum ars., Petr., Sars. (Eruptions
appear in spring and are worse in summers. dry itchy eruptions, cracked skin of
hands and feet. emaciation, white coated tongue), Calc sulph., Kali sulph. (Psoriasis of
scalp), Hepar sulph. are useful in pustular psoriasis, Hydrocotyle (circumscribed red
scaly lesions, with severe itching or pricking worse at night and after scratching ),
Castor equi for thickening of skin, psoriasis of tongue. Corrallium rubrum for
psoriasis of palms and soles. Cuprum aceticum for chronic psoriasis without itching,
generalized psoriasis and psoriasis in spots. Bryonia, Rhus tox, Phytolacca- d. and
Thyroidinum are used for psoriatic arthritis. Medorrhinum, Psorinum, Syphilinum,
Thuja and Tuberculinum are useful as intercurrent remedies. Other useful drugs
include Astr., Aur- m-n, Mang., Merc. C., Muriatic acid, Naphth., and Ustaligo.2
Indications of some important remedies are given below for glimpse 16,17
13 Ben-Arye E, Ziv M, Frenkel M, Lavi I, Rosenman D Complementary medicine and psoriasis: linking the
patient's outlook with evidence-based medicine. Dermatology. 2003;207 (3):302-7
14 Smolle J. Homeopathy in dermatology. Dermatol Ther. 2003;16(2):93-7
15 Witt CM, Lüdtke R, Willich SN Homeopathic treatment of patients with psoriasis--a prospective
observational study with 2 years follow-up. J Eur Acad Dermatol Venereol. 2009 May; 23 (5):538-43. doi:
10.1111/j.1468-3083.2009.03116.x. Epub 2009 Feb 2
16 Allen HC. Allen’s Keynotes- Rearranged and classified with leading remedies of the materia medica and

17 Boericke W. Boericke’s New Manual of Homoeopathic Materia Medica with Repertory: Third Revised &

1. Arsenic Skin itching, burning, dry, rough, and scaly. Worse cold
album and scratching. The lesion may also have oedema,
redness, excoriations, crusting. Sleep is disturbed
anxious, restless. Disposition include Depression,
melancholia, despair, indifference, anxiety, fear,
restlessness, anguish or irritability sensitiveness, and
peevishness. Marked prostration with fainting, mental
restlessness, burning pain better by heat, night
aggravation and offensive discharge are the leading
indications.
2. Borax Psoriasis with unhealthy skin with tendency for easy
suppuration. The hair is untidy, dirty, tangled, split, sticks
together at tips and cannot be combed smoothly. The
eyelashes are loaded with dry gummy exudation
agglutinated in morning and turns inwards. Used in
highly nervous constitutions who get frightened easily
from downward motion, rocking, dancing, swinging etc.
and are sensitive to noise, sharp sound, cough, sneeze
and cry.
3. Calcarea Skin is unhealthy readily ulcerating; flaccid. These
carbonica persons have great apprehension and fear that people
will observe their confusion, are sensitive to hearing
about accident, cruelties, riots, etc. Profuse sweating
from head while sleeping, desire for eggs, feeling better
when constipated are the leading indications.
Leucophlegmatic constitution.
4. Fluoric Itching especially of the orifices and in spots, worse
acidicum warmth. Profuse, sour, offensive perspiration. Nails grow
rapidly. Young persons with great ability to exercise
without fatigue and is sensitive to extremes of
temperature and worse from warmth.
5. Graphites Unhealthy skin, eruptions on ears, between fingers, toes
or other skin folds. Cracks, fissures at tips of fingers,
nipples, labial commissures, anus and between toes.
Rough, hard persistent dryness of portions of skin.
Chilly individual, constipated, sad, despondent.
6. Lycopodium Skin with thickening, indurations, brown spots on face,
clavatum fissures, pre-mature graying of hair. Violent itching
worse on warm application. Viscid and offensive
perspiration, especially of feet and axilla. Complexion is
pale, dirty, unhealthy, sallow with deep furrows and
senile look. Intellectually keen, but physically weak,
upper part of body emaciated, lower parts dropsical,
having deep seated progressive chronic diseases. Person
predisposed to gastric affections.
7. Mercurius Itching or burning pains worse at night. Lesions with
solubilis suppurations. Profuse sweating without any relief, thick
very offensive acrid discharge, large flabby, thickly
coated tongue, internal chilliness, tendency for diarrhea
with slimy stools and offensive breath are the general
indications.
8. Natrum Greasy, oily, especially on hairy parts. Dry eruptions on
muraiaticum margin of hairy scalps. Itch and burn, crusty eruptions in
bends of limbs, margin of scalp behind ears. Anaemic,
cachetic, emaciated subjects resulting from loss of fluid
or mental stress, emaciation marked around neck.
Awkwardness, abruptness, irritable, weeping disposition
which are aggravated by consolation and complaints
precipitated after grief are the characteristics mental
symptoms. Desire for excessive salt, dry, geographical
tongue, sweats while eating and aggravation at the sea
shore and sunlight; better in open air are leading
symptoms.
9. Petroleum Skin dry, constricted, very sensitive, rough, cracked,
leathery. Psoriasis of hands. Skin symptoms worse in
winters. Itching worse at night, painful sensitiveness of
whole body.
10. Phosphorus Dandruff, hair fall in bunches, formication, itching,
burning, ecchymosis, scaly lesions over various parts of
body, including eyebrows. Brown spots on face. Skin is
fair and delicate. Suited to tall, slender, stoop shouldered
persons of sanguine temperament. Very sensitive,
sympathetic, nervous and weepy with depressed spirits,
palpitation. Desire for juicy, refreshing, cold food and
drinks.
11. Sepia Ring shaped lesions on upper part of body, appearing in
spring, itching worse on elbows and knee, hyper-
pigmented spots over face. Great sadness, weeping,
indifference to loved ones, yellow saddle across upper
part of cheeks and nose. Intolerable, offensive, profuse
sweat. Worse after washing, exposure to cold air, better
from warmth of bed, hot application and violent
exercise.
12. Staphysagaria Itching changing location after scratching, thick scabs.
Hyper sensitive to mental impressions, irritability,
Ailments from stress due to indignation, insult and
reserved displeasure.
13. Sulphur Dirty, filthy skin, excessive burning all over, marked
itching, wants to scratch, burning after scratching.
Eruptions dry, scaly, pustular, cracks and excoriations in
skin folds. Relapsing complaints. Lean, stoop shouldered
and scrofulous persons, nervous temperament, cannot
stand for a long time, marked aversion to bathing.

Well defined erythematous

Scaly plaques with silvery scalps
Assess for body

surface area
(BSA)
Extensive BSA fever chills

No fever chills
Erythematous psoriasis or
Psoriasis generalized pustular psoriasis
confirmed
Refer
No Yes
Referral Criteria:
 Fever
Advice skin biopsy Examine  Chills
 BSA  Erythematous psoriasis
 Nails  Very extensive BSA
 Scalp involvement
 Joints
Start homoeopathic treatment Provide information
Follow up at least once a month for 6 months
At each follow up assessment change in BSA involvements
Continue treatment and check for resolution

RHINITIS
CASE DEFINITION
Rhinitis is inflammation of the mucous membrane lining of the nose, characterized by nasal
congestion, rhinorrhea, sneezing, itching of the nose, and postnasal drainage1.
INCIDENCE
 Coryza can occur throughout the year.

 Young children have an average of six to seven colds per year but 10-15% of
children can have upto12 infections per year or even more.
 In India, 1 out of every 6thperson has allergic rhinitis2.
 Symptoms of cold usually resolve after about one week, but can last up to 14 days,
with cough and nasal stuffiness lasting longer than the other symptoms.
AETIOLOGY
Rhinitis especially acute may be caused by various factors like: Viral (adeno, picorna and
its sub groups such as rhinovirus, coxsackie, ECHO, Influenza viruses-H1N1, H2N2, H5N1
etc., B or C; Bacterial (pneumococcus, streptococcus, staphylococcus, Moraxella
catarrhalis) and some Irritative agents like dust, smoke, irritative gases.3,4
Recurrent attacks of acute rhinitis in the presence of predisposing factors leads to
chronicity. These factors include: persistence of nasal infections due to sinusitis, tonsillitis
and adenoids; irritation from dust, smoke, cigarette smoke, industrial irritants; prolonged
use of nasal drops; endocrinal or metabolic factors like hypothyroidism, lack of exercise;
genetic predisposition; racial dominance; emotional upsets; nutritional deficiency of
vitamin A , D and iron; autoimmunity; exposure to hot, dry, dusty environments.
Rhinitis may also be caused by exposure to allergens like pollen from trees and grasses,
mold spores, house dust, debris from insects or house mite in patients with a genetic
predisposition. Risk factors for allergic rhinitis include a family history of atopy, serum
IgE>100 IU/mL before age of 6 years, higher socioeconomic class, and presence of a
positive allergy skin prick test.
1
Dykewicz MS, Fineman S, eds. Diagnosis and management of rhinitis: complete guidelines of the joint task
force on practice parameters in allergy, asthma, and immunology. Ann Allergy Asthma Immunol1998;
81:478–518.
2 Sukumaran TU; Allergic Rhinitis and Co-morbidities: Training module (ARCTM). Indian Pediatr 2011; 48:
511-513.
3Dhingra PL & S; Diseases of Ear, Nose and Throat; 5 th Edition; Elsevier, A division of Reed Elsevier India
Private Limited; New Delhi; 2010: 168.

4Faltz P, founding authors; Becker W, Naumann HH, Rudolf C; Ear, nose, and throat diseases: with head and
neck surgery (3rd ed ed.). Stuttgart: Thieme. (2009). p. 150.

DIAGNOSIS 3,5,6
TYPES DIAGNOSIS
CLINICAL PRESENTATION PHYSICAL EXAMINATION FINDINGS INVESTIGATIONS
ACUTE RHINITIS • Burning sensation at the back of nose • Nasal mucosa is pale in color. -
1. Viral • Tickling sensation in nose • Turbinates may be swollen
Common cold • Sneezing
Influenzal Rhinitis • Running nose initially this is watery and profuse but may become
Rhinitis associated with mucopurulent due to secondary invasion.
exanthemas • Nasal stuffiness/ congestion Cough
2. Bacterial • Postnasal drainage
3. Irritative • Headache
• Loss of smell
• Low grade fever
CHRONIC RHINITIS • Nasal obstruction • Nasal mucosa is dull red in color In children with rhinitis,
1. Chronic simple Rhinitis • Nasal discharge: mucoid, mucopurulent, thick, viscid • Swollen turbinates which pit on pressure and shrink with the use of immune studies,
2. Hypertrophic Rhinitis • Post nasal drainage application of vasomotor drops (Chronic simple Rhinitis), donot pit sweat test, sinus computed
3. Atrophic Rhinitis • Foul smell from nose with marked anosmia (Atrophic Rhinitis) esp. on pressure (Hypertrophic Rhinitis) tomography (CT), and
4. Rhinitis sicca seen in females of pubertal age group • Hypertrophy of turbinates nasal endoscopy may be
5. Rhinitis caseosa • Nasal obstruction even with unduly wide chambers(Atrophic • Greenish or grayish black crusts in the cavity which cause bleeding indicated when they are
Rhinitis) on attempt to remove (Atrophic Rhinitis) suspected to have
• Unilateral affections with discharge of cheesy offensive material • Atrophy of nasal turbinates with unduly wide chambers (Atrophic comorbid conditions such
from nose (Rhinitis caseosa) Rhinitis) as immune deficiency,
• Impairment in hearing tests cystic fibrosis (CF), and
• Small and underdeveloped paranasal sinuses with thick walls chronic sinusitis.
(Atrophic Rhinitis)
• Removal of crusts causes ulceration, epistaxis and even perforation.
ALLERGIC RHINITIS  No age or sex predilection. May start in infants as young as 6  Nasal signs: transverse nasal crease; swollen turbinates; presence  CBC : reveals
months or older people. Usually the onset is at 12-16 years of age. of thin, watery, mucoid discharge. eosinophilia
 Seasonal nasal allergy presents as paroxysmal sneezing, 10-20  Ocular signs: oedema of lids, cobblestone appearance of  Nasal smear : reveals
sneezes at a time, nasal obstruction, watery nasal discharge and conjunctiva, dark circles under the eyes (allergic shiners). eosinophils
itching in nose.  Otologic signs: retracted tympanic membrane or serous otitis media  Skin test to identify
 Perennial nasal allergy isn’t that severe. Present as frequent colds, as result of eustachian tube blockage. allergen
persistently stuffy nose, and loss of sense of smell due to mucosal  Pharyngeal signs: granular pharyngitis due to hyperplasia of  Radioallergosorbent test
oedema, post nasal drip, chronic cough and hearing impairment. submucosal lymphoid tissue. (RAST): measures IgE
 Laryngeal signs: hoarseness of voice, oedema of vocal cords. antibody in the patient’s
serum.
VASOMOTOR RHINITIS  Paroxysmal sneezing: Bouts start just after getting out of bed in the Nasal mucosa over the turbinates is generally congested and
morning. hypertrophic. May be normal in some cases.
 Excessive rhinorrhoea
 Nasal obstruction: which alternates from side to side
 Post nasal drip
5CCRH; Homoeopathy for Mother and Child Care (Pediatrics); Training Manual Vol.2; Reprint Edition; Central Council for Research in Homoeopathy,
New Delhi; 2010:80-83.
6Wallace DV, Dykewicz MS, Bernstein DI, Moore JB, Cox L, Khan DA. The diagnosis and management of rhinitis: An updated practice parameter; J Allergy
Clin Immunol 2008; 122 (2): Supplement: S1–S84.

COMPLICATIONS 3
 Recurrent sinusitis
 Nasal polypi
 Serous otitis media
 Orthodontic problems or other ill effects of prolonged mouth breathing
 Bronchial asthma
 Measles
 Bronchiolitis
 Pneumonia
 Whooping cough
 Acute bronchitis
 Acute rhinitis symptoms score (ARSS) developed by the Central Council for
Research in Homoeopathy7.
 Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ)8
MANAGEMENT
Acute rhinitis is a common disorder which seen by the physician in their day to day
practice. Effectiveness of homeopathy can be supported by clinical evidence and
professional and adequate application be regarded as safe.9 Numerous clinical studies
demonstrate that homeopathy accelerates early symptom relief in acute illnesses at much
lower risk than conventional drug approaches. Clinical research in homoeopathy suggests
that over the-counter homeopathic medicines offer pragmatic treatment alternatives to
conventional drugs for symptom relief in children with uncomplicated URIs10. Several
researches on this condition and other associated conditions such as allergies, rhinitis,
7Nayak C, Singh V, Singh K, Singh H, Oberai P, Roja V, et al. A multi-centric open clinical trial to evaluate the
usefulness of 13 predefined homeopathic medicines in the management of acute rhinitis in children. Int J High
Dilution Res [online]. 2010 [cited 2015 Nov 6]; 9(30):30-42.
8 Juniper EF, Guyatt GH, Griffith LE, Ferrie PJ. Interpretation of rhinoconjunctivitis quality of life questionnaire
data. J Allergy ClinImmunol 1996; 98: 843-845.

9Bornhoft G, Wolf U, Ammon Klaus v, Righettic M Bergemann SM et al. Effectiveness, Safety and Cost-
Effectiveness of Homeopathy in General Practice – Summarized Health Technology Assessment.

ForschKomplementärmed 2006;13(suppl 2):19–29
10Bell IR. Homeopathic Medications as Clinical Alternatives for Symptomatic Care of Acute Otitis Media and
UpperRespiratory Infections in Children. Global Advances in Health And Medicine 2013;2(1):32-43

acute respiratory complaints have been treated successfully with homeopathy7,11,12,13,14
,15,16,,17. Apart from medicinal management the following general advice to the patients
should be given 3,5,6
 Avoid exposure to cold weather or intake of cold food

 Avoid common allergic triggers for rhinitis which include pollens, fungi, dust mites,
furry animals, and insect emanations.
 Avoid outdoor activities in morning and evening as pollen levels due to high pollen
levels.
 Reduce indoor fungal exposure by removal of moisture sources, replacement of
contamination materials.
 Older children should use handkerchief while coughing, sneezing and blowing the
nose.
 Encourage hand-washing as it minimizes person to person transmission of the virus.
 Advice for adequate rest, fluid and good nutrition
 Advice steam inhalation.
Around 402 medicines are enlisted in the reportorial index18 under the symptom coryza.
The presenting totality of symptoms in each case is the guide to the correct remedy.
However, there are several specific medicines for allergic rhinitis such as Ambrosia
Artmisiae folia: allergic rhinitis with intolerable itching in eyes lids; Wyethia helenoids:
Itching of throat nose and palate; constantly clearing and hemming the throat, nose feels
dry and irritated but still be running; Eucalyptus globulus: stuffed up sensation in nose,
thin watery coryza, continuous running of nose; Solidago: Rhinitis excited by pollens,
burning in throat, repeated colds after tuberculosis. Enlisted below are few medicines with
their indications recommended from experiences, research papers and text books.
11Haidvogl M, Riley DS, Marianne H et al.Homeopathic and conventional treatment for acute respiratory and
ear complaints: A comparative study on outcome in the primary care setting; BMC Complementary and
Alternative Medicine; 2007. 7:7 [doi:10.1186/1472-6882-7-7].
12Colin P. Homeopathy and respiratory allergies: a series of 147 cases; Homeopathy 2006, 95( 2): 68-72
13 Allen TF. Encyclopedia of Pure Materia Medica. B Jain Publishers, New Delhi
14Taylor R D, Morgan T, Beattie NGM, Cambell J H, McSharry C. Aitchinson T et al. Is evidence for
Homoeopathy reproducible? The Lancet 1994; 344 (8937):1601-1606.
15 Van Wassenhoven M. Clinical verification in homeopathy and allergic conditions. Homeopathy. 2013 Jan;
102 (1):54-8. doi: 10.1016/j.homp.2012.06.002.
16Goossens M, Laekeman G, Aertgeerts B, Buntinx F; ARCH study group. Evaluation of the quality of life after
individualized homeopathic treatment for seasonal allergic rhinitis. A prospective, open, non-comparative
study.Homeopathy. 2009 Jan; 98 (1):11-6. doi: 10.1016/j.homp.2008.11.008.
17 Rossi E, Crudeli L, Endrizzi C, Garibaldi D. Cost-benefit evaluation of homeopathic versus conventional
therapy in respiratory diseases.Homeopathy. 2009 Jan; 98 (1):2-10. doi: 10.1016/j.homp.2008.11.005.
18Zandovoort R. Complete Repertory. In Shah J Hompath [CD Rom]. 2000-2005

1. Allium Rhinitis especially in August every year; Nasal discharges
cepa watery, copious, acrid and excoriates upper lip with bland
lacrimation. Cold begins from right side and travels to left.
Burning sensation in eyes as from smoke, must rub them.
Constant sneezing on entering warm room. Canine hunger;
salivation increased, worse: in cold damp weather, in warm
room.
2. Euphrasia Profuse acrid lachrymation but bland coryza. Margins of
eyelids red, swollen and burning. Frequent inclination to
blink. Chilly patient cannot get warm in bed, subjects to cold
that affect the eyes, worse: in evening, indoors and from
warmth, better: in open air.
3. Nux Coryza fluent in morning or day; stuffed up at night and
vomica outdoors; or alternates between nostrils; crawling and
tickling inside the nose which causes sneezing. Worse:
warm room, better: open air. Chilly patient; thin, dark
complexion; spare, quick, active; prone to indigestion and
hemorrhoids; sedentary lifestyle; tongue coated yellowish
in the posterior part; desire for stimulants; nervous
disposition; oversensitive to external impressions, to noise,
odors, light or music,etc.; zealous and irritable, impatient,
spiteful with violent action; ardent nature.
4. Dulcamara Dry coryza renewed by slightest exposure, worse after
getting wet, in the open air and at night. Summer colds.
Running of nose, sneezing and nasal obstruction,worse: in
the rainy weather, crawling and tickling inside the nose,
itching in both eyes worse in open air. H/o exposure to
damp, rainy weather or dwelling in the damp place.
5. Pulsatilla Coryza withnasal discharge thick, mucopurulent, yellowish
nigricans or yellowish-green; large green fetid scales in the nose;
stoppage of nose in the evening; thick discharge in the
morning and thin discharge in the evening, nasal discharges
bland and never irritating; loss of taste and smell.Worse: in
warm room, evening. Better: in open air; Hot patient,
marked changeability of symptoms; thirstlessness with
great dryness of mouth, tongue coated yellow or whitish;
discharges thick, bland, and yellowish-green, worse in
evening and warm room, better from open air, by slow,
gentle motion and cold applications.; desires for company,
mild, gentle, affectionate, yielding, weeping disposition.
6. Chamomilla Congestion of the nasal mucosa, thin, watery, bland, copious

discharge with occasional sneezing, worse: at night, open
air. Fever with irritability, restless, crying always, easily

annoyed, better by carrying.Capricious, irritable,
quarrelsome, nothing pleases. Asks for something then
rejects it. Sensitive to pain, moaning and frenzied; Better
when carried. Chilly patient, complaints during dentition.
One cheek red, other pale, hot, thirsty for cold drinks. Worse
evening, until midnight.
7. Hepar Extremely chilly patient, hypersensitive (to cold, pain),
sulphuris faints easily, Yellowish acrid, scanty, nasal discharge, worse:
in cold, uncovering, better: by warm, heat sneezing, nasal
obstruction, itching in throat with fever. Sensitive, Irritable,
difficult to please.
8. Mercurius Discharge watery yellowish, acrid, sneezing, nasal blockage.
solubilis All symptoms are worse at night, from warmth of bed, from
damp, cold, rainy weather, worse during perspiration.
Sensitive to change of temperature, profuse offensive
perspiration, tongue flabby with imprint of teeth, increased
salivation, increased thirst. Fearful, shy, hurried, violent,
impulsive, weak memory, nervous and irresolute.
9. Kalium Sneezing worse in early morning nasal obstruction,
bichromicum yellowish, stringy, sticky nasal discharge.
Chilly patient, susceptible to cold, fat, chubby, short necked,
shifting pains, complaints occurring in hot weather,
aversion and intolerance to meat, desires sour things.
10. Arsenicum Thin, watery, irritating discharges from nose, stuffed nose
album with frequent sneezing, worse in open air. Winter colds.
Anxiety, anguish and restless. Chilly patient, rapid
disproportionate prostration, increased thirst, drinks often
but little at a time.
11. Sabadilla Coryza, with severe frontal pains and redness of eyes and
lachrymation. Copious, watery, nasal discharge. Spasmodic
sneezing, with running nose. Worse: from cold and cold
drinks. Better: from warm food and drink, wrapped up.
12. Arum Coryza, acrid nasal discharges with raw nostrils and
triphyllum upper lip. Constantly boring and picking at the nose or lip
until it bleeds; although the child screams but continues
tobore the nose. Raw and sore throat; painful on clearing or
coughing. Cold associated with aphthae and cracked sore
corners of mouth. Sneezing, worse :at night. Nose feels
stopped in spite of watery discharges.
13. Arsenicum Coryza burning and acrid. Thin, watery, irritating and
iodatum excoriating discharges from anterior and posterior nares.
Irritation and tingling in nose with constant desire to
sneeze, which aggravates. Marked itching and burning in
nose. Worse: from tobacco; smoke. Better: in open air.

14. Kalium Red, swollen. Tip of nose red; profuse, acrid, hot, watery,
iodatum thin discharge. Accumulation of very tenacious mucus in the
throat. Worse from heat, night damp, changing weather,
cold air. Better: open air.

 Sneezing
 Running nose initially which is watery and profuse but may become
mucopurulent due to secondary invasion
 Burning sensation at the back of nose
 Nasal stuffiness/ congestion
 Post nasal discharge
 Headache
 Tickling sensation in nose
 Cough
On Examination:
 Nasal cavity: swollen erythematous nasal turbinates
 Nasal mucosa is pale/red
 Presence of crusts
 Post nasal drip
 Otologic signs, ocular signs, laryngeal, pharyngeal signs in allergic rhinitis
Symptoms of cold usually resolve after about one week, but can last up to 14 days, with
a cough and nasal stuffiness lasting longer than the other symptoms
Advise:
Start homoeopathic treatment and  Avoid exposure to cold weather or intake of
Advice for general management
cold food
 Avoid common allergic triggers for rhinitis
which include pollens, fungi, dust mites,
furry animals, and insect emanations.
Follow up
 Avoid outdoor activities in morning and
evening as pollen levels due to high pollen
levels.
NO YES  Reduce indoor fungal exposure by removal
Improvement of moisture sources, replacement of
contamination materials.
 Older children should use handkerchief
while coughing, sneezing and blowing the
nose.
 Encourage hand-washing as it minimizes
person to person transmission of the virus.
Check for other conditions Stop treatment  Advice for adequate rest, fluid and good
that mimic cold nutrition
 Foreign body in nasal  Advice steam inhalation.
passage
 Sinusitis
 Measles
 Otitis media
 Bronchiolitis
 Pneumonia
 Whooping cough
 Acute bronchitis
SINUSITIS
CASE DEFINITION
Sinusitis is an inflammation of the mucosa lining the paranasal sinuses. The medical term is
"rhinosinusitis" ("rhino-" meaning "nose"), because it affects the mucous membranes lining
the nose and the sinuses (which are air-filled spaces located behind the forehead, nasal
bones, cheeks, and eyes in the skull)1.
AETIOLOGY
A. Exciting Causes
 Nasal allergies
 Nasal infections
 Swimming and diving
 Trauma
 Dental infections
B. Predisposing causes2,3,4
1. Local:
 Obstructionof the sinus ostia
 Nasal Packing
 Deviated nasal septum
 Hypertrophic turbinates
 Nasal polypi
 Benign or Malignant neoplasm.
 Congenital anatomical abnormality of the nose and sinuses causing inflammatory
edema of the sinus mucosa as from common cold,
 Decreased mucociliary activity.
2. General:
a) Environment: Sinus is common in cold and wet climate. Atmospheric pollution,

smoke, dust and overcrowding also predispose to infection.
1 Fact sheet: Acute sinusitisInformed Health Online [Internet] [cited 23rd August 2015] Available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0005171/
2Dhingra PL & S; Diseases of Ear, Nose and Throat; 5 th Edition; Elsevier, A division of Reed Elsevier India
Private Limited; New Delhi; 2010: 208

3Sande MA and Gwaltney JM; Acute Community-Acquired Bacterial Sinusitis: Continuing Challenges and
Current Management; CID 2004:39 (Suppl 3):151

4 Sharma SR, Murty KB, Sahagal GC et al; Clinical Evaluation of homoeopathic medicines in sinusitis; IJRH
(2008), Vol.2, No. 1: 26-37

b) Poor general health: Recent attacks of exanthematous fever (like measles,
chickenpox, whooping cough etc.), nutritional deficiency, systemic disorder
(diabetes, immune deficiency syndromes)
c) Hereditary.
The underlying causes of acute sinusitis are diverse and include viruses, bacteria, fungi,
and allergies. Viral infections are a common cause of acute sinusitis5. Most individuals
resolve the infection spontaneously and only a small proportion develops a secondary
bacterial infection. Acute bacterial rhino sinusitis (ABRS) is generally diagnosed in the
presence of more than 7-10 days of nasal discharge. The most common bacteria are
Streptococcus pneumonia, Haemophilusinfluenzae, Moraxellacatarrahlis, Group A beta-
hemolytic streptococci and Staphylococcus aureus. Anaerobes predominate in rhino
sinusitis of dental origin, and fungi and Pseudomonas aeruginosa in
immunocompromised patients6.
INCIDENCE7,8
 The incidence of acute sinusitis ranges from 15 to 40 episodes per 1000 patients per
year;it is much more common in adults than it is in children, whose sinuses are not
fully developed.
 Maxillary sinusitis is the most common type of sinusitis, followed by ethmoidal,
frontal and sphenoidal sinusitis.
 Dental infection may cause 5-10% of cases of maxillary sinusitis.
RISK FACTORS9
• Allergic rhinitis or hay fever
• Cystic fibrosis
• Going to day care
• Diseases that prevent the cilia from working properly
• Changes in altitude (flying or scuba diving)
• Large adenoids
• Smoking
• Weakened immune system from HIV or chemotherapy
5Sande MA and Gwaltney JM; Acute Community-Acquired Bacterial Sinusitis: Continuing Challenges and
Current Management ;CID 2004:39 (Suppl 3):151
6 Brook I. Acute Sinusitis; Antimicrobe 2010; USA: 2010 [cited 23rd August 2015] Available at
http://www.antimicrobe.org/e2.asp#top
7 Worrall G.; Acute sinusitis; Can Fam Physician. May 2011; 57(5): 565–567
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093592/
8 CCRH; Homoeopathy for Mother and Child Care; Training Manual Vol.2; Reprint Edition; Central Council for
Research in Homoeopathy, New Delhi; 2010:84-87.

9 Medical encyclopedia of Sinusitis,U.S. National library of medicine [Updated 4/18/2014 , cited 25 th
September 2015] Available athttp://www.nlm.nih.gov/medlineplus/ency/article/000647.htm

TYPES
There are two types of sinusitis:
 Acute sinusitis is when symptoms are present for 4 weeks or less. It is caused
by bacteria growing in the sinuses.
 Sub-acute is when the symptoms last for 4-8 weeks.
 Chronic sinusitis is when swelling and inflammation of the sinuses are
present for longer than 3 months.
 Recurrent sinusitis is when there are several attacks within a year.
SYMPTOMS9, 10
The symptoms of acute sinusitis in adults very often follow a cold that does not get
better or that gets worse after 5 - 7 days. Symptoms include:
• Symptom of common cold persist beyond 10 days
• Nasal stuffiness and discharge
• Facial pain on pressure is felt depending on sinus involved:
 Maxillary sinus pain is often perceived as being located in cheeks or
upper teeth.
 Ethmoid sinus pain is perceived between the eyes or in retro-
orbital region
 Frontal sinus pain is perceived above the eyebrow
 Sphenoid sinus pain is felt in the upper half of the face or retro-
orbital radiating to occiput.
• Fever
• Headache
• Bad breath or loss of smell
• Cough, often worse at night
• Pressure-like pain, pain behind the eyes, toothache, or tenderness of the
face
• Sore throat and postnasal drip
• Fatigue and general feeling of being ill
Chronic rhino sinusitis (CRS)10refers to a condition when inflammation lasts twelve

(12) weeks or longer and causes atleasttwo or more of the following signs and
symptoms:
• Mucopurulent drainage (anterior, posterior, or both)
• nasal obstruction (congestion),
• facial pain-pressure-fullness, or
• decreased sense of smell
And inflammation is documented by one or more of the following findings:
10Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al; "Clinical practice
guideline: adult sinusitis". Otolaryngology--head and neck surgery: official journal of American Academy of
Otolaryngology-Head and Neck Surgery 137 (3 Suppl) (September 2007): pg1–31.

• purulent (not clear) mucus or edema in the middle meatus or ethmoid region,
• polyps in nasal cavity or the middle meatus, and/or
• radiographic imaging showing inflammation of the paranasal sinuses
• Recurrent acute rhino sinusitis Four (4) or more episodes per year.
Table: Major and minor clinical criteria suggestive of bacterial sinusitis 7
Major criteria Minor criteria

Facial pain or pressure (requires a second major criterion to Headache
constitute a suggestive history)
Facial congestion or fullness Fever (for subacute and chronic sinusitis)
Nasal congestion or obstruction Halitosis
Nasal discharge, purulence or discoloured postnasal drainage Fatigue
Hyposmia or anosmia Dental pain
Fever (for acute sinusitis; requires a second major criterion to Cough
constitute a strong history)
Purulence on intranasal examination Ear pain, pressure or fullness
* A strongly suggestive history requires the presence of two major criteria or one major and two or more minor criteria. A
suggestive history requires the presence of one major criterion or two or more minor criteria.
PHYSICAL EXAMINATION 7
Physical examination should include:

 A thorough and complete general and head and neck examination (including the
orbit, extra ocular motility, the response of the pupils, vision, and cranial nerve
function).
 Palpation and/or percussion over the frontal sinuses, cheeks (maxillary
sinuses), and medial orbit (ethmoid sinuses).
 The nasopharynx should be assessed for postnasal drip and obstruction caused
by adenoid hypertrophy, choanal atresia, malignancy, polyps, and septal
deviation.
 Nasal examination including anterior rhinoscopy with a good light source
looking for edema, erythema, crusting, purulent secretion, and presence of a
foreign body.
 Bend the patient’s head forward (when sitting) and holding it at knee level for
45–60 seconds can elicit a sensation of fullness and pain at the involved sites
(compliance in young patients may be difficult).
 Endoscopic examination performed by an otolaryngologist may localize pus
within the nasal cavity directing the examiner to the involved sinus(es);
bacterial cultures can also be obtained; however, the specimens may contain
nasal mucosal flora.
• Transillumination is infrequently utilized because the findings do not always

correlate with the disorder, and reproducibility between observers is poor.
Signs of sinus infection that can be observed by physical examination are:

• Mucopurulent nasal or posterior pharyngeal discharge.
• Erythematous nasal mucosa that can be pale and boggy.
• Signs of throat infection that can be associated with mal-odorous breath.
• Acute otitis media can be present in association with acute bacterial rhino
sinusitis.
• Facial tenderness is inconsistent and nonspecific.
• Periorbital edema with skin discoloration may be present, especially with
ethmoidsinusitis.
• Upper molar teeth pathology may be the source of maxillary sinusitis.
INVESTIGATIONS9
1.X-ray examination of Paranasal sinuses: Water’s view is taken for better

visualization of maxillary sinuses. Caldwell’s view is ideally suited for frontal
sinuses. Sub-mento-vertical view is ideally suited for Sphenoid sinuses. Lateral view
can help in distinguishing various pathologies of frontal sinuses. Oblique view helps
in demonstrating posterior ethmoidal air cells and optic foramen.
Following features indicate bacterial infection
 Radiologic opacity
 Air-fluid level
 Sinus mucosal thickening-more than 4 mm
2. Transillumination of the sinuses: Press a light source against the patient’s upper cheek,
close to nose. Ask the patient to open his mouth widely and look at his palate to see red
spot of light passing through in normal sinuses. No red dot or light would be seen if sinuses
are blocked.
3. CT of sinus is more sensitive particularly for ethmoid and sphenoid disease.
Imaging by X-ray, CT or MRI is generally not recommended unless complications develop14.
Imaging studies utilized for the diagnosis of acute bacterial rhino sinusitis. However, they
are non-specific and cannot differentiate viral from bacterial rhino sinusitis.Sinusitis
lasting more than 12 weeks (Chronic) a CT scan is recommended7, 14.
COMPLICATIONS10:
Although very rare, complications may include:
 Abscess

 Bone infection (osteomyelitis)
 Meningitis
 Skin infection around the eye (orbital cellulitis)
EVALUATION AND ASSESSMENT11
History7
Recorded medical history should include:
 History of upper respiratory allergies
 Previous episodes of sinusitis, and other respiratory tract infections
 Previous use of antibiotics
 Potential of nasal foreign bodies
 Having a child attend a day care center
 Immunizations; history of allergy
 exposure to cigarette smoke
The presence of any swelling and pain especially in the facial, forehead, temporal,
orbital area or any other site in the head should be noted. Information about what
makes the symptoms worse or better should be obtained. The length of symptoms
such as cough, nasal secretions, headaches, pain, fever, hyposmia, dental pain or
problems should be recorded.
Outcome test
Sino-nasal outcome test (snot-20) can be used to analyze the condition.

(www.northwestern-sinus.com/wp-content/uploads/2011/12/snot20.pdf
PREVENTION10
The best way to prevent sinusitis is:

 To avoid colds and flu or treat problems quickly.
 Eat plenty of fruits and vegetables,
 Reduce stress.
 Wash hands often, particularly after shaking hands with others.
 Avoid smoke and pollutants.
 Drink plenty of fluids to increase moisture in body.
 Take decongestants during an upper respiratory infection.
 Treat allergies quickly and appropriately.
 Use a humidifier to increase moisture in nose and sinuses.
 Breathing exercises and Yoga
RED FLAG
• High fever
Piccirillo Jay F, Sino-nasal outcome test (snot-20) ;Washington University School of Medicine, St. Louis,
11
Missouri available at http://www.northwestern-sinus.com/wp-content/uploads/2011/12/snot20.pdf

• Orbital infections like orbital cellulitis or orbital abscess which is indicated
by:
 Fever
 Erythema
 Conjunctival injection
 Chemosis
 Proptosis
 Ophthalmoplegia
 Diplopia
• Intracranial Complications like: Meningitis, subdural empyema, epidural
abscess and cerebral abscess
• Bony complications like: Pott’s puffy tumor, Osteomyelitis and Osteitis.
MANAGEMENT
Medicinal management when given along with the followingauxillary measures can help to
effectively manage acute attacks of sinusitis.9,10
 Drink plenty of fluids to thin the mucus

 Inhale steam 2 - 4 times per day
 Use nasal spray
Certain other measures when followed can further aid in managing the
conditionandprevent further attacks. These include:
• Intake of plenty of fruits and vegetables,
• Reduction of stress.
• Avoidance of smoke and polluted environments
• Prompt treatment of upper respiratory infectionsand allergies
• Practicing breathing exercises and Yoga
Homoeopathic medicines can help relieve symptoms of sinusitis and also reduce the
frequency of recurrence of attacks when prescribed a constitutional remedy after
complete case history and analysis and taking into account all the accessory
circumstances of the case.Few research studies show the beneficial role of
homoeopathic therapy in such cases. 12 , 13 , 14 Several medicines are given in the
12 Nayak Cetal. Homoeopathy in chronic sinusitis: a prospective multi-centric observational study.

Homeopathy. 2012 Apr; 101(2):84-91. doi: 10.1016/j.homp.2012.02.002
13.Sharma S.R, MurtyK.Bhanu, Sahagal G.C., Sharma Bindu,.BharatalaxmiK.S.V,.Raju K, Kumar S.Ravi. Clinical
evaluation of homoeopathic medicines in sinusitis. Indian Journal of Research in Homoeopathy Vol. 2, No. 1,
January-March 2008
14Ramteke Sunil S., Nayak C., Singh V, Oberai P, Roja V An open clinical observational study on the usefulness
of pre-defined homoeopathic medicines in the management of chronic sinusitis. Indian Journal of Research in
Homoeopathy Vol. 3, No. 1, January-March 2009

homoeopathic repertories for the condition; someare given under the peculiar sub-
rubrics which when found in a case shall indicate the required remedy. 27 medicines are
indicated in Murphy’s repertory, under the rubric “sinusitis, infection, nose”.15 In
Synthesis repertory,the rubric “sinuses of” (sinusitis) has 83 medicines.Indications of a
few specific remedies which may be found useful in cases of sinusitis with paucity of
symptoms include16:
Eucalyptus globulus- Chronic catarrhal, purulent and foetid discharge. Ethmoid and
frontal sinus involved,
Teucriummarumvarum- Chronic nasal catarrah with atrophy; large, offensive crusts
and clinkers, ozena, loss of sense of smell (anosmia).
The commonly indicated remedies with their indications are given below for a
glimpse. However, the present totality of symptoms in each individual case shall
always be the guide to the indicated remedy.

Affected from throbbing frontal right side headache with
congestion of face which is characterized by Sudden, violent
effects, bright redness, burning heat, throbbing pains,
1. Belladonna appear and disappear suddenly.Adapted to sensitive and
nervousperson. Bell Patient worse in afternoon (3 p.m.),
drafts, washing head, after taking cold. Better: light
covering, rest in bed, better in bending backward.
Stuffy coldsafter exposure to dry, cold atmosphere.
Nux patient worse in warm room. Stuffed up, at
night especially.Odors tend to produce fainting.
Coryza: fluent in daytime; stuffed up at night and
outdoors; or alternates between nostrils. Bleeding
2. Nux vomica in morning. Acrid discharge, but with stuffed up
feeling.Frontal headachewith desire to press the
head against something. Adapted to nervous
disposition, spare, quick, active, zealous and
irritable, impatient, spiteful with violent action.
Found useful in maxillary, frontal and fronto-

maxillary sinusitis. Nasal obstruction, worse
indoors and better inopen air.Headache, shifting
3. Pulsatilla
type, character of discharge may be thick, purulent,
greenish yellow catarrh.Low grade fever with
chilliness and thirstlessness. Patient will be worse
Murphy Robin Homoeopathic Medical Repertory. Third Edition. Lotus Health Publishers; 2005
15
16Boerick
W. Boericke’s New Manual of Homoeopathic MateriaMedica with Repertory: Third Revised &
Augmented Edition based on Ninth Edition. B. Jain Publishers, New Delhi; 2010

in evening and warm room and better from fresh
air.Pulsatilla patient is mild, gentle, affectionate,
yielding, weepy, clingy, and whiney.Changeable
moods. Needs attention and reassurance.
Sinusitis of allergic origin with patient being very

sensitive to cold. Acute sinusitis (frontal / fronto-
maxillary) becoming chronic with the passage of
time. Allergic rhinitis, sneezing culminating into
Hepar
5. sinusitis. Patient worse in dry, cold air, better in
sulphuricum
damp weather. Adapted to irritable, difficult to
pleaseextremely chilly patient, hypersensitive to
cold, pain, faints easily, sweats easily.
Chronic fronto-maxillary sinusitis withsupraorbital

headache, commencing in themorning around 9-10
a.m.and increases with sun.Bouts of sneezing and
lachrymation.Pain worse from reading, laughing
Natrum
6. and mentalexertion. Better in Open air, Cool
muriaticum
bathing, Sweating. Natrum mur patient is
melancholic, sad,irritable, cross. Disposition to
weep without cause, consolation aggravates.
Frontal sinusitis with pain in supraorbital region or

inner canthi of both the eyes and at the root of the
nose. Postnasal catarrh exciting cough, discharge
from nose relatively scanty but sticky, purulent,
yellow.Chilly patient, susceptible to cold,shifting
8. Kali bichromicum
pains, complaints occurring in hot weather,worse
from cold, damp, open air, morning, after sleep,2-3
a.m.Better from heat, motion. Adapted to
indolent,aversion to mental and physical labor.
Left sided chronic maxillary sinusitis, nasal

obstruction causing choking at night. Highly
offensive muco-purulent nasal discharge from left
nostril. Sometimes discharge is blood
stained.Mentally patient is loquacious, jumps from
9. Lachesis one idea to another, jealous, suspicious,
indolent.Other symptoms are Hot patient,
emaciated, hemorrhagic diathesis, great sensitive
to touch, hot flushes and perspiration, all
complaints are worse after sleep.
Calcarea Chronic sinusitis with thick yellow, lumpy, and

10.
sulphuricum bloody discharge.Tendency to suppuration.Mucous
discharges are yellow, thick and lumpy. Recurrent
or running abscesses. Better from open air, bathing,
eating, local heat, uncovering. Worse from drafts
touch, cold, wet, heat of room.
Catches cold frequently. Often used as specific
medicine in case ofsinusitis.Prescribed in chronic
sinusitis with nasalobstruction, resulting in post
nasal catarrh, thedischargebeing yellowish, muco-
11. Natrum arsenicum
purulent withinvolvement ofpharynx i.e.
pharyngeal congestion.Worse in damp cold
weather.Easily excited, Mental exertion makes the
symptoms worse.
Frontal sinusitis, pain worse at night with nasal
obstruction. Fever associated with sweat, chilliness,
worse at night.Pain and swelling of nasal bones, and
caries, with greenish fetid ulceration.Sensitive to
change of temperature, profuse offensive perspiration,
tongue flabby with imprint of teeth, increased salivation,
13. Mercuriussolubilis
increased thirst. All symptoms are worse at night, from
warmth of bed, from damp, cold, rainy weather, worse
during perspiration.Mentally patients is fearful, shy,
hurried, violent, impulsive, weak memory, nervous and
irresolute.
Nasal bone painful when touched, in nasal bones

soreness as if beaten.Gnawing pains (and ulcers) in
upper part of nose, with heaviness when stooping, and
excessive sensibility to contact and pressure.
Uncovering the head aggravates catarrhal
symptoms and those pertaining to head.Extremely
14. Silicea
chilly patient, profuse offensive discharges. Sweat
profuse especially on feet, easy suppuration, glandular
affinity, large head and distended abdomen.Silicea
patient is Obstinate, headstrong, nervous,
oversensitive, irritable and fearful.
Ozæna, with profuse, offensive yellowish discharges

may be associated with nasal polyp.Periodical sick
headache; pain begins in occiput, spreads upwards,
Sanguinaria
15. and settles over eyes, especially right. Worse from
canadensis
with sun, weekly,night,Climaxis,odors.Is a right-sided
remedy pre-eminently, and affects chiefly the mucous
membranes, especially of the respiratory tract.

Stoppage and dryness of anterior nose, with copious
discharge of whitish and yellowish mucus from
posterior nares. Frequent sneezing; discharge of
bloody mucus which is at one time white, at another
16. Spigelia
time yellow, is discharged from nose.Worse:touch,jar,
periodically, with the sun,better:lying on r. side, with
head high.
Sneezing; fullness at root of nose. Dryness of nasal

fossæ,swelling of turbinates,watery, excoriating
discharge. Acute coryza, with dull headache and fever
17. Gelsemium may be associated with Heaviness of head; band-
feeling around and occipital headache.Worse
fromweather, spring, foggy, humid, muggy, heat of
summer.
Increased secretion of mucus, with frontal headache
secretion of mucus from nose, viscid, yellow-green.The
nose, which used to feel "hot and burning," has lost
18. Tuberculinum this sensation.Worse:close room, weather: damp
(cold), before a storm; standing; dampness; from
draught; early morning, and after sleep. Better, open
air.
Constant discharge of thick white mucus; frontal
headache.Secretion runs more from posterior nares,
Hydrastis
19. thick and tenaciousDull, heavy frontal headache over
canadensis
eyes; catarrhal. Worse: air, inhaling, cold, dry winds,
open.
Pressure or stuffy fullness at root of nose; blows it
without relief.Constant need to blow nose, but no
result on account of dryness. Excessive and painful
Sticta
20. dryness of mucous membrane; secretions dry rapidly,
pulmonaria
forming scabs difficult to dislodge.Worse: night, lying
down,change of temperature better:free discharges,
open air.
Nose; heavy pressure at root; < pressure of glasses;
discharges foul, acrid, burning serum or dark lumps.
Dry mouth, wakes from sleep. Hawks down stringy
21. Cinnabaris
mucus or lumps of mucus drop from posterior
nares.Naso-pharyngeal catarrh.worse:Touch, light,
Dampness. Better:open air, sunshine.

Nose ulcerated, painful, swollen, obstructed.
Inflammation of nose; caries; fetid discharge, purulent,
Aurum met. bloody. Boring pains in nose. Putrid smell from
22. nose.worse: cold, Night, Sunset to sunrise, abuse of
merc. Or kali-iod. Cloudy weather.Better from open
air, cold bathing.

Acute Sinusitis
 Nasal congestion or obstruction
 Nasal discharge, purulence or discoloured postnasal drainage Facial pain or pressure (requires a second
major criterion to constitute a suggestive history)

Improvement
Facial congestion or fullness
equal or more

than 50 %
Hyposmia or anosmia
 Fever (for acute sinusitis; requires a second major criterion to constitute a strong history)
 Purulence on intranasal examination
Chronic Sinusitis
When inflammation last twelve (12) weeks or longer of two or more of the following signs and symptoms:
 Mucopurulent drainage (anterior, posterior, or both)
 nasal obstruction (congestion),
 facial pain-pressure-fullness, or
 decreased sense of smell
Clinical
examination/Investigations: Start homoeopathic treatment and
1. Transillumination of the sinuses: Advice for general management
Press a light source against the
patient’s upper cheek, close to nose.
General management:
Ask the patient to open his mouth
Follow up • Apply a warm, moist washcloth
widely and look at his palate to see
to face several times a day.
red spot of light passing through in
• Drink plenty of fluids to thin
normal sinuses. No red dot or light
the mucus.
would be seen if sinuses are blocked.
• Inhale steam 2 - 4 times per
2. X-ray examination: Following
day (for example, while sitting
features indicate bacterial infection.
Improvement in the bathroom with the
3. Radiologic opacity
shower running).
 Air-fluid level • Spray with nasal saline
 Sinus mucosal thickening-more several times per day.
than 4 mm • Use a humidifier.
4. CT of sinus is more sensitive • Avoid bending over as it may
particularly for ethmoid and NO YES
increase facial pain.
sphenoid disease.
Refer for treatment Continue Homoeopathic

Referral criteria Treatment
• High fever
• Orbital infections like orbital cellulitis or Check for complete resolution
orbital abscess which is indicated by:
 Fever
 Erythema
 Conjunctival injection
If resolution is incomplete If resolution is Complete
 Chemosis
 Proptosis
 Ophthalmoplegia
Reassess the case and give
 Diplopia
appropriate homoeopathic medicine
• Intracranial complications like: Stop treatment
Meningitis, subdural empyema, epidural
CCRHabscess and cerebral abscess 13 Updated on 10th Jul, 16
• Bony complications like: Pott’s puffy
tumor, Osteomyelitis and Osteitis.
UROLITHIASIS
CASE DEFINITION
The deposition or formation of stones in the urinary tract is called Urolithiasis. Urinary
stone disease is a worldwide common health problem and causes significant morbidity and
contributes even to mortality. A stone is an aggregation of solute materials from urine into
a solid form. Most often it is a hard substance and calciferous due to its calcium content.
Usually it is the solute constituents of urine such as calcium, oxalate, phosphate and uric
acid which form stones but occasionally products of bacterial infection can form soft stones
also called matrix stones.1
Urinary stones, according to its location in the urinary system, are labeled as renal calyceal
or pelvic stone, ureteral stone, bladder stone and urethral stone.
INCIDENCE
The epidemiology of urolithiasis differs according to geographical area in term of

prevalence and incidence, age and sex distribution, stone composition and stone location.
Such differences have been explained in terms of race, diet and climate factors.
Furthermore changing socio-economic conditions have generated changes in the
prevalence, incidence and distribution for age, sex and type of urolithiasis in terms of both
the site and the chemical-physical composition of the calculi.
Epidemiological surveys have been previously reviewed showing that in economically

developed countries the prevalence rate ranged between 4% and 20%.2
In developing countries the prevalence of stones is probably underestimated considering

that silent and not yet discovered kidney stones were diagnosed by renal sonography in
3% of non-symptomatic subjects.3
AETIOPATHOGENESIS
Calcium is the most common component of urinary calculi. It is a major constituent in

nearly 75% of stones. Following are types of stone and their compounds.
1Central Council for Research in Homoeopathy; Urolithiasis; Disease Monograph-4; Central council for
Research in Homoeopathy, New Delhi: 2009
2 Hesse A. Reliable data from diverse regions of the world exist to show that there has been a steady increase
in the prevalence of urolithiasis. World J Urol.2005;23:302–303

3 Buchholz NP, Abbas F, Afzal M, Khan R, Rizvi I, Talati J. The prevalence of silent kidney stones–an
ultrasonographic screening study. J Pak Med Assoc. 2003;53:24–5

Mechanism of stone formation
Stone formation is the culmination of a series of physiochemical events that occurs as the
glomerular filtrate traverses through the tubules of nephron. The most fundamental step in
stone formation is the supersaturation of urine with stone forming salts resulting in
crystallization of the dissolved ions or molecules. Once formed, crystals may flow out with
the urine or become lodged in the kidney at different sites. Once retained at such sites there
is further growth of the crystal and aggregation leading to stone formation.
Types of stones
Type Compound
Calcium stones Calcium oxalate dehydrate
Calcium oxalate monohydrate
Calcium phosphate
Non-calcium stones
Infection stones Magnesium ammonium phosphate
Carbonate apatite
Matrix calculi
Uric acid and urates Uric acid, Ammonium urate, Sodium urate
Cystine Cystine
Drugs Indinavir, Triamterene
Calcium oxalate makes up about 60% of all stones; mixed calcium oxalate and
hydroxyapatite makes up 20%; and brushite stones constitute 2% of the stones. Both uric
acid and struvite (magnesium ammonium phosphate) stones occur approximately 10% of
the time. Cystine stones are very rare and only 1% of all urinary stones contain cystine.
Recurrence rates are estimated at about 10% per year, totaling 50% over a 5-10 years
period and over 75% over 20 years. Age and sex differentials in urinary stone formers are
substantial: more common in males of age group 30-40 years in the industrialized
countries and in children under 10 years in the developing countries.
RISK FACTORS
The risk factors for stone formation are discussed under the following four headings:
1. General risk factors:

 Occupation that involve exposure to radiant heat. Mostly people who are
working outdoors or near heated equipment’s
 Gender

 Climate and geography
 Intake of hard water for drinking purpose
2. Metabolic risk factors

 Calcium stones
 Hypercalciuria (35% to 65%)
 Hyperoxaluria
 Hyperuricosuria
 Hypocitraturia (20% to 60 %)
 Low Urine pH
 Hypomagnesuria
 Uric Acid Stones
 Low Urine pH
 Low urine volume
 Hyperuricosuria
3. Urinary tract infections (5% to 15%)

 Proteus
 Klebsiella
 Pseudomonas
 Staphylococcus species
 Proteus mirabilis
4. Anatomic risk factors
 Ureteropelvic Junction Obstruction (20%)
 Horseshoe Kidneys (0.25%)
 Caliceal Diverticula (40%)
DIAGNOSIS1
Diagnosis will be based on clinical signs and symptoms followed by confirmation with
radiological evidence of stone by X-ray & ultrasound (Kidney, Ureter & bladder) and
laboratory investigations.
Symptoms:
 Symptoms of Acute Renal colic - Pain in flank which may spread downwards and
anteriorly towards ipsilateral groin, and testis in male and vulva in females,
sometimes extending to thigh, excruciating pain.

SEVERE PAIN: Most of the patients with urolithiasis experience pain which may vary
from dull aching to severe colicky in nature. The site of pain differs depending upon
the position of stone.
Acute Renal Colic- When stone is at the renal pelvis.
Acute Ureteric Colic- When stone is in the ureter.
 Strangury- It is severe pain experienced at the tip of penis in males and at labia
majora in females accompanied by intense desire to pass urine but resulting only in
the passage of few drops of urine, which may or may not be blood stained. This is
typical of urinary bladder calculi. Sometimes similar type of pain is experienced,
when the stone becomes impacted in posterior urethra
 Burning micturition
 Haematuria or reddish discoloration of urine
 Urgency and frequency of urine
 Dysuria
 Fever
 Vomiting
Signs:
 Rigidity of lateral abdominal wall
 Tenderness over renal angle/kidney region.
 Percussion over kidney or renal angle leading to stabbing pain.
 Reduced output of urine
 Haematuria
 Rise in body temperature
 Increase in Blood Pressure
Investigations1
1. PLAIN X-RAY OF KUB: A plain film of kidney, ureter and bladder area (KUB) usually
shows a radio-opaque density. In case of doubt a lateral radiograph is done.Ninety
percent of urinary stones are radio-opaque and will be seen on plain film.
2. ULTRASONOGRAPHY OF KUB: Ultrasound examination of kidneys can reveal the

presence, position of stone and also helps in measuring the exact size of the stonein
kidney. At the same time the structural alterations in terms of hydronephrosis or
any other anatomical changes taking place in the kidneys can be known. The
location and the size help in determining the approach to treatment and therapeutic
strategy.It is most valuable in locating stone for treatment by extracorporeal shock
wave lithotripsy (ESWL).

3. EXCRETORY UROGRAPHY (INTRAVENOUS UROGRAPHY IVU): Kidney function
should be normal for this investigation. It will establish the presence and exact
location of calculus within the urinary tract. It also gives important information
regarding the function of kidney on the same side as well as function of the other
kidney. IVU is done before any surgical treatment.
Other laboratory investigations include:

 Routine urine examination- and culture if required
 Renal/kidney function test
 Complete Haemogram
 Serum calcium, uric acid, phosphate, Alkaline Phosphatase
 Stone analysis (for recurrent stone formers)
Most of the cases of Urolithiasis will require only these above mentioned investigation for
diagnosis. However, in some difficult situations few other investigations are also helpful as
mentioned below:
1. RETROGRADE URETEROPYELOGRAPHY (RGP)

It is used when there is doubt about an intraluminal lesion or if the renal function is
deranged where Intra venous Pyelogram cannot be done. It is valuable in cases with
radiolucent stone. It is usually performed as an immediate preliminary to an
endoscopic procedure for stone removal.
2. SPIRAL CT-SCAN: Non contrast spiral CT scan has now become an important
investigation for acute ureteric colic and for diagnosing ureteric calculi.
3. URETHROCYSTOSCOPY: Usually not required for diagnosis of Urolithiasis but it is

used for endoscopic treatment of lower urinary tract calculi. An impacted urethral
stone can be confirmed and treated by urethrocystoscopy.
COMPLICATIONS
ACUTE
a. Acute retention of urine: A large urethral stone may completely block the urethra
and may cause acute retention of urine. Patient presents with symptoms of acute
retention with painful and distended bladder. Sometimes the impacted stone can
be felt with fingers palpating the anterior urethra and glans.

b. Urinary infection: The urinary tract infection is dangerous in presence of
obstruction. There is a risk of life threatening septicaemia.
LONG TERM
a. Hydronephrosis: It is the most common delayed complication of an obstructing

calculus untreated for some time. Any calculus which is causing proximal
hydronephrosis with significant back pressure should be treated and removed
before the kidney function deteriorates.
b. Pyonephrosis: It results from infection of hydronephrosis. The Kidney becomes a

multilocular sac containing pus or purulent urine. Pyonephrosis is usually
unilateral. There is real danger of permanent renal damage and lethal septicaemia.
c. Renal failure (Uraemia): When there are bilateral renal stones, especially stag
horn for long time, there is gradual derangement of renal functions without any
symptoms and leads to chronic renal failure. All the features of uremia are present
and on investigation they are found to have bilateral obstructing urolithiasis.
Similarly, bilateral ureteric calculi may also cause uremia.
d. Anuria: Anuria is defined as complete absence of urine production or urine

<100ml in 24 hours.
e. Development of cancer in pelvicalyceal system: Occasionally long standing

stone in renal pelvis may be associated with the development of renal pelvic
tumor.
It is important to distinguish urolithiasis from the many other conditions (gynecologic and
nongynecologic) that can cause flank pain: Abdominal Abscess, Acute Glomerulonephritis,
Appendicitis, Cholecystitis, Cholelithiasis, Diverticulitis, Epididymitis, Gastritis and Peptic
Ulcer Disease, Gastrointestinal Foreign Bodies, Ileus, Inflammatory Bowel Disease, Large
Bowel Obstruction, Liver Abscess, Pancreatitis, Papillary Necrosis, Pelvic Inflammatory
Disease, Pyonephrosis, Rectal Foreign Bodies, Renal Arteriovenous Malformation, Renal
Cell Carcinoma, Renal Vein Thrombosis Imaging, Small Bowel Obstruction, Splenic Abscess,
Testicular Torsion, Urinary Tract Infection in Females, Urinary Tract Infection in Men,
Urinary Tract Obstruction, Viral Gastroenteritis.

RED FLAG4
1. Fever or other features, e.g. rigors, consistent with systemic infection which can lead
to life-threatening sepsis
2. Suspected bilateral obstructing stones
3. Known clinically significant renal impairment
4. The presence of only one kidney
5. Pregnancy
MANAGEMENT
Several preventive measures when followed can aid in reduction of formation of urinary
calculi. Advice about such measures must be given to all the patients to check the incidence
of recurrence of stone formation as well as part of effective general management during
treatment:
 Maintenance of adequate water and fluid intake (at least 2.5–3.0 l) so as to produce
a daily urine output of about two and a half liters,
 Consumption of a diet rich in fiber and natural forms of citrate in diet,
 Restriction of salt intake,
 Regular exercise and maintenance of BMI between 18.5–24.9 kg/m2,
 Reduction of factors associated with obesity i.e. excessive consumption of animal
proteins, fats or refined carbohydrates (particularly fructose).
Not all urinary stones require surgical intervention. Kidney stones may present as acute
renal colic requiring immediate management or sometimes may even remain
asymptomatic for long.Homoeopathic medicines can play a role in management of
acute/chronic condition as well in result in expulsion of stone.
Homoeopathy has wide scope in managing patients from urolithiasis. Apart from managing
acute attacks, recurrence of renal stones is the area where homoeopathic medicines have
greater scope when prescribed along with ancillary measures.Individualized constitutional
medicines as per indications are helpful in such casesto prevent recurrent episodes of pain
and recurrence of stone formation, once the acute episode has tided over and managed
effectively.
4Managing patients with renal colic in primary care. Best Practice Journal [ Internet] 2014; Issue 60 (cited
2016 June 1) Available at http://www.bpac.org.nz/BPJ/2014/April/docs/BPJ60-colic.pdf

Few research studies and case reports show the beneficial role of homoeopathic
medicines in such cases. 5,6,7There are 32 medicines in Homoeopathic Medical repertory8
for “kidney stones”. Many rubrics reflect medicines which are indicated in conditions
where renal colic is associated with other concomitant symptoms. Few medicines are
known for their beneficial role in acute renal colic include: Cantharis: used when there is
constant desire to micturate with violent paroxysms of cutting and burning pain in renal
region; Equisetum hyemale, Thuja & Sarsaparilla: for frequent urging with severe pain at
close of micturition; Hydrangea: for renal calculi with colic, hematuria and profuse deposit
of white amorphous salts in urine; Ocimum canum for right sided renal colic with red sand
in the urine and the urine has odour of musk. Hydrangea – sharp pain in left loins with
enlarged prostate. Morgan gaertner-renal colic especially with lithiasis.
Given below are indications of medicines commonly prescribed in urolithiasis:

1. Belladonna Indicated in acute renal colic which causes spasmodic, crampy
pains; straining along the ureter as far as the bladder. Pains; of
maddening severity; coming and going, in repeated attacks. Pain as
if clutched by hand; < jar, pressure. Extreme sensitiveness to
touch, bedclothes. Colicky pains comes quickly and goes quickly;
>bending double or bending backward; also> lying on the
abdomen. Urine is scanty with tenesmus; dark and turbid, loaded
with phosphates. Urine may even be frequent and profuse.
Suited to plethoric persons with red face; and to conditions where
there is local plethora. Tendency to be chilled easily, with great
sensibility to cold air. Internal coldness with external, pungent,
burning heat. Belladonna always is associated with hot, red skin,
flushed face, glaring eyes, throbbing carotids, excited mental state,
hyperæsthesia of all senses, delirium, restless sleep, convulsive
movements, dryness of mouth and throat with aversion to water.
5
Jyothilakshmi V, Thellamudhu G, Kumar A, Khurana A, Nayak D, Kalaiselvi P Preliminary investigation on
ultra-high diluted B. vulgaris in experimental urolithiasis. Homeopathy. 2013 Jul;102(3):172-8. doi:
10.1016/j.homp.2013.05.004
6 Gupta A.K, Gupta J, Siddiqui V.A. & Mishra A. A big urinary calculus expelled with homoeopathic medicine.
Indian Journal of Research in Homoeopathy Vol. 2, No. 4, October-December 2008

7 V. A. Siddiqui etal. A multicentre observational study to ascertain the role of homoeopathic therapy in
Urolithiasis. Indian Journal of Research in Homoeopathy Vol. 5, No. 2, April - June, 2011
8
Murphy Robin Homoeopathic Medical Repertory. Third Edition. Lotus Health Publishers; 2005

2. Berberis Indicated when there is pain in small of back; very sensitive to
vulgaris touch in renal region; < when sitting and lying, from jar, from
fatigue. Burning and soreness in region of kidneys. Numbness,
stiffness, lameness with painful pressure in renal and lumbar
regions. Stitching, cutting pain from left kidney following course of
ureter into bladder and urethra. Renal colic. < left side with urging
and strangury. Rubbing sensation in kidneys. Urine: greenish,
blood-red, with thick, slimy mucus; transparent, reddish or jelly-
like sediment. The emission of urine is frequently accompanied by
pains in thighs and loins .Movement brings on or increases urinary
complaints.
Of value in persons with hepatic and rheumatic affections,
particularly with urinary, hæmorrhoidal and menstrual
complaints. Persons with pale, earthy complexion, with sunken
cheeks and hollow, blue-encircled eyes. Worse motion, walking or
carriage riding; any sudden jarring movement.
3. Pulsatilla Pressure in abdomen and small of back as from a stone. Colic, with
nigricans chilliness in the evening. Increased desire; < when lying down.
Burning in urethral orifice, during and after micturition.
Involuntary micturition at night, while coughing or passing flatus.
After micturating, spasmodic pain in the bladder. Sensation of a
stone rolling in the bladder. Urine passes only in drops and stream
interrupted. Urine watery, colorless; brown, bloody.
Suitable for mild, timid, peevish, tearful, emotional and sensitive
persons. Symptoms are changeful & shifting. Chilly, yet averse to
heat; in a warm room; with the pain; on lying down at
night. Thirstlessness with dryness of mouth. Better open air,
consolation.
4. Sulphur This drug is of value when there is a fullness, heaviness, tension,
and pressure, as if from stone in abdomen, chiefly in epigastrium
and hypochondria. Violent pain in region of kidneys after stooping
a long time. Aching in small of back all day, esp. < while urinating.
Frequent urination, esp at night. Burning in urethra during
micturition, lasts long after. Mucus and pus in urine; parts sore
over which it passes. Must hurry, sudden call to urinate. Great
quantities of colorless urine.
Suitable for nervous, quick tempered, emotionally irritable and
sluggish persons. Hot patient, dirty filthy, lean thin, with stoop
shoulders. Sinking feeling at stomach about 11 a.m. Local
throbbing, burning or congestion; soles; vertex is seen in this drug.
Ebullitions of heat, red orifices; dry skin and hair, dislike for water.

Complaints that relapse. Offensive discharges and exhalations.
Worse morning, standing, at rest, warmth of bed, bathing. Better
dry, warm weather, lying on right side.
5. Lycopodium Indicated in kidney affections. Pain in the back before urinating;
clavatum ceases after flow. Renal colic in ureter to bladder Urine slow in
coming; must strain. Urine scanty; person cries before urinating.
Polyuria at night. Hematuria from gravel or chronic catarrh.
Frequent urging to urinate, > riding in cars, etc.. Red sand in urine.
Acrid urine Urine milky, turbid.
Peevish and depressed in mind. Miserly and coward. Irritable,
contradiction aggravates. Adapted to old persons or children who
age prematurely and have a weak body but sharp mind
(intellectually keen but bodily weak). Great weakness of digestion,
Eating ever so little creates fullness. Earthly complexion and
yellowish spots on skin with or without vertical furrows on
forehead. Desire sweets, warm drinks. Aversion to breads. All
complaints < 4-8 pm Better: warm drinks, food, cold applications,
eructation, urinating.
6. Sarsaparilla Suitable for persons with tendency to gravel. Renal colic; pain from
right kidney downward. Tenesmus of bladder; urine passes in thin
feeble stream. Can pass urine only when standing. Gassy
urine. Crusty urinary sediment; deposit in the urine which looks
like grey sand. Urine is high-coloured with lithates, enuresis day
and night. Indicated in gloomy, ill- humoured, thin frail, shrivelled
and old looking patients. Worse at the close of urination, cold etc.
Better standing.
7. Terebinthina The remedy has a selective affinity for mucous membranes of the
kidneys. Affections of kidneys and rheumatism. Sensation of
heaviness and pain in region of kidneys. Inflamed kidneys
following any acute disease. Burning or pain along ureters.
Burning sensation, incisive pains, and spasmodic tenesmus of
bladder. Urine; smoky; with coffee grounds or thick, yellow, slimy,
muddy sediment; odor of violets; bloody. "Drowsy with retention
of urine." Smooth, glossy, red tongue, as if deprived of papillæ.
With cystitis and uro-genital and rectal troubles there is
sensitiveness of hypogastrium and pains in symphysis pubis. Pains
alternate between navel and bladder, > walking. Worse dampness,
night, lying, when urinating. Better motion, stooping, walking.

Symptoms of:
Burning micturition/frequency/urgency.
Haematuria or reddish discoloration of urine
Dysuria/Fever/vomiting
On examination:
Rigidity of lateral abdominal wall
Tenderness over renal angle/kidney region.
Percussion over kidney or renal angle leading to stabbing
pain
Suspected case of Urolithiasis
Patient with acute renal pain Patient without acute renal pain
Select a most similar medicine No/partial relief of pain

on the basis of acute symptoms despite correct selection
present during acute phase Clinical examination and
laboratory investigations
Plain X-ray & USG (KUB) for
diagnosis of Urolithiasis
Relief of pain Look for: 
Obstruction
Bleeding
High Blood Pressure
With removal Stone still
Renal function affected
stone present
Complications
 Start homoeopathic
individualized Clinical
treatment for examination and  Detail case taking
prevention of laboratory
Refer for emergency
 Start individualized
recurrence investigations homoeopathic medicine
 Advise lifestyle allopathy treatment
modifications
and advise lifestyle
modifications
Follow up
regularly till 6
months

UTERINE FIBROIDS
CASE DEFINITION
Uterine fibroids (myomas or leiomyomas) are common benign smooth muscle tumors of
the uterus which often appear during childbearing years.1
INCIDENCE
 Estimating the overall prevalence of fibroids in the population is difficult, since
estimates shall vary depending on the population examined, whether asymptomatic
women are included, and the sensitivity and specificity of the methods used to detect
fibroids.
 It is also observed that fibroids are seen in women of child bearing age group, 30-40
years (rarely before 20 years), nulliparous or of low parity (only 20-30% women are
multiparous).1,6
AETIOLOGY
Fibroids arise when a single muscle cell in the uterine wall multiplies rapidly to form a
tumor. The exact cause of uterine fibroids is unclear, but obesity, nulliparity, early
menarche (onset of menses before 10 years), are implicated. However, the most important
underlying factor is high estrogen levels which promotes the growth of fibroids. Hence,
they tend to grow in pregnancy and decline after menopause. Their growth and
development may also be impacted by other hormones viz. progesterone.1,2,3,4,5,6
TYPES OF FIBROIDS
 Fibroids are usually found inside or around the body of the uterus, but sometimes occur
in the cervix. Fibroids can be divided into three categories1,3,6,7(See figure below )
1The American College of Obstetricians and Gynecologists. Uterine Fibroids– FAQ’s [Internet]. US [cited 2015
Jan 01] Available at: https://www.acog.org/~/media/For%20Patients/faq074.ashx
2 Parker W H. Uterine myomas: management. Fertility and Sterility 2007,88(2):255-271
3 U.S. National Library of Medicine. Uterine Fibroids: Overview [Internet].U.S [cited 2015 Jan 01] Available at
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001912
4Agency for Healthcare Research and Quality. The fibroid registry: Report of Structure, Methods, and Initial
Results. AHRQ Publication No. 05(06)-RG008 [Internet]. Rockville [updated October 2005; cited 2015 Jan 01].
Available at https://www.acog.org/-/media/For-Patients/faq074.pdf?dmc=1&ts=20160323T0115264592
5Okolo S. Incidence, aetiology and epidemiology of uterine fibroids. Best Practice & Research Clinical
Obstetrics & Gynaecology. Aug 2008; Volume 22(4), 571–588

6Padubidri VG, Daftary N S. Howkins and Bourne Shaw’s Text book of Gynecology; 14 th edition; Elsevier;
2008: p-316
7 American society for reproductive medicine. Uterine fibroids- A guide for patients. Patient information
series; [Internet]. U.S.; 2003. [Cited 2015 Feb 09]. Available at

www.wbamc.amedd.army.mil/Documents/uterine_fibroids.pdf

Types of fibroids
 75% of fibroids are
subserosal (located in the
outer wall of the uterus)
 15% are intramural (found in
the muscular layers of the
uterine wall)
 10% are submucosal (which
protrude into the uterine
cavity).
DIAGNOSIS
Clinical presentation 1, 2, 3, 7, 8, 9,10

Most women with uterine fibroids have no symptoms. However, abnormal uterine bleeding
is the most common symptom of a fibroid which is seen as:
 Bleeding between periods
 Heavy bleeding during the period, sometimes with blood clots
 Periods that may last longer than normal
Fibroids can also cause a number of symptoms depending on their size, location within the
uterus, and how close they are to adjacent pelvic organs. Large fibroids can cause:
 Pelvic cramping or pain with periods
 Feeling fullness or pressure in lower belly
 Pain during intercourse
 Pressure on the rectum with painful or difficult defecation
 Frequency and in later cases retention of urine
 Ureteric obstruction
 Backache or leg pain
Investigations 1,2,3,7,8
Uterine fibroids are diagnosed by
8 Carolyn J. Hildreth Uterine Fibroids Journal of American Medical Association. 2009; 301(1):122.
doi:10.1001/jama.301.1.122
9 Gupta S, Jose J, Manyonda I. Clinical presentation of fibroids. Best Practice & Research Clinical Obstetrics &
Gynaecology 2008 , 22 (4): 615-626

10 Lumsden MA, Wallace E M. Clinical presentation of uterine fibroids. Baillieres Clin Obstet Gynaecol. June
1998, 12(2):177-195

 Pelvic examination (Per speculum (PS), per vaginal (PV) examination of uterus to
inspect, palpate and assess fibroid size). Often, a pelvic mass cannot be determined to
be a fibroid on pelvic exam alone, and further investigation is required to differentiate it
from other conditions such as ovarian tumors.
 Pelvic and/or transvaginal ultrasonography: for fibroid size and uterine volume
 Hysteroscopy to see the fibroids in the uterus when inserted through the vagina and
cervix by aid of a hysteroscope
 Other test such as Hb. for assessing anemia if any.
COMPLICATIONS 1,6
 Twisting of the fibroid resulting in pain, usually caused by blocked blood vessels
that feed the tumor
 Anemia from heavy bleeding
 Urinary tract infections, consequent to deficient emptying of bladder
 Infertility
 Fibroids when present along with pregnancy can result in requirement for C section;
pre term delivery or cause heavy bleeding right after giving birth.
Differential diagnosis includes conditions resulting in abdominal swellings
These commonly include:
 Ovarian cyst
 Pregnancy
 Endometrial carcinoma
 Adenomyosis
 Endometriosis (Chocolate cyst)
RED FLAG
 Severe pain (twisting of the fibroid)
 Anemia from heavy bleeding,
 Recurrent Urinary tract infections
 Malignancy
CLINICAL ASSESSMENT AND EVALUATION

The UFS-QOL11 can be used to assess the quality of life of patients suffering from
symptomatic uterine fibroids.
11 Spies JB, Coyne K, Guaou Guaou N, Boyle D, Skyrnarz-Murphy K, Gonzalves SM. The UFS-QOL, a new
disease-specific symptom and health-related quality of life questionnaire for leiomyomata. Obstet Gynecol.
2002 Feb;99(2):290-300

MANAGEMENT
Fibroids which are asymptomatic and often very small in size usually do not require
treatment. Medicinal treatment is indicated in symptomatic fibroids. However, a careful
and timely assessment of the pathology as well its symptoms is required to understand the
response to the treatment and requirement of referral for surgery. 1, 3, 7, 8, 12
Certain food habits are implicated in prevention of fibroids or in arresting the
growth of fibroids and aid in treatment. 13 These include increased consumption of fruits,
green or sea vegetables, whole grains, nuts, and seeds; soy foods such as tofu etc., flaxseeds;
Vitamin E; Vitamin C and bioflavonoids. Avoidance of foods with high fat or sugar content,
caffeine and alcohol.
Homeopathic literature14,15,16,17,18,19,20,21 highlights role of various medicines in
uterine fibroids. Clinical research studies22,23,24,25,26 and case reports27,28,2930,31 by
12 Marret H. etal. Therapeutic management of uterine fibroid tumors: updated French guidelines. Eur J Obstet
Gynecol Reprod Biol. 2012 Dec; 165 (2):156-64. doi: 10.1016/j.ejogrb.2012.07.030. Epub 2012 Aug 29
13 Uterine fibroids. Gale Cengage learning 2008; Miami: 2008 [cited 2015 Nov 12] Available at
http://www.altmd.com/Articles/Uterine-Fibroids--Encyclopedia-of-Alternative-Medicine
14 Zandvoort RV. Complete Repertory 3.0. (English) 5.1 Repertory, Mac Repertory for Windows, Kent
Homoeopathic Associates, USA.

15 Murphy R. Homoeopathic Medical Repertory. Third Edition. Lotus Health Publishers; 2005
16 Boericke W. New Manual of Homoeopathic Materia Medica with Repertory: Third Revised & Augmented
Edition based on Ninth Edition. B. Jain Publishers, New Delhi; 2010

17 Allen HC. Keynotes- Rearranged and classified with leading remedies of the material medica and bowel
nosodes. 10th Reprint edition. Jan 2006

18 Clarke JH. A dictionary of Practical Material Medica . Reprint edition 2007.B Jain Publishers Pvt. Ltd.
19 Pulford. Key to the Homeopathic Materia Medica. Second Edition. B Jain Publishers, N Delhi
20 Boger CM. A synoptic key of the Materia Medica. Reprint edition 2008, B. Jain Publishers Pvt. Ltd.
21 Allen T.F. Handbook of Materia Medica and Homeopathic Therapuetics First edition 1889. Philadelphia: F E
Boericke
22 Oberai P, Indira B, Varanasi R, Rath P, Sharma B, Soren A, et al. A multicentric randomized clinical trial of
homoeopathic medicines in fifty millesimal potencies vis-à -vis centesimal potencies on symptomatic uterine
fibroids. Indian J Res Homoeopathy 2016; 10:24-35.
23 Popov A.V. Homœopathy in treatment of patients with fibromyoma of the uterus. British Homoeopathic
journal 1992; 81(4): 164-167

24 Gupta G, Gupta N, Singh V, Bisht D Uterine Fibroids: A Clinical Study with USG Follow-up. National Journal
of Homoeopathy 2003; 5 (3) available at

http://www.njhonline.com/2003/may_jun_vol5_no3/mixedbag/uterine_fibroids_study.shtml
25 Shangloo G.K. Role of Homoeopathy in Uterine Fibroid and Ovarian Cyst Treatment. Hpathy Ezine, August,
2006. Available online at http://hpathy.com/clinical-cases/role-of-homoeopathy-in-uterine-fibroid-and-

ovarian-cyst-treatment/1/
26 Quadri I J, Ali S, Vatsalya B, Ponnam HB, Nikhat PS. Role of homoeopathic medicines in treating uterine
fibroid: a prospective observational Study. Indian J Res Homoeopathy 2012;6(1 & 2); 8-14
27 Wadhwani G. G. Uterine Fibroma: A case cured by homoeopathy AJHM 2003; 106 (3): 121-124
28 Sevar R. Aurum muriaticum natronatum—four case reports Homeopathy 2007;96(4): 258-269

researchers also throw light on the usefulness of homeopathy not only to control
distressing symptoms of uterine fibroids but also to some extent in complete dissolution of
fibroids. A complete case history eliciting the presenting totality of symptoms formulated
after considering the symptomatology, mind and dispositions, generals, predispositions,
past history, etc. (i.e., all accessory symptoms) is indicative of the similimum for the case
and shall always be the sole guide for the individual case.
Few remedies are known to have a palliative role especially in controlling bleeding
associated with fibroids when given on their specific indications. For e.g.: Thlaspi Bursa
Pastoris: Uterine hemorrhage, with cramps and expulsion of clots; metrorragia;
Hemorrhage from violent uterine colic; blood dark offensive stains indelibly. Hæmorrhage
from uterine fibroid with aching in back or general bruised soreness; Sabina: Uterine
hemorrhage, blood is fluid and clots together < least motion; Pain from sacrum to pubes,
and from below upwards shooting up the vagina.; Trillium pendulum: Hemorrhage from
fibroids; with sensation as though hips and back were falling into pieces; better tight
bandages; Erigeron: Hemorrhage from the uterus with painful micturition; Metrorrhagia
with violent irritation of rectum and bladder; profuse bright red blood; Hamamelis
virginica: Uterine hemorrhage, bearing down pain in back. Bruised soreness of the affected
part. Lapis albus: Fibroid tumors with intense with intense burning pains through the parts
with profuse hemorrhage; Calcarea iodatum: Uterine fibroids with goitre, and other
glandular remedies such as Conium maculatum, Kalium iodatum and Aurum iodatum.
Limitations of Homoeopathic Treatment/Referral should not be ignored. Fibroids
larger than 5 cm, subserous fibroids causing obstructive symptoms on other abdominal
structures (ureters/rectum) and submucosal fibroids which tend to bleed heavily
(resulting in severe anemia due to blood loss) in child bearing age during menstrual cycles
if not responding to homoeopathic treatment in 3 months will have limitations in
management and may need surgical intervention.
The indications of the remedies prescribed are given below:
29 Iqbal JQ, Ali S, Nikhat PS, Vatsalya B. A case of uterine fibroid. Indian J Res Homoeopathy 2008; 2:50‑8.
30 Sharma A. Homoeopathic management of uterine leiomyomata: A case report. Indian J Res Homoeopathy
2010; 4(3):51-55
31 Gupta G. Singh R. An Evidence Based Case of Uterine Fibroids Cured by Pulsatilla. Journal of Case Studies in
Homeopathy 2013; 1(3): 1 – 8 Available online at www.jcshom.com

1. Pulsatilla Suitable in females who suffer from tardy menses. These
nigricans women have delayed first menstruation and suffer from
derangements at puberty. Menses: too late, scanty, slimy, thick,
dark, clotted, changeable, irregular, intermittent. Menstrual
flow with evening chilliness; nausea and downward pressure.
Uterine troubles with heavy pressive pain in abdomen and
small of back; as from a stone; limbs go to sleep; ineffectual
urging to stool. Menses suppressed from getting feet wet;
nervous debility or chlorosis.
Desire company, mild, gentle, affectionate, yielding, weeping
disposition. Hot patient; marked changeability; thirstlessness
with great dryness of mouth. Desire for cheese, pungent
things, highly seasoned food; aversion to fat, warm foods and
drinks; tongue coated yellow or whitish; worse towards
evening and in the warm room, always better in open air, by
slow, gentle motion and cold applications..
2. Sepia Indicated in women who suffer from irregular menses of
officinalis nearly every form - early, late, scanty, profuse, amenorrhoea or
menorrhagia. Violent stitches upward in the vagina; pains
from the uterus to the umbilicus. Associated symptoms include
weakness of the female sexual organs and prolapse of uterus
with sensation of pressure and bearing down as if everything
would protrude from pelvis; must cross limbs tightly to "sit
close" and cross her limbs to prevent protrusion of the parts.
Persons who are sad, indifferent even to loved ones, irritable,
indolent and quarrelsome. Chilly patient; predisposed to take
cold at the change of weather; thin built with narrow pelvis;
yellow saddle across nose; past history of repeated abortions;
sudden prostration with sinking faintness with all complaints;
offensive sweat; desire for vinegar, acids, pickles and sour, but
sour food aggravates. Aggravated after laundry work and
better by warmth of bed, after violent exercise.
3. Calcarea Suitable for females who suffer from premature and too
carbonica copious menses. Pale blood; blood too thick and of strong
odour. Menses too early, too profuse, too long, with vertigo,
toothache and cold, damp feet; the least excitement causes
their return. Menorrhagia, burning across sacrum, passive
flow.
Indicated in torpid, fair, flabby, anaemic persons with large
head, distended abdomen and tendency to lymphatic glandular
enlargement; fearful, shy, timid, slow and sluggish; who are
chilly and take cold easily; sweat profusely on head while
sleeping or mostly on back of head and neck, or chest and

upper part of body; have sour smelling discharges; longing for
fresh air, cold sweaty extremities, desire for eggs, sweets and
aversion to meat and milk. Feel better in every way when
constipated and have desire to be magnetized.
4. Aurum Burnett considers that this remedy has more power over
muriaticum uterine tumours than any other gold preparation. Indicated
natronatum when there is induration of one part, softening of another part
of the uterus. Inflammation of the uterus filling the whole
pelvis, interfering with the action of the bowels and bladder.
Menses are profuse and premature.
The patient suffers from characteristic boring pains in parts
which are worse at rest; Symptoms in general < cold wet
weather, < by rest.
5. Natrum Suitable in persons with irregular, usually profuse menses.
muriaticum Menses preceded and followed by headache. Hot during
menses. History of delayed appearance of menses. Associated
bearing-down pains; worse in morning; > lying on back; has to
sit up to prevent prolapse.
Hot patient; poorly nourished; great emaciation (marked on
neck); losing flesh while eating well; oily, greasy face; craving
for salt; aversion to bread and fatty things; constipated;
increased thirst; mapped tongue with red insular patches;
difficult speech, children slow in learning to walk; melancholic,
sad, plays alone, irritable, cross, cries when spoken to;
awkward, hasty, drops things from nervous weakness;
disposition to weep without cause, consolation aggravates.
6. Phosphorus Menses are too early and scanty-not profuse, but prolonged.
Frequent and profuse metrorrhagia. Weeps before
menses. These persons suffer from slight hæmorrhage from
uterus between periods.
Nervous persons, oversensitive to external impressions – light,
noise, touch, odour, etc; desire to be magnetized and those
who have anxiety especially during thunderstorm. Chilly
patients; tall, slender, narrow chested; have a craving for salt
and cold water.

 Bleeding between periods
 Heavy bleeding during the period, sometimes with blood clots
 Periods that may last longer than normal
 Pelvic cramping or pain with periods
 Feeling of fullness or pressure in lower belly
 Pain during intercourse
 Pressure on the rectum with painful or difficult defecation
 Frequency and in later cases retention of urine
 Ureteric obstruction
 Backache or leg pain
Examination and investigations:
 Pelvic examination
 USG/MRI/CT
 Haemogram
Mild to moderate symptoms Severe symptoms/

USG findings: small to medium sized USG findings shows large sized
fibroids (more than 5 cm)
Referral criteria
 No clinical improvement
Start homoeopathic treatment and  Worsening general
Advice for general management condition
 Development of
complications like severe
pain (twisting of the
fibroid), Anemia from heavy
Review the patient periodically clinically
bleeding, Urinary tract
and through USG
infections.
Yes No
Improvement
Continue homoeopathic Refer for standard

Treatment care
If improvement is Complete improvement Stop treatment

incomplete
Reassess the case and give appropriate

homoeopathic medicine
VITILIGO
CASE DEFINITION
Vitiligo is a common chronic skin depigmentation disorder.It is due to stoppage of melanin

formation by the melanocytes and presents as asymptomatic depigmented macules
anywhere on the body including mucous membranes of lips and genitalia. 1
INCIDENCE
It affects around 0-5% of the world population. Prevalence as high as 8.8% have been
reported in India where stigma associated with the disease is high. 2,3
AETIOLOGY1
 Auto-immune mechanism
 Genetic factors
 Prolonged pressure in a particular area
 Repeated trauma to prone areas of skin
 Psychological stress (often appear to initiate or accelerate the development of the
lesions)
 Associated with other diseases like hyper & hypothyroidism, pernicious anemia,
Addison’s disease, diabetes mellitus, malignant melanoma and halo naevus.
 Other factors like destruction of melanocytes themselves due to a defect in natural
protective mechanism which removes toxic melanin precursors.
PATHOPHYSIOLOGY1
There is a marked reduction or even absence of melanocytes and melanin in the epidermis.
Studies have not yet proved whether there is destruction of melanocytes or destruction of
pigment producing granules in the cells or the cells are structurally maintained but
function less.
Histochemically, there is lack of DOPA – positive melanocytes in the basal layer of
epidermis. The macules vary in size and shape as well as in color. Some of the lesions or
some part of the lesions may be hypopigmented rather than depigmented. The course of
1Ramji Gupta & R K Manchanda; Textbook of Dermatology for Homeopaths, B.Jain publisher, Delhi, 3 rd
edition2009.
2Eleftheriadou V., Which Outcomes should we measure in Vitiligo? Results of a Systemic Review and a survey
among Patients and Clinicians on Outcomes in Vitiligo Trials; The British Journal of Dermatology. 2012
Oct;167(4): 804-814 Accessed from http://www.ncbi.nlm.nih.gov/pubmed/22591025
3 Whitton ME, Interventions for Vitiligo (Review); The Cochrane collaboration, published by John Wiley &
Sons, Ltd, accessed from http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003263.pub4/pdf

the disease is very variable. The lesions in some patients may remain static or progress
very slowly while in others the disease progresses very fast and cover the whole body in
few months. In few cases spontaneous repigmentation has been noticed it is usually
perifollicular. In some lesions the hair are white, this is called leucotrichia.
TYPES4
Two types:
 Non-segmental vitiligo is an acquired chronic de-pigmentation disorder
characterized by white patches. These are often symmetrical and usually
increase in size with time.
 Segmental vitiligo is a variant of vitiligo confined to one unilateral segment.
One unique segment is involved in most patients but two or more segments
on the same or opposite sides may be involved or de-pigmentation may follow
a dermatome distribution or Blaschko’s lines.
DIAGNOSIS4
Where vitiligo is classical, the diagnosis can be made even in primary care setup,
based on the clinical presentation:
 Characteristic depigmented skin patches, no surface change and usually no

redness.
 Very occasional inflammation may be seen at the advancing edge of a vitiligo
macule.
 No loss of sensation
Atypical presentations may require expert assessment by a dermatologist. A Wood’s

lamp examination may be of use in determining extent and activity of vitiligo, as well
as monitoring response to therapy and the progress of lesions over time.
Certain relevant points in the clinical history must be elicited. (Refer to ‘Management’
given below)
Investigations5
Recommended procedures in case of vitiligo to identify underlying

factors/comorbidity include:
 Anti-TPO, antithyroglobulin antibodies
4D.J. Gawkrodger, A.D. Ormerod et.al; Guideline for the diagnosis and management of vitiligo; ;British Journal
of Dermatology ;2008 159, p 1051–1076
5A. Taieb, A. Alomar, M. Böhm et.al. Guidelines for the Management of Vitiligo; The European Dermatology
Forum Consensus;The British Journal of Dermatology. 2013;168(1):5-19

 TSH to assess thyroid function and anti-TSH antibodies
 Additional autoantibodies (only if patient's history, family history and/or
laboratory parameters point to a strong risk of additional autoimmune disease),
endocrinologist/immunologist advice if multiple autoimmune syndrome detected
If diagnosis is uncertain
 Punch biopsy from lesional and nonlesional skin.
 Other tests e.g., mycology, molecular biology to detect lymphoma cells, etc. to
confirm diagnosis.
The three main diseases that can be mistaken for vitiligo are:
 Tinea versicolor: superficial yeast infection, cause loss of pigment in darker
skinned individuals, pale macules typically on the upper trunk and chest, with
a fine dry surface scale.
 Piebaldism: an autosomal dominant disease, absence of melanocytes from the
affected areas of the skin, usually presents at birth with depigmented areas
that are usually near the mid-line on the front, including a forelock of white
hair.
 Idiopathic guttate hypomelanosis: multiple small, white macules are noted,
mostly on the trunk or on sun-exposed parts of the limbs.
 When vitiligo affects only the genital areas, it can be difficult to exclude lichen
sclerosis, which sometimes can coexist with vitiligo.
Other conditions to be differentiated include:
 Halo naevus
 Hypopigmentednaevus
 Idiopathic guttatehypomelanosis
 Leprosy
 Lichen sclerosus (for genital vitiligo)
 Melanoma-associated leucoderma
 Melasma
 Mycosis fungoides-associated depigmentation
 Naevus anaemicus
 Naevus of Ito
 Piebaldism
 Pityriasis alba
 Pityriasis versicolor
 Post inflammatory depigmentation, e.g. scleroderma, psoriasis,
 atopic eczema

 Post-traumatic depigmentation
 Topical or drug-induced depigmentation
 Tuberous sclerosis
RED FLAG
 Uncontrolled TSH levels

 Endocrinal disturbances
 Uncontrolled level of auto antibodies
ASSESSMENT AND EVALUATION 6
 Vitiligo Symptom Score (VSS) 9
MANAGEMENT1
Vitiligo is an absolutely harmless disease except for its cosmetic implications. A patient of
vitiligo can be as efficient, physically, mentally and sexually as any other individual. The
spread of disease can be arrested and a substantial amount of repigmentation of the lesions
can be achieved in a majority of individuals who undergo appropriate treatment. The
following points must be kept in mind during treatment:
 Each & every case should be evaluated in depth, to find out any known factors
causing vitiligo like pressure, trauma, etc. which should be removed or minimized
as far as possible. Nails should be trimmed and filed to avoid scratching. These
simple procedures may start re-pigmentation of the lesion in early cases of vitiligo.
 Response to the treatment is slow. Re-pigmentation of the lesions usually starts
around hair follicles thus the lesions in the hairy area shows early and quick
response.
 In the patients with extensive vitiligo, lesions with leucotrichia of long duration or
located on non-hairy areas like palms, soles, fingertips or mucosal surfaces, the
response to treatment is very poor and incomplete.
 Skin phototype, duration of disease (progressive or regressive, stable over the last
6 months), premature hair greying, age at onset, involvement of genitals, type and
duration of previous treatments and ongoing treatment, previous spontaneous
repigmentation, koebners phenomenon, history of autoimmune disease in family
including vitiligo.
 Photographs may be required for monitoring treatment response.
6AfsheenBilal, Irfan Anwar; Guidelines for the management of vitiligo; Journal of Pakistan Association of
Dermatologists. 2014;24 (1):68-78

 Psychological status and assessment quality of life of the patients is of importance
(Refer text above)
Few case reports7,8 and research studies9,10,11 in the past show the beneficial role of
homoeopathy in being able to halt the progression, reduce the hypopigmentation/ bring
about hyperpigmentation in vitiligo.
Homoeopathic literature gives many remedies for this disease condition.
Medicines need to be selected individually by holistic coverage of the entire
symptomatology, taking into account all the characteristic symptoms, mental make-up as
well as accessary circumstances. Boericke’s repertory12 gives Arsenicum album, Ars. sulph.
flavum, Bacillinum, Graphites, Merc sol, Natrum muriaticum, Nitric acid, Nux vomica,
Phosphorus, Sepia, Silicea, Sulphur and Thuja under the rubric “skin: leucoderma.”
Frequently used drugs include Argentum nitricum, Calc, carb, Lyco, Natrum mur, Nitric
acid, Sepia, Silicea and Sulphur.
Other drugs of importance are Alumina, Ars-s-f, Calotropis, Hydrc., Lac. c., Mang., Natrum-
caust., Oxyg., Pip- m., Pitu-gl., Sel., Stannum, Sambucus, Thuja, Zinc- p.
Indications of few important constitutional drugs are given below for glimpse7
S.no. Medicine Indications

1. Arsenicum Skin dry, rough, and scaly < cold and scratching. The
Album lesion may also have itching or burning, oedema,
redness. General tendency to pick at roughened
places in the skin until they bleed. White, pasty
looking skin.
Suitable for persons with anxiety with fear of death;
Restlessness with tossing about in agony. Fastidious
and oversensitive patients. Chilly patient but wants
head uncovered. Great debility and prostration. Mid-
day, mid-night and periodical aggravation. Worse cold:
7Jha D K, Debata L. A Case of Vitiligo Treated by Sulphur. Indian J Res Homoeopathy 2009; 3: 34-40
8 Ravi Kumar S. A case of vitiligo treated with phosphorus. Indian Journal of Research in Homoeopathy Vol. 2,
No. 1, January-March 2008
9Chakraborty P S, Kaushik S, Debata L, Ram B, Kumar R, Shah M, Jha D K, Ramesh D, Padmanabhan M, Nayak
C, Singh V. A multicentric observational study to evaluate the role of homoeopathic therapy in vitiligo. Indian J
Res Homoeopathy 2015; 9: 167-75
10Ganguly S, Saha S, Koley M, Mondal R. Homoeopathic treatment of vitiligo: an open observational pilot
study. Int J High Dilution Res [online]. 2013 [cited 2015 November 13]; 12(45):168-177. Available from:
http://www.feg.unesp.br/~ojs/index.php/ijhdr/article/view/638/683
11Khatua G.K., Dasgupta S., Basu S.K, Swarnakar G. Significant remission of vitiligo by ultradiluted alternative
medicines. Asian Journal of Pharmaceutical and Clinical Research Vol 5, Issue 2, 2012
12Boericke W. Boericke's New Manual of Homeopathic MateriaMedica with Repertory: Third Revised &
Augmented Edition Based on Ninth Edition. India : B. Jain Publishers; 2010

food, drinks, air, damp weather. Better: hot
applications, warm drinks, wrapping up, in company
and while sweating.
2. Calcarea Skin is unhealthy readily ulcerating; flaccid. Small
Carbonica wounds donot heal quickly. Milky white spots.
Tendency to chilblains.
Adapted to apprehensive fearful (fear of night, dark,
alone strangers), sluggish, obstinate, mischievous and
irritable persons having anxiety with palpitation.
Sensitive to noise, and averse to work or exertion. Fat,
flabby persons with easy and profuse perspiration,
which is cold, damp and sour. Suited to persons with
blond hair, light complexion, blue eyes, fair skin,and
distended abdomen with thin extremities.Chilliness
with internal coldness who get cold easily. Desire for
undigested food like chalk, coal, pencil, sweets, eggs and
aversion to boiled food and meatwith intolerance to
milk. Character of discharges are yellowish, greenish
thick or thin < from physical and mental exertion.
Worse from cold, bathing, morning; during full moon.
Better in dry weather; lying on painful side.
3. Lycopodium Skin, dry, shrunken, especially palms; hair becomes
clavatum prematurely gray. Skin becomes thick and indurated.
Violent itching worse on warm applications. Offensive
secretions; viscid and offensive perspiration, especially
of feet and axilla.
Sensitive, intelligent, dominating, dictating and
headstrong. Peevish and depressed in mind. Miserly
and coward. Irritable, contradiction aggravates.
Adapted to old persons or children who age
prematurely and have a weak body but sharp mind
(intellectually keen but bodily weak). Persons
predisposed to gastric affections.
Earthly complexion and yellowish spots on skin with or
without vertical furrows on forehead. Desire sweets,
warm drinks. Aversion to breads. All complaints < 4-8
pm Better: warm drinks, food, cold applications,
eructation, urinating.
4. Natrum Greasy, oily, especially on hairy parts. Dry eruptions
muriaticum on margin of hairy scalps. Itch and burn, crusty
eruptions in bends of limbs, margin of scalp behind
ears. Alopecia.
Awkwardness, abruptness, irritable, weeping
disposition which are aggravated by consolation and

complaints precipitated after grief are the
characteristics mental symptoms. Anaemic, cachetic,
emaciated subjects resulting from loss of fluid or
mental stress, emaciation marked around neck.
Desire for excessive salt, dry, geographical tongue,
sweats while eating and aggravation at the sea shore
and sunlight; better in open air are leading
symptoms.
5. Phosphorus Brown spots on face. Skin is fair and delicate.
Tendency for dandruff and hairfall in bunches; loss
of sensation and formication. Itching and burning
better by cold applications.
Suited to very sensitive, sympathetic, nervous and
weepy with depressed spirits, palpitation. Tall,
slender, stoop shouldered persons of sanguine
temperament. Haemorrhagic diathesis; burning
pains; weak empty all gone sensation in various
parts of the body. Desire for juicy, refreshing, cold
food and drinks.
6. Sepia Itching of skin; of various parts; of external genitalia; is >
officinalis scratching; and is apt to change to burning, not relieved
by scratching; worse in bends of elbows and knees.
Chloasma. Ring shaped eruption on upper part of the
body which appears every spring. Spots on skin.
Indurations from constant pressure. Skin blotched; raw,
rough, hard and cracked; <flexures.
Indicated in chilly patients; predisposed to take cold at

the change of weather; thin built with narrow pelvis;
yellow saddle across nose; past history of repeated
abortions; sudden prostration with sinking faintness with
all complaints; offensive sweat; desire for vinegar, acids,
pickles and sour, but sour food aggravates; aversion to
food; sad, indifferent even to loved ones, irritable,
indolent and quarrelsome. Aggravated after laundry work
and better by warmth of bed, after violent exercise.
7. Sulphur Dirty, filthy skin, excessive burning all over, marked
itching, wants to scratch, burning after scratching.
Eruptions dry, scaly, pustular, cracks and
excoriations in skin folds. Relapsing complaints.
Suitable to quick motioned, quick tempered, irritable
persons who are mentally egoistic, dwell on
philosophical and religious speculations (ragged
philosopher). Lean, stoop shouldered and scrofulous

persons, nervous temperament, cannot stand for a
long time, marked aversion to bathing. Hot patients
who desire sweets and in whom milk disagrees.
Aggravation from rest, warmth of the bed, washing,
11am, night, early morning, standing. Amelioration dry
warm weather lying on right side, drawing limbs.
Burning all over the body especially in all the orifices
e.g. nose, ear, rectum vagina, urethra etc.; flushes of
heat on face.

White/hypopigmented patches
Examination for sensory loss
No Sensory loss Sensory loss

refer refer
Rule out Tineaversicolor, Piebaldism & Idiopathic guttate

Hypomelanosis
Vitiligo confirmed
Investigations
Start homoeopathic treatment and
 Anti-TPO, anti-thyroglobulin Advice for general management
antibodies
 TSH and other tests if needed to General Management :
assess thyroid function or Follow up atleast once a month &
diagnosis(e.g. anti-TSH assess improvement in degree of
antibodies if Grave’s disease) Avoid pressure, trauma
pigmentation& surface area forat
 Additional autoantibodies (only etc. (Refer text)
least 1 year
if patient's history, family
Nails should be
history and/or laboratory
trimmed and filed to
parameters point to a strong
avoid damage to skin
risk of additional autoimmune
while scratching.
disease)
Continue Homoeopathic
Treatment
Presence of Red flags

 Uncontrolled TSH
 Endocrinal Assess for resolution of
disturbances case
 Uncontrolled level
ofauto antibodies
Refer for standard care

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STANDARD

Central Council for Research in Homoeopathy,

Publisher: Central Council for Research in Homoeopathy

Globally' health service delivery institutions

3' Based upon the information available

4' I am pleased to support this initiative undertaken

New Delhi (Ajit M. Sharan)

This advancement in medical field has been of paramount importance for a

Over the years, RCTs/ Observational studies, experiences of homeopathic

Council has made an attempt to develop a standardised guideline for management of

Evidence rating B − requires the availability of well−conducted clinical studies but no

Evidence rating C − requires evidence obtained from expert committee reports or

HOW TO USE THIS BOOK?

The contents of this book have been arranged in alphabetical order/acute/chronic.

Homoeopathic therapeutics have been suggested, which includes the characteristic

Homoeopathy, a therapeutic system of medicine discovered by a German physician, Dr.

Holistic concept of Health and Disease

A holistic model of health in Homoeopathy, taking an overview of the patient, including

Repetition of the remedy

1.2. Long aggravation but final and slow improvement.

1.4. Some patients prove every remedy they get.

2.1 Disappearance of symptoms/no aggravation with recovery of the patient.

2.2 Too short relief of the symptoms.

Interpretation: There are latent conditions (existing organic conditions) in a few

3. No Change / Status Quo

Interpretation: when no change is observable in the symptomatology in a patient, even

Follow up action: Intercurrent medicine may be prescribed.

5.1. New symptoms appearing after the remedy.

5.2 Old symptoms are observed to reappear.

5.3 Symptoms take the wrong direction.

CCRH 1 Updated on 10th Jul, 16

Although pneumatic otoscopy is helpful in the diagnosis of AOM, it is not routinely

CCRH 2 Updated on 10th Jul, 16

CCRH 3 Updated on 10th Jul, 16

CCRH 4 Updated on 10th Jul, 16

S.No. Medicines Indications

comparisons with conventional therapy. Int J Clin Pharmacol Ther. 1997;35(7):296-301

resolution? Br Homeopath J. 2001;90(4):180-2.

children? Homeopathy. 2013 Apr;102(2):145-50.

CCRH 5 Updated on 10th Jul, 16

CCRH 6 Updated on 10th Jul, 16

7. Mercurius Shooting pains in ears, which feels stopped and swollen.

CCRH 7 Updated on 10th Jul, 16

 In case of high grade fever

Referral criteria Check for complete

CCRH 8 Updated on 10th Jul, 16

A disorder characterized by a pathological pattern of alcohol use that causes a serious

CCRH 1 Updated on 10th Jul, 16

Conceptual causal model of alcohol consumption and health outcomes3:

5Warren T. Alcoholism. [Cited 2014 Sep 18].Available from: http://emedicine.medscape.com/article/285913-

CCRH 2 Updated on 10th Jul, 16

ICD-10 criteria for Alcohol dependence clustering:

Signs and symptoms of alcohol withdrawal syndrome5:

CCRH 3 Updated on 10th Jul, 16

Signs of chronic alcoholism:

Liver function tests o AST:ALT ratio – >2 suggests alcoholic etiology

CCRH 4 Updated on 10th Jul, 16

CCRH 5 Updated on 10th Jul, 16

A. Scales for screening: