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| Hpathy Ezine - Sept., 2006 | ||||
Violent Man with Chronic Pancreatitis- Dr. Praful M Barvalia |
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| Philosophical Analysis:
Deciding on the remedy is only half the work done in situations like these. Before we see the follow up management, it is important to get a good philosophical grasp of the pathology one is dealing with in order to have a good long term management strategy. As a teacher, this is how I teach my students to handle serious pathology in any clinical setting.
First, we need to understand the pathology one is dealing with:
The leading clinical symptoms in chronic pancreatitis are upper abdominal pain and maldigestion. I like to use a clear concept of form-function-structure in every clinical situation I encounter as it helps us to get deeper insight to the clinical state that needs to be cured. Once the patient presents with complaints, it is important for the clinician to comprehend the degree/level of disturbance in function as well as nature of changes in the tissues and organs responsible for this symptom expression. I will explain how I use this concept. What is perceptible to the homeopath are the external signs and symptoms. Based on this we recognize the disease and perceive it as a FORM (symptom expression) that evolves over a period of time. This expression keeps changing as the patient interacts with his environment. Ultimately changes in STRUCTURE take place. In other words, changing FORMS express themselves to us through disease complaints which result in structural changes over time. When we appreciate the interrelationships between these various expressions, we perceive a PATTERN in the expression of this form - which is the symptom picture that indicates a similimum remedy. Diseases arise due to a fault in the functioning of a system. Thus a FORM is an expression of disturbances in the organ function. These disturbances of FUNCTION over a period of time produce a disturbance in the STRUCTURE and then, the latter aggravates the former. Thus a vicious circle is set up in chronic diseases. Again both these disturbances are revealed to us through changing complaints --> changing FORMS (pictures). In other words, as the disease progresses, it is revealed to us in a continued change in FORM, FUNCTION AND STRUCTURE. It is important to have an integrated understanding of this phenomenon for management of serious diseases.
Based on an understanding of this inter-related phenomenon, one can arrive at logical formulations about following homeopathic parameters: i) Susceptibility of the patient:
ii) Miasmatic diagnosis: Identification of the dominant miasm as well as degree of miasmatic activity. iii) Posology formulations iv) Phase diagnosis: Accurate identification of the current phase for a remedy choice :- constitutional , chronic, acute or purely antimiasmatic. We also get insight about possible pattern in which the case might unfold --> future projections.
Now, let us apply this model to appreciate different clinical patterns of chronic pancreatitis: A) The Form: is the acute sudden expression of excruciating abdominal pain extending to the back. This is often precipitated by increased consumption of alcohol . The Funtion: Raised Serum Amylase Levels with indigestion. The Structure: Acute inflammation of ductal and acinar cells which over time undergo fibrosis following frequent relapses.
B) The Form: This has relapsing features: - severe epigastric pain with or without radiations
And constant features:
The Function:
The Structure: 80% PANCREATIC FUNCTION DESTROYED
Hence, initiate treatment with chronic/constitutional . Susceptibility : Moderate to Low Miasm : Advanced Tubercular miasm Posology : 30 potency (medium to low) and will require frequent repetition.
Prognosis & Homoeopathic Projections:
According to modern medicine, Chronic pancreatitis implies the presence of irreversible damage to the pancreas. In the presence of diabetes mellitus and pancreatic insufficiency, the prognosis becomes guarded. The survival rate in some series in the presence of such complications is less than 10 years. Classical Homoeopathic experience is otherwise. The following points should be kept in mind for management of Acute on Chronic Pancreatitis: * The Susceptibility here is moderate to low. So one must start with the 30 potency of constitutional and gradually build up the repetition depending on the sensitivity of the system. * Judicious use of Tub. bov. as the intercurrent antimiasmatic helps a lot in improving the susceptibility of the patient. * They may present with an acute exacerbation of symptoms. In such instances, if a clear cut Form is expressed, only then treat that phase of symptom expression with a different (acute)medicine; otherwise it's advisable to enhance your repetition or potency of the constitutional remedy instead. * During course of treatment, they may present with episodes of loose motion; DO NOT TREAT THIS WITH UNNECESSARY SUPERFICIAL MEDICINES * Often they develop skin rashes. Here one must learn to differentiate between exteriorization of symptoms, and opportunistic / staphylococcal and fungal infections due to Diabetes Mellitus or poor general health and hygiene so take appropriate measures.
The cause of chronic pancreatitis, which is invariably alcohol , should be emphasized. The patient should be told that unless alcohol consumption is discontinued, no improvement can be expected. An explanation of the various complications encountered with chronic pancreatitis should be explained to both patient and family.
Let us understand the intricacies of the philosophical explanations above through the management of this case.
Follow up Synopsis for 1st 1 month of treatment : 23/3/1994 to 26/4/1994 Since the patient was admitted with an acute excruciating pain which made him quite restless, the first line of treatment was an acute remedy. This is typical of the type A expression of Form - Function - Structure explained above. The analysis of his symptoms indicated Colocynth. It was given in 200C 2 hourly. With no significant relief after 4 doses, he was switched over to Mag Phos 200 2 hourly and later 4 hourly. There was significant relief in his distress within 4 hours but the Mag Phos 200 4 hourly was continued for 3 days. Now was the need to start the chronic remedy as the constitutional features were beginning to become more evident. The KALI-IOD 200 was given at bed time every night, while the Mag Phos was going forward. Later Kali Iod was increased to a b.i.d. [two times a day] and then t.d.s.[three times a day] dosage. Tub bov 1M 1 dose interpolated on 19/4/1994. Other measures:
He was advised on other ancillary measures to support the healing process.
Follow up Synopsis of the following 1.5 years of treatment: 27/4/1994 to 31/12/1995
* There was not a single episode of Jaundice or acute exacerbation of pancreatitis. * He had recurrent bouts of loose stools which required Podophyllum 200 and later Podo 1M. * On 9/11/1994 – He developed several boils all over the body which required Calcarea sulf 30 qds [four times a day] for a week. * On 9/12/95 he had one episode of URTI [upper respiratory tract infection] that required Ars alb 200. * Serum amylase returned to Normal by 6/12/1994 (42 SC units/100ml ), nearly 8 months after the start of treatment. LFT and lipids became normal by 1/5/1995, a little over a year
since Kali Iod was started.
* Over all his irritability and mental state improved quickly in the initial phase of treatment, but his relationship with his wife remained almost the same. His wife ran away to her parents place at Bihar. The patient went to bring her back but he was very angry with her. He felt like killing her! He even got into a physical fight with his brother-in-law who tried to defend her. Both were in an enraged state of mind and the patient stabbed him. Luckily the Brother-in-law survived. But the patient turned himself in and was arrested. He was sent to jail for 3 months.
* From 27/4/1994 to 9/8/1994: He was on Kali-iod 200 4 hourly. Tub bov 1M was interpolated twice
* From 9/8/1994 to 31/12/95: The potency was increased to Kali-iod 1M 1 dose every night. During this phase the Laboratory Parameters began to improve and returned to normal .
* From 1/1/1996: all active medication was discontinued as he remained stable and normal clinically as well as from biochemical angle. His L.F.T was rechecked and it was W.N.L .
* 10/2/1999: He brought one of his neighbours for treatment with us. We observed that the patient had mellowed down considerably. This was also attributed to his parents demise. He had developed Grief++, Guilt+, “I did not listen to my Father”. His wife had left him and he felt very lonely. His Diabetes Mellitus remained under control . He had no other health problems.
References: 1. Medicine for Practising Physicians: J. Willis Hurst 2. Text book of Pathology: Willium Boyd 4. Materia Medica: Hering, Phatak, Robert, Kent. 5. Chronic Pancreatitis: New Pathological Aspects, Shailesh Shrikhande, Helmut Fries, Marcus E. Bombay Hospital Journal Vol .44 - No.4, 1999.
This article was published in ijhm vol . 33 issue 1/2000-2001 Dr. Praful M Barvalia, MD(Hom) |
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Chronic
pancreatitis (CP) is an inflammatory disease of the pancreas which
leads to persistent and progressive morphological and functional
alterations of the whole organ. In the terminal state of the disease
the extended fibrosis leads to exocrine and endocrine pancreatic
insufficiencies. Histomorphologically, the chronic inflammation
of the pancreas is often characterized by:
