A case of vertigo and diabetes adapted from a presentation by Dr S.K. Phansalkar on the 15^th of January, 2005 at the Dr. M.L. Dhawale Memorial Rural Homoeopathic Hospital in Palghar, India

Objectives:

1. Learning the importance of clinical diagnoses
2. Learning to perceive the Essential Evolutionary Totality
3. Assessing susceptibility, sensitivity and miasm

The Case

Presentation 6/3/98:

Mr. P. aged 30 yo was brought for consultation with his wife and mother. His mother was in tears and said, “Dr., for the last 3 weeks he is not going to work. He just sits at home, doesn’t do anything and sleeps the whole day”. The patient has been having vertigo, diabetes and tingling numbness in lower part of legs. Dr. Y., a diabetologist is suspecting this is due to diabetes only. During the consultation the patient recounted the following complaints:

He has had attacks of vertigo from 1988-1990, but since October 1997 there is a horrible feeling while walking. One day while getting ready for the office, he bent his head forward to locate his keys and he felt horribly dizzy. Since that time the vertigo is more or less continuous. He denied any tension in the family, work or society and said. “My disease is causing a lot of anxiety”.

Location	Sensation/Pathology	AF, < >	Concomitants
Head	Vertigo SAI: Falling down while walking (> rest, < physical exertion), but has never fallen	< bending forward, crowds, open spaces, travelling by motorcycle	If vertigo remains for long time → palpitations, suffocation, anxiety
Eyes	Feels vision is not steady, no nystagmus
Back	Pain with weak sensation and burning	< morning when going to bank
Extremities, Lower	Tingling & numbness since 6 mths

Diabetelogist is suspecting that tingling and numbness in lower extremities is due to Diabetes (nerve involvement) and suggested EMG studies, but patient does not want to undergo any investigation “I am fed up of all this. Do something about the vertigo. As soon as I bend head forward it starts.”

He is also suffering from sleeplessness since November 1997. Again he denied any apparent reason for it and said “I am fed up with vertigo which may be creating tension and sleeplessness”.

Background information:

Mr. P. comes from a middle class Brahmin family who lived in their own house in Pune. Family consists of father, mother, son (Mr. P) and daughter.

His childhood was quite disturbed; his parents used to have frequent fights. His father was a bank clerk suffering from paranoid schizophrenia and severe Diabetes; the diabetes developed when he was 35 and he was under psychiatric treatment from 1987 onwards. Mr. P. was afraid of his father who was an extremely irritable  and suspicious person whose marital life was very disturbed. He would beat his children & wife and had fights with his mother over a property at Vai. The patient used to feel quite unsafe at home and internally used to feel irritated towards his Father, who passed away in 1994 due to a myocardial infarction. Mr. P. early on lost interest in the family & frequently passed his time outside with friends. Mr. P. was quite friendly and had a large circle of friends.

The patient always felt much closer to his mother who was under homoeopathic treatment from 1987-88 for migraines and anxiety. She comes from a village near Kalyan, was educated up to XI standard and was a teacher before marriage. She was temperamentally non-fighting & adjustable and had great difficulty handling her negativity about her husband till the end. The physician many times felt sorry for her and took the stand of a listener

Mr. P’s sister was brought up in the same atmosphere of frequent fights. She was under homoeopathic treatment in 1986-87 for nocturnal enuresis & frightful dreams. She was quite fearsome, insecure & timid.

Mr. P’s health has not been sound since childhood. He had abdominal pains, headaches and colds. Parental fights & exams would increase his troubles. He used to feel sad about family affairs but couldn’t do anything. His stamina for studies was not much. He would get colds or headache if he studied for a long time. Mother would take him to the doctor and medicines would give temporary relief. His family difficulties were known to his friends, he used to share it with them but not very frequently because he would get more tensed and the complaints would aggravate.

Mr. P. wanted to become self sufficient as early as possible. Hence he went for a job in his 2^nd year at college. His career till 10^th standard was first class. His hobby was cricket. He would like movies, mainly family type. His reading was mainly of historical novels. His ambition was to get a stable job after completing the Bachelor of Commerce.

Mr. P. currently holds a job at Bank of Maharastra in his father’s place. Mr. P. got married to a Christian lady from the bank in 1993; Father opposed but mother supported the marriage.

Presentation 13/3/98 including life space around onset of complaints:

One week later on the 13/3/98  Mr. P. didn’t answer clearly but said no change. He appeared as if withdrawn. Patient still didn’t answer anything about potential causative factors in the last 3 months. Hence his mother and wife were asked in details about the onset of his diabetes & precipitating factors.

In Sep 95, he was complaining of dimness of vision in Rt. eye for which he consulted an ophthalmologists. She asked to undergo BSL which was PP=182. It was attributed to physical & mental strain experienced at the Bank; daily traveling of 120 km & continuous work without rest. His earlier job was at closer to home and less time consuming. He was put on glynase 5 mg O.D. After that nobody bothered to follow his BSL. He didn’t have many complaints in between Aug 97 to Oct 97.

There was continuous mental & physical stress. They shifted to a new flat July 97, which one month later flooded, destroying most belongings. Shifting of damaged items and restoring it has put a lot of physical & mental strain on patient. He was not home at the time of the flood. His mother was trapped in the house and had to be escorted by the fire brigade. She suffered a heart attack in Jan 97 and the patient constantly feels tensed because neither him nor his wife can be with her during the days. He is trying hard to get a transfer to Pune but is not getting it. He is not sleeping well and is frequently telling his wife and mother that this flat is not good for them.

His sister got married 3 yrs back but the marriage has still not consummated. The SIL’s blamed his sister and they are accusing her of having an extra marital affair. Therefore Mr. P and his mother went to her in-laws place where they had many heated exchanges. Mr. P shouted and was quite tensed. Within some days he came down with vertigo. He was quite sad about these events; anxiety, sadness, physical exertion contributed heavily to his illness.

Husband-Wife relationship is all right. His wife is calm and quiet. His mother and wife said that otherwise family atmosphere is very good. I.P.R’s are good.

At present he only wants a transfer to Pune, otherwise job satisfaction is OK. He is not very ambitious about bank promotion. IPR with colleagues and officer is quite good.

He loves to visit friends, but has no time since going to Shirur. Since the vertigo started he has progressively gotten worse. In the last two weeks he hasn’t gone to the office at all. He doesn’t take much interest in family matters. He either sees T.V. or sleeps in one position throughout the day. His BSL is progressively increasing. “Doctor, we are worried - Is he is following his father?”

Patient as a person:

Height:	5’ 8"
Weight:	65.5 kg (2kg increase in 2 mths)
BP:	120/90
Perspiration:	Head + Back +; no stains, no odour.
Cravings:	Pungent 2
Aversions:	Sweets 2 (very choosy about food)
Thermals:	Hot Summer < 2 → Prickly heat, h/a   - < Sun < Cold, monsoon Winter: 2 chadars Monsoon & summer: no covering Fan Slow: Winter feels less cold than others, Woolens only if severe cold temp

Current BSL and medication: Fasting = 171, PP = 192. Mdx: glynase 5 mg. B.D.

Past complaints

He had been under treatment from 1988-91 for various complaints: Case Recorded on 2-1-1988 : Age- 20 yrs.

Location	Sensation / Pathology	AF, < >	Concomitants
G.I.T- Colon Since childh. 4-5 BM/d Abdomen On & off	Stools ↑ frequency Gases + Mucus + Takes time (30-40 min) pains weakness	< Bhel, chillies2, outside food. < Morning < Tea, omelette < Before exams	Salivation
Resp. Tract / Sinuses	Heaviness	< exam time, prolonged study
Nose 1/mth for 8-10 d since childhood Chest	Blocked Watery discharge. Cough2 No vomiting, No mucus Occ. fever	< Monsoon < Dust2 < Sun 2 < Rains < Late nights2 not better by steam inhalation
Head Vertex Occiput On & off 1-2/weak since 2-3 yrs has increased	Pains Weakness Fatigued feeling No interest in Environment	AF: Anxiety- Father-mother fights, < Mental tension2 < Mental exertion, study < Summer > Binding Head Tightly3

Treatment in past

His treatment started in 1988. He reported regularly in 1988-89, then in 1991, 1992, quite infrequently.

Headache & cold responded well to Kali Bi-30-1M. but G. I. was not ameliorated with Kali Bi.

He was put on Nat mur, Mag mur, Nat sulph but his G. I. didn’t improve.

1990 to 1998 there was not much contact of physician with this family. Mother, daughter, son didn’t report regularly.

Investigations:

Date	Reports
3/12/97	Pulse: 48 to 60/min, BP:130/80, ECG: sinus arrhythmia, T inverted in AVF, changing R-R interval.
10/12/97	Refraction test: No nystagmus
13/12/97	Diagnosis on medical certificate: vertigo.
15/12/97	X ray of cervical spine, Chest A.P , CT Scan of brain: no findings
16/12/97	Audiogram: Bilateral very mild sensory-neural-deafness SISI = more than 70% → DD: Meniere’s disease. Mitral valve shows prolapse, No Mitral regurgitation, No pulmonary HT. Neural examination: no findings + Haemoglobin: normal

CASE DISCUSSION

Clinical Diagnosis

1) Vertigo;

Definitions: Vertigo vs Dizziness

Vertigo comes form the latin word for turning; the patient feels as if he is moving in relation to his environment, or as if the environment is moving in relation to him. Dizzy comes from an old English word (dysig), meaning foolish or stupid. Dizziness refers to unsteadiness or lightheadedness, without movement, motion or spatial disorientation.

It is important to establish the cause of vertigo in this case.

The differential diagnosis includes the following:

• Nervous system; vestibular system (commonly 8^th cranial nerve involvement), cerebellum (degeneration, tumours)
• Cerebro-vascular;  brain stem (vertebrobasilar insufficiency, infarction), incl. other spinal dysfunstion
• Infections: ear (chronic otitis media) NB: Ear (80-85% of cases); often with tinnitus, hearing disorder
• depression / anxiety; psychogenic                                                
• Ménière’s disease
• Vascular; arrhythmias, aortic stenosis, hypotension
• Anaemia
• Trauma, drugs (prescribed & illicit)

The clinical investigations have not found any clear organic causes for the patient’s vertigo. It is therefore probably of functional origin. The fact that he has SAI: Falling down, and aggravation of the complaint in crowds and open spaces, as well as the concomitants of breathlessness, feelings of suffocation and palpitations during prolonged episodes, points to the vertigo being due to anxiety. The state of anxiety has worsened along with the vertigo to an extent that the patient currently does not attend work or leave the house.

Non-psychogenic vertigo is commonly aggravated by turning the head or movement; in Mr. P’s case though the modality ‘< bending head forward’ becomes characteristic because of the vertigo’s pychogenic character.

2) Diabetes Type 2 with diabetic polyneuropathy

Demyelination of axons in diabetics often gives rise to nerve affections, such as tingling in lower extremities; it commonly occurs as a distal, symmetrical, predominately sensory polyneuropathy that causes sensory deficits, which begin with and are usually most marked by a stocking-glove distribution.

3) Anxiety

The Use of The Essential Evolutionary Totality Form (EET)

"The EET is an integrated, synthetic and evolutionary representation of the most important an necessary elements of the object in question with its process of development that represents the whole i.e.  we are able to perceive a moving picture in its entire dimension from birth till today. This represents the essential attributes and their pattern of organization from the evolutionary standpoint" (ICR Operational Manual, p.94)                

Significance of the EET (ICR Operational Manual, p. 96):

It represents the essence in terms of the evolution of the object; it helps us understand the problem definition in an integrated way in the life of the patients. When we cut at any transverse level we get a totality of events that guide us to see the specific problem at that given moment in time.

It helps us integrate cause → effect → concomitant → phase in a single view

Problem definition guides us to an integrated problem resolution in terms of knowing the different states and stages of disease so that susceptibility can be assessed in an integrated way, formulating different approaches, remedies, miasms, understanding of the maintaining causes etc. It also guides us towards prognosis and taking care of any dangers or precautions

It helps in understanding the remedy in all the dimensions of time so that the images of living Materia Medica can be erected

It helps in understanding the march of events from predisposition → disposition → diathesis → disease so that proactive steps can be taken.

Psychosomatic understanding can very well be appreciated through the EET

The EET applied to the presenting case

Miasmatic Analysis

The patient has been in a sycotic phase for much of his life; his respiratory complaints have been of a chronic persistent nature and < damp, the IBS was characterized by requiring 30-40min for a bowel motion. He has moved beyond  sycosis into a tubercular phase though, as his diabetes manifested. In his first years of suffering from diabetes type 2 he has developed diabetic neuropathy. Usually this takes 8-10 years. This indicates that the pace of the disease process is fast, as is characteristic of the tubercular miasm. Therefore the physician must act fast to halt the disease process. If sycosis were still dominant a slower deterioration would be observed.

Analysis, Programming and Planning

1) Structuralisation Approach:

The EET helps in perceiving consistent features in multiple disease processes and phases in life; weakness / debility if under mental or physical strain; currently to the extent that he doesn’t work; TV / sleeps all day.

Weakness/Debility (mental & physical) in times of increased demand and as concomitant to various physical ailments: headaches, respiratory complaints, back pains, vertigo and diabetes Debility has been a feature throughout his life; This leads to two remedy groups:

• Ferrums
• Acids
  → the remedy must cover hot thermals of patient → Fe-sulph, Fe-iod, Pic-ac, Fl-ac, Mur-ac (Ph-ac cold, Sulph-ac: ambi)

Fluoric acid is known for its endurance and hard work as well as the ‘letting go’ of self constraints / morals which is not perceived in this case.

Answering the question of how Ferrum’s develop certain complaints and why Picric acid would will lead to the selection of the Similimum. The causal line of EET seen in this case must be represented in the Remedy EET.

In Ferrums there is hypersensitivity → excitability → debility, whereas in this case this sequence is not seen in the EET. In Picric acid there is no preceding phase of excitability before developing debility.

1)    Repertorial approach:

 

 

 

 

 

 

 

 

 

 

 

Remedy differentiation:

Ferrum sulph	Ferrum iod	Picric acid
*Hypersensitivity → excitability → debility *Suppressed anger *Irritability *Changeability *Local atony; disposition to congestion	* Hypersensitivity → excitability → debility *Suppressed anger *Irritability / General phys anxiety *Changeability *Scrofulous affections *Glandular congestion / enlargements, Goitre *Tumors, Boils	Acts upon the generative organs probably through the lumbar centers of the spinal cord; prostration, weakness and pain of back, pins and needle sensation in extr.   Weakness of body and mind. < least exertion esp. mental, after sleep, wet weather > cold, bandaging, rest SOA Nerves
- Severe vertigo; with diarrhoea.	- Vertigo while walking - Pressing throbbing headache,  forehead, tinitus, sensation of blood rushing into head and face > in fresh open air, < warm room - Colicky pains, with flatulence and diarrhea	- Vertigo from mental exertion - Head aches after prolonged mental strain, < examinations, > bandaging tightly - weakness of lower limbs with numbness and/or tingling Clinical: Diabetes

Remedy selection:  Picric acid

Potency & Frequency:

Susceptibility: lowered
Sensitivity: heightened
Suppression: emotion / anger
Correspondence: degree & level; high
General vitality: gen ok but low tolerance
Dominant miasm: TubPace: fast

200C, infrequently

Follow up

1	Sleep	6	Anxiety
2	Interest in surrounding	7	Extremities Tingling Numbness
3	Weakness	8	BSL
4	Vertigo	9	Weight/BP
5	Attendance work	10	Allopathic Medicines

 

Date	1	2	3	4	5	6	7	8	9	Prescription
13.03.98										Picric acid 200C
19.03.98	G	S to >	>	>2	>	>	>	-	120/80	Picric acid 200C
27.03.98	>2	>2	>2	>2	S	>2	>2	F-96 PP-110	--	Placebo
03.04.98	-	>3	>3	>3	S	>3	O	--	130/90	Placebo
10.04.98	Started attending work regularly from 04/04/98 onwards								Wt-65	Placebo
17.04.98	Attending work regularly. No problem								130/80	Placebo
24.04.98	Feels little exhausted & pressure at work - due to exertion Adv- BSL. Tingling extremeties +								140/90	Picric acid 200C