Clinical Cases

Anal Fissure and Piles in a Woman of 53

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Written by Ilyas Akhundzada

Dr. Ilyas Akhundzada presents a case of anal fissure and piles in a woman of 53.


Homeopathic management of the patient requires not only thorough knowledge of Materia Medica and repertorization techniques but also clear understanding of what is going in the organism during the treatment. Besides the totality of the symptoms, which is sometimes announced as the one and only method of right prescription, there are also other methods, more suitable for some special cases.  These methods was outlined by G.Vithoulkas as prescriptions based on keynotes, mental-emotional pictures (essence), specific combinations of symptoms (essentials), pathology and causative factors.  The other very important issue in taking a case is an underlining or matching the symptoms according to the degree of their intensity. This is particularly important in cases of so named “one-sided diseases”, where the patient shows a paucity of symptoms and we need to select the most prominent ones to prescribe correctly.

The main goal in treatment by homeopathy is not only the right prescription but also proper evaluation of the case and selection of the next necessary remedies. The utter importance of this evaluation together with more than 20 patterns of possible reactions was outlined in a treatise of G.Vithoulkas  “Levels of Health”.

The following case is given to show usage of the above mentioned principles in practice.

The Case

N.A. is a female, born 1965.  Her height is 170 cm and body weight is 78 kg. She has rather stout complexion with dark eyes and hairs. She works as a teacher in a university. Her main complaint is a painful anal fissure (Homeopathy for Anal Fissure) and piles for which she was about to be operated on. However, she didn’t want surgery and has decided to try homeopathic treatment first.

Main complaints and modalities, present illness history:

(The score in brackets is used to indicate intensity of the corresponding symptom).  She has painful hemorrhoids and anal fissure. She first had it in 2006 and at that time doctors recommended operation but she refused and tried allopathic treatment, which had some effect. Since August of 2013 she again has been having this problem. She has a tendency to constipation and her bowel motion is once in 2-3 days (2). Her stool is usually hard, sometimes even like  sheep-dung. There are no visible piles, but they go out during the stool. Since August of 2013 she had 3 episodes of slight anal bleeding. There is burning pain before stool which is better after defecation (3). Then, after 3-4 hours of emptying there is dull pulsating pain, which is better from walking (3), worse from lying. She often uses suppositories and micro enemas for relief of anal discomfort.  Sometimes she has headaches (no other details).

She has flatulence, which is worse after farinaceous food and fizzy drinks (1). She feels heaviness in stomach 1-2 hours after eating (1).

Personal history (past illnesses, medications, vaccinations):

She got all the child vaccines and had mumps in childhood. 7-8 years before she had strong backaches, which were treated allopathically. Then she had episodes of sensation of swelling in the mouth and throat, which passed without any interventions. In 2003 she has an episode of cystitis treated by allopathy. Since 2006 she was diagnosed with fibroids of the uterus. From time to time she has leucorrhea for which she uses allopathic treatment. In 2006 she developed exacerbation of her anus problems after vaginal douche. Three years before she had sclerotherapy for varicose veins of the legs, after which she developed edema of a foot, which is better from walking and worse from sitting. Two years ago she developed urticaria with eruptions all over her body and swelling of her lips. It lasted for 5-6 months and was treated by allopathy together with ozone therapy (complementary treatment).  The previous year she had unpleasant sensations in the region of the heart caused by problems of her children. She doesn’t reveal details. She took tincture of Passiflora for this.

Generals:Temperature regulation (feels warm or cold) – how weather affects complaints (e.g. wet, dry, stormy weather):

She experiences occipital headache from wind. She doesn’t like cold as she feels very chilly during winter. She doesn’t like the sea, as she has palpitation and difficult breathing at the seashore. She feels stiffness in knees during damp weather (1).

Perspiration (e.g. inability to perspire, profuse perspiration, which parts): No particularities.

Thirst and characteristics (e.g. for sips, for large quantities, desire for warm drinks, cold drinks): She likes tea and doesn’t like water. She particularly doesn’t like cold water.

Appetite (e.g. increased, decreased, changeable, specific time): No particularities

Foods that aggravate: She has flatulence after farinaceous food (1).

Desires: Pepper and spicy food (1).

Aversions: Doesn’t like smell of offal (1).

Sleep: (position of sleep, cold feet at night or uncovers feet, salivation during sleep, grinding of teeth during sleep, repeated dreams):

She goes to bed at 22.00, watches TV and falls asleep at 01.00. She sleeps on her right side and can’t sleep on the back or abdomen (1). She gets up at 07.00.

 Mental & emotional symptoms: No particular symptoms here. Before she liked to be in company, but the last years she prefers to stay alone. She is calm, but doesn’t like when a third person interferes in dialogue. Sometimes she feels like crying when getting angry. She feels exertion at work, as she must be precise.

Phobias: No symptoms

Marked mental symptoms (e.g. too timid, reserved, excessive loquacity, haughty): No symptoms

Mood (sadness, anxiety, discontented): Normal

Memory-concentration: (e.g. weakness of memory, forgetful for words) When she exerts herself, she sometimes forgets words during talking.

Physical symptoms:

Head (headaches, perspiration, eruptions): Occipital headache during exposure to cold wind. Pulsating headache in temples 1 day before menses (1-2).

Face, nose, ear: Normal

Respiratory system: Normal

Cardiovascular system: No symptoms

Gastrointestinal system (pain, eructation, distention and modalities): Described as a main complaint.

Urinary system (e.g. urination offensive, feeble stream, forked stream): No symptoms

Genital system (e.g. menses in women, painful, copious, intermittent, clotted):

Menses are regular and since age of 15 years.  She has pulsating headache in temples, 1 day before menses and takes painkiller for this (2).. Sometimes this headache is better from sleeping.

For the last 2-3 month she has pains low in the abdomen during menses.

Sexual desire: Normal

Back-extremities, joints (e.g. pains and modalities, sensations): No symptoms
Skin: No symptoms

Nails (e.g. hard, brittle, in-growing toenails): No symptoms
Other: No symptoms

 Latest high fever: She doesn’t remember.

Family history: Her father, brother, sister were operated on for hemorrhoids. Her father died from cardiac insufficiency. Her paternal grandmother had diabetes. Her mother had arterial hypertension.

Level of health: As we don’t have a clear picture here and long absence of acutes we can think about group C. However, there is no great disturbances in general health and the vital force is able to localize symptoms on peripheral tissues, so we can suppose placement of this patient in lower levels of group A.

Comments: It seems that she has got inherent weakness of veins which is presented as hemorrhoids and varicose veins. Suppression by allopathic treatment can be considered an exciting cause of her diseases. Based on her personal history we can trace development of pathology as following: 2006 hemorrhoids and fibroid of uterus, 2007 backaches, 2010 varicose veins, 2011 urticaria, 2012 heaviness in the heart because of stress with children, 2013-2014 return of hemorrhoids and development of dysmenorrhea.

First prescription:

There are no clear mental, emotional or general symptoms in this case. However, as I was not aware of other methods at that time, I just used totality of the symptoms. According to the flat repertorization, I selected Nux-vomica. She was given Nux-vomica C30 at 27.03.2014. The repertorization was performed by Homeopathy Pro software and based on Kent’s repertory.


Follow-up 1, 27.04.2014

She arrived after a month with the same symptoms. The pains in anus were even more, with no amelioration of the general energy or mood. She had one episode of elevated arterial pressure before menses, which she never had before. However she didn’t have pulsating headache this time (This can be supposed to be a shift of the symptom).

Notes: Clearly there was no local amelioration but aggravation and shift of the symptoms without any change in the general state of organism. According to pathology she was given Aesculus C6 and after 2 weeks Aesculus C30 with very short amelioration. She had to repeat the remedy every 10-14 days. Again there was no positive progress in the case.

Follow-up 2, 22.10.2014

Her case was retaken and Sulfur 30 was prescribed at 14.08.2014. The prescription was based on most prominent local symptoms and their modalities. After taking 2 doses of Sulfur c30 and one of C200 (each every 3 weeks approximately) her symptoms changed as follows.

Her menses become less, her headaches before menses disappeared. Now she complains of absence of urge for defecation and constipation (1 stool in 4-5 days), pulsating pain 1-2 hours after defecation. She says that she isn’t much bothered by having constipation (3). She also says that her leucorrhea has increased (1). She also notes flatulence after apples and dates. She tends to be chilly; likes to wear socks at night, and notices ameliorations of rectal pains from it (3). Again sometimes she has urticaria (1). A day before she had heart pains and numbness of the left hand. She notices that after-stool, pains are radiating onto the back (1). She has eructation with smell of rotten eggs at morning, particularly if eating something late in the evening (2).

Notes: Now one can clearly see key features of Calcarea carbonica: not disturbed by constipation, cold feet in the bed requiring her to put on socks Therefore we can assume that Sulfur helped to “open” the case, i.e. to bring up a more clear clinical picture. This is in accordance to reaction pattern number 8 (See “Levels of Health” by G. Vithoulkas and E. Woensel).  She was prescribed Calc-c C30, and C200 2 months after the first dose.

Follow-up 3, 22.01.2015

She says that there is no change after taking Calc-c C200. However, now she has stool every 3 days. Pains in the anus are the same. Sometimes she gets itchy eruptions all over the body at evenings. She has difficulties in remembering reading text and sometimes she forgets words during talking (2). Now she is not as chilly as before. Now she again has headache before menses. She feels better after drinking sweetened water and from a rest (when lying). She likes to drink water with honey before sleep (3), otherwise she can have sleeplessness. She usually wakes up at 3-4 a.m. and cannot sleep anymore (2). She has flatulence and eructation after 6 p.m. (3). She notes that she has become very sensitive to the smell of perspiration (3). She doesn’t like sharp sounds (1). 

Notes: Now we can see a clear change in generals (the patient become less chilly, desire for sweets), return of old symptom (urticaria, headache before menses) and some new peculiar symptoms (sensitiveness to odor of sweat, flatulence at the evening).

The patient was prescribed Lycopodium C30.

Follow-up 4, 20.02.2015

Her hemorrhoid is the same. However she has some marked new symptoms. She has edema of upper eyelids, like small bags on inner corners of both eyes (3). It is more marked at morning. She complains of stiffness of the left knee (3). She drinks 3-4 glasses of water on the morning in order to make her stool more regular. However, it tends to be once in 3-4 days. She wakes up at 3-4 a.m. and cannot sleep till morning. Her food modalities have been slightly changed. She has started to eat more sweets recently (2). She doesn’t eat pickles as much as before. She again becomes quite chilly and has to wear socks at night. She has slight episodes of urticaria. She had 3 episodes of “giving up” sensation in the lumbar region. She also has sensation of swelling in the throat in the morning. She has foul eructation at the morning. Her menses come once in 2 months but they are more copious and she feels better after them. She tries to avoid drafts by any means (3).

Notes: Here we have strong particular symptoms of Kali-c (baggy swelling of the inner corners of upper eyelids) together with some generals (waking at 3-4 p.m., chilliness, desire for sweets). The picture of the remedy is clearer than in previous follow-ups. She was prescribed Kali carbonicum C30.

Follow up 5, 15.08.2016

She visited after almost 1 year.  After 1 month from taking the remedy she had developed edema on knees and ankles. She had pains when sitting. She also had some episodes of anxiety. These symptoms resolved spontaneously.  Her swelling of eyelids became less. She has developed skin slough and itching between toes on the right foot. Her sleep is much better; she can sleep till morning without waking in between. She doesn’t want sweets anymore. She still has flatulence toward evening. Her memory for words while talking also disturbs her. Her stool is once in 3-4 days, however there are no pains, since 1 month after taking the last remedy.

Notes: Here we can see clear amelioration of the main complaint together with initial aggravation of some other symptoms. She still has minor symptoms, which is in accordance to reaction pattern number 3 which indicates choice of the right remedy. No prescription was given.

Follow up 6, 30.06.2017

She has no more anal pains. Her stool is more regular; once in 2-3 days. She had got a cold with high fever (38,6 C) at February 2017. She is still sensitive to draft. Her memory is much better. She has small pimples on inner thighs. From time to time she experiences swelling and itching of the lips. Sometimes she has sudden itchy eruptions on the legs, particularly in the morning and after bathing. Her flatulence is less than before.


Despite that the last remedy was given almost 2 years before, the organism is still very balanced. It is amazing that she could develop an acute with fever that shows strengthening of the defense mechanism. Her memory has become better, which also indicates right action of the remedy, as amelioration on the mental level. This is interesting, as we usually expect amelioration first on the deep levels. Nevertheless, sometimes the energy of the defense mechanism is not sufficient to act in all directions, so we can see delayed or partial ameliorations as it was in this particular case. Now she has her old symptom (urticaria) back. She may need some new remedy in the future. It is also possible that her defense mechanism can overcome it without any intervention.

One can speculate whether Kalium carbonicum could have been given as a first remedy. It must be noted, that according to the law of similarities, the main law of Homeopathy, only a correct (i.e. most similar) remedy will affect the patient. Therefore prescribing remedies in correct sequence is a key factor for success in cases with a small number of reliable symptoms (“one-sided diseases” by Hahnemann).

About the author

Ilyas Akhundzada

Dr. Ilyas Akhundzada (MD, PhD) has been practicing Homeopathy since 2005. He graduated from medical university of Baku, Azerbaijan in 2001 and completed his residency training of plastic, reconstructive and aesthetic surgery at Ege Medical Faculty Hospital, Izmir, Turkey in 2009. He became a fellow of European Board of Plastic Reconstructive and Aesthetic Surgery in 2011 (Fellow of EBOPRAS). Since 2015 he has been studying the E-learning program by Prof. George Vithoulkas. After completing the E-learning program by passing the exam in June 2017 he has become coordinator of the E-learning Program of the International Academy of Classical Homeopathy in Azerbaijan.

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