Clinical Cases

Bleeding Per Rectum in a Woman of 75

Rati Vajpeyi
Written by Rati Vajpeyi

Dr. Rati Vaipeyi shares a case of rectal bleeding in a woman of 75. Lycopodium, Natrum Mur, Sulphur and Arsenicum were considered before the simillimum was selected. (CCHM Student Presentation)

 Case report

S.J., a 75 year old widowed lady presented with the following complaints in Aug 2020. She was from South Asia and the consultation took place online on Google Meet with Video.

  1. Acidity and Pain above navel from the day before,
  2. Recurrent Fresh bleeding from rectum since 1½ years in the mornings after passing   stool
  3. Varicose Veins
  4. Hair loss
  5. Fatigue

Acidity and Pain -Since the day before she has the feeling of fullness and has not passed any flatus or burped. Complains of acid belches and feeling bloated after eating a little more than usual for some time. She feels full after eating a few mouthfuls and is unable to eat more.

Recurrent fresh bleeding per rectum -About 3 months ago there was spontaneous painless excessive bleeding in the morning after passing stool, staining her clothes, and cushions of the chair. She had no sensation of bleeding, or any burning or itching in the anal or rectal area.

The episode recurred 10 days and 3 days ago. She can feel a soft mass in her anus. She has been passing blood after stool since 1½ years. She was advised surgery after she was diagnosed with enlarged internal haemorrhoids about 1 year ago. She is regularly constipated and took, soluble fibers, stool softeners and laxatives, but they were not effective, and she was straining at stools for many years.

She refused surgery and was self medicating herself with a homeopathic proprietary product for piles.

Varicose veins- She has large varicose veins on both her legs, feet and around ankles, there are dark blotches on both the feet which increase and decrease and both ankles are swollen. She tries to keep her feet elevated on a footstool when sitting and puts a few pillows under legs when lying down.

Hair loss – She has recent hair loss and parts of her scalp are visible near the forehead hairline. In 1999 she had sudden hair loss with extreme fatigue and was diagnosed at that time to have hypothyroidism. She has been on Eltroxin 75 mg since then.

Fatigue -After 1 pm she feels fatigued and it gets worse by evening. She lies down in the afternoon and conducts her business (Stock market) on the phone. In the morning she is better, and she is busy with gardening, housework, and cooking, which she enjoys.

She said that she was habitually constipated since her first childbirth. Perineal stitches after 1st delivery were too tight and she had to take enemas to pass stool and since then it has been difficult to expel faeces. She was in the habit of ignoring / suppressing her bowel urges. Stools were dry, hard, and often needed manual evacuation with lubrication. She had not sought any medical advice.

The description of her bowel problems motivated her to voluntarily give the following narration –She has never felt happy. Since childhood she felt unloved by her family, then her in-laws and now her children. Her parents were of simple means but through an arranged marriage, her good looks made her the only daughter -in -law of an orthodox wealthy joint family. There she felt used and was bullied by her sister -in laws and mother -in -law. She felt they were jealous, insulting, and rude to her.

In trying to fulfill her obligations in the demanding joint family, she neglected herself, did not have the time to follow her bowel urges and became habitually constipated.  She was not allowed to breastfeed her firstborn (her son) under the belief that her constipation would affect the child ‘s health. She suppressed her resentment on this and many other slights and insults. This is a culture where girls are not considered equals.

Her husband was the only son with 5 sisters and spoiled, had never worked. She herself has one son and two daughters and she has spoiled him. He too has never worked and lives off the family fortunes, yet she loves him the most.

It hurt her very much when on becoming an adult, the son too became rude and abusive to her, causing her severe depression in 1991. She lost 12 Kgs in 3 months then, and lots of hair, and was diagnosed with Hypothyroidism and advised Thyroxine since then.

Widowed she currently lives with her son, who is divorced and still behaves rudely towards her and she feels does not care for her. She feels very hurt and angry and lonely, especially in the evenings. She is trying to manage the family finances which her son has neglected and let slide

She feels the domestic servants also disrespect and ignore her requests. She does not trust them with anything She feels depressed and cannot share her feelings with anyone. Her gynaecological history was unremarkable.

Generals 

She has no record of her weight, though her blouses have become loose, she wears a sari, so the lower body is difficult to comment on. She feels cold and yet cannot tolerate the heat. She enjoys cooking and gardening and is very meticulous about cleanliness and routine.

She cannot depend on or trust any domestic help. She sleeps in 1–2-hour snatches at night. She does not feel thirsty and drinks little as she does not like going to the washroom too often especially at night. She is vegetarian and loves fruits.

Past History –Gall bladder removed by classical open surgery (many decades ago. does not remember when), Uterine polyp removed about 4 years ago and fractures of the shoulder and knees over last 5 years.

Investigations

Proctoscopy 3 months ago —Large internal hemorrhoids (no report available)

Current medications 

  • Eltroxin  75mg daily
  • Dr Reckweg  R13

Observation

From what I could see on the video screen, she was silver haired  and  areas of pink scalp on top and either side of her head were visible .She had sunken cheeks with prominent cheekbones and her neck and face had loose and wrinkled skin. I could see her collar bones clearly.

Analysis

The symptoms from her story were analysed. This was done in 2 ways.
A. Listing the symptoms in a chronological order
B. Listing the symptoms according to importance

A                                                                                                     B

   Chronological order Order of importance
1 Since childhood felt unloved by her family, her in-laws and now her children Has never been happy
2 .  Feels   used by everybody. Severe depression
3 .  suspects people are jealous of her, insulting and rude  feels very hurt and angry when she is ignored.
4 she neglected herself. suspects people are jealous of her, insulting and rude to her.
5 She suppressed her resentment. Feels used by everybody
6 Became habitually constipated since first childbirth, Since childhood felt unloved by her family, her in-laws and now her children.
7 ignored her toilet urges and became constipated lonely in the evenings and fatigued
8 fastidious about domestic work, food. She neglected herself
9 Does not trust anyone. Does not trust anyone.
10 Severe depression very fastidious about domestic work, food
11 feels hurt and angry when she is ignored She suppressed her resentment.
12 Has never been happy Ignored her toilet urges and became constipated.
13 lonely in the evenings and fatigued. habitually constipated since first childbirth,
14 Has varicose veins and swelling of ankles. Recurrent excessive bleeding per rectum
15 Feels bloated, has acidity Has varicose veins and swelling of ankles.
16  Recurrent excessive bleeding per rectum Feels bloated, has acidity

Her key symptoms were taken from the column B and repertorized with Schroyen.s The Essential Synthesis

   KEY SYMPTOMS                                                   RUBRICS 

1        She suppressed her resentment———————-MIND – EMOTIONS – suppressed

2.        Recurrent excessive bleeding per rectum——RECTUM – HEMORRHAGE FROM ANUS

3        Has varicose veins and swelling of ankles —– -EXTREMITIES – VARICES – Lower limbs

4        Is very fastidious about domestic work, food ..—– MIND – FASTIDIOUS

5        feels lonely in the evenings and fatigued ———-MIND – SADNESS – evening

6        Feels bloated, has acidity ————————– STOMACH – ACIDITY.

7        She feels cold and yet cannot tolerate the heat—-GENERALS –    HEAT – lack of vital

Heat, Warmth. Agg.

8        She is vegetarian and loves fruits. ————- GENERALS – FOOD AND DRINKS – fruit desires

The Remedies that were suggested were Lycopodium, Nat-Mur, Sulphur, Arsenicum Alba and Lycopodium [ 3], [4], [5].   Lycopodium- it is a well proven, chronic remedy, matching majority of the patient’s symptoms e.g.: Feels full after little food, feels worse in the evenings, habitual constipation with ineffectual urging. “Constipation, rectum contracts and protrudes during stool, developing piles [3] “has troublesome haemorrhoids, but they are nondescript. Any kind of haemorrhoids may be cured by Lyc. if the flatulence, the stomach symptoms, the mental symptoms, and the general symptoms of Lyc. are present because the haemorrhoidal symptoms are numerous.” [3] “Patient has the most troublesome constipation” [4]. Upper part of the body is emaciated “The patient emaciates above, especially about the neck, while the lower extremities are fairly well nourished “[2].  “Distrustful, suspicious and fault finding. “Patches of hair loss with scalp showing, “Ailments from anger, mortification, vexation “. [ 3] Mentally and emotionally, there is vexation with feelings of inferiority, and avoidance of people. Warmth aggravates.

“The complaints of Lyc. are likely to be worse at a fixed time, viz., from four till eight o’clock in the evening” “smooth patches with the hair off.” She was sad, had performance anxiety, timid, suppressed her anger, and was suspicious.

However, there was no indication of being one sided except that she had a history of surgery for Gallbladder removal which is on the right side.

Natrum Mur, is a chronic remedy, shows an introverted personality with prolonged grief and sorrow and dwells on insults and gets easily hurt. “It seems to take a long time for food to digest. “[3] “Constipation: sensation of contraction of anus; torn, bleeding, smarting afterwards; stool, dry, hard, difficult, crumbling “[4] But there are no hemorrhoids and she has no craving for salt or any emaciation even though she ate well.

Sulphur is a polycrest, hot, with easy satiety. Patient has haemorrhoids, an egoistic person finding faults with others and “Chronic diseases, that result from suppressed emotions.” [4] There are hard knotty stools. It did cover her prominent symptoms but there is no early morning diarrhoea. No burning or itching of the anus [5]. She is neat and meticulous about cleanliness and not slovenly. She does not have a fixation to eat at 11am.  This ruled out Sulphur.

Arsenicum Alba [4] Insecure, anxiety with restlessness, melancholia, easily vexed, fastidious, haemorrhoids but there is a great thirst for cold water “Stomach. –Cannot bear the sight or smell of food. Great thirst; drinks much, but     little at a time. Nausea, retching, vomiting, after eating or drinking. Anxiety in pit of stomach” [5]. It was not a suitable remedy.

The REMEDY:  She was advised to take Lycopodium 30C as a water dose, once and to have another meeting after 4 weeks.

On Follow up 

She had her 1st Follow up after 4 weeks and she reported that she did not have any bleeding per rectum, since taking the remedy. All her other symptoms persisted without any change, but she stated that she was now able to pass flatus on exerting herself and was determined to learn on-line technology and gain confidence, she did not want to rely on her son.  Her remedy was repeated.

2nd Follow up was done after another 4 weeks in October. There were changes evident now. She was determined to live her life now and not be exploited. She accepted that people’s jealousies, could not be changed and was going to ignore the jibes and insults. The varicose veins and patches on her legs persisted but now new ones had appeared, the swelling of the ankles had not increased. Her constipation happened only the day after she had not taken any fibre in her diet. She had stopped all bowel modulators. The stools were softer. There had been no bleeding per rectum since the start of her treatment. She had more energy and was noticing tiny hair sprouting on her scalp here and there, very sparingly. She took her remedy again.  I was encouraged by her positive response even though it was slow and subtle.

On the 3rd Follow-up 4 weeks later, there were some more changes. She had accepted that she could not depend on anyone. There was no new varicosity, the swelling in the ankles had subsided, there much less fatigue BUT she had hard constipated stools for 3 days, her rectum felt full all day and she had no appetite and a pain in her right side of the upper abdomen.

She was also feeling very sad that her grown up children did not care for her and were busy with their own problems. There were cramps in her legs and she feared getting old. I considered her recent symptoms and concluded that these were not different from usual complaints but possibly the potency or the frequency of the remedy she was being given was too low. I increased her remedy to every 2 weeks from once a month.

On her 4th Follow up 3rd Jan. 2021, She has put on weight. her bones are no longer visible. She sleeps 3-4 hours every night and has more energy. Appetite is better. Her constipation occurs only if she drinks less water or forgets to have prunes or raisins daily. Her hair loss is still persisting and the varicose veins have faded and small new ones have shown up, but they are much less. Overall, she is better. She admits she has bouts of sadness but recognizes that the pandemic restrictions are also part of it.

Her recent 5 th follow -up on 15th Feb 2021 , she had improvement of her all physical symptoms but her mental and emotional hurt was still present and, also aggravated by a recent spate with her son .  The remedy has to reach a deeper level and, needs to be increased. She is now being prescribed Lycopodium Clavatum 200C .

Discussion

The first and the most important task for me was to connect with my patient and establish trust and a rapport [7]. We were physically apart, and she was talking to a face on her computer screen. This was the first challenge. It was a new experience for her to talk to someone across the world.

Perhaps it was easier for her to talk to a stranger this way. It was a professional consultation, with no disturbances, intimate and yet impersonal and she needed this safe space to confide,  She was reticent and spoke timidly about her physical symptoms .

It is always easier to talk about what is seen, or touched . It was only when enquiring about her bowels habits that the flood gates opened, and she shared her emotional life. I felt that she was finally able to confess her pent-up feelings and speaking to a stranger made it easier [8]

It was important to know the sequence of events in her case, the past and the present. Her story illustrated her mental, emotional and physical condition and I learnt more about this person who was a woman, a daughter, a wife, a daughter -in law and a mother and not just a case. The sequence of events gave me an insight of how her emotions gave rise to physical symptoms, the shift of the deep level to the exterior.

Step by step as we moved forward with her case and Hahnemann’s words took on a greater meaning ( Aph 3, 5).[6]  What appeared to be a  straightforward  case of bleeding from the bowels, was actually a case with  multiple symptoms. Listing the symptoms chronologically showed the fundamental cause was mental and emotional. (Vide: Column A).

I was learning about the patient, After Repertorization and seeing the different remedies that could qualify (aph 18) [6] and following the Law of Homeopathy, “Similia Similus Curantur , and the infinitesimal dose,  she was given Lycopodium 30C once every 4 weeks .  The different Materia Medica helped find the most similar remedy that could be used.

It was interesting to note that the sequence of the reduction of her symptoms was very subtle and appeared to be opposite to the sequence in Column A . This seemed to be conferring with Hering’s Principles of Direction of Cure (Popularly known as Hering’s Law of Cure , they are actually postulates )[9]

The last symptoms for which she sought help has been the first to abate. The change in her is slow and it may take a long time before she can be termed cured. However, I also noted that her symptoms were not reducing from above down, though there may be some tissue changes deep in her which has shown externally in her improved vaso-circulatory system and the reduction of the varicose veins.

Her mental emotional symptoms have been there since she was young and perhaps, they are part of her personality, it is difficult to be specific at this point. If she continues her therapy and improves, I will learn more.

Conclusion 

Hahnemann was very emphatic that the only goal of a physician was to heal. He laid guidelines and methods, the importance of not being biased or judgemental but by using all the senses ‘perceive alterations in the condition of the body and soul, disease signs, befallments, symptoms which are outwardly discernible.’ (from Aph 6) [6]

Nonbiased observation, active listening, patience, and understanding starting from the initial interview and at each follow up can go a long way in increasing the knowledge of a patient, which is necessary in finding the specific suitable similar remedy.

Bibliography

[1] Close S. The Genius of Homœopathy. Philadelphia: Boericke & Tafel, 1924.Pg 9

[2] Homeopathic clinical case reports: Development of a supplement (HOM-CASE) to the CARE clinical case reporting guideline–Author links open overlay panelR.A.van Haselen

[3]-Kent Materia Medica

[4] Allen ‘s Keynotes

[5] Boericke’s Materia medica

[6 ] Hahnemann S. Organon of the medical art –Wenda O’Reilly (Author)

[7] Eyles C, Leydon GM, Brien SB.Patient Educ Couns. 2012 Dec;89(3):501-6. doi: 10.1016/j.pec.2012.02.004. Epub 2012 Feb 26. PMID: 22370197-Forming connections in the homeopathic consultation

[8]. A Grounded Theory Study of Homeopathic Practitioners’ Perceptions and Experiences of the Homeopathic Consultation -Eyles C,. Leydon GM, Lewith GT, Brien S,Evidence-Based Complementary and Alternative Medicine,Volume 2011 |Article ID 957506 |https://doi.org/10.1155/2011/957506

[9]-Hering’s Law: Law, Rule or Dogma? Dr. André Saine, D.C., N.D., F.C.A.H.

Presented at the Second Annual Session of the Homeopathic Academy of Naturopathic Physicians in Seattle, Washington, April 16-17, 1988.

  • Kent JT –lectures on Homeopathic Philosophy .
  • Hayes D , MBRCP(H), CCH, RSHom(NA) – Editor-in-Chief –How to Write an Article for The American Homeopath

           https://homeopathy.org/the-american-homeopath-journal/journal-
           submissions

  • https://www.nejm.org/author-center/article-types

About the author

Rati Vajpeyi

Rati Vajpeyi

Rati Vajpeyi MD is a qualified Consultant Clinical Oncologist and researcher, a palliative and pain specialist, an artist and a certified life coach based on Neurosciences. She has many years of experience in clinical practice internationally. Her method is wholistic and involves Mindfulness, Yoga , Ayurveda, and other complementary methods. She says she is a daughter, sister, friend, lover, wife, mother, grandmother, artist, teacher and consultant oncologist and palliative care specialist and each of these is important and equally valuable. Dr. Vajpeyi started a support group for psychosocial rehabilitation of those with life limiting illnesses and their caregivers - called PRERAK - support for cancer fighters and cancer care in India.

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