A Europeanlady of 83 years, weighing 140kgs was brought to a reputed hospitalin Goa in a semi comatose state with history of not having drunk much water for two days and not having eaten anything. Her mouth was extremely dry and signs of severe dehydration were visible on skin folds. She was breathing shallowly with open mouth. Her husband reported that her last words were “Give me some cold water to drink”. Four days ago she had admitted that wiping her body with a cloth dipped in cold water was extremely soothing.
In twohours’ time she could not be aroused. RBSL was 165mg/dl. B.P= 130/80mmHg. ESR= 15mm/hr. PCV=41.1%. Sr. Electrolytes were Na=138mmol/L, K=5mm/L, Cl=106mmol/L, Total WBC=14000/cumm, B. Urea=120mg/dl. Sr.Creat=2.0mg/dl, Sr. Bilirubin Total =2.9mg/dl, Direct==1.8mg/dl, Indirect=1.1mg/dl, SGOT=2414IU/L, SGPT==1763IU/L. Prothrombin time= 39.5 seconds, INR=3.2. ABG was done and pHwas 7.355, Na=128.9mmol, pO2=70mmol, Pco2=31.4mmol. A picture of metabolic acidosis with respiratory alkalosis emerged. Even after catheterization was done and an IV was run with normal Saline, 1 pint @100ml/hr, there was hardly any urine output. Preliminary diagnosis was acute renal failure with hepatic encephalopathy.
A consultant advised C.T Scan of brain which was found to be normal. The patient was shifted to ICU and intubated. At that time B.P= 150/100mmHg. Inj Lasix was started with InjNorad. Yet, not much urine resulted and the prognosis was very poor. Relatives were told to prepare for her death at anytime.
At this critical moment I took the rubrics: Suppressed urine with stupor and Desires Cold drinks. Differential Diagnosis was between Digitalis and Plumbum Met. so the progress of the disease before this present state was looked into.
One month agothis woman had a fall from the staircase and fractured the left neck of her femur. Watson Jones’s text book on fractures states that “we come to the world under the brim of the pelvis and go out through the neck of the femur”. She was operated on successfully but had wheezing before and after the surgery and received allopathic and homoeopathic treatment (Spongia) for the same. After suture removal she was discharged to home.
The first week she had good appetite but after that she developed horrible colicky pain in the abdomen which kept her from sleeping at night. She was afraid to eat, as it gave rise to abdominal colic and she would not be able to pass any flatulence nor eructations. Cold Soda and sitting up would relieve her only for a short while. Early in the morning she felt strong palpitations as if she had got a heart attack accompanied with cold sweat and she thought she was going to die. During these days house painting was going on.
Following this, she began complaining of extreme weakness and even speaking a few words was very tiring for her. She would breathe heavily with open mouth.The next few days she lost her appetite completely except for a piece of bread and she constantly demanded chilled drinks, like Red Bull and soda. However, she would not drink more than a few sips. She would sleep day and night and if questioned, would wake from the sleep, answer correctly and fall asleep immediately. Sometimes would not find the words to convey something. She felt chilly and was thirstless. Two days prior to being hospitalized she developed backache that was better by putting a hard pillow under her back and by rubbing. Vomiting relieved her.
Thereafter, I referred to Boger’s synoptic key: Digitalis acts more on heart and circulation, and is aggravated by sitting.Plumbum acts on nerves of kidneys, abdomen, and navel and it has a slow, insidious processes. Plumbum is better by sitting. Plumbum is also better by hard pressure. I looked up Allen’s Keynotes under Plumbum: Slowness of perception, unable to find the proper words, violent colic in abdomen at night, which causes the patient to stretch for hours. In addition,Plumbum covered the aspect of jaundice. Boerickewritesabout all the symptoms of acute nephritis with cerebral symptoms. Dr. Kent says under Plumbum: “Remember how many become sick from sleeping in a newly painted room” which was another astonishing revelation to me.
My choice was PlumbumMetallicum 200, one dose diluted in water. I prescribed it on 8th December 2018 at 11am in the ICU, while the patient lay still on the ventilator. Around 2 pm the same afternoon I checked the patient.She opened her eyes when I called her and even held out her tongue. She spoke through eye movements. My happiness doubled when I saw urine pouring into the urobag 100ml/hr. A urine test routine showed 35-40 pus cells/HPF. 6-8 RBCS’s and 8-10 epithelial cells/HPF.
On 9th December when the Liver Function Tests were repeated SGOT reduced to 978 and SGPT reduced to 1372. Sr. Creat reduced to 1.7. She was smiling, fully conscious, recognized all visitors and even attempted to speak. She was constantly moving her toes. They stopped Inj Lasix and still she was passing 300ml urine/hr. The ventilator setting had been kept the same.
On 10/12/18 The SGOT reduced further to 449, SGPT reduced to 1006. Prothrombin time= 30.6 seconds. INR=2.48Sr. Hb=11.2 PCV=28.7, ESR=25. Creat was 1.1 and Urea 143. Bilirubin==2.1. Na=141.7, K=3.21, Cl=108.6. Due to these remarkable improvements she was removed from the ventilator in the morning and at noon she was extubated. In the evening when her visitors came by,she expressed anger towards her husband. She could speak fairly well but chose not to.
At 11 pm I received a phone call from the ICU saying that she had developed sudden active Gastro-intestinal bleeding. Kent’s repertory was consulted 1) Ailments from Anger 2) Vomiting of blood, sudden first dark and coagulated. Ipecacuanha is haughty like Platina, critical, discontented and it happens when patients have bled until they have become anaemic. I hurriedly gave Ipecacuanha200 every 15 minutes in water for four doses. She appeared very pale, even her gums had lost their colour. Yet, she was fully conscious and told me that the entire bedsheet was full of thick blood. I could see fresh dark blood come out of the Ryle’s tube as she coughed occasionally. After 15 minutes she smiled and told me that she could feel the blood oozing stop.
She began desiring to drink milk at 1.30am. Imagine a dark coffee drinker asking for milk, unheard of in the past! The Tubercular miasm was actively dominating the situation with unpredictability, with the cravings of Psoraand physical restlessness as in stretching her hands above her head.There was also the syphilitic tendency to bleeding at night following ulceration in the duodenum.I inquired if she was afraid and she said “No”.I spoke to her till she fell asleep.
The next morning, she was again in coma and had to be intubated and ventilated. Hb=5.6gm/dl, PCV=16.6%, Platelet count =0.84 Lakhs/cumm, ESR=44mm/hr, SGOT=283U/L, SGPT=269U/L, Urea=106mg/dl. Prothrombin time=32.8 sec, INR= 2.68, MNPT=13.4 sec, ISI=1.03. WBC=23,990/cumm, N=90, L=06. At 9 am her heart went into arrhythmias, and she was received defibrillation. I prescribed China 200,one dose, keeping in mind the loss of vital fluids and as an anti-tubercular remedy. My idea was to buy time until the blood could be arranged and cross-matched). After one single dose of China 200, her heart rhythm regularized. I then set out to make necessary arrangement for blood. At 10.15 am; a gastro-duodenoscopy report revealed large haemorrhagic mucosal lesions in the duodenum and no active bleeding. Adrenaline flush was done. This proved the efficacy of Ipecac. A blood culture report showed significant growth of Klebsiella.
Blood for transfusion was on its way but the patient collapsed at 4.15pm on 11/12/18 due to low blood pressure. Cause of death was given as Klebsiella urinary tract infection with septicemia.
Commentary – Clinical Analysis
Homoeopathy succeeded in helping her regain consciousness and in arresting her bleeding but the miasm could not be eradicated. Destructive, deadly diseases coming all of a sudden are syphilitic. Miasms are responsible for evolving pathology and symptoms. After homoeopathic treatment the hepatic enzymes coming down can indicate two things.One,is that the liver is regenerating, whereas the other possibility is that liver is not functioning and has totally gone into acute yellow atrophy. The liver is completely shrunken and not functioning. Then, enzymes will not come as the cells are already gone. So, enzymes will again drop down. What tells us this is the albumin. If albumin and prothrombin time are improving, it means that the liver is regenerating, not otherwise.Procalcitonin levels were high and that explains septicemia. But septicemia due to what,is the question. She suffered an acute critical illness because of which she developed acute gastritis ulceration and bleeding. Hence haemorrhagic lesions are seen on the gastro-duodenoscopy report.
It is unlikely that Hepatic failure per se has caused portal hypertension and the bleeding, because ultrasound does not reveal any oesophageal varices. Any critical illness can develop these types of stress ulcerations. Acute renal failure and acute hepatic failure are the manifestations.Altered sensorium is the third manifestation and respiratory dysfunction is the fourth. They are not the final diagnosis but manifestations of the underlying process. The process is septicemia here. The underlying aetiology is septicaemia, but what has caused septicemia is to be clinically evaluated? One possibility is of that the implant/prosthesis itself has got infected.The other possibility is, she was just recently operated on, so post- operative liver dysfunction (acute Hepatitis B or C). Although less likely, that can always happen due to some contamination. A third possibility could be acute cholecystitis secondary to septicaemia, based on the ultrasound finding.
Klebsiella can be a cause, or as is most often seen, secondary to having been put on the ventilator. Once they are put on ventilator, they develop nosocomial infections. This Klebsiella could come from the cholecystitis itself or it could be a primary urine infection. The first possibility was ruled out by the orthopedic surgeon. The second possibility was also ruled out by investigations. The chance of Klebsiella appearing after ventilator intubation doesn’t corroborate, since blood was sent for culture before the patient was intubated. After homoeopathy treatment, hepatic and renal dysfunction seemed corrected. However, what has happened here is, theoriginal problem was the infection, from where we don’t know. That is the first process which has caused septicemia. Septicemia in turn caused multi organ failure called as MODS i.e. renal failure, hepatic failure, altered sensorium, and respiratory dysfunction. This is called critical illness. When MODS (multiple organ dysfunction syndrome) are there, one tends to have haemorrhagic gastritis. Now what might have further worsened the thing is Inj. Clexane (Heparin) which was going on. With so much of septicemia there could have been a DIC (Disseminated intravascular coagulation/ consumptive coagulopathy) which can also lead to bleed. Two or three things must have contributed to the bleed.
Her susceptibility was good, but the liver cells were dead, which had become very progressive. So it is also the susceptibility of the location where the disease is developed and how much that disease has taken up all other vital organs. Thereforewe have good characteristic symptoms in a gone case. For example, a patient is gasping for breath, with no nutrition and such a patient cannot revert back from a clinical point of view and everything is going down progressively in terms of physical weakness, mental weakness, etc. And there you may get some characteristic symptoms.That speaks not of reverting of the disease, not at all. That only speaks of the “Last fight”; it doesn’t give us a prognosis that we can cure. There are two aspects: Presence of characteristic symptoms may allow you to cure a case even if it is incurable. On the other hand, the presence of characteristic symptoms coming up in a totally lost case with total loss of susceptibility, reaction and responses, indicates that the patient is breathing her last, just as a light brightens up for the last time before it goes out. However,we have to make this judgment. Therefore,miasms are responsible in evolving pathology and symptoms.This patient was a staunch lover of homoeopathic science, who had studied, practiced and cured several people in her life. Death could not scare her. The courage that she displayed was indeed extraordinary. She will be missed by everyone.