Enuresis

Enuresis

Introduction

Ashima is a 7-year old girl who wakes up each morning only to cry in shame. As usual she seems to have wet her bed once again. It is the very same story each morning. Her father shouts, her mother screams while her Gangubai grumbles and her little sister snickers. But what can little Ashima do as she does not even feel the urge or remember the sensation of passing urine. If only she could, she certainly would not do it and have to face this filth and embarrassment each and every day.

This has been going on for years and her parents are really worried. They feel that she might never stop. They have shown her to their family doctor who suggested that they take her for counseling to a child guidance clinic.

Bed-wetting, also called Enuresis, is one habit disorder that causes trauma, pain and disturbance to all concerned. It is the parents who normally wake up each night to check on the child, maybe even to disturb her sleep to check on whether she wants to go to urinate. And then when she wets her bed, it is the parents and the maid who have to change and wash the sheets and air the room. And what about what the little girl has to go through herself? Can you even begin to imagine her pain and shame at having lost control once again? She feels inadequate and totally at a loss, especially when she is aware of the trouble that she is inadvertently causing to other members in her family.

History

The Ebers Papyrus documents that bed wetting was well known in 1500 B.C. Enuresis is one of the most common and perplexing problems brought to the attention of the physician.

By the 19th century doctors that no matter what sort of treatment was suggested, if done with authority or zeal or kindliness, many cases of enuresis could be ameliorated. Today more is known about its causes and treatment possibilities but enuresis still defies medical expertise.

The ubiquity and frequency of this minor malady oblige it to e considered one of the most important pathologies of childhood. Further, in a considerable manner of cases, enuresis persists into adulthood. A few cases have been seen in persons in late life who have never known dryness.
Definition

Enuresis is defined as repetitive, inappropriate, involuntary bed wetting or clothes wetting in persons over the age of three, who fail to inhibit the reflex to pass urine when the impulse is felt during waking hours and those who do not rouse from sleep of their own accord when the process is occurring during the sleeping state.

Although bowel and bladder control at night is usually achieved around the age of three years, a number of children have difficulty with this stage of development.

A child becomes dry at night after she/he becomes dry during the day. Having achieved daytime bladder control, she/he knows what is required of her at night. The most common sign of readiness for night training is when her nappy is regularly dry in the morning when she wakes up. Girls frequently reach this stage earlier than boys.

Toilet training is an important task for all children to complete. It gives them a sense of accomplishment and control and relieves the parents of diaper changing’s and washings as well! Even in “normal” children, a large percentage might have “nighttime accidents”. For example, one study found that 56 percent of boys and 40 percent of girls continued to wet at night.

Interestingly, the rate of enuresis in males is about twice that of females.

Types of enuresis

Psychologists have identified two types of bed wetting, which occur in children beyond the age of five years; “primary enuresis” applies to a child who has never achieved bladder control at night, and “secondary enuresis” applies to a child who has been dry at nights consistently and then unexpectedly begins to wet her bed.

Primary enuresis can be caused by many factors including:

Heredity – It is found that parents who themselves were slow to achieve bladder control at night often have children who follow a same pattern.

Maturation – In some children, enuresis may be caused by a delay in the development of that part of the brain needed for bladder control.

Poor training – Not all parents adopt a consistent method when training their child to be dry, and sometimes the situation develops into a battle; inconsistent strategies only confuse the child, or make them anxious.

Urinary problems – Enuresis can be associated with physical abnormalities or urinary tract infection, which is why medical advice should always be sort in the first instance.

The cause of secondary enuresis is virtually always stress. Although a child who starts to wet a night after she has been dry consistently for a long period may be suffering from an infection or other physical illness, it is more likely that the waiting is due to an emotional difficulty (e.g. the birth of another child in the family, starting playgroup or school, worries about friends and parental arguments).

Persons whose enuresis persists into adolescence show a greater frequency of combination with one or more of the following disturbances:

– Passive aggressive or passive dependent reactions

– Past history of sleep walking

– Family history of sleep walking

– Inferior dentition as measured by decayed, filled or missing index

– Chronic genitor-urinary tract complaints (urgency, frequency, nocturia)

– Family history of enuresis

However in general, no psychiatric diagnosis is associated with enuresis.
Normal Development of Sphincter Control

The frequency of urination in babies varies from child to child. There is often a temporary phase of increased frequency at the age of about 21 months. At two and a half years, there is often a retention span of about 5 hours. The retention span then rapidly increases with age.

Babies commonly empty the bowel and bladder immediately after a meal, especially in the first 8 months, and they can often be ‘conditioned’ to use the potty any time after 2-3 months of age. This condition frequently breaks down as a result of teething or some disturbance of routine, particularly between 12 and 18 months. It is important to realize that there is no voluntary control at this time, for voluntary control does not begin till about 15-18 months of age.

The first indication of voluntary control is awareness at about 15 to 18 months of having passed urine, the child pointing it out to the mother. He now begins to tell the mother just before he passes urine, but he does not give her time to ‘catch’ him.

The urgency decreases as he grows older, and by 18-24 months he tells the mother in sufficient time for her to place him on the potty. By two to two and a half years, he is able to put his pants down, and go to the lavatory and may limb on to the lavatory seat unaided. These children take their responsibility for not wetting their pants, and as a result the napkin is discarded during the day, but they are still wet by night.

By two and a half, the retention span is longer, and between two and a half and three, if lifted out at 10 or 11 p.m. he is dry in the morning and the night time nappy is discarded. He rarely soils his pants after age of 2 years, girls tend to acquire sphincter control earlier than boys.

Mechanisms Involved

The mechanisms relevant to the acquisition of sphincter control are mainly four – maturation, development, learning and conditioning:

Maturation:

The mechanism of sphincter control is a complex one, and one must

depend on the maturation of the nervous system. There is commonly a familiar pattern; just as some children are earlier or later than others in learning to sit, walk talk or use their eyes or ears, so some children are earlier or later than others in controlling the bladder or bowel.

Learning:

Children learn to control the bladder partly by instruction and training. Training consists largely by helping the child when he is developmentally ready. As one famous poet said, “When the clock strikes certain hours, little pots are punctually applied to little botts”.

Conditioning:

Here the babies empty the bladder when his buttocks feel the rim of the potty.

Other Causes

Weak Emotional Foundation:

Bed-wetting is common in both timid and weak as well as in strong aggressive children. The child has a basically weak emotional foundation and could come from a broken home or any kind of disruptive, unstable atmosphere. Either one of the parents could be physically or psychologically missing and the child could be feeling insecure for some reason. In highly aggravated cases, sometimes the child cannot even control the urge during the day and could embarrass himself in public leading to a further complex. Then it would be difficult to ever send him anywhere, even to school.

In some cases placebo drugs are given to the child to make him feel that he is being physically treated for the problem. But much, much more important is his mental welfare and sense of belonging as most of the time; enuresis has a deep psychological foundation. Therefore it is important that both the parents accompany the child for counseling.

New Environment:

I remember reading about the case of six year old Nitin. An extremely well-adjusted child who had learnt to brush his teeth, change his clothes and tie his shoelaces by the age of five. He performed very well in school and was a well-behaved, intelligent young boy. He displayed absolutely no signs of any sort of behavioral disorder right until his mother was carrying her second child. One evening she sat and explained to him that he would soon have a baby to play with. And that very night little Nitin wet his bed for the very first time.

All was well until his mother delivered a baby girl. Then the enuresis started once again until the time that she was discharged from the hospital. It seemed to have stopped for awhile as Nitin tried to play and grow fond of his little sister. Then on her first birthday it started once again and did not stop for about three to four months, at the end of which his parents sought professional help.

After studying his case, the counselor realized that Nitin was torn between hate as well as outward displays of love towards his sister. These dual feelings in one so young were what had manifested in the form of this habit disorder. The counselor helped him to feel secure, loved and wanted once again and the enuresis disappeared after about a year of therapy.

Delayed Developmental Milestones:

Sometimes, when the doctors are not able to pinpoint a physical cause for this problem, the mental capacity of the child must be looked into, as it is quite possible that the child could be mentally deficient. In such cases, as a rule, most of the developmental milestones are generally delayed and toilet training could start much later than usual.

The child guidance clinic is a good place to start investigations as the enuresis could be a case of serious maladjustment. Some children do not want to accept basic responsibilities like tying their own shoelaces or going to the toilet. They want to prolong their infancy and total dependency much longer than is normal. This could even be the result of sibling rivalry or jealousy. Because when a younger child is born, most of the attention gets diverted and the older one does everything possible to get it back, on a conscious or even subconscious level.

Faulty Conditioning:

If the child is punished for not using the pottie when placed on it he will become conditioned against it and may refuse to use it.

Faulty Learning:

If the mother fails to give her child an opportunity to empty the bladder when he first begins to announce that he wants to void, he is liable to be retarded in acquiring control.

The Child’s Developing Ego and Personality:

From about 6 months onwards the child is developing his ego and his determination to be recognized as a person of importance. At 9 or 10 months he begins to repeat a performance laughed at. From about 12 months he characteristically enters the stage of negativism, so that if an attempt is made to try to force him to do anything against his will, in this case to use the pottie, he will refuse. Hence determined and overenthusiastic efforts to “train him” will lead to the opposite of the effect desired.

The Personality of the Mother:

The mother who is determined to teach the child early and who is determined to teach discipline early and who compels the child to keep sitting on the pottie when he is trying to get off it, is the mother who is likely to meet with refusal to use the pottie.

Ignorance of normal development and its variations:

Mothers often fail to realize that children vary greatly in the age at which they acquire control and become worried when the child is later than others. She is then liable to punish the child for his failure and he responds by refusing to use the pottie or by wetting.

Laziness:

On a cold night, particularly if the lavatory is at the other side of a yard, the child may prefer to wet himself rather than to go to the lavatory.

Depth of Sleep:

It is commonly said that bed-wetters are usually heavy sleepers.

Small Bladder Capacity:

It has long been thought that one of the problems of the enuretic child had small bladder capacity.

Clinical Features of Enuresis

Essential Features:

1. Persistent involuntary voiding of urine by day or night that is considered abnormal for the age of the patient.
2. Primary enuresis – passage of urine in inappropriate and unacceptable circumstances with a frequency of at least one event a month after age of 5 years.
3. Secondary enuresis – passage of urine in inappropriate and unacceptable circumstances with a frequency of at least one event a month after a period of urinary continence of at least 1 year.

Treatment:

The doctor first takes a detailed history and examines the child to exclude structural abnormalities that may be the cause of bed-wetting. In case a doubt persists after examination, the doctor will order a urine test to exclude urinary infection. An ultrasound scan may be done to evaluate the urinary system for structural abnormalities. Rarely, special tests may be asked for, like intravenous pyelography (IVP) that is a special X-ray test after an injection into the vein, or cystometry in which the pressures inside the urinary bladder are measured.

No treatment method is so successful as to win universal endorsement. The management of a case of enuresis is difficult. That leaves the following array of approaches in the armamentarium of the psychiatrist.

1. Placebos
2. Conditioning devices
3. Psychotherapy
4. Drugs
5. Bladder training
6. Sleep interruption
7. Hypnosis
1. Placebos:

In homeopathic literature marvelous cases of success are reported by using placebos. Maybe, because it works at more of psychologically making the child feel that he is under some treatment.
2. Conditioning Devices:

The most effective way of banishing the symptom of bed wetting is to use a conditioning device that awakens the patient by an alarm bell or buzzer as soon as a drop of urine contacts a wire pad on which he is sleeping. The conditioning process quickly leads to the cessation of bed wetting, since the patient learns to awaken and void before the stimulation of the bell or buzzer.

Disadvantages: Conditioning devices are of little help and relapse is bound to occur. The treatment according to many homeopaths is cruel, punitive and insensitive. The other practical problem is that when the buzzer sounds it also awakens other children sleeping in the same room thereby spoiling peaceful sleep. Also false alarms are very common because few children perspire a lot and these very drops of perspiration stimulate the alarm.
3. Psychotherapy:

Critical to the management of any case of enuresis is psychotherapy. The psychiatrist must be supportive and must be capable of promoting and sustaining feelings of confidence and hope in the patient.

On guard, the psychotherapy involves encouragement sand patience both in the consultation room and at home. The parents must be partners in the process so that, with their co-operation the patient feels that there are attitudinal changes in regard to bed wetting.
4. Drugs:

The array of drugs includes anticholinergics, sympathomimetics, sedatives, relaxants, diuretics, anti-diuretics and antidepressants.

At the present time, antidepressants are the drugs of choice in the treatment of enuresis for the allopathic physicians. However it is seen in practice that those patients who were given tricyclic antidepressants, including amitriptyline and nortriptyline by their family physician, the children developed many side-effects like dysuria, retention, dryness of mouth, dizziness, headache, constipation, loss of appetite, weight loss, sleep disturbance and above all drug addiction.
5. Bladder Training:

For a long time it has been known that some enuretics have smaller than normal functional bladder capacities. That fact led urologists to promote the treatment method of bladder training. In this therapy, the patient is asked to quantify his ability to drink measured volumes of fluid and to withhold the urination for as long as possible. The desired result is that the patient becomes able to withhold increasingly larger volumes of fluid over longer periods of time. Hence, the vesicle is trained and becomes adaptive in accommodating greater quantities of urine. At night the patient’s heightened threshold for retention eliminates the problem of bed-wetting.
6. Sleep Interruption:

In view of the hypersomnia observed in enuretics long before the era of laboratory sleep research, it has been suggested that parents wake up the child to void during the night. Favourable responses may have been due to positive behavioral reinforcement.

7. Hypnosis:

Hypnosis has been used in the treatment of enuretics in Europe and in the United States. Like all treatment methods in enuresis, there are enthusiastic claims and counter claims concerning its success.

Alternative therapies

Herbal medicine:

Chewing on a piece of cinnamon bark several times a day is said to reduce the need for night voiding. Another time honoured remedy calls for taking corn silk extract just before bedtime. Some herbalists also advocate uva-uris tea or elecampane decoction.
Self treatment:

If a child continually wets the bed, refrain from scolding, punishing or embarrassing him. Instead give a reward for staying dry. If you have a night voiding problem, drink fluids during the day and cut back a few hours before going to bed. If you invariably have to go the bathroom in the middle of the night but wake up too late, set an alarm clock. The same tactic may help the child. Some people find that avoiding certain foods reduces urinary urgency. Acidic juices are a common bladder irritant. Coffee, tea and other sources of caffeine not only may irritate the ladder but they also act as diuretics, increasing output of urine. Nicotine is another bladder irritant, as is alcohol, which also has a diuretic effect. If you are taking a diuretic for high blood pressure, ask your doctor about an alternative drug or about taking your medication in the morning. Self-help groups often benefit people who have incontinence problems. Adult diapers, waterproof bed pads, and similar products can help in coping with night voiding. Pay extra attention to skin care if you sleep with a device that rings the skin in contact with urine. Shower in the morning, dry the area thoroughly, and apply cornstarch or talcum powder.
Change in parents’ attitude:

In most cases, a simple change of attitude on the part of the parents is all that is required to solve the problem. If your child feels safe and secure in a home filled with love, most personality disorders get sorted out on there own, if at all they were to arise.

The selection of the appropriate method depends on the individual circumstances as comprehended by the physician. Usually, the clinician elects a combination of methods.
Homeopathic Reportorial References

Bladder; URINATION; involuntary

Bladder; URINATION; involuntary; children, in

Bladder; URINATION; involuntary; children, in; nervous and irritable

Bladder; URINATION; involuntary; children, in; weakly

Bladder; URINATION; involuntary; daytime

Bladder; URINATION; involuntary; daytime; and night

Bladder; URINATION; involuntary; daytime; night, and

Bladder; URINATION; involuntary; night

Bladder; URINATION; involuntary; night, incontinence in bed; tangible cause except habit, when there is no

Bladder; URINATION; involuntary; night; incontinence in bed; weakly children, in

Bladder; URINATION; involuntary; night; children, in

Bladder; URINATION; involuntary; night; tangible cause except habit, when there is no

Homeopathic Therapeutics of Enuresis

1. Belladonna

Time of enuresis: Generally after midnight or towards early morning. Daytime

Sleep Pattern: Half opened eyes. Restless sleep with sleep. sudden starts; moaning and screaming during Grinding, stertorous sleep. Somnolence, sleepy yet cannot sleep. Sleeps with hands under the head.

Cause: Eating too much sugar. Paralysis of bladder.

Character of urine: Yellow and scanty. Turbid. Dark red. Profuse deposits of phosphate. Acidic.

Constitution: Scrofulous

Temperament: Anxiety. Quarrelsome. Bilious. Lymphatic

Accompaniment: Easy perspiration, faeces escape while urinating, sensation of worms in the bladder.
2. Benzoic acid

Time of enuresis: During midnight in girls.

Sleep Pattern: Starts up, awakes with breathlessness and palpitation.

Character of urine: High coloured, smells like that of horse’s. Sour. Ammoniacal. Hot, profuse, alkaline.

Constitution: Gouty, rheumatic

Temperament: Confused ideas, cross.

Accompaniment: Sheets are unusually brown stained.
3. Calcarea carbonica

Time of enuresis: Enuresis in bed when walking. After midnight. Hysterical spasm of the bladder.

Sleep Pattern: Screams and cannot be pacified. Nightmares. Fearful and fantastic dreams. Snoring.

Cause: Masturbation, loss of fluids, fright, egotism.

Character of urine: Dark brown. Strong odour. White sediment, offensive.

Constitution: Fat, flabby children with red faces. gouty, Tendency to catch cold. Leucophlegmatic. Scrofulous. Plethoric, delicate.

Temperament: Dull, delayed, confused, fearful, forgetful. Nervous bilious, sanguine.

Accompaniment: Pica. Pitutary and thyroid dysfunctions. Tendency to take cold.

4. Causticum

Time of enuresis: During first sleep.

Sleep Pattern: Restless sleep. Starts laughs and cries. Drowsy-can hardly keep awake. Sensitive wakes up. No sensation of passing urine; scarcely believes until he makes sure of sense of touch.

Cause: Fright, grief, night-watching, retention.

Character of urine: Deposits of urates. Cloudy, uric acid, bloody.

Constitution: Children with lack hair and eyes and rigid fires. Delicate skin, hydrogenoid, scrofulous.

Temperament: Nervous girls, slow in learning.

Accompaniment: Warts, weakness, stools passed in standing position.
5. Cina

Time of enuresis: During second half of the sleep. Full moon.

Sleep Pattern: Restless during sleep. Lies on abdomen, knee-chest. Talks, cries, screams, wakes frightened. Hangs his head to one side. Will not sleep unless rocked.

Character of urine: Copious. Turns milky on standing. Turbid white.

Constitution: Big, fat, rosy and scrofulous.

Temperament: Restless, touchy, capricious.

Accompaniment: Hungry, worms, grids teeth. Convulsions.

6. Ferrum Metallicum

Time of enuresis: More frequently in a day time than at night.

Sleep Pattern: Sleepy of debility. Restless lies o back. Vivid, unpleasant, fell into water.

Cause: Weakness of the sphincter, vesicae. Worms.

Character of urine: Light colour of urine stains the sheet very dark and smell strong ammonia. Hot, profuse, mucous sediment.

Constitution: False plethora, pale. Emaciated. Weak, delicate, lymphatic. Hemorrhagic

Temperament: Sensitive, excitable, sanguine, choleric, phlegmatic.

Accompaniment: Allergies. Changeable.
7. Kali bromatum

Time of enuresis: 2 a.m. New moon.

Sleep Pattern: Somnambulism. Starts. Deep sleep, moans, cries, grinding. Horrible dreams.

Cause: Nightmare worries. Spasmodic.

Character of urine: Pale, profuse, sugar+

Constitution: Obese

Temperament: Depressed, forgetful, weepy. Lymphatic. Sanguine.

Accompaniment: Thirst, appetite, constipation, tender liver, diabetic headache.
8. Kali phosphoricum

Sleep Pattern: Night terrors. Somnambulism. Amorous dreams. Restlessness. Wakes up with fright.

Cause: Nervous debility.

Character of urine: Saffron, yellow, milky.

Temperament: Nervous, sensitive, depressed, gloomy, forgetful, fearful.

Accompaniment: Diabetics
9. Kreosotum

Time of enuresis: First part of night.

Sleep Pattern: Dreams of falling, poisoned, fire, of urination, in a descent manner. Wakes with urinating from deep sleep but cannot retain. Restless, tosses. Would not sleep until caressed and fondled.

Character of urine: Copious, pale urine. Offensive, brown red sediment.

Constitution: Overgrown, poorly developed children. Marasmus.

Temperament: Capricious, Leucophlegmatic.

Accompaniment: Black caries.

10. Lac caninum

Sleep Pattern: Screams, lies with one leg flexed and other stretched. She dreams of urinating.

Character of urine: Scanty, dark, thick, reddish sediment.

Constitution: Dark hair, eyes. Rheumatic, enlarged glands.

Temperament: Forgetful, cross, irritable.

Accompaniment: Diphtheria, sore throat.
11. Mercurius

Time of enuresis: Night 3 a.m.

Sleep Pattern: Sleepless of anxiety. Restlessness, dreams of water, thieves, animals.

Cause: Paralysis

Character of urine: Copious/scanty, urinates more than he drinks. Mixed with blood white sediment. Strong smelling. Staining diaper, hot acrid.

Constitution: Tendency to sweat profusely. Light hair with lax skin and muscles. Scrofulous, strong, florid complexion. Lively, brunette.

Temperament: Nervous, lack of will. Lymphatic, choleric.

Accompaniment: Easily suppurative tonsillitis. Thirsty, indented tongue. Stomatitis.

12. Argentum metallicum

Time of enuresis: Nocturnal (spasmodic forms)

Sleep Pattern: Restless sleep, anxious, frightful dreams. Screams.

Character of urine: Turbid, pale, fetid, profuse, sweat odour.

Constitution: Lean, thin, robust, anaemic.

Temperament: Anticipatory anxiety, fear, depressed, irritable.
13. Baryta carbonica

Time of enuresis: Night

Sleep Pattern: Talks in sleep. Twitchings. Lies on one side.

Character of urine: Scanty, dark brown, copious.

Constitution: Dwarfish, retarded, scrofulous.

Temperament: Absent minded.

Accompaniment: Oversensitive to all impressions. Tendency to take cold.
14. Natrum muriaticum

Time of enuresis: Alternate days, full moon.

Sleep Pattern: Somnambulism. Starts and talks in sleep. Dreams of robbers, vivid, frightful

Cause: Fright, grief.

Character of urine: Clear, watery, red sediment, turbid, dark.

Constitution: Lean, thin, scrofulous, brown hair, blue eyes. Dark complexion.

Temperament: Awkward, irritable, melancholic, nervous.

Accompaniment: Hopeless, school girl’s headache. Water brash, diabetics.
15. Phosphorous

Sleep Pattern: Somnambulism, dreams of fire, lewd, vivid, business. She couldn’t finish. Starts in sleep, lies on right side.

Cause: Anger, grief, diabetes, during typhoid.

Character of urine: Profuse, pale, haematuria, albumin, watery, turbid, brick dust sediment, offensive.

Constitution: Lean, thin, tall, beautiful. Grow too rapidly, gouty, scrofulous, fair, delicate eye lashes and smooth hair. Hemorrhagic.

Temperament: Sensitive, nervous, sanguine, quick, lively perceptions.

Accompaniment: Craving cold. Wants to be magnetized.
16. Pulsatilla

Time of enuresis: In little girls In autumn

Sleep Pattern: Lies with hands over head or crossed on abdomen and feet draw up. Talks, screams. Restless. Tosses, Dreams-confused, frightful.

Cause: Anger, spasm, measles after.

Character of urine: Mucus, scanty, red brown, profuse.

Constitution: Fair complexion. Sandy hair, blue eyes. Pale face.

Temperament: Mild, timid, weepy. Indecisive, slow, phlegmatic, sanguine, hysterical.

Accompaniment: Thirstlessness.

17. Sepia

Time of sleep: First sleep.

Sleep Pattern: Talks loud, wakes up. Restless. Dreams of urinating. Anxious.

Cause: Anger, vexation

Character of urine: Foul, sour, white, milky. Red, scanty, cloudy.

Constitution: Delicate, plethoric, yellow complexion, rigid Leucophlegmatic, in boys of light complexion with onanist. Dark hair, fibres, scrofulous.

Temperament: Nervous, irritable. Bilious.
18. Silicea

Time of enuresis: Moon phases.

Sleep Pattern: Somnambulism. Talks loudly. Dreams of lascivious, pleasant, murders, restless, wakes up frightened.

About the author

Sumit Goel

Sumit Goel

Dr. Sumit Goel M. D. (Hom)
Gold Medalist
Consultant Homoeopath and Teacher
www.homeopathyspace.com

1 Comment

  • Dear Sumit, Your apprach is very analytical. I appreciate it. We need such articles for easy remenberance and differential diagnosis. You should have added miasmatic analysis and few modalities also. Example-For custicum and Nux v this problem improves on its own in the rainy season. I peronally feel a dose of Medorrhinum for sycotic inheritance and sulpher for psoric inheritence is must at the end to complete the cure.

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