Aphale et al. World Journal of Pharmaceutical SJIF Impact Research Factor 6.805 Volume 5, Issue 11, 1691-1706. Research Article ISSN 2277 7105 TO STUDY THE IMPORTANCE OF CONCOMITANT SYMPTOMS IN MANAGEMENT OF ACUTE CASES Dr. Parth Aphale* and Dr. Atul Rajgurav Dr. D.Y. Patil Homoeopathic Medical College & Research Centre, Pune. Article Received on 20 Sept. 2016, Revised on 11 Oct. 2016, Accepted on 01 Nov. 2016 DOI: 10.20959/wjpr201611-7394 *Corresponding Author Dr. Parth Aphale Dr. D.Y. Patil Homoeopathic Medical College & Research Centre, Pune. ABSTRACT Background: Boenninghausen, in his close relationship with Hahnemann, learned to look at disease conditions from Hahnemann s point of view and the totality of the case meant to Boenninghausen a matter of concomitance- a group of related symptoms, not expressing the disease so much as expressing the individual who suffered. Therefore in homoeopathic philosophy the symptoms of the disease, especially the common or typical symptoms of any named disease grouping are of little value for prescribing. It is the totality of the symptoms- the whole picture of the suffering man that must be considered and this is made up not alone of the symptoms one expects to find. But of that.in other parts of the suffering individual or those atypical or seemingly unrelated symptoms which the alert physician must observe or elicit. Materials: It was a clinical study wherein 30 acute cases were studied, inclusion and exclusion criteria were defined, crieteria for assessment were laid down. Results: Tabular as well as graphical presentation of the data collected was done, statistical analysis was made, null as well as alternate hypothesis was laid down, t-test was applied. Conclusion: Concomitants are important in acute prescribing. KEYWORDS: Concomitants, Totality of Symptoms, t-test, Boenninghausen, Hypothesis. INTRODUCTION In our formative years of training in Homeopathy, we came across many practitioners treating both acute and chronic cases. There, we realized that the result in acute cases has to hit the bulls eye and this becomes then a firm stepping stone for a practitioner to build up his/her practice. www.wjpr.net Vol 5, Issue 11, 2016. 1691
In case of chronic cases he/she can buy some time in case the prescription does not hit right in the first go but this does not happen in acute ones. Then after a few years of seeing good practitioners prescribing with ease for acute cases and getting the desired result, it felt pretty simple and something that we can easily follow in our practice. [1,2,3] When actually the day came when we were on the hot seat and patient in front of me, we got lost in the maze of symptoms thrown by the patient at me.that s when we realized that acute cases are even more difficult since there is added pressure to make the patient fine within a very short span of time. That s when we started working on the concept of concomitants which Hahnemann calls peculiar, rare, and characteristic. We started trying to find out these concomitant symptoms in every patient so as to reach the similimum faster and more important, accurately. [4,5] Then when we got the opportunity to study this topic in depth we wanted to find out how much importance we can give these symptoms in my cases. That is when we felt the need to relate these symptoms to acute cases. In the third aphorism, Dr. Hahnemann has said If the physician clearly perceives what is to be cured in diseases, that is to say in every individual case of disease (knowledge of disease) then he understands how to treat judiciously and rationally and is a true practitioner of the healing art. Now when we consider a disease, the only way it can make itself evident in an organism is by giving out signs and symptoms which forms the portrait of the disease. Concomitant is a part of what is called as complete symptom the rest being location, sensation and modality. Concomitant means existing or occurring together, attendant, the noun concomitant means attendant circumstance. Time modality is thus the important aspect. www.wjpr.net Vol 5, Issue 11, 2016. 1692
Its importance was first highlighted by Boenninghausen. In the introduction of Therapeutic Pocket Book written by H. A. Roberts, he says, For a brief and comprehensive classification of homoeopathic symptomatology for therapeutic purposes, no plan has ever been devised superior or equal to that of Boenninghausen. Symptoms appear in constantly varying combinations in proving and in sickness. The form which symptoms may take in any given case is governed by the peculiarities of the individual. [6,7,8] All cases of Rheumatism for instance, will present with certain symptoms, but besides these common symptoms each case will present what Hahnemann called Uncommon, Peculiar (Characteristic) symptoms, which differentiate it from the other cases of its class. Boenninghausen emphasized the value of a complete symptom by Location Sensation Modality by adding a fourth requirement, equally imperative to the first three and yet in itself divisible into those three divisions. This was the Concomitant symptom and has led to the statement that Therapeutic Pocket Book is based on the doctrine of concomitants. The Concomitant symptom is to the totality what the condition of aggravation and amelioration is to the single symptom. This implies that as modality characterises a symptom, concomitant characterises totality. It is the differentiating factor. [9,10,11] PURPOSE OF SELECTION OF TOPIC The diseases to which man is liable are rapid morbid processes of the abnormally deranged vital force, which have a tendency to finish their course more or less quickly, but always in a moderate time (aphorism 72, 6 th edition of Organon of Medicine) In acute diseases, the symptoms take a quick evolutionary course, and it is easy for the physician to ascertain the complete picture of the disease. [12,13,14] Disease is not a substantiative entity, we observe individuals suffering from pneumonia, syphilis, diabetes, typhoid fever. Then in our mind we construct a picture consisting of signs and symptoms which we call disease. There are always some features along with general ones which render him unique and distinctive from any other patient of the same group. [15,16,17] So in the matter of matching, it will never be most similar unless the individualizing or striking uncommon peculiar features are also matched with one another. www.wjpr.net Vol 5, Issue 11, 2016. 1693
The interpretation of what constitutes a striking, singular uncommon peculiar feature, is left in the judgment of a physician and was first ably done by Boenninghausen in the following seven considerations, quis, quid, ubi, quibis auxilis, cur, quamondo and quando. Under quibis auxilis, he says, in finding the similimum for the whole case the concomitants provide the individualizing features in many cases. Acute cases have been studied as concomitants will show most strikingly in acute cases. As the cases progress to more chronic, these striking peculiar symptoms, the concomitants [18, 19] reduce and are replaced by more common symptoms. Aims & Objectives To ascertain the importance of Concomitants in acute case prescribing. To confirm that the selection of remedy on the basis of concomitants is a certain way to prescribe in acute cases. To ascertain that selection of remedy mainly on the basis of Concomitants is the fastest and best way to prescribe in acute cases. To report any associated findings or observations in course of the study. MATERIALS AND METHODS (METHODOLOGY) SOURCES Cases that will be available at OPD s of the authoes. A total of 30 cases will be studied, over a period of one year. TYPE OF STUDY Clinical study CASE DEFINITION ACUTE CASES Cases having rapid onset 24-48 hours, short duration and a short course less than 10 days. INCLUSION CRITERIA All those cases that fit in the case definition. Acute cases coming for the first time with no history of similar episode in the past. Acute cases coming for the first time with history of similar episode in the past. Acute exacerbation of the existing disorder. www.wjpr.net Vol 5, Issue 11, 2016. 1694
EXCLUSION CRITERIA All those cases that do not fit in the case definition. Purely chronic cases Multi-organ involvement All potentially life threatening acute phenomenon. Indisposition Phenomena presenting due to poisoning CASE RECORDING All the cases will be recorded as per the standard case performa, being acute cases stress will be laid on the onset, pace & characteristics that the patient shows. Unnecessary details of irrelevant chronic phenomena were not taken as per guidelines given in Aphorism 92. INVESTIGATIONS/ DIAGNOSTIC TECHNIQUES Complete clinical assessment and then investigations to assist diagnosis if necessary. ANALYSIS & EVALUATION All cases were evaluated keeping the acute totality in mind, importance will be given to recent deviations from health which is fresh in the patients mind, in terms of hierarchy concomitants to the acute phenomena will be given highest importance in this study as per guidelines laid down in Homeopathic Philosophy. REPERTORIZATION All cases were repertorized using Synthesis repertory in RADAR software after evaluation. SELECTION AND ADMINISTRATION OF DRUG Selection of remedy will be done after verification from standard text books of Materia Medica. Dose and repetition will be based on principles of Homeopathic Posology. The potency of remedy will be decided by the individual susceptibility. Route of administration will be oral. All cases will be given Placebo once improvement is seen. (Aphorism 246) FOLLOW UP Being acute cases follow up may be within 24 hours to 7 days, depending upon the pace of disease. www.wjpr.net Vol 5, Issue 11, 2016. 1695
CRITERIA FOR ASSESSMENT Response to treatment was assessed on basis of objective and subjective relief of the symptoms, signs and over all wellbeing reported by the patients. Cure Complete disappearances of symptoms-complex within a week time or before 10 days. Complete disappearance of Pathology if any Good Response Improvement more than 70% of the symptom complex within a week or maximum of 10 days Incomplete regression of the pathology, if any No relief/worse No improvement whatsoever within a week or maximum 10 days. For ease of evaluation I have graded the follow up thus, Grade I - Complete removal of symptoms and signs within definitive period of each case Grade II - Complete removal of symptoms but signs remains. Grade III - Some symptoms and some signs remain. Grade IV - No relief followed by natural recovery or progressive worsening of case. STATISTICAL ANALYSIS Effectiveness of the treatment was assessed according to statistical principles on the basis of change in score taken before and after treatment with Homeopathy. The data obtained from patients before the introduction of variable (similar remedy) has formed the control which was compared with the outcome of the symptom complex through the objective assessment after the Homoeopathic treatment in same patients. Since efficacy of Homoeopathic remedies on patients having definite group of signs and symptoms before giving Homoeopathic remedy were taken as control and compared with their symptomatology after the administration of similar remedy as response, no separate strategies of elimination of error or bias like use of controls, randomization, cross over design or placebo group and blinding techniques were used in this study. The following marks were given to the clinical features of the cases. www.wjpr.net Vol 5, Issue 11, 2016. 1696
Table 1 Scores Before Treatment Table 2 Scores After Treatment Observation & Analysis Charts Table no. 1 Sex Distribution Sr. No. Clinical Features Score 1 Presence of sign 3 2 Presence of symptom 2 3 Presence of pathology 4 Sr. No. Clinical Features Score 1 Disappearance of sign 2 2 Amelioration of symptom 1 3 Aggravation of symptom 3 4 Disappearance of pathology 4 Sr. No. Sex Number of % OF NO. of 1 MALE 11 36.66 2 FEMALE 19 63.33 TOTAL 30 100 Sex Ratio Graphical Representation Table no. 2 Acute Case Presentation Sr. No. Acute Cases Total % OF NO. of 1 1 ST Time With No History 21 70 2 1 ST Time With History 4 13.33 3 Acute exacerbation of Existing disorder 5 16.66 Total 30 100 www.wjpr.net Vol 5, Issue 11, 2016. 1697
Acute Case Presentation- Graphical Representation Table NO. 3 Age Group Sr. No. Age Groups Number of % OF NO. of (Years) patients 1 1-9 2 6.67 2 10 19 5 15 3 20 29 4 12 4 30 39 9 27 5 40 49 7 21 6 50 59 2 6.67 7 60-69 1 3 Total 30 100 Age Group- Graphical Representation Observation 4 System Affected Sr. No. System Affected Number of % OF NO. OF 1 Respiratory System 7 21 2 Git 4 12 3 Genito Urinary M/F 5 15 4 ENT 4 12 5 CNS 6 20 www.wjpr.net Vol 5, Issue 11, 2016. 1698
6 Infectious Disease 3 10 7 Dental 1 3 Total 30 100 System Affected-Graphical Representation Table No. 5 Basis of Remedies Sr. No. Basis of Remedy Number of % OF NO. of 1 Totality With Concomitants 20 70 2 Totality Irrespective of Concomitants 10 30 TOTAL 30 100 Basis of Remedy Graphical Representation Table No. 1.1 sex distribution Sr. No. Sex Number of Good No Relief OR Cured Response Worse 1. Male 11 4 5 2 2. Female 19 6 11 2 www.wjpr.net Vol 5, Issue 11, 2016. 1699
Sex Ratio-Graphical Representation Table no. 2.2 Acute Case Presentation Sr. No. Acute Cases Number of Good No Relief or Cured Response Worse 1 1 ST Time With no History 21 9 10 2 2 1 ST Time With History Acute 4 1 3 0 3 Exacerbation of Existing disorder 5 0 3 2 Acute Case Presentation Graphical Representation Table No. 3.3 Age Group Sr. No. Age (Years) Number of Good No Relief Cured Response or Worse 1 1-9 2 2 0 0 2 10 19 5 1 4 0 3 20 29 4 2 2 0 4 30 39 9 3 4 2 5 40 49 7 1 4 2 6 50 59 2 0 2 0 7 60-69 1 1 0 0 www.wjpr.net Vol 5, Issue 11, 2016. 1700
Age Group- Graphical Representation Table No. 4.4 System Affected Sr. No. System Affected Number of Good No Relief Cured Response or Worse 1 Respiratory System 7 3 2 2 2 GIT 4 2 1 1 3 Genito Urinary M/F 5 0 5 0 4 ENT 4 2 2 0 5 CNS 6 2 4 0 6 Infectious Disease 3 1 1 1 7 Dental 1 0 1 0 System Affected- Graphical Representation Table No. 5.5 Basis of Remedies Sr. No. Basis of Remedy 1 2 Totality With Concomitants Totality Irrespective of Concomitants Number of Cured Good Response No Relief or Worse 20 7 12 1 10 3 4 3 www.wjpr.net Vol 5, Issue 11, 2016. 1701
Basis of Remedies Graphical Representation Statistics Distribution of scores before & after Homoepathic Treatment Case No. X Y X-Y A Ā (A Ā)² 1 16 9 7 4.07 16.56 2 10 6 4 1.07 1.14 3 5 5 0-2.93 8.56 4 4 2 2-0.93 0.86 5 6 3 3 0.07 0.0049 6 4 2 2-0.93 0.86 7 5 3 2-0.93 0.86 8 7 4 3 0.07 0.0049 9 10 7 3 0.07 0.0049 10 11 11 0-2.93 8.56 11 4 2 2-0.93 0.0049 12 13 8 5 2.07 4.28 13 6 3 3 0.07 0.0049 14 4 2 2-0.93 0.86 15 11 7 4 1.07 1.14 16 9 5 4 1.07 1.14 17 10 5 5 2.07 4.28 18 4 2 2-0.93 0.86 19 8 4 4 1.07 1.14 20 11 7 4 1.07 1.14 21 13 7 6 3.07 9.42 22 10 6 4 1.07 1.14 23 10 7 3 0.07 0.0049 24 9 10-1 -3.93 15.44 25 4 2 2-0.93 0.86 26 10 6 4 1.07 1.14 27 4 2 2-0.93 0.86 28 8 5 3 0.07 0.0049 29 13 9 4 1.07 1.14 30 13 13 0-2.93 8.56 www.wjpr.net Vol 5, Issue 11, 2016. 1702
Statistical Working X= score before treatment Y= score after treatment A= difference between the scores. Ā=mean of the difference between the scores S=S.D of Differences S E= Standard Error of Mean Now we assume H o null hypothesis states that concomitants are not useful in acute case prescribing. H 1 alternate hypothesis states that concomitants are useful in acute case prescribing. Ā = Σ A n = 2.93 S = Σ (A - Ā) ² n-1 = 90.83 29 =1.76 SE= S n = 1.76 5.47=0.32 t = Ā SE= 2.93 0.32= 9.15 Thus t =9.15 At 5% level for 29 degrees of level of freedom the value of t = 2.05 At 1% level for 29 degrees of level of freedom the value of t = 2.76 Thus the value obtained is more than the above values so; we reject the null hypothesis and accept the alternative hypothesis. Therefore concomitants are useful in acute case prescribing. DISCUSSION In this study, the effectiveness of homoeopathic medicine in the treatment of acute diseases was evaluated over a time period of 12 months in 30 patients fulfilling the case definition and inclusion criteria. The evaluation was based on improvement with respect to signs, symptoms and pathology (if present) and, on the statistical verification the scores were taken before and after. On the basis of these they were termed Cured 33% Good response 53.33% No relief or Worse 13.33% 30 patients were studied over a period of 12 months were analysed for parameter of Prescription based on concomitant alone Prescription based on totality irrespective of the concomitant. www.wjpr.net Vol 5, Issue 11, 2016. 1703
Thus 66.66% cases were based on concomitants alone and 33.33% based on totality. (1) Prescription based on concomitant alone Cured 35% Good response 60% No relief or Worse 5% (2) Prescription based on totality irrespective of the concomitant Cured 30% Good response 40% No relief or Worse 30% 95% of cases lie in the bracket of cure and good response belong to those where prescription is based on concomitant alone. 70% of cases lie in the bracket of cure and good response belong to those where prescription is based on totality irrespective of concomitant. The prevalence was noted in female sex (63.33%) followed by male sex (36.67%) in this study. The age group distribution was as follows, 30-39yrs (27%) followed 40-49yrs (21%) then by 10-19yrs (15%), 20-29yrs (12%), equally 1-9yrs and 50-59yrs (6.67%) and 60-69yrs (3%). Coming for the first time with no previous history of acute episode (70%) followed by acute exacerbation of existing disorder (16.66%) and a previous history of similar episode (13.34%). Maximum system affection was seen in respiratory system (21%), central nervous system (20%), genitourinary system (15%), gastrointestinal and ear nose throat affections (12%) each, infectious diseases (10%) and lastly dental (3%). SUMMARY AND CONCLUSION In a nutshell, out of the 30 cases which were evaluated: In 20 cases the remedy was principally based only on the concomitant. If the concomitant were not to be considered the similimum was not the same. In 10 cases, irrespective of the concomitant the remaining totality itself brought out the similimum. www.wjpr.net Vol 5, Issue 11, 2016. 1704
In (a) Cases we see that 19 show results either cured or giving good response. In (b) Cases we see that 7 show results either cured or giving good response. Thus in (a) Cases where concomitants were the key to prescribing we have seen 95% positive results. Thus in (b) Cases where totality was the prescribing factor we have seen 70 % results. According to the 30 cases we have studied, we can say that concomitants are the key symptoms to prescribing in acute cases. This inference is not only for statistical purpose but it gives us guidelines for prescribing in acute cases.even if we find one such symptom and prescribe only on the basis of this symptom we are sure to succeed in at least 9 out of 10 cases. This will give us consistent results in acute cases. This will then be a feather in the cap for Homeopathy. Thus will also make people get over the myth that Homeopathy takes very long to act and has little or no role in treating acute cases. ACKNOWLEDGEMENT We, Dr. Parth Aphale, M.D.(Hom.), & Dr. Atul Rajgurav, M.D. (Hom.), Faculty, Department of Homoeopathic Pharmacy, Dr. D.Y. Patil Homoeopathic Medical College & Research Centre, Pune (Dr. DYPHMCRC), would like to thank respected Dr. D.B. Sharma, Principal, Dr. DYPHMCRC, Pune for giving us this opportunity to take up this research project and test the efficacy of high potencies in acute cases. We also would like to thank the ethics committee of our college for accepting this research project. BIBLIOGRAPHY 1. Samuel Hahnemann, Organon of Medicine, B. Jain publisher 6th edition. Reprint edition 1993; 92: 180, 171. 2. CMF von Boenninghausen, The lesser writings translated from the original German by Prof. L.H. Tafel. B. Jain publishers (P) Ltd. Reprint edition 1998; 112, 113. 3. Dr. Dhawale M. L, Principles and Practice of Homeopathy, reprint 1994; 77, 78. 4. Allen T.F., Therapeutic Pocket Book for Homoeopathic Physicians to use at bedside and in the study of the material medica. B.Jain publishers (P) Ltd. Reprint edition 1999; 20, 21. 5. Dr. Shaikh A.M. Concomitants. Published by Homoeopathic Medical College Belgaum. Printed at Jokap Printers Dr. SPM Road, Belgaum pg1 to 11. www.wjpr.net Vol 5, Issue 11, 2016. 1705
6. Harrison s textbook of medicine, diseases and classification 14th edition pg-10, 11. 7. RADAR (Rapid Aid to Drug Aimed Research) Dr. Freidrik Schroyen, Gent, Belgium. 8. Shah Jawahar HOMPATH M.D. computer software. 9. Stuart Close, The Genius of Homeopathy, Lectures and Essays on Homoeopathic Philosophy, Published by Haren and Brothers, Calcutta 1959; 54, 55. 10. Roberts H.A., Introduction to Boenninghausens Therapeutic Pocket Book edited by Dr. T.F. Allen, Publisher Swaran Publishing House, New Delhi pg 20,21. 11. Dr. Arya M.P, A Study of Hahnemann s Organon of Medicine Based on English Translation of the 6th edition by Dr. William Boericke, M.D. B. Jain Publishers (P) Ltd. 1st edition pg 63,213. 12. HPATHY.COM web portal. 13. SIMILIA.COM. web portal. 14. WIKEPEDIA the free encyclopaedia. 15. Bradford & Hill: Principles of Medical Statistics, Edition 12, And Publisher: Hodder & Stoughton, Chapter 10. Pg. 88-96. 16. ICR Symposium 2nd edition 1994. 17. Farokh J Master,M.D., Clinical Organon of Medicine, BJain Publishers (P) Ltd. Edition 2006 pg 131. 18. Dr. Krishnamurty P.S, Applied Organon Salimashraf Publishers, published 2006, pg 140,141. 19. Dr. Datta Ashish, The Science and Art of Homoeopathic Case Taking, reprint edition July 2007 Indian Books and Periodicals Publishers. Pg 212, 229. www.wjpr.net Vol 5, Issue 11, 2016. 1706