BHARATESH HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL,

POST-GRADUATE RESEARCH CENTRE,

BELGAUM-590016, KARNATAKA.

Recognised by:

CENTRAL COUNCIL OF HOMOEOPATHY, NEW DELHI.

Affiliated To:

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE

SYNOPSIS

M.D (Homoeopathy)

STUDY OF GOUT WITH MIASMATIC APPROACH

By

Dr. RAJIV RUI VIEGAS PERES

DR.(Mrs) M.N. SHAIKH, M.D.(Hom)

Professor,HODP.G Guide,

DEPARTMENT OF ORGANON OF MEDICINE & HOMOEOPATHIC PHILOSOPHY.

BHARATESH HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL, BELGAUM

From,

Dr. RAJIV RUI VIEGAS PERES

To,

Dr. (Mrs) M.N. SHAIKH, M.D (Hom)

Professor,HODP.G guide.

Dept. Of Organon of Medicine & Homoeopathic Philosophy.

Bharatesh Homoeopathic Medical college & Hospital, Belgaum.

Sub: Application to accept my synopsis for dissertation

Respected Sir,

I, Dr. Rajiv Rui Viegas Peres would like to forward my application for approval of my synopsis under your guidance for the following topic, “Study of Gout with miasmatic approach”.

Hope you will approve the same.

Date:

Place:

Yours sincerely

Dr. RAJIV RUI VIEGAS PERES

Dept. Of Organon of Medicine & Homoeopathic Philosophy

Bharatesh Homoeopathic Medical College &Hospital, Belgaum.

From:

Dr. (Mrs) M.N. SHAIKH, M.D.(Hom)

Professor,HODP.G Guide.

Dept of Organon of Medicine & Homoeopathic Philosophy.

Bharatesh Homoeopathic Medical College & Hospital, Belgaum.

To,

Dr. RAJIV RUI VIEGAS PERES

Sub: Acceptance of synopsis for dissertation

Dear Doctor,

I, have accepted your topic “STUDY OF GOUT WITH MIASMATIC

APPROACH”,for the dissertation.

Your synopsis will be forwarded to RGUHS

Date:

Place:

Dr. (Mrs) M.N. SHAIKH, M.D.(Hom)

Professor,HODP.G Guide.Dept. of Organon

Of Medicine & Homoeopathic Philosophy

Bharatesh Homoeopathic Medical College

& Hospital, Belgaum.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

ANNEXURE-II

APPLICATION FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS (IN BLOCK LETTERS ) / Dr. RAJIV RUI VIEGAS PERES
BHARATESH HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL, BELGAUM, KARNATAKA.
PERMANENT ADDRESS / HOUSE NO 488, XINDOLEM, CURTORIM, SALCETE, GOA.403709
2. / NAME OF INSTITUTION / BHARATESH HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL, BELGAUM, KARNATAKA.
3. / COURSE OF STUDY & SUBJECT / M.D. (HOMOEOPATHY)
ORGANON OF MEDICINE AND HOMOEOPATHIC PHILOSOPHY
4. / DATE OF ADMISSION TO COURSE / 23rd March 2011
5. / TITLE OF THE TOPIC / “STUDY OF GOUT WITH MIASMATIC APPROACH”
6. / BRIEF RESUME OF INTENDED WORK:
6.1 NEED FOR STUDY
Gout is a type of metabolic disorder having tremendous impact on public health, ninety per cent of people suffering from primary gout are males associated with high social status, alcohol intake, achievement & increased intelligence.It presents in middle age 40-50 yrs.Thus gout is one of the commonest illnesses affecting the working class people, resulting in gross deformity.Gout is an abnormality of uric acid metabolism resulting in deposition of sodium urate crystals in joints,soft tissue & urinary tract.Hippocrates was the first to note that it does not occur in men before puberty & women until after menopause.It is a disease which mostly starts in middle life.Patients may present with a sudden acute excruciating pain in the great toe,having started in the early hours of the morning,the joint is red & swollen,warm and very tender.This condition is Gout.
An acute gouty arthritis affects the metatarso-phalangeal joints of the big toe initially and later feet,ankles,knees,hands,wrist & elbow.The excruciating pains are usually at night.Gout is a disease that is as obstinate as it is painful.
Treatment of Gout is aimed at relieving the acute synovitis,Allopathic treatment of Gout involves use of Non-steroidal anti-inflammatory medications such as Indometacin or naproxen.Colchicine is also effective. Secondly thetreatment is aimed at preventing further crystal formation.If oral therapy is not effective,the attack can usually be terminated by an intramuscular corticosteroid injections.Howeversome of these drugs create dependency & unwanted side effects, when used for an extended period of time.Allopathic medicines have tried to help, but has many drawbacks.The world needs a system which is safe & effective for such complaints.
Honourable Dr Hahnemann has provided us a unique and well proven scientific theory to care for those suffering from such illnesses.Dr Hahnemann has the answer to these all.He has given us the information, how to deal with the various stages of sickness; Acute & chronic and with its subdivisions.With this science of holistic healing namely Homoeopathy, we have been successful not only to relieve the symptoms but also the cause & thereby restoring your inner harmony and health.
Since the existing treatment types are helpful only to some extent, and since most medicines have side effects, there is need for study of the efficacy of Homoeopathic medicines in such a disorder.Our Homoeopathic medicines are not only economically feasible but also have no any side effects,besides they can control & treat acute episodes of gout effectively.The present day study taken by me “Study of Gout with miasmatic approach” is an earnest attempt to study the efficacy of Homoeopathic medicines in this condition.
Hypothesis:
Null Hypothesis:Homoeopathic management of treating Gout in adults may be effective.
6.2 REVIEW OF LITERATURE
DEFINATION
Gout is a form of metabolic crystal arthropathy associated with hyperuricaemia. It can be defined as the pathological reaction of the joint or periarticular tissues due to presence of monosodium urate crystals. As the crystal deposits slowly, there is progressive involvement of more proximal sites & the potential for cartilage and bone damage with consequent development of ‘secondary Osteoarthritis’, renal disease and nephrolithiasis.1
Prevalence and age of onset: The prevalence of Gout is approximately 2 in 1000 population, Men are 10 times more likely to have gout than women, and it rarely occurs before young adulthood and seldom in premenopausal females. The prevalence increases with age & the prevalence in older females is increasing with increased diuretic use.
Gout presents in middle life 40-50 yrs. Studies suggest a multifactorial inheritance, and a family history may be obtained from 30% of patients with gout. Values are higher in urban than in rural communities & correlate positively with high social status, class, weight, high protein intake, achievement and increased intelligence.2
ETIOLOGY
Diuretic drugs are the main cause of hyperuricaemia, accounting for some 60% of cases , Genetic & environmental factors lead to hyperuricaemia by decreasing the excretion, or increasing the production of uric acid. In most patients there is often a family history. In 20% of patients gout is due to overproduction of uric acid & can be detected by measuring the excretion of uric acid.
Gout & hyperuricaemia are often associated with obesity, type iv hyperlipoproteinaemia, impaired glucose tolerance, hypertension and ischaemic heart disease. Hyperuricaemia may occur when large quantities of nucleoprotein are broken down during the treatment of leukaemia or lymphoma, enzyme defects cause overproduction of uric acid. Hypoxanthine-guanine phosphoribosyl transferase deficiency is associated with accelerated purine synthesis, Gout & renal stones. Complete deficiency is rare, X-linked, inborn error of metabolism in which gout is associated with spasticity, a variable degree of mental deficiency and a compulsive self mutation( the Lesch-Nylan Syndrome).
Phosphoribosyl pyrophosphate synthetase overactivity is another X-linked inborn error of metabolism associated with gout and increased purine synthesis. Many drugs affect renal elimination of uric acid. For example, aspirin reduces renal clearance at low doses, but is uricosuric at high doses. Other drugs reducing clearance include diuretics(except amiloride & spironodactone), pyrazinamide and ethambutol, lead also reduces clearance.3
CLINICAL FEATURES
The natural history of Gout can be considered in four stages: Asymptomatic hyperuricaemic; Acute gouty arthritis; Intercritical gout; and Chronic tophaceous gout.4
  1. ASYMPTOMATIC HYPERURICAEMIA
The tendency to develop acute gouty arthritis increases with the level & duration of hyperuricaemia. Nearly all patients with gout have hyperuricaemia, but only approximately 5% of those with hyperuricaemia develop gout. The first attack of gouty arthritis (or nephrolithiasis) comes after many years of sustained hyperuricaemia.
  1. ACUTE GOUTY ARTHRITIS
This usually manifests as exquisitely painful monoarthritis, first affecting the big toe in 50% of patients. Adjacent skin may become red and peel. As there may be a fever and polyarticular symptoms, it needs to be differentiated from infected arthritis. There may be asymptomatic periods between attacks, which commonly occur spontaneously at night, but they may be triggered by a specific event (e.g. trauma). The duration of an attack varies, but if treated is rarely longer than 2weeks. Although acute gout most commonly affects the lower, more distal areas, it should always be considered in the diagnosis of an arthritis affecting any joint.
  1. INTERCRITICAL GOUT
After the first attack there is an asymptomatic intercritical period, which may last up to 10years, although approximately 60% of patients have a further attack within the first year. Each successive attack may last longer and resolve less completely, and is often associated with fever. Differentiation from other polyarticular arthritides (e.g. RA) may be difficult.
  1. CHRONIC TOPHACEOUS GOUT
If gout is not treated, crystals of monosodium urate (tophi) will deposit in cartilage(e.g. in the helix of the ear), in synovial membranes(e.g. in the Achilles tendon) and in soft tissues(e.g. in the ulnar surface of the forearm). Tophi may resemble rheumatoid nodules, and may ulcerate and exude urate crystals.
  1. RENAL MANIFESTATIONS
Approximately 90% of patients with gouty arthritis have reduced renal uric acid clearance. The prevalence of uric acid stones in gouty patients ranges from 10 to 25%, compared with 0.01% in the general population. Parenchymal renal damage may be caused by deposition of urate crystals within renal interstitial tissue (urate nephropathy), or by formation of uric acid crystals within the collecting tubules, renal pelvis or ureter(obstructive uropathy). Gouty patients also have an increased incidence of calcium- containing renal stones.
DIAGNOSTIC CRITERIA
Haematology:
  • ESR may be raised.
  • Synovial fluid leucocyte count: increased and composed mainly of neutrophils.
Biochemistry:
  • Serum uric acid: elevated in 90% of patients with gout.
  • Serum creatinine and urea: elevated in renal failure.
Urine:
  • Uric acid excretion greater than 300 to 800 mg/day suggests overproduction of uric acid.5
MANAGEMENT
Treatment of Gout is aimed at relieving the acute synovitis, Allopathic treatment of Gout involves use of Non-steroidal anti-inflammatory medications such as Indometacin or naproxen. Colchicine is also effective. The secondly treatment is aimed at preventing further crystal formation. The affected joint should be rested until the attack has subsided. If oral therapy is not effective, the attack can usually be terminated by an intramuscular corticosteroid injections. However, some of these drugs create dependency & unwanted side effects when used for an extended period of time.
Dietary advice for patients with hyperuricemia:
  • Avoid foods containing large amounts of purine
    e.g. sardines, bacon, liver, kidneys and meat proteins.
  • Purine rich foods in vegetarians: cabbage, cauliflower, pulses, lentins, spinach, apple, mushrooms, tomato, beetroot, beans, peas etc.
  • Excessive purine intake and over indulgence in alcohol should be avoided.
  • Drink plenty of fluid.
  • Avoid aspirin and diuretics.6
Allopathic medicines have tried to help but has many drawbacks. The world needs a system which is safe & effective for such complaints as Homeopathy.
Dr. Hahnemann was able to distinguish several patterns of symptoms, behaviour and illnesses that were commonly passed down from parent to offspring.
We must keep in mind that certain symptoms in conjunction with familial histories signify an inherited disposition towards certain diseases. Miasm is understood to be such volatile derangement of the vital force that predates the current illness and is more fundamental than his present trouble. We must find out the basic disease entrenched deep within the patient and not just the current trouble. We must identify the Miasm that is impending the lasting cure.7 Dr Hahnemann has made this abundantly clear in aphorism 206.
In the Organon of Medicine,Vide aphorism 5,Dr Hahnemann distinguishes the origin of disease into two categories; The exciting cause and The fundamental cause and correlated them to susceptibility of the physical constitution. He emphatically concluded that psora is the root cause of all the illnesses which occurred in human being.8 Dr Hahnemann gives us clinical etiology of miasms where as Dr Kent provides a philosophical concept of miasm. Dr H.A Robert & Dr Speight further classified the miasms according to the symptoms. Dr Subrata K. Banerjea states that stiffness, soreness & lameness are characteristic of sycosis, and gouty diathesis have a sycotic base. This amply demonstrates Dr Hahnemann’s & Burnett’s concepts that only those belonging to sycotic families will show the symptoms of gout. 9
Therapeutics of Gout:
There are several effective homoeopathic remedies for Gout some of which are:
Colchicum: Toe joints become inflamed, dark red and hot, intensely painful, urine scanty & red. Cannot tolerate any noise & external impressions.
Ledum pal: is useful after abuse of alcoholic drinks. Foot with tearing, grinding & shooting pains, cannot bear least covering or the warmth of bed. The nodes of the frequent attacks turn very painful & sore, better by ice applications.
Benzoic Acid: usually has a very offensive urine & deposits a reddish cloudy sediment but with attack the urine becomes more or less clear, old nodes become painful, the pain abates with the palpitation in the heart and ceases only when they increase.
Lycopodium: will be very useful in sub-acute & chronic cases. It has a weak digestion. There is lot of flatulence with bloated abdomen. Desire for sweets, cannot eat oysters & onions, beans as eating them causes severe swelling of joints. Red sand in urine & offensive. Usually there is relief in joint pain after urine freely passes.
Causticum: has painfulnodes on the joints, stiff joints & the pains are relieved by warmth of bed.
Bryonia: has swollen joints, tense & not very red. Feels deathly sick & has a white-coated tongue; is unbearably cross.
Graphites: has tearing in toes, the pains drive him out of bed at night & the gastralgia is relieved by eating.
Lithium carb: has gouty constitution & uric acid diathesis.Soreness is marked. Violent sharp pains as from hot needles.10
Some rubrics for Gout are:
[Kent’s repertory] ( Extremities ) Arthritic - Nodosities
[Kent’s repertory ] ( Extremities ) Pain – Joints – Gouty
[Kent’s repertory] ( Generalities ) Food – Meat – agg
[Kent’s repertory] ( Generalities ) Food – Beer – agg
[Kent’s repertory] ( Desires ) Alcoholic drinks 11
6.3 AIMS AND OBJECTIVES
  • To study the clinical presentation of Gout .
  • To study the miasmatic cleavage of gout.
  • To study the efficacy of Homoeopathic medicine in the treatment of Gout in adults.

7. / MATERIAL AND METHODS:
7.1 SOURCE OF DATA:
The patients for the study will be taken from O.P.D/I.P.D. and peripheral clinics of Bharatesh Homoeopathic Medical College and Hospital.
7.2 METHODS OF COLLECTING DATA (including sampling procedure, if any)
  • Patients will be selected on the basis of inclusion and exclusion criteria, history and findings.
  • History and interview will be taken as per proforma prepared for the topic.
  • Simple Random Sampling procedure shall be adopted.
  • Sampling size will be minimum 30 in number.
  • Duration of study – all the cases that fit into the designed criteria, registered between 15th Nov 2011 to 15 July 2013 will be taken up for study.
  • Follow up criteria will be seen fortnightly & as per requirement.
  • Result criteria: Assessment of results shall be done based on –recovered, improved and not improved.
Inclusion Criteria:
  1. Patients between age group of 25-60 years will be taken for study.
  2. All patients irrespective of sex, occupation and socioeconomic status shall be considered for the study.
  3. Patients fitting the biochemistry criteria of elevated Serum Uric acid will be considered.
Exclusion Criteria:
  1. Cases of Gout along with serious systemic or pathological disease.
  2. Cases of Gout along with immunodeficient disease.

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO, PLEASE DESCRIBE BRIEFLY.
Diagnosis of the cases will be done on eliciting the case history and clinical findings. Serum Uric acid will be done in the patients considered in this study.
7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3?
YES, ethical clearance has been obtained from the institution.
8. / LIST OF REFERENCES:
  1. Harrison TR. Harrison’s Principles of Internal Medicine. 16th edition. published in New Delhi: Churchill livingstone. Elsevier; 2006. 2046, 2308 pp.
  2. O’Callaghan C. Oxford Medicine; 2nd edition. published in New Delhi: Churchill livingstone. Elsevier; 2004. 241 pp.
  3. Siddharth NS. API Text Book of Medicine.7TH Edition. Mumbai: The Association of India; 2003. 1155 pp.
  4. Clark K. Clinical Medicine. 6th edition. Published in New Delhi: Elsevier Saunders; 2005. 568 pp.
  5. Robbins KC. Basic Pathology. 7th edition. Published in New Delhi: Elsevier Saunders; 2003. 774 pp.
  6. Kumar P. Homoeo Era. Vol. 1 Issue 4. Manglore: Published by E.S.J Prabhu Kiran. May 2010. 16 pp.
  7. Mehta K. Miasms the devious Intrigue. Published in Mumbai: by Mind Technologies; 2008. 7 pp.
  8. Hahnemann S. Organon of Medicine. 6th Edition. Reprint edition.published in New Delhi: Indian Books & Periodicals Publishers;2007. 185 pp.
  9. Banerjea SK. Miasmatic Diagnosis. 1st Edition. Reprint edition. Published in New Delhi: B. Jain Publishers ( P ) ltd; 2004. 94 pp.
  1. Muzumdar KP. Textbook of Homoeopathic therapeutics. 2nd Edition. Published in West Bengal: by New Central Book Agency ( P ) ltd; 2006. 146 pp.
  2. Kent JT. Repertory of the Homoeopathic Materia Medica. Reprint edition. New Delhi: Indian Books & Periodicals Publishers; 2009. 953 pp.
  3. Davidson S. Davidson ‘s Principles & Practice of Medicine. 20th Edition. Published in Edinburg: by Churchill Livingstone; 2006. 1112 pp.
  4. Khair DV. The Homoeopathic Heritage. Vol. 34 no 2. New Delhi: Published by Dr Kuldeep Jain; February 2009. 48 pp.
  5. dated on 12-12-11

9. / SIGNATURE OFCANDIDATE
10. / REMARKS OF THE GUIDE
11. / NAME &DESIGNATION OF (IN BLOCK LETTERS)
11.1 GUIDE / DR. (Mrs) M.N. SHAIKH M.D (HOM)PROF,HODP.G GUIDE,DEPT. OF ORGANON OF MEDICINE & HOMOEOPATHIC PHILOSOPHY BHARATESH HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL,
BELGAUM-590016
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF DEPARTMENT / DR. (Mrs) M.N. SHAIKH M.D (HOM)PROF,HOD & P.G GUIDE,DEPT. OF ORGANON OF MEDICINE & HOMOEOPATHIC PHILOSOPHY, BHARATESH HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL,
BELGAUM-590016.
11.6 SIGNATURE
12. / 12.1 REMARKS OF
CHAIRMAN &PRINCIPAL
12.2 SIGNATURE