Asthma is a syndrome of variable airflow obstruction. It is characterized by bronchial inflammation with prominent eosinophil infiltration, variable cough, chest tightness and wheeze.
1. Extrinsic asthma
2. Intrinsic asthma
3. Mixed forms
Seen in young persons, child or teenage. Most having history of eczema during their childhood, and family history of asthma eczema or hay fever. Intermittent attacks are seen. Attacks are acute but usually self-limiting. Prognosis is favorable.
Seen in the adult patients over 35 yrs or more. No history of eczema in childhood. Attacks related to infection, exercise, etc. Attacks are more fulminant and severe. Prognosis is poor.
1-premonitory symptoms/asthmatic symptoms/asthmatic aura-
Sneezing,flatulence,drowsiness,restlessness, and irritability.
Dry irritant cough may precede or accompany attacks of wheezy breathlessness.
2. Paroxysm: usually seen in the middle of the night. Sense of oppression in the chest. Patient sits up and leans forward fighting for breath or runs to the window to relieve the sense of suffocation. Wheezing heard. Anxiety, cyanosis, perspiration and cold extremities are seen.
3. Termination: spontaneously or as a result of therapy. As bronchial spasm gets less, patient can cough a little and may bring out viscid mucofibrin.
4. Duration of attack: It varies from few minutes to several hours. Sometimes paroxysms are continuous -status asthmaticus.
The association between atopy and asthma suggests that sensitation and exposure by allergens is an important risk factor. Warm humid centrally heated homes favor the multiplication of house dust mites. This contributes child hood asthma. The relationship between exposure to pet and asthma is a little controversial. Some say pet exposure in early life may offer a protective role against asthma. Milk fat vitamin E and selenium may protect the child from asthma. However, cow’s milk protein may develop atopy and asthma.
1. Chest radiograph: It may be normal, or show the signs segmental or lobar collapse.
2. Full blood count: eosinophilia
3. Sputum: eosinophil, Charcot, and at times Curschmann spirals may appear.
4. Skin tests: It may confirm allergens suggested by history.
5. Provocation test (challenge) test: exercise challenge tests useful in young adults and can be used to confirm the diagnosis of asthma, since fall in FEV1or PEFR occurs after 5-7 minutes of vigorous exercise.
6. IgE and IgE specific test
Keep away from dust, mites and pollen
Keep away furry things like the teddy bear, especially in children
Keep away from smoke and other atmospheric pollution.
Aim of homeopathic treatment
To cut short the episodes.
To reduce intensity and severity.
Complete cure in children and young adults.
Palliation in old aged persons.
Homeopathy is the apt choice for the treatment of asthma. It works wonders in asthma. Both the acute exacerbation, as well as chronic asthma can be completely curable in the homeopathic system of treatment.
In acute onset, the time of aggravations, and other worsening factors, amelioration factors, and positions, etc. are all taken into consideration.
And the selected remedy is given in a frequent interval until an improvement is obtained.
Once the acute episode is controlled then it is time to give a miasmatic remedy that cures completely in a permanent manner.
For this, a detailed case taking as per homeopathic philosophy is needed. The mental and physical built of the patient with his and family histories are needed. The remedy thus selected is usually tried in medium potency. Since it being a chronic disease, remedies may change when the symptoms changes. In short, homeopathy and homeopathic medicine is a ray of hope for asthma. Especially in situations where the conventional treatments like bronchodilators, inhalers, etc. have got too many demerits.
Acute cases are managed by Antimonum tart in different potencies, Ars alb, Amm- carb, Grindelia Q, SenegaQ, Spongia Q, etc.
Thuja, Syphyllinum, Bacillinum, kali carb etc. are the main remedies
Bronchiectasis is a destructive lung disease characterized by chronic dilatation of the bronchi associated with persistent though a variable inflammatory process in lungs. Usually acquired, but may result from the underlying genetic or congenital defects of airway defences.
The diagnostic feature of Bronchiectasis is dilated bronchi.
The Ried’s classification differentiates between pathological and radiological appearances of Bronchiectasis.
Saccular and cystic bronchiectasis
Congenital-cystic fibrosis, primary hypogammaglobulinemia
Acquired-in children-inhaled foreign body, pneumonia complicating from measles, whooping cough, primary TB
In adult-pulmonary TB, bronchial tumor, suppurative pneumonia
1. Bronchitis: attacks of recurrent bronchitis more common in winter. Clubbing of finger is diagnostic.
2. Hemorrhagic or bronchiectasis sicca: recurrent hemoptysis with good health in between
3. Suppurative: chronic cough, copious purulent expectoration general toxemia clubbing of fingers varying from slight beak curvature of finger nails to bulbous drumstick enlargement
4. with a relatively rapid onset: symptoms developing with comparative suddenness as a sequale to partial bronchial obstruction by foreign body or after anesthesia
There may be signs of bronchitis, fibrosis, consolidation, collapse or of cavitations.
Early stages: fine crackles or sticky rhonchi and slight alteration in character of breathe sounds.
Late stages: bronchial breathing, coarse creps and perhaps signs of cavity. Sharp metallic or leathery rales are characteristic. Recurrent pneumonia in the same area of the lung is classically associated with bronchiectasis.
Culture and sensitivity of sputum.
HRCT: high resolution CT
Alpha 1 antitrypsin deficiency
Detection of cystic fibrosis
Since it belongs to syco-syphilitic miasm, if not treated with anti miasmatic remedies the prognosis will not be favorable. And in clinical, it is seen that, bronchiectasis due to acquired causes responds very well to the homeopathic treatment. However, if bronchiectasis due to genetic or congenital factors complete cure is impossible but palliation of the symptoms only.
Moreover, in the young and adult patients, the prognosis is favorable, but in aged people, symptomatic relief is the result.
Anyway overall results are favorable with homeopathic treatment.
Treatment-homeopathic medicines-Antim tart, Phosphorus, Acalypha indica, etc.
It is the acute infection of the mucous membrane of trachea and bronchi produced by viruses and bacteria or external irritants.
1)Infection - bacterial or viral or descending infection from nasal sinuses or throat.
2) Complicating other diseases:e.g.:measles, whooping cough
3)Physical and chemical irritants: inhaled dust, steam, gases like SO2, ether.
4)Allergic bronchitis following inhalation of pollen or organic dust.
X Toxemic: malaise,fever,palpitation,fever,sweating, etc.
X Irritative cough with expectoration. At first scanty viscid sputum later more copious and muco purulent. Substernal pain or raw sensation behind the sternum.
X Obstructive: chocked up feeling, paroxysms of dyspnoea particularly following spells of coughing relieved by expectoration.
In early stages few abnormal signs apart from occasional rhonchi. After 2 or, 3 days diffuse bilateral rhonchi often with rales at the bases, prolonged expiration and then expiratory wheeze.
A clinical disorder characterized by productive cough due to excessive mucous secretion in the bronchial tree not caused by local bronchopulmonary disease, on most of the days for at least three months during the year for at least two consecutive years.
a) As a result of acute bronchitis
b) Infective focus in the upper respiratory tract
c) Infective focus in lungs.eg:bronchiectasis,fibrosis or tuberculosis
2) Smoking: particularly of cigarettes
3) Air pollution: due to industrial fumes and dust.
4) General illness: which favors infection: obesity, alcoholism and chronic kidney disease.
Symptoms of bronchitis
1) Cough: constant paroxysmal cough, worse in winter or on exposure to cold winds or sudden change of temperature.
2) Expectoration: variable. It may be little, thin and mucous or thick or frothy, mucoid and sticky. It may become mucopurulent during attacks of acute bronchitis in winter.
3)Dyspnoea: in advanced cases, breathing becomes quick and wheezing present even at rest.
4) Fever: absent except in acute exacerbation.
5) Hemoptysis: usually in the form of streaks of blood.
1) Build: usually short and stalky
b)Cyanosis:rarely with clubbing.
c)signs )signs of air way obstruction: prolonged expiration, pursing of lips during expiration, contraction of expiratory muscles of respiration, fixation of the scapula by clamping the arms at the bedside, in drawing of supraclavicular fossa and intercostal spaces during inspiration and jugular venous distension during expiration due to excessive swings of intrathoracic pressure.
d) Wide-spread wheezes of variable pitch usually marked in expiration. Crackles of lung bases in patients with excessive bronchial secretions. Both wheezing and crackles may be altered in character by coughing.
1) Ventillatory indices: reduced PEF and VC.
2) Chest radiography: It may be normal. Infective episodes may produce patchy shadows of irregular distribution due to pneumonic consolidation, and small linear fibrotic scar may result.
Since acute bronchitis presents with too many symptoms, homeopathy has got a better scope in the treatment of acute bronchitis. The advantage of homeopathic treatment is that the change of acute bronchitis to chronic bronchitis can be very well prevented.
In chronic bronchitis, especially if it occurs in old aged people and with a history of smoking complete cure is very difficult. But symptomatic relief can be given, and thus the quality of life can be increased.
But in young people if homeopathic treatment is tried with lifestyle modification definitely complete cure is possible.
Medicines for acute bronchitis
Antim, tart, Ipecac, Ars alb, Grindelia, etc.
Medicines for chronic bronchitis-
Thuja, Ars alb, Tuberculinum, Bacil, Senega, Aspidosperma, etc.
In simple term, it can be defined as heart disease secondary to lung disease. Here the right ventricle of the heart is structurally and functionally damaged due to the disease of the respiratory system.
Pulmonary hypertension due to the increased blood pressure in the lungs is the
primary cause of cor pulmonale. It may be acute or chronic.
Conditions that lead to cor-pulmonale.
1- Chronic obstructive pulmonary disease (COPD)-chronic bronchitis more common, and emphysema less common
3- Pulmonary tuberculosis
4- Primary pulmonary hypertension
5- Multiple emboli
6- Cystic fibrosis
7- More prevalent in smokers
X Chest pain
X Wheezing, cough
X Cyanosis of lips and fingers
Chests x ray- hilar prominence, with pulmonary artery dilatation.
ECG-Right Ventricular Hypertrophy, tricuspid valve regurgitation
Complete cure impossible. However, quality of life can be markedly improved by homeopathic medicine. The main of homeopathic treatment is to reduce the use of cortisone and other medicines, and to prevent further damage to the lung tissues.
The disease being the result of some irreversible pathology, as per homeopathic miasmatic theory, it belongs to syphilitic miasm. So back to normalcy is impossible not only in homeopathy but in any system of medicines. But homeopathy has got an upper hand in the symptomatic management of COPD, since it safe and free from unwanted side effects.
In severe cases along with homeopathic medicines, oxygen supplements is a great relief for the patient.
Emphysema is a component of COPD (chronic obstructive pulmonary disease) characterized by abnormal, permanent enlargement of air spaces distal to terminal bronchioles. It is caused by the combination of mechanical obstruction in the small airways from inflammation and later scarring, and loss of elastic recoil of the lung which makes these airways more likely to collapse during expiration.
ANATOMICAL TYPE OF EMPHYSEMA
1. Centrilobular emphysema
2. Panacinar or pan lobular emphysema.
3. Parietal or periacinar emphysema
Bronchiolitis: comprising infiltration of inflammatory cells, particularly macrophages, into the bronchiolar wall is one of the earliest lesions in the cigarette smokers. It can produce fibrosis of small airways in the patient with COPD.
In predominant emphysema, the patient will be very thin and there will be marked weight loss. The sputum is very scanty. Dyspnoea is intense with purse lip breathing. The cough usually starts after dyspnoea. The bronchial infections are less frequent and episodes of respiratory failure often terminal. Pulmonary hypertension is none or mild unrelenting downhill. The chest radiograph shows narrow cardiac shadow, attenuated vessels, and emphysematous bullous changes. The arterial partial CO2 is normal. The elastic recoil is markedly decreased. Resistance is normal or slightly increased, and diffusing capacity is increased.
In emphysema, the outcome is, the lungs fail to recoil back to its original shape. To happen this it takes many years. So in well established cases complete cure and make the lung back to normalcy is impossible. The miasm behind the emphysema is tubercular changes into syphilitic as disease progress into an established form.
So homeopathic remedies should cover both this miasm.
But if homeopathic treatment starts in the early stage and with lifestyle changes marked relief of symptoms is possible, and the patient can lead almost normal life.
Homeopathic medicines usually prescribed are.
Anti tart, Bacillinum, Tuberculinum, Phos, Ars alb, Aspidosperma, etc.
RESPIRATORY DISEASE CAUSED BY FUNGI.
Some fungi infect the human tissues and cause damage, resulting in allergic reaction or producing toxins.
The disease caused by fungal infection is called as mycosis.
Bronchopulmonary aspergillosis is caused by aspergillus fumigatus.
Classification of Bronchopulmonary aspergillosis
1. Atopic asthma
2. Allergic aspergillosis
3. Extrinsic allergic alveolitis
4. Intracavitary aspergilloma
5. Invasive pulmonary aspergillosis
ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS
This is caused by hypersensitivity reaction to aspergillus fumigatus involving the bronchial wall and peripheral parts of the lungs.
X Cough and worsening of asthmatic symptoms
Inhaled air borne spores of aspergillusfumigatus may lodge and germinate in the damaged pulmonary tissue, and an aspergilloma can form in any area of damaged lung in which there is a persistent abnormal space.
X Recurrent hemoptysis
X Presence of the fungus ball in the lung can give rise to features such as lethargy and weight loss.
INVASIVE PULMONARY ASPERGILLOSIS
Invasion of previously, healthy lung tissue by aspergillus fumigatus is uncommon but can produce the serious and often fatal condition which usually occurs in patients who are immuno compromised either by drugs or disease.
X There will be consolidation, necrosis and cavitations of the lung.
X Formation of multiple abscesses is associated to the production of copious amounts of purulent sputum, which is often blood stained.
Homeopathic medicines are equally effective for infections, whether it is bacterial, fungal or any other infections. Since the outcome of infections is plenty of signs and symptoms, the selection of remedy and accuracy of the selected remedy will have more sharpness.
Homeopathic medicines if selected based on symptomatology and the patient’s mental and physical characteristics the fungal infection of lungs can be controlled and further recurrence with can be prevented.
90% of lung cancers are due to cigarette smoking. The risk fall slowly after the cessation of smoking. 5% of death due to lung cancer is because of passive smoking. The incidence is higher for urban areas than in rural areas.
Etiology: Age: 40-50.
SEX: males are more prone to lung cancer than women.
1) Cigarette smoking
2) Occupational exposure
3) Atmospheric pollution
4) Lung disease
c)Large cell and anaplastic carcinoma
d)Small cell carcinoma
a) Nonspecific symptoms: weakness, loss of weight, tiredness, anorexia and fever
b) Respiratory symptoms like-
1) Cough: affect majority of patients and is often associated with influenza like illness.
Pneumonia distal to the obstruction may be caused by a tumor. Increasing persistence of cough is the most common symptom.
Recurrent pneumonia in the same site or pneumonia which is slow to respond to treatment in smokers is an indicator to bronchial carcinoma.
2) Hemoptysis:It is usually a common symptom, especially in tumors arising in the central bronchi. On the other hand, repeated episode of spitting of scanty blood, or blood streaked sputum in a smoker should raise the suspicion of bronchial carcinoma.
3) Dyspnoea: It is usually associated with increased cough and sputum.
4) Chest pain
Phrenic nerve, recurrent laryngeal nerve, cervical sympathetic, vagus, brachial Plexus and intercostal nerve are affected.
Vessels: superior venacava, azygous vein, thoracic duct and axillary vessels
Erosion of ribs: local pain and bony tenderness
Invasion of heart and pericardium
Supra renal metastasis
SYMPTOMS DUE TO NON METASTATIC/EXTRAPULMONARY MANIFESTATION:
Endocrine and metabolic
b) Palpable supraclavicular nodes
c) Mid inspiratory crackles
e) Pleural effusion
Good prognosis with homeopathic treatment. Homeopathic medicine can be given along with conventional medications or homeopathic medicines alone.
In terminal stages homeopathic medicines act, act as a good palliative and homeopathic medicine can improve the quality of life.
Mantoux test and its significance
Earlier Mantoux test was considered as the specific diagnostic test for tuberculosis. However, the co-existence of another disease, age, and immunological status has made the result controversial.
Five units of tuberculin (TU- 0. 1 ML) is injected into the left forearm under the skin, and the result is interpreted as a period 48 to 72 hours. If the injection is correctly done there should be a pale red elevation of 6 to 10 millimeter in diameter. The presence or absence of induration is the basis to determine whether the test is positive or negative. The induration should be determined by inspection in side view and palpation.
The test determines the hypersensitivity to tuberculin. The size of induration has nothing to do with the current active tuberculosis. But the positive reaction can be interpreted as the future risk of developing TB.
X The test is read as positive if the induration is 5 mm or above.
X False-positive reaction is seen in cases of previous vaccination with BCG.
X False-negative reaction is seen in viral infections such as measles and chicken pox.
X Recent live vaccination, e.g.; measles
X Very old as well as recent TB infection
Pneumonia is the accumulation of secretions and inflammatory cells in the alveolar spaces within the lungs caused by infection. The infecting organism, the inflammatory response and the disturbances of gas exchange caused by alveolar involvement are responsible for the clinical manifestations.
Pneumonia can be classified as community acquired, nosocomial (hospital acquired), or pneumonia in patients with underlying damaged lung, or in immunocompromised patients.
Community-acquired pneumonia spread by droplet infection.
Nosocomial pneumonia or hospital-acquired pneumonia is the pneumonia occurring in patients at least two days after admission to the hospital.
Factors predispose to pneumonia.
X Cigarette smoking
X Old age
X Upper respiratory infection
X Preexisting lung disease
X Recent influenza infection
1) Bacterial- streptococcus pneumonia, microplasma pneumonia, chlamydia pneumonia, gram-negative pathogens and Staphylococcus aureus
2) Primary atypical:
a) Viral: psittacosis, respiratory Syncytial virus, measles and influenza, cytomegalovirus, herpes zoster, adenovirus
b) Rickettsial -Coxiella burnetti
c) Mycoplasmal- mycoplasma pneumoniae
3) Protozoa-entameoba histolytica
4) Yeast and fungi- actinomycosis, aspergillosis, nocardiosis, histoplasmosis
5) Chemical pneumonias
a) Aspiration of vomit
b) Dysphagic pneumonia caused by pharyngeal diverticulum, achlasia cardia or hiatus hernia
c) Lipoid pneumonia: kerosene, paraffin, petroleum.
d) Toxic gases and smokes:
6) Radiation pneumonia
BASED ON THE ANATOMICAL PART OF THE LUNG PARENCHYMA INVOLVED.
Pneumonia can be classified as.
1)LOBAR PNEUMONIA: It occurs due to acute bacterial infection of a part of a lobe or complete lobe.
2)BRONCHO PNEUMONIA:acute bacterial infection of terminal bronchioles.
3)INTERSTITIAL PNEUMONIA:this is mainly confined to the interstitial tissue within the lung.
X Fever, rigors
X Night sweats
In the elderly, confusion and disorientation.
X Cough and sputum which is often blood stained and rusty and difficult to expectorate.
X Pain aggravated by cough deep breath or movement Usually localized tothe site of inflammation.
General: patient appears ill with tachycardia, rapid respiratory rate, high fever, dry skin, herpes labialis, confusion, and hypotension.
a)Early signs:slight impairment of the percussion knots over the affected area, with weakness of breath sounds or possibly harshness with prolonged expiration and fine crackles on deep inspiration or after cough.
b)Signs of consolidation on 2nd or 3rd day
c)Resolution:most signs disappear by the end of 2nd week. But fine crackles and impairment of the percussion notes may be found longer.
A- blood test-
a) White cell count marginally raised or may even be normal.
b) Neutrophil leucocytosis in bacterial etiology
c) C-reactive protein-CRP – typically elevated
Homeopathic remedies for pneumonia-
Antim ars, veratrum viride, Phos, Pulsatilla, Antimtart,etc.
PULMONARY FUNCTION TEST
PFT detects the impairment and assesses the effect of treatment and progress in the disease. It is done to assess the lung capacity, and it determines how quickly the lung can move air in and out. Spirometry is the common lung function test.
In respiratory function test, lung volume, gas exchange capacity and airway, narrowing is quantified and compared with normal values adjusted for age and gender. The most convenient home monitor test is peak flow meter, but values are an effort dependent.
Abbreviations used in PFT.
X FEV1 forced expiratory volume in 1 second
X FVC forced vital capacity.
X VC vital capacity
X PEF peak expiratory flow.
X TLC total lung capacity
X FRC functional residual capacity
X RV residual volume
X TLCO Gas transfer factor for carbon monoxide
X DLCO diffusing capacity for carbon monoxide
X KCO transfer coefficient for carbon monoxide
Measurement of gas transfer factor.
The gas transfer factor may be thought of as the conductance of the lungs for the gas being studied. It forms the useful overall estimate if the ability of the lungs to exchange gases and is of particular value in interstitial lung disease, sarcoidosis and emphysema. It is normally estimated by measuring the uptake of carbon monoxide from a single breath of a 0.3% mixture in air.
Arterial blood gas analysis
Modern automatic analysers give a rapid direct read out of PaO2(Partial pressure of arterial oxygen) , PaCO2( Partial pressure of carbon dioxide in the blood) and H ion concentration in arterial blood, often supplemented by derived variables, which may be of value in assessment of hypoxemia or acid base balances, which may be of value in assessment of hypoxemia.
PATTERNS OF ABNORMAL VENTILATORY CAPACITY
What is a respiratory failure?
When the pulmonary gas exchange fails to keep normal arterial oxygen and carbon dioxide level respiratory failure results.
-Respiratory failure can be defined in two ways.
Type 1-Failure of oxygenation resulting in PaO2 lesser than 8. 0 KPa
Type 2 -Failure of ventilation resulting in PaCO2 greater than 7.7 KPa with accompanying acid base changes.
The basis of classification is the absence or presence of hypercapnia.
CAUSES OF RESPIRATORY FAILURE
1. Airway obstruction:
Upper airway- obstructive sleep apnoea, trauma, angio oedema, foreign body inhaling
Lower airway- Chronic Obstructive Pulmonary Disease (COPD), asthma, cystic fibrosis
2. Disorders of lung parenchyma:
Acute respiratory distress syndrome.
It includes the following conditions
B-Acute pulmonary edema
C-Acute pulmonary embolism.
It may be due to-
a-Chronic fibrosing alveolitis
3. Disorders of the respiratory muscle pump
Examples are -Brain stem disease, over sedation, central sleep apnoea, and cervical cord trauma.
Examples are scoliosis, chest wall trauma, muscular dystrophy.
X Due to hypoxemia:
Patient becomes restless, mental confusion, sweating, tachycardia, and central cyanosis, depressed level of consciousness, poor peripheral circulation, and cardiac arrhythmias.
X Due to hypercapnia:
Breathlessness, headache, warm extremities, bounding pulse, muscle twitching, elevated blood pressure, papilledema occasionally, cardiac dysrhythmias.
Effects on CNS functions -such as asterixis, hyperreflexia, miosis, confusion and coma.
Tuberculosis was under control until recently. However, due to the emergence of drug resistant and new strain bacteria it is again becoming a challenge to the health authorities.
This is a disease of lung, pleurae or mediastinal lymph nodes caused by Mycobacterium tuberculosis. This disease is seen in all age groups but highly susceptible to three years of age.
They are most common in poor communities due to poverty, poor sanitation, housing state, nutrition and overcrowding,etc.;And also seen in people who are addicted to tobacco, alcohol, etc.
The causative organism of tuberculosis includes two species M.tuberculosis and M.bovis.
1) Primary tuberculosis
2) Post primary tuberculosis.
The primary infection usually occurs in childhood and in the majority of patients, the primary infection produces no symptoms or signs and passes unnoticed until routine radiological examination of the chest happens to be performed at the appropriate time.
1) Asymptomatic type
This is the commonest type and Ghon's focus in the X-ray and positive Mantoux test is the evidence of past infection.
2) Febrile type
Fever ranging from 37.5 - 39.5 c -lasting for 1 to 2 weeks.
3) Allergic type
The patient shows erythema nodosum, or phlyctenular keratitis, conjunctivitis or both.
4) Progressive type
Patient may develop tuberculosis pneumonia, bronchopneumonia, pleurisy, pleural effusion. Military tuberculosis, and tuberculosis meningitis, lobar or segmental collapse.
POST PRIMARY TUBERCULOSIS
The onset of post primary tuberculosis is usually insidious, with gradual development.
General symptoms are cough and sputum. The lesions are most frequently situated in the upper lobes. Sometimes the dramatic event like hemoptysis, pleural pain or spontaneous pneumothorax marks the onset. The earliest physical sign includes few crepitations, physical signs of consolidation, cavitations and fibrosis.
1) Mantoux test shows a positive reaction.
2) Sputum examination
3) X RAY -chest (PA) may show enlarged hilar nodes with sub pleural lesion.
4) ESR (Erythrocyte Sedimentation Rate) is raised.
From my clinical experience, it is found that instead of trying homeopathic medicines alone, a combined therapy is highly effective.