Case Studies / Dr. Rajan Sankaran / Dr. Rishi Vyas / Dr. Sneha Thakkar

A Case of Chronic Hoarseness by Dr. Rajan Sankaran, Dr. Rishi Vyas and Dr. Sneha Thakkar

A Case of Chronic Hoarseness

by Dr. Rajan Sankaran, Dr. Rishi Vyas and Dr. Sneha Thakkar

A thirty-seven year old woman consulted us on 27th March 2012 for hoarseness of voice due to a teacher’s node[1]. As she is a school teacher she has to speak loudly for long hours every day. There is no pain or sensation in her throat with this problem. She has observed that sometimes the hoarseness is worse from change of weather, and after she has eaten something cold.

She has been suffering from this problem intermittently over the past few years, but it has been worse for the past year, ever since an episode of cold and cough. At the time of the cold-cough she also had breathlessness, and was diagnosed with allergic bronchitis for which she was given allopathic medicine. At the time, an ENT specialist advised voice modulation and speech therapy, telling her that if these did not help she should consider surgery.

She has a history of chest infection with pleurisy, for which she was admitted to the hospital. There it was discovered that fluid had collected in her chest. Her chest was tapped and she was given a six-month course of medication, as the doctors suspected tuberculosis.

She also has a history of two miscarriages.

On asking about her desires and aversions with regard to food and drink, she says that she is not choosy about food; she likes everything and eats whatever is available.

Describing her nature and temperament she says that she was anxious and irritable before her marriage, especially if some work was not done. She has become more patient since marriage. Now if she gets angry or irritated she will not show it.

She was then asked if she had any current anxiety, which she denied. But she then said that she is very sensitive to the health of elderly people in the family, particularly her parents, in-laws and uncles. She feels helpless and worried about their health, thinking, what if something happens to them? She could not describe these feelings in more depth. She simply said, “It is like how you are worried about your parents, and insecure regarding them – it is the same feeling.”

When asked about insecurity, she said “It means you need to take care, being there for them, being there when they need you in difficulties.” She also feels insecure when there is no one to take care of her and support her in difficult times. Asked more about this, she says it is like when she has to go out and her daughters are alone at home; she feels insecure and anxious about who will feed them, who will take care of them. She thinks, will they be safe? What if they do something wrong? She says it is insecurity about looking after them, taking care of them to ensure that they are safe.

She tells about a dream in which, on looking out of the window, she sees a dark colored dog. The dog jumps on her and she feels afraid.


[1] “Small, circumscribed, bilateral, beadlike enlargements on the free edge of the vocal folds at the junction of the anterior one third and the posterior two thirds caused by misuse or abuse of the voice…singer’s nodes, singer’s nodules.” – “Vocal fold nodules”. The Free Dictionary, http://medical-dictionary.thefreedictionary.com/teachers+nodes

In another dream she feels exhausted, and has an urge to go to pass urine but she is not able to do so. This dream comes when she is very tired after a long day, and sometimes afterwards she finds she has passed urine in bed.

She also has dreams of falling down stairs; dreams of an Indian deity, Ganpati; dreams of relatives who passed long ago; and dreams of being lost somewhere.

As a child she was rarely angry, especially with her friends. She would occasionally express anger or irritability with her parents or brother.

She perspires mainly on the forehead and in the axillae. The sweat leaves yellow stains after washing. Her menses are usually regular. The color is red and the stains are difficult to wash off. Before menses she experiences some bloating and leg pain.

She can bear cold but is uncomfortable in AC and very cold weather. She startles from sudden unexpected noises, which brings on trembling.

We advised her to speak softly, to speak more slowly, and to use an amplifier during her lectures.

 

 

Analysis

She comes with main complaint of hoarseness of the voice. We do not see very characteristic modalities that could help us in narrowing down to a small number of remedies. So we explored further to find if any characteristics could be elicited in other areas.  On asking what she likes in food and drink, she says I am not choosy, everything is ok, so we hear that she does not express her own choice.

So what does it mean, that she doesn’t express any choice? It is peculiar not to express a personal preference in food and drink. It means that she is at the beginning of developing her own choice, which is part of identity. So this is the beginning. When someone talks in this way, then it becomes my first anchor, and I will not leave it. She is saying, “I will eat whatever is there.” This is very typical of magnesium, and you pick it up right away when you simply ask about food and drink. Magnesium people have a choice but they don’t express it, whereas in Natrum they don’t even know their own choice, their own preference. So they simply can’t say what it is. Magnesium begins to know what their own choice is, as they are in the second column in row three.

Then when we asked about her nature, she said, “I am patient person”, so this is going in the same direction. When we inquired further, we saw that there is a sensitivity to the potential loss of a relative, particularly any of her elderly in-laws, and she is very worried and fearful about this. She says that the feeling in losing them would be ‘helpless’. And then she says she does not know how to express that feeling, cannot tell it, and that is an exact expression of Magnesium carbonicum – that they are feeling something but they are not able to express exactly what they are feeling. There is some anxiety and they are not able to express it, tell it. Again this is the same thing we see regarding personal choice – they know they have some choice, but they are unable to express it.

When we probe further she says, “I feel insecure”, and when we ask a bit further about that she can say no more. So the main thing is they feel something but they are unable to tell; they are unable to know what exactly is the thing. Related to this is a rubric, “Sleeplessness, causeless” – it means, ‘I am sleepless, there is something troubling, I know that, but I don’t know what the reason is.’ Something is happening but it is too vague to be crystallized, to be identified. All she can say further is that there is no one to take care, and by this she means, ‘in times of difficulty, there will be no one to take care.’ When asked what kind of difficulty she says, “anything”. This is very important. She is not able to specify – she knows there are difficult times but she is not able to identify what those might be. And this is we see in all of her answers, that she is not able to tell.

When we ask further, she says that ‘taking care’ would be like feeding them. This is yet another important issue of Row 3, so now we have seen in her case nourishment, care, familiarity and the issue of choice, which is identity. But identity comes much later. As she is in the second column she has just started to form her identity.  When you do not have identity at all, that is column one, and when you are just beginning to form it, it is the second column. Also in the second column people have a great fear of losing support, as in ‘what will happen when they die?’, just as we see in Calcarea.

Then comes the issue of carbonate which is ‘fear of adapting to a new situation’. So in Magnesium carbonicum you have fear of the loss of loved ones. Dreams of the death of relatives is the big theme of magnesium, and that of carbon is adapting to a new situation; whether he will be able to adapt or not, how will he adapt etc. So the fear of Mag carb is of adapting to a new situation after a sudden loss of somebody. From this comes the Mag carb symptom, “anguish and fear as if some accident would happen”.[1]

Also we see that she starts from and is frightened by noise. This is a very prominent trait in the carbonates.

The patient’s dreams can be expressed by the following rubrics[2]:

  • Dreams of being lost
  • Dreams, frightful
  • Dreams of unsuccessful efforts
  • Dreams of dead relatives

[2] Phatak, S. R. “Magnesium carbonicum: Mind” Concise Materia Medica of Homoeopathic Medicines, as published in ReferenceWorks Pro 4.2.1.1, Kent Homeopathic Associates.

[3] All rubrics, except where otherwise indicated, as well as the graph below, are taken from The Complete Repertory 2012 by Roger Van Zandvoort, as published in MacRepertory Pro 8.2.0.1, Kent Homeopathic Associates.

The repressed emotions of Mag carb can often be expressed in the form of dreams. The dreams usually give the strongest confirmation of magnesium. Magnesium patients have plenty of dreams, and having too many dreams is an indication for this remedy.[1]

Simultaneously, at the physical level we see a strong symptom of staining: we have ‘Perspiration, staining yellow’ and ‘Menses, difficult to wash’.

We chose the following characteristic symptoms which were translated into the rubrics below (see graph):

  • Fear something will happen to a relative
  • Fear as if some accident will happen; all the day[2]
  • Dreams of dead relatives
  • Perspiration staining yellow
  • Menses, stains difficult to wash
  • Sensitive to draft of air
  • Tuberculosis
  • Starting from noise.

[1] For further information see my book, The Soul of Remedies.

[2] Hering, Constantine. The Guiding Symptoms of our Materia Medica. As published in ReferenceWorks Pro 4.2.1.1, Kent Homeopathic Associates.

Rubrics

These are clearly covered by Mag carb. Further, we see an important hint in the past history in the form of tuberculosis, which if we are to refer Allen’s Keynotes, we see is also related to Mag carb: “Inordinate craving for meat in children of tuberculous parentage.”[1]

So we see Magnesium carbonicum fitting the case from both the perspective of symptoms and that of system; in this case we approached from a system understanding, and then went to the symptoms.

References

Phatak’s Materia Medica[2]

Generalities:…Ill effects of shocks, blows, mental distress, vexation, fit of passion, pregnancy, excess of care and worry.

Mind: Trembling; anguish and fear as if some accident would happen; all day; better when going to bed. Least touch causes starting. Sad and taciturn. Dazed feeling; packs and unpacks her clothes, without consciousness of having done so.


[1] Allen, H. C. Keynotes and characteristics with comparisons of some of the leading remedies of the materia medica with bowel nosodes. 8th ed. Delhi: Jain, 1995

[2] Phatak, op. cit.

Rajan Sankaran’s Soul of Remedies[1]

 His feeling like that of an infant, i.e. dependent for care, nourishment, security and support, is very deep in Magnesium carbonicum. In the adult, this feeling seems so out of place that it is not expressed at all at a conscious level; it is repressed so that the patient is unaware of what he actually feels. These repressed emotions can be manifest in the form of a tremendous causeless anxiety, especially anxiety or fear that something will happen to the people the patient is close to. This anxiety usually involves the person on whom he is dependent for care and nourishment, and can be so great as to cause sleeplessness.

Their repressed emotions can also be expressed in the form of dreams and these usually give the strongest confirmation of Magnesium. Magnesium patients have plenty of dreams. Often these dreams are symbolic, i.e. the real meaning of the dream is not clear. There may be dreams of houses, weddings, fruits, etc. Some of the dreams that recur in Magnesium patients are those of falling, of water, of dead relatives and of the death of relatives.

Remedy: Magnesium carbonicum 200C

Mode of dispensing:  A single dose to be dissolved in a half cup of water, one teaspoon to be taken from the same cup, twice a day for two days.

Potency: We see that the pathology is not progressive. Also, the whole complaint was aggravated after a single incident, an exciting factor. For these reasons the centesimal scale was chosen.

In this case, symptoms are seen mainly at the local and emotional levels. We do not see many delusions; the patient’s day-to-day experience is mainly about anxiety and stress, with the physical affection being at a local level – the throat.  So she is currently at Level 3, the level of emotions. Hence, the 200th potency was given.

Follow-ups  

First follow up, 11/5/12

She says that she is better. On 1st May one of her relatives met with an accident. From all of the stress she had one episode of urination during sleep. She felt very anxious and scared.

Describing the incident she says, “That night suddenly my relative had a fall and fractured his leg, but later on he was also diagnosed as having ischemic heart disease, so I was very stressed as to what would happen then. He has two small children, no wife, no support from any other family member and is the only earning member in the family. So for him, there is no support, parental or financial.”

She felt very tense, as her tension generally builds up when such incidents happen. On hearing the news at first she began shivering, and later felt hurt because she had not been informed about it immediately. She cried, and she went to see him right away. Now she is feeling much better and she says that the relative is much better too.

She says that her voice has improved.  She tried singing to her baby and found that she could do it.

She is sleeping well, without dreams.

Overall she is more than 50% better.

Remedy: Placebo

 Comment

 When seeing a patient for a follow-up, we are looking to see if the features of the remedy selected for her are coming up. The stressful situation was of a close relative meeting with an accident; this put the patient into an anxious state. She was worried about his family, especially his children, about what will happen to them and who will take care of them. For her the main issue concerning her was that he was unwell with no support. So in the follow-up too, the remedy was confirmed.

 

Follow-up, 18/7/12

The patient had an episode of upper respiratory tract infection with slight hoarseness which got better without medication. Before, her voice would not return to normal but would remain hoarse. But following this episode her voice returned to normal in a short time.

She can now speak for a longer time, and she can sing, too. She says  “… so that is an improvement… It was impossible to sing before so I was worried.”

In her mood and mental state she feels much better. Before if something was not getting done she would feel agitated and angry; now that reaction is less; she feels okay about it.

Before menses she still has slight bloating and leg pain, but these are now much less. Her appetite and sleep are good. She is not noticing dreams at all.

Remedy: Placebo

 Follow-up, 1/6/13, by phone

She is better, and this is why she had not followed up in the last six months. She has been steadily improving and does not have any complaints to report. There have been no further episodes of hoarseness. She continues to give lectures daily at her school with no problem. She says that her energy is good, and she has not had any cold or cough. Overall she is in a much healthier state, thanks to homeopathy.

In this case we can see not only an improvement in the presenting complaint,  but in the outlook of the patient. My main understanding of the patient was that she was having no exact choice of her own, was not expressive, and could make do with whatever was available. This pattern was the one to which I anchored. Once this anchor is sure, we can then see all of the other areas of the case in relation to this aspect, and thus form an accurate totality which will lead us to the similimum.  The anchor is the first definite piece of the pattern which helps us to be grounded in the case.[2]

Dr. Rajan Sankaran

Head, ‘the other song’ – International Academy of Advanced Homoeopathy

Dr. Rishi Vyas & Dr. Sneha Thakkar

Resident Doctors


[1] Sankaran, Rajan. The Soul of Remedies. As published in Reference Works Pro 4.2.1.1, Kent Homeopathic Associates.

[2] For further explanation of the anchor, please refer to my recent book, The Synergy In

Homoeopathy – An Integrated Approach to Case-Taking and Analysis.

4 thoughts on “A Case of Chronic Hoarseness by Dr. Rajan Sankaran, Dr. Rishi Vyas and Dr. Sneha Thakkar

  1. LESSONS I LEARNED:
    – about role of ANCHOR which patient has expressed by casual way through choice of food.
    – when I worked out the case i considered all those security/anxiety for elders/her daughters as of 4th row…came to CAL CARB but i saw half part of CASE and not connected all expressions.
    – whether repeat ENT opinion for F/U of vocal nodule done???

    OVERALL VERY GOOD LEARNING EXPERIENCE…THANK YOU!!!

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