UTILITY OF CARBONEUM SULPH IN TREATING ACUTE ALCOHOL WITHDRAWAL: CASE STUDIES

Sunita B. Nikumbh, MD (Hom)

Associate Professor, Department of Psychiatry, Dr. M. L. Dhawale Memorial Homoeopathic Institute (MLDMHI), Palghar & Consultant – General Psychiatry, Child Psychiatry, Anukampa (Psychiatry IPD ward), Rural Homoeopathic Hospital, Palghar

Address of correspondence: Dr. Sunita Nikumbh

Email: sunita.nikumbh@gmail.com

How to cite this article:

Nikumbh SB. Utility of Carboneum Sulph in treating Acute Alcohol Withdrawal: case studies. Journal of Integrated Standardized Homoeopathy (JISH) 2019; 02(02)

Received on: January 13, 2019

Accepted for Publication: June 24, 2019

Abstract:

Treating alcohol withdrawal syndrome (AWS) and its different stages and states with different aetiologies with Homoeopathy is a challenge. An in-depth study of 2 cases evolves an understanding of how to study the clinical states resulting from AWS. Moreover, the cases demonstrate the practical application of the first 6 aphorisms of the Organon and help demonstrate – “the only Mission of the Physician – to cure”, by identifying the relevant data for clinical diagnosis, differentiating the common and characteristic expressions in clinical states for application in Homoeopathic Materia Medica, understanding the susceptibility, planning the interventions, and studying the results, all of which led to considerable learning.

 

Key words:

Acute Alcohol withdrawal, Homoeopathy, Concept of Constitution, Carboneum Sulph

 

Introduction

Treating alcohol withdrawal syndrome (AWS) with Homoeopathy poses various difficulties for Homoeopaths. The difficulties lie in the details: the clinical presentation of AWS, chronicity of addiction, type of alcohol consumed, history of abstinence, the assessment of susceptibility, rapidly changing clinical state or mental state, and the process of selection of the most appropriate similimum.

This study of two cases that were treated at different stages / phases of AWS will give us a different perspective of looking at AWS as a clinical entity and the utility of the remedy Carboneum Sulph in managing the AWS in a subtle way. Both patients showed different cognitive disturbances that precipitated after emotional ailments, although the intensity varied. This indicates the range of expressions and the extent of action of the prescribed remedy at the mental level.

 

Definition

AWS is an acute condition resulting from sudden cessation of alcohol intake in a person addicted to / dependent on alcohol. The withdrawal runs its course depending on the type and amount of alcohol consumed; the level of susceptibility and sensitivity of the individual at the general and specific levels also influences the individual’s reactions. All these factors determine the phase of withdrawal.

Both the cases studied here have different susceptibilities at the tissue, organ, and system levels along with heightened mental sensitivity. The Homoeopathic literature has therapeutics for alcohol in general, but lacks data on mental symptoms. To treat this condition, the coordination of Homoeopathic Materia Medica and Repertory needs to be more qualitative.

 

Case 1

HIMS Number 35608

Mr. V. A. G., 52 years, Hindu, male, married for 29 years, is a father of 3 sons, and working as an assistant sub-inspector in the GRP after dropping out during S.Y.B.Com.

 

Chief complaints

Location	Sensation	Modality	Accompaniments
C.N.S. Brain Since 8 days Left side of body	Weakness – left side of body Difficulty in walking Loss of balance while walking Slurred speech H/O sudden fall No loss of consciousness / GTC / vomiting	A/F Vexation A/F Alcohol abstinence
Since 8-10 days	Hallucination- visualà sees ants are crawling on his bed hence tries to catch the ants Sleeplessness, Trembling of extremities ++	> Allopathic treatment
Mind Since 23 yrs. F: daily Since 2-3 days	Chronic alcoholic taking country liquor 180 ml/day Abstinence.
Since 23 yrs. F: daily 2-3 times / day	Habit of tobacco chewing

 

Addiction History: Taking alcohol since 25 yrs. Beer, whisky, 180 ml / day morning & evening

Abstinence: Stopped since 8 days. 5- 6 months back had abstinence for 1 month.

Symptoms of Abstinence: Sleeplessness, trembling of extremities, and restlessness; was treated by an allopathic psychiatrist.

Chews tobacco twice a day, 1 small packet daily.

Family History: P/H: typhoid in childhood, viral hepatitis 1 yr. back

F/H: Father: chronic alcoholic, Mother: died due to bronchial asthma

 

Life Situation:

Patient is from average socio-economic strata from the interior of Maharashtra. Both his parents were farm workers. He was very mischievous as a child, instigating fights and beating up his friends. If his mother found what he was doing, he would hide and return after a long time.

 

 

His life changed drastically after starting the job in the Railways, with irregular duty hours and weekly off days. Along with the security of the commuters, he had to pick up parts of dead bodies from the railway tracks. He had severe nausea and could not eat for weeks together after this work. Being junior, often he did not even get gloves to pick up the human pieces. It was likely that he consumed alcohol to cope with this experience, leading to the addiction. This addiction led to a lot of trouble. His much younger boss has scolded and insulted him in front of other staff and he could not react. In the current situation too, he was scolded and warned for attending work while drunk. He felt very insulted this time, remained in a vexed state for the whole day, and could not sleep at night. The next day, he developed an intracranial haemorrhage that was managed with allopathic medicine. Naturally, alcohol was stopped, he went into severe withdrawal, complained of seeing ants on his bed, and was trying to remove them.

 

Physical Generals:

Appearance: fair, stocky, hair dyed and well combed.

Tongue: coated yellowish white edges red     Perspiration: forehead, non- offensive++

Hunger <++

Craving: Sour++, Spices+++, Meat+++, Alcohol+++, Tobacco+++, Eggs++

Aversion: sweets+++, Thirst: 5-6 lit / day

Stool: semisolid, satisfactory Urine: Morning: 6-7 times / Night: 2-4 times

Sexual function: desire – Normal,

Meteorological: Sun<++ causes nausea and vomiting, Summer<+

Thermal: Ambithermal àHot

Physical examination:

Pulse: 80/min BP: 150/100 Respiratory rate: 20/min

Respiratory System: NAD Cardiovascular System: NAD

Central Nervous System: Deep tendon reflexes: normal

Tandem walk: tends to fall on left side

Muscle power 5/5 all extremities

Per Abdomen- soft, liver palpable 1, spleen not palpable

Investigation: (Date: 14 August 2013): MRI scan: well defined rounded hyper intense lesion in right thalamus capsular region. S/o sub-acute hematoma (measures 2.8 x 2.0 cm) causing mass effect on adjacent third ventricle. Mild to moderate cerebral and cerebellar atrophy. Same hyper intense area in atrium of left lateral ventricle. S/o Sub-Acute Haemorrhage.

 

Planning of the case:

The case has posed a considerable diagnostic and treatment challenge, as the patient was treated for the current clinical state and withdrawal with allopathic medicines, but the residual symptoms persisted. Therefore, when the case was referred to the Psychiatry department, we decided to manage the residual and withdrawal symptoms together, as a common emotional precipitating modality was available in the inquiry.

 

 

Symptom list and classification:

	Symptom list	Classification of symptoms
1.	Complaints from alcohol abstinence	Precipitating modality
2.	Complaints from vexation	Precipitating Mental Emotional modality
3.	Weakness of left side of body	Characteristic physical general symptom
4.	Difficulty in walking	Characteristic physical general symptom
5.	Loss of balance while walking	Common physical general modality
6.	Hallucination- visualà sees ants are crawling on his bed	Characteristic Mental Intellectual symptom
7.	Sleeplessness alcohol after	Characteristic physical general symptom
8.	Trembling of extremities ++alcohol after	Characteristic physical general symptom
9.	Restlessness alcohol after	Characteristic physical general symptom

 

Totality:

1. Ailment from Alcohol abstinence
2. Ailment from vexation
3. Trembling of extremities ++ alcohol after
4. Weakness of left side of body
5. Slurred speech alcohol after
6. Hallucination- visualà sees ants are crawling on his bed
7. Sleeplessness alcohol after
8. Restlessness alcohol after

 

 

REPERTORIAL SHEET

 

HOMOEOPATHIC MATERIA MEDICA DIFFERENTIATION:

The common remedies for withdrawal came up in the repertorial result after repertorization, with few uncommon remedies like Opium, Carboneum Ars, Carboneum Sulph, Cocculus, and Capsicum. The patient had all the common expressions of alcohol withdrawal, with one characteristic delusion: ants on his bed; Plumbum Met (which covers no other symptom) is the only one specific remedy that has this symptom while other remedies cover delusion of insects around.

The main precipitating emotional modality of vexation is preceded by abstinence of alcohol, which is covered by Carboneum Ars, Carboneum Sulph, and Capsicum only. However, the patient had never shown any symptoms or state of homesickness in any situation; neither did he have any gastrointestinal or genitourinary symptoms indicating Capsicum. Rather, because of certain work stresses, he was an alcoholic and his constitution was susceptible to diseases related to alcohol abuse and withdrawal; this is mainly covered by Carboneum Ars and Carboneum Sulph.

Carboneum Sulph is prepared using Sulphuric Acid, a drug known to produce aversion for alcohol in alcohol addicts. Patients often have an intense sensation of biting all over the body. This patient had delusion of ants on bed and to avoid being bitten he is cleaning the bed often. Further study of the Materia Medica indicated that this drug also has diminished sensibility of arms, hands, and feet with peripheral neuritis; our patient had the same symptoms. Hence, Carboneum Sulph was the final choice. As per Dr. T. F. Allen, in Carboneum Sulph, initially thet intellectual activity is excited, talks more than usual, has increased activity of the mind, raging delirium, tries to bite the father.

 

 

 

Assessment of Susceptibility and its impact on Planning and Programming:

This particular case posed a lot of challenges in understanding the susceptibility of the patient’s clinical state. There were 3 sectors involved in this case, at the mental level, immediate reaction to humiliation; the need / demand of the body due to alcohol dependence, and third is the organ affected in the time of crisis. All the 3 factors have interacted and altered the state of susceptibility and symptom; expressions of clinical condition were mixed in this alcohol withdrawal.

The actual intracranial bleed settled without any repercussion, but the withdrawal effects progressed rapidly. Therefore, the susceptibility is moderate to high.

Characteristic symptoms are ++ in all the three sectors in terms of immediate expression as – fall followed with vertigo, delusions as a result of withdrawal.

Sensitivity at Mind Level: High, as the precipitating modality is emotional, i.e. humiliation with an underlying chronic vexed state.

Pace: High – the response followed immediately the day after the humiliation and the effects of alcohol withdrawal set in quickly.

The potency selected was 200, based on the presence of characteristic symptoms with high sensitivity and rapid pace of all the disease processes involved.

Follow-Up summary:

After the 1^st dose of Carboneum Sulph 200 C, the trembling in the extremities was immediately better. His sensation of loss of balance gradually disappeared. In the further course of recovery, he showed marked improvement in walking. At the same time, changes in the mind were appreciable. His delusion of ants disappeared. There was no need to repeat another dose.

Conclusion:

Three clinical conditions with their characteristic expressions have been managed by a single dose of Carboneum Sulph, a remedy not so commonly prescribed in alcohol withdrawal. The remedy has taken care of –

1. His disturbed mental state of vexation resulting in a transient ischemic attack
2. Alcohol withdrawal
3. To some extent, the nicotine withdrawal.

Though the totality of one sector alone was formulated, it has helped many sectors, confirming that “what is true to the part, is true to the body”. In this case, Carboneum Sulph can be considered as the similimum and a constitutional medicine for the patient.

 

Case 2                                                                                                            

HIMS No -54859

Screened in casualty on 06/12/14 Patient’s Name: Mr. H B J Age: 40 Years Sex: Male

Address: B Occupation: Tempo / Rickshaw Driver Informant: Self/Wife/Brother

 

Chief complaints:

Patient was brought by relatives for irrelevant talking; talks about God, God will kill him, talks about insects, which will kill him.

Fear, crying intermittently.

Sleeplessness since last 3 days and forgetfulness after drinking alcohol.

Tremors+         Thirst increased           Appetite decreased

ADDICTION HISTORY:

Alcoholism since 20 years. Had quit drinking for almost 10 years, but restarted since the last 3 years. Till 3 days prior, he was drinking 2-3 quarters daily

Last intake today morning (06/12/14)

Tobacco chewing since 20 years, dry chewing, 1 packet daily

Three years prior, the patient had had an accident and somebody predicted that he would die soon and should eat and drink whatever he wants to. Due to this, the patient became fearful and started drinking.

 

Medical History

Six years prior: traffic accident, fracture of left femur, operated

Three years prior: bike accident under influence of alcohol, injury to right thumb and right shoulder

Family History

Mother: Diabetes Mellitus Father: expired 25 years ago due to ?pulmonary tuberculosis

Physical Examination: General Pulse: 100 /min BP: 140/80 mmHg Skin: dry Tongue: dry

Systemic: RS: AEBE, clear, Breath sounds: vesicular CVS: S1S2+

P/A: soft, bowel sounds present in all quadrants

CNS: gait: unsteady sensory functions: intact++

Previous investigations: Haemoglucose test (HGT) 110 mg/dL

Operations: for fracture of left femur and fracture of right thumb

Current mental state: Fear of death, delusions and hallucinations

 

Observations:

Physiognomy / behaviour / interaction: Calm, cooperative but fearful and restless, occasionally maintaining eye contact during the interview

PROVISIONAL DIAGNOSIS: Alcohol intoxication followed by withdrawal

 

INVESTIGATION REPORTS DATE: 07/12/14

CBC: Hb: 15.2	Platelets -Adequate	ESR 5	BUN 25.3	SR. CRET 1.3
Total Bilirubin 1.8	SGPT 123.7	SGOT 144.7
URINE REPORTS-	ALB- traces	Epithelial Cells- Few	Pus Cells- 6-8	RBC- 1-2

Chief Complaints:

Location And Spread (Tissue, Organ, System) Onset Duration Progress Direction	Sensation And Pathology	Modalities A/F < >	Accompaniments
Mind O: 2 days P: gradual	Irrelevant talks+2 Fearful+2 He thinks he will die He thinks God will kill him Fear of death   Sleeplessness	A/F- Alcohol	Thirst increased Appetite decreased
MIND D: 20 years	Addicted to Alcohol H/O abstinence (which was for total 10 years), re-started since last 3 years.	< at night
Since 3 years increased F: daily Quantity: 2-3 qtr Quality: Desi/ Whisky	Irrelevant talk – under the influence Tremors+2	A/F: after his accident and someone has predicted that he will die soon
H/O withdrawal symptoms before 10 years

 

Planning of the case:

This case was quite difficult to manage as the patient could remain sober / or could manage abstinence for quite a long period i.e. for 10 years and has come up with a history of heavy drinking. The type of alcohol varied with the availability. However, the peculiar mental state that precipitated this episode of drinking had a strong effect on his mind; the repercussions of this were severe and the patient developed delusion. We therefore needed to use rubrics and differentiate relevant Materia Medica images. What needed to be treated first, acute withdrawal with delusion, which is an expression of severe withdrawal, or the fears that compelled this man to seek the help of alcohol? Or can both be managed; this was the dilemma. In short, active effects of intoxication with concomitant mental state needed to be managed with the Homoeopathic remedy.

 

Symptom Evaluation and Repertorial Analysis

Serial Number	Symptoms	Classification
1.	Complaints after alcohol	Causative modality
2.	Irrelevant talking alcohol after	Characteristic Mental Behavioural symptom
3.	Talks about God	Characteristic Mental Intellectual symptom
4.	Thinks God will kill him	Characteristic Mental Intellectual symptom
5.	Talks about insects	Characteristic Mental Intellectual symptom
6.	Fear of dying	Characteristic Mental Emotional symptom
7.	Crying intermittently	Characteristic behavioural symptom
8.	Sleeplessness alcohol after	Characteristic physical general symptom
9.	Forgetfulness alcohol after	Common Mental Intellectual symptom
10.	Tremors alcohol after	Characteristic physical general symptom
11.	Thirst increased	Common physical particular expression
12.	Appetite decreased	Common physical general expression
13.	Tongue Dry	Common physical particular sensation

 

Repertorial Result:

 

Homoeopathic Materia Medica Differentiation:

After Repertorization, Ars. Alb, Phosphorus, Stramonium, Lycopodium, Pulsatilla, and Carboneum Sulph are the remedies coming close. The patient has fear of death and of dying very soon, along with delusions of insects. This, as well as many general physical symptoms, is covered by Arsenic Alb, but the mental restlessness, a key note of Arsenic Album, and the effect of alcohol on the gastrointestinal tract, were not present. Same applies for Phosphorus, but the debility / prostration was not seen in this case. Stramonium also has a lot of fears, which were seen in the patient, except the fear of death. Lycopodium covered all the mental and physical symptoms in this case, except the delusion of insects and ants. Carbonuem Sulph covered most of the symptoms except the trembling of extremities after alcohol.

 

Assessment of Susceptibility and its impact on Planning and Programming:

In this case, the susceptibility kept on changing with the patient’s determination. He remained sober for 10 years without showing any hazardous effects of alcohol; the same susceptibility was suddenly altered due to anxiety and fear that developed after 2 incidences of RTA. A strong precipitating mental component: anxiety leading to fear of death and being reprimanded indicates high mental sensitivity. Therefore, mind and body both showed high susceptibility.

Characteristic symptoms at the physical and mental level are available.

Sensitivity of Mind: High, as entire process has begun after precipitating emotional modality, i.e. fear of death after 2 RTA

Pace: Rapid with the immediate response after becoming apprehensive about his future health status.

Potency selected: 200 based on characteristic symptoms with high sensitivity and rapid pace of all the disease processes involved at the time. Frequent repetition in anticipation of change in mental state, which maintained the clinical state.

Final Selection of Remedy with Reasons:

Carboneum Sulph was selected as Constitutional remedy as it has covered many physical complaints as well.

Patient was given first dose of Carboneum Sulph 200 C, which was repeated every hour. Within 2 hours, the patient was 50% better.

After 2 hours: no more delusions about death. Only once he told his wife that he sees something different on the wall. Passed urine and stool 3 times. The patient slept for 5 hours without any disturbances; hence, no medicine was administered at night.

On the next day i.e. Day 2 of admission, around afternoon by 1300 hours, the patient c/o delusions, auditory, as if people are coming to beat him, so the potency was increased to 1 M and one dose of Carboneum Sulph 1M was repeated. By evening, he was better by 60-70% and slept for 1-2 hours in during the day, so the medicine was not repeated.

 

On Day 3 of admission he was completely better.

 

Conclusions for Case 2:

The mind and body were affected by a heavy quantity of alcohol. The what and how of treatment was the primary issue we as a team faced; we had to anticipate the consequences and complications of a severe withdrawal state. Our previous experience of treating withdrawal with Carboneum Sulph gave us an idea of this remedy and its action in various states of alcohol withdrawal. Knowledges were revisited; re-searching the drug picture of the remedy gave idea about acute mental symptoms of remedy and the concomitant state available. It is said in Organon, in acute state glimpses of personalities can be observed if the minute observations are made. In this case, Carboneum Sulph can be considered as the Similimum and be a constitutional medicine for the patient.

 

General Conclusions from both the cases:

1. Both the cases were challenging in terms of arriving at the acute clinical state as the patients had co-morbid clinical conditions and personal history of other substance addiction. Therefore, it was a challenge to arrive at the clinical diagnosis through the available presentations and limited information shared by frustrated relatives.
2. Importance of observation was the major learning from these cases.
3. In both cases, the presence of characteristic mental emotional and intellectual symptoms was the feature that directed us to the remedy. The concept of PQRS symptoms that Dr. Hahnemann mentions in Aphorism 153 was completely applicable. Alcohol withdrawal has some common symptoms and a peculiar pace. Cognitive impairment in the beginning of the course of disease indicates the severity of the altered susceptibility and pace and also the individuality in expressions.
4. Knowledge of Aphorism 3 (the role of observations) helped the team. Having residents constantly supervising the patient and co-operation and faith by relatives also helped.
5. Relevant Homoeopathic Materia Medica differentiation made the journey smooth but full of anxiety as these were the first experiences of the team with Carboneum Sulph.
6. The main take-away lesson of this case report is that thorough knowledge of Medicine, Homoeopathic Philosophy, and HMM is must for holistic management of the cases.

 

Acknoweldgements:

Dr. Abhishek Kukade; MO Dept of Psychiatry, and the Psychiatry IPD team for helping in the Materia Medica differentiation.

Dr. Kumar Dhawale and Dr. Nikunj Jani for their constant support, motivation, and encouragement, which enabled me to convert my experiences into this manuscript.

 

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