Repertory as an Aid in The Management of Fevers

Fever or pyrexia as it is so commonly known is one of the commonest yet at times most challenging cases in our clinical practice. Fever (also known as pyrexia, from the Greek pyretos meaning fire, or a febrile response, from the Latin word febris, meaning fever, and archaically known as ague) is a frequent medical sign that describes an increase in internal body temperature to levels above normal. Fever is most accurately characterized as a temporary elevation in the body's thermoregulatory set-point, usually by about 1-2⁰C.

Fever differs from hyperthermia. Hyperthermia is an increase in body temperature over the body's thermoregulatory set-point, due to excessive heat production or insufficient thermoregulation, or both.

Fever Classification

The last is a medical emergency because it approaches the upper limit compatible with human life.

Carl Wunderlich discovered that fever is not a disease but a symptom of disease. Fever is body's mode of self preservation, it is a bodily reaction towards the cause of disease. Fever serves a function for the organism by enhancing neutrophil migration, increasing neutrophilic production of antibacterial substances, increasing interferon production, upregulating antiviral and antitumor activity, and increasing growth of T-cells.

Thus Fever is how the vital force cries for attention. So instead of suppressing it we should try to relieve the inner turmoil by prescribing similimum. But we should always remember that Fever can also cause damage to the body's integrity. Continued fever can also cause convulsions and delirium especially in children. When Fever escalates to hyperpyrexia tissue change is imminent.

Homeopathy not only helps the patient to recover fast but also shortens the convalescence period. For a homeopath it is the inner cause which requires major attention than the outer manifestations for by removing the cause we can remove the disease, "Cessante causa, cessat effectus".  

When the patient presents with fever we have to remember certain facts:

The first and foremost, Diagnosing the case, though we accept that nosological diagnosis or naming of the disease has got nothing to do with homeopathic prescribing. But yet, in present scenario it forms one of the most important steps in our prescription. The patient today is well informed and cautious and he certainly has a choice. He will only put his faith in the person who satisfies his curiosities about his disease. Moreover diagnosing the case also helps us in Removing the maintaing, exciting cause of disease, Controlling of case, Advising do's and don'ts, Deciding our plan of action and last but not the least assessing the prognosis of the case.

Nowhere in our literatures has Dr. Hahnemann advised against this, he advocated in Aphorism 3 that the physician should have the knowledge of disease. This precisely means all the facts about disease, what he meant by opposing the nosological diagnosis was that if as homeopaths we take Disease in totality we cannot justify its diverse manifestations to the layman who only restricts a particular disease to a set of symptoms.

The Next is How to take the Case. In taking the case of Fever our chief objective should be in interrogating

• The Most Probable Cause of Fever
• The Presentation of Symptoms; in compound fevers each stage should be assessed single and combined together.
• The Modalities specifically the Time modality.
• Concomitants to the case.
• Peculiarities of patient as a person i.e disposition, appetite, desires, aversions, thirst, sleep etc.
• Most importantly objective symptoms i.e tongue, offensiveness, negative symptoms etc. These help in clinching the characteristics of the case.

The important thing here is to precisely discriminate the pathognomic and non-pathognomic symptoms. For we have to prescribe on the patient picture and not the disease picture.

Prescribing Similimum: Aggressive treatment of fever and too little fever control both can be detrimental.
Presently we have many views regarding quick selection of similimum. One of the most used being Dr. Vijayakar's idea of assessing the activity, thirst and thermal and using it to choose the medicine. I don't deny that it produces results and is much easier to use considering the concise guidelines. But it is always preferable to go for the longer yet acclaimed method of prescribing on the totality of Symptoms.

Now, here is where the Repertories help us; it is always advisable to refer to repertories rather than quick key note prescribing in Fevers. For Fever being a general symptom deals with the patient as a whole, there is no denying in the fact that we can get characteristic in some cases calling for particular medicine but that is not every day's song. While in Repertory at times, we can find those medicines topping the list which we have never thought of in cases of fevers. And, yes they even produce noteworthy results.  

Repertories as an Aid in managing the Cases of Fevers: We have both General and specifically Clinical Repertories for treating cases of Fever. It solely depends on one's own discretion and experience which path he chooses. If followed rightly they all lead to Ultimate Cure or Relief (in terminal cases). In General Repertories we have "Boenninghausen's Therapeutic Pocket Book" in cases with not well marked Characteristics and "Boger Boenninghausen's Characteristic Materia Medica and Repertory" in cases where we have the Complete Symptom. While in Clinical Repertories we have unmatched contribution of Boericke, Murphy etc, and in Regional Repertories we have specifically Dr. W.A. Allen's and H.C. Allen's Repertories on Intermittent Fevers. There are many other remarkable works by great many authors but yes, these form the prime pick. 

Understanding the Terminologies under Types of Fevers: Now, the next question which arises is that the maximum part of Fever section in Earlier Repertories (until 19^th century) and a handful part of Modern Repertories is constituted of the terms which we no longer use in our practice. So, prescribing on the basis of these becomes difficult. Yes, it is difficult but not impossible. I am compiling herewith the meaning of some of the commonly used terms describing the types of fever used frequently in our books. It may be possible that some terms like "Mediterranean Fever, Winter Fever, Febricula etc" may not be used today but understanding their symptom presentation can help one identify them with the newer types of fevers discovered recently.  And also I must say that understanding of each in the form they presented in the 18^th-19^th century should be preferable as it helps us in understanding our limits for e.g what we have as hectic fever for tuberculosis is different from a T.B case secondary to AIDS. So it will help us in knowing where the case has deviated from its decided course and hence to change your course of action. The terms used are:

AUTUMNAL FEVER: Autumnal Fever generally assumes a bilious aspect. Those of the intermittent kind are much more obstinate than when they appear in the spring. [Dunglison1868]. A fever that prevails largely in autumn, such as typhoid, typhomalarial, and malarial fevers. [Appleton1904]

BILIOUS FEVER: Fever with digestive disturbances (vomiting, copious clayey stools).

CATARRHAL FEVER: A fever, either typhoid, nervous, or synochal, attended with symptoms of catarrh. [Hooper1843].
Old term for the group of respiratory tract diseases including the common cold, influenza, and lobular and lobar pneumonia. [CancerWEB]

CATHETER FEVER: (urinary fever) a sharp elevation of body temperature sometimes associated following the introduction of catheter into the urethra.

CHAGRES FEVER: a malignant form of malarial fever, named after Panama's Chagres River.

CONGESTIVE FEVER: Fever accompanied by obscure symptoms; or by great oppression and depression; in which it is difficult - and often impossible - to induce reaction. Congestive fevers occur in various parts of this country, especially in the fall; and they are very common in India. The term congestive fever is often used in some parts of the south of the United States very indefinitely, - to include winter typhus, and typhoid fevers, typhoid pneumonia, as well as intermittents and autumnal remittents. [Dunglison1874

ENTERIC - TYPHOID FEVER (ship fever, putrid fever)

EXANTHEMATA: ERUPTIVE FEVERS

RUBELLA (rotheln, German measles. Epidemic rubeola, French measles, roseola) an acute contagious, eruptive viral disease of short duration and of milder character than measles/rubeola. After a period of incubation (1-3 weeks), the disease starts with a sore throat and slight fever. The eruption consists of red maculopapular lesions, and disappears without desquamation in about 3 days. Enlargement of the superficial neck and posterior ear glands occurs.

RUBEOLA - MEASLES (morbilli) a disease which (after exposure and an incubation period of two weeks) begins with coryza, cough, conjunctivitis and spots in the mouth (Koplik's spots). A few days later chills, fever, and a red maculopapular eruption appears first on the face or behind the ears. Three days later the eruption fades and is followed by a branny desquamation. It is caused by a virus, and one attack confers immunity.

SCARLET (scarlatina) an acute contagious disease commencing with vomiting or chill, followed by a high fever, rapid pulse, sorethroat, swollen neck glands, and the appearance of a red rash, from 1-5 days after. The rash lasts for 5-6 days, fades and then flakes off. The tongue looks red like a strawberry. The kidneys are often involved. It is caused by Streptococcus hemolyticus.

FEBRICULA (Simple Continued Fever) A slight transient fever of doubtful etiology, unattended by any characteristic lesions, and terminating in recovery in from twenty-four hours to seven days. [Thomas1907]

GASTRIC FEVER (Febris gastrica) a fever in which the inflammation of the stomach is the primary characteristic.

HECTIC FEVER (habitual). A term often used to describe the constant fever of tuberculosis: an afternoon rise of temperature, accompanied by a flush on the cheeks, occuring in active tuberculosis. Of, relating to, or having an undulating fever, as in diseases such as tuberculosis or septicemia.

INDIAN CONTINUED FEVER: a fever in which there are no intermissions in the temperature curve. The temperature is very constant, not varying more than 1-2 F during 24 hours.

INFLUENZA (Grippe, epidemic catarrh, epidemic catarrhal fever, epidemisches schnupfenfieber) (The Italian word for influence.) The disease is so named because it was supposed to be produced by a peculiar influence of the stars. [Hooper1829].

  Epidemic febrile catarrh. The French call it la grippe, under which name Sauvages first described the epidemic catarrhal fever of 1743. It was formerly called coceoluche, "because the sick wore a cap close over their heads." [Hoblyn1855]

    An acute contagious viral infection characterized by inflammation of the respiratory tract and by fever, chills, muscular pain, and prostration. Also called grippe. [Heritage].
INTERMITTENT FEVER (ague, malarial) refers to a type of fever in which the temperature falls to normal at regular intervals, and then goes back up. (Ague: a chill; recurrent chill or fit of shivering; an intermittent fever attended by alternating cold and hot fits. The length of the interval determines the variety of ague. When the interval is twenty-four hours, it is called quotidian; thirty-six hours, tertian; and when seventy-two hours, it is called quartan. These varieties duplicate, and are then called double quotidian, etc.

The disease is announced by a proxysm which has three stages, the cold, the hot, and the sweating. The cold stage is well marked; the patient yawns, has a feeling of weakness, stretches, no appetite, and no inclination to move. Paleness is observed in the face and extremities; the patient shakes, the teeth chatter, and the skin shrinks, causing horripilation or "goose'flesh."
When this stage declines, the hot stage comes on, which is characterized by high fever. This is followed by the sweating stage, which increases from a mere moisture at first to a profuse perspiration. After this the body returns to its natural temperature, and apparent health returns.
During the cold stage the circulation is thrown upon the internal organs, the spleen becomes congested, which organ is enlarged, causing what is known as the ague cake.
A quotidian begins generally in the morning, a tertian at noon, and a quartan in the afternoon. The cold stage is shortest in the quotidian, and longest in the quartan. Intermittent fever is more common in the spring and autumn than at other seasons of the year, and in fall more severe and dangerous.

Ague-brow: an intermittent neuralgia of the area just above the eye)

Dumb ague: (dumb chill) a subacute form of malaria with irregular attacks of fever without chills. A form of intermittent fever which has no well defined "chill"

Hahnemann's Classification of Intermittent Fevers
In Aphorism235-244 Dr. Hahnemann has classified Intermittent Fevers into the following four Types:

1. Intermittent Fever prevailing sporadically or epidemically (not those located in marshy districts) - sporadic or epidemic intermittent fever.
2. Epidemic of intermittent fever in situations where none are endemic (Epidemic in non-marshy districts).
3. Very pernicious type of intermittent fever attacking indivudals not residing in a marshy district.
4. Intermittent fever endemic in a marshy district and tracts of country frequently exposed to inunadations (endemic in marshy districts)

LOW FEVERS (Typhus)

MALIGNANT, tend to Fever which may make its approaches insidiously and subsequently becomes formidable. Any fever which exhibits a very dangerous aspect. Typhus Gravior. [Dunglison1874]

MEDITERRANEAN FEVERS (brucellosis, Malta fever, Rip granade fever, undulant fever) a remittent febrile disease caused by infection with bacteria of the genus Brucella. In humans it causes weakness, loss of weight, and anaemia. It rarely spreads from person to person, but spreads readily from animal to animal and from animal to man.

MILK FEVER: a slight rise in mother's temperature once her milk begins to flow.

MUCOUS FEVER Adenomeningeal Fever

PERNICIOUS FEVER: tending to cause death or serious injury; deadly. Causing great harm.

PUERPERAL FEVER (childbed fever, puerperal sepsis) septicemia occuring within three weeks after abortion or childbirth. Symptoms include chills, abdominal tenderness and pain, rapid pulse and respiration, and fever.

RELAPSING FEVER: Any of several forms of an acute epidemic infectious disease marked by sudden recurring paroxysms of high fever lasting from five to seven days, articular and muscular pains, and a sudden crisis and caused by a spirochete of the genus Borrelia transmitted by the bites of lice and ticks and found in the circulating blood. Also called recurrent fever. [Webster]

SEPTIC FEVER: having infections or toxins present.

SYNOCHAL FEVER (synochus, febris synocha) a continued fever

THERMIC FEVER: sudden prostration due to exposure to the sun or excessive heat.

TRAUMATIC FEVER: Elevation of temperature following an injury. [CancerWEB]

TYPHUS FEVER also known as Camp fever, jail fever, gaol fever, continued fever, classic typhus, ship fever, hospital fever, dungeon fever, fleck typhus) a rickettsial disease (Rickettsia prowazekii) transmitted by lice (Pediculus humanus). Symptoms produced after after a 7-14 day incubation period include head, back and limb pains and fever rapidly rising to 104-105*F. An eruption occurs on the 4^th or 5^th day as rose colored spots scattered all over body become haemorrhagic. Chief complications are high fever, pneumonia and inflammation of the kidneys. Other symptoms may include dry tongue, stupor, delirium and great prostration.

URETHRAL FEVER: fever occurring as a consequence of operations upon the urethra. [1913 Webster]

WINTER FEVER Pneumonia in southern Illinois and other malarial parts of the United States. [Appleton1904]

WORM FEVER: When worms are generated in the intestines, they often produce the following symptoms; variable appetite, fetid breadth, acrid eructions and pains in the stomach, grinding of the teeth during sleep, picking of the nose, paleness of the countenance; sometimes dizziness, hardness and fullness of the belly; slimy stools, with occasional griping pains, more particularly about the navel, heat and itching about the anus; short dry cough; emaciation of the body; slow fever, with evening exacerbations and irregular pulse, and sometimes convulsive fits. [Hooper1843]

YELLOW FEVER: (also called yellow jack, febris flava, black vomit or sometimes American Plague) is an acute viral disease. It is an important cause of hemorrhagic illness in many African and South American countries despite existence of an effective vaccine. The yellow refers to the jaundice symptoms that affect some patients. Yellow fever is an acute systemic (bodywide) illness caused by a virus called a Flavivirus. In severe cases, the viral infection causes a high fever, bleeding into the skin, and necrosis (death) of cells in the kidney and liver. The damage done to the liver from the virus results in severe jaundice which yellows the skin (provides the "yellow" in "yellow fever").

The virus of yellow fever is transmitted in most cases by a bite of the Aëdes aegypti mosquito. (In a very few cases, the virus may be transmitted by a monkey bite.)

ZYMOTIC: relating to fermentation. Used to describe a vast number of diseases which acted in a similar way to the fermentative process. Sometimes referred to chief fevers and contagious diseases e.g. Cholera, measles, typhus.

The above list clears the vision of all of us about the meaning of subrubrics of Fever in our Repertories. Depending upon the characteristics of case or the totality of symptom presentation we can choose the similimum and prescribe it to the patient.

Hahnemann's Directions about Time of Administration of Medicine and Repetition of Medicine:
The most appropriate and efficacious time for administering medicine is immediately or very soon after the termination of the paroxysm, as soon as the patient has partially recovered from its effects. If at all the stage of apyrexia is very short the dose should be administered during the declining period of the paroxysm.

Dr. Hahnemann further advises that in cases when the fever relapses again after a temporary period of relief after prescribing similimum; the physician before thinking for second prescription should reassess about the presence of exciting/maintaining cause or removal of miasmatic blockage.

Management:

Other than prescribing similimum the physician should also advise to the patient auxilary modes of fever management. The chief among them are:

• Heat removal is generally by wet cloth or pads, usually applied to the forehead, but also through bathing the body in tepid water.
• Cold water bath is never advised in fever, it leaves the person chilled; instead luke warm water should be used.
• Easily digestible, bland food with plenty of liquids is advised as fever often leaves the patient dehydrated.
• Instead of restricting patient's room of light and air it should be well ventilated with provision of natural light.
• Attendants should never wake the patient to take medicines. Rest is vital for recovery.

Thus we see that Repertory as a tool helps in simplifying our choice of similimum in every case and if applied properly it can help in providing relief to the patient.