Decubitus in clinical practice: a repertorial connotation and homoeopathic purview

Dr Seeta Singh MD(Hom)

ABSTRACT
Observation of the patient undoubtedly forms a part of the case taking and selection of the similimum. Master Hahnemann, in Organon of Medicine, has deeply narrated regarding mal-observation and non-observation. Stalwarts of Homoeopathy press for through observation of the patient from the time of entry to the chamber till his exit. But some of the common observations are often missed; may be due to busy schedule, maybe due to casual attitude. But many times it is missed because of a lack of thorough knowledge regarding the apparent value of the observation in final selection of the remedy. Not to forget these observations play a great role in one-sided diseases and diseases with few symptoms. A review of decubitus, it’s importance and application in homoeopathy in relation to the rubrics. Decubitus adds to the totality of symptoms leading to the selection of the simlimum.

KEYWORDS- Decubitus, Purview, clinical utility, types, stalwart’s views, organon of medicine, homoeopathy, repertory, Rubrics. 

INTRODUCTION
Decubitus means posture or attitude of the patient in bed assumed by him/her in most of the time of day and night. [1]  Analysis of posture especially decubitus of a patient is of major importance in diagnosis. The patient decubitus may give valuable information. Just like as in severely ill patient slip down the bed or chair into uncomfortable attitudes which they are unable to correct. Patients with heart failure sit up because they may become dyspnoeic if they lie flat (orthopnea). Patients with abdominal pain due to peritonitis lie still, while the patient with colic are restless or may even roll about in futile attempts to find relief. People with painful joint diseases often have an attitude of helplessness. Various neurological disorders produce characteristic postures. In the severest cases of meningitis the neck may be bent backwards so that the head appears to bore into the pillow (neck retraction).When it is purely preferable to lie down then it is characteristic. 

Decubitus is such an observation which is equally important like many clinical observations. Various postures of the patient during his healthy life and changed posture during his sickness is of vital importance in obscure case. Many a time’s decubitus stands to be a prominent observation in obscure case. Not to forget patient assumes certain decubitus to get relief from pain which is acts as a circumstantial modality. This topic aims to discuss various decubitus that are observed in common clinical practice and their significance in selection of the remedy. A special emphasis has been given to the connotation of various decubitus as reference. 

ETYMOLOGY OF DECUBITUS-
Decubitus is derived from Latin word – Decumbere  i.e. (de= down and cumbre = to lie).[2]

RELATED TERMS-

  • Angina decubitus – pain in chest at rest.
  • Decubitus ulcer – a bed sore, an ulcer. [3]
  • Decubitus ulcer – morbid change in uterine prolapse. [4]   
  • TYPES OF DECUBITUS AND CLINICAL SIGNIFICANCE-
  1. OF CHOICE: The patient is comfortable in any position in bed. [1]
  1. DORSAL DECUBITUS OR SUPINE POSITION: Lying on back (back pain, abdominal problems). Dorsal decubitus position with a pillow placed below the legs  (poedal oedema and cellulitis of foot ) or below the popliteal fossa (acute inflammation of knee. e.g., in rheumatic and rheumatoid arthritis, heamophilia).[1]
  • KENT’S REPERTORY-

STOMACH- PAIN- lying, on back amel.: Calc.

BACK- PAIN- lying, back on amel.: Nat-m., Ruta.

GENERALITIES- LYING- back on amel.: Am-m., Bry., Calc., Merc-c., Puls., Rhus-t. [5]

  • BBCR- ABDOMEN- AMELIORATION- Lying, back on: Bry,. Ign. 

BACK- AMELIORATION- Lying: Nat-m. [6] 

  • PHATAK- LYING- Back on- AMEL: BRY; CALC; Pul; Rhus-t. [7]
  • BOERICKE- MODALITIES- AGGRAVATION- Lying on back: Nux-v. [8]
  1.   LATERAL DECUBITUS:
  • Lying on sides (pleuritis, pneumonia, bronchiectasis, liver abscess). The patient is most comfortable lying on the affected side because the movement on the affected side is restricted. [9]        
  • Right lateral decubitus. 
  • Left lateral decubitus. (Patient of liver abscess prefers to lie on the left side). [1]
  • KENT’S REPERTORY-  

STOMACH- PAIN, cramping- lying side left, amel.: chel.

RESPIRATION– DIFFICULT– lying, on right side amel.: Spig.

CHEST- HEPATIZATION. of lungs, lying on right side, amel.: Phos.

SLEEP- POSITION, side right: Phos. 

GENERALITIES- LYING- side on amel.: Cocc., Nux-v. [5]

  • BBCR- RESPIRATION- AMELIORATION- Lying, side on: Pho. [6]
  • PHATAK- ABDOMEN- Lying on- Left side, amel: Scil. [7]
  • K. K. SIRKER- GENERALITIES- LYING- on side, amel.: Coloc.

RESPIRATION- ASTHAMATIC- lying- side, right amel: Spig. [10]

  • BOERICKE REPERTORY- 

ABDOMEN- PAIN (hepatalgia)- Pain worse lying on right side: Mag-m., Merc. [8]

  1. VENTRAL DECUBITUS OR PRONE POSITION: 

Lying on abdomen. E.g. colic, worm troubles, abdominal aortic aneurysm (eroding vertebrae and producing back pain). [2]

  • KENT’S REPERTORY- STOMACH- PAIN- lying, on adomen amel.: Elaps. 

ABDOMEN- PAIN- lying, on abdomen, amel.: Bell., bry., coloc.,phos., stann. [5]

  • BBCR- ABDOMEN- AMELIORATION- Lying, abdomen on: Calc-c., plb. 

SLEEP- POSITIONS DURING SLEEP- Lying on abdomen: Bell., Colo., MED., Stra. [6]

  • PHATAK- ABDOMEN- Lying on- Stomach, amel: Rhus-t.

LYING- Abdomen, on AMEL: BELL; COLO; MED; Pod; Psor; Sep. [7]

  • BOERICKE- MODALITIES- AMELIORATION- Lying, on stomach: Acet-ac., Coloc., Podo., Tab. [8]
  1. PROPPED UP POSITION OR FOWLERS POSITION:

Head rest is adjusted to desire height and bed is raised slightly under patient’s knees. Propped up position with a              back- rest is found in patients suffering from dysponea. The back-rest can be adjusted according to the requirement of the patients. E.g.

  • Mild dyspnoea- adopts 450
  • Modeate dyspnoea- adopts 600
  • Severe dyspnoea or orthopnea- adopts 900 (i.e. patient sits in bed).

                Dyspnoea is basically due to respiratory and cardiovascular ailments (cardio-respiratory embarresment). Gastrointestinal cause like massive ascites and neurological causes like diaphragmatic palsy, respiratory muscles, myasthenia gravis may also produce dyspnoea. [2] 

  • KENT’S REPERTORY- BED- Sitting up in AMEL: Kali-c; Samb.

RESPIRATION- RATTLING- lying- sitting upright amel.: Nat-c. [5]

  • BBCR- COUGH- AMELIORATION- Sitting up: Sang. 

SLEEP- POSITIONS DURING SLEEP- Sitting, erect: Cina. [6]

  • PHATAK- SITTING- AMEL: BRY; COLCH; Nux-v.

SITTING- Erect- AMEL: ANT-T; DIG; Hyo; Nat-s. [7]

  • K. K. SIRKER- COUGH- DRY- sitting up, amel.: Hyos., Puls. [10]
  • BOERICKE- RESPIRATORY SYSTEM- DYSPNEA, relieved from sitting up: Ars., Samb. [8]
  1. STOOPING FORWARD POSITION (Mohammedan’s prayers position) on a cardiac table:

Seen in severe dyspnoea of pericardial effusion, acute severe asthma, cardiac asthma and COPD. It is also observed in acute pericarditis or acute pancreatitis patients to get relief of pain .Patients with acute pancreatitis is partly relieved by lying down with knees drawn towards the chest. [1]

  • KENT’S REPERTORY- CHEST-ANXIETY, in- bending forward amel.: Colch. [5]
  • BBCR- SLEEP- POSITION DURING SLEEP- Head, inclined forward: Stap. [6]
  • PHATAK- BENDING- forwards, or doubling up AMEL:Calc; Colo; Kali-c; Mag-p; Rhe; Rhus-t; Sep; Sul. [7]
  1. SQUATTING: Fallot’s tetralogy is the commonest cyanotic congenital heart disease where squatting is observed, as soon as the Patient becomes dyspnoeic, he adopts squatting posture to relieve from dyspnoea. Squatting increases the peripheral resistance i.e. pressure in aorta increases and thus reduce the right to left shunting through VSD. [1]
  1. EMPROSTHOTONUS: 

The patient’s body is arc in forward direction (hyperflexion). E.g. Tetanus and strychnine poisioning. [1]

  1. OPISTHOTONUS (Opisthen – behind):

The patient’s body is arc in backward direction (hyperextension). E.g.  Meningitis, tetanus,                            uremia, epilepsy, strychnine poisoning and rabies. [11]       

  • KENT’S REPERTORY- BACK- OPISTHOTONOS: Bell., Cic., Cupr., Hyos., Nux-v., Op., Stram., Stry. [5]
  • BBCR- SLEEP- POSITIONS DURING SLEEP– Head, inclined backward: Cina. [6]
  • PHATAK- BENDING- Backward, stetching limbs- AMEL: ANT-T; Calc; Dios; Ign; Nux-v. 

LYING- Back on– Jerks the head backward, while: Hypr.

RESPIRATION- Bending- Head, backward amel: Hep; Lach; Spo. [7]

  • K. K. SIRKER- BACK- OPISTHOTONUS: Cupr., Cic., Hyos. [10]
  • BOERICKE- LOCOMOTOR SYSTEM- BACK Bent, arch- like, opisthotonos: Cic., Nicot. [8]
  1. PLEUROSTHOTONUS:

Patient’s body is arched laterally to one side. E.g. tetanus and strychnine poisoning. [1]

  1. LISTLESS ATTITUDE: Where the patient lies still in bed. This attitude is usually seen in peritonitis (abdominal wall movements causes intense pain) angina pain, hysteria, parkinsonism and unconsciousness. [12] 
  • PHATAK- HEAD- Sitting- still amel: Nat-m. [7]
  • K. K. SIRKER- MIND- UNCONCIOUSNESS: lies like a log: Ph-ac. [10]
  1. CURLED UP:

Observed in renal colic and biliary colic, restless, tossing- in colics. AMI. Restlessness occurs in many disorders, acute and chronic, and is generally a grave sign in the former-e.g. in acute pericarditis. [13]   

  • KENT’S REPERTORY- SLEEP- POSITION- Curled up like a dog: Ars; Bap; Bry. [5]
  • PHATAK- CHANGE OF POSITION- AMEL: IGN; Meli; Nat-s; RHUS-T; Sep; Val. [7]
  1. HEAD END DOWN (usually adjusted by placing bricks or wooden blocks in the foot end of bed):In the treatment of bulbar palsy, after lumbar puncture after spinal anesthesia, balanced traction in orthopaedic, in treatment of sinus bradycardia developed from acute myocardial infarction. [2]

Deep venous thrombosis in leg and in postural drainage of bronchiectasis and lung abcess (lower lobes). [1]

  • KENT’S REPERTORY- SLEEP- POSITION, back on, with head low: Dig. [5]
  • PHATAK- HEAD- Lying- With head low- amel: Bry. [7]
  • BOERICKE- SLEEP- POSITIONS DURING SLEEP- Head, lying low, with: Spo. [8]
  1. ANDRAL’S DECUBITUS OR SIGN: 

The patient lies on affected side e.g. pleuritis, pleural effusion etc. The position usually assumed in the early stage of pleurisy by the patient, who seeks to alleviate the pain by lying on the sound side. [3]     

  • KENT’S REPERTORY- CHEST- PAIN- lying while, side on, painful amel.: Bry. [5]
  1. KNEE CHEST POSITION: The patient resting on knee and upper chest. [14]
  • BBCR- AGGRAVATION AND AMELIORATION IN GENERAL:Lying on, knee chest position, amel.: Sep. [6]
  • BOERICKE- NERVOUS SYSTEM-  SLEEP- POSITION: Must lie in knee- chest position: Med. [8]
  1. KNEE – ELBOW POSITION: The patient resting on knees and elbows with chest elevated (In chronic pancreatitis).[2]
  • KENT REPERTORY- RESPIRATION-DIFFICULT- lying, on knees and elbow amel.: Med.[5]
  • BBCR- ABDOMEN- AMELIORATION- Lying, knees and elbows on: Euphor. [6]
  • PHATAK- CHEST-  Lying- With, arms, near chest amel: Lac-ac. [7]
  • BOERICKE- NERVOUS SYSTEM-  SLEEP- POSITION: Must lie on hands and knees: Cina. [8]

 DECUBITUS IN RELATION TO DYSPNOEA-

  1. ORTHOPNOEA:

Dyspnoea in recumbent (lying down) position and is of such a degree as to make the patient sit upright for relief. The patient may sleep in a chair or uses some extra pillows at night. E.g. CCF, LVF, Bronchial asthma, COPD or Interistitial lung disease (ILD), Massive pleural effusion, Pericardial effusion (cardiac temponade), Huge ascites and Bilateral diaphragmatic palsy. [1]

  1. TREPOPNOEA: 

Dyspnoea only in left or right lateral decubitus position, most often in patients with heart diseases (CCF); may be found in pleural effusion or pneumothorax. [1]

  1. PLATYPNOEA OR ORTHODEOXIA:

Dyspnoea that occur only in upright position. It happens to be due to some cardiac diseases. [1]

  1. DECUIBITUS OF HEMIPLEGIA:

The affected arm remain flexed, adducted and semi pronated, and the affected Lower limb adopts extended, adducted and plantiflexed attitude. As a whole, the affected side shows less movement while the patient is in bed.[1]

  1. Decerebrate posture: Extended elbows and wrist with arms pronated there is tonic extension and plantiflexion of the lower extremity associated with head retraction and jaw clenching. The lesion lies at upper brainstem level (i.e. midbrain or upper pons), disconnecting cerebral hemisphere from brainstem. [1]
  2. Decorticate posture: Flexed elbow and wrist with arms supinated, lower extremities show tonic extension. It is seen in bilateral hemispherical lesion above midbrain. [1]
  3. Neck extended with head buried in pillow – meningitis. [1]

FEW VIEWS OF SOME OF THE STALWARTS ON DECUBITUS-

  • Dr. P. SANKARAN gave some hints on case taking (METHOD)-

“In acute cases, the case taking is somewhat easier. The changes due to the disease being more recent and more marked, both the patient and those around him are able to observe and describe these symptoms clearly to us. This makes our work lighter. In addition, the observant physician will be able to note various small but significant details such as the decubitus, the expression, perhaps a flapping of the alae nasi or twitching somewhere, etc., which will all add up to a totality”. [15]

  • Dr. RAUE C. G. described about decubitus postion of the child in the preface of Diseases of Children- 

“The position assumed by the child during sleep and waking is important to note. We see the child burying its head in the pillow in cerebral inflammations; lying on the back with limbs drawn up in abdominal inflammations; on the affected side in acute pleurisy; the head drawn back and the spine arched during opisthotonos; unable to lie in the prone position in the dyspnoea of capillary bronchitis”. [16]

  • Dr. JAMES TYLER KENT mentioned decubitus in Section 5; BETTER OR WORSE to make a successful prescription-

“Is there any position which you may assume that causes the trouble or any single symptoms to be better or worse? It may be when you first lie down,…or leaning the head backward, forward, to one side, or leaning the head on the table or the hand; lying with the head high or low; lying in some particular position; crawling on the hands and knees; or some other of many possible positions”. [17]

  • According to Dr. BHANU D. DESAI-

“The generals which need to be especially looked for in children are:…(10) POSITION IN SLEEP: on abdomen or in knee- chest position”. [14]

DECUBITUS IN ORGANON OF MEDICINE- [18]

  • Dr. Hahnemann in organon of medicine 5th & 6th ed. has also described about decubitus of the patients.
  • In aphorism 89, in case taking, he has written about  to ask more precise more special questions”. And among that questions he has nicely said to enquire about the decubitus of the patient.
  • Foot note 3 of aph – 89 “Does he lie only on his back, or on which side?…how often does this or that symptoms occur? what is the cause that produces it each times it occurs? Does it come on whilst sitting, lying or when in motion?”……..      
  • In aph – 90, “When the physician has finished writing down these particulars, he then a makes a note of what he himself observes in the patient.”
  • Foot note 1 of aph – 90 “Wheather he lay with head thrown back, with mouth half or wholly open, with the arms placed above the head on his back, or on in what other position?”….

QUESTIONS ASKED REGARDING DECUBITUS DURING CASE TAKING-

  • During case taking what are the questions to be put regarding position as a whole and position of parts .e.g.

Position in general- lying on back- <acetic acid, >Ars.

  • lying on abdomen- > medo., acetic ac.
  • lying on sides- lying on left side <phos. >lying right side-Bry.
  • lying with legs crossed- rhododendron. 
  • sitting(bending forward > colo., mag-p., bending backward > dios.)

Position in particularHead (bending forward< Bell., bendig backward< glon. 

DECUBITUS IN MATERIA MEDICA-

  • ACETIC ACID: Cannot sleep lying on back (sleeps better on back, Ars.). Sensation of sinking in abdomen causing dyspnoea; rests better lying on belly (Am. c.) [19]

I Can not remain  long in Same position. 

I Lying on belly: rests > during sleep. [20]

  • ARSENIC ALBUM: In respiratory complaint < lying on affected side, with head low. [19]Asthmatic breathing < after 12 O’ clock, unable to lie down for fear of suffocation, > sitting up, bent forward.

II  Breathing asthmatic; must sit or bend forward; springs out of bed at night, especially after 12 p.m. [20] 

  • BELLADONNA: Head- head sensitive to drafts of cold or haircut.Throbbing hammering headache in temples.    < lying downHead pain worse light, noise, jar, lying down and in the afternoon; and better by pressure and in a semi-erect posture. [8] 

II  Headache < when leaning forward; > when bending backward. 

I  Female genitalia- Sensitive, forcing downward as if all viscera would protrude at genitals. < lying down, sitting bent; > standing and sitting errect. [20] 

  • BRYONIA  ALBA: Useful in aching heaviness in hepatic region; > lying on right side, pain sticthing, tearing worse at night < motion; > by absolute rest and  lying especially on painful side ( Ptel, Puls). [19] 

I Sciatica: Pains < sitting up. [20] 

  • CACTUS GRANDIFLORUS: HEART- heart feels clutched and released alternately by an iron band and there is no room to beat. Fluttering palpitation day and night <lying on left side, <lying on back. Violent palpitations worse lying on the left side, at approach of menses. Menstrual flow ceases when lying down(Bov., Caust.) [19] 
  • CAUSTICUM: Constipation: frequent, ineffectual desire (Nux.); stool passes better when person is standing. At night unable to get an easy position or lie still a moment (Eup., Rhus). [19] 
  • CUPRUM METALLICUM:Stretched upon the floor without sense, lay constantly with legs drawn up; constant dorsal decubitus; on back, with head bent backward; the child lay upon its stomach with jerking upward of pelvic.[21]  
  • DIOSCOREA: Colic pain < from bending forward and while lying; > on standing errect or bending backwards (rev. of colocynth). [19]  
  • KALI CARB: Asthma relieved when sitting up or bending forward or by rocking; worse from 2-4 am. Pains stitching darting worse during rest and lying on affected side.( stitching, darting, better during rest and lying on painful side, Bry.). [19]
  • MEDORRHINUM: Dyspnoea; cannot exhale (samb.) cough better lying on stomach. [8]Asthma choking caused by a weakness or spasm of epiglottis; larynx stopped so that no air could enter, only > by lying on face and protruding tongue. [19] 
  • MECURIUS CORROSIVE: Dorsal decubitus. II Lies on back with knees drawn up; Pott’s disease. [20] 
  • NATRUM SULPH: Dry cough < morning after rising < night, on lying down, > sitting up and holding chest with both hands, cough thick, ropy, greenish expectoration, all gone sensation in the chest. [8] Sycotic pneumonia; lower lobe of left lung; great soreness of chest; during cough has to sit up  in bed and hold the chest with both hands ( Nic., rt lung, Bry.). [19] 
  • PHOSPHORUS: Pain acute especially in the chest, < from pressure,  even slight; in intercostal spaces and lying on left side. Cough; < lying on the left side (Dros., Stram.). [19] Marked heat in chest; pneumonia, with oppression; worse, lying on left side. Voilent palpitation with anxiety, while lying on left side. [8] 
  • PLUMBUM METALLICUM: Decubitus on right side;lower limbs strongly, flexed upon the abdomen, and the head sunk between the shoulders, so that he seems doubled up and huddled together. [20] 
  • PSORINUM: Asthma, dyspnoea: < in open air, sitting up (laur.); > lying down and keeping arm stretched far apart (rev. of Ars.); despondent think he will die. [19]
  • RUTA: Pain in nape, back and loins. Backache better pressure and lying on back. Lumbago worse morning before rising. [8]     
  • SPIGELIA: Dysponea: must lie on right side or with head high (Cac., Spong.); pain in chest are stitching, needle- like. [19] 
  • SULPHUR: Stitching pain extending to the back, worse lying on back, or breathing deeply (Pleurisy). Dysponea in the middle of the night, relieved by sitting up (Asthma, Hydrothorax). [8] 
  • ZINCUM MET: Can only void urine while sitting bent backwards. [19]. Pain in the lumbosacral region. Can not bear to be touched   on the back (Sulph., Ther., Chin.). Dull aching around the last dorsal or first lumbar vertebra; worse sitting. [8]

CASE OF BRONCHIAL ASTHMA-
A patient name xyz, years, male, came with chief complaint of breathing difficulty and cough since 10 years. Breathing difficulty was aggravated in night, in cold air, taking cold food or drink. The character of cough was dry with rattling of mucus < cold weather, night. His complaints were amelioration by sitting and bending his head backwards. On the basis of this, HEPER SULPH 0/1/16 doses AD was given.

In the follow up, after 1 month, his breathing difficulty was reduced by 40% and cough also relieved.

  • BOERICKE-RESPIRATORY SYSTEM- ASTHMA- AMELIORATION- From sitting up, with head bent backward: Hep.

A CASE OF EMPHYSEMA-
A patient came in OPD 11 dated on 01-12-17, Reg. No. 478904, name PQRS, age 70 years old, male complaints with cough since7-8 years < at night and sitting up, > by lying down at lateral side ( Rt/Lt), lying on hard bed. Accompanying complaints- lower back pain < by motion and during work > lying down and pressure. His past history was smoking (20 bidi/day), typhoid.

 On examination- pt’s chest was in barrel shaped. On palpitation, there was dull sound on 6th and 7th intercostal space, liver palpable, apex beat not palpable, spleen not palpable. On auscultation, Vesicular sound > Expiration, and Ronchi in both lungs. The Chest X- Ray report- Emphymatous changes in both Lungs. After repertorization, BRYONIA ALBA 0/1/16 doses AD…..upto 0/7/16 doses AD.

In follow up, the patient’s complaints was much better.

ANDRAL’S DECUBITUS present in this case.

  • KENT’S REPERTORY- CHEST- PAIN- lying while, side on, painful amel.: Bry. [5]
  • PHATAK REPERTORY-CHEST- Lying- Painful side, on amel: Bry.

CONCLUSION-Decubitus is a clinical sign (symptom if said by the patient) was having immense importance in diagnosis of the diseases in the past. However as the sophisticated investigation procedures are being developed, the importance of decubitus, in modern medicine for diagnosis is decreased because of lack of specificity. 

However, in homoeopathic system of medicine, the prescription depends on totality of symptoms i.e. symptoms and signs. Every sign and symptom play important role in selection of remedy and the decubitus of a patient is a sign, which is readily available in patient and useful for physician for selection of medicine to achieve his mission.

REFERENCES-

  1. Kundu Arup Kumar. Bedside Clinics in Medicine. (1). 7th ed. Kolkata: Academic Publishers; 2014. p.463-464.
  2. Oxford Dictionary: Available from; https://en oxforddictionaries.com
  3. Jain B. Pocket Medical Dictionary of the Principal Words Used in Medicine and Collateral Sciences.
  4. Dutta D. C. Text book of gynaecology. 5th ed. Kolkata: New Central Book Agency; 2008. p. 201.
  5. Kent J. T. Repertory of the Homoeopathic Materia Medica. Student ed. New Delhi: B. Jain Publishers (P) Ltd; 2005.
  6. Boger C. M. Boger Boenninghausen’s Characteristics & Repertory. 42 Impression. New Delhi: B. Jain Publishers(P) Ltd; 2016. 
  7. Phatak S. R. A Concise Repertory Of Homoeopathic Medicines.4th ed. New Delhi: B. Jain Publishers (P) Ltd; 2009.
  8. Boericke W. New Manual of Homoeopathic Materia Medica with Repertory. 2nd ed. New Delhi: B. Jain Publishers (P) Ltd; 2000.
  9. Meheta’s P. J. Practical Medicines.17th ed. Mumbai: The National Book Depot; 2005. p.13.
  10. Sirker Captain K. K. A Repertory based on Allen’s Keynotes and Nash’s Leaders. Revised ed. Noida: B. Jain Publishers (P) Ltd; 2005.
  11. Bose Akhil. Medicine Clinical and Descriptive for student and Practitioners. 8th ed. Calcutta: Academic Publishers; 1960. p. 3.
  12. Sen Sunil K. Essentials of Clinical Diagnosis. 9th ed. CBS Publishers and Distributors (P). Ltd;      
  13. Warner e. c. (ed). Savill’s System of  Clinical Medicine.14th ed. New Delhi: CBS Publishers and Distributors (P). Ltd; Reprint 2005. p.24.
  14. Desai Dr. Bhanu D. The Hahnemannian Gleanings, Homoeopathy For Children. (V. XL VI). Bombay; Nov. 1979. P.502-504.
  15. Sankaran P. The Elements Of Homoeopathy. India: Homoeopathic Medical Publishers;1975.
  16. Raue C. G., Diseases of Children (res1). 3rd ed. New Delhi: B. Jain Publishers (P) Ltd;     P. 49.
  1. Kent Dr. James Tyler. What the Doctor Need to Know in Order to Make A Successful Prescription. Calcutta: Eastend Printers; Copyrighted-1957. p. 7.
  2. Hahnemann Samuel. Organon Of Medicine. 5th and 6th Reprint ed. New Delhi: India Books and Periodicals Publishers; 2012. p. 105-106. 
  3. Allen H. C. Keynotes and Characteristics with Comparisions of Some of the Leading Remedies of the Materia Medica. 8th  reprint ed. New Delhi: B. Jain Publishers (P) Ltd; 2014.
  4. Hering C. The Guiding Symptoms of our Materia Medica. (Vol.VIII). New Delhi: B. Jain Publishers (P) Ltd; .2000.
  5. Allen T. F. The encyclopedia Of Pure Materia Medica. Reprint edition.(Vol VII).  B. Jain Publishers (P) Ltd; 2005.

Dr Seeta Singh MD(Hom)
National Institute of Homoeopathy
Email : see.singh2022@gmail.com

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