on study of

UNDER GUIDANCE OF-

Dr.A.K.RASTOGI
(Lecturer) National Homoeopathic Medical College

Submitted by: YOGESH KUMAR SINGH

Intern 2000 Batch

ACKNOWLEDGEME NT
This is a great honour to offer my sincere thanks to prof. Dr. B.N.Singh, principal, National Homoeopathic Medical College, lucknow, under whose guidance I completed this dissertation. I also offer my thanks to Dr.R.S.Jaiswal, incharge O.P.D. and Dr. A.K.Rastogi who extended their kind help in every possible way, whenever required. Yo gesh kumar singh Intern 2000 Batch

CERTIFICATE
This is to certify that Intern Yogesh kumar singh of 2000 Batch has completed his dissertation Titled Pulmonary Tuberculosis &, Its homoeopathic Treatment under my guidance. .

He has worked hard.

Dr. A.K.Rastogi (Lecturer)

Guide National Homoeopathic Medical College

CERTIFICATE
This is to certify that Intern Yogesh kumar singh 2000 Batch has completed his

dissertation titled Pulmonary Tuberculosis and its homoeopathic treatment. He has worked hard.

Dr. B. N. Singh
incipal)

Prof.
(Pr

National Homoeopathic Medical College

INDEX
CONTENTS PAGE NO. 1) Introduction

2) Aims and objectives 3) Review of general medical literature 4) Review of homoeopathic literature 5) Material and methods 6) Management and treatment 46 7) Annexure 56 i. ) Case Proforma ii. ) Graphs iii. ) Synopsis of cases 8) Bibliography 66

INTRODUCTION
Tuberculosis has been present in humans since antiquity, as the origins of the disease are in the first domestication of cattle (which also gave humanity viral poxes). Skeletal remains show prehistoric humans (4000 BC) had TB and tubercular decay has been found in the spines of Egyptian mummies from 3000-2400 BC. There were references to TB in India around 2000 BC and TB was present in The Americas from about 2000 BC Phthisis is a Greek term for consumption. Around 460 BC, Hippocrates identified phthisis as the most widespread disease of the times which was almost always fatal. Due to the variety of its symptoms, TB was not identified as a unified disease until the 1820s and was not named tuberculosis until 1839 by J.L. Schoenlein. The first TB sanatorium opened in 1859 in Poland, with another opening in the United States in 1885. The bacillus-causing tuberculosis, Mycobacterium tuberculosis, was described on March 24, 1882 by Robert Koch. He received the Nobel Prize in physiology or medicine for this discovery in 1905. Koch did not believe that bovine (cattle) and human

tuberculosis were similar, which held back the recognition of infected milk as a source of infection. Later, this source was eliminated by pasteurization. Koch announced a glycerine extract of the tubercle bacilli as a "remedy" for tuberculosis in 1890, calling it tuberculin. It was not effective, but was later adapted by von Pirquet for a test for pre-symptomatic tuberculosis. The first genuine success in immunizing against tuberculosis developed from attenuated bovine strain tuberculosis by Albert Calmette and Camille Guerin in 1906 was BCG (Bacillus of Calmette and Guerin). It was first used on humans on July 18, 1921 in France, although national arrogance prevented its widespread use in either the USA, Great Britain, or Germany until after World War II. Tuberculosis caused the most widespread public concern in the 19th and early 20th centuries as the endemic disease of the urban poor. In 1815 England one in four deaths were of consumption; by 1918 one in six deaths in France were still caused by TB. After the establishment in the 1880s that the disease was contagious, TB was made a notifiable disease in Britain; there were campaigns to stop spitting in public places, and the infected poor were "encouraged" to enter sanatoria that rather resembled prisons. Whatever the purported benefits of the fresh air and labor in the sanatoria, 75% of those who entered were dead within five years (1908). In Europe, deaths from TB fell from 500 out of 100,000 in 1850 to 50 out of 100,000 by 1950. Improvements in public health were reducing

tuberculosis even before the arrival of antibiotics, although the disease's significance was still such that when the Medical Research Council was formed in Britain in 1913 its first project was tuberculosis. Hopes that the disease could be completely eliminated have been dashed since the rise of drugresistant strains in the 1980s. For example, TB cases in Britain, numbering around 50,000 in 1955, had fallen to around 5,500 in 1987, but in 2001 there were over 7,000 confirmed cases. Due to the elimination of public health facilities in New York in the 1970s, there was a resurgence in the 1980s. The number of those failing to complete their course of drugs was very high. NY had to cope with more than 20,000 "unnecessary" TB-patients with many multi-drug resistant strains. The resurgence of tuberculosis resulted in the declaration of a global health emergency by the World Health Organization in 1993. In 2003, by disabling a set of genes, researchers accidentally created a more lethal and rapidly reproducing strain of tuberculosis bacteria. Christmas Seals was started in 1904 in Denmark as a way to raise money for tuberculosis programs. It expanded to the United States and Canada in 1907-08 to help the National Tuberculosis Association, later called the American Lung Association. During the Industrial Revolution, tuberculosis was more commonly thought of as vampirism. When one member of a family died from it, the other members that were infected would lose their health slowly. People believed that the cause of this was the

original victim was draining the life from his/her family members. To cure this, people would dig up the body of what they thought was the vampire, open the chest and burn the heart, sometimes with the rest of the body. Furthermore, people who had TB exhibited symptoms similar to what people considered vampire traits (and may be where much of the common mythology of the vampire comes from) . People with TB often had symptoms such as red, swollen eyes (which also creates a sensitivity to bright light), pale skin and would cough blood (which people often figured needed to be replenished because of the loss in this manner, i.e. sucking blood. Global and regional incidence The largest number of cases occurs in the SouthEast Asia Region, which accounts for 33% of incident cases globally. However, the estimated incidence per capita in sub-Saharan Africa is nearly twice that of the South-East Asia, at 350 cases per 100 000 population. It is estimated that 1.75 million deaths resulted from TB in 2003. As with cases of disease, the highest number of estimated deaths is in the South-East Asia Region, but the highest mortality per capita is in the Africa Region, where HIV has led to rapid increases in the incidence of TB and increases the likelihood of dying from TB. Tuberculosis (TB) is a contagious disease. Like the common cold, it spreads through the air. Only people who are sick with TB in their lungs are infectious. When infectious people cough, sneeze, talk or spit, they propel TB germs, known as bacilli, into

the air. A person needs only to inhale a small number of these to be infected. Left untreated, each person with active TB disease will infect on average between 10 and 15 people every year. But people infected with TB bacilli will not necessarily become sick with the disease. The immune system "walls off" the TB bacilli which, protected by a thick waxy coat, can lie dormant for years. When someone's immune system is weakened, the chances of becoming sick are greater.

Someone in the world is newly infected with TB bacilli every second. Overall, one-third of the world's population is currently infected with the TB bacillus. 5-10% of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life.

AIMS AND OBJECTIVES

o

To know the efficacy of Homoeopathic medicine

o To see the place of deep acting & short acting medicines in treatment. o To see homoeopathic dosage directions. o To see miasmatic and constitutional background in the treatment. o To see the auxiliary management in the treatment.

REVIEW OF GENERAL MEDICAL LITERATURE

STRUCTURE & FUNCTION OF LUNGS

The lungs are paired cone-shaped organs lying in the thoracic cavity. They are separated from each other by heart and mediastinum. Two layers of serous membrane, collectively called the pleural membrane, enclose and protect each lung. The outer layer is attached to the wall of the thoracic cavity and is called parietal pleura. The inner layer, the visceral pleura, covering the lungs themselves. Between the visceral and the parietal pleurae is a small potential space, the pleural cavity, which contains a lubricating fluid secreted by the membranes. The lungs extends from the diaphragm to just slightly above clavicles and lie against the ribs anteriorly and posteriorly. The broad inferior portion of of the lung, the base, is concave and fits over the convex area of the diaphragm. The narrow superior portion of the lung is termed as the

apex(cupula). The surface of the lung lying against the ribs, the costal surface, is rounded to match the curvature of the ribs. The mediastinal surface of each lung contains a region, the hilus, through which bronchi, pulmonary blood vessels, lymphatic vessels, and nerves enter and exit. These structures are held together by pleura and connective tissue and constitute the root of the lung. Medially, the left lung also contains a concavity, the cardiac notch, in which the heart lies . Lobes and fissures Each lung is subdivided into lobes by one or or more fissures. Both have an oblique fissure, which extends downward and forward. The right lung also has a horizontal fissure. The oblique fissure in the left lung separates the superior lobe from the inferior lobe. The upper part of the oblique fissure of the right lung separates the superior lobe from the inferior lobe, where as the lower part of the oblique fissure separates the inferior lobe from the middle lobe. The horizontal fissure of the right lung subdivides the superior lobe, thus forming the middle lobe. Each lobe receives its own secondary (lobar) bronchus. From these secondary arises tertiary bronchi, which are 10 in each lung. The segment of lung tissue that each supplies is called a broncho- pulmonary segment. Lobules - Each bronchopulmonary segment of the lungs has many small compartments called lobules. Each lobule is wrapped in elastic connective tissue and contains a lymphatic vessel, an arteriole, a venule, and a branch from a terminal bronchiole.

Terminal bronchioles subdivide into microscopic branches called respiratory bronchioles. As the respiratory bronchioles penetrate more deeply into the lungs, the epithelial lining changes from cuboidal to squamous. Respiratory bronchioles, in turn, subdivide into several alveolar ducts. Around the circumference of the alveolar ducts are numerous alveoli and alveolar sacs. An alveolus is a cup- shaped out pouching lined by epithelium and supported by a thin elastic basement membrane. Alveolar sacs are two or more alveoli that share a common opening. The alveolar walls consist of two types of epithelial cells. Type I alveolar(sqamous pulmonary (epithelial) cells form a continuous lining of the alveolar wall, interrupted by occasional type II alveolar (septal) cells. Alveolar-Capillary (Respiratory) Membrane The exchange of respiratory gases between the lungs and blood takes place by diffusion across alveolar and capillary walls. Collectively, the layers through which the respiratory gases diffuse are known as the alveolar-capillary (respiratory) membrane. It consists of - : 1) A layer of type I and type II alveolar cells with free alveolar macrophages that constitute the alveolar (epithelial) wall. 2) An epithelial basement membrane underneath the alveolar wall. 3) A capillary basement membrane that is often fused to the epithelial basement membrane. 4) The endothelial cells of the capillary.

Blood Supply to the lungs- There is a double blood supply to the lungs. Deoxygenated blood passes through the pulmonary trunk, which divides into a left pulmonary artery that enters the left lung and a right pulmonary artery that enters the right lung. The venous return of the oxygenated blood is by way of the pulmonary veins, typically two in number on each side-the right and left superior and inferior pulmonary veins. All four veins drain into the left atrium. Oxygenated blood is delivered through bronchial arteries, which branch directly from the aorta. There are communications between the two systems, and most blood returns via pulmonary veins. Some blood, however, drains into bronchial veins, branches of azygous system.

PHYSIOLOGY OF RESPIRATION The principal purpose of respiration is to supply the

cells of the body with oxygen and remove the carbon dioxide produced by cellular activities. The three basic processes of respiration are pulmonary ventilation, external(pulmonary) respiration, and internal(tissue) respiration. PULMONARY VENTILATION It is the process by which gases are exchanged between the atmosphere and lung alveoli. Air moves into the lungs when the pressure inside the lungs is less than the pressure in the atmosphere. Air moves out of the lungs when the pressure inside the lungs is greater than the pressure in the atmosphere. It consist of the following two processesInspiration Breathing in is called inspiration . Just before each inspiration, the air pressure inside the lungs equals the pressure of the atmosphere, which is about 760 mm of Hg, or 1atm. For air to flow into the lungs, the pressure inside the lungs must become lower than the pressure in the atm. . This condition is achieved by increasing the volume of lungs. The first step in expanding the lungs involves contraction of the principal inspiratory muscles- the diaphragm, and external intercostals muscles. Contraction of the diaphragm causes it to flatten, lowering its dome. This increases the vertical dimension of the thoracic cavity and accounts for the movement of about 75% of the air that enters the lungs that enters the lungs during inspiration. The distance the diaphragm moves during inspiration ranges from 1cm during normal quite breathing upto

10cm during heavy breathing. As the diaphragm contracts, the external intercostals contract. These skeletal muscles run obliquely downward and forward between adjacent ribs, and when these muscles contract, the ribs are pulled upward and sternum is pushed forward. This increases the anterior-posterior dimension of the thoracic cavity. During normal breathing, the pressure between the two pleural layers, called intrapleural pressure, is always below atmosphere pressure. Just before inspiration, it is about 4mm hg less than the atmospheric pressure, or 756mm hg if the atm. Press. Is 760mm hg. As the diaphragm contracts and the overall size of the thoracic cavity increases, the intrapleural pressure falls to about 754mm hg. Consequently, the walls of the lungs are pulled outwards. The parietal and visceral pleura normally adhere strongly to each other because of the below atmospheric pressure between them and because of the surface tension created by their moist adjoining surfaces. As the thoracic cavity expands, the parietal pleura lining the cavity is pulled outward in all directions, and the visceral pleura and lungs are pulled along with it. When the volume of the lungs increases, the pressure inside the lungs, called the alveolar pressure, drops from 760 to 758mm hg. A pressure gradient is thus established between the atm.and the alveoli. Air rushes from the atm.into the lungs due to a gas pressure difference, and inspiration takes place. Air continues to move into the lungs as long as the pressure difference exists. The term for normal quite breathing is eupnea .It involves shaiiow, deep, or combined

shallow and deep breathing. Shallow breathing is called costal breathing. It consists of an upward and outward movement of the chest as a result of contraction of the external intercostals muscles. The intercostals muscles receive innervation from the intercostal nerves, which emerge from thoracic segments of the spinal cord. Deep breathing is called diaphragmatic breathing. It consist of the outward movement of the abdomen as a result of the contraction and descent of the diaphragm. During deep, labored inspiration, accessory muscles of inspiration also participate in increasing the size of the thoracic cavity. These include the sternocleidomastoid, which elevate the sternum, the scalenes, which elevate the superior two ribs, and the pectoralis minor, which elevate the third through fifth ribs. Inspiration is an active process because it is initiated by skeletal muscle contraction. Expiration Breathing out is called expiration. It is also achieved by pressure gradient, but in this case it is reversed. The pressure in the lungs is greater than the pressure of the atmosphere. Normal expiration during quiet breathing, unlike inspiration, is a passive process since no muscular contractions are involved. It depends on two factors-: 1) the recoil of elastic fibres that were stretched during inspiration. 2)The inward pull of surface tension due to the film of alveolar fluid. Expiration starts when the inspiratory muscles relax. As the external intercostals relax, the ribs move downward, and as the diaphragm relaxes, its dome

moves upward. These movements decrease the vertical and anterior-posterior dimensions of the thoracic cavity. Also, surface tension exerts an inward pull and the elastic basement membranes of the alveoli and elastic fibres in bronchioles and alveolar ducts recoil. As a result lung volume decreases and the alveolar pressure increases. Air then flows from the area of high pressure in alveoli to the area of low pressure in the atmosphere.

PULMONARY AIR VOLUME AND CAPACITIES PULMONARY VOLUMES : Tidal volume: The volume of air inspired or expired in normal quiet breathing. It is 500 ml. Anatomic dead space : Only 350 ml of tidal volume reaches the alveoli. The remaining 150 ml remain in air spaces of the nose, pharynx, larynx, trachea, bronchi, and bronchioles. These areas are known as anatomic dead space. Minute volume of respiration : The total air taken in during one minute. It is calculated by

multiplying the tidal volume by the normal breathing rate per minute. Average is 6000ml/min. Inspiratory reserve volume : It is the additional air inspired forcefully in addition to tidal volume. Average it is about 3100ml. Expiratory reserve volume : It is the additional air expired forcibly after inspiring the tidal volume. It is about 1200ml. Residual volume: Even after the residual volume is expelled, a good deal of air remains in the lungs. It is about 1200ml. PULMONARY CAPACITIES : These are combinations of specific lung volumes. Inspiratory capacity : It is the total inspiratory ability of the lungs. It is the sum of tidal volume and inspiratory reserve volume, i.e. 500 +3100 = 3600ml Functional residual capacity : It is the sum of residual volume and expiratory reserve volume, i.e. 1200 +1200 = 2400 ml. Vital capacity : It is the sum of inspiratory reserve volume, tidal volume, and expiratory reserve volume, i.e. 3100 +500 +1200 = 4800 Total lung capacity : Sum of all volumes. It is 6000ml

EXTERNAL ( PULMONARY ) RESPIRATION External respiration is the exchange of oxygen and carbon dioxide between the alveoli of the lungs and pulmonary blood capillaries. It results in the conversion of deoxygenated blood coming from the heart to oxygenated blood returning to the heart. During inspiration, atmospheric air containing oxygen enters the alveoli. Deoxygenated blood is pumped from the right ventricle through the pulmonary pulmonary arteries into the pulmonary capillaries surrounding the alveoli. The po2 of alveolar air is 105mm hg. The po2 of deoxygenated blood entering pulmonary capillaries is only 40mm hg. As a result of this difference, there is a net diffusion of oxygen from the alveoli into the deoxygenated blood until equilibrium is reached, and the po2 of the oxygenated blood is 105mm hg. While oxygen diffuses from the alveoli into deoxygenated blood, there is a net diffusion of carbon dioxide in the opposite direction. The PCO2 of deoxygenated blood is 45mm hg, where as that of the alveolar air is 40mm hg. Because of this difference in pCO2 , carbon dioxide diffuses from deoxygenated blood into alveoli until the PCO2 of the blood decreases to 40mm hg. This is the PCO2 of fully oxygenated blood. The carbon dioxide that diffuses into the alveoli is eliminated from the lungs during expiration.

PHYSIOLOGY OF INTERNAL (TISSUE) RESPIRATION The exchange of oxygen and carbon dioxide between tissue blood capillaries and tissue cells is called internal (tissue) respiration. It results in the conversion of oxygenated blood into deoxygenated blood. Oxygenated blood entering tissue capillaries has a pO2 of 105mm hg, whereas tissue cells have an average pO2 of 40mm hg. Due to this difference, oxygen diffuses from the oxygenated blood through interstitial fluid and into tissue cells until pO2 in the blood decreases to 40mm hg. This is the average pO2 of deoxygenated blood entering tissue venules when you are at rest. While oxygen diffuses from the tissue blood capillaries into tissue cells, carbon dioxide diffuses in the opposite direction. The average pCO2 of tissue cells is 45mm hg, whereas that of tissue capillary oxygenated blood is 40mm hg. As a result , carbon dioxide diffuses from tissue cells through interstitial fluid into the oxygenated blood until the pCO2 in the blood increases to 45mm hg, the pCO2 of tissue capillary deoxygenated blood. The deoxygenated blood now returns to the heart. From here it is pumped to the lungs for another cycle of external respiration.

TUBERCULOSIS
DEFINITION:

Tuberculosis is an infection with the bacterium Mycobacterium tuberculosis, which most commonly affects the lungs (pulmonary TB) but can also affect the central nervous system (meningitis), lymphatic system, circulatory system (miliary TB), genitourinary system, bones and joints. Other names for the disease are:

TB (short for tuberculosis and also for Tubercle Bacillus) Consumption (TB seemed to consume people from within with its symptoms of bloody cough, fever, pallor, and long relentless wasting) Wasting disease White plague (TB sufferers appeared markedly pale) Phthisis (Greek for consumption) and phthisis pulmonalis Scrofula (swollen neck glands) King's evil (so called because it was believed that a king's touch would heal scrofula) Pott's disease of the spine Miliary TB (x-ray lesions look like millet seeds) Tabes mesenterica (TB of the abdomen) Lupus vulgaris (the common wolf - TB of the skin)

Prosector's wart, also a kind of TB of the skin, transmitted by contact with contaminated cadavers to anatomists, pathologists, veterinarians, surgeons, butchers, etc.

Tuberculosis is the most common major infectious disease today, infecting two billion people or onethird of the world's population, with nine million new cases of active disease annually, resulting in two million deaths, mostly in developing countries. Most of those infected (90 percent) have asymptomatic latent TB infection (LTBI). There is a 10 percent lifetime chance that LTBI will progress to active TB disease which, if left untreated, will kill more than 50 percent of its victims. TB is one of the top three infectious killing diseases in the world: HIV/AIDS kills 3 million people each year, TB kills 2 million, and malaria kills 1 million. AETIOLOGY The bacterium

Acid-fast bacilli (AFB) (shown with an arrow) are tubercle bacilli Mycobacterium tuberculosis. The cause of tuberculosis, Mycobacterium tuberculosis (MTB), is a slow-growing aerobic bacterium that divides every 16 to 20 hours. This is

extremely slow compared to other bacteria, which tend to have division times measured in minutes (among the fastest growing bacteria is a strain of E. coli that can divide roughly every 20 minutes). It is not classified as either Gram-positive or Gramnegative because it does not have the chemical characteristics of either, although it contains peptidoglycan in their cell wall. If a Gram stain is performed, it stains very weakly Gram-positive or not at all. It is a small rod-like bacillus which can withstand weak disinfectants and can survive in a dry state for weeks but, spontaneously, can only grow within a host organism (in vitro culture of M. tuberculosis took a long time to be achieved, but is nowadays a normal laboratory procedure). MTB is identified microscopically by its staining characteristics: it retains certain stains after being treated with acidic solution, and is thus classified as an "acid-fast bacillus" or "AFB". In the most common staining technique, the Ziehl-Neelsen stain, AFB are stained a bright red which stands out clearly against a blue background. Acid-fast bacilli can also be visualized by fluorescent microscopy, and by auramine-rhodamine stain. The M. tuberculosis complex includes 3 other mycobacteria which can cause tuberculosis: M. bovis, M. africanum, and M. microti. The first two are very rare causes of disease and the last one does not cause human disease. Nontuberculous mycobacteria (NTM) are other mycobacteria (besides M. leprae which causes leprosy) which may cause pulmonary disease

resembling TB, lymphadenitis, skin disease, or disseminated disease. These include Mycobacterium avium, M. kansasii, and others. PATHOGENESIS While only 10 percent of TB infection progresses to TB disease, if untreated the death rate is 51 percent. TB infection begins when MTB bacilli reach the pulmonary alveoli, infecting alveolar macrophages, where the mycobacteria replicate exponentially. Bacteria are picked up by dendritic cells, which can transport bacilli to local (mediastinal) lymph nodes, and then through the bloodstream to the more distant tissues and organs where TB disease could potentially develop: lung apices, peripheral lymph nodes, kidneys, brain, and bone. Tuberculosis is classed as one of the granulomatous inflammatory conditions. Macrophages, T lymphocytes, B lymphocytes and fibroblasts are among the cells that aggregate to form a granuloma, with lymphocytes surrounding infected macrophages. The granuloma functions not only to prevent dissemination of the mycobacteria, but also provides a local environment for communication of cells of the immune system. Within the granuloma, T lymphocytes secrete cytokine such as interferon gamma, which activates macrophages and make them better able to fight infection. T lymphocytes can also directly kill infected cells.

Importantly, bacteria are not eliminated with the granuloma, but can become dormant, resulting in a latent infection. Latent infection can be diagnosed only by tuberculin skin test, which yields a delayed hypertype sensitivity response to purified protein derivatives of M. tuberculosis in an infected person. Another feature of the granulomas of human tuberculosis is the development of cell death, also called necrosis, in the center of tubercles. To the naked eye this has the texture of soft white cheese and was termed caseous necrosis. If TB bacteria gain entry to the blood stream from an area of tissue damage they spread through the body and set up myriad foci of infection, all appearing as tiny white tubercles in the tissues. This is called miliary tuberculosis and has a high case fatality. In many patients the infection waxes and wanes. Tissue destruction and necrosis are balanced by healing and fibrosis. Affected tissue is replaced by scarring and cavities filled with cheese-like white necrotic material. During active disease, some of these cavities are in continuity with the air passages bronchi. This material may therefore be coughed up. It contains living bacteria and can pass on infection. Treatment with appropriate antibiotics kills bacteria and allows healing to take place. Affected areas are eventually replaced by scar tissue. Transmission

TB is spread through aerosol droplets which are expelled when persons with active TB disease cough, sneeze, speak, or spit. Close contacts (people with prolonged, frequent, or intense contact) are at highest risk of becoming infected (typically 22 percent infection rate but everything is possible, even up to 100%). A person with untreated, active tuberculosis can infect an estimated 20 other people per year. Others at risk include foreign-born from areas where TB is common, immunocompromised patients (eg. HIV/AIDS), residents and employees of high-risk congregate settings, health care workers who serve high-risk clients, medically underserved, low-income populations, high-risk racial or ethnic minority populations, children exposed to adults in high-risk categories, and people who inject illicit drugs. The Progression In those people in whom TB bacilli overcome the immune system defenses and begin to multiply, there is progression from TB infection to TB disease. This may occur soon after infection (primary TB disease 1 to 5 percent) or many years after infection (post primary TB, secondary TB, reactivation TB disease of dormant bacilli 5 to 9 percent). The risk of reactivation increases with immune compromise, such as that caused by infection with HIV. In patients co-infected with M. tuberculosis and HIV, the risk of reactivation increases to 10 percent per year, while in immune competent individuals, the risk is between 5 and 10 percent in a lifetime. About five percent of infected persons will develop TB disease in the first two years, and another five percent

will develop disease later in life. In all, about 10 percent of infected persons with normal immune systems will develop TB disease in their lifetime. Some medical conditions increase the risk of progression to TB disease. In HIV infected persons with TB infection, the risk increases to 10 percent each year instead of 10 percent over a lifetime. Other such conditions include drug injection (mainly because of the life style of IV Drug users), substance abuse, recent TB infection (within two years) or history of inadequately treated TB, chest X-ray suggestive of previous TB (fibrotic lesions and nodules), diabetes mellitus, silicosis, prolonged corticosteroid therapy and other immunosuppressive therapy, head and neck cancers, hematologic and reticuloendothelial diseases (leukemia and Hodgkin's disease), end-stage renal disease, intestinal bypass or gastrectomy, chronic malabsorption syndromes, or low body weight (10 percent or more below the ideal). Some drugs, including rheumatoid arthritis drugs that work by blocking tumor necrosis factor-alpha (an inflammation-causing cytokine), raise the risk of causing a latent infection to become active due to the importance of this cytokine in the immune defense against TB. CLINICAL HISTORY Signs & symptoms

limited to minor cough and mild fever, if apparent Fatigue

Unintentional weight loss Coughing up blood Fever and night sweats Phlegm-producing cough

Additional symptoms that may be associated with this disease:

Wheezing Excessive sweating, especially at night Chest pain Difficulty in Breathing

TB disease most commonly affects the lungs, where it is called pulmonary TB. Symptoms include a productive, prolonged cough of more than three weeks duration, chest pain, and hemoptysis. Systemic symptoms include fever, chills, night sweats, appetite loss, weight loss, and easy fatigability. The term consumption arose because sufferers appeared as if they were "consumed" from within by the disease. .

extrapulmonary sites include the pleura, central nervous system (meningitis), lymphatic system (scrofula of the neck), genitourinary system, and bones and joints (Pott's disease of the spine). An especially serious form is "disseminated", or "miliary" TB, so named because the lung lesions so-formed resemble millet seeds on x-ray. These are more common in immunosuppressed persons and in young children. Pulmonary TB may coexist with extrapulmonary TB

PHYSICAL EXAMINATION

Examination of the lungs by stethoscope can reveal crackles (unusual breath sounds). Enlarged or tender lymph nodes may be present in the neck or other areas. Fluid may be detectable around lung. Clubbing of the fingers or toes may be present. DIAGNOSIS A complete medical evaluation for TB includes a medical history, a physical examination, a tuberculin skin test, a serological test, a chest X-ray, and microbiologic smears and cultures. The measurement of a positive skin test depends upon the person's risk factors for progression of TB infection to TB disease

MATERIAL AND METHODS Investigations:

Chest x-ray Sputum cultures Tuberculin skin test Bronchoscopy Thoracentesis Chest CT Interferon (IFN)-gamma blood test. This type of test looks for an immune response to proteins produced by M. tuberculosis. In December 2004, the FDA approved the QuantiFERON-TB Gold (QFT-Gold) test as an alternate to the traditional tuberculin skin test (TST). Rarely, biopsy of the affected tissue (typically lungs, pleura, or lymph nodes)

AFB Culture -Also known as: TB culture and sensitivity Formal name: Acid-fast bacillus smear, culture, and sensitivity Related tests: TB Skin Test The Test How is it used? AFB smears and cultures are used to determine whether you have an active M. tuberculosis infection, an infection due to another member of the Mycobacterium family, or TB-like symptoms due to another cause. They are used to help determine whether the TB is confined to the lungs (pulmonary) or has spread to organs outside the lungs (extra pulmonary). They are ordered to identify TB and multi-drug resistant TB, as well as to grow pure cultures for drug sensitivity testing. They can be used to monitor the effectiveness of treatment and can help determine when a patient is no longer infectious. Since TB is airborne and infectious - spread through respiratory secretions - it is a public health risk. It can spread in confined populations, such as correctional facilities, nursing homes, and schools; those who are very young, elderly, or have diseases and conditions that compromise their immune systems tend to be especially vulnerable. AFB smears and cultures can help track and minimize the spread of TB in these populations. When is it ordered? AFB testing is ordered when:

you have symptoms that suggest pulmonary TB, such as a lingering cough that may include streaks of blood you have a positive TB skin test and have characteristic lung involvement (as shown by Xray) someone you are in close contact with, usually a family member or co-worker, has been diagnosed with TB and you either have symptoms or you have a condition or disease that puts you at a much higher risk of contracting the disease, such as HIV (those with AIDS are more likely to have extrapulmonary TB with few and vague symptoms) you are being treated for TB; AFB smears and cultures are usually ordered at intervals, both when your doctor is evaluating the effectiveness of treatment and when they are attempting to determine whether or not you are still infectious

What does the test result mean? Positive AFB smears indicate a likely mycobacterial infection. Positive AFB cultures identify the particular mycobacteria causing your symptoms and give your doctor information about how resistant it may be to treatment. A positive AFB smear or culture several weeks after drug treatment has started may mean that your treatment regimen is not effective and needs to be changed. It also means that you are likely still infectious and can pass the mycobacteria to others through coughing or sneezing.

Negative results mean that you do not have an AFB infection or that the mycobacteria was not present in that particular specimen (which is why multiple samples are often collected). If you have TB, the infection may be in another part of your body and a different type of body sample may need to be collected. Negative results several weeks after treatment most likely mean that your TB is responding to drug treatment and that you are no longer infectious.

Sometimes, young children may be treated based on the culture results and sensitivities of the TB source (the adult infected). This is because the child's AFB smear and culture results may be more likely to be negative. Several other testing methods, based on genetic components of mycobacteria, have been developed to help decrease the amount of time necessary to diagnose tuberculosis. These include genetic probes and molecular TB testing. They amplify/replicate pieces of the microorganisms genetic code to detect mycobacteria in body samples in less than 24 hours and can narrow the identification to a complex of mycobacteria (a combination, of which M. tuberculosis is the most common). They are fairly sensitive and specific when they are paired with positive AFB smears; but when they are done on samples that are AFB negative by smear, they tend to be less accurate. These methods are approved for

respiratory samples and must be confirmed with an AFB culture, but they do provide the doctor with a quick answer, allowing him to isolate potentially infectious patients and minimize the spread of the disease. Chest X-ray

Tuberculosis creates cavities visible in x-rays like this one in the patient's right upper lobe. A posterior-anterior chest X-ray is the standard view used; other views (lateral or lordotic) or CT scans may be necessary. In active pulmonary TB, infiltrates or consolidations and/or cavities are often seen in the upper lungs with or without mediastinal or hilar lymphadenopathy. However, lesions may appear anywhere in the lungs. In HIV and other immunosuppressed persons, any abnormality may indicate TB or the chest X-ray may even appear entirely normal. Old healed tuberculosis usually presents as pulmonary nodules in the hilar area or upper lobes, with or without fibrotic scars and volume loss. Bronchiectasis and pleural scarring may be present.

Nodules and fibrotic scars may contain slowly multiplying tubercle bacilli with the potential for future progression to active tuberculosis. Persons with these findings, if they have a positive tuberculin skin test reaction, should be considered high-priority candidates for treatment of latent infection regardless of age. Conversely, calcified nodular lesions (calcified granuloma) pose a very low risk for future progression to active tuberculosis. Abnormalities on chest radiographs may be suggestive of, but are never diagnostic of, TB. However, chest radiographs may be used to rule out the possibility of pulmonary TB in a person who has a positive reaction to the tuberculin skin test and no symptoms of disease. Chest X-Ray Findings that Can Suggest ACTIVE TB: This category comprises all findings typically associated with active pulmonary TB. An applicant with any of the following findings must submit sputum specimens for examination. 1. Infiltrate or consolidationOpacification of airspaces within the lung parenchyma. Consolidation or infiltrate can be dense or patchy and might have irregular, ill-defined, or hazy borders. 2. Any cavitary lesionLucency (darkened area) within the lung parenchyma, with or without irregular margins that might be surrounded by an area of airspace consolidation or infiltrates, or by

nodular or fibrotic (reticular) densities, or both. The walls surrounding the lucent area can be thick or thin. Calcification can exist around a cavity. 3. Nodule with poorly defined marginsRound density within the lung parenchyma, also called a tuberculoma. Nodules included in this category are those with margins that are indistinct or poorly defined. The surrounding haziness can be either subtle or readily apparent and suggests coexisting airspace consolidation. 4. Pleural effusionPresence of a significant amount of fluid within the pleural space. This finding must be distinguished from blunting of the costophrenic angle, which may or may not represent a small amount of fluid within the pleural space (except in children when even minor blunting must be considered a finding that can suggest active TB). 5. Hilar or mediastinal lymphadenopathy Enlargement of lymph nodes in one or both hila or within the mediastinum, with or without associated atelectasis or consolidation. 6. Linear, interstitial disease (in children only) Prominence of linear, interstitial (septal) markings. 7. OtherAny other finding suggestive of active TB, such as miliary TB. Miliary findings are nodules of millet size (1 to 2 millimeters) distributed throughout the parenchyma.

Chest X-Ray Findings that Can Suggest INACTIVE TB: This category includes findings that are suggestive of prior TB, that is inactive. It must be remembered that assessments of the activity of TB cannot be made accurately on the basis of a single radiograph alone. If there is any question of active TB, sputum smears must be obtained. Furthermore, if the applicant has any signs or symptoms of TB, sputum smears must be obtained. Obtaining sputum smears is necessary if there is any question of active TB. Therefore, any applicant might have findings grouped in this category, but still have active TB as suggested by

The presence of signs or symptoms of TB (Class B1). Sputum smears positive for AFB (Class A).

1. Discrete fibrotic scar or linear opacityDiscrete linear or reticular densities within the lung. The edges of these densities should be distinct and there should be no suggestion of airspace opacification or haziness between or surrounding these densities. Calcification can be present within the lesion and then the lesion is called a fibrocalcific scar. 2. Discrete nodule(s) without calcificationOne or more nodular densities with distinct borders and without any surrounding airspace opacification. Nodules are generally round or have rounded edges. These features allow them to be distinguished from infiltrates or airspace opacities. To be included here, these nodules must be noncalcified. Nodules that are calcified

are included in the category OTHER X-ray findings, No follow-up needed. 3. Discrete fibrotic scar with volume loss or retractionDiscrete linear densities with reduction in the space occupied by the upper lobe. Associated signs include upward deviation of the fissure or hilum on the corresponding side with asymmetry of the volumes of the two thoracic cavities. 4. Discrete nodule(s) with volume loss or retraction One or more nodular densities with distinct borders and no surrounding airspace opacification with reduction in the space occupied by the upper lobe. Nodules are generally round or have rounded edges. 5. OtherAny other finding suggestive of prior TB, such as upper lobe bronchiectasis. Bronchiectasis is bronchial dilation with bronchial wall thickening. Tuberculin test : This test, also known as Mantoux Test, was discovered by Von Pirquet in 1907. A positive reaction to the test is generally accepted as evidence of post or present infection of Mycobacterium tuberculosis. The test is the only mean of estimating the prevalence of infection in the population There are three main tests in use currently -: Mantoux intradermal test. The heaf test. Tine multiple puncture test The heaf test is usually preferred for testing large group of people because it is easy and quick to

perform, reliable and cheap.The mantoux is favoured when a more precise measurement of tuberculin sensitivity is required. The tine test is considered by some authorities as unreliable and therefore not recommended. Mantoux test : This is carried out by injecting intradermally on the flexor surface of the forearm 1TU of PPD in .1ml. the W.H.O. advocates a preparation known as PPD-RT-23 with 80. The result of test is read after 72 hrs.Tuberculin reaction consist of erythema and induration. Reaction exceeding 10 mm are considered positive. Those less than 6mm are considered negative. Between 6-9mm are doubtful. PREVENTION Prevention and control efforts include three priority strategies:

identifying and treating all persons who have TB disease finding and evaluating persons who have been in contact with TB patients to determine whether they have TB infection or disease, and treating them appropriately, and testing high-risk groups for TB infection to identify candidates for treatment of latent infection and to ensure the completion of treatment.

In tropical areas where the incidence of atypical mycobacteria is high, exposure to nontuberculous mycobacteria gives some protection against TB. BCG VACCINE Many countries use BCG vaccine as part of their TB control programs, especially for infants. The protective efficacy of BCG for preventing serious forms of TB (e.g. meningitis) in children is high (greater than 80 percent). However, the protective efficacy for preventing pulmonary TB in adolescents and adults is variable, from 0 to 80 percent. In the United Kingdom, children aged 10-14 are typically immunized during school. The effectiveness of BCG is much lower than in areas where mycobacteria are much less prevalent. In the USA, BCG vaccine is not routinely recommended except for selected persons who meet specific criteria:

Infants or children with negative skin-test result who are continually exposed to untreated or ineffectively treated patients or will be continually exposed to multidrug-resistant TB. Healthcare workers considered on individual basis in settings in which high percentage of MDR-TB patients has been found, transmission of MDR-TB is likely, and TB control precautions have been implemented and not successful.

Tuberculosis vaccine The first recombinant tuberculosis vaccine entered clinical trials in the United States in 2004 sponsored

by the National Institute of Allergy and Infectious Diseases (NIAID). [1] A 2005 study showed that a DNA TB vaccine given with conventional chemotherapy can accelerate the disappearance of bacteria as well as protecting against re-infection in mice; it may take four to five years to be available in humans. PMID 15690060. Because of the limitations of current vaccines, researchers and policymakers are promoting new economic models of vaccine development including prizes, tax incentives and advance market commitments.

TREATMENT
The goal of treatment is to cure the infection with antitubercular drugs. Daily oral doses of multiple drugs -- which may include combinations of rifampin, isoniazid, pyrazinamide, ethambutol, or occasionally others -- are continued until culture results show the drug sensitivity of the mycobacterial infection. This helps to guide the selection of drug therapy. Treatment is typically continued for 6 months, but longer courses may be required for AIDS patients or those whose disease responds slowly. For atypical tuberculosis infections, or drug-resistant strains, other drugs and different lengths of therapy may be indicated to treat the infection.

DOTS (Directly Observed Treatment, Shortcourse) is a strategy for the control of TB. DOTS is based on research done in India over the past 40 years DOTS combines 5 elements Government commitment, Diagnosis primarily by microscopy Direct observation of treatment, at least in the intensive phase, and Systematic monitoring and accountability DOTS ensures that patients take medicenes regularly until they are cured. During the intensive phase a health worker watches as the patient swallows the drugs in his/her presence

REVIEW OF HOMOEOPATHIC LITERATURE

Tubercular Miasm Tubercular diathesis is the combination of the syphilitic and psoric stigmata, and hence it has characteristic symptoms of both. It is, however, not necessary that every psora syphilitic person should have tuberculosis but every tubercular patient must have both. The classical tubercular type is the thin, stoop shouldered person with low resistance and a tendency to catch cold. In babies and children and young persons under 20 years of age we find very widely dilated pupils, the tubercularly inclined children have structural changes in the ear. Everything that attacks them such as cold or sore throat or any of the so acute diseases shows its relation to the stigmatic combination of suppuration of ear. This suppuration no matter how painful is the safety valve of child life. In appearance these people develop very large ears. The lobe of the ear is pale,

white and transparent. In tubercular stage combined with syphilis, the child will have haemorrhage from the nose at the slightest provocation (epistaxis). Tuberculous children may have diarrhoea every now and then from the day that they are born until they are two or three years old. The least error in diet or exposure to cold produces it. When the children begin the eruption of the first teeth the diarrhoea often begins or else if present, they grow worse and continue throughout the entire period of dentition, coming or going at the appearance of eruption of the tooth. A tubercular child cannot take cows milk in any form, the casein has to be modified before they can digest it at all. They thrive better on anything else than milk. The tubercular individual has a feeble constitution. He lacks vitality, is debilitated, nervous and always tired. He usually has a thin neck. His pale sunken face sometimes has circumscribed red patch on each cheek. He has indurated glands every wherea syphilitic manifestation. In this the chest wall is narrow having not only width laterally, but depth antero-posteriorly, the sub-clavicular spaces are hollow, even the action of the diaphragm is limited. While there may be no structural change in the lung itself, there is a less air capacity and less residual air in the lung. The pumping power is so cramped that they are incapable of supplying sufficient oxygen for the body needs. The tubercular people suffer from neuralgias, prosopalgia, sciatica, insomnias, hysterias, and all the other nervous symptoms peculiar to the diathesis. Lymphatic involvement of the abdomen

is of tubercular origin, as also the hernia. The diabetic patient is as a rule a tubercular, and may have nocturnal enuresis with aggravation during sleep and soon after falling asleep. In the rectum, strictures, sinuses, fistula and pockets are all of tubercular origin. Pinworms or intestinal worms are the part and parcel of tubercular miasm. Granulations of the eye lids as well as styes are also tubercular. Corns and hypertrophies are also tubercular manifestations. Varicose veins, urticaria are of tubercular origin. Ringworms have relation with tuberculosis. Mentals : Changeability, happy at one moment and sad at another, is marked in tubercular miasm. A curious symptom is his optimism in acute lung disease. Although his case may be hopeless, he still thinks he will get better. He cannot rest at night. Tuberculous children can be very difficult. They are slow in comprehension, dull, unable to keep a line of thought, unsocial, sullen and morose. They are inclined to be whining and fretful, obstinate and give to fits of temper if they are approached to medical examination or any purpose which they do not like. Sometimes the mental condition is so bad that borders on insanity. There is direct connection between tuberculosis and some forms of insanity. Kent says that : Pthisis and insanity are convertible conditions, the one falls into the other, and also that :

 The intellectual symptoms and the lung symptoms are interchangeable. Nose : A tubercular patient will have a haemorrhage from the nose from slightest provocation- blowing the nose, a slight blow, or washing the face even will produce it in some people. The catarrhal discharge in tubercular patient is thick, usually yellow and of the odour of old cheese. Desires and Aversions : There is much craving for acids, for sweets, a longing to chew chalk, lime and pencil, a craving for indigestible things. The craving for salt is particularly noticeable in tubercular diathesis. In these un-natural cravings we find that are particuarly prone to crave spiritous liqurs and it is tubercular diathesis which produces the people who are apt to be drunkards. The tubercular child can not assimilate cows milk, such child has undigested curd in his stool. Modalities : the psoric syphilitic patient is sensitive to every change in weather especially to cold and to damp, and cold aggravates all his symptoms. Yet he cannot endure much heat. The heat from stove drive him from the room. He suffocates in warm room and can only breath easily when out in the cold wind. He longs for open air, likes cold food and drinks and loves- riding in a storm.

MIASMATIC BACKGROND
Tubeculosis comprises pseudosoric miasm .the pseudosoric miasm is also known as tubercular

miasm. It is the combination of both psora and syphilis miasm . a problem child i.e. a slow in comprehension , dull ,unable to keep align of thought, on social , morose usually characterised tubercular child . he / she getting relief from offensive foot or axillary sweat which when suppressed often induces lung troubles or some other severe disease.the patient always feel better of mental symptoms by an outbreak of an ulcer.the slightest bruise suupurate , the strong tendency is to formation of pustules; as ageneral rule the key word of tubercular miasm are dissatisfaction and incapability of tolerance . the patient is very intelligent ,keen ovserver and programmatic planner who wants his life always busy but possesses sedentary life style .due to his nature of dissatifaction he /she is ot capable to continue his relation. INDICATION OF MIASM As the miasm progresses and predominates , weight loss ,depreciation and destructi0n are the first indication of this miasm. Other indication are cosmopolitan habit, but mentally keen physically weak individual. Symptom of this miasm is ever changing .i.e rapid response to any stimulation (eg.any slightest change of weather or atmosphere ) fear of dogs , emaciation inspite of taking proper diet and drink , tendency to cough and cold easily ,desire and craving of unnatural things to eat ,with desire and craving for narcotics such as tea ,tobaccoo,coffee and any other stimulant have often there origin in psoric and tubercular miasm . they sometimes have constant hunger and beyond their capacity to digest or they have no

appetite in the morning but hunger for other meals.tubercular face is look as around with sunken eyes , skin is reddish or pale , furry and thin ,bright eyes, fear of artificial lights.and usually ulcer at the corner of the mouth.

HOMOEOPATHIC APPROACH FOR THE TREATMENT

Homoeopathic treatment for the tuberculosis involves two approaches depending upon the severity and duration of disease. The two approaches are Constitutional treatment Therapeutic treatment Constitutional treatment - Since there is degeneration of the lung tissue, the treatment is aimed for the suffering constitution who is prone to develop such a degeneration than for the actual degeneration itself, the reason being many times patient with X-RAY changes of lung parenchyma may be quite asymptomatic and then suddenly one fine day they may develop symptoms of mild to moderate or severe form. Also it has been observed that often, symptoms disappear after indicated homoeopathic remedy is given but the changes in the lungs persist. A detailed homoeopathic history is the first step in treatment of tuberculosis.The essence of homoeopathic history lies not only in recording the sufferings or the complaints of the patient but to try and get information of the individual i. e. to inquire about the whole evolution of the patient`s illness considering the causative factor which can be physical or mental, also one should inquire about the state of mind at the time of presentation. In chronic cases, one should explore the evolution of the whole personality in relation

to time, dimension e.g. birth history, early childhood, puberty, parental background, schooling and college, nature of the person as a child premarital and marital relationships, career and occupation, sleep pattern and dreams, all the above should be taken into consideration before selecting the remedy. Drug dosage and its repetition- A simillimum(usually a deep acting medicine) is selected on the basis of above guidelines and a dose of it is given in high potency (usually 1m) . After that we see for the action to commence. As long as the medicine acts no medicine is required. When the action of the medicine ceases, a detailed history is taken again and on the basis of new picture a similar medicine is given. Therapeutic treatment In this, few symptoms of the patient are taken into consideration that are peculiar to a remedy. In this only local symptoms are taken, such as character of cough, discharge, site, modality, concomitant, etc.. After selecting a remedy, it is administered to the patient usually in the low potency with frequent repetition. The medicine is given as long as the symptoms persist. Therapeutic treatment is given when the complaints are of recent origin, or there is acute exacerbation of chronic ailments. Sometimes the patient is in such a severe condition that we cannot give constitutional treatment as it may aggravate the symptoms of the patient, in such condition we opt for therapeutic treatment.

HOMOEOPATHIC TREATMENT OF TUBERCULOSIS

Phosphorus King of pthisical remedies. It corresponds to T.B. in the rapidly growing young, who are brilliant in mind, but who have a hereditary tendency to lung troubles, who are chicken thoraxed, tall and pthisical, and to those who take cold easily owing to a general relaxation of the system. The chief symptoms of it are the following: great hoarseness with evening aggravation, weak chest, cough, copious sputum and hectic fever. Especially has it blood streaked expectoration and tightness across the chest. There are pains in the apex of the left lung, and the patient cannot lie on the left side. The oppression of the chest is worse at night, forcing the patient to sit. The cough may be short and dry, worse from change from warm to cold air or from lying on the left side or back. The expectoration is mostly in the morning, and is white and tough, and, perhaps, blood-streaked. Cavities form rapidly, there is constantly increasing hectic fever and flushing of the face towards evening, and another useful symptom is a burning between the shoulder blades. Calcarea carbonica: It suits pale, sallow, nonresistant patients of a leucophlegmatic temprament, and those whose constitution has been broken down by frequent and profuse menstruation, or by frequent miscarriages. Patient takes cold easily, and it corresponds especially to the third stage of the disease, when large cavities are forming. Its special seat of action is middle third of right lung; loud rales

are heard all over the chest, more over the middle of the right lung. The cough is loose and rattling, or short and dry in the evening; there is much soreness of the chest and great fatigue and shortness of the breath on going upstairs or on making any ascent whatever. The expectoration is of purulent yellowishgreen and bloody matter. There is great emaciation, sweat, suppression of the menses in females, and these symptoms would indicate the remedy in incipient phthisis in young girls of an anemic type. Calcarea phosphorica : It is indicated when the emaciation is more rapid, and more marked, where there is greenish purulent expectoration, headache and languor; in short, some meningeal complications. Calcarea iodata: This is preferable, when glandular complications are present, in young subjects who grow rapidly with tickling, teasing cough, rapid pulse, high fever, and rapid hepatization; it corresponds more exactly to military form of tuberculosis. Tuberculinum Bacillinum : Adapted to person of light complexion, tall, slim, flat, narrow chest; active and precocious mentally, weak physically. Takes cold easily without knowing how or where. Emaciation rapid and pronounced. There is acute cerebral or basilar meningitis, with threatened effusion. Tubercular deposits begin in apex of lungs, usually the left lung. Nitric acid : It is a powerful anti-tubercular remedy before cavities are formed. It is most useful in phthisis. It has sudden rush of blood to the chest, soreness of chest, frequent haemorrhages, profuse

and of bright red blood, dyspnoea, sharp stitching through the right chest to the scapula. the sweat is worse at night and towards morning.there is a tickling cough which annoys the patient all the night. Silicea: In the suppurative stage of tuberculosis, it is very much useful. It is usually indicated by a low grade of vitality where the patient finds it difficult to keep himself warm. It is an excellent constitutional remedy and corresponds well to slow phthisis mucosa of old people. The cough at first is dry, racking, but afterwards loosens, there is rattling in chest and expectoration of offensive muco-pus. There are large cavities in the lungs, profuse night sweats and hectic and suppurative fever. Stannum metallicum : It corresponds to especially to the catarrhal cases which are engrafted upon a scrofulous habit. There is marked hectic fever, chills at 10 A.M., flushed and hot in the evening, aggravation on every exertion and profuse night sweats, worse about 4 or 5 in the morning. Weakness is a grand characteristic, and must be present, the patient is so weak that he cannot talk more than two or three minutes at a time. The cough is paroxysmal, and seems to be most frequently caused by mucus in the chest. An abundant secretion of mucus and an empty feeling in the chest are keynotes for stannum. A blood-streaked expectoration is a contra-indication. Yerba santa: This has been successfully used in bronchial phthisis with night sweats, emaciation, intolerance of food, and it will often cause a free

expectoration of the mucus, and thus will cause a relief. Sulphur: It is the best-adapted medicine in the early stages of phthisis when there is an increase of blood to the chest, beginning dullness over the apices of the lungs on percussion and diminished chest movement. The guiding symptoms are hot feeling of the body, desire for air, flushes of heat and pain from the left nipple through to the back. The cough is mostly dry, worse in the evening, exited by talking, with occasional profuse discharge of mucus; there are profuse night sweats and the perspiration is offensive; there is burning of soles and palms. Arsenicum : It must be used cautiously in tuberculosis. The symptoms calling for its use are: utter prostration, emaciation, thirst, oppressed breathing, sharp pains that are aggravated by motion. The cough is worse at night, on lying, and in morning on waking. The paroxysms of cough are long lasting accompanied with dyspnoea and expectoration is profuse, greenish and salty. There is throughout much anxiety. Arsenicum iodide : It is very closely related to tubercular manifestations and the profound prostration, rapid, irritable pulse, recurring fevers and sweats, emaciation and tendency to diarrhea indicate it. Patient is cachectic; hacking cough; cavities; hectic fever, night sweats; great debility. Kali carbonicum : Hahnemann says that patients suffering from ulceration of lungs can scarcely get well without the use of this antipsoric. It has stitching

pains in the chest, with dry cough and much difficulty in raising the mucus; it seems to come up part way and slip back, or flies in lumps from the mouth while coughing. The expectoration is profuse, purulent and bloody. The cough is worse from 3 to 5 A.M. and the patient is apt to be chilly, there is much whistling respiration which prevents sleep, and a marked symp. is weakness in chest. It is also a valuable remedy in the later stages.

MANAGEMENT AND TREATMENT

Management of tuberculosis through dietary modification From ancient time it has been realized that diet plays a crucial role in the management of diseases. Diseases bring about changes in the bodys need for nutrients. The reason is usually a change in metabolic or physiologic processes as well accompanying changes in the structure or/and function of specific

organs and tissues. Sometimes it becomes difficult to convince people that a simple dietary change can help to cure or control a disease. It is expected that only pills, tablets, capsules, injections can do wonders. A simple modification in diet, addition of certain nutrients or deletion of certain food articles can do wonders in the overall management of the disease and this management of the disease with diet is known as dietary management. It must be emphasized that Tb patients have special nutritional needs. In Tb there is low grade fever. Fever pushes up the metabolic rate. If the metabolic rate increases energy will also be required more, which implies that diet of a Tb patient should be rich in carbohydrates. The patient is also losing weight so the diet should also contain large amount of proteins. During sweating there is loss of fluids and electrolytes, so the patient should be encouraged to increase the fluid and electrolyte intake. Calcium is needed to promote healing of tuberculous lesions, that is why milk intake is important. In addition, in Tb carotene is poorly converted to vit A and hence diet should provide adequate amount of vit A(retinol). Drug therapy in Tb also creates problems. Isoniazid- an anti-tubercular drug is an antagonist of vit B6. it kills the intestinal bacteria which normally synthesize the vit B6. Patients on ATT should be given vit B6 supplement. Management through hygienic measures Tb occurs more frequently in populations living in substandard houses which are ill ventilated and have inadequate floor spaces. Miners and textile workers are more prone to disease. Overcrowding as

in slums helps in rapid spread of disease. Social customs as purdah, smoking of hukka, spitting openly in public places, also help in spread of disease.Therefore condition which increase risk of becoming infected with Tb, such as overcrowding should be removed. Houses with proper ventilation(allowing proper sunlight and air) should be provided particularly to poorer communities. The community should be educated about the mode of spread of disease, to avoid indiscriminate spitting in public places and motivated to seek medical help early in case of prolonged fever, cough, loss of appetite, etc. Early detection of Tb also helps in the prevention and control of Tb. For early detection, the people must know the common signs and symptoms of disease. For this, community education is a must. INCEDENCE AND MORTALITY IN RELATION WITH SEX
2 1.5 1 0.5 0

male

female

Incidence Of Tuberculosis

2 1.5 1 0.5 0

male

female

Mortality in Tuberculous Patients

Percent people affected in different age group

Age group(years) 0-4 5-9 10-14 15-24 25-34 35-44 45-54 55+ Total

Infected(%) 1.0 6.4 15.4 31.9 47.3 54.8 60.7 62.1 30.4

70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 0-4 yrs 5-9 yrs 10-14 15-24 25- 35-44 45-54 55 + yrs yrs 34yrs yrs yrs

SYNOPSIS OF THE CASES

Case 1 Mr. Kamal Narayan, 36y/m/h, complaining of dry cough & low grade fever since 4 months. The patient also complained of pain in chest.

On the basis of local symptoms Kali carb 30/tds was prescribed. Case 2 Mr.Ratan Singh, 67y/m/h, retired professor, complaining of low grade fever with profuse expectoration of offensive mucoid sputum since 2 months. The pt. is susceptible to colds , is thin with profuse ,offensive perspiration.On the basis of mental generals & physical generals, Silicea 1m/3 doses was prescribed. Case 3 Mrs. Savitri Sharma 46y/f/h, house wife complaining of pain in chest with bloody expectoration, cough aggravated at night,sweat aggravated at night .Chilly patient, desire company ,fatty & salty food. A constitutional remedy, Nitric Acid 200/3 doses, one hourly were prescribed. Case 4 Mrs. Shanti devi, 49y/f/h, housewife complaining of cough that agg. at night, bloody expectoration, very social, fearful, desire salty food& cold water; Chilly pt., constitutional remedy, Phosphorus-1m/3 doses were prescribed. Case 5 Mrs. Shahnaaz Bano 55y/f/m, housewife complaining of cough, with bloody expectoration, evening rise of temp. with profuse night sweat. Chilly patient, desires meat, ice cream , very restless, fear of animals, a constitutional remedy, Tuberculinum 1m/3 doses were prescribed. Case 6 Mr. Ram Singh 75y/m/h, farmer complaining of recurrent fever and sweat, profound prostration, emaciation and recurrent diarrhea. The

patient also complained of coryza that was fluent along with lachrymation. On the basis of local complaints Arsenicum iodide 30/tds was prescribed. Case 7 Mr. Kishan kumar 52y/m/h, shopkeeper complaining of cough with expectoration (bloody), fever recurrent, night sweats, chest pain, the patient was very restless, desires traveling, desires meat and ice cream. The patient seems to come under tubercular miasm. On the basis of local as well as general symptoms a constitutional medicine, Tuberculinum 1m/3doses were prescribed. Case 8 Mrs. Raj Khosla 49y/f/h Teacher complaining of dry cough which is teasing in nature, agg. at night; the expectoration has little blood in it. On the basis of local symptoms, Laurocerasus 30/ tds was prescribed . Case 9 Mr. Raggan 58y/m/m, sweeper complaining of cough with bloody sputum, low grade fever since one year, profuse perspiration esp. on head, salivation sleep during, thirst extreme, desires bread and butter, sensitive to both hot and cold weather. The patient lies under the syphilitic miasm. Merc sol 1m/3doses were prescribed on the basis of local and general symptoms. Case 10 Mr. Chotelal 63y/m/h watchman, complaining of cough that agg. at night, bloody expectoration, very social, fearful, desire salty food& cold water; Chilly pt. The patient seems to be covering

tubercular miasm. Constitutional remedy, Phosphorus-1m/3 doses were prescribed. Case 11 Mr Rahul,15y/m/h, complaining of dry cough & low grade fever since 2 weeks. The patient also complained of pain in chest. On the basis of local symptoms Bryonia 200/bd was prescribed. Case 12 Mr.Ramesh Kumar, 35y/m/h, retired professor, complaining of low grade fever with profuse expectoration of offensive mucoid sputum since 2 days. The pt. is susceptible to colds, is thin with profuse, offensive perspiration. On the basis of mental generals & physical generals, Rhus tox/30 tds was prescribed. Case 13 Mrs. Sarita,28y/f/h, house wife complaining of pain in chest with Fever at night, sweat aggravated at night .Chilly patient, desire company ,fatty & salty food. According to symptoms the remedy, Eupatorium perfriatum 30 /tds were prescribed. Case 14 Mrs. Sadhana devi 26y/f/h, housewife complaining of cough that agg. At night, bloody expectoration, very social, fearful, desire salty food& cold water; Chilly pt., constitutional remedy, Hepar sulph/ 30 tds were prescribed. Case 15 Mrs. Kanti 55y/f/h, housewife complaining of cough, with bloody expectoration, evening rise of temp. with profuse

night sweat. Chilly patient, desires meat, ice cream , very restless, fear of animals, a constitutional remedy, Tuberculinum 1m/3 doses were prescribed. Case 16 Mr. Anup kumar 39y/m/h, farmer complaining of recurrent fever and sweat, profound prostration, emaciation and recurrent diarrhea. The patient also complained of coryza that was fluent along with lachrymation. On the basis of local complaints Arsenicum iodide 30/tds was prescribed. Case 17 Mr. Kiran kumar 32y/m/h, shopkeeper complaining of cough with expectoration (bloody), fever recurrent, night sweats, chest pain, the patient was very restless, desires traveling, desires meat and ice cream. The patient seems to come under tubercular miasm. On the basis of local as well as general symptoms a constitutional medicine, Tuberculinum 1m/3doses were prescribed. Case 18 Md.Kadir 40y/m/m complaining of dry cough which Fever, agg. at night; the expectoration has little blood in it. On the basis of local symptoms, Pulsatilla 30/ tds was prescribed . Case 19 Mr. Ramu 39y/m/h, sweeper complaining of cough with bloody sputum, low grade fever since one year, profuse perspiration

esp. on head, salivation sleep during, thirst extreme, desires bread and butter, sensitive to both hot and cold weather. The patient lies under the syphilitic miasm. Merc sol 30/tds were prescribed on the basis of local and general symptoms. Case 20 Mr. Ramrsh, 27/m/h watchman, complaining of cough that agg. at night, bloody expectoration, very social, fearful, desire salty food& cold water; Chilly pt. The patient seems to be covering tubercular miasm. Constitutional remedy, Phosphorus 200/3 doses were prescribed.

BIBLIOGRAPHY

Snells clinical anatomy Tortora GrabowskiPrincipals of Anatomy & Physiology Harrisons Practice of Internal medicine Kents Repertory of the homoeopathic materia medica William boerickes Materia Medica

J.Compton BurnettThe New Cure for Consumption W.A Dewey Practical Homoeopathic Therapeutics Dr.H.L. ChitkaraBest of Burnett

INTRODUCTION

REVIEW OF GENERAL MEDICAL LITERATURE

Structure and function of lungs. Physiology of respiration. Pulmonary air volume and capacities. External pulmonary respiration. Internal pulmonary respiration. Tuberculosis.
Definition Aetiology Pathogenesis Transmission

 Progression Clinical History Physical Examination Diagnosis

REVIEW OF HOMOEOPATHIC LITERATURE

Tubercular Miasm Miasmatic background. Indication of miasm

MATERIAL AND METHODS

MANAGEMENT AND TREATMENT

Management of tuberculosis through dietary modification. Management through hygienic measures. Prevention. Treatment.

ANNEXURE

Case Proforma Graphs Synopsis Of Cases