Deceived by his family: a case of Arsenicum album

We were asked to make a home visit to a patient who was suffering from dry gangrene of both feet; he had been advised that amputation was the only solution to keep his legs. Doppler studies showed that the arterial blood flow to both his lower limbs were almost negligible, though, so surgery was impossible. Given the condition, it was decided that two of our senior resident doctors would visit the patient the next day. The patient was bed ridden, and his wife let us in. At first, the doctors noticed that his left second and third toe had already undergone the process of self amputation. His right big toe was in bad condition and was on the verge of self-amputation as well. There was blackish discoloration on both the feet along with fungal growth on the gangrenous portion. The wound was extremely offensive. On examining the feet, it was cold to touch and no pulsations were felt.

On further enquiry, it was revealed that the patient had been diagnosed diabetes mellitus ten years previously, and had diabetic peripheral neuropathy since seven years.  The patient also had hypertension since seven years, and residual hemiparesis since four years, with two cardio-vascular accidents. He manifested symptoms of early Parkinson, as well as corneal opacity with vitreous hemorrhage and glaucoma. He was under extreme stress and insomnia. He had pain in his toes since January 2012, diagnosed as a fungal infection of the left big toe. As a part of treatment protocol, he was given medication and advised hygiene maintenance but due to his own negligence, it got worse. His wound became aggravated and he changed the dressings every alternate day. The fasting blood sugar increased to 240mg/dl; at that time, he was on oral insulin, later injections three times per day, as well as medication for his blood pressure and Ayurvedic medicines.

Later on, he started to have severe pain, which made him anxious and demanding: “Give me something to relieve the pain.”

History given by his wife

Eight years ago, the family has exploited and looted my husband.  He was in a partnership with his father and uncle. He spent all the money on his three sisters and his family. When his mother passed away, in January 1995, his uncle threw him out of the business. He did not retaliate then but came home and cried. That was a huge shock for him. He was 53 years old at the time; he had nervous breakdown. His behavior changed, he would just stare, gazing at one place. He developed thick pustules with scabs all over, filled with pus. He was admitted to hospital seven times for the same situation. During that time level of lead in the blood was more than 100. His mother’s death did not have a big impact on him, but when he was thrown out of the business he asked himself “did I make some mistake?   What have I done that could have brought on such a bad thing?” At 54, he developed hypertension and diabetes mellitus. He was blindly devoted to his mother and sisters; he never questioned them at all. It took him six months to recover from the lead poisoning; after six months his lead levels decreased. He was in a financial crisis and was very depressed.

In December 2006, he received a court notice from our daughter-in-law claiming him for dowry harassment, which was all fake and created by our daughter-in-law to get more money from us; that case is still going on. A warrant without possibility of bail was issued against us. Our daughter helped us and we were in exile for three months. Until then, he only had DM and hypertension but his blood sugar increased to 350. From 2006 December, he would continuously cry and remain alone. When he was asked what happened, he would not answer. For the last month, he hallucinates, saying: “People have ruined us. I never had a family life. I have been deceived. They will go to hell.” He was sitting on the divan and said, “I am on a railway platform and I won’t leave advocate, DAUGHTER IN LAW and her father.  They have been given jail for five years, see, they are imprisoned.” Guilt had set in. He started blaming himself.

Patient’s words

“I don’t react at all. My mother made me like this. I used to pray a lot. My nature was such that I would smile and not react. Mother was good with me.

“I started working at sixteen, after my father died. I am mild, I don’t get angry. I have never fought with anyone. If someone comes to fight, I keep quiet, I don’t react. When people ask ‘how are you?’ I say I am fine. My childhood was good. I am the eldest of five children. I studied law but didn’t practice it, since my mother asked me to work in our hotel.  I was cheated by my own relatives, since I do not have the nature to fight anyone. I was not mischievous. No one was strict and I made my sister study and got her married. I was obedient, I never took money for myself, and I told my uncle to give money to my mother (cries). I never asked my mother to give me money.”

Patient as described by his wife

“He never bothered about his family. He is very suspicious. When I pray, he tells me ‘dhongi’ (= fake prayer – what you are praying is fake.) He demands that things are done on the spot, otherwise he becomes aggressive and demanding, shouting at me and our son. “Bloody…  I want to pass urine, come here.” “What is this - give me cold water. Can’t you keep water in the fridge?” He is very accusing. Social prestige is important to him. He is worried about it. He wants to prove his wealth and greatness in front of people, but he has had to sacrifice his house. He is very timid. For instance, if his mother said ‘sit down”, he would do it. He worked like a servant. When he is lonely, he becomes worried and aggressive. At present, he is aloof, not reacting to problems and saying that there is no problem.

Physicals

• Pain in right big toe
• Feet are cold since one year. He has to wear thick leggings since 6 months.
• Screams and shouts with severe cold and cannot bear the fan.
• He wants 2-3 blankets. Shouts “close the door and windows”, even in summer.
• Glaucoma in March 2012, both eyes:  he can see little from right eye.

Generals

• Appetite-good
• Likes paneer (cottage cheese)
• Observation: constantly wiping mouth (excessive salivation?)
• Thermals: chilly. Sensitive to drafts of cold air: screams
• Thirst- earlier – more. Now –less since 1-2 years
• Urine – normal
• Stool- loose motion
• Sleep, when taking sedatives, heavy sleep, otherwise insomnia++, waking every half an hour, asking the time
• Wants everything on time about medicines and demands delicious food. If it is not given, he says: “What you will do with this money? “
• Fear of dark, wants all the lights in the house on at all times                           
• Since two months, lost concept of direction: walks into the wall and starts shouting when he gets hurt

Present mental state
The deception made a big impact on him. He did not care for others and he feels that whatever has happened is wrong. He says it was his mistake:  “My mother kept me under the impression that I would get the money but she gave all the money to her daughters.” He keeps recalling his youth and how he was exploited. He likes to please and impress people, especially his family, wanting to make everyone happy and become saint in their eyes. He now feels sorry as he has lost everything; he obeyed his mother and  realizes that he was fooled by her.

Summary of the case 
A major obstacle in this case was that the history was mainly given by the wife rather than the patient himself, which meant that her own anger was included. The main factor seemed to be that the patient felt that he has been deceived by his mother, uncle and relatives; because of that he has become suspicious and he has started abusing his son and wife, on whom he is dependent. He blames his wife, saying that her praying to God is nothing more than a false show. An important aspect in this case is the history of lead poisoning, which had suddenly manifested, from which he suffered from skin eruptions. He also entered into a state of depression and memory weakness, in which he used to keep staring.

Lead poisoning generally affects the central nervous system, with signs of short term memory weakness, loss of coordination, slow motor nerve conduction, low appetite, tremors and irritability. Lead poisoning can be responsible for hallucinations and delusions; in this case the patient became delirious, abusing and cursing his family, as well as the people who had cheated him. If anyone asked him how about his health, he used to say he was fine. He was so oversensitive to drafts that he wanted the doors and windows closed, the fan to be switched off, and needed thick woolen socks and two woolen blankets covering, even in summer.

Rubrics taken in this case

• Abuse of, poisoning with lead
• Industrious, mania for work
• Abusive, insulting
• Sudden manifestations
• Covering ameliorates and desire for

Other rubrics considered for the case

• Ailments from disappointment, deception
• Business, incapacity for
• Well says he is, when very sick
• Delusions, well, he is
• Delusion well, declares she is
• Delirium raging, raving
• Suspicious
• Company aversion to, solitude fond of
• Fear of dark
• Veneration
• Abusive, insulting  husband insults wife in front of children or vice versa

Prescription:  Arsenicum Album 200C

Follow-ups 

28/1/13: pain is reduced. Wound seems a little better than before. Random Blood Sugar: 156mg/dl. B.P.: 150/100 mm of Hg. Sleeplessness –Status quo (SQ). Sensitivity to draft of cold air has decreased. Mental State: his anger has reduced, as well as the episodes of hallucination.
Treatment: Sac Lac given for a month

16/2/13: pain has reduced by up to 50 %. Wound status is better. Random Blood Sugar: 146 mg/dl. Sleeplessness: same as before. Anger has reduced, had one episode of hallucination. Treatment: Sac Lac

22/3/14: pain reduction by 75%. Wound of the gangrene healing much faster. Random Blood Sugar: 152 mg/dl. B.P. : 140/90 mm of Hg. Anger is less. Sleeplessness better. Treatment: Sac Lac

23/4/14: pain of the toe much better. Wound of left foot is healing well. Right toe has fallen off but the wound healing on the entire right leg has been very clean. Sleeplessness improved.
Treatment: Sac Lac

The patient came walking to our clinic and until today enjoys good health.
Present condition: The patient’s random blood sugar levels stay at 140 mg/ dl with the same doses of insulin. Also the blood pressure has reduced to 110/70 mm of Hg. We have advised the patient to consult his physician and diabetologist in order to review his antihypertensive and insulin dosages.