Disease Management

A Homeopathic Approach to Acute Pharyngitis

Timothy Fior, MD, DHt
Abstract: This article presents an approach to treating acute pharyngitis in homeopathic practice which relies less on laboratory testing. Also, two cases of group A beta-hemolytic streptococcal pharyngitis are presented which responded to a lesser known remedy, Phytolacca decandra. Some selected materia medica of this remedy is then presented. Keywords: group A -hemolytic streptococcal pharyngitis, homeopathic treatment of; acute pharyngitis, Phytolacca decandra

It is much more important to know what sort of patient has a disease than what sort of disease a patient has.
Sir William Osler

recent article in this Journal described a homeopathic approach for treating Streptococcal pharyngitis.(1) The discussion in this article about the diagnosis and epidemiologic factors in Streptococcal pharyngitis was excellent. However, the approach taken homeopathically was a routine one, a fact which the editors made note of and the author himself admitted was potentially inferior to an individualized homeopathic approach.(2) One of the reasons cited for such an approach was the inconsistency of results when solely using well-indicated acute remedies prescribed on physical, mental and emotional symptoms.(1) Inconsistent results in homeopathic practice can be due to the case being defective (3) or due to the homeopath being defective in his knowledge of the materia medica. This article will attempt to remedy this latter defect by presenting a perhaps lesser-known remedy which, in the authors experience, often must be considered in the remedy differential for acute pharyngitis. Finally, an approach to acute pharyngitis cases in general will be presented which does not rely so heavily on microbiologic testing.

Allopathic Considerations

Testing for group A -hemolytic streptococcal (GABHS) pharyngitis was stressed in the aforementioned article.(1) However, laboratory testing is
Volume 100 Number 3

much less common in homeopathic practice than in conventional medical practice.(4) This may be especially true for physicians who specialize in homeopathy, as these physicians are typically paid out of pocket by patients. Thus, patients wish to avoid any unnecessary costs. Furthermore, laboratory testing for GABHS can be problematic due to the possibility of a carrier state.(5) Carriers are classically defined as asymptomatic individuals who have a positive GABHS culture. However, even this definition has been questioned.(6) These carriers are generally not thought to be at risk for streptococcal complications and are not a significant source for the spread of GABHS.(7) A positive GABHS test can occur in such a chronic carrier when they have an intercurrent viral phayrngitis.(5) Thus, in such a patient the GABHS is not the cause of the patients acute symptoms. Attempts have been made to distinguish such a state by looking at acute and convalescent anti-streptococcal antibody titers (e.g. ASO titers). Lack of change in the titers indicates GABHS carriage with intercurrent viral pharyngitis.(5) However, getting these titers is generally only done in research settings and is not common practice. Given the varying sensitivity and specificity values for various quick GABHS tests and throat culture, a seemingly simple diagnosis quickly becomes much more complex. For this reason, we have found it safe to
AJHM Autumn 2007 179

Tim Fior, MD, DHt

reserve tesing for GABHS to those patients who are not responding to homeopathic treatment of their acute pharyngitis. Studies have shown that antibiotics can be delayed up to 10 days without increasing the risk of acute rheumatic fever.(1) Furthermore, due to the cost of having acute GABHS tests on hand which, if not used, must be thrown away after an expiration date, our office has used outside laboratory culture as the preferred method of GABHS testing. Usually by waiting a few days to culture, if treated with well-indicated remedies, the symptoms will resolve and the need to culture disappears. This also prevents the troublesome occurrence of a positive culture on day 2 or 3 when the patient is already mostly or completely asymptomatic and one is left considering possible antibiotic treatment of an asymptomnatic or minimally symptomatic patient. Of course, if there is a personal or family history of acute rheumatic fever, immunocompromise, or chronic heart or lung disease, then antibiotic treatment and early culture can be discussed with the family.(8) By adopting this treat-and-then-test strategy in our office for most patients we have obviated the need for extensive streptococcal testing and thereby helped to demedicalize this condition(8) and have not unduely traumatized patients with positive GABHS results. Interestingly, the CDC along with other organizations published a guideline for treating acute pharyngitis in adults which offered one (out of three) possible treatment strategy involving no diagnostic testing at all.(8) They then suggest limiting treatment (i.e., antibiotics) to patients with 3 or 4 Centor criteria (history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy). This strategy is in fact the guideline-recommended approach to acute pharyngitis in the Netherlands. It is felt to be an approach which focuses more on the clinical picture of the host rather than on the presence of the microbe.(10) Well, alas, we as homeopaths are all too familiar with the pitfalls of focusing on the disease rather than the patient. It is heartening to see that our allopathic brethren are coming to see the importance of focusing on the patient rather than the disease. Perhaps they are hearing the echoes of Sir William Oslers aforementioned quote. in these cases. Both of these cases had a positive GABHS test at one time.

A Case of Acute Streptococcal Sore Throat during Pregnancy

ME is a 26 year old Gravida 1/Para 0 white female working as a fitness trainer. Her first visit was on 10/15/02 at 27 weeks pregnant to establish herself with a homeopathic practitioner. At that visit her complaints included 1-2 loose stools, worse first thing in the morning and worse after beef. Also, she had hemorrhoids, heartburn with the pregnancy, and mild sciatica. She also had a heavy yellowwhite leucorrhea, bad breath, and became warmer as she slept since the pregnancy. Her energy was worse at 10-11 am (1). She had clammy perspiration on the abdomen and behind the knees every night. She craved sweets (2) and apples (3) for the first time in her life. She was happy and a little weepy; shed been shy when younger. At that time she was very even-tempered and had a slight fear of labor (1) and of high places (1). She had been put on 15mg of Armour thyroid daily two months before by her obstetrician despite normal TSH and free T4 lab tests. At this first visit she received Sulphur 200C, 2 pellets once by mouth. She was also told to wean off the Armour thyroid (with her obstetricians permission) due to palpitations she was having just since starting the thyroid medicine. Over the next month she took the Sulphur three to four times total by mouth without noticing much change, except that the stools were more formed; the following acute appeared within the first month of treatment. She called on 11/7/02 with an acute sore throat at thirty weeks into an otherwise uneventful pregnancy. It began on waking and was worse on the left side, was worse lying on the left side, and the left neck glands were swollen. It hurt to swallow saliva (2), and was worse swallowing water or cold drinks. She had stringy phlegm from drinking milk. The throat pain radiated into the ear. There was no fever, and her energy level was normal. This bout was like a Strep throat she had had in 1999. The throat felt constricted. Assessment: Acute pharyngitis in a pregnant woman (rule out Streptococcal pharyngitis. The MacRepertory graph for this visit is seen in figure one. Looking back, the one thing that made me uneasy about prescribing Lachesis was the fact that the sore throat was worse with cold drinks. Lachesis is a remedy for left-sided sore throats which are better with cold drinks. In any case, the fit seemed close enough for Lachesis. Prescription: Lachesis 30C, 2 pellets by mouth every 1/2 hour until a change and then as needed.
Volume 100 Number 3

Homeopathic Approach

So our approach is to essentially treat the patients acute sore throat first and then only test if the patient is not responding to treatment, which, with experience, becomes less and less frequent. To illustrate and assist in this approach two cases follow which utilize a lesser-known remedy (at least lesser known to this author) which must often be considered
180 AJHM Autumn 2007

Acute Pharyngitis

Figure 1

11/8/02 Friday She was slightly better than the day before with taking the remedy every 1/2 hour, but the throat was still sore and was worse swallowing. The saliva was very stringy. Her obstetrician did a Strep test, but the results wouldnt be available until Monday 11/11/02. The sore throat was worse at night, and the pain extended to her left ear with swallowing. She grimaced with swallowing. She was having a hard time sleeping. She had heartburn which was worse from hot drinks. Assessment: The graph (see figure 2) now lists two additional symptoms at the bottom. Because the patient had only improved a little, it

strep culture was + for Group A strep and her obstetrician recommended antibiotics. She refused to take the antibiotics because she was doing better and didnt want her unborn child exposed to antibiotics. Within one day the sore throat was totally gone. 1/13/03 She was induced and delivered an 8 pound 12 ounce girl. The mom and baby were both doing well. 8/29/03 She has had no more sore throats. Shes been healthy and her daughter has been perfectly healthy

Figure 2

was felt that it was time to change the remedy. From looking at the graph and correlating this with the fact that the sore throat was worse at night, the saliva was stringy, and she was worse from hot drinks, Phy tolacca was chosen. Prescription: Phytolacca 200C, 2 pellets by mouth every hour until change and then as needed. She was also told to get Lachesis 200C as a back up remedy. 11/25/02 She was much better with the remedy. Within 4-5 hours the sore throat was 50% better. The
Volume 100 Number 3

too. She takes an occasional remedy for first aid,and thats all that she has needed to do. 1/06 I spoke with a relative of ME who I saw as a new patient. She reported that ME and her baby are doing fine, and that ME has had no further problems with sore throats.

The Authors Case

As a senior in high school I got a very severe sore

AJHM Autumn 2007 181

Tim Fior, MD, DHt

throat which tested positive for Strep and was treated with antibiotics. This acute resolved, but over the years and since that event, whenever I got a cold it would commence with a severe sore throat. These sore throats got worse and worse over time and would often last for days to a week and turn into a severe cough and bronchitis and coryza. As these illnesses always began with a sore throat, I tried many remedies for the sore throat but never found any remedy that would help it. Early on I tried Sulphur, which only aggravated the sore throat without any improvement. There would often be a stitching pain with the sore throat, which would radiate to the ears on swallowing. The throat appeared more of a dark red. When I finally discovered Phytolacca, I studied it for this sore throat and took it in the 30C potency at the beginning of an illness. I took a dose every hour or so, and found to my amazement that even after 2-3 doses the sore throat was improving. I continued the Phytolacca and the sore throat resolved. This was the first time a remedy had ever stopped the progression of the sore throat! Since then I am much less susceptible to colds and if I do get a sore throat it is much milder and very short-lived. Finding this remedy really helped turn this condition around for me. Breast: shows an early tendency to cake; is full, stony, hard and painful, especially when suppuration is inevitable; when child nurses pain goes from nipple all over body (goes to back, Crott.; to uterus, Puls., Sil.). Nipples, sensitive, sore, fissured (Graph.); agg. intensely by nursing, pain radiates over whole body. Hastens suppuration (Hep., Lach., Mer., Sil.). Aggravation. When it rains; exposure to damp, cold weather. Compare: Kali its analogue. From Boericke: Teething children with irresistible desire to BITE THE TEETH TOGETHER. Teeth clenched; low lip drawn down; lips everted; jaws firmly set; chin drawn down on sternum. Tongue RED TIP feels rough and scald, ed; bleeding from mouth; blisters on side. Mapped, indented, fissured, with yellow patch down center. Much stringy saliva. (Recall that ME had this stringy saliva.) Throat: DARK RED OR BLUISH RED. Much pain at root of tongue; soft palate and tonsils swollen. Sensation of a lump in throat. (BELL.; LACH.) THROAT FEELS ROUGH, NARROW, HOT. TONSILS SWOLLEN, especially right; dark-red appearance. SHOOTING PAIN INTO EARS ON SWALLOWING. Pseudo-membranous exudation, grayish-white; thick, tenacious yellowish mucus, difficult to dislodge. CANNOT SWALLOW ANYTHING HOT. (LACH.) Tension and pressure in parotid gland. Ulcerated sore throat and diphtheria; THROAT FEELS VERY HOT; PAIN AT ROOT OF TONGUE EXTENDING TO EAR. Uvula large, dropsical. QUINSY; TONSILS AND FAUCES SWOLLEN, with burning pain; cannot swallow even water. MUMPS. FOLLICULAR PHARYNGITIS. BETTER, warmth, dry weather, rest. WORSE,sensitive to electric changes.Effects of a wetting, when it RAINS, exposure to DAMPcold weather, , night, exposure, motion, right side. From Lippe Keynotes: SCIATIC PAINS, RUN FROM THE HIP DOWNWARD AND MOSTLY ON THE OUTWARD SIDE OF THIGHS; WORSE AT NIGHT [N.] (This symptom of sciatic pain running on the outside of the thigh has been used to help several patients with this remedy with sciatica.) Entire indifference to life (Ars., Aur.) [A.] Is sure she will die (Ars.) [A.] Albuminous urine (Apis, Canth., Merc., Phos., Sep.) [Bt.] Dark-red urine, leaving a deep-red stain in the vessel (Berb., Colch., Lyc.) [Bt.] (This sounds like the urine of a patient with post-streptococcal glomeruloneVolume 100 Number 3

Materia Medica of Phytolacca decandra

Poke Root. Phytolaccaceae From Allen Keynotes: Irresistible desire to bite teeth or gums together (Pod.); during dentition. Sore throat; of a dark red color: uvula large, dropsical, almost translucent (Kali bi., Rhus). Note: A colleague, while working with the late John Bastyr in his clinic, related the story of how Dr. Bastyr showed him a patients dark red throat and then without any further history or exam asked the student for the remedy. Of course, the dark red throat alone suggested Phytolacca, which in fact is what was prescribed.) Diphtheria: pains shoot from throat into ears on swallowing; great pain at root of tongue when swallowing; burning as from a coal, of fire or red-hot iron; dryness; difficult to swallow with trembling of the hands; sensation of a lump in the throat with continuous desire to swallow; tonsils, uvula and back part of throat covered with ash-colored membrane; cannot drink hot fluids (Lach.). Mammae full of hard, painful nodosities.
182 AJHM Autumn 2007

Acute Pharyngitis
phritis, a condition this author has seen once in a child with Strep despite three courses of antibiotics for strep throat and otitis media. This child had the classic coke colored urine. Interestingly, there is no evidence that antibiotics decrease the incidence of this complication.(8)) AGGRAVATION: From exposure to damp, cold weather; from motion; at night; when swallowing; from hot drinks; from nursing the child; and when rising from bed. AMELIORATION: From cold drinks; from lying on the abdomen; from rest; from warmth; and in dry weather. RELATIONSHIP: Phyt. occupies a position between Bry. and Rhus t.; cures when these fail, though apparently well-indicated. COMPLEMENTARY: Sil. Herings Condensed Materia Medica: Ears: Shooting pains through both ears when swallowing; right side worse. Eustachian tubes feel obstructed. Throat: Sore, worse right side; fauces dark, bluish-red; worse swallowing saliva; feels as if a red-hot ball was lodged in fauces; cannot bear touch of clothing about neck. Uvula large, transparent. Tonsils large, bluish, ulcerated; throat feels as after choking; dry, rough, burning, smarting fauces. Like a plug in throat, worse left side. Dirty, wash-leather pseudo-membrane; mucus hawked with difficulty, from posterior nares; hangs down in strings; severe pains in head, neck and back; great prostration; faint on rising. Diphtheria. Cannot drink hot fluids; choking; ulcers on tonsils. Syphilis. Pharynx dry, rough, feels like a cavern. From the British Homeopathic Journal With Wyethia and Ignatia it is (the) answer to follicular pharyngitis in public speakers; Phytolacca when there is burning. In teething youngsters, the empty chewing or bruxism is a strange, rare, peculiar symptom, and, when discharges are tough, stringy, adherent and offensive, Phytolacca is the remedy of choice. Pains of Phytolacca come and go suddenly, radiate from a centre or move about and change place. Nash found that Phytolacca CM given during the wane of the moon is effective against breast tumours. Over sensitive to pain like Aconite, Chamomilla and Coffea; breast pain with menses like Calcarea carbonia and Conium; has same sensation in right arm that Aconite, Kalmia and Rhus toxicodendron have in left arm; is considered a right-sided remedy;
Volume 100 Number 3

aggravated by dampness like Rhus toxicodendron, Dulcamara and Natrum sulphuricum; desires cold water like Physostigma; desires hot drinks. The modalities are many and distinctive: worse at night, at menstrual period, the right side (except with heart involvement), lying on right side, standing, motion, raising arm, hot drinks, 3-4-5 AM and waking (Lachesis), damp weather, washing, swallowing. Better lying on left side or on abdomen. It hastens suppuration. From Nash Therapeutics Phytolacca decandra is one of our most valuable remedies for sore throat, and the indications are plain. The throat becomes generally inflamed; the tonsils swell and become very red at the first, and then white spots appear which (unless checked) soon spread and coalesce and form patches of a diphtheritic appearance. There are sharp pains often running up into one or both ears. These are the local throat symptoms, and constitutional symptoms are: Intense head and backache, and a sore, aching, bruised feeling all over the body, causing the patient to groan, and while, like Rhus toxicodendron, he feels as if he must move, the act of moving greatly aggravates all his pains and soreness. The patient is also greatly prostrated, and sitting upright makes him faint and dizzy like Bryonia. There is high fever, for the pulse is very quick; but the heat, like that of Ar nica, is mostly in the head and face while the body and limbs are cool. The choice often lies between this remedy and Bryonia, and they complement each other. Almost every case of swollen breasts with the milk fever, when the breasts fill for the first time after confinement, may be speedily relieved with one or the other of these two remedies. If the case should have gone on to suppuration, with large fistulous, gaping and angry ulcers discharging a watery or foetid pus, Phytolacca is still the remedy, and will often do more good than Hepar sulphur. and Silicea. Do not forget that the bruised, sore feeling of Phytolacca that we noticed at length when writing of Arnica is sometimes markedly present in sciatica, for which it is one of our successful remedies. The characteristic symptom for Phytolacca in this painful affection is that the pain runs down the outer side of the limb. As a final note Mssinger, in a randomized controlled trial involving 118 patients, showed Phytolac ca D2 to be significantly better than placebo at decreasing the duration of pharyngitis symptoms.(11, 12) In this journal, there is a published report of Phytolacca significantly reducing the size of breast
AJHM Autumn 2007 183

Tim Fior, MD, DHt

fibroadenomas in pre-menopausal women. (9) yngitis inAdults: Background. Ann Intern Med 2001;134(6):509-17. 9. Moiloa M, Brodie K, Roohani J. The Efficacy of Phytolacca decandra in the Treatment of Fibroadenoma of the Breast. American Journal of Homeopathic Medicine 2006;99(2):116-9. 10. Zwart S, Sachs A. Appropriate Antibiotic Use for Acute Pharyngitis. Ann Intern Med 2002;136(8):632-3. 11. Linde K, Clausius N, Ramirez G, et al.Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. Lancet 199; 350:834-43. 12. Mossinger PUntersuchung uber die Behandlung . der akuten Pharyngitis mit Phytolacca D2. Allgemeine Homoopathische Zeitung 1976;221(5):17783.
About the Author: Timothy Fior, MD, DHt is current vice president and former president of the Illinois Homeopathic Medical Association and a founding member of that associa tion. He has been practicing homeopathy for sixteen years, currently at the Center for Integral Health in Lombard, Il linois. He has lectured about homeopathy at several of the medical schools in the Chicago area. He is currently the co ordinator for the Primary Care Homeopathy course in Oak brook, Illinois.

References

1. Capobianco A. A Homeopathic Approach for the Treatment of Streptococcal Pharyngitis. American Journal of Homeopathic Medicine 2005;95(2):115-9. 2. Capobianco A.Streptococcal Pharyngitis Clarifications. American Journal of Homeopathic Medicine 2005;98(4):207. 3. Schmidt P Defective Illnesses. New Delhi, India: . Indian Books and Periodicals Syndicate. 4. Jacobs J, Chapman E, Carothers D. Patient Characteristics and Practice Patterns of Physicians Using Homeopathy. Archives of Family Medicine 1998;7:537-40. 5. Gerber M, Tanz R, Kabat W. Potential Mechanisms for Failure to Eradicate Group A Streptococci From the Pharynx. Pediatrics 1999;104:911-7. 6. Casey J, Pichichero M. Defining and dealing with carriers of group A streptococci. Contemporary Pediatrics 2003;1:46. 7. Hayes C, Williamson H. Management of Group A Beta-Hemolytic Streptococcal Pharyngitis. American Family Physician 2001;63(8):1557-64. 8. Cooper R, Hoffman J, Bartlett J, al. e. Principles of Appropriate Antibiotic Use for Acute Phar-

184 AJHM Autumn 2007

Volume 100 Number 3