Description.
Rheumatoid arthritis is commonly of greater incidence amongst the poor, hence we may not be wrong in deducing from this that poor nourishment, poor housing and clothing with exposure to weather inclemencies, overwork and emotional disturbances are all strong etiological factors.
The onset is usually acute, subacute, or slow and insidious and chronically progressive, often developing fully only over many years and usually during the third to fourth decades. In the acute variety, there is reasonably quick onset of periarticular swelling and pain in one or sometimes more joints.
This may run for days or weeks, slowly abating into apparent complete resolution, or may continue in a subacute state, with more acute exacerbations following, or other joints may be affected progressively in a migratory fashion. This form is most productive of inflammatory exudates which effuse into the bursae and joint spaces. Sweating and fever usually accompany this form. The acute disease often subsides for long periods, leaving the patient comparatively well during the interim.
The subacute variety may manifest in pain around the joints but usually there are no swelling, sweating or rise in temperature, or these are not so well marked.
Insidious onset is marked by vague pains in and around the joints often lasting for a long time and gradually spreading until a number of joints are affected. All of these forms usually end in marked deformity of the joints, ankylosis, with chronic impairment of junction, crippling and muscular wasting.
The joints characteristically affected are the proximal interphalangeal joints of the fingers and metacarpo-phalangeal joints with ulnar deviation of the fingers. Usually the distal interphalangeal joints are not affected. The wrists, elbows, shoulders, ankles, knees, hips are progressively affected, as well as the temporo-maxillary joint. Often there is contraction of muscles with increased tendon reflexes. Clammy palms and soles of the feet are not uncommon in this disease.
Other characteristics of this disease are the formation of subcutaneous nodules or in the bursae, especially in the olecranon bursae, and the organization of the exudates in the joints with hypertrophy and destruction of the joint surface and periarthritic fibrosis resulting in adhesions. There is an osteoporosis of the cancelous bones near the joints, shown by x- rays, leaving these affected areas with a “punched-out” appearance.
Quite commonly in the chronic form of this disease there is a freckled pigmentation of the skin about the face, neck and fore- head. These patients give the appearance of undernourishment; they usually eat but little and are sensitive to certain foods and to atmospheric changes. There may be slightly above normal temperature and pulse-rate for many years. Usually there is a secondary anaemia and the sedimentation rate of red blood cells is considerably increased.
Treatment.
From a general point of view it will be best to attend to the acute manifestations of the disease first of all if such should exist. Under proper physical, dietetic and homoeopathic treatment this is usually speedily accomplished. After this the patient must be prepared for a rather lengthy treatment of the chronic condition. Several so called “curative crises” may come along while this treatment goes on, but these should be rather looked upon as favorable reactions, and the patient should be warned about this possibility at the outset, lest they falsely believe this temporary aggravation to be a renewed attack of the disease.
It is also much wiser to follow a roughly preplanned course of treatment and inform the patient about this plan. The very best results in therapy are always obtainable with the patients voluntary and enthusiastic cooperation. A very thorough anamnesis of the case is essential and such dietetic, environmental and mental or emotional factors that may prove a hindrance to the progress of the treatment must be eliminated as soon as possible and as far as practicable. Only this way can the best results be expected.
Diet.
In all cases of rheumatoid arthritis where the patient is sufficiently strong, the treatment for the chronic condition could be most profitably preceded and supplemented with a therapeutic fast or a predominantly vegetarian and fruitarian diet for a week or two or even longer. Intake of fluids must be increased and may consist of pure cool water, preferably aerated, or fruit juices. Some rather unpleasant reactions may set in, especially from the third up to the seventh or tenth days with
diminishing severity after that and a gradual increased feeling of well-being. There should be, however, no relaxation in this apparently drastic regimen. During this period some very powerful autogenous reactions are initiated which have profound and far- reaching effects in restoring the patient to health. As a matter of fact, it may be even harmful to abort this process before the return of a sensation of well-being.
For the patients comfort wet compresses, either hot or cold as required, may be freely employed, as well as high colonic irrigations with pure warm water, even as often as twice per day. Very gentle whole body massage will also be in order during this stage. No other treatment should be given during this period. Nor is it necessary to give any medicines, although they may be symptomatologically indicated.
With the patients body thus purified and with a return to normal diet, still devoid of stimulants, we may now proceed with our physical and medicinal therapy.
Physiotherapy.
It is useful to employ the luminous heat lamp or infrared over the painful areas. The carbon arc lamp is also recommended for its combined source of ultra-violet and infrared radiation. A small luminous lamp of 150 to 500 watts may be left with the patient for self-application several times during the day or night as required.
Diathermy, especially short wave, is very excellent for its deep, penetrating heating with resultant increase in circulation and metabolism. The flexible coil may be employed, the cuff method, or the air-spaced disks. The coil is usually more suitable for the extremities, while the others may be used for the less accessible joints.
The Oudin current may be very beneficially employed, the operator drawing the current to the affected part by light stroking. As a matter of fact, this may be the ideal form of electrical treatment combined with short-wave diathermy and local packs.
Local paraffin baths to the joints or extremities may be very useful. So also wet sand or mud packs for several hours at a time. These are excellent for increasing local circulation and thus relieve congestion, swelling, pain and tenderness.
Exercising currents may be indicated where there is muscular wasting and also to take the place of natural exercise where such is impractical in the beginning. Later, when sufficient progress has been made, graduated physical exercise may be instituted, as well as walking followed by complete relaxation and rest. It is not necessary to fatigue the patient unduly. All forms of exercise should be substantiated by proper deep breathing. As a matter of fact, relaxation, proper living, diet and breathing should form the first of instructions to the patient. Prognosis can be much more favorable by seeing to this.
In this authors personal experience, it is useful, when the patient has made good progress, to give thorough manipulation to the affected joints. This will probably be followed by an inflammatory local reaction, because of the crushing of some of the concretions in the joints and bursae around the joints. Now it will be necessary to resort to packs, healing and local massage again. The best plan is to do only one or two joints at a time and wait until local reaction has completely subsided, before treating the next.
This way, many a useless joint may be restored to usefulness again. Most physicians neglect this most important treatment, because it requires great skill and dexterity combined with proper experience. Some practitioners prefer to do this under local anaesthesia, but with considerable experience, the author has found the use of anaesthesia unnecessary. It is useful, however, to give the parts to be manipulated, a deep heating first and to follow the manipulation with prolonged mechanical vibration as well as deep, soothing stroking massage.
The actual manipulation must always be very smartly executed and while the patient is properly relaxed. Never make an unsatisfactory movements and then follow it up with more half-hearted and clumsy efforts, because, obviously, the patient will contract the part, and actual grave injury may be inflicted. In greatly pathological joints manipulation is positively contra-indicated. It is always, therefore, necessary to have diagnostic radiograms made before manipulative therapy is attempted.
Homoeopathic Treatment.
Abrotanum: The affection is of marasmic nature with wasting most pronounced in lower extremities. There are pains in wrists, arms, shoulders and ankles with coldness in feet and fingers and a sensation of pricking. Soreness, stiffness and lameness, with painful contraction of limbs are at times present. Malnutrition and metastasis from suddenly checked diarrhoea, dysentery or other discharges are most likely causative factors.
