RHEUMATOID ARTHRITIS


RHEUMATOID ARTHRITIS.
JACOB GENIS, M.D.

 

Description.

Rheumatoid arthritis is commonly…


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.

Aconite: Suddenness of onset, great anxiety and fear with acute shooting pains, violent inflammation, numbness and tingling, red, shiny swelling and symptoms of acute febrile disturbance, often coming on at night, generally marks this patient. Exposure to dry, cold weather, draught of cold air or checked perspiration from such, form the most likely etiological consideration.

Actaea spicata: Small joints, fingers, wrists, ankles, and toes are swollen and red, worse from motion, touch and slight fatigue. Paralytic weakness and lameness of arms and hands with tearing, tingling pains and pulsations over the whole body. (Compare Caul. and Cimicifuga).

Antimonium crud: Twitching, jerking and pain in muscles. Brittleness of nails with a tendency to grow out of shape and an inclination to develop warts, corns and callosities on hands and soles, are conditions most often found with this patient. “Some of the worst cases of chronic rheumatism have been cured by this remedy, guided by the excessive tenderness of the soles of the feet.” (Nash).

Apis mel: Blanched puffiness with peculiar stinging pains, sensitiveness, soreness, bruised feeling and stiffness and awkwardness of the hands, dropping things, are very characteristic symptoms of this remedy.

Arnica: Soreness, lameness and bruised feeling as from injury, as if beaten, with fear of being touched, are characteristic symptoms. Whenever this remedy is required the cause of the disease is likely due to over-exertion or trauma, whether immediate, systematic or remote.

Belladonna: Joints swollen, shiny, uniformly red. Shifting pains, often coming suddenly and going as suddenly. The skin feels dry and there is pungent heat over the affected joints. These patients are worse from touch and the least jar of the part is almost unbearable. Acuteness and violence are predominant in this patients symptom picture and mentally he is perverse, ugly, abusive and often violent.

Berberis vulgaris: “It is especially to be thought of in arthritic and rheumatic affections, when these back symptoms, (i.e. persistent pains in back with turbid, flocculent, copious, mucous or reddish, mealy, or blood-red urinary sediment) connected with urinary alterations are present”. (Nash). The shoulders, arms, hands, fingers, legs, feet, and heels are affected, with swelling, stitching and pain in the balls of the feet when walking. Weariness and lameness of the legs with characteristic urinary symptoms.

Bryonia alba: Joints swollen, red and hot with stitching and tearing pains,worse on least movement and ameliorated by lying absolutely still. Exposure to cold after heat or to draughts, cold winds or suppressed discharges or the eruption of the acute exanthemata may be etiological.

Calc. carb.: Rheumatoid pains, arthritic nodosities, tearing pains, rawness and soreness of feet with coldness and sour sweat. Palms of hands sweaty. Sensation as if the patient had cold, damp stockings on, especially in fair, fat, flabby individuals, hypersensitive to cold. When Calcarea is indicated there is likely to be a history of working in cold water, wet clay, or standing a lot on damp, cold ground.

Calc. phos.: Pain and stiffness, coldness and numbness, as if asleep, characterize these rheumatoid symptoms, usually worse in fall and spring with the melting snow. It may have a definite retarding and reparative effect on cartilaginous degeneration and osteoporosis. (N.B.: Calc. fluor. is often useful as an intercurrent with this remedy).

Caulophyllum: Rheumatic affection of the smaller joints, fingers, toes, etc. (Actaea spic.). The pains are spasmodic, severe, erratic, with drawing, stiffness, and changing place every few minutes. (Puls.). These symptoms are most often found in women during gestation or women suffering with menstrual complaints.

Causticum: “Rheumatic and arthritic inflammations with contractions of the flexors and stiffness of the joints.” (Nash). Tearing pains in hands, arms, and dullness, weakness and numbness or burning in joints, or cracking and tension. Exposure to raw, cold air, cold draughts of air, or from getting wet with chilling, are most likely etiological factors. These symptoms are often relieved in damp, wet weather and warmth.

Chamomilla: “Violent rheumatic pains drive him out of bed at night; compelled to walk about.” (William Boericke). There is burning of the soles of the feet; he sticks them out of bed. (Puls., Med., Sulph.). Numbness with pain and paralytic loss of power in the legs. Dietetic abuses, especially stimulants, and emotional disturbance may be causative.

Cimicifuga: Rheumatic pains in muscles of neck and back; feeling lame, contracted; spine sensitive; rheumatism affecting the belly of muscles by preference. Stiffness in tendo achilles, restlessness, uneasiness and tensive aching and jerking of lower limbs. These symptoms are apt to be associated with menstrual difficulties and overstrain in nervous women. (Compare Caulophyllum).

Cinchona: Pains in joints, limbs and bones; drawing, tearing, as if strained, sore all over, obliging the patient to move, which gives relief (Rhus tox.). Weariness of joints, great debility, trembling, with numb sensations, worse from touch, draught of air, every other day, emotions and loss of vital fluids. These symptoms are often associated with those suffering from the malarial cachexia.

Colchicum: Arthritic pains in the joints, very sensitive to touch or movement. Limbs lame, weak and tingling pins-and-needles sensation in extremities. Oedematous swelling and coldness of legs and feet.” Affects markedly the muscular tissues, periosteum and synovial membranes of joints.” (W. Boericke). N.B.: A strong guiding symptom to the choice of this remedy is often an intense nausea from the smell of food. (Ars., Sepia).

Colchicine: The alkaloid from Colchicum is employed in 2x or 3x triturations by some practitioners for somewhat similar rheumatoid and gouty arthritis with intense pain and deformity of joints.

Dulcamara: “Stitching, tearing, rheumatic pains in limbs after exposure to cold, better by motion, worse at night, or in the evening, with some fever, sore, bruised feeling all over the body.” (Kent). Rheumatic symptoms apt to alternate with diarrhoea. A history of exposure to cold, wet weather, living in damp houses or working in cold, damp places or sudden changes of weather from warm and dry to cold and wet is strongly suggestive of this medicine.

Ferrum phos: The classical Biochemic remedy for the first stages of fever and inflammation. Joints painful and actively inflamed, from catching cold; palms hot and hands swollen and painful. The typical Ferrum phos. patient is an anaemic individual, but usually presents a false plethora and flushes easily. (Ferr. m.).

Formica rufa: Rheumatic pains; stiff and contracted joints; pains worse from motion and better from pressure. Weakness of lower extremities; suddenness of onset with restlessness and no relief from sweating; better from warmth, pressure and rubbing.

Gaultheria: Recommended for articular, inflammatory and muscular rheumatism. There is cystic and prostatic irritation with undue sexual excitement. (Note: The author once treated a very bad case of rheumatoid arthritis on whom wintergreen had been very much abused over many years and thus probably caused a thorough proving. His wife asked me to speak to him,about frequently sexual relationships, because notwithstanding his condition and over 60 years of age he expected this to happen nightly).

Ginseng: Rheumatism with bruised feeling in lower back and thighs, and burning, stiffness and cracking in joints, and with contraction, numbness and heaviness in the lower limbs, and a swollen, tight feeling in the hands.

Guaiacum: Rheumatic pains in shoulders, arms and hands. Rigid painfully swollen joints, intolerant of pressure and heat. Stinging and lancinating pains with contraction of limbs and a feeling of heat in parts. So-called growing pains in young people.

Iodine: Joints inflamed and painful, white swelling, gonorrhoeal rheumatism; upper extremities and nape of neck painful; cold hands and feet; acrid sweat of feet; pulsations in large arterial trunks. Nightly pains in joints and constrictive sensations. Withered and emaciated notwithstanding eating well, feels over hot and seeks a cool place.

Jacaranda caroba: Gonorrhoeal and syphilitic arthritis with morning soreness and stiffness of muscles, and rheumatic pains in right knee. (Used in tincture and lowest potencies).

Kali bich.: The rheumatic symptoms of this remedy are characterized by rapid shifting from place to place (Puls.). They are also inclined to alternate with dysentery (Abrot.) or gastric symptoms, which are very marked when present. Stiffness of limbs in morning; cracking in joints, soreness of bones to touch and deep pressure. Pains in shoulders, lameness, burning in forearms; pains in elbows; weakness and bruised feeling in hands and fingers with great tenderness to hard pressure. Marked rheumatic pains in hips and knees worse from walking.

Kali iod.: Rheumatism of knees with effusion, contraction of joints and pain in hip causing limping. Formication of limbs. Severe bone pains, thickened periosteum and sensitiveness is characteristic of this remedy. Rheumatic complaints are apt to have a mercurial or venereal etiology.

Kali mur.: “I have seen enlarged joints after acute rheumatism rapidly reduced to normal size under its action, sometimes after they had resisted other remedies a long time.” (Nash). Lightning pains from small of back to feet, cold hands and feet, cramp in legs, twitching and tension in extremities.

Kalmia lat.: “Rheumatism, pains intense, change places suddenly, going from joint to joint; joint hot, red, swollen, worse from least movement”. (H.C. Allen). Deltoid rheumatism, especially right; weakness, pricking and sense of coldness in limbs; tingling and numbness of left arm. Rheumatic symptoms descend, from above down. (Ledum opposite).

Ledum pal.: Rheumatism begins in feet and travels upward (Kalmia, opposite). “Affects especially the rheumatic diathesis, going through all the changes, from functional pain to altered secretions and deposits of solid, earthy matter in the tissues.” (William Boericke). The swellings are pale, sometimes oedematous, and worse at night, in the heat of the bed; uncovering or cold water relieves.

Lilium tigrinum: The most distinguishing symptom of this remedy in rheumatic complaints is that the patient is unable to walk on uneven ground. “Pricking in fingers; pain in right arm and hip. Legs ache; cannot keep them still. Pain in ankle joint. Burning palms and soles.” (W. Boericke).

Lithium carb.: Pains in shoulder joint, arms, fingers, small joints generally; nodular swellings, with great tenderness and redness. These symptoms are apt to be associated with heart diseases. There are often heavy deposits in the urine of mucus, uric acid or pus. (Nash).

Lycopodium: Numbness, also drawing and tearing in limbs; heaviness of arms, tearing in shoulder and elbow joints. Right foot hot, left cold. Profuse sweat and soreness of feet, starting with worst symptoms in the right foot and as the right gets better the left gets worse; movement of symptoms from right to left. Cramps in calves; toes; limbs go to sleep; twitching and jerking; pain in heel as if treading on a pebble. In a personal proving the author has also observed a tendency to exercise the cold foot, the left one, which momentarily improved the coldness and numbness. Deposits form in the joints, with heavy red sand or red sediment in urine.

Medorrhinum: Heavy legs, aching all night; heels and balls of feet very tender, making walking very difficult. Burning of hands and feet (Puls., Cham., Sulph.), soreness of soles (Lyc.), intense restlessness and fidgetiness of feet (Zinc.). Legs give way when walking; legs feel heavy; coldness of legs, feet, hands, forearms; drawing and contraction of hamstrings; cramps in calves and soles. Concretions form in joints, deforming them; puffiness and painful swelling. There is often a specific history. Rheumatism often improves at the seaside; better from damp weather.

Mercurius: “Mercurius especially affects the joints; inflammatory rheumatism with much swelling, aggravated from the heat of the bed and from uncovering. It is difficult to get the right weight of clothing. Rheumatic affection with sweat aggravated at night,from warmth of the bed and while sweating, with sickly countenance. It especially attacks the upper limbs, but is also found in lower. Tremulous conditions of extremities like paralysis agitans.” (Kent).

Natrum mur.: One of the most characteristic symptoms of this remedy is a painful contraction of the hamstrings, often associated with backache relieved by hard pressure or support. Palms are hot and perspiring: the legs, arms, knees feel weak and trembling; fidgety feet (Zinc.). Ankles turn easily, joints cracking on motion. A peculiarity of this remedy is that there is a congestion of blood upward and often associated with severe headaches worse round 10 oclock in the morning. These symptoms are often associated with the anaemic or chronic malarial cachexia.

Natrum phos.: Rheumatic pains in the joints, weak feeling in the legs; acid and sour-smelling perspiration; crepitation in joints, with pain and soreness and weariness of extremities. Hamstrings sore; weakness of joints and easy turning of ankles when walking. In adults there is often associated sexual hyperaesthesia and a history of over-indulgence; while in children there is great acidity with yellow coated tongue.

Natrum sulph.: The outstanding indication for this remedy in rheumatic complaints is great aggravation from damp and cold water, the hydrogenoid constitution. Burning in soles, itching of toes; pain in limbs necessitating frequent change. Pains in hip- joints, worse left. Stiffness of knees, cracking of joints. Useful in some forms of gonorrhoeal and “sycotic” rheumatism.

Jacob Genis