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Case Study

Encounter With Cases Of Arthritis And Rheumatism
Dr N L Tiwari

Introduction :
Arthritis and Rheumatism have been aptly described as "The disease which kill the fewest but cripple the most". The socio economic problem to community is heightened by the fact that the diseases often affect the young, at the peak of their earning capacity and housewives looking after young children and old people.
The three most prevalent - Osteoarthrosis, Degenerative disc disease and Rheumatoid arthritis - cause much suffering and disability which may be spread over several decades but they seldom threaten life acutely. 
In this article I will take three cases- one a case of Osteo-arthritis of an old man, second a case of prolapsed vetebral disc in middle aged female to demonstrate scope of Homoeopathy in the case of Arthritis - Rheumatism . The third case will demonstrate the role of Homoeopathy in a case of Rheumatoid Arthritis

Case 1:
Osteoarthritis: Makes me Helpless
Mr X, 76 year old Gujarathi Lohana, retired as dy controller of Rationing, consulted me for arthritis-spondylosis-rheumatism. He was bed ridden since 3 months and was taking analgesic besides applying Relaxyl ointment and no free life.
I visited the patient on 9/11/94. I found him lying on bed. He greeted me with a smile on his face and tears in his eyes. I could see his helpless suffering and his pathos. The man who loved and walking used to go for evening and morning walks on the seashore is now bed ridden. In in own words " I have a mania to walk down the sea shore...."

Case Receiving And Case Taking:
Following information was collected:
1. Both the knee joints were affected. Pain is reflected throughout whole body.
2. Similar things occurred in Feb 1993 while he was traveling in bus when he developed sudden pain in the knees and whole body.
3. Six months back on he had pain in [R] knee joint, which was dull and continuous
4. Recently since 3 to 4 months he is bed ridden and just moving around the house with great difficulty. He cannot sit in Indian style toilet.

Past History:
1. He has been operated for enlarged prostate. He had been advised not to strain for urine.
2. Suffering from chronic constipation for which he was taking laxative.
3. Suffering from leucoderma since 5 years for which he has taken herbal medicine
4. Operated for Nasal Septum defect when he was 20 years old
5. At the age of 50 years, he was operated for Nasal polyp

Life Story Of The Patient:
He is the 16th child of his father and 7th [last] child of his mother. His mother was the second wife of his father. Father died of heart failure at the age of 50 years. All his elder brothers have expired. One brother who died recently at the age of 82 years suffered from spondylosis. Mother died at the ripe age of hundred.
Present Family Set Up: He and his wife are living together. Wife is 65 years old. She was a nurse by profession but now retired. He has two sons. Both are well settled in life. Elder son is 52 and a physician. DIL is also a physician. Grand son has completed Diploma in construction engineering and grand daughter her schooling. Second son is 50, doing his own business.
Our patient Mr X, advocate by qualification, has done LLM and DBM but never practiced and is a sentimental person with the philosophical bent of mind. Gets hurt easily.

Physical Examination: Both the knee joints are stiff.

INVESTIGATIONS: X-ray of both knee joints was taken in Nov 1993. Findings are suggestive of Osteoarthritis of [R] knee joint with degeneration of medial meniscus. Cervical spine indicated cervical spondylosis C5-C6

Histopathology of Prostate - Adenomatous Hyperplasia of Prostate.

Case Discusssion:
Mr X and Mrs X are living together and both the sons are living separately. He appeared to be very much concerned about them, and both sons are happy in their own world. He told me " Doctor Saab, my son and DIL are successful doctors but they do not believe in Homoeopathy. As Allopathy has not given me relief therefore I have called you and given you trouble" Wife was nursing well and taking all the necessary care of him.
Though advocate by education, he could not fit himself in that profession. Basically, having a philosophical mind and remaining in dream world of life, he easily gets attached to people, gets influenced by them and wants to help people. He goes out of his way to help. During the interview, he was in depressed state of mind with a feeling of helplessness as to whether he would walk again. He was confused and indecisive.

Management Of The Case:
As we see , in this case there are no characteristic at the level of physical generals or at the level of chief complaints.
There is no qualified mental symptom but mental state is evident from the life situation. In this case Bogers view was taken:
1] Pathology Degenerative [old age]
2] Location joints stiffness as movement and painful
3] Chilly patient
4] Depressed state of mind, hopelessness, and confusion.

Thuja was chosen as phase remedy and Rhus-tox as acute remedy. Constitutional: probably Kali-carb > anxious nervous person attachment to people

Treatment: started on 9/11/94 Thuja 30 7 powders, 1 powder daily at bed time. Rhus-tox 30 4 pills 4 hourly made him feel 50% better.
Susceptibility Low: No characteristic available
Sensitivity high: Reaction to illness, high emotional state, hopelessness, tears emerges Structured changes: Irreversible
Dominant miasm: Sycosis [mind] confusion, hopelessness, and depression.

Follow Up Criteria:
1. Emotional state - depression, hopelessness
2. Joint [knee, body pain]
3. Stiffness
4. Movements
5. Blood pressure

The patient reported 80% better within 3 weeks [23/11/94] and at the end of 4 weeks he restarted his morning and evening walks. He was very happy and started talking to people about miracle of Homoeopathy.
The patient is still under treatment and reports regularly. He comes personally from the suburb to the clinic in South Bombay.
At present he is on Thuja 1M daily and 
Rhus-tox 1M 4 pills SOS. Patient last reported on 7/11/97. Patient is regularly doing yoga and meditation.

Case 2:
To Avoid Surgery - A lawyer uses her Logic

39 years old, Brahmin Hindu female patient Mrs Y. She is practicing as a high court advocate. She consulted me in July 1996 for the complaint of low back pain radiating to [R] thigh and [R] leg. The pain started slowly on 8th or 9th May when she was travelling to her native place from Bombay. It started very slowly lasted for 5 to 10 minutes in the whole leg intermittently. Shooting pain, sparkling type aggravated by motion, standing, walking , fan, cold draft, relieved by lying down, applying hot water bag or sitting.

Since last 10 days, cramps in calf muscle tightness and stiffness of leg, takes about 5 to10 minutes stretching her leg.

Investigations : X-ray, L-S spine AP and Lateral 25/5/96 - Bony and joint appearance are normal. Idiopathic osteitis condensaitis noted. Normal variation which may cause chronic backache. The patient has taken pain killer but no relief.

MRI was done on 20th July 1996. 
Observation: There is loss of water content of the L5-S1 intervertebral disc.
There is a right paracentral disc herniation at the L5- S1 level with resultant indentation on the traversing right S1 nerve root.
A small posterior disc bulge is noted at the T4-T5 level. Rest - NAD. The conus medullaris terminates at the L1 level and the cal sac terminates at the S2 level. 

The AP dimensions of the lumbar canal at the level of the intervertebral discs are as follows
16.1 mm at L1-L2
15.3 mm at L2-L3
15.1 mm at L3-L4
12.9 mm at L4-L5
11.4 mm at L5-S1


A [R] paracentral disc herniation at the L5-S1 level with resultant indentation on the traversing right S1 nerve root.
Surgeon suggested complete bed rest and advised antiflammatory and analgesic treatment after which to undergo surgery. The patient was not mentally prepared for surgery. She felt she would first try Homoeopathy and then think of operation.

Physical Examination:
Tenderness in L-S region L4, L5, S1 movement of leg restricted and painful.

B.P 130/180 WEIGHT 51 Kgs HEIGHT. 4' 9"
BLOOD Hb 12 Gm% /WBC 9900/cmm BUN 46 mg CREATININE 0.9

During case taking following information was collected.
1. Menses are irregular since Feb 1995, before that they were regular, profuse bleeding lasting for 10 to 15 days cycle every 30-35 days
2. Leucorrhea since Jan 1995
3. Both caesarian deliveries. After second delivery she developed stiffness of back [10 years back] and cannot get up from lying down position immediately. She can walk properly only after 10-15 minutes of stiffness but no pain.

1] Short stature, average built with curly hair, fair looking, soft and free spoken female.
2] Loud voice and talking confidently.

Life Story Of Patient:
Eldest daughter in a Hindu Brahmin middle class family born and brought up in Bombay. Father was a postmaster, died in 1986 at the age of 64 years. He enjoyed good health throughout his life but had a stroke and expired within 15 days.
Mother 64 years, was working in government office as a typist, suffered from Ca lymphnode for which received treatment at Tata hospital. No complaints at present. Younger sister aged 35, done B Com and is married. She is working in a bank and enjoys good health.
Husband is 40 years old and is a practicing advocate in Bombay high court. Patient has two daughters aged 15 and 10 years old. Elder one was getting recurrent cold cough, fever till the age of 12 years. Younger daughter also suffered from recurrent cold and cough.
FIL 67 years is a doctor practicing as Family physician, MIL expired in 1980 just before her marriage. She was an Ayurvedic doctor. She was suffering from Tubercular Meningitis Her SIL, elder one is a dentist and the younger one has done M Sc and is staying in USA. Third has done Ph D and is a lecturer in Pune. All are married and well settled. Socially conscious family. They engage in many social activities.
She is very much attached to FIL and he has love and affection for her. He supported her to complete LLB after marriage. She has done B Sc in 1976. Got married in 1980. She was working as a clerk in SBI but was not satisfied. She left her job in 1982 when her elder daughter was born. She started studying LLB in 1984-85 and completed in 1989 and started practicing from 1990. She became tense before appearing for court cases as used to happen during exams. Also get dreams sometime as though she has not completed her studies and has to appear for her exams. But rarely she gets them now.

Perceiving : She appears to be anxious, nervous temperament, which is evident form anticipatory anxiety before appearing for the cases or attending any engagement. She is sentimental and worrisome, which manifests when younger daughter or FIL becomes sick. She has strong will and commitment to do her work, which is evident from the manner in which she completed her LLB after marriage. No active problems in family relationship. Husband and in-laws involved in social activities putting lot of stress and strain on her but she likes company and feels happy.
Only conflict came to surface that she wanted to be a doctor. This she could not resist when she visited a hospital or meets a doctor. She gets upset during these moments.

Physical Generals 
CRAVING - sweets
THERMAL - hot patient.

Management: The remedies, which came for consideration, were:
Mag-phos: nerve pain AMEL. Hot footer bg < fan < cold draft 
Kali-bich: Hot patient anticipatory anxiety, attachment sentimental involvement of spine
Thuja: Dominant miasm sycosis. Spasm, pain, stiffness , cramps.
Medorrhinum: hot patient, anticipatory anxiety, sycotic miasm.
Susceptibility - moderate
Sensitivity - high
Miasm - sycotic
Structural Changes -reversible

The treatment started on 12/7/96 with Thuja and Mag-phos 30 4 hourly. He obtained partial relief. The surgeon was consulted. He put the patient on traction for relief from pain and patient was bed ridden. 
Kali-bich 30 was introduced on 2/8/96 daily HS. Partial response at general and sector level. The husband reported on 16/8/96 and Kali-bich 200 single dose was given. It did not give expected response. The case was reviewed and Medo 200 single dose was given on 16/8/96. This produced remarkable response at both levels general and sector. Further planning and programming were done as follows.
Medo 200 infrequent weekly doses and Mag-phos 30 during acute pain were prescribed. The patient became 60% better within 4 weeks and started to work besides attending to house holds work. From Dec 1996 the patient was kept on placebo till March 1997. She was completely all right and was asked to report as and when required.
Ancillary Measures: She has been advised to do yoga and back exercise regularly and avoid forward bending or lifting any heavy weight which she followed.

1.Arthritis and Rheumatism as we know are crippling diseases which produce a lot of emotional trauma as well as physical disabilities that take away the mobility from the life. The physician is required to handle both these aspects sensitively and patiently.
2. Ancillary measures like physiotherapy and yoga play an important role.
3. Remedies like Thuja, Med requires due attention not only to consider them as antimiasmatic or intercurrent remedies only but also as constitutional remedies.
4. The patients should be considered as a whole and not only at the tissue level.
5. Homoeopathic medicines have a large role to play in the management of Arthritis and Rheumatism. Therefore surgical measures come in as a last resort.