Sepia and Rheumatoid Arthritis - A Case Study
NATIONAL JOURNAL OF HOMOEOPATHY 1999 Mar / Apr VOL VIII NO 2.
Dr (Ms) Meena Mankani
'Sep

A 24-year businessman, married 3 months, came with his wife, sharp at the appointed time of 9AM. This 5'10'' and 97 kilos man, had an acne- scarred, bloated face, with dark circles beneath the eyes. Abdomen also was protruding.
(S 747 Pendulous). He spoke confidently and politely with gesticulations (S 114 Gestures talking, gesticulates while).

Chief Complaints:
In 1987 while playing in school he injured his Rt ankle. The pain persisted and did not yield to treatment. By 1988, most of his peripheral joints were affected. All routine investigations were normal except for normocytic anaemia. He was simply put on steroids and anti-inflammatory drugs. He lost around 32 kilos by 1989. Mantoux test came mildly positive. He was treated for Tuberculosis of the joints. Anti-TB drugs helped him to some extent. On 23/05/90 the RA factor showed positive. Since then, he is on regular intra-articular corticosteroid injections supplemented by oral anti-inflammatory analgesics giving temporary relief. He came to me on 20/12/96.

Complaints - excruciating pain in all peripheral joints, AGG Rt acromio-clavicular joint, Rt elbow, Rt Knee and Rt ankle (Side, Rt - S 1679). He must constantly move and play vigorous games like squash. The more he plays, the better he feels.
(S1633-Motion, violent Amel and S 1633- Motion, rapid Amel)
But within 10-15 minutes of lying down, he gets so stiff that he has to call someone to assist him even to change sides. (S 1672 - Rest Agg)
Impossible to get up from bed in the morning and 2-3 persons have to literally lift him from bed. The stiffness and pain gradually decreases after he moves about a little (S 1632-Motion, continued Amel) and after he has had a hot bath (S1702 -Warm, becoming Amel). Then he takes his regular dose of painkillers, after which he is ready to face the day.
This daily morning suffering makes him not want to get up at all but just while away his time (S 23 - Bed, remain in, desires to, morning). But no matter what, he attends to every demand of his business without fail (S126 -Industrious).

Lab Investigations-
Haematology reports on 13 and 15/12/96

·         Hb - 10.6g/dl (N 12.8 - 18 g/dl)

·         RBC - 5.22 (10)6/mm 3 (N)

·         WBC 17,900 cmm (N4-11,000cmm)

·         ESR 52 mm (N in male - 0.9 mm)

X-Rays-
In Nov 96 and April 97
All X-rays of cervical spine, chest, LS spine and knee joints NAD except for sacralization of the L transverse process, evident since 1987. 02/05/95 A total body bone scan - NAD.

Radiological progression of RA:

1. Periarticular osteoporosis
2. Loss of articular cartilage (joint space)
3. Erosion
4. Subluxation and Ankylosis

Associated Complaints

1. He is a B-thalassaemic. His Hb A2 level on 24/04/88 is consistent with the diagnosis of B-thalassemia trait.
2. Recurrent attacks of ulcerative colitis. Hospitalized 3 times in 5 yrs.

Personal and Family History
1990 Malaria.
Severe Acne as a teenager (S 497 Face, eruptions, acne).
Father, 57, has diabetes.
Mother 53, has IDDM; and has mild rheumatic pains. C-reactive Proteins (CRP) - positive RA factor -negative.

Patient as a Person
Our patient is the youngest among 2 brothers and 1 sister. All are obese. (His brother weighs 117 kg). He himself also has a large appetite. Once he starts eating, he would eat 7-8 pieces. He is a vegetarian and loves cheese3 (S 1595food, cheese, desire) and potatoes2. He doesn't like to drink water although his mouth remains dry (S539Mouth, dryness, thirstless). Sleep restless due to aches and pains. Always uncovers feet due to burning soles. (S1262Extremities, Pain, burning, foot, sole; S 1380 Extremities, Uncover, inclination to, feet). Sexual life is quite satisfactory. He smokes and indulges in drinking wine off and on.

Life Situation and Mentals:
He had to leave his education after his Matriculation due to persistent health problems. Being an average student no interest in studies. After that, whenever time permitted, he helped his father and elder brother in ceramic fixtures.

Very stubborn as a child (S154 Obstinate). Even now he wants his way or else gets very angry (S8 Anger, contradiction, from). Everyone in the house gives in to him considering that he is sick. With his wife too, it has been smooth sailing since she is submissive, caring and affectionate.

He is very social and mixing. He loves to eat out and fool around with his friends, which he cannot do to his heart's content owing to his diseased condition. This depresses and frustrates him.
(S83 Despair, existence about, miserable).
S 202 Unfortunate, feels.
S 171 Sadness, health, about)
His frustrations get compounded because he feels that his joints are unhealthy owing to hereditary factor, as his mother also suffers from rheumatic pains. (S 104 Fear, joints are weak, that) and hence feels that he will never get well (S 83 Despair, recovery, of)

He weeps worrying over his health problems (S17 Anxiety, health, about; S194 Thoughts, disease, of). He worries as to what would happen to him in future (S194 Thoughts, future, of the). His dreams are generally about his day to day dealings - friends and business.

On Examination

·         Rt Knee, elbow, ankle and shoulder joints very tender

·         No joint deformities. No nodules

·         B P - 130/80 mm of Hg

·         T-99 0F Pulse-84/m

·         Smooth shiny nails

·         Few small warts on front of neck

·         Tongue slightly cracked in the centre and indented +

Analysis And Remedy Selection:
Sepia covers every rubric mentioned so far. But the most distinguishing features of the case pointing unmistakably toSepia are:

·         S 8 Mind, Anger, contradiction from

·         S 1633 Generalities, Motion, violent >

·         S 619 Stomach, Appetite, ravenous

·         S 1595 Generalities, Food, cheese, desire

·         S 539 Mouth, Dryness, thirstless

·         S 1380 Extremities, uncover, inclination to, feet

 These distinguish patient as a person and not the active disease process. Although the remedy selected must have in its pathogenesis, the pathological totality of the patient as well, yet it is generally the Non-Pathognomic characteristic totality of the patient that represents the Deranged Vital Force and hence sets the curative similimum apart from so many other seemingly similar remedies.

Prognosis Assessment: Good

·         Functional index is only of moderate restriction

·         No joint destruction or deformity.

·         Young age

·         A strong will to fight and survive

·         Strong, clear mentals and physical generals

Prognosis could have been much better in the absence of the heredity factor.

Treatment and Follow-Up

1. Folic acid 5 mg daily to combat the adverse effects of the inherent B-thalassaemic trait
2. One dose of Sepia 1M on 28/12/96, followed by placebo
3. Report after 2 weeks: much better in his pain and stiffness. Could get up from bed in the morning without much help. Instead of 3 combiflams, now he can manage on 2.
   His next course of intra-articular corticosteroid injections is due next week. He hopes that he would not need it any more. Placebo.
4. Report after 2 months: did not need his steroid course. Much better. Not desperate; stiffness and pain much better. His appetite has reduced considerably - can remain hungry for sometime and eats within limits. He has lost 3 kgs. He is very cheerful and hopeful of getting well completely. He does not lose his temper as much as before. Placebo
5. Report after 2 weeks: He came in a very bad condition. All pains worse +++. Had gone to a hill station for a vacation and indulged in a lot of wrong food, swimming and alcohol and now is almost back to square one. Besides, he had a bad cough with stitching pain on the Rt side. T1020F. Pulse-112/m. Very restless. Wept during consultation. Desperate again and feels that he can never get well. He was thirstless though his mouth was dry.
6. Urine and stools were normal. The chest X-ray NAD. Clinically the condition seemed to be that of pleuritis. The totality taken now:

§  S 83 Mind, Despair, recovery, of

§  S 208 Mind, Weeping, Telling of her sickness when

§  S 539 Mouth, Dryness, Thirstless

§  S10434 Chest, Pain, Stitching, Coughing on

§  S 1015 Chest, Inflammation, Pleura

He was now given Sepia10M in water in plussing doses every 3 hourly. Gradually he started improving at all levels. In 2 weeks time he was so much better that he could discontinue all his anti-inflammatory analgesics. Sepia10M was continued in daily doses in plussing.

7. In July 1997, he had an iced drink in a party and the very next day came down with severe tonsillitis and severe pains in the head and all joints. His ASO (Antistreploysin O) was 400 IU per ml. Higher level represents Beta haemolytic streptococcal infection.
   He was now put on Sepia 50M in water in plussing doses. In 4 days he got completely all right and was put back on placebo. Since then, whenever he gets a slight relapse of pain and stiffness, he is put on plussing doses of Sepia 50M for 4 days and then back on placebo. At the moment he is free of any pain whatsoever. He has lost around 18 kilos and is much more active than before.

Current Assessment:
(Clinical and Lab Findings)
Clinical: Free of pain and stiffness. No limitations at all. Cheerful and hopeful. Laboratory: Haematology reports on 22/07/98
Date : 25/07/98

·         Hb - 11.3 g/dl(Normal12.8 -18)

·         RBC- 3.9 million/ mm (Normal 4.00-6.50)

·         WBC-6900/mm^3(Normal 4,500-10,000)

·         ESR 22mm at 1 hour (Normal upto 16)

·         CRP Positive

·         IgG - 1450 mg/dl (Normal 800-1700mg/dl)

·         IgM - 95mg/dl (Normal 50-200mg/dl)

·         RA - negative

 Observed Value: 95.0 mg/dl
Normal Value: 50-200 mg/dl

The ESR is negligibly high. The RA being negative and the IgG + IgM (Rheumatoid factors) also being within normal limits, the possibility of any rheumatic mischief at the moment is low. Yet we know that the joint trouble still persists to some extent which is evident by the CRP test being positive. The Hb will always remain on the lower side owing to the B-thalassaemia factor.

Points to Ponder
The case as yet is not completely cured. As per the Hering's Law of Cure, there has yet not been any externalization of the internal disorder. The vital force has yet to throw out the internal toxicity from some outlet that it may choose. It is only when that level is reached and cleared that we can perhaps say that we have cured the case. That may take some more years and careful repetitions. Till then we have to wait and watch.

References

1. Davidson's Principles and Practice of Medicine
2. S=Synthesis Repertory