An advanced case of Rheumatoid Arthritis
NATIONAL JOURNAL OF HOMOEOPATHY 1999 Mar / Apr VOL VIII NO 2.
Dr N L Tiwari
'Calc-fl

Dr (Mrs) BGP, 46-year-old Ayurvedic physician, was brought to us by her husband, Dr GJP. She was suffering from Rheumatoid Arthritis with metacarpal joint deformity and pulmonary interstitial fibrosis, since Dec 1984

PRELIMINARY INTERVIEW:
She developed pain in all small joints in 1969. Sudden stiffness & swelling.

1. Deformity Rt proximal metacarpal jt.
2. Cold and dry cough, diagnosed as Pulmonary Interstitial Fibrosis.
3. She had taken Ayurvedic Treatment (Swarn Bhasma) and was taking cortisone 11/2 tab daily (1/2 tab TDS) without much relief.

Husband was very keen to start Homoeopathic treatment and taper off the cortisone. As the patient was on cortisone from 1979, whatever balance the system had achieved with the other treatment would be upset by tapering off the cortisone, leading to respiratory failure and certain death. When this was explained to the husband, he could understand the whole dimension of the case.

Initially, the point arose as to whether we should take up the case at all; and what Homoeopathy could achieve-cure or palliation. The point, which swung the balance, was that in spite of taking cortisone for last 5 years there was no evidence of Cushingoid features. This signified positively that the susceptibility was not seriously tampered with. That strong point led us to accept the case.

Case History:
A detailed inquiry was done to get evolutionary totality of the disease and reaction of the patient to the disease.
The whole process started in 1969 and continued in a progressive manner resulting in Deformity and Interstitial fibrosis. In spite of this illness, she was attending her clinic regularly, discharging her responsibility at home in the kitchen and attending social functions, though it did tire and exhausted her.
Her husband is a general practitioner. She has two sons - one was in final year of LCEH and the second studying in Gujarat in the Xth std..

Family History:
Mother died of Tetanus in 1958.
Father suffered from cerebral haemorrhage. She has 2 brothers and 2 sisters who are in good health. She got married in 1965. Father-in-law expired in 1965- of myocardial infarction. Mother-in-law also expired in 1981 at the age of 75 because of same complaint. Brother in law expired in 1964 from sarcoma.
She completed her BA in 1961, Diploma in Ayurveda in 1969 and started her practice in 1970.

Physical Generals:
Craving: sour2, takes strong tea. AVERSION: Banana, sweets.
Menstruation: Menarche at 14 years. No complaints.
1st delivery 1965
2nd delivery 1969
Menopause 1979

Physical Examination:
Rt. ulnar deviation
Rt. thumb deformity (Proximal interracial joints deformity)
Varicose veins ++ Rt. leg more than Lt
Cyanosis nails ++

Investigations:
22/1/84
Hb. 11.5Gms
WBC 9800/ cmm; N - 60; L - 36; E - 04
ESR westergreen 103mm at end of 1 hr.
Uric acid 6.9 mg %
ANA +ve
X-ray chest PA view
Lungs on either side showed honeycomb appearance. Amongst the many causes RA is one which can give rise to such appearance.

Analysis:
Boger's point of view was taken as it was a case of Rheumatoid Arthritis with advanced pathology i.e. Interstitial Fibrosis of lungs and deformity of proximal metacarpal joints.

Totality:

Thermal C2H2
Suppression, but motivation +++ Person's will power ++
Two drugs were coming close -
Calc-fl and Kali-bich.
Kali-bich was ruled out on - evolution of mind, reaction to evolution of disease, absence of anxiety and insecurity, and nature of discharge and inflammation.

Overall Assessment:
Assessment of the Susceptibility - poor Sensitivity - moderate
Structural change - irreversible
Dominant miasm - Syphilitic
Fundamental miasm- Syphilitic
Potency Selection - 30

Treatment and Follow-Up:
Calc-fl 30 HS daily

Prognosis - Palliation is possible
The case in under our treatment from 1984 to date.
Cortisone was tapered within 3 months
Calc-fl as deep acting chronic remedy was given 30 HS then daily dose and multiple doses; potency was raised to 200 and again back to 30
For acute exacerbation of Interstitial Fibrosis: Ant-ars 30, 200, 1M
Coccus-cacti. 30, 200
Kali-bich 30, 200 from time to time
Thuja 30, 200, as intercurrent.
To overcome suppression of susceptibility by steroid often a multiple dosage schedule has to be followed, with various acutes, according to the need of the hour.

Last Prescription:
Thuja 1M daily
Ant-ars 1M 1P=6, 4hrly
Investigations were repeated from time to time. ESR came down to 45 and X-ray of chest shows considerable improvement and so did her functional capacity.

Conclusion:

1. In Homoeopathic practice selection of case is very important. Physician must know what he can do in a case and what he cannot and keep in mind the scope of Homoeopathy in dealing with cases of advanced pathology.
2. Tapering of Cortisone requires judicious assessment of susceptibility and tapering off should be done slowly while taking care of the acute exacerbation, with acute remedies and intercurrent.
3. For management of complex case it is necessary to take evolutionary point of view.
4. Boger's view is suitable for advanced cases of pathology i.e. Time and Tissue Affinity, Pathogenesis Pathology and the patient as a person.