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Dec 18, 2011

Rheumatism By P.P. Wells, MD PART I

 This Article on RHEUMATISM was published by P.P.Wells in The American Homeopathic Review, Vol 3, New York, Nov, 1862. No 5,6,7. Here it is again published in two parts. PART II can be read here.



By this term we indicate an extended class of affections by no means easily brought within the brief and explicit terms of scientific definition. The difficulty is not so much in the vagueness of the subject, as in its extent, and the varied character of cases brought within the domain ascribed to it. When we suffer the pains of rheumatism we find them neither shadowy nor uncertain, but when we attempt to define what we mean by the word, to present the elements belonging to the genus, found in all its examples and found no where else, we fail, even after much labor, to produce anything satisfactory, and may be compelled to sit down, as the writer now is to the employment of the word, trusting to its general use by readers, for a recognition of the fact that we refer to that numerous class of painful affections which are gathered under this denomination, for the good reason that it has not been so convenient to place them under any other. When he says Rheumatism, the reader thinks he means a definite thing enough, and if perchance he has felt its grip he is quite sure of it. Will he be so good as to tell us what he means, and in terms which shall equally describe the tortures of his ten dear neighbors and friends who also had suffered and who certainly came to sympathize with him, and each to bring the knowledge of a "certain cure." If he will do this, he will have made an addition to the literature of this subject which will deserve to be remembered. If this definition were essential to that understanding of cases as they occur in practice, requisite to their intelligent treatment and speedy cure, it would be a matter for the deepest regret. But as the relationship of curatives to diseases has not been made to depend on strictly scientific definitions, however valuable these may be, and as the chief duty of the physician, in these, as in all other cases, is to find the curative, and as definition, if given, cannot materially aid him in the discharge of this duty, its consideration may for the present be safely waived. The improvements in nomenclature may hereafter make definitions more possible, the signification of terms used more explicit, and thereby enhance convenience in the interchange of ideas, but whether increased certainty of cure, or an abridged duration of the disease, would necessarily result may well be doubted.

In order to a certain and speedy cure of rheumatism, it is essential to begin with that first of all requisites to intelligent and successful treatment of diseases, a strict individualization of the case. It will be a help towards this, if at the outset the case can be referred to either of the following classes: With fever; without fever; swelling with redness and heat; without swelling; swelling with oedema; pains aggravated by motion; pains relieved by motion; pains suddenly shifting from place to place; pains aggravated by change of weather, especially on the approach of a storm. The exciting cause, if known, should be carefully considered, as this is often an important element in the individualization, and also the quality of the pain. The time and circumstances of aggravation are also matters for the strictest inquiry. The character of the tissue invaded—is it muscular, tendonous, ligamentous, membranous, or a mixture of these?

The necessity of this individualization is apparent from the nature of disease of whatever kind, and if there be any variety where this is more imperative than with others, perhaps this variety is rheumatism. If disease be a modification of those actions of the vital forces, the just balance of which conserves the whole and each part of the individual, so that these forces, instead of conservative become destructive of the whole or of parts—-and we assert of disease that it is nothing else—then it is evident that a proper knowledge of their modifications can only be reached after a thorough examination of all the elements of a case, which alone can disclose the nature of the modifications with which we have to deal. This is what we mean by individualization, and this the result we propose to attain by it.

It is only by this process that we gain possession of the elements of these modified vital actions, the finding of the similimum of which is the great duty of the physician, and the cure. Different exciting causes of these disturbances must produce different modifications of vital action; and the same cause, under different circumstances, may be so affected by these as to produce results quite different in their nature, and consequently in their curative relations, though for convenience we give the same name to them all. A man becomes severely chilled by exposure to low temperature, the atmosphere at the same time being dry, and there follows after* the reaction from this state, swelling of the joints, which is red and painful, intolerant of touch and motion, with fever more or less violent. Another is chilled by becoming wet in a rain storm, and results follow so similar that no eyes can perceive a difference. But that sensibility, keener than all human sense, the sensibility of diseased condition to the presence and action of its curative, will, and most certainly the remedy which promptly and completely cures the one will be found powerless for good with the other. Another is chilled by falling into water, or by long working in it, and suffers in like manner, but though we call his pains, swelling and fever rheumatism, his cure requires a different remedy from each of the others, though the sufferings of all result from chill, and we are compelled to call all by the same name. And this requirement of different curatives in these cases is determined by the one circumstance of dry or wet, in the two first cases, and by the manner of becoming wet in the two last. An interesting instance of rheumatism from the last cause came under the notice of the writer about a year and a half since. It was of two years standing, had resisted all remedies, and seemed to have fastened on the poor man a torture for life. He was given a single powder of Calc. carb. 200 which he took, and in a week was perfectly well. He has ever since done duty as a good soldier of the United States. Even the exposures of camp life, for more than a year, have been borne with impunity. Another has suffered from the poison of Gonorrhoea, and has similar sufferings, but the drugs which cured the other cases are powerless with him, and yet we call his case rheumatism also. These examples sufficiently illustrate the necessity of careful attention to the nature of the exciting cause in all cases where it can be ascertained.

The quality of the pain in different cases is exceedingly various, being determined either by the nature of the exciting cause, the vital condition or susceptibilities of the individual, or the circumstances of the attack. There is often a difficulty in the way of investigating this element, arising from the peculiarity of our national mind. It has been trained to the consideration, and has had to do almost exclusively with objective life and phenomena. The life within is to our nation almost an unobserved domain. This fact has stamped itself on our language, and left it poor in the terms necessary to the description of its phenomena, and hence great difficulty is often met in attempts to individualize this element of cases, the patients having no words to express what they feel. A pain is to them only a pain—and every one has been thought of as like every other. The word to most, certainly to many, patients has never had an adjective prefixed to it in their minds. And there is still another difficulty in the way of obtaining exact information, in the liability of persons to attach different meanings to the same word; or what is nearly equivalent to this, of using different terms to describe the same sensation. To avoid errors from these causes, will require the utmost caution. But it is believed the importance of the subject warrants and demands that patient care and perseverance which can and will overcome these and all other difficulties in the way of that knowledge necessary to success.

It is not necessary to say to the experienced observer that almost all diseases have their periods of exacerbation; and when the time arrives in successive days of their progress, it brings with it the aggravation of some or all their elements. Each case has its own periodicity. It is as little necessary to say to the experienced Homoeopathist that this periodicity is of immense importance in directing to the choice of curative remedies. But all have not had the experience which has shown to this class of physicians the extent of this imporance, and it may not be amiss to urge upon such the careful observation of this element, and to assure them that often it alone brings the light which can rightly decide the choice between two remedies, so equal else may the claims of each be, till the case is so decided. The same remark is equally applicable to whatever circumstance aggravates or relieves the sufferings of the case.
The disposition of the patient is also often very significant of the relationship of the proper curative to the case. It is often decisive between Aconite and Bryonia; Pulsatilla and Sulphur, etc. This should never be overlooked.

Having made all the necessary preliminary examinations and drawn out all the essential elements of a case of rheumatism, how shall the curative be found? To show the manner of this will be one object of the remainder of this paper.

When about to attempt a prescription, after the individualization which has been insisted on, and after noting that the case has attacked one or more of the joints with swelling, which is red, hot, painful; the skin is burning and dry or moist, it may be either; the patient has great thirst; the affected parts are intolerant of touch and motion; the pulse has increased frequency, fullness, and hardness; the urine is scanty and high colored. These are the symptoms ordinarily met at first visits to acute, or, as it is often called, and well enough, inflammatory rheumatism. It is a tolerably complete picture of such a case, for all purposes except prescribing; and yet for this, it is all but valueless. With only these elements, a Hering is as powerless for a specific prescription as the veriest tyro, and even more so. He would clearly perceive the necessity of a knowledge of other elements, before such a prescription could be made, and consequently would do nothing till this should be gained, while the tyro would guess, move, and probably blunder and fail. The case so presented has nearly equal claims on Acon., Arn., Bell., Bry., Dulc, Nux v., Puls., Rhus tox., so nearly equal that no man can say that one should be preferred to the others, and yet the physician must select. There are two courses open to him, and whether he takes the one or the other depends much on the knowledge he has of the Materia Medica, and his personal habits of practice. A very moderate share of this knowledge will probably suggest the above named remedies, and perhaps some others, and if his habits of prescribing are loose he will begin by giving two or more of them in alternation, at short intervals, and substituting others for those first selected, if these fail, as most likely they will, till the series has been run through, if the right remedy have not been stumbled on before, and then if the poor patient is not relieved, the prescriber is at the end of his tether. It is certain that this course sooner exhausts the number of supposed available remedies than a simpler and exact one, but it as certainly fails to show any other very obvious recommendation for its adoption, while to it there are two very strong objections. The first is it begets and perpetuates a loose practice, with no definite aims, and can rarely be followed by definite results, other than decided failures. It must be regarded, if rightly, at the best, as only a convenience of either indolence or ignorance, in the first instance, and perhaps of habit afterwards. The second objection is, we have no certainty in this course of practice, that the second remedy given will not injure or destroy the specific curative action of the first, if it be perchance specific, or the first that of the second. We have no right to infer from them conjointly the sum of their actions when employed singly. That they do continually modify the action of each other when so employed there can be no doubt. How, no man can tell. This objection must be fatal to whatever of claim may be set up for this course as an example of specific practice. There may be added a third objection. When the practice is not successful, it leaves the case in increased, and often inextricable, confusion. A further discussion of the practice of alternating remedies is deferred to a future occasion, when we propose to show the class of cases where it may be admissible, and the principles by which it should be governed.

The second course is to proceed to the discovery and analysis of the other symptoms of the case which alone can show its true nature and the remedy required for the cure. The general symptoms of the case supposed are strongly suggestive of Aconite, at the first glance, but a second look, and the query arises, may not Bryonia be better, or Arnica, or Belladonna, or Rhus tox.? The group of symptoms here given is well represented in the pathogenesis of Aconite and Bryonia, but there are differences in the other symptoms of these drugs. The disposition under the sufferings of these two remedies is not the same, nor is there much need of confounding the two. Aconite is characterized by loud complaints and outcries, with weeping, tears and despairing anxiety. Any attempted playfulness, on the part of attendants, for the encouragement of the patient is very offensive to him. He is timid, and intolerant of noise, even musical sounds offend. Bryonia has not the characteristic outcries and complaints of Aconite. Its general tone of disposition is more subdued, or easily excited to anger. It has weeping and despairing with Aconite. Thirst with the two is somewhat different. With Aconite the thirst is incessant, while with Bryonia the calls are occasional for large draughts of cold drinks. In the general symptoms given above there is much resemblance to those of Bryonia and Nux vom., but these drugs differ in the disposition they excite, and also in the time of their aggravation. Nux is after midnight and morning. Bryonia, evening and before midnight. Aconite, evening and night. The disposition of Nux is sad, depressed, silent or angry, despairing of health and recovery. Excessive sensibility to all external impressions. The slightest jarring or concussion is insupportable. The patient complains much of his sufferings but is not so loud, as are the outcries of Aconite. He is impatient of the least opposition. Arnica, in disposition resembles both Nux and Pulsatilla; Nux, in its angry irritability, Pulsatilla, in its despairing hopelessness. The great irritability of Arnica is of the mind; of Nux, of the senses. In periodicity Arn. ranks with Puls., evening and night. In disposition Rhus resembles Puls, but in periodicity Nux. The patient is depressed, sad, without courage, despairing, tearful, with exacerbations chiefly after midnight and morning. Belladonna, in disposition, ranks with Nux, but the manifestations are more violent; its period is rather with Puls., afternoon, evening, and before midnight. The disposition of Dulc. is angry, impatient, morose; which rather affiliates it with Nux, but its period is that of Puls., evening and night.

The quality of the pains is an element of importance. With the above named remedies we have with Acon. pressure like a weight, shooting, as if bruised, tearing (drawing). With Arn. pains as if bruised, broken, dislocated, burning, cutting. Bell., shooting or tearing pressure, and cramp like. Bry. has painful tension, like bruise, shooting, as if the flesh were loose on the bones. Dulc, dull shootings, shooting drawings. Nux v., like bruise (in the joints), painful tension, drawing. Puls., drawing, fine shootings, drawing especially in the joints, like the pains of abscess, on touching the affected part. Rhus, tension, drawing, tearing with sense of dull numbness after motion, shooting (in the joints), like a bruise, like a sprain, as if the flesh were loosened on the bones, paralytic pains (in the joints).

It will be seen that while some of the pains are repeated by the different medicines, there is on the wholes marked individuality in the others, not easily overlooked. In the case of the repetitions, other symptoms must decide the choice of the remedy. The aggravation or relief of pains by motion is an element of the first importance to a specific prescription. In those cases, with the symptoms given, where the pains are increased by motion, if the exacerbation occurs evening and night, Bry. is appropriate; if after midnight and morning, Nux v. When the pains are relieved by motion, and the exacerbation is after midnight and morning, Rhus tox. is called for; if in the evening and before midnight Puls. or Dulc. In relation to the relief of pain by motion, it should be remembered that in many cases of this kind, the pains are much increased by the beginning of motion, though relieved by its continuance. This is true of many of the pains of Rhus.

In the matter of the swelling, it is intense with Acon., Bry., Puls. and Rhus. It is bright red with Acon. Bright and shining with Bry.; with Puls. and Rhus the color is more dull; with Arn., blvmh. Bell. is likely to show an erysipelatous hue, while the swelling in cases characteristic for Dulc. and Nux v. is likely to be less intense. With Nux the color is dull; Dulc. brighter. If the swelling be oedematous, especially of the feet or ankles, Merc. sol. is the remedy.

As to the exciting cause of the variety of rheumatism presented in the group of symptoms given above, it may be stated that most of these cases are the result of atmospheric impressions. Sudden change of temperature from a higher to a lower degree. Continued cold and damp, or cold and dry weather; small jets or currents of air falling upon an individual for a length of time, are all sufficient to produce rheumatism in persons predisposed by their vital condition to this form of disease; and the variety most likely to result is that which we have been considering. In its relationship to remedies it will be found that those cases caused by cold dry air will most frequently call for Acon. and Bry.; cold damp air, Dulc. and Rhus; from currents and jets, Nux and Puls. Rhus has this specialty that it is almost a specific for those cases contracted by exposure to chill and rain. Puls. shares with Rhus a relationship to cases contracted by exposure to rain, while it is especially appropriate to cases caused by protracted wet weather.

We have attempted by the analysis of the above group of symptoms which generally represents rheumatism accompanied by fever to point out its relationships to remedies, and also to show the method by which those relationships are ascertained. For this purpose we have taken a group most commonly met in acute cases and have purposely avoided in its consideration the many modifying symptoms and circumstances which are sometimes associated with this group, and which indicate or establish relationships to other remedies. This has been avoided because it has been thought a view of the simple case better adapted to the object in view—to show the homoeopathic method of dealing with this sometimes obstinate enemy. This being clearly understood, it is easy to extend its application to other cases composed of more numerous elements, it being only an extension of the same process.

Thus, if with the symptoms considered, the swelling and pain suddenly leave the joint affected and appear with the same attending phenomena in another, how are we to decide on the remedy?  Am. and Puls., among the remedies cited above, have this peculiarity of sudden transition from joint to joint. It will not be difficult to decide which is the right, if we note the character of the swelling and the disposition of the patient. In both these elements the remedies differ, as has been already noted. But there is another variety of rheumatism with erratic pains, which has neither heat, redness nor swelling, which is relieved by other remedies. Sulphur if the pains are increased at night and by the heat of the bed; Nux mos., if it has been the result of protracted cold, wet weather; Asaf., if the seat of the pain is in the periosteum.

The difficulty of bringing the different forms of rheumatism into classes, the better to show their relation to remedies, is scarcely less than that of giving a definition of the genus. This grows very much out of the fact that the same remedy, on examination, will be found required in individual cases of several, and perhaps many classes. That most common division into acute and chronic is of very little avail in practice, many remedies being almost equally called for in both Nux vom., Puls., Rhus, and Sulph. are examples of this. Besides, the curative power of a drug in a given case depends on the similarity of its pathogenesis to the symptoms to be cured, and not much, generally, on the duration of the case. In view of this difficulty it has been decided in what we have to say on the relation of rheumatism to remedies, to take these up and point out some of the more common and prominent symptoms of each, by which they may be related to cases in practice.

Ant. crud., if there be drawings, shootings, and tensive pains; shortening of the muscles or tendons, with bending of the limbs; the pains are aggravated by warm air and heat of the sun. It is chiefly appropriate in rheumatic inflammation of muscular tissue; especially of the biceps flexor cubiti. It is oftener appropriate in chronic than acute case's.

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