Arthritis and rheumatism Comment on 12 months" consultations

GEOFFREY MARTIN, FRCP, FFHOM

Case material During the twelve-month period 1.10.80 to 30.9.81, 155 patients with "rheumatic disease" were referred and followed up. The patients were selected in that they were all referred outside the NHS by their family doctors, and they were largely, but not entirely, from social classes I-III.

The record and analysis would have been more useful if it had been possible to include patients referred to hospital outpatients during the same period. For technical and other reasons this was not possible. Against this, however, observa- tions in this analysis were consistent in that they have been made by one physician alone. This would not have been possible from hospital outpatients.

For analysis and comment the 155 patients, 34.2% male and 65.8% female, were for convenience divided into unusual clinical groupings. These are tabulated as follows:

No. of Sex Percentage of Classification patients Ma le Female total seen

1 Inflammatory polyarthritis 23 11 12 15 20steoarthritis of hip 14 3 11 9 3 Osteoarthritis of knee 20 7 13 13 4 Osteoarthritis of elbow 2 1 1 1.3 5 Osteoarthritis & disc lesions of spine 43 13 20 28 6 Primary generalized osteoarthritis of menopausal 24 5 19 15

type 7 Cervical spondylosis 30 5 25 19 8 Ankylosing spondylitis 2 2 - - 1.3 9 Psoriasis with arthropathy 2 2 - - 1.3

10 Primary hyperuricaemia 2 2 - - 1.3 11 Infective arthropathy 1 1 - - .6 12 Connective tissue arthropathy 2 - - 2 1.3 13 Shoulder joint lesions 5 1 4 3.2 14 Chronic muscular & ligamentous strain 2 - - 2 1.3 15 Psychological rheumatism 2 - - 2 1.3

In the series, of the less common rheumatic diseases no patients were seen with septic arthritis, Henoch-Schonlein purpura, pure primary myositis, pyrophosphate arthropathy (pseudogout) and, especially interesting, polymyalgia rheumatica.

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Patients with osteomalacia and neuropathic joints were not included, nor were primary injuries. The latter have been regularly reported in the homceopathic literature and the value of homoeopathic treatment generally acknowledged.

Each clinical subdivision will now be dealt with in detail.

1 Inflammatorypolyarthritisoftherheumatoidtype Different countries have different names for this chronic and potentially sinister disease. Worldwide records show that 3% of females and 1% of males are affected; 75% of rheumatoid patients are seropositive to the Latex/Rose test and 20% have antinuclear factor in their blood.

By the time they reach a consultant physician, the majority will have had initial lassitude, loss of appetite and mild fever. This will be associated with morning stiffness, pain and swelling of joints. Commonly, these are the metacarpo- phalangeal and proximal interphalangeal of the fingers, knees, wrists, neck and sometimes feet, but on occasion even only one joint may be involved. Untreated the disease, if mild, may remit or pass into gross deformity from permanent contractures of the fingers, knees and elbows. Subluxation of the wrist is common. Other lesions may involve skin, eyes or lungs. The differential diagnosis is from lupus erythematosus (high circulating LE cells), ochronosis (homogentisic acid), gout, polymyalgia rheumatica, scleroderma (skin and X-rays), neuropathic joints, osteoporosis and other less common diseases.

In this series all patients were studied by radiology and in the laboratory. One interesting finding was that no clinical difference in response to homoeopathic treatment could be found in patients who were seronegative or seropositive.

The course of rheumatoid arthritis is so variable and indeed unpredictable that I find it unhelpful to give any precise figures in the way of results. Like the Glasgow Rheumatic Study, this may come from a careful statistical study within a Dept of Rheumatology, by a joint team of conventional and homoeopathic physicians; it is hoped that the new Research Dept of the Royal London Homoeopathic Hospital may take on this task.

Surgically three patients had had knee synovectomies with much benefit; some had had appropriate ankyloses, but three patients who had had joint replacement in the hands had all been unsuccessful; two had had their artificial finger joints removed and were without formal finger joints at all, yet nevertheless had remarkably useful residual function, limited though it was.

Careful constitutional prescribing is the bedrock of treatment in this generalized disease. Over three-quarters of the 23 patients seen in this study themselves felt that hom~eopathy had helped them to a significant degree. Most of these had reduced their conventional treatment (aspirin in full dosage, non-steroidal anti- inflammatory drugs, penicillamine and cortisone) by half and they remarked on the improvement in their general health and well-being.

One patient whose improvement I had rather diffidently discussed with her con- ventional family doctor led to his reply: "Not improved? She is transformed."

There was one patient with juvenile polyarthropathy (Stills disease). When seen his condition was serious; the disease was active clinically and biochemically. He was on extensive conventional polypharmacy including penicillamine, cortisone

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and non-steroidal anti-inflammatory agents all together. It was not practicable to withdraw these and he made no improvement with homoeopathic treatment, which was abandoned after four weeks.

20steoarthri t is of the hip Fourteen patients were referred, with 16 hips involved; 3 were male and 11 female. Twelve were of the "degenerative" type, 2 arose in patients suffering from extensive rheumatoid arthritis. One patient had developed arthritis following Perthes' disease in adolescence.

Of the degenerative patients, 8 have had successful operations and have not needed subsequent hom0eopathic treatment. Six have not had an operation; two were very early and mild (both had been diagnosed as having lumbar disc lesions by their family doctors, but had the characteristic early reduction in circumduction of the hip) and one felt that at 73 she was too old for operation. This is of course not so, as I have seen an international ballet examiner who had both hips so well replaced at 77 that she resumed dancing.

Of the non-operated patients who were severe enough to have been previously referred for operation, six have done sufficiently well with hom~eopathic treat- ment not to be considered for operation (at the present--and we hope never!) Four were able to reduce their analgesic therapy by half or more.

The patient with Perthes' disease was a solicitor aged 43, with a strong sporting history, who developed this ailment at 17. He came crippled, following unsuccess- ful conventional medical treatment. His radiograph was reported as showing "severe arthritis" of the hip. After 6 months' treatment he reported "I forgot myself the other day and took my young daughter for a 3 mile walk without trouble"!

The early stages of this degenerative disease are increasing fatigue, pain and tenderness in the inguinal region associated with stiffening of the joint. The loss of mobility is at first most marked in extension, internal rotation and adduction, later in forced flexion and adduction, and finally the patient puts his weight on the sound hip and the affected hip is held in flexion, adduction and external rotation.

The pioneering surgery of Judet has led to the widespread use of the Charnley low friction total hip replacement operation. In experienced hands and in the wards of a well-trained and interested department of orthopaedic surgery, the results are highly impressive and indeed dramatic. In my experience, however, where these preconditions are not met- -and this is not uncommon even in centres of excellence--a definite if low failure rate results. These patients are always worse than before. The family doctor has indeed a most important role here in advising his patient wisely.

30steoarthri t is o f the knee This condition can arise as a primary degenerative older age process or following disorganization of a knee affected with rheumatoid arthritis.

I was surprised at the number of patients (20) referred with osteoarthritis of the knee. Twelve were part of widespread inflammatory "rheumatoid" type. One was primarily from injury and multiple cartilage operations, but the remaining 7 were

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of the degenerative type, so called because no other cause than age can be attributed.

Several of the patients were very definitely overweight; only a small number co- operated with the necessary dietary regime. As Hahnemann stressed, the need for the removal of any cause is especially appropriate here. Important though homoeopathy is, it is but one aspect in the overall management of a patient.

Synovectomy had been successfully carried out on 3 patients. Sixteen of the patients had a useful improvement with homoeopathy, but 4 were failures. Before consultation some had been under the threat of an artificial knee replacement. This in general was discouraged because the operation is still experimental. All patients so threatened felt that the improvement from homoeopathy and ancillary methods-- in some cases little--was sufficient for them to decline the operation.

40steoarthritis of the elbow Two patients were seen with osteoarthritis of the elbow. One was male and the other female. The female patient was aged 53 and had associated pain and stiffness in her shoulder. She was considered to be a variant of primary generalized osteoarthritis of the menopausal type, and made no response to homoeopathy. The other was a male teacher aged 57 with marked osteoarthritis of the elbow with a painful plantar spur on the heel. He made no improvement and actually deteriorated under homaeopathic treatment: conventional treatment was equally ineffective.

5 Spinal "rheumatism and arthritis" To read the literature alone it might be supposed that a clear-cut,pathological diagnosis could be made with some ease in any patient. Whilst this is undoubtedly true in some individual cases, there are many more where no such certainty can exist. Thus any analysis of the 73 patients in this group must be taken with reserve.

Of these 73 patients, 30 (just less than half) had pain coming from the cervical spine. They are discussed separately. Forty-three pat ients--20% of the 155 patients in the series--had pain coming from the thoracolumbar or sacral region. Of these, 30 (two-thirds) were female and 13 male. Twenty-five patients were thought to have predominantly "disc" lesions and 18 degenerative osteoarthritis.

As compared with cervical and lumbosacral regions, rheumatic lesions of the thoracic spine have been less well reported in the past. Acute arthritic and more chronic disc lesions are not common but do occur. Compression fractures are not uncommon in osteoporotic old ladies and often lead to a very severe and crippling but rarely very painful thoracic kyphus. Congenital deformities occur, and a hermivertebra, for instance, gives a very marked kyphoscoliosis. Orthopaedic surgeons today are often keen to "screw out" such deformities. Except in unusual cases, their help should be avoided.

Whilst spinal pain may be the presenting symptom, irritation of the spinal root is much more interesting. It must always be considered in the differential diagnosis of any thoracic or abdominal pain. "It can mimic pleurisy, pericarditis, hiatus hernia, mediastinal lesions, angina, gall bladder or stomach conditions. The pain is

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of a burning, pricking, tingling neuritic type, clearly defined to a dermatome. One patient in this series was a young teacher of 23 who had had five gastrointestinal and gall bladder radiographic studies at two different hospitals. When he was turned over the cause of his pain was very clear from the well disguised but gross kyphoscoliosis.

One aspect of spinal root irritation I believe is helpful in explaining the otherwise inexplicable persistence of shingles pain in the elderly. Afferents from the effects of the viral neuritis join with afferents from the root involvement from degenerative osteoarthritis, and summate to lead to long-standing--indeed some- times permanent--perception of pain. In my opinion summation comes first in the persistence of postherpetic pain, the chronic pain syndrome comes, if at all, later.

To distinguish primary degenerative osteoarthritis from disc lesions clinically, there is often quite good flexion but very poor hyperextension of the lumbar spine, whereas the reverse is true from acute or chronic disc lesions. Radiology, however, can be very helpful, and in difficult cases, scans, radiculogram and myelograms may be needed.

I have little faith in conventional physiotherapy, but at times local injections, osteopathy or manipulation can be helpful. Some patients had tried acupuncture before referral, but only two patients in this series reported temporary benefit.

Traction is very popular with orthopaedic surgeons--most of my patients had had this before referral and there were very few indeed who could give this conventional treatment any praise. The anatomy and function of the lower spine is directed towards support. Thus bed rest on boards in disc lesions is mandatory in an acute case and I favour temporary support thereafter by a surgical corset from a reputable maker. Even then its fit should be checked by the physician, for I have seen an old gentleman wearing a corset upside down. At any sign of recurrence the corset can be reapplied.

However, the combination of a sensible physical regime, adoption of suitable ancillary measures, encouragement, selection of the appropriate constitutional remedy or less frequently symptom-prescribing can help considerably. On the patients so reported, I felt that two-thirds had had improvement and half showed considerable improvement, equally between female and male, in men even to the extent of being able to resume again their occupations, and women their house- hold duties.

There were no cases of Paget's disease or secondary cancer deposits in this series, but they must always be considered. Impending litigation will delay any cure.

6 Primary generalized osteoarthritis of the "menopausal" type Primary generalized osteoarthritis or arthrosis--have it as you will--is probably one of the most outstanding pathological problems in rheumatology. It is also one in which treatment is most neglected. At best it is treated casually by the profes- sion. Often even by homoeopaths it is treated only on symptom-prescribing. Treatment on homoeopathic constitutional lines is the only treatment I have in the long term found worthwhile.

It is commonly described as a complaint of women starting up to 2 years after

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the menopause, and generally thought to run a mild course in the smaller joints of the hands and fingers lasting perhaps two or three years, then subsiding.

However, in my experience, it can occur not uncommonly in middle-aged men and the course can be much longer, even up to 10 years. One or more of the bigger joints may be more seriously involved, but most have involvement of the distal and proximal interphalangeal joints and have marked Heberdens nodes. The Irish physician Heberden first described these well-known nodes in the middle of the eighteenth century, but has more claim to fame in his clear description of angina and its course.

Whilst a certain number of women had their symptoms shortly after the menopause, and some had a longer interval, an appreciable number had their first symptoms well before the cessation of their menses.

It is well known that while hormone replacement therapy in menopausal patients may dramatically improve the patients serendipity, it does not help with the joint symptoms. I found, however, that in patients who had marked disturbances of their menstrual cycle and flow--irrespective of whether their arthritic symptoms came before or after the menopause--special attention to these changes was paramount in making the homoeopathic prescription. In fact in women who menopausally had subliminal surges of ovarian hormone production, homaeopathy was almost always clearly indicated and very helpful.

7 Pain in the neck "cervical spondylitis "---"cervical spondylosis" Most of the men had symptoms for over 3 years and the women for over 6 years, but 75% of patients had a worthwhile improvement as judged by patient and doctor; 15% were judged unchanged and 10% deteriorated within the times of study.

Conventional medical authorities say that most neck pain is cervical spondylosis, and generally psychosomatic or psychogenic in origin and largely "tension". Indeed they argue that radiological changes unless extreme are of no significance. My studies of neck disease, however, make me feel that our rheumatology colleagues are talking from the book and not from experience. The fact is that a very great deal of neck, shoulder and arm pain is organically determined. Soft tissue pathology does not show up on X-ray; radiology can be a very poor help in diagnosis, for the absence of bony change does not exclude soft tissue damage.

Radiologically evident osteophytes should not be needed for a diagnosis of spinal root irritation. The type of pain--neurit ic--is almost invariably a "burning", often with dysaesthesia, and with evident dermatotomic distribution. Of course, chronic pain and the consequent anxiety can aggravate the symptoms, but the anatomy and pathology is there, easy to perceive. It is just not true that most patients with pain in the neck are psychosomatic. Many cases are clearly due to disc degeneration--but not all. Many have a disturbance of posture and may have compensatory symptoms in the lumbar spine--at times indeed it may be the disease in the LS spine that is primary to cervical pain.

Cervica! discs are subjected to particular dynamic and pressure stresses as a result of lifting and carrying loads, especially when done with out-stretched arms

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or when leaning forward, as well as when sudden uncoordinated movements are made.

8 Ankylosing spondylitis In this series only two patients were suffering from ankylosing spondylitis. Both were male, one responded partially to hom~eopathy and the other did not. A pottery worker aged 34 had had symptoms for 10 years. He gave a classical history of preliminary transient dragging pains in joints and muscles; when he was seen, he had limited spinal mobility with much pain especially in the night, with general malaise and loss of weight. He developed progressive stiffening of the spinal column with the development of an exaggerated lordosis of the cervical spine. Thoracic kyphus, flat restricted chest movement and girdle chest pain were present and he developed the chronic pain syndrome. His X-rays showed sacroiliitis, involvement of spinal apophyseal joints and the symphysis pubis. There was calcification of anterior and lateral spinal ligaments, "squaring" of vertebra, and ossification (bamboo spine).

Conventional treatment was by mobilization of the thoracic spine as f~.r as was practicable, in particular Klapp's crawling and low crawling exercises were stressed. Homeeopathy did not help.

The other was a working farmer of 43 who had to give up most of his activities on the farm. He had marked deformity of the left leg and came in to see me using a stick and hobbling in pain. After 5 months' hom~eopathic treatment his pain had been reduced by half; he had halved his analgesic therapy, and he had resumed driving his tractor and the week before he had put in 400 yards of heavy fencing. He was very satisfied with his progress. Treatment is being continued.

9 Psoriasis with arthropathy Arthritis is reported as occurring in 10% of patients suffering from psoriasis. It must not be forgotten that an inflammatory polyarthritis of the rheumatoid type can occur in a patient who coincidentally has psoriasis. Clinical separation is not always easy, though involvement of the distal interphalangeal joints is helpful. Laboratory investigation can help to identify, for 75% of cases of psoriatic arthropathy have HLA.B27 present and all have negative rheumatoid and anti- nuclear factors. Surprisingly the serum uric acid is varied in 30% of cases. Homoe- opathy helped in neither of these cases.

10 Primary hyperuricaemia (gout) Three cases of gout were recorded in this series. With this interesting metabolic disorder, the clinical course varies so unpredictably that I do not feel 1 can truly assess the value of homceopathic treatment. This is not to deny that homoeopathic prescribing may be of help in preventing attacks; but I have not been especially impressed with hom0eopathic treatment in acute gout as compared to conventional therapy. Pyrophosphate arthropathy (pseudogout) may need to be distinguished by joint aspiration of calcium pyrophosphate crystals. Also haemochromatosis, hypercalcaemia and hyperphosphatasia must be excluded from the diagnosis.

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11 Infective arthropathy In this series there was one young man with Reiter's disease following known sexual exposure. Though this man had a determined trial of homeeopathy, his disease was of the relapsing kind and I felt homeeopathy was of no real value. The help he had from conventional non-steroidal anti-inflammatory drugs was equally dubious. No other infective arthropathy was seen in this series.

12 Connective tissue disease Two cases of connective tissue disease were seen in this series. Both had been diagnosed before referral. One was a housewife of 43 with a 5-year history who had pain and stiffness around the neck and shoulders associated with a high count of LE cells in the blood. Her ESR was 67 mm/h and she needed prednisone 10 mg t.d.s, before she had suppression of her symptoms. After 5 months' constitutional prescribing she was still on prednisone, but it had been reduced to 7�89 mg a day and her sedimentation had fallen to 28 mm/h. A further reduction ofprednisone is anticipated. As well as having had her pain reduced, she feels very much better in herself. The other patient was a lady of 37 with relatively minor joint symptoms but an active SLE pathology in the kidney. She was under the care of a consultant nephrologist and was taking 10 g prednisone t.d.s. I would only agree to treat her if the nephrologist (whom I new well) would keep a close watch on her kidney condition. He was agreeable and thereafter monitored her exhaustively and more frequently. Constitutional prescribing led to a complete relief of joint symptoms and on my advice a slow, steady reduction of prednisone to 2.5 mg b.d. She is still under combined observation and treatment.

13 Shoulder joint pain Five patients with symptoms predominantly in the shoulder joint were seen. One female patient had associated lumbosacral arthritis and was thought to be suffering from primary generalized osteoarthritis, and another had osteoarthritis of the elbow. The remaining 7 had varying degrees of periarticular capsulitis (Codman's bursitis, frozen shoulder). Four patients had no benefit from homeeopathy, but one patient and an identical clinical picture responded within 6 weeks to pathological prescribing (Ruta 6ell t.d.s.). In general I find most patients with frozen shoulder are best treated with intracapsular HCI injection; this may need to be repeated once or twice for full resolution.

14 Chronic muscular and ligamentous Such patients are mainly fat and out of condition. They need much encouragement and help, but even then the results are poor by any method of treatment, conventional or homoeopathic. Compliance is poor and often they are not worth the effort that has to be put into helping them.

Two patients were seen who could be so classified. One was a very plump and square farmer's wife aged 60 who had a ligamentous strain of right ankle, also a recently fractured poorly set left ankle, and was very overweight. The joint was painful and the surrounding tissues swollen and thickened. She did not respond to homeeopathy, either on constitutional or pathological prescribing, but rapidly resolved after injections of hydrocortisone.

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The other patient was part of a generalized rheumatoid arthritis.

15 Psychological disease masquerading as rheumatism Two psychological cases were seen in which in spite of a full history, clinical examination, radiology, and biochemistry, no organic disease, rheumatic or otherwise, could be found. Both had long-standing major stress and bad social histories; these could not be alleviated. One made no improvement with treatment and defaulted, not wishing,. I think, to recover. The other has made slow improve- ment and treatment is still continuing though it is somewhat of a strain both to him and to me!

Most patients with primary generalized osteoarthritis or cervical spondylosis (the conditions are virtually but not entirely similar) are said to be psychosomatic: whilst a proportion of the community are anxious individuals--as indeed a large proportion of the public are said to be - - in all the cases of primary generalized osteoarthritis that I saw in this series, psychological factors were minor and only contributing a small part to the symptomatology.

Chronic pain syndrome In the last 15 years there has been a change in attitudes towards the concept of pain. This has given new insight and understanding which has led to the formula- tion of the "chronic pain syndrome". In this, pain is now regarded in a much wider sense as if it were a disease in its own right. Whilst this has led to a new medical speciality centred around Pain Centres, the concept interlocks neatly with the whole ethos underlying homaeopathy.

For instance, it has been demonstrated that pain receptors can be sensitized by bradykinin; Beck has shown that local application of this polypeptide increases the frequency of the (afferent) discharge in response to a standardized heat stimulus.

The analgesic opiate substrate in the brain stem probably activates, via the monoanergic descending tracts, opiate neurones in the spinal cord and in the trigeminal nucleus. The latter in their turn inhibit, via a presynaptic action, the release of substance P from the nociceptive afferents to the synapse of the second neurones.

The chronic pain syndrome is likewise of great importance; it must be diligently sought for, evaluated and considered in the prescription. The patient's family can help the patient find a new style of living, help him to find his real self again and to learn to live with the pain. But it is not only mental factors which are of importance; physical influences can also affect subjective experience of pain. Systemic effects such as fever, anaemia or loss of appetite, or concomitant illnesses (for example, those of cardiovascular nature) can also lead to intensifica- tion of pain. The same applies of course to adverse reactions to drugs, especially in certain cases related to dizziness, headache, nausea and gastro-intestinal complaints.

Finally, any symptom--and pain is the commonest--which arises from an actual lesion can take on a different deeper significance when coloured by the personality.

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Prescribing for arthrigs and rheumaHsm When I first took an interest in treating rheumatoid disease by homoeopathy, Hench's cortisone was about to become the cure-all wonder drug. Spa treatment reigned supreme and only aspirin and gold had any serious place in treatment. When the dangers of cortisone therapy became evident, and non-steroidal anti- inflammatory drugs arrived, I wondered if homoeopathy would work in patients who had either been heavily drugged or who were addicted to their orthodox treatment.

There is controversy as to whether homoeopathic medicine works in patients receiving oral or parenteral corticosteroids. The subject is of twofold interest, for whilst I believe most homoeopathic remedies will not work when the cortisone 24- hour dosage is greater than 17.5% mg/day, constitutional homeopathic remedies carefully chosen most probably are effective when the dosage does not exceed 15 mg/day and are certainly effective when the dosage is 10 mg/day or less. But there is the second interest, for in my experience a well-chosen remedy can reduce the cortisone dosage by 50% or more, even down to 2.5 mg/day, which is a relatively safe level.

Intra-articular cortisone--so popular--and often rightly so in acute joint disease-~loes not interfere with homoeopathic treatment in any way.

Penicillamine, though useful in conventional hands in patients with chronic inflammatory polyarthritis, needs constant and careful observation. It-can rarely cause obliterative bronchitis, acute cholestatic jaundice and even morphoea-like skin lesions. One case I saw was interesting, for not only did he improve in himself when recommended that penicillamine was discontinued, but later, when a constitutional remedy was given, he improved still further.

Intramuscular gold is still being given by expert conventional rheumatologists. There is no doubt that in some cases it can be helpful, but often the toxic dose is close to the pharmacological. Recent work showed that Auranafin, an oral gold preparation, has a more rapid mode of action, a longer half life, inhibits lysozyme release and acts with an immunoregulatory potential not seen with gold anthiomalate.

The modern drug manufacturers are producing more and more "non-steroidal anti-inflammatory" drugs. There is a good deal of opinion that they are not much more effective than aspirin in larger doses. There is suggestion that their side effects are not so severe as from massive aspirin therapy, but this is not always so-- the solar photo-sensitivity from Opren can be disturbing. Their best use is in the relief of morning stiffness.

Hom~eopathy, however, does not have the disadvantage of potentially harmful side effects, as well as being substantially less expensive and very often more effective. Prescribing can be either on pathological evidence or by constitution. Some physicians would have it that "their" way of prescribing is the only way. Those of a wider experience, however, would confirm that help can be given whichever approach is adopted. Especially in dealing with local symptoms which are often episodic, pathological prescribing can be most helpful. When the whole being of the patient is involved, whether physical or mental in preponderance, then constitutional prescribing is very often better. In arthritis of the menopause both

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aspects are involved; in arthritis of the hip predominant ly the physical; in inf lammatory polyarthri t is both aspects, with a superimposed chronic pain syndrome.

There are some patients who benefit from a combined approach. In this series the homceopathic t reatment, whether local or general, single or combined, has been given with the benefit of the patient in mind, not with any doctrinaire approach. Most patients were given the medium range of potencies, 6cH or 30cH twice or three times a day, though 6x and 3x have been used with benefit in patients with gross pathological changes, such as osteoarthri t is o f the hip. Where, however, "s trong mentals" were present, an occasional 200cH repeated in 24 hours was given. Though used very occasional ly, 1M and 10M potencies from previous experience were found to be less useful and used only rarely, better results being obtained from lesser potencies in repetition. It is my belief that the use of the lowest potencies (3 and 6x), now neglected by many, could lead to a marked overall improvement in the t reatment of chronic rheumatic disease.

S U M M A R Y

With an eye to effect it is said that doctors get the patients they deserve. A more true general statement is that they get the patients with diseases in which they are interested. Nevertheless, the rheumatic diseases are so common at all ages after youth, and homoeopathy has so much to contribute to the management of these illnesses, that it is instructive to record and analyse the case- load of rheumatic disease referred to one consultant physician over a twelve-month period. There will be a brief reference to the concept of the chronic pain syndrome, and to certain aspects of homoeopathic prescribing in general, but not to the materia medica of individual remedies or the homoeopathic treatment of individual patients.

Five Sulphur eases

KURT-HERMANN ILLING, MD

Today , I would like to present five patients t reated with Sulphur. Sulphur is found in three amino acids---cyst in , cystein, and methionin. It therefore is an impor tant consti tuent of many proteins, e.g. serum albumin. Regulating sulphur metabolism, it acts deeply into the metabolic processes, and in potentized form therefore plays such a major role in homeeotherapy that Hahnemann called it his great psora remedy, and Kent wrote in his Materia Medica, "Sulphur is such a full remedy that it is somewhat difficult to tell where to begin".

Paper read to the 35th LMHI Congress, Brighton, on 1 April 1982.

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