THE UTILITY OF RHUS TOX IN

“ANKYLOSING SPONDYLITIS”

By

DR. MAMATA GIDNAVAR  

Dissertation

Submitted to the

Rajiv Gandhi University of Health Sciences,

Karnataka, Bangalore

In partial fulfillment of the requirement for the award of the degree of

DOCTOR OF MEDICINE

IN HOMOEOPATHY

(HOMOEOPATHIC MATERIA MEDICA)

Under the guidance of Dr. S. S. DIVATE M.D. (HOM)

PROFESSOR AND GUIDE

DEPARTMENT OF HOMOEOPATHIC MATERIA MEDICA

BHARATESH HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL, BELGAUM – 590016

2009

DECLARATION BY THE CANDIDATE

I here by declare that this dissertation / thesis entitled THE 

UTILITY OF RHUS TOX  IN  “AKYLOSING  SPONDYLITIS  "  is a

bonafide and genuine research work carried out by me under the guidance

of Dr.  S.  S.  DIVATE  M.D  (HOM),  Professor and Guide, Department of

Homoeopathic Materia Medica, Bharatesh Homoeopathic Medical

College & Hospital, Belgaum.

Date: DR. MAMATA GIDNAVAR 

Place: Belgaum

 

CERTIFICATE BY THE GUIDE

This is to certify that the dissertation entitled THE UTILITY OF 

RHUS TOX IN “AKYLOSING SPONDYLITIS " is a bonafide research

work done by DR. MAMATA GIDNAVAR  in partial fulfillment of the

requirement for the degree of DOCTOR OF MEDICINE

(HOMOEOPATHY) in Homoeopathic Materia Medica.

Date:

Place: Belgaum

Dr. S. M. DIVATE M.D. (HOM) Professor and Guide,

Department of Materia Medica,

Bharatesh Homoeopathic

Medical College & Hospital,

Belgaum- 590016.

 

 

ENDORCEMENT BY THE HOD, PRINCIPAL/HEAD OF

THE INSTITUTION

This is to certify that the dissertation entitled THE UTILITY OF 

RHUS TOX IN “AKYLOSING SPONDYLITIS " is a bonafide research

work done by DR. MAMATA GIDNAVAR  under the guidance of

Dr. S. S. DIVATE M.D. (HOM) Professor and Guide, Department of Materia

Medica, Bharatesh Homoeopathic Medical College and Hospital

Belgaum.

Dr. S. M. ANGADI M.D. (HOM.)              DR. S. B. KONKANI M.D. (HOM.)  

Professor, Guide, HOD of Principal

Department of Materia Medica Bharatesh Homoeopathic

Bharatesh Homoeopathic Medical College and Hospital

Medical College and Hospital Belgaum- 590016

Belgaum-590016

Date: Date:

Place: Belgaum Place: Belgaum

COPYRIGHT

Declaration By The Candidate

I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the rights to preserve, use and disseminate

this dissertation in print or electronic format for academic / research

purpose.

Date: DR. MAMATA GIDNAVAR 

Place:

© Rajiv Gandhi University of Health Sciences, Karnataka.

ACKNOWLEDGEMENT

An endeavour of this work is the result of contributions from several quarters.

First and foremost, I am thankful to God for bestowing upon me patience and

fortitude to complete this work. A journey is easier when you travel together.

Interdependence is certainly more valuable than dependence. This dissertation is a

result of hard work during which I have collaborated with many people for which I

have great regards and wish to extend my warmest thanks to all those who have

helped me in this endeavour.

I wish to express my heartfelt gratitude to reverend teacher and Guide

Dr.S.S.Divate,M.D.(Hom), Professor, Dept of Homoeopathic Materia Medica, Bharatesh

Homoeopathic Medical College & Hospital, Belgaum under whose supervision this

work of dissertation has been accomplished. It was only due to his patient guidance,

constant encouragement, inspiration and meticulous attention that I have been able to

complete this study.

I owe a great debt of gratitude to Dr. Shrikant Konkani,M.D.(Hom) Principal,

Bharatesh Homoeopathic Medical College & Hospital, Belgaum who is a pallor of

ingenious knowledge and wisdom in himself.

I express my sincere thanks to Dr, S. M. Angdi, M.D.(Hom), H.O.D. of

Homoeopathic Materia Medica whose invaluable help, stimulating suggestions and

encouragement helped me to go ahead with my thesis. He has always been available

whenever I needed his advise has been valuable during the preparation of this thesis.

With a deep sense of reverence, I extend my heartfelt obligations to our

beloved Dr. Raveendra Nadhan, M.D. (Hom), Bharatesh Homoepathic Medical College,

Hospital and Post Graduate Institute, Belgaum for his unflinching support and

constant encouragement during the course.

I owe my sincere thanks and gratitude to Dr. D.H. Ajgaonkar,M.D.(Hom), P.G.

co-ordinator, of this institution for their valuable timely guidance and suggestions

when ever and what ever needed.

I thank Dr. P.A. Choudhary,M.D.(Hom), Dept of Repertory,

Dr.Ramdas,M.D.(Hom), Department Organon of Medicine of this institution.

I wish to express my warm and sincere thanks to the staff of Department of

Materia Medica, Dr. C.J. Desai, M.D(Hom), Dr. D.S. Varoor, M.D(Hom),

Dr.Jairaj,M.D(Hom), Dr. Anand, M.D(Hom) and Dr.Lingaraj, M.D(Hom) for their support

and numerous fruitful discussions.

My special appreciation goes to my esteemed teacher Dr. Shahala

Nadaf,M.D(Hom) who has been my mentor, throughout the period of my study.

I express my gratitude towards the Management of Bharatesh

Homoeopathic Medical College & Hospital, Belgaum, for providing seat in post

graduate course in homoeopathy and freedom granted to me in availing all the

institutional facilities to carry out the study.

The most overwhelming enthusiasm, good will, love and affection have

generously come from Chairman, Institute, Teaching and Non-teaching staff, Medical

officers and Hospital staff for which I shall remain always indebted to them.

My deepest gratitude goes to my parents, husband, children, brothers,

teachers and friends for their unflagging love and support throughout this period.

Several colleagues have added to the luster of this dissertation, so it suffices

here to note my gratitude to Dr. Sudharshan Jinagond , Dr. Yogesh, Dr. Abhijeet, Dr.

Nandkumar, Dr. Mahantesh, Dr.Renuka, Dr. Varsha, Dr. Jaiprakash and Dr. Shivaji..

I express my sincere thanks to Mr. Umesh S.P. UniSys IT Solutions, and Sai

Xerox & DTP Centre, Belgaum for helping in completing the manuscript of this

dissertation.

I apologize, if I fail to mention those names that have equal efforts in this

work either directly or indirectly, I remain grateful to them in this regard.

I also thank the patients for their kind cooperation.

Dr. Mamata Gidnavar

LIST OF ABBREVIATIONS USED

AMA American Medical Association

AP Anteroposterior

Ars. alb Arsenicum Album

AS Ankylosing Spondylitis

Bell Belladonna

Br. Asthma Bronchial Asthma

Ca Carcinoma

CRP C- Reactive Protein

CT Computed Tomography

DISH Diffuse Idiopathic Skeletal Hyperostosis

DM Diabetes Mellitus

DRE Diagnosis-related estimates

EA Enteropathic Arthritis

EMG Electromyography

ESR Erythrocyte Sedimentation Rate

F Female

GI GastroIntestinal

GU Genitourinary

H/W House wife

HLA Human Leucocyte Antigen

HNP Herniated nucleus pulposus

HTN Hypertension

IBS Irritable Bowel Syndrome

IgA Immunoglobulin A

IPD Indoor patient department

JCA Juvenile Chronic Arthritis

Kali Mur Kali Muraticum

Kali Sulph Kali Sulphuricum

Lach Lachesis

Led. Ledum Pal

LS Lumbar spine

Lyco Lycopodium

M Male

MRI Magnetic resonance Imaging

Nat. M Natrum Muraticum

Nit. Ac Nitric Acid

NSAID Nonsteroidal Anti-Inflammatory Drugs

OA Osteoarthritis

OPD Out patient department

PsA Psoriatic Arthritis

Puls Pulsatilla

RA Rheumatoid Arthritis

ReA Reactive Arthritis

Rhod Rhodendron

Rhus. T Rhus Toxicodendron

ROM Range of motion

SAPHO Synovitis-acne-pustulosis-hyperostosis-osteomyelitis

Sep Sepia

SI Sacroiliac

SLR Straight leg raising

SpAs Spondyloarthropathies

Staphs Staphysagria

Sulph Sulphur

TB Tuberculosis

Tub. Tuberculinum

URTI Upper Respiratory Tract Infection

U-SpA Undifferentiated Spondyloarthropathies

ABSTRACT

BACKGROUND

Ankylosing spondylitis is a long term disease that causes inflammation of

joints between the vertebral bones and the joints between the spine and the pelvis. It

eventually causes the affected spinal bones to join together and results in restricted

movements, such as peripheral arthritis and iritis. Sacroiliac joints are usually the first

to be involved and as a rule they are bilaterally involved within six months from the

onset of the disease. Sacroilitis produces sciatica – like pain, radiating down to one or

both thighs.

AS though a constitutional disorder, is clinically characterized by acute

exacerbations. The homoeopathic materia medica is a vast treasure house of remedies,

which when prescribed on the basis of totality help in treating any condition

effectively. The acute exacerbations, can be controlled with the presenting acute

totality Rhus tox, a well proved homoeopathic remedy has a wide spread sphere of

action, especially on the locomotory system. This present study is taken up to study

the efficacy of Rhus tox in managing the ankylosing spondylitis.

Thus the present study is taken up to study the utility of Rhus tox in

Ankylosing spondylitis.AS is prototype of the seronegative spondoarthritis group is a

chronic inflammatory arthritis with a progressive stiffening and fusion of the axial

skeleton.

The exact etiology of AS is still unknown. The familial nature of AS has been

stressed for many years and a genetic basis for this has been provided by the

discovery between 88 and 96% of patients with AS. It occurs in 1% of patients who

carry HLA B27 and is postulated that environmental factors, specifically carriage of

GI or GU micro-organisms, acts as triggering factors in individuals rendered

genetically susceptible by cell surface expression of the HLA B27 coded

polypeptides.

In more recent years, the frequency of this articular disorder increasing still

more as advances in modern medical science have led to a more prolonged life

expectations for humans. Homoeopathy being a holistic science treats the patient

effectively without any side effects.

OBJECTIVES

The following objectives were fixed up for the study:

1. To study the clinical spectrum of Ankylosing spondylitis.

2. To study the role and efficacy of Rhus tox and to evaluate the role of Rhus tox

in assessing the intensity of symptoms, frequency of remission and progress of

disease.

METHODS

The subjects for the study were taken from the OPD/IPD and village campus,

peripheral clinics and regular camp visits of Bhartesh Homoeopathic Medical College

and Hospital, Belgaum. Subjects were selected on the basis of inclusion and exclusion

criteria which are elaborated in the study. Sample of 30 size were considered by

simple random sampling procedure. All the cases were taken proforma. The drugs

were selected on the basis of the constitution and underlying miasms. Acute drugs

were also administered to provide symptomatic relief during acute exacerbation.

Routine blood investigations with ESR as required, HLA B27 and X-ray

investigations were the main parameters to confirm the diagnosis and to assess the

response to treatment. The inclusion criteria for cases of AS were diagnosed

clinically with articular manifestation like hip pain, stiffness low back pain and

limited joint motions in the low back.The exclusion criterias were the extra articular

manifestation, progressive disease with deformities and secondary to any other

systemic diseases with gross pathology.

The following parameters were fixed according to type of response obtained

after treatment:-

a) Recovered – patient has shown remarkable positive response to the treatment

and the considerable improvement helped them to perform their regular chores

effectively.

b) Improved – feeling of mental and physical well being along with the

disappearance of the old symptoms and considerable reduction in the

appearance of new complaints.

c) Not Improved – initial response but lots of suffering continued inspite of

administering the drugs. No reduction of complaints even after defined period

of treatment.

RESULTS

Out of 30 cases, 6 cases recovered accounting 20%, 13 cases improved

accounting 43.33% and 11 cases did not improve accounting 36.66%.

INTERPRETATION AND CONCLUSION

In the present study, out of 30 patients, 6 patients recovered, 13 patients

improved and 11 patients did not improve. The miasmatic background in most of the

cases was found to be psoro-syco-syphilitic. Hence it can be concluded that AS is tri

miasmatic. The X-ray changes of the AS were found in most of the cases along with

HLA B27 positive. Here the utility of Rhus tox proved its efficacy. The constitutional

remedies used were Lycopodium, Natrum mur, Calc carb, Sulphur, Phosphorus,

Aurum met, Sepia and Pullsatilla. The intercurrent remedies used were Thuja,

Medorrhinum, Tuberculinum, Mercurius and Syphillinum. Most of the cases were in

their initial stages.

The homoeopathic medicines found to be efficacious in reducing the mobility

and bring about significant improvement. The constitutional medicine, in addition to

alleviating the present ailments brings about the general well being of the patients.

The utility of Rhus tox is found efficacious in management of AS more speedily and

with less aggravations i.e. mildly, gently and permanently. In most of the cases there

are improvent, hence homoeopathy has good therapeutic scope in the management of

AS with use of Rhus tox.

The scope varies in every individual case depending upon the clinical

presentation, whether there are reversible or irreversible structural changes, the

underlying pathology and progress of disease. It was seen from the study that earlier

the cases were detected better were the results.

KEY WORDS

Seronegative spondoarthritis; Vertebral bones; Low back pain; Syphilis; Remedy;

Constitutional; Ankylosing spondylitis; Sciatica; Sacroilitis.

 

TABLE OF CONTENTS

CHAPTER PARTICULARS PAGE NO

1. INTRODUCTION 1-9

2. OBJECTIVES 10

3. REVIEW OF LITERATURE 11-104

4. METHODOLOGY 105-110

5. RESULTS 111-119

6. DISCUSSION 120-122

7. CONCLUSION 123

8. SUMMARY 124-126

9. BIBLIOGRAPHY 127-131

ANNEXURE-I- CASE PROFORMA 132-139

ANNEXURE-II- GRAPHS 140-142

ANNEXURE-III - MASTER CHART 143-146

ANNEXURE-IV – SYNOPSIS OF CASES 147-154

 

 

LIST OF TABLES

SR. NO. TABLES PAGE NO.

1. Age Incidence 111

2. Sex Incidence 112

3. Past History 113

4. Family History 114

5. Presenting complaints 115

6. Miasmatic background 116

7. Acute remedy 117

8. Incidence of Intercurrent Remedy 118

9. Results of treatment 118

 

 

LIST OF FIGURES  

 

FIGURE NO.

FIGURE PAGE NO.

1. Leonard Trask 12

2. Vertebral column 20

3. Lateral view of vertebral column 22

4. Lumbar vertebra 23

5. Spine 26

6. Spinal cord 27

7. Sacrum 30

8. Anterior sacroiliac ligament 31

9. Posterior sacroiliac ligament 32

10. Sacrotuberous ligament 33

11. Angle of femoral neck 35

 

12. Bones of hip 42

13. Blood vessels of hip 43

14. Bursa of hips 45

15. Intervertebral disc 46

16. Simplified view of muscles 47

17. a. Biomechanics of hip 50

b. Biomechanics of hip 51

18. Classic areas of inflammation of spondyloarthropathy

54

19. Spine in Ankylosing spondylitis 61

 

 

 

 

 

 

 

 

 

LIST OF GRAPHS

SR. NO.  GRAPHS   PAGE NO. 

1.  Incidence of AS with reference to HLA-B27 60

2.  Age Incidence 140

3.  Sex Incidence 140

4.  Presenting Complaints 141

5.  Miasmatic Background 141

6.  Acute Remedies 142

5.  Result of treatment 142

 

 

Introduction

INTRODUCTION

Research is the backbone of any science. No science can progress unless and

until sincere efforts are made in all fields. Research is the basic foundation of science

and a scientific method of thinking according to a set of rules .It generates new

information which can be applied for means of solution for the problem we are facing

with. Today’s medicine is an evidence based medicine besides the subject

improvement other parameters need to be evolved as to measure objectively,

quantitatively and qualitatively what Homoeopathy the medical system especially

seeks to achieve.

Life is the journey. When it becomes hard and long. Homoeopathy is the oasis

where we can quench our thirst. We can drink from this fountain of youth—the

benefits will flow through us like an inward spiral joining mind, body and spirit until

it reaches the soul, our very core, our Vital Force, our spirit like dynamic. There it

swirls like a river, engulfing all we have experienced, in all our lives, connecting to

our collective unconscious and bringing us peacefully to the ebb and flow of life

where we are joined with the rest of the world as one living breathing organism all

wind, fire, earth, metal and water......1

A new curiosity and enthusiasm to learn about this autoimmune disease

ankylosing spondylitis finally have stimulated the considerable investigation that this

common and significant condition deserves.

The classical homoeopathy is highly individualised therapeutic approach and

success is often indirectly assessed by the changes in the system and general health

status of individual .Scientifically speaking this subjective evaluation is less valid and

reliable. Modern research has started to uncover a fascinating set of complex,

biophysical and biochemical processes. Further work lead to more fundamental

understanding of cartilage and connection tissues in general.

This research provides a fresh understanding of disease, mechanism of action

of our drug and will provide new tools for disease management. We use the scientific

method to discover facts and will provide new tools for disease management. We use

the scientific method to discover facts and their inter-relationship and allow the

application of this new knowledge in practical settings.

A physician must think scientifically and develop scientific attitude towards

patient’s management and research. Such attitude is useful in assessing new

approaches to management of patients .The need of this dissertation is to study in

depth and a thorough research work should be done which is helpful in reducing

prevalence under our homoeopathic management effectively. The potential benefits

hazards and discomfort of old method should be weighed against the advantages of

rational art of healing.

The understanding of the AS has undergone a sea change with the

advancement in the medical science .It is sufficient to establish that the patient is

suffering from AS, but needs further study. The modern physician is an alert clinician

who anticipates the problem before hand and institutes intervention planning as sound

clinical footings, incorporating latest developments in medical science.

One purpose of studying a disease is to gain insight concerning its causation.

In few of requirements for continuing education for licensure and relicensure, as well

as the emphasis on the certification a review over the arthritic condition is essential.

Since the time of Hahnemann, Homoeopathy is an identified system among

different systems of medicines having astonishing results in various difficult diseases

without harmful effects. Results are not occasional, accidental are by fully scientific

in accordance with the principles and laws. Still our development in the field of

scientific world through homoeopathy giving authentication as that of modern

systems of medicine which is required distressed and attended for vast acceptance of

Homoeopathic systems. We must realize that Homoeopathy is our identity, our

dignity. We selected Homoeopathy to serve people because we found it most useful

and affective even when our patients are disappointed by other systems of their

choices. Our practice confirms this truth again and again .We must realise the truth

and accept a challenge to establish this fact in the minds of our people. I have made

attempt for the same under the topic of Ankylosing spondylitis.

We need other dimensions of physical, mental and spiritual support in life if

we want to lead a holistic, well-rounded existence with a satisfactory quality of life.

The following thesis is essentially aimed at supplementing that noble medical role by

sharing some experiences by means of taking this nagging sensation in one stride in

the best interest of our patient.

Ankylosing spondylitis was probably first recognised as a disease which was

different from Rheumatoid arthritis by Galen as early as the second century AD;

however skeletal evidence of the disease (ossification of joints and enthuses primarily

of the axial skeleton, known as archaeological dig that unearthed the skeletal remains

of a 5000 year- old Egyptian mummy with the evidence of “bamboo spine” An

autoimmune disease known to be associated with tissue type HLA B27, affecting

facet joints between vertebrae together causing spine to become increasingly rigid.

Ankylosing spondylitis is long term disease that causes inflammation of joints

between the spinal bones and the joints between the spine and the pelvis. It eventually

causes the affected spinal bones to join together.

The cause of ankylosing spondylitis is unknown, but gene problems seem to

play role. The majority of people with Ankylosing spondylitis have gene called HLA

B27. There are theories on its link with some bacterial infection as a triggering factor.

The disease most frequently begins between age 20 and 40, but may begin before age

10. It affects more males than females. Risk factors include a family history of

ankylosing spondylitis and male gender. Ankylosing spondylitis is a systemic

rheumatic disease and is one of the seronegative spondyloarthropathies. About 90% of

patients express the HLA B27 genotype. Tumour necrosis factor-alpha (TNF α) and

IL-1 are also implicated in ankylosing spondylitis. Although specific autoantibodies

cannot be detected, its response to immunosuppressive medication has promoted its

classification as an autoimmune disease. The disease always begins in the sacroiliac

joints, and then extends upwards to involve the lumbar, thoracic and often cervical

spine. The articular cartilage, synovia and ligaments show chronic inflammatory

changes and eventually becomes ossified.

The classical Homoeopathy is highly individualized therapeutic approach and

success is often indirectly assessed by the changes in the system and general health

status of individual. Scientifically speaking this subjective evaluation is less valid and

reliable. This research will provide a fresh understanding of disease, mechanism of

action of Rhus tox will provide new tools for disease management. We use scientific

method to discover facts and their inter-relationships and allow the application of this

new knowledge in practical settings. A physician must think scientifically and

develop scientific method, attitude towards patient’s management. The need of this

dissertation is to study in depth and a thorough research work should be done which is

helpful in reducing prevalence under our homoeopathic management effectively .Such

attitude is useful in assessing new approach’s to management of patient. The potential

benefits hazards and discomfort of old method should be weighed against the

advantages of rational art of healing.

The understanding of Ankylosing spondylitis has undergone a sea of change

with the advancement in the medical science. It is sufficient to establish that patient is

suffering from Ankylosing spondylitis but needs further investigation. The modern

physician is alert clinician who anticipates the problem before hand and institutes

intervention planning as sound clinical footings, incorporating latest developments in

medical science.

One purpose of studying Ankylosing spondylitis is to gain insight concerning

its causation. In few of requirements for continuing education for licensure and

relicensure, as well as the emphasis on the certification and recertification a review

over the Ankylosing spondylitis condition is essential. Since the time of Hahnemann,

Homoeopathy is an identified system among different medicines having astonishing

results in various difficult diseases without harmful effects. Results are not

occasional, accidental or by chance but fully scientific, in accordance with principles

and laws. Still our development in field of scientific world through Homoeopathy

giving authentication as that of modern systems of medicine which is required

distressed and attended for vast acceptance of Homoeopathy system. We must realise

that Homoeopathy is our identity, our dignity. We selected Homoeopathy to serve

people because we found that Homoeopathy was useful and effective even when our

patients are disappointed by other systems of their choice. Our practice confirms the

truth again and again. We must realise this truth and accept a challenge to establish

this fact in the minds of our people. I have made attempt for the same under the topic

of Utility of Rhus tox in Ankylosing spondylitis.

We need other dimensions of physical, mental and spiritual support in life if

we want to lead a holistic, well-rounded existence with a satisfactory quality of life.

The following thesis is essentially aimed at supplementing that noble medical role by

sharing some experiences by means of taking this nagging sensation in one stride in

the best interest of our patients. Learning to live with pain is something that is thrust

on many of us. Such are the ways of cosmic force that moves men and matter, but the

charm lies in minimising its negativity impact while optimising all other elements of

day to day living. Needless to say we are the best person to advice the patient on the

art and science of living without pain. Medicine is an ever changing science as new

research and clinical experience broaden our knowledge, changes in the mode of

treatment and drug therapy is required.

Our school of Homoeopathy proposes a holistic approach to health care. The

word holistic comes from the Greek ‘halos’ meaning ‘whole’ i.e viewing the person

and his well being from every possible perspective. There is no doubt that the Holistic

approach is all encompassing. However it needs multidisciplinary health care system,

and requires a shift in roles and task among different professionals involved .The

western medicine felt the need that degree of specialization of different organs is

essential, but we Homoeopaths take the person as a whole. Since, we consider and

take care of physical, social, psychological and spiritual needs of our patients the

focus on Homoeopathy has helped us to realise that there are other models of health

care aspects from Western medicine and that each model has a different conceptual

framework, which must evaluated on a scientific basis. Our holistic approach

involves:

1. Responding to the person as a whole (body, mind and spirit) with in the

context of his environment.

2. Willingness to use wide range of interventions

3. An emphasis on a participatory relationship rapport between doctor and a

patient.

4. An awareness of the impact of the health of the patient.

“The perfection of our, the only healing art and the weal of the patients appear

well to deserve that the physicians take to requisite pains to procure for his medicines

the proper, the greatest possible efficacy.”2

The aim of this thesis is to adapt to this transition field of Ankylosing

spondylitis. So to bridge the gap in a meaningful manner. The amalgam of prevalent

medical applications, when incorporated in the light of homoeopathic principles,

beings about uniformity in the treatment planning of each individual case and using

Dr.Hahnemanns most perfected method. This facilitates the smooth interaction among

medical professionals as a rational and scientific basis, with uniformity in expression.

At the same time it maintains our great tradition of healing art in the purest form, and

provides an ample room and flexibility for every homoeopathic physician in his

individual professional judgement in every individual case in question.

To gather out from our boundless literature the multitude of facts relating to

the action and uses of our medicine, to shift the true form the false, has been a most

formidable task. To aid in this undertaking, I supply my self with all available works

treating upon this disease , in all schools of medicine. It is with this problem of clear

differentiation in mind that we submit these studies of cases pertaining to AS and

because of primary importance of these fold basis for preserving homoeopathically,

we to say little about the fearful diagnostic tags. Let me close with Hahnemann’s own

words concerning homoeopathy: I demand no faith at all, and do not demand that

anybody should comprehend it. Neither do I comprehend it. It is enough , that it is

fact and nothing else. Experience alone declares it, and I believe more in experience

than in my own intelligence. But who will arrogate to himself the power of weighing

the invisible forces that have hither to been concealed in the inner blossom of nature,

when they are brought out of the crude state of apparently dead matter through a new,

hitherto undiscovered agency, such as potentizing by long continued trituration and

succession. But he who will not allow himself to be convinced of this and who will

not, therefore, imitate what I now teach after many years ,trial and experience . He

who is not willing to imitate it exactly, can leave this greatest problem of our art

unsolved, he can also leave the most important chronic diseases uncured ,as they have

remained unhealed, indeed up to the time of my teaching .I have no more to say about

this. It seemed to me my duty to publish the great truths to the world that needs them,

uncontrolled as to whether people can compel themselves to follow them exactly or

not .If it is not done with exactness, let no one boast to have imitated me, nor expect a

good result.3 Try out these advanced methods for yourself, gain experience with

them, and you will become a true classical Hahnemannian Homoeopath , beloved by

all patients. This following work has been done with care and while it may approach

the perfection we hope it may prove of benefit in picking out the symptom of this

disease in relation to the individualizing the case.

The following steps are taken for evolving at the time of treatment :

1. Detailed case taking according to proforma specially rearranged for Ankylosing

spondylitis

2. Analysis of symptoms

3. Evaluation of symptoms

4. Repertorization to evolve the group of similar drugs

5. Miasmatic repertorization to confirm this miasmatic diagnosis.

6. To study the clinical spectrum of Ankylosing Spondylitis.

7. To study role and efficacy of Rhus tox and to evaluate the role of Rhus tox in

assessing the intensity of symptoms, frequency of remission and progress of

disease.

 

 

 

Objectives

AIMS AND OBJECTIVES

The following objectives were fixed up for the study:

1. To study the clinical spectrum of Ankylosing spondylitis.

2. To study the role and efficacy of Rhus tox and to evaluate the role of Rhus tox

in assessing the intensity of symptoms, frequency of remission and progress of

disease.

Review of Literature

REVIEW OF LITERATURE

HISTORICAL REVIEW

Ankylosing spondylitis (AS) is a systemic inflammatory disease that results in

ossification of joints and entheses primarily of the hip, spine, and peripheral joints.

The first signs of AS were first unearthed in the skeletal remains of a 5000 year–old

Egyptian mummy. The first description of AS in the literature was in 1559 by Realdo

Colombo and first account of the changes to the bones was given in 1669 by Bernard

Connor. Sir Benjamin Brodie in 1818 was the first to note that iritis accompanied

spondylitis. Charles Fagge and Carl von Rokitansky also reported similar findings of

AS in cadaveric specimens and patients. However, the first well–known description of

AS was reported by W. von Bechterew from Russia in 1883. Others, such as Adolph

Strumpell from Germany in 1897 and Pierre Marie from France in 1898 were also

among the first to offer a classic description of AS. Therefore, AS is also known as

Bechterew Disease or Marie–Strumpell Disease.4

The anatomist and surgeon Realdo Colombo described what could have been

the disease in 1559 and the first account of pathologic changes to the skeleton

possibly associated with AS was published in 1691 by Bernard Connor.

It was recognized as distinct from rheumatoid arthritis by Hippocrates as early

as the second century. Egyptian mummies have been found with ankylosing changes

to their skeleton.5(997pp)

“It was not until he [Trask] had exercised for some time that he could perform

any labor and that his neck and back have continued to curve drawing his head

downward on his breast.”

This account became the first documented case of AS in the united States,

since its indisputable description of inflammatory disease characteristics of AS, and

the hallmark of deforming injury in AS. It has been suggested that AS was first

recognized as a disease which was different from rheumatoid arthritis by Galen as

early as the second century A.D however, skeletal evidence of the disease

(ossification of joints and entheses primarily of the axial skeleton, known as "bamboo

spine") was first discovered in an archaeological dig that unearthed the skeletal

remains of a 5000-year–old Egyptian mummy with evidence of "bamboo spine".

In 1858, David Tucker published a small booklet which clearly described a

patient by the name of Leonard Trask who suffered from severe spinal deformity

subsequent to AS. In 1833 Trask fell from a horse, exacerbating the condition and

resulting in severe deformity.

In 1973 the association between AS and the gene HLA B27

was found.

It has been identified as the condition which Saint Banus

(355-395 AD) suffered from (named Father Palm Tree in

local language due to his stooped posture), forcing him to

eat and sleep standing for 18 years. A disease much like AS

has been found naturally in prehistoric crocodiles, monkeys.

CLASSIFICATION OF DISEASES OF JOINTS

Fig. 1: Leonard Trask

Infectional arthritis

• Acute (streptococcus, staphylococcus, gonococuss)

• Chronic (tubercle bacillus)

Probably inflectional

• Rheumatic fever

• Rheumatoid arthritis (arthropathic arthritis, proliferative arthritis, chronic

infectious arthritis)

• Ankylosing spondylitis (Marie-Stumpell disease)

• Psoriatic arthritis

Toxic arthritis associated with various infections.

Degenrative arthritis e.g.lumbar spondylosis (oestioarthritis, hypertrophic arthritis)

Arthritis associated with metabolic diseases

• Gout

• Other metabolic diseases

Neuropathic joints

• Tabes dorsalis

• Syringomyelia

Neoplasms of joints (cyst, xantoma, hemangioma,gaint cell tumor, synovioma)

Traumatic arthritis

• Direct trauma

• Indirect trauma (secondary to postural strain)

Systematic disease manifestation

• 1.Serum sickness

• 2. haemophilia

• 3. Intermittent hydrarthosis

• 4. Pulmonary osteoarthropathy

• 5. Hysterical joints

Local joint disturbances

• Aseptic necrosis

• Osteochondritis dissecans

• Osteochondromatosis

• Pigmented villonodular synovitis6

The spondyloarthropathies are a group of conditions which share similar

clinical features. Classification criteria permit separation of the conditions, allow

better targeting of therapies, better measurement of outcomes, and better prognostic

information. Early diagnosis remains problematic, but validated criteria for

established disease are now emerging.

Histopathology and histochemistry are providing a better understanding of the

underlying process of inflammatory arthritis in spondyloarthropathy and other

inflammatory arthritides. Early disease, however, continues to challenge current

criteria. Sophisticated imaging with magnetic resonance imaging is being increasingly

used and is proving useful for early diagnosis as well as helping to understand the

pathophysiology of disease. Juvenile idiopathic arthritis continues to provide

problems and criteria have recently been modified to allow a greater clinical utility

and inclusion of more patients. Poststreptococcal reactive arthritis appears to be a

heterogeneous clinical entity, with a group looking more like rheumatic fever and a

group with spondyloarthropathy traits. It may be that the association is not

streptococcal, but is a throat infection. Currently available criteria for psoriatic

arthritis have been evaluated in a large cohort. Four of the criteria performed well

with high specificity and sensitivity whereas the other two had moderate specificity

and low sensitivity. It was shown that rheumatoid factor positivity does not exclude a

diagnosis of psoriatic arthritis--the single most important clinical feature of this

condition being the presence of psoriasis.

The spondyloarthropathy classification criteria continue to be an area of

development. This is most apparent in juvenile arthritis and psoriatic arthritis. The

latter is currently undergoing intense scrutiny to develop classification criteria and

outcome measures.

CLASSIFICATION OF SPONDYLOARTHROPATHY (SpA)

THE EUROPEAN SPONDYLOARTHROPATHY STUDY GROUP (ESSG)

According to the ESSG criteria, for a patient to be classified as having SpA, he

or she has to satisfy one of two entry criteria: Inflammatory spinal pain or synovitis

that is either asymmetric or predominantly in the lower limbs.7

Inflammatory back pain: Back pain is common among the general population.

However, "inflammatory" back pain is much less common. Back pain is considered

inflammatory if four of the following five criteria are found:

Onset of back discomfort before the age of 40 years

Insidious onset

Persistence for at least three months

Associated with morning stiffness

Improvement with exercise

Asymmetrical synovitis: predominantly of the lower limbs is manifested by soft tissue

swelling, warmth over a joint, joint effusion, and reductions in both active and passive

range of motion. As with inflammatory spinal pain, the symptoms are worse after a

period of rest. It is clear the HLA is strongly associated with the SpAs. Yet prevalence

of HLA B27 varies widely in different racial and ethnic clusters around the world.8

Additional criteria: If a patient has one or both of the entry criteria listed above, he or

she should then be evaluated for the presence of one or more of the following

features:

Positive family history

Psoriasis

Inflammatory bowel disease

Urethritis, cervicitis, or acute diarrhea within one month before arthritis

Buttock pain alternating between buttocks

Enthesopathy

Plain film radiographic evidence of sacroiliitis

Importantly, blood tests, including an assessment for the presence of HLA-

B27, are not part of the ESSG criteria; in addition, only the sacroiliac joints need to be

evaluated radiographically.

The term spondyloarthritis (formerly spondyloarthropathy), is used to refer a

group of disorders that includes ankylosing spondylitis (AS), undifferentiated

spondyloarthritis, reactive arthritis (ReA), and the arthritis and spondylitis that may

accompany psoriasis and inflammatory bowel diseases.

Seronegative spondyloarthropathy:

Spondylarthropathy are inflammatory conditions affecting the spine and

occasionally other joints. The condition is often characterized by back pain but the

severity of the symptoms can vary greatly. Seronegative spondylarthropathy is

where the blood does not have a certain antibody (rheumatoid factor) which enables

it to be distinguished from rheumatoid arthritis. Seronegative spondylarthropathies

includes ankylosing spondylitis, psoriatic arthritis and Reiter's syndrome.

Seronegative spondyloarthropathies comprise a group of inflammatory

arthritides, which consists of:

ankylosing spondylitis,

psoriatic arthritis,

reactive arthritis (Reiter's syndrome),

enteropathic arthritis, and

undifferentiated spondyloarthropathy.

All of them share common laboratory, clinical, and imaging findings, with

characteristic involvement of the sacroiliac joints, spine, and, to various degrees,

peripheral joints. For many years, conventional radiography was the mainstay for

definitive diagnosis of sacroiliitis and for follow-up of the anatomic changes in the

spine, peripheral joints, and entheses. Conventional radiographs remain the imaging

investigation of choice; however, they are unable to detect early inflammatory

changes of sacroiliitis, which are important for establishing a diagnosis without delay.

Other imaging modalities, such as computed tomography, bone scintigraphy,

magnetic resonance imaging, and ultrasonography have improved the capabilities of

detecting early disease and became useful adjuncts to plain films. In addition, they

also have enabled more accurate detection of pathology at various anatomic sites of

the musculoskeletal system predominantly involved in spondyloarthropathies. This

article will review and highlight the role of each of these modalities in the assessment

of the axial and peripheral skeleton in seronegative spondyloarthropathies.

CLASSIFICATION OF SPONDYLOARTHROPATHIES

It is a member of the group of the spondyloarthropathies with a strong genetic

predisposition. Complete fusion results in a complete rigidity of the spine, a condition

known as bamboo spine. Although Hippocrates described a condition identical to

modern disease, it was not until the separate description Bechterew, Strumpell and

Marie at the end of the 19th century.9

Condition that overlap to form the seronegative spondylarthritides and their

common features

Types of seronegative spondyloarthrides

Ankylosing spondylitis

Psoriatic arthritis

Enteropathic arthritis(associated with ulcerative colitis, crohn’s disease and

whipple’s disease.)

Retier’s syndrome /Reactive arthropathy

Behcet’s syndrome

Common features

Negative tests from rheumatoid factor

Absence of rheumatoid nodules

Inflammatory peripheral arthritis

Radiological sacroilitis

Tendency to familial aggregation

ANATOMY

A thoroughly detailed study of anatomy of the spine, hip and peripheral joints,

is a need to treat the illness. Thus basics of AS starts from how the spine is developed

structurally. Generally the physician interested in the pain is not inclined to read essay

on anatomy, they are more interested in the bottom line how do I treat it? However

we need an understanding of anatomy to appreciate which elements of the spine is

inflamed and thus become painful, so as to prescribe treatment on a rational basis.

Modern research has revealed the leading contenders for previously but still the cause

is unknown, only hypothesis have been proposed like linked with genetic

predisposition.

In ankylosing spondylitis (AS), the whole spine can be affected, but symptoms

usually begin in the low back. To understand how ankylosing spondylitis can cause

your spinal bones to fuse, you should have a basic understanding of how your spine

works.

As you can see from the image below, your back, or spine, is made up of

many parts. First, we're going to look at the bone structures. Your backbone, also

called your vertebral column, helps support a lot of your body weight, and it protects

your spinal cord. You have 33 vertebrae (bones) that make up the vertebral column. In

the image, they're labeled as "Vertebral Body."

Your spine is divided into regions: there's your neck (cervical spine), mid-

back (thoracic spine), and low back (lumbar spine). At the bottom of your spine, you

also have the sacrum and the coccyx, which is commonly called your tailbone. Again,

AS generally starts in the lumbar spine and works its way up to the cervical spine.

The vertebrae in your neck are labeled C1-C7, meaning that you have seven

vertebrae in that region. Most adults have 12 vertebrae in the thoracic spine (T1-T12),

which goes from your shoulders to your waist. Then there are five vertebrae in your

low back (L1-L5).

Below your lumbar region, your sacrum is made up of five vertebrae between

the hipbones. By the time you're an adult, these five bones have fused into one bone.

The coccyx is made of small fused bones at the very tail of your spine (hence the

tailbone).

In between your vertebrae, you have intervertebral discs (also labeled on the

image). These act like pads or shock absorbers for your spine as it moves. Each disc is

made up of a tire-like outer band called the annulus fibrosus and a gel-like inner

substance called the nucleus pulposus.

Together, the vertebrae and the discs provide a protective tunnel (the spinal

canal) to house the spinal cord and spinal nerves. These nerves run down the center of

the vertebrae and exit to various parts of the body, where they help you feel and

Fig. 2: Vertebral column

move. With ankylosing spondylitis, your spinal nerves can be pinched (also known as

impinged or compressed) by the extra bone that develops as a result of AS.

Your spine also has facet joints, which are on the posterior side (back) of your

vertebrae. These joints (like all joints in your body) help facilitate movement and are

very important to your flexibility. The joints are covered by cartilage that protects

your bones as you move. In ankylosing spondylitis, the cartilage can be destroyed—

inflammation and chemicals released by the inflammation can destroy it. The cartilage

can then be replaced by scar tissue.10

Your back also has muscles, ligaments, tendons, and blood vessels. Muscles

are strands of tissues that act as the source of power for movement. Ligaments are the

strong, flexible bands of fibrous tissue that link the bones together, and tendons

connect muscles to bones and discs. Blood vessels provide nourishment. These parts

all work together to help you move.

The Skeletal System serves many important functions; it provides the shape

and form for our bodies in addition to supporting, protecting, allowing bodily

movement, producing blood for the body, and storing minerals. The number of bones

in the human skeletal system is a controversial topic. Humans are born with about 300

to 350 bones, however, many bones fuse together between birth and maturity. As a

result an average adult skeleton consists of 208 bones. The number of bones varies

according to the method used to derive the count. While some consider certain

structures to be a single bone with multiple parts, others may see it as a single part

with multiple bones. There are five general classifications of bones. These are Long

bones, Short bones, Flat bones, Irregular bones, and Sesamoid bones. The human

skeleton is composed of both fused and individual bones supported by ligaments,

tendons, muscles and cartilage. It is a complex structure with two distinct divisions.

These are the axial skeleton and the appendicular skeleton. The Skeletal System

serves as a framework for tissues and organs to attach themselves to. This system acts

as a protective structure for vital organs. Major examples of this are the brain being

protected by the skull and the lungs being protected by the rib cage.

Located in long bones are two distinctions of bone marrow (yellow and red).

The yellow marrow has fatty connective tissue and is found in the marrow cavity.

During starvation, the body uses the fat in yellow marrow for energy. The red marrow

of some bones is an important site for blood cell production, approximately 2.6

million red blood cells per second in order to replace existing cells that have been

destroyed by the liver. Here all erythrocytes, platelets, and most leukocytes form in

adults. From the red marrow, erythrocytes, platelets, and leukocytes migrate to the

blood to do their special tasks.

Another function of bones is the storage of certain minerals. Calcium and

phosphorus are among the main minerals being stored. The importance of this storage

"device" helps to regulate mineral balance in the bloodstream. When the fluctuation

of minerals is high, these minerals are stored in bone; when it is low it will be

withdrawn from the bone.11

Lumbar Spine:

Physicians use a code to number each of the

24 vertebrae in the spine. The low back officially

begins with the lumbar region of the spine directly

below the cervical and thoracic regions and directly

Fig. 3: Lateral view of vertebral column

above the sacrum. The lumbar vertebrae, L1-L5, are most frequently involved in back

pain because these vertebrae carry the most amount of body weight and are subject to

the largest forces and stresses along the spine.

The true spinal cord ends at approximately the L1 level, where it divides into

many different nerve roots that travel to the lower body and legs. This collection of

nerve roots is called the "cauda equina," which means horse's tail and describes the

continuation of the nerve roots at the end of the spinal cord.12

Vertebrae:

The vertebral body is a thin ring of dense cortical bone. The vertebral body is

shaped like an hourglass, thinner in the center with thicker ends. Outer cortical bone

extends above and below the superior and inferior ends of the vertebrae to form rims.

The superior and inferior endplates are contained within these rims of bone.

Pedicles:

The pedicles are two short rounded processes that extend posteriorly from the

lateral margin of the dorsal surface of the vertebral body. They are made of thick

cortical bone. The vertebrae surround and protect the spinal cord, a column of nerves

running down from the brain. Peripheral nerves branch off from the spinal cord and

Fig. 4: Lumbar vertebra

with their roots passing through the vertebrae, extend all over the body. As a result,

pain from a back problem may also travel to other parts of the body

Laminae:

The laminae are two flattened plates of bone extending medially from the

pedicles to form the posterior wall of the vertebral foramen. The Pars Interarticularis

is a special region of the lamina between the superior and inferior articular processes.

A fracture or congenital anomaly of the pars may result in a spondylolisthesis.

Intervertebral Discs

Intervertebral discs are found between each vertebra. The discs are flat, round

structures about a quarter to three quarters of an inch thick with tough outer rings of

tissue called the annulus fibrosis that contain a soft, white, jelly-like center called the

nucleus pulposus. Flat, circular plates of cartilage connect to the vertebrae above and

below each disc. Intervertebral discs separate the vertebrae, but they act as shock

absorbers for the spine. They compress when weight is put on them and spring back

when the weight is removed. Intervertebral discs make up about one-third of the

length of the spine and constitute the largest organ in the body without its own blood

supply. The discs receive their blood supply through movement as they soak up

nutrients. The discs expand while at rest allowing them to soak up nutrient rich fluid.

When this process is inhibited through repetitive movement, injury or poor posture,

the discs become thinner and more prone to injury. This may be a cause of the gradual

degeneration of the structure and function of the disc over time.

Facet Joints

Joints between the bones in our spine are what allow us to bend backward and

forward and twist and turn. The facet joints are a particular joint between each

vertebral body that help with twisting motions and rotation of the spine. The facet

joints are part of the posterior elements of each vertebra. Each vertebra has facet

joints that connect it with the vertebrae above and the vertebrae below in the spinal

column. The surfaces of the facet joints are covered with smooth cartilage that help

these parts of the vertebral bodies glide smoothly on each other. A facet joint joins

each pair of vertebra (i.e., the one above to the one below). Like hinges, the facet

joints guide the movement of the spine, while also stabilizing the vertebral column.

Ideally, the joints in the spine are lined up so that the back can twist and bend with

little friction between the vertebrae. Between each pair of vertebrae lies a flat,

circular inter-vertebral disc. The outer part of the disc, the annulus, is strong and

hard. The inner portion, the nucleus pulposus is soft and absorbs shocks to the spine

during movement

Ligamentum Flavum:

The ligamentum flavum is a strong ligament that connects the laminae of the

vertebrae. The term "flavum" is used to describe the yellow appearance of this

ligament in its natural state. The ligamentum flavum serves to protect the neural

elements and the spinal cord and stabilize the spine so that excessive motion between

the vertebral bodies does not occur. It is the strongest of the spinal ligaments and

often has a thinner middle section. Together with the laminae, it forms the posterior

wall of the spinal canal.

Spine anatomy:

The human spine is a complex structure that provides both mobility (so you

can bend and twist) and stability (so you can remain upright all day). The normal

spine has an “S” –like curve when looked at from the side. This curvature allows for

even distribution of weight. The “S” curve helps a healthy spine withstand stress.

Ultimately, this interdependence among all sections of the spine, plus the competing

demands of mobility and stability make the spine vulnerable to injury and

deterioration due to ageing.

The spine features three natural curves, the cervical (neck) curve, the thoracic

(middle back) curve and lumbar (lower back) curve. The thoracic spine is made up of

the 12 vertebrae in the upper back and each thoracic vertebra is attached to a rib. The

lumbar spine is made up of the next 5 vertebrae. The lower lumbar region. Finally,

below the lumbar region are 5 fused vertebrae of the sacrum and the 5 fused vertebrae

of the coccyx

Fig. 5: Spine

The spinal cord is part of the central nervous system of the human body. It is a

vital pathway that conducts electrical signals from the brain to the rest of the body

through individual nerve fibers. The spinal cord is a very delicate structure that is

derived from the ectodermal neural groove, which eventually closes to form a tube

during fetal development. From this neural tube, the entire central nervous system,

our brain and spinal cord, eventually develops. Up to the third month of fetal life, the

spinal cord is about the same length as the canal. After the third month of

development, the growth of the canal outpaces that of the cord. In an adult the lower

end of the spinal cord usually ends at approximately the first lumbar vertebra, where it

divides into many individual nerve roots (L1).

Spinal Canal:

Fig. 6: Spine cord

The spinal canal is the anatomic casing for the spinal cord. The bones and

ligaments of the spinal column are aligned in such a way to create a canal that

provides protection and support for the spinal cord. Several different membranes

enclose and nourish the spinal cord and surround the spinal cord itself. The outermost

layer is called the "dura mater," which is a Latin term that means "hard mother,"

indicating that early anatomists had at least a rudimentary sense of humor. The dura is

a very tough membrane that encloses the brain and spinal cord and prevents

cerebrospinal fluid from leaking out from the central nervous system. The space

between the dura and the spinal canal is called the "epidural space". This space is

filled with tissue, vessels and large veins. The epidural space is important in the

treatment of low-back pain, because it is into this space that medications such as

anesthetics and steroids are injected in order to alleviate pain and inflammation of the

nerve roots.13

Vertebra:

A vertebra (plural: vertebrae) is an individual bone in the flexible column that

defines vertebrate animals, e.g. humans. The vertebral column encases and protects

the spinal cord, which runs from the base of the cranium down the dorsal side of the

animal until reaching the pelvis. From there, vertebra continue into the tail.

Vertebrae are defined by regions. Cervical vertebrae are those in the neck area,

and can range from a single vertebra in amphibians, to seven in most mammals and

reptiles, and as many as 25 in swans or 76 in the extinct plesiosaur Elasmosaurus. The

dorsal vertebrae range from the bottom of the neck to the top of the pelvis. Dorsal

vertebrae attached to ribs are called thoracic vertebrae, while those without ribs are

called lumbar vertebrae. The sacral vertebrae are those in the pelvic region, and range

from one in amphibians, to two in most birds and modern reptiles, or up to 3 to 5 in

mammals. When more than one sacral vertebrae are fused into a single structure, it is

called the sacrum. The synsacrum is a similar fused structure found in birds that is

composed of the sacral, lumbar, and some of the thoracic and caudal vertebra, as well

as the pelvic girdle. Caudal vertebra compose the tail, and the final few can be fused

into the pygostyle in birds, or into the coccygeal or tail bone in chimpanzees or

humans.

Sacro-iliac Joint :

There is without a doubt a connection between chronic fixations in the

Sacroiliac Joint Anatomy, and hip arthritis. Every case of hip arthritis that I find has a

concommitent SIJ fixation. However, what we haven't yet discovered is whether the

SIJ fixation causes the hip arthritis, or the hip arthritis the SIJ fixation. Chicken and

egg. Sacroiliac joint anatomy (SI or sacro-iliac) is quite unlike any other joint in the

body, because the joint surfaces are covered by two different kinds of cartilage. Like

all true joints, there is cartilage on both sides of the SI joint surfaces, but the articular

surfaces have both hyaline cartilage (glassy) and fibro cartilage (spongy) surfaces that

rub against each other. No other joints have this feature!

The joint also has many large ridges and depressions that fit together like the

pieces in a puzzle. Unlike most other joints, the Sacroiliac Joint Anatomy is not

designed for large movements. The rocking movements made with every step are in

fact very small. The SI joint usually only moves about two to four millimeters during

weight bearing and forward flexion. It is a "viscoelastic joint", meaning that its major

movement comes from giving or stretching. Furthermore, it is common for the SI

joint to become even more stiff and actually lock, usually due to injury, but also due

to prolonged sitting, for example. This explains why manipulation is the treatment of

choice for the very painful SI joint syndrome.

Normal Sacrum Fused sacrum

The S-I joint can be thought of as the bottom joints of the spine relating to the

hip bones, The sacrum(bottom of the spine) relates on each side to the ilia (hip bones)

to form the sacroiliac joints. The ilia accept the femoral shafts of the lower extremities

to form the hip joints. Therefore, as a person walks with reciprocal motion of the legs,

the S-I joints also reciprocally move. There are muscles and ligaments that transverse

the S-I joint in the front and the back, all of which can be causes of pain and

inflammation if these joints are in dysfunction. The sacroiliac joint or SI joint is the

joint between the sacrum, at the base of the spine and the ilium of the pelvis, which

are joined by ligaments. It is a strong, weightbearing synovial joint with irregular

elevations and depressions that produce interlocking of the two bones. The human

body has two sacroiliac joints: a left and a right joint that often match individually but

are highly variable from person to person.The sacroiliac joints are two paired "kidney

bean" or L-shaped synovial joints that have minimal motion (2-18 degrees, which is

debatable at this time), that are formed between the articular surfaces of the sacrum

Fig. 7: Sacrum

and the ilium bones. The two sacroiliac joints move together as a single unit and are

considered bicondylar joints (where the two joint surfaces move correlatively

together). The joints are covered by two different kinds of cartilage; the sacral surface

has hyaline cartilage and the ilial surface has fibrocartilage. The stability of the SIJs

are maintained mainly through a combination of both bony structure and very strong

intrinsic and extrinsic ligaments. As we age the characteristics of the sacroiliac joint

change. The joint's surfaces are flat or planar in early life but as we start walking, the

sacroiliac joint surfaces develop distinct angular orientations (and lose their planar or

flat topography.) They also develop an elevated ridge along the ilial surface and a

depression along the sacral surface. The ridge and corresponding depression, along

with the very strong ligaments, increase the sacroiliac joints' stability and makes

dislocations very rare. The fossae lumbales laterales ("dimples of Venus") correspond

to the superficial topography of the sacroiliac joints.

Ligaments

The anterior sacroiliac ligament consists of

numerous thin bands, which connect the anterior

surface of the lateral part of the sacrum to the

margin of the auricular surface

Fig. 8: Anterior sacroiliac ligament

Interosseous sacroiliac ligament:

The Interosseous Sacroiliac Ligament lies deep to the posterior ligament, and

consists of a series of short, strong fibers connecting the tuberosities of the sacrum

and ilium. The major function of the interosseous sacroiliac ligament is to keep the

sacrum and ilium together and therefore prevent abduction or distraction of the

sacroiliac joint. This is performed by the nearly horizontal direction of the fibers

running perpendicular from the sacrum to the ilium.

Posterior sacroiliac ligament : Articulations of pelvis. Posterior view. (Short post.

sacroiliac ligament labeled at upper left; long post.

sacroiliac ligament labeled at center right.)

The posterior sacroiliac ligament is situated in a

deep depression between the sacrum and ilium

behind; it is strong and forms the chief bond of

union between the bones.

It consists of numerous fasciculi, which pass between the bones in various

directions. The upper part (short posterior sacroiliac ligament) is nearly horizontal in

direction, and pass from the first and second transverse tubercles on the back of the

sacrum to the tuberosity of the ilium.

The lower part (long posterior sacroiliac ligament) is oblique in direction; it is

attached by one extremity to the third transverse tubercle of the back of the sacrum,

and by the other to the posterior superior spine of the ilium.

Fig. 9: Posterior sacroiliac ligament

Sacrotuberous ligament: Articulations of pelvis, anterior view, with greater sciatic

foramen (labeled in red) and its boundaries.

The sacrotuberous ligament (great or

posterior sacrosciatic ligament) is situated at

the lower and back part of the pelvis. It is flat,

and triangular in form; narrower in the

middle than at the ends. It runs from the

sacrum (the lower transverse sacral tubercles,

the inferior margins sacrum and the upper

coccyx) to the tuberosity of the ischium.

The membranous falciform process of the

sacrotuberous ligament was found to be

absent in 13% of cadavers. When present it extends towards the ischioanal fossa

travelling along the ischial ramus and fusing with the obturator fascia. The

sacrotuberous ligament contains the coccygeal branch of the inferior gluteal artery.

The lower border of the ligament was found to be directly continuous with the

tendon of origin of the long head of the Biceps femoris in approximately 50% of

subjects. Biceps femoris could therefore act to stabilise the sacroiliac joint via the

sacrotuberous ligament.

If the pudendal nerve becomes entrapped between this ligament and the

sacrospinous ligament causing perineal pain, the sacrotuberous ligament is surgically

severed to relieve the pain.

Fig. 10: Sacrotuberous ligament

The anterior ligament may be described as just a slight thickening of the

anterior joint capsule. The anterior ligament is certainly not as strong and well defined

as are the posterior ligaments.

The posterior sacroiliac (SI) ligaments can be further divided into short

(intrinsic) and long (extrinsic). The dorsal interosseous ligaments are very strong

ligaments. This ligament is even stronger than bone; such that the pelvis will usually

fracture before the ligament tears. The dorsal sacroiliac ligament runs perpendicular

from just behind the articular surfaces of the sacrum to the ilium and function to keep

the sacroiliac joint from distracting or opening. The extrinsic sacroiliac joint

ligaments, the sacrotuberous and sacrospinous ligaments, limit the amount the sacrum

flexes (or nutates).16

The ligaments of the sacroiliac joint become loose during pregnancy due to the

hormone relaxin; this loosening allows widening of the pelvic joints during the

birthing process, especially the related symphysis pubis. The long SI ligaments may

be palpated in thin persons for pain and compared from one side of the body to the

other; however, the reliability and the validity of comparing ligaments for pain have

currently not been shown. The short ligaments (e.g. interosseous) cannot be assessed,

since they are located deep inside the pelvis.

The acetabulum is oriented inferiorly, laterally and anteriorly, while the

femoral neck is directed superiorly, medially, and anteriorly.

The transverse angle of the acetabular inlet can be determined by measuring

the angle between a line passing from the superior to the inferior acetabular rim and

the horizontal plane; an angle which normally measures 51° at birth and 40° in adults,

and which affects the acetabular lateral coverage of the femoral head and several

other parameters. The sagittal angle of the acetabular inlet measures 7° at birth and

increases to 17° in adults.

Femoral neck angle:

The angle between the longitudinal axes of the femoral neck and shaft, called

the caput-collum-diaphyseal angle or CCD angle, normally measures approximately

150° in newborn and 126° in adults (coxa norma). An abnormally small angle is

known as coxa vara and an abnormally large angle as coxa valga. Because changes in

shape of the femur naturally affects the knee, coxa valga is often combined with genu

varum (bow-leggedness), while coxa vara leads to genu valgum (knock-knees).

Fig. 11: The angles of femoral neck

Changes in trabecular patterns due to altered CCD angle. Coxa valga leads to

more compression trabeculae, coxa vara to more tension trabeculae.

Changes in CCD angle is the result of changes in the stress patterns applied to

the hip joint. Such changes, caused for example by a dislocation, changes the

trabecular patterns inside the bones. Two continuous trabecular systems emerging on

auricular surface of the sacroiliac joint meander and criss-cross each other down

through the hip bone, the femoral head, neck, and shaft.

In the hip bone, one system arises on the upper part of auricular surface to

converge onto the posterior surface of the greater sciatic notch, from where its

trabeculae are reflected to the inferior part of the acetabulum. The other system

emerges on the lower part of the auricular surface, converges at the level of the

superior gluteal line, and is reflected laterally onto the upper part of the acetabulum.

In the femur, the first system lines up with a system arising from the lateral

part of the femoral shaft to stretch to the inferior portion of the femoral neck and

head. The other system lines up with a system in the femur stretching from the medial

part of the femoral shaft to the superior part of the femoral head.

On the lateral side of the hip joint the fascia lata is strengthened to form the

iliotibial tract which functions as a tension band and reduces the bending loads on the

proximal part of the femur capsule.

The capsule attaches to the hip bone outside the acetabular lip which thus

projects into the capsular space. On the femoral side, the distance between the head's

cartilaginous rim and the capsular attachment at the base of the neck is constant,

which leaves a wider extracapsular part of the neck at the back than at the front. The

strong but loose fibrous capsule of the hip joint permits the hip joint to have the

second largest range of movement (second only to the shoulder) and yet support the

weight of the body, arms and head.

The capsule has two sets of fibers: longitudinal and circular. The circular

fibers form a collar around the femoral neck called the zona orbicularis. The

longitudinal retinacular fibers travel along the neck and carry blood vessels.

Blood and nerve supply:

The hip joint is supplied with blood from the medial circumflex femoral and

lateral circumflex femoral arteries, which are both usually branches of the deep artery

of the thigh (profunda femoris), but there are numerous variations and one or both

may also arise directly from the femoral artery. There is also a small contribution

from a small artery in the ligament of the head of the femur which is a branch of the

posterior division of the obturator artery, which becomes important to avoid avascular

necrosis of the head of the femur when the blood supply from the medial and lateral

circumflex arteries are disrupted (e.g. through fracture of the neck of the femur along

their course).

The hip has two anatomically important anastomoses, the cruciate and the

trochanteric anastomoses, the latter of which provides most of the blood to the head of

the femur. These anastomoses exist between the femoral artery or profunda femoris

and the gluteal vessels.

Muscles of the hip:

The hip muscles act on three mutually perpendicular main axes, all of which

pass through the center of the femoral head, resulting in three degrees of freedom and

three pair of principal directions: Flexion and extension around a transverse axis (left-

right); lateral rotation and medial rotation around a longitudinal axis (along the thigh);

and abduction and adduction around a sagittal axis (forward-backward); and a

combination of these movements (i.e. circumduction, a compound movement in

which the leg describes the surface of an irregular cone). It should be noted that some

of the hip muscles also act on either the vertebral joints or the knee joint, that with

their extensive areas of origin and/or insertion, different part of individual muscles

participate in very different movements, and that the range of movement varies with

the position of the hip joint. Additionally, the inferior and superior gemelli may be

termed triceps coxae together with the obturator internus, and their function simply is

to assist the latter muscle.

The movement of the hip joint is thus performed by a series of muscles which

are here presented in order of importance with the range of motion from the neutral

zero-degree position indicated:

Extension or retroversion (20°): gluteus maximus (if put out of action, active standing

from a sitting position is not possible, but standing and walking on a flat surface is);

dorsal fibers of gluteus medius and minimus; adductor magnus; and piriformis.

Additionally, the following thigh muscles extend the hip: semimembranosus,

semitendinosus, and long head of biceps femoris.

Flexion or anteversion (140°): iliopsoas (with psoas major from vertebral column);

tensor fascia latae, pectineus, adductor longus, adductor brevis, and gracilis. Thigh

muscles acting as hip flexors: rectus femoris and sartorius.

Abduction (50° with hip extended, 80° with hip flexed): gluteus medius; tenso fascia

latae; gluteus maximus with its attachment at the fascia lata; gluteus minimus;

piriformis; and obturator internus.

Adduction (30° with hip extended, 20° with hip flexed): adductor magnus with

adductor minimus; adductor longus, adductor brevis, gluteus maximus with its

attachment at the gluteal tuberosity; gracilis (extends to the tibia); pectineus,

quadratus femoris; and obturator externus. Of the thigh muscles, semitendinosus is

especially involved in hip adduction.

Physiology:

Like most joints, the SI joints' function includes some shock absorption for the

spine, along with torque conversion, allowing the transverse rotations that take place

in the lower extremity to be transmitted up the spine. The SI joint, like all lower

extremity joints, provides a "self-locking" mechanism (where the joint occupies or

attains its most congruent position, also called the close pack position) that helps with

stability during the push off phase of walking. The joint locks (become close pack) on

one side as weight is transferred from one leg to the other, and through the pelvis, the

body weight is transmitted from the sacrum to the hip bone.

The motions of the sacroiliac joints are:

Anterior innominate tilt of both innominate bones on the sacrum (where the

left and right move as a unit). Posterior innominate tilt of both innominate bones on

the sacrum (where the left and right move together as a unit). Anterior innominate tilt

of one innominate bone while the opposite innominate bone tilts posteriorly on the

sacrum (antagonistic innominate tilt) which occurs during gait

The Skeletal System serves many important functions; it provides the shape

and form for our bodies in addition to supporting, protecting, allowing bodily

movement, producing blood for the body, and storing minerals. The number of bones

in the human skeletal system is a controversial topic. Humans are born with about 300

to 350 bones, however, many bones fuse together between birth and maturity. As a

result an average adult skeleton consists of 208 bones. The number of bones varies

according to the method used to derive the count. While some consider certain

structures to be a single bone with multiple parts, others may see it as a single part

with multiple bones. There are five general classifications of bones. These are Long

bones, Short bones, Flat bones, Irregular bones, and Sesamoid bones. The human

skeleton is composed of both fused and individual bones supported by ligaments,

tendons, muscles and cartilage. It is a complex structure with two distinct divisions.

These are the axial skeleton and the appendicular skeleton.

The Skeletal System serves as a framework for tissues and organs to attach

themselves to. This system acts as a protective structure for vital organs. Major

examples of this are the brain being protected by the skull and the lungs being

protected by the rib cage.

Located in long bones are two distinctions of bone marrow (yellow and red).

The yellow marrow has fatty connective tissue and is found in the marrow cavity.

During starvation, the body uses the fat in yellow marrow for energy. The red marrow

of some bones is an important site for blood cell production, approximately 2.6

million red blood cells per second in order to replace existing cells that have been

destroyed by the liver. Here all erythrocytes, platelets, and most leukocytes form in

adults. From the red marrow, erythrocytes, platelets, and leukocytes migrate to the

blood to do their special tasks.

Another function of bones is the storage of certain minerals. Calcium and

phosphorus are among the main minerals being stored. The importance of this storage

"device" helps to regulate mineral balance in the bloodstream. When the fluctuation

of minerals is high, these minerals are stored in bone; when it is low it will be

withdrawn from the bone.

Human synovial joint composition :

Joints are structures that connect individual bones and may allow bones to

move against each other to cause movement. There are two divisions of joints,

diarthroses which allow extensive mobility between two or more articular heads, and

false joints or synarthroses, joints that are immovable, that allow little or no

movement and are predominantly fibrous. Synovial joints, joints that are not directly

joined, are lubricated by a solution called synovia that is produced by the synovial

membranes. This fluid lowers the friction between the articular surfaces and is kept

within an articular capsule, binding the joints with taut tissue.

Understanding how the different layers of the hip are built and connected can

help you understand how the hip works, how it can be injured, and how challenging

recovery can be when this joint is injured. The deepest layer of the hip includes the

bones and the joints. The next layer is made up of the ligaments of the joint capsule.

The tendons and the muscles come next.

The important structures of the hip can be divided into several categories.

These include

• Bones and joints

• Ligaments and tendons

• Muscles

• Nerves

• Blood vessels

• Bursae

• Bones and Joints

The bones of the hip are the femur (the thighbone) and the pelvis. The top end

of the femur is shaped like a ball. This ball is called the femoral head. The femoral

head fits into a round socket on the side of the pelvis. This socket is called the

acetabulum.

The femoral head is attached to the rest of the femur by a short section of bone

called the femoral neck. A large bump juts outward from the top of the femur, next to

the femoral neck. This bump, called the greater trochanter, can be felt along the side

of your hip. Large and important muscles connect to the greater trochanter. One

muscle is the gluteus medius. It is a key muscle for keeping the pelvis level as you

walk.

Articular cartilage is the material that covers the ends of the bones of any

joint. Articular cartilage is about one-quarter of an inch thick in the large, weight-

bearing joints like the hip. Articular cartilage is white and shiny and has a rubbery

consistency. It is slippery, which allows the joint surfaces to slide against one another

without causing any damage. The function of articular cartilage is to absorb shock and

provide an extremely smooth surface to make motion easier. We have articular

Fig. 12: Bones of the hip

cartilage essentially everywhere that two bony surfaces move against one another, or

articulate.

In the hip, articular cartilage covers the end of the femur and the socket

portion of the acetabulum in the pelvis. The cartilage is especially thick in the back

part of the socket, as this is where most of the force occurs during walking and

running.

Blood Vessels:

Traveling along with the nerves are the large vessels that supply the lower

limb with blood. The large femoral artery begins deep within the pelvis. It passes by

the front of the hip area and goes down toward the inner edge of the knee. If you place

your hand on the front of your upper thigh you may be able to feel the pulsing of this

large artery.

The femoral artery has a deep branch, called the profunda femoris (profunda

means deep). The profunda femoris sends two vessels that go through the hip joint

capsule. These vessels are the main blood supply for the femoral head. As mentioned

Fig. 13: Blood vessels of hip

earlier, the ligamentum teres contains a small blood vessel that gives a very small

supply of blood to the top of the femoral head.

Other small vessels form within the pelvis and supply the back portion of the

buttocks and hip.14

Bursae:

Where friction occurs between muscles, tendons, and bones there is usually a

structure called a bursa. A bursa is a thin sac of tissue that contains fluid to lubricate

the area and reduce friction. The bursa is a normal structure. The body will even

produce a bursa in response to friction.

Think of a bursa like this. If you press your hands together and slide them

against one another, you produce some friction. In fact, when your hands are cold you

may rub them together briskly to create heat from the friction. Now imagine that you

hold in your hands a small plastic sack that contains a few drops of salad oil. This

sack would let your hands glide freely against each other without a lot of friction.

A bursa that sometimes causes problems in the hip is sandwiched between the

bump on the outer hip (the greater trochanter) and the muscles and tendons that cross

over the bump. This bursa, called the greater trochanteric bursa, can get irritated if the

iliotibial band (discussed earlier) is tight. Another bursa sits between the iliopsoas

muscle where it passes in front of the hip joint. Bursitis here is called iliopsoas

bursitis. A third bursa is over the ischial tuberosity, the bump of bone in your buttocks

that you sit on. Many powerful muscles connect to and cross by the hip joint making

it possible for us to accelerate quickly during actions like running and journey.

SPINE BIOMECHANICS

We briefly touch upon spine biomechanics and estimates of muscle forces

about the spine because this area of research is critical to ergonomics and whole body

biomechanics and is a heavily studied area. There are a number of reasons for

studying spine biomechanics, among these:

• Spine disorders are the most prevalent cause of chronic disability.

• Annual prevalence of AS is one in 250 people.

• HLA B27 antigen has been found in the blood of 95% of patients with AS.

• Environmental factors such as genitourinary or bowel infections acting as

triggers in the genetically predisposed individuals.

• Synovitis producing hyperplasia and accumulation of mononuclear

inflammatory cells is seen in the spine sacroiliac joint and costo-vertebral

joints leading to erosion, destruction of cartilage.

Fig. 14 : Bursa of hips

To better understand how muscle loads are placed on the spine, we need to

know some reference of anatomy. First consider the bony anatomy of the spine as

illustrated above.

• The major vertebra within the spine are grouped as cervical, thoracic and

lumbar. There are soft cartilaginous disks between each vertebra, that are

named appropriately enough intervertebral disks. A schematic of an

intervertebral disc is shown below:

• It is typically a problem with the disk that occurs when people complain of

low back pain. The disk contains an interior gel, the nucleus pulposus, and an

outer layer of laminated concentric rings formed primarily of type I collagen.

Typically severe lower back pain associated with numbness occurs when the

nucleus pulposus is "squeezed out" through the annulus fibrosus and places

pressure on the spinal cord. Although there is evidence that excessive loads

experimentally can cause disk prolapse, the clinical relationship is much more

complex and may involve genetic predispositions as well. Still, it is widely

theorized that excessive loads on the disks can cause damage, namely fissures

in the disk, that over time lead to disk degeneration and prolapse. Thus,

understanding the compressive loads on the spine is of critical importance for

Fig. 15 : Intervertebral disc

understanding the etiology of low back pain. To estimate spinal compression

loads, we also need to know something of spinal muscle anatomy.

• Spinal Muscles: The musculature of the spine is complex and is divided into 5

major classifications by location:

• Posterior Wall Musculature: erector spinae of paravertebral muscles

• Respiratory or Intercostal Muscles: between ribs

• Abdominal Wall Muscles: intertransversus, interior and exterior obliques,

rectus abdominus

• Superficial Trunk Muscles - broad muscles including the rhomboids,

latissimus dorsi, pectoralis, and trapezius

• Lower Trunk Muscles: transversis abdominus

A simplified view of muscles affecting the spine are shown below:

Fig. 16: Simplified view of muscles

Biomechanics of the Hip:

This section is not intended to be a comprehensive analysis of the forces

acting on the proximal femur and the acetabulum. It is, however, important to the

success of total hip arthroplasty that one understands the factors influencing both the

direction and magnitude of forces acting upon the femoral head. The forces exerted on

the hip have their biological expression in the form of the femur and acetabulum,

particularly in the location and orientation of the trabecular pattern. The forces

exerted on the prosthetic femoral head in a properly performed total hip replacement

will be very similar in both direction and magnitude.

Of all the species in the animal kingdom, only birds and man habitually use a

bipedal gait. Even the larger primates use a quadripedal ambulation mode for most of

their activity. When the weight of the body is being borne on both legs, the center of

gravity is centered between the two hips and its force is exerted equally on both hips.

Under these loading conditions, the weight of the body minus the weight of both legs

is supported equally on the femoral heads, and the resultant vectors are vertical.

When the hips are viewed in the sagittal plane and if the center of gravity is

directly over the centers of the femoral heads, no muscular forces are required to

maintain the equilibrium position, although minimal muscle forces will be necessary

to maintain balance. If the upper body is leaned slightly posteriorly so that the center

of gravity comes to lie posterior to the centers of the femoral heads, the anterior hip

capsule will become tight, so that stability will be produced by the Y ligament of

Bigelow. Therefore, in symmetrical standing on both lower extremities, the

compressive forces acting on each femoral head represent approximately one-third of

body weight.

In a single leg stance, the effective center of gravity moves distally and away

from the supporting leg since the nonsupporting leg is now calculated as part of the

body mass acting upon the weight-bearing hip. Since the pillar of support is eccentric

to the line of action of the center of gravity, body weight will exert a turning motion

around the center of the femoral head. This turning motion must be offset by the

combined abductor forces inserted into the lateral femur. In the erect position, this

muscle group includes the upper fibers of the gluteus maximus, the tensor fascia lata,

the gluteus medius and minimus, and the pyriformis and obturator internus. The

combined resultant vector of the abductor group can be represented by the line of

action M in Figure below. Since the effective lever arm of this resultant force (BO) is

considerably shorter than the effective lever arm of body weight acting through the

center of gravity (OC), the combined force of the abductors must be a multiple of

body weight. The vectors of force K and force M produces a resultant compressive

load on the femoral head that is oriented approximately 16° obliquely, laterally, and

distally. The orientation of this resultant vector is exactly parallel to the orientation of

the trabecular pattern in the femoral head and neck.

The effect of this combined loading of body weight and the abductor muscle

response required for equilibrium results in the loading of the femoral head to

approximately 4 times body weight during the single leg stance phase of gait. This

means that in normal walking the hip is subjected to wide swings of compressive

loading from one-third of body weight in the double support phase of gait to 4 times

body weight during the single leg support phase. The factors influencing both the

magnitude and the direction of the compressive forces acting on the femoral head are

• The position of the center of gravity;

• The abductor lever arm, which is a function of the neck-shaft angle;

• The magnitude of body weight.

Shortening of the abductor lever arm through coxa valga or excessive femoral

anteversion will result in increased abductor demand and therefore increased joint

loading. If the lever arm is so shortened that the muscles are overpowered, then either

a gluteus minus lurch (the center of gravity is brought laterally over the supporting

hip) or a pelvic tilt (Treridelenburg gait) will occur.

Forces on the hip with sideways limping. Note the reduction of vector M and

R even though K is unchanged. R is also more vertically oriented.15

Since the loading of the hip in the single leg stance phase of gait is a multiple

of body weight, increases in body weight will have a particularly deleterious effect on

the total compressive forces applied to the joint. The effective loading of the joint can

be significantly reduced by bringing the center of gravity closer to the center of the

femoral head. Sideways limping, however, requires acceleration of the body mass

laterally, its deceleration during the stance phase of gait, and then its acceleration

back to the midline or even to the other side as the single leg stance phase changes to

the opposite extremity. This requires considerable energy consumption and is a much

Fig. 17.a: Biomechanics of hip

less efficient means of ambulation than the normal situation in which the hip is

subjected to these considerable forces. Another effect of sideways limping is that the

resultant vector becomes more vertical because the center of gravity is acting in a

more vertical direction, and therefore the bending moment the femoral neck is

increased.

Another mechanism for reducing the resultant load on the femoral head is the

use of a walking stick in the opposite hand. Since some of its force is transferred to

the walking stick through the hand, the effective load of body weight is thus reduced

in two ways:

• The effective load of body weight is reduced;

• Since the turning moment around the femoral head is reduced, the abductor

demand is also reduced. 17

Fig. 17.b: Biomechanics of hip

ANKYLOSING SPONDYLITIS

Ankylosing spondylitis (AS, from Greek ankylos, bent; spondylos, vertebrae),

previously known as Bechterew's disease, Bechterew syndrome, and Marie Strümpell

disease, a form of Spondyloarthritis, is a chronic, inflammatory arthritis and

autoimmune disease. It mainly affects joints in the spine and the sacroilium in the

pelvis, causing eventual fusion of the spine.

Ankylosing Spondylitis A chronic progressive inflammatory disease of the spine,

sacroiliac joints, and paravertebral soft tissues. It is characterised by early sacroiliac

joint involvement, followed by ossification of the annulus fibrosusand surrounding

connective tissue, along with arthritic changes in the intervertebral joints, which

results in bony ankylosing of the spine. Peripheral joints may also be involved. The

disease occurs predominantly in young adult males and is often associated with the

presence of the HLA-B27 antigen, absence of rheumatoid factor in the serum, and

lack of rheumatoid nodules.18

Ankylosis.(n) Abnormal fixation, stiffness, immobility and consolidation of a joint.

This may result from bony, cartilaginous, or fibrous tissue overgrowth.

Ankylosing spondylitis belongs to a group of seronegative

spondyloarthropathies. A chronic form of arthritis, AS is estimated to affect 1.4 % of

the general population. Severity of the disease varies among individuals as well as

remission and exacerbation periods. Ankylosing spondylitis primarily affects the

spine and hip joints causing progressed bone fusion including fusion of the

costovertebral joints, erosion, destruction of the vertebral endplates, osteophytes,

subchondral sclerosis, squaring of vertebral bodies, ossification of the intervertebral

disc, narrowing of joints, and osteoporosis. Fusion of the spine mainly occurs at the

lumbar level with progression cranially to the cervical spine. Enthesopathy, or

inflammation of bone attachment to tendons, ligaments, and joint capsules also

occurs. The spine adopts a long bone persona and is easily susceptible to fracture. As

the spine undergoes chronic inflammation, the patient develops a more pronounced

curvature to lessen the severity of pain. The result is a fixed flexion deformity of the

spine or otherwise referred to as a "bamboo spine" when viewed radiographically.

Such an irregular posture contributes to a loss of horizontal gaze, physiologically

incorrect sagittal contour, physical embarrassment, respiratory restriction, and a

higher risk for trauma.

THE SPONDYLOARTHROPATHIES

The spondyloarthropathies (SpAs) encompass a group of clinical syndromes

that are linked in terms of disease manifestations and in terms of genetic

susceptibility. The clinical subsets most commonly recognized are ankylosing

spondylitis, reactive arthritis, psoriatic arthritis and enteropathic arthritis.8

In addition, there is sizeable population of patients that does not fit into one of

these distinct diagnostic categories but shares some of common clinical features. The

syndrome associated with this subset is termed undifferentiated SpA, which over time

may evolve into classical pattern such as AS but which may remain in an

undifferentiated pattern.

Family studies in which there are multiple individuals with an SpA have

emphasized some of the commonality between the four distinct subsets .The

impression from such studies is that there is shared common path of immunogenetic

susceptibility upon which various genetic and environmental influences lead to

characteristic clinical subsets. Thus, if enteropathic arthritis occurs in such a family,

in another family it may be psoriatic arthritis. In this sense, the SpAs seem to “breed

true”. It should be recognized, that some distinct feature can be clinically very close in

their manifestations (e.g. guttate psoriasis and keratodermia blennorrhagica), making

simple discrimination sometimes difficult.

There are several common features in family of SpAs, which at once link them

and serve to distinguish them from the other major contributor to chronic

polyarthritis, RA. The arthropathies have a strong predilection for spine, in

particularly the sacroiliac joints, There is shared predilection for new bone formation

Fig. 18

at sites of chronic inflammation, with joint ankylosis as a consequence. When

peripheral arthritis occurs, it is commonly lower extremity and asymmetrical. There is

predilection for the sites of tendon insertion into bone (enthese), so that enthesis

becomes one of the most specific clinical manifestations of SpAs.The basis for the

target organ involvement has invoked biomechanical factors, innervation, local

vascularity and bone marrow derived inflammatory mediators, but the precise

mechanism for this relationship remains in completely defined.

Whatever the reason, inflammation in the enthesis and contiguous subchondral

bone as a characteristic feature of this arthritis, and the appearance of this

inflammation on MRI is distinct enough to lead some investigators to use such

imaging for diagnostic purposes.

Predilection for ocular inflammation, particularly acute anterior uveitis, is

common feature of all subsets and indeed is considered by some to be a member of

SpA in its own right because it may occur in the same susceptible populations of

patients even in the absence of joint involvement. Finally all subsets have an

association with the class I HLA B27 allele, with the strength of the association

varying somewhat between them. Increasingly, diagnostic criteria are being used that

emphasizes the clinical common features, namely inflammatory spinal pain or

asymmetrical, lower extremity synovitis. There are several distinctive features that

differentiate the SpA from rheumatoid arthritis (RA), the other main contributor to the

differential diagnosis of chronic polyarthritis in the table below. These include sex

predilection, HLA association, pattern of joint involvement, and presence of

rheumatoid factor, which becomes the serologic borderline between seropositive

disease (RA) and seronegative disease (SpA).

CONTRAST OF RHEUMATOID ARTHRITIS & SPONDYLOARTHROPATHY

Feature Rheumatoid

arthritis

Ankylosing

spondylitis

Entropathic

arthritis

Psoriatic

arthritis

Reactive

arthritis

Male/female

ratio

1:3 3:1 1:1 1:1 10:1

HLA

association

DR4 HLA B27 HLA B27

(axial)

HLA B27

(axial)

HLA B27

Joint pattern Symmetric,

Peripheral

Axial Axial and

peripheral

Axial and

asymmetric

peripheral

Axial and

asymmetric

peripheral

Sacroiliac 0 Symmetric Symmetric Asymmetric Asymmetric

Syndesmophyte 0 Smooth,

marginal

Smooth,

marginal

Coarse,

nonmarginal

Coarse,

nonmarginal

Eye Scleritis Iritis +/- 0 Iritis or

conjunctivitis

Skin Vasculitis 0 0 0 Keratoderma

Rheumatoid

factor

80% 0 0 0 0

HLA =human leukocyte antigen.

Furthermore, it is common for the SI joint to become even more stiff and

actually lock, usually due to injury, but also due to prolonged sitting, for example.

This explains why manipulation is the treatment of choice for the very painful SI joint

syndrome.

Orthopaedic surgeons, researching arthritis in knees and hips make the

following statement: Mechanical factors, including joint instability and malalignment,

contribute to the progressive degeneration that characterizes hip and knee arthritis.

Mobilization may also be useful for keeping the joint loose using certain specific

exercises and stretches that are important in the rehabilitative phase of the treatment.

Normal upper sacrum, sacroiliac joint and presacral soft tissues is involved.

The positioning of the cadaver during preparation of the cadaver has induced a slight

malalignment of the sacroiliac joints. These joints carry a true diarthrodial synovial

joint anteriorly and a complex array of dense ligaments posteriorly. The joints are

covered anteriorly by the iliacus muscle which in turn is bounded anteriorly by the

psoas major muscle. The iliolumbar nerve trunk and blood vessels are firmly stretched

over the (anterior) convexity of the ala. The lower poles of the ganglia, arteries and

veins are embedded in the fat filling the wide SI foramina, between them is the

vestige of the SI disc. Posteriorly the sacral canal contains the S2 ganglia and the

terminating thecal sac.

FACTORS PREDISPOSING

HLA B27

The major histocompatibility complex (MHC), on the short arm of

chromosome 6 in humans in one of the most polymorphic regions of the human

genome. This is particularly so for the B locus, which constitutes part of the class1

MHC genes in this complex. There are more than 200 different alleles at this locus

of which B27 is one As with all HLA alleles, there is codominant expression of B

locus genes, so that most individuals who are “B27 positive” are heterozygous for the

B locus and there appears to be little clinical or prognostic significance associated

with the less common homozygous B27 state. The conventional role of class1HLA

antigens is to present a processed peptide to the T-cell receptor of a specific CD8+

cytotoxic T cell, there by initiating an immune response against the pathogen from

which that peptide was derived by intracellular proteolysis and processing. This

function places the HLA antigens in a critical role in host defense against pathogens.

Three hypothesis have been put forward:

• HLA B27 acts as a receptor site for an infective agent.

• HLA B27 is a marker for an immune response gene that determines susceptibility

to an environmental cause.

• HLA B27 may induce tolerance to foreign antigens with which it cross-reacts.

The offspring of an individual with HLA B27 have 50% of chance of carrying

the same antigen.19

The role of class I HLA antigen in pathogenesis is supported by the fact that

HLA-B27 transgenic mice spontaneously develop arthritis, skin, gut and

genitourinary lesions. There are clues that infections play a role, with part of the

organism which are structurally similar to the HLA molecule triggering cross-reactive

antibody formation. AIDS is increasing the prevalence of reactive arthritis and

spondylytis is sub-Sharan Africa even in the absence of HLA B27. The types of

arthritis that follow a precipitating infection are called reactive arthritis. The

specialized immune systems of the gut and genitourinary mucous membranes may

also play causal role, perhaps reacting to local infections or to antigens which cross

the damaged mucosa.20

Aetiology:

The tendency to develop ankylosing spondylitis is believed to be genetically

inherited, and the majority (nearly 90%) of patients with ankylosing spondylitis are

born with the HLA-B27 gene. Blood tests have been developed to detect the HLA-

B27 gene marker and have furthered our understanding of the relationship between

HLA-B27 and ankylosing spondylitis. The HLA-B27 gene appears only to increase

the tendency of developing ankylosing spondylitis, while some additional factor(s),

perhaps environmental, are necessary for the disease to appear or become expressed.

For example, while 7% of the United States population have the HLA-B27 gene, only

1% of the population actually have the disease ankylosing spondylitis. In Northern

Scandinavia (Lapland), 1.8% of the population have ankylosing spondylitis while

24% of the general population have the HLA-B27 gene. Even among HLA-B27-

positive individuals, the risk of developing ankylosing spondylitis appears to be

further related to heredity. In HLA-B27-positive individuals who have relatives with

the disease, their risk of developing ankylosing spondylitis is 12% (six times greater

than for those whose relatives do not have ankylosing spondylitis).28

Recently, two more genes have been identified that are associated with

ankylosing spondylitis. These genes are called ARTS1 and IL23R. These genes seem

to play a role in influencing immune function. It is anticipated that by understanding

the effects of each of these known genes researchers will make significant progress in

discovering a cure for ankylosing spondylitis.21

Epidemiology:

Ankylosing spondilitis is also called as Strumpell and Marie, it was described

at the end of 19th century.27 It occurs in both the sexes but milder in female. The sex

ratio suggests that (M:F = 10:1). The prevalence in different ethnic groups is related

to the frequency of HLA-B27 in these populations shown in the figure below.

Graph 1: Incidence of Ankylosing spondilitis with reference to HLA-B27

Pathology:

The early histological changes in the synovial joints resemble rheumatoid

arthritis, but with less prominent lesions of the surface layers. The most important

effects are in the cartilaginous joints. Bony ankylosis is more frequent and the

sacroiliac joints often become fused. The apophyseal joints are involved and the discs

show replacement of the nucleus pulposus, the annulus fibrosus and parts of the

vertebral body by vascular fibrous tissue without any evidence of marked

inflammatory changes. In the spine, the lesion is in the ligamentous attachment to

bone (the enthesis) and this is characteristic of the disorder. 29

50%

8%

14%

8%

8%

0.50%

0.50%

0.50%

5%

1%

1%

1%

1%

0.50%

0.50%

0.50%

Haida Indians 

White Americans 

Finns 

English 

Germans 

Japanese 

Black Africans 

Aboringines Ankylosing spondylitis 

HLA‐B27

As the disease extends up to the intervertebral joints, there is ‘squaring’ of the

vertebral bodies and calcification of the annulus fibrous giving the characteristic

syndesmophytes which fuse to form the classic ‘bamboo spine’. This is caused by

inflammation of the anterior corners of the vertebrae which extends into the outer

layers of the annulus fibrosus.

Fig. 19: Spine in ankylosing spondylitis

Calcification of the inter-vertebral ligaments occurs. At this stage, there is

osteoporosis of the vertebra, and fractures of the spine after minor trauma can occur.

Other cartilaginous joints, such as the sternomanubrial joint and symphysis pubis, can

be affected with erosions and bony ankylosis.

http://w w w .medindia.net/patients/patientinfo/Images/anky losing_spondy lit is . g i f

Clinical features:

A gradual onset of low backache often with bilateral sciatic radiation as far as

knees, worse on waking and eased by exercise, occurring in young male is the

classical presentation of disease.24

The following features suggest inflammatory, not mechanical, low back pain

• The disease most commonly begins between 16 and 40 years of age.

• insidious and persistent discomfort for months with constitutional disturbances,

• Morning stiffness, the pain usually disturbs the sleep and stiffness after

immobility.

• Improvement of pain and stiffness with exercise.

In late stages of the disease there may be reduction in spinal pain as the axial

skeleton becomes ankylosed. Involvement of the costovertebral joints may result in

chest pain and, later, decreased chest expansion.

Other historic features that suggest the disease include common associations

such as eye disease, tendonitis, and a family history of low back pain, inflammatory

bowel disease, or psoriasis.25

The patient complains of back pain especially in the early sages when there

may be tenderness over the sacro-iliac joints. Later, examination will show abnormal

rigidity of the spine, reduced chest expansion and fixation of the hip joints. In

untreated cases, a flexion deformity of the spine ie, Kyphosis, lordosis, scoliosis,

asymmetry and range of motion is disturbed.26

Diagnosis is often delayed, symptoms being ascribed to lumbar disc disease.

In spondylitis, spinal mobility is limited in all directions in contrast to disc prolapse,

hen lateral flexion is usually normal. The lumbar spine becomes flattened and the

normal lordosis is lost. Sarco-iliac tenderness may be present. In an advanced case,

the diagnosis is usually decided on the posture, gait and limitation of back

movements. Only a few patients exhibit marked kyphosis and spinal rigidity.

Peripheral joints are involved in about a quarter of patients, and involvement

of the hip is important because of the functional implications. Sometimes, pain and

tenderness at thesite of tendinous insertions can be prominent feature, with the back,

pelvic brim and ischial tuberosities being characteristic sites. Several joints are

involved, usually the large joints of the lower limb frequently in an asymmetric

fashion.

The chest may also be involved. However, chest expansion is more difficult ot

measure, chest involvement usually is pronounced only later in the course of the

illness.

Although primarily an articular disease of the axial and peripheral skeleton,

other organs may be involved.

Extra-articular features of ankylosing spondylitis

• Malaise and weight loss

• Iritis

• Apical pulmonary fibrosis

• Amyloidosis

• Cardiac involvement

a. Aortic regurgitation

b. Conduction defects

• Neurological features

a. Spinal fractures

b. Cauda equine syndrome

Laboratory findings:

HLA-B27 gene is present in approximately 90% of patienst with AS. A mild

normochromic, normocytic anemia may be present. Patients with severe disease may

show an elevated talkaline phosphatase level. Rheumatoid factor and antinuclear

antibodies are largely absent. In cases with restriction of chest wall motion, decreased

vital capacity and increased functional residual capcity are common, but airflow

measurements are normal and ventilatory function is usually well maintained. The

ESR is raised while the disease is active.

At the level of joint histopathology, sites of chronic inflammation in the

former are associated with erosions but in the latter are associated with new bone

formation. This suggests a fundamental difference in the cytokine profile in the

microenvironment of the joint, and although there is some evidence that SpAs reflect

more of a type 2T helper cell (Th2) cytokine profile as opposed to the (Th1) profile

of RA.

• Bone mineral density and osteoporosis in Ankylosing Spondylitis

• Analysis of posture in patients with Ankylosing Spondylitis

• Sagittal balance of the spine in Ankylosing Spondylitis

• Planning the restoration of view and balance in Ankylosing Spondylitis.22

Diagnosis:

• A history of inflammatory back pain

• Limitation of motion of the lumbar spine in both the sagittal and frontal planes.

• Limited chest expansion, relative to standard values for age and sex.

• Definite radiographic sarcoiliitis.

Treatment

There is no definitive treatment for AS. Several nonsteroidal anti-

inflammatory drugs (NSAIDs) have proved effective in reducing the pain and

stiffness of AS and are commonly used.

Mostly conservative treatment which consists of rest, drugs, hot packs, spinal

exercises, traction, corset and education regarding the prevention of back pain.

Alternative Treatments

The National Institutes of Health defines complementary and alternative

medicine (CAM) as a group of diverse medical and health care systems, practices, and

products that are not presently considered to be a part of conventional medicine. CAM

therapies used alone are often referred to as "alternative". 23

Americans spend more than $1 billion a year on nontraditional treatments for

arthritis. The reasons for seeking CAM treatments vary – many people want relief

from pain and suffering that traditional medications have not provided; they hope to

avoid potentially serious side effects associated with such medications; and certain

conventional medical and surgical treatments cost more than many of us can afford.

Although there has been no rigorous scientific evidence to support the use of

CAM by people with ankylosing spondylitis (AS) and its related diseases, some

patients have benefited from such treatments.

Acupuncture

The exact way in which acupuncture works on the body remains unclear, but

stimulation of acupuncture points by puncturing the skin with hair-thin needles may

lead to release by the brain and spinal cord of opium-like molecules that help relieve

pain.

Enough research suggests that acupuncture relieves pain in some people, and

is safe if performed by a trained professional using sterile or disposable needles. More

scientific studies are underway to help determine its effect on various forms of

arthritis.

Treatments may be time-consuming and expensive, although some health plans cover

a certain number of acupuncture treatments per year for a variety of conditions.

Chiropractic Treatment

Some people with spondylitis swear by regular chiropractic sessions, but

doctors do not recommend this treatment for us. "Anyone with limited spinal mobility

due to [spondylitis] should avoid manipulation of their back or neck by chiropractors

and masseurs because it can be dangerous," claims Dr. Muhammad Asim Khan,

rheumatologist, researcher, and AS patient. Dr. Khan explains that chiropractic

treatments have sometimes inadvertently led to spinal fractures and neurological

complications, especially in people with fusion (extra bone growth) due to

spondylitis.

Massage

Many people with spondylitis find therapeutic massage very helpful, and if

done carefully, it can be a beneficial tool for pain relief and stress reduction. If a

massage therapist is aware of a person's spondylitis and understands the disease and

any potential manipulation issues, gentle massage can help promote well being. It

may provide temporary relief of pain or stiffness, and in some cases improve

flexibility because of the increased blood circulation. "In all my years of experience

as a physical therapist, I have never known massage to worsen the symptoms of

inflammation in a patient with AS. Deep tissue mobilization is nearly always

welcomed by those with AS and is usually given in combination with passive

stretches and ultrasound, heat or ice,".

Yoga Therapy

Yoga has been practiced for over 5,000 years and can greatly benefit people

with spondylitis under the instruction of a knowledgeable instructor who can tailor the

program to the individual.

DIET'S EFFECT ON SPONDYLITIS SYMPTOMS

In recent years many specialized diets have gained popularity among some

people with arthritis. To date, none of these claims have been substantiated by

rigorously controlled studies. That said, some people find that certain foods trigger

changes in symptoms - either for the better or the worse. If you find yourself noticing

this type of pattern, try keeping a food diary for a few weeks to find out if indeed

what you eat makes a difference or if you have food sensitivities.

Whether a person is affected by a chronic illness or not, there are some

straightforward guidelines that if followed, would lead to improved health and well-

being for almost everyone.

• Both calcium and alcohol affect the strength of the bones, and it is a well known

fact that people with spondylitis are already at higher risk for osteoporosis, a

dangerous thinning of the bones that can lead to fractures. Following a diet with

adequate amounts of calcium and vitamin D will help reduce the risk of

osteoporosis. Alcoholic beverages can also weaken bones. Consuming more than

two alcoholic drinks per day increases a person's chances of developing weakened

bones. In addition, alcohol mixed with certain medications can cause serious side-

effects to the gastro-intestinal tract and to major organs such as the liver and the

kidneys.

Experts agree that there are basic guidelines to good nutrition, which are:

• Eat a variety of foods that make you feel good - avoid those that do not.

• Eat plenty of vegetables, fruits, and whole-grain products.

• Use fat (especially saturated fat found in animal products), cholesterol, sugar,

and salt in moderation.

• Drink 8-10 glasses of water a day.

• Most people receive daily requirements of vitamins and minerals by eating a

well-balanced diet, but others need to take vitamin supplements.

• Avoid alcohol or foods that can interact with your medication. Talk with your

doctor and/or pharmacist about potential interactions.

Radiologic Findings

Erosions are much less than seen with other spondyloarthropathies. The

synovial portion of the SI joint, i.e. the anteroinferior 1/2 to 2/3 of the joint, ankyloses

first, follwed by the ligamentous portion. Ankylosis of the posterosuperior

ligamentous portion is considered to look like a "star."

Other findings you might see in the pelvis, if you're not overwhelmed by those

SI joints and a glimpse of the spine, are ossification of ligamentous attachments in the

iliac crests and ischial tuberosities, classically giving a purported "whiskered" look.

That sounds cute doesn't it. Looks just kind of fuzzy to me. The symphysis pubis can

show tiny "serrated" erosions like the SI joints, before it ankyloses. Purportedly,

~25% of ankylosing sponylitis eventually has symphysis pubis involvement.

HOMOEOPATHIC CONCEPT OF HEALTH, DISEASE, CURE AND

APPROACH TO THE DISEASE

Hahnemann explained in the aphorism 11 as “It is only this spiritual, self

acting (automatic) vital force every where present in the organism, that is primarily

deranged by the dynamic influence upon it of the morbific agent inimical to life, it is

only the vital principle, deranged to such an abnormal state, that can furnish the

organism with disagreeable sensations, and incline it to the irregular processes which

we call disease; for as a power invisible in itself and only cognizable by its effects on

the organism, its morbid derangement only makes itself known by the manifestation

of disease in the sensation and functions of those parts of the organism exposed to the

senses of the observer and the physician, that is by morbid symptoms and in no other

way can it make itself known.

Homoeopathy not only deals with the disease but the person as a whole.

Disease are nothing more than alteration in the site of the health of the individual

which expresses themselves with morbid signs and symptoms. This is where the

approach of homoeopathy varies from modern method of patient cure. Much stress

and value is placed on homoeopathic physician when his duty is not only to treat the

desire but to deal with this whole person to define problem of the patient and to

formulate the totality based on which the remedy should be selected using “the law of

similar”30

The biological concept of disease as elaborated above stands accepted in

Homoeopathy. The study of disease however, the homoeopathic physician as is

already indicated considers the individual response on the greater importance from the

standpoint of the selection of curative remedy and is guided by the totality of

symptoms.

Hahnemann explained the cause of disease in the aphorism 5 as “a chronic

maism which is fundamental cause for every disease”. Further he explains about it in

the aphorism no.8 as “after removal of all the symptoms of the disease and of the

entire collection of the perceptible phenomena, there should or could remain anything

else besides health, or that the morbid alteration in the interior could remain

uneradicated”.

He has further stated in aphorism no. 12 as “it is morbidly affected vital

energy alone that produces diseases, so that the morbid phenomena perceptible to our

senses express at the same time all the internal change, that is to say, the whole

morbid derangement of the internal dynamics”.

He has explained in the aphorism no 17 “ the practitioner ,therefore only

needs to take away the totality of the disease signs and has removed the entire

disease”.

He has explained in the aphorism no 78 “the true natural chronic diseases are

those that arise from a chronic miasm, which when left to themselves, unchecked by

the employed of those remedies that are specific for them, always go on increasing

and growing worse, not with standing the best mental and corporeal regimen and

torment the patient to the end of his life with ever aggravated suffering”.

In the aphorism 79 ”Syphilis alone has been to some extent known as such a

chronic miasmatic disease which when uncured ceases only with the termination of

life. Sycosis (the condylomatous disease) equally ineradicable by the vital force

without proper medicinal treatment was not recognized as a chronic miasmatic

disease of peculiar character, which it nevertheless undoubtedly is and the physician

imagined they had cured it when they had destroyed the growths upon the skin , but

the persisting dyscrasia occasioned by it escaped their observation”.

In aphorism 80 Hahnemann “incalculably greater and more important that the

two chronic miasm just named, however is chronic miasm of psora. The monsterous

internal chronic maism-the psora, the only fundamental cause and producer of all the

other numerous . I may say innumerable nervous debility, hysteria, hypochondriasis,

mania, melancholia, imbecility, madness, epilepsy and convulsions of all sorts,

softening of bones(rachits), scoliosis and kyphosis, caries, cancer, fungus heamatodes,

neoplasms, gout, haemorrhides, jaundice, cyanosis, dropsy, amenorrhoea,

haemorrhage

from stomach, nose, lungs, bladder and womb. Asthma and ulceration of

lungs, impotence and barrenness,of migraine, deafness, cataract, amaurosis, urinary

calculus, paralysis, defects of the senses and pains of thousands of kinds, etc figure in

systematic works on the pathology as peculiar, independent diseases.

Dr.Kent31 states disease as “Disorder of the activities of the internal man, a

lack of harmony or lack of balance, which gives forth the signs and symptoms by

which we recognize disease. These sensation constitute the language of the disorder.

Further he explains as “only the vital principle thus disturbed can give to the organism

its abnormal sensations and incline it to the irregular actions to which we call

disease”. Morbid disturbances can be perceived solely by means of expression of the

disease in the sensations and actions. For him symptoms are language of sickness, at

the level of mind, emotions and body.

Dr.Boenninghausen32 opines that diseases as, “The invisible, morbid

mutation in man’s internal change in condition perceptible to our senses in the

external (complex of symptoms), from before eyes of creative omnipotence, what we

call disease: but only the totality of symptoms is the slide of the disease, which in

turned to the disciple of healing; and what he needs to know for the purpose of cure”.

Dr.Richards33 opines disease as “It may be concealed that every disease is

dependent on an alteration in the interior of organism. But the alteration is only

guessed at by the understanding in a dim and illusionary manner from what the

morbid symptom reveal concerning it, and the exact nature of this inner invisible

alteration cannot be ascertained in any reliable manner. The invisible morbid

alteration in the interior and the alteration in the health perceptible to our senses

together constitute to the eye of creative omnipotence, what we term disease”.

Dr. Charles J.Hemple said that “Disease is totality of the effect by which an

organism which has been specifically adapted, or prepared for their reception”.

Dr. Allen34 Quotes “The character of the maism yields the character to the

disease or the form of illness”.

Dr. C.A. Gutierrez tells “chronic disease is a modification of the vital

dynamism, leading to the creation of a special state called susceptibility; when we

neutralize this state, we cause it to lose its essential modality, i.e. its driving force. In

the patient we should recognize two perfectly defined facets; on one hand the illness,

which is only is only the vital dynamism neutralizes or denatured by something which

produces a pure modification, giving rise to susceptibility, and which Hahnemann

called the maism, and on the other hand, the human being in his environment which

colored by a series of modalities, permits us to catalogue the individual case of

sickness”.

Dr.Hahnemann35 regarding the three explains “Psora is the most universal,

most destructive and yet most misapprehended chronic miasmatic disease which for

many thousands of years has disfigures and tortured mankind, and during the last

centuries has become the mother of all the thousands of incredibly various acute and

chronic (nonveneral) diseases by which the whole civilized human race on the

inhabitated globe is being more and more afflicted. It is most infectious , most general

of all the chronic miasms. At least 7/8th of all the chronic maladies spring from it as

their only source, while the remaining 1/8th springs from syphilis and sycosis or from

a combination of two of these miasmatic chronic diseases or from a combination of

three of them (which is rare)”.

He explains regarding Syphilis that it began to raise its dreadful head in 1493.

It only passes into a tedious malady difficult to cure, when it is complicated with

Psora, the second chronic miasm, which is more widely spread than the fig wart

disease, and which for 31/2 centuries has been the source of many other chronic

aliments, is the miasm of venereal disease proper, the chancre disease.

He explains regarding Sycosis, as being that miasm which has produced by far

the fewest chronic diseases, and has only been dominant from time to time. The fig

wart disease, during the French war, was treated in an inefficient and injurious

manner, internally with mercury, because it was considered homogenous with the

venereal chancre disease. After the violent treatment of fig warts by allopathic

physicians, we often find developed Psora complicated with Sycosis, when the Psora,

as is often the case, was latent before in the patient. At times, when a badly treated

case of venereal chancre disease has proceeded, both these miasma are conjoined in

threefold complication with syphilis.

Dynamisation;

C.M.Boger36 Dynamism, until lately laughed out of court, is about to rend

asunder its mockers before the whole world and it is high time to realize that it is not a

thing apart, but an essential factor of our very nature and life and must be reckoned

with if we would practice medicine. They are intended to condition him, elevate the

profession and benefit the community. Actually we see the reverse; want of logic,

incoherence and prideful selfishness. If there be lack harmony, among us, our

foundations cannot be very secure and no amount of subtle reasoning can make them

so, hence we have no right to call ourselves scientist much less artist. If science or art

holds anything at all for the benefit of man, by that much is medicine concerned

therein. These being true how are we going to disassociate the dynamics of action

from action itself. Preposterous as the idea is, it is just what is being attempted in

everyday practice.

The real homoeopathic physician is such a specialist; he makes materiamedica

and the exemplification of the law his being. Thus and only thus can he make cures

that are impossible to the old line physician and there by justify a separate existence it

must be his aim to do things and do them well; no other course is honestly possible

under the law, which like all natural laws is exacting in its demands. And knows no

compromise.

The first step in the study of Homoeopathic science is not always the same,

but as obvious things make the strongest appeal many convert have been made after

seeing or experiencing the power of similia. Such clinical demonstrations keep for

you a perennial interest because each new hopes, the greatest of all aids to curing.

Every problem solved opens the way for other better work. This is in itself not only a

source of satisfaction to all concerned, but a mental exercise in which all the powers

of thought are concentrated upon finding and applying the suitable remedy.36

A new mode of Dynamisation:

Dr. B.K.Sarkar2 Again, there are people who have read 6th edition of organon

(unfortunately, the translation of the 6th edition is at many defective and does not

represent Hahnemannian thinking) and still frown on Hahnemann’s writing on the

matters and those have taken ideas with prejudiced ‘minds’ have given unfair trials,

and left their efforts in the midst and did not come to any conclusions and so all have

again gone to the same old erroneous practice. These are the people who ‘cry’ to

make Homoeopathy more scientific, as if Homoeopathy is not scientific and there are

‘gaps’ in Homoeopathy, because they cannot understand and make people understand

our Master. I have read those ‘cries’ of our learned bosses in Journals. My humble

request to them is “be scientific minded first and then make Homoeopathy more

scientific”. When other ‘so called’ sciences are borrowing ideas from our Master’s

pen, what further proof do they want to make Homoeopathy “more scientific”. Is

science for scientists or scientists for science? Brothers! Better change your outward

makeup and look at your real face in the mirror. It will give you more pleasure than

pain. If you are not getting results. it is your defeat and it is the greatest defeat as you

cannot win the hearts of the suffering “Souls”.

Health:

Man has the will and the understanding and the house which he lives in is his

body. The organs are not the man .The man is prior to the organs. The order of

sickness as well as the order of cure is from man to his organs. The real sick man is

prior to the sick body. A man is sick prior to localization of disease. When we wait for

localization, the results of disease have rendered the patient incurable. Symptoms are

but the language of nature, talking out, as it were, and showing as clearly as the

daylight, the internal nature of sickman or woman. Crude drugs cannot heal the sick

and that what changes they effect are not real but only apparent. Tissue changes are

the body and are the results of the disease, they are not the disease. The bacteria are

the results of the disease. The disease cause is more subtle. The remedy, which will

produce on healthy man similar symptoms, is the master of the situation, is the

necessary antidote, will overcome the sickness, restore the will and understanding to

order and cure the patient. Man consists in what he thinks and what he loves and there

is nothing else in man.

The physician has to’ perceive’ in the disease that which is to be cured, and

that is through ‘totality of symptoms’. He has to perceive the nature of remedy .

Experiences has only a confirmatory place. It cannot take the place of science and

truth. All true diseases of the economy flow from centre to circumference. All miasms

are true diseases. The active cause is within, and apparent cause of sickness is

without. If a man has no deep miasmatic influence, outer causes will not affect them.

Homoeopathy has two parts ; the science of homoeopathy is the art of homoeopathy.

One has to learn the art of homoeopathy to prepare himself for the application of the

science of homoeopathy. Vital force is constructive and formative in its thing in the

universe has its aura. Every star and planet has it. The remedy to be Homoeopathic

must be similar in quality and similar in action to the disease cause . As soon as the

internal economy is deprived in any manner of its freedom, death is threatening;

where freedom is lost, death is sure to follow. Potency should suit the varying

susceptibility of sick man. Any more than just enough to supply the susceptibility is a

surplus and dangerous. Human race has been greatly disordered in the economy

because of surplus drug taking. Primitive cause is not in the bacteria. Bacteria

themselves have a cause to appear and survive. Over sensitive patients are actually

poisoned by inappropriate administration of potentized medicines. Their chronic

maisms are complicated with chronic drugging and its effect upon vital force. The

physician who can only hold in his memory the symptoms of a disease or remedy will

never succeed as a homoeopath. The majority of such who call themselves

homoeopaths at the present time, are perfectly incompetent to examine a patient, and

therefore incompetent to examine homoeopathy. It is impossible to test homoeopathy

without learning how to get the disease image so before eyes that the homoeopathic

remedy can be selected. At the present day, there is almost no such thing as an

unprejudiced mind. Do not prescribe until you have found the remedy that is similar

to the whole case, even although it is clear in your mind that one remedy may be more

similar to one particular group of symptoms and another remedy to another group.37

The life and composition of cells is complex nature. The composition of

animal protoplasm is capable of analysis, yet there is in each cell and its life function

that which is beyond our comprehension and defies analysis. We cannot as yet fathom

the reason why a human ovum takes on growth and development only when the

spermatozoa imbed itself deep in its innermost nuclei. We only know that it possesses

some hidden vital function that compels it to develop and grow. The power of each

life to develop from the single ovum into its own ego, unfolding and expressing itself

forever in its own way and individuality, never varying from the ideal that is once

stamped, to carry out its perfection all the powers of adult life, distinguishing it from

all other created species, is a marvel until we comprehend the principle of the vital

force or the energy permeating all created things. That power, although defying

analysis, nevertheless continues all through life as a mysterious manifestation of the

vital functions. It is the close study of these vital functions that becomes the chief

study of the physician. In order to obtain a thorough knowledge of these vital

functions we must study them in their manifestations during health. From the earliest

period of its existence growth is manifest from within the cell out; it is never observed

growing from without in. The point most vital to observe is the course and the

direction of its expression always from within outward. This is true in embryonic state

and always maintained as long as life exists. This is equally true in the specialization

of functions. The special organs are developed and their functions maintained by the

expression of the vital energy as the life giving principle. All expression of the mind

are such manifestations. Indeed, it is the expression of the vital force in and through

the mind and intellect that has a very great influence in the functioning of all life and

the special organs. In health all expressions of vital force may be expressed by perfect

functioning of all parts of the body by the sense of general well-being.38

Health is that balanced condition of the living organism in which the integral,

harmonious performance of the vital functions tends to the preservation of the

organism and the normal development of the individual.39

Cure:

Dr Kent says homoeopathy always demands for cure, the remedy that

provokes symptoms most like those to be cured. But the most like of all often is the

disease poison itself; not in its crude condition, but changed y preparation and

potentization; rendered inert for mischief, and only potent for good. You have heard

in a Compton Burnett Lecture that, where old school is using disease products,

rendered “similar” by preparation, it is being forced into what Hahnemann was forced

into and taught one hundred years ago. That is to say……. They have to change their

polypharmacy for the single remedy. They have to adopt his single dose, to evoke

vital reaction; repeated as symptoms demand. To realize that he is correct when he

contended that it is only the reaction of vital force against drug or against disease, that

is curative. That disease is merely the rebellion of vital force against noxious agent,

inimical to life and that cure comes from the stimulated reaction of vital force against

diseases. They experience also his initial aggravation sometimes of great severity,

because they lack his experience in the preparation, the administration, and the dosage

of homoeopathic remedies; which differ entirely from those of the old school37.

Health is restored after the removal of all symptoms, then only than is all disease

removed.

Hahnemann this way distinguishes between disease itself and its causes,

manifestation, and products and then show at once that sphere of homoeopathy is

limited to functional changes from which the phenomena of disease arise. Thus

homoeopathy operates only in the dynamic sphere. Directly, homoeopathy has

nothing in common with the physical cause or product of disease, but secondarily it is

related, here is the place where surgery may have its functions, yet many of the

tangible effects may remain. If these effects are too far advanced, they may be

removed. If this is not done, it stands to reason that the best effects of the remedy will

not primarily within the range of similia, and therefore not the objective of

homoeopathic treatment, the morbid process from which they arise or to which they

lead is under the control of homoeopathic treatment, This medication may control and

retard the development of pathological conditions. Thus tumors may be retarded or

completely arrested, and absorption increased, and finally the disappearance of the

growth; secretions or excretions increased or decreased, ulcer healed; but all this is

secondary to the real cure which takes place solely in the dynamic sphere, restoring

the patient to health and harmonious functioning of this whole being by the dynamic

influence of the symptomatically similar remedy.39

As Stuart Close has well said, that real field of homoeopathy is to those

agents which effect the organism as to health in ways not governed by chemistry,

mechanics or hygiene, but those capable of producing ailments similar to those found

in the sick.

Fincke has shown that in the development and growth of the child much can

be done to make this symmetrical, for the child is peculiarly under the influence of

the laws of assimilation, here the laws of similia have pre-eminence, for the child is

peculiarly under the influence of the laws of action and reaction as applied to the

action of similar remedy in its development and growth. The homoeopathic principle

is not used in another field of what might be called extreme emergency, but rather we

use what may be called a principle of palliation.

MIASMATIC APPROACH OF ANKYLOSING SPONDYLITIS

Miasm interpretation varies in degenerative joint disorders depending upon the

presentation or stages. Depending upon the expression available it can be identified

Psoric, structural changes.

Miasm is interpreted by the family history and past history. This also is

appreciated as predisposition. In the back ground of this current presentation of

degenerative joint disorders has to be understood. Miasm dominant at this phase may

be analyzing the present symptoms. This may be pertaining to this presentation only.

But this attains momentum from the fundamental miasm.

Miasm is always expressed by the signs and symptoms that the patient

produces. These permit the individual expression of the characteristic of miasm which

allow us to determine, recognize and handle out patients individually.

Dr. Ortega Proceso stand that “The natural healing force inside the human

body, in its integral completeness, represent of the universe acting on one point and

with the inherent purpose of preserving what has been created i.e. of enabling it to

continue-the specific objective which the human intellect can deduce from all that

exists, all things.”

Man’s natural healing power is undoubtedly undermined, caused to

deteriorate, and lessened as a restorative or reconstructive force by the presence of a

miasmatic condition-a profound and indelible stamp permanently imprinted on the

being by repeated perversions, excesses or deficiencies in its functioning.

Psora is perturbation of nutrition; sycosis compels it to accumulate debris

which should be eliminated, and syphilis causes it to degenerate. Since all of these

conditions can act as the true causes of all imbalances etiology for every degenerative

disease.

According to C.G.Jung human unconsciously pursue an archetype, a sort of

pattern of self, through accumulation of qualities establishing in the transcendent

realm a pattern which in the future will be of use to animist, spiritual, or organic

groupings. In other words, individual today are tracing-by virtue of rather indefinable

functions-the somewhat esoteric shapes of other existences.

Life as a succession of perfectly linked phenomena constitutes an order whose

result is persistence, i.e. affirmation. Disorder is negentropy or negative entrophy. The

miasm is disorder, a profound form of entrophic disorder which can scarcely be held

in check by the preservative vital force; and if it is greatly augmented and complicated

by another sycosis-syphilis, it can easily burst through the dike opposed to it by the

natural healing power, the destruction becomes evident, and the individual is headed

for death-with what is, from the medical point of view, a degenerative disease.

PSORA: Effects occur at the level of protecting envelops with the touch of

hypersensitivity & reativity metabolism nutrition glands, endothelial system, cardio

vascular system, nervous system, disorders represent with reversible functional

disturbances. Incoordinatiion and imbalance of function on account of induced

changes of control persist. Adverse environments act as mere accelerators.

In the early stages when only a subjective feeling is available and

investigations prove negative the available picture suggests of predominantly Psora.

Neuralgic pains usually better by quiet rest and warmth. Often worse motion.

Psora the sympathetic overactive express the labile hypertension under

emotional stress, blood pressure, with secondary effect on kidneys, dry skin, altered

fat, protein metabolism, ovarian imbalance, functional menstrual problems. Acrid

non-infective leucorrhoea with emotional background imbalance in general make-up,

malabsorption, malnutrition allergic response, spasm with emotional, hysterical

functional origin, vicarious, congestive haemorrhage.

SYPHILIS: A whole miasmatic disease expression terminates in the phase

characterized by destruction all over and at all levels. Homoeopathic physician with

right appreciation promotes reversal of disease. Over stimulated and exhausted system

under continued adverse environmental inputs leads to total loss of controls at

intellectual, emotional, and physical levels. Progressive loss of valves of life leads to

lack of discriminative intelligence, intelligence, perception, thinking and decision

making worst feeling of-anger, hate, envy, jealousy, suspicion leading to paranoid

traits with violent outbursts.

Stitching, shooting or lancinating pains in the periosteum or long bones of the

upper or lower extremities. Worse at night or approach of night, worse change of

weather; by cold and damp. Feet become deformed because legs cannot take weight

of body in osteoarthritis signifying combination of miasms.

Miasm express in the level of physical as cracks, fissures, ulceration which

destruction, abscess carries, explosive inflammation with toxaemia, malignant rapid

spread, necrosis with crippling deformities, ostoeoporotic changes and fractures, deep

disfigured scar formation, atrophy, degeneration of tissues, vessels, aneurysm,

ischemic attacks, calcium deposition, damage of myelin sheath, organic degenerative

states.

According Homoeopathy treatment is needed for the patient not for the

disease. This system considers the organism as a whole treatment starts from the

collection of data the case taking. Mostly person are victims of osteoarthritis. They

will not have much attention from the expected ones. From the detailed homoeopathic

case taking itself they will have a feeling that this physician will given enough

attention for them. It will boost up their confidence so the improvement will start

form this point.

SYCOSIS: Over stimulated responsive system with failed arrested activity, activity,

loss of control leads to inefficient aberrant immune responses and metabolic

maladjustments. Miasm engulfs severe refractory anaemia, weakness disproportionate

aggravation by suppression of discharges, fatigue with slowness, indolence, altered

mental expression, slow registration of sensory inputs, inadequate interpretation, with

paranoid ideas, guilt, feeling of insecurity which are mostly seen in majority geriatric

patients.

According to Hahnemann’s concept of chronic diseases joint disorders with

stiffness and early morning aggravation are expressions of sycotic miasm. As phyllip

Speight writes in comparison of Chronic miasms, arthritic-deformans is Sycotic.

Pains in joint or muscles are of shooting or tearing type. Pains in fingers or

small joints. Slow progress of inflammatory process. Recovery is slow. Oedema and

lack of heat may be present. Worse at approach of storm or a damp, humid

atmosphere and falling barometer or becoming cold. Stiffness and soreness especially

lameness is very characteristic of sycosis. Worse stooping, bending or beginning to

move.

THE UTILITY OF RHUS TOX IN ANKYLOSING SPONDYLITIS

Common name: Poison ivy; poinson oak.40

Natural order : Anacardiaceae.

Habitat : North America. Grows in woods and along fences on low ground.

Part Used : Tincture of the fresh leaves gathered at sunset just before flowering.

Active Principles : Toxicodendric acid; Toxicodendrol.

Physiological action:

Farrington H. says if applied locally to the skin , Rhus tox. is an irritant and

causes itching and vesicular eruption on the skin which may extend to the mucous

membranes where it produces edematous swelling, dryness, rawness and burning.

When taken internally or inhaled there are colicky pains in the abdomen worse at

night, diarrhoea, tenesmus, bloody stools and urine, and fever which is often typhoid

or intermittent in character; pains of a rheumatoid type in fibrous structures, joints and

lumbar region, ameliorated by heat and aggravated by rest. Fatal results have not

followed any case of poisoning recorded.

General characteristics :

Antipsoric, rheumatoid, paretic and typhoidal conditions due to exposure to

cold and dampness; from getting wet; from overexertion and straining ; from trauma.

Left sided complaints ; or extending from left to right). Restlessness; anxiety; fear;

mild disposition, irritability. Impatience; absent mindedness; confusion; forgetfulness,

sadness, discouragement; suspiciousness; impulse to commit suicide; aversion to

company; delirium; unconsciousness; prostration. Aversion to the open air. Thirst.

Jerking of muscles; trembling.

Sensations: dryness of mucous membranes ; heaviness, numbness; tingling;

numbless of single parts; of affected parts; coldness of affected parts. Pains. As if

sprained, as if torn loose; pressing; bruised soreness; aching; stitching; burning.

Paralysis. Haemorrhage, periodicity. Septic infection; phlegmonous inflammation;

suppuration; carbuncle; gangrene; inflammation of lymphatic glands. Eruptions:

moist; fine vesicular; pustular; eczematous; crusty; erysipelatous. Worse: morning;

night; after midnight; in repose; on beginning to move while lying down; exertion;

cold; becoming cold; cold drinks ; bathing; wet weather; change of weather; open air;

touch. Better : continued motion; change of position; motion of the affected part; after

sweating; hot applications; warm covering; pressure.

Rhus toxicodendron is indigenous to North America but was brought to

England in 1640. The earliest record of its use as a medicine was in 1798. Its

poisonous effects were noted by a Doctor Dufresnoy of Valenciennes, in the case of a

young man who was cured of a vesicular eruption of six years’ duration by being

accidentally exposed to the volatile emanations of the plant. Dufresnoy and others

used it successfully in rheumatism, paralysis, amaruosis and certain forms of chronic

skin disease. Hahnemann and his followers have made extensive provings,

establishing it as one of the principal polychrests.

The active principles of Rhus tox are toxicondendrol, a fixed oil, and a volatile

substance known as “ toxicodedric acid”, which is given off from the plant in greatest

amount after the sun goes down, in damp or cloudy weather and in the warm days of

June and July. Its poisonous effects are augmented if the victim is warm and sweaty

when exposed. It is a remarkable fact that these peculiarities were brought out in the

provings and have become important modalities through clinical experience.

Although many persons are immune, some are so susceptible to the action of

the volatile principle of Rhus tox, that merely passing to the leeward of the paint will

precipitate a violent attack of poisoning.

Two varieties of Rhus tox. are recognized, one growing in the form of shrub

with erect, comparatively smooth and slender stem, seldom reaching more than four

feet in height, and known as poison oak; the other known as foison ivy or Rhus

radicans, a climbing vine with thick tortuous stem, heavily fringed with brownish

rootlets by which it clings to its host.

In spite of the fact that the two varieties may spring from one and the same

root stock and their morphology seems to be due merely to habit, they differ

somewhat in pathogenetic action and clinical usefulness. But since they are so nearly

identical in action, they are treated as one remedy, - Rhus tox. And their differences

noted briefly at the close of this lesson.

The leading characteristics of Rhus are lameness, stiffness, anxiety and

restlessness; fevers of typhoidal type; phlegmonous inflammation; paretic conditions;

aggravation from cold and dampness, repose and over – exertion; amelioration by

heat and continued motion.

Around these central features may be grouped all the many and varied phases

of this powerful and useful polychrest. Common colds, influenza, rheumatism,

neuritis, typhoid, intermittent and eruptive fevers, septic infections and erysipelas are

among the many ailments that it will curve.

Rhus stands next to Arnica as a vulnerary and often follows that remeday in

the after effects of injuries. But, since it has an especial affinity for fasciae,

aponeuroses and the sheaths and fibrous prolongations of muscles, rather than the

musclar tissues themselves, it is most useful in the after effects of sprains, lifting of

heavy objects and strenuous effort such as running and swimming. If indicated after

contusion, it is because the fibrous tissues have been injured – tissues which do not

fall within the sphere of Arnica.

Rhus has cured more cases of arthritis, both acute and chronic, than any other

remedy. It is not usually suitable in cases that develop suddenly from exposure to dry

cold wind, as are Aconite and Belladonna, but more to the acute pains and stiffness

following a thorough drenching in a rain storm, sleeping on damp ground, from being

chilled while perspiring or after strenuous physical effort. The patient needing Rhus is

more susceptible to exposure when his skin is moist. Moisture seems to be an

essential factor favoring the production of Rhus symptoms.

In acute arthritis the joints become smooth, shining and edematous with little

or no redness. The stitching, tearing pains force the patient to move although motion

may be excruciatingly painful. After moving a while, the pains and stiffness abate and

he stops and tries to rest. However, his respite is but short lived for the pains return

with renewed severity and he must move again. This is repeated until he is exhausted.

At times he feels as though the flesh were being torn from the bones, or the bones

scraped. Often there is numbness and tingling in the affected members and a sensation

of on-coming paralysis.

In chronic arthritis there is less swelling but much stiffness and lameness,

often with contractures in the structures about eth joints. The patient is a veritable

barometer. Every change in the weather increases his suffering, especially if a change

to wet weather. He hugs the stove by day and piles on the covers as night. After long

sitting his joints grow sore and stiff so that motion is very difficult, but soon they

limber up after he walks a while.

However, the Rhus patient cannot walk very far. He lacks endurance and soon

tires. He becomes weak and exhausted from slight effort and must lie down.

Weakness and prostration and a feeling of helplessness are of frequent occurrence in

acute Rhus poisoning and appear early in the provings.

Nash says about Rhus Tox41. Pains running down the limbs in streaks, with

every stool. Lumbago from sleeping on damp sheets, or ground; on getting wet while

perspiring; pains, strain, etc., worse while at rest; on beginning to move; better when

gets in motion and by pressure. Stiffness and aching, bruised pains in small of back;

when siting still or when lying; better from motion or lying upon something hard.

Pains in back compelling to move constantly in bed. Lameness in back as if strained

or after straining. Great restlessness, cannot lie long in one position, changes often

with temporary relief, tosses about continually. Lamensess and stiffness on beginning

to move after rest; on getting up ni the a.m.> by continued motion.

Stupor and mild, persistent delirium; continually tossing about, with

labourious dreams. Modalities: < when quietly sitting or lying and on beginning to

move; wet, cold weather; lifting or straining; getting wet when perspiring. > by

continued motion, by warmth, dry air or weather; lying on hard floor (backache).

Muscular rheumatism, sciatica, left side (col.); aching in left arm, with heart disease.

Great sensitiveness to open air; putting the hand from under the bed cover

brings on the cough (Bar., Hep.) Back; pain between the shoulders on swallowing.

This is the third remedy of our so called restless trio the other two are Acon.,

and Ars. This restlessness of Rhus is on account of the aching pain and soreness

which is temporarily relieved by movement. There is also an internal uneasiness

which is purely nervous which causes the patient to want to be on the move, even

when there is no particular pain present; but not nearly to the degree that we find it

under Aconite and Arsenicum.

As in Bryonia, so in Rhus, the leading characteristic is found in its modality.

The aggravation on movement, in the former, is no less marked than the aggravation

when quiet of the latter. The patient tosses and turns from side side with Rhus. The

same as with Aconite and Arsenicum. With Rhus. The change relieves, while with eth

other two it does not. In Bryonia, the more the patient moves the more the suffers,

while with Rhus, the more and longer he moves the better he feels, until he is

exhausted. In acute affections, constant movement seems to be the patients only relief.

With chronic diseases like chronic rheumatism the patient must move, suffers on first

beginning to move, but as he continues to move, or as he express it, “gets limbered

up,” he feels better. But he cannot long lie comfortably in either the acute or chronic

trouble, for the aching comes on and he must move even if it does hurt him at first.

The pains causing the restlessness of Rhus are not so agonizing as they are under

Aconite and Arsenicum, nor is the prostration so great as under Arsenicum nor the

excitement so great as under Aconite.

Swollen around the ankles after sitting too long, particularly in traveling.

Powerlessness of lower limbs; cannot draw them up. Lameness, stiffness, and

paralyzed sensation in joints, from sprains, over-lifting or over – stretching.

Rheumatic tension, drawing, tearing in limbs during rest. Lameness, stiffness and pain

on first moving after rest or on getting up in the morning; relieved by constant motion.

Rheumatic tension, drawing, tearing in limbs during rest. Lameness, stiffness and pain

on first moving after rest or on getting up in the morning; relieved by constant motion.

Aching pains in legs; must change position every moment. Labourious dreams of

excessive bodily exertion, as running, wading in the snow, hurrying and the life.

Restless at night, has no change position frequently. Complaints from getting wet in

the rain when over heated or perspiring. Pains as if sprained; ailments from spraining

or straining, lifting, particularly from reaching up high for things.

Complaints worse while at rest; after midnight; before storms, or on rising

from a seat or bed; on beginning to move after quiet; from getting wet and in wet

weather. Bad effects from sprains, bruises , etc. Bad effects from getting wet in a rain

storm while sweating or over – heated.

Richard Hughes42 says that the rheumatoid pains described by Dr. Phillips as

occurring in Rhus poisoning are seen in an especial degree in the provers of the drug.

From Rhus venenata the joints, as well as the fibrous tissues, were affected –

especially the knees, ankles, feet, and hands; but there was no genuine synovial

swelling, as with Bryonia and Pulsatilla. It is chiefly to these rheumatoid pains that

Hahnemann’s well-known observation belongs, that unlike those of Bryony, the are

most violent when the part affected is an a state of perfect rest. He extends the

statement, indeed, to the symptoms produced by the drug generally; and the recent

provings of Rhus venenata support his statement.

Rhus has thus come to occupy a high place in homoeopathi therapeutics

amongst the remedies for rheumatism. It is not often indicated in rheumatic fever. It

would be so where, as in a case mentioned by Dr. Bayes, restlessness and constant

desire to change the position were present. Dr. Phillips also say that “in the after stage

of acute rheumatic fever, when aconite may have been employed, and when the

temperature has fallen to 100°, or below it, and where the patient still suffers from

wearing stiffness, and aching in the neighbouthood of the joints, rhus is positively

ionvaluable:. But in various subacute and chronic rheumatic affections it is a most

precious remedy, especially when they can be traced to a wetting. Herein it resembles

Dulcamara, the differs from Acornite and Bryonia, whose local rheumatic symptoms

are rather such as drug cold produces. Its action is mainly, if notentirely, upon the

fibrous tissues – tendons, fasciae, sheaths of nerves, and c. – and perhaps the muscles.

I do not think that it controls the rheumatic affections of the synovial membranes, but

only those of the ligaments external to the capsules of the joints. Nor do I think that is

acts upon the nerves themselves. Its undoubted value in rheumatic sciatica depends, I

take it upon its influence on the fibrous sheath of the nerve, which is so often the seat

of the pain. It is powerless in pure neuralgia here or elsewhere. It is certainly the best

remedy pect that here the lumber fascia is the part affected rather than the actual

muscles. It is thus especially indicated when lumbago and sciatica are present

together. In rheumatic lameness of the lower extremities, depending largely cures. In

all these maladies the characteristic features, “worse at rest, relieved by motion,” are

of immense weight in determining our choice of Rhus. Dr. Neidhard has added the

important observation that on first moving after rest the pains are increased. It is not

until the parts have been moved for some little time that relief ensues. With Bryony,

on the other hand, the longer the movement continues, the worse the pains become;

and with Rhododendron, as we have seen, movement relieves from the first. Dr.

Carroll Dunham has drawn out these characteristics of the pains of Rhus in a which

you will find in the first volume of his Lectures. “The rheumatic symptoms of the

drug,” he says, “come on with severity during repose, and they increase as long as the

patient remains quiet, until, at length, their severity compes him to move. New, on

first attempting to move, he finds himself very stiff, and the very first movement is

exceedingly painful. But as he continues to move, however, the stiffness is relieved

and the pains decidedly decrease, the patient feeling much better.” He goes on to paint

out that this improvement does not continue indefinitely; for weariness readily comes

on in such patients, and then rest is at first grateful, only after a while to be disturbed

by a recurrence of the aching pain. As chronic rheumatisms of muscles, ligaments,

and fascia are generally of this character, Rhus is by far the most frequently indicated

remedy for them, and in my hands has made many a cure.

The action of Rhus on the white fibrous tissues has led to its being used in the

treatment of sprains. Hahnemann says, - “I have recognized in these latter years that

Rhus is the best specific against the consequences of muscular strains and

contusions”. He does not say what relation it bears to Arnica. It is very valuable in

ankylosing spondilytis.

Henry B.43 says that this powerful drug was first introduced into English

practice by Dr. Alderson, of Hull, in 1793; who successfully treated some cases of

Paralysis, Dyspepsia, many Stomach complaints, and Gout, with the powdered leaves

of the plant. Dr. A. Duncan, however, gave it in large doses, and failed to cure –

observing that it only acted as as a gentle laxative. This might be accounted for in

consequence of the clumsy mode of administration. The powdered leaves were, of

course, dried, and the medicinal properties lost in most cases; while in a few it acted

with immense power, producing Convulsions, and many untoward symptoms. Thus a

very valuable medicine was cast aside as dangerous and useless, for the simple reason

that the physicians of the period did not know how to use it. Now Hahnemann has

come to the rescue. Thanks to his beautiful mode of preparation, we posses, in Rhus, a

remedy of immense value, daily and hourly used by Homoeopathic practitioners, with

almost unvarying success when properly selected and administered. It seems to have a

powerful action on the cerebro-spinal system, both sensitive and motor; also the

Ganglionic nerves. Its salutary effects on the human body are especially manifested

during a state of rest. Its action on the ligments, tendons, serous mucous membranes,

and the skin, is now tolerably well ascertained. According to recorded experience,

Rhus will be found useful under the following conditions: - Acute and chronic

rheumatism, with or without swelling of the parts. Sufferings caused by a heavy

shower of rain, when in a state of perspiration; Evil consequences of bathing in cold

water, or wet feet during the menses; Straining of tendons or single muscles; swelling

and induratino of the glands in the parotid region; paralysis of the extremities;

Vesicular and Phlegmonous Erysipelas; Pemphigus; Moist eruptions on the hairy

scalp; impetigo; swelling of the head and face; inflammation of the eyelids; some

states of typhoid and typhus fever.

Neck and back: Pain and stiffness in the cervical region; pains in the dorsal region,

and across the loins, as from a strain; pains in back as if bruised ; tearing beween the

scapulae; swelling of the axillary and parotid glands.

Upper extremities: Tearing , burning in the shoulder, with lameness of the arm;

Burning, pricking below the axilla; Burning and itching pustules; Coldness

Insensibility of the arm; Vesciles on the wrists; smarting cracks on the back of the

hands.

Lower extremities: Sensation as if the joins were sprained; Aching pain in the hip-

joints at every step; Paralysis of the lower limbs; Cramp in the calves; Cramp-like

pressure in the legs; Heaviness in the legs; Painless swelling of the feet; Inflammation

and swelling of the instep ( erysipelatous), with vesicles and pimples; Red Blotches

on the balls of the toes; Heels red, painful.

Characteristic of Rhus Tox. The Rheumatism of Rhus Tox. Is characterized by

rigidity and pain on first moving the joints after rest. Motion relieves the pain; but

frequently the pains are greatly increased during rest, and when warm in bed.

Notwithstanding this, rest is absolutely necessary to promote the curative action.

Dr. Neidhard states, that the Rheumatism cured by Rhus is as follows:

“Rigidity; Paralytic, weakness of the joints; stinging in the tendons and muscles;

Swelling and redness about the joints, especially the hip and wrist. ( The greatest

rigidity and pain are felt on frist moving the joint after rest, and on awaking in the

morning).

Farrington44 say the chief member of the Anacardiaceae, namely, the poison-

ivy or Rhus toxicodendron. It is complementary to Bryonia, a fact discovered by

Hahnemann in his experience with an epidemic of war typhus, during which he

treated many cases, losing but two; the success he then gained was acknowledged on

all sides. Rhus tox. Bears an inimical relation to Apis mellifica. Although the

symptoms of the two are superficially similar, for some reason which I cannot

explain, these drugs do not follow each other well.

We find Rhus tox. Forming the centre of a very large group of medicines. If

we were to study them al comparatively. We will study the action of Rhus on the

fibrous tissues. The are also including tissue the aponeuroses and tendons of muscles,

the ligaments about joints and the connective tissue. No remedy has a more prodound

action on the fibrous tissues than has Rhus tox. First of all, I wil speak of its action on

the tendons of muscles. We find Rhus useful whenever these tendons are inflamed,

whether it be from over-exertion or from a sudden wrenching, as in the case of sprain.

We find, also that we may give Rhus in other affections arising from over – exertion.

For example, if a musician from prolonged performing on wind instruments suffers

from pulmonary hemorrhages. Rhus will be his remedy. If from violent exertion a

patient is seized with paralysis, his trouble may yield to Rhus tox. In sprains, Calcarea

ostrearum follows when Rhus has relieved, but failed to cure.

Arnica acts more on the muscular tissue than on the ligaments. Henc, we

would find it indicated when, as a result of long exertion, there is a great soreness of

the muscle. The patient feels as if he had been pounded. It has not that strained feeling

of Rhus. When a joint is clearly sprained, Arnica is not the best remedy, unless there

is considerable inflammation of the soft parts other than the ligaments.

Arsenicum is to be thought of for the effects of over – exertion, particularly if

that exertion consists in climbing steep hills and mountains. Here you have the effects

of breathing rarefied air as well as those of the exertion. It is also useful for

inflammation and soreness in enarthrodial joints from concussion, as, for instance,

when the head of the femur is jammed violently into its socket.

The general characteristic, however, which helps you to decide for Rhus in all

these cases is this: the patient has relef of his symptoms by continued motion, while

he experiences aggravation on beginning to move. The reason for this symptom is that

the fibrous tissues become timbered up as the patient continues to move.

There is somewhat of an exception to this characteristic, and that is in that

painful disease known as lumbago. I find that in the beginning of this affection Rhus

is the remedy, whether the patient is better from motion or not. The symptoms calling

for Rhus are great pains on attempting to rise, stiff neck of rheumatic origin from

sitting in a draught, rheumatic pains in the interscapular region, better from warmth

and worse from cold. There may also be constrictive pains in the dorsal muscles,

relived form bending backward.

In rheumatism Rhus is incdicated, not so much in the inflammatory form as in

the rhueumatic diathesis, when the characteristic modality just mentioned is present,

and when there is aggravation during damp weather, or from dwelling in damp places.

Another peculiarity of Rhus is that prominent projections of bones are sore to the

touch, as for example, the cheek-bones. This shows you that Rhus affects the

periosteum. Still another characteristic is that the patient cannot bear the least

exposure to cool air.

Farrington EA.45 says about Rhus Tox. Involves the fibrous tissues nad sheaths of

the muscles. Rheumatism after exposure to wet, especially when overheated or

perspiring. Relief from moving about. Bryonia Copious effusion. Muscular

rheumatism. Lacks the excitement of chamomilla. Relief by continued motion, while

aggravation on beinning to move. Aggravation during damp weather or from dwelling

in a damp place; the patient cannot bear the least exposure to cool air. Prominent

projections of the bones are sore to the touch.

Calcarea Ostrearum - Rheumatic affections, caused by working in water.

Rheumatism of the muscles of the back and shoulders, after the failure of Rhus.

Causticum - Joints are stiff and tendons shortened, drawing the limbs out of

shape. Articulation of the jaw particularly involved. Worse from cold and relieved by

warmth. Restlessness at night. Worse weather.

Chamomilla - Feverishness and excitement.pains drive the patient out of the

bed and compel him to walk about. Stitching pains jump from place to place, worse in

the ankles and knees, and leave a sense of weakness. Sweat does not relieve him, but

his pains are better after sweat. The patient is corss and excitable.

Colchicum - Begins in one joint and travels thence to another, or in one side of

the body and then flies to the other. The pains are worse in the evening. The joints are

extremely sensitive to touch and the slightest motion. The patient is extremely

irritable. Metastasis of rheumatism to the chest. The sensation, as if the chest were

being squeezed in a vise. Pulsatilla - The patient is mild and tearful. The erratic paints

do not leave any weakness.

Dulcamara - Aggravation from cold, damp weather or from changes from hot

to cold weather, especially if these changes are sudden. Calcarea Phos. - In women –

joints ache in every change of weather. Kali Bichromicum - Rheumatism of the

smaller joints – particularly of the finger and wrists, in spring or summer weather

when there are cool days or nights. Gastric and rheumatic symptoms alternate.

Kali Carb. - Stubborn rheumatism. Sharp stitching pains. 3 am aggravation.

Lumbago. Rananculus Bulb. - Inter-costal rheumatism. Worse in damp weather and

particularly from a change of weather or change of temperature.

Ledum - The pains travel upward worse from warmth of the bed and

ameliorated by cold applications. Drawing pains in the joints aggravated by wine. The

muscles feel sore, as if out of place. Pains in the joints, extended from feet upwards.

Worse from covering up.

Rhododendron - Susceptibility to changes in the weather and to electric

changes in the atomosphere. Pains in the limbs especially in the bones of forearms,

hands and feet. Numbness. Formication.

Carroll Dunham46 says about Rhus Tox, in the region of the neck and back

we find stiffness of the nape and entire neck, with tensive pain and crying out on

moving. The sacral region is stiff when he moves, but pains when sitting, as if he had

been stooping and bending the back too much. Stitching and pressing pains.

In the extremities we have, most frequently, sticking pains. They may occur in

all parts. Also tearing pains, aggravated by hard labor. When felt of, the bones feel

sore. The salient osseous processes, condyles, olecranon, etc, are sore to pressure.

Drawing pains are frequent. They go from the elbow to the hand. In Dr.

Joslin’s proving of Rhus radicans a pain is described as following the ulnar nerve. I

have twice met this in patients and relieved it permanently with a dose of Rhus

redicans. Tensive pain; aching and pains as it luxated are common under Rhus. They

affect all parts of the extremities and all the joints.

Besides the above pains and sensation there is a feeling of creeping,

formication and numbness as if the fingers were asleep. This is allied to the paralysis.

Also a sensation of great weakness in the limbs; a trembling of the arms and fingers

on moderate exertion; a heaviness and lassitude of the lower extremities so that one

can hardly move. There is painless and lassitude of the feet at evening, evidently

oedematous. Also swelling and pain of the axillary glands.

Dr Hering 47 says it has its action on neck, back, lower limbs. Stiff neck, with

painful tension when moving. Pains in shoulders and back, with stiffness as from a

sprain. Curvature inflamed, even myelitis; from getting wet or sleeping on damp

ground.Pains in small of back, better lying upon something hard. Lumbago.

Tearing and burning in shoulder, arm lame, worse in cold, wet weather, in bed

and at rest. Axillary glands suppurating. Hot swelling of hands in evening. Rhagader

on back of hand. Warts on hands. Swelling of the fingers. Hang-nails.

Coxaligia; involuntary limping; pains felt mostly in knee and worse from

overexertion; pain worse at night. Spasmodic twitching in limbs when stepping out.

Sciatica right side, dull, aching by rubbing and formication.

Paroxysmal pains in legs from getting wet, especially when warm and sweaty.

Cramps in legs and feet, must walk about.Ulcers: on lags, discharging profusely; on

dropsical legs, discharging serum. Swollen about ankles after too long sitting; feet

swell in evening. Intolerable itching of legs and feet at night; old rash.

Swelling and stiffness of joints from sprains, over lifting, or over stretching.

Rheumatoid pains in limbs: also with numbness and tingling; joints weak or stiff, or

stiff, or red, shining swellings of joints, stitches when touched; worse on beginning to

move: after I2 P.M and in wet, damp weather or places; better from continued motion.

Tearing pains in limbs, during rest.

Dr Phatak48 says, this remedy is irritating to the Skin, esp. of face, scalp,

genitals; affects the fibrous tissue, ligaments and joints causing Rheumatic

Symptoms; it is an infective agent producing Typhoid-Like Fever. Affections of

Nerves and Spinal Cord give rise to Paretic Effects. Glands are swollen, hot and

painful; indurated; suppurating. Symptoms appear on the left side or go from left to

right. Pains are tearing, Shooting, <at Night, Cannot Rest in any position. Parts feel

sore, bruised and stiff. Pain as if the flesh was torn loose from the bone. Dislocative

sensation. Mucous discharges are acrid, rusty red, like meat water; musty; causing

eruptions. Infection, septicemia, carbuncles in early stage. Cellulites; inflammation

and swelling of the long bones; scraping, gnawing, tearing in periosteum.

Rheumatism in cold season. Post-operation complications. Hemiplegia, right side;

sensation as if gone to sleep. Infantile pox. Stricture after inflammation. Soreness of

prominent projections of bones. Paralysis after unwanted exertion, after parturition.

Boils, abscesses.

Worse from exposure to wet, Cold air draft. Chilled when hot or sweaty.

Uncovering parts-head, etc. Beginning of Motion. Rest. Before Storm. Sprain. Over-

exertion. After Midnight. Blows; jar. Riding. Ice. Cold drink. Side lain on. Better after

Continued motion. Heat. Hot bath; if heated. Warm wrapping Rubbing. Nosebleed.

Holding affected part, abdomen, head, etc. stretching limbs. Change of position.

Warm dry weather.

Stiff neck, with painful tension when moving. Interscapular pain, <

swallowing. Contractive or breaking backache, > hard pressure; lying on something

hard; walking about or bending backwards. Lumbago. Coccyx aches into thighs.

Numbness, and prickling in limbs. Arms nervous and shaky. Paralytic pains in

elbows. Rhagades on back of hands. Plams are dry, hot, and cracked; washing causes

burning. Pains down back of thighs <stools; Legs feel dead, wooden. Cramps in

claves. Involuntary limping. Soreness of condyles of the bones. Limbs stiff,

paralysised. Hot painful swelling of the joints. Pricking like pins in the tip of fingers

and palms when grasping. Pain along ulnar nerve. Ulcers; on legs ;gangrenous; runs

bloody water; on dropsical legs. Itching of lags and feet. Ankles swollen after too

Long sitting and long standing; feet swell in the evening. Paraplegia; after

parturition, sexual excess; fevers. As if walking on needles.

Allen.H.C.49 describes pains as if sprained; as if a muscle or tendon was torn

from its attachment; as if bones were scraped with a knife; worse after midnight and

in wet, rainy weather affected parts sore to touch. Lamness, stiffness and pain or first

moving after rest, or on getting up in the morning, >by walking or continued motion.

Back pain between the shoulders on swallowing pain and stiffness in small of back <

sitting or lying, > by motion or lying on something hard. Muscular rheumatism,

sciatica, left side; aching in left arm, with heart disease.

Vermeulen50 describes. Back- pain between scapulae on swallowing

>warmth, <cold. Pain and stiffness in small of back; >motion or lying on something

hard; <while sitting as after long stooping stiffness of nape of neck as if it is been

lying in an uncomfortable position and painful tension when moving. Contractive

backache, or as if back would break, >hard pressure, lying on hard, moving about or

bending backward. Aching in coccyx thighs. Pain in the cervical muscles, as if asleep,

or as if head had been too long in an unaccountable position, esp toward evening.

Stitches inback,> bending back, < bending forward. Cutting in sacrum when standing

and bending backwards .PAINS IN THE BACK COMPELLING HIM TO MOVE

CONSTANTLY IN BED. In Extremities-Hot, painful swelling of joints. Tearing

pains in tendons, ligaments and fasciae. Rheumatic pains spread over a large suface at

nape of neck, loins, and extremities; > motion [Agar.].Soreness of condyles of bones.

Limbs stiff, paraysed. Pain along ulnar nerve. Sciatica; <cold, damp weather, at night.

Numbness and formication, after overwork and exposure. Paralysis; trembling after

exertion. Tenderness about knee-joint. Loss of power in forearm and fingers; crawling

sensation in the fingertips. Tingling in feet. 2Arms nervous and trembling [L].

paralitic pains in elbows. Rhagades on back of hands. Palms; dry, hot, cracked and

sore; washing=burning. Pain down back of thighs, <stools. Legs feel dead, wooden.

Cramps in calves; 7in legs and feet, must walk about, esp. at night. Involuntary

limping. Pricking like pins in fingertips and palms when grasping. Ulcers; on legs;

gangrenous; discharge of bloody water; on dropsical legs. Itching of legs and feet.

Ankles awollen after sitting too long; feet swell in the evening. Paraplegia; after

parturition; sexual excess; fevers. As if walking on needles. 5Rheumatic gnawing

pains, & desire to move the limbs frequently, which >. Limbs on which he lies fall

asleep; 7esp. arms. Pains in the bones of the legs at night; must constantly move them.

5Stiff and paralysed sensation in joints from sprains. Over lifting and overstretching.

Lameness. Stiffness and pain on first moving after rest, or on getting up in the

morning; > constant motion. Sprained pain in arm when carried far upward and

backward. Swelling of hands; of fingers. Tingling pain in shafts of tibia at night when

feet are covered, & constant necessity to move legs, preventing sleep. Sprained pain

in feet in morning on rising. Drawing like paralysis in feet when sitting. Tension as

from shortening of the 0..muscles. Powerlessness of the lower limbs; cannot draw

them up.

Methodology

METHODOLOGY

The present study was conducted in the Bharatesh Homoeopathic Medical

College and Hospital – Belgaum. During the period of 1st August 2007 to 31st July

2009.

This study consist of 30 patients of Ankylosing spondylosis, attending OPD,

IPD, village camps and peripheral clinics of Bharatesh Homoeopathic Medical

College and Hospital – Belgaum were selected at random irrespective of their age,

sex, socio – economic status and occupation. These cases make the material for the

present study.

The inclusion and exclusion criteria for the present study are as follows.

Inclusion Criteria:

Cases of Ankylosing spondylitis will be diagnosed clinically with articular

manifestation.

• Hip pain and stiffness.

• Low back pain that is worse at night, in the morning or after inactivity.

• Stiffness and limited motion in the low back.

Exclusion Criteria:

• Extra articular manifestation

• Progressive disease with deformities

• Ankylosing spondylitis secondary to any other systematic disease with gross

pathology will be excluded.

Case taking was done according to the scheme of model case format with a

special emphasis on ascertaining the following points.

1. History of present complaints :

The complaints along with the duration have been recorded with a special

reference to the age of on set, nature, duration and progress.

Special criteria for the diagnosis of Ankylosing spodylitis have been included

to spot out the complaints in a more systematic and perfect order. Also considered the

significant impairments of patients in various aspects like occupational,

environmental along with destructive tendencies, and considered regarding whether

the patients has got the difficulty in morning, position, motion to elicit the causative

factor, to know the influence of the environmental factors, to unify the system and

pattern of approach in the homoeopathy. Modalities are considered and recorded.

2. Past history:

It is recorded with special reference first illness after birth vaccination past

disorders in chronological order with the nature of treatment and the result.

3. Family history :

A detailed family history was taken to find the incidence of an acute and

chronic disease which becomes important in framing the evolution of miasms in the

patient. A detailed family history of both paternal and maternal side is recorded.

4. Personal history :

All the generalities of the patient are recorded with special reference to

physical built (constitution), thermal, seasonal and atmospheric, diurnal and postural

modalities, diet, appetite, the desire, aversions, food habits, thirst, micturation, bowel

movement, perspirations, sleep, dreams, menses (in women), hobbies, mental

reactions and the findings of observations regarding the behavior of the patient as well

as physical examination are also recorded.

5. Life space investigations :

The significant events in the life and the effects of such events on the

constitution of the patient are recorded in order to demonstrate the role of miasm and

the role of exciting factors and early malnutrition and other factors whichcontribute in

the progress of Ankylosing spondylitis.

6. General physical examination :

The positive findings of the built, nourishment and vital data along with

congenital anomalies if present were recorded.

7. Systemic examination :

Positive finding from all the system were recorded with a special emphasis to

locomotor system. Detailed locomotor system findings were recorded under different

headings

8. Laboratory investigation :

The study requires few investigations

• Routine blood investigation with ESR

• HLA B27

• X-ray(lumbar region)

• Other higher investigations as required like CT Scan and MRI.

9. Diagnosis :

Diagnosis of Ankylosing spondylitis is done on the basis of case history and

clinical findings.

10. Steps for homoeopathic prescription :

a. Analysis of symptoms :

The cases were taken by the guidelines laid by Dr Hahnemann

in the Organon of Medicine 6th edition. The symptoms of the patient

were grouped into various categories like mental generals physical

generals and particulars.

b. Evaluation :

After analyzing the symptoms into various categories like pain

–continuous /intermittent / morning /afternoon /night rest/ better after

exercise / any other.

Stiffness- always /morning /night.

Muscle spasm.

Restriction of movements and pain radiating to other parts

Were evaluated to give value or rank according to the order of their

importance.

c. Repertorization : 

    To  aid    in  the  selection  of  a  suitable  remedy,  repertorisation 

according to Kent, and Murphy. Repertorisation with synthesis was done for 

all  cases.  Characteristic    particular  considered  at  the  final  stage  of 

repertorisation.   

d. Miasmatic diagnosis: 

      Miasmatic diagnosis is done using the knowledge acquired from the 

book ‘Miasmatic Diagnosis’‐Banerjee, Speight, Ortega.  

e. Selection of the medicine:                              

      Reportorial  result,  rare,  peculiar,  uncommon  symptoms  and 

miasmatic  diagnosis  of  the  patient  were  considered  for  selecting  the 

constitutional medicines, acute medicine on sector  totality and  intercurrent 

remedy was selected on symptomatology, follow‐well relation and miasmatic 

predominance.  

f. Potency and repetation: 

      Starting  with  200th  potency  in  single  dose  the  medicine  was 

repeated only when  there was no  further  improvement higher potencies  in 

acute cases. 1M were restored to only after exhausting the  lower potencies 

but intercurrent was started with 1M in single dose according to the need of 

the case 

g. Acute remedies : 

      In  cases where  the  intensity of  symptoms were unbearable  to  the 

patient and demanded  immediate  relief acute, short acting medicines were 

prescribed. 

h. Constitutional remedies : 

      The constitution of the patient was thoroughly investigated and the 

miasmatic  tendencies  were  identified.  Based  on  these  observations  the 

constitutional drug selected.                                                                                                             

i    Intercurrent remedies : 

      These remedies are used in 1M potencies for clearing the miasmatic 

block  in  cases  where  the  improvement  of  patient  makes  no  progress  or 

comes  to  stand  sill  stage even after  repeating  the  constitutional  remedy  in 

higher potency. 

10.   Follow up criteria: 

  Patients shall be reviewed every  fortnight  for the  first two months and  later every 

month for the remaining period of study or may be called as per the demand of particular 

case. New case  is taken only during the period. 1st August ‐2007 to 31st July‐2009. No new 

cases will be  taken after  July 2009 but  the cases will be  followed up  for  the period of  six 

months. 

11.   Para‐meters : 

     The  following para‐meters were  fixed  according  to  type of  the  response obtained 

after the treatment. 

a. Recovered – Feeling of mental and physical well being with disappearance of all the 

symptoms and signs for more than six months. 

b. Improved – Feeling of mental and physical well beings with marked disappearance 

of symptoms and signs for a period less than six months. 

c. Not‐improved –  

   No relief of symptoms and signs even after sufficient period of treatment. 

Results

OOBBSSEERRVVAATTIIOONNSS AANNDD RREESSUULLTTSS

The study was conducted on 30 cases of Ankylosing spodylitis, irrespective of their age, sex & socio economic status.

1. Age Incidence

Statistical study was conducted to identify the age group with the highest

incidence of Ankylosing spondylitis.

Table No 1: Age Incidence

Sr. No. Age group No. of Patients Percentage

1. 10-20 4 13.33 %

2. 21-30 14 46.66 %

3. 31-40 7 23.33 %

4. 41-50 5 16.66 %

Total 30 100%

As shown in the above chart the maximum incidence seen in the age group 21-

30 i.e 46.66% in 14 cases. In 31-40 age group the incidence was 23.33%. i.e in 7

cases. Between the age group 41-50 i.e 16.66% in 5 cases. And in the age group 10-20

years i.e 13.33% in 4 cases.

2. Sex incidence:

Statistical study was conducted to identify the Sex incidence with the highest

of Ankylosing spodylitis.

Table No 2: Sex Incidence

Sr. No. Sex No. of Patients Percentage

1. Male 20 66.66%

2. Female 10 33.34%

Total 30 100%

The above table shows statistical study of sex incidence in 30 patients with

Ankylosing spondylitis. As per the study, maximum sex incidence seen in male i.e 20

cases accounting 66.66% of total and minimum incidence of 33.34% of the total who

where males in 10 cases.

3. Past History:

Statistical study was conducted to identify the past history of the patient

suffering from Ankylosing spondilitis to know the highest incidence.

Table No.3 Past History

Sl. No. Past History No of cases Percentage

1. Typhoid 06 20.00%

2. Jaundice 03 10%

3. Joint complaints 03 10%

4. Respiratory complaints 06 20.00%

5. Haemorrhoids 01 03.33%

6. HTN 05 16.66%

7. Malaria 01 03.33%

8. Chicken pox 02 06.66%

9. Measles 02 06.66%

10. Skin eruptions 03 10.00%

11. Peptic ulcer 04 13.33%

12. Others 02 06.66%

Above table shows maximum incidence in 06 patients of Typhoid accounting

of 20.00% of the total. 03 patients are having joint complaints accounting 10% of the

total.06 patients are having respiratory complaints accounting 20.00% of the total. 1

patient is having haemorrhoides and malaria accounting 03.33% each of the total.

HTN in 5 patients accounting 16.66% of the total. 2 patients are having chicken pox

and measles accounting 6.66% each.

4. Family History

Statistical study was conducted to identify the incidence of disease in the

family was analysed.

Table No 4: Family History

Sr. No Family History No of Subjects Percentage

1 Joint complaints 17 56.66%

2 HTN 2 6.66%

3 DM 2 6.66%

4 Bronchail asthama 2 6.66%

5 CVS 2 6.66%

6 Kochs 2 6.66%

7 Paralysis 2 6.66%

8 Haemorrhides 1 3.33%

Total 30 100%

30 cases were taken to have a statistical study of their family history. The

study carried out on the 30 patients, showed 17 patients had family history of joint

pain which accounted for 56.66% of total. 02 patients were having family history

HTN accounted to 6.66% of the total. 02 patients were having family history of DM,

accounted to 6.66% of the total. 02 patients were having family history of bronchial

asthma were accounted to 6.66% of the total.02 patients were having family history

of CVS, accounted to 06.67% of the total.02 patient have family history of Kochs

accounted to 6.66% of the tota02 patients were having F/H of paralysis accounted to

6.66% .

5. Presenting Complaints:

The statistical study shows that the highest incidence of presenting

complaints.

Table No 5: Presenting Complaints

Sr. No Presenting

Complaints

No of Patients Percentage

1 Low back pain 14 46.66%

2 Stiffness 8 26.66%

3 Limitation in chest

expansion

3 10.00%

4 Constitutional

symptoms

2 6.66%

5 Improvement in

pain by exercise

3 10.00%

The above table shows statistical study of presenting complaints in 30 patients

the study shows 14 patients presented with low backache accounting to 46.66% of the

total.8 patients had stiffness accounting for 26.66%. Of the total 03 patients each

presented with limitation in chest expansion accounting for 10.00%, of the total.02

patients presented with constitutional symptoms accounting for 6.66%. Of the total.03

patients presented with improvement in pain by exercise accounting for 10.00% of the

total.

6. Miasmatic Background:

Statistical study of 30 cases were done to know the miasmatic background of

the patient.

Table No 6: Miasmatic Background

Sr. No Miasmatic

Background

No of Patients Percentage

1 Psoro-sycotic 3 10.00%

2 Psoro-syphilitic 10 33.33%

3 Psoro-syco-syphilitic 17 56.66%

In this study 56.66%of patient had psoro-syco-syphilitic miasmatic

background, 33.33% of patient had psoro-syphilitic and 10% of patients had psoro-

sycotic.

7. Acute Remedies:

The statistical study of 30 cases was done to know the acute remedies used in

Ankylosing spondylitis..

Table No. 7: Acute Remedies

Sr. No Acute/ Sectoral Remedies No of cases Percentage

1 Rhus Tox 17 56.66%

2 Bryonia 04 13.33%

3 Kali Bich 04 13.33%

4 Causticum 02 06.67%

5 Dulcamara 02 06.67%

6 Chammomila 01 03.33%

The most commonly prescribed acute remedy in this study was Rhus Tox

.Other remedies are Bryonia, Kali bich, Causticum, Dulcamara, Chammomilawhich

had also produced a good response. Rhus Tox was given in 17 cases, Bryonia in 4

cases, Kali bich in 4 cases, Causticum in 2 cases, Dulcamara in 2 cases, and

Chammomila in 1 case.

8. Incidence of Intercurrent remedies:

Statistical study was conducted to identify the incidence of intercurrent

remedies used for the treatment of Eczema with their highest incidence.

Table No. 8: Incidence of Intercurrent Remedies

Sr. No Intercurrent remedy No of cases Percentage

1 Tuberculinum 5 16.66%

2 Sulphur 2 6.66%

Out of 30 patients Tuberculinum was prescribed as a intercurrent remedy in

16.66% of total i.e 5 cases. Sulphur was prescribed as a intercurrent remedy in 6.66%

of total i.e 2 cases.

9. Results of the Treatment:

The statistical study shows that utility of Rhus Tox in the treatment of

Ankylosing spondylitis with highest incidence.

Table No. 9 : Results of the Treatment

Sr. No Result No of cases Percentage

1 Recovered 06 20.0%

2 Improved 13 43.33%

3 Not-improved 11 36.66%

Out of 30 cases 20% showed recovery i.e 6 cases. 43.33% of total cases

showed improvement i.e 13 cases and 36.66% of total cases showed no improvement

i.e 11 cases.

 

Discussion

DDIISSCCUUSSSSIIOONN

Ankylosing spondylitisis is an auto immune disease known to be

associated with tissue type HLAB 27, affecting facet joints between vertebrae

together causing spine to become increasingly rigid.

The critical evaluation of the 30 cases of the present study, shows that the

cause of the disease is unknown. The family history is one of the factors

accountable The results of various observations are discussed below under

different headings.

1. Age incidence:

The maximum incidence seen in the age group 21-30 i.e 46.66% in 14

cases. In 31-40 age group the incidence was 23.33%. i.e in 7 cases. Between the

age group 41-50 i.e 16.66% in 5 cases. And in the age group 10-20 years i.e

13.33% in 4 cases.

2. Sex Incidence:

Statistical study shows the sex incidence in 30 patients with

Ankylosing spondylitis. As reviewed in the literature male are more prone to

have Ankylosing spondylitis. As per the study, maximum sex incidence seen in

male i.e 20 cases accounting 66.66% of total and minimum incidence of 33.34%

of the total who where males in 10 cases.

3. Past History:

The maximum incidence in 06 patients of Typhoid accounting of 20.00% of

the total. 03 patients are having joint complaints accounting 10% of the total.06

patients are having respiratory complaints accounting 20.00% of the total. 1 patient is

having haemorrhoides and malaria accounting 03.33% each of the total. HTN in 5

patients accounting 16.66% of the total. 2 patients are having chicken pox and

measles accounting 6.66% each.

4. Family History:

30 cases were taken to have a statistical study of theirfamily history. The

study carried out on the 30 patients, showed 17patients had family history of joint

pain which accounted for 56.66% . of total. 02 patients were having family history

HTN accounted to 6.66% of the total. 02 patients were having family history of DM,

accounted to 6.66% of the total. 02 patients were having family history of bronchial

asthma were accounted to 6.66% of the total.02 patients were having family history

of CVS, accounted to 06.67% of the total.02 patient have family history of Kochs

accounted to 6.66% of the tota02 patients were having F/H of paralysis accounted to

6.66% .

5. Presenting Complaints:

The statistical study of presenting complaints in 30 patients, shows 14 patients

presented with low backache accounting to 46.66% of the total.8 patients had stiffness

accounting for 26.66%. Of the total 03 patients each presented with limitation in chest

expansion accounting for 10.00%, of the total. 02 patients presented with

constitutional symptoms accounting for 6.66%. Of the total.of the total.03 patients

presented with improvement in pain by exercise accounting for 10.00% of the total.

6. Miasmatic Background:

In this study 56.66%of patient had psoro-syco-syphilitic miasmatic

background, 33.33% of patient had psoro-syphilitic and 10% of patients had

psoro-sycotic.

7. Acute/Sectoral Remedies :

The most commonly prescribed acute remedy in this study was Rhus Tox.

Other remedies are Bryonia, Kali bich, Causticum, Dulcamara, Chammomila which

had also produced a good response. Rhus Tox was given in 17 cases, Bryonia in 4

cases, Kali bich in 4 cases, Causticum in 2 cases, Dulcamara in 2 cases, and

Chammomila in 1 case.

8. Incidence of Intercurrent Remedies:

Out of 30 patients Tuberculinum was prescribed as a intercurrent remedy in

16.66% of total i.e 5 cases. Sulphur was prescribed as a intercurrent remedy in 6.66%

of total i.e 2 cases.

When the action of the well indicated constitutional remedy gets blocked and

the patient fails to respond to further medication, the obstacles in the way of to cure

has looked for. When this analysis pointed to a miasmatic block, an antimiasmatic

prescription has cleared the way for the constitutional medicine to act in many of the

cases.

9. Result of treatment:

Out of 30 cases 20% showed recovery i.e 6 cases. 43.33% of total cases

showed improvement i.e 13 cases and 36.66% of total cases showed no improvement

i.e 11 cases

Conclusion

CCOONNCCLLUUSSIIOONN

This study enables us to draw some valid conclusions. They are :

1) The highest incidence of Ankylosing spondylitis was most common in the age

group 21-30 i.e 46.66% in 14 cases.

2) In this study the maximum incidence of male i.e 20 cases accounting 66.66%

of total and minimum incidence of 33.34% of the total who where females in

10 cases.

3) The maximum incidence of patient had family history of joint pains, most

common 17 cases i.e. 56.66% .next highest presentation was HTN in 2 casec

i.e. 6.66%. .

4) The most common miasmatic background was psora-syco-syphilitic which

was 56.66% of total, followed by psora-syphilitic in 33.33% of total; psoric

and psora-sycotic was 10.00% of total each.

5) The result has been satisfactory with 13 cases improved i.e.43.33% of total; 06

cases recovered i.e. 20% of total & 11cases did not improve 36.66 % of total.

So the present study has been a confirming one wherein according to the

tenets placed in Organon of Medicine, it has been clearly mentioned that in such

instances the totality taken into consideration with holistic approach, these cases can

be treated effectively.

Summary

SSUUMMMMAARRYY  

  Low back pain is one of the common ailments to man. Ankylosing spondylitisis is one 

of the cause for low back pain and if not diagnosed and treated early, leads to chronic pain 

and  long term disability and resulting  in the  increase of personal suffering and health care 

costs. Therefore, through this study, an attempt has been made to find out the effectiveness 

of  homoeopathic  medicines  in  the  management  of  acute  pain  and  the  long  term 

constitutional  treatment  as  required  for  Ankylosing  spondylitis  and  utility  of  Rhus  Tox  in 

most of the cases.    In this study, 30 cases of Akylosing spondylitis    irrespective of both the 

sexes between  the age group 15‐47 yrs which satisfied the  inclusion and exclusion criteria 

were considered. 

The most common age for AS in this study is found 21‐30 yrs age group and the next 

common in age group of 31 – 40yrs. 

In this study, the sex incidence showed a male predominance than females. 

In this study of 30cases the statistical study of the mode of presentations  were low 

back pain  in 14cases, next  in order was  stiffness  in 8cases  followed by  limitation of  chest 

expansion  in  3cases,  improvement  in  pain  after  exercise  in  3cases  and  constitutional 

symptoms in 2cases. 

In this study of 30 cases the family history with which the patients presented were 

17cases  had  joint  complaints,  HTN,  DM,  Bronchial  asthma,  CVS,  Kochs,  Paralysis,  and 

Hemorrhoids  in 2 cases. 

In this study of 30 cases the presenting complaints was digged up which showed that 

14  patients  had  low  back  pain,  8  cases  had  stiffness,  3  cases  had  limitation  of  chest 

expansion, 2 had constitutional symptoms and 3 had improvement in pain after exercise. 

The maximum incidence of past history of typhoid in 06 patients, 03 patients

are having joint complaints. 06 patients are having respiratory complaints. 1 patient is

having haemorrhoides and malaria each of the total. HTN in 5 patients of the total. 2

patients are having chicken pox and measles each.

30 cases were taken to have a statistical study of their family history. 17

patients had family history of joint pain. 02 patients were having family history HTN.

02 patients were having family history of DM.. 02 patients were having family history

of bronchial asthma. 02 patients were having family history of CVS. 02 patient have

family history of Kochs. 02 patients were having family history of paralysis.

The statistical study of presenting complaints in 30 patients showed 14

patients presented with low backache. 8 patients had stiffness, 03 patients each

presented with limitation in chest expansion.02 patients presented with constitutional

symptoms.03 patients presented with improvement in pain by exercise.

In the study of miasmatic background, 17 patients had psoro-syco-syphilitic

miasmatic background, 10 patients had psoro-syphilitic and 3 patients had psoro-

sycotic.

The most commonly prescribed acute remedy in this study was Rhus Tox.

Other remedies are Bryonia, Kali bich, Causticum, Dulcamara, Chammomilawhich

had also produced a good response. Rhus Tox was given in 17 cases, Bryonia in 4

cases, Kali bich in 4 cases, Causticum in 2 cases, Dulcamara in 2 cases,and

Chammomila in 1 case.

Out of 30 patients Tuberculinum was prescribed as a intercurrent remedy in 5

cases. Sulphur was prescribed as a intercurrent remedy in 2 cases.

Out of 30 cases 6 showed recovery. 13 cases showed improvement and 11

cases showed no improvement.

 

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Annexure - I

ANNEXURE-I : CASE TAKING PROFORMA

BHARATESH HOMOEOPATHIC MEDICAL COLLEGE & HOSPITAL,

BELGAUM

DEPARTMENT OF HOMOEOPATHIC MATERIA MEDICA

UTILITY RHUS TOX. IN THE TREATEMENT OF ANKYLOSING

SPONDILITIS

UNDER THE GUIDANCE OF DR.S S.DIVATE.

DOCTOR INCHARGE: DR. MAMATA GIDNAVAR.

SL NO : OPD NO : IPD NO:

NAME OF THE PATIENT :

AGE: SEX: RELIGION:

MARITAL STATUS:

OCCUPATION :

ADDRESS :

PHONE :

D.O.A : D.O.D :

DIAGNOSIS: 1.NOSOLOGICAL:

2. REMEDIAL :

MIASMATIC DIAGNOSIS:

REMEDY : ACUTE/ CONSTITUTIONAL/ INTER-CURRENT

RESULTS :

IMPROVED /NOT IMPROVED /RECOVERED

SIGNATURE OF THE SIGNATURE OF THE

GUIDE: H.O.D :

I) CHIEF COMPLAINTS WITH DURATION:

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

II) HISTORY OF PRESENT COMPLAINTS:

a) ORIGIN/PROBABLE CAUSE:

• Pain : Continuous/ intermittent/ Morning / Night/ Rest/ Exercise/ any other

• Stiffness: Always/ morning / night

• Numness and lower extremities : Always / occasionally / whole of lower limb/

any other.

• Muscle spasm:

• Restriction of movements of chest/ back/ hips/ any other :

• Pain radiating to the thigh/ thoracic region / neck

• Modalities

• Any other complaints/ concomitant

III) PAST HISTORY (WITH TREATMENT ADOPTED)

Any history of trauma , tuberculosis, dysentery, malaise, sore throat, fever, iritis,

urethritis or any other illness.

IV) FAMILY HISTORY (WITH RELATIONSHIP)

PATTERNAL SIDE MATERNAL SIDE

A. FATHER A. MOTHER

IMMIDIATE RELATIONS

A. BROTHERS

B. SISTERS

C. CHILDRENS

Complaints:

Joint pains / Bronchial asthma / HTN/ DM/ haemorrhoides / Kochs/ any other

V) PERSONAL HISTORY

ASSIMILATIONS

a) DIET: VEG MIXED

b) APPETITE :

c) THIRST:

d) DESIRES: salty/ sweet/ sour/ fried

e) AVERSIONS: salty/ sweet/ sour/ fried

ELIMINATIONS

h) BOWELS : Regular / Irregular / Satisfactory/ Unsatisfactory

j) PERSPIRATION: Site/ odour/ character/ stain/ Moderate/ scanty/ profuse

k) MENSTURATION:

l) SUPPRESION OF ELIMINATION: (IF ANY)

m) HABITS: SMOOKING ALCOHOL TOBACCO

DRUGS

o) ADDICTIONS:

p) SLEEP :

q) DREAM:

THERMAL REACTION

r) SEASONAL PREFERENCE ANDAFFECTION: summer/ winter/ rainy

s) COVERING: Yes/ No

t) FAN/A.C/OPEN AIR PREFERENCES:

u) BATH: HOT/COLD/LUKE WARM

v) FOOD AND DRINKS: HOT/LUKE WARM/COLD

w) MENSTURAL HISTORY ASSOCIATED COMLAINTS:

x) OBSERVATIONS MADE (IF ANY):

y) LIFE SPACE/ MENTAL/ REACTIONS:

X) EXAMINATION:

GENERAL PHYSICAL EXAMINATION

1. VITAL SIGNS

a. TEMPRATURE:

b. PULSE RATE _____________ beats/min.

c. RESPIRATORY____________ rate /min.

d. BLOOD PRESSURE__________mm of Hg.

2. BUILT (FRAME): SMALL MEDIUM LARGE

3. ANAEMIA:

4. HEIGHT:

5. WEIGHT:

6. GAIT;

7. PALLOR CYANOSIS ICTERUS CLUBBING

PEDAL ODOEMA LYMPHADENOPATHY

8. HAIR AND SCALP :

9. FACE:

10. EYES/VISION:

11. EAR/HEARING:

12. NOSE/SMELL:

13. MOUTH/LIPS/TOUNGE/ORAL CAVITY/ GUMS/TEETH:

14. EXTREMITIES: UPPER LIMB/ LOWER LIMB

15. VERTEBRAL COLUMN:

16. JOINTS:

17. NECK:

SYSTEMIC EXAMINATION:

1. RESPIRATORY SYSTEM:

INSPECTION/ PALPATION/ PERCUSSION/ AUSCULTATION:

2. CARDIOVASCULAR SYSTEM:

INSPECTION:/ PALPATION/ PERCUSSION/ AUSCULTATION:

3. CENTRAL NERVOUS SYSTEM:

VERTEBRAL COLUMN: INSPECTION/ PALPATION

4. ABDOMEN:

INSPECTION:/ PALPATION/ PERCUSSION/ AUSCULTATION:

EXAMINATION OF THE LOCOMOTOR SYSTEM:

1. INSPECTION : Spinal part involvement/ swelling / deformity/ wasting of

muscles

2. PALPATION: Temperature of local part / tenderness/ corroboration of the

findings of inspection/ any swelling

XI) INVESTIGATIONS:

BLOOD

a. HB%: __________

b. TC: ____________

c. DC: Neutrophils

Eosionophils

Lymphocytes

Monocytes

d. ESR:

e. X-RAY

f. HLA B27 : Antigen

g. ANY OTHER INVESTIGATIONS:

XII) NOSOLOGICAL DIAGNOSIS:

XIII) TOTALITY OF SYMPTOMS:

XIV) ANALYSIS OF SYMPTOMS:

XV) EVALUATION OF SYMPTOMS:

XVI) REPERTORIAL TOTALITY:

XVII) MIASMATIC ANALYSIS:

XVIII) REMEDY ANALYSIS:

XIX) CONSTITUTION

XX) MIASMATIC REPERTORISATION TAB

Sr No SYMTOMS PSORA SYCO SYPH

1

2

3

4

5

6

1

2

3

4

5

6

1

2

3

456

TOTAL

PHYSICAL GENERALS

PARTICULAR SYMPTOMS

MENTAL         GENERALS

FINAL MIASMATIC DIAGNOSIS:

XXI) GENERAL MANAGEMENT (DIET, REGIMENT, ETC,)

XXII) HOMOEOPATHIC TREATEMENT:

FIRST PRESCRIPTION:

XXIII) FOLLOW-UP CRITERIA:

DATE FOLLOW UP REMEDY

 

Annexure -II

ANNEXURE – II GRAPHS

AGE INCIDENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

SEX INCIDENCE 

 

 

 

 

 

 

 

 

 

 

0

2

4

6

8

10

12

14

10‐20 yrs 21‐30 yrs  31‐40 ysr  41‐50 yrs 

67%

33%

Male

Female

PRESENTING COMPLAINTS

 

 

 

 

 

 

 

 

 

 

 

 

 

MIASMATIC BACKGROUND 

 

 

 

 

 

 

 

 

 

 

0

5

10

15

20

25

30

Low Backache 

Stiffne

ss

Limitation of 

chest 

expansion 

Constitution

al 

symptom

s

Improvem

ent 

in pain after 

exercise

No. of P

atients

0

5

10

15

20

25

30

Psoro‐sycotic Psoro‐Syphilitic  Psoro Syco  Syphilitic 

No. of P

atients

 

ACUTE REMEDIES  

 

 

 

 

 

 

 

 

 

 

 

 

RESULT OF TREATMENT 

 

 

 

 

 

 

 

 

 

 

 

0

5

10

15

20

25

30

Rhus.Tox Bryonia Kali.bich Causticum Dulcamara  Chamomilla

No. of P

atients

0

5

10

15

20

25

30

Recovered  Improved  Not improved 

No. of P

atients

 

Annexure - III

 

 

 

AANNNNEEXXUURREE­­IIIIII::  MMAASSTTEERR    CCHHAARRTT  

Remedial diagnosis Sl. No. 

Name  Age  Sex  Occ  Presenting complaints 

Associated Complaints 

Past history 

Family history Acute   

Remedy Constitutio

nal Remedy 

Inter currant Remedy 

Miasm   Result 

1.   Mr. SSN  

28  M  Engineer  Pain in low back Lt knee joint pain 

 

Headache  Pain in knee joint  

F‐ AR  M‐ Rheumatism   Rhus. Tox  Lyc  Tub 

Psoro‐syco‐

syphilitic  

Recovered  

2.   Mr. NBN 

27  M  Engineer  Back pain on rising   

GI disturbance   Haemorrhoides  

F‐ BrA M‐ HTN  Rhus. Tox  Lyc  ‐ 

Psoro‐syco‐

syphilitic  

Improved  

3.   Mr. PGG 

29  M  Business   Pain in low back From prolong sitting  

 

Dull mental feeling  

Jaundice  F‐ DM M‐ HTN  Bry  Thuja  ‐ 

Psoro‐sycotic  

Improved  

4.   Mrs. NGG 

31  F  h/w  Pain in back Leg pain T/N 

 

Haemorrhoides  Haemorrhoides  

F‐ DM M‐ HTN  Bry  Nat.mur   ‐ 

Psoro‐sycotic   

Improved  

5.   Mr. RPR  

29  M  Clerk   Pain in low back Drawing, stitching 

 

HTN  Typhoid   No significant family history   Kali. bich. 

Aurum mat. 

‐ Psoro‐sycoitic  

Improved  

6.   Mrs. RJS 

28  F  House made  

Pain in low back T/N, legs 

 

Dyspnoea   Similar complaints 4 yrs back  

M‐ HTN 

Rhus. Tox  Sepia   ‐ 

Psoro‐syco‐

syphilitic  

Improved  

 

 

Remedial diagnosis Sl. No. 

Name  Age  Sex  Occ  Presenting complaints 

Associated Complaints 

Past history 

Family history Acute   

Remedy Constitutio

nal Remedy 

Inter currant Remedy 

Miasm   Result 

7.   Mrs. S.b.s 

38  f  HW  Pain in low back Rt.ankle joint pain 

eructation  HTN   F‐joint pain M‐HTN 

Rhus Tox  Sulp.  Sulp.‐ Psoro—‐ syphilitic  

Improved  

8.   Mrs. M.pT  

43  M  Manager  Pain in low back Burning in spots 

URTI  URTI    M‐ HTN  CAUST.   PHOS.  ‐ 

Psoro‐syco‐

syphilitic   

Improved  

9.   Mrs A.B.B 

29  F  HW  Pain in back  before menses while sitting 

Pain hip to knee  UTI  F‐HTN  M‐HTN  Bryonia  Lachesis  ‐ 

Psoro‐syco‐

syphilitic 

Recovered 

10.   Mr R.S.S 

39  M  Govt. service 

LBP, stiffness and pain radiating downward. 

Distention of stomach 

Burning micturatio

n 

No significant history  Kali bich  Lyc.  ‐ 

Psoro‐syco‐

syphilitic 

Recovered 

11.   Mr D.P.P 

19   M  Student  LBP, burning sensation of spine 

Headache  Chicken pox  

F – HTN M – TB   Rhus. Tox  Gels.   ‐  

Psoro‐syco‐

syphilitic 

Improved  

12.   Mr. BPN  

23  M  Attender   Low backache, Rheumatic pain 

Thoughts of disease, despair of recovery  

Typhoid   M‐ DM Rhus. Tox  Sulph.   ‐ 

Psoro‐syco‐

syphilitic 

Not Improved  

13.   Mr. PRP 

30   M  Service   Low backache, T/N in LL  

Mild yielding, fear something 

bad  

HTN, similar 

complain 

F‐Br. Asthma  Rhus.tox   Cal.carb  ‐ 

Psoro‐syco‐

syphilitic 

Not Improved  

14.   Mrs.TRR 

28  F  House made  

Backpain Rheumatic   Recurrent tonsillitis 

NAD  F‐died of CA throat   Bryonia   Lyc  Thuja  

Psoro‐syco‐

syphilitic 

Recovered  

 

 

 

Remedial diagnosis Sl. No. 

Name  Age  Sex  Occ  Presenting complaints 

Associated Complaints 

Past history 

Family history Acute   

Remedy Constitutio

nal Remedy 

Inter currant Remedy 

Miasm   Result 

15.   Mr. PTT 

44  M  Manager  

Backpain,   Sadness of disease  

Neck pain  NAD Rhus. Tox  Aur. Mat  Tub 

Psoro‐ syphilitic 

Not improved  

16.   Mr. PRN 

35  M  Business   Backpain in cold air   A/F alcoholic beverages, Headache  

Typhoid   F‐TB Bryoniya   Nux.V  ‐ 

Psoro‐ syphilitic 

Not Improved  

17.   Mrs. NPS 

28  F  Teacher   Back pain, extremities pain  

Headache   Jaundice   F‐HTN Rhus.tox  Puls.   ‐ 

Psoro‐syco‐

syphilitic 

Recovered  

18.   Mrs. CPR 

21  F  H/W  Pain in lumbar region in morning, chill 

during  

Pain in rectum and swelling  

HTN  F‐Peptic ulcer  M‐HTN  Rhus. Tox  Sepia  Tub  

Psoro‐syco‐

syphilitic 

Improved  

19.   Mr. APR 

29  M  Business   Pain in lower back, sacral region  

Eye recurrent agglutination  

NAD  F‐Cirrhosis of liver  

Rhus. Tox  Sulph.   ‐ Psoro‐ syphilitic 

Recovered  

20.   Mr. SRR 

30  M  Clerk   Pain in lower back   Fear of lonelyness  

Recurrent tonsillitis  

F‐DM M‐HTN 

Cali.Bich  Nat.mur   ‐  Psoro‐ syphilitic 

Not Improved  

21.   Mr. HSP  

31  M  Laundry   Backpain,    Cursing and swearing  

DM, Headache 

M‐Br.asthma  Bell.  Caust.  ‐ 

Psoro‐syco‐

syphilitic 

Not improved  

22.   Mr. APK 

21  M  Student   Backpain,    Sciatica   Measles,  URTI  

F‐Backpain  M‐HTN  Rhus. Tox  Ars. Alb  Tub 

Psoro‐syco‐

syphilitic 

Improved  

 

 

 

Remedial diagnosis Sl. No. 

Name  Age  Sex  Occ  Presenting complaints 

Associated Complaints 

Past history 

Family history Acute   

Remedy Constitutio

nal Remedy 

Inter currant Remedy 

Miasm   Result 

23.   Mr. AVR 

28  M  Taxi driver  

Low back pain as if sprain with stiffness  

Irritable easily, indifferent  

Jaundice   F‐ HTN  M‐ Flatulence  

RhusTox.  Nux V.  Tub  Psoro‐ syphilitic 

Improved  

24.   Mr. APR 

28  M  Bus Driver  

Low back pain with stiffness  

Nervousness   HTN  F‐HTN M‐Knee joint pain  

Rhus. Tox  Sepia   ‐  Psoro‐ syphilitic 

Not Improved  

25.   Mr. RBD 

25  M  Field officer  

Spinal stiffness, formication sensation  

Fastidious, desire for company  

HTN Duodenal ulcer  

F‐ Operated for  peptic ulcer  M‐ HTN 

Rhus. Tox  Ars.alb  ‐ Psoro‐ syphilitic 

Improved  

26.   Mr. AKT 

22  M  Tailor   Backache with tingling  

Distension abdomen  

Typhoid   F – DM  M‐ HTN  Calc.flour   Lyc  ‐ 

Psoro‐syco‐

syphilitic 

Not improved  

27.   Mrs. RCM 

30  F  Housewife  

Backache bodyache  Talkative suicidal thoughts  

Pneumonia  F – TB M‐ DM 

Colcy.  Nat. sulph  Tub Psoro‐ syphilitic 

Not Improved  

28.   Mrs. RSM 

24  F  H/w  Backpain spinal stiffness  

Bleeding gums, contraction sensation  

Gastric ulcer 

F‐ Flatulence  M‐DM  Kali. Bich   Alumna    

Psoro‐ syphilitic 

Improved  

29.   Mr. DTD  

28  M  Govt. Service  

Backpain burning, sciatica  

A/F – Business failure 

Skin eruption  

F‐HTN   Rhus tox   Lach.  ‐ 

Psoro‐syco‐

syphilitic 

Not Improved  

30.   Mrs. PNK 

27  F  H/w  Pain in lower extremities  

Expressive, egoistic, talk+ 

Amoebic dysentery  

F‐Br. Asth M‐Myoma of Uterus  

Rhus tox   Lyc  Sulph Psoro‐syco‐

syphilitic 

Not Improved  

 

 

 

 

 

Annexure - IV

 

 

ANNEXURE – IV : SYNOPSIS OF THE CASES

1. Mr. CSN aged 25 yrs male presented with pain in back, stiffness early morning.

He had headache. Had past history of left knee joints. Family History of Father

suffering from Allergic Rhinitis & Mother from Rheumatism. He was diagnosed

as a case of as Ankylosing Spondylitis. The miasmatic diagnosis was Psora-Syco-

Syphilitic based on all the above data Lycopodium was selected as constitutional

remedy & Rhus tox as acute remedy & Tuberculinum as intercurrent remedy. The

patient recovered.

2. Mr. NBN. age 27yrs male presented with back pain on rising in the morning. He

complained about calf pain & cramps, GI disturbance and flatulence. He had past

history of Hemorrhoides & HTN father suffered from Bronchial Asthma and

mother is HTN & DM. He was diagnosed as a case of as Ankylosing Spondylitis.

Miasmatic diagnosis was Psoro-Syco-Syphilitic. From above data Rhux tox was

given as an acute medicine and Lycopodium was presented as constitutional

medicine & the patient was improved.

3. Mr. PGG age 29, male, with complaints of lumbar pain from prolonged sitting &

shifting kind pain, Anxiety about health, dull feeling mentally. He had wart on

neck. Had past history of Jaundice and pneumonia, his mother is HTN and father

DM. Case was diagnosed as Ankylosing Spondylitis. Miasmatic diagnosis was

Psora-Sycoti. Bryonia was given as acute medicine. Thuja was given as a

constitutional remedy. Patient improved.

 

 

4. Mrs. NGG age 31yrs, came with complaints of back pain, leg pain & tingling

numbness some times. She had Irritability at trifles, Her father is having problem

of Hemorrhoides. The case was diagnosed as Ankylosing Spondylitis. Miasmatic

diagnosis was Psora-Sycotic. Bryonia was acute remedy and Nat. mur was

prescribed as constitutional remedy. Patient improved.

5. Mr. RPR age 29yrs, male came with the complaints of pain in low back. drawing

stitching type, stiffness & HTN. He had a past history of typhoid, malaria. He had

no significant family history. He was diagnosed as a case of Ankylosing

Spondylitis. Miasmatic diagnosis was Psora-Sycotic. Kali bich was given as an

acute remedy & Aurum met as constitutional remedy. The patient improved.

6. Mrs. RJS aged 28yrs. Female came with the complaints of pain in low back,

tingling numbness of legs & dyspnoea. She had similar complaints four years

back. Her mother was hypertensive. Miasmatic diagnosis was Psoro-Syphitic.

Rhus.tox was given as acute remedy & Sepia as a constitutional remedy. Patent

improved.

7. Mrs. SBS aged 38 yrs, female came with complaint of low back pain, sciatica. She

was a case of primary infertility and complaint of eructation . she had past history

of HTN & pain in right ankle joint. Her father had joint pain &mother HTN. She

was diagnosed as Ankylosing Spondylitis. Miasmatic diagnosis was Psoro-

Syphilitic. Rhus tox was given as acute remedy and Kali.bich as constitutional

remedy and sulphur as intercurrent remedy. Patient improved.

8. Mr. MPT age 43 yrs male came with the complaint of back pain on slight

exertion, morning stiffness, having burning pain in spots on rubbing. In the past he

was having upper respiratory tract infection. In the family history mother was

 

 

HTN. He was diagnosed as a case of Ankylosing spondilitis. Miasmatic diagnosis

was Psora-Syco-Syphilitic. Causticum was acute remedy and Phosphorous was

constitutional remedy. Patient improved.

9. Mrs. ABB, 29 yrs F, came with c/o LBP before menses, sitting while. Better by

rising in morning. She was having pain in hip to knee. She had past history of

recurrent urinary tract infection. In her family history her father, M & brother are

suffering from HTN. She was diagnosed as case of Ankylosing spondilytis and

her miasmatic diagnosis was Psora-Syco-Syphilitic Bryonia was given as acute

remedy, Lachesis as constitutional medicine. The patient recovered.

10. Mr. RRS , 39 yrs M, came with c/o LBP with stiffness and pain radiating

downwards. He was having wart on his face recurrent burning micturation. There

is no significant family history. He was diagnosed as a case of Ankylosing

spondilytis and his miasmatic diagnosis was Psora-Syco-Syphilitic Kali bich. was

given as acute remedy. Lycopodium was prescribed as constitutional medicine.

The patient recovered.

11. Mr. DPP aged 19 yrs M, came with C/o LBP burning sensation in spine. Also

complained of headache. In the past he suffered from chicken pox. His Father -

HTN and Mother – Kochs elder brother DM. he was diagnosed as case of

Ankylosis spondilytis. The miasmatic diagnosis was Psora-Syco-Syphilitic. Rhus

tox was acute remedy. Gelsem was constitutional remedy. The patient improved.

12. Mr. BPN age 23 years Male, with C/o bhack pain, rheumatic. He also complained

of thoughts of disease, despair of recovery. In the past he suffered from typhoid,

family history – Mother – DM, HTN, sister had Ca breast. He was diagnosed as

case of ankylosis spondilytis. Rhus tox. Was acute remedy given and Sulphur as

 

 

constitutional remedy and Thuja as intercurrent remedy. Miasmatic diagnosis is

Psora-Syco-Syphilitic Patient did not improved.

13. Mr. PRP age 30 yrs, Male came with complaint of low back pain extending to

right lower leg. Tingling numbness and he complained mild, yielding fear

something bad. Family history – Father – Asthma. He was diagnosed as a case of

Ankylosing spondylitis. Miasmatic diagnosis was Psora-Syco-Syphilitic. Rhus tox

was given as acute remedy and Calcarea carb as constitutional. The case did not

improve.

14. Mrs. TRR, age 28 yrs, female came with low back pain and Rheumatic kind of

pain. No significant past history. Father died due to carcinoma of throat. Family

history – Mother – knee pain. She was diagnosed. Miasmatic diagnosis was Psora-

Syco-Syphilitic. Bryonia was given as acute remedy and Lycopodium as

constitutional and Thuja as intercurrent remedy. The patient recovered.

15. Mr. PTT aged, 44 yrs, Male came with complaint of back pan, < night sitting >

motion during, and pressure and complaint of sadness of disease. He had a history

of neck pain in past. No significant family history. He was diagnosed as a case of

ankylosis spondilitis. Miasmatic diagnosis was Psora-Syphilitic. Rhus tox was

given as acute remedy and Aurum-met as constitutional remedy Tuberculinum as

intercurrent remedy. The case did not improved.

16. Mr. PRN, Age 35 yrs, Male came with complaint of back pain on cold air, < from

lifting. The patient had ailments from alcoholic beverages. Headache. In the past

he had suffered from Kochs. He was diagnosed as a case of ankylosing

spondilytis. Miasmatic diagnosis was Psora-Syphilitic. Bryonia was given as acute

remedy and Nux-v as constitutional. The case did not improved.

 

 

17. Mrs. NPS age, 28 yrs, female came with complaint of back pain and stiffness. She

also complained of Headche. In the past she had suffered from jaundice and

chicken pox. Her father is suffering form HTN. She was diagnose ankylosing

spondilitis. Miasmatic diagnosis was Psora-Syco-Syphilitic. Rhus tox was given

as acute remedy and Pulsatilla as constitutional. The patient recovered.

18. Mrs. CPR age 21 yrs, female came with complaint of pain in lumbar region in

morning chill during. She also complained of pain in rectum. She is known HTN.

Family history – Father – peptic ulcer and Mother – HTN. She was diagnosed

case of Ankylosing spondilitis. Miasmatic diagnosis was Psora-Syco-Syphilitic.

Rhus tox was given as acute remedy and Sepia as constitutional and Tub as

intercurrent remedy. The patient improved.

19. Mr. APR, age 29yrs, male came with complaint of low back pain and sacral

region. Eye recurrent agglutination. No significant past history. In his family

father suffered from cirrhosis of liver. He was diagnosed as case of lumbar

spondylosis and miasmatic diagnosis was Psora-Syphilitic. Rus. Tox was given as

acute remedy and Tub. as intercurrent. The patient recovered.

20. Mrs. SPR, age 30 yrs female, came with complaint of pain in low back, fear of

loneliness. Past history – recurrent tonsilitis, family history – Father Diabetes

mellitus, mother – HTN. She was diagnosed as case of Ankylosing spondilitis and

Miasmatic diagnosis was Psora-Syphilitic. Kali.bich was given as acute remedy

and Nat.mur as constitutional. The patient not improved.

21. Mrs. HSP, 31 yrs, Back pain, < pressure, night, patient was always cursing and

swearing. Past history diabetes mellitus and headache. Family history- Mother had

Br. Asthma. She was diagnosed as case of Ankylosing spondilitis and Miasmatic

 

 

diagnosis was Psora-Syco- Syphilitic. Belladonna was given as acute remedy and

Causticum as constitutional. The patient did not improved.

22. Mr. APK, 21 years male, came with complaint of backpain, < evening cold air,

night. Associated with fever. Past history with measles and upper respiratory tract

infection. Family history of father had back pain mother was HTN. He was

diagnosed as case of Ankylosing spondilitis and Miasmatic diagnosis was Psora-

Syphilitic. Rhus.tox was given as acute remedy and Sepia as constitutional

remedy Tuberculinum as intercurrent remedy. The patient not improved.

23. Mr. AVR, 28 yrs male, came with the complaint of low back pain and pain as if

sprain with stiffness in the back. Also patient was irritable easily, indifferent to

every thing, nervous. He is known HTN. In the past patient had extensive skin

eruption on the legs. In his family history father was HTN and mother was

suffering from pain in knee joint. He was diagnosed as case of Ankylosing

spondilitis and Miasmatic diagnosis was Psora-Syphilitic. Rhus.tox was given as

acute remedy and Lycopodium as constitutional remedy Tuberculinum as

intercurrent remedy. The patient not improved.

24. Mr. APR 23 yrs male came with the complaint of low back pain, with eye

complains with stiffness of back which increased by rest. Patient was nervous

having past history of HTN, in the family father had HTN, and mother had knee

joint pain. He was diagnosed as case of Ankylosing spondilitis and Miasmatic

diagnosis was Psora-Syphilitic. Rhus.tox was given as acute remedy and

Causticum as constitutional. The patient not improved.

25. Mr. RBD age, 25 yrs male came with the complaint of stiffness and fatigue,

formication sensation. Anxious about health fastidious and desires for company.

 

 

He had HTN in the past. And in his family father was operated for perforated

duodenal ulcer and mother had HTN. He was diagnosed as case of Ankylosing

spondilitis and Miasmatic diagnosis was Psora-Syphilitic. Rhus.Tox was given as

acute remedy and Ars.alb as constitutional. The patient not improved.

26. Mr. AKT age 22 yrs male came with complaint of low pack pain tingling

numbness in back, neck pain with distension in abdomen. With his past history of

eruption over the legs and he had suffered form typhoid. In family mother had

diabetic mellitus and father was HTN. He was diagnosed as case of Ankylosing

spondilitis and Miasmatic diagnosis was Psora-Syco-Syphilitic. Calc.flour was

given as acute remedy and Lyco as constitutional. The patient not improved.

27. Mrs. RCM aged 30 yrs, Female came with complaint of low back pain and sciatic

and was fastidious, talkative, sucidal thoughts. She had past history of typhoid,

measles. Her family history tells us that her father had asthma and he had suffered

from TB and mother was diabetic mellitus. She was diagnosed as case of

Ankylosing spondilitis and Miasmatic diagnosis was Psora-Syphilitic. Colocynth

was given as acute remedy and Nat.sulph as constitutional and Tub. as intercurrent

remedy. The patient not improved.

28. Mrs. RSN, age 24 yrs, female came with the complaint of back pain, spinal

stiffness and sciatica. She was also having tendency of bleeding gums. She

suffered in the past from typhoid and gastric ulcer. Her mother had diabetes

mellitus and father had flatulence dyspepsia. She was diagnosed as case of

Ankylosing spondilitis and Miasmatic diagnosis was Psora-Syphilitic. Kali.bich

was given as acute remedy and Almina as constitutional. The patient improved.

 

 

29. MR. DTD age 28 yrs male came with the complaint of low back pain and pain

radiating to the legs. Ailments from business failure. He was irritable and hatred

to express feelings. He had past history of skin eruption over trunk. In his family

father had HTN. He was diagnosed as case of Ankylosing spondilitis and

Miasmatic diagnosis was Psora-Syco-Syphilitic. Rhus. Tox was given as acute

remedy and Lachesis as constitutional. The patient not improved.

30. Mrs. PNK age 27 female came with low back ache, restricted movements, pain in

the lower extremities, and was not expressive. Use to talk very fast and was

egoistic. In the past she had amoebic dysentery. In her family father had bronchial

asthma and mother had myoma of uterus and was diabetic. She was diagnosed as

case of Ankylosing spondilitis and Miasmatic diagnosis was Psora-Syco-

Syphilitic. Rhus.tox was given as acute remedy and Lycopodium as constitutional

remedy Sulphur as intercurrent remedy. The patient not improved.