Saturday, June 17, 2006
Saturday, June 10, 2006
The Wilder Shores of Arthritis: Fit the First

I would like to thank The Goldfish without whose patient expert advice this blog would have no pictures.
Non-steroidal anti-inflammatory drugs. The very phrase is like a bell, to toll me back to my arthritic self. For reasons with which I won't bother anyone, I've been off my usual intake for a while now, with the result that I am slowly but surely stiffening up, especially in the mornings. Where would we be without them?
Arthritis is as old as mankind, huddled miserably in damp pigskin loin-cloths and dripping mammoth-hair overcoats around the cave fire. Bones showing arthritic changes go back millennia. Oetzi the Iceman had not only bones with arthritic changes, but also tattoo-like puncture patterns suggesting that he might have been treating the pain by acupuncture*. So, although it seems to have been accepted as part of life's rich tapestry to a degree - there are not nearly as many old recipes for arthritis or rheumatism cures and treatments as there are, for example, for the pox, or even mad dog bites - mankind put their heads together and observed that some things made it easier, some worse.
The ancient Egyptians certainly knew about arthritis. Ramses II (1279-1213 BCE) suffered from it, as evidenced by his mummy. There is nothing like a royal connection to concentrate the doctors' minds on an illness; look at porphyria and haemophilia.

Then you shall say: someone having mucilaginous matter in his neck.
Then you shall cause him to anoint himself and to apply ointment, so that he will improve at once."
The diagnosis of sciatic pain was described with precision in the Edwin Smith Papyrus (1700 BCE): "If thou examine a man having a sprain in a vertebra of his spinal cord, thou shouldst say to him: extend now thy two legs and contract them both again. When he extends them both, he contracts them both immediately because of the pain he causes in the vertebra of his spinal column in which he suffers. Thou shouldst say concerning him: One having a sprain in a vertebra of his spinal column".
- This method of examination is what medical students today know as Lassauge’s test.
Painful joints were treated by ointments which had, as a base fat, oil, bone marrow, gum or honey. To this they added flour, natron, onion, cumin, flax, frankincense or pine. (Flax seed (linseed) or animal fat is still used today in Egyptian and European folk medicine as an ointment or poultice for rheumatic pains). Poppy and thyme were noted as analgesics. Myrrh was the treatment prescribed for backaches, whether internally or externally I don't know.



Some of the things our ancestors tried - usually on the belt-and-braces principle that if two things helped a bit separately, they must be even better when combined - make the treatment seem worse than the condition, at least to modern eyes.

The Lacnunga, an 11th century collection of Old English recipes, suggests for "liðwyrce" (limb pain) an ointment made of elecampane, radish, wormwood, bishopwort, cropleek, garlic, holleek, celandine, and red nettles, ground and boiled in butter then stored in a bronze vat until it turned blue (?mouldy). Alternatively, you could say a charm Ad articulorum dolorem constantem malignantem: "diabolus ligauit, angelus curauit, dominus salutauit, in nomine, amen." (The devil bound, the angel cured, the Lord saved, in [His] name, amen." History does not report what you were to do when that didn't work either.


When considering Anglo-Saxon remedies, it's important to remember that their theories of disease were not quite like modern ones. They certainly believed in restoring balance and harmony as a cure for some disorders, but also in the activities of malign supernatural entities: flying venom (fleogende attor),worms (wyrmas, burrowing entities), dwarfs (dweorh, no, not Tom Shakespeare, more like what we would call gnomes or trolls), and elves who were believed to shoot darts into humans and animals (ylfa gescot), the shot causing, especially, rheumatism, arthritis and stitch. The existence of tiny stone arrowheads (Neolithic or Mesolithic in origin) was held to prove this, and as late as the twentieth century, such arrowheads were also used in folk medicine to "cure" such conditions, as like cures like (an usage that would have appealed to Hahnemann himself - see below).

*I am indebted to Sally for this information.
Thursday, June 08, 2006
The Wilder Shores of Arthritis: Fit the Second

Rev Stone and his predecessors adhered to the old Doctrine of Signatures, which said that every plant, being created for man's use (cf The Book of Genesis), had in its appearance or habitat something to guide one to its use. Willow, growing and flourishing in damp conditions, would naturally be a specific for diseases associated with such conditions. Felix Hoffmann later independently developed acetyl-salicylic acid for the Bayer Drug Company in 1899: aspirin. This is a synthetic form of the substance which naturally occurs in willow-bark, which had been recommended by physicians for its analgesic properties as far back as Hippocrates. A substance might be used for the wrong reasons; but the fact that it kept on being used might suggest that it did have some efficacy. Only now, driven by the need for new treatments, are medical researchers studying folk usages with an objective instead of a dismissive approach.

Back to the story. In medieval times the situation wasn't much changed. A MS of the reign of Henry VII contains a recipe "ffor all maner ache yn senos [sinews] or juntys [joints]" which suggests that you boil thyme in wine to a concentrate, in which you then boil a red cloth. Then wash yourself with the hot herb water and cover the affected parts with the cloth. As a matter of fact, red flannel was supposed to have protective properties - the flannel certainly would be very insulating, although the colour choice is probably down to sympathetic magic - and petticoats made of it were in use well into the twentieth century in Britain.





Of course, Culpeper was a professional, licensed, physician. Thousands of amateurs, housewives, wise men and women of all sorts, had their own private recipes concocted in their stillrooms up till the end of the eighteenth century at least. One such, from Essex, is "Sir George Horseyes Green Ointment for Aches proceeding from a Cold Cause for Shrunke Sinews in Man, or Beast, & for Strains it's incomparably good & holds Perfection 40 years." It should; collecting the list of ingredients alone would take long enough: mallow, groundsel, strawberry, cotton lavender, birch leaves, chickweed, comfrey, parsley, sage, bay leaves, chamomile, adders' tongue [a fern], ox-eye daisy. But you haven't finished: roses, frankincense, pork lard, butter made in May and clarified in sunlight, salad oil, turpentine, verdigris. Blend and boil this lot, decant into closed containers and bury them three-feet deep in a pile of horse manure [I swear I am not making this up] for three weeks. Then boil them up again, strain, and add spike lavender oil. Apply to the affected place gently warmed. Well, it might smell nice.


Tuesday, June 06, 2006
The Wilder Shores of Arthritis - Fit the Third

The eighteenth century had added the attraction of visits to spas and hot springs and sea-bathing (for the rich), and this survived until the Edwardian era at least. Hydrotherapy (hot or cold) and medicinal waters had been known since antiquity; certainly since the Ancient Greeks venerated the shrine of Aesculapius; now they were re-invented with the impetus of dubious scientific theories. Crounotherapy is the process of "drinking the waters", balneotherapy of medicinal baths, and thalassotherapy of medicinal sea-bathing (recreational sea-bathing didn't come in, in Europe, until well into the 19th century). Spa waters were usually either sulphurous, chalybeate (iron-contaminated, Sam Weller's warm-flat-irons taste) or saline (salt or brackish); the most effective for arthritic and rheumatic complaints was the saline, externally; it was the ancestor of the modern hydrotherapy pool.

St Ann's Well, at Buxton, goes back to Roman times. Thomas Cromwell tried to close it as a Papist shrine during the Reformation, but evidently did not succeed; Mary Queen of Scots, who had rheumatoid arthritis, paid several visits, and in the 17th century some anonymous poet wrote

Old men's numb'd joints new vigour here acquire;
In frozen nerves this water kindleth fire,
Hither the cripples halt, some help to find,
Run hence, their crutches unthank'd left behind. (1662)
It is perhaps necessary to remark, that the same waters were used for internal and external treatments, occasioning some temptation to the more economically-minded spa owners and risks to their clients, as one Christopher Anstey pointed out in 1766:
You cannot conceive what a number of ladies
Were washed in the water the same as our maid is...
So while little Tabby was washing her rump
The ladies kept drinking it out of the pump.
Not that that possibility deterred the arthritics, who will try anything once: Madame de Sévigné treated her aching joints to the cure at Vichy, which consisted of drinking water tasting of saltpetre and then being hosed down by hot douches of the same (which she describes as "a good rehearsal for Purgatory"). Jane Austen's brother Edward took his gout to Bath in 1799; "I fancy we are all unanimous in expecting no advantage from it," she wrote.

Homeopathy was also formally discovered in the eighteenth century, 1790 to be precise, by a German physician, Samuel Hahnemann (1755-1843). It remains a contentious subject, even today, with many ardent adherents and bitter opponents. The basic principle, which Hahnemann, a humane practitioner, developed in reaction to the increasingly aggressive and toxic treatments being inflicted on patients by his fellow doctors, was similia similibus curentur, "let likes be cured by likes": so that if you have a symptom, say, fever, you give a little of something which promotes fever, in order to stimulate the body into producing its own reaction. Like immunisation, in fact.

Unfortunately the elaborations and rationalizations which have accrued to justify his theory have thoroughly discredited homeopathy in the minds of most mainstream scientists. Put brutally, the physical and physiological bases of these theories are nonsense. They are based on eighteenth-century knowledge and theories, pre atomic theory, pre microbiology and germ theory itself, pre any notion of the endocrine system, the lymphatic system, the immune system....



Sunday, June 04, 2006
The Wilder Shores of Arthritis - Fit the Fourth

Before leaping into the twentieth century, a word about painkillers in general, not just anti-arthritis drugs. (We'll get to the NSAIDs one day, I promise.) Pain is only a symptom that something has gone wrong. If you have acute pain from a single reversible cause, such as a fracture or an abscess, you can hope to relieve the pain by curing the cause. If, however, you have a chronic condition, such as arthritis, where the pain is due to multiple irreversible tissue changes and damage, you could, excluding surgery, relieve the pain only by (a) physically interrupting the sensory nerves which supply the information to the brain (b) distracting the patient physically (by counter-irritant) or psychologically (by analgesic, antidepressant, sedative or hypnotic) (c) continually damping down the inflammatory response which is causing the pain.
For most of history, option (b) has been the only one available. The daddies of all analgesics are, of course, opium, and alcohol. Opium goes back long before Hippocrates (fourth century BCE); it has been recorded by the ancient Assyrians, Sumerians and Egyptians, and appears in ancient Greek legends as well. Alcohol probably dates to when the first man ate a bit of rotting, fermented fruit and liked the sensation of getting high. The problem with them is that they are both potent CNS (central nervous system, ie the brain) depressants and they both cause habituation. A weaker ancient alternative to opium is lactuarium, extracted from the juice of wild lettuce.

Opium dissolved in alcohol became the basis of many analgesic/sedative tinctures, the most well-known of which is laudanum, the favourite tipple of Samuel Taylor Coleridge, Wilkie Collins, Branwell Brontë and many other unfortunates, who became insidiously addicted. In 1805 morphine was refined from raw opium. When its addictive properties were realised in turn, diamorphine was developed as a further, safer, refinement; ironically, although it is a much stronger painkiller, it is also many times more addictive. After the first world war, in the UK and many other countries, the opiates (except for codeine in the UK) were declared to be Dangerous Drugs and their use strictly forbidden without prescription; cannabis followed in the 1930s and the barbiturates in the 1950s.
Also in the 1950s came a Wonder Drug, the first of all the synthetic steroids - cortisone. Its discoverer, Tadeus Reichstein, and his co-scientists, got the Nobel Prize for its discovery. Corticosteroids are produced naturally in the body by the adrenal cortex; they are essential hormones involved in the stress response, immune response, and inflammatory response amongst other functions; the immune and the inflammatory are the ones that concern arthritics. They revolutionised the treatment of intractable disabling inflammatory and autoimmune conditions like Crohn's, ulcerative colitis, asthma, lupus, sarcoidosis, psoriasis. They also had horrendous and often irreversible side-effects, as may any drug, but this was not realized until quite some time later.

When the side-effects of steroids became apparent, many alternative painkillers were developed: good old over-the-counter paracetamol, phenacetin (long-since banned); the NSAIDs: mefenamic acid, ibuprofen, indomethacin, naproxen, diclofenac sodium; the opioids: tramadol, pentazocine, buprenorphine....they all have their disadvantages to the continual user. Those that aren't gastric irritants or addictive tend to be hepatotoxic (paracetamol) or nephrotoxic (phenacetin).

These are still largely unanswerable questions in the 21st century.
Let's say there's going to be a genetic predisposition: even if (when) we can identify the gene(s) responsible, and if (large presupposition) it turns out that these genes don't also have a benevolent function as well which we can ill do without: what are we going to do about it? Is the arthritis gene to be added to the growing list of ills that flesh is no longer going to be heir to because they are going to be screened out at the pre-implanted embryo stage or by abortion?

Friday, June 02, 2006
The Wilder Shores of Arthritis - Fit the Fifth

In the face of this mainstream helplessness, alternative therapies have burgeoned. Some people swear by acupuncture, not just as a treatment but as a cure. Acupressure can also work, but for a while only; as soon as the pressure is released, back comes the pain.
People with rheumatoid have a list as long as your arm of food they should, and should not, eat. Studies show that fish oils, for example, have a beneficial effect, on both rheumatoid and osteo, so we all gulp cod-liver-oil until another set of studies casts doubt. Partly, of course, this is the fault of the modern media intrusion into areas of scientific interpretation they are just not competent to dabble in. For instance, I recall an excited news report a couple of years ago that some component of green tea had found to be useful in preventing/reversing the degeneration of osteo. So of course, I pricked up my ears. The truth is rather less dramatic. It is likely, that if you drank green tea every day for about forty years, you might slightly reduce or delay the damage to the joints. That's all. You might well also suffer some side-effects, such as hallucinations, from the green tea, which itself is mildly toxic in quantity, if you overdid it.
The media also never seem to be able to distinguish between osteo and rheumatoid; it never seems to occur to them that, if the causes and effects are quite distinct, the preventatives and treatments might be so as well.

A recent report on osteopathy and chiropractic has concluded that the benefits they bestow, as far as these diseases are concerned, are no better than placebo, much to the predictable outrage of their professional associations. This seems to me to miss the point with admirable precision: if you have no effective treatment or cure, then placebo is what you use, allopath, homeopath or whatever. It may even help. I myself have got much benefit from reflexology, which the BMA doesn't even deign to recognise, much less assess; I am quite sure that the benefit is placebo-derived but what the hell? It relieves the pain for a while without giving me an ulcer, blood dyscrasia, or liver damage, and that, these days, is something to be thankful for.

Urtication (nettle-stings) and capsaicin (derived from capsicum peppers) are local skin irritants just like Ralgex. Probably it's the rubbing-in, the massage, which gives as much relief as anything. St John's Wort oil (Hypericum perforatum) is another rubifacient with a good reputation. They can all cause local skin allergic reactions.

(Incidentally, it was hoped that a dermal plaster of paracetamol preparation would be just as effective an analgesic as an oral dose while avoiding the gastric irritant effects; sadly, longer trials have revealed that any but the briefest usage reduces the user's response to the drug to the point where pain relief is inoperative.)


