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Author's Note: Sections of this paper were first published on my long-defunct blog "The Meanderings of a Politically Incorrect Crip" My thanks to Dave, who read it in proof to check for howlers, and to Andy, without whose patient and skillful editing it would never have made it to the screen.

Arthritis literally means, inflammation (-itis) of the joint(s) (arth-). It has always been the convention until recently to name disorders after the part of the body which seems to be affected (I say “seems” because in the days before internal medicine, how could you be sure that a pain at the bottom of the ribs was the fault of the stomach, the liver, the diaphragm, the heart, or the gall bladder? Even today, immediate diagnosis by place is chancy. Unless, of course, you can see broken bone sticking through the skin of the upper leg, in which case you can say, “Ah-ha, compound fracture of the femur” and look ineffably wise.) But this kind of naming is, if you think about it, not always entirely sensible. If you go to your doctor complaining of, say, “headache”, s/he immediately has to think, now are we talking hangover, migraine, tumour, stroke, sinusitis, fractured skull, cerebral aneurysm, referred pain from cervical spondylosis....?

In the case of arthritis, it has led to considerable confusion, as more than one condition has been subsumed under this term. I myself suffer from osteo-arthritis (OA), which used to be held to be a degenerative condition commonly associated with wear-and-tear and old age. Even the name is technically incorrect, in that the proper term, if we are talking about a non-inflammatory, chronic, condition, should be arthrosis, whereas the –itis suffix denotes an acute inflammation. Then there are rheumatoid arthritis (RA) (correct suffix this time) which is now held to be an autoimmune disorder, juvenile chronic arthritis (including Still’s disease (named after the doctor who first described it, not the patient, naturally) now held to be almost certainly another autoimmune), ankylosing spondylitis (that is the one that doubles the spine up like a hairpin), gout, arthritis secondary to psoriasis or lupus, and any number of more obscure musculo-skeletal conditions. The familiar term “rheumatism” likewise covers a multitude of sins in and around the joints, including fibromyalgia (lit: muscle pain), bursitis, polymyalgia rheumatica, tendonitis, tenosynovitis, and so on.

Anatomy and physiology of synovial joints

The mammalian joint is a beautiful bit of bio-engineering (excuse the teleology). Here is a rough diagram of a typical synovial joint (in this case the hip, which is a ball-and-socket), in which you can see how the articular surfaces are aligned to glide over one another to permit movement. (Please note that, in life there is only potential space between the articulating surfaces.) But no picture can do justice to the physical reality; try this: Next time you or someone you know is roasting a joint, a leg of pork or lamb, say; get hold of the meat before it goes in the oven and examine the bone at the joint end. (Thanks to modern farming policies, this will be a very young animal.) See and feel how exquisitely the surface on the end of that joint is formed: perfectly smooth, indeed glassy in texture. This surface is not, in fact, bone, but the hyaline (articular) cartilage which covers it. Further, in life these articular surfaces are continually bathed in synovial fluid, which (in health) is a clear viscous fluid (rather like white of egg) secreted by the synovial membrane. This fluid not only lubricates the joint, it also provides nutrient materials to the joint structures and it contributes to the stability of the joint by preventing the ends of the bones separating, rather like a film or water or oil acts between glass or metal plates. The whole joint is surrounded by a tough, fibrous capsule, which has to be strong enough to hold the structures together and protect them from injury, but at the same time, elastic enough to permit desired movement.

So what could possibly go wrong? Life being what it is, plenty. Hewing grimly to topic, I propose to limit my remarks to the OA type; anyone who wants more topics can find information easily on the net, where every disease you can name has its self-help group.

OA is experienced by the patient as:

• Joint soreness after periods of overuse or inactivity
• Morning “stiffness”, which usually lasts no more than 30 minutes.
• Pain and weakening of muscles surrounding the joint.
• Joint pain is usually less in the morning and worse in the evening after a day’s activity.
• Deterioration of coordination, posture and walking.
• The affected joints "creaking" or "cracking" (crepitus) when moved.
• Reduced range of motion in the affected joints.

• In OA of the hips, there may be:

  • Pain in the groin, inner thigh and buttock
  • Referred pain in the knee and side of the thigh
  • Limping when walking
  In OA of the knees:
  • Pain when moving the knee
  • Grating or “catching” when moving the knee
  • Pain when walking up and down stairs or getting up from a chair
  • Weakened large thigh muscles
  In OA of the hands:
  • Pain and swelling of the finger joints
  • Bony growth spurs (osteophytes) at the joint at the end of the finger (Heberden’s nodes), or at the middle joint (Bouchard’s nodes)
  • Redness, tenderness and swelling in the affected joints, especially early on when the nodes are forming
  • Enlarged joints
  • Difficulty with pinching movements, such as picking an item up from a table or grasping a pencil or pen
  In OA of the feet:
  • Pain and tenderness in the first metatarsophalangeal joint (the large joint at the base of the big toe).
  • Pain when wearing tight shoes or high heels
  In OA of the spine:
  • A breakdown of the spinal discs resulting in bony overgrowths (osteophytes)
  • Pain from pressure on the nerves in the spinal cord (“pinched nerves”)
  • Pain in the neck, shoulder, arm, lower back and legs; headache.
  • Weakness or numbness in arms and legs (due to neuropathy){mospagebreak title=OA In Later Life}

  Radiographic studies indicate that OA occurs in 30% of individuals aged 45-65 years and in more than 80% by their eighth decade of life, although most are asymptomatic.

  In health, the cartilage is maintained by chondrocytes[1], which undergo changes as a result of age, injury or disease. Normally a balance is maintained between synthesis and degradation of components of the collagen-rich matrix of the cartilage; in arthritis, degradation is increased by the action of chondrocyte-derived metalloproteinases[2]. There is concomitant synovial inflammation, but whether this is a cause of, or result of, cartilage breakdown is still disputed. Similarly, weakness in the associated muscles and ligaments, and misalignment of the bones, are now thought to be possibly causes, rather than results, of the joint degeneration.

  What is happening is this: the precious articular hyaline cartilage grows thinner, with focal ulcerations in the load-bearing areas; in advanced cases it disappears altogether, leaving the ends of the bones to rub against one another. Now bone is very smooth, but it’s not as smooth as healthy hyaline cartilage.

  At the same time osteophytes develop at the joint margins, through ossification of cartilage outgrowths, restricting movement and compressing other tissues. There are major changes in the vascularity and turnover of the subchondral bone (the bone beneath the cartilage) and the fibrous capsule itself becomes thickened and less elastic.

  The current idea is that OA involves the whole articular system and the entire joint organ, including the subchondral bone and the synovium. Joint damage is caused by a combination of systemic predisposing factors, plus local mechanical factors (“wear and tear”) which dictate its distribution and severity. It has traditionally been classified as a noninflammatory arthritis; yet, there is increasing evidence for inflammation occurring, with cytokines[3] and metalloproteinases shown to be released into the joint.

  Now, how about wear-and-tear? Since just about everyone over the age of 70, assuming they get that far, will show signs of OA, it had again been traditionally assumed that these signs are a sort of RSI, solely the mechanical result of years of continual jolting, banging, straining of the joints. For example, if you are a shot-putter, it is likely that you will develop arthritis, if you do, in the shoulder; joggers will develop it in the knees. It is true that OA is much commoner in the weight-bearing joints (hips and knees) than elsewhere; and that it is particularly prevalent in overweight subjects, but....

  ...In the first place, OA can occur in any joint, weight-bearing or not (and why are hip or knee arthritis vastly more common than ankle?); in the second, it can appear (admittedly much less commonly) at any age, from infancy upwards, despite the perception of it as a disease of old age.

  In point of fact, the exact causes are not well understood. Is the damage attributed to excess weight, for example, a result of that weight, or an exacerbation of an existing pathology? (Plus the fact that, faced with pain on movement, most subjects court obesity by becoming progressively less mobile, thus obesity is as much a result of OA as a cause.) OA changes will be seen in joints where it is the bones, and not the joints themselves, that have previously been fractured; is this some kind of response to the inflammatory and healing processes? (The healing of bones is a fascinating process I haven’t time to go into here.) Statistically, the risk of post-traumatic OA is greatly increased by a family history of the condition. So is there a genetic component? Certainly, although OA is so common that asking “does it run in the family?” nearly always elicits an affirmative answer anyway.

  Most research had been focussed away from OA, because it was seen as an inevitable disease of old age, and onto the more dramatic life-altering conditions like RA, ankylosing spondylitis or juvenile chronic arthritis. Thus, we presently know a lot more about the genetics of such conditions than we do about those pertaining to OA.

  Back in the 1960's research turned up a major genetic link which was discovered between the gene HLA-B27 and the spondyloarthropathies, a group of diseases affecting the spine and other joints: 90% of people with ankylosing spondylitis have the HLA-B27 gene, which occurs in 7% of the general population.

  And the HLA-DR4 gene, which has been associated with rheumatoid arthritis, has also shown involvement in Lyme disease (borreliosis), which is caused by microorganisms[4] which are transmitted to humans via sheep/deer ticks. And among the symptoms of Lyme disease are, guess what, joint pain and inflammation and arthritic changes. People who have the disease more severely and do not respond well to the available antibiotic treatment are more often found to have the HLA-DR4 gene. It has been theorized that, once the microorganism moves to the joints, the immune response against it cross-reacts with the person's own joint tissue in people who have the HLA-DR4 gene, leading to an autoimmune reaction, such as RA.

  Other research has led to the discovery of a genetic mutation which causes OA in some people. Several members of a family who had early onset OA were found to have a genetic mutation in type II collagen, which is the basis for hyaline cartilage. The mutation caused premature breakdown of joint cartilage in the affected family members. Since this discovery other genetic mutations in other families have been found and even more mutations are thought to exist. Several chromosomal loci and gene variations associated with an increased risk of OA have now been identified, but so far each identified gene variation identifies only a small proportion of the total incidence of OA. It is suspected that as many as 25% of people with OA may have a specific gene mutation directly responsible for their OA.

  Some researchers dispute whether there even is a single disease entity we can call OA. They claim that it is in fact a heterogeneous cluster of diseases, distinguishable according to location, pathogenesis, progression, genetic component, gender and age component: for example, prevalence increases with age. Equivalent prevalence occurs in men and women aged 45-55 years. After age 55, prevalence becomes greater in women; Heberden's and Bouchard's nodes are more common in women.{mospagebreak title=Diagnosis}

  Diagnosis

  Diagnosis and treatment of exactly what is going on is, believe it or not, quite difficult. Radiological diagnosis is sure, but it can only show the late changes of established disease. And there seems to be little, if any, correlation between the X-ray evidence and the patient’s perception of pain and/or malfunction. (This makes prescribing of palliatives, in particular, very difficult.)

  By arthrocentesis (sampling the synovial fluid) it is now possible to detect inflammatory changes much earlier than previously. While normal synovial fluid is clear, abnormal fluid is discoloured and opaque. For patients whose synovial fluid is compatible with osteoarthritis alone, their white blood cell count will be in the range of 200 to 2,000 per cubic millimetre. The white cell count of normal synovial fluid is less than 200; the range of 200 to 2,000 is abnormal, but noninflammatory. White blood cell counts above 2,000 are definitely abnormal and indicate an inflammatory, possibly septic, arthritis.

  With the development of molecular biology techniques, potential biological markers for osteoarthritis can now include matrix components (and/or their breakdown products), cytokines, and proteases (e.g., matrix metalloproteinases and their inhibitors) (Garnero, 2003), quantifiable before any of the gross symptoms appear to warn the patient or physician.

  It is now also possible to detect the crude bony changes of arthritis much earlier and more easily. Arthroscopy (putting a mini camera into the joint) can provide clearer pictures than static X-rays, but has the usual risks of surgery and anaesthetics; and there is now a recently-developed technique called acoustic emission which can be used by any GP in his local surgery, to actually hear the noise made by the moving joint, before any symptoms of pain or stiffness have even become noticeable.

  Treatments Through the Ages

  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. 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.

  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 doctors' minds on an illness; look at porphyria and haemophilia. The Ebers Papyrus, from 3,000 BCE, deals with gout, and also with neck stiffness: "Another remedy: When you see a man in whose neck is mucilaginous matter and he suffers from the joint of his neck, he suffers from his head and the vertebrae of his neck are stiff, his neck is heavy. it is impossible to look at his belly or very difficult.

  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 sciatica[5] 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 medics 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[6], onion, cumin, flax, frankincense or pine. (Flax seed (linseed) or animal fat are still used today in Egyptian and European folk medicine as the bases for ointments/poultices for rheumatic pains). Poppy (ie opium) and thyme were noted as analgesics. Myrrh was the treatment prescribed for backaches, whether internally or externally I don't know; it has been shown to have some local anaesthetic action, at least in mice (Dolora, 2000).

  But even before that, in the Austro-Italian Alps, Oetzi the Iceman (fl. c.3300BCE) was suffering from OA (Murphy, 2003), among other painful conditions. Oetzi has been shown to bear sets of tattoos, and it has been claimed by acupuncturists (Dorfer, 1999) that these bear a striking resemblance to the patterning still in use to treat the type of pain he would experience, arising from the arthritis in his ankle and knee.

  Twenty-five hundred years after the Ebers scribe, Hippocrates wrote an entire and very sensible, practical treatise (On the Articulations) about treating all varieties of fractures and dislocated joints, but seems to have lost it a little when it comes to "pains of the back, the loins and of the hip joint". Observing that these come on with walking, the good doctor suggests that they are therefore caused by the walking, so you should stop it, thus ushering in immobilization therapy for arthritis, which only well into the latter half of the twentieth century has been conceded to do much more harm than good.

  Hippocrates, unfortunately, also roundly declared that "All diseases are resolved either by the mouth, the bowels, the bladder, or some such other organ. Sweat is a common form of resolution in all these cases." (On Regimen in Acute Diseases) Again, these words were treasured by his successors down the ages and we shall meet something very like them published less than fifty years ago.{mospagebreak title=OA and the Romans}

  The Romans also experienced arthritis: skeletons exhumed from the remains of Herculaneum and Pompeii (destroyed 79CE) show clear signs of early onset of the disease (Sidwell and Jones, 1999). Cato the Elder (234-149BCE) includes in a severely down-to-earth treatise on agriculture a few recipes for what were, presumably, the commonest conditions he had encountered - constipation, urinary problems, and – Ch. 123: Vinum ad isc[h]iacos sic facito. De iunipiro materiem semipedem crassam concidito minutim. Eam infervefacito cum congio vini veteris. Ubi refrixerit, in lagonam confundito et postea id utito cyathum mane ieiunus; proderit. (Make a wine for gout sufferers as follows. Break up finely juniper wood 6 fingers thick. Bring to the boil in 1 congius[7] old wine. When it has cooled, bottle the whole. Afterwards take 1 cyathus[8] of this wine in the morning before eating. This will work.)

  This was an unusually generous recipe for Cato, who mostly preferred to rely on the virtues of cabbage, to excess on occasion, one might think:

  (Ch 157): Verum morbum articularium nulla res tam purgat, quam brassica cruda, si edes concisam et rutam et coriandrum concisam siccam et sirpicium inrasum et brassicam ex aceto oxymeli et sale sparsam. Haec si uteris, omnis articulos poteris experiri. Nullus sumptus est, et si sumptus esset, tamen valetudinis causa experires. Hanc oportet mane ieiunum esse......Et hoc amplius lotium conservato eius qui brassicam essitarit, id calfacito, eo hominem demittito.....Si caput aut cervices dolent, eo lotio caldo lavito, desinent dolere. (Now nothing clears illness of the joints as well as raw cabbage, whether you eat it cut up, with rue and coriander chopped in, dry, with grated sirpicium[9], or as cabbage in honey vinegar and sprinkled with salt. If you use this, you will be able to use all your joints. It costs nothing, and even if it did you should try it for the sake of your health. You should take it in the morning before eating......In addition, store the urine of anyone who habitually eats cabbage; warm it, bathe the person in it......If the head or neck is painful, wash in this urine, heated: they will stop hurting.)

  (afterthought: Cato may have been on to something here, but not for arthritis. Raw cabbage is a very good source of Vitamin C, and if the aching joints were caused by scurvy, as would be very possible at the end of a winter, the cabbage treatment would do a lot of good.)

  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 even worse than the condition, at least to modern eyes.

  Bald's Leechbook dates from about 950 CE. Bald didn't write it; he commissioned scribes to compile it from much earlier Mediterranean and English sources, now lost. He has an interesting cure for "healswærce" (pain in the neck): the lower part of a nettle boiled in ox fat and butter mixed with ox gall in vinegar. Interesting, because "urtication" is still used today as a sort of herbal TNS (transcutaneous nerve stimulation), akin to capsaicin therapy [see below]. Memo: don't try either of these yourself except under medical supervision. Mind you, I much prefer the idea of that to another of his ointments: pigeon's and goat's droppings dried, crushed, and mixed with honey and butter. Shoulder and arm pain are to be treated with betony boiled in ale (drunk) and an ointment made of wenwort (probably Ranunculus acris, which contains a very acrid, skin-blistering juice; photo on right), which was still probably much safer than the recipe for a painful knee: "cnua beolenan & hemlic, beþe mid & lege on." (Grind henbane [active principle: hyoscyamine] and hemlock [active principle: coniine] (both powerful poisons; hemlock photo below left), bathe with it and lay it on". Assuming there was some broken skin, very likely in those days, to permit absorption, it would certainly more than take care of the pain. (Belladonna plasters for rheumaticky aches and arthritic pains are still available via the internet, but no longer in the British National Formulary).

  The Lacnunga, an 11th century collection of Old English recipes, suggests for "liðwyrce" (limb pain) an ointment made of elecampane, radish, wormwood, bishopwort, cropleek (probably a species of Allium), 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.

  The Herbal of Apuleius was translated into Old English from Latin and isn't any the more appetising; it suggests you take six ounces of greatwort (?) and six of goat's grease together with eighteen ounces of oil of cupressus, grind and mix them together and use as an ointment. Alternatively, for "stiðnes on lichoman" (body stiffness) you could try wood dock and old pig's grease and breadcrumbs crushed and made into a poultice. People would certainly know that you were present.{mospagebreak title=Folk Remedies}

  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 to the system as a cure for some disorders, but also in the activities of malign supernatural entities: flying venom (fleogende attor[10]),worms (wyrmas[11], 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 (ylfa gescot) into humans and animals, the shot causing, especially, rheumatism, arthritis and stitch. The existence of tiny prehistoric stone arrowheads 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).

  Pause for a rant here: the treatment of folk remedies by the medical establishment highlights one of the most irritating facets of a discipline that claims to be ruled by scientific thought: their persistence in throwing the baby out with the bathwater. In deriding and dismissing the old herbalists and wise women, medical scientists never seem to have grasped that it is possible for the former to be right for the wrong reasons. Just as Dr Withering gets all the credit for digitalis (extract of foxglove) as an effective treatment for one kind of heart failure (for which it is still used, incidentally, in its synthetic form, digoxin), despite the fact that it had been so used by wise men and women for centuries, so the Reverend Edward Stone's reporting of the febrifuge properties of willow-bark was disregarded by the medical establishment for a hundred years. (The good Rev. confounded willow bark’s action with that of quinine, likewise originally derived from the bark of a tree, hoping that he had found a native equivalent. In his day, ague [malaria] was endemic in marshy areas of Eastern England.)

  Rev. Stone and his predecessors[12] 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 application. “As this tree delights in a moist or wet soil, where agues chiefly abound, the general maxim, that many natural remedies carry their cures along with them, or that their remedies lie not far from their causes, was so very apposite in this particular case, that I could not help applying it....” (Stone, 1763). 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 originally be employed for the wrong reasons; but the fact that it kept on being used might suggest that it did have some efficacy.

  When looking at this early medical advice, it's important to remember also the Doctrine of Humours. This was a theory, going back to Hippocrates at least, formalised by Galen and still surviving unconsciously today in folk remedies. It's similar in essence to Chinese and other eastern medical theory: the body contains certain elements (the humours in this case) that can get out of whack for one reason or another; one comes to dominate over the others; disease is the result of this, and the treatment must consist of restoring balance and harmony to the humours. In Western medicine they were held to be: black bile, yellow bile, phlegm and blood, and each would have the qualities of cold/heat and moist/dry. So plants and, later, post Paracelsus, chemicals with these qualities were the ones to be used to sort things out. We are now drifting well into the realm of abstract philosophical theorising and to hell with what actually was wrong with or helped the patient.

  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 (photo on left)[13] in wine to a concentrate, in which you then boil a red cloth. Then wash yourself with the hot herb tincture 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.

  (A propos sympathetic magic, I can't resist quoting two instances from Frazer's The Golden Bough: if your fingers are stiff, collect some long-legged spiders and roast them, then rub your fingers with the ashes. The suppleness and nimbleness of the spiders will be transferred to your fingers. Again, for a case of gout or rheumatism, rub Spanish pepper into the fingers and toes of the sufferer: the pungency of the pepper will be too much for the gout or rheumatism, which will then depart in haste - a classic case of being right for the wrong reasons: the Spanish pepper (most likely Piper nigrum,) probably provided, like capsaicin [see below], a counter-irritant.)

  Our anonymous medieval scribe has a cure for sciatica also: "Take a sponnefulle of the galle of a rede oxe and ij sponnfull of the wat[er] of Culerage [water pepper] and iiij of his owne water [urine] and as moche comyn [cumin] as half a french note [nut] and as moche sewet [suet] as a small notte and breke and bruse thy cumyn then boyll all thes together tyll they be grewell [gruel]." The patient then warmed his bottom against the fire and the concoction was rubbed in and he was sent to bed in heated sheets. I don't think the heat treatment would do much for the sciatica but it would help the patient to relax and, if he had arthritis and muscle spasm, heat and massage would help those. The contents of the spice cupboard I'm not so sure about; maybe they were local skin irritants.{mospagebreak title=Nicholas Culpeper}

  Nicholas Culpeper (1616-54) was an astrologer-physician (the disciplines were not mutually incompatible then) who wrote a hugely influential Herbal, firmly based in the Doctrines of Signatures and of Humours, and with the astrological qualities of the herbs conveniently specified. By which we learn that All-Heal (aka Self-Heal, Prunella vulgaris; photo on right) is "under the dominion of Mars, hot, biting, and choleric.... helps all joint aches." While also effective against "the bite of mad dogs and venomous beasts", hence the name, I suppose. Oil of chamomile (Anthemis nobilis), which he says "is much used against all hard swellings, pains or aches, shrinking of the sinews, cramps or pains in the joints", is still much prized by herbalists today as an anti-inflammatory. Comfrey (photo left) (Symphytum officinalis), similarly, has been investigated and found to have therapeutic qualities, particularly in wound and skin ulcer healing; Culpeper suggests a poultice of the fresh leaves applied to painful or gouty joints.

  Ground Pine (Ajuga chamæpitys) is, apparently, another martial plant, and is to be prescribed for palsy, gout, sciatica, rheumatism, scurvy, and all pains of the limbs. Palsy (Parkinson’s Disease) and scurvy (Vitamin C deficiency) are presumably in there because both of them can include joint and/or muscle pain in their symptoms. The root of horseradish (Cochlearia armoracia) (Mars again) is also recommended as a poultice for sciatica and joint-ache; I wonder if this would be yet another capsaicin-like counter-irritant [see below]? Raw horseradish certainly is, as is rue (Ruta graveolens) (photo right) (under the sun, and Leo, this time); contact with rue causes extremely painful blistering of the skin, if gathered in sunlight. Tea made from tansy (Tanacetum vulgare) (Venus), a known, and drastic, vermifuge, if it didn't help the sciatica and joint-aches, at least provided an urgent distraction.

  The gardener's foe Ground Elder (Ægopodium podagraria; photo left) (Saturn) is also significantly known as Goutweed; "it heals the gout and sciatica; as also joint-aches, and other cold pains."

  Of course, Culpeper was a professional apothecary. 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 (in Lewer, 1908), is "Sir George Horseyes Green Ointment for Aches proceeding from a Cold Cause for Shrunken 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 for three weeks[14]. Then boil them up again, strain, and add spike lavender oil. Apply to the affected place gently warmed. Well, it might smell nice.

  This recipe illustrates what a pickle medicine had got itself into by the dawning of the nineteenth century. The professionals were increasingly distanced from reality into theories, while the laity were piling Pelion on Ossa in vain attempts to make sure that something worked, even if it was only the application of local heat and massage. Meantime the nineteenth-century arthritis sufferer found less emphasis placed on purely herbal treatments, although the principles of heat and counter-irritant remained basically unchanged (in Anon, 1859): "Rheumatic Plaster. Take one-fourth pound of resin and a like quantity of sulphur; melt by a slow fire, and add one ounce of cayenne pepper and one-fourth of an ounce of camphor gum; stir well until mixed, and temper with neatsfoot oil."

  Those who rejected "chemical drugs", then as now, tended to retreat into a dream of "natural" remedies, like Sir William Withey Gull, Queen Victoria's personal physician (and one-time candidate for the rôle of Jack the Ripper); he wrote Rheumatism Treated by Mint[15] Water, though whether he tried it on his Royal patron I don't know. She, by all accounts, preferred whisky, laudanum and cocaine. (How unlike, how very unlike, the home life of our own dear Queen.) To be fair, the mint water was only part of a comprehensive non-pharmacological therapeutic regimen aimed at preventing the worst sequelae of acute rheumatism; and he seems to have wanted to prove that people would get better, or not, irrespective of drugs: an early placebo trial? (Greenfield, 2004).{mospagebreak title=The Eighteenth Century}

  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 end of Edwardian era at least (Turner, 1967). Hydrotherapy (hot or cold) and medicinal waters had been known since antiquity; certainly since the Ancient Greeks venerated the shrine and sacred spring 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.

  Because bathers float better in a strong salt solution, they can mobilize inflamed joints and muscles gently and safely, freed of much of the strain of weight-bearing. The "brine baths" at Droitwich were four times as salty as the Dead Sea and were much in vogue in the early 19th century.

  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 drenchings 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 (Austen, ed. Chapman, 1985).

  Cold hydrotherapy, reasonably enough, was much less popular with arthritics, although Sir John Floyer of Lichfield (Samuel Johnson's family doctor, incidentally) in the 18th century did build a cold bath for his rheumatic patients, accompanied by the standard bleeding and purging, just to make unpleasantly sure.{mospagebreak title=Homeopathy}

  Homeopathy was also formally founded 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, a 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.

  (Actually it was all based on a misunderstanding of a disease process. Hahnemann had observed that quinine "cured" malaria. He found that when he, not having malaria, took some quinine, he developed, and then recovered from, symptoms which he assumed were the same as those of malaria - they were not, they were his idiosyncratic reactions to the drug, which were alleviated as the drug wore off. Not for another hundred years would people know that the symptoms of malaria are caused by a parasite in the blood, and that quinine kills one stage of the life cycle of this parasite.)

  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 microbiology and germ theory, pre any notion of the endocrine system, the lymphatic system, the immune system....Nevertheless, homeopathic remedies can work. I say that because I have seen them work, in people and animals, just as I have Bach Flower Remedies[16], and I don't know any reason why they should succeed either.

  My personal opinion is that it’s down to the power of placebo (even an animal can sense that you are trying to help it and revel in the attention.) Homeopaths hate it when you say that: they claim that you are fudging the issue by substituting one not-understood process (mind over matter) for another (water memory). Not so: one is substituting one admittedly not-understood (psychological) process, which has been observed in many properly-conducted scientific trials, for another which, alas, when subjected to scientific scrutiny in controlled blind experiments, has repeatedly been shown to be non-existent.

  For arthritis, some of the remedies used in homeopathic doses include Rhus Tox, Poison Ivy (Rhus toxicodendron), Bryonia, White Bryony (Bryonia alba), Ledum, Wild Rosemary (Rhododendron tomentosum, formerly Ledum palustre), Ruta Grav, Rue (Ruta graveolens) and some non-botanical compounds Calc fluor[17] and Causticum[18]. Take at your own risk; they are diluted so far that not one molecule of the active ingredient remains, anyway. Fortunately, as they are all extremely toxic.

  Aspirin is a useful anti-inflammatory, thrombolytic, analgesic, and febrifuge. The chemical basis was first synthesised as salicylic acid in the 1850s, but in that form it was dangerously irritating intestinally and it was not until the 1890s that, as I have said, it became available to the general public. Moreover, it's cheap and available off-prescription everywhere, as far as I know. Unfortunately, and this is a quality it shares with almost all subsequent arthritis treatments, it is also a gastric irritant. Take a lot of it and you will probably not die, but you will have one hell of a bellyache and bleeding, ulcerated gastric mucosa. This is why, if you have to take it regularly, or in high doses, it should always be buffered by enteric coating, food, or at least milk.

  (An interesting sidelight on patient psychology: aspirin has no sedative or hypnotic action whatsoever, but in the first half of the twentieth century, it was very commonly taken as a sleeping-pill. Why? Presumably because, when taken by someone with some kinds of chronic pain, it eased the pain and allowed the person to sleep. So does morphine, but morphine does also have a sedative effect. The popular assumption must have been that aspirin works in the same way: the power of placebo illustrated.){mospagebreak title=Patheogenesis of OA Pain}

  Pathogenesis of OA Pain

  Cartilage itself cannot feel pain: it has neither nerves nor blood vessels. Bone, however, the synovial membrane, and the capsular ligament, have ample supplies of both, so whatever pain is being felt, must come from nocioreceptors in these tissues. There seem to be two types of pain sensation involved: peripheral (at the joint itself) and central (at the spinal or cortical level). Add to that various psychological and social factors (including past experiences) mediating the experience of pain.

  It has been suggested that OA pain could, in fact, be due to local/central sensitization of pain pathways resulting in normal stimuli becoming painful (Dieppe, 2005). Normal joint tissues seem to be pretty insensitive to pain stimulation: they have to be, or ordinary movement would be unbearable for anyone.

  It is also now thought that chronic and acute pain states are quite distinct. At least four different pain states are now recognised: transient (in response to immediate injury), neuroplastic/inflammatory (in response to persistent tissue injury such as OA), neuropathic (nerve injury) and idiopathic (idiosyncratic). It is argued that in OA, substances released from the joint tissues will induce the sensitization of articular pain receptors. There is enhanced pain perception at the site of the damage plus pain and tenderness in undamaged tissues around the site. And neurogenic inflammation can itself contribute to joint damage.

  Analgesia

  Before leaping into the twentieth century, a word about painkillers in general, not just anti-arthritis drugs. Pain is only a symptom that something has gone wrong. If you have acute pain from a discoverable 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 a late symptom, due to irreversible tissue changes and damage, you could, in the days before 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 psycho-pharmacologically (by analgesic, antidepressant, sedative or hypnotic) (c) continually damping down the inflammatory response which is causing the pain.

  For most of history, options (a) and (b) have been the only ones 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) depressants and they both cause habituation. A weaker ancient alternative to opium is lactuarium, extracted from the juice of wild lettuce (Lactuca spp).

  Mandrake (Atropa mandragora) contains atropine, hyoscyamine, and scopolamine and was used by the ancient Egyptians 1400 years BCE; it is one of the Solanaceae (potato family) as is henbane (Hyoscyamus niger). Cannabis (Cannabis sativa) was known to the ancient Chinese as an analgesic but seems to have been used recreationally by everyone else. Hemlock (Conium maculatum), the poison that killed Socrates, was used by the Romans and in medieval times, with other anodynes, in poultices and as "soporific sponges" - a form of analgesic glue-sniffing.

  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 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.

  In the 1950s came a Wonder Drug, the first of all the 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 vitally concern arthritics. They have 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.

  Meanwhile, over-prescribing ("Let's see what other conditions it will cure") and overdosage ("If one milligram works then two milligrams must work better") had done their damage: the loss of bone, the thinning of skin, damaged gastric mucosa, development of iatrogenic[19] hypercortisolism (Cushing’s Syndrome), behavioural changes, notably aggression and delusions. Nowadays, the normal steroid treatment for OA consists of intra-articular injections thus minimizing the systemic effects (Raynauld, 2003).

  When the systemic side-effects of oral steroids became apparent, many alternative painkillers were developed: good old over-the-counter phenacetin (long-since banned), paracetamol; the NSAIDs: mefenamic acid, ibuprofen, indomethacin, naproxen, diclofenac sodium; the opioids: tramadol, pentazocine, fentanyl, 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). Recently we have had scares over COX-2 inhibitors[20] which have been implicated in increased risk of cardiovascular and cerebrovascular disease (see the MHRA site http://www.mhra.gov.uk/index.htm for details.){mospagebreak title=Complementary / Alternative Therapies}

  Complementary/Alternative Therapies

  In the face of this, alternative therapies have burgeoned. Some people swear by acupuncture, not just as a treatment but as a cure. One interesting recent study (Haake, 2007) (which caused quite a row in the journal where it was published) found that any needling, whether fake or “verum acupuncture”, worked better than pharmacological analgesia. Another study (Vas, 2004) involved not just acupuncture but also moxibustion[21] and “auricular therapy”, which apparently involves sticking Vaccaria (soapwort) seeds in the ear. Acupressure can also work, but for a while only; as soon as the pressure is released, back comes the pain.

  People with RA have a list as long as your arm of food they should, and should not, eat. (At the moment, a vegan diet is favourite.) Studies show that fish oils, for example, have a beneficial effect, on both RA and OA, so we all gulp cod-liver-oil until another set of studies casts doubt. Mainly, 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 few years ago that some component[22] of green tea (Camellia sinensis) had found to be useful in preventing/reversing the degeneration of OA. So of course, I pricked up my ears. The truth is rather less dramatic. As David Buttle, one author of the paper (Adcocks, 2002) tried to point out to journalists, 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 toxic in quantity, if you overdid it, as Sheridan Le Fanu’s hero[23] found out.)

  Aromatherapy apparently traces its origins back to Ancient Egypt, specifically the use of spices and essential oils in embalming. Erm, yes, though I can't imagine an allopathic clinician would seek to win confidence for his ars longa by claiming skills and practices honed in the undertaking trade. Anyway, it is a branch of phytotherapy, or herbal medicine. I had not realised that it can be internal as well as external in application. A popular work consulted (Lautié, 1979) boasts an impressive list of essential oils that can be used externally for arthritis (which type? it doesn't distinguish), gout, and rheumatism, from Angelica, via Eucalyptus and Nutmeg, to Thyme. This means, of course, massage with rubbing alcohol or sweet oil; a treatment in itself. Internally, Garlic, Juniper, and Onion are among the oils recommended.

  A recent BMA report on osteopathy and chiropractic[24] 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 (a form of deep foot massage, basically), 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? As a recent BBC2 programme (24 March 2008) pointed out, there is no scientific rationale behind it whatsoever, not in the present state of knowledge anyway. But, 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, TNS and capsaicin therapy all work essentially on the counter-irritant principle. TNS is derived from the "gate theory" of pain transmission. The idea is that the spinal cord can transmit only so much pain information; fill the fibres up with the impulses generated from the TNS machine, and there is no room for the signals from the complaining skeleton. It's a bit of a circular argument: TNS works because the gate theory is correct, and the gate theory is proved to be correct because TNS works. (It does, incidentally, but not for every kind of pain.)

  Similarly, urtication (nettle-stings) and capsaicin (derived from capsicum peppers) are local skin irritants just like Ralgex. Possibly it's the rubbing-in, the massage, which gives as much relief as the counter-irritant. St John's Wort (Hypericum perforatum) oil is another rubifacient with a good reputation. They can all cause local skin allergic reactions. In some people, for example the late actor Jack Warner, bee-sting therapy has worked dramatically; the toxin seems to stimulate the innate anti-inflammatory response just right, and the stiffened, aching joints are released and move freely. Bee-sting (to be precise, honeybee) venom contains formic acid and, its major component, melittin, which is an antimicrobial peptide. Nobody yet knows how exactly it works in this instance.

  (Incidentally, it was hoped that dermal plasters of NSAID and opioid preparations would be just as effective an analgesic as an oral dose while avoiding the gastric irritant effects. Initial results had been encouraging (Mason, 2004); sadly, longer trials have revealed that the situation is by no means clear-cut as to habituation and side-effects.){mospagebreak title=Herbal Remedies}

  Herbal remedies, of course, persist, many of them never having been updated since Hippocrates, either in their materials or in the theory behind them. A sentence such as "constipation is almost always a factor in rheumatic disease, causing toxic overload" and recommending purgatives and diaphoretics[25], would have commended itself to all those ancient practitioners who thought that disease was down to mysterious malignant entities who must be physically expelled - by any orifice available - before curing could take place. I am considerably pro herbalism, but only if it is conducted in a properly scientific manner, accompanied by at least some knowledge of anatomy, physiology and disease processes, not a regurgitation of a couple of millennia's worth of exploded theories born of nothing but ignorance.

  The book I am quoting from - I won't be so cruel as to reference it, because it's only typical of popular, as opposed to scientific publications - cheerfully conflates rheumatism, fibromyalgia, OA and RA as if they were all one and the same, then states "in all forms of rheumatic disease there are two main causes: stress, tension, and personality problems....and a poor, inadequate diet." We-ell, up to a point, Lord Copper. Stress and tension and personality problems generally are certainly factors in autoimmune inflammatory conditions, in that they make them worse, but cause....? Diet, again, can exacerbate these conditions by inadvertently providing allergens or excluding needed nutrients, but cause....?[26] Face it, nobody knows precisely what triggers off such conditions, least of all the authors of popular herbals.

  Willow, of course, is recommended, so are nettles (taken internally, as tea); and soothing rubs of chamomile; so far, so traditional. Other remedies include cowslip, onion, lemons, celery (seed) and seaweeds; more exotic are Devil's Claw (Harpagophytum procumbens) from Africa, which has been properly clinically investigated, mainly in Germany, and Guiacum (Lignum vitae) from the West Indies, which as far as I can discover has not, at least for arthritic conditions. Devil's Claw needs to be treated with care; I don't know how effective it is in treating rheumatism or the arthritises, but it can have a potent effect on insulin metabolism, so diabetics beware. Guiacum, curiously enough, has a long history as a specific for syphilis; there is a form of acute inflammatory arthritis which is secondary to untreated syphilis, so perhaps that is the connection: it doesn't cure that either.

  Serious attention is being paid to several hoary specifics, including ginger (Zingiber officinale), turmeric (Curcuma longa), cat’s claw (Uncaria tomentosa) and others which have a long tradition of anti-inflammatory use in the East. Initial investigations have turned up definite therapeutic possibilities (Ahmed, 2005), hindered as usual by previous slipshod reporting and non-standard preps. Whether any of these will make it to the corner pharmacy remains to be seen.

  Some hope appeared in the 1990s with the development of glucosamine and chondroitin as alternative drug therapies. Both have been investigated thoroughly, but not thoroughly enough for NICE; they're not in the British National Formulary nor freely available on the NHS. So reliable information about them is somewhat limited. They are both substances that occur naturally in the body; glucosamine is an amino sugar and chondroitin a protein. Glucosamine is believed to be essential for cartilage formation and repair, while chondroitin gives cartilage elasticity. So far so good; it seems reasonable to hope that supplements of these might possibly help to repair, and/or prevent, the tissue damage. The patent-medicine form of glucosamine you can buy over the counter is derived mostly from sea creatures such as crabs, lobster and shrimps, and chondroitin from sharks (sharks, a very primitive vertebrate, do not have bones in their bodies, only cartilage).

  Glucosamine sulphate has been extensively studied, and the general conclusion seems to be, that it gives results better than placebo in two respects: pain relief and slowing-down the degenerative process (Reginster, 2007). For chondroitin the picture is considerably less clear (Mazieres, 2007). They both seem to be reasonably free of toxic side-effects at therapeutic doses, although studies of long-term usage have not yet been completed. They do not either prevent or reverse the damage, as far as is currently known. Wouldn't you know it, the commonest reported side-effects of glucosamine are gastro-intestinal; plus ça change.

  Even the medicinal leech (Hirudo medicinalis) has been called out of retirement (Michalsen, 2003). Needless to say, this trial did not involve a placebo, although I would love to have seen them trying to train the leeches to pretend to bite. With only 51 patients involved, statistics don’t mean much, but the authors claim that “function, stiffness and total symptoms remained significant in favour of leech therapy until” the end of the trial (pain didn’t).

  And the eighteenth-century spa philosophy rides again, in a trial of mud-pack compresses (Flusser, 2002). The authors note that for any palliate effect to operate, it has to be natural mud.{mospagebreak title=Copper Bracelets}

  Surely the oddest prophylactic/treatment for rheumatism and arthritis must be the wearing of copper bracelets. Odd, because any effect is almost certainly pure placebo; I say almost, because inevitably there may be things about the role of copper in the human metabolism not yet discovered. The theory is, as I understand it, that traces of copper are absorbed through the skin under the bracelet and are in some way beneficial to the disease. The enzymes cytochrome c oxidase and superoxide dismutase are essential to normal cell function; both contain copper atoms which is why some copper (about 70 mg per average adult, with a daily intake of 1-2 mg) is essential to life, but copper is so ubiquitous in foods of all kinds that deficiency is virtually unknown (Goodman & Gilman, 2005).

  There is a very rare condition, Menke's disease, where the gene responsible for copper use is lacking, but it is incurable and untreatable, and leads to death in early infancy. In any case, copper's function is principally within the liver, muscles, and brain; it is not, as far as is known, more than marginally necessary for the normal function of joints, bones and collagen. Deficiency, induced artificially in clinical trials, produced raised cholesterol, hypertension, anaemia and lethargy, not joint disorders.

  Moreover, copper itself, in excess, is a poison. Wilson's disease is a genetic disorder resulting in the inability to utilise copper properly, so that it builds up in and damages the brain; it is treatable. Workers on fruit farms and vineyards used to be exposed to high levels of copper sulphate from sprays (Bordeaux Mixture) and suffered accordingly. They would be liable to inhale the sprays and absorb some through the eyes and mucous membranes. But it is, after all, unlikely that the wearer of a copper bracelet would absorb any of the copper at all, intact skin being a very efficient barrier.

  The most likely derivation of copper bracelet therapy goes back to magic and the very ancient, still continued, practice of wearing of protective amulets and talismans. Nonetheless, if you think it is doing you good, then it probably is, psychologically at least, so why not?

  There has even been a little study (194 patients) published on the efficacy of magnetic bracelets in arthritis (Harlow, 2004), which concluded that wearing them does have a “beneficial effect”, as far as perception of pain is concerned, placebo effect or not; proof, if proof were necessary, that just about anything will work on OA – to start with.

  And finally, music really doth have charms to soothe the savage joints, according to recent nursing studies (McCaffrey, 2005; Siedliecki, 2006).

  Mobilization Therapy

  Medical opinions on this have been completely reversed within the last generation. Traditional wisdom had it that people with painful joints and muscles, whatever the reason, should be sent to bed for the duration, and possibly even splinted. This naturally had the result of totally coking up the articular system, and deformity, worse pain, and worse immobility were the results. Two remarkable women, Sister Kenny (polio nurse specialist) and Barbara Ansell (paediatric rheumatologist specialising in juvenile chronic arthritis) independently noticed this and each in her own field campaigned vigorously for early mobilization, physio-and hydro-therapy. It only took about 100 years for mainstream medical opinion to catch up. Today, non-weight-bearing exercises such as swimming and cycling are positively recommended as therapy.{mospagebreak title=Surgery / Future Therapies}

  Surgery

  I have deliberately left surgical intervention till last. This is, after all, in historical terms, a very recent option. Emergency orthopedic surgery, for accidental fractures and battle injuries, is probably as old as mankind, but surgery for arthritis comes under the heading of elective surgery. Anaesthetics, blood transfusions, asepsis and antibiotics were needed to render surgery safe, especially the latter two, as bone infections used to be killers and are still very difficult to treat even today. Also needed was the development of modern hypoallergenic lightweight metals, and plastics and glues.

  The first elective orthopedic surgery was done, as early as the 18th century, on cases of bone and joint deformity due to rickets, polio, or TB. The first arthritic-specific prosthesis I can find was made of ivory, for the femoral head, and was developed by Ernest William Hey Groves (1872-1944) in the nineteenth century. Rejection must have been a problem in the days before immunosuppressive drugs. Consistently successful modern total hip replacements (hip arthroplasty) date no further back than the 1960s, when Sir John Charnley[27] developed prostheses of metal and high density polyethylene, attached to the existing bone with methylmethacrylate cement. Since then, uncemented arthroplastic techniques for the hip have appeared, and, in the 1970s, total knee replacements using similar methods. Nowadays, shoulders, elbows, wrists, finger-joints and ankles can also be replaced.

  It is perhaps not always appreciated, though, that these replacements have a limited life. Anyone requiring them early in life is liable to be readmitted to hospital fifteen or twenty years later, suffering, quite simply, from metal fatigue.

  Arthroplastic surgery also includes lavage and debridement (“washing out” the joint capsule of debris from torn and damaged cartilage and trimming back same); changes in bone alignment (osteotomy) to relieve stress, and surgical fusion of bones (arthrodesis) which these days usually is a last resort and confined to the spine, for stabilization of the joint (it was a neck operation undergone by Christopher Reeve and other high-SCI victims.)

  Future therapies

  · Chondroprotective agents

  · autologous chondrocyte transplantation

  · metalloproteinase inhibitors

  · cytokine inhibitors

  · tissue engineering; soft tissue grafts; autologous osteochondral transfer

  · growth factors

  · newer cartilage substitutes

  · mesenchymal stem cell therapy

  · genetic engineering

  · more sophisticated understanding of placebos such as massage therapies, for pain control. Normal 0 false false false EN-GB X-NONE X-NONE /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-style-parent:""; font-size:11.0pt; font-family:"Calibri","sans-serif"; mso-fareast-font-family:"Times New Roman";}

  ...and just as this paper was being finalized, a press release from the UKNSCN announced that human adult bone stem cells may be cultured to produce the chondrocytes which make up articular cartilage, thus opening a practicable way forward for the repair of OA damage without engaging in the ethical minefield of embryonic stem cell research.

  One change there may yet be, and it's not medicinal. Ageism is a powerful factor in deciding which medicines get developed, which treatments get funded for research. Up until now, the diseases of age have got a very poor slice of this particular cake, and osteo-arthritis, traditionally, has been seen as a disease of the elderly. So who cares if an eighty-year-old can't get out of bed in the morning? He's not an Economic Unit.

  Well, first, it is becoming increasingly clear that OA is not exclusively a disease of the old. Second, even eighty-plus-year-olds may be needed in the workplace if current trends continue. There is now a rapidly-growing body of research into these neglected areas, so OA and other "diseases of ageing" may well achieve an economic and political importance at last.

  Footnotes

  ---

  
  [1] chondrocytes are the cells which produce and maintain cartilage.

  [2] Metalloproteinases are protolytic enzymes (enzymes that can break down proteins).

  [3] Cytokines are (mostly) proteins which are released in inflammatory, immunological or infectious conditions

  [4] Borrelia spp.

  [5] inflammation of the sciatic nerve; neuropathic pain is very difficult to treat even now.

  [6] According to Wikipedia, natron is “a naturally occurring mixture of sodium carbonate decahydrate ((Na2CO3·10 H2O, a naturally occurring form of soda ash) and about 17% sodium bicarbonate along with small quantities of household salt (halite, sodium chloride) and sodium sulfate.”

  [7] About 3¼ litres

  [8] About 4½cl.

  [9] What this was exactly is now lost; quite possibly asafoetida.

  [10] which seems, in some sense, to be a vague conception of infection/contagion

  [11] for example, they devoutly believed that toothache was caused by worms eating the teeth.

  [12] And successors; would you believe it, there are still people who believe in this, according to their websites.

  [13] Thyme’s active ingredient is thymol, a phenol which is used as a stabilizer in pharmaceutical preparations. It has been used for its antiseptic, antibacterial, and antifungal actions, and was formerly used as a vermifuge. It has no analgesic action as far as is known.

  [14] This would ensure that it was held in a mild, even warmth, assisting any fermentation or bacterial activity.

  [15] The active ingredient of mint (Mentha spp) is menthol, which does have mild local anaesthetic and counter-irritant properties. Gull, however, required his patients to drink it.

  [16] Bach Flower Remedies are a variant on homeopathy: a cold water infusion is made of flower petals which is then strained and alcohol (originally brandy; I don’t know if it still is) added. Even if there is any active ingredient in the flowers, it is so diluted that it is extremely unlikely that any of it makes its way into the end product.

  [17] calcium fluoride (CaF₂), fluorite, fluorspar; extremely insoluble and therefore, although toxic, relatively harmless to humans because almost none can be absorbed.

  [18] a mixture of burnt lime (calcium oxide, CaO) and potassium hydrogen sulphate (KHSO₄); extremely caustic.

  [19] literally: caused by the physician

  [20] COX-2 inhibitors are drugs which selectively block the COX-2 enzyme. Blocking this enzyme impedes the production of the prostaglandins that cause the pain and swelling of inflammatory processes.

  [21] aka blistering, another ancient and medieval remedy.

  [22] in fact several polyphenols have been isolated and investigated, of which EGCG (epigallocatchin gallate) seems the most hopeful.

  [23] In the novella “Green Tea” (1869).

  [24] Chiropractic is based on the idea that vertebral misalignment and/or spinal dysfunction can react with the nervous system and result in illnesses.

  [25] substances which promote sweating.

  [26] as previously mentioned, scurvy (which is a deficiency disease) was once considered to be an arthritic condition; it is not. The pathology of tissue degeneration in scurvy is completely different.

  [27] Charnley belonged to the Old Heroic School of surgeons; investigating the role of the periosteum in bone healing, he had himself operated on and gave himself osteomyelitis as a result; not deterred, he later injected himself with polytetrafluoroethylene (PTFE), which he wanted to use as an artificial cartilage, to test its toxicity. “PTFE proved unsuitable” he remarked with some restraint of the consequences (Gomez, 2005).

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  References
  History:
  (Oetzi and his tattoos):

  Murphy, W.A. et al (2003): ‘The Iceman: discovery and imaging’ Radiology 226, pp. 614-629 online version at

  http://radiology.rsnajnls.org/cgi/content/full/226/3/614 with x-ray images and photographs

  Dorfer, L. et al (1999): ‘A medical report from the Stone Age?’ The Lancet 1354 (Sept 18), p.1023-5

  Nutton, V. (2005): Ancient Medicine, London: Routledge

  Greenfield, M.L. (2004): ‘Of plagues, blights, and bloodletting: historical highlights of the randomized controlled trial’

  http://www.socra.org/pdf/200402_Plagues.pdf.

  Edwin Smith papyrus translation:

  http://www.neurosurgery.org/cybermuseum/pre20th/epapyrus.html

  Ebers papyrus translation:

  http://www.macalester.edu/~cuffel/ebers.htm

  Hippocrates texts in translation:

  http://ancienthistory.about.com/library/bl/bl_text_hippocrates.htm
  Roman problems:

  Jones, P., Sidwell, K. (eds) (1997): The World of Rome, Cambridge: Cambridge University Press

  Cato the Elder: On Agriculture

  English translation at:

  http://www.soilandhealth.org/01aglibrary/010121cato/catofarmtext.htm

  Stone, E. (1763): ‘An Account of the Succeſs of the Bark of the Willow in the Cure of Agues’, Philosophical Transactions of the Royal Society of London (1683-1775) 53, pp. 195-200

  http://www.rsl.ox.ac.uk/ilej/ will get to the Bodleian collection of early journals, including the Philosophical Transactions of the Royal Society of London

  brief article on William Withering and digitalis:

  http://www.csdl.tamu.edu/FLORA/Wilson/481/medbot/bot2.htm

  Culpeper's Herbal e-text:

  http://www.bibliomania.com/

  a nineteenth-century memoir of Sir William Gull reproduced here:

  http://www.casebook.org/ripper_media/rps.gull.html

  Frazer, Sir J. (1993): The Golden Bough, London: Wordsworth Editions Ltd (abridged edition)

  Austen, J. (1985): Selected Letters 1796-1817, Oxford: OUP (edited by R.W. Chapman)

  On spas and hydrotherapy:

  Turner, E.S. (1967): Taking the Cure, London: Michael Joseph

  Hartley, D.(1964): Water in England, London: MacDonald

  Pollington, S. (2003): Leechcraft: Early English Charms, Plantlore and Healing, Norfolk: Anglo-Saxon Books. Contains original texts and translations of Bald, Apuleius, and the Lacnunga.

  Henry VII MS (Pepys 1047) reproduced in:

  Godgett, H.A.(1972): Stere Hit Well, Adelaide: Mary Martin Books

  18^th century receipt reproduced in:

  Lewer, H.W. (ed.) (1908): A Book of Simples, London: Sampson Low

  19^th R_x, one of many found in:

  Anon (1859): A Dictionary of Daily Wants, London, Houlston & Wright

  On homeopathy:

  http://en.wikipedia.org/wiki/Samuel_Hahnemann
  http://www.skylarkbooks.co.uk/Hahnemann_Biography.htm
  http://www.homeopathyhome.com/reference/organon/organon.html e-text of The Organon, English version

  Modern allopathic treatments:

  Dieppe, P.A. and Lohmander, I.S.(2005): ‘Pathogenesis and management of pain in osteoarthritis’, The Lancet 365, pp. 965-73

  Goodman & Gilman (2005): The Pharmacological Basis of Therapeutics, London: McGraw-Hill Medical 11th ed (edited by Laurence Bronton, John Lazo & Keith Parker)

  Kidd, B.L. et al (2007): ‘Arthritis and pain. Current approaches in the treatment of arthritic pain’, Arthritis Research and Therapy 9 (3) pp. 214-22

  Le Loët, X. et al (2005): ‘Transdermal fentanyl for the treatment of pain caused by osteoarthritis of the knee or hip: an open, multicentre study’, BMC Muscoskeletal Disorders 6

  http://www.biomedcentral.com/1471-2474/6/31

  Mason, L. et al (2004): ‘Topical NSAIDs for chronic muscoskeletal pain: systematic review and meta-analysis’, BMC Muscoskeletal Disorders Aug 19, 5:28

  www.biomedcentral.com/bmcmusculoskeletdisord/

  Raynauld, J.P. et al (2003): Safety and efficacy of long-term intrarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial’, Arthritis and Rheumatism 48 (2), pp. 370-7

  http://en.wikipedia.org/wiki/Cortisol on hydrocortisone

  Rubin, B.M. (2005): Management of osteoarthritic knee pain’, The Journal of the American Osteopathic Association 105 (Suppl. 4) pp.23-28

  Problems with COX-2 inhibitors:

  http://news.bbc.co.uk/1/hi/health/5040294.stm

  Alternative Therapies: General:

  Ahmed, S. et al (2005): ‘Biological basis for the use of botanicals in osteoarthritis and rheumatoid arthritis: a review’, Evidence-Based Complementary and Alternative Medicine 2 (3), pp.301-8

  BMA comment on alternative therapies 2003:

  http://www.bma.org.uk/ap.nsf/Content/publicpetitioncam

  Preamble to House of Lords Report on complementary therapies:

  http://www.publications.parliament.uk/pa/ld199900/ldselect/ldsctech/123/12303.htm

  Gagnier, J.J. et al (2006): ‘Herbal medicine for low back pain’, Cochrane Database of Systematic Reviews, Issue 2, Art. No. CD004504

  Doctrine of signatures, modern version:

  http://articlesofhealth.blogspot.com/2008/01/law-of-similars.html

  Green tea:

  Adcocks, C. et al (2002): ‘Catechins from green tea (Camilla sinensis) inhibit bovine and human cartilage proteoglycan and Type II collagen degradation in vitro’, Journal of Nutrition 132, pp.341-346

  BBC report on green tea:

  http://news.bbc.co.uk/1/hi/health/2756635.stm

  Haqqi, T.M. et al (1999): ‘Prevention of collagen-induced arthritis in mice by a polyphenolic fraction from green tea’, Proceedings of the National Academy of Sciences of the United States of America 96 (8), pp. 4524-29

  Glucosamine and Chondroitin:

  http://en.wikipedia.org/wiki/Glucosamine
  http://en.wikipedia.org/wiki/Chondroitin_sulfate

  Mazières, B. et al (2007): ‘Effect of chondroitin sulphate in symptomatic knee osteoarthritis: a multicentre, randomised, double-blind, placebo-controlled study’, Annals of the Rheumatic Diseases 66, pp. 639-645

  Reginster, J.Y. et al (2007): ‘Current role of glucosamine in the treatment of osteo-arthritis’, Rheumatology 46 (5) pp.731-5

  Devil’s Claw:

  http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-devilsclaw.html

  Wegener, T., Lüple, N-P. (2003): ‘Treatment of patients with arthrosis of hip or knee with an aqueous extract of Devil’s Claw (Harpagophytum procumbens DC.)’, Phytotherapy Research 17 (10) pp. 1165-72

  a current clinical trial of Devil's Claw:

  http://www.controlled-trials.com/ISRCTN57843703
  http://en.wikipedia.org/wiki/Guaiacum

  (No reports of any clinical trials in arthritis therapy discovered.)

  And the others:

  Dolora, P. et al (2000): ‘Local anaesthetic, antibacterial and antifungal properties of sesquiterpenes from myrrh’, Planta Medica 66 (4), pp. 356-8

  Harlow, T. et al (2004): ‘Randomised controlled trial of magnetic bracelets for relieving pain in osteoarthritis of the hip and knee’, British Medical Journal 329 (18-25 December), pp. 1450-54

  Lautié, R. and Passebecq, A, (1979): Aromatherapy: The Use of Plant Essences in Healing, Wellingborough: Thorsons Publishers

  McCaffrey, Ruth and Freeman, Edward: "Effect of music on chronic osteoarthritis pain in older people" Journal of Advanced Nursing 44 (5), 2003, p. 517-524

  Michaelsen, A. et al (2003): ‘Effectiveness of leech therapy in osteoarthritis of the knee’, Drugs 139 (9), pp.724-30

  Siedliecki, S.L. and Good, M. (2006): ‘Effect of music on power, pain, depression and disability’, Journal of Advanced Nursing 54 (5) pp. 553-62

  Vas, J. et al (2004): ‘Acupuncture and moxibustion as an adjunctive treatment for osteoarthritis of the knee – a large case series’, Acupuncture in Medicine 2004 , 22 (1), pp. 23-8

  http://www.acupunctureinmedicine.org.uk

  BBC report on vegan diet and RA:

  http://news.bbc.co.uk/1/hi/health/7301188.stm

  BBC report on fish oils and RA:

  http://news.bbc.co.uk/1/hi/health/7307298.stm
  Surgery:

  Obituary of E.W.H. Groves in The Journal of Bone and Joint Surgery 1945, 27, 340-342

  http://rheumatology.oxfordjournals.org/cgi/reprint/41/7/824.pdf Obituary and account of Sir John Charnley

  Gomez, P.F., J.A. Morcuende (2005): ‘A historical and economic perspective on Sir John Charnley, Chas F. Thackray Limited, and the early arthroplasty industry’ Iowa Orthopedic Journal, 25 p.30-37 , available via http://www.pubmedcentral.nih.gov/

  In the Future:

  Ulrich-Vinther, M. et al (2003): ‘Articular cartilage biology’ Journal of the American Academy of Orthopedic Surgeons 11 (6) pp. 421-30

  Garnero, P. (2003): ‘Osteoarthritis: biological markers for the future?’ Joint Bone Spine 69 (6), pp.525-30

  New stem cell research preliminary report:

  http://www.uknscn.org/pressreleases/2008/080411_stem_cells_arthritis.html

  Picture credits:

  Unless otherwise stated, public domain courtesy of Wikipedia

  M0019124 Credit: Wellcome Library, London

  Hand deformed by "rheumatoid" or osteo-arthritis. Taken in the early days of radiography.

  X-ray circa 1897

  From: The Rontgen Rays in Medical Work, 4th edition.

  By: David Walsh

  Published: Bailliere, Tindall & Cox London 1907

  Page 134

  Collection: General Collections

  Library reference no.: Slide number 5894

  ‘The Pump Room at Bath’ old print of a picture by Rowlandson, 1798

  Drawing of flax, diagram of synovial joint, photos of hemlock, all-heal, comfrey, rue, tansy, ground-elder, mint, ranunculus, nettle, devil’s claw, guiacum and thyme: author

  Bath chair, Malvern/Vichy high douche: illustrations in old magazines