Personal experience with neostigmine therapy in rheumatoid arthritis.

Within the group of the chronic rheumatic diseases, rheumatoid arthritis and rheumatoid spondylitis undoubtedly constitute the most important syndromes from the medical standpoint, not only because of their symptomatology and evolution, but also because their aetiological agents are unknown and because they are, therefore, a difficult and complex therapeutic problem. No wonder, therefore, there is nowadays such a multiplicity of treatments, which vary according to the criteria and experience of each physician. Clinicians have been working hard to find a therapeutic element which could really be relied upon in such affections, since researches into the aetiology are still yielding entirely negative results. Trommer and Cohen (1944), for instance, decided to experimiet with neostigmine methylsulphate in a group of patients with various rheumatic affections, basing their decision on the fact that, from the point of view of muscle spasm and atrophy, there is a certain correlation between rheumatoid arthritis and anterior poliomyelitis, and also on the fact that in subacute and chronic poliomyelitis Kabat and Knapp (1943) reported encouraging results with the use of neostigmine, a drug that proved very effic.'ent in the treatment of postoperative intestinal atony and of myasthenia gravis. In a preliminary paper these authors report the results registered in 19 patients, duly selected beforehand, in whom deformity, decrease of movement, and disability were present in a marked form, but with a minimum of demonstrable anatomical lesions. Thirteen of these patients, some of them with rheumatoid arthritis, responded favourably to the neostigmine therapy (subcutaneous injections, either daily, or every two or three to six days, according to the type of case). In 3 cases of rheumatoid arthritis with marked functional disability and invalidism the improvement led to functional recovery; and 2 -of them, who had been confined to their' beds for some time, were able to get up. In the 6 remaining patients, results were insignificant or completely negative. Trommer and Cohen state in their conclusions that neostigmine is the most efficient drug for muscular spasm in rheumatoid arthritis. Later, Kabat (1944) used neostigmine in 53 selected patients with various affections (hemiplegia, facial and cerebral paralysis, subacromial bursitis, and rheumatoid arthritis) complicated by chronic neuromuscular dysfunction, and in wlhom muscle pain, spasm, contracture, or partial paralysis were the main factors in the functional disability (cases in which the disability was devoid of an organic substratum). This group included 6 cases with chronic rheumatoid arthritis and 3 others with rheumatoid spondylitis, whose rheumatic complaints were of many years' standing, and who suffered also from severe disability. There were also 2 cases of rheumatoid arthritis in an acute stage. The first 9 patients (chronic cases) improved to some degree with the treatment, and Kabat noted a relief of pain, an improvement of motion, and an increase of the active muscular strength in the-cases in which there was spasm, hypertony, or muscle pain. In the 2 cases in the acute stage the results were negative, so that the author considers the use of neostigmine in cases of rheumatoid arthritis with active inflammatory process to be contraindicated. Kabat states in his conclusions that the results are encouraging enough to warrant further. investigation. It was due to the results of Trommer and Cohen and of Kabat that we decided to experiment with neostigmine in a group of our own patients.