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It makes the change from no failure in allegiance to homoeopathy. "It has been the aim," the editors write, "of this journal in the past, and will continue to be in the future, to give that prominence to the law of similars which its importance demands." But "it seeks to occupy a place in the ranks of journalism in which it is free to discuss the great questions pertaining to every department of medicine with candour and courtesy. There will be no change in the policy of our journal; as a matter of honesty and good taste we prefer a name which will enable us to look to the vastness of the whole of medical science rather than to a single law, however important."
April.—Dr. Delavan communicates a case of regressive infantile paralysis cured by Gelsemiurn and Calcarea carb. (both 3x), with occasional galvanic stimulation. The following is so practical that we give it entire:
Treatment of Ulcers. By A. M. Eastman, M.D., House Surgeon.
There is probably not a hospital in the United States where a better clinic of ulcers may at all times be seen than here. We will not encumber this article by an extended table of statistics. Suffice it to say, that during the year 1880, there were 617 cases treated, which may be said to be about the average number per annum. From the fact that treatment is not always followed by brilliant results, and many times, to say the least, is tedious, and from the fact that in many cases the ulcerative process is so extensive as to render ligation or amputation necessary, we will endeavour to give in a limited space a digest of our most approved methods of treatment.
|. All surgeons agree that ulcers may be either constitutional or local. Of the constitutional, the causes may be traced to some well known disease, such as syphilis, scurvy, metallic poison, &c„ which have run a regular course, leaving a dyscrasia; or, the disease itself may be actively present, such as paralysis, phthisis, or Bright's.
Here the question might come in whether ulcers should always be healed. My observations indicate that in the two latter diseases, the nearer you approach healing the ulcer or diminishing the discharges by topical means the more rapidly does the disease become fatal. Other constitutional causes may be intemperance, or an impoverished condition of the system from deficient nourishment. These causes should be primarily considered in treatment. In all ulcerations the objects to be accomplished are to prevent extension or the formation of slough, to produce a deposit of plastic matter and healthy pus, and to repair by granulation and cicatrisation.
From these stages and their complications there have been based classifications which we will endeavour to avoid, only so far as it concerns treatment. More is to be expected from the indicated remedy than from local applications, though combining the two produces the happiest results.
Many cases have been cured by the internal remedy, water dressings alone being used.
Concerning remedies we will refer the reader to the works of Drs. Helmuth and Lilienthal for indications.
Those principally used have been Silicea, which stands foremost for almost any class of ulcer, and has cured them without any other remedy.
Under Hepar, unhealthy discharges have been corrected and decreased.
Under Arsenic, the burning pains have disappeared, extensive sloughs removed, foul discharges corrected, healthy granulations induced, and the patient built up.
Under Carlo veg., the bluish tinge removed, foul discharge changed to healthy pus.
Under Asafoetida, the intense night pains disappeared in ulcers over the shins, and the healing process forwarded.
Under Lachesis, the sensitiveness has been removed. Under Graphites, unhealthy granulation disappeared. Under Secale sloughs have been removed. Under Sepia, where there were uterine complications, ulcers were cured.
Under Apis, the acute inflammation from about the ulcer has disappeared.
Under Argentum nitricum, one very indolent ulcer, granulations dark red, scattered over which were grey spots, was entirely cured.
The Kalis have been of use. The mineral acids, too, have, in many cases given satisfaction.
The Iodide of Arsenic, in many so-called irritable ulcers, where a syphilitic taint could be traced, has been of great service. There are three remedies we desire to speak especially of.
First: Apium Oraveolens (celery) on which several patients were placed. It seemed to stop a too profuse discharge from the granulations, and cicatrisation would follow. However, in one patient, a young man, whose ulcer was doing splendidly, shortly after taking the Apium it commenced to break down, and an extensive gangrenous slough formed. A symptom which nearly all of the Apium patients had, was an intense constriction over the sternum—in some eases this was accompanied by a drawing feeling extending through to the back, especially on lying down.
The second remedy is Potassium Iodide, and its effects on ulcers of syphilitic origin. After the. mercurials, Hepar and Nitric acid, had failed, Potassium Iodide healed them up quickly. At first from ten to fifteen grains were given per diem with splendid results. Afterwards the potentised drug was prescribed. In three extensive cases, all ulcerations below the knee, all similar in appearance, having numerous ulcerated holes, surrounding tissues blue, pus thin and offensive, in short, the leg having a honeycombed appearance, all healed up under Potassium Iodide 200. Two of them had Carbolic acid 1 to 100 locally, the other water dressings. Under Potassium Iodide, & very deep ulcer below the malleolus of the tibia was cured.
The third remedy is Ferri et Potassi Tartras, which was given where extensive sloughs had formed, with good results.
In every case it has been the endeavour to obtain the totality of symptoms.
Concerning local treatment; position and rest are the two great factors in nearly all cases. However, these seem to have disadvantages. It has been noticed that ulcers on the legs healed by keeping the patient in bed in a horizontal position, soon break down when they begin to walk about, whereas, those healed out of bed break down less easily. On the other hand they healed much quicker in bed than out.
Of the special varieties of ulcers, we will speak first of the sloughing, which is too well known to need description. Some of these have been very extensive, requiring amputation of limbs. Various local measures have been resorted to, such as Carbolic acid, Nitric acid, charcoal poultices, &c. Poultices will, in many
VOL. XLI, NO. CLXHI. JANUARY, 1883. P
cases, remove the slough, but if kept on too long they soften the adjoining tissue and another slough forms, when hsemorrhage may result. The application par excellence is a saturated solution of Permanganate of potash. This deodorises the horrible stench and soon stops the sloughing. A case in point was a man admitted to the hospital covered with vermin; his left leg from the knee to a few inches above the ankle, extending over the entire anterior surface, also involving a portion of the calf, was composed of an immense slough. Radiating in different directions from the ulcer were sinuses filled with maggots. The visiting surgeon pronounced amputation necessary and the day of operation was appointed. The patient was in a very low condition, unconscious a part of the time, stertorous breathing, involuntary stool and urine. The remedy given was Opium 3 and locally Permanganate of potash. Under this treatment the slough cleaned off and granulations started; soon the patient's condition was much improved; the remedy was changed to Silicea 30 and the permanganate wash considerably diluted. The patient is now nearly cured.
Next we will speak of that class of ulcers which have become somewhat excavated and there has been a plastic matter thrown out; then, instead of granulating and cicatrising, the plastic matter forms a dirty white coating, which becomes tough and firmly adherent to its base. The edges are elevated, the discharge thin, and the ulcer becomes a receptacle for dirt. They may remain in this condition for months or years. First, we clean off the dirt with a flaxseed poultice, which also softens and relaxes the tissues, then to displace the plastic matter several applications have been used, Nitric acid, Nitrate of silver, the knife, Ac., but the best application seems to be Zinc oxide 1 part to 16 parts of simple cerate, which does the work effectually. One case, in an old lady, proved to be very obstinate. The ulcer was of several years' standing and for many months the plastic matter resisted treatment. The ulcer extended nearly around the leg and dipped deeply. To this case irrigation was applied with the effect of not only cleaning the ulcer, but forming healthy granulations and finally cicatrising it. Here let me say that irrigation stands at the head in the treatment of ulcers. It seems to form firm granulations, and the cicatrix under the treatment appears to be superior in quality. However, in one case, where the granulations were purplish, irrigation failed to benefit in the least after two months of the treatment. The method of applying irrigation is to have a receptacle for water a few feet above and at the side of the bed. Extending from this and acting as a syphon should be a piece of rubber tubing, at the lower end of which is inserted a glass tube drawn nearly to a point. Through this the water runs slowly, falling directly on the ulcerated surface, when it is caught beneath by a rubber blanket and directed downward into a second receptacle at the Bide of the bed. This should be applied from four to six hours a day. After the base of the ulcer has been cleaned by one of the above methods, granulations should be induced. This is assisted by Calendula or balsam of Peru (1 to 8 of simple cerate), the balsam being the best in the majority of cases; and this application cannot be too highly spoken of, for its virtues lie not only in inducing granulations, but when they have become flabby, unhealthy, and dark coloured it brings back the desired rosy hue. It has also many times removed the severest pain from ulcerated surfaces. Of the unhealthy granulations at the base of ulcers, we find many varieties as to appearance, and they must all be stimulated. A cabbage leaf has been found to do this in some cases, and now we are trying macerated seaweed. Both of these cause much pain. Another application in similar cases, and especially if there is much foul discharge and the ulcer is deep, is the earth treatment. Fill the ulcer with dry earth and apply adhesive plaster to retain. Similar to the earth is dry charcoal, applied in the same manner. They absorb offensive discharges and induce healthy granulations. The dressing should be changed every twenty-four hours. In ulcers not so deep, Carbolic acid 1 to 40 acts nicely. Afterwards apply Carbolic cerate. Dr. Helmuth's Mercurius dulcis lx acted well in these cases, so also has the Mercurius precipitatus ruber, though the latter often leaves a dry cracked base. In one case where this was used a severe salivation followed, which amounted to three or four quarts per day, at the same time the ulcer became gangrenous. Hepar and Nitric acid internally did little good, but Jaborandi tincture internally, and Permanganate of potash locally, cured the salivation, cleaned the ulcer, and started healthy granulations.