December 2009 | Vol 6 | Issue12

December 2009 | Volume 6 | Issue 12



Cure
 
A case of Diabetic Ulcer
 


 


Dr.Winston Vargheese, DHMS
Lissy Homoeo Clinic,
6-78 Fletcher Compound
Main Road, Martandam
Tamil Nadu - 629165
Email: drwinston@rediffmail.com


    Introduction:

       Dr.Winston Vargheese, Lecturer in Sarada Krishna Homoeopathy Medical College, Kulasekaram is a leading academician and research scholar. His contributions reflected to the community as scientific papers in seminars and articles in journals. He has organized many seminars and known for excellence in the field.

       A 67 years old male presented with painful ulcer in the left foot since 3 months. Pain aggravated in night. He has also got numbness of the lower extremities especially at night. This gets worsened while walking and lying on sides.

    History of presenting complaints
       Patient is known diabetic since 3 yrs. Three months before he got injured on left little toe and took some herbal external application, but his condition worsened and went to allopathic hospital near by to his house where the toe was amputated. Then the patient developed gangrene over the amputated site and referred to Chennai hospital where it was diagnosed as vascular obstruction and advised to undergo vascular surgery which requires nearly eight hours of anaesthesia.

    Past illness
       13years of age developed chicken pox
       32 years of age had fracture of leg
       64 years of age operated for cataract

    Family History
       Brother and Mother Diabetic
       Brother and Father Hypertensive
       Brother Insane
       Brother Bronchial asthma

    Personal History
       Non vegetarian
       Smoking 35- 40 cigarettes per day
       Consumes alcohol every day but since two months stopped

    Physical Generals
       Appetite- diminished
       Thirst- increased for cold water
       Sleep- disturbed due to pain
       Stool- regular
       Urine- increased frequency to pass < night
       Sweat- increased over head and chest
       Desires -cold food and drinks, sweets and alcohol

    Thermal State
       Desires fanning, aversion to covering and prefers winter season and cold water bathing

    Physical Examination
       Ulcer 13cm x12 cm, Floor with slough and gangrenous matter, base of Meta tarsal bone.

    Arterial Doppler Study
       Done on 25-01-08 of lower limb reveal that severe atherosclerotic peripheral vascular occlusive disease (diffuse irregular, intimal thickening, fibro fatty plaques, calcified plaques, focal arterial wall calcification, atherosclerotic changes) involving the entire left lower limb arterial system.
    Entire left superficial femoral artery shows long segmental narrowing with irregular intimal thickening with luminal thrombus formation causing near total (90-98%) arterial occlusion with absence of spontaneous flow

    Left deep femoral artery and geniculate arteries show diversion of flow causing little collateral flow around the knee joint.

    Distal arteries (left popliteal, proximal anterior tibial and peroneal arteries) show compromised high diastolic continuous low velocity biphasic flow.

    MR Angio Report done on 28-01-08

    Technique: Post contrast study

    3D flash coronal plane

    Conclusion
    1. Ascending arch and thoracic abdominal aorta appear normal except for mild atheromatous changes
    2. Diffuse disease of Osteo-proximal portion of Coeliac trunk, SMA, IMA and renal arteries seen
    3. Aortic bifurcation, both sides common iliac, internal iliac, and external iliac appear normal.

    Right Lower Limb
       Common femoral arteries appear normal. Complete occlusion of superficial femoral artery seen immediately after profunda femoris with distal flow formed by muscular and profunda femoris collaterals. Length of occluded segment measuring 20cm.
    Anterior tibial artery appears normal. Tibio peroneal trunk and peroneal artery show mild diffuse disease. Significant diffuse disease of posterior tibial artery seen with distal flow formed by collaterals.

    Left Lower Limb
       Common femoral artery appears normal. Complete occlusion of superficial femoral artery seen after profunda femoris. Length of the occluded segment measuring 30 cm.Distal flows formed by profunda femoral and muscular collaterals. Significant disease of profunda femoris artery seen. Popliteal and anterior tibial arteries appear normal. Mild disease of posterior tibial and peroneal arteries noticed

    Impression: The above findings are suggestive of peripheral femoral popliteal vaso occlusive disease.



    Diagnosis
    Dry Gangrene with Peripheral Vaso Occlusive Disease and Diabetes Mellitus.
    With this presentation and investigations the following repertorial totality was constructed
    1. Circulation Blood vessels hard, sclerotic, thickened (816)
    2. Skin and Exterior of body, Gangrene cold (765)
    3. Skin and Exterior of body Ulcer gangrenous (782)
    4. Skin and Exterior of Body Ulcer sensitive(785)
    5. Appetite desire for alcoholic liquors (285)
    6. Appetite desire sweets (287)
    7. Appetite desires cold liquids, water (286)
    8. Condition in general < time night (914)
    9. Lower extremities numbness (669)
    Finally Ars alb was selected and treatment started with Ars alb 0/3 QDS. Then the potency was raised to 0\6 and 0\12. Over a period of six months patient showed improvement in ulcer and diabetes.

    Accessory Management
    The diet was modified in such a manner that the patient is asked to consume lot of fresh vegetable salads and sprouted materials. As the patient was already on insulin, it was allowed to be continued after strict monitoring of urine sugar. Patient was admitted in the IP for a period of three months. The wound was dressed with calendula glycerine twice.

    Before
    After

    Discussion
    The case has presented with very advanced pathological changes and so there was lack of characteristic symptoms which has forced us to select the pathological symptoms for prescription. As the pathology was very prominent the Boger Boenninghausen Characteristic Repertory was used for repertorization. Since we are dealing with very advanced pathology we felt the need of a safe potency so 50 Millesimal Potency was used which has also allowed frequent repetition of doses. During the course of treatment after a month the patient was seen by a surgeon who has nibbled the metatarsal bone which has allowed the growth of granulation tissue. While the patient was under the surgeons care he was given a course of antibiotics by him. The surgeon was astonished over the bleeding while nibbling the bone and while referring back he has marked that the vascularity is adequate.