External Applications:
- Sumit Goel.
PHILOSOPHICAL UNDERSTANDING OF THE NATURE OF LOCAL DISEASES
A study of the History of Medicine reveals the baseless belief and teachings of the Old school of Medicine that - ' Local diseases are those conditions where the external surface of the body was morbidly affected and that the rest of the body were not an integral part of the disease. ' Hahnemann termed this a theoretical, absurd doctrine, a pernicious blunder that has led to the most disastrous medical treatment. [Aphorism 185)
The method of treatment in the Old school is based on the fallacious logic that a disease, manifested on the external surface of the body, i.e skin, was the 'DISEASE' itself. Hence the mode of treatment was directed at removing the manifestations and that if the outward manifestations were removed, the disease was cured.
But, Hahnemann proclaimed that there couldn't be any "local disease" of the living organism. It is the INDIVIDUAL that is sick and not the individual parts. The human organism is a living indivisible whole. Practically, the term 'local disease' is used in common usage to signify the localization of the changes to the particular part of the body, the skin, due to a dynamic derangement of the vital force and the term 'external application' for a medication applied on the affected part for its removal.
Hahnemann's teachings in regard to local diseases and external applications are clear and distinct and are based on the following logic -
* No local disease can originate, persist or even worsen without the co-operation of the entire organism, which consequently must be in a diseased state. It is impossible to conceive its production without the instrumentality of the whole (deranged) life; so intimately are all parts of the organism connected together to form an indivisible whole in sensations and functions. No eruptions on the lips, no whitlow can occur without previous and simultaneous internal ill health. (Aphorism 189)
* All true medical treatment of a disease on the external parts of the body that has occurred from little or no injury from without must therefore be directed against the whole, must effect the annihilation and cure of the general malady by means of internal remedies, if it is wished that the treatment should be judicious, sure, efficacious and radical. (Aphorism 190)
* This is confirmed by the fact that the homoeopathic similimum, after its ingestion, acts curatively not only on the general health, but also particularly in the affected external parts, even in the so-called 'local disease'; the change it produces is most salutary, being the restoration to health of the entire body, along with the disappearance of the external affection. (Aphorism 191)
* It is not useful, either in acute local diseases of recent origin or in local affections that have already existed a long time, to rub in or apply externally to the spot an external remedy, even though it be the specific and, when used internally, salutary by reason of its homoeopathicity, even though it should be at the same time administered internally; for the acute topical affections (e.g. inflammations of individual parts, erysipelas, etc.), which have not been caused by external injury of proportionate violence, but by dynamic or internal causes, yield most surely to internal remedies homoeopathically adapted to the perceptible state of the health present in the exterior and interior, selected from the general store of proved medicines, and generally without any other aid; but if these diseases do not yield to them completely, and if there still remain in the affected spot and in the whole state, notwithstanding good regimen, a relic of disease which the vital force is not competent to restore to the normal state, then the acute disease was a product of psora that had hitherto remained latent in the interior, but has now burst forth and is on the point of developing into a palpable chronic disease. (Aphorism 194)
* It may be argued that the external application of the medicine that is homoeopathic to the whole disease along with the internal administration of the same remedy might expedite cure. This is objectionable, because by such a topical application, the chief symptom (local affection) will be annihilated sooner than the restoration of the internal derangement, often leading to a deceptive impression that a complete cure has been effected. It will be difficult and in some cases impossible, to determine from the premature disappearance of the local symptom, if the general disease is destroyed by the simultaneous employment of the internal medicine. (Aphorisms 196, 197)
* The medicine homoeopathically indicated for the whole case should not be used exclusively as a topical application because, with the disappearance of the chief symptom, the residual picture of the whole disease remains in a mutilated and vague form. There remain only the other, less distinguishable symptoms, which are less constant and less persistent than the local affection, and frequently not sufficiently peculiar and too slightly characteristic to display after that, a picture of the disease in clear and peculiar outlines depriving the physician to get a hold of the individualizing symptoms for selection of the similimum. (Aphorism 198)
* Treatment of local affections with unhomoeopathic external remedies, with corrosives, caustics, escharotics or by excision distorts and obscures the 'outwardly reflected picture of the internal essence of the disease', thus intensifying the internal disease and driving the disease manifestations to other parts of the body.
SYNOPSIS
* It is the individual that is sick and not his isolated local parts.
* The treatment for 'local diseases ' must be directed at the 'whole' and not towards the local part.
* It is only the HOMOEOPATHIC SIMILIMUM that cures.
* Simultaneous administration of homoeopathic similimum and homoeopathic specific external application is not permitted because the local affection will be removed sooner than the restoration of the internal derangement, leading to a deceptive impression that a complete cure has been effected.
* Exclusive topical application of a homoeopathic medicine is also not permissible, because with disappearance of the chief symptom, the residual portion of the disease remains in a mutilated and vague form, making it then difficult to select the right remedy.
* Use of unhomoeopathic external applications is totally inadmissible as they lead to suppression, obscuring the 'outwardly reflected picture of the internal essence of the disease' and driving the disease manifestations to other parts of the body.
In 6th edition of Organon of Medicine, aphorisms 284, 285, Hahnemann clarifies about the various routes of administration of the Homoeopathic Similimum.
"Besides the tongue, mouth and stomach which are most commonly affected by the administration of the medicine, the nose and respiratory organs are receptive of the action of medicines in fluid form by means of olfaction and inhalation through mouth. But the whole remaining skin of the body clothed with epidermis is adapted to the action of medicinal substances, especially if the inunction is connected with simultaneous internal administration.
In this way, the cure of very old diseases maybe furthered by applying externally, rubbing it in the back, arms, extremities, the same medicine he gives internally and which showed itself curatively. In doing so, he must avoid parts subject to pain, spasm and skin eruption."
"The homoeopathic physician will derive all the benefit from a well-selected remedy, which can be obtained in any special case of chronic disease by doses given through the mouth. But if the diseased organism is affected through this remedy, at the same time, in sensitive spots other than the nerves of the mouth and the alimentary canal, i.e. if this same remedy that has been found useful is at the same time in its watery solution rubbed in into one or more parts of the body that are most free from morbid ailments (e.g. on an arm or on the thigh or leg, which have neither cutaneous eruptions, nor pains, nor cramps) - then the curative effects are much increased. In order to introduce change and variation, one limb after the other should be used, in alternation, on different days, (best on days when the medicine is not taken internally). A small quantity of the solution should be rubbed in with the hand, until the limb is dry. Also for this purpose, the bottle should be shaken five or six times."
This procedure also explains the wonderful cases where chronic crippled patients with sound skin recovered quickly and permanently by a few baths in mineral water, the medicinal constituents of which were homoeopathic to their chronic disease.
On the other hand, such baths have also inflicted a proportionally greater injury with patients who suffered from ulcers and cutaneous eruptions. At times instead, the ocular nerve would become paralyzed and produce amaurosis, sometimes the crystalline lens would become clouded, hearing lost, mania or suffocating asthma would follow or an apoplexy would end the sufferings of the deluded patient." (Footnote 165, aphorism 285)
Therefore the homoeopathic remedy given internally must never be rubbed in on parts that suffer from external ailments.
INDICATIONS FOR EXTERNAL APPLICATIONS
* The figwarts, if they have existed for some time without treatment have need for their perfect cure, the external application of their specific medicines as well as their internal use at the same time. (Footnote 163, Aphorism 282)
* The maladies that deserve topical application are more or less of recent origin and produced solely by an external lesion, i.e. adynamic diseases e.g. accidental case, injuries, burns, etc. that require local dressing and cleaning.
* If by local applications we mean something that will thwart the expression of the disease, this is prohibited. But if the use of local applications is based upon physical principles, it may be considered.
MOTHER TINCTURE FOR EXTERNAL USE When a mother tincture is to be used for the purpose of preparing external applications, it needs to undergo a modification.
1. When the mother tincture is prepared according to old Hahnemannian method, the mother tincture of the drug to be used in the preparation of the external application should comply with the following guidelines -
* Tincture prepared according to Class I and Class II - If no special direction for the preparation is given, 1 part by weight of mother tincture and 1.5 parts by weight of ethyl alcohol (45 Pecent) are to be mixed.
* Tincture prepared according to Class III - If no special direction for the preparation is given, 1.5 parts by weight of mother tincture and 1 part by weight of ethyl alcohol (60 Pecent) are to be mixed.
* Tincture prepared according to Class IV - If no special direction for the preparation is given, 1 part by weight of mother tincture and 1 part by weight of ethyl alcohol that was used for the preparation of the mother tincture are to be mixed.
2. If the mother tincture is prepared according to New method, equal weight of mother tincture and ethyl alcohol are to be taken and this mother tincture will be used for external application.
3. Normally, except otherwise specified, 10 Pecent mixture of mother tincture for external application and suitable base is used.
VEHICLES AS BASES FOR EXTERNAL APPLICATION The following are the vehicles that are used as bases for preparing external applications. The choice of the vehicle depends upon the purpose of use and the nature of application.
* Distilled water, Alcohol, Glycerin, Olive oil, Almond oil, Sesame oil, Chaulmoogra oil, Coconut oil, Sandalwood oil, Lavender oil, Rosemary oil
* Paraffin, Beeswax, Lanolin, Spermaceti, Prepared lard, Isinglass, Soap, Starch
TYPES OF EXTERNAL APPLICATIONS
External applications may be -
(a) Liquid
(b) Solid or semi solid
LIQUID PREPARATIONS
Liquid preparations for external applications can be classified as follows -
* Application on skin - liniments, lotions, glyceroles, paints, oils
* Application in mouth and throat - gargles, mouth washes
* Application in ear, eye - ear drops, eye drops
* Application in nasopharynx - inhalations
* Application into vagina, urethra and rectum
LINIMENTS
* Liniments (embrocations) are suitable for application, rubbing, anointing or painting.
* Liniments are liquid preparations for external use and may be applied with or without friction.
NATURE
Liniments may be alcoholic solutions, oily solutions or emulsions.
Two types of vehicles are used for liniments - (I) strong alcohol - tincture of soap (II) oil - olive oil
Liniments are generally prepared by mixing one part of the required drug with four parts of olive oil or tincture of soap.
Tincture of soap -------------- Soft soap - 10 gm
Alcohol fortis - 25 ml
Purified water - 16 ml
Dissolve with gentle heat and strain.
UTILITY
* For the relief of pain resulting from falls or blows, liniments may be applied or painted onto the skin by means of a brush.
* As stimulants, liniments may be massaged into the skin with considerable friction.
* Soap liniment is used for sprains and bruises.
PRECAUTIONS
* The bottles should be labeled " For external use only".
* Liniments should never be applied to broken skin, as they are irritating, especially if the solvent is alcohol. The label should carry the warning " Not to be applied on wounds and broken skin".
* Cool storage is necessary since all liniments have volatile ingredients.
LOTIONS
* Lotions are aqueous solutions, suspensions or dispersions intended for application to the skin surface. If they contain insoluble solids in suspension, they are sometimes referred to as 'Shake Lotions'. On application to the skin, the water evaporates leaving a residue of the medicament on the skin surface. The evaporation also causes cooling. The cooling effect is enhanced by the inclusion of alcohol. Glycerin may be included to promote adherence of residual medicine on skin surface.
* Lotions may also take the form of dilute emulsions, usually of oil-in-water type and contain emulsifying wax. They should contain a preservative to inhibit the growth of microorganisms.
* When purified water is used for preparation of lotions, it should be freshly boiled and cooled before use. As water is an unstable media for preservation, aqueous lotions have a short shelf life.
PREPARATION
One part of the requisite mother tincture and nine parts of purified water are mixed thoroughly for the preparation of lotion.
Lotions are occasionally prepared by simply diluting the medicine with distilled water in the proportion of 1 to 10 or 1 to 100 or alternatively by adding one part of glycerole of the intended medicine with 4 to 9 parts of distilled water.
To prepare evaporating lotion, add 1 part of the medicine to 99 parts of dilute alcohol.
UTILITY
* Lotions are usually soothing and are applied gently by dabbing or after spreading on a dressing. It may be used in bruised pain without bloodshed arising from falling, injuries or blows.
PRECAUTIONS
* The bottles should be labeled " For external use only".
* It should carry the instruction " Shake well before use".
GLYCEROLES
* Glyceroles are mixtures of solutions of mother tincture in glycerin. They are usually viscous with jelly like consistency.
* The glyceroles are very convenient preparations and being soluble in all proportions in water and alcohol and can be diluted to make liniments, lotions, etc.
PREPARATION Glyceroles are readily made by adding the mother tincture of a drug or a crude drug to glycerin in various proportions.
In preparing glyceroles of a pure substance, finely triturate it in a mortar before mixing with glycerin. All glyceroles (except of starch) are prepared by mixing one part of the required drug with four parts of glycerin.
UTILITY
* Glyceroles are anti-fungal, anti-pruritic and used in cases of stomatitis and gingivitis as it causes a soothing effect on the lesion.
GLYCEROLE OF STARCH
Take one part of starch and mix it with eight parts of glycerin. Rub together till intimately mixed. Transfer the mixture to porcelain dish. Apply heat gradually raising to 116?C and stir constantly till the starch particles are completely broken and a jelly like preparation is made. This is glycerole of starch.
PRECAUTIONS
* The bottles should be labeled "For external use only". Specific instructions, depending on the nature of drug used in the preparation of glycerole, should be mentioned as in case of gingival and oral preparations.
PAINTS
* Paints are liquid preparations for external application for circumscribed areas.
* They maybe aqueous or alcoholic solutions and are prepared with a colloidion base to form a film on skin.
OILS
* Some oils such as olive oil, almond oil or coconut oils are used as base in which the medicinal substance is steeped for some time. Oils may be applied with friction by massaging on to the skin or scalp.
GURGLES AND MOUTHWASHES
* Gurgles are aqueous solutions intended to be used after dilution with warm water. They are intended to bring the medicament into contact with the mucous surface of the throat and pharynx.
* Gurgles may be useful in giving symptomatic relief. They are usually clear solutions, but occasionally medicated with the desired medicine. The gargle is kept in throat and air from lungs is forced through for the solution to come in contact with the above membranes.
* Gurgles should not be unduly irritant to the mucous membrane of the oral cavity.
* Mouthwashes are similar to gargles but are intended to wash out the mouth. They are of value only for the local hygiene of the mouth.
EAR DROPS
* Ear drops are often aqueous solutions, sometimes glycerin or alcoholic, intended for instillation into ear e.g. Mullein oil
EYE DROPS
* Eye drops are usually aqueous or oily solutions of drugs intended for instillation into eye. E.g. Cineraria eye drops
IDEAL CHARACTERISTICS OF EYE DROPS
* Eye drops should be sterile formulations to prevent infection to eye. Ophthalmic solutions and suspensions should be sterile when dispensed in the unopened container of the manufacturer.
* Formulations should be free from suspended particles and foreign matter.
* Eye formulations should be isotonic with lachrymal secretions to avoid irritation.
* Ophthalmic preparations should be viscous to increase period of contact with eye.
* Eye drops should contain suitable preservative to inhibit growth of microorganisms.
Viz. Benzalkonium Chloride 0.01 Pecent or Phenyl mercuric nitrate 0.001 Pecent or Chlorobutanol 0.5 Pecent or Phenyl ethyl alcohol 0.5 Pecent.
* Ophthalmic solutions and suspensions should be contained in bottles made of either neutral glass or soda glass specially treated to reduce the amount of alkali released when in contact of aqueous liquids or in suitable plastic containers that are not incompatible with the solutions. The accompanying droppers should also be made of neutral glass or of suitable plastic material and should be packed in sterile cellophane or other suitable packings.
One of the main hazards in use of local applications to the eye is the danger of introducing pathogenic microorganisms or other foreign bodies into the eye. The resulting damage may be more serious than the original condition.
Eye drops are commonly dispensed in bottles with a screw cap fitted with a rubber teat and glass dropper for application of the drops or in plastic containers with a narrow nozzle from which drops can be exuded. Care should be taken to avoid touching any part of the eye with the tube or nozzle. If the applicator touches an infected area, the remaining solution may get contaminated.
The standards for Homoeopathic Ophthalmic preparations are laid down in Schedule FF of the Drugs and Cosmetics Act, 1940 of India.
INHALATIONS
* Inhalations are solutions of medicaments administered by nasal or respiratory route, intended for local or systemic effects. Inhalations are applied in form of vapors that are to be inhaled alongwith breath from the surface of hot water.
* Vehicles preferred are normal saline and other water based liquids. 1 tsp of medicine is poured to 1 pint of hot water, not boiling water.
* Respiratory tract is known to be an excellent system for introduction of the medication for systemic effect. This capacity of the respiratory tract is yet to be exploited.
VAGINAL INJECTIONS
A very convenient general formula for these is
Medicine - 1/2 fluid ounce
Glycerin - 11/2 fluid ounce
Distilled water - 2 fluid ounce ...Mix.
One teaspoonful of this with sufficient tepid water is used for each injection.
URETHRAL INJECTIONS
With the exception of Infusion of Hydrastis (1 oz to the pint), these mostly consist of solutions of various drugs in distilled water in the said proportion as prescribed by physician.
RECTAL INJECTIONS
When it is thought desirable to apply any medicine to the rectum, it is convenient to mix the quantity intended to be administered with about 2 fluid ounce of starch or arrowroot and injected slowly, so that it may be retained.
SOLID OR SEMI-SOLID PREPARATIONS
Many medicaments meant for topical application to intact or broken skin or to mucous membranes are presented in form of semi-solids. They have been variously designated as ointments, opodeldocs, cerates, creams and pastes.
OINTMENTS
Ointments are semi-solid preparations used for application to the skin. They are used for emollient, protective or other surface effects.
BASES
The bases used for ointments are animal, vegetable or mineral fats and oils. Thus an ointment may be a solution, suspension or emulsion of medicament in the base. The ointment base is a substance that serves as a vehicle or carrier for the medicament.
CHARACTERISTICS OF AN IDEAL OINTMENT BASE
* Compatible with the skin
* Stable
* Smooth and pliable
* Able to readily release its incorporated medication
* Inert
* Easily washable
* Non irritating
* Non sensitizing
* Compatible with a variety of medicaments
CLASSIFICATION AND PROPERTIES OF OINTMENT BASES
- Hydrocarbon bases (oleaginous) - include vegetable fixed oils, animal fats and semi-solid hydrocarbons obtained from petroleum. Eg. Olive oil, lard, beeswax, spermaceti, petrolatum. : - Emollient; occlusive; non-water washable; greasy.
- Absorption bases (anhydrous) - Eg. Hydrophilic petrolatum, anhydrous lanolin. : - Emollient; occlusive; absorb water; anhydrous; greasy.
- Emulsion bases (w/o type) - Eg. Lanolin, cold cream. : - Emollient; occlusive; contain water; some absorb additional water; greasy.
- Emulsion bases (o/w type) - Eg. Hydrophilic ointment. : - Water washable; non-greasy; can be diluted with water; non-occlusive.
- Water soluble bases - Eg. Polyethylene glycol ointment. : - Usually anhydrous; water soluble and washable; non-greasy; non-occlusive; lipid free.
PREPARATION
* Fusion method - When wax, spermaceti or other hard fusible bodies are to be incorporated with soft, oleaginous materials, fusion method is employed. The insoluble solid medicament is finely powdered.
When an ointment base contains several ingredients of different melting points, it is better that the substance having a higher melting point be first prepared and the other in descending order of melting point is added next. After melting the base or its components, add the medicaments and stir until dissolved. Stir until cooled and until homogeneity is achieved.
* Mechanical incorporation or trituration method - This method is used when the base is soft and the medicament is either a solid insoluble in the base or a liquid present in small quantity.
Finely powder the solid medicament. Weigh out the base and add a portion of it to the medicament. The portion of base should be about three times the weight of the medicament. Triturate thoroughly until a homogenous product is formed. Add the remainder of the base, mix well to form a homogenous product and incorporate any liquid medicaments, if any. Mechanical incorporation is performed by trituration in a mortar or a glass slab with a spatula.
UTILITY
* Ointments are used as dressings for torn, jagged wounds, ulcers, burns, etc.
PRECAUTIONS
* Ointments should be stored in cool dark place, out of contact with air. Preferably, all ointments can be refrigerated.
STANDARDS FOR OINTMENTS (as per HPI)
A. Standards for simple ointment :
Wool fat 50gm
Hard paraffin 50gm
Melt together and stir until cold
White soft paraffin 850gm
Cetostearyl alcohol 50gm
Unless otherwise directed, simple ointment prepared with white soft paraffin should be used in a white ointment.
B. Standards for eye ointment :
Eye ointment should contain the following composition:
Liquid paraffin 10gm
Wool fat 10gm
Yellow soft paraffin 80gm
Heat together the wool fat, yellow soft paraffin and liquid paraffin. Filter while hot through a coarse filter paper placed in a heated funnel and sterilize by heating for a sufficient time to ensure that the entire matter is at 160oC for at least one hour. Allow to cool, add the drug and triturate the mixture.
C. Cream based ointment :
Cream based ointments should be hydrophilic or emulsion based ointment.
Ingredients should be of Pharmacopoeial grade and free from allergic abnormal toxicity. Ingredients of base material should be non-reactive to the medicinal substances included in the formulation
D. Paraffin ointment :
White beeswax 20gm
Hard paraffin 30gm
Cetostearyl alcohol 50gm
White soft paraffin 900gm
Melt together, stir, remove the source of heat and continue stirring until the mass reaches room temperature.
OPODELDOCS
These are semi-solid liniments prepared by mixing -
White curd soap 140 gm
Purified water 266 ml
Alcohol fortis 444 ml
Mother tincture of the drug 100 ml
PREPARATION
* Specified quantities of white curd soap and purified water are heated gently till the solution becomes transparent. Strong alcohol is then added gradually. The mother tincture of the drug is then added and it is stirred well. The solution is then strained into a suitable phial.
CERATES
* Cerates are unctuous (oily) substances that owe their name to the presence of cera or wax. They are of such consistency that they may be easily spread at ordinary temperature, upon gauze or similar material with a spatula and yet not be so soft as to liquefy and run when applied to the skin.
PREPARATION
* They are generally made with oil or lard as base with sufficient beeswax to give the desired consistency.
* Simple cerate is prepared by mixing spermaceti 3 parts, white wax 6 parts and olive oil 14 parts. Melt the mixture on a water bath, remove it and when cool (but not set), gradually add the medicating tincture, stirring briskly till cold.
* One part of the mother tincture is mixed thoroughly with nine parts of simple cerate.
UTILITY
* Cerates are mostly used as dressings for inflamed areas.
CREAMS
* The term ' cream ' is applied to viscous emulsions of semi-solid consistency intended for application to the skin.
* Creams may be w/o (water-in-oil or oily creams) or o/w (oil-in-water or aqueous creams).
PASTES
* Pastes are similar to ointments but the bases used are generally non-greasy. Pastes are stiffer preparations than ointments and contain high proportions of powder.
POULTICES (CATAPLASMS) AND FOMENTATION
* Poultices are soft, semi-solid external applications that either stimulate the body surface or alleviate an inflamed area by applying medicated substances in the presence of heat and moisture. It helps in drawing infective material from the affected area due to its hygroscopic and absorptive properties of the ingredients. They are applied to promote maturation of boils and abscesses, to relieve pains in various parts and acute inflammatory diseases of the chest.
PREPARATION
* Linseed poultice
Poultices are usually made from hot water and linseed meal or flax plant seed or other cohesive material that maintain intimate contact with skin, at the same time remaining hot and moist for a fairly long period.
The boiling water is poured into a heated bowl. The meal is quickly sprinkled with one hand while the mixture is constantly stirred with a spatula with the other till a thin smooth paste is formed. The paste is then quickly spread on a muslin cloth. Smear the surface with a little olive oil. A few drops of the mother tincture are added to it. Cover outside with several folds of flannel and apply to the affected part.
* Spongic-piline poultice
It is composed of sponge and wool with an outside waterproof covering. Steep the sponge surface in hot water, wring out and apply to the painful part.
* Hot salt or sand pad
Fill a flannel bag or thick cloth bag with hot salt or sand and apply to the affected part to relieve pain.
* Hot fomentation
Wring a folded cloth out of hot water. If necessary, impregnate water with the indicated drug. Cover it with oiled silk and dry flannel to prevent evaporation and apply to the painful part or fill a rubber hot water bottle and apply to the affected part.
* Cold fomentation
Wet a folded cloth in cold water, leave it uncovered to favour evaporation and apply to the affected part.
Baths of pure water prove themselves partly palliative, partly as homoeopathic serviceable aids in restoring health in acute diseases as well as in convalescence of cured chronic patients with proper consideration of the conditions of the convalescent and the temperature of the bath, its duration and repetition. But even if well applied, they bring only physically beneficial changes in the sick body, in themselves they are no true medicine. The lukewarm baths at 25 to 27oC serve to arouse the slumbering sensibility of fibre in the apparent dead (frozen, drowned, suffocated), which benumbed the sensation of the nerves. Though only palliative, still they often prove themselves sufficiently active, especially when given in conjunction with coffee and rubbing with the hands. They may give homoeopathic aid in cases where the irritability is very unevenly distributed and accumulated too unevenly in some organs, as is the case in certain hysteric spasms and infantile convulsions. In the same way, cold baths, 10 to 6oC in persons cured medically of chronic diseases and with deficiency of vital heat, act as a homoeopathic aid. By instantaneous and later with repeated immersions they act as palliative restorative of the tone of the exhausted fibre. For this purpose, such baths are to be used for more than momentary duration, rather for minutes and of gradually lowered temperature, they are a palliative, which, since it acts only physically has no connection with the disadvantage of a reverse action to be feared afterwards, as takes place with dynamic medicinal palliatives. (Aphorism 291)
SURGICAL DRESSINGS
Surgical dressings are commonly used to cover wounds.
FEATURES OF AN IDEAL DRESSING
* Porous to water vapor; otherwise sweat from surrounding skin, water evaporated from the epidermis and tissue fluid exuded from the wound will accumulate and delay healing.
* Capable of absorbing excess secretions.
* Non adherent to granulating surfaces and not penetrable by capillary loops.
* Free from substances that cause tissue reactions, allergy or hypersensitivity response.
* Impervious to microorganisms.
* Impervious to fluid from outside.
* Capable of following joint contours during movement.
* Smooth on both surfaces.
* Satisfactory tensile strength.
* Sealable to the skin, but easily removable when required.
* Inexpensive.
TYPES OF SURGICAL DRESSINGS Surgical dressings can be classified as -
A FIBERS - Cotton is by far the most useful fibre for surgical dressings, but regenerated cellulose, wood fibers and wool are also used.
Absorbent Cotton - It is prepared from raw cotton fibers.
* The fibers should be well carded, bleached to a good white to ensure visual cleanliness and should be free from pieces of thread.
* The quality should be the same throughout.
* It should offer appreciable resistance when pulled.
Absorbent cotton is mainly used for cleansing, swabbing and medicating wounds and applying antiseptic solutions to the skin, as also for absorption of wound exudates. A thick layer of cotton wool is light in weight but provides good physical protection to the wound, warmth to the area and a barrier to infection.
B FABRICS - Fabrics give tensile strength and at the same time maintain the absorbent quality of the material.
Absorbent Cotton Gauze - Absorbent cotton gauze contains cotton in form of spun threads and not loose fibers. Hence gauze can be applied directly to wounds and is the most important dressing for this purpose. It also absorbs water readily.
Gauze Pad - A gauze pad is absorbent gauze folded into a square pad. The number of layers and dimensions of pad vary according to use. To minimize adhesion and shedding of fibers, no cut edges should be visible and the edge of the pad should be stitched.
C BANDAGES - Bandages may be non elastic, elastic, impregnated or adhesive.
* Non Elastic - Absorbent cotton thread woven in mesh and prepared in continuous roll of length, called as roller bandage is a variety of non elastic bandage.
Non elastic bandages are used to secure and protect dressings, for support and immobilization or used as a sling.
* Elastic - Elastic bandages conform well to body contours allowing limited movement and stretching, if swelling takes place. They are used for giving light support to sprains and strains, for correctional purposes and as compression bandage. E.g. cotton crepe bandage.
* Adhesive - Adhesive bandages provide excellent support for the affected region aided by the adhesive mass that holds the bandage firmly in place.
* Impregnated - Plaster of Paris bandage is an impregnated bandage and is used for immobilization, splinting of fractures, correction splinting and rest splints. These are always kept in waterproof packings, as moisture tends to harden the plaster rending it unfit for use.
Bandages may also be impregnated with homoeopathic medicament to protect and soothe the skin as well as to promote healing.
PLASTERS
Plasters are substances intended for external application, made of such material and of such consistency as to adhere to the skin and thereby attach a dressing.
PREPARATION
Take 30 g of isinglass in shreds and dissolve it first by digesting and then by boiling a sufficient quantity of purified water.
Filter through a clean towel moistened with purified water.
Evaporate the solution on a water bath until it is reduced to 300 g. Spread about half of this evenly on a piece of linen or muslin, silk, etc.
Now add the desired mother tincture to the remaining half and mix, with this complete the spreading.
E.g. Arnica plaster, Calendula plaster.
SELF ASSESSMENT
* What are external applications? Discuss the homoeopathic view regarding use of external applications. What are the various types of external applications?
* What is mother tincture for external use? Discuss classification and uses of external applications.
* Discuss the nature, preparation, utility of liniments / glyceroles / lotions / ointments.
* Discuss ointments in detail.
QUIZ
1. Liniments are prepared by taking one part of the requisite mother tincture and four parts of
(a) Glycerin
(b) Olive oil
(c) Yellow's beeswax
(d) Distilled water
2. Which one of the following method is used for the preparation of ointment, when the base is spermaceti or wax?
(a) Gravimetric method
(b) Fluxion method
(c) Fusion method
(d) Stapf's method
3. Cerates are unctuous substances due to the presence of
(a) Prepared lard
(b) Wax
(c) Starch
(d) Distilled water
4. 'Shake well before use' needs to be mentioned on the label of
(a) Lotions
(b) Ointments
(c) Cerates
(d) Liniments
5. External application of remedies is discussed in 6th edition of Organon of Medicine in
(a) Aphorism 3
(b) Aphorism 267
(c) Aphorism 270
(d) Aphorism 285
ANSWERS: 1 (b); 2 (c); 3 (b); 4 (a); 5 (d).
PHILOSOPHICAL UNDERSTANDING OF THE NATURE OF LOCAL DISEASES
A study of the History of Medicine reveals the baseless belief and teachings of the Old school of Medicine that - ' Local diseases are those conditions where the external surface of the body was morbidly affected and that the rest of the body were not an integral part of the disease. ' Hahnemann termed this a theoretical, absurd doctrine, a pernicious blunder that has led to the most disastrous medical treatment. [Aphorism 185)
The method of treatment in the Old school is based on the fallacious logic that a disease, manifested on the external surface of the body, i.e skin, was the 'DISEASE' itself. Hence the mode of treatment was directed at removing the manifestations and that if the outward manifestations were removed, the disease was cured.
But, Hahnemann proclaimed that there couldn't be any "local disease" of the living organism. It is the INDIVIDUAL that is sick and not the individual parts. The human organism is a living indivisible whole. Practically, the term 'local disease' is used in common usage to signify the localization of the changes to the particular part of the body, the skin, due to a dynamic derangement of the vital force and the term 'external application' for a medication applied on the affected part for its removal.
Hahnemann's teachings in regard to local diseases and external applications are clear and distinct and are based on the following logic -
* No local disease can originate, persist or even worsen without the co-operation of the entire organism, which consequently must be in a diseased state. It is impossible to conceive its production without the instrumentality of the whole (deranged) life; so intimately are all parts of the organism connected together to form an indivisible whole in sensations and functions. No eruptions on the lips, no whitlow can occur without previous and simultaneous internal ill health. (Aphorism 189)
* All true medical treatment of a disease on the external parts of the body that has occurred from little or no injury from without must therefore be directed against the whole, must effect the annihilation and cure of the general malady by means of internal remedies, if it is wished that the treatment should be judicious, sure, efficacious and radical. (Aphorism 190)
* This is confirmed by the fact that the homoeopathic similimum, after its ingestion, acts curatively not only on the general health, but also particularly in the affected external parts, even in the so-called 'local disease'; the change it produces is most salutary, being the restoration to health of the entire body, along with the disappearance of the external affection. (Aphorism 191)
* It is not useful, either in acute local diseases of recent origin or in local affections that have already existed a long time, to rub in or apply externally to the spot an external remedy, even though it be the specific and, when used internally, salutary by reason of its homoeopathicity, even though it should be at the same time administered internally; for the acute topical affections (e.g. inflammations of individual parts, erysipelas, etc.), which have not been caused by external injury of proportionate violence, but by dynamic or internal causes, yield most surely to internal remedies homoeopathically adapted to the perceptible state of the health present in the exterior and interior, selected from the general store of proved medicines, and generally without any other aid; but if these diseases do not yield to them completely, and if there still remain in the affected spot and in the whole state, notwithstanding good regimen, a relic of disease which the vital force is not competent to restore to the normal state, then the acute disease was a product of psora that had hitherto remained latent in the interior, but has now burst forth and is on the point of developing into a palpable chronic disease. (Aphorism 194)
* It may be argued that the external application of the medicine that is homoeopathic to the whole disease along with the internal administration of the same remedy might expedite cure. This is objectionable, because by such a topical application, the chief symptom (local affection) will be annihilated sooner than the restoration of the internal derangement, often leading to a deceptive impression that a complete cure has been effected. It will be difficult and in some cases impossible, to determine from the premature disappearance of the local symptom, if the general disease is destroyed by the simultaneous employment of the internal medicine. (Aphorisms 196, 197)
* The medicine homoeopathically indicated for the whole case should not be used exclusively as a topical application because, with the disappearance of the chief symptom, the residual picture of the whole disease remains in a mutilated and vague form. There remain only the other, less distinguishable symptoms, which are less constant and less persistent than the local affection, and frequently not sufficiently peculiar and too slightly characteristic to display after that, a picture of the disease in clear and peculiar outlines depriving the physician to get a hold of the individualizing symptoms for selection of the similimum. (Aphorism 198)
* Treatment of local affections with unhomoeopathic external remedies, with corrosives, caustics, escharotics or by excision distorts and obscures the 'outwardly reflected picture of the internal essence of the disease', thus intensifying the internal disease and driving the disease manifestations to other parts of the body.
SYNOPSIS
* It is the individual that is sick and not his isolated local parts.
* The treatment for 'local diseases ' must be directed at the 'whole' and not towards the local part.
* It is only the HOMOEOPATHIC SIMILIMUM that cures.
* Simultaneous administration of homoeopathic similimum and homoeopathic specific external application is not permitted because the local affection will be removed sooner than the restoration of the internal derangement, leading to a deceptive impression that a complete cure has been effected.
* Exclusive topical application of a homoeopathic medicine is also not permissible, because with disappearance of the chief symptom, the residual portion of the disease remains in a mutilated and vague form, making it then difficult to select the right remedy.
* Use of unhomoeopathic external applications is totally inadmissible as they lead to suppression, obscuring the 'outwardly reflected picture of the internal essence of the disease' and driving the disease manifestations to other parts of the body.
In 6th edition of Organon of Medicine, aphorisms 284, 285, Hahnemann clarifies about the various routes of administration of the Homoeopathic Similimum.
"Besides the tongue, mouth and stomach which are most commonly affected by the administration of the medicine, the nose and respiratory organs are receptive of the action of medicines in fluid form by means of olfaction and inhalation through mouth. But the whole remaining skin of the body clothed with epidermis is adapted to the action of medicinal substances, especially if the inunction is connected with simultaneous internal administration.
In this way, the cure of very old diseases maybe furthered by applying externally, rubbing it in the back, arms, extremities, the same medicine he gives internally and which showed itself curatively. In doing so, he must avoid parts subject to pain, spasm and skin eruption."
"The homoeopathic physician will derive all the benefit from a well-selected remedy, which can be obtained in any special case of chronic disease by doses given through the mouth. But if the diseased organism is affected through this remedy, at the same time, in sensitive spots other than the nerves of the mouth and the alimentary canal, i.e. if this same remedy that has been found useful is at the same time in its watery solution rubbed in into one or more parts of the body that are most free from morbid ailments (e.g. on an arm or on the thigh or leg, which have neither cutaneous eruptions, nor pains, nor cramps) - then the curative effects are much increased. In order to introduce change and variation, one limb after the other should be used, in alternation, on different days, (best on days when the medicine is not taken internally). A small quantity of the solution should be rubbed in with the hand, until the limb is dry. Also for this purpose, the bottle should be shaken five or six times."
This procedure also explains the wonderful cases where chronic crippled patients with sound skin recovered quickly and permanently by a few baths in mineral water, the medicinal constituents of which were homoeopathic to their chronic disease.
On the other hand, such baths have also inflicted a proportionally greater injury with patients who suffered from ulcers and cutaneous eruptions. At times instead, the ocular nerve would become paralyzed and produce amaurosis, sometimes the crystalline lens would become clouded, hearing lost, mania or suffocating asthma would follow or an apoplexy would end the sufferings of the deluded patient." (Footnote 165, aphorism 285)
Therefore the homoeopathic remedy given internally must never be rubbed in on parts that suffer from external ailments.
INDICATIONS FOR EXTERNAL APPLICATIONS
* The figwarts, if they have existed for some time without treatment have need for their perfect cure, the external application of their specific medicines as well as their internal use at the same time. (Footnote 163, Aphorism 282)
* The maladies that deserve topical application are more or less of recent origin and produced solely by an external lesion, i.e. adynamic diseases e.g. accidental case, injuries, burns, etc. that require local dressing and cleaning.
* If by local applications we mean something that will thwart the expression of the disease, this is prohibited. But if the use of local applications is based upon physical principles, it may be considered.
MOTHER TINCTURE FOR EXTERNAL USE When a mother tincture is to be used for the purpose of preparing external applications, it needs to undergo a modification.
1. When the mother tincture is prepared according to old Hahnemannian method, the mother tincture of the drug to be used in the preparation of the external application should comply with the following guidelines -
* Tincture prepared according to Class I and Class II - If no special direction for the preparation is given, 1 part by weight of mother tincture and 1.5 parts by weight of ethyl alcohol (45 Pecent) are to be mixed.
* Tincture prepared according to Class III - If no special direction for the preparation is given, 1.5 parts by weight of mother tincture and 1 part by weight of ethyl alcohol (60 Pecent) are to be mixed.
* Tincture prepared according to Class IV - If no special direction for the preparation is given, 1 part by weight of mother tincture and 1 part by weight of ethyl alcohol that was used for the preparation of the mother tincture are to be mixed.
2. If the mother tincture is prepared according to New method, equal weight of mother tincture and ethyl alcohol are to be taken and this mother tincture will be used for external application.
3. Normally, except otherwise specified, 10 Pecent mixture of mother tincture for external application and suitable base is used.
VEHICLES AS BASES FOR EXTERNAL APPLICATION The following are the vehicles that are used as bases for preparing external applications. The choice of the vehicle depends upon the purpose of use and the nature of application.
* Distilled water, Alcohol, Glycerin, Olive oil, Almond oil, Sesame oil, Chaulmoogra oil, Coconut oil, Sandalwood oil, Lavender oil, Rosemary oil
* Paraffin, Beeswax, Lanolin, Spermaceti, Prepared lard, Isinglass, Soap, Starch
TYPES OF EXTERNAL APPLICATIONS
External applications may be -
(a) Liquid
(b) Solid or semi solid
LIQUID PREPARATIONS
Liquid preparations for external applications can be classified as follows -
* Application on skin - liniments, lotions, glyceroles, paints, oils
* Application in mouth and throat - gargles, mouth washes
* Application in ear, eye - ear drops, eye drops
* Application in nasopharynx - inhalations
* Application into vagina, urethra and rectum
LINIMENTS
* Liniments (embrocations) are suitable for application, rubbing, anointing or painting.
* Liniments are liquid preparations for external use and may be applied with or without friction.
NATURE
Liniments may be alcoholic solutions, oily solutions or emulsions.
Two types of vehicles are used for liniments - (I) strong alcohol - tincture of soap (II) oil - olive oil
Liniments are generally prepared by mixing one part of the required drug with four parts of olive oil or tincture of soap.
Tincture of soap -------------- Soft soap - 10 gm
Alcohol fortis - 25 ml
Purified water - 16 ml
Dissolve with gentle heat and strain.
UTILITY
* For the relief of pain resulting from falls or blows, liniments may be applied or painted onto the skin by means of a brush.
* As stimulants, liniments may be massaged into the skin with considerable friction.
* Soap liniment is used for sprains and bruises.
PRECAUTIONS
* The bottles should be labeled " For external use only".
* Liniments should never be applied to broken skin, as they are irritating, especially if the solvent is alcohol. The label should carry the warning " Not to be applied on wounds and broken skin".
* Cool storage is necessary since all liniments have volatile ingredients.
LOTIONS
* Lotions are aqueous solutions, suspensions or dispersions intended for application to the skin surface. If they contain insoluble solids in suspension, they are sometimes referred to as 'Shake Lotions'. On application to the skin, the water evaporates leaving a residue of the medicament on the skin surface. The evaporation also causes cooling. The cooling effect is enhanced by the inclusion of alcohol. Glycerin may be included to promote adherence of residual medicine on skin surface.
* Lotions may also take the form of dilute emulsions, usually of oil-in-water type and contain emulsifying wax. They should contain a preservative to inhibit the growth of microorganisms.
* When purified water is used for preparation of lotions, it should be freshly boiled and cooled before use. As water is an unstable media for preservation, aqueous lotions have a short shelf life.
PREPARATION
One part of the requisite mother tincture and nine parts of purified water are mixed thoroughly for the preparation of lotion.
Lotions are occasionally prepared by simply diluting the medicine with distilled water in the proportion of 1 to 10 or 1 to 100 or alternatively by adding one part of glycerole of the intended medicine with 4 to 9 parts of distilled water.
To prepare evaporating lotion, add 1 part of the medicine to 99 parts of dilute alcohol.
UTILITY
* Lotions are usually soothing and are applied gently by dabbing or after spreading on a dressing. It may be used in bruised pain without bloodshed arising from falling, injuries or blows.
PRECAUTIONS
* The bottles should be labeled " For external use only".
* It should carry the instruction " Shake well before use".
GLYCEROLES
* Glyceroles are mixtures of solutions of mother tincture in glycerin. They are usually viscous with jelly like consistency.
* The glyceroles are very convenient preparations and being soluble in all proportions in water and alcohol and can be diluted to make liniments, lotions, etc.
PREPARATION Glyceroles are readily made by adding the mother tincture of a drug or a crude drug to glycerin in various proportions.
In preparing glyceroles of a pure substance, finely triturate it in a mortar before mixing with glycerin. All glyceroles (except of starch) are prepared by mixing one part of the required drug with four parts of glycerin.
UTILITY
* Glyceroles are anti-fungal, anti-pruritic and used in cases of stomatitis and gingivitis as it causes a soothing effect on the lesion.
GLYCEROLE OF STARCH
Take one part of starch and mix it with eight parts of glycerin. Rub together till intimately mixed. Transfer the mixture to porcelain dish. Apply heat gradually raising to 116?C and stir constantly till the starch particles are completely broken and a jelly like preparation is made. This is glycerole of starch.
PRECAUTIONS
* The bottles should be labeled "For external use only". Specific instructions, depending on the nature of drug used in the preparation of glycerole, should be mentioned as in case of gingival and oral preparations.
PAINTS
* Paints are liquid preparations for external application for circumscribed areas.
* They maybe aqueous or alcoholic solutions and are prepared with a colloidion base to form a film on skin.
OILS
* Some oils such as olive oil, almond oil or coconut oils are used as base in which the medicinal substance is steeped for some time. Oils may be applied with friction by massaging on to the skin or scalp.
GURGLES AND MOUTHWASHES
* Gurgles are aqueous solutions intended to be used after dilution with warm water. They are intended to bring the medicament into contact with the mucous surface of the throat and pharynx.
* Gurgles may be useful in giving symptomatic relief. They are usually clear solutions, but occasionally medicated with the desired medicine. The gargle is kept in throat and air from lungs is forced through for the solution to come in contact with the above membranes.
* Gurgles should not be unduly irritant to the mucous membrane of the oral cavity.
* Mouthwashes are similar to gargles but are intended to wash out the mouth. They are of value only for the local hygiene of the mouth.
EAR DROPS
* Ear drops are often aqueous solutions, sometimes glycerin or alcoholic, intended for instillation into ear e.g. Mullein oil
EYE DROPS
* Eye drops are usually aqueous or oily solutions of drugs intended for instillation into eye. E.g. Cineraria eye drops
IDEAL CHARACTERISTICS OF EYE DROPS
* Eye drops should be sterile formulations to prevent infection to eye. Ophthalmic solutions and suspensions should be sterile when dispensed in the unopened container of the manufacturer.
* Formulations should be free from suspended particles and foreign matter.
* Eye formulations should be isotonic with lachrymal secretions to avoid irritation.
* Ophthalmic preparations should be viscous to increase period of contact with eye.
* Eye drops should contain suitable preservative to inhibit growth of microorganisms.
Viz. Benzalkonium Chloride 0.01 Pecent or Phenyl mercuric nitrate 0.001 Pecent or Chlorobutanol 0.5 Pecent or Phenyl ethyl alcohol 0.5 Pecent.
* Ophthalmic solutions and suspensions should be contained in bottles made of either neutral glass or soda glass specially treated to reduce the amount of alkali released when in contact of aqueous liquids or in suitable plastic containers that are not incompatible with the solutions. The accompanying droppers should also be made of neutral glass or of suitable plastic material and should be packed in sterile cellophane or other suitable packings.
One of the main hazards in use of local applications to the eye is the danger of introducing pathogenic microorganisms or other foreign bodies into the eye. The resulting damage may be more serious than the original condition.
Eye drops are commonly dispensed in bottles with a screw cap fitted with a rubber teat and glass dropper for application of the drops or in plastic containers with a narrow nozzle from which drops can be exuded. Care should be taken to avoid touching any part of the eye with the tube or nozzle. If the applicator touches an infected area, the remaining solution may get contaminated.
The standards for Homoeopathic Ophthalmic preparations are laid down in Schedule FF of the Drugs and Cosmetics Act, 1940 of India.
INHALATIONS
* Inhalations are solutions of medicaments administered by nasal or respiratory route, intended for local or systemic effects. Inhalations are applied in form of vapors that are to be inhaled alongwith breath from the surface of hot water.
* Vehicles preferred are normal saline and other water based liquids. 1 tsp of medicine is poured to 1 pint of hot water, not boiling water.
* Respiratory tract is known to be an excellent system for introduction of the medication for systemic effect. This capacity of the respiratory tract is yet to be exploited.
VAGINAL INJECTIONS
A very convenient general formula for these is
Medicine - 1/2 fluid ounce
Glycerin - 11/2 fluid ounce
Distilled water - 2 fluid ounce ...Mix.
One teaspoonful of this with sufficient tepid water is used for each injection.
URETHRAL INJECTIONS
With the exception of Infusion of Hydrastis (1 oz to the pint), these mostly consist of solutions of various drugs in distilled water in the said proportion as prescribed by physician.
RECTAL INJECTIONS
When it is thought desirable to apply any medicine to the rectum, it is convenient to mix the quantity intended to be administered with about 2 fluid ounce of starch or arrowroot and injected slowly, so that it may be retained.
SOLID OR SEMI-SOLID PREPARATIONS
Many medicaments meant for topical application to intact or broken skin or to mucous membranes are presented in form of semi-solids. They have been variously designated as ointments, opodeldocs, cerates, creams and pastes.
OINTMENTS
Ointments are semi-solid preparations used for application to the skin. They are used for emollient, protective or other surface effects.
BASES
The bases used for ointments are animal, vegetable or mineral fats and oils. Thus an ointment may be a solution, suspension or emulsion of medicament in the base. The ointment base is a substance that serves as a vehicle or carrier for the medicament.
CHARACTERISTICS OF AN IDEAL OINTMENT BASE
* Compatible with the skin
* Stable
* Smooth and pliable
* Able to readily release its incorporated medication
* Inert
* Easily washable
* Non irritating
* Non sensitizing
* Compatible with a variety of medicaments
CLASSIFICATION AND PROPERTIES OF OINTMENT BASES
- Hydrocarbon bases (oleaginous) - include vegetable fixed oils, animal fats and semi-solid hydrocarbons obtained from petroleum. Eg. Olive oil, lard, beeswax, spermaceti, petrolatum. : - Emollient; occlusive; non-water washable; greasy.
- Absorption bases (anhydrous) - Eg. Hydrophilic petrolatum, anhydrous lanolin. : - Emollient; occlusive; absorb water; anhydrous; greasy.
- Emulsion bases (w/o type) - Eg. Lanolin, cold cream. : - Emollient; occlusive; contain water; some absorb additional water; greasy.
- Emulsion bases (o/w type) - Eg. Hydrophilic ointment. : - Water washable; non-greasy; can be diluted with water; non-occlusive.
- Water soluble bases - Eg. Polyethylene glycol ointment. : - Usually anhydrous; water soluble and washable; non-greasy; non-occlusive; lipid free.
PREPARATION
* Fusion method - When wax, spermaceti or other hard fusible bodies are to be incorporated with soft, oleaginous materials, fusion method is employed. The insoluble solid medicament is finely powdered.
When an ointment base contains several ingredients of different melting points, it is better that the substance having a higher melting point be first prepared and the other in descending order of melting point is added next. After melting the base or its components, add the medicaments and stir until dissolved. Stir until cooled and until homogeneity is achieved.
* Mechanical incorporation or trituration method - This method is used when the base is soft and the medicament is either a solid insoluble in the base or a liquid present in small quantity.
Finely powder the solid medicament. Weigh out the base and add a portion of it to the medicament. The portion of base should be about three times the weight of the medicament. Triturate thoroughly until a homogenous product is formed. Add the remainder of the base, mix well to form a homogenous product and incorporate any liquid medicaments, if any. Mechanical incorporation is performed by trituration in a mortar or a glass slab with a spatula.
UTILITY
* Ointments are used as dressings for torn, jagged wounds, ulcers, burns, etc.
PRECAUTIONS
* Ointments should be stored in cool dark place, out of contact with air. Preferably, all ointments can be refrigerated.
STANDARDS FOR OINTMENTS (as per HPI)
A. Standards for simple ointment :
Wool fat 50gm
Hard paraffin 50gm
Melt together and stir until cold
White soft paraffin 850gm
Cetostearyl alcohol 50gm
Unless otherwise directed, simple ointment prepared with white soft paraffin should be used in a white ointment.
B. Standards for eye ointment :
Eye ointment should contain the following composition:
Liquid paraffin 10gm
Wool fat 10gm
Yellow soft paraffin 80gm
Heat together the wool fat, yellow soft paraffin and liquid paraffin. Filter while hot through a coarse filter paper placed in a heated funnel and sterilize by heating for a sufficient time to ensure that the entire matter is at 160oC for at least one hour. Allow to cool, add the drug and triturate the mixture.
C. Cream based ointment :
Cream based ointments should be hydrophilic or emulsion based ointment.
Ingredients should be of Pharmacopoeial grade and free from allergic abnormal toxicity. Ingredients of base material should be non-reactive to the medicinal substances included in the formulation
D. Paraffin ointment :
White beeswax 20gm
Hard paraffin 30gm
Cetostearyl alcohol 50gm
White soft paraffin 900gm
Melt together, stir, remove the source of heat and continue stirring until the mass reaches room temperature.
OPODELDOCS
These are semi-solid liniments prepared by mixing -
White curd soap 140 gm
Purified water 266 ml
Alcohol fortis 444 ml
Mother tincture of the drug 100 ml
PREPARATION
* Specified quantities of white curd soap and purified water are heated gently till the solution becomes transparent. Strong alcohol is then added gradually. The mother tincture of the drug is then added and it is stirred well. The solution is then strained into a suitable phial.
CERATES
* Cerates are unctuous (oily) substances that owe their name to the presence of cera or wax. They are of such consistency that they may be easily spread at ordinary temperature, upon gauze or similar material with a spatula and yet not be so soft as to liquefy and run when applied to the skin.
PREPARATION
* They are generally made with oil or lard as base with sufficient beeswax to give the desired consistency.
* Simple cerate is prepared by mixing spermaceti 3 parts, white wax 6 parts and olive oil 14 parts. Melt the mixture on a water bath, remove it and when cool (but not set), gradually add the medicating tincture, stirring briskly till cold.
* One part of the mother tincture is mixed thoroughly with nine parts of simple cerate.
UTILITY
* Cerates are mostly used as dressings for inflamed areas.
CREAMS
* The term ' cream ' is applied to viscous emulsions of semi-solid consistency intended for application to the skin.
* Creams may be w/o (water-in-oil or oily creams) or o/w (oil-in-water or aqueous creams).
PASTES
* Pastes are similar to ointments but the bases used are generally non-greasy. Pastes are stiffer preparations than ointments and contain high proportions of powder.
POULTICES (CATAPLASMS) AND FOMENTATION
* Poultices are soft, semi-solid external applications that either stimulate the body surface or alleviate an inflamed area by applying medicated substances in the presence of heat and moisture. It helps in drawing infective material from the affected area due to its hygroscopic and absorptive properties of the ingredients. They are applied to promote maturation of boils and abscesses, to relieve pains in various parts and acute inflammatory diseases of the chest.
PREPARATION
* Linseed poultice
Poultices are usually made from hot water and linseed meal or flax plant seed or other cohesive material that maintain intimate contact with skin, at the same time remaining hot and moist for a fairly long period.
The boiling water is poured into a heated bowl. The meal is quickly sprinkled with one hand while the mixture is constantly stirred with a spatula with the other till a thin smooth paste is formed. The paste is then quickly spread on a muslin cloth. Smear the surface with a little olive oil. A few drops of the mother tincture are added to it. Cover outside with several folds of flannel and apply to the affected part.
* Spongic-piline poultice
It is composed of sponge and wool with an outside waterproof covering. Steep the sponge surface in hot water, wring out and apply to the painful part.
* Hot salt or sand pad
Fill a flannel bag or thick cloth bag with hot salt or sand and apply to the affected part to relieve pain.
* Hot fomentation
Wring a folded cloth out of hot water. If necessary, impregnate water with the indicated drug. Cover it with oiled silk and dry flannel to prevent evaporation and apply to the painful part or fill a rubber hot water bottle and apply to the affected part.
* Cold fomentation
Wet a folded cloth in cold water, leave it uncovered to favour evaporation and apply to the affected part.
Baths of pure water prove themselves partly palliative, partly as homoeopathic serviceable aids in restoring health in acute diseases as well as in convalescence of cured chronic patients with proper consideration of the conditions of the convalescent and the temperature of the bath, its duration and repetition. But even if well applied, they bring only physically beneficial changes in the sick body, in themselves they are no true medicine. The lukewarm baths at 25 to 27oC serve to arouse the slumbering sensibility of fibre in the apparent dead (frozen, drowned, suffocated), which benumbed the sensation of the nerves. Though only palliative, still they often prove themselves sufficiently active, especially when given in conjunction with coffee and rubbing with the hands. They may give homoeopathic aid in cases where the irritability is very unevenly distributed and accumulated too unevenly in some organs, as is the case in certain hysteric spasms and infantile convulsions. In the same way, cold baths, 10 to 6oC in persons cured medically of chronic diseases and with deficiency of vital heat, act as a homoeopathic aid. By instantaneous and later with repeated immersions they act as palliative restorative of the tone of the exhausted fibre. For this purpose, such baths are to be used for more than momentary duration, rather for minutes and of gradually lowered temperature, they are a palliative, which, since it acts only physically has no connection with the disadvantage of a reverse action to be feared afterwards, as takes place with dynamic medicinal palliatives. (Aphorism 291)
SURGICAL DRESSINGS
Surgical dressings are commonly used to cover wounds.
FEATURES OF AN IDEAL DRESSING
* Porous to water vapor; otherwise sweat from surrounding skin, water evaporated from the epidermis and tissue fluid exuded from the wound will accumulate and delay healing.
* Capable of absorbing excess secretions.
* Non adherent to granulating surfaces and not penetrable by capillary loops.
* Free from substances that cause tissue reactions, allergy or hypersensitivity response.
* Impervious to microorganisms.
* Impervious to fluid from outside.
* Capable of following joint contours during movement.
* Smooth on both surfaces.
* Satisfactory tensile strength.
* Sealable to the skin, but easily removable when required.
* Inexpensive.
TYPES OF SURGICAL DRESSINGS Surgical dressings can be classified as -
A FIBERS - Cotton is by far the most useful fibre for surgical dressings, but regenerated cellulose, wood fibers and wool are also used.
Absorbent Cotton - It is prepared from raw cotton fibers.
* The fibers should be well carded, bleached to a good white to ensure visual cleanliness and should be free from pieces of thread.
* The quality should be the same throughout.
* It should offer appreciable resistance when pulled.
Absorbent cotton is mainly used for cleansing, swabbing and medicating wounds and applying antiseptic solutions to the skin, as also for absorption of wound exudates. A thick layer of cotton wool is light in weight but provides good physical protection to the wound, warmth to the area and a barrier to infection.
B FABRICS - Fabrics give tensile strength and at the same time maintain the absorbent quality of the material.
Absorbent Cotton Gauze - Absorbent cotton gauze contains cotton in form of spun threads and not loose fibers. Hence gauze can be applied directly to wounds and is the most important dressing for this purpose. It also absorbs water readily.
Gauze Pad - A gauze pad is absorbent gauze folded into a square pad. The number of layers and dimensions of pad vary according to use. To minimize adhesion and shedding of fibers, no cut edges should be visible and the edge of the pad should be stitched.
C BANDAGES - Bandages may be non elastic, elastic, impregnated or adhesive.
* Non Elastic - Absorbent cotton thread woven in mesh and prepared in continuous roll of length, called as roller bandage is a variety of non elastic bandage.
Non elastic bandages are used to secure and protect dressings, for support and immobilization or used as a sling.
* Elastic - Elastic bandages conform well to body contours allowing limited movement and stretching, if swelling takes place. They are used for giving light support to sprains and strains, for correctional purposes and as compression bandage. E.g. cotton crepe bandage.
* Adhesive - Adhesive bandages provide excellent support for the affected region aided by the adhesive mass that holds the bandage firmly in place.
* Impregnated - Plaster of Paris bandage is an impregnated bandage and is used for immobilization, splinting of fractures, correction splinting and rest splints. These are always kept in waterproof packings, as moisture tends to harden the plaster rending it unfit for use.
Bandages may also be impregnated with homoeopathic medicament to protect and soothe the skin as well as to promote healing.
PLASTERS
Plasters are substances intended for external application, made of such material and of such consistency as to adhere to the skin and thereby attach a dressing.
PREPARATION
Take 30 g of isinglass in shreds and dissolve it first by digesting and then by boiling a sufficient quantity of purified water.
Filter through a clean towel moistened with purified water.
Evaporate the solution on a water bath until it is reduced to 300 g. Spread about half of this evenly on a piece of linen or muslin, silk, etc.
Now add the desired mother tincture to the remaining half and mix, with this complete the spreading.
E.g. Arnica plaster, Calendula plaster.
SELF ASSESSMENT
* What are external applications? Discuss the homoeopathic view regarding use of external applications. What are the various types of external applications?
* What is mother tincture for external use? Discuss classification and uses of external applications.
* Discuss the nature, preparation, utility of liniments / glyceroles / lotions / ointments.
* Discuss ointments in detail.
QUIZ
1. Liniments are prepared by taking one part of the requisite mother tincture and four parts of
(a) Glycerin
(b) Olive oil
(c) Yellow's beeswax
(d) Distilled water
2. Which one of the following method is used for the preparation of ointment, when the base is spermaceti or wax?
(a) Gravimetric method
(b) Fluxion method
(c) Fusion method
(d) Stapf's method
3. Cerates are unctuous substances due to the presence of
(a) Prepared lard
(b) Wax
(c) Starch
(d) Distilled water
4. 'Shake well before use' needs to be mentioned on the label of
(a) Lotions
(b) Ointments
(c) Cerates
(d) Liniments
5. External application of remedies is discussed in 6th edition of Organon of Medicine in
(a) Aphorism 3
(b) Aphorism 267
(c) Aphorism 270
(d) Aphorism 285
ANSWERS: 1 (b); 2 (c); 3 (b); 4 (a); 5 (d).
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