Lecture Notes on Surgery For
Under-Graduates & Graduates of Homoeopathy
A wound is any injury, where there is a breach in the continuity of the skin or mucous membrane with or without the involvement of the underlying soft tissue.
As per said definition, bruise, closed fractures or rupture of an internal organ, etc; does not qualify as wounds, as they are not associated with rupture of overlying skin.
- The etiology of wounds can be classified as follows:
- Blunt injuries
- Penetrating injuries
- Surgical insult
- Burn injuries
- RTA (Road Traffic Accident)
- Sport injuries
- Bite injuries [animal or human]
- Stab wounds
- Gunshot wounds
Wounds caused by a surgical procedure.
Surgical Wounds or Incisions result when you have surgery, or if you get a cut accidentally.
- Thermal burn
- Chemical burn
- Electrical burn
- Radiation burn
- Cold injury
According to morphological characteristics
TYPES OF WOUNDS:
Abrasion is a wound caused by superficial damage to the skin. In a word, abrasions are simple, superficial, blunt impact injuries.
Abrasions will be produced by falling over rough surfaces, blowing with a hard blunt object, lash, whip etc or by scratching by the fingernails, thorns or from teeth bite etc.
1) Scratch: These are linear injuries caused by sharp objects like fingernails, thorns, pins etc.
2) Graze (Sliding, scraping or brush abrasion) This type of injury will happen when the broader surface of the skin scrapes or slides against any rough surface or object.
Abrasions are very common in athletics and typically occur from scraping on a hard surface, like when a soccer athlete slide-tackles on a hard field. This friction removes the top layer of skin. This scraping of skin is called abrasion, “Road Rash” or “strawberry.” Most abrasions are shallow wounds and do not bleed a lot. There are many superficial nerve endings in the skin, which can make abrasions very painful.
The best treatment for abrasions is to thoroughly clean the wound with soap and water or a mild antiseptic wash.
- Wash the wound with soap and water to remove dirt and debris.
- Use a clean gauze pad to clean the wound. Do not scrub too vigorously.
- Cover the wound with a non-stick gauze pad and tape.
- Change dressing daily to prevent infection.
- Keep wound moist with ointment until healed.
(Arn, Calen, Led P, Rhus T, Canth, etc,)
B. BRUISE OR CONTUSION.
These are injuries characterized by infiltration of extravagated blood into tissue spaces following rupture of capillaries of the subcutaneous and subepithelial tissues, as a result of the application of blunt force.
These are caused by blunt force or blows with blunt weapons. The size of the bruise depends upon the number of blood vessels ruptured and the extent of spread of the extravasation.
Bruises may vary from small pin head ecchymosis resulting from minute bleeding to a widespread area commonly known as haematoma from the rupture of bigger blood vessels.
(ꝶ Arn, Led P, Bella, Hyper, Bry, etc)
C. LACERATED WOUNDS
These wounds are produced by blows with hard blunt weapons, missiles, or by fall from a height over hard project or rough objects. A laceration is a wound that occurs when skin, tissue, and/or muscle is torn or cut open. Lacerations may be deep or shallow, long or short, and wide or narrow. Most lacerations are the result of the skin hitting an object, or an object hitting the skin with force. Laceration repair is the act of cleaning, preparing, and closing the wound.
Minor lacerations (shallow, small, not bleeding, and clean) may not require medical attention. However, most lacerations do require repair. Cleaning and preparing a laceration for repair is crucial for preventing infection and reducing the appearance of scarring.
Cleaning not only washes away dirt but also removes the germs that could trigger infection. Cleaning is done in the same manner regardless of the technique that will be used for wound closure. Preparation is done to even out jagged edges so that scarring may be less noticeable. (Calen, Led p, Hyper, Caust.)
D. INCISED WOUND:
These wounds are caused when body tissue is struck or pressed by weapons or instruments having sharp linear or pointed edges. These types of wounds are produced by sharp-cutting weapons like knives, scalpels, razors, safety razors, blades, swords etc.
An incised wound is a specific type of injury where the skin is open, characterized by a relatively clean cut mark. A person most likely receives this type of wound from a bladed implement like a knife. In contrast to this type of wound, an injury that is made by a blunter edge that not only creates an open wound but damages the tissue around the wound is called a lacerated wound. (Calen, Stahys, Bellis P, Lach, Millefolium.)
E. AVULSION(from the Latin avellere, meaning “to tear off”)
In Surgery, an avulsion is an injury in which a body structure is forcibly detached from its normal point of insertion by either trauma or surgery. The term most commonly refers to a surface trauma where all layers of the skin have been torn away, exposing the underlying structures (i.e.—subcutaneous tissue, muscle, tendons, or bone). This is similar to abrasion but more severe, as body parts such as an eyelid or an ear can be partially or fully detached from the body.
The most common avulsion injury, skin avulsions usually occur during motor vehicle collisions. The severity of avulsion ranges from skin flaps (minor) to degloving (moderate) and amputation of a finger or limb (severe). Suprafascial avulsions are those in which the depth of the removed skin reaches the subcutaneous tissue layer, while subfascial avulsions extend deeper than the subcutaneous layer. Small suprafascial avulsions can be repaired by suturing, but most avulsions require skin grafts or reconstructive surgery.
In rock climbing, a “flapper” is an injury in which parts of the skin are torn off, resulting in a loose flap of skin on the fingers. This is usually the result of friction forces between the climber’s fingers and the holds, arising when the climber slips off a hold.
To fix this injury and to be able to continue climbing, many climbers will apply sports tape to the flapped finger to cover up the sensitive area of broken skin. Some climbers may even use super-glue to adhere the loose skin back to the finger.
The most common cause of ear avulsions is human bites, followed by falls, motor vehicle collisions, and dog bites. A partially avulsed ear can be reattached through suturing or microvascular surgery, depending on the severity of the injury. Microvascular surgery can also be used to reattach a completely avulsed ear, but its success rate is lower because of the need for venous drainage. The ear can also be reconstructed with cartilage and skin grafts.
Eyelid avulsions are uncommon, but can be caused by motor vehicle collisions, dog bites, or human bites. Eyelid avulsions are repaired by suturing after a CT scan is performed to determine where damage to the muscles, nerves, and blood vessels of the eyelid has occurred. More severe injuries require reconstruction, however, this usually results in some loss of function and subsequent surgeries may be necessary to improve structure and function. Microvascular surgery is another method of repair but is rarely used to treat eye avulsions. Sometimes botulinum toxin is injected into the eyelid to paralyze the muscles while the eyelid heals.
Trauma to the nail can cause the nail plate to be torn from the nail bed. Unlike other types of avulsions, when a nail is lost, it is not typically reattached. Following the loss of the nail, the nail bed forms a germinal layer which hardens as the cells acquire keratin and become a new nail.
Until this layer has formed, the exposed nail bed is highly sensitive, and is typically covered with a non-adherent dressing, as an ordinary dressing will stick to the nail bed and cause pain upon removal. In the average person, fingernails require 3 to 6 months to regrow completely, while toenails require 12 to 18 months.
SIGNS AND SYMPTOMS IN GENERAL
- The signs and symptoms depend on the wound site, depth and causative agent.
- In general, wounds present with pain, redness, swelling, bleeding and loss or impairment of function to the wounded area.
- Symptoms may include fever, malodorous pus drainage and heat, particularly in cases of infection.
- Infections: Wound infection presents with pus drainage, foul odour, fever, dull throbbing pain, mild swelling and heat at wound site.
- Inflammation: Inflamed wounds are hot, red, painful, swollen and hard to move.
- Scarring: Regenerated cells have different characteristics and fibrous tissue that can heal the wound, but may leave a scar behind.
- Loss of function: Many wounds can be disabling and life threatening if a major organ, blood vessel or nerve was damaged.
- Either way, while the wound is still fresh or healing, the affected limb or area will lose its functionality until all lost or damaged tissue is repaired.
HEALING OF WOUND:
Healing is nothing but the body response to injury in an attempt to restore normal structure and function.
Wound healing, or wound repair, is the body’s natural process of restoring normal function and structure after injury.
Once the protective barrier is broken, the normal (physiologic) process of wound healing is immediately set in motion. The process of healing involves two distinct processes.
Regeneration means when healing takes place by the proliferation of parenchymal cells and usually results in complete restoration of the original tissues. Some parenchymal cells have short life while others have a longer life span. If tissue injury is severe or chronic and results in damage of both parenchymal cells and the stromal framework of the tissue, healing cannot be accomplished by regeneration.
Repair means when the healing takes place by the proliferation of connective tissue elements resulting in fibrosis and scarring. Repair is the replacement of the injured tissue by fibrous tissue.
Two processes are involved in repair:
- Granulation tissue formation
- Contraction of wounds.
Granulation tissue formation:
The term granulation tissue derives its name from slightly granular and pink appearance of the tissues. In the formation of granulation tissue three Phases are observed:
- Phase of inflammation: Following trauma blood clots appears at the site of injury.
- Phase of clearance: Combination of proteolytic enzymes liberated from neutrophils, autolytic enzymes from dead tissues, and phagocytic activity of macrophages clear off the necrotic tissue, debris, and red cells.
- Phase of ingrowth of granulation tissue: This phase consists of mainly two process; angiogenesis or neo-vascularization and fibrogenesis.
Contraction of Wounds:
The wound starts contracting after 2-3 days and the process is completed by the 14th day. During this period the wound is reduced by 80% of its original size. Healing of the skin over lying the wounds provides a classical example of combination of regeneration and repair. This can be accomplished in one of the following two ways.
- Healing by first intention (primary union)
- Healing by second intention (secondary union).
Healing by first intention:
The sequence of events are:
Initial haemorrhage: Immediately after injury, the space between the approximated surfaces of incised wounds is filled with blood which then clots.
Acute inflammatory response: This occurs within 24 hours with appearance of polymorphs from the margins of incision.
Epithelial changes: The basal cells of epidermis from both the cut margins start proliferating and migrating towards incisional space in the form of epithelial spurs. The migrated epidermal cells separate the under lying viable dermis from the overlying necrotic material and clot.
Organisation: Fibroblast invade the wound area.
Suture tracks: Each suture track is separate wound and incites the same phenomena as in the healing of primary wound.
Healing by second intention:
The sequence of events is:
Initial haemorrhage: As a result of the injury the wound space is filled with blood and fibrin clot which dries.
Inflammatory phase: There is an initial acute inflammatory response followed by the appearance of macrophages which clear off the debris as in primary union.
Epithelial changes: Epidermal cells from both the margins of wound proliferate and migrate into the wound in the form of epithelial spurs till they meet in the middle and re-epithelialise the gap completely.
Granulation tissue: The main bulk of secondary healing is by granulations
Wound contraction: Due to the action of myofibroblasts present in granulation tissue the wound contracts. Bacterial contamination of an open wound delays the process of healing.
COMPLICATIONS OF WOUND HEALING
Major complications are:
- Deficient Scar Formation: Result in wound dehiscence or rupture of the wound due to inadequate formation of granulation tissue.
- Excessive Scar Formation: Hypertrophic scar, Keloid, Desmoid.
- Exuberant Granulation (Proud flesh).
- Deficient Contraction (in skin grafts) or excessive contraction (in burns).
- Others: Dystrophic calcification, pigmentary changes, painful scars, inscisional hernia etc. During the course of healing following complications may occur:
A. Infection of wound due to entry of bacteria delays the healing.
B. Implantation cyst formation may occur due to persistence of epithelial cells in the wound after healing.
C. Excessive contraction: An exaggeration of wound contraction may result in the formation of contractures or cicatrisation.
Ex: Dupuytren’s contracture, plantar contracture etc.
FACTORS INFLUENCING HEALING:
- Infection which delays the process of healing.
- Poor blood supply to wound slows healing.
- Foreign bodies interfere with healing.
- Movement delays wound healing.
- Age: wound healing is rapid in young and somewhat slow in aged and debilitated people due to poor blood supply.
- Nutrition: deficiency of constituents like protein, vitamins, etc delays wound healing.
- Uncontrolled diabetes delays wound healing.
- Haemotological abnormalities delays wound healing.
- In treatment of all wounds the aim is to have primary healing without pus formation.
- All wounds should be thoroughly cleansed with plenty of soft soap and water. The skin around it should also be thoroughly cleaned. If necessary it may be shaved.
- All foreign bodies and dead tissues should be removed.
- Skin edges if lacerated may be trimmed. Bleeding should be stopped by tying the blood vessels. All dead space should be explored.
- If however pus formation has occurred; when wound gets infected a drainage tube should be left to drain out the pus or partial stitching may be done.
- Grossly infected wound can be left as such and dressed. When pus formation gets controlled then secondary stitching is undertaken.
SURGICAL MANAGEMENT AS AND WHEN REQUIRED.
- PLAN OF TREATMENT
- For the treatment of all wounds the aim is to have primary healing without pus formation and the homoeopathic remedy is selected based on the categorization of wounds.
- This depends upon the phase of wound healing. (Phase of inflammation, phase of clearance, phase of ingrowth of granulation tissue).
- For asepsis all wounds should thoroughly cleaned with plenty of soap and water and proper dressing should be done.
- Lower potency & repetition of the dose can be decided considering the pain and discomfort of the patient.
- During the process of wound healing medium potency can be given.
BASE OF TREATMENT:
- Depending upon the cause and type of injury homoeopathic approach may vary.
- The medicinal dosage depends upon the severity and type of wounds.
- Tinctures, and ointments are advisable to use as external applications and they should be used along with proper internal medication.
- It acts on the muscles, tendons, nerves, etc.
- Produces a condition similar to Lacerated injuries with the solution of continuity of skin with suppuration.
- It is suitable in all cases of injuries where the skin is broken.
- It prevents suppuration and brings about healing promptly.
- This remedy corresponds to ragged wounds with or without loss of substance, accompanied with soreness and pain.
- It reduces inflammation and promotes healthy granulations.
- Useful in case of gunshot injuries also.
- To get its best effects it should be applied externally and given internally at the same time.
- Useful for open wounds, parts that will not heal etc.
- Indicated remedy for clean cut wounds, wounds with or without loss of substance, sharp cutting pains.
- The chief action of arnica is on blood and blood vessels, particularly on capillaries.
- It is generally believed to possess the power of absorbing extravasated blood.
- Arnica plant was used in any injury from falls, mechanical injuries etc. in ancient times.
- Trauma in all its varieties and effects, recent or remote is met by arnica.
- It suits particularly for soft part injuries which accompany fractures, dislocations, bruises, ecchymosis etc.
- It has the greater power of delaying and preventing suppuration.
- It is used in case of long-standing injuries, concussion of the brain or spinal cord etc,
- Marked effect on the blood, affects the venous system inducing stasis.
- Ecchymosis and haemorrhage.
- Relaxed blood vessels, black and blue spots.
- Sore, lame, bruised feeling.
- Mainly acts upon the muscular fibres of the blood vessels.
- It also acts upon the muscles and tendons; it causes injuries to the deeper tissues, after major surgical work.
- Traumatism- of the pelvic organs with sore, bruised feeling in the pelvic area
- It produces stasis and fag, swellings of all kinds is the keynote.
- Mainly indicated for sprains and contusions, railway spine, bad effects of icy coldness when overheated with sore lame sensation.
- Sprains & bruises. Traumatic neurosis.
- Venous congestion due to mechanical causes.
- It is a valuable remedy for old labours, especially gardens.
- Ecchymosis, parts are very sensitive to touch.
- Useful in deep trauma or septic wounds.
- It removes the bad effects of auto traumatism.
- Its seat of action is mainly on the skin, serous and mucous membranes, fibrous tissues, circulatory system and joints.
- It produces extravasations of blood causing ecchymosis of lids and conjunctiva.
- The action of Ledum on the skin retards capillary circulation, especially on the external surface of the body and the extremities.
- Used for any wound or puncture that is deeper than it is wide.
- Ledum lotion is helpful for punctured wounds and sprains.
- Used in case of contusion of an eye caused by a blow, especially
- There is much extravasation of blood, causing ecchymosis of lids and the conjunctiva.
- The injured part remains cold and numb.
- Long discolouration after injuries.
- Haemorrhage into the anterior chamber of eyes after iridectomy.
- Pain is as if the whole body is bruised and beaten.
- Its action directly influences the spinal cord, brain and whole nervous system.
- It suits to mechanical injuries of spinal cord, bad effects of spinal concussion and pain after fall on coccyx.
- It produces injury to the sentient nerves.
- It modifies and arrests ulceration, sloughing and tetanus after traumatic injuries.
- For puncture wounds.
- Indicated for incised, lacerated wounds, crushed fingers.
- For severe concussions of the spine and the brain.
- This remedy heals injured areas, which have a rich nerve supply.
- Indicated in case of wounds got from splinters, needles etc.
- Lacerated wounds with much prostration from loss of blood.
- Useful for chronic wounds such as old ulcers or sores in the mouth when very sensitive.
- A great remedy for injuries to nerves, especially of fingers, toes, and nails.
- Relieves pain after operations.
- Quite supersedes the use of morphia after operations.
- It acts upon the skin, and causes inflammation.
- It causes bad effects of injuries from sharp cutting instruments and post-surgical operations.
- There is a mechanical injury, from sharp objects, that produces a cutting type of pain.
- It acts upon the tissues causes laceration of tissues.
- Indicated for surgical wounds, which is slow to heal.
- Sphincters become lacerated or stretched.
- There is a keynote of a sensitive episiotomy scar.
- The scars become indurated, thick and painful.
- Indicated in case of mechanical injuries from sharp cutting instruments.
- The skin becomes very sensitive after a surgical incision.
- For post- surgical operations, with stinging and smarting pain like the cutting of a knife.
- The special seat of action of Nitric acid is at the junction of skin and mucous membranes of the body.
- It mainly acts upon the inflammatory phase of wound healing.
- It disorganises the blood causing decomposition; it produces intense irrigation, resulting in inflammation, destruction and ulceration of the parts.
- Regulates various cellular activities of the inflammatory phases of the wound.
- For penetrating wounds.
- For wounds which heal very slowly.
- Indicated in case of the proliferative phase of a wound.
- It is an excellent remedy for haemorrhages from anywhere and everywhere.
- The character of the blood is bright red or may also be dark, but profuse and coagulable.
- Sticking, Pricking, Lancinating and Splinter-like pain.
- It acts upon the skin and mucous membrane.
- It disorganises and decomposes the blood, making it more fluid and non-coagulable.
- It acts upon the blood vessels and produces haemorrhage and malignant inflammation, ecchymosis etc. Profuse blood oozes following an injury.
- Wounds due to bites of poisonous animals.
- Indicated for wounds from cuts, dissecting.
- For bleeding wounds.
- For wounds due to constitutional effect.
- Useful for chronic wounds such as varicose ulcers, bed sores, with black edges.
- Small wounds bleed easily and profusely.
- Bleeding with malignant and aesthetic inflammation, gangrene and pyaemic condition.
- The Character of blood is dark, watery, offensive and non-coagulable.
- It acts upon cellular tissue, it causes oedema of the skin and mucous membrane.
- Mainly used for puncture wounds, and bites from insects.
- Skin is very sensitive to touch with stinging, burning, pricking and smarting type of pain.
- Apis acts especially on outer parts, skin, and coatings of inner organs producing constricted sensations.
- For painful wounds.
- Affected parts become extreme sensitive to touch and general soreness is marked.
- Rosy or red inflamed spots on the skin with swelling.
- Burning, soreness and stinging pain.
- Purple spots on extremities.
- Indicated for formation of gangrene.
- Character of the pain is burning, stinging and soreness, suddenly migrating from one part to another.
- It acts upon the skin and blood vessels.
- Produces haemorrhages from all the orifices of the body, from wounds or of mechanical origin; painless haemorrhage.
- Blood is bright red and fluid.
- Profusely bleeding wound especially after fall.
- Is one of the haemorrhagic remedies.
- Bleeding is bright red is usually profuse.
- Haemorrhages, painless, without fever, bright red, fluid blood, from lungs, bronchi, larynx, mouth, nose, bladder, rectum, and uterus.
- Bad effects from falling from a height, over lifting.
- It causes bruised soreness and congestion, and is a valuable remedy for profuse, painless, bright red fluid haemorrhages.
- Oozing of blood from edges of closed wounds.
- Ill effects of operations, fall from a height, sprains.
- Das, Concise Text Book of Surgery 10th Edition reprinted in March 2019
- SRB’s Manual of Surgery, 6th 2019, Sriram Bhat M
- Hand Book of Surgery by S. C. Basu. 2nd Edition reprinted in 2005
- Pocket Manual Of Homoeopathic Materia Medica, Boericke William, M.D
- Clinical Materia Medica. Farrington. E.A., M.D.
- A Dictionary of practical materia medica Clarke Henry John, M.D.
- Homoeopathic Therapeutics. Samuel Lilienthal. M.D.