Dr'G'Srinivasulu

1
GANGRENE

• Dr.G.Srinivasulu
• Asst.Professor,
• Dept. of Organon of Medicine
• J.S.P.S.Govt.Homoeopathic Medical College
• HYDERABAD
• E-mailsrinivasulugadugu_at_gmail.com
• Mobile[phone]
• _______________________________________________
• REORIENTATION TRAINING PROGRAM IN PATHOLOGY
  MODULE IV
• 20-6-2009, Vinayaka Mission Homoeopathic
• Medical College, Salem

2
(No Transcript)
3
MY SALUTATIONS TO THE MASTER
4
This paper is dedicated to Padmasri
Dr.K.G.SAXENA, First Homoeopathic Advisor to
Govt. of India, Founder of I.I.H.P. Father of
Qualified Indian Homoeopathic Doctors
5
"Great people are great because they solve
countless seemingly unsolvable problems you can
too.. if you choose to." Mark Victor Hansen
6
can we reverse this condition ?
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
(No Transcript)
22
Abstract

• A case of diabetic foot gangrene, advised for
  amputation, was treated with homoeopathic
  medicines. The gangrenous foot was not only saved
  from amputation but completely healed up beyond
  the expectations of attending/supervising General
  and Orthopedic Surgeons in a multidisciplinary
  health care hospital at Hyderabad.

23
Patient Details

• Name Mrs. X
• Age 45 Years
• Gender Female
• Profession Housewife
• Marital Status Married
• Address Hyderabad
• Date of Admission 13-7-2006

24
Chief Complaints with duration

• 1. Ulcer over Left Foot Sole and dorsum since
  12 days
• 2.Numbness of both lower limbs since 1 year

25
History of presenting complaints

• The complaint started 12 days back when an hot
  application made of the cashew nut shell was
  applied for the left foot for a nail prick
  injury. Initially a blister appeared with fever
  and chills, later the blister bursted and
  transformed into an ulcer. Burning pain in the
  affected part, numbness in both lower limbs
  present since 1 year.

26
History of Past Illness and treatment

• She was a known diabetic ( type II) since 2 years
  and was on oral hypoglycemic agents with
  fluctuations in sugar levels. Her blood pressure
  was found to be high ( 180/110 mm of Hg.) when
  she has reported with the present complaints.
  Previously there was no significant clinical
  history as per the patients narration and also
  from the attendants version.

27
Family History

• Father died of heart attack. Mother 90 years
  alive taking treatment for diabetes (type-II).
  Her sister is also taking treatment for diabetes.

28
Patient as a person

• PHYSICAL GENERALS
• Appetite Less usually, no change after present
  complaint
• Desires Cold water, spicy food
• Aversion Sweets
• Intolerance nothing
• Thirst Thirst for cold water, dry mouth
• Bowel habits Once daily, normal
• Sleep Refreshing
• Dreams Nothing specific
• Perspiration cold perspiration whole body in all
  seasons lt physical exertion
• Thermal Reaction hot patient, aggravation heat,
  summer
• Female Complaints Menarche at the age of 12
  years. Cycle at 30 days interval duration 5
  days, dark, red color, flow with no clots. Before
  marriage the cycle was once in 2 months, after
  marriage became regular 30 days cycle. No pain
  during menses

29
Mental Generals

• Loquacious
• Jealous
• Religious
• Sad

30
Life space investigation

• Patient was from a lower socio-economic status.
  The patient is an illiterate. Childhood history
  has no significant events. She has always been
  commented for overchatting and being jealous with
  her other friends possessions. She got married
  at an early age. She is a house wife. At one
  time, she had to sell vegetables due to financial
  problems.

31
General Physical Examination

• Dark brown complexion, large built. Weight 70
  kgs. Height 52, Anemia Nil, Jaundice
  Nil, Cyanosis Nil, Generalized Lymphadenopathy
  - Nil

32
ULCER

• Duration 12 days
• Pain Burning sensation
• Edges Ragged, everted
• Depth Up to bone and shows signs of
  gangrene
• Discharge No. previously pus
• Odour Absent
• Floor Reddish but there is blackish
  discoloration around showing signs of
  gangrene
• Lymph nodes Not palpable

33
Investigations on 13-07-2007
34
Diagnosis Foot Gangrene

• Routine CBC, Serum Creatinine Blood Urea levels
  are found to be within normal limits

35
Totality of Symptoms

• Bold personality
• Loquacious
• Religious
• Aggravation heat and summer
• Desires spicy food, cold water
• Aversion Sweets.
• Dry mouth with thirst for cold water
• Cold perspiration lt Physical exertion
• Diabetes mellitus
• Ulcer- Left Foot
• Ulcer Gangrenous
• Burning sensation in the affected limb
• Numbness of lower lims

36
(No Transcript)
37
Repertorial analysis and Evaluation

• Loquacious
• Heat sensation
• Cold water desires
• Spices desires
• Sweets aversion
• Diabetes mellitus
• Ulcer gangrenous, cold dry gangrene
• Ulcer lower limbs, gangrenous

38
Follow up criteria

• Subjective Burning sensation of the affected
  limb, Numbness of both lower limbs
• Objective ulcer Heating signs ( edges, floor,
  margins) through periodical photographs

39
First Prescription 13-7-2006

• Insulin given for sugar control- 10 units in
  morning 15 units in evening. No other
  medication given
• Diet restrictions advised. Regular dressing for
  the ulcer advised.
• LACHESIS 30 /1 d
• SL

40
Follow up -1 on 21-7-2006

• No improvement in the ulcer, worsening signs
  found. Insulin continued
• Diet restrictions advised. Regular dressing for
  ulcer advised.
• FBS-120 mgs/dl. PPBS 170 mg/dl.

41
(No Transcript)
42
Follow up -2 on 28-7-2006

• No improvement in the ulcer, worsening signs
  found. Insulin continued
• Diet restrictions advised. Regular dressing for
  the ulcer advised
• FBS-120 mg/dl. PPBS -176 mg/dl

43
Here the case was re analysed

• Since there was no response in spite of the
  perfect match of symptoms still. Does the case
  have irreversible pathology ?
• Is the drug selected wrong or the potecny
  selection wrong ?
• There is not enough time to wait also. Still the
  patient was addressed about things once again. At
  this stage the particular symptoms were given
  more importance than the constitution as such

44
(No Transcript)
45

• Gangrene dry, not discharging
• Black discoloration of the affected limb
• Burning in the affected limb
• It has been accidentally observed while dressing
  of the wound that the patient asked the attending
  nurse to keep the wound open for a long time and
  also asked the nurse to keep the fan high speed.
  Later the patient when enquired, replied that she
  liked to keep her wound exposed to direct cold
  breeze which ameliorated her the burning
  sensation. It may be a common symptom but still
  looked a little strange.

46

• 4. On close analysis of the case, it was found
  that the patient needed cold breeze from the
  nearest where one can easily grade off Lachesis ,
  as the Lachesis patient needs fanning from a
  distance.
• 5. Also Lachesis has not covered the rubric
  Diabetes mellitus in the repertorisation chart.
• 6. There came the thought ofCarbo Veg Secale
  Cor. Carbo Veg was excluded as its intense
  symptoms were not found. So we decided to try
  Secale Cor.

47
Follow up -3 on 5-8-2006

• Burning sensation slightly better, numbness same,
  ulcer showed sings of improvement. Insulin dosage
  reduced to 5 units morning 10 units evening.
• Diet restrictions advised. Regular dressing for
  the ulcer advised.
• FBS 110 mg/dl. PPBS 156 mg/dl.

48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
Follow up -4

• Burning sensation of affected limb reuced,
  numbness better, ulcer showing signs of
  improvement. Insulin stopped.
• FBS100 mg/dl PPBS -146 mg/dl
• Sac Lac /7 days

52
(No Transcript)
53
(No Transcript)
54
Follow up -5 on 6-9-2006

• Ulcer improvement seemed to be static, numbness
  same
• FBS 112 mg/dl PPBS 150 mg/dl
• Secale Cor 30 1d
• SL for 1 month

55
(No Transcript)
56
Follow up -6 on 07-10-2006

• Numbness relieved, ulcer healing well.
• FBS 110 mg/dl PPBS 140 mg/dl

57
(No Transcript)
58
Follow up -7 on 08-11-2006

• Ulcer healing well. No other symptoms. Oral
  hypoglycaemic drugs continued.
• FBS -112 mg/dl PPBS 150 mg/dl
• SAC LAC for 1 month

59
(No Transcript)
60
Follow up-8 on 10-01-2007

• Ulcer improvement seemed to be static. Oral
  Hypoglycaemic agens reduced -1/2 1/2
• FBS 110 mg/dl PPBS -180 mg/dl Hb A1C 8.0
• Secale Cor 30/1 dose
• SL for 30 days

61
(No Transcript)
62
Follow up -9 on 9-4-2007

• Ulcer healed up well. No other symptoms
• Diet restrictions advised.
• FBS 100 mg/dl PPBS -150 mg/dl HbA1C- 7.9
• Placebo for 1 month

63
(No Transcript)
64
Follow up -10 on 11-07-2007

• Ulcer healed up well. No other symptoms
• FBS -108 mg/dl PPBS 140 mg/dl Hb A1C -7.8

65
(No Transcript)
66
(No Transcript)
67
(No Transcript)
68
(No Transcript)
69
(No Transcript)
70
(No Transcript)
71
(No Transcript)
72
Gangrene  

• WHAT YOU SHOULD KNOW
• Gangrene is the medical term for the death of a
  patch of tissue.

73

• It can occur in the skin, the muscles, or even
  the internal organs.

74

• Symptoms usually start suddenly, then get
  steadily worse..

75

• The problem is most commonly found in the arms
  and legs

76

• It is a form of ischaemic necrosis with super
  imposed bacterial infection.

77

• It is a form of necrosis of tissue with super
  added putrefaction.
• This is a complication of Necrosis

78
Causes

• The death of tissue that defines gangrene begins
  when a section of the body loses its blood
  supply. It's often the result of a serious
  accident in which an arm or leg is crushed. Less
  commonly, it follows an internal blockage, such
  as a clogged or obstructed artery. There are
  three major types of gangrene

79
Types

• 1. Dry Gangrene
• 2. Wet Gangrene
• 3.Gas Gangrene

80
DRY GANGRENE
81
(No Transcript)
82

• It begins in the distal part of a limb due to
  ischemia
• E.g. Gangrene in the toes and feet of an old
  patient due to arteriosclerosis.

83
Causes of Dry Gangrene

• 1. Thromboanginitis Obliteran ( T.A.O.) or
  Burgers Disease
• 2.Raynauds disease
• 3. Trauma
• 4.Ergot Poisoning

84
MECHANISM

• It is usually initiated in one of the toes which
  is farthest from the blood supply.

85

• The gangrene spreads slowly upwards until it
  reaches a point where the blood supply is
  adequate to keep the tissue viable.

86

• A LINE OF SEPARATION is formed at this point
  between gangrenous part and the viable part.

87
PATHOLOGICAL CHANGES

• MACROSCOPIC
• 1. Affected part is dry, shrunken and dark black,
  resembling the foot of a mummy.

88

• 2.It is black due to liberation of haemoglobin
  from haemolysed R.B.C. which is acted upon by the
  hydrogen disulfide. Produced by bacteria
  resulting in formation of black iron sulphide.

89

• The line of separation with eventual falling off
  of the gangrenous tissue if it is not removed
  surgically.

90
Histological Changes

• THERE IS NECROIS WITH SMUDGING OF THE TISSUE. The
  line of separation consists of inflammatory
  granulation tissue.

91
Dry gangrene.

• This variety is free of infection. It is usually
  brought on by a blood clot, frostbite, or poor
  circulation that causes the tissues to become dry
  and shriveled.

92

Wet gangrene
93

• .

94

• This occurs in naturally moist tissues and
  organs.
• E.g. Mouth, bowels, Lung, Cervix, Vulva

95

• Diabetic foot is an example of wet gangrene due
  to high sugar content in the necrosed tissue
  which favors growth of bacteria.

96

• Bed Sores occurring in bed-ridden patient I due
  to pressure on sites like sacrum, buttocks and
  heels .

97

• It appears rapidly due to blockage of venous and
  less commonly arterial blood flow from
  thrombosis or embolism.

98

• The affected part is stuffed with blood which
  favors the rapid growth of putrefactive bacteria..

99

• The toxic products formed by bacteria are
  absorbed causing systemic manifestations of
  septicemia, and finally death.

100

• The spreading wet gangrene lacks clear-cut line
  of demarcation and may spread to peritoneal
  cavity accusing peritonitis.

101
PATHOLOGICAL CHANGES

• Macroscopic Affected part is swollen, soft,
  putrid,rootten and dark.
• Classic example is gangrene of bowel, commonly
  due to strangulated hernia, volvulus or
  intussception,
• This part is stained dark due to same mechanism
  as in dry gangrene.

102
HISTOLOGICALLY,

• there is Coagulative necrosis with stuffing of
  affected part with blood.
• Ulceration of the mucosa and intense inflammatory
  infiltration.
• Lumen of the bowel contains mucus and blood.
• The line of demarcation between gangrenous
  segment and viable bowel is generally not clear
  cut.

103
Wet gangrene

• In this form of the disease, dead tissue becomes
  a breeding ground for bacteriatypically
  Clostridium, which thrives in the absence of
  oxygencausing the area to become moist and
  foul-smelling.

104

• Signs/Symptoms
• Typically, the skin may look pale at first, then
  become red or bronze, and finally turn dark red
  or purple. Infection makes the skin warm and
  swollen. Inflammation at the site of the
  infection can become extremely painful as the
  tissue swells.

105
(No Transcript)
106
GAS GANGRENE

• It is a special form of wet gangrene caused by
  gas forming Clostridia ( Gram positive anaerobic
  bacteria) which gain entry into the tissues
  through open contaminated wounds, especially in
  the muscles, or as a complication of operation on
  colon which normally contains Clostridia.

107

• Clostridia produces various toxins which produce
  necrosis and edema locally and are also absorbed
  producing profound systemic manifestations.

108
PATHOLOGICAL CHANGES

• Grossly, the affected area is swollen, edematous,
  painful and crepitant due to accumulation of gas
  bubbles within the tissues.
• Subsequently, the affected tissue becomes dark
  black and foul smelling.

109
Microscopically,

• the muscle fibers undergo Coagulative necrosis
  with liquefaction.
• Large number of gram positive bacilli can be
  identified.
• At the periphery, a zone of leucocytic
  infiltration, edema and congestion are found.
• Capillary and venous thrombi are common.

110

• Gas produced by the infecting bacteria may
  produce a crackly sensation when the swollen area
  is pressed. The margins of the infection expand
  so rapidly that changes are often noticeable
  within minutes.

111

• A foul-smelling brown-red or bloody discharge may
  drain from the afflicted tissues, which are
  completely destroyed.

112

• Gas produced by the infecting bacteria may
  produce a crackly sensation when the swollen area
  is pressed. The margins of the infection expand
  so rapidly that changes are often noticeable
  within minutes. A foul-smelling brown-red or
  bloody discharge may drain from the afflicted
  tissues, which are completely destroyed.

113

• Elsewhere in the body, the infection soon
  produces sweating, fever, and increased heart
  rate. Left untreated, the victim will develop a
  shock-like syndrome with decreased blood
  pressure, kidney failure, coma, and finally
  death.

114
Care

• Because gangrene spreads rapidly, immediate
  treatment is essential. The goal is to prevent
  infection from spreading.

115

• Any dead tissue must be removed at once. Homoeo
  Medicines are needed to keep bacteria from
  attacking surrounding tissues

116

• Pain killers ( Apis, Belladonna etc.,) may be
  necessary and the doctor will also attempt to
  treat the underlying cause, restoring the
  disrupted blood supply if possible.

117

• Hyperbaric oxygen therapy (pure oxygen under high
  pressure) may also be administered, but offers
  varying degrees of success

118

• Unfortunately, in severe cases, amputation of the
  infected body part or parts, usually part of an
  arm or leg, is necessary to prevent the gangrene
  from attacking the rest of the body.

119
Risks

• Gangrene can be fatal if not treated immediately.
  The sooner treatment begins, the better the
  outcome.

120

• Amputation is a major risk. Additional
  complications as the infection spreads can
  include liver damage, kidney failure, shock,
  stupor, delirium, and coma.

121

• Gangrene is the death of tissue. It most commonly
  occurs in toes or fingers, usually because of a
  problem with the blood supply.

122
Causes

• Gangrene is commonly caused by severe arterial
  disease such as atherosclerosis, in which not
  enough blood can get through the narrowed
  arteries to the affected area.

123

• Diabetes also increases the possibility of
  gangrene, mainly by its effect on the blood
  vessels, but also by reducing the bodys ability
  to resist infection.

124

• Other important causes include embolism, blood
  clotting in an artery (Thrombosis) and severe
  arterial injury.

125
Symptoms

• The affected skin and tissue turn black.
  Gangrenous tissue has no feeling, but there may
  sometimes be considerable pain in the tissues at
  the borderline of the affected area.

126
Gas Gangrene.
127
Gangrene associated with critical
128
Gangrene of the Hand Sepsis ...
129

Gangrene!
130
Amputated Finger Due To Gangrene
131
Gangrene in Fingertips
132
(No Transcript)
133
Gangrene in Fingertips
134
infected foot with gangrene
135
BEFORE TREATMENT
136
DURING TREATMENT
137
AFTER TREATMENT
138
(No Transcript)
139
(No Transcript)
140
(No Transcript)
141
(No Transcript)
142
(No Transcript)
143
(No Transcript)
144
(No Transcript)
145
(No Transcript)
146
(No Transcript)
147

148
(No Transcript)
149
(No Transcript)
150
(No Transcript)
151
(No Transcript)
152
(No Transcript)
153
(No Transcript)
154
(No Transcript)
155
(No Transcript)
156
(No Transcript)
157
(No Transcript)
158
(No Transcript)
159
(No Transcript)
160
(No Transcript)
161
(No Transcript)
162
(No Transcript)
163
(No Transcript)
164
(No Transcript)
165
(No Transcript)
166
(No Transcript)
167
(No Transcript)
168
A picture's worth a 1000 words

• Adi Dinshaw Mistry ex-Mr Bombay lost a toe to
  diabetic foot. Yet his daughter, a practising
  allopath, opposed homeopathic treatment when the
  condition developed in his other foot. Mistry
  however, insisted and was eventually cured. These
  pictures bear testimony to that.
• Mr Mistrys foot affected by the diabetic foot
  condition
• When his condition worsened, Mr Mistry
  volunteered to follow the homeopathic treatment
  for his problem
• The homeopathic treatment cures Mr Mistry in a
  record span of 15 days

169

• Mr Mistrys foot affected by the diabetic foot
  condition

170

• Mr Mistrys foot affected by the diabetic foot
  condition

171
The homeopathic treatment cures Mr Mistry in a
record span of 15 days
172

• "No matter how dark things seem to be or actually
  are, raise your sights and see the possibilities
  always see them, for they're always there.
• Norman Vincent Peale

173
When we put love and enthusiasm into what we do,
it rebounds in the form of opportunities and
blessings, two of the most important ingredients
of a truly wealthy life
174
Thank you one and all