Monday, October 29, 2007
In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favorable as possible for the body to heal itself. For without the body's amazing powers of defense and repair, nothing we do -- especially we surgeons -- would be lasting at all. The most immediate and palpable reminder of this is the process of sewing someone up, and watching what happens.
Wound healing is a wonderfully complex process, and it would be folly for me to attempt explanation in detail; mainly, because I've forgotten the pathways, the kinins and the prostaglandins involved. I'm not going to look it up again, but you can if you like. Anyone who's had an operation, from minor to a big deal, has had the opportunity to witness it. Maybe you were too sore to be in awe. But I always liked to point out the easy evidence to my patients.
I've gotten calls about red incisions (despite trying to explain it in advance.) Of course, it's necessary to separate the natural from the infected (digital photography and email have been known to save an office visit, for the technologically inclined); but all incisions get red for at least a few millimeters out from the cut. An inflammatory response, it's the process of bringing the building materials into the work site: capillaries dilate and proliferate, blood flow increases. That, and much more, goes on under the surface as well. Attracted by "injury chemicals," various cell types arrive and unload their cargo, set up lattice work, induce structural changes. The result of the influx is a gradual thickening and hardening of the area for an inch wide or more, and which carries the unofficial-official name "healing ridge." When the ridge isn't there, you know there's trouble ahead. In the very ill, in people on high-dose steroids, in the malnourished, a soft and non-pink incision is an unwelcome and unhappy harbinger.
As much as feeling the healing ridge can alarm the unexpecting, it's a sign of health, the indication that help is on the way, that work is going on to effect healing. I'd warn people. To hernia patients, I'd say, "In a few days it's going to feel like a sausage under there. You might think the hernia is back." Or, after removing a lump of some kind from some place, "In three weeks, you'll think I didn't remove it at all." It takes many weeks for the ridge to melt away. The zone of redness dims, but the incision itself gets increasingly red, and doesn't simmer down for a year or more. (It also fades after the application of vitamin E, of ear wax, and of snake-oil, singly or in combination.) It's a living monitor of how long healing is active. Given an explanation of what's going on, surgipatients get a ridge-id ringside seat from which to watch the body do its work. (A corollary is the tiredness that most everyone feels after surgery. There's lots of work going on, I'd tell them. While you're lying around feeling lazy, your body is doing the equivalent of walking around all day. Give yourself a break.)