LECTURE 10
PURULENT DISEASES OF CELLULAR TISSUE AND ORGANS
Classification of the surgical infections:
1. Acute surgical infections.
2. Chronic surgical infections.
Acute purulent surgical infections
1. Acute purulent aerobic infections.
2. Acute anaerobic infections.
3. Acute specific infections.
4. Viral infections.
Acute Purulent Aerobic Infections
The cause of the most frequently purulent surgical infections it’s:
1. Staphylococcal infections.
2. Streptococcal infections.
4. Mixed bacterial infections.
Staphylococcal infections
A large number of infections encountered in surgical practice are caused by Staphylococcus aureus. It is an important pathogen in postoperative wound infection and in infections following penetrating wounds. The lesions produced by S. aureus are characteristically localized with an indurated area of cellulitis that undergoes central necrosis and abscess formation with a thick, creamy, odorless, and yellow or cream-colored pus. Bacteraemia may occur, with the development metastatic abscesses. Fever and leukocytosis are usually present. Antibiotic- resistant bacteria of increased virulence often cause those infections acquired during the course of hospitalization. Recent studies have shown that the emergence of new bacteriophage type Staphylococcus aureus may occur spontaneously.
Streptococcal infections
A variety of streptococcal organisms produce infections seen in surgical practice. The most frequent of these is Streptococcus pyogenes, although others such as S. viridans, Pepto-streptococcus, aerophilic streptococcus, and S. faecalis (Group D enterococci) may be encountered.
The lesions caused by S. pyogenes are characteristically invasive with a rapid course. Full-blown infections are often seen within 12 to 24 hours after the time of contamination, but may occur as late as 1 or 2 weeks. The infections are characterized by diffuse cellulitis, lymphangitis, lymphadenitis, and extension of the inflammation along fascial planes. Thin, watery pus may develop, but frank abscess formation rarely occurs.
Several specific disease syndromes are related to streptococcal infections. Among these is erysipelas, which is most often produced by the haemolytic streptococci. It usually occurs in the epifascial tissues and skin although it may develop at other sites of trauma or surgical incisions. After an incubation period of 1 to 3 days, fever, chills, rapid pulse, and severe toxaemia develop, associated with a spreading superficial cellulitis that has a characteristic appearance with an indurated, raised, and irregular margin. These infections are often self-limited, and improvement is seen within a period of 4 to 8 days.
Acute, recurrent lymphangitis may also result from infection with S. pyogenes, which usually has its portal of entry through small cracks in the skin.
Infections caused by Gram-negative bacilli
A variety of gram-negative bacteria indigenous to the genitourinary and gastrointestinal tracts of humans may cause surgical infection. Wound infection by these organisms usually results from operative contamination of spilled gastrointestinal content and may be related to improper surgical technique. In other instances of wound infection or invasive systemic infection, these organisms act as opportunistic invaders and most frequently cause infection when there is impairment of the host defense mechanisms, as previously discussed. They are frequent pathogens when there has been bacterial contamination from exogenous sources of incompletely removed devitalized tissue in burns and in infections associated with perforations of the gastrointestinal or genitourinary tract. Gram-negative infections are often polymicrobic, with both anaerobic and aerobic organisms, but are ofteot recognized as such because anaerobic cultures are infrequently done on a routine basis in clinical practice. Postoperative wound infections caused by enteric bacilli usually have a longer incubation period than those caused by the staphylococcus or streptococcus.
In all cases of inflammation there are specific signs. The patient feels ill, the degree depending upon the size of the pathological process, the virulence of the organism, and tension within the cavity. The temperature is elevated. In severe cases rigors may occur.
Five classical local signs of inflammation are:
1. Heat-the inflamed area feels warmer than the surrounding tissues.
2. Redness of the skin over the inflamed area.
3. Tenderness, due to the pressure of exudates on the surrounding nerves.
4. Swelling.
5. Loss of function-an inflamed tissue does not perform possible its physiological function.
Purulent infection penetrates through small injuries to the skin (so-called minor traumatism). In such cases a purulent process most frequently develops because the patients at first fail to pay proper attention to their affections and are not given timely and required aid. If aid is administered in due time (the wound is painted with iodine tincture and a sterile dressing is applied), i.e., the wound is protected against contamination, purulent diseases develop only in exceptional case.
Failure to observe the rules of personal hygiene (dirty body, scratches, etc.) is favors development of purulent infection.
Penetration of bacteria deep into the tissue does not always result in development of a purulent inflammatory process. A pathological process may develops or fails to develop, depending on the inborn and acquired properties of the body (age, sex, nutrition, mental state, etc.), which determine its inter-relations with the pathogenic factor.
In some cases, under the influence of purulent infection only a local reaction in the form of an inflammation of the tissues at the point of entrance of pyogenjc bacteria develops. But usually the process does not end there and a general reaction manifested in rather marked disturbances throughout the body develops.
The clinical picture of the disease develops according to the virulence of the microbes, which have gained entrance into the body and the state of the natural defensive powers of the latter.
Boil (Furuncles)
Boil constitute one of the very widespread purulent diseases of the hair follicle and sebaceous.
The disease begins with an appearance of a painful infiltrate in the skin in the form of an inflammatory node differing in size from a pea to a pigeon egg; the skin grows red over the swelling and local pyrexia is observed in the region of the focus. The disease develops over a period of 4 – 6 days, and a purulent blister (exfoliation of the epidermis by pus) is formed at the most protruding part of the swelling. A focus consisting of a necrotic gland with surrounding subcutaneous tissue is found under this blister; the subcutaneous tissue is subsequently discharged together with the pus (the core of the boil). The remaining small cavity fills with granulations and heals.
Complications:
a) boil may lead to cellulilis, particularly in those whose power of immunity is less.
b) boils may also lead to infection of the neighboring hair follicles where numbers of hair follicles are too many (e.g. axilla) leading to hidradenitis.
a) boils usually secondarily infect the regional lymph nodes.
Treatment:
- The general health of the patient has to be improved, as boils often occur in individuals with debility and ill-health.
2. Incision is usually unnecessary as the pustule is very small. Only a touch of iodine on the skin pustule will hasteecrosis of the overlying skin and help the pus to drain out.
3. If escape of pus does not occur spontaneously or with application of iodine, removal of the affected hair allows ready escape of pus.
4. Antibiotic is usually not required. It is possible when multiple boils appear or if boils recur.
5. After escape of pus this placed should be cleaned twice with a suitable disinfectant e.g hexachlorophene. This discourages development of further boils.
6. If boils are recurrent, diabetes should be excluded.
Carbuncles
After penetration of pyogenic bacteria under the skin through hair follicles and sebaceous glands the process spreads in depth, if the conditions are unfavorable to the body, and affects considerable sections of subcutaneous tissue. It is an infective gangrene of the subcutaneous tissue due to Staphylococcal (Staphylococcus aureus) infection. Gram-negative bacilli and Streptococci may be found coincidently.
Sites Carbuncles are mostly seen on the back, in the nape of the neck where the skin is coarse and vitality of the tissue is less. The shoulders, the cheek, dorsum of the hand are the other rare sites. Hirsute portions of the chest and abdomen may also be involved.
Pathogenesis. When the invading staphylococci penetrate the deeper layers of the skin and the subcutaneous fat, a carbuncle is formed. This consists of a series of communicating abscesses, which discharge by separate openings on the surface. That is why the surface is sieve-like. Individual compartments in the carbuncle are maintained through persistence fascial attachment to the skin. Carbuncles may be more extensive than they appear. There is a central large slough, surrounded by a rosette of small areas of necrosis. In untreated cases infection may extend widely with fresh openings appear on the surface, which coalesce with those previously formed. Under treatment when the central slough is drained off, fibroblastic reactions start from the surrounding granulation tissue and carbuncle heals with a characteristic indurations.
Clinical features It generally affects males above 40 years of age. Often the subject is diabetic.
It commences as painful and stiff swelling which spreads very rapidly with marked indurations. The overlying skin becomes red, dusky and oedematous. Subsequently the central part softens and a multiple of vesicles appear on the skin. Later these vesicles transform into pustules. These pustules subsequently burst allowing the discharge to come out through several openings in the skin producing a sieve-like or cribriform appearance. These openings enlarge and ultimately coalesce to produce an ulcer. At low floor of the ulcer lies the ashy-grey slough. Finally the slough separates leaving an excavated granulated fascia, which heals by itself. When the resistance of the individual is poor in diabetic subject, the sloughing process may extend deeply into the muscle or even bone.
Constitutional symptoms and toxemia vary according to the degree of the resistance of the individual and to result of the treatment.
Treatment:
a) improvement of the general health of the patient should be brought about.
b) proper antibiotic should be started immediately from the culture and sensitivity test. If the surface openings have not formed, synthetic penicillins may be used. At this time a paste composed of anhydrous magnesium sulphate and glycerin may be applied or S. Mag Sulph powder is used on a moisten cotton and placed on the affected area. This will exercise a valuable osmotic effect and will not only reduce oedema but also will help to burst the carbuncle. Hot compress is helpful before bursting. It may be supplemented by infra-red or short wave diathermy.
Operation may be required:
a) when toxemia and pain persist even after a course of antibiotics and
b) when the carbuncle is more than
Technique. A large cruciate incision is made extending up to the margin of the inflammatory zone. Sloughs should be cleared with a piece of gauze. Epices of the four skin flaps are generously excised. The wound is covered by gauze with Vaseline or sofratulle dressing. The part should be kept in perfect rest for a week and antibiotic is continued till resolution.
Abscess
An abscess is a collection of pus. The suppurative infection gradually leads to cell death and liquefaction. The toxins of pyogenic organisms kill both tissue cells and those of the exudates. Liquefaction of the dead tissue is caused by proteolytic enzyme released from the dead polymorpho-nuctear leucocytes. The resulting yellow alkaline fluid is called “pus”. It contains both disintegrating and living leucocytes and living and dead bacteria.
An abscess is a cavity filled with pus and lined by a pyogenic membrane. This pyogenic membrane consists of dead tissue cells and a wall of granulation tissue consisting for the most part of phagocytic histiocytes.
As recovery starts this pyogenic membrane is converted into fibrous tissue and the cavity is gradually covered with granulation tissue, which transforms into collagen fibres.
Sometimes the abscess cavity persists, it becomes firm and contains sterile pus. The firmness is due to thickness of its wall. This is known as “antibioma”. This is due to continuous administration of antibiotics. The lump may even be hard, when it may mimic a carcinomatous lump.
Clinical features. Cardinal features of acute inflammation are usually present. These are: a) rubor—there is redness over the area particularly before localisation of the abscess. This is due to hyperaemia.
b) dolor— is a throbbing pain is characteristic of presence of pus.
c) color— the inflamed area is hot due to hyperaemia (e.g. in cold abscess this is not present and that is why it is called “cold”).
d) tumor— is swelling of the soft tissues, due to presence of pus inside the abscess cavity.
e) functio laesa — the function of the part is definitely impaired. This is more obvious when an abscess occurs near a joint, when movement of the joint will be painful and patient tries not to move the joint.
Special Investigations Nowadays various sophisticated investigations have been introduced to correctly located and accurately diagnosed abscess cavities in different parts of the body. The various methods are:
a) conventional radiology is only successful when there is air or gas with pus. This examination then reveals fluid levels, e.g. subphrenic abscess, lung abscess, etc. Sometimes presence of pus is suggested by opacity, e. g. in the nasal antrum, pleural cavity, etc.
b) isotope scanning is helpful in locating collection of pus or site of infection by accumulation of radioactive technique after its intravenous injection. This is mostly used as diagnostic tool in demonstrating brain abscess, hepatic abscess and osteomyelitis. Similarly radioactive gallium scan is sometimes used to detect pelvic, perinephric, mediastinal or suprarenal abscesses.
c) ultrasound have considerable value in the diagnosis of gallbladder’ stones or empyema and also to detect abscesses in the liver or spleen.
b) CT scan is particularly helpful to distinguish between abscess and tumor by showing necrotic centre in case of abscess. It is helpful to locate abscess cavity inside the abdomen as also in the brain.
Treatment:
2. When the pus has been localized, it should be drained. The old adage holds true today also where there is pus, let it out.
So the basic principle of treatment of an abscess is:
a) to drain the pus;
b) to send a sample of pus for culture and sensitivity test;
c) to give proper antibiotic.
Free or liberal incision In this technique a liberal incision is made on the most prominent part of the abscess so as to cause least damage to the surrounding healthy tissue. It should be placed on the most dependent part also, so that gravity will help drainage. Incision must be adequate (liberal) for easy drainage of pus and to avoid chronic.
If any important structure like nerve or vessel is liable to be present in the depth, the incision should be made parallel to these structures. This incision should be bold through the skin, subcutaneous tissue and deep fascia. The muscle should be incised along the line of the fibres.
Hilton’s method This method is chosen when there are plenty of important structures like nerves and vessels around the abscess cavity, which are liable to be injured. This is a particularly employed in place like neck, axilla or groin. In this technique the skin and subcutaneous tissue are incised on the most prominent and most dependent part of the abscess cavity. A pair of artery forceps or sinus forceps is forced through the deep fascia into the abscess cavity. The blades are gradually opened and the pus is seen to be extruded out. The forceps is now taken out with the jaws open to increase the opening in the deep fascia. A finger is introduced to explore the abscess cavity.
Exploration After the incision of the abscess cavity was executed and some amount of pus has been extruded, a finger is inserted into the abscess cavity and all the walls of the loculi are broken. There must not be any loculus unbroken as this will lead to chronicity. All loculi are broken into one cavity for complete drainage.
Counter-incision When the most prominent part is not the most dependent part, complete drainage of pus is not possible with a single incision. So a counter-incision is required at the most dependent part to facilitate drainage by gravity. In this technique, through the first-made incision on the most prominent part, a sinus forceps is passed to the most dependent part. The blades are slightly made apart, and then with a knife a fresh incision is made on the skin between the tips of the sinus forceps.
Drainage A corrugated rubber drain is usually used for drainage of an abscess cavity. When counter-incision is used, the drain extends from the first incision to the counter – incision. When the surrounding granulation tissue is bleeding too much, roller gauze should be packed inside the wound and it can be kept for 48 hours. Some surgeons believe in local application of antibiotics into the abscess cavity.
Follow-up Rest to the affected part is very important postoperative measure. This expedites healing.
Proper antibiotics selected by culture and sensitivity test should be started immediately.
After 48 hours the dressing or drain should be removed. Fresh dressing is done everyday with acriflavine lotion and sterile gauze. If the cavity has to be packed, the packing should be made gradually lighter to help the cavity to heal.
Necrosis of lung tissue due to localized area of lung infection is called a lung abscess.
Erysipelas
It is an acute inflammation of the lymphatic of the skin or mucous membrane. The causative organism is usually Streptococcus haemolyticus. The infection may be transmitted from one patient to another through the dressing material, hands of the medical personnel, instruments, etc. In erysipelas the disease begins with prodromal phenomena—general indisposition suddenly followed by excessive chills and a temperature of 40 –
The disease spreads from the site of inoculation and the advancing margin becomes bright, red and slightly raised above the general surface. The margin itself is irregular in outline. Just beyond the sharp margin the lymphatic are crowded with streptococci. The margin shows acute congestion. The lymph spaces of the corium of the skin are crowded with cells. The inflammatory cells are mainly lymphocytes and wandering mononuclear cells. It should be remembered that whereas in ordinary streptococcal infections the characteristic defence cell is the polymorpho-nuclear leukocyte, in erysipelas this cell is small mononuclear cell. The centre of the patch shows little change. There is notable absence of pus formation. Following the fading of the inflammation, brown discolouration of the skin may remain.
Clinical features The condition, which predisposes this disease are debilitating state and poor health. The condition commences as a rose-pink rash, which extends to the adjacent skin like a drop of grease spreading on a piece of paper. The vesicles appear sooner or later over the rash and rupture. Serous discharge comes out from these vesicles. Fever and other constitutional symptoms may be present with varying degrees. When it affects skin below which there is loose areolar tissues, e.g. orbit, scrotum etc., there is considerable swelling of the part due to edema of the subcutaneous tissues and thus very much resembles cellulites.
To distinguish between true erysipelas and cellulites, the following points in favor of erysipelas should be born in mind:
a) the typical rosy rash disappears on pressure and feels stiff;
b) the raised rash of erysipelas has a sharply defined margin, which is better felt than inspected;
c) the vesicles of erysipelas contain serum in contradistinction to the cellulites in which they contain pus;
d) in case of the face, Milian’s ear sign is significant in which erysipelas can spread into the pinna (being cuticular affection), whereas cellulites cannot spread to the pinna due to close adhesion of skin to the cartilage of the ear (without any areolar tissue).
The patient must be confined to bed, all pressure or rubbing bandages must be removed and the tissues around the redness must be painted with iodine to prevent the disease from spreading. Irradiation by an ultraviolet lamp is effective. The wounds, which served as the source of infection must be examined to see if any pus is retained under their edges and if the pus is being well discharged.
Daily is administration of antibiotics and sulfanylamides.
Lymphangitis
A spread of infection along the lymphatic system is manifested in a disease of the lymphatic vessels and lymph nodes. Inflammation of the lymphatic vessels (lymphangitis) is one of the frequent complications of infected wounds, especially during the first weeks following injury, and of local purulent diseases. Lymphangitis also develops in cases in which the discharge of pus from the wound is hampered, new infection gains entrance into the wound during dressing and during accelerated outflow of lymph, for example, as a result of untimely or vigorous movements of the affected organ.
The local manifestations of lymphangitis is appearance of longitudinal red lines on the skin along the course of the lymphatic vessels, i. e., inflamed superficial lymphatic vessels which are palpated as dense cords and are painful to touch. Simultaneously the adjacent lymph nodes (regional, for example inguinal or axillary) become swollen and painful; general phenomena in the form of chills and fever up to
The treatment of lymphangitis consists primarily in elimination of its cause (incision of the abscess, pockets of the wound, etc.) and in giving the affected organ complete rest. Confinements of the patient to bed in lymphangitis of the leg and splint bandages if the disease affects the arm are obligatory. The red lines and the region of the swollen lymph nodes are painted with iodine. Hot compresses and prescription of antibiotics are recommended. If pus is retained in the region of the wound, an attempt may be made to remove it (the pockets are opened, the crusts are taken off and absorbent dressings are applied).
Under the influence of the foregoing measures the inflammatory phenomena in the lymphatic vessels usually abate, the temperature drops within 2-3 days, the redness disappears and within a week everything returns to normal. In some cases purulent foci (abscesses) formed along the course of the lymphatic vessels. These abscesses are at first treated with the hot compresses and then incised. Early surgical treatment of purulent processes: incision of abscesses to diminish absorption of pus. Antibacterial treatment is used.
Lymphadenitis
In purulent processes the infection spreads through the lymphatic vessels and penetrates into the lymph nodes where it is retained. In infected wounds this is very frequently manifested in swelling, enlargement and painfulness of the adjacent lymph nodes. If the disease develops on the arm, the elbow and axillary nodes enlarge; if the disease is on the leg or in the region of the perineum or the anus the inguinal lymph nodes become enlarged. The infection sometimes gains entrance into the lymph nodes after lymphangitis and sometimes develops spontaneously without any visible inflammatory phenomena in the lymphatic vessels. Not infrequently the enlargement and painfulness of the lymph nodes disappear within 2-3 days because of a limitation of the inflammatory process, but sometimes further development of the process is observed. The painfulness sharply increases, a swelling in the region of the nodes appears, the temperature rises and general feverish phenomena develop. Sometimes the process in the region of the lymph nodes abates, but often the purulence extends from the node to the surrounding cellular tissue. The abscess thus formed is usually opened. Remains of necrotic lymph nodes are found in the depth of the cavity. Treatment of lymphadenitis is the same as that of lymphangitis, i. e., rest for the affected organ, hot compresses and fomentations of the region of the inflamed lymph nodes.
Phlebitis and Thrombophlebitis
The blood vessels constitute another way for the spread of purulent infection. Penetration of infection into the blood stream is not infrequently preceded by an inflammatory disease of the veins (phlebitis) with simultaneous thrombophlebitis. In thrombophlebitis the local manifestations are painfulness and indurations along the course of the veins, wich palpable as dense cord, is painful by touch. If large veins are affected, for example, the femoral vein, edema of the extremity and cyanosis develop.
In some cases the process may be arrested and the thrombus is gradually resorbed, but even in these cases the disease lasts several months. After thrombophlebitis the lumen of the vein usually fails to be restored, the vein is obliterated and blood circulation takes place only through collaterals. In other cases the thrombus may be dissolved. One or several abscesses may appear along the course of the affected vein; these abscesses either open spontaneously or are opened by a surgeon. With purulent dissolution of the thrombus (purulent thrombophlebitis) the process may extend with the blood stream and may lead to septicaemia.
In addition to thrombophlebitis caused by penetration of infection into the vascular bed, there are also nonpurulent forms of thrombophlebitis (phlebothrombosis) in which a certain part is played by haemostasis in varicose veins, disorders of metabolism and increased blood coagulation, for example, during the post-operative period, in cancer, vascular diseases and general disorders of the cardiovascular function, for example, in cardiac failure.
Treatment of thrombophlebitis consists primarily in giving the affected organ complete rest; to improve the conditions for blood outflow the organ must be placed in an elevated position. The patient may sometimes have to be in this position for several months, until the process has completely abated. It should be remembered that in thrombophlebitis any rubdowns and massages are strictly prohibited because they may induce the spread of the purulent process throughout the body and by carrying a disengaged blood clot in the blood stream may cause obstruction of important arteries (embolism), for example, the cerebral or pulmonary arteries. Leeches are not infrequently used in thrombophlebitis, five or six leeches being sticked to the skin of the extremity. Leeches clotting to prevent the progress of thrombosis by diminishing blood clotting, synthetic anticoagulants (dicoumarin, neodicoumarin, pelentan) are administered in thrombophlebitis. Since haemorrhages complications, which are possible during prescribing of anticoagulants, it is used permissible only with control of blood clotting (tests for prothombin) and systematic urine tests.
The blood is tested every third day. If the prothrombin index drops below 50, or erythrocytes appear in the urine and haemorrhages occur, usage of anticoagulants is discontinued. Sulfanilamids and penicillin therapy are used in cases of infectious thrombophlebitis.
Local treatment in thrombophlebitis consists in application of compresses with Vishnevsky’s ointment (resorbing action), followed by warm, preferably dry air baths. Physiotherapeutic treatment is resorted to very cautiously and gradually, and in the beginning consists merely of rest.
Thrombophlebitis patients must be strictly confined to bed; moreover, since thrombophlebitis of the lower extremities occurs most frequently, the foot on bed, especially in the beginning of the disease, must be raised. Failure to stay in bed may gravely complicate the course of thrombophlebitis, i.e., the thrombus may be carried by the blood stream and give rise to embolism in the pulmonary artery. This fatal disease sets in suddenly and develops rapidly. The patients complain of compression and pain in the chest and dyspnoea; pallor and cyanosis appear, the cardiac function declines and death soon ensues.
Prophylaxis Early exercise and rising during the postoperative period; proper treatment of the varicose veins. To prevent relapses general invigorating measures for the cardiovascular system, and prevention of venous congestion by wearing an elastic bandage or elastic stocking.
Mediastenitis – is purulent inflammation of friable connective tissue of mediastinum.
Aetiology and pathogenesis Pathogenic microorganisms are: staphylococcus, enterobacteriums, and rarely anaerobic bacteriums. The cause of the disease could be the damages of the esophagus by heterogenus body or damage at endoscopia, purulent complications after the operations on the esophagus, lungs, and heart. Rarely infection gets there by lymph (lymphogeneousely) from the oral cavity (at caries, infection of the tonsils).
Clinical features Diagnostics of mediastenitis is difficult because of primary process, which was the cause of the disease (pneumonia, phlegmon of the neck, damage of the oesophagus).
There are limited (abscesses) and spread (phlegmons) processes. Mediastenitis has no marked symptoms on the background of intoxication (fever is up to
At the back mediastenitises are characters: pain in the area between shoulder-blades, epigastrial area. At the wounds of the esophagus pain at the swallowing is typical. In the case of anaerobic and putrid processes there is observed emphysema of the mediastinum by X-ray examination. Sub skin emphysema is detected by palpation on the neck.
People who suffer from this disease are usually taking the forced position (they are sitting with the head bended forward).
One of the hardest complications is pressing on the vessels and nerves (aorta, pulmonal artery, vagus and diaphragmal nerves, sympatic trunk). In the result of it husky voice, hiccough, vomiting, fitting cough, breathlessness are observed. Purulent mediastenitis must be distinguished from the pneumonia, pleuritis, pericarditis, and tumors of the mediastinum, tuberculosis. To distinguish these diseases there are such methods are used: X-ray examination, oesophago- and mediastinoscopia, computer tomography.
Treatment must be started from the antibiotic therapy (semisynthetic penicillines, aminoglicosides and cephalosporines). At the presence of sings of abscessing and putrid inflammation operative treatment (mediastinotomia) is needed. Because of high mortality at this disease indications to the operation were enlarged. At anterior mediastenitises the section is made in the area of breastbone or in the epigastric area. There is widely used neck mediastinotomia by V.I. Razumovsky (the section is made along the internal side of noding muscle). Back mediastinotomia is usually made by the method of I.I. Nasilov (the section is made on the back along the spinal column with the additional two horizontal sections on the ends of the first section which allows cutting out the rags and after cutting the rib we can outpleuraly opening the back mediastinitis). It is very necessary at the operative treatment to make the aspiration of the pus with flowing bathing (double gaps silicone drainage tubes, aspirator with the osmotic pressure of 50-
Paranephritis – is purulent inflammation of the paranephral cellular tissue.
Aetiology and pathogenesis Pathogenic microorganisms are: staphylococcus, esherichia coli, rarely saprofits and anaerobic microorganisms. Disease begins in the result of direct infectioning at acute and chronic processes in the kidneys (purulent nephrirtis, pyelitis, abscess), rarely in the result of lymphogeneous infectioning at purulent processes in the abdominal cavity.
Clinical features In the first stages of the disease it is very difficult to make a correct diagnosis because of common symptomatic (chill, indisposition, general weakness and headaches) and not marked regional signs (pains in the small of the back, swelling, tissue edema). Pain very rare haz definite localization; the next stages edema has definite localization irradiate to the leg (especially at moving down of the abscess along the big lumbar muscle and formation of psoas-abscess). There can be reveled painful inflammatory infiltrate which has dense consistation in the lumbar area (sometimes in the right sub costal area). In the position on the stomach we can see lateral curvature of the lumbar part of the spinal column with deflection of spinal line in the healthy side, tension of muscles of the back. Disease is accompanied by changes in the urine: leucocyteuria, haematuria, cylindruria. Paranephritis should be distinguished from the phlegmon of the retroperitoneal cellular tissue, retroperitoneal acute appendicitis.
Treatment Therapy should be started from the antibiotic therapy (semisynthetic penicilines, aminoglicosides and cephalosporines). At the first signs of appearing of the abscess (hectic fever, pulsing pains) there is must be made lumbotomia with the wide oppening of the abscess. In the postoperational period there is used flowing lavage of the abscess, active aspiration. At the generalisation of the infection there are widely used methods of intra- and extracorporal detoxication.
Paraproctitis– is the purulent inflammation of around rectal cellular tissue.
Aetiology and pathogenesis It is caused by mixed micro flora (staphylococcus, enterococcus, esherichia coli and anaerobic microorganisms). Usually it is observed in men. Appearing of the process is promoted by such things as chaps of the anus, inflammation of haemorrhoidal lymphatic nodes, damage of the mucous membrane of rectum.
Clinical features There are exist two forms of disease: diffuse (phlegmon of the para-rectal cellular tissue) and limited. Phlegmon of the para-rectal cellular tissue is characterized by the serious passing (fast distribution, necrosis of the tissue, marked intoxication); it is observed at shotgun wounds, decaying cancer of rectum, urinal phlegmons.
Limited paraproctitis can proceeds in the following forms: hypodermic, ishio-rectal, sub-mucous, pelvic-rectal, and retro-rectal. Hypodermic abscess usually is around the anus. There are revealed swelling, hyperemia of the skin, difficulties and pain at defecation. Ishio-rectal paraproctitis usually proceeds more seriously (high temperature, chill, intoxication). Around the rectum up to the prostate and pelvic cellular tissue this process spread. At finger examination of the rectum there is observed painful infiltrate. Sub mucous abscess is usual localized in the sub mucous layer of the rectum above the anorectal line. At finger examination there is determined painfull and swelling in the area of the anus. In the difference from hypodermic process this pain is less intensive. Pelvic-rectal abscesses are rare forms of paraproctitis; abscess is usually localized above the pelvic bottom. Retro-rectal abscesses are formed in the result of infectioning of lymphatic nodes, which are located behind the rectum; in the beginning there are no symptoms; and then it can move down in the ishio-rectal cellular tissue with the development of phlegmon. Paraproctitis in the most cases are usually finished by formation of fistulas.
Treatment In the stage of infiltration conservative therapy usually used (antibiotics, sparing that). At the phlegmon or abscess there is indicated urgent operation. It is frequently used the
Parotitis– is purulent inflammation of the parotic gland. It is occured in the result of infectioning the parotic gland haematogenously or lymphogenously or along the excretory ducts from the oral cavity of. It is arised at weaked persons with general infection or after big operations with dehydratation of the organism and bad cars of the oral cavity. Pathogenic microorganisms are often staphylococcuss and streptococcus. Limited abscesses are formed in the gland or phlegmon with spreading on the cellular tissue. We can see purulent swellings on the neck and in the temporal area at these persons.
Clinical features In the area of the parotic gland there is observed swelling and painfulness at palpation. It is accompanied by worsening of the general condition (chill, increasing of the temperature up to 39-
In the area of swelling redness of the skin and fluctuation is appearing. Swelling moves on the soft palate, neck, cheek, and sub-mandibular area. At some ill persons we can determine paresis of the facial nerve. Abscess can self-dissects with the formation of fistulas through which sequesters of the necroses tissue of the gland come out. Serious complication is the generalization of infection (sepsis), which gives the high mortality.
Treatment In the first stages usually use: antibiotics (semi synthetic penicilines, aminoglicosides, cephalosporines), warm procedures (compresses, UHF, sollux), and sanation of the oral cavity (rinsing with the solutions of antiseptics, massage of the mucous membrane of die oral cavity).
At the abscessing there, is indicated operation- dissection of the purulent focuses in the gland and formation of pus outflow. Dissection of the abscess must be made in the region of the most fluctuation with taking into account the direction of the basic branches of the facial nerve. We dissect the skin and capsule of the gland; than by the blunt way (corcang or finger) open the abscess in the glandular tissue. Then there is used draining, bathing with antiseptics, proteolytic enzymes. Localy are use antibiotics, water-soluble ointments (levosin, levomekol, dioxykol and other). There is indicated plentiful drinking, diet, and therapy with vitamins, protein preparations.
At parotitis several serious complications can occur: haemorrhages from the vessels in the gland or carotic arteries at purulent leaking, phlegmons of arround-pharyngeous cellular tissue, deep phlegmons of the neck.
Mastitis – is inflammation of lactic gland tissue. There is distinguished lactation mastitis at nursing mothers, mastitis of newborns and in period of pubescence.
Aethiology and pathogenesis Pathogenic microorganisms arc often staphylococcus and enterobacteries. The ways of infectioning: chaps of the nipple, intra-canalicular (at nursing mothers), haemotogenous, and lymphogeneous (at endogeneous infection). Promotional factors are: stagnation of the milk in the gland, bad care of gland in the period of nursing.
Clinical features Distinguish acute and chronic forms. Acute mastitis mostly at the period of lactation appears. Chronic form are very rare appear in the result of wrong treatment of the acute one or in the result of specific damage (tuberculosis, syphilis).
Acute mastitis into serous, infiltrative, abscessing, phlegmonous, gangrenous is divided. It can be said mastitis are the stages of the same process, which turn one into another.
Serous form of mastitis is characterized increasing of temperature up to 38-
Gangrenous form of the mastitis occurs in the result of thrombosis of the lactic gland vessels and is character by the very serious flow with the signs of intoxication (fever, temperature up to
Treatment The kind of treatment depends on the stage of the process. At serous and infiltrative forms there is indicated conservative therapy: nursing must not be stoped, the milk must be strained off by hand or with milksucker off), antibioticotherapy (semisynthetic penicilines, aminoglicosides, macrolids and cephalosporines), physiotherapy (sollux, UHF, ultrasound, UVR (Ultra Violet Radiation), Novocain-electrophoresis). There is also can be used retro-mammary Novocain blockade with antibiotics. At abscessing form it is indicated operative treatment. Sections are made dependent on localization of abscesses: at sub-areolar- semi lunar, at intra-mammary- radial sections along the lactic ducts, at retro-mammary- arched section under the gland.
Sick persons with phlegmonous and gangrenous form of mastitis need in the urgent operation (several radial sections of 8-
