PURULENT DISEASES OF
CELLULAR TISSUE AND ORGANS
Classification of the surgical infections:
1. Acute surgical infections (see appendix 16).
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.
3. Gram - negative 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-coloured
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 selflimited, and improvement is seen within a period
of 4 to 8 days.
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 often not 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.
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
exudate on the surrounding nerves.
4. Swelling.
5. Loss of function-an inflamed tissue does
not perform 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.
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)
Fig.1 purulent processes at the skin and underskin tissue
Boil constitute one of the very widespread
purulent diseases of the hair follicle and sebaceous
(Fig.1). 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
neighbouring hair follicles where numbers
of hair follicles are too many (e.g. axilla)
leading to hidradenitis.
c) boils usually secondarily infect the
regional lymph nodes.
Treatment:
1.
2.
3.
4.
5.
6.
The general health of the patient has to be
improved, as boils often occur in individuals with
debility and ill-health.
Incision is usually unnecessary as the pustule is very
small. Only a touch of iodine on the skin pustule will
hasten necrosis of the overlying skin and help the
pus to drain out.
If escape of pus does not occur spontaneously or
with application of iodine, removal of the affected
hair allows ready escape of pus.
Antibiotic is usually not required. It is possible when
multiple boils appear or if boils recur.
After escape of pus the part should be cleaned twice
with a suitable disinfectant e.g hexachlorophene.
This discourages development of further boils.
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 unfavourable to
the body, and affects considerable sections of
subcutaneous tissue (Fig.1). 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.
It commences as painful and stiff swelling which
spreads very rapidly with marked induration. 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 toxaemia vary
according to the degree of the resistance of the
individual and Scarecy 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, a synthetic
penicillin e.g. erythromycin may be used. At this time a paste
composed of anhydrous magnesium sulphate and glycerin may be
applied or S. 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 toxaemia and pain persist even after a course of antibiotics and
b) when the carbuncle is more than 2 inches in diameter. It must be
remembered that incision is never made unless there is softening in
the centre.
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 with vaseline gauze or sofratulle dressing. The part
should be kept in perfect rest for a week and antibiotic is continued
till resolution.
Abscess
Fig.2. Lung abscesses:
a) the big abscess of the lung communicate with bronchus;
b) gangrene of the lover lobe with abscesess
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
exudate. Liquefaction of the dead tissue is
caused by proteolytic enzyme released from the
dead polymorphonuctear 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.
Clinical features.
Cardinal features of acute inflammation are usually
present. These are: a) redness or rubor—there is
redness over the area particularly before localisation
of the abscess. This is due to hyperaemia.
b) pain or dolor— a throbbing pain is characteristic of
presence of pus.
c) heat or 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) swelling or tumor— due to presence of pus inside the
abscess cavity.
e) impairment of function — 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 subphrenic abscesses.
c) ultrasound is of considerable value in the diagnosis of gallbladder
stones or empyema and also to detect abscesses in the liver or
spleen.
d) CT scan is particularly helpful to distinguish between abscess and
tumour by showing necrotic centre in case of abscess. It is helpful
to locate abscess cavity inside the abdomen as also in the brain.
Treatment:
1. In the initial stage, when the pus is not localised,
conservative treatment may be advised. The
affected part is elevated and given rest. A suitable
antibiotic should be started.
2. When the pus has been localised, 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.
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 has been made up
to the abscess cavity 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, 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, a roller gauze should be
packed inside the wound and it can be kept for 48
hours. Some surgeons believe in instilling local antibiotic
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.
Erysipelas
It is an acute inflammation of the lymphatics
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 - 41°C; vomiting is sometimes observed.
Subsequently the temperature either persists on
a high level or from time to time drops.
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 oedema of the
subcutaneous tissues and thus very much
resembles cellulitis.
To distinguish between a true erysipelas and a
cellulitis, the following points in favour 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 cellulitis 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 cellulitis 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 a sun 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 administration of antibiotics and
sulfonylamides.
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.
In lymphangitis the local manifestations consist in 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 40°C are also
observed.
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.
Confinement 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
administration 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).
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.
Phlebitis and Thrombophlebitis
The blood vessels constitute another avenue
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 induration
along the course of the veins, the latter being
palpable as dense cord is painful to touch. If
large veins are affected, for example, the femoral
vein, edema of the extremity and cyanosis
develop
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 complications in the form of
haemorrhages are possible during administration of
anticoagulants, their use is permissible only with control of blood
clotting (tests for prothombin) and systematic urinalyses.
Paraproctitis- is the pumlent inflammation of
aroundrectal cellular tissue.
Aetiology and pathogenesis. It is caused by
mixed microflora (staphylococcus, enterococcus,
esherichia coli, anaerobic microorganisms). It is
usually observed at 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.
Clinics. There are exist two forms of
disease: diffuse (phlegmon of the
pararectal cellular tissue) and limited.
Phlegmon of the pararectal cellular
tissue is characterised by the serious
flow (fast distribution, necrosis of the
tissue, marked intoxication); it is
observed at shotgun wounds, decaying
cancer of rectum, urinal phlegmons.
Treatment.
In the stage of infiltration conservative therapy b
usually used (antibiotics, sparing thet). At the phlegmon
or abscess there is indicated imidiate operation. It is
frequently used the semilunar section 2 cm off of the
external sphincter of the rectum. At submucous
abscesses dissection of the abscess is made from the
cavity of the rectum. At anaerobic paraproctitis there
are indicated wide sections with the carving of
necrodsed tissues and using of GBO. In the
postoperative period there is used flowing bathing with
the solutions of antiseptics (hydrogen peroxide,
dioxidine), proteolytic enzymes, hip-baths with die
solutions of antiseptics
Parotitis
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. At these persons we can
see purulent swellings on the neck and in the temporal
area.
Parotitis
Clinics. 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- 40°C,
difficulties at swallowing and chewing).
In the area of swelling redness of the skin and
fluctuation is seen. Swelling moves on the soft palate,
neck, cheek, submandibular area. At some ill persons we
can determine paresis of the facial nerve. Abscess can
self-dissects with the formation of fistules through which
secvestres of the necrodsed tissue of the gland come
out. Serious complication is the generalization of
infection(sepsis) which gives the high mortality.
Parotitis
Treatment. In the first stages usually use: antibiotics
(semisynthetic 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 coonsideration 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, profund phlegmons of the neck.
Mastitis
Mastitis- is inflammation of lactic gland
tissue. There is distinguished lactation mastitis at
nursing mothers, mastitis of newboms and period
of pubescence.
Aethiology and pathogenesis. Pathogenic
microorganisms arc often staphylococcus and
enterobacteries. The ways of infectioning: chaps
of the nipple, intracanalicular (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.
Mastitis
Clinics. Distinguish acute and chronic forms.
Acute mastitises are mostly at the period of
lactation. Chronic arc very rare appear in the
result of wrong treatment of the acute one or in
the result of specific damage (tuberculosis,
syphilis).
Acute mastitises is divided into serous,
infiltrative, abscessing, phlegmonous,
gangrenous. It can be said diat dlis are the
stages of the same process, which turn one into
another.
Mastitis
Treatment. The kind of treatment depends on the
stage of the process. At serous and infiltrative forms
there is indicated concervative therapy: nursing must
not be stoped, the milk must be strained off by hand or
with milksucker off), antibioticotherapy (semisynthetic
penicilines, aminoglicosides, macrolids,
cephalosporines), physiotherapy (sollux, UHF,
ultrasound, UVI (Ultra Violet Irradiation), novocaineelectrophoresis). There is also can be used retromamaric
novocaine blockade with antibiotics. At abscessing form
it is indicated operative treatment. Sections are made
dependent on localization of abscesses: at subareolaricsemilunar, at intramamaric- radial sections along the
lactic ducts, at retromamaric- arched section under the
gland
Ill persons with phlegmonous and
gangrenous form of mastitis need in
the urgent operation (several radial
sections of 8-10 cm, carving of
necrotised tissues, draining, flowing
bathing with antiseptics). Treatment is
suplemented'by infusion therapy
(antibiotics, transfusion of the blood,
stimulators of immunity),
desintoxication (UVTB, haemosorbtion,
hyperbaric oxygenation)