SURGICAL INFECTION. ACUTE PURULENT INFECTION OF THE SKIN, CELLULAR SPACES

Infection in surgery occupies one of leading places concerning lethality and determines the essence of many inflammatory diseases and postoperative complications. Last years, an increase in the incidence of pyoinflammatory diseases and postoperative purulent complications, which is connected both to the spreading of antibioticresistant strains of microflora and to the increase in complexity of operative interventions (operations on the heart, the esophagus, the lungs, the brain, organ transplantation, etc.), has been observed. Infringement of the immune status of patients is predetermined by many factors: allergies, influence of harmful ecological factors of the environment (increased background of radiation in connection with failures on the atomic power stations, pollution of water, the use of poorquality products with high contents of agricultural chemicals, pesticides, etc.) has special value in the purulent infection spreading.

Classification of Surgical Infection

Depending upon the ethiology: staphylococcal, streptococcal, pneumococcal, collibacillosis, pseudomonas aeruginosa, gonococcal, anaerobic asporous, claustrid anaerobic, mixed and other kinds of infection are distinguished.

After the localization of the infectious process: surgical infection of the skin and hypodermis, infection of the skin on the skull and its contents (brain, membranes), purulent infection of the thorax and organs (lungs, mediastinum), infections of the peritoneum and abdominal organs, damage to the pelvic organs, infection of the bones and joints.

According to the extent of the clinical picture manifestation, acute and chronic forms are distinguished. Acute surgical infection depending upon the infectious agent and character of the clinical picture is divided into purulent, putrefactive, nonspecific anaerobic (gas gangrene), specific anaerobic (tetanus, diphtheria).

Chronic surgical infections are divided into nonspecific and specific (tuberculosis, syphilis, actinomycosis). Each of the listed forms can run with the prevalence of local signs (local surgical infection) or systematic phenomena with a septic course (systematic surgical infection).

Aetiology and Pathogenesis of Surgical Infection

Now the basic agents of purulent infection are staphylococcus, E. coli. Staphylococcus takes the central place among the agents of purulent infection; it is observed (up to 80%) both in monoculture and in associations with E. coli, streptococcus, fungi, etc.

Prominent features of a staphylococcal infection are fast occurrence of antibiotic-resistant strain, significant toxic influence on the organism due to toxins and enzymes (staphylohemolysin, staphyloleukolysis, plasmocoagulase), high virulence, ability to migrate and form metastatic abscesses.

Wide-spread in the pre-antibiotic era, aerobes (streptococcus, gonococcus, and pneumococcus) seldom cause purulent infection today; they are excreted, basically, in association with other microflora. E. coli takes the second place (47%) in the aetiology of purulent processes; it can exist in aerobic and anaerobic conditions, frequently forms associations with staphylococcus and streptococcus, especially in the pathology of the abdominal organs.

Sources of purulent infection can be saprophytes (protei, pseudomonas aeruginosa), widely spread in the environment, on skin and mucous membranes. They have special value with the decrease in immunity, extensive traumas (burns), may be the cause of sepsis.

Last years after the introduction into the clinical practice of special microbiological methods and nutrient mediums, it was proved that in the aetiology of pyoinflammatory diseases a significant role is played by aclostrium (asporous) anaerobes, which were not revealed by common methods. They consist of Gr-positive (peptococcus, peptostreptococcus, lactobacills) and Gr-negative (bacteroids, fusobacteria, campylobacteria) types.

Peculiarity of anaerobic aclaustrium infection is its fast progressiveness and spreading to the areolar tissue with the prevalence of necrolysis processes and endogenic intoxication. Aclaustrium anaerobes are excreted during wound infection of the abdominal cavity, peritonitis, pelvic abscesses, paraproctitis, and abscess of the lungs.

Many factors influence the pathogenesis of purulent infection development. The most important ones are infringement of the skin or mucous membrane trophic at the entry of infection, the condition of the organism’s protective forces, microflorae virulence. Microbes will not penetrate an organism through undamaged skin or mucous membranes. Even an insignificant trauma of the skin promotes microbic invasion into the organism. The conditions of blood and lymph circulation of the given area have special value. Purulent processes develop less often on the head and face (due to dense blood vessel network) than on other areas of the body. An important role is played by “local” immunity of the tissue. For example, the perineum area, as a result of constant action of microbes and their toxins, has a significant skin resistance to microbic invasion. Damage to the skin and mucous membranes promotes the penetration of microflora, but their division and growth take place only in 6 h. The principles of primary surgical processing of infected wounds are based on this fact. The presence of nutrient medium (haemorrhages, dead tissue) in the injured zone promotes to the development of infection.

An important factor in the pathogenesis is microflora virulence and its resistance to antibiotics. Toxic microbic substrata (hemolysin, leukocidin, necrotoxin, etc.) along with enzymes (plasmocoagulase, hyaluronidase) operate on the cell penetration and the entire organism. The spreading and development of the inflammatory process during microbic invasion are determined by the interrelation between the amount and virulence of microflora, which gets to an organism, with the immune forces of an organism.

With a big doze of virulence of the microflora and weak protective forces of an organism, there is fast development of the inflammation and even generalization of the process (sepsis). With the reverse ratio, the inflammatory process localizes and stops.

The organism reacts to the penetration of infection with local and systematic signs — pain, hypostasis, infringement of function, hyperemia, venous stasis, and increase in temperature. Hyperergetic, normergic, hypergic and anergic forms of inflammation are distinguished.

Hyperergetic reaction is characterized by a rough course with the development of significant hypostasis, necrolysis, sharp deterioration of the general condition (intoxication, hyperthermia, hypotension). Normergic inflammation is accompanied by moderate tissue hypostasis, favorable course with non-pronounced general reaction of the organism. Hypergic reaction is expressed by vague general and local symptomatology: local process, subfebrile temperature. The inflammation is quickly stopped; it is observed during non-pronounced immune status, frequently does not require therapy, and completes spontaneously.

Anergic reaction occurs during sharp decrease in the immune status, in the case of long usage of antibiotics or hormonal preparations. An extensive neglected purulent process with significant destruction without hyperemia and hypostasis of the skin, a so-called “sac of pus” is observed. Besides, the general protective reaction is sharply reduced (non-pronounced leukocytosis, leukopenia, secondary immunodeficiency phenomena).

The organism’s general reaction to microbic invasion appears as symptoms of intoxication (headache, weakness, fever, tachycardia, hypotension, encephalopathy) and changes in the blood (leukocytosis, increase in the ESR, left shift of leukocytes, hypoproteinemia, increase in immunoglobulin, growth in the phagocytar activity). In the case of infection spreading, the intoxication phenomena progress, infringements of the detoxification organs functions (acute hepatic or renal insufficiency) occur, decrease in the immune status (decrease in the leukocytic activity, phagocytosis, immunodeficiency phenomena occur).

Modern Methods of Treating Pyoinflammatory Diseases

It is reasonable to combine general and local kinds of treatment. Local therapy is directed on fighting against microflora and correcting the course of the wound process. The action on microflora is achieved with antibiotic therapy and antiseptics.

Antibiotic therapy should be carried out with due regard for microorganism’s sensitivity and the macroorganism’s reaction. Before using antibiotics it is necessary to identify the microflora in the wound and determine the antibiotic-sensitivity (pure culture, antibioticogram). The microflora’s sensitivity is mostly determined with the antibioticogram disk (if the zone of growth delay is less than 15 mm in diameter — sensitivity; from 15 up to 25 mm — resistance; if it is more than 25 mm — high resistance ). It is possible to use an express-method to determine sensitivity without the excretion of a pure culture by using indicators (2.6-dichlorophenolindophenol, red blood salt) with the help of phase-contrast microscopy. In order to prevent complications (rash, anaphylactic shock) it is necessary to conduct for all the patients the skin test before using antibiotics. Patients with medical allergies should be carried out sequentially the over-skin, scarification and skin tests.

Antibiotics are appointed in sufficient dozes (many doctors prefer the dozes higher than therapeutic), some preparations with taking into account synergism and for a short time (4–5 days) with the following check of the antibioticogram and change of the preparation to prevent the occurrence of antibiotic-resistant or antibioticdependant strains of bacteria. Antibiotic therapy is applied parenterally. A few preparations are entered locally into the wound, because a majority of them inactivate in the acidic medium of inflammation. Intravenous, intraarterial and endolymphatic ways of introduction prevail, which provides effective concentration of antibiotics in the pathological focus.

Last years, antibiotics of the second generation are mostly used: semisynthetic penicillin (ampicillin, carbenicillin, ampiox), cephalosporin, aminoglycoside, semisynthetic tetracycline. Antibiotics of the first generation (benzylpenicillin, streptomycin, chloramphenicolum, tetracycline) are almost not applied, because of wide spreading of antibiotic dependance as a result of mutagen action on microflora. In order to prevent the complications it is necessary to follow the rules: antibiotics are applied in large doses;

they combine antibacterial preparations and antibiotics whichhave different mechanisms and spectrum of action, as well as combine the ways of introduction.

Among chemical antibacterial preparations, sulfanilamides, mainly of long action, are applied (sulfapyridosin, sulfadimethoxin, sulfalen), preparations of sulfanilamides with derivatives of diaminopyrimidin (bactrim, biseptol). Besides, the derivatives of quinoxaline are applied (dioxydinum, chlorhexidin gluconate), which take effect on resistant antibiotic strains, microflorae. Such derivatives of nitrofuran as furacilinum, kalium furagin are applied in the treatment of pyoinflammatory diseases.

The action on the course of the wound and purulent processes, first of all, begins with surgical methods: early removal of the infection foci, incision and rational drainage of the abscesses, it is better to use active methods of drainage. Proteolytic enzymes are applied successfully on the hydration phase for necrolysis (trypsin, chymotrypsin, plasmin, papain, ribonuclease, desoxyribonucleasa) which have proteolytic, anticoagulant and dehydrational effects. Cleansing the wounds of pus, necrotic masses, and the occurrence of granulations during treatment with proteolytic enzymes happens 1.5 times faster than with traditional methods of treatment. It allows the application of an early secondary suture, autodermoplasty. For the last years physical methods of treatment of purulent surgical infection have become widespread: treatment by laser, ultrasound, ultra-violet irradiation of wounds, diodynamical currents. Focused laser rays are used (quantum generators on carbonic gas or argon), and non-focused rays (helium-neon). The first ones are applied as a surgical scalpel for incision of abscesses and removing necrotic mass. Thus, the bactericidal action (reduction of microbes in wounds, decrease in the pathogenicity of microflora) is pronounced. The nonfocused therapeutic laser (helium-neon) also corrects the bactericidal action, promotes early cleansing of necrolysis from the wound and the occurrence of granulations. Ultrasound is successfully applied too. Bactericidal property of ultrasonic waves is predetermined by physical, chemical, and biological processes (cleansing of pus and necrotic tissue from a wound, action on microflora and stimulation of physical processes in the patient’s organism).

The greatest effect of ultrasound is with gram-negative flora (Pseudomonas aeruginosa, E. coli). Methods of systematic action on purulent infection consist of transfusion and disintoxication therapies, as well as immunological methods.

Disintoxication therapy is directed on absorption of toxins from the damaged site, dilution, binding and removing the toxins from the circulatory system. A decrease in absorption of toxins from the infection focus is achieved by surgical methods (wide sectioning, necretomy, drainage, active aspiration), as well as continuous irrigation with antiseptic solutions and antibiotic therapy. In order to dilute and remove toxins, blood substitutes with desintoxication actions are used (haemodes, neohaemodes, rheopolyglucin), albuminous preparations (albumin, albuminous hydrolysate), colloidal solutions with the total amount of 4–5 l a day. In order to remove toxins, intensified diuresis, peritoneal dialysis, and haemodialysis are used.

Adsorption of toxins is successfully carried out by methods of extracorporal detoxification (hemosorption, plasmosorption, plasmapheresis, lymphosorption, haemofiltration, xenospleen application, xenoliver). The destruction of toxins is promoted by such methods as oxygenotherapy, hyperbaric oxygenation, ultra-violet irradiation of the blood.

Immunotherapy for purulent infection is pathogenetically justified, because to a certain extent secondary immunodeficiency develops, which can worsen the patient’s condition by using antibiotic therapy. Immunotherapy consists in the application of the substitute therapy and immune correction. Haemotransfusions, hyperimmune serums (antistaphylococcal, anticollibacillary, etc.), gamma-globulin, staphylococcal anatoxin, and bacteriophage, which are applied for sepsis, peritonitis, i.e. in the case of a severe purulent infection with its generalization, are used as substitute therapy. With a chronic infection staphylococcal anatoxins, Pseudomonas aeruginosa and Proteus vaccines, which allow the creation of a local active immunity, are used. Synthetic (prodigiosan, methyluracil, decaris, levamizol) and natural immune stimulators (preparations of the thymus — tactivin, thymalin, timosin; the bone marrow — myelopeptide and so forth) are applied as active immune therapy, besides of vaccines and anatoxins.

PURULENT DISEASES OF THE SKIN AND SUBCUTANEOUS FAT

Furuncule, anthrax, hydradenitis, abscess, phlegmon, and erysipelatous inflammation belong to diseases of this group. Purulent diseases of the skin and subcutaneous fat have two stages of development: the infiltration stage and the abscess stage. Treatment is carried out according to the stage of the disease. Conservative methods are applied at the I stage: antibiotic therapy, physiotherapy (UVrays, solux, quartz, dry heat), desintoxication therapy. At the ІІ stage with the development of an abscess operative methods are applied (cutting, drainage), treatment of purulent wounds. It is supplemented with antibiotic and antiseptic therapy, desintoxication therapy and if necessary — immunotherapy.

Furuncule is an acute purulent inflammation of the hair follicle and surrounding tissue. The preceded factors are pollution of the skin, avitaminosis, metabolic disorders (for example, diabetes). The direct reason — a repeated trauma to the skin.

Localization: the forearm, the back of the hand, the neck, the buttocks. Basic attributes: itching, pain, redness, hypostasis of the skin, subfebrile temperature. In the I stage (2nd–3rd day) — around of hair a small pustule with inflammatory infiltration like a nodule forms. In the ІІ stage (3rd–7th day) on the top of the infiltration necrosis (black speck) appears, purulent disintegration of the infiltration as a core occurs. Pus discharge is observed, the purulent wound after cleansing is full of granulations. Further, a whitish scar is formed. Complications: thrombophlebitis, thrombosis of the venous sinus of the brain (with the localization on the upper lip), basal meningitis, sepsis.

Formation of multiple furuncules is called furunculosis, a systematic disease. It develops in weakened patients with infringement of the immune status, metabolism illnesses (diabetes, etc.). Treatment of a furuncule is determined by the stage of the disease. With the infiltration stage conservative therapy is applied: broad-spectrum antibiotics, rubbing with spirit, brilliant green, dry heat (hot-water bottles, UV, quartz, solux). With the abscess stage (3–8 days) — incision of the abscess and subsequent treatment of the purulent wound. With furunculosis, treatment is supplemented with autohemotherapy, immunotherapy (staphylococcal anatoxin, vaccine, thymus preparations, decaris).

Carbuncule is acute extensive pyonecrotic inflammation of several hair follicles and sebaceous glands with necrosis formation on the skin and subcutaneous layer. The reasons are the same as for furunculosis. The disease is promoted by: hypovitaminosis, exhaustion, metabolic diseases (adiposity, diabetes). The localization is the same as for furunculosis. The clinical picture is characterized by systematic and local semiology. At the I stage, a sharply painful infiltration with crimson skin that covers the hair saccule and sebaceous glands is observed; there are several apertures, through which pus discharges. During the ІІ stage, the apertures merge, forming a defect on the skin, lots of pus discharge, necrosis reaches the subordinate fascia. Systematic phenomena: the temperature is up to 39– 40°C , attributes of intoxication (headache, nausea, vomiting, sleeplessness, sometimes delirium). Complications: lymphangitis, lymphadenitis, thrombophlebitis, thrombosis of the venous sinus of the brain, meningitis (localized on the upper lip and face), sepsis. Treatment depends upon the phase of the process. During the I phase — conservative therapy like for furunculosis. Antibiotic therapy should be carried out intravenously in combination with sulfanilamide. Surgical treatment begins in 3 days if conservative therapy was inefficient. Incisions on the abscess are done x-like while removing the necrotic tissue. The following treatment is carried out by the principle of treating purulent wounds (drainage, local application of antiseptics, proteolytic enzymes, etc.).

Hydradenitis — acute purulent inflammation of the sudoriferous glands. Localization: underarm, genital and perianal areas, in women — the nipples area. Reasons and assisting factors for the disease: sweating, untidiness, eczema. During the I stage — a dense painful nodule covered with unchanged skin. During the I stage — a purple-reddish nodule with fluctuation; milky pus discharges through the small aperture. The merging of several inflammatory infiltrations is possible. Hydradenitis is seldom accompanied by intoxication, frequently has sub-acute and long-term course. Treatment: during the I stage — conservative therapy similar to treating furunculosis. During the ІІ stage — incision and treating the purulent wound. With a long-term course autohemotherapy in small dozes can be applied.

Abscess is a limited accumulation of pus in tissues and organs. Reasons: injections, wounds, penetration of infection during medical measures (hypodermic, intramuscular injections), and purulent hematomas. Abscesses can develop around foreign objects. Their agents can be diverse microflora. However, more often — staphylococcus, streptococci, E. coli, Protea. Abscesses occur in cavities of purulent inflammation (furuncule, anthrax, hydradenitis, lymphadenitis, etc.). With superficial abscesses, hyperemia of the skin, swelling, fluctuation are observed over them. The clinical disease is accompanied by pain (mostly pulsating), attributes of intoxication, fever, tachycardia, headache, weakness, left-shift leukocytosis. The peculiar feature of the abscess is a pyogenic membrane — the inner wall, covered with granulation tissue, that precisely separates the pyogenic abscess from the healthy tissue. Abscesses should be distinguished from hematomas, spinal tuberculosis, aneurysms, and vascular tumours. The diagnosis of deeply located abscesses, especially internal organs’, is difficult. Computer tomography, roentgenography help in diagnosis. Treatment is surgical. Incision, removal of necrotic tissue, drainage (preferably — active), subsequent treatment is conducted similar to a purulent wound.

Phlegmon is an acute extensive purulent inflammation of the areolar tissue (hypodermic, intermuscular, retroperitoneal). Unlike to abscesses, with phlegmons the process is not limited but spreads to the areolar tissue. The phlegmon is an independent disease, but can be a complication of purulent processes (anthrax, abscess, sepsis). Purulent, pyo-hemorrhagic, and putrefactive forms of phlegmons are distinguished by the character of the exudate. Depending upon the localization, phlegmons can be epifascial or subfascial (intermuscular). Special localizations are distinguished: paranephritis, paracolitis, paraproctitis. The clinical course is characterized by inflammatory infiltration without precise borders with the following softening, high fever, intoxication, chills. Complications: lymphadenitis, erysipelas, thrombophlebitis, sepsis, purulent arthritides, purulent meningitis.

During the initial stage, conservative treatment (antibiotics, plenty of liquids, cardiac substances, dry heat, solux) is carried out. With the formation of abscesses — incision and drainage. In specialized hospitals active surgical management is applied — wide incision of the dead tissue, drainage with active aspiration. With extensive phlegmons, complicated by sepsis, hyperbaric oxygenation and other kinds of extracorporal detoxifications (hemosorption, plasmosorption, plasmapheresis) are applied. After incision of the extensive phlegmons, it is possible to apply aerotherapeutic apparatuses (АТV3, АТV-5) with regulated abacterial medium.

Erysipelatous inflammation is acute purulent damage to the skin (occasionally mucous membranes), which are often caused by haemolytic streptococcus. Erysipelas is a version of the organism’s reaction to microflora with allergic reorganization: acute or latent infection, endogenic completing factor, allergic reaction, skin trophic damage, transition of the infection into the latent form. The clinical course is progressing with the prevalence of systematic intoxication phenomena (headache, vomiting, fever, tachycardia). Local changes have a phase course. The following clinical forms of erysipelas are distinguished: erythematous, bullous, phlegmonous, necrotic. These phases turn one into another. The erythematous form is characterized by redness with pronounced precise border between the healthy and damaged sites (“tongues of fire”), pronounced itching and hypostasis of the skin. The bullous form is characterized by the occurrence of blisters in the redness zone with yellowish or haemorrhagic exudate. Deeper damage with the occurrence of a phlegmon (phlegmonous form) or necrosis of the skin (necrotic form) is observed if purulent infection accompanies. Localization: the extremities, the scrotum, the penis, the face. Erysipelas can be crawling (with gradual spreading to the next area) or migrating (wandering) — consecutive damage to different parts of the body. Complications: development of severe toxemia, purulent damage to mucous membranes, tendons, muscles, joints, thrombophlebitis.

Treatment is conducted depending upon the form. With erythematous form they appoint antibiotics, sulfanilamides, ultra-violet irradiation (sub-erythematous and erythematous doses). With the bullous form, the blisters are incised open, processed with spirit, and suspensions or ointments with antibiotics are applied. With phlegmonous or gangrenous forms, the congestion of pus are opened; the wound is drained; the necrotic tissue is deleted. Desensitized means are also applied (dimedrol, suprastin, calcium chloride, roentgenotherapy in small doses), immunotherapy can be applied (antistreptococcal vaccine), especially for the migrating recurrent forms.

Erysipeloid is a crawling erythema of the skin, or pig erysipelas. It is caused by the pig erysipelas bacillus (Erysipelothrix rhusiopathiae) during contact with sick animals (workers of meat-packing plants, farms suffer from it), it is possible to catch it while processing raw meat or fish. It is characterized by serous inflammation of all layers of the skin with hyperemia, hypostasis, pronounced itching. It is accompanied by lymphostasis and lymphangitis. Localization: fingers, hands. The patient’s general condition usually does not change. Erysipeloids can relapse and migrate to other fingers.

Treatment. Antibiotic therapy, application of specific serums, ultra-violet irradiation, roentgenotherapy.

Purulent Diseases of Cellular Spaces and Organs

Mediastinitis is a purulent inflammation of the connective tissue of the mediastinum.

Aetiology and pathogenesis. Causative agents are more often staphylococcus, enterobacteria, less often anaerobes. Reason: damage to the esophagus by foreign objects or during endoscopy, purulent complications after operations on the esophagus, the lungs, the heart. Less often: lymphogenic or from the oral cavity (carious teeth, tonsils).

Clinical picture. Diagnosis of mediastinitis is complex, because the clinical course is frequently hidden behind the primary process, the source of the disease (pneumonia, phlegmon of the neck, damage to the esophagus).

Limited (abscesses) and extensive (phlegmons) processes are distinguished. After the type of the agent: purulent and putrefactive. Mediastinitis has the course without precise symptoms against a background of pronounced intoxication (fever, temperature up to 40°C, fever, tachycardia, hypotension). Pain behind the sternum is the most pronounced symptom. For anterior mediastinitis, pains in the sternum and behind it, their amplification during sternum percussion, while leaning the head backward, and swelling of the neck are typical.

During posterior mediastinitis, pains are typical between the scapulas, in the back, in the epigastric area. With wounds to the esophagus, pains occur during swallowing. In cases of anaerobic or putrefactive processes emphysema of the mediastinum is detected radiologically. Hypodermical emphysema is determined during palpation of the neck.

With the purpose of reducing the pain, patients take a compelled position (sitting or semi-sitting with the head leaned forward).

Compression of the neurovascular formations (the aorta, the pulmonary artery, the vagus and diaphragm nerves, sympathetic fulcrum) is a very severe complication. As a result, hoarseness, hiccups, vomiting, paroxysmal coughs, dyspnea may occur. Purulent mediastinitis is necessary to distinguish from pneumonia, pleurisy, pericarditis, tumours of the mediastinum, tubercular spots. Computer tomography, radiography, esophagoscopy and mediastinoscopy are applied with this purpose.

Treatment should begin with antibiotic therapy (semisynthetic penicillin, aminoglycosides, cephalosporins. With the presence of attributes of abscesses and putrefactive inflammation surgical treatment (mediastinotomy) is carried out. Taking into account high lethality of the disease, today there are many indications to an operation. With anterior mediastinitis, the incision is made above the sternum and in the fossa under the sternum (under the xiphoid process). The cervical mediastinotomy by В. І. Razumovsky (incision along the internal edge of the m.sternocleidomastoideus while accessing the periesophageal space, the anterior mediastinum) is widely applied. Posterior mediastinotomy is carried out by I. І. Nasilov’s method (incision on the back parallel to the spinal column with additional two horizontal incisions on the ends, which allows to find the orifice and after the ribs incision to make incision of mediastinitis behind the pleura). It is very important during surgical treatment to provide active aspiration of the pus with flowing washing (two-opening drainage tubes, an aspirator with a dilution rate of 50–100 mmH₂O).

For washing the cavity they use antiseptics (dioxydine, dimexide, furacilin), proteolytic enzymes (trypsin, chymotrypsin). Intra- and extracorporal detoxification, haemotransfusions, desintoxication with blood substitutes are methods widely used to fight against intoxication.

Paranephritis is purulent inflammation of the renal cortex.

Aetiology and pathogenesis. Causative agents are more often staphylococcus, E. coli, less often — saprophytes and anaerobes. Reason: direct bringing of the infection during acute or chronic processes in the kidneys (purulent nephritis, pyelitis, abscess), less often — lymphogenic way during purulent processes in the abdominal organs.

Clinical picture. In the initial stages of the disease, the diagnosis is difficult to determine, because the clinical course consists mostly of systematic semiology (indisposition, fever, headache) and non-pronounced local attributes (pain in the back, swelling, tissue hypostasis). Pain seldom has a precise localization. Later, the pain is more precisely located, irradiates into the leg (especially during crawling abscess along the big lumbar muscle and the psoas-abscess formation). Painful inflammatory infiltration of dense-elastic consistence in the lumbar area (sometimes in the right subcostal area by the edge of the rectal muscles) is determined. When lying on the stomach, lateral curvature of the lumbar department of the spine with the deviation of the line of the spinous process towards the healthy side, smoothed contours on the corresponding half of the back, pressure of the muscles of the back are marked. The disease is accompanied by pronounced changes in the urine: leukocyturia, hematuria, cylindruria. Paranephritis should be distinguished from phlegmons of the retroperitoneal cavity, retroperitoneal acute appendicitis.

Treatment should begin with antibiotic therapy (semisynthetic penicillin, aminoglycosides, cephalosporins). With the first attributes of abscess (hectic fever, pulsating pains) lumbotomy with wide incision of the abscess is carried out. In the postoperative period, washing the abscess, active aspiration are conducted. With the phenomena of generalization of the infection and endotoxicosis, intra- and extracorporal detoxication methods are widely used.

Paraproctitis is a purulent inflammation of the perirectal tissue.

Aetiology and pathogenesis. Disease is caused by mixed microflora (staphylococcus, enterococcus, E.coli, anaerobes). It is observed more often in men. The disease is caused by cracks in the rectum area, inflammation of haemorrhoidal nodules, damage to the rectal mucosa, skin scretches.

Clinical picture. Two forms of the course are distinguished: diffuse (phlegmon of the pararectal area) and limited. Phlegmon of the pararectal tissue is characterized by a very severe course (fast spreading, necrosis of tissue, pronounced intoxication), observed during gunshot wounds, cancer of the rectum, uric phlegmons.

Limited paraproctitis can be observed in the following forms: hypodermic, ischiorectal, submucosal, pelviorectal, retrorectal. The hypodermic abscess, as a rule, is around the anus. Swelling, hyperemia of the skin, difficulty and pain during defecation are determined. Ischiorectal paraproctitis has a much more severe course (high temperature, fever, intoxication). Thus, the process spreads around the rectum to the prostate gland and pelvis. During palpation of the rectum painful infiltration is determined. Submucosal abscess is usually located in the submucous layer of the rectum above anorectal lines. During palpation painful hypostasis of the abscess in the anus area is determined. Unlike to hypodermic abscess the pain is less intensive. Pelviorectal abscesses is a rare form of paraproctitis; the abscess is located, as a rule, above the pelvic floor. In contrast to other forms the onset of the disease has an asymptomatic course.

Retrorectal abscesses are formed as a result of the infection bringing into the lymph nodes; it is located behind the rectum; it is also asymptomatic in the beginning, then the process can go down into the ischiorectal area with the development of a phlegmon. Paraproctitis generally completes with the formation of intestinal fistulae.

Treatment. In the infiltration stage, conservative therapy is applied (antibiotics — semisynthetic penicillin, aminoglycosides, cephalosporin, liquid diet to delay defecation). With a phlegmon or abscess, urgent surgical treatment is indicated. A simicircular incision is made, step 2 cm back from the external sphincter of the rectum. At submucosal abscesses the abscess incision is made from the side of the rectal lumen. With anaerobic paraproctitis wide incisions while removing the necrotic tissue is shown. In the postoperative period, washing with antiseptic solutions (hydrogen peroxide, dioxydin), proteolytic enzymes, sedentary baths with antiseptic solutions are used.

Parotitis is an inflammation of the parotid glands. The infection is brought from the oral cavity moving through the excretory duct of the parotid gland or by hematogenous or lymphogenous way. It occurs in weakened patients during general infection or extensive operations with pronounced dehydration or bad care of the oral cavity. Causative agents: staphylococci and streptococci. Limited abscesses in the glands are formed or phlegmon of the glands occurs with spreading into the external cellular tissue. These patients frequently have purulent oedemas on the neck, temporal area.

Clinical picture. In the parotid area there is swelling, acute pain during palpation. It is accompanied by deterioration of the general condition (fever, rise in temperature to 39–40°C, complicated swallowing and chewing).

In the area of swelling there is redness of the skin, fluctuation. Hypostasis passes to the soft palate, neck, cheeks, submaxillary area. In some patients, paresis of the optical nerve occurs. The abscess can move to the outside with the formation of fistulae through which sequestrations of dead parenchyma leave. Grave complications can be generalization of the infection (sepsis), causing high lethality.

Treatment. In the initial stages antibiotics are used (semisynthetic penicillin, aminoglycosides, cephalosporins), thermal procedures (warming compresses, solux), careful sanitation of the oral cavity (rinsing with antiseptic solutions, massage of the oral mucosa).

With an abscess surgical treatment is indicated — removing the purulent cells from the gland and creating good conditions for draining the pus. Incision of the abscess should be carried out on the area of greatest fluctuation taking into account the direction of the basic branches of the optical nerve (in parallel to them). They dissect the skin and gland capsule, further with a dressing forseps or finger open the abscess in the parenchyma, without damaging the optical nerve branches. Further they drainage, wash the wound with antiseptics, proteolytic enzymes. Local antibiotics, water-soluble ointments (levosin, levomecol, dioxicol, etc.) are used. Abundant drinking, full-value diet, vitamin therapy, protein preparations.

With parotitis grave complications are possible: bleeding from the gland vessels or carotid artery with purulent oedemas, development of a phlegmon in the peripharyngeal space, deep phlegmons of the neck.

Mastitis — inflammation of the mammary gland tissues. Lactational mastitis of breast-feeding women, mastitis neonatorum and mastitis of puberty are distinguished.

Aetiology and pathogenesis. Causative agents: staphylococcus and enterobacteria. Ways of infection: cracks in the nipple, intracanalicular (in feeding women), hematogenous, lymphogenous (with endogenous infections). Assisting factors: galactostasia, bad care of the breast during feeding.

Clinical picture. According to the course, acute and chronic forms are distinguished. Acute mastitis is mainly lactational. Chronic mastitis is seldom; they are the consequence of wrong treatment of acute processes or specific damage (tubercular, syphilitic). According to the clinical picture acute mastitis has the following forms: serous, infiltration, abscess, phlegmonous, gangrenous. Basically, these are phases of one process which can pass to each other.

The serous form of mastitis is characterized by the rise in the temperature up to 38–39°C , diffuse hypostasis and pain in the breast. Any swelling of the glands with a rise in temperature should be considered as serous form. The subsequent progress of the process with wrong treatment results in the infiltration form. Sharp painful infiltration with indistinct contours, with hyperemia of the skin above it appears in the mammary glands; axillary lymph nodules are increased, painful. Pain in the glands increases; headaches, sleeplessness, weakness are marked.

Changes in the blood: increase in leukocytosis (10–12·109/l), increase in the erythrocyte sedimentation rate (ESR) (30–40 mm/h). With ineffective therapy the abscess phase occurs. Restricted infiltration and the presence of fluctuation, occurrence of pulsating pains in the glands are marked. General phenomena increase: fever with the rise in the temperature up to 39–40°C, increase in leukocytosis (15–20·109/l), increase in the ESR (50–60 mm/h). Abscesses in the gland can be located in different places: under the nipple (subareolar), inside the mammary gland (intramammary), behind the mammary gland (retromammary). Retromammary localization frequently is the consequence of other inflammatory processes (osteomyelitis of the ribs). The subsequent deterioration of the general condition with septic phenomena (repeated fever, increase in the ESR and increase in left-shift leukocytosis, lymphopenia, eosinophilia) results in the phlegmonous form. The mammary gland is increased and swollen, sharp pain, hyperemia of the skin, nipple is pulled in, areas of multiple fluctuations in the gland, acute dilation of the hypodermic veins, lymphangitis phenomena are observed.

The gangrenous form of mastitis develops as a result of thrombosis of the mammary vessels, characterized by the most severe course with intoxication phenomena (temperature of 40°C, tachycardia up to 120 per min, hypotension, headache). Significant changes in the blood: with left-shift leukocytosis up to 25 thousand/l, increase in the ESR up to 60–70 mm/h. The hypochromic anemia phenomena are observed. The gland is sharply increased, pastose, painful. The skin above it is pale-green or dark blue-crimson, with sites of blisters and areas of necrosis. The regional lymph nodes are increased, painful. Complications: development of sepsis.

Treatment is carried out depending upon the phase. With serous and infiltration forms, conservative therapy is administered: breast feeding is not stopped and promote the liquidation of galactosaria (manual or with device expression of breast milk), antibiotic therapy (semisynthetic penicillin, aminoglycosides, macrolides, cephalosporins), physiotherapy (solux, ultrasound, UV-irradiation, novocain, electrophoresis). It is possible to apply retromammary novocain blockades with antibiotics. With the abscess form, surgical treatment is done. It is necessary to make incisions depending upon the localization of the abscesses: with subareolar — semilunar, with intramammary — radial incisions according to the direction of the lactic ducts, with retromammary — an arch-like incision along the skin fold under the gland. Patients with phlegmonous and gangrenous forms require urgent surgical treatment (some radial incisions in length of 8–10 cm, removing the necrotic tissue, drainage, washing with antiseptics). Treatment is supplemented with infusion therapy (antibiotics, haemotransfusions and blood substitutes, immunity stimulators), as well as disintoxication (hemosorption, hyperbaric oxygenation).