LECTURES 10

Surgical infection classification.

- Acute suppurative disease of purulent tissues: abscess,
furuncle, carbuncle, hydradenitis, mastitis, erysipelas,
lymphadenitis, lymphangitis, paraproctitis. Acute
hematogenous osteomyelitis.
- The acute specific surgical infection. Gas gangrene. Tetanus.
Diphtheria of wounds. Anthrax.
- Chronic specific surgical infection. Tuberculosis.
Actinomycosis. Syphilis. The general purulent infection. SIRS.
Sepsis.
Abscess (abscessus) - Separated by a collection of pus in the different
tissues and organs due to purulent fusion of tissues and the formation of cavities
(unlike empyema in which the accumulation occurs in the natural body cavities
and hollow organs).

Etiology and pathogenesis. Pathogens purulent infection is staphylococcus -

monoculture or in association with other microbes (Escherichia coli, streptococcus,
Bacteroides, and others.).
Pathogen infection usually enters from outside (exogenous infection),
although possible and endogenous infection - penetration with neighboring or
distant organs, metastatic abscesses with sepsis. The cause of the abscess can be
input into the tissue kontsentrovannyh solutions of drugs - 25% solution of
magnesium sulfate, 24% solution kordiamin, 50% solution of aspirin and others.
Purulent inflammation that develops, leading to melting of tissues, and sometimes
to the exclusion of necrosis and gangrenous tissue-sequestration. Sequestration
could face further enzymatic melting.
Abscess cavity can be as simple rounded and complex, with numerous
pockets. The walls of the abscess initially covered with purulent fibrinous layers
and remnants of necrotic tissue. Then, on the periphery of the abscess developing
area of inflammation, which leads to the formation of pyogenic membrane,
surrounded by connective tissue.
Formed as a result of purulent or aseptic inflammation abscesses have
different resolution: spontaneous dissection of breakthrough outside (abscess
subcutaneous fat, muscle abscess, mastitis, paraproctitis etc..) Perforation abscess
in a closed cavity (peritoneal, pleural, in the joint space and so on.) with the
development of septic processes (peritonitis, pleurisy, pericarditis, arthritis, etc.).
Possible ulcer perforation into the cavity of communicating with the external
environment (the cavity intestine, bladder, etc.).. Abscess cavity, which freed,
under favorable conditions, reduced in size, and subjected spadayetsya scarring,
with incomplete released, the process can go into with chronic fistula formation at
the place of abscess.

Clinical manifestations and diagnosis. When superficial acute abscesses

marked redness, swelling, pain, local temperature increase, dysfunction, sometimes
referred floktuatsiya. Inflammation may hold a different area. Character pus
abscess (texture, color, smell) contained in the cavity, determined by the type of
agent: stinky smell, dirty-gray pus typical putrefactive flora thick yellow-green pus
- for staph, blue-green color and sweet smell - for blue-purulent sticks etc.
Common clinical manifestations abscess: fever of sub-febrile to high,
malaise, weakness, loss of appetite, headache. In the peripheral blood -
leukocytosis with a shift neutrocytosis and leukocyte formula. ESR increased.

SEVERE abscess dominated phenomena of intoxication may be due as

absorption of toxic products from the lesion (purulent resorptive fever), and the
development of sepsis (see Sepsis).
Abscess should be distinguished from the hematoma, cysts, tumors that fail.
Of great importance is the diagnostic puncture: a manure allows, in addition to
establishing the diagnosis in doubtful cases to bacteriological examination -
abjection and determine its sensitivity to antibiotics.
If aerogenous flora in the oral abscess may form and accumulate gas - gas
abscess. Percussion over the area abscess appears timpanichesky sound, X-ray
images of the abscess cavity defined by gas bubbles and horizontal fluid level
below it (usually occurs when an abscess caused by septic infection).
Treatment consists in opening the abscess, drainage and emptying his
mouth. Not subject to section cold abscesses of tuberculous etiology due to
superinfection, which inevitably occurs while hnoyeridnoyu microflora. A small
abscess formed, with well-defined capsule removed completely.
For opening an abscess choose the shortest line access including anatomical
features and topography of the body. Often used method of opening the abscess by
needle, first punktuyut abscess, then the needle cut through tissue. The autopsy
abscess possibly suited to its lower pole to create good conditions for drainage.
In order to reduce infection operative field in the course section abscess
surrounding tissue carefully isolated gauze napkins and making a small hole in the
wall of the abscess, remove manure electric pumps. Aspiruvavshy pus incision
expand, the abscess cavity examined finger, sharing existing bridge is removed
sequesters tissue. Avoid rough manipulations that violate pyogenic membrane.
Abscess cavity was washed with antiseptic solution, then draining one or more
rubber or PVC tubes or injected into her gauze swabs soaked solution of
proteolytic enzymes and antiseptics. With insufficient emptying of the abscess
through the main incision is made additional - counterpuncture. Treatment abscess
after opening conducted on the principle of treatment of purulent wounds.
General treatment includes strengthening therapy, blood and plasma,
antibiotics considering the sensitivity of the microbial flora of specific therapy
(staphylococcal toxoid immunization, the use of specific y-globulin, etc.)..

Phlegmon - acute diffuse purulent inflammation of adipose tissue, not prone

to separation. Depending on the location distinguish subcutaneous, intramuscular,
retroperitoneal phlegmon and others of its species. A sharp localizations are some
special names: purulent mediastinitis paraproctitis, paranefryt, paraartykulyarna
abscess and others. A sharp that developed as a result of the transition of purulent
inflammation of lymph nodes, called adenoflehmonamy. A sharp prone to spread
klitkovynnyh spaces, vascular bed, fascial cases.

Etiology and pathogenesis. Causative agent of the disease is different

hnoyeridni microorganisms (Gram-positive and Gram-negative, aerobic and
anaerobic), but more often - staphylococci, streptococci, enterobacteria, Proteus, E.
coli. Microorganisms penetrate into the fatty tissue directly or hematogenous
routes. Possible formation of secondary abscess - spreading suppurative
inflammation in adipose tissue with osteomyelitis (parakistkova abscess), septic
arthritis (paraartykulyarna abscess), pyelonephritis (paranefryt) and others.
Development phlegmon begins with serous infilfatsyiyi subcutaneous fat.
Fluid rapidly becomes purulent character, formed areas of necrosis, which are then
merged. Necrosis and melting fat lead to abscess phlegmon.
Changes in the tissues under phlegmon depend on the nature of the
pathogen: putrefactive anaerobic infection and lead to tissue necrosis with the
formation of bubbles of gases. When coccal microflora is purulent fusion of
fabrics. The inflammatory process in phlegmon has no tendency to limit, as
observed by an abscess, and distributed in the intervals between klitkovynnyh
connective tissue.
Inflammation in adipose tissue is certain stage of development, starting with
serous edema, with subsequent formation of an inflammatory infiltrate with
subsequent tissue necrosis.

Clinical manifestations and diagnosis. Signs phlegmon are the same as the
symptoms of inflammatory processes (fever, fatigue, malaise, headache). They
determine complaints of patients who also noted pain and swelling at the site of
inflammation, pain with movement, change of body position.
Local manifestations subcutaneous phlegmon characterized classical signs of
inflammation. Swelling usually increases, the skin over it red, shiny, then gradually
fades and becomes a normal color. Palpation determined painful compression
without clear boundaries, real, hot to the touch. When abscess phlegmon can
determine softening infiltrate symptom fluctuations. Regional lymph nodes are
enlarged, painful. In some cases around infilfatu defined mesh red stripes or bands
(mesh or tubular, lymphangitis).
Active and passive movements of the limbs, head turns, changes in body position
caused a sharp increase in pain in the phlegmon.

When deep-seated (intramuscular) phlegmon limbs, its volume increases as

compared with the healthy. Measurement measuring tape can accurately determine
volume increase limb. Sometimes there is a protrusion of tissue in the area of
phlegmon. Palpation defined deep, sharply painful infiltration. Movement of limbs
sharply painful, sometimes there is protective (painful) contractions of the muscles
in the form of involuntary limb position in which pain is expressed to a lesser
extent. Regional lymph nodes are enlarged and painful. Detection by puncture pus
confirms the diagnosis of deep intermuscular phlegmon.
On the neck with mild clinical symptoms of purulent inflammation may be
determined infiltrate woody texture with bluish color of the skin over it - woody
phlegmon. Infiltration malobolyuchyy, fused with the skin, fascia, aponeurosis,
absolutely motionless, gradually increasing in size. Suppuration infiltrate observed
rarely. Latent disease occurs, the body temperature low-grade, mild symptoms of
intoxication.

Treatment phlegmon operative. Only in the initial stage, the expected serous
inflammation acceptable conservative treatment: bed rest, rest the affected limb,
antibiotykoterapiya, UHF-therapy, electrophoresis of chymotrypsin. Effective
novocaine blockade packs with antibiotics Vishnevsky. Improve the general
condition of patients, reducing local inflammation are favorable signs that indicate
a separation or reverse the development process. If no effect within 12-24 minutes
or progression shown in operation.
In urgently operated patients admitted late with severe intoxication, progressive
process, the presence of purulent inflammation. Under anesthesia conducted
autopsy cellulitis, manure removing necrotic tissue. Reveals swelling and pus
pocket wound thoroughly washed with antiseptic solutions, drain. To ensure good
drainage sometimes make additional cuts - counterpuncture. Treatment after
surgery is performed on the basis of treatment of purulent wounds.

Folliculitis - purulent inflammation of the hair follicle. Available as single

and multiple lesions. They are located in any area of the skin where there is a long,
well-developed vellus hair.
 Etiology and pathogenesis. Development of folliculitis is caused mainly
Staphylococcus aureus. Penetration of bacteria in the hair sac in disturbed outflow
contents causes inflammation. Development folliculitis contribute exhaustion,
colds, vitamin deficiency, chronic diseases, metabolic disorders.

Clinical manifestations and diagnosis. Folliculitis is a small cone-shaped

pustules that appears on the skin, in the center of which is hair. Pustules
surrounded by a narrow strip of flushing. Around the small pustules palpable
infiltration. After reducing signs of inflammation produced purulent crusts, which
vidpadayuchy leaves little morning with red shiny surface. After epithelialization
remains for awhile stain bluish-pink. With the localization of follicles on the scalp
are determined inflammatory nodes that merge together. Rozm'yakshuyuchys,
infiltrates leading to the formation of deep purulent moves. After recovery still
infiltrates remain severe scarring.

Treatment. Excluded, baths and even moisture follicles. Recommended

observance of safety measures. The skin around fires wipe 2% salicylic alcohol,
hair short obstryhayut. Follicles reveal a sterile needle and treated with iodine
tincture, green diamond to form crust.
In chronic folliculitis being treated comorbidities, antibiotic therapy,
immunotherapy, vitamin correction metabolic (eg, diabetes). Use physiotherapy
equipment - UV-irradiation of the lesion, electrophoresis of staphylococcal phage
or antibiotics to the affected area, diadynamic lesion area and others.

Boil (furunculus) - acute necrotic inflammation of the hair follicle,

sebaceous gland and surrounding subcutaneous fat. The most frequent localization
is boils back of the neck, forearms, back of the hand, hip. The appearance of 2 or
more boils shows abrasions. In the occurrence of boils play a role microtrauma,
such scratches skin in diseases involving itching.

Etiology and pathogenesis. The most common pathogen is Staphylococcus

aureus furunculosis, at least – purulent other microbes. Favorable conditions for
furuncle is a weakening of the body, metabolic disorders (often diabetes), vitamin
deficiency, skin diseases. Development boil begins with festering pustule
formation: after distribution of micro hair follicle in the papillary layer of the skin
there is an inflammatory infiltrate. The center infiltrate formed foci of necrosis
(necrotic core), around the accumulated manure. After exclusion of pus and
necrotic skin defect rod filled with the subsequent formation of granulation tissue.
Patients with early disease complain of the appearance of abscess (pustule)
or painful compression in the thickness of the skin. With an increasing
inflammation align complaints malaise, fever, pain in the seal increases. The most
severe pain is the localization boil on the skin are closely adjacent to neighboring
tissues: on the scalp, neck, ear canal, dorsum of fingers.
 Clinical manifestations and diagnosis. On examination of patients with
early disease in inflammation is a small abscess (pustule) with hyperemia of the
skin around. Less can be found in the thick seal skin and flushing of skin
thickening, abscess while absent. As the boil formed infiltrate cone rises above the
skin, with a diameter of 0.5-1.5 cm, with no clear boundaries. The skin over it
purplish-red color. In the center of infiltration appears crusty area of softening,
from the peel allocated a small amount of pus. After removal of pus in the center
infiltrate defined area of green fabric - top necrotic rod. With the formation of
necrotic rod of purulent discharge increases with pus and blood is separated and
refill. In the center of infiltration after removal of the rod appears fairly deep
wound, which quickly filled with granulation and healing in 2-3 days to form
embroiled scar that moderate bleeding.
Sometimes when viewed on the site furuncle defined globular swelling,
softening, slight purulent discharge. This abscesses boil, formed as a result of
complete meltdown purulent necrotic rod and violation of the outflow of pus.
Identified during the inspection of the skin of patients with red stripes
running from the boil, suggest joining lymphangitis, increased tenderness to
palpation of regional lymph nodes - to join lymphadenitis.
When localization boil on the face (Fig. 97) - the upper lip, eyelids, eyebrow
arches - patients sometimes complain of a severe headache, high body temperature,
which are signs of complications boil purulent thrombophlebitis facial veins. The
latter is sometimes accompanied by a purulent meningitis due to the transition of
inflammation in the veins of the face through a vein in the eye cavernous sinus.
Joining such symptoms as intermittent fever, chills, excessive sweating,
delirium, dizziness, pale skin, indicating the occurrence of sepsis, and the
appearance of abscesses in other organs (metastatic abscesses) confirms the
diagnosis septikopiemia.

Treatment of furuncle conservative. Patients should be warned about the

potentially serious complications of pressing boils, pustules a razor cutting, use
warming compresses. At the onset of the disease is treated skin 70% ethanol, 2%
salicylic alcohol, spend UHF therapy. After opening the boil make bandages with
proteolytic enzymes, hypertonic sodium chloride, used UVR. After removing the
rod impose ointment dressings with sintomitsinovoy emulsion metyluratsylovoyu
ointment. When complications boil lymphangitis and lymphadenitis shown
antibiotic.
Patients with facial boils subject to urgent hospitalization in the surgical
ward, where the local and general treatment, including antibiotics. Patients
prescribed bedrest, pureed food.
When abscess furuncle conduct surgical treatment - opening the abscess.
In rare recurrent boils and abrasions require the examination of patients that
can detect metabolic disorders (diabetes, vitamin deficiency). In order to increase
resistance to infection transmitting staph staphylococcus toxoid immunization.
 Carbuncle - acute diffuse necrotic inflammation of several hair follicles and
sebaceous glands, accompanied by the formation of general infiltration and
necrosis of the skin and subcutaneous tissue due to thrombosis.
Etiology and pathogenesis. The most frequent pathogen anthrax,
Staphylococcus aureus, at least - streptococcus, sometimes - mixed infection
(staphylococcus and streptococcus). Factors predisposing to the development of
carbuncle is weakening the overall resistance of the organism with debilitating
diseases, hypo-and avitaminosis, metabolic diseases (diabetes).
The main localization carbuncle - back of the neck, neck, upper and lower
lip, back, back.
The disease begins with the appearance of infiltration, covering multiple hair
follicles and sebaceous glands. There circulatory disorders caused by local
thrombosis with the formation of necrotic skin, subcutaneous tissue, sometimes
hlybsheroztashovanyh tissues. Together with necrosis occurs purulent fusion of
fabrics and oozing pus through the openings of hair follicles. After rejection
formed festering wound of deep tissue defects which healing occurs by secondary
intention.
Clinical manifestations and diagnosis. Patients complain of severe pain,
the presence of painful infiltrate, fever, chills, malaise, fatigue, weakness, loss of
appetite, headache. In compiling the history clarify the possible presence of
diabetes, beriberi, depletion.
When examining patients, but general signs of purulent inflammation
(increased body temperature, increased heart rate), it turns blue and Scarlet
swelling in the back of the neck, back, lower back, face, at least - the extremities.
At the onset of the disease may be several infiltrations, which are then joined
together to form a pronounced swelling, which rises above the surface of the skin.
The skin over the infiltrate intense, brilliant, with intense blue-purple color in the
center to the periphery, it gradually fades. On the surface infiltration determined
several purulent necrotic pustules that are in the center merge together to form
extensive skin necrosis. Thinned area of necrosis breaks in several places to form
holes (symptom "sieve") who stands manure. Infiltration dense, sharply painful
around it - pronounced swelling of tissues. Regional lymph nodes are enlarged and
painful (lymphadenitis), rarely observed lymphangitis.
With self-rejection tissues nekrosis, center infiltrate produce large cavity,
covered with gray-green necrotic tissue with abundant Department manure.

If the observation of the patient revealed an increase in tissue edema,

progression of necrosis, and increased symptoms of intoxication (tachycardia,
headache, weakness), chills, excessive sweating, lymphangitis, lymphadenitis,
thrombophlebitis, it should be regarded as unfavorable carbuncle, the development
of cellulitis, sepsis.
Especially dangerous is anthrax through face may develop meningitis.
 Carbuncle should be differentiated from sybirvyrazkovym anthrax,
characterized by the presence of hemorrhagic blisters, no purulent discharge,
painless infiltration, pronounced swelling of tissues, necrotic tissue black, formed,
and surrounded by small bubbles with hemorrhagic content. In content bubbles are
sybirkovu stick.
Treatment of carbuncles in early stages conservative. It includes the
complete rest of the affected organ. When carbuncles face patients required bed
rest. They prohibit talking, prescribe a liquid diet. After processing carbuncle 70%
ethanol impose aseptic bandage appoint UHF-therapy. Parenteral antibiotics
administered orally - sulfanilamidnye long-acting drugs. When carbuncles in
patients with diabetes, the necessary correction of metabolic disorders, careful of
insulin, which reduces the development of the inflammatory infiltrate and necrosis.
Failure of conservative therapy within 2-3 days, increase necrosis, purulent
intoxication are indications for surgery, which is done under general anesthesia.
Cut crosswise cut through infiltration to cut off the fascia and necrotic tissue
throughout, separating them from the fascia, skin, revealing purulent edema (Fig.
99). Bleeding with minor (vessels in the inflammatory infiltrate trombovani), it
stops when injected into the wound swabs with hypertonic saline or with
proteolytic enzymes.

On the face of anthrax reveal linear incision after the abscess.

Postoperatively treatment carbuncle conducted on the principle of treatment of
purulent wounds for removing necrotic tissue used proteolytic enzymes.
When to start treatment promptly carbuncle prognosis is favorable, but in
depleted patients with severe diabetes, as well as anthrax face does not exclude the
possibility of a bad outcome.

Hidradenitis - purulent inflammation apokrynes sweat glands.

Etiology and pathogenesis. Gidradenity caused mainly Staphylococcus
aureus, which penetrates through the excretory ducts of sweat glands. Precipitating
factor for the development of the disease are non personal hygiene, excessive
sweating, skin contamination, skin diseases (dermatitis, eczema).
In sweat glands develop inflammatory infiltration of tissues with subsequent
purulent melting.
Clinical manifestations and diagnosis. An examination of patients is
painful swelling - often in the underarm, at least in the groin or perianal areas
(locations apokrynovyh sweat glands). From history we can determine the presence
of triggering factors: increased sweating, rules of hygiene, the use of depilatories,
shaving hair in the armpits.
Disease begins acutely, with the appearance of small painful nodule that
increases in diameter of 1-2 cm and sharply above the surface of the surrounding
skin.
 On examination, marked swelling purplish-red color. In engaging in the
process of the sweat glands several nodes merge into dense infiltrate, which can
hold all the armpit. Single units are superficially fused with the skin. After 10-15
days in the heart swelling appears softening, defined fluctuant with infiltration,
disclosed, begins to stand creamy pus. After discharge of pus occurs with the
formation of scar healing. The disease can recur.
In engaging in the process of surrounding subcutaneous fat may develop
abscess, with involvement of lymph nodes - lymphadenitis.
Unlike boil speaker infiltration has follicular pustules and necrotic center.
For axillary lymphadenitis specific location deep infiltration, enlarged lymph
nodes, lack of cohesion tumor lesion of the skin.

To treat gidradenitis using antibiotics, long-acting sulfonamides. Spend

staphylococcal toxoid immunization. In the armpit shaved off the hair, skin rubbed
with alcohol, cologne, smeared 3% solution of brilliant green. Apply physiotherapy
- UHF, UV-irradiation.
When abscess gidradenitis conduct surgery, autopsy abscess manure. With
prolonged unsuccessful treatment gidradenity and the threat of sepsis divide all the
fatty tissue in the armpit, as in anthrax.

Mastitis - inflammation of the parenchyma and interstitial tissue of the

breast. Acute mastitis is mainly found in the first 2 weeks postpartum in women
who are fed milk - postnatal (lactational) mastitis, at least - in women who are not
breast-feeding and very rare - in pregnant women. The incidence of puerperal
mastitis ranges from 1.5 to 6% (relative to the number of births). Occurrence of
mastitis contributes to change the species composition of agents of purulent
infection, their antigenic properties and resistance to antibiotic . Usually mastitis
develops in one breast, bilateral mastitis is rare.
Classification of mastitis
I. Swollen form.
II. Infiltrative form.
III. Suppurative destructive form.
1) abscesses mastitis;
2) phlegmonous mastitis;
3) gangrenous mastitis.

Etiology and pathogenesis. Causative aureus mastitis is often in the form of

monoculture and in association with E. coli and streptococcus, at least - in the form
of isolated E. coli or Streptococcus, sometimes found Proteus, Pseudomonas
aeruginosa, anaerobic flora, fungi. There are also specific forms which are rare,
mastitis - tuberculous, syphilitic. The source of infection is bacteria carriers and
patients with sore forms purulent-inflammatory diseases that surround the patient.
Of primary importance in causing mastitis is nosocomial infections.
 Input Worth infection is often cracked nipples. Can also intrakanalikulyarne
of infection during breastfeeding or pumping milk, rarely spread of infection is
hematogenous and lymphogenous ways of endogenous foci of infection. The
presence of pathogenic bacteria on the skin and nipple of the mother, as well as in
the mouth of the child does not always lead to mastitis. Contributing points for
disease development is the weakening of the mother comorbidities, lower
immunobiological reactivity, Running across a difficult childbirth (especially the
first or large fruit), various complications of childbirth and the postpartum period
(bleeding, infection of the birth canal, and others.). A major factor predisposing
disease, is a violation of the outflow of milk from the development of its
stagnation, which often occurs in childbirth due to lack of milk ducts, irregular
structure nipples and functional disorders of the breast. When ingested bacteria in
enhanced milk ducts milk thickens, wall ducts swell, which increases galactostasia
and if damaged ductal epithelium promotes penetration of microbes in tissue
cancer.
Features purulent process in glandular organs are mild ability to its
differences and almost unlimited proliferation involving inflammation is more
glandular tissue. This distribution often does not stop at opening fire and then
created more new abscesses in the parenchyma of the gland.
The inflammatory process in the gland may be limited by inflammation of
mammary ducts (halaktoforit), which is accompanied by milk, whether pus or
inflammation of glands in the areola area (areolit). During the transition process in
the tissue and its development can be consistently observed phase serous and
purulent inflammation, often with marked destructive changes. In the phase of
serous inflammation of the gland tissue soaked with serous fluid around the vessels
observed accumulation of leukocytes. With the progression of inflammation serous
impregnation breast parenchyma changes diffuse purulent infiltration with small
foci of purulent fusion, which later merged to form abscesses. Recent dramatic
thinning due mizhchastochkovyh walls caused by inflammation and increased
secretory apparatus during lactation may coalesce and burst into subcutaneous
tissue or retromamarnyy space.

The most frequent localization of ulcers - intramamarna, subareolyarna.

When the location of the abscess in pieces on the back of the gland it can be
opened in klitkovynnyy space behind it to form a rare form - retromamarnoho
abscess. Sometimes due to involvement in the inflammatory process vessels and
thrombosis following necrosis of individual sections of cancer developing
gangrenosum form of mastitis.
Underlying chronic suppurative mastitis is the formation of small abscesses
with marked induration of the surrounding tissues. He develops as a result of
improperly conducted the treatment of acute mastitis (irrational antibiotic use by
local re-entered them in the inflammatory infiltrate).
 There are acute and chronic mastitis. Inflammatory processes may wonder
predominantly parenchyma (parenchymal mastitis) or breast interstitium
(interstitial mastitis). However, the distinction between these forms on the basis of
clinical data is not practically possible, the more frequently they are combined with
one another.
For practical purposes, is the most appropriate clinical classification of acute
mastitis in view of inflammation: serous (initial stage), acute infiltrative and
destructive - abscesses, abscess, gangrenous. In the group of chronic mastitis
distinguish purulent and purulent form.

Clinical manifestations and diagnosis. Early diagnosis of early forms of

mastitis and promptly started treatment in most cases to achieve the reverse of the
process, prevent its transition in purulent, destructive phase.
Acute inflammation in the mammary gland must be differentiated from
acute congestion of milk. In women after the first birth galactostasia meets 2 times
more often. Patients complain of heaviness and tension in the gland that gradually
increases. Tumor formation corresponds contours lobules of the breast, it is quite
moving, with clear boundaries, uneven surface, painless. When you click on him
milk secreted freely pumping painless. After racking comes relief. Overall
condition is deteriorating slightly, body temperature, clinical blood tests often are
normal. Acute galactostasia more often bilateral and develops in terms of the flow
of milk (3-5-day after birth).

Distinguished initial forms of acute mastitis milk stagnation is not always

easy, so any swelling of the breast that occurs with fever should be considered
stage serous mastitis. This allows time to start treatment and prevent the transition
process in purulent phase.
With the penetration of purulent microflora galactostasia 2-4 days becomes
inflammation - phase serous mastitis. Disease begins acutely with chills, fever,
sweating, weakness, weakness, sharp pain in the gland. The gland is enlarged,
painful on palpation, infiltration is defined clearly. Pumping milk painful and
brings relief. In blood leukocytosis to 10,0-12,0 - 109 / l ESR 20-30 mm / h. In late
begun treatment within 3-6 days process can go in infiltrative phase with severe
clinical signs of inflammation, severe general condition. There is a rise in body
temperature to 38-40 degrees. Palpable tumor formation has sharper contours.
The inflammatory process leads to changes in the acidity of milk toward
increasing pH, which is associated with increased activity of alkaline phosphatase.
Microscopic examination of the cellular composition of breast secretions
determined by a large number of leukocytes.
Go early forms of mastitis in purulent inflammation phase characterized by
increased general and local symptoms of inflammation. Body temperature is
constantly high or hectic nature. Infiltration in the gland increases, flushing of the
skin increases, fluctuations appear in one of the areas of cancer.
 Critical condition of patients observed in the form of gangrenous mastitis:
the body temperature rises to 40-41 ° C, heart rate - up to 120-130 per minute,
sharply increased breast, skin swelling, with bubbles filled with hemorrhagic
content, with areas of necrosis. Swelling spreads to surrounding tissues. In the
blood - high leukocytosis with a shift to the left and leukocyte toxic grit
leukocytes, protein appears in the urine.
The course of mastitis may be complicated lymphangitis, lymphadenitis and
(rarely) sepsis. After opening the pustules, especially involuntary, can be formed
mammary fistula, which closed itself over time.
Treatment of early forms of mastitis conservative, festering - operative. If
signs of stagnation of milk glands provide an elevated position by mobilizing
bandages or a bra that need support, but do not squeeze the gland. To drain the
gland suck milk breast pumps, breast feeding does not stop, limit fluid intake,
prescribe oxy-totsyn and no-silos. In serous and infiltrative venerable used
antibiotics (semi penitsyllin, aminohlikozid, cephalosporins, macrolides),
sulfonamides (in combination with antibiotics), infusion therapy with the
introduction blood substitutes liquids gemodez, protein preparations, saline, used
as means of improving the body's defenses (γ-globulin, and others.). Mandatory
regular pumping milk (to prevent stagnation in the gland). Reverse the
development process contribute retromamarni novocaine blockade with antibiotics
and proteolytic enzymes: 70-80 ml of 0.5% solution of novocaine, 500 000 ED
kanamycin and 10 mg of trypsin or chymotrypsin. In serous and infiltrative forms
of mastitis to accelerate the development process used reverse electric field UHF,
D, UV irradiation of cancer. All procedures carried out after emptying cancer. In
severe mastitis recommend suppress lactation combination of estrogen from
androgen.
When purulent mastitis shows the operation, which is done under general
anesthesia, only for small surface-located abscess can use infiltration anesthesia,
supplemented retromamarnoyu novocaine blockade. Conduct broad and deep
enough cuts breast, remove all necrotic tissue and accumulation of pus.
Intramamares ulcers reveal radial slits. Manure is removed, the cavity ulcer
examined finger, separating bridge washed with a solution of hydrogen peroxide
and dried. Then cut edges throw hooks and in good light inspect the abscess cavity,
pushing the gland. If you find a connection with another abscess located deep
abscess, the hole which receives manure, expanding forceps. Cuts and remove
necrotic tissue associated with cancer tissue that hang in the cavity of the abscess.
If there are multiple abscesses intramamarise each one revealing a separate
incision.

Retromamares and deeply located abscesses intramamarni reveal semioval

section of the lower transition crease. It peeled gland from the pectoralis muscle.
Intramamarni ulcers reveal behind abscess cavity drain the wound stitched to
drainages. This method of opening the abscess avoids crossing intralobular
mammary ducts, providing good conditions for the outflow discharge of pus and
necrotic tissue gives a good cosmetic result. In localized forms of acute mastitis,
especially in chronic mastitis possible cuts purulent focus within the healthy tissue
and blending "blind seam" with leaving small drainage for the introduction of
antibiotics.
Treatment of wounds after opening the abscess spend considering phases of
wound healing process. The use of secondary sutures reduces treatment time and
improves the cosmetic surgery results.
Prevention of mastitis begin in antenatal long before birth. The basis for
preventive measures is to increase the body's resistance pregnant woman. An
important place is occupied rehabilitation endogenous foci of infection, studies of
women, especially those in which the first birth, breast feeding rules, care for
breast cancer, hardening of the body, staphylococcus toxoid immunization, UV
irradiation of the body, etc. Particular attention should be given to pregnant women
with high risk of mastitis (with mastitis, suppurative infections of different
localization in history), as well as mastopatiyey, abnormalities of the breast, nipple,
with complications of pregnancy.
The complex of preventive measures include preventing injuries and
hospital blood loss, anesthesia delivery, combating congestion milk processing
nipples before and after breastfeeding breastfeeding, prevention and early
treatment of cracked nipples. Given the importance of nosocomial infection in the
development of mastitis, an extremely important outlet sanitary-epidemiological
profile of hospitals to prevent purulent-inflammatory diseases of infants and
mothers. This is particularly timely identification and rehabilitation of bacteria,
careful implementation of sanitation requirements in the care of women in labor,
regular wet cleaning, ventilation chambers using germicidal lamps etc.

Erysipelas - progressive acute inflammation own skin, less mucous

membranes.
Etiology and pathogenesis. Erysipelas caused by various forms of
streptococcus refers to contagious diseases. As to the antiseptic period it was one
of the major complications of wounds in hospitals. Which can lead to nosocomial
diseases significant contingent of wounded and sick.
Microflora penetrates the skin from the external environment;
lymphogenous, especially hematogenous, route of infection is extremely rare.
In place of getting pathogenic streptococci growing focus serous
inflammation localized in the reticular layer of the skin. In fluid determined
neutrophilic leukocytes, stasis in blood and lymphatic capillaries. Marked
inflammatory changes extend the width, capturing all the new skin. Such changes
are characteristic erythematous erysipelas.
As the process occurring epidermal desquamation, exfoliation last
inflammatory exudate to form blisters (bullous form of erysipelas). Content
bubbles are transparent yellowish fluid, sometimes there is a collection of pus,
rarely fluid in the bladder is hemorrhagic nature.
 The progression of the inflammatory process in the skin with purulent
infiltration of tissues leads to the formation of subcutaneous tissue phlegmon
(abscess form erysipelas).
Development of inflammation in the skin can lead to circulatory disorders,
thrombosis with the formation of skin necrosis (necrotizing form of erysipelas).
In the pathogenesis of erysipelas importance is allergic factor. Erysipelas
prone to relapses, which are based on the state of sensitization of the organism.
Relapses inflammation leads to sclerosis subcutaneous tissue and lymph flow
disorders of development lymphostasis first and then elephantiasis.
Erysipelas may develop as a result of primary infection with exogenous and
endogenous sources. But erysipelas may develop as a manifestation of secondary
process - as a result of complications of various inflammatory diseases (furuncle,
carbuncle, osteomyelitis, and others.).

Some forms of erysipelas, diagnosed on the basis of clinical signs, in fact are
the phases of the development process, the progress of which can be terminated at
any given stage.

Clinical manifestations and diagnosis. The disease occurs with severe

clinical manifestations; infringement general condition prior to the development of
local symptoms. A small group of patients experienced prodromal period
characterized by malaise, weakness, headache. The disease often begins acutely
with stunning chills, severe headache. There are sharp tachycardia, rapid breathing,
body temperature for a short period reaches 40-41 ° C. From the general symptoms
of intoxication observed insomnia, decreased amount of urine, it determined the
protein, erythrocytes, leukocytes, hyaline and granular cylinders.
In the blood - marked leukocytosis and neutrophilia, mild anemia, reduced
the number of eosinophils, but the beginning of recovery decreases neutrophilia
disappears eozynopeniya appears lymphocytosis. Sometimes it may be noted
enlargement of the liver and spleen. In some cases, severe intoxication leads to
changes in the central nervous system with the emergence of agitation, severe
headache, sometimes delirium.
Local symptoms erythematous erysipelas - a burning pain, feeling the heat in
the affected area, the appearance of a bright red with sharp, jagged like, outside.
Erysipelas often localized on the face, head and lower extremities. For all circuits
zone lesions similar to a map, areas of hyperemia resembling flames.
The skin in the area of inflammation swelling, its temperature is increased,
pain intensely expressed on the periphery, there is observed a more pronounced
redness, whose intensity in the center of lesions gradually decreases. In areas
where the skin is inactive, tightly coupled with the appropriate tissues, redness
usually breaks. For bullous form of erysipelas, but signs of erythematous
erysipelas, characteristic of bubbles of various sizes, filled with serous, purulent or
hemorrhagic exudate, which are streptococci; fluid is very contagious and can be a
source of transmission of erysipelas by contact. The duration of this form of the
disease is usually 1-2 weeks. By the end of the disease is critical body temperature
falls with considerable sweating. After calming down local inflammation remains
strong exfoliation of the epidermis, the skin on the scalp noted significant hair loss.
Abscess erysipelas changes on the surface of the skin (redness, itching, pain)
may be less pronounced, but the common symptoms are stronger than in the
erythematous and bullous beshysi. The general condition of the patient difficult:
tachycardia, fever, chills. In emaciated, frail and elderly patients with phlegmonous
erysipelas form can go into necrotic, which is characterized by the appearance of
skin necrosis - black limited painless dense areas in the field of severe congestion,
edema, blistering.
Localization erysipelatous inflammation defines some features of its flow.
On the face of erysipelas characterized by its swelling. Phlegmonous erysipelas of
the scalp accompanied by plenty of pus, purulent edema, exfoliation of skin.
In the trunk of erysipelas characterize active dissemination process,
accompanied by severe intoxication. This inflammation can move sequentially
capturing all the new skin and even areas previously affected (creeping erysipelas).
Erysipelas may affect areas of the body surface at a certain distance between them
(erysipelas migrans). With the localization of erysipelas on the limbs mainly
observed erythematous and bullous forms of it, but clinically it runs hard, when
expressed commonplace. This form is often accompanied by lymphadenitis,
phlebitis, thrombophlebitis.
In places where loose connective tissue erysipelas occurs with noticeable
swelling of tissues, circulatory disorders and the development of extensive skin
necrosis (areas eyelids, scrotum).
Erysipelas mucous membranes characterized by the same general and local
symptoms, as in skin lesions: clearly delineated redness, swelling, pain in
erytematoznoy phase, the development of blisters containing serous fluid in
bullous phase formation of necrosis with necrotic form of erysipelas.
Erysipelas is distinguished by frequent relapses (in 20-25% of cases),
recurrence of disease in the extremities lymphostasis lead to the development of
elephantiasis.
Erysipelas can spread from the skin to the surrounding tissues to cause
metastasis streptococcal infection with the development of foci of inflammation
with severe toxemia. The inflammatory process in flehmonoznoy beshysi may
apply to tendon sheath, joints, muscles.
In typical cases the diagnosis of erysipelas has no complications. It is based
on such manifestations as fever, a sharp increase in body temperature in the
presence of pronounced redness with clear boundaries, swelling and hyperesthesia
certain areas, abrasions, often located near scuffs, scratches, wounds and so on. No
redness observed in rapidly debilitated patients (old and depleted patients), or
disguise her scalp greatly complicate diagnosis. In these cases correctly diagnosed
erysipelas allow the presence of severe intoxication, fever and detection on the
periphery of the inflammatory skin lesions summed shaft, featuring a sharp pain.
 Differential diagnosis should be made with erysipelas erythema, dermatitis,
cellulitis, limfanhytom in some cases of anthrax.
Major complications occur in the differentiation of erysipelas with ordinary
phlegmon. When rose process is localized in the skin and more pronounced on the
periphery of lesions, in contrast with phlegmon inflammation affects subcutaneous
and intramuscular fat, skin changes (swelling, redness) are secondary in nature and
amplified from the periphery to the center of the lesion. Maximum tenderness
phlegmon also localized in the center of swelling, but not in the periphery, as in
beshysi. In addition, the phlegmon in the area of skin lesions observed dense
infiltrate in appropriate tissues, which is not the case with erythematous and
bullous form of erysipelas.

When abscess beshysi process usually begins with a skin lesion, while
abscess - subcutaneous and intramuscular fat skin changes connected to other
displays. Suspicion of bullous and gangrenous erysipelas, especially in severe
general condition of the patient and contact with animals, skins, wool, should be
performed differentiation of cutaneous anthrax. For anthrax is characterized by
lesions in the central area nekrotyzo-bathroom tissue with subsidiaries bubbles on
the periphery and extensive soft tissue edema (sybirkovyrazkovyy anthrax). In
these cases, usually considerably enlarged regional lymph nodes. Local changes in
beshysi differ from described the clinical picture.
Result erysipelas depends on the severity of the process and the patient, his
immunological forces, the presence or absence of comorbidities on the timeliness
and accuracy of treatment. The best results are observed in erythematous and
bullous beshysi significantly worse prognosis in phlegmonous and gangrenous
forms.
Treatment in hospital. Significant progress in the treatment of erysipelas
was achieved after began to use UV rays, especially combined therapy with
antibacterials (sulfonamides, antibiotics). When UV irradiation is usually used
Erythemic or suberytemni dose. When erythematous or bullous beshysi radiation
dosing based localization process: on a limb - 4-5 biodoz on the face - 3 biodozy. If
exposure started in the first days of the disease, usually after 1-2 sessions is the
body temperature drops, redness is reduced, improving the health of the patient, ie,
the process terminates. When abscess beshysi exposure spend carefully because it
may lead to increased swelling and thrombosis of small vessels of the skin. When
gangrenous beshysi irradiation is contraindicated.
Along with the radiation used antibiotics and sulfanilamide preparations.
With antibiotics being used penicillins, semisynthetic penicillins (the
disappearance of redness and normalization of body temperature). Effective in
these cases, the simultaneous use of sulfonamides prolonged action. The earlier
treatment is begun, the faster the recovery comes. In severe cases of erysipelas
limbs used Endolymphatic administration of antibiotics.
 Wet bandages, compresses, baths absolutely contraindicated. In bullous
form of bladder after treatment with alcohol and reveal a plot defeat bandage with
sintomitsinovoy emulsion streptotsydnoyu suspension, tetracycline ointment, and
others. In phlegmonous and gangrenous forms other than the described treatment,
conduct an autopsy accumulations of pus, drainage, removal of necrotic tissue.
Of great importance is the high calorie milk and vegetable diet with a high
content of vitamins. Required adherence asepsis, patient better isolate in a separate
ward.
Prophylactic treatment of erysipelas is to microtraumas, careful adherence to
the rules of asepsis in surgical hospitals, implementation of preventive measures.

Eryzepeloyid, pork measles or swine erysipelas, erythema creeping -

infectious disease, resulting in inflammation of all layers of the skin.
Etiology and pathogenesis. The causative agent of the disease - swine
erysipelas bacillus - crosses mikrotravmatychni skin damage when cutting meat
infected animals. The incubation period of 3-7 days. Most affected people directly
associated with the processing of meat, fish, fowl, ie working meat, fish, canned
and skin industry, domestic housewives and others. The disease is not a rare but
often visible or diagnosed as "erysipelas finger", "dermatitis", "felon",
"lymphangitis". In the skin develops serous inflammation of all layers of the
accession limfangita and tissue edema with congestion in the area of inflammation
mast cells.

Clinical manifestations. Most affected fingers. On the 1st day of the disease on
the dorsum of the thumb appears painful stain pink-red, itchy, with clear
boundaries, towering above the surrounding skin. After a few days of itching
increases in 2-3 weeks decreases swelling, itching stops, congestion persists,
remains exfoliate the skin. Inflammation can spread to the back of the hand and
fingers with the accession of lymphangitis and lymphadenitis. Sometimes acute
arthritis of interphalangeal joints. The general condition of almost constant body
temperature usually does not rise and only a mixed infection can be high.
When diagnosis is necessary to bear in mind diseases such as erysipelas and acute
lymphangitis, but they are accompanied by more severe general symptoms of high
fever. From panaritiums erizipeloyid differs less acute course, the presence of
itching, lack of local pain. The disease can go into the chronic form, there is also a
relapsing disease.
As treatment used immobilization brush antibiotics by intramuscular injection, UV
radiation skin effective novocaine blockade packs with simultaneous
administration of antibiotics.
Prevention of the disease is to improve sanitary conditions of work in the meat and
fish industry, to protect hands from micro-traumas and infection.

Paraproctitis. Acute paraproctitis - purulent inflammation pararectal fiber.

Etiology and pathogenesis. Pathogens paraproctitis often are Escherichia coli,
Staphylococcus and white staphylococci, anaerobes, and others. Usually defined
mixed microflora.
Penetration of microorganisms in the perianal tissue contribute anal fissures,
hemorrhoids inflammation, damage to the mucous membrane of the rectum and
anal canal, inflammation of crypts, perineum bruising, rozchuhy covers the anus,
and others. A sharp navkolokyshkovoyi tissue as possible complications of
gunshot wounds, and tumors that splits. The inflammatory process differs edema
and purulent infiltration of loose connective tissue. Putrid infection
rospovsyudzhuyuchys on navkolopryamokyshkoviy tissue or lymphatic tissue on
the pelvis, often causes necrosis - the disintegration of tissue without the formation
of abscesses (suppurative necrotic paraproctitis). There are 5 forms of limited
perianal abscesses: subcutaneous, ishiorektalis, subcutaneus, pelviorektalis and
retrorektalis.

Subcutaneous paraproctitis localized under the skin near pozadoprohidnoho hole.

Patients feel a sharp pain in the pozadoprohidnoho channel, especially during
bowel movements. Increases body temperature. Clearly defined painful swelling of
the skin over her hyperemic. When it abscessed can determine symptom
fluktuation.
Ishiorektalis paraproctitis occurs with severe general symptoms. Process, capturing
the deeper layers of tissue sciatic-rectal cavities, spreads behind the rectum to the
other side to the prostate and, going up, grabs pelvic tissue. Patients noted
throbbing pain in the rectum, high body temperature, sometimes chills.
Swelling, redness of the skin at the general intoxication facilitate diagnosis in
patients with this form paraproctitis. However, in the early stages of the disease
when no external signs of it, we need a bimanual examination, introducing the
finger of one hand into the rectum and placing a finger of the other hand on the
swelling out. It is possible to define a painful infiltration.
Submucosal paraproctitis localized in submucosal layer of the rectum above
pozadoprohidnyh pillars. With digital examination can determine the swelling and
soreness in the anus. Unlike subcutaneous abscesses pain pidslyzystiy form
paraproctitis less intense.
Pelviorektalis paraproctitis - rare but most severe form pararectalis ulcers. An
abscess is formed above the pelvic floor, but may also be located low in front,
behind, on the sides of the rectum. Disease at an early stage is characterized by the
absence of any external signs of inflammation in the anus, ishyorektalnyh
depressions. Later inflammations, punching muscle lifting anus descends down
between tendon reflex arc and fascia tissue in the gluteal-rectal cavity, while here
there is abscess with characteristic clinical signs ishyorektalis abscess.
If pelviorektalis abscesses are low on soft yazom, raising the anus, then the digital
examination of the rectum can be determined relatively early swelling.
Retrorektalis paraproctitis formed as a result of infection in the lymph nodes and
differs from pelviorektalis only that originally abscess located in the tissue behind
the rectum, and may well go down in ishyorektalis fiber and cause it phlegmonous
inflammation.
Treatment. In the very early stage of the disease in the presence of a small
infyltratu in perianal area used conservative treatment: sitting warm bath with a
solution of potassium permanganate, lumbar novocaine blockade radiators, UHF-
therapy and others. All heat treatments combined with antibiotic therapy.

Surgical treatment of acute paraproctitis includes early emergency surgery by

opening the abscess with removal of manure and nekrosis tissue abscess cavity
examination finger separation bridges and drainage cavity.

Apply radial, venous, cross sections, the most comfortable with them - venous and
radial. They provide an open wound and outflow of purulent exudate, and less
traumatic. After surgery, the purpose of delay stool for 3-4 days patients prescribed
tincture of opium (5-6 drops 3 times a day). Requires strict bed rest. When reflex
urinary retention patients put a heating pad on the area of the bladder or
intravenously injected 5.10 ml 40% solution of hexamine.
When putrefactive necrotic paraproctitis during surgery is performed complete
excision of tissue that numb within healthy tissue, and do this 2-3 more cuts skin
and subcutaneous tissue for drainage.

Lymphangitis - inflammation of the lymphatic vessels, complicating

inflammatory disease. Penetration of bacteria in the interstitial spaces and lymph
vessels there always, with any disease, but clinical manifestations are possible only
when the inflammatory changes in blood vessels.
Etiology and pathogenesis. The most common pathogen is Staphylococcus
limfangita, other pus germs are rare.
Lymphangitis - disease secondary. It complicates the course of this disease,
as abrasions, karbunkuloz, abscesses, cellulitis, felons, nahnyvayuchi wounds etc.
Inflammatory process affects both surface and deep lymphatic vessels. In the
wall of the lymphatic vessels and surrounding tissue edema, tissue infiltration by
lymphocytes with phenomena perylymfanhitis.
Clinical manifestations and diagnosis. Joining acute lymphangitis with
varying purulent process indicates the progression of the underlying disease and
increases the severity of its occurrence. Typically, the body temperature rises to 39
- 40 ° C, accompanied by chills, headache, increased sweating, weakness, high
leukocytosis. When reticular lymphangitis there is a pronounced hyperemia of the
skin, similar to erysipelatous, but without clear boundaries, sometimes you can
define mesh drawing in a zone of intense redness. When stem (trunkulyarnomu)
lymphangitis congestion has some kind of bands, ranging from inflammation to the
area of regional lymph nodes - to the axillary fossa or groin folds, skin swelling.
Palpation perceptible painful consolidation in the form of strands along the lymph
vessels. Regional lymph nodes are enlarged, thick, painful on palpation. In
engaging in the process of deep lymphatic vessels dermahemia absent, defined
pain in extremity, swelling, tenderness on deep palpation and early appearance
lymphadenitis.
When perylymfanhitis defined areas induration along the lymph vessels.

Treatment is directed primarily at eliminating the primary lesion: an autopsy

abscess, cellulitis, purulent swelling, drainage of abscesses. Antibiotic therapy
prescribed by the nature of the microbial flora and its drug resistance. Important
creating calm, elevated position affected organ, for this purpose, using
immobilization of the limb.
Prevention lymfangitis reduced to a thorough and timely primary surgical
treatment of wounds, limb immobilization, timely incision and drainage of
purulent foci, regional antibacterial therapy.