Draining pus is the commonest surgical operation all over the developing world. It is also one of the most useful and is usually one of the simplest. Quite a small district hospital can expect to drain 200 large abscesses each year, some containing up to 3 litres of pus. Although pus can collect almost anywhere, particularly important sites are a patient's pleura (6.1), his peritoneum (6.2), his muscles (7.1), his bones (7.2), and joints (7.16), his hand ]](8.1), and his eye (endophthalmitis, 24.3). This chapter and the immediately following ones tell you how to drain pus. Pus in the breast (21.2) and the eye (24.3), and the most serious consequence of pyogenic infection[md]septic shock[md]are described elsewhere (53.4).
Why septic infections of all kinds are so common here is not altogether clear, but anaemia, malnutrition, and poor hygiene may all play a part in causing them. Abscesses are more common in children and young adults, and a patient may have a dozen or more at the same time. Staphylococci are almost always responsible, except in the perineal and perianal region, which is commonly infected by coliforms and anaerobes. Some abscesses are tuberculous (29.1). AIDS predisposes a patient to infections of many kinds, including abscesses anywhere.
If bacteria are multiplying in a patient's tissues, antibiotics will only be effective in killing them early, when there is cellulitis only, and before much pus has formed. At this early stage antibiotics may start to control cellulitis within 24 hours. But once pus has formed, you must drain it. Conversely, before pus has had time to form drainage is useless. Antibiotics and drainage thus both have their proper indications, and one is no substitute for the other. The tighter the space, the more urgent the need for drainage. If a patient has pus in his bones, joints, tendon sheaths, or the pulp space of his fingers, draining it early is particularly urgent. Elsewhere, you have more time.
If pus gathers in loose tissues near the surface of the body, you can usually detect fluctuation. But you will not detect fluctuation, or only detect it very late, if pus is under tension in some tight compartment, such as: (1) the pulp spaces of a patient's fingers or toes, (2) the fascial spaces of his hand (8.1) or foot, (3) his ischiorectal fossae, (4) the lobules of a woman's breast (21.2), (5) the neck or iliac region (iliac abscesses, 5.12), (6) the parotid gland (5.9). Incise abscesses in any of these places without waiting for fluctuation, or for pus to point. For fluctuation to be a useful sign, a minimum quantity of pus must be present, and it must be near the surface. If you wait for fluctuation in any of these places, you will have to wait until there is a huge bag of pus and much tissue has been destroyed unnecessarily.
Fig. 5-1 SOME SITES OF SEPSIS. Pus can gather almost anywhere, but here are some of the commoner places where you will find it. WHERE THERE IS PUS, LET IT OUT