Chapter 4. The surgery of sepsis

Table of Contents
''Where there is pus let it out'
Abscesses
Boils
Carbuncles
Extradural abscesses
Infections of the orbit, cavernous sinus thrombosis
Peritonsillar abscesses
Retropharyngeal abscesses
Dental abscesses
Parotid abscesses
Pus in the neck[md]Ludwig's angina
Thyroid abscesses (acute bacterial thyroiditis)
Pancreatic abscess
Axillary abscesses
Perinephric abscesses
Iliac abscesses
Anorectal abscesses
Periurethral abscesses
Prostatic abscesses
Abscesses in the seminal vesicles (rare)
Pus in the pleural cavities[md]empyema
Pus in the pericardium
Peritonitis
Abscesses in the peritoneal cavity
Subphrenic abscess
Pelvic abscesses
Infection of the female genital tract; pelvic inflammatory disease[md]PID
Septic abortions
Puerperal sepsis
Infection following Caesarean section
Pyomyositis
The pathology of osteomyelitis
Acute osteomyelitis
The general method for osteomyelitis
Exploring a bone for pus
Chronic osteomyelitis
Osteomyelitis of the humerus
Osteomyelitis of the radius
Osteomyelitis of the ulna
Osteomyelitis of the femur
Osteomyelitis of the tibia
Osteomyelitis of the fibula
Osteomyelitis of the calcaneus and talus
Osteitis of the cranium
Osteomyelitis of the jaws
Osteomyelitis of the spine and pelvis (both uncommon)
Septic arthritis
Methods and positions for particular joints [s8]apart from the hip, most of the methods for which are in the next section
Septic arthritis of the hip
Girdlestone's operation for an infected hip
The general method for an infected hand
Subcutaneous hand infections
Infections of the apical finger space
Paronychia
Infection of the pulp space of the finger
Infections of the spaces over the volar surfaces of the middle and proximal phalanges
Web space infections
Infection of the superficial palmar space
Infection of the middle palmar space
Infection of the thenar space of the hand
Infections on the dorsum of the hand and fingers
Infections of the flexor tendon sheaths of the hand
Infection of ulnar bursa of the hand
Infection of the radial bursa of the hand
Septic arthritis of the fingers
Other problems with hand infections
Pus in the foot
Before a major operation
Laparotomy
Resecting and anastomosing gut, end-to-end anastomoses
End-to-side and side-to-side anastomoses
Stomata and bypasses for large gut obstruction
Methods for ostomies
A feeding jejunostomy
Draining and closing the abdomen
After an abdominal operation
Non-respiratory postoperative complications
Respiratory postoperative complications
If a laparotomy wound becomes infected
Burst abdomen (wound dehiscence)
Intestinal fistulae
The general method for an acute abdomen
Diagnosing an acute abdomen
Intestinal obstruction
The diagnosis of intestinal obstruction
The management of intestinal obstruction
The surgery of ascariasis
Obstruction by bands and adhesions
Intussusception
Volvulus of the small gut
Volvulus of the sigmoid colon
Closing Hartmann's operation
Volvulus of the caecum (rare)
Obstruction following abdominal abscesses
Ileus and obstruction follow abdominal surgery
Other problems with intestinal obstruction

''Where there is pus let it out'

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