IV. Table of contents of teaching

Hydradenitis is purulent inflammation of sweat-glands.

Etiology and pathogeny. Hydradenitis causes mainly Staphylococcus aureus, penetrable through the conclusion channel of sweat-gland. A failure to observe of the personal hygiene, promoted sweaty, contaminations of skin, diseases of skin, serve as predisposing moments to development of disease (dermatitis, eczema).

In a sweat-gland inflammatory infiltration of tissues develops with the subsequent purulent melting.

Clinical displays and diagnosis. At the inspection of patients the sickly slight swelling is marked — more frequent in an armpit, rarer in inguinal or perianal areas (places of sweat-glands location). From anamnesis it is succeeded to find out the presence of predisposing moments: promoted sweaty, failure to observe of rules of hygiene, application of depilators, shaving of hairs in the cavities of arm-pits.

A disease begins sharply, from appearance of small sickly node which is increased in a diameter to 1-2 sm and sharply comes forward above the surface of surrounding skin.

At examination the slight swelling of purple-red color is marked. At engaging in the process of a few sweat-glands nodes meet in dense infiltrate which can occupy all of armpit cavity. Single knots are disposed superficially, soldered with a skin. In 10-15 days softening influence appears in the center of the slight swelling, fluctuation is determined. Cicatrization with forming of scar comes after outgoing of pus. A disease can recur.

A phlegmon can develop at engaging in the process of surrounding hypodermic fatty cellulose, at involving of lymphatic nodes is lymphadenitis.

Unlike a furuncle salient infiltrate does not have follicle pustule and necrotic center. For armpit lymphadenitis characteristic deep location of infiltrate, increased lymphatic nodes, absence of cohesion of tumular education with a skin.

For treatment Hydradenitis utillize antibiotics, сульфаниламиды of the protracted action. In an armpit cavity shave off hairs, a skin is wiped an alcohol, eau-de-cologne, 3% oil by solution of diamond green. Apply physiotherapy are currents ultrahigh frequencies, ultraviolet radiation.

At abscessed Hydradenitis come running to surgical treatment, dissection of abscess, leaving to rot a delete. At the protracted unsuccessful treatment of Hydradenitis and threat of development of sepsis excise all of fatty cellulose in an armpit cavity, as at a carbuncle.

Mastitis is inflammation of parenchyma and interstitial tissues of mammary gland.

Acute mastitis mainly meets in the first 2 weeks of postnatal period for feedings women is post-natal (lactation) mastitis, rarer — at unfeedings and extremely rarely — at pregnant. Frequency of development of postnatal mastitis hesitates from 1,5 to 6% (in relation to the number of births).

Classification is mastitis.

I. Edema form.

II. Infiltration form.

III. Purulent-destructive form.

• abscessed;

• phlegmonic;

• gangrenous.

Etiology and pathogeny. Mastitis an exciter more frequent there is staphylococcus as a monoculture and in associations with an intestinal stick and streptococcus. A primary value in the origin of mastitis has hospital infection. The entrance collars of infection more frequent than all are cracks of nipples. Rarer distribution of infection takes a place hematogenous and lymphogenic by a way from the endogenous hearths of infection. Playing in the favour of moments for development of disease it is been weakening of organism of mother by concomitant diseases, decline of immunological reactivity of organism, heavily flowings births, different complications of births and postpartum period. A substantial factor, cooperant a disease, is violation of outflow of milk with development of his stagnation, that quite often is observed at first-born in connection with insufficiency of milk channels, wrong structure of nipples and violations of functional activity of mammary gland. At the hit of microbes in the extended milk channels milk coagulates, the walls of channels swell up, that aggravates stagnation of milk and at the damage of epithelium of channels instrumental in penetration of microbes in fabric of gland.

On localization abscesses in a mammary gland divide by hypodermic, intramammarial and retromammarial. Such location of abscesses is conditioned the topography of fascia and fatty cellulose. Intramammarial abscesses because of the acute thinning of interlobular bridges, conditioned an inflammatory process and increase of secretory vehicle during a lactation, can meet between itself. Just they can penetrate retrad through thin fascia with formation of retromammarial abscess. More frequent than all abscesses are disposed intramammarial. Sometimes because of engaging in the inflammatory process of vessels and them trombing comes necrosis of separate areas of gland, a gangrenous form develops mastitis.

Clinical displays and diagnosis. Acute inflammatory process in a mammary gland it is necessary to differentiate with acute stagnation of milk. For first-born women stagnation of milk meets in 2 times more frequent. Patients grumble about feeling of weight and tension in iron which increases gradually. Tumular education corresponds the contours of lobules of mammary gland, it suffices mobile, with clear scopes, uneven surface, painless. At pressing on milk is selected freely on him, straining painlessly. A facilitation comes after straining. The general state suffers insignificantly, temperature of body, clinical blood tests more frequent remain normal. Acute stagnation of milk more frequent is bilateral: develops in the terms of wave of milk (on a 3-5th day after births).

Differentiate initial forms mastitis from acute stagnation of milk not always easily, therefore any callous of mammarys glands, flowing with the increase of temperature of body, it is necessary to consider the serous stage mastitis. It allows in good time to begin treatment and warn passing of process to the purulent phase.

Transition of initial forms mastitis in the purulent phase of inflammation characterized strengthening of general and local symptoms of inflammation. Temperature of body constantly high or hectic character. Infiltrate in a gland is increased, hyperemia of skin grows, fluctuation appears in one of areas of gland.

The extremely grave condition of patients is observed at a gangrenous form mastitis: the temperature of body rises to 40-41 °С, pulse – to 120-130 in a minute, a mammary gland is acutely increased, a skin is an edema, with bubbles, filled with haemorrhagic content, with the areas of necrosis. An edema spreads on surrounding fabrics. In blood is high leucocytosis with the change of leucocytal formula to the left and by the toxic graininess of leucocytes; an albumen appears in urine. The flow of mastitis can be complicated by lymphadenitis and (rarely) sepsis.

Treatment of initial forms mastitis conservative, purulents – operative. At appearance of signs of stagnation of milk the elevated position is given a gland by retaining bandage, which must support, but not to squeeze a gland. For emptying glands aspirate milk; mammary is not halted, limit the reception of liquid, appoint oxytocin and no-spani. At serous and infiltrative mastitis apply antibiotics (ampicillin), utillize facilities also, promoting protective forces of organism (γ-globulin and other). The regular straining of milk is obligatory (for warning of stagnation in a gland). Retromammarial novocaine blockades are instrumental in reverse development of process with antibiotics and proteolytic enzymes.

Dissection of retromammarial abscesses is made only under anesthesia.

Operations on a mammary gland. For dissection of intramammarial abscess apply a radial cut above the place of compression and hyperemia of skin. Present necrotic tissues excise, a pus is deleted. An operation is concluded drainage of wound. Drainage an abscess a tube or put right flowing-wash drainage of wound.

For dissection of retromammarial abscess apply the cut of Bardengeyera, which is conducted on the lower transitional fold of mammary gland.

Drainage can be conducted through an additional cut on the front surface of gland and through a basic cut under a gland. A gland is laid into place and lay on a few stitches on a skin wound. Such method of dissection of abscesses allows to avoid crossing of channels of ferrous lobules, provides good terms for an outflow leaving to rot necrotic tissues, gives a good cosmetic result — a barely visible scar which is covered an overhanging gland a stay after convalescence.

At the subareolar location of abscess he is unsealed a circular cut. Such abscess can be unsealed a small radial cut, not crossing areola.

Erysipelas. Acute inflammation of skin or mucous membranes and lymphatic ways, caused a haemolytic streptococcus.

An entrance gate is scratches, wounds. A leading role in the origin of Erysipelas is played by the state of patient. For people, carrying Erysipelas, immunity is not produced, and, vice versa, inclination appears for the repeated disease. Most often a Erysipelas strikes the skin of face, head, shins, rarer than trunk. A latent period (time from the beginning of microbial contamination to appearance of clinical picture) is equal to 2-7 days.

Clinical picture. A disease is begun acutely with a chill and increase of temperature to 40-41°С. At the same time redness and slight swelling appear on a skin. A skin becomes tense, sickly, hotter by touch and acquires the bright red colouring with the acutely outlined border, on the edges of which there is the roller-form swelling. The described picture got the name of erythematous form. Sometimes bubbles, containing transparent, rather yellow exudation (bubble form), appear on the redden area of skin, at his suppuration (pustulous form), at presence of haemorrhagic content (haemorrhagic form), at suppuration and distribution of process on a hypodermic cellulose (phlegmonic form) and necrosis of skin (necrotic form).

The so-called wandering flows most heavily, or migrant, an erysipelas is a form at which a process passes from one area of body on other.

Erysipelas can be complicated the fever of lungs, phlegmon, abscesses, sepsis. It is necessary to remember that Erysipelas can be passed from one man to other, therefore a patient with Erysipelas must be isolated.

Treatment. The area of Erysipelas is exposed to the rays ultraviolet rays in suberythermal doses, oil by 1% solution of diamond green. The general is conducted antibiotic therapy preparations of penicillin row (retarpen 2,4 million intramuscular). At phlegmonic and necrotic forms come running to operative treatment.

Lymphadenitis is inflammation of lymphatic nodes. Arises up because of hit in them of microorganisms and their toxins from a primary inflammatory hearth (carbuncle, phlegmon).

A clinical picture shows up the increase of lymphatic node and sickliness of him at palpation. The expressed inflammatory process from a lymphatic node passes to the surrounding cellulose. In a number of cases lymphatic node, purulent is melted and fluctuation appears in this place. Sometimes Lymphadenitis develops at an already calming down inflammatory process in a primary hearth.

Treatment. It is necessary to liquidate a primary inflammatory hearth. At the initial form of Lymphadenitis apply warmly, create rest. Appoint antibiotics. At purulent inflammation dissection of abscess is shown.

Lymphangiitis is inflammation of lymphatic vessels. Limfangiitis usually is the second result of other inflammatory process (carbuncle, phlegmon). Acute Limfangiitis is divided by reticulated and trunk (trabeculated), and also on superficial and deep. At reticulated Limfangiitis shallow lymphatic capillaries are struck, at a trunk are lymphatic trunks. At superficial a Limfangiitis process takes the lymphatic system, being in a skin, at deep – subject tissue.

Clinical picture. At reticulated Limfangiitis round the area of inflammation the vast hearth of reddening of skin appears without clear scopes, transitory in healthy areas. Clinical picture. At reticulated Limfangiitis round the area of inflammation the vast hearth of reddening of skin appears without clear scopes, transitory in healthy areas. At trunk Limfangiitis the redden areas of skin are distinctly visible as bars from the primary hearth of defeat to the center, to the regional lymphatic nodes. The compression of tissues and sickliness appear in area of bars. Deep Limfangiitis, as a rule, accompanied the edema of soft tissues. There are gettings up of temperature, algors, head pain, leucocytosis.

Treatment. It is necessary to liquidate a basic inflammatory hearth, resulting in Limfangiitis, create rest, immobilize extremity by a retaining bandage, on the area of inflammation to impose a bandage with ointment on hydrophilic basis (Oflokain), to conduct antibiotic therapy.

Anorectal abscess.

Classic proctology was begun exactly with research of problem of Anorectal abscess. Veritable Anorectal abscess – inflammation, at which an infection penetrates in tissue of pararectal area from the mouths of anal glands, located on the bottom of anal (Morgagni’s) crypts.

An inflammatory process develops usually on the type of phlegmon, that acute hearth of infection with the poured out reaction of surrounding tissues. At sufficient resistance of organism, and also under influencing of the conducted treatment an inflammatory process is delimited and passes to the accumulation leaving to rot – in an abscess which breaks through independently or unsealed a surgeon.

Classification. Most widespread, grounded and accepted many authors there is classification of pararectal abscesses accordingly cellular and fascial spaces, to adjoining to the rectum: 1) subcutaneous-submucous, 2) sciatic-rectal (ischiorectal), 3) pelvic-rectal, 4) retrorectal.

Most often there is subcutaneous-submucous Anorectal abscess (56,4%), on the second place is sciatic-rectal localization – 35,3%. Rarely there are pelvic-rectal (4,8%) and retrorectal abscess (3,5%).

Purulent motion can be disposed inside from sphincter (intrasphincteric Anorectal abscess), through sphincter (transsphincteric) and ectad from sphincter (extrasphincteric).

Treatment. On principle it is needed correct to count the most early operative interference at large majority of anorectal abscess. The first sleepless night, sure, is foundation for operative interference. Usually patients come to the doctor with the already expressed phenomena of anorectal abscess and operative treatment must be accepted immediately, without delay.

Preparation to the operation of dissection of anorectal abscess begins at once, as soon as diagnosed and a decision is accepted about urgent interference. The skin of crotch and anus is washed a patient, shave off hairs. Before an operation a patient a cleansing enema is put, entering the tip of which is necessary carefully on opposite inflammation a side. It is necessary, that a patient urinated before an operation, and if for him urination is laboured, catheterization of urinary bladder is made.

Basic operations at anorectal abscesses

Foremost, it is never needed to ignore three basic rules of operative treatment of anorectal abscesses: a) treatment must be undertaken possibly before; b) cuts must be wide, providing a good outflow leaving to rot; c) it is impossible to damage sphincter.

For exact authentication of the internal foramen of abscess in the wall of rectum after conducting of spinal anaesthesia carefully punctuate an abscess, evacuate a pus and, not extracting a needle, enter a vital dye in the cavity of abscess (1% solution of diamond green with a hydrogen peroxide 1:1).

The choice of method of operative treatment of anorectal abscess depends on the location of purulent motion in relation to the fibres of anal sphincter. At subcutaneous and subcutaneous-submucous forms (all of about 60% patients) execute the operation of Gabriel: an abscess is unsealed in the road clearance of rectum with simultaneous excision of his internal opening, staggered crypt of Morgagni. In position of patient on the back with arcuated in hip and knee joints and by the divorced feet an abscess is unsealed a small cut, evacuate a pus and inspect the cavity of abscess a finger, to define the location of his cavity and basic purulent motion in relation to sphincter. For this purpose a surgeon enters the finger of other hand in a rectum and determines the thickness of tissues between fingers. It helps to recognize a form and depth of abscess. Sounding of abscess helps: at subcutaneous or transsphincteric abscesses a probe is sent at once toward an anal channel and easily can get to his road clearance through the internal foramen of abscess.

At treatment of anorectal abscess with deep transsphincteric or extrasphincteric location of purulent motion in 10-12 days after dissection of abscess and calming down of acute inflammatory changes in area of the internal foramen come running to the deferred closing of the internal foramen by voiding of mucous membrane of distal department of rectum. A relegate viable shred is provided by main principle of surgical treatment of anorectal abscess – reliable liquidation of the internal foramen without violation of obturator function of anal sphincter.

In the conditions of purulent edema of tissues, for example, at ischiorectal or pelvic-rectal abscess use a radical operation which is developed yet Hippocrates. Through a wound on a crotch in a rectum through the internal foramen of purulent motion conduct and tighten silk ligature. Gradually tightening such ligature cross part of sphincter and liquidate the internal foramen.