thus both have their proper indications, and one is no substitute
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 lit-
res of pus. Although pus can collect almost anywhere, particu-
larly important sites are a patient's pleura (6.1), his perito-neum
(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 conse-
quence of pyogenic infection - septic shock - are described else-
where (53.4).
Why septic infections of all kinds are so common here is not al-
together 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 respon-
sible, except in the perineal and perianal region, which is com-
monly infected by coliforms and anaerobes. Some abscesses are
tuberculous (29.1). AIDS predisposes a patient to infections of
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 par-
ticularly 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 fluctu-
ation, 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 wait-
ing 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.
WHERE THERE IS PUS, LET IT OUT
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 A patient with an abscess has severe throbbing pain. The
only, and before much pus has formed. At this early stage anti- infected part is tender and swollen, and the skin over it stretched,
biotics may start to control cellulitis within 24 hours. But once shiny, and red, although this may not be evident on a dark skin.
pus has formed, you must drain it. Conversely, before pus has Moving it is acutely painful. If his abscess is large or he has
had time to form drainage is useless. Antibiotics and drainage several abscesses, he may be febrile, weak, toxaemic, and anae-
mic. The usual signs of inflammation and suppuration suggest
SOME SITES OF SEPSIS the diagnosis, but don't necessarily expect to find fluctuation in
the sites listed in the previous section.
Severe pain is a useful sign that an abscess is ripe for incision,
mastoiditis but pain may be mild when the tissues are loose. So incise it and
let the pus flow out; break down any septa in a large cavity and
orbital open up any loculi (smaller cavities off the main one). If diagno-
sepsis
periurethal sis is difficult, try aspirating it with a syringe and a wide bore
prostatic
abscess (1.5 mm) needle; but remember that this is an unreliable test and
abscess Ludwig's
anorecta
labscess
angina that pus may be present even if you fail to aspirate any. Never try
to treat an abscess by aspiration. There is no need to curette the
carbuncle walls of an abscess, except in the hand where you want inflam-
axillary
abscess
mation to resolve particularly rapidly and completely.
empyema
subphrenic Abscesses are usually placed at the end of a list of otherwise
abscess 'clean' cases, and are often left to very junior staff. Nevertheless,
peritonsillar peritonitis
be careful: (1) The diagnosis can be difficult, as with an iliac
abscess
boils retropharyngea abscess (5.12). (2) Drainage has its risks, especially severe
l abscess bleeding when a patient has a large abscess or many of them, so
PID watch blood loss carefully (see below). (3) A superficial abscess
over the tibia, femur, or humerus may turn out to be pyomyositis
septic (7.1), or, more seriously, osteomyelitis (7.2). (4) A 'chronic abs-
arthritis hand sepsis cess' may turn out to be a solid tumour. Some sarcomas are first
treated as infections! (32.8).
iliac
pyomyositis
abscess

osteomyelitis

 

 

EXAMINATION. Assess the patient's general condition carefully,
especially if he has many abscesses, or large ones. Look for
anaemia.
Fig 5-1: SOME SITES OF SEPSIS. Pus can gather almost
anywhere, but here are some of the commoner places where you SPECIAL TESTS. (1) If his infection is severe, take blood cult-
will find it. ures. You may be able to isolate the causative organism (this is

1
important in osteomyelitis). (2) Test his urine, he may be diabetic INCISION AND DRAINAGE
— always do this if he has had more than one septic infection.
Your work load will probably be too heavy to test the urines of all
patients with abscesses. (3) If he has a particularly large or un- A linear incision
usual abscess, or recurrent ones, test for HIV. A B
ANTIBIOTICS are not usually needed. Give them if: (1) He has a
severe constitutional disturbance with high fever and toxaemia. (2) C
There are signs that his infection is spreading — increasing ery-
thema, cellulitis, lymphangitis, severe lymphadenitis, or fever. (3)
Rapid resolution is important, for example, in a deep infection of a
hand or finger, or in a woman with a breast abscess where the re-
establishment of breast feeding is critical.
If you decide to give him an antibiotic and you can culture the pus,
give the first dose in the theatre immediately after drainage. If you A cruciate incision
cannot culture the pus, give it with the premedication, or an hour
before the incision (2.7). D E F

DRAINAGE OF AN ABSCESS
INDICATIONS. A collection of pus anywhere. If you suspect that
there is a foreign body in an abscess this is an added reason for
exploring it.
If you are not sure if pus is present or not, aspirate the lesion with a
needle to see if you can withdraw pus. If pus is present drain it. If
you fail to aspirate pus with a needle, this does NOT mean that
there is no pus present!
Fig 5-2: INCISION AND DRAINAGE. A, B, and C, show a
Signs that an infection is spreading are not a contraindication to
drainage — if you think pus is present, drain it. linear incision being made and its edges spread. D,E, and F,
show you how to make a cross-shaped incision, cut off the edges
ANAESTHESIA. (1) You don't need muscular relaxation, so of the skin, and so remove the roof of the abscess. After Hill GJ,
ketamine will do (A 8.1). (2) If an abscess is already pointing, you 'Outpatient Surgery', Fig. 5.12. WB Saunders, with kind permission.
can infiltrate the site of the incision with a local anaesthetic solu-
tion (A 5.7). (3) Intravenous thiopentone with pethidine (A 8.8). (4)
Morphine. (5) Ethyl chloride local spray is the least satisfactory, incision at its lowest point, and it also avoids making two incisions.
but you can use it for very superficial abscesses. It makes the
tissues hard and difficult to incise. IF AN ABSCESS BLEEDS, pack the cavity (3.1). If necessary, set
up a drip and give him 0.9% saline. Blood is seldom needed.
INCISION. Drain the abscess at the site of maximum tenderness
and try to follow Lange's lines (61-3). This is safer than following GENERAL MEASURES. If his abscess is in some critical place,
any set rule or the dotted line on a diagram. If an abscess is such as his lateral pharyngeal space, or his mid palmar space,
superficial, use a pointed (No. 11) blade, as in Fig. 5-2. admit him. Make sure his fluid intake is adequate, and don't forget
CAUTION! (1) If the abscess is deep, try to incise parallel to any to give him an analgesic — abscesses are painful!
nerves or vessels, not across them. (2) The common mistake is
POSTOPERATIVE CARE. Rest the part, and where possible raise
not to make the incision large enough.
it. For example, put his hand in a St John's sling (71-1), or, if he is
HILTON'S METHOD should always be used if there is anything an inpatient, raise his hand in a roller towel, as in Fig. 75-1. If his
near the abscess which you might possibly injure. Incise the tis- foot is infected, raise the foot of his bed (81-1).
sues down to the deep fascia, then push blunt scissors or a hae-
mostat into the softest or most prominent part of the swelling. DIFFICULTIES WITH ABSCESSES
Open them out inside the abscess. If necessary, enlarge the
wound by blunt dissection inside the tissues. If he has NO FEVER BUT IS OBVIOUSLY 'ILL', suspect that his
resistance to infection is low and treat him with particular care.
DRAIN THE PUS by putting your finger into the abscess, and If he has MANY ABSCESSES, he has pyaemia, multiple pyomyositis,
breaking down all loculi, so that there is only one cavity. Use your or septicaemia. He may bleed much when you drain them. If he is
little finger if the abscess is small. If there is much pus, suck it out very anaemic, transfuse him first, and, if necessary, again during
or clean out the cavity with a swab. Make sure you remove it all. the operation. Draining multiple abscesses is a major procedure,
particularly if a child is anaemic or malnourished, so be careful
PROVIDE FREE DRAINAGE. Make sure that any more pus which
before you incise too many abscesses at once — children have
forms can drain from the bottom of the cavity.
bled to death!
If the abscess you are draining has a tendency to heal over and leave a
If he is VERY ILL AND HAS HUGE ABSCESSES, he will not tolerate an
cavity, deroof it, as in F, Fig. 5-2. This is especially necessary with
extensive procedure. It may occasionally be necessary to take
perianal abscesses and Bartholin's abscesses. Cut away some
him to the theatre several days in succession and drain a few
skin, particularly any dead skin. Then pack it to make sure that
abscesses at a time.
the opening remains wider than the base and allows it to granu-
If an abscess FAILS TO HEAL, don't forget the possibility of tubercu-
late from the bottom up. Gently fill the cavity with gauze. Replace
losis (29.1) or HIV (28a.2).
this on the second or third day, and continue renewing it until pus
If a child has abscesses, FAILS TO THRIVE, and is miserable, mal-
no longer discharges. If the cavity is large, use ribbon gauze or
bandage. If you use separate pieces of gauze, tie them together. nourished, and backward with his milestones, suspect HIV and exa-
Small pieces are easily lost in a deep cavity. Even a large one will mine his mother for palpable nodes (28a.2).
quickly contract and disappear.
If an abscess is deep, push a corrugated rubber drain down to its
deepest extension. This cannot block, and is better than a tube ALWAYS INCISE AT THE POINT
drain. OF MAXIMUM TENDERNESS
If pus has to drain downwards, as in the breast, try to incise the
lowest part of the abscess. This is better than making a counter

2
EXPLORING AN ABSCESS

blunt
A B C D
E

loculi
broken
down

Fig 5-3: EXPLORING AN ABSCESS BY HILTON'S METHOD. A, incise the abscess at its lowest point, if this is practicable. B, push
blunt scissors or a heamostat into it. C, open the haemostat. D, explore the abscess with your finger. E, insert a drain.

If a collection of pus forms, cut down on it and drain it.


Boils and carbuncles are contagious skin infections, which are
usually caused by penicillin-resistant staphylococci. The patient


 
may have a crop of them, and in a closed community they may
become epidemic.
BOILS For the general method, see Section 5.2.
Clean the skin round the a boil with hexachlorophane solution,
and cover it with a dry dressing. Let it burst spontaneously. If it is
pointing, a small incision will let it discharge and will reduce the
pain. Alternatively, aspirate it.
CAUTION! Never squeeze a boil; especially on the face, never let
the patient squeeze it.
If he has many boils, tell him to wash thoroughly with soap and
water, and to bath in salt water. Ideally, he should bath with hexo-
chlorophane soap, or 70% spirit, change his underwear daily, and
boil it. For very fortunate patients a seaside holiday is one of the
best cures.
Pus may gather between a patient's skull and his dura as the
result of: (1) The spread of infection from sepsis nearby. (2) Ex-
posure of the bone as the result of an injury. (3) Metastatic
spread from elsewhere in his body. If his abscess is large, he will
be very ill with signs of raised intracranial pressure (impaired
consciousness and pupillary changes) and localizing motor
signs, usually on the other side of his body, but not always so.
Locally, he may have a diffuse inflammatory oedematous
swelling of his scalp over the lesion (Pott's puffy tumour). If his
abscess is not so large, he will not be so ill, and may have no
signs of raised intracranial pressure. Making burr holes should
be one of your basic skills (63.5), so draining the pus should not
be too difficult. With your limited imaging facilities your prob-
lem will be to diagnose that he has an extradural abscess, and to
know where it is — Pott's puffy tumour is the most useful sign.

  EXTRADURAL ABSCESS X-ray his skull.
A carbuncle is typically the result of neglected skin infection in
If his abscess is secondary to osteitis, and there is a sequestrum,
a dirty, malnourished, and underprivileged patient, particularly a
removing it will drain the abscess adequately.
diabetic. A staphylococcal infection starts in one of his hair fol-
licles, usually at the back of his neck or on the back of a finger If his extradural abscess is secondary to metastatic spread, drain it
(8.1), and then spreads. In doing so the infection lifts the skin through a burr hole. Make this on the edge of the area of swelling
above it on a sea of necrotic fat and pus. By the time you see on his skull, and nibble away his skull around it until the abscess
him, pus will probably be discharging. Antibiotics don't cure a is well drained.
carbuncle, although they may stop it spreading. You will probab-
ly have to let the slough separate slowly, and then remove it.




 

CARBUNCLES For the general method, see Section 5.2. Be sure
to test the patient's urine for sugar. ! 
 "
If the skin around his carbuncle is hairy, shave it with as little trau-
ma as you can. Wash it with hexachlorophane solution, apply dry
gauze, and change this frequently. A large slough will form in the
middle of the carbuncle. You may be able to lift the slough off
painlessly without an anaesthesic.
If the slough is slow to separate, excise it, and apply a dressing of
vaseline gauze.
If the bare area is large, apply a split skin graft, as soon as it is clean
and granulating.
3
Acute suppurative infection is common near the eye, especially
in children. It can occur in front of or behind the orbital septum.
This is a sheet of fibrous tissue which stretches from the edges
of the orbit into the eyelids, and divides the periorbital region
from the orbit. Infections of both these regions usually start
acutely with erythema and oedema of the eyelids; distinguish
between them as described below. The danger with any infection
in this region is that infection may occasionally kill the patient
by spreading to his cavernous sinus or his meninges.
Periorbital cellulitis occurs in front of the orbital septum, is
more common than orbital cellulitis and occurs in younger child-
ren. It can be primary, or secondary to: (1) Local trauma. (2)
Skin sepsis. (3) A recent upper respiratory infection; H. influ-
enzae is commonly responsible for the latter, and the child may
be bacteraemic.
Orbital cellulitis occurs behind the orbital septum, and is less
common but more serious. It is usually due to spread from the
paranasal sinuses, commonly from the frontal or ethmoid
sinuses
Subperiosteal abscesses may form when bacteria spread from
the adjacent sinuses.
Cavernous sinus thrombosis can be: (1) Occasionally, aseptic
as result of trauma, tumours, or marasmus. (2) More commonly,
it is septic as the result of the spread of infection from the nose
(a nasal furuncle is the commonest source), face, mouth, teeth,
sphenoid or ethmoid sinuses, the middle ear, or the internal ju-
gular vein. A cord of thrombus spreads from the site of the
infection to the cavernous sinus, and sometimes to the cerebral
veins and meninges to cause: (1) A rise in pressure in the veins
draining the eye, resulting in severe oedema and proptosis. (2)
Paralysis of the 3rd, 4th, 6th (commonly) and the first two bran-
ches of the 5th cranial nerves. (3) Meningeal irritation. In the
days before antibiotics the patient almost always died; now he
should not. If you treat him late, he may be left with visual
impairment, ocular palsies, and hemiplegia.
Don't be frightened of operating in the orbit. Because of the
danger of cavernous sinus thrombosis you must drain pus early.
A negative exploration will not harm him, and you are very un-
likely to damage his globe.
RANGIT (60 years) was admitted with a history of septic teeth for many
years. Recently he had had fever, headache, rigors, and gradual swelling
of his mandible. He was ill, dehydrated, shocked, jaundiced, and
confused. Pus discharged from his mouth, his submental glands were
enlarged, his neck was stiff, and Kernig's test was positive. Both his
globes were proptosed, particularly the left, which was fixed; his fore-
head and cheek were oedematous, and his CSF turbid. Despite vigorous
penicillin treatment he died. Postmortem examination revealed left
dental and mandibular abscesses; his left orbit and cavernous sinus were
full of pus. LESSONS (1) This is a very dangerous condition. (2) Prop-
tosis in the presence of facial sepsis is a dangerous sign. (3) The orga-
nisms responsible are often penicillin-resistant.





cess through the upper fornix of his conjunctiva, or through his
For the general method, see Section 5.2. Gently separate the
patient's lids. Examine for induration and tenderness of his lids,
chemosis (subconjunctival oedema), proptosis (his globe is push-
ed forwards), limitation of ocular movement, and loss of visual
acuity. If you find these, suspect orbital cellulitis, take blood cultu-
res and start parenteral antibiotics immediately!
CAUTION! (1) Oedema and erythema of the lids are common to
both orbital and periorbital cellulitis. (2) If the treatment of orbital
cellulitis is delayed or incorrect, cavernous sinus thrombosis may
follow.
X-RAYS. Infection may have spread from his paranasal sinuses,
so consider X-raying them (if this is possible), to see if you can
find a loss of translucency on the affected side. The films will be
difficult to interpret, especially in children in whom the sinuses are
small.
PUS IN
A
THE ORBIT Sites of
suppuration ¬ ­
°
B Spread from the ¯ ®
frontal sinus ±
C
Spread from the
ethmoid sinuses
Fig 5-4: PUS IN THE ORBIT. A, some important infections
around a patient's eye. B, pus spreading under his periosteum
from his frontal sinus. C, pus spreading under his periosteum
from his ethmoid sinus. 1, the lachrymal gland (dacryoadenitis).
2, the frontal sinus and anterior ethmoidal air cells (sinusitis).
3, the tear sac (dacrocystitis). 4, tarsal cysts. 5, styes (hordeola).
6, periostitis of the margin of the orbit. Styes and suppurating
tarsal cysts can occur anywhere on the lids, and periostitis
anywhere in the orbit. After Hamilton Bailey's Emergency Surgery,
edited by HAF Dudley, Figs 187, 188, and 189. John Wright, with kind
permission.
and its movement impaired, per-haps accompanied by loss of visual
acuity, suspect that he has a subperiosteal abscess of his orbit.
For example, an abscess above his eye will displace it down-
wards. Try aspirating the pus from the roof of the abscess with a
needle. His eye may go back into place. Then incise and eva-
cuate his abscess through a con-junctival fornix — his inferior for-
nix if swelling is maximal inferiorly, and his superior fornix if it is
maximal superiorly. Pus will probably be coming from a paranasal
sinus and you may find a track through to it. Insert a drain.
If he has an inflammatory SWELLING IN THE UPPER, OUTER PART OF HIS
ORBIT, involving the outer third of his upper lid, suspect that his
lachrymal gland is infected (DACRYOADENITIS). Incise the abs-
eyelid.
If he has an inflammatory SWELLING BELOW THE MEDIAL ASPECT OF
HIS LOWER LID, suspect that he has an abscess in his lachrymal
gland (DACRYOCYSTITIS). Press it, pus may exude through the
punctum. If it suppurates, incise it through the skin of his lower lid.
When the infection has subsided, refer him for a dacryocysto-
rhinostomy, which will usually re-establish the flow of his tears.
If his conjunctiva becomes increasingly congested, his globes proptose,
his OCULAR MOVEMENTS BECOME PRO-GRESSIVELY IMPAIRED, his
accommodation paralysed, his pupil fixed and dilated, and his
cornea anaesthetic, he has CAVERNOUS SINUS THROMBOSIS.
It will probably involve both his eyes. Early vigorous chemo-
therapy may save him (2.9). Give him penicillin and cephradine,
or chloramphenicol.

#$ 
 
TREATMENT. Give him penicillin with cloxacillin. Or, give him
cephradine alone (2.9). Or, give him penicillin and chlorampheni-
col.
DIFFICULTIES WITH ORBITAL SEPSIS
If the patient's GLOBE IS DISPLACED BY AN INFLAMMATORY SWELLING,
Abscesses round the tonsils are quite common, and follow
tonsillitis. The patient, who is usually a child, has a tense swel-
ling above and behind one of his tonsils, displacing it down-
wards and forwards. Non-operative treatment is almost always
successful, and is much safer than draining it, which is a heroic

4
CAVERNOUS
SINUS A get an aspiration pneumonia. The major differential diagnosis is
THROMBOSIS
Proptosis in the
presence of facial
sepsis is dangerous
B intravenously, give only just enough, and keep his head down.
Eyes
Nose
Middle
ear
Teeth
Fig 5-5: CAVERNOUS SINUS THROMBOSIS. A, orbital oede-
ma and proptosis may be associated with paralysis of the 3 rd,4th,
6th (commonly), and the first two branches of the 5th cranial ner-
ves, and also with meningeal irritation. B, infection may spread
to the cavernous sinus from the eyes, nose, teeth, meddle ear, or
the paranasal sinuses.
procedure and is seldom necessary, because much of the
swelling is inflammatory oedema.
PERITONSILLAR ABSCESSES
For the general method see Section 5.2.
NON-OPERATIVE TREATMENT. Admit the patient, and give him
intramuscular benzyl penicillin, or ampicillin, or intravenous chlor-
amphenicol (2.9). He will also need intravenous fluids and mor-
phine or pethidine. He should respond within 24 hours and his
abscess will probably burst spontaneously, or the inflammation
will subside sufficiently to make drainage much easier.
INCISION. In the unlikely event that he fails to respond to non-
operative treatment, sit him upright in a chair with his head sup-
ported, and a gag in his mouth. Get a very good headlight.
Spray his pharynx with a local anaesthetic solution, such as 4%
lignocaine. If he cannot open his mouth wide enough, you may
have to give him a general anaesthetic, intubate him, and place
him on his side with his head as low as possible. If intubation is
impossible, give him ketamine and keep his head down.
Use a guarded scalpel to incise the abscess over its most promi-
nent part, as in Fig. 5-6. Divide only the mucosa, then use sinus
forceps to find pus by Hilton's method (5-3).
CAUTION! (1) Don't let him inhale pus. (2) Have suction instantly
available.
If severe bleeding follows and you cannot control it, try firm com-
pression through his mouth with a tightly rolled swab, or tight
mattress sutures. Tying his external carotid artery is a heroic last
resort (3.3), and means that you have put your knife too deep.

%&

the result of infection round an impacted fish bone. If the
swelling is large enough, he may asphyxiate. If it bursts, he may
a chronic tuberculous retropharyngeal abscess.
RETROPHARYNGEAL ABSCESSES
For the general method, see Section 5.2. If the patient is dehy-
drated, give him intravenous fluids.
ACUTE ABSCESS IN A CHILD. The great danger of a general
anaesthetic is that the patient will inhale pus. Ketamine is rela-
tively safe because his cough reflex is less suppressed. Give it
Have a tracheostomy set (52.2) and suction ready. Lie him on his
back with his head over the end of the table, so that his pharynx is
as nearly upside down as possible.
If his abscess is pointing, you may be able to open it with sinus
forceps alone. If you can get a really good view, you may be able
to aspirate it with a needle. If this is impractical, open his abs-cess
with a guarded knife (5-6). Put your index finger into his mouth,
and slide the knife along it. Drain it by Hilton's method (5-3), as for
a peritonsillar abscess.
CAUTION! Don't let him inhale pus — suck immediately you
incise.
If severe bleeding follows, and you cannot control it, apply local
pressure for 15 minutes. If that fails (rare), be prepared to tie his
external carotid artery (3.3).
ACUTE ABSCESS IN AN ADULT. Anaesthetize the mucosa over
the abscess with 4% lignocaine, preferably as an aerosol, and
incise it with his head down and on one side, as in a child.
TUBERCULOUS RETROPHARYNGEAL ABSCESSES (rare) are
usually subacute and follow infection of the body of a verte-bra.
Refer him if you can. Only consider drainage if obstruction to his
airway is a real danger. Drain his abscess through an external
incision in front of his sternomastoid down to his prevertebral
fascia. Displace his thyroid gland and trachea anteriorly.
PUS IN THE
A
THROAT
Retropharyngeal
abscess
B
Peritonsilliar
abscesses
Both these incisions
use a guarded knife
Fig 5-6: TWO ABSCESSES IN THE THROAT. A, the danger
with a retropharyngeal abscess is that an unconscious child may
inhale pus and get bronchopneumonia. Avoid this by incising it
 '( while his head is hanging over the end of a table. B, a periton-
sillar abscess occasionally follows tonsillitis, and needs drain-
Occasionally, an abscess forms in the lymph nodes behind a ing. Do both these incisions with a guarded knife that cannot cut
child's pharynx which bulges forwards. Sometimes an abscess is so deeply.

5
 he tells you that he has had pain for a week. He has fever,

)*
 trismus, and a unilateral, tender, shiny, warm, indurated swelling.
If a patient comes to you with a painful, throbbing, swollen, red
face (a 'at face'), perhaps with fever, trismus and lymphadenitis,
he is probably suffering from an acute dental or oral infection,
most probably an alveolar abscess. He may have:
(1) An alveolar abscess begins as an infection in the bone
around a non-vital infected tooth. He has severe pain, which be-
comes less as pus is released into more superficial tissues and
his face starts to swell. After 36 hours of cellulitis he usually has
a fluctuant abscess which needs draining. If drainage is delayed,
the pus in his abscess discharges spontaneously through a sinus
(26-8) in his gum or face, which may become chronic.
First, control infection with antibiotics, and then drain the abs-
cess, either by incising it where it is pointing, or by removing the
infected tooth, which acts as a cork to prevent the pus escaping,
or by doing both these things. If you remove a tooth before you
have controlled the infection with antibiotics, and while his face
is still severely swollen, you may spread the infection; your task
will also be more difficult.
(2) A periodontal abscess at the side of a tooth, caused by
spread from an infected gum.
(3) A pericoronal abscess caused by infection of the gum over
the crown of an unerupted and impacted tooth, usually a lower
third molar ('an infected wisdom tooth'). Often, an abscess does
not form, and the gum round the tooth is merely inflamed.
Pus from all three of these foci of infection, and particularly
from an alveolar abscess, can track in various directions, towards
his cheek, his tongue, or his palate, or downwards into his neck.
It can discharge inside his mouth or outside. It can collect: (1)
On any of the surfaces of his gum ('gumboils'). (2) In the buccal
sulcus of either jaw on the oral or deeper side of the attachment
of his buccinator muscle (common). (3) On the surface of his
face superficial to the buccinator attachment. (4) On his palate
(less common). (5) In his submasseteric space between his mas-
seter and the ascending ramus of his mandible. (6) In his ptery-
gomandibular space between his medial pterygoid and the as-
cending ramus of his mandible. (7) In his sublingual space above
or below his mylohyoid muscle. (8) In his submandibular space
superficial to his mylohyoid. (9) In his submental space in the
midline under his jaw. (10) Anywhere down the side of his neck.
Don't be daunted by the complexity of this anatomy. Some of
these spaces communicate with one another and more than one
space may be involved incise the abscess where it points, having
due regard, where you can, for the skin lines on his face (61- 3).
Infection can spread in some particularly dangerous directions:
(1) From his upper jaw (or upper lip or nose) to his cavernous si-
nus, which may thrombose, perhaps fatally (5.5). (2) From his
lateral pharyngeal space up towards the base of his skull, down
to his glottis or into his mediastinum. Infection of this space is
one of the most dangerous conditions in dentistry. He has diffi-
culty swallowing and speaking. (3) From his lower jaw, via his
sublingual and submandibular spaces, to the tissues of his neck,
where it may cause oedema of his glottis, respiratory obstruction
and death. This is Ludwig's angina (5.10).
BEWARE OF CAVERNOUS SINUS THROMBOSIS AND
LUDWIG'S ANGINA
Looking at him will tell you which side of his face and which jaw is
involved. Feel for warmth with the back of your index finger and
test for fluctuation. A tooth with large holes in it probably has an
apical abscess under it. It may be firm, but is usually loose. If he
has obvious periodontal disease, or several loose teeth, suspect a
periodontal abscess.
If you are in doubt as to which of his teeth is the site of infection, tap
them with some metal object or press them with your gloved index
finger. A tooth which is much more painful than the others is pro-
bably the source of an alveolar infection. It may also be slightly
raised in its socket. A tooth with a periodontal abscess is much
less tender to percussion.
X-RAYS. If possible, X-ray the offending tooth. You may see: (1) A
a radiolucent area at its apex when an apical abscess has been
present for 2 or 3 weeks. (2) Caries between two adjacent teeth
which may not be visible from his mouth. (3) The impacted tooth
which is responsible for a pericoronal abscess. (4) Some other
source for the infection, such as an infected cyst, or a fracture.
THE DIFFERENTIAL DIAGNOSIS includes acute inflammation of
the salivary glands (5.9), mumps, Burkitt's lymphoma (32.3),
lymph node swellings and glandular fever.
GENERAL MEASURES. Admit him and make sure that his fluid
intake is adequate; he may find drinking difficult.
CAUTION! Don't apply poultices or any kind of local heat to his
face - they may spread the infection. If an abscess is pointing in-
side his mouth, hot saline mouth washes may ease his pain.
ANTIBIOTICS are often unnecessary, because many dental infec-
tions can be treated by local drainage only. If there is spread-ing
cellulitis he needs an antibiotic. Procaine penicillin 600,000 units
(2 ml) intramuscularly is adequate in most cases. But if his con-
dition is serious give him a megaunit of benzyl penicillin 4 to 6-
hourly.
When you have drained an abscess, culture the pus and change
the antibiotic if necessary.
CAUTION! Make sure that he understands that a course of
antibiotics is not sufficient treatment for his abscess, and that he
must return, even if his swelling improves.
ANAESTHESIA. (1) 2% or 4% lignocaine spray or a swab soak-
ed in lignocaine solution. (2) Inject a local anaesthetic solution
into the outer wall of the abscess over the proposed site of the
incision. (3) Ethyl chloride local spray is suitable for an abscess
which presents on his face or in his labial or buccal sulci. Isolate
the infected area with gauze packs, and then spray on ethyl
chloride until crusting occurs. Then open the abscess with a No.
11 blade.
CAUTION! Avoid general anaesthesia, if you can, unless it is
expert (especially if he is in danger of respiratory obstruction —
see A 13.2), and you can intubate him and pack off his throat.
ALVEOLAR ABSCESSES
If you can refer him, a dentist may be able to save his tooth by
draining the abscess through it, and later filling its root. If you
cannot refer him, remove it. Many abscessed teeth are loose, and
you can easily pick them out of their sockets. Removing his tooth
to allow pus to drain through the socket, combined with antibiotic
treatment may be sufficient. Don't incise a non-fluctuant swelling.
If it is not yet fluctuant and ripe for incision, ask him to use hot
saline mouth washes, as hot as he can bear without the risk of
being scalded, several times a day. Give him an antibiotic and
wait. This may control his infection and arrest pus formation.
CAUTION! (1) Don't pull out his tooth (26.3) before you have

  controlled his cellulitis. (2) If he has a tense inflammatory swelling
of the upper part of his neck, suspect Ludwig's angina and treat
For the general method, see Section 5.2. him urgently (5.10).

HISTORY AND EXAMINATION. A patient of any age over 5 years PUS POINTING INSIDE HIS MOUTH can point in several places:
walks into casualty with a fat face looking ill and distressed. He If an abscess is pointing on his alveolus, open it into his mouth.
has usually had toothache in the past, but the pain has gone. Now If it is pointing in his labial sulcus (C, 5-7), make a 1.5 cm incision

6
through his mucous membrane parallel to his alveolar ridge. Push
a fine haemostat into it and open the jaws.
If it is pointing in his palate, make an anteroposterior incision, paral-
lel to its nerves and vessels, remove an ellipse of tissue and let
the pus flow out.
If he has pus in his pterygomandibular, lateral pharyngeal, or sub-
masseteric spaces, drain it through a vertical incision inside his
mouth parallel to the ascending ramus of his mandible, taking
care to avoid his parotid duct (61-5). This runs in his cheek under
the middle third of a line between the tragus of his ear and the
commissure of his lips, and opens in line with his first molar tooth.
Push forceps to the lingual or buccal side of his ramus, wherever
the pus seems to be pointing. If it is under his masseter, insert a
drain deep to this muscle down to his mandible from outside his
face. Insert the drain through an incision just below the inferior
border of his mandible.
PUS POINTING OUTSIDE HIS MOUTH. Drain it through one of
the incisions below, as soon as any cellulitis he may have has
stopped spreading. Removing his tooth to let the pus drain is not
enough, even if it does drip from his root canal. If his abscess is
fluctuant, it needs draining too. If you are not sure if it is ready for
drainage or not, insert a wide bore needle under local anaesthe-
sia. If you aspirate pus, incise it by Hilton's method (5.2) where it
points at the softest and most tender spot. To minimize scarring,
make an incision below the inferior border of his mandible, where
possible. If you have to make it on his face, make it in line with the
creases in his skin (61-3). These may not always be over the most
fluctuant part of the abscess.
CAUTION! When you plan your incision, consult Figures 5-7a and
61-3 and remember: (1) The extension of the lower pole of his
parotid gland into the side of his neck (61-5). (2) The man-dibular
branches of his facial nerve. These run horizontally and cross the
lower border of his mandible, just anterior to his masseter, deep to
his platysma muscle in his anterior mandibular region and deep to
the fascia posteriorly. (3) His facial artery and vein. These enter
his face from between his submandibular salivary gland and the
lower border of his mandible; they cross the ramus of his man-
dible 3 cm from the angle of his jaw and then run obliquely across
the lower third of his face superficially on his buccinator muscle.
You may have to compromise between chosing the best site for
dependent drainage and an inconspicuous scar in the crease
lines of his face. Here are some likely sites:
If he has a submental abscess, drain it through a small midline trans-
verse incision under his chin.
If the abscess is under the body of his mandible, drain it through a
horizontal incision 1 to 2 cm below the lower border of his man-
dible, taking care to avoid the mandibular branch of his facial
nerve and his facial vessels. Push sinus forceps towards the
lingual side of his mandible to drain the pus there.
If the abscess points external to his buccinator, drain it through a small
incision over the swelling.
DRAINS. Stitch a corrugated or tubular rubber or plastic drain into
the wound for 2 to 5 days, or leave it open with its edges
separated by gauze.
PERIODONTAL ABSCESS. If you cannot refer him for a con-
servative operation, pull out his tooth (26.3).
PERICORONAL INFECTION (infected 'wisdom tooth'). See
Section 26.4.
POSTOPERATIVELY, after you have incised any intraoral abs-
cess, give him hot mouth washes to help the incision stay open as
long as is necessary.
DIFFICULTIES. If he CANNOT OPEN HIS MOUTH to let you get at the
abscess, he probably still has cellulitis, and his abscess is not yet
fit for incision. So continue antibiotics and try again later.

+$ 
INFECTION
INFECTIONS C
FROM THE
TEETH
AA
lateral
pharyngeal
space
buccinator
B buccal
sulcus
submasseteric
pus
space
to the
surface
buccal
space submandibular
space
mylohyoid sublingual
space
Fig 5-7: THE DIRECTIONS IN WHICH PUS CAN SPREAD. A,
and B, are views of the same structures at 90° to one another.
The attachments of a patient's mylohyoid and buccinator mus-
cles determine whether pus, orginating in his lower jaw, points
inside or outside his mouth. A, shows pus from his lower third
molar spreading into his buccal space, his buccal space, his
submasseteric space, and his lateral pharyngeal space. B, shows
the attachments of his mylohyoid and buccinator muscles. The
attachments of these muscles determine whether pus spreads
into his sublingual space, his submandibular space, his buccal
sulcus, or on to the surface of his face. C, shows the incision of
an abscess in his buccal sulcus. Partly after 'Hamilton Bailey's
Emergency Surgery', edited by Dudley HAF, Fig. 151. John Wright,with
kind permission.
ter major surgery when mouth care has been neglected. The pa-
tient's parotid is painful and is usually much swollen; the skin
over it is tight and shiny. You may see pus coming from his paro-
tid duct (inside his cheek level with his first molar tooth). Pus
forms in several lobules of the gland between its septa, and does
not form a single abscess. This, and the division of his facial
nerve into its five branches within his parotid gland, make drai-
nage difficult; it is however essential. Don't wait for fluctuation.
PAROTID ABSCESS
For the general method, see Section 5.2.
THE MAIN DIFFERENTIAL DIAGNOSIS is mumps. There is no
pus at the orifice of the parotid duct, mumps is usually bilateral,
and the skin over the swelling is less shiny. Mumps parotitis does
NOT require surgical drainage, it resolves spontaneously.
INCISION. Start incising anterior to the patient's pinna. Keeping
close to it, proceed towards his mastoid and then continue in the
angle between his pinna and his neck until you reach a skin crea-
se, then cut along this for up to 10 cm. Raise a flap of skin and
subcutaneous tissue, so as to expose his parotid gland. Make
 multiple incisions into this in line with the branches of his facial
Although parotid abscesses can occur without any obvious nerve. Explore each incision by Hilton's method and clean out
cause, you will see them most often in debilitated patients, or af- each abscess cavity with gauze. Close the wound with continu-

7
ous or interrupted sutures of 3/0 monofilament, leaving a depen-
dent corrugated drain emerging from the inferior part of the
PAROTID
incision. ABSCESS
Ä
Æ
A À

,$
-–./( Á
(
Ã
Å
You may see these acute suppurative infections in a patient's
B
neck:
Â
(1) Suppuration in a lymph node, especially a deep cervical
one, is common in children, and is much like suppuration in any
other lymph node.
(2) Suppuration arising from an infected tooth (Ludwig's
angina) occurs in children and adults. It is a severe bilateral
brawny cellulitis of the sublingual and submandibular regions,
and may extend as far as the patient's clavicles. It usually starts
as a dental abscess in his mandible, which makes him febrile and
very ill. If Ludwig's angina is neglected, it may obstruct his
respiration by causing oedema of his glottis, and by pushing his
tongue up against the roof of his mouth. Anaerobes and spiro-
chaetes may be responsible. He can also die from septicaemia.
He needs intensive antibiotic treatment urgently, and drainage to
decompress the tissues at the floor of his mouth.
Fig 5-7a:DRAINING A PAROTID ABSCESS. A, the anatomy of
LUDWIG'S ANGINA the parotid gland. A patient's facial nerve enters the substance
For the general method, see Section 5.2. This is an acute emer- of his parotid gland. A patient's facial nerve enters the substance
gency: admit the patient, and give him high doses of antibiotics of his parotid so that, if you only incise his skin and subcut-
(2.7). He needs a megaunit of penicillin 4 to 6-hourly, metroni- aneuous tissue superficial to the gland when you reflect the flap,
dazole and chloramphenicol (2.9). you will not injure it. Note that it extends well down into his
If his breathing is not significantly obstructed, you may be wiser to wait neck. Incise where his pinna meets the skin of his face and neck
for 24 hours for the antibiotics to act and the oedema to subside a and continue on in a skin crease. B, turn back the flap and
little, before you drain his lesion. incise radially to avoid the branches of his facial nerve. 1, the
If it is significantly obstructed, you may be forced to do a tracheo-
parotid gland. 2, the parotid duct. 3, the border of the mandible.
stomy (unusual, 52.2). This is difficult, because the tissues of his
4, the facial artery crossing the mandible about 3 cm anterior to
neck are firm and oedematous.
its angle. 5, the facial vein. 6, the incision. 7, the facial nerve.
ANAESTHESIA. (1) Ketamine is acceptable, unless his airway is
almost totally obstructed. (2) Don't give him an inhalation anae- neral anaesthetic with intubation. Local anaesthesia is not satis-
sthetic. He probably needs the help of his voluntary muscles to factory, unless the pus is pointing, but if your anaesthetist is not
maintian his airway, and you will be unable to pass a tracheal expert, you may have to use it. If he is to have a general anae-
tube. (3) You may occasionally have to use local infiltration anae- sthetic the anaesthetist must be experienced.
sthesia, but it will be painful and distressing.
INCISION. Use a scalpel to make a transverse incision 5 cm or
INCISION. Make a generous incision below the angle of his man- larger over the area of maximal swelling. Insert a haemostat and
dible, over the point of maximum tenderness, taking care to avoid drain the pus by Hilton's method (5-3). Insert a drain and give him
his facial artery and in the line of a skin crease if possible. The an antibiotic (chloramphenicol or a cephalosporin) for 5 days.
abscess will be surrounded by inflammatory oedema. Cut through
his skin and deep fascia, and explore it by Hilton's method (5-3).
You may need to do some careful blunt dissection to release a
,$ 

little pus at the centre of the abscess. Leave the wound open, or
partly close it and insert a drain. Later, remove the offending tooth
This is a dangerous complication of acute pancreatitis (13.9). A
(if this is the cause, 26.3). collection of pus, necrotic tissue, and clot fills the patient's lesser
sac; it enlarges behind his peritoneum, it expands anteriorly to
obliterate his lesser sac, and it pushes his stomach and transverse

,0' 1
 colon forwards.

 
' 
2 If his abscess develops during the course of an attack of pan-
Absceses of the thyroid are rare in the developed world, but are
not uncommon here in the developing world. The patient pre-
sents with a wide, very painful, oedematous swelling of his neck
which is maximal over his thyroid. The pus is too deep for you to
be able to detect fluctuation. Inflammatory oedema may be so
marked as to cause Ludwig's angina (5.10).
THYROID ABSCESSES
For the general method, see Section 5.2.
DIAGNOSIS. Confirm the presence of pus by needle aspiration.
ANAESTHESIA. Give the patient intravenous ketamine or a ge-
8
creatitis, the diagnosis is usually obvious, but it may be difficult
otherwise. So if ever a severely sick patient has an ill-defined
deep-seated epigastric mass, remember that he might perhaps
have a pancreatic abscess.


SPECIAL TESTS. The patient's urinary and serum amylase are
high. A plain erect film may show a large cavity with a fluid level,
or gas. A barium meal may show a deformity in the outline of his
stomach, caused by a mass behind it pushing it forwards. See
also Section 13.10.
DRAINAGE. Under general anaesthesia and with adequate rela-
LUDWIGS
A
ANGINA
B tongue up against palate
oedema
of glottis
Fig 5-8: LUDWIGS ANGINA. A, note the massive swelling of
the patient's chin. B, his swollen tissues have compressed his
tongue against his palate. The infection may spread to cause
oedema of his glottis. Partly after 'Hamilton Bailey's Emergency
Surgery', edited by Dudley HAF, Figs. 153 and 154, John Wright, with
kind permission.
xation, prepare and drape his upper abdomen. Then feel for the
mass again.
Make an upper midline incision from his xiphisternum to his umbi-
licus. Open his peritoneal cavity with care, because the mass, or
his stomach or colon, may have stuck to his abdominal wall.
You may find it difficult to know what you are seeing. Dissection is
difficult and dangerous, because his tissues are so vascular and

 '
Suppuration in a patient's axilla can take several forms: (1) Pus
can form superficially in his apocrine glands. (2) It can form
more deeply in the lymph nodes under his pectoralis major.
Open deep abscesses promptly, because pus can track along his
nerve trunks into his neck.
AXILLARY ABSCESSES
For the general method, see Section 5.2. Abduct the patient's
arm.
If his abscess is superficial (usual), incise over it.
If his abscess is deep (unusual), make a 3 to 5 cm incision just behind
the fold of his pectoralis major, so as to avoid his axillary vessels.
Push a haemostat upwards into the swelling, open its handles
parallel to important structures, and open the abscess. Insert a
drain.
If his whole axilla is a bag of pus, incise low in his axilla.
If he has a large subacute or chronic abscess, consider the possibility
of tuberculosis, especially if the surrounding tissues are indurated,
sinuses are present, and the breast is swollen from lymphoe-
dema, perhaps with peau d'orange.
If he has multiple recurrent small abscesses in his skin, they may: (1)
Be caused by tuberculosis, so biopsy one. Otherwise do a thera-
peutic trial with chemotherapy for tuberculosis. (2) Be caused by
fungi. (3) Originate in sweat glands (HIRADENITIS SUPPURA-
TIVA, unusual). Incision will not help much and may lead to keloid
formation. If you suspect this try metronidazole and regular
swabbing with a mild antiseptic, such as cetrimide.

$ 
 
oedematous. Lift and free his abdominal wall from the organs Perinephric abscesses are not uncommon; they are usually
under it, and insert a self-retaining retractor. caused by staphylococci, and arise from a small metastatic abs-
Feel for the upper border of the abdominal mass. Try to find a cess in the cortex of the kidney, which may be solitary, or one of
place where you can incise it without injuring anything. This will many pyaemic abscesses.
usually be through his gastrocolic omentuum, or his lesser
The patient, who may be any age, presents with fever and a tend-
omentum.
er swollen area in his loin or subhepatic area. If his abscess is
When you have decided where to drain, seal the area from the
rest of his peritoneum with large moist packs. Using a syringe and small and related to the upper pole of his kidney, he may have no
a large needle, aspirate the place where there seems to be the localizing signs. The approach to the kidney is the same as that
thinnest layer of tissue between the abscess and your finger. Take for a nephrostomy, so see Section 23.13, and particularly Fig. 23-
pus for culture. 16.
If you find pus under pressure, decompress the abscess with a
trocar and cannula, to which suction is attached. Enlarge the abs-
cess so that you can insert two fingers, but don't try to dissect AXILLARY ABSCESS
further. Wash out floating solid matter.
CAUTION! At the same time, don't disturb the necrotic pancreatic
tissue at the bottom of his abscess — it will bleed!
Place two Malecot catheters in the abscess cavity, and bring them
out through stab wounds. Bring one out anteriorly, and the other
as far back as possible, in the most 'dependent' position. Use
these to irrigate the abscess cavity continuously with saline (about
2 l in 24 hours). Make a feeding jejunostomy (9.7), because he
will not be able to eat for 3 weeks, and you will pro-bably be un-
able to feed him parenterally. Feeding him through a jejunostomy
results in less secretion of gastric juice than feeding him through a
gastrostomy.
Close his abdomen securely as a single layer (9.8). Leave his skin
open, and lay a hypochlorite or saline pack on it.
Continue nasogastric suction, fluids, and antibiotics until his
temperature is normal. Don't be in a hurry to remove the drains,
even if leaving them in does seem to increase the risk of a fistula.
Allowing pus to collect again is a greater risk. If the wound is
looking fairly clean, close it by secondary suture in 7 to 10 days.
Fig. 5-9: AN AXILLARY ABSCESS can form superficially in a
CAUTION! A pancreatic abscess carries a 30 to 50% mortality,
patient's apocrine glands. Pus can also form more deeply in the
and often reforms, even with adequate drainage. If so, be pre-
pared to reoperate 3 or 4 times if necessary. lymph nodes under his pectoralis major. Open deep the
abscesses promptly, because pus can track along his nerve
trunks into his neck.

9
PERINEPHRIC ABSCESS
X-RAYS. Take a plain X-ray. Look for obliteration of the patient's
psoas shadow, and scoliosis with a concavity towards the abs-
cess. Look also for disease of his spine, especially narrowing of
intervertebral discs and erosion of the bodies of his vertebrae
nearby, especially anteriorly (osteomyelitis, an important differen-
tial diagnosis).
Screen the movement of his diaphragm. This is reduced in most
cases of subphrenic abscess, but seldom with perinephric abs-
cesses.
An IVU shows a normally functioning kidney which may be dis-
placed, especially medially or posteriorly.
CAUTION! An intravenous urogram is essental. Without one you
cannot exclude a pyonephros.
DIFFERENTIAL DIAGNOSIS. (1) Pyomyositis of the abdominal
wall or paraspinal muscles. (2) Pyonephros. (3) Subphrenic abs-
cess. (4) Osteomyelitis of the spine, with spread to the paraspinal
tissues.
MANAGEMENT. His pus must be drained. You may not know for
certain if it is perinephric, subphrenic (especially in the posterior
or subhepatic spaces), or has spread from osteitis of his spine.
ANTIBIOTICS. Give him an antibiotic (chloramphenicol or a
cephalosporin, 2.9).
ANAESTHETIC. (1) General anaesthesia with intubation. (2)
Intravenous ketamine.
POSITION. Lie him in the kidney position as for a nephrostomy —
see Section 23.13.
 
THE DIFFERENTIAL DIAGNOSIS is that of the 'sick child with the
painful flexed hip'. It is more difficult if his right hip is flexed, be-
cause the diagnosis on this side includes appendicitis.
Suggesting iliac adenitis with periadenitis or an abscess - a septic
lesion on the skin which may be minimal and have healed (adeni-
tis may appear 2 weeks after the primary lesion has settled), a
markedly flexed hip with a short history, a mass in his groin or
right iliac fossa just above his inguinal ligament, no pain when you
percuss his greater trochanter; you can flex his hip a bit more, no
spasm of his sacrospinalis, and no X-ray changes.
Suggesting pyomyositis of his iliopsoas - the same signs as iliac
adenitis. The differential diagnosis may be impossible, and is not
important because the treatment is the same.
Suggesting an appendix abscess - a different anatomical site intra-
peritoneally in his right iliac fossa, nausea and vomiting, less
spasm, and only mild flexion of his hip.
Suggesting septic arthritis of his hip - severe joint spasm, acute pain
on percussing his greater trochanter, no palpable mass, and an X-
ray showing a widened joint space. No movement of his hip due
to severe pain. This is also osteomyelitis because the epiphyseal
plate is inside the capsule of the hip joint.
Suggesting tuberculosis of his hip - a subacute history and X-ray
signs of tuberculosis (29.1).
Suggesting a tuberculous psoas abscess arising from his spine - a sub-
acute history, X-ray changes in his spine. A psoas abscess does
not usually need drainage, unless it is very large and causing
pain. It will resolve slowly on chemotherapy for tuberculosis; incis-
ing it can lead to secondary infection.

INCISION. Make a 15 to 20 cm incision starting posteriorly over

his 12th rib just lateral to his sacrospinalis muscle (about the mid
PERINEPHRIC
point of the rib). Cut down on the rib, incise and deflect the A ABSCESS
periosteum, so as to push the nerves and vessels aside. Remove
the distal two thirds of his rib and dissect through its bed to
expose his perinephric space containing the abscess.
If the pus is in his muscles (pyomyositis), you will discover this
before you reach his rib (unless it is in his psoas or quadratus
lumborum). If it is spreading from his spine or is subphrenic, you B
will also find it.
Drain the pus by Hilton's method (5-3). Insert a wide bore tube or
corrugated drain and close the wound in layers.


When you see a child or young adult with a painful flexed hip, C
and about a week's history of fever, anorexia, pain, and swelling
in his inguinal area, think of iliac adenitis. The infection may
have reached his iliac nodes from his leg, his perineal area
(including his genitalia), or his buttocks. The abscess lies near
his psoas muscle; this goes into spasm and sharply flexes his perinephric
fascia
hip, so that he will not let you extend it beyond 90°, and he
cannot walk. He has a tense, tender, hard mass in his iliac fossa, D perinephric fascia
which is lower, and closer to his anterior iliac spine, than an ap- renal capsule
pendix mass. You will probably be unable to elicit fluctuation,
and only occasionally will you find the site of the primary
infection. He has a moderate leucocytosis.
It is useful to distinguish 'periadenitis' without suppuration
(common), which resolves on antibiotics and does not need
drainage, from an iliac abscess (less common), which needs
drainage and which can follow periadenitis, or pyomyositis of Fig. 5-9a: A PERINEPHRIC ABSCESS. A, an unusually large
the iliopsoas, or be an extension from osteomyelitis of the spine. perinephric abscess. B, approach a perinephric abscess through
An appendix abscess is quite different, and is inside the perito- the bed of the 12th rib. C, put the patient into the left lateral
neum, whereas all these other conditions are outside it. position. D, the true renal capcule is closely applied to the sur-
This condition (iliac abscess) is also known as iliac adenitis, face of the kidney. Outside this, the perinephric fat is surround-
deep inguinal adenitis, extraperitoneal iliac abscess, or suppurat- ed by the perinephric fascia (Gerota's fascia). After Robert C
ing deep iliac nodes. It has several important differential dia- Flanigan in Rob's 'Operative Surgery'. Figs. 1b, 3, and 12a. With kind
permission of Hugh Dudley.
gnoses, and is often misdiagnosed.

10
 ischiorectal abscess

Suggesting acute and usually staphylococcal osteomyelitis of his spine

A PAINFUL
(uncommon) - more pain, spasm of his sacrospinalis, X-ray signs in
his spine. Drain the lesion as for osteomyelitis (7.2). FLEXED HIP
Other possibilities include Perthes' disease (27.14), a slipped A
epiphysis (77.10), and a fracture (77.1).
If the diagnosis is difficult, and you suspect an abscess, you can:
(1) Examine him under anaesthesia, with his abdominal muscles
relaxed. Feel the exact site of the mass and its consistency and C
boundaries, and feel for fluctuation.
(2) Make a 4 cm oblique skin incision, medial to his anterior
superior iliac spine, and aspirate the mass with a large-bore
needle.
Tender!
NON-OPERATIVE TREATMENT. Deep inguinal (iliac) adenitis
with periadenitis and without pus formation does not require drain- painful
age. His hip is flexed as when an abscess is present. You can feel flexed
hip
deep tender glands above his inguinal ligament. Give him an anti-
biotic (penicillin or chloramphenicol). If infection is slow to resolve, abscess
use skin traction (1/7th of his bodyweight, 70.10) and raise the
B
foot of his bed.
DRAINAGE. If you have aspirated pus with a needle, you can
safely open up the deeper layers. The abscess will have pushed
the peritoneal lining of his right iliac fossa medially and superiorly.
Make an incision 5 to 10 cm or more over the swelling about 2 cm
above his inguinal ligament, starting just medial to his antero-
superior iliac spine (D, 5-10). Take a long haemostat and push
this through the muscle over the abscess until you find pus. Then,
using your fingers, enlarge the opening until it will take 3 or 4 of
sometimes a
D
them. septic lesion
Take a specimen, drain the lesion, and continue antibiotics. peripherally
If his leg remains in spasm, apply traction as above.
CAUTION! Draining an iliac abscess is potentially dangerous -
you may injure his caecum or his iliac vessels. So follow the
method above and aspirate first. Fig. 5-10: A PAINFUL FLEXED HIP in an ill patient has a
variety of differential diagnoses. A, his hip is typically more
flexed than is shown here. B, an iliac abscess forms in the iliac

 
 nodes. C, exploring extraperitoneally for iliac suppuration. D,
Trouble starts when an abscess near a patient's anus bursts
through to his skin. It probably originated in an anal gland, and
may communicate through a tiny opening with his anal canal, at
the pectinate line. A connection betweeen the skin and the anus
(a fistula) is the reason why about half of these abscesses recur,
or discharge persistently on to the perianal skin as chronic
fistulae in ano. Abscesses (with no opening to the skin), sinuses
(with an opening to the skin, but not to the anus), and fistulae
(with openings to both) are thus part of the same disease
process. Most abscesses settle by discharging spontaneously, or
being drained, but a serious life-threatening infection can some-
times spread through a patient's perineum, or deeply into his
pelvis. For an account of the anatomy of this region and the
treatment of fistulae see Section 22.2.
The patient is usually a middle-aged man who says that a severe
throbbing pain has kept him awake for several nights. When you
examine him, you find a tense tender swelling near his anus.
Sometimes, there may be little to see or feel, except mild tender-
ness at his anal margin, or, his whole perineum may feel tense
and tender. If his abscess bursts to the surface, his pain goes. But
he may now have a persistently discharging sinus or fistula open-
ing on to the skin near his anus.
The anal glands are mostly posterior, so that most abscesses and
most fistulae are posterior. These glands also extend into the
sphincters, so that pus does too. It can track in various direc-
tions: (1) It usually tracks downwards to cause a perianal abs-
cess. (2) It sometimes tracks laterally, through the sphincters, to
cause an ischiorectal abscess. The ischiorectal spaces connect
with one another behind the anus, so that infection on one side
can spread to the other side (horseshoe abscess). (3) Rarely, pus
tracks upwards: (a) under the mucosa of the anal canal to form a
submucous abscess, or (b) between the sphincter muscles to
11
the incision for an iliac abscess. C, and D, after 'Hamilton Bailey's
Emergency Surgery', edited by Dudley HAF. John Wright with kind
permission.
form a high intermuscular abscess, or (c) above the levator ani
muscles to form a supralevator abscess.
A perianal abscess (common) presents as a red tender swelling
close to the patient's anus. On rectal examination, there is little
or no tenderness, induration, or bulging in his anal canal. There
is usually no fistulous track, but if there is one, it goes straight
through or above his subcutaneous external sphincter, and
usually through the lowest part of his internal sphincter.
The abscess usually bursts spontaneously (unless it is treated
surgically), and may persist as a fistula. Its external opening is
surrounded by a button of granulation tissue within 5 cm of his
anus. If the track is low, you can feel it through his skin as a cord
passing from the external opening towards his anus. You may be
able to feel its internal opening as a tender swelling, which is
usually below his pectinate line.
An ischiorectal abscess (common) lies deeper than a perianal
one, is larger and further from his anus; it forms a deep tender
brawny swelling and is not fluctuant until late. He is likely to be
toxic, febrile, and debilitated. On rectal examination you may
feel a tender induration bulging into his anal canal on the same
side. The infection may spread posteriorly and then to the other
side as a horsehoe abscess, so that he now has signs on both
sides. When an ischiorectal abscess discharges, it does so
through an external opening, which is typically more than 5 cm
from his anus. If a fistula forms, it almost always opens into his
anus in the midline posteriorly below his anorectal line. From
there it curves backwards and laterally into one or both of his
ischiorectal fossae.
A submucous or high intermuscular abscess (rare) presents
with pain in a patient's rectum and no external swelling, unless it
is complicated by an ischiorectal or perianal abscess. On rectal
examination you may be able to feel a soft, diffuse, tender
swelling extending upwards from his pectinate line.
A pelvirectal abscess (rare) presents with fever, but no local
anal or rectal signs. Later, it may extend downwards into his
ischiorectal fossa. With your finger in his anus, you may be able
to feel fluctuation above and lateral to his anorectal ring.
Don't delay treatment in the hope that an anorectal abscess will
cure itself — always incise it. Pus will have formed by the time
the patient presents, and antibiotics will not make it go away -
they are only indicated if he has a high temperature and a
spreading infection (rare). If his abscess is large, warn him that it
is going to take weeks to heal. Unroof it and let it granulate.
Don't try to curette it, and close it by curettage and primary
suture. A large incision will not necessarily give a better resul -
recurrence depends on whether or not there is a tiny communi-
cation between the abscess and his anal canal - see Section 22.2.
ZBIG (50 years) complained of painful defaecation and passing pus and
blood rectally. He was found to have an anorectal swelling, given a
course of antibiotics, and sent home for readmission later for exami-
nation under anaesthesia. He returned after three days with severe pain,
swollen crepitant buttocks, and a black gangrenous scrotum. His urine
was tested and was found to contain sugar. He was referred, but died
soon afterwards. LESSONS (1) Bacteria in anorectal abscesses come
from the gut and are usually benign, but anaerobic infections can be
dangerous. (2) Never treat an anorectal or perineal abscess with anti-
biotics without also draining it. (3) Spreading anaerobic infections origi-
nating in the gut need metronidazole. (4) Always test the urine. Serious
infections are particularly common in diabetics.

 
CAUTION! (1) If a patient has an acute abscess don't probe
around looking for fistulae — wait until his lesion has become
chronic. If you probe unwisely, you may create an iatrogenic
extrasphincteric fistula which will be very difficult to treat. (2) In
the chronic phase, look carefully for the tracks in his skin and
rectum that show its presence. If he has a fistula and you fail to
diagnose it, he will not be cured. (3) If an abscess lies anteriorly,
consider the possibility of a periurethral abscess in a man, and a
Bartholin's abscess in a woman.
INDICATIONS FOR INCISION. Operate immediately you can feel
a tender swelling. Don't wait for fluctuation. If pain has kept him
awake, open his abscess.
ANTIBIOTICS are useless unless there are signs of spreading
infection. If so, give him chloramphenicol and metronidazole.
EQUIPMENT. A scalpel and a bivalve speculum. A proctoscope
and a sigmoidoscope are not essential; you are unlikely to see
A PERIANAL OR ISCHIORECTAL ABSCESS
A B C twice the depth of the lesion over its most prominent or fluctuant
anus
Fig 5-12: AN ANORECTAL ABSCESS. A, a cruciate incision. B,
insert your finger and break down loculi. C, the wound with its
edges trimmed, being left to granulate.
12
ANORECTAL ABSCESSES supralevator abscess
submucus
anorectal
abscess
line
dentate line
fistula from intermuscular ischiorectal
opening of perianal
intermuscular anorectal abscesses abscess abscess
abscess gland CAUTION! Don't cut deeper
than this wavy line or the
patient may become incontinent
Fig 5-11: ANORECTAL ABSCESSES form in the anal glands.
The pus can track in any of the directions shown here. When an
abscess bursts into the anal canal and on to the skin a fistula,
may form. After Macleod JH, 'A Method of Proctology', Fig. 7.9.
Harper and Row, with kind permission.
anything you cannot feel.
ANAESTHESIA. (1) For a large abscess, use ketamine, or
general anaesthesia. (2) Local anaesthesia is unsatisfactory, al-
though you can use it for a perianal abscess; but the patient will
not be pain-free. It is even less satisfactory for other abscesses.
(3) Intravenous thiopentone with pethidine is not ideal, because
you may need more time than they allow you (A 8.8).
EXAMINATION UNDER ANAESTHESIA. Put him into the litho-
tomy position. Put a finger into his anus and feel its entire wall
between two fingers, as in F, Fig. 22-2. Feel if there is an
indurated upward extension of the abscess under the mucosa 3
cm or more above his internal sphincter. Feel the extent of the
abscess, and for the point of maximum fluctuation.
Insert a bivalve speculum and look for pus coming out of an
internal opening in the appropriate segment of his anal canal. You
will only find one in about 10% of cases. You may feel the opening
as a localized tender depression in his anal canal in the place
suggested by Goodsall's rule in Fig. 22-6. Press on the abscess -
you may see a bead of pus escape from the internal opening. If
you do find a fistula, determine where it is in relation to his pecti-
nate line.
If his abscess is acute, there is no defined wall, so you will not find a
track. DON'T probe around, you may make one!
If his abscess is chronic with a well-defined wall, probe carefully to look
for a fistula.
INCISION AND DRAINAGE. Support the mass with your finger in
his rectum. Make a substantial cross-shaped incision at least
part. This will be externally for a perianal or ischiorectal abscess,
and inside his rectum above his anorectal line for a rare submu-
cous or pelvirectal abscess. Make the incision large enough to
admit one or two fingers, so that you can explore the abscess fully
with your finger and break down all loculi by Hilton's method (5-3).
Don't break down any natural barriers to the spread of infection. If
possible, send a specimen of the pus for culture.
Now look again — but don't probe — to see if there is a fistulous
opening.
If there is no fistula, cut off the corners of the flaps to prevent the
edges of the wound coming together and adhering. A linear
incision is never adequate. Wrap your finger in gauze and clean
the walls of the abscess cavity.
If there is a fistulous opening, you can proceed immediately as
follows, or better, wait 4 or 5 days.
If his fistula is low in his anal canal, at or below his pectinate line,
lay it open and manage it as a low anal fistula (22.2).
If the opening of the fistula is above his pectinate line, leave it and
either refer him, or deal with it later. Some surgeons thread a silk
ligature through the fistula and tie it loosely round the sphincter, to
mark its internal opening.
POSTOPERATIVELY, pack the cavity lightly with gauze - don't
pack it too tight, or it won't drain. Tuck the edge of a gauze square
into the wound to keep the edges of the skin apart, until the
wound cavity has collapsed. Apply a T-bandage. Follow this with
daily salt baths and packing, until the abscess cavity has healed
from within outwards. It will heal slowly. Discharge him as soon as
there is a flat granulating area, and review him regularly.
CAUTION! (1) Be sure to push a piece of gauze down to the
bottom of the cavity, so that it heals from the bottom up, without
bridging of the edges. (2) Don't pack it so tightly that the pack
interferes with granulation.
If you lack dressings, use salt baths (1.12) and ask a nurse to use
her gloved hands to separate the walls of the abscess, which may
be sticking together superficially.
DIFFICULTIES WITH ANORECTAL ABSCESSES
If you find AN ABSCESS ON BOTH SIDES, open them both as
described above, and incise both his ischiorectal fossae. There is
sure to be a track between them, behind his anus; some surgeons
would lay this open also at this stage.
If he has SIGNS OF SPREADING INFECTION, such as gross inflamma-
tory swelling, areas of necrosis, or crepitation, he probably has an
ANTIBIOTICS. Give the patient ampicillin, or chloramphenicol,
until you have the results of culture of his urine and pus — if this
is possible.
MANAGING HIS URINE. Most patients have retention of urine.
If he has retention of urine, try passing a soft rubber catheter. If this
fails, as it probably will, do a suprapubic cystostomy, preferably a
suprapubic puncture with a fine plastic tube (23.6). When the
abscess is healing, start to pass bougies. This will be difficult, but
take care not to use force.
If you succeed, bougie him every 3 months to start with, and less
often later.
If you fail, try again a week later. If you still have difficulty, refer
him; he may need a urethroplasty.
If he does not have retention of urine, dilate his stricture later.
THE ABSCESS. If pus is present, and he fails to respond to anti-
biotics, drain the abscess on to his perineum, and be sure to open
it widely. Give him salt baths and pack the wound post-opera-
tively.
DIFFICULTIES WITH A PERIURETHRAL ABSCESS
If his urine EXTRAVASATES, see Section 23.10.
If you CANNOT REFER HIM for urethroplasty, he will have to continue
passing his urine through his perineum (32.33), or you will have to
attempt a urethroplasty yourself (23.9).
If his ABSCESS RECURS, consider the possibility of tuberculosis or
carcinoma of his urethra.
If he develops a FISTULA, see Section 23.9.


$ 


anaerobic infection, and needs urgent treatment, particularly
metronidazole (2.9) and wide drainage.
If A FISTULA DEVELOPS later (common), treat it as in Section 22.2.
If he presents with a RECURRENT ABSCESS (common), there is almost
certainly an underlying fistula. The opening may be very small,
and you may have overlooked it when you drained his first
abscess.
If you find an INTERNAL OPENING which communicates with his
ischiorectal fossa above his anorectal ring, (rare) don't cut the muscle
superficial to it, or he will become incontinent! Drain the abscess
from below. A fistula will probably form.
If THE ABSCESS EXTENDS INTERNALLY under his submucosa, (rare)
pass a director along the track and lay it open. It will bleed co-
piously. Try to tie the vessels. This may be difficult, so don't spend
too long trying. If you fail, grasp them with haemostats, and leave
these in place for 48 hours.
If he has a SUPRALEVATOR ABSCESS (very rare), refer him -
treatment is difficult and controversial.

$  
Gonococci or coliforms can infect a patient's prostate. To begin
with they cause a prostatitis, and later a frank abscess. He pre-
sents with urgency, frequency, and dysuria, or with retention. He
has fever, rigors, and severe rectal or perineal pain, sometimes
with tenesmus. His prostate is enlarged, usually more so on one
side than the other, and is exquisitely tender. Untreated, his
abscess may burst into: (1) his urethra, (2) his perirectal tissues,
where it can present as an ischiorectal abscess, (3) his perineum,
or (4) his rectum, forming a rectourethral fistula.
PROSTATIC ABSCESSES
DIFFERENTIAL DIAGNOSIS. Extreme prostatic tenderness
should make the diagnosis clear. Don't confuse a prostatic abs-
cess with: (1) An ischiorectal abscess — the swelling is to one
side of the midline. (2) An abscess in a seminal vesicle - rectally,
the site of maximum swelling and tenderness will be higher and
more to one side.
SPECIAL TESTS. Test his urine for sugar, and culture it.
 
A patient with a periurethal abscess has a tender inflamed area
in his perineum, or under his penis. His abscess commonly ari-
ses in his bulbar urethra, probably in the paraurethral glands of
Cowper, and is usually caused by gonococci to begin with; but
these are soon replaced by secondary invaders. The danger is
that his urine may leak from the abscess cavity, extravasate
widely, and cause extensive cellulitis (23.10), or a fistula. His
urine is infected, so this kind of cellulitis is more dangerous than
that following traumatic rupture of his urethra. He may or may
not have retention of urine due to an inflamed stricture, which
will prevent you passing a catheter, so you may have to drain his
bladder with a suprapubic cystotomy (23.5).

 
DIFFERENTIAL DIAGNOSES. (1) A perianal abscess. (2) A scro-
tal abscess is in a different place and is not associated with uri-
nary symptoms. (3) Localized penile extravasation of urine.
13
ANTIBIOTICS. Give him a broad-spectrum antibiotic, such as
ampicillin or chloramphenicol, until you know the results of
culture.
MANAGEMENT. If his prostate is not fluctuant, see what anti-
biotics alone will do in 48 hours.
If antibiotics fail to cause a marked improvement in 48 hours, or his
abscess is fluctuant, refer him to an expert urologist, who will drain
his abscess into his urethra with a resectoscope.
If you cannot refer him, drain the abscess yourself, as follows.
Fortunately, this is very rarely necessary.
DRAINAGE. Anaesthetize him, and put him in an exaggerated
lithotomy position. Start by passing a rubber Jacques catheter. If
this passes easily, leave it in place. If you cannot pass it, do a
suprapubic cystotomy.
To drain his abscess, pass a metal sound, and cut down on to this
through a 5 cm midline incision immediately in front of his anus.
Remove the sound and control bleeding. Put your finger through
the incision into his prostatic urethra, and then through its post-
erior wall into the abscess cavity. If this contains several loculi,
break down the septa between them.
Pack the wound loosely with a dry dressing and leave it open, or
suture the skin edges loosely over it. Remove the catheter about
the 7th day.
Alternatively, make an oblique lateral incision, as when removing
the prostate by Ghadvi's method (23.21).

#
"
!1  2
The symptoms are the same as with an abscess of the prostate,
but the warmth, the swelling and the tenderness, instead of being
over the patient's prostate, are higher and more to the side, over
one, or occasionally both, of his seminal vesicles. He may also
have pain suprapubically, in his back, or down the inner side of
his thighs.
TREATMENT. Place the patient in an exaggerated lithotomy
position, and and make an oblique lateral perineal incision.
Dissect bluntly until you feel the swollen vesicle. Push a haemo-
stat into it, drain it, and close the wound lightly round a drain.

14