PHLEGMON (Greek phlegmone heat, an inflammation) — a diffuse purulent inflammation of cellulose. Unlike abscess (see), to-ry it is delimited from surrounding fabrics by a piogenic membrane, T. tends to distribution on kletchatochny spaces.
Etiology and pathogeny. Phlegmon develops owing to implementation in cellulose of the microflora causing purulent, putrefactive or anaerobic forms F. As a rule, activators F. pyogenic bacteria (see), especially different types of stafilokokk are (see). Much more rare reason F. there can be streptococci (see), to-rye usually associate with stafilokokka; in such associations the pyocyanic stick meets (see). Causative agents of a putrefactive infection are found considerably less than purulent. From them come to light colibacillus (see), a putrefactive stick, vulgar proteas (see Proteus) and a putrefactive streptococcus. Cases F became frequent., caused by gas-forming neklostridial-ny anaerobe bacterias (see), napr, gram-positive cocci (Pepto-coccus, Peptostreptococcus). Their pathogenicity is connected with existence of the conditions promoting decrease in reactivity of an organism of the patient (e.g., an immunodeficiency, alcoholism, a diabetes mellitus, prolonged use of corticosteroid drugs).
Emergence chronically proceeding so-called ligneous F. etiologically connect with low-virulent strains of various microbic flora — streptococci, stafilokokk, pneumococci, diphtheritic and paratyphoid sticks; quite often in scanty exudate microbic flora is not found at all.
Penetration of microbes into cellulose happens more often at open damages, U-2014\by a hematogenous drift from the septic center is more rare \(see Sepsis), as a result to-rogo phlegmons, a purulent psoitis (see), a paranephritis (see), etc. can develop deep (paraossalny and intermuscular). Phlegmon can arise also owing to distribution of the activator from the next suppurative focus (e.g. as a complication of an anthrax, purulent lymphadenitis, a violent ugly face, a purulent tendovaginitis, purulent arthritis, etc.).
Peculiar form F. local post-injection purulent complications are, to-rye can proceed and as abscesses. Usually they are connected with an injection of the concentrated solutions of pharmaceuticals (most often — solutions of magnesium sulfate and analginum), and also violation of the rules of an asepsis (see).
T. (unlike abscess) develops very quickly, leading to sharp circulator, biochemical and neurotrophic frustration and the expressed intoxication (see). It is connected with delay of formation of a restrictive barrier, suppression nonspecific and immunol. reactivity of an organism.
Pathological anatomy. Depending on the nature of change of fabrics distinguish serous, purulent, putrefactive and necrotic forms F. Morphologically F. begins with development of a serous inflammation in cellulose, edges becomes jellylike, becomes impregnated with muddy serous liquid. At gistol. a research find a picture of an exudative inflammation (see) with infiltration of soft tissues polymorphonuclear leukocytes. At low virulence of microflora and rather high resistance of a macroorganism process is sometimes limited to an acute serous inflammation (serous F.) or gains character of chronic. Gistol. picture serous F. it is characteristic also of immediately proceeding forms of a mephitic gangrene (see) differing in development of a large amount of endotoxins and for F. nek-ry localizations, napr, a mediastinitis (see). In other cases serous exudate soon turns in purulent (purulent F.), and at inoculation of the microflora causing a putrefactive infection (see) becomes ichorous (putrefactive F.). At the same time there are small disseminated sites of a necrosis (see), to-rye in the subsequent merge, forming the extensive centers of nekrotizirovanny cellulose with sites of purulent fusion (necrotic F.). On the periphery it is purulent - necrotic infiltrate the zone of serous treatment is found. In certain sites on border the inflammatory shaft presented by polymorphonuclear leukocytes with high phagocytal activity decides on not changed fabrics. Most often bystry development of a necrosis is observed in the friable cellulose located between dense fabrics where inflammatory infiltrate squeezes vessels and leads to ischemia (see), napr, at F. brushes (see).
During the progressing F. inflammatory infiltrate can spread to the next fabrics and bodies (a fascia, a muscle, a bone, etc.). At F. muscles inflammatory infiltrate quickly spreads on a stroma, and in case of involvement in process of the fastion surrounding the affected muscle — and to others, the muscles nearby located. The affected muscles become pale owing to sharp disturbance of blood circulation, become impregnated with the yellow-greenish pus consisting of polymorphonuclear leukocytes, nekrotizirovanny muscular tissue and fibrin. In the beginning in muscle fibers granular and fatty dystrophy (cm, Proteinaceous dystrophy, Fatty dystrophy) develops, and then there comes their necrosis and disintegration. At distribution of an inflammation the amount of synovial fluid with impurity of polymorphonuclear leukocytes increases by synovial vaginas of sinews in them, the quantity to-rykh increases, there is a fibrin, exudate becomes purulent. In walls of a synovial vagina of a sinew the plethora, the serous treatment which is replaced by purulent infiltration with a necrosis of fabric is noted (see the Tendovaginitis). Involved in patol. process a sinew tarnishes, becomes gray-green, becomes impregnated with pus, is stratified and nekrotiziruyet-sya. Sometimes the inflammatory infiltrate located in the neighbourhood with internals (a throat, a liver, kidneys, large vessels, etc.), can spread to these bodies and lead to generalization of an infection and sepsis.
At a favorable current F. it is purulent - the necrotic site is delimited by a leukocytic, and then and granulyatsionny barrier and on site phlegmons abscess which can spontaneously be opened is formed.
Clinical picture. On a wedge, to a current F. can be acute and chronic, inclined to an otgranicheniye and progressing. F. Klien, manifestations acute F are in most cases observed acute. are very various, they depend on virulence of microflora, immunobiol. conditions of an organism and many other factors. Localization of inflammatory process is of great importance, in particular. T. it can be localized in various bodies and areas of a body where there is a cellulose. On localization distinguish hypodermic (epifastsialny), subface-tsialnuyu, intermuscular, organ, it seems a lysis a thuja, interorgan, retroperitoneal, subphrenic, pelvic F.
Ostraya hypodermic purulent F. it is characterized by emergence of sharp pain, quickly increasing swelling with dense diffusion infiltration of fabrics, a dermahemia over it, dysfunction of the struck part of a body. The general condition of the patient worsens, raises the body temperature which is quite often accompanied with a fever and tachycardia, the local hyperthermia is observed. In the subsequent in certain sites of dense infiltrate the centers of a softening can be formed, the symptom of fluctuation is defined (see Zybleniye). To thicket hypodermic F. it is delimited by a granulyatsionny barrier and its distribution stops. The progressing forms F are less often observed., at to-rykh an inflammation, quickly extending, occupies extensive sites of cellulose and causes heavy intoxication, and it is frequent — a septic state. Body temperature sharply increases and has constant character, in blood the high leukocytosis with a band neytrofilnykhm shift is noted to the left. Hypodermic phlegmons of the person especially hard proceed and are life-threatening (see), to-rye quite often are followed by thrombophlebitis of veins of the person and eye-socket (see), thrombosis of brain vessels and sine of a firm meninx (see Thrombosis of vessels of a brain), purulent meningitis (see).
Deep (subfascial and intermuscular) purulent F. are characterized by the acute beginning, sudden fervescence to 39 — 40 °, a fever. From among local symptoms are characteristic: inflammatory hypostasis of fabrics and increase in volume of the struck area, disorder of function and a painful (protective) contracture (see) muscles. Skin of area F. becomes intense, sometimes in the beginning a little pale. The dermahemia can appear in late stages F., when inflammatory process extends to hypodermic cellulose. Regional lymphadenitis is usually expressed (see). At deep F. seldom the symptom of fluctuation comes to light. At the progressing deep intermuscular phlegmons process sometimes proceeds so violently (heavy intoxication, it is purulent-rezorb-tivnaya fever, mental disturbances, circulatory disturbances and breath, hepatonephric insufficiency, etc.) that the lethal outcome can come before a stage of diffusion serous treatment of fabrics (serous F.) will be replaced by gnoynonekrotichesky.
Wedge, manifestations and current deep F. in many respects are defined by topografo-anatomic features of the struck area, existence of fastion in it (see) and kletchatoch-ny spaces (see). An important role is played at the same time dense a fascia, by the forming cases and showing resistance to proteolytic influence of the pus which is in a case. On these cases generally there is also a distribution of purulent process. However at especially virulent (e.g., putrefactive and pyogenic) microflora these can be exposed to a fascia is purulent - necrotic to fusion and then purulent process can cover several fascial cases. E.g., T. an axillary pole (see) quite often extends to subpektoralny space in this connection brachialgias appear; the patient aims to lead a shoulder to a thorax that promotes relaxation of pectoral muscles and reduction of a prelum of the inflammatory center located under them. For F. this localization also strengthening of pains in pectoral muscles at the passive movements in a shoulder joint is characteristic and emergence in a big pectoral muscle of the painful swelling which was more expressed in upper, department of a muscle. At the progressing form F. inflammatory process can extend to the infrascapular area, and sometimes through intercostal spaces in a pleural cavity (see Pleurisy).
In a shoulder (see) distinguish two fascial vaginas for muscles — front and back, in a forearm (see) — three — front, back and outside. On a shoulder and a forearm pus seldom breaks fascial barriers, being limited, as a rule, to a framework of cases; however the break U-shaped F is sometimes observed. brushes (see) in Pirogov's space on a forearm. In a hip (see) allocate three fascial vaginas for muscles. Muscular groups here most of a massivna, there is a large amount of the friable connecting fabric located in the fascial spaces which are reported with each other that complicates definition of exact localization F. and ways of its distribution. On a shin (see) distinguish three fascial vaginas for muscles — front, outside and back. They are limited to dense fastion and bones, except the forefront of the back fascial case which is reported with average bottom space that creates conditions for distribution of an abscess on foot (see).
From purulent F. other localizations F especially sharply develops. in the spaces rich with friable cellulose, for example F. mediastinums (see the Mediastinitis), retroperitoneal and pelvic F. (see. Retroperitoneal space, Ileal area, Taz). As a phlegmonous inflammation proceed usually a paranephritis (see), a paracolitis (see), a paraproctitis (see). Submucosal F. are observed in walls of hollow bodies, e.g. at phlegmonous cholecystitis (see) the 7th phlegmonous appendicitis (see), phlegmon of a stomach (see), phlegmon of intestines (see). As phlegmon the terminal or regional ileitis can proceed (see Krone a disease). The inflammation limf is frequent, nodes can be the beginning of a so-called adenoflegmona (see Lymphadenitis), edges most often meets in inguinal area (see) and submaxillary area (see).
Putrefactive F. develop and extend much quicker and proceed heavier, than purulent; they arise in the presence of putrefactive infection of fabrics — uric zateka, wound of a large intestine, etc. The heaviest are putrefactive retroperitoneal F. and putrefactive F. mediastinums. Treats similar defeats also putrefactive and necrotic F. a bottom of an oral cavity (see Ludwig quinsy). Usually putrefactive defeats happen combined — is purulent - putrefactive or putrefactive pus - nymi. For putrefactive F. fervescence, a fever, falling of the ABP are characteristic. The wound has gray or black color, nekrotizi-rovanny fabrics melt, allocations have ichorous character (with a smell and gases); inflammatory and necrotic process, as a rule, is followed by lymphadenitis (see) and limfangiity (see).
T., caused by asporous (neklostridialny) anaerobe bacterias, are characterized by progressing of process against the background of prolonged use of antibiotics, tendency to a nekrotizirovaniye of the struck fabrics, allocation from a wound of the dark fetid gas separated with impurity, development of intoksikatsionny jaundice (see), a serious general condition of the patient.
Peculiar form F. is chronically proceeding ligneous F. necks, described to Rekl (P. Reclus, 1894). The disease meets seldom and is characterized by slowly current inflammatory process in intermuscular and hypodermic connecting fabric, the low subfebrile temperature, formation of infiltrate of soft tissues with his insignificant tendency to suppuration. Ligneous F. begins usually in a submucosal layer of an oral cavity and extends to a neck. In the beginning there is a small ligneous low-painful infiltrate on a side or front surface of a neck, to-ry slowly increases and takes all neck. When skin is involved in inflammatory process, she is accustomed to drinking with more deeply - the lying fabrics, becomes hyperemic and cyanochroic. From the next not struck fabrics infiltrate is delimited by accurately acting valikoobrazny eminence. In several weeks, sometimes months, in the field of infiltrate there are sites of a softening — abscesses without the expressed local and general inflammatory reaction. The general condition of patients changes slightly, the phenomena of intoxication, as a rule, are absent. Pains, even in the presence of abscesses, disturb a little, in most cases patients note feeling a raspira-niya, pressure and weights in the field of infiltrate. Sometimes at distribution of infiltrate on glubzhele-zhashchy tissues of a neck painful hypostasis of a throat, difficulty of swallowing and breath is observed.
Complications. At the progressing current organ and interbody - ache F. are quite often observed peritonitis (see), can develop an adhesive desease (see), be formed fistulas (see), etc. At localization F. near joints purulent arthritises can develop (see). Often F. are complicated by development of lymphadenitis (see) and a limfangiita (see). Phlegmon can be complicated by thrombophlebitis (see), and also be a source of development of sepsis (see).
The diagnosis is based on data a wedge, inspections of the patient, a lab. researches, and also bacterial. researches wound separated and blood. Diagnosis hypodermic F. in most cases does not cause difficulties, but sometimes (when F. results for the second time from an erysipelatous inflammation or thrombophlebitis) happens it is necessary to differentiate it with intermuscular F.; quite often it is necessary to differentiate it is purulent - putrefactive hypodermic F., caused by neklostridialny anaerobe bacterias with gas gangrene (see. Mephitic gangrene). At recognition deep F. it is necessary to differentiate it with acute hematogenous osteomyelitis (see), deep thrombophlebitis, an arterial embolism (see), the suppurating hematoma (see), purulent lymphadenitis, etc. In this case are extremely important in details collected anamnesis (see), survey and especially a palpation (see), at a cut are defined localization of the greatest morbidity, the sizes and character of infiltrate, existence of a muscular contracture, etc. In doubtful cases make a puncture of the inflammatory center.
For differentiation F. with abscess (see) apply pnevmoabstsesso-grafiya and contrast abstsessogra-fiya (see).
Diagnosis submucosal F is most difficult. hollow bodies, to-rye are quite often distinguished only during operation. From other forms of an inflammation of hollow bodies F. differ in the acute beginning and very heavy a wedge, a current. The adynamia, nausea and vomiting, anorexia, sharp pains in the respective area of a stomach are characteristic of them sharp fervescence (to 40 ° above) from oznoba. In blood usually find a neutrophylic leukocytosis, toxic granularity of granulocytes; sharply ROE accelerates. In addition to clinical and X-ray inspection of the patient, for specification of the diagnosis use tool techniques. E.g., diagnosis of phlegmonous gastritis (see) can be helped by gastroscopy, (see) with a biopsy (see), a phlegmonous duodenitis (see) — a duodenoskopiya (see) with an aim biopsy, phlegmonous cholecystitis (see) — a laparoscopy (see Pe-ritoneoskopiya) and a termografiya (see).
Diagnosis of phlegmon to Rekl quite often causes difficulty. In the first days of a disease it should be differentiated with an actinomycosis (see), Ludwig's quinsy (see Ludwig quinsy), and later — with a skirrozny form of cancer (see), a tularemia (see). Diagnosis is helped by a puncture biopsy (see).
Treatment. Main method of treatment purulent F. operational. Despite great success of conservative therapy of a purulent infection, the available arsenal sovr. antibacterial agents, methods of influence, the protective forces of an organism directed to increase, postponement of operation is admissible only in the most initial stages of a disease when distribution of process is not clear yet, is absent is purulent-rezorb-tivnaya fever (see), local symptoms of an inflammation are not expressed. In such cases creation of functional rest of the struck area is necessary, at localization of inflammatory process on extremities — an immobilization (see); purpose of antihistaminic, antibacterial agents; topical administration of the electromagnetic field (see Magnetotherapy), UVCh (see UVCh-therapy), the warming compresses (see the Compress); the so-called short novocainic block and futlyarny novocainic blockade according to Vishnevsky can be used (see. Novocainic blockade). Conservative treatment should be continued only at its visible bystry efficiency (subsiding of a pain syndrome, improvement of the general state, normalization of body temperature, improvement of indicators a wedge, blood tests other). In the absence of effect and furthermore emergence of symptoms of intoxication, strengthening of local manifestations of an inflammation, danger of transition of an infection to a vagina of sinews, cavities of joints, serous cavities, etc., an immediate operative measure irrespective of a stage of development of suppurative process is shown. Early operations prevent distribution of phlegmonous process, reduce danger of development of the systemic purulent infection, purulent fusion of fabrics and emergence of extensive necroses.
Operations at an epifastsi lny F. can be carried out under an inhalation anesthesia (see) or an intravenous anesthesia (see. Not inhalation anesthesia). At deep intermuscular, paraossa lny and interorgan F. (especially localized in zabryutpinny space, a mediastinum, etc.), the demanding careful audit, opening of purulent zatek and other manipulations, use of an endotracheal anesthesia with relaxants is shown, and also infusions of anti-toxic it is low - or high-molecular means, depending on indicators of a hemodynamics.
Quick accesses for opening F. shall be anatomically proved; on the one hand, they shall ensure anatomic safety of neurovascular bunches and vitals, with another — to create good conditions for outflow of exudate in the postoperative period. During the opening hypodermic, subfascial and intermuscular F. it is possible to be guided by the standard scheme of typical cuts (fig. 1). Open with a wide section the struck kletchatochny space (it is desirable in the place of a softening of infiltrate), getting into depth to border of infiltrirovanny fabrics (in cases of a deep arrangement suppurating the place of its accumulation previously define by a puncture). Then a stupid way move apart fabrics and empty an abscess; a finger inspect a cavity of an abscess, destroy in it crossing points and delete nekrotizirovanny fabrics. In the presence of purulent zatek, pockets, drainage to-rykh is not provided with one section, make additional cuts or counteropenings (see) in the foot of an abscess. Good drainage (see) is reached by introduction to the opened cavity of phlegmon through counteropenings of rubber drainages with many openings, to-rye stack on a bottom of a wound and through them carry out long washing of a cavity solutions of antibiotics (fig. 2). The wound to the bottom rykhlo is filled with gauze tampons. After correctly performed operation in the next days it is liquidated it is purulent-rezor-btivnaya fever, the general condition of the patient improves, the phenomena of intoxication decrease, indicators a lab improve. researches (wedge, analyses of urine and blood, biochemical indicators of a functional condition of a liver, kidneys, etc.). Postoperative treatment putrefactive F is perspective. with an extensive necrosis of skin and hypodermic cellulose in conditions gnotobiol. isolation (see. The managed abakterial-ny environment).
In sovr. to surgical practice after subsiding of inflammatory process (standard temperature of a body, satisfactory condition of the patient, normalization of indicators of a gemogramma, full clarification of a wound from nekrotiziro bathing fabrics, existence of healthy granulations, lack of bacterial impurity of a wound) apply imposing on a wound of secondary seams (see. Secondary seam).
For treatment of ligneous phlegmon Reklya is used by physiotherapeutic procedures (magnetic field, UVCh, sollyuks), and also sulfanamide drugs and antibiotics. In the absence of effect of conservative treatment deep cuts through all infiltrate with an exposure of the struck intermuscular spaces are shown. An operative measure is especially necessary when infiltrate complicates swallowing and breath. At cuts pus is not always found, however in a wound secret activators can be revealed that gives the chance to carry out their identification and to define sensitivity to antibiotics.
Treatment of phlegmons of hollow bodies — operational in a combination with the parenteral administration of high doses of antibiotics of a broad spectrum of activity and measures directed to increase in immunobiological forces of an organism. At limited distribution of process in a wall of a stomach or a gut the resection of an affected area is shown. At widespread process and serious condition of the patient the affected area of body is delimited tampons (see the Tamponade) and bring to it drainage tubes (see Drainage), and the struck loop of a gut is quite often removed outside; enter solution of antibiotics into surrounding cellulose, the found abscesses open and drain. The phlegmonous changed gall bladder is deleted (see the Cholecystectomia), and at very serious condition of the patient or extensive defeat of surrounding fabrics are limited to a cholecystostomy (see), by the image which is the most sparing edges it can be made through laparoskop. The phlegmonous changed worm-shaped shoot is deleted (see Appendectomy).
Fig. 1. The diagrammatic representation of typical cuts at various localizations of hypodermic, subfascial and intermuscular phlegmons.
Forecast. At timely and correct treatment of uncomplicated
Fig. 2. Diagrammatic representation of half-open long postoperative drainage of a cavity of phlegmon: 1 — the drainages with openings entered into a cavity of phlegmon (it is shown in dark color) through counteropenings; 2 — a gauze tampon, rykhlo filling the opened cavity of phlegmon (black shooters showed the direction of current of the washing-out antiseptic solution, the white arrow showed the direction in which outflow of contents is carried out).
superficial F. forecast favorable. At progressing deep and interorgan Fm submucosal F., serous F., and also complicated F. the forecast is quite often adverse. The forecast at ligneous phlegmon to Rekl, as a rule, favorable.
PHLEGMON of NEWBORNS 347
Prevention. To measures of prevention F. belong the prevention of open injuries on production and in life; immediate rendering medical aid (processing by antiseptic agents, imposing of a bandage) to persons, but luchivshy wounds, including so-called microtraumas (see); timely treatment of patients with purulent processes; identification and elimination of the centers of the masked infection, etc.
F. various localization — see also in articles devoted to bodies, separate parts of a body, topographical areas of a body, e.g. Head, Duodenum, Lumbar area.
V. F. Sketches of purulent surgery, JI., 1956; Zhakov M. N. Acute purulent inflammatory diseases of the person and neck and their treatment, M., 1969; Kurban-galeev S. M., Yelets O. I. and Zykov A. A. Topical issues of purulent surgery, page 215, JI., 1977; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 6, page 398, 429, M., 1962; Popkirov S. It is purulent - septic surgery, the lane with bolg., Sofia, 1977; V. I Pods. Purulent surgery, M., 1967; Struch
k V. I., Grigoryan A. V. and Gostishchev V. K. Purulent wound, page 17, M., 1975; V. I. pods, etc. Proteolytic enzymes in purulent surgery, page 131, etc., M., 1970.
V. M. Buyanov; N. K. Permyakov, G. M. Mogilevsky (stalemate. An.).