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ABSCESS : Types and Methods of Treatment

An abscess is a cavity filled with pus and lined by a pyogenic membrane. There are three varieties of abscess :

Pyogenic abscess (commonest)
Pyaemic abscess
Cold abscess

Sometimes, the abscess cavity persists, which becomes firm and contains sterile pus. The firmness is due to thickness of its wall. This is known as 'antibioma'. This is due to continuous administration of antibiotics. The lump may even be hard, when it may mimic a carcinomatous lump.

Basic principle of treatment of an abscess is:

to drain the pus
to send the pus for culture and sensitivity test, and
to give proper antibiotic

Drainage of a pus can be obtained by free incision or by Hilton's method. Hilton's method is chosen when there are plenty of important structures like nerves and vessels around the abscess cavity, which are liable to be injured.

Incision should be made parallel to important structures like nerves and vessels, while the muscle should be incised along the line of the fibers.

Counter incision : When the most prominent part is not the most dependent part, complete drainage of the pus is not possible with single incision. So, counter incision is required at the most dependent part to facilitate the drainage by gravity.

A corrugated rubber drain is usually used for drainage of an abscess cavity. When counter incision is used, the drain extends from the first incision to the counter incision.

Pyaemic Abscess : In this condition, multiple abscesses develop from infected emboli in pyaemia. Pyaemia is a condition characterized by formation of secondary foci of suppuration in various parts of the body. These foci are caused by lodgement of septic emboli formed as a result of breaking up of an infected thrombus.

Pyaemia is also seen in acute appendicitis when the infective emboli pass in to the portal venous system and cause portal vein pyaemia. (forming multiple pyaemic liver abscesses)

Bacteremia Vs Septicemia :

Bacteremia is the condition in which bacteria circulate in the blood stream. The organisms are usually very rapidly destroyed.

Septicemia is the development of certain clinical manifestations due to liberations of toxins by the bacteria in the blood stream. The manifestations include pyrexia, rigors, hypotension, petechial hemorrhages, etc. In absence of systemic disease, B hemolytic streptococci.

Toxaemia : Condition in which toxins, either chemical or bacterial blood circulate in the blood stream

Cold Abscess: This abscess is cold and non reacting in nature. It does not produce hot and painful abscess as seen in pyogenic abscess. It is almost always a sequel of tubercular infection anywhere in the body, commonly in the lymph nodes, bone and joint. Caseation of the lymph nodes forms the cold abscess. The commonest sites are the neck and axilla.

Once the diagnosis is established, full antitubercular regime should be started. An incision should not be made on a cold abscess for drainage, as it almost always invites secondary infection and forms a persistent sinus. Aspiration may be attempted through the normal surrounding skin and not the most prominent and most dependent part as this will innvariably cause sinus formation.

BPKIHS Anatomy Past Questions for MBBS and BDS Second Year - Basic Sciences : Central Nervous System

Anatomy
2016
1. Draw a well-labeled diagram of the transverse section of midbrain at the level of the superior colliculus. 5
2. Write down the blood supply of internal capsule with suitable diagram. 5
3. Mention the blood vessels forming the Circle of Willis along with a diagram. 5
4. Name the lobes of the cerebral cortex. Name the functional areas & the functions related to any one lobe of the cerebral cortex. 5
5. Write a short note on: 2x5=10
a. Medial Medullary Syndrome
b. Nuclei of thalamus

2015
1. Draw a well-labeled diagram of T.S. of midbrain at the level of the superior colliculus. 5
2. Draw a well-labeled diagram of T.S. of spinal cord showing ascending and descending tracts. 5
3. Draw a labeled histological diagram of cerebrum.5
4. Mention nuclei of thalamus with suitable diagram. 5
5. Draw a labeled diagram of Circle of Willis. 5
6. Draw a labeled diagram of the floor of the fourth ventricle. 5

2014
1. Draw a labeled diagram of blood supply of spinal cord. 5
2. Draw a labeled diagram of T.S. of medulla at the level of secondary decussation. 5
3. Enumerate the structures present on the floor of the fourth ventricle with suitable diagram. 5
4. What is corpus callosum? Illustrate with the help of a diagram the different lobe of the cerebral hemisphere. 5
5. Draw a labeled diagram of the circle of Willis. 5
6. Mention the arterial supply of internal capsule. 5
2013
1. Draw a well-labeled diagram of the floor of the fourth ventricle. 5
2. Write blood supply of Internal Capsule. 5
3. Write about Medial lemniscus. 5
4. Write about the White matter of cerebrum. 5
5. Write about the Lateral Medullary Syndrome. 5
6. Draw a labeled diagram of the transverse section of midbrain at the level of the superior colliculus. 5

2012
1. Draw a labeled diagram of the floor of the 4th ventricle. What is neurobiotaxis? 5
2. Name the nuclei of the cerebellum with the phylogenetic origin and draw a labeled diagram of these nuclei. 4+1=5
3. With well-labeled diagram write briefly about the floor of the fourth ventricle. 5
4. What are the structures present in the floor of 4th ventricle? 2.5
5. Write the venous drainage of the cerebrum. 2.5
6. Draw a labeled diagram of Circle of Willis. 5
7. What are the functions of Broadman’s areas 39 and 40? Where are they located? 5

2011
1. Write briefly on: 3x5=15
a. Lateral spinothalamic tract.
b. Red Nucleus.
c. Lateral medullary syndrome

2. Enumerate the deep cerebellar nuclei and write the features of the cerebellar syndrome. 2+3=5
3. Illustrate with a labeled diagram the:
a. Arterial supply of superolateral surface of the cerebrum. 5
b. Structures at the floor of 4th ventricle. 5

Inspirational Story : Struggle is necessary for Success

A man found a cocoon of a butterfly. One day a small opening appeared, he sat and watched the butterfly for several hours as it struggled to force its body through that little hole. Then it seemed to stop making any progress. It appeared as if it had gotten as far as it could and it could go no further.

Then the man decided to help the butterfly, so he took a pair of scissors and snipped off the remaining bit of the cocoon. The butterfly then emerged easily. But it had a swollen body and small, shriveled wings. The man continued to watch the butterfly because he expected that, at any moment, the wings would enlarge and expand to be able to support the body, which would contract in time. Neither happened! In fact, the butterfly spent the rest of its life crawling around with a swollen body and shriveled wings. It never was able to fly.
What the man in his kindness and haste did not understand was that the restricting cocoon and the struggle required for the butterfly to get through the tiny opening were nature’s way of forcing fluid from the body of the butterfly into its wings so that it would be ready for flight once it achieved its freedom from the cocoon.

Sometimes struggles are exactly what we need in our life. If we were allowed to go through our life without any obstacles, it would cripple us. We would not be as strong as what we could have been. And we could never fly.

Transform your greatest weakness into your greatest strength

Weakness to Strength

There was once a 10 year old boy who decided to study judo despite the fact that he had lost his left arm in a devastating car accident. The boy began lessons with an old Japanese judo master. The boy was doing well, so he couldn’t understand why, after three months of training, the master had taught him only one move.

“Sensei,” the boy finally said, “shouldn’t I be learning more moves?”

“This is the only move you know, but this is the only move you’ll ever need to know,” the sensei replied.

Not quite understanding, but believing in his teacher, the boy kept training.
Several months later, the sensei took the boy to his first tournament. Surprising himself, the boy easily won his first two matches. The third match proved to be more difficult, but after some time, his opponent became impatient and charged; the boy deftly used his one move to win the match.
Still amazed by his success, the boy was now in the finals. This time, his opponent was bigger, stronger, and more experienced. For a while, the boy appeared to be overmatched. Concerned that the boy might get hurt, the referee called a timeout. He was about to stop the match when the sensei intervened.

“No,” the sensei insisted, “Let him continue.”

Soon after the match resumed, his opponent made a critical mistake: he dropped his guard. Instantly, the boy used his move to pin him. The boy had won the match and the tournament. He was the champion.

On the way home, the boy and sensei reviewed every move in each and every match. Then the boy summoned the courage to ask what was really on his mind.

“Sensei, how did I win the tournament with only one move?”

“You won for two reasons,” the sensei answered. “First, you’ve almost mastered one of the most difficult throws in all of judo. Second, the only known defense for that move is for your opponent to grab your left arm.”

The boy’s biggest weakness had become his biggest strength.

Gas Gangrene

Gas gangrene is a rapid spreading infective gangrene of the muscles characterized by collection of gas in the muscles and subcutaneous tissue. It is also called "Clostridial myonecrosis".

Gas Gangrene is most likely to develop in wounds where there has been extensive laceration or devitalization of muscle mass with gross contamination of the wound by soil and other foreign bodies.

Clostridial organisms can be divided into two groups - namely Saccharolytic and Proteolytic. Of the Saccharolytic group of anaerobes, Clostridium perfringes (Cl. welchii) plays the main part in gas gangrene.

Other organisms that cause gas gangrene are Clostridium oedematiens, Clostridium septicum, Clostridium histolyticum, and Clostridium bifermentans.

Two important factors necessary for the formation of gas gangrene include :

Entry of Clostridial organisms, particularly Clostridium perfringes (Cl. welchii), and
Anaerobic conditions within the wound

Diabetes and other occlusive arterial diseases predispose to gas gangrene.

The various exotoxins produced by these organisms (particularly Clostridium welchii) are:


Alpha toxin (Lecithinase)	Is hemolytic, and splits lecithin to phosphocholine and diglyceride.
Collagenase	Is a proteinase and breaks down collagen
Hyaluronidase	Breaks down hyaluronic acid
Theta toxin	Is hemolytic, lethal and necrotic
Leucocidin	Kills the leucocytes

Clostridial invasion affects the whole of the involved muscle from origin to insertion producing a foul smelling necrosis of the muscle which becomes dull red to green and ultimately black in appearance.
The muscle becomes green to black due to the action of the sulphurated hydrogen on iron liberated from broken down muscle hemoglobin. The gas is chiefly hydrogen, being odorless in the beginning, but soon it becomes fetid due to the liberation of sulphurated hydrogen (H2S), ammonia and volatile gases.

TYPES OF GAS GANGRENE


Clostridial cellulitis	Crepitant infection involving necrotic tissue, but healthy muscle is not involved and is characterized by foul smelling, seropurulent infection of a wound.
Single muscle type	Limited to one muscle only
Group type	Limited to one group of muscles, eg. extensors of the thigh
Massive type	Involves almost whole muscle mass of one limb
Fulminating type	Spreads very rapidly even beyond the limb, associated with intense toxemia

The most characteristic feature of gas gangrene is profuse discharge of brownish, foul smelling fluid between the sutures and the presence of crepitus due to presence of gas in the muscle and subcutaneous tissue.
The first prophylactic step in the prevention of gas gangrene wound is excision or debridement in which all the devitalized tissues, blood clots, dead and damaged muscles and foreign bodies should be removed.

What is Gastric lavage ?

Gastric lavage, also commonly called stomach pumping or gastric irrigation, is the process of cleaning out the contents of the stomach. It has been used for over 200 years as a means of eliminating poisons from the stomach. Gastric lavage involves the passage of a tube (such as an Ewald tube) via the mouth or nose down into the stomach followed by sequential administration and removal of small volumes of liquid.

- Useful within three hours after ingestion of the poison

PROCEDURE FOR GASTRIC LAVAGE

A stomach tube (Ewald's tube or Boa's tube) or ordinary, soft, noncollapsible rubber tube of length 1.5 meter and diameter 1 cm with a glass funnel attached on one end and a mark at 50 cm from the other end (which should be rounded with lateral openings) is used
Denture must be removed and mouth gag should be placed
Patient should be in left lateral position or head hanging over the edge of the bed and face supported by assistant.
The end is lubricated with olive oil or glycerine and is slowly passed into mouth and through the pharynx and oesophagus into the stomach till the 50 cm marking.
About 1/4th liter of lukewarm water should be passed through the funnel held high above the patient's head
When funnel is empty, compress the tube below the funnel between finger and thumb and lower it below the level of stomach. the contents will be emptied by siphoning action when the pressure is released.
This first stomach contents should be preserved for chemical analysis.

Gastric lavage can be done with:
- water
- 1:5000 Potassium Permanganate (KMnO4)
- 5 % Sodium Bicarbonate (NaHCO3)
- 4 % Tannic acid
- 1 % Sodium or potassium iodide
- 0.9 % saline

Repeat the wash with 1/2 liter suitable solution till clear and odorless fluid comes out.

CONTRAINDICATIONS OF GASTRIC LAVAGE:
Absolute Contraindication:
Corrosive poisoning except for carbolic acid

Relative Contraindication:
i. Convulsant poisoning
ii. Comatose patient
iii. Volatile poison
iv. upper GIT disease
v. Patient with marked hypothermia and hemorrhagic diathesis

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