Michael Patkin's
website
Publication history, Reflections & comments
Most doctors are concerned- with the treatment of inflammation every day of their working lives. More common than congenital, vascular or neoplastic disease and perhaps even trauma, it may take the-form of paronychia, pneumonia or cerebral abscess among its innumerable forms. The treatment of- inflammatory conditions has been revolutionised since the introduction of antibiotics, the practical outcome of Paul Ehrlich's "magic bullets" which he envisaged at the turn of the century. Probably for this reason it has become common to neglect the other principles of treatment, with a consequent impairment of the results obtained in the day-today work of medicine.
Therefore it is important to restate these principles from time to time. What follows is an attempt to list them completely, with qualifications as to their appropriate place.
It is not enough to diagnose, say, acute cholecystitis. To complete this diagnosis in a patient, it is necessary to qualify it in a number of ways, in particular, the stage and severity of the disease, the degree of local peritonitis, whether an empyema is forming, and the general condition of the patient with regard to his usual health, the degree of toxaemia and his state of hydration. In addition there may be the complication of biliary obstruction by oedema or by stone.
Similarly, acute unilateral pyelonephritis must be further defined regarding the severity of the infection, the causal organisms (and their antibiotic sensitivities) and any anatomical abnormality present. One surgeon has taught that a diagnosis must be " anatomical, pathological, and bacteriological."
2. Rest the patient, rest the part
Over 100 years ago John Hilton emphasised the importance of decreasing 'activity of a part affected by inflammatory disease. He wrote largely of resting the hip-joint when it' was affected by tuberculosis, but the same principle applies in other cases -the low residue diet for the patient with colitis, mental rest for the patient with encephalitis, or the small plaster splint for the pulp space infection of a finger.
In conjunction with other measures, antibiotics have a great part to play in the modern treatment of most serious infections, but this is a subject very often discussed elsewhere. Attempts to give anti-inflammatory or fibrinolytic agents with them are not completely accepted.
" If there is pus, let 'it out." Once pus has formed, it is unlikely that the patient will recover quickly unless it is removed, usually by open drainage and less often by aspiration. Most doctors who have worked in a casualty department would be surprised by a case of breast abscess or. even "mastitis" accompanied by fever, that has resolved without drainage by use of antibiotics alone. Less rarely, there is resolution of a pelvic or subphrenic abscess without drainage. Pus, being liquid, usually gives rise to the sign of fluctuation if superficial.
There are, however, five classical sites of inflammation where fluctuation is a late sign, and its presence means that some unnecessary and serious extension has taken place. These sites are:
In these five superficial areas drainage should be performed after one or two days if local and general signs of inflammation persist despite treatment with antibiotics, rest, and elevation; or in the case of puerperal breast abscess, despite also careful emptying. of the breast by continued feeding or with a pump. Of course, fluctuation is- not a sign of deeply placed pus next to the kidney or in the thoracic or cranial cavities.
If pus is not drained at the right time the result is phalangeal necrosis, an anal fistula, an indurated honeycombed breast, or chronic osteomyelitis. The result is inefficient, unkind and inelegant.
Drainage is necessary for anticipated as well as actual fluid accumulations. Under the large skin flaps of a radical mastectomy it is more readily provided by suction drainage than by pressure dressings which tend to spoil the local circulation.
Finally, drainage is necessary for the normal secretions of the body, either by restoring a blocked lumen, or by establishing a proximal diversion., cholangitis is associated with a stone or a stricture of the common bile duct, and parotitis may be due to a small calculus in the parotid duct which should be removed.
5. Local factors other than pus
When a medical condition does not respond to therapy in the expected way, one must suspect an incomplete diagnosis. A persistent infective discharge may be due to a foreign body of wood, glass or metal, often showing on X-ray, and sheltering a few fertile pathogens out of reach of leucocytes. A crochet hook may catch on to a silk or nylon stitch unluckily implanted in a contaminated area. Even a chromic catgut stitch may extrude after. some weeks when used under the ankle incision for varicose veins.
Surgical exploration may show some more permanent condition such as a specific chronic inflammation or a neoplasm.
The inflammatory process itself may be responsible for severe general upset of the , patient; osteomyelitis and endocarditis can both cause anaemia requiring the patient to be' transfused. A bowel infection may deplete the patient of water, sodium, chloride and potassium to a fatal extent if not replaced.
Independent of the inflammatory process there may be a pre-existing deficiency of proteins or vitamins, or a disease such as diabetes mellitus may present to the doctor in the form of recurrent boils or some other infection. The diagnosis must be local, general, and complete.
The physical disposition of the patient is important from two points of view. The first is that of using gravity to help in the drainage of local inflammatory oedema. For example, a patient with an angry varicose ulcer improves much more quickly if put to bed with the foot of the bed elevated. Similarly, a severe hand infection is benefited by elevating the arm by some simple mechanical arrangement at the side of the bed. Where a drainage tube is used, it is best to co-operate with gravity, given a choice.
The second point about posture is that an immobile joint should be kept in a position of function, so that any remaining stiffness will be the least possible bother to the patient.
Local heat is a great comfort to the patient with a wound cellulitis, when the presence of pus is not certain. It may be applied as a kaolin poultice or an infra-red lamp.
Appendicectomy is the treatment par excellence of acute appendicitis. In other sites, excision is less often the best treatment, depending on the usual course of the disease without this line of therapy. It is usually best in acute cholecystitis and less common chronic abscess, tuberculosis of the lung, cerebral abscess, and has been used with success in treating axillary and other superficial abscesses.
10. Symptomatic treatment of the patient
The measures discussed above will make the patient more comfortable, but he may still be worried, in pain or feverish. To neglect these symptoms is to treat the patient incompletely.
Spread may be from one part to another, or from the patient to other people, so that adequate preventive measures must be taken.
Eleven principles of treating inflammatory disease have been discussed. Only some will apply to any one patient, and their indications will vary from one doctor to another, but these indications will become more accurate as they are tempered by experience.
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Contents
1. Complete the diagnosis
2. Rest to the patient, rest
to the part
3. Antibiotics
4. Drainage of pus and secretions
5. Local factors
6. General factors
7. Posture.
8. Local heat or cooling
9. Excision
10. Symptomatic
11. Prevention of spread
I'm not sure about this article. Forty five years ago much more was known about infection that a century earlier, but much less than is known today. Much wasn't understood about mechanisms of inflammation, and several new principles have been added, apart from specific practices (examples - hyperbaric oxygen for clostridial gas gangrene, cooling for the rare Bairnsdale bacillus, Mycobacterium ulcerans, . pneumococcal vaccine, and . probiotics, made popular by Russian medicine.
Prevention should be a main theme, all the way from handwashing between patients to guarding immuno.-compromised patients.
The whole tenor of the article is theoretical, centralist and prescriptive. It is not a substitute for experience. However it is useful in teaching, and it can be a powerful corrective for forgetting to drain pus, rushing to MRI before taking a decent history and examining the patient.
It needs a major re-think. However I still like the check-list approach. It's just me.
Publication notes:
Nursing Mirror, 19 November 1965
Principles of treating bacterial inflammation
This article by Michael Patkin, F.R.C..S., F.R.C.S.Ed., which originally
appeared in the British Journal. of Clinical Practice, makes many. points
which will be of value to nurses
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