Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Abscesses and Other Infections Treated by Surgery
Figure 17. Two-bottle waterseal
drainage for the pleural
space.
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Bartholin’s Abscess
Bartholin’s abscess usually occurs in a pre-existing cyst of one of the greater vestibular
glands (Bartholin’s glands) at the introitus of the vagina. A tender mass is
present deep to the labium majus on one side of the vaginal outlet. Treatment is
incision and drainage. If possible, marsupialize the infected cyst by opening the
cavity and suturing the lining to the skin. This may not be possible due to inflammation,
in which case marsupialization may be done at a later stage.
Deep Abscesses
In this section, we briefly discuss the abscesses which occur in or around the
thoracic and abdominal cavities. Diagnosis of deep abscesses has been a major challenge
and, even with modern imaging technology, diagnosis is sometimes difficult
and tentative. Where advanced technology is not available, we are forced to resort to
old and time-tested methods to achieve a diagnosis and embark on effective treatment.
Exploratory laparotomy for intra-abdominal infections is an effective diagnostic
and therapeutic technique, albeit an invasive one. We could still more often
use this “technology” in “hi-tech” centers when persistence with one imaging test
after another fails to reveal the problem and causes undue delays and adverse outcomes.
There is a useful role for ordinary X-rays.
Pulmonary
Empyema, is an abscess in the pleural space. It is much commoner in poor regions
than privileged populations due to the tardy or absent diagnosis and treatment
of pneumonias. Tuberculous empyema is also relatively more common in poor
populations. Therefore the surgeon in developing regions needs to know how to
manage these problems safely and effectively. Untreated empyema will produce a
collapsed lung trapped in fibrous tissue with eventual severe respiratory disability.
An early empyema which has not developed a thick fibrous peel can be treated
by tube thoracostomy. Diagnosis of an early empyema is based on the observation
that the fluid pus will shift when the patient is placed in lateral decubitus position
for X-ray. Drainage is necessary, using a tube and a water-seal bottle arrangement
(Fig. 17). Before inserting the intercostal tube, confirm the site and diagnosis with a
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