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 Fig. 489

The stem is withdrawn while the finger fixes the tube. (Lejars.)

Standing in front of the patient the operator identifies the tip of the
epiglottis with the forefinger of the left hand in the pharynx, this finger
being used at the same time to raise and fix the epiglottis and also to
serve as a guide to the tip of the tube, which is passed downward
alongside it, by a maneuver similar to that by which the
laryngoscopic mirror is used in the pharynx (Fig. 487). When the tip
of the tube reaches the location behind the epiglottis the finger may
be passed a little farther downward, plugging the entrance to the
esophagus, while at the same time the handle of the instrument is so
manipulated as to bring the tube forward. With gentle movement in
the right direction it passes into the larynx (Fig. 488). It is then
pressed downward until the flanged upper end has passed the
epiglottis, after which the tube is disengaged, the handle and the
obturator withdrawn, and the upper end of the tube pressed gently
into place by the finger which still rests in the pharynx (Figs. 488,
489 and 490). During the manipulation there is almost complete
obstruction of the glottis for two or three seconds. The effort,
therefore, should be to shorten the procedure, and at no time should
it occupy more than two or three seconds. If the landmarks are not
easily recognized, and the tube is not placed at the expiration of
three seconds, the operator should discontinue for a few more
seconds in order that a few inspirations may be taken, after which he
should try again.
 Fig. 490

The finger pushes the tube into place. (Lejars.)

 Fig. 491

Withdrawal of the thread. (Lejars.)

When the tube is in place there will come ease of respiration, at

the same time violent coughing efforts, because of the irritation thus
suddenly produced. So soon as it is apparent, both to the finger in
the pharynx and from the relief of obstructive symptoms, that the
tube is in its proper place, the finger may be once more passed into
the pharynx, the tube pressed down, while the silk thread is
withdrawn, since it is not intended to leave it for more than the time
necessary to be assured that the tube will not have at once to come
out again (Fig. 491). Before removing the thread the gag should be
removed for a few moments, so that the effect of the excitement may
pass, after which it may be re-introduced for the purpose of
withdrawing the thread.
The procedure is by no means a simple nor necessarily easy one,
and it should be practised with the instruments upon the cadaver
before resorting to it on the living child.
The tube being placed it will remain to be decided by the
subsequent course of events how long it should be allowed to
remain—in some cases a few hours, in others a few days. With
young children it should remain for at least a week. The time having
arrived for its removal, the procedure is similar to that required for its
introduction. The assistants hold the child in the same position as
before, while the operator substitutes the extractor, guiding its tip
again by the sense of touch along the left index finger, which, passed
down into the pharynx, is made to discover and identify the upper
end of the metallic tube. So soon as the point of the extractor is
engaged within the tube the blades are separated and it is then
drawn out, while the finger is withdrawn along with it in order to make
its removal easier and to prevent its loss should it slip off the
instrument. Unless the patient struggles violently the whole
procedure should be conducted so as to scarcely cause the slightest
staining of the expectoration with blood.
Various causes may require abrupt removal of the tube. Thus it is
possible for its caliber to be become occluded with tenacious
secretion. This may produce a violent fit of coughing, during which
there may occur spontaneous expulsion of the tube. At any time,
when it is seen that asphyxia is increasing, or when violence of
respiratory effort would indicate obstruction within the tube, it should
be removed, cleaned, and re-introduced. After its introduction and
removal the operator should remain within easy reach for a short
time, to be sure that no unpleasant effects result and that no re-
introduction may be suddenly required. Should obstructive efforts
occur the child should be held head downward and be slapped
vigorously upon the chest. This may loosen membrane or it may
permit dislodgement of the tube and its spontaneous expulsion. The
latter may also occur during the act of vomiting.
The above description is meant especially to apply to intubation as
performed upon young children for the relief of the laryngeal
obstruction consequent upon diphtheria. It has given better results
than tracheotomy, which was the only resort previous to O’Dwyer’s
device. It is usually performed easily, and is devoid of the horrors
frequently attendant upon an emergency tracheotomy. But intubation
is not necessarily limited to children nor to cases of diphtheria. The
emplacement of such a tube may be called for at any time in cases
of threatening or actual edema of the glottis, as, for instance, from
inhalation of steam or flame. It may be advisable in other forms of
intralaryngeal disease, both acute and chronic, while individuals
suffering from laryngeal stricture or stenosis find that they can wear
an O’Dwyer tube almost constantly, not only with relief, but that they
are thereby saved from the more serious measure of opening the
trachea or removing the larynx.
Impending suffocation having been relieved by intubation, the
question of feeding arises. The principal disadvantage attendant
upon the use of the tube is partial or complete inability to swallow, for
the epiglottis does not always easily close over the tube and prevent
entrance of fluid into the larynx. It is necessary to feed patients,
especially the young, with extreme care. For this purpose there is no
food better than ice-cream, while little children should be placed
upon their backs, with the head lower than the body, and made to
swallow in this position, at least until they have been accustomed to
the presence of the tube and instinctively learn how to avoid irritation
by involuntary regulation of the act of swallowing.
 CHAPTER XLII.
THE NECK.

CONGENITAL ANOMALIES OF THE NECK.

These consist largely of defects due to arrest of development
along the lines of the branchial clefts. Necessarily of embryonic
origin, they do not reveal this until varying periods after birth,
sometimes not until old age. They consist of fistulas, opening either
externally or internally, or more commonly of cystic dilatations of the
interior portions of the original fissures. External openings are
usually seen along the sternomastoid, either in front or back of it, or
between the larynx and the clavicle. Vestiges are also present in the
shape of little tags of skin containing portions of cartilage or bone.
They frequently occur together, the tag indicating the location of the
fistula, whose opening may be found obstructed with crusts.
Internally the openings are usually found in the pharynx, perhaps in
the larynx or trachea, generally near the tonsil and base of the
tongue. An external fistula may be tested for its completeness by
injecting a colored fluid and inspecting the pharynx. The fistulous
portion is usually marked by a cord-like mass which extends inward,
usually toward the hyoid bone. Internal blind fistulas may gradually
expand and constitute one variety of the so-called pulsion diverticula
of the pharynx and upper esophagus, their dilatation being due to
accumulation of food, and gradual stretching in this way.
All of these embryonic relics are of interest because from their
small beginnings large growths may take place, constituting even
serious surgical problems. These growths may present in almost any
region of the neck and frequently extend into the mouth, where they
give rise to certain forms of ranula. Almost every cystic tumor
beneath the tongue or jaw is open to the suspicion of having an
embryonic origin. Most of these vestiges are amenable to surgical
treatment should they give rise to discomfort or trouble. The
operations required are sometimes quite extensive, as any tumors of
branchiogenic origin are especially liable to adhesions to the large
vessels; moreover, they are nearly always firm and the dissection
thus made difficult. A dermoid cyst may be evacuated and its wall or
sac destroyed or dissected out. It may then be made to heal by
packing.
Treatment.—In the treatment of fistulas of the neck, König has
advised that a curved probe be passed through the
tract to a point close to the tonsil, at which point on the inside of the
mouth or pharynx the mucous membrane is incised, a silk thread is
fastened to the end of the probe, pulled out with it, then made to
pass to the external end of the fistulous tube, which is then
invaginated and pulled back into the mouth, where it is reduced to a
short stump which is fastened to the margins of the opening of the
mucous membrane. The external wound is then made to heal as
usual. This treatment suffices for blind internal fistulas of the cervical
region.
It is a matter of great surgical importance and interest that certain
branchiogenic remnants persist in a perfectly harmless manner until
advanced life is reached, after which there take place therein
cancerous changes which convert them into the so-called cancers of
branchiogenic origin. These are too often of hopeless character by
the time they are seen by the surgeon.
Other congenital defects consist of atrophies, such, for instance,
atrophy of the sternomastoid muscle, or of certain hypertrophies
which may be unilateral or symmetrical.

WOUNDS AND INJURIES OF THE NECK.

The neck is everywhere exposed to incised and perforating
wounds, partly as the result of pure accident, too often as the result
of homicidal efforts. The most exposed parts are supplied with veins
of large caliber which connect directly with the heart, and whatever
danger there may be of entrance of air into the veins, under any
circumstances, is in this region enhanced. This entrance of air has
been regarded as a serious and often fatal accident. The writer’s
experience and research have shown that it may often occur in mild
degree with but little temporary disturbance. Should it occur the fact
will be indicated by a slight gurgling sound, with tumultuous action of
the heart, dilatation of the pupils, embarrassed breathing, and every
indication of lowered blood pressure. Every competent operator will
secure these large veins before dividing them, but if anything of this
kind should be noted during an operation, pressure or plugging of
the wound, with artificial respiration, perhaps even massage of the
heart, and tracheotomy if necessary, should be practised until the
patient has revived. If in the course of an exceedingly deep
dissection the accident can be foreseen it may be avoided by
keeping the wound filled with warm sterilized salt solution. This,
however, will seriously embarrass the operative work, as it obscures
vision.
The lower in the neck a serious wound be received, other things
being equal, the more dangerous it becomes. Thus penetrating
wounds above the larynx are of less importance than those below it.
All injuries or wounds about the larynx are not only likely to dislodge
its interior cartilages, but are especially likely to be followed by
pressure of effused blood, or the consequences of a rapid edema of
the glottis, which may prove fatal unless the trachea be opened
below. It is this fact which makes fracture of the larynx so dangerous
an injury.
A wound of the trachea rarely occurs by itself, as it lies deeply, and
it may be especially serious if vessels in this neighborhood have
been so injured that blood may be easily poured or escape into the
lungs. If the trachea be completely divided its ends will be separated
and gap, while the lower end will be drawn out with each deep
inspiration. In this way suffocation may quickly occur. In all such
cases the head should be placed lower than the body (Rose’s
position), the lungs emptied completely, the wound enlarged, and the
tracheal wound be sutured or else a tube be inserted. The treatment
must largely depend upon the number of hours which have elapsed
since its infliction, and the condition of the wound itself. In these
cases it may be assumed that such a wound is infected, therefore it
should not be closed without provision for drainage.
Any injury to the respiratory tract proper will be indicated by the
character of the expectoration and the sounds heard on auscultation.
Such injuries are likely to be complicated by a subsequent bronchitis,
pneumonia, deep abscess, or various other undesirable sequences.
Under the suggestive term “Schluck-pneumonie” the Germans have
described a condition which we describe in the term “inhalation
pneumonia.” It implies a septic type of pneumonia caused by the
passage downward of foreign material, including septic wound
secretions, which, not being expelled promptly, cause a type of
inflammation, with consolidation, which will give most of the ordinary
physical signs of pneumonia.
A rather distinct type of incised wound is that included in the term
“cut-throat.” It implies a homicidal, usually suicidal, attempt on the
part of the ignorant to sever the large vessels in the neck. This is but
rarely accomplished, the injury being done to the larynx and the
trachea and the tissues anterior to the vascular trunks. Usually
inflicted with the right hand, one side of the wound may be deeper
than the other. While the trachea is usually cut and often divided, the
injury may be to the larynx instead. At all events, a wide gash is
made and there is considerable hemorrhage, the external jugulars
being nearly always severed. By the time such a wound is seen by
the surgeon it is an infected wound and it should not be closed too
tightly. The trachea may be sutured by itself, but it will be best to
place therein a tracheal tube. Ample provision should also be made
for drainage. In some instances the wound may be left open, at least
for a few days, until it is granulating, and then be closed by deep
sutures. Care should always be given to those of desperate suicidal
intent and to the maniacal, that they do not reopen the wound in
continuation of their previous efforts. This requires careful watching.
Rupture of the trachea, either due to violent coughing or straining
efforts or to external violence, is known. It will call for tracheotomy,
because of the emphysema which will ensue. Penetrating wounds of
the large arteries and veins are always serious. When not extensive
they may be followed by diffuse or circumscribed hematoma or by
aneurysm. Nélaton is reported to have stated that it takes four
minutes for a man to bleed to death from the carotid artery, and that
two minutes should suffice for its ligation. Any injury to the vessels
should be followed by their exposure, and probably by ligation or
suture, in order to prevent the conditions above mentioned. If the
wound be low in the neck it would be proper to remove the upper
end of the sternum or to divide the sternomastoid sufficiently to
expose it.
The vertebral artery is occasionally injured, mostly in the osseous
canal through which it passes. At the base of the neck a wound at or
near its origin is an exceedingly serious injury. The same rules apply
as above.
Wounds of the large veins are supposed to be of a more serious
nature because of the possibility of inspiration of air, i. e., air
embolism. These vessels are occasionally injured during removal of
deep-seated and adherent tumors. It has been possible in some
instances to make a lateral suture of the jugular vein at the point of
injury, providing this be not too extensive. Effort at reunion of this
kind is always legitimate if the operator feel himself equal to the task.
The jugular vein is also occasionally exposed and tied low down,
then opened above the ligature, for the purpose of cleaning out its
upper portion when filled with infective thrombi, a condition
occasionally seen with mastoid abscess, etc. To open it before tying
would be a surgical mistake. By this process it is practically
obliterated as recovery ensues.
If such a muscle as the sternomastoid be partially or completely
divided muscle suture should be practised and the head and neck
kept at rest for the ensuing few days.
Injuries to the cervical nerves may be followed by peculiar and
interesting features. That of the recurrent laryngeal will cause
paralysis of the laryngeal muscles on one side, with consequent
difficulty in speech; injury to the cervical sympathetic will be followed
by dilatation of the pupils and protrusion of the eyeballs with flushing;
of the spinal accessory, by mastoid and trapezius paralysis; of the
phrenic, by paralysis of the diaphragm on one side; and of the
pneumogastric, by embarrassment of respiration, with pupillary and
abdominal symptoms, which are variable. Of all of these injuries that
to the phrenic is probably the most serious. Some years ago I
tabulated the then recorded cases of injury to the pneumogastric and
was able to show that only about 50 per cent. of such cases were
immediately or tardily fatal. The phrenic nerve is then the only one
within the neck which can scarcely be spared. Any of these nerves
when divided should be reunited by sutures, as elsewhere
described.
When any portion of the brachial plexus has been injured a
corresponding paralysis of the arm will follow. Wounds of these
nerves should be sutured at once. A distinction should be made in all
cases between hysterical anesthesia, malingering, and the actual
paralysis of injury. Sometimes the amount of callus thrown out after a
fracture of the clavicle will include a nerve of sufficient size to
produce a neurosis, usually neuralgia, or possibly a paralysis.
Excessive callus, or, in effect, the bony tumor which is thus
produced, may be removed by operation, and any entangled nerve
should be hunted out and liberated.
Pressure of a tumor upon a nerve will cause paralysis
corresponding to its degree. When this comes on gradually, even
though it involve the phrenic nerve, the consequences are not so
serious. Repeated irritation or pressure may cause paralysis, as in
the cases of the strap of letter-carriers or those who carry burdens
slung from the neck.
Injuries occur to the cervical muscles during parturition and a
hematoma of the sternomastoid in the newborn is described. The
muscle is contracted and the head bent over. It usually disappears
by resolution within a short time. This muscle is also ruptured by
violence in the adult; again, hematoma is the result, with at least
temporary torticollis, pain, and tenderness. When an abrupt division
can be recognized, exposure of the ends and muscle suture would
be indicated. At any time, in the presence of clot, it would be proper
to cut down and turn it out.
Syphilitic myositis is often seen in the sternomastoid, where it may
affect the entire muscle, transforming it into a cord-like mass, or
where it may occur as gummatous infiltration. These cases occur
without pain and without known cause save the disease itself, whose
possibility should be established by the history of the case. Again,
these muscles are sometimes contracted because of reflex
excitement from adjoining inflammatory foci. Such an affection
subsides shortly after due attention to the exciting cause, unless it
has been allowed to continue too long. Inflammation, even of the
destructive type, may be propagated to the muscles by continuity
from a neighboring suppurating focus.
Serious phlegmons of the neck may be followed by phlebitis of the
internal jugular vein, which may be recognized by the presence of a
palpable cord-like clot within its lumen. Such a condition is serious
because of the ease with which pyemia may ensue. It would be
better to expose the vein, to tie it low down, to freely excise and turn
out such a clot, than to leave it to create serious disturbance a little
later.
Of the posterior portions of the neck we have fewer injuries, and
these less serious, excepting those by which the vertebral column or
the enclosed spinal cord are injured. These injuries have been
referred to in the chapter on the Spine. A high perforating injury of
the cord, especially if it involve the medulla, is promptly fatal.
Infanticide has been produced by a long needle driven between the
occiput and the vertebræ, corresponding to the pithing of small
animals in the laboratory. An injury above the origin of the phrenic,
on one side, is not necessarily fatal. Injuries to the posterior portion
of the high cervical cord, as well as to the membranes, may be
followed by more or less atrophy of the genital organs, with
corresponding impotence, Larrey claiming that this may take place
even when the cord itself is not affected.
Ruptures of muscles and separations from their insertions or
origins are occasionally noted. The scapular muscles are
occasionally torn loose. A reflex spasm of the trapezius which
follows some of these injuries will produce a posterior form of acute
torticollis (wryneck) described in the chapter on Orthopedics
(XXXIII). The resulting deformity and stiffening might be confounded
with arthritis of the upper vertebral joints. It is to be overcome by
traction and by suitable apparatus, save in extreme cases, when
division or excision of a sufficient portion of the muscle may be
practised.
Of great interest are the blood vascular tumors of the neck, both
those of spontaneous and of traumatic origin. Large angiomas, either
of the arterial (cirsoid aneurysm) or of the mixed or venous type, are
seen about the neck. Here more than anywhere else are found
peculiar venous dilatations, especially of the smaller veins, which
form cavities in a Fig. 492
tissue that becomes
thereby almost
erectile. Should these
tumors connect with
the arteries they will
pulsate. If composed
of larger veins they
will prove quite
compressible. These
tumors should be
extirpated, care being
taken to place a
provisional or
permanent ligature
upon the large
vessels connecting
therewith before the
tumor itself is
attacked.
Occasionally the
ampullæ of these Carotid aneurysm successfully treated by complete
extirpation. (Author’s Clinic.)
growths become
sufficiently large to entitle the growths to be considered as
sanguineous cysts. The neck is also frequently the site of the smaller
varieties of these growths which constitute the ordinary nevi. (See
chapter on Tumors.)
Aneurysms of the cervical vessels are more frequently of
spontaneous than traumatic origin. They may, however, result from
contusions or penetrating injuries. While no vessel in the neck
always escapes, it is the common carotid which is more frequently
affected than the others. The general subject of aneurysm has been
considered. Care should be taken not to confuse the vascular and
pulsating goitres, or other pulsating cysts of the thyroid. It is
necessary also to distinguish aneurysmal pulsation from that which
is transmitted through a tumor overlying the vessels or which may be
seen in some of the extensive malignant tumors of the neck. When
the diagnosis of aneurysm is made the surgeon should decide what
vessel is primarily affected. This, however, is not always possible, as
an aneurysm of the vertebral artery projecting forward is liable to be
mistaken for one of some other trunk.
Aneurysm in the neck, unless very deep, and in a very unfavorable
subject, is always an indication for operation. While operation
necessarily includes ligation, either on the proximal or distal side, if
this can be practised the sac itself may be treated just as though it
were a tumor of any other character, and extirpated. I have myself
had satisfactory results by the last-mentioned procedure (Fig. 492).
The existence of laryngeal paralysis, especially unilateral, which is
not easily accounted for in other ways, should excite a suspicion of
aneurysm, with consequent pressure upon the recurrent laryngeal
nerve. Its possibility should be excluded as part of the diagnosis.
Wounds of the subclavian vessels give rise to serious hematomas
which may be converted into spurious traumatic aneurysms of
arteriovenous character. When such a tumor pulsates it is probably
connected with the subclavian artery, which should be ligated. It may
be possible to make this ligation above the clavicle, but a portion of
the sternum should be removed as well as the inner end of the
clavicle for a more complete exposure. On the right side at least the
artery can only be reached above the bone after dividing the
scalenus anticus, where a provisional ligature may be placed. After
this the sac should be incised and the vessel ligated, on either side
of it, so that the provisional ligature may be removed. On the left side
it is safe to ligate the second portion of the artery at once. The
clavicle should be divided to afford better exposure, and its ends
reunited with silver wire (Fig. 493).
 Fig. 493

Traumatic aneurysm of axillary artery.

Any open wound of the subclavian vein is a serious affair, as

bleeding will be profuse, and there is also danger of air embolism.
Immediate occlusion with an antiseptic dressing would probably
afford better prospect than any attempt to enlarge the wound and
secure the divided vessel. If the vein be thus attacked its proximal
portion should be first secured in order to avoid the entrance of air.
Meantime much of the hemorrhage from the distal end may be
prevented if pressure be made in the axilla upon the axillary vein. If
the vessel be secured both ends should be tied.
In instances of accidental injury, or that included in the removal of
large and deep tumors, the thoracic duct on the left side and the
lymphatic duct on the right have been injured or divided. It is one of
the possible dangers in performing extensive operations on the root
of the neck, especially on the left side. Its occurrence would be
indicated by oozing of the milk-like lymph. The accident has not been
frequently reported. It would render closure of the wound without
drainage impracticable, but it has been found sufficient to place a
deep packing and to rely upon the natural healing process
(granulation) by which such a wound would be gradually closed.
It may be said of vascular lesions that when it appears to be
necessary the upper part of the sternum may be resected, as it adds
little to the danger and exposes the operative field in a more
desirable way. There is no better operative method for ligation of the
innominate artery than that which includes removal of the upper end
of this bone. Incidentally it may be added that this is also justifiable in
certain penetrating wounds of the trachea and in attacking
retrosternal goitres or lesions of the thymus.

PHLEGMONS OF THE NECK.

Phlegmonous affections in the region of the neck are serious
because of the complications which may ensue. The more deeply
they lie the greater this danger. This comes not only from septic
processes which may follow veins and lymphatics, but from
burrowing of pus along and between the deeper muscle planes,
which may carry it into one of the mediastinal spaces or within the
thorax. These phlegmons may be primary, or may follow infection
spreading through the open crypts of the tonsils, or the open
pathways afforded by diseased teeth and by superficial ulcerations.
An infection of a tonsil may cause an abscess which presents
beneath the jaw, while a deep axillary abscess may be the
consequence of a phlegmon beginning in the neck. Not infrequently
they come about through the mechanism of infected lymph nodes,
which may sometimes produce multiple or extensive single
abscesses. These phlegmons occasionally follow the exanthems,
especially scarlatina, and the variety of directions in which infection
may spread from the middle ear is well known, since it may cause
phlegmon in the neck or empyema of the mastoid antrun and even
fatal disturbance within the cranium. When the resulting pus travels
downward in front of the thyroid and sternum it will appear upon the
thoracic wall; when behind the trachea and the oesophagus, or along
the large vessels of the neck, it will be seen either within the thorax
or at the root of the neck, possibly opening into the esophagus or
spreading to the axillary space. Retropharyngeal abscesses are
often the result of caries of the vertebræ, but may occur in
consequence of a deep cellulitis caused by extension from some
focus within the nasopharyngeal cavity. This is an illustration of the
rule that pus travels in the direction of least resistance.
Diagnosis.—The diagnosis of cervical phlegmons is usually not
difficult, especially when they are superficial. The ever-
present indications of redness and edema of the surface, pitting
upon pressure, tender swelling, and loss of function of the
surrounding parts, often with fixation through muscle spasm, coupled
with the general systemic disturbance, and, in desperate cases, the
indications afforded by the blood and the urine, will enable a
diagnosis to be made, usually without the use of the exploring
needle. This, however, may be employed if necessary. The same is
true in lesser degree of tuberculous collections of pus and pyoid,
which have been earlier described as “cold abscess.” Only in the
beginning of its course can any doubt arise concerning the nature of
a carbuncular process.
A somewhat typical type of deep phlegmon is often referred to as
angina and Vincent’s angina. Semon regards these manifestations
as expressions of an acute septic cellulitis which has been described
as abscess of the larynx and as erysipelas of the larynx, and which
other writers refer to as cynanche tonsillaris, acute peritonsillitis, etc.
The disease may occur in healthy individuals, more often in the
diabetic. A violent sore throat is followed by serious dysphagia, with
considerable edema of the pharynx, whose surface is of a dark-blue
color. Patients may become unable to swallow, while hoarseness
with aphonia will result from edema of the glottis. The epiglottis will
be darkly discolored, greatly tumefied, and nearly obscuring the
entrance to the larynx. Dyspnea may necessitate tracheotomy. A
light-colored false membrane may be seen in the throat. There is
always marked lymphatic involvement. The disease may be more
confined in some cases to one side. Vincent has described a
particular spirillum or bacillus which he found in some of these
instances. The infection here doubtless proceeds from the mouth or
the tonsils, its activity being due to symbiosis of various organisms. It
is to be distinguished from Ludwig’s angina, which is rather a
submaxillary affection than a retropharyngeal. It infrequently leads to
retropharyngeal abscess.
Ludwig’s angina, also called infectious submaxillary angina, is an
infectious cellulitis of the mouth. The tongue is swollen and
immovable; the mouth more or less fixed, with difficulty of
swallowing, and the condition is one of extensive infiltration, with
formation of pus, which is likely to burrow. In some of these cases
the Micrococcus tetragenus is the organism at fault. In my
experience when present it leads to a brawny infiltration which is
slow to subside or disappear.
Treatment.—The early recognition and evacuation of pus are
called for in all cervical phlegmons. The presence of
pus may be assumed before it can be recognized from external
evidence. Therefore when swelling begins to mask anatomical
outlines, or to produce difficulty of swallowing or breathing, free
external incision, with deep dissection, will prove much safer than to
leave such a case to itself. Retropharyngeal abscesses, or such
collections as may be recognized in the tonsil or in the pharynx, may
be opened from within the mouth. That there should not be too much
haste in this direction, however, was indicated to me when a well-
known surgeon plunged a bistoury into what he supposed to be an
abscess of the tonsil and found it to be an aneurysm, the patient
dying within five minutes in his office.
Early and free incision will relieve tension, and do good by a
certain amount of bloodletting, even if pus is not reached, while an
easier outlet for it will be afforded when it does form. However, the
surgeon will rarely fail to find it if he goes sufficiently deep or in the
right direction, when the existing symptoms and signs are of serious
import.
The operator should incise freely in the beginning, after which
deep dissection is best effected with some blunt instrument. The
exploring needle may afford valuable information, but if the deep
tissues be edematous we may feel quite sure of the presence of pus
in the neighborhood. Souchon has described a method of guided
dilatation which requires a series of dilating instruments, and which
will give good results. Search for pus can be made without them by
using the blade of a dissecting knife or hemostatic forceps, or the
blades of a pair of scissors to stretch a small opening. The less
tissues are cut and the more they are thus separated the better.
Perilaryngeal or peritracheal abscesses are likely to cause
dyspnea and show a tendency to extend downward along the
trachea into the thorax. In these locations they produce a peculiar
diffuse cellulitis, which was described by Dupuytren. Such
phlegmons may extend from the ear to the clavicle or from the back
of the neck to the larynx. Pus will collect in many small interspaces,
and purulent infiltration will affect many of the tissues, and may
produce gangrene. This condition has also been described by Gray-
Coley and by Hannon. The surface not infrequently seems to be
involved in erysipelas. In fact it is doubtless true that most of these
affections are of the streptococcus type, where it is impossible to
distinguish between erysipelas and cellulitis. Tracheotomy as well as
the other free incisions may be indicated. An early tracheotomy
should be made whenever suffocation threatens from any swelling or
edema. The latter occurs so suddenly that a tracheotomy should be
made early rather than wait for its necessity, especially when
patients cannot be kept under constant observation. The operation
may be done under cocaine, while the presence of the tube will then
permit the administration of one of the ordinary anesthetics without
embarrassing respiration.
All of the other phlegmons, no matter what type they assume, are
to be treated on the same general principles. If seen, however,
before incision and drainage appear these cases may be treated
locally with the compound ichthyol-mercurial ointment, or with
Credé’s silver ointment, re-inforced by hot external applications; and