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.