—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 the mouth should be frequently rinsed with warm antiseptic solutions. Any lesion within the mouth should receive its own proper treatment.
Carbuncles.
—Carbuncles, which appear perhaps more frequently upon the back of the neck than elsewhere, should be treated by the radical method, i. e., excision of all tissue which is evidently so involved that it will subsequently slough. Even an extensive carbuncle several inches in diameter, with numerous crater-like openings, and presenting large amounts of already necrotic tissue, is best treated in this same way. The more quickly the dead and dying tissues are removed the better for the patient. Such an operation requires an anesthetic and the free use of scissors and a sharp spoon, even the scalpel. After being freed of necrotic tissue the exposed surfaces should then be dressed with brewers’ yeast. In general, of all these phlegmons, it may be said that nowhere does the general rule elsewhere laid down in this work better apply, i. e., that pus left to itself will always do more harm than will the surgeon’s knife if judiciously used.
The various fixations of the neck by muscle spasm or muscle infiltration due to these phlegmons, i. e., the temporary forms of wryneck, will nearly always subside as infiltration disappears. Some degree of permanent contracture may follow neglected cases and may call for massage, stretching, and the use of a suitable brace.
AFFECTIONS OF THE CERVICAL LYMPH NODES.
The cervical lymphatics are abundant in number, as they need to be to serve their purpose, considering the variety and extent of the possible sources of infection, both from within and without. They become enlarged even in a trifling case of tonsillitis, while in more serious infections they participate with the surrounding tissues, but sometimes suppurate independently of them. They are involved in nearly every case of constitutional syphilis, and serve as an index of the saturation of the system with the specific poison. Treatment for the same should never be discontinued so long as they are perceptibly enlarged. They participate, then, in both the local and the constitutional infections.