Ludwig's angina, or phlegmonous cellulitis of the floor of the mouth, is a comparatively rare affection. It is a disease which is so rapid in its development, and is attended by symp toms so distressing in character and accompanied by such a high rate of mortality, that any addition to the literature extant upon the subject may be of interest.
Ludwig, of Stuttgart; in 1836 was the first to describe the disease in detail, hence the name.
The disease is an infection of the thick layer of loose con nective tissue which fills in the space between the symphysis of the jaw and the muscles of the floor of the mouth. This tissue is rich in lymphatics and blood-vessels, and contains the ducts of the sublingual and submaxillary glands The disease may be either primary or secondary.
Primary infection may arise from wounds or ulcerations of the floor of the mouth and carious teeth; retarded develop ment of the third molar or so-called wisdom tooth is an espe cially fruitful source of the trouble. Frequently a third molar will develop in the angle of a jaw already filled with teeth, causing pressure necrosis of the tooth and the portion of alveo lar process of the jaw forming its bed, thus giving rise to an abscess and a subsequent infection.
The secondary infections arise in conjunction with those infectious diseases which are accompanied by manifestations in the mouth, e.g., diphtheria, scarlet fever, tonsillitis, etc.
An interesting discussion has arisen as to the differentia tion of the acute infectious diseases of the larynx, pharynx, and floor of the mouth. Semon (Royal Medical and Chirurgi cal Society, London, 1895, Vol. lxxviii, pages 181-238) claims that "the various forms of acute septic inflammation of the throat and neck, hitherto considered as so many essentially different diseases, are in reality so pathologically identical that they merely represent degrees varying in virulence of one and the same process, that the question of their primary localiza tion and subsequent development depends in all probability upon accidental breaches of the protecting surface through which the pathogenic micro-organism, which causes the subse quent events, finds an entrance, and that it is absolutely im possible to draw, at any point, a definite line of demarcation be tween the purely local and the more complicated, or between the cedematous and the suppurative forms." He reports fourteen cases, all of which were of the second ary type of infection. It would seem clear, from his cases, to consider the acute septic infection of the larynx and pharynx as one and the same disease, and, so far as the character of the invading micro-organisms is concerned, the primary may be included.
However, in true angina Ludovici the course is different and the infection essentially primary. The point of entrance is in the mouth proper, and the disease manifests itself pri marily in the floor of the mouth, and secondarily in the pharynx and larynx.
The pathology so far as known is very similar, if not tical, with that of erysipelas. The organisms which have been discovered, from the researches of modern investigators, are the streptococcus and the staphylococcus. It has been gested that there is some organism which is especially virulent and active in this disease, but as yet it has not been discovered. G. Leterier (" Du Phlegmon sublingual dit Angina," These, Paris, 1893) has collected thirty-one cases with teen recoveries. This series includes cases collected from old literature, and the mortality is therefore higher than at present.
Early recognition of the disease and prompt surgical interfer ence will in all probability still further reduce the death-rate. Spontaneous cure by rupture of the abscess into the mouth may occur, but the majority will terminate fatally unless opera tion is instituted.
The symptoms are marked from the onset of the disease. They develop very rapidly and are of the greatest severity. Frequently, in a few hours after the earliest manifestation of the disease, a hard swelling will be found between the arch of the lower jaw and the hyoid bone. The swelling spreads rapidly, soon involving the neck and face in a hard, dark red, brawny induration. Respiration is soon impeded by involve ment of the deep connective tissue of the neck. The pharynx and larynx become involved, and attacks of acute dyspncea with cyanosis supervene. The swelling may spread down ward to the anterior mediastinum and on to the chest wall. Inspection of the mouth, although unsatisfactory, due to fixa tion of the jaw, will disclose the sublingual tissue to be so cedematous as to push the tongue against the roof of the mouth. In the early stage the swelling is unilateral, but soon both sides become involved, and deglutition becomes difficult or impos sible. Supervening the local condition a marked general sepsis occurs.
I. Dr. W. S., while studying in Berlin, had an acute infection of the submaxillary region arising from a necrotic and undeveloped wisdom tooth. The inflammation developed rapidly, and in twelve hours from the onset of the attack the symptoms were so marked that operation was demanded without further delay. The wisdom tooth being pried away from the last molar, fetid gas and pus escaped ; the inflammatory mass in the sub maxillary region was then incised. The symptoms rapidly sub sided, only to recur a few weeks later, when he was again operated upon and the offending tooth chiselled out.
II. Carl S., Austrian, aged twenty years. Family history good. Personal history excellent. Gastric fever at the age of six ; no venereal trouble. Uses alcohol moderately and tobacco in excess.
He worked his way to this country, and attributes his bad teeth to neglect during the voyage. He is a printer by trade, but had been a farm-hand for the three months of his residence in America. He had had toothache for four days prior to his ad mission to the German Hospital, September 29, 190o, about 8 P.M. At the time of admission there was some swelling and induration in the left submaxillary region, red and angry looking, very pain ful to touch, and interfering with the motions of the jaw. Res piration, 24; temperature, 102° F.; pulse, 86, full and bounding. Three hours after admission he awoke with a marked dyspncea and cyanosis, which partially subsided, only to recur again with increased severity. The attacks of dyspncea seemed to come in periods, and were relieved by violent voluntary inspiration. He would grasp the porch railing, extend his neck forcibly, and thus enable himself to inspire enough oxygen to last for a few minutes. The house surgeon prepared for an immediate tracheotomy, which, however, was deferred from time to time upon the ameli oration of the attacks. By 12.30 the induration and swelling had extended from the angle of the jaw on the left side to that of the right and down the neck to the clavicles. The hyoid bone and pomum Adami could not be made out. The swelling was hard, very painful, dark red, and brawny in character, not unlike that of erysipelas.
The chin was held well advanced and rigid. The jaws were separated about half an inch, and between the teeth the under surface of the tongue could be seen ; the latter being pushed upward to the hard palate by the cedematous sublingual tissue. The jaws were forced apart, disclosing a general cedema of the anterior pillars of the fauces, buccal mucous membrane, and the sublingual tissues ; the last two molars were carious, and an un developed wisdom tooth was present.
An incision was made into the cedematous sublingual tissue on both sides of the frxnum. A considerable amount of bloody serum escaped, and in a few minutes his respiration became less labored. Ice-bags were applied, and the patient returned to bed ; he slept for some hours. The temperature reached 104° F. and the pulse 118 by 5 P.M., September 30.
On October 1 the swelling had increased until it extended upward upon the face as far as the zygomatic arches and down upon the chest wall to midsternum. Fluctuation was now unmis takable for the first time just below the symphysis of the jaw. A few whiffs of chloroform were administered, and the abscess opened by an incision which went through the muscles forming the floor of the mouth. The abscess cavity extended around the entire underside of the jaw from angle to angle. The pus which escaped was extremely fetid. As this stage of the proceeding was reached, the patient ceased breathing, necessitating an immediate tracheotomy, and this in a neck with obliterated landmarks. Res piration being re-established, the operation was completed by the removal of the offending teeth. A mallet and chisel were neces sary for the extraction of the wisdom tooth. The patient reacted promptly. By the fourth day after operation two patches of im paired resonance could be made out, one in the right lung in the midaxillary line, the other at the left base. There was, however, no evidence of a frank pneumonia.
On the fifth day, a secondary abscess on the right side, ex tending from the submaxillary region to the zygomatic arch, was opened, which allowed a quantity of fetid pus to escape. Prior to the evacuation of this secondary collection deglutition had been impossible, and rectal alimentation had been resorted to. In a few hours he was able to swallow liquids freely. The tracheal tube was removed in thirty-six hours. The convalescence was progres sive despite an attack of bronchitis. The after-treatment consisted of iron, quinine, and forced nourishment.
As a result of the inflammation of the larynx, aphonia has resulted. The condition of his larynx (as reported by the laryn gologist) is as follows: "The larynx shows evidence of an at tack of perichondritis. The vocal cords are hidden by the greatly swollen and thickened ventricular bands. The arytenoid cartil ages are also obscured by swollen mucous membrane which also involves the interarytenoid space. There appears to be no paraly sis of the laryngeal muscles, but their normal action in phonation it.: prevented by the greatly thickened condition about them. Directly in the centre of the laryngeal opening a passage sufficient for respiration leads down to the trachea, between the swollen ventricular bands." The pathological report states the bacteriological findings as follows : "Examination was made of the patient's blood and of pus from the wound, both taken October 2, 19o0. The blood was re moved from the median cephalic vein by means of an aseptic hypodermic needle after aseptic incision of the skin overlying the vein. A moderate quantity of blood was introduced into six bouillon tubes and four agar tubes. These were examined on several occasions, but all remained sterile at the end of ten days. From the pus cover-slip preparations were made and several bouillon tubes and agar tubes were inoculated. The cover-slip preparations revealed staphylococci and streptococci. The inocu lated tubes also revealed streptococci and staphylococci ; the latter by further culture methods proved to be the staphylococcus pyo genes aureus. On October 6 another examination was made of the pus from the wound, cover-slip preparations and inoculations again being utilized. These again revealed the staphylococcus pyogenes aureus and the streptococcus pyogenes. The latter grew both in short chains as well as in long chains, many of them being excessively long. Blood count : Hxmoglobin, 63 per cent. ; eryth rocytes, 4,630,000 ; leucocytes, There is another lesson to be learned from a study of Case II. The character and intensity of the symptoms and the destructive tendency of the inflammation lead to the isola tion of the patient. The pathological findings indicate that the disease is in all probability erysipelatous in character, and therefore, in an active surgical hospital, these cases should be isolated.