The areolar tissues are less resistant than others. The streptococci in their mode of development tend to spread out that, under favorable circumstances, the streptococcic infection of the subcutaneous connective tissues becomes one of the most dangerous conditions, demanding immediate and radical surgical intervention.<Callout type="important" title="Immediate Action Required">Do not wait for pus formation before evacuating products.</Callout> The rapid development of toxins makes death from septicemia to be feared; or, short of this, there may be great destruction of tissue and subsequent loss of function. Certain regions, owing to the opportunities for infection and the arrangement of the tissues, are more likely to be affected than others; but the general symptoms and the principles of treatment are the same.<Callout type="risk" title="Introduction of New Infections">Incisions must reach the deepest layer of the affected tissues.</Callout> One peculiarity of this inflammation is that pus is often slow to form, so that when the engorged tissues are incised in the earlier stages, merely a serum exudes. It is innocent-looking, but it is toxic in the extreme.<Callout type="tip" title="Use Hot Antiseptic Poultices">For superficial phlegmon of moderate severity, hot antiseptic poultices or baths may be harmless to try.</Callout> In the case of superficial phlegmon of moderate severity, it will often be harmless to try to localize the process by the use of hot antiseptic poultices or baths, but the safest thing is free incision.<Callout type="warning" title="Avoid Wounding Important Structures">When making an incision for phlegmon of the ulnar synovial sheath, avoid wounding the palmar arch.</Callout> When the pus is reached, enlarge the incision so that the tendon may be seen the entire length of the wound. Superficially and deep, the incision must be of the same length.<Callout type="important" title="Complete Drainage">Complete drainage is indispensable for phlegmon treatment.</Callout> Operation for Phlegmon of the Ulnar Synovial Sheath. —Continuous with the synovial sheath of the flexor tendon of the little finger, the ulnar synovial sheath is larger than the radial and its suppuration more serious.<Callout type="gear" title="Thermo-cautery">Lejars recommends using the thermo-cautery for phlegmon of the neck.</Callout> Under general anesthesia several deep vertical incisions are made with the thermo-cautery with numerous punctures between. Do not go too deep over the anterior border of the sterno-mastoid, for the great vessels are there.<Callout type="important" title="Monitor Temperature Closely">Watch the temperature closely after surgery.</Callout> If it rises, there is a retention of pus, the site is not sufficiently drained, or there is a new infection.<Callout type="risk" title="Risk of Asphyxia">An infection in the floor of the mouth may spread rapidly down the neck and cause asphyxia.</Callout> Symptoms of sepsis will be aggravated in the extreme and death may rapidly supervene, either from sepsis or asphyxia.<Callout type="tip" title="Use Antistreptococcic Serum">Lejars recommends using antistreptococcic serum for phlegmon treatment.</Callout> Pack each incision and puncture with gauze saturated with peroxide of hydrogen, and cover the whole with a similar dressing and absorber cotton. The dressing must be kept saturated with the peroxide.<Callout type="warning" title="Avoid Bleeding">If some large vessels are opened and bleed too freely, ligate them.</Callout> Change the dressing and irrigate two or three times daily. To dry dressings when granulation is well under way, grafting may be necessary. In the long time necessary for repair, massage and passive motion must be given the muscles.
Key Takeaways
- Immediate surgical intervention is crucial for phlegmon treatment.
- Complete drainage is essential to prevent further complications.
- Use of antiseptic poultices or baths can be harmless but incision is safest.
- Monitoring temperature and managing bleeding are critical post-surgery steps.
Practical Tips
- Always prioritize immediate surgical intervention for phlegmon cases to avoid sepsis.
- Use hot antiseptic poultices as a temporary measure before definitive treatment.
- Ensure complete drainage by making multiple incisions when treating phlegmons of the forearm or neck.
Warnings & Risks
- Avoid introducing new infections through superficial incisions that do not reach the deepest layer of affected tissues.
- Be cautious with the use of the thermo-cautery to avoid damaging important structures like the median nerve.
- Watch for signs of asphyxia when treating infections in the floor of the mouth.
Modern Application
While the techniques described in this chapter are rooted in historical practices, the principles of immediate surgical intervention and complete drainage remain critical in modern survival medicine. The knowledge of recognizing and managing phlegmon can be invaluable in remote or resource-limited settings where timely medical care is not readily available.
Frequently Asked Questions
Q: What is the most important action to take when treating a case of phlegmon?
Immediate surgical intervention is crucial for phlegmon treatment, as it can rapidly lead to sepsis and tissue destruction if left untreated.
Q: Can hot antiseptic poultices be used in the treatment of phlegmon, or should incision always be performed?
For superficial phlegmon of moderate severity, hot antiseptic poultices or baths may be harmless to try. However, the safest thing is free incision.
Q: What are some risks associated with using the thermo-cautery for treating phlegmon?
Using the thermo-cautery can risk damaging important structures like the median nerve and requires careful application to avoid excessive bleeding.