Ludwig angina: rapidly progressive gangrenous bilateral cellulitis of the submandibular space and soft tissues of the neck with risk of life-threatening airway compromise. Ludwig angina can rapidly lead to an airway obstruction and death with a mortality rate of up to 50% in untreated cases and 8% for treated disease. [see LITFL CCC]
The condition is named after the German physician Wilhelm Frederick von Ludwig (1790–1865) following his 1836 description
History of Ludwig angina
Early descriptions of deep neck infections date back to Hippocrates and Galen.
1769 – John Fothergill (1712–1780)
Those who were seized with it, first complained of a pain or soreness in the thorat, with a stiffness of the neck, an uneasiness on moving it, as if a cord was twisted about it, a difficulty in swallowing, and frequently in breathing also, with a disagreeable fetid smell and taste.
The voice was hoarse and obscure; not as in a common cold, but as in those people who have venereal ulcers in the throat.
The neck and throat soon after began to swell externally (…) About the fourth day this tumour was generally grown very large, and the white places in the fauces began to turn black; a putrid corrosive Sanies was discharged by the mouth, and nostrils; the breath grew extremely offensive.
Respiration, if hitherto not much affected, now became difficult, and the patient expired in a very short time.Fothergill, 1769
1822 – George Gregory (1790-1853) Physician to the Small-Pox and Vaccination Hospital. cynanche (Greek: kyōn “dog” – ankhein “to strangle”; “dog collar”)
It has never occurred to myself to witness anything at all similar to it, either before or since, nor have I been able to ascertain that in the practice of any of my professional friends, one analogous case has ever presented itself. The disease consisted in an extensive inflammation of the cellular membrane of the neck and anterior mediastinum, of a highly malignant character. Its course was rapid, and the symptoms which attended it were of unusual severity. It bore, in the first instance, the appearance of a rheumatic affection of the joints of the cervical vertebrae.
Ann Jones, 25 years of age, housemaid, was attacked on Tuesday, February 13, 1821, with feverish symptoms and pains of the back part of the neck, resembling rheumatism…She had a considerable degree of fever, attended with great difficulty of swallowing. There was swelling, hardness, and some tenderness of the external parts of the throat. The swelling and tenderness extended round the neck on each side, but were chiefly felt and complained of at the junction of the clavicles with the sternum…After a great deal of suffering, she died on Monday, February 19th, seven days from the invasion of the disease.
To this singular variety of quinsy I have ventured to apply the term cynanche cellularis, from a belief that it has not yet received anymore appropriate appellation. An extensive acquaintance with the works of the old authors might possibly have furnished me with cases offering an exact parallel to the one now detailed, but hitherto I have only succeeded in detecting one or two, which appear to resemble it in some of its characterGregory 1822
1836 – Willhem Frederick von Ludwig described five patients with pronounced neck swelling that progressed rapidly to involve the tissues between the larynx and the floor of the mouth. “gangrenous indurations of the connective tissues of the neck that advanced to involve the tissues that cover the small muscles between the larynx and the floor of the mouth”.
His first patient was Queen Catherine of Württemberg.
Fieberbewegungen mit vielem Frösteln, ziehenden Kopfschmerzen, Mattigkeit, etwas gestörtem Appetit, (…) mässiger Beschwerde im Schlucken (…) eine härtliche Geschwulst und zwar gewöhnlich in dem Zellgewebe, welches die Submaxillar-Drüse umgibt.
Diese harte Zellgewebe-Geschwulst schreitet (…) zunächst unter der Kinnlade bis an das Kinn, und bis über den Kehlkopf herab, nicht selten auch rückwärts bis über das Zellgewebe der Parotis fort.
Die Fähigkeit den Mund zu öffnen ist sehr vermindert und schmerzhaft; (…) die Sprache etwas erschwert.
Die Gruppe der Zufälle verfolgt nun in reissender Schnelligkeit den Gang eines putrid-typhosen Processes und in (…) dem 10. bis 12. vom Beginn der Krankheit, erfolgt der Tod.
Unter denjenigen Fällen, in welchen die Sektion der Verstorbenen gestattet war, zeigte sich (…) unter dem Platysmamyoides und in allen seinen Schichten, (…) eine grauschwärzliche, kaum noch cohaerente, von Luftblassen und theils grünlicht, theils graubrauner Jauche durchdrungene Masse darstellend
Fevers with much rigoring, tearing headaches, lethargy, somewhat disturbed appettite (…) significant difficulty in swallowing (…) a solid swelling, commonly in the soft tissue which surrounds the submaxillary gland.
This hard connective tissue swelling spreads (…) under the mandible up to the chin, and down towards the larynx, not uncommonly also posteriorly over the tissue of the Parotis.
The ability to open the mouth is much reduced, and painful (…) the speech somewhat impeded.
This group of symptoms now rapidly undergoes a putrid-typhoid process and (…) in the 10th-12th day of the illness, death follows.
In those cases, where autopsy was permitted (…) there was to be found, under the Platysmamyoides and in all it’s layers, (…) a gray-blackish, barely coherent mass, perforated by air cells and partly green, partly grey-brown excrement.
1837 – Ludwig’s Stuttgart colleague, Dr. Camerer in Langeuau further highlighted the description by Ludwig, though fell short of formal eponymous attribution
Auch ich hatte diese Form von Hals-Entzündung früher nie beobachtet und sie unterscheidet sich wirklich von allen uns bekannten Hals-Entzündungen durch die schon von Herrn Leibmedicus von Ludwig aufgeführte eigentlich pathognomische Merkmale, als namentlich die eigene hölzerne Härte der Zellgewebs-Geschwulst, und dann das successive Fortschreiten dieser Geschwulst von einem Theil des Halses zum andern, so sehr, dass man sie als eine eigene, von andern verschiedene Form von Hals-Entzündung anerkennen muss.
I too, had never observed this form of neck inflammation before, and it certainly does distinguish itself from all known inflammations of the neck by the particular pathognomic features already detailed by Mr. Leibmedicus von Ludwig, namely the wooden hardness of the tissue swelling, and then the successive progression of the swelling from one part of the neck to the other, such that one must recognize it as it’s own, separate form of neck inflammation
Angina Ludovici (Latin angere “to throttle, torment”)
1890 – William Morrant Baker (1839 – 1896)
The name by which the several forms of submaxillary cellulitis have been chiefly known of late years (angina Ludovici) is an unfortunate one. It has the disadvantage, common to all cases in which a disease is named after its supposed first observer, of giving no clue to the nature or site of the malady; and, in this instance, the term is not appropriate in any sense, inasmuch as Ludwig of Stuttgart, after whom it is named, was not the first author who described it. His description of the disease, for which he proposed the term “gangrenous induration of the cellular tissue of the neck,” appeared in the year 1836; but a well-marked example of the affection had been recorded some years previously (1822) by Dr. GregoryBaker 1890
- George Gregory (1790-1853)
- Wilhelm Frederick von Ludwig (1790–1865)
- William Morrant Baker (1839 – 1896)
- Angina Ludovici, Ludwig’s angina
- Cynanche cellularis of Gregory
- Fothergill J. An account of the putrid sore throat. 1769
- Gregory G. Case of Cynanche Cellularis With Remarks. The London medical and physical journal. 1822; 48: 287-290
- Von Ludwig WF. Über eine in neuerer Zeit wiederholt hier vorgekommene Form von Halsentzündung. Medicinisches Correspondenzblatt des Württembergischen ärztlichen Vereins, Stuttgart, 1836; 6(4): 21–25.
- Recherches sur une espèce particulière d’angine. Observation du Docteur Ludwig. Gazette médicale de Paris. 1836; 4(37): 577-581
- Ludwig WF. Ueber eine neue Art von Halsentzündung, Schmidt’s Jahrbücher 1837; 15(35): 25-27
- Camerer. Ein Beitrag zur Geschichte derjenigen Form von Halsentzündung welche Herr Leibmedicus v. Ludwig zuerst beschrieben hat. Medicinisches Correspondenzblatt des Württembergischen ärztlichen Vereins, Stuttgart, 1837; 7(10): 73-78.
- Murchison F. A Note on Angina Ludovici. Br Med J. 1875; 2(782): 778-779
- Doig A. Angina Ludovici. Br Med J. 1876; 1(798): 475-476
- Baker WM. Submaxillary cellulitis: syn. cynanche cellularis of Gregory, angina externa, angina Ludovici, cynanche sublingualis rheumatico-typhoides. 1890
- Ross GG. VII. Angina Ludovici. Ann Surg. 1901; 33(6): 720-725
- Burke J. Angina Ludovici: a translation, together with a biography of Wilhelm Frederick von Ludwig. Bulletin of the History of Medicine. 1939; 7(9): 1115–1126.
- McCaskey CH. Ludwig’s angina. Arch Otolaryngol. 1942; 36(4): 467-472
- Hall SF. Ludwig’s-like angina (pseudo-angina Ludovici). J Otolaryngol. 1984; 13(5): 321-324
- Nguyen VD, Potter JL, Hersh-Schick MR. Ludwig angina: an uncommon and potentially lethal neck infection. AJNR Am J Neuroradiol. 1992; 13(1): 215-219
- Hulme P. Ludwig’s Angina. St Emlyn’s
- Nickson C. Ludwig angina. LITFL CCC
the names behind the name