Dyspncea is another symptom which is usually to be noticed, and often occurs at the same time with the preceding. There appears to be direct interference with the entrance of air into the lungs, for at each inspiration the child makes a curious grating or whistling sound, and at the same time the soft parts of the chest sink in, and the epigastrium is retracted. The clyspncea varies in degree. It is subject to paroxysmal exacerbations, but in the intervals the respiration is far from tranquil. When the child lies down, the breathing is always especially difficult, and the dyspncea is therefore particularly noticeable at night. In severe cases, the patient is obliged to raise himself in bed in order to breathe with any approach to ease, and may often be found sitting up in his cot with his legs doubled beneath his body. He cries fretfully if disturbed, or invited to take either food or drink, and will not willingly make any attempt to swallow. The dyspncea is always increased when pressure is made externally upon the larynx.
Cough is usually present, generally dry and hard, but sometimes par oxysmal like the cough of pertussis. The voice has a nasal quality, espe cially if the swelling is high up in the pharynx. It is seldom hoarse if the case be uncomplicated.
Stiffness of the neck is a characteristic symptom, for movement of the head upon the shoulders is always painful. Consequently, the child holds the head in a curiously rigid way, sometimes inclined to one side or bent somewhat backwards. When the neck is examined, it is often found to be swollen. Sometimes the depression behind the angle of the jaw is obliter ated, and Mondiere points to this as a characteristic symptom. Sometimes the larynx is pushed forwards, or forced to one side out of the middle line. Pressure upon the neck or larynx is always painful.
On inspecting the throat, a swelling can usually be seen at the back of the pharynx, protruding from beneath the soft palate, and seeming to touch the back of the tongue. The mucous membrane may not be altered in colour, and often there is no redness of the fauces. On touching the swelling with the finger, it is usually felt to be soft and elastic like a sac filled with fluid, but may feel firm like a solid growth. The finger should be passed round the borders of the prominence so as to define its limits. The swelling does not always come into view when the mouth is opened ; for not only is it often obscured by more or less frothy mucus, but its situ ation may be such that it is not readily discovered. If, then, we suspect its existence, the finger should be rapidly passed upwards to the back of the nose, and downwards behind the glottis. By this means the position of the abscess can usually be ascertained.
The above symptoms are to be discovered in most cases of the disease ; but the course and form of the illness vary greatly according to whether the suppuration is an acute or chronic lesion.
In an acute suppuration behind the pharynx the symptoms are very much more pressing and severe than in the more chronic form of retro pharyngeal abscess. The disease generally begins with high fever, severe
headache, and vomiting. After a few days, stiffness of the muscles of the neck is noticed, with a peculiar fixed position of the head, and there may be swelling of the neck and great tenderness. In some cases, the stiffness extends to the muscles of the jaw, so that the mouth can be opened only imperfectly. At the same time, or soon afterwards, there is difficulty in swallowing, and the breathing is laboured and stertorous. If the child is laid clown these symptoms are increased, and often the recumbent position induces a state of somnolence approaching to stupor. If the symptoms are not relieved, the condition of the child becomes more and more distressed. His face is swollen and livid, and the jugular veins are prominent. He lingers for a few days in this state, and then dies, exhausted from inanition, or suffocated in a paroxysm of dyspncea. Death is often preceded by a se ries of convulsive attacks.
In the more chronic cases, there is little or no fever, and the symptoms generally are much less urgent. There is, however, usually a noticeable interference with nutrition, and the loss of flesh is considerable.
The duration of the disease varies greatly. In some cases it runs a very acute course, and ends fatally in a fortnight or three weeks. This form is most common when the suppuration occurs as a sequel of fever. In other cases, the dyspncea and clysphagia continue for months before their true significance is realised.
A little girl, aged three years, was brought to me at the hospital for difficulty of breathing. The mother stated that two years previously, while teething, the child had suffered from an eruption on the head. This had been quickly followed by a swelling at the right side of the neck,. which, after growing larger for two months, had burst. Very shortly af terwards the breathing had been noticed to be oppressed, and the respi ration had begun to be accompanied by a peculiar whistling or rattling noise. This symptom had continued ever since, and was always worse at night. The child was said to sleep very heavily, with her eyes only partially closed. Sometimes she had seemed to have a difficulty in swal When first seen, the child was lying asleep, resting on the right side of her chest. She was sweating profusely about the head and neck. Her face was flushed, and the eyes were only partially closed. The mouth was open, and the nares were motionless in respiration. At each breath the in tercostal spaces sank in deeply, and the epigastrium was depressed. With each inspiration a peculiar grating noise was heard, which seemed to pro ceed from the throat. The expirations were less noisy, but still abnormal. The glands along the edge of the sterno-mastoid, and those below the jaw, were enlarged and painless, and the larynx and trachea seemed pushed out of the middle line to the left.