On inspecting the fauces, a swelling about the size of a plover's egg could be seen at the back of the pharynx. On pressing this with the finger, it felt firm like a solid tumour.
The swelling was punctured with a large trocar and canula, and half an ounce of thick pus was evacuated. After the operation the breathing became quieter, and swallowing was effected without difficulty. The ab scess continued to discharge for some days and then healed. When the child left the hospital she seemed well in health, but some thickening re mained at the back of the pharynx.
In this case, the disease had lasted for two years, and was apparently the consequence of slow softening of a cheesy gland at the back of the pharynx. The cervical glands were also enlarged and caseous ; and from one of these, seated behind the angle of the jaw, a quantity of cheesy mat ter was scooped out by my colleague, Mr. Reeves.
Whatever be the length of its course, a retro-pharyngeal abscess, if un recognised, generally terminates in death. As has been before remarked, the child usually dies suffocated in a paroxysm of dyspncea, or gradually wastes away from starvation and exhaustion. Even spontaneous bursting of the abscess appears to be attended with great danger, and cases are re ported in which suffocation has been the consequence of the passage of the purulent matter into the trachea.
Diagnosis.—Amongst the various causes of dyspncea in the child, it must not be forgotten that retro-pharyngeal abscess is one ; and in every case where the breathing is difficult and stertorous, the pharynx should be ex amined as a matter of routine. If this be clone, the disease is not likely to be overlooked, for a finger passed to the back of the pharynx at once detects the presence of the abscess. Moreover, information may be some times gained from mere inspection of the neck. Any unusual prominence of the trachea, or displacement of that tube to the right or left of the middle line, suggests an extra-laryngeal cause for the dyspncea. So, also, if we find the child sitting up in bed and refusing to lie down ; or if laid down, starting up again in an access of suffocation, we should suspect external pressure upon the larynx. The more characteristic symptoms are : Stiff ness and swelling of the neck, and difficulty of swallowing, combined with orthopncea and stridulous breathing. The most characteristic sign is a swelling at the back of the pharynx, which is not, indeed, always to be seen, but can invariably be felt by digital exploration.
The disease is more likely to be misapprehended in the acute than in the chronic form ; for the violence of the symptoms, the lividity of the face, the urgency of the dyspncea, and the stertorous character of the breath ing, suggest the presence of membranous croup. But in that disease, stertor
is present from the beginning ; the dyspncea is not increased by pressure made upon the trachea, and is relieved when the head is low ; the voice rapidly becomes hoarse and then whispering ; and unless the pharynx be the seat of false membrane, there is no difficulty in swallowing.
(Edema of the glottis also presents many points of similarity with abscess of the pharynx ; but in the former case the stridor is only marked in inspiration, the expiration being noiseless ; and when the finger is passed into the throat it detects no tumour, but can feel the thickened epiglottis and the swollen ary-epiglottidean folds. Still, the two diseases may be present together ; but if a tumour can be felt at the back of the phar ynx "on digital examination, the nature of the disease cannot be doubtful.
Prognosis.—If the abscess is detected in time, the prognosis is favoura ble. When death occurs in this disease, it is usually in cases where the cause of the symptoms has been overlooked, and no attempt has been made to relieve the child by the only means which are likely to prove ef fectual. The worst cases are those in which the abscess is the consequence of careous disease of bone ; but even these may end in recovery if the matter be evacuated before the child has become exhausted.
Treatment.—In the treatment of retro-pharyngeal abscess, no time should be lost. Directly the tumour is recognised, it should be opened, whether fluctuation be present or not. In order to avoid any risk of penetration of the pus into the larynx, it is perhaps safer to use a large trocar and can ula ; but the abscess may be opened with a knife without danger if care be taken to bend the child's head promptly forwards when the incision is made. The bistoury should be guarded to within half an inch of its point by winding adhesive plaster round the blade. The opening must be made as near the middle line as possible ; and the instrument may be pushed boldly forwards, for the pus often lies at some distance from the surface. If a trocar be used, the abscess sometimes refills, and may require a second puncture after a few days.
The general health of the child must be attended to. Good diet and a certain quantity of stimulant should be allowed ; and he may take quinine and cod-liver oil. When convalescent, the patient will be benefited by a visit to the seaside.