A ALLIN ON IMrn-^jjflrijiigfal iUrswss. RETRO-PHARYNGEAL ABSCESS; JMtral H5istnrt| TREATMENT; STATISTICAL TABLE OF FIFTY-EIGHT CASES. BY | CHARLES M. ALLIN, M. D., RESIDENT SfRGEON OF THE NEW-YORK HOSPITAl. [REPKINTED FROM THE NEW-YORK JOURNAL OF MEDICINE.] NEW-YORK: JOHN F. TROW, PRINTER, 49 ANN-STREET. 1651. » RETRO-PHAMNGEAL ABSCESS; ITS medical history and treatment. The formation of abscess between the posterior wall of the pharynx and the cervical vertebrae is not of so rare occurrence as the very general silence of medical and surgical authors upon the subject would prepare us to believe. When we con- sider that the diseases and obstructions to which the pharynx and oesophagus are liable, have received a large share of the attention of the profession, it is not a little surprising that this affection, comparatively easy in its diagnosis, in the majority of cases, and vitally important in its results, should have so generally escaped the notice of careful observers. It is very true, that in the periodical medical publications, may be found, with reference to this subject, quite a large number of valua- ble facts and observations, the records of the practice and opinions of thinking men, but these lose much of their value by isolation and diffusion. In but one general work,* how- ever, upon the practice of medicine or surgery, which I have been able to examine, is there to be found more than a slight allusion to the occurrence of abscess in this situation, and. even there, we have only a citation of two cases, almost directly from the journals where they were originally publish- ed. In an edition of .Sir Astley ( Vxiper's lectures, published in London, in IS'21, the sources of danger in cases of abscess are * " S'okcs' and Bell's Practice of Medicine,'' Vol. 1. 4 Allin on Retro-Pharyngeal Abso-ss. enumerated, and among them, I have found the following :— "Thirdly, when not seated in parts important to life, yet by their pressure on any essential organs render the case very different. .Matter, for example, seated behind the pharynx, so as to press on the trachea, will destroy life." A similar refer- ence is made in another edition of the same lectures, by Mr. Tyrrell, and the occurrence of two cases briefly alluded to, the first of which being unrecognized, terminated fatally, the other recovered. In some of the medical dictionaries, too, similarly slight suggestions are met with. Mr. Porter, in an appendix to his very able work upon the " Surgical Patho- logy of the Larynx and Trachea" states, that he has met with purulent collections between the oesophagus and trachea, and indeed Hippocrates makes a like statement, but neither of them makes any mention of such collections behind the pha- rynx or oesophagus. One reason for this silence is, probably, to be derived from the fact, that other diseases with which the abscess is very generally associated, and which are, in truth, often its conse- quences and indices, are of so severe a character as of them- selves to absorb the entire attention of the practitioner, and are attributed, without sufficiently accurate physical examination, to the influence of other and more generally recognized causes. Hence the subject is rendered one of no small degree of inte- rest ; and it will be my endeavor, in this article, to bring to- gether as many of the facts and phenomena belonging to it as may be of practical utility, and to point out the methods by which at least relief may be afforded, and in the greater num- ber of cases, a permanent cure be effected. My attention was first attracted to an extended investiga- tion of this disease by the admission of a very interesting and instructive case into the New-York Hospital in the earl" part of the summer of 1850, the phenomena and treatment of which I had the opportunity of observing during a period of nearly three months.* In December of the same year, another case, very different in its origin, progress, and termination, from the first, and therefore of increased interest, came under my ob- * Case 47. Allin on Retro-Pharyngeal Abscess. 5 servation ;* and within a little less than two years, two other cases still have been met with in the institution. In the first of these latter cases,t the existence of the abscess was not de- tected until the post-mortem examination, the symptoms being attributed to inflammation of the larynx, and treated accord- ingly ; and in the other,! the anterior wall of the abscess was accidentally ruptured during the introduction of a prohang, the object being to apply a solution of the nitrate of silver to what were supposed to be syphilitic ulcers of the throat, the true nature of the disease having been neither recognized nor sus- pected. In addition to these, Professor Parker, of the College of Physicians and Surgeons, has met with three patients af- flicted with the disease, two of whom died,§ a cure being effected in the other case,|| after an explorative opening of the abscess. I have also had the opportunity to learn the history of two cases occurring in the private practice of Professor Al- fred C. Post, of this city, both of which wrere of the chronic variety, and associated with caries of one or more of the cer- vical vertebryj<*j7,By the kindness of Dr. YV. H. Van Buren, I have been enabled to examine a very beautiful specimen of abscess in this region, which he removed, post mortem, from the neck of a child six months old, and which is preserved in his pathological collection, in the museum attached to the Col- lege of Physicians and Surgeons. The history of the case is recorded very briefly in the minutes of the New-York Pathological Society, and published in the "New- York Journal of Medicine" for July, lSotLt-T** The earliest mention of the occurrence of abscess behind the pharynx, which 1 have seen, is to be found in the medical works (Praxeos Medicae) of Platerus, published in 1625.U This being included, 1 have encountered reports, more or less ex- tensive, of fifty-eight cases ; and among all these, only twenty- eight have been relieved or cured. This is a large mortality to attend a disease so amenable to treatment as is this, when early recognized; and there is no doubt that it is simply from the very general ignorance, or forgetfulness of its existence, * Case 49. f Case 42. J Cast 50. } Cases 43 and 55. || Case/fc. ** Casejtfy ft Cases 57 and 58. ft Case 1. 6 Allin on Retro-Pharyngeal Abscess. that the real cause of that mortality is to be derived. It is a fact worthy of notice, that in seven of the cases which re- covered, the formation of the abscess was actually completed before a thought of its existence was entertained, and a cure effected by the spontaneous or accidental opening of its cavity, rather than by any preconceived plan of treatment. These facts have led me to consider the subject a very important one, and deserving a careful investigation. In order to be prepared to comprehend many points in the diagnosis and effects of abscess in this region, it is necessary to remember the anatomical relations of the pharynx ; ante- riorly, to the tonsils, velum palati, and larynx ; laterally, to the internal carotid arteries, internal jugular veins, glosso- pharyngeal, pneumogastric, spinal accessory and hypo-glossal nerves, the superior cervical ganglion of the sympathetic nerve, and some of the deep cervical lymphatics (glandular concaten- ates) ; and posteriorly, to the five superior cervical vertebrae, with their superjacent muscles, and a few of the deep lym- phatic glands, which are prolonged backwards' between the pharynx and vertebral column.* These glands are more fre- quently found behind the pharynx in infants and children than in adults, though their presence is not confined to this •period. The situation and arrangement of the petro-pharyn- geal, occipito-pharyngeal, and deep cervical aponeuroses, to- gether with the proper fascia of the pharynx, are to be con- stantly borne in mind, as well as the loose texture of the areolar tissue, intervening between the pharynx and spine, in which the abscess has its seat. The occurrence of retro-pharyngeal abscess is confined to no one period of life. It has been met with in an infant in the first month of its existence, and in the adult of sixty years. Of the cases that have been recorded, however, the greater number were observed in children who had not reached the age of ten years. The reason for this more frequent occur- rence of abscess at this period it is somewhat difficult to as- sign; though, perhaps, some propriety may be attached to the suggestion, that, in many instances, it is attributable to a scrofu- * CloqueCs Anatomy, page 755. All in on Retro-Pharyngeal Abscess. 7 lous diathesis, of an hereditary character. This view receives support from the fact, that in nearly all these patients the dis- ease is traceable either to an inflammation, enlargement and suppuration of the lymphatic glands, behind the pharynx, or to caries of the vertebrae. The irritation and tendency to inflam- mation, always attendant upon the process of dentition, may also be referred to as influencing in some degree the com- mencement of suppurative inflammation in this neighborhood. In the consideration of this subject, two distinct forms of abscess will require attention, the acute or idiopathic, depend- ing upon a local acute inflammation, and the chronic or symptomatic, consequent upon disease primarily affecting the cervical vertebrae. These two varieties present many points of resemblance, both in their effects upon neighboring organs, and in their surgical treatment; but, at the same time, in their origin, progress, pathological conditions, and medical treatment, there are many and strongly marked distinctions. Etiology. 1. Of Acute Abscess. a. Predisposing Causes.—The conditions of the system in which abscess is liable to be formed here, are the same which predispose to their formation in other parts of the body, and do not materially differ, whether they contribute to the de- velopment of the acute or chronic form. They may be the result of -an hereditary scrofulous tendency; for, under the in- fluence of that disease, the lymphatics are particularly liable to inflammation, and that of suppurative character. In a simi- lar manner, a system affected with the poison of syphilis is pre-eminently exposed to the operation of external influences, which a strong and untainted constitution would be able to resist. Long continued habits of intemperance, also, produce an irritable, inflammatory condition of the system, and hence, abscess is not unfrequent in persons addicted to this vice. Diflicult dentition has already been referred to as another and an important predisposing cause. To these may also be add- ed that state of the system, and locally, of this region, re- 8 Allin on Retro-Pharyngcal Abscess. suiting from various cutaneous diseases, and especially those complicated with soreness of the throat, such as scarlatina, variola, and others. /3. Exciting Causes.—One of the most common exciting causes of the formation of acute abscess in this region is ex- posure to cold and damp air, followed by an inflammation in the pharynx itself, this inflammation proceeding to suppura- tion, the pus being deposited between the proper pharyngeal fascia, and the muscles of the pharynx lying upon it. Mr. Fleming, inan article upon this disease, (" Dublin Jour- nal of Medical Science," vol. 17,) asserts his belief, that a very frequent source of its origin is to be looked for in an acute in- flammation of the small lymphatics behind the pharynx. He says, " That this affection is, not unfrequently, an acute in- flammation of those glands, particularly in childhood, I am strongly disposed to think, and I am confirmed in the opinion even by the history of the very cases which I have adduced.* That those glands are only occasionally found in this situa- tion, I admit, and hence, probably, the rare occurrence of this particular form of disease ; but that they exist more frequently than is generally imagined, I am equally certain, and I also believe that those affections of the throat termed scrofulous, when engaging the back of the pharynx, and presenting deep ulcerations, are often no more than chronic suppuration and ulceration of them." In some of the recorded cases, suppurative inflammation was induced by the presence of foreign bodies in the pharynx, such as a bone of a fish, penetrating, or, as in one case,t passing entirely through the posterior wall of the pharynx, the bone it- self having been found in the cavity of the abscess at the post- mortem examination. M. Mondiere has assigned " retrocession of erysipelas of the face." as the cause of an abscess, of this kind, which came under his observation, and M. Prion, of Nantes, has also met with an instance, which he attributes to the same origin.t In the earliest of the cases at the N. Y. Hospital, to which I have alluded,§ erysipelas of the face must have coexisted with, and it is possible that it was the * Cases 23 and 24. f Case 39. } Cas?\5. § Case 42. Allin on Retro-Pharyngeal Abscess. 9 cause, direct or indirect, of the abscess. Again, the existence of stricture of the oesophagus, or of rheumatism, has been mentioned as a reason for inflammation, and acute abscess in this region. Sometimes the abscess is developed without any assignable immediate cause, as in the very interesting case re- ported by Dr. J. H. Clark, of New Jersey, in the JV. Y. Journal of Medicine, for July, 1849.* 2.— Of Chronic Abscess. a. Predisposing Causes.—These, as has already been re- marked, are of the same character with those of the acute form, and therefore, it is not necessary that they should be here repeated. /?. Exciting Causes.—Chronic abscess behind the pharynx is referable, in nearly every instance, to caries, or to tubercu- lar disease of the cervical vertebras. The process of forma- tion in psoas abscess is well understood, and as it is almost precisely identical with that connected with the upper portion of the vertebral column, it will not be advisable at present to enter into any detail with reference to it. The irritation and subsequent inflammation produced by the presence of a fish-bone, was mentioned as one cause of the acute variety of this disease. This same cause may also be, indirectly, the origin of an abscess, chronic in its formation and general characteristics, by producing, primarily, caries of one of the vertebrae. A case of this kind, the bone piercing the pharynx, and entering the body of one of the vertebrae, is recorded in the London Lancet, for June, 1847, page 581.T Having thus briefly alluded to the main circumstances, to which may be ascribed the commencement of this disease, we are prepared to enter upon the consideration of the SYMPTOMS. 1. Of the Acute Abscess.—The phenomena, which are * Case 43. f Case 39. 10 Allin on Retro-Pharyngeal Abscess. strictly peculiar to acute pharyngeal abscess, are somewhat equivocal in their nature, and it is principally by symptoms, common to this and the chronic form, that the existence of their true cause would be suspected, and accurately ascer- tained. The premonitory signs of the disease, like those of nearly all inflammatory affections of the throat, are, an unde- fined sensation of local uneasiness, stiffness in the back of the neck, accompanied with chilliness, followed, in a greater or less degree, by febrile excitement. These general symptoms are soon succeeded by pain and soreness in the throat, which pain is aggravated during the act of deglutition. Febrile ex- citement is not, in all cases, well marked, for very frequently the feeling of chilliness is continuous,* never leaving the pa- tient entirely, though more severe at one time than at another; a fact peculiar to this form of disease, if associated with the local pain just mentioned, and one that should always lead us to suspect, and endeavor to arrest, if possible, the formation of a purulent deposit in the region of the pharynx. Unfortunate- ly, it is not probable that the aid of the physician would be solicited at so early a period, for in this stage of nearly all the throat diseases, domestic remedies are called in requisition, rather than the advice of an intelligent medical man. In very young children, the commencement of the disease may be at- tended by convulsions, a fact which receives explanation in the very great preponderance of the nervous system, at this period of life; and the strong tendency to its disturbance by any un- natural source of irritation. Associated with the pain and soreness of the throat, of which I have spoken, there is not unfrequently swelling, oedematous in its character, of the an- terior and lateral portions of the neck. Sometimes this tume- faction is very extensive, and will be very liable to occupy the attention to the neglect of the actual source of danger. This symptom is also common to this disease and to oedematous laryngitis, an affection in which it is of exceedingly great im- portance that an early and accurate diagnosis should be made. As the disease advances in its course, pain and soreness of the throat are increased, a peculiar fulness about the fauces, * Case 34. Allin on Retro-Pharyngeal Abscess. 11 and a sensation as of some foreign body arrested at the base of the tongue are experienced, deglutition becomes difficult and painful, the patient complains of excessive thirst, the respira- tion, at first attended with a slight snuffle, becomes labored, irregular, sometimes hissing, at other times, stertorous or roar- ing, or accompanied with a gurgling sound, from the passage of air through the viscid mucus, which collects about the fauces; the voice is very much changed, becoming markedly nasal, and resembling that consequent upon cleft palate, a cool perspiration, more or less profuse, appears about the head, the face and surface of the body are pallid, and the pulse some- times full and forcible, but always quick and very frequent. If the disease is not recognized, and consequently is allowed to proceed, all these symptoms are rapidly aggravated. The dysphagia becomes very severe, attempts to swallow solid food proving entirely unsuccessful, and even fluids taken into the mouth, being immediately rejected, partly by the mouth, though chiefly by the nostrils. The laboriousness of the breath- ing is greatly augmented, and interrupted by frequent and con- vulsive paroxysms of dyspnoea, or of suffocative cough, threatening immediate death. At this stage of the disease, also, in young children, the dyspnoea is liable to produce con- vulsions, from which the little patients never recover. At other times derangement of the cerebral function, indicated by somnolency, or perhaps coma, is a prominent feature in their case. These paroxysms are induced or rendered more severe, by attempts to swallow, or by assuming the horizontal position, and the patient consequently maintains an erect or partially erect posture. During these attacks of suspended respiration, the face is flushed, and sometimes of a dark leaden hue, the head thrown forcibly backward between the shoulders, the lower maxilla projected forward, the lips livid and cold, the tongue often protruded from the mouth, and the pulse exceed- ingly rapid, sometimes attaining the height of 130 or 140 beats in a minute. Should the tongue be retracted within the mouth, and the patient requested to protrude it, it is spasmodically thrust out, and returned with considerable difficulty. There is also frequently a course mucous rale to be heard along the course of the larynx and trachea. 12 Allin on Retro-Pharyngeal Abscess. Upon examining the throat, there may be detected more or less congestion of the internal surface of the mouth and pharynx, and when this is the case, there may be also some swelling and redness of the tonsils, and of the epiglottis. Should the seat of the abscess extend above the level of the glottis, as is the fact, in nearly every instance, a tumefaction of the pharyngeal parietes can be seen, upon which is spread out the velum of the palate. If now the fore-finger be passed into the mouth, back to the posterior wall of the pharynx, a firm, elastic tumor can be distinctly felt, commonly ovoid in shape, situated between the vertebrae and pharynx, pushing forward the latter, and, in many instances, even separating the alae of the thyroid cartilage of the larynx. This separation can sometimes be detected by an external examination. The tumor may not always be found directly in the median line, and it may involve other organs in the neighborhood, but this does not change the character, though it may influence the severity of the disease, for the results will be the same, and the same plan of treatment will be required. I have spoken of the tumor as conveying an elastic feel, rather than one of fluctuation, for the reason that it is almost impossible to ob- tain, satisfactorily, the sensation of fluctuation in this region, inasmuch as but one finger can be passed down to the swelling. When the termination of this abscess is fatal, death is al- most always the result of asphyxia, produced by compression upon the larynx, though it may be caused by the opening, either spontaneous, or artificial, of the abscess, its contents passing into and deluging the larynx and trachea. 2. Of the Chronic Abscess.—The chronic variety of this abscess is almost universally symptomatic of some constitu- tional disease, traceable, more or less directly, to hereditary or specific taint; and the most frequent of these is caries of the vertebrae. The symptoms which belong exclusively to it are manifested, therefore, principally, during its formation, and are similar, with a few local modifications, to those attendant upon vertebral caries generally. Among the earliest of thses are to be noticed more or less stiffness and dull pain about the neck, posteriorly, the pain being increased by the movements of the head, and, in some instances, being most severe in the Allin on Retro-Pharyngeal Abscess. 13 evening and night. Very frequently these phenomena, from the small amount of inconvenience they occasion, are, for a long time, overlooked or neglected, or attributed to other causes than vertebral disease, a neglect which involves consequences of the most serious character to the patient. As the abscess becomes augmented in size, these symptoms become more marked, and are sometimes accompanied by a partial or com- plete closure of the jaws, a feature of the case, by the influence of which the diagnosis, derived from physical examination, is rendered unsatisfactory or impossible. In cases of this kind, the cavity of the abscess is liable to follow a more extended route than is usual in the acute form. Thus, the purulent matter may find its way, downward, through the loose areolar tissue behind the oesophagus, even into the posterior mediastinal space,* or, again, into the lateral portions of the neck, beneath the deep fascia. In the case re- ported by Dr. Clark, of New Jersey, to which allusion has been made, the abscess not only existed behind the pharynx, but "extended from the mastoid process down along the course of the sterno-cleido-mastoid muscle of the right side, to the situation of the thyroid gland, which it fully occupied, giving it the appearance of goitre."t All these symptoms may continue, and the abscess con- stantly increase in size, for an extended period, before produc- ing any of the phenomena which excite alarm, and demand immediate and active treatment; for it is a well-established law in pathology, that a steady but gradually augmenting pressure may be continued, with impunity, upon organs essen- tial to life, during a long time, no urgent symptoms presenting themselves until the compression has been carried beyond a definite limit. When the collection of purulent matter has become so great, as to begin to press upon and interfere with the function of important neighboring organs, another class of phenomena is presented. Dysphagia, increasing in severity, is followed by excessive dyspnoea, and nearly all the symptoms of acute * Case 34. f Xew- York Journal of Medicine. July, 1849. Case 43. 14 Allin on Retro-Pharyngeal Abscess. idiopathic abscess. These have already been described fully under their appropriate head, and require no repetition. There is one peculiarity, however, which is exhibited in very many cases of the chronic variety, of great importance to re- collect. In its later stages, fever, of a low typhoid character, makes its appearance, and, unless it is promptly met and skil- fully treated, death will inevitably ensue. The alleviation of ihe dysphagia, too, by opening of the chronic abscess, is not always as satisfactory as in the acute form ; for, by the long- continued tension, and greatly increased thickness of the pos- terior wall of the pharynx, its elasticity and contractile power are very much impaired, and the obstruction of the canal con- tinues, nearly as complete as before the opening, the result be- ing, sooner or later, death from defect of nutrition. diagnosis. In the greater number of cases of retro-pharyngeal abscess occurring in adults, its existence can be distinguished from any other affection with but little difficulty, if the surgeon pos- sesses the knowledge of, or suspects the possibility of its occa- sional formation. A local examination by the eye, or the fin- ger, or by both, will generally reveal the true character of the disease. But this examination cannot always be satisfactorily effected. This is especially true in very young children, for obvious reasons, so that the recognition of the difficulty must be derived principally, if not wholly, from the rational signs. Complicated, as these sometimes are, with convulsions, or cerebral derangement, they are very liable to misinterpreta- tion, the treatment being directed to these symptomatic com- plications, a suspicion of purulent collection behind the pha- rynx being never entertained. The disease which most resembles acute pharyngeal abscess, and with which, therefore, it is most liable to be confounded, in the earlier period of life, is croup. By referring to the ac- count of the phenomena, exhibited during the formation of the abscess, already recorded, it will be noticed that very many are entirely identical with those which occur in the course of an ordinary case of croup. There are, however, some well- Allin on Retro-Pharyngeal Abscess. 15 marked points of difference between the two diseases, a care- ful attention to which will almost always guide to an accurate diagnosis. In the first place, the commencement of an attack of croup is very different from that of pharyngeal abscess. In the former, the peculiar crowing cough marks the beginning of the disease, in almost every instance, and more or less difficult and audible respiration is present from the first; in the latter, the crowing cough is never heard, and dyspnoea, increasing gradually in severity, is always and necessarily preceded by difficulty of deglutition, which is seldom urgent in croup. Again, in croup the difficulty of breathing is often very much relieved when the head is low, and is not increased by exter- nal pressure upon the larynx ; in retro-pharyngeal abscess, on the contrary, the assumption of a horizontal position is imme- diately attended with so severe aggravation of the dyspnoea as to render its continuance impossible, without sacrifice of life ; and pressure against the larynx from before, backwards, produces a similar effect, though in a less degree. The cha- racter of the voice, too, will very generally afford material as- sistance in the formation of a diagnosis between these diseases. In croup, it is at first hoarse, then weak and whispering, but always distinct; in pharyngeal abscess the peculiarity is well marked, and consists, as has already been intimated, in an obstructed nasal or guttural modification, it being very difficult to understand what the patient endeavors to communicate. A specimen of a singular form of retro-pharyngeal abscess, the symptoms having been attributed to spasmodic croup,* was exhibited at the first meeting of the Pathological Society of London, by Dr. Peacock, a brief report of which, on account of its peculiarity and interest, I will transcribe : " The sac of the abscess, which was the size of a small egg, was seen situ- ated between the bodies of the upper cervical vertebrae and the back of the pharynx, not causing, however, much projection of the latter from its being flattened in front. In connection with the anterior surface of the sac there sprang a small cyst, forming a nipple-like prolongation into the pharynx, and com- pletely closing the orifice of the glottis. It admitted the point * Case 41. 16 Allin on Retro-Pharyngeal Abscess. of the little finger, and was freely movable, and perfectly trans- lucent at its extremity and sides. The preparation was from an infant seven months old. The child had occasionally suf- fered from dyspnoea for three weeks, the symptoms having been very urgent for the last three days of its life. In the in- tervals of the dyspncea, the respiration was natural, but the slightest exposure to cold, motion, or excitement, brought on a recurrence of the symptoms, which were attended, in inspira- tion, with a croupy sound."* Another disease with which acute pharyngeal abscess may be confounded is laryngitis, accompanied with oedema of the glottis and epiglottis. The one can, however, be almost al- ways distinguished from the other, if it be remembered that, in cases of the oedematous effusion, difficulty of breathing is most urgent during an inspiration, while, when this form of abscess is the cause, the dyspnoea is more continuous, being nearly the same during expiration as during inspiration. The sensa- tion communicated to the finger in an examination by the mouth, is very different in the two cases. In the one, a soft pultaceous swelling is felt just at. the base of the tongue, and the epiglottis, swollen and curled upon itself, is detected with comparative ease ; in the other, the tumor is hard and elastic, situated behind the larynx; and the epiglottis may he felt or seen, entirely free from oedema. The more rapid progress of inflammation, and the total absence, or comparatively small degree, of dysphagia in laryngitis, will also aid in the forma- tion of a diagnosis. The chronic form of pharyngeal'abscess has been mistaken for stricture of the oesophagus, for syphilitic ulceration of the throat, and for wry neck ; but the error is directly traceable, in every instance, to ignorance or forgetfulness of the occasion- al occurrence of abscess in this region. Thorough explora- tion, then, is the'great means by which this affection is to be distinguished from others occurring in the neighborhood, and when made intelligently, will seldom fail to reveal the true * Land, and Edin. Month. Jour. Oct. 1847. Allin on Retro-Pharyngeal Abscess. 17 cause of the dangerous conditions of deglutition and respiration above enumerated. PATHOLOGY. The appearances presented in a post mortem examination of abscess in this region do not materially differ from those of abscess elsewhere. Enough has already been said in the course of this dissertation to indicate the seat of the affection, and to suggest its effects upon neighboring organs. The only peculiarity worthy of special notice is connected with the chronic variety. One of the causes, as we have seen, of this form, is scrofulous disease of the vertebrae; and it is an im- portant fact that, while in the lumbar and dorsal regions the bodies of the bones are the seat of the disease, in the cervical region it ordinarily is confined to the articular surfaces. For this reason, in long-continued cases, in which the abscess has been opened, and the disease has not been arrested, disloca- tion of the vertebrae may take place, and death may, in this way, be the result of laceration or compression of the spinal cord. PROGNOSIS. From what has now been said with reference to this affec- tion, it is right to infer, that in cases of its acute variety, if the difficulty is recognized, and the proper treatment employed, a favorable termination may be expected. If it passes unre- cognized, and no spontaneous or accidental opening into its cavity be made, death is certain. In chronic cases, the result of treatment is not always so satisfactory. The existence of an abscess may be definitely ascertained, and immediate and essential relief afforded, by opening it, yet the disease of the bones may not be benefited by treatment, but continue to annoy the patient, until the dislocation just mentioned, or want of nutrition, terminate the case. In these chronic cases, too, as has been before noticed, the pus may extend downwards, in the loose areolar tissue behind the oeso- phagus, into the thorax, death being produced by an inflamma- tion of the pleurae and lungs, induced by this contact of puru- lent matter ; and again, it is possible, that the prognosis may 2 18 Allin on Retro-Pharyngcal Abscess. be modified by the formation of metastatic abscesses in one of the important internal organs, as the liver, or the lungs.* TREATMENT. From the enumeration which I have given of the different varieties of disease with which this form of abscess has been frequently confounded, it may be easily understood, how, in these cases, attempts have been made to effeet a cure by eme- tics, purgatives, vesication, the application of leeches, phlebo- tomy, and other antiphlogistic remedies. In more than one instance, too, where the symptoms have been attributed to the existence of syphilitic ulceration of the throat, a strong solu- tion of the nitrate of silver has been applied, locally, and the constitutional treatment of syphilis been persevered in, until the accidental rupture of the abscess, or death, revealed the nature of the affection. It is very evident, however, that it is only in the early stages of this disease, before the formation of the abscess has far progressed, that benefit is to be expected from the employment of these remedies, if indeed they are of service at any period of its progress. The process of suppura- tion, when once established, and deep seated, cannot be arrested simply by the use of antiphlogistic treatment, either general or local. Resort, therefore, to an operation, as a more direct and reliable means of relief, is inevitable, though this is, by no means, all that is required, to effect an entire recovery of the patient. Hence, the proper mode of treatment is necessarily divided into the surgical, or that adapted to a removal of tire immediate cause of the urgent symptoms, and the medical, or that by which the patient is restored, as nearly as may be, to his original condition. The surgical treatment of retro-pharyngeal abscess must obviously be the same in both the acute and chronic forms. I ^hall therefore lay aside these distinctions, for the present, to be again referred to, when I come to consider the medical treat- ment required by each variety. A temporary relief to the alarming dyspnoea may be af- forded, by an opening into the larynx, the opening being made * Case 43. Allin on Retro-Pharyngeal Abscess. 19 between the thyroid and cricoid cartilages, as in the usual operation of laryngotoiny. This formidable operation would certainly never be resorted to, if the real cause of the symptom it is intended to relieve were ascertained, and it is mentioned here, not for the purpose of recommending its employment, in any case of this kind, but because, in some recorded cases, the practitioner supposing the case to be croup, the operation has been performed, the alleviation of the dyspnoea has been prompt, and apparently satisfactory, but a speedy return of all the fearful phenomena has given a fatal termination to the case, and the post mortem examination alone has discovered to the surgeon his error. The history of a case of this kind is given in the "Archives Generates de Medicine," torn. 57. p. 257.* Tracheotomy has also been adopted, as a remedy for the same symptom, but with the same ultimate result as laryngo- tomy, though somewhat longer delayed. Mr. Carmichael, of Dublin, was called to see a woman at the "Female Peniten- tiary," in that city, who presented the symptoms which I have described, as belonging to abscess behind the pharynx. The existence of such abscess was not detected, the diagnosis of acute laryngitis was decided upon, and the operation of trach- eotomy was performed. The condition of the breathing was much amended, for the time, but on the second day she died, and a large abscess was found between the pharynx and the cer- vical vertebrae. It is very evident that these operations can only afford, even temporary, benefit to any other symptom than the dyspnoea. The difficulty of deglutition will, of necessity, re- main as permanent as before. Thus, in the case just referred to, Mr. Carmichael says, on the day after the operation, "the patient now respired with ease, but the most alarming symp- tom was her total inability to swallow, even the smallest drop of liquid. She informed me, by writing, that she was starving, and felt the most acute pain from hunger."t These operations therefore, at best, are only palliative in their effects, and are not to be relied upon in the treatment of this disease. The only method of operating, from which permanent bene- * Case 19. f Medico-Chirurgical Renew, Vol. II. p. 518. Case 7. 20 Allin on Retro-Pharyngcal Abscess. fit can be expected, is that of a free opening into the cavity of the abscess, through which its contents may be discharged, and the immediate cause of the dyspnoea and dysphagia thereby be, partially at least, removed. This opening may be made in various ways. Mr. Fleming, in a somewhat extend- ed article on " Peculiar Affections of the Throat," &c, pro- poses, for this purpose, the use of a "pharynx trochar," which he has invented, and which he thus describes:—"It consists of a trochar about four inches long, one extremity of the canu- la being slightly curved, the other with a ring on the upper surface to receive the fore-finger; into this canula was passed a jointed stilette, with, at its opposite extremity, a ring for the thumb, and a movable screw to graduate the projection of its point."* The head of the patient being held by an assistant, this instrument, the point of the stilette being concealed, is guided upon the finger, backward, through the mouth to the anterior wall of the abscess; the stilette is then pressed for- ward to its limited mark, withdrawn, and the pus discharged through the canula. There is one good quality belonging to this instrument, and but one. It is, that, by the aid of the canula, the purulent collection maybe evacuated, and the pos- sible entrance of matter into the trachea be thus avoided. But, notwithstanding this advantage, I would not recommend its use. I have already mentioned the great thickness and firmness of the posterior wall of the pharynx, in this disease, and have also spoken of its elasticity. If, now, the trochar be pressed against this firm elastic surface, the wall will yield be- fore it, to a considerable distance; the stilette, being pushed forward, will pierce this wall, and by the sudden elastic spring, may, unless the utmost caution be observed, be driven against or into, one of the vertebrae: caries may take place, and an abscess, acute in its character, and promising a speedy reco- very, be converted into a chronic sinus, requiring months for its closure. The same objection may be urged against the use of the "pharyngotome" of Petit, invented expressly for the opening of abscesses of the velum palati, and tonsils, but which has * Dublin Journal of Medical Science, Vol. XVII. p. 49. Allin on Retro-Pharyngeal Abscess. 21 also been used for opening abscess behind the pharynx. The curved trochar of Sir Everard Home, for puncturing the blad- der through the rectum, has also been recommended, but to that again the same objection is offered. Another very serious objection to the use of a trochar is, that the opening made by it is too small, and will close the moment the canula is with- drawn, so that the operation must either be frequently repeat- ed, or the opening enlarged, by the aid of some other instru- ment. The method which I would adopt, to effect the discharge of pus, is much more simple and effectual than those which have been mentioned, and may be described as follows. The head of the patient being firmly supported by an assistant, pass the fore-finger of the left hand into the mouth, raise the velum palati. and press the point of the finger against the tumor. Then, with an ordinary scalpel, or bistoury, the blade being covered with adhesive plaster to within half an inch of its extremity, let a free incision be made, in the median line, through the posterior wall of the pharynx, into the cavity of the abscess; withdraw the instrument, and the operation will be completed. The pain attending the operation will not be great, for the tension and thickening will have destroyed, to some extent, the sensibility of the part. By making a free in- cision at once, the necessity of repeating the operation is avoided, and the discharge of the purulent collection is more complete and satisfactory. No fistulous track is left to annoy the patient, and the recovery is more speedy, than when only a small opening is made. Should rhe position of the abscess be such, as to render it advisable that the incision be made at either side of the pharynx, particular care should be observed to avoid wounding the internal carotid artery, an accident which has occured, in opening an abscess of the tonsil. The consequences of such an event are evident. The abscess being thus opened and the dyspnoea relieved, our attention must now be turned to the subsequent treatment of the case. And here we find it necessary to recur to our for- mer divisions of this abscess into the acute and chronic forms. The treatment adapted to cases of acute pharyngeal ab- scess, after the purulent matter is discharged, is very simple, 22 Allin on Rctro-Pharyngcal Abscess. and demands but a moment's remark. It consists, in the ex- ternal application to the neck of emollient and soothing reme- dies, such as poultices or warm fomentations, until the urgent symptoms shall have been entirely relieved, and the quantity of discharge from the abscess shall have been much dimin- ished. When this result has been attained the recovery may often be facilitated, by the local employment of some astrin- gent gargle. A very excellent combination for this purpose is the following: R. Bi Borntis Sodae, .... 3ij. Tincturae Myrrhae, .... §j. S\rupi Simplicis, .... %e refers to thirty cases which he had then collected. I have endeavored to find a copy in several of the private medi- cal libraries in the city, but my search has been unsuccessful. I cannot add these cases to the present tables, inasmuch as it is very probable that the greater number, if not all of those which he mentions, are the same that I have encountered. I may, however, here remark, that of these thirty cases, eighteen terminated fatally; other than this fact, I can obtain no satis- factory information concerning them. 24 Allin on Retro-Pharyngeal Abscess. Sex. Age. Cause. Duration of Disease. Treatment. 1. Infant. Swallowing a fish bone. Acute. Antiphlogistic. No opening. 2. M. 14 Existed for a long time withoutannoy-ing patient. Phlebotomy and leeches. No opening. 3. M. Youth Exposure to cold. Acute. Decoct. Sarzae, with various gargles. Later, laryngotomy. 4. F. Adult. Swallowing a fish bone. Acute. Leeches applied, but spontane-ous opening on 7th day. 5. M. Adult. A blow with button Three weeks Antiphlogistic, until spontane- of fencing foil, pas- from date of ous discharge of pus by the sing through right injury, 13 days mouth, on eighth day of abscess. nostril into pha- from first rynx. symptoms of abscess. 6. M. Syphilis and caries of vertebras. Chronic, though symp-toms not ur-gent until a few days be-fore death. Not opened. 7. F. About a month Antiphlogistic, during a month. Tracheotomy then performed with temporary benefit. 8. Infant. A few days. Not opened. 9. 3 years Had suffered from convulsions and en-largement of cervi-ral glands. Pro-bably scrofulous. A few days. Leeches, blisters, and emetics in early stage. Afterwards abscess opened by a gum-lancet. 10. M. 24 Swallowing a piece of bone. Thirteen days. Very little treatment. Not opened, but on seventh day patient vomited small quantity of bloody purulent matter, and globules of pus were found in the stools. Allin on Retro-Pharyngeal Abscess. 25 Death by asphyxia. Death. Death. Recovered. Recovered. Death by asphyxia. Death by asphyxia, 3 days after operation. Death by asphyxia. Recovered. Death from an attack of fever, ex- cited by the abscess. Post Mortem Appearances. Three cervical vertebrae opposite larynx were carious. Abscesses extended from 2d to 7th cervical vertebrae. Its walls firm and unyielding. Abscess extended from left side of vertebra? to right mastoid process ; its coats were strong and thick, white, fibrous externally, and granular within. At junction of pharynx and oesophagus, mucous membrane had been pierced by the bone; at left side of neck ab- scess had formed in which the bone was lodged. Bone discharged with the pus of the abscess. The injury was follow- ed by extensive em- physema of neck, which continued seven days, when abscess began to appear. A tumor, supposed to be an indurated gland, formed at angle of jaw, and bloody purulent matter was twice ex- pectorated. At time of spontaneous discharge of pus and blood, pain ceased, and patient could swallow with comparative ease. Authorities. Platerus. Praxis Medicina. 1625. Severintjs. De Recondita Ab- scessuum, Nutura, p 190. 1643. Severinus. Op. Cit. p. 191. 1643. M. Hevin. Mem. de I'Acad. Royale de Chirurg. T. l,p. 465. 1761. Mr Morel. Parisian Chirurg. Jour. Vol. 2, p. 318. 1794. Mr. Carmichael. Med. Chirurg. Re- view. Vol. 2, p. 520. 1819. Mr Carmichael. Med Chir. Rev. Vol. ■2, p. 518. lc*21. Also, Trousseau & Bei.loc " Traite Prat, de la Phthisie Laryngi- enne," p. 83. Dr. Stm. Glasgow Med. Jour. Feb. 18:28. Dr. R. J. Culver- well. Lond. Lancet. Mar. 1&28. p. 927. Dr Gibert. Lond Lancet. June 1828, p.393. Allin on Retro-Pharyngeal Abscess. Cause. 11. 12. 13. 14. 15. M 1G. F. 48 Swallowing a piece of bone. Swallowing a piece of bone. Exposure to cold and damp air and erysipelas of face, of three days dura- lion. Caries of cervical vertebras from sy- philis. 17. M. 30 18. M Adult, j Acute inflamma- tion of pharynx j after syphilis. ]9. M. 40 Exposure to cold. Duration of Disease. Acute. Acute. About twenty days. Four months, from June 28th to Oct. 16th. Several weeks A few days. Eleven days. Bronchotomy proposed, but ab- scess opened by puncture with scalpel. Same treatment as in last case. An incision with a " pharyngo- tome" on the ninth day, and again on tenth. The existence of abscess was early recognized but the open- ing delayed. Opened by straight bistoury through the mouth. Opened through anterior part of neck. Abscess not opened, but laryn- gotomy performed. Allin on Retro-Pharyngeal Abscess. 27 Result. Post Mortem Appearances. Remarks. Authorities. Death. Dr. Corby. Lond. Lancet. June, 1828, p. 393. Recovered. Bone at length descend- M. Fii.i.eau. ed into stomach and Lond J^aiiret. June, escaped per anum. 1828, p. 393. Recovered. Mr Tapi.ey. Lond Lancet. Dec, 1829, p.359. Recovered. Mr. Tapi.ey. Lond. Lancet. Dec, 18-2!), p 359. Recovered. The pus was of color of M. Priov. wine lees. Arch. Generates de Med. Vol. 22, p. 412, 1830. Death by Cavity of abscess lined Head was inclined to Dr. M. Soi.on. Asphyxia. with false membrane, left side, and patient Arch. Generates de containing four ounces treated for several Med. Vol. 24, p. of pus, serous, inodorous months for torticollis, 335,1830. and of grayish color; supposed to be depend- left and superior articular ent upon " muscular apophysis of axis eroded spasm." and cartilage destroyed ; left lateral mass of atlas destroyed, and no arti- cular surfaces on that side; left condyle of occipital also eroded, and its artic. cartilage gone. Abscess and caries also of left parie- tal, and sixth rib, and of fifth lumbar vertebra. Recovered. Tumor situated in right M. Forget. parotid region. Gazette Med. de Paris. Sept. 1835. Death by Asphyxia. Abscess extended into Epiglottis scarified, J. S. F. Meandre thorax, and pharynx presented evidences of hyperemic inflammation oedema being suspected. Dassit. Theses de Montpel-lier. No. 78. 1836. Death by Asphyxia. Abscess found pressing on cavity of larynx. Considered to be a case of croup. Dr. Ballot. Arch. Gen. de Med. Vol. 57, p. 257. 1837. 28 Allin on Retro-Pharyngeal Abscess. 20. M 21. 22. 23. M 24. M 25. M 26. F. 27. ASe. Cause. Duration of Disease. Treatment. Adult. Chronic. Abscess opened by an incision in neck five lines posterior to edge of mastoid muscle. 1 year. A few days, Abscess not opened. Tracheo- not more than tomy advised, but not allowed seven. by parents. Four months Not assigned ; though probably scrofula. Thirteen days. Not opened. 34 Following cerebri-tis. Acute. Abscess opened on tenth day and enlarged same evening. Seven months Acute. Abscess opened by " pharynx trocar." Four weeks. Erysipelas of face and scalp. Spontaneous opening. Nine months Inflammation of fauces from ex-posure. Nine days. Treated as a case of croup No opening. Nine weeks. Supposed to be congenital. From birth, child had whenever it took the breast thrown itself backward and seemed nearly suf-focated. Otherwise in good health. Eight days. Treated as a case of laryngis mus stridulus. No opening. Patient had convulsions. Allin on Retro-Pharyngeal Abscess. 29 Recovered. Death by asphyxia. Death by asphyxia. Recovered. Recovered. Recovered. Death by asphyxia. Death by asphyxia. Post Mortem Appearances, Abscess lined with co- agulable lymph, and ex- tending from cranium to near thorax ; pressed upon larynx and tra- chea. Epiglottis, larynx and trachea covered with viscid mucus ; pus thick, flocculent, and of green- ish yellow color. Remarks. Accidentally cut into ; no traces of disease in larynx or oesophagus; anterior wall of abscess very thin ; pus healthy. Cyst thick, firm, and cartilaginous, sending a process behind the ster- nocleido mastoid ; pus healthy. Several abscesses had appeared before in other situations. Attended with convul- sions. Entire family scrofulous. Several children of same family had died of hy- drocephalus. Attended with convul- sions. Existence of abscess not suspected. An elder sister of fifteen months, a few days be- fore was seized with a fit of suffocation, follow- ed by severe convul- sions, which subsided and recurred again and again, and died in the night. No physican called and no post mor- tem. Dr. Mequin. Journal des Connais- sances. July, 1837. Dr. J. Byrne. Am. Journal Med. Sciences. Vol. 22, p. 511. 1838. M. Besserer. Arch. Gen. de Med. Vol. 71, p. 483. 1840. Dr. C. Fleming. Dub. Jour. Med. Vol. 17, p. 42. Ic40. Dr. C. Fleming. Dub. Jour. Med. Vol. 17, p. 45. 1840. Dr. Fitzpatrick. Dub. Jour. Med. Vol. 17, p. 58. 1840. Dr. W. C. Wor- THINGTON. Provincial Medical and Surg. Jour. Vol. 3, p. 494. 1842. Dr. E. O. Hocken. Provincial Medical and Surg. Jour. Vol. 5, p. 45. 1842. 30 Allin on Retro-Pharyngeal Abscess. 28. F. 29. M 30. F. 31. 32. M 33. M GO Four months 50 35 34. M 40 Exposure to cold. Lodgment of bone in pharynx which remained three hours. Caries of vertebrae Exposure to cold. Exposure to cold Ushered in by a chill, and shivering continued a week though the skin was hot. Duration of Di^ea^e. Six days. Acute. Six days. Acute. Chronic. A few days. Eight days. Treatment. Free bloodletting, leeches to neck, and astringent ta'gles. No opening. Fauces and neck repeatedly examined but no cause of the symptoms ascer- tained. Abscess opened spontaneously during an act of vomiting on eighth day. Abscess opened by puncture with a trocar. Some air escaped from the wound. Punctured several times. Not opened. Not opened. Treated antiphlogi?tically as laryngitis, till day ot his death, when a probang was passed into oesophagus but no pus escaped. Allin on Retro-Pharyngeal Abscess. 31 Death. Recovered. Death by entrance of air into the veins a few minutes alter punc ture was made. Recovered. Death by hemoptysis. Death by asphyxia. Post Mortem Appearances. Death. Abscess situated imme- diately behind glottis, containing half an ounce of pus; also mi- nute deposits of pus be- tween cricoid and ary- tenoid cartilages. Remarks. Abscess behind pharynx and oesophagus extend- ing into posterior medi- astinum. It had burst by numerous openings into oesophagus, and reticular tissue between it and vertebrae was in- filtrated with pus ; the veins bad been eroded and opened by ulcera- tion. Lungs filled with tuber- cles ; disease of first two, fourth and fifth cervical vertebra. Mucous membrane of pharynx and of larynx reddened ; abscess con- tained unhealthy pus of chocolate color. Membrane of pharynx and larynx reddened ; abscesses at back part and in muscular struc- ture of pharynx ex- tending down through posterior mediastinum to diaphragm ; pus healthy ; some pleuritis. There were intense ar- terial excitement, dys- phagia and aphonia, with but little difficulty of respiration. Par- lurition took place on fifth day of disease, and in the intervals of pain she could speak with natural tones of voice. Of delicate constitution. This tumor was also observable on right side of neck exteriorly. Patient had been treated for synovitis of knee joint. Drank largely of stimu- lants for six day3 after chills commenced ; pus in expectoration on 6th day. Dr. Caspar Morris. Quarterly Summary of College of Physi- cians, Phila. 1842. M. DUPARCQUE. Annates d'Obstetri- que. Dec. 1842. Mr. R. W. Smith. Dub. Jour. Med. Vol. 25, p. 497. 1844. Dr. O'Ferrall. Dub. Hospital Gaz. March, 1845. Jour, des Connais- sances. April, 1845, p. 156. M. Rodriguez. La Clinique de Mont- pellier. July, lt45. Dr. Taylor. London Lancet. Jan. 1846, p. 74. 32 Allin on Retro-Pharyngeal Abscess. 35. 36. 37. 38. M 39. F. 40. F. 41. F. 42. M. Age. 2J 20 Adult. Seven months 29 Cause. Lodgment of fish bone in pharynx. An attempt was made to remove it by a blunt hook, which was unsuc- cessful, and a pro- bang was passed down to stomach, followed by great pain, and difficulty of swallowing. Impaction of fish bone in pharynx, producing caries of cervical verte- brae. " Debility." Exposure to cold, and erysipelas of face. Duration of Disease. Five months. Seventeen months. Three months. Eighteen days. Twelve days. Eight weeks. Three weeks. Urgent symp- toms three days. Entire dura- tion twelve days. Urgent symptoms two days. Not opened. Abscess opened. Abscess opened. Abscess opened by a pharyngo- tome on fifteenth day. Leeches and antiphlogistic treatment at first. On tenth day, laryngolomy performed, with relief to breathing but not to swallowing; on the eleventh day, a piece of cartilage of larynx removed, but without much benefit. Abscesses recognized and opened by pharyngotome on seventh day ; required re- opening on twenty-second day, after which recovery was rapid. No opening. Tracheotomy proposed, but not performed ; symptoms attributed to " spas- modic croup." Treated for erysipelas and de- lirium tremens. Abscess not opened. Allin on Retro-Pharyngeal Abscess. 33 Result. Death by asphyxia. Recovered. Recovered. Recovered. Death by asphyxia. Recovered. Death by asphyxia. Death from the compli- cated dis- eases. Post Mortem Appearances. Large abscess behind pharynx and oesophagus accidentally opened, containing very foetid pus mixed with air; the bone, an inch and a quarter in length, was lying loose in abscess; no evidence of point of entrance of the bone. Abscess behind pharynx having a cul de sac, which entirely filled opening of glottis ; wall of cul de sac very thin and transparent. Large abscess, contain- ing healthy pus, extend- ing from second to fifth cervical vertebrae ; lar- ynx healthy ; vessels of pia mater much inject- ed and sinuses of brain distended. Remarks. Presented characteris- tics of, and for some days mistaken for, croup. Throat could not be ex- amined, for patient was unable to open the mouth ; bone doubtless pushed through pharynx by probang. First apparent indica- tion of abscess was a diffused, indistinct swel- ling on right side of trachea and extending behind it; posterior wall of pharynx very much thickened; pus very foetid. Dyspnoea intermit- tent and produced by exposure to cold or any excitement. Examination ©f throat was made, and though Dr. B. felt a bulging at posterior portion of pha- rynx, he did not suspect abscess. Authorities. London fy Edin Monthly Jour. Aug. 1846. p. 146. London $■ Edin. Monthly Jour. Aug. 1846, p. 146. Dr. M. Wade. London <$• Edin. Monthly Jour. Aug. 1846, p. 146. M. Bessems. Gaz. Med de Paris. Dec. 1846, p. 994. Dr. Jno. Adams. Lond. Lancet. June, 1847, p. 581. Dr. Jno. Adams. Lond. Lancet. June, 1847, p. 581. Dr. Peacock. Arch. Gen. de Med. Vol. 79, p. 220 ; and Lond. and Edin. Mon. Jour. October, 1847. With a draw- ing. N. Y. Hospital Re- cords. Attendance of Dr. Gurdon Buck, Jr. March, 1849. Allin on Retro-Pharyngeal Abscess. Duration of Sex. Age. Cause. Disease. Treatment. 43. M 49 For some months Two months, Antiphlogistic at first; after- previous he had ar- with an inter- wards an unsuccessful explora- ticulated with con- mission of a tive opening into external siderable difficulty, week. tumor near larynx ; and still and occasionally later, another explorative open- had " sensation of ing in front of larynx, through choking." Imme- which a large quantity of diate cause, pro- illaudable pus of a pea-green bably riding several color escaped. miles, exposed to severe snow-storm. 44. M. Two Influenza was epi- About four Abscess ruptured on eighth months demic at the time. weeks. day by pressure with finger. 45. F. 11 Probably caries of cervical vertebrae. Eight months. Abscess opened by transverse incision. 46. Six months A few days. Tracheotomy suggested but not performed. Abscess not opened. 47. M. 29 Patient of scrofu- Disease com- Antiphlogistic in early stages. lous constitution. menced five Upon admission into hospital, Immediate cause, months before abscess readily recognized, and exposure to cold. symptoms be-came urgent, when he was admitted to Hospital. En-tire duration, about eight months. opened by a guarded scalpel through mouth. 48. M. 56 4 days under treatment: en-tire duration not mentioned. Large swelling pn right side of neck, involving the tonsil and velum palati, opened in velum, and pus discharged. The next day another opening in tumor externally, enlarged on third day. Pus fcetid ; dis-charge free. Patient improving on fourth day. Allin on Retro-Pharyngeal Abscess. 35 Post Mortem Appearances. Remarks. Authorities. Death from as enia and metas- tatic ab- scesses in the lungs. Purulent absorption 1 Recovered. Recovered with excep- tion of lim- ited motion of head. Death from exhaustion. Recovered with stiff- ness of the neck, and some ob- struction of voice. Died very suddenly. Cause of death un- certain, but not from as- phyxia. Sinus leading to ab- scess extended from near thyroid gland, along stemo-cleido- mastoid of right side to mastoid process; ab- scess directly in front of vertebrae, and ex- tending nearly to tho- rax ; lungs contained tubercles, and several small metastatic ab- scesses. Abscess passed behind pharynx ; inclosed in a dense cyst; lying on bodies of cervical verte- brae and in contact with basilar process. Walls of pharynx much thickened, and contain- ed large quantity of pus in sinuses between the muscular fibres ; also a deep sanious abscess ex- tended upwards towards palate, downwards and backwards behind la- rynx, and opened oppo- site epiglottis. Eighteen days before death a small tumor ap- peared in front of larynx, presenting indistinct fluctuation. Dr. J. H. Clark. New-York Journal Medicine. July, 1849, p. 34. Symptoms at first attri- buted to influenza. Dr. C Fleming. Dublin Jour. Med. Feb. 1850, p. 223. Of strumous constitu- Dr. C. Fleming. tion : lateral curvature Dublin Jour. Med. of spine. Pathological specimen in Museum of College of Physicians and Sur- geons, New-York. Pus inodorous, and mix- ed with it lumps of curdy substance. At time of opening, no in- dication of vertebral disease, though suspect- ed at a later period; glands of neck became much enlarged. Lungs were much con- gested, and left pleura contained six ounces of purulent serum ; super- ficial veins of brain and dura mater filled with blood. Feb. 1850, p. 224. Dr. W. H. Van BUREN. New- York Journal Med. July, 1850, p. 32. N. Y. Hospital Re- cords. Attendance of Dr. Gurdon Buck, Jr., Sept. 1850. Mr. Curling. London Lancet. Oct. 1850, p. 485. 36 Allin on Retro-Pharyngeal Abscess. Sex. Age. Cause. Duration of Disease. Treatment. 49. M. 40 Fell on a door step, Entire dura- Abscess easily recognized, and striking inferior tion, eleven opened by scalpel through maxilla, and sup- weeks. mouth. purative inflamma- Urgent symp- tion extending from toms appeared the wound. nine weeks after injury. 50. M. Adult. Inflammation of fauces after syphi-lis. Acute. Treated for secondary syphilis. Abscess accidentally ruptured by probang, while applying solu-tion of" Nit. Arg." to ulcers of fauces. 51. F. Adult. Exposure to cold, and inflammation of pharynx. Acute. Abscess not opened. 52. M. Adult. Abscess opened by trocar. 53. Adult. So long as to be considered stricture of oesophagus. Abscess opened by a probang, accidentally. 54. Abscess not opened. 55. M. One Scrofulous diathe- Nine months. year. sis. Mother died of phthisis soon after birth of child. Abscess not recognized, and no opening. Treated as tonsil-litis. 56. F. 4 Child of scrofulous constitution. Chronic. Abscess opened through mouth with a lancet. 57. M. 30 Caries of cervical Several weeks Abscess recognized, and open- vertebrae. under observa-tion. ed through mouth by bistoury. About a drachm of pus escaped. 55. F. 4 Supposed to be More than Abscess opened through mouth caries of cervical three months. by bistoury; required reopen- vertebrae, though ing several times, from recur- no rough bone de- rence of severe dyspnoea. tected. Cause of dyspnoea not re-cognized immediately. Allin on Retro-Pharyngeal Abscess. 37 Post Mortem Appearances. Recovered. Recovered. Death by asphyxia. Recovered. Recovered. Death by asphyxia. Death by asphyxia. Recovered. Recovered, probably, though ab- scess not entirely closed when last ob- served. Recovered. Abscesss pressing on epiglottis and glottis. " Abscess found be- tween vertebrae and up- per part of oesophagus." Uvula and tonsils na- tural ; abscess two inches long, containing ounce and a half of pus, thick, caseous, and chalky matter mingled with it; several pieces of bone in left pleura. Vertebrae not diseased. Remarks. Pus thin and mingled with firm and opaque flocculi; had suffered from epilepsy for several years. Existence of abscess not suspected. From its birth child had an eruption on skin, which passed away after three months, when dis- ease of throatj com- menced. Symptoms not urgent; no dyspnoea; rough bone felt, with a probe through abscess. Some disease had ex- isted for a long time, in neck, drawing head to one side, and attend- ed with pain and ten- derness on motion; posterior wall of pha- rynx pushed forward,and entirely closing larynx. Authorities. N. Y. Hospital Re- cords. Attendance of Dr. John Watson. Dec. 1850. N. Y. Hospital Re- cords. Aug. 1849. Sir Astley Cooper. Lectures by Tyrrell. Vol. l,p. 68. Sir Astley Cooper. Op. cit. Dr. Abercrombie. Diseases of Stomach, &c. p. 99. Edin. 1832. Dr. Ibid. Abercrombie. Dr. W. Parker. 1839. Dr. W. Parker. 1848. Dr. A. C Post. 1848. Dr. A. C. Post. 1850. 3S Allin on Retro-Pharyngeal Abscess. The following is a synoptical review of the fifty-eight cases of retro-pharyngeal abscess, reported in the preceding table :— fifer—Males, 28. Females, 13. Not stated, 17. Age.—Under 10, 20 ; 10 to 20, 4 ; 20 to 30, 5 ; 30 to 40, 5 ; 40 to 50, 4 : 50 to 70. 3; age not mentioned, 17. Causes.—Exposure to cold, 10; erysipelas of face, 2; lodgment of bone in pharynx, 8 ; blow with a fencing foil, 1 ; inflammation fol- lowing a fall upon the inferior maxilla, 1 ; after cerebritis, 1 ; syphi- lis, 4 ; caries of cervical vertebrae, 6 ; scrofula, 5 ; cause not assigned, 22. Duration.—Acute, 33 ; chronic, 17 ; no note of, 8. Treatment.—Abscess opened, 30; through the mouth, 21 : through the side of neck, 3 ; through the neck, anteriorly, 2 ; acci- dentally, 3 ; spontaneously, 4 ; abscess not opened, 23 ; operation of laryngotomy, 3 ; tracheotomy, 2. Result.—Death, 30. From asphyxia, 18 ; asthenia, 2 ; asthenia and metastatic abscesses, 1 ; hemoptysis, 1 ; fever excited by the ab- scess, ■ 1: delirium tremens, etc., 1 ; entrance of air into veins, 1 ; cause of death not given, 5. Entirely recovered, 25 ; some stiffness of neck remaining, 2; abscess not entirely closed, 1. Post-mortem Appearances.—These present so great variety in their character, in the cases reported, that no satisfactory classifica- tion of them can be made, and the reader is therefore referred back, for information on this point, to the appropriate column in the table.