retro-pharyngeal abscess; and erosion of internal

THE CANADIAN MEDICAL ASSOCIATION JOURNAL 635

days the girl was sent to her work with herfingers only slightly sensitive and with a veryslight limitation of movement in the second jointof the middle finger.Henri B., age 37; injured March 13th, 1923.-

Distal portion of left little finger caught in thecrank shaft. of a loom and all but amputated.Distal phalanx was fractured. The laceratedfragment was strapped into position and unionoccurred within two days. Infection set in andhot solutions were resorted to. A perfect plastic

and functional result was obtained in forty-onedays.Joseph D., age 15; injured April 17th, 1923.-

Right middle finger caught in gears.... Distalphalanx crushed and lacerated; the tissue overthe palmar surface of the second phalanx deeplylacerated. A long palmar flap was used andsutured to the dorsum of the finger after thephalanx had been removed. Returned to workwith a good stump after forty-one days.

RETRO-PHARYNGEAL ABSCESS; AND EROSION OF INTERNALCARODID ARTERY; WITH PATHOLOGICAL SPECIMEN*

D. E. S. W1SHART, B.A., M.B., Toronto

Assistant Surgeon, Department of Laryngology, Hospital for Sick Children, Toronto; Junior

Demonstrator, Department of Oto-laryngology, University of Toronto

THE unique pathological specimen whichaccompanies this paper, I owe to the kind-

ness of the Surgical Staff of the Hospital forSick Children, to whose service the case wasadmitted in August, 1922. The possibility ofthe occurrence of the fatal complication of whichthis case is an illustration is mentioned in severalof the references given below, and four similarcases were reported by Carmichael' in 1881,Lidell2 in 1883, Travers3 in 1902, and Wylieand Wingrave4 in 1906, but no evidence hasbeen found to show tEat a specimen illustratingthe condition exists in any other collection.Advantage has been taken of the opportunity

presented by this specimen to investigate therecords of cases of retro-pharyngeal abscess atthe Hospital for Sick Children in order to gleanfrom them a composite clinical picture of thesymptoms, signs, course, and fate of actual cases.The tabulation of these cases has been made inthe last eight years only and the records have beenfound deficient in many respects. For example,one record gave but a few lines of history and agood description of the position of the abscess,while another had an excellently written storyof the illness and no description of the throat.This report therefore is not to be considered final.

*From the Department of Oto-laryngology Univer i tyof Toronto, Toronto.

An effort is now being made to greatly raise thestandard of our case histories so that futurereports may be sufficiently accurate for statisticalpurposes.

Definition.-A retro-pharyngeal abscess is acollection of pus in the connective tissue beneaththe mucous membrane of the posterior wall ofthe pharynx.Anatomy.-The anatomy of the posterior wall

of the pharynx will be readily understood bycareful consideration of the following threecross-sections taken from Eycleshymer and Shoe-maker5. The first cross-section (Figure I) iscut through at the level of the hard palate. Di-rectly behind the mucosa of the pharynx is a thinstrip of muscle continuous at the sides with thepalate-the M. pharyngo-palatinus (Palato-pha-ryngeus). Behind this muscle a thin layer ofconnective tissue, which becomes broader at thesides represents the retro-pharyngeal space atthis level. It is bounded posteriorly by twomuscles-the M. longus capitis (rectus capitisanticus major) and the M. rectus capitis anterior(rectus capitis anticus minor). At the sidesthe retro-pharyngeal space is continuous with thepharyngo-maxillary fossa-a fossa having firmmuscle boundaries, but a fossa in name only, forit is completely filled by connective tissue andimportant vessels and nerves.

THE CANADIAN MEDICAL ASSOCIATION JOURNAL

W. caninusM. orbiculauis oris aw

Lig.. longitudinale anterius at

Sinus maaillaris[lHighmorij \ jM. quadratus labii superiorisfaput infraorbitate] cc, \ \

e naea eli palatiaiV.. angularis (4

M. zygomticus o%M. pterygo;deus internus cl*,

M.. pterygoideas eaternus co

M. temporalas an

VY. pauryngean is

N. masstericus

W. lingualis v

N. atneolaris inferiorM. levator neli palatina

Lig. uphenomandibulare 5.*

Glandale puotis N__A. carotis eaterna et interns SLt_,

1. glossopharyngeus sN. nugus et truncus sympaticas

N. aeccessorius et n. hypogloa u

facialis et a. auriculuris posterior 47.----

euricularis posterior et jagularis interna 69.

M. digastricusaEventer posteorior] Ue

A. occipii.set et m. rectua capitis laterasis .t'A

M. stemocleidomastoideus I

W. longissimus capitis Ata

A. occipitalisaramus descendens]et condylus oecipitalii

Plexuaaaenosilvetebrales posteriores 01

V. eta. nertebralis W9/

Membrana tectoria et lig. cruciatum atlantis a

M. trapesius et n. accessorius a7oM. semispinalis capitis 50'

N. occipitatis major 355Medulla oblongata

FiG

Uvula [palatina] us

Lig. longitedinale anterius. et cavum articalare ati;Labium inferius

WI. longitudinalis superior linguae .

Ml. orbicularis oris .q

Tonsilla pulatina w *

V facialis anterior ct M. buccinator Xr

M. constrictor pharyngis superior _

M. masseter ti

Raphepterygomandibulars et n. lnogualiseq

W. pterygoideus internus '."Idandibuta (ramesJa.

N. alneolatis infenor et mn. long. colli et capitis

Processus styloideus et n. glossophaaryngeurs ue

A. carotis interna et ganglion ceriale superius

A. curotis externa et n. acceotorius So

V. jugularis eaterna et n. facialis a_

N. hypoglossus et a. cagesua.. _V. auricutaris posterior et a. et alertebrulistiz....

M. digastricas et procesus transsnerus atlantis eg...-

M. steemocluidomatoideaus _s..-

Mo. bliquua capitis inferior

M. long4oimus capitis 4i.

1.upleniasacaptisn..i

Pleaus [venosi] et brales poateriuweaet a. occipihlis [ramus descandens] A/

Rete vnmom netebrae tw /

Membrana atlaocciptalis posterior

Cans.n ubwachnoideale iev

Arcus poterior atlantis a,:

N. occipitalis major -'

Pharynx et palatum durwn.2 Canalis incisivus et maxlla

M caninus

i Glandulac palatinae} f Mm. constrictores pharyrgis

'.' i U/ / .C 1i1. pharyngopalatieus1k / / ,O7 M. quadratus labii superioris tcaput infraorbitale]

eatibulum orisM. buccinator

M. zygomaticus

.11 d. pterygoideus externua'

a M. masseterf.m M. temporalis et ramus mandibulan

,at M. longus capitis et n. mrassetericus

V. pharyngea et n. lingualis

|,I .atyeotaris infertor et lig.LI- nsphenomandibalare

so_17 Truncus sympatbicus etm. levator veli palatini

_,---s A.caroteIs intems It n. giossolpharyngeus

.--.o U. stylopharyingeus et a carotis. elterna

-S-- N hypoglosaus et n. accessorluS

M. rectus capitis anterior et n. vagus

- digastricus [venter posteriorlet n. facialis

M---M. rectas capitis lateralis

M*blngisSimus capitlsnet m.

sternocleidomastaideus

Plexus [enosilvertebrales posterioreset m splenius capitis

Atlaset m obliquus capitrs superlar

N occipitalis minor

M rectus capitis posterior majorN subacc;ipitalis [radix]

M0' remtus capitis posterior minor

.31 Membrana attantooccipitalis posterior. SP!nalis crprtis

Ltg nucho.

.1I

t Pharyna [pars naulia]

M. transveraus linguaeoA.pfunda linguae tramus dorsatis]

Mm constrictorespharyngis

; ; M. orbicularis oris

Mbl glossopalatinus,s M. pharyngopal-atinus

s.M. buccinator et v. facialis anterior.

sto N. lingualia et raphe ptergomandibularits

ll s _,,.~~11 Platysma1.1. pterygoideum internus

Mm. long; colli et capitis et v.pharynges

N..alveolaris inferior

Procesus styloideusMm. styloglosaus et stylopharyngeus et stylolyaideua.

Ruamus pharyngus n. nagi et L carotis eaterna

us N. hypuglomas et n. accesauriusGanglion cervicale sapertus et a. juaglaris eaterna

.-_ h.j occipialis et * facialis

...saN. waguset v. jngularis inierna.Proca.sstraunerus atluatisM. interranonemarius *t m digastricus [venterfposteriorj

M. sternaceidomastuideus-U Atla et LSt a. nedebralisLg. trwerum alluntis

.M. tiqusu capitio inferioram lesimu capitis

mAn.Uplenis capitis* Dons episatrphei et n. occipitats misnw

as1 U. reclus capitia poterior major

LS receacapitiapuatrte minor et ig. nuchae

636

ki'g. 11.s


Descending to the next section (Figure II)-at the level of the tongue-the retro-pharyngealspace is less evident, but the pharyngo-maxillaryfossa is better defined than in the preceding sec-tion. The pharyngeal veins are now fewer innumber but of larger calibre and lie in the outeredge of the superior constrictor of the pharynx.Just lateral to them is seen a bundle of muscles-the M. styloglossus, M. stylopharyngeus, andM. stylohoideus-which in their descent divide

X1. quldratus labii infer;orirs , t M.genxiN. lingualis [ramus] 7,.M. hyoglossus , .

I. triangularis #, 'N. mentalis et pharyns (pars oralis] 7. %' * t

J. orbicularsoris

M.buccenato \ \'Vestibulum on'a

V. facialis anterior et a. maxillais exterma 0

MandibulaMi. mylohyoideus o.,'

Tonsilla palatina usN. lixigualix

M..atylogouus.M,maaseter e,

VY.pharyngeae ..Mm.constrictores pharyngia u.

M. styloxyoidexs et m. stylophaiynpux m..._Ascaroineatema ab.....

Glandula parotis et n. glossophaiyngeus N..hypoglossus et ramus pharyngeuc n. vagi ...

N. aecessonrus et a. caroisi intemza N_--N. vaus et ganglion cervicale superius M_..-

V.juuanris ;nmeta R.-M. revator scapula* et m. speniuscery;cia ,

M. scaleowa med;us m,-M. stemocleidomastdoideus I

A. et v.vertebali;blsplexiun capkis

M8. b_s~ a"Plexus (venosilveta~ postera At

N.cervicall1 !

N occipitalis major et M. obliquuncuptisinfeori /

Rete nenoxum ertabse 41 /W.tebpz.uset epistopheus AS I

Cavem aubarachnoideal iM.eemispinalis capitis et medulla apinalis 4X1 i

Epistroph.us [processus spinosun]tGFIG.

the pharyngo-maxillary space (Figure III) intoan anterior chamber contiguous with the tonsil,and a posterior chamber containing in its hinder-most part the internal carotid artery, the internaljugular vein, and their accompanying nerves.It is this posterior compartment which meritsour attention in the consideration of the patho-logical specimen here presented. Figure III.shows well the broad band of connective tis-sue which is continuous laterally with the pos-terior compartment of the pharyngo-maxillaryspace and its main structure the internal carotidartery.

In the midline the retro-pharyngeal connective-

tissue is condensed into a fairly resistent raphe,which binds the midline of the pharyngeal mucosato the spine, so that a suppurative process whichis opening up a space in the retro-pharyngealconnective-tissue on one side will not readilyspread to the opposite side.

Theoretically the retro-pharyngeal space ex-tends upwards to the septum nasi. Practicallyit extends but a short distance upwards owingto the fact that the subpharyngeal connective-

;oglosnUSbptum linguaea Glandula sublingualis

t N.lingualis tramu7]M triangularis6 Gingiva

i ; N. mentalis/ S ,8 lxi hyoglossus

M.buccinatorA. maxillaris externa

it V. facialis anterior

".,/ Tonsilla palatina

r/ .15 M. mylohyoideux,a1 N. tingzualis

isMj. pharyngop?aatinut,I N.alveolanis inferior.4 1.tyloglosns

.a- lM.stylophaiyngeus* m,PPat~s

M.isN. pterygoideux interousm. longi collihet capitis ct n. glossopharyngenis

_ A. carotis eatorna et n.facialisMbl. tylohyuldeus et V.jugularisexterna

--a Ramux phxux n.aegi et m. d.gastricus(venter postfarorl--- A. Caro intxfita t n. accessorius_ 9?N. hypoglonus et Vjugulais interna

_ .N Geixglion cereicale superius et n.vagust.o . splenius cervicia et m. Iecyt~e scapula.N'mX.*atera rxu et m. aclenuson4xdqaMsaN. sternocleidomastoideuaLA.et v. vertebralis

\ M.loengissimuscapitis\. N. cerv.calisDet n. occipitalis minor

X M. splenius capitix

bl.uemispinalis capitis

. N.occipitalis major

Jas V certicalis profunda

m@ W rectus capitxs posterior major

III.

tissue binds the mucosa very firmly to theanterior face of the basilar process of the oc-cipital bone. Downward there is almost nolimit to the theoretically possible extension.The retro-pharyngeal space may merge into theretro-oesophageal space.

Figure IV taken from St. Clair Thomson6,ilustrates the vertical extent of a retro-pharyngealabscess and, therefore, of the retro-pharyngealspace. It will be seen that the cavity extendsfrom the level of the basi-occipital above tothat of the fifth cervical vertebra below; theswelling is greatest opposite the body of thesecond cervical vertebra. The way in which

637


pressure can be exercised on the upper openingof the larynx is well illustrated.

So much, therefore, to demonstrate the exis-tence and position of the retro-pharyngeal spaceand its lateral connection.

FIG. IX.-RE'rLol IARYNGEAlI . 38CE8E

Section through the cervical vertebrwe, pharyiix, andadjacenit parts of a boy ageld 21/,, sliowinig the cavityof a retropharyngeal abscess. The abscess extends fromthe level of the basi-occipital above, to that of the 5thcervical vertebra below; the swellinig is greatest oppositethe body of the 3rd cervical vertebra. The abscesscavity is lined by a br.ownish membrane; the posteriorpharyngeal wall, which forms the anterior boundary ofthe cavity, appears thickened. The way in whichpressure lhas been exercised on the upper opening of thelarynx is well illustrated. There is no evidence of spinalcaries, nor anything to explain the cause of the abscess.(St. Bartholomew's Hosp. Mus., No. 1841a.)

.The first three figures are photographs of sec-

tions of the adult body and show no lymph-nodes in the retro-pharyngeal space. Accord-ing to Most7 and to Delamere, a few lymph-nodes are found in infancy beneath the mucousmembrane of the pharynx, that is, in the retro-pharyngeal space; but these nodes are said toatrophy before the fifth year in the great ma-jority of cases.These retro-pharyngeal lvmph-nodes are ar-

ranged in four groups, two on each side of themidline of the pharynx. They vary in size andnumber in each group but their general arrange-

ment is vertical. The lateral group is foundmedian to the internal carotid and is describedas more constant than the medial group whichlies in the retro-pharyngeal space closer to themidline. Both groups receive some afferentlymphatic vessels from the accessory nasal sinuses,the nasal fossae, the naso-pharynx, and pharynx,and send efferent vessels to the internal jugulargroup of the posterior deep cervical chain.Fairly constant in the first years of life theselymph-nodes rapidly undergo retrogression, sothat whereas ten or more may be found in theinfant there will rarely be found more than onein the entire retro-pliaryngeal space of the adult.

FIG. V.

Figure V is (liagramnmatic, but a closeapproximation to the exact anatomy as shownby cross sections, and is the result of my observa-tions while studying this region under the in-struction of Dr. H. P. Mlosher, who has beenprominent in emphasizing the importance of thepharyngo-maxillary fossa'0. The advantages ofthis representation are as follows: it shows thatthe large vessels lie in the centre of the space:it emphasizes the fact that the lateral extensionof an abscess would show as a bulge under thelower edge of the parotid in the upper part ofthe neck: and it demonstrates how a petitonsillarabscess will tend to locate in the pterygoid com-partment of the pharyngo-maxillary fossa andhave difficulty in extending either to the carotidsheath or to the retro-pharyngeal space proper.

Further the diagram indicates the structurespenetrated by the incision into a retro-pharyngealabscess, which are: 1, the pharyngeal mucosa;2, the pharyngeal aponeurosis; 3, the superior

638


constrictor muscle; 4, the bucco-pharyngealfascia, (compare left side of Figure II); 5, the looseareolar tissue of the retro-pharyngeal space.The median raphe of the pharynx has been

emphasized. The superior constrictor musclehas been represented by lines parallel to thepharynx to in.dicate that the fibres of the muscleare more horizontal in their course than they areperpendicular which is the anatomical reasonfor our preference for using a vertical incision.

Etiology.-Theoretically suppuration may oc-cur in the tissues between the mucous mem-brane of the posterior wall of the pharynx andthe spine, as the result of: 1, injury to the pos-terior wall of the pharynx from blows or foreignbodies; 2, the burrowing of pus from other re-gions; 3, caries of the spine; and 4, suppurationin the retro-pharyngeal lymph-nodes.During the last eight years there have occurred

at the Hospital for Sick Children, forty-onecases of retro-pharyngeal abscess. Not one ofthese have been known to be the result of anyof the first three theoretical causes just men--tioned. This series may, therefore, be con-sidered to be due in 100 per cent. of cases tosuppurative lyihphadenitis.

In twenty-four of the forty-one cases the onsetwas without assigned cause, but in seventeen,or forty per cent., there was an accompanyinginfectious process in the nose or ears.

Retro-pharyngeal AbscessEtiology

Total cases of retro-pharyngeal abscess..... 41Cases preceded by a definite illness ............ 17Cases of unknown origin ..................... 24

Cases accompanied by acute otitis media....... 7Cases accompanied by naso-pharyngitis ........ 9Cases accompanied by cervical adenitis........ 25

Pathology.-The process is essentially first anadenitis, then a periadenitis, and finally a break-ing down with suppuration and the formation~of an abscess.

In twenty-six cases the absee&s was describedas definitely unilateral; in only a few cases wasit noted that the abscess extended especiallydownward; in no case was it seen to extend muchabove the level of the soft palate; so that it maybe concluded that the majority were confinedto the oro-pharyngeal region.The cervical lymph-nodes below and behind

the angle of the lower jaw on the side of theabscess were enlarged or indurated in twenty-five cases, or sixty-one per cent. They werenoted as inflamed in one case only. In one recent

case the unilateral cervical swelling which wasvisible from a distance disappeared at once fol-lowing the internal incision of the abscess, thereason for which can be easily understood bythe study of plate No. V.The age of the youngest child affected was four

months; that of the oldest was thirty-six months;the aveiage age was fifteen months.Symptoms.-It is manifest that the condition is

essentially one of infancy. The onset is, there-fore, obscure, and dependence for history hasto be placed upon parents who are frequentlypoor observers. Careful tabulation of our re-cords shows that by far the most frequent causesfor the anxiety of the parents were: 1, that thechild was breathing or swallowing with diffi-culty and, 2, the appearance of swelling on oneside of the neck.

* Retro-pharyngeal AbscessComplaint of Parent on admission of Child

Swelling in the neck.....................Breathing with difficulty.................Difficulty in swallowing................Coughing ..............................Feverish ...............................Nose running...........................Ear running............................

242316101097

The history has usually been meagre. Theimpression is gathered that the onset was acutein eleven cases or twenty-seven per cent., andinsidious in twenty-eight cases or sixty-eightper cent.; and that, as a rule, the diagnosis hasbeen made at the first examination of the child.The clinical picture presented by the average

case can be best understood by an examinationof the signs presented by our series of cases.

Retro-pharyngeal AbscessExamination of child at time of Admission

Acutely ill ............... ............... 24Not acutely ill ............. .............. 13Head markedly retracted .11Highest temperature ...................... 104.60Lowest temperature ........... ........... 980Average temperature..................... 100.40Cervical glands markedly enlarged ....... . 25Marked dyspnoea ... ..................... 26Retro-pharyngeal swelling noted as definitely

unilateral ............................. 26

Diagnosis.-The examination of a sick child,especially one with marked swelling of the cervicalglands and with history or signs of difficulty inbreathing or swallowing would be criminallyinadequate without examination of the throat.This should reveal to the physician the presenceof any pharyngeal swelling and hence lead tothe consideration of the probability of retro-pharyngeal abscess.Yet the pharyngeal examination is the step

most often accompanied by error. Our records

639


show that one case was sent to the operating roomfor removal of tonsils and adenoids. The opera-tor, the chief of the laryngological service,looked in the child's mouth, ptut away the tonsil-lectomy instruments, evacuated the abscess andhas since refused to countenance operation onthe throat without previous examination byone of his own department.There are two factors which are responsible

for the non-recognition of the condition. Thefirst is its relative infrequency. The majority ofany class graduating in medicine will not have seena single case. During the last eight years therehave been 33,892 new cases admitted to this hos-pital and yet a total of only forty-one cases ofretro-pharyngeal abscess has been found. Thesecond factor is the great difficulty of making asatisfactory examination of the inflamed throatof an infant or young child, especiall.y if the childbe seen at home in the arms of an apprehensiveor perhaps indignant parent. The sympatheticphysician working under disadvantageous con-ditions tends to relinquish his efforts before hehas completed his examination and palpation.The detection of fluctuation in the swelling shouldat once lead to the diagnosis, but the anatomicrelations of the parts may be thrown into chaosby the squirming of the child or the palpatingfinger may be untrained.However, having determined the presence of a

fluctuating swelling the physician must endeavourto rule out several possibilities before he diagnosesthe condition under discussion here. Tubercu-lous disease of the vertical spine is rare but mustbe considered if there is history of rigidity ofthe neck of long standing, or if the child hold itshead in its hands. In such a case it will beapparent that treatment can be delayed longenough to procure an X-ray photograph of theneck. Aneurysm of the carotid will be excludedby the absence of pulsation. In spinal osteo-myelitis the symptoms will be very acute withhigh fever.

If, on the other hand, there be swelling butno fluctuation the possibility must be consideredof lymphadenitis of the retro-pharyngeal nodeswithout the formation of pus, or of an acutepharyngitis in the throats of patients sufferingfrom cervical scoliosis.

Progress.-In three cases the abscess had beenopened prior to admission; in two cases the ab-scess was opened more than once; in nineteencases the abscess was opened on the day of ad-mission and in the cases so treated the fever, in

all cases but six, lasted for not more than forty-eight, hours following the evacuation of the ab-scess. Only one case died and it was the onlycase which presented any of the possible compli-cations described in the references.Treatment.-Many and various are the methods

enumerated in the texts, for the procedure tobe followed in the surgical treatment of thiscondition. The procedure to be described isthat followed and taught by the laryngologicalservice of the Hospital for Sick Children.A case of retro-pharyngeal abscess is always

to be considered an emergency, to be admittedat once for immediate evacuation of the abscess,and to be given constant supervision until outof danger. The operation is to be considereddangerous but at the same time safe if it isproperly performed.No anaesthetic is necessary. The child is

swathed, placed on its back on a table, and amouth gag inserted. The assistant stands be-hind the child's head, holds it between his twohands, and turns the head so that the abscess ison the lower side. Under inspection by re-flected light the tongue is depressed by a suitabletongue depressor held by the surgeon in his lefthand. The surgeon then takes in his right hand apair of special pointed tonsil scissors, which hepasses closed into the child's mouth until theytouch the apex of the pharyngeal swelling. Thescissors are plunged through the mucosa and thesuperior constrictor muscle covering the swelling,and opened wide so as to make a vertical slitand pulled out while still widely open.

All this is but the work of a few seconds. Theimportant part of the operation is to follow. Itconsists in the attendant at once rolling the childon its side while the surgeon with the tonguedepressor holds the tongue down and the cheekopen so that the pus unable to find its way intothe trachea and larynx flows freely out of themouth. No local after-treatment is necessary.The above procedure sounds and, in good

hands, looks very simple; but the student, beingtaught an operation he may have to perform asan emergency, is cautioned that he must knowwhat he is going to do, must be able to see wherehe is working, and must do what is to be donequickly. A child with this condition may easilyand rapidly die if the operator bungle his job.Of the forty-one cases at this hospital diag-

nosed as retro-pharyngeal abscess in the pasteight years and given the treatment described,not one has been a fatality. One case which

640

THE CANADIAN MEDICAL ASSOCIATION JOURNAL 641

was not diagnosed, died and was found to havebeen suffering from retro-pharyngeal abscess-the case about to be reported.

E. B., 18 months old, was perfectly well untilthree weeks previous to being seen when apatchy sore throat developed. Two weeks latera swelling in the side of the neck appeared whichwas fomented and went down gradually. Thechild was playing about on the day before admis-sion. On the morning of the day of admissionit had a sudden haemorrhage from the mouth andlost about a bowlful of fairly dark clotted blood;and in the evening about seven o'clock had asimilar haemorrhage of about a cupful of bloodof a brighter red colour and more fluid. The signsof exsanguination were then very marked, themucous membranes being almost white.The child was brought to hospital for. trans-

fusion about eleven o'clock that night, was ex-tremely anaemic and died within two minutes ofreaching the admitting room. As the child hadnot been examined, a clinical diagnosis of haemorr-hage, probably gastric, was made, but the autopsyrevealed the true diagnosis of retro-pharyngealabscess with erosion of the internal carotidartery, (Figure VI).

...

dark rdcos It ha sprea dinote hrn

justto theleftofthemidlinebyanopening........

.... .................~....................

FIG. VI.

On dissecting the retro-pharyngeal tissue justto the left of the middle line of the pharynxthere was found an abscess cavity which wouldhold about a drachm of fluicl and which containeddark red clots. It had spread into the pharynxjust to the left of the micl-line by an opening

one-half centimetre in diameter. The wall ofthe internal carotid artery (Figure VII) was erodedfor a distance of about two centimetres and layon the posterior wall of the cavity. The tissuesabout the cavity were red and boggy.

1 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. :.': . '. '.,'.. ..... .'.':":' :

1'''w~~~~~~~~~~~~~~~~~~~~~~.......ocLreF4..........

FIG. VII.

A section made of the tonsil on the side of theabscess showed no inflammatory change. Themuscle wall of the tonsillar fossa was intact andthick. The abscess was, therefore, definitelyretro-pharyngeal and not peritonsillar, and hadextended laterally in the posterior compartmentof the pharyngo-maxillary space and involvedthe internal carotid artery.

All of which demonstrates the truth of themaxim of Georges Laurens-"A retro-pharyngealabscess not diagnosed and not opened is fatalto the child; nearly all treated appropriately,recover. "

BIBLIOGRAPHY

(1) CARMICHAEL, J.; Retro-pharyngeal Abscess in aninfant; sudden death by haemorrhage; Edinburgh MedicalJournal, 1881, 27, July 24. (2) LIDELL, J. A.; Oncertain abscesses of the neck which may cause suddendeath, and how to treat them with success; AmericanJournal Medical Science, 1883, 86, 321, October.(3) TRAVERS, F. T.; Retro-pharyngeal Abscess; secondaryhaemorrhage; ligature of internal jugular vein and com-mon carotid artery on left side; recovery; British MedicalJournal; 1902, 2: 703, September 6. (4) WYLIE,A., AND WINGRAVE, V. H. W.; A case of retro-pharyngealabscess in a female aged 21 years; evacuation of pus fordyspnoea; death from sloughing of the internal carotid;Lancet, 1906, 1: 1042; April 14. (5) EYCLESHYMER ANDSHOEMAKER; Cross-section Anatomy, New York, Appletonand Co. (6) THOMSON, SIR ST. CLAIR; Diseases of the Noseand Throat; London, New York, Toronto and Melbourne:Cassell & Co. Ltd.; 1916. (7) MOST; Chirurgie der Lymph:gefasse und der Lymphdruse, 1917, p. 27. (8) MOSHER,H. P.,; Deep Cervical Abscess and Thrombosis of theInternal Jugular Vein; Transactions of the AmericanLaryngological, Rhinological and Otological Society, 1920.(9) FRANK, I.; Retro-pharyngeal Abscess; Journal of theAmerican Medical Association, 1921, Vol. 77, August 13.(10) PIERSOL, G. A.; Human Anatomy; Philade'phiaand London: J. B. Lippincott Company, 1908.

retro-pharyngeal abscess; and erosion of internal

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