HubertJ Starling
1906 The Lancet  
846 (b) When the deep lymphatic glands of the neck ar enlarged under certain conditions they push the side wall o the pharynx inwards. If the gland which is nearest to th pharyngeal wall has already broken down it will form i tense, rounded, elastic swelling bulging into the oral par of the pharynx. It has, therefore, all the appearances off i pharyngeal abscess, but from its mode of origin it is extra pharyngeal. (The glands in the neck may have enlarged a the result of a purely tuberculous
more » ... ection, but as a rule th4 infection is a mixed one and therefore this type of abscesJ is not classed with those arising from caries of the spine.' It is clear from the mode of its formation that it musi always be preceded by an enlargement of glands in the neck which has persisted for some considerable time. It ough1 to be detected as the result of a routine examination of thE pharynx before it has had time to give rise to characteristi( pharyngeal symptoms. Evidence of softening of enlargec glands in the neck is always carefully watched for in thOSE glands immediately underlying the skin. It is of equal importance to watch for it in those glands which lie close tc the wall of the pharynx. The most satisfactory treatment of intra-pharyngeal abscesses is to prevent their formation. This can only be done when they are detected in the first stage of their formation as a small indurated mass behind a posterior pillar of the fauces. The throat must then be syringed at short intervals with an alkaline lotion and the ulcerated surface of the tonsil painted with a solution of salol in glycerine, or with compound tincture of benzoin, or with any of the usual applications for inflammatory conditions of the throat. A mixture containing chlorate of potassium and salicylate of sodium given every few heurs further aids in keeping the mouth and throat clean. The patient must be kept upon a strictly fluid diet. In many cases the adoption of these measures leads to the disappearance of the indurated mass within five or seven days. As soon as all signs of acute inflammation have disappeared the tonsils must be removed completely by enucleation and so the future formation of an intra-pharyngeal abscess rendered practically impossible. In several hundreds of cases in which this procedure has been adopted so far no case has appeared again with an intra-pharyngeal abscess, whilst in those in which an abscess had already formed before they came under my observation there was not one from which the tonsils had been previously removed. When an abscess has already formed immediate operation is the only treatment. The consideration as to whether the abscess is of intra-pharyngeal or extra-pharyngeal origin will determine the controversy as to whether it should be opened through the neck or through the mouth. No one would seriously advocate the opening of a quinsy through the neck nor would they advocate the evulsion of enlarged glands from the neck through an opening in the mouth. Intra-pharyngeal abscesses can only be successfully treated by an incision made through the inner wall of the pharynx and extra-pharyngeal abscesses by an operation through the neck. In the former case an anaesthetic must be given unless the patient is already moribund from obstructive dyspnoea. A sand-bag must be placed under the shoulders so that the head falls backwards sufficiently to form an inclined plane down which the pus can travel towards the naso-pharynx and yet does not form so great an inclination as to cause a congestion of the pharyngeal plexuses of veins. A guarded scalpel must be used and with the index finger of the left hand as a guide an incision must be made extending over the whole length of the abscess cavity. Unless this is done a pocket will be left at the lower end which cannot be drained properly and will be a fruitful source of future complications. If the abscess is very large it is impossible to make the incision along the whole length of it by one cut. The pus must be evacuated through a small opening, so that the tumour partially collapses, and then the incision can be extended to its proper length. The operator must stand behind the patient's head and the direction of the cut must be from below npwards. The most suitable after-treatment for these cases is to syringe the back of the throat frequently with an alkaline lotion, keep the patient on liquid food, and give a mixture containing chlorate of potassium and salicylate of sodium. Most cases are quite well within from five to seven days after the operation. An extra-pharyngeal abscess must be opened externally through the neck. The operation to be successful involves the complete removal of all the enlarged glands and from re the position of the abscess these have generally to be of removed before the abscess is reached. The direction of ie incision must be so planned that all the glands from the a anterior and posterior triangles of the neck can be removed rt if necessary. When the abscess has been opened the cavity a must be dissected away from the surrounding structures as t-far as possible and when dissection is impossible the lining ts membrane must be carefully removed by a sharp spoon. ie After well washing with a sterilised saline solution the ss wound in the neck must be stitched up. A small drainage-.) tube may be inserted with advantage for 24 hours. In nearly 3t all cases if the infected glands have been adequately removed :, healing takes place by first intention. it These methods have been applied to 25 cases of pharyngeal te abscesses, excluding those arising from caries of the spine. ic In this series there was one death. The child was moribund d from obstructive dyspnoea when admitted to the hospital and ie died from sudden syncope on the operation table. The Ll remaining 24 cases have all been discharged well, those o suffering from an intra-pharyngeal abscess within about a week from the date of operation and those suffering from an 1 extra-pharyngeal abscess within about a fortnight from the e date of operation. There has not been a single instance among f them of those dreaded complications-septic pneumonia, a septic mediastinitis, bronchitis, or a fistula in the neck. e Such complications probably arise from failure to recognise e the type of abscess in each case and therefore the appropriate f site of operation is not chosen. r
doi:10.1016/s0140-6736(01)43301-0 fatcat:xfeep6ewofcellofw7z22ktptm