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instance. The presence of a septic bacillus that rapidly kills animals inoculated with it, the specific microbe of the bank note, has also been discovered. Besides this, for which the name bacillus septicus aureus has been suggested, there were eight distinct pathogenic species found upon the Havanese notes, among which were the Indocin Pda bacilli of tuberculosis and diphtheria, and the streptococ- cus of diphtheria. October 28, 1893] MEDICAL RECORD. 549 OUINSY AND ITS TREATMENT BY EARLY INCISION.i By JOHN WINTERS BRANNAN, M.D., ST. FRANCIS HOSPITAL, ETC. The subject of this paper may perhaps seem better suited to a society of specialists rather than to an organization like this made up for the most part of general practition- ers. And yet there is probably no one present who has not at some time been obliged to act promptly and without the aid of a surgeon in a severe case of phlegmon of the fauces. The writer, at all events, has been placed in such a situation more than once, and a recent experience of the kind has led him to make Indocin Generic a somewhat extended study of the subject. Until within recent years, the affection we are about to consider was included under the head of tonsillitis. Fletcher Ingalls," in the latest edition of his work, and practically all systemic writers on medicine, still fail to separate the disease from inflammatory processes located in the tonsil, though Ingalls admits that the abscess forms outside the gland itself in at least four-fifths of the cases. Bosworth,^ however, and laryngologists generally, now usually employ the term of peritonsillar abscess as more correctly describing the condition in the throat. I have retained the old name, quinsy, as leaving the ground open for discussion as to the exact seat of the pus in the most common form of the affection. Quinsy is not a very rare disease and in pri\ate prac- tice probably the majority of cases are seen in the first instance by the family physician rather than by the specialist in throat diseases, though the aid of the latter may be recjuired later. A severe case of quinsy is never a light matter to the patient. Though of almost uni- formly favorable prognosis there is, perhaps, no affection which for a time causes such acute discomfort to the in- dividual affected with it. Most cases result in the forma- tion of pus, and until this is evacuated, either spontane- ously or by incision, the patient's misery is extreme. Many practitioners and even some surgeons, among them Verneuil,* have expressed themselves as opposed to instrumental interference. But the general practice at the present day is to give vent to the pus as soon as its situation can be determined. The instantaneous relief given by an opening in the right place is most striking. On the other hand, scarification of Order Indocin the tonsils, as is sometimes recommended, does no good, and usually ag- gravates the patient's condition. As an illustration, I will narrate briefly a case seen by me last spring. The patient was a servant in a family in my neighborhood and was under the care of a physician living in a distant part of the city. I was roused in the night and asked to see her at once, her husband telling me that Indocin Vs Ibuprofen she was in danger of suffocation. I found the patient in great dis- tress, presenting the picture with which you are all fa- miliar. I learned that she had been ill for some three days and that both tonsils had been repeatedly lanced on the previous day with the result of simply adding to her discomfort. With some difficulty I succeeded in opening the patient's mouth sufficiently to get a fair view of the in- terior. Both tonsils were enlarged and red and showed also a white follicular deposit. The uvula was very uedematous, and the soft palate on the left side was enormously swol- len and bulging and livid red in color. To the finger it felt elastic, with a doubtful sense of fluctuation. After applying a solution of cocaine I made a free incision at a point about midway between the base of the uvula and the last upper molar tooth on the left side. There was at once a gush of pus, with immediate relief to the patient, and in two or three days she was well. ' Read Generic Indocin before the American Climatological Association at its tenth Annual Meeting, May 26, 1893. ' Diseases of the Chest, Throat, and Nasal Cavities, 2d edition, p. 362. ' Diseases of the Nose and Throat, vol. iL, p. 125. * Gazette des H6pitaux, 1879, p. 162. I afterward discussed the case with the attending phy- sician. He frankly admitted the good results of the in- cision through the soft palate, but believed that the operation was attended with the danger of wounding some of the large vessels in the neighborhood. As Indocin And Ibuprofen he is a man of large experience and good judgment, and such danger had never occurred to me, I thought the subject would repay investigation. I have asked the opinions of a number of medical men, including both laryngologists and general practitioners, and their answers have been pretty much to the same effect. The specialists have all said that the abscess is usually situated outside the tonsil and Buy Indocin lies in the anterior or posterior pillar of the palate or in the palate itself They believed in giving free vent to the pus wherever found, and were convinced that the operation was attended with no danger if properly per- formed. Indocin Suppository The general Indocin For Pda practitioners were naturally rather less positive in their opinions. They admitted that it was good practice to let out the pus when you were sure where it was, but that it was not always easy to find. On consulting the literature of the subject I found the most recent authorities agreed as to the location of the suppurative process and the proper point for incision. Chiari,' Bosworth,^ and Shech ^ state that the inflamma- tion begins in the connective tissue about the tonsil and usually extends into the soft palate. Indocin Headache They advise that the opening should be made at the point I have already indicated, namely, midway between the uvnala and the upper alveolar process of the affected side. Of 32 cases seen by Chiari, in which pus formed and was evacuated spontaneously or by incision, the point of opening was through the soft palate in 18 cases, through the tonsil in S, through the posterior faucial pillar in 2, through the anterior pillar in i, near the ramus of the lower jaw in 2, and in i case the place of discharge was not found. Bosworth's statistics show that of Indocin Tablets 130 cases of quinsy, the process was located in the soft palate in 115, in the posterior pillar of the fauces in 11, in 2 cases the abscess developed beneath the tonsil and discharged upon its sur- face through one of its Indocin Iv crypts, and in 2 cases the poste- rior wall of the pharynx was involved. In the few cases of which I have notes, seven in num- ber, all seen in private practice during the past three years, the soft palate was uniformly the chief seat of sup- puration. Rice,^ in a careful study published some two years ago, came to the same conclusions as the above, except that he usually prefers to puncture through the anterior pillar of the fauces. All of these writers, with the e.xception of Bosworth, regard the operation as perfectly safe when performed with a good illumination and with care. Bosworth expresses himself as follows: " In making this incision one always bears in mind the proximity of the large blood-vessels of the neck, and the possible danger of wounding them. I have incised the phlegmon in a very large number of cases of quinsy, and in no case have I done it without a cer- tain degree of nervousness on this account ; and yet it seems to me that if one recognizes the true pathological condition, and has localized the suppurating point, one ought to feel confidence in the manipulation. When, however, we Indocin Suppositories 100mg consider that so great a surgeon as Chas- saignac, in operating upon a faucial phlegmon, wounded what was probably the internal carotid artery, necessitat- ing the ligation of Indocin 25 Mg the common carotid, it would seem to be an accident that might happen to anyone. Simi- lar instances are re|)orted by Duke and Murphy." Bosworth's caution would appear to be well founded when we read what the standard anatomists have to say on this point. According to Holden,' " The tonsil Indocin 25mg lies close to the inner side of the internal carotid artery. It ' Wiener klin. Wochenschrift, 1889, ii., p. 820. '^ Loc. cit. ' Diseases of the Mouth, Throat, and Nose, translated by Blaikie, P- 135- ' Medical Record, 1891, vol. xxxix. , p. 125. ' Manual of Dissection of the Human Body, 4th ed., p. 186. 550 MEDICAL RECORD. [October 28, 1893 Indocin Sr 75 is only separated from this vessel by the superior con- strictor and the aponeurosis of the pharynx." Gray ' also warns us that " the relation of the inter- nal carotid with the tonsil should be especially remem- bered, as instances have occurred in which the artery has been wounded during the operation of scarifying the tonsil, and fatal hemorrhage has supervened." (^uain " does not treat of the surgical relations of the artery, but simply states that " it rests on the rectus anticus major muscle and has the pharynx and tonsil on its inner side." Cruveilhier ^ says, "the relation of the artery with the external surface of the pharynx explains how this vessel may be wounded from the interior of that cavity. Some- times one of its curves approaches the region of the tonsil ; and this may, perhaps, have been the case when the artery has been wounded by an instrument directed transversely outward and carried into the tonsil, either to open an abscess or to excise the gland." Leidy,* ex- presses himself in terms almost identical with those of Quain. Tillaux " also asserts that "the tonsil is only separated from the internal carotid by the thickness of the pharyngeal wall," and that "the relations of the artery with the gland should be present Indocin Suppositories to the mind of the sur- geon each time that he opens an abscess of the lateral wall of the pharynx." The views I Indocin High have just quoted of the relations of Indocin Injection the internal carotid artery, are the same as those generally taught by lecturers on anatomy at the present day. The special studies of the laryngologists should, how- ever, lead us to a modification of these views. Delavan " was, I believe, the first in this country to question the accuracy of the observations of the older anatomists. As long ago as 1880, he wrote that " the relations of the ton- sil to the internal carotid artery are not so intimate as commonly is supposed, for, between the lateral wall of the pharynx, the internal pterygoid, and the upper cer- vical vertebrK, there is a space filled with cellular tissue, the ' pharyngo-maxillary interspace,' in the posterior part of which are located the large vessels and nerves, and which lies almost directly backward from the pharyn- go-palatine arch. The tonsil corresponds to the anterior part of this interspace, so that both carotids are behind it, the internal carotid 1.5 centimetre, the external caro- tid two centimetres distant from its lateral periphery. Hence, the danger of direct injury to the internal carotid in excision of the tonsil is infinitely small." Zuckerkandl ' also has recently made a most careful

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