study of this region. The drawings made from his dis-
sections show that the pharyngo-maxillary space is di-
vided by the stylo-glossus and the stylo- pharyngeus
muscles into an anterior and a posterior chamber. The
anterior chamber is contiguous to the tonsil ; the poste-
rior chamber contains in its hindermost ]5art the internal
carotid artery, the jugular vein, and the vagus nerve.
The two chambers are filled with fat and loose cellular
tissue and communicate with each other by a very small
opening, which gives passage to the inferior palatine
It is probable, as suggested by Chiari, that the anterior
chamber of the pharyngo-maxillary space is alone in-
volved in the great majority of cases of quinsy. The
firm wall formed by the muscles described by Zucker-
kandl prevents the passage of the pus into the [wsterior
chamber, whereas the tissues of the soft palate yield
readily to the advancing inflammation. In rare instances,
however, the pus does force its way backward between
the stylo-glossus and stylo pharyngeus muscles, with the
results to be indicated later.
The soft palate, through which the evacuating incision
is usually made, is distant in adults at least three centi-
metres from the vertebrae against which lies the internal
' Anatomy. Descriptive and Surgical, p. 464.
'' Dose Keflex Elements of.\natomy. StVied.. vol i.. p. 374.
= The An?.tomy of the Human Body, p, 526.
^ Elementary Treatise on Anatomy, 2d ed., p. 483,
^ Traite d'Anatomie Topographique. p. 353.
^ Archives of Pharyngology, 1880, vol. i., No. 4. p. 339.
' Wiener Med. Jahrbtlcher. 1887. vol. vi.. p. 309.
carotid artery. Even in the child the space is consider-
able, larger relatively 500 Keflex Mg than in the adult. I have lately
had the opportunity of dissecting a number of new-born
infants, and in no case did the distance between the
palatal border and the anterior surface of the spinal
column measure less than 1.5 centimetre. These meas-
urements apply to the normal pharynx. In the condi-
tion we are considering, the soft palate is pushed so Order Keflex Online far
forward by the purulent collection that its anterior mar-
gin must be nearly double its normal distance from the
vertebrre. An incision of even two centimetres in depth
could not, therefore, possibly reach the internal carotid
arteiy. The ascending pharyngeal artery, which has been
thought to be wounded in some cases, also lies on the
vertebra;, and is therefore equally out of reach of the
Having apparently shown the impossibility of wound-
ing the carotid artery, what are we to say of the cases
alluded to by Bosworth, Gray, and Cruveilhier. I have
analyzed every case cited Keflex For Mrsa by these writers and have failed
to find one in which the autopsy showed this artery to
have been wounded by the knife. In those cases in
which no autopsy is recorded, it is evident from the clini-
cal history that the bleeding vessel was diseased Keflex Oral Suspension before
the surgeon intervened. Let us first take the cases re-
ferred to by I'lOsworth, those of Chassaignac, Duke, and
Chassaignac ' reported his case to the Surgical Society
of Paris. It was that of a man with a fluctuating tumor
at the base of the lower jaw on the left side, ])rojecting
into the pharynx. There was no pulsation and Chassaig-
nac made the diagnosis of retro-pharyngeal abscess. An
incision was made with no result. A second incision
nearer to the median line was followed by a jet of arterial
blood. The hemorrhage continued in spite of Keflex Dosage local
pressure and was only checked by ligature of the com-
mon carotid. It was a question whether the tumor was
an abscess involving the vessels or was an anomaly of the
internal carotid. It has apparently escajjed the notice of
all commentators on this case of Chassaignac, that he
reported at another meeting of the same society, .some
two weeks later, that the tumor still persisted, leaving its
nature still more in doubt, whether a phlegmon, an
aneurism, or a neoplasm. It is possible, from the location
of the incision, that the case was one of abnormally large
pharyngeal artery, such as those recently described by
Duke's ' case was that of a man who had received a
blow on the side of the head. During the following year
he complained of headaches and sometimes of a rushing
sound in the head. He then had symptoms of a sore
throat. Examination showed Keflex Purchase swelling and inflammation
of the Keflex Online right tonsil and fauces, accompanied with diffi-
culty of swallowing and fever. On digital exploration
with the view of incising the supposed abscess, strong pul-
sation was felt. An aneurismal bruit was also heard
behind the angle of the jaw. Duke refused to puncture
the swelling, but an incision by a less cautious colleague
was followed by free arterial hemorrhage. Ligature of
the carotid became necessary and the patient apparently
recovered. Five weeks later, in consequence of a journey
and the use of spirits, secondary hemorrhage occurred
and death resulted. There was no autopsy. The case
was supposed by Duke to be one of false aneurism,
consei|uent upon the blow to the head. The editor of
the Lancet, however, in commenting upon the case,
thought it rather a case of abscess caused by the blow,
with subsequent communication with the carotid by
The case narrated by Murphy' did not occur in his
own practice, but was simply known to him by hearsay,
he having been in the neighborhood at the time. The
story was as follows : The celebrated Irish surgeon, Cu-
' Bui. de Soc. de Chir. de Paris, vol. x. , p. 83.
'■^ Boston Medical and Surgical Journal, 1890, vol. cxxiii., p. 6.
= Lancet. 1848, vol. i. , p. 233.
< Albany Medical Annals, 1888, vol. ix. , p. 78.
October Keflex Order 28, 1893J
sack, of Dublin, was shooting with friends on the bogs of
Tipperary. A woman suffering from tonsillar abscess
was brought to him. He plunged his lancet into the
tonsil and she died of hemorrhage in five minutes.
There was no autopsy, as the surgeon was obliged to run
for his life. It was thought at the time (fifty years ago)
that the internal carotid artery had been wounded. In
the light of our present knowledge it is more probable
that the hemorrhage was due to previous ulceration of
the carotid or was from the tonsillar artery, as in the
following case of Stanley.
Stanley's ' case is very instructive, the clinical history
being supplemented by an autopsy. The patient, a man,
twenty- four years of age, entered St. Bartholomew's Hos-
pital, bleeding slightly from the left tonsil. The tonsil
was the seat of an abscess which had been punctured by
a .surgeon in attendance outside the hospital. The
hemorrhage recurred from time to time during the next
three days, then became profuse, necessitating the liga-
ture of the common carotid artery. The patient did well Buy Keflex
for eight weeks, then died suddenly from acute softening
of the brain. It had been supposed that the internal
carotid artery had been wounded, but the autopsy re-
vealed a wound of the tonsillar artery and not of the Keflex 500mg Price
carotid. Had a correct diagnosis of the condition been
made in this case, the hemorrhage might have been
checked by pressure over the tonsil, or, at all events, by
ligature of the external carotid instead of the much more
serious operation that was resorted to.
The above cases comprise all those 1 have been able to
find recorded in which excessive hemorrhage has followed
incision of an abscess in or about the tonsil. And in no
one of them was it proved that the internal carotid artery
was wounded by the knife of the surgeon. But there is
another danger to be considered in operating on a phleg-
mon of the fauces, which has been alluded to in the his-
tories of the cases of Duke and Murphy. A number of
instances have been reported of fatal hemorrhage in
quinsy, in which autopsy showed an Purchase Keflex eroded or ruptured
artery, generally the internal carotid. Both Bosworth '
and Chiari '' mention the occurrence of this accident,
but neither one connects it with the operative interference
of the attending surgeon. And yet it is the evacuation
of the abscess into the pharynx, whether spontaneously
or by incision, that causes the rupture of the weakened
walls of the artery, or allows free escape of the blood
already outside of the vessel, but pent up in the pharyngo-
It has long been held by surgeons that the walls of
arteries are proof against the destructive action of pus, so
that even prolonged contact with it does not cause per-
foration of the vessel, unless there be local mechanical
irritation, as from a drainage-tube or a bony sequestrum.
When Liston ' reported his celebrated case of spontane-
ous perforation of the common carotid artery fifty years
ago, the London Medical and Surgical Society refused
to incorporate it in their Transactions, and he was obliged
to publish it at his own expense. Since that time, how-
ever, other cases, e(|ually striking, have been recorded,
and it can no longer be doubted that spontaneous ulcera-
tion of arteries does occur simply from the corrosive ac-
tion of pus.
Monod,' in an interesting study of this question, made
a collection of eighty-eight cases of erosion of arteries,
including six in which the carotid was the vessel involved
as a complication of quinsy. Vergely " adds ten cases of
perforation of the carotid to Monod's list, one of the cases
being from his Keflex Dose own practice. Four of Vergely's cases
are not strictly instances of acute suppuration in the ton-
sillar region, hence I have excluded them. I have, how-
ever, found eight additional cases " in the literature of
' Lancet, 1859, vol. ii., p. 509, and i860, vol. i. . p. 35.
' Loc. cit. a Loc, cit.
' On a Variety of False Aneurism, Bvo, pp. 39. J. Palmer, London.
'■ Bui. et Mem. de Soc. de Chir. de Paris, 1882, viii.. p. 666.
" Jour, de Med. de Bordeaux, 1886, Nos. 49. 50, and 54.
^ These eight cases are reported by the following observer^ ; Xor-
ton : The Throat and Larynx, London, 1875, p. 12. Miiller : Bui.
the subject, making a total of twenty in all. All of these
were cases of acute faucial phlegmon. The only doubtful
one in the series is that of Keflex 1000 Mg Duke, in which the long dura-
tion of the symptoms and the history of trauma com-
plicate the question somewhat.
It is not necessary to give all these cases in detail, as
they resemble each other very clcsely. In 18 the open-
ing was spontaneous, occurring in ,5 cases on the third day
of the disease, in 4 on the eighth, and in i as late as the
twelfth day. The 2 cases, those of Duke and Murphy, in
which the Keflex 400 Mg hemorrhage followed upon operative interfer-
ence, have already been given above. The common
carotid artery was ligated in 7 cases, 4 of which recovered,
the other 5 dying of secondary hemorrhage or of cerebral
softening. Of the 13 patients in whom the carotid was
not tied, all died but one. He was apparently saved by
syncope, though the hemorrhage was supposed to have
come from the internal carotid artery. Autopsies were
obtained in 8 of the 20 cases, showing perforation of the
internal carotid artery in 5. The source of the hemor-
rhage proved to be the internal maxillary in one case, a
branch of the external carotid in Keflex 500mg one case, and the ton-
sillar artery in one case.
In the fatal cases without autopsy, and in the cases
which recovered, the hemorrhage was attributed to the
internal carotid in all but one. In that case the ascend-
ing pharyngeal Keflex 750 Mg artery was thought to be the vessel in-
volved, but upon what grounds does not appear in the his-
tory. It may be well to give brief details of two of the
most striking cases in which the diagnosis was verified by
The first case is that of a man, forty-four years of age,
of previous good health, whose symptoms were those of
an Antibiotics Keflex ordinary acute sore throat. Miiller,' who reports Keflex 250 Mg the
case, first saw the patient on the seventh day of his ill-
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