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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 artery. 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 knife. 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 Murphy. 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 Farlow.' 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 erosion. 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 MEDICAL RECORD. 551 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- maxillary space. 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 autopsy. 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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