PERREZ (a), who is a disciple of BROUSSAIS, does not consider incision of a carbuncle sufficient unless it produces free bleeding, and, if it do not, then leeches are indispensable, "the incision merely putting an end to the mechanical cause which adds to the existing irritation; and the latter continuing after, although much diminished by the separation of the slough, requires a persistence in the antiphlogistic remedies to lessen still further and to put it out completely. Marsh-mallow or linseed-meal poultices must be used, and if, from any cause, the inflammation be re-excited, local and general means must be had recourse to. In the case which PERREZ mentions as having treated on these principles, the advantage gained does not seem so great as he would wish to be inferred. On the first day thirty leeches and on the second fifteen leeches were applied, and the carbuncle covered up in boiled marsh-mallow poultices. The patient was strictly debarred from all solid or liquid food for three days, during which time she was, being of a nervo-sanguineous temperament, well drenched with a quantity of acidulated and gummy drinks. In the following days the sloughs separated, and, as usual, the pain almost entirely subsided. A short time after, the surface again inflamed, leeches were applied around, the wound did well, but, from the recital of the case, although not positively stated, probably not very quickly. The older surgeons, and even POUTEAU, employed caustic, and even the actual cautery; but both practices are now completely exploded.] 123. The Malignant Carbuncle requires, especially, the proper treatment of its accompanying fever, and the local application of stimulating poultices, even of the actual cautery, or other caustics, if the swelling will not proceed the other treatment agrees with that already described. THIRD SECTION. OF INFLAMMATION IN CERTAIN SPECIAL ORGANS. I.-OF INFLAMMATION OF THE TONSILS. LE CAT, C. L., Mémoire sur l'Extirpation des Amygdales Squirrheuses, in the Journal de Médecine, vol. ii. p. 115. 1755. Louis, Sur la Resection des Amygdales Tuméfiées, in the Mém. de l'Académie de Chirurgie, vol. v. p. 423. DESAULT, Euvres Chirurgicales, vol. ii. PERRIN, N., Diss. sur la Rescission des Amygdales, Paris, an XIII. 4to. CHEVALIER, THOMAS, Description of an improved Method of tying Diseased Tonsils, in Med.-Chir. Trans., vol. iii. p. 80. PHYSICK, PH. SYNG.; in Philadelphia Journal of the Medical and Physical Sciences, vol. i. 1820, November, p. 17. LISFRANC, Considérations anatomiques, physiologiques et pathologiques, sur la Luette, in Révue Médicale, July, 1823. CHOLLET, Des Moyens Chirurgicaux appliqués au Traitement de l'Amydalité. Paris, 1827. 124. Quinsy, or Inflammation of one or both Tonsils, (Angina Tonsillaris, Lat.; Kehlsucht, Germ.; Esquinancie, Fr.,) when accompanied by much swelling, interferes with swallowing and breathing; the patients speak through the nose, and are much troubled by the phlegm which collects in the throat. Not unfrequently there is singing and pain in the ears, from closure of the Eustachian tubes. The swollen tonsils are felt beneath the jaw, and seen distinctly when the patient's mouth is opened and the tongue thrust down; and the swelling is often so great as to block up completely the passages of the throat. More or less active febrile symptoms are present, according to the degree of the inflammation. (a) As above. 125. This inflammation originates most commonly from cold in delicate persons unused to exposure to the air, also from any severe irritation of the throat, from spreading of the inflammation from other parts, from the venereal disease, from eruptions of the skin, and so on. 126. In most cases the inflammation of the tonsils is resolved; not unfrequently it runs into suppuration less indeed as consequence of its own activity than of a peculiar disposition which inflammations of the throat in many persons have to pass into suppuration, more especially if former attacks of the kind have terminated in a similar manner. This may be looked for when the inflammation of the throat has existed for several days with uniform severity, when the sensation of pressure in the throat becomes greater and much mucus is collected therein. The passing into hardening is never observed in active, rapid inflammation of the throat, but when it creeps on slowly and recurs frequently; the consequence of which is, a growth (or hypertrophy) of the parenchyma of the tonsil gland rather than an actual hardening. The passage into gangrene is always dependent on a malignant character of the accompanying fever, and is extremely dangerous. [Abscess in the tonsil having once occurred, is very commonly again and again produced whenever inflammation attacks the gland, and so quickly that any attempt to prevent its formation is useless, the inflammation rushing, as it were, headlong into suppuration. During its course the agony and inconvenience are very great; but, on the bursting or opening of the abscess, the symptoms as suddenly cease. Dr. TWEEDIE(a) says, that although enlargement of the tonsils results from repeated attacks of inflammation, "it is, however, in some instances congenital, and occasionally appears to be hereditary, and in such individuals it is often associated with traces of the strumous diathesis. The enlargement generally exists without induration of the tonsil, more especially when it occurs in young persons: when it arises as a consequence of inflammation, and more particularly in elderly people, the enlargement is generally accompanied by induration." (p. 185.) Gangrene of the tonsils is very rare, and in the two cases, both fatal, mentioned by GUERSENT (b), it was only attendant on more important disease. In the first case the tonsils appeared to be attacked simply with severe inflammation, and were fortunately relieved by antiphlogistic treatment; but subsequently they became livid, produced a secretion resembling wine lees, and very offensive, and on the seventeenth day the patient died. On examination, besides softening and black or dark-grayish disorganization of the tonsils and soft palate, the same change was found in a portion of the right lung. In the second case, the tonsils were at first but slightly inflamed; on the third or fourth day, however, they assumed a brownish colour, and a very offensive smell, and when cut into were not painful. The patient gradually sunk with vomiting and severe gastro-enteritis, but unaccompanied with much febrile excitement. After death the mucous membrane of the stomach and part of the small intestines were bright red, and in the former covered with a white soft elastic false membrane. (p. 134.)] 127. The treatment differs according to the activity of the inflammation and the accompanying fever. In slight inflammation mild diaphoretics are of service, as elder and lime-flower tea, solution of acetate of ammonia, hydrochlorate of ammonia, and so on; in the more active degree, bleeding, application of leeches, nitre in emulsion, calomel. For bathing the inflamed part soothing decoctions are used in form of gargles or injections, which latter more readily clear away the mucus and do not produce any straining of the parts. The inhaling of warm soothing vapours also serves the same purpose. *** [Dr. WATSON (c) says the only gargle he considers "admissible in the commencement of the malady, is a gargle of warm milk and water. But far better than any(b) Dict. de Médecine, vol. ii.-Article, Angine Gangreneuse. (a) Diseases of the Throat; in Cyclopædia of Practical Medicine, vol. iv. (c) Lectures on the Principles and Practice of Physic, vol. i. London, 1843. 8vo. thing else, as a local application to the inflamed fauces, is the steam of hot water; whether we are hoping for resolution of the inflammation, or whether we desire to promote and hasten the process of suppuration already begun. *** The most convenient and effectual inhaler is that of HERCY, from which a large volume of steam is carried inwards against the fauces by the mere natural breathings of the patient." (p. 790.)] 128. In great swelling of the tonsils scarifications are specially useful; these are made with the palate-lancet or with a common bistoury, the edge of which is guarded nearly to the point, or with the pharyngotome. The patient is to be placed so that the light may fall into his mouth, which is kept open by thrusting a piece of cork between the molar teeth; the tongue is pressed down with a spatula, and shallow cuts are made with the instrument just mentioned into the swollen tonsils. The bleeding is to be promoted by soothing luke-warm gargles. [In scarifying the tonsils, there is danger of wounding the carotid artery, or some branch, which will continue bleeding and cause serious alarm. WATSON mentions in his Lectures a case of fatal bleeding from wound of the internal carotid artery :—“ Only a very few years ago, in Ireland, it was struck by a surgeon while scarifying a gentleman's tonsil, and he died in three minutes." In another case, which occurred under WATSON'S Own care in 1838, in which the tonsil glands, during convalescence from scarlet fever, having become so enlarged as to impede breathing considerably, “the surgeon in attendance punctured the tonsils. The next day a good deal of hæmorrhage took place; and this recurred several times, to a considerable and even alarming amount. When the clots that formed were wiped away with a sponge, the blood could be seen welling out in a little stream, with a pulsating motion, from a small incision in the left tonsil. The hæmorrhage was ultimately, after much trouble and anxiety, arrested, by applying a pencil of lunar caustic freely within the bleeding orifice." (p. 792.) I believe, in such a case, the use of the actual cautery would be preferable to any other remedy, and should certainly employ it if opportunity occurred.-J. F. S.] 129. When the inflammation subsides, but the swelling still continues, astringent remedies, as the liquor ammonia acetatis, hydrochlorate of ammonia, sage, vinegar, and so on, are to be added gradually to the gargles, by the proper employment of which the disposition of the parts to chronic inflammation is prevented. 130. When an abscess forms in the tonsil, which can be distinguished by the above-noticed signs (par. 126), by fluctuation on touching the tonsil with the finger, and often by the pus itself showing through, and it does not break of itself under the use of softening gargles, great danger of suffocation, or burrowing of the pus, is to be feared; and it must then be opened with a guarded bistoury, or the pharyngotome, used as in scarification of the tonsils. Irritation of the throat, and straining by vomiting, often effect the bursting of the abscess. After the pus has been discharged, soothing gargles with honey are to be frequently used, and commonly produce a speedy cure. In rare cases the abscess penetrates externally beneath the jaw, and then must be treated as common abscess. [In reference to the spontaneous bursting of abscess in the tonsil, which generally occurs between the pillars of the fauces, ALLAN BURNS (a) observes:-" But Dr. BROWN has informed me that in two patients it burst through the velum palati. In both these cases, the sore formed very much resembled a venereal ulcer, and, without great care, in tracing the origin and progress of the disease, would have been mistaken for a venereal affection. I may also mention," he continues, "that where the chief prominence in abscess of the tonsil is seen, not between the pillars of the fauces, but on the fore part of the velum, it is not to be expected that the tumour will point as in external suppurations. On the contrary, the pus will continue long deep-seated, and, were the surgeon to delay, in the expectation that it would become more superficial, the patient, before this event took place, would be suffocated. So soon, therefore, as the difficulty of breathing renders it necessary, an opening is to be made in the abscess, and that even where the matter is still (a) Observations on the Surgical Anatomy of the Head and Neck. Edinburgh, 1811. 8vo. deep-seated; but fluctuation, generally obscure indeed, must be felt, before we presume to thrust an instrument into the tumour. If this point be not fully ascertained, a polypus may be mistaken for an abscess of the tonsil." (p. 255.) BURNS considers that the bursting of a tonsillar abscess is attended with much danger. He says:-"Whenever the abscess bursts, the mouth and fauces are filled by a gush of matter, every obstruction to the free entrance of the air is suddenly removed, the patient fetches an involuntary and deep inspiration, air and matter rush together into the trachea, and death, from suffocation, is almost the immediate consequence." And, in support of this statement, he mentions the case of a strong, active, young man who thus lost his life :"He had been complaining for a few days of a sore throat, for which he had consulted his surgeon, who had employed the usual remedies. The inflammation terminated in suppuration; the abscess enlarged, till, at length, the tumour occupied almost entirely the fauces; yet, ten minutes before his death, he was walking about the house, restless indeed, anxious, and gasping for breath. The bursting of the abscess and death followed each other so rapidly, that no measures could be taken to prevent the latter event. The cause of death was not conjectured in this instance. The body was examined, and the trachea found deluged with purulent matter. To prevent a similar accident, it would be advisable, where the tumour is large, and the difficulty of breathing great, to puncture the abscess as we would do a hydrocele. Were the matter evacuated through a canula, there would be no risk of its finding way into the windpipe, and, if the stilet were made to project only a little beyond the canula, the trocar may be as safely used as any other instrument." (p. 257, 8.) In most cases of tonsillar abscess, the effort of vomiting excited by emetics is generally sufficient to burst the walls and discharge the pus; but, if this treatment be ineffectual, and the patient's breathing be much interfered with, it is better to open the abscess, for which ALLAN BURNS gives the following directions:-"One who is familiar with the parts in connexion with the tonsil, will, in entering the knife into an abscess here, take care not to direct its point in the line of the angle of the jaw; for, he is well aware, that if he do this, he may injure a large artery. He will push the instrument into the front of the cyst and carry it directly backwards, as if he intended to cut off a segment of the tumour; if he follow this course, and transfix the abscess, the worst which can happen will be injury of the back part of the pharynx, a trivial accident when compared with the effects resulting from opening a large blood-vessel." (p. 257.) I think, however, that a gum-fleam is the most convenient instrument; its edge should be rested against the enlarged gland, as near the mesial line of the body as possible, to penetrate the swelling and then moved vertically and gently up and down, the handle of the instrument being held like a pen, till the abscess is penetrated, which in general is done quickly, and immediately the pus appears the fleam should be withdrawn. It is recommended, very properly, that the incision or puncture should be made directly backwards or from without, inwards and backwards, to avoid puncturing the internal carotid artery which might be easily done if the knife or fleam were thrust outwards. The student is always very properly exhorted to puncture tonsillar abscess with great caution, for fear of wounding the carotid artery. But, although this operation must be often carelessly and clumsily enough performed, yet dangerous bleeding is not so frequent as might be expected; and I have only been able to collect the following authentic accounts: - PORTAL (a) mentions a case in which, in performing this operation with a pharyngotome, "a dexterous surgeon of Montpellier had the misfortune to open a large artery, and see the patient perish of so severe a hæmorrhage that nothing could arrest it." (p. 509.) ALLAN BURNS also says:- In this country, (Scotland,) I have been informed that a surgeon, in opening a tonsillitic abscess, actually did plunge the knife into the carotid. I need hardly add that he lost his patient before he could suppress the bleeding." (p. 256.) My late colleague TYRRELL was accustomed to mention, in his Surgical Lectures, a case to which he was fetched by a practitioner, who, having punctured an abscess in the tonsil gland, the wound was immediately followed by severe bleeding, and the patient was dead before he could reach the house. Sir BENJAMIN BRODIE informs me that he is cognizant of two cases in which death from bleeding ensued after the puncture of tonsillar abscess. From the puncture of an immature tonsillar abscess, alarming hæmorrhage may occur, without, however, destroying life; for the following instance of which I am indebted to my friend LAWRENCE:— CASE." In a gentleman labouring under cynanche tonsillaris, a premature puncture was made, with the expectation of evacuating matter. A most profuse bleeding ensued, (a) Cours d'Anatomie Médicale, vol. v. which stopped from the occurrence of fainting, and did not recur. It, however, not only seriously alarmed the patient and those around him, but also the gentleman who made the puncture. A long time elapsed before the patient recovered his strength."] 131. When inflammation of the throat passes into mortification, the fever especially must be treated according to its character. The local treatment consists in removing the sloughs and foul ichor from the throat by injection of decoction of bark, of scordium with alum, camphorated vinegar, and so on. Hydrochloric acid with honey applied with a pencil of charpie on the mortified part is of great use. 132. The hardening of the tonsils which remains after inflammation, is of a good character; it is little painful, but is commonly subject to repeated inflammatory attacks, yet very seldom does it run into cancer. It may be treated with gargles of hemlock, belladonna, hydrochlorate of ammonia, and so on; by rubbing of mercurial or iodine ointment externally upon the neck, by the internal use of hemlock and by derivation, by repeated scarifications and the frequent use of leeches. If inflammation should occur and run on to abscess, suppuration must be suitably promoted, and the opening of the abscess delayed till all hardness has subsided. In hardening of the tonsils, frequent painting during the day with fresh juice of chelidonium, at first mixed with honey of roses, but subsequently pure, is very efficient. [ELSE (a), who, many years since, was Surgeon to St. Thomas's Hospital, denied that this so-called scirrhus of the tonsils was true scirrhus; the tonsils, in his opinion, never being affected with scirrhosity. And TWEEDIE (b) observes on this point:-" It is more consistent with pathological anatomy to ascribe those cases of supposed scirrhus of the tonsils to hypertrophy and induration alone." (p. 185.) A very common attendant on enlargement of the tonsils is a disagreeable roughness of the voice; and deafness also is produced, either by blocking up the apertures of the Eustachian tubes, or by pressing against their cartilaginous part. It has also been asserted within the last few years, that enlarged tonsils are the cause, or one of the causes, of stammering, in consequence of which they have been very freely lopped by the practitioner who broached the opinion, but the success of his operations has been less than he would wish to allow (c). Local treatment with astringent gargles, in these cases, is of little benefit, and painting the tonsils with nitrate of silver not much more efficacious, though it should be tried. I believe that constitutional treatment, attending to the state of the bowels, and giving occasional doses of rhubarb with calomel, or mercury and chalk, and a grain or two of sulphate of quina, twice or thrice a-day, with good diet and fresh air, is by far the most efficacious proceeding; although, whatever may be done, the tonsils, once enlarged, will, under excitement, again and again enlarge, and be very troublesome.-J. F. S. In connexion with the inflammatory affection of the tonsils, and its occasional results, it may be convenient here to notice the formation of calculi in these glands, of which ALLAN BURNS makes the first mention. He says:-"It is not to be inferred that every chronic enlargement of the tonsil depends on thickening and induration of the substance of the gland; it is sometimes produced by the formation of calculi. These seldom in the amygdala acquire any considerable size; but their presence is productive of irrita⚫tion and repeated attacks of cynanche, the inflammation generally proceeding to suppuration. After each successive discharge of matter, a solid and circumscribed tumour remains in the situation of the tonsil, where, sometimes by a probe, the calculus may be detected." (p. 261.) He mentions three cases of this disease, all occurring in members of the same family. In the first there was, during eighteen months, repeated abscess of the tonsil, which burst always externally; a regular and solid tumour was then noticed on the left side, which protruded the skin just below the angle of the jaw, and was followed by a severe attack of inflammation, which ended in suppuration, and bursting externally by eight small apertures, discharged matter during a full year. She then applied to a surgeon, who, having probed the wounds, found a calculus in the gland, and attempted its removal by an external incision, but was deterred (a) MS. Lectures on Surgery. (5) Above quoted. (c) On the Cure of Stammering, by the removal of the Uvula and Tonsils; in the Lancet for 1840--41, vol. ii. p. 587. |