by the bleeding from completing the operation, and brought away only a small fragment. "In the course of fourteen days the calculus dropped from the tonsil into the mouth," and the patient did well. In the other two cases the calculus also escaped from the tonsil into the mouth. BURNS says that "these and, indeed, all tonsillitic concretions have been distinguished by a fetid stercoraceous odour. Sometimes the concretion does not acquire the same degree of solidity as in the cases mentioned. In some patients it forms in the cryptæ of the tonsil, enlarging them, and even projecting into the fauces. Where it assumes that form, it can, by any blunt instrument, be turned out from the recesses of the tonsil in gritty masses of a dirty-white colour. The formation of this gritty matter would seem to be connected with some deranged state of the intestinal canal. It will be necessary to pick the foreign substance from the tonsil, and, to prevent its reproduction, the bowels must be restored to their natural action. It is by no means an uncommon affection." (pp. 263-5.)] 133. If the swelling of the hardened tonsils be so great that breathing and swallowing become very difficult, their partial extirpation is necessary. If the swelling be not very great, two or three transverse, but not very deep, incisions are sufficient to produce their diminution in the course of a few days. The removal is best effected by a narrow, slightly curved, blunt-pointed or button-ended bistoury, or with a narrow, straight, button-ended scalpel. The patient should be placed on a seat opposite the light, his head resting on the bosom of one assistant and a little inclined forwards, and his mouth kept open by a piece of cork placed between the hind molar teeth; whilst another assistant keeps down the tongue with a spatula. The operator fixes a double hook, or MUSEUX's hook forceps, which are preferable, in the swollen tonsil, holds the forceps with one hand and manages the knife with the other, so as to divide as much as is necessary of the tonsil at one stroke from beneath upwards. (The hook or forceps are to be used with the left, and the knife with the right, hand, if the left tonsil is to be removed; but the contrary, if the right.) If the tonsil still remain partially attached, it must be cut off by a second stroke of the knife or with COOPER's scissors. In unsteady patients DESSAULT's kiotome is often preferable, which, when the patient is seated as above, the mouth open, and the hook, fixed in the tonsil, is so introduced with its edge retracted, that the tonsil comes against the slit part of the sheath, and the projecting part is cut off by the protrusion of the knife. The introduction of the hook often produces severe tickling in the throat, suffocation, and so on, in order to avoid which the division may be made without previous introduction of the hook. If, on account of its size, the whole tonsil cannot be received into the curve of the kiotome, a part of it must be removed by two oblique cuts meeting at an angle; or cross cuts are to be made with the kiotome, first at the upper part, and next at the lower third of the tonsil; the isolated part is then to be taken into the curve of the instru ment, and the two transverse connected by a third longitudinal incision. The deep cleft thus formed falls together in the course of five or six days (a). FAHNESTOCK's tonsillitome (b), with the alterations of VELPEAU and RICORD, is preferable to DESSAULT'S kiotome. This instrument closed, that is, with the annular blades covering each other, and with the piercer retracted, is placed over the tonsil, which, projecting through the opening, is to be thrust through with the piercer; the movable stem is then pushed forward upon the immovable one, and the latter, at the same time, drawn back, so that the tonsil is taken off by the rings, of which the inner margins have each a cutting edge. Tying the tonsils is not to be preferred (a) ITARD, Traité des Maladies de l'Oreille et de l'Audition, Paris, 1821, vol. ii. p. 174. to their removal by the knife; but their destruction by caustic is to be rejected. Only in not very great swelling of the tonsils, can their diminution be effected by the repeated application of lunar caustic sufficiently to produce a superficial slough. The removal of the hardened tonsils has been performed from the earliest time by cutting, by tearing out, by tying, and by destroying with caustic. CELSUS advised taking hold of the tonsil with a hook and cutting off the hardened part with a knife. In this manner the operation has been performed with little variation. According to Louis, the cut should be made from below upwards; according to RICHTER, from above downwards, and the imperfectly divided piece is to be removed with scissors; according to MOSCATI, the cuts are to be made in various ways, by splitting the tonsil from above downwards and sideways, by introducing charpie, by removing it piece-meal, and by cauterizing the surface of the wound with nitrate of silver. For holding the tonsil, a single or double hook is employed, CAQUE's hook (a), MUZEUX's hook forceps (b), WASSERFUHR's forceps with thick blunt hooks, so that it may be more easily removed in case of vomiting. For the cutting, a narrow, buttonended, curved or straight scalpel, special knives of PAULUS EGINETA, of CAQUE, of BEN. BELL, of BOYER, DESSAULT'S kiotome; the scissors of SOLINGEN, PERCY, LEVRET; the instrument of RIVIERI (c) and of J. CLOQUET (d), with two branches, which cross, and each of which has an edge at its extremity. Tearing out the tonsils was performed by CELSUS with the fingers; by FABRICIUS AB AQUAPENDENTE with the hook or forceps. Tying the tonsils, mentioned so early as by GUILLEMEAU (e), was performed by SHARP (f) with silver wire or catgut; by CHESELDEN (g) the loop was applied with the finger and fastened with an eyed probe; swellings with a broader base were tied on the side with a double thread introduced by a needle having an eye near the point; by BIBRACH (h) with a silver wire by means of LEVRET's double cylinder; by SIEBOLD (1) with a loop pushed on upon a pair of forceps, the ligature having been slipped on to them by an assistant; BELL introduced through the nose a loop which by means of the finger was carried over the tonsil and tied with a polypus-cylinder introduced through the nose; by CHEVALIER (k), a double thread was drawn through the base of the tonsil, after CHESELDEN'S method and tied with a ring-shaped knot closer. HARD also invented a tying instrument (l) for the same purpose.. Cauterization of the tonsil with red hot iron or with caustic, after the manner of SEVERINUS and WIESEMAN. [ELSE objected to the excision of the tonsils, especially in children, on account of the troublesome and dangerous hæmorrhage; neither was he favourable to tearing them away with the forceps, nor to destroying them with caustic, but preferred CHESELDEN'S apparatus, consisting of a tonsil probe, needle, iron, and speculum oris, or a piece of cork. If the base of the swelling be narrow, a thread can be readily carried round with the probe; but if it be broad, it will be requisite to thrust the needle, armed with a double thread, one white and the other black to prevent confusion, through the base from without inwards, and, when the eye of the needle appears behind the tonsil, the threads are to be taken hold of, the needle withdrawn, and the corresponding threads tied. The instrument for amputating the tonsils, invented by PHYSICK of Philadelphia (m), consists of an oval iron loop, of two plates, rather larger than the ordinary size of the tousils, and attached to a long stem, upon which rests a sliding rod, terminating in a knife of hexagonal form. The tonsil is received within the ring, and the knife being ⚫then thrust forward, cuts it off as it traverses the loop. He also uses a pair of forceps, with lunated extremities, and their opposing faces toothed, to draw the tonsil more firmly through the loop. I do not know whether this is PHYSICK'S guillotine instrument, which has been further improved by MITCHELL, as I have not seen either. Within the last eighteen months, SIMPSON, instrument maker, of Westminster, has adapted THORBERN'S staphylotome (which he has much simplified) to amputation of the tonsil, by giving the sliding knife an oblique cutting edge, like the guillotine knife, and the tonsil, being drawn through the aperture with a double hook, is readily cut off. Each side of the throat requires its own instrument, on account of the obliquity of the knife-edge. In the United States some surgeons prefer scissors to the knife, and others the guillotine instrument of PHYSICK, with or without modification. The best scissors are those of Dr. SMITH of Baltimore, the blades of which are curved on the flat, and bent like a hawk-bill towards each other, so that the points cross when the instrument is shut. Two small steel points are, in addition, attached to the side of each blade, so as to catch the portion excised, and prevent its falling into the glottis (a). GIBSON of Philadelphia (b), with the view of getting rid of the numerous instruments formerly used for the removal of enlarged tonsil, has invented an instrument which at once keeps down the tongue, holds the gland firmly, and separates it nearly at the same moment. "It consists of a pair of forceps nine inches long, the eighth of an inch thick, half an inch broad when shut, with extremities an inch and a-half long, slightly serrated and somewhat curved, including, when closed, an oval space a quarter of an inch wide, and terminating, at the other extremity, in handles which stand off obliquely from the shafts of the instrument. A knife or blade, the length and breadth of the forceps, rounded on its cutting edge, and having a button placed perpendicularly to its axis on the opposite extremity, works backwards and forwards, by means of a groove, to the extent of an inch and upwards, between the blades of the forceps, to one of which it is secured by screws. A sheath upon each end of the forceps, to keep the knife from starting off the moment it touches the tumour, completes the instrument." (p. 27.) "It is to be passed into the mouth with the blades closed, and resting flat on the tongue, which it presses. The instrument is turned edgewise, still resting on the tongue, its blades expanded, placed fairly around and completely behind the tumour, which is then seized and firmly held, while the thumb, resting on the button-like extremity of the knife, pushes it forwards, and instantly separates the enlarged tonsil, which is immediately brought away in the grasp of the forceps." (p. 27.) The ordinary practice now is to remove the tonsil by cutting through with a knife, of which the blade is guarded to within an inch of its tip, the gland being drawn inwards towards the mesial line with a tenaculum or double hook. There is soreness for a few days, but granulations soon form, and the wounded part heals.-J. F.S.] 134. The bleeding after this operation is usually stopped by frequent gargling with cold water and vinegar; or charpie dipped in some astringent wash is applied with dressing-forceps to the bleeding part. In cases of necessity the red hot iron must be applied. During the inflammatory and suppurative periods, soothing and subsequently astringent gargles, with borax and so on, should be applied to the cut surface. If the suppurating surface assumes a luxuriant appearance, stronger astringents, even lunar caustic and the hot iron, must be used. [Of wound of the carotid artery in removing the tonsil gland, I have not met with, nor heard of, a single instance. LAWRENCE writes:-"I have removed enlarged tonsils very frequently, the loss of blood, in the majority of cases, not exceeding a tea-spoonful. It would, I believe, always be so, if the parts are in a perfectly quiet state. I once performed the excision in a gentleman from the country, who was obliged to leave London immediately, where there was a state of active congestion in the fauces; the bleeding was considerable, but not alarming." But their removal is sometimes attended with very fearful hæmorrhage. My friend CALLAWAY informs me, that he has "seen sometimes considerable, and, in one case where he had removed the tonsil by the knife, alarming hæmorrhage in a boy of seven years of age, which required stimuli, &c., to recover him from the fainting which followed." I have to thank my friend SHAW for the following CASE-A man aged forty years was deaf in the left ear, and the tonsil on that side being enlarged, it was excised with the guillotine on Saturday. No bleeding of consequence followed, the gland being hard and light-coloured, as if of old standing. On Monday he complained of sore throat, and the incised surface appeared as if a superficial slough were about to form. On the afternoon of Tuesday bleeding commenced in the lower part of the cut surface where ulceration had taken place adjoining the slough. An oozing of blood, varying in quantity, continued, in spite of repeated attempts to check with styptics, till the afternoon of Thursday, when he was so much exhausted that the See PANCOAST's Treatise of Operative Surgery. (b) Institutes and Practice of Surgery, vol. ii. carotid artery was tied. The bleeding now ceased completely; the wound rapidly closed, and the ligature came away on the twelfth day; in a short time after which he was discharged cured. This case seems to bear a close resemblance to that of LAWRENCE's; and both may, perhaps, be explained, on the presumption that the small vessels of the enlarged tonsil gland were unable either to contract or retract, in consequence of the adhesive matter with which the cellular tissue of the gland was filled, and by which its enlargement was caused, preventing their closure.-J. F. S.] 135. The Uvula is frequently so relaxed and lengthened by longcontinued and repeated inflammation, that great inclination to cough and vomit, and difficulty in swallowing, is produced. In less degrees of swelling strongly astringent gargles of decoction of oak bark with alum, tincture of catechu, touching with acid, stimulating substances, with lunar caustic (1) and so on, are serviceable. In greater swelling, if these means fail, the removal of the uvula is called for. The patient being placed in the same position as for the removal of the tonsils, the uvula is to be taken hold of with a pointed hook, and the superfluous part cut off with scissors or with the kiotome. The after-treatment is similar to that for removal of the tonsils. (1) BENNATI (a) recommends cauterization with nitrate of silver by means of a double caustic-holder. The simple operation of removing the uvula was performed before the time of HIPPOCRATES by cutting, and in this way it has been mentioned by CELSUS, GALEN, ORIBASIUS, AETIUS, and PAULUS EGINETA, by means of the already-mentioned various instruments used for removal of the tonsils, to which must be added the staphylagra of Paulus ÆginETA, to hold, and the staphylotome to cut with; THORBERN'S (of Norway) instrument (b), with the alterations by RAU (c), by BASS (d), by FRITZE (e). The cauterization first mentioned by DEMOSTHENES of Massilia was performed by PAULUS EGINETA with the aid of a staphylokauston, and, by the Arabians, partly by caustic and partly by red hot iron; PARÉ used the ligature and the two FABRICII employed, by turns, scissors, caustic and ligature. [Relaxation and elongation of the uvula is a most troublesome complaint. ASTLEY COOPER, who never removed more of the uvula than would reduce it to its proper proportions, as, if the whole were cut-off, fluids could not be taken without their passing into the nostrils, and without interference with articulation being produced, did not, however, consider any benefit was derivable from the operation, as the uvula almost invariably again acquired its natural length. Neither can I advise it, because from personal experience I know it to be unnecessary. It is commonly sympathetic with irritation of the alimentary canal, and when that is quieted, the uvula resumes its ordinary length. It often becomes very red, lengthens and swells in the course of an hour, and, by its constantly dropping on the epiglottis, irritates it, and excites a constant hacking cough, and frequently a sense of choking; the best immediate remedy for which is closing the mouth, and breathing through the nostrils. I have tried all sorts of astringent gargles, but found little relief from them; and have only been benefited by painting with a strong solution of nitrate of silver twice or thrice a-day, according to the irritation produced.-J. F. S.] II.-OF INFLAMMATION OF THE PAROTID GLAND. LAGHI, T., Historia Epidemicæ constitutonis, in quâ Parotides seroso glutine tumentes redduntur, quæ anno 1753 Bononiæ contigit; in Comment. Bonon., vol. v. p. 1. HAMILTON, R., Account of a Distemper, by the common people in England vulgarly called the Mumps; in Trans. of Roy. Soc. of Edinburgh, vol. ii. p. 59. 1790. HOPFF, Diss. de Anginâ Parotideâ. Goetting, 1799. (a) Bulletin des Sciences Médicales, 1831, Août, p. 215. (b) THOS. BARTHOLIN., Obs. Anatom., cent. ii. obs. 88. SCULTETUS Armament, pl. ix, fig. 1. (c) HEISTER, pl. xxi. fig. 8. Leipsic, 1781. BRENNECKE, Diss. Anginæ Parotideæ Descriptio pathologico-therapeutica. Helmst, 1801. BURNS, ALLAN, Observations on the Surgical Anatomy of the Head and Neck. Edinburgh, 1811. 8vo. GOOD, MASON, M.D., Study of Medicine. London. Second Edition, 1825. Vol. II. 136. Inflammation of the Parotid Gland (Inflammatio parotidis) has a different course, according as it is connected with catarrhal fever, or is a symptomatic, critical, or idiopathic disease. As 137. The Mumps, in Scotland the Branks, (Angina seu Cynanche parotidea, Lat.; Bauernwetzel, Germ.; Oreillons, ou Ourles, Fr.,) consists in a sometimes cold and rather oedematous, at other times hot, tense, painful flat or raised swelling of the parotid and submaxillary glands, with which also the tonsils are sometimes swollen, and swallowing and opening of the mouth prevented. The skin generally preserves its natural colour, or has an inflammatory blush. The swelling is frequently unaccompanied with fever, soon disperses, and does not easily run into suppuration; catarrhal symptoms, chilliness, rigors, and depression commonly precede, and it is mostly connected with fever similar to catarrhal, and frequently with active fever. In these cases a metastasis of the fever easily occurs. the swelling of the parotid gland subsides, a fresh attack of fever with severe shivering, with pain in the loins and pubes, takes place, followed by inflammatory swelling of the testicle, and, in women, of the labia and breasts. Itching and burning in the generative organs, and frequently untimely menstruation, follow. The swelling of the parotid gland often still continues; but sometimes the inflammation, though it may have subsided, returns to the gland. Other parts are also frequently attacked; drowsiness, severe headache, wanderings, inflammatory or spasmodic affections of the breast, active vomiting, dropsical swelling of the whole body, with short breathing and high fever occur. In trifling cases the inflammation often subsides in a few days, sometimes later, with perspiration spreading over the whole tumour or over the whole surface of the body, with critical flow of urine and bleeding from the nose. The passage of this inflammation into suppuration or hardening is very rare. In some cases wasting of the testicle has been observed. [DR. MASON GOOD (a) speaks of two kinds of inflammation of the parotid gland; the one just mentioned, and another, which he calls Parotid Phlegmon, but both exhibiting two species or varieties, a simple or benignant, and a malignant form. The first kind, his parotid phlegmon, GooD briefly characterizes as "a tumour situated under the ear, reddish, hard; pain obtuse, suppuration slow and difficult,” (p. 326,) and is "troublesome, and sometimes fatal." (p. 408.) Of its benignant variety he says:"Though the suppurative process is slow and inactive, the incarnation subsequent upon the breaking of the abscess is regular and unobstructed." He mentions a case of this kind, in which a girl of fifteen years had, after the duration of the disease for ten weeks, "for about a fortnight an evident pointing towards the surface, and a feel of irregular fluctuation; it afterwards broke, a large quantity of good pus drained away daily, and the tumour, which at first was extensive and hard, by degrees very considerably diminished, and clustered or divided into lobes, and at length disappeared altogether." "The abscess, in some cases of this variety, is of considerable magnitude, and consequently the discharge of pus very large." He says, that, sometimes, "the pus has been absorbed, and carried off by metastasis to some remote organ," of which he cites examples. (pp. 327, 8.) The malignant variety, GooD says, "seldom appears in early life, and, in females, seems sometimes to follow upon the cessation of the catamenia. It is still slower in its progress than the preceding; and, when at length it breaks, the pus is (a) Above quoted. |