OBSERVATIONS SURGICAL ANATOMY HEAD AND NECK, ILLUSTHATED BY antr BY ALLAN BURNS, Member of the Royal College of Surgeons, London,- and Lecturer on Jlnatomy and Surgery, Glasgow. FIRST AMERICAN EDITION, WITH A LIFE OF THE AUTHOR; AND ADDITIONAL CASES AND OBSERVATIONS. BY GRANVILLE SHARP PATTISON, SURGEON, Professor of Surgery in the University of Maryland, &c. &c. Ealtttnort: PUBLISHED BT F. LUCAS, JR., K. J. COALE, AND CUSHING & JEWETT; and H. CARE! & I. LEA, PHILADELPHIA, John D. Toy, printer. 1823. DISTRICT OF MARYLAND, TO WIT: BE IT REMEMBERED. That an this seventh day of August, in the forty-eighth year of t!.e independence of the United Staien of A.-neitc,. Gtanville Sharp Pattison, of the said District hath deposited in this office the title of > book, the right whereof he claims as proprietor, in the words following, to vvit: "Observations on the Surgical Anatomy ol the Head and Neck, iiinstra-ed In Case, and Ensravings. Bv Allan Bni Member of the Royal Col.ege of Surgeons, London; and Lrctuter on Anatomy and Surgery, Glasgow First American Edition, with a Life of the Author, and atidit-onal Cuses and Observations. By Gianville Sharp Pauiion, Surgeon, Professor of Surgery in the Univei s:ly i,f Maryland, &c, &c » In conto;rnity with the Act of the Congress of the United State*, entitled, -*An Act lor the encouragement of l-?rning, by securing the copies of m>ps, char'*, and hooks to the authors and proprietors of sticii copies, during the times therein mentiuned: • and also tu the Act, entiiled, "An Act Supplementary to the Act, entitled -An Act fnr the encouragement of learning, by securing the coptrs of maps, charts and books, to the authors and proprietors of such copies, Hunng the times' therein mentioned,' and extending the benefits thereof to the arts of designing, engraving, and etching, historical and other prints." PHILIP MOOP.E, Clerk ol the District oj Maryland. MS B EDITOR'S PREFACE FIRST AMERICAN EDITION To affix one's name to the productions of others, as the editor of their works, has ever appeared to me a very humble office for a man who has a respect for his own reputation. I am aware that this has been much in fashion in this country; and, that even men of distin- guished character and great acquirements, have condescended to become the mere press correctors for their Trans-atlantic brethren. I trust the day will never arrive when we shall cease to value European publications of merit; but, I sincerely hope, that the time is now at hand, when men of talent in this country, 1 ii EDITOR'S PREFACE. will disdain to become the name-fathers of works for which they have only performed the slavish duty of reading the proofs, and correcting the typographical errors. As I at present appear before the public in this cha- racter; one, which under other circumstances I should consider a degradation, I am very anxious that the objects which have induced me to do so, should be fully understood. My late very dear friend, Allan Burns, pub- lished the present volume as the commence- ment of a series, it having been his intention to have proceeded upon the same plan, and described all the other parts of the body, so as to have formed a complete system of Surgical Anatomy. The Surgical Anatomy of the Head and Neck, was however, all of the work which he was permitted to finish, and I am not aware that he has left a single note for the completion of the other departments of the System. Honoured by Mr. Burns during the term of my professional studies, with a friendship and EDITOR'S PREFACE. iii affection which resembled more the love of a brother than the regard of a preceptor, at his death I was bequeathed, as a testimony of his esteem, the copy-rights of all his works. My having become the legal possessor of these, is not however the cause which has induced me to become their editor. The Surgical Anatomy of the Head and Neck having been out of print, I was applied to, before I left Europe, for permission to publish a new edi- tion, to continue myself the plan which Mr. Burns had commenced, and to complete, by a series of new volumes, the Surgical Anatomy of the whole Body. My removal to this coun- try having prevented me at that time from fulfilling this engagement, the object of the present publication is now to commence it, and I propose to publish every autumn a new volume, until the system shall be completed. Feeling persuaded from my education, that had I attempted to write myself the volume on the Head and Neck, that my views and descriptions would have borne so close a iv EDITOR'S PREFACE. resemblance to those of Mr. Burns, as to have subjected me to the charge of plagiarism, I have considered it best that his work should form the first volume of the series. In republishing the Surgical Anatomy of the Head and Neck, I have added a life of the author, and an Appendix. In the former, I have given a very short history of Mr. Burns' professional labours, other circumstances hav- ing been merely stated so far as they have tended to connect and illustrate their origin, and the order of their occurrence. Knowing well the high reputation which this book has obtained in Great Britain, I have felt so appre- hensive, lest it should be suspected that by its publication, I was desirous to obtain a surrep- titious reputation, that even in the Appendix I have endeavoured to avoid, as much as possi- ble, any appearance of attempt at originality. Therefore, in stating any improvements, I have employed, where I had the power, the language of their authors. I once intended to have posted up all that had been done in the EDITOR'S PREFACE. branches of surgery mentioned in this work, from its publication to the present day, but, I soon discovered that to do so, I should have been obliged to make the Appendix as large as the rest of the book. I have there- fore confined myself to the relation of some remarkable cases which, from their connex- ion with the anatomy of the head and neck, tend either to support or controvert the opin- ions of Mr. Burns. In the future volumes, the subjects of aneurism, tumours, &c. &c. will necessarily require to be mentioned, and I shall then have an opportunity of laying before my readers, a concise statement of any new views or modes of treatment introduced to public notice, since the date of the publication of the first edition of this work. Baltimore, Oct. 10, 1823. Vlll LIFE OP THE AUTHOR. application, he was enabled two years afterwards to take upon himself the sole direction of the dis- secting-rooms of his brother, Mr. John Burns, who, at that time was a lecturer on anatomy and surgery in Glasgow. From the excellent opportunities he here enjoyed for cultivating the study of anatomy, and from the enthusiasm with which he pursued anatomical inquiries, it is not surprising that he soon became a very good practical anatomist. But his mind was not to be satisfied with mediocrity; he was anxious to be superior, not equal with his cotemporaries. Placing before himself, as models for imitation, the men who had been the most dis- tinguished in his profession, and aware, from their histories, that they had only obtained honour and eminence by unwearied application, his exertion in the pursuit of professional knowledge, so far from relaxing, increased with his acquirements. In fulfilling the duties of his situation as his brother's demonstrator, it was necessary for Mr. Burns to be much occupied in making anatomical preparations. The preservation of preparations in spirits was performed before his time, in as elegant a manner as possible by the Hunters and Monros. Vascular preparations were, however, by no means, dexterously executed; to the preser- LIFE OF THE AUTHOR. 1A vation of these he therefore particularly directed his attention; — he changed both the injections and manner of injecting; he dissected the parts more minutely than had been done before him, and, from his attention to this branch, I can state without hesitation, that his collection of vascular prepara- tions were, at one time, superior to any other in the world. Mr. Burns' time was, however, at this period by no means wholly occupied in making prepara- tions; he visited a number of his brother's cases, and noting the symptoms of the different diseases, he endeavoured to explain these on anatomical principles. Where the patients died, he, if pos- sible, obtained permission to inspect the body, and, when he succeeded in this, he compared the morbid appearances with his former speculations, which, if correct, became fixed on his mind; if the reverse, he endeavoured to account for the symptoms from the disorganization which had been produced. Conducting these examinations with a minuteness and attention which is very rarely bestowed upon them, he was much struck with the frequency of mal-formation in the me- chanism, or morbid change in the structure ol' the hearL In a number of cases, where the symptoms X LIFE OF THE AUTHOR. manifested during the progress of the disease, had Jed the physician to form very incorrect views as to its seat, his dissections proved the heart to have been the viscus affected, Cardiac affections appear- ed to him to be a subject so important, yet so little understood, that he devoted himself with great attention to their investigation. He watched, arid endeavoured to distinguish and characterize the Protean symptoms which they presented during life; and after death the morbid changes were at- tentively noted. From Mr. Burns' labours in this hitherto much neglected class of diseases, he had soon in his Case Book a vast fund of original information on these interesting, but ill understood affections. At this period, however, he had no intention of publishing on that subject, his atten- tion being much occupied in collecting materials for a work which he proposed to give to the pub- lic on the subject of Hernia. Mr. Burns, during the summer of 1802, whilst dissecting the part concerned in the operation for crural hernia, discovered a process of the fascia lata, which had never before been described by anatomists, and in attending to the pathology of the disease, in relation to this process, which he yarned falciform, he found that it had a very great LIFE OF THE AUTHOR. Xi effect upon the strangulation in certain cases of incarceration. It was this discovery which led him to pay particular attention to hernia, and to prepare for the press the work on that subject, which has been already alluded to. The pub- lication of Mr. Cooper's splendid work on hernia, prevented him from laying his thoughts on this subject before the public in the form of a volume. He, however, in the year 1806, published a very perspicuous paper "On the Anatomy of the parts concerned in Femoral Rupture," in the Edin- burgh Medical and Surgical Journal. In the year 1804, Mr. Burns, having deter- mined to enter the medical service of the army, went to London, for the purpose of obtaining a commission; but, previous to his making an appli- cation for one, he received a letter, offering him a situation in St. Petersburg, of which he accept- ed, and accordingly left London for the purpose of repairing to Russia. The empress Catharine, acting in the name of her son Alexander, having established, in the metropolis of her country, an hospital on the English plan, was desirous of procuring for its director an able British surgeon. For this office Mr. Burns was named to her majesty, by his ex- XII LIFE OF THE AUTHOR. cellency Dr. Creighton, as a gentleman in every way qualified; the appointment was according- ly immediately offered for his acceptance — and, by a further indulgence of the empress, he was allowed to remain six months in the country, be- fore he was required to make up his mind on the subject of the appointment. ""Passionately at- tached to the customs and institutions of his own country, after the term of trial, he could not be induced, valuable as the appointment was, to accept of it; and the empress, finding that his determination to return to Scotland could not be changed, presented to him, in testimony of her admiration of his character, a very valuable dia- mond ring. In the month of January, 1805, Mr. Burns left St. Petersburg, and having travelled through Sweden, he arrived in London the following April. Mr. John Burns having discontinued his lec- tures on anatomy and surgery, the idea of re- turning to Glasgow and delivering lectures on these subjects, was first suggested to his brother's mind whilst residing in Russia. This plan was so congenial to his inclination, that on his return home, he at once began to occupy himself in pre- LIFE OF THE AUTHOR. paring a course of lectures; and the following winter he commenced his career as a Public Teacher. In the autumn of 1808, Mr. Burns prepared his work on the Diseases of the Heart for publi- cation, and printed it early the following spring. During the spring of 1810, Mr. Burns was attacked with dyspeptic symptoms. With the view of removing these, he was induced, at the termination of his lectures, to travel to the island of Arran, where he remained a month. From this journey, his health was so completely re-esta- blished, that he was enabled, on his return to Glasgow, to enter again, with his wonted ardour on his professional pursuits. The restoration to health was, however, of short duration; his close application to study, and constant attendance at the dissecting rooms, having been the causes which originally gave the disposition to the dis- ease, soon reproduced it. In a few months he was in a much worse state of health than he had been previous to his visit, to Arran; but, so much interested and occupied was he in preparing ma- terials for the publication of his work on the Sur- gical Anatomy of the Head and Neck, that no XIV LIFE OF THE AUTHOR. persuasions could prevail upon him to relax in his application and visit the country. His complaints increased so rapidly during the spring of 181 1, that he was with great difficulty enabled to finish his lectures. So soon as he had concluded them, he left Glasgow for the island of Cambray, where he remained for a month. His health having been considerably benefited by this short visit, the hopes of his friends became elevated, and he was induced, by their solicitations, to remain for only a very short time in Glasgow. To gratify them, he determined to make a voyage to the Hebrides. From the sea air, exercise, and change of scene, Mr. Burns appeared to derive much benefit, but, towards the close of the voyage, he had a most severe attack of cholera morbus, a disease to which he had not before been subject, and which, in a great measure, destroyed all the advantages which he had before received from his excursion. Indeed, he returned to Glasgow in the month of September, in a more debilitated state of health than when he left it, on his departure for the He- brides. Yet, although his health was in a most wretched state, his mind was still in the meri- dian of its vigour; his ardour in the improve- LIFE OP THE AUTHOR. XV ment of his profession continued unabated, and his zeal was such, that, immediately after his re- turn to Glasgow, he laboured more diligently than ever, in finishing his work on the Surgical Ana- tomy of the Head and Neck, which he published a few months afterwards. This second work of Mr. Burns, must remain a most valuable standard work as long as surgery continues to be cultivated as a science. It con- tains no hypothesis nor theories, but consists en- tirely of pathological inferences, drawn from the most acute and accurate observations on the ana- tomical structure of the parts. Ever after the period when Mr. Burns had the attack of cholera morbus, he continued so subject to this complaint, that if he happened to eat fruit, or was exposed to the slightest change of tem- perature, he was seized with a paroxysm of this most painful disease. From the frequent recur- rence of the cholera, and the continued uneasi- ness produced by the dyspepsia, his strength and spirits became so much exhausted during the win- ter session, that he was under the necessity of concluding his lectures a month before the usual period for their termination; and, immediately on their conclusion, he left the city for the island of XVI LIFE OF THE AUTHOR. Bute, where he remained until the month of September. Having occasion to visit London that summer,, I was separated from Mr. Burns for the first time since the commencement of our acquaintance. When I visited Bute, after an absence of three months, I was delighted to observe the great improvement which air and exercise had pro- duced in his appearance. He seemed restored to perfect health; but, unfortunately, all he had gained during the summer, was lost by a violent attack of cholera, which he had the day after his return to Glasgow. As this paroxysm may be considered as the primary cause of the disease which produced Mr. Burns' death, a particular account of it may be interesting. The evening before the attack, Mr. Burns and myself spent together in the dissecting-room. We were busily employed in dissecting and preparing a piece of morbid structure, and were under the ne- cessity of using, in its preservation, a considerable quantity of corrosive sublimate. Whether a small quantity of this mineral had or had not been inhaled by Mr. Burns, it is impossible to decide. The vio- lence of the attack of cholera which followed seemed to indicate some. such cause for its production. On LIFE OF THE AUTHOR. XVU taking leave of me, after our departure from the dissecting-rooms, he appeared to have a melan- choly foreboding of what was to happen, and un- fortunately it was too just. At two o'clock in the morning I was called up by a messenger, request- ing me immediately to visit him. Upon my arri- val at his house, I found him in a state of the most indescribable agony. The violence of the disease was such, that not only the muscles of the abdo- men, but likewise those of the extremities, were under the influence of severe spasms. Laudanum and other medicines were administered in very large doses, but he remained in this state of suf- fering until eight o'clock, a. m. when the symptoms began gradually to abate. For some days after- wards his life was despaired of, but by care and attention, he was enabled in a fortnight to leave his bed. From an anxiety to gain sufficient strength to enable him to fulfil his laborious winter vocations, so soon as Mr. Burns was able to travel, he re- turned to the island of Bute, where he remained for three weeks. From this visit his general health was considerably benefitted, but, he suffered constantly during his absence, from a severe pain in the right iliac I'egion, the muscles in this situa- XV111 LIFE OF THE AUTHOR. tion having been particularly affected with spasms during the late attack of cholera. This pain con- tinued, although with less severity, after his re- turn home; he described it as perfectly fixed, and so local that he could cover it with the point of his finger. In this miserable state of health, Mr. Burns commenced his last course of lectures, but was only permitted to continue them for a very short time. During the second week of the session, an abscess burst into the rectum and discharged about two ounces of pus. The discharge became every day more and more profuse; the constitution began to suffer, and in a week Mr. Burns found it neces- sary to confine himself to his bed, which he never afterwards left for more than a few hours. It is unnecessary to detail the progress of the disease; like other internal abscesses, it under- mined the powers of the system, and speedily pro- duced hectic fever, which terminating in colliqua- tive diarrhoea, closed the scene on the twenty- second of June, 1813. Twenty-four hours after death the body was examined by Dr. Brown, Mr. Russel, and some ether professional gentlemen. LIFE OF THE AUTHOR. XIX From the last attack of cholera morbus until the period of his death, Mr. Burns having com- plained of a continued and local pain in the situa- tion of the right iliac region, this part of the ab- domen naturally attracted particular attention. The most superficial examination at once dis- covered that morbid changes had taken place in it. The caput colli, instead of being simply bound down to the surface of the iliacus inter- nus, by the inflexion of the peritoneum, was firmly united by a deposition of coagulable lymph to that membrane, where covering the inferior portion of the transversalis abdominis, the adhe- sion between this part of the muscle and the caput colli, was so perfect, that the one could not be separated from the other. On dissecting and separating the transversalis from the obliquus in- ternus, an abscess was discovered situated be- tween them, just above the point where they are attached to Poupart's ligaments. From this ab- scess, two sinus openings passed off; on trac- ing them, the one was found to terminate in the caput colli, and the other was followed completely under that portion of the intestine towards the promontory of the sacrum; from thence taking as its guide the rectum, it ran down about four XX LIFE OF THE AUTHOR. inches, and then entered the gut. The other vis- cera of the abdomen, as well as those of the chest, were healthy. This examination satisfactorily explained all the circumstances of the case. The spasm, which was particularly severe, during the last attack of cholera, in the situation of the right iliac region, had probably produced a tearing of the fibres of the transversalis muscle. This was followed by inflammation, which ended in sup- puration An abscess being thus formed between the obliquus internus and transversalis abdominis, ulceration of that portion of the latter muscle which formed the abdominal wall of the sac na- turally occurred. The peritoneum covering it became inflamed, and, as the inflammation of that membrane is necessarily followed by the effu- sion of coagulable lymph, an adhesion was esta- blished between it and the caput colli. The ab- scess being thus prevented from discharging its contents into the belly, sinuses passed off from it, one of which opened into the caput colli, and the other into the rectum. Before concluding this biographical sketch of Mr. Burns' life, it is proper to make a few obser- vations on his character, viewed as an AUTHOR, & PUBLIC TEACHER, and a MAN. LIFE OF THE AUTHOR. XXI Mr. Burns has left behind him four works. Two of which were Essays published in the Medical and Surgical Journal of Edinburgh. The one on the anatomy of the parts concerned in the operation for Crural Hernia, and the other on the operation of Lithotomy. His first elaborate work is an octavo volume of three hundred and twenty- two pages, entitled. "Observations on some of the most frequent and important diseases of the heart; on aneurism of the thoracic aorta; on preternatural pulsation in the epigastric re- gion: and on the unusual origin and distribu- tion of some of the large arteries of the human body. Illustrated by cases." The other is the work now offered to the profession in America. Of the Essays which he published in the Edin- burgh Journal, I shall only observe, that they dis- play great anatomical knowledge, and that per- spicuity of description for which Mr. Burns was eminently distinguished, both as a writer and a teacher. When it is recollected, that although "before the publication of Mr. Burns' book, many detach- ed works had been published on particular affec- tions of the heart, that, still no treatise had ap- peared presenting a connected view of the causes XX11 LIFE OF THE AUTHOR. and consequences of the various diseases to which that most important organ is liable," and when it is further remembered, how insidious and dif- ficult of explanation many of the symptoms of these diseases are, and how apt they are to be mistaken for other affections, the value of Mr. Burns' work will be duly appreciated. The valuable work of Corvisart on this subject, which was published in France about the same time, may be considered, in connexion with Mr Burns' book, as fixing an important era in the his- tory of these most important, and, heretofore, ill- understood diseases. Both works possess many and peculiar excellencies; but I trust I shall not be accused of permitting the feelings of friendship to influence my judgment, when I give it as my opinion, that, as a book of practical observation and philosophical explanation of the causes of symptoms, from anatomical connexions and change of structure, the treatise of Mr. Burns is de- cidedly superior to the one published by the Parisian Professor. The second of Mr. Burns' great works is now presented to the American public. It has been con- sidered by Sir Astley Cooper, Mr. Abernethy, and the other distinguished public teachers of Lon- LIFE OF THE AUTHOR. XX111 don, as well as by those in other parts of Great Britain as one of the very best books on surgical anatomy, and that it will obtain the same rank in this country, I cannot doubt. In doing justice to the author, it should be recollected, that the plan of writing general observations on surgery with anatomical descriptions, is in a great measure peculiar to himself. Since his time, this has become general, and its excellency is now univer- sally admitted. Mr. Burns' style, as a writer, is far from being free from defects. Accustomed from very early youth to the habit of extemporaneous speaking, he acquired a rapidity of expression, which, although sufficiently correct for the purposes of oral de- monstration, was too diffuse and colloquial for written compositions. Yet, although his manner is far from being critically correct, there is still a vividness and perspicuity in his descrip- tions, which repays us for their want of elegance. It is very justly observed by Mr. Burns' re- viewers, that ua more zealous and eloquent teacher was never known." Possessing the most perfect knowledge of his subject, he was never at a loss in his descriptions, nor in want of materials for the illustration or elucidation of his subject. He XXIV LIFE OF THE AUTHOR. had likewise a most happy talent for arresting the attention, and of throwing around the most dry demonstrations a charm of which they could hardly be supposed to be susceptible. For per- spicuity he had certainly no equal. The most intricate subject became, from the lucid order he pursued in their demonstration, clear and simple. Mr- Burns' temper was warm, perhaps irasci- ble, his passion however was but for a moment; and if, under its influence, he did any one an injury, he was the first to confess it and make ample re- paration. In his intercourse with mankind, he was a perfect gentleman. To his friends his man- ners were most endearing. Destitute of every selfish feeling, he had their interests more at heart than his own, and for them he was at all times ready to make any personal sacrifice. For four years I was scarcely an hour separated from him, and it is now with feelings of gratitude I ac- knowledge, that if I have been at all successful, either as a Practitioner or Public Teacher, it is to his example and friendly instruction I am in a very great measure indebted for my success. AUTHOR'S PREFACE IN the following work it has been my object to describe the Surgical Anatomy of the Head and Neck. I have not, however, entirely confined my attention to the anatomy of the head and neck, and to the practical deductions from that alone; but, on the contrary, I have entered pretty fully into the consideration of the general principles which ought to regulate us in the treatment of some diseases incident to the neck, in common with other parts of the body. This I have espe- cially done in regard to Aneurism, the practical doctrines of which I have examined, and, in some instances, freely criticised. I have also entered occasional remarks on the nature of tu- mours, but these are very cursory and limited. They are, however, as full as I thought my object in introducing them required. xxvi AUTHOR'S PREFACE. In the following pages, I have treated the names of some of the promoters and improvers of our art with freedom; but, I trust, on no occa- sion with disrespect. I have combated opinions, but never because they belonged to this or to that author, but because I believed them to be erro- neous. In executing the surgical part of this book I have collected my facts from various sources, which I have generally acknowledged; but in regard to the anatomical part, there are few de- scriptions introduced which have not been given from numerous observations and dissections made by myself. I would also wish it to be understood that I have never described the relative anatomy of a part, from any individual subject; on the contrary, each description has been drawn up from the inspection of many bodies. In doing this, the points wherein these corres- ponded were noted, and assumed as a standard, and the anomalies, where of practical importance, were not overlooked. Most, however, of what relates to varieties in the origin and position of the arteries, has already been made public in a paper on that subject, contained in a book which I lately published on the Diseases of the Heart. AUTHOR'S PREFACE. xxvii For every quotation, therefore, from that work, I consider the present acknowledgement sufficient. To obtain correct anatomical descriptions, and to deduce from them just practical conclusions, has been my anxious endeavour; how far I have succeeded in the execution of this part of my plan, belongs to others to decide. I may, how- ever, with propriety, mention, that the descrip- tions are not the result of hasty examinations; — they were sketched six years ago, during which time I have carefully compared many subjects, and added cases in illustration as they occurred. The present volume has no pretensions to more than merely containing a few hints, and these not always in very regular order, of the most import- ant surgical anatomy of the head and neck — hints which I hope will be found useful by the student, but most of which are probably familiar to the experienced practitioner. It will be found very different from the elementary works on anatomy, which are required to initiate the student to names and individual parts: — the present obser- vations being intended to introduce him to the contents of regions. As a book of this nature would be of no value, without sketches to illustrate the descriptions, xxviii AUTHOR'S PREFACE. Mr. WILLTAM P. HnDr.E, of St. Eustatius1, an in- dustrious pupil of mine, has had the goodness to give his assistance in this department. As all of the drawings were made under my own inspec- tion, and by one acquainted with the anatomy of the parts he was delineating, I flatter myself they will be found faithful copies of nature. Some of them are mere sketches, others are more finished drawings; but in no instance have we ever sacri- ficed accuracy of representation for beauty of execution. It has been mentioned by some authors, that to render plates really useful, the parts ought to be of their natural size; but this I have never con- sidered essential. Drawings, I am convinced, may be employed advantageously of any size, provided, in reducing them, the proportion of the different parts be justly preserved; and I am equally persuaded, that in delineation of natural texture, it is not necessary to colour the bones, muscles, vessels, and nerves. CAMPER, by a few well chosen lines, has, in his inimitable plates, expressed more than many modern artists do, with their varied tints and complicated shading. A highly finished drawing certainly does please the eye more than an unpolished sketch; but in AUTHOR'S PREFACE, xxix the former, it is to be remembered, that boldness and accuracy are often sacrificed to elegance. With these remarks I lay the following Obser- vations before the public, with an anxious wish that they may prove useful to the student and young surgeon, for whom they are chiefly inten- ded. They may, perhaps, lead him to combine circumstances, and to judge from these how far an operation would be advisable, in any indivi- dual case; or they may put him on his guard against undertaking rashly, an operation with which, had he been better acquainted with the group of parts concerned, he would prudently have declined interfering. If, indeed, in any way, he find them useful to him, I shall not view the time employed in arranging them as mispent. Glasgow, IQth October, 1811. OBSERVATIONS SURGICAL ANATOMY IN works on Anatomy, each separate system is generally considered apart, and without a re- ference to the others; and in surgical books, it is presumed that the student has already acquired a sufficient knowledge of the structure of the human body. Although we have, perhaps, little reason to complain of the want of tolerably accu- rate descriptions of the bones, the muscles, the blood vessels, the nerves, the absorbent system, and the glands; still, this to the operator is not sufficient. It requires a greater degree of dis- crimination, and a more accurate conception of the parts, than most students, nay, I believe, than most surgeons possess, to be able to combine these disjointed lessons^ so as to form from them a useful ON THE SURGICAL ANATOMY and connected whole. I am afraid, that in plan- ning operations, the surgeon, too frequently, pro- ceeds on a limited view of the parts amongst which he has to cut. More than once I have heard the propriety of an operation argued from the inspection of a mere blood vessel dried pre- paration;— a guide surely more liable to mislead, than to lead to a rational practice. The blood vessels are, no doubt, highly necessary to be per- fectly understood, but this knowledge, to be prac- tically useful, must be conjoined with a compre- hensive acquaintance with the neighbouring parts. On this account, I endeavour to connect the de- monstrations of the arteries, with the local struc- ture of the muscles, nerves, and glands, and with the performance of surgical operations. That this is the most advisable plan of teaching the student the true value of anatomy, few will dis- pute; but I fear that the execution will not prove equal to the design. In attending to the general structure of the neck, the platysma myoides and the fascia must be first considered, for both have a share in modifying disease. The platysma myoides lies immediately below the skin and cellular mem- brane. It is often composed of a slender set of pale scattered fibres, but sometimes, and espe- cially in short thick-necked males, it forms a strong muscular defence to the throat. It covers the front and sides of the neck, is attached to the OP THE HEAD AND NECK. 33 cellular membrane lying over the jaw bone, and is indistinct at its termination, where it is incor- porated with the fat and fascial muscles. No doubt, as this muscle is attached to the integu- ments, it can wrinkle the skin of the neck, as in rage, or depress the angles of the mouth, as in grief; but these are subordinate and accidental offices performed by this muscle, whose chief use is surely to support the deep seated parts. Be- sides the platysma myoides, the throat is covered by an aponeurosis or fascia. My attention was first called to this fascia about seven years ago, during the dissection of an emaciated anasarcous subject, in which it was nearly as strong as the fascia of the limbs. Since that time, I have uniformly de- monstrated it in every course. The cervical fascia in its natural state is thin, but even in this condition, it is more resisting than its texture would lead us to suppose. To see it where it is really an object of interest to the surgeon, we must contemplate it where thick- ened by the pressure of tumours formed beneath it. If we do this, we shall be convinced, that both it and the platysma myoides perform the office of fascise, and we shall at once be satisfied that the neck, so far from being without a fascia, is provided with a double sheath; a fact which cannot be too firmly impressed on the mind of the student. It will lead him to form a just estimate of the nature of some diseases, and will assist him 5 34 ON THE SURGICAL ANATOMY in explaining the causes of particular symptoms. Nor is it sufficient that it be known that the neck is invested with a fascia; there are likewise pecu- liarities in its mechanism, at different parts, which must be pointed out. The fascia of the neck descends from the lower edge of the maxilla inferior, and is thinner at the front than at the angle of the jaw. At that part, a fold of the fascia is tucked back to the styloid process, to which it adheres, and here it is incor- porated with an aponeurotic expansion from the pterygoid muscle, forming the ligament of the jaw. This ligament may readily he felt, chord- like, extending from behind the angle of the jaw backward and downward. It is rendered distinct, by bending back the head, and inclining it to the side opposite the one we are to examine. In emaciated bodies, it forms a stringy line, which seems to be lost about the anterior margin of the sterno-mastoid muscle. The fascia, as it descends along the neck, dips down among the muscles and glands, forming capsules for the latter. These are productions from the inner surface of the fascia, in the same way that the falx is a production from the dura mater. On its outer surface the fascia is pretty smooth, and it is nearly of uniform thick- ness in every part below the os hyoides, till it comes to expand over the pectorul muscle, when it puts on more of a cellular appearance. At the lower part of the throat, there is some peculiarity in OF THE HEAD AND NECK. 35 the mechanism of the fascia. When the integu- ments are dissected off, the fascia, which has heen described, is brought into view, covering the sterno-mastoid muscles, and extended between their tendons. By dividing this fascia, a mass of fat, equally thick as the upper bone of the ster- num, and often having imbedded in its substance a small conglobate gland is brought into view. When these are cleared away, another layer of firm, tense, and fibrous fascia, is exposed cover- ing the outer surface of the sterno-hyoid and thy- roid muscles. By pulling the superficial fascia, the deep seated one will be seen to be derived from it. Where the fold from the superficial fas- cia is inflected along the upper end of the ster- num, it is greatly strengthened by the crossings and bindings of strong tendinous fibres The deep fascia over the sterno-hyoid muscles, is much stronger than the superficial fascia; indeed it for- cibly resists any effort to push the finger through it into the chest. It likewise prevents the finger being pushed from the chest higher than the lower edge of the thyroid gland. These are facts which I would wish to impress on the mind, for they are highly necessary to be remembered. The first will assist us in explaining the use of these fasciae and muscles, while the second leads to an illustration of some morbid phenomena. From what takes place on the removal of the superficial and deep fasciae,, accompanied with 36 ON THE SURGICAL ANATOMY destruction of the sterno-hyoid and thyroid mus- cles, we learn the value of them. So long as these remain entire, hreathing is performed with ease, provided there be no disease in the lungs, or neighbouring parts; but whenever these fascise and muscles are removed, then, on every attempt to increase the size of the chest, the atmospheric air pushes back the unresisting skin on the tra- chea, compressing that tube to such a degree, as to occasion very serious difficulty in breathing. The sterno-hyoid and thyroid muscles are capable of steadying the hyoid bone and thyroid cartilage, or of depressing these parts; but their great use is to co-operate with the fascise, in preventing the gravitation of the air on the windpipe. That this is a correct account of their office, will be illustra- ted by the following case, which was, some time ago, under the care of Dr. Brown, by whose kindness I had an opportunity of seeing the pa- tient, and taking a cast from the parts. The gentleman was between twenty and thirty. He liad the hooping-cough when three years of age; the disease was pretty severe, and ever after- wards he experienced some difficulty in breathing, but till within these few years, there was no exter- nal mark of disease. About that time he perceived a fulness and tension just above the sternum, which increased during three months, when the integuments burst, and a quantity of fluid was discharged. The ulcer soon put on a decidedly OF THE HEAD AND NECK. 37 scrophulous appearance, and from it the patient drew out from between the laminse of the medias- tinum, a portion of lymphatic substance about three inches in length. Soon after this the sore began to skin over, but without restoration of the lost substance. After the opening was complete- ly closed, the trachea, the arteria innominata, and the thyroid branch of the lower thyroid ar- tery, were found to be covered merely by a very thin pelicle of polished skin, — a defence not suf- ficient to prevent the pressure of the air on the trachea; consequently, whenever this person, by increasing the size of the chest, forms a vacuum in the trachea, the air passes into its canal in part by the rima glottidis, but it likewise endeavours to force its way directly above the sternum. The fascise and muscles being destroyed, the mecha- nical pressure of the atmosphere compresses, to a certain degree, the canal of the windpipe. On this case I would remark, that there is reason to believe, that the irritation excited in the thorax, during the hooping-cough, had begun the disease in the thymus gland, which had con- tinued slowly to increase, till, at last, an abscess formed in it. If this be a correct supposition, we learn why the breathing has been uniformly diffi- cult from the time he had the hooping-cough, even to the present day. Previous to the formation of abscess in the gland, it is probable that it had been enlarged, and that it had, by its mechanical ON THE SURGICAL ANATOMY pressure on the trachea, produced dyspnoea. — After the healing of the ulcer, which, in its pro- gress, had destroyed both the fascia and muscles, no one can wonder that there should be great dif- ficulty in breathing. The destruction of these parts, and the matting about the top of the chest, afford a satisfactory explanation of the cause of this. By the loss of the former, the resistance to the air being removed, there is at each time that the patient inspires, a deep hollow formed at the upper part of the sternum, and a wheezing sound is produced by the passage of the air along the narrowed trachea. I have often thought, but have had no opportunity to put it to the test of experiment, that by artificially supplying the lost parts, we might alleviate the difficulty of breath- ing. This might be done by applying a piece of lea- ther, spread with adhesive plaster, over the lower part of the neck, taking care to place it there while the patient was in the act of expelling air from the lungs. By pressure with the hand, it might be retained in a proper situation, till it was so fixed as not to be forced back by the atmos- phere. To prevent the starting of the edges of the leather, and the insinuation of the air be- tween the skin and the plaster, they might both be brushed over with a solution of sealing wax in alcohol, as recommended by Mr. Abernethy after operations on the knee joint. OP THE HEAD AND NECK. 39 The structure of the fascia and muscles is next to he attended to, as illustrating disease. The thymus gland, which is in a manner peculiar to young animals, is lodged between the layers of the anterior mediastinum immediately behind the sternum, and lying over the forepart of the arch of the aorta, the roots of its primary trunks and the subclavian vein, between which and the spine, the trachea and oesophagus are placed. This gland is apt to enlarge in those of a pecu- liar habit, and its position is such, that whenever it begins to swell, it occasions most serious unea- siness. On the front the tumour is prevented by the sternum from protruding outwardly; above the sternum, the fascia and muscles repress its growth; as it enlarges, therefore, it must press backwards on the important parts which are between it and the spine. No wonder, then, that the patient should in the end, die from suffocation and star- vation. Even what food passes into the stomach, fails to nourish the body properly. The pressure of the tumour on the subclavian vein, interrupts the entrance of the chyle into the heart, and thence the mesenteric glands are, in such cases, generally found enlarged and obstructed. In three children who had died from disease of the thymus gland, I found the lacteal gland increased in size.* * There is no doubt that marasmus of the system is generally present in those cases, where the thymus gland is affected with the enlargement 40 ON THE SURGICAL, ANATOMY As this disease generally occurs in children of a scrophulous constitution, I have repeatedly pre- scribed muriate of lime, burnt sponge, and the other remedies usually employed in that disease, but have never seen them of advantage. I have witnessed decidedly good effects from repeated blisters and long continued friction, but even these seldom do more than merely alleviate, and that only before tabes mesenterica has been in- duced. When topical and internal remedies have failed, it is practicable, although many may be inclined to think not prudent, to remove the gland. — Where the thymus is so much enlarged as to give rise to serious symptoms, a fulness and swelling is felt above the sternum, where it is only covered by the fascia, and sterno-hyoid and thyroid mus- cles. After death I have twice removed the tumour. To do this, I made an incision on the front of the neck, just above the sternum, and be- tween the sterno-hyoid muscles, as in the opera- described in the text, but the explanation of the cause, of this emaciation given by the author, is by no nit-ans satisfactory. I have dissected many cases of this disease, and have never met with one in which the transverse vein had become obliterated. But, even allowing that the pressure of the tumor did ciose that vessel, still its blood mixed with the chyle, would enter the circulation by anastomosis. It is probable that the tabes mesenterica, and the disease of the thymus gland, commence at the same time, and ori- ginate from the same cause, — a scrophulons disposition of the system. If this opinion be correct, the operation recommended for the removal ot the thymus gland, although it might relieve the dyspnoea, could in no case restore the patient to health; the diseased enlargement of the mesenteric glands remaining, would speedily destroy life. — ED. OF THE HEAD AND NECK. 41 tion of tracheotomy. By this cut, the rounded knob of the diseased thymus was exposed. Hav- ing done this, I next insinuated the fore finger between the gland and the adjacent parts, till the former was insulated so far as I could reach. Af- ter this, by a pair of polypi forceps, cautiously in- troduced between the mediastinum and the gland, I grasped the tumour, and wrenched it from its connexions. This, on the living subject, would be a most dangerous operation, yet where death is otherwise inevitable, it might perhaps be war- rantable to try it. I think, that were it cautious- ly executed, injury of the large vessels might be avoided, and the sponge would easily command any bleeding which might take place from its own nutrient arteries; an event which is hardly possi- ble, if the tumour be pulled away. Some may suppose, that inflammation would be apt to follow this operation, but this is to be little dreaded; the debilitated state of the patient will be a sufficient security against its occurrence. It has been mentioned, that one or more conglo- bate glands generally lie imbedded among the loose fat and thready cellular substance which occupies the space between the two plates of fas- cia. Where these glands enlarge, they form a tumour, in many respects resembling a diseased thymus, but by attention, the one disease may be easily distinguished from the other. Enlarge- ment to the same degree of the thymus, would be 6 42 ON THE SURGICAL ANATOMY productive of most serious dyspnrea, but swelling of the lymphatic gland, although productive of difficulty in breathing, does not, till very large, endanger the life of the patient. Besides, by ex- amination, it can generally he ascertained, that such a tumour is unconnected with the chest. My friend, Dr. Gordon, Lecturer on Anatomy and Physiology in Edinburgh, very lately met with an instance of enlargement of this gland, in a patient who had died from tetanus. Mr. Cruikshanks saw a fatal case of this disease. As the tu- mour is exterior to the deep fascia and muscles, there can be no reason why it should not be ex- tirpated; it is not connected with any vessel or nerve of importance, and can, on cutting into its capsule, be easily started from its seat. Besides these glands, there are many other conglobate glands about the neck and throat. Of these, some lie more superficial, and others deeper seated than the fascia. This, therefore, leads to a natural division of tumours about the throat, into those which are covered by the fascia, and into those which lie exterior to it. This is a distinction of practical importance. Tumours by being placed more superficial, or deeper than the fascia, are modified in their complexion, varied in their effect, and more or less difficult in their removal. As may naturally be supposed, those tumours which form exterior to the fascia, are superficial, moveable, and as they enlarge, spread laterally, OP THE HEAD AND NECK. 43 and even when of great size, are comparatively easily extirpated. They are circumscribed, ele- vated, and for a length of time, by grasping them, we can pull them so far outward, as to allow, in some degree, of the insinuation of the finger be- tween them and the parts behind. It is of consequence to extirpate such tumours, so soon as we have ascertained that they are of a nature requiring removal, for although they at first lie exterior to the fascia, yet in the progress of their enlargement, they press on this sheath, producing thickening and adhesion of it to them- selves, and the parts below; or at other times the pressure is productive of absorption of the inter- posed layer of fascia, after which the tumour, as if it had originally been placed beneath the fascia, dips backward, and contracts adhesion to the deeper and more important parts. These tu- mours do not, however, invariably produce either of the effects described. Sometimes even where very large, they remain free from adhesion to the parts behind. A man, ten months ago, while in the West In- dies, observed a small moveable tumour at the angle of the jaw, not larger at first than a horse bean, and productive of very little inconvenience. As it evidently continued to increase, he was advised to leave the country, in order to get the diseased parts extirpated in a colder climate. With a view to this he came to Glasgow. When 44 ON THE SURGICAL ANATOMY I saw him, the tumour was about the size of the head of a new born child, was situated over the lowest part of the parotid gland, and over the sterno-mastoid muscle, was regular on its sur- face, elastic to the touch, and only painful at one particular spot, unless when pressed on, at which time he complained of a diffused, al- though not acute pain, over the whole extent of the tumour. It neither gave rise to inconveni- ence in breathing nor swallowing, nor impeded the motion of the jaw, and when grasped between he fingers, it could be pulled out from its attach- ments behind; a clear proof that it was still un- connected with any part which would render its extirpation hazardous. This tumour, I have no doubt, originally arose from enlargement of one of the subcutaneous lym- phatic glands, and I believe that it will generally be found, that such swellings, from the small quantity of interstitial fluid which they contain, are firm and unyielding, or only slightly elas- tic. They are commonly called wens; when cut into, they appear as if composed of a mixture of cellular membrane, and intervertebral sub- stance. They are very indolent, have few blood vessels, and very few fibrillse of nerves can be traced into their substance; of consequence, they are torpid, and even when large, produce only a dull heavy sensation, not generally amoun- ting to pain. Such tumours seldom suppurate, OF THE HEAD AND NECK. 45 but sometimes by their irritation, they excite in- flammation in the parts with which they are in contact. This deprives them of their due supply of blood, they die, and I have seen the body of the tumour when the skin which covered it gave way, cast off as an extraneous substance. In this way a natural cure is sometimes accomplished, but it is a rare occurrence. Where the tumour is nei- ther extirpated, nor otherwise destroyed, it con- tinues progressively to increase in size; and often when it has continued for a length of time, its ves- sels assume a new mode of acting, they form a pretty solid substance, sometimes cartilaginous, and at other times osseous. Mr. Travers, Demonstrator of Anatomy in Guy's Hospital, writes me, that Mr. Astley Coop- er, some time ago, extirpated three large tu- mours of this kind, from about the angle of the jaw. In his cases, the tumours began just below the zygoma, they descended considerably lower than the angle of the jaw and extended forward till they reached the spot where the fascial artery makes its turn over the jaw, and posteriorly they included the lobe of the ear. They were, as Mr. Travers observes, in their external features, such as would generally deter country practition- ers from interfering with them. Their extirpa- tion is extremely simple, they have seldom, even when large, above a single artery of such a size as to require a ligature, entering into their sub- 46 ON THE SURGICAL ANATOMY stance. The veins, however, belonging to the tumour are often varicose, so that when divided, they pour out a considerable quantity of blood. — This is the only inconvenience which generally attends the extirpation of such tumours. In extirpating a tumour of this kind, it is ad- vantagrous not to leave too much skin. Where, therefore, the swelling is large, even although the integuments be not diseased, a portion of the skin must be removed by an elliptical incision. Then, by dissection, the whole extent of the tumour to its base, is to be fairly exposed, after which, it is to be grasped with the left hand, and pulled out- ward, while, with the scalpel, its cellular connex- ion with the fascia is to be divided. Where the tumour is small, it is preferable, when the whole of it is uncovered, to grasp it firmly between the fingers, and suddenly, with a twisting motion, wrench it from its place. This possesses several advantages over the use of the knife; we do, in- deed, occasion a more pungent pain by the for- mer, but then it is of less duration, and we sel- dom or never have any bleeding from lacerated vessels. I have seen a subcutaneous tumour over the parotid gland, when not larger than a walnut, by its pressure, produce absorption of a part of the parotid, by which it made a bed for itself in the substance of the gland. In such a case, it is evi- dent that it would be very difficult to dissect OF THE HEAD AND NECK. 47 away the tumour with the knife, without, at the same time, injuring the parotid, which is avoided by tearing away the tumour with the fingers. After the tumour has been taken away, the edges of the wound are to be brought accu- rately together, and retained in contact by strips of adhesive plaster. Sutures, so much employed by the older surgeons are now justly laid aside, as they generally retard the cure. It is not only necessary to keep the lips of the wound in contact, the skin must also be support- ed, in connexion with the parts beneath, by means of a compress, retained in its situation by a proper bandage. Tumours beneath the fascia are more frequent in their occurrence, than those exterior to it, and are much more dangerous in their nature. Such tumours are firmly bound down by the fascia, they are flattened on their surface, are conse- quently large before they protrude externally, and are intimately connected with the deep seated parts. They produce greater effect on breathing and swallowing than would be expect- ed, from their apparently small size. Indeed, the extent of their adhesions can hardly be dis- covered, because although they be small and re- gular on their outer surface, they often stretch back amongst the muscles and vessels, and ad- here to the large nerves. Where, therefore, a tumour is deep-seated; is of a specific nature. ON THE SURGICAL ANATOMY and is evidently on the increase, there can be no doubt, that if other circumstances be favourable, it ought, without delay, to be removed. In the neck, even simple tumours may require extirpation, because, if they do not yield to me- dicine, but, on the contrary, continue to enlarge, they, in the end, come to compress the trachea and oesophagus, by which, ultimately, they will produce as much mischief, as if they had been of a specific nature. About the throat there are many muscles which leave interstices between themselves, and there are many primary branches of vessels and nerves interwoven with these mus- cles, which all become intimately concerned with tumours here. From the resistance afforded by the platys- ma myoides and the fascia, such tumours pe- netrate between the contiguous muscles, and encircle the subjacent vessels and nerves, ren- dering, where the disease is advanced, the ex- cision of these swellings peculiarly perplex- ing to the surgeon, and dangerous to the pa- tient. Indeed, there are many tumours formed in the region between the chin and the chest, to attempt the removal of which would, on the part of the operator, betray the grossest igno- rance of the structure of the neighbouring parts. Some tumours are so deeply attached to the pharynx, are so intricately entangled among important arteries and nerves, and so firmly fixed OF THE HEAD AND NECK. 49 to the muscles in the vicinity, that to undertake their extirpation would be to form the resolution to injure all these parts. This establishes most forcibly the propriety, nay, it proves the absolute necessity, of as speedy a removal of the morbid parts, as is compatible with prudent attempts to remove the tumour without operation. If distant parts have suffered from an extension of the morbid action, no one can be certain that all the diseased sub- stance has been cleared away; and if a single atom of the contaminated parts be permitted to remain, the patient is in a condition equally dangerous as before we operated. The disease is suspended, not eradicated, and the secondary affection is worse than the first. A useful distinction of tumours might be form- ed, were we a priori able to determine their structure, by dividing them into such as depend merely on a preternatural deposition, of parti- cles, resembling in texture the original structure of the part; and into such as depend on an in- crease of size, produced by a change of the natu- ral organization It will be found that the first species is generally indolent, and little prone to inflame or ulcerate, except when teazed and irri- tated by improper treatment. The second species from the very nature of their constituents, are liable to inflame, and either sphacelate, fungate, or ulcerate. 7 50 ON THE SURGICAL ANATOMY Mr. John Bell maintains, that, originally, every tumour is produced by an excess of healthy nutri- tion, and he would persuade us, that ultimately the parts are modified "in form and character, by many changes produced by occasional inflamma- tion or ulceration." One would hardly have expec- ed such an assertion from a surgeon, who would make us believe that he had traced the nature and properties of these morbid productions from their simple beginnings to their final termination. Shall Mr. Bell convince any one, that in cancer or scrophula, the tumour was, in the first instance formed of healthy parts; but that, eventually, the swelling obtained the peculiar character be- longing to these different affections, "by occasion- al inflammation or ulceration?" I should be sorry to waste time in animadverting on this con- jecture, were it not that, to me, it appears a a point highly requisite to be well ascertained. It must be the regulator of our practice. If pri- marily every tumour be simple, then the whole art of the surgeon must consist in keeping it sim- ple. His object must be to avoid the induction, of "occasional inflammation or ulceration." There is in this hypothesis nothing precise, and nothing really useful; but if admitted, there is much positively hurtful, as will lead to a timid and procrastinating practice. It would, therefore, be a most desirable object with the surgeon to become acquainted with the criteria, by which he OF THE HEAD AND NECK. 51 would be enabled to distinguish those tumours which were of a specific, from those which were of a simple nature. VVere this practicable, he would be able, in almost every case, to cure the patient; for in the incipient stage, few tumours, in comparison of the many which occur, are so placed as to prevent his extirpating them. But, as in the present state of our knowledge, we have it not in our power to do more than form a rude notion of the nature of swellings, we often mis- take a specific for a simple tumour, and waste time in useless endeavours to promote its removal without an operation. We, in fact, allow it (to acquire such a size, and to form such connexions, that when we become convinced of its intractable disposition, it is no longer optional with us to take up the knife with any reasonable prospect of success. With more zeal than success, Mr. Abernethy has endeavoured to arrange tumours according to their textures, but his plan is liable to this great objection, that we can, for the most part, only discover the real nature of the parts by actual examination. That Mr. Abernethy has failed to communicate criteria, by which we may generally estimate the nature of tumours in the living pa- tient, is indisputable; yet, let it not be imagined, that I would insinuate that this is to be imputed to any insufficiency on his part for the execution of the task he has undertaken. On the contrary, 52 ON THE SURGICAL ANATOMY all must allow, that the facts, as yet collected, re- specting tumours, are too limited, and our in- formation respecting morbid structure, is too vague, to enable any one to form, on a solid basis, a classification of tumours which shall be emi- nently useful to the practical surgeon. It is well known, that tumours essentially different in their nature, present externally similar fea- tures, which renders futile any attempt to classify such morbid productions. After these remarks, it would be folly in me to offer any other than a few very general obser- vations on tumours, reserving the considerations regarding the extirpation of these, till after I shall have pointed out the relation of parts about the neck, and attended to the local connexions of the numerous variety of tumours which form in the region of the throat. From the high importance of the vessels and nerves about the neck, it becomes the duty of the surgeon, in every morbid condition of these parts to inquire into the cause of the disease, to ascertain carefully, whether it be a primary, or a secondary affection; and if secondary, whe- ther it be sympathetic, or dependent on absorp- tion of a specific morbid poison. If it be clear- ly ascertained to be a primary affection, then it is necessary to investigate the origin, the pro- gress, and the existing state of the tumour, to en- able us to decide justly, as to the propriety of OF THE HEAD AND NECK. 53 allowing it to remain, or to determine on its im- mediate extirpation. It is not in primary affections alone, that the surgeon is sedulously to trace the progress of the disease; he is called on to he equally careful to make himself acquainted with the causes of se- condary tumours. But here it is to be remem- bered, that the field is less extended; if the pri- mary disease be simple, the secondary must be so also, and vice versa, where the latter swelling is dependent on absorption. Where, however, the primary tumour has not proceeded to ulcera- tion, we may hesitate regarding the nature of the secondary; we may suspect that it is merely sym- pathetic. Facts connected with the history of tumours, render it probable that the lymphatic glands never do become specifically contaminated pre- vious to the formation of an ulcer, or a fungus in the part primarily affected; but earlier than this, we know that they often swell from sympathetic connexion with the morbid parts. This we some- times see exemplified in carcinoma of the breast, accompanied with enlargement of the axillary glands. These tumours occasionally disappear after the removal of the mamma, which clearly shews, that they were not dependent on specific contamination. Although I have stated that it is probable that the absorbent glands are never specifically 54 ON THE SURGICAL ANATOMY contaminated, till the primary disease has pro- ceeded to ulceration, or to the formation of the fungus, yet I am not ignorant, that some are of a different opinion. It has, indeed, been conjec- tured, that there may be specific irritation, as well as specific absorption, but this is a doctrine which ought not to be admitted, without complete proof of its accuracy; a proof, which on this point is still a desideratum. As I would wish To be perfectly understood on this subject, I may mention, that we are by no means to infer, that a secondary tumour is sympa- thetic, merely because the primary one has not ulcerated externally; this is really no proof. Af- ter the removal of the latter, we are carefully to examine, whether there be any fungi, or ulcera- ted points in its centre. If these existed, I would incline to the belief that the secondary tu- mour was specific, and would, therefore, without hesitation advise its removal; but if after a minute inspection of the primary tumour no traces of fungi or ulceration could be perceived, I do not know how far it would be advisable to extirpate the secondary.* * The editor's observation on the subject of tumours, which has been considerable, lead him to differ from the opinion expressed by Mr. Burns, as to its being necessary that ulceration or fungus shall have taken place in the primary affection, before the secondary one can become specifically con- taminated. In many instances where the most accurate and minute dissection has been unable to detect in the original tumours either incipient ulcera- tion or fungus, the structures of those which have arisen secondarily have heen found to present the same characters of their being of a specific na- OF THE HEAD AND NECK. 55 Our great object, therefore, and our chief in- ducement to distinguish those tumours about the neck, which originate from simple irritation, f'-om those which are dependent on specific contamina- tion, is with a view to regulate our proceedings. If we incontrovertible ascertained, that the tu- mour was of a specific nature, we would, without delay, extirpate the diseased parts. Where, how- ever, we were uncertain, we would be less deci- ded in our conduct. In doubtful cases, there is an obvious motive for delay. While there is a probability that the tumour is simple, we may succeed in removing it without an operation; but, in specific tumours we have no such inducement, procrastination will only permit the disease to gain ground. These general observations shew, that there is much uncertainty in the diagnosis of tu- mours about the neck; some being produced by simple irritation, which, to one who satisfied him- self with a superficial inquiry into the case, would seem to be induced by the absorption of specific virus, while others really of a specific nature, are, from the indolence of their actions, supposed to be simple; and under this impression, are ture, as those exhibited in the primary affections. The rule of practice •which his experience would induce him to inculcate, would be, in every case, bef ire performing an operation tor the removal of a tumour supposed to be of a specific character, to examine carefully those glands, which re- ceive their lymphatics from that situation, and should any of them be found enlarged , to remove them at the same time that we extirpate the primary tumour. — ED. • 56 ON THE SURGICAL ANATOMY allowed to remain and extend their connexions^ till they get beyond the reach of surgery. This want of well defined character in the early stage of the disease, is a source of great ambiguity. I have thus known a small tumour of the spongoid species, which, when the patient first applied for assistance, could have been » easily and safely extirpated, left for months, gaining ground daily, plunging deeper and deeper, becoming more and more intricately, attached to the parts in the vici- nity, during all which time the woman was teazed with burnt sponge, muriate of lime, and repeated blisters; remedies which are well known to have no control over that disease. At last, when the character of the complaint became so decided, that no one could mistake it, the surgeon consoled himself, that now the tumour had extended too far to permit of ex- tirpation; that to attempt this, would be to form the resolution to destroy the patient. This is, however, at all times a poor excuse, especially when the practitioner is conscious that the ma- lignancy of the disease depended, in a great mea- sure, on his own procrastination arid want of knowledge. Tumours in any part of the body, are of a nature to require the most prompt and decided practice, but our vigilance must be doubled, when the morbid parts are seated in the vicinity of large vessels and important nerves. I have OF THE HEAD AND NECK. 57 known one surgeon, after much unnecessary de- lay? undertake to renove a tumour from the neck, but I may safely venture to affirm, that the same gentleman will be in no hurry to begin a similar operation. When the tumour is decidedly of a simple na- ture, the object of the surgeon plainly is, to pro- mote the absorption of the newly formed parts; but where he fails to accomplish this, he next attempts to induce suppuration. In primary tu- mours, however, as it is often difficult to disco- ver the real nature of the disease, we necessarily act on an uncertainty. Yet, in all doubtful cases, I think we are authorised to use means to pro- cure absorption of the morbid parts; but it is by no means so clear, that in such cases, we are, after these have failed, to delay endeavouring to in- duce suppuration, since this event would only be useful in tumours of such a nature, as not to require extirpation, unless from their mechanical effect on some neighbouring and highly important part. In simple swelling, we are, however, to the latest, to continue our endeavours to promote absorption, or to procure suppuration; for if we can succeed in effecting this, all danger is compa- ratively at an end. The patient, when the ab- scess bursts, or is opened, is placed beyond the reach of immediate risk, and time is afforded to the surgeon to suit his plans to the nature of the case. 8 58 ON THE SURGICAL, ANATOMY After the description of the fascia, and the ge- neral remarks on the modification of the charac- ters of tumours by that sheath, it will be neces- sary to attend to the anatomy of the lower and lateral part of the neck. We must trace the con- nexions of the subclavian arteries at the root of the neck. From their origin, these arteries mount up- ward, and incline outward, and are covered, till they reach the scaleni muscles, by the sterno- mastoid muscles. Between the aorta and scaleni muscles, the subclavian artery is connected with several important vessels and nerves. It is in the vicinity of the nervus vagus, of the recurrent laryngeal nerve, of the sympathetic nerve, of vthe phrenic nerve, and the subclavian vein; and on the left side it is intimately con- nected with the termination of the thoracic duct. These parts are all grouped together in a very narrow space, and the perplexity of their dissection is further increased by the in- terlacement of the different nerves with one another. The natural connexion of these parts are best shown by merely raising the sternal extremity of the sterno-mastoid muscle. If this be done, the nervus vagus will be brought into view, lying oiv the fore part of the subclavian artery, almost directly behind the sternal end of the clavicle; and exactly opposite to the nervous vagus, but OF THE HEAD AND NECK. 59 behind the artery, the lower cervical ganglion of the sympathetic nerve will be brought into view. The recurrent nerve on the right side, hooks round the subclavian artery, and in its course towards the larynx, ascends along the tracheal side of the sympathetic nerve. On the left side it twines round the arch of the aorta, and in mount- ing upward, is interposed between the subcla- vian artery, and the oesophagus. The subclavian vein lies anterior to the artery, and in the col- lapsed state, sinks nearer to the thorax. This is its usual position in the dead body, but in the living person its relation to the artery is constantly changing. Alternately it is flaccid and full; in the first state it bears the same rela- tion to the artery, as in the dead subject; under the latter circumstances it swells out quite tense, and ascends, so as in some measure, to overhang and conceal the artery. The thoracic duct en- ters the left siibclavian vein about an eighth of aa inch nearer to the acromion, than the point where the internal jugular vein empties itself into the subclavian vein. The termination of the tho- racic duct is situated between the sternal and clavicular portions of the sterno-mastoid muscle. I have been thus particular in the description of the parts connected with the subclavian artery, between its origin and the scaleni muscles; be- cause, one who knows their position, and is aware of their importance, will correctly estimate the 60 ON THE SURGICAL ANATOMY risk of attempting to tie the artery nearer to the heart than the scaleni muscles It will also impress on the mind of the surgeon, the great danger of extirpating tumours from behind the root of the sterno-n astoid muscle. Our ances- tors, who were very deficient in anatomical know- ledge, had the sense and modesty to decline any very hazardous operation. In the present age, timidity forms no part of the character of the ge- nerality of surgeons. But in operating, some- thing more than boldness is required; knowledge, prudence, and caution, are requisite. In tying the subclavian artery nearer to the heart than the scaleni muscles, there is not only considerable risk on account of its connex- ions, but there is even much danger to be ap- prehended from confounding aortic aneurism, with aneurism of the subclavian artery. It would be doing injustice to Mr. Astley Cooper, were I to omit mentioning, that to him I was first indebted for the communication of this fact, which I had lately an opportunity of seeing verified in a most striking and highly interesting case, — a case on which several of the most distinguished practi- tioners in Edinburgh, and almost every surgeon in Glasgow, were consulted. The nature of the disease appeared to be so de- cided, and its situation in the subclavian artery so clear, that on that subject there was no diiference of opinion. Some were, however, of opinion, that OF THE HEAD AND NECK. 61 an operation might be performed, while others were fully convinced that the case was hopeless. For myself, I must confess, that I was firmly per- suaded, that in the early stage of the disease, an operation might have been beneficial; those who dissented, did it on the belief that the aneurism was seated so near to the origin of the subcla- vian artery, that to get beyond the limits of the disease, the ligature must have been passed round the arteria innominata itself, — an opera- tion, said they, for which there was no prece- dent, arid which there was much reason to sup- pose would fail. Those who approved of it, did so, on the ground that death was inevitable, if the disease was left to run its course; that if an operation was performed, the most which was ever expected was, that by cutting off the direct current of blood through the sac, coagulation of its contents might take place. To the occurrence of this event, and of this event alone, a favour- able issue, if it did take place, must have been attributed. The great objection which wre had to the expe- riment, was the uncertainty with respect to the state of the coats of the arteria innominata; we entertained no dread of the circulation being supported in the right arm, nay, we reduced it to a demonstration. On the dead subject, I tied the arteria innominata with two ligatures, and cut across the vessel in the space between them, 62 ON THE SURGICAL ANATOMY without hurting any of the surrounding vessels. Afterwards, even coarse injection impelled into the aorta, passed freely hy the anastomosing branches into the arteries of the right arm, filling them and all the vessels of the head completely. After these remarks, I shall, without alteration, transcrihe the history and progress of the disease from my case hook: — "On Friday the 13th of October, 1809, I was requested to visit an officer belonging to one of the regiments in town. He had risen from the ranks, and had, till about that time, been an able, active, and useful soldier. He had been engaged in very laborious service in India, and while in that country, he had been confined by an affection of the liver, which had produced a depression of his spirits, from which he had not fully recovered at the time I saw him. When I visited him he was ailing, but felt diffi- culty in defining his complaints, — he told rather what lie had not, than what he actually had. A few weeks ago, he supposed that his left arm felt benumbed, and nearly about the same time, he experienced some unpleasant sensations about his head. "Till Sunday last, however, he was not sup- posed to be seriously unwell. On the afternoon of that day, while travelling at an easy rate in a post- chaise, he was suddenly seized with a very acute pain over the uppermost rib, on the right side,-^- OF THE HEAD AND NECK. 63 a pain which extended even to the top of the shoul- der. This pain was so much increased by the motion, of the carriage, that he was compelled to quit it, and finish his journey on foot. He walked about two miles. On his arrival in town, he was led to examine the pained part, where he discovered foF the first time, a firm pulsating tumour, which alarmed him very much. When I saw him, which was at the request of the practitioner who had already visited him, he had an anxious, though by no means an unhealthy look. He complained of little present inconvenience from his complaint, except pain, stretching from the root of the neck towards the back; but he dreaded the result of his disease, the nature of which he had disco- vered. "A tumour about the size of a pigeon's egg was situated just behind the clavicle, and on the acromial edge of the sterno-mastoid muscle. It pulsated strongly, while the radial artery of the right arm acted with little vigour; but on compa- rison with the artery of the opposite arm, the pulse was stronger. In both arms the pulse was regular, when I examined it, but during the two preceding days, I was informed that it had been intermittent. In regard to the tumour itself, it was placed in part beneath the clavicular portiere of the sterno-mastoid muscle, but the greatest part of it lay nearer to the acromion than the muscle. By pressure the tumour could be nearly 64 ON THE SURGICAL AtfATOMV emptied, but while doing this he complained of considerable uneasiness. So soon as the pres- sure was removed the sac became again distend- ed, and the blood in entering it communicated a whizzing sensation to the finger. The impulse was at the same time great, and on the contrac- tion of the ventricle, the sac became exceedingly tense, and the throbbing, and whirlpool-like mo- tion of its contents, were conspicuous features of the disease. The arteria innominata was felt beating at the top of the sternum, apparently in no degree enlarged. The common carotid acted more feebly than on the opposite side. The skin was free from discoloration, and his rest was un- broken. "On reviewing this case, we had no doubt as to the nature of the disease, indeed its character was too decided to be mistaken. We earnestly wished to be of use to him, and he declared his readiness to submit to any operation. Yet who could urge an operation in such a case? — What certainty was there that the coats of the arteria innominata were not diseased, even to where that vessel arises from the aorta? The immediate risk of operation would have been immense, it would probably have accelerated the fatal issue, which he was directed to retard by low diet, by ab- stinence from wine, spirits, or fermented liquors, by keeping the bowels most easy, by avoiding either corporeal exertion, or mental irritation, OF THE HEAD AND NECK. 65 and by employing digitalis to moderate vascular action. "I had occasional opportunities of seeing the patient, but, till toward the end of December, there was little change on either the tumour or general health, if we except a tendency to cedema and depression of the spirits. The former was completely removed by the use of digitalis. On the 28th December, I found the tumour much flattened, and could perceive very little pulsation about the arteria innominata. Along the subcla- vian, vertebral, and common carotid arteries, there was a peculiar thrilling sensation during their action. He has now frequent paroxysms of pain, extending along the right side of the head, and complains of constant numbness of the left arm. "The food he takes is light, his bowels are easy, but he is weaker and more anxious than before. The pulse is nearly similar at both wrists. On one occasion, he lately felt a sudden rushing of blood to his head, followed for a short time, by dimness of vision. "January 27th, 1810. — The tumour is no lar- ger, but it is flatter, broader, and fully more incompressible. It now extends to the very tracheal edge or the sterno-mastoid muscle, but appears, as yet, to make no pressure on the as- pera arteria. When the sac is squeezed, he com- plains of a sharp pain extending round the shoul- 9 66 ON THE SURGICAL ANATOMY der. The jarring action of the subclavian and carotid arteries is not so well marked as before^ The pulse in the right arm is sunk and feeble, the numbness of the left is less, but the right hand has of late become slightly cedematous. He has coldness of the feet, vertigo, and feeling of blood at times rushing into his head. His general ap- pearance is somewhat improved, but his spirits are very much depressed, — he is weak, and feels fully persuaded, from his sensations, that the disease is extending into the chest. One of the perforating arteries, from the internal mammary vessel is distinctly felt enlarged. "March 53d. — Till yesterday there was very little alteration in the size of the tumour, and almost no change in the constitutional symptoms. The right arm had slowly lost its power, the hand remained permanently of a purplish colour, and was sometimes cedematous. When he walked the swelling became tense, and by its distension pro- duced pressure on the veins, returning the blood from the head, occasioning vertigo, failure of sight, and turgescence of the veins of the head and neck,-— symptoms which soon abated after desisting from exercise." "Yesterday, a short time after dinner, which consisted merely of bread and water, the tumour suddenly became greatly increased in size — not only projecting farther out, but extending late- rally in every direction, except towards the tra- OP THE HEAD ANB NECK, 6? The clavicle appears to be forced away from the sternum, and pungent pain is occasion- ed by even gentle pressure on either the tumour or right side of the neck. But it is rather cu- rious, that he felt little pain during the sudden enlargement of the sac, — he had, at that time, rather the sensation of something giving way or yielding. The integuments covering the sac are now slightly discoloured, and obscure pulsation can be discovered in the upper part of the right side of the chest. The pulse in the right arm is rather more distinct, yet it is less so than in the opposite arm. He has no actual difficulty in breathing, but he says that he is short winded. The rest which he procures, is obtained by the employment of the ext. of hyoscyamus, and his bowels are kept regular by the daily use of stewed fruits. "March 31st. — The tumour has increased con- siderably in size, and for several days past, his voice has been gradually impaired, and is now so much injured, that he can only converse in a low under tone, hardly audible. The sternal extre- mity of the clavicle seems partly absorbed. "April 15th. — The tumour has considerably increased in size, and has extended toward the left side, but although it overhangs the trachea, he does not experience much difficulty in breath- ing; he complains, however, of some uneasiness when swallowing, and his voice is still weak and 68 ON THE SURGICAL ANATOMY raucous. He is disturbed with painful sensa- tions about the left shoulder, similar to those he felt in the right about the commencement of the disease, and he is frequently distressed with palpitation, and feeling of failure about the re- gion of the heart, accompanied with a tendency to syncope. His feet are still unusually cold, even when the rest of his body is warm. At one point the tumour is thin, projects into a small papilla, seated just on the acromial side of the sterno-mastoid muscle, and covered with delicate but not diseased skin. In other respects, he is much the same as formerly. "October 10th. — I was requested to-day to visit the patient. His appearance and conversa- tion were so much altered, that he hardly re- sembled himself; his face was oedematous, and streaked with purple veins; his right hand and arm were cold, lumpish, and anasarcous, and the cellular membrane of the lower extremities was loaded with water. He moved slowly, and held his head inclined forward. He spoke in a short and hurried whisper, interrupted every few minutes by a hollow cough, and profuse expecto- ration of greenish yellow matter. He had no pain; difficulty in breathing and want of sleep were his chief complaints. The aneurism was in no degree enlarged outwardly, the papilla-like projection had even disappeared, and its cover- ings were now much thickened; yet it caused OF THE HEAD AND NECK. 69 more pressure on the trachea, and from the very evident tremulous motion which I could perceive in the upper and right side of the thorax, I could not doubt the extension of the disease into the chest. The disease was now drawing to a conclusion; it neither admitted of alleviation, nor of being cured, and of this the patient was fully aware. He was not, therefore, disappoint- ed, when I informed him that I had no remedy to propose. I left him with directions to send for me if he became worse. "In four days we were called to inspect his body. The dissection, which was carefully per- formed, proved highly interesting. Appearances were presented, which, a priori, no one expect- ed; the vessel which was supposed to have been most materially affected, was found perfectly healthy. The aneurism arose from the aorta, and included a considerable part of the arteria innominata. The right subclavian artery was only slightly dilated at its root; along its course, it was rather reduced in size. The tumour mount- ed from the aorta, considerably above the ster- num, pressing in its ascent, the descending vena cava to the right, and the trachea to the left; ob- structing thus the breathing, and intercepting the return of the venous blood from the head and arms. It also pressed the root of the right sub- clavian artery and the carotid against the spine, retarding in this way, the circulation along these 70 ON THE SURGICAL ANATOMY vessels. The trachea is so much displaced, that the left carotid slants across its front to reach the side of the neck. The right side of the heart is little affected; the left ventricle is much thickened, and the aoitic valves are in part ossified, which, together with the obstruction to the circulation arising from the pressure of the tumour on the right carotid and subclavian arteries, will ex- plain the increased strength of the muscular fibres of the ventricle. Just above the heart, the aorta is somewhat dilated; I say dilated, be- cause its coats are healthy, and its canal free from lymphatic incrustation. This swelling termi- nates below the commencement of the arch. The inner surface of the aneurismal sac, was coated over with many layers of organized lymph, which coating was especially thick and strong about the highest part of the sac. The left part of the arch is of natural size, but a little below the com- mencement of the descending aorta, the vessel is again dilated into a small pouch. The cesopha- phagus is pushed completely from behind the trachea." The importance of this case, is the only apo- logy I have to offer for its great length. It clearly and satisfactorily demonstrates, how se- rious the consequences would have been, had an operation been undertaken. It corroborates Mr. Astley Cooper's remark, that aneurism of the aorta may assume the appearance of being seated OF THE HEAD AND NECK. 71 in one of the arteries of the neck; an inference drawn from the examination of a case which came under his own observation, and of which he had the goodness to transmit a short history to me along with a sketch, illustrative of the position of the tumour. In our case, the aneurism was at- tached to the right side of the aortic arch, and involved a part of the arteria innominata; in Mr. Cooper's, the tumour arose from the left side of the arch, from between the roots of the left sub- clavian and carotid arteries. It formed a Flo- rence-flask-like cyst, the bulbous end of which, projected at the root of the neck, from behind the sternum, and so nearly resembled aneurism of the root of the carotid artery, that the practitioner who consulted Mr. Cooper, actually mistook the disease for carotid aneurism.* DESCRIPTION OF THE PLATES OF THESE CASES. PLATE I. contains an anterior view of the aneurism de- scribed in page 62, et seq. A A, the right and left ventricles of the heart. — B. the pulmonary artery.— C, the aorta, which is considerably dilated just above its origin. — D, the arch contracted to its proper size. — E, the aneurismal tumour involving the root of the arteria innominata, mounting up behind.— F, the Sternum, displacing G, the clavicle, the sternal extremity * See Appendix, (A.) ON THE SURGICAL ANATOMY of which, is sunk into the coats of the sac, and roughened by partial absorption of its substance. Almost the whole of the cyst which projected above the sternum was filled, and rendered solid by different strata of buff- coloured in- crustation. Toward the aorta, the lymphatic exudation •was less copious, and more intermixed with coagulated blood. — H, the trachea pushed toward the left side, inso- much, that I, the left carotid artery, crosses it in a slanting course to reach the side of the neck. — The trachea is not only displaced; it is likewise reduced by the pressure of the tumour in its lateral diameter, and increased in itsan- tero posterior, and K, the (Esophagus, is forced completely from behind the windpipe. — L, denotes the little saculated dilatation of the descending aorta. Had the tumour in its commencement, occupied the same situation which it did in the last stage of life, there would have been no hesitation in referring the disease to the ar- teria innominata. But it is to be carefully remembered, that in this very patient, the first appearance of the sac was nearer to the acromion than the sterno-mastoid muscle; at a point where no one would expect a tumour to present, which had worked its way from within the chest. The gradual progress of the tumour, first toward the trachea, and then apparently into the thorax, tended still more to mislead, as to the real nature of the complaint. There was no wonder, therefore, that we should have been led to the belief, when we were first consulted, that the disease was seated nearer to the scaleni muscles, than the origin of the subclavian artery, and that this artery alone was in fault. An opinion which induced us to hint, that the ar- teria innominata might be tied, but the boldness of the operation, and the deficiency of data whereupon to esti- mate the probability of its issue, forbade us to urge the proposition. OF THE HEAD AND NECK. 73 As to the practicability of passing a ligature round that artery, we had no hesitation, and experiments made on the dead subject, convinced us that we had nothing to dread in regard to the arm being supplied with blood; but there was still another consideration, which we were entirely without the means of solving. We had no proof of the effects which would be produced on the brain, by suddenly cutting off the supply of blood from two of its vessels. "YVe well knew that the circulation along the carotid artery, might be intercepted without detriment to that organ, but we possessed no testimony that both it and the vertebral artery might be tied with equal impunity. Yet, in so des- perate a disease as aneurism of the subclavian artery, es- pecially where it had a decided tendency to extend toward the chest, we thought it allowable to risk applying a liga- ture round the arteria innominate; we are still of the same opinion, but it is an operation which ought not to be rashly undertaken.* I have related the present case as a warning to all sur- geons; and I have to add, that in subclavian aneurism an operation oujjjht never to be advised, unless where the fin- gers can be insinuated between the tumour and the chest, and even then the arteria innominata ought to be tied, without any very sanguine expectations of success. There are many causes which tend to lessen the probability of this operation having the desired effect. In aneurism about the extremities, we can completely, or nearly completely, intercept the flow of blood through the sac. But in aneu- rism at the commencement of the right subclavian artery, tying the arteria innominata has no such control over the circulation. By passing a thread round that vessel, we may, indeed, very materially lessen the quantity of blood sent into the sac; but while the common carotid and verte- * See Appendix, (B.) 10 74 ON THE SURGICAL ANATOMY bra! aHeries remain unsecured, the retrogade circulation through the tumour must be considerable. Our only pros- pect of success, therefore, when we tie the arteria inno- minata, is founded on the natural tendency which the con- tents of the aneurism have to coagulation — a tendency which will be increased by rendering the circulation more languid, and which, perhaps, may ultimately transfer the circulation into a new channel. With this slender expec- tation we can alone undertake this operation. Some pa- tients may prefer the chance of recovery it affords, to cer- tain death from the extension of the disease; but no sur- geon can conscientiously urge submission — that ought to be a voluntary choice of the patient, formed after a full and explicit acquaintance with the danger. PLATE II. exhibits a posterior view of the same aneu- ism. It is intended to illustrate the way in which the ar- teria innominata A, is connected with the tumour, and how the sac extended upward between the right carotid artery B, and the right subclavian C, and the sternum by which both of these vessels were forced backward against the Spine. In this view there is also represented the slight dilatation found at the root of the subclavian artery, and the contracted diameter of the vessel more remote from its origin. D, the vena cava superior is seen squeezed and displaced by the tumour. E, the trachea, and F, the oeso- phagus are both greatly displaced by the distension of the sac. As the other parts of the engraving have little reference to the disease I shall pass them over without further notice. SKETCH III. I have added from the case which occurred to Mr. Astley Cooper. It is not to be considered as af- fording a representation of the actual appearance of the disease, it is merely a plan illustrative of the locality of the tumour A, which is seen arising by a very narrow neck from the arch of the aorta, between the roots of the left War,- // OF THE HEAD AND NECK. 7£ siibclavian artery B, and the left carotid artery C. It pushed up between these vessels, and appeared at the root of the neck, so that it resembled an aneurism of the carotid artery more than an aneurism of the aorta. These Sketches are highly valuable, as they shew the great difficulty in distinguishing aneurism of the aorta from, aneurism of one of the large arteries. In the latter case, even if the disease had really been seated in the carotid or subclavian artery, no operation could, with any degree of propriety, have been undertaken. From the closeness of the connexion of the arteries at the root of the neck, on the left side, with the visceral nerves and the thoracic duct, it would be madness to attempt to pass a thread round either of them verv near to the chest. When the occiput is turned back, if we draw a line from the angle of the jaw to the spot where the clavicle touches the coracoid process of the scapula, and if we trace another from about half an inch behind the mastoid process to the acromial edge of the origin of the sterno- mas- toid muscle, and extend another along the upper margin of the clavicle, a triangular portion of the side of the neck is marked, in which many important parts are lodged. In cutting into this space, the skin and fascia require to be first divided and turned back. When this is done, the space itself is seen to be divided into two unequal portions by »the poste- rior belly of the omo-hyoideus. The course of 76 ON THE SURGICAL ANATOMY this muscle is easily discovered on the living body, by drawing a line from the junction of the clavicle and coracoid process, to the sterno-mas- toid muscle, two inches in the adult above the sternum. Above this line there is only lodged some small conglobate glands, some trifling branches of nerves, the arteria transversalis colli, and often the arteria cervicalis superficialis. Be- low it, nearer to the clavicle, there is found the subclavian plexus of nerves, and the great artery. The nerves at this part lie clustered and inter- laced v-bove and behind the artery. It is in this confined space that the incision is to be made, and the artery detached from the nerves when a ligature is to be passed round it, after it has passed from between the scaleni mus- cles; and it is here that tumours seated below the fascia are so dangerous to extirpate. They are then deeply nitched in and connected with parts with which we would not wish to intermeddle. This remark is only, however, applicable to those tumours which are formed beneath the fascia; those which are subcutaneous, circumscribed, and moveable, may even when very large be easily extirpated. When, however, any of the deep-seated glands enlarge, the tumour is formed behind the posterior belly of the omo-hyoideus muscle, is bound down by it and the fascia, con- tinues for a length of time flat, and is long forming an external projection. At last it does OF THE HEAD AND NECK. 77 protrude outwardly, pushing before it the omo- hyoideus muscle, by which the acromial margin of the sterno-mastoid is turned forward, its clavi- cular portion is pulled up on the side of the tu- mour, and carried away from the sternal part. This position of the sterno-mastoid depends on the connexion of the omo-hyoideus with that mus- cle. Wherever, therefore, the sterno-mastoid is seen pulled over a tumour situated between that muscle and the trapedzius, the surgeon may be certain that it is deeper seated than the omo- hyoideus. The position of the tumour, and the change produced on the course of the clavicular portion of the sterno-mastoid muscle are very perfectly represented in an excellent cast taken by Profes- sor Thomson from one of his patients. From this cast, I had, by his permission, a drawing, taken from which plate 4th, fig. I. has been engraved. In this plate, A represents the clavicle, a little above which B marks the most prominent part of the tumour. — C denotes the clavicular portion of the sterno-mastoid, which, by the protrusion of the omo-hyoideus is pulled away from the sternal part, describing a curve along the tracheal side of the tumour. The tumour, in this case, is braced back on the arteria transversalis colli, the arteria cervicalis superficialis, the upper se- ries of the subclavian plexus of nerves, and on the posterior branch of the fourth pair of cervical 78 ON THE SURGICAL ANATOMY nerves. Had it been higher it would have been entirely unconnected with the large nerves, and had it been lower it would not only have been in contact with the subclavian plexus of nerves, but it would also hrive touched the artery. In this triangular space, the tumour being cov- ered by the fascia, renders it difficult to ascer- tain with precision its attachments. By the tenseness of the sheath spread over it, we are prevented from moving it fully from side to side, neither can we pull it from its bason. We may, however, in some degree, judge of its connex- ions, from its size, duration, and effects on the arm. Its adhesion to the branches of the arte- ries or nerves, can never be discovered, but we can generally ascertain whether it be connected with the large artery, or subclavian plexus of nerves. By grasping the swelling with the left hand, while we push the fore and middle finger of the right hand, deep behind the clavicle, we can usually touch the subclavian artery, and by moving the tumour from side to side, as freely as the fascia will permit, we discover whether in its motions, it drags the vessel along with it. If the pulsation remain unchangeably in the same spot, we may reasonably infer, that the morbid parts are free from adhesion to the great artery, and if the arm be not benumbed, there is reason to hope that the nerves are free from adhesion to the tumour. OF THE HEAD AND NECK. 79 It is only, however, in those cases where the tumour has not enlarged so far, as to be jammed in behind the clavicle, that any approximation can be made to the nature of its adhesion. Where the tumour has originally been formed by enlargement of a gland, seated just above the cla- vicle, it is not only physically impossible to dis- cover its connexions, but without care, even its nature may be mistaken. A simple glandular swelling may, from its being affected by the pul- sation of the artery, be conceived to arise from aneurism of that vessel. This I have actually known happen. I remember the case of a middle-aged man, in whom a pretty large pulsating tumour appeared from behind the sternal extremity of the left cla- vicle. It was bigger than a hen's egg, pulsated very strongly, and produced an inequality in the pulse at the wrist, great difficulty in swallowing, and a slight dyspnoea. The surgeon had no doubt of its being an aneurism; and accordingly he explained to the man his danger, and the great risk he would run of the tumour bursting, if he fatigued himself, or lived freely. On the faith of this, he prevailed on the patient to keep quietly in the house, and persuaded him to take great care of himself, and regularly once a-day, during some months, he visited him. During which time, the tumour did not enlarge, neither did the 80 ON THE SURGICAL ANATOMY pulsation become either more violent or more obscure. This tedious restriction being not altogether to the patient's mind, and as he did not perceive that the danger was such as had been represent- ed, he began to entertain an opinion of his own; he walked out, and ate and drank as plentifully as his means would permit, and found that the swelling, in place of enlarging, as had been pre- dicted, really became smaller, the pulsation de- creased in strength, and, in the end, to the asto- nishment of all who saw him, both the tumour and beating disappeared. The history and issue of this case, proves that it was not aneurism. It was merely a glandular swelling, receiving an impulse from an artery beneath it, an occurrence by no means rare about the neck. In extirpating tumours from this part of the neck, so soon as they are exposed the scalpel is to be laid aside. Then the morbid parts are to be cautiously detached by the fingers, tearing them from the tracheal toward the acromial side, by which the course of the vessels and nerves are followed. After the tumour has been in this way removed, it is to be carefully washed and exam- ined lest any of the morbid substance has been torn, and left behind. Even when we are satisfied that the tumour has been removed en- tire, the finger is to be run over the wound, to ascertain that no enlarged gland, or indurated OF THE HEAD AND NECK. 81 cellular membrane be left. But here it is proper to remark, that the ruptured arteries, which are felt like small hard points projecting from the wound, are not to be confounded with specks of diseased matter. By enlargement of the little glands exterior to the fascia over this angular space, or over the sterno-mastoid muscle, tumours are frequently formed. Such swellings, even when large, may be very easily extirpated. I remember, how- ever, a curious and fatal affection of one of these glands, which occurred to my brother several years ago. The patient was a strong and athle- tic man, who, about six years previous to his ap^ plication at the Royal Infirmary, had received a smart blow on the neck, from the keel of a boat. This injury was soon followed by the formation of a firm, tense tumour, on the place which had been hurt. The swelling increased very slowly during the five years immediately succeeding its commencement, but during the sixth, it received a very rapid addition to its bulk. At this time it measured nearly six inches in diameter, seemed to be confined by a firm and dense cover- ing, and the morbid parts had an obscure fluctua- tion. From first to last the tumour had been productive of very little pain. Judging from the apparent fluctuation, that the tumour was incysted, it was resolved, at a con- sultation, to puncture the swelling, draw off its 11 82 ON THE SURGICAL ANATOMY contents, and then pass a seton through it. By plunging a lancet into it, only, a very small quan- tity of blood, partly coagulated and partly fluid, was discharged, — a quantity so trifling, that after its evacuation the size of the tumour was not per- ceptibly reduced. A seton was passed through the swelling. At this time the man was in per- fect health. About ten hours after the operation, the pa- tient was seized with extremely violent rigors, followed by heat, thirst, pain in the back, exces- sive pain in the tumour, and oppressive sick- ness. An emetic was prescribed, but instead of pro- ducing vomiting, it operated as a cathartic. To remove the irritation, the seton was withdrawn. The pain in the tumour, however, and the ge- neral uneasiness continued to increase, and thirty hours after making the puncture, air began to issue from the tract of the seton; and afterwards the cellular membrane of the neck, and of the other parts of the body in succession, became dis- tended with a gaseous fluid. In the course of a few hours after the commencement of the general emphysema, the man died. Twelve hours after death, when the body was free from putrefaction, it was inspected. The emphysema was neither increased nor diminished since death, and some idea may be formed of its extent, when the scrotum was distended to the OF THE HEAD AND NECK. 8J size of the head of an adult. Even the cavities of the heart and the canals of the blood-vessels contained a considerable quantity of air. We could discover no direct communication between the tumour and the trachea or lungs, although such was carefully sought for. This is not an unique case. Dr. Baillie gives the history of one which occurred in a female.* and another is to be found detailed by Dr. Hux- am in the London Medical Observations and In- quiries, t Emphysema was also witnessed by Wiliner, occurring during tedious labour. f In all of these cases it would appear that the em- physema had been dependent on rupture of some of the bronchial cells. Portal in his "Cours d' Anatomic Medicale,?7|| and in his Work on Phthisis Pulmonalis,§> has shewn that a connex- ion does subsist between the cellular texture of the lungs, and that of the rest of the body. He has proved this by wounding the lungs and blow- ing air into their substance, for in this way he filled the cellular membrane of the neck and arms. Portal does not, however, apply this fact to the explanation of emphysema not dependent on external violence. * Transactions of the Medical Society of London, vol. i. t Huxham's Letter to Mr. Leake, London Med. Obs. and Inquiries, vol iii, T Wilmer's Observations in Surgery, p. 143. 5 Cours Leod, a poor woman above sixty years of age, ascribed the beginning of a tumour of the thyroid gland, "to a stress," to use her own expression, "of the neck," which had taken place 30 334 ON THE SURGICAL ANATOMY nearly thirty years before. During all that time, she carried a tumour about with her, not produc- tive of very great uneasiness, yet still disturbing her. Latterly, the swelling increased very ra- pidly, and without any apparent cause, enlarged to such a size, as besides producing a great de- gree of deformity, to endanger her life. The state of the tumour at that time, I do not very fully know, but her surgeons were much astonished, when she told them shortly afterwards, that the swelling was gone; they inquired how that had taken place, and were informed, that it had been occasioned by the bursting of the skin, and sub- sequent discharge of a small quantity of bloody serum. They, like the patient, flattered themselves that the cure would soon be complete. At the dis- tance of six months after that occurrence, the wo- man came to shew me the tumour, which had re- turned, and was now worse than ever. For two nights before I saw her she had been unable to lie in the recumbent position, or even to procure sleep in any posture. She was in constant uneasiness, tormented with a tension and confusion in her head, and worn out with apprehension of suffoca- tion. She neither knew to whom to apply for re- lief, nor what to do to procure a momentary re- spite from suffering. She could not fetch her breath without dreadful gasping, neither could she swallow till after tedious mastication, and even OF THE HEAD AND NECK. 235 then the morsel was thrust over with fear and trembling, for she verily believed that some time or other it would choke her. The expression of her suffused purple counte- nance was characteristic of keen anxiety about her fate; she dreaded the struggles for breath which she soon felt she would be obliged to make, if something was not done to remove the tumour. No one could, however, hold out any prospect of this kind, nor afford her more consolation than a promise, that in the eventful period to which her disease was drawing, every thing would be done which it was possible to accomplish to relieve her. When I saw her the tumour jutted out, as big as the fist on the left side, and it felt as hard as a stone. On the front of the neck there was an ugly puckered sinus, just over the cross slip of the thy- roid gland, from which a bloody ichor was dis- charged, and she always felt easiest when this dis- charge was most profuse. The tumour on the right side was as large, but more flattened than on the opposite, and on the outer edge of it the ca- rotid artery was felt, quite superficial, labouring with rapid motion, and hard and firm as a cord. It formed, when dilated, a rope about the size of the little finger. On the opposite side the artery was also pushed outward, although not to the same extent. It felt deeper, and was more restrained in its action. The tumour was productive of dreadful irritation about the larynx, inducing 236 ON THE SURGICAL ANATOMY severe and reiterated fits of coughing, during which she said "her head seemed ready to burst/* and the eyes to start from their sockets. Various medic. nes were tried, but the only re- lief she obtained, was from large doses of the am- moniated tincture of opium. She continued during some months gradually becoming worse, and at length died in dreadful agony. On inspecting the body, the thyroid gland was found to be much enlarged. On the right side there were several pretty large cysts attached to the gland, filled with bloody serum, and studded over on their inner surfaces with little cartilagin- ous knobs. On this side, the internal jugular vein, from a little below the angle of the jaw down to near the chest, was completely obliterated. The blood was sent across to the opposite vein by a large communicating vessel which ran parallel to the body of the hyoid bone. The substance of the sympathetic and eighth pair of nerves was thick- ened and indurated, and the trachea and larynx were flattened by the pressure of the tumour. The substance of the tumour itself was distinctly carcinomatous. The membranous intersections, and the softer texture of this disease, were too characteristic of its nature to be mistaken. From the description of the spongoid tumour given by my brother.* and of the fungus hsema- * Dissertations on Inflammation, by John Burns, vol. 2. OF THE HEAD AND NECK. 237 todes by Mr. Hey,* we learn that the disease be- gins with a small colourless swelling, elastic when touched, firmer the deeper it is seated, and which, if covered by a fascia, is very tense. As the tu- mour increases, it acquires more and more of its characteristic trait, it becomes more elastic than formerly, generally projects more at some points than at others, and seems to contain within it a quantity of fluid. This is, however, a deception; from a puncture, only a very small portion of bloody ichor issues, a quantity so immaterial as not to lessen the size of the swelling. The prominent points are the most elastic, are covered with the most diseased integuments, and are generally marked with small varicose veins, from which they derive a bluish livid colour. Be- neath these diseased integuments the rudiments of fungi are placed; this being a complaint in which there is a disposition to form fungus, previous to the bursting of the skin. The fungi are darker coloured than the rest of the tumour, which con- sists of a light grayish, medullary looking sub- stance, disposed in irregular cells, which are form- ed by laminae, arising either from the bursae of the joints, from a fascia in the neighbourhood, or from the periosteum of the bones themselves. Where the tumour has existed for a length of time, the parts in the vicinity come to suffer. The bones are softened, their cancelli are removed, and their * Observations in Surgery, by Mr. Hey. 238 ON THE SURGICAL ANATOMY place supplied by a soft mass of cineritous looking matter; the muscles are entirely changed, they lose completely their fibrous texture, but they still retain their shape. They are either of a dusky white or brown colour. When the integuments over a protuberance burst, a small quantity of bloody ichor is discharg- ed, a fungus rapidly sprouts from the orifice, over the margin of which it is soon folded. From the surface of this fungus a profuse haemorrhage fre- quently takes place, and at all times it is smeared over with a film of bloody lymph. About this time the patient begins to suffer from hectic; formerly his nights had been restless, ow- ing to the acuteness of the pain; now he is pre- vented from sleeping by the febrile exacerbations, equally as by the local pain; and now the lym- phatic glands begin to swell. They assume the same morbid condition, but the secondary affec- tion is more rapid in its progress than the pri- mary. I have thus detailed the general appearances presented by fungus hsematodes, a disease, which, although fully established to be altogether differ- ent from cancer, is yet, perhaps, not perfectly un- derstood. There are several of its features with which we are by no means familiar; we are ac- quainted with its more common character, but many of its modifications, I am fully persuaded, remain to be demonstrated. Mr, Wardrop, in his OF THE HEAD AND NECK. 239 late work on Fungus Haematodes, has very accu- rately pointed out the differences in texture in car- cinoma and this disease; he has shewn them to be very dissimilar. This is one step gained, but there still remain important matters for investiga- tion; we have yet to learn wherein cancer arid fungus hssmatodes differ in their external appear- ances; we have also to ascertain whether these two diseases can, or ever do exist at the same time in different parts of the same body, or in different parts of the same organ; we have also to inquire whether fungus hsematodes, and medullary sar- comse be identically the same diseases, or whether they are really dissimilar in their nature. These are points of considerable consequence, and were we able to solve them, it would mate- rially improve our knowledge, not only of these complaints, but it would also elucidate the doc- trine of tumours in general. Unfortunately, how- ever, we are hardly possessed of a sufficient num- ber of facts, to decide on any of these questions. What little information we have obtained from the inspection of these diseases in the living body, and from the examination of the morbid parts after death, I shall shortly detail. I cannot, however, do this, without making an apology for their in- sufficiency; indeed, they are more to be consider- ed as hints to future observers, than as affording any very defined idea of the subjects in question. 240 ON THE SURGICAL ANATOMY In carcinoma, the tumour is solid, irregular on its surface, and incompressible; whereas, in fungus hasmatodes, the tumour is yielding, it is elastic un- der the finger; it is indeed irregular on its surface, but so far from the prominent points being the most stony as in carcinoma, they are really the most compressible. They even communicate an obscure feeling of fluid. In carcinoma, after the skin has given way, the margins of the ulcer are thin, livid, glassy, and often retroflected; but in fungus hsematodes, I have never seen a case in which the edges of the sore, were in even the slightest degree reflected. Generally, in the lat- ter disease, the fungus, in the course of a few days, is spread over the margin cf the opening, through which it has passed, and I have repeatedly seen the neck of the fungus so closely embraced by the skin, that a profmr venous haemorrhage was pro- duced from the surface of the cauliflower-like ex- crescence. In carcinoma, a fungus does also some- times spout out from the ulcers, but from the sloughing of this, and of the mass of tbe tumour, a deep cavern is formed, bounded by livid, under- mined, arid ragged, and occasionally reverted edges. In fungus hsematodes, I never knew a loss of substance, except where the neck of the fungus was tightly begirt by the skin; then, indeed, the fungus has dropped off in the same way that a po- lypus decays, when a ligature is fixed round its root. Carcinoma and fungus hsematodes resemble OF THE HEAD AND NECK. 241 each other in some features; in both, there is a to- tal destruction of the natural texture of the part affected; in both, there is a disposition to form fungus, but still, the appearance of the fungus is different in the two diseases. "The fungus, instead of having a firm texture, like that which sometimes arises from the cancerous ulcer, is a dark red or purple mass, of an irregular shape, and of a soft texture, is easily torn, and bleeds profusely when slightly injured/'* In carcinoma, the fungus sometimes sloughs from some increased action in the diseased parts, but in fungus hsematodes, the fungus progressively enlarges, and only sloughs from accidental causes. In their external characters, therefore, we per- ceive a marked difference between carcinoma and fungus hsematodes. The internal differences are not less striking. "The morbid growth in fungus hsematodes, consists of a soft pulpy matter, which mixes readily with water, and is hardened by acids, and boiling in water. It has been also compared by all who have attempted to describe it, to medullary matter in colour and consistence."* "The colour of the tumour when small is generally of a pale grey, or brownish red hue; but when it is large, the different portions which are separa- ted from one another by capsules, assume very different appearances, the general mass being thus composed of a number of parts differing in, colour * Wardrop, paa;e 186. 31 ON THE SURGICAL. ANATOMY and structure. Some of these are of the colour and consistence of brain, some are of a deep yel- low colour, and some of them have the colour and consistence of the boiled yolk of an egg: some portions are of a dark red colour, like masses of coagulated blood, and others more resemble liver/'* Sometimes portions of it are excavated, the little cells containing a bloody fluid., and al- ways the tumour is intersected by thin membra- nous septa, which separate the different lobes of which it is composed from each other. Some- times several of these lobes are hard and car- tilaginous, and in other instances they are ossified. "The scirrhous tumour, from its commence- ment, is a hard, firm, and incompressible mass, which, by a minute examination, will be found to be composed of two distinct and very different substances. The one is hard and fibrous, the other more soft, and apparently inorganic. "The fibrous substance composes the chief part of the scirrhous mass, and consists of septse, which are opaque, and commonly of a paler colour, than the soft part. These septae are very unequal in their length, breadth, and thickness, and disposed in various directions, so as to form sometimes a solid mass, and at other times, a greater or lesser number of irregular cavities, which contain the soft part. "The soft or inorganic part is sometimes semi- transparent, of a bluish colour, and resembling in * Wardrop, page IOC. OF THE HEAD AND NECK. £43 consistence, softened glue. In other cases, it is softer, somewhat oleaginous, and more resembling cream in colour and consistence. ''The proportion and mode of distribution of these two substances are very different in scirrhous affections of the same, and of different organs; and give that great variety which may be observed by examining a number of tumours of this kind. In some, the fibrous part is most conspicuous, and is condensed into a very solid form, having the ap- pearance of a nucleus, from which septse come off in all directions, and giving a section of the tu- mour a radiated appearance. This is, perhaps^ the most usual form of the disease: in some, the tumour is very irregularly shaped, and nearly a uniform hard mass, in which scarcely any defined structure can be traced. In some, the fibrous part has a cellular appearance, the cells being filled with the soft pulpy matter, which can be readily pressed out with the finger. In others, it has cysts formed in it of various dimensions, which generally contain a bloody or dark chocolate- coloured fluid, and have sometimes a fungus tu- mour growing within them. It occasionally hap- pens, too, that parts of scirrhous tumours acquire a great degree of hardness, being converted into a substance resembling cartilage, in which bony de- positions are sometimes formed. When scirrhous tumours are formed in the substance of a gland, their limits cannot be 244 ON THE SURGICAL ANATOMY accurately determined, the two structures being apparently inseparably connected. At other times, they condense the cellular membrane, which is in their immediate vicinity, and acquire a more circumscribed appearance"* I have thus, from my own observation, and that of others corroborated by my own, endeavoured to draw the distinction between the external and internal characters of carcinoma and fungus hse- m;> lodes. It has appeared that the features in these diseases are distinct and well defined. If, therefore, we meet with one part of a tumour pre- senting the decided marks of carcinoma, and ano- ther part indelibly impressed with the lineaments of fungus hsematodes, we must surely conclude, that both these diseases have coexisted in the same body. This remark I have been led to make, from the result of careful dissection which I made of a diseased breast, lately extirpated by Dr Brown. One extremity of this organ pre- sented the decided features of fungus hsematodes, while the other end displayed the peculiar and characteristic texture of carcinoma. A single case, it may be said, is not sufficient to establish so important a fact; yet, although I cannot speak positively as to any other instance of a similar combination, I am pretty certain that such have come under my observation. Neither is it incon- sistent with established facts, to suppose that one * Wardrop, page 181, et, seq. OF THE HEAD AND NECK. 245 part of the tumour may be of one specific nature, and another of a different. From what I my- self have witnessed, I believe that one part of a tumour may be scrophulous, while another may be of the nature of fungus hsematodes. It seems that fungus hsematodes has now be- come a general name for all non descript tumours, as heretofore scirrhous was. Many dissimilar affections are thus huddled together. No two surgeons have the same ideas regarding the morbid texture of this disease; therefore, what- ever does not resemble any of the complaints with which they were already familiar, must be fungus hsematodes. My brother and Mr. Hey gave an account of the general appearances pre- sented by this affection. Mr. Abernethy next published an account of a disease which he called medullary sarcoma. Surgeons immediately in- ferred, because some features were common to fungus hsematodes and medullary sarcoma, that they must be identically the same disease. That they are not, however, is pretty certain, from the nature of the morbid parts themselves. In fungus hsematodes the body of the tumour is intersected by numerous membranous bands, but in medullary sarcoma the mass is of uniform pulpy consistence, and resembles in colour the cortical portion of the brain. In the former, we can wash out the soft brain-looking matter, while the membranous bands are left remaining; if we 246 ON THE SURGICAL ANATOMY treat a section of the latter tumour in a similar manner we leave only the capsule in which it was contained, and a numher of floculi hanging from its inner surface. I have seen and examined several specimens of medullary sarcoma, and uniformly with the same result; but the best ex- ample of it I ever saw was from the ovarium of a lady about forty. The tumour was very large, its centre contained a considerable quantity of glary fluid, and the surface of the cyst which contained this was studded over with numerous projections, each about the size of an orange. When these were cut into I found them composed of a pulpy organized mass of a medullary con- sistence, and of various shades in different places. Some parts of the tumour were of a dark purple tinge, and others were of a dirty yellow hue. The line of junction of the dark coloured with the brighter substance was abrupt and well denned. Mr. Abernethy, when treating of medullary sarcoma, informs us, that "the tumour, in those cases of the disease which I have most frequently met with, has been of a whitish colour, resem- bling, on a general and distinct inspection, the appearance of the brain. The disease is usually of a pulpy consistence, and I have, therefore, been induced to distinguish it by the name of medullary sarcoma. Although I have more fre. quently met with this disease of a whitish colour, yet I have often seen it of a brownish red ap- OF THE HEAD AND NECK. 247 pearance. Which is the most common I cannot decide, the structure and feel of both are the same, and their progress is also similar, they are, therefore, to be considered as varieties of one species."* That the membranous septse which are never wanting in fungus hsematodes, were not existing in the disease described by Mr. Ahernethy, was accidentally demonstrated in one of Mr. Abernethy's dissections. "I took out the lumbar glands and put them in water; and the weather being extremely hot when I examined thena next day, I found that all the unorganized deposited matter which had enlarged them had become putrid, and was washed away, leaving the capsule of the gland, and a congeries of flaculent fibres, occupying the interior of it."f That the structure of medullary sarcoma is different from that of fungus haematodes, is, I think, demonstrated; we have, however, to regret, that they are equally intractable in their disposi- tion, and equally fatal in their issue. Medullary sarcoma is sometimes met with in the thyroid gland. It begins with an elastic swelling, at first uniform to the touch, but by degrees, becoming unequal on its surface; the muscles are rigid, the integuments are tense, and in the advanced stage they are dark coloured; and over the prominent parts are bestudded with * Abernethy's Observations on Tumours, page 51. t Ibid, p. 56 248 ON THE SURGICAL, ANATOMY varicose veins, which 1 have noticed where the tumour was not larger than a billiard ball. At the same time the looks were squalid, the nights restless, the respiration difficult and wheezing, deglutition much impeded, the pulse frequent, the pain of the tumour great, lancinating, and almost incessant, although liable to exacerba- tions. The patient generally dies before the tu- mour has become very large, but to this there are occasional exceptions. I have once seen the tumour occupying the left side of the neck, com- mencing a little to the right side of the junction of the alse of the thyroid cartilage, projecting outward beyond the transverse processes of the cervical vertebrae, descending till it came in con- tact with the clavicle, and stretching upward till it touched the margin of the lower jaw bone. The patient was a most miserable creature, unable to breathe or swallow, except with great difficulty, and with many struggles. Her sur- geons visited her, they saw her deplorable con- dition, they advised one thing after another, and each did as little good as the one which had gone before: — They allowed the swelling to increase to the enormous size I have mentioned, and then, to give momentary respite, they made a long and deep gash into the tumour. They practised an old and pernicious expedient, which cannot be too strongly reprobated. It was an operation for which there could be no apology. The tumour OF THE HEAD AND NECK. 249 was evidently of a specific nature, and the sur- geon ought to have known, that to cut into such a mass, and not at the same time to remove it en- tirely, was a certain way to exasperate the dis- ease, and to destroy the patient. I must not quit the history of this case until I have explained some other points con- nected with it. I must advert to the position of the common carotid artery, which was deep- ly buried amidst the diseased suhstance. It lay imbedded in the very centre of the tu- mour, and in making the extensive wound into the swelling, the knife had penetrated to within the hundredth part of an inch of the coats of the vessel; how it escaped injury is hardly conceivable: it was not from the know- ledge of the operator, who hardly knew that there ought to be an artery in the neck, far less could he appreciate the changes which would take place in its locality from disease. The carotid artery being placed in the body of the tumour, is neither very rare in occurrence nor very difficult to explain. It is, indeed, a na- tural consequence of the extension of the tumour laterally; yet it will not happen in every tumour: it will only occur in those cases where the con- sistence of the morbid parts is soft. When the tumour is firm, it pushes the artery, nervus va- gus, and internal jugular vein, aside. When it is soft, these, as in the present instance, sink 250 ON THE SURGICAL, ANATOMY into its substance. This a fact which ought never to be forgotten. In carcinoma it never takes place; in fungus haematodes it sometimes occurs, and in medullary sarcoma, I havemore than once proved it by dissection to'^^iave** nap- pen ed. These are diseases for which there is no curer except the use of the knife; but it is only under certain circumstances, that it can be employed. It is only? when, from the limited connexions of the tumour, it is in our power to remove com- pletely the diseased substance, that we can con- scientiously recommend its use. Experience daily proves, that if the smallest particle of morbid matter be left behind, the diseased action spreads from it, as from a centre, the wound refuses to heal, the sore assumes an unhealthy aspect, it gleets out a profusion of abominably fetid ichor, and the patient soon dies, worn out by hectic. In the present case, the tumour might undoubt- edly have been extirpated at its commencement, and that without much danger; but procrastina- tion, and the employment of trifling remedies, permitted the period for active operation to pass by, and left to the surgeon only the melancholy task of witnessing the protracted sufferings, and miserable death of the patient: a death accelerated, and its pain aggravated, by the unskilful wound made into the tumour. Let this be impressed on the mind, for it will enforce OF THE HEAD AND NECK. 251 the necessity of having recourse to prompt and vigorous measures in similar cases. In bronchocele, even when the tumour is very large, and even where the carotid is imbedded in its substance, we may palliate either by external remedies, or by tying one or more of the large arteries which nourish the morbid parts; but in the advanced stage of carcinoma, fungus hsema- todes, and medullary sarcoma, we cannot control the growth of the tumour. The arteries be- longing to it are not enlarged in proportion to its bulk, nor would tying these, destroy the spe- cific action of the parts. Extirpation of the whole of the diseased substance, will alone se- cure the patient from its ravages; but this it is evident, can only be prudently undertaken in the early stage of the complaint: at a time when the tumour is small, and free from adhesion to the important vessels and nerves, which can readily enough be ascertained, in the same way that we discover whether an enlarged concatenated gland adheres to these parts. Even, however, where the nature of the disease has been early ascertained, where the tumour, is still small and moveable, many entertain a dread at intermeddling with it; a dread founded on preceding failures, arising from unskilful man- agement, and also from a review of the parts with which the tumour is in contact. It is, no doubt, an operation dangerous in its performance, ON THE SURGICAL ANATOMY but it has been safely executed, and the life of the patient saved. In Paris, the right lobe of the thyroid gland has been successfully extir- pated by Desault. Freytag informs us, that in his time, this gland had been completely re- moved, and the same has more lately been done in London. Nor was this more than we would have been led to believe and expect, from the favourable result of Mr. Astley Cooper's experi- ments on the inferior animals. In extirpating this gland, an incision of an eliptical shape, if tl\e tumour be large, or if the integuments be diseased, is to be made over it, with the long diameter directed from above to below The surface of the swelling is next to be uncovered, by dissecting back the integu- ments on both sides. Then the finger is to be insinuated between the skin and the muscles, pushing it upward and backward, till it comes in contact with the thyroid artery, round which a ligature is to be passed with a blunt needle. In a similar manner, the other superior thyroid ar- tery, and the two inferior vessels, are to be se- cured, where the whole gland is to be removed. By these ligatures we cut off the circulation into the tumour, and consequently are left at liberty to finish the operation, by cutting the vessels nearer to the morbid parts, than where the threads have been applied, and by dividing the sterno-hyoidj and thyroid muscles, above and OF THE HEAD AND NECK. 253 below the tumour, which is afterward to be de- tached from the trachea and gullet, by cautious working with the fingers. In this way, we may remove one or both lobes of the thyroid gland; but the operation is difficult, tedious, and not without danger. Where this gland is enlarged, it descends into the angular space, just above the sternum, and comes in contact with the arteria innominata, to which I have seen it adhere. When the parts with which an enlarged thyroid gland is in contact, are attended to, we shall not wonder much, that the extirpation of this gland is rarely recommended. In front, it is covered with, and bound down by the sterno-hyoid and thyroid muscles; when it descends low, it touches the arteria innominata; on the left side, it is in contact with the gullet, and lies over the branches of the recur- rent nerve; and on both sides, when it extends a little further out, it touches the carotid artery, the jugular vein, and the visceral nerves. To those, therefore, who are accustomed to do every thing with the knife, the extirpation of the thyroid gland must appear a formidable operation; but to one who knows where to use the scalpel, and where to substitute the fingers, the removal of the thyroid gland, although hazardous, does not ap- pear impracticable. Albucasis has related a case, where in extirpat- ing a bronchocele, the large cervical vessels were divided. The patient died from excessive hse- 254 ON THE SURGICAL ANATOMY morrhage. When we remember the rudeness of anatomical knowledge among the Arabians, their ignorance of the true nature of the circulation; and when we add to these, the size of the vessels in the vicinity of such a tumour, we shall not feel surprised at the result of this operation; nor can we, with justice, from its fatal issue, argue the impropriety of cutting out a diseased thyroid gland. Palfin* also informs us, that a young lady died during the extirpation of a bronchocele. Prosser reprobates the excision of this organ, and adduces the cases of extirpation of the thyroid gland, witnessed by Gooch, to prove the impro- priety of the operation. In the first case \\nich Gooch saw, the patient was in a very unfavoura- ble state. The person was reduced to extreme debility by the disease, arid weakness was still further increased, by the profuse haemorrhage which accompanied the removal of the morbid parts. Under circumstances such as these, we need not be surprised that the patient died within eight days after the excision of the gland, and more especially, when we learn that during all that time, the bleeding was never completely re- strained. In the other case, also witnessed by Gooch, the young lady lost a considerable quantity of blood during the operation; but in this instance, her life was saved by the assistants keeping up a constant * Falfin Anatom. torn. ii. page 313. OF THE HEAD AND NECK. 255 pressure with the fingers on the divided vessels, for nearly eight days after the removal of the tumour. Gooch adds, that in this case, the sur- geon was foiled in his attempts to secure the ves- sels by ligature. These are the cases from which Prosser con- cludes, that on no account, ought the thyroid gland to be removed by operation. If, however, we attend to even the imperfect account which is given of them, we shall at once be convinced, that Prosser, misled by an abuse of the operation, inferred its inexpediency in every case. In both of these instances, the operation without doubt, was most injudiciously performed. It has ap- peared, that in both cases the surgeon trusted to securing the arteries after the removal of the tumour; a plan by which the haemorrhage would unquestionably be increased, by which the opera- tion would be protracted, and the operator embar- rassed. Had he, on the contrary, secured the four arteries before he attempted to remove the tumour; and had he then torn the diseased parts from their attachments, in place of using the knife in separating them, there is every reason to be- lieve, that in the last case, at least, there would have been but little haemorrhage. But even had this plan been adopted in the first case, the event would have been doubtful. For independently of the injudicious performance of the operation in this instance, the probability is, that the patient 256 ON THE SURGICAL ANATOMY would have died from the mere effects of the irri- tation produced on the dehilitated frame, by the removal of the tumour; but when to this, we add a profuse bleeding during the operation, and a con- secutive haemorrhage, the event must necessarily, even in a stronger person, have been fatal. From the first c se, therefore, we can hardly draw any fair conclusion; and from the second, the only in- ference we can draw, is, that eventually the ope. ration may succeed, even where the extirpation of the tumour has been very injudiciously accom- plished. Wilmer, in his Essay on Bronchocele; says, "when we reflect upon the situation of the thy- roid gland, and consider its numerous arteries, which increase in diameter in proportion to the enlargement of the part, we shall not be surprised at the difficulties that must attend its extirpation in a diseased state, and the danger there ever must be of incurring a fatal haemorrhage. "* These are the notions entertained by all who re- probate this operation, but they are founded on a mistake in anatomy. A diseased thyroid gland really derives all its blood from four arteries; if, therefore, the surgeon secure these, he will, in de- taching the morbid parts, have nothing further to dread from bleeding arteries.f By venous * Wilmer's Cases in Surgery, p. 243 t The thyroid gland generally receives its supply of blood from foul1 vessels, but we sometimes find a fifth sent to it by the arteria innominata. Where this anomalous vessel exists, it will usually be found catering the OF THE HEAD AND NECK. 257 haemorrhage, he may still be incommoded, but it will easily be checked. Where, however, he employs the knife, and trusts to tying the arteries after he has divided them, he will unquestionably experience all the difficulty, and the patient will run all the hazard, that Gooch's did. The life of the patient will be saved, "only by having a succession of persons, to keep a constant pressure upon the bleeding vessels day and night, for near a week, with their fingers upon proper com- presses, after the operator had been repeatedly disappointed in the use of the needle and liga- ture."* Having in succession, attended to the relatibn of the different parts in the lower and middle regions of the neck, I am next led to inquire into those parts which lie above the digastric muscle. But here the muscles, glands, vessels, and nerves, are so much interwoven with one another, and so perplexed in their relations, that I hardly know how to explain them. Description cannot com- municate a clear idea of their connexions, it can only present a mere sketch; a rough outline of cross slip of the gland, just on the fore part of the trachea. This artery sonietii.ies supplies the place of one of the regular thyroid branches. Jn extirpating the thyroid gland, these facts must be^ecollected, * fiooch's Med. and Chir. Obs. p. 136. 33 258 ON THE SURGICAL ANATOMY the most prominent points. The details must be studied on the dead body; for it is by dissection alone that the student can hope to make himself familiar with surgical anatomy. Even the best and most spirited descriptions, convey but a very imperfect idea of the structure, and such an idea, as no one would think of employing as a substitute for actual dissection, more especially about the angle of the jaw. The few following remarks are, therefore, to be considered as hints, to be read preparatory to, or while examining the ana- tomy of the angle of the jaw, on the recent sub- ject. As the relation of these parts is considera- bly influenced by the position of the cranium, it will be necessary to say a few words, respecting the mechanism of the skull. As the cranium is attached to the spine, con- siderably behind the axis of the head, a vacuity is left between the front of the vertebrae and the inner surface of the lower jaw bone. In a fully grown adult, the base of whose skull is placed parallel to the horizon, the surface of the teeth in the upper jaw bone is generally not much either above or below the line of the foramen magnum. By this position, and by the concavity of the roof of the mooth, a sufficient space is left between the spine and the lower jaw to give lodgement and protection to the tongue, also to some of the large vessels, nerves, and important glands. Between the mastoid process of the temporal OF THE HEAD AND NECK. 2(5 £ bone, and the ascending plate of the maxilla i^e- rior, there is only the transverse diameter of the external auditory sinus interposed. In a well- formed jaw the ascending plate is about two in- ches in length, and the angle of the jaw is situat- ed about an inch anterior to the cervical vertebrae. A little before the root of the mastoid process, and a little nearer to the centre of the base of the skull, the styloid process begins. From the inclination forward of the styloid process its distal extremity comes to be hid behind the ascending plate of the jaw-bone, although its root be placed considerably behind it. This is a character pe- culiar to the adult; it is one which neither exists in childhood, nor is to be found in an edentulous subject. When the base of the skull is placed parallel to the horizon, and when the muscles about the throat are in an easy state of relaxation, the pharynx is flattened, and the back part of the larynx rests on its posterior surface, which is in close contact with the face of the spine. In this position of the head the os-hyoides is nearly as high as the margin of the lower jaw-bone. Hence the posterior belly of the digastric muscle has only a slight declination, while the anterior runs almost in a straight line forward. In tracing the relation of the parts about the angle of the jaw, the preferable plan, I believe^ 260 ON THE SURGICAL ANATOMY will be to begin behind, and notice them in suc- cession forward. The spinal accessory nerve appears betweea the transverse process of the atlas and the inter- nal jugular vein. It lies in such a situation that it may be exposed by an incision made along the anterior margin of the sterno-mastoid muscle, just opposite to the transverse process of the atlas. Lower than this the nerve is completely covered by the muscle, which it finally perforates to reach the trapezius muscle. Nearer to the angle of the jaw than the spinal accessory nerve, but in contact with it, the jugular vein is found; next to it, we see the lingual nerve, and then the internal carotid artery. The external carotid is separated from the internal, which is the deep- est seated, by the styloid process; or, where that process is very short, by the ligament which is extended from it to the appendix of the os- hyoides. A little lower than the angle of the jaw the occipital artery generally arises from the external carotid. The occipital artery in its course slants upward and outward, traversing the internal carotid, the nervus vagus, the lingual nerve, and the internal jugular vein; after which it slips in behind the digastric muscle, and passes round the root of the mastoid process, just above the transverse process of the atlas. From be- tween the internal carotid and jugular vein, but OP THE HEAD AND NECK. 261 262 ON THE SURGICAL ANATOMY and the genio-hyoideus. By an incision through these, the artery will be brought into view, ly- ing between the genio-glossus and the lingualis muscle. This view of the locality of the lingual artery puts it beyond a doubt, that the proper place to expose the vessel, when we wish to pass a liga- ture round it, is while it is running parallel to the horn of the os-hyoides. There, it is com- paratively superficial, and consequently easily reached; it is neither entangled among many mus- cles, nor- connected with more than one large nerve. It is rare, however, that this operation requires to be performed; yet, when we recollect that many patients have been allowed to die a lingering death, when the tongue has been dis- eased, purely from the dread of the bleeding which would arise from extirpation of this organ, it becomes necessary to shew the command which the surgeon actually has over the lingual arte- ries. The older operators imagined that it would be necessary to tie the vessels just where they were divided; but the known difliculty of accom- plishing this in a deep and confined cavity, natu- rally made them timid. Mr. Everard Home and others have proved, that portions of the tongue may, with the great- est safety, be removed by ligature. Yet there are cases, in which, from the situation of the diseased parts, it would be impracticable to apply OP THE HEAD AND NECK. 263 the thread. In such cases, I hardly think it too much, when I say, that the morbid parts may be extirpated by the knife. Have not we seen, that by a superficial and safe incision, the trunks of the lingual arteries may be tied before they have given off' any important branches. Now, I would inquire, if this has been done, what have we to dread? not the bleeding surely, for that we have controlled; not the loss of the tongue, for that organ, we without hesitation, remove with the ligature; and we know, that by disease, the whole of it may be destroyed without much detriment.* When I thus argue the practicability of extir- pating the tongue with the knife, I should be sorry to be misunderstood, or to have it supposed, that I would, when the ligature could be em- ployed, prefer the scalpel. On the contrary, I have used the ligature in removing a considera- ble portion of the tongue, and would still con- tinue to employ it whenever I could apply it. But every surgeon may have seen cases, where from the situation of the disease, he could not use a ligature. I have myself seen three, under the care of other surgeons, who, after the ap- plication of many and various remedies, local as well as general, had the mortification to see their patients daily sinking under the extension of the disease, which began at the root of the Mliolanaml Portal. '264 ON THE SURGICAL ANATOMY tongue and proceeded forward. In such cases, at least, I would, after having tied the trunks of the lingual arteries, be inclined to try the ef- fect of extirpating the morbid parts with the knife. It is not tlie relations of the trunk of the lin- gual artery alone which the student ought to make himself acquainted with. He will do well to study the position of the arteria ranina in respect to the frcenum linguae. This informa- tion will teach him the impropriety of pointing the scissors upward and backward, when snip- ping the frrenum, an operation, oftener per- formed than needed. He will learn that the ranular artery lies just above the attachment of the froanum, so that if he would avoid it, he must turn the points of the scissors rather downward; if he do not, the artery will probably suffer. As the*consequences of injuring this vessel, and the plan of treatment are very fully related in differ- ent works, I refer to them. As the os-hyoides is nearly as high in the throat as the jaw bone, when the base of the cranium is placed parallel to the horizon, the mylo-hyoideus muscle has very little descent. When, therefore, the submaxillary gland is cut away, a consider- able cavity is left between the side of the tongue and the lower jaw bone. The roof of this hollow is formed toward the chin by the mylo-hyoideus, and nearer to the angle of the jaw by the hyo- OF THE HEAD AND NECK. 265 glossus, which is intersected by the stylo-glossus. Between the carotid arteries and this cavity, the ligament of the angle of the jaw is interposed. Above the hyo-glossus muscle, the lingual branch of the third division of the fifth pair of nerves runs towards the tongue. In this cavity, the submaxillary conglomerate and conglobate glands are lodged, along with the fascial artery and vein, together with the branches sent off from them before they mount on the face. In this position of the head, little of the submaxillary gland is exposed, it is almost entirely covered by the body of the jaw bone. It is all, indeed, nitched in between the two bellies of the digastric muscle and the jaw bone. The fascial artery at its origin is very little lower than the angle of the jaw, hence, it soon becomes closely connected with the submaxillary gland; but be- fore it does so, it gives off the ascending palatine-, and the tonsillitic branches. It then mounts over the submaxillary gland, lying in a sulcus, formed for its reception. The fascial vein descends along the side of the gland nearest to the ear, and empties itself generally into the internal jugular vein, just below the edge of the digastric muscle. Behind this cavity, deep-seated, and nearly opposite to the root of the alveolar process of the second molar tooth, the tonsil lies sunk into the recess formed between the pillars of the fauces. It is situated in the angle between the 34 S66 ON THE SURGICAL ANATOMY stylo-glossus and stylo- pharyngeus, and is cover- ed by the fibres of the palato-pharyngeus muscle, It is supplied by an artery arising sometime* from the lingual, but generally from the labial artery, just where that vessel is passing along the insertion of the stylo glossus muscle. The tonsillitic artery is therefore short, and it is also- generally small, but where the tonsil was dis- eased, I have seen its nutrient vessel larger con- siderably than a crow quill. A little higher than the origin of the labial artery, the external carotid is nearly opposite to the tonsil, but the internal lies a little behind the natural situation of that gland. The glosso-pha- ryngeal nerve which escapes from between the external and internal carotid arteries, just at the origin of the stylo- pharyngeus muscle, is, as well as that muscle and the stylo-glossus, completely sunk behind the jaw bone. These are the relations which the different parts bear to each other, and to the jaw bone in the full grown adult, in whom the head is neither inclined backward nor forward. By bending back the head, the position of all the parts becomes materially altered; but none are more changed than the submaxillary gland, the fascial artery and vein. These parts, which in the natural position, of the head, lie retired behind the body of the jaw bone, are much exposed by the elevation of the chin. The cavity which formerly existed be- OF THE HEAD AND NECK. 267 twcen the maxilla and the mylo-hyoideus, is much reduced in size, and its contents are brought out from behind the jaw bone. They are rendered more accessible where we wish to extirpate them. These changes ought to be remembered, when about to remove a tumour from this region, be- cause the operation will be materially facilitated by placing the head in a proper position. The frequency of such tumours will be readily estima- ted by one who knows the number of conglobate glands which are clustered round the submaxillary salivary gland, and who remembers how liable these are to contamination from sores in the neigh- bourhood. The salivary glands are very rarely swelled, the lymphatic, ones very frequently, but it for- tunately happens, that these glandular swellings are not often of such a nature as to require ex- cision. They are usually scrophulous, running their course slowly, but at length suppurating. Sometimes, however, the tumour is of a less tractable nature; for sometimes it arises from ab- sorption of specific pus, from ulceration of the lip, or of the cheek, or below the tongue. A tumour of this species, may, in the early stage of the complaint, be removed with tolerable ease; but where it has been neglected from the compression and matting of the parts in the vi- cinity, the excision is attended with greater dif- ficulty and more danger. Extirpation of the 268 ON THE SURGICAL, ANATOMY tumour is only, indeed, practicable, when the mor- bid mass is defined and moveable. If it has become fixed, it will, by the resist- ance of the fascia and platysma myoides, be pre- vented from extending downward; it will become pushed upwards, forcing its way into the mouth from below the tongue. Here, however, I would caution the surgeon not to mistake the fulness na- turally produced by the sublingual gland for a tu- mour; a fulness which is much increased when the submaxillary glands are enlarged. The granulat- ed surface, and doughy feel of the salivary gland, may assist him in distinguishing it from a part of the diseased mass, which generally pushes the sublingual gland towards the tongue, making thus a way for itself into the mouth, between the displaced sublingual gland and the gum. Thus, a tumour, which superfically has only a small appearance, may have formed deep-seated con- nexions, which would forbid any attempt to operate. Such a tumour will be in contact on the side nearest to the chin with the digastric muscle; above it will touch the mylo-hyoideus, and be- hind that muscle, it will be absolutely in contact with the lingual branch of the fifth pair of nerves, which is interposed between it and the sublingual gland; and posteriorly, it will be more or less connected with the primary branches of the carotid artery, and with the side of the pha- OF THE HEAD AND NECK. £9 rynx. Even in the simplest tumour, the morbid parts are closely connected with the labial artery and vein, for these vessels are generally more or less buried in the diseased substance; and in planning our operation, we must decide on sa- crificing them. But when the tumour has ex- tended so far as to have come in contact with, and become fixed to the other parts which have been mentioned, the difficulty of dissecting away all the diseased substance, will be insuperable. Mrs. McDonald's was a very deplorable case of disease in the salivary and conglobate glands below the jaw. From ear to ear, her throat was girded by a chain of tumours, some inter- woven with the muscles and vessels, and others wedged into the fauces, but all so clustered, so much matted among the surrounding parts, and so widely connected, as to defy any operation. When I first saw her, she was gasping for breath, and the anxiety and leaden hue of the counte- nance bespoke the severity of the struggles for air, and its great deficiency. Nothing relieved her but the occasional burst- ing of small kernel-like cysts, which pervaded the more solid texture, and which discharged trifling quantities of glutinous fluid into the mouth streaked with blood. Blisters, and the other remedies employed, had no effect; an ope- ration was out of the question; earnestly, there- fore, as we desired to alleviate her sufferings, 270 ON THE SURGICAL ANATOMY we could do no more, than at each visit wit- ness her distress, and regret the impotence of our art. In deciding on the expediency of extirpating a tumour from below the jaw, we may be con- siderably assisted by ascertaining the origin of the disease, discovering whether it be idiopath- ic, or dependent on absorption from some sore in the vicinity, the length of time the swelling has continued, and the rapidity of its growth. If it has been produced by absorption from a specific sore, if it has been of short continuance and slow in its actions, and if it still continues as moveable as could be expected, considering the effect of the fascia, we may undertake its removal. But if, on the other hand, it has dated its origin from a distant period, has been brisk in its actions, and has become fixed to the mus- cles, vessels, and nerves in the neighborhood, it would be foolish to attempt its extirpation. Be- cause, although from the resistance of the fascia, the tumour externally may not appear formidable, yet, internally it may have extend- ed its connexions, and embraced parts from which it could not possibly be cleared. To at- tempt, therefore, its removal under such circum- stances, would be fruitless; we might, indeed, cut away what we saw of the diseased substance, but a portion would still remain behind. OF THE HEAD AND NECK. 271 Before resolving on the extirpation of a can- cerous lip, the surgeon ought most carefully ta examine the state of the submaxillary absorbent glands This he ought to do in every case; but where the disease is in an advanced stage, and seated in the lower lip, he ought to be doubly watchful. From inattention to this point, I have more than once seen the disease, after the extir- pation of a cancerous lip, reproduced below the jaw; a gland which had been contaminated there was overlooked, it continued to increase in size, and, before the death of one of the patients, which was occasioned by a different complaint, the tumor had acquired such a size as to give rise to considerable inconvenience. When a tumour is to be extirpated below the jaw, the operator will most easily accomplish his purpose, by placing the patient on a chair, and reclining his head on the breast of an assistant, who ought to stand behind him. The jaw of the patient must be kept closed, while the surgeon by a crucial incision through the skin, platysma my- oides, and fascia, exposes the tumour, which he is fully to uncover, by dissecting the flaps to a side. Next he is to push his fingers between the swell- ing and the surrounding parts, working his way among the cellular membrane, till, at the lower end of the tumour, he feels the pulsation of the labial artery. By insinuating the finger along the tumour, following the course of the vessel, he 272 ON THE SURGICAL ANATOMY will ascertain its connexions. If he find that the artery is not imbedded in the substance of the swelling, he may, by continued working with the fingers, insulate and remove the tumour, without injuring the trunk of the labial artery. Gene- rally, however, he will find the vessel so closely connected with the morbid mass, that it would be out of the question to attempt their separation. Here the plan to be pursued is evident. A liga- ture is to be passed round the labial artery, just where entering into, and passing out from the diseased gland, and next the vessel is to be divided at both places, nearer to the gland than where the threads have been applied. On the dead subject I have found it easiest to detach the gland when I began its separation nearest to the angle of the jaw, and proceeded towards the chin, near to which the submental artery will require to be snipped across. It is demonstrable, that in this way the submaxillary conglomerate gland will be torn away along with the tumour; but this, so far from proving disad- vantageous, will add to the security of the patient. But let the surgeon remember, that in many sub- jects the submaxillary and sublingual glands are connected by a communicating slip, which will require to be cut across, else the sublingual gland will be pulled away, which, to say the least, would be generally unnecessary. The salivary glands, although not so often dis- OP THE HEAD AND NECK. 273 eased as the lymphatic glands which are clustered around them, are nevertheless, sometimes affected. For instance, they are subject to inflammation, producing a painful swelling helow the tongue, accompanied with interruption of the secre- tions of that part of the gland which is inflam- ed. Resolution or induration are the usual ter- minations of this inflammation. Gariot, a late French author, on the diseases of the mouth, conjectures that the secreting part of a gland is incapable of suppurating; when, therefore, an inflanfed gland suppurates, he asserts, that the purulent matter is formed by the cellular texture entering into the composition of the gland. This, if correct, is an important fact, because, as the cellular matter is the medium through which the blood-vessels are conducted into the glandular substance, it follows, that if the former be destroyed, the latter^ also must decay, and. then the whole or a part of the gland must die according as the suppuration has been general or partial. The salivary glands are not only liable to be- come inflamed, but calculi likewise form in them. When a concretion has formed in the sublingual gland, a chronic, irregular, and dense tumour is produced below the tongue. The disease is readily discovered and easily cured. The foreign substance is to be extracted by an incision into the gland, just by the side of the froenum linguse. 35 274 ON THE SURGICAL, ANATOMY A calculus, weighing a drachm, was in this way easily extracted. The hard tumour occasioned by a concretion gives rise to a considerable inconvenience; but obstruction of the termination of the sublingual duct is a more dangerous, because a more insidious complaint. Its commencement is marked by a small and painful papilla beneath the tongue, which slowly enlarges, till it finally presses the tongue firmly against the roof of the mouth, injur- ing the speech, and impairing the functions of respiration and deglutition. At length the most prominent point of the tumour bursts, and dis- charges a considerable quantity of a transparent glary fluid. By the evacuation of the fluid, the tongue recovers its natural position, every incon- venience is suddenly removed, and the patient flatters himself with the delusive hope that he will soon be cured. Sometimes, however, the com- plaint assumes a more alarming appearance. Ehrlich in the observations collected during his travels, relates a curious case of this disease: "Un jour un homme demanda a parler a M. Cline. On le fit entrer dans Pantiehambre: tout a coup M. Cline, entendit tomber quelque chose et des plaintes et gemissemens d'une personne. En ouvrant la port il vit 1'homme en question, etendu par terre, sans connoissance et pret a etouf- fer. Cline soupconna la presence d'une corps ctranger dans la trache*e artere; et se disposoifc OF THE HEAD AND NECK. 275 deja it pratiquer la bronchotomie, lorsqu'il ap- per^ut la langue du malade poussee fortement en arriere par une grenouillette qui de plus faisoit saillie au dehors. II y plongea une lancette, et donne par la issue a une grande quantitc de pus et de lymphe. "Le malade, revenu a lui, declara que depuis long-terns il avoit port£ une tumeur considerable sous la langue, sans en etre gene ni en parlant ni en respirant; que cette tumeur, pendant le peu de mi- nutes qu'il avoit attendu dans Fantichambre, avoit acquis tres subitement un acroissement si consi- derable qu'elle Pauroit infailleblement etouffe sans la prompt secours que M. Cline lui avoit donne." This was a peculiar case, generally the pro- gress of the tumour is slow, and it bursts before such a size as in the present instance has been acquired. The opening seldom, however, con- tinues pervious for more than a few days; it slowly closes, again a tumour forms, it enlarges, bursts, but effuses a smaller quantity of fluid than the former one, and the tongue returns less per- fectly to its situation than before. The sides of the sac have, now begun to thicken, and the parts in the vicinity have begun to swell. The original complexion of the disease is about to change, yet the alteration is not suddenly accom- plished. The collection and evacuation of fluid is continued for a length of time; but after each suc- cessive discharge the patient is less and less £76 ON THE SURGICAL ANATOMY relieved, till at length the tumour becomes alto- gether solid. Now it increases more rapidly, and now it more completely displaces the tongue. Formerly this organ had only been pressed against the r?)of of the mouth; now its apex is reverted, so that it presses on the epiglottis, disturbing breathing and swallowing very materially, and about this time the tumour begins to project below the jaw. The nature of the tumour is most thoroughly ly changed; from containing a fluid, it has be- come solid, it is daily enlarging, and we can now anticipate no spontaneous alleviation of the dis- ease, such as took place in the former period. This is a disease, which in the early stage, is easily cut short, but when permitted to gain ground, its treatment becomes more complicated; and after the tumour becomes solid, it baffles every attempt at cure. This ought to be firmly impressed on the mind, for here it is the duty of the surgeon, to decide early on the plan he is to follow, and having once resolved, it is his busi- ness to act up to his intentions with promptitude. Before the sides of the cyst have begun to thicken, the treatment is exceedingly simple. The sac is to be treated as a sinus; we are to plunge a bistoury into it behind; are to open it through its whole extent; are to irritate its inner surface, to produce reunion of its sides, and the destruction of its glandular function. The natu- OF THE HEAD AND NECK. 277 ral bursting of the sac, or the mere puncture, are only palliative. Before we can cure the complaint, the callous inner surface of the cyst must be fairly exposed, and brought into a gran- ulating state, by the use of stimulating applica- tions, such as tincture of myrrh, or diluted aq. potass. The sore must be healed from the bot- tom, otherwise we merely teaze the patient, and convert a curable into an incurable complaint. Generally so soon as the sides of the sac have begun to form granulations, the further use of irritating applications is to be given up; they are now detrimental, in so far as they tend to check the formation of healthy granulations. Where the surgeon has been consulted suffi- ciently early, the preceding plan of treatment will generally prove effectual, but where the dis- ease has advanced so far, as to have induced a considerable degree of induration about the ter- mination of the sublingual duct, then the plan advised by Gariot must be adopted. He directs that the tumour be completely opened by a cru- cial incision, after which the callous sides of the cyst are to be cut off with a bistoury. The sponge will control the bleeding. In a few days suppuration commences, granulation soon follows, and the wound heals up progressively.* Pare and Tulpius, after opening the cyst, ap- plied a heated iron to its inner surface. Dionis rf!ariot Traite des Maladies rle la Douche, p. 131. 278 ON THE SURGICAL ANATOMY touched it with sulphuric acid, in place of which M. de la Faye employed the caustic. Wilmer in one instance, passed a seton through the tumour which not inducing sufficient irritation, was with- drawn. He then removed with the knife, a cir- cular portion of the cyst, below the tongue and next used the caustic, by which a radical cure was accomplished.* In another case of ranula, where the tumour was very large, and projected far below the circle of the jaw, he made an incision into the cyst from below the chin, removed the lower part of the sac, stuffed the wound with dry lint, which he removed on the fifth day, and applied the pure pot- assa to what remained of the sac. In a few days the slough separated, and in six weeks the pa- tient was cured. f I mention this case, not on account of any peculiarity in the principle of treatment, but on account of the place where the incision was made into the sac. Where the sublingual gland is affected, the tumour is pre- vented by the mylo-hyoideus from descending to- ward the throat, and pushes itself into the mouth: where the submaxillary gland is the seat of the disease, that muscle prevents the tumour mount- ing into the mouth; it swells below the chin. In the first case, therefore, we would cut into the cyst, just below the tongue, but in the last, we * Wilmer's Cases in Surgery, p. 80. t Ibid, p. 78. OF THE HEAD AND NECK. 279 would prefer Wilmer's plan of cutting below the chin. In a very large ranula, of so long continuance as to displace the teeth, the tumour was extirpa- ted at a time when the risk of suffocation was imminent. The cure was not completed, on ac- count of tedious exfoliations from the jaw bone, and the growth of fungi, till three months after the operation.* When mentioning the relation of the parts near to the angle of the jaw, it was stated that the ton- sil lay almost opposite to the root of the alveolar process of the second molar tooth — deep-seated — crossed by some of the branches of the carotid, and pretty near to the external carotid artery itself. As this is a secreting organ, intended to form a fluid to assist in lubricating the parts when swallowing the food, it is freely supplied with blood; but by this very mechanism it is subjected to dis- ease; it is liable to inflammation; it swells, and as it enlarges, it encroaches on the passage by which the air is admitted into the larynx, whereby the breathing is obstructed, and the deglutition impair- ed. From the mechanical effect of the tumour on these functions, we would wish as speedily as possi- ble to procure its removal; we would therefore, vig- orously use the means commonly employed to obtain resolution, and where these failed to produce the desired effect, we would without temporizing, * Meraoires de I'Acad. de Chirurg. torn. iii. 280 ON THE SURGICAL ANATOMY endeavour to conduct the disease to suppuration. The abscess generally bursts between the pillars of the fauces, but Dr. Brown has informed me, that in two patients, it burst through the velum pendulum palati. In both of 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, that where the chief pro- minence in abscess of the tonsil is seen, not be- tween 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-seat- ed, and were the surgeon to delay making an open- ing, in the expectation that it would become more superficial, the patient before this event took place, would die from suffocation So soon, therefore, as the difficulty of breathing renders it necessary, an opening is to be made into the abscess, and that even where the matter is still 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 ascer- tained, a polypus may be mistaken for an abscess of the tonsil. A case in which a mistake of this kind had been committed, came under the obser- vation of Mr. John Bell, who has very properly described it in his late work on tumours. OF THE HE AI> AND NECK. hen we have resolved on opening an abscess in the tonsil, some caution is required; it is to be remembered, that this gland naturally, is very near to the carotid artery, and that by enlarge- ment, it is brought still more closely in connexion with it. Hence this vessel may, by passing the cutting instrument too deep, and inclining it too much toward the angle of the jaw, be injured. In this country, I have been informed, that a sur- geon 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 sup- press the bleeding. In Portal's work, a case may also be read, where in opening an abscess in the tonsil with a pharyngotome, "un habile chirurgien de Montpelier eut le malheur d'ouvrir une grosse artere et de voir perir un malade d'une hsemorr- hag6e si violente, qu'on ne put jamais parvenir a I'arreter." On these cases, I would only remark, that they betray rashness and ignorance of the structure of the parts about the angle of the jaw; they prove most incontrovertibly, that the operators were de- ficient in a knowledge of the relations of the ton- sil. One who is familiar with the parts in con- nexion 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 36 ON THE SURGICAL ANATOMY the front of the tumour, and carry it directly backward, as if he intended to cut off a segment of it; if he follow this course, and transfix the ab- scess, the worst which can happen, will be injury of the back part of the pharynx; a trivial accident when compared with that of opening a large blood vessel. Where the collection of matter is large before the abscess burst, the patient is in a more dan- gerous situation than is generally imagined. His breathing is obstructed and gasping, he feels much anxiety in the chest, his face is dark and bloated, his eyes are painted with vessels con- taining purple-coloured blood, they are prominent, and seem ready to start from their sockets; we cannot be deceived in regard to the origin of these symptoms, which decidedly shew, that the lungs are imperfectly supplied with pure air. 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 invo- luntary and deep inspiration, air and matter rush together into the trachea, and death from suffocation, is almost the inevitable consequence. This to some, may have the appearance of a fanciful description, or at all events, an over- charged picture; but its fidelity will be admitted, when I inform them, that in this very way, a strong active young man lately lost his life. He OF THE HEAD AND NECK. 283 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 in- flammation 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 ad- visable, where the tumour is large, and the diffi- culty 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 a way into the windpipe, and if the stilet were made to project only a little be- yond the canula, the trocar may be as safely used as any other instrument. In some patients, after repeated suppuration, but in others without any obvious cause, the ton- sils become enlarged and indurated, occasioning serious inconvenience both in breathing and swal- lowing. Sometimes the tumour slowly decreases in size by occasional detraction of blood, followed by the repeated application of small blisters just 284 ON THE SURGICAL ANATOMY below the angle of the jaw, conjoined with the daily internal use of some purgative salt. One drachm of the sulphate of magnesia, dissolved in eight or ten ounces of water, will keep the bowels easy, which is all that is required. Where the tonsil still continues swelled, notwithstanding the use of these remedies, benefit may be derived from pass- ing electric sparks through the tumour. Where the tumour, in place of decreasing in size, continues to enlarge, we must, on account of the effect produced on respiration and deglu- tition, remove the diseased substance. It is not, however, generally necessary to extirpate the whole tonsil, nor, in fact, is that an operation which, even if required, could be safely accom- plished. It is fortunate therefore, that in the dis- eased state of the tonsil, which renders its remo- val necessary, if a part of the tumour be extir- pated, what remains skins over, and gives no further inconvenience. In taking away a portion of the tonsil, differ- ent plans have been employed. Bertrandi was in the habit of cutting away a portion of the gland with perfect safety. Gariot also prefers the bistoury or sheathed cystome for this purpose, and he recommends it as both the surest and most expeditious mode of operating.* We have the testimony of these and other authors to prove, that the haemorrhage is seldom profuse after the * Gariot des Maladies de la Bouche, p. 99. OF THE HEAD AND NECK. 285 excision of a part of the tonsil. The bleeding will generally be checked by gargling the throat with cold water, or by touching the orifices of the vessels with a camel's-hair pencil, dipped in oil of turpentine or alcohol, and where these fail, it may be certainly counteracted by the applica- tion of a hot wire. In using the latter, we must use the precaution of conveying the heated wire along a canula, otherwise it would be liable to come in contact with parts which we would not wish it to touch. Sometimes after the prominent part of a dis- eased tonsil has been cut off, the wound does not heal readily; the cure is retarded by a soft lymphatic looking fungus, which shoots up from the surface of the sore. Before recovery will take place, this excrescence must be destroyed. This has been accomplished, by touching it twice or thrice a- day with the muriate of ammonia, finely powdered; but on the whole, the actual cautery is, perhaps, preferable to any other plan. Some surgeons are afraid to use the knife, and some patients dread the pain of cutting; such may employ the double ligature proposed by Cheselden. A curved needle, armed with a double ligature, composed either of very flexible wire or waxed thread, is to be passed through the tonsil, as near to its junction with the sound parts as possible, by which the swelling is divid- ON THE SURGICAL ANATOMY ed into two equilateral portions. Then separate the threads, and run the two belonging to the upper segment of the tumour through a polypus canula, next push the latter home against the root of the morbid mass, and retain it there by twist- ing the ends of the ligature round the bars of the canula. Treat the under half of the tumour precisely in the same manner, and tighten the threads daily, till the intercepted parts drop off. This operation which seems to be very simple and easily planned, is nevertheless, difficult in execution; the tumour on which we are to ope- rate is large; the cavity in which we are to act is confined. I would never, therefore, employ the ligature, until foiled in removing the tumour by other means, and until the patient decidedly ob- jected to the use of the knife.* It is not to be inferred that every chronic en- largement of the tonsil depends on thickening and induration of the substance of the gland; it is sometimes produced by the formation of cal- culi. These seldom in the amygdalae acquire any considerable size, but their presence is produc- tive of irritation, and repeated attacks of cyn- anche; 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. It is * See Appendix (D.) OF THE HEAD AND NECK. 287 evident, that a surgeon who is not aware that calculi may be formed in this gland, will be liable to consider the tumour as dependent on some more serious affection. I have never had an opportunity of examining a patient with a cal- culus in the tonsil, bu I have received the history of three cases of this disease, all oc- curring in the same family, and known to Mr. Robert Wilson, an intelligent practitioner in Beith, who sent me the calculi. The first case was that of Agnes Wark, who scon after exposure to cold and wet feet, com- plained of a fulness about the fauces, accom- panied with pain, which extended along the Eustachian tube of the left side. Her respira- tion was obstructed, and her deglutition difficult. After three weeks, the tumour suppurated and burst externally. The sore discharged purulent matter for a fortnight, when it healed. Two months afterward, from a similar cause, the throat became again inflamed, suppurated, burst, and healed. Indeed, during eighteen months, she had frequent attacks of cynanche tonsillaris, all of which uniformly terminated in suppura- tion, and all of the abscesses burst externally. It was not, however, till about this time, that she discovered after the sore had healed, a regu- lar and solid tumour on the left side, which pro- truded the skin, just below the angle of the jaw. Soon afterward, and without any obvious cause, 288 ON THE SURGICAL ANATOMY she had a very severe and long continued attack of imflammation in her left tonsil. An abscess formed and burst externally, discharging matter during a full year, by eight small appertures. Before this time she had never consulted any medical practitioner, but she was now induced, from the long duration of the disease, and the inconvenience resulting from the pain and dis- charge, to shew the ulcerated part to a surgeon, who discovered by probing the sore, that a cal- culus was lodged in the tonsil. Having ascer- tained this point, he next endeavoured by an external incision, to extract the concretion; but the bleeding deterred him from enlarging the wound to a sufficient extent, so that his operation ended in detaching a fragment from the body of the calculus. Being foiled in this attempt, he next advised the application of a cataplasm over the wound, and directed the patient to wash the throat frequently during the day with some simple gargle. By this treatment, little altera- tion was apparently produced; but in the course of fourteen days, the calculus dropped from the tonsil into the mouth. From this time the sores began to heal, the discharge lessened, the pain abated, and after the cure, which was completed in a few weeks, she had no return of cynanche during a period of twelve years. The brother of this woman was similarly af- fected, but in him the disease continued during OF THE HEAD AND NECK. 289 twenty years Before the calculus was discharged from the tonsil. In the third patient, who was nearly related to the two former ones, the con- cretion dropped into the mouth, about two years after the commencement of the complaint in the tonsil. In these patients considerable inconvenience was occasioned by the encroachment of the tonsil on the fauces, an inconvenience which was rather increased than diminished by suppuration, and which was constantly on the increase. Consider- ing this, a surgeon who satisfied himself with a cursory examination of the patient, might have imagined the enlargement depended on thicken- ing of the substance of the gland itself, and on that supposition he might have begun an operation, which would have terminated in his own discom- fiture. In the first case, I would likewise notice an impropriety committed by the surgeon, who be- lieved that by enlarging the external sore he would have it in his power to extract the stone, Here it is evident, that he forgot that the con- cretion was deep-seated, that it was by sinous passages that he brought the probe to grate against it, and above all, that it lay imbedded amongst large vessels, which must have been di- vided, before a wound could be made of sufficient size to permit of the extraction of the calculus. On these accounts an external incision is com- 37 290 ON THE SURGICAL ANATOMY pletely out of the question, so long as the concre- tion continues deep-seated; it is only allowable when the calculus has, by suppuration and ulcera- tion, worked its way outward, so that it is only detained by the skin. Here, any other than an external incision vvouM be preposterous; but there can be no doubt regarding the propriety of an internal cut into the substance of the tonsil, in order to extract the foreign substance, so soon as its existence has been ascertained. 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 preceding cases. In some patients it forms in the cryptte of the tonsil, enlarging them, and even projecting into the fauces. Where it assumes that form, it can, by any blunt pointed 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 a 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 un- common affection. So soon as the external carotid artery has emerged from behind the stylo-hyoideus and the OF THE HEAD AND NECK. 291 digastric muscles, and while it is lying over the internal carotid, it attaches itself to the parotid gland, with which, for the remainder of its course, it continues to he very intimately con- nected, and in the substance of which it sends off its branches. This glapd and its connexions are too important to be passed over with a cur- sory notice; its situation and extent ought to be known to every student; it is not the circumscri- bed and well-defined gland which many believe it to be, neither is it confined to the space be- tween the ascending plate of the lower jaw- bone and the ear. That is really a small part of the gland, the limits of which cannot be shewn by a superficial dissection, which can give no just idea of either the extent or connexions of the parotid gland. To unfold these, we must penetrate deeper, we must follow the gland to the very root of the external auditory sinus, al- most to the internal carotid artery and jugular vein; we must trace it sunk behind the plate of the jaw bone, and see it adhering there to the internal pterygoid muscle; we next follow it be- hind the bterno-mastoid muscle, and down along the neck a little way below the angle of the jaw, and examine it where folded over the pos- terior edge of the masseter muscle, and when we have done all this, we shall only have made our- selves acquainted with the mere locality of the gland. We shall have still to learn vhat it is, 292 ON THE SURGICAL ANATOMY while buried in the deepest part of the parotid gland, that the external carotid artery gives off the arteria posterior auris, and divides into the internal maxillary and temporal arteries, and likewise that it is while imbedded in this gland that the portio dura crosses the artery. The parotid gland is then sunk so deep, and is so firmly locked in between the ascending plate of the lower jaw bone and the mastoid pro- cess, that when it becomes diseased the patient cannot open his mouth, and from the effect of the fascia the tumour is flat. Its extirpation is quite out of the question; its impracticability is pro- ved by reviewing the connexions of the gland. Whoever hc.s, in situ, injected the salivary duct with mercury, and then, even where the gland was healthy, where it was free from preternatur- al adhesions, and limited to its natural size, has tried to cut it out, would be convinced, when he saw the mercury running from innumerable pores, that the gland extends into recesses into which he could not trace it in the living body. If this be true in health, what must it be in disease, where the parts are wedged between the angle of the jaw and the mastoid process, and nitched into every interstice around. On the dead sub- ject I have attempted the extirpation of such tu- mours, but even there have never succeeded in clearing away fully the diseased substance. OF THE HEAD AND NECK. 293 The inference from this fact is too plain to re- quire to be expressed. Those who assert that they have extirpated the parotid gland, have, I am fully convinced, mistaken that little conglo- bate gland which lies imbedded in its substance, and which does sometimes enlarge, producing a tumour in many respects resembling a diseased parotid, for the parotid itself. I have seen an enlargement of the lymphatic glands taken for a diseased parotid, and the same has occurred to Mr. Cruickshank. This author, when speaking of the absorbents and glands about the parotid, adds, that he had known these "indurated and enlarged to the size of a hen's egg, which gave suspicion of a cancerous affection in the parotid itself."* This gland, in the early stage of the complaint, may be extirpated, but the parotid cannot. "The cutting out completely the parotid gland is a thing quite impossible, since the greatest of all the arteries, viz. the temporal and the maxil- lary, lie absolutely imbedded in the gland. "f If we may credit the assertion of Mr. Charles Bell, we must believe that his brothe", assisted by himself, actually accomplished this impossi- bility: "I assisted my brother formerly in this operation. The whole gland was diseased; it * Cruickshank's Anatomy of Absorbent Vessels, second edition, page 203. Anatomy, vol. 2d, page 293. -94 | TTTE StTIGICJLL A3fATO3irT was dlvsrcUd all round, unti it remained attach- ed only at that deep point which b behind the a^gfe of the jaw. where it encircles the artery. A Hgamre was put upon its root, and in a few- days it dropt off, more completely eradicated than could have been possible with the knit Nor does this assertion of Mr. Charles Bell's rest on his authority alone. Mr. John Bell avows die operation which he would wish to mak he had often performed, -for I had of. extirpated the diseased parotid."! With his ds he shall condemn himself: -What shaD we think, then, of those surgeons who talk in such familiar tarns of catting out the parotid Did Mr. Befl know the connexions of this gland less perfectly when he wrote his System of than afterward? Did this lately ac- knowledge teach him that his former in- was incorrect? Did it convince him that die parotid gland mar really be extirp^ Did he from this belief actually undertake and accomplish its excision with the assistance of his brother? Let Mr. C. Bell determine the motives to -talk in such familiar terms out the parotid glandr5 and let Mr. for OP TH£ HEAD AVD 1 duJiaJac the extirpation of this gland than ite connexions with the temporal and •axillary arte- ries, for these ma&t both be ewtroOed. The arteries are not our dread; they do not deter as the gland into interstices fro* which we cannot extricate it, leave us no hope of clearing away all the diseased substance, without which any opera- tion would prove abortive. This is our chief con- sideration, and this iniuiUMHMfihir obstacle, our only objection. I have endeavoured to place the qntstiou re- gankBgtheexUTK^i^oftheparatidslandinds proper light, and to shew front the its connexions, that it is ai ought to be undertaken. If the disease he really seated in the parotid itself, which, m nine out of ten, it will not be, we could have no tation of extirpating every particle of the tainted substance. This must decide the question. But how are the ope rations to be explained, in which this gland was reported to have been cut out? This will not be a diScuh task. The tioos of the operations prove. I think, (hat it not the parotid itself which was removed, but < eased conglobate gland, of which there are .vo connected with the parotid. One is erally placed beneath that lobe of the which extends lower than tli 296 ON THE SURGICAL ANATOMY other is imbedded in the very centre of the paro- tid, lying commonly opposite to the division of the external carotid artery into the temporal and maxillary branches. The first is not very deep-seated, it is merely covered by the cervical fascia and the thin de- pendent lobe of the parotid gland. When it swells, it forms a tumour just below the angle of the jaw, and rather behind it; not fully circum- scribed, not even in the incipient stage freely moveable; still where it is not very large, it may be easily enough extirpated. Anterior to it there is no part of consequence; behind it the trunk of the external carotid artery is placed; yet, by the fingers, the tumour may be safely detached from that vessel. This was the species of tumour ex- tirpated by Mr. John Bell from about the angle of the jaw of the late Mr. William Dunlop.* These remarks on tumours formed at the angle of the jaw, will be well illustrated by the follow- ing case, which was under the care of Mr. Ander- son, with whom I saw the patient.f In this patient there were three tumours about the angle of the jaw, one of which at least, had existed during seven years. The largest tumour, which was about the size of a pullet's egg, was * Bell on Tumours, vol. ii. p. 216. t The facts which I have mentioned in this case, were derived from dif- ferent letters which passed between the patient and the medical gentlemen to whom he submitted his case. These letters I saw and read at the time the operation was performed. OF THE HEAD AND NECK. 297 seated between the mastoid process and the ascending plate of the jaw bone. It was pro- minent, and in part moveable; it was as move- able as could be expected, since it was covered by a fascia. It could be moved from side to side, but it could neither be fully grasped by the fingers, nor its extent fairly defined; its depth, especially could not be determined. It might dip backward, but there was no proof that it did so; nay, from its being moveable, there was rea- son to suppose that it did not. The tumour next in point of size lay just below the angle of the jaw; was rather less than a walnut, and rolled freely under the skin and fascia, and the fingers could be made nearly to encircle it. When pulled forward, the large vessels could be distinguished behind, completely unconnected with the tumour. The third and smallest tumour was placed by the side of the last, and both lay nearly over the di- grastic muscle. From first perceiving these tumours, they had steadily increased, although slowly; or if at any period they had been stationary, it was after an incision had been made into the uppermost: their consequences were, therefore, to be dreaded, which made the patient naturally enough anxious to have them removed. With a view to this, he consulted several practitioners of the highest professional talents, both in London and Edin- burgh. 38 398 ON THE SURGICAL ANATOMY Mr. John Bell, who was first applied to, was decided in his opinion, that the tumours were formed by dilated veins, but the veins were not simply varicose; there was something strange and undefined in his notions. He talked about the dilated veins being inclosed in a bag; and so fully was he impressed with the truth of this conjec- ture, that he actually made an incision into the largest tumour; blood only followed the knife, yet both the surgeon and his patient flattered them- selves, that this cut would effectually resist the progress of the disease. Mr. Bell predicted, that by the inflammation consequent to this ope- ration, the sides of the cyst containing the veins would become so thickened, that if it did continue to enlarge, the increase would be extremely slow. For a time the patient believed this. Soon, how- ever, he was convinced that his hopes were ill- founded; again, therefore, he had recourse to Mr. Bell, who still persisted, that the nature of the disease was the same as formerly; and again he repeated his opinion that the sac would not en- large with rapidity. Nevertheless, the swellings augmented, the patient became more and more anxious, for he began to lose confidence in Mr. Bell's prediction. He still believed that the tumours were produced by dilated veins; but now not even the boldness of Mr. Bell's tone could persuade him that they would not some time or other endanger his life. OP THE HEAD AND NECK. 299 Impressed with this belief, he submitted his case to three of the most eminent surgeons in London, all of whom coincided in opinion that the tumours were glandular; but regarding the nature of the complaint, there was a difference of opinion. One practitioner supposed the swell- ings to depend upon derangement of the biliary system; another thought that they might arise from the torpidity of the absorbent system; one turned his attention to the state of the bowels; while the other prescribed such medicines as are supposed to increase the activity of the lympha- tics. All the three practitioners dissuaded the patient from submitting immediately to an opera- tion; but one of them encouraged him to hope, that when the swellings had become larger and more prominent, they might be extirpated. He followed th prescriptions given him, but found that the growth of the tumours was uncontrolled. Disappointed in his expectations, and rendered solicitous about his safety, he was desirous of having the diseased parts removed by operation. Mr. Anderson saw him, and gave him hopes that it was not yet too late to operate; but re- quested, at the same time, the advice of, some other surgeons. Several were consulted; and the general voice was against operation. The patient, who was a most intelligent gentleman, was faithfully informed respecting what had passed. He was explicitly told^ an operation 300 ON THE SURGICAL ANATOMY might prove unsuccessful, since, perhaps, it would be found impracticable to clear away all the dis- eased substance; the smallest portion of which being allowed to remain, he was taught to be- lieve, would prevent the wound from healing. This was the only risk, there was no immediate hazard, because it was in the power of the sur- geon to stop short at the point where actual dan- ger began. The uncertainty, therefore, of the issue of the operation was what the patient had to consider, and to balance. He was apprised, that from the previous history of the tumours, there could be little doubt, that they would still continue to enlarge; their nature was also such, that there was reason to fear that ulceration would ultimately take place, fungus be formed, hectic induced, and death follow. On these facts the patient reflected, and his decision was, that an operation should be performed. In an hour he was prepared. With firmness he seated himself on a chair, then reclined his head on the breast of an assistant, and with for- titude and an unmoved countenance, bore a pro- tracted and painful operation. An incision was made by Mr. Anderson from the root of the ear to below the angle of the jaw. It was of such a length as to expose fully the whole ex- tent of the tumours. The smallest tumours were readily, after the division of the fascia, de- tached merely by the fingers, and when brought OF THE HEAD AND NECK. 301 away, the diseased substance was found included in a firm membranous capsule. The removal of the uppermost tumour was rather more diffi- cult, owing to its connexion with the parotid gland. It had originally been formed by en- largement of one of the small glands, which are covered by the depending lobe of the parotid. As the tumour increased, it pushed this lobe up- ward and outward, and this was the only cause of difficulty. So soon as this lobe of the parotid was turned aside, the diseased gland was, with the slightest effort, started from its bed or cup, in- vested with its sheath. After the first incision, all the other parts of the operation were executed by the fingers; and as each of the tumours were, after their removal, found to have their capsules entire, there could not possibly be any of the diseased substance left behind. Two little arteries which had been divided, were now secured, and the margins of the wound brought together and retained in con- tact. In a few weeks, the wound was completely (healed. Plate VI. will illustrate the deep-seated con- nexions of a tumour, nitched in between the parotid gland and the digastric and stylo-hyoideii muscles. The latter only are interposed between the swelling and the external carotid artery. Above and below the line of these muscles, the tumour is absolutely in contact with that vessel. 302 ON THE SURGICAL ANATOMY On this account, a tumour which had formed be- hind the angle of the jaw in the woman Mander- son, had a vigorous pulsatory motion, insomuch, that one would without care, have been induced to believe the carotid artery to be aneurismal. In this woman, the swelled gland does not simply lie over the carotid artery, it turns round its tracheal side, insinuating itself between the vessel and the posterior margin of the hyo-glossus muscle, so that by pressing aside the ligament running from the pterygoid muscle to the side of the neck, it touched the pharynx. This I was rendered cer- tain of, by introducing a linger deep along the mouth, and examining the pharynx, where the tumour can be distinctly felt adhering to its side, and establishing connexions which completely forbade any operation. Disease of the lower lobe of the parotid gland is not to be mistaken for enlargement of the con- globate gland, which it covers. Sometimes this lobe of the parotid gland becomes sacculated, forming a collection of watery viscid fluid. Such a tumour begins just behind the angle of the jaw, and from that nucleus, proceeds downward and laterally. As the swelling is covered by the fascia, it is consequently tense; and although the sides of the cyst be thin and pliant, fluctuation is obscure. Yet although ill-defined, it may generally, by care, be detected. This species of tumour does not require to be extirpated, its na- OF THE HEAD AND NECK. 303 lure, so long as it is sacculated, is simple; it is a mere body of saliva, hollowed out in the glandular substance. In the incipient stage, therefore, the tumour is to be opened, its gelatinous contents evacuated, and the inner surface of the bag irrita- ted by passing a seton through it, or by stimulat- ing injections. Just below, and behind the angle of the jaw, I have mentioned, that a sacculated tumour is sometimes formed by the lobe of the parotid gland. At other times, the internal jugular vein is dilated at the same place, into a considerable sized pouch. I have a cast which I received from my friend Dr. Monro, which very finely illus- trates the position and external characters of a tumour of this nature. No operation can be per- formed here; the surgeon must, therefore, be careful, not to confound a dilatation of the jugular vein with a sacculated parotid tumour. In the latter, we cannot by pressure disperse the swell- ing; in the former, the tumour can be completely emptied by squeezing it between the fingers. There cannot, therefore, be any apology for a surgeon who mistakes the one for the other. In planning the removal of a tumour from be- hind the angle of the jaw, the situation of the lobe of the parotid is to be kept in remembrance, be- cause this connexion, will, in some measure, regu- late the surgeon; it will direct the form of his incision. His object must be to avoid injury of 304 ON THE SURGICAL ANATOMY the glandular substance, not from any idea that a wound of it would affect the ultimate success of the operation, but because it would probably retard the cure. A salivary fistula would be the consequence, unless steady compression was ap- plied and persisted in for some time after the removal of the tumour. This it would be desira- ble to avoid. Such a tumour will, with the greatest prospect of avoiding the formation of a salivary fistula, be removed, by making a triangular flap of the skin over it, directing the apex towards the clavical. The knife is not in the first instance, to penetrate deeper than the fascia, from which the integu- ments are to be turned up. Next the fascia is to be divided by a similarly shaped incision, after which, the lobe of the parotid gland and the fas- cia are to be raised from over the tumour, and held back by an assistant during the time occu- pied by the surgeon, in detaching with the fingers the swelled gland from its adhesions behind.* If the fingers be alone employed for this purpose, there will be no danger of injuring any vessel, but where the scalpel has been used, the poste- rior facial vein has been cut. This, although a trifling accident, may be easily avoided. * Mr. Walker, after having insulated the tumour, "finding its roots to run very deep, a:sd tlie artery pulsating strongly, the tumour being in actual contact with the external carotid he put a ligature round the root of the gland, which came away on the following day."* * Bell's System of Dissections, 3d edit. p. 249. OF THE HEAD AND NECK. 305 When the tumour is removed, the parts which have been raised are to be laid back, and retained in their place by a compress, supported by a twist- ed roller. Sutures will not, in any instance, be re- quired to keep the edge of the wound, together, but strips of adhesive plaster may be used. Sometimes spontaneously, sometimes from blows about the angle of the jaw, but oftener from ab- sorption of irritating matter from the gums, the antrum, or the recess of the nose, the little gland in the centre of the parotid swells. As the gland lies deep, the tumour formed by it, is for a length of time, very ill-defined. Between the jaw and the mastoid process, we discover by examination, rather a fullness than a regular swelling, and the patient complains of tension and stiffness in the region of the parotid. During the enlargement of this gland, it pres- ses on the parotid, producing absorption of its substance, by which the tumour comes ultimately to take the place of the parotid: it is in the end, equally nitched in among the parts at the angle of the jaw, and its extirpation is equally imprac- ticable. Unless, therefore, we resolve in the very early stage of the disease, to cut out the tumour, we shall never afterward have it in our power to accomplish that operation; nor even in the inci- pient period, can the swelling be taken away without some difficulty and danger. It is this difficulty, arising from the confined bed of the ' 39 308 ON THE SURGICAL, ANATOMY The small gland, the parotid gland, and all the parts in the vicinity, were blended together into an unseemly, fetid, morbid mass, the greatest bulk of which had the decided character of fun- gus hsematodes. In the centre of the tumour, we found a large insulated irregular piece of fiew formed bone lodged. Before quitting the angle of the jaw, the con- nexions of the portio dura must be attended to. This nerve, when passing from the foramen stylo- mastoideum lies behind the parotid gland, but it almost immediately dips into its substance It continues a single and undivided trunk for about half an inch of its course. This part of the nerve runs in a slanting direction downward and for- ward, imbeded in the gland. Where the portio dura is escaping from the skull, it is deep-seated, and nearly in contact with the arteria posterior auris, and where that artery and the occipital arise by a common trunk, the latter vessel is also quite in the vicinity of the portio dura. By the styloid process, the nerve is separated from the internal carotid artery and jugular vein. About midway between the ascending plate of the jaw bone, and the mastoid process, the portio dura is nearly opposite to the posterior facial vein, and the external carotid artery. It is at this point, at a place where the nerve is still deeply covered by the glandular substance, that it divides into its branches, which separately /'/„//• 17. 7'/i,- fioi-lio />innv/.v In •// thi-. li-t,'ti<\ft,-ri,m*t bvtji? r,-m,,ni/ ,>f //>,• Ihv-lilv/swi mutcl?. / tlif •initi/ , l.'nr .t,-n,/<>i,i <•/>' h' tl,,- r«mus d<-scenin«l , 1?c?/sfr\; \rrvf ? ^fern,>in,,,tt,u,#,-(f. fl tht l«>i-n «t' t OF THE HEAD AND NECK. 309 perforate the gland, to reach the cheek and the other parts on which they are to be distributed. Some of these branches pass upward, some for- ward, and others downward. The largest of these branches inclines upward and forward, and while still imbedded in the gland, it subdivides into a numerous set of twigs, which cover, as with a net-work, the zygoma and the arteria transversalis faciei. The largest of these twigs2 runs nearly midway between the zygoma, and the parotid duct. The other divisions of this nerve ramify over the face, and about the side of the throat. PLATE VI.— -This view was taken from a full grown male subject. The arteries were injected with wax, pre- vious to dissection. A is placed on the trunk of the portio dura, which has been carefully dissected out of the substance of the parotid gland The branches and twigs of the nerve, were more minutely traced than has been represented. I wished merely to shew the great divisions of the portio dura; those which require to be re- membered when studying tic douloureux. This plate will likewise be useful in illustrating the deep-seated connex- ion of tumours formed about the angle of the jaw. The large vessels, and the stylo-hyoideus and digastricus mus- cles are fully exposed by the removal of the parotid and conglobate glands. This view of the connexions of the portio dura will shew, that the trunk of that nerve can 310 ON THE SURGICAL ANATOMY only be reached with safety by an incision made along the anterior edge of the mastoid process; at a part where the nerve is unquestionably deep- er seated than it is further forward; but where it is, at the same time, less connected with important parts. By an incision beginning at the very root of the mastoid process, and continued downward and forward, along the anterior margin of the sterrio-mastoid muscle, the portio dura may be reached. The dissection, no doubt, will require to be deep, but in performing it, the surgeon will not experience much difficulty. The lobe of the ear will require to be pulled upward, and held forward, while prosecuting this dissection. In performing this dissection, the nervus superfi- cialis coli will necessarily be divided, where en- tering the lower angle of the parotid; the glan- dular substance itself will be injured, and the arteria posterior auris will be cut across. But these are the only parts which will require to be intermeddled with, in order to reach the nerve at its very exit from the stylo- mastoid foramen. Where the disease is seated in the portio dura, it is hardly to be supposed that division of one or more of the branches of that nerve, will radically remove the complaint. Those who remember the deep situation of the nerve, where it divides into its branches, and the way in which these perforate the gland to reach the face, will be convinced, that an operation performed on OF THE HEAD AND NECK. 311 it after passing the parotid gland, cannot suc- ceed; enough may be done to suspend the mor- bid action in the body of the nerve, for a short time, but generally the disease will recur. This is one cause of failure, but there is yet another, for the complaint does recur, even where the trunk of the affected nerve has been divided, provided it has been simply divided. Some- times the pain returns within a few hours after the operation, which had led to a belief that the nerve had not been fully divided. The ion at the instant of cutting the nerve, is bo peculiar that no surgeon can be deceiv- ed; the reproduction of the pain, depends on the manner . in which the operation has been performed, not on the incomplete division of the nerve. To insure success, a portion of the trunk of the nerve must be cut out. So much of it must be removed as will prevent reunion of the divided extremities. This ought to be a fixed principle, because on this the permanency of the cure will, in a great measure, depend: I would, perhaps, not be far wrong were I to say, that it entirely depended on the prevention of the reunion of the cut ends of the nerve. The facts with which we are acquainted would lead us to suppose, that anastomosis of the nerves is not of the same value to the nervous system, nor productive of any of 312 ON THE SURGICAL ANATOMY those striking effects, which arise from vascular inosculation.* * Ur Haighton lias performed a series of experiments which throw considerable light on the consequences arising from division of nerves. The experiments made by this gentleman, and related in the 85th vol. of the Philosophical Transactions, go to prove, that it is by reunion or re- production of lost substance, that divided nerves regain their functions. This position has been fully established by observations ma was not larger than a sewing thread, I have seen the transverse facial artery equal to the diameter of a goose quill. But in this subject, it furnished the coronary artery of both lips, as well as the nasal arteries. It also ran nearer to the parotid duct than it usually does, when the labial artery is of its com- mon size. Connected with the parotid duct, the trans- verse artery of the face, and the twigs of the portio dura, and covering part of the masseter muscle, we find the socia parotidis, a texture in every respect similar to the parotid gland, secret- ing a similar fluid, and pouring it by one or more little orifices into the parotid duct. The socia parotidis, however, is neither uniform in its size, nor constant in its place, and is even in some sub- jects altogether wanting Where it exists, it sometimes presents the appearance of a broad 318 Otf THE SURGICAL ANATOMY thin patch; at other times, there are two patches* or it is collected into a little knob. Sometimes it is continued from the edge of the parotid gland, ac- companying the parotid duct to the anterior mar- gin of the masseter muscle. But these are the an- omalies of the socia parotidis. To represent it as it usually appears, it must he described as a little glandular process lying between the parotid duct and the zygoma, generally in close contact with, or even overlapping the former, and seated some- what nearer to the parotid gland than the middle of the masseter muscle. Frequently one or two little conglobate glands are found in the vicinity of the socia parotidis. Leaving these parts, the parotid duct dips from the anterior margin of the masseter, ever the mass of fat which is interposed between that muscle and the buccinator. When it comes in contact with the buccinator, it suddenly contracts to a very small size; in its previous course it is about the thickness of a large crow quill, and its canal will admit a common sized probe; but where passing through the buccinator muscle, its orifice will hardly admit a catheter wire. It usually opens into the mouth opposite to the space be- tween the second and third molar teeth of the upper jaw, a little below the margin of the gum. Just before its termination, the parotid duct is crossed, and touched by the facial vein, but the OF THE HEAD AND NECK. 319 artery inclines considerably nearer to the angle of the mouth. After pointing out the situation of the portio dura, the parotid duct, the socia parotid is, the transverse artery of the face, and the facial arte- ry and vein, a few remarks on the extirpation of tumours from this part of the face will not be out of place. In removing tumours from this region, it ought to be a primary consideration to avoid injury of either of these parts, but more especially of the parotid duct, which occasions a most troublesome fistula. All this can, generally, in the extirpa- tion of tumours, be guarded against. Let the student make himself fully acquainted with the line which the parotid duct follows, with its rela- tion to the masseter muscle and the buccinator; let him bear in remembrance the conglobate glands which are in the vicinity of the duct, and let him not overlook the mass of fat which fills up the space between the buccinator and masseter muscles. If he be familiar with these points, he will have little to dread in extirpating a tu- mour from the side of the face, nor will he find much difficulty in avoiding the parotid duct. There are two spots chiefly where tumours form, in which the parotid duct is concerned; it will hardly be necessary for me to add, that the one is where the duct is crossing the masseter muscle, and the other where it is passing from 320 ON THE SURGICAL ANATOMY the edge of that musel >. to reach the buccinator. In the former case th° tumour is usually produced by swelling of one ot the little conglobate glands which lie by the side of the socio parotidis; in the latter, the tumour is originally formed by dis- ease of the bundle of fat which occupies the hol- low between the masseter and buccinator muscles, or by enlargement of a lymphatic gland lodged among that fat. The latter is, perhaps, a rare occurrence. When a glandular tumour has formed over the masseter, the parotid duct will either be found lying directly behind it, or it will be displaced by the enlargement of the swelling; but in either case it will, generally, by tearing with the fin- gers, be easily separated from the morbid parts. Where, however, the tumour is formed by the contents of the space between the masseter and buccinator muscles, the position of the duct will vary according to the nature of the morbid parts „ Where the tumour is adipose, and continues soft and pliant, if it have projected to any consider- able extent from between the muscles, the duct will be more or less indented into the morbid parts, or even fairly encircled by them. Not only the parotid duct, but the facial vein also, may be sunk into such a tumour. The duct and vein can only be connected in this manner, with tumours of a soft texture. I have seen it sur- rounded by an adipose tumour, by a fungus OP THE HEAD AND NECK. 321 hsematodes tumour, and by an anastomosing aneurism. In hard glandular swellings, the duct is projected on the front of the morbid parts, or it is pushed aside. Let these facts be studied, and we shall not hear surgeons talk of extir- pating indiscriminately, and in the same way, the different varieties of tumours which form about the face. They will, on the contrary, re- member, that the relation of the parotid duct, and other parts, will be varied according to the posi- tion or nature of the morbid parts. They will even be able to judge pretty accurately whether it will be found behind, or on the front, or sunk into the substance of the swelling. PLATE VII. FIG. 1. and FIG. 2. are plans illustrative of tumours con- nected with the parotid duct. FIG. 1. shews a tumour, glandular but not very firm, seated over that portion of the duct which traverses the masseter muscle. Not only the duct, but also some of the twigs of the portio dura, are connected with the posterior surface of the swelling. It will be necessary to explain those parts in order: A is the little glandular and slightly knobbed swelling. B repre- sents that portion of the parotid duel nearer to the gland than the tumour, and C that part anterior to the tumour. D is the facial vein, which, in its course, is seen traversing the buccinator muscle, and crossing the termination of the parotid duct. E the facial artery, very serpentine in its rourse, and observed from where it turns over the jaw ON THE SURGICAL ANATOMY bone up to the angle of the mouth inclining forward, and crossed just at the angle of the mouth by the insertion of F, the zygomaticus major muscle. FIG. 2. is a plan, shewing the relation of the parotid duct to a tumour which has protruded from between the masseter and buccinator muscles. It is a tumour of a soft texture, so soft, indeed, that, even although not large, the the duct is indented into its surface, and would, had the tumour continued to increase, have been fairly buried deep in its substance. This species of tumour is closely connected with the duct. A A is the swelling. B B B the parotid duct, which runs over the anterior part of the tumour. C is the facial vein, covered, along part of it* course, by the tumour. A tumour of this size may easily be extirpated, and the parotid duct saved, provided the morbid parts have not formed adhesion to the cheek. When, however, the cheek and tumour are incorporated into one mass, the facial vein cannot escape; buried in the diseased parts, it must be re- moved along with them. This is, however, a trifling cir- cumstance, compared with what is sometimes required to be done. It is an absolute nothing, in comparison with what must be done and taken away where the gums are involved. In this sketch the tumour is circumscribed; nitched, in- deed, into the small and confined space between the mas- seter and buccinator muscle, but so free from attachment to the parts in the vicinity, so well denned, a mere knob, that except from the position of the parotid duct, there could have been no difficulty in its excision. It is one of the most favourable cases which a surgeon can expect to meet. It is one where there ought to be no hesitation, regarding the propriety of operation. I would even give the patient a chance, where the tumour simply adhered to OP THE HEAD AND NECK. 323 the cheek; but I would never, on any consideration, OP under any circumstances, attempt the extirpation of a tu- mour when connected to the gums. The mangling and scraping, and the risk of previous absorption, and the almost physical impossibility of removing completely the whole of the diseased parts, preclude, in rny opinion, any reasonable prospect of success for such an operation. To attempt it, therefore, conscious as we must be that it can- not succeed, is only putting the patient to the pain of a fruitless operation. It is unquestionably the duty of every surgeon to undertake an operation, even where the pros- pect of success is not very great; but it surely cannot be incumbent on him to attempt what he is fully aware he cannot execute. I believe there is no one instance in which recovery has taken place, where an operation had been performed under si":h circumstances; nay, there are very few surgeons who would either advise or perform the operation. Mr. John Bell did, in the case of Mr. Taylor, endeavour to extirpate an extensively diseased mass from the hollo'w of the cheek; a mass covered by very unhealthy skin, rough, discoloured, warty, and Dickered, and firmly fixed to the gums. This Mr. Bell hoped to dig away at the expense of the parotid duct and the facial vessels; but although he cut •widely, sparing nothing which savoured of disease, still the issue v\as unfortunate. The complaint recurred, and ultimately killed the patient. That a tumour has formed between the mas- seter and buccinator muscles, is ascertained by examination with a finger introduced into the wiouth. lu this way a projection will be discor- 324 ON THE SURGICAL ANATOMY ered just between the gums of the upper and lower jaws, extending some way forward, and pushing the cheek inward. When the tumour is solid in its consistence, has continued for a length of time, is not perceptibly moveable, or, when moved, carries along with the lining membrane of the cheek, and when this membrane feels in- durated, and the patient cannot freely open the mouth, it may be inferred that the morbid parts have extended backward behind the ascending plate of the maxilla inferior and the buccinator, lodging themselves between the internal and ex- ternal pterygoid muscles. Such a case is hopeless; an operation is out of the question; no prudent surgeon would propose it, nor any intelligent patient, when apprized of the danger, insist on its performance Yet, al- though under such circumstances, the surgeon has it not in his power to extirpate the morbid parts, still he is not to desert the patient. I have known a solid tumour of this kind, which had continued for a considerable time, and which had completely curbed the motions of the jaw, ab- sorbed. The patient was under the care of Dr. Brown, with whom I saw him. He was a stout young man, with a fulness on the one side of the face, just before the edge of the masseter muscle. This muscle was rigid, and the limits of the tumour externally, were not distinctly marked — there OF THE HEAD AND NECK. 325 was a gradual change from induration to natural ;xtiire. Internally, a hard knob was readily liscovered pushing inward the lining membrane of the cheek. This tumour extended as far back as the finger could reach, which was not very far, since the mouth could not be opened. Although, therefore, it could not be proved, by actual exa- mination, still it was evident, from the effects produced, that the tumour must have extended deep behind the ascending plate of the lower jaw bone. Its nature, connexions, and position, were altogether such as to forbid any operation. Various local remedies were tried, but the tu- mour did not begin to decrease till sometime after a seton had been passed through the skin below the jaw. At last it was completely removed by the absorbents. The result of this case was highly satisfactory, yet it is not mentioned for the purpose of recom- mending local remedies in preference to the knife; it is brought forward to shew, that even in the worst of cases, perseverance may do good. It never can furnish an apology for neglecting to remove a tumour of a similar kind, when within the reach of an operation. In extirpating tumours, the primary considera- tion with the surgeon ought to be, to remove the morbid parts without injuring the capsule which defines them. If he accomplish this, he has no- thing to dread from a return of the disease. 326 ON THE SURGICAL ANATOMY Where, however, he nibbles at the tumour with the knife, and cuts it away piece meal, he has no security; amidst the blood and confusion he can never say when the whole is taken away; much may be left,* or too much may be removed, the clear bed of the tumour can never be fairly ex- posed. There is every reason, therefore, to induce an operator to plan his operation so, that the tu- mour may be cut out entire; nor about the face, will this be so difficult as many would imagine. The parotid duct is to be avoided. Its relation to the tumour, it has been seen, will vary accord- ing to the locality of the latter, but fortunately, these variations can generally be pretty accu- rately ascertained before beginning our operation. To this, however, we must never trust; our dependence for the safety of this vessel must be placed in exposing the duct nearer to the parotid gland than the tumour. If this be done, its firm- ness will be its protection during the subsequent progress of the operation. The tumour, in those cases where the duct lies behind it, is to be exposed on every side, either by a careful dissection with the scalpel, or by working with the fingers. In whatever way its lateral connexions are destroyed, its final separa- * If it would serve any useful purpose, I could relate different cases from my own observation, to corroborate this assertion; at present, however, I have more than one reason for declining the task. OF THE HEAD AND NECK. 327 tion, from its adhesion to the parts behind, is to be accomplished by the fingers. This will sel- dom be difficult, never indeed, unless where the capsule of the tumour has, by inflammatory adhe- sion, been fixed to the neighbouring parts. Then, 10 doubt, it is less easily accomplished, but still, >y care and cautious working with the nails, it may be removed without injury of either its cap- sule, or of the parotid duct. These are to be sedulously guarded against; the first secures the patient from a return of the disease; the second from the formation of a salivary fistula. The excision of tumours lying anterior to the parotid duct, is generally very simple, but the removal of those in which the duct lies before the tumour, is more difficult; and where the duct is imbedded in the morbid parts, we can seldom, where the tumour is of a specific nature, accom- plish a cure. Considering the greater difficulty of extirpating tumours lying behind the parotid duct, it is the duty of the surgeon to enforce the early removal of every swelling, situated be- tween the masseter and buccinator muscles. If executed while the tumour is small, and as freely moveable as its confined situation will permit, the surgeon may reasonably hope to be able to extir- pate it fully. If, however, he delay till it has be- come wedged into that hollow, till it has formed firm adhesion to the surrounding parts, and till the cheek has become indurated, all reasonable 328 ON THE SURGICAL ANATOMY hope from an operation, must be at an end. It may be attempted, but cannot succeed. From this view it will appear, that no time ought to be lost in attempts to discuss such tu- mours by external applications. Here an opera- tion must be speedily performed, or the patient must resolve to run all hazard. Better, there- fore, that a surgeon should unnecessarily extirpate a simple glandular swelling, than that he should, on the presumption of a tumour being simple, permit it to gain ground, and form connexions, from which, were it really of a specific nature, he could not afterwards detach it. Since this sheet was sent to press, I have been consulted by a gentleman regarding a tumour on the cheek, which began some years ago, soon af- ter the extraction of one of the molar teeth from the upper jaw. It has, since its commencement, continued slowly to increase in size; it is now as large as an orange, elastic when touched, free from pain, but covered by thin integuments of a reddish purple colour. It extends from the an- terior margin of the masseter muscle, to the angle of the mouth, and reaches from the lower edge of the orbit, to the alveolar processes of the lower jaw. Between the mouth and the tumour, there is only a membrane interposed; not thicker than writing paper, but the morbid parts are perfectly moveable; they have little connexion either with the skin, or lining membrane of the cheek. OF THE HEAD AND NECK. 329 The tumour seems to be simply steatomatous, id its connexions are not of such a nature, as to forbid an operation The parotid duct, some of the branches of the portio dura, and the facial ar- tery and vein, will, no doubt, be implicated, but icy could surely be extricated; our objection to an operation, is the general state of the patient's health, and his advanced period of life. He is above sixty, and has been an irregular living man; his constitution seems injured, his nose is carbunenlous, and the skin of his face is far from having a healthy appearance. When I view these facts, and take into consideration the thinness of the inttguinents covering the tumour, and separating it from the mouth, I cannot divest myself of a tear, that adhesion would not take place after the excision of the tumour. It is pro- bable, that in a constitution such as this gentle- man possesses, the wound would slough, inducing that febrile condition so inimical to the success of any operation. On this account I dissuaded the patient from urging the extirpation of the swelling, which he wished to have removed. In extirpating a tumour seated behind the pa- rotid duct, the first point is to expose the duct, just where passing from the edge of the masseter; then it is to be traced forward along the whole extent of the tumour. In doing this, the duct is to be left attached to the integuments on one 43 330* ON THE SURGICAL ANATOMY side; then with the fingers, the coverings of the tumour and the duct are to be turned aside, a hook is to he struck into the tumour, which will generally, from the quantity of loose fat in which it lies imbedded, be easily pulled outward, when it may be detached, by snipping with the scissors the fatty process by which it is connected to the deep seated parts. By cutting this, the nutrient vessels of the tumour, which are derived from the internal maxillary artery, will generally be divided, but they will seldom be found of such a size, as to require the ligature. To some, it may seem that in describing the external incision along the course of the parotid duct, I have overlooked the risk of injuring the facial vein. This is really inconsiderable; gene- rally the vein is pushed towards the angle of the mouth by the tumour, but even if it did lie over the morbid parts, and if it were cut across, it would prove of very little consequence. Where the tumour lies either anterior or pos- terior to the parotid duct, it can, and consequent- ly ought to be removed with its capsule entire; but when the duct is imbedded in a fatty mass, the sheath of the morbid parts must be cut intor and the tumour extirpated in two portions. Where the disease is not of a specific nature, the duct may be safely extricated, and a cure accomplish- ed; but where the duct is imbedded in a specific tumour, it is hardly possible to dissect it out, with- X)F THE HEAD AXD NCCK. 331 •out some of the morbid substance adhering to it. I would, therefore, in such a case, prefer cutting out the portion of the duct connected with the tumour, to any attempt to extricate it. Where, however, the tumour is not of a specific nature. I can confidently speak of the propriety of dis- secting the duct out of the substance of the swel- ling. In extirpating an anastomosing aneurism from the living subject, I have found it necessary to dissect the parotid duct, and a large branch of the portio dura, from amongst the substance of the tumour, so as to insulate them completely along nearly three quarters of an inch of their course. To the result of this operation, I would call the attention of the student. It was such, as, a pri- ori, might have been inferred from Mr. Hunter's experiments on adhesion. As the case to which I have alluded is interesting, I shall transcribe it from my note book: "A middle-aged and stout young man, lately applied to me for advice, respecting a large, livid, and compressible tumour, which was seated in the vicinity of the right orbit. On inquiring, I was told that the swelling had existed from his birth, that it was sometimes more distended than at other times, that it seldom was productive of pain, except when injured, on which occasion it poured out a considerable quantity of fluid blood. The patient likewise stated, that the tumour 332 ON THE StiRftlCAI* ANATOMY never pulsated nor throbbed, but during exertiofi or walking during a very hot or very cold day^ it became exceedingly tense. ^Externally the tumour covered about one- third of the temporal extremity of the upper eye- lid; it likewise occupied the whole extent of the lower one, the folds of which were sepa- rated by the blood to such an extent, as to pro- duce an unseemly, irregular, and pendulous swell- ing, which hung down over the cheek. Towards the outer canthus of the eye, the morbid texture was interposed between the tunica conjunctiva and the sclerotic coat, forward, to within the eighth part of an inch, of the attachment of the lucid cornea. It was chiefly in this direction, that the disease was spreading. From the ex- ternal angle of the eye the tumour was prolonged both outwards and downwards. In the first direc- tion, it extended to the point of junction of the tem- poral and malar bones; in the latter, it descended nearly half an inch below the line of the parotid duct. "Through its whole extent, the tumour was free of pulsation; no large artery could be traced into it; by pressure, it was readily emptied of its con- tents; but slowly, on the removal of the pressure, it was again filled. When emptied, by rubbing the collapsed sac between the fingers, a doughy impression was communicated to them. On the surface, it was of the dark purple colour of the OP THE HEAD AND NECK. 333 grape, with a tint of blue on those parts covered by the skin, but where invested by the tunica con- junctiva, it had a shade of re,d. It was cold and flabby, communicating to the fingers the same sen- sation which is received on grasping the wattles of a turkey cork." DESCRIPTION OF PLATE VIII. FIG. 1 — This figure affords an accurate representation of the situation and external character of the aneurismal tumour just described The course of the parotid duct, may be shew-i, by a line drawn from the junction of the lobe with the cartilaginous portion of the ear, to the point intermediate between the root of the nose and the angle of the mouth. The situation of the branch of the portio dura, \vhich was, along with the parotid duct, dissected from the diseased substance, will be readily remembered. It lies a little nearer to the zygoma than the parotid duct. These are the chief points which this drawing is meant to illus- trate; yet it will also have its use in explaining the extent of the tumour, and its connexions with the eye-lids. "As the tumour was increasing, and threatened to extend over the eye, the patient was anxious for its removal. By a careful examination, I was sa- tisfied that it might be extirpated; the arteria transversalis faciei, the largest branch of the por- ON THE SURGICAL, ANATOMY tio dura, and the parotid duct, would unquestiona* bly be found more or less connected with it. On the sixth of May, I performed the operation, in presence of Dr. Balmanno, Dr. Brown, and Dr. King; and was assisted by Mr. Russell. "I began by detaching the lower eye-lid along its whole extent, then I readily enough dissected away that part of the tumour adhering to the sclerotic coat, and I next removed that portion of the tumour which adhered to the upper eye-lid. This being done, I tied a pretty large artery, which passed into the tumour from the outer and lower part of the orbit. The vessel lay just to the temporal side of the inferior oblique muscle. The next stage of the operation consisted in dissecting off the tumour clearly from the aponeurosis of the temporal muscle — the zygomatic process — from the malar bone, and from over the large branch of the portio dura, and the parotid duct. After the great body of the tumour was in this way removed, I found that still a part of the spongy morbid mass remained attached to the parts behind the parotid duct, and portio dura; I also discovered that some of the tumour dipped beneath the fascia of the temporal muscle, which was reticulated. "From these parts there was a general oozing of blood, and from the divided transverse facial artery, as well as from the arteries which perfo- rated the malar bone and the masseter muscle, there was a pretty profuse bleeding. The vessels OF THE HEAD AND NECK. 335 I secured, and then with the forceps and scissors I cleared away the diseased matter from behind the parotid duct and branch of the portio dura, both of which were thus detached from all con- nexion with the neighbouring parts. In the same way I was obliged to cut out a quantity of diseased substance from behind the zygoma. As the mor- bid parts were here ill defined, and much inter- mixed with the fibres of the temporal muscle, a considerable part of it required to be taken away; now, in doing this, the deep-seated anterior tem- poral artery was divided. What of it remained on the cheek adhered so firmly to the zygomatic muscle, and was so closely incorporated with its substance, that the one could not be separated from the other. "In performing the latter part of the operation no large artery was divided, and all those which had been cut were secured, yet there still conti- nued a considerable oozing from the surface of the malar bone, and from about the zygoma. "Immediately after the operation, the insulated part of the portio dura and of the parotid duct were laid back on the masseter muscle, and the edges of the integuments were kept in contact over them, by means of a single suture. Over the malar bone the lips of the wound could not be made to approach, nor did the oozing from the bone cease. A fold of linen and a layer of sponge, were therefore laid into this part of the wound, 336 ON THE SURGICAL AN \TOMY and retained there by a compress and bandage^ applied so tightly as to restrain the bleeding. "The sponge was kept firm in its place during two days, then it was removed without a renewal of the bleeding. So soon as the sponge was taken away, we endeavoured with strips of adhe- sive plaster, to bring the lips of the wound nearer to each other. The sore soon began to form gra- nulations, which, in a few days, notwithstancl ng the use of regulated pressure, became so luxu- riant, that they had risen considerably above the level of the wound. They had not a healthy look, but on the contrary formed a flabby red fungus, perfectly unconnected with the margins of the sore. "Although the granulations did not she w any tendency to form skin, yet the sore was daily reduced by the approximation of its edges. An eschar was repeatedly formed on the surface of the granulations, by the application of sulphate of copper, without the effect of checking their exuberant growth, or disposing them to form skin. Still, however, by bringing the edges of the sore nearer to each other, its limits were re- duced, and in the end were brought to a size little larger than the diameter of a shilling, without apparently the cicatrization of a single granula- tion. When the sore was reduced to this diame- ter, new skin began to extend from the margin over the granulations, which, before the end of OF THE HEAL) AND NECK. 337 July, were completely covered by a new formed pelicle of skin, which occasioned a very little de- formity of the countenance." It is now more than three years since the sore was healed, and still the patient continues free from any return of the disease, and the cica- trix is becoming smaller. The only inconveni- ence which the patient now experiences, arises from the motion of the upper eye-lid, being im- paired by its adhesion to that part of the sclero- tic coat from which the tumour had been dis- sected. From the same cause, the ball of the eye does not possess the same latitude of motion as formerly. It requires a considerable effort to turn the pupil toward the nose. This case is not only valuable in so far as it illustrates the surgery of the side of the face; but it is also interesting, as illustrative of one species of anastomosing aneurism. In the aneurism from anastomosis, there is no loss of muscularity — no dilatation of the coats of the vessels from weakness; there is no partial growth from any individual artery; but, on the contrary, the tumour is formed by an enlargement of the inosculating twigs. By the dilatation of vessels, which in the healthy state, would hardly have been visible to the naked eye, the pulsating mass is composed. This is, therefore, a disease of a singular nature, and its characters are so de- cidedly marked, that we cannot but wonder that 43 338 ON THE SURGICAL ANATOMY it should, till so lately, have almost completely escaped notice. It is most unquestionably cer- tain, that hints of its existence are to be met with in more ancient works than Mr. Bell's Principles of Surgery; but they were so vague, and had so little effect in calling the attention of surgeons to this affection, that Mr. Bell is justly considered the first who accurately described aneurism from anastomosis — a disease which differs widely from true aneurism. In anastomosing aneurism, the blood remains always fluid in the vessels, and these, though enlarged, still retain their contractibility, and are still competent to the propulsion of their con- tents by their own action. The structure of the tumour is also altogether unlike that of true aneurism. The blood, in place of being lodged in a circumscribed sac, is contained in the ex- treme vessels, which are, in this disease, much enlarged and exceedingly active. Mr. John Bell describes the tumour as made up of a cellular structure like the placenta, and into each cell he tells us an artery opens and a vein rises from it. In this disease there is "a violent action of the arteries, and a mutual en- largement of the arteries and veins; while the intermediate substance of the part is, by this im- pulse, and in course of time, slowly distended into large intermediate cells, which dilate at last into formidable reservoirs of blood." — "The OP THE HEAD AND NECK. 339 veins form a conspicuous part of such a tumour, but the intermediate cells are as sensible a part of the structure; for when the tumour is emp- tied, we feel that the blood is repressed from the sacs in the veins; and when the tumour is large, with a purpled surface, we feel the sacs individually prominent; when they burst we see the blood flow out from them; and when the tu- mour is extirpated, they seem to compose its chief bulk." "The altered structure of the part resembles, then, that imaginary parenchyma or cellular sub- stance which the early anatomists of Europe pre- sumed, and indeed pretended to prove by injec- tion, was interposed betwixt the extremities of the arteries and those of the veins in all parts of the body, especially in the secreting viscera." These are Mr. Bell's observations on the struc- ture of such tumours, and it is but justice to add that they are corroborated by Mr. Freer, who has injected one of these tumours with mercury, so as satisfactorily to demonstrate its cellular structure. Other pathologists deny the existence of these cells, affirming that the tumour is entirely composed of a congeries of coiled up vessels. I can readily conceive how both Mr. Bell and Mr Freer may have been deceived. Till the time of the illustrious Haller, it was currently believed that the vesiculse seminales were cellular. This anatomist unraveled them, and observed 340 ON THE SURGICAL ANATOMY that they were really composed of convoluted tubes. Were I to speak from my own observation, regarding the texture of the tumour in anastomos- ing aneurism, I would certainly be inclined to believe that it was really cellular. There would seem to be two species of anasto- mosing aneurism: one in which the arteries are chiefly affected, and another in which the veins are principally concerned. The f rst is an acute and most dangerous disease; the latter is chronic and less to be dreaded. The arterial anastomosing aneurism begins from a mark which had existed as a discoloured spot from birth; or it appears at first like a small fiery pimple, or it succeeds a blow or some other injury, or it begins without any obvious exciting cause. In whatever way it begins, it is at first small, but gradually increases in size; the pulsa- tion, which originally was obscure, becomes a prominent feature in the complaint, the swelling still enlarges, the pain and feeling of distension augments, "and when the cells are enlarged into sacs, and the mutual communications consequently free betwixt the extreme arteries and veins, the whole tumour pulsates distinctly, and when ex- cited by exertion or muscular struggles, it throbs furiously; the tumour assumes then a purple hue; the apices of the sacs become sensibly thin; the patient is alarmed from time to time with slighter haemorrhages, which becoming more frequent OF THE HEAD AND NECK. 341 from various points, and very profuse, he is at last debilitated, changes his complexion and colour, loses his health, and dies." From the first to the last the swelling is com- pressible, and it is even more easily reduced in size by pressure, in the advanced, than in the early stage, when it is "of a doughy consistence, and having a woollen or cushion like feeling, when pressed and moulded under the finger." In the latter stage, in those cases which I have seen, the tumour was easily emptied; but on the removal of the pressure, was almost instanta- neously filled by one, two or three large tortuous arteries which could be traced into its substance, and which were left beating much more vigorous- ly than the arteries in any other part of the body. The working of these arteries and the labouring of the tumour, when the circulation is hurried by exertion, or increased by hot weather, is most dreadfully increased. And during these periods of excitement, it is proper to mention, that the heat of the tumour, as measured by the thermome- ter, is actually greater than the temperature of the other parts of the body. From the description of anastomosing aneurism, it will appear to be a peculiar affection of the vas- cular system, and therefore not to be treated on the general principles applicable to true aneurism. In the latter, we tie the great artery considerably above the aneurismal spot, and we allow the tu- 342 ON THE SURGICAL ANATOMY mour to decay from operations carried on within itself; in the former, we must proceed on a very different principle, for were we to rest satisfied by securing the arteries passing into the tumour, we would unly suspend its growth till the collateral vessels had enlarged. So soon as this took place, and experience proves that it is not a tedious ope- ration, the tumour would again be supplied with blood, and would again resume its peculiar char- acter, and proceed in the extension of its limits. Any attempt, therefore, to cure this disease, by ligature of the arteries which support it, is entirely out of the question. Mr. John Bell strenuously argues the necessity of cutting out all the diseased parts; and in equally decided terms, reprobates any interference where we judge this to be im- practicable. This seems to be the generally re- ceived opinion of surgeons on this subject; and it was one, the propriety of which I never ventured to call in question, till I accidentally witnessed a case, which shewed in the most striking manner, the expediency of acting differently, under certain circumstances. My brother was requested to visit Mr. , on Wednesday the 18th of October, 1809, about seven o'clock in the morning. He went, and found, that during the night, the gentleman had lost a great quantity of blood, from a wound which had been made about fourteen days before by a surgeon who had opened the temporal artery, on OF THE HEAD AND NECK. 343 account of an apoplectic affection. The wound had never healed, neither was this the first time he had been alarmed by profuse bleeding from it. Means had, indeed, been employed to prevent the haemorrhage. Compression had been tried, and an attempt had even been made by a practitioner to tie the trunk of the injured artery. But neither the one nor the other proving effectual, my bro- ther was called in on the third day after the ap- plication of the ligature. He desired that I would visit the patient along with him. When we examined him, he was complaining of considerable pain and tenderness along the side of the head, which was greatly distended. The in- teguments over the temporal muscle, the eyelids, and the right side of the face, were swollen by effusion into the cellular membrane. The finger, when pressed firmly on those parts, sunk deep, and the pit remained for some minutes. We now directed our attention to the parts more immedi- ately concerned with the bleeding, and were sur- prised on finding the wound filled by a tumour, oblong and about the size of a hazel nut — of a pur- plish colour — beating in unison with the action of the arteries — easily compressed, but becoming in- stantaneously, on withdrawing the pressure, full and tense; and from a small orifice, projecting with great impetus, a stream of arterial blood. We could have no doubt that this was an anas- tomosing aneurism — the ready compression of the 344 ON THE SURGICAL ANATOMY defined purple tumour — its throbbing and hard- working under the restraint of pressure — its full and rapid distension on removing the pressure — the copious, though small stream of pure blood, which sprung from the lacerated looking hole, and the strong pulsation of the trunk and branch- es of the temporal artery, were characters which no one could mistake. They established in the most decided manner, the nature of the disease, which, as yet, appeared manageable. The beating tumour was circumscri'/ed, and of small size: the diffused swelling had the appear- ance of arising from intersticial fluid effused be- neath the skin; only the temporal artery could be felt pulsating with unusual vigour, and not even a twig of the frontal artery could be traced into the diseased part; nor could any undulation be per- ceived in any part beyond the limits of the tu- mour. This circumscribed swelling was situated about midway between the zygoma and the mar- gin of the planum semicirculare, just over the fibres of the temporal muscle, and we supposed exterior to the fascia of that muscle. On a full review of the case, and on taking into consideration the nature of the disease we had to contend with, the failure of pressure, and the attempt, which without benefit, had been made to secure the artery, we resolved on dis- secting out the tumour. My brother, with a full and instantaneous sweep of the scalpel, first - OP THE HEAD AND NECK, 345 on the one side, and then on the other, insulated fche tumour from its lateral connexions, and with- out loss of time, finished the removal of the morbid parts, by separating them from their deep- seated connexions. In doing this, it was found necessary to take away a part of the temporal muscle. So soon as this was done, blood gushed from behind the zygoma, and from innumerable pores in the situation of the temporal muscle it spurted with impetuosity and per saltern. No sooner had the wound been cleared with the sponge, than it was filled and overflowed. The trunk of the temporal artery still laboured vio- lently, and we now found that pressure on this vessel did not interrupt the bleeding. The disease, which before operation appeared to have been circumscribed, was in reality widely extended. It descended beneath the zygoma — was incorporated with the substance of the tem- poral muscle; hence the body of the tumour was firmly bound down, by the aponeurosis of the temporal muscle, and was liberally fed with blood by the temporal branches of the internal maxil- lary artery. When the tumour was cut out, the base of the wound could readily be compress* ed by the thumb thrust down behind the zygoma; but so soon as the pressure was removed, it heaved, worked, and puffed up, till it rose to the level from which it had been squeezed. All this was accomplished in an instant; and was followed 44 346* ON THE SURGICAL ANATOMY by most impetuous bleeding. We plainly saw that it was out of the reach of surgery to dig out the placenta-looking spongy pulsating mass from its recesses behind the cheek bone. Had this been resolved on during the attempt to execute our purpose, the patient must have lost a great quantity of blood; and after all, I do not believe that the diseased parts would have been fully taken away. Under these circumstan- ces, we were reluctantly compelled to thrust a sponge, firmly wedged down behind the zygoma, and afterward we trusted the prevention of hse- xnorrhage to compression kept up by the twisted bandage. The tumour which was removed had quite the usual structure of anastomosing aneurism. The case was curious, however, because, although the disease was extended deep behirjd the malar bone, still as the morbid parts were bound down by the strong aponeurosis of the temporal muscle, ex- cept at the point where the external swelling was seated, no pulsation, no undulation, nor motion of any kind could be perceived, except at that spot. The short duration of the complaint, and the apparent small size of the tumour, deceived us as to the real extent of the disease, and led us to operate. But so soon as the superficial part of the tumour was taken away, we saw enough to convince us, that any further attempt in the way of cutting, would have been fruitless. OF THE HEAD AND NECK. 347 It was not with superficial arteries we had to eontend; on the contrary, it was with branches so sunk into a deep and inaccessible hollow, that had we even completed the removal of the whole of the diseased parts, still the bleeding must have been commanded by the sponge. We, therefore, in using the pressure at tne time we employed it, had a two -fold object in view; our primary en- deavour was to restrain the haemorrhage, but we trusted that if the pressure could be steadily and firmly kept up for a sufficient length of time, it would not only prevent the bleeding, but we hoped, that it would also produce a consolida- tion, or destruction of what remained of the dis- eased substance. Such was our wish — how well we succeeded, will be learned from the subsequent history of the case. On Monday, the 23d, all the dressings were removed except the sponge, which remained firm- ly wedged in behind the zygoma, and likewise adhered firmly to the bottom of the wound above the zygoma. There had been no haemorrhage, and very little secretion of pus, but the little which had been formed, was very fetid. The edges of the wound looked clean and healthy. On the 29th, the sponge was equally firm as at last dressing. On slightly moving it, a small quantity of blood oozed from its side. There was no appearance of reproduction of the tu- mour. 348 ON THE SURGICAL ANATOMY Till the sixth of November the sponge coti- tinned slowly to be detached, and on that day it c;*me away, leaving the base of the sore healthy, the granulations firm> and the discharge moderate. The original disease was completely destroyed by the pressure of the sponge, which was kept stea- dily in its place by the twisted bandage. After the sponge came away, the sore daily contracted in its dimensions, and in a short time was completely cicatrized. The beating about the head, which had formerly distressed the patient so much, and for the removal of which, the tem- poral artery had been opened was now hardly complained of, and the general health was much improved. The ope^tion of arteriotomy had been twice performed on this patient. The first time the temporal artery was opened, the bleeding readily ceased, and the wound healed kindly. On the last occasion, the bleeding was never fully com- manded, nor did the wound heal. Its lips were forced asunder by the new pulsating growth, which before my brother was called in, had re- peatedly burst, alarming the patient and his friends, by effusing a prodigious quantity of florid blood. I have never heard of any patient in whom arteriotomy acted as the exciting cause of anasto- mosing aneurism; nor am I convinced that it was the exciting cause in even this case. The tumour^ although connected with the superficial temporal OF THE HEAD AND NECK. 34$ artery, was more intimately connected with the deep branches of the internal maxillary artery. Were speculation warrantable, it might be sup- posed that the tumour in this patient had exit- ed beneath the temporal fascia, before the artery had been opened-^-that the lancet had penetrated into it while opening the vessel, and that after- Wards the morbid parts had sprouted up through the incision in the fascia, and involved the super- ficial arteries in the propagation and extension of the disease. It is hardly conceivable, that had the disease been first excited by the puncture into the temporal artery, it could in the short space of fourteen days have extended so far be- neath the aponeurosis, while it remained so small and circumscribed exterior to it. The superficial tumour seemed more of the size of a fortnight's growth, than the deep seated one. Indeed it is probable, that the throbbing and unpleasant sen- sations in the head, which called for the per- formance of arteriotomy, had been produced by the working of the deep-seated tumour. It is a curious circumstance, that the operation of opening the temporal artery should have un- folded the true nature of this gentleman's com- plaint. I cannot suppose, that in saying this I convey the slightest insinuation against the me- dical attendants for their not having sooner ascer- tained the precise nature of the case. I rather point out a fact hitherto unnoticed in the history 350 ON THE SURGICAL ANATOMY of anastomosing aneurism, and intended to that where the tumour is seated beneath a firm and unyielding fascia, its working and beating may escape detection by external examination, and about the head may, to the patient, convey the feeling as if it were within the cranium. Such an idea may lead the practitioner to a belief of the patient i eing threatened with apoplexy; and may, as in the present instance, induce him to open the temporal artery. If. in doing this, he penetrate the aponeurosis, he will soon have clear evidence of the true character of the disease he has interfered with. From the successful result of the firm pressure employed in this case, I would be led to operate, even where I had but little expectation of being able to remove the whole of the diseased sub- stance, provide^ the tumour was seated over a bone, and in such a position that I could employ sufficient compression. This case will be considered as valuable; the characters of the complaint were decided, and had the extent of the disease been previously known, an operation would not have been undertaken; yet the issue of it will, I think, establish the propriety of giving the patient the chance afforded by an operation, even although from the circum- stances of the case, we know, a priori, that it must be incomplete. This is a position directly the reverse of that laid down by Mr. John Bell. OF THE HEAD AND NECK. 351 who tells us that we are "not to cut into, but to cut it out " This I should have believed, had I not witnessed the beneficial effects of an oppo- site conduct in the present instance — a case in which there was no alternative. The operation was begun under the impression of the practica- bility of extirpating all the diseased matter, but it was soon discovered that the morbid parts could not be fully disbected away. We were much pleased, on finding, as the sponge came away, the sore looking clean, furnish- ing firm and healthy granulations, with a moderate secretion of good pus, where we had dreaded a renewal of the morbid texture and bloody dis- charge. I am convinced that this gentleman owes his recovery to the operation and subsequent com- pression; but the one was undertaken on the idea that the disease was superficial and circumscribed, while the other was had recourse to, in order to avoid immediate death, which would have been the inevitable consequence, had it not been em- ployed. The favourable result of this case would embol- den me to operate in even a very bad case of this disease, and in which I could have no hope of be- ing able to remove with the knife all the morbid mrts; but I would only do so where I had it in power to use very firm pressure. If the posi- tion of the tumour was such as not to permit of this, I would most cordially conclude with Mr, 352 ON THE SURGICAL ANATOMY Bell, that no operation ought to be attempted; as under such circumstances it would, to a certainty, accelerate the death of the patient* Such is the nature and plan of treatment to be adopted in the arterial anastomosing aneurism, which is more fully described, although, perhaps, not more frequent in its occurrence, than the ve- nous anastomosing aneurism, which, in nine out of ten cases, arises from a nsevus maternus. The case which I formerly related, in which the paro- tid duct was dissected out of the substance of the tumour, furnishes an epitome of all that requires to be said on this subject. I might, no doubt, add other cases to those already described, but these I deem sufficient. They are so decided in their character, that their nature cannot be mistaken; they shew the marked difference which exists be- tween the arterial and venous anastomosing aneu- rism. Different, however, as they are in some points, and unlike as they are in their general fea- tures, the practice in both is similar; and their re- sult, if the disease be permitted to run its course, will not be very dissimilar. The anterior facial vein, begun by the veins of the forehead, is, at the root of the nose, about the diameter of a large crow quill. In its descent it touches the insertion of the orbicularis palpebra- rum, and a little lower in the face it is covered by of the fibres of that muscle. It runs in ai* * See Appendix (E.) OP THE HEAD AND NECK. 353 oblique line from the angle of the eye to the ante- 2*ior margin of the masseter muscle. About an inch below the junction of the eye-lids, but consi- derably nearer to the zygoma, the facial vein ge- nerally crosses the infra-orbitar foramen. Be- tween the vein and the infra-orbitar nerve and ar- tery, there is only the thickness of the levator labii superioris muscle interposed. Descending lower, it inclines nearer to the angle of the jaw, and in its course crosses the parotid duct. Along its whole extent the facial vein lies nearer to the ear than the artery, which, however, runs parallel to it, and nearly in contact with it, from a little be- low the angle of the mouth to the margin of the jaw bone. Along that part of the face these ves- sels are covered by the scattered fibres of the pla- tysma myoides. Opposite to the angle of the mouth the artery inclines forwards, and at the same time mounts gently upwards, running always in a waving course, and often, about this part, forming one or two coils on itself. About midway between the margin of the lower jaw and the mouth, the arteria labialis superfifiialis is given off. Then in succession, and at a very short distance from each other, the facial artery gives origin to the upper and lower coronary arteries, which are im- mediately deeply buried in the substance of the lips. To this point the attention of the student must be directed; he ought clearly to understand 45 354 ON THE SURGICAL ANATOMY that there is only the lining membrane of the lip nearer to the mouth than the coronary vessels. If every surgeon were aware of this fact, fewer mistakes would be committed in dressing the wound after operations performed on the lip. Many surgeons, knowing no better, believe that pins are passed through the margins of the wound, solely for the purpose of keeping them in contact. With this object in view, they pass them in such a way, that the cut edges are carefully kept in contact in front, but, so that they are allowed to recede from each other behind. But although re- tention of the divided surfaces in contact, forms a primary consideration in employing pins, still it is not the only one; the operator is really desirous at the same time that he keeps the lips of the wound together, to prevent haemorrhage from the divided coronary arteries. The latter object can only be accomplished, by passing the pin completely behind the artery between it and the investing membrane of the lip, directly opposite or nearly so, to the point where the vessel is seated. Let an operator do this, and no bleeding can take place, neither can the edges of the wound stand gaping behind; let him pass, how- ever, the pins in front of the artery, and there is no security that bleeding shall not take place; on the contrary, we know that it has frequently happened. Some patients soon after an operation become faint, and arteries even, larger than the OF THE HEAD AND NECK. S55 eoronary vessels of the lips cease to effuse blood. If in this state of the circulation, the surgeon pass the pins in front of the arteries and finish the dressing of the wound, every thing for a time will go on well. The patient is desired to avoid speaking or spitting, and he is enjoined to swallow whatever flows into his mouth. He obeys his instructions — he revives and as he recovers, blood runs from the divided arteries back into the mouth; it is swal- lowed, and I have actually known a patient to ad- here so pointedly to his directions, as to swallow such a quantity of blood, as occasioned a dreadful sickness and severe vomiting, during which the lips of the wound were burst asunder, and the pins torn from their hold; new pins required to be passed, but the margins of the wound were now ragged and irritated — the cure was retarded, and the patient compelled to suffer much unnecessary pain. By a little attention on the part of the operator all this may be avoided. If fine pins be employed, the mark left by them is very trifling. In cuts about the lips and face, I have repeatedly employed fine sewing needles, which are equally adapted for the purpose, as gold or silver pins. If the points of the needle be carefull cleaned, and as Mr. John Bell properly advises, if they be well oiled, they will be found to enter very smoothly, and with less pain. When they are to be with- drawn, let them be first rotated and then extract- 356 ON THE SURGICAL AN \TOMY fed. To obtain a firmer hold of them, Mr. Belt passes a thread through the eye of each needle.* After the origin of the upper coronary artery, the continued branch of the facial artery mounts along the side of the nose, more superficial than the levator anguli oris, but covered by the levator labii superioris alseque nasi. It then covers the wing of the nose with its twigs, but is not by this quite exhausted, it still ascends till at the root of the nose it receives additions from the orbit* The slender branch formed by the union of these reaches the forehead, where it is lost in inoscula- tion, with the ophthalmic and temporal arteries. The lachrymal sac is sunk into the recess be- tween the margin of the orbit and the tendon of the orbicularis palpebrarum. The fibres of that muscle cover the sac, and also the ducts continued from the puncta lachrymalia. The sac, which is of an oblong shape, is placed with the taper- ing extremity turned downwards. From the most depending part of the sac the nasal duct arises. It opensj by a small rounded mouth into the nos- tril, about half an inch behind the ascending plate of the jaw-bone, and nearly opposite to the middle of the inferior spongy bone. It is to be recollected, that the margins of this aperture are membranous and loose, even in some instan- ces puckered, a conformation which sometimes Obstructs the entrance of the probe. As the * Bell ou Tumoursj page 208. OF THE HEAD AND NECK. 35? surgeon is often called on to decide regarding the state of the duct, it may be proper to make a few remarks on the mode of examining this canal. The introduction of the probe is not generally difficult, yet I have seen several foiled in their endeavours to pass it. They attempted by force what they ought to accomplish by artifice; they endeavoured without an acquaintance with the mechanism of the parts, to do what can only be done by one who is familiar with the or- ganization. The position of the orifice of the nasal duct, and the after course of the canal, ought to be carefully studied, because the probe must be adapted to the curve of these parts. It is to be passed by gentle efforts; force must never be employed* I pass the probe along the floor of the nostril, with its concavity directed towards the antrum, and its convexity looking towards the septum of the nose* I carry it on in this course till I feel that its point has passed beyond the as- cending plate of the jaw bone; then I rotate the probe between my fingers, till its point looks up- ward and outward toward the eye. While the probe is making this turn, it is of consequence that its point be maintained in close contact with the side of the nostril. When this turn is com- pleted, the handle "of the probe is to be gently depressed, while its body and point are elevated. This motion conveys its point into the orifice of 358 ON THE SURGICAL ANATOMY the nasal duct, and carries it up into the lachry- mal sac. If the duct be free from obstruction, this is generally readily accomplished; but it must be mentioned, that where the lining membrane of the nostril is preternaturally loose and pendulous, the point of the probe sometimes catches a fold of it, which is carried into the orifice of the duct, where as a valve, it hinders the further progress of the instrument. This cause of obstruction is most easily overcome, by retracing the probe a little, and moving its point slightly away from the side of the nostril. DESCRIPTION OF PLATE IX. This sketch illustrates many points connected with the operations 'performed on the nose. The chief object it is intended to explain, is the situation of the termination of the nasal duct, A, which opens just behind the upper bor- der of the lower spongy bone. The spongy bone has been displaced, to bring into view this opening, which is na- turally overhung by the bone. The probe must therefore be insinuated between the nasal process of the superior maxillary bone, and the lower spongy bone, before its point can be conveyed into the duct. These parts are de- lineated of their natural size, hence it will be seen, that the orifice of the nasal duct is deeper seated than many imagine. It is from not being aware of this fact, that some surgeons, who attempt to give the turn too soon to the point of the probe, are disappointed in their endea- OF THE HEAD AND NECK. 359 vours to get it into the duct. Let the student examine this sketch, and he will see the spot, where he ought to turn the probe into the orifice of the duct. Besides shewing the place of the nasal duct, this plate also represents the situation of the opening, leading from the nostril into the maxillary sinus. This apperture B, is placed in the middle meatus of the nose. In the natural state, it is completely overhung and concealed from view, by the upper spongy bone. To expose it, considerable liberty has been taken with the spongy bone. It has in- deed been broken from its connexions with the ^ethmoid bone. From the slanting manner in which this duct ea- ters the nose, I conceive that no fluid can pass from the sinus into the nose, neither is it practicable to introduce a probe from the nostril into the antrum. This I would insist on, since it will correct our notions regarding the office of the antrum, and unfold the absurdity of the pro- posal made by some, of introducing an instrument by the nostril into the maxillary sinus in some of its diseases. It will, I believe, be found, that in the healthy state of the lining membrane of the antrum 3 no more fluid is se- creted by its vessels, than can be easily re-absorbed by its lymphatics; secretion and absorption balance each other. But sometimes by disease the secretion is increased be- yond what the absorbents can remove — hence the fluid ac- cumulates in the antrum; little can naturally pass from the sinus into the nostril, and the greater the quantity col- lected in the cavity, the less can pass from it, because the opening is so formed, that whenever fluid is collected in considerable quantity in the sinus, it presses the one lip of the opening against the other. Urine might as readily regurgitate from the bladder along the ureter, as fluid pass from the antrum into the nose. From this mechanism, fluid collected in the antrum can- not escape, and owing to the same cause, when it would 360 ON THE SURGICAL ANATOMY be necessary to open a passage for it, we cannot accom- plish it, by passing a probe along the natural opening, as in the case of obstructed nasal duct. A new passage must be formed, and we know that it may be most conveniently formed, by extracting one of the grinding teeth, and per- forating from its socket into the antrum. Indeed, in many subjects, the fangs of these teeth have little except the lining membrane of the sinus interposed between them and the cavity of the sinus. In every case, the solid substance is so trifling, that no difficulty can be experienced in pass- ing through it. I would also call the attention of the student to the ca- nal of communication between the frontal sinus and the nostril, which opens at C, into the middle meatus of the nose. A knowledge of the situation of this opening, and the direction of the canal, may be of use to him in cases, where insects have nestled in the sinus. He may, by this information, be enabled to introduce such substances into the sinus, as will destroy them. I have in my possession, a worm dislodged in this way from the frontal sinus. The opening of the eustachian tube D, ought likewise to be noticed. The form of its trumpet like orifice, and its position at the root of the pterygoid process of the sphenoid bone, ought to be familiar to the surgeon. This know- ledge will enable him to pass a probe from the nostril along the tube, in cases of deafness, supposed to depend on ob- struction of this canal. Where the deafness is produced by mucus impacted in the mouth of the tube, one intro- duction of the probe will generally clear the passage; but where partial adhesion of its sides had taken place, I have generally found a repetition of the operation necessary. The last time I had occasion to pass the probe, I forced three obstructions in the course of the duct. The passage of the probe along the eustachian tube, is far from being difficult. The probe, if slightly curved, OF THE HEAD AND NECK- 361 and if conducted along the floor of the nostril, readily enters the orifice of the duct, and if not too flexible, it aa easily follows its course. Where adhesions require to be forced, I employ a silver probe, but where mucus alone has to be removed, a leaden wire about the diameter of a crow quill will be preferable. This drawing would also illustrate the operations re- quires!, where polypi are lodged in the nose; but as this department has already been very completely treated by Mr John Bell, I refer to his and other surgical works for information on that subject. If there be no stricture in the course of the nasal duct, the surgeon will generally succeed in conducting the probe from the nostril into the lachrymal sac, and where the obstruction is slight he may even overcome it. Wiiere the obstruc- tion is firmer, the probe bends before the stric- ture will yield. Where this has happened, I have made a puncture with a common bleeding lancet into the lachrymal sac, and through that opening have conveyed a straight probe along the duct into the nostril. In this way a very firm stricture may be forced,— to keep the passage pervious is the next object. To accomplish this, I have introduced a curved wire from the nostril along the nasal duct, and healed the punc- ture over it. This is the same in principle as the French mode of passing a sctou irom tlie sa« along the ,iasal duct into the nostril. 46 362 ON THE SURGICAL, ANATOMY Both are equally effectual, but the seton Is liable to this objection, that it lays the founda- tion of a fistulous opening into the lachrymal sac, whereas, if the other plan be adopted in the inci- pient stage of the obstruction, before the skin covering the sac has become inflamed, the punc- ture will generally heal kindly, and without leav- ing any perceptible cicatrix. Where, however, the operation is delayed till the surface has become diseased, the wound will be apt to become sloughy — in the end it will heal by granulation, leaving a polished and sometimes puckered cica- trix. We have, therefore, a great inducement to operate in the early stage of the obstruction, and much to dread if we delay till inflammation has taken place. I have supposed that an operation will really be useful — that in fact we have it in our power to keep the nasal duct pervious, securing thus a passage for the tears from the lachrymal sac into the nostril. Some doubt the truth of this, while others positively assert, that it is impracticable to preserve the canal patent for any considerable time after the operation. By those who adopt the lat- ter sentiment, the primary object of operation is to destroy the sac, and annihilate the function of the pnncta. This practice has, I suspect, been de- rived from a limited source of observation — it has, perhaps, originated from a supposition that the nature of the disease is similar m every case; but OF THE HEAD AND NECK. 363 who that has read Mr. Pott's very excellent tract on fistula lachrymalis, and has not been convinced of the fallacy of this notion? The disease is, indeed, more or less tractable, according to its nature; sometimes it may be re- moved, and the functions of the sac and duct pre- served, at other times these p irts must be sacri- ficed. On this subject I shall not require to en- large much, I would only observe, that where acute inflammation has produced partial adhesion of the sides of the nasal duct, the decided object of the surgeon ought to be to render it pervious and to retain the duct patent. Failure in accom- plishing this, is as frequently referable to the sur- geon as to the disease. He never can succeed if the operation be undertaken while the duct is acutely inflamed, nor will he often fulfil his pur- pose if he delay till ulceration of the sac has taken place. Failure not only arises from performing the operation during an improper stage of the disease, but is also occasioned by underta- king it in affections of the duct, not remova- ble by operation. This is especially the case where the sac and duct are thickened from chronic inflammation. Where the obstruction is dependent on this species of disease, the inner canthus of the eye is swelled, but is free from pain. By pressing on the tumour, a clear fluid is generally forced back by the puncta, but the 364 ON THE SURGICAL, ANATOMY last drops are sometimes turbid, and in the morn- ing the fluid has often a milky tinge. Under such t ircumstances the opening cannot be kept pervious — not even where a direct communication has been established between the sac and the nose. Here, therefore, it will be preferable to destroy the sac and annihilate the office of the puncta. To attempt to maintain a pervious opening from the sac into the nostril is futile; any endeavour to do so only teazes the patient. Where, however, the nasal duct is merely ob- structed by adhesion of its sides produced by acute inflammation, I can confidently aflirm, that if the duct be rendered pervious at a proper stage of the disease, it may by care be kept patent. If we may believe some authors, the conse- quences arising from the loss of the lachrymal ap- paratus, are hardly deserving of notice. In their opinion, tbe tears are evaporated from the surface of the eye-ball, as fast as they are poured from the ducts of the lachrymal gland, hence the puncta are only called on to absorb the superfluous tears, when the action of the gland is increased beyond its usual degree. If the nasal duct be obstructed, it is at this time, and at this time only, that the tears flow over the cheek. It may here be said, if there be not a constant absorption of the tears by the puncta, why is obstruction of the nasal duct productive of so much inconvenience? This has really no force, since the bad effects which are OF THE HEAD AND NECK. 365 occasioned by obstruction of the nasal canal, can be otherwise accounted for. When the nasal duct is strictured, the tears which occasionally are absorbed by the puncta, stagnate in the sac, and are thence a source of irritation. The first effect produced, is an alter- ation of the mucous secretion from the inner sur- face of the sac — it is changed to a puriform na- ture— presently the sac and integuments inflame and ulcerate. The unpleasant effects then, which result from obstruction of the mlsal duct, do not arise from the mere interruption to the passage of the tears, but are occasioned by the irritation pro- duced by the detensiori of the tears in the lachry- mal sac. If, therefore, the sac be completely de- stroyed, we have reason to believe, that an occa- sional epiphora will alone incommode the patient. Tumours not ^infrequently form over the situa- tion of the lachrymal sac, and are mistaken for the commencement of fistula lachrymalis. Even, how- ever, where these tumours were large, I have ne- ver seen the passage of the tears obstructed, nor have I ever experienced any difficulty in passing the probe from the nose upwards, which I would advise to be done in all doubtful cases. Purmanus, in his Chirurgia Curiosa, alludes to the species of tumour I am at present considering, and he details a case in which he cured the pa- tient. The tumour, which was very large, was seated at the inner canthus of the eye. It was 366 ON THE SURGICAL ANATOMY attached by a neck, and had continued during two years. Purmanus applied a ligature round its root, and renewed it six times. These did not completely destroy the tumour, which he at last removed with the knife. In this way the whole tumour could not be perfectly got away; a portion of it was left behind, which he destroyed by the actual cautery and escharotic powders. It was two months before the wound was cured.* The tumours which form about this part are generally sacculated, containing melicerous-look- ing matter, sometimes intermixed with hair, or at other times the cyst is filled with hydatids.f I have generally found it unnecessary to attempt the complete removal of the cyst by the knife. By cutting off the fore part of the sac, and smearing its posterior surface with either potassa or nitrate of silver, the cure is readily enough completed. This, it will be observed, is, in principle, the plan adopted by Purmanus, who only employed the ac- tual in place of the potential cautery. The application of caustic to the inner surface of that portion of the sac which remains, is essen- tial, because in those tumours there is a morbid ac- tion of the sac, which would perpetuate the dis- ease. By many surgeons it has been deemed su- perfluous to do more than merely evacuate the contents of an incisted tumour, but Mr. Abernethy * Purmanns ChirurgiaCuriosa, page 60. * Wilraer, page 60. OF THE HEAD AND NECK. 367 has proved, th t in some species more is required. Those sacculated tumours which form about the eye- lids, are of this description. I have seen se- veral cases where the front of the sac had been sliced away, but I never saw an instance in which that practice was effectual. I have seen one when exposed, produce, in an irritable patient, a very considerable degree of constitutional affection — a derangement of the circulating and digestive or- gans, which one would hardly have expected from the exposure of so limited a surface. Where the tumour is permitted to burst, if the inner surface of the cyst be not destroyed, it soon assumes an unhealthy aspect, discharging a consi- derable quantity of fetid matter, and presenting an irregular ragged coat, or ill conditioned fungi sprout from the surface of the sac, which require the utmost vigilance of the surgeon to destroy. In some tine longer the parts around become indu- rated and thickened. Here, as much of the dis- eased substance as possible is to be removed by the knife, and the rest destroyed by caustic. The caustic is to be applied till the surface assumes a healthy appearance, which will sometimes be after the first, second, or third application. It will hardly be necessary for me to put the student on his guard not to apply too much of the caustic, as the lachrymal sac might be injured, and the cure protracted. 368 ON THE SURGICAL ANATOMY T.o enter into the consideration of the anatomy of the eye, and an enumeration of its various dis- eases, followed by a history of the operations per- formed for their removal, would be altogether fo- reign to my purpose. I refer those who wish for information on these subjects, to the numerous works on surgery in which they are treated. I cannot, however, omit a few remarks respecting one of the diseases of the eye. I allude to fungus hsematodes, a disease which was confounded with cancer, till Mr. Wardrop pointed out the differ- ence. His observations clearly establish, that fungus hsematodes is an affection more frequently met with in young than in old people. "The first appearances of the fungus hsemato- des, when it attacks the eye, are observable in the posterior chamber. The pupil becomes dilated and immoveable, and, instead of having its natural deep black colour, it has an amber, and, in some cases, a greenish hue; giving to the eye very much that appearance which is observed in the sound eye of the sheep, the cat, and in many of the lower animals. As the progress of the disease advances, the colour becomes more remarkable, and it is soon discovered to be produced from a solid substance which is forming at the bottom of the eye, and gradually approaches the cornea. "The surface of this substance is generally rug- ged and unequal, and not unlike what may be sup- posed to arise from a quantity of effused lymph. tfF TTTE HEAD AND NECK. 369 IH some cases, red vessels can be seen running across the opaque body; but these are not the ves- sels which nourish it, but, the ramifications of the central artery of the retina lying above it. Dur- ing the progress of the disease, the new formed substance gradually fills up the whole of the pos- terior chamber; its surface advances, so as to ar- rive at the same plane with the iris, and has the appearance of an amber or brown coloured mass* In this stage of the disease J have known two cases which were mistaken for cataracts, and in one of them an experienceo* surgeon attempted to couch it. When the disease advances still further, the form of the eye- bail begins to alter, acquiring aa irregular knotted appearance; at the same time, the sclerotic coat loses its natural pearly white co- lour, and becomes of a dark blue or livid hue, The tumour, by its continued growth, finally occu- pies the whole anterior chamber, and, in some ca- ses, a quantity of purulent matter collects between it and the cornea. At last the cornea ulcerates, and a fungous tumour shoots out from the portion of the diseased substance, contiguous to the ulce- rated cornea; and, in other cases, the tumour pushes itself through the sclerotic coat. "This fungus is very rapid in its growth, and before the disease arrives at a fatal termination, it often acquires a very great bulk. When it is small, it has a good deal the appearance of the softer kinds of polypi which grow irom mucous 47 370 ON THE SURGICAL ANATOM\ membranes. It is generally of a dark red or pur- ple colour. Its surface is irregular, and often co- vered with coagulated blood. "The substance of this fungus is very readily torn; and when a portion of it is separated, or if it be slightly scratched, it bleeds profusely. In other cases, the tumour is of a firmer texture, and if, as sometimes happens, instead of coming through the cornea, it bursts through the sclerotic coat, it then pushes before it the tunica conjunctiva, and thus derives a mucous covering. When the tu- mour becomes very large, portions of the most prominent parts begin to lose their vitality, and separate in sloughs, which have a very fetid and offensive smell, and are accompanied with the dis- charge of an acrid sanies."* This is a description given by Mr. Wardrop of the fungus hsp,matodes in the eye, to the fidelity of which I can, from my own observation, bear testimony in every point, except the sloughing of the tumour, which I have never seen happen, un- less where the fungus was tightly girded by the apperture through which it had passed. As, however, a reference to individual cases is more valuable than general description, I shall tran- scribe the following very interesting case which occurred to myself, and which has been published by Mr. Wardrop, in his work on Fungus Hsema- todes. * Wardrop on Fungus Hamatodes, p. 13. OP THE HEAB AND NECK. 371 "The patient, Mrs. Scot, was about forty-one years of age. She had always been of a delicate habit of body, and of a sallow complexion, but had never observed any affection of her eyes till two years and a half ago. About that time she be- gan to see less distinctly than usual with her left eye; and on looking at that organ, a milkiness was seen behind the pupil. This opacity of the Jens gradually increased during four months, when she became completely blind of that eye. After having been blind for about four months, the eye became very much inflamed, without any ob- vious cause. By bleeding with leeches, &c. the inflammation abated, but the redness and pain never entirely left the eye. From what I have been able to learn, the opacity of the lens could not be so decidedly ascertained after this attack, owing to the turbidity of the contents of the ante- rior chamber. <*The further progress of this case was not traced till within the last six months. At the beginning of that period, a tumour began to pro- trude from the lower side of the sclerotic coat, just behind the attachment of the lucid cornea. When I examined the eye about four months ago, it appeared that the cornea was rather more pro- minent that usual, and I could neither distinguish with accuracy the iris nor crystalline lens. The appearances impressed me with the idea, that a fungus was lodged behind the cornea, ready to 37$ ON THE SURGICAL 'AN ATOM f protude so soon as the cornea gave way; and in regard to the tumour attached to the lower side of the sclerotic coat? it, at that time, seemed to contain a dark-coloured transparent fluid? which I thought was a part of the aqueous humour, which had escaped from the eye-ball by a rup- ture of the proper coats of that organ. This cyst was about the size of a musket ball, and was formed by a distension of that part of the tunica conjunctiva which covers the sclerotic coat; and over the surface of the sac a number of red ves- sels were seen running in every direction. The pain was intense and lancinating; her sleep was interrupted; and besides being affected with hys- teria and pain iri the back^ she was in some degree hectic1. "When I saw this patient, four months after- wards, matters were in a much worse state than formerly; her health was now completely broken, she had confirmed hectic fever, and was often at- tacked with paroxysms of hysteria. She was much reduced and exceedingly weak, and had not been out of bed for two months. On examining the eye, it was found that the cyst, which formerly was not larger than a musket ball, had now become as large as a pigeon's egg, forming a solid fungous mass, which could with difficulty be raised, so as to uncover the under eye-lid. The cornea was now flat, and hid beneath the upper eye-lid, and from *he body of the large fungus, two small fungi OF THE HEAD AND NECK. J7J protruded. Towards the temporal angle of the under eye-lid, there was a hard tumour, situated underneath the integuments, which adhered firmly to the cheek bone. "As extirpation of the morbid parts afforded the only hope of recovery, the patient was ex- tremely anxious to have the operation performed, in which we concurred. Assisted by Mr. War- drop, I performed the operation. As the tumour exterior to the eye-lid was of considerable size, I followed the mode advised by Desault, which is highly conducive to the celerity and ease of ex- tirpation. At the outer canthus of the eye, I separated, by an incision, the palpebrse, for about half an inch from each other. I then grasped the tumour, and dissected back the eye- lids from it. "As I wished to take out all the diseased parts in connexion, I endeavoured to detach them from the lower margin of the orbit, but found to my surprise and regret, that the bone on which they rested was softened and black in colour. I there- fore gave Up this idea, and proceeded to detach the eye- ball from its connexion, with a common scalpel. While separating it from the roof of the orbit, I was cautious, lest the bone being there soft, the point of the knife might have passed into the brain, and I also kept the scalpel at some distance from the aethmoid bone, to avoid injury of the nasal branch of the ophthalmic artery. I $74 ON THE SURGICAL, ANATOMY "By the pressure employed in pulling forward the morbid parts, they burst, and a considerable quantityjof inky fluid was poured from the opening. I traced the optic nerve to its exit from the skull, and there divided it. Yet even here its medul- lary substance was as black as ink. I next chis- selled away as much as I could of the diseased edge of the orbit, but with little hope that the issue of the operation would be favourable. The diseased state of the optic nerve, and condition of the bone, hardly allowed any reasonable expec- tation that the patient would ultimately recover. "We now dressed the orbit. The first point was to check the bleeding from the divided vessels. This was readily done without employing a liga- ture, which is now seldom or never thought ne- cessary after extirpation of the eye. I laid first a very small piece of lint on the orifice of the ar- tery, and over this applied a plug of rolled up lint, to which a strong thread was fixed. This was made of such a size as nearly to fill the orbit, and it projected to the level of the palpebrse; hence by pressing the eye-lids back on the plug, it was kept steadily in contact with the divided vessel, and haemorrhage was prevented. By ha- ving a thread fixed to the plug, it could be with- drawn so soon as suppuration had loosened it from the part with which it was in contact. "This woman although much reduced by a hec- tie fever, and emaciated to a great degree at the OF THE HEAD AND NECK. time of the operation soon appeared to recover — she gained flesh and strength — her appetite was restored — the pains in her back and loins left her — she slept well, and was able to walk about. The orbit even discharged good pus in moderate quantity, and was at last filled up with a soft substance, which although dark in colour, skinned over. "At this stage, when she herself and her friends considered her recovery certain, the weather be- came cold and damp; the pain soon recurred about her back; she lost her appetite; and was unable to walk from exquisite pains in the loins. After she was confined to bed, she became rapidly worse. The pains increased in severity, inso- much that she could obtain no sleep except from the use of opium. The lower eye-lid was pro- truded by an elastic fungus, which also began to project from between the palpebrse. "The disease in the orbit gave her no uneasi- ness, her whole complaint being seated in the back and loins. The pain there was so excru- ciating, and occasionally so much increased in intensity, that she screamed from ago- ny. She could neither turn in bed, nor permit herself to be turned, for on every motion she felt as if many sharp instruments were pushed into her back. In this deplorable condition, she lin- gered for two or three months; the tumour below 376 ON THE SURGICAL ANATOMY the orbit all the while increasing in size, and the pain in the loins in no degree remitting. "When I saw her three weeks before her death, she was a hideous picture of disease; she was emaciated to the last degree; and the tumour be- low the orbit was as large as a pullet's egg. Its surface was unequal, the most prominent parts of it were covered with livid integuments, and the swelling conveyed to the fingers the impres- sion as if it contained a fluid. From between the palpebrae a very small fungus protruded, which was covered with a coat of bloody-looking matter. She had, however little or no pain, either in the orbit or in the head, and the vision of the other eye remained unimpaired. "From this time to her death she sunk gradu- ally, and the tumour enlarging, became more dis- coloured on its surface and more irregular, but the fungus between the eye-lid did not alter. About twenty-four hours previous to her death, she became suddenly comatose." Dissection of the Eye. As soon as possible after the operation we made a section of the morbid parts, and the following very accurate description of the phenomena was drawn up by Mr. VVardrop: "When dividing the eye- ball and optic nerve, a great quantity of a thick viscid matter, having a very dark brown OF THE HEAD AND NECK. 37? colour covered the knife. The eye-ball and tumour, seemed, at first sight, entirely composed of a simi- lar dark coloured matter. This singular looking substance was of the consistence of thick oil paint, though not so clammy nor oleaginous. It soiled the fingers of a dark brown or amber colour. It was readily dissolved in water, and both Mr. Burns and I were struck with its resemblance to the pig- mentum nigrum; but we were much at a loss how- to account for the formation of such a quantity of that substance. I kept the eye-ball in water foF twenty-four hours, so that a great quantity of the black matter was dissolved, leaving the solid parts of the mass more distinct. The cornea appeared sound, and the crystalline lens behind it was of an. amber colour. "The sclerotic coat, at that part which corres^ ponded to the malar portion of the orbit, was rup- tured by the tumour, and the torn edges were se- parated about a quarter of an inch from one ano- ther. . At the same place the sclerotic coat was split into two layers, a small quantity of the dark Coloured substance being interposed between them. "I could not trace any remains distinctly of the iris, but the choroid coat appeared much more vas- eular than natural, and at one part it was five OP six times its natural thickness- At the place where the sclerotic coat was ruptured, the choroid coat insensibly terminated in a white pulpy substance^ composing part of the diseased mass, 48 378 ON THE SURGICAL, ANATOMY "The contents of the eye-ball were chiefly com- posed of a medullary-looking pulpy substance, va- riously tinged in different places by the dark brown colouring matter. The tumour projecting beyond the sclerotic coat, appeared to be com- posed of a similar structure, and from the macera- tion, numerous white strise, and in some places spots, appeared throughout the substance of the diseased mass. The tumour, exterior to the eye- ball was covered with a thick mucous membrane, except at the two small prominent parts where it had been ulcerated, and this covering had proba- bly been derived from the tumour pushing before it during its growth, the conjunctiva, which lies over the sclerotic coat. "The optic nerve was of its natural size, but by examining its section, it was found that the medul- lary part of it had a black appearance, exactly re- sembling the tumour in the eye ball, whilst the membrane was of its natural colour and appa- rently healthy. I could not detect any remains of the retina. "One of the lymphatic glands lying by the side of the optic nerve, was changed into a dark coloured substance." Dissection of the Body. The liver contained some tumours of a similar texture and appearance with the contents of the «P THE HEAD AND NECK. 379 eye-ball. There was also a cyst in the substance of the liver, filled with a great quantity of gru- moas-looking purulent matter. Above the kidneys there were similar tumours of pretty considerable size, and the uterus was cartilaginous. The urinary bladder was enor- mously distended with a turbid bloody-looking fluid, but otherwise in so far as this viscus was examined, its structure appeared healthy. By making a vertical section of the orbit and fungus it contained, we found the tumour is en- tirely arising from the antrum maxillare, which was burst open both above and in front. The fun- gus also projected beyond the lower spongy bone arid investing membrane of the nose, into the nos- tril. The tumour proceeding from the antrum, was on its outer surface, studded over with small knobs of a dark livid colour. Internally, this tu- mour was made up of a soft substance of an ink co- lour, intersected by membranous slips, intermixed with a grayish looking substance and ragged frag- ments of bone. The anterior wall of the antrum was destroyed at the upper part, and the floor of the orbit was elevated, so as merely to have the periosteum and a thin layer of fat between it and the orbitar plate of the frontal bone. The fungus was exterior to the orbit, although from the destruction of the periosteum attached to the malar portion of the orbit, it was allowed to protrude from between the eye-lids. This 580 ON THE SURGICAL, ANATOMY portion of the periosteum was in part destroyed by disease, and in part in consequence of the removal of a carious portion of the bone, when the eye was extirpated; With regard to the optic nerve, it was expected that its extremity wirild have been joined and connected with the fungus. Between them, how- ever, the periosteum of the floor of the orbit was interposed. The nerve itself was of its natural size, but of a black colour where it entered the foramen opticum. From this point to near where it had been divided at the extirpation of the eye- tall, it was in a similar state; the neurilema had only a slight connexion with the diseased substance of the nerve. At the bottom of the orbit, there was considerable matting and induration of the origin of the muscles. At its termination the nerve formed a sharp point, and here the coats of the nerve ad- hered to the thickened periosteum of the floor of the orbit, which was pressed in contact with it, by the fungus from the antrum. The optic nerve within the cranium was as thick as the little finger, and as dark in colour as that part of it in the or- bit. The junction of the nerves was so much en- larged, that it formed a tumour extending into the third ventricle. As from the dark colour of the diseased parts? this was a favourable opportunity for ascertaining whether the optic nerves decussate each other, or inerely come in contact, I examined carefully the OF THE HEAD AND NECK* 381 state of these parts. I found the dark colour ex- tending much beyond the point where the nerves join; but this change of colour was confined to the left side, or to the nfcrve of the affected eye. On the right side the nerve was of its natural size and colour, and was merely attached to the black dis- eased parts by cellular shreds. This dissection, therefore, clearly proved that the nerves did not, in this individual, cross each other. I would be, however, inclined to believe, from what I saw, that the optic nerves were joined to each other by in- terposed nervous substance common to both. The left optic thalamus was of natural structure, but about a third larger than the opposite one. The third and fourth ophthalmic branches of the fifth and sixth pairs were all healthy. In cases of medullary sarcoma and fungus haematodes, the disease is generally propagated by absorption, hence, in the case just related, a gland, in the course of absorption, was found contaminated; but besides, there is in some pa- tients, disease of parts seated at a distance from each other, and having no connexion which is ob- vious to the anatomist. The present case furnish- es an example of this fact, the eye, the antrum, and the liver, were similarly diseased. In each of these parts the black tumour existed, and in each the appearance and nature of the morbid parts were alike. 382 ON THE SURGICAL ANATOMY This case illustrates the formation of fungus in the antrum, which is not an unfrequent occur- rence. I have seen the fungus in its incipient stage, when it appeared as a circumscribed effu- sion of organized lymph from the vessels of a diseased part of the lining membrane. This slowly increases, and in the advanced stage of the disease, the tumour by its pressure, produces absorption of the earthy matter of the bones; the antrum is burst open, the lachrymal duct is com- pressed, epiphora is produced, ending sometimes in fistula lachrymalis; — the face is deformed, and the lymphatic glands about the angle of the jaw are contaminated. The primary and secondary tumours become incorporated, the integuments ul- cerate, fungi sprout from these openings, and the discharge and hectic presently kill the patient. From the nature of this affection, it will appear that the disease can only be cured in the early stage. If, at that period, we could destroy the vessels passing from the membrane of the antrum into the fungus, it would decay. In one case treated in London, Dr. Brown in- forms me, that the surgeon made an opening into the antrum, at the spot where it is generally per- forated. This was accomplished without difficul- ty, since the bones were so softened as to permit of their being easily cut with a scalpel. After he had entered the antrum, he touched the base of the fungus with a heated wire, conducted OF THE HEAD AND NECK. 380 through a canula. By two applications of the actual cautery, the size of the tumour was very materially reduced. Gariot, in his work on the diseases of the mouth, describes fungus of the antrum, and ad- vises, that so soon as the nature of the disease had been detected, we should open the sinus, and destroy the morbid growth by the actual cautery. "Dan cette operation on commence d'abord par detacher la joue de Pos maxillaire, en incisant la membrane interne de la bouche; puis, apres avoir bien denude Pos des parties molles qui le recouvrent, on emporte avec un instrument en forme de petite serpette toute la partie inferieure du sinus maxillaire, on est oblige de s e servir du ciseau et du maillet pour les parties qui offrent trop de resistance." Sometimes the haemorrhage is considerable, while cutting away the base of the antrum, but authors inform us, that they have never seen the bleeding resist the application of the hot wire. I have seen and dissected three cases of fun- gus in the antrum, but never have seen any in- stance in which an operation had been attempted; I can readily believe, however, that if it be suf- ficiently early had recourse to, the fungus may be destroyed, and the patient cured. Even in a more advanced stage of the com- plaint, it has been proposed to perforate the base of the sinus. The object of this practice can 384 ON THE SURGICAL ANATOMY only be as Dr. Thomson remarked, to allow the fungus to form where it will occasion least de^ formity, *nd where we can control its growth by ligature, or by the actual cautery. This, however, in the generality of cases, will afford only a temporary palliation, since presently the conglobate glands which have been contaminated, will, by their progress to ulceration and the for- mation of fungus, destroy the patient. I saw a very fine illustration of this fact some months ago:-^the patient had complained, during a length of time, of deep-seated pain in the cheek, which came afterwards to be accompanied by a feeling of distention. Presently he breath- ed with constraint through the left nostril, where, by examination, I was informed, a pretty solid tumour had been discovered. It was not, how- ever, till some weeks after that period when I saw the man; then the fungus had widely dilated the nostril from which it projected, so that the neck of the tumour where encircled by the nos- tril, was considerably thicker than the thumb; that portion which lay exterior to the nostril was expanded, irregular on its surface, of a dark purple colour, and distilled constantly a thin fetid ichor, sometimes mixed with venous blood. The patient, on account of the constant and severe pain that had injured his look and impair- ed his strength, was anxious to have the diseased parts removed; but that no one could undertake, OF THE HEAD AND NECK. 385 since the antrum and nostril were filled with fun- gus, and the glands behind the jaw contaminated, forming two tumours each larger than a turkey's egg, nearly in contact, exquisitely painful, elastic, and irregular on the surface, but still covered by healthy coloured skin. The man was informed that no operation would now avail; that it only remained for him to abate, if possible, the pain by the use of opium, and to avoid, as much as he could, irritation of the tu- mours. These remarks, it is evident, are only applica- ble to specific fungi. Where the morbid parts are of the simple nature of polypi, they may, even when large, be destroyed. Such must have been the description of those tumours which have been removed by operation, even after they had, by their pressure, caused absorption of the earthy matter of the bones.* To the very interesting case of Mrs. Scott, which illustrates so well the nature and termina- tion of fungus hsematodesf in the orbit and an- trum, and which has afforded me an opportunity of pointing out the manner of extirpating the eye and dressing the wound, I shall add another pe- culiar case, operated on by my brother. * See Appendix, Note F. t Dr. Thomson has informed me, that lliis variety of the disease, where the tumour is nearly black, had been twice noticed by llaller, and particu- larly described, although under a different name, by Lcennee. 49 386 ON THE SURGICAL ANATOMY The patient, a young man, began three months before to observe a fulness below the superciliary ridge toward the temporal side of the orbit. For some time he felt little inconvenience, but, at last, to use his own expression., he saw gray or misty with that eye. Fifteen days after his vision began to be impaired, the tumour had considera- bly increased, and now when he viewed an object with both eyes, he saw double. Till within four- teen days, the eye-ball was not materially pro- truded from the socket. Much about that time it was rapidly forced out, and the pain, which had hitherto been very moderate, was greatly aggra- vated. Eight days ago, the protruded eye became highly inflamed. On the accesion of this inflam- mation, vision was still more obscured, and on the following day was, after the application of a cataplasm, entirely lost. Since that time the pain became excessive and stinging, darting back into the head* every part of which felt as if bruised. The tumour in the mean time increas- ed with amazing rapidity; the protruded eye- ball was of a dusky red colour, and the tunica con- junctiva covering it was thickened, had a gela- tinous appearance, and, in spots, was patched with lymphatic exudation. Behind the lucid cornea, which was no\\ very opaque, a drop of purulent matter was lodged. OP THE HEAD AND NECK. 387 To palliate the severity of the pain, a punc- ture was made through the cornea, but a small quantity of pus only was evacuated. The open- ing was soon obstructed by a protrusion of the iris, which was coated over with lymph. This case was viewed as a disease of the lachrymal gland, accompanied with a morbid state of the eye ball, produced by the pressure of the enlarged gland. On this idea it might have been supposed unnecessary to remove the eye along with the gland; but as vision was now irretrievably lost, and as there was a possibility that the disease might be of a specific nature, it was considered safest to remove it. The opera- tion was performed by my brother in the usual way. After the operation the patient never felt com- fortable; the pain in his head continued, the nal- pebrse sloughed, intense pains became fixed about the joints, tumours seemingly arising from the bone, formed on each side of the head and on each th;gh; the right lachrymal gland began to enlarge, pushing out the eye as on the opposite side; he gradually lost the power of his lower ex- tremities, and the capability of discharging his urine; sloughs formed on the buttocks, his appe- tite failed, his mind and body were equally un- settled, so that at length he died completely exhausted. 388 ON THE SURGICAL ANATOMY Dissection of the eye-ball and lachrymal gland. The vitreous humour having, by the pressure, escaped during the operation, the eye was col- lapsed, when sent to me for examination. The tunica conjunctiva was fleshy and rough on its outer surface, and a considerable quantity of transparent intersticial fluid was effused into the cellular membrane, connecting it to the adjacent parts. It was this deposition which occasioned the gelatinous look of the conjunctiva, previous tp the operation. By alcohol this fluid was co- agu!ated. At the centre the cornea was very thin, but transparent; towards the circumference it was thickened, and of a dirty greenish yellow colour. The sclerotic coat, along its whole extent, was healthy. The choroid coat was of a very deep red colour, and entirely without pigmentum nigrum. At the ligamentum ciliare it terminated in a thick ragged edge, formed by the agglutination of the corpus ciliare, and the thickened and lacerated iris. By the most careful examination, before and after immersion in alcohol, I could discover no vestige of the pulpy part of the retina. A delicate dark red coloured membrane, resembling in texture the tunica arachnoides, lay in the situ- ation of the retina. The optic nerve, exterior to the eye was healthy. OF THE HEAD AND NECK. 389 The lachrymal gland, as large as a hen's egg, was flattened, defined by a capsule, was without trace of division into lobules, in density and smoothness it resembled cartilage, and it was of a pale straw colour, inclining slightly, in some lights, to a greenish tinge. DESCRIPTION OF PLATE VIII.— FIG. 2. This Figure is intended to illustrate the external ap- pearance of the diseased lachrymal gland, just described. The tumour has pushed the eye from its socket, and pro- truded the upper palpebree, disfiguring the face. The lucid cornea is traversed, by the incision made the day before the parts were extirpated, for the purpose of evacuating a little purulent matter which was contained in the anterior chamber of the eye. See page 333. Dissection of the Body. The orbit from which the eye had been extir- pated, was filled with a substance resembling in texture and colour, the diseased lachrymal gland. It wanted, however, the uniform smoothness of the gland. It was fibrous, and the fibres ran ac- cording to the direction of the recti muscles. By removing what remained of the upper eye-lid and the skin covering the eye-brow, a tumour was brought into view, resembling in texture the con- 390 ON THE SURGICAL ANATOMY tents of the orbit. It was attached to the super- ciliary ridge of the frontal hone, which, at the point of attachment, was rough and rather swell- ed. The frontal sinuses were occupied by tu- mours of a similar texture, which were chiefly connected with the investing membrane of the si- nuses. Even where the tumours were not attach- ed, the lining membrane of the sinuses was thick- ened and altered in their appearance. In every part they had the greenish yellow colour of the contents of the orbit, diversified by spots of a florid colour, produced by the ramification of blood vessels filled with arterial blood. The sBthmoidal and sphenoidal sinuses, and many of the cells connected with the nose, were found .containing similar tumours, and much of the schneiderian membrane had assumed the same morbid appearance and colour, but on both sides the investing membrane of the antrum maxillare was free from disease. In the opposite orbit, the lachrymal gland was found precisely similar in texture to what it had been on the other side, and the periosteum also, on which the gland rested, was changed in its organization. The eye- ball, the fat, the muscles, and the nerves, were still free from disease. In various spots the dura mater was thickened, and presented the same characters as the other morbid parts, and opposite to each of these points, the internal table of the skull was rough and OF THE HEAD AND NECK. 391 more porous than usual. Two similar tumours were attached to the other surface of the skull. The disease in this case was surely of a specific nature. It was widely extended, and as intracta- ble as fungus haematodes Yet few, from the or- ganization of the diseased parts, will be inclined to believe the disease to have been fungus hsema- todes. It presented none of the characters of that disease. The complaint seemed to me to have been one sui generis. The series of parts affected, and the mode of propagation of the dis- ease, were different from what is generally met with in either fungus hsematodes or medullary sarcoma. In these the neighbouring parts are commonly contaminated, either by actual contact,, or by absorption; or in a less obvious way some of the internal viscera are diseased. But I have never heard of an instance, in which the tex- tures affected in this patient, were the seat of medullary sarcoma or fungus hsematodes; neither have I known any instance, in which the latter disease had advanced so far, without producing contamination of the conglobate glands in the course of absorption. In this disease, however, the conglobate glands which received the lymphatics from the morbid parts were unaffected. The disease was exten- ded to parts dissimilar in texture, and in so far as vve know, entirely unconnected by absorbents. The dura mater, the lining membrane of the 392 ON THE SURGICAL ANATOMY nasal sinuses, the contents of the orbit from which the eye and lachrymal gland had been ex- tirpated, and the lachrymal gland on the op- posite side, all presented unequivocal features of the disease. These could not be contaminated by either absorption or continuity; but how the disease was propagated, or what its nature was, are points on which we must confess our igno- rance. Nevertheless, I would not have it supposed that the case is without value. In its progress and termination it is highly interesting; never was an operation undertaken with greater probability of success, and never were diseased parts, to appear- ance, more completely removed, than in the pre- sent instance. Yet it has been seen, that from the first to the last day after the operation, the symp- toms were untoward. There was not, as gene- rally there is after the removal of carcinomatous or spongoid tumours, even a temporary suspension of the complaint; the operation only seemed to have added force to the disease and accelerated its pro- gress. While the external carotid artery is deeply im- bedded in the substance of the parotid gland, it sends off1 the large internal maxillary artery, which instantly dives behind the ascending plate of the lower jaw bone, and protected by it, sends its branches in safety to all the deep-seated parts about the face. OF THE HEAD AND NECK. 393 From the point where the internal mixilUry artery is sent off the temporal artery becomes more superficial, till at last it passes over the zy- go muitic process of the temporal bone, to be im- bedded in the cellular substance which covers the aponeurosis of the temporal muscle. Here it is quite superficial, and here the surgeon gen- erally opens that vessel. 1 know no operation simpler, nor at the same time, oftener imper- fectly executed, than arteriotomy. The causes of failure are worth the investigating, because when understood they are easily avoided. From what I have observed in many instances, I am fully convinced that the surgeon may be foiled in two ways. If he cut the artery completely across, he will only obtain a small quantity of blood, and if he attempt to open the vessel while it is in a state of contraction, the orifice made by the lancet can neither be fair nor large. Let these two facts be kept in remembrance, and disap- pointment will seldom be experienced in perform- ing this operation. In opening the temporal artery, I always make firm pressure with the fore finger of tiie left hand on the artery, a little higher than the point where I intend to open it, and with the thumb of the same hand a little lower. In this way I keep the canal of the vessel distended, by intercepting a quantity of blood. Then with a scalpel 1 make an incision about half an inch in length, down to 50 394 ON THE SURGICAL ANATOMY the artery, which I next puncture longitudinally with a lancet, Having removed the pressure with the thumb, eight or ten ounces of blood gen- erally flow from the artery. Then the bleeding begins to flag, and may be fully checked, either by cutting the artery across, or by applying a small compress over it, retained by a proper bandage.* I have heard some complain, that when they trusted to the first plan, the haemorrhage was sometimes renewed. This generally depends on the artery having been divided at some distance from the lower angle of the wound. I do not remember ever to have seen the bleeding return, where the vessel had been fairly cut across at the lowest point of the wound, but even if it did, touching it with the oil of turpentine would in- stantly check the effusion of blood. In mania, where it is necessary to detract blood, I uniformly open the temporal artery, because where a vein in the arm has been punctured in an unruly patient, the compress is apt to slip aside, and blood be lost. After division of the tempo- ral artery in a high patient, I have repeatedly trusted the person with merely a slip of adhesive plaster over the wound, and have seldom been troubled with a return of haemorrhage. * The editor's experience on the subject of securing the patient against haemorrhage after the operation of arteriotomy has been executed, would induce him to recommend tying the artery in preference to either oi the plans stated in the text. — Ed. OF THE HEAD AND NECK. 395 Some way above the zygoma, the temporal ar- tery, like the other arteries of the head, becomes imbedded in the tough and firm substance of the scalp. This gives a peculiarity of character to wounds of the vessels of the head. When an ar- tery is wounded where lodged among loose and fatty cellular membrane, if external bleeding be prevented, the blood is injected among the cellu- lar meshes, forming a dense dark black placenta- looking mass, from innumerable pores of which blood issues as from a sponge. Where, however, the artery is running among muscles, or is imbed- ded in the scalp, the blood is collected, forming a circumscribed effusion, which is soon defined by a lymphatic exudation, and under these circum- stances, a trumpet- like process of coagulating lymph is sometimes attached to the orifice of the vessel through which the blood has been poured out. This has been observed in the tho- rax by Morgagni;* in wounded ischiatic artery it has been met with by Dr. Jeffray;f and I have had an opportunity of seeing it in a young wo- man whose occipital artery had been injured. In a street quarrel she received a blow on the occiput, inflicted by a large angular stone. By the injury she was stunned, so that she fell down and remained in a state of insensibility for a length of time, during which blood continued to *Morgagni, vol. i. letter 17, art. 14. t Bell's Principles of Surgery, ?ol. i. 396 ON THE SURGICAL ANATOMY flow from the wound. When discovered, further bleeding was prevented by a compress and roller. Some days after the accident, my brother was desired to visit the patient. The integuments round the wound were elevated into a conical tu- mour, perforated at its apex by the injury done by the sharp corner of the stone. The aperture was ragged, and the surrounding skin was dark- coloured. The tumour neither pulsated nor was diminished by pressure, but it evidently contain- ed blood, which was prevented from escaping by a large coagulum which plugged the orifice. The patient, although warned of the risk, would not consent to the tumour being opened; she followed her own inclinations in regard even to dressing, which was so clumsily applied, that the coagulum slipped from the wound during the night, a profuse bleeding followed its removal, she fainted, and during the continuance of syn- cope, a new coagulum formed. This kept its place for a few days, then came away, and as be- fore, its removal was followed by a considerable loss of blood. This discharge and reproduction of the coagulum and consequent bleeding, were continued during two weeks, before her consent could be obtained to cut into the tumour and secure the artery. At last the cyst was laid fully open, the clotted blood cleared away, after which, the florid jet of blood was seen issuing from a trumpet- like orifice; languid indeed, since from OF THE HEAD AND NECK. 397 the frequent repetition of haemorrhage, she was much reduced, and fainted on every trivial exer- tion. The pedicle of this trumpet-like expansion was included in a ligature, but it wanted strength to hear the necessary tightening of the thread. It tore across, the bleeding was renewed, but was finally suppressed by passing a ligature round the artery itself. This case occurred before Mr. John Bell's Principles of Surgery were published, therefore my brother was not at first aware, that this lym- phatic expansion was neither possessed of sufficient strength to resist the ligature, nor organization to effect adhesion. It must, of course, be brushed off from the vessel with the handle of the scalpel, and the extremity of the artery itself included in the ligature. OBSERVATIONS ON THE STRUCTURE OF THE NECK INj THE YOUNG SUBJECT. IN some points, the differences between the relative situation of the various parts about the neck, in the child and adult, are strongly marked, and of considerable importance. In a child aged about twelve months, the space from the chin to the sternum measures, when the base of the skull is placed parallel to the ho- rizon, three finger- breadths. At this age the os-hyoides is placed on the same plane with the inferior margin of the lower jaw-bone, and at the distance of two finger-breadths behind the chin, and as yet no projections are formed by the car- tilages of the larynx. One finger covers the space from the os hyoides to the lower margin of the cricoid cartilage; then, allowing half the breadth of the finger for the thyroid gland 400 ON THE SURGICAL ANATOMY itself, which is broader in proportion than in the adult, there will 'remain, for the distance between the thyroid gland and the sternum, a finger- breadth and a half. When the head is turned back, five fingers can be introduced between the chin and the chest, and four of these can be laid between the os-hyoides and the sternum. By the stretching of the membrane between the os hyoides and thy- roid cartilage, half a finger-breadth is gained on the distance between that bone and the lower margin of the cricoid cartilage; then deducting, as formerly, half a finger- breadth for the thyroid gland, there are two finger- breadths left between that gland and the sternum. Generally, at this early period of life, the thy- mus gland mounts about half an inch above the level of the sternum. It is interposed between the sternum and the left subclavian vein and arte- ria innominata. The upper margin of the former vessel is parallel to the highest point of the ster- num, while its lower crosses the origins of the arteries rising from the arch of the aorta. The arteria innominata seldom turns to the side of the trachea, lower than a quarter or half an inch above the chest. The sterno-mastoid muscle and the omo-hyoi- deus decussate each other two finger breadths above the clavicle, and three below the angle of the jaw. As in the adult, the common carotid OF THE HEAD AND NECK. 401 artery Hes just behind the point of intersection of these muscles. The division of the carotid into its external and internal trunks, takes place a finger- breadth above the crossing of the omo- hyoideus and the sterno-mastoid muscles, and consequently two finger-breadths below the angle of the jaw, nearly opposite to the upper margin, of the thyroid cartilage. The division, therefore, of the carotid takes place, in regard to the la- rynx, at precisely the same point in the young and old subject. Yet, when we view the rela- tion of the bifurcation of the carotid to the jaw, in the child and adult, we find a wonderful dif- ference— a difference entirely dependent on the non-evolution of the alveolar processes, and of the teeth. When these are evolved, the margin of the jaw descends, so as to cover, in a great de- gree, several of the arteries exposed in the young subject. In the child, the superior thyroid, the lingual^ the labial, the inferior pharyngeal, and the occi- pital arteries, generally arise from the external carotid lower than the digastric muscle, and the latter vessel is proportionably nearer to the portio- dura than in the adult. In summing up the differences in the relation of the parts between the chin and the chest, in the adult and young subject, we are first led, in the latter, to notice the great distance between the bifurcation of the carotid and the angle of the 51 402 ON THE SURGICAL ANATOMY jaw, the exposure of the primary branches of the arteries, and the immense space between the jaw and the point of decussation of the omo-hyoideus and the sterno-mastoid muscle. In the adult, when the head is turned back, the space from the chin to the sternum measures twelve finger-breadths, and the intersection of these muscles is placed four finger-breadths be- low the angle of the jaw. In the child, whose head is turned back, we can only place five fin- gers between the chin and the sternum, yet here the decussation of the omo-hyoideus and the sterno-mastoid, is situated three finger-breadths below the jaw. The reason of this difference has already been pointed out. It has been shewn, that it is occasioned by the shortness of the as- cending branch of the lower jaw-bone, and by the narrowness of both maxillae, previous to the for- mation of the alveolar processes. About the se- venth year the permanent teeth begin to protrude, now the jaws deepen, the angle is carried back- ward, to make way for the evolution of the grind- ers, and at the same time the ascending branch of the maxilla elongates; the parts about the neck assume more and more of the adult arrangement. In comparing the young subject with the adult, one is naturally struck with the difference in the capacity of the larynx. Neither the external size, nor the canal of the trachea, is, in the child, proportioned to the body. On this subject, Rich- OF THE HEAD AND NECK. 403 erand has written a very ingenious and useful memoir, in which the facts are so clearly stated, and the inferences so just, that I prefer transcri- bing his own words: "Un jeune homme age de quatorze ans, encore impubere, mourut a Phospice de la charite". En ouvrant le larynx, je fus surpris de sa pititesse, et sur tout du pen d'enteridue de la glotte, qui n'avoit que cinq lignes dans son diametre antero- posterieur, et une ligne et demie environ dans le transversal, a 1'endroit oil elle a le plus de largeur. Une observation qui ne doit point £tre negligee, c'est que la taille de Pindividu etoit elevee, mais que le developpement de ses parties genitales etoit aussi pen avance que celui de Porgane vocal. Pai re*itere la meme observation sur des sujets plus eloignes de Fepoque de la puberte; j'ai eten- du mes recherches a ceux qui Pavoient depassee, et j'ai obtenu pour resultat gen ral; qu'entre le larynx et la glotte d'un enfant age de trois ou de douze annees, les differences de grandeur sont tres-peu remarquables, presqu'imperceptibles, et ne peuvent point se mesure par la stature des individus. "Qu'a 1'epoque de la puberte, Porgane de la voix grossit rapidement, et qu'en moins d'une ann6e Pouverture de la glotte augmente dans la proportion de 5-10 qu'ainsi son etendue est dou- blie, soit sous la rapport de sa longetir, soit dans le sens de sa largeur. 404 ON THE SURGICAL ANATOMY "Que ces changeraens sont moins prononces chez la femme, dont la glotte ne s'aggrandit guere que dans la proportion de 5-7; qu'ainsi, sous ce rapport, elle se rapproche de Penfant, comme le timbre de sa voix 1'avoit deja fait presumer. "Les differences de grandeur de la glotte ren- dent raison du danger qui? dans les enfans, ac- compagne Pangine laryngee; soit en effet une ouverture d'une ligne et demie de largeur, dont les bords se couverent d'une lame albumineuse de trois quarts de ligne d'epaisseur, Pouverture sera entierement bouchee. Elle seroit seulement re- trecie; si sa largeur etoit double; un espace suf- fissant resteroit libre pour le passage de Pair. Cette supposition, dont je me suis aide pour me rendre plus intelligible, n'est que Pexpression de la verite, puis que Pinspection anatomique demon- tre que la glotte a dans les adultes une grandeur double de celle qu'elle presente dans les individus impuberes."* A change is not only produced on the voice, by the evolution of the larynx, but the relative position of some of those parts in the vicinity of the larynx is altered. Richerand has confined his whole attention to the changes produced in the economy of the larynx itself; but these changes, although highly important, are not the only effects springing from the evolution of the * Recherches sur la Grandeur fie la Glotte, par A. Rieherand. Me- moircs (le la Societc Medicate cl'Em illation, tome iii. p. 32t). OF THE HEAD AND NECK. 405 organ of voice, which interest the practitioner. We must now study the variations in the rela- tive distance between the lower edge of the thy- roid gland, and the upper edge of the sternum. When we compare the space between these two points in a child of two years of age, with the space between the same points in the adult, we find that the distance is equally great in both subjects. And I have uniformly found, in a subject just before the age of puberty, an actual measurement of from a quarter to half an inch more between the sternum and the thyroid gland, than in the adult. The cause of these peculi- arities is easily explained; it has already been stated, that in the early period of life the larynx is diminutive, in proportion to the other parts of the body, hence it follows, in childhood that the trachea must be proportionally longer than in the adult. The position of the cricoid cartilage regulates the situation of the thyroid gland, consequently in children, in whom this cartilage is relatively high placed in the neck, the space between the lower border of that gland and the sternum must be large. As the larynx, however, begins, at the age of puberty, to be evolved, the crocoid carti- lage is depressed, the thyroid gland descends along with it, and the distance between that gland and the chest is reduced. This fact will explain the reason why, by bending back the head in the 406 ON THE SURGICAL ANATOMY adult, the measurement is chiefly increased be- tween the chin and the thyroid vjjland; and why, before the evolution of the larynx, the space is principally increased, by bending back the head, between the gland and the chest. From these facts it may fairly be inferred, that in children, in whom the operation of tracheotomy will chiefly.be required, it may be equally safely performed as in the adult. Having mentioned the operation of bronchotomy, it may not be superflu- ous to enter a little into the consideration of the causes rendering it necessary, and into an inquiry concerning the way in which the operation has been performed. Formerly this operation was recommended on more trivial occasions than at present. Some ad- vising it to be resorted to whenever the surgeon was foiled in his endeavours to introduce a tube into the larynx, in suspended respiration from drowning, hanging, or noxious exhalation; but in asphyxia from these causes, bronchotomy, in the hands of a skilful surgeon, will seldom,, if ever, be required. This opinion is precisely the reverse of that en- tertained by Mr. Samuel Cooper, who is an advo- cate for the employment of bronchotomy in sus- pended respiration: "From the manner in which the epiglottis covers the top of the larynx, it is ob- viously very inconvenient to make any attempt to introduce the muzzle of a pair of bellows into the OF THE HEAD AND NECK. 407 rima glottidis, even though the pipe be curved; it is much better to have recourse, at once, to a very safe and simple operation, which consists in mak- ing an opening into the front of the trachea, suffi- cient to admit the pipe of the bellows." While writing these remarks, the author has, I suppose, overlooked the substitute proposed by Desault, and most happily employed both in France and in this country. That celebrated surgeon was well aware of the difficulty of introducing a pipe from the mouth into the larynx. Before this can be done the epiglottis must be commanded, which is not an easy matter. He found, however, that a tube passed along the right nostril, and properly curved, slipped very readily into the opening of the glottis. Here there was no obstacle afforded by the epiglottis, and no risk of folding it over the top of the larynx, since the point of the tube is behind the line of that valve. This, therefore, is decidedly the mode to be adopted in suspended respiration, unless where the subject is so young, and the rima so small, that a proper sized canula cannot be introduced into the trachea. As the facility of introducing the curved tube by the nose into the larynx, will entirely depend on the possession of a correct knowledge of the relation of the larynx to the nostril and adjacent parts, I have subjoined a sketch, which will illus- trate these points more completely than can be done by any verbal description. 408 ON THE SURGICAL ANATOMY DESCRIPTION OF PLATE X. While preparing this sketch, the subject was laid on its back, and the left half of the lower jaw was removed, along with that side of the pharynx. By keeping the tongue pulled out of the mouth, the bag of the pharynx is fully ex- panded, and all the parts are rendered distinct; they are placed in a situation favourable for the introduction of an instrument from the nostril into the larynx. This view, therefore, will be useful in many respects. It illustrates the relation of the epiglottis and the rima glotti- dis, to the velum pendulum palati. It shews how easily a flexible tube may be passed from the nostril into the rima, and it at the same time, explains the cause of the difficulty experienced while introducing a pipe from the mouth into the larynx. The deepness of the epiglottis, and the facility with which that valve is folded over the rima, render the intro- duction of a tube from the mouth into the larynx, by no means an easy process. It cannot indeed be accomplished, till the finger has been thrust so far back as to get behind the epiglottis. If this be managed, and if that valve be laid flat along the dorsum of the tongue, a curved flexible tube may be conducted along the finger into the larynx. Where the muscular action is completely suspended, the pipe will enter readily enough, but if the laryngeal muscles be still irritable, the rima will be closed so soon as it is touched by the tube; the point of the instrument will slip back into the pharynx, and the stomach will be inflated. All this has frequently happened, and that time which ought to have been employed in another way, has been spent in futile endeavours to get the tube into the windpipe. This delay and discomfiture may be avoided by following the practice of Desauit. OF THE HEAD AND NECK, 40$ This sketch shews, that in the natural condition of the throat, the epiglottis A, is placed nearer to the mouth than, the line of the posterior face of the velum B. By passing, therefore, the curved flexible tube C along the nose, it pre- sents behind the velum, directly over the rima glottidis, into which it may be directed by a pair of common dressing forceps passed along the mouth. In this sketch, a com- mon flexible catheter has been employed, which may be adapted to any bellows, by merely wrapping folds of linen round its extremity, till it be made of a size just fitted to slip within the nozzle of the bellows. During the hurry, however, and the confusion usually attendant on an acci- dent requiring inflation of the lungs, the surgeon sometimes overlooks such substitutes. Hence I have actually known a person who had fallen into the water, allowed to He without any attempt having been made to inflate the lungs, till a regular apparatus for that purpose was procured from a distance. In suspended animation, what is to be done must be done quickly — there is no leisure for deliberation — no time for experiments. A surgeon is liable every hour of his life to be called on to give his assistance, and ought, therefore, to have made up his mind how to act. In regard to inflating the lungs, there cannot remain a doubt about the propriety of passing the tube along the nostril; the structure of the throat is to be our guide, and I will venture to affirm, that he who is familiar with those parts, will, without difficulty, pass a tube from the nose into the windpipe. D the uvula. E the divided body of the hyoid done. JF the bag of the pharynx terminating in G the gullet, which just at its com- mencement is overhung by H the thyroid gland. By permitting the tongue to fall fairly back into the mouth, the epiglottis is brought considerably behind the line of the velum. In that situation, an instrument intro- duced by either the mouth or nose strikes on the valve, 52 410 ON THE SURGICAL ANATOMY and folds it over the glottis. This is, therefore, the situa- tion in which the parts ought to be placed, when a tube or the probang is to be passed along the oesophagus. If the tube is to be conveyed from the nostril into the gullet, the base of the skull ought to be kept parallel with the horizon; but where vve are to pass the probang along the mouth, the head ought to be turned back. There can only be two inducements to perform the operation of bronchotomy, one to admit air into the lungs, the other to remove foreign sub- stances from the windpipe. Where a solid sub- stance has entered the larynx, it can seldom be expelled — generally an operation is required for its removal. If permitted to remain, even where it is not of such a size as to obstruct to any great degree the breathing, when it first slips into the larynx, its irritation will produce, especially in young subjects, inflammation and death. In one case which happened in this town, not very long ago, a small horse-bean accidentally dropped into the larynx of a young child; imme- diately her breathing became exceedingly difficult; an incessant cough and general convulsions nearly terminated her life. She continued in an insen- sible state for half an hour, during which she could not be observed to breathe. Then the breathing became easy, and the face which before OF THE HEAD AND NECK. 411. had been inflated and dark coloured, began gra- dually to resume its usual complexion. Next day the girl had another attack of diffi- culty in breathing, which after a violent paroxysm of coughing, abated, but left her in a smart fever. In this way she passed a week, during which she was bled, and her breast was blistered. It may be proper to mention, that during the whole of this week she was anxious to lie on her back, and also that at the commencement of the attack, she breathed during six hours with a whistling noise. On the ninth day after the acci- dent, she suddenly died during a very severe fit of coughing. Next day the body was inspected, the larynx found inflamed, coated in part with lymphatic exudation, and containing, just below the rima, a horse bean. Other cases of a similar nature have come to my knowledge, in which the children died with symp- toms of cynanche trachealis, after having at in- tervals threatening of instant suffocation from the severity of the cough. When, therefore, a fo- reign substance has slipped back, and the child has immediately had great difficulty in breathing, violent paroxysms of coughing, followed, in a few days by symptoms of inflammation of the larynx, we cannot be enough on our guard — we cannot too sedulously watch the patient, nor can we too soon endeavour to arrest the progress of the inflamma- 412 ON TUB SURGICAL ANATOMY tion; I would add, that this cannot be accomplisli- ed till after the removal of the foreign substance, by an opening made into the windpipe. Till, however, the opening be made, we seldom can be certain that there really is any extraneous sub- stance lodged in the trachea: we operate, there- fore, on a probability; but we have this security, that nothing else, if there be a foreign body in the windpipe, will save the life of the patient. There is, therefore, every reason to induce us to under- take the operation, and none to deter us. Where a foreign body had unquestionably slip- ped into the larynx, it was the general opinion, till lately, that the operation of bronchotomy would only be useful in those cases, where the substance was situated above the point where the perforation is to be made. It was universally be- lieved, that if it had descended along the canal of the trachea, it could not be extracted by any opening made into the windpipe. This was at least a plausible speculation; it therefore main- tained its ground, till disproved, I believe, by the experiments of Favier. After introducing a pea fairly into the trachea of a dog, he made an opening into the windpipe below the thyroid gland, and found that by the force of the air ex- pelled from the lungs, the pea was thrown out by • the wound. This took place as often as the foreign substance was put into the windpipe. OF THE HEAD AND NECK. 413 This experiment, uniform in its result, proves that hronchotomy will be equally useful where the extraneous substance has descended into the trachea, as where it has been impacted in the larynx. In the human subject, I have seen a com- plete corroboration of this fact. About twelve months ago, during the autumn, a young woman called on me relative to a plumb stone which had passed into the trachea. The account which she gave of the accident was, that she had been eating plumbs two days before — that in a hurry she had incautiously attempted to swallow, at the same time that she was inspiring* She was conscious that a stone had at this in- stant entered the windpipe, where it excited con- siderable irritation, and long continued and se- vere coughing. The latter had greatly abated in the course of a few hours, and at the time I saw her, was only momentarily excited by forci- ble expiration. I examined her carefully, and ascertained that while she was taking air into the lungs, the foreign substance descended with rapidity along the trachea, to the point where it bifurcates, from which, during extirpation, it was again forced up into the larynx, but could riot, by any effort, be projected through the rima. During its ascent and descent, it was productive of a tickling sensation along the course of the trachea. 414 ON THE SURGICAL ANATOMY As she suffered very little inconvenience from its presence, she would not submit to its removal; she was fully persuaded that it would come away as unexpectedly as it had entered. Whether her expectations were ever realized, I never heard; but the fact of the stone changing its position from the larynx to the bifurcation of the trachea, is quite conclusive as to the fact it was meant to corroborate. . In performing the operation of bronchotomy, the perforation is sometimes made into the la- rynx, and sometimes into the tranchea below the thyroid gland. Vicq. D'Azyr first advised the opening to be made between the thyroid and cri- coid cartilages, and in this county laryngotomy was afterwards patronized by Mr. Coleman. Notwithstanding the high authority of the cele- brated French anatomist, and the opinion of Mr. Coleman, the propriety of laryngotomy in prefer- ence to tracheotomy, may be doubted. In the former we enter at once into the la- rynx, below the rima glottidis indeed, but still too much in the vicinity of that opening not to afford just ground for apprehension; we excite incessant and very distressing coughing. If it be really necessary to perform bronchoto- my? let it be done at least, in those not arrived at the age of puberty, below the thyroid gland; let us cut into the trachea, by which we shall with less inconvenience to the patient, gain all OF THE HEAD AND NECK. 415 the advantage which can be derived from a high- er incision. Here I need hardly remark, that the younger the subject, the more easily may tracheotomy be performed, and the less easily laryngotomy. It may be proper to mention, that in the adult female, the conformation of the neck resembles,, in some points, the young subject. In her the larynx is not only smaller in proportion to the body than in the male, but it is also higher placed in the neck.* When we have resolved on performing trache- otomy, caution is required in the execution of the operation., If considerable care be not employ- ed, we may injure some of the arteries about the root of the neck. The arteria innominata is in risk in some sub- jects. I have seen it mounting so high on the fore part of the trachea, as to reach the lower border of the thyroid gland. Even the right carotid artery is not always safe. I am in possession of a cast taken from a boy of twelve years of age, which shews the right carotid artery crossing the trachea in an oblique direction. In this sub- ject that vessel did not reach the lateral part of the trachea, till it had ascended two inches and a quarter above the top of the sternum. Where both carotid arteries originate from the arteria innominata, there is considerable danger in * Soeimerring de Corporis Humani Fabrics, vol. vi. p. 18 416 ON THE SURGICAL ANATOMY performing the operation of tracheotomy, for in such cases, the left carotid crosses the trarhea pretty high in the neck. Professor Scarpa has seen a specimen of this distribution in a male sub- ject, and I have met with five. These varieties in the course of the arteries, are worthy of being known and remembered; they will teach the operator to be on his guard, since he can never, a priori, ascertain the arrangement of the vessels with any degree of certainty. It will impress on his mind the impropriety of using the knife further, than merely to divide the integ- uments and fasciae. If he then clear the trachea with the finger, he will never injure any of the large arteries. When with the finger he has fairly brought the trachea into view, he ought to examine carefully, whether any of the large arte- ries lie in front of it, and if he discover one, he ought to depress it toward the chest before he penetrates into the windpipe. In cutting into the trachea, the preferable plan is to cut the rings from below upward, avoiding in- jury of the thyroid gland. Mr. Cooper seems to cut them from above to below, at least if we may judge from his directions, not to have the incision carried "at all below the first bone of the sternum, lest the subclavian vein should unfortunately be cut."* This is not, however, the only risk; it has been seen that there is more danger of injur- * Cooper's First Lines of the Practice of Surgery, p. 310, OP THE HEAD AND NECK. 417 ing one of the large arteries, since these mount higher than the vein. Whether, however, the in- cision he made in the one way or the other, it ap- pears to be the uniform opinion, that cutting t;«e trachea longitudinally, is preferable to cutting across between the rings. In a child about six months, the arteria innomi- nata, when on a level with the top of the sternum, and at the distance of an eighth part of an inch from its division into the carotid and subclavian vessels, gave off from its left side, a branch about the size of a crow quill. This ascended along the front of the trachea, for about a quarter of an inch, and there divided into two equal sized branches. From the left branch an artery of some size was sent into the thymus gland, which in this child was very large. Soon after the origin of this thymic branch, the artery divided into six twigs, which finger-like embraced the lower margin of the thy- roid gland. The other division of the artery sent some twigs into the sterno-hyoid and thyroid mus- cles, but its chief twigs passed into the thyroid gland. The twigs of this anomalous artery, which just above the chest were few, large, and close to each other, subdivided and receded as they as- cended, so that at last they covered not only the whole fore part of the trachea, but even overhung its sides. From the sternum up to the thyroid gland, there was hardly a single point of the trachea intotwhich 53 418 ON THE SURGICAL ANATOMY an incision could be made, without dividing some of the pretty large twigs of this vessel. This is not a solitary case— I have met with other three children, in whom there was a similar arivnge- ment of the vessels going to the thyroid gland. It is well to know these facts; not that they afford any objection to the performance of tracheotomy, but to shew, that while performing that operation, there may, from the division of the twigs of this vessel, be considerable bleeding. The two inferior thyroid arteries arise by a common trunk from the right subclavian artery, in a preparation in the possession of my friend Dr. Barclay. In this subject, the vessel creeps up the side of the trachea, lower than the gland, and when it has reached the front of the windpipe it divides into two branches. The right branch runs along the trachea, and the left ascends till within two tracheal rings of the cricoid cartilage. The first lies, as I have been informed, nearly in the line of the small vein which generally covers the trachea, and which, during the operation of tra- cheotomy, is usually divided. Haller, when describing the inferior thyroid ar- tery, mentions, "semel rarissimo example, a caro- tide vide natam;'?* but as he does not specify the course of the vessel, it is quite uncertain whether it ran, in his case, in such a direction as to come in * Icouuin Anatomiearum Fasciculus xi. p. 18. OF THE HEAD AND NECK. 419 the way of the knife, in performing the operation of tracheotomy. When the operation of bronchotomy is required in the adult, laryngotomy may, by some, be thought preferable to tracheotomy. In the full grown per- son, the space between the lower edge of the thy- roid gland and the sternum, is less than in the child, while the larynx is comparatively much larger. Laryngotomy, therefore, may, in the adult, have some advantages; but tracheotomy is the opera- tion adapted to the mechanism of the throat in childhood. In tracheotomy, the anomalous artery is liable to come in the way, and where it exists it must inevitably be divided. In laryngotomy; we shall more rarely meet with any aberrant ves- sel, although even here they sometimes do occur. In one subject which I dissected, the ramus thy- roideus arterise thyroidse superioris was amazingly large, being considerably bigger than a crow quill^ and it likewise ran in an uncommon course. Tiiis vessel slipped in beneath the omo and sterno-hyoid muscles, running along the line of junction of the hyo-thyroideus and sterno-thyroideus, till it reach- ed the front of the neck. Then it suddenly turned downward to the thyroid gland, which it touched at the central part. From its course it could not have escaped in laryngotomy; it would have pour- ed its blood into the windpipe. A large vein is often found running just be- n,eath the fascia, and between the contiguous 420 ON THE SURGICAL ANATOMY edges of the sterno-hyoidei muscles. This vessel, in performing the operation of laryngotomy, would of necessity be divided. This cannot be consi- dered as forming any objection to that operation; it is mentioned, to shew that there may be bleed- ing, and to hint the propriety of securing every vessel which may be injured before cutting into the larynx. By doing so, considerable inconve- nience may be avoided. In a patient of Mr. Harrold's, who had cut into the larynx, between the thyroid and cricoid car- tilages, the lips of the wound were brought closely together by sutures. On the fifth day the man died suddenly. A small artery had poured its blood into the windpipe and formed a coagulum there, extending even into the branches of the trachea.* That the arteries of the thyroid gland, and even the veins, may occasion disagreeable con- sequences, if divided, in performing the operation of tracheotomy, is incontrovertible: "La glande thyro'ide envoie inferieurement a la veine soucla- viere gauche, des veines qui, apres s'etre rami- fiees a sa face anterieure, se reunissent en deux troncs dont celui qui est a gauche rampe le plus ordinairement au devant de la trachee-artere, dans 1'intervhlle qui separe les deux muscles bronchiques, a leur partie inferieure. Ces troncs n'en forment plus qu?n, a 1'endroit de leur inser- * Wilraer'a Observations, p. 92—93. OF THE HEAD AND NECK. 421 tion, dans le plus grande nombre de sujets. Quelquefois ils restent separ-s. Quelquefois aussi Pun d'eux aboutit a la souclaviere gauche, et 1'autre a la souclaviere droite. Le gauche pent etre interesse dans 1'incision du tissu grais- seux qui couvre la trachee-art re. Ce canal a lui-meme des vaisseaux qui lui sont propres, et qui peuvent etre ouvcrts et fournir beaucoup de sang. C'est ce qui est arrive dans un cas ins -re par Hevin dans son memoire sur les corps etrangers arretes dans 1'cesophage et dans la trachce-artere, tome premiere des Memoires de 1'Acad. de Chirurg. Un soldat Espagnol age de vingt-trois ans, etoit pres de perir de suffo- cation dans une esquinancie. On jugea qu'on ne pouvoit le sauver que par la bronchotomie. La tractive arte*re ayant etc mise a decouvert par une incision longitudinale, ce canal fut ouvert entre deux anneaux cartilagineux; mais le malade n'en eprouva ancun soulagement, parce que le sang y tomboit, et causoit une toux convulsive qui ne permettoit pas de maintenir la cannule en place. Le cas parut si pressant, que Vir- gili ce determina a inciser la trachee-artere en long jusqu'au sixieme anneau, apres quoi il fit pencher le malade en devant. Bientot le sang cessa de couler, et on j^ut mettre dans la plaie uae plaque de plonib percee de plusieurs trous, et garnie de deux atles repliees a peu pres com- me celles dont Belioste a fait usage dans le traite- 422 ON SURGICAL ANATOMY. ment de la plaie du trepan. Des le lendemain, la fievre etoit deminuee et la deglutition plus aisee. Virgili pensa que peutetre le malade pourroit respirer sans le secours de la plaque, et il 1'dta. Ses esperances ne furent pas tromp^es. II ne fut plus question alors que de rapprocher les bords de la plaie et de travailler a sa con- solidation que rie tarda que quelques jours a se faire."* The thyroid gland itself may come in the way of the knife, while performing the operation of tracheotomy. I, in one subject, found the slip of the thyroid gland which crosses the front of the trachea, so broad, that it descended almost to the sternum. This conformation must be remem- bered, because by injuring the substance of the gland, a very considerable bleeding will be occa- sioned, and the same bad effects may be produced as result from division of the arteries or veins. * Medicine Opera toire, par Sabatier, tome ii. page 360. OBSERVATIONS STRUCTURE OF THE NECK EDENTULOUS SUBJECT. IN an edentulous subject, there are considera- ble peculiarities in the relation of the parts about the throat. In some points, an edentulous person bears a resemblance to the young subject, and in others it is similar to the adult, with the head turned back; but it has also a character peculiar to its own period of life. In the child, from the non-evolution of the jaw and of the teeth, the large vessels at the top of the throat are fully exposed; the parotid gland, from the distance between the angle of the jaw and the anterior edge of the sterno-mas- toid muscle is broad, but at the same time short, and from the quantity of adipose matter, there is a fulness and plumpness which is lost when 424 ON THE SURGICAL ANATOMY the fat, instead of being collected exterior to the muscles, is more regularly distributed among their fibres and interstices. In the perfectly formed adult, the jaws are broad, their circle is wide, and the space be- tween the angle and the mastoid process is con- tracted. In the adult, therefore, the parotid is larger but of less breadth than in the child; the primary branches of the carotid and the styloid process, are, in a great measure, covered by the jaw bone, and there is a uniform fulness of all the parts. In the edentulous subject, there is not only a loss of the teeth, but the alveolar processes are likewise absorbed. By the falling out of the teeth and the loss of the alveolar processes, the distance between the palatine plate of the upper jaw bone and the chin is much reduced; again the infantile conformation would exist, were it not from the length of the lower jaw. When the mouth is closed, the chin is raised and projected forward, and the angle of the jaw is removed from the mastoid process; the space between these points is greatly increased, the breadth of the parotid gland is augmented, a hol- lowness is formed behind the jaw, the whole of the styloid process is uncovered, and the large vessels and nerves about the top of the throat are exposed. OF THE HEAD AND NECK. 425 By bringing the jaws into contact, the mylo- Lyoideus, and the anterior belly of the digastric, are, even when the base of the skull is placed parallel to the horizon, put on the stretch, con- sequently the submaxillary gland is exposed; it is brought almost completely below the margin of the jaw bone. In this, respect, therefore, the edentulous subject resembles the adult with the head turned back; in other points, however, they are very dissimilar. In the edentulous per- son, the peculiarities are produced by alterations in the conformation of the jaw, chiefly by the loss of the teeth and the decay of the alveolar processes. From the elevation of the angle of the eden- tulous jaw, the point where the sterno-mastoid and omo-hyoid muscles intersect each other, is relatively to the angle of the jaw as low seated as in the young subject. In the perfect adult it has been shewn, that a line drawn from the point of decussation of the omo-hyoideus and sterno-mas- toid muscles, to the angle of the jaw, follows nearly the course of all that part of the common carotid artery above that spot, and likewise of a conside- rable portion of the external carotid. In the edentulous body, a line drawn in the same direc- tion, is very far from following the course of the artery; it turns forward from the vessel, with which it forms an acute angle. APPENDIX. NOTE A. — p.71, A CASE similar in its nature, but attended with somewhat different symptoms, came under my own observation in the year 1817. I have already published this case in the tenth number of the American Medical Recorder, p. 194, but as I con- sider it one of great interest, and one which proves most forcibly the lesson taught in the text, — the difficulty of ascertaining before death the exact nature of such affections, I shall offer no apology for transcribing it. Mr. J. M'C. was, at the period of his death, in the forty- seventh year of his age. He was a man of superior talents and of remarkable activity, and, until six months previous to his dissolution, tyad enjoyed excellent and uninterrupted good health. In the autumn of the year 1816, he was attacked with a severe, and as he and his physician^ thought, rheumatic pain in the lower part of his neck. It was continued, nor did all the local and general remedies used, operate towards its allevi- 428 APPENDIX. ation. The neck was again and again examined; but as nothing could be there discovered amiss, the first opinion of the medical gentlemen was re* tained, and the rheumatic plan of treatment per- severed in until the patient's death. Although suffering severely from the local pain, Mr. M'C. did not confine himself constantly to his house; but was actively engaged during a great part of the period of illness in arranging his affairs, which from commercial convulsions, had become embarrassed. One evening in the month of April, 1817, he re- tired to bed in his usual state of health, and was discovered next morning in a state of insensibility arising from apoplexy. Under this attack he re- mained until the evening, when he recovered his sensibility; but after conversing with his friends rationally for about an hour and a half, the coma returned, and terminated his life early the follow- ing morning. I was not consulted as a medical man during Mr. M'C's illness, but was requested by a friend, one of the physicians who had attend- ed him, to conduct the dissection. The apoplexy being the most prominent feature in the case, the head was first examined. When the convolutions of the brain were exposed by the removal of the scull-cap and dura mater, the cere- bral veins were observed very much distended with blood. But although the dissection of the brain was conducted with the utmost care and APPENDIX. 429 attention, neither sanguineous nor serous effusion could be discovered in the ventricles or suhstance of that organ. The general and very great tur- gescence of the cerebral vessels was, however, quite sufficient to account for the coma. On opening the chest, the nature of the original disease was at once exposed. There arose from above the arch of the aorta a large tumour, which, projecting sternally, adhered firmly to the spinal aspect of the sternum. Upon separating this con- nexion we discovered that the tumour was formed by an aneurism of the arteria innominata, and that the sternum where pressed on had become ca- rious. The transverse vein formed by the union of the left subclavian and jugular veins, presented a very uncommon appearance. It had more the character of a ligamentous cord than of a distend- ed vessel; and when opened it was found filled with coagul'able lymph, which completely oblite- rated its cavity. Being curious to ascertain the cause of this, I traced it carefully downwards to- wards the right auricle. Upon arriving at the sternal aspect of the aneurismal tumour, the vein terminated, that portion of it which crossed the tu- mour, having from pressure become obliterated. The tumour measured four inches in its transverse diameter, and three in its longitudinal. The depth of the sac from its spinal to its sternal sur- face was two inches and three quarters. From its situation it completely covered and concealed the 480 APPENDIX. Irachea and gullet. The whole length of the arteria innominata was involved in it, and those arteries into which that vessel naturally divides, arose separately, as independent branches from the spinal aspect of the aneurismal sac. Both the superior and inferior thyroidean veins were en- larged and distended with blood; they appeared to be the channels through which the venous blood from the left superior extremity and left side of the head and neck was conveyed to the pulmonie auricle. We are naturally struck, frpm the consideration of this case, with the fact, that such a derange- ment could exist in the arterial system, and yet remain undiscovered until after the patient's death. It is a very rare occurrence even for aneurisms of the arch of the aorta to remain un- suspected. \ye cannot, it is true, in many instan- ces, give a positive assurance of their existence, but the palpitations of the heart, the intermissions of the pulse, and those painful indescribable pec- toral sensations which are thejr usual attendants,, leave generally in the mind of the intelligent prac- titioner little doubt of their presence. Another fact in the history which strikes us as curious, is, that although the aneurismal tumour was situated immediately before the trachea and (Esophagus, although it had from its enlargement obliterated the transverse vein, and from its pres- sure rendered the upper bone of the sternum APPENDIX. 431 earious, still that no symptom of its having pressed either on the aspera arteria or gullet, was mani- fested during the life of the patient. Writers on aortic aneurisms inform us, that when ihese tu- mours are situated on the right side they produce dysphagia, when on the left dyspnoea. Yet in this case neither of these symptoms were present. Can it be supposed that the enlargement of the tumour was directed towards the sternum by the force of the circulation? That the blood coagulating upon the anterior inner surface of the sac, and remain- ing fluid on the posterior, that the current of the circulation behind directed the pressure from the trachea and gullet, and directed it towards the sternum? I have in my possession the morbid parts of both Mr. Burns' patient, and likewise those which were taken from the above case. In every point of structure they bear a striking resemblance to each other. Indeed, this is so remarkable that it would be difficult to distinguish the one pre- paration from the other. In the record of their symptoms, it will, however, be observed that they seemed to be very different. A pulsation situated above the clavicle, was in Mr. Burns* patient the symptom which chiefly occupied the attention of the medical attendants. In the case where I conducted the dissection, this symptom escaped altogether the observation of the physicians. They were men of the first consideration, yet, 432 APPENDIX. they declared that "no pulsation was to be dis- covered." I must confess I am sceptical on this subject, the thyroid margin of the tumour was in contact with the sternal margin of the thyroid gland, and consequently, the pulsation must have been observed, had the examination been conducted with attention. The probability is that the symptom of rheumatism was the only one to which the minds of the physicians in at- tendance was directed. It is worthy of remark, that the rheumatic symptoms which was so prominent in Mr. M'C's case, was also present in Mr. Burns' patient. Rheumatic pains in such a situation so local, so obstinate, and so severe, are always to be viewed with suspicion. That rheumatism does frequent- ly occur in this situation, cannot be doubted; but that a pain of the same character is almost a never failing attendant on aneurism of the arch of the aorta and its great vessels, should never be for- gotten. The rheumatic pain may and probably will be removed by medical treatment, the aneur- ismal never can. Let this fact be recollected and we may be assisted in forming a just prognosis in cases similar to those we have recorded. Another character in which the cases resem- bled each other, was the disposition to apoplexy. In Mr. Burns' patient, there were "vertigo, fai- lure of the sight, a turgescence of the veins of APPENDIX. 433 the head and neck." In my own case the disease terminated in apoplexy. From these observations it will appear, that the difference in the symptoms of the two cases was more apparent than real, and demonstrates the ne- cessry of examining both local and general symp- toms before we form an opinion as to the nature of obscure diseases. NOTE B. — p. 73. That a ligature may be passed around the ar- teria innominata, so as to stopt the circulation of blood through it without materially affecting the functions of the brain or the actions of the right superior extremity, is a question which rests no longer on speculation. Dr. Mott, Professor of Surgery in the University of New York, has ac- tually performed the operation on the living sub- ject. The great interest of this case will be a suf- ficient apology for the very long extract which I make from it. "Since the publication of Allan Burns' inval- able work on the Surgical Anatomy of the Head and Neck, I have been in the habit of showing in my surgical lectures the practicability of secur- ing in a ligature the arteria innominata; and I 55 434 APPENDIX. have had no hesitation in remarking that it was my opinion, that this artery might be taken up for some condition of aneurisms; and that a surgeon, with a steady hand and a correct knowledge of the parts, would be justified in doing it. I felt myself warranted in this, from the singular suc- cess which this celebrated anatomist informs us attended his injections, and from my own investi- gations of this subject. If the right arm, right side of the head and neck, can be filled with in- jection, after interrupting its passage through the innominata, as we believe they can, who can doubt the possibility of the blood to find its way there also, as it will pass through thousands of channels, which art could not penetrate even by the finest injections? The well known anastomoses of arteries, and the great resources of the sys- tem in cases of aneurism, encouraged me to be- lieve, that this operation might be performed with reasonable prospects of success. With all this sanction, and the analogy of the other great ope- rations for aneurism, I could not for a moment hesitate in recommending and performing the ope- ration. "The following operation, as the steps of it will show, was performed with the two-fold intention: 1st, of tying the subclavian artery before it pas- ses through the scaleni muscles, if it should be found in a fit state; and 2dly, to tie the arteria innominata m case the former should be diseased APPENDIX. 435 or too much encroached upon by the aneuris- mal tumour. "Michael Bateman, aged fifty-seven years, was born in Salem, Massachusetts, and by occupation a seaman. He was admitted into the New York hos- pital on the first of March, 1818, for a catarrtial affection, having at the same time his right arm. and shoulder much swollen. At the time of his admission the catarrh being thought the most considerable disease of the two, he was received as a medical patient, and placed under the care of the physician then in attendance. During the three first weeks of his residence in the house, the catarrh had greatly yielded to the remedies prescribed. The inflammation, which had pro- duced an enlargement of the whole superior ex- tremity, extending itself to the muscles of the neck on the right side, was also gradually sub- siding. "A tumefaction, however, situated above and posterior to the clavicle, at first involved in the general swelling, and not to be distinguished from it, began to show itself. This resisted the reme- dies which were effectual in relieving the other, and became more distinct and circumscribed as the latter subsided; at length assuming the form of an irregular tumour. "The history which he gave of the case is as fol- lows: He said, about a week before he entered the hospital, while at work on ship. board, his feet ac- 436 APPFNDIX. cidentally slipped from under him, and he fell upon his right arm, shoulder, and the back part of his head; that he felt but little inconvenience from the fall, and after a short time returned to his duty. Two days subsequent to this, however, he felt pain in the shoulder, and the succeeding night was un- able to lie upon it in bed. The whole arm and shoulder then began to swell, and became so pain- ful that he was unable any longer to perform his dm.y as a seaman. The ship having arrived in New York, he was admitted into the hospital. "For some time after the general swelling had subsided, leaving the tumour distinct and circum- scribed, no circumstance occurred which gave rise to a suspicion of its being aneurismal. The en- largement was thought to be a common indolent tumour, and was repeatedly blistered, with a view to discuss it. The tumour gradually diminished under this treatment; though a considerable time elapsed before any very striking change took place. "At length a faint and obscure pulsation was perceived; still it was a matter of doubt whether the tumour was aneurismal, or whether the pul- satory motion was communicated to it by the sub- clavian artery, immediately over which it was situ- ated. From its firm unyielding nature upon pres- sure, the latter was considered as the most proba- ble, and the blisters were continued as before. During the whole of this time the patient had worn APPENDIX. 437 his arm in a sling, the motions of it being very limited, and always attended with pain. "The patient remained in this state for several days, without any marked change either in his feelings, or in the appearance of the tumour. "On the 3d of May, at six o'clock in the after- noon, the patient complained that he "felt something give way in the tumour," that his shoulder was very painful, and that he was able to raise it only a few inches from his side. The tumour at this time suddenly increased about one third, and a pulsation was distinctly perceptible. Its most prominent part was below the clavicle; at which place the pulsation was most distinct. The por- tion above the clavicle was also much enlarged; it still, however, had its usual firmness, except in one point near its centre. "May 4th. — The tumour is evidently increased, that portion of it more particularly which is below the clavicle; it is not as firm and resisting as it has been. Pulsation is not so distinct as yesterday, but appears to be more diffused. "He was this day transferred to the surgical side of the house, and became my patient. The cough having become comparatively slight, the tu- mour appeared to be the most urgent disease, and, in my opinion, to call for prompt attention. The arm is now perfectly useless, and any motion at the shoulder joint gives him severe pain. The patient is naturally of a spare habit, and from the 438 APPENDIX. nature of his disease, and the confinement to which he has been subjected, has become much reduced in strength. "May 5th and 6th. — The tumour is still pro- gressing, and the pain in the shoulder is also more severe. During the three last days his medicines have been discontinued, except that he is allowed to rub the parts about the clavicle with volatile liniment. "On the seventh I directed a consultation of my colleagues to be called, consisting of Drs. Post, Kissam and Stevens. I now stated to them that I wished to perform an operation which would enable me to pass a ligature around the subclavian artery, before it passes through the scaleni mus- cles, or the arteria innominata, if the size of the tumour should prevent the Accomplishment of the former. This 1 was permitted to do, provided the patient should assent, after a candid and fair representation was made to him of the probable termination of his disease; and that the operation, though uncertain, gave him some chance, and, as we thought, the only one of his life. "Dr. Post, at my request, communicated with him privately on this subject, and after a full explanation of the nature of the case, my patient requested to have any operation performed which promised him a chance for his life, saying* that in his present case he was truly wretched. APPENDIX. 439 "May 8th, 9th, and 10th. — The tumour is ac- knowledged by all to be increasing, and it is thought proper not to defer the operation any longer. I therefore requested that preparation be made for performing it to-morrow. "It is difficult to give an idea of the size of a tumour so irregular in its form, and so peculiarly situated. A thread passed over it, from the lower part of that portion of it which is below the clavicle, extending upward obliquely across the clavicle toward the back of the neck, will mea- sure five and a quarter inches. — Another crossing this at right right angles one inch above the cla- vicle, will measure four inches; two and a half inches of the thread are on the sternal side of the former, and one and a half on the acromial. It rises fully an inch above the clavicle, which, added to the depression below the clavicle on the opposite shoulder, will make the size of the swelling above the natural surface about two inches. "May llth. — One hour before the time as- signed for the operation, the patient appeared perfectly composed, and apparently pleased with the idea that the operation afforded him a pros- pect of some relief. He was directed to take of tinct. opii. seventy drops. "No difference can be perceived in the pulsa- tion of the arteries in the two extremities, his 440 APPENDIX. pulses are uniform and regular, each beating sixty- nine in a minute. He was placed upon a table of the ordinary height, in a recumbent posture, a 'little inclining to the left side, so that the light fell obliquely upon the upper part of the thorax and neck. Seating myself on a bench of a convenient height, I commence my incision upon the tumour, just above the clavicle, and carried it close to this bone and the upper end of the sternum; and ter- minated it immediately over the trachea; making it in extent about three inches. Another incision about the same length, extended from the termina- tion of the first along the inner edge of the sterno- cltido-mastoid muscle. The integuments were then dissected from the platysma myoides, beginning at the lower angle of the incisions, and turned over upon the tumour and side of the neck. "Cutting through the platysma myoides, I cau- tiously divided the sternal part of the mastoid- muscle, in the direction of the first incision, and as much of the clavicular portion as the size of the swelling would permit, and reflected it over upon the tumour. The internal jugular vein was encroached upon by the swelling, which made this part of the operation of the utmost delicacy, from the morbid adhesion of that part of the cla- vicular portion of the muscle to it, which was detached. I separated this portion of the muscle to as great an extent, however; as the case would APPENDIX. 441 possibly allow, to make room for the subsequent steps of the operation; only a part of the vein was exposed. The sterno-hyoid muscle was next divided, and then the sterno- thyroid, and turned upon the opposite side of the wound over the tra- chea. This exposed the sheath containing the carotid artery, par vagum, and internal jugular vein. A little above the sternum, I exposed the carotid artery, and separated the par vagum from it; then drawing the nerve and vein to the out- side, and the artery towards the trachea, I readily laid bare the subclavian about half an inch from its origin. In doing this, the handle of a scalpel was principally used, nothing more being re- quired but to separate the cellular membrane, as it covers the artery, I judged it would be very imprudent to introduce a common scalpel into so narrow and deep a wound, especially as it would be placed between two such important vessels or parts, as the carotid and par vagum, and where the least motion of the patient might cause a wound of one or the other of them. The proper instrument, in my opinion, for this part of the operation, is a knife, the size of a small scalpel, with a rounded point, and cutting only at the ex- tremity; this was used, and found to be very con- venient for this stage of the operation. It can be introduced into a deep and narrow wound, among important parts, without the hazard of dividing any but such as are intended to be cut. 56 442 APPENDIX^ "On arriving at the subclavian artery, it ap- peared to be considerably larger than common^ and of an unhealthy colour; and when I exposed it to the extent of about a half an inch from its origin, which was all that the tumour would per- mit, to ascertain this circumstance more satisfac- torily, my friends concurred with me in opinion, that it would be highly injudicious to pass a liga- ture around it. The close contiguity of the tu- mour would of itself have been a sufficient objec- tion to the application of the ligature in this situ- ation, independent of the apparently altered state of the artery. "While separating the cellular substance from the lower surface of the artery, with the smooth handle of an ivory scalpel, a branch of an artery was lacerated, which yielded for a few minutes a very smart haemorrhage, so as to fill the wound perhaps six or eight times. It was about half an inch distant from the innominata, and from the stream emitted, was about the size of a crow- quill. It stopped with a little pressure. I can scarcely believe this to have been the internal mammary, from the haemorrhage ceasing sa quickly; though, from its situation, it would ap- pear so; and if from some irregularity it were not the superior intercostal, it must have proceeded from an anomalous branch. "With this appearance of disease in the subcla- vian, artery, it only remained for me either to APPENDIX. 443 •pass the ligature around the arteria innominata, or abandon my patient. Although I very well 'knew, that this artery had never heen taken up for any condition of aneurisms, or ever performed as a surgical operation, yet with the approbation of my friends, and reposing great confidence in the resources of the system, when aided by the noblest efforts of scientific surgery, I resolved upon the operation. "The bifurcation of the innominata being now in view, it only remained to prosecute the dis- section a little lower behind the sternum. This was done mostly with the round edged knife, taking care to keep directly over .and along the upper surface of the artery. After fairly denud- ing the artery upon its upper surface, I very cau- tiously, with the handle of a scalpel, separated the cellular substance from the sides of it, so as to avoid wounding the pleura. A round silken lig- ature was now readily passed around it, and the artery was tied about half an inch below the bi- furcation. The recurrent and phrenic nerves were not disturbed in this part of the operation. "In no instance did I ever view the counte- nance of man with more fluctuations of hope and fear, than in drawing the ligature upon this arte- ry. To intercept suddenly one fourth of the quantity of blood, so near to the heart, without producing some unpleasant effect, no surgeon, a ^priori, would have believed possible. I there- 444 APPENDIX. fore drew the ligature gradually, and with my eyes fixed upon his face, I was determined to re- move it instantly if any alarming symptoms had appeared. But, instead of this, when he show- ed no change of feature or agitation of body, my gratification was of the highest kind. "Dr. Post now asked him if he felt any unplea- sant sensation about his head, breast or arm, or felt any way different. from common, to which he replied, that he did not. "Immediately after the ligature was drawn tight, the tumour was reduced in size about one third, and the course of the clavicle could be distinctly felt. "The parts were now brought into coaptation, and the integuments drawn together by three interrupted sutures and straps of adhesive plais- ter; a little lint and additional straps completed the dressing. Three small arteries were tied in the course of the operation: the first was under the sternum, and divided with the sternal part of the mastoid muscle, and from its course may have been a branch of the internal mammary re- flected upwards; the second, in raising the inner edge of the mastoid muscle, about the upper an- gle of the longitudinal incision, and must have been the most descending branch of the superior thyroid; and the third, was a branch of the in- ferior thyroid, and cut while raising the sterno thyroid muscle. The patient lost perhaps from APPENDIX. 445 two to four ounces of blood, most of which came from the ruptured branch of the subclavian. The operation occupied about one hour. "Ten minutes after the operation the pulse is regular, and not the least variation can be per- ceived; it beats sixty- nine strokes in a minute; the patient says he is perfectly comfortable, and has no new or unnatural sensation, except a little stiffness of the muscles of the neck, which he thinks is owing to the position in which his head was placed during the operation; the tempera- ture of the right arm is a little cooler than the left; his breathing has not been the least affect- ed by the operation^ but is perfectly free and natural. "Two o'clock, p. m. — Patient expresses a desire to eat, and is directed a little thin soup and bread; the temperature of both arms is very nearly the same; breathing perfectly natural; pulse as before. "Three o'clock, p. m. — There is still a trifling difference in the temperature of the two arms; or- dered the right to be wrapped in cotton wadding; not the least unpleasant symptom has as yet made its appearance. "Six o'clock, p. m. — Complains of a little pain in his head, not more on one side, however, than the other; describes it as a common head-ache: the pain of the shoulder and arm much less than be- fore the operation: no difference can now be per- 446 APPENDIX. ceived in the temperature of the two arms; pulse a little accelerated, and perhaps a little full. "Nine, p. m. — Patient complains of head-ache; skin is rather hotter than natural, pulse strong and full, and beats seventy five in a minute; the carotid on the left side of the neck is observed to be much dilated and in strong action; tongue moist and clean. "Half past nine, p. m. — Symptoms continuing the same, directed him to be bled from the left arm to sixteen ounces. After bleeding the pulse fell se- ven beats, and was less full. Complains of some thirst; let him drink common tea. "Twelve, p. m. — Patient has slept a? little; is free from pain; pulse full and less frequent, beats sixty; skin moist and of a natural temperature." From the daily reports given of the case, it ap- pears that no disagreeable symptom occurred until the twenty-third day after the operation. Indeed, the patient felt so well on the twentieth day, that he was enabled to walk down two pair of stairs and several times across the yard. The report of the twenty-third day is as follows: "Twenty-third day. — A few minutes before the hour of visiting to-day, a message was brought that the patient was bleeding from the wound. The dressings were immediately torn off, and dry lint crowded into the wound, and slight pressure applied for a few minutes, when the haemorrhage ceased. The patient lost at this time, perhaps, about APPENDIX. 447 twenty-four ounces of blood, and was very much prostrated. Pulsation ceased in the radial artery of the left arm, and the countenance, gasping, and convulsive throes of the patient, threatened im- mediate dissolution; all present apprehended the instant death of the patient. The first impres- sion was, that the trunk of the arteria innominata had given way. The conjecture afterwards was, that the subclavian artery, from the diseased state of it, had not united by adhesion, arid that the fluid blood from the tumour had regurgitated through its ulcerated coats. This appeared to be the most probable, both from the suddenness with which the blood ceased flowing, and the cause the patient assigned for the haemorrhage. He says, that he felt weary of lying on his left side and back; that he had just turned on the right, which he had not done before since the operation, agree- ably to my request. At the instant of turning over, something arrested his attention, which caused him to turn his head to the opposite side suddenly, and he felt the gush of blood from the wound. "He was directed some wine and water fre- quently, which soon revived the circulation. The wound was dressed with dry lint and a compress. Pulse as frequent as natural, but very small and soft: he appears very languid, and complains of a numbness and painful sensation in his hands; says also that his back aches. During the last 448 APPENDIX. twenty-four hours he has taken a pint and a halt" of Madeira wine: lie also took occasionally some egg and wine, which was immediately rejected from the stomach. "Nine, p. m. — Patient has lost his appetite, and appears considerably depressed; circulation very languid in the right arm; temperature of it is a little less than the left: directed a hot brick to be wrapped in flannel, and placed close to the arm. For a profuse perspiration which he has been in for the last three hours, he was ordered to be bathed with cold rum. "Twenty -fourth day, six, a.m. — Slept the great- er part of the night, and feels comfortable; is still languid, and has no disposition to eat any thing; says he feels sick, and once last evening vomited after drinking some wine and water. "Wound looks exceedingly pale, and the dis- charge is thin and foetid, for which the carbon and yest dressings were applied. He has vomited se- veral times to-day, and has some considerable difficulty in swallowing and complains of a sore- ness in the wound upon pressure. "Nine, p. m. — Dressings removed; wound very pale; right arm of the natural temperature; feels occasionally a little numbness in the hand; has taken very little nourishment during the day; pulse natural as to frequency? but small and feeble; a few minutes after dressing the wound, information was brought that hsemorrnage had APPENDIX. 449 ensued and, before it could be commanded, he pro- bably lost four ounces of blood. For his restless- ness and pain in the bones he was ordered two grains of opium. "Twenty-fifth day. — Has rested well during the night, and is perhaps a little better this morning. The repeated haemorrhages have debilitated him exceedingly, and from the irritable state of the stomach he can take only a very little nourishment. In the morning he was directed the effervescing draught, to be repeated every two hours; this al- layed the irritability of his stomach, and enabled him to take a little breakfast. "His countenance has altered since the first bleeding surprisingly, his eyes are now heavy, and for the most part fixed; his cheeks are sunken, and an universal palor has spread itself over his countenance; and from every appearance, a short time will terminate his existence. He has not vo- mitted since early in the morning; is advised to take a little soup, and to drink freely of wine and water; dressings were renewed at three o'clock, p. m. shortly after which the patient again bled, but not to exceed, however, an ounce. He was dressed with dry lint as usual. "Eleven, p. m. — Patient has not as yet had any sound sleep, is restless and apparently distressed, although he says he feels no pain; breathing is attended with some difficulty; his hands and legs are continually in motion; pulse small and feeble. 57 450 APPENDIX. sixth day, six, a. m. — Patient has not rested well; is occasionally falling into little slumbers, but is awaked by the least motion: Pulse small and feeble; respiration somewhat la- boured; appears to be sinking: seems disinclined to take any thing; legs and arms constantly in motion, "Eleven, a. m. — More feeble than before; has been forced to take a little chocolate; is evidently sinking; wound was dressed, but there was no secretion of pus in it; countenance of the patient foretells his approaching dissolution. "Six, p. m.-— Is extremely low; respiration very laborious; is not able to articulate: for the last three hours there has not been such continued throwing of the legs and arms about the bed; he lays in a state of insensibility; temperature of the two arms the same to the last. My pupil, Mr. Abraham I. Duryee, the house sur- geon, (to whom I am indebted for the correct re- ports, and the most unwearied attention to this case, and whose ingenious application of means for the recovery of many of my patients, will long he held by them in grateful remembrance,) having for a few minutes left the patient, he was sent for immediately, as there was another bleeding from the wound, by which he lost probably eight ounces of blood: during the whole time he did not mani- fest the least appearance of consciousness, nor 'was the least motion perceptible, except that APPENDIX. 451 necessary for respiration and circulation: the hse- mon hage was stopped with lint after removing the former dressings; respiration is now performed with the utmost difficulty, and the patient appears as if every respiration would be the last: he expired at half past six in the afternoon: the temperature of the right arm after death, appeared by the touch to be the same as the left. It was as natural and uniform as other parts of the body. Examination of the Body. "About eighteen hours after death, I opened his body; there was considerable emaciation, and the surface of the wound was of a dark brown colour, and foetid; the wound was perhaps about one third of its original size; it had been enlarged by the pressure of lint into it, and other means to arrest from time to time the haemorrhage: the ulcer between his shoulders was ill conditioned. "For the purpose of examining the condition of the aorta, where the arteria innominata is given off, as also the origin of the latter vessel, as well as the state of the pleura at the part about which the ligature had been applied around the artery, the chest was opened in the following manner: after removing the integuments and muscles from the fore part of the chest, the sternum was care- fully sawed through about an inch from its upper extremity, and raised by sawing through the ribs below the junction of the cartilages; this removed 452 APPENDIX. so much of the front part of the chest as to facili- tate and expose fully to view the subsequent steps of the dissection; by thus leaving the clavicles at- tached, every part connected with the ulcer and great vessels could be seen and examined in situ. "The arch of the aorta and origin of the inno- minata being fairly exposed, not a vestige of in- flammation or its consequences could be disco- vered, either upon them, the lungs, or the pleura^ at any part. An incision was next made, longi- tudinally into the aorta opposite the origin of the innominata, and upon introducing a probe cau- tiously up the latter vessel, it was seen to pass into the cavity of the ulcer; the innominata was then laid open with a pair of scissors into the ulcer; the internal coat of this vessel was smooth and natural about its origin, but for half an inch below where the ligature had cut through the artery, it showed appearances of inflammation, and there was a coagulum adhering with conside- rable firmness to one of its sides; showing that nature had made an effort to plug up the extre- mity of so large a vessel, after the adhesion, which no doubt had been effected by the ligature, was swept away by the destructive process of ulceration. The upper extremity of this vessel was considerably diminished in its diameter by the thickened state of its coats, occasioned by the surrouuding inflammation. The innominata about half an inch from the aorta, and a little to the left APPENDIX. 453 side, gave off an anomalous artery large enough to admit a small size crow quill. "The ulcer at the bottom was more, than twice the size of the wound in the neck; it extended la- terally towards the trachea; and under the clavi- cle, towards the tumour. The tripod of great vessels, consisting of the innominata, subclavian, and carotid arteries, to the extent of nearly an inch, was dissolved and carried a*vay by the ul- ceration. The extremities of the two latter ves- sels were found also to open into the cavity of the ulcer. The upper surface of the pleura was very much thickened by the deposit of newly organized matter, for the safety and protection of the cavity of the thorax. Indeed, instead of having increased the danger of penetrating this membrane, the adhesive inflammation which pre- ceded the ulcerative, seemed, by the consolidation of cellular membrane, and the addition of new substance, to have more securely and effectually shielded it from danger. "The internal surface of the carotid artery was lined with a coagulum of blood, more than twice the thickness of its coats, and extending above the division into internal and external, so as al- most to give them a solid appearance, insomuch that a probe could barely be introduced. The subclavian artery, internally and externally to the disease, was pervious. The brachial and other arteries of the right arm were of their com- 454 APPENDIX. tnon diameter, and in every respect natural. The external thoracic or mammary arteries, as they went off from the subclavian, were larger than natural: the right internal mammary was pervious, and of the usual appearance. Upon opening into the tumour, which now gave (from its small size,) no deformity to the shoulder, the cla- vicle was involved in it, and found carious, and entirely disunited about the middle. A number of lymphatic glands under the clavicles, and par- ticularly the left, were considerably enlarged, and when cut into, very soft, and evidently in a state of scrophulous suppuration. No other morbid ap- pearances were observed. " Although this case terminated unfortunately still its result, in so far as it concerns the operation of tying the arteria innominata, must be considered as conclusive evidence of its practicability. The operation was in fact so far as it was immediate- ly concerned, successful; no alarming symptoms followed the tightening of the ligature, and the obstruction of the circulation through the channel of the vessel; the patient continued to improve in his health until the twenty-third day, when a hse- morrhage took place from an ulceration of the coats of the artery, an ulceration which fre- quently has occurred in instances where even the smaller arteries have been tied. If I might be per- mitted to offer a criticism on the performance of an operation, so novel in its character and so bold APPENDIX. 455 in its design, I should feel disposed to object to the previous exposure of the subclavian artery. Indeed I am inclined to think, that it was from the destruction of the vasa vasorum of so large a portion of the artery, that the fatal haemorrhage is to be attributed, and I can hardly doubt from the facts of the case that had the arteria innomi- nata been at once exposed and tied, without any reference to the subclavian artery, that the event would have been different. This opinion I deliv- er, not with the view of detracting from the credit due to the intrepid operator, but, only from a de- sire to support and corroborate the sentiments of Mr. Burns. I cannot dismiss this case without adverting to the very unfair and unhandsome criticisms which have been made on it, in some of the periodical journals of this country. It is, however, the fate of all who become the improvers of science, to be assailed by the malice and envy of their less distinguished cotemporaries. Dr. Mott has the satisfaction of knowing that their attempts to in- jure his reputation have proved abortive, for the verdict of his merit is now attested by the most eminent and honorable members of his profession. 456 APPENDIX. NOTE C. — p. 195. Mr. Burns is not singular in giving an exagger- ated account of the dangers and difficulties attend- ant on the operation of tying the carotid artery. His never having had an opportunity of passing a ligature around that vessel on the living subject, and his views in relation to it having been wholly derived from speculation, and the descriptions of the operations published by those who had per- formed them, offer for him a sufficient apology. As I am persuaded that nothing tends more to retard the advancement of surgery, than the exaggeration of difficulties, which, if they do exist, are easily surmounted, I consider it my duty, so far as my own experience will enable me; to assist in their removal. One of the difficulties which has been particu- larly insisted upon, by most of those who have tied the carotid artery, is the alternate swell and collapse of the internal jugular vein. "During inspiration it falls collapse, but during expira- tion it swells out full and tense, covering al- most completely the artery. The transitions from emptiness to fullness are so rapid, that sufficient time is not allowed to detach it from the carotid." So powerful an impression did this and similar overcharged descriptions of the state of the vein, in relation to the artery. APPENDIX. 457 make on my mind, that I confess, when I was first called on to tie the carotid, I proceeded to the performance of the operation with painful feel- ings of uncertainty and doubt, such as I had never experienced on any previous occasion. I was perfectly acquainted with the situation of the vessel; I had in hundreds of instances, with a single sweep of the scalpel, exposed it to view on the dead body, and its most minute connexions were familiar to my mind. Still this knowledge was not sufficient to inspire that confidence, which alone can give firmness and decision to the ope- rator. The jugular vein swelling out so as to cover the artery must be in an unnatural situ- ation— a situation where it might be injured immediately after the division of the platys- ma myoides, and fascia. Operating, therefore, under the influence of this uncertainty as to the state of the vein, I proceeded with a cau- tion, I may say a timidity, which prevented me from executing it with that rapidity and dex- terity, for which my practical knowledge of anat- omy, should have fitted me. Instead of dividing freely and with a large incision the skin, platysma myoides, and fascia, the wound of the skin was small, and that through the facia still smaller, so that when the artery was exposed it lay deep seat- ed in a narrow pit-like wound, where it was im- possible to detach it from its connexions. Indeed; finding it difficult to do this, and satisfied that 58 458 APPENDIX. there was no swelling of the vein which could at all endanger its safety, I made a free dilation of the wound, and then with facility, secured the artery. This operation occupied nearly eight minutes in its performance. In the next case where I had occasion to perform the same opera- tion, from erroneous impressions as to the state of the vein having been corrected, I accomplished it in less than three minutes. I have been particular in this statement, and feeling persuaded that a confession of our difficul- ties and doubts will advance, more than a history of our successes, the science which we cultivate, I have not hesitated to speak openly of my own fears and misgivings. Mr. Burns seems to consider, that the termina- tion of the thoracic duct will be in danger, if "the operation be performed loic in the neck on the left side." This fear, I conceive, is altogether ground- less. The duct, it is true, in its passage from the chest, does lie behind the left carotid; but, before that vessel has reached the lowest situation in the neck, where it would be possible to secure it with a ligature, the duct has separated from it, and passed outwards to reach the point of its ter- mination. As to injury of the nervous superficial cordis, this can only happen where the operator is so awkward as to destroy the posterior wall of the cervical sheath. Should it, however, happen, I confess I should not apprehend those alarming APPENDIX. 459 consequences which some have anticipated. It will, by minute dissection, be discovered, that the nervous superficialis cordis is joined by numerous small nerves sent off from the lower cervical gan- glion, so that even allowing that the nerve was destroyed above this point, there can be little doubt but that through the medium of these branches derived from the parent trunk, its func- tions would still continue to be performed. NOTE D. — p. 286. The method recommended by Mr. Cheselden, for removing enlarged tonsils by ligature, is one of great difficulty in its performance, and were there no other way in which it could be em- ployed, I should, without hesitation, subscribe to the justness of Mr. Burns' observations, and give a preference to the knife in every instance. The application of a wire around the base of an enlarged tonsil, is, however, an operation which may be executed with the greatest facility, and should obtain, in my opinion, a decided preference over every other plan of operating. Dr. Physick, who is justly distinguished for his eminence in his profession, has published in the first number of the 460 APPENDIX. Medical and Physical Journal of Philadelphia, an account of the method of using the wire and double canula in the removal of schirrous tonsils, which, as it explains the different steps of the operation, I shall take the liberty of transcribing. "The double canula I employ is about four inches long, with short arms soldered on its sides, near one end of the instrument, at right angles to it. Through the canula I next pass a double iron wire, and fasten one of its extremities round one of the arms of the instrument, leaving the other free and projecting five or six inches. This enables me to increase or diminish the size of the noose, formed by the doubling of the wire, at pleasure. The selection of a proper piece of wire I consider of much importance. It should be tough and flexible, formed of soft pure iron, hav- ing firmness enough to allow of its being pushed backwards and forwards in the canula, without bending too easily, so that the noose may be en- larged or diminished. It should also have suffi- cient firmness to allow of a little lateral pressure, otherwise the noose cannot be pressed down so certainly on the base of the tumour. The wire I use is about one twenty -fourth of an inch in dia- meter, or perhaps rather less. "It is moreover necessary to be provided with a flat pair of pliers, to take hold of and move the wire conveniently. These instruments being pre- pared, the noose formed by the doubling of the APPENDIX. 461 wire projecting beyond the end of the instrument, is to be made large enough to pass easily over the enlarged tonsil, and should be bent a little to one side, in order that it may more easily be pushed down upon the base of the tumour. "The patient is to be seated opposite a window, and his tongue must be held down by an assistant, with the handle of a large spoon, or with a spa- tula. The surgeon is then to slip the noose over the tonsil, and down to its base, taking care not to include the uvula, which, when the swelling is large, is apt to be in the way. The wire is then to be drawn sufficiently to fix it loosely on the part, and the surgeon is to satisfy himself, by an. attentive inspection, that it is properly applied. This being accomplished, the wire is to be taken hold of with the pliers, and drawn through one side of the canula, so as to secure it at once on the base of the tonsil as firmly as possible, and then to fasten it on the arm of the instrument, and thereby prevent all entrance of fresh blood into the tumour. This method of stopping the circu- lation of blood in the swelling, necessarily occa- sions severe pain at the moment; but the severity of it soon ceases. "On examining the tonsil after a few minutes, its colour will be observed to be changed to a deep purple, or almost black, and its surface smooth and polished, owing to the exterior mem- brane being stretched. 462 APPENDIX. "It has hitherto been my custom to allow the instrument to remain thus applied for twenty four hours, with the view of destroying completely the life of the enlarged gland. I am, however, of opinion, that a much shorter time would be suffi- cient, as eight or twelve hours, which I propose soon to ascertain. After having destroyed the life of the swelling by the above means, the next step of the operation is the removal of the instru- ment, which is very easily accomplished, in the following manner. Take a firm hold of the end of the canula projecting from the mouth, then dis- engage the wire on one side from the arm of the instrument; straighten it, and with the pliers push a small portion of it back through the canula, and repeat this until the noose is so much enlarged as to slip off the tonsil. "The operation is now completed; the tumour appears shrivelled and of a dull white colour; the patient suffers no pain; the inflammation is mo- derate, and, after a few days, the dead parts are separated and thrown off, either entire or in frag- ments, which are sometimes spit out, sometimes swallowed. Until the separation is completed the breath is somewhat offensive. I have never had any trouble with the small ulcer remaining after the separation of the tumour. It has healed so rapidly as generally to escape notice.'7* * Philadelphia Medical and Physical Jouniul, p. 18, et seq. APPENDIX. 463 Another plan for applying the ligature has been recommended lately by Mr. Chevalier;* but the one just described, whether viewed in relation to its simplicity or certainty, is decidedly superior to it. NOTE E.— p. 352. Mr. Burns observes, in speaking of the cure of aneurism by anastomosis, that "any attempt to cure this disease by ligature of the arteries which support it, is entirely out of the question. Mr. John Bell strenuously argues the necessity of cut- ting out all the diseased parts, and in equally de- cided terms reprobates any interference when we judge this to be impracticable." From these ob- servations it would appear, that at the time when Mr. Burns' work was published, anastomosing aneurisms were considered as incurable, unless when placed in situations where they could be completely extirpated, or if this was impossible, where we had the "power to line very firm pres- sure" on all the morbid parts which remained. As there are many cases of this disease in which it is neither practicable to extirpate the whole of the morbid parts, nor to apply "firm pres- sure" to those which remain; if the doctrine delivered by Mr. Bums and Mr. Bell, was cor- * Medico Cliimvgieal Transactions, vol. iii. p. SO. 464 APPENDIX. rect, patients, so situated, must be left to their fate. Fortunately* however, the progress of science has shown the fallacy of those opin- ions, and has demonstrated, that by tying the great artery, passing to the morbid parts, we can cure an anastomosing aneurism nearly with the same certainty as a common aneurism. To Mr. Travers, a gentleman whose name is familiar to every member of the profession, we are indebt- ed for this improvement in the treating of aneu- rism by anastomosis. In a case where a tumour of this kind was situated in the orbit, he tied with complete success the common carotid ar- tery of the same side.* The same operation has since been performed by Mr. Dalrymple,f for the cure of an anastomosing aneurism, which in its situation and character exactly resembled the one described by Mr. Travers, and the liga- ture of the carotid was attended with the same success. In a case of the same disease, situated in the branches of the internal maxillary artery, which came under my own observation, I had an op- portunity of testing and proving the justness of the views taught by Mr. Travers. As this case is one of great interest I shall transcribe it. "Mr. C. C. aged eighteen years, consulted me the sixth of April, 1821, on account of a great "See Medico Chirugical Transactions, vol. ii. t Ibid. vol. vi. APPENDIX. 465 tumefaction of the left side of the face. As the history of the origin and progress of the dis- ease is very ably detailed in two letters, which I have received from my patient after his return home, I shall introduce them, as containing a more distinct account of the complaint than any I could furnish. "George Town, May 30th, 1821. "DEAR Sm, " Agreeably to my promise, I now send you a detailed account of the disease in my face, from its commencement down to the period of the late operation. My own recollections have been as- sisted by my nurse, who has been in the family during the whole course of the disease, and whose situation, whilst I remained at home, afforded her a better opportunity than others of observing the circumstances attending it. "To the best of my recollection, the disease first appeared in the cheek early in the summer of 1813, I being then ten years of age; about the end of the season, it began to make its appearance about the temple, when it first excited the alarm of my friends. After this time, I paid several visits to Philadelphia, for the purpose of con- sulting the professional gentlemen of that city, and I recollect these were for some time in doubt before they determined the disease to be a poly- pus. At one time they decided that it was not, 59 466 APPENDIX. and perhaps their final determination was in- fluenced by this circumstance, I told them, and with much confidence too, that I believed the dis- ease to have originated in the nostril. As the disease at first gave me no uneasiness, and occu- pied little of my thoughts, I might readily have beerr*mistaken in this circumstance, and my own subsequent reflection, as well as the opinion of my nurse, induces me to believe that I did err. "The period of the first operation I do not re- member, but its duration was about three-fourths of an hour; and, though I was able to walk about the same evening, I considered it more disagree- able than the second. The next operation was in the spring of 1815, and was much more extensive; but as I believe you are acquainted with its na- ture, I will not enter into a detail of it.* I would, however, mention, that after a considerable time, I fainted from loss of blood, which forced them to stop the operation. The doctors hoped that they had rid me of the disease, and for some time there * Both of the operations to which Mr. C. refers, were performed under the erroneous impression that the disease was a polypus. The first was executed with a ligature, and forceps introduced through the nostril. The surgeon at this time entertaining the belief that the disease was confined to the nostril. The cheek, however, beginning to swell shortly afterwards, it was supposed that the polypus h^d originated from the antrum, and au operation was performed with a view of extirpating it. The operation consisted in removing with the trephine, the anterior wall of the antrum, and thus having exposed the tumour, an attempt was made to cut it out. The bleeding was, however, such as soon to put a stop to the operation. '1 'he quantity of blood lost during it was very great, and the patient was so enfeebled as to be oblisred to remain in bed for some weeks afterwards. APPENDIX. 467 was a diminution of the cheek and an absence of the disease in the nose. These favourable ap- pearances were of short duration; the disease reappeared, and gradually increased, without the application of any remedy, until the commence- ment of the last falL I was induced a short time previously, to consult a person who had the reputation of being successful, in treating several novel cases; and as his remedies appeared sim- ple, and he appeared confident, I determined to follow his advice. Having been foolish enough to submit to his directions, the hope of relief in- duced me to continue that submission when his treatment became more severe; and thus I sub- jected myself to much trouble, pain, and expense, without reaping any good fruits. "I do not remember any violent bleedings pre- viously to the first operation; and though I re- collect having experienced them between this and the second, yet, from the lapse of time, I have a very indistinct idea of the circumstances attending. It was after the second operation that they were most frequent and most violent. In the summer of 1817, they became so frequent as to alarm my friends. If I overheated myself, or suffered a slight blow on the nose, or was jarred, my nose would bleed violently; sometimes it would bleed spontaneously. In two days (in three bleedings) it bled so very copiously, from my having blown my nose, that I was confined, from ite 4()8 APPENDIX. effects, for some days after. The blood I would lose at each of these bleedings, would frequently measure a pint, and sometimes would exceed this quantity: it would stream out most violently, and all exertions to stop it appeared to have no good effect. In the summer of 1818, I was at college, and the bleedings were then more violent than ever. Having no person with whom I could con- sult, I felt much alarm at my situation, and it must have been Very dangerous. Very frequent- ly, whilst I would be sitting quietly in my room, (I was careful to use as little motion as possible,) the blood would gush forth in torrents, I having no previous notice that it was coming. Especial- ly during the warmest part of the season, I was obliged to restrict myself very much in exercise; a slight exertion, a very short walk in the heat of the day, was generally followed by a violent bleeding. At one time, I was obliged to debar my- self entirely of exercise; a walk of twenty yards in the sun has produced a violent bleeding. Sometimes I had warning of a violent bleeding by a slight spontaneous one, and in this case, I gen- erally took a dose of salts, which had the effect of retarding it. Sometimes, though not so violent- ly, the blood would descend through the orifice to the mouth, as if unable to obtain a vent in the usual way. I have remarked this circumstance in the bleedings, that they were most violent and frequent in the warmest weather, in the winter, I APPENDIX. 469 seldom bled beyond what many persons in health are subject to. Since 1818, I do not remember any violent bleedings until the last winter. If there have been any, they were very rare. Dur- ing the last winter I had two or three that were pretty copious, but they were all caused by fol- lowing the prescriptions of the German doctor. "Having delayed writing for some time, I now address you in such haste as, perhaps, to omit some points on which you wish information. Should this be the case, I will gladly give you any further information in my power. With much respect, I remain, dear sir, Your most obedient servant, C. C. "George Town, June 4, 1821. "DEAit SIR, "In the haste of my former communication, I omitted some particulars which it may be agreea- ble to you to hear. The left cheek, at its usual temperature, was always warmer than the other, and was much more easily affected by exposure. So delicate was it, that when obliged to expose myself to the summer's sun, if the rays fell in that direction, I was obliged to cover the affected cheek; and I have frequently suffered inconvenience from lying on it. 470 APPENDIX. "There was also in this cheek a very peculiar feeling, which extended itself over the left half of the upper jaw. I am at a loss to describe this peculiarity; but it has now entirely disappeared, and, to the feeling, the parts are as well as those corresponding on the opposite side of the face. "The fine air of our town has worked a miracle in my favour; my strength is returning very fast, and both neck and cheek are doing very well. With the highest respect, I am, your obedient servant, C. C. "The tumour of the cheek was at the time I saw Mr. C. very large its central point occupied the situation of the antrum higmorianum; but the walls of this cavity having been destroyed, it passed from thence in every direction upwards, into the orbit, protruding the eye, nasally it pas- sed into the nostril of the left side, which it com- pletely filled, and pressing on the septum-narium, it gave a general character of distortion to the nose. This tumour was, however, most prominent in a direction outwards. The second operation hav- ing removed the anterior wall of the antrum in this direction, there was nothing opposed to its passage, except the small facial muscles; and their forces, although they might have a tenden- cy to prevent its direct growth outwards, could have little effect in restraining it from growing in APPENDIX. 471 a direction outwards and backwards. The sym- metry of the left side of the countenance was completely destroyed. The tumour, which in size was nearly equal to the head of a new born child, extended from the left margin of the nose, to the line which is marked on the neck by the tracheal margin of the sterno-cleido-mastoideus muscle. When the disease was examined as it appeared in the nostril, the first impression produced, was that it was a polypus of the antrum. This im- pression could not, however, after an attentive examination be entertained; there is in all po- lypi, an expression, if I may use the term, alto- gether peculiar; their vitality is of a low grade, and their imperfect organization is so marked as to enable us to distinguish them from all other af- fections. Had it, however been otherwise, and had we, from the examination of the tumour as it appeared in the nostril, been led to adopt an erro- neous opinion as to its true nature, this must have been corrected by pressing the tumour betwixt the fingers, one having been introduced into the mouth, and another placed on its external sur- face; as thus examined, the distinguishing char- acter of anastomosing aneurism was at once de- tected, that peculiar pulsatory throbbing which characterizes them from all other affections, being distinctly felt. The opinion I delivered to my very intelligent friend, Mr. Hayden, was, that the disease was an anastomosing aneurism, situated in 47£ APPENDIX. the terminating branches of the internal maxillary artery; that the disease having begun behind the tuber maxillare had first entered the nostril, in- ducing the belief that polypus had formed there; that from thence it had, by destroying the poste- rior wall of the antrum higmorianum passed into and occupied that cavity; that enlarging, it had protruded and rendered prominent the external wall of the antrum, which was by the surgeon re- moved, with the view of extirpating it, under the impression that the polypus had entered the cave of the cheek. "Mr. Hayden, on receiving this statement, as- sured me that from the examination which he had made when consulted by Mr. C. at Washington City, he had believed that the disease was a com- mon aneurism; but as this opinion was opposed to the one given by the eminent surgeons who had performed the two operations upon it, he had begged Mr. C. to visit Baltimore and consult me; and anxious that his patient might hear my opin- ion unbiassed by any observations of his, he had determined not to state his suspicions until I had delivered to Mr. C. my opinion. "Had I from an examination found any difficulty in deciding on the nature of the disease, recalling to recollection the facts of its history, I could not have hesitated. Its progress, the suspicious tern* perature of the tumour, but above all, its frequent APPENDIX. 473 and tremendous haemorrhage, were symptoms which could not have been found attendant on any other affection. As to the proper plan of treat- ment, there could he with hold and intelligent sur- geons hut one opinion. Mr. C. held his life on a most uncertain tenure, every hour he was in emi- nent jeopardy of losing it, and every evening, as he closed his eyes in sleep, a hleeding occurring during his slumbers, might have placed the cold seed of death upon his eyes, and prevented them from ever again beholding the light of the morn- ing. "To prove that his state was as dangerous a one as we have represented, it is only necessary to state, that about two months before Mr. C. came to Baltimore the blood gushed in such a torrent from his nostril, as to render him insensible before he could reach the bell, and he was only acciden- tally discovered sometime afterwards, in a st#te of syncope, by a member of his family who happened to enter his chamber. The operation of extirpat- ing the tumour of vessels was out of the question. Could we even have flattered ourselves that our patient could have survived the great effusion of blood which must have followed cutting into it; it was impossible to expect that a substance so soft and pliable, would not have passed into some of the sm ill osseous recesses situated in the facial bones, and would there have eluded our search, and formed a root from which the disease would GO 474 APPENDIX. speedily have been reproduced. The only opera- tion by which we could hope to benefit Mr. C. was that of tying the great carotid artery, and thus throwing the circulation of the facial arte- ries of that side into new channels, and by this means taking off its pressure from those branches which were diseased. Reasoning upon general principles, we were entitled to hope this result. And bringing to mind the success which had fol- lowed the ligature of the carotid, in the cases of anastomosing aneurism recorded by Messrs. Tra- vers and Dalrymple, the justness of our hopes were confirmed. There was, however, more to be apprehended in the case of Mr. C. than in the ones alluded to. From its situation, and from its long continuation and great size, very considerable disease in the parts surrounding it was to be ap- prehended. The ligature of the artery would destroy the aneurismal character of the tumour; but its irritation had produced so much thickening and disease in the surrounding parts, that it was not improbable that they, receiving a sufficiency of blood tor their support, might continue to in- crease, and finally, by ulceration and the assump- tion of a specific morbid action, terminate in the death of our patient. As Mr. C. possessed a mind of a very superior order, 1 did not hesitate to make him fully ^cquninted with every particular of his case. I informed him, that in my opinion, an opera- tion ought to be performed, but, at the same time APPENDIX. 476 requested him, on account of the very different view which had been taken of his case by the pro- fessional gentlemen of Philadelphia, to consult, be- fore submitting to it, my distinguished friend and colleague Dr. Davidge. Having seen that gen- tleman and obtained from him an -opinion which coincided in every particular with the one which I had before delivered; Mr. C. with the most manly fortitude, at once consented to the performance of an operation. "The operation was performed in the way it is usually executed. Immediately after its per- formance, the appearance of the tumour, as it presented itself in the nostril, became remarkably changed; just before it seemed distended, even to bursting; but so soon as the direct circulation was removed, its distension was destroyed, and it became shrivelled on its surface. The pulsatory movement, which could, previous to the operation, be easily discovered in the body of the tumour, could not, after it was executed, be detected. As nothing remarkable occurred during the pro- gress of the cure, it is quite unnecessary to give a detailed account of it. It is sufficient, in regard to the treatment, to observe, that with the view of taking from the force of the circulation, and of preventing the spreading of the inflammation from the wound to the neighbouring parts, free deple- tion by means of the lancet and purgatives was adopted. And in respect to the appearance of 476 APPENDIX. the tumour, it is only necessary to state, that there was a daily improvement in the expression of the countenance. The ahsorbents fulfilled their duties with much more energy than could have been expected; the tumefaction entirely disap- peared; the malar bone, and zygoma which were completely buried in the tumour, as it was ab- sorbed became evident, and the whole character of the countenance became altered. "The deformity, in so far as it was produced by the aneurismal tumour, was completely removed before Mr. C's return home; but, as the tumour had produced an enlargement and forcing of the bones of the side of the face outwards, and as their ab- sorption is a slow process, the side of the face where the disease had been seated continued some- what more enlarged than the opposite side. The absorption is however going on steadily, and there is every reason to hope, that by the employment of pressure, the natural symmetry of the counte- nance will be speedily restored."* * It is now two years and a half since the operation was performed on Mr. C. and during the whole of this period, no symptom has manifested itself which could lead to t'ie suspicion that the disease was about to re- turn. On the contrary, the improvement in his appearance lias been re- gularly progressive, and he has enjoyed the most perfect and n:, inter- rupted good health. At present the deformity is so trifling as to be hardly perceptible. APPENDIX. 477 NOTE F.— p. 385. There have been, perhaps, no operations per- formed, which have been so unfortunate in their results, as those executed for the removal of tumours from the antrum maxillare. Buried amongst the bones of the face, before they have increased to such a size as to attract either the attention of the patient or his surgeon, they have, in most cases, passed into numerous recesses, from which it was impossible to remove every diseased part. As these affections are far from being uncommon, I had devoted considerable at- tention to their study, and had, from reasoning on general principles, formed certain conclusions as to the best method of proceeding to their removal, the correctness of which I think has been con- firmed, by the result of some cases where these principles have been adopted. We are well aware, that the vitality, or capa- city for action of a part, is proportioned to its vascularity. We know also, that if we excite a part to the performance of an action beyond its power, that as a necessary consequence, its vital- ity is destroyed, it sloughs, and is thrown off. These principles, which are universally admit- ted, constitute the basis of a theory which has dictated the plan of treatment, I have considered 478 APPENDIX. the most advisable to be pursued in cases of tu- mours in the antrum, and which has, where exe- cuted in the only cases I have known, proved successful. When in Baltimore on a visit, in the month of July, 1820, before my election to the Chair of Surgery in the University of Maryland, I was re- quested by Dr. Baker, to visit a James Under- wood, who was affected with a tumour of the an- trum. The disease had proceeded to a very great extent. The walls of the cavity, from which it had originated, were burst asunder. It passed down through the osseous palate, so as to fill the mouth and to push backwards the velum pendu- lum palati, and outwards so as completely to dis» figure the cheek of that side, forming there a large and unseemly fungus. I particularly stated at this time, to Drs. M'Dowell, Revere, and Hall, that, as the disease manifested so many characters of its being of a specific nature, I did not feel my- self warranted to press the patient to submit to an operation, as no man, I conceived, could en- sure its being successful; at the same time, I ex- plicitly declared, that if he would be willing to submit to one without an assurance of certain success, I was perfectly ready to operate. I heard nothing more of the case until the fol- lowing October, when I was politely invited by Dr. Gillingham to be present at the operation which he proposed to perform on the same patient. APPENDIX. 479 There were in the chamber, where the opera- tion was to be performed a great number of pro- fessional gentlemen, and I there openly and freely expressed my views as to the operation which I thought ought to be performed. To my friend Dr. Davidge, who was standing with Dr. Ja- meson, in one part of the room, I explained particularly my sentiments, and insisted on the propriety of tying the common carotid artery of the side on which the tumour was situated, before any attempt was made to extirpate it. I did not apprehend that during the operation of its remo- val, the patient would be subjected to a danger- ous haemorrhage, and that this was to be guard- ed against, by the ligature of the artery. An- other and in my opinion, a much more impor- tant object, was to be gained by it. The vas- cularity and consequent vitality of the tumour was much inferior to that of the parts with which it was connected, and as they, arid like- wise any portions of the diseased mass, which it might be impossible to remove with the knife, would by the operation be brought into a state of inflammation, and increased action. I hop- ed by diminishing the circulation of blood through them that the morbid parts, whose power of action were previously weak, would in the enfeebled state in which they would be placed by the ligature of the artery, be incapable of supporting the increased action which would be demanded of them, and that 480 APPENDIX. they would mortify and fall off. These sentiments I had stated fully to Drs. McDowell, Revere, and Hall, when I was first consulted on the case, and repeated them at this time to Dr. Davidge in the presence of Dr. Jameson. The operation for which the company had as- sembled having been postponed, I heard nothing more of the case for some days when having learn- ed that Dr. Gillingham declined interfering in it. I made inquiries for the purpose of getting the patient to submit to the operation, I had suggested. Having been informed that Dr. Jameson had taken charge of the case, I, of course, gave up all thoughts of interfering with it. Dr. Jameson operated sometime afterwards, tying the carotid artery and then removing a part of the tumour. Believing it "to be a case of tu- mour of the gums" he did not enter the antrum. This fact I consider important, as it tends to cor- roborate and support the principles I have alrea- dy stated. That it did originate from the cave of the cheek, my learned colleague, Dr. Davidge had demonstrated in the presence of several medical gentlemen, some months before, by cutting through the palate and showing the whole of that cavity impacted and filled with the morbid sub- stance. The operation, therefore, only removed a very small part of the tumour, and the removal of the rest must be attributed to its not possess- ing power after the artery was tied for the fill- APPENDIX. 481 iilment of that action which it was called on to perform. The justness of the principle which I have brought before the observation of the profession, does not, however, rest on the success of ihis single case. My friend, Dr. Davidge, has carried it farther than I had contemplated, and, as it will appear from the following letter, in so far as the tumour was concerned, with the happiest result. "Professor Pattison, "DEAR SIK, "In pursuance of my promise, I transmit to you the -subjoined account of the operation, performed by me, for the fungus of the antrum of the face. "On the third of April, 1823, a negro man, at the house of Mr. Floyd, was put under my pro- fessional charge; he laboured under a fungus of the antrum of the left side of the face; the condi- tion of the body was hectic, and very much ema- ciated; the upper part of the cheek protruded, and was much distorted; the tumour had destroyed a considerable portion of the lower and external re- gion of the superior maxillary bone, and descend- ed into the mouth. The finger, by pressing the fungus a little to one side, could be passed up into the antrum. "The day precedent to the operation, a cathartic was administered. "After having placed the patient in a proper sitting position, and opposite a good li^ht, attend- 482 APPENDIX. ed by several young professional gentlemen, I made an incision of about three inches in length, down to the delicate fascia, along the track of the carotid artery, inclining my knife a little to the trachea, to avoid exposing the internal jugular vein. I then, by a second cut, exposed the ster- no-cleido-mastoideus just where it is somewhat obliquely traversed by the omo-hyoideus, in its course from the upper costa of the scapula, to the os-hyoides, and by a careful dissection in the angle formed by these two muscles, discovered the sheath of the artery, which was immediately laid open directly in front, and the artery made bare. I passed under it, by means of the eye-handled probe, an animal ligature; this upon tightening gave way, and its place was supplied by one of silk,, which was prepared. The artery being secured by single ligature, I dressed the wound after my common method of securing incised wounds. Du- ring the operation, which occupied altogether three or four minutes, there were no difficulties encountered, either from the jugular vein or ner- vus vagus. And when it was over, I could not avoid a kind of criticism in thought, on the ha- zards and difficulties enumerated by Sir Astley Cooper, hazards and difficulties surely created by his fears and manner of approaching the artery. Had this great surgi-on* according to the sugges- tion -if the able Abernethy, kept a little more, in his cut, to the trachea, he would have had no APPENDIX. 483 aecasion to alarm the profession by the fearful decription he had furnished to the world. "Subsequent to the operation, the patient was free of complaint, except the unimportant sensa- tion resulting from incision, until the fifth or sixth day, when he complained of pain and soreness about the parotid. To this pain and soreness succeeded inflammation, swelling, and finally, co- pious suppuration. This was at a considerable distance, even at its most inferior point from the wound, which continued to go on well; he swal- lowed with facility, and breathed throughout the whole time with the utmost ease and freedom. His appetite became good, and he improved very much in flesh and strength; about the fifth week he went home in a vessel, which was at the wharf from the county in which he lived. A day or two previous to his leaving the city, a very considerable haemorrhage took place from the nose; which, however, soon ceased. The lig- ature was riot away, when he left the city; it was cut close. But about five days after his arrival at home, that is, about six weeks subsequent to the operation, he was attacked by lock-jaw (tris- mus) of which he died. uMr. Fitzhugh, a young gentleman of my office, who was present at the operation and continued to visit the patient, has been so polite as to in- quire into the circumstances of his death. He also reports that the physician of the family? 484 APPENDIX. examined after death the parts concerned in the operation, and found every thing in the best pos- sible condition. "Had I been apprised of your wish sooner, I would have written to the family physician, and obtained a detailed account of what occured. Very respectfully, yours, JOHN B. DAVIDGE." October 15, ]823. "P.S. Perhaps it may be of moment, that I men- tion to you what attentions were directed to the tumour itself, subsequently to the tying the ar- tery. The tumour was left to itself, protruded down through the opening in the bone. It gradu- ally fell into mortification, and sloughed away so completely, that no vestige could be discovered by the most careful examination, by .the finger in- troduced into the antrum; no part was removed, either by knife, scissors, or caustic. I was solici- tous to ascertain the effect of tying the artery on the tumour, and perceiving it to fall away so rapidly, I merely desired the patient to pay re- gard to the state of the mouth, and frequently cleanse it." Since I have received the proof of this sheet, I have been informed by my friend Dr. Hall, that he has lately tied the carotid artery, in a case of fungus ot the antrum, and that although no ope- APPENDIX. 485 ration was performed on the tumour itself, the disease was removed. Believing the application of this principle to the treatment of tumours of the antrum original and important, I have considered it my duty to take some pains in placing a correct statement of the subject before the profession. Mr. Burns, says nothing in his work on the subject of operations for the removal of portions of the lower jaw, in cases where it is affected with medulary sarcoma. Indeed, this operation is one of very late date. Dr. Mott, whose name I have already had occasion to mention, as one to whom surgery is much indebted; was the first, who suggested the bold operation of removing nearly the whole of the lower jaw in a case of this disease, and has now operated successfully in four cases. It is true, that we have lately been infor- med that Graffe, had done something of the same kind, but the particulars are not stated. Dupuy- tren, when I was in Paris, removed a considera- ble portion of the angle of the jaw, in a case where a cancerous sore was situated over it; the extent of this operation was, however, trifling when compared with those executed by Dr, Mott. My friend Dr. M'CIellan, whose talents have already procured for him a distinguished rank in his profes- 486 APPENDIX. sion, a few months ago, removed nearly the whole jaw bone from a child. I transcribe two cases where this operation has been performed. No. I, is the first case on which Dr. Mott operated, and No. 2, is a notice of Dr. M'Clellan's case, published by some person who had witnessed the operation, in the Boston Medi- cal Intelligencer. No. I. "Catharine Bucklew, the subject of the follow- ing operation, was an interesting young woman, aged about seventeen years, of a healthy appear- ance and good constitution* "She says that about two years since, a swelling commenced behind the last molar tooth of the low- er jaw, attended with acute pain about the angle of the jaw, that continued about three weeks; at which time it left her without any evident resolu- tion of the inflammation At this period there was no inflammation of the integuments, nor could any pus be discovered either on the cheek or about the bone within the mouth. Some domestic ap- plications were made to the cheek, but the tume- faction continued to increase, and assumed a smooth, hard, and bony character. "About twelve months after its commencement she applied to a physician in New-Jersey, who advised her to apply blisters to the cheek, and the use of topical applications of caustic to the to- APPENDIX. 487 mour, together with a general antiphlogistic con- stitutional treatment. After having submitted to this course for two months without experiencing any benefit, she came to this city, and became my patient. "The first molar tooth came away early in the disease, and the second soon followed; then, three or four of the other teeth of that side of the lower jaw. She states, that previously to this disease she never had a decayed tooth. "No fluctuation was to be felt at any time in the tumour. She had no constitutional symptoms as the effect of this disease, nor any inordinate headache on that side. The lymphatic glands of the neck were however swollen, during the con- tinuance of the inflammation in the early part of the disease; but they disappeared as soon as the pain subsided. "When she came under my care, the tumour extended from the root of the coronoid process to the second bicuspid tooth, elevated nearly an inch above the level of the teeth, and spreading con- siderably wider than the alveolar process. Its appearance was smooth, and to the touch some- what elastic, though firm. An incision on each side of the alveolar margin, with a scalpel, ena- bled me pretty readily to remove the tumour with a gum-lancet to the level of the jaw-bone. The tumour, on examination, contained many cartila- ginous and osseus spiculse> and in the substance of 488 APPENDIX. it was imbedded one of the molar teeth in a per- fectly sound state. "About three weeks after this operation a small portion of the size of a nutmeg, which had gran- ulated and grown rapidly, was taken off, and soon after she retired to the country, and remained in a very comfortable state for several months. The tumour began now to re-appear, and continued to increase gradually in every direction. "The tumour at present (Nov. 10th, 1821,) has the same firm and slightly elastic feel which char- acterized it in the early stage, involving all the right side of the inferior maxillary bone. Project- ing outwards, it produces great convexity of the cheekt upwards it divides into two portions, the outer and longest reaches up to the os malae, and between the two is a considerable furrow, formed by the teeth of the upper jaw, which occasions an abrasion and constant discharge; the latter, though offensive, does not appear to be acrid or irritating; downwards it comes nearly in contact with the thyroid cartilage; inwards it extends be- yond the middle line of the mouth, pushing the tongue and uvula very much to the left side, hav- ing the velum pendulum palati of the right side attached to it in its whole course. The inward portion is considerably raised above the level of the tongue when the mouth is opened. "The posterior extremity of the tumour has en- croached so much upon the passage leading into APPENDIX. 489 the posterior fauces, and the pressure of the lower parts upon the larynx is so considerable, as to render deglutition very difficult; and from the great difficulty of mastication, she has been com- pelled for some time to subsist upon liquid ali- ment. Her speech is considerably interfered with in consequence of the displacement of the tongue* She experiences no pain in any part of the tu- mour. "The gradual increase of the disease rendering mastication and deglutition more difficult and dis- tressing, she is very desirous of knowing if an operation could not be performed which might extend to her some chance of life; observing, that with the constant growth of the tumour, such as has taken place for a few weeks past, she should not be able to swallow any thing in a short time. Fully aware of the dangerous nature of the novel operation her case requires, she is determined to submit to it, and hazard the consequences; the uncertain result of which I carefully explained to her, and informed her, that she might die during the performance of the operation; but that I be- lieved it to be both practicable and proper. After preparing the system for about a week with light diet, and the exhibition of several doses of neutral salts, to obviate any great degree of inflammation, the operation was commenced about eleven o'clock on the morning of the 17th. 490 APPENDIX. "As most of the important branches of the exter- nal carotid artery would be interfered with in the course of this operation, I believed it most pru- dent to pas a ligature around the trunk of the carotids as a first and preparatory step. This would not only enable me to go through it with more safety to the patient, but appeared the most important of all means to avoid inflammation. Indeed inflammation was much to be dreaded, from the immense extent of the external incision, and the violence which would necessarily be done to the tongue, palate and pharynx. "From these considerations, I felt it doubly im- portant to intercept the current of blood through the common carotid, and from what I had ob- served to attend the application of ligatures to the large arteries of the extremities, in cases of severe injuries, by preventing inflammation, I thought great advantage would attend it in this case, as I am satisfied will be fully shown. "An incision about two inches and a half long, was made a little below the thyroid cartilage on the inner edge of the sterno-cleido-mastoideus muscle, and after exposing the carotid, a single ligature was passed under it and tied. In this situation it was deemed most proper to tie the carotid, in order to prevent the second part of the operation from interfering with the first in- cision. Very little blood was lost, only one small cutaneous branch at the lower angle of the wound APPENDIX. 491 required a ligature; yet she became pale and al- most pulseless during, and immediately after the operation, notwithstanding her position was re- cumbent. She submitted to the operation with great firmness and resolution, but her mind soon became agitated and perturbed to a great degree, and it seemed altogether impossible for her to regain her former fortitude. The operation was suspended, and some cordial was administered, but it failed to remove from her mind the presen- timent that any further proceeding at present would be fatal. In this state of remarkable agi- tation I resolved not to proceed, and informed her that with such fears as she then entertained, the result was to be dreaded. The wound was then dressed, and she was put in bed, faint and exhausted. After recovering a little, I apprised her that this was only preparatory to the most important part of the operation, and that what had been done would prove of little or no benefit to the dis- ease, and urged her seriously to consider of it, and if possible make up her mind to submit to the per- formance of the remaining part, which should by no means be deferred longer than the following day. One o'clock, p. m. — She is still pale, and in a cold sweat; pulse has not recovered itself, and when asked, nodded that she felt some uneasiness. 492 APPENDIX. Seven o'clock, p. m. — Much more collected; pulse natural; no uneasiness whatever, except some obtuse pain about the wound in breathing, and in swallowing saliva: no increase of heat; left a student to watch with her through the night, and again took leave, earnestly recommending to her private consideration ihe expediency of sub- mitting to the remainder of the operation. 18th. — Seven o'clock, a. m. — Found her this morning in a very composed state of mind; having slept well, and free from fever. Upon putting the question, would she submit to the remainder of the operation? she nodded assent with much apparent decision, and said she was determined to undergo it. "At ten o'clock, finding my patient cheerful and resolute, she was again placed upon the table, and, in the presence of William Anderson, sur- geon, Dr. Hosack, and a number of other gentle- men, the operation was continued. Feeling for the condyloid process, an incision was commenced upon it, opposite the lobe of the ear, carried down- wards over the angle of the jaw in a semicircular direction along the lower part of the tumour, as it rested upon the thyroid cartilage, and terminated it about half an inch beyond the angle of the mouth, on the chin. The termination of this in- eision upon the chin, was just above the attach- ment of the under lip to the bone, and the iiiouth was thereby laid open. 1 now extracted the se- APPENDIX. 493 eond incisor tooth of that side, as it was in a sound part of the hone, and after separating the soft parts from the side of the chin, and laying bare the bone, I introduced a narrow saw, about three in- ches long, similar to a key hole saw, from within, the mouth, through the wound, and sawed through the jaw bone from above downwards. The lower part of the tumour was then laid bare, by cutting through the mylo-hyoid muscle, and the flap of the cheek carefully separated and turned up over the eye. This exposed fully to view the whole extent of the tumour as it rose upwards to the os malai. After the integuments were carefully dis- sected from the parotid gland, the masseter mus- cle was detached from its insertion,until it came to the edge of this gland, then separating a thin plane of the fibres of this muscle, I now readily raised the parotid, without wounding it at this part. The maxilla inferior was now laid bare just below its division into two processes, and it appeared sound. To facilitate the sawing of the bones, it was necessary to make a second incision, about an inch long, close to the lobe of the ear, and terminating at the edge of the mastoid mus- ele; then, with a fine saw, made for the purpose, smaller and more convex than Hey?s, I began to saw through the bone, obliquely downwards and backwards, and finished with one less convex. The latter part of the sawing was done with great caution, to avoid excruciating pain from the lacer- 494 APPENDIX. ation of the inferior maxillary nerve. When the bone was sawed through, the two processes were observed to be split asunder, and the coronoid to be drawn up by the action of the temporal muscle. "An elevator was now introduced where the bone was divided at the chin, by which the dis- eased portion was raised, when, with a scalpel passed into the mouth, the tumour was separated from the side of the tongue, as far back as the posterior fauces, from the velum pendulum palati and pterygoid processes. This loosened it very much, so that it could be turned upon the side of the neck. It was then separated from the parts below the base of the jaw, and also from the pharynx, and detached at the posterior angle, carefully avoiding the trunk of the internal caro- tid and deep seated jugular vein, both of which were exposed. "The diseased mass, being now separated above and below, was turned up, the pterygoid muscles detached, and the third branch of the fifth pair of nerves divided from below, a little above the foramen at which it enters the bone. By this manner of proceeding, with a constant reference to this nerve, I apprehend my patient was sav- ed from much acute pain, and the nerve more safely divided, than at an earlier stage of the operation. APPENDIX. 49 D "At several periods of this onerat'on, the cur- ved spatulas, used iu my operation, upon the ar- teria inominata, were found very useful, particu- larly in elevating the parotid gland, and keeping the tongue steady, whilst the tumour was separa- ted from it. "Very little blood was lost during this opera- tion. Two arteries only of any size were divided, the facial and lingual; and these only required the ligatures at the branch extremities; but each end was tied for safety. Another small artery behind, and a little underneath the posterior angle of the jaw, yielded some blood and was tied. "The flap of the cheek was now brought down, after waiting a few minutes to observe if any hae- morrhage should come on, and secured in close ap- position by three sutures, and adhesive straps. Lint, a compress, and the double-headed roller, completed the dressing. She was made as com- fortable as possible upon the table, and directed to remain a few hours to recruit, and to be more con- venient in case any haemorrhage should make it necessary to remove the dressings. "At eight o'clock in the evening, I found her removed to a bed, and in a comfortable situation. Some reaction of the circulation had taken place, but there had been no haemorrhage. The pain from the operation, she said, was less than she ex- pected. For the first time, since the operation, she sipped three tea-spoons full of cold water, 496 APPENDIX. and gave evidence, by a nod, that she could swal- low. Directed one hundred drops of tinct. opii to be given, if any twitching, more pain, or rest- lessness should supervene. ''19th. — Seven o'clock, a. m. — Found her quite free from fever and irritation, and, in every res- pect comfortable. Swallows cold water by the tea-spoon full with but little inconvenience. Did not take the tinct. opii last night. Slept several hours during the night. "Twelve o'clock, at noon — Is comfortable; skin moist; pulse less frequent, and soft; directed an enema to be administered of soft-soap and water; has a little more difficulty in swallowing, but none in breathing. Nine o'clock, p. m. — As well as in the morning. Enema operated three times, and relieved her. Pulse frequent, but not tense. She has taken about two ounces of cold water by the tea-spoon full since day light. 20th. — Seven o'clock, a. m. — Had a very com- fortable night. This morning, instead of nodding she answers "yes" and "no" to the several ques- tions, in an audible whisper. Nine o'clock, p. m. — Much as in the morning. 21st. — Nine o'clock, a. m. — As comfortable as yesterday morning. Nine o'clock, p. m. — No material alteration. 22d. — Nine o'clock, a. m. — Directed an enema to be administered as before. Allowed her t© APPFNDIX. 497 take, in addition to her cold water and teas, some thin chicken soup; is in every respect doing well. "Nine o'clock, p. m. — Tumefaction of the lips and cheek very trifling, not rurugh to effect the least change in the eye-lids of the right eye. "23d. — Is in every respect comfortable. "24th. — Eleven o'clock, a. m. — Makes no com- plaint; dressed the wounds; union by adhesion has taken place in the whole extent, excepting about the ligatures and sutures. Suppuration having come on about two of the sutures, they were removed. Pulse about one hundred and twenty. Renewed the adhesive straps with lint interposed between them and the wound, and the double-headed roller. "25th. — Every way comfortable. Pulse one hundred and twenty. "26th. — Says she has no complaint to make. Pulse eighty. Directed her to take a small dose of sulphate of magnesia. 27th. — Speaks audibly, and says she is very well; pulse about eighty-four. 28th. — As well as before; dressed the wounds; removed the two sutures at the upper part near the ear; wounds appear healed at every part, ex- cept where the ligatures remain upon the arteries. Pulse eighty. 29th. — Feels very well; speaks distinctly; takes freely of soup and other thin food: pulse one hun- dred. 63 498 APPENDIX. "December 3d. —Ligature from the carotid came away and the other three ligatures from the up^ per wound. A small collection of matter was evacuated from under the integuments in the low- er wound, which was produced by the irritation of the ligature. "4th. — Speaks and swallows very well; wounds just healed. Has used for some days a wash of spirits and water to the mouth with a view to correct some factor of the saliva, and cleanse the mouth. "6th. — Found her dressed and sitting in an ad- joining room, reading by the fire; looks and says she is very well. The bandages being all left off, the only deformity apparent is a little more tume- faction of the right cheek than the left; wounds just well; can move very readily the sound half of the under jaw. Permitted her to chew some animal food. "10th. — Wounds all healed — makes no com- plaint. "March, 1822. — To-day having visited her, I found scarcely any perceptible deformity. The right cheek appeared, upon close examination, to be a little more depressed than the left. I felt from within the mouth some osseous deposit to have commenced at the two situations at which the bone was divided. Her health in every res- pect is perfectly good, and she enjoys the free use pf the left side of the lower jaw. APPENDIX. 499 "November 5th. — I have repeatedly heard of and seen the patient during the past season, and she continues to enjoy uninterrupted health.'' No. II. "A. B. aged four years, had a severe fall upon her chin, which loosened the lower incisors; they became black The whole substance of the jaw in front began to swell soon after, upward and backward, till the swelling filled the mouth, and downward and forward, so as to produce most hideous deformity. The skin of the chin and lower lip was greatly attenuated, and protruded downward by the tumour, so as to overlap the os- hyoides and thyroid cartilages. The vessels were considerably enlarged; the arteries beat actively on almost every part of the surface. The part of the tumour which projected out of the mouth, and was uncovered by the lip, presented precisely the appearance of an enlarged tongue; the parents declared that every physician who had seen it before, had mistaken it for the tongue, which was not easily discovered, even by the closest inspec- tion; for it was pushed backward by the tumour into the upper part of the pharynx. The lympha- tic glands did not appear affected. The child's general health was declining fast. '"An incision was made from the left com- missure of the lips downward, and backward 500 APPENDIX. over the anterior edge of the mastoid muscle, so as to command the carotid in case it should be- come necessary to secure it. The anterior edge of this incision was then extended forward by a bold and rapid dissection, till the whole surface of the tumour was uncovered round to the opposite side. Though numerous arterial twigs bled, he did not stop to meddle with them, but proceeded at once to secure the facial artery on each side, just as it emerged from the submaxillary gland beneath the jaw. As this supplied nearly all the divided twigs, the haemorrhage immediately ceased. The surface of the sound bone being next exposed behind the tumour, the metacarpal saw was applied on each side, so as to divide the bone just in front of its angles. By pressure in front, the whole tumour was turned outward from the mouth with a crash, and carefully dissected from the under surface of the tongue, and sub- maxillary glands and muscles on each side. A part of the sublingual glands, and a considerable portion of the left submaxillary appearing to be tumefied and somewhat discoloured, he removed them by the scalpel. "Only three more small twigs, probably branch- es of the lingual artery, required to be secured. Not more than six or eight ounces of blood were lost; the patient did not faint. The huge flap, or rather pouch of skin was re-applied, and the edges of the first, and only incision, were retained in APPENDIX. 501 apposition by three sutures and some strips. The large cavity left beneath the tongue was partly filled by lint, bent into the shape of the lost circle of bone, upon which the pendulous integuments were afterwards lightly braced by a bandage. The wound healed in less than three weeks, inter- nally and externally. The divided extremities of bone shot out a luxuriant crop of granulations, which have since become ossified, so as to extend the angles of the jaw nearly an inch on each side towards the point formerly occupied by the chin. The girl speaks and eats nearly as well as ever, and goes to school every day in good health and spirits." INDEX. Page. ABBHITETHT, Mr. his classification of tumours, how far useful, . 52 his description of raeilullary sarcoma, . 246 his case where tic douloureux recurred after removal of half an inch of affected nerve, 313 has proved that sorre encysted tumours require to have their cyst destroyed to prevent a return of the disease, .... 366 tied the carotid artery, but the patient died, 192 Abscess over oesophagus to be opened early, . . . 104 of thyroid gland, effects produced by, . . 215 in tonsil, to be punctured before pointing, . . . 280 case where in puncturing, large artery was opened, 281 where large, when it bursts, patient sometimes suffo- cated, ... . • 282 sometimes bursts on fore part of velum, and sore re- sembles venereal ulcer, .... 280 how to be opened, .... 283 Albucasis relates a case, where in removing a diseased thyroid gland, a large artery of the neck was cut, .... 253 Anastomosing twigs of arteries support the member after obliteration of the large vessel, . . . . . 163 Anatomy, relative, at the angle of the jaw, . . . 259 Anel , his operation for the cure of aneurism, . . . 161 Aneurism, anastomosing, arterial, remarks on, . . . 340 case of, on temple, . 342 may be cured by tying the great artery lead- ing to the morbid parts, . . 464 venous case of, . . . . 331 504 INDEX. Aneurism, inominata, case of, was mistaken for suhclavian aneurism, 62 Mr. Pattison's case of. . . 427 external, may be cured occasionally by general compression, 463 dissection of, ..... 69 carotid parts concerned in operation for, . . 194 effects of operation on the limb and tumour. . 172 operation for, generally among the ancients failed, . 159 sometimes fails from bursting of an internal aneurism, . . . . 167 treatment, previous and subsequent to the operation for, 200 Arteria transversalis facie i, description and anomaUy of, . 316 Arteriotomy, how to be performed, . . . . 393 Artery, adhesion of its sides, may be procured by merely retaining them in contact, ...... 143 anatomical description of its coats, note, . . 139 change Y>roduced on, by ligature, . . . 147 detachment of, from connexions, frequent cause of second- ary hemorrhage, ..... 156 how to be treated in operation for cure of aneurism, . 174 sheath of, tied by mistake for vessel, . . 127 RELL, Mr. J. his advice not to remove part of an anastomosing aneurism without removing the whole, not always to be adhered to, 350 remarks on his assertion, that he has removed the parotid gland, ... .... 294 his description of the point where the common carotid di- vides, erroneous, .... 124 saw a patient with carotid aneurism, . .193 Bell, Mr. C. his experiment, which shows that adhesion of the sides of an artery may be obtained by placing a ligature loosely around it, .... 144 his remarks on gangrene after the operation for aneurism, 184 Bichat's description of the effects produced on the coats of an artery by ligature, ..... 140 Bleeding, arising from slipping of ligature, causes of, . . 155 Blizzard, Mr. tied arteries of enlarged thyroid gland, after which the tumour diminished, but patient died from hospital gangrene, 229 Bronchocele, not the cause of cretinism, . . . 219 dissection, of a case of, .... 222 remarks on, ..... 225 treatment of, . . . . . 230 Bronchotomy, seldom or never required in asphyxia, . . 406 performed either to admit air into the lungs, or to extract foreign bodies trom the trachea, . . 410 INDEX. 505 Mrown, Dr. his case of tumour between the masseter and buccinator rauscles, cured by a seton below the jaw, . 301 CALCULI in the sublingual gland, ..... 273 in the tonsil, ...... 286 mode of extracting them, . . . 290 Carcinoma, general description of, . . « . 233 of thyroid gland, ease of, and dissection, . . 233 and fungus hsematodes, are they ever co-existent in dif- ferent parts of the same body, or of the same organ? 244. Carotid aneurism, description of the operation for, . . 201 3,rtery, an instance in which all the primary branches of the external carotid arose at one point, . . 125 an instance in which the common carotid sent off branches up to the root of the styloid process, . 125 case in which it was buried in the centre of an enlarged thyroid gland, ..... 249 common, an instance in which it divided into the inter- nal and external vessels, three inches below the angle of the jaw, ..... 125 external connexions with the parotid gland, . 290 how to be found in the living body, . . .99 most liable to disease at its division, . . 191 not endangered in performing the operation of cesopha- gotomy, ..... 10 place of its division in childhood, . . . 401 position of, in lower region of the neck, . 103 relations of the, . . . . .110 reasons why a knowledge of the anomalies of that vessel are valuable to the operator, . . . 200 Changes produced in the relations of the parts below the jaw, by bend- ing back the head, . . . . . -260 Coagulura, probable reason why formed, and under what circum- stances formed in an artery which has been tied, . 146 Coleman, Mr. advocate for laryngotomy, .... 414 Compression, general, usual mode employed by the ancients for the cure of aneurism, . . . 130 in aneurism, how to be employed, . . 133 often tails from being improperly applied, 132 what are those cases when advisable, and what are those where injurious? . . 131 Conglobate glands at the angle of the jaw, case of, where they were extirpated, ... . 297 tumour formed by, in the centre of the parotid, 305 64 506 INDEX. €onglobate glands, between hyoid bone and thyroid cartilage, connec- tions of, . . . . . 116 tumour formed by these glands, case of, and dissec- tion of person, . . . . 117, 118 critical remarks on this case, . . . 121 over the oesophagus swell, forming tumours which may be extirpated, . . . 103 Contents of space between sterno-mastoid and trapezius muscles im- mediately above the clavicle, .... 70 Cooper, Mr. Astley, his case of aortic aneurism, where the disease was supposed to be seated in the carotid artery, 71 his case of camtid aneurism, . . . 204 first case in which he operated on carotid aneu- rism, patient died, . . . 193 remarks, that aortic aneurism may be mistaken for subclavian aneurism, . . .60 Coronary arteries of the lip, origin and course of, . . 354 Cricoid cartilage, situation of, ..... 96 Cruickshanks, Mr. saw an enlarged lymphatic gland mistaken for diseased parotid gland, ..... 293 , Dr. his case of tumour in antrum, . . . 481 Desault & iJesehamps, their opinion, that in aneurism, a ligature ap- plied to the artery, further from the heart than the tu- mour, would have proved efficacious, erroneous, . 18G extirpattd the right lobe of the thyroid gland, . 252 shewed that a curved tube might be easily introduced, by the right nostril, into the larynx, . . . 407 Diseased thyroid gland, relations of, .... 253 Dissection of a man who died sometime after the subclavian artery had been tied, ..... 93 of a tumour formed by a concatenated gland, where the com,mon carotid, jugular vein, and nervus vagus were buried in its substance, . . . . 115 Distance between the chin and chest in the adult, when the base of the scull is parallel to the horizon, and general relation of parts in this region, ..... 95 between the chin and chest in the adult, when the occiput is turned back, and the alterations in the relations of parts by this change of position, .... 97 between the chin and chest in the young child, and the rela- tion of the parts in this region, when the base of the scull is parallel to the horizon, . . . .399 INDEX. 507 Distance between the clim ami cli^st in the voting child, and the effect produced on those relations bv turning back the- head, 40d Dropsy of thyroid gland sometimes cured by solution of muriate of ammonia, ....... 218 I'DENTUtors subject, remarks on the conformation of the neck of, 428 Khrlich, his case of ranula, ..... 274 Emphysema, spontaneous, authors who have written on it, . 83 case where it happened, . . 84 causes of, .... 85 Epiphora, not constant, when the nasal duct is obstructed, . 365 FACIAL arteiy, relations ot, ..... 265 course of, ..... 353 tumours ought to be removed with capsula entire, . 325 case of, ...... 328 Fascia, cervical , description of the ..... 39 consequences resulting from its destruction, . 36 Febrile state, dependent on peculiarity of constitution renders opera- tion abortive, . . . . . .179 Femoral artery, subject in which about two inches of that vessel were obliterated, . . . . . . 142 Fistula lachrymalis, remarks on, ..... 363 Freytag, extirpated the thyroid gland, .... 252 Fnenum linguse,in snipping, how to avoid injuring the arteria ranina, 264, Fungus from the sore, after removal of the tonsil, how to be destroyed, 28S in antrum, case of, ..... 384 hsematodes behind the jaw, case of, . . . 307 contrasted with carcinoma, . . . 240 general description of, • . . 237 propagated otherwise than by absorption, . 381 GAKGKENE, produced by the use of stimuli, after operation for aneu- i-ism — how? . . . . . 178 seldom dependent on insufficient circulation, but on over excitement, . . . . . .181 Gariot, destroyed fungus in antrum by actual cautery, . 38S his assertion that glandular substance is incapable of suppu- rating, ....... 273 Gooch, his cases of extirpation of the thyroid gland, . . 254 Glandulae Concatenate, case of a female, in whom enlargement of one of these glands was mistaken for ca- rotid aneurism, . . . Ill 508 INDEX. Glandulaj Concatenx, situation of the, . . . .111 symptoms induced by their enlargement . 114 tumour formed by, how to discover its con- nexions on the living subject, . .114 tumour formed by, how to be extirpated, . 116 Glands, conglobate, below the jaw, tumours formed by, relations of, 267 only under certain circumstances that they can be extirpated, 270 connected with the parotid gland, . . 295 Gland conglobate lodged in the parotid, tumour formed by it mistaken for diseased parotid, . . . 306 submaxillary, relations of, ..... 265 thyroid, dissimilar effects produced by enlargement of, . 214 its different parts when swelled, but not from specific disease; tumour if too large to admit ot extirpation, may be reduced by tying its nutrient arteries, . 228 Gullet, foreign substances impacted in, . . . 105 HALLKR, met with the lower thyroid artery arising from the carotid, 418 twice saw the black variety of fungus hasmatodes, . 385 Harrold, Mr. lost a patient from effusion of blood into the trachea, 420 Heberden, Dr. his cases of pulsating tumours which disappeared without suppurating or bursting, were probably enlarged glands over the common carotid artery, . . 113 Hemorrhage, secondary , arises from including parts around the artery, 1 53 causes of, .... 148 Home, Sir, Everard, has shewn that the tongue may be extirpated by ligature, .... 262 Humeral artery, obliterated without any obvious cause, . . 148 Hunter, Mr. John, the first scientific improver of the operation for the cure of aneurism, . . . 164 causes of failure in his first operation for aneurism, 165 Hyoid bone, situation ,)f, .... .96 ISTEHXAL maxillary artery, case of anastomosing aneurism of, . 464 successfully treated by the application of a ligature to the common carotid, . 475 JOKES, Dr. his description of the effects produced by the application of a ligature on an artery, . . . . )3 Opinion that early exertion may rupture a newly adhered artery, considered, .... 158 supposition that division of the two internal coats of an artery is essentially necessary to adhesion, erroneous, 141 INDEX. 509 Jugular vein, situation of, . . . . .100 abscess, burst into, • 103 dilatation of, case where it formed a tumour just below the angle of the jaw, . . . . 303 LTBTAUS superficial, arteria, origin of, ... 353 Lachrymal duct, mode of examining the, .... 357 stricture of, how to be treated, . . 361 Lachrymal gland, diseased, case of, .... 386 dissection of, ..... 3S8; 389 sac, situation ot, ..... 356 Lsennee describes a peculiar variety of fungus haematodes, note, 385 Laryngotomy, objection to its performance, . . . 414 Ligature, improperly applied, how productive of secondary haemorr- hage, 150 instantaneous effects produced by its application on the aneu- rismal arteries, ...... 172 never requires to be stitched to the vessel, . . 156 ot reserve, highly injurious, ...» 160 Lingual artery, relations of, ..... 261 nerve, description of its relations, * . • 261 Lip, cancerous, disease reproduced after operation in gland below the jaw, . .... 271 wounds of. often improperly dressed, .... 354 case where, from improper treatment, it was burst asunder, after it had been dressed, . . 355 MAXTXI.AWY artery, internal origin of, . 392 M' Donald, Mrs. case of diseased glands "below the jaw, . 269 Medullary sarcoma, description of, in thyroid gland, . . 247 is it the same disease as fungus hsematodes? 245 Mott. Dr. his case, \vhere the arteria innominate was included in a ligature, . ... 433 case of osteo sarcoma, in which a portion of the lower jaw was successfully removed, . . . 486 NECK, division of, into regions — middle region of, how to be discovered, 101 Needles sewing, finely polished, useful in wounds of the lip, . 355 Nerves, experiments on their re-union, by Dr. Haughton, note, 312 Nervus descendens noui, description of the, . . . 100 OCCIPITAL artery, description of, . . . . 260 GEsophagotomy, anomalous vessel endangered in operation, . 109 relative anatomy of the parts concerned in this ope- ration, . . . . . .106 Optic nerves, dissection of, which proved that they did not decussate, 381 510 INDEX. PAKOTID duct, course and connexions of, . . . .315 sunk into solt tumours protruding from between the masseter and buccinator muscles, . . 320 gland, lobe of, forming an enc\ steel tumour, . . 302 proof that it cannot be extirpated, . . 292 situation of, . . . . .291 Pharynx, its mode of junction with the oesophagus, . . 105 Platysma Myoides, description of, . • . . .32 use of this muscle considered, . . 33 Portal remarks, that a connection exists between the cellular mem- brane of the neck, and texture of the lungs, . . 83 Portio dura, description of, ..... 308 Prosser, his description of bronchocele unsatisfactory, . . 220 Pulsation of a tumour resembling; true, manner in which apparent may be distinguished from real pulsation, . , . 112 Pnrmanus, his case of tumour at the inner canthus of the eye, . 365 Physick, Dr. his mode of extirpating diseased tonsils, . . 460 RANTTLA, description of, . . . . . . 274 treatment of, ...... 276 SALTVAKY glands, inflammation of, .... 273 Scarpa's description of the state in which he found the femoral artery shortly after amputation, . • . .145 mode of operation for aneurism, . . . 166 success greater than that of Mr. Hunter, . . . 168 Scott, Mrs. her case of diseased eye, .... 371 dissection of the body, ..... 376 Sinuses in vicinity of artery, causes of secondary haemorrhage, 152 Spinal accessory nerve, position of, ... .* 260 Sterno-mastoid and omo-hyoid muscles, point where they decussate each other, how to be discovered in the living subject, . 99 Sterno-mastoid and omo-hyoid muscles, point where they intersect each other in the child, ..... 402 Sternum and thyroid gland, relative distance between those parts at different ages, ...... 405 Socio parotidis, description of, . . . . . 317 Stimuli applied to limb, subsequent to the operation of aneurism, in- jurious, ....... 173 general, effects resulting from their use after operation for aneurism, case of, .... 174 Subclavian artery, case where an attempt was made to tie it previous to its passage between the scaleni muscles, . 86 course and connexions of the, . , 58 INDEX. 511 Subclavian artery, successful operation of Mr. Ramsden, . . 87 Superior larynsreal nerve, course and connexion with artery described, 110 Sympathetic nerve, situation of the, .... 100 TEMPOUAL artery, course of the, ..... 393 Thymus glaud, situation and connexions of the, . . 39 scrnphulous enlargement of — fatal consequences re- sulting from its pressure on the subclavian vein and trachea, ...... 39 removal of, proposed, . . . . 41 Thyroid arteries, in bronchocele, much enlarged and easily tied, 226 Thyroid gland, anatomy of the, . . . . .212 anomaly of, « .... 213 case of medullary sarcoma of, ... 248 chronic inflammation of, . . . 217 description of extirpation of, ... 252 dropsy of, ; 217 extensive suppuration of, case, . . .215 nature and severity of symptoms induced by its en- largement, determined by the part of gland affected, and state of fascia and muscles covering the tumour, 214 situation of, in adult, .... 215 Tic douloureux, operation for, often fails because improperly per- formed, ....... 34 Tongue, diseased, may it not be removed by the kuife, after securing the lingual arteries, • . . . • 263 Tonsil, inflammation and suppuration of the, . . . 279 extirpation of, ...... 284 by ligature, ..... 285 relations of the . . . . . . 265 Tracheotomy, in childhood, preferable to laryngotomy, . . 414 carotid artery sometimes endangered in this operation, 415 Trachea to be cleared with the lingers, and rings to be cut from be- low upwards, ... ... 416 Tumours, anterior to the parotid duct, how to be extirpated, . 326 behind, ..... • 3-29 cervical, division into superficial and deep-seated, . 42 importance of this division considered in a practical point of view, . . 42 advantages of their early extirpation illustrated, 121 mode of extirpating them, ... 46 connected with the parotid duct, .... 319 glandular, above the clavicle, mistaken for aneurism, 79 over an artery often pulsate strongly — causes why they do this, 112. 512 INDEX. Tumours formed between masseter and buccinator muscles, how to be discovered, ..... 323 from swelling of glandulse concatenated, effects produced by, 114 form over the lachrymal sac, and are mistaken tor com- mencement of fistula lachrymalis, . . . 365 Mr John Bell's theory on their origin and formation, 50 absurdity of this doctrine illustrated, by the formation and progress of cancer and other analogous affections, . 50 remarks on, in space between the sterno-mastoid and tra- pezius muscles, . . . . , .78 sacculated about the eye-lids, treatment of, . . 366 situated in antrum maxillare, remarks on, . 477 situated in antrum maxillare, prooi that they will die, if carotid artery of the same side be tied, . . . 480 UNBEBWOOD, James, his case of tumour situated in antrum maxillare, 478 cured by tying the carotid artery, . . 489 Vica. D'AzTn, the first proposer of laryngotomy, . . 414 Vein, lascial, course and relations of, .... 352 Vertebral artery, anomaly of, ..... 197 WAKDHOP, Mr. his case of fungus hsematodes of the eye, . . 368 Wark, Agnes — case where a calculus formed in the tonsil, . 287 \Vilmer advises that the thyroid gland should not be extirpated, 256 Wishart, Mr. his case of gangrene, subsequent to the operation for aneurism, . . . . , .178 cause assigned for its occurrence, erroneous, . 179 Woman, case of, in whom a plum stone had slipped into the trachea, 413 PLATES. Deicription. To be placed PLATE I. — Anterior view of aneurism of arteria inno- minata, page 71 PLATE II. — Posterior view of same preparation, . . 74 PLATE 111.— Plan of aortic aneurism, . . . , . . 74 PLATE IV. FIG. 1st. — External view of tumour in angular space above the cla- vicle, 77 2d. — View of the connexions of the subclavian artery, ... 86 PLATE V. FIG. 1st.— External view of tumour between hyoid bone and thyroid car- tilage, 119 -> 2d. — Internal view of same tumour, . 1203 PLATE VI. — View of distribution of portia dura, . . 309 PLATE VII. FIG. 1st. — Plan of a tumour lying over the parotid duct, .... 321 ~] 2d. — Plan of a tumour lying behind } the paroti'l duct, .... 322 j PLATE VIII. FIG. 1st. — External view of anastomosing aneurism around the orbit, 333 -\ 2d. — External view of a tumour / formed by a diseased lach- £ ryir.al gland, 389 ) PLATE IX. — View of the openings of the nasal duct, and sinuses into the nose, .... 358 PLATE X. — View of the relations of the rima glottidis, 408 page 71 74 74 77 120 309 322 333 358 408 65 S A 3 $ § . CC £-1 •dl o -P •H -P tjQ qj c O • CQ O o e ts\ 0; t3 CQ