OCR Text |
Show 228 or removes. or removes. ly attended to, will greatly facilitate its extirpation; Whilst the body of the gland is hardening, the surrounding membrane is condensed. The pressure, and probably the slight inflammation, forms the cellular membrane into a distinct capsule. By bearing in mind that these hard scirrhous tumours are surrounded by a membrane, we are enabled to cut out a tumour from a seeming dangerous depth. I shall suppose that a patient comes to my reader with a hard tumour under the angle of the jaw, and which threatens to posh towards the throat. The surgeon calculates the place of the arteries. an for the assistant, with tenacula, and needles; but above all, with pieces of sponge having ligatures attached to them; and with adhesive straps, and a graduated compress and' bandage. o [>m*v-Wmv-V~<r~m~ --~ Ni . ‘1"!!er 3:1. He presses the root of the veins, and when they swell, he sees which are in his way. He then moves the tumour to ascertain whether its roots be deep, or if it has any firm adhesion; in doing this, he relaxes the muscles, and especially the platysma myoides. If the tumour has not encroached on the great vessels too much, if it has not adhered, and communicated its bad in‘ fluence to the surrounding parts, it may be extirpated. But my experience prompts me to say here, in the most confi~ dent manner, that if the tumour be not sufficiently free in its attachments, but on the contrary, has pushed deep, and taken attachment to the jaw, or transverse processes of the cervical vertebrae, no good will come of the operation. The patient after suffering considerable risk, and being the subject of a most painful operation, will have the mortification of finding the part grow hard soon after the cicatrization, and increase in its growth with a rapidity, which the progress of the tumour before the operation shall not have led him to expect. If it shall be determined to attempt the extirpation of an indurated and scirrhous gland, the surgeon has to provide himself with knives, and a strong hook, and a blunt hook ' 229 He begins his operation by cutting so that the fibres of the platysma myoides are cut across. To do this, it is not necessary that he carries the incision across the neck, for in that case he would open veins needlessly; but I mean to warn the young surgeon against cutting betwixt two of the fasci- culi of the fibres of that muscle by which he will find him- self restrained, in a most distressing manner, in the prosecution of the dissection around the base of the tumour. The first incision being made through the skin, I have seen the operator begin his sweeping cuts round the tumour, forget- ful of the cutaneous muscle of the neck ; and forgetful too of that essential circumstance, that the gland is now surrounded with a proper capsule. If he begins to dissect round the gland before he has cut, down to it, he will find himself in much confusion; and vessels bleeding in the progress of his operation which ought not to have been cut. He has therefore to lay back this cu- taneous muscle freely, and then he will find himself rewarded for his decision by the gland starting more forward, and becoming, in fact, more superficial. But still he has not exposed the proper surface of the gland; if he cuts perpendicularly on the cellular coat which covers the tumour, he discovers that this cellular substance is a loose capsule, from which the gland can almost be turn~ ed out with the point of the thumb! with the handle of the knife he separates the capsule from the gland :--he finds a part where there is more resistance; a stronger union be~ twixt the gland and capsule by a cellular cord; in this he will find the principal artery which supplies the tumour; and when he cuts this tag across, he must be prepared to take up the vessel with the tenaeulum. In our dissections, every day we see, that the lymphatic glands have one principal ramification of a neighbouring artery running into their substance. It is this same artery, which by its activity enlarges the gland; and this artery, for the most part, is all a surgeon has to take up in the extirpation of the gland. WON) .4."M09817 4 "a" ._ . 5 I |