A man (Choo Yihleang), facing front, with a massive spherical tumour on the right side of his neck. Gouache, 18--, after Lam Qua, 1838.

Described in Peter Parker's notebook, case no. 4903, 1838: 'Tumor of a peculiar character. March 5th. Choo Yihleang, aged 31, a shoemaker of Kaouyaou, had a tumor on the right side of the neck as large as his head, as it appeared from a front view. It was situated benath the sterno-cleido-mastoideus muscle, and the superficial fascia. It extended from the ear to the clavicle, and from upon the trachea to the posterior edge of the above muscle, which was drawn very tense above it. When the patient entered the hospital it was firmly fixed, scarcely admitting a perceptible motion in any direction. At a point on the surface near the apex was indicated a slight collection of fluid. The patient was blooming in health, and resolutely desirous of its extirpation. He was admitted to the hosptial, and in the course of a week or ten days, after repeated examinations it was manifestly more moveable--a fact that the patient also observed. With the advice of several surgeons who had seen the patient, it was determined to extirpate it, though it was possible the external carotid artery might require a division in the event. On the 25th of April the operation was performed, assisted by Messrs. Cox, Jardine and Holgate. Precaution was taken for tying the carotid if necessary. The patient took 25 drops of laudanum half an hour before coming to the table. The preceding day he requested not to be tied, assuring me he would not move a limb, or speak a word. When the moment arrived, instead of shrinking from the crisis, he put one hand on the table and skipped upon it with great agility, as if joyful of the prospect of being freed of his troublesome companion. The incisions were made in the direction of the muscle, from the mastoid process to the clavicle. A small portion of the anterior edge of the mastoid muscle was divided, but to our great satisfaction soon after the incisions were completed, the tumor readily separated from its nidus, and in four minutes was completely out. A few small arteries that were divided soon contracted, and gave no further trouble; but two veins continued to discharge their contents so copiously that neither cold water or pressure would stop them, and ligatures became indispensible. One upon the external jugular apparently (for when natural positions are so altered we cannot speak confidently) and upon a large branch of the same, passing under the lower jaw. During the operation the patient was perfectly collected, and did not utter a groan: spoke with natural voice when spoken to, and repeatedly requested the operator might not be alarmed. The tumor weighed 5 1/3 lbs. It was surrounded by a firm wall an inch thick, resembling in hardness the full grown cocoa nut, except at one point: then came another layer of three quarters of an inch of white pulpy substance, and centrally there were several ounces of milky fluid quite inodorous. The large muscle resumed its natural place, the wound healed chiefly by the first intention and in twenty days the patient, in good health, and with unequivocal sentiments of gratitude, returned to his family. Thus the case that appeared formidable in prospect, has really proved of less trouble than often attends the removal of a tumor but a hundredth part of its size. It has been the more interesting as being the first instance in which I have applied a ligature to a vein. But the result favors the conclusion that, veins may be tied with as much impunity as arteries. In the present instance one ligature came away of itself on the 12th, the other on the 14th day.'--Rachman, loc. cit.