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The new question which has thus been raised, as to whether belladonna exerts its action through the medium of the nervous, or directly on the muscular fibres, belongs to the more general question of the nature of muscular irritability, and need not be entered on here. An experiment, however, which Dr. Harley performed to test the correctness of this view is worth quoting. He placed the eyes of a cat immediately after death, the one in a solution of atropia, the other in water, and found that the pupil of the former became dilated, while that of the latter contracted. The same experiment was tried on the eyes of two dogs, but with no result. It may be mentioned that Ruiter had before observed that atropia still dilates the pupil if applied to the eye immediately after death by decapitation, in the calf, the rabbit, and the frog.
In arguing that belladonna dilates the pupil by exciting to contraction the dilator pupillæ muscle, the writer of this article* has always meant by muscle the proper muscular fibres, together with the fibres of the iridal sympathetic distributed among thein.
REVIEW V. 1. A Treatise on the Diseases of the Breast and Mammary Region.
By A. VELPEAU, &c. Translated from the French by MITCHELL HENRY, &c., for the Sydenham Society.--London, 1856. 8vo,
pp. 608. 2. A Treatise on the Cancer of the Breast and of the Mammary Region.
By A. VELPEAU. Translated from the French by W. MARSDEN,
M.D., &c.—London, 1856. 8vo, pp. 293. 3. A Treatise on Cancer and its Treatment. By J. WELDON FELL, - M.D., &c.—London, 1857. 8vo, pp. 95.
We have carefully perused the work of M. Velpeau, and regard it, on the whole, as a valuable contribution to surgical literature. The author is at times wordy and prolix, and evinces indecision on some important points of doctrine; his work, nevertheless, gives evidence of remarkable industry in accumulating and assorting facts, and of great experience in clinical research. He has done good service, by showing that an overweening reliance on the microscope in surgical diagnosis, to the exclusion of practical tact and observation, is fraught with error. We have no hesitation in commending the translation by Mr. Henry, with the useful notes which he has supplied. We regret our inability to speak in equally eulogistic terms of the translation of the latter part of the work, executed by Dr. Marsden. - Diseases of the female breast are divided by Velpeau into two principal classes ist, diseases of an innocent kind, inflammatory or non-inflammatory; 2nd, diseases of malignant or cancerous nature. After treating minutely of diseases and deformities of the nipple and
* See two clinical lectures On the Use of Belladonna in Ophthalmic Practice, in the Medical Times and Gazette for Jan. 10th and 24th, 1857.
areola, the author proceeds to describe inflammation of the breast. Premising that here, as elsewhere, inflammation is modified by age and constitution, by normal and abnormal conditions of the functions of the part, by the state of the general health, and by the nature of its exciting cause, he lays great stress on the varieties dependent on anatomical structure-varieties which have been admitted by some of the leading surgeons of Paris.
“Regarded in this point of view, three classes of cases must be established. The first originates between the gland and the skin, in the subcutaneous cellular fatty tissue; the second is seated, either primarily or secondarily, beneath the breast, between the gland and the chest, and the third class has its principal focus in the interlobular network, or in the glandular structure itself.”*
Each of these branches off into several subdivisions. Some interesting observations are made on lymphatic inflammation, not pre viously described as a distinct affection, doubtless, he believes, because it has been confounded with certain varieties of erysipelas or phlegmon, for it is not very rare.
“ The symptoms which usher it in are
“1st. Irregular chills, sometimes a downright shivering fit, a rapid and tumultuous pulse, which is unequal rather than strong, heat of the skin, restlessness, loss of sleep and appetite, and sometimes nausea.
“ 2nd. In the breast there are pain, great heat, swelling, and red patches irregularly scattered about, coming to a focus in painful spots, more or less raised from the surface.
“ 3rd. Generally there is a painful state of the axillary glands, and sometimes reddish striæ lead from the breast to the armpits. Chaps, excoriations, eczematous eruptions, abrasions of the skin, and all affections of the nipple and areola, are the ordinary causes of lymphatic inflammation of the breast." |
The author states, that when left to itself, this kind of inflammation sometimes ends by resolution and rapid and complete cure. If suppuration result, the abscesses terminate by opening, contracting, and eventually cicatrizing. Sometimes, however, the disease is tedious and painful. The treatment which he recommends, should the surgeon be called in, during the first two or three days is heroic—viz,
“To bleed from the arm to the extent of from seven to twelve ounces, and the next day to apply fifteen or thirty leeches to the breast. If the inflammation does not now abate, mercurial ointment should be freely applied to all the affected parts, and renewed three times a day, without discontinuing the employment of poultices. If there is 110 reason to the contrary, the bleeding may be repeated, and a purgative administered, should the digestive organs not be disturbed.”
Now, concurring with M. Sappey, who has discovered several strata of lymphatic vessels in the breast, and according to whom the majority of abscesses in this situation are only the results of lymphatic inflammation, or, as it is called, angio-leucitis, we consider the above practice too energetic. By the employment of saline purgatives combined with antimony, and oft-renewed poulticing at the outset, followed by the topical use of tincture of iodine, and those means best adapted • Sydenham Society's edition, p. 20.
Ibid., p. 22.
to support the patient's strength, the disease will be found to yield in pumerous instances.
For each kind of inflammation the author has a different line of treatment. Thus, for subcutaneous phlegmon he advises leeches in large number to the affected part, mercurial friction, and compression; for deep-seated, as also parenchymatous inflammation, general bleeding, with leeches around the breast, and large poultices with mercurial ointment; for glandular inflammation, purgatives, alterative drinks, and emollient topical applications—a line of practice which it will be somewhat difficult to persuade English surgeons to adopt, inasmuch as we do not believe that such vigorous measures of depletion are in general needed, or that the resulting lowering of the systern at all countervails any presumed influence they may have in controlling the disease.
With respect to deep-seated abscesses, with sinuses in the breast, the author advocates the plan recommended by the late Mr. Hey, of Leeds—namely, that the breast should unhesitatingly be divided in its entire extent through the whole length of the sinuses, with the view of healing them. (p. 81.) This proceeding, although condemned by Sir A. Cooper, is, in the opinion of the author, the most certain of success sometimes the only one that can produce a radical cure, and which would be generally adopted were it not for its severity, and he might add, the unseemly scars which are left behind. Before resorting to such an extreme measure as the above, we suggest the trial of moderate, well-adjusted compression, conjoined with repeated dilatation of the orifice or orifices with a pencil of lunar caustic, applied once or twice a week, the part being in the interval covered with lint smeared over with compound mercurial cerate surmounted with a piece of leather spread with soap plaster, and a roller employed in order to maintain the dressing in its place, and also exercise a suitable amount of pressure. This has answered admirably in the instance of deep and circuitous sinuses.
Under the head of Chronic Abscess the author refers to some difficulties of diagnosis which seem entitled to notice. Those which assume the form of cysts are met with not only under the breast and in the substance of the gland, but also all around it.
“At the circumference of the breast, it is hardly possible to mistake them for tumours of malignant or cancerous nature; but beneath, or in the substance of the gland, the error is not always easy to avoid. Such a mistake was committed a few years ago in one of the great hospitals of Paris, by one of the most eminent and experienced practitioners.
Sir A. Cooper cites a similar case, and we know that a like occurrence has taken place since his time in 'at least one London hospital. Surely the introduction of an exploratory trocar, or even the plunge of a bistoury at the outset of the operation, would be conclusive.
There are two therapeutic agents connected with phlegmon and abscess on which the author lays considerable stress-namely, blistering and compression. Blisters are not indicated in cases of lactiferous engorgement or parenchymatous inflammation before the formation of pus, but chiefly in deep-seated inflammation of the breast. In subcutaneous inflammation, also, they frequently prove successful. According to the author, the blister acts,
“When pus has not yet formed, as a powerful resolvent, and when resolution is no longer possible, as an energetic means of maturing the abscess. It delays suppuration, and hastens the resolution of the inflammation, if applied at an early stage. At a later one it expedites the formation of the abscess, by softening the tumour, and diminishing the sensibility, tension, and thickening of the parts around. In cases of open abscess, when the cure is tedious, blisters are also useful. Applied over the whole extent of the swollen surface, comprising the ulcers and the open wounds, they tend both to close the depôts, to heal the fistule, and to resolve the concomitant engorgement."*
The author most properly takes exception to the indiscriminate employment of the word engorgement, as being a source of serious mistakes in the prognosis and treatment of diseases of the breast. Many practitioners confound under this appellation affections of the most opposite character-such as colloid, melanotic, scirrhous, encephaloid, tuberculous, and fibrinous tumours, and simple sub-inflammatory thickening. Velpeau would apply it only to
"A lesion characterized by thickening, with a lardaceous condition, and loss of a part of the elasticity and porous lamellar structure, and of the extensibility natural to the tissues, together with the absence of any heterologous formation."|
The consideration of tumours properly so called, extends over nearly 160 pages. These are disposed of group by group. The first group comprises tumours of an innocent nature, made up of the natural structures of the mamma-such are, hypertrophies, fatty growths, and neuromata. With respect to neuromatous tumours—those small painful indurations in the breast which often harass patients for years—the author suggests by way of cure subcutaneous incision, in despair of tracing the cause of the disease. This plan has been resorted to by M, Rufz with success in two cases. He introduced a tenotomy knife between the centre of the pain and the root of the nerves or vessels, and then divided the tissue of the breast; he thus cut through several structures at one sweep; in one case, where all the nervous filaments had not been freely divided, and there was still pain, he repeated the operation, and the result proved successful. These deep subcutaneous sections determined sometimes a slight hæmorrhage, which, however, was readily stayed by pressure: also extravasation of blood underneath the integuments of the breast, but never any accident of moment. M. Rufk was indeed surprised at the rapidity of cicatrization.
The author has devoted a long chapter to the consideration of ima. ginary pains and tumours. With regard to the former, we can scarcely conceive it possible that a woman should complain of pain which does not exist. The question of imaginary tumours is important, because it has happened that even medical practitioners have been led to believe in the existence of tumours where the mammary region was perfectly free from any morbid alteration. The source of error has Sydenham Society's edition, p. 124.
Ibid., p. 164.
been clearly pointed out by M. Velpeau. It may depend, 1st, on inequality in the form and consistence of the lobules of the breast; 2nd, on a prominence of a rib, in consequence of being larger and more convex than natural, a circumstance which may induce the belief of there being a deep-seated and adherent tumour; 3rd, the exaggerated arching of the upper part of the chest; 4th, lastly, on the manner in which the examination is made: it happens, for example, when the surgeon seizes a portion of the breast between his fingers, he perceives a resistance proportionally great, because no portion of the gland can escape being firmly held between two solid planes namely, the fingers; and if, at the same time, the patient should complain of a swelling in the breast, the sensation experienced by the surgeon will persuade him as to the presence of a tumour, which has really no existence. To avoid this mistake, let the surgeon support with the fingers of one hand the circumference of the mammary gland, while with the other he will press on the different regions, resting the fingers on the anterior or cutaneous surface. M. Velpeau insists on these modes of exploration in order to establish an accurate diagnosis of tumours of the breast.
The author gives a careful description of tubercular tumours, designated by Sir A. Cooper as scrofulous tumours, but whose account of them is brief and incomplete. He is decided as to their close affinity with tubercular deposit in other textures of the body. In the same chapter he furnishes details respecting the tumours formed by cysts filled with purulent or semi-purulent matter, and a half concrete substance resembling that of tubercle. It is difficult to determine the origin of these kinds of collections; in one case it was attributed to some affection of the sternum, to one of the cartilages of the ribs, or to a gland contained in the anterior mediastinum; in other cases the cyst was moveable, and did not appear to have connexion with any other structure but that of the mamma; in another case, again, it was attached so closely to the walls of the chest, as to convey the impression of being a symptomatic abscess.
Under the head of Galactocele the author treats of “tumours formed of milk, or by some of its constituents, accumulated either in the natural ducts of the gland, or amidst the organic structures of the mammary region.”* This class of tumours, of which but few ex. amples have been published, never, he says, received any special description, until he wrote a short account of it in 1838. It occurs in several forms—as swellings, that may be acute, chronic, liquid, solid, inflammatory, indolent, temporary, or permanent. It has, the author believes, been frequently confounded with tumours of an entirely different nature. With respect to treatment, he enjoins resort to incision or a seton:
“Rather a large seton is best for large cysts, and an incision of some extent for cysts of moderate size. In the one case, as in the other, it is necessary for the whole interior of the galactocele to suppurate, and for its cavity, no longer distended by the fluid, to retract and become reduced to a sort of sinus
* Sydenham's Society's edition, p. 232,