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or fistula. Afterwards, it is sufficient to keep the lower opening patulous by means of a thread, so that it may close filially from the anterior towards the exterior."*
Velpeau attaches but little value to the efficacy of injections of iodine or wine in such cases, because from investigations which he has made into the effect of medicated injections into closed cavities, it has resulted that irritating injections are only efficacious when they are applied to cavities which are bond fide serous. He observes, however, as they may perchance succeed, he should not hesitate to try them. He treats serous cysts, of course, with iodine injections. After emptying the tumour by means of a small trocar, he immediately injects into the sac a solution composed of one-third of tincture of iodine to two-thirds of water, and the operation is complete. He has employed it on ten occasions in the female.
Upwards of fifty pages are occupied with the consideration of adenoid tumours, signifying thereby gland-like tumours; termed by Cruveilhier fibrous tumours; by Sir A. Cooper chronic mammary tumours; and by Vidal, in common with most microscopic observers^ tumours from partial hypertrophy of the matnma. Allusion is made to the confounding together of tumours of this kind with "scin-hus," "encephaloid," or " blind cancer," but such cannot apply, as the translator justly observes, to this country, and we agree with him as to its certainly appearing strange, that after the descriptions of Sir A. Cooper and Mr. Lawrence, such a mistake should be common, even in a foreign land; still more strange, as shown by a remark of M. Velpean, that even so late as the year 1844, during a discussion at the Academic de M6decine, several medical men maintained that the innocent were undistinguishable from the malignant tumours of the breast.
"It is impossible (continues Mr. Heury) to read over the admirable account of the chronic mammary tumour in Sir A. Cooper's work, which was published in the year 1829, without acknowledging that he has almost exhausted their history; and in all points, save in their microscopic characters, that he has anticipated what has been since said about them. One of the cases quoted in that book had been operated on by Sir Astley in the year 1815, whilst M. Vclpeau's earliest case appears not to have occurred until the year 1824."t
The prineipal diagnostic signs of theso tumours are, their mobility, their absence of adherenee to the integument, a condition not met with iu scirrhus, which is always more or less closely united with the skin and the mammary gland. The slowness of their development, at variance with the rapid evolution of encephaloid disease, which advances so rapidly to the surface, that it is not long of implicating the integuments; the absence of indurated glands in the axilla and in the vicinity of the breast; finally, the state of the general health, which continues unaffected, even where the tumours have attained a large size. These signs will enable the surgeon in most instances to form an accurate diagnosis.
• Sydenham Society's edition, p. 245. t Ibid., note, p. 281.
M. Velpeau fully discusses the notion entertained by some surgical ■writers concerning the transformation of benign into malignant tumours. This notion, which was controverted by Mr. Pearson in his ■work on cancer, published in the year 1793, has been frequently urged as a pretext for resorting to the use of the knife in cases where no operation was required. Nervous women, terrified into the belief that some simple swelling in the breast, if not removed, will eventually become cancerous, submit to a painful mutilation, the result of which has sometimes been most disastrous. M. Velpeau states that M. Martin Solon, seconded by Blandin, published in 1844 the account of a tumour in a woman aged forty-five, which had remained in a benign condition nearly twenty years, and then became transformed into encephaloid. Similar examples have been reported by others, especially by M. Iloux.
"To the first case two things may be objected: 1st, There is nothing to show the innocent nature of the tumour in the first period of its history. 2nd, Neither is there any absolute proof that it was really encephaloid at the time of its removal. To say that women advanced in life, that those who are married or have borne children, are more subject to cancer than to innocent tumours, does not authorize the conclusion that innocent tumours become cancerous in this class of persons. Moreover, adenoid tumours have remained innocent, as my observations show, to the very last, in a vast number of married women, mothers of children. If it be true that tumours which seemed to be innocent have taken on the characters of cancer, at a more advanced period of life; after the cessation of menstruation, for instance, it does not by any means follow that they were primarily adenoid in nature. It may be that tumours cancerous in nature from the very first do not display themselves, or show their malignity, until after the lapse of a considerable time."*
After proceeding at some length to show that the differences are as well marked in respect to return as in all other points of view, between adenoid tumours and cancers, the author subjoins:
"Although hitherto the cancerous degeneration of adenoid tumours has never been demonstrated, I cannot absolutely deny the possibility of its occurrence;—some facts appear to me to call at least for reserve on the subject."f
Now, we regard this as simply a gratuitous assumption. The facts to which he refers are chiefly the case of a tumour composed entirely of caseous material, ending by undergoing the cancerous transformation; that of another patient, in whom the tumour, under the microscope, was found to be cancerous in one half and simply adenoid in the other. We admit that the germ of cancer may originate and be developed in a tumour of au innocent nature; there may be interposition, but no transformation. Cancer is a disease sui generis. We deem the question, indeed, one of such importance in a practical point of view, that we venture to quote the passage of Mr. Pearson above mentioned, as well entitled to notice at the present day:
"Writers have indeed said much about certain tumours changing their nature and assuming a new character, but I strongly suspect that the doctrine of the mutation of diseases into each other stands upon very uncertain founda
• Sydenham Society's edition, p. 302. t Ibid., p. 308.
tiou. Improper treatment may without doubt exasperate diseases, and render a complaint which appeared to he mild and tractable dangerous or destructive; but to aggravate the symptoms and to change the form of the disease, are things that ought not to be confounded. I do not affirm that a breast which has been the scat of a mammary abscess, or a gland that has been affected by scrofula, may not become cancerous, for they might have suffered from this disease, had no previous complaint existed; but these morbid alterations generate no greater propensity to the cancer than if the parts had always retained their natural condition. There is no necessary connexion between the cancer and any other disease, nor has it ever been clearly proved that one is convertible into the other."*
We therefore reiterate our conviction, that wherever a cancerous tumour is met with in connexion with a growth of a different nature, it has pre-existed, but in a comparatively quiescent state. In short, cancer is always an original disease, and never appears as the sequel of any morbid affection whatever.
A large proportion of the volume (2C0 pages) is occupied with the study of diseases of a malignant nature. Cancer in the breast shows itself in three principal varieties, as scirrhus, encephaloid, and fibroplastic cancer. These 3eem occasionally to be associated together, but usually from the commencement to the termination preserve very dissimilar clinical characters. Melanosis, keloides, and epithelial cancer, are rare in this situation. Under the head of scirrhus, the author includes ligneous scirrhus, lardaceous scirrhus, diffused scirrhus, and scirrhus in the form of plates. All these are fully described.
In order to distinguish scirrhus from encephaloid, it is sufficient, he considers, to attend to two observations: the one is, that scirrhus almost always tends to involve the skin in its neighbourhood, from the moment that it attacks or invades the part; the other, that encephaloid pushes before it, and makes this membrane prominent in front, at the same time that it thins it, and endeavours to perforate or destroy it. (p. 365.) Some misconceptions which the author labours under with respect to colloid tumours and to epithelioma are pointed out by Mr. Henry.
We now approach a highly important subject—the diagnosis from microscopical anatomy. It must be allowed, that in as far as the blood is concerned, the researches of observers have remained as fruitless as those of chemists, in discovering a trace of the elements of cancer in that liquid. It may nevertheless happen that the so-called blastema of cancer may be circulating in the blood, and yet elude the subtlest means of investigation.
"In the meantime (observes M. Velpcau) we must thank microscopical observers for the exertions thev have made in another direction, and for certain important results already "attained by them. Their investigations have been directed to the intimate composition of tumours themselves. After much groping in the dark, and after oscillations which, perhaps, have not yet ceaseil, they have been enabled to demonstrate, in cancerous tumours, certain forms of cells, which are never, or at least rarely, formed elsewhere."!
After alluding to the inquiries of Gluge, Lebert, Bobin, Broca, and • Lib. cit., p. 8. t Sydenham Society'! edition, p. m.
others, he gives a resume of their observations by M. Follin, who has accomplished his task in an able and complete manner. M. Velpeau agrees with M. Lebert, that it is generally impossible to confound the cancer-cell with any other, when it is perfectly developed or unaltered; but it also seems to him, as to M. Virchow—
"That certain cells of epithelium—of pavement epithelium in particularhave in some cases a considerable resemblance to it; that tlie numerous alterations of its circumference, the variable number of its nucleoli, and of the granules which are infiltrated or contained within it, may in many instances render confusion easy. Moreover, we cannot help comiug to the conclusion, that different microscopists are far from agreeing as to the characters and the nature of this cell. The opinion of M. Vogel differs markedly from that of M. Lebert, and M. Virchow, on his side, does not hold the same language as M. Miiller. In France even some differences arc already perceptible between the views of M. Follin, M. Kuss, and M. Robin, for instance, and M. Lebert and M. Courtz."*
Velpeau then proceeds to detail instances of tumours of a malignant nature, in which the most expert observers were unable to detect the so-called cancer-cells, and likewise of those of an innocent nature, which teemed with acknowledged cancer-cells. We concur, therefore, in opinion with the author, that it would be imprudent—at least, up to the present time—to consider the cell, upon which so much stress is laid by microscopic observers, as the absolute characteristic of cancer. As far as concerns the demonstration of the normal tissues of healthy structure, the microscope is of great value, but with respect to morbid tissues it is far otherwise. In regard to the latter we must rely mainly on clinical tact and experience.
Cancer, according to M. Velpeau, results from a morbid exudation. This exudation, which is well marked, and he believes incontestable, in cases of encephaloid cancer, in cartilaginous cancer, and in fibro-plastic cancer, is less manifest, but still pretty well marked, in the greater number of cases of scirrhus. It seems to occur in two different forms; in that of deposit, and in that of infiltration. Is it not rather a cellgrowth in a fluid or fibrous matrix, devoid of healthy plastic properties, evolved and interposed amid the tissues?
With respect to comparative diagnosis, special symptoms demand notice. One to which importance is attached, in the investigation of cancer, is pain. It is a common notion that a painless tumour of the breast cannot be cancerous. This is an entire mistake. Almost all innocent tumours of the breast are at times accompanied with pain; and women have been tormented for mouths, or even years, with acute pain at one spot in the breast, without the slightest tumefaction being discoverable. On the other hand, says M. Velpeau, enormous encephaloid tumours occasionally pass through all their stages without causing any pain to the women in whom they have occurred, and who, from this circumstance, scarcely considered themselves at all ill. Scirrhus itself, especially lardaceous scirrhus, and scirrhus en masse, often exists for several months without being accompanied by pain. Indeed, the
• Sydenham Society's edition, p. 899.
majority of cancers are painful only at an advanced period of their development. The author considers the contagious nature of cancer, not as demonstrated, but as possible. As regards prognosis, he asserts that, abandoned to the resources of nature, cancer never disappears. Those who believe or affirm the contrary are mistaken. Their assertions depend upon errors in diagnosis, or, at any rate, from their confounding tumours of different kinds under the title of cancer.
"A scirrhus, an encephaloid, a napiform or fibro-plastic tumour, or a wellmarked epithelial or melanotic cancer, fatally follow their destructive evolution until the death of the patient. When once it has commenced, cancer never retrogrades." (p. 447.)
He properly repudiates the notion entertained by some pathologists, that there may take place in cancer a spontaneous cure through a process of retraction analogous to what occurs in the tissues of a cicatrice:
"According to M. Virchow, the object of this process is to eliminate the cancerous material by a profound interstitial or molecular action, so as to cause the gradual disappearance of the tumour, and, in fact, to cure it. Any one who can satisfy himself with such notions, or fall into such strange delusions, can scarcely have followed the history of patients, or observed the course of cancers, otherwise than very superficially. *
"We now arrive at the treatment of cancer of the breast—a subject which has engaged the attention of the professors of the healing art for centuries past. Incapable of spontaneous disappearance, endowed with destructive energy, cancer invariably terminates, sooner or later, by overcoming the powers of the constitution, and consigning its victim to the tomb. Hence the incessant endeavours that have been made to find a remedy for this ruthless malady. Have the lights of modern science brought to bear on therapeutic art at all deprived it of the attributes assigned to it by the Roman poet—
"Utque malum late solet immedicabilc cancer
or does it still continue, wrapt in mystery, to baffle human skill, and constitute one of the most distressing modes in which man is doomed to " shuffle off this mortal coil T
"Cancers of the breast," says M. Velpeau, "like cancers in general, have been treated by all sorts of remedies and applications. It would require a volume to name or simply pass in review what has been proposed for this purpose. Like most surgeons, I have, at first, admitted the efficacy of some of these measures, but, after submitting them to a rigorous trial in a great number of patients, I have come to the mortifying conviction that not one of them is capable of curing genuine perfectly characterised cancer. The contrary opinion is maintainable only in consequence of errors of diagnosis."!
"With respect to general treatment, he has come to the conclusion that when the cancerous nature of the disease is well marked, we do not, up to the present day, possess a single remedy—a single constitutional or internal application—that has ever succeeded in curing it. His condemnation of external applications in the form of ointments,
» Sydenham Society's elition, r-. 448. f Ibid., p. 453.