Part 54

The gland itself is most frequently affected by carcinoma. Sometimes it is attacked by, or involved in, medullary sarcoma; and bloody tumours are also met with. In some cases, the gland is enlarged and softened, and penetrated by cysts of greater or less size, and more or less numerous, containing a fluid either serous, albuminous, bloody, or thin and black.

The appearance and progress of carcinomatous and other tumours have been already described. The mamma is more frequently the seat of malignant disease than any other gland; it is frequently excited, and much exposed to injury. Often the induration following abscess remains stationary for several years, and at length takes on a new action, forms morbid deposit, and is of rapid growth. The disease seldom occurs in young subjects; though I have met with several well-marked cases under thirty. Before that time of life, the tumour is generally of a strumous nature, and this should not be confounded with the malignant; for the one is remediable under the influence of constitutional means, the other is not. Malignant disease is in most cases developed about the period when the menstrual discharge ceases; when the discharge is irregular previously to its entire cessation, the mamma is excited, and then hardness is perceptible. The disease also forms, though seldom, long after the “critical period,” but in such cases its progress is usually slow. It occurs, also, and not unfrequently, in those who have never had the mamma excited by lactation; the mammilla is also subject to malignant disease in males advanced in life.

When the malignant nature of the disease is recognised, the tumour should be extirpated without delay, before it has made much progress—before it has contracted extensive adhesions, or contaminated the lymphatics. The circumstances rendering interference unadvisable have been fully spoken of when treating of tumours generally. If the patient is a female, the period of the menstrual discharge, if still regular, must be attended to, and avoided; indeed this maxim should apply to every operation on the female. The most favourable time for operating is some days after the cessation. The position of the patient should be sitting, unless the dissection is expected to be tedious; but it ought not to be so,—the extirpation of glands, or the detachment of the tumour from parts to which it may have contracted firm adhesions, can alone cause delay; and when these circumstances exist, interference is not allowable. Any warrantable operation on the mamma can be completed in a very few minutes. Two elliptical incisions are made from the border of the pectoral muscle, in the direction of the fibres, embracing the nipple and any portion of the integument which may be adherent or altered. The surgeon need never hesitate to sacrifice the nipple, for in this disease it can be of no further use; besides the malignant action is apt to return in it when saved, it being almost always adherent to the tumour: it must be removed. The incisions are made quickly with either a scalpel, or a sharp-pointed and broad bistoury; the lower should be the first, that the flow of blood may not interfere with it and obscure its course. This is carried at once through the skin and subjacent adipose tissue, and then the upper is made rapidly, to get over the most painful part of the operation as soon as possible. The dissection is next proceeded in, from the axillary region forwards, and the tumour detached first on one side, and then on the other. A few strokes of the knife will separate the remaining cellular attachments to the fascia of the muscle, or of the fascia to the muscle. The surface of the wound and of the extirpated mass should be carefully examined, so that no part may remain whose structure is altered. The vessels are tied; and after oozing has ceased, if sufficient integument has been saved, the edges of the wound are put together and retained. The patient is placed in bed, with the head raised and the arm slung.

Operation is scarcely justifiable when it is evident that the absorbents are affected. Yet a small glandular tumour on the border of the axilla, without any enlargement more deeply seated, may be removed along with the mamma. With this view, the incisions should be made so as to include the tumour, and detach it previously to the mamma being interfered with. But when swelling has taken place deep in the axilla, it is impossible to ascertain its exact extent, and it may be considered very certain that a chain of altered and enlarged glands lie along the course of the axillary vessels. The whole of such a tumour cannot be taken away, and, in removing even the more prominent and accessible parts of it, there is great risk of wounding the axillary vein. This blunder I have seen committed more than once, and I have also seen the vein, the artery, and the majority of the nerves, all included in one ligature in order to stop the bleeding. I need scarcely add that the patients soon perished. When enlarged glands are perceptible above the clavicle, or in the intercostal spaces, the practitioner who would advise interference with the original tumour must be grossly ignorant, or very unprincipled.

After removal of the mamma for carcinoma, in favourable circumstances, some patients remain healthy. Those practitioners who do not recognise the malignant disease, and operate for every tumour, and at all ages, have boasted of great success. But it is not so with those of mature experience. The _disposition_ to malignant action often remains latent for many months, sometimes for many years, and at length becomes fully developed. The disease may return in the skin; the cicatrix hardens, ulceration occurs, and makes progress. Or tubercles form in the cellular tissue, enlarge, and involve the skin. Or the glands become tender and swell; and the swelling is often unattended with uneasiness. Œdema of the hand and forearm, to a great extent, may have existed for a considerable time, and on examination extensive glandular tumours are detected in the axilla and above the clavicle. These, perhaps, ulcerate; or cough and hectic cut off the patient. In short, permanent riddance from mammary carcinoma is scarcely to be expected by operation, or any other means.

Neither are operations for medullary and bloody tumours of the mamma more successful in their results; though I have certainly witnessed permanent cures under unpromising circumstances,—when the tumours were large, of long duration, and even ulcerated.

AFFECTIONS OF THE CHEST.

Inflammation of the pectoral serous tissue would come to be considered more properly in a work exclusively on the practice of physic; but the affection not unfrequently occurs in consequence of wounds or other external injuries, and its terminations must be shortly noticed.

Effusion of serum may take place into the cavities, attended with subsidence of the symptoms of pleuritis. In such circumstances, the lung collapses, either entirely, or still admits a small quantity of air; and, if the collection lodge for a considerable time, that side of the chest enlarges. When the cavity is not quite full, the fluid is heard to be troubled, and on motion of the trunk a sound of splashing is perceived. Part of the cavity may be occupied with air which has escaped from an opening in the lung; or halitus may be extricated from the accumulated secretion. There are other signs, sufficiently distinct, imparting a knowledge of such effusion. The previous history of the case leads to a shrewd suspicion. The chest is unnaturally immovable, as well as enlarged; the intercostal spaces are widened, and ultimately protuberant; there is dulness on percussion, and no respiratory murmur perceptible in those parts where there is fluid; the sounds are natural in that part of the lung which is permeable to air, and distended.

Suppuration often is the result of the incited action; and purulent matter forms in the cavity of the pleura, generally without breach of surface. The membrane is covered with lymph, more or less extensively organised. _Empyema_ is established. Suppuration may take place in the substance of the lungs, and from ulceration the matter may escape, in small quantity at a time, into the bronchial tubes, giving relief to the patient; or it may be poured in profusely and suddenly, so as to cause instant suffocation; or it may work its way into the cavity of the pleura, and occupy the same place as if it had been secreted by that membrane. Or, again, if the lung adhere to the costal pleura, the matter may approach the surface of the body, by the aid of interstitial absorption of the intervening parts, and the collection may then be opened, like a common superficial abscess, by division of the integuments only.

When the pleura is full, the chest enlarges, the integuments become œdematous; and if, from the preceding and collateral circumstances, no doubt exist of the presence of matter, paracentesis may be performed with a chance of relieving and saving the patient. The patient is placed horizontally, with the shoulders slightly elevated; and the affected side should be as dependent as possible, that he may be readily turned over on his face should the breathing become embarrassed. The position of the diaphragm, in regard to the inner surface of the false and lower true ribs, must be kept in view. When the distention is great, this important muscle is displaced; it is pushed downwards, carrying before it the viscera in the upper part of the abdomen; it is thus removed far from the place at which the incision is usually made. The point of election, as it is called, is between the fifth and sixth ribs, and midway between the sternum and the spine. An incision is made through the integuments, over the upper edge of the sixth rib, an inch and a half in extent; in this situation there is no risk of wounding the intercostal artery. If the operator intend to shut the cavity as soon as the fluid has been discharged, the integuments are drawn upwards previously to making the incision, in order that they may afterwards overlap the wound. A cautious opening is then made through the intercostal muscles, and the pleura punctured. This is immediately followed by forcible ejection of fluid. The wound of the pleura is then enlarged by a probe-pointed knife. The thrust of a trocar, or sharp-pointed bistoury, is here inadmissible, as in some cases the diaphragm, perhaps the liver or stomach, or even the lung, might be wounded. The fluid at first escapes rapidly; afterwards it is ejected chiefly during expiration. After its discharge, a tent is placed in the wound, over which a compress is put, and the chest is firmly bandaged. The closure cannot be maintained safely longer than twenty-four hours; the dressing must be undone, the tent removed, and the matter again allowed to flow. I would certainly not recommend any attempt to heal the wound by the first intention. In consequence of continued closure, the secretion soon becomes very profuse, mixed with blood, and of a putrid nature; irritative fever is established. The treatment principally consists in obtaining gradual, and at the same time free, evacuation of the fluid, restraining the motions of the chest, and supporting the general strength. As the discharge ceases, the lung may in part expand; it may, however, continue collapsed, become consolidated, and the chest fall in. In neglected cases, absorption of the intercostal substance takes place; the integuments bulge outwards, and distinct fluctuation is perceived. The skin has been allowed to become thin, and even to give way, without the nature of the case being known; but this can be the result only of ignorance or of inattention. In such cases, the ribs have been denuded, and become necrosed to a large extent,—the sequestra separating slowly and in fragments; and causing long-continued and wasting discharge. It is plain, therefore, that pointing of the matter should never be waited for. Chronic collections are occasionally met with of some years’ duration, and producing great enlargement of the chest. Surgical interference with such is less likely to prove beneficial than with the acute.

Wounds of the large bloodvessels of the chest, or of the cavities of the heart, are almost immediately fatal. Mere punctures, however, of these parts, have closed for a time, and in some cases even permanently. All wounds of the chest, though not involving bloodvessels of a large size, are productive of severe consequences—effusion of blood or bloody fluids into the cavities, escape of air into the external cellular tissue, collapse of the lung, and inflammation and its results, are always to be dreaded. The danger is not uniformly tantamount to the extent of injury inflicted. Individuals have recovered from extensive wounds causing profuse hemorrhage, and great displacement and laceration of the parts; whilst, from much slighter injuries, untoward and fatal consequences have quickly resulted. Wounds may penetrate the chest, and be continued into the abdomen; the stomach, liver, and intestines—one or all—may be perforated as well as the lung; in such cases the hemorrhage is in general speedily fatal. Injury of the intercostal arteries, and of the mammary and its branches, is attended with serious bleeding. It is easily arrested, however, by pressure. A piece of fine linen is pushed into the wound, followed by charpie, so as to form a small bag within the chest, a little larger than the opening; by pulling this gently outwards and fixing it, efficient pressure is made on the bleeding vessel. At the same time the motions of the chest are to be restrained by bandaging; indeed this is necessary in almost all injuries of that part. When reaction has been established, antiphlogistic treatment must be pursued, and it generally requires to be extremely active. Bloody, serous, or purulent fluids, lodging in the cavity of the pleura, are to be evacuated, if need be, either by incision or by enlargement of the original wound. In the course of the cure hectic usually supervenes to a greater or less degree, and requires the reverse of the previous treatment.

AFFECTIONS OF THE ABDOMEN.

Inflammation of the peritoneum, when idiopathic, is generally treated by the physician. But it occurs in consequence of wound, obstruction from hernia, or affection of the lower bowels. There is a burning heat in the belly; the pain is constant and increasing, much aggravated by the slightest pressure or exertion of the abdominal muscles, and the patient, in consequence, lies with these muscles in a state of relaxation. The pain is of a very different character from that arising from spasm, induced by the irritating nature of the intestinal contents, which supervenes in paroxysms, and is relieved by pressure or by evacuation. In inflammation the countenance is very anxious, and generally pale; the extremities are cold and bathed in perspiration; the patient vomits frequently; and the bowels are generally constipated. The pulse is small, wiry, and rapid.

_Hernia_ has been classed with tumours. It is a swelling, but of a peculiar kind, and attended in some states by peculiar symptoms. The term rupture is in common use instead of hernia, but was at first applied from a false notion of the disease. There is a descent of viscera, but not often rupture of the parietes. By hernia is meant protrusion or escape of the contents of any cavity, but the term is most frequently applied in regard to the abdomen. The protrusion may occur at various parts of the abdomen; through the diaphragm, constituting _Phrenic_ Hernia; through the umbilicus, constituting _Exomphalos_; through the dilated apertures for transmission of vessels, constituting _Ventral_ Hernia; through the inguinal canal, constituting _Inguinal_ Hernia; through the crural aperture, constituting _Crural_ or _Femoral_ Hernia. The most frequent forms are the inguinal and crural,—the effects of pressure or action of the muscles on the abdominal contents being concentrated towards the lower part of the cavity. It is but rarely that the bowels protrude through the sacro-ischiatic notch, or through the obturator foramen, or by the side of the vagina, or betwixt the bladder and rectum.

It is of great importance for the student to study attentively and reflect on both the healthy and morbid anatomy of this disease. When a hernia is strangulated, there is an absolute necessity for early interference; the bowels are obstructed, and their action inverted; feculent vomiting ensues, and enteritis is threatened, with all its dangerous consequences. He may meet with the affection at a very early period of his practice, and may be so situated as to command no assistance or advice; he must be guided by his own judgment and knowledge. He should be well aware of the relations of the parts to each other, and the changes likely to have been occasioned by the disease. If, through delay, the patient lose his life, or if an operation be attempted, and its object improperly accomplished, or not accomplished at all, his reputation may be blasted. But if he interferes skilfully, and at the proper time, and save his patient, relieving him at once from all his painful and dreadful symptoms, great credit and professional fame may be in consequence acquired. An examination of the healthy anatomy is not sufficient; many changes take place, which mere anatomical and physiological knowledge could never anticipate. Extraordinary displacements and adhesions occur. The parts are altogether changed; and repeated examination of the morbid state alone can impart the requisite knowledge to one previously well acquainted with the healthy structure.

In consequence of laceration or separation of fibres, hernia may occur suddenly, and even in the best formed parts, from very violent exertion—as in leaping, wrestling, pulling, lifting heavy weights; from sudden exertion of the abdominal muscles in any way; from blows, &c. Or the protrusion may come on gradually, after slight exertions, where the tendons are naturally weak or deficient; or it may be slowly induced by repeated and almost constant muscular action, as in urinary, intestinal, and pulmonary complaints: in such cases, slight pain is usually felt at the site of the protrusion before the tumour is perceived. The disease is often congenital. But the common cause of abdominal hernia is powerful action of the abdominal muscles, compressing the viscera to a greater or less degree, and with more or less suddenness; the viscera resisting the compressing force, react on the parietes, and these, yielding at the points which are naturally weak or deficient, permit enlargement of the coerced cavity by protrusion of part of the contents. When the compression and reaction are sudden and violent, the protrusion is the same; but when the former are not sufficient to overcome the cohesion of the parietes by a single occurrence, by repetition the morbid end is gradually effected, the hernia is proportionally slow in making its appearance, and gradual in its increase.

To understand the nature of _congenital scrotal hernia_, the student must recollect that the testicle in the fœtus is lodged in the cavity of the abdomen immediately below the kidneys, and resting on the psoas muscle; that it gradually descends into a process of peritoneum, called spermatic, which extends from the general peritoneal cavity down towards the scrotum, and which ultimately constitutes the tunica vaginalis. The orifice of this peritoneal pouch not closing immediately after the descent, may permit a fold of intestine to slip into its cavity, and remain in contact with the testicle. Or the testicle may, though rarely, contract in the abdomen an adhesion to a portion of bowel, and in its descent bring this along with it. In either case the bowel remain in its new situation, and constitutes congenital hernia.

_Hernia infantilis_ differs from the hernia congenita, and is a kind of protrusion peculiar to the early period of infancy. In the congenital form the protruded intestine is in immediate contact with the testicle, and surrounded by the tunica vaginalis testis; but in hernia infantilis a process of peritoneum is interposed betwixt the intestine and the vaginal coat. The affection occurs after the abdominal aperture of the spermatic process has closed, but before the rest of that process has become incorporated with the spermatic vessels and their surrounding cellular tissue. In fact, only the peritoneum proper has closed, and forms the septum between the cavities of the abdomen and of the tunica vaginalis; but being insufficient to withstand the impulse of the abdominal contents, yields before it, and descending along with the protruding portion of bowel, forms its envelope, or the proper hernial sac, within the cavity of the tunica vaginalis.

Such is the opinion generally adopted in regard to the nature of hernia infantilis; but its accuracy is doubtful. It seems more probable that the bowel, covered by a fold of peritoneum, is protruded into the cellular tissue of the spermatic chord, after closure and contraction of the spermatic process, and descending till it reach the upper and posterior part of the tunica vaginalis, adheres to this tunic, bulges it forwards, and is covered by it. On cutting down in such a case, the hernial tumour may appear to be lodged within the tunica vaginalis; whereas the bowel is actually placed exterior to the tunic and behind it. Indeed, the case is similar to the common scrotal hernia, only the tumour is behind, not anterior to the vaginal coat. And this relation of parts is more apt to occur in the infant than in the adult; for in the former the testicle does not for some time descend fully into the scrotum, and whilst it is lodged in the groin a fold of peritoneum protruded into the spermatic chord may soon contract adhesion with the tunica vaginalis, afterwards descending along with it and the testicle. The subjoined case, illustrative of the preceding statement, came under my observation in 1814.—J. S., æt. 21, was admitted into the Royal Infirmary, with symptoms of strangulation which had been of eight days’ duration. The hernia had existed from infancy; it was on the right side, and tolerably large. In the operation, on dividing the integuments and various coverings, a sac was opened, which proved to be the tunica vaginalis, containing the testicle, a considerable quantity of serum, and a large, smooth, transparent tumour above the testicle and behind the posterior layer of the tunica vaginalis. The operator was puzzled, but finally determined on cutting into this tumour; it proved to be the hernial sac, covered by the tunica vaginalis, containing three or four ounces of serum and a portion of omentum. The protrusion could not be returned; after relieving the stricture, the omentum was cut away, and the bleeding vessels tied separately. The patient died on the third day after. An analogous case is on record; and a third has been related to me by an old and experienced surgeon: in that instance, both the anterior and posterior layer of the tunica vaginalis, together with the true sac, were simultaneously divided; omentum and intestine protruded into the vaginal coat, and for a time the opening through the posterior part of that cavity and sac was mistaken for the inguinal ring. On extension of the incision, the nature of the case became more apparent, the stricture was relieved, and the protrusion reduced. A case, in many respects similar to those above described, occurred a few years ago in my practice at the North London Hospital. It is recorded in the _Lancet_ and in the _Practical Surgery_.

Children are sometimes born with deficiency of the umbilicus, and protrusion of bowel into the loose cellular tissue of the umbilical chord; the disease is termed _congenital exomphalos_.