matter, from the sense of fluctuation, and from the tenderness the patient expressed upon slight pressure, which would not have been the result if a serous fluid had been collected. "In similar cases I have seen the operation for removing the swelling begun, and in its progress, the knife having accidentally entered the abscess, the Surgeon, by escape of the matter, having been informed of his error, the operation was suspended, and a poultice being applied, the case ended favourably." 15.

As, in these cases, there is generally some fault in constitution, or vitiation of the secretions, the compound calomel-pill should be given at night, and the bark with soda two or three times a day-or the compound infusion of gentian, with soda and rhubarb.

LACTEAL OR LACTIFEROUS SWELLING.

This is so denominated by our author, because he supposes it to arise from a large collection of milk in one of the lactiferous tubes, the result of chronic inflammation in one of these conduits, near the nipple, with closure of its aperture, and obliteration of the canal for an inch or more.

"The patient applies to the Surgeon some time after delivery with a swelling in the breast; unpreceded by the symptoms of abscess, it distinctly fluctuates, and she complains exceedingly of a sense of distention in the part; and when the child is put to the breast to relieve it, the pain and distention are increased by the draught of milk which enters the breast so soon as the child begins to suck. The swelling is confined to one portion of the breast, from the nipple to the circumference of the organ, and it gives a distinct sense of fluctuation. The cutaneous veins are very large, but the part is otherwise undiscoloured. If a lancet be passed into the swelling, several ounces of milk are discharged; and the milk being suffered to rest for a few hours, forms a cream upon its surface. If a slight puncture only be made, the milk be discharged, and the opening suffered to immediately close, the accumulation recommences, and in a short time the same appearances and sufferings are renewed.

"When the distention of the swelling is excessive, it sometimes ulcerates, and discharges the milk which it has contained, by a small aperture at a little distance from the nipple; and the opening so produced often continues through the whole period of suckling, the milk being lost, from the aperture not being received into the child's mouth and this opening is difficult to heal, until by weaning the child, and by purges, the secretion of milk be entirely checked.

"The treatment which this case requres is as follows :-If the mother be prevailed upon to wean her child, as the secretion of milk will soon cease in this obstructed part as in other parts of the breast, a simple puncture will suffice to relieve the distended tube of the milk which it contains.

"But if the child still continue at the breast, the opening may be made larger, and the milk be suffered to escape at the artificial aperture whist the child is sucking; thus imitating the natural relief which the ulcerative process sometimes produces, until the secretion of milk ceases, from the weaning of the child, and from purges to the mother." 18.

CHAP. III. HYDATID DISEASE OF THE BREAST.

There are four species of these swellings-three of which are non-malignant. To the description of these our author directs his attention.

1st Species-Simple bags containing a serous fluid, and which Sir A. calls cellulous hydatids. Symptoms:--The breast gradually swells, being free from pain or tenderness--becomes hard, without fluctuation--enlarges gradually for months or even years, sometimes acquiring great magnitude. Sir A. has seen one breast weighing nine pounds.

"At first the swelling feels entirely solid, so that it bears a great resemblance to a simple chronic enlargement of the breast; but after a great length of time, a fluctuation can at one part be discovered in it, and then the breast begins to increase more quickly; and in several parts similar fluctuations can be detected.

"The cutaneous veins become varicose; but although the breast is immensely enlarged, it still continues almost entirely free from pain: but to this there are exceptions, for some persons feel an unusual heat, and some, as the breast increases, suffer pain in the part and in the shoulder.

"The tumour is extremely moveable upon the pectoral muscle; is very pendulous; and in some cases the whole of the mammary gland, in others only a small portion of it, becomes involved in the disease.

"At length one of the fluctuating portions of the breast slowly inflames, ulcerates, and discharges a large quantity of serum, or of a fluid having its general character, but of a consis ence somewhat more glairy; and the sac being emptied, and the external opening closed, if the fluid be entirely discharged, it is a long time before it re-accumulates; and sometimes the sides of the sac adhere, and the cyst ceases to secrete. In other instances I have known the swelling break, and discharge a mucilaginous fluid mixed with serum; and several of the cells in succession, and at distant periods, pass through the ulcerative process, and form sinuses, which are very difficult to heal." 22.

Except during ulceration, the general health remained undisturbed, and nothing but the apprehension of CANCER would induce the patient to make her case known or submit to an operation. However large the breast becomes, however extensively it ulcerates, however freely it discharges, yet the axillary glands remain free from disease.

Dissection.

"When the swelling, and the breast in which it is situated, are examined, it is found, upon a careful dissection, that the interstices of the glandular structure itself, and the tendinous and cellular tissue connecting it, are in a great measure filled with fibrous matter, poured out by a peculiar species of chronic inflammation; but in some of the interstices a bag is formed, into which a serous or glairy, or sometimes a mucous fluid is secreted, according to the degree of inflammation attending it; and this fluid, from its viscidity, and from the solid effusion which surrounds it, as well as from the cyst being a perfect bag, cannot escape into the surrounding tissues; but by its quantity, its pressure, and by the gradual yielding of the bag, it becomes of very considerable size; and vast numbers of these cysts are found to occupy each part of the breast, producing and supporting a continued but slow irritation, and occasioning an effusion of fibrous matter, by which the breast forms an immense tumour, consisting of solid and fluid matter. Within these bags of fluid, Hydatids, hanging by small stalks, but some, which from their appearance I supposed to be simple cells before I opened them, instead of being entirely hollow, had a cellular tissue within them, in which a fluid was collected, which, although it produced the appearance of cells or Hydatids on the outside, within, assumed character of anasarcous swellings.

"The breast, when not greatly enlarged, is almost entirely filled with cellulous Hydatids: some are produced in clusters, but the greater number are completely distinct from each other; and in those cases in which the breast is but slightly increased, the constitution is but little irritable, and only a slight adhesive inflammation accompanies it." 23.

The size of these cells varies from that of a pin's head to that of a musket-ball, of which an example is seen in the first plate. The cyst contain

ing the fluid is highly vascular, the veins being greatly dilated. This disease, in its first stage, resembles simple chronic inflammation; but is distinguishable from it by the absence of tenderness on pressure, and the good health of the patient--proving it to be an entirely local disease. in the second stage, when fluctuation exists, it may be distinguished by the distinct seats of the fluctuation, and by the absence of tenderness; but the surest criterion is puncture of the bag, when a clear serum will be evacuated, instead of pus. From scirrhous tubercle it is to be discriminated by the absence of those occasional acute darting pains that accompany malignant affection--by the continuance of health-and by the absence of that excessive hardness which characterises scirrhus. Sir A. has, however, seen a case "where true scirrhus had hydatids connected with it.' The tumour was removed, and again returned. It had the usual pain of scirrhus.

"In the treatment of Hydatid disease, no local applications are beneficial, and the constitution requires no attention, because the general health does not suffer from the complaint. "If only one bag is discovered, and that is of considerable size, it sometimes, if punctured, does not again fill, as will be seen in several of the cases

"But when the enlargement is excessive-when a multitude of bags are producedwhen the weight of the swelling becomes several pounds-when the breast is very pendulous, and drags upon the surrounding parts, and shakes upon every motion-when there is great apprehension, on the part of the patient, of some malignant disease, then the Surgeon will be wise in removing it.

"The operation itself is a simple piece of dissection, in which it is the best plan to secure each divided vessel in immediate succession, to prevent any great loss of blood; but it must be confessed that this is not absolutely necessary, as the operation does not require much time in its performance, and the vessels can be compressed by an assistant, whilst the Surgeon is removing the tumour; or, if he prefer it, each vessel may be secured in a ligature, as the operation proceeds.

"When the tumour requires removal for this disease, it is necessary to take away all the hardened and swollen parts of the breast, for they have cysts, or cells, formed in them; and if any cyst be suffered to remain, it will still continue to grow, and the remaining part of the breast to form an Hydatid tumour." 26.

It is a great consolation to know that this disease does not contaminate other structures in the neighbourhood. Numerous cases in illustration of the foregoing observations are detailed by our author; but of these we can only notice one or two.

CASE VIII. LADY HEWETT, ETAT. 60.

In November, 1815, Lady H. fell against a chair, and some weeks afterwards felt uneasiness in the right breast, extending to the axilla. In January, 1816, she discovered a small tumour in the same breast, just below the nipple. By the middle of the year the tumour was the size of a melon, and she was sent to Harrowgate, where she applied leeches every day for two months--and afterwards every second day till September. Pressure was next employed by means of bandages and machines, but without advantage. The swelling increased, and it was left to Nature till November, 1817, when it began to undergo a change. It increased quickly and became soft at its upper part, apparently suppurating, but matter did not form, though poultices and fomentations were applied. An operation was then determined on, which our author performed on the 10th of June, 1818.

"The swelling was of great size, weighing nine pounds. It was in part solid; in some parts evidently contained a fluid; and upon the surface of the cyst part there was a

slight blue tint. The swelling was moveable, and reached to the upper part of the abdomen. Lady H.'s general health was good.

"The first steps of the operation consisted in making a puncture into the tumour at its most prominent part, and discharging a quantity of serum from it; by which it was at once clear the disease was of the Hydatid kind, and the magnitude of the swelling was lessened. "An incision was then made across the tumour, a little above its middle, and the flap of the integuments being raised, the upper part of the swelling was detached from the pectoral muscle, and with the handle of the knife the swelling was further separated; and a flap of skin being left below to meet that at the upper part, the operation was then concluded. Its removal was borne with great fortitude. Two arteries of considerable size required to be secured The integuments were brought together by a single suture, and by adhesive plaster. On the 16th of June the wound was first dressed, and the 30th Lady H. was quite well." 34.

We understand lady Hewitt is now in good health at the age of 71. The removed tumour forms the subject of the second plate. A section is made through the tumour, and it is seen to be composed of a solid fibrous material, (coagulable lymph,) in which there are cavities containing hydatids. This is a splendid plate, and highly illustrative of the subject.

CASE XII. CELLULOUS HYDATIDS WITH SCIRRHOUS TUBERCLE.

This was an unfortunate case. The patient was a Miss S, of Canterbury, aged 29 years, apparently healthy, but of thin and spare habit. Twelve months prior to consultation she perceived a small swelling in her left breast, attended with a sense of aching on pressure. When she had a cold on her, she experienced a thrilling pain, with darting in the part, and a sense of soreness in the nipple. The swelling increased, together with the pain and tenderness, and, on the 20th November, 1822, she came to London to undergo an operation The tumour was now very hard, and impressed Sir Astley's mind with the idea of its being a scirrhous tubercle. Still her youth, health, and the fulness of the breasts, induced a hope that it might not be malignant. The operation was performed on Saturday, the 23d November. The tumour was deeply buried in the breast. On the succeeding Tuesday she had a rigor, succeeded by erysipelas, from which she narrowly escaped. Upon dissection of the tumour, it had the appearance of scirrhous tubercle at its upper part, while, at the lower, there were found several cellulous hydatids, as may be seen in the first plate. In about twelve months the disease returned, and the patient ultimately died of deeply ulcerated cancer, in the year 1826.

The second species of hydatid disease in the breast is of a very curious nature, and cannot be quite clearly understood without reference to the plate. The tumour was taken from breast of Mrs. King, of Charing Cross, and the following graphical description we shall give in the words of the author.

"The breast was, in this case, enlarged, and in the greater part hardened by the effusion of fibrine (coagulable lymph) in lobes into the cellular tissue; but in several parts it contained bags of serum, and formed fluctuating cysts of various sizes. In each of these cells there hung a cluster of swellings, like polypi, supported by a small stalk; and the little pendulous projections appeared to float in the fluid which had been produced around them in the different cysts.

"Many Hydatids were found in a detached state, both in the fluid within the bags, and in the solid effusion in the breast; and taking the whole tumour, vast numbers of them had been formed in it.

"Their size varied, but the largest did not much exceed that of a barley-corn, the figure of which they assumed.

In general they were of an oval form, or I ought to say oviform, as they were larger at one end than the other.

"When opened, they were found to be composed of numerous lamellæ, like the crystalline humour of the eye, or like the layers in the onion, which could be readily peeled from each other.

"When removed from the breast, they had a pearly appearance and the laminated character of pearl internally.

"The cyst in which they were contained was a perfect bag, and it was composed internally of a membrane which was highly vascular, like other secreting surfaces; and the solid part surrounding the cyst had a greater number of vessels near the bag than at a remote distance from it; but the whole of the diseased structure was endowed with great vascularity, as will be seen in the Plate.

66 Upon examining Plate the 4th, seven of these bags will be seen with clusters of pendulous tumours growing in them, connected by the stalks, which are delineated in Plate the 3d, and which contains sections from the same breast. Single Hydatids will be seen in the diseased solid structure, as well as cells containing a number of these bodies; and in one the cell is emptied, to show its vascularity.

"It is doubtful if these structures are not of the nature of globular Hydatids, (which is the next I shall describe,) and which have perished from the pressure of the solid matter with which they are surrounded; or whether they are productions, or secretions of the arteries of the part: but the determination of this point must be left to future observation and diagnosis," 42.

In its external characters this disease resembles the first species described the absence of tenderness common to both, will distinguish it from the simple chronic disease of the breast. From the former species of hydatid disease it cannot be discriminated. Extirpation is the only mode of relief; for no constitutional remedy can check the progress of the disease. A puncture of the cyst gives temporary relief-but the extirpation is free from danger, and by it the patient's mind is secured from future apprehension.

Mrs. King, of Charing Cross, ætat. 58, had an enormous enlargement of her left breast, which she first discovered fourteen years ago, and then supposed it arose from a blow. When she first observed it, its size was that of a marble; it felt hard, and was unattended with pain.

"It appeared to be buried in the substance of the breast, and was not very movable in the glandular structure. It increased gradually until two years ago, by which time it had acquired the size of a melon. At that period it seemed to increase suddenly, and to grow faster than before; but it was still unattended with pain, and her general health did not appear to suffer.

"Last Christmas it again suddenly increased; but was still devoid of any painful sensations excepting that sometimes when she had a cold, she felt a slight uneasiness in the part. "On the 30th of September, 1822, I first saw her, and the tumour then measured thirtyfive inches in circumference; in the greater part it was solid, but in other parts it was soft and fluctuating and one bag evidently contained a large quantity of fluid.

"The solid portion of the tumour was placed at its upper part; the fluid occupied the lower part of the swelling. Her general health was good, but she suffered much from its weight drawing down the skin and pectoral muscle, and putting the nerves exceedingly upon

the stretch.

"On the first of October I removed the tumour in the presence of Mr. Key, of Guy's Hospital, and Mr. Lavies, a Surgeon in Westminster.

"The large vessels, divided in the operation, were immediately secured, or compressed by an assistant as soon as divided, so as to prevent any loss of blood in the operation.

The wound, when dressed on the seventh day, appeared healthy. The irritative fever consequent upon the operation was very slight, and she recovered without any untoward circumstances." 45.