and as yet there is no enlargement of the axillary glands, the diagnosis from an innocent tumor, a tense cyst, or lobular inflammation will be, to say the least, difficult. The age of the patient, the rate of growth, and the history of the case must then to a great extent be relied upon for distinguishing it. But where the patient, as is occasionally the case, is young, the diagnosis may then be impossible without making an incision into the growth, a proceeding which, under such circumstances, after the difficulty has been explained to the patient, is not only justifiable but imperatively called for. 66 Rarer forms of scirrhus in the breast are occasionally met with. Thus-1, the cancer may begin as a general infiltration of the entire gland, when its course is usually very rapid; 2, it may chiefly affect the skin, the whole side of the chest in such a case becoming infiltrated, hard, brawny and leathery in consistency, a condition sometimes known as hide-bound; 3, it may begin as an infiltration of the nipple, or may be engrafted upon chronic eczema around the nipple; 4, in elderly women it may run a very chronic course, often remaining stationary, if not interfered with, for many years; and, 5, in very exceptional instances, the carcinomatous mass has apparently undergone complete atrophy, even, it is said, after ulceration has occurred, and a spontaneous cure has thus been brought about. Treatment. In the breast, as elsewhere, the only hope of cure lies in the early and complete extirpation of the carcinoma. Unless, therefore, the surgeon is consulted before the skin, pectoral muscle, and the lymphatic glands, are more than slightly involved, he can hold out but little prospect that the disease will not return, and return shortly; and that life will be materially, if at all, prolonged by an operation. Under such circumstances, therefore, there are some surgeons who hold that an operation with the disease thus advanced ought not to be undertaken, as it can only bring discredit on surgery, and may possibly prevent other patients seeking advice while there is yet a probability that a free and complete removal of the breast and axillary glands may eradicate the disease. While admitting that this may be true, we must not lose sight of the fact that even although the growth may soon recur either in the cicatrix or glands, or in internal organs, and although life may not be prolonged, still, removal of the growth may rid the patient of a foul and loathsome disease and often of great pain, at any rate for a time, and death may occur in a less distressing way from dissemination of the carcinoma in internal organs. In the meanwhile the patient's mind will be relieved, even if she is not buoyed up with the hope that there may still be a chance of a non-return. Regard ing the question of operation, therefore, it may be briefly said that-1. When the skin is not involved, or to a very slight extent, the tumor not adherent to the pectoral muscle, and the glands are not felt enlarged, or if enlarged are not hard, free removal of the breast and clearing out the axilla is imperatively called for. 2. Where, on the other hand, the skin is extensively infiltrated, the tumor is firmly adherent to the pectoral muscle, the glands are enlarged, hard, and adherent to the side of the chest, enlarged glands can also be felt above the clavicle, and perhaps have already caused cedema of the arm, marked cachexia is present, and there is evidence of dissemination of the carcinoma in other organs and tissues-then no operation should be performed. In cases such as the above, there can be little question as to the propriety of operating or not operating. But there is a large class of intermediate cases in which some surgeons would, and some would not, operate. Much will then depend upon the presence or absence of pain, and each case must be judged on its own merits. MEDULLARY CARCINOMA is much less common in the breast than the scirrhous form, and generally appears at an earlier age. It occurs as a soft, non-encapsuled, compact, white or bloodstained, brain-like mass infiltrating the gland and surrounding tissues. Its growth is much more rapid than the scirrhous variety, and it sooner involves the skin, pectoral muscles, and axillary glands, and rapidly becomes disseminated through internal organs. Early and free removal of the whole breast, and of any glands in the axilla that may be felt enlarged, is the proper treatment. Other varieties of carcinoma in the breast, as the so-called villous and the colloid, are too rare to require further notice in a work of this description. EXCISION OF THE BREAST.-The arm being held out from the side by an assistant so as to put the pectoral muscle on the stretch and well expose the axilla, an elliptical incision should be made below and another above the nipple, cutting widely of any adherent or infiltrated skin. The skin above and below should now be reflected from the breast, and the latter dissected off the pectoral muscle, taking care to remove the pectoral fascia and any portion of the muscle that appears affected with the disease. Should any gland be felt in the axilla, the incision should be prolonged in an upward and outward direction, the axillary fascia opened by the scalpel, and all the glands that can be felt enucleated in part by the fingers, and in part by the handle of the scalpel, taking care not to injure the axillary vessels or large nerve cords, both of which are situated at the upper and outer part of the space. The skin should be now drawn together by sutures, a drainage tube having been placed in the deeper part of the wound. Where the skin cannot be made to cover in the wound, the flaps should be drawn as much together as possible by stout silver sutures, and the remainder of the wound left to granulate. The arm should be secured to the side with the forearm and hand across the chest. DEFORMITIES OF THE NECK, KNEES AND FEET. WRY NECK OF TORTICOLLIS is a distortion chiefly dependent upon contraction of the sterno-mastoid muscle. It may be congenital or acquired. Causes. The congenital form is attributed to-1, spastic contraction of the sterno-mastoid muscle due to disease of the nervous system; 2, malposition in utero; or, 3, injury at birth. The acquired form is due to-1, the head having been held for a long time in the distorted position as a consequence of stiff neck following cold, injury, or inflamed cervical glands; 2, hysteria; or, 3, spasm set up by irritation of the spinal accessory nerve consequent upon central nerve trouble. FIG. 227. Signs.-The head, supposing the right sterno-mastoid to be affected, is drawn forward and toward the right shoulder and also rotated, so that the chin points to the left. The right mastoid is prominent, the right side of the neck concave, and the left convex. In long-standing cases some lateral curvature of the dorsal spine is generally acquired. The congenital form may be distinguished from the spasmodic not only by its history but by the sterno-mastoid becoming tense in the former and yielding in the latter on attempting to straighten the head. The hysterical variety will be known by the presence of other signs of hysteria. Treatment.-In congenital wry neck division of the sterno-mastoid is generally required, followed by a course of systematic exercises in the slighter cases, and the use of some such instrument as that shown in Fig. 227, in the more severe. The sterno-mastoid is best divided immediately above the clavicle, as here it is furthest removed from the import MANOLD ant structures that lie beneath it. A puncture wry-neck Apparatus. should be made at the inner side of the tendon, a director passed behind it, and the division made toward the skin with a blunt-pointed tenotome. The tense bands of con tracted cervical fascia which now start forward will yield to stretching; it is not safe to divide them. The puncture should be given three or four days to heal before the exercises are begun or the instrument is applied. In spasmodic cases conium, Indian hemp, bromide of potassium, etc., may be tried. These failing, the spinal accessory nerve may be stretched or divided just above the spot where it enters the sterno-mastoid; but tenotomy of the sterno-mastoid should in these and in hysterical cases on no account be done. In the latter, hysterical remedies should of course be used. KNOCK-KNEE OF GENU VALGUM is a deformity in which, when the knees are placed together in the extended position with the patellæ looking directly forward, the legs diverge. One or both knees may be affected, or there may be genu valgum on one side and genu varum on the other. Cause.-Knock-knee is generally the result either of rickets, when it occurs between the second and the seventh year; or of carrying heavy weights, long standing and the like, when it is most common in growing, underfed, and overworked lads and girls from fourteen to eighteen. The deformity is variously believed to depend on : 1, an overgrowth of the internal condyle of the femur, and a corresponding uprising of the inner tuberosity of the tibia; 2, the relaxation of the internal lateral ligament; or 3, the contraction of the biceps tendon. In the majority of cases the osseous lesion is certainly present, and I have no doubt in my own mind that it is upon this that the deformity usually depends, though I admit that in some of those rapid cases induced by excessive weight-bearing in weakly lads, a relaxation of the ligaments may be the principal factor. The contraction of the biceps tendon when present I regard as the result, and not as the cause, of the affection. Treatment.-In slight rickety cases keeping the child entirely off its legs, the application of splints, and the internal use of appropriate remedies, will generally effect a cure. In confirmed cases, and in older patients, however, little must be expected from splints or instruments. By their use the limb can no doubt be straightened, but only at the expense of stretching the external lateral ligament, the legs being rendered flail-like and the patient being unable to walk or even stand without his irons. For such some form of osteotomy is usually required. The best of these is, perhaps, Macewen's and Reeves' modification of Ogston's operation. 1. Macewen's operation consists in chiseling through the femur just above the epiphysis, but leaving the posterior surface, which is in contact with the popliteal artery, intact, and snapping this across by forcibly bending the bone. 2. In Reeves' modified Ogston's operation the internal condyle is first loosened with a chisel, and then made to slide upward on the shaft of the femur by forcibly straightening the leg. The chisel is introduced behind the synovial membrane and should not be driven sufficiently far into the condyle as to endanger the opening of the joint. The line of incision through the femur in these operations is shown in Fig. 228. The operations should be performed antiseptically and the limb secured to a long splint, or placed in Bavarian plaster splints in a straight position for about a month, and subsequently kept in an ordinary plaster case for six weeks to two months till sound union has taken place. GENU VARUM, or BOW LEGS, is the opposite deformity to genu valgum, and what has been said of the latter as regards pathology, treatment, etc., will apply to it if external be substituted for internal in the phraseology. frequently associated with a bowing of the shaft of the tibia, either at its upper or its lower third, and sometimes with a bowing of the femur. It is FIG. 228. A B A, line of section in TALIPES OF CLUB FOOT is a distortion in which the relations of the tarsal bones to each other and to the bones of the leg are variously altered, and the bones held in their abnormal position by the contraction or shortening of certain of the muscles, ligaments, and fascia attached to the foot. Cause. Talipes may be either congenital or acquired. The congenital form has been attributed to―1, spastic muscular contraction induced by some lesion of the nerve centres; 2, malpositions of the fœtus in utero; 3, structural alteration in the form of some of the tarsal bones. The supporters of the first view maintain that the bones are drawn into their abnormal position by muscular contraction, and regard any alteration in the shape of the bones as the result and not as the cause of their malposition; while those who uphold the second and third views deny that spastic contraction occurs, as no lesion of the nerve centres has been found to account for it, and look upon the contraction of the muscles as merely due to adaptive shortening consequent upon the altered position of the bones. The congenital variety is often hereditary, occurs in several members of the same family, and is frequently associated with other congenital malformations, as spina bifida, meningocele, etc. The acquired form is generally the result of infantile paralysis, the bones being then |