imperfect, and cheesy or serous. It is also profuse, and protracted to a long period, and accompanied with fatal sloughs. The patient is debilitated by the discharge, the irritation excites hectic fever, and the case frequently terminates fatally." (p. 328.) The second kind, or Mumps, of which CHELIUS has just treated, GooD observes, "is altogether of a different kind" from his first kind; "is more extensive, more painful, and rarely tends to suppuration." This kind, he proceeds to say, "in advanced life, is sometimes apt to run into a chronic form, accompanied with very mischievous symptoms; in which state it is denominated a malignant parotid. This is more especially apt to take place in females, when menstruation is on the point of ceasing, and the general action of the system labours under some disturbance.” (p. 409.)]

138. This disease prevails mostly as an epidemic, more frequently in southern than in northern regions, in very changeable, especially moist and wet weather, and in spring time. Some consider it contagious; it, however, attacks only once during life; it seizes on all ages and both sexes, young people especially, and particularly young males. The severity of this disease differs materially in different epidemics.

139. Inflammation of the parotid glands not unfrequently occurs in typhus fever, sometimes with, sometimes without, benefit. Scrofula, syphilis, repulsed eruptions, often giving origin to it, or it is caused by improper use of mercury, carious teeth, difficult dentition, by cold, or by external injury. The character and course of the inflammation differs in these cases. It may be so severe as to run into mortification, but generally has a milder result, and passes into suppuration (1), hardening (2), and sarcomatous hardening of the parotid.

[(1) EVANSON and MAUNSELL (a) say, that the swelling of mumps "at times, but very rarely, will proceed to suppuration, and may cause immediate death, by discharging its contents into the larynx, if it burst internally, or lead to great deformity when it opens externally." (p. 216.)]

(2) MASON GOOD says, his parotid phlegmon "assumes, occasionally, a scirrhous hardness, and grows to a considerable extent; it has been extirpated, but with variable success, when upwards of three pounds in weight (b); sometimes with a cure (c); but, at other times, it has degenerated into a foul bleeding and extensive ulcer" (d). (p. 328.)

140. If the inflammation be mild, the preservation of warmth in the swelling by covering it with flannel, or bags of elder flower and so on, and the use of gentle diaphoretics, are sufficient. If the condition be decidedly inflammatory and the fever severe, antiphlogistic means, and even bloodletting must be employed; moderately, however, and with great caution. But, if the patient be very weakly, and the fever incline rather to the nervous type, mild infusions of balm, valerian, with solution of acetate of ammonia, camphor, and so on, must be given. When the swelling has not properly risen, when it has subsided, or when the perspiration upon it ceases, a blister may be applied. When the inflammation attacks the generative organs they must be kept warm, covered with flannel, and the testicles supported by a suspensory bandage. If the brain be attacked, blisters must be laid upon the scrotum and on the parotid glands and liquor ammon. acet. with warm drinks administered internally, and, in depressed vital powers, camphor, antimonial wine and the like. The vomiting originating in nervous irritation must be treated by suitable remedies both external and internal. If the swelling continue long and do not disperse, a volatile liniment with camphor is to be rubbed in.

141. If the inflammation of the parotid gland be connected with dyscratic

(a) Above quoted.

(b) KALTHCHMIED, Pr. de Tumore Scirrhoso trium cum quadrante librarum Glandulæ Parotidis extirpato. Jenæ, 1752.

(c) SIEBOLD, Parotidis scirrhosæ feliciter extirpatæ Historia. Erf., 1791.

(d) Commerc. Lit. Nor., 733-8.

state of the body, a corresponding general treatment must be had recourse to; according to the variety of the symptoms, leeches, mercurial friction, dispersing plasters, herb bags, and derivative remedies are to be used locally.

If the inflammation be critical, every thing must be withheld which may produce its revulsion. If the swelling be accompanied with a proper degree of inflammation, it must be simply covered with a mild poultice; if the living activity in it be too low, stimulating poultices and plasters must be applied.

142. When suppuration has taken place the abscess either breaks of itself under the use of the remedies mentioned in the treatment of abscesses, in which case the cure commonly soon follows; or the formation of abscesses is accompanied with severe symptoms, delirium, lock-jaw, and so on, under which circumstances the swelling is to be soon and sufficiently opened, so that the tension of the aponeurotic sheath of the gland may be relieved. According to its condition, the abscess must be treated with soothing or stimulating remedies. The treatment is always tedious; knotty scars and detached hardnesses readily form. If a fistulous aperture remain, through which the spittle flows, it must be treated by touching with lunar caustic, which, aided by proper compression, will close it (a). If the gland become hard, it must be treated after the ordinary rules.

III. OF INFLAMMATION OF THE BREAST.

SCHLEGEL, F. A., De Statu sano et morboso Mammarum in Gravidis et Puerperis. Jenæ, 1792.

MÜLLER, fragmentarische Bemerkungen über die Entstehung und Heilung der Entzündung und Vereiterung der Brüste bei saügenden Weibern; in VON SIEBOLD'S Chiron., vol. ii. p. 2, par. 344.

BOER'S natürliche Geburtshülfe und Behandlung der Schwangern, Wöchnerinnen und neugebornen Kinder, Wien, 1817, vol. iii. p. 23.

BENEDICT, T. W., Bemerkungen über die Krankheiten der Brust und Achseldrüsen. Breslau, 1825. 4to. I. IV.

COOPER, A. P., Illustrations of Diseases of the Breast. London, 1829. 4to.

JEANSELME, G., Mémoire sur les Inflammations et les Abcès du Sein chez la Femme; in Gazette Médicale. January, 1839.

143. Inflammation of the Breast (Inflammatio Mammarum) occurs in women either nursing or after that period; and is situated either in the skin and cellular tissue alone, or in the parenchyma of the gland itself.

144. If the inflammation occur during suckling, the breast on a sudden becomes tense, red, and swollen. If the inflammation be superficial, a regular smooth and shining swelling may be felt, but the secretion of milk does not always cease. In inflammation of the parenchyma of the gland the swelling is harder, different knobby swellings are felt, and the secretion of milk is completely stopped. It is not unfrequently accompanied with febrile symptoms.

145. The superficial inflammation of the breast generally subsides of itself; but, if the parenchyma be attacked, the inflammation at a certain stage proceeds to suppuration, and not unfrequently hardening remains. 146. The usual causes of this inflammation are cold, mental excitement, (a) For the further consideration of the treatment of fistulous opening in the parotid duct, see Salivary Fistula, par. 902.

mechanical injury and so on. Women who do not suckle, or who wean their children early, are specially subject to inflammation of the breast. In order to prevent it, they must use a strict diet, encourage perspiration, take purgatives; apply cotton fumigated with sugar to the breasts, rub the nipples often with spittle, and support the breasts.

[Too many women, to their great shame, refuse suckling their children, on account of the restraint which this, one of their most important duties, puts upon them; some, unfortunately, early loose the progeny they would sacrifice themselves to bring up; and others, either from ill-health or from soreness of the nipples, are incapable of giving suck. In all these cases the secretion of milk must be checked, and the milk already secreted induced to absorb. Spare diet and purging, as recommended by CHELIUS, will usually effect the first object. As to the second, an evaporating lotion of spirit of wine or Cologne water, kept constantly on the breasts, which are to be carefully supported, and, therefore, the recumbent position and undress are the best for the purpose. The ordinary practice of monthly nurses is continued and gentle friction of the breasts with oil and brandy performed three or four times a-day.-J. F. S.]

147. The same remedies must also be employed at the commencement of inflammation. And not until it becomes more active, and the swelling tense and hard, must warm softening poultices and soothing steam be applied to the breast, and emollient ointment rubbed in. If the inflammation disperse, the tension and swelling gradually subside; isolated hardenings slowly disappear under the use of softening poultices and mercurial salve. If the inflammation take place whilst the child is still suckling, it may be freely put to the breast, so long as the swelling and pain are not great. If with a free flow of milk the child cannot draw off sufficient, it must be withdrawn by a milk-glass in the intervals. If the inflammation become very severe, all attempts to remove the milk from the breast are injurious.

148. If the inflammation pass into suppuration, the softening poultices must be continued, cicuta or mercurial plaster applied, and the opening of the abscess left to nature. In general many openings take place at different parts, and they are to be treated in the usual way till they close.

If during suppuration fistulous openings are formed and the breast remain very hard, (which is commonly the case when the abscess is opened artificially, or lumps of charpie are introduced into the openings,) the before-mentioned mode of treatment can alone effect the resolution of the hardening and the closure of the openings.

After much experience, I cannot but reject the opening of abscesses of the breast recommended by many. There are, however, exceptions; when the abscess is very deep, when it has proceeded slowly, when the local pain is very great and the fever high, and profuse perspiration and continued restlessness are present. After the artificial opening, poultices must be always applied as above mentioned. In lengthy fistulous passages in the breast gland, LANGENBECK recommends the introduction of ligatures. I have, in such cases, even when the fistulous passages have been accompanied with much surrounding hardness, always attained my purpose with the treatment above stated. If milk escape from these passages, its secretion must be lessened by the use of purgative remedies, together with a sparing diet; or, in weakly constitutions, by the use of bark and strengthening food. Nothing is more objectionable than the introduction of tents into fistulous passages of the breast gland, or, as has been very recently advised, the putting in little tubes to keep up the flow of pus. The irritation is always thereby much increased and hardening of the whole neighbourhood originated.

[CHELIUS's recommendation of leaving "the opening of the abscess to nature" must on no account be followed, as its certain result is, according to his own observation, the occurrence of "many openings at different parts" of the breast, and the necessary production of very unsightly scars, which most grievously annoy the patient and her friends, and deservedly discredit the reputation of the medical attendant. The abscess is always to be punctured freely, so soon as fluctuation can be distinctly felt, and whilst the walls of

the abscess are still thick. The almost immediate ease gained by relieving the tension of the fibrous covering of the breast gland is the first advantage obtained; the burrowing of pus is also prevented, and thereby a smaller cavity left, when emptied, to fall together and fill up by granulation; and, most important of all, the sloughing of the skin almost to a certainty precluded. No squeezing or kneading of the breast to evacuate the pus, as often most improperly practised, is to be on any account resorted to, the agony thereby produced is extreme, the benefit gained nothing, for the aperture made should be sufficiently large to permit the free escape of the matter, which, having been allowed to flow as long as it will, a strip of lint, oiled, is to be introduced between the lips of the wound to prevent their union, and a light bread poultice, or warm fomenting flannels laid over the breast and repeatedly renewed. In the course of a few hours the lint should be withdrawn, and the wound generally remains sufficiently open to permit the continual flow of the pus. If, as not unfrequently happens, clots of adhesive matter, or dead cellular tissue, block up the opening so that the matter does not readily escape, they may be gently removed if they protrude between the lips of the wound. But, if not, and the pus be still retained, a grooved director should be very gently introduced into the cavity of the abscess, and by its canal the discharge will pass; but no pressure is on any account to be used. If a second, or even a third, abscess point, or if the same abscess point at a different part of the breast, these are severally to be opened as they occur, the prime object of the treatment being to remove every chance of sloughing and scar of the skin. Oftentimes the first discharge is extremely fetid, more particularly if the opening of the abscess have been delayed, or if it have been left to burst spontaneously, and in these cases the constitutional excitement is frequently very great, amounting even to delirium. The character of the suppuration, however, usually soon becomes healthy, and the febrile symptoms speedily subside. CHELIUS's objections to passing tents or tubes into the fistulous passages, which generally alone occur from leaving the abscess to burst of itself, are well founded; they never ought to be employed. Neither should LANGENBECK's plan of introducing ligatures be for a moment thought of; it is very bad practice.

Fistulous passages almost invariably occur from the pus not having a convenient and complete discharge. Sometimes gentle, well-applied pressure along the course of the sinuous passage may be sufficient to produce inflammation and adhesion of its walls; but, if not, or if the patient cannot, as sometimes happens, bear the necessary pressure, then a probe should be introduced, and its extremity cut down upon through the skin at that part of the sinus which is most depending. Usually in a few days the old aperture heals, the pus is discharged by the new wound, and soon a cure is effected. As a general rule, injections of these adventitious canals is not advisable; but, when the opening is at the most depending part, and they can be employed simply to wash out the canal and slightly irritate it, but without being retained, which will often create more inconvience than that to be got rid of, then they may be used with discretion. A mild solution of sulphate of zinc is, I believe, the best injection.-J. F. S.]

149. After previous inflammation there frequently remain the so-called Milk-knots, (Milchknoten, Germ., Ganglions laiteux, Fr.); or they appear at a shorter or longer period after the suppression of the secretion of the milk, or after weaning the child, in cases where the secretion of milk seemed to have entirely ceased. Their hardness varies, and is often cartilaginoid, though only containing milk; they may remain for a long while, and on superficial examination are easily mistaken for scirrhus. Their termination is in resolution, which is still possible after a long while, or in suppuration if they accidentally inflame. The remedies which effect their dispersion are, gentle rubbing of the breast towards the nipple, sucking the nipple, softening poultices, especially oatmeal, linseed meal, cicuta, hyoscyamus, saffron and oil, rubbing in lard and hartshorn. Some recommend belladonna internally. The dispersion is always accompanied with a flow of milk from the breast. Milk-knots which have not yielded to any remedies often subside at the next lying-in.

150. Inflammation of the breast, apart from suckling-time, has generally an insidious course. The pain in the neighbourhood is very slight; but the swelling of the breast is always very hard, and the inflammation has a marked disposition to hardening. Its causes are external injury, dyscracy,

scrofula, gout, syphilis, and so on. In many cases the inflammation sets in without any manifest cause, and the ground of the irritation may be merely the sympathetic relation of the breast to the womb, which discovers itself especially at the period of decrepitude, and in unfruitful women, in whom the functions of the womb have never gone on regularly.

151. The treatment of such inflammation must be guided by the previous mischief. Repeated application of leeches, infriction of mercurial ointment, warm covering of the breast, and internal remedies suited to the general dyscracy, are here required, although they can rarely prevent the production of hardening. When this takes place, it must be treated after the general rules.

152. In rare cases, either during suckling or not, deep-seated abscesses form in the breast gland or between it and the pectoral muscles, the formation of which is connected with a deep-seated pain, at first shifting, burning, tearing, with a considerable colourless swelling of the whole breast, and pain on moving the arm, and it continues for a long time before any external fluctuation can be perceived. The pus frequently makes its way out at several points, and the breast gland is hard and swollen. If these suppurating passages be opened, they present a soft reddish fungus. When fluctuation in such abscesses can be ascertained, they must be opened early. If fistulous passages have formed, they must be laid open throughout their whole length, or, in order to prevent deformity of the breast, and interference with its function, (according to LANGEN BECK, the ligature should be introduced,) softening poultices and rubbing with mercurial ointment should be employed. If a part of the breast be so distended by these passages that, after opening them, it seems to hang as it were by a neck, it should be entirely removed; the cure soon follows. The passage to suppuration may perhaps be prevented by the early employment of diaphoretics, by emetics, by dry warmth, and by the application of derivative blisters in the very neighbourhood of the breast. HEY, WILLIAM, Surgical Observations.

RICHTER'S, Medicinische und chirurgische Bemerkungen, vol. i. p. 50.

LANGENBECK, Nosologie und Therapie der chirurgischen Krankheiten, vol. ii. p. 264. [In the description which ASTLEY COOPER gives of chronic abscess of the breast, it will be seen that he had not noticed the severe pain to which CHELIUS alludes. "Under chronic inflammation," says COOPER," an abscess is sometimes produced, which, from the length of time it is forming, from the little pain which attends it, from the absence of redness and heat in the part, and from the want of rigors and other constitutional symptoms, prevents the suspicion of the formation of matter, and the swelling is supposed to be a malignant tumour, which requires an operation for its removal." (p. 14.)

I had once the ill luck of operating on such a case, of which the following is the account, and will be found to tally so nearly with the ordinary history and course of scirrhus that I may be held excused.

CASE-E. S., aged forty-five years, a married woman, admitted,

July 23, 1835. About twelve months since received a blow on the right breast, and four months after, whilst suckling, received another, but she felt nothing more than a slight shooting, of which she took no heed till after weaning her child four months since. She had not suckled from this breast, as the last child would not take it; but the secretion continued, and the milk flowed out till she ceased to suckle. After weaning, the breast began to swell, and she first noticed the lump, for which she applied leeches and fomentations. These diminished the general swelling, but without dispersing the lump, which, on the contrary, continued increasing, accompanied with smarting pain, and at the time of her admission was about the size of a pigeon's egg, situated just below and to the outer side of the nipple, with the skin slightly adherent, very hard, and the nipple somewhat retracted.