A. (Alfred) Velpeau.

A treatise on the diseases of the breast and mammary region online

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M. Velpeau's ' Treatise on the Diseases of the Breast'
belongs to a necessarily small class of works^ the chief value of
which lies in their practical character. It contains the results of
the experience of a man whose opportunities for observation have
been immense, and whose diligence in the use of them is familiar to
all professional readers. It can fall to the lot of but few to have seen
so much, and it is not in the power of many to have observed so
faithfully. Whatever advances, therefore, may be made in theo-
retical medical and surgical knowledge, the facts upon which this
work is based can never lose their value. It represents the views
entertained by a large class of the older surgeons, who, while
they have not, on the one hand, remained insensible to the value of
modern microscopical researches, have, on the other, hesitated to ac-
cord entire belief to doctrines which tend to overturn, on what they
consider insufficient grounds, the experience derived from years of
observation. In executing the task which, as Editor, the Council of
the Sydenham Society has been pleased to confide to me, I have
endeavoured, to the best of my ability, to preserve the peculiarities
in the style of the original, without wholly sacrificing the comfort
of the English reader. If he should be inclined to find fault with
the construction of sentences that too unmistakeably bear upon
them the marks of their foreign origin, T would beg him to


remember that, whatever ideal standard of perfection he may
propose for a translation, in practice the limit is almost neces-
sarily confined to a faithful rendering of the original, and leaves
but little scope for the graces of style.

It is not for me to express any opinion as to the value of this
Treatise ; but, as a key to certain peculiarities that may strike
the reader, it may be observed that M. Velpeau is a great
Clinical teacher ; and as such he appears to exercise a license in
his writings which would pass unnoticed in the lecture theatre,
although sure to attract attention in a written document. Some
of his statements seem hardly reconcileable with each other; yet
it is evident that this is less inherent in the statements them-
selves than in the mode of their expression. The lecturer, when
engaged in delivering a clinical discourse, often makes an asser-
tion which he is afterwards induced to modify, though not alto-
gether to contradict, by the sudden recollection of some point in
the history of a case that for the moment had escaped his memory.
In the class-room such a circumstance is either unimportant
or may even add spirit and life to his instructions ; but when
reduced to the terms of a written proposition, this license is apt
to produce a very opposite effect. If I may be allowed to charac-
terise M. Velpeau's composition, I should be inclined to call
it a clinical style ; and as such it must be judged and estimated.

It will be seen that upon many points of importance I
have considered it my duty to express dissent from claims of
priority and the like, which, if alloAved, would pluck a leaf from
the chaplet that adorns the illustrious dead, for the purpose of
adding to the reputation, already great, of the author himself. I
refer especially to the chapters on Cysts and on Adenoid Tumours.
I think the deliberate judgment of any impartial person must be
that Sir A. Cooper is not open to the criticisms advanced against
him, but that he is fairly entitled to the honours that have
usually been accorded to him, and by no one more unreservedly
than by the author's friend and former pupil, M. Lebert.

If what M. Yelpeau states as to the views entertained


respecting cancer and adenoid turaours, &c., be correct, the
general condition of pathological knowledge on these subjects in
France must be vastly below what it is throughout England and
America. A similar remark applies to many of his observations
on the diagnosis of cancerous diseases ; but as I have added,
wherever it seemed called for, a short note to these statements,
it is needless to repeat them here.

The Council of the Society considered it inexpedient to repro-
duce the original drawings ; but no alteration has been made in
the text of M. Velpeau's work, excepting the omission of the
details of some of the numerous illustrative cases, and also, for
reasons stated in the foot-note at pp. 590-1 of the summary of
the tables of cancerous diseases.

As respects the general subject of the treatment of cancer in
the breast, it must be confessed that M. Velpeau has not been
more fortunate than others in advancing our therapeutical know-
ledge. There are, however, some indications that a brighter era
is beginning to dawn upon us in this respect.

The aim of the majority of observers has been the discovery of
a specific remedy capable of acting as a direct antidote to cancer ;
but reflection, perhaps, points to the conclusion that more is to be
hoped for from well-directed efforts to discover the nature and
cause of that error in nutrition which leads to the production of
the cancer-cell and cancer-stroma, in place of the more enduring,
though, as it were, less independently vitalized, normal tissues.

Cancer seems to be a substitution for the natural structures of
the body, of a cell-growth endowed with amaziug reproductive
vitality, but very deficient in stability; early prone to degeneration
into fat, the lowest of the animal constituents ; and altogether
incapable of resisting inflammatory changes.

What, it appears to me, we may hope from therapeutics is the
discovery of some means of assisting this imperfect kind of nutrition
and growth, so that it shall no longer stop at the production of a
cancer-tissue, but become developed into the higher and normal
structures of the healthy being. Thus, in the end, we may possibly


arrive at a species of knowledge, such as stands us in good stead
in the treatment of what was once considered an incurabk;
disease — Diabetes mellitus, — and learn to prolong our patient's
existence, not by curing his cancer so much as by altering liis
assimilating and nutritive powers, and enabling him to avoid those
conditions which lead to the development of the cancer germs.

To effect this, the question of operation must be placed in a
somewhat different light to that in which it is generally regarded.

Those surgeons who extirpate cancerous tumours, even if tliey
do not, unlike some pathologists, in theory acknowledge the local
nature of cancer, yet practically act as though they did so ; for, as
a general rule, when once the wound has healed, the patient is
subjected to no further treatment. On the other hand, those
who decline to operate on a cancer leave behind a focus of the
disease, which must almost inevitably render nugatory any kind
of constitutional management.

Thus in neither case is the patient placed in a favorable
position ; and yet the fact still remains, that the cessation in the
progress of some cases of cancer, and the length of time that
may elapse before the return of a tumour after removal, are
circumstances that appear to point out that the cancerous dia-
thesis may become latent for months and years.

I have to express my deep sense of obligation to many friends
for their assistance in the preparation of this translation, but
especially to my colleague, Mr. de Morgan, who was kind enough
to read over the proof sheets.

IIauley Strkkt,

April, 185G.


A TREATISE on tlie diseases of the mamma is yet wanting in
French practice ; for the articles by Boyer, by Astley Cooper^ and
by writers on the subject in our dictionaries, can no longer hold
their ground. The work which I now place before the public is
intended in part to supply this deficiency. It was commenced
more than thirty years ago. Some of the cases upon which it is
based were collected in the Hospital of Tours, at the commence-
ment of my medical studies, under the guidance of those distin-
guished men MM. V. O. Gouraud and Bretonneau. The
experience of large hospitals, consultations grown to be numerous,
and a practice of considerable extent, have enabled me to accumu-
late the particulars of more than two thousand original cases
bearing on the whole subject. The result of these investigations,
both anatomical and clinical, and the doctrines deduced from
them have, howevei', been partially made known in different
publications since the year 1822.^

The duties of the professorship intrusted to me at the Faculté
de Médecine have daily compelled me to the reconsideration
of these matters, as a number of theses and articles in the
journals testify.^ My earliest communications, indeed, excited
some attention, both in the press and in the Academy, during

' ' Revue Médicale,' 1825, vol. ii, pp.257, 326; ibid., 1825—1826; ' Arch. Gen.
Méd.,' 1826—1827, &c.

- See, amongst others, Berigny, 'Gazette des Hôpitaux,' 1835, No. 165, &c. ;
Duclicsne, ' Tlicse de Paris,' 1839, No. 283 ; Colomb, ibid., 1841, No. 14; Traichet,
ibid., 1843; Tareja, ibid., 1844, No. 207 ; Gaffarot, ibid., 1846, No. 71; Tizon, ibid..
1847, No. 42 , Moisin, ibid., 1851, No. 230; Doré, ibid., 1851, No. 218 ; Robeiin, ibid.,
1852, No. 32, &c.


the years 1824 and 1825/ and my article on the breast in
the ' Répertoire des Sciences Médicales/ which seems to have
served as the starting points for the important memoirs of M.
Nélaton on inflammation, and of M. A. Bérard on tumours of the
mamma, shows what views I entertained on the subject in the
year 1839; and thus it happens that numerous fragments of the
present work have long been before the public.

The examination, the study, and the discussion of facts which
continually present themselves at the bedside of the sick, have
perpetually interfered to delay its completion ; still, when once
the impulse had been given, it was impossible not to persevere.
Daily compelled to submit my opinions to the test of practice, I
have had to modify and by degrees to correct them by the light
which continually flashes from experience and reflection. My
present work has thus been remodelled several times.

Its completion, however, has never been interfered with by
deficiency of material, for no other observer has, I believe, had a
similar mass to work upon. The consequence has been that
without absolutely neglecting what has been accumulated by my
predecessors, T have nevertheless been able, almost throughout, to
content myself with my own observations. Even with this
restriction my embarrassment has been great. As the cases
alone in my possession would have filled more than a volume,
I have limited myself to narrating only a few of them, and
have simply tabulated the rest. To their illustration numerous
drawings would also have been necessary, but this the price of the
work would not permit, for it has been my object to place it
within the reach of every one.

Of the three principal parts which compose it, t\\e first, that
which treats of inflammation, does not appear to require any pre-
liminary apology. The classification that I have adopted, founded
as it is upon surgical anatomy, and moreover susceptible of asso-
ciation with any other, may be improved or modified ; but can
scarcely be altogether rejected.

The other two sections, which relate to innocent and to malig-
nant tumours, do not stand in the same position. The dis-
cussions on the subject which I entered into in various publica-
tions, and at the meetings of difl'erent scientific societies, during the
years 1825 and 18-1 i, show that my endeavours have always been

' Mémoire on a remarkable case of cancerous disease, 1825.


directed to the removal from the category of cancers of such
tumours as, from their nature, might or ought to be kept distinct.
So much confusion prevailed on the subject, and the difficulties
were so great, that thirty years of assiduous labour have been insuf-
ficient to dissipate entirely the doubts and uncertainty that
envelope it.

Meanwhile, one important result has been obtained ; for
henceforth we may admit as demonstrated that, out of 400
cases of tumours, confounded together under the common name
of cancer, there were nearly a hundred which were not cancerous,
and which we can now distinguish at the bedside of the patient.
Further study, and the natural progress of science, will, I am
persuaded, still more augment this proportion ; but if the further
I advance the larger becomes the number of innocent tumours in
my tables, we are not therefore to conclude that they are more
common now than formerly ; no, it is solely that as our powers
of diagnosis improve this number naturally enough increases year
by year. There is, therefore, reason to hope that, starting from
this point, surgeons will one day or other be enabled to contract
the circle of genuine cancer to a still greater degree.

Innocent tumours are not all of the same species ; and
as in former times I often confounded them together, I
formerly gave descriptions which, though applicable to some,
cannot be applied to others. Hence it is that I have by turns
made use of different names to distinguish them. In the first
place it is essential to make at least two groups : one of tumours
which are really hypertrophies, the other of tumours of new
formation. The young Parisian School, resting upon data derived
from the microscope, makes no distinction between these groups,
but includes them all under the common title of partial hyper-
trophy of the breast. According to the microscopists, in fact,
non-cancerous tumours are due to the accumulation of epithelium
in the radicles of the milk-tubes and to the hypertrophy of a
certain number of the mammary acini. This doctrine is satis-
factory as regards the first group, but does not appear to me by
any means so as regards the second.

Genuine hypertrophic tumours differ in so many characters
from adenoid growths that it is difficult not to keep them separate.
Even in the month of May of this very year, and again in Novem-
ber, two new examples of the most conclusive kind were brought
under my notice. In both patients — the one a healthy young


woman, regular, the mother of two children ; in the second an un-
married person, forty-four years old, Immp-backed, aud of broken
constitution and health — the tumours, which were of the size of
an egg, and softened towards the centre, were undistinguishable
from the mammary tissue, with which^ indeed, they were found
to be everywhere continuous without appreciable line of demar-
cation. Placed side by side with adenoid tumours removed
at the same period from other women, these growths were as
different in their appearance as, for instance, is a fatty tumour
from an hypertrophy of the tongue. The microscopical struc-
ture was, it is true, the same in both cases ; but I have
stated in the body of this work what amount of confidence
should be accorded to this evidence.

I may here narrate a case of some importance. In a woman
who was operated on for an enormous adenoid tumour, which was
ten pounds in weight, eighteen months afterwards there arose at
the border of the pectoralis major, a secondary globular and
moveable growth, which I was able to remove by simple enuclea-
tion, and which, in other respects, both before and after the
operation, presented all the appearances of other adenoid tumours.
However, M. Follin, who made a very careful microscopical
examination of it^ sent me the following note :

" The tumour was composed of two different portions. The
one, the cortical portion, dense, fibrous, and of a gray- white
colour, slightly opaline, creaked under the knife, and on pressure
gave exit to nothing but a serous transparent fluid, altogether
distinct from the milky juice of cancerous tumours. The other,
the central portion of the mass was throughout made up of
yellowish deposits, grumous, and mixed in some parts with blood
which had not lost its colour. Under the microscope the cortical
portion was composed of the following elements : 1st, of a large
number of elongated and elipsoid bodies, provided with a central
nucleus, and terminating in rounded or thread-like ends ; 2d, of
fusiform bodies much elongated, slightly raised in the centre, and
furnished with tails sometimes of great length. These fusiform
bodies heaped together so as to form a somewhat dense mass
constituted the fundamental part of the tissue.

"As for the central portion, it did not exhibit to me any definite
structure. I observed in it nothing but an assemblage of fibres,
and a few blood-globules, which were deposits of blood in process
of decolor ization."


Thus there were in this tumour neither epithelial cells, nor
closed tubes, nor the elements of breast tissue, and yet how can
we deny that it was of the same species as the one originally
removed from the mamma ? And, moreover, what Avas this tu-
mour, which was as large as the two fists, and bore no resem-
blance whatever to the lymphatic glands, if it Avas not a tumour
by deposition or by new formation?

The patient here referred to had scarcely recovered, when
there came into the ward another female with an adenoid tumour
of about forty pounds in weight, the like of which I have never
seen. I maintained the innocent nature of this growth, notwith-
standing, according to popular belief, it bore every resemblance
to encephaloid ; and although, according to the microscope, it was
of hypertrophic composition, yet it was foreign to the proper
mammary tissue.

Science and practice may therefore unite in inquiring whether,
at all events, in the present state of our knowledge, adenoid
tumours are not confounded with simple partial hypertrophies of
the mamma, just as much as are fibrous tumours with hypertrophy
of the uterus.

As for genuine cancers, I have found it very difficult to classify
them. Microscopical researches, the assistance of which I sought
so far back as the year 1830, and which I have promoted on all
occasions, have not, in my opinion, as yet supplied us with data
sufficiently definite to serve as the foundation of a good classifi-
cation of tumours. I think I have, contrary to the assertions of
the ultra-raicroscopists, incontestably shown — 1st, that that cell,
which is called the cancer-cell, is not the specific element of
cancer ; 2d, that well-marked cancers may not contain this cell
at all ; 3d, that it has been found in non-cancerous tumours.

In order to remove every pretext for doubt upon the subject,
I have only made use of facts furnished by the microscopists
themselves, and especially by M. Lebert. The ' Physiologie
Pathologique ' and the ' Traité du Cancer ^ of this author, works
as conscientious as they are laborious, show that a multitude of
tumours furnished by my practice have been examined and
analysed by him. Consequently we have both witnessed the
same facts. If, then, M. Lebert had limited himself to affirming
the existence of certain forms of cells in the tumours of which
he speaks ; if, in one word, he had confined himself within the
bounds of pathological anatomy, I should have no objection to


urge, and should not^ to my deep regret, have found myself under
the necessity of rejecting his interpretations, both theoretical and
practical, on the subject of the cancer-cell.

Without speaking of M. Miiller, and of some other eminent
German anatomists, who deny the specific nature of the nu-
cleated cell, I may observe that M. Alquie, of Montpelier ;
M. Michel, of Strasbourg; MM. Marjolin, Robert, Forget, and
others, in Paris, have, on their side, arrived at conclusions similar
to my own.^

Mons. Lebert, and, following him, M. Robin, are, it seems
to me, mistaken in assuming as settled that which is still
a matter of doubt, viz., what species of definite cell forms
the fundamental element of each kind of tumour. In making
the assertion, that each tumour made up of homologous cells
ought to be classified amongst innocent growths, and that every
tumour in which there exist heterologous cells, must necessarily
be a cancer, they have drawn their conclusions too rapidly. To
say that cancers of the lips, face, arms, uterus, or penis, and
cancers of the integuments in general, are only hypertrophied
follicles, or masses of epithelium ; and that verrucœ, corns, warts,
horny growths, steatomatovis tumours, and the above-named
cancers, are identical in kind,^ must even, « prio7'i, appear ex-
ceedingly strange to all experienced surgeons. Before the time
of Sertuerner, analytical chemistry found in opium nothing but
the elements of gum ; but should we therefore have been justified
in concluding that gum and opium are identical ?

Consistently with his doctrine, M. Lebert has not hesitated
to maintain that those ulcers, prominent eruptions, tumours and
vegetations of the lips or face, &c., which are known to surgeons
under the name of noli me tangere, herpes eœedens, and cutaneous
cancers, are not genuine cancers, but only pseudo-cancers, can-
croid productions ; and further, that when completely removed
by operation, they are not liable to reproduction. In this way,
too, he endeavours to explain the circumstance that cancers of
the lips, for example, only reappear in their original situation,
and are not usually followed by secondary formations.

Two mistakes attach to these propositions. In the first place,
it is not true that cancers of the lips are not liable to return ;
perhaps they grow again with even as much obstinacy as cancers

' ' Union Medic.,' 1852—1853.
- See Mayor, ' Tliesis,' 1846, No. 8.


of the breast ; and, in the second place, it is certain that when once
operated upon, they re-appear as readily at a distance as in their
original scat, and it is also certain that they may become gene-
ralized. I was as well aware of this ten years ago as I am now; but
then the microscopists object, that up to that period we confounded,
in practice, epithelial tumours with true cancers, and that, there-
fore, observations, instituted anterior to modern researches, should
not be brought into the question. Such a reason for not taking
them into the account can have no weight with me; for it is
evident enough to me that cancroid is precisely the disease for
which surgeons have always operated under the name of cancer.

Nevertheless, the question raised by such a man as M. Lebert
deserves examination. I therefore once more apply myself
to it. All the cases of cancroid that I have met with have
been submitted to microscopical examination, and I do not
hesitate to assert, that in no instance have the microscopists
seen me mistake a tumour of this kind for any other at the bed-
side of the patients. Now the result of my modern practice
shows that the pseudo-cancers, like the real cancers, return Avith
a deplorable tenacity.

Daring no longer to deny the fact, M. Lebert at first
answered that this return may be due to a portion of the
disease having escaped, the knife. A new error ; cancroid tu-
mours do not re-appear exclusively in the neighbourhood of the
primary tubercle; they show themselves under the jaw, under
the ear, and in the lymphatic glands of the neck, as well as
along the borders of the cicatrix. Driven back upon this
point, the advocates of the Cell doctrine entrench themselves in
another proposition as little stable as the preceding. If, say
they, cancroid disease occasionally does recur at some distance
from its primary seat, it is, at any rate, only in the lymphatic
structures of the part, and never in the viscera ; if, in short, the
disease does become multiplied, it is in the same way as scrofu-

Online LibraryA. (Alfred) VelpeauA treatise on the diseases of the breast and mammary region → online text (page 1 of 62)