J.W. Alexander
1895 The Lancet  
of recurrence after the removal of the breast was doubtful in 8 cases, within three months in 8, three to six months in '7, six to twelve months in 1, one to two years in 8, two to three years in 3, three to four years in 1, four to five years in 1, and after ten years in 1. The recurrent growth was situated in the axilla without recurrence in the cicatrix in 9 cases it affected the cicatrix on the chest wall or its immediate vicinity in 19, and the internal organs without local reccurrence in
more » ... (lungs 2, uterus 1, and subperitoneal glands 1). The opposite breast became affected by carcinoma in a late stage of the disease in 4 of the 38 cases. Operations for the removal of recurrent growths were undertaken in 11, or just 20 per cent. of the total number of cases ; of these, three had two subsequent operations. The rule with regard to recurrent growths should be to remove them whenever practicable and as soon as possible after they are discovered. The remaining 6 patients are living and show no signs of return of the growth, the time since operation being eleven years, and three months in two instances, eight years and four months in two others, seven years in a fifth, and six years in the sixth. Leaving out of consideration those patients who died soon after the operation, those who have since died from independent diseases, and those who cannot be traced, 6 cases out of 48 have no recurrence after periods varying from five to eleven years. If we adopt Volkmann's rule that if a patient is free from recurrence three years after the removal of the growth she is to be considered cured, we can claim that 12'5 per cent. of our cases were cured by operation. This rule, however, is not always correct, for recurrence sometimes takes place at a very late period ; one of our cases had recurrence after ten years. From a careful consideration of the foregoing facts we have drawn the following conclusions :-1. Cancer of the breast, although a formidable disease, is amenable to treatment by operation, and the proportion of cures so obtained may confidently be put down at 12 per cent. 2. Nonsuccess after operation is very frequently due to the extensive character of the disease when it first comes under observation; probably if relief were sought earlier a much larger proportion of cures would be obtained. 3. Moderate enlargement of the axillary glands is no bar to operation or to a successful issue provided they are systematically and carefully removed and the axillary space thoroughly cleared. 4. It is well-nigh impossible to discover trifling enlargement of the axillary glands by an examination through the unbroken skin. 5. No operation for removal of cancer of the breast can be considered complete unless the axilla be examined through the wound, the additional risks of such a procedure being very slight. 6. The large number of cases in which recurrence occurs locally points to the necessity of very free removal of the disease ; all doubtful skin must be taken away and great care must be exercised not to leave any outlying portions of breast tissue. 7. Operation is contra-indicated when the whole of the growth cannot be removed or when the supra-clavicular glands are enlarged. The only condition which might render an operation justifiable under such circumstances would be the presence of a foul cancerous ulcer, the removal of which is desirable on account of the great inconvenience which it occasions. Manchester. THE following case of epilepsy, in which the patient recovered after having had an extraordinary number of convulsions, may be considered of interest. It occurred in a woman twenty-six years of age, who was admitted to Rainhill Asylum on Jan. 4th, 1890, suffering from mania with epilepsy. From the date of her admission till the end of December, 1894, she had on an average four fits per month ; one to two days intervened, as a rule, between each, ani at no time were more than five fits recorded in twentyfour hours. After each group of fits she became excited, the excitement frequently assuming the form of post-epileptic mania of a violent type. Bromide of potassium was taken by the patient in thirty-grain doses twice daily from the middle ot May, 1891, till the middle of December, 1894. The series of convulsions which forms the subject of this communication began on Jan. 2nd of this year, a fortnight after the bromide of potassium was discontinued, and ended twenty-one days later. The aggregate number of fits recorded during these twenty-one days amounted to 3205, the daily total reading as follows:- The convulsions were almost entirely confined to the right side of the body, beginning in the arm and spreading rapidly to the head, face, and leg. The arm was flexed, the leg drawn up, and the head and eyes rotated to the right; occasionally the left leg was involved, and more rarely the left arm also. During the paroxysm urine was passed, but not faeces, nor was the tongue bitten. Each fit was a distinct entity, well marked and severe, but of short duration, generally lasting from about thirty to forty seconds, and separated from that immediately preceding and succeeding it by a period of semi or complete consciousness. There can be little doubt that the patient's recovery may be attributed to the fact that these periods existed and were taken advantage of to give her a sufficiency of nourishment. As to treatment, a brisk purge was administered at the outset, and 111 grains of chloral hydrate were given in the first twenty -four hours, followed during the second twenty-four hours by 105 grains of the same drug. Afterwards ten grains of bromide of potassium and ten grains of chloral hydrate were given every three hours till Jan. 17th, when the amount of each drug was increased to thirty grains every four hours at first, and less frequently as the fits decreased in number and severity. After the final cessation of the convulsions the right arm and leg remained completely paralysed for a fortnight ; then the paralysis gradually passed off. At this time, the patient's mental activity having returned, an examination into the state of her nervous system was made. She complained of great pain in the right shoulder, which was purely due to passive or active movement; there was no hyperaesthesia ; sensibility to pain and touch remained unimpaired; the motor speech mechanism was unaffected; ophthalmoscopic examination revealed no morbid change; there was slight wasting of the right arm and leg, and the tendon reflexes were brisk, that of the right patella more so than the left. Concerning the further course of the illness, the paralysis has now (April, 1895) oompletely disappeared, some slight stiffness of the shoulder alone remains, and no more fits have been recorded.
doi:10.1016/s0140-6736(01)13518-x fatcat:t53ekl7dmjb4bgwgxi2rhbvfwe